Você está na página 1de 81

Interpretasi EKG

ECG interpretation

Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval

Quality of the ECG

Patient name
Date of the ECG
Is there any interference?
Is there electrical activity from all 12
leads?
Calibration:
- speed = 25mm/second
- height = 1cm/mV (10mm/mV)

The ECG Paper

Horizontally

One small box - 0.04 s


One large box - 0.20 s

Vertically

One large box - 0.5 mV

The ECG Paper (cont)


3 sec

3 sec

Every 3 seconds (15 large boxes)


is marked by a vertical line.
This helps when calculating the
heart rate.
NOTE: the following strips are not
marked but all are 6 seconds long.

Calibration

Calibration

ECG interpretation

Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval

Rhythm Analysis

Step
Step
Step
Step
Step

1:Calculate rate.
2:Determine regularity.
3:Assess the P waves.
4:Determine PR interval.
5:Determine QRS duration.

Step 1: Calculate Rate


3 sec

3 sec

Option 1

Count the # of R waves in a 6 second


rhythm strip, then multiply by 10.
Reminder: all rhythm strips in the
Modules are 6 seconds in length.

Interpretation? 9 x 10 = 90 bpm

Step 1: Calculate Rate


R wave

Option 2

Find a R wave that lands on a bold line.


Count the number of large boxes to the next
R wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes
- 100, 4 boxes - 75, etc. (cont)

Step 1: Calculate Rate


3 1 1
0 5 0 7 6 5
0 0 0 5 0 0

Option 2 (cont)

Memorize the sequence:


300 - 150 - 100 - 75 - 60 - 50
(30 10 5 3 2)

Interpretation? Approx. 1 box less than


100 = 95 bpm

Rate

300/number of big squares between R waves


1500/number of small square between R
waves
Number of R waves in a 6 second rhythm strip,
then multiply by 10
Rate is either:
- normal: 60-100/mnt
- bradycardic: <60/mnt
- tachycardic: >100/mnt

Differential Diagnosis of
Tachycardia
Tachycardi Narrow
a
Complex
ST
Regular
SVT
Atrial flutter

Wide Complex
ST w/
aberrancy
SVT w/
aberrancy

VT

Irregular

A-fib
A-flutter w/
variable
conduction

A-fib w/
aberrancy

A-fib w/ WPW

Rate

Step 2: Determine
regularity
R

Look at the R-R distances (using a caliper


or markings on a pen or paper).
Regular (are they equidistant apart)?
Occasionally irregular? Regularly
irregular? Irregularly irregular?

Interpretation?

Regular

Step 3: Assess the P


waves
Are there P waves?
Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation? Normal P waves with 1 P

wave for every QRS

P-Wave:
SA Node

AV
Node

LA/RA
Depol

1.SA Node fires


2. Right and Left
Atria Depolarize
3. AV Node
pauses
Questions:
P waves
present?
Regular
rhythm?

1/QRS?

Step 4: Determine PR
interval

Normal: 0.12 - 0.20 seconds.


(3 - 5 boxes)

Interpretation?

0.12 seconds

Step 5: QRS duration

Normal: 0.04 - 0.12 seconds.


(1 - 3 boxes)

Interpretation?

0.08 seconds

Sinus Rythm

HR: 60 100 bpm


Irama: Reguler
Gel P: mendahului setiap kompleks QRS &
bentuknya konsisten
Interval PR: 0,12 0,20 dtk
Kompleks QRS: 0,04 0,10 dtk

Normal Sinus Rhythm

Mattu, 2003

Rhythm Summary
Rate
Regularity
P waves
PR interval
QRS duration
Interpretation?

90-95 bpm
regular
normal
0.12 s
0.08 s

Normal Sinus Rhythm

Gelombang P

Tidak Ada

Ada / Normal

Komplek QRS

Diikuti QRS

PR Interval

Normal

Irama

Teratur

Frekwensi

Memanjang

AV Blok

Tidak Teratur

Tidak dapat dihitung

Gel P teratur spt mata


gergaji

Atrial Flutter

Sinus Aritmia

< 60 x/mnt

60-100 x/mnt

> 100 x/mnt

Sinus
Bradikardi

Sinus Rhythm

Sinus Takikardi

Sempit

Lebar

Atrial Takikardi/
Supra ventricular
takikardi

Irama

Gel P tidak teratur

Teratur

Tidak teratur

Ventrikel
takikardi

Ventrikel fibrilasi

Atrial Fibrilasi

N
o

Jenis-jenis irama listrik


jantung

Jenis
Irama

3.

Ciri Utama

Contoh

Irama
sinus

Nodus
sinoatrial
(NSA)

Adanya P diikuti
QRS

Irama
atrial

Sel-sel atrial

Gelombang P nya Takikardi (150-250),


berbeda dengan P ekstrasistol, flutter
sinus
(gergaji), fibrilasi
(getaran)

Irama
juncti
onal

Nodus
P
atrioventrikul hilang/inversi
er
/mundur

Takikardi (>60),
ekstrasistol, junctional

Irama
ventri

Sel-sel
ventrikuler

Takikardi, ventrikular,
ekstrasistol, flutter,

1.

2.

Pemacu
dominan

P menghilang,
jika ada biasanya

Normal (NSR), takikardi


(100-150), bradikardi
(<60), aritmia (R-R
ireguler), arrest/paust
(PQRS menghilang min. 1
siklus)

Types of Arryhthmias:
Sinus Problems: Formed in the
sinus node, but irregular
Ectopic Problems: Formed outside
of the sinus node
Conduction Problems: Formed in
the sinus node, but conduction in
error
Pre-Excitation Problems: Short
circuits in normal conduction

Causes of
Hypoxia: Lung disease
Arrhytmias:

Ischemia: CAD, angina (local hypoxia)


Sympathetic Stimulation: Nervous,
exercise, CHF, hyperthyroidism
Drugs: Caffeine, cocaine, stimulants
many antiarryhtmic drugs
Electrolyte Disturbances: K+, Ca++, Mg++
Bradycardia: Escape rhythms
Stretch: CHF, hypertrophy, valve disease

Sinus bradikardi

Sinus takikardi

NSR with premature atrial contractions/PAC

NSR with premature ventricular


contractions/PVC (multiform)

Atrial fibrillation No organized atrial


depolarization, chaotic

Atrial flutter sawtooth pattern

Paroxysmal SVT The heart rate suddenly


speeds up

VT

Ventrikel flutter
Ventrikel fibrilasi

SVT

(Narrow complex, regular;

retrograde P waves, rate <220)

VT

The QRS Axis


Represents the overall direction of the hearts activity
Axis of 30 to +90 degrees is normal

Axis

Axis

The Quadrant Approach

QRS up in I and up in aVF =


Normal

What is the axis?


Normal- QRS up in I and aVF

Axis
Positive in I and
aVF = NORMAL

Positive in I and
negative in aVF =
LAD
Negative in I and
positive in aVF =
RAD

Kondisi-kondisi yang
ditandai perubahan axis

Gangguan konduksi, mis. Left


anterior hemiblock
Pembesaran ventrikel, mis. RVH
Penyakit jantung kongenital, mis.
Atrial septal defect
Konduksi pre eksitasi
Embolus pulmoner

ECG interpretation

Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval

Gelombang P

Mewakili
depolarisasi otot
atrium
Normal: Kecil,
melengkung
Tinggi < 2,5 mm,
lebar < 0.11 dtk

P wave

Are there P waves present?

Bifid = P mitrale (LA hypertrophy)


Pointy = P pulmonale (RA
hypertrophy)

P mitrale

P pulmonale

Gelombang, Kompleks &


Interval, Cont
Interval PR

Diukur dr awal gel P


awal kompleks QRS
Mewakili waktu yang
diperlukan untuk
impuls bergerak dr
atrium, AV junction
dan sistem purkinje
Normal: 0,12 0,20
dtk

PR interval

Start of P wave to start of QRS complex

Normal = 0.12 - 0.2 seconds (3-5 small


squares)

Decreased = can indicate an accessory


pathway

Increased = indicates AV block (1st/2nd/3rd)

1st Degree AV Block irama sinus normal,


PR>0,2 detik (>5kk)

2nd degree block, type 1 Pemanjangan


progresif interval PR, disusul hilangnya QRS

2nd Degree AV Block, Type II munculnya


gelombang P tanpa diikuti QRS secara tiba-tiba

3rd Degree AV Block (block total):


tidak terkoneksinya P dan QRS. P &
QRS memiliki pola sendiri-sendiri.

ECG interpretation

Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval

Gelombang, Kompleks &


Interval, Cont
Kompleks QRS

Mewakili depolarisasi
otot ventrikel
Gel Q: defleksi I,
<0,03 dtk, <25 %
tinggi R
Gel R: defleksi + I
Gel S: defleksi
mengikuti R
Lebar Kompleks QRS:
0,04 0,10 dtk

QRS complex

Normal = <0.12 seconds

>0.12 seconds = Bundle Branch


Block

QRS complex
W I LL ia m = LBBB
Monophasic R wave in I and V6, QRS
> 0.12 sec
Loss of R wave in precordial leads
QRS T wave discordance I, V1, V6
Consider cardiac ischemia if a new
finding

M a RR o w = RBBB
V1: RSR prime pattern with
inverted T wave
V6: Wide deep slurred S wave

QRS complex

Is there LVH?

Sum of the Q or S wave in V1 and the


tallest R wave in V5 or V6
>35mm is suggestive of LVH

Q waves

Q waves are allowed in V1, aVR & III

Pathological Q waves can indicate previous MI


Q patologis:

Lebar >1kk
Dalam >2kk
(>1/3 R)

ECG interpretation

Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval

Gelombang, Kompleks &


Interval, Cont
Segmen ST

Mewakili waktu yang


diperlukan oleh
ventrikel untuk
depolarisasi
Mulai dr akhir
kompleks QRS
permulaan gel T
Segmen ST harus
pada garis isoelektrik

ST segment

ST depression
- downsloping or horizontal =
ABNORMAL

ST elevation
- infarction
- pericarditis (widespread)

ST segment

ST segment

ST segment

EKG Distributions

Anteroseptal: V1, V2, V3,


V4
Anterior: V1V4
Anterolateral: V4V6, I,
aVL
Lateral: I and aVL
Inferior: II, III, and aVF
Inferolateral: II, III, aVF,
and V5 and V6

What is the diagnosis?


Acute inferior MI with ST elevation
in leads II, III, aVF

What do you see in this


EKG?
ST depression II, III, aVF, V3-V6 =
ischemia

Lateral MI

Reciprocal changes

Inferolateral MI

ST elevation II, III, aVF


ST depression in aVL, V1-V3 are reciprocal changes

Anterolateral / Inferior
Ischemia

LVH, AV junctional rhythm, bradycardia

Right Ventricular Myocardial


Infarction

Found in 1/3 of patients with inferior MI


Increased morbidity and mortality
ST elevation in V4-V6 of Right-sided EKG

Gelombang, Kompleks &


Interval, Cont
Gelombang T

Mewakili repolarirasi
otot ventrikel
Tinggi: < 5 mm pd
lead di ekstremitas
< 10 mm pd lead di
precordial
Bentuk: melengkung
& sedikit Asismetris

T wave

Small = hypokalaemia

Tall = hyperkalaemia

Inverted/biphasic =
ischaemia/previous infarct

T wave

T wave

T wave

Gelombang, Kompleks &


Interval, Cont
Gelombang U

Gelombang kecil
melengkung, kadang2
mengikuti gel T
Sering dijumpai pd lead
V2-V3
Tinggi: 10 % tinggi gel T
Merupakan bagian dr
repolarisasi ventrikel dan
menunjukkan repolarisasi
serat purkinje

Gelombang, Kompleks &


Interval, Cont
Interval QT
Menunjukkan
durasi aktivasi
dan recovery
ventrikel
Diukur mulai awal
Kompleks QRS
akhir gel T

QT interval

Start of QRS to end of T wave

Needs to be corrected for HR

Normal QTc = < 400ms

Long QT can be genetic or iatrogenic

QT interval

Normal Intervals

PR

QRS

0.20 sec (less than one


large box)
0.08 0.10 sec (1-2
small boxes)

QT

450 ms in men, 460 ms


in women
Based on sex / heart
rate
Half the R-R interval
with normal HR

Torsades de Pointes

Notice twisting pattern


Treatment: Magnesium 2 grams IV

Wolff-Parkinson-White
Syndrome

Short PR interval <0.12 sec


Prolonged QRS >0.10 sec
Delta wave
Can simulate ventricular hypertrophy, BBB and previous MI

Hyperkalemia

Tall, narrow and symmetric T waves

Hypokalemia

U waves
Can also see PVCs, ST depression, small T waves

Digitalis

Dubin, 4th ed. 1989

Você também pode gostar