EKG Dasar

transcript

ELEKTROKARDIOGRAFIELEKTROKARDIOGRAFI

Departemen Kardiologi dan Kedokteran VaskulerFakultas Kedokteran

Universitas Sumatera Utara

Conduction System

ECG interpretation…?

1. Calibration2. Rate and rhythm3. QRS axis4. P morphology5. PR interval6. QRS duration7. QRS morphology8. ST segment morphology9. T morphology10.Others: LVH, LV strain, BBB11.Conclusion: normal/abnormal

DEFINISI KONFIGURASI EKG

Gel. P = defleksi akibat depolarisasi atrium Gel. Q(q) = defleksi negatif awal akibat depolarisasi ventrikel yg mendahului gel. (R)

Gel. R(r) = defleksi positif awal akibat depolarisasi ventrikelGel. S(s) = defleksi negatif awal akibat depolarisasi ventrikel yg mengikuti gel. (R)

Gel. R’(r’) = defleksi negatif awal akibat depolarisasi ventrikel yg mengikuti gel. (R) Gel.T = defleksi akibat repolarisasi ventr. Gel. U = defleksi (biasanya positif) sete- lah gel T dan mendahului gel P

-------- = depolarisasi atrium -------- = depolarisasi dan repolarisasi

ventrikel

-------- = depolarisasi ventrikel

The diagram illustrates ECG waves and intervals as well as standard time and voltage measures on the ECG paper.

Gelombang ECG dan INTERVAL: Apa arti dari gelombang EKG ? Gelombang P : sekuensial depolarisasi atrium kiri dan kanan Kompleks QRS complex: depolarisasi ventrikel kiri dan kanan Gelombang ST-T : repolarisasi ventrikel Gelombang U : sumber gelombang ini masih dalam perdebatan Interval PR interval: waktu mulai dari depolarisasi atrium (gelombang P) sampai permulaan depolarisasi ventrikel (kompleks QRS) Durasi QRS duration: durasi depolarisasi otot ventrikel (lebar kompleks QRS) Interval QT: durasi depolarisasi dan repolarisasi ventrikel Interval PP : rate dari atrium atau sinus cycle Interval RR : rate dari ventricular cycle

DEFINISI KONFIGURASI GELOMBANG EKG

Kertas EKGHorizontal menyatakan kecepatan kertas dalam waktu1 mm = 0,04 detik 5 mm = 0,2 detik

Vertikal menyatakan voltage elektris jantung dalam millivolt

10 mm = 1 mV

Pada pemeriksaan rutin kecepatan rekaman kertas EKG 25 mm/detik

1 mm = 0,1 mV

10 mm = 1 mV

1 mm = 0,04 detik

5 mm = 0,2 detik

NILAI NORMAL :

Gelombang P : durasi : 0.08 – 0.10 / 0,12 detik

tinggi (voltase) : < 2,5 mm

Interval PR : 0,12 – 0,20 detik

Kompleks QRS : durasi : 0,06 – 0,10 detik

tinggi : > 5 mm standard limb lead ; > 10 mm chest lead

Interval QT : ♀ < 0,42 ; ♂ < 0,44 detik

Interval QTc : QT √ RR

Gelombang T : 1/8 – 2/3 dari tinggi gelombang R

Segmen ST : isoelektris

- - + ++ + - -

+ + - -- - + +

- - + +- -

Stimulasi sel otot

Defleksi atas Defleksi bawah

Defleksi bifasik

DEPOLARISASI

SANDAPAN JANTUNG (LEAD)

Lead jantung ada 2 :

1. Bipolar standard lead (Einthoven) yaitu :I, II, III dan aVR, aVL, aVF

2. Unipolar lead (Wilson 1932) yaitu V1 sampai V9 dan V3R sampai 9R serta 3V1-9 sampai 3V3R-9R dan adalagi esofageal lead (E lead)

EKG rutin terdiri dari 12 lead yaitu : I,II,III; aVR, aVL, aVF dan V1-6 pada dewasa serta pada anak yaitu : I,II,III; aVR, aVL, aVF dan V1-6 ditambah V3R dan V4R

Standard Lead

CHEST LEAD

Posisi chest lead dari depan

Posisi chest lead dari belakang

Ilustrasi posisi unipolar chest lead pada potongan transversal toraks

HEART RATE

Menentukan Heart Rate dari Electrocardiogram

Ada berbagai metode yang dapat digunakan untuk menghitung denyut jantung dari EKG, dengan kecepatan kertas EKG25 mm/sec. Salah satu metode adalah membagi 1500 dengan jumlah kotak kecil diantara dua gelombang R (garis panah merah). Sebagai contah, rate diantara beat 1 dan 2 pada EKG diatas adalah 1500/22, yang sama dengan 68 denyut /min. Alternatif lain,adalah dengan membagi 300 dengan jumlah kotak besar (garis panah biru pada diagram), yaitu 300/4.4 (68 denyut /min). Metode lain, adalah "count off" method. Dengan menghitung jumlah kotak besar diantara gelombang R mengikuti rate: 300 - 150 - 100 - 75 - 60. Sebagai contoh jika ada 3 kotak besar diantara gelombang R denyut jantung adalah 100 denyut/min.

MENGHITUNG DENYUT JANTUNG DARI EKG :a. Irama Sinus : 1.1500 / jarak RR (kotak kecil)

2. 300 / jarak RR (kotak besar)

b. Sinus aritmia : 1. Hitung jumlah RR dalam 5 detik atau,

2. Hitung jumlah RR dalam 6 detik atau,

3. Hitung jumlah RR dalam 10 detik,

kemudian

1. HR = (jumlah RR dalam 5 detik x 12), atau

2. HR = (jumlah RR dalam 6 detik x 10 atau), atau

3. HR = (jumlah RR dalam 10 detik x 6)

HR = jumlah gel R x 60/5 atau jumlah gel R x 60/6

1 kotak besar = 300

2 kotak besar = 150

3 kotak besar = 100

4 kotak besar = 75

5 kotak besar = 60

6 kotak besar = 50

7 kotak besar = 43

8 kotak besar = 37

1 2 3 4 5 6 70 8

“Count off" method

AKSIS JANTUNG

Stimulus depolarisasi dan repolarisasi didalam jantung menyebar ke berbagai arah didalam jantung sesuai dengan posisi anatomi jantung

Aksis jantung : 1. Aksis QRS

2. Aksis gelombang P

3. Aksis gelombang T

1. Aksis QRS : arah depolarisasi gelombang QRS pada frontal plane yang ditentukan oleh posisi anatomi jantung

2. Aksis P : arah depolarisasi gelombang P pada frontal plane

3. Aksis T : arah repolarisasi gelombang T pada frontal plane

Determining the Mean Electrical Axis (QRS axis)

Lead I : 4 – 0 = 4

Lead aVF : 12 – 2 = 10

Lead I : 4 – 0 = 4

Lead aVF : 12 – 2 = 10

+ = 90°

+ = 0°/360°- = 180°

- = 270°

Axis nomenclature Lead I Lead aVF

1. Normal axis (0 to +90 degrees) Positive Positive

2. Left axis deviation (-30 to -90) Also check lead II. To be true left axis deviation, it should also be down in lead II. If the QRS is upright in II, the axis is still normal (0 to -30).

Positive Negative

3. Right axis deviation (+90 to +180) Negative Positive

4. Indeterminate axis (-90 to -180) Negative Negative

Determining the Mean Electrical Axis (QRS axis)

Differential Diagnosis

Left axis deviation

LVH, left anterior fascicular block, inferior wall MI, PVC from the right ventricle, WPW syndrome activating the right ventricle, Pregnancy, Ascites, Abdominal tumor, exhalation.

Right axis deviation

RVH, left posterior fascicular block, lateral wall MI, PVC from the left ventricle, WPW syndrome activating the left ventricle, Emphysema, Inhalation

ARTI KLINIS AKSIS QRS

HIPERTROFI

Hipertrofi JantungHipertrofi Jantung : 1. Atrium : a. Atrium kiri

b. Atrium kanan

c. Biatrial

2. Ventrikel : a. Ventrikel kiri

b. Ventrikel kanan

c. Biventrikel

1. Pembesaran atrium : (leads II and V1).

a. Hipertrofi atrium kiri - lead II : Notched wide (> 3mm) gelombang P. - V1 : defleksi terminal negatif bertambah

b. Hipertrofi atrium kanan - lead II : Amplitudo gelombang P > 2.5mm. - V1 : defleksi terminal negatif bertambah.

c. Biatrial : gabungan

P PulmonalHipertrofi atrium : (leads II and V1).

P Mitral

Hipertrofi atrium kiri

Hipertrofi atrium kanan

Biatrial

2. Ventrikel : a. Ventrikel kiri

b. Ventrikel kanan

c. Biventrikel

•1. LVH: (Left ventricular hypertrophy). a. Gelombang S (terbesar) di V1 atau V2 (dlm mm) ditambah gelombang R (terbesar) di V5 atau V6 (dlm mm) > 35mm. ("voltage criteria“) b. Gelombang R > 12 mm di aVL (LVH is more likely with a "strain pattern" which is asymmetric T wave inversion in those leads showing LVH).

a. Ventrikel kiri

Summary :• S wave V1 or V2 or R wave V5 or V6

of 30mm or greater. • LAD• QRS duration upper limit of normal• Shift in the ST segment or T wave

(strain pattern) V5 and V6

b. Ventrikel kanan

Summary of Criteria for RVHRemember, again, that the electrocardiographic criteria for chamber enlarge-ment have both low sensitivity and specificity. In summary, these are thethings to look for when trying to diagnose RVH:1. R to S ratio of >1.0 in V1 or V22. RAD3. Normal QRS duration4. Strain pattern V1 or V2 and in limb leads with the tallest R wave

•RVH: (Right ventricular hypertrophy). Gelombang R > gelombang S di V1 dan Gelombang R menurun dari V1 sampai V6.

c. Biventrikel

Merupakan gabungan kriteria RVH dan LVH

ARTI KLINIS HIPERTROFI JANTUNG :

1. Pembesaran atrium kanan : ASD, PAPVR, Ebstein anomali

2. Pembesaran atrium kiri : Mitral stenosis, Mitral regurgitasi

3. Hipertrofi ventrikel kiri : Hipertensi, Aortic stenosis, Aortic regurgitasi, Mitral regurgitasi, VSD, PDA

4. Hipertrofi ventrikel kanan : PPOK, ASD, Pulmonal stenosis

RAE LAE

RVH LVH

ISKEMIA & INFARK

Infarct , injury and ischaemic

Progression of an Acute Myocardial Infarction

An acute MI is a continuum that extends from the normal state to a full infarction:

■ Ischemia—Lack of oxygen to the cardiac tissue, represented by ST segment depression, T wave inversion, or both■ Injury—An arterial occlusion with ischemia, represented by ST segment elevation■ Infarction—Death of tissue, represented by a pathological Q wave

Normal

Ischemia

Injury

Infarction

Hubungan antara lokasi infark dan oklusi arteri koroner (panah), dan lead elektrocardiogram. a. Anteroseptal infark. b. Anterior infark

Extensive (anterolateral infarction)

c. Infark lateral isolated infarction

d. Infark Inferior

e. Infark Posterior

f. Right ventricular “infarction” (combined to inferior infarction)

Ishemia – Injury - Infarct

Accurate ECG interpretation in a patient with chest pain is critical. Basically, there can be three types of problems - ischemia is a relative lack of blood supply (not yet an infarct), injury is acute damage occurring right now, and finally, infarct is an area of dead myocardium. It is important to realize that certain leads represent certain areas of the left ventricle; by noting which leads are involved, you can localize the process. The prognosis often varies depending on which area of the left ventricle is involved (i.e. anterior wall myocardial infarct generally has a worse prognosis than an inferior wall infarct).

V1-V2 anteroseptal wall

V3-V4 anterior wall

V5-V6 anterolateral wall

II, III, aVF inferior wall

I, aVL lateral wall

V1-V2posterior wall (reciprocal)

depresion

elevation

NON-TRANSMURAL = SUB ENDOCARDIAL = non Q-WAVE M.I.

TRANSMURAL = MYOCARDIAL = Q-WAVE M.I.

Figure. a. Acute infarction: correlation between the electrocardiogram (ECG) and the stage of myocardial ischemia. Monophasic ST deformation /“transmural” lesion = lesion / injury. b. Subacute infarction. Correlation between the ECG and the stage of myocardial ischemia (ST elevation = lesion, plus pathologic Q wave = necrosis, plus negative T wave = ischemia). c. Evolution of subacute infarction to chronic infarction

Figure V3 lead: Evolution of QRS and ST/T morphologies in STEMI due to occlusion of LAD.(a) Few minutes; (b) 1 hour; (c) 1 day; (d) 1 week.

Figure 9.3. The evolution of an inferior wall myocardial infarction, as seen in lead III of a 55-year-old white male. Note that the admission tracing shows only ST elevation. A Q wave is beginning to form by 1 hour, and ST elevation is on the way down. By 24 hours, Q wave formation is complete,and the T wave is fully inverted. By 1 year, a pathologic Q wave is the only remaining evidence of infarction.

Myocard infark :

1. Hyperacute T wave

2. ST segment changes

3. Pathological Q wave

4. Resolution of changes of ST segment and T wave

5. Reciprocal ST segment depression

T wave changes associated with ischaemia

The ECG shows:• Sinus rhythm• Normal axis• Q waves in leads V2-V4• Raised ST segments in leads V2-V4• Inverted T waves in leads I, VL, V2-V6

The ECG shows:• Sinus rhythm• Normal axis• Small Q waves in leads II, III, VF• Biphasic T waves in leads II, V6; inverted Twaves in leads III, VF• Markedly peaked T waves in leads V1-V2

ARITMIA

Normal Sinus RhythmLooking at the ECG you'll see that:•Rhythm - Regular •Rate - (60-100 bpm) •QRS Duration - Normal •P Wave - Visible before each QRS complex •P-R Interval - Normal (<5 small Squares. Anything above and this would be 1st degree block) •Indicates that the electrical signal is generated by the sinus node and travelling in a normal fashion in the heart.

Source: Male, 48 years old, Heart Rate: 65bpm, PR: 188ms, QRS: 92ms

1. SINUS RHYTHM

•Sinus BradycardiaLooking at the ECG you'll see that:•Rhythm - Regular •Rate - less than 60 beats per minute •QRS Duration - Normal •P Wave - Visible before each QRS complex •P-R Interval - Normal •Usually benign and often caused by patients on beta blockers & healthy athletic person

•Sinus TachycardiaAn excessive heart rate above 100 beats per minute (BPM) which originates from the SA node. Causes include stress, fright, illness and exercise. Not usually a surprise if it is triggered in response to regulatory changes e.g. shock. But if their is no apparent trigger then medications may be required to suppress the rhythm Looking at the ECG you'll see that:•Rhythm - Regular •Rate - More than 100 beats per minute •QRS Duration - Normal •P Wave - Visible before each QRS complex •P-R Interval - Normal •The impulse generating the heart beats are normal, but they are occurring at a faster pace than normal. Seen during exercise

•Atrial Fibrillation Many sites within the atria are generating their own electrical impulses, leading to irregular conduction of impulses to the ventricles that generate the heartbeat. This irregular rhythm can be felt when palpating a pulse. Looking at the ECG you'll see that:•Rhythm - Irregularly irregular •Rate - usually 100-160 beats per minute but slower if on medication •QRS Duration - Usually normal •P Wave - Not distinguishable as the atria are firing off all over •P-R Interval - Not measurable •The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm

Note ectopic focus top right corner of atria.

•Atrial Flutter Looking at the ECG you'll see that:•Rhythm - Regular •Rate - Around 110 beats per minute •QRS Duration - Usually normal •P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but sometimes 3:1 •P Wave rate - 300 beats per minute •P-R Interval - Not measurable •As with SVT the abnormal tissue generating the rapid heart rate is also in the atria, however, the atrioventricular node is not involved in this case.

•Supraventricular Tachycardia (SVT) AbnormalA narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not under direct control from the SA node. SVT can occur in all age groupsLooking at the ECG you'll see that:•Rhythm - Regular •Rate - 140-220 beats per minute •QRS Duration - Usually normal •P Wave - Often buried in preceding T wave •P-R Interval - Depends on site of supraventricular pacemaker •Impulses stimulating the heart are not being generated by the sinus node, but instead are coming from a collection of tissue around and involving the atrioventricular (AV) node

•1st Degree AV Block1st Degree AV block is caused by a conduction delay through the AV node but all electrical signals reach the ventricles. This rarely causes any problems by itself and often trained athletes can be seen to have it. The normal P-R interval is between 0.12s to 0.20s in length, or 3-5 small squares on the ECG. Looking at the ECG you'll see that:•Rhythm - Regular •Rate - Normal •QRS Duration - Normal •P Wave - Ratio 1:1 •P Wave rate - Normal •P-R Interval - Prolonged (>5 small squares)

•2nd Degree Block Type 1 (Wenckebach)Another condition whereby a conduction block of some, but not all atrial beats getting through to the ventricles. There is progressive lengthening of the PR interval and then failure of conduction of an atrial beat, this is seen by a dropped QRS complex. Looking at the ECG you'll see that:•Rhythm - Regularly irregular •Rate - Normal or Slow •QRS Duration - Normal •P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0. •P Wave rate - Normal but faster than QRS rate •P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped

•2nd Degree Block Type 2 When electrical excitation sometimes fails to pass through the A-V node or bundle of His, this intermittent occurance is said to be called second degree heart block. Electrical conduction usually has a constant P-R interval, in the case of type 2 block atrial contractions are not regularly followed by ventricular contraction. Looking at the ECG you'll see that:•Rhythm - Regular •Rate - Normal or Slow •QRS Duration - Prolonged •P Wave - Ratio 2:1, 3:1 •P Wave rate - Normal but faster than QRS rate •P-R Interval - Normal or prolonged but constant

•3rd Degree Block3rd degree block or complete heart block occurs when atrial contractions are 'normal' but no electrical conduction is conveyed to the ventricles. The ventricles then generate their own signal through an 'escape mechanism' from a focus somewhere within the ventricle. The ventricular escape beats are usually 'slow'Looking at the ECG you'll see that:•Rhythm - Regular •Rate - Slow •QRS Duration - Prolonged •P Wave - Unrelated •P Wave rate - Normal but faster than QRS rate •P-R Interval - Variation •Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles generate their own rhythm

•Junctional RhythmsLooking at the ECG you'll see that:•Rhythm - Regular •Rate - 40-60 Beats per minute •QRS Duration - Normal •P Wave - Ratio 1:1 if visible. Inverted in lead II •P Wave rate - Same as QRS rate •P-R Interval - Variable

Below - Accelerated Junctional Rhythm

Accelerated Junctional RhythmRegular Rhythm•Heart Rate: 60 to 100 beats per minute (BPM) •P Wave: Inverted, absent or after QRS •PR Interval: Less then 120ms •QRS Interval: Less then 120ms

•Asystole - AbnormalLooking at the ECG you'll see that:•Rhythm - Flat •Rate - 0 Beats per minute •QRS Duration - None •P Wave - None •Carry out CPR!!

Sinus PauseIrregular RhythmHeart Rate: Undetermined P Wave: Before each QRS, identical, dropped beat, p to p is undisturbed PR Interval: 120 to 200ms QRS Interval: Less then 120ms

Sinus ArrestIrregular RhythmHeart Rate: Undetermined P Wave: Before each QRS, identical, dropped beat, p to p is undisturbed PR Interval: 120 to 200ms QRS Interval: Less then 120ms

Premature Atrial Contraction IsolatedIrregular Rhythm•Heart Rate: None •P Wave: Premature and abnormal or hidden •PR Interval: Less then 200ms •QRS Interval: Less then 120ms

Premature Atrial Contraction PairedIrregular Rhythm•Heart Rate: None •P Wave: Premature and abnormal or hidden •PR Interval: Less then 200ms •QRS Interval: Less then 120ms

Premature Atrial Contraction Atrial BigeminyIrregular RhythmHeart Rate: None •P Wave: Premature and abnormal or hidden •PR Interval: Less then 200ms •QRS Interval: Less then 120ms

Wandering PacemakerIrregular Rhythm•Heart Rate: Less then 60 beats per minute (BPM) •P Wave: Multiple forms •PR Interval: Variable •QRS Interval: Less then 120ms

Ventricle Extra Systole = Ventricle Premature Contraction

•Premature Ventricular Complexes Due to a part of the heart depolarizing earlier than it should. Looking at the ECG you'll see that:•Rhythm - Regular •Rate - Normal •QRS Duration - Normal •P Wave - Ratio 1:1 •P Wave rate - Normal and same as QRS rate •P-R Interval - Normal •Also you'll see 2 odd waveforms, these are the ventricles depolarising prematurely in response to a signal within the ventricles.(Above - unifocal PVC's as they look alike if they differed in appearance they would be called multifocal PVC's, as below)

•Ventricular Tachycardia (VT) AbnormalLooking at the ECG you'll see that:•Rhythm - Regular •Rate - 180-190 Beats per minute •QRS Duration - Prolonged •P Wave - Not seen •Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse

•Ventricular Fibrillation (VF) AbnormalDisorganised electrical signals cause the ventricles to quiver instead of contract in a rhythmic fashion. A patient will be unconscious as blood is not pumped to the brain. Immediate treatment by defibrillation is indicated. This condition may occur during or after a myocardial infarct.Looking at the ECG you'll see that:•Rhythm - Irregular •Rate - 300+, disorganised •QRS Duration - Not recognisable •P Wave - Not seen •This patient needs to be defibrillated!! QUICKLY

The Deadly

Rhythms

VT VFPEA

(Pulse less ElectricalActivity)

Asystole

Wolff-Parkinson-White syndrome

Diagnostic criteria for right bundle branch block1. QRS duration >0.12 s2. A secondary R wave (R’) in V1 or V23. Wide slurred S wave in leads I, V5, and V6Associated feature1. ST segment depression and T wave inversion

in the right precordial leads

RIGHT BUNDLE BRANCH BLOCK (RBBB)

Diagnostic criteria for left bundle branch block1. QRS duration of >0.12 s 2. Broad monophasic R wave in leads 1, V5, and V63. Absence of Q waves in leads V5 and V6Associated features1. Displacement of ST segment and T wave in an opposite direction to the

dominant deflection of the QRS complex (appropriatediscordance)2. Poor R wave progression in the chest leads3. RS complex, rather than monophasic complex, in leads V5 and V64. Left axis deviation—common but not invariable finding

LEFT BUNDLE BRANCH BLOCK (LBBB)

KRITERIA LAH :1. LAD, sering mendekati −60 derajat2. Gelombang R kecil di lead III3. Gelombang Q kecil di lead I4. Normal QRS durasi

LEFT ANTERIOR HEMIBLOCKS

KRITERIA LPH :1. RAD, sering mendekati +120 derajat2. Gelombang Q kecil di lead III3. Gelombang R kecil di lead I4. Normal QRS durasi

LEFT POSTERIOR HEMIBLOCKS

TERIMA KASIH

BUNDLE BRANCH BLOCK :1. KOMPLIT : - kanan : RIGHT BUNDLE BRANCH BLOCK (>0,12”) - kiri : LEFT BUNDLE BRANCH BLOCK

2. INKOMPLIT : - kanan : INCOMPLETE RIGHT BUNDLE BRANCH BLOCK

(<0,12”) - kiri : INCOMPLETE LEFT BUNDLE BRANCH BLOCK

1. RIGHT BUNDLE BRANCH BLOCK (RBBB)

2. LEFT BUNDLE BRANCH BLOCK (LBBB)

3. LEFT ANTERIOR HEMI BLOCK (LAH)

4. LEFT POSTERIOR HEMI BLOCK (LPH)

INTRAVENTRICULAR CONDUCTION DELAY

Dextroposisi dan Dextrocardia

Normal

Dextroversi / Dextroposisi

Dextrocardia

Cara membedakan normal/dextroposisi dengan dextrocardia

Normal Dextrocardia

LA-RA I -I

LL-RA II III

LL-LA III II

aVR aVL

aVL aVR

aVF aVF

Normal Dextrocardia

LA-RA I -I

LL-RA II III

LL-LA III II

aVR aVL

aVL aVR

aVF aVF

EKG Dasar

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