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![Page 1: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/1.jpg)
EKG
Rachmat Kamaluddin
![Page 2: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/2.jpg)
Intrinsic Conducting System
• Sinoatrial node– Electrical pace maker
• Atrioventricular node– Receives impulses
originating from SA node
• Bundle of His– Electrical link between
atria and ventricles
• Purkinje fibres– Distribute impulses to
ventricles
![Page 3: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/3.jpg)
Sistem Konduksi Jantung
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SANDAPAN UNIPOLER PREKORDIAL
V1 parasternal Ka, ICS 4V2 parasternal Ki, ICS 4V3 titik tengan V2 dan V4V4 grs mid klavikula ICS 5V5 grs aksila depan ICS 5V6 grs aksila tengah ICS 5
Pada posisi normal V1 dan V2 gambaran epikardial kanan, V3 dan V4 gambar an septum interventrikel sedang V5 dan V6 merupakan gambaran ventikel kiri
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SANDAPAN BIPOLER SANDAPAN STANDART
Bipolar standart limb lead untuk beda potensial anara 2 tempat
Lead I, II, III (elektroda positif di LA dan LL, pada L I RA negatif, LA positif, pada L II RA negatif, LL positif dan pada L III LA negatif dan LL positif)
RL dihubungkan pada arde(ground)
Segitiga Einthoven
Rumus Einthoven
II = I + III
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SISTEM SUMBU FRONTAL
I = garis mendatar 0o
II = sudut + 60o dg IIII = sudut +120o dg IaVR = sudut – 150o aVL = sudut - 30o aVF = sudut + 90o
Sudut + searah jamSudut – berlawanan
jam
![Page 7: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/7.jpg)
Kalibrasi Standar
Defleksi 10 mm=1 mV, kecepatan kertas 25 mm/detik.
1 mm=0.04 detik, 5 mm=0.20 detik, 10 mm=0.40 detik
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Bacalah EKG berikut dengan lengkap;
Irama : sinus / tidak sinus Frekwensi : kali / menit Aksis : normal / LAD ( bergeser ke kiri ) / RAD ( bergeser ke kanan ) / Superior Gelombang P : normal / LAE ( P mitral ) / RAE ( P Pulmonal ) Interval PR : normal / memendek / memanjang Lebar QRS : normal / melebar Morfologi QRS : normal / LVH / RVH / RBBB / LBBB / WPW Segmen ST : normal / depresi / elevasi ( ukuran dan letak ) Gelombang T : normal / negatif ( letak )
Kesan ……
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Normal Sinus Rhythm
Rhythm : RegularRate : 60 – 100P wave : Normal in configuration; precede each QRSPR : Normal ( 0. 12 – 0.20 seconds )QRS : Normal ( less than 0.12 seconds )
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AXIS
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Right Axis Deviation Left Axis Deviation
RAD
LAD
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NILAI NORMAL DEVIASI FRONTAL
Normal Axis : - 30o sd +110o
No Axis deviation : +30o sd + 90o
Abnormal Left Axis Deviation : - 30o sd -90o
Abnormal Right Axis Deviation : +110o sd + 180o
atau : +110o sd – 90o
Superior Axis : + 180o sd - 90o
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PENENTUAN SUMBU LISTRIK JANTUNG 1
Pilih 2 sandapan yang saling tegak lurus misal I dan aVF
Tentukan jumlah aljabar dari defleksi dan gambarkan vektor QRS pada sumbu X untuk L I dan pada sumbu Y untuk aVF
Kemudian tentukan resultante kedua vektor
Sudut deviasi = arc tg(7/5) = 54.46
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PENENTUAN SUMBU LISTRIK JANTUNG 2
Pilih sandapan dengan jumlah aljabar = nol (defleksi positif = negatif)
Sumbu jantung (QRS) tegak lurus pada sandapan itu.
Pada contoh aVL dengan jumlah aljabar = nol, sumbu listrik tegak lurus pada aVL, besar vektor tergantung pada jumlah aljabar vektor L I
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PENENTUAN SUMBU LISTRIK JANTUNG 3
Cara lain yang lebih tepat ialah menghitung luas area di bawah defleksi bukan hanya dari tinggi defleksi
Dari contoh :Untuk L I R= 4 mm, lebar 1
mm luas = 0.5x4x1 tertulis 4, angka 0.5 di abaikan
S =- 4 mm,lebar 2 mm luas = 0.5x4x2 = - 8
Resultante = - 4Untuk aVF resultante = - 4
Sudut = arc tg (-4/-4) = - 45 atau + 135
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L A D R A D • LVH• Inferior wall MCI• Chronic Lung Disease• Hyperkalemia• LAFB• LBBB• ASD ostium primum
• RVH• Lateral wall MCI• Chronic lung disease• Dextrocardia• Emboli paru• LPFB• ASD ostium secundum
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Dengan mengukur beda potensial dari ke enam sumbu tadi kita dapat seolah olah “memotret” jantung dari berbagai sisi frontal. Dari enam sumbu tadi kita kira kira dapat melihat keadaan jantung dari :
Sisi Lateral Kiri : aVL dan I
Sisi Inferior : II, aVF dan III
Sisi Lateral Kanan : aVR (biasanya diabaikan)
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1500Heart Rate = ————————
Σ kotak kecil
Dengan rumus ini heart rate dapat dihitung secara tepat dengan menggunakan kakulator
300Heart Rate = ————————
Σ kotak besar
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GELOMBANG P
NormalTinggi : < 0,3 mvoltLebar : < 0,12 detikSelalu positif di L IISelalu negatif di aVR
KepentinganMengetahui kelainan di Atrium
“ Gelombang P Pulmonal “
“Gelombang P Mitral”
Gambaran yang ditimbulkan oleh depolarisasi atrium
![Page 22: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/22.jpg)
Interval PRDiukur dari permulaan P s/d permulaan QRS
Normal : 0,12 - 0,20 detik
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Mengapa kita harus menghitung PR interval?
• PR interval mengukur waktu antara mulainya depolarisasi atrium sampai mulainya depolarisasi ventrikel.
• PR interval > 0.20 detik waspada adanya AV Block (1st, 2nd atau 3rd / complete heart block).
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GELOMBANG QRS
Gambaran yang ditimbulkan oleh depolarisasi ventrikel
Normal :Lebar : 0,06 - 0,12 detikTinggi : Tergantung lead
Normal gelombang QLebar : < 0,04 detikDalam : < 1/3 tinggi R
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Gelombang Komplek QRS
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Mengapa kita harus menghitung QT interval ?
QT interval mengukur waktu yang diperlukan ventrikel dalam melaksanakan systole (depolarisasi dan repolarisasi ventrikel)
QT int
QT= O.4 RR atau QTc = ────── < 0.40-0.44 √ RR
• Subarachnoid bleeding• Ischaemia / MCI• Quinidine, Procainamide• Hypokalemia• Hypocalcemia
• Digitalis dosis terapetik• Hypercalcemia
Memanjang Memendek (?)
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HIPERTROFI
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Left Ventricular Hypertrophy
• R V5/V6 + S V1/V2 > 35 mm • R V5 > 27 mm• R V6 > 18 mm• R V6 > RV5
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Left Ventricular Hypertrophy
• R aVL > 13 mm • R I > 14 mm• R I + S III > 25 mm • ( R aVF > 21 mm )
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Right Ventricular Hypertrophy
• V1 : R > S• V6 : S > R
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Right Ventricular Hypertrophy
• QRS axis > 100o
• RI < SI
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Right Atrial Enlargement (RAH)
P Normal P Pulmonal
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Left Atrial Enlargement (LAH)
P Normal P Mitral
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ISCHEMIA - INFARK
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Jika terjadi pengurangan aliran darah dalam arteri koroner maka akan terjadi iskemia myocardium yang ditandai dengan adanya “inverted T” yang simetris.
Non-Iskemik
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Jika aliran darah sampai terhenti dan berlangsung lama maka ischemia akan ber-kembang menjadi infark atau kematian jaringan yang ditandai dengan timbulnya elevasi ST segmen.
Elevasi ST segmen saja sudah menunjukkan adanya infark myocard.
![Page 38: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/38.jpg)
Jika jika telah terjadi nekrosis jaringan maka akan muncul “Q” wave yang khas yaitu Q wave dengan lebar 1 mm dan dengan dalam 1/3 QRS complex.
Q wave tanpa persyaratan ini dianggap sebagai “q” wave yang tidak berhubungan dengan proses MCI.
![Page 39: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/39.jpg)
ST depresi dan perubahan gelombang T
• ST depresi dianggap bermakna bila > 1 mm di bawah garis dasar PT di titik J• Titik J didefinisikan sebagai akhir kompleks QRS dan permulaan segmen ST
Bentuk segmen ST :
• up-sloping ( tidak spesifik )• horizontal ( lebih spesifik untuk iskemia )• down-sloping ( paling terpercaya untuk iskemia )
Perubahan gelombang T pada iskemia kurang begitu spesifik Gelombang T hiperakut kadang2 merupakan satu-satunyaperubahan EKG yang terlihat
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Anatomi Koroner dan EKG 12 sandapan
• Sandapan V1 dan V2 menghadap septal area ventrikel kiri
• Sandapan V3 dan V4 menghadap dinding anterior ventrikel kiri
• Sandapan V5 dan V6 ( ditambah I dan avL ) menghadap dinding lateral ventrikel kiri
• Sandapan II, III dan avF menghadap dinding inferior ventrikel kiri
![Page 41: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/41.jpg)
V1 – V4 anterior
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Occlusion of diagonalbranch ( arrow )
ST elevation in I and aVL
![Page 44: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/44.jpg)
ECG, large Anterior Infarction
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Proximal large RCA occlusion
ST elevation in leads II, III, aVF, V5, and V6
with precordial ST depression
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ARITMIA
![Page 48: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/48.jpg)
MEKANISME
• Gangguan automatisasi (impuls keluar sblm impuls normal)
• Triggered activity (Impuls muncul saat repolarisasi)
• Re-Entry (impuls menstimulasi jaringan yg sdh terdepolarisasi)
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• Bradikardia (bradiaritmia)– Gangguan pmbentukan impuls : SA, S3, syncope– Gangguan konduksi (Blok AV, SA)
• Takikardia (takiaritmia)– QRS
• Lebar : VT, SVT dgn BBB• Sempit
– Reguler : SVT, atrial flutter– Ireguler : AF, atrial flutter
– Atrial• AF, atrial flutter, PAC
– Ventrikel• VT, VF, PVC
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DISRITMIA ATRIAL
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Premature atrial complex
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Supraventrikel takikardi
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DISRITMIA VENTRIKEL
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Premature ventricular complex
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PVC multiform
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PVC trigemini
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Triplet PVC
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Accelerated idioventricular tachycardia
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COARSE TYPE
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MONOMORFIK
> 30s = sustained VT< 30s = non sustained VT
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Lethal arrythimias
• VT• VF• PEA (pulseless electricity activity)• asistol
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IRAMA JUNCTIONAL
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Junctional escape beats
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Takikardia junctional/ irama junctional
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GANGGUAN KONDUKSI
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First-degree AV block
Rhythm : RegularRate : Usually normalP wave : Sinus P wave present; one P wave to each QRSPR : Prolonged ( greater than 0.20 seconds )QRS : Normal
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Second -degree AV block, Mobitz I
Rhythm : IrregularRate : Usually slow but can be normalP wave : Sinus P wave present; some not followed by QRS complexesPR : Progressively lengthensQRS : Normal
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Second-degree AV block, Mobitz II
Rhythm : Regular usually; can be irreguler if conduction ratios varyRate : Usually slowP wave : Two, three, or four P waves before each QRSPR : PR interval of beat with QRS is constant; PR interval may be normal or prolongedQRS : Normal if block in His bundle; wide if block involves bundle branches
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Mobitz II
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Third-degree AV block
Rhythm : RegularRate : 40 – 60 if block in His bundle; 30 – 40 if block involves bundle branchesP wave : Sinus P wave present; bear no relationship to QRS; can be found hidden in QRS complexes and T wavesPR : Varies greatlyQRS : Normal if block in His bundle; wide if block involves bundle branches
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0.04
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Right Bundle Branch Block
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Left Bundle Branch Block
![Page 83: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/83.jpg)
LAFB/LPFB
• LAFB– LAD (without LVH)
• LPFB– RAD (without RVH)
Both no ST or T changes and QRS normal
![Page 84: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/84.jpg)
Left anterior fascicular block
![Page 85: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/85.jpg)
Left posterior fascicular block
![Page 86: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/86.jpg)
ARITMIA KONDISI LAIN
![Page 87: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/87.jpg)
![Page 88: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/88.jpg)
Wolff-Parkinson-White syndrome
![Page 89: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/89.jpg)
Wolff-Parkinson-White syndrome
![Page 90: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/90.jpg)
Torsade de pointes
![Page 91: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/91.jpg)
Sick sinus syndrome
![Page 92: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/92.jpg)
Brugada syndrome
![Page 93: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/93.jpg)
hyperkalemia
![Page 94: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/94.jpg)
hypokalemia
![Page 95: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/95.jpg)
Emboli pulmonal (S1Q3T3)
![Page 96: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/96.jpg)
Acute Anterior Myocardial Infarction
![Page 97: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/97.jpg)
Acute Anterolateral Myocardial Infarction
![Page 98: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/98.jpg)
Acute Lateral Myocardial Infarction
![Page 99: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/99.jpg)
Atrial Fibrilasi
![Page 100: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/100.jpg)
Acute Inferoposterior Myocardial Infarction
![Page 101: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/101.jpg)
Incomplete Right Bundle Branch Block
![Page 102: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/102.jpg)
Right Bundle Branch Block
![Page 103: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/103.jpg)
Second degree AV Block -Weckenbach
![Page 104: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/104.jpg)
First degree AV Block
![Page 105: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/105.jpg)
Third degree AV Block
![Page 106: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/106.jpg)
Second degree AV Block –Mobitz II
![Page 107: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/107.jpg)
HR: , P wave : normal/ mitral/pulmonal, PR interval: QRS axis: normal/LAD/RAD/ERAD
QRS duration: Twave: inverted/ flat / bifasik di: ST segmen elevasi di: , depresi di: SV5+SVI: mm.
Kesimpulan:
Diagnosis ?
![Page 108: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/108.jpg)
HR: 50/m, P wave : normal, PR interval: 0.16” QRS axis: normal, QRS duration: 0.08” Twave: inverted aVR, biphasic pada V1, Flat (-), ST segmen elevasi (-), depressi (-) SV5+SVI: 19 mm.
Kesimpulan: Sinus bradycardia
Diagnosis ?
![Page 109: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/109.jpg)
HR: QRS axis: QRS duration: P wave: PR int.:
R V5 + S V1: , ST segmen; elevasi di: depressi di: T wave: flat di, inverted di: , bifasik di:
Kesimpulan:
Diagnosis EKG ?
![Page 110: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/110.jpg)
HR:68/m, QRS axis: normal, QRS duration: 0.06” (1,5 kotak kecil), P wave: normal, PR int.: 0.16”,
R V5 + S V1: 39 mm, ST segmen; Inverted pada I, aVL, V5 dan V6.
Kesimpulan: Lateral wall ischaemia & LVH
Diagnosis EKG ?
![Page 111: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/111.jpg)
QRS rate : P wave: n/m/p PR int: axis: (n) / ab (n)
QRS duration: (n) / ab (n), Q wave (+) / (-) di:……………
ST elevasi :
ST depresi :
Diagnosis:
Diagnosis ?
![Page 112: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/112.jpg)
QRS rate : 88/m P wave: normal, PR int: 0.16 detik, axis: normal,
QRS duration: normal, Q wave (+) di aVL, V2 – V4
ST elevasi : I, aVL, V2-v6
ST depresi : II, III, aVF
Diagnosis: Acute extensive anterior MCI
![Page 113: EKG](https://reader036.fdocuments.net/reader036/viewer/2022081602/5571fab9497959916992f2ed/html5/thumbnails/113.jpg)
Hiperkalemia