BASIC MEDICINE

Hawani Sasmaya Prameswari

Minggu, 13 Oktober 2019

Harris Hotel Festival Citylink Bandung
INTRODUCTION
 What is an Electrocardiogram?

An ECG is the recording (“gram”) of the electrical activity

(“electro”) of the cells of the heart (“cardio”) that
reaches the body surface

Initiates the heart muscle to contract, to

pump blood to the tissues
 What does an ECG actually measure?

An ECG records voltage on its vertical axis

against time on its horizontal axis

• Measurement along the vertical axis indicates “summation” of the

electrical activation of all of the cardiac cells

• Measurement along the horizontal axis indicates heart rate,

regularity, and the time intervals required for electrical activity to
move from one part of the heart to another
ECG - Measure(s):
• Rate and regularity of heartbeats
• Size and position of the chambers
• Presence of any damage (ie, infarct) to the heart
• Effects of drugs or devices used to regulate the heart
• Systemic condition that gives effect to the heart
 What medical problems can be
diagnosed with an ECG?

• Enlargement of cardiac chambers

• Hypertrophy of cardiac muscle

• Cardiac arrhythmias

• Insufficient coronary blood flow

• Death of heart muscle and its location

• Electrolyte abnormality
 Resting cells
+ + + + + + + +
– – – – – – – – – – – –
+ + + + + + + +
Depolarizing cell

+ + – – – + + + +
– – – + + + – – – – – –
+ + – – – + + + +

Depolarized cells
– – – – – – – – – – – –
+ + + + + + + + + + + +
– – – – – – – – – – – –
 Depolarized cells

– – – – – – – – – – – –
+ + + + + + + + + + + +
– – – – – – – – – – – –
Repolarizing cell

– – – + + + – – – – – –
+ + + – – – + + + + + +
– – – + + – – – – – –

Repolarized cells
+ + + + + + + +
– – – – – – – – – – – –
+ + + + + + + +
 Terms describing cardiac cycle

Systole Diastole
Electrical Activation Recovery

Excitation Recovery

Depolarization Repolarization

Mechanical Shortening Lengthening

Contraction Relaxation

Emptying Filling
The Normal Conduction System
Sino-atrial node
(SA node)

13
 Atrio-ventricular node
(AV node)

Sino-atrial node
(SA node) His bundle

Left bundle branch

Right bundle branch

Purkinje
14
 LA
RA (HB)
(SAN) V
V (BB)
(AVN)
(BB)

R
HB
SAN AVN BB T
P

RA Q S
LA
15
V
ECG Terminology

 P wave : activation of the

atria
 PR interval: duration of AV
conduction
 QRS complex: activation of
right and left ventricular
 QRS duration: duration of
ventricular muscle
depolarization
 PP interval: duration of
atrial cycle (an indicator or
atrial rate)
 RR interval: duration of
ventricular cardiac cycle (an
indicator of ventricular rate
 QT interval: duration of
ventricular depolarization
and repolarization
 Paper speed

• 25 mm/second

• 50 mm/second
Normal ECG
• P wave
• Width < 0.12 s
• Height < 0.3 milliVolt
• Always positive in lead II, negative in aVR
• PR interval
• From the start of P wave to the start of
QRS
• Normal duration 0.12 – 0.20 s
• QRS complex
• Width 0.06 – 0.12 s (~ 0.10 s)
• Length varies among leads
• Q  first negative deflection
• R  first positive deflection
• S  negative deflection after R
• ST segment
• From the end of S to the start of T
• Normal : iso-electrical
• T wave
• Positive in lead I, II, V3 – V6, biphasic in
V1,V2, and negative in aVR
Normal ECG
 Langkah membaca EKG

IDENTITAS
WAKTU
Kalibrasi

Rate
Rhythm
Axis
P wave morphology
Interpretasi Dasar
EKG PR interval
QRS complex morphology
ST segment morphology
T wave morphology
U wave morphology
QTc interval
Determining the Heart Rate
• Rule of 300
• 300/[number of large boxes between two R waves].
• only works for regular rhythms !!

300/7.5 large boxes = rate 40

 Six second methods (30 boxes)

 Count the number of R-R intervals in six seconds and multiply by
10
 Useful for irregular rhythm  average rate

There are 8 R-R intervals

within 30 boxes. Multiply 8 x
10 = Rate 80
Determining the Rhythm
• Source of depolarization
• Sino-atrial (SA) node: sinus rhythm
• Depending on rate can be sinus bradicardi or sinus tachycardia
• Non-sinus: atrial/ventricular rhythm
Normal ECG
Axis (QRS axis)

Defleksi positif Defleksi negatif

Normal axis?
P morphology
• Indicate wave of atrial depolarization
• Normal characteristic:
1. Smooth and rounded
2. Upright in leads I, II, aVF, aVL
3. Upright or downward in lead III
4. Biphasic in right precordial lead (V1,V2)
5. P wave duration: 120 milliseconds (measured in the widest P wave)
6. Amplitude in limb lead: < 0.25 mV and terminal negative deflection in V1 or
V2 < 0.1 mV in depth
P morphology
PR interval

• Including P wave until the beginning of QRS complex

• Normal duration is 0.12-0.2 seconds
PR interval
QRS duration

• Wave of ventricular depolarization

• 5-20 mm tall
• Duration 0.06-0.10/0.12 seconds
• Low voltage criteria?
Lead II (normal QRS?)
QRS morphology

qRs Rs R rS

QR Q/QS rSr’
RsR’
Q wave
• Any pathological Q wave or not
• >1/3 of QRS complex

QR Q/QS
R wave progression (determine in precordial lead)
ST segment
• Begins at J point
• Between ventricular depolarization and ventricular repolarization
• Generally isoelectric
 QT interval

• Time from ventricle

depolarization to
repolarization

• Corrected for heart rate

• QT/square root of R-R (in

sec)
T wave

• Ventricular repolarization
• Positive in lead : I, II, V3-V6
• Negative in lead avR
THANK YOU