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P. Pujowaskito
Circulation System, Block General Ahmad Yani University
Electrocardiography
Electrical phenomena, science Simple, cheap, usefull but limited Almost all arrhythmias Infarction or ischaemia LVH Electrolyte imbalance
The 12 leads allow tracing of electric vector in all three planes of interest Not all the leads are independent, but are recorded for redundant information
ECG Information
ECG recording
Electrical phenomena
Electrical phenomena
Recording
Waves
T
P U? Q S
Katrina Kardos, MD PGY-3 Albany Medical Center
Nomenclature
Cardiac Cycle
ELEKTROKARDIOGRAM N a m a : ......... Kalibrasi : voltase...mV, speedmm/detik Heart rate : .............../minute, teratur tidak teratur rhythm : .............................. Gelombang P Kontour : normal tidak normal, Alasan:....................................................... Konfigurasi: normal tidak normal, Alasan: .................................................. Durasi : detik normal tidak normal Amplitudo: mV normal tidak normal PR interval detik normal tidak normal Konfigurasi gelombang Q: normal tidak normal, Alasan:....................................... Kompleks QRS: Durasi : normal tidak normal, Alasan:........................................................... Axis : .....derajat Normal LAD RAD Superior Konfigurasi: normal tidak normal, Alasan:..................................................... Segmen ST : normal tidak normal, Alasan:.................................................... Gelombang T : normal tidak normal, Alasan:.................................................... Gelombang U : normal tidak normal, Alasan:................................................... QTc : ................................detik normal tidak normal Index hipertrofi ventrikel: LVH: Score Romhilt-estes: ............................................................ ................................. normal tidak normal RVH: R/S ratio di V1: ............................. normal tidak normal Kesimpulan:
ECG paper
Small box
: 1 x 1 mm : 0.1 mV x 0.04 s
Big box
: 25 x 25 mm : 2.5 mV x 1 s
S1
MENGHITUNG LAJU JANTUNG : A. Jarak R R : -1 kotak sedang -2 kotak sedang -3 kotak sedang -4 kotak sedang -5kotak sedang -6 kotak sedang = 300 x / minute = 150 x / minute = 100 x / minute = 75 x / minute = 60 x / minute = 50 x / minute
B. Hitung jumlah R- R dalam 6 kotak besar = 6 detik Jumlah R x 10 = heart rate / minute
C. 1500 / jarak R-R ( dlm mm ) = heart rate / minute
75
Start
300 150 100
75
60
50
43
38
Pace maker
ISO ELECTRICE
Rhythm
Pace maker
Junctional Rhythm
ISO ELECTRICE
Normal Sinus Rhythm Rate: 60-100 b/min Rhythm: regular P waves: upright in leads I, II, aVF PR interval: < .20 s QRS: < .10 s
P wave
Contour : -normal : smooth, monophasic (except V1) -abnormal: monophasic > 0.25mV or P biphasic (notched) Configuration : -normal : positive at I,II, aVF, V3-V6, negative at aVR -abnormal: negative at II,III or aVF, may be an inversal leads or junctional rhytm Duration (horisontal axis): 0.08-010 second (2-2.5 small box) Amplitudo (vertikal axis): 0.25 mV or 2.5mm or 2.5 small box PR interval: 0.12-0.20 second (3-5 small box), -short PR interval: may be preexitacion syndrome -long PR interval: may be AV blokade
Direction of the normal frontal and horizontal plane P vectors with resulting P wave in the 12-lead ECG
P wave
Q wave
Configuration : -normal : small q -abnormal : patologic Q, wide ( 0.04s) and deep ( 4mm or 25% R) Lead of abnormal Q: infarction area -lead V1-V4 : anteroseptal -lead V1-V6, I and aVL : anterior extensive -lead V4-V6, I and aVL : anterolateral -lead V3-V5 : anterior -lead II,III and aVF : inferior -lead I and aVL : high lateral -Mirror image of V1-V3 to horisontal line: true posterior
The significance of Q for old infarction if more than 1 lead
QRS complex
Capital letter for deflection > 5mm (Q,R,S), Small letter for deflection < 5mm (q,r,s). QRS complex could be variable Duration: normal: < 0.12s (narrow QRS) abnormal: > 0.12s (wide QRS/bizare)
normal: -30 to +110 LAD (left axis deviation): -30 to -90 RAD (right axis deviation): +110 to -180 Superior (extreme RAD): +180 to -90
ST Segment
Depol.
Repol.
Normal: Isoelektris Abnormal: - Elevation: > 1mm - Depression: horizontal, downsloping, upsloping > 1mm was significant; deeper: more specific
Lead of ST depression: ischaemic area -lead V1-V4 : anteroseptal -lead V1-V6, I and aVL : anterior extensive -lead V4-V6, I and aVL : anterolateral -lead V3-V5 : anterior -lead II,III and aVF : inferior -lead I and aVL : high lateral
T Wave
Normal adult: positive T wave in all lead except aVR and V1. Abnormal: - Tall T/ hyperacute T: Injury/ Acute Infarction - Negative T (vector of T was on opposite direction than QRS vector/ T inversi): myocardial ischaemia, more specific if arrow head T inversion. Area of injury or ischaemic
Bazetts formula
QTc =
QT R-R
U Wave
Normal: unpresent U (interferrence with T wave). wave
LEFT ATRIAL HYPERTROPHY Wide P Interval 0.12s at lead II and notched (two peak) P wave with negative terminal deflection at V1, duration 0.04s and deeper 1 mm P wave of left atrial abnormality was called P Mitral
3 3 2 1
1. Reversal R/S ratio, at V1 > 1, at V6 < 1 2. QRS complex frontal axis deviate to the right (RAD) Aux criteria: ventricular activation time at V1 0.035s, ST depression and T inversion at V1, S at I, II, and III
Diagnosis 1. Basic rhythm: sinus, junctional, Ventricular, Atrial Fibrillation (AF), Ventricular Fibrillation (VF), Supra-Ventricular Tachycardia (SVT), Ventricular Tachycardia (VT) 2. Heart rate 3. QRS complex axis 4. Abnormality Example: sinus rhythm 80 x/minute, normal axis (normal sinus rhythm) sinus rhythm 80 x/minute, LAD, LVH sinus rhythm 75 x/minute, RAD, RA abnormality, RVH sinus bradycardia 50x/minute, normal axis, Inferior LV wall ischaemic sinus tachycardia 110 x/minute, normal axis, acute myocardial infarction on anterior LV wall
Refference
1. Mirvis DM, Goldberger AL. Electrocardiography. In: Braunwalds Heart Disease, A Textbook of Cardiovascular Medicine. Eighth Edition. Philadelphia: Saunders Elsevier; 2008. p. 155-183. 2. Ferry DR. ECG In 10 Days. Second Edition. Singapore: Mc Graw Hill; 2007. p. 37-93 and 151-193. 3. The Alan E. Lindsay. ECG Learning Center in Cyberspace. http://library.med.utah.edu/kw/ecg/image_index 4. Pratanu S. Buku Pedoman Kursus Elektrokardiografi. Surabaya; PT. Karya Pembina Swajaya; 2000. h. 19-36.