Download - Kuliah Ekg Unswagati
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Irwan M. Loebis, dr., SpJP
ELECTROCARDIOGRAPHY
UNSWAGATI, CIREBONUNSWAGATI, CIREBON
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Lecture outlinePart oneInformation provided by ECGCardiac conduction system: anatomy and
physiology (Normal) ECG interpretationPart two Abnormal ECG
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ECG is…?Printout as a result of a particular
electrical function of the heart
The standard 12-lead electrocardiogram is a representation of the heart's electrical activity recorded from electrodes on the body surface
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Information provided by Information provided by ECG: what do you think?ECG: what do you think?
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Cardiac conduction system
SA nodeAV nodeBundle His
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Impulse Transmission
SA Node Internodal branch AV Node Hiss Bundle Purkinje Fiber Contraction
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the sequentialactivation (depolarization) of the right
and left atria
right and left ventricular depolarization (normally the ventricles are activated simultaneously)
ventricular repolarization
One ‘complex’ of ECG waveform
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Leads positionLeads position
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Limb leadsLimb leads
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Einthoven Triangle
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Chest lead
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Chest leadChest lead
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Chest leadChest lead
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ECG interpretation…?1. Calibration2. Rate and rhythm3. QRS axis4. P morphology5. PR interval6. QRS duration7. QRS morphology8. ST segment morphology9. T morphology10. U morphology11. Others: LVH, LV strain, BBB, QT interval12. Conclusion: normal/abnormal
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Calibration1 mV = 1 cmImportant in
assessing tall waves in hypertrophic state
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Paper speed and normal value
One small box: 0.04 sOne small box: 0.04 sOne large box: 0.2 sOne large box: 0.2 sPR Interval: 0,12’’ - PR Interval: 0,12’’ - 0,20’’0,20’’QRS duration: 0,04’’ - QRS duration: 0,04’’ - 0,12’’0,12’’
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Rate calculation Method:
300 divided by number of large boxes between R-R
1500 divided by number of small boxes between R-R,
Number of QRS complexes in 6 seconds times 10.
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Rate calculationpaper 25 mm/s
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Sinus Rhythm Sinus Rhythm
Rhythm: RegularRate: 60 – 100P wave: Normal in configuration; precede each QRSPR: Normal (0. 12 – 0.20 s)QRS: Normal (<0.12 s)
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QRS Axis (N: - 30 s/d + 110)
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P wave Wave of atrial depolarization Normal characteristic:1. Smooth and rounded2. ≤ 3 mm tall3. Upright in leads I, II avF
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PR intervalIncluding P wave until the beginning of QRS
complexNormal duration is 0.12-0.2 seconds
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QRS complex Wave of ventricular depolarization 5-20 mm tall Duration 0.06-0.10 seconds
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QRS morphology qRs Rs R rS
QR Q/QS RsR’ rSr’
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ST segmentBegins at J pointBetween ventricular depolarization and
ventricular repolarizationGenerally isoelectric
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T wave Ventricular repolarization, followed by
ventricular relaxation Positive in lead : I, II, V3-V6 Negative in lead avR
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Interpret this ECG..
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And this..
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Abnormal ECG Myocardial ischemia/infarct Hyperthrophy Hyperkalemia Arrhythmia
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ACUTE CORONARY SYNDROMEACUTE CORONARY SYNDROME
No ST ElevationNo ST Elevation ST ElevationST Elevation
Unstable Angina
NSTEMI
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Acute myocardial infarction
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STEMI Non STEMI
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Mid LAD occlusion after the first septal perforator (arrow) ECG : large anterior MI
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Occlusion of diagonalbranch ( arrow )
ST elevation in I and aVL
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ECG demonstrates 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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Small inferior distal RCA occlusion
ECG changes in leads II, III, and aVF
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Acute inferoposterior MI
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Questions…??
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• Peaking T• Shortening QT interval
• Widening P wave, QRS complex• Prolongation PR interval
HIPERKALEMIA
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PPM
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How to identify arrhythmias ?
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QRS complex Regular / irregular ?
QRS complexNormal-looking QRS complex?
Wide / narrow ?
P wave ?
Relationship between P and QRS ?
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NORMAL SINUS RHYTHM
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PSVT :-due to re-entry mechanism-narrow QRS complex-regular-retrograde atrial depolarization-P wave ?
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PSVT
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Atrial Fibrillation :
-from multiple area of re-entry within atria-or from multiple ectopic foci-irregular, narrow QRS complex-very rapid atrial electrical activity (400-700 x/min).-no uniform atrial depolarization
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Atrial Flutter :
-The result of a re-entry circuit within the atria-Irregular / regular QRS rate-Narrow QRS complex-Rapid P waves (300x/min), “sawtooth”
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Junctional rhythm:-AV junction can function as a pace maker (40-60 x/min).-due to the failure of sinus node to initiate time impulse or conduction problem.-normal-looking QRS.-retrograde P wave.-P wave may preceede, coincide with, or follow the QRS
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VES
SR
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SR SR SR SRSR SR
VES VES
Sinus rhythm with Multifocal VES
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Sinus rhythm with VES couplet
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Sinus Rhythm with VES, R on T
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Ventricular Tachycardia
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Torsade de Pointes
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Ventricular Fibrillation
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Prolonged PR interval
1st degree AV block
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Missing QRS Missing QRS
2nd degree AV block, type 1
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2nd degree AV block, type 2
Missing QRS
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P P P P P P P
QRS QRS QRS
Total AV Block / 3rd degree AV block
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