12a.EKG Anatomi.ppt

7/27/2019 12a.EKG Anatomi.ppt

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Electrocardiography

P. Pujowaskito

Circulation System, BlockGeneral Ahmad Yani University


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Electrocardiography

Electrical phenomena, science

Simple, cheap, usefull but limited

Almost all arrhythmias

Infarction or ischaemia

LVH Electrolyte imbalance


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Bipolar standard leads I, II and III


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The unipolarlimb leads and

their axes


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Locations of unipolarprecordial leads


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The precordial leads and their axes


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ECG Information The 12 leads allow

tracing of electric

vector in all three

planes of interest Not all the leads are

independent, but are

recorded forredundant

information
http://localhost/var/www/ECGCourse/ecg/15/15x/1509x.htm


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Electrocardiographic views of the heart


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Regions of the Myocardium

PED 596

Inferior

II, III, aVF

Lateral

I, AVL,

V5-V6

Anterior /

Septal

V1-V4


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ECG recording


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Electrical phenomena


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Electrical phenomena


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Waves

P

Q

R

S

T

Katrina Kardos, MD

PGY-3

Albany Medical Center

Recording

U ?


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Nomenclature


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Cardiac Cycle


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Garis Isoelektris/ baseline

Upward/Positive deflection

Downward/Negative deflection

Normal ECG pattern


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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:


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ECG paper

Small box : 1 x 1 mm : 0.1 mV x 0.04 s

Moderate box: 5 x 5 mm : 0.5 mV x 0.2 s

Big box : 25 x 25 mm : 2.5 mV x 1 s


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Paper speed and voltage calibration in ECG recording

S1

S


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A. Jarak RR :

-1 kotak sedang = 300 x / minute



-4 kotak sedang = 75 x / minute-5kotak sedang = 60 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

MENGHITUNG LAJU JANTUNG :


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Rapid Estimation of Heart rate

R R R R

300Start

Heavy black line

150 10075 Start

Heavy black line

300 150100 75 60 50 4338

Mnemonic

Rh h


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Durasi

Amplitudo:voltase

ISO ELECTRICE

RhythmSinus Rhythm

Pace maker

Rh th


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Durasi

Amplitudo:voltase

ISO ELECTRICE

Rhythm

JunctionalRhythm

Pace maker


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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


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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 rhytmDuration (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


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Direction of thenormal frontal andhorizontal plane P

vectors withresulting P wave in

the 12-lead ECG


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P wave


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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


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QRS complex Capital letter for deflection > 5mm

(Q,R,S), Small letter for deflection 0.12s (wide QRS/bizare)


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QRS complex configuration


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Genesis of leftventricular epicardial

complex


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Genesis of rightventricular epicardial

complex


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Genesis oftransitional zone

ventricular epicardialcomplex


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Genesis of right

ventricularcavity complex


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Electric Axis of the Heart This axis changes during cardiac cycle as shown earlier

generally lies between +30 and -110 in the frontal planeand +30 and -30 in the transverse plane

Clinically, it is generally taken where the QRS complex

has the largest positive deflection Note: Often use aVR Deviation to R: increased activity in R vent. obstruction

in lung, pulmonary emboli, some heart disease

Deviation to L: increased activity in L vent.hypertension, aortic stenosis, ischemic heart disease


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QRS frontal axis

f l


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QRS frontal axis

normal: -30 to +110 LAD (left axis deviation): -30 to -90 RAD (right axis deviation): +110 to -180 Superior (extreme RAD):+180 to -90


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Determination of

axis deviation


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QRS axis: look at the net deflection in I and aVF


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QRS frontal axis


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Horizontal plane electrocardiographic patterns(QRS horisontal axis)


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QRS horisontal axis


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QRS horisontal axis


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QRS horisontal axis

ST S


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Depol. Repol. Restoration of

ionic balance

ST Segment

Normal: IsoelektrisAbnormal:

- Elevation: > 1mm- Depression: horizontal,

downsloping,upsloping

> 1mm was significant;deeper: more specific

ST S m nt d pr ssi n : Isch mic


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ST Segment depression : Ischaemic area

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


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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 directionthan QRS vector/ T inversi): myocardial ischaemia,more specific if arrow head T inversion.

Area of injury or ischaemic


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Nomogram forrate correction of

Q-T interval

Bazetts formula

QT

R-RQTc =


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U Wave

Normal: unpresent U wave(interferrence with T wave).

Abnormal: prominent U wave,particularly in V2 and V3 (suspect

hypokalemia)


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RIGHT ATRIAL HYPERTROPHY

P prominent: tall 2.5 mm andspike (interval 0.11 detik) atlead II, III dan aVF

Initial deflection of P wave atV1 1.5 mm

COPD or cor pulmonale, so we callP Pulmonal


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LEFT ATRIAL HYPERTROPHY

Wide P Interval 0.12s atlead 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 abnormalitywas called P Mitral

LVH index: Romhilt-Estes score


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LEFT VENTRICULAR HYPERTROPHY(LVH) criteria Score1. LV by voltage: 3

R or S 20 mm at extremities lead, or

S at RV complex (V1-V2) 25 mm, orR at LV complex (V5-V6) 25 mm, orS at V1-V2 plus R at V5-V6 35 mm

2. ST Depression and T inversion at 3LV complex V5-V6 (strainpattern)

3. Left Atrial Abnormality (P mitral) 34. QRS complex frontal axis > -15 (LAD) 25. Prolong interval of QRS complex at V5-V6, 0.09s 1

or ventricular activation time 0.04s

If score > 5 : definitive LVHIf score =4 : porobable LVH

LVH index: Romhilt Estes score


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RIGHT VENTRICULAR HYPERTROPHY(RVH):1. Reversal R/S ratio, at V1 > 1, at V6 < 12. 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


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Ischaemia: mild and reversible, ST T changesInjury: moderate, but reversibleNecrosis/ myocardial Infarction: permanent, patologic Q

Acute Coronary Syndrome



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ST Elevation Myocardial Infarction (STEMI)


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Diagnosis


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Diagnosis

1. Basic rhythm: sinus, junctional, Ventricular, Atrial Fibrillation(AF), Ventricular Fibrillation (VF), Supra-Ventricular Tachycardia

(SVT), Ventricular Tachycardia (VT)2. Heart rate3. QRS complex axis4. 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 wallischaemic

sinus tachycardia 110 x/minute, normal axis, acutemyocardial infarction on anterior LV wall


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Refference

1. Mirvis DM, Goldberger AL. Electrocardiography. In:Braunwalds Heart Disease, A Textbook of CardiovascularMedicine. 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_index4. Pratanu S. Buku Pedoman Kursus Elektrokardiografi.

Surabaya; PT. Karya Pembina Swajaya; 2000. h. 19-36.

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12a.EKG Anatomi.ppt