Presentasi ekg rs agung

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DASAR INTERPRESTASI

EKG

DASAR INTERPRESTASI

EKGDr Fonda RP Silalahi Dr Fonda RP Silalahi

www.themegallery.com

DASAR YANG AKAN DIPELAJARIDASAR YANG AKAN DIPELAJARI

• Menilai Ritme

• Mengetahui Frekuensi

• Mengetahui Jenis Irama

• Transisi Zone

• Aksis Jantung

• Morfologi gelombang (silahkan dilihat di slide “Pengenalan EKG Dasar ”)


MENILAI RITMEMENILAI RITME

Kita lihat regularitasnya dengan menghitung

Interval R-R dan P-P

Penghitungannya kita menggunakan kertas lalu diberi titik, lalu kita lihat regularitasnya.


CARA MENILAI RITMECARA MENILAI RITME

Setelah tahu reguler/ireguler kita akan menghitung frekuensi.


MENGHITUNG FREKUENSIMENGHITUNG FREKUENSI• Metode I Menghitung Kotak Kecil

Rumusnya :

• Metode II Menghitung Kotak Besar

Rumusnya:

Frekuensi = 1500/jumlah kotak kecil

Frekuensi = 300/jumlah kotak besar

Hanya untuk yang REGULER saja


MENGHITUNG FREKUENSIMENGHITUNG FREKUENSI• Metode IIII Menghitung 6 detik EKG

Rumusnya :

Frekuensi = Jumlah komplek QRS dalam 6 detik x 10

BISA UNTUK REGULER MAUPUN IRREGULER

3 sec 3 sec

3 detik = 15 kotak besar


BELAJAR EKG TERNYATA

MENYENANGKAN, SIAP KE LANGKAH SELANJUTNYA??!


JENIS IRAMA EKGJENIS IRAMA EKG

• Irama EKG akan sangat dipengaruhi oleh SUMBER KELISTRIKAN JANTUNG. – jika berasal dari SA node Irama Sinus,– jika berasal dari Atrium Irama Atrial – jika dari penghubung (AV node ) Irama

Junctional, – jika dari ventrikel Irama Ventrikuler– jika dari pacemaker buatan Irama Pacing


IRAMA SINUSIRAMA SINUS

• Irama denyut jantung yang sumber pacu listriknya dari SA node

• Ciri gel P diikuti kompplek QRS


IRAMA ATRIALIRAMA ATRIAL

• Irama yang pemacu utamanya adalah atrium

• Mirip gel P namun berbeda dengan gelombang P yang dari sinus


IRAMA JUNCTIONALIRAMA JUNCTIONAL

• Irama yang pacuannya dari AV node• Ciri:

– Gel P inversi = Junctional letak atas– Gel P hilang = Junctional letak

tengah– Gel P retograde (setelah QRS

komplek) = Junctional letak bawah


IRAMA VENTRIKULERIRAMA VENTRIKULER

• Irama denyut jantung yang pemacu dominannya Ventrikel

• Ciri mirip komplek QRS namun tidak sempurna


IRAMA PACINGIRAMA PACING

• Irama yang berasal dari alat pacu jantung (pace maker)

• Irama pacing atrial

• Irama pacing ventrikuler


RHYTHM

Atrial Fibrillation

A-fib is the most common cardiac arrhythmia involving atria.Rate= ~150bpm, irregularly irregular, baseline irregularity, no visible p waves, QRS occur irregularly with its length usually < 0.12s


RHYTHM

Atrial Flutter

Atrial Rate=~300bpm, similar to A-fib, but have flutter waves, ECG baseline adapts ‘saw-toothed’ appearance’. Occurs with atrioventricular block (fixed degree), eg: 3 flutters to 1 QRS complex:


RHYTHM

Ventricular Fibrillation

A severely abnormal heart rhythm (arrhythmia) that can be life-threatening. Emergency- requires Basic Life SupportRate cannot be discerned, rhythm unorganized


RHYTHM

Ventricular tachycardia

fast heart rhythm, that originates in one of the ventricles- potentially life-threatening arrhythmia because it may lead to ventricular fibrillation, asystole, and sudden death.Rate=100-250bpm


RHYTHM

Supraventricular Tachycardia

SVT is any tachycardic rhythm originating above the ventricular tissue.Atrial and ventricular rate= 150-250bpmRegular rhythm, p is usually not discernable.

*Types:•Sinoatrial node reentrant tachycardia (SANRT)•Ectopic (unifocal) atrial tachycardia (EAT)•Multifocal atrial tachycardia (MAT)•A-fib or A flutter with rapid ventricular response. Without rapid ventricular response both usually not classified as SVT•AV nodal reentrant tachycardia (AVNRT)•Permanent (or persistent) junctional reciprocating tachycardia (PJRT)•AV reentrant tachycardia (AVRT)


RHYTHM

Asystole

a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow.Rate, rhythm, p and QRS are absent


BELAJAR EKG SEMAKIN

MENANTANG, SIAP KE LANGKAH SELANJUTNYA??!


AKSIS JANTUNGAKSIS JANTUNG

• Aksis adalah sudut yang dibentuk oleh vektor listrik terhadap garis horizontal.

• Analisis terhadap aksis dapat membantu menemukan lokasi kelainan yang terjadi pada jantung.– Aksis normal +90o hingga -30o

– Deviasi Kiri -30o hingga -90o

– Deviasi Kanan +90o hingga +180o

– Deviasi Kanan Ekstrem -180o hingga -90o


AKSIS JANTUNGAKSIS JANTUNG


MENILAI AKSISMENILAI AKSIS

Lead I Lead aVF Arah Aksis

+ - Deviasi kiri

+ + NORMAL

- + Deviasi kanan

- - Deviasi kanan ekstrim

(+) artinya gelombang cenderung ke atas atau panjang gel R > q + S(-) artinya gelombang cenderung ke bawah atau panjang gel R < q + S


MENILAI AKSISMENILAI AKSIS

• Bisa juga dengan diagram


Cardiac Axis Causes

Left axis deviation Normal variation in pregnancy, obesity; Ascites, abdominal distention, tumour; left anterior hemiblock, left ventricular hypertrophy, Q Wolff-Parkinson-White syndrome, Inferior MI

Right axis deviation normal finding in children and tall thin adults, chronic lung disease(COPD), left posterior hemiblock, Wolff-Parkinson-White syndrome, anterolateral MI.

North West emphysema, hyperkalaemia. lead transposition, artificial cardiac pacing, ventricular tachycardia

CARDIAC AXIS


ASAL GELOMBANG EKGASAL GELOMBANG EKG

Untuk lebih jelasnya bisa dilihat di flash dunia jantung di Elisa Blok 4.2


KERTAS EKGKERTAS EKG

1 kotak kecil horizontal = 0.04 detik1 kotak kecil vertikal = 0.1 mV1 kotak besar terdiri atas • 5 kotak kecil horizontal• 5 kotak kecil vertikal

Hal ini penting untuk anda ingat karena dari sini kita bisa mengetahui apakah ada kelainan atau tidak pada sebuah hasil EKG.


GELOMBANG EKG Normal GELOMBANG EKG Normal

Pada gambar disamping dapat kita lihat adanya gelombang (P, Q, R, S, T dan U), komplek (QRS), interval (PR, QT) serta sebuah segmen (ST segmen)


Gelombang PGelombang P

• Gelombang yang tampak pertama kali• Bentuk normalnya melengkung kecil ke atas• Menunjukkan depolarisasi atrium• Kelainan gelombang P menunjukkan adanya kelainan di atrium.• Gelombang P normalnya adalah sebagai berikut:

• Positif (kecuali di aVR & V1 bisa negatif)• Letak di depan QRS• Tinggi < 2,5 kotak kecil• Lebar < 3 kotak kecil

Yang ditebal harus kamu hafal


P -WAVE

P pulmonaleTall peaked P wave. Generally due to enlarged right atrium- commonly associated with congenital heart disease, tricuspid valve disease, pulmonary hypertension and diffuse lung disease.

Biphasic P waveIts terminal negative deflection more than 40 ms wide and more than 1 mm deep is an ECG sign of left atrial enlargement.

P mitraleWide P wave, often bifid, may be due to mitral stenosis or left atrial enlargement.


PR IntervalPR Interval

•Jarak antara gelombang P dan permulaan komplek QRS• Untuk mengukur perjalanan depolarisasi dari atrium ke ventrikel• Normalnya

Lebar 3-5 kotak kecil


PR-INTERVAL

First degree heart block

P wave precedes QRS complex but P-R intervals prolong (>5 small squares) and remain constant from beat to beat


Second degree heart block

1. Mobitz Type I or Wenckenbach

Runs in cycle, first P-R interval is often normal. With successive beat, P-R interval lengthens until there will be a P wave with no following QRS complex. The block is at AV node, often transient, maybe asymptomatic

PR-INTERVAL


Second degree heart block

2. Mobitz Type 2

P-R interval is constant, duration is normal/prolonged. Periodically, no conduction between atria and ventricles- producing a p wave with no associated QRS complex. (blocked p wave). The block is most often below AV node, at bundle of His or BB,May progress to third degree heart block

PR-INTERVAL


Third degree heart block (Complete heart block)

No relationship between P waves and QRS complexesAn accessory pacemaker in the lower chambers will typically activate the ventricles- escape rhythm.Atrial rate= 60-100bpm. Ventricular rate based on site of escape pacemaker. Atrial and ventricular rhythm both are regular.

PR-INTERVAL


QRS KomplekQRS Komplek• Tiga defleksi yang yang mengikuti gelombang P• Mengindikasikan depolarisasi (dan kontraksi) ventrikel• Gel Q = defleksi negatif pertama setelah P. Normalnya lebar < 1 kotak kecil, dalamnya < 2 kotak kecil.• Gel R = defleksi positif pertama setelah P. Normalnya tinggi < 27 kotak kecil, tidak bertakik • Gel S = defleksi negatif pertama setelah R. Normalnya tidak ditemukan di V6, dalamnya < 7 kotak besar di V1-V2• Normal QRS

Lebar 1 ½ - 3 kotak kecil


QRS COMPLEX

Left Bundle Branch Block (LBBB)indirect activation causes left ventricle contracts later than the right ventricle.

Right bundle branch block (RBBB)indirect activation causes right ventricle contracts later than the left ventricle

QS or rS complex in V1 - W-shapedRsR' wave in V6- M-shaped

Terminal R wave (rSR’) in V1 - M-shapedSlurred S wave in V6 - W-shaped

Mnemonic: WILLIAM Mnemonic: MARROW


ST SegmentST Segment

• Jarak antara gelombang S dan permulaan gelombang T•Menunjukkan repolarisasi ventrikel• Normalnya

Terletak pada garis iso elektris


ST-SEGMENT

Look at ST changes, Q wave in all leads. Grouping the leads into anatomical location, we have this:

Ischaemic change can be attributed to different coronary arteries supplying the area.

Location of MI

Lead with ST changes

Affected coronary artery

Anterior V1, V2, V3, V4

LAD

Septum V1, V2 LAD

left lateral I, aVL, V5, V6

Left circumflex

inferior II, III, aVF RCA

Right atrium aVR, V1 RCA

*Posterior Posterior chest leads

RCA

*Right ventricle

Right sided leads

RCA

*To help identify MI, right sided and posterior leads can be applied

Localizing MI

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

(LAD)

(RCA)


Criteria:ST elevation in > 2 chest leads > 2mm elevationST elevation in > 2 limb leads > 1mm elevationQ wave > 0.04s (1 small square).

*Be careful of LBBBThe diagnosis of acute myocardial infarction should be made circumspectively in the presence of pre-existing LBBB. On the other hand, the appearance of new LBBB should be regarded as sign of acute MI until proven otherwise

DIAGNOSING MYOCARDIAL INFARCTION (STEMI)

Definition of a pathologic Q waveAny Q-wave in leads V2–V3 ≥ 0.02 s or QS complex in leads V2 and V3Q-wave ≥ 0.03 s and > 0.1 mV deep or QS complex in leads I, II, aVL, aVF, or V4–V6 in any two

leads of a contiguous lead grouping (I, aVL,V6; V4–V6; II, III, and aVF)R-wave ≥ 0.04 s in V1–V2 and R/S ≥ 1 with a concordant positive T-wave in the absence of a

conduction defect.A little bit troublesome to remember? I usually take pathological Q wave as >1 small square deep

Pathologic Q waves are a sign of previous myocardial infarction.


ST SEGMENT

ST-ELEVATION MI (STEMI)

0 HOUR

1-24H

Day 1-2

Days later

Weeks later

Pronounced T Wave initiallyST elevation (convex type)

Depressed R Wave, and Pronounced T Wave. Pathological Q waves may appear within hours or may take greater than 24 hr.- indicating full-thickness MI. Q wave is pathological if it is wider than 40 ms or deeper than a third of the height of the entire QRS complex

Exaggeration of T Wave continues for 24h.

T Wave inverts as the ST elevation begins to resolve. Persistent ST elevation is rare except in the presence of a ventricular aneurysm.

ECG returns to normal T wave, but retains pronounced Q wave. An old infarct may look like this


I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

Check again!

>2mm

Yup, It’s acute anterolateral MI!

Let’s see this

ST elevation in > 2 chest leads > 2mm

Pathological Q wave

Q wave > 0.04s (1 small square).

ST SEGMENT


I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

Check again!

Inferior MI!

How about this one?

ST SEGMENT


NSTEMI is also known as subendocardial or non Q-wave MI.In a pt with Acute Coronary Syndrome (ACS) in which the ECG does not show ST elevation, NSTEMI (subendocardial MI) is suspected if

ST SEGMENT

NON ST-ELEVATION MI (NSTEMI)

•ST Depression (A)•T wave inversion with or without ST depression (B)•Q wave and ST elevation will never happen

To confirm a NSTEMI, do Troponin test:•If positive - NSTEMI•If negative – unstable angina pectoris


A ST depression is more suggestive of myocardial ischaemia than infarction

1mm ST-segment depressionSymmetrical, tall T waveLong QT- interval

MYOCARDIAL ISCHEMIA

ST SEGMENT


QT IntervalQT Interval

• Permulaan QRS hingga akhir T• Menunjukkan aktivitas ventrikel total• Normalnya

Lebar < ½ interval R-R atauLebar < 2 kotak besar


Gelombang TGelombang T

• Gelombang lengkungan ke atas yang mengikuti QRS• Menunjukkan repolarisasi ventrikel • Normalnya

Postif (terutama bersama R tinggi) atau

Inversi di III, aVR, V1


Narrow and tall peaked T wave (A) is an early signPR interval becomes longerP wave loses its amplitude and may disappearQRS complex widens (B)When hyperkalemia is very severe, the widened QRS complexes merge with their corresponding T waves and the resultant ECG looks like a series of sine waves (C).If untreated, the heart arrests in asystole

T wave becomes flattened together with appearance of a prominent U wave.The ST segment may become depressed and the T wave inverted.these additional changes are not related to the degree of hypokalemia.

HYPERKALAEMIA

HYPOKALAEMIA


SUMMARYSUMMARYUnsur EKG Tinggi/Dalam Lebar

Gelombang P < 2,5 kotak kecil < 3 kotak kecil

PR Interval - - - 3 – 5 kotak kecil

Gelombang Q < 2 kotak kecil < 1 kotak kecil

Gelombang R < 27 kotak kecil - - - -

Gelombang S < 7 kotak besar di V1-V2 - - - -

QRS Komplek - - - 1 ½ - 3 kotak kecil

QT Interval - - - < ½ interval R- R< 2 kotak besar

TERNYATA MUDAH DAN MENYENANGKAN YA BELAJAR EKG

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Presentasi ekg rs agung

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