Elektrokardiografi

P wave
PR Interval QT interval < on ½ RR interval
QT is rate dependent. So QTc
QRS complex
ST segment
T Wave
QT Interval
RR Interval

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Normal Impulse Conduction
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

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Impulse Conduction & the ECG
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

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The “PQRST”
• P wave - Atrial
depolarization

• QRS - Ventricular
depolarization
• T wave - Ventricular
repolarization
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Identify the ECG Complex
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4
5
1
8
2

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 Pacemakers of the Heart
• SA Node - Dominant pacemaker with an
intrinsic rate of 60 - 100 beats/minute.

• AV Node - Back-up pacemaker with an

intrinsic rate of 40 - 60 beats/minute.

• Ventricular cells - Back-up pacemaker

with an intrinsic rate of 20 - 45 bpm.

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 The ECG Paper
• Horizontally
– One small box - 0.04 s
– One large box - 0.20 s
• Vertically
– One large box - 0.5 mV

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Time Intervals

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Recording of ECG

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 Standard 12 Leads
Limb and Chest Leads
• Standard ECG is recorded in 12
leads
• Six Limb leads – LI, LII, LIII, aVR,
aVL, aVF
• Six Chest Leads – V1 V2 V3 V4 V5
and V6

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ECG Chest Leads

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 ECG - Chest Leads
• Precordial (chest) Lead Position
• V1 Fourth ICS, right sternal border
• V2 Fourth ICS, left sternal border
• V3 Equidistant between V2 and V4
• V4 Fifth ICS, left mid clavicular Line
• V5 Fifth ICS left Anterior axillary line
• V6 Fifth ICS left mid axillary line

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 The 12 Camera Photography
• There six cameras photographing frontal plane
• Lead I and aVL are horizontal left sided cameras
• Lead II, aVF, Lead III are vertical inferior cameras
• aVR is horizontal Rt. side camera (cavitary lead)
• V1 – V6 six cameras positioned in transverse plane
• Lateral Leads – LI, aVL, V5 and V6
• Inferior Leads – LII, aVF, and LIII leads
• Septal Leads – V1 and V2;
• Anterior – V3 and V4
• Anterolateral – V3, V4, V5, V6 , LI and aVL

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 The 12 Camera Photography
• There SIX cameras photographing in the
transverse or Antero-Posterior plane
• V1 and V2 record events of septum
• V3 and V4 record events of the Anterior wall
• V5 and V6 record events of left lateral wall
• To record right side events V2 R to V6 R are
needed – In dextrocardia, in RV infarction

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Normal ECG

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KUCING ????
 Normal ECG
• Standardization – 10 mm (2 boxes) = 1 mV
• Double and half standardization if required
• Sinus Rhythm – Each P followed by QRS, R-R fixed
• Always examine P waves in LII, V1, LI
• QRS positive in LI, LII, LIII, aVF and aVL. - Neg aVR
• QRS is < 0.08 narrow, Q in V5, V6 < 0.04, < 3 mm
• R wave progression from V1 to V6, QT interval < 0.4
• Axis normal – LI, LIII, and aVF all will be positive
• ST Isoelectric, T ↑, Normal T ↓ in aVR, V1 and V2

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 AC Interference

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 Muscle Tremor

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 Wandering base line

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SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
To summarize:
1. Calculate RATE
2. Determine RHYTHM
3. Determine QRS AXIS
4. Calculate INTERVALS
5. Assess for HYPERTROPHY
6. Look for evidence of INFARCTION
7. Look any other ABNORMALITY

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HEART RATE
 NSR Parameters

• Rate 60 - 100 bpm

• Regularity regular
• P waves normal
• PR interval 0.12 - 0.20 s
• QRS duration 0.04 - 0.12 s
Any deviation from above is sinus
tachycardia, sinus bradycardia or an
arrhythmia
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What is the Heart Rate ?

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 What is the Heart Rate ?
 To find out the heart rate we need to know
 The R-R interval in terms of # of Big Squares
 If the R-R intervals are constant
 In this ECG the R-R intervals are not constant
 R-R are varying from 2 boxes to 3 boxes
 It is an irregular rhythm – Sinus arrhythmia
 Heart rate is 300 ÷ 2 to 3 = 150 to 100 approx
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No. of Big Boxes R – R Interval Rate Cal. Rate TA
CH
One 0.2 sec 60 ÷ 0.2 300 Y

Two 0.4 sec 60 ÷ 0.4 150

NO
Three 0.6 sec 60 ÷ 0.6 100 R
M
Four 0.8 sec 60 ÷ 0.8 75 AL

Five 1.0 sec 60 ÷ 1.0 60

Six 1.2 sec 60 ÷ 1.2 50 BR
A
Seven 1.4 sec 60 ÷ 1.4 43 DY

Eight 1.6 sec 60 ÷ 1.6 37

Determination of heart rate

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RHYTHM
 Normal Sinus Rhythm (NSR)

• Etiology: the electrical impulse is formed in

the SA node and conducted normally.
• This is the normal rhythm of the heart; other
rhythms that do not conduct via the typical
pathway are called arrhythmias.

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 Rhythm #1

• Rate? 30 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.12 s
• QRS duration? 0.10 s
Interpretation? Sinus Bradycardia
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 Rhythm #2

• Rate? 130 bpm

• Regularity? regular
• P waves? normal
• PR interval? 0.16 s
• QRS duration? 0.08 s
Interpretation? Sinus Tachycardia
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 Rhythm #3

• Rate? 70 bpm
• Regularity? occasionally irreg.
• P waves? 2/7 different contour
• PR interval? 0.14 s (except 2/7)
• QRS duration? 0.08 s
Interpretation? NSR with Premature Atrial
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Contractions
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 Rhythm #4

• Rate? 60 bpm
• Regularity? occasionally irreg.
• P waves? none for 7th QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s (7th wide)
Interpretation? Sinus Rhythm with 1 PVC
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 Rhythm #5

• Rate? 100 bpm

• Regularity? irregularly irregular
• P waves? none
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Fibrillation
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 Rhythm #6

• Rate? 70 bpm
• Regularity? regular
• P waves? flutter waves
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Flutter
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 Rhythm #7

• Rate? 74 148 bpm

• Regularity? Regular  regular
• P waves? Normal  none
• PR interval? 0.16 s  none
• QRS duration? 0.08 s
Interpretation? Paroxysmal Supraventricular
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Tachycardia (PSVT)
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 Rhythm #8

• Rate? 160 bpm

• Regularity? regular
• P waves? none
• PR interval? none
• QRS duration? wide (> 0.12 sec)
Interpretation? Ventricular Tachycardia
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 Rhythm #9

• Rate? none
• Regularity? irregularly irreg.
• P waves? none
• PR interval? none
• QRS duration? wide, if recognizable
Interpretation? Ventricular Fibrillation
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AXIS
 The Six Limb Leads
FRONTAL PLANE

RIGHT

LEFT

INFERIOR
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 QRS Axis
NW NE

-30 to +90 +90 to +180

SW -30 to -90 +180 to -90 SE
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 QRS Axis Determination
Axis Lead 1 aVF TIP

Normal Axis Positive Positive Both Up

Right Axis Negative Positive Meet

Left Axis Positive Negative Leave

Indeterminate Negative Positive Meet

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 ECG with
What Normal
is the Axis ? Axis

LEAD 1
aVR

LEAD 2 aVL

LEAD 3 aVF

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 ECG
Whatwith
is theRight
Axis ?Axis

LEAD 1

LEAD 2

LEAD aVF

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 ECG with
What is theLeft
Axis ?Axis

LEAD 1 aVR

LEAD 2 aVL

LEAD 3 aVF
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INTERVAL
 3

4
5
1
8
2

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 Identify the ECG Complex
1. P wave : Atrial contraction 0.12 sec (3)
2. PR interval – P to begin. of QRS 0.20 sec (5)
3. QRS complex - Ventricular 0.08 sec (2)
4. ST segment - Electrical silence Isoelectric
5. T wave - repolarization 0.12 sec (3)
6. QRS interval – Ventricular cont. 0.08 sec (2)
7. QT interval - From Q to T end 0.40 sec (10)
8. TP segment - Electrical silence 0.20 sec (5)

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 Rhythm #10

• Rate? 60 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.36 s
• QRS duration? 0.08 s
Interpretation? 1st Degree AV Block
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 Rhythm #11

• Rate? 50 bpm
• Regularity? regularly irregular
• P waves? nl, but 4th no QRS
• PR interval? lengthens
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block, Type I
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 Rhythm #12

• Rate? 40 bpm
• Regularity? regular
• P waves? nl, 2 of 3 no QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block, Type II
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 Rhythm #13

• Rate? 40 bpm
• Regularity? regular
• P waves? no relation to QRS
• PR interval? none
• QRS duration? wide (> 0.12 s)
Interpretation? 3rd Degree AV Block
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HYPERTROPHY
 ECG in LVH

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 What is in this ECG ?

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 Atrial Waves

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•INFARCTION
 MI, Blood Supply, Leads

ANTERIOR LATERAL INFERIOR POSTERIOR

LAD LAD or LCx RCA RCA + LCx
V1, V2, V3, V4 V5, V6, L1, aVL L2, L3, aVF V1, V2 Mirror
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 MI and ECG Lead

Lead I aVR V1 V4

Lead II aVL V2 V5

Lead III aVF V3 V6

Anterior – DG LAD Lateral - LCx

Septal – SB LAD Inferior – PDA RCA

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 Serial ECG changes of MI

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 AcuteChest
Severe Anterolateral
Pain – WhyMI
?

A AL
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 Inferior
Identify the and Posterior
double wall MI

I+P
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 Acute Posterior
Decipher V1, V2, V3MI

Acute Posterior
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 AcuteWhat is striking ? MI
Inferio-Posterior

Acute Inf Post

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 Acutechanges
What Anterolateral
we see MI
?

A AL
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 Very Striking
Hyper ? MI
Acute

HYPER ACUTE
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 Complete
Interpret This LBBB
ECG

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 Interpret this ECG
Complete RBBB

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•ABNORMALITIES
 Hypokalemia

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 Hyperkalemia

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 Electrical Alternans

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 Ventricular Bigeminy
Normal VPC

Normal

VPC

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Normal ECG

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ALHAMDULILLAH …