Dr. Nurkhalis Muchlis, SpJP,FIHA

Fakultas Kedokteran Universitas IndonesiaPusat Jantung Nasional Harapan Kita

Conduction System

SA Node Internodal branch AV Node Hiss Bundle Purkinje Fiber Contraction

The Electrocardiogram ( ECG )The Electrocardiogram ( ECG )

P wave : atrial P wave : atrial depolarisationdepolarisation

QRS complex : QRS complex : ventricular ventricular depolarisationdepolarisation

T wave : T wave : ventricular ventricular repolarisationrepolarisation

Atrial repolarisation Atrial repolarisation hidden by QRShidden by QRS

P

Q

R

S

T

PR Interval

QRS Complex

ST Segment

T Wave

Pola Membaca EKGPola Membaca EKGIramaIramaRate QRSRate QRSAksis QRSAksis QRSMorfologi Gelombang PMorfologi Gelombang PInterval PRInterval PRDurasi QRSDurasi QRSMorfologi QRSMorfologi QRSDeviasi Segmen STDeviasi Segmen STMorfologi Gelombang TMorfologi Gelombang TMorfologi Gelombang UMorfologi Gelombang ULain-lain (LVH,LV Lain-lain (LVH,LV Strain,BBB, QT interval)Strain,BBB, QT interval)Kesimpulan EKGKesimpulan EKG

Nilai Normal :

Interval PR 0,12’’ s/d 0,20’’

Durasi QRS 0,04’’ s/d 0,12’’

Aksis Normal - 300 s/d + 1100

IramaIrama

Sinus RitmeSinus RitmeSinusTakikardiSinusTakikardiSinus BradikardiSinus BradikardiSinus AritmiaSinus AritmiaIrama JungtionalIrama JungtionalIrama IdioventrikularIrama IdioventrikularIrama VentrikularIrama VentrikularTakiaritmia Takiaritmia (SVT,Atrial Fibrilasi, (SVT,Atrial Fibrilasi, Atrial Fluter,VT)Atrial Fluter,VT)Bradiaritmia (blok Bradiaritmia (blok konduksi AV) konduksi AV)

Sinus Aritmia

A. Jarak R – R :

-1 kotak sedang = 300 x / menit-2 kotak sedang = 150 x / menit-3 kotak sedang = 100 x / menit-4 kotak sedang = 75 x / menit-5kotak sedang = 60 x / menit-6 kotak sedang = 50 x / menit

B. Hitung jumlah R- R dalam 6 kotak besar = 6 detikJumlah R x 10 = heart rate / menit

C. 1500 / jarak R-R ( dlm mm ) = heart rate / menit

MENGHITUNG LAJU JANTUNG :

P Pulmonale

P Mitrale

Pemasangan Lead Terbalik

Normal Sinus Rhythm

Rhythm : RegularRate : 60 – 100P wave : Normal in configuration; precede each QRSPR : Normal ( 0. 12 – 0.20 seconds )QRS : Normal ( less than 0.12 seconds )

First-degree AV block

Rhythm : RegularRate : Usually normalP wave : Sinus P wave present; one P wave to each QRSPR : Prolonged ( greater than 0.20 seconds )QRS : Normal

Second -degree AV block, Mobitz I

Rhythm : IrregularRate : Usually slow but can be normalP wave : Sinus P wave present; some not followed by QRS complexesPR : Progressively lengthensQRS : Normal

Second-degree AV block, Mobitz II

Rhythm : Regular usually; can be irreguler if conduction ratios varyRate : Usually slowP wave : Two, three, or four P waves before each QRSPR : PR interval of beat with QRS is constant; PR interval may be normal or prolongedQRS : Normal if block in His bundle; wide if block involves bundle branches

Third-degree AV block

Rhythm : RegularRate : 40 – 60 if block in His bundle; 30 – 40 if block involves bundle branchesP wave : Sinus P wave present; bear no relationship to QRS; can be found hidden in QRS complexes and T wavesPR : Varies greatlyQRS : Normal if block in His bundle; wide if block involves bundle branches

Wolff-Parkinson-White syndrome

ST depresi dan perubahan gelombang T

• ST depresi dianggap bermakna bila > 1 mm di bawah garis dasar PT di titik J• Titik J didefinisikan sebagai akhir kompleks QRS dan permulaan segmen ST

Bentuk segmen ST :

• up-sloping ( tidak spesifik )• horizontal ( lebih spesifik untuk iskemia )• down-sloping ( paling terpercaya untuk iskemia )

Perubahan gelombang T pada iskemia kurang begitu spesifik Gelombang T hiperakut kadang2 merupakan satu-satunyaperubahan EKG yang terlihat

LOKASI ISKEMIA BERDASARKAN PERUBAHAN DI SANDAPAN EKG

SANDAPAN LOKASI ISKEMIA / INFARK

• II ,III, aVF Inferior• V1,V2,V3 Anteroseptal•V1-V4 Anterior• V1- V6 Anterior ekstensif• I,aVL ,V5,V6 Lateral• I, V6 Apikal• V7-V9 Posterior• V3R-V4R Ventrikel kanan

Unstable angina

Acute anteroseptal myocardial infarction. Hyperacute T-wave changes are noted

Acute anterolateral myocardial infarction

High lateral infarction

Inferior myocardial infarction

Acute inferoposterior myocardial infarction

Wolff-Parkinson-White syndrome

Aritmia Yang Fatal

A Fib/Flutter spectrumA Fib/Flutter spectrum

PSVT :

-due to re-entry mechanism-narrow QRS complex-regular-retrograde atrial depolarization-P wave ?

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

VES

SR

SR SR SR SRSR SR

VES VES

Sinus rhythm with Multifocal VES

Sinus rhythm with VES couplet

Sinus Rhythm with VES, R on T

Ventricular Tachycardia

Torsade de Pointes

Ventricular Fibrillation