MODULATION SUPPLEMENT

DEPOLARISASI
VENTRIKEL

DEPOLARISASI REPOLARISASI
ATRIUM VENTRIKEL

J point
SISTEMATIKA PEMBACAAN EKG
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1 IRAMA

2 HEART RATE, REGULARITAS

3 AKSIS

4 PR INTERVAL

5 MORFOLOGI a GELOMBANG P

b KOMPLEKS QRS

c SEGMEN ST

d GELOMBANG T
1 IRAMA Sinus│ Bukan sinus

Irama Sinus
• Berasal dar SA Node
• Setiap kompleks QRS yang normal didahului oleh gelombang P

Bukan Irama Sinus

• Fibrilasi
• Blok AV
• Ventrikuler takikardi
• Dll.
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1 IRAMA

2 HEART RATE, REGULARITAS

3 AKSIS

4 PR INTERVAL

5 MORFOLOGI a GELOMBANG P

b KOMPLEKS QRS

c SEGMEN ST

d GELOMBANG T
 •Reguler │ Ireguler
2 HEART RATE, REGULARITAS •Normal │ Takikardi │ Bradikardi

Regular : Jarak tiap interval R-R’ sama

300 / RR’ (kotak besar)
= 300 /4
=75

1500 / RR’ (kotak kecil)

= 1500 /20
=75

Iregular : Jarak tiap interval R-R’ berbeda

Jumlah R (dalam 30
kotak besar) X 10
= 5 x 10
=50

*) 30 kotak besar = 6 detik

Jumlah R selama 6 detik x 10 = HR selama 60 detik
2 HEART RATE, REGULARITAS
2 HEART RATE, REGULARITAS

Normal:
Reguler, HR = 60-100x/menit
• <60 x/m : Bradikardia
• >100 x/m: Takikardia
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1 IRAMA

2 HEART RATE, REGULARITAS

3 AKSIS

4 PR INTERVAL

5 MORFOLOGI a GELOMBANG P

b KOMPLEKS QRS

c SEGMEN ST

d GELOMBANG T
3 AKSIS Normal │ LAD │ RAD │ ERAD
 3 AKSIS Normal │ LAD │ RAD │ ERAD

Lihat lead I dan avF

Lead
I

Lead
aVF

Lead
II
EXTREME
AKSIS NORMAL LAD RAD AXIS
3 AKSIS
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1 IRAMA

2 HEART RATE, REGULARITAS

3 AKSIS

4 PR INTERVAL

5 MORFOLOGI a GELOMBANG P

b KOMPLEKS QRS

c SEGMEN ST

d GELOMBANG T
4 PR INTERVAL Normal │ memendek│
memanjang

•Menggambarkan impuls
melalui atrium dan AV node

NORMAL 3 – 5 KOTAK KECIL

MEMENDEK < 3 KOTAK KECIL

• SINDROM PREEKSITASI
•PENINGKATAN AKTIVITAS SIMPATIS

MEMANJANG >5 KOTAK KECIL

• AV BLOK
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1 IRAMA

2 HEART RATE, REGULARITAS

3 AKSIS

4 PR INTERVAL

5 MORFOLOGI a GELOMBANG P

b KOMPLEKS QRS

c SEGMEN ST

d GELOMBANG T
a GELOMBANG P Normal │ P pulmonal │ P mitral
│Absent

•Menggambarkan depolarisasi
atrium

T : ≤ 2,5 KOTAK KECIL

Normal L : ≤ 2,5 KOTAK KECIL

P pulmonal T : > 2,5 KOTAK KECIL

• PEMBESARAN ATRIUM KANAN/ RAE

P mitral L : > 2,5 KOTAK KECIL

• PEMBESARAN ATRIUM KIRI / LAE
 •Interval: Normal/sempit │ Lebar
b KOMPLEKS QRS •Amplitudo
•Ada tidaknya P yang diikuti QRS
•Ada tidaknya gelombang Q

•Menggambarkan depolarisasi
ventrikel

• Interval

L : < 3 KOTAK KECIL

Normal (Durasi 0,06-0,11 s)

Lebar L : ≥ 3 KOTAK KECIL

Gangguan konduksi intraventrikuler
• BBB
•Aritmia ventrikuler
 •Interval: Normal/sempit │ Lebar
b KOMPLEKS QRS •Amplitudo
•Ada tidaknya P yang diikuti QRS
•Ada tidaknya gelombang Q

•Menggambarkan depolarisasi
ventrikel

• Amplitudo

Kecil : Low <5 mm di lead ekstremitas

<10 mmdi lead prekordial
voltage Efusi perikard, PJK luas, gagal jantung

Besar >25-30 mm
•Irama Ventrikuler
•Hipertrofi ventrikel
 •Interval: Normal/sempit │ Lebar
b KOMPLEKS QRS •Amplitudo
•Ada tidaknya P yang diikuti QRS
•Ada tidaknya gelombang Q

•Menggambarkan depolarisasi
ventrikel

• Q patologis

•Lebar >0.04 s
•Dalam >1/3 tinggi R
• Minimal 2 lead yang
berhubungan
•Old Myocardial Infarction (OMI)
•Infark miokard akut (bila disertai ST
elevasi)
patologis
c SEGMEN ST Normal - isoelektrik│
│ ST elevasi│ST depresi

.
Normal ST elevasi ST depresi

• Infark miokard • Iskemik/infark

transmural (full subendokard
thickness) • Intoksikasi digitalis
• Perikarditis •Hipertrofi ventrikel
• BER (strain)
• Sindrom Brugada
• Emboli paru
c SEGMEN ST
ST elevasi

Non-concave (i.e. convex)

morphology has a sensitivity of
77% and a specificity of 97%
for a diagnosis of STEMI.

•However, do not assume that

because ST segment elevation
is not convex that it cannot be
a STEMI!
c SEGMEN ST
ST elevasi
ST segment changes of STEMI (with reciprocal changes)
in a distribution clearly reflecting coronary artery territory
 c SEGMEN ST
ST elevasi
PERICARDITIS
• 5% of ED admissions with chest pain are due to acute pericarditis. 90% of cases are classified as
idiopathic or viral in aetiology.
• 85% of patients have an audible friction rub during the course of their disease.
• widespread concave ST elevation, ST depression in lead aVR and widespread PR depression. The ST
segment to T wave height ratio in lead V6 is normally > 0.25

• ST elevasi difus
•Bentuk ST konkaf /
senyum
•PR segmen depresi
•Segmen ST/ gel.T>0.25
•Klinis perikarditis
c SEGMEN ST
ST elevasi
BER (BENIGN EARLY REPOLARIZATION)
• upward sloping notch at the end of the QRS segment. ( concave, notch J point)
• Varian normal, banyak pada usia muda

Representation of notch at the end of the QRS complex

c SEGMEN ST
ST elevasi
BRUGADA SYNDROME
• This is a rare but serious cause of ST segment elevation without AMI.
• It is an autosomal dominant condition with incomplete penetrance that has an incidence
ranging from 5 to 66 per 10 000. It is endemic in Southeast Asia.
• Clinical features include: episodes of arrhythmia (usually rapid polymorphic VT), collapse or
sudden death. The episodes are more common in the night or the early hours of the morning.
There may be a family history of sudden death. It has a male predominance (ratio 8:1).
• These ECG findings can be dynamic and can be unmasked or exaggerated by sodium channel
blockers such as flecainide. Brugada Syndrome is not associated with identifiable structural
cardiac abnormalities.
• ST segment elevation occurs in the right precordial leads V1 to V3.

Consider Brugada Syndrome in anyone with downward

sloping ST segment elevation in the right precordial chest
leads
c SEGMEN ST
ST elevasi
Left Bundle Branch Block (LBBB)
•The appearance of LBBB on an ECG makes any further interpretation of the ECG
difficult.
•There are various features that allow you to “read through” LBBB to identify an acute
STEMI: Sgarbossa described 3 independent ECG signs suggestive of AMI in a patient
with LBBB on their ECG
•These are highly specific but not sensitive for AMI and so have limited use in
everyday clinical practice. Much more importance is attached to a good history for
AMI.
Sgarbossa Criteria for AMI in LBBB

A patient presenting with a good history of AMI and with LBBB on their ECG should be treated as an AMI
even in the absence of the Sgarbossa criteria
c SEGMEN ST
ST elevasi
EMBOLI PARU
•ECG changes associated with significant PE reflect right ventricular strain (due to
outflow obstruction) and are mainly in the inferior and anteroseptal leads.
c SEGMEN ST
ST depresi

• ischemic abnormality Ischemic Heart

Can be a normal variant or •Digoxin effect
disease
artifacts, such as: •Strain
• poor skin contact of the padahipertrofi
electrode ventrikel
• Physiologic J-junctional
depression with sinus
tachycardia
• Hyperventilation
c SEGMEN ST
ST depresi
Upslopping??

A slow upsloping ST A rapidly upsloping ST segment

segment( <1.5mv.sec )can be a (> 1.5mv /Sec) is a non ischemic
significant marker of ischemia. response
 d GELOMBANG T Normal ││T tall │T inverted│T flat

•Menggambarkan repolarisasi
ventrikel

Normal T tall T flat T inverted

Tinggi: •Hiperkalemia •Iskemia •Iskemia
•Lead prekordial •Hiperakut T •Hipokalemia •Normal pada anak
1-10 kk
pada infark (semua lead) (v1-v3)
(0,1-1 mV) •Ventricular
•Lead ekstremitas
miokard hypertrophy
1-5 kk (‘strain’ patterns)
(0,1-0,5 mV) •Bundle branch
block
Upright in all
•Emboli paru
leads except
aVR and V1
Morfologi gelombang T
 RINGKASAN
1 IRAMA Sinus│ Bukan sinus
2 HEART RATE, REGULARITAS Regular│ Ireguler, HR = ...x/m

3 AKSIS Normal│ LAD │ RAD │ ERAD

4 PR INTERVAL Normal│ Memendek │ Memanjang

5 MORFOLOGI

a GELOMBANG P Normal│ P pulmonal (RAE) │ P mitral (LAE) │ absent

b KOMPLEKS QRS Normal│ Melebar, Q patologis?

c SEGMEN ST Normal│ST elevasi │ ST depresi

d GELOMBANG T Normal│T tall│ T flat │ T inverted