KULIAH ECG Dinkes Purworejo

ELECTROCARDIO
GRAPHY
Dr CHUSNI MUBARAKH MSc SpPD
Staf Medis Fungsional Ilmu Penyakit Dalam

RSUD Purworejo
ECG is…?
 Printout as a result of a particular electrical

function of the heart
 The standard 12-lead electrocardiogram is a

representation of the heart's electrical
activity recorded from electrodes on the
body surface
Information provided by ECG:
what do you think?
Cardiac conduction
system
 SA node
 AV node
 Bundle His
Impulse Transmission
SA Node
 Internodal branch
 AV Node
 Hiss Bundle
 Purkinje Fiber
 Contraction
One ‘complex’ of ECG waveform
right and left ventricular depolarization (normally the

ventricles are activated simultaneously)
the sequentialactivation
(depolarization) of the right and
left atria
ventricular repolarization
Leads position
Limb leads
Chest lead
Chest lead
ECG interpretation…?
1. Calibration
2. Rhythm
3. Rate
4. QRS axis
5. P morphology
6. PR interval
7. QRS duration
8. QRS morphology
9. Abnormal Q wave
10. R wave progression
11. ST segment morphology
12. QT interval
13. T morphology
14. U morphology
15. Others: LVH, LV strain, BBB,
16. Conclusion: normal/abnormal
Calibration
 1 mV = 1 cm
 Important in
assessing tall waves
in hypertrophic
state
Paper speed and normal
value
One small box: 0.04 s

One large box: 0.2 s
PR Interval: 0,12’’ - 0,20’’
QRS duration: 0,04’’ - 0,12’’
Rate calculation
 Method:
– 300 divided by number of large boxes
between R-R
– 1500 divided by number of small boxes
between R-R,
– Number of QRS complexes in 6 seconds
times 10.
Sinus Rhythm
 Sinus Rhythm
–Rhythm: Regular
–Rate: 60 – 100
–P wave: Normal in configuration; precede each
QRS
–PR: Normal (0. 12 – 0.20 s)
–QRS: Normal (<0.12 s)
QRS Axis
P wave
 Wave of atrial depolarization

 Normal characteristic:
1. Smooth and rounded
2. ≤ 3 mm tall
3. Upright in leads I, II avF
PR interval
 Including P wave until the beginning

of QRS complex
 Normal duration is 0.12-0.2 seconds
QRS complex
 Wave of ventricular depolarization

 5-20 mm tall
 Duration 0.06-0.10 seconds
QRS morphology
R
qRs Rs rS
QR Q/QS RsR’ rSr’

ST segment
 Begins at J point
 Between ventricular depolarization and
ventricular repolarization
 Generally isoelectric
T wave
 Ventricular repolarization, followed by

ventricular relaxation
 Positive in lead : I, II, V3-V6
 Negative in lead avR
Interpret this ECG..
And this..
Abnormal ECG
 Myocardial ischemia/infarct
 Hyperthrophy
 Hyperkalemia
 Arrhythmia
ACUTE CORONARY SYNDROME
No ST Elevation ST Elevation
NSTEMI
Unstable Angina
Acute myocardial
infarction
STEMI Non STEMI
Mid LAD occlusion
after the first septal
ECG : large anterior MI
perforator (arrow)
Occlusion of diagonal
branch ( arrow )
ST elevation in I and aVL

ECG demonstrates large anterior infarction
Proximal large RCA occlusion
ST elevation in leads II, III, aVF, V5, and V6

with precordial ST depression
Small inferior distal RCA occlusion
ECG changes in leads II, III, and aVF

Acute inferoposterior MI
HIPERKALEMIA
• Peaking T
• Shortening QT interval
• Widening P wave,
QRS complex
• Prolongation PR interval
PPM
How to identify arrhythmias ?
QRS complex
Regular / irregular ?
QRS complex
Normal-looking QRS complex?
Wide / narrow ?
P wave ?
Relationship between P and QRS ?

NORMAL SINUS RHYTHM
PSVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
PSVT
Atrial Fibrillation :
-from multiple area of re-entry within atria

-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical activity
(400-700 x/min).
-no uniform atrial depolarization
Atrial Flutter :
-The result of a re-entry circuit within
the atria
-Irregular / regular QRS rate
-Narrow QRS complex
-Rapid P waves (300x/min), “sawtooth”
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
SR
VES
Sinus rhythm
with
Multifocal VES
VES VES
SR SR
SR SR SR SR
Sinus rhythm with VES couplet
Sinus Rhythm with VES, R on T
Ventricular Tachycardia
Torsade de Pointes
Ventricular Fibrillation
1st degree AV block
Prolonged PR interval
2nd degree AV block, type 1
Missing QRS Missing QRS

2nd degree AV block, type 2
Missing QRS
Total AV Block /
3rd degree AV block
QRS QRS QRS
P P P P P P P
Terima Kasih
Semoga Bermanfaat Bagi
Kehidupan

KULIAH ECG Dinkes Purworejo

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ELECTROCARDIO

Dr CHUSNI MUBARAKH MSc SpPD

Staf Medis Fungsional Ilmu Penyakit Dalam

 Printout as a result of a particular electrical

 The standard 12-lead electrocardiogram is a

right and left ventricular depolarization (normally the

One small box: 0.04 s

 Wave of atrial depolarization

 Including P wave until the beginning

 Wave of ventricular depolarization

QR Q/QS RsR’ rSr’

 Ventricular repolarization, followed by

ST elevation in I and aVL

ST elevation in leads II, III, aVF, V5, and V6

ECG changes in leads II, III, and aVF

Relationship between P and QRS ?

-from multiple area of re-entry within atria

Missing QRS Missing QRS

QRS QRS QRS

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