HOW TO INTERPRETATION ECG

dr. Dhani Tri Wahyu N, SpJP-FIHA

WORKSHOP ECG INTERPRETATION

RSI SAKINAH 2019
Have u see an EKG like this !!
Or may be this..
Upon completion one will be able to :
• Describe what an ECG is
• Describe the proper hook-up procedure for a
12-lead ECG
• Identify basic normal ECG
• Distinguish between basic ECG arrhythmia and
artifact
The Normal Conduction System
 12 Lead ECG
• Describe correct
placement of all
electrodes
• Proper skin
preparation
• Care of the ECG
machine, wires and
electrodes
 Electroda Placement
• Limb Lead : Bipolar (I,II, III)
Augment (AVR, AVL, dan AVF)
• Chest Lead : Unipolar (V1-V6)
Lead Placement
LIMB LEADS CHEST LEADS
Normal 12-lead COLUMN III
• AVR – always negative • R wave progression
• Lead I – always positive • Small to Tall
• Lead II, III – positive or
biphasic
COLUMN IV
• R wave progression
• Tall to Small
 OTHER PROBLEMS WITH ECG

• Artifact
• Electrical interference
• Somatic tremor
• Wandering baseline
KALIBRASI

Kalibrasi standard
Defleksi 10 mm = 1 mV
Kecepatan kertas 25 mm/detik
1 mm = 0,04 detik
5 mm = 0,20 detik
10 mm = 0,40 detik

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 WAVES, SEGMENTS, AND INTERVALS

• Gelombang P : Depolarisasi Atrium

• Interval PR : Diukur dari awal gelombang P hingga awal kompleks QRS
• Interval QRS : Diukur dari awal hingga akhir kompleks QRS
• Interval QT : Diukur dari awal kompleks QRS hingga akhir gelombang T
• Gelombang T : Repolarisasi Ventrikel
• Segmen ST : Isoelektrik, depolarisasi Ventrikel
• Gelombang U : Terlihat pada keadaan hipokalemia, bradikardia
 WAVES
P Waves :
• < 120 ms in duration (3 ‘small squares’)
• < 2.5 mm in amplitude in the limb leads
• < 1.5 mm in amplitude in the chest leads
• Positive in lead II and negative in lead AVR

QRS Waves :
• less than 0.12 seconds in duration (3 ‘small squares’)
• For q waves < 40 ms wide (1 ‘small square’)
• And < 25% of the depth of the QRS complex

T Waves :
• Positive in all leads except V1 and AVR
• < 5 mm in amplitude in the limb leads
• < 15 mm in amplitude in the chest leads
 P Wave
• Present
• 1 per QRS
• Shape
• Duration
• Voltage
 INTERVAL
• PR
– 0.20 sec (less than one large box)

• QRS
– 0.08 – 0.10 sec (1-2 small boxes)
– For q waves < 40 ms wide (1 ‘small
square’) and < 25% of the depth of
the QRS complex

• QT
– 450 ms in men, 460 ms in women
– Based on sex / heart rate
– Half the R-R interval with normal
HR
 INTERPRETATION

• Rhythm
• Rate
• Axis
• Interval
 RHYTHM

• Is the rhythm regular or irregular?

• Is there a P wave before every QRS
complex
• Are they any abnormal beats.
 RHYTHM
• Originating from SA Node
• P wave before every QRS
• P wave in same direction as QRS
 RATE
• 300 : number big boxes
between R-R intervals
• 1500 : number small
box between R-R
intervals
• 10 x Σ R in 6 seconds ( • HR of 60-100 per
30 big boxes) minute is Normal
• HR > 100 = tachycardia
• HR < 60 = bradycardia

3 sec 3 sec
Atrial Fibrilation
 Determine regularity
R R

• Look at the R-R distances (using a caliper

or markings on a pen or paper).
• Regular (are they equidistant apart)?
Occasionally irregular? Regularly
irregular? Irregularly irregular?
Interpretation? Regular
 The QRS Axis

 Represents the overall direction of the heart’s activity

 Axis of –30 to +90 degrees is normal
NORMAL EKG
Left Atrial Enlargement
Right Atrial Enlargement
Rhythm Summary

• Rate 90-95 bpm

• Regularity regular
• P waves normal
• PR interval 0.12 s
• QRS duration 0.08 s

Interpretation? Normal Sinus Rhythm

 BLOCKS
• AV blocks
– First degree block
• PR interval fixed and > 0.2 sec
– Second degree block, Mobitz type 1
• PR gradually lengthened, then drop QRS
– Second degree block, Mobitz type 2
• PR fixed, but drop QRS randomly
– Type 3 block
• PR and QRS dissociated
Ventricular Tachycardia

• Rate : > 100 per minute

and usually not > 220
• Rhythm : Usually regular
• P Wave : (-) P wave, if
present not associated
with qRs
• qRs : Wide (>0,12 sec),
bizzare
• ST/T wave opposite
direction of qRs

A group of three PVC’s in a

row or more than at rate
greater than 100/mnt
 Ventricular Fibrillation
• Rhythm: irregular-coarse or fine, wave form varies in size
and shape
• Fires continuously from multiple foci
• No organized electrical activity
• No cardiac output
• Causes: MI, ischemia, untreated VT, underlying CAD, acid
base imbalance, electrolyte imbalance, hypothermia,

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 Asystole
• Ventricular standstill, no electrical activity, no cardiac
output – no pulse!
• Cardiac arrest, may follow VF or PEA
• Remember! No defibrillation with Asystole
• Rate: absent due to absence of ventricular activity.
Occasional P wave may be identified.

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 IdioVentricular Rhythm
• Escape rhythm (safety mechanism) to prevent ventricular
standstill
• HIS/purkinje system takes over as the heart’s pacemaker
• Treatment: pacing
• Rhythm: regular
• Rate: 20-40 bpm
• P wave: absent
• QRS: > .12 seconds (wide and bizarre)

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Coronary Heart Disease
Gambaran EKG pada IMA : Evolusi
a. Fase hiperakut
b. Fase evolusi lengkap
c. Fase infark lama
Location of the Infarct
 EKG Stat!!

ECG, Willem Einthoven, assigning P, Q, R, S and T to the various deflections

and awarded the 1924 Nobel Prize