Cara membuat rekaman Cara membuat rekaman EKGEKG

Syamsu IndraSyamsu Indra

Division of Cardiology, Division of Cardiology, Dept of Internal Medicine, Dept of Internal Medicine,

Sriwijaya University,Sriwijaya University,Dr. Moh Hoesin General HospitalDr. Moh Hoesin General Hospital

POKOK BAHASANPOKOK BAHASAN

1. Persiapan pasien1. Persiapan pasien

2. pelaksanaan perekaman(posisi standard dan posisi 2. pelaksanaan perekaman(posisi standard dan posisi

tidak standard)tidak standard)

3. Pengertian kertas EKG3. Pengertian kertas EKG

4. Pengertian EKG 12 lead4. Pengertian EKG 12 lead

5. EKG layak baca(identitas jelas & gelombang-5. EKG layak baca(identitas jelas & gelombang-

gelombang standar sesuai dg kriteria normal.gelombang standar sesuai dg kriteria normal.

Anatomical PositionAnatomical Position of the Heart of the Heart

Lies in the mediastinum behind the sternumLies in the mediastinum behind the sternum

between the lungs, just above the diaphragmbetween the lungs, just above the diaphragm

the apex (tip of the left ventricle) lies at the fifth intercostal space, the apex (tip of the left ventricle) lies at the fifth intercostal space, mid-clavicular linemid-clavicular line

Location of The Heart in The ThoraxLocation of The Heart in The Thorax

Surfaces of the Left VentricleSurfaces of the Left Ventricle

Inferior - underneathInferior - underneath

Anterior - frontAnterior - front

Lateral - left sideLateral - left side

Posterior - backPosterior - back

Coronary Artery SystemCoronary Artery System

Coronary Artery CirculationCoronary Artery Circulation Left Main Stem Artery divides in two:Left Main Stem Artery divides in two:

Left Anterior Descending Left Anterior Descending ArteryArtery

antero-lateral surface of antero-lateral surface of left ventricleleft ventricle2/3 interventricular 2/3 interventricular septumseptum

Circumflex ArteryCircumflex Arteryleft atriumleft atriumlateral surface of left lateral surface of left ventricleventricle

From : Sheelagh Scott, Practice Development Centre, NHS Lanarkshire

What does cardiovascular system do?

The Conduction System of The HeartThe Conduction System of The Heart..

Conduction SystemSinoatrial (SA) node– Natural pacemaker– Automaticity– Atrial contraction– Produces the P wave

Conduction System

Atrio-Ventricular Node– Allows conduction from

atria to ventricles– Occurs slowly– Normal delay of

0.12 to 0.20 seconds– Produces PR interval

on EKG

Conduction System

His Bundle & Bundle Branches– Beginning of ventricular system– Depolarization occurs rapidly– Immediately bifurcates

into L & R bundles– Bundles are Purkinje fibers

His Bundle

R Bundle

L Bundle

Conduction SystemPurkinje fibers then

depolarize the ventricles

Produces a QRS complex

on the EKG

Aktifita SA node (pace maker alamiah)

Miokardium atrial : Depolarisasi (P): repolarisasi (Ta)

Jalur internodal

Nodus AV

Bundle His

Bundle Branches

Miokardium ventrikel: depolarisasi (QRS), repolarisasi (T)

Sistim konduksi jantung

Gambar sistim konduksi Jantung

Apa yang direkam ?Apa yang direkam ?

Potensial listrik yang merupakan jumlah Potensial listrik yang merupakan jumlah keseluruhan dari arus listrik yang keseluruhan dari arus listrik yang dihasilkan oleh setiap sel otot jantung.dihasilkan oleh setiap sel otot jantung.

Tahun 1903 Willem Einthoven dengan Tahun 1903 Willem Einthoven dengan menggunakan string galvanometer menggunakan string galvanometer menghasilkan beberapa menghasilkan beberapa konvensikonvensi mengenai kelistrikan ini.mengenai kelistrikan ini.

ElectrophysiologyElectrophysiology

If an electrode is placed so that wave of If an electrode is placed so that wave of depolarization spreads toward the depolarization spreads toward the recording electrode, the ECG records a recording electrode, the ECG records a positive (upward) deflection.positive (upward) deflection.

If wave of depolarization spreads away If wave of depolarization spreads away from recording electrode, a negative from recording electrode, a negative (downward) deflection occurs.(downward) deflection occurs.

ElectrophysiologyElectrophysiology

Cardiac Current FlowCardiac Current Flow

Cardiac Current FlowCardiac Current Flow

ECG Time & VoltageECG Time & Voltage

ECG machines can run at 50 or 25 ECG machines can run at 50 or 25 mm/sec.mm/sec.

Major grid lines are 5 mm apart, at Major grid lines are 5 mm apart, at standard 25 mm/s, 5 mm corresponds standard 25 mm/s, 5 mm corresponds to .20 seconds.to .20 seconds.

Minor lines are 1 mm apart, at standard 25 Minor lines are 1 mm apart, at standard 25 mm/s, 1 mm corresponds to .04 seconds.mm/s, 1 mm corresponds to .04 seconds.

Voltage is measured on vertical axis.Voltage is measured on vertical axis.

Standard calibration is 0.1 mV per mm of Standard calibration is 0.1 mV per mm of deflection.deflection.

ElectrophysiologyElectrophysiology

When myocardial muscle is completely When myocardial muscle is completely polarized or depolarized, the ECG will not polarized or depolarized, the ECG will not record any electrical potential but rather a record any electrical potential but rather a flat line, flat line, isoelectric lineisoelectric line..

After depolarization, myocardial cells After depolarization, myocardial cells undergo repolarization to return to undergo repolarization to return to electrical state at rest.electrical state at rest.

Dimana Lokasi Merekam ?Dimana Lokasi Merekam ?Pertimbangkan aspek anatomi !Pertimbangkan aspek anatomi !

Limb leadsLimb leads Chest LeadsChest Leads

Limb LeadsLimb Leads

3 Bipolar Leads 3 Bipolar Leads

form (Einthovens Triangle)form (Einthovens Triangle)

Lead I Lead I - measures electrical potential - measures electrical potential

between right arm (-) and left arm (+)between right arm (-) and left arm (+)

Lead IILead II - measures electrical potential - measures electrical potential

between right arm (-) and left leg (+)between right arm (-) and left leg (+)

Lead IIILead III - measures electrical potential - measures electrical potential

between left arm (-) and left leg (+)between left arm (-) and left leg (+)

Limb LeadsLimb Leads

3 Unipolar leads3 Unipolar leads

avR - right arm (+)avR - right arm (+)avL - left arm (+)avL - left arm (+)avF - left foot (+)avF - left foot (+)

note that right foot is a note that right foot is a ground leadground lead

Limb lead tampak dari jantung dalam bidang vertikal

Lead prekordial terletak dalam bidang horizontal

Perspektif lead vertikal dan horizontal

RIGHT

Antero-SeptalV1,V2, V3,V4

Lateral I, AVL, V5, V6

LEFT

Inferior II, III, AVF

V1-V2: 4th intercostal space –R/L of sternumV4: 5th intercostal space – midclavicle lineV3: Between V2 and V4V5: At horizontal level of V4, anterior to axillaV6: Midaxillary at horizontal level of V4

Lokasi Lead Prekordial 

V1 : Sisi kanan sternum ICS 4V2 : Sisi kiri sternum ICS 4V3 : Antara V2 dan V4V4 : Mid klavikula kiri ICS 5V5 : Garis aksilaris ant ICS 5V6 : Garis mid aksilaris ICS 5V3R : simetris V3, di kananV4R : simetris V4, di kanan

ELEKTRODE PREKORDIAL

ELEKTRODE ELEKTRODE EKSTRIMITASEKSTRIMITASDAN DAN PREKORDIALPREKORDIAL

Limb leadsLimb leads Chest LeadsChest Leads

The standard 12 Lead ECGThe standard 12 Lead ECG

6 Limb Leads 6 Limb Leads 6 Chest Leads (Precordial leads)6 Chest Leads (Precordial leads)avR, avL, avF, I, II, IIIavR, avL, avF, I, II, III V1, V2, V3, V4, V5 and V6 V1, V2, V3, V4, V5 and V6

Rhythm StripRhythm Strip

Bagaimana Merekam ?Bagaimana Merekam ?

Pasien dalam keadaan tenang / rileks.Pasien dalam keadaan tenang / rileks.

Letakkan 12 lead dgn benar dan Letakkan 12 lead dgn benar dan firm.firm.

Limb leadLimb lead– Lead I, II dan IIILead I, II dan III

Augmented limb leadAugmented limb lead– aVR, aVL dan aVFaVR, aVL dan aVF

Precordial / Chest leadPrecordial / Chest lead– V1 – V6V1 – V6

Recording an ECGRecording an ECG

1. Explain procedure to patient, obtain consent and check for allergies

2. Check cables are connected

3. Ensure surface is clean and dry

4. Ensure electrodes are in good contact with skin

5. Enter patient data

6. Wait until the tracing is free from artifact

7. Request that patient lies still.

8. Push button to start tracing

Ingat bahwa ke – 12 lead tersebut akan Ingat bahwa ke – 12 lead tersebut akan merekam secara sama persis dengan merekam secara sama persis dengan kejadian / aktivitas listrik di dalam kejadian / aktivitas listrik di dalam jantung !!!jantung !!!

Posisi dan orientasi lead yang berbeda Posisi dan orientasi lead yang berbeda akan memberikan hasil yang berbeda. akan memberikan hasil yang berbeda.

Mengelola RekamanMengelola Rekaman

Identitas pasienIdentitas pasienWaktu --- sekuensialWaktu --- sekuensialLayak baca ??Layak baca ??– Identitas dan waktu rekamIdentitas dan waktu rekam– Ada tanda kalibrasi ½, 1 atau 2 mV dan kecepatan Ada tanda kalibrasi ½, 1 atau 2 mV dan kecepatan

(EKG non computer reading)(EKG non computer reading)– Gelombang P di lead aVR hampir selalu negatif Gelombang P di lead aVR hampir selalu negatif – Rekaman di V1-6 tidak boleh sama.Rekaman di V1-6 tidak boleh sama.

Copyright ©2002 BMJ Publishing Group Ltd.

Meek, S. et al. BMJ 2002;324:415-418

Kalibrasi EKG

                                 

                                 

                                 

                                 

                                 

                                 

                                 

                                 

                                 

                                 

                                 

                                 

0,20 SEC

0,5 mV5 mm

0,04 sec

0,1 mV1 mm

Kertas Grafik EKG

Kecepatan kertas (standard)25 mm/menit

Bisa 50,100/mnt

Cara Membaca EKGCara Membaca EKG

Menentukan iramaMenentukan irama

Menentukan heart rateMenentukan heart rate

Menentukan aksis Menentukan aksis

Menentukan IntervalMenentukan Interval

Kesimpulan Kesimpulan EKG yang layak baca harus menyampaikan hasil EKG yang layak baca harus menyampaikan hasil

perekaman yang benar yaitu :perekaman yang benar yaitu :

Ada data pasien yang direkamAda data pasien yang direkamDilakukan peneraan sebelum proses perekamanDilakukan peneraan sebelum proses perekamanGelombang P selalu positif di lead II dan negative di Gelombang P selalu positif di lead II dan negative di aVRaVR

TERIMA KASIHTERIMA KASIH