Ali Haedar

Department of Emergency Medicine

Faculty of Medicine University of Brawijaya
Saiful Anwar General Hospital Malang
Normal Impulse Conduction
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
Impulse Conduction & the ECG
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
The PQRST

P wave - Atrial
depolarization

QRS - Ventricular
depolarization
T wave - Ventricular
repolarization
The PR Interval
Atrial depolarization
+
delay in AV junction
(AV node/Bundle of His)
(delay allows time for the
atria to contract before the
ventricles contract)
Pacemakers of the Heart
SA Node - Dominant pacemaker with an intrinsic rate
of 60 - 100 beats/minute.

AV Node - Back-up pacemaker with an intrinsic rate of

40 - 60 beats/minute.

Ventricular cells - Back-up pacemaker with an intrinsic

rate of 20 - 45 bpm.
The ECG Paper
Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
The ECG Paper (cont)
3 sec 3 sec

Every 3 seconds (15 large boxes) is marked by a vertical

line.
This helps when calculating the heart rate.
NOTE: the following strips are not marked but all are
6 seconds long.
Rhythm Analysis

Step 1: Calculate rate.

Step 2: Determine regularity.
Step 3: Assess the P waves.
Step 4: Determine PR interval.
Step 5: Determine QRS duration.
Step 1: Calculate Rate
3 sec 3 sec

Option 1
Count the # of R waves in a 6 second rhythm strip, then
multiply by 10.
Reminder: all rhythm strips in the Modules are 6
seconds in length.
Interpretation?

9 x 10 = 90 bpm
Step 1: Calculate Rate

R wave
Option 2
Find a R wave that lands on a bold line.
Count the # of large boxes to the next R wave. If the
second R wave is 1 large box away the rate is 300, 2 boxes
- 150, 3 boxes - 100, 4 boxes - 75, etc. (cont)
Step 1: Calculate Rate
3 1 1
0 5 0 7 6 5
0 0 0 5 0 0

Option 2 (cont)
Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50

Interpretation?

Approx. 1 box less than

100 = 95 bpm
Step 2: 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
Step 3: Assess the P waves

Are there P waves?

Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation?

Normal P waves with 1 P

wave for every QRS
Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)

Interpretation?

0.12 seconds
Step 5: QRS duration

Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)

Interpretation?

0.08 seconds
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
 Apakah Arrhythmia ?
Suatu irama ECG abnormal
Apakah berupa rate atau adanya bentuk dari
gelombang individual yang abnormal.

Fundamentals of ECG 20
Lethal Arrhythmia
Ventricular tachycardia
Ventricular Fibrilasi
Total AV blocks

21
Penyebab sinus bradicardia
Penyebab utama adalah dominasi para simpatis pada
SA node a.l.;
ischemia myocard,
perubahan metabolime hypo thyroidism
obat Beta blocker

Interpretation of Arrhythmias 24
 Tatalaksana
Terapi diberikan bila terdapat gangguan
hemodinamik
Sulfas Atropin 0.5 mg IV
Dopamin infus

Interpretation of Arrhythmias 25
Sinus tachycardia
Penyebab
Aktifitas simpatis yang dominan seperti pada
demam,cemas,obat ventolin
Shock
Hyperthyroidism
Gagal jantung

Interpretation of Arrhythmias 27
Sinus tachycardia
Tatalaksana
Nilai pasien, terapi bila mengganggu hemodinamik
Cari penyebabnya.

Interpretation of Arrhythmias 28
Sinus Arrhythmia
Penyebab
Irregularitas berhubungan dengan variasi vagal pada
SA node

Interpretation of Arrhythmias 30
Sinus Arrhythmia
Tatalaksana
Terapi biasanya tidak diperlukan, kecuali bila terdapat
gangguan hemodinamik.

Interpretation of Arrhythmias 31
Sinus Arrest
Penyebab
Dominasi vagal pada SA node
Keracunan digitalis , quinidine
Ischemia pada SA node akibat dari IMA

Interpretation of Arrhythmias 33
Sinus Arrest
Tatalaksana
Bila periode pause sering muncul,mungkin diperlukan
Pace maker

Interpretation of Arrhythmias 34
SA Block
Tatalaksana
Bila periode block sering muncul,mungkin diperlukan
Pace maker
Penyebab PAC
Distensi atrium
Obat obatan
Irritabilitas otot atrium

Interpretation of Arrhythmias 40
Tatalaksana PAC
PACs yang jarang tidak memerlukan pengobatan
Bila penyebabnya nicotine, caffeine segera
berhentikan pemakaiannya
Terapi obat untuk PACs yang sering munculnya

Interpretation of Arrhythmias 41
Tatalaksana SVT
Beri oksigen
Vagals maneuvers
Adenosine ,Verapamil bila hemodinamik stabil
Synchronized cardiovertion

Interpretation of Arrhythmias 45
Atrial Flutter
Site of origin : satu fokus di atrium
Rate : atrium 250-350/1, 2-3-4 impulse
disalurkan hanya satu tiba di ventricle
ventricular rate 60 100 /1
Rhythm : regular
Flutter wave : gigi gergaji
PR interval :sulit diukur
QRS complex : same size & shape, <0.12 sec
Onset : mulai dan berhenti secara tiba-tiba

Interpretation of Arrhythmias 47
Penyebab Atrial Flutter
Gagal jantung
Katekolamine ( adrenalin, nor adrenaline ) berlebihan
Injury SA node

Interpretation of Arrhythmias 48
Tatalaksana Atrial Flutter
Nilai pasien ,stabil tidak?
Beri oksigen
Pasang infus
Bila tidak stabil : synchronized cardioversion, obat-
obatan

Interpretation of Arrhythmias 49
Atrial fibrillation
Site of origin : atria ,lebih dari satu fokus
Rate : atrium > 350/1
ventricular :<60 slow AF
60-100 controlled AF
101-150 Fast AF
> 150 - Uncontrolled AF
Rhythm : irregular
P wave : tak ada , diganti Fibrillatory wave
PR interval : sulit diukur
QRS complex : same size & shape, <0.12 sec

Interpretation of Arrhythmias 51
Tatalaksana AF
Nilai pasien stabil tidak?
Beri oksigen
Pasang infus
Bila tidak stabil : synchronized cardioversion, obat-
obatan ;digoxin,amiodarone
Bila tekanan darah rendah pikirkan dopamine

Interpretation of Arrhythmias 52
Ventricular Conduction

Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles through the ventricles
R on T PVC
2005 2010 73
Adult BLS
Algorithm

74
Pediatric
BLS
algorithm

75
76
b.

77
78
79