心電圖易上手

ECG易上手王 遷Dept.ofMedicineDec.4th,2006SeminorIToStartoutWhat’sECG?心臟電活動的三維同步立體攝影IIIAVF（+90）IIIAVLAVR-90±180（0）WhentoECG?要訣：惠而不費立等可取心臟本身病變節(jié)律異常起搏點異常傳導(dǎo)異常血管異常冠脈血壓心肌異常心包異常心臟以外病變肺腦低體溫電解質(zhì)鉀鈣藥物代謝CalldeathHowtoECG？要訣：無它，唯手熟爾。幾種危險的心電圖趕緊叫老大?。?！要訣：啥叫易損期？實習(xí)醫(yī)師應(yīng)掌握的ECG惡性心律失常：竇停、Vf、VT、VF、III°AVB常見心律失常：PAC，PVC，Af，AVB，WPW，（BBB，PSVT，）心肌缺血：STEMI（演變、定位）電解質(zhì)紊亂：高鉀/低鉀藥物：洋地黃、長QT、其它：心包炎/積液、肺栓塞Let’sdoit!!!#101:RBBB型VT，不完全AV脫落，室性融合波#102:RBBB型VT（Brugada標(biāo)準(zhǔn)1）#103:RBBB型VT，LAD#104:RVOT-切口性RBBB型VT（Brugada標(biāo)準(zhǔn)1）#106:RVOT-VT(LBBB,RAD），2:1VA阻滯#107:左側(cè)室間隔VT（RBBB-LAD），2:1VA阻滯#108:RonT，尖端扭轉(zhuǎn)VT（由于普魯卡因酰胺）#113:II度2型AVB，不同的AV下傳比例#114:III度AVB，交界性逸搏，LVH伴勞損（缺血）Howtoread？6Aspects心率心律電軸轉(zhuǎn)位缺血和梗死肥厚抽絲剝繭忙而不亂要訣SeminarII：ArrhythmiaTheoneswhicharemostinteresting

快速心率300－150－100－75－60－50HR×10節(jié)律的基本概念如何判斷竇律：P波:

I,II,aVF,aVR,<0.12,<0.25mV固有頻率：竇－60-100；房－75；結(jié)－60；室－30～40加速頻率：傳導(dǎo)阻滯：SAB，AVB；MobitzI型和II型旁路：WPW心律失常鑒別要點過速？過緩？規(guī)則？不規(guī)則？QRS的寬窄寬QRS（要認(rèn)真思考）：必須首先假定為室性窄QRS找P波那個導(dǎo)聯(lián)看得清楚？P波的形態(tài)（竇性？P’波？f波？F波？形態(tài)是否一致）P波和QRS間的關(guān)系1:1?整倍數(shù)？脫落？PR間期代償間歇房顫

Irregularlyirregular寬QRS心動過速的DdxVTSVT伴差傳或旁路下傳人為干擾人為干擾Brugada標(biāo)準(zhǔn)LeadsV1-V6areinspectedtodetectanRScomplex.IftherearenoRScomplexes,concordanceispresentandthediagnosisofVTcanbemade.IfanRScomplexispresent,theintervalbetweentheonsetoftheRwaveandthenadiroftheSwave(RSinterval)ismeasured.IfthelongestRSintervalinanyleadis>100msec,thediagnosisofVTcanbemade.IfthelongestRSintervalis<100msec,thepresenceorabsenceofAVdissociationisassessed.IfAVdissociationisseen,thediagnosisofVTismade.IftheRSintervalis<100msecandAVdissociationcannotclearlybedemonstrated,theQRSmorphologycriteriaforV1-positiveandV1-negativewideQRScomplextachycardiasareconsideredV1positive(RBBB)pattern—InthepatientwithaWCTandpositiveQRSpolarityinleadV1,thefollowingassociationshavebeenmade[5,17,24-27]:

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FindingsinleadV1—AmonophasicRorbiphasicqRcomplexinleadV1favorsVT.

AtriphasicRSR'orRsR'complex(theso-called"rabbit-ear"sign)inleadV1usuallyfavorsSVT.Asanexception,iftheleftpeakoftheRsR'complexistallerthantherightpeak,VTismorelikely(likelihoodratio>50:1)[18,28].

-FindingsinleadV6—AnrScomplex(RwavesmallerthanSwave)inleadV6favorsVT(likelihoodratio>50:1)[18].Incontrast,anRscomplex(RwavelargerthanSwave)inleadV6favorsSVT.V1negative(LBBB)pattern—InthepatientwithaWCTandnegativeQRSpolarityinleadV1,thefollowingassociationshavebeenmade

-FindingsinleadV1orV2—AbroadinitialRwaveof40msecdurationorlongerinleadV1orV2favorsVT.Incontrast,theabsenceofaninitialRwaveorasmallinitialRwaveoflessthan40msecinleadV1orV2favorsSVT.TwootherfindingsthatfavorVTareaslurredornotcheddownstrokeoftheSwaveinleadV1orV2,andadurationfromtheonsetoftheQRScomplextothenadiroftheQSorSwaveof60msecinleadV1orV2.Incontrast,aswift,smoothdownstrokeoftheSwaveinleadV1orV2withadurationof<60msecfavorsSVT.Inananalysisofseveralstudies,thepresenceofanyofthesethreecriteria(broadRwave,slurredornotcheddownstrokeofSwave,anddelayednadirofSwave)wasastrongpredictorofVT(likelihoodratio>50:1)

-FindingsinleadV6—ThepresenceofanyQorQSwaveinleadV6favorsVT(likelihoodratio>50:1)[18].Incontrast,theabsenceofaQwaveinleadV6favorsSVT.SeminorIII：心肌缺血和梗死Theoneswhicharemostuseful缺血T波改變：正常：III和V1可倒置超急性期T波高尖：局部高鉀冠狀T波ST段壓低：損傷ST抬高/ST壓低：原理：從動作電位講起透壁梗死－Q波生理性Q波：I、avL、V5、V6病理性Q波：寬＞0.04″，深＞1/3R波心肌梗死的演變超急性期：T波高尖急性期：ST抬高－T波倒置Q波形成：恢復(fù)期：ST回到基線，T波繼續(xù)倒置室壁瘤STEMI診斷標(biāo)準(zhǔn)啥叫“相鄰”？IIIAVF（+90）IIIAVLAVR-90±180（0）幾個要注意的問題鏡向變化：注意后壁LBBB：R波進(jìn)展不良：鑒別：膈肌附近病變、肥厚性心肌病、腦血管意外Let’sdoit！#19：AMI（前壁），向側(cè)壁延展，心尖受累#20：廣泛前壁AMI