心电图基础.ppt

心电图阅读的基础与方法,心率节律间期电轴肥大梗死临床相关性,1912年,CambridgeInstrument,心电图的地位与作用,心电图阅读的基本问题,正常心电图？异常心电图？,正常心电图,异常心电图,BasicCompetencyinElectrocardiography,(Modifiedfrom:ACC/AHAClinicalCompetenceStatement,JACC2019;38:2091),NORMALTRACINGNormalECGTECHNICALPROBLEMLeadmisplacedArtifactSINUSRHYTHMS/ARRHYTHMIASSinusrhythm(50-90bpm)Sinustachycardia(90bpm)Sinusbradycardia(50bpm)SinusArrhythmiaSinusarrestorpauseSino-atrialexitblock,OTHERSVARRHYTHMIASPACs(nonconducted)PACs(conductednormally)PACs(conductedwithaberration)Ectopicatrialrhythmortachycardia(unifocal)MultifocalatrialrhythmortachycardiaAtrialfibrillationAtrialflutterJunctionalprematuresJunctionalescapesorrhythmsAcceleratedJunctionalrhythmsJunctionaltachycardiaParoxysmalsupraventriculartachycardia,VENTRICULARARRHYTHMIASPVCsVentricularescapesorrhythmAcceleratedventricularrhythmVentriculartachycardia(uniform)Ventriculartachycardia(polymorphousortorsades)Ventricularfibrillation,AVCONDUCTION1stdegreeAVblockTypeI2nddegreeAVblock(Wenckebach)TypeII2nddegreeAVblock(Mobitz)AVblock,advanced(highgrade)3rddegreeAVblock(junctionalescaperhythm)3rddegreeAVblock(ventricularescaperhythm)AVdissociation(default)AVdissociation(usurpation)AVdissociation(AVblock),INTRAVENTRICULARCONDUCTIONCompleteLBBB,fixedorintermittentIncompleteLBBBCompleteRBBB,fixedorintermittentIncompleteRBBBLeftanteriorfascicularblock(LAFB)Leftposteriorfascicularblock(LPFB)NonspecificIVCDWPWpreexcitationpattern,QRSAXISANDVOLTAGERightaxisdeviation(+90to+180)Leftaxisdeviation(-30to-90)Bizarreaxis(-90to-180)IndeterminateaxisLowvoltagefrontalplane(0.5mV)Lowvoltageprecordial(1.0mV),HYPERTROPHY/ENLARGEMENTSLeftatrialenlargementRightatrialenlargementLeftventricularhypertrophyRightventricularhypertrophy,ST-T,ANDUABNORMALITIESEarlyrepolarization(normalvariant)NonspecificST-TabnormalitiesSTelevation(transmuralinjury)STelevation(pericarditispattern)SymmetricalTwaveinversionHyperacuteTwavesProminentuprightUwavesUwaveinversionProlongedQTinterval,MIPATTERNS(acute,recent,old)InteriorMIInferoposteriorMIInferoposterolateralMITrueposteriorMIAnteroseptalMIAnteriorMIAnterolateralMIHighlateralMINonQ-waveMIRightventricularMI,CLINICALDISORDERSChronicpulmonarydiseasepatternSuggestshypokalemiaSuggestshyperkalemiaSuggestshypocalcemiaSuggestshypercalcemiaSuggestsdigoxineffectSuggestsdigoxintoxicitySuggestsCNSdisease,PACEMAKERECGAtrial-pacedrhythmVentricularpacedrhythmAVsequentialpacedrhythmFailuretocapture(atrialorventricular)Failuretoinhibit(atrialorventricular)Failuretopace(atrialorventricular),Theectopicatrialrateis150bpm.SomeoftheectopicPwavesareeasilyseenandindicatedbythearrows.OtherPwavesareburriedintheTwavesandnotsoeasilyidentified.AtrialtachycardiawithAVblockisoftenasignofdigitalisintoxication.3:2and2:1AVblockisseeninthisexample.,心率节律间期电轴肥大梗死临床相关性,心率节律间期电轴肥大梗死临床相关性,心率节律间期电轴肥大梗死临床相关性,心电图讨论,记住,心率节律间期电轴肥大梗死临床相关性,心率节律间期电轴肥大梗死临床相关性,心率节律间期电轴肥大梗死临床相关性,心率节律间期电轴肥大梗死临床相关性,心率节律间期电轴肥大梗死临床相关性,图中箭头所指的是什么？,这是什么图型？,心率节律间期电轴肥大梗死临床相关性,这是什么图型？,心率节律间期电轴肥大梗死临床相关性,问题在哪里？,问题在哪里？,请给出诊断,心率节律间期电轴肥大梗死临床相关性,请给出诊断,心率节律间期电轴肥大梗死临床相关性,这是什么图形？,心率节律间期电轴肥大梗死临床相关性,这是什么图形？,心电图诊断?,心电图诊断?,心率节律间期电轴肥大梗死临床相关性,心电图诊断?,心率节律间期电轴肥大梗死临床相关性,Matchthetracingswiththecorrectinterpretation,A.SecondDegreeBlockType1B.PACC.SecondDegreeBlockType2D.ParoxysmalSupraventricularTachycardia,Matchthetracingswiththecorrectinterpretation:,A.VentricularTachycardiaB.SecondDegreeBlockType1(Wenckebach)C.JunctionalRhythmD.WanderingAtrialPacemaker,Thecorrectmatches？,ClinicalCases,Case1：A60-year-old“walk-in”patientwithoutaprimarycarephysicianarrivesatyourclinicneartheendofabusyafternoonclinicsession.Thepatientisnotonanymedicationsandhasnotseenaphysicianinyears.Thepatientcomplainsofseveralhoursofseverechestpressureandashelivesnearbyhethoughthewouldcometoyourclinicandtrytoseeaphysician.Althoughthevitalsignswereremarkableonlyforsomebradycardia,themedicalassistantisconcernedthatthepatientappearsill.Astatecgwasdoneandyouareaskedtoseethispatientimmediately.Thefollowingecgishandedtoyouasyouareonyourwaytoseethispatient.一位既往无特殊病史的60岁的患者傍晚走进了你的诊所就诊.该患者未曾服用任何药物，数年来也未曾就诊过.这次来主要是因为胸部压迫感持续了数小时不缓解.表情痛苦，脉搏较缓慢，入院后随即做了心电图，如下图所见：,心率节律间期电轴肥大梗死临床相关性,Case1Answer,心率-50节律-窦性心动过缓间期-PR、QRS间期正常电轴-正常肥大-无梗死-V1-V4导联ST段抬高，提示急性心肌损伤临床相关性-急性心梗是临床特别是急诊科常见的急危症之一.结合其剧烈胸痛及急性前壁损伤的心电图表现，该患者的情况不容乐观.于是立即拨打120启动急救系统,Case2,A55-year-oldpatientcomesintogetyouradviceonstartinganewexerciseprogramtogetbackintoshape.Theprograminvolvesheavyaerobicworkoutsandheneedsaformfilledoutthatheismedicallyclearedtoparticipateinthisworkoutprogram.Intalkingtohimyoulearnhehascardiacriskfactorsforsmoking,positivefamilyhistory,highcholesterolandhypertension.Hehasasedentarylifestyleandhasnotparticipatedinanystrenuousphysicalactivityforyears.Althoughhiscardiorespiratoryreviewofsystemsisnegative,youareconcernedthathisactivitylevelisverylimitedandhehassignificantriskfactors.Aspartoftheworkupyouobtainthefollowingecgtointerpret:一位55岁的患者想通过参加一种新的锻炼保持体形，该锻炼方式对体力要求很大.你对该患者详细评估后发现他虽然无心肺疾患的体征，但是存在诸多危险因素：吸烟，阳性家族史，高胆固醇血症，经常坐着，很少运动.故告知该患者他的运动量是受限的，下图是他的心电图:,Case2Answer,心率约70节律窦性心率并1度房室传导阻滞间期-PR间期延长至.2S,QRS时限正常电轴正常肥大左室肥大伴劳损图形梗死V2、V3导联可见Q波，可能为前间壁陈旧性心梗临床相关性此类病人临床上不能轻易放走.他有众多的危险因素，且心电图有陈旧性心梗改变，故需进一步检查评估心脏情况.,Case3,一位70岁的女性高血压患者来访.一直在服用利尿剂，近几天自觉心率较乱，且轻微眩晕.既往心电图提示正常.体检脉搏为130，其余体检阳性体征未及.如下图是她的心电图：A76-year-oldpatient,withahistoryofhypertension,comestoseeyou.Sheiscurrentlyonadiureticprescriptionandiscomplainingofafewdaysofskippedheartbeats.Shehasfeltslightlydizzylatelybutdoesnothaveanyothersymptoms.Overallshehasbeenfeelingwell,heronlymedicalissuehasbeenhypertension.Previouselectrocardiogramsinherchartshownormalsinusrhythmandareotherwiseunremarkable.Herexamshowsanirregularpulseinthe130raterangebuttherestoftheexamisunremarkable.Youobtainthefollowingelectrocardiogram,Case3Answer,心率在130-150之间节律房颤间期-PR无法测量,QRS时限正常电轴正常(aVF向下，II向上)肥大-无梗死无临床相关性-房颤是最常见的心律失常之一，常见于老年患者，是血栓事件发生的主要原因.对于该患者应积极寻找病因，并给予常规治疗：如控制心室率，抗凝，抗心律失常等.,Case4,A35-year-oldmancomesin