见习医师心电图教学基础.ppt

Introduction BasicoftheEKG MackeyMemorialHospital心臟內科楊翔惟 Normal12leadcompleteEKG V7 V9 ECGreading RateRhythm含interval PR QRS QTc AxisPwavePRsegmentandintervalQRSmorphology voltage anddurationST TsegmentQTcintervalUwave NormalRangesinMilliseconds PRInterval120 200msQRSComplex60 100msQTInterval360 440ms NormalECG STsegmentTPsegmentisusedasthereferencebaselineforSTelevationordepression IfHRisrapid PRsegmentmaybeused exceptatrialTwavepresent Twave AlwaysuprightinleadI IIinvertedinAVRNormal 0 5mm 6mminlimbleadNormal asymmetricalnormalabnormalInwomen TwaveuprightinV5 V6InvertinV1 50 V2 10 V3 rare NormalECG QTintervalHR45 115 0 46 0 30sec normallimit QTc QT RRnormalmen0 39secwomen0 41sec 0 44sec abnormal ECGreading RateRhythmAxisPwavePRsegmentandintervalQRSmorphology voltage anddurationST TsegmentQTcintervalUwave Calculatetherate Pacemakerrate Normalpacemaker SAnode 60 100 minJunctionaltissue 40 60 minLowerbundleofHis 40 50 minVentricularpacemaker 15 40 min idioventricularrhythm HR 300 RR間的大格數1500 RR間的小格數10秒的totalheartbeats 6 ReadingEKGSquares IntervalsandTiming Eachsquare 40ms 0 04秒 Eachinterval 200ms 0 2秒 Quits這張心跳幾下 ECGreading RateRhythm 含interval PR QRS QTc AxisPwavePRsegmentandintervalQRSmorphology voltage anddurationST TsegmentQTcintervalUwave 分析心律時 要謹記四個問題 這是P波嗎 QRS是寬的還是窄的 心律是否規則P波跟後面的QRS是不是有關係 AVblocksAVdissociation leadII的P波一定要向上才算NormalSinusRhythm NSR heartrate HR 在60 99beats min而且心律需規則SinusbradycardiaHR99但心律規則 對一般成年人來說 如果躺著心跳仍大於160beats min 那麼通常就不是來自sinus的心律了 Sinusarrhythmia心律不規則 但還是可以看到P波PPintervalvariation 120ms SinusRhythm Sinusarrhythmia SupraventricularArrhythmias 心室上的心律不整 其來源來自AVnodal以上的地點大部分是narrowQRScomplexAtrialFibrillation Af AFib MultipleAtrialTachycardia MAT AtrialTachycardia AT AtrialFlutter AFlutter AF PSVT ParoxysmalSupra VentricularTachycardia PrematureBeats PrematureAtrialContractions PAC 伴隨著窄的QRSPrematureJunctionalContractions PJC 伴隨著窄的QRSPrematureVentricularContractions PVC 伴隨著寬的QRS臨床上 比較具有重要意義的是 新出現的PVC 特別是在心肌梗塞後的病人身上 VentricularArrhythmias SlowIdioventricularescaperhythm 寬的QRScomplex 心室速率約30 40beats minAIVR AcceleratedIdioVentricularRhythm 心室速率 40beats min 但是不超過110 120beats minVentricularTachycardia 心室速率超過120 130beats minVentricularFibrillation 雜亂無章寬的QRScomplex QuitsWhat stherhythm 30 105 RateRhythmAxisPwavePRsegmentandintervalQRSmorphology voltage anddurationST TsegmentQTcintervalUwave ECGreading Traditional12 leadECG Rightaxisdeviation RAD 右心軸偏轉 LeadI andLeadAVF Leftaxisdeviation LAD 左心軸偏轉 LeadI andLeadAVF Extremeaxisdeviation心軸極度偏轉 QuitsWhat stheaxis Apatientofextremehyperkalemia ECGreading RateRhythmAxisPwavePRsegmentandintervalQRSmorphology voltage anddurationST TsegmentQTcintervalUwave NormalECG Pwave0 08 0 11secLeadI IIalwaysupright aVRinverted Why PRinterval0 12 0 20secshorterinchild longerintheelder 3 5小格 RAE1 Tall widePwaveinthelimbleads 2 5mminleadII andrightprecordialleads 1 5mminV1 2 OftenassociatedwithRVH LAEPwaveduration 0 12sinfrontalplane usuallyleadII TerminalPnegativityinleadV1 i e P terminalforce duration 0 04s depth 1mm PRdepressioninpericarditis QuitsWhat stheabnormality ECGreading RateRhythmAxisPwavePRsegmentandintervalCommonQRSmorphology voltage anddurationST TsegmentQTcintervalUwave NormalECG QRScomplex10 06 0 11sec thewidestinV1 V2 M F Axis 30 105 most 30 75 Amplitude decreaseinadvancedage 40y o women white obesity 小於 格 QwaveorDeltawave BundleBranchBlock CRBBB QRS 0 12scersR orrSR initialR0 05secWideSinI V5 V6 IncompleteRBBB QRS 120ms CompleteRBBB LBBBandRBBB CriteriaofcompleteBBB allofbelow QRS 0 12sSupraventricularrhythmAbsenceofWPWpatternCriteriaofcompleteLBBB allofbelow CriteriaofcompleteBBBBroadandnotchedorslurredRinIandV5orV6AbsenceofQwaveinIandV5andV6Rpeaktime 0 06sinV5orV6 Clockwise counterclockwiserotation NormallytheRwaveamplitudeincreasesfromV1toV5AroundV3orV4theRwavesbecomelargerthantheSwavesandthisiscalledthe transitionalzone Counterclockwiserotation EarlyRwaveprogression ashiftofthetransitionalzonetotherightofV2 Clockwiserotation PoorRwaveprogressionashiftofthetransitionalzonetotheleftofV5 Rightventricularhypertrophy LVH QuitsWhat stheabnormality ECGreading RateRhythmAxisPwavePRsegmentandintervalQRSmorphology voltage anddurationST TsegmentQTcintervalUwave NormalECG STsegmentTPsegmentisusedasthereferencebaselineforSTelevationordepression IfHRisrapid PRsegmentmaybeused exceptatrialTwavepresent Twave AlwaysuprightinleadI IIinvertedinAVRNormal 0 5mm 6mminlimbleadNormal asymmetri