心电图基础与临床.ppt

DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 心电图 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 心电图的产生 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 心电通路 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 3 3 非不应期 4 4 绝对不应期 5 5 总不应期 超常期 6 6 1 2 AP与ECG1 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 0期 QRS波 去极化 AP与ECG2 0期 2期 1期 3期 4期 1期 J点 2期 ST断 3期 T波 4期 等电位线 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 常规心电图的波形组成和测量示意图 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU QRS波 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 振幅测量 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 时间测量 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 峰值测量 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 电轴测量 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 正常心电图1 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 正常心电图2 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 正常心电图特征及正常值 1 心电图纸 小方格 0 04s 横 0 lmV 纵 2 心率 正常为60 100bpm之间 3 心律 窦性心律 aVF V4 6直立 aVR为倒置 4 P波 aVF V4 6直立 aVR为倒置 T 0 11S 电压 肢导 0 25mV 胸导0 2 mV 5 P R间期 P波开始至QRS波群开始的时间 正常范围为0 12 0 20s 6 QRS波群 时间 0 06 0 10s 7 ST段 自J点开始至T波开始的一段 sT段平行的压低或斜向下的压低不正常 轻度抬高可见于正常人 8 T波 aVR导联倒置 余在R波高于0 5mV时均应直立 9 U波 V2 3中易见 正常应直立 10 Q T间期 QRS波开始至T波终了的间期 Q T间期与心率不符合的延长有较重要意义 异常缩短多为药物或电解质紊乱影响 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 窦性心律失常 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 窦性心动过速Sinustachycardia DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 窦性心动过缓Sinusbradychycardia DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 特点 1 Pvl负向波 0 04s 深 1 0mm 2 P 时间常超过O 11s 3 P 出现双峰 峰距常超过0 04s 4 P波宽度与P R段之比超过1 6 左房扩大leftatrialenlargement DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 右房扩大RightAtrialEnlargement 特点 l P波时间不延长2 Pv1高达0 15mv或P 高达0 25mv3 本图除右房大外 还有电轴右偏 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 左心室肥厚leftatrialhypertrophy DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 左心室肥厚特点1 QRs波群电压的改变 A 肢导 R 1 5mV R S 2 5mV Ravl 0 7 Ravf 2 0mvB 胸导 Rv5 Sv1 3 5mV 女 4 0mV 男 R5 R6 Sv1 Sv3 4 Omv2 心电轴 0 30度属电轴左偏 电轴左偏对诊断只有参考价值 3 QRS时间延长 可延长 0 09s 但不超过0 11s 4 ST T波改变 以R波为主的导联ST段下降超过0 05mv T波倒置 属不正常 原因 继发性或原发性 5 目前认为电压增高加以ST T改变 诊断左心室肥厚最为准确 仅有ST改变者为左心室 劳损 劳损的改变有时呈可逆的 仅有电压升高不能属于器质性病变 应属于正常范围心电图 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 右心室肥厚RightVentricularHypertrophy DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 右心室肥厚特点 1 QRS Rv1 1 OmV v1 R S l V5 R S1 2mVRavR 0 5mv avR R Q 2 心电轴右偏可达 110 对诊断右心室肥厚有较大意义 3 V1的室壁激动时间超过0 03s 诊断意义较大 4 ST T改变 V1 V2的ST下降 Tv1倒置 有参考价值 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 双侧心室肥厚 显著电轴右偏显著顺钟转位V1导联R S 1RavR 0 5mvV1的室壁激动时间 0 03s DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 双侧心室肥厚 近似正常心电图 出现一侧肥厚心电图改变 出现两侧肥厚心电图特征 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 房室传导阻滞 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 一度房室传导阻滞firstdegreeheartblock DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 2 1房室传导阻滞2to1AVblock DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 度1型 P R间期逐渐延长 直至P波落在房室结区的绝对不应期时 出现一次完全阻滞 可见于健康人 也可因迷走神经刺激如颈动脉窦受压 洋地黄中毒等所引起 多为暂时性 无需特殊治疗 度2型 系希氏束 浦顷野纤维传导系统病变所致 P R间期正常或延长 部分P波后无QRS波 房室阻滞比例多为2 1或3 1 型预后严重 多数存在房室结 房室束纤维化病变或损害 且有演变为 度AVB的危险 药物治疗或需安置起搏器治疗 单纯2度 无血流动力学紊乱情况 只要做好维护血流动力学稳定 无缺氧CO2蓄积 输液输血合理即可 术中伴有血流动力学显著波动 如血压下降 心率增快 缺氧 CO2蓄积等 则很可能转为3度AVB 必须有置入起搏器的准备 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 完全性房室传导阻滞CompleteHeartBlock P波与QRS波均规律发生 但P波与qrs波完全无关 心电图诊断1 窦性心律不齐2 度房室传导阻滞 室性逸搏心律 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 完全性房室传导阻滞伴心房纤颤trialfibrillationandcompleteheartblock DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 右束支传导阻滞RightBundleBranchBlock V1呈rsR 其余导联终末波粗qrs时间 0 12秒 为完全性右束支传导阻滞 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 房性早搏AtrialPrematureBeat DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 房性早搏二联律AtrialBigeminy DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 房颤的形成 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 心房纤颤伴左束支阻滞Atrialfibrillationwithpre existingLBBB DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 锯齿状规则的F波 频率300次 分左右患者因服用地高辛过量导致房室传导阻滞 心室律缓慢 心房扑动AtrialFlutter DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 锯齿状的F波一般在 AVF导联明显 有些时候在V1导联明显当心室率在150次 分的时候 应该想到可能有房扑2 1下传 心房扑动2 1传导Atrialflutterwith2 1AVconduction DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 交界性早博 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 特点 提前的宽大畸形的QRS波 T 0 12S 其前无相关P波 代偿间歇一般完全一次正常搏动后就有一次室早 称室早二联律 室早Ventricularprematurebeats DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 特点 1 急性下壁心梗2 室早二联律 急性心梗伴室早 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 特点 QRS宽大 形态多变R R间距多变QRS波看上去像围绕基线扭转可见于以下情况 心脏传导阻滞 低血钾或低血镁 药物 如 三环类抗抑郁剂过量 先天性QT延长综合征 其他QT延长的原因 尖端扭转性室性心动过速 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU W P W综合症Wolff Parkinson Whitesyndrome DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU PR间期缩短 0 12s 没有 波 下侧壁ST T改变和左室高电压 L G L综合症Lown Ganong LevineSyndrome DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 急性下壁心梗Acuteinferiormyocardialinfarction DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 急性前壁心梗Acuteanteriormyocardialinfarction DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 下壁前壁心肌梗塞并左束支阻滞 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 1 AVF异常Q波 T 0 04S H 同导联R波的1 42 房颤 陈旧下壁心梗 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 1 QT间期缩短2 特征性ST T改变 ST T融合呈鱼钩样改变 V5 V6 3 节律异常 一般见于洋地黄中毒 室性或房性早搏 阵发性房速及不同程度的房室传导阻滞 室速 室颤 其他 洋地黄效应Digitaliseffect DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 低钾血症Hypokalaemia 1 T波变小或消失2 U波增高突出3 到 度房室传导阻滞4 ST段轻微压低 DepartmentofAnesthesiology TheFirstHospitalofNanHuaUniversityZhiGang ZHOU 1 P波变小或消失2 房颤3 QRS波增宽4 ST段变短或消失5 T波基底部变窄 T波高尖呈帐篷状6 室颤 高钾血症