ECG presentation课件

1、1,Basic Arrhythmias, 2011 American Heart Association. Do not edit.,2,Objectives,Explain Heart Anatomy and Basic Electrophysiology Explain Normal ECG Measurements Recognize and Understand Basic Arrhythmias,3,Basic ArrhythmiasContent,Basic Anatomy Electrophysiology Baseline ECG Parameters Normal Sinus

2、 Rhythm,4,Sinus Bradycardia and Tachycardia Supraventricular Arrhythmias Ventricular Arrhythmias Asystole and Pulseless Electrical Activity (PEA) Atrioventricular Block Atrial and Ventricular Pacing,Basic ArrhythmiasContent,5,Basic Arrhythmias,Cardiac Anatomy Understanding Electrophysiology,6,Anatom

3、y of the Heart,AO = Aorta,LA = Left Atrium,RA = Right Atrium,RV = Right Ventricle,LV = Left Ventricle,RA,LA,RV,LV,AO,PA = Pulmonary Artery,PA,7,Conduction System Anatomy,Sinus Node Internodal Pathways Atrioventricular (AV) Node,Common Bundle of HisLeft Bundle BranchRight Bundle BranchPurkinje System

4、,RV,LV,8,Pacemakers of the Heart,Sinus Node60-100 bpm,Purkinje System 30-40 bpm or less,AV Node (junctional cells) 40-60 bpm,Failure of a pacemaker allows a subsidiary pacemaker to fire.,His Bundle,9,Anatomy of the ECG,P wave PR interval QRS complex ST segment T wave QT interval,p,PR,QT Interval,ST

5、Segment,AVN,10,Mean Electrical VectorPositive and Negative,Positive Electrode,Current Toward Electrode,Current Away From Electrode,Negative Electrode,11,Lines and Calibration,10 mV,What is the approximate PR interval in this rhythm strip?,1 millivolt (mV) = 1 mm,12,ECG Measurements,PR interval0.12 0

6、.20 s QRS complex0.12 s QT intervalCorrected for Heart Rate,13,Heart Rate Estimation,Pick a complex that falls on a heavy line Then estimate the rate by counting heavy boxes Using 300, 150, 100, 75, 60, 50, 40, 30,So about 75,150 100 75 60 50 40 30,300,14,Standard Monitoring Leads Lead 1,15,Standard

7、 Monitoring Leads Lead 2,16,Standard Monitoring Leads Lead 3,17,12-Lead ECGThe Big Picture,=,18,19,Basic Arrhythmias,Rhythm Strip Interpretation Normal Sinus Rhythm Sinus Bradycardia Sinus Tachycardia,20,Initial ApproachAnalysis4 Questions,Rate? Normal Bradycardia, Tachycardia Rhythm? Regular or Irr

8、egular Are there P waves? Is each P wave related to a QRS with 1:1 impulse conduction? QRS normal or wide?,21,ArrhythmiasEtiology,Disturbance in Automaticity Pacemaker speeds up New pacemaker takes over Disturbance in Conduction Slowing or block in conductionof electrical impulse Combination of Both

9、 Reentry arrhythmias,22,Normal Sinus Rhythm,Rate Rhythm P waves P QRS Therapy,60-100/min Regular Present 1:1 conduction None,23,Sinus Bradycardia,Rate Rhythm P waves P QRS Therapy,60/min Regular Present 1:1 conduction Treat underlying cause,24,Sinus Tachycardia,Rate Rhythm P waves P QRS Therapy,100/

10、min Regular Present 1:1 conduction Treat underlying cause,25,Self-Assessment,What are the rate and rhythm?,26,Self-Assessment,What is this rhythm?,If there is no pulse, what is this rhythm?,27,Basic Arrhythmias,Supraventricular Arrhythmias Premature Atrial Contraction (PAC) Premature Atrial Beat (PA

11、B) Atrial Premature Beat (APB)Premature Atrial Complex Atrial Fibrillation Atrial Flutter Reentry Tachycardia,28,Premature Atrial Contraction (PAC),Sinus rate Irregularinterrupted by PAC Incomplete compensatory pause Different morphology Usually conducted with normal QRS Treat underlying cause,Rate

12、Rhythm P waves P QRS Therapy,QRS Normal,29,Premature Atrial Contraction (PAC),30,Atrial Fibrillation,Atrial rate cannot be measured Ventricular ratevariable Irregular (irregularly irregular) Absent (fibrillation waves) Conduction irregular Slow ventricular rate Treat underlying cause,Rate Rhythm P w

13、aves F QRS Therapy,31,Atrial Flutter,Atrial rate 250-400/min (often 300) Ventricular ratevariable Regular (2:1 AV block common) Absent (flutter waves) Conduction regular (unless variable block) Slow ventricular rate: terminate arrhythmia Treat underlying cause,Rate Rhythm P waves F QRS Therapy,QRS N

14、ormal,32,Supraventricular Tachycardia (SVT),AV Nodal Reentry Tachycardia,AV Reentry Tachycardia,Atrial Tachycardia,Connection between atria and ventricle,Uses dual pathway within AV node,Ectopic atrial focus,33,Reentry (Paroxysmal) SVTAV Nodal Reentry Tachycardia,Dual AV Nodal Pathway,PAC , Blocked

15、in fast pathway,Allowing reentry,Should the QRS complex normally be narrow or wide?,34,Supraventricular Tachycardia (SVT),AV Reentry Tachycardia,Connection between atria and ventricle,Connection between atria and ventricle,What is different between these 2 examples? (Look carefully at the arrow dire

16、ctions),Is the QRS complex normal or wide for each? Why?,35,Reentry (Paroxysmal) SVT,Atrial rate 150-250/min Onset tachycardia abrupt Regular Presentinverted in leads 2, 3, and aVF Conduction regular Vagal maneuvers, adenosine, synchronized cardioversion,Rate Rhythm P waves P QRS Therapy,Usually ons

17、ets with PAC,QRS Normal,36,Self-Assessment,What are the rate and rhythm?,37,Clinical Correlation,This patient is unresponsive and BP is 70/50 mm Hg. What is the rhythm? What is your next action?,38,Basic Arrhythmias,Ventricular Arrhythmias Premature Ventricular Contraction (PVC) Ventricular Prematur

18、e Contraction (VPC) Premature Ventricular Beat (PVB)Premature Ventricular Complex Ventricular Tachycardia Ventricular Fibrillation Asystole Pulseless Electrical Activity (PEA),39,Premature Ventricular Contraction (PVC),Compensatory pause Sinus node continues to discharge,40,Premature Ventricular Con

19、traction (PVC),41,Comparison of PVC and PAC,42,Mechanism PVCs,Unidirectional Block,Reentry,Purkinje Fiber,Muscle Fiber,43,PVC MorphologyMatch the Name,Unifocal PVCs Multifocal PVCs Bigeminy Ventricular Tachycardia Torsades,44,Ventricular TachycardiaMonomorphic*,Atrial rate normal Onset tachycardia a

20、brupt Regular Presentobscured Blockedfusion complexes possible Antiarrhythmic agent, cardioversion, high-energy (defibrillation dose) shock,Rate Rhythm P waves P QRS Therapy,*Sustainedrequires intervention for 30 seconds,45,Ventricular Tachycardia,FUSION BEAT An occasional sinus impulse “catches” th

21、e AV node repolarized. The resulting beat is part supraventricular and part ventricular in morphology.,Sinus Node Fires,X,AV node refractory from PVC below,X,X,X,VT,F,P wave present but blocked. Occasionally seen “buried” in the QRS or T wave,46,Polymorphic VT*,Atrial rate normal (obscured) Onset ta

22、chycardia abrupt Irregular Presentobscured Blockedfusion complexes possible Unsynchronized high-energy shock, magnesium (beneficial with baseline QTC prolongation),Rate Rhythm P waves P QRS Therapy,*Torsades de pointesQT prolonged,47,Ventricular Fibrillation,Chaotic, uncountable Onset abrupt Irregul

23、ar Absent; no normal QRS complexes Not applicable Immediate shock(s),Rate Rhythm P waves P QRS Therapy,Coarse VF,48,Ventricular Fibrillation,Chaotic, uncountable Onset abrupt Irregular Absent; no normal QRS complexes Not applicable Immediate shock(s),Rate Rhythm P waves P QRS Therapy,Fine VF,49,Asys

24、tole,Absent None“flatline” Absent Not applicable CPR, vasopressor, atropine,Rate Rhythm P waves P QRS Therapy,Agonal Complexes Pulseless Electrical Activity,ASYSTOLE,50,Pulseless Electrical Activity (PEA),Variabledepends on baseline rhythm PEA is not a single rhythm but any organized rhythm without

25、a pulse Identify and treat underlying cause CPR, vasopressor,Rate Rhythm Therapy,ARTERIAL PRESSURE,51,Self-Assessment,What are the rate and rhythm?,52,Clinical Correlation,You see this rhythm on the monitor while standing next to the patient. How many rhythms do you see? What is your first action?,5

26、3,Basic Arrhythmias,Atrioventricular Blocks First-Degree AV Block Second-Degree AV Block Third-Degree AV block,54,Atrioventricular Blocks Classification,Complete AV Block Third-Degree AV Block,Incomplete AV Block First-Degree AV Block Second-Degree AV Block,Type IWenckebach Mobitz I Type IIMobitz II

27、,55,Atrioventricular Block Normal AV Conduction,Underlying sinus rhythm One P wave PR interval 0.12 to 0.20 second One P wave for each QRS,56,First-Degree AV Block,Underlying sinus rhythm One P wave PR interval 0.20second One P wave for each QRS,57,Underlying sinus rhythm One P wave PR interval 0.20

28、second One P wave for each QRS,First-Degree AV Block,58,Underlying sinus rhythm P wave fails to periodicallyconduct PR interval prolonged One P wave for each QRS until block,PR interval,AV Nodal Tissue,His-Purkinje System,0.20 seconds,Sinus Node,QRS,X,P,Second-Degree AV BlockMobitz IWenckebach Pheno

29、menon,59,Underlying sinus rhythm One P wave PR interval usually normal, no prolongation One P wave for each QRS until sudden block and dropped QRS,Second-Degree AV BlockMobitz II,60,Underlying sinus rhythm (usual) Escape junctional rate 40-60 PR interval variable P waves unrelated to QRS Narrow QRS

30、= block above His junction,Third-Degree AV BlockJunctional Escape,61,Underlying sinus rhythm (usual) Escape ventricular rate 30-40 PR interval variable P waves unrelated to QRS Wide QRS = block below His junction,Third-Degree AV BlockVentricular Escape,62,AV BlockWhich Type?,63,Clinical Correlation,What treatment is indicated?,An athlete in the ED with a sprained ankle,A diabetic woman in the ED with chest tightness,64,What treatment is indicated?,A 78-year-old woman with altered consciousness, BP 80/60 mm Hg,External pacer not immediat