心脏起搏器培训资料：心脏的传导系统

1、Cardiac Conduction System 心脏的传导系统心脏的传导系统 Properties of cardiac tissue: Selective permeability Excitability Conductivity Automaticity Components of the Electrical System 心脏组织的特性: 选择性的通透性 兴奋性 传导性 自律性 电传导系统的组成 Terminology Polarized: No flow of electricity; balanced or resting state; the inside of the c

2、ell membrane is more (-) as related to outside. Depolarization: Movement of ions reflecting a flow of electrical current to cells along the pathway of conduction; the inside of the cell membrane is more (+) as related to outside; allows contraction. Repolarization: Return to resting state. 术语术语 极化：无

3、电流；平衡或静息状态；细胞膜内比 膜外有更多的 (-) 除极：离子的移动，电流通过传导通道进入细 胞；细胞膜内比膜外有更多的 (+)；引起收缩 复极：恢复到静息状态 cell membrane K+ Na+ Na + Ca+ K+ ATP ase 0 1 2 3 4 ARP RRP Diastole Actin filament Myosin Excitability Automatism 心电生理 细胞膜 K+ Na+ Na + Ca+ K+ ATP 酶 0 1 2 3 4 ARP RRP 舒张 肌动蛋白纤维 肌球蛋白 兴奋性 自律性 Phases of Cardiac Action Pot

4、ential Five Phases Total Phase 0 Depolarization Phase 1 - 3 Repolarization Phase 4 Resting phase 心脏动作电位的时相 共5个时相 0相 除极 1 3相 复极 4相 静息相 Refractory periods ERP RRP Vulnerable window 不应期 ERP RRP 易损窗口易损窗口 ECG Limb Leads StandardAugmented ECG 肢体导联 标准加压 ECG Chest Leads ECG 胸导联 ECG QRS Vector ECG QRS向量 ECG

5、Components P wave PR interval QRS complex T wave QT interval ECG组成 P波 PR间期 QRS波群 T波 QT间期 Specialized Cardiac Network Atria Sinoatrial (SA) Node Ventricles Atrioventricular (AV) Node Bundle of HIS Purkinje Fibers 特有的心脏传导系统 心房 窦房(SA)结 心室 房室(AV)结 希氏束 浦氏纤维 Cardiac Stimulation 心脏刺激 SA Node 窦房结 Atrial Dep

6、olarization 心房除极 AV Node 房室结 AV Delay (PR Interval) PR间期 Junctional Rhythm 交界区节律 Bundle of His 希氏束 Right and Left Bundle Branches 左束支和右束支 Ventricular Depolarization 心室除极 Ventricular Repolarization 心室复极 QT Interval Represents ventricular depolarization and repolarization combined. Length is dependent

7、 upon heart rate. QT interval represents the time of ventricular depolarization and repolarization QT间期 代表心室除极和复极， 其长度基于心率的快慢 QT间期代表心室除极和复极的时间 The Cardiac Cycle 心动周期 Dubin, Dale, M.D., Rapid Interpretation of EKGs, Tampa, Florida; Cover Publishing Company, 2000:29 心心 房房 除除 极极 心室心室 除极除极 心室复极心室复极 平台期平

8、台期 快速期快速期 ECG ECG Graph ECG ECG网格 ECG intervalles 0.1mV 0.5mV 120-200 ms 1 big box 120ms 3 sm boxes 400 ms By Dubin Rapid Interpretation of EKGs ECG间期 0.1mV 0.5mV 120-200 ms 1大格大格 120ms 3小格小格 400 ms By Dubin Rapid Interpretation of EKGs Summary of Electrocardiographic Components Remember : Small Box

9、 = _ ms and Large Box = ms (25 mm Paper Speed) 40 200 ECG组成 记住 : 小格 = _ ms ，大格 = _ ms(25 mm/s 走纸速度) 40 200 Component Measurements Normal timing or duration is measured along the horizontal axis R-R or P-P interval: interval measured between the peaks of two consecutive R- or P-waves to determine hea

10、rt rate (Normal 60 to 100 beats per minute) PR interval: measured from the onset of the P-wave to the onset of the first deflection in the QRS (Normal 100 - 200 ms) QRS interval: measured from the onset of the QRS complex to the termination of the S-wave (Normal 60 - 120 ms) 200 ms 120 ms 1000 ms EC

11、G中各部分的测量 沿水平轴进行测量 R-R或P-P间期：测量两连续R或P波峰值之间的距离，确定心率(正常 值60 - 100次/分) PR间期：测量从P波起始部至第一个QRS波群起始部之间的距离(正常 值100 - 200 ms) QRS波群时限：测量从QRS波群起始部至S波结束处之间的距离 (正常 值60 - 120 ms) Rhythm Interpretation Determine heart rate -Ventricular -Atrial Evaluate rhythm (regularity) Examine P-waves Measure P-R interval Measu

12、re QRS duration Identify normal or abnormal rhythm 节律诊断 决定心率 心室 心房 评估节律 (规律性) 检查P波 测量P-R间期 测量QRS波群时限 识别正常或不正常的节律 Rhythm Interpretation Determine heart rate -Ventricular -Atrial Evaluate rhythm (regularity) Examine P-waves Measure P-R interval Measure QRS duration Identify normal or abnormal rhythm 决

13、定心率 心室心室 心房心房 评估节律 (规律性) 检查P波 测量P-R间期 测量QRS波群时限 识别正常或不正常的节律 节律诊断 R-R Interval Method (msecnbpm) Heart rate = = bpm 60,000 ms cycle length 60,000 880 = 68 bpm R-R间期方法（ms bpm） 测量间期的ms值 心率 = = bpm 60,000 ms 周期长度 60,000 880 = 68 bpm Large box: 5 mm = 200 ms Small box: 1 mm = 40 ms Six-Second Count Metho

14、d 大格: 5 mm = 200 ms 小格: 1 mm = 40 ms 6s 间期 3s 间期3s 间期 6秒计算方法 Six-Second Count Method 6秒计算方法 6s 间期 3s 间期3s 间期 心率大约90bpm （实际心率90bpm） The Triplicate Method Triplicate方法 心率大约心率大约70bpm Determination of Heart Rate Summary 判断心率 间期间期 2个个QRS波群波群 之间的之间的 大格数大格数 bpm Determination of Heart Rate Summary 判断心率 Rhyt

15、hm Interpretation Determine heart rate -Ventricular -Atrial Evaluate rhythm (regularity) Examine P-waves Measure P-R interval Measure QRS duration Identify normal or abnormal rhythm 节律诊断 决定心率 心室心室 心房心房 评估节律 (规律性) 检查P波 测量P-R间期 测量QRS波群时限 识别正常或不正常的节律 Regularity 规律性 如果如果R波之间的距离相等，则节律规律波之间的距离相等，则节律规律 如果如

16、果R波之间的距离不相等，则节律不规律波之间的距离不相等，则节律不规律 Rhythm Interpretation Determine heart rate -Ventricular -Atrial Evaluate rhythm (regularity) Examine P-waves Measure P-R interval Measure QRS duration Identify normal or abnormal rhythm 节律诊断 决定心率 心室心室 心房心房 评估节律 (规则与否) 检查P波 测量P-R间期 测量QRS波群时限 识别正常或不正常的节律 P波 Rhythm In

17、terpretation Determine heart rate -Ventricular -Atrial Evaluate rhythm (regularity) Examine P-waves Measure P-R interval Measure QRS duration Identify normal or abnormal rhythm 节律诊断 决定心率 心室心室 心房心房 评估节律 (规则与否) 检查P波 测量P-R间期 测量QRS波群时限 识别正常或不正常的节律 PR Interval Determination Measured from the beginning of

18、 the P-wave as it leaves baseline to the beginning of the QRS complex. PR间期的测量 测量从P波开始至下一组QRS波群开始 正常值 = 100-200ms Rhythm Interpretation Determine heart rate -Ventricular -Atrial Evaluate rhythm (regularity) Examine P-waves Measure P-R interval Measure QRS duration Identify normal or abnormal rhythm

19、节律诊断 决定心率 心室心室 心房心房 评估节律 (规则与否) 检查P波 测量P-R间期 测量QRS波群时限 识别正常或不正常的节律 QRS Interval Determination Measured from the beginning of the QRS as the first wave leaves baseline to the point where the last wave of the complex begins to flatten out. QRS 间期的测量 测量从QRS波群的第一个波的开始至最后一个波的结束 正常值 = 60-120ms Types of Ve

20、ntricular Complexes (QRS) QRS波群的不同形态及命名法 Practice: Determine Rate 100 bpm, controlled RR Intervals: irregularly irregular No P-waves, chaotic electrical activity or fib waves seen QRS morphology is usually normal 房颤 ECG标准： 心室率：100-180bpm，未控制；100 bpm Intervals: Usually regular Wide, bizarre QRS compl

21、ex morphology Defined as three or more PVCs in a row Abrupt onset and termination if non-sustained 单形性室性心动过速 ECG标准： 频率：心室率 100 bpm 通常间期规则 宽大、畸形的QRS波群 定义：3个或3个上连续的PVC 突发突止 Ventricular Tachycardia, Polymorphic ECG Criteria: Rate: Usually 200 bpm Intervals: Irregular Wide, bizarre QRS complex morpholog

22、y 多形性室性心动过速 ECG标准： 频率：通常 200 bpm 间期不规则 宽大、畸形的QRS波群 Ventricular Fibrillation ECG Criteria: Rate: Too fast to measure, 300 bpm Wide, irregular, chaotic wave No discernible P-QRS-T waves present Will cause clinical death within 4 6 minutes if not treated 室颤 ECG标准： 频率：太快，无法测量，300 bpm 宽大、不规则、紊乱的波 无法辨认P-Q

23、RS-T波 如果4-6分钟内未得到救治，患者可能死亡 Asystole / Cardiac Standstill ECG Criteria: Complete absence of ventricular electrical activity May see P-waves only 心脏停搏 ECG标准： 心室电活动完全丧失 可能仅看见P波 ECG Workshop Practice Rhythm Strips ECG Workshop Practice Strip #1 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:

24、_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ Not measurableNot measurable 188 bpm Regular Not measurable 60 80 msec Supraventricular tachycardia 练习（1） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 无法测量无法测量 188 bpm规则 无法测量 60 80 ms 室上性心动过速 Practice Strip #2 Atrial Rate:_P-P Interval:_ Ve

25、ntricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 125 bpm Regular (except for 7th one) 125 bpm Regular 120 msec 60 msec Sinus tachycardia with one PAC 练习（2） 心房率：_P-P间期：_ 心室率：_ R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 125 bpm 规则（除了第7个） 125 bpm规则（除了第7个） 120 ms 60 ms 窦性心动过速伴1个P

26、AC Practice Strip #3 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 61 bpm (at end of strip) Cannot determine 136 bpm (at start) Regular (at start) 160 msec (at end) 80 msec SVT with one junctional beat and two sinus beats 练习（3） 心房率：

27、_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 61 bpm（结束时） 不能确定 136 bpm（开始时） 规则（开始时） 160 ms（结束时） 80 ms SVT伴1个结性心律和2个窦性心律 Practice Strip #4 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 67 bpm Regular VariableIrregular Variable 40 mse

28、c Second degree heart block, Mobitz I 练习（4） 心房率：_P-P Interval:_ 心室率：_R-R Interval:_ PR间期：_ QRS波群时限：_ 节律诊断：_ 67 bpm 规则 可变的不规则 可变的 40 ms IIAVB，莫氏I型 Practice Strip #5 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 70 bpm Regular 30 bpm

29、Regular Not applicable 120 msec Third degree heart block 练习（5） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 70 bpm 规则 30 bpm 规则 不适用 120 ms IIIAVB Practice Strip #6 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 56 bpm (variable)

30、Irregular 56 bpm (variable) Irregular 160 msec 80 msec Sinus bradycardia with sinus pause 练习（6） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 56 bpm (可变的)不规则 56 bpm (可变的) 不规则 160 ms 80 ms 窦性心动过缓伴长间歇 Practice Strip #7 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS

31、Duration:_ Rhythm Interpretation:_ 108 bpmRegular 54 bpm Regular 200 msec 80 msec Second degree heart block, Mobitz II 练习（7） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 108 bpm规则 54 bpm 规则 200 ms 80 ms IIAVB，莫氏II型 Practice Strip #8 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ P

32、R Interval:_ QRS Duration:_ Rhythm Interpretation:_ 105 bpmRegular (where present) 105 bpmRegular (on non-ectopics) 140 msec 100 msec ST with two PVCs and a 4 beat run of ventricular tachycardia 练习（8） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 105 bpm规则 105 bpm规则（没有PVC时） 140 ms 100 ms ST伴2个PV

33、C和1阵VT Practice Strip #9 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 60 bpmRegular 60 bpmRegular 160 msec 100 msec Sinus rhythm with one PJC 练习（9） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 60 bpm规则 60 bpm规则 160 ms 100 ms 窦

34、性节律伴1个PJC Practice Strip #10 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 105 bpm Regular 42 bpmRegular Not applicable 160 msec Third degree heart block 练习（10） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 105 bpm 规则 42 bpm规则 不

35、适用 160 ms IIIAVB Practice Strip #11 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 37 bpmRegular 37 bpm Regular 320 msec 80 msec Sinus bradycardia with first degree AV block 练习（11） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 37

36、 bpm规则 37 bpm 规则 320 ms 80 ms 窦性心动过缓伴IAVB Practice Strip #12 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 81 bpmRegular 38 bpm Regular Not applicable 160 msec Third degree heart block 练习（12） 心房率：_P-P间期：_ 心室率：_R-R间期：_ PR间期：_ QRS波群时限：_ 节律诊断：_ 81 bpm规则 38 bpm规则 不适用 160 ms IIIAVB Practice Strip #13 Atrial Rate:_P-P Interval:_ Ventricular Rate:_R-R Interval:_ PR Interval:_ QRS Duration:_ Rhythm Interpretation:_ 100 bpmRegular 100 bpm