心电图教学英文版.ppt
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心电图教学英文版.ppt
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ClinicalElectrocardiographyTeachingCourse,苏州大学附属二院心内科邵春来,GriffithJoyner38yearsolddiedin1998,Vivianfu28yearsolddiedin2003,MarcoPantani35yearsolddiedin2004,心电图学基础
(一)心电发生的原理basicprinciplesoftheelectromechanics,
(1)心肌静止时restingmyocardium(复极状态repolarizationstatus),
(2)心肌细胞受刺激stimulatedmyocardium(从左到右开始除极depolarizationbeginningfromlefttoright),(3)除极过程processofdepolarization(depolarizationfromlefttoright),除极方向(-+),1.,2.,3.,4.,DeplaorizationSequenceofa“Strip”of5MyocardialCells,Depolarizationprogressingfromlefttoright,2.whendepolarizationspreadsawayfromanylead,itproducesanegative(downward)deflectioninthatlead.,1.whendepolarizationspreadstowardanylead,itproducesapositive(upward)deflectioninthatlead.,3.whendepolarizationspreadsfirstlytowardandthenawayfromanylead,itproducesabiphasicdeflection.,1)Vector,+,+,+,MagnitudeDirectionfrom0,Anarrowrepresentstwophysicalparameters:
directionandmagnitude,2)resultantvector,0,同一轴axile的二个心电向量的方向相同者,其幅度argument相加;,方向相反者则相减。
ABC,ABC,VectorsmaybesummedbyparallelogrammethodtoproduceResultantVector,=,Translate,=,Summed,ResultantVector,Theintegrationcanonlybeperformedwhenthetwovectorsaregeneratedatthesamemoment.,
(二)心血管传导系统cardiovascularconductionsystem,心脏的传导系统由以下几部分组成,窦房结SAnode结间束internodalatrialpathways房室结AVnode希氏束AVbundle右束支rightbundlebranches左束支leftbundlebranchesPurkinje纤维网Purkinjesystem,SAnode,AVnode,两结之间用vector表示,1,3,4,2,SAnode,AVnode,运用4原则记录心脏的vector传导过程位置不重要,1,2,3,4,不同部位记录电极的电位,Ineachcardiaccycletherearemanyinstantvectorsandifthetipofeachvectorisconnectedtogetheraloopwillbeobtained,whichiscalledasvectorloop,suchasQRSloop.,VariouspatternsoftheECGcanbeobtainedfromthesamevectorloop.Thepatterndependsonthepositionoftheelectrode.,P,T,QRS,Intheheartthevectorloop,infact,isathree-dimensionalvectorloop.,ECG,innature,isdoubleprojectionsofathree-dimensionalvectorloop.,frontalplane,frontalplane,transverseplane,Thethree-dimensionalvectorloopprojectsonasectionofthebodyfirst.Thatisthevectorloopofthissection.,Then,thevectorloopofthesectionprojectsonalead.ThatistheECGofthislead.,(四)心电图导联leadsoftheECG,双极肢体导联bipolarextremity,RA,LA,LL,LARA,LLRA,LLLA,加压肢体导联augmentedextremityleads,aVR,aVL,aVF,包括aVR、aVL、aVF导联,Leadv1:
4thintercostalspacejusttotherightofthesternum,Leadv2:
4thintercostalspacejusttotheleftofthesternum,Leadv3:
alinemidwaybetweenleadV2andV4,Leadv4:
themid-clavicularlinein5thintercostalspace,Leadv5:
theanterioraxillarylineatthesamelevelasleadV4,Leadv6:
themidaxillarylineatthesamelevelasleadV4,angleofLouis,Totallydifferentpatternsofthepotential(ECG)canbeobtainedfromthesamecardiaccycle.Thepotential(ECG)patterndependsonthepositionoftheelectrodes.,Now,youknow,theECGisagraphicrecordingoftheelectricalcurrentsproducedbytheheartmuscleduringtheatrialandventriculardepolarizationandrepolarization.,Insummary,心电图的临床应用ClinicalapplicationoftheECG,
(一)心电图的测量方法determinationmethodoftheECG,StandardizedMethods&Devices,ECGPaperDevicePaperSpeedDeviceCalibrationElectrodePlacement,HorizontalAxis,VerticalAxis,EKGPaper,StandardizedMethods&Devices,ECGGraphPaperVerticalaxis-millivolt1smallbox=1mm=0.1mVHorizontalaxis-time1smallbox=1mm=0.04sec.,StandardizedMethods&Devices,PaperSpeed&CalibrationPaperSpeed-25mm/secstandardCalibrationofVoltageisAutomaticBothSpeedandvoltagecalibrationcanbechangedonmostdevices,Whatistheheartrate?
(300/6)=50bpm,WhatisQRSAxis?
TheQRSaxisisdeterminedbyoverlyingacircle,inthefrontalplane.Byconvention,thedegreesofthecircleareasshown.,ThenormalQRSaxisliesbetween-30oand+90o.,AQRSaxisthatfallsbetween-30oand-90oisabnormalandcalledleftaxisdeviation.,AQRSaxisthatfallsbetween+90oand+150oisabnormalandcalledrightaxisdeviation.,AQRSaxisthatfallsbetween+150oand-90oisabnormalandcalledsuperiorrightaxisdeviation.,HexaxialarrayandECGvectorsfromvariousleads.Findnet+orQRSinlead1Findnet+or_QRSinLeadaVFResultantVector.ThisisMeanElectricalAxisofHeartorCardiacVector.,Electricalaxisisabout+60o,Transitionalzone(chestleads),Representsthelocationofthelead,havingpositiveandnegativedeflectionsofthesamemagnitude.,Clockwise,normal,Counterclockwise,
(二)ComponentsoftheECG,ComponentsoftheECGComplex,PWavefirstupwarddeflectionrepresentsatrialdepolarizationusually0.10secondsorlessusuallyfollowedbyQRScomplex,Whentheatriaareexcited,thisdepolarizingelectricalcurrentcanberecordedbyECG,anditisnamedPwave.,ComponentsoftheECGComplex,QRSComplexCompositionof3WavesQ,R&Srepresentsventriculardepolarizationmuchvariabilityusually0.12sec,ComponentsoftheECGComplex,QWavefirstnegativedeflectionafterPwavedepolarizationofseptumnotalwaysseen,ComponentsoftheECGComplex,RWavefirstpositivedeflectionfollowingPorQwavessubsequentpositivedeflectionsareR,R”,etc,ComponentsoftheECGComplex,SWaveNegativedeflectionfollowingRwavesubsequentnegativedeflectionsareS,S”,etcmaybepartofQScomplex,ComponentsoftheECGComplex,PRIntervaltimeimpulsetakestomovethroughatriaandAVnodefrombeginningofPwavetonextdeflectiononbaseline(beginningofQRScomplex)normally0.12-0.2secmaybeshorterwithfasterrates,ComponentsoftheECGComplex,QRSIntervaltimeimpulsetakestodepolarizeventriclesfrombeginningofQwavetobeginningofSTsegmentusually0.12sec,ComponentsoftheECGComplex,JPointpointwhereQRScomplexreturnstoisoelectriclinebeginningofSTsegment,ComponentsoftheECGComplex,STSegmentearlyrepolarizationofventriclesmeasuredfromJpointtoonsetofTwaveelevationordepressionmayindicateabnormality,ComponentsoftheECGComplex,TWaverepolarizationofventriclesconcurrentwithendofventricularsystole,(三)心房与心室肥大Atrialandventricularhypertrophy,downward,leftward,TheearlyportionofPwave:
therightatrium.Thelateportion:
theleftatrium.,1.心房肥大Atrialhypertrophy,ItisimportanttorememberthatthePwaverepresentsthesequentialactivationoftherightandleftatria,anditiscommontoseenotchedorbiphasicPwavesofrightandleftatrialactivation.Pduration0.12secPamplitude2.5mm,V1,
(1)
(2),R.A.,L.A.,12,LeftatriumenlargementaffectsthelatepotionofthePwaveandprolongsthedurationofthePwave.,leftatrialhypertrophy(LAH),Pwaveduration0.12sinfrontalplane(usuallyleadII)NotchedPwaveinlimbleads(usuallyleadII)withtheinter-peakduration0.04s,R.A.,L.A.,R.A.,L.A.,V1,12,TerminalPnegativityinleadV1(i.e.,P-terminalforce)duration0.04s,depth0.1mv.,12,RightatrialenlargementincreasethemagnitudeoftheatrialdepolarizationvectorandproduceatallPwave.,右心房肥大rightatrialhypertrophy(RAH),Pwaveamplitude2.5mminIIand/or1.5mminV1,R.A.,L.A.,R.A.,L.A.,V1,双侧心房肥大biatrialhypertrophy,FeaturesofbothRAEandLAEinsameECGPwaveinleadII2.5mmtalland0.12sindurationInitialpositivecomponentofPwaveinV11.5mmtallandprominentP-terminalforce,R.A.,L.A.,R.A.,L.A.,V1,Leftventricularhypertrophy(LVH),MeanQRSaxis,Changesinlimbleadsinthefrontalplane,TallerRwaveinleadI,deeperSwaveinleadIII,leftaxisdeviation,Changesinchestleadsinthehorizontalplane,TallerRwaveinleadv5,deeperSwaveinleadv1,v5,v5,STsegmentdepressionandTwaveinversion,左心室肥大leftventricularhypertrophy(LVH),Limb-leadvoltagecriteria:
RinaVF25mmRinI+SinIII25mmChest-leadvoltagecriteria:
SinV1+RinV5orV635mm(women),V1V2V3,V4V5V6,左心室肥大leftventricularhypertrophy,V1V2V3,V4V5V6,Rightventricularhypertrophy,GeneralECGfeaturesinclude:
Rightaxisdeviation(90degrees)TallR-wavesinRVleads;deepS-wavesinLVleadsSlightincreaseinQRSdurationMayseeincompleteRBBBpatternorqRpatterninV1,Changesinlimbleadsinthefrontalplane,TallerRwaveinleadIII,deeperSwaveinleadI,Rightaxisdeviation,MeanQRSaxis,Rightventricularhypertrophy(RVH),V5,V5,Changesinchestleadsinthehorizontalplane,TallerRwaveinleadv1,deeperSwaveinleadv5,STsegmentdepressionandTwaveinversion,右心室肥大Rightventricularhypertrophy,Rightaxisdeviation(90degrees),V1V2V3,V4V5V6,Rightventricularhypertrophy,Chestleadcriteria:
RinV1+SinV5(orV6)10mmR/SratioinV5orV61,V1V2V3,V4V5V6,右心室肥大rightventricularhypertrophy,V1V2V3,V4V5V6,双侧心室肥大Biventricularhypertrophy,InthepresenceofLVEanyoneofthefollowingsuggeststhisdiagnosis:
R/SratioinV5orV66mmRightaxisdeviation(90degrees),V1V2V3,V4V5V6,心律失常,Cardiacarrthythmias,(四)心律失常cardiacarrthythmias,1.心脏激动异常所致的心律失常arrhythmiasinvolvingabnormalimpulseformation2.心脏传导异常所致的心律失常arrhythmiasinvolvingabnormalcardiacconduction,1.心脏激动异常所致的心律失常arrhythmiasinvolvingabnormalimpulseformation,
(1)窦性心律sinusrhythmia
(2)交界性心律atrialventricularjunctionalrhythm(3)过早搏动prematurebeat(4)逸搏与逸搏心律escapeandescaperhythms(5)异位性心动过速ectopictachycardia(6)扑动与颤动flutterandfibrillation,sinusrhythmandsinusarrhythmias,Sinusrhythm,ECGofSinusRhythms1).ThePwaveisupwardinleadI,II,avF,V4-5anddownwardinleadavR.2).ThePRinterval0.12second.3).Heartratebetween60and100ratesperminute.,Sinusbradycardia,Heartrateislessthan60perminute,Sinustachycardia,Heartrateexceeding100perminute,Sinusarrhythmia,P-PorR-Rintervalvariesindurationbyatleast0.12second,Sinusarrest,ThereisnosinusPwaveinECGsuddenly.ThelongintervalisnottimesofP-Pinterval.,期前收缩(过早搏动)prematurecontraction/beat,Technicalword,联律间期(couplinginterval)distancefromtheprecedingnormalQRScomplextotheprematureventricularbeat代偿间歇(compensatoryp
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