in tm (ECG-Electrocardiography)Bin son: Bs Nguyn Quang Ton Kho DHY34 Hc vin Qun Y

Mt s khi nim c bn v in tm

Mc tiu ca ECG* Cac bat thng Kha nang phat hien - Day nh, day that ++ - Loan nhp tim +++ - Nhoi mau c tim +++ - Suy ong mach vanh man ++ - Viem mang ngoai tim ++ - Roi loan chat ien giai + - Viem c tim, tam phe man +(*): Bi ging ECG ca PGS.TS Phm Nguyn Vinh- Vin tim mch TPHCM

ECG bnh th-ng b

12 chuyn o chun (The Standar 12 Lead)

Gm: - 3 chuyn o mu: D1, D2, D3 3 chuyn o n cc cc chi tng c-ng: aVR, aVL, aVF 6 chuyn o tr-c tim: V1, V2, V3, V4, V5, V6

Cc chuyn o mu

-

D1: in cc m c tay phi, in cc d-ng c tay tri. in cc c tay l d buc cn thc cht n phn nh in th vai phi v tri do trc chuyn o l -ng thng ni vai phi sang vai tri. Khi ic cc tay tri d-ng tnh t-ng i th my in tim ghi mt ln sng d-ng, cn khi ic cc tay phi d-ng t-ng i th my s ghi mt ln sng m. Vi iu kin nh- th gi chiu d-ng ca trc chuyn o l chiu t vai phi sang vai tri

-

D2: in cc m c tay phi, in cc d-ng t c chn tri. Trc chuyn o l -ng t vai phi(hay tay phi: RA) xung gc chn tri(LL: left leg) v chiu d-ng l chiu t R ti F

-

D3: in cc m tay tri, in cc d-ng chn tri. Trc chuyn o l -ng thng ni t vai tri(hay tay tri: LA) ti chn phi(RL:right leg)

S 3 chuyn o mu v 3 chuyn o chi tng c-ng

Cc thng s ca giy ghi in tim

Cc chuyn o n cc cc chi Th no l chuyn o n cc? Cc chuyn o mu u c 2 in cc, khi mun nghin cu ti 1 im th ng-i ta ni in cc (in cc m) ra 1 cc trung tm c in th = 0(tm ca mng in hnh sao). Cn cc in cc cn li (in cc d-ng) t ln v tr cn thm d in cc d-ng nu t c tay phi -c chuyn o VR(Voltage Rightin th tay phi), c tay tri -c VL, c chn tri -c VF(F:foot) Tng c-ng: ct b cnh sao ni vi chi c t in cc thm d lm tng bin cc sng 1,5 ln m vn gi nguyn hnh dng sng=> gi l cc chuyn o n cc cc chi tng thm k hiu aVL, aVR, aVF (a=augmented= tng thm) Cc chuyn o D1, D2, D3, aVL, aVR, aVF gi l cc chuyn o ngoi bin v u c in cc thm d t cc chi. Chng gip thm d ri lon dng in tim bn pha xung quanh mt phng chn(frontal planel)

Cc chuyn o tr-c timCch mc: N l cc chuyn o n cc m c mt in cc trung tnh ni vo cc trung tm v mt in cc thm d -c t ln l-t trn 6 im vng tr-c tim Gm: - V1: khoang LS 4 cnh b c phi - V2: Khoang LS 4 cnh b c tri - V3: Giao -ng ni V2 v V4 - V4: Giao -ng dc i qua im gia x-ng n tri v -ng ngang i qua mm tim - V5: giao im ca -ng nch tr-c vi -ng ngang i qua V4 - V6: Giao im ca -ng nch gia vi -ng ngang i qua V4, V5 Ngoi ra: - V7: LS V trn -ng nch sau - V8: gia -ng x-ng vai - V9: cnh -ng lin gai sng tri

* Cc chuyn o khc: V3R, V4R, V5R, V6R: Cc in cc ln l-t LS V trn -ng gia n phi, LS VI trn -ng nch tr-c phi, LS VII trn -ng nch gia phi Chuyn o thc qun: in cc -c nut vo thc qun v ghi in tim nhiu v tr cao thp khc nhau. Dng pht hin sng P nhng tr-ng hp m cc chuyn o thng dng khng thy P hoc chn on NMCT thnh sau Chuyn o trong bung tim: in cc -c ghp vo u 1 ng thng d tim v -a qua mch mu vo trong tt c cc bung tim dng pht hin P in His: in cc -c t st vng thn b His xc nh v tr nghn nh tht v chn on nhp nhanh tht

Cc vect t 1 n 7 ch ra s kh cc ca cc thnh tim v vch lin tht

TIEN TRNH KH CC (depolarization) VA TAI CC (repolarization) BNH THNG TIM

Ngun gc xung ng v s kh cc tm nh

S kh cc tht

Qu trnh kh cc sm tm tht v vng mm tim

Kh cc mun tm tht

S ti cc

tM tT qu trNH iN hC cA tim

Cc sng

TIEN TRNH OC ECG Khao sat co he thong - Song P - Khoang PR (PR interval) - Khoang QRS (QRS interval) - Phc hp QRS - oan ST (ST segment) - Song T - Song U - o dai QT - Truc QRS

in tm bnh th-ng b1. Sng P 1.1 Bnh th-ng: L sng kh cc 2 nh, ty u, khng nhn v khng c b-u. Nh tri kt thc kh cc sau nh phi khong 0.01- 0,03 s . o sng P DII c kch th-c ln nht Thi gian 0,12s: dy nh tri

Sng P bnh l* P m trn cc chuyn o m bnh th-ng n d-ng(D2, D3, aVF) v d-ng trn aVR(bnh th-ng n m): nhp b ni

Sng P bnh l* Nu P va rng v va cao: kh nng dy 2 nh

Cac song P bat thng: A- Song P do hep 2 la (P rong, 2 nh) B: Song P phe (do benh phoi) C: Song P nhp bo noi nh that (ao C 2 va 3 kem PR ngan)

Khong PQ

2. Kho ng PQ: l thi gian dn truyn nh tht tnh t khi im sng P ti khi im ca sng Q(hoc u sng R trong tr-ng hp khng c sng Q) * PQ bnh th-ng: Th i gian 0,12 0,20s ng i n

PQ bnh l* PQ bnh l: - PQ di 0,2s( ng-i c tn s tim l 100l/p); 0,22s ng-i c tn s tim 70l/p: Block nh tht cp I - PQ b t(P v QRS khng cn lin h g vi nhau: tu theo c th l phn ly nh tht, block A-V cp 2, nhp nhanh hay ngoi tm thu(s cp r phn sau) - PQ < 0,12s: Hc W-P-W, NTT nh, NNKPTT( cp phn sau)

PR tang : - Bloc nh that (do suy MV, thap tim ...) - Mot vai trng hp cng giap - Bat thng ngi bnh thng PR giam : - Nhp bo noi hay nhp nh that - H/C Wolf-Parkinson-White - H/C Lown-Ganong-Levine - Benh tu chat Glycogene - Vai benh nhan cao huyet ap - Benh Fabry - U tuy thng than - Bat thng ngi bnh thng

Cac khoang PR:

A- PR bnh thng 0,14 giay B- PR ngan 0,10 giay C- PR dai 0,30 giay, kem TP ao

3. Phc hp QRS : - o rong - o cao - Co song Q - Truc QRS - Thi gian xuat hien nhanh noi ien (intrinsicoid deflection : Ventricular activating time - VAT )

Phc b QRS: Cc gi tr bnh th-ng 3.1 Sng Q: l sng m tnh u tin hp v nhn khng c sng Q vn l bnh th-ng * Sng Q bnh th-ng: Th i gian 7mm: dy tht phi - Dng rsR: block nhnh ph i - Dng QS: nhi mu c tim c tr-c vch * V5, V6: - R 25mm: dy tht tri - Dng rS: dy tht phi - Q su >3mm, rng > 0,03s: NMCT 3. Bin i thi gian: - QRS 0,1s: block nhnh, HC W-P-W, NTTT, block A-V 3 - Nhnh ni in ti mun( V1, V2 0,035s; V5, V6 0,045s):dy tht tri hoc block nhnh tri

Dy tht tri

6. on ST: L on thng tnh t im cui ca phc b QRS ( t im J) n khi im ca sng T Quan tm n hnh dng v v tr ca n so vi -ng ng in * ST bnh th-ng: Bnh th-ng ST ng in hoc chnh ln khng qu 0,5 mm ( chuyn o ngoi bin) v chnh ln khng qu 1mm chuyn o tr-c tim * ST bnh l: - ST chnh xung > 0,5mm v i ngang: thiu mu c tim - ST chnh xung cong lm hnh y chn: nhim c digitalis - ST chnh ln, un cong: NMCT

Cac oan ST: A- bnh thng B- ST chenh xuong C- ST chenh xuong nhe, goc ST-T sac D- ST chenh len do ton thng c tim E- ST chenh len do tai cc sm

ST chnh xung trn DI, DII, DIII, aVF v V4, V5, V6

ST chnh ln

ST cong lm hnh y chn

Sng t Sng T bnh th-ng: T l sng ti cc, rng, m nt, nh ty, 2 s-n khng i xng vi s-n dc ng hn cn s-n ln thoai thoi vi on ST c ch : - Hng - Hnh the - o cao = Chuyen ao chi < 5mm Chuyen ao ngc < 10mm Bnh thng : T(+) DI DII , V3 - V6 T(-) aVR Thay oi DIII, aVL, aVF, V1V2 - Lun d-ng trn D1, aVF, V3-> V6(t V1-> V6: chuyn dn t m sang d-ng) Lun m trn aVR(ging sng P)

T bnh lKhi T khc vi quy lut nh- trn th lc T bnh l. chc chn phi xt sng T trong quan h vi QRS: - Nu QRS gin rng hoc cao tc l lc ny c nhng bin i bnh l nh- block nhnh, NTT, NN tht, dy tht tri, HC W-P-W. V y T m l hu qu ca cc nguyn nhn trn, do gi l sng T th pht. T y vn gi -c hnh dng bnh th-ng(khng i xng), cong v mm mi - Nu QRS bnh th-ng m T m(hay dt), gp trong cc bnh c thiu mu c tim nh- bnh tim thiu mu cc b, NMCT, bnh tim bm sinh, suy tim, thiu mu, c-ng gip Lc ny T m tnh l do nhng ri lon ti cc tin pht xy ra -> gi l sng T tin pht. V T y c c im l i xng - T hn hp tc l c c T th pht(dy tht tri) li c thm c T tin pht(thiu mu c tim). T s c c im l m tnh rt su, i xng v nhn

T tin pht(trong NMCT thnh tr-c vch)

Sng T th pht trong block nhnh tri

Cac song T (A) Song T bnh thng (B) T cao do thieu mau c tim (C) T ao benh nhan nhoi mau c tim (D) T oi xng, cao benh nhan nhoi mau c tim

KHO NG QT:* QT bnh th-ng: Khong QT th hin thi gian tm thu in hc. N -c tnh t khi im sng Q ti im cui cng T, th-ng hay o trn V2, V4 - QT ph thuc vo tn s tim. Do th-ng hay o c khong RR tr-c v tnh theo cng thc: QT QTc = RR QTc = K = 0,39 + 0,04 QT bnh l: QT tang : - Suy tim - Benh mach mau nao - Thieu mau c tim - Roi loan ien giai - Thap tim - Thuoc (Quinnidine, Procainamide, - Viem c tim Phenothiazine) QT giam : - Digitalis - Ca ++ tang - K + tang

QT di trong h Kali mu QTc 0,55s

sng uSng U: L sng d-ng tnh nh ng sau sng T khong 0,01-0,04s Bnh l: U cao trong gim kali mu

tnh tn s tim

*Ch : - Khi sng R nh hoc nt qu c th chn sng S tnh - Khi nhp tim khng u phi chn ly vi khong RR di ngn khc nhau tnh ly gi tr trung bnh ri tnh ra tn s tim trung bnh - Khi c phn ly nh tht hoc block nh tht cc sng P v R tch ri nhau phi tnh tn s nh (P) ring v tn s tht (R) ring - Tnh tn s cc sng f( rung nh) hoc sng F( cung nh) cng theo ph-ng php trn * Trong lm sng c th p dng cch tnh nhanh nh- sau: Trong tr-ng hp nhp tim khng qu chm : - Trn mt chuyn o ta tm mt sng R c nh ri vo -ng k m - Nu sng R ca chu chuyn tip theo ri ng vo -ng k m lin sau th tn s tim l 300 - Nu sng R ca chu chuyn tip sau ri vo -ng k m th 2 hoc th 3 lin sau th tn s tim l 150 hoc 100 t-ng ng - T-ng t nh- vy nu sng R ri ng vo -ng k m 4,5,6 ta c tn s tim l 75,60 v 50 t-ng ng Vy tn s tim = 300/ s ln ( 1 ln = 5 1mm hay bng mt khong gia 2 -ng k m) Trong tr-ng hp nhp chm: - m s chu chuyn tim trong 6 giy trn mt chuyn o Tn s tim = s chu chuyn tim trong 6 giy *10

Tnh tn s tim Xt tr-ng hp c rung nh sau: Ta tnh s ln trung bnh ca khong RR (trn 8 khong RR)trn V1 tnh -c 4,7 .Tn s tim trung bnh l 300/4,7 64 ck/p

trc in tim*Cch xc nh trc in tim: - Dng in tim gm c 3 thi k pht in ch yu : kh cc nh ( sng P), kh cc tht( QRS), v ti cc tht ( sng T) V do ta c th v -c 3 trc in t-ng ng ca 3 thi k .Nh-ng v kh cc tht l qu trnh in hc ch yu ca tim nn trc QRS -c gi l trc trung bnh ca tim hay cn gi l trc in tim - Cch xc nh: Xt 2 o trnh DI v DIII:Tnh tng i s cc sng Q,R,S cc o trnh v cn c vo bng sau xc nh trc in tim - Xc nh chuy n o c t ng i s c a cc thnh ph n ph c QRS b ng 0. Tr c QRS s l 90o so v i chuy n o ny.

-c l-ng trc in timc l-ng trc in tim bng tam trc kp Bayley: 6 o trnh ngoi bin ca tam trc kp Bayley vung gc vi nhau tng i mt - DI vung gc vi aVF - DII vung gc vi aVL - DIII vung gc vi aVR Cch -c l-ng : + Tm mt o trnh no c tng i s cc sng ( QRS) bng 0 hay gn bng 0 nht gi l o trnh X.Trc in tim s gn trng vi trc vung gc vi o trnh X gi l Y + Nhn vo phc b QRS ca o trnh Y xem tng i s bin ca n d-ng hay m .Nu l d-ng th s trng vi h-ng na trc d-ng ca o trnh Y, nu l m th trc in tim s trng vi h-ng ca na trc m ca o trnh Y + Mun chnh xc hn phi iu chnh : Nu d-ng th iu chnh trc in tim khong 10150 v na trc d-ng ca o trnh X, nu m th iu chnh trc in tim cng khong 10150 v pha na trc m ca o trnh X. Nu bng 0 th khng cn phi iu chnh

-c l-ng trc in timV d: Xt in tim sau:Trn in tim trn ta thy tng i s cc sng Q, R,S trn o trnh aVR gn bng 0 nht .Vy trc in tim s gn trng vi trc vung gc vi aVR tc l o trnh DIII - o trnh DIII ( o trnh Y) c tng i s l m nn trc in tim h-ng v na trc m ca DIII - V o trnh aVR (tc o trnh X) c h-ng m nn phi dch trc in tim v pha m ca aVR khong 100 Vy gc vo khong -500

ECG bnh lPhn I: Cc ri lon nhp tim Phn II: Tng gnh nh v tht Phn III: Dn truyn nhanh: HC W-P-W v HC L-G-L Phn IV: Nhi mu c tim Phn V: Ri lon in gii v nhim c digitalis

Cc ri lon nhp timGm: - Nhp xoang, ch nhp l-u ng, block xoang nh - Nhp b ni, thot b ni, phn ly nh tht - Ngoi tm thu - Nhp nhanh kch pht - Rung nh, cung nh - Xon nh - Rung tht - Block nh tht, block nhnh

Nhp xoang*i c-ng: Nt xoang lun gi vai tr ch nhp v n c tc hnh thnh xung ng nhanh nht so vi nhng trung tm khc, trung bnh khong 70 ln /pht.Cng xa v pha mm tim tn s pht xung ng cng km i Vic xc nh nt xoang c hot ng khng rt quan trng v nu khng c nhp xoang c th l mt triu chng c nng hay thc th Cch xc nh c nt xoang hot ng: - C sng P ng tr-c QRS - Khong PQ khng i - Sng P d-ng tnh DI, V5,V6 v m tnh aVR Xc nh sng P trong tr-ng hp kh xc nh: qua 5 b-c: - Chn trn bn in tim ly 2 sng nghi l 2 sng P i tip theo nhau lm chun v d sng P1v P2 - t mt bng giy di d-i mp -ng ng in v ly bt vch ln 2 vch ngn ng d-i 2 sng chun gi l cc vch P ta s c mt khong PP m ta nghi l khong PP c s - -a giy v pha tay tri mt khong di bng 1 PP c s sao cho vch P th hai n nm ng d-i P1 ri vch thm mt vch P th 3 ng d-i P2 - Li -a bng giy mt ln na sao cho vch P th 3 n nm ng d-i P1 v vch thm mt vch P th tng d-i P2 C tip tc nh- vy 5,6 ln ta s -c mt bng giy c 8,9 vch P gi l bng vch nhp trong ta nhn khong PP c bn ln 7,8 ln - -a bng vch nhp tr v v tr ban u v n cc chuyn o khc khng cng ghi ng thi vi chuyn o v nhn xt: + Nu cc sng P ca bn in tim c nhp u th c trn mi vch P ca bng vch nhp li c mt sng P + Nu P c nhp khng u hay c nhng sng P vng mt hay bin dng th s tu theo tnh cht bnh l v mi quan h gia P v QRS m kt lun loi ri lon nhp g

nhp xoang bnh th-ng

Nhp xoang nhanh - Tn s tim t 100 n d-i 160 ln /pht ( trn 160 l/p l nhp nhanh kch pht ) - Khong TP ngn nh-ng vn gii hn bnh th-ng - Cc sng v khong cch cc sng u ngn i nh-ng vn gii hn bnh th-ng VD: f = 100ck/p

nhp xoang nhanh

nhp xoang chm f< 60 ck/p TP di ra nh-ng vn gii hn bnh th-ng Cc sng v khong cch cc sng di ra nh-ng vn gii hn bnh th-ng V d:Nhp chm xoang, NMCT thnh bn cao: Q su rng, sngT m su i xng trn DI,aVL f = 50l/p

nhp xoang chm

Lon nhp xoang Do tnh trng nt xoang pht xung ng khng n nh gy nhp khng u hay gp nht l lon nhp xoang do h hp ECG: Trn mt bng in tim thy nhp tim thay i c tnh cht chu k nhanh dn ln cui thi k th vo v chm dn i cui th th ra

ch nhp l-u ng(Wandering Atrial Pacemaker ) Ch nhp l-u ng l hin t-ng trung tm ch nhp i l-u ng t u n cui nt xoang hoc c th xung tn ti b ni hay thp hn ECG: Sng P lun thay i hnh dng trn cng mt o trnh , sng P lc m lc d-ng, dt hoc m tnh khng c qui lut g c Tn s tim c th thay i tu theo vt tr pht xung ng gn hay xa nt xoang . Nu P m tnh th khong PQ ngn hn PQ ca nhp c sng P d-ng tnh nh-ng th-ng PQ vn trong gii hn bnh th-ng QRS-T bnh th-ng Gp trong c-ng ph v, thp tim, gy m, dng digitalis

ch nhp l-u ng

block xoang nh* L hin t-ng xung ng ca nt xoang b tc li khng truyn t -c ra c nh * ECG: Block xoang nh ch thnh thong xy ra 1 vi nht bp nn trn ECG ta thy: trn c s 1 ECG nhp xoang bng mt hn 1 hay 2 PQRS. o khong ngng tim n s gp 2 hoc 3 ln PP c s

nhp b ni (Junctional rhythm)* Nt xoang pht xung chm -> nt nh tht thay th lm ch nhp-> nhp b ni * ECG: Nhp chm f 0,1s t nht 1 chuyn o => tim nhanh tht + Nu RS b-c3 - B-c 3: Tm du hiu phn ly nh tht. + Nu c s QRS > s sng P => tim nhanh tht + Nu khng c phn ly A-V => b-c 4 - B-c 4: Xem hnh dng ca QRS/V1 v V6 nu c c im ca tim nhanh tht th chn on l tim nhanh tht nu khng c th l tim nhanh trn tht dn truyn lch h-ng Tiu chun QRS ca tim nhanh tht: - QRS rng 0.14s - Trc QRS: trc tri mnh

rung nh, cung nh, cung ng nh1. Rung nh L 1 lai lon nhp rt nhanh do nhi pht xung nm c nh lm cho cc th c nh rung ln ch khng cn co bp do nt xoang ch huy. Trong cn rung nh cc xung ng truyn xung tht khng u do c block nh tht chc nng Tiu chun: Mt sng P thay bng sng f (fibrillation)r trn V1,V2 Phc b QRS: + Khng u v bin : cc sng R cao thp khc nhau + Khng u v tn s: Cc khong RR khng u * Cc th: - Rung nh bn c HC W-P-W: + Tn s tht nhanh > 200l/p + QRS gin rng + RR ngn

- Rung nh vi block nh tht hon ton: + Tn s tht chm v u + QRS c th hp hoc gin - Rung nh trn bn c block nhnh t tr-c: + QRS c dng ca block nhnh - Rung nh vi nhp tht u v nhanh

Rung nh

Rung nh bnh nhn c HC W-P-W

Cung nh (Atrial Flutter)* L tnh trng nh bp rt nhanh v rt u d-i s ch huy ca nhng xugn ng bnh l c tn s khong 300ck/p * ECG: Mt sng P thay bng sng F(Flutter) c hnh dng ging nhau, u nhau v lin tip vi nhau rt u to nn hnh nh ging nhl-i c-a hoc cnh chim v nn cn gi l v nh QRS bnh th-ng cung c th mo m do sng F chng ln Nu c 2 sng F c 1 tht (QRS) gi l cung nh 2/1, 3 sng F c 1 QRS gi l cung nh 3/1.... th-ng gp loi cung nh 2/1

Cung nh vi dn truyn nh tht 2/1

Cung nh 2/1

Cung nh 2/1

Cung nh 3/2

Cung nh 3/2

Cung nh 2/1: mi tn ch v tr 2 sng F(Flutter) mi c 1 QRS Tn s nh 280; tn s tht 140

Cung nh 2/1 vi block nhnh tri

Trn nn cung nh 2/1, xut hin block A-V v block nhnh tri

Cung nh 2/1 v 4/1 vi block nhnh tri khng hon ton: f sng cung nh

Rung cung nh, Cung tht

* Cung nh phi hp vi rung nh, trn ECG c hnh nh ca c rung nh v cung nh tc c c sng f v sng F( Cc sng F c bin ln hn v u hn sng f) * Cung tht: Trng thi chuyn tip gia NNT v rung tht Khng phn bit -c P, QRS, T, th-ng l nhng dao ng u hn rung tht bin ln

xon nh, Rung tht 1. Xon nh: L ri lon nhp trung gian gia nhp nhanh tht v rung tht * ECG: - Tn s tht nhanh 200-250/pht - RR khng u - Bin i QRS lun thay i theo 1 chu k: tng dn ri gim dn 2. Rung tht : QRS-T b bin dng dn rng thnh -ng ngon ngoo

Rung tht

block nh tht (AV block)* L tnh trng c mt ton th-ng nt nh tht hoc b his lm chm tr hay tc nghn hon ton s dn truyn xung ng t nh xung tht * Phn loi: - Block AV cp 1 - Block AV cp 2 - Block AV cp 3 1. Block AV cp 1: PQ > 0,20s QRS- T bnh th-ng

Block AV cp 1: PQ= 0,28s

Block AV cp 1

Block AV cp 2 * Mt s xung ng khng xung -c ti tht nn trn ECG thy c mt s sng P khng c QRS i km * C 2 loi: - Block AV cp 2 kiu chu k Wenckebach: Gm 3-4 nhp c c im PQ di dn ti khi ch cn sng P vng QRS ,PP u, sau lp li - Block AV cp 2 kiu Mobitz: PQ khng i thnh thong ch c sng P n c khng c QRS i km : P b block v tht ngh 1 nhp ; nu c 2P c 1 QRS-T l block A-V 2 kiu 2/1, c th gp 3/1, 4/1.

Block AV cp 2 kiu chu k Wenckebach

Block AV cp 2 kiu chu k Wenckebach

Block AV cp 2 kiu chu k Wenckebach vi nhp thot b ni(E:Junctional escapes-thot b ni)

Block AV cp 2 kiu Mobitz:

Block AV cp 2 kiu Mobitz v block nhnh tri

Block AV cp 2 kiu Mobitz vi block nhnh tri

Block AV cp 3Tt c cc xung ng t nh khng th dn truyn xung tht -c do nh v tht p theo nhp p ring. Nh do nt xoang lm ch, cn thaats th do mt ch nhp phi d-i ch b block ch huy c th l nt nh tht c th thn b his c th cc nhnh b his * ECG: P khng lin quan QRS, P c th ln vo QRS hoc T, nhp nh u Nhp tht chm 30-40ck/p u, QRS bnh th-ng hoc c th dn rng bin dng nh- block nhnh

Block AV cp 3 vi nhp thot b ni

Block AV cp 3 vi nhp thot b ni v Ventriculophasic Sinus Arrhythmia

S 4 loI block nh thT

Block nhnhBlock nhnh(Bundle Branch Block- BBB) l nhng ri lon v dn truyn xung ng trong mt nhnh ca b his. Ri lon ny c th do nhnh b ct t hoc ch b th-ng tn. Khi xung ng s phi i vo nhnh bn kia v kh cc tht bn tr-c ri mi truyn sang kh cc tht b block sau - Khi nhnh b his ch b t mt phn th gi l block nhnh khng hon ton cn khi b t hon to s gy ra block nhnh hon ton 1. Block nhnh tri( Left Bundle Branch Block- LBBB) C sng P, QRS dn rng D/h trc tip: R rng , c mc th-ng trn DI,aVL,V5,V6 D/h gin tip: Dng rS/ V1,V2 QRS > 0,12 block nhnh tri hon ton QRS < 0,12 block nhnh tri khng hon ton

Block nhnh tri hon ton(R rng c mc/DI, aVL, V5, V6; Dng rS trn V1, V2; QRS =0,2s)

LBBB

LBBB

LBBB

Block phn nhnh tri tr-c (Block of anterior division of the left bundle branch(anterrior fascicular block- LAFB))ECG: - QRS > -300 - Dng qR/DI,aVL

V d in tim ny c trc ca QRS l - 70 , dng qR trn DI, aVL

LAFB

Block phn nhnh tri sau (Block of posterior division of the left bundle branch (posterior fascicular block- LPFB)) * ECG: - QRS >900 - qR/D2,D3,aVF

01/8/92: RBBB + LPBB; 01/10/92: RBBB + LAFB

Block nhnh phi( Right Bundle Branch Block -RBBB)

ECG: C sng P,QRS dn rng D/h trc tip: Sng S dn rng, c mc/V5,V6 D/h gin tip: Dng rSR /V1,V2 QRS > 0,12 block nhnh phi hon ton QRS < 0,12 block nhnh phikhng hon ton

RBBB + LAFB = Bifascicular block(block c 2 b)

RBBB + LAFB

RBBB

( NMCT sau d-i v block nhnh phi:Inferoposterior MI with RBBB)

Infero-posterior MI with RBBB

Infero-posterior MI with RBBB

Infero-posterior MI with RBBB

Inferior & Anteroseptal MI(NMCT thnh tr-c vch v thnh d-i) + RBBB

S ecg block nhNH b hIS

Phn ii Tng gnh nh v tht

tng gnh nh* Tng gnh nh cn gi l dy nh, l tnh trng mu nhiu tm nh lm c nh phi tng co bp do thnh ca n dy v gin ra 1. Dy nh tri(Left Atrial Enlargement- LAE) - P rng ( > 0,12s), c th c mc, 2 nh - P 2 pha +/- vi pha (-) > (+)/ V1,V2 2. Dy nh phi(Right Atrial Enlargement -RAE) P cao > 2,5mm/DII P 2 pha +>- /V1,V2 ( Du hiu Soli Pallares: QRS c dng QR/ V1) 3. Dy 2 nh: P va rng va cao P 2 pha +/- c 2 pha u rng/V1, V2

Dy nh tri: P rng(0,12s) c mc, dng 2 pha vi pha m rnghn phad-ng trn V1, V2

Dy nh tri(LAE)

DII

V1

Dy nh triP rng(0,12s) c mc, dng 2 pha vi pha m rng hn phad-ng trn V1, V2. ECG ny cn c block AV cp 1(PR >0,2s)

Dy nh tri

Dy nh phi(RAE) (P cao 3mm, pha (+ )> pha (-) trn V1, V2)

Dy nh phi

Tng gnh tht Trc tri ( QRS+/DIv QRS- /DIII) Sokolow- lyon tht tri(+) ( RV5 +SV1>=35mm) R/V5,V6 >25mm ST-T tri chiu QRS * Tng gnh tm thu tht tri c thm cc du hiu sau: T m su, khng i xng/V5,V6 T d-ng cao khng i xng /V1,V2 * Tng gnh tm tr-ng tht tri: ST ng in hoc chnh xung t T lun d-ng , khng i xng /V4,V5,V6 2. Tng gnh tht phi:(Right Ventricular Hypertrophy -RVH) Trc phi Sokolow-lyon tht phi(+):RV1(RV2) + SV5 > 11mm R 7mm/V1, R/S( V1,V2) 1, R/S( V5,V6) 1 ST -T tri chiu QRS 3. Tng gnh 2 tht : R cao v S-TT m c V1 ,V5,V6 R cao v STT m V5,V6 nh-ng c trc phi mnh( > +1000)

1. Tng gnh tht tri(Left Ventricular Hypertrophy - LVH)

Tng gnh tm thu tht tri

Tng gnh tm tr-ng tht tri

Right Ventricular Hypertrophy (RVH) & Right Atrial Enlargement (RAE)

Tng gnh tht tri v nhiu ngoi tm thu tht (LVH and many PVCs )

RVH

RVH

dn truyn nhanh1. Hi chng Wolff- Parkinson- White(W-P-W): * C ch: Do tn ti b Kent * ECG: PQ nhn(< 0,12s) QRS gin rng ,mc c sng delta trt m u QRS ST-T tri chiu QRS * C 2 tp: - Tp A: sng delta (+)/ chuyn o tr-c tim - Typ B: sng delta m cc chuyn o tr-c tim phi v d-ng cc lead tr-c tim tri Sng delta l sng nm phn u ca R do xung ng t nh truyn qua b ph(cu Kent) xung kh cc sm tm tht 2. Hi chng Lown- Ganong- Levin(L-G-L): * C ch: do cn tn ti -ng dn truyn ph, -ng James * ECG: PQ ngn (< 0,12s) QRS-T bnh th-ng

S HC W-P-W

S hc w-p-w v hc QT di

W-P-W

sng

HC L-G-L

Hnh A

Hi chng W-P-W v nhi mu c tim cp Hnh A: W-P-W vi sng delta v PR ngn Hnh B: Ghi sau 1 nm khi b nhi mu c tim cp.

Hnh B

HC W-P-W v nhi mu c tim cp Hnh A:HC W-P-W vi sng delta m, NMCT thnh sau B: Bnh th-ng C: Xut hin tr li ca HC W-P-W v NMCT

Hnh A

Hnh B

Hnh C

nhi mu c tim (Myocardial Infarctions)* Vng c tim b nhi mu th-ng c 3 vng vi cc mc tn th-ng khc nhau gm: - Vng gia b hoi t: th hin bng sng Q bnh l - Vng tip theo l vng b tn th-ng: th hin bng on ST chnh - Vng ngoi cng l vng thiu mu: th hin sng T bnh l * Thiu mu: T m nhn i xng: thiu mu d-i th-ng tm mc T(+) nhn i xng: thiu mu d-i ni tm mc * Tn th-ng c tim: ST chnh ln:tn th-ng d-i th-ng tm mc ST chnh xung: tn th-ng d-i ni tm mc * Hoi t: Xut hin sng Q bnh l: Q rng > 0,03-0,04s Su > 4mm Q/R > 40%

cc giai on ca nmct1. Giai on cp: 1,2 ngy u - Sng cong vm, c th c Q bnh l 2. Giai on bn cp: t vi ngy n vi tun, hay gp nht trn lm sng ST chnh ln thp hn - T m su i xng to hnh nh sng vnh Pardee - Q bnh l r rt 3. Giai on mn tnh(NMCT c): vi thng n vi nm ST ng in T d-ng hoc vn m Tn ti Q

chn on vng nhi mu

Chuyn oDI, aVL DII, DIII, aVF V1, V2, V3 V3, V4 V1->V6, DI, aVL V3R, V4R V7, V8 ,V9

VngThnh bn Thnh sau d-i tr-c vch Vng mm tim thnh tr-c rng NMCT tht phi y

Cc giai o n NMCT v bi u hi n trn ECG: A.Bnhth ng u thay i: bin B. Sng T b t

t ng v r ng h n, c th th t ST C. Giai o n c p tnh: ST chnh ln cao D. Sng Q b nh l xu t hi n, XT chnh ln th p h n, sng T l n ng (ho i t c tim) E. Sng Q b nh l, T m (ho i t v hnh thnh s o ho i t c tim) F. Sng Q b nh l , sng T d ng(t n th ng thnh s o) c

bin i cc sng trong NMCT theo thi gian

NMCT cp

TM d-i ni tm mc T d-ng cao i xng /V1,V2 ; Tn th-ng c tim d-i ni tm mc vng tr-c rng: ST chnh xung /DI,DII,V1-V6

NMCT cp thnh sau-d-i .Block nhnh tri tr-c trn

NMCT cp thnh bn: DI, aVL

NMCT cp thnh tr-c bn

NMCT thnh d-i :DII, DIII,aVF

NMCT cp vng thnh bn cao: DI, aVL

NMCT c vng thnh sau d-i

nmct tr-c bn

nmct thnh tr-c

nmct thnh sau d-i(Infero-posterior Myocardial Infarctions(MI))

NMCT thnh sau

NMCT thnh sau

Acute Inferoposterior MI(NMCT cp thnh sau d-i)

NMCT thnh bn cao

NMCT c thnh d-i

NMCT c thnh sau d-i

NMCT c thnh d-i, NTT tht v rung nh

NMCT tht phi

NMCT thnh d-i v tht phi

Ri lon in gii 1. Gim kali mu: ST chnh xung dn, T thp hoc dt Bin sng U cao ln so vi sng T 2. Tng kali mu QT ngn li vi T hp y cao nhn Bin dng QRS do dn truyn kh khn P rng v thp ,PQ ko di thm do tng cao hn 3. Gim calci mu: Do gim calci mu nn lm ST keo di ra nn ko theo QT di ra Nu h nhiu QRS hp li sng T c th thp dt hay m 4. Tng calci mu: - ST ngn li sng T tip lin ngay vo QRS

A- Thay i ECG do tng kali mu: ngy 1nng Kali mu mc 8,6mEq/l th khng cn nhn thy sng P na, QRS gin ra. Ngy 2: Kali mu l 5.8mEq/l sng P nhn, QRS khng cn gin rng na ra B- Thay i ECG do gim Kali mu: ngy 1 kali mu l 1,5mEq/l. ngy th 4 kali mu l 3,7mEq/l

Gim kali mu

sng U

gim kali mu

Gim calci huyt

A-Tng calci mu: QT ngn li B- Gim calci mu: QT di ra

nhim c digitalis Khi c tim nhim c digoxin: ST chnh xung hnh y chn v tri chiu vi QRS, T dt hay m QT ngn li

vim mng ngoi tim1. Th cp: ST chnh ln tt c cc chuyn o ngoi vi v tr-c tim 2. Khi c trn dch mng ngoi tim: in th thp 3. Khi vim mng ngoi tim co tht: P rng v c mc, c th c rung nh 4. Mn tnh: T thp

Vim mng ngoi tim cp: ST chnh ln tt c cc o trnh

Trn dch mng ngoi tim: in th thp

Mi ng gp xin lin h Bs Nguyn Quang Ton Email: digoxin_y34@yahoo.com Tell: 0982012581