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1、心电图易上手,心电图易上手,Seminor I,To Start out,Seminor ITo Start out,Whats ECG?,心脏电活动的三维同步立体摄影,Whats ECG?心脏电活动的三维同步立体摄影,III AVF（+90） II,I,AVL,AVR,-90,180,（0）,III AVF（+90） IIIAV,心电图易上手,When to ECG?,要诀：,惠而不费立等可取,When to ECG?要诀：惠而不费,心脏本身病变,节律异常起搏点异常传导异常血管异常冠脉血压心肌异常心包异常,心脏本身病变节律异常,心脏以外病变,肺脑低体温电解质钾钙药物代谢Call death,
2、心脏以外病变肺,How to ECG？,要诀：,无它，唯手熟尔。,How to ECG？要诀：无它，唯手熟尔。,心电图易上手,心电图易上手,几种危险的心电图,赶紧叫老大！,要诀：,几种危险的心电图赶紧叫老大！要诀：,心电图易上手,心电图易上手,心电图易上手,啥叫易损期？,啥叫易损期？,心电图易上手,心电图易上手,心电图易上手,心电图易上手,心电图易上手,心电图易上手,实习医师应掌握的ECG,实习医师应掌握的ECG,恶性心律失常：窦停、Vf、VT、VF、IIIAVB常见心律失常：PAC，PVC，Af，AVB，WPW，（BBB，PSVT，）心肌缺血：STEMI（演变、定位）电解质紊乱：高钾/低钾药
3、物：洋地黄、长QT、其它：心包炎/积液、肺栓塞,恶性心律失常：窦停、Vf、VT、VF、IIIAVB,Lets do it!,Lets do it!,#101:RBBB型VT，不完全AV脱落，室性融合波#102:RBBB型VT（Brugada标准1）#103:RBBB型VT，LAD#104:RVOT-切口性RBBB型VT（Brugada标准1）#106:RVOT-VT(LBBB,RAD），2:1VA阻滞#107:左侧室间隔VT（RBBB-LAD），2:1VA阻滞#108:R on T，尖端扭转VT（由于普鲁卡因酰胺）#113:II度2型AVB，不同的AV下传比例#114:III度AVB，交界性逸
4、搏，LVH伴劳损（缺血）,#101:RBBB型VT，不完全AV脱落，室性融合波,How to read？,How to read？,6 Aspects,心率心律电轴转位缺血和梗死肥厚,抽丝剥茧忙而不乱,要 诀,6 Aspects心率抽丝剥茧要 诀,Seminar II：Arrhythmia,The ones which are most interesting,Seminar II：ArrhythmiaThe ones,快 速 心 率,300150100756050HR10,快 速 心 率3001501007560,心电图易上手,心电图易上手,心电图易上手,节律的基本概念,如何判断窦律： P波
5、 : I, II, aVF, aVR, 0.12, 0.25mV固有频率：窦60-100；房75；结60；室3040加速频率：传导阻滞：SAB，AVB；Mobitz I型和II型旁路：WPW,节律的基本概念如何判断窦律：,心电图易上手,心律失常鉴别要点,过速？过缓？规则？不规则？QRS的宽窄宽QRS（要认真思考）：必须首先假定为室性窄QRS找P波那个导联看得清楚？P波的形态（窦性？P波？ f波？ F波？形态是否一致）P波和QRS间的关系1:1?整倍数？脱落？PR间期代偿间歇,心律失常鉴别要点过速？过缓？,心电图易上手,房 颤Irregularly irregular,房 颤Irregularl
6、y irregular,心电图易上手,宽QRS心动过速的Ddx,VTSVT伴差传或旁路下传人为干扰,宽QRS心动过速的DdxVT,人为干扰,人为干扰,Brugada标准,Leads V1-V6 are inspected to detect an RS complex. If there are no RS complexes, concordance is present and the diagnosis of VT can be made. If an RS complex is present, the interval between the onset of the R wave
7、and the nadir of the S wave (RS interval) is measured. If the longest RS interval in any lead is 100 msec, the diagnosis of VT can be made. If the longest RS interval is 100 msec, the presence or absence of AV dissociation is assessed. If AV dissociation is seen, the diagnosis of VT is made. If the
8、RS interval is 100 msec and AV dissociation cannot clearly be demonstrated, the QRS morphology criteria for V1-positive and V1-negative wide QRS complex tachycardias are considered,Brugada标准Leads V1-V6 are inspe,V1 positive (RBBB) pattern In the patient with a WCT and positive QRS polarity in lead V
9、1, the following associations have been made 5,17,24-27: -Findings in lead V1 A monophasic R or biphasic qR complex in lead V1 favors VT. A triphasic RSR or RsR complex (the so-called rabbit-ear sign) in lead V1 usually favors SVT. As an exception, if the left peak of the RsR complex is taller than
10、the right peak, VT is more likely (likelihood ratio 50:1) 18,28.- Findings in lead V6 An rS complex (R wave smaller than S wave) in lead V6 favors VT (likelihood ratio 50:1) 18. In contrast, an Rs complex (R wave larger than S wave) in lead V6 favors SVT.,V1 positive (RBBB) pattern I,V1 negative (LB
11、BB) pattern In the patient with a WCT and negative QRS polarity in lead V1, the following associations have been made - Findings in lead V1 or V2 A broad initial R wave of 40 msec duration or longer in lead V1 or V2 favors VT. In contrast, the absence of an initial R wave or a small initial R wave o
12、f less than 40 msec in lead V1 or V2 favors SVT.Two other findings that favor VT are a slurred or notched downstroke of the S wave in lead V1 or V2, and a duration from the onset of the QRS complex to the nadir of the QS or S wave of 60 msec in lead V1 or V2. In contrast, a swift, smooth downstroke
13、of the S wave in lead V1 or V2 with a duration of 50:1) - Findings in lead V6 The presence of any Q or QS wave in lead V6 favors VT (likelihood ratio 50:1) 18. In contrast, the absence of a Q wave in lead V6 favors SVT.,V1 negative (LBBB) pattern I,Seminor III：心肌缺血和梗死,The ones which are most useful,
14、Seminor III：心肌缺血和梗死The ones wh,缺血,T波改变：正常：III和V1可倒置超急性期T波高尖：局部高钾冠状T波ST段压低：,缺血T波改变：,损伤,ST抬高/ST压低：原理：从动作电位讲起,损伤ST抬高/ST压低：,透壁梗死Q波,生理性Q波：I、avL、V5、V6病理性Q波：宽0.04，深1/3R波,透壁梗死Q波生理性Q波：I、avL、V5、V6,心肌梗死的演变,超急性期：T波高尖急性期：ST抬高T波倒置Q波形成：恢复期：ST回到基线，T波继续倒置室壁瘤,心肌梗死的演变超急性期：T波高尖,STEMI诊断标准,啥叫“相邻”？,STEMI诊断标准啥叫“相邻”？,III AV
15、F（+90） II,I,AVL,AVR,-90,180,（0）,III AVF（+90） IIIAV,心电图易上手,心电图易上手,心电图易上手,心电图易上手,心电图易上手,心电图易上手,几个要注意的问题,镜向变化：注意后壁LBBB：R波进展不良：鉴别：膈肌附近病变、肥厚性心肌病、脑血管意外,几个要注意的问题镜向变化：注意后壁,Lets do it！,Lets do it！,#19：AMI（前壁），向侧壁延展，心尖受累#20：广泛前壁AMI#21：正常心室率的Af，AMI（ant）#22：AMI（ant），心尖和侧壁受累 #23：窦速，RBBB/LAFB，AMI（ant）侧壁受累#24：RAD 2AMI（lat）心尖延展#25：不典型RBBB，前壁ST抬高（ARVD）#26：AMI（下后心尖右室）；V4RST抬高；基线（正常，但S1Q3T3）,#19：AMI（前壁），向侧壁延展，心尖受累,27282930323335,27,心电图易上手,感谢聆听,感谢聆听,
