典型心电图诊断课件

,*,单击此处编辑母版标题样式,精选课件ppt,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,典型心电图诊断,心内科：党群,1,精选课件ppt,正常时，每次心动周期在心电图上都可以出现P波、QRS波群、T波和U波、P-R段、S-T段和T-P段，P-R间期和Q-T间期及J点,2,精选课件ppt,心电图成份的组成及各波段的测量,3,精选课件ppt,心电图测量,4,精选课件ppt,R Rs qRs RS rS rSr,qR QR Qr QS R rsR,QRS波群的命名,5,精选课件ppt,平均心电轴估测方法示意图,图中箭头示,QRS,主波方向,6,精选课件ppt,正常心电图,P波,：反映左、右心房去极化过程中的电位和时间变化。,P-R段,：反映兴奋通过房室交界区，因其传导非常缓慢，形成的电位变化也很微弱，一般记录不出来而成等电位线。,QRS波群,：反映左、右心室去极化过程中的电位和时间变化。,S-T段,：表示心室去极刚结束后尚处于缓慢复极的一段短暂时间，即代表心室早期复极的电位和时间变化。,T波,：反映心室晚期复极过程中的电位和时间改变。,U波,：一般认为是心肌传导纤维的复极所造成，也有人认为是心室的后电位。,7,精选课件ppt,Normal ECG,(1) P wave:,atrial depolarization,l,Amplitude,0.20 mv,l,Duration,0.11 sec,l,Positive in I, II, aVF, V4-V6;,Negative in aVR,(2) PR interval: the time for intraatrial,AV nodal, and His-Purkinje conduction,Duration: 0.12 0.20 sec,8,精选课件ppt,(3) QRS complex: ventricular depolarization,l,The width: 0.06,0.10 sec,0.11 sec.,l,From V,1,to V,6, the R waves gets bigger and bigger, the S waves gets smaller and smaller.,l,R/S l in V,5,l,R in V,5,and V,6, 2.5 mv, R in V,1, 1.0 mv,l,R in aVR 0.5 mv,l,R in aVL 1.2 mv and R in aVF 2.0 mv,l,R in I 1.5 mv,l,Q 0.04 sec in width, 1/4 R in the same lead.,9,精选课件ppt,正常人胸导联R波和S波振幅变化规律示意图,10,精选课件ppt,(4) ST segment:,it reflects Phase 2 of the action potential.,l,ST elevation 0.3 mV in V,1、,V,2;,0.5 in V,3, 0.10 mV in V,4,V,6,l,ST depression 1/10 R in the same lead, maybe,3.5mV (female), 4.0mV (male);,Rv,5,or Rv,6, 2.5 mV;,R,I, 1.5mV;,R,aVL, 1.2mV;,R,aVF, 2.0 mV;,R,I,+ S,III, 2.5 mV;,B. Left axis deviation,C. ST depression and T inversion in V,5-6.,23,精选课件ppt,24,精选课件ppt,25,精选课件ppt,Right Ventricular Hypertrophy,A. Increased voltage (adults over 30),R/S ratio in V,1, 1.0;,R/S ratio in V,5,or V,6, 1.0;,R/q or R/S ratio in aVR1;,R,V1,+ S,V5,1.05mV (severe1.2mV);,R,aVR,0.5mV;,B. Right axis deviation +90,0,(severe +110,0,).,C. ST depression and T inversion V,1-2.,26,精选课件ppt,27,精选课件ppt,Biventricular Hypertrophy,A. Normal ECG.,B. One ventricular hypertrophy.,C. Biventricular Hypertrophy.,28,精选课件ppt,心肌缺血和心肌梗死Myocardial Ischemia and Myocardial infarction,29,精选课件ppt,ECG of myocardial ischemia shows,ST segment depression;,ST segment elevation( coronary spasm);,Inverted, diphasic, low T wave.,30,精选课件ppt,31,精选课件ppt,32,精选课件ppt,33,精选课件ppt,34,精选课件ppt,Myocardial infarction,(1) Basic changes,“Hyperacute” T Waves,. Tall peaked T waves, often appear as the earliest ECG sign of acute MI.,ST Elevations,. The ST segment elevated in one or more leads and may be straightened and fuse with the T wave (mono-phasic curve),Pathologic Q Waves,. the sudden developed Q wave may indicate an acute MI.,35,精选课件ppt,T Wave Changes,. The elevated ST segments return to the baseline, and deep symmetrical T waves appear in these leads. Tall, symmetrical, upright T waves will appear in reciprocal leads at the same time.,36,精选课件ppt,37,精选课件ppt,38,精选课件ppt,(2) Progressive ECG changes,39,精选课件ppt,(3) Localization of the ECG patterns,Leads with Abnormal Q Waves in MI,Leads with Abnormal Q Waves location of MI,V,1,V,3,Anteroseptal,V,3,V,5,Anterior,I, aVL, V,5,V,6,Lateral,V,1,V,6,Extensive Anterior,II, III, aVF Inferior,40,精选课件ppt,41,精选课件ppt,42,精选课件ppt,43,精选课件ppt,44,精选课件ppt,45,精选课件ppt,46,精选课件ppt,47,精选课件ppt,48,精选课件ppt,(4) Old myocardial infarct,A definitive diagnosis of old myocardial infarct depends on the presence of a,pathological Q wave,49,精选课件ppt,50,精选课件ppt,51,精选课件ppt,急性心肌梗死的图形演变及分期,52,精选课件ppt,心律失常,53,精选课件ppt,心脏起搏传导系统,窦房结,位于右心房上腔静脉入口处，是控制心脏正常活动的起搏点，,窦房结的冲动经前、中、后三条结间束传导至,房室结,，向前延续成,房室束,（又称,希氏束,）。,房室束先发出,左束支,后分支，再分出左束支前分支，本身延续成,右束支,，构成三条系统。,左束支后分支细长，分支晚；,两侧束支于心内膜下走向心尖分支再分支，细支相互吻合成网，称为,浦顷野纤维网,深入心室肌。,心脏起搏传导系统包括窦房结、结间束、房室结、房室束（希氏束）左右束支及其分支以及浦顷野纤维网。,54,精选课件ppt,心脏的特殊传导系统,55,精选课件ppt,SINUS RHYTHM AND SINUS ARRHYTHMIAS,窦性心律和窦性心律失常,56,精选课件ppt,正常窦性心律,正常窦性心律：,ECG,诊断,频率,60,100bpm,P,avF,直立，,avR,倒置,PR,间期,0.12,0.20S,57,精选课件ppt,Sinus rhythm features,:,(1) Every P wave is following by a QRS complex;,(2),P wave is upright,in lead I,II, aVF, V4-V6,inverse in aVR;,(3)P-R interval 0.12sec;,(4)Normal rate is 60-100 beats/min,58,精选课件ppt,窦性心动过缓,Sinus Bradycardia,(1) Sinus rhythm,(2) Heart rate 1.0 sec ),59,精选课件ppt,窦性心动过缓及不齐,60,精选课件ppt,窦性心动过速（sinus tachycardia),成人窦房结冲动形成的速率超过每分钟100次，称为窦性心动过速，速率常在每分钟101160次之间。窦性心动过速开始和终止时，其心率逐渐增快和减慢。,健康人运动和情绪紧张可引起心动过速。酒、茶、咖啡和药物如异丙肾上腺素和阿托品常引起窦性心动过速。在疾病状态中常见的病因为发热、低血压、缺氧、心功能不全、贫血、甲状腺机能亢进和心肌炎。,心电图显示窦性p波，p波速率超过每分钟100次，P-R间期大于0.12秒。,治疗主要是针对病因，必要时可应用镇静剂或-受体阻滞剂。,61,精选课件ppt,窦性心动过速,Sinus Tachycardia,(1) Sinus rhythm, rate 100 bpm,The R-R interval (or the P-P interval) 0.60 sec.,(2) P-R and Q-T interval are shorter than usual,(3) S-T segment is slight depression, T waves may be flattened,62,精选课件ppt,窦性心动过速,63,精选课件ppt,窦性停搏,窦性停搏,：,ECG,诊断,较正常,PP,间期显著长的时间内,无,P,波，长,PP,与短,PP,无倍数关系。,可有逸搏或逸搏心律。,64,精选课件ppt,Sinus arrest,The P wave missed for a short time,65,精选课件ppt,窦房阻滞,窦房阻滞：,型,PP,间期进行性缩短，出现一次长的,PP,间期,长,PP,间期,2,倍短,PP,间期,型,PP,间期固定,长,PP,间期,2,倍短,PP,间期,66,精选课件ppt,病态窦房结综合征（SSS),定义：窦房结病变导致的以过缓性心律失常为基础的临床症候群。,病因,窦房结内的病变：感染，淀粉样变，纤维化，钙化。,窦房结缺血。,迷走神经张力增高，抗心律失常药应用。,67,精选课件ppt,Sick Sinus Syndrome (SSS),(1),Sinus bradycardia (HR50/min);,(2) Sinus arrest or SA block;,(3) Tachycardia: Atrial tachycardia,Atrial Flutter,Atrial fibrillation;,(4),AV block.,68,精选课件ppt,病态窦房结综合征（SSS),症状：心脑等器官供血不足的表现,心电图表现,显著的心动过缓（,0.12s.,(3) There may be a,noncompensatory pause.,72,精选课件ppt,频发性房性期前收缩有时形成三联律,73,精选课件ppt,频发性房性期前收缩,74,精选课件ppt,频发性房性期前收缩心室差异性传导,75,精选课件ppt,房性早搏,房性早搏：,定义：起源于窦房结以外任何,心房部位过早激动,ECG,诊断,P,波提前发生与窦,性,P,波形态不一样,QRS 0.12 sec.,T wave in direction is opposite to QRS complex .,(3),Complete compensatory pause,83,精选课件ppt,bigeminy,trigeminy,84,精选课件ppt,频发室性期收缩形成二联律,85,精选课件ppt,室性早搏,心电图诊断,宽大畸形,QRS,波无相关,P,波,代偿间期完全,继发,ST,T,改变,心电图类型,二联律、三联律,成对、短阵室速,单形型，多形型,86,精选课件ppt,频发性多源性室性期前收缩形成短阵二联律 低血钾,87,精选课件ppt,四、多源性早搏,房性或室性早搏有时由两个以上的起搏点产生。,心电图中房性早搏的p波和室性早搏的qrs波有两种或两种以上的不同形态，且配对间期不等，称为多源性早搏。,频发的早搏可接连发生，如超过3次则称为短阵心动过速。,88,精选课件ppt,频发性多源性室性期前收缩形成短阵二联律 低血钾,89,精选课件ppt,阵发性室上性心动过速,房室结折返性心动过速,：,病因：大多无器质性心脏病,发生机制：房室结双径路,（,快）径路：传导速度快，但不应期长,（,慢）径路：传导速度慢，但不应期短,90,精选课件ppt,阵发性室上性心动过速,Paroxysmal supraventricular tachycardia,(PSVT,),a. Heart rate between,160 250 bpm,.,b. A precisely regular rhythm,with,normal QRS,.,91,精选课件ppt,92,精选课件ppt,93,精选课件ppt,阵发性室上性心动过速,临床表现：,突发突止,症状轻重取决于心率，原发病和持续时间,心律绝对规则,心电图诊断,HR150,250bpm,，,节律规则,QRS,形态大多正常,P,波逆行性，常在,QRS,之内或终末部,94,精选课件ppt,阵发性室上性心动过速,房室结折返性心动过速图,95,精选课件ppt,阵发性室上性心动过速,96,精选课件ppt,阵发性室上性心动过速,97,精选课件ppt,阵发性室上性心动过速,98,精选课件ppt,预激综合征,预激综合征,:,定义：心房冲动提前激动心室的一部分,或全体，或者心室冲动提前激动,心房的一部分或全体,机制：显性旁路,99,精选课件ppt,预激综合征,病因：,1.5,的正常人,器质性心脏病：三尖瓣下移畸形，二尖瓣脱垂，心肌病等,临床表现：快速室上性心律失常,AVRT,（,80,）,Af(15-30%),AF(5%),100,精选课件ppt,预激综合征,典型预激的心电图：,P-R0.12S,波,ST-T,继发改变,A,型预激,B,型预激,101,精选课件ppt,预激综合征,典型预激的心电图图示,102,精选课件ppt,预激综合征（A型）,103,精选课件ppt,预激综合征（A型）,104,精选课件ppt,预激综合征（B型）,105,精选课件ppt,房性心动过速,ECG诊断：,心房率,150,200bpm,P,波形态与窦性不同,P,波之间有等电位线,刺激迷走神经不能终止,常合并房室阻滞,106,精选课件ppt,房扑,心电图诊断,规律的,F,波，,F,波之间有等电位线，频率,250,350,心室率可规则或不规则,QRS,波形大多正常，也可差传,107,精选课件ppt,房扑,Atrial Flutter,(1),Absence,of normal,P waves,;,(2),P waves,replaced,by saw-tooth flutter wave (,F,waves,);,(3),Flutter waves seen best in leads II, III,aVF;,(4),F waves always,uniform,in size, shape and,frequency and absence of isoelectric line,between F waves;,(5),Regular atrial rhythm with a rate of,250-350 /min,;,(6),Ventricular response of 1:1,2:1,3:1,4:1 or higher,108,精选课件ppt,109,精选课件ppt,房扑心电图,110,精选课件ppt,典型房扑一例,II、III、aVF导联F波呈负相，V1呈正相,111,精选课件ppt,心房扑动2：1房室传导,112,精选课件ppt,心房扑动2:16:1房室传导,113,精选课件ppt,房颤,心电图诊断,P,波消失，代之以,f,波，频率,350,600bpm,心室率不规则,QRS,形态正常，也可差传,114,精选课件ppt,房颤,Atrial Fibrillation,(1),Absence of clear P waves ;,(2) P waves replaced by,f waves,;,(3)f waves:,irregular in size, shape, best seen in lead V,1,;,(4)Rate of f waves is,350 - 600/min,;,(5),Irregularly irregular ventricular rate,;,(6)Generally, duration of QRS complex 0.12S,，,ST-T,与主波方向相反,HR 100,250bpm,房室分离,心室夺获和室性融合波,118,精选课件ppt,室性心动过速,Ventricular Tachycardia,a)The rate is,140,200/min,and the rhythm is very slightly,irregular,.,b)QRS complex is the wider and the bizarre , Duration of,QRS 0.12 sec,.,c),P wave dissociated from QRS,;,The rate of P wave is less than The rate of QRS,d) Ventricular capture ;,e)Fusion beats are present.,119,精选课件ppt,120,精选课件ppt,室性心动过速,121,精选课件ppt,女，36岁，反复晕厥。（ICD):植入性心脏复律除颤器。长导联可见一大的偏转（箭头所示）是去纤颤器放电，在此之后是房室双腔起搏器起搏心脏,122,精选课件ppt,男，69岁，下壁心梗后两周。室速伴不明确的房室分离,123,精选课件ppt,尖端扭转性室速,（,tordes,de points),心电图,QRS,波群振幅与波峰周期性改变，,HR200,250bpm,常见,QT,延长，,U,波,病因,先天性,电介质紊乱,抗心律失常药物,124,精选课件ppt,尖端扭转型室速,Torsde de pointes,125,精选课件ppt,室扑室颤,室扑室颤,：,心电图表现：,室扑：,QRS,波群成正弦波图形，频率,150,300bpm,室颤：振幅波形极不规则，无法识别,QRS,，,ST-T,126,精选课件ppt,室扑室颤,Ventricular Flutter and Ventricular fibrillation,Ventricular flutter:,It is impossible to separate the QRS complexes from the ST segment and the T waves,Ventricular fibrillation:,The ECG shows fine or coarse waves that are rapid, and irregular in size, shape, and width .,127,精选课件ppt,128,精选课件ppt,室扑室颤,室扑室颤心电图：,129,精选课件ppt,传导阻滞,概述,发生部位：传导系统的任何部位,130,精选课件ppt,传导阻滞,分度：,：传导时间延长,：,型，传导时间进行性延长直至脱漏,型，传导时间固定而脱漏,：完全传导阻滞,131,精选课件ppt,房室传导阻滞,房室传导阻滞,定义：房室交界区,脱离了生理不应期,后，心房传导延迟或不能传到心室,病因：多种原因，正常人可有文氏型阻滞,临床表现：症状取决于心率,心电图表现：,132,精选课件ppt,房室传导阻滞,：PR间期0.20S，可发生于交界区以下任何部位, 型（文氏型)：,PR,间期进行性延长，直至,P,波受阻不能下传心室,RR,间期进行性缩短,长,RR,间期,心室率,133,精选课件ppt,1. First Degree A-V Block,Prolonged P-R interval:,P-R interval 0.20sec,.,134,精选课件ppt,2.Second Degree A-V Block,(1) Mobitz type I (Wenckebach phenomenon).,The pattern is a,progressive prolongation of the P-R interval until a beat is dropped,.,The first beat after the pause has the shortest P-R interval, which may or may not be normal.,135,精选课件ppt,Mobitz type I (Wenckebach phenomenon).,136,精选课件ppt,(2) Mobitz type II,There is a fixed numerical relationship between atrial and ventricular impulses, which may be 2:1 (2 atrial beats to one ventricular beat) or 3:1 or 4:1.,137,精选课件ppt,Third Degree A-V Block (Complete heart block),(1) The atrial and the ventricular rhythms are absolutely, independent of one another.,(,There is no relationship of P to QRS,.,),(2),atrial rate ventricular rate,.,QRS is 0.12 sec. or greater,.,138,精选课件ppt,139,精选课件ppt,Third Degree A-V Block,140,精选课件ppt,室内传导阻滞,右束支传导阻滞,：,V1,呈,rsR,V5,、,V6,呈,qRs,，,S,波宽阔,T,波与主波方向相反,QRS0.12S,左束支传导阻滞,：,V5,、,V6 R,波宽大有切迹，其前无,q,波，,V1,、,V2,呈,QS,或,rS,T,波与主波方向相反,QRS0.12S,141,精选课件ppt,左束支阻滞,右束支阻滞,142,精选课件ppt,室内传导阻滞,左前分支阻滞,：,电轴左偏,-45-90,、,avL,呈,qR,，,、,、,avF,呈,rS,QRS,0.12S,左后分支阻滞,：,电轴右偏,90,120,、,avL,呈,rS,，,、,、,avF,呈,qR,QRS,0.12S,排除右室肥厚、肺气肿、侧壁心肌梗死与正常变异,双分支与三分支阻滞,：,143,精选课件ppt,Complete Right Bundle Branch Block,(1) Right axis deviation.,(2) QRS,0.12 sec.,(3) rsR pattern (M pattern ) in V,1,or V,2,;,(4) Wide and slurred S wave in leads 1, V,5,and V,6,.,(5) ST-T changes in leads V,1,and V,2,.,144,精选课件ppt,Complete Left Bundle Branch Block,(1) Left axis deviation.,(2) A wide, slurred R in I,V5 ,V6. The wide, aberrant QRS , QRS,0.12 sec.,(3) The QRS in V1 may be QS or rS type.,(4) ST-T changes.,145,精选课件ppt,室内传导阻滞,右束支阻滞,146,精选课件ppt,右束支阻滞,147,精选课件ppt,右束支阻滞,148,精选课件ppt,室内传导阻滞,左束支阻滞,149,精选课件ppt,左束支阻滞,150,精选课件ppt,左前分支传导阻滞,电轴左偏-45-90；、avL呈qR，、avF呈rS,QRS0.12S,151,精选课件ppt,室内传导阻滞,左前分支阻滞图,152,精选课件ppt,冠状动脉供血不足,153,精选课件ppt,慢性冠状动脉供血不足,154,精选课件ppt,电解质紊乱低血钾,典型改变为ST段压低，T波低平或倒置，U波增高QT-U间期延长。,155,精选课件ppt,低血钾,156,精选课件ppt,高血钾,157,精选课件ppt,洋地黄引起的特征性ST-T改变,158,精选课件ppt,对心电图检查的评价,1.心电图正常绝不能排除心脏病。如较轻微的瓣膜病或双心室肥大时心电图可以正常；亦不能由于心电图有些不正常之处而肯定其患有心脏病，如预激综合征，右束支传导阻滞的改变可以见于正常人。,2.心电图的正常范围较大，多数值的判定标准，也不是绝对的，应避免将一些正常变异误认为不正常，甚而做出心脏病之诊断，而造成不应有的医源性错误，如T波的改变就很不稳定。,159,精选课件ppt,对心电图检查的评价,3.心电图的某些改变并不具有特异性，同样的心电图改变可见于多种心脏病，如右室肥厚，即可见于肺源性心脏病，先天性心脏病，也可见于风湿性心脏病；T波改变可见于心肌缺血、心肌炎，也可见于药物作用及电解质紊乱 故对其判断必须结合临床资料才能作出较恰当的结论,4.心电图对于心脏的收缩功能的估计与瓣膜损害情况的反映无帮助。因而不能作为心脏功能的判断依据。,160,精选课件ppt,此课件下载可自行编辑修改，此课件供参考！,部分内容来源于网络，如有侵权请与我联系删除！感谢你的观看！,