典型心电图诊断ppt课件

.,1,典型心电图诊断,心内科：党群,2,.,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,3,.,心电图成份的组成及各波段的测量,4,.,心电图测量,5,.,RRsqRsRSrSrSr,qRQRQrQSRrsR,QRS波群的命名,6,.,平均心电轴估测方法示意图,图中箭头示QRS主波方向,7,.,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。,8,.,NormalECG,(1)Pwave:atrialdepolarizationlAmplitude0.20mvlDuration0.11seclPositiveinI,II,aVF,V4-V6;NegativeinaVR(2)PRinterval:thetimeforintraatrial,AVnodal,andHis-Purkinjeconduction,Duration:0.120.20sec,9,.,(3)QRScomplex:ventriculardepolarization,lThewidth:0.060.10sec,0.11sec.lFromV1toV6,theRwavesgetsbiggerandbigger,theSwavesgetssmallerandsmaller.lR/SlinV5lRinV5andV62.5mv,RinV11.0mvlRinaVR0.5mv,lRinaVL1.2mvandRinaVF2.0mvlRinI1.5mvlQ0.04secinwidth,2.5mV;RI1.5mV;RaVL1.2mV;RaVF2.0mV;RI+SIII2.5mV;B.LeftaxisdeviationC.STdepressionandTinversioninV5-6.,24,.,25,.,26,.,RightVentricularHypertrophy,A.Increasedvoltage(adultsover30)R/SratioinV11.0;R/SratioinV5orV61.0;R/qorR/SratioinaVR1;RV1+SV51.05mV(severe1.2mV);RaVR0.5mV;B.Rightaxisdeviation+900(severe+1100).C.STdepressionandTinversionV1-2.,27,.,28,.,BiventricularHypertrophy,A.NormalECG.B.Oneventricularhypertrophy.C.BiventricularHypertrophy.,29,.,心肌缺血和心肌梗死MyocardialIschemiaandMyocardialinfarction,30,.,ECGofmyocardialischemiashows,STsegmentdepression;STsegmentelevation(coronaryspasm);Inverted,diphasic,lowTwave.,31,.,32,.,33,.,34,.,35,.,Myocardialinfarction,(1)Basicchanges“Hyperacute”TWaves.TallpeakedTwaves,oftenappearastheearliestECGsignofacuteMI.STElevations.TheSTsegmentelevatedinoneormoreleadsandmaybestraightenedandfusewiththeTwave(mono-phasiccurve)PathologicQWaves.thesuddendevelopedQwavemayindicateanacuteMI.,36,.,TWaveChanges.TheelevatedSTsegmentsreturntothebaseline,anddeepsymmetricalTwavesappearintheseleads.Tall,symmetrical,uprightTwaveswillappearinreciprocalleadsatthesametime.,37,.,38,.,39,.,(2)ProgressiveECGchanges,40,.,(3)LocalizationoftheECGpatterns,LeadswithAbnormalQWavesinMILeadswithAbnormalQWaveslocationofMIV1V3AnteroseptalV3V5AnteriorI,aVL,V5V6LateralV1V6ExtensiveAnteriorII,III,aVFInferior,41,.,42,.,43,.,44,.,45,.,46,.,47,.,48,.,49,.,(4)Oldmyocardialinfarct,AdefinitivediagnosisofoldmyocardialinfarctdependsonthepresenceofapathologicalQwave,50,.,51,.,52,.,急性心肌梗死的图形演变及分期,.,53,心律失常,54,.,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。,55,.,心脏的特殊传导系统,.,56,SINUSRHYTHMANDSINUSARRHYTHMIAS,窦性心律和窦性心律失常,57,.,正常窦性心律,正常窦性心律：ECG诊断频率60100bpmPavF直立，avR倒置PR间期0.120.20S,58,.,Sinusrhythmfeatures:,(1)EveryPwaveisfollowingbyaQRScomplex;(2)PwaveisuprightinleadI,II,aVF,V4-V6,inverseinaVR;(3)P-Rinterval0.12sec;(4)Normalrateis60-100beats/min,59,.,窦性心动过缓SinusBradycardia,(1)Sinusrhythm(2)Heartrate1.0sec),60,.,窦性心动过缓及不齐,61,.,窦性心动过速（sinustachycardia),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。,62,.,窦性心动过速SinusTachycardia,(1)Sinusrhythm,rate100bpmTheR-Rinterval(ortheP-Pinterval)0.60sec.(2)P-RandQ-Tintervalareshorterthanusual(3)S-Tsegmentisslightdepression,Twavesmaybeflattened,63,.,窦性心动过速,64,.,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。,65,.,Sinusarrest,ThePwavemissedforashorttime,66,.,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,67,.,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。,68,.,SickSinusSyndrome(SSS),(1)Sinusbradycardia(HR50/min);(2)SinusarrestorSAblock;(3)Tachycardia:Atrialtachycardia,AtrialFlutter,Atrialfibrillation;(4)AVblock.,69,.,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)Theremaybeanoncompensatorypause.,73,.,频发性房性期前收缩有时形成三联律,74,.,频发性房性期前收缩,75,.,频发性房性期前收缩心室差异性传导,76,.,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QRS0.12sec.TwaveindirectionisoppositetoQRScomplex.(3)Completecompensatorypause,84,.,bigeminy,trigeminy,85,.,频发室性期收缩形成二联律,86,.,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STT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,87,.,频发性多源性室性期前收缩形成短阵二联律低血钾,88,.,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。,89,.,频发性多源性室性期前收缩形成短阵二联律低血钾,90,.,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,91,.,阵发性室上性心动过速Paroxysmalsupraventriculartachycardia(PSVT),a.Heartratebetween160250bpm.b.ApreciselyregularrhythmwithnormalQRS.,92,.,93,.,94,.,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HR150250bpm，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,95,.,阵发性室上性心动过速,房室结折返性心动过速图,96,.,阵发性室上性心动过速,97,.,阵发性室上性心动过速,98,.,阵发性室上性心动过速,99,.,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,100,.,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%),101,.,预激综合征,典型预激的心电图：P-R0.12sec.c)PwavedissociatedfromQRS;TherateofPwaveislessthanTherateofQRSd)Ventricularcapture;e)Fusionbeatsarepresent.,120,.,121,.,室性心动过速,122,.,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,123,.,男，69岁，下壁心梗后两周。室速伴不明确的房室分离,124,.,尖端扭转性室速（tordesdepoints)心电图QRS波群振幅与波峰周期性改变，HR200250bpm常见QT延长，U波病因先天性电介质紊乱抗心律失常药物,125,.,尖端扭转型室速Torsdedepointes,126,.,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150300bpm室颤：振幅波形极不规则，无法识别QRS，ST-T,127,.,室扑室颤VentricularFlutterandVentricularfibrillation,Ventricularflutter:ItisimpossibletoseparatetheQRScomplexesfromtheSTsegmentandtheTwavesVentricularfibrillation:TheECGshowsfineorcoarsewavesthatarerapid,andirregularinsize,shape,andwidth.,128,.,129,.,室扑室颤,室扑室颤心电图：,130,.,传导阻滞,概述发生部位：传导系统的任何部位,131,.,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,132,.,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：,133,.,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,134,.,1.FirstDegreeA-VBlock,ProlongedP-Rinterval:P-Rinterval0.20sec.,135,.,2.SecondDegreeA-VBlock,(1)MobitztypeI(Wenckebachphenomenon).ThepatternisaprogressiveprolongationoftheP-Rintervaluntilabeatisdropped.ThefirstbeatafterthepausehastheshortestP-Rinterval,whichmayormaynotbenormal.,136,.,MobitztypeI(Wenckebachphenomenon).,137,.,(2)MobitztypeII,Thereisafixednumericalrelationshipbetweenatrialandventricularimpulses,whichmaybe2:1(2atrialbeatstooneventricularbeat)or3:1or4:1.,138,.,ThirdDegreeA-VBlock(Completeheartblock),(1)Theatrialandtheventricularrhythmsareabsolutely,independentofoneanother.(ThereisnorelationshipofPtoQRS.)(2)atrialrateventricularrate.QRSreater.,139,.,140,.,ThirdDegreeA-VBlock,141,.,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、V6R波宽大有切迹，其前无q波，V1、V2呈QS或rST波与主波方向相反QRS0.12S,142,.,左束支阻滞,右束支阻滞,143,.,室内传导阻滞,左前分支阻滞：电轴左偏-45-90、avL呈qR，、avF呈rS,QRS0.12S左后分支阻滞：电轴右偏90120、avL呈rS，、avF呈qR,QRS0.12S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：,144,.,CompleteRightBundleBranchBlock,(1)Rightaxisdeviation.(2)QRS0.12sec.(3)rsRpattern(Mpattern)inV1orV2;(4)WideandslurredSwaveinleads1,V5andV6.(5)ST-TchangesinleadsV1andV2.,145,.,CompleteL