Dynamic Dysrrhythmia 快速心律判讀準則與方法 三總急診部

竇房結 房室結 希氏束 結間路徑 左束枝 右束枝 浦金纖維

心電圖的基本原理

U 波: 心室內 Purkinje fiber 的再極化 QRS:心室去極化 P波:心房去極化 T波:心室再極化

正常的心電圖

快速心律判讀準則與方法 1. 心跳數（快、慢） 2. QRS（寬、窄） （wide or narrow QRS） 3. P波（P wave） 4. 規則性（Regularity） 5. P & QRS 相關性

快速心律判讀準則與方法 心律命名 出處＋心跳數 (快or慢) (origin＋HR)

快速心律判讀準則與方法 1-(1):沒有脈搏(致命的心律) (Vf, pulseless VT, PEA, asystole) 1-(2):有脈搏 (Normal, Tachycardia, Bradycardia)

沒有脈搏(致命的心律)

有脈搏 每分鐘心跳數 > 100 則為心搏過速 每分鐘心跳數 < 60 則為心搏過緩

快速心律判讀準則與方法 2-(1):寬QRS波 (VT, Idioventricular rhythm) 2-(2):窄QRS波 (Sinus, Atrial, Junctional rhythm, PSVT)

寬QRS波(Ventricle)

窄QRS波(SA, A, AV)

快速心律判讀準則與方法 3-(1):正常(明顯) P波 (Sinus rhythm, A-V block) 3-(2):不同型P波 (Atrial Tachy-, Atrial flutter, MAT(Multifocal AT)(>3種P)) 3-(3):沒有或不明顯的P波 (Asystole, Junctional rhythm, Idioventricular rhythm, Af)

正常(明顯) P波

不同型P波

不同型P波 MAT

不同型P波 MAT

沒有或不明顯的P波

快速心律判讀準則與方法 4-(1):規則心律 (VT, PSVT, Sinus、Junct-rhythm, Idioventricular rhythm, 1st & 3rd degree A-V block) 4-(2):不規則心律 (Af, MAT, APC, JPC, VPC, 2nd degree A-V block, 分 Mobitz type I & type II)

規則心律

規則心律

不規則心律

快速心律判讀準則與方法 AF (atrial flutter) 心房撲動 (P波呈鋸齒狀) Af ( atrial fibrillation ) 心房顫動 (60/分<心跳<100/分) (沒明顯P波(亂抖)，R-R不規則)

快速心律判讀準則與方法 1. Af with RVR (心跳>100/分) (rapid ventricular response) 心房顫動合併快速心室反應 2. Af with SVR (心跳<60/分) (slow ventricular response) 心房顫動合併慢速心室反應

Af with RVR

WPW Syndrome Wolff-Parkinson-White Syndrome  先天性心臟異常，AV之間多一條輔助道路（肯特束），傳導路徑繞過AV node，心室提早被激活  EKG特點： PR interval＜0.12秒 QRS：緩慢上升的Delta波 心搏過速

WPW Syndrome

WPW Syndrome with Af

了解急性心肌梗塞 知道如何尋找— ST 升高 >1 mm 連續三個導程 J point plus 0.04 second PR baseline ST-segment deviation = 4.5 mm

12導程心電圖變化 Baseline 缺血—tall or inverted T wave (infarct), ST segment may be depressed (angina) 損傷—elevated ST segment, T wave may invert 梗塞 (急性)—abnormal Q wave, ST segment may be elevated and T wave may be inverted 梗塞 (時間不知）—abnormal Q wave, ST segment and T wave returned to normal

前壁心肌梗塞

Acute Anterior Wall MI

下壁心肌梗塞

Acute Inferior Wall MI

Acute myocardial infarction in the presence of left bundle branch block Features suggesting acute MI ST changes in the same direction as the QRS (as shown here) ST elevation more than you'd expect from LBBB alone (e.g. > 5 mm in leads V1 - 3) Q waves in two consecutive lateral leads (indicating anteroseptal MI) (ref. Sgarbossa EB et al, N Engl J Med 1996;334:481-7)

Polymorphic VT

Ventricular Pacemaker

Long Q-T interval Romano-Ward syndrome is an autosomal dominantly inherited form of long QT interval and there is a risk of recurrent ventricular tachycardia, particularly Torsade de Pointes. Ventricular premature beats (VPBs)

Junctional rhythym This is a recording from a a woman in her 50's with a long standing history of asthma and palpitations, she was on amiodarone at the time of the recording. The patient had just been converted from supraventricular tachycardia. The rhythm is regular, the QRS is narrow, and p waves are not clearly seen, except for a possible one at the beginning of the second QRS in the rhythm strip. This could be a sign of digitalis toxicity but this was not believed to be the case for this patient.