Nhng

vn c bn v
in Tim trong
thc hnh lm sng

PGS.TS. Phm Mnh Hng

Tip cn n gin ha in tm

Mong mun g t T?
Khi nim hot ng in ca TB c Im
Hnh dng T c bn
Lm th no ghi mt T?
Trc in Im?
Phn Pch cc sng T c bn
Cc bc c bn c v Tr li kt qu mt
T

Mong ch g t T??
L phng In chn on b tr (lm sng v
cn lm sng khc), khng phi l quyt nh
C gi tr chn on, nh hng iu tr trong
cc ri lon nhp
Gip h tr chn on nguyn nhn au ngc;
theo di hiu qu sau Iu huyt khi
H tr chn on kh th
=> cn c mt s quy tc c T cho n
gin ha

Ch nh lm T

Tt c bnh nhn c bit bnh Im mch

Tt c bnh nhn c biu hin bnh Im mch
Tt c bnh nhn nguy c Im mch
Trc phu thut
Theo di iu tr
Khm sc khe ngi trn 40 tui

Khi nim hot ng in hc ca Im

C Im hot ng do hin tng ti kh cc
ca t bo (trao i ion qua mng t bo)
in th hot ng ny c th ghi chp c
nh cc in cc t trn b mt c th (khi
c trn tm ngng hot ng)
Tim c 4 bung; in hc ch chia 2 tng (nh
tht)

H thng dn truyn ca Im

H thng dn truyn ca Im

Nguyn l c bn ghi ECG

C th l cht dn in tt
Baery

in tm l g???
T (ECG Electrocardiogram):
Ghi li biu hot ng in hc ca Im trn mt
n v thi gian.
in th hot ng TB c Im c truyn dn ra trn b
mt c th v co th ghi li c thng qua cc in cc

T KHNG phi l o c dng mu (lu lng) chy

trong Im.

My in Jm (Electrocardiograph): l thit b ghi li
c hot ng in hc ca Im
9

Cc pha hot ng ca TB c Im v
biu in hc ghi c

S cc pha hot ng v hnh nh mt

biu hot ng in th t bo c Im

T ghi li c phn nh tng hp

ca cc vector

i chiu hng phn nh T nhn

t cc pha

Cc v tr in cc khc nhau dn ti hnh dng

T khc nhau theo trc vector in hc

Hnh dng sng T c bn

Hot ng kh cc ca nh (sng P) v dn
truyn xung nt nh-tht (on PR)

 sng P v on PR

Hot ng kh cc ca tht

Phc b QRS

Thi gian v tc T quy c

Tn s Im = 300/s ln hoc 1500/s nh

o thi gian PR

o rng phc b QRS

Cc khong (on) trn T thng thng

PR : 0.12 0.20 sec
QRS : 0.08 0.10sec
QT : 0.40-0.43sec
ST: 0.32 - sec

23

Cch ghi T 12 chuyn o

Chun b BN; chun b my ghi
BN nm nga, th gin, trnh co c
t cc in cc theo ng trnh t: 4 in cu
ngoi bin; 6 in cc trc Im; dy m (ch
vng da dn in cc sch hoc c cht dn in
tt)
Chun ha (calibrate) cng 1 mV
Ghi 6 chuyn o ngoi vi trc; 6 chuyn o
trc Im sau
Ghi thm cc chuyn o khc theo yu cu lm
sng

Nguyn tc tam gic Einthoven

Trc ca cc chuyn o
cc chi hnh tam gic
ngc bao quanh Im

25

Chuyn o ngoi bin chun/ Bipolar

(D1,D2,D3)

Ghi li in th hot ng theo mt phng trc-

sau
Ghi in th gia hai cc electrodes.

26

Chuyn o tng cng Unipolar

(Augmented)

Cng ghi in th theo mt phng dc, trc-

sau
Ghi li hot ng in hc vi mt in cc so
vi mc zero.

27

Mc in cc ngoi bin

Cc chuyn o ngoi bin

Mc in cc trc Im

Lun nh chun ha trc khi ghi T

 Trc in hc ca Im
Vector in hc l s ch hng i v
cng hot ng in hc

32

Trc in Im l trung bnh tng hp ca cc

vector
L tng hp ca tt c
cc vector in th hot
ng to ra t mi t
bo c Im
Trc T ghi li hng
i ch o ca vector
tng hp di ghi nhn
cc in cc

33

Hot ng ton b c Im theo hng

vector in hc

Lu vi hot ng vector in Im
vi cc in cc
-Hng in th kh cc (vector) i v gn pha
in cc th sng dng (R) l tri (a)
- Hng in th kh cc (vector) i ra xa pha
in cc th sng m (S) l tri (b)
-Hng in th kh cc (vector) i trung gian
pha in cc th sng dng v m ngang nhau
(c)

Trc in Im c biu din theo mt

phng dc

Trc in Im bnh thng

Hng vector
tng hp i v
pha c 3 chuyn
o ngoi vi D1,
D2, D3
i gn D2 nht,
do vy R D2 l tri
nht

Trc in Im Phi
Tht phi dy
hoc Im quay
phi
Hng vector
tng hp i v
pha phi D3
i v gn D3
nht, do vy R D3
l tri nht v
ngc vi D1 nn
S su D1

Trc in Im tri
Tht tri dy
hoc Im quay
phi
Hng vector
tng hp i v
pha tri D1
i v gn D1
nht, do vy R D1
l tri nht v
ngc vi D3 nn
S su D3

Cch o c th Pnh trc in Im

Chn chuyn o
no m c sng R v
S tng ng nhau
Trc in Im l
vung gc vi
chuyn o
nh hng theo
chuyn o k Ip
vung gc da trn
R hay S tri

Trc in tim QRS theo cc gc

Bnh thng: -30o n +110o.
Tri: -30o n -90o
-90o

Phi: +110 n + 180

-120o

V nh: +180o n -90o

-60o

-150o

-30o

180o

0o
30o

150o
120o

90o

60o

V d Pnh trc in Im QRS

Trc in Im trng hp trn

Tnh nhanh: nhn
QRS D1 v D3: trc
Phi
Tnh c th hn:
D2 c R gn bng S
Trc in Im l
vung gc vi D2, v
S su D1, nn trc
in Im l +1500

Trc in Im QRS c ngha g?

Phn nh nh trng ph i tm tht bn phi
hay tri
C th c thay i trc trong mt s trng
hp khc:
Truc phi: Nhi mu phi
Trc tri: ri lon dn truyn

Rt t thay i theo th trng c th (cao gy;

bo ln)

Hnh dng phc b QRS trn cc

chuyn o trc Im
V1; V2: nhn bn tht
phi
V3; V4: nhn vo vch
lin tht
V5, V6: nhn vo bn
tht tri

Hnh dng phc b QRS trn cc

chuyn o trc Im

Giai on I

Giai on II

Hnh dng phc b QRS trn cc

chuyn o trc Im

Giai on III

Hnh nh cc chuyn o trc Im

Vng chuyn Ip

Chuyn o trung chuyn: R = S

Phn Pch cc sng in Im c

bn

c im sng P

Dng D1 v D2
Nhn r nht D2, V1
C th hai pha V1
Rng < 3 nh (< 12 ms)
Cao < 2,5 nh (< 2,5 mV)

Cc dng
sng P

Dy nh phi (P ph)

Dy nh tri (P hai l)

on PR
PR (PQ): 12 20 ms
Di: Bloc AV cp I; ngn: HC In kch thch

c im phc b QRS
Rng khng qu 12 ms (3 nh)
chuyn o trc Im phi (V1): S >> R
chuyn o trc Im tri (V5,6): cao khng
qu 25 mm
chuyn o tri c th c sng Q do kh
cc vch lin tht nhng: su khng qu 2mm
v rng khng qu 1mm

Bt thng QRS
Rng qu: bloc phn nhnh; nhnh, nhp ngoi
tm thu
Cao qu: ph i tht
Dy tht phi: trc phi (>1100 ); R >>S V1, V2; S
su V5-6
Dy tht tri: trc tri (< 00 ); R cao V5,6 (>=
25mm); S su V1-2; ch s Sokolow-Lyon (SV1 +
RV5 hoc RV6) >= 35mm

V d dy tht phi

Vector hng phi

R cao V1
S su V6
Thng gp: bnh
phi mn Pnh; bnh
Im bm sinh c dy
tht phi; hp van
hai l

Mt s Iu chun chn on dy tht phi

Mt s Iu chun chn on dy tht tri

Sng Q
Bnh thng: hnh thnh do kh cc vch lin
tht t tri qua phi; < 1mm rng; < 2mm su
Bnh l: T bo c Im b cht (hoi t) -> kh
cc t trong ra ngoi b mt Im ti v tr hoi
t -> sng Q bnh l vng i chiu

Sng Q bnh thng

Sng Q bnh thng

on ST
ST bnh thng l ng in
Thay i lin quan n tn thng mi c Im
hoc vim mng ngoi Im; ph i tht; thuc
digoxin
C th chnh ln; chnh xung
Cc hnh dng khc nhau, cc v tr khc nhau
cho php chn on bnh

Mt s hnh dng ST

ST chnh mt ngi khe

Sng T
Thng cng
chiu QRS
Sn ln thoai
thoi, sn
xung dc hn
Cao nht V3-
V4
Khng c Iu
chun gii hn
cao

Bt thng T

Do bnh MV
Ph i tht
Bloc nhnh
Digoxin

Bt thng sng T

on QT
QT: 0,35 0,45 ms
Chnh theo nhp Im:
QTc = QT/RR1/2

QT di
QT ngn

Cc bc c v ghi kt qu mt T
trong lm sng

Nhp g? Tn s bao nhiu?

on PR (Q) v vn dn truyn?
Trc in Im QRS
M t sng P
M t phc b QRS
M t on ST v T
M t bt thng v ri lon nhp nu c
Kt lun

V d 1

Tr li kt qu
M t cc nt chnh:
Nhp xoang; tn s 110 CK/pht
on PR bnh thng (140 ms)
QRS bnh thng (rng 120ms)
Trc trung gian (bnh thng)
on ST v sng T bnh thng

Kt lun: in tm bnh thng

V d 2 (T ca mt siu mu i
khm sc khe, cao 173cm nng 47kg)

Tr li kt qu 2
M t cc nt chnh:
Nhp xoang; tn s 75 CK/pht
on PR bnh thng (200 ms)
QRS bnh thng (rng 120ms)
Trc phi (S su D1)
on ST v sng T bnh thng

Kt lun: in tm bnh thng, trc phi

c th do t th Im ng ngi cao gy

V d 3 (T ca mt bnh nhn va i my bay

xa v, au ngc, kh th nhiu)

Tr li kt qu 3
M t cc nt chnh:
Nhp xoang nhanh; tn s 140 CK/pht
on PR bnh thng (140 ms)
QRS bnh thng (rng 120ms)
Trc trung gian
S su D1; Q D3 sng T m nhn D3

Kt lun: in tm ngh ti Nhi mu phi

cp