.

..

: , ,
: AVR, AVL,
AVF
: V1-V6

: I, AVL, V5, V6
: V1, V2
: V3, V4
: II, III, AVF
: AVR
: V7, V8,

: : 0
: : +60
: : +120
AVR: : -150
AVL: : 30
AVF: : +90
V1-V6:

V1:
V2:
V3:
V4:
V5:
V6:

4
4
V2 V4
5
5
5

His
His


= :

=
QRS = :
Q = :

R = :
S = :

25 mm/sec
= 0.04 sec
= 0.20 sec
5 = 1 sec

= 0.1 mV
= 1 mV

60 sec 100 = 6000

= 6000/ 2 R (
= 0.04 sec)

1500/

1
2
3
4
5
6
7
8

=
=
=
=
=
=
=
=

300
150
100
75
60
50
43
37

= 0 90
= 0 -90 0
= 90 180 0
= -90 180 0
, , :
AVF:
,


= 10 mm
= 25 mm/sec
= ,
AVR, 2,5 mm, 0,12
QRS = 13 mm AVL, 20
mm AVF, = -30 +90
ST = 1 mm

= QRS
QRS

QRS

R 8 mm
R = 27 mm
S = 30 mm
R S = 40 mm

P = 0,12 sec
P-Q = 0,20 sec
QRS = 0,10 sec
Q-T = 0,35 0,40 sec

QRS

ST-T

: , , ,

: , ,

: , , , ,
,

: , ,

60-70 /min

40-50 / min

QRS
His Purkinje
0 30/ min QRS

Purkinje

P =

QRS =
(< 0.12 s)
T =

 12

. ST II, III
aVF. ST

. ST V1 - 6, I
aVL. ST

 . V1
3: R T

LBBB. ST QRS,
ST LBBB ( > 5 mm
V1 - 3). Q ( )

:
Q III > 1 mm, Q aVF > 0.5 mm Q
II

Sokolow + Lyon (Am Heart J, 1949;37:161) S V1+ R V5 or V6 > 35 mm
Cornell criteria (Circulation, 1987;3: 565-72) SV3 + R avl > 28 mm in men SV3 + R avl > 20 mm in women
Framingham criteria (Circulation,1990; 81:815-820)
R avl > 11mm, R V4-6 > 25mm S V1-3 > 25 mm, S V1 or V2 + R V5 or V6 > 35 mm, R I + S III > 25 mm
Romhilt + Estes (Am Heart J, 1986:75:752-58) Point score system
Left atrial abnormality (dilatation or hypertrophy)M shaped P wave in lead II
prominent terminal negative component to P wave in lead V1 (shown here)

 . P.
.
, S

. P II > 2.5 mm (2.5

)

. QRS axis > -30,

R II, III aVF.
LVH : S III > 15 mm. PR > 0.2
(1 ) .

2 1 . 2 P .
Mobitz type I II.

.
.

 .
300/

. 2:1. II, III aVF.

V1. 2:1
150 bpm.

RBBB QRS > 120 ms (3 ) R

V1, S T

. < 60 bpm

10

 . > 100 bpm

Wolf-Parkinson-White
.

.

.
QRS. .

. (Torsade de pointes).
QRS .
R - R .
: , ,
, QT .

.
.

11

QRS (>140 ms).

, QRS

Implantable cardioverter
defibrillator

. , ,
QRS P

.
QRS.

12

Lown Ganong Levine Syndrome

PR, < 3 (120 ms)

. S1Q3T3. S I,
Q T wave III.
.

. P,
, QRS, ST
segment, -, T,

. T, U waves,
1 2 , ST

. QT,
ST, , .

13

Cardioversion

!
synchronised shock
/

14

QRS

QRS

- WPW

1
2
3

< 40/
;
< 90 mmHg
< 40 min-1 ;

;

500 g i.v.

:
;
Mobitz ;
QRS;
> 3 ;

15

1. , 3 mg (3
)
2.
3. , 2-10 g min-1
4.

NAI
Atropine
500 g i.v.

;
<90 mm Hg
< 40/ min

;
OXI

NAI

NAI
:
Atropine 500 g i.v.
, 3 mg

2-10 g min-1

;

Mobitz II AV block

QRS
>3 s

;
!


;

< 90 mmHg


> 150 min-1

16

(
)

;
<90 mm Hg


>150 min-1

Amiodarone 150 mg i.v. 10 mins

Lidocaine i.v. 50 mg 2 mins

5 mins
200mg;

60 mmol,
30mmol h-1
magnesium sulphate
i.v. 5ml 50% 30 min

<90 mm Hg


>150 min-1

;
<90 mm Hg


>150 min-1

Synchronised DC shock 100 J: 200 J: 360 J

YES
, amiodarone 150 mg i.v. 10 mins,
300 mg I

60 mmol,
30mmol h-1
magnesium sulphate
i.v. 5ml 50% 30min

Synchronised DC shock 100 J:200J: 360 J

<90 mm Hg


>150 min-1

Amiodarone 150 mg i.v. 10 mins

,

KCL
Amiodarone 150 mg i.v. 10 mins

Lidocaine i.v. 50 mg 2 mins

5 mins
200mg;

60 mmol,
30mmol h-1
MgSO4
i.v. 5ml 50% 30min

Synchronised DC
shock 100 J:200J: 360 J

Amiodarone 150 mg i.v. 10 mins

,

amiodarone, lidocaine, procainamide
sotalol

Synchronised DC shock
100 J: 200 J: 360 J

amiodarone 150 mg i.v. 10 mins,

300 mg I

,
amiodarone,
lidocaine, procainamide sotalol

> 150
min-1

-

< 100
min-1

100-150
min-1

17

;
> 150 min-1

> 150 min-1

!
1.
2.Synchronised shock 100J, 200J, 360J
3.Amiodarone 300mg 1 (
)

synchronised DC shock 100J, 200J,360J

Amiodarone 300mg 1
,

100-150 min-1

!
1.
;
2. 24 ;

> 24
:

< 24
:

synchronised
DC shock

Synchronised DC
shock

> 24
:

< 24
:

miodarone
(
)

synchronised
DC shock

Synchronised DC
shock

Amiodarone

< 100 min-1

-
> 24 :

DC shock

< 24 :

DC shock

18

 ?
> 150 min-1

?
100-150 min-1

?
< 100 min-1

< 24

synchronised DC shock
100J, 200J:360J
Amiodarone 300mg 1
,

/ ?

< 24 ;

Rate control with:

Beta blockers,
Verapamil,
Diltiazem,
Digoxin,
:
Heparin
Warfarin, then
DC shock

Amiodarone: 300mg 1 hr

Flecainide 100-150 mg
i.v. 30 mins
/ DC shock

Warfarin
, synchronised
DC shock

< 24 ;?

- cardioversion
Heparin
Flecainide 100-150 mg i.v.,
Amiodarone 300 mg i.v. 1 h
Synchronised DC shock

:
Amiodarone 300mg 1hour,

:
Heparin
Warfarin
synchronised DC shock

Heparin
Synchronised DC shock
100J, 200J, 360J
Amiodarone 300mg 1 ,

( )

( )

1. > 250 / min-1,

1. synchronised DC shock

1.

2. Adenosine i.v.

2.
1. AF

3. ,
SVT
( )

Synchronised DC shock
100J, 200 J, 360 J

6mg, bolus

12mg, 1-2 , ( 3 )

( )

:
!

(
> 250 min-1)

Valsalva

( )

( digitalis, ,

Adenosine 6 mg bolus ; , 3 ,
12mg 1-2 mins*
Wolf-Parkinson-White

< 90 mmHg


> 200 min-1

Synchronised DC shock
(

Amiodarone

19


( )

( )

(
> 250 beats min-1)

Synchronised DC shock
100J, 200 J, 360 J

?
< 90 mm Hg


>200 min-1

Adenosine 6 mg bolus ;
3 12mg 1-2 mins*
adenosine with known Wolf-Parkinson-White syndrome

:
Esmolol: 40 mg 1 min + 4 mg/ min
( i.v.
12 mg min-1

Verapamil 5-10 mg i.v.

Amiodarone: 300 mg 1 ,

Digoxin: 500 g 30 mins x2

Synchronised DC shock 100 J:200J: 360 J

,
amiodarone 150 mg 10
mins
300 mg 1 hour,
shock

< 90 mm Hg


>200 min-1

:
Esmolol: 40 mg 1 min + 4 mg min-1
(
12 mg min-1

Verapamil 5-10 mg i.v.

Amiodarone: 300 mg 1 ,

Digoxin: 500 g 30 mins x 2

Synchronised DC shock
100 J:200J: 360 J
amiodarone
150 mg 10 mins
300 mg 1 ,
shock

. ( QRS) ( QRS)
. ( )
.

.
.
.

. Sinus
arrhythmia.
.

. P
.
.

20

. 2:1
.

.
.

.
B: orsade de pointes QT.
. quinidine
digitalis.
.

.
. 1

21

 .
. 2

.
. 2
Mbitz Type II Block

Mbitz Type I (Wenckebach) Block

. PR
. 1 (Wenckebach phenomenon)
PR
. Mobitz type II P
PR
. - -

.
.

Epinephrine

1 mg intravenous 10 ml 1:10,000 (1 ml 1:1,000) 2-3 mins

2-3 mg
210 mcg min-1
0.5ml 1:1,000 i.m., 3-5 ml 1:10,000 i.v.

22


Atropine

/ PEA (rate < 60 beats min-1)

PEA ( < 60 min-1)

3 mg i.v.,
6 mg

0.5 mg i.v., , 3 mg

Amiodarone

VF / VT

VF / VT
VT

300 mg in 20 ml 5% dextrose, bolus i.v.

150 mg in 20 ml 5% dextrose over 10 mins

150 mg
300 mg 100 ml 5% dextrose 1 hour

Q-T

Magnesium

Shock VF ( )

( )
Torsades de pointes

Shock VF ( ) 24 ml 50% (48 mmol) i.v. over 1-2 mins

10-15

5 ml of 50% (10 mmol) i.v. over 30 mins

Sodium Bicarbonate

(pH < 7.1)

50 mmol (50 ml of 8.4% solution) i.v.

( pH)

Lidocaine

VF / VT
VT

VF / VT

100 mg i.v.
boluses of 50 mg, 200 mg

VT

50 mg i.v.
boluses 50 mg, 200 mg

Calcium

10 ml 10% calcium chloride (6.8 mmol)

sodium bicarbonate

23

 Adenosine

Naloxone

6 mg bolus
3 12 mg 12 mins

AV node

0.2 - 2.0 mg i.v.

10 mg

24