Atlas of Eletrocardiography

Phn 1

Bs Nguyn Quang Ton

Cc o trnh: DI, DII, DIII, aVR, aVL. aVF

V8: khoang LS V trn ng gia

xng vai
V9: gia V8 v CSTL trn khoang
LS V pha sau

Cc o trnh ngc phi:

V1R: LS IV cnh b c tri
V2R: LS IV cnh b c phi

V3R: im gia ng ni V2R v V4R

V4R: khoang LS V trn ng gia
n phi
V5R: giao ng qua V4R vi ng
nch trc
V6R: giao ng qua V5R vi ng
nch gia

Nhp xoang bnh thng

Nhp chm xoang

Nhp nhanh xoang

6

Lon nhp xoang: thng do h hp

- Nhp xoang, tn s lun bt(60-100), tn s tng khi ht vo, gim khi

th ra c th < 60. S khc nhau gia RR ngn nht v RR di nht >
0,12s.
- Hnh dng sng P, thi gian PR, QRS bnh thng

Ngng xoang

Ch nhp lu ng nh
8

Nhp nhanh nh

Ngoi tm thu nh

Nhp nhanh nh (f: 150-250 l/p)

Nhp nhanh trn tht(f: 150-250, sng P ln vo QRST)

10

Nhp nhanh kch pht trn tht

Cung nh

Rung nh

11

Hc Wolf-Parkinson-White

12

Nhp b ni

Nhp b ni gia tc

13

Nhp b ni nhanh

Nhp thot b ni
14

Ngoi tm thu b ni

15

Nhp t tht

Nhp t tht gia tc

16

Ngoi tm thu tht

NTT tht 1 dng

NTT tht a dng

17

NTT tht nhp i

NTT tht nhp ba

NTT tht nhp bn

NTT tht 2 nhp lin tip

18

NTT tht R on T
NTT tht xen k(INTERPOLATED PVC)

Xon nh

19

Nhp nhanh tht 1 dng

Nhp nhanh tht nhiu dng

20

Rung tht

Phn ly in c(Hot ng in v mch)

21

Atrioventricular
and
Bundle Branch Blocks
(Block nh tht v block nhnh)

22

Block AV I

Block AV III
23

 Bl
Block AV II: Mobitz typ I hay chu k Lucian-Wenkebach

Block AV II: Mobitz typ II

24

Block nhnh phi hon ton

Block nhnh tri hon ton

25

NHI MU C TIM

26

27

Nhi mu
c tim cp
thnh
trc

28

NMCT cp thnh di

NMCT cp thnh di

NMCT cp thnh bn

29

NMCT cp vng vch

30

ECG Case

31

001

Ri lon nhp xoang do h hp

32

002

Nhp nhanh xoang

33

003

Nhp xoang vi block AV II dn truyn 2:1

34

004

Nhp xoang vi block AV II 2:1

Block nhnh phi hon ton
Block phn nhnh tri trc
C th dy nh tri; c th NMCT thnh di

35

005

Nhp b ni chm(25l/p)
C th l hi chng suy nt xoang
36

006

Nhp xoang 64l/p; nhp tht 45l/p

Block nh tht III
C th c dy nh tri

37

007

Nhp xoang 90l/p, block AV III

Nhp my to nhp 60l/p
Vim tim trong bnh Lyme

38

 Nhp nhanh nh a : P c nhiu dng, PP khc nhau; tng gnh nh tri vi P cao
DII, DIII, aVF; sng R ngho nn cc chuyn o ngoi vi
39
ECG ca bnh nhn COPD

 Nhp nhanh nh(f=200l/p); block AV 2:1; NTT tht tha; tng gnh
tht tri

40

 Nhp nhanh nh vi block AV 2:1;block nhnh phi khng hon ton;

QT ko di
41

Nhp nhanh nh(f=180l/p); block AV 2:1(r trn V1); Dy tht tri, R ct

ct t V1-V4(dng QS)=> NMCT c thnh trc vch
42

008

Nhp nhanh trn tht vng vo li nt nh tht(AVNRT)(f=150l/p)

43

009

Cung nh 2:1(r trn DII, V1)

44

010

Cung nh(tn s nh 300l/p), t l dn truyn 2:1 v 3:1

45

011

Rung nh vi block nhnh tri hon ton

46

012

Cung nh dn truyn 2:1; block nhnh tri hon ton

Hot ha nh r DII(tn s 320l/p)
47

013

Rung nh vi block tim hon ton v nhp thot b ni.

QRS rng cho thy c s ri lon dn truyn trong tht nh trc tri, tng gnh tht tri
48

014

Rung nh; trc phi, tng gnh tht tri

ECG ny gi c tng gnh 2 tht bin chng ca hp 2 l v bnh van m ch
49

015

Sng delta

HC W-P-W: PR ngn, QRS dn rng, sng delta

50

016

Rung nh; HC W-P-W

51

017

Nhp t tht gia tc

52

018

Hc QT di(0,6s)
53

019

Nhp nhanh tht n dng(f=170l/p): hnh dng ca block nhnh phi hon ton v t l R:S < 1 trn V6
54
gi nhp nhanh tht vi pht nhp mt tri tim gn y tim

020

Bn n 43t, th trng bo, kh th, nn v v m hi

55

Phn tch:
- Nhp xoang
- NMCT cp thnh di: ST chnh ln DII, DIII, aVF

- NMCT tht phi: gi ST chnh ln DIII v V1

- in th thp

A
A- phn bit ST chnh trong ti cc sm(Ber)
v trong NMCT cp (AMI)
B-C: ST chnh trong khng NMCT cp v trong NMCT
cp

56

Bn nam 46t, hi
hp trng ngc
ko di, kh th
tng t
ECG:
Nhp xoang u
69l/p
Tng gnh tht
tri
HC WPW tng
cn

021

57

022

Bn n 46t, b nn v i ngoi 2 ngy nay

ECG: nhp xoang u 82l/p; QT ko di

58

023

Bn nam 58t b k di cn phi, hin c kh th, tm, tt HA(88/45)

59

Phn tch:
- Nhp xoang u tn s 97l/p, trc phi
- Block nhnh phi khng hon ton
- Sng T bt thng ph hp vi thiu mu c tim vng di v trc vch
Comment:
- S o ngc sng T cc chuyn o trc tim gi tc nghn on gn LAD. Ngoi ra s o ngc song T cng c
th gi ti sng Wellen hay du hiu Wellen. Tuy nhin hin ti trn ECG ny vi trc phi, block nhnh phi v ng
thi s o ngc song T vng thnh di v trc vch gi ti thuyn tc phi ln.
- Bn ny sau t vong, gii phu t thi cho thy c tc nhiu m phi trong c tc m phi vng yn nga

60

024

Bn n 75t, b nn v a chy

61

ECG:
- Nhp nhanh xoang (f=115l/p)
- NTT nh
- Dy nh phi
- Dng QS V1, V2: NMCT c trc vch
- Sng T ti cc khng c hiu

62

025

Bn n 64t tnh trng sau ngt

ECG: Nhp xoang nhanh vi block AV cp II dn truyn 2:1, tn s tht 75l/p(sng P r /V2,V3, tn s 150l/p)
Dng QS V1, V2: NMCT c thnh trc vch
63

026

BN nam 29t, trng thi tm thn bin i v thay i hnh vi sau khi dung thuc qu liu(khng r thuc g)
64

ECG:
- Nhp xoang nhanh(f=128l/p)
- Chm dn truyn trong tht khng c hiu
Comment:

ECG ny gi qu liu thuc chng trm cm 3 vng:

+ Nhp tim nhanh

+ Trc phi
+ Bin song P/aVR 3mm
+ QRS dn nh

+ Ngoi ra du hiu thng gp na l QT di

- Ng c thuc chng trm cm 3 vng l mt trong nhng chn on phn bit quan trng khi gp
trc phi, QRS dn, QT di. Bn trong ca ny l do qu liu Amitriptyline

65

027

BN n 18t, ang c thai 26 tun, kh th, hi hp trng ngc, lo lng

66

ECG:
- Nhp xoang u 79l/p
- Block nhnh phi khng hon ton
- Sng T m V1-V3: thiu mu c tim trc vch
- Bt thng song T khng c hiu thnh di
Comment:
ECG ny gi 1 nhi mu phi. Block nhnh phi khng hon ton c th gi dn tht
phi. Sng T bt thng l du hiu thng thy ca nhi mu phi. Sng T o ngc
thnh di v trc vch l c hiu cao cho nhi mu phi. Tuy nhin sng T o ngc

ch c lp vng trc vch th c nhy cao hn. Ch rng bn ny khng c nhp

nhanh. Nhp nhanh xut hin t hn mt na cc trng hp nhi mu phi
67

028

68

* LS: Bn n 48t, b bnh c tim hn ch nng,

kh th khi gng sc, tin ngt.
* ECG:
- Nhp xoang bt
- NMCT cp trc vch
Sau vi gi ghi tip in tim...
69

029

70

 ECG:
- Nhp xoang chm
- NMCT trc vch:ST chnh ln V1, V2
- Block nhnh phi hon ton: QRS >0,12s; Dng RsR/V1; S rng DI, aVL,
V5, V6
- Block phn nhnh tri sau: trc phi t nht > 1200, dng qR/DII,DIII,aVF

Nh vy sau vi gi ghi li in tim thy c them block nhnh phi,

hemiblock. y l hu qu ca nhi mu c tim trc vch

71

030

72

 LS: BN nam 74t, kim tra tim mch trc PT thay khp gi. Bn c tin s
ph hp vi bnh mv c pt bc cu ni ch-vnh cch 1 nm.
ECG:
- Nhp xoang bt
- Block AV I
- NMCT c trc vch
- Phn ly nh tht(atrioventricular dissociation)

73

031

74

 LS: Bn nam 48t, b suy tim xung huyt, hin ti c bun nn, nn, kh
th
ECG:
- Tn s nh 200l/p, u: nhp nhanh nh
- Tn s tht 70l/p
- Block AV III
in tim gi nhim c digoxin. nh lng nng digoxin mu l
4,4ng/ml(bt 0,5-2,2ng/ml)

75

032

76

 LS: Bn n 40t, c kh th, au tc ngc. HA 85/50

ECG:
- Nhp xoang nhanh 130l/p
- in th thp
Comment:
- in th thp: khi bin QRS cc chuyn o chi <5mm, cc
chuyn o trc ngc < 10mm

77

033

78

 LS: Bn nam 37t, tnh trng sau ngt. Hin ti bnh thng
ECG
- Nhp xoang f=75
- Tng gnh tht tri
- Block nhnh phi khng hon ton
- ST chnh ln cc chuyn o trc ngc => Hc Brugada

79

Hi chng Brugada
1. nh ngha: HC Brugada l mt bnh l knh ion v in hc tin pht ca tim
c trng bi on ST chnh ln chuyn o trc tim bn phi, khng c
bt thng cu trc tim. Bnh nhn thng c nhng cn ngt hoc t t do
nhp nhanh tht hoc rung tht.
2. PL ECG:

80

Cc typ hc brugada

81

HC Brugada typ 1

82

Hc Brugada typ 1

83

Hc Brugada typ 1

84

Hc Brugada typ 2

85

HC Brugada type 2
86

034

87

 LS: Bn n 53t cm thy chng mt

ECG
- Nhp xoang
- Block nh tht cp II kiu Mobitz 1(chu k Lucian-wenkebach)
- NTT tht tha

88

89

* LS: Bn nam 50t, ang trong tnh trng au

ngc d di
ECG:
- Nhp xoang
- Ngoi tm thu tht
- Sng Q V3-V5
- ST chnh ln DI, aVL, V3-V6
- ST chnh xung DIII, aVF
KL: NMCT cp thnh trc bn; Ngoi tm thu tht

90

91

LS:BN nam 65t, tin s v hin ti khng c biu hin g

bnh tim. ECG c ghi thng quy trc m.
ECG:
- Nhp xoang
- Trc bnh thng
- Block AV I(PR = 0,28s)
- Block nhnh phi hon ton

92

035

93

LS: Bn nam 50t vo cp cu v au ngc ko di

1h. Khm khng pht hin triu chng tim mch
ECG:
- Nhp xoang vi 1 nht ngoi tm thu nh
- Sng T o ngc trn aVL, V1-V6
KL: NMCT cp khng ST chnh thnh trc bn

94

036

95

LS: BN nam 50t vo cp cu v au vng gia ngc ko di 2h vi

c im cn au ngc ca NMCT cp. Cch 6 thng ECG ca bn
bnh thng
ECG:
- Nhp xoang
- Trc bnh thng
- NTT tht
- Block nhnh tri cc nhp xoang

96

037

Nhp xoang, block AV I

Block nhnh tri hon ton

97

038

H/c W-P-W

98

039

99

* LS: BN nam 40t, khng c triu chng g.

Vo cp cu sau khi b ngt
ECG:
- Nhp xoang, 70l/p
- Thi gian PR v QRS bnh thng
- Trc bnh thng
- Phc b QRS V1, V2 c dng RSR
- ST chnh ln i xung V1, V2
KL: HC Brugada

100

040

101

* LS: BN n 30t, iu tr trm cm nhiu nm. Bn

vo cp cu sau khi t t bng ung nhiu aspirin
ECG:
- Sinus rhythm
- Normal axis
- Normal QRS complexes
- T wave inversion in leads I, VL, V4-V6(T o ngc DI, aVL, V4-V6)
KL: T o ngc thnh trc bn do dung lithium

102

041

103

* LS: ECG ca 1 cu b 15t, b ngt khi chi

bng . Gia nh c b b cht t ngt
ECG:
- Nhp xoang
- Khong PR bnh thng tr phc hp th 3 trn aVL, nht ny gi 1
tin kch thch
- Trc v QRS bnh thng
- QT di(khong 640ms)
- Cc sng U thy r trn cc chuyn o ngc
KL: Hi chng QT ko di
104

042

105

* LS: Bn nam 70t vo vin v kh th

ECG:
- Nhp xoang
- Sng P 2 pha, r V1, V2, cao gn 3mm DII
- Trc chuyn phi
- Ch s Sokolyon tht phi > 12mm
- Sng S su V6, khng c dng ca tng gnh tht tri
Kl: Dy nh phi

106

043

107

* LS: BN nam 25t, vo vin v au ngc

ECG:
- Nhp xoang
- Trc bnh thng
- ST chnh ln DI, DII, DIII, aVF, V4-V6
KL: Vim mng ngoi tim

108

044

109

* LS: Bn nam 65t vo vin v kh th, bn c

cc biu hin ca suy tim mc va
ECG:
- Nhp xoang
- Ngoi tm thu tht nhiu
- Block nhnh phi
- Sng Q cc nhp xoang trn DIII, aVF
KL:
- NTT tht nhiu
- Block nhnh phi
- C th l nhi mu c tim c thnh di
110

045

111

* LS: Bn nam 50t vo vin v au ngc vi c

im ca thiu mu c tim, HA 150-80, khng c
biu hin suy tim
ECG:
-

Nhp nhanh phc b rng, tn s 200l/p

Khng c song P
Trc phi
Broad-complex tachycardia, rate 200/min
Thi gian QRS khong 140ms
QRS dng block nhnh phi

- QRS complex duration about 140 ms

Right bundle branch block pattern, with the R
peak taller than the R1
peak in lead V1
Non-concordant QRS complexes with negative
QS pattern in lead V6 (i.e. complexes are upwards

in lead Vl but downwards in lead V6)

112

046

113

Bn n 60t, b suy tim thi gian di, hin ti

kh th, gim cn, n ung km
Rung nh(Atrial fibrillation)
Ngoi tm thu tht nhp i(Coupled ventricular extrasystoles)
Sng Q aVL( cc nhp trn tht)(Q waves in lead VL (in the
supraventricul beats)
Cc song T dt v song U (thy r V3)(Flattened T waves and prominent
U wave (best seen in lead V3)
ST chnh xung V6
KL:
- Rung nh vi nhp thot tht
- C th nhim c digoxin v h kali mu
114

047

115

Bn nam 40t, khng c biu hin g, ECG thc

hin trong khm sc khe nh k
Nhp xoang(Sinus rhythm)
Trc bnh thng(Normal axis)
Mt song R V3
ST chnh ln cao V4
Sng T o ngc DIII, aVF
KL:
- C th l ST chnh ln cao bnh thng
- C th l thiu mu c tim thnh di
- C th l nhi mu c tim c thnh trc
116

117

118

119

120