DIEN TIM Huong Dan PDF

HNG DN
C IN TIM
Gio s Trn Trinh
Tng cc bn quan tm n in tm - c bit cc
bn cao hc Ni 12 i hc Y Dc Hu.
DINHTUAN
11/1/2008
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MC LC
CHNG MT ............................................................................................................................ 8
NHNG KHI NIM C BN ............................................................................................ 8
PHNG PHP GHI IN TM ................................................................................. 8
NH CHUN ......................................................................................................................... 9
CC QU TRNH IN HC CA TIM .......................................................................... 11
S HNH THNH IN TM ..................................................................................... 11
Mc in cc ...................................................................................................................... 12
NH ................................................................................................................................... 12
THT ............................................................................................................................... 13
A- KH CC..................................................................................................................... 13
B- TI CC ....................................................................................................................... 15
TRUYN T NH THT .................................................................................................. 16
CC CHUYN O THNG DNG ................................................................................ 17
IN TRNG TIM ........................................................................................................ 17
K THUT T CC IN CC V CHUN B BNH NHN .......................... 17
CCH T CC CHUYN O ...................................................................................... 18
CC CHUYN O MU ............................................................................................. 18
CC CHUYN O N CC CC CHI .................................................................. 20
CC CHUYN O TRC TIM ................................................................................ 21
CC CHUYN O KHC ........................................................................................... 23
CHNG HAI............................................................................................................................ 25
HNG DN C MT IN TM ........................................................................ 25
CCH PHT HIN CC SAI LM KHI GHI IN TM ...................................... 26
A- GHI IN TM SAI LM .................................................................................. 26
B- MY IN TIM KHNG CHNH XC .................................................................. 27
C- CC NH HNG TP BN NGOI .................................................................... 28
TNH TN S TIM ............................................................................................................... 30
1. Dng thc tn s .......................................................................................................... 30
2 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12
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2. Dng bng tn s............................................................................................................ 31
3. Dng cng thc tn s ................................................................................................... 31
TRC IN TIM CCH XC NH TRC IN TIM .............................................. 32
TAM TRC KP BAYLEY ............................................................................................. 33
Vng trn nh mc ........................................................................................................... 33
Lun thuyt hnh chiu....................................................................................................... 34
Tm trc in tim, gc .................................................................................................... 34
TRC IN TIM BNH THNG ..................................................................................... 35
TRC IN TIM BNH L ................................................................................................ 36
Trc phi ............................................................................................................................. 36
Trc tri............................................................................................................................... 37
CC T TH IN HC CA TIM .................................................................................. 38
Phn loi cc t th in hc ca tim................................................................................ 38
Tim xoay xung quanh trc ngang ...................................................................................... 40
T TH IN HC CA TIM TRONG TRNG HP BNH THNG V BNH
L.................................................................................................................................................... 41
ngi bnh thng .......................................................................................................... 41
ngi c bnh tim........................................................................................................... 41
PHN TCH HNH DNG CC SNG ............................................................................. 42
SNG P ................................................................................................................................... 44
SNG P BNH THNG ..................................................................................................... 44
Hnh dng v bin ......................................................................................................... 44
Thi gian ............................................................................................................................. 45
SNG P BNH L ................................................................................................................ 45
1. Khi P b bin dng .......................................................................................................... 45
2. P m D1 , aVL, V5, V6 ................................................................................................. 45
3. P thay i hnh dng trn cng mt chuyn o .......................................................... 45
4. P cao > 2,5mm v nhn ................................................................................................. 45
5. P rng (> 0,12s) .............................................................................................................. 45
6. Khi P bin mt (P ng in) ........................................................................................ 45
KHONG PQ ......................................................................................................................... 46
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Cch o ............................................................................................................................... 46
Khong PQ bnh thng ......................................................................................................... 47
Khong PQ bnh l................................................................................................................. 47
1. PQ di ra ......................................................................................................................... 47
2. PQ b t ..................................................................................................................... 48
3. PQ ngn hn bnh thng (< 0,12s).............................................................................. 48
PHC B QRS ...................................................................................................................... 49
M T K HIU V O C CC SNG ................................................................ 49
PHC B QRS BNH THNG ........................................................................................ 52
cc chuyn o ngoi bin ............................................................................................. 52
cc chuyn o trc tim ............................................................................................... 53
Thi gian ............................................................................................................................. 54
PHC B QRS BNH L ..................................................................................................... 55
ON ST ................................................................................................................................ 57
V tr ca ST c th l: ....................................................................................................... 57
ON ST BNH THNG.................................................................................................. 59
ON ST BNH L ............................................................................................................. 59
SNG T ................................................................................................................................... 60
Bin ................................................................................................................................ 61
SNG T BNH THNG..................................................................................................... 61
SNG T BNH L ................................................................................................................ 62
KHONG QT ......................................................................................................................... 65
Khong QT bnh thng .................................................................................................... 65
Khong QT bnh l ............................................................................................................ 66
SNG U .................................................................................................................................. 67
Sng U bnh l ................................................................................................................... 67
CHNG BA ............................................................................................................................. 68
TP HP THNH HI CHNG ............................................................................................. 68
TNG GNH NH TRI ...................................................................................................... 68
TNG GNH NH PHI ...................................................................................................... 69
TNG GNH HAI NH ........................................................................................................ 69
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TNG GNH THT TRI .................................................................................................. 70
cc chuyn o trc tim ............................................................................................... 70
on STT............................................................................................................................ 71
TNG GNH THT PHI .................................................................................................. 72
cc chuyn o trc tim ............................................................................................... 72
on STT............................................................................................................................ 73
TNG GNH HAI THT .................................................................................................... 73
BLC NHNH ...................................................................................................................... 74
Blc nhnh tri hon ton....................................................................................................... 74
QRS chuyn o trc tim ............................................................................................. 75
QRS chuyn o ngoi bin ........................................................................................... 75
on STT............................................................................................................................ 75
Blc nhnh tri khng hon ton ........................................................................................... 76
CC CHNG PHI HP ..................................................................................................... 76
Blc nhnh phi hon ton ..................................................................................................... 76
QRS chuyn o trc tim ............................................................................................. 76
QRS chuyn o ngoi bin ........................................................................................... 77
on STT............................................................................................................................ 77
Blc nhnh phi khng hon ton ......................................................................................... 77
Cc chng phi hp ................................................................................................................ 78
Dy tht phi....................................................................................................................... 78
Dy tht tri ........................................................................................................................ 78
Bnh mch vnh ................................................................................................................. 78
Cc hnh thi blc khc .......................................................................................................... 78
HI CHNG WOLF PARKINSON WHITE (W-P-W) ............................................... 79
Triu chng (Hnh 52) ....................................................................................................... 79
BNH MCH VNH ................................................................................................................ 80
CC DU HIU .................................................................................................................... 80
1. Thiu mu (Ischemia) .................................................................................................... 80
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2. Tn thng (Injury) ....................................................................................................... 80
3. Hoi t (necrosis) ........................................................................................................... 80
CC TIU CHUN CHN ON BNH MCH VNH .............................................. 80
Sng Q ................................................................................................................................ 80
on ST .............................................................................................................................. 81
Sng T ................................................................................................................................. 81
NHI MU C TIM ............................................................................................................. 81
CC GIAI ON CA NHI MU .................................................................................. 82
CC LOI NHI MU ........................................................................................................ 83
1. Nhi mu trc vch (antero septal infarction) ........................................................ 83
2. Nhi mu trc bn (Lateral wall infarction) ........................................................... 84
3. Nhi mu sau di (Posterior infarction) .................................................................. 84
4. Nhi mu di ni tm mc (tht tri) (Subendocardial infarction): ......................... 84
NHI MU C THM BLC NHNH ............................................................................ 85
CN AU THT NGC ..................................................................................................... 85
Ngoi cn au ..................................................................................................................... 86
Trong cn au ..................................................................................................................... 86
HI CHNG TRUNG GIAN ............................................................................................... 86
NGHIM PHP GNG SC ............................................................................................... 87
CC RI LON NHP TIM ................................................................................................. 87
Phng php tm sng P .................................................................................................... 88
NHP XOANG ........................................................................................................................ 89
CH NHP LU NG ....................................................................................................... 90
BLC XOANG NH .............................................................................................................. 90
NHP B NI, THOT B NI, PHN LY NH THT ................................................ 91
NHP NT .............................................................................................................................. 91
PHN LY NH THT ........................................................................................................ 91
THOT B NI .................................................................................................................... 92
NGOI TM THU ................................................................................................................ 93
NGOI TM THU THT .................................................................................................... 93
NGOI TM THU TRN THT ........................................................................................ 94
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NHP NHANH KCH PHT................................................................................................. 96
NHP NHANH KCH PHT TRN THT......................................................................... 96
Triu chng (Hnh 64): ...................................................................................................... 96
Tin lng v iu tr ......................................................................................................... 97
NHP NHANH THT............................................................................................................ 97
Triu chng (Hnh 65) ....................................................................................................... 97
Chn on phn bit ........................................................................................................... 98
Tin lng v iu tr ......................................................................................................... 98
RUNG THT.......................................................................................................................... 99
Triu chng (Hnh 66) ....................................................................................................... 99
Nguyn nhn v tin lng ................................................................................................ 99
iu tr ................................................................................................................................ 99
RUNG NH ...........................................................................................................................100
Nguyn nhn .....................................................................................................................100
Triu chng (Hnh 67): ....................................................................................................100
iu tr ..............................................................................................................................101
CUNG NG NH ...........................................................................................................101
Nguyn nhn .....................................................................................................................101
Triu chng (Hnh 68) .....................................................................................................101
BLC NH THT ................................................................................................................102
Nguyn nhn .....................................................................................................................103
Blc nh tht cp 1 ................................................................................................................103
Blc nh tht cp 2 ................................................................................................................103
1. Chu k Luciani Wenckeback (Hnh 70) ..................................................................103
2. Blc mt phn (Hnh 71) .............................................................................................104
Blc nh tht cp 3 ................................................................................................................104
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CHNG MT
NHNG KHI NIM C BN
in tm l mt ng cong ghi li cc bin thin ca cc in lc do tim pht ra trong

khi hot ng co bp.
in lc rt nh, ch tnh bng milivn nn rt kh ghi. Cho n nm 1903, Einthoven
mi ln u tin ghi c n bng mt in k c mc nhy cm.
Ngy nay, ngi ta sng ch ra rt nhiu loi my ghi in tim nhy cm, tin li. Cc
my c b phn khuch i bng n in t hay bn dn, v ghi in tm trc tip ln
giy hay v ln mn hunh quang. Ngoi ra, chng cn c th c mt hay nhiu dng, ghi ng
thi c nhiu chuyn o cng mt lc, ghi in tm lin tc 24 gi trn bng ca mt my
nh gn vo ngi (cardiocassette type Holter).
PHNG PHP GHI IN TM

Phng php ghi in tm cng ging nh cch ghi cc ng cong bin thin tun hon
khc: ngi ta cho dng in tim tc ng ln mt bt ghi lm bt ny dao ng qua li v v ln
mt mt bng giy, n c mt ng c lm chuyn ng u v lin tc theo mt vn tc no
; nh th ta c mt ng cong tun hon gm nhiu ln sng bin thin theo thi gian,
l in tm (Hnh 1).
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Nh vy, in tm c th coi nh mt th c honh l thi gian v tung l in

th ca dng in tim. Ty thuc in th ny cao hay thp, bt ghi s vch ln giy mt ln
sng c bin cao hay thp.
NH CHUN
nh gi thi gian di hay ngn v bin cao hay thp ca cc ln sng in tm ,
ngi ta inh chun nh sau:
Thi gian.
Ngi ta in sn trn giy nhng ng k dc cch nhau 1mm. Nh vy, khi cho giy chy
theo (Hnh 2):
- Vn tc 25mm/s th mi 1mm c gi tr 0,04s

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Ngoi ra, ngi ta cn cho chy cc vn tc chm hn nh 2,5; 10mm/s ty theo yu cu
nghin cu.
Tuy nhin, lc bnh thng, ta nn ghi thng nht mt vn tc khi c in tm quen
mt, chn on nhanh hn. Vn tc thng thng l 25mm/s. Nh vy, nu l mt ln sng
bao gm 3 dc th thi gian ca n l: 0,04s3 = 0,12s.
Bin (Hnh 3)
Ngi ta in sn ln giy nhng ng k ngang cch nhau 1mm. Trc khi cho dng in
tim chy vo my, ngi ta phng vo mt dng in 1mv v vn nt iu chnh sao cho bt ghi
dao ng va ng mt bin 10 . Lc ny, giy s ghi c mt ng gp khc c bin
1cm, mi ch gp khc tng ng vi mt nht n nt phng in 1mv v ng tc ny c gi
l ly milivn.
Nh vy, khi ghi in tm , mt ln sng c bin 12mm chng hn, s l th hin ca
mt dng in tim c in th 1,2mv.
Ch :
1. C nhiu loi giy k ngang cao 2mm ch khng phi 1mm, nh vy:
5 ngang = 10mm = 1mv.
2. Vi cch ly mv nh trn, rt nhiu khi ghi in tm n cc chuyn o trc tim,
hoc cc cas dy tht cc sng in tm s c bin qu cao (th d sng R cao ti 3540mm) v vt ra ngoi kh giy ghi. Trng hp , ngi ta ly li milivn theo tiu chun N/2
ngha l vn nt giao ng ca bt rt xung mt na v lt vo kh giy ghi. Nhng khi ta c
ti chuyn o , ta phi nhn bin cc sng ln gp i mi c con s thc ca bin
sng. Th d: khi thy mt chuyn o no c ch thch k hiu N/2 m mt sng R cao
12mm th ta phi c l: bin R = 24mm = 2,4mm.
Ngc li, cng c khi ngi ta mun cho cc ln sng nh cao ln nghin cu k hn,
ngi ta iu chnh cho 20mm tng ng vi 1mv v ghi ch thch k hiu 2N. Lc ny, ta li
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phi chia bin cc sng lm i ly con s thc, th d: mt sng R cao 12mm s c bin
thc l 6mm = 0,6mv.
CC QU TRNH IN HC CA TIM
Dng in do tim pht ra v u m c?
Ngy nay, khoa in sinh l hc hin i cho ta bit r: l do s bin i hiu th gia
mt trong v mt ngoi mng t bo c tim. S bin i hiu th ny bt ngun t s di chuyn
ca cc ion K+, Na+, t ngoi vo trong t bo v t trong t bo ra ngoi khi t bo c tim
hot ng. Lc ny tnh thm thu ca mng t bo i vi cc ion lun lun bin i.
Khi t bo bt u hot ng (b kch thch), in th mt ngoi mng t bo s tr thnh m
tnh tng i (b kh mt cc dng) so vi mt trong: ngi ta gi l hin tng kh cc
(dpolarisation) (Hnh 4).
Sau , t bo dn dn lp li th thng bng ion lc ngh, in th mt ngoi tr li dng

tnh tng i (ti lp cc dng): ngi ta gi l hin tng ti cc (rpolarisation).
S HNH THNH IN TM
Tim l mt c rng, gm 4 bung dy mng khng u nhau. Cu trc phc tp lm cho
dng in hot ng ca tim (kh cc v ti cc) cng bin thin phc tp hn mt s t bo
n gin nh ni trn.
Tim hot ng c l nh mt xung ng truyn qua h thng thn kinh t ng ca tim.
u tin, xung ng i t nt xoang ta ra c nh lm cho nh kh cc trc, nh bp trc y
mu xung tht. Sau , nt nh tht Tawara tip nhn xung ng truyn qua b His xung tht
lm tht kh cc. Lc ny, tht y mu s bp mnh y mu ra ngoi bin. Hin tng nh
v tht kh cc ln lt trc sau nh th chnh l duy tr qu trnh huyt ng bnh thng
ca h thng tun hon. ng thi iu cng lm cho in tm bao gm hai phn: mt nh
, ghi li dng in hot ng ca nh i trc v mt tht , ghi li dng in ca tht i sau.
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Mc in cc
thu c dng in tim, ngi ta t nhng in cc (xem chng Cch mc in cc)
ca my ghi in tim ln c th. Ty theo ch t cc in cc, hnh dng in tm s khc
nhau. Nhng trong cc v d di y, cho thng nht v n gin, chng ta quy c (Hnh 5)
t in cc dng (B) bn tri qu tim, v in cc m (A) bn phi qu tim.
Nh vy (Hnh 5):
- Khi tim trng thi ngh (tm trng) khng c dng in tim no qua my v bt s ch
ghi ln giy mt ng thng ngang, ta gi l ng ng in (Isoelectric line).
- Khi tim hot ng (tm thu) m in cc B thu c mt in th dng tnh tng i so
vi in cc A th bt s v ln giy mt ln sng dng, ngha l m trn ng ng in.
Tri li, khi in cc A dng tnh tng i th bt s v mt ln sng m, ngha l m

di ng ng in.
NH
Nh trn ni, xung ng i t nt xoang ( nh phi) s ta ra lm kh cc c nh nh
hnh cc t sng vi hng chung l t trn xung di v t phi sang tri (Hnh 6). Nh vy,
vc t kh cc nh (ngha l vc t biu din dng in kh cc nh) s c hng t trn xung
di v t phi sang tri, lm vi ng ngang mt gc +490 (Hnh 6) v cn gi l trc in
nh. Lc ny, in cc B s dng tnh tng i v my s ghi c mt ln sng dng thp,
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nh, ty u vi thi gian khong 0,08s gi l sng P (Hnh 6). Do , trc in nh cn c tn
gi l trc sng P, k hiu l
hay
Khi nh ti cc, n pht ra mt dng in ghi ln my bng mt sng m nh gi l sng Ta

(auricular T), nhng ngay lc ny cng xut hin kh cc tht (QRS vi in th mnh hn
nhiu nn trn in tm thng thng ta khng nhn thy c sng Ta. Rt cc, nh c
ngha l s hot ng ca nh ch th hin ln in tm bng mt ln sng n c: sng P.
THT
A- KH CC
Ngay khi nh cn ang kh cc th xung ng bt vo nt nh tht ri truyn qua thn v
nhnh b His xung kh cc tht.
Vic kh cc ny bt u t phn gia mt tri vch lin tht i xuyn sang mt phi vch
ny, to ra mt vc t kh cc u tin hng t tri sang phi: in cc A s dng tnh tng
i v my s ghi c mt ln sng m nh, nhn, gi l sng Q (Hnh 7a).
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Sau , xung ng truyn xung v tin hnh kh cc ng thi c hai tm tht theo hng
xuyn qua b dy c tim, t lp di ni tm mc ra lp di thng tm mc. Lc ny, kh cc
hng nhiu v bn tri hn v tht tri dy hn v tim nm nghing hng trc gii phu v bn
tri. Do , vc t kh cc lc ny hng t phi sang tri; in cc B li dng tnh tng i
v my ghi c mt ln sng dng cao, nhn gi l sng R (Hnh 7b).
Sau cng, kh cc nt vng y tht, li hng t tri sang phi, to ra mt vc t hng t
tri sang phi: my ghi c mt ln sng m nh, nhn, gi l sng S (Hnh 7c).
Tm li, kh cc tht bao gm ba ln sng cao, nhn Q, R, S bin thin phc tp nn c

gi l phc b QRS (QRS complex). V n c sc in ng tng i ln li bin thin nhanh
trong mt thi gian ngn, ch khong 0,07s nn cn c gi l phc b nhanh. Cn ch l
trong phc b nhanh, sng chnh ln nht l sng R.
Nu ta em tng hp 3 vc t kh cc Q, R, S ni trn li, ta s c mt vc t kh cc
trung bnh c hng t trn xung di v t phi sang tri, lm vi ng ngang mt gc
khong 580 (Hnh 8), vc t cn c gi l trc in trung bnh ca tim, hay gi tt l trc
in tim, trc QRS, k hiu l QRS hay QRS.
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B- TI CC
Tht kh cc xong, s qua mt thi k ti cc chm, khng th hin trn in tm bng
mt ln sng no ht m ch l mt on thng ng in gi l on ST. Sau n thi k ti
cc nhanh (Sng T).
Ti cc ni chung c hng i xuyn qua c tim, t lp di thng tm mc vo lp di
ni tm mc. S d ti cc i ngc chiu vi kh cc nh vy l v n tin hnh ng vo lc
tim bp li vi cng mnh nht, lm cho lp c tim di ni tm mc b lp ngoi nn vo
qu mnh nn ti cc mun i.
Mt khc, tri vi kh cc, ti cc tin hnh t vng in dng ti vng in m. Do ,
tuy n tin hnh ngc chiu vi kh cc, n vn c vc t ti cc hng t trn xung di v
t phi sang tri (Hnh 9) lm pht sinh mt ln sng dng thp, ty u, gi l sng T.
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Nu ta k mt ng thng ng qua nh sng T ly lm trc i xng th ta s thy sng
khng i xng, ngha l c sn ln thoai thoi hn v sn xung dc ng hn. Hn na,
thi gian ca n rt di 1 lm hai chn ca n rt xa nhau nn n cn c gi l sng chm.
Vc t ti cc nh trn ni cn c tn l trc sng T, k hiu l T hay T. N thng
bn tri QRS 200, ngha l lm vi ng ngang mt gc khong 380. Nh vy n gn nh
cng hng vi QRS. Do m sng T v hng chnh ca phc b QRS u dng; ngi ta
bo nh th l T cng hng (hay cng chiu) vi QRS.
Lin ngay sau khi T kt thc, c th cn thy mt sng chm nh gi l sng U. Ngi ta
cho sng U l mt giai on mun ca ti cc (Hnh 10).
Tm li, tht c th chia lm 2 giai on:
- Giai on kh cc, bao gm phc b QRS v cn c gi l pha u (Initial phase).
- Giai on ti cc, bao gm ST v T (v c U na) v c gi l pha cui (Terminal
phase).
Thi gian ton b ca tht k t u sng Q n ht sng T, c gi l thi gian QT. N
th hin thi k tm thu in hc ca tht, bnh thng di khong 0,36s.
TRUYN T NH THT
Nh trn ni, khi sng P kt thc l ht nh , khi bt u sng Q l bt u tht .
Nhng nhn vo in tm , ta thy gia P v Q c mt khong ngn ng in (gi l khc
PQ) chng t rng sau khi nh kh cc xong ri, xung ng vn cha truyn t xung ti tht.
Nhng khc PQ khng th i din cho thi gian truyn t t nh xung tht. V ngi ta bit
rng, ngay khi nh cn ang kh cc (ngha l cn ang ghi sng P) th xung ng bt vo nt
nh tht v bt u truyn t xung pha tht ri.
Do , t mt mc chnh xc cao hn (tuy khng hon ton ng), ngi ta thng o
t khi im sng P n khi im sng Q (hay khi im sng R trong trng hp khng c
sng Q) tc khong PQ, v gi l thi gian truyn t nh tht, bnh thng di t 0,12s n
0,21s.
Tm li, in tm bnh thng ca mi nht bp tim (hay chu chuyn tim) gm 6 ln
sng ni tip nhau m ngi ta dng 6 ch ci lin tip t tn l P, Q, R, S, T, U. Trong ,
ngi ta phn ra mt nh , sng P, mt tht : cc sng Q, R, S, T, U vi thi gian truyn t
nh tht: khong PQ.
Ngi ta khng o thi gian ca T v n rt thay i, ty tng ngi. Hn na, ch khi

im ca n tip vi ST rt thoai thoi, kh o.
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Vi tn s tim bnh thng, khong 75l/pht th sau sng T (hoc sng U), tim s ngh p
khong 0,28s th hin bng mt khong thng ng in (Hnh 10) ri li tip sang nht bp sau
vi mt lot sng P, Q, R, S, T, U khc. C nh th tip din mi. Thi gian ngh trn gi l thi
k tm trng ton th ca tim.
CC CHUYN O THNG DNG

IN TRNG TIM
C th con ngi l mt mi trng dn in; v th, dng in do tim pht ra c dn
truyn khp c th, ra ti da, bin c th thnh mt in trng ca tim. Nu ta t hai in cc
ln bt c hai im no c in th khc nhau ca in trng , ta s thu c mt dng
in th hin hiu th gia hai im v gi l mt chuyn o hay o trnh (lead). N hin
ra trn my ghi bng mt ng cong in tm c mt hnh dng no ty theo a im t
cc in cc. ng thng ni hai a im t in cc trn c th gi l trc chuyn o.
K THUT T CC IN CC V CHUN B BNH NHN
Nh trn ni, dng in tim c in th rt nh nn trong khi ghi, in tm rt d b
nh hng bi cc dng in tp nh: dng in cng nghip thp n, chy qut, chy my
Xquang c dy dn i qua gn , cc dng in pht sinh t c v da bnh nhn.
Mun loi b cc dng in , cn ch t cc dy t ni ging bnh, my ghi in
tim v cc my ph cn ra vi my nc hay xung t. Ngay dy in ca my in tim cng
phi tht cch in v nu cn, phi bc st, phi bo bnh nhn nm tht yn lng, thoi mi,
cc bp tht mm mi, mt nhm. Nu c nhiu dng in cm ng xung quanh th nn b cc
dng c bng kim kh trong ngi bnh (nh ng h, dao) ra. i vi tr em giy gia hoc
bnh nhn tinh thn qu kch ng, run chn tay, phi cho thuc an thn cho ng yn. Phng ghi
in tm nn c nhit khong 200C khng nn nng qu (bnh nhn ra m hi) hay lnh
qu (bnh nhn run rt).
Khi t in cc ln da, nn cho m gia in cc v da mt ming gc dn in tt (th d
c thm nc mui) nhng nu da ch bn hay nhn m th phi ty bng te trc khi t
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in cc ln nhng nh trnh lm xy st da, gy sai s v in tr da. V cng nn chn ch tht
mm mi m t in cc, ch t ln xng.
in cc l nhng mnh kim kh trng bc hay thit rng t 2 n 4cm, loi nh dng t
vng trc tim (v cn v tr chnh xc), loi ln t cc chi. Li c loi in cc cm hn vo
di da bnh nhn, thng dng khi mun loi b cc dng in tp v in tr da (nh khi
tin hnh phu thut tim hay lm thc nghim trn sc vt).
Khi ghi cc chuyn o thng dng, ngi ta thng t in cc cc chi (c tay, c chn)
v trn lng ngc vng trc tim. Theo quy c quc t, cc in cc hoc dy ni vo cc in
cc s dng:
- Mu khi t tay phi.
- Mu vng khi t tay tri.
- Mu lc (xanh l cy) khi t chn tri.
Ngoi ra, ngi ta cn dng mu en cho in cc chng in tp (dy t) t chn phi
(Hnh 12) v cc mu xanh da tri, nu, tm cho cc in cc lng ngc.
CCH T CC CHUYN O
Vi mt in trng tim nh trn, ta nn t cc in cc, thu ly cc chuyn o nh th
no c th nghin cu dng in tim bnh thng v bnh l mt cch c ch nht.
Cho n nay, ngi ta cho rng, i a s cc ca, nn t in cc theo 12 cch, thu ly 12
chuyn o thng dng bao gm 3 chuyn o mu, 3 chuyn o n cc chi v 6 chuyn o
trc tim. mi chuyn o s c mt hnh dng sng in tm khc nhau, cng nh hnh
nh ta nhn thy c khi ng 12 gc khc nhau xung quanh mt vt c hnh dng g gh,
phc tp.
CC CHUYN O MU
Cc chuyn o mu (Standard) l nhng chuyn o c nghin cu sm nht, ngay t
thi Einthoven, chng cn c gi l cc chuyn o lng cc cc chi (bipolar limb leads) hay
cc chuyn o lng cc ngoi bin (bipolar peripheral leads) v c hai in cc ca chng u
l nhng in cc thm d, c t nh sau:
- in cc m c tay phi, in cc dng c tay tri, gi l chuyn o I, vit tt l
D1 (Hnh 11).
P a g e | 19
in cc t c tay ch ct d buc, thc ra n phn nh in th vai phi v vai tri

(trong in trng tim) l nhng ch kh gn in cc, cn hai cnh tay ch lm nhim v hai
dy dn in. Do , trc chuyn o s l mt ng thng ni t vai phi (R) sang vai tri (L)
(Hnh 12).
Theo cch mc nh trn, khi in cc tay tri dng tnh tng i th my in tm s

ghi mt ln sng dng, cn khi in cc tay phi dng tnh tng i th my s ghi mt ln
sng m. Vi iu kin nh th, ta gi chiu dng ca trc chuyn o l chiu t vai phi sang
vai tri (t R n L trong hnh 12).
- in cc m t c tay phi, in cc dng t c chn tri, gi l chuyn o 2,
vit tt l D2. Nh th, trc chuyn o y s l mt ng thng i t vai phi (R) xung gc
chn tri (F) v chiu dng l chiu t R n F.
P a g e | 20
- in cc m t tay tri, v in cc dng chn tri gi l chuyn o 3, vit tt l
D3. Nh th, trc chuyn o s l ng thng LF v chiu dng l chiu t L n F.
Cc trc chuyn o RL, RF, v LF ca D1, D2, D3 lp thnh 3 cnh ca mt hnh tam gic,
c th coi nh tam gic u vi mi gc bng 600 gi l tam gic Einthoven).
CC CHUYN O N CC CC CHI
Nh trn thy, cc chuyn o mu u c hai in cc thm d ghi hiu th gia 2
im ca in trng tim. Nhng khi mun nghin cu in th ring bit ca mi im th ta
phi bin mt in cc thnh ra trung tnh. Mun nh vy, ngi ta ni in cc (in cc
m) ra mt cc trung tm gi tt l CT (central terminal) c in th bng 0 (trung tnh) v n l
tm ca mt mch in hnh sao mc vo 3 nh ca tam gic Einthoven (Wilson). Cn in cc
thm d cn li (in cc dng) th em t ln vng cn thm d: ta gi l mt chuyn o
n cc.
Khi in cc thm d ny c t mt chi th ta gi l mt chuyn o n cc chi.
Thng, ngi ta t n 3 v tr nh sau:
- C tay phi: ta c chuyn o VR (V: voltage; R: right) (Hnh 13). N thu c in th
m bn phi v y tim v t y tim m nhn thng c vo trong bung hai tm tht. Trc
chuyn o ca n l ng thng ni tm im (O) ra vai phi.
- C tay tri: ta c chuyn o VL, n nghin cu in th y tht tri. Trc chuyn o

y l ng thng OL.
- C chn tri: ta c chuyn o VF, n l chuyn o c nht nhn thy c thnh
sau di ca tim. Trc chuyn o l ng thng OF.
P a g e | 21
Nm 1947, Goldberger em ci tin ba chuyn o trn bng cch ct b cnh sao ni vi
chi c t in cc thm d, lm cho cc sng in tim ca cc chuyn o tng bin ln
gp ri m vn gi c hnh dng nh c: ngi ta gi l nhng chuyn o n cc cc
chi tng cng, k hiu l aVR, aVL, aVF (a: augmented = tng thm) (Hnh 14) ngy nay thng
dng hn cc chuyn o VR, VL, VF.
Nhn chung, cc trc chuyn o (OR, OL, OF) ca cc chuyn o n cc cc chi chnh l
ba ng phn gic trong ca tam gic Einthoven.
Tt c 6 chuyn o: D1, D2, D3, aVR, aVL, aVF c gi chung l cc chuyn o ngoi
bin v u c in cc thm d t cc chi. Chng h tr cho nhau d xt cc ri lon ca
dng in tim th hin bn pha xung quanh qu tim trn mt phng chn (frontal plane).
Nhng cn cc ri lon ca dng in tim ch th hin r mt trc tim chng hn th cc
chuyn o bt lc. Do , ngi ta phi ghi thm cc chuyn o trc tim (precordial
leads) bng cch t cc in cc nh di y.
CC CHUYN O TRC TIM
Ngi ta thng ghi ng lot cho bnh nhn 6 chuyn o trc tim thng dng nht, k
hiu bng ch V (voltage) km theo cc ch s t 1 n 6. l nhng chuyn o n cc, c
mt in cc trung tnh ni vo cc trung tm (CT) v mt in cc thm d, c t ln lt
trn 6 im vng trc tim sau y (Hnh 15):
P a g e | 22
- V1: khong lin sn 4 bn phi st b xng c.

- V2: khong lin sn 4 bn tri, st b xng c.
- V3: im gia ng thng ni V2 vi V4.
- V4: giao im ca ng dc i qua im gia xng n tri vi ng ngang i qua
mm tim (hay nu khng xc nh c v tr mm tim th ly khong lin sn 5 tri).
- V5: giao im ca ng nch trc vi ng ngang i qua V4.
- V6: giao im ng nch gia vi ng ngang i qua V4, V5.
Nh vy, trc chuyn o ca chng s l nhng ng thng hng t tm im in ca
tim (im O) ti cc v tr ca in cc tng ng (Hnh 16), cc trc nm trn nhng mt
phng nm ngang hay gn ngang.
P a g e | 23
ng v mt gii phu hc m ni, V1 v V2 coi nh c in cc thm d t trng ln

vng thnh ngc st ngay trn mt tht phi v gn khi tm nh, do chng c kh nng
chn on c cc ri lon in hc ca tht phi v khi tm nh mt cch r rt hn c.
Ngi ta gi V1, V2 l cc chuyn o trc tim phi. Cng v l , V5, V6 thnh ngc st
trn tht tri, c gi l cc chuyn o trc tim tri. Cn cc chuyn o V3, V4 khu vc
trung gian gia 2 tht, ngay trn vch lin tht nn c gi l cc chuyn o trung gian. Tuy
nhin, trong nhiu trng hp bnh l v ty tng ngi, t th tim trong lng ngc c th khc
nhau lm cho s lin quan gia in cc v cc tm tht khng ng hn nh th na (xem cc
chng sau).
CC CHUYN O KHC
Su chuyn o ngoi bin v 6 chuyn o trc tim ni trn hp li thnh 12 chuyn
o thng dng, thng l p ng yu cu chn on thng thng ca lm sng. Nhng
trong mt s trng hp kh chn on, ngi ta phi a in cc thm d ti nhiu vng khc
xung quanh tim, to ra rt nhiu chuyn o m chng ti ch k my th d thng thng nht
sau y:
- V7, V8, V9: in cc m tri v sau lng ngc dng thm d tht tri.
- V3R, V4R, V5R, V6R: in cc m phi lng ngc dng nghin cu tht phi hay
tim sang phi.
P a g e | 24
- Chuyn o thc qun (K hiu VOE): in cc c nut vo thc qun v ghi in tm
nhiu v tr cao thp khc nhau: dng pht hin sng P cc trng hp m cc
chuyn o thng dng khng thy P, hoc chn on nhi mu c tim thnh sau.
- Chuyn o trong bung tim: in cc c ghp vo u mt ng thng tim v a qua
mch mu vo trong tt c cc bung nh, tht: cng dng pht hin sng P v chn on
nhiu bnh khc.
- in His: in cc bung tim c t st vng thn b His (ch vch lin tht trn,
tip ni gia nh v tht phi). Dng ch yu xc nh v tr nghn nh tht v chn on
nhp nhanh tht.
P a g e | 25
CHNG HAI
HNG DN C MT IN TM
Mun pht huy n mc ti a tc dng chn on ca in tm , cn phi phn tch n
theo s di y:
1. Trc khi c in tm , phi nm vng tui, gii tnh, chn on lm sng ca bnh
nhn.
Ngoi ra, cn nn bit thm s lc bnh n, hnh nh X quang, cc kt qu xt nghim khc
v nht l hai vn sau y:
a) Kh ngi bnh nhn gy bo, cao thp nh hng rt nhiu n t th tm v bin
sng, n nh hng nhiu n chn on dy tht.
b) C ang dng thuc tr tim hay thuc chng lon nhp di ngy khng? Nht l digitan
v quinidin v cc thuc ny tc ng rt nhiu n hnh dng in tm v d lm sai lc
chn on c bn.
2. Kim tra k thut ghi in tm , pht hin ghi sai, nh hng tp, milivn ly ng 1cm
hay khng? Tc ghi bao nhiu? Ngha l cc ng k dc cch nhau bao nhiu phn trm
giy.
3. Nhp tim: bc vo c in tm trc ht bao gi cng phi xem nhp xoang hay
khng xoang? C nhng ri lon nhp tim g? ng bao gi qun tnh tn s tim. Nu c blc
nh-tht th phi tnh ring c tn s nh.
4. Trc in tim vi gc , t th tim.
5. Hnh dng cc sng: c ng thi c 12 chuyn o thng dng:
- Sng P: chiu cao (bin ), chiu rng (thi gian), hnh dng (m, dng, hai pha, mc).
- Khong PQ di bao nhiu?
- Phc b QRS: bin v thi gian chung v ring ca sng Q, hnh dng (mc).
Ring vi V1 v V5 th tm thm thi gian xut hin nhnh ni in.
- on ST c chnh khng?
- Sng T (v sng U): dng (dng, m hay hai pha), bin .
- Khong QT di bao nhiu?
6. Kt lun chn on: v tn thng c tim v v ri lon nhp tim.
25 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12
P a g e | 26
CCH PHT HIN CC SAI LM KHI GHI IN TM

Phn ny dnh ch yu cho ngi y t k thut vin ghi in tm : phi bit pht hin kp
thi cc sai lm trn ng cong in tm lm li ci khc ngay cho bnh nhn, trnh gi
bnh nhn n ln th hai lm li. Nhng i vi bc s c in tm , y cng l mt
vic nht thit phi lm trong khi c in tm trnh nhng sai lm ng tic. Thng
thng, cn pht hin cc vn sau y:
A- GHI IN TM SAI LM
Thng hay xy ra cc phng thm d tim mch, l:
1. Mc dy sai tay: th d mc nhm dy in cc sang tay tri v dy in cc vng sang
tay phi: nh vy trn in tm , ta s thy cc sng D1 u m (nht l P1 m), D2 c dng
D3 v ngc li, aVR c dng aVL v ngc li. Cn cc chuyn o trc tim th khng nh
hng g v iu ny gip ta phn bit tt bm sinh tim sang phi (xem chng ny).
2. Vn nt my ghi nhm th t cc chuyn o.

3. nh du v vit tn nhm chuyn o ny vi chuyn o kia.
4. Dn nhm th t cc chuyn o hoc dn nhm in tm ca ngi ny sang ngi
khc, khi dn bng in tm vo t h s in tm ca tng bnh nhn.
P a g e | 27
Theo kinh nghim ca chng ti, mun pht hin cc lm ln ny, trc ht phi lun lun
nh thuc lng hnh dng bnh thng ca 12 chuyn o thng dng (xem cc hnh 36, 27 v
37). Hn na, cn ch my qui lut c bn sau:
a) nh lut Einthoven: do cch b tr cc trc ca 3 chuyn o mu, Einthoven tnh ra
c cng thc sau:
D 1 + D3 = D2
Th d: sng R1 (sng R D 1) l 10mm, R3 l 8mm th R2 phi l 18mm. Nu o thy khng
ng nh th th c th l ghi sai. Nhng l tt nhin, l k nhng ca sai nhiu, cn nu ch sai
lch vi ba milimt th khng k v c th l do nh hng ca s th hay lch in tr t
chc.
b) Tnh cht lin tc ca cc chuyn o trc tim: do cc chuyn o c in cc thm
d t lin tip cnh nhau (Hnh 15) nn cc sng ca chng cng phi bin thin lin tc (Hnh
37a). Th d: sng R thp nht V1, sau cao dn ln qua V2, V3, V4 n V5 ri hi thp xung
V6. Nu mt ca ta thy R V2 cao vt ln hay thp hn xung, i lch hn khi ng cong
biu din trn m khng nm trong mt bng bnh cnh in tm bnh l no r rng th chc
l ghi sai. i vi sng T cng c quy lut tng t (xem mc sng T)
c) Tnh cht ging nhau ca mt s chuyn o: cc chuyn o D1 , aVL, V5 , V6 c trc
chuyn o gn nhau v cng hng nn hay c hnh dng cc sng hao hao ging nhau. D3 v
aVF cng vy. Th d khi thy c mt sng Q D 1 th thng cng phi thy c mt sng Q
tng t V5, V6 . Nu khng c th c th l ghi sai. Tuy nhin, iu khng tuyt i v cn
phi tnh n cc ri lon bnh l lm bin i cc chuyn o mt cch khng u nhau na.
B- MY IN TIM KHNG CHNH XC
Vn ny pht hin c ch yu l da vo ng milivn. Nh chng mt ni,
ng milivn phi i ngang hay ch hi bc nh, vi cc gc vung vn hay gn nh th (Hnh
18a). Nay nu n:
- C cc gc t ra (Hnh 18b) th l hin tng m cn qu ng (overdamping) do b
phn ghi ra giy ca my b m qu ng nn yu i. Nhng cng c khi l do sc cn da qu
cao nh khi in cc qu kh. Nu ta ghi in tm trong iu kin my hot ng nh th,
cc sng Q, R, S s nh i, c nh ty hn, cc sng nh bin mt v cc on, khc b chnh.
- C cc gc nhn li (Hnh 18c): l hin tng ny qu (overshooting) ngc vi
hin tng trn do b phn m cn vn khng cht mc. Nh th, cc sng in tm s b
phng i ln vi bin cao hn, b rng dong ra hn, nt sng trt m hn, nht l phc
b QRS.
- C mt phn lch xung (Hnh 18d): in tm s c cc sng m gn nh bin mt.
P a g e | 28
- C on hi phc (tr v ng in) ko di (Hnh 18) lm cc sng cng hi phc ko

di do s thay i ca in tr ton b.
C- CC NH HNG TP BN NGOI
Ch yu l:
1. Cc on gp khc hay rung ng tng ch ca ng ng in, c ch chnh hn ra
khi ng ng in (Hnh 19) hoc ng ng in un ln (nht l khi ghi chuyn o
thc qun) (Hnh 20) u l do bnh nhn c ng nh, hay th, hay in cc di ng trong khi
ghi. Cc hin tng u c mt c tnh chung l c hnh dng rt
khng u, khng ging nhau, xut hin khng c nhp iu v chu k nh cc sng in
tm .
P a g e | 29
Trng hp cc rung ng nh ln tn v c sut dc bn in tm (Hnh 21) lm n

c dng te hay ri bn, nt bt th l do s run ry ca cc th tht nhng bnh nhn d xc
cm, s lm in tm , hay cng thn kinh. Trng hp ny nn cho h ung thuc an thn
v gii thch cho h yn tm trc khi ghi in tm .
2. Cc dao ng rt u vi nhp iu rt nhanh, th d vi tn s 50 chu k/s, ngha l 3000

chu k/pht.
Con s ny c th tnh c bng phng php ging nh tnh tn s tim (xem mc sau).
Khc vi cc rung ng loi trn, cc dao ng ny c th xut hin c trn ng ng
in v trn phc b nhanh lm in tm c dng te u. y l do s cm ng ca dng
in xoay chiu bn ngoi c tn s nh th v thng xy ra khi c mt mng in mnh chy
qua gn my ghi in tim, nht l khi dy t b t hay t khng tt (Hnh 22).
P a g e | 30
Theo kinh nghim ca chng ti th dy t khng tt hay t ngm l nguyn nhn ch yu

ca i a s cc nh hng tp m ta thy xut hin trn ng in tm . Nhng ngoi
nguyn nhn ra, cn c cc nguyn nhn khc v mch in thng thng nh cc cng tc
khng tt, dy in cc t ngm, ch ni dy v in cc khng cht, in cc buc lng, cch
in khng tt, phng ghi b m qu, nng qu hay lnh qu gy nh hng tp hoc sai lch ca
cc sng in tm . Tt c cc nguyn nhn , ngi k thut vin cn phi bit pht hin
t sa cha ly my v ghi in tm cho chnh xc v kp thi; c khi phi hm tt c cc
dng in (qut, n,) trong phng, b cc kim kh ra, t cc cch in bng s chn
ging bnh nhn nm ghi, cho bt ngi ra khi phng v lun lun kim tra my.
TNH TN S TIM
1. Dng thc tn s
l nhng thc rt tin li m chng ti cho in vi kch thc ng nh tht di y
(Hnh 23), cc c gi c th ct ra dn ln mt mnh ba cng hay dn di mt mnh nha
cng trong sut m dng.
Thc c 2 mt, mt 1 dng cho cc in tm ghi vi vn tc 25mm/s cn mt 2 l
50mm/s. Mt 1 c 2 b, b th nht gi l b 2RR, c in mt hng cc vch tn s v ch 2RR
(RR ngha l khong cch t mt sng R n sng R lin sau n). B ny dng cho cc ca tn s
tim bnh thng v chm; cn b kia gi l b 10RR dng cho cc ca nhp nhanh, rung tht hay
khi tnh tn s ring ca cc sng f hay P ca rung nh, cung ng nh.
Cn mt hai cng c hai hng vch vi li chia tng t.
Th d: khi ta mun tnh tn s ca mt ca in tm c nhp bnh thng hay chm ghi
vi vn tc 25mm/s, ta hy chn mt mt, b 2RR. Ta p t b ny dc theo mt chuyn o
no sao cho mi tn ca b ch ng vo nh mt sng R, ri c kt qu (tn s tim) vch
tn s ng vi nh ci sng R cch sng R ni trn mt khong cch di 2RR. Trong th d
hnh 23, tn s tim l F = 76/min.
Ch : trn thc mt mt, c v thm tam trc kp Bayley (xem mc sau) v cc vch o
thi gian sng vn tc 25mm/s ( u thc), mt hai c v thm ng cong QT sinh l
(xem mc khong QT) v cc vch o thi gian sng vn tc 50mm/s.
P a g e | 31
2. Dng bng tn s
Trc ht, tnh xem mt khong RR l bao nhiu phn trm giy. Th d, vi mt bn in
tm ghi theo vn tc 25mm/s trong mi khong RR ta m c 18 th nh vy l RR =
0,04s 18 = 0,72 phn trm giy. Sau , tm trong bng tn s (bng 1) con s F tng ng vi
con s phn trm giy ca RR. Trong th d trn, cui cng hng th ba ca bng cho ta tn s
tim F = 83/min.
Ch : trong bng trn, c ct s th nht ca mi l khong RR th ct s th nh ca
l tn s tim (F) tng ng.
3. Dng cng thc tn s
Khi khng bng v thc, ta lm mt con tnh nh: o ly mt khong RR tnh ra giy ri
ly 60 chia cho n s c tn s:
Th d: RR = 0,70s th tn s tim s l:
Ch :
1. Trng hp sng R nh qu hay m, nt, ta c th chn mt sng khc m tnh (nh S
chng hn).
2. Khi nhp tim khng u, ta phi chn vi khong RR di ngn khc nhau m tnh ly
trung bnh cng ri hy tnh ra tn s tim trung bnh.
3. Khi c phn li nh tht hay blc nh tht, cc sng P v R tch ri nhau ra, do , ta phi
tnh tn s nh (P) ring v tn s tht (R) ring.
4. Tnh tn s cc sng f hay P ca rung nh hay cung ng nh cng lm theo cc phng
php trn.
P a g e | 32
BNG 1
RR
RR
RR
RR
RR
RR
RR
10
600
20
300
30
200
40
150
50
120
60
100
70
86
11
545
21
286
31
193
41
146
51
117
61
98
71
84
12
500
22
273
32
187
42
143
52
115
62
97
72
83
13
461
23
261
33
182
43
139
53
113
63
95
73
82
14
429
24
250
34
176
44
133
54
111
64
94
74
81
15
400
25
240
35
171
45
133
55
109
65
92
75
80
16
375
26
230
36
166
46
130
56
107
66
91
76
79
17
353
27
222
37
162
47
127
57
105
67
89
77
78
18
333
28
214
38
158
48
125
58
103
68
88
78
77
19
310
29
207
39
154
49
122
59
101
69
87
79
78
RR
RR
RR
RR
RR
RR
RR
di mt khong RR (tnh ra phn trm giy) vi tn s tim (F) mi pht tng ng (xem
bi) ca n.
TRC IN TIM CCH XC NH TRC IN TIM

Nh phn mt ni, trc in tim ( QRS) l vc t tng hp m t qu trnh kh cc
ca tim. Bnh thng, n c hng gn vi trc gii phu ca tim nhng trong mt s trng
hp bnh l, hng ca trc b lch i, v l mt du hiu rt quan trng phc v tt cho
nhiu chn on. V th, khi c in tm bao gi ta cng phi tm trc in tim.
C rt nhiu cch tm trc in tim. Nhng theo kinh nghim ca chng ti, c mt phng
php t mc chnh xc kh cao (sai s gc ch khong 50) m li rt tin li. l phng
php c lng trc in tim bng tam trc kp Bayley nh sau.
P a g e | 33
TAM TRC KP BAYLEY
tm trc in tim, Bayley em ghp 3 trc chuyn o (xem mc Cc chuyn o mu
chng mt) ca D1, D2, D3 li thnh mt h thng 3 trc c gc chung (tm O) gi l Tam trc
kp Bayley (hnh 24).
Nh vy, tm O s chia 3 trc thnh 3 na trc dng v 3 na trc m ta ra thnh

6 ci nan hoa cch u nhau mt gc 600. Sau , ng li ghp thm 3 trc chuyn o ca aVR,
aVL, aVF vo thnh mt h thng 6 trc, gi l tam trc kp Bayley. Nh vy, tm O cng s
chia 3 trc ny thnh 3 na trc dng v 3 na trc m. V trc cc chuyn o n cc chi l
nhng ng phn gic ca trc cc chuyn o mu (xem chng mt) nn ta thy:
a) 6 chuyn o ngoi bin lp thnh 12 na trc dng v m cch u nhau mt gc l
0
30 .
b) Chng vung gc vi nhau tng i mt lp thnh nhng cp chuyn o nh sau:
- Cp 1: D1 v aVF.
- Cp 2: D2 v aVL.
- Cp 3: D3 v aVR.
Vng trn nh mc
nh mc phng hng ca cc na trc v trc in tim, ngi ta v xung quanh tam
trc kp mt vng trn tm O v gi im 3 gi ca vng trn l im 00, cc im ca na
di vng trn c ghi dng v nh mc ln lt theo chiu kim ng h xut pht t
P a g e | 34
im 00 cho n +1800. Cc im ca na trn vng trn c ghi m v nh mc ngc
chiu kim ng h t 00 n -1800. Ring na trc dng ca D1 cn c gi l trc 00 v dng
lm gc tnh gc ca trc in tim.
Lun thuyt hnh chiu
Cch tm trc in tim da trn c s lun thuyt hnh chiu ca Einthoven. Theo lun
thuyt ny th di ca vc t hnh chiu ca trc in tim ln trc ca mt chuyn o no
t l vi bin QRS ca chuyn o . Nh th, khi QRS cng gn vung gc vi chuyn
o no th bin QRS ca chuyn o cng nh; ngc li khi QRS cng gn song song
(trng) vi chuyn o no th bin QRS ca n cng ln tng i so vi cc chuyn o
khc tuy rng iu ny cng cn ph thuc vo mt vi iu kin khc na. Cn ch l bin
QRS y l bin tng i (xem mc Phc b QRS) ch khng phi bin tuyt
i, cho nn khi phc b QRS ca mt chuyn o no c hai sng R v S vi bin cng
ln nhng li gn bng nhau th cng coi nh chuyn o c bin nh (bng 0 hay gn 0),
ngha l QRS gn vung gc vi chuyn o .
Tm trc in tim, gc
Gm 3 giai on:
a) Nhn trn in tm , tm trong 6 chuyn o ngoi bin xem phc b QRS chuyn
o no c bin nh nht v gi n l chuyn o A (trong hnh 25, l chuyn o aVR).
Nh vy, QRS m ta nh tm s gn vung gc vi chuyn o A, ngha l gn trng vi
chuyn o cng cp vi n (xem trn) m ta gi l chuyn o B. trong th d hnh 25,
QRS vung gc vi aVR v gn trng vi D 3. Vy D3 l chuyn o B.
P a g e | 35
b) Nhn vo phc b QRS ca chuyn o B xem bin ca n l dng hay m. Nu l

dng th QRS s trng vi na trc dng ca chuyn o B, cn nu l m th QRS s
trng vi na trc m ca chuyn o ny. Trong th d trn, bin ca D 3 l dng nn QRS
s trng vi na trc dng ca D3 , ngha l c hng +1200 hay ni cch khc gc = +120 0.
Mun chnh xc hn na, ta c th lm thm mt ng tc iu chnh: nhn li phc b QRS
ca chuyn o A, nu c:
- Hi dng tnh th ta phi iu chnh mi ca QRS 10 150 (ty theo dng nhiu
hay t) trn vng trn v pha na trc dng ca chuyn o A.
- Hi m tnh th phi iu chnh mi ca QRS cng 10 150 v pha na trc m ca
chuyn o A.
- Bng 0: ta khng iu chnh g. Trong th d trn, QRS ca aVR hi dng do , ta phi
iu chnh QRS 100 v pha na trc dng ca n, ta c = +1300.
TRC IN TIM BNH THNG

Bnh thng, chiu hng ca trc in tim tc l gc bng +580, nhng c th bin thin
trong khong t 00 n +900 (Hnh 26).
P a g e | 36
ngi Vit Nam, chng ti thy = +650 v bin thin t +260 ti +1000, ngha l hi
lch sang phi hn ngi u. Trc in tim trong nhng iu kin nh trn c gi l trc bnh
thng hay trc trung gian.
Trc in tim tr nh bnh thng khc hn ngi ln do u th tht phi hu qu ca tun
hon thai nhi. Lc mi sinh, n lch sang rt mnh gia +1200 v +1800. Sau mt thng th
lui dn v pha trung gian gia +600 v +1500. Sau mt tui l gia +400 v +1200 v sau 4 tui
l gia 00 v +900, ngha l tin st gn n hnh thi trc in tim ngi ln.
TRC IN TIM BNH L

Trc phi
Trong nhiu trng hp bnh l nh tng gnh tht phi (xem chng ba), tht phi dy ra,
ko vc t kh cc v pha bn phi, ng thi n cng gin ra v da vo xng c m y c
khi tm tht xoay theo chiu kim ng h (xung quanh trc dc ca tim): hai bin i l trc
in tim lch phi vt qua +900, cho ti -1500 (Hnh 26). Tnh trng ny c gi l trc phi
(right axis deviation). y l trng hp xy ra nhiu bnh tim: hp hai l, hp ng mch
phi, thng lin nh, tm ph mn, nhng ngay trong s cc bnh ny, mc lch nhiu (trc
phi mnh) hay lch t (trc phi nh) cng rt khc nhau. Hn na, li cn ph thuc vo giai
on pht trin ca bnh na (xem chng Ba v Bn).
C nhng ca bnh tim cha gy c trc phi tht s, ch lm gc = +75 0 m chng ta
thng gi l trc xu hng phi. Ngc li, cng c mt s ngi khng c bnh tim l li c
P a g e | 37
trc phi, thng l trc phi nh, khong +100 n +1100: l nhng ngi c tim ng
nht l nhng ngi cao, gy, lng ngc hp, hay b trn kh, trn dch mng phi tri, xp ph
nang bn phi, nhng iu ni ln rng: trong sinh vt hc, gii hn gia bnh thng v
bnh l nhiu khi xen k, chng cho ln nhau lm cho ngi thy thuc khi c in tm
phi c tr xt on v kinh nghim ca mnh, kt hp vi lm sng v cc phng php thm d
khc.
Trc tri
Khi trc in tim b lch sang tri vt qu 00 cho ti 900 th ta gi l trc tri (Hnh 26).
y thng l trng hp tng gnh tht tri do tng huyt p, hp hay h van ng mch ch,
h van hai l, hp eo ng mch ch, thiu nng vnh. Tng gnh tht tri lm tht tri dy ra,
ko vc t kh cc v pha tri, ng thi n cng gin ra v da vo cc c quan mm pha sau
m y khi tm tht xoay ngc chiu kim ng h: hai bin i gy ra trc tri.
Tuy nhin, tng gnh tht tri thng khng gy ra trc tri nhiu nh tng gnh tht phi
thng hay gy ra trc phi, l do l tht tri khng c ch da vng chc y tim xoay nh
tht phi (tht phi c xng c). Trc tri thng ch xy ra nhng ca bnh tim c km tui
gi, x ha c tim, tng huyt p nhng ca ny hay c thm cc tc nhn a tim xoay ln v
tr nm ngang nh: kh ngi to ngang, c honh nng cao v bo ph, quai ng mch ch m
rng. Tri li, hi chng tng gnh tht tri ngi tr thng c trc bnh thng, thm ch c
khi trc phi nh na (do t th tim).
Khi trc in tim cn khong +200, +100 th ta gi l xu hng tri. Cn nhng ngi
khng c bnh tim m c trc tri (thng l trc tri nh, khong -200, -30 0) l nhng ngi c
tim nm, nht l, nhng ngi thp, bo, to ngang, ngi c thai v bnh nhn c bng nc,
hi d dy, ct dy thn kinh honh tri, trn kh mng phi phi, xp ph nang phi tri,
Ch :
1. Khi trc in tim trong khong t - 900 n -1500 (Hnh 26) th rt kh ni l trc phi
hay trc tri (trc v nh); phi phi hp thm vi chn on lm sng. Ni chung, hnh nh ny
hay c trong cc bnh lm cho mm tim lch ra pha sau nh kh ph thng chng hn.
2. n gin ha cch tm trc in tim, c nhng ngi khng tnh gc m ch nhn
hnh dng i cng ca D1 v D3 nh sau:
- Khi phc b QRS ca c D1 v D3 cng hng ln (dng): ta c trc trung gian.
- Khi chng chc mi v pha nhau (D1 m, D3 dng): trc phi.
- Khi chng ngonh ra xa nhau (D1 dng, D3 m): trc tri.
P a g e | 38
- Khi chng cng hng xung di (m): trc v nh. Nhng phng php ny khng
chnh xc, ch nn dng khi c s b lc u, cn khi xem k th cn phi tnh gc l bao
nhiu.
CC T TH IN HC CA TIM
Mt trong nhng yu t quan trng nht gy nhng bin i v hnh dng v nht l chiu
hng (m hay dng) ca cc sng in tm l cc t th gii phu khc nhau ca tim trong
lng ngc.
Ty theo tim nm t th no, hng mi bung ca n v pha thnh ngc no v chi no
m in lc tim thu c thnh ngc , chi s m hay dng tc l hng sng ca P, T
v nht l QRS ca chuyn o s m hay dng. V th, khi c in tm , sau khi tnh
trc in tim, ngi ta cng tm c t th tim.
T th tim m ta tm ra, cn c vo chiu hng ca cc sng in tim, c gi l t th
in hc ca tim. Trong a s cc trng hp, t th in hc ca tim ni ln c t th gii
phu ca tim. Nhng trong dy tht th c thm t nhiu nh hng ca s kh cc vng tht b
dy. Cn trong blc nhnh, nht l blc nhnh phi v trong nhi mu c tim th hng kh cc
ca c tim b hon ton o ln. V th, trong blc nhnh phi v nhi mu, ngi ta khng tm
t th in hc ca tim na hay c tm cng ch tham kho.
Mt khc, tuy n nay c nhiu phng php xc nh t th in hc ca tim nhng
cha c phng php no tht hon ho. Xin gii thiu mt phng php:
Phn loi cc t th in hc ca tim
Tim c th nm trong lng ngc theo nhiu t th:
1. Bnh thng, tim nm nghing trong lng ngc nh hnh 27a, ngi ta gi l t th
trung gian. t th ny, cc chuyn o aVL v aVF u nhn c in th t tht tri truyn
ra nn u dng tnh vi dng Rs hay qR (xem cc chng sau).
2. Tim c th nm ngang, vi mm tim hng v bn tri nh hnh 27b: ngi ta bo, so vi
t th trung gian th tim xoay ngc kim ng h xung quanh trc trc sau ca n. Nhng
iu t nh hng n cc sng in tim.
Tri li, trong khi xoay nh th, n cn phi hp xoay cng ngc chiu kim ng h nhng
xung quanh trc dc ca n (nhn t mm tim ln y tim, v iu mi nh hng nhiu n
hng sng: n lm cho aVL nhn c in th tht tri nn dng tnh v c dng R hay qR,
cn aVF th li nhn in th ca tht phi nn m tnh v c dng rS. Hnh thi ny c gi l
t th tim nm (Hnh 27b).
Thng thng, t th ny, ta c trc tri hay xu hng tri. Hn na, D1 s c dng R
hay qR (ging aVL) hoc qRs nhng vi q su hn s, cn D3 th c dng rS (ging aVF) hoc
P a g e | 39
qRS vi S su hn q; l hnh nh Q1S3 . Cn cc chuyn o trc tim th ta thy dng
chuyn tip dch v bn phi ngha l v pha V1 V2 (xem cc chng sau).
3. Tim c th ng thng vi mm tim hng xung di nh hnh 27c: ngi ta gi l n

xoay theo kim ng h xung quanh trc trc sau ca n. Nhng iu cng t nh hng
n hng sng. V trong khi xoay nh th, n cng phi hp xoay theo kim ng h xung
quanh trc dc ca n, lm cho in th tht phi truyn ra tay tri: aVL m tnh v c dng rS,
cn in th tht tri truyn xung chn: aVF dng tnh v c dng qR, hnh thi ny c gi
l t th tim ng (Hnh 27c).
Thng thng, t th ny, ta c trc phi hay xu hng phi. Hn na, D1 s c S su
hn Q, cn D3 th c Q su hn S: l hnh nh S1Q3. cc chuyn o trc tim, dng chuyn
tip dch v pha tri tc l v pha V5 V6.
P a g e | 40
4. Khi tim xoay theo li t th nm nhng khng nm hn m mi na chng th aVL cng
dng nhng aVF th cha m v bin tng i (xem mc m t phc b QRS) ch gim
xung gn 0: ta gi l t th tim na nm.
5. Khi tim xoay theo li t th ng nhng xoay na chng th aVL c bin tng i
rt thp, aVF dng tnh v c dng pR: y l t th tim na ng.
6. Khi tim xoay khng theo mt quy lut no, lm cho aVL v aVF khng c hnh thi r rt
nh trn hoc u c bin tng i gn 0 th coi nh in tm nh chu b tay khng xc
nh c t th tim: ngi ta gi y l t th v nh.
Tim xoay xung quanh trc ngang
Ngoi li xoay xung quanh trc trc sau v trc dc, tim cn c th xoay xung quanh
trc ngang sinh ra:
- T th mm tim ra sau: cc sng S D1, D 2, D3 u su xung, ta gi l hnh nh S1 , S2,
S3, ng thi bin ca 6 chuyn o trc tim u thp xung.
- T th mm tim ra trc: cc sng Q D1 , D2, D3 u su xung, ta gi l hnh nh Q1,
Q2, Q3 ng thi bin ca 6 chuyn o trc tim u tng ln.
P a g e | 41
Ch :
Cc li xoay xung quanh ba trc tim, trc trc sau, trc dc v trc ngang, ngc v xui
kim ng h, khng phi bao gi cng phi hp vi nhau, sinh ra cc dng sng ng nh trn
m c khi phi hp rt phc tp v tri ngc nhau, to nn nhiu t th phi hp m chng ti
s ni n trong nhng chng sau.
T TH IN HC CA TIM TRONG TRNG HP

BNH THNG V BNH L
ngi bnh thng
T th tim ty thuc nhiu vo kh ngi v lng ngc: tim ng v na ng hay gp
ngi cao, gy, lng ngc hp, cn tim nm v na nm th hay gp ngi thp, bo, to ngang
(xem thm mc Trc in tim).
T th tim cng ty thuc c vo tui: theo ti liu th gii, tr em v thanh nin hay c tim
ng v na ng; ngi ng tui, k t 30 tui tr i, s ngi c tim na ng rt t, a s l
tim trung gian hay na nm. T 40 tui tr i, phn ln l tim nm, nht l nhng ngi c c
honh cao. S tin trin ca t th tim nh th c th do nhiu nguyn nhn: cng ln tui, kh
ngi v lng ngc cng to b ra, quai ng mch ch ngy cng x cng, dui ra v a tim
nm ngang, c honh nng cao ln nhng theo kinh nghim ca chng ti, t 30 40 tui, s
ngi Vit Nam c tim na ng vn chim a s.
ngi c bnh tim
Trn c s ni trn, khi c dy tht xy ra, tht b dy c th y tim xoay ra cc t th khc
so vi t th nguyn thy:
1. Dy tht phi, nht l bnh van tim bm sinh, hay c tim ng hay na ng. Khi thy
tim ng, trc phi qu mnh tr em m nu khng c o ph tng hay blc nhnh phi th
gn nh chc chn l dy tht phi do tim bm sinh.
2. Dy tht tri hay c tim nm. Khi tim nm, trc tri qu mnh, vi R1 cao, S2, S3 su
(nh ca R1, S2, S3 chiu ng vo nhau khi ghi ng thi) th thng l dy v tng gnh tht
tri.
3. Nhng khi R1 thp, S2, S3 vn su nhng ng mun hn R1 . Khi ghi ng thi th phn
nhiu l t th v nh, v hay gp trong kh ph thng, tm ph mn, i khi trong nhi mu c
tim thnh trc, blc vng y tht tri.
Cc trng hp 2 v 3 ni trn cho thy rng, khi bin tng i ca D2 l m (S2 su),
bt k l vi tim nm hay ng, th cng l biu hin ca mt tnh trng tim xoay phi hay xoay
tri rt mnh vi tnh cht bnh l r rng.
P a g e | 42
Tm li, nhng phn tch trn cho thy t th in hc ca tim v trc in tim thng hay
song song tin trin, tng ng vi nhau trong nhiu trng hp. Hai yu t b sung, h tr
cho nhau lm cho chn on cng chnh xc hn.
PHN TCH HNH DNG CC SNG

y l phn quan trng nht, tng t nh khi khm thc th mt bnh nhn.
Theo cch phn tch hin nay, ngi ta m t ln lt cc sng P, khong PQ, phc b QRS,
on ST, sng T, sng U v khong QT (Hnh 29).
P a g e | 43
V mi sng hay khong , ngi ta u ng thi phn tch tt c cc chuyn o ghi

(thng l 12 chuyn o thng dng) v thng chn lc ra nhng du hiu v yu t tiu biu
(ngha l i din cho bn in tm ) dng tng hp thnh cc hi chng (xem chng
sau) v a n kt lun chn on in tm .
Ch :
i vi D1, D2, D3, ngi ta hay dng k hiu vit tt cho cc sng, th d: P1 (sng P D1),
QRS3 (phc b QRS D3), PQ2 (khong PQ D2)
P a g e | 44
SNG P
SNG P BNH THNG
Hnh dng v bin

Bnh thng, sng P :
- D 1, D2 , aVF, V3 , V4 , V5, V6: bao gi cng dng.
- D3 , aVL, V1, V2: a s l dng nhng cng c th m nh hay hai pha, P m D3 nu c
km QRS3 v T3 m hay bin thp th l do t th tim nm: nu cho bnh nhn ht vo su, P,
QRS v T s c xu hng bin thnh dng. Cn P m aVL nhiu khi li l do t th tim ng.
- aVR bao gi cng m.
D m, dng hay hai pha, P cng c th c mc nh hay ch i nh.

P a g e | 45
Bin sng P thng tiu biu D 2 (ngha l sng P2 thng ln nht).
Sng P tiu biu thng trung bnh l 1,2mm, ti a 2mm, ti thiu l 0,5mm (Hnh 29)
tr em, bin P hi cao hn ngi ln.
cc chuyn o thc qun v trong bung nh, sng P cao gp 10 ln P2 v c hnh dng
ging nh mt phc b QRS.
Thi gian
Thi gian tc l b rng ca P thng cng tiu biu (ln nht) D2 .
P tiu biu c b rng trung bnh l 0,08s, ti a 0,11s, ti thiu 0,05s.
tr em, thi gian P thng ngn hn ngi ln.
SNG P BNH L
1. Khi P b bin dng
m, dt < 0,5mm v hp < 0,05s, hai pha ( cc chuyn o ng l n phi dng), ch i
hay c mc su, mo m, trt m hay dy cm ta phi ngh n mt tn thng cc b nh
hay dy gin nh, hoc mt ri lon nhp tim (nhp nt, rung nh).
2. P m D1, aVL, V5 , V6
L du hiu c trng ca chng ngc v tng tim.
3. P thay i hnh dng trn cng mt chuyn o
ngh n ch nhp lu ng hay ngoi tm thu nh.
4. P cao > 2,5mm v nhn
Ngh n dy nh phi ri n dy nh tri, bnh tim c tm (thiu oxy nng). Khi tim b kch
ng hay nhp nhanh, P cng c th cao nhng thng khng qu 2,5mm.
5. P rng (> 0,12s)
L du hiu ch yu ca dy nh tri.
6. Khi P bin mt (P ng in)
Khi P ng in tt c cc chuyn o th phi p dng cc bin php tm P (xem mc ri
lon nhp tim), nht l cc chuyn o thng c P r nht nh: D2, V1 , X1 , V3R, S5, V,
chuyn o trong bung tim, v nu cn th cho lm nghim php gng sc, tim atropin, n
xoang cnh thy r P hn. Vic xc nh bn in tm c P hay tht s khng c P c
mt tm quan trng rt ln, nht l trong vic chn on cc ri lon nhp tim.
P a g e | 46
KHONG PQ
Cch o
Khong PQ l i din cho thi gian truyn t nh tht. N l khong cch o t khi
im ca P ti khi im ca Q (hay ti khi im ca R nu khng c Q).
Thng ngi ta ly PQ tiu biu D2. Nhng nu em so vi cc chuyn o khc m thy
D2 thi gian P qu ngn (lm PQ2 ngn i mt cch gi to) hay thi gian Q hay QRS qu ngn
(lm cho PQ 2 di ra mt cch gi to) th ta phi chn PQ tiu biu chuyn o khc.
Nu khng c my nhiu dng (bt) ghi c ng thi nhiu chuyn o chn th ta nn
chn PQ tiu biu chuyn o no c c P v Q rng nht, hay nu khng c Q th c QRS
rng nht.
P a g e | 47
Khong PQ bnh thng

ngi Vit nam, PQ bnh thng trung bnh l 0,15s, ti a l 0,20s, ti thiu l 0,11s.
tr em, PQ hi ngn hn. Th d tr 7 tui, PQ ti a l 0,18s, ti thiu l 0,10s. Nhng
tn s tim cng nhanh th PQ cng b rt ngn.
Hnh 32 l mt th v ln mi lin h gia PQ v tn s, th d mt in tm c tn
s l 100/ph th ng cong 1 (gii hn ti a) ca th cho ta con s gii hn ti a ca PQ
bnh thng l 0,16s.
Khong PQ bnh l
1. PQ di ra
Khi PQ di ra vt qu con s ti a bnh thng th l bnh l chc chn v l blc nh
tht cp 1. Th d ngi ln vi tn s tim 68/ph m PQ l 0,22s hoc vi tn s 100/ph m PQ
l 0,20s.
Trong cc trng hp trn, khi ta chiu cc honh 68 v 100 ln cho gp cc tung 22
v 20 trong hnh trn, ta s c 2 im nm khu vc m trn ng cong 1 l khu vc ni ln
tnh trng PQ di ra.
P a g e | 48
2. PQ b t
Ngha l P v QRS khng cn lin lc vi nhau th ty theo hnh thi v mc , c th l
phn ly nh tht, blc nh tht cp 2 hay cp 3, nhp nhanh tht, ngoi tm thu (xem mc ri
lon nhp tim).
3. PQ ngn hn bnh thng (< 0,12s)
C th l nhp nt trn, nhp nh, nhp nhanh kch pht trn tht, ngoi tm thu nh, hay hi
chng Wolf Parkinson White.
P a g e | 49
PHC B QRS
M T K HIU V O C CC SNG
1. Theo quy c quc t, trong mt phc b QRS, nu c mt sng dng th sng gi l
sng R (Hnh 33 e, k, l, m). Nu c hai sng dng th sng th hai gi l sng R (Hnh 33a) v
c th: sng R, R (Hnh 33i).
Nu trc sng R c mt sng m th sng ny gi l sng Q (Hnh 33 c, ).

Nu sau sng R c mt sng m th ta gi n l sng S (Hnh 33 a, b, c, d)
Sng m ng sau sng R gi l sng S (Hnh 33 b, i), sau sng R gi l sng S v c
nh th.
Nu mt phc b QRS khng c sng dng m ch c mt sng m th ta gi n l sng
QS (v khng th phn bit n l Q hay l S) (Hnh 33 g, h).
Ngoi ra, trn mi sng cn c th c nhng ci mc (Hnh 33 h, l, m) hay dy cm, trt
m (Hnh 33 e, k, m).
2. Mt phc b QRS c th ch c mt sng dng: R (Hnh 33 e, k, l, m) hay mt sng m:
QS hay 2 sng, Q v R (Hnh 33) hoc R v S (Hnh 33d) hay 3 sng QRS hoc R, S, R (Hnh
33a) hay 4 sng Q, R, S, R hoc R, S, R, S (Hnh 33b).
P a g e | 50
3. Khi ghi k hiu dng ca mt phc b QRS ta dng ch hoa ghi sng no c bin
ln nht v ch con ghi cc sng cn li.
Th d mt phc b QRS c 3 sng Q, R, S m R ln nht th ta k hiu l: qRs; Q ln nht
th k hiu Qrs. Nu ch c 2 sng Q v R m Q ln hn th k hiu Qr (Hnh 33). Nhng nu
c 2 sng cng ln ngang nhau th ta phi ghi c 2 sng bng ch hoa. Th d: qRS (Hnh
33c), RS (Hnh 33d).
4. im m sn ln ca S hay sn xung ca R (nu khng c S) bt vo ng ng
in gi l im J (t ch Junction = ni tip). Trong nhiu trng hp, ch qu thoai thoi,
khng r bt vo ng ng in im no, ta gi l J v nh.
5. Bin tng i ca mt phc b QRS l hiu s ca tng bin cc sng dng
tr i tng bin cc sng m. Khi con s ny dng, ta ni phc b QRS dng. Cn khi
n m th ta ni QRS m.
Th d hnh 33a l mt phc b QRS dng v tng bin cc sng R v R ln hn bin
sng S; hnh 33c l mt phc b m v bin R nh hn tng bin Q v S cng li.
6. Bin tuyt i ca mt phc b QRS l tng bin tt c cc sng ca phc b
cng li, khng phn bit sng m hay sng dng.
7. Thi gian QRS (tc l thi gian kh cc) cn gi l b rng ca QRS, c o t khi
im sng Q (hay sng R nu khng c Q) n ht sng S (hay sng R, S nu c) tc l n
im J.
im J
Trong mt bn in tm , QRS mi chuyn o c th rng hp khc nhau vi phn

trm giy; nhng ch cn chn o chuyn o c QRS rng nht. Thng thng, trong 3
chuyn o mu, QRS2 rng nht. Nhng QRS cc chuyn o trc tim thng rng hn cc
P a g e | 51
chuyn o ngoi bin, nht l V2, V3, V4; do , ngi ta thng ly QRS tiu biu cc
chuyn o ny tr khi im J cc chuyn o ny v nh.
8. Thi gian xut hin ca nhnh ni in2
Thi gian xut hin nhnh ni in ca phc b QRS trc tim c o t khi im phc
b n im hnh chiu ca nh sng R xung ng ng in (Hnh 34).
Nu phc b c nhiu sng dng (R, R) th ly hnh chiu ca nh sng dng

cui cng (Hnh 35). Thi gian thng c o V1, V2, V5, V6.
Nhnh ni in l nhnh xung ca sng R (hay R, R) tc l cc nhnh sng t ch a

n ch b ca hnh 35. N xut hin lc xung ng kh cc i qua vng c tim m trn ta
t in cc thm d.
P a g e | 52
PHC B QRS BNH THNG

cc chuyn o ngoi bin
Hnh dng v bin tng i ca phc b QRS chu nh hng nhiu ca t th tim (xem
mc ny).
- Vi t th trung gian l t th ph bin nht th QRS ca cc chuyn o mu u dng
vi bin tng i ca QRS2 ln nht (Hnh 36).
QRS1 v QRS3 xp x bng nhau. Cn QRS ca aVL v aVF cng u dng (Hnh 27a)
- mt s ngi khc, nht l nhng ngi cao, gy v theo nhn xt ca chng ti th

mt s kh ln ngi Vit Nam c tim na ng v nh vy, bin tng i ca QRS3 c th
ln gn bng hay bng QRS2 cn QRS1 th nh hn.
P a g e | 53
Lc ny QRS ca aVL c th rt nh v ca aVF th dng.
- Tri li mt s nh ngi khc, nht l ngi gi, x cng ng mch hay thp ln, to
ngang th li c tim na nm: QRS1 bng hay ln hn QRS2 cn QRS3 th nh hn i hay c khi
hi m na. Lc ny QRS ca aVL dng. Trong tt c cc trng hp trn, QRS ca aVR u
lun m.
Vi nh hng ln ca t th tim nh trn, nu ta o bin tuyt i ca tng sng Q, R, S
chuyn o ngoi bin, ta s thy chng rt khc nhau ty tng c nhn.
Sng R D2 c ngi cao 28mm, c ngi ch c 0,5mm. D3 c ngi 22mm, c ngi
0mm cc con s ny u c nghin cu t m nhng v qu phc tp v khc nhau qu
nhiu nh trn nn ch dng trong nghin cu, t c dng trong thc t lm sng, tr mt vi
con s c bit chng ti s ni cc mc sau.
Ring i vi vn ng vin th thao th bin QRS thng cao hn ngi thng.
cc chuyn o trc tim
a) V1, V2 : nhn in th ca tht phi nn QRS m, vi dng rS (tc t s R/S < 1) (Hnh 33a
v b) hay i khi (ngi cao gy) vi dng rSr. tr cng nh, cng hay thy dng RS hoc Rs
(Hnh 37c), cn ngi gi c khi c dng QS.
Cc chuyn o V3R, V4R, V5R, V6R th c hnh dng tng t nh V1 nhng vi bin
thp dn i.
b) V5 , V6: nhn in th ca tht tri nn QRS dng, vi dng qR hay qRs.
tr nh, i khi c dng RS hay rS.
c) V3, V4: nhn in th ca vng chuyn tip gia tht phi v tht tri nn c hnh dng
trung gian gia V1, V2, V5, V6, thng gi l dng chuyn tip: l dng RS hay dng rung
ng.
Nhng c khi dng RS khng c V3, V4 m li thy V5 ,V6: ta ni l dng chuyn tip
dch sang tri do t th tim xoay theo kim ng h
Ngc li, khi dng RS c V1 , V2 th ta ni l dng chuyn tip dch sang phi do tim
xoay ngc kim ng h.
Ch :
- Hin nay, ngi ta quan nim dng chuyn tip khng nht thit phi l dng RS m c th
Rs hoc rS, min l n ng lin trc chuyn o trc tim u tin c xut hin sng Q k t
V1 ti V6.
P a g e | 54
Thi gian
Thi gian QRS tiu biu bnh thng l 0,07s, ti a 0,10s v ti thiu l 0,05s
Ring sng Q c thi gian ti a l 0,04s D3, aVF v 0,03s cc chuyn o khc
Thi gian xut hin cc nhnh ni in bnh thng ti a: V1 , V2 l 0,035s; V5 , V6 l
0,045s.
P a g e | 55
Thi gian ny rt c nh, ch cn di thm ra 0,01s hay 0,015s l coi nh bnh l. Khi
thi gian ny di ra, ngi ta ni l nhnh ni in mun.
PHC B QRS BNH L

1. Bin i bin tuyt i.
2. S tng bin tuyt i ca phc b QRS i a s cc chuyn o c th l du hiu
ca cng thn kinh, tim kch ng (tng t) hay ca tng gnh tht, ngoi tm thu tht.
3. S gim bin tuyt i ca QRS tt c cc chuyn o l mt du hiu bnh l c
gi l in th thp . Du hiu ny i hi:
a) chuyn o ngoi bin: bin tuyt i ca chuyn o c QRS ln nht khng
c qu 5mm (Hnh 38).
b) chuyn o trc tim: bin tuyt i ca V2 khng qu 9mm v V6 (hay V5)

khng qu 7mm.
P a g e | 56
Nu c 2 iu kin ny th chc chn l bnh l. Nhng theo kinh nghim ca chng ti
th rt nhiu ca, ch c in th thp chuyn o ngoi bin (iu kin th nht) m xt
nghim t thi, chc d mng tim cng thy bnh l.
Du in th thp thng hay gp nht trong vim mng ngoi tim c nc ri n
cc bnh:
- Kh ph thng,
- Ph ton thn,
- Suy tim nng,
- X ha c tim,
- Nhi mu c tim,
- Vim mng ngoi tim co tht,
- Thiu nng gip,
- Trn dch mng phi, mng bng,
- i khi gp trong cc bnh truyn nhim.
4. Bin i hnh dng: s c t nhiu hn chng Tp hp thnh nhng hi chng.
y, chng ti ch nu ra mt s th d quan trng nht:
- V1, V2 khi QRS c:
+ Dng Rs, hoc rS nhng vi R > 7mm: Phi ngh n dy tht phi.
+ Dng rsR hay rsRS: ngh n blc nhnh phi.
+ Dng QR hay qR: blc nhnh phi, gin nh phi, hay nhi mu trc vch.
+ Dng QS ( V1 , V2, V3): nhi mu trc vch, dy tht tri rt mnh, blc nhnh tri hay
tm ph mn.
- V5, V6, khi QRS c:
+ Sng R rt cao > 25mm phi ngh n dy tht phi.
+ Khng c Q hay Q rt nh: ngh n blc nhnh tri hay x ha vch. Nhng theo kinh
nghim ca chng ti, th c kh nhiu ngi bnh thng cng th, do bin Q nh qu khng
thy c.
+ Sng S su, c khi a ti dng rS: dy tht phi.
P a g e | 57
+ Sng S rng, dy cm: blc nhnh phi.
+ bt k chuyn o no tr aVR, khi sng Q rng qu 0,03s, su qu 3mm v trt
m phi ngh n nhi mu c tim c hay mi.
+ Nu du hiu ny xut hin ring D3 th phi xt thm kh nng chng tm ph cp.
5. Bin i thi gian
- Khi thi gian QRS tiu biu vt qu gii hn ti a ( 0,10s ngi ln, 0,09s tr
em) th phi ngh u tin n blc nhnh ri n hi chng W-P-W, ngoi tm thu tht, nhp
nhanh tht, dng quinidin hay procainamide, blc nh tht hon ton.
- Khi nhnh ni in mun V1 , V2 ( 0,035s) th ngh n dy tht phi hay blc nhnh
phi; V5,V6 ( 0,045s) th ngh n dy tht tri hay blc nhnh tri.
ON ST
Nh chng Mt ni, on ST khng bao gm mt ln sng no m ch l mt on
thng i t im tn cng ca QRS (tc im J) ti khi im ca sng T (Hnh 29).
Khi im ca T thng rt kh xc nh v ST tip vo T rt thoai thoi. Cn im J th

cng nhiu khi v nh. V th, thi gian ca on ST rt kh xc nh v t c dng trong lm
sng. Tri li, ngi ta ch nhiu n hnh dng ca ST v v tr ca n so vi ng ng
in.
V tr ca ST c th l:
- ST chnh ln trn ng ng in, cn gi l ST dng (k hiu : ST hay ST+ (Hnh 39
d, e, g).
- ST chnh xung di ng ng in, cn gi l ST m (k hiu: ST hay ST-) (Hnh 39
a, b, c, ).
P a g e | 58
- ST ng in (trng vi ng ng in) (k hiu: ST) (Hnh 43).
Khi chnh ln hay chnh xung, ST c th i ngang (Hnh 39a), i dc ln (Hnh 39d), hay
i dc xung (Hnh 39b).
Ch :
Khi xc nh v tr ST, cn trc ht xc nh v tr im J, n l mt b phn quan trng
hng u ca ST; v c khi cn o ST chnh ln hay chnh xung, cch ng ng in bao
nhiu milimt, ngi ta cng o t im J. Nhng khi nhp nhanh, khi lm nghim php gng
sc hay khi im J v nh th, theo kinh nghim ca chng ti, mun bo m chnh xc ta
khng nn n nh gng p mt im J u o m nn o t im gia ca ST.
Hnh dng ca ST c th l:
P a g e | 59
- ST thng un (Hnh 39a).
- ST un cong xung (Hnh 39) hay un cong ln (Hnh 39c, g).
ON ST BNH THNG
a s ngi bnh thng, ST ng in hoc hi chnh ln (khng vt qu 0,5mm)
chuyn o ngoi bn, v thng chnh ln chuyn o trc tim (khng vt qu 1,5mm
V4 v 1mm cc chuyn o trc tim khc).
mt s t ngi bnh thng khc, ST c th chnh xung V6 nhng khng vt qu
0,5mm.
Ni chung, ST khng un cong m i thng v tip vo T mt cch mm mi, cng khng
bao gi i dc xung m ch i ngang hoc hi dc ln.
ON ST BNH L
Trong trng hp bnh l, cc bin i ca ST rt nhiu v v thng hay phi hp phc
tp vo cc hi chng s c ni n trong cc chng sau. Di y, chng ti ch nu ra mt
vi bin i thng thng nht:
1. Khi ST chnh ln hay chnh xung nh, m i dc ln th thng l do nhp nhanh hay
cng thn kinh (Hnh 39d).
2. Khi ST chnh xung qu 0,5mm nhng i ngang hay i dc xung, nht l V5, V6 th
phi ngh n thiu nng vnh.
3. Khi ST chnh ln v un cong ln (Hnh 39g) th nn ngh n nhi mu c tim giai on
cp.
P a g e | 60
4. Khi ST chnh v un cong tri chiu vi QRS (ngha l chuyn o c ST v un cong
xung th QRS+ m chuyn o c ST+ v un cong ln th QRS) (Hnh 39) th nn ngh
n tc dng ca glucozit tr tim.
5. Khi ST chnh cng chiu vi T v tri chiu vi QRS (ngha l ST+ chuyn o c T+
v QRS, v ST chuyn o c T v QRS +) (Hnh 39c): ngh n dy tht, blc nhnh,
WPW, ngoi tm thu tht.
6. Cng c khi ST chnh hay ng in do tc ng ca nhiu bnh phi hp vo nhau
(Hnh 42), trng hp ny gi l ST hn hp.
SNG T
Trong lm sng, thng ngi ta ch ch trng hnh dng v bin sng T m
khng cn tnh thi gian tc b rng ca T.
Cc hnh dng hay gp ca sng T nh sau: (Hnh 40)
P a g e | 61
Bin
Khi T dng, ngi ta hay t bin ca n bng cc t ng T cao, T bnh thng, T thp
,T dt (Hnh 40c), T ng in v ngi ta cng hay tnh bin tng i ca T so vi R cng
chuyn o (nht l V5, V6), th d: T/R = 1/3
Khi T m, ngi ta t bin n bng cc t ng T m nh, T m su v cng c tnh
bin tuyt i ca n ra milimt, th d T = 4mm
T hai pha thng ch l dng trung gian hay chuyn tip gia T dng v T m.
SNG T BNH THNG

Bnh thng, sng T rng v m nt, nh ty, hai sn khng i xng, vi sn xung
dc ng hn cn sn ln tip thoai thoi vi on ST. Sng T:
Bao gi cng dng D1, aVF, V3, V4, V5 , V6 vi bin ln nht V3 , V4; y, bin
trung bnh l 6mm v ti a l 12mm. Bin tng i T/R V5 , V6 trung bnh l 1/3 v ti
thiu l 1/10.
Bao gi cng m aVR.
D2: a s l dng, mt s nh 2 pha.
D3, aVL, V2 : a s l dng, mt s nh hai pha hay m.
V4: a s l m (ti a su 4mm) mt s nh l hai pha hay dng.
Nh vy, quy lut chung cc chuyn o trc tim l: nu xem xt sng T ln lt t V1
n V6 (ngha l t phi sang tri bnh nhn) th sng T phi chuyn dn t m tnh sang dng
tnh (Hnh 41).
P a g e | 62
Tuy nhin, n V5 , V6 , T c th hi thp xung do in cc xa tim hn.

cc chuyn o thc qun cao v trong bung tim, sng T u m.
SNG T BNH L
Khi T m mt chuyn o m bnh thng n phi dng (hoc dng mt
chuyn o m bnh thng n phi m nh aVR chng hn) th l mt du hiu bnh
l chc chn, nhng l ca rt nhiu bnh ch khng c hiu cho bnh no.
Mun bit T m do bnh g th vic u tin l phi xt mi tng quan ca n vi QRS:
1. Nu QRS b gin rng hay c bin cao ngha l c nhng bin i bnh l ca blc
nhnh, ngoi tm thu tht, nhp nhanh tht, hi chng W-P-W, dy tht tri hay mt s t ca dy
tht phi th c th T m ch l triu chng ca cc bnh . Ngi ta gi l T th pht. Trong
trng hp ny, T vn gi c hnh dng khng i xng, cong, mm mi
2. Nu QRS khng gin rng hay qu cao, ngha l khng c triu chng ca cc bnh
nu trn th T m (hay dt) thng l triu chng ca bnh mch vnh (nhi mu c tim, cn
nghn tim), ca vim mng ngoi tim, ca tnh trng c tim thiu oxy (vi dy tht phi) trong
tim bm sinh tm hay tm ph mn. Ngi ta gi l T tin pht.
Ngoi ra, T m tin pht cn gp trong suy tim, t ph, thiu mu, thiu oxy trong mu ni
chung, cc ri lon chuyn ha trong vim hng cp, h canxi mu, tng kali mu, nhim toan,
nhim kim, hoi t gan,
P a g e | 63
3. T th pht thng bin i, t l vi mc bin i ca QRS, th d QRS cng gin rng
hay cng cao th T cng m su hn.
Nhng c nhng ca, vi mt mc rng hay cao nht nh no ca QRS m T m
khng su hay li su qu, hay c khi li dng th phi ngh l c c mt T tin pht phi
hp vo n gy cho n hnh dng na di, na chut nh vy. Trng hp ny ta gi l T hn
hp thng l do cc bnh phi hp nhau sinh ra.
Th d: trong dy tht tri (T th pht) phi hp vi bnh mch vnh (T tin pht) v c th
cho mt sng T hn hp m rt su, i xng v nhn. Cn ch rng ST chnh thng cng
hay hn hp tng t v i km vi T hn hp lp thnh STT hn hp (Hnh 42).
Tt c cc mc m su, nng ca T so vi QRS nh ni trn thng c th nh gi

c qua kinh nghim c v chn on in tm .
cc chuyn o trc tim, mt sng T m s chc chn l bnh l (thiu nng vnh)
nu n ng tri quy lut (xem trn) ngha l c km mt sng T dng cc chuyn o nm
m bn phi ca n. Th d T V1 bnh thng c th m nhng nu T V1 dng th T V2
m chc chn l bnh l.
Ni chung, T cng m su th cng bnh l hn. T hai pha kiu /+ c gi tr bnh l nh
T m nh, cn T hai pha kiu +/ v T dt th c gi tr bnh l thp hn.
P a g e | 64
Khi T tr thnh i xng vi hai sn c dc bng nhau, ch ni tip vi ST khng
thoai thoi m gp khc thnh mt gc r rt, T c nh nhn hoc c dng ch i, nht l V5,
V6 th u tin phi ngh n bnh mch vnh, ri n cc nguyn nhn tin pht khc (xem
trn).
Khi T c dng qu trn trnh th nn ngh n mt ri lon in gii.
Tt c cc hnh dng u c th i mt mnh hoc phi hp vi T m, nh th n cng c
gi tr bnh l hn.
Khi T dng v cao (v do cao qu nn nh hi nhn) nhiu chuyn o th thng l
do nhp nhanh hay cng thn kinh ngi tr, do gng sc hay tim vn ng vin. Nu T
cao nhn xy ra t xut mt vi chuyn o th i khi l hnh nh gin tip ca bnh
mch vnh.
Khi T dt hu ht cc chuyn o th phn ln l do phi hp vi s gim bin ca
QRS, to nn hnh nh in th thp (xem mc ny).
P a g e | 65
KHONG QT
Nh chng Mt ni, khong QT th hin thi k tm thu in hc ca tht v c o
t khi im sng Q (hay sng R nu khng c Q) ti im cui sng T (Hnh 29)
Ngi ta ly QT tiu biu V2 hay V4 nhng nu c g kh khn (nh T dt, kh c) th

ly D2 .
Khi c sng U qu cao chng tip vo sn ca T, ngi ta d lm U l phn ui ca T
v o QT lm sang QU ngha l xc nh QT di ra mt cch sai lm. Trng hp ny phi so
snh QT nhiu chuyn o v o QT theo phng php ch dn trong hnh 43.
Khong QT bnh thng

Vi nhp tim bnh thng, khong 70/min, th khong QT n ng trung bnh l 0,36s, ti
a 0,40s, ti thiu l 0,31s.
ph n, QT hi di hn, trung bnh l 0,37s, ti a 0,41s v ti thiu l 0,32s.
tr nh t 3 n 5 tui, nhp tim thng nhanh hn (trung bnh 100/min), QT trung bnh l
0,30s.
P a g e | 66
Khong QT bnh l
1. QT di ra:
u tin l ngh n cc bnh ni tit, ri lon th dch: gim canxi mu, thiu nng cn
gip, gim kali mu, thiu nng gip, nhim kim, ur mu cao.
Cc bnh tim: dy tht, blc nhnh ,thiu nng vnh, thp tim, bch hu bin chng tim,
Tc dng ca cc thuc: quinidin, procainamide.
2. QT ngn li:
Cc ri lon ngc li cc ri lon nu trn.
Tc dng ca Digitalis.
P a g e | 67
SNG U
Sng U (Hnh 45) l mt sng nh thng ch c mt mt s chuyn o, nht l V2, V3 ,
v bao gi cng tch ri hn khi T, ng sau T t 0,01s n 0,04s.
Sng U bao gi cng dng vi bin rt thp. V2 l chuyn o c U cao nht trung
bnh l 1mm v ti a l 2mm. Nhng bin ny cn ty thuc bin sng T i trc n, khi
T cao th U cng cao v ngc li.
T l U/T V1 trung bnh l 1/5, ti a ; V5 trung bnh l 1/10, ti a l 1/5.
Rng t 0,16s n 0,25s.
Sng U bnh l
U cao nhiu chuyn o v dnh lin vo T, c khi cao hn T: ngh n gim K+ mu.
Trong chy mu no, u no, bnh tim t ph, ngi ta cng c th thy U rt cao. Nhng:
+ Khi U ch cao ring V1 , V2 th l du hiu ca dy tht tri.
+ Khi U ch cao ring V5 , V6 th l du hiu ca dy tht phi.
+ U m D1 (v c th c V5 , V6): c gi tr bnh l cao, gp trong dy tht tri vi bnh
ng mch ch hay tng huyt p, bnh mch vnh.
P a g e | 68
CHNG BA
TP HP THNH HI CHNG
TNG GNH NH TRI
Hay gp trong:
Hp hai l (P hai l).
H hai l.
H ng mch ch.
Tng huyt p.
Tng gnh nh tri gm cc triu chng sau y (Hnh 46):
P (tiu biu) rng ra > 0,12s, c khi ti 0,16s. y l triu chng quan trng nht.
P 2 nh hay c mc nh.
D3, aVF, V1, P hai pha +/ hay m hn. Ring V1, dng hai pha +/ c pha m rt rng
v c mc.
Trc P lch sang tri, gia 400 v 00.
68 CHNG BA | typewriter: Nguyn nh Tun Cao hc Ni 12
P a g e | 69
TNG GNH NH PHI

Hay gp nht trong tm ph mn (P ph) ri n cc bnh tim bm sinh: bnh Fallot, hp
ng mch phi, thng lin nh v hp hay h ba l.
Triu chng:
P cao: y l triu chng quan trng nht, P cao, nhn, i xng, P tiu biu
(thng l P 2) vt qu 3mm, c khi ti 100mm.
V1, P cng cao, thng vt qu 2,5mm nhng c th hai pha +/ hay m hn. D sao,
pha m y cng rt hp cn pha dng th rng hn nhiu.
Trc P hi lch sang phi, gia +600 v 900.
Phc b QRS V1 c dng QR (du hiu Sodi Pallares).
TNG GNH HAI NH

Hay gp nht trong bnh van hai l, ba l, bao gm cc triu chng ca dy nh tri v dy
nh phi phi hp thnh rt nhiu hnh thi, th d:
P tiu biu va rng (> 0,12s) va cao (> 3mm) v c hai nh hay c mc.
V1, P hai pha +/ hay m su. C hai pha + v u rng v dy cm.
Phc b tht bao gi cng c du dy tht phi hp vo.
69 TP HP THNH HI CHNG | typewriter: Nguyn nh Tun Cao hc Ni 12
P a g e | 70
TNG GNH THT TRI

Thng gp trong:
Tng huyt p.
H hay hp ng mch ch.
Hp eo ng mch ch.
H hai l
Cn ng ng mch
Phng ng tnh mch
Thiu nng vnh
Tng gnh tht tri gm cc triu chng xp theo th t quan trng sau y (Hnh 48):
cc chuyn o trc tim

V5, V6 :
Bin R cao ln v nhiu khi vt qu 25mm ngi c thnh ngc dy v qu 30mm
ngi c thnh ngc mng.
Sng Q hi su nhng khng rng.
P a g e | 71
Sng S khng c hoc rt nh.
Nhnh ni in mun ti > 0,045s.
V1, V2 :
Sng R b i, c khi bin hn.
Sng S di ra.
Vng chuyn tip: dch sang phi.
Cc ch s:
Sokolov Lyon: RV 5 + SV 2 35mm.
Du Shane: Q V 5 hay V 6 su hn 4mm.
cc chuyn o ngoi bin
a s cc ca, tim t th nm, trc in tim lch tri v nh th D1 v aVL s dng
vi R aVL vt qu 12mm, D3 v aVF s m.
mt s ca khc, c t th tim ng hay na ng, trc in tim c th bnh thng hay
xu hng phi, v nh vy D3 v aVF s dng vi R aVF vt qu 20mm, D1 v aVL s m.
mt s ca c t th trung gian, trc in tim bnh thng v c ba chuyn o mu u
dng.
Ring aVR ni chung vn m, i khi c dng QR.
on STT
nhiu ca, tt c cc chuyn o u c STT tri hng vi QRS, th d V5 , V6 c QRS
dng, ta thy ST chnh xung v T m. Cn V1, V2 th ngc li.
mt s ca khc, T ni chung li dng v nhn vi ST bnh thng hay hi chnh
xung: y l hnh nh tng gnh tm trng, hu qu ca cc bnh c lu lng mu v tht tri
qu nhiu lc tm trng nh h ng mch ch, h hai l, ng ng mch.
QT di ra.
i khi, ta thy U m D1 , V5, V6, v dng V1, V2 .
P a g e | 72
TNG GNH THT PHI

Thng gp trong hp hai l, tm ph mn v nhiu bnh tim bm sinh c tm (Fallot, o
gc ng mch, thn ng mch chung) v khng tm (hp ng mch phi, thng lin nh,
thng lin tht, ng ng mch c tng p phi).
Triu chng:
cc chuyn o trc tim
V3, V1 :
R 7mm v c th bng S (dng RS) hay hn S (dng Rs) hay mt hn S (dng R
thng gp trong Fallot).
Ni chung, Q khng c mt: nu n c mt th phn ln l mt dng ca blc nhnh phi
(gy ra bi dy tht phi), i khi l do c thm gin nh phi, cng c khi l nhi mu trc
vch.
Kh nhiu trng hp R khng cao m c dng blc nhnh phi (rS vi S c mc, rsrS,
rsRS, rsR, rR): mt s ln cc ca ny l do tng gnh tm trng, hu qu ca cc bnh c
lu lng mu vo tht phi qu nhiu lc tm trng nh: thng lin nh, h ng mch phi,
h ba l.
nhiu ca tm ph mn c kh ph thng, R khng cao m c dng rS hay QS: mt s ln
cc ca ny c dng rS sut t V1 n V6.
Nhnh ni in ti trn 0,03s hay 0,035s.
V5, V6 : sng S su hn bnh thng.
Vng chuyn tip: vng chuyn tip dch sang tri.
P a g e | 73
Ch s: RV 1 + SV 5 > 11mm.
cc chuyn o ngoi bin
hu ht cc ca, tim t th ng, vi trc phi ( 1100) v nh th D1, aVL s m, D2,
aVF s dng vi dng S1 Q3.
mt s t ca, nht l khi dy tht phi rt mnh do Fallot hay tm ph mn, tim t th
nm hay v nh v mm tim ra sau, ta c: trc phi rt mnh hay v nh (+ 1500 ti 900); D1,
D2, D3, aVF u m v dng S1 , S2, S3.
Ring aVF, bt k l t th no, cng c mt sng dng kt thc phc b QRS (th d:
dng Qr, QR hay rSr). Sng dng ny vt qu 5mm.
on STT
Ni chung, nhiu chuyn o, ta thy STT tri hng vi QRS ngha l khi QRS dng
th T m v ngc li.
Trng hp V3R, V1 c QRS dng (dng Rs) v STT tri hng vi n (ngha l ST, T
m) th ta gi l tng gnh tm thu, hu qu ca cc bnh gy cn dng mu ra khi tht phi lc
tm thu nh: hp ng mch phi, Fallot, tm ph mn, hp hai l
QT di ra.
i khi ta thy U m V1, V2 v dng cao V5,V6.
TNG GNH HAI THT

Thng gp trong cc bnh c hai tn thng ng thi tc n ln hai tht, th d: bnh hai
l ng mch ch, tm ph mn km tng huyt p.
Tng gnh hai tht gm nhng triu chng ca dy tht phi v dy tht tri phi hp li, th
d:
R cao v STT m c V1 ln V5 , V6.
Hoc R cao v STT m V5 , V6 nhng li c trc phi mnh (> +1000).
Hoc c dng hai pha RS vi bin rt cao (khong 50mm) V3, V4.
P a g e | 74
BLC NHNH
Blc nhnh l mt danh t ch hnh nh in tm khi c nhng ri lon v dn truyn
xung ng trong mt nhnh ca b His. Ngi ta cn gi n l ri lon dn truyn trong tht.
Ri lon dn truyn trong mt nhnh c th do nhnh b ct t hay thng tn,
xung ng t nh truyn xung s phi i vo nhnh bn kia v kh cc tht bn
trc ri mi truyn t sang kh cc tht b blc sau.
Vic kh cc i quanh co, chm chp nh th s lm cho QRS gin rng, c mc vi

nhnh ni in mun, trc QRS lch v pha tht b blc. ng thi STT cng b bin
i th pht (xem Chng hai) v c hng tri vi QRS.
Khi nhnh b His ch b t mt phn, th gi l blc nhnh khng hon ton vi cc triu
chng ni trn mc nh hn.
Ch :
Trc khi chn on l blc nhnh, ta phi xc nhn l in tm c xung ng t nh
truyn xung, th d c nhp xoang, nhp nt, cung ng nh, rung nh,
Ty theo nhnh tri hay phi ca b His b tn thng m ta c hi chng blc nhnh tri
hay phi.
Blc nhnh tri hon ton

Hn 90% cc ca blc nhnh tri l do bnh tim thc th c dy tht tri: bnh mch vnh,
tng huyt p, hp hay h ng mch ch v th, tin lng ca n khng tt.
Triu chng quan trng nht khng th thiu c l QRS tiu biu gin rng 0,12s. Cn
v hnh dng sng th nh sau (Hnh 50):
P a g e | 75
QRS chuyn o trc tim

V5 , V6:
1. Ch c mt sng R gin rng, c mc nh. Sng Q v sng S bin mt.
2. Nhnh ni in mun qu 0,055s v rt nhiu khi vt xa con s ny. Hai loi du hiu
gp li gi l hnh nh trc tip v ghi c bng nhng in cc (V5 , V6) t trc tip trn
tht b blc. Nhng khi t th tim thay i, hnh nh ny c th ch c aVL v V5, V6 t cao
ln mt khong lin sn.
V1 , V2: dng rS c mc, i khi l dng QS: ta gi y l hnh nh gin tip.
V3 , V4: dng trung gian (RS).
QRS chuyn o ngoi bin
Ty thuc nhiu vo t th tim:
i a s cc ca, ta c tim nm vi gc < +300 v hnh nh trc tip D1, aVL, hnh
nh gin tip D 3, aVF, dng trung gian D2.
mt s t cc ca khc (11%), ta c t th tim bnh thng vi gc t +300 n 600 v
hnh nh trc tip D1, D2, aVL v nhiu khi c D3, aVF na. Cng c khi D3, aVF c dng
trung gian.
Cn aVR th lun lun c hnh nh gin tip.
on STT
C nhng bin i th pht: cc chuyn o c hnh nh trc tip th STT m, cc
chuyn o c hnh nh gin tip th STT dng.
P a g e | 76
Blc nhnh tri khng hon ton

C cc triu chng sau:
QRS gin t hn: 0,09 n 0,11s.
cc chuyn o c hnh nh trc tip: R c mc nh, c th c Q nh hay khng; nhnh
ni in mun t (0,04 0,055s). STT c th dng.
CC CHNG PHI HP
Dy tht tri: ta thy ghp thm vo cc triu chng ca blc nhnh tri: bin QRS v T
u tng r rt.
Bnh mch vnh: ta thy STT hn hp. Khi l nhi mu trc bn, ta c th thy trn
hnh nh blc nhnh tri (khng c Q) nay c xut hin mt sng Q bnh l. Nhng cng c khi
khng thy do sng R gin qu rng che khut i.
Blc nhnh phi hon ton

C mt s ln ca blc nhnh phi khng c km mt bnh tim thc tn no khc, do tin
lng tng i tt, cn mt s khc c km bnh tim th ch yu l bnh mch vnh, bnh c
tng gnh tht tri nh tng huyt p, hp ng mch ch
Ring blc nhnh phi khng hon ton th hay gp trong cc bnh c tng gnh tm trng
tht phi nh thng lin nh v cc bnh hp van hai l, tm ph cp hay mn, bnh Ebstein.
Triu chng quan trng nht cng vn l QRS gin rng 0,11s. Cn hnh dng sng
th nh sau:
QRS chuyn o trc tim
V3R, V1 :
Dng rsR vi R gin rng, trt m hay c mc. i khi l dng QR cng vi R gin
rng nh th.
Nhnh ni in mun qu 0,055s, c khi qu 0,10s.
Hai loi du hiu ny gp li gi l hnh nh trc tip.
V5 , V6: dng QRS vi S gin rng, c mc: hnh nh gin tip.
V2 , V3, V4: dng trung gian gia hai hnh nh trn.
P a g e | 77
QRS chuyn o ngoi bin

Thng c hnh nh rt khc nhau v phc tp ty tng ca do t th tim khc nhau hay do
dy tht phi hp. Ch ring c chuyn o aVR l lun gi c mt hnh thi gn nh thng
nht tt c cc ca: hnh thi l hnh nh trc tip t trn.
Cn i vi cc chuyn o khc th hnh nh thng gp nht nh sau:
D1, aVL c hnh nh gin tip.
D3, aVF, D2 c hnh nh trc tip hay dng rR. Khi D1 bin tuyt i ca R ln hn
S th ngi ta gi y l blc Wilson. Blc Wilson thng c tin lng tt, chng no QRS
khng gin qu 0,14s v sng S khng rng qu 0,08s.
on STT
C nhng bin i th pht: STT lun tri chiu vi sng cui cng (gin rng, trt m)
ca QRS. Th d: V1 , aVR (c R gin rng) th ST chnh xung, T m; V6 , D1 (c S
gin rng) th ST chnh ln, T dng.
Blc nhnh phi khng hon ton

Ni chung, cng ging nh blc nhnh phi hon ton, ngha l V3R, V1 , aVR c dng rsR
vi R rng, v nhnh ni in mun qu 0,03s; V5 , V6 c S rng. Ch khc blc nhnh phi
hon ton ch QRS gin rng t hn, t 0,08s n 0,10s.
C ngi gi blc nhnh phi khng hon ton l blc nhnh phi cp 2, v blc nhnh phi
hon ton l blc nhnh phi cp 3. Cn khi QRS khng gin rng t no (0,07s) m ch c
nhng ci mc V3R, V1 , V2 , aVR th gi l blc nhnh phi cp 1 hay c ngi cn gi bng
mt danh t rt chung chng l ri lon dn truyn trong tht.
P a g e | 78
Cc chng phi hp
Thng l dy tht phi, dy tht tri hay thiu nng vnh. Chng lm hnh dng blc nhnh
phi khc i v rt phc tp, ng thi cng lm tin lng nng ln rt r rt.
Dy tht phi
Phi hp vo blc nhnh phi thng lm:
V1: sng R (ca dng rsR) cao ln c th vt qu 15mm, thm ch lm trit tiu c
sng S v bin sang dng rR. V hu qu l STT m rt su.
D1, V5 , V6 : sng S su v nhn hn.
Trc phi rt mnh, c th ti +1700: trng hp ny c gi l blc him (v t gp), n
c th gp trong tim bm sinh hay thp tim, i khi tm ph mn.
Dy tht tri
Phi hp ny thng lm:
D1, V5 , V6 : sng R cao ln, ring RV5 c th qu 25mm vi S ngn li.
V3R, V1, V2 : sng S (ca dng rsR) su xung r rt. C khi V1, V2, S su lm trit
tiu c sng R v bin sang dng rS vi S gin rng: y thng l trng hp blc ng hng
ngc (xem di) v nguyn nhn l tim xoay ngc kim ng h qu mnh. Do , phi ghi
thm V3R, V4R hay V1 cao ln 1 hay 2 khong lin sn mi chp c dng in hnh rsR
v chn on chc chn c blc nhnh phi.
Trc in tim lch sang tri. Nhng cng c khi trc tri qu mnh n ni QRS c 3
chuyn o mu u m, vi S su, rng: Katz gi y l blc ng hng ngc, n thng gp
trong bnh mch vnh c dy tht tri, thng nh tht, nhng cng c ngi gp c tim bm
sinh c dy tht phi qu mnh.
Bnh mch vnh
Phi hp vi blc nhnh phi thng gy ra STT hn hp (Hnh 42): ST ko di ra, thng
un hay cong vm, T i xng. c QRS cng c th hn hp (xem mc Nhi mu c tim).
Cc hnh thi blc khc

Blc nhnh tm thi: l nhng phc b blc nhnh i tng t hay xen k vi nhng phc
b bnh thng.
Blc hai nhnh lun phin, cn gi l blc u a, lun phin lc th blc nhnh phi, lc
th blc nhnh tri.
Blc hai nhnh ng thi: a s gy ra hnh nh blc nh tht hon ton.
P a g e | 79
HI CHNG WOLF PARKINSON WHITE (W-P-W)

Hi chng W-P-W, l mt hi chng in tm bao gm mt phc b QRS gin
rng + khong PQ ngn li.
Hi chng ny c th gp ngi bnh thng mt s bnh nhim khun, d ng, thoi
ha hay cc bnh mch vnh, thp tim, tim bm sinh, nht l bnh Ebstein.
c bit W-P-W rt hay phi hp vi chng nhp nhanh kch pht trn tht. a s tc gi
cho rng hi chng ny sinh ra do mt ci cu gii phu hc ni lin nh vi tht gi l cu Kent.
Cu ny truyn tt xung ng t nh xung (tin xung ng), kh cc sm mt phn ca tht,
lm rt ngn thi gian PQ v sinh ra sng delta (, ). Sau , xung ng chnh thng theo
ng bnh thng qua b His mi xung ti ni v kh cc phn tht cn li. Cu Kent l bm
sinh, nhng c th ch hot ng khi c tc ng thm ca mt tn thng hu sinh.
Triu chng (Hnh 52)
Khong PQ ngn li (< 0,12s).
Xut hin sng , n l mt on trt m phn u phc b QRS.
QRS (bao gm c sng ) c thi gian qu di (0,10s 0,12s hay hn na) b tr cho PQ
b rt ngn; do khong PJ di bnh thng (< 0,26s).
on STT bin i th pht, ngha l tri chiu vi sng .
Ngi ta chia hi chng W-P-W ra hai kiu:
Kiu A: sng dng tt c cc chuyn o trc tim.
Kiu B: sng m cc chuyn o trc tim phi v dng cc chuyn o trc tim
tri.
P a g e | 80
BNH MCH VNH

in tm c gi tr rt ln trong chn on cc bnh mch vnh.
Mt ng mch vnh b x ha c nng hp hay tc li s lm cho vng c tim m n ph
trch b km nui dng; ngi ta gi l thiu nng vnh (thiu mu thiu oxy tn
thng hoc cht hn hoi t).
CC DU HIU
Cc du hiu thy c trn in tm thng gm c ba loi, quy c gi bng cc danh
t sau y:
1. Thiu mu (Ischemia)
T m, nhn, i xng, nu l thiu mu mt vng di thng tm mc.
T dng, cao, nhn, i xng nu l thiu mu di ni tm mc.
2. Tn thng (Injury)
ST chnh ln v cong nh ci vm, gp c sng T vo n, gi l sng mt pha: y l tn
thng di thng tm mc thng xy ra giai on cp ca nhi mu di thng tm mc.
ST chnh xung, thng un: y l tn thng di ni tm mc, thng c trong chng
nhi mu di ni tm mc hay chng au tht ngc.
3. Hoi t (necrosis)
Xut hin mt sng Q su, rng, c mc, trt m nu l nhi mu di thng tm mc.
Nhng cc du hiu ni trn cn c nhng tiu chun ni ln mc n u th l bnh l.
CC TIU CHUN CHN ON BNH MCH VNH

C th da ch yu vo Quy tc Minnesota l bn tiu chun c WHO p dng.
Di y l tm tc my im chnh ca quy tc :
Sng Q
D1, D2, aVL, V1 n V6 (nhi mu trc v bn):
Q rng 0,04s
Q su = R
Dng QS t V1 n V4 (V5, V6)
Q rng 0,03 0,04s
Dng QS t V1 n V3
Q su 1/5 R
Dng QS t V1 n V2
: Bnh l r rng
: Bnh l r rng
: Bnh l r rng
: Nghi bnh l
: Nghi bnh l
: C th bnh l
: C th bnh l
80 BNH MCH VNH | typewriter: Nguyn nh Tun Cao hc Ni 12
P a g e | 81
D3, aVF (nhi mu sau di):
Q rng 0,05s
Q rng 0,04 0,05s
Q su 5mm
: Bnh l r rng
: Nghi bnh l
: Nghi bnh l
on ST
tt c cc chuyn o, tr aVR th ngc li:
Chnh xung:
1mm
0,5 0,9mm
0,5mm
: Bnh l r rng
: Nghi bnh l
: C th bnh l
Chnh ln bnh l:
2mm V1 n V4.
1mm cc chuyn o khc.
Sng T
tt c cc chuyn o tr D3, V1 .
m su t 1mm tr i
: Bnh l
Dt
: C th bnh l
NHI MU C TIM
Khi thiu nng vnh xy ra t ngt, nhiu khi l do mt stress (cm xc, c gng, b
lnh) tc ng ln c th th c th pht sinh nhi mu c tim.
Thng thng, vng c tim b nhi mu c mt vng ng gia b hoi t, ri n mt
vng tn thng bao quanh n v ngoi cng l mt vng thiu mu bao quanh vng tn thng
(Hnh 53).
Nh th, in tm s thu c c 3 loi du hiu , nhng khng phi cng mt lc m
thng bin chuyn qua ba giai on chnh di y (Hnh 54):
P a g e | 82
CC GIAI ON CA NHI MU
Giai on 1 (cp): trong 1, 2 ngy u.
Sng cong vm: c th xut hin Q bnh l, QT di ra.
Giai on 2 (bn cp): t vi ngy n vi tun l giai on hay gp nht: ST chnh ln
thp hn, T m su, nhn, i xng (gi l sng vnh Pardee). ng thi thy Q bnh l r rt
v QT di ra.
P a g e | 83
Trong hai giai on ny, thng hay c xut hin c cc loi ri lon nhp tim hay blc nh
tht, nht l loi nhi mu vch (lin tht).
Giai on 3 (mn tnh): t vi thng n vi nm: ST ng in, T c th dng hay
vn m, cn Q bnh l th thng hay tn ti vnh vin.
CC LOI NHI MU
Cc du hiu ni trn khng phi l xut hin tt c cc chuyn o nh nhau m ch thy
r chuyn o no c in cc t trng (trc tip) ln trn vng c tim b nhi mu: v th
ngi ta gi cc du hiu l hnh nh trc tip. Tri li, chuyn o no c in cc t
vng xuyn tm i ca vng b nhi mu s thu c nhng du hiu tri ngc, soi gng
ca cc du hiu trn: ta gi l hnh nh gin tip (Hnh 53, 54).
Nhi mu c th xut hin nhiu vng rng hp khc nhau ca tht tri (tht phi rt t khi
b). Ty theo vng b tn thng, ngi ta t 3 loi nhi mu chnh v hay gp nht (di thng
tm mc) vi cc du hiu giai on 2 (bn cp) sau y:
1. Nhi mu trc vch (antero septal infarction)
Tc l b thnh trc tht tri v phn trc vch lin tht.
Ta c (Hnh 55):
Hnh nh trc tip (sng QS, ST chnh ln, T m) V2 , V3 , V4.
P a g e | 84
i khi T thp hay m V5 , V6, aVL, D1 (T1>T3) do vng thiu mu n lan sang thnh
bn (tri) ca tht tri.
2. Nhi mu trc bn (Lateral wall infarction)
B phn ngoi thnh trc v thnh bn ca tht tri.
Ta c:
Hnh nh trc tip (Q su v rng, ST chnh ln, T m su) V5 , V6 , D1, aVL.
Hnh nh gin tip (ST chnh xung, T dng rt cao) D3 i khi aVF.
3. Nhi mu sau di (Posterior infarction)
B thnh sau v di ca tht tri.
Ta c (Hnh 56):
Hnh nh trc tip (Q su, rng, ST chnh ln, T m su) D3, aVF, c khi c D2.
Hnh nh gin tip (T dng cao, c th nhn, i xng, ST c th chnh xung) V1, V2,
V3 , V4.
4. Nhi mu di ni tm mc (tht tri) (Subendocardial infarction):
Ch yu l thnh trc bn: ST chnh xung, i khi T bin dng V5, V6 , D1, aVL.
i khi l thnh sau di: ST chnh xung D3, D2, aVF.
P a g e | 85
NHI MU C THM BLC NHNH

C nhiu trng hp, thiu nng vnh gy ra nhi mu cng ng thi lm mt nhnh b
His b km nui dng sinh ra blc nhnh, cc du hiu ca blc nhnh s phi hp vi cc du
hiu c bn ca nhi mu. Th d:
Blc nhnh tri + nhi mu trc bn: xem mc blc nhnh tri.
Blc nhnh phi + nhi mu sau di: Q su D3 , D2 + dng rSR V1 , V2.
Blc nhnh phi + nhi mu trc vch: V1, V2 , V3 (V4) c dng QR vi nhnh ni in
mun.
Trong tt c cc trng hp trn u c th c STT hn hp.
CN AU THT NGC
Khi thiu nng vnh ko di mn tnh, ta c bn bnh n ca cn nghn tim (angina
pectoris): in tm s cho ta hnh nh thiu mu tn thng di ni tm mc v ch yu
thnh bn tht tri (ngha l V5, V6) nh sau (Hnh 57):
P a g e | 86
Ngoi cn au
T dt, hay m, hay c mc. C khi li dng, nhn, i xng. c khi ch c sng T ca
mt ngoi tm thu hay ca phc b lin sau ngoi tm thu mi c dng thiu mu nh vy.
ST chnh xung, thng un, i ngang hay i dc xung.
Blc nh tht hay blc nhnh.
Ngoi tm thu tht hay cc ri lon nhp khc.
Cc hnh nh trn c th xut hin rt sm trn in tm bo hiu c thiu nng vnh
nhng ngi m lm sng khng h c cn au tht ngc, nht l ngi 55 60 tui.
Trong cn au
Cc du hiu trn c th:
Vn gi nguyn nh th.
R nt, su sc hoc y hn, hoc bin sang hnh thi khc (th d: T m bin thnh T
dng, nhn, i xng).
Xut hin ra nu nh cha c mt trc cn au. V theo nhiu thng k, c ti 10 40%
cc ca c cn nghn tim chc chn trn lm sng m in tm li bnh thng. Trong s ny,
c nhng ca in tm gi nguyn bnh thng c trong cn au.
Thng thng, cc du hiu xut hin ra trong cn au s bin i trong 5 -15 pht sau khi
cn au chm dt.
HI CHNG TRUNG GIAN

Hi chng trung gian l mt loi bnh mch vnh nm trung gian gia nhi mu v cn
nghn tim
c im ca n l c nhng du hiu lm sng ging nh nhi mu nhng li khng c
du hoi t trn in tm (Q bnh l) v cc xt nghim khc (transaminase ) m ch c cc
triu chng sau:
Hnh nh thiu mu tn thng khu tr mt vi chuyn o no v bin i nhanh
chng (th d t hnh thi di ni tm mc sang hnh thi di thng tm mc).
R v S tng hay gim bin .
QT di ra.
Ri lon nhp tim, blc nh tht, blc nhnh.
P a g e | 87
C khi c Q bnh l nhng bin i rt nhanh v th, n khng phi l do hoi t, m do t
lit in hc ca vng c tim : l hin tng nc ao (Knock out) c tim.
NGHIM PHP GNG SC

Khi ta nghi mt thiu nng vnh mn tnh nhng trn lm sng, cn au khng in hnh m
in tm li bnh thng hay gn bnh thng th nn lm mt nghim php gng sc
(exercise test) xc minh thm.
Trong nhiu trng hp, nu ng tht c thiu nng vnh th in tm ghi trong v sau
gng sc s cho thy cc du hiu thiu mu.
Lm nghim php gng sc: chng ti thng cho bnh nhn p mt xe p c lc k vi
cng gng sc t 300 900kpm/min (kilopoud mt/pht) trong 3-6 pht ty ngi. Trong
thi gian , chng ti ghi trn in tm (V4 , V5, V6). C na pht hay mt pht mt ln v
sau khi gng sc tip tc ghi mt pht mt ln cho ti pht th 6 hoc pht th 15. Cng c th
dng nghim php Master: leo ln v leo xung hai bc thang, mi bc cao 22,5cm t 20 n 25
ln trogn khong thi gian 90 giy.
Cn ch l trong khi lm nghim php gng sc, nu bnh nhn thy au tc trong ngc,
hay mch nhanh qu 120/ph ngay t pht u hay xut hin du hiu in tm nng n th
phi ngng ngay nghim php v bnh nhn ngh ngi.
Du ST chnh xung nhng i dc ln thng ch l do nhp nhanh khi gng sc khng c
gi tr chn on thiu nng vnh.
Mt nghim php gng sc m tnh khng th loi tr hon ton kh nng mt bnh mch
vnh kn o.
CC RI LON NHP TIM

in tm c gi tr rt ln trong chn on cc ri lon nhp tim.
Chng ta u bit bt c im no, no trong h thn kinh t ng ca tim (Hnh 5) cng
u c tnh t ng pht ra xung ng ch huy tim bp. V th, m bo cho tim p iu ha
th phi c mt no gi vai tr ch huy thng nht v kim ch c xung ng ca cc
khc: ta gi l ch nhp hay to nhp (Pacemaker).
Bnh thng, nt xoang gi vai tr ch nhp v n pht xung nhanh nht: 70/pht. Cc
khc, cng thp cng pht xung chm hn: nt nh tht 50/pht; thn b His 40/pht; mng
Purkinje 30/pht
Nhp tim c th b ri lon do ri lon v tnh chu kch thch hay tnh dn truyn ca c tim.
Cc ri lon c th n c hay phi hp rt phc tp, kh chn on. Trong hu ht cas, cha
kha chn on cc ca kh l tm sng P.
P a g e | 88
Phng php tm sng P
Thng qua 5 giai on:
1. Chn trn bn in tm ly hai ln sng nghi l hai sng P i tip nhau lm

chun, th d P1 v P2 trong hnh 58a.
2. t mt bng giy di di mp ng ng in v ly bt vch ln hai vch ngn
ng di hai sng chun (hai vch ngn di P1 v P2 trong hnh 58a) gi l cc vch P: nh
vy ta c mt khong PP m ta nghi l khong PP c bn ca bn in tm .
3. a bng giy v pha tay tri mt khong di bng mt PP c bn sao cho vch P th hai
n nm ng di P1 ri vch thm mt vch P th ba ng di P2 (Hnh 58b).
4. Li a bng giy mt ln na sao cho vch P th ba n nm ng di P1 v vch thm
mt vch P th t ng di P2 (Hnh 58c).
C tip tc lm 5, 6 ln nh th na, ta s c mt bng giy c 8, 9 vch P gi l bng
vch nhp trong ta nhp khong PP c bn ln 7, 8 ln.
5. a bng vch nhp tr v v tr ban u v n cc chuyn o khc khng cng ghi
ng thi vi chuyn o v nhn xt.
a) Nu cc sng P ca bn in tm c nhp u th c trn mi vch P ca bng vch
nhp li c mt sng P.
b) Nu P c nhp khng u hay c nhng sng P vng mt hay bin dng th s ty theo
tnh cht bnh l v mi quan h gia P v tht QRS (khong PR) m kt lun l loi ri lon
nhp g.
P a g e | 89
Rt nhiu khi ta tm c v tr ca nhng sng P n nu trong cc phc b QRS hay
trong sng T, hay m qu nhn khng r. Th d: vch P th ba trong hnh 58d pht hin c
mt sng P xoang nm n nu trong khong ST ca mt ngoi tm thu tht.
Mt th d khc c th thy c trong hnh 65.
Nu nh sau cc sng P khng c QRS i km (blc nh tht) th phi tin hnh xc nh
nhp iu ca QRS ring ra bng mt bng vch nhp khc cng ging nh cch tm P ni trn.
Sau cng, ng bao gi qun tnh tn s P v tn s QRS.
Khi P vng mt hay nh qu nhn khng r th phi dng cc chuyn o c bit c P r
hn: V1, V3R, V4R, VOE, chuyn o trong bung tim
NHP XOANG
Nhp xoang (sinus rhythm) l nhp tim do nt xoang lm ch nhp: cng l nhp bnh
thng ca tim.
Chn on nhp xoang da vo 3 du hiu chnh:
1. C sng P ng trc cc phc b QRST, chng t xung ng i bnh thng t nt
xoang qua nh xung tht.
2. Sng P cch QRS mt khong PQ khng thay i v di bnh thng (0,11 0,20s).
3. Sng P dng D1, V5 , V6 v m aVL, tr trng hp tim sang phi.
Nhp xoang bnh thng c tn s 60 -70 ln/pht. Khi nhp xoang:
Nhanh hn 80/pht (c khi ti 170/pht): ta gi l nhp nhanh xoang, thng gp khi
cng giao cm, st, gng sc,
Chm hn 50/pht (c khi ti 30/pht) ta gi l nhp chm xoang, thng gp trong
cng ph v, dng digitalis.
Khng u, ta gi l lon nhp xoang, thng gp tr em (do h hp), lon trng lc
thn kinh thc vt.
c im chung ca cc loi nhp xoang l tn s v nhp iu ca chng b bin i khi
gng sc, cm xc, n mt, h hp, tim atropin,
P a g e | 90
CH NHP LU NG
Ch nhp lu ng (wandering pacemaker) l hin tng di chuyn ca ch nhp
trong vng nt xoang.
Triu chng ch yu l trn cng mt chuyn o ta thy P bin i hnh dng, t dng
sang hai pha, c mc ri m hay ngc li, trong khi PQ v tn s tim cng hi bin i theo.
Cn QRST th khng bin i g c (Hnh 59).
Chng ny hay gp trong cng ph v, thp tim, ung digitan, gy m.
BLC XOANG NH
Blc xoang nh l hin tng xung ng ca nt xoang b tc li khng truyn t c ra
c nh.
Khi hin tng ch thnh thong xy ra mt vi nht bp th ch ta c mt
khong ngng tim: trn c s mt in tm nhp xoang, bng mt hn i mt hay hai nht bp
vi tt c cc sng PQRST ca n. Nu ta o thi gian ca khong ngng tim, ta s thy n gp
hai hay ba ln mt khong PP c s (Hnh 60).
Khi hin tng xy ra lin tc, thng xuyn th ta c nhp nt (xem di).
P a g e | 91
NHP B NI, THOT B NI, PHN LY NH THT

Khi nt xoang pht xung ng qu chm (b c ch) th nt nh tht ng lin di n phi
ng ra thay th n lm ch nhp. Nu lc , b ni nh tht:
Ch huy c c tht (ch huy xui dng) th ngi ta quy c gi l: tim c nhp b ni.
Trng hp ny cn c th xy ra khi c blc xoang nh (xem trn).
Ch ch huy c tht cn nh th vn do nt xoang ch huy: ngi ta gi y l phn ly nh
tht (atrio-ventricular dissociation).
Nu phn ly nh tht ch xy ra vi nht bp th ngi ta gi l thot b ni.
Trong tt c cc trng hp trn, cch tm sng P ni trn rt c hiu lc chn on.
NHP NT
Gm cc triu chng sau (Hnh 60):
Tn s tim chm: 40 50/pht.
Sng P m, ch yu D2, D3, aVF, dng aVR, dt D1.
Khong PQ bin i, c th l:
PQ ngn li < 0,11s.
PQ chng ln QRS nh mt ci mc, nhng hu ht cc ca khng thy P u c v b QRS
t i.
P ng sau QRS, trn on ST, cch khi im ca QRS t 0,10 0,20s.
Nhp b ni thng gp trong cc bnh nhim khun (thp khp, bch hu,) bnh tim
thoi ha, ri lon thn kinh thc vt
PHN LY NH THT
Gm cc triu chng sau (Hnh 61):
P a g e | 92
P v QRS khng c lin h g vi nhau: P lc th ng trc, lc th ng sau, lc th
chng ln QRS, nhng cc khong PP vn bng nhau. C cc khong RR cng th.
Tn s QRS cao hn tn s P.
C khi c cc nht bt c tht: ta thy mt nht bp sm ngha l khong RR t nht
bp trc n ngn hn cc khong RR khc; hn na, n c sng P ng trc QRS vi khong
PQ bnh thng hay hi di ra: ngi ta gi y l phn ly nh tht c giao thoa
Phn ly nh tht hay gp trong thiu nng vnh, nhim c digitan, thp khp cp, c khi
cc bnh nhim khun, hay cng thn kinh thc vt (xoang cnh).
THOT B NI
C cc triu chng sau:
Trn c s mt nhp xoang c nhng on ngh di gy ra bi nhp chm hay blc xoang
nh, ngoi tm thu tht, chu k Wenkeback, ta thy xut hin ch ngh di (Hnh 62).
Mt nht bp mun ngha l khong RR t nht bp trc n ti n di hn cc khong RR

khc. Hnh dng tht QRST ca nht bp ny, v c bn, khng c g khc vi cc nht bp
khc trn chuyn o .
Tht ny thng c km mt sng P, n c th chng ln bt c ch no ca tht (QRS,
ST hay T) hay i trc tht mt khong PQ ngn hn 0,12s. Tm li, sng P ny v tht
khng c lin h g vi nhau tuy ng cnh nhau.
Thot b ni thng gp cng ph v, c bit l khi n nhn cu v mt s bnh tim bm
sinh.
P a g e | 93
NGOI TM THU
Theo thuyt c in, ngoi tm thu l mt nht bp ngoi lai gy ra bi mt xung ng pht
ra t xut v ln hn bnh thng t mt no ca c tim b kch thch.
Trong thc nghim hay khi m lng ngc, ngi ta c th gy ra ngoi tm thu mt cch d
dng bng cch chm mt vt nhn vo bt k mt im no ca c tim.
Nh vy, trn in tm , ta thy ngoi tm thu l nhng nht bp l kiu xen k y
vo dng cc nht bp ging nhau ca nhp c s.
Khi xung ng xut pht:
T tm tht, th ta gi l ngoi tm thu tht rt hay gp trong lm sng.
T tm nh, th gi l ngoi tm thu nh hay ngoi tm thu trn tht t gp hn.
phn bit vi cc sng ca cc nht bp c s, ngi ta nh thm du phy vo cc
sng ca ngoi tm thu, th d P, R, QRS
NGOI TM THU THT

Ngoi tm thu tht l mt nht bp c nhng tnh cht sau (Hnh 63):
Tht QRS gin rng ( 0,13s), trt m, c mc, vi STT tri chiu, ngha l
chuyn o no QRS dng th ST chnh xung v T m v ngc li: l mt hnh dng
mo m trng khc hn cc nht bp c s nn rt d nhn bit. c bit l bin ca ngoi
tm thu thng cao hn hn phc b c bn do hnh thi kh cc ca ngoi tm thu bt u t
mt bn tm tht (b kch ng) lm tng s lng cc t bo m tnh ( kh cc) i lp vi
cc t bo dng tnh (cn cc) pha tm tht bn kia, do m sn sinh ra mt sc in ng
ln hn. Nhng iu khng c ngha l nht bp s mnh hn. Tri li, n cn yu hn v kh
cc bt thng khng ng u, hn na li qu sm, cha thi gian y tm tht.
P a g e | 94
Hnh dng c th ging hnh blc nhnh phi (ngoi tm thu tht tri, n c tin lng
nng hn) hay ging blc nhnh tri (ngoi tm thu tht phi) hay bin dng linh tinh trn cng
mt chuyn o (ngoi tm thu nhiu dng vi tin lng nng hn na).
Cng c khi n lai na trc ging ngoi tm thu (gin rng, bin dng), na sau ging
QRS bnh thng (thanh, mnh). Ngi ta gi l nht bp hn hp vi do mt xung ng
xoang v mt xung ng t ngoi lai cng ng thi tin vo kh cc tht sinh ra. V th, nht
bp hn hp bao gi cng sm rt t (RR RR) (xem di).
Tht phi sm, ngha l nu ta o khong cch RR (t nht bp i lin trc ngoi
tm thu n ngoi tm thu), ta s thy n ngn hn mt khong RR ca nhp c s (RR < RR):
y l mt tnh cht bt buc phi c, nu khng c th khng gi l ngoi tm thu.
Khong RR c gi l khong ghp ca ngoi tm thu. Trong a s trng hp trn
cng mt bn in tm cc khong ghp ca tt c cc ngoi tm thu u bng nhau: ngi ta
gi l hin tng khong ghp khng i. Trng hp khong ghp thay i v ngoi tm thu
nhiu dng th gi l ngoi tm thu nhiu , n c tin lng rt xu.
a s trng hp, ta c ngh b sau ngoi tm thu, ngha l nu ta o khong RR (t
ngoi tm thu n nht bp i lin sau n), ta sx thy n di hn mt khong RR c s, mc
b cho s ngn li ca khong ghp RR. Tm li, nu o thng khong RRR, ta s thy n di
ng gp i mt khong RR c s.
Ring nhng ca nhp chm, i khi ta thy khng c ngh b m khong RRR cng ch
di bng mt khong RR c s: y ngoi tm thu coi nh ch lt vo gia hai nht bp c s
bnh thng ch khng th tiu mt nht bp c s no. Trng hp ny c gi l ngoi tm
thu xen k.
Trng hp l ngoi tm thu ngh b, ta c th thy i km vo tht ngoi tm thu, c
mt sng P n c th ri vo bt k trc, trong hay sau tht m khng c lin h g vi n.
Hn na, ta thy khong cch t sng P ti sng P trc n u bng mt khong PP c
s, v nu P ng trc QRS th khong PQ bao gi cng nh hn 0,12s (Hnh 58)
NGOI TM THU TRN THT

Ngoi tm thu trn tht l mt nht bp c nhng tnh cht sau (Hnh 64):
Tht QRST rt ging cc tht ca nhp c s; v th, nhiu ngi khng ch v
khng pht hin ra ngoi tm thu nh.
Nhng cng c khi, QRS li gin rng vi STT tri chiu, ging nh ngoi tm thu tht,
y l loi ngoi tm thu trn tht c dn truyn lch hng. Cng c khi tht QRST bin
hn, ch cn li mi sng P: ta gi l ngoi tm thu trn tht b blc. Hai loi ny l do ngoi
P a g e | 95
tm thu xut hin qu sm nn vp phi tnh trng tr tng i ca truyn tht do nht bp
trc sinh ra.
Mi tht c km mt sng P sm (ngha l PP < PP), nhiu khi sm n ni chng

ln c T ca nht bp trc nh mt ci mc ca n.
Sng P ny thng l bin dng (c mc, dt, m) vi hnh dng khc vi P c s.
Sng P ny c th ng trc QRST vi PR ngn li hay di ra, hoc ng sau QRST
hoc chui mt ht vo trong QRST (ngoi tm thu nt gia).
Khong cch t ngoi tm thu n nht bp sau n di ng bng mt khong RR c s:
ngi ta gi l ngoi tm thu dch nhp; nhng phn ln cc ca, RR hi di hn RR, ngha
l trung gian gia dch nhp v ngh b.
Nh vy, ta thy r chnh s vng mt ca khong ngh b l c gi tr chn on nht v n
chng minh l c s tham gia ca nh.
Nguyn do: ngoi tm thu (nht l ngoi tm thu tht) l mt chng rt ph bin trong lm
sng v c th do nguyn nhn thc tn hay c nng.
Ngoi tm thu thc tn thng i km vi nhi mu c tim hoc mt bnh c tim hay van
tim. N khng mt i v c khi tng nhiu ln khi gng sc. N c th: nhiu , c bin thp,
c QRS gin qu 0,16s, c nhnh ni in chm nhiu, c Q rng, c sng mt pha STT hn
hp
Ngoi tm thu c nng phn ln l do ri lon thn kinh thc vt (tim d b kch ng) hay
do mt phn x t b tiu ha, sinh dc, tit niu, ng mt. Qua nghin cu trn 150 ca, chng
ti thy ngoi tm thu c nng bao gi cng gim i hay mt hn khi lm gng sc.
P a g e | 96
Ngoi ra, ngoi tm thu cn c th do: thiu oxy, dng digitalis, quinidin, procainamid,
thuc gy m,
NHP NHANH KCH PHT

Nhp nhanh kch pht l mt loi nhp nhanh pht ra t ngt vi tn s rt cao (trn
140/pht).
Theo thuyt c in, tn s cao ny l do nhng xung ng t mt lc ch no ca c
tim b kch thch pht ra v cp c quyn ch huy tim ca nt xoang (v pht xung nhanh hn
hn nt xoang). Do , c v sinh bnh hc ln v du hiu trn in tm , nhp nhanh kch
pht chnh l mt chui nhng ngoi tm thu lin tip ko di.
Khi xung ng xut pht:
T tm tht, ta gi l nhp nhanh tht. Trng hp ny nh vn p ring theo s ch huy
ca nt xoang.
T cc vng trn tm tht (nh, nt nh tht) th ta gi l nhp nhanh kch pht trn tht:
y, c nh ln tht u phi p theo s ch huy ca kch pht.
NHP NHANH KCH PHT TRN THT

a s l n c (Bnh Bouveret) ngha l khng km mt tn thng tim no khc. Do ,
c tin lng tt. Ch trong 20 30% cc ca mi c km mt bnh tim: thp tim c vim van 2
l, thiu nng vnh, cng gip. Cng c khi do nhim c, ri lon thn kinh, ri lon tiu ha,
mt nhc,
Triu chng (Hnh 64):
Tn s tim rt nhanh, t 140 n 220/pht v rt u.
Tht QRST c hnh dng bnh thng, nhng cng c khi ST chnh xung, T m ngay
trong cn hay sau cn v mt i vi ngy sau cn.
i khi ta thy QRS gin rng (thng ging ku blc nhnh phi): y l loi nhp nhanh
trn tht c dn truyn lch hng rt kh phn bit vi nhp nhanh tht (xem mc sau).
Sng P rt kh thy v nm ln vo tht . Mt vi trng hp thy c th P c dng
khc vi P ngoi cn. C PQ cng vy.
Cn nhp nhanh bt u rt t ngt.
Cn kt thc cng t ngt v thng tip vo c mt on ngng tim my giy ng
h trc khi tr v nhp xoang.
P a g e | 97
n nhn cu hay xoang cnh: nhp tim hoc t ngt tr v nhp xoang nhanh (90
120/pht) hoc khng bin i t no, rt t khi c hnh thi trung gian.
in tm ngoi cn: QRS ging trong cn, i khi c ngoi tm thu trn tht vi
sng P ging P trong cn. Cn loi nhp nhanh c dn truyn lch hng th sau cn QRS thu
hp li nh bnh thng. Nu khng thu hp th l c blc nhnh tht km vo.
Tin lng v iu tr
Nhp nhanh kch pht trn tht l mt cp cu ni khoa v nu khng iu tr s dn n bin
chng suy tim, ngt. Ring tr cn b, nhp thng rt nhanh (300/pht), d cht nu khng
iu tr sm bng digitan liu cao.
Trc ht, bo bnh nhn t ngt thay i t th, hoc th tht mnh, hoc nut mt ngm
nc nng hay lnh. Nu khng khi th n nhn cu tht mnh trong 1 5 pht. Nu cng
khng khi, nn dng sc in (150 200W/s) hay digitan tim tnh mch chm (tr cn b:
Lanatoside 0,02mg/kg). Ngoi ra, cn c th dng propranolol, phenazolin, acetylcholin,
NHP NHANH THT

t gp hn nhp nhanh trn tht nhng li hay gn b hn vi mt bnh tim: nhi mu c
tim, hi chng Adams Stokes, suy tim, v l bin chng quan trng ca ng c digitan. Ngoi
ra cn xy ra khi gy m, dng adrenalin, quinidin, in git; rt t khi i n c.
Triu chng (Hnh 65)
Tn s tim khong 170/pht v c th bin i ln xung cht t, khc vi nhp nhanh trn
tht.
P a g e | 98
QRS gin rng, trt m, c mc, mi phc b c th c mt vi chi tit khc nhau, ST v
T tri chiu vi QRS.
C khi c nhng phc b hn hp (xem mc Ngoi tm thu tht) hay nht bt c tht
(xem mc phn ly nh tht).
P khng thy r hu ht cc ca. Ch mt s t ca, mi thy c P; trng hp
ny ta thy P c hnh dng bnh thng nhng tch khi QRS v p theo tn s ring
khong 80/pht: y l du hiu chc chn nht ca nhp nhanh trn tht nn ta phi c
ht sc tm n, nht l cc chuyn o c P r nht (V 1, V 3R, V 4R, chuyn o thc
qun) bng phng php tm sng P (xem mc ny).
Cn thng bt u bng mt s ngoi tm thu tht.
Cn kt thc khng c on ngng tim nh nhp nhanh kch pht trn tht. Tri li, n c
chm dn i hoc chuyn sang hnh thc tng lot ngoi tm thu.
C nhng nht bt c tht hay nht hn hp chn on chc chn.
n nhn cu khng c tc dng ln cn nhp nhanh tht.
in tm trc hay sau cn: QRST c th bnh thng hay c blc nhnh, nhng bao
gi cng khc hn lc trong cn. Ngoi ra, nu n c nhng ngoi tm thu tht c hnh dng
ging nh cc phc b tht trong cn hay c blc nh tht hon ton th chn on chc chn l
nhp nhanh tht.
Chn on phn bit
Bao gi cng phi lm chn on phn bit vi nhp nhanh trn tht dn truyn lch hng
bng cch tm ra sng P vi quy lut ca n (Hnh 65). Nu khng thy P th phi tm cc du
hiu khc (xem trn) nht l n nhn cu, nghe tim hay ghi tm thanh tm ting dn vang
(cannon beats), ghi tnh mch c tm tn s sng a. Cc chng , nu khng phn bit
c th nn iu tr bng sc in, propranolol hoc procainamide, v chng c tc
dng trn c 2 loi nhp nhanh; khng dng digitan v n chng ch nh trong nhp
nhanh tht.
Tin lng v iu tr
Nhp nhanh tht nu ko di, thng c tin lng xu, nht l khi xut hin mt ca c
bnh tim nng.
Khi ko di, n d chuyn sang rung tht hay ngng tim t ngt. V th, phi cp cu khn
trng bng sc in (150 200W/s), hay procainamide (0,5 1 gam dung dch 100mg/1ml
tim tnh mch chm 1ml/pht).
Ngoi ra, c th dng propranolol, phenazolin, lidocain, morphin.
P a g e | 99
Chng ch nh digitan trong nhp nhanh tht.
RUNG THT
Rung tht l tnh trng tht khng bp na m tng vng hay tng th c tht rung ln v co
bp khc nhau do nhng ngoi v trong tht pht xung ng lon x gy ra. Kt qu l tun
hon b ngng hn, bnh nhn ngt i v s cht sau my pht.
Triu chng (Hnh 66)
Khng cn thy du vt g ca cc phc b PQRST na, m ch thy nhng dao ng ngon

ngoo vi hnh dng, bin , thi gian v tn s khng u, lun lun thay i khong 300
400/pht.
C khi c nhng t ngn dao ng rt cao v u hn, vi tn s khong 250/pht v gi l
cung tht.
Nguyn nhn v tin lng
Rung tht l mt siu cp cu ni khoa, ngha l nu khng khn trng x l trong
khong my pht th bnh nhn s cht khng cu vn c.
Ty theo nguyn nhn, rung tht:
C th khi hn (tin lng tt), nu do in git, cht ui (mi), chn thng, m tim,
thng d tim, gy m, dng quinidin, procainamide
Kh hi phc (tin lng xu) nu l do mt bnh tim c suy tim nng vi tim to nhiu,
cn ngt ca hi chng Adams Stokes, nhi mu c tim, nhp nhanh tht ko di do ng c
digitan
iu tr
Sc in (300 400W/s) kt hp vi xoa bp tim ngoi lng ngc v h hp nhn to vi
oxy di p lc.
P a g e | 100
M lng ngc, xoa bp tim trc tip.
RUNG NH
Rung nh cng ging nh rung tht l tnh trng nh khng bp na m tng th ca
n rung ln do tc ng ca nhng xung ng rt nhanh (khong 400/pht) v rt
khng u.
C|c xung ng ny trc kia (1925) ~ c Lewis chng minh l xut pht t
mt vn ng vng trn xung quanh gc tnh mch ch trn. Nhng gn }y,
Rothberger, ri Prinzmetal (1952) ~ dng nhng phng php nghin cu hin
i chng minh rng chng cng xut pht t cc lc ch trong c nh nh
tron g nhp nhanh kch pht trn tht. C iu tn s ca chng qu| nhanh nn nh
khn g bp theo kp v rung ln.
Cn tht th cng p rt khng u nhng chm hn nh nhiu v thi k tr ca cc ng
dn truyn nh tht (nt Tawara, b His) cn bt li rt nhiu cc xung ng ca nh mun
truyn xung tht (blc nh tht sinh l).
Nguyn nhn
Trong lm sng, chng ta rt hay gp rung nh, th nht l trong hp hai l, ri n thp tim
ni chung, cng gip trng, thiu nng vnh. i khi gp trong vim mng ngoi tim c bit l
hi chng Pick, ng c digitan, bch hu, thng hn
Triu chng (Hnh 67):
P a g e | 101
Sng P v ng ng in u bin mt v c thay th bi nhng sng f l nhng
sng ngon ngoo mo m, to nh, di ngn rt khng u vi tn s khong 400/pht. Hnh nh
ny thng thy r nht V1 , V3R, S5.
Cc khong RR rt khng u: l hnh nh lon nhp hon ton. Trng hp n u
v chm th l c phi hp blc nh tht cp 3. Tn s QRS c th nhanh (100 -160/pht), bnh
thng hay chm. N tng ln khi gng sc v chm i khi n nhn cu.
Hnh dng cc phc b QRST trn cng mt chuyn o c th c nhng chi tit hi khc
nhau; ci ny hi cao hn, c mc, ci hi rng hn, trt m do cc sng f chng ln.
Nhn g cng c khi c mt phc b hay mt lot phc b c hnh dng khc
hn i theo kiu blc nhnh phi (gin rng, c mc) v rt gi ng ngoi tm thu
th t: l{ dng dn truyn lch hng thng xut hin khi tn s tht tng
nhan h ln. Dng ny ch khc ngoi tm thu tht ch khng c khong ghp c
n h, tht bin dng t hn, khng c khong ngh b: }y l{ m t chn o|n
phn bi t rt quan trng v ngoi tm thu th t c chng ch nh tng i ca
digitan cn dn truyn lch hng th khng.
iu tr
Sc in (50 100, c khi ti 350W/s): kt qu thng rt tt.
Propranolol: cng c nhiu ca kt qu tt.
Quinidin: cng c kt qu, nhng s dng phin phc v nguy him hn. Khi nhp nhanh
th nn cho mt t digitan trc, ri hy cho quinidin th kt qu hn.
CUNG NG NH
L tnh trng nh bp rt nhanh v rt u di s ch huy ca nhng xung ng bnh l c
tn s khong 300/pht.
Cn tht th p theo mt tn s chm hn cng do tnh trng blc nh tht sinh l cn bt
li
Nguyn nhn
Ging nh rung nh nhng t gp hn.
Triu chng (Hnh 68)
Sng P v ng ng in u bin mt v c thay th bi mt chui nhng sng P
rt u, ni ui nhau lin tc ging nh hnh rng ca hay sng nc dao ng.
Cc sng P c tn s khong 300/pht, bin ln hn sng P bnh thng, nht l
D2, D3 v aVF.
P a g e | 102
Phc b QRST ni chung khng b bin dng, gin rng nhng v chng cht ln cc sng
P nn trng c v mo m.
Tn s QRS thng bng tn s P v nh th gi l cung ng loi 2/1 (nh bp 2 nht
th tht bp 1 nht).
Cng c khi c cung ng loi 3/1, 4/1, 5/1.
BLC NH THT
L tnh trng tn thng nt nh tht hay b His lm chm tr hay tc nghn hn s dn
truyn xung ng t nh xung tht v do lm bin i khong PQ.
Blc nh tht chia 3 loi:
Blc cp 1: cn gi l blc kn o.
Blc cp 2: cn gi l blc khng hon ton.
Blc cp 3: cn gi l blc hon ton.
C 3 loi ny u c th tm thi hay vnh vin.
P a g e | 103
Nguyn nhn
Blc nh tht hay gp nht cc bnh mch vnh, bnh van tim do thp, tim bm sinh, vim
nhim nh bch hu, thng hn, ng c digitan, quinidin, tng kali mu, chn thng hay khi
u tim, cng ph v,
Blc nh tht cp 1
Ch c mt triu chng c nht l PQ di ra > 0,20s vi tn s tim bnh thng (c khi ti
0,60s, thm ch ng trc c sng T ca nht bp trc; trng hp ny ch khc nhp nt ch
P2 v P3 vn dng v khi gng sc PQ ngn li lm P ri khi T (Hnh 69).
Khong PQ tuy di nhng thng c nh v iu gip ta phn bit blc vi ngoi tm

thu nh b blc, phn ly nh tht ng nhp, chng thng cng c th c PQ di ra nhng ch
vi nht bp thi.
Blc nh tht cp 2
C 2 kiu:
1. Chu k Luciani Wenckeback (Hnh 70)
P a g e | 104
Trn mt on in tm di, ta thy mt chu k gm 3, 4 nht bp lin tip, c nht sau
c PQ di hn nht trc, cho n mt sng P b blc (khng c QRS i theo) kt thc chu k.
sau , PQ li ngn li nh nht bp u tin ri li di dn ra, lp li nh chu k trc.
c bit, cc khong PP vn rt u, cn RR ca cng mt chu k th ngn dn li (do
khong di thm ca mi PR ngn dn i).
2. Blc mt phn (Hnh 71)
C mt hay hai nht bp c P km vi QRS (PQ c th bnh thng hay di ra) th li c
mt sng P i n c khng c km QRS: ta gi n l P b blc hay nhp ngh tht.
Hin tng c th chng c quy lut no nhng thng l: c mt nht bp c P + QRS
li tip mt nht bp ch c P; nh vy c 2P th c mt QRS v gi l blc 2/1.
Khi gng sc, c th t nhin mt blc tr v nhp xoang, sau gng sc blc li tr li
nh c.
Blc cp 2 c th c nhng thot b ni nhng ch ngh, v cng hay c cc tai bin
thn kinh nh blc cp 3.
Blc nh tht cp 3
P a g e | 105
Tn s cc QRS rt chm khong 30 40/pht, u, khng b nh hng bi gng sc,
atropin hay n nhn cu.
Ni chung, QRS c dng bnh thng nhng cng c khi gin rng kiu blc nhnh. Thnh
thong li c vi ngoi tm thu tht.
Sng P khng ng trc v cng khng c lin h g vi QRS: vi phng php tm P ta
c th thy tn s ca n khong 70/pht.
Cng c khi (rt t gp) c mt sng P ri trng trc mt mt QRS vi mt khong PQ
trong gii hn bnh thng v lm cho QRS ny hi sm so vi nhp c s: ta gi l nht bt
c tht.
Blc nh tht cp 3 thng gy ra nhng tai bin thn kinh mnh danh l hi chng Adams
Stokes, khi c hi chng ny trn in tm c th thy:
Hoc l mt hn QRS trn mt on di: l cc cn ngng tim v y, ta gi l
Adams Stokes th lit tim.
Hoc l c cn nhp nhanh tht, hay nng hn na l cn rung tht hay cung ng tht:
y gi l th kch thch tim.
Cch cp cu hai th trn c khc nhau m lm sng th rt kh phn bit v cng mt mch
v nghe tim rt kh (bnh nhn th rng, on oi)

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DIEN TIM Huong Dan PDF

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HNG DN

7 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

in tm l mt ng cong ghi li cc bin thin ca cc in lc do tim pht ra trong

PHNG PHP GHI IN TM

8 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

Nh vy, in tm c th coi nh mt th c honh l thi gian v tung l in

- Vn tc 25mm/s th mi 1mm c gi tr 0,04s

9 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

Sau , t bo dn dn lp li th thng bng ion lc ngh, in th mt ngoi tr li dng

11 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

Tri li, khi in cc A dng tnh tng i th bt s v mt ln sng m, ngha l m

Khi nh ti cc, n pht ra mt dng in ghi ln my bng mt sng m nh gi l sng Ta

13 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

Tm li, kh cc tht bao gm ba ln sng cao, nhn Q, R, S bin thin phc tp nn c

14 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

15 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

Ngi ta khng o thi gian ca T v n rt thay i, ty tng ngi. Hn na, ch khi

CC CHUYN O THNG DNG

18 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

in cc t c tay ch ct d buc, thc ra n phn nh in th vai phi v vai tri

Theo cch mc nh trn, khi in cc tay tri dng tnh tng i th my in tm s

19 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

- C tay tri: ta c chuyn o VL, n nghin cu in th y tht tri. Trc chuyn o

21 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

- V1: khong lin sn 4 bn phi st b xng c.

22 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

ng v mt gii phu hc m ni, V1 v V2 coi nh c in cc thm d t trng ln

23 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

24 CHNG MT | typewriter: Nguyn nh Tun Cao hc Ni 12

CCH PHT HIN CC SAI LM KHI GHI IN TM

2. Vn nt my ghi nhm th t cc chuyn o.

26 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

- C on hi phc (tr v ng in) ko di (Hnh 18) lm cc sng cng hi phc ko

Trng hp cc rung ng nh ln tn v c sut dc bn in tm (Hnh 21) lm n

2. Cc dao ng rt u vi nhp iu rt nhanh, th d vi tn s 50 chu k/s, ngha l 3000

29 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

Theo kinh nghim ca chng ti th dy t khng tt hay t ngm l nguyn nhn ch yu

31 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

TRC IN TIM CCH XC NH TRC IN TIM

32 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

Nh vy, tm O s chia 3 trc thnh 3 na trc dng v 3 na trc m ta ra thnh

34 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

b) Nhn vo phc b QRS ca chuyn o B xem bin ca n l dng hay m. Nu l

TRC IN TIM BNH THNG

35 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

TRC IN TIM BNH L

37 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

3. Tim c th ng thng vi mm tim hng xung di nh hnh 27c: ngi ta gi l n

39 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

40 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

T TH IN HC CA TIM TRONG TRNG HP

PHN TCH HNH DNG CC SNG

42 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

V mi sng hay khong , ngi ta u ng thi phn tch tt c cc chuyn o ghi

43 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

Hnh dng v bin

D m, dng hay hai pha, P cng c th c mc nh hay ch i nh.

46 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

Khong PQ bnh thng

47 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

48 CHNG HAI | typewriter: Nguyn nh Tun Cao hc Ni 12

Nu trc sng R c mt sng m th sng ny gi l sng Q (Hnh 33 c, ).

Trong mt bn in tm , QRS mi chuyn o c th rng hp khc nhau vi phn