HOT NG IN CA TIM

in th hot ng
Khi TB ngh: do s chnh lch nng Na+, K+, Ca++...
+ TB c tim trng thi phn cc: mt ngoi (+), mt trong (-).
+ in th qua mng (in th ngh) = - 90 mV
Khi TB hot ng:
+ Tc nhn kch thch mng TB cc ion vn chuyn qua mng TB thay i in th mt
trong v mt ngoi mng TB ng cong in th hot ng
2. ng cong in th hot ng
Giai on O: kh cc nhanh
+ Na+: di chuyn o t t ngoi TB vo trong TB
+ in th qua mng - 90 mV + 30 mV
+ QRS T ngoi bin
Giai on 1: ti cc nhanh sm
+ Na+: gim i
+ in th qua mng h xung gn mc 0
Giai on 2: tI cc chm (cao nguyn tI cc)
+ Ca++ chm i vo TB, Na+ chm vo TB, K+ i ra TB
+ in th qua mng thay i khng ng k
Giai on 3: ti cc nhanh mun.
+ K+ i ra TB tng ln
+ in th qua mng h nhanh xung mc ban u: - 90 mV

Giai on 4: lp li tnh trng ni mi hng nh

+ ATPaza
1. y Na+ ra TB, bm K+ vo TB
2. y Ca++ ra TB, bm Na+ vo TB
+ in th qua mng n nh mc: - 90 mV

Cc pha hot ng in ca t bo c tim

in th hot ng tng v tr trong tim

H thng dn truyn

Tnh t ng:
Hin tng TB t mnh i vo hot ng kh cc v ti cc t pht xung ng.
+ G 4 TH: Na+ chm t ngoi vo trong TB: kh cc chm tm trng
+ G 4 TH i dc thoi ln ti mc T ngng (-70 mV): t kch thch khi pht kh cc,
ti cc TB
+ y l hin tng sinh l. C TB bit ho ca tim: nt xoang, nt NT, b His, nhnh b His,
mngPurkinje
+ Kh nng pht xung ca chng khc nhau: do tc dng Na+ tm trng khc nhau.
+ Nt xoang c tc pht xung cao nht nn nmquyn ch nhp iu khin tim p.

in sinh l t bo si co bp
Theo b dy ca c tim cc t bo c chia thnh 3 lp gm lp thng tm mc, lp t bo M
(mid-myocardial cell) v lp ni mc.
Theo quan im truyn thng: ni mc kh cc trc, ti cc sau. Ngoi mc kh cc sau ti cc
trc.
Quan nim mi:
+ kh cc: ni mac t bo M ngoi mc.
+ ti cc: ngoi mc ni mc t bo M.
IN TM (ECG)
Khi c tim ngh ngi, trng thi phn cc (mt ngoi mang in dng, mt trong mang in m).
Khi c kch thch c hin tng kh cc. Khi kch thch i qua, c hin tng ti kh cc. Ghi in
tm tc l ghi nhng thay i in th ca tim nhiu v tr khc nhau trn b mt c th. ghi
in tm bnh thng, ngi ta s dng cc h thng chuyn o c nh hng trn mt vi mt
phng ca c th. Lc in hc ca tim c trong mt thi im no c th c biu din bng
mt vect ba chiu. Mt h thng chuyn o c nh hng trong mt mt phng cho php ghi
c hnh chiu chu vect ba chiu y trn mt phng .
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 ghi ny dao ng v v ln mt bang
giy, n c mt ng c lm cho chuyn ng u v lin tc theo mt vn tc no . Nh th, ta
c mt ng cong tun hon gm nhiu ln song bin thin theo thi gian, l in tm .
Nh vy, in tm c th coi nh mt th c honh l thi gian v tung l in th ca
dng in tim.

nh chun:
in th: Trc khi c dng in tim vo my, ta phi phng mt dng in 1mV vo my c cao
tng ng l 1cm. Khi mun cho ln sng cao hn d nghin cu, iu chnh cho 2cm tng ng
vi 1mV v k hiu l 2N, khi sng in c bin qu cao, vt ra ngoi kh giy th iu chnh cho
0,5cm ng vi 1mV v k hiu l N/2.
V 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 = 2,4cm.
Thi gian: Nu vn cho giy chy vi tc 25mm/s th mi 1mm ng vi 1/25 = 0,04s; nu giy
chy vi tc 50mm/s th mi 1mm ng vi 1/50 = 0,02s. Thng s dng 25mm/s.
in tm bnh thng:
Phn tch in tm bnh thng c dng chung l P-QRS-T, dng ny thay i trogn cc chuyn
o.
- Sng P: L sng kh cc 2 nh. Sng trn, i khi c mc, 2 pha. Thi gian 0,08-0,11s. Bin
<2mm. Sng P lun (+) DI, DII, aVF; (-) aVR; (-) hoc (+) DIII v aVL.
- Khong cch PR: L thi gian dn truyn xung ng t nh n tht. Thi gian 0,18s (t 0,12-0,20s)
- Phc hp QRS: L thi gian kh cc 2 tht. T 0,06-0,08s. Sng Q <0,04s, bin < 1mm. Dng
QRS thay i ty chuyn o.
- on ST: Bt u t cui phc hp QRS n u sng T. Bnh thng on ST nm trn ng
ng in.
- Khong QT: Bt u phc hp QRS n cui sng T. y l thi gian thu tm in c hc ca tim.
Thi gian 0,35-0,40s ty tn s tim.
- Sng T: L sng ti cc 2 tm tht. Sng T mt in tm bnh thng th cng chiu vi QRS,
bt i xng, nhnh ln di hn nhnh xung, ddinhrtr trn. Thi gian 0,20s.

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 tng ca tim. Nu ta t hai in cc ln bt c hai im
no c in th khc nhau cu in trng ta s nhn c mt dng in th hin hiu in th
gia hai im gi l mt chuyn o hay o trnh. 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:

Dng in tim c in th rt nh nn trong khi ghi, in tm rt d b nh hng bi cc dng
in tp. Mun loi b 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 day in ca my in tim cng tht cch in, 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 (ng
h, da) ra. i vi tr em hoc bnh nhn tinh thn qu kch ng, run chn tay phi cho ung thuc
an thn cho ng yn. Phng ghi in tm nn c nhit khong 25 C, 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 (v d c thm
nc mui) nhng nu da ch bn hay nhn m th phi ty bn ete trc khi t in cc ln
nhng trnh lm xy st da gy sai s v in tr da. Nn chn ch tht mm mi, ch t ln xng.
in cc l nhng mnh kim kh trng bc hay thit rng t 2 n 4cm, loi nh dng t v tr
trc tim (v cn v tr chnh xc), loi ln t cc chi; li c loi cm hn vo di da bnh nhn
(thng dng khi mun loi b cc dng in tp v in tr da.
Theo quy c quc t, cc in cc hay dy ni cc in cc s dng:
- Mu khi t tay phi
- Mu vng tay tri
- Mu lc (xanh l cy chn tri)
- Ngoi ra, mu en dng cho in cc chng in tp (dy t) t chn phi v cc mu
xanh da tri, nu, tm, cho cc in cc lng ngc.
Cho n nay, i a s cc ca ngi ta cho rng nn t in cc theo 12 cch thu c 12 chuyn
o thng dng gm 3 chuyn o mu, 3 chuyn o n cc chi v 6 chuyn o trc tim.
Cc chuyn o thng dng:
A- CHUYN O NGOI VI HAY CHUYN O MU
y l nhng chuyn o hai cc, ghi hiu s in th gia hai im:
- Chuyn o DI: mt in cc c tay phi, mt c tay tri.
- Chuyn o DII: mt in cc tay phi, mt c chn tri.
- Chuyn o DIII: mt in cc c tay tri, mt c chn tra.

B- CHUYN O MT CC CC CHI
Do Wilson ra. Trong cch mc ny, ngi ta dng mt cc thm d t mt im no trn c
th, in cc kia gi l in cc trung tnh (cc ny l giao im ca on dy, mi on c in tr
5000hm, ni vi tay phi, tay tri chn tri, in th giao im s c nh bng khng); ngi ta
k hiu:
VR: 1 cc trung tnh, cc kia c tay phi.
VL: 1 cc trung tnh, cc kia c tay tri,
VF: 1 cc trung tnh, cc kia c chn tri,
By gi ngi ta dng cch mc ca Golbugu: b i mt nhnh ni gia mt chi vi cc trung tm.
Nh th bin sng in tm s ln hn, cc chuyn o ny c k hiu l aVR, aVL, aVF.
C- CC CHUYN O TRC TIM.
y cng l nhng chuyn o n cc. in cc thm d t trn cc im ngc.
Loi chuyn o trc tim c k hiu l V. Di y l 6 chuyn o trc tim thng dng.
V1: Cc thm d khong lin sn 4 bn phi, st xng c.
V2: Cc thm d khong lin sn 4 bn tri, st xng c.
V3: Cc thm d im gia ng thng ni V2 vi V4.
V4: Cc thm d giao im ca ng thng 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: Cc thm d giao im ca ng nch tri vi ng ngang i qua V4.
V6: Cc thm d giao im ca ng nch gia vi ng ngang i qua V4 v V5.
Cc chuyn o khc:
12 chuyn o tnh by thng l p ng cc chn on thong thng ca lm sang. Nhng
trong mt s trng hp kh chn on, ngi ta phi a in cc thm d n nhiu vng khc
xung quanh tim to ra rt nhiu chuyn o, m trong thong dng nht l:
-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 thm d tht phi hay tim sang
phi.
-Chuyn o thc qun (VOE): in cc c nut vo thc qun v ghi in tm nhiu
v tr cao thp khc nhau, dng kho st sng P m cc chuyn o thng dng khng thy sng
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 than b His, dng ch yu xc nh v
tr nghn nh-tht v chn on nhp nhanh tht.

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 nhtht 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?
- Kt lun chn on: v tn thng c tim v v ri lon nhp tim.

SAI LM KHI MC V C IN TM
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 D 1 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
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.

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 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: 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 :in tm s c cc sng m gn nh bin mt.
- 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 .
Trng hp cc rung ng nh ln tn v c sut dc bn in tm 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
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

PHN TCH MT IN TM :
Nhp Tn s:
Nhn xt nhp tim l xoang hay khng xoang, nhanh hay chm, u hay khng u, c ngoi tm thu
hay khng.
Cch tnh Tn s tim: o ly mt khong RR tnh ra giy ri ly 60 chia cho s s c tn s F.
Ngoi ra cn c th dng Thc tn s hoc Bng tn s tnh.
Ch :
- trong trng hp sng R qu nh, nt hay m ta c th chn sng khc tnh (sng S)
- khi nhp tim khng u ta phi chn vi khong RR di ngn khc nhau m tnh ra trung bnh cng
ri hy tnh ra tn s trung bnh.
- 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) v tn s tht (R) ring.

TRC IN TIM CCH XC NH TRC IN TIM

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 c mt phng php t mc chnh xc kh cao
0

(sai s gc ch khong 5 ) m li rt tin li. l phng php c lng trc in tim

bng tam trc kp Bayley nh sau.

TAM TRC KP BAYLEY

tm trc in tim, Bayley em ghp 3 trc chuyn o 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

0
6 ci nan hoa cch u nhau mt gc 60 . 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
0

kp mt vng trn tm O v gi im 3 gi ca vng trn l im 0 , cc im ca na di

vng trn c ghi dng v nh mc ln lt theo chiu kim ng h xut pht t im
0

0 cho n +180 . Cc im ca na trn vng trn c ghi m v nh mc ngc chiu

0

kim ng h t 0 n -180 . Ring na trc dng ca D1 cn c gi l trc 0 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 D3. Vy D3 l chuyn o B.

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 D3 l dng nn
0
QRS s trng vi na trc dng ca D3, ngha l c hng +120 hay ni cch khc gc =
0
+120 .
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:
0

- Hi dng tnh th ta phi iu chnh mi ca QRS 10 15 (ty theo dng nhiu hay t)
trn vng trn v pha na trc dng ca chuyn o A.
0

- Hi m tnh th phi iu chnh mi ca QRS cng 10 15 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

0

chnh QRS 10 v pha na trc dng ca n, ta c = +130 .

TRC IN TIM BNH THNG

0

Bnh thng, chiu hng ca trc in tim tc l gc bng +58 , nhng c th bin thin
0
0
trong khong t 0 n +90 (Hnh 26).

ngi Vit Nam, thng = +65 v bin thin t +26 ti +100 , 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
0
0
tun hon thai nhi. Lc mi sinh, n lch sang rt mnh gia +120 v +180 . Sau mt thng
0
0
0
0
th lui dn v pha trung gian gia +60 v +150 . Sau mt tui l gia +40 v +120 v
0
0
sau 4 tui l gia 0 v +90 , 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, 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
0
0
in tim lch phi vt qua +90 , cho ti -150 (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
0

C nhng ca bnh tim cha gy c trc phi tht s, ch lm gc = +75 m chng ta thng gi
l trc xu hng phi. Ngc li, cng c mt s ngi khng c bnh tim l li c trc phi,
0

thng l trc phi nh, khong +100 n +110 : 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
0

Khi trc in tim b lch sang tri vt qu 0 cho ti 90 th ta gi l trc tri (Hnh
y thng l trng hp tng gnh tht tri do tng huyt p, hp hay h van ng mch ch,
van hai l, hp eo ng mch ch, thiu nng vnh. Tng gnh tht tri lm tht tri dy ra,
vc t kh cc v pha tri, ng thi n cng gin ra v da vo cc c quan mm pha sau
y khi tm tht xoay ngc chiu kim ng h: hai bin i gy ra trc tri.

26).
h
ko
m

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).
0

Khi trc in tim cn khong +20 , +10 th ta gi l xu hng tri. Cn nhng ngi
0

khng c bnh tim m c trc tri (thng l trc tri nh, khong -20 , -30 ) 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 :
0

1. Khi trc in tim trong khong t - 90 n -150 (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.
- 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.

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) 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 V1V2 hoc qRs nhng vi q su hn
s, cn D3 th c dng rS (ging aVF)

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 V5V6.
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 D 1, D2, 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.

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
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.
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.