TRNG I HC Y DC CN TH

IN
TIM
NG
DNG
LM
SNG

(LP C BN DO ON THANH NIN T CHC)

Ph trch: Ths.Bs.Trn Kim Sn (BM Ni-Tim mch)
Cc ging vin tham gia:
1. Ts.Bs.Trn Vit An (BM Ni-Tim mch)
2. Ths.Bs Nguyn Th Dim (BM Ni-Tim mch)
3. Ths.Bs.Trn ng ng Khoa (BM DK-Tim mch)

TI LIU LU HNH NI B
---2011---

MT S KHI NIM C BN
in Tm (T) l mt th tun hon ghi li cc bin thin ca
dng in do tim pht ra. Cc tn hiu ny c ghi li bng cch t cc in
cc cc chi, thnh ngc bi my o in tim. y l mt k thut khng th
thiu dng chn on trong lm sng tim mch.
I. K thut ghi T:
Trn giy ghi T ngi ta in sn nhng ng k dc v k ngang
cch nhau 1 mm (mt nh), 5 nh thnh ln

1. Thi gian (trc honh):

Ty theo vn tc ko giy:
- Vn tc 25 mm/s th mi nh c thi gian 0,04s.(chun)
- Vn tc 50 mm/s th mi nh c thi gian 0,02s.
- Vn tc 100 mm/s th mi nh c thi gian 0,01s.

2. Bin (trc tung):

Ty theo chiu cao ca sng m ngi ta iu chnh bin (test
mV) cho ph hp:
- Test chun N: 1mV= 10mm.
- Test N/2: 1mV= 5mm (khi o bin sng rt cao c th gia 2
chuyn o lin tip chng ln nhau, lc ny ngi ta s dng
test N/2 gim bin xung nn khi c kt qu phi nhn i
bin ).
- Test 2N: 1mV= 20mm (i vi mt s bnh l lm bin rt
thp rt kh xc nh, ta phi s dng test 2N tng bin
sng nn khi c ta phi chia i).
II.

in sinh l:
T bo c tim c cu trc rt phc tp do dng in hot ng

trong c tim cng phc tp hn rt nhiu. Dng in pht ra l do s bin

i mt trong v mt ngoi mng t bo, nguyn nhn l do s di chuyn
ca cc ion Na+ v K+.
- Qu trnh phn cc: c tim trng thi ngh, mt ngoi t bo
tch in dng, mt trong tch in m lc ny khng c dng
in i qua nn khng ghi c sng trn T.

- Qu trnh kh cc: khi kch thch mt ngoi t bo c tim tch

in m, mt trong tch in dng. Chiu dng in i t cc m n
cc dng.

- Qu trnh ti cc: sau khi kh cc t bo c tim s tr v trng

thi ban u, mt ngoi tch in dng, mt trong t bo tch in m.

Tim hot ng c l nh h
thng thn kinh t ng bt u t
nt xoang (nt pht nhp mnh
nht) ta ra c nh theo chiu dc
gy kh cc nh, ri n nt nh
tht (nt Tawara) qua b His gy
kh cc tht, sau qu trnh kh cc
l ti cc. Kh cc ri ti cc nh
v tht ln lt nh vy to nn cc
sng trn T.
III.

V tr t cc in cc (theo IEC International Electrotechnical

Commission)
1. in cc t trc tim

- V1 (mu ): Lin sn 4 bn cnh bn phi xng c.

- V2 (mu vng): Lin sn 4 bn cnh bn tri xng c.
- V4 (mu nu): Lin sn 5 ng trung n tri.
- V3 (mu xanh): gia V2 v V4.
- V5 (mu en): Lin sn 5 ng nch trc bn tri.
- V6 (mu tm): Lin sn 6
2. in cc t chi:
- R: Tay phi (mu )
- L: Tay tri (mu vng)
- F: Chn phi (mu xanh)
- RF: Chn tri (mu en)
3. Cc chuyn o khc:
- V7,V8,V9: in cc t bn tri sau lng ngc.
- V3R,V3R: i xng vi V3 v V4 bn phi.

PHN TCH CC SNG

y l phn quan trng nht trong T, phn tch cc sng theo trnh
t nh sau: sng P, khong PQ, phc b QRS, on ST, sng T, sng U v
khong QT.

1. Sng P:
u tin xung ng t nt xoang pht ra, ta ra c nh gy nn hin tng
kh cc nh, lc ny trn T ta ghi c sng P (sng kh cc nh)
- Sng P bnh thng:
+ Dng: DI v DII, V3,V4,V5,V6.
+ m: aVR
+ Hnh dng: trn u
+ Thi gian: 0,05-0,11s
+ Bin : 0,5-2 mm
- Sng P bt thng: Khi sng P bt thng v hnh dng hoc
thi gian hoc bin ta ngh ngay mt tn thng nh hay ri lon
nhp tim trn tht:

+ Hnh dng: P c 2 nh, 2 pha, thay i nhiu hnh dng trn

cng mt chuyn o(gp trong ln nh, ch nhp lu ng, ngoi tm thu
nh,)
+ P rng >0,12s: ln nh tri.
+ P cao >2,5 mm: ln nh phi.
2. Khong PR (PQ)
L thi gian dn truyn t nh n tht c o t u sng P n u
phc b QRS.
- Thi gian PR bnh thng: 0,12-0,20s, trn lm sng thng
gp PR=0,16s. Nhp tim cng nhanh th PR cng ngn v ngc
li.
- Thi gian PR bnh l:
+ PR di ra: block nh tht 1, 2
+ PR khng lin lc nhau: phn ly nh tht, block nh tht 3.
+ PR ngn hn bnh thng: hi chng kch thch sm, ri lon
nhp nhanh trn tht.
Note: Nhp xoang l nhp chnh tha cc tiu chun nh sau:
+ Sng P i trc phc b QRS, P(+) D1, V5, V6, m aVR.
+ Khong PR khng i trn 1 chuyn o v bnh thng.
3. Phc b QRS
QRS l phc b i din cho s kh cc tht
- nh danh: sng m u tin l sng Q, sng dng u l sng
R, sng m sau R l sng S (nu c sng dng th hai th sng
R hay r).
- Sng Q: trong thc hnh lm sng khi pht hin sng Q, ngi ta
thng ngh n NMCT, tuy nhin sng Q cng xut hin trong

mt s trng hp khc. Sng Q khng xut hin cc chuyn

o trc tim phi (V1-V3), cc chuyn o khc sng Q xut
hin rt nh tr D3 v aVR.
+ Thi gian <0,04s
+ Bin < sng R
- Phc b QRS bnh thng
+ Hnh dng: nhn hp
+ Thi gian: 0,06-0,10s
Nhnh ni in: thi gian hot ng in ca tht (VAT), o t
u phc b QRS n nh sng dng cui cng, chuyn o
ngc phi VAT 35ms, tri VAT45ms), l mt tiu chun chn
on ph i tht tri.
+ Bin :
R/S V1, V2<1
R/S V5,V5>1
- Phc b QRS bnh l
+ Bin i v hnh dng: dn rng (block nhnh, nhp t tht, hi
chng tin kch thch, dn truyn lch hng,), dng QS trong
NMCT,
+ Bin i v thi gian: nhnh ni in mun ngh n dy tht,
thi gian QRS>0,10s ngh n block nhnh, ri lon dn truyn
trong tht, ngoi tm thu tht, block nh tht,
4. on ST
Bt u cui phc b QRS (im J) n u sng T, biu hin kt thc
qu trnh kh cc tht v bt u qu trnh ti cc.

- Bnh thng ST nm trn ng ng in: khng chnh ln qu

0,1mV, khng chnh xung qu 0,05mV.
- on ST trong mt s bnh l:
+ ST chnh ln: NMCTC, cn au ngc bin thi, vim mng
ngoi tim cp, ti cc sm, tng Kali mu, hi chng Brugada.
+ ST chnh xung: NMCTC, thiu mu c tim, vim c tim, bnh
c tim ph i, bnh c tim gin n, ng c Digital, h Kali mu.
5. Sng T
L sng ti cc tht.
- Sng T bnh thng: hnh dng rng, u t, khng i xng,
sn xung dc ng hn, sn ln thoai thoi vi on ST,
cng chiu vi QRS
- Sng T trong mt s bnh l
+ T cao, nhn: Ri lon thn kinh thc vt, thiu mu c tim cp,
vim c tim, tng Kali mu,.
+ T hai pha: Thiu mu c tim, ng c Digital
+ T o chiu: Thiu mu c tim, Hi chng WPW, ph i c
tim.
+ T hnh thc Niagara trong tn thng mch mu no.
6. Khong QT
Khong QT biu hin thi gian ton thi k tm thu, c o t
u phc b QRS n cui sng T. Ty thuc vo tn s tim m QT s thay
i (t l nghch).
- V d nu nhp tim bnh thng 70 ln/pht, QT=0,36s0,04s
- QT di ra: h canxi mu, nhc gip, bnh mch mu no, ure mu
cao, thuc quinidin,

- QT ngn li: ngm Digital, tng canxi, tng kali mu.

7. Sng U
Do ti cc c tr, ti cc h Purkinje
Sng U bnh thng hnh trn u, thng sng U khng xut
hin, cng chiu v nh hn sng T.
Sng U bnh l: sng U cao nhiu chuyn o ngh n tng
kali huyt.