EKG 10
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EKG patologic
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Hipertrofie atriala dreapta
• P inalta (>2,5 mm) si ascutita in derivatii
inferioare DII, DIII, aVF (p pulmonar) sau p
difazic in V1/V2
• HTP
• stenoza/insuf tricuspidiana
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Hipertrofie atriala stanga
• Unda p larga >0,12 sec, bifida in DI, DIII si aVL
(p mitral) sau difazica in V1
• Stenoza/ insuf Mi
• Stenoza/ insuf Ao
• Insuf VS
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Hipetrofii ventriculare
• Alterarea depolarizarii
- cresterea amplitudinii si duratei undelor R
- modificari ale axului inimii
• Alterarea repolarizarii
- Modificari secundare ale fazei terminale(segment ST si unda T)
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Modificari de faza terminala
• In opozitie fata de deflexiunea majora a
complexului QRS:
– In derivatiile directe (de ex pt VS V5,V6 si pentru
VD V1, V2)- T inversat si ST subdenivelat
– In derivatiile indirecte (VS- V1, V2 si VD- V5, V6)-
ST supradenivelat si T pozitiv, simetric
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Hipertrofie ventriculara dreapta
- R>S in V1- V2 SAU R V1>7 mm
- S adanc in V5,V6
- Deflexiune intrinsecoida > 0.035-0.055 s in V1
- R V1 + S V5/6> 10.5 mm
- qrS in derivatiile drepte
- Modificari de faza terminala- subdenivelare ST si inversare T in V1,V2
- Ax deviat la dreapta
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Cauze HVD
• B pulmonare cronice
• Stenoza mitrala
•
Stenoza pulmonara
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Hipertrofie ventriculara stanga
• In derivatii frontale – RDI + S DIII >25 mm
– R in derivatii inf (DII, DIII, aVF)>20 mm
– R aVR> 13 mm
•In derivatii orizontale – Indice SOKOLOV-LYON
S V1+R V5/V6> 35 mm
- S maxim V1/V2 > 26 mm
- R maxim V5/V6 >26 mm
• Faza terminala- opozitie de faza in V5,V6,DI si aVL• Ax QRS normal dar deviat spre 0-10 grade; HVS f severa-
spre – 30 grade
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Cauze HVS
• HTA
•
Stenoza Ao• Insuf Ao
• Insuf Mi
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• SOKOLOV LYON INDEX= R in V5/ V6 + S in V1 >35 mm
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Hipokalemie
• Modif EKG- cand valoarea este sub 3mEq/l
•
Amplitudine T scazuta• Subdenivelare ST
• Unda U
• QT scurt• Tulburari de ritm
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Hiperkalemie
• T amplu
• Aplatizare p pana la disparitie
•
QRS larg• Aritmii
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TULBURARI DE RITM
Aritmii sinusale
- Tahicardie sinusala
- Bradicardie sinusala
- Aritmie respiratorie
- Pauza sinusala
Aritmii atriale- Extrasistola atriala
- Fibrilatie atriala
- Flutter atrial
- Tahicardie paroxistica supraventriculara
Aritmii ventriculare- Extrasistola ventriculara
- Tahicardie ventriculara
- Fibrilatie ventriculara
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Tahicardie sinusalaMecanism:
descarcare crescuta a NS
Ritm: sinusal regulatFrecventa: >100 bpm
- la adulţi nu depăşeste 140-180 bpm
- la copii 200-220 bpm
Unde P: normale, uniforme; daca ritmul este crescut unda P se poate pierde in unda T
Interval PR: normal (0.12 – 0.20 sec), dar poate scadea cu ↑ ratei
QRS: normal (0.06 – 0.10 sec)
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Tahicardie sinusala
• Cauze:
- Fiziologice: exercitii ,anxietate, durere,
- Patologice: febra, anemie, hipovolemie, hipoxie, insuf
cardiaca
- Endocrine: tireotoxicoze- Farmaceutice: adrenalina eliberata in feocromocitom;
salbutamol (medicamente simpatomimetice), alcoolul,
cafeina
- Poate fi primul semn al Insuf Ventric Stg
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Bradicardie sinusalaMecanism: descarcare scazuta a NSA
Frecventa: < 60 bpm
Ritm: regulat
Unde P: normale, uniforme, urmate de compl qRS
Interval PR: normal (0.12 – 0.20 sec),
QRS: normal (0.06 – 0.10 sec)
- Bradicardia sinusala este normala in timpul somnului si la
persoanele cu tonus vagal crescut, cum ar fi atletii si adultii
tineri sanatosi.
- Cea mai obisnuita cauza patologica este IMA
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Aritmie respiratorie
• Aritmie fiziologica
• Cresterea frecventei cardiace in inspir si
scaderea in expir (expirul stimuleaza nc
ambiguu + nv X scade frecventa cardiaca)
• Oprirea voluntara a respiratiei duce la
disparitia aritmiei
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Pauza sinusala
• Lipsa generarii impulsurilor cu absenta
undelor p
• Durata intervalului fara unde p nu se coreleaza
cu ritmul de baza
• Bradicardie severa
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Extrasistola atriala
• QRS prematur
• Unda p a complexului ES are morfologie diferita
• Urmata de o pauza necompensatorie
•
QRS de durata normala- conducere pe cai normale
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Fibrilatia atriala
• Focare ectopice in atrii
• absenta undelor p- inlocuite de mici oscilatii
ale liniei izoelectrice numite unde f de
fibrilatie, cel mai bine vizibile in V1/V2
• frecventa atriala este de 400-600/min
• QRS inguste, dar complet neregulate
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Flutter atrial
• Focare ectopice multiple atriale cu mecanism
de reintrare
• Fara unde p, inlocuite cu unde F de flutter in
dinti de fierastrau
• Frecventa de 250-350/min
• Frecventa ventriculara este de obicei la
jumatate din cea atriala
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Tahicardie paroxistica
supraventriculara
• Frecventa cardiaca de 150-250/min
• Succesiune de minim 5-6 ESA
•
P prezente, dar de morfo diferita (alt focar)• QRS de aspect normal
• Se opreste cu manevre vagale (masaj
carotidian, compresie glob ocular)
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Extrasistola ventriculara
• QRS prematur, dar fara unda p ce il precede
• Pauza compensatorie
• QRS larg>0,12 s
•
Mai mult de 3 ESV= tahicardie ventriculara
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Tahicardie ventriculara
• Trei sau mai multe ESV consecutive
• Frecventa de >100/min
• QRS pot fi monomorfe sau polimorfe
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Fibrilatie ventriculara= stop cardiac
(contractii ineficiente)
• Unde rapide neregulate cu frecventa de 130-
300/min
• Complexe QRS aberante- largi si deformate
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Anomalii de conducere
• Bloc SA
• Bloc AV
• Bloc de ramura dr/stg
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Bloc AV
• Gr I- pR> 0,21 s
• Gr II
– A. Mobitz 1- cu perioade Luciani Wenckebach
– B. Mobitz 2
• Gr III- complet
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Bloc AV I= PQ/PR > 0.21 s
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Bloc AV II.1- Mobitz 1 cu perioade
Luciani- Wenckebach• Alungire progresiva a intervalului PR, cu fiecare ciclu succesiv, pana cand
o unda p este complet blocata
• Distanta dintre 2 unde p blocate se numeste per LW
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BAV II.2- Mobitz 2
• Interval PR normal cu blocarea brusca a
conducerii undei p catre ventriculi
• Gradele blocarii impulsurilor pot fi de 2/1;
3/1; 4/1
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BAV III- complet
• Blocarea completa a conducerii AV
• frecventa atriala- ritm sinusal/alt ritm atrial
• Ventriculii- ritm de scapare cu frecventa de 30-40/min
• Disociatie completa atrioventriculara
• Implant de pacemaker permanent
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Bloc de ramura
• stanga- QRS larg V5, V6
• dreapta- QRS larg V1, V2
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BRD
• Ritmul e generat deasupra ventriculilor
• QRS >100 ms- bloc incomplet
• QRS> 120 ms bloc complet
• Unda R terminala in V1 R, rR', rsR', rSR' or qR
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BRS
• Ritm generat deasupra ventriculilor
• QRS≥ 120 ms
• QS / rS in V1
• RsR‘ in V6.
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SINDROAME DE PREEXCITATIE
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• CONDUCERE DIRECTA A IMPULSULUI DE LA A-
V PRIN FASCICULE ABERANTE- SUNTAREA NAV
• TIPURI
Wolf- Parkinson- White (WPW)
Lown- Ganong- Levine (LGL)
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Wolf- Parkinson- White (WPW)
• FASCICUL KENT- PR< 0,12, UNDA DELTA, QRS >
0,1s
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Lown- Ganong- Levine (LGL)
- INITIAL S-A CREZUT IN EXISTENTA F JAMES- de
fapt NAV conduce mai rapid- PR< 0,12, fara
unda Delta- problema este intranodala- fara
unda de sumatie
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Tulburari de perfuzie
• ischemie- cea mai usoara- este reversibila siafecteaza repolarizarea- subdenivelare ST +/- Tnegative, simetrice
•
leziune- stadiu intermediar, greu reversibil,produce intarziere de repolarizare- pe EKGmodificari de segment ST: supradenivelare de ST
• necroza= moartea miocardului- nu este
reversibila- pe EKG= unda Q de necroza (cuamplitudine >1/4 R si durata >0,04 s, in derivatiilecorespunzatoare
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IM acut
Stadii
1.Unda T pozitiva, ampla, larga- T hiperacut- in primeleore de la debut
2.Supradenivelare ST, initial concava, apoi convexa- undaPardee- se reduce progresiv in evolutie pana ajunge lalin izoel in 1-2 sapt de la debut=leziune
3.Unda T devine negativa, ascutita, simetrica in 1-2 zile,maxim in primele 2 sapt=ischemie
3.Unda Q larga si adanca dupa 8-10 ore de la debut(durata>0.04s si ampl>1/4 din R adiacent)=necroza
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Leziune
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Acute myocardial infarction
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Inferior infarction=Q in D2, D3, aVF