心电图诊断指南及操作
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第一节 心电图诊断指南
一、正常心电图
1.心律:(1)基本心律:窦性或异位。(2)窦性心律最基本条件:PV5，PV6直立，PavR倒置。
2.心率:大于3大格小于5大格(1格300，2格150，3格100，4格75，5格50)，房颤时计算平均心室率。(1小格为0.04s)
3.P波:(1)正常圆钝。(2)正常肢导<0.25mv，胸导<0.2mv。(3)正常<0.12s。
4.P-R间期:正常为0.12,0.20s。
5.QRS波群:(1)时间为0.06,0.10s。(2)电压:Q<1/4R，主要分析V1，V5。RV1<1.0mv，RV5<2.5mv。(3)胸导自V1-V6，R波逐渐增高，S波逐渐减少，V1:R/S<1，V5:R/S>1。(5)RV5+SV1<4.0mv(成年男子)，<3.5(成年女子);RV1+SV5<1.05mv。
6.S-T段:(1)时间为0.05,0.15s。(2)移位:以j点后0.06,0.08s为准，以P-R段为基线，需结合形态分析。上移:正常V1-V2<0.3mv，V3<0.5mv，其余导联<0.1mv;下移:正常各导联主要均应<0.05mv。
8.T波:主要分析R波占优势的导联，肢导联主要看I、II，胸导主要看V4.V5.V6，正常时R波占优势导联T波直立，振幅>R/10。异常T波表现为低平、平坦、双向或倒置。
9.Q-T间期:与心率快慢有关，正常值应根据相应的心率校正(0.32,0.44s)。
10.U波:V2，V3清楚，U与T方向相同，U
100次/分。1岁>140次/分，1,6岁>120次/分。
13.窦性心动过缓:窦性心律频率<60次/分。
14.窦性心律不齐:节律不整，P-P间期差异>0.12s。
二、期前收缩
1.房性早搏:(1)提前发生的房性P波(称P`波)，P`波与窦性P波形态不同，P`-R>0.12s，代偿间歇一般是不完全的(P`-P<2倍P-P)。
2.室性早搏:(1)QRS波>0.12s并提前出现，其前无相关P波。(2)代偿间歇多是完全的(P`-P,2倍P-P)。
3.房室交界性早搏:(1)提前发生的P`波(逆行P波)，QRS之前P`-R<0.12s，其后R-P`<0.20s，P`avR直立，P`V5V6倒置。(2)代偿间歇多完全。
三、束支阻滞
1.右束支传导阻滞:(1)各导联QRS终末粗钝或切迹。(2)V1呈rsR，R及M型。(3)右胸导联(V1，V2，V3R等)继发ST-T改变。(4) QRS时限>0.12s为完全性，0.10,0.11s为不完全性。
2.左束支传导阻滞:(1)I，avL，V5，V6无Q波，多呈R型，R波顶端圆钝或切迹。(2)左胸导联(I，avL，V5，V6)继发ST-T改变。(3)QRS>时限>0.12s为完全性，0.10,0.11s为不完全性。
3.左前分支传导阻滞:(1)QRS电轴左偏,30度至,90度。(2)II，III，avF呈rs型，SIII>SII。(3)I，avL呈QR或QRS或RS型，RavL>RI>RavR。
四、房室阻滞
1.一度房室传导阻滞:P-R延长>0.20s。
2.二度I型房室传导阻滞:P-R间期逐渐延长，有QRS脱漏。
3.二度II型房室传导阻滞:P-R间期等长，有QRS脱漏。
4.三度房室传导阻滞:P波与QRS波群无关，房率>室率，心室率<60次/分。
for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the
5.房室交界性逸搏心律:长间歇后有一个QRS波群，P-R<0.10s，或无P波，或在QRS波群前后有逆行P波。
6.二度I型窦房传导阻滞:长P-P <基本P-P的2倍。
7.二度II型窦房传导阻滞:长P-P,基本P-P的2倍。
五、扑动与颤动
1.房扑:(1)P波消失代之以规律的F波，频率为250,350次/分(2)房室传导(F-R)保持固定，心室率规则。
2.房颤:(1)P波消失代之以一系列大小不等，形态各异，间隔极不均匀的f波，频率为350,600次/分。(2)R-R间期绝对不等。
3.室扑:(1)P波消失(2)QRS波群畸形增宽且与T波相连难以分辨，频率150,250次/分，较规则。
4.室颤:QRS-T波群完全消失，代之以形状不同大小各异不整齐的波群，频率为250,500次/分。
六、室上性心动过速
1.三个或三个以上连续而频速的QRS波群，P波逆行难认或位于R波终末，频率160,250次/分。
2.继发ST-T改变，R-P间期均等。
七、预激综合征
1.QRS波前有预激波?，QRS>0.11s，继发ST-T改变。
2.P-R<0.12s，P-J间期正常(0.27s)。
3.常有阵发性室上性心动过速。
4.A型V1-V6的主波向上;B型V1的主波向下，V2-V6的主波向上。
八、心肌梗死
1(基本图形
(1)缺血型T波:?升支与降支对称;?顶端尖耸而呈箭头状;?T波由直立变为倒置。
(2)损伤型ST段:ST段“弓背向上”抬高超过正常以及“单向曲线”for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the
的出现。
(3)坏死型Q波:面对梗死区的导联出现坏死型Q波或QS波，而在背向梗死区的导联则出现增高的R波。“坏死型Q波”:?Q波时间?0(04s;?Q波电压>同导联R波的1,4。
2(图形演变与分期
(1)早期(超急性期):巨大高耸T波，以后迅速出现ST段抬高，ST-T也可联成单向曲线，但无坏死型Q波。此期通常持续数小时。
(2)急性期:坏死型Q波、损伤型ST段抬高和缺血型T波倒置同时并存。有无坏死型Q波是早期与急性期的区别点。此期持续数日至数周。
(3)近期(亚急性期):抬高的ST段回复到基线，而坏死型Q波及缺血型T波改变依然存在。ST段是否回到基线是急性期与近期的区别点。此期持续数周至数月。
(4)陈旧期(愈合期):遗留有坏死型Q波，倒置的T波已恢复正常或长期无变化。
3(心肌梗死的定位 前间壁心肌梗死，特征性心电图改变出现在Vl、V2.(V3)导联;前壁心肌梗死在V3.V4.(V5)导联;侧壁心肌梗死在?、aVL、V5.(V6)导联;下壁心肌梗死在?、?、aVF导联;后壁心肌梗死时坏死型Q波出现在V7.V8导联，而对应的Vl、V2导联出现R波增高变宽、ST段压低及T波高尖对称。
4(无Q波心肌梗死 约占急性心肌梗死的1,4。诊断
标准
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为:?特征性的心前区疼痛持续30分以上;?血清酶的改变符合急性心肌梗死，如肌酸激酶在发病后4—6h上升，约在20h达高峰，超过正常值高限50,以上，并于48—72h降至正常;?ST-T衍变超过24h以上。
心电图改变包括:?ST段水平下移?0(1mV，伴或不伴T波改变;?ST段上抬，常伴有其后的T波改变;?T波倒置，常呈冠状T波改变。
九、心肌缺血
1(典型心绞痛 ?ST段下移:ST段呈水平型或下垂型下移?0(1mV，for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the
持续时间多在15min左右，一般不超过30min。?T波倒置、低平或双向。?Q-T间期延长。?一过性U波倒置。?一过性心律失常。
2(变异型心绞痛 心电图表现为:?ST段抬高?0(2mV，ST段抬高随着症状的缓解而逐渐回到基线。?ST段抬高的导联上T波进一步增高、变尖。?QRS波群时间及室壁激动时间延长，QRS波群振幅增高。?部分患者出现一过性心律失常，以室性早搏多见。
3(慢性冠状动脉供血不足 ?ST段改变:在R波占优势的导联上，ST段呈水平型或下垂型缺血性下移，ST段压低?0(05mV。近似缺血型改变时，ST段与通过R波顶点所作的垂线的交角介于81-89?，ST段下移>0(075mV、持续时间>0(08s，ST段与T波的分界清楚。?T波改变:表现为低平、双向或倒置。“冠状T波”则更有把握。?Q-T间期延长。?U波 持续性倒置。
第二节 心电图操作规范
1.必须用检验合格(包括阻尼、走纸速度、电压等参数)，性能良好的心电图机进行检查。为了避免交流电和其他外来电的干扰，心电图机附近不宜有大型的带电子设备如电风扇、X线机、电疗机等。
2.受检者一般采用仰卧位，检查前静卧数分钟，使全身肌肉放松，室内温度不低于18?，以避免肌肉震颤而引起伪差;为避免基线漂移，描图时，受检者不宜说话、移动肢体以及过度呼吸。
3.操作前先将心电图机接通电源，接着按下心电图机电源开关。
4.安放电极的部位，要将皮肤擦干净，并涂上导电液体或导电胶，以减少皮肤与电极之间的阻力;依次正确接上四肢电极及胸前导联电极。 for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the
5.常规导联应包括:?、?、?、AVR、AVL、AVF、V1.V2.V3.V4.V5.V6
等12个导联。还应根据需要和心电图变化决定时间的长短和是否加做导联，
如长?导或长V1导联以及18导联(加做V3R、V4R、V5R、V7.V8.V9)。
6.描记完毕后，应马上在图纸上注明姓名、性别、年龄、检查日期和
时间以及导联名称，然后结合临床进行分析。
for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the
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