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¡ÒÃãªé warfarin



  ¡ÒÃàÃÔèÁÂÒ

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¡Ã³ÕÃÑ¡ÉÒẺäÁèàÃ觴èǹ
´Ù ÍÒÂØ âäÃèÇÁ ãªéÂÒÍÐäúéÒ§
ÊÓËÃ麤¹ä·Âá¹Ð¹ÓãËéàÃÔèÁã¹¢¹Ò´µèÓæ ¤×Í»ÃÐÁÒ³ 3 mg/day ËÃ×Í 21 mg/week 
¡àÇ鹶éÒà»ç¹¤¹á¡èæ ÁÕ¤ÇÒÁàÊÕè§àÃ×èͧâä comorbid ÁÒ¡ ¹éÓ˹ѡµÑǹéÍ ÍÒ¨àÃÔèÁµèÓ¡ÇèÒ 3 mg/day

ËÅѧ¨Ò¡ä´éÂÒä»»ÃÐÁÒ³ 3 Çѹ ãËéÅͧà¨ÒÐ INR ¤ÃÑé§áá
INR < 1.5 => à¾ÔèÁÂÒ 
INR 1.5-1.9 => ¤§ÂÒà·èÒà´ÔÁ 
INR > 2.0 => ãËéÅ´ÂÒ 
à¾×èÍãËé·Õè Day 7-10 ÃдѺÂÒÍÂÙè㹪èǧ 2.0-3.0
**ªèǧááÍÒ¨µéͧ PT ·Ø¡Çѹ¨¹¡ÇèÒ INR ¨Ðà¢éÒ range ¨Ò¡¹Ñé¹à¨ÒÐÊÑ»´ÒËìÅÐ 3 ¤ÃÑé§ÍÕ¡ 1-2 ÊÑ»´ÒËì ¶éÒ¤§·ÕèáÅéÇÍÒ¨à¨Òзء 4 ÊÑ»´ÒËì
¨Ó§èÒÂæ ÇèÒ
“·Ø¡Çѹ (¨¹à¢éÒ range) -> ÇѹàÇé¹Çѹ (1-2 ÊÑ»´ÒËì) -> ·Ø¡ÊÑ»´ÒËì -> ·Ø¡à´×͹"
> ¼Ùé»èǤÇÃä´éÃѺ¡ÒõÃǨ INR ËÅѧàÃÔèÁÂÒ 3 Çѹ
> ¼Ùé»èǤÇÃä´éÃѺ¡ÒõÃǨ INR «éÓã¹ 1 ÊÑ»´ÒËìËÅѧ»ÃѺÂÒ
> ¶éÒà»éÒ¤§·ÕèáÅéÇãËé F/U at least ·Ø¡ 4 ÊÑ»´ÒËì
> ¶éÒ INR äÁè¤èͤ§·Õè F/U at least ·Ø¡ 2 ÊÑ»´ÒËì
àÁ×èÍàÃÔèÁÂÒáÅéǵéͧ advice, patient education ãËé´Õ
**¡Ã³Õ·Õèµéͧ¡ÒüšÒÃÃÑ¡ÉÒàÃçÇ ãËé heparin ¡è͹áÅéÇ start ÂÒ¾ÃéÍÁ¡Ñ¹ ¾Í INR ä´é level áÅéÇ 2 ÇѹµÔ´¡Ñ¹¤èÍ off heparin (Bridging)
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 ¡ÒûÃѺÂÒãËéä´é INR goal
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·Ø¡¤ÃÑ駷ÕèÁÒ F/U àÃÒµéͧ´ÙÇèÒ INR ¢Í§¼Ùé»èÇÂÍÂÙèã¹ goal ËÃ×ÍäÁè? «Öè§ goal áµèÅÐâäáµèÅÐÀÒÇÐäÁèà·èҡѹ
> ¶éÒ¾ºÇèÒ INR ÍÂÙè¹Í¡ goal ãËéËÒÊÒà˵ءè͹àÊÁÍ
ãËé´ÙÇèÒ¡Ô¹ÂÒ¶Ù¡µéͧÊÁèÓàÊÁÍ Å×Á¡Ô¹ ËÃ×Í»ÃѺÂÒàͧ ËÃ×ÍäÁè 
ÁÕ drug-interaction ËÃ×ÍäÁè 
«×éÍÂÒÁÒ·Ò¹àͧ ¡Ò÷ҹÍÒËÒÃà»ÅÕè¹ä»ËÃ×ÍäÁè âäÃèÇÁ¢Í§¼Ùé»èÇ ¶éÒËÒà¨ÍãËé¡Ó¨Ñ´ÊÒà˵شéÇ ÍÂèÒÅ×Á¤Ô´àÃ×èͧ lab error à¾ÃÒоºä´é¹Ð
> ãËé¤Ô´¢¹Ò´ÃÇÁµèÍÊÑ»´ÒËìáÅéÇ»ÃѺà»ç¹ %
ËÒ¡¤èÒ INR ÍÂÙè¹Í¡à»éÒ <0.5 : »ÃѺ 5-10% weekly dose
ËÒ¡¤èÒ INR ÍÂÙè¹Í¡à»éÒ >0.5-1.0 »ÃѺ 10-20% weekly dose
·Ø¡¤ÃÑ駷Õè»ÃѺÂÒãËé F/U INR 1 week (ÍÂèÒ§¹éÍ·ÕèÊØ´) 
¶éÒ¤§·ÕèáÅéǤèÍ F/U q 4 weeks
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 Warfarin overdose ÃÑ¡ÉÒÍÂèÒ§äÃ
—————————————————————————
¡ÒÃÃÑ¡ÉÒ¡Ã³Õ INR à¡Ô¹¨Ò¡ goal
´ÙÇèÒÁÕ major bleeding äËÁ?
¶éÒÁÕ major bleeding 
-> hold warfarin,
->Vit K 10 mg IV 
-> plus FFP
â´Â vit K µéͧãËé¼èÒ¹ËÅÍ´àÅ×Í´´ÓªéÒæ <1mg/min ÍÒ¨¾Ô¨ÒóÒãËé«éÓ·Ø¡ 12 ªÑèÇâÁ§ 
***VitK IV ÁÕ·Õèãªéà¾Õ§·Õèà´ÕÂǤ×Í major bleeding, any INR only!
****Vit K IV äÁè¤ÇÃãªé㹤¹ä¢é·ÕèÁÕ mechanical prosthesis

äÁèÁÕ major bleeding ãËé´Ù INR
INR > 9, no bleeding : hold warfarin, Vit K 2.5-5.0 mg oral áÅÐ F/U INR ¤ÇáÅѺÁÒ»¡µÔã¹ 24-48 hours
INR 5-9, no bleeding : omit 1-2 doses ËÃ×ÍãËéËÂØ´ 2 Çѹ áÅеԴµÒÁ INR ¾ÍàÃÔèÁãËÁèãËéàÃÔèÁ·ÕèµèÓŧ 20% ¨Ò¡ weekly dose à´ÔÁ ¶éÒÁջѨ¨ÑÂàÊÕè§ bleed ãËé vit K 1-2.5 mg orally 

ä´é
INR 4-5, no bleeding : ãËéËÂØ´ÂÒ 1 Çѹ µÔ´µÒÁ INR ¨¹à¢éÒªèǧà´ÔÁ ¾ÍàÃÔèÁãËÁèãËéàÃÔèÁ·ÕèµèÓŧ 10% ¨Ò¡ weekly dose à´ÔÁ
INR 3-4, no bleeding : Ŵ dose ŧ 5-10%
****ËÅÕ¡àÅÕ觡ÒÃãªé Vitamin K ã¹ÃÒ·ÕèäÁè¨Óà»ç¹à¾ÃÒзÓãËé INR µèÓÁÒ¡ à»ç¹¡Òà reverse ÍÂèÒ§àÃçÇ áÅШзÓãËéà¡Ô´ warfarin resistance à»ç¹ÊÑ»´ÒËì¶Ö§à´×͹ àÇÅÒ¨ÐàÃÔèÁÂÒ

ãËÁè¨ÐÅÓºÒ¡ áÅÐàÊÕ觵èÍ anaphylaxis ¡Ã³ÕãËé IV
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Peri-operartive warfarin management
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à¹×èͧ¨Ò¡¡ÒÃãËéÂÒ warfarin ¨Ð·ÓãËé¼Ùé»èÇÂÁÕâÍ¡ÒÊàÊÕ觵èÍàÅ×Í´ÍÍ¡ÁÒ¡¢Öé¹ áµèã¹·Ò§¡ÅѺ¡Ñ¹¼Ùé»èǨÐä´éÃѺ¼Å»ÃÐ⪹ì¨Ò¡ÂÒã¹´éÒ¹¡Òûéͧ¡Ñ¹ Thromboembolic 

phenomenon ËÃ×Í VTE ·Õè¨Ðà¡Ô´¢Öé¹ËÒ¡äÁèä´éÃѺÂÒ
áµèËÒ¡¼Ùé»èǵéͧä´é¼èҵѴ¨ÐàÃÔèÁÁջѭËÒ à¾ÃÒШзÓãËéÁÕâÍ¡ÒÊàÅ×Í´ÍÍ¡§èÒÂáÅÐËÂØ´ÂÒ¡ÁÒ¡ ¼Ùé»èÇÂÍÒ¨ÁÕ major bleeding ä´éµÑé§áµè intra-op áÅÐ post-op
¶éÒà»ç¹ÍÂèÒ§¹Õé ¶ÒÁÇèÒàÃÒ¤Ç÷ÓÍÂèÒ§äôÕ?
-> -> ËÂØ´ÂÒ : ¶éÒàÃÒËÂØ´ÂÒ¡è͹¼èҵѴ á¹è¹Í¹ÇèÒÃдѺ INR ÊÒÁÒöŧÁÒ»¡µÔä´é áÅШÐÁÕ¤ÇÒÁàÊÕè§àÅ×Í´ÍÍ¡¨Ò¡¡ÒüèҵѴà·èÒ¤¹·ÑèÇä» áµèÍÂèÒÅ×ÁÇèÒàÃÒ¨Ðà¾ÔèÁâÍ¡ÒÊàÊÕ觵èÍ 

VTE ãËé¼Ùé»èÇÂàªè¹à´ÔÁ 
«Öè§â´ÂÁÒ¡áÅéÇ¡ÅØèÁ¼Ùé»èÇ·Õèä´éÃѺÂÒ warfarin ¡ç¨ÐÁÕ¤ÇÒÁàÊÕ觵èÍ TE ÁÒ¡¡ÇèÒ¤¹·ÑèÇä»ÍÂÙèáÅéÇ -> äÁè Bleed áµè stroke ¨Ó§èÒÂæ
-> -> ËÂØ´ÂÒ + Bridging : ËÃ×Í¡ÒÃãªé Bridging anticoagulant ¤×Í¡ÒÃãËéËÂØ´ÂÒ warfarin áÅÐàÁ×èÍ INR < 2.0 áÅéǨ֧ãËé¡ÅØèÁ anticoagulant ·Õèà»ç¹ short-acting à¢éÒä»á·¹ àªè¹ 

LMWH, IV Unfractioned Heparin (UFH) «Ö觨Ðà»ç¹¡ÒÃÅ´ risk ¢Í§ TE (ÃѺªèǧµèͨҡ warfarin »ÃÐÁÒ³¹Ñé¹) áµè¨ÐÂѧÁÕ risk of bleeding ä´é -> äÁè stroke áµè bleed
àÃÒ¨Ö§µéͧÁÒªÑè§ risk ¢Í§¼Ùé»èÇÂÇèÒ ÃÐËÇèÒ§ Risk TE ¡Ñº Risk Bleeding Íѹä˹àÊÕ觡Çèҡѹ? à¾ÃÒÐáµèÅФ¹äÁèàËÁ×͹¡Ñ¹
àªè¹à´ÕÂǡѹ¡ÑºàÇÅÒàÃÒ¨ÐàÃÔèÁÂÒ warfarin 㹤¹ä¢é AF àÃÒµéͧªÑè§ÃÐËÇèÒ§ CHADSVASC áÅÐ HASBLED ãªèäËÁ¤ÃѺ 
àÁ×èÍäËÃè¡çµÒÁ·Õè¶éÒ Bleeding risk > TE risk ¡çäÁè¤Çà Bridge
ÊÔ觷ÕèàÃÒµéͧ¨Óä´é¤×Í High TE risk ·Õè¨Ðµéͧä´éÁÒ Bridge 
> ¼Ùé»èÇ on Mechanical valve : mitral valve, aortic valve
> ¼Ùé»èÇ AF : CHADS2 >=5, Rheumatic MS
> ¼Ùé»èÇ VTE : severe thrombophilia, protein C,protein S deficiency, Antiphospholipid syndrome
> ¼Ùé»èÇ recent CVA/TIA < 6 months if on mechanical valve
> ¼Ùé»èÇ recent CVA/TIA < 3 months if AF or VTE
*****¶éÒ¼Ùé»èÇÂÍÂÙè㹡ÅØèÁ¹Õé¤Ç÷ӡÒà Bridge àÊÁÍ !! *****
Bleeding Risk ¢Öé¹ÍÂÙè¡Ñºª¹Ô´ operation/procedure
áºè§à»ç¹ low/intermediate/high risk
¶éÒ low risk ÊÒÁÒö¼èÒä´éâ´ÂäÁèµéͧËÂØ´ÂÒ
intermediate : ãËé»ÃÖ¡ÉÒÈÑÅÂá¾·Âì
high risk : µéͧËÂØ´ÂÒ Êèǹ¨Ð bridge ËÃ×ÍäÁè bridge ãËé´ÙTE risk

Procedure ·Õè low risk àªè¹
>Endoscopy, Biopsy, Endovascular intervention, PCIs
>Cataract surgery, Dermatologic surgery, Dental extraction
>Total knee arthroplasty, Arthroscopic surgery
>Minor noncardiac surgeries
Steps ¡Òà Approach ¨Ðà»ç¹¡ÒöÒÁµÑÇàͧ ´Ñ§¹Õé
¶éÒ¼Ùé»èÇè on warfarin ÍÂÙèà´ÔÁ áÅÐÂѧäÁèÁÕ·Ò§ÇèÒ¨Ðä´éËÂØ´
1.> ¼èҵѴ´èǹäËÁ?
——> ¶éÒÃÍäÁèä´é ÍÒ¨äÁèÁÕàÇÅÒ bridge 
——> ¶éÒÃÍä´é ¨ÐÁÕàÇÅÒ bridge
2.> ¼èҵѴãË­èËÃ×ͼèҵѴàÅç¡?
—> ¼èҵѴãË­è ÁÕ high bleeding risk -> ¤ÇÃËÂØ´ÂÒ
Keep INR < 1.5
—> ¼èҵѴàÅç¡ ÁÕ low bleeding risk -> äÁèµéͧËÂØ´ÂÒ
3.> ¨Ð Bridging äËÁ? (¡Ã³ÕËÂØ´ÂÒ ¶éÒäÁèËÂØ´ÂÒ¡çäÁèµéͧ bridge ÊÔ)
—> ´Ù TE risk ¶éÒ high TE risk -> Bridge 
--> Low TE risk äÁèµéͧ Bridge
ÊÃØ»¤×Í
Emergency -> ¶éÒ¼èÒãË­èµéͧ reverse ´éÇ FFP, Vitamin K IV ¡è͹
****Vit K IV äÁè¤ÇÃãªé㹤¹ä¢é·ÕèÁÕ mechanical prosthesis
Minor operation -> äÁèËÂØ´ÂÒ ¨º ¼èÒä»àÅÂ
Major operation -> ËÂØ´ÂÒ 5 Çѹ -> ¾Ô¨ÒÃ³Ò risk TE
ÀÒ¾ÃÇÁ¢Í§¡Òà Bridging warfarin
¡µÑÇÍÂèÒ§ elective major surgery
¹Ñ´ãËé¼Ùé»èÇÂËÂØ´ÂÒàͧ¡è͹¼èҵѴ 5 Çѹ
¹Ñ´ãËé¼Ùé»èÇÂÁÒ admit ËÅѧËÂØ´ÂÒä´é 2 Çѹ à¾×èÍàÃÔèÁ start LMWH àÁ×èÍ INR < 2.0
ËÂØ´ LMWH ¡è͹·ÓËѵ¶¡Òà 12 hours à¨ÒÐ INR ¶éÒ INR > 1.5 ãËé Vitamin K 1-2.5 mg reverse
ËÅѧ¼èҵѴ¶éÒäÁè bleed ãËéàÃÔèÁ Warfarin + LMWH ã¹ 12-24 hours 
ãËé warfarin ä»àÃ×èÍÂæ ¨Ð off LMWH µèÍàÁ×èÍ INR à¢éÒ range 2 ÇѹµÔ´
à»ç¹Íѹ¨º¡Òà Bridging
( Dose : LMWH 1.5 mg/kg SC OD, LMWH 1 mg/kg SC bid)

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Warfarin ¤×ÍÂÒµéÒ¹¡ÒÃá¢ç§µÑǢͧàÅ×Í´ 
à»ç¹ VKA ËÃ×Í Vitamin K antagonist 
¡Å䡤×Í ã¹¢ºÇ¹¡Ò÷ÓãËéàÅ×Í´á¢ç§µÑÇ Warfarin ¨Ðµéҹķ¸Ôì¢Í§ vitamin K «Öè§à»ç¹ cofactor ·ÕèÊӤѭ㹡Òà activate clotting factor 2,7,9,10 ·Ñé§ã¹ extrinsic pathway áÅР

common pathway
Warfarin ¨Ðä»Ãº¡Ç¹ Vitamin K epoxide reductase 
â´Â enzyme ¹ÕéÁÕ˹éÒ·Õè reduct vitamin K ãËé¡ÅÒÂà»ç¹ Reduced vitamin K   «Öè§ Reduced vitamin K ¹Õéà»ç¹ cofactor ¢Í§ Vitamin K dependent carboxylase ·Õè¨Ð·Ó»¯Ô¡ÔÃÔÂÒ 

carboxylation hypofunctional Factor 2,7,9,10 ãËé¡ÅÒÂà»ç¹ functional Factor 2,7,9,10
¼Å¢Í§ Warfarin ¡ç¤×ͨзÓãËéÁÕ functional factor 2,7,9,10 Ŵŧ¹Ñè¹àͧ
â´ÂàÁ×èÍàÃÒãËéÂÒ warfarin à¢éÒ仹Ñ鹨ÐÊÒÁÒöŴ»ÃÔÁÒ³ clotting factor ä´é 30-50% àÅ·Õà´ÕÂÇ áµè¨ÐÊÒÁÒöŴä´é੾ÒÐ clotting factor ·ÕèÂѧäÁè¶Ù¡ÊÃéÒ§¢Öé¹à·èÒ¹Ñé¹ clotting 

factor ·ÕèäËÅàÇÕ¹㹡ÃÐáÊàÅ×Í´ÍÂÙèáÅéÇ¡è͹ä´éÃѺÂÒ ¨ÐäÁèä´éÃѺ¼ÅÍÐäÃàÅ (à¾ÃÒÐÊÃéÒ§ÁÒáÅéÇ) 
àÃÒ¨Ö§µéͧãËéÂÒ 7-10 Çѹ¶Ö§¨ÐàÃÔèÁàË繼ŢͧÂÒ

·Õèãªé¢Í§ÂÒ warfarin ¤×Í
> ãªé㹡ÒÃÃÑ¡ÉÒáÅлéͧ¡Ñ¹ PE, DVT
> ãªé㹡Òûéͧ¡Ñ¹ Thromboembolic phenomenon ã¹
—> ¼Ùé»èÇ·Õè on mechanical valve
—> ¼Ùé»èÇ post MI ·ÕèÁÕ indication
—> ¼Ùé»èÇ atrial fibrillation
—> ¼Ùé»èÇÂâäàÅ×Í´ºÒ§ª¹Ô´àªè¹ protein C, protein S deficiency

Warfarin µéͧÃÐÇѧÍѹµÃÒÂ㹡ÒÃãªéà¾ÃÒÐÁÕ  therapeutic index ᤺
¤×ͪèǧ¡ÒÃÃÑ¡ÉÒ᤺ÁÒ¡ ¹éÍÂ仡çäÁèä´é»ÃÐ⪹ì Áҡ仡çàÊÕè§ÍѹµÃÒ  µéͧ»ÃѺÂÒãËé¾ÍàËÁÒÐ( therapeutic  dose )

¡ÒõԴµÒÁÃдѺÂÒàÃÒ¨Ðãªé¤èÒ INR (International Normalized Ratio) «Ö觤ӹdz¨Ò¡ PT ¢Í§¼Ùé»èÇÂà·Õº¡Ñº mean PT ¢Í§»ÃЪҡÃ
áµèÅÐ condition ·ÕèàÃÒ¨ÐÃÑ¡ÉÒ¨ÐÁÕ¡Òà keep INR goal ·ÕèµèÒ§¡Ñ¹ ÊèǹÁÒ¡¨Ð keep »ÃÐÁÒ³ 2.0-3.0 
¶éÒËÒ¡ INR<2.0 ¨ÐÁÕ¤ÇÒÁàÊÕ觵èÍ¡ÒÃà¡Ô´ ÅÔèÁàÅ×Í´ÁÒ¡ äÁèä´é»ÃÐ⪹ì¨Ò¡ÂÒ
¶éÒËÒ¡ INR>3.0 ¨ÐÁÕ¤ÇÒÁàÊÕ觵èÍ¡ÒÃà¡Ô´àÅ×Í´ÍÍ¡ÁÒ¡ ·ÕèÊӤѭ¤×Í intracranial hemorrhage

´Ñ§¹Ñ鹤ÇûÃѺÂÒ warfarin ãËéàËÁÒÐÊÁ à¾ÃÒÐwarfarin»ÃѺÂÒ¡ à¹×èͧ¨Ò¡ ÁջѨ¨ÑÂËÅÒÂÍÂèÒ§·Õè·ÓãËéÁѹá¡Çè§ ÁÕ·Ñ駷Õè·ÓãËé INR ÊÙ§¢Öé¹ áÅзÕè·ÓãËé INR µèÓŧ

“ÍÒËÒÔ-- à»ç¹ÊÔ觷ÕèÊӤѭÁÒ¡ â´Â੾ÒÐÍÒËÒ÷ÕèÁÕ vitamin K ÊÙ§ ¤×;ǡ¼Ñ¡ãºà¢ÕÂÇ ¤Ð¹éÒ ¼Ñ¡â¢Á ¡ÃÐËÅèÓ»ÅÕ »ÇÂàÅé§ ¨Ðä»Å´Ä·¸Ôì¢Í§ warfarin ä´é 
áµèäÁèãªèÇèÒäÁèãËé¡Ô¹àÅ ËÅÑ¡·ÕèÊӤѭ¤×ÍÊÒÁÒö·Ò¹¼Ñ¡·Ò¹ä´éàËÁ×͹à´ÔÁ áµè¾ÂÒÂÒÁ·Ò¹ã¹»ÃÔÁÒ³à·èÒæ à´ÔÁ  ÍÂèÒ·Ò¹ÁÒ¡à¡Ô¹¡Çèҵ͹ªèǧ»ÃѺÂÒadvice ¼Ùé»èÇÂàÊÁÍÇèÒãËé

·Ò¹ÍÒËÒÃẺà´ÔÁ·Õèà¤Â·Ò¹ §´´×èÁáÍÅ¡ÍÎÍÅÅì §´ÊÙººØËÃÕè 
ã¹¢³Ð·ÕèâÊÁ (Ginseng) ¡ÃÐà·ÕÂÁ¨Ð·ÓãËé INR ÊÙ§¢Öé¹ ¨Ö§¤Çëѡ»ÃÐÇѵÔÍÒËÒÃàÊÃÔÁ ÊÁعä¾Ã·Õèãªé´éÇÂ

“ÂÒ”--warfarin  à»ç¹ÂÒ·ÕèµéͧÁÕ metabolism ¼èÒ¹·ÕèµÑº â´Âà͹䫹ì CYP450 
¼Ùé»èÇ·Õè on warfarin ÍÂÙèÊèǹãË­è¨ÐÁÕÂÒÍ×è¹·Õèµéͧ·Ò¹ÍÕ¡ËÅÒµÑÇ  ÂÒµÑÇ·Õèà»ç¹ CYP inhibitor áÅÐ CYP inducer ¨ÐÊ觼ÅÍÂèÒ§ÁÒ¡µèÍÃдѺÂÒ ·Õè¹èÒ¡ÅÑǤ×;ǡ CYP inhibitor 

à¾ÃÒШзÓãËéÃдѺÂÒà¡Ô¹ àÊÕ觵èÍ¡ÒÃÁÕàÅ×Í´ÍÍ¡ÁÒ¡¢Öé¹

“âäÃèÇÁÍ×è¹æ”--
Liver failure, cirrhosis: ·ÓãËé clotting factor ÁÕŴŧ warfarin ÍÍ¡Ä·¸Ôìà¾ÔèÁ¢Öé¹ 
Heart failure : àÅ×Í´ä»àÅÕ駵ѺŴŧ ÊÃéÒ§ clotting factor Ŵŧ áÅÐÅ´¡ÒáӨѴÂÒ warfarin ·ÓãËéÃдѺÂÒÊÙ§¢Öé¹ä´é
Kidney failure : à¡ÕèÂǡѺàÃ×èͧ¡ÒâѺÂÒÍÍ¡¨Ò¡ÃèÒ§¡ÒÂ
Malnutrition/hypoalbuminemia : ã¹¼Ùé»èÇ·Õè albumin µèӨзÓãËé free form ¢Í§ warfarin à¾ÔèÁ¢Öé¹ à¾ÔèÁÃдѺÂÒ (à¾ÃÒÐ warfarin à»ç¹ highly-protein binding)
“Hypermetabolic status” ä¢é hyperthyroidism infection ¨Ðà¾ÔèÁ¡Ò÷ÓÅÒ clotting factor Ä·¸Ôì¢Í§ warfarin ¨Ö§à¾ÔèÁ¢Öé¹ã¹ÀÒÇÐ stress àËÅèÒ¹Õé

à¾ÃÒЩйÑé¹ã¹¼ÙéÊÙ§ÍÒÂØ âäàÂÍÐæ ÇÒÂËÅÒÂæ ÍÂèÒ§µéͧÃÐÇѧÍÂèÒ§Áҡ㹡ÒÃãªéÂÒ  ÁÕâÍ¡ÒÊ·ÕèÃдѺÂÒ¨Ðá¡Çè§ä´éÁÒ¡ ¤ÇÃãªé¢¹Ò´µèÓæ áÅÐÂÔ觤¹ä¢é·Õè critically ill ·ÕèÁҹ͹

âç¾ÂÒºÒŵéͧÁÕ¡ÒõԴµÒÁ INR ´éÇÂà¾ÃÒÐÍÒ¨á¡Çè§ä´é¨Ò¡ hypermetabolic state
—————————————————————————
¡ÒÃàÃÔèÁÂÒ ´Ù¢éÒ§µé¹
—————————————————————————
 ¡ÒûÃѺÂÒãËéä´é INR goal ´Ù¢éÒ§µé¹

 Drug interaction ·ÕèÊӤѭ

áºè§à»ç¹¡ÅØèÁ·Õè·ÓãËéÄ·¸Ôì¢Í§ warfarin à¾ÔèÁ¢Öé¹ËÃ×Í INR ÊÙ§¢Öé¹áÅСÅØèÁ·Õè·ÓãËéÄ·¸ÔìŴŧ ËÃ×Í INR Ŵŧ
INR à¾ÔèÁ¢Öé¹ (¡ÅØèÁ¹Õé¹èÒ¡ÅÑÇà¾ÃÒШзÓãËé bleed)
Analgesics : Paracetamol, NSAIDs, Tramadol
Cardiovascular : Amiodarone, Statin, Propanolol
Antibiotics : Macrolides, FQs, Metronidazole, Bactrim
Antifungals : Azoles group
Acid suppression : PPIs, Cimetidine
NSAIDS : -coxib, -xicam
ÊÃØ»¤×;ǡ ATB: FQs, Azoles, Macrolides, MetronidazoleµéͧÃÐÁÑ´ÃÐÇѧ¡ÒÃãªé

¡ÅØèÁÂÒá¡é»Ç´·Ø¡¡ÅØèÁ Paracetamol, NSAIDS, Tramadol ÃÐÇѧINR Ŵŧ (¡ÅØèÁ¹ÕéäÁè¹èÒ¡ÅÑÇ à¾ÃÒÐá¤è¨Ð·ÓãËéäÁè¶Ö§ range §èÒÂæ)
Rifampin, Griseofulvin
Carbamazepine, Phenytoin
Phenobarbital
Cigarettes smoking
Cholestyramine
Sucralfate
—————————————————————————
Peri-operartive warfarin management ´Ù¢éÒ§µé¹
—————————————————————————

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Vitamin E, Fish oil, Gingko biloba (á»Ð¡êÇÂ) , Ginseng (âÊÁ)
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Create Date : 23 ÁÕ¹Ò¤Á 2561    
Last Update : 23 ÁÕ¹Ò¤Á 2561 10:29:37 ¹.
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EKG Parameter áÅÐ Argument ·Õèãªéá»Ã¼Å



´Ù EKG à¾×èÍ»ÃÐàÁÔ¹
1.Rate áÅФÇÒÁ¼Ô´»¡µÔ¢Í§ Rate
2.Rhythm (Pace) áÅФÇÒÁ¼Ô´»¡µÔ¢Í§ Rhythm
----Rhythm (Pace) = ËÑÇã¨àµé¹â´Â¡ÒáÃеØ鹨ҡµÓá˹è§ä˹
3. conduction áÅÐ conduction  ·Õè¼Ô´»¡µÔ(conductivity and blocking pathway ,or by pass pathway ,or reentry )
4.specfic condition  ÀÒÇмԴ»¡µÔ¨Óà¾ÒÐàªè¹ IHD ,MI ,electrolyte abnormal ,drug effect ,Brugada syndrome,cardiomegaly

EKG Parameter ¢éÍÁÙÅ·ÕèµéͧÃǺÃÇÁ áÅÐÊѧࡵءÒûÃÒ¡¯
Argument ÃÒÂÅÐàÍÕ´»ÅÕ¡ÂèÍ·ÕèäÁ褧·Õèã¹áµèÅÐ Parameter
----¢ÍãËéÃÐÅÖ¡àÊÁÍÇèÒ¶Ö§¤ÇÒÁ¼Ô´»¡µÔ¢Í§ EKG ÍÒ¨ÁÕËÅÒÂÍÂèÒ§á·Ã¡¼ÊÁ ÍÂèÒÅÐàÅ´éÒ¹Í×è¹àªè¹ MI ÍÒ¨ÁÕ SVT ,ËÃ×ÍÁÕAV block ÃèÇÁ´éÇ áÅÐ EKG ÍÒ¨¼Ô´»¡µÔ ä´éâ´ÂäÁèãªè¨Ò¡ËÑÇ㨠àªè¹à¡Å×ÍáÃè ¼¹Ñ§·Ãǧ͡

----EKG Parameter and Argument Íѹ·Õè¨ÃÔ§¡ç¤×ÍÃٻẺµèÒ§æ¢Í§¤Å×è¹ áÅЪèǧ·ÕèÊÒÁÒö¾ºä´éã¹áµèÅÐ EKG áµè·Õè¹ÓÁÒᨡᨧ áÅÐá¡áÂÐ ¡çà¾×èͪèÇÂ㹡ÒÃÇÔ¹Ô¨©ÑÂá¡ (Differential Diagnosis) ·Ñ駹Õéà¾ÃÒеÑǼÙéà¢Õ¹¤ÇÒÁ¨ÓäÁè´Õ ¨Ö§µéÍãªéÇÔ¸Õ¡ÒÃÁÒªèÇ (ÇÔ¸Õ¡ÒÃÇÔ·ÂÒ)
----àªè¹ Áͧà»ç¹ Wide QRS ¡çÍÒ¨µéͧᡨҡ bundle branch block ËÃ×Íᡨҡ ST elevation 㹺ҧÀÒ¾¢Í§ EKG

Parameter ÀÒ¾ÃÇÁ
----´ÙáÅéǼԴ»¡µÔäËÁ
----˹éÒµÒ¤ÇÒÁ¼Ô´»¡µÔàËÁ×͹¡Ñ¹ ËÃ×ÍᵡµèÒ§¡Ñ¹
----à»ç¹·Õè Lead ä˹ºéÒ§ ,à»ç¹·Ø¡ Lead ËÃ×ͺҧLead
----à»ç¹·Õè Chest lead ËÃ×Í Limb lead ËÃ×Íà»ç¹·Ñé§Êͧ·Õè
----à¡Ô´ºÒ§¤ÃÑé§ ËÃ×͵ÅÍ´àÇÅÒ ËÃ×Íà»ç¹ªèǧæ
----ÊÁèÓàÊÁÍËÃ×ÍäÁè (pattern «éÓæ¡Ñ¹ ¤Ò´à´ÒÅèǧ˹éÒä´é ,ËÃ×ÍÍÒ¨ÁÕ pattern à»ç¹¡ÅØèÁæáÅФҴà´Ò¡ÅØèÁµèÍä»ä´é) ,ËÃ×Í à»ç¹áººÊØèÁ¡ÒÃà¡Ô´¤Ò´à´ÒÂÒ¡
----¡éÒÇ˹éÒ¢Öé¹µÒÁÅӴѺáÅéÇàÃÔèÁãËÁè ËÃ×Í¡ÒÃà»ÅÕè¹á»Å§¡éÒÇ˹éÒä»àÃ×èÍÂæ

Parameter àº×éͧµé¹
----P
----PR interval
----PR segment
----Re-entry wave
----Q wave
----R
----R Wave Progression
----S wave
----Axis of QRS
----J point
----ST
----early repolarization
----QT interval  
----T
----U  
----Rate
----Regularity ãËé´Ù·Ñé§ P-P áÅÐ R-R  
----Rhythm Íѹ¹Õéà»ç¹ Parameter à¾×èÍÇÔ¹Ô¨©ÑÂà§×è͹䢤ÇÒÁ¼Ô´»¡µÔºÒ§ÍÂèÒ§ áµè㹺ҧ¡Ã³Õ¨ÐÂѧºÍ¡ä´éÂÒ¡ µéͧÍÒÈÑ  Parameter ¢éÒ§µé¹ÁÒ»ÃÐàÁÔ¹¡è͹¨Ö§¨ÐºÍ¡ä´é

¾×é¹°Ò¹
----12 Lead EKG =6 limb lead   ,6 chest lead
----¹ÔÂÁãªé Lead II à»ç¹¾×é¹°Ò¹
----¤Å×è¹ã¹ aVR ÁÑ¡¡ÅѺ¡Ñ¹¡Ñº Lead Í×è¹

normal conduction pathway

ã¹Åѡɳл¡µÔ ¨ÐÁÕ¡ÒèѺ¤Å×è¹ä¿¿éÒ¨Ò¡ËÑÇ㨵ÒÁÅӴѺ´Ñ§¹Õé
SA node---->atrium fiber---->AV node---->bundle of His---->ventricular branch---->ventricular fiber (Perkinje fiber) áÅШÐÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸ì¢Í§ atrium áÅР ventricular àÊÁÍ

ªèͧÁҵðҹ
1ªèͧàÅç¡ =0.04 sec ,5ªèͧàÅç¡=0.2 sec ¤ÇÒÁÊÙ§ 1 mv=10mm

P ( »¡µÔ¤×Í P ¨Ò¡ SA node---->Sinus P)
----Sinus P ¡ÇéÒ§ 0.12 sec (3 ªèͧ) ÊÙ§ <3 mm sinus PËÑǵÑé§ã¹ II ,ËÑÇ¡ÅѺ㹠aVR
----ÁÕ QRS µÒÁ
ÅѡɳÐP parameter  Argument ·Õ辺ºèÍÂ
----biphasic P(Pp')
----nonSinus P
----not seen P ( absent P ËÃ×ÍäÁèÁÕ P ,P «è͹㹤Å×è¹Í×è¹  ,P on T  ,P on QRS)
----flat P ,P àµÕéÂæ (ºÒ§¤ÃÑé§àµÕ騹ÁͧäÁèàËç¹)
----tall P
----multi morphic P
----P¢ÂØ¡¢ÂÔ¡  ,P ¿Ñ¹àÅ×èÍÂ......ºÒ§·Õ¡çÁͧäÁèÍÍ¡ ÃÙéáµèÇèÒäÁèÁÕ P ËÃ×ÍäÁèãªè Sinus P ¨Ò¡¹Ñ鹨֧ÊѧࡵØàÍÒ áµè¾Ç¡¹ÕéÁÑ¡ÁÕ QRS ᤺
----invert P
----Retrograd P (ÁÑ¡à¡Ô´¨Ò¡ junction áÅéÇÂé͹仡ÃеØé¹àÍàµÕÂÁ ´Ñ§¹Ñé¹Áѹ¨ÐµÒÁËÅѧ R)
----à»ç¹·Ø¡ PËÃ×ÍÁÕá¤èºÒ§¤ÃÑé§ (junctional escape beat ¡çÁÕ¹Ð)
----P associate ¡Ñº QRS ËÃ×ÍäÁè
----QRS µÒÁ PËÃ×ÍäÁè  à»ç¹·Ø¡µÑÇËÃ×ÍäÁè  ,QRS·ÕèµÒÁ P ˹éÒµÒàËÁ×͹¡Ñ¹ËÃ×Íà»ÅèÒ
----P ·Õè¹Ó˹éÒ QRS àËÁ×͹¡Ñ¹·Ø¡µÑÇäËÁ áÅÐà»ç¹ Sinus PËÃ×ÍäÁè
----QRS  irregular ËÃ×ÍäÁè  (AF/A flutter QRS ÁÑ¡ irregular)
----¤ÇÒÁ¼Ô´»¡µÔ·Õ辺ÁÕÅѡɳРà»ç¹µèÍà¹×èͧ ËÃ×Íà»ç¹ºÒ§¤ÃÑé§ ËÃ×ÍÁÕà»ç¹ªØ´æ㹺ҧ¨Ñ§ËÇÐ

¨Ò¡ÅѡɳРP parameter Argument ¹Óä»»ÃÐàÁÔ¹ rate ,rhythm (Pace),coductivity ,specific condition (ÍÒ¨µéͧ´Ù Parameter  ¤Å×è¹Í×è¹»ÃСͺ)

PR interval
¤èÒ»¡µÔàÃÔèÁ¨Ò¡¨Ø´àÃÔèÁ P 件֧¨Ø´àÃÔèÁ R  ÂÒÇ 0.12-0.2 sec (3-5 ªèͧ)
ÅѡɳÐPR parameter  Argument ·Õ辺ºèÍÂ
----vary PR
----PR dissociation
----long PR
----Short PR
----Progress length of  PR
----P no QRS (look for Progress PR first,then look complete AV block)
----pause of P and QRS (ËÃ×Í long TP)

PR segment
----àÃÔèÁ¨Ò¡¨Ø´ÊÔé¹ÊØ´ P wave ËÁ´·Õè¨Ø´àÃÔèÁ¢Í§ QRS complex »¡µÔ¨ÐàÃÕº
ÅѡɳÐPR segment parameter  Argument ·Õ辺ºèÍÂ
----elevated(¾ºã¹ atrial infarction or pericarditis )
----depressed (¾ºã¹ large repolarization wave (Tp) following the P wave)

QRS
QRS ¡ÇéÒ§ 0.06-0.1 sec (1ªèͧ¤ÃÖè§ ¶Ö§ 2ªèͧ¤ÃÖè§) normal Q äÁèà¡Ô¹ 0.03 sec (¹éÍ¡ÇèÒ 1 ªèͧ)
QRS amplitude normal.........S amplitude in V1 + R amplitude in V5 < 3.5 millivolt (mV)
....................................................R+S in a precordial lead < 4.5 mV
....................................................R in V5 or V6 < 2.6 mV
ÅѡɳÐQRS parameter Argument ·Õ辺ºèÍÂ
----ÃٻẺQRS à·èÒ·ÕèÃǺÃÇÁä´é

>>>>>  qRs (»¡µÔ¨ÐẺ¹Õé)  ,QS(but maybe looklike deep Q) ,Rs ,rS ,qR ,rSR' ,RsR' ,R ,S ,q ,QR

----QRS â´ÂÃÇÁ´Ù᤺ áµè´ÙáÅéÇäÁ軡µÔ
----QRS without P
----QRS¡ÇéÒ§ ( wide QRS ) áµèµéͧá¡ÀÒÇÐ QRS ¡ÇéÒ§äÁè¨ÃÔ§àÊÕ¡è͹ (¤×Í QRS᤺ áµèÁÕÀÒÇÐÍ×è¹·ÓãËé´ÙàËÁ×͹¡ÇéÒ§  retrograde P ,ÁÕ P ÍÂÙèªÔ´ QRS ,ÁÕ Delta wave ,ÁÕ ST change ,ÁÕ J point ¼Ô´»¡µÔ(early repolalization) ,ÁÕ BBB
----QRS¡ÇéÒ§ ( wide QRS ) áÅÐà»ç¹ QRS ·Õè¡ÇéÒ§¨ÃÔ§ ¡çÂѧÍÒ¨ÁÕ¤Å×è¹àÅ硤Å×è¹¹éÍ áÅСÒùÓä¿¿éÒ·ÕèµÔ´¢Ñ´(BBB) ÃÇÁ·Ñé§ Node block à¢éÒ¼ÊÁâç´éǹÐ
----Same different shape QRS
----Group of Same different shape QRS
----multi of different shape QRS
----notch QRS(RsR')
----low QRS
----tall QRS
----¤ÇÒÁ¼Ô´»¡µÔ·Õ辺ÁÕÅѡɳРà»ç¹µèÍà¹×èͧ ËÃ×Íà»ç¹ºÒ§¤ÃÑé§ ËÃ×ÍÁÕà»ç¹ªØ´æ㹺ҧ¨Ñ§ËÇÐ
Q wave
-Duration up to 0.04 seconds in leads other than III and aVR
-Amplitude less than 1/3 QRS amplitude[4] (R+S)
-Amplitude less than 1/4 of R wave
ÅѡɳÐQ  parameter Argument ·Õ辺ºèÍÂ
----Q > 1/3 R
----large Q
----no Q
----¾º small Q ºèÍÂã¹ aVf ,V5

R wave ,S wave
-normal R wave ¨Ò¡ V1-V6 ¨ÐÁÕ progression (ÊÙ£¢Öé¹àÃ×èÍÂæ) ¢³Ð·ÕèS wave ¨Ð¤èÍÂæàÅç¡Å§µÒÁÅӴѺ
- R wave ¨ÐÊÙ§¾Íæ¡Ñº¤ÇÒÁÅÖ¡¢Í§ S wave ( Transitional zone ) ·Õè V3-4
- »¡µÔ  R wave ã¹ lead V3 ¨ÐÊÙ§ÁÒ¡¡ÇèÒ 3 ÁÁ. ¶éÒäÁè¶Ö§ àÃÕ¡ÇèÒ poor R progression - ¤ÇÒÁÊÙ§¢Í§ R wave ã¹ limb leads ¤ÇÃÊÙ§ > 5 ÁÁ. ¶éÒ¹éÍ¡ÇèÒàÃÕ¡ÇèÒ low voltage in limb leads
- ¤ÇÒÁÊÙ§¢Í§ R wave ã¹ chest leads ¤ÇÃÊÙ§ > 10 ÁÁ. ¶éÒ¹éÍ¡ÇèÒàÃÕ¡ÇèÒ low voltage in chest leads
- ¤ÇÒÁÊÙ§¢Í§ QRS complex äÁè¤ÇÃà¡Ô¹ 25 ÁÁ.
ÅѡɳÐR parameter Argument ·Õ辺ºèÍÂ
----Dominant R wave in V1
----Dominant R wave in aVR
----Poor R wave progression («Öè§ËÁÒ¶֧ Old MI, RVH, LVH ËÃ×Í normal)
----early R
----Tall R
----Low R

QRS axis
¢ÍÊÒÃÀÒ¾ÇèÒ äÁè¤èÍÂä´é¤Ó¹Ç³ à¾ÃÒдéǾ×鹤ÇÒÁÃÙé  äÁè¤èÍÂä´é¹ÓÁÒãªé  áÅкҧ·ÕÁѹäÁèãªè Normal QRS ·ÓãËéá»Ã·ÔÈ·Ò§àǤàµÍÃì QRS áÅéÇ ¡çäÁèä´é¹ÓÁÒµèÍÂÍ´
»¡µÔÁÕÇÔ¸Õ¡ÒÃÅÐàÍÕ´ áµè¢Í§¼Á¢Íãªé¡ÒûÃÐàÁÔ¹¤ÃèÒÇæ â´Â´Ù  lead I, aVF áÅÐÍÒ¨´Ù  lead II ´éÇÂ
Normal axis »¡µÔ
 I + ,aVF +   
Lf axis Deviation
 I + ,aVF -
Rt axis Deviation
 I - ,aVF +
áµè¶éÒ
 I - ,aVF -  >>>á»Ã¼ÅÂÒ¡

[ »¡µÔ QRS axis ÍÂÙèÃÐËÇèÒ§ -30o ¶Ö§ +100 o â´Â´Ù¨Ò¡ leadI áÅÐ AVF ÃèÇÁ¡Ñº reciprocal lead
----1. Right axis deviation (RAD > +90 o) ¾ºä´éã¹ Normal variant (child 90-120o), dextrocardia, RV overload (pulmonary embolism, COPD, asthma, RVH), lateral wall MI, LPHB (> +120 o diagnosis by exclusion)
----2. Left axis deviation (LAD > -30o) ¾ºä´éã¹ LVH, LAHB (> -45 o), LBBB, Inferior wall MI ]

J point áÅÐ ST segment
J point
----J point  à»ç¹¨Ø´ÊѧࡵØÍѹ˹Öè§ µÓá˹觤×ͨشÊÔé¹ÊØ´  S wave  â´Âà»ç¹¨Ø´·Õèà»ÅÕè¹á»Å§ÅѡɳТͧ QRS complex à»ç¹ ST segment
----»¡µÔ j point ¨ÐÍÂÙèã¹àÊé¹  Isoelectric line  ¤×ÍàÊé¹ÅÒ¡¨Ò¡ P wave  µÃ§ PR segment  ÁÒ¶Ö§¨Ø´ÊÔé¹ÊØ´¢Í§ T wave ¨Ðä´éàÊé¹ÃÒº isoelectric line áÊéǴٵç¨Ø´·ÕèÁÕ¡ÒÃà»ÅÕÂ蹨ҡ QRS -> ST µÃ§¹Ñ鹤×Í J point
----J point ¨ÐÊѧࡵاèÒ¶éÒ  ST segment ÍÂÙèã¹á¹ÇÃÒº áÅÐÁØÁËÑ¡¢Í§ QRS à»ç¹ÁØÁáËÅÁ áµè¶éÒ ST segment ÅÒ´àÍÕ§ ËÃ×Í QRS ¡ÇéÒ§¡ç¨ÐÊѧࡵØÂÒ¡
----J point ¹ÔÂÒÁ¨Ò¡ wiki
    The "first point of inflection of the upstroke of the S wave"[11]
    The point at which the ECG trace becomes more horizontal than vertical[12]
----¡Òô٠J point  ÊÙ§ËÃ×͵èÓ  ãËéÇÑ´¨Ò¡ isoelectric line â´ÂãËé´Ù·Õè 1 ªèͧàÅ硶Ѵ¨Ò¡ J-point (0.04 sec)
----¡ÒÃà»ÅÕè¹á»Å§µÓá˹觠 J point  ËÁÒ¶֧¡ÒÃàà»ÅÕè¹á»Å§ ST segment
  J point  ÍÂÙèÊÙ§ =  ST  elevation  , ¶éÒ  J point  µèÓŧ ¤×Í ST depress
ÅѡɳÐJ point  parameter  Argument ·Õ辺
----J point  elevate
----J point  depress
----J-point notching ( fish hook pattern )

ST segment
----àÃÔèÁ¨Ò¡¨Ø´ÊÔé¹ÊØ´ S (J point)件֧¨Ø´àÃÔèÁ T
----ÊÙ§ä´éäÁèà¡Ô¹ 1 mV ã¹ Limb Lead ,äÁèà¡Ô¹ 2 mVã¹ chest Lead
----»¡µÔ¨ÐàÃÕºâ¤é§àÅ硹éÍ áµèËÒ¡ÁÕÍÐäÃà¾ÔèÁ ¡çÁÑ¡äÁèàÃÕº
----ST segment à»ç¹¢éÍ·ÕèÂѧÊѺʹ¡Ñº¡ÒÃÃÐºØ Argument ¢Í§ parameter µÑǹÕé à¾ÃÒÐ ST segment  ¹ÓÁÒãªéºÍ¡¶Ö§¡ÒúҴà¨çº¢Í§ Myocardium  â´ÂÃкØä»·Õè¤ÓÇèÒ ST elevation  áÅÐ ST elevation
----áµèàÁ×èÍÇÔà¤ÃÒÐËç¨ÃÔ§æ¡ÅѺäÁè§èÒ à¾ÃÒÐÁÕºÒ§ÀÒÇТͧ¡ÒÃà»ÅÕè¹á»Å§ ST elevation  ·ÕèäÁèãªèàÃ×èͧÃعáç àªè¹ Early Repolarization à»ç¹µé¹
----¨Ö§ä´éÁÕá¹Ç·Ò§ÇÔà¤ÃÒÐËç ST elevation  ËÅÒÂẺà¾×è͹ÓÁÒÁͧÇèÒÁÕ¡ÒúҴà¨çº¢Í§ myocardium  ¨ÃÔ§ËÃ×ÍäÁè  ¶éÒÁÕâÍ¡Òʤ§ä´éàÅèÒÊÙè¡Ñ¹
ÅѡɳÐST parameter   Argument ·Õ辺ºèÍÂ
----ST elevation concave  ( J point elevation ) with or without  reciprocal ST depression
----ST elevation convex ( J point elevation ) with or without  reciprocal ST depression
----ST elevation  ¹Ñé¹ straight ËÃ×Í convex ,concave   ,primary ,secondary ËÃ×ÍÁÕ·Ñé§ÊͧÍÂèÒ§ÃÇÁ¡Ñ¹
----ST depression (ÍÒ¨à»ç¹  reciprocal ST depression ¡çä´é)
----ST ËÒäÁèà¨Í ËÃ×ÍäÁèàË繪Ѵਹ
----ST depression ¹Ñé¹ straight or horizontal ,sagging( àÇéÒáÅéÇâ¤é§¢Öé¹) ,strain pattern ,,primary ,secondary ËÃ×ÍÁÕ·Ñé§ÊͧÍÂèÒ§ÃÇÁ¡Ñ¹

QT interval
----àÃÔèÁ¨Ò¡¨Ø´àÃÔèÁ Q 件֧¨Ø´ÊÔé¹ÊØ´ T                   
----»¡µÔäÁèà¡Ô¹ 0.44                
----ËÒ¡ ÁÕU wave ¨ÐÇÑ´¶Ö§¨Ø´ÊÔé¹ÊØ´ U wave áÅÐàÃÕ¡ÇèÒ Q-TU interval.á·¹
----â´Â»¡µÔ QT interval ¨ÐÁÕ¤ÇÒÁÂÒǹéÍ¡ÇèÒ¤ÃÖè§Ë¹Ö觢ͧ RR interval áµè¶éÒËÑÇã¨àµé¹àÃçÇ¡ÇèÒ 90 ¤ÃÑ駵èÍ¹Ò·Õ QT interval ÍÒ¨ÂÒÇà¡Ô¹¤ÃÖ觢ͧ RR interval ä´é
QTc : corrected  QT interval
----QTc »¡µÔ 330-440 ms
----à¾ÃÒФèÒ QT interval ¨ÐÁÕ¤ÇÒÁᵡµèÒ§µÒÁÍÒÂØ à¾È  áÅÐÍѵÃÒ¡ÒÃàµé¹¢Í§ËÑÇã¨
----¨Ö§µéͧ¤Ó¹Ç³¤èÒà¾×èÍÅ´¼Å¡ÃзºÍѵÃÒ¡ÒÃàµé¹¢Í§ËÑÇ㨠µèÍ QT segment ãËé¶Ù¡µéͧ â´Âãªé corrected  QT interval  :  QTc
----QTc = QT/square root RR = QT + 1.75(HR - 60) ...ÁÕÍÕ¡ËÅÒÂÊÙµÃ
ÅѡɳРQT parameter   Argument·Õ辺ºèÍÂ
----1.Short QT
----2.Long QT

T    
----T ¨ÐÁÕ·ÔÈà´ÕÂǡѺ QRS complex. ´Ñ§¹Ñé¹ËÒ¡ QRS complex  negative,T ¡çÍÒ¨ negativeàªè¹¡Ñ¹
ÅѡɳÐT »¡µÔ
----up right ã¹ I ,II ,V3-V6 ,invert ã¹ aVR  ,áÅÐÍÒ¨¨Ð positive ËÃ×Í negative ã¹ lead III, aVL, aVF
----ÊÙ§ < 5 mV ã¹ Limb lead ,ÊÙ§ < 10 mV ã¹ chest Lead     
ÅѡɳРT parameter  Argument ·Õ辺ºèÍÂ
----Tall T  
----Flat T
----Deep T Inversion
----·ÔÈ·Ò§¼Ô´ä»¨Ò¡·Õè¤ÇèÐà»ç¹ã¹áµèÅÐ lead               

U
----¾ºËÅѧ T
----»¡µÔ¾ºã¹ V2-V4  
----¢¹Ò´ < 0.2 mV ·ÔÈà´ÕÂǡѺ T
---- Purkinje fibers repolarization
---- à¡Ô´µÒÁËÅѧ T wave
Åѡɳ ÐU parameter  Argument ·Õ辺ºèÍÂ
----Prominent U wave
----U wave inversion




 

Create Date : 05 Á¡ÃÒ¤Á 2561    
Last Update : 10 ¾ÄÉÀÒ¤Á 2561 7:47:51 ¹.
Counter : 3680 Pageviews.  

ÍèÒ¹ EKG



ÍèÒ¹ EKG

àÃÒ´Ù EKG à¾×èÍ»ÃÐàÁÔ¹¡Ò÷ӧҹËÑÇã¨
ã¹ÀÒÉÒªÒǺéÒ¹¤×Í
´ÙÇèÒËÑÇã¨àµé¹ÍÂèÒ§äà àµé¹àÃçÇËÃ×ͪéÒ ÊÁèÓàÊÁÍäËÁ 
¡ÒÃàµé¹¶Ù¡µÇº¤ØÁã¹ÅѡɳÐã´ 
ÁÕ¡ÒùÓä¿¿éÒ¼Ô´»¡µÔäËÁ 
ÁÕÀÒÇоÔàÈÉÍÐäà ËÃ×ÍÁÕÍÐäáÃзº¡Ò÷ӧҹËÑÇ㨷Õè´Ùä´é¨Ò¡  EKG 
áÅÐËÑÇã¨àµé¹ÊÙº©Õ´àÅ×Í´ä´é¾Íà¾Õ§µèÍ¡ÒùÓàÅ×Í´ä»àÅÕéÂÇÃèÒ§¡ÒÂÊèǹÍ×è¹ËÃ×ÍäÁè 

«Öè§ã¹ÅѡɳРOfficial report ÁÑ¡ÃÒ§ҹµÒÁËÑÇ¢éÍ¢éÒ§ÅèÒ§
1.Rate áÅФÇÒÁ¼Ô´»¡µÔ¢Í§ Rate
2.Rhythm (Pace) áÅФÇÒÁ¼Ô´»¡µÔ¢Í§ Rhythm
----Rhythm (Pace) = ËÑÇã¨àµé¹â´Â¡ÒáÃеØ鹨ҡµÓá˹è§ä˹
3. conduction áÅÐ conduction  ·Õè¼Ô´»¡µÔ(conductivity and blocking pathway ,or by pass pathway ,or reentry )
4.specfic condition  ÀÒÇмԴ»¡µÔ¨Óà¾ÒÐàªè¹ IHD ,MI ,electrolyte abnormal ,drug effect ,Brugada syndrome,cardiomegaly

áµè㹡Ò÷ӧҹ¨ÃÔ§æàÃÒÁÕà»éÒËÁÒ¡ÒÃÍèÒ¹´Ñ§¹Õé
1......à¾×èÍÂ×¹Âѹ¡ÒÃÇÔ¹Ô¨©Ñ¨ҡ»ÃÐÇѵÔáÅСÒõÃǨÃèÒ§¡Ò Ac MI ,cardiac arrhythmia
2......à¾×èÍÂ×¹Âѹ¼Å·Ò§Ëéͧ»¯ÔºÑµÔ¡Òà àªè¹ hyperkalemia ,hypokalemia
3......à¾×èÍ»ÃÐàÁÔ¹¡Ò÷ӧҹËÑÇ㨠áÅÐÃÒ§ҹ Ẻ Official report

1 áÅÐ 2 ¨ÐäÁè¤èÍ«Ѻ«é͹ à¾ÃÒÐÊèǹãË­è¨ÐÁÕÃٻẺ·Õèà·Õºà¤Õ§ä´é ¡àÇé¹ÇèÒÁÕÀÒÇÐÍ×è¹á½§ ·ÓãËé EKG pattern äÁèà»ç¹»¡µÔ
µÑÇÍÂèÒ§àªè¹
.....Acute ST elevate MI ,NonST - segment elevate MI ,PVC ,SVT ,VT ,myocardial ischemia
.....electrolytes imbalance ( hypokalemia, hyperkalemia), drugs (àªè¹Ê§ÊÑÂÁռŨҡÂÒ㹡ÅØèÁ class IA, III antiarrhythmic agents, psychotropic agentsà»ç¹µé¹.)áµè㹺ҧ¤ÃÑ駡çÍÒ¨äÁè§èÒ¹ѡ àªè¹¼Ùé»èÇÂÁÕ Old infarct ÁÒ¡è͹ ËÃ×ÍÁÕ BBB ÁÒ¡è͹
ÊÁÁصÔÇèÒ¤¹ä¢éà¨çºÍ¡ á¹è¹Í¡ ʧÊÑ MI ¡ç Run EKG áÅéÇ´Ù  pattern ÇèÒà¢éÒä´é¡Ñº MI ËÃ×ÍäÁè
ËÃ×ͼÙé»èÇÂã¨ÊÑè¹ËÑÇã¨àµé¹àÃçÇ ¡ç Run EKG áÅéÇ´ÙÇèÒ¤×ÍÍÐäà VT ,SVT (áµèºÒ§¤ÃÑ駡çà¨Í SVT with BBB «Öè§ÁÕ QRS ¡ÇéÒ§ áÅд٤ÅéÒ VT ¡çÍÒ¨ÂÒ¡ºéÒ§áµè¤§¾Íá¡ÀÒÇСѹä´é

ËÃ×Íà¨ÒÐàÅ×Í´¾º hyperkalemia ¡çÍÒ¨ Run EKG à¾×èÍÂ×¹ÂѹÇèÒÊÙ§¨ÃÔ§ áÅСÃзº¡Ò÷ӧҹËÑÇ㨠áÅéǨ֧´Óà¹Ô¹¡ÒôÙáÅÃÑ¡ÉÒãËé¶Ù¡µéͧµèÍä»

·Ñé§ËÁ´¹Õé¢ÍãËé´Ùã¹ËÑÇ¢éÍ EKG ã¹ÀÒÇШÓà¾ÒÐ µèÍä»

ÊÓËÃѺ¡ÒÃÍèÒ¹ã¹ÅѡɳРOfficial report
ºÒ§¤ÃÑ駡çÍèÒ¹ä´é§èÒ áµèºÒ§¤ÃÑ駡çÍèÒ¹ÂÒ¡ ã¹ËÅÒ¡óը֧ãªéà¤Ã×èͧ EKG ·ÕèÁÕ¼ÅÍèÒ¹àº×éͧµé¹ÁÒãªé «Ö觡çÊ´Ç¡ áµèºÒ§¤ÃÑé§àÁ×èÍãªéà¤Ã×èͧ·ÕèäÁèä´éÍèÒ¹¼ÅÁÒãËé ¡çµéͧÍèÒ¹àͧáÅÐÁÑ¡¨Ðà»ç¹àÃ×èͧÂÒ¡àÊÁÍà¾ÃÒмÙé»èÇÂÁÑ¡ÁÕÊÀÒ¾·ÕèµéͧµÑ´ÊÔ¹¡ÒÃÃÑ¡ÉÒÇèÒ¨ÐãªéÃٻẺã´
â´Â·ÑèÇ仨ÐÍèÒ¹´Ñ§¹Õé

¡è͹Í×è¹»ÃÐàÁÔ¹àº×éͧµé¹
----´ÙáÅéǼԴ»¡µÔäËÁ
----˹éÒµÒ¤ÇÒÁ¼Ô´»¡µÔàËÁ×͹¡Ñ¹ ËÃ×ÍᵡµèÒ§¡Ñ¹
----à»ç¹·Õè Lead ä˹ºéÒ§ ,à»ç¹·Ø¡ Lead ËÃ×ͺҧLead
----à»ç¹·Õè Chest lead ËÃ×Í Limb lead ËÃ×Íà»ç¹·Ñé§Êͧ·Õè
----à¡Ô´ºÒ§¤ÃÑé§ ËÃ×͵ÅÍ´àÇÅÒ ËÃ×Íà»ç¹ªèǧæ
----ÊÁèÓàÊÁÍËÃ×ÍäÁè (pattern «éÓæ¡Ñ¹ ¤Ò´à´ÒÅèǧ˹éÒä´é ,ËÃ×ÍÍÒ¨ÁÕ pattern à»ç¹¡ÅØèÁæáÅФҴà´Ò¡ÅØèÁµèÍä»ä´é) ,ËÃ×Í à»ç¹áººÊØèÁ¡ÒÃà¡Ô´¤Ò´à´ÒÂÒ¡
----¡éÒÇ˹éÒ¢Öé¹µÒÁÅӴѺáÅéÇàÃÔèÁãËÁè ËÃ×Í¡ÒÃà»ÅÕè¹á»Å§¡éÒÇ˹éÒä»àÃ×èÍÂæ
----ÍÕ¡Íѹ˹Ö觤×ÍÁբͧà´ÔÁà·ÕºäËÁ ÍѹãËÁèᵡµèÒ§¨Ò¡à´ÔÁËÃ×ÍäÁè «Ö觺ҧ¤ÃÑ駪èÇÂä´é´Õ㹡ÒõѴÊÔ¹ã¨ÃÑ¡ÉÒ

·Ñé§ËÁ´à¾×èÍàµ×͹ã¨äÁèãËéÅÐàÅ ¨Ò¡¹Ñé¹äÅè

1.Rate áÅФÇÒÁ¼Ô´»¡µÔ¢Í§ Rate
´ÙÇèÒËÑÇã¨àµé¹´éÇ Rate à·èÒã´ â´Â੾ÒСÒÃàµé¹¢Í§ Ventricle à¾ÃÒСÒÃàµé¹¢Í§ Ventricle ËÁÒ¶֧¡ÒúպàÅ×Í´ÍÍ¡¨Ò¡ËÑÇã¨ä»àÅÕé§ÃèÒ§¡Ò +仿͡·Õè»Í´
ËÒ¡ÍèÒ¹ Rate äÁèä´é ¤Çè´äÇé¡è͹ áÅÐÃкØÇèÒ¨Ò¡ÊÒà˵Øã´àªè¹ àµé¹äÁèÊÁèÓàÊÁÍ à¾ÃÒкҧ¤ÃÑé§àÁ×èͤú¢Ñ鹵͹¡ÒÃÍèÒ¹ ¡ÅѺÊÒÁÒöÃкØä´é

2.Rhythm (Pace) áÅФÇÒÁ¼Ô´»¡µÔ¢Í§ Rhythm
----Rhythm (Pace) = ËÑÇã¨àµé¹â´Â¡ÒáÃеØ鹨ҡµÓá˹è§ä˹
----Rhythm â´Â·ÑèÇä»ãËéËÁÒ¶֧¡ÒÃàµé¹¢Í§ Ventricle ÇèҤǺ¤ØÁâ´Â Atrium ËÃ×ÍäÁè  ÍÂèÒ§äà ËÃ×Íàµé¹àͧ  áÅÐ㹺ҧ¤Ãé§ÍÒ¨µéͧÃкءÒÃàµé¹¢Í§ Atrium ´éÇÂàªè¹ AF
----Rhythm ÁÑ¡ÇÔà¤ÃÒÐËìä´é ¨Ò¡ÃÙ»ÃèÒ§ µÓáË¹è§ ¢¹Ò´ ¤ÇÒÁÂÒÇ¡ÇéÒ§ áÅРArgument Í×蹢ͧ parameter  P ,PR ,QRS «Ö觺ҧ¤ÃÑ駡çÂÒ¡ËÒ¡ÁÕ conduction·Õè¼Ô´»¡µÔ
àªè¹¡Ñ¹¡Ñº¡ÒÃÍèÒ¹ Rate ËÒ¡äÁèÊÒÁÒöÍèÒ¹ Rhythm ä´é㹤ÃÑé§áá ¤Çè´ Argument ¢Í§ parameter ¤Å×è¹µèÒ§æäÇé¡è͹ áÅÐÃкØÇèÒẺ㴠à¾ÃÒÐàÁ×èͤú¢Ñ鹵͹¡ÒÃÍèÒ¹ ÁÑ¡ÊÒÁÒöÃкØä´é
3. conduction áÅÐ conduction·Õè¼Ô´»¡µÔ(conductivity and blocking pathway ,or by pass pathway ,or reentry )
 ¡ÒùÓä¿¿éÒâ´Â»¡µÔà»ç¹´Ñ§¹Õé 
SA node---->atrium fiber---->AV node---->bundle of His---->ventricular branch---->ventricular fiber (Perkinje fiber)
¡ÒùÓä¿¿éÒ·Õè¼Ô´»¡µÔ¤×Í ÍÒ¨ÁÕ¡ÒõԴ¢Ñ´(·Ñé§áººªéÒ¡ÇèÒà´ÔÁ ËÃ×Íä¿¿éÒäÁè¼èÒ¹) ÍÒ¨ÁÕ¡ÒÃÅÑ´¼èÒ¹¨Ò¡·ÔÈ·Ò§»¡µÔ ÍÒ¨ÁÕ¡ÒÃÂé͹¡ÅѺ¢Í§ä¿¿éÒ(retrograde)  ËÃ×ÍÍÒ¨ÁÕ¡ÒÃËÁعǹ¢Í§ä¿¿éÒ ³ µÓá˹è§ã´
¡Ã³Õ RhythmäÁèãªè SA node ¡çÂѧµéͧÇÔà¤ÃÒÐËì¡ÒùÓä¿¿éÒÃèÇÁ´éÇ (ÊèǹãË­èµÑé§áµè AV node Å§ÁÒ)

4.specfic condition  ÀÒÇмԴ»¡µÔ¨Óà¾ÒÐàªè¹ IHD ,MI ,electrolyte abnormal ,drug effect ,Brugada syndrome,cardiomegaly
 Íѹ¹ÕéÁÕÁÒ¡ÁÒ ÁÑ¡µéͧãªéËÅÒ¤Å×è¹áÅÐËÅÒªèǧÁÒÃèÇÁ»ÃÐàÁÔ¹ à¾×èÍãËéá»Ã¼Åã¡Åéà¤Õ§·ÕèÊØ´





 

Create Date : 05 Á¡ÃÒ¤Á 2561    
Last Update : 4 ¾ÄÉÀÒ¤Á 2561 9:50:14 ¹.
Counter : 592 Pageviews.  

Rate áÅÐ Rhythm





Rate áÅÐ Rhythm

Rate ¤×Í ÍѵáÒÃàµé¹¢Í§ËÑÇ㨠ÁÕ·Ñ駡ÒÃàµé¹¢Í§ Atrium áÅÐ Ventricle áµèÊèǹãË­è¨Ðà¹é¹ä»·Õè¡ÒÃàµé¹¢Í§ ventricle (à¾ÃÒÐàÅ×Í´¨Ðä»àÅÕé§ÃèÒ§¡ÒÂä´é¨Ò¡¡ÒúպµÑǢͧ ventricle ¹Ñè¹àͧ)

Rhythm ¤×Í â´Â·ÑèÇä»ËÁÒ¶֧ÇèÒ ¡ÒÃàµé¹¢Í§ Ventricle ÁÕµÑÇ¡Ó˹´¨Ñ§ËÇÐẺä˹ ¨Ò¡áËÅè§ä˹ ÁÕ¡ÒùÓä¿¿éÒ¼Ô´»¡µÔËÃ×ÍäÁè ã¹ÅѡɳÐã´

Rate 

¤Ó¹Ç³â´ÂÍÒÈÑÂËÅÑ¡´Ñ§¹Õé

Paper Speed = 25 mm / sec

25mm (25 ªèͧàÅç¡) = 1 sec

1mm (1 ªèͧàÅç¡) = 1 / 25 = 0.04 sec

5mm (5 ªèͧàÅç¡=1 ªèͧãË­è)= 0.04 X 5= 0.2 sec

60sec = 60/0.04 =1500 ªèͧàÅç¡

1) rate=  1500/¨Ó¹Ç¹ªèͧàÅç¡ÃÐËÇèÒ§ QRS·ÕèµÔ´¡Ñ¹(ËÃ×Í P ·ÕèµÔ´¡Ñ¹ ËÒ¡¹Ñº P rate)

ãËé¹Ñº¨Ò¹Ç¹ªèͧÃÐËÇèÒ§ R-RÇèÒËèÒ§¡Ñ¹¡Õèªèͧ Rate= 1500/¨Ò¹Ç¹ªèͧàÅç¡

2)¹ÑºªèͧãË­è  

2.1)¹ÑºªèͧãË­è  Rate= 300/¨Ó¹Ç¹ªèͧãË­è

2.2) ¹ÑºªèͧãË­èÃÐËÇèÒ§ QRS 2 µÑÇÇèÒÁÕ¡Õèªèͧ

 1ªèͧ Rate=300 ,2ªèͧ Rate=150 ,3ªèͧ Rate=100 ,4ªèͧ Rate=75 ,5ªèͧ Rate=60 ,6ªèͧ Rate=50 ,7ªèͧ Rate=43 ,8ªèͧ Rate=37 ,9ªèͧ Rate=33 ,10ªèͧ Rate=30

3) rate =¨Ó¹Ç¹ QRS ã¹ 25 ªèͧãË­è x 12 (25ªèͧãË­è ¤×Í 5 sec)

-¹ÔÂÁãªé Lead II à»ç¹¾×鹰ҹ㹡ÒÃÇÑ´ Rate

-ÍÂèÒÅ×Á´ÙÇèÒ Rate ÊÁèÓàÊÁÍËÃ×ÍäÁè  ÍÂèÒ§äÃ

-ËÒ¡ Atrium ,Ventricular äÁèµÒÁ¡Ñ¹ ¤Çäӹdz ·Ñé§  Ventricular rate áÅÐ P rate 


-àº×éͧµé¹ãËéÊÃØ»ÇèÒ

-ÇÑ´ Rate ä´éäËÁ

-à»ç¹ sinus rhythm ËÃ×ÍäÁè ËÃ×ÍÂѧÊÃØ»äÁèä´é

-regular ËÃ×Í irregular

-Tachycardia , Bradycardia ,ËÃ×ÍÍÂÙè㹪èǧ»¡µÔ

- P áÅÐ QRS àµé¹µÒÁ¡Ñ¹ËÃ×ÍäÁè ËÃ×Íàµé¹á¡¡Ñ¹ áÅÐà»ç¹µèÍà¹×èͧ¡Ñ¹ËÃ×ÍäÁè (à¾×èÍá¡äÇéã¹ã¨¡è͹ÇèÒËÑÇã¨àµé¹â´Â¡ÒäǺ¤ØÁ¨Ò¡  supraventricular  , junction  ,ËÃ×Í ventricular àµé¹àͧ )


Rate¨Ò¡SA–Node

Normal sinus rhythm  Rate =60– 100 Beat/min 

Sinus bradycardia - sinus rate < 60 ¤ÃÑé§/¹Ò·Õ.

Sinus tachycardia - sinus rate 100-180 ¤ÃÑé§/¹Ò·Õ

Sick sinus syndrome - ¡Ò÷ӧҹ¢Í§ SA node·Õè¼Ô´»¡µÔ¢³ÐÍÍ¡¡ÓÅѧà»ç¹¼ÅãËéÁÕ¡ÒÃàµé¹¢Í§ËÑÇã¨à»ÅÕè¹á»Å§ÍÂèÒ§ÁÒ¡àªè¹ bradycardia áÅÐtachycardia ÁÑèǡѹä»


ÅѡɳРNormal sinus rhythm

1.Rate »¡µÔ¤×Í 60-100¤ÃÑé§/¹Ò·Õ  Atrial rate = Ventricular rate

2.¨Ñ§ËÇСÒÃàµé¹ÊÁèÓàÊÁÍ PPáÅÐRRinterval ÁÕ¤èÒ¤§·Õè

3.P waveÃÙ»ÃèÒ§»¡µÔáÅÐàËÁ×͹¡Ñ¹ (Lead II ËÑÇµÑ é§ , aVR ËÑÇ¡ÅѺ ) ,P ¹Ñé¹¹Ó˹éÒ QRS·Ø¡µÑÇ ( P áÅÐ QRS àµé¹µÒÁ¡Ñ¹ )

4.PR, QRS »¡µÔ·Ñé§ÃÐÂÐàÇÅÒáÅÐÃÙ»ÃèÒ§ 

Rhythm

ÊÓËÃѺ¼Ùéà¢Õ¹¡è͹»ÃÐàÁÔ¹ rhythm  ¨Ð´ÙÇèÒÁÕ  Hyperkalemia ËÃ×ÍäÁè â´ÂãªéÇÔ¸Õà½éÒÁͧáÅÐÊѧࡵØÃٻẺ¢éÒ§ÅèÒ§¡è͹àÊÁÍ àÁ×èͨÐÍèÒ¹ EKG â´Â੾ÒÐã¹ ER áÅÐ ICU

--à¨ÍP àµÕéÂæ ËÃ×ÍäÁèÁÕ P  , QRS ¡ÇéÒ§  , Depress ST  ËÃ×ÍVT Ë¹éÒµÒá»Å¡æ ãËé¤Ô´
¶Ö§ hyperkalemia´éÇÂ
--àÃÕ§§èÒÂæ äÅèµÒÁÅӴѺ  µÒÁÃдѺ K ·Õèà¾ÔèÁ¢Öé¹


Tall peaked T wave

Tall peaked T wave, shorted QT interval, decreased P wave amplitude

Tall peaked T wave, shorted QT interval,  P wave absent , prolonged PR interval  ,ST depression

Tall peaked T wave, shorted QT interval,  P wave absent , prolonged PR interval  ,ST depression, Bundle-branch block (widened QRS)

Tall peaked T wave, shorted QT interval,  P wave absent , prolonged PR interval  ,ST depression, Bundle-branch block (widened QRS), ectopic ventricular beat(ÍÒ¨äÁ辺)

Tall peaked T wave, shorted QT interval,  P wave absent , prolonged PR interval  ,ST depression, Bundle-branch block (widened QRS) àÁ×èÍà»ç¹ÁÒ¡¢Öé¹àÃ×èÍÂæ  >>>sine wave

áÅжéÒ sine wave ¡ÇéÒ§ÁÒ¡¢Öé¹àÃ×èÍÂæ >>>>>à»ç¹ VT ,VF





 

Create Date : 05 Á¡ÃÒ¤Á 2561    
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