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¡ÒÃãªé warfarin   ¡ÒÃàÃÔèÁÂÒ ————————————————————————— ¡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) —————————————————————————  ¡ÒûÃѺÂÒãËéä´é INR goal ————————————————————————— ·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 —————————————————————————  Warfarin overdose ÃÑ¡ÉÒÍÂèÒ§äà ————————————————————————— ¡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 : Å´ 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 ————————————————————————— Peri-operartive warfarin management ————————————————————————— 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»àÅ 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) ————————————————————————— ————————————————————————— 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§»ÃЪҡà 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´éÇ “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§¡Ò 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 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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ºèÍ ----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ºèÍ ----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ºèÍ ----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ºèÍ ----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´éǹР----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ºèÍ ----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ºèÍ ----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 ´éÇ 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ºèÍ ----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§ËÑÇ㨠----¨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¡ËÅÒÂÊٵà ÅѡɳРQT parameter   Argument·Õ辺ºèÍ ----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ºèÍ ----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ºèÍ ----Prominent U wave ----U wave inversion   Create Date : 05 Á¡ÃÒ¤Á 2561     Last Update : 10 ¾ÄÉÀÒ¤Á 2561 7:47:51 ¹. 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ÍèÒ¹ EKG ÍèÒ¹ EKG àÃÒ´Ù EKG à¾×èÍ»ÃÐàÁÔ¹¡Ò÷ӧҹËÑÇ㨠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¨ÐãªéÃٻẺ㴠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 : 514 Pageviews.   0 comment Share Tweet

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§äà -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 ÁÑèÇ¡Ñ¹ä» 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´éÇ --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     Last Update : 1 ÁԶعÒ¹ 2561 12:31:40 ¹. Counter : 974 Pageviews.   0 comment Share Tweet