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厦门市医学会心电学会标准系列(二)常规心电图操作标准化


心电学是常见和危重的心肌梗死和恶性心律失常等疾病诊断与治疗的主要依据。心电图在医学上应用已经有一百多年的历史了, 因其所含诊断信息丰富、检查简便、经济耐用而得以普及并在临床发挥了重要作用。目前,完成一例检查仅需要几分钟的时间,尤其是十二导联数字心电图机的出现, 给临床和病人带来了更大的便利, 但也存在一些不容忽视的质量问题和安全隐患, 需要引起人们的关注并有效地解决, 这些措施包括严格遵守操作规范、做好心电检查前的条件准备、心电图描记过程中的质量控制、机器的日常维护、保养和计量检测等环节的质量保证工作。否则,会影响心电诊断质量,给医患双方带来风险、或者带来不必要的麻烦和患者的心理负担。
随着心血管病学和心电学专业的发展,对疾病的认识不断加深,心电技术发展也日新月异,因此、学科的规范化质量控制工作就更显得重要了。
标题
  1. 对环境的要求
  2. 准备工作
  3. 皮肤处理和电极安置
  4. 描记心电图
  5. 心电图机的维护
 

二、常规心电图操作标准化


 


为了获得质量合格的心电图,除了心电图机性能必须合格以外,还要求周围环境符合条件,受检者的配合和正确的操作方法。


对环境的要求


1.室内要求保持温暖(不低于18℃),以避免因寒冷而引起的肌电干扰。


2.使用交流电源的心电图机必须接可靠的专用地线(接地电阻应低于0.5Ω)。


3.放置心电图机的位置应使其电源线尽可能远离诊察床和导联电缆,床旁不要摆放其它电器具(不论通电否)及穿行的电源线。


4.诊察床的宽度不应窄于80┩,以免肢体紧张而引起肌电干扰。如果诊察床的一侧靠墙,则必须确定墙内无电源线穿行。


准备工作


1.对初次接受心电图检查者,必须事先作好解释工作,消除紧张心理。


2.在每次作常规心电图之前受检者应经充分休息,解开上衣,在描记心电图时要放松肢体,保持平静呼吸。


皮肤处理和电极安置


1.如果放置电极部位的皮肤有污垢或毛发过多,则应预先清洁皮肤或剃毛。


2.应该用导电膏(剂型分为:糊剂、霜剂和溶液等)涂擦放置电极处的皮肤,而不应该只把导电膏涂在电极上。此外还应尽量避免用棉签或毛笔沾生理盐水或酒精甚至于用自来水代替导电膏,因为用这种方法处理皮肤,皮肤和电极之间的接触阻抗较大,极化电位也很不稳定,容易引起基线飘移或其它伪差,尤其是皮肤干燥或皮脂较多者,伪差更为严重。


3.严格按照国际统一标准,准确安放常规12导联心电图电极(附图)。必要时应加作其它胸壁导联,女性乳房下垂者应托起乳房,将V3V4V5电极安放在乳房下缘胸壁上,而不应该安置在乳房上。


4.描记V7V8V9导联心电图时,必须取仰卧位,而不应该在侧卧位时描记心电图,因此背部的电极最好使用扁平的吸杯电极,或临时贴一次性心电监护电极并接上连接导线来代替。


5.不要为了图方便,将接左、右下肢的电极都放在一侧下肢,因为目前的心电图机都装有“右下肢反驱动”电路,它能有效地抑制交流电干扰,上述作法等于取消了此项功能,从而降低了抗交流电干扰的性能。此时操作者虽然可以用“交流电滤波”来减轻干扰,但是却同时使心电图波形失真。上述情况在使用旧式的心电图机时尤需注意。


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描记心电图


1.心电图机的性能必须符合标准。若使用热笔式的记录纸,其热敏感性和耐储存性应符合标准。单通道记录纸的可记录范围不窄于40mm。


2.无自动描记1mV定标方波的热笔式心电图机,在记录心电图之前必须先描记方波(“打标准”),以便观察心电图机的各导联同步性、灵敏度、阻尼和热笔温度是否适当,必要时可按心电图使用说明加以调整,以后每次变换增益后都要再描记一次定标方波。方波勿过宽(约0.16s),尽可能与P、QRS、T波不重叠。


3.按照心电图机使用说明进行操作,常规心电图应包括肢体的Ⅰ、Ⅱ、Ⅲ、aVR、aVL和胸导联的V1-V612个导联。


4.疑有或有急性心肌梗塞患者首次作常规心电图检查时必须加作V3RV4RV5RV7V8V9,并在胸壁各导联部位用色笔、龙胆紫或放射治疗标记用的皮肤墨水作上标记,使电极定位准确以便以后动态比较。


5.疑有右位心或右心梗塞者,应加作V3RV4RV5R导联。


6.不论使用哪一种机型的心电图机,为了减少心电图波形失真,应该尽量不使用交流电滤波或“肌电滤波”。


7.用手动方式记录心电图时,每次切换导联后,必须等到基线稳定后再启动记录纸,每个导联记录的长度不应少于3~4个完整的心动周期(即需记录3~5个QRS综合波)。


8.遇到下列情况时应及时作出处理:①如果发现某个胸壁导联有无法解释的异常T或U波时,则应检查相应的胸壁电极是否松动脱落,若该电极固定良好而部位恰好在心尖搏动最强处,则可重新处理该处皮肤或更换质量较好的电极,若仍无效,则可试将电极的位置稍微偏移一些,此时若波形变为完全正常,则可认为这种异常的T波或U波是由于心脏冲撞胸壁,使电极的极化电位发生变化而引起的伪差。②如果发现Ⅲ和/或aVF导联的Q波较深,则应在深吸气后屏住气时,立即重复描记这些导联的心电图。若此时Q波明显变浅或消失,则可考虑横膈抬高所致,反之若Q波仍较深而宽,则不能除外下壁心肌梗塞。③如发现心率>60bpm而PR>0.22s者,则应取坐位时再记录几个肢体导联心电图,以便确定是否有房室阻滞。


心电图机的维护


1.每天作完心电图后必须洗净电极。用铜合金制成的电极,如发现有锈斑,可用细砂纸擦掉后,再用生理盐水浸泡一夜,使电极表面形成电化性能稳定的薄膜,镀银的电极用水洗净即可,使用时应避免擦伤镀银层。


2.导联电缆的芯线或屏蔽层容易断路损坏,尤其是靠近两端的插头处,因此使用时切忌用力牵拉或扭转,收藏时应盘成直径较大的圆环,或悬挂放置,避免扭转或锐角折叠。


3.交直流两用的心电图机,应按说明书的要求定期充电,以利延长电池使用寿命。


4.心电图主机应避免高温、日晒、受潮、尘土或撞击,用毕盖好防尘罩。


5.由医疗仪器维修部门定期检测心电图机的性能。热笔记录式心电图,应根据记录纸的热敏感性和走纸速度而调整热笔的压力和温度。


 


 


(中华医学会心电生理和起搏分会心电图学学组)


 


 

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