麻醉專業(yè)培訓-嚴重心律失常的識別和處理

嚴重心律失常識別和處理心律失常四個問題決定診斷和處理：HR>100or<60?BP穩(wěn)定與否?QRS窄與寬?R-R間期規(guī)則與不規(guī)則??如何決定心率？QRS波正常,R-R間期規(guī)則

的快速心律失常1. 竇性心動過速2.室上性心動過速房室折返性房室旁路3. 房撲心動過速竇性心動過速陣發(fā)性室上性心動過速心房撲動?QRS波正常,R-R間期不規(guī)則

的快速心律失常1.心房纖顫2. 心房撲動3. 房性早搏4. 多元性房性心動過速心房纖顫心房撲動多源性房性心動過速?QRS波增寬,R-R間期

正常心動過速

1. 室性心動過速2. 室上性心動過速合并：束支傳導阻滯旁路心肌病室性心動過速室性心動過速的特點P波與QRS波沒有關(guān)系QRS>0.16sec嚴重電軸左偏室性奪合QRS波增寬室上性心動過速特點右束支傳導阻滯模型R-R間期不規(guī)則Rate>250腺苷治療有效SVT合并傳導異常?寬QRS,RR間期不規(guī)則

心動過速房顫/房撲合并：束支傳導阻滯或者旁路傳導尖端扭轉(zhuǎn)性室速旁路旁路:消融房顫合并旁路傳導尖端扭轉(zhuǎn)性室速

(多源性VT)室顫心動過緩病例82，女，因頭暈和短暫暈厥2天住院，無頭痛、惡心或者嘔吐，無胸痛氣緊。病例過去史:高血壓,糖尿病,高脂血癥和短暫腦缺血發(fā)作藥物史:ASA81mgdaily,Lisinapril10mgBID,Metformine500mgBIDandLipitor20daily.VS:T37,RR18,P34andBP98/56ECG顯示:ABCD房室傳導阻滯診斷P多余QRSPR固定?noQRSs看上去規(guī)則?noyesyesyes2度II型3度2度I型診斷？診斷?診斷?診斷?診斷?麻醉期間心律失常的處理原則診斷一般不需要像12導心電圖準確

針對病人進行處理，而不是針對心律進行處理

心動過速

心動過速Narrow-complextachycardia

electricalconversionphysicalmanoeuvrespharmacologicalconversionratecontrolUnstablepatients:electricalcardioversionNarrow-complextachycardia

(excludingatrial?brillation)Vagalmanoeuvres,IVadenosine,verapamil,anddiltiazemarerecommendedas?rst-linetreatmentstrategiesintheterminationofnarrow-complextachycardias.Nadolol心得樂,sotalol鹽酸索他洛爾,propafenone普羅帕酮,andamiodaronemaybeconsidered.PediatricSVTForinfantsandchildrenwithSVTwithapalpablepulse,adenosineshouldbeconsideredthepreferredmedication.Verapamilmaybeconsideredasalternativetherapyinolderchildrenbutshouldnotberoutinelyusedininfants.ProcainamideoramiodaronegivenbyaslowIVinfusionwithcarefulhaemodynamicmonitoringmaybeconsideredforrefractorySVT.Atrial?brillationunstableshouldreceivepromptECChemicalcardioversioncanbeachievedwithibutilide伊布利特,dofetilide多非利特,and?ecainide氟卡胺盯.AmiodaroneislesseffectiveQuinidineorprocainamidemaybebuttheiruseislesswellestablishedPropafenone普羅帕酮ismoreeffectivethanplacebobutnotaseffectiveasamiodarone,pro-cainamide,or?ecainide.Thereisnorolefordigoxininchemicalcardioversion同步電復律能量選擇：PSVT:50J,100J,200J,300J,360JVT（穩(wěn)定型單型性）:100J（雙相波）PolymorphicVT(treatlikeVF):200J,

200to300J,360JAtrialfibrillation:100J-200J（雙相波）,200J（單相波）Atrialflutter:50-100J（雙相波）心動過速的其他處理異搏定：verapamiltocontrolventricularrate:2.5-5mggiveninitiallyover2min,then5-10mgevery15-30min,Maximum20mg.西地蘭：forratecontrol普魯卡因酰胺：procainamideforconversionofthetachyarrhythmias

-受體阻滯劑：Esmolol:500mcg/kgover1min,followedbyaninfusionof50—200mcgkg//min室性心動過速280/min危及生命需緊急處理找出原因(Hypoxia,hypercarbia,hypokalemiaand/orhypomagnesemia,digitalistoxicity,andacid-basederangements室性心動過速的治療胺典酮：intravenousamiodaroneinitialdoseis150mgin100mLdextroseinwatergivenover10minutes,followedbyaloadinginfusionof1mg/minfor6hours.利多卡因：lidocaineinitiallyinadoseof1.0to1.5mg/kgandisrepeatedinadoseof0.5to0.75mg/kgevery5to10minutes,untilthearrhythmiaissuppressedoratotalof3mg/kghasbeengiven普魯卡因酰胺：procainamidecanbeadministeredinadoseof20to30mg/minuntilthetachycardiaiscontrolledoratotalof17mg/kghasbeeninjected同步電復律：Inunstablepatients(e.g.,inthepresenceofsystemichypotension,pulmonaryedema,orclinicalorECGsignsofacuteischemiaorinfarction),cardioversionisthetreatmentofchoice,withenergydosesof100,200,300,and360JWide-complextachycardiaProcainamideisrecommendedforpatientswithhaemodynamicallystablemonomorphicventriculartachycardia(mVT)whodonothaveseverecongestiveheartfailureoracutemyocardialinfarction.AmiodaroneisrecommendedforpatientswithhaemodynamicallystablemVTwithorwithouteitherseverecongestiveheartfailureoracutemyocardialinfarction.Wide-complextachycardiaNifekalant尼非卡蘭(notapprovedforuseinallcountries)maybeusefulinimprovingoutcomesinshockrefractoryVF/VTeventhoughitdidnotseemtobeeffectiveinimmediatelyterminatingthearrhythmia.Sotalol鹽酸索他洛爾maybeconsideredforpatientswithhaemodynamicallystablesustainedmVT,includingpatientswithacutemyocardialinfarction.Undifferentiatedregularstablewide-complextachycardiaIVadenosinemaybeconsideredrelativelysafe,mayconverttherhythmtosinus,andmayhelpdiagnosetheunderlyingrhythm.Polymorphicwide-complextachycardiaPolymorphicwide-complextachycardiaassociatedwithfamiliallongQTmaybetreatedwithIVmagnesium,pacingand/or-blockers;Isoprenalineshouldbeavoided.wide-complextachycardiaassociatedwithacquiredlongQTmaybetreatedwithIVmagnesium.AdditionofpacingorIVisoprenalinemaybeconsideredwhenpolymorphicwide-complextachycardiaisaccompaniedbybradycardiaorappearstobeprecipitatedbypausesinrhythm.Polymorphicwide-complextachycardiawithoutlongQTmayberesponsivetoIV-blockers(ischaemicVT;catecholaminergicVT)orisoprenaline(Brugada).心動過緩心動過緩注意事項Afterinferiormyocardialinfarction,cardiactransplant,orspinalcordinjury,theophylline100–200mgslowinjectionIV(maximum250mg)maybegiven.AtropineshouldbeusedwithcautioninpatientswithbradycardiaafterhearttransplantasitmaycauseparadoxicalAVblock.小兒心動過緩心動過緩可能竇性或結(jié)性II房室傳導阻滯(typesIandII)或III房室傳導阻滯若導致收縮壓降低，立即處理atropine,0.5to1.0mgintravenouslyandrepeatedasneededat3-to5-minuteintervalsto0.04mg/kgor3mg經(jīng)皮或經(jīng)