严重心律失常的识别和处理.ppt

严重心律失常识别和处理,左云霞四川大学华西医院麻醉科,心律失常,四个问题决定诊断和处理：HR100or0.16sec严重电轴左偏室性夺合,QRS波增宽室上性心动过速特点,右束支传导阻滞模型R-R间期不规则Rate250腺苷治疗有效,SVT合并传导异常,?,宽QRS,RR间期不规则心动过速,房颤/房扑合并：束支传导阻滞或者旁路传导尖端扭转性室速,旁路,旁路:消融,房颤合并旁路传导,尖端扭转性室速(多源性VT),室颤,心动过缓,病例,82，女，因头晕和短暂晕厥2天住院，无头痛、恶心或者呕吐，无胸痛气紧。,病例,过去史:高血压,糖尿病,高脂血症和短暂脑缺血发作药物史:ASA81mgdaily,Lisinapril10mgBID,Metformine500mgBIDandLipitor20daily.VS:T37,RR18,P34andBP98/56,ECG显示:,ABCD,房室传导阻滞诊断,P多余QRS,PR固定?,no,QRSs看上去规则?,no,yes,yes,yes,2度II型,3度,2度I型,诊断？,诊断?,诊断?,诊断?,诊断?,麻醉期间心律失常的处理原则,诊断一般不需要像12导心电图准确针对病人进行处理，而不是针对心律进行处理,心动过速,心动过速,Narrow-complextachycardia,electricalconversionphysicalmanoeuvrespharmacologicalconversionratecontrolUnstablepatients:electricalcardioversion,Narrow-complextachycardia(excludingatrialbrillation),Vagalmanoeuvres,IVadenosine,verapamil,anddiltiazemarerecommendedasrst-linetreatmentstrategiesintheterminationofnarrow-complextachycardias.Nadolol心得乐,sotalol盐酸索他洛尔,propafenone普罗帕酮,andamiodaronemaybeconsidered.,PediatricSVT,ForinfantsandchildrenwithSVTwithapalpablepulse,adenosineshouldbeconsideredthepreferredmedication.Verapamilmaybeconsideredasalternativetherapyinolderchildrenbutshouldnotberoutinelyusedininfants.ProcainamideoramiodaronegivenbyaslowIVinfusionwithcarefulhaemodynamicmonitoringmaybeconsideredforrefractorySVT.,Atrialbrillation,unstableshouldreceivepromptECChemicalcardioversioncanbeachievedwithibutilide伊布利特,dofetilide多非利特,andecainide氟卡胺盯.AmiodaroneislesseffectiveQuinidineorprocainamidemaybebuttheiruseislesswellestablishedPropafenone普罗帕酮ismoreeffectivethanplacebobutnotaseffectiveasamiodarone,pro-cainamide,orecainide.Thereisnorolefordigoxininchemicalcardioversion,同步电复律,能量选择：PSVT:50J,100J,200J,300J,360JVT（稳定型单型性）:100J（双相波）PolymorphicVT(treatlikeVF):200J,200to300J,360JAtrialfibrillation:100J-200J（双相波）,200J（单相波）Atrialflutter:50-100J（双相波）,心动过速的其他处理,异搏定：verapamiltocontrolventricularrate:2.5-5mggiveninitiallyover2min,then5-10mgevery15-30min,Maximum20mg.西地兰：forratecontrol普鲁卡因酰胺：procainamideforconversionofthetachyarrhythmias-受体阻滞剂：Esmolol:500mcg/kgover1min,followedbyaninfusionof50200mcgkg/min,室性心动过速,280/min,危及生命需紧急处理找出原因(Hypoxia,hypercarbia,hypokalemiaand/orhypomagnesemia,digitalistoxicity,andacid-basederangements,室性心动过速的治疗,胺典酮：intravenousamiodaroneinitialdoseis150mgin100mLdextroseinwatergivenover10minutes,followedbyaloadinginfusionof1mg/minfor6hours.利多卡因：lidocaineinitiallyinadoseof1.0to1.5mg/kgandisrepeatedinadoseof0.5to0.75mg/kgevery5to10minutes,untilthearrhythmiaissuppressedoratotalof3mg/kghasbeengiven普鲁卡因酰胺：procainamidecanbeadministeredinadoseof20to30mg/minuntilthetachycardiaiscontrolledoratotalof17mg/kghasbeeninjected同步电复律：Inunstablepatients(e.g.,inthepresenceofsystemichypotension,pulmonaryedema,orclinicalorECGsignsofacuteischemiaorinfarction),cardioversionisthetreatmentofchoice,withenergydosesof100,200,300,and360J,Wide-complextachycardia,Procainamideisrecommendedforpatientswithhaemodynamicallystablemonomorphicventriculartachycardia(mVT)whodonothaveseverecongestiveheartfailureoracutemyocardialinfarction.AmiodaroneisrecommendedforpatientswithhaemodynamicallystablemVTwithorwithouteitherseverecongestiveheartfailureoracutemyocardialinfarction.,Wide-complextachycardia,Nifekalant尼非卡兰(notapprovedforuseinallcountries)maybeusefulinimprovingoutcomesinshockrefractoryVF/VTeventhoughitdidnotseemtobeeffectiveinimmediatelyterminatingthearrhythmia.Sotalol盐酸索他洛尔maybeconsideredforpatientswithhaemodynamicallystablesustainedmVT,includingpatientswithacutemyocardialinfarction.,Undifferentiatedregularstablewide-complextachycardia,IVadenosinemaybeconsideredrelativelysafe,mayconverttherhythmtosinus,andmayhelpdiagnosetheunderlyingrhythm.,Polymorphicwide-complextachycardia,Polymorphicwide-complextachycardiaassociatedwithfamiliallongQTmaybetreatedwithIVmagnesium,pacingand/or-blockers;Isoprenalineshouldbeavoided.wide-complextachycardiaassociatedwithacquiredlongQTmaybetreatedwithIVmagnesium.AdditionofpacingorIVisoprenalinemaybeconsideredwhenpolymorphicwide-complextachycardiaisaccompaniedbybradycardiaorappearstobeprecipitatedbypausesinrhythm.Polymorphicwide-complextachycardiawithoutlongQTmayberesponsivetoIV-blockers(ischaemicVT;catecholaminergicVT)orisoprenaline(Brugada).,心动过缓,心动过缓,注意事项,Afterinferiormyocardialinfarction,cardiactransplant,orspinalcordinjury,theophylline100200mgslowinjectionIV(maximum250mg)maybegiven.AtropineshouldbeusedwithcautioninpatientswithbradycardiaafterhearttransplantasitmaycauseparadoxicalAVblock.,小儿心动过缓,心动过缓,可能窦性或结性II房室传导阻滞(typesIandII)或III房室传导阻滞若导致收缩压降低，立即处理atropine,0.5to1.0mgintravenouslyandrepeatedasneededat3-to5-minuteintervalsto0.04mg/kgor3mg经皮或经静脉起搏dopamine(210g/kg/min)orepinephrine(210g/min),abetterchoicethanisoproterenol,病例,患儿，男，9岁，体重23kg以心悸2年，发现血压升高3天于2005年10月10日入住我院小儿外科。现病史：患儿2年前无明显诱因出现心悸，自觉心跳加快，心率120次/分左右，伴多汗，乏力，神萎，偶有活动后呕吐，不伴发热，黄疸，腹痛。多次到当地医院求治无效。症状反复，近1月来出现头痛，无视物模糊，3天前于附二院求治，测血压180/140mmHg。CT提示“腹膜后占位”，为求进一步诊治入院。入院