宽qrs波心动过速课件 (2)

APPROACHTOWIDEQRSCOMPLEXTACHYCARDIA DrHATUANKHANHDrDAVIDTRAN Content DefinitionCausesofWCTDiagnosiscriteriaClinicalhistoryPhysicalexaminationECGcriteria Brugadacriteria othercriteria findingsfavoringSVT VTvsAVRTcriteriaManagementUnstablehemodynamicStablehemodynamic Definition WideQRScomplextachycardiaisarhythmwitharateofmorethan100b mandQRSdurationofmorethan120ms VT 80 SVT 20 StewartRB AnnInternMed1986 Supraventriculartachycardia withprexsistingBBB withBBBduetoheartrate aberrantconduction antidromictachycardiainWPWsyndromeVentriculartachycardia CausesofwideQRScomplextachycardia SVTvsVTClinicalhistory SVTvsVTPhysicalexamination PhysicalfindingsthatindicatepresenceofAVdissociation cannonAwaves variable intensityS1 variationinBPunrelatedtorespiration ifpresentareusefulTerminationofWCTinresponsetomaneuverslikeValsalva carotidsinuspressure oradenosineisstronglyin favorofSVTbuttherearewell documentedcasesofVTresponsivetothese SVTvsVTECGcriteria Brugadaalgorithm BrugadaP Ciculation1991 Step1 Step2 Step3 Step4 LBBB typewideQRScomplex SVT VT smallRwave notchingofSwave Rwave 40ms fastdownslopeofSwave noQwave Qwave 70ms V1 V6 Step4 RBBB typewideQRScomplex SVT VT V1 V6 or or R S 1 R Sratio 1 QScomplex rSR configuration monophasicRwave qR orRs complex Step4 RBBBmorphology Step4 LBBBmorphology OtherECGcriteria North westQRSaxisdeviationNegativeorpositiveconcordanceFusionbeats capturebeatsVentriculoatrialconductionwithblockRBBBmorphologywithLAD 300LBBBmorphologywithRAD 900PreviousECGshowMIorpreviousECGshowthatduringsinusrhythm bifascularblockispresent whichchangesinconfigurationduringtachycardia ConcordanceandNorthwestAxis Fusionbeatandcapturebeat Ventriculoatrialconductionwithblock RBBBmorphologywithLAD LBBBmorphologywithRAD PreviousMI PreviousLBBB FindingsfavoringSVT TriphasicpatterninV1andV6Rabbit searPreviousECG PreexistentBBBorpreexcitation Triphasicpattern Rabbit sear WidecomplexSVTfrompreexistingRBBB WidecomplexSVTfrompreexistingLBBB VTvsAVRTECGcriteria BrugadaP Ciculation1991 WidecomplexSVTfrombypasstract Summary diagnosisevaluation ACC AHA ESCguidelinesformanagementofptwithSVT Circulation2003 Management Hemodynamiccompromise Unstablepatient butstillresponsiblewithadiscernibleBPand orpulse Emergentsynchronizedcardioversion IftheQRScomplexandTwavecannotbedistinguishedaccurately immediatedefibrillationUnstablepatient unresponsiveorpulseless standardACLSresusciationalgorithms ACLSpulselessarrestalgorithm AHAGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCare Ciurculation2005 Management Stablehemodynamic VTorWCTofuncertainetiology Anyassociatedconditions cardiacischemia heartfailure electrolyteabnormalitiesordrugtoxicities ClassIandIIIantiarrhythmicdrugs Amiodarone 150mgIV 10minsfollowedbyaninfusionof1mg minfor6hours then0 5mg min Procainamide 15 18mg kginfusionover25 30mins followedby1 4mg minbycontinuousinfusion Lidocaine 1 1 5mg kgIV 2 3minsfollowedbyaninfusionof1 4mg minUrgentorelectivecardioversion Management Stablehemodynamic SVTVagalmaneuvers carotidsinuspressure ifnocarotidbruits orValsavamaneuverAdenosine 6mgover1 2seconds Iftheinitialdoseisineffective a12mgdosemaybegivenandrepeatedonceifnecessaryCalciumchannelblocker Verapamil2 5to5mgIV orbetablokers Metoprolol5to10mgIV Cardioversion Acutemanagementhemodynamicallystableandregulartachycardia ACC AHA ESCguidelinesformanagementofptwithSVT Circulation2003 Recommendationacutemanagementhemodynamicallystableandregulartachycardia ACC AHA ESCguidelinesformanagementofpt