麻醉专业培训-严重心律失常的识别和处理

严重心律失常识别和处理心律失常四个问题决定诊断和处理：HR>100or<60?BP稳定与否?QRS窄与宽?R-R间期规则与不规则??如何决定心率？QRS波正常,R-R间期规则

的快速心律失常1. 窦性心动过速2.室上性心动过速房室折返性房室旁路3. 房扑心动过速窦性心动过速阵发性室上性心动过速心房扑动?QRS波正常,R-R间期不规则

的快速心律失常1.心房纤颤2. 心房扑动3. 房性早搏4. 多元性房性心动过速心房纤颤心房扑动多源性房性心动过速?QRS波增宽,R-R间期

正常心动过速

1. 室性心动过速2. 室上性心动过速合并：束支传导阻滞旁路心肌病室性心动过速室性心动过速的特点P波与QRS波没有关系QRS>0.16sec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Rate>250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,P34andBP98/56ECG显示:ABCD房室传导阻滞诊断P多余QRSPR固定?noQRSs看上去规则?noyesyesyes2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:electricalcardioversionNarrow-complextachycardia

(excludingatrialfibrillation)Vagalmanoeuvres,IVadenosine,verapamil,anddiltiazemarerecommendedasfirst-linetreatmentstrategiesintheterminationofnarrow-complextachycardias.Nadolol心得乐,sotalol盐酸索他洛尔,propafenone普罗帕酮,andamiodaronemaybeconsidered.PediatricSVTForinfantsandchildrenwithSVTwithapalpablepulse,adenosineshouldbeconsideredthepreferredmedication.Verapamilmaybeconsideredasalternativetherapyinolderchildrenbutshouldnotberoutinelyusedininfants.ProcainamideoramiodaronegivenbyaslowIVinfusionwithcarefulhaemodynamicmonitoringmaybeconsideredforrefractorySVT.AtrialfibrillationunstableshouldreceivepromptECChemicalcardioversioncanbeachievedwithibutilide伊布利特,dofetilide多非利特,andflecainide氟卡胺盯.AmiodaroneislesseffectiveQuinidineorprocainamidemaybebuttheiruseislesswellestablishedPropafenone普罗帕酮ismoreeffectivethanplacebobutnotaseffectiveasamiodarone,pro-cainamide,orflecainide.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,followedbyaninfusionof50—200mcgkg//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,and360JWide-complextachycardiaProcainamideisrecommendedforpatientswithhaemodynamicallystablemonomorphicventriculartachycardia(mVT)whodonothaveseverecongestiveheartfailureoracutemyocardialinfarction.AmiodaroneisrecommendedforpatientswithhaemodynamicallystablemVTwithorwithouteitherseverecongestiveheartfailureoracutemyocardialinfarction.Wide-complextachycardiaNifekalant尼非卡兰(notapprovedforuseinallcountries)maybeusefulinimprovingoutcomesinshockrefractoryVF/VTeventhoughitdidnotseemtobeeffectiveinimmediatelyterminatingthearrhythmia.Sotalol盐酸索他洛尔maybeconsideredforpatientswithhaemodynamicallystablesustainedmVT,includingpatientswithacutemyocardialinfarction.Undifferentiatedregularstablewide-complextachycardiaIVadenosinemaybeconsideredrelativelysafe,mayconverttherhythmtosinus,andmayhelpdiagnosetheunderlyingrhythm.Polymorphicwide-complextachycardiaPolymorphicwide-complextachycardiaassociatedwithfamiliallongQTmaybetreatedwithIVmagnesium,pacingand/or-blockers;Isoprenalineshouldbeavoided.wide-complextachycardiaassociatedwithacquiredlongQTmaybetreatedwithIVmagnesium.AdditionofpacingorIVisoprenalinemaybeconsideredwhenpolymorphicwide-complextachycardiaisaccompaniedbybradycardiaorappearstobeprecipitatedbypausesinrhythm.Polymorphicwide-complextachycardiawithoutlongQTmayberesponsivetoIV-blockers(ischaemicVT;catecholaminergicVT)orisoprenaline(Brugada).心动过缓心动过缓注意事项Afterinferiormyocardialinfarction,cardiactransplant,orspinalcordinjury,theophylline100–200mgslowinjectionIV(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