严重心律失常的识别与处理-2014-04.pptVIP

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: ASA 81 mg daily, Lisinapril 10 mg BID, Metformine 500 mg BID and Lipitor 20 daily. VS: T 37, RR 18, P 34 and BP 98/56 ECG 显示: A B C D 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-complex tachycardia electrical conversion physical manoeuvres pharmacological conversion rate control Unstable patients :electrical cardioversion Narrow-complex tachycardia (excluding atrial?brillation) Vagal manoeuvres, IV adenosine, verapamil, and diltiazem are recommended as ?rst-line treatment strategies in the termination of narrow-complex tachycardias. Nadolol心得乐, sotalol盐酸索他洛尔, propafenone普罗帕酮,and amiodarone may be considered. Pediatric SVT For infants and children with SVT with a palpable pulse, adenosine should be considered the preferredmedication. Verapamil may be considered as alternative therapy in older children but should not be routinely used in infants. Procainamide or amiodarone given by a slow IV infusion with careful haemodynamic monitoring may be considered for refractory SVT. Atrial ?brillation unstable should receive prompt EC Chemical cardioversion can be achieved with ibutilide伊布利特, dofetilide多非利特, and ?ecainide氟卡胺盯. Amiodarone is less effective Quinidine or procainamide may be but their use is less well established Propafenone普罗帕酮is more effective than placebo but not as effective as amiodarone, pro-cainamide, or ?ecainide. There is no role for digoxin in chemical cardioversion * Determining the Rate 1. Find where the R-S junction of a QRS complex falls on one of the darker 5-mm lines. 2. Note the next R-S junction; mark it. 3. Label each of the darker 5-mm lines between the first R-S junction and th