《电复律和起搏》由会员分享,可在线阅读,更多相关《电复律和起搏(33页珍藏版)》请在金锄头文库上搜索。
1、cardioversion,心脏电复律,Definition 应用高能电脉冲直接或经胸壁作用于心脏,使心肌在瞬间同时除极(depolarize),中断折返(reentry)激动和抑制异位兴奋灶,转复多种快速心律失常(tachyarrhythmias)为窦性心律(sinus rhythm)的方法。,Classification 1.电流类型:alternating current and direct current, 2.电极板与病人接触的位置:internal and external 3.发放的电脉冲电流与R波同步:synchronize and asynchronize,Synchron
2、ize,指电击与心动周期在时间上步调一致。为了避开波顶峰附近的心室易损期,复律脉冲的发放是利用心电图波触发同步装置,使电剌激落入波降支或波起始后30ms左右处,相当于心室绝对不应期(refractory period)中。,Asynchronize,不用同步触发装置,可随时在任何时间放电。用于转复心室颤动和扑动(ventricular fibrillation and flutter)。,Indications,原则上适用于转复各类ectopic rapid dysrhymias,尤其是药物治疗无效者,转复ventricular fibrillation and flutter可首选本法。,E
3、mergent cardioversion,室颤和室扑ventricular fibrillation and flutter 。室性心动过速Ventricular tachycardia:1.药物治疗无效;2.伴有低血压、休克等血流动力学障碍;3.超过2小时;4.洋地黄所至者禁用。心脏骤停(cardiac arrest) 室颤波细小时静注肾上腺素0.3-1mg,必要时隔35分钟重复,使其波幅增大,易于转复。,Indictions for atrial fibrillation,病史1年以内,无心衰,心脏扩大不明显去除基本病因后仍有房颤者CHD伴心绞痛(Angina pectoris )、快速
4、心室率或心衰药物治疗无效RHD术后46周仍有房颤者Pre-excitation syndrome(W-P-W)并AF药物治疗无效AF并有栓塞史,Contraindications for AF,心脏明显增大,房颤持续大于5年CHD并慢心室率型AFSick sinus syndrome 并 AFAF并II度、III度Digitalis excess,rheumatic fever、severe electrolyte disorders,especially lower serum potassium levels风湿活动或心肌炎急性期不能耐受抗心律失常药物者,location,一前一后:左肩胛
5、下区和胸骨左缘第四肋间一左一右:心尖和右胸骨旁第二肋间2个电极板至少相隔10厘米,Choice of electrical energy,室上性心动过速(Supraventricular),首次2550J,无效可递增至75100J,不 超过200J。Atrial flutter:25-50JVentricular tachycardia and Atrial fibrillation:100150J,不超过250J。Ventricular fibrillation and flutter:250J,每次递增50100J,最大可达400J。连续电击不超过5次,Energy for childre
6、n,Atrial flutter 0.5J/kgSupraventricular tachycardia 0.25-0.5J/kgVentricular tachycardia 1-2J/kgVF 2J/kg to 5-10J/kg,Internal cardioversion电极板分别置于左右心室外壁,首次电能20J无效每次递增20J,最大不超过100J,Procedure of operation (external) 一、asynchronize 用于VF,立即将电极板上涂以导电糊或垫以生理盐水浸湿的纱布分置于胸骨右缘第2-3肋间和心尖区。按非同步放电纽放电,通过电极板,可从心电示波器上
7、观察到病人心律是否转为窦性。,二、Synchronize(Prepare),正确选择病例检测电解质,纠正电解质紊乱有心衰的AF,先用洋地黄控制心衰和心室率,电击前停用清晨空腹为宜,术前排空膀胱准备好复苏药品和器械有栓塞史者,术前48W口服抗凝,Procedure1.建立静脉通路set up a intravenous route2.连接好心电图机和复律机:3.复律前常规ECG,检查机器同步性能、放电情况、机器电源充电情况。4.术前充分吸氧,静注安定达(tranquillizer)嗜睡状态(lethargic )电极板上涂以导电糊或裹以生理盐水浸过的纱布,放置方法和部位同前复律机按预定的电能量充
8、电电击后立即听诊并记录ECG心电监护blood pressure、pulse rate、respiratory rate,Affected factor,复律脉冲足够的能量窦房结有形成起搏冲动的能力异位起博点兴奋性的降低传导通路的传导功能是否正常,AF发生到电除颤的时间间隔和 颤动波的形态心肌供氧酸中毒(acidosis)是否纠正,Complication,皮肤灼伤dysrhymias心肌损害(myocardial injury)栓塞(embolism)急性肺水肿(acute pulmonary edema)低血压(hypotension)呼吸抑制:,人工心脏起搏,Artificial car
9、diac pacing,Definition,应用人工心脏起搏器(pacemaker)的脉冲发生器,周期性的发放一定频率的电脉冲,通过电线和电极刺激心脏,引起心脏兴奋或收缩。,(二)起搏器类型,体外佩带式用于临时起搏器(temporary pacemaker)埋藏式用于永久性起搏器(permanent pacemaker),Pacing code,The first code indicates the chamber paced:A=atrial、V=ventricular、D=dual chamberThe second indicates the chamber in which ele
10、ctrical activity is sensed:A、V、D and OThe third refers to the response to a sensed electric signal T=triggering、I=inhibition、D(T/I)=a dual response,Additional 4th and 5th letter of the pacing code have been recommended to indicate whether the pacemaker is programmable and has rate modulation(4th) P=
11、 programmable ,M=muti-,O=noneand whether special antitachycardia function are availabla,固定频率型心室起搏:VOO心室同步型:1、R波触发型:VVT 2、R波抑制型:VVI心房同步型:AAT AAI心房同步心室起搏型:VAT心房同步心室按需型:VDD房室顺序心室按需起搏型:DVI房室全能型:DDD抗快速性心律失常的起搏器,Indications for permant pacing,有以下各种严重的心律失常且已固定不可恢复或有加重的趋势III度AVB者有症状(symptomatic)多束支阻滞并心动过缓有症
12、状(symptomatic bradycardia)SSS有症状(symptomatic SSS)颈动脉窦高敏综合征(hypersensitive carotid sinus),有明确因果关系的晕厥(Syncope)发生反复发作(recurrent)顽固性(stubborn)室性或室上性心动过速,药物治疗无效而临时起搏有效,Indications for temporary pacing凡符合上述适应症,但病情尚未稳定,心律失常可能被治愈,以后不一定复发安装永久起搏器前紧急过渡胸外科术后留置电极导线顽固性室性或室上性快速心律失常,药物或电复律无效或有禁忌。诊断或心脏电生理预防性应用,Compl
13、ications,感染(infection)电极脱位(electrode displacement)心肌穿孔(myocardia perforation)导线折断、接插件松脱lead fracture起搏阈值升高threshold value感知功能障碍over or under-sensing皮肤压迫坏死necrosis,脉冲发生器故障:不能起搏和按需不良、起搏器频率“奔放”电源耗竭起搏器综合征(pacemaker syndrome),Management after pacing,适量应用抗生素(antibiotic)预防感染切口(incision)用沙袋压迫24小时,每日查看有无出血(bleeding)和感染心电监护4872H,卧床12天术后67天拆线(take out stitches),After temporary pacing1.Observe 要观察导线、连接线和脉冲器的连接情况2.Measure 每日测定起搏阈值,调整脉冲电压3.Notice AMI注意脉冲感知功能,以防VF 一周后可试关脉冲器 不超过二周,