IN TM CHN ON

CC RI LON NHP THT

TS. TRN SONG GIANG

VIN TIM MCH VIT NAM

H thng dn truyn trong tim

CC RI LON NHP THT

1. NTT/T.
2. NNT.

3. Xon nh.
4. Cung tht.

5. Rung tht

NGOI TM THU THT

- Tht n sm: RR<RR.
- QRS gin rng, c mc.
- Khng c P i trc.

- Ngh b.
- Kh cc nh do DT ngc:
c hoc khng.

CC HNH THI NTT/T

- NTT/T n l.
- NTT/T chm.

NTT/T N L

NTT/T NHP I

NTT/T NHP 3

NTT/T CHM

NTT/T DNG NGH B

NTT/T DNG XEN K

CC HNH THI NTT/T

- NTT/T n dng.
- NTT/T a dng: 2 hnh dng khc nhau.

CC HNH THI NTT/T

- NTT/T sm (dng R/T).
- NTT/T thng thng.
- NTT/T mun.

NTT/T mun
NTT/T dng R/T

NTT/T PHI

NTT/T TRI

CHN ON PHN BIT

1. NTT/N c dn truyn lch hng.
2. WPW cch hi.

3. Rung nh c dn truyn lch hng.

1. NTT/N c DTLH :
C sng P i trc.
Khng c ngh b.

Thng dng BNP.

Phn u QRS ca NTT/N DTLH ging vi lc nhp

xoang.
2. NTT/T:

Khng c sng P.

C ngh b.

QRS cc C trc tim c dng ng hng m hoc

ng hng dng.

RUNG NH C DTLH

1. Rung nh c DTLH:
Khng c ngh b sau phc b QRS gin rng.

Dng block nhnh phi ( a s).

Phc b QRS a hnh.

2. Rung nh c NTT/T:

Cc phc b QRS gin rng c khong ghp c nh.

C ngh b ( do NTT/T c DT ngc qua nt N-T, lc

nt N-T s thi k tr vi cc xung ng tip theo

t trn nh xung.)

Phn loi nng nh (Lown)

Cp 1: NTT/T l t, thnh thong xut hin
Cp 2: NTT/T mau trn 30 nht 1 pht, nhp i
(Bigeminisme)
Cp 3: NTT/T chm i (2 ci lin nhau), chm 3
(nhp nhanh tht khng bn b)
Cp 4: NTT/T a dng (hnh QRS lc m, lc dng,
)

Cp 5: NTT/T c R/T

nhp nhanh tht

y l cn nhp tim nhanh, m ch nhp l cc

kch thch bt thng xut pht t tm tht v ch

huy tht p vi tn s cao (>100ck/ph).

Thng gp bnh nhn c tn thng tim:
NMCT, vim c tim, suy tim...
Tai bin mt s thuc: Quinidine, Aconit .
Tai bin khi m tim, khi gy m, in git...
Dng tr tim, li tiu m khng theo di st din bin

bnh (NTT nhp i do mt K+ mu).

Tuy nhin c th gp ngi khng c bnh tim thc tn:

NNT v cn.

in tm
C 3 NTT/T lin tip.

Nhp nhanh >100ck/ph. Thng l 140-

200ck/ph.
QRS gin rng, trt m, c mc.
Kh u ( 90%).
Khi pht cn bi NTT/T.

CHN ON PHN BIT

1. NNTT c dn truyn lch hng.
2. NNTT c blc nhnh t trc.

3. NNTT c WPW.
4. NN bnh nhn c my to nhp vnh

vin.

CC DU HIU C TRNG CA
NHP NHANH THT

PHN LY NH THT ( AV dissociation)

50%

NHT BT C THT- (Ventricular Capture)

NHT BP HN HP- ( Fusion Beat)

Tim nhanh c nht bt c tht v nht bp hn hp

Cn nhp nhanh c QRS gin (rng 0,14s, dng rS, tn s 145ck/ph)
c 1 nht bt c tht vi QRS hp (xoang) (X), v 4 nht bp hn
hp vi QRS gin t (lai gia xoang v gin rng ) (0).

< 7%

QRS NG HNG CC C TRC TIM

< 5%

NTT/T NGOI CN

Cc du hiu chn on NNT:

Phn ly nh tht.
Nht bp hn hp.
Nht bt c tht.
QRS cc C trc tim ng hng. ng h-

ng m hoc ng hng dng.

Ngoi cn c NTT/T vi hnh dng ging ht

QRS trong cn nhp nhanh.

CHN ON DA VO HNH DNG QRS

Kh nng nhiu l NNT khi:
- rng QRS: >140ms vi BNP.
>160ms vi BNT.
- Trc QRS: v nh ( Northwest).

TIU CHUN BRUGADA

Bc 1: Khng c dng RS tt c cc C

trc tim:
- C NNT.
- Khng Bc 2.
Bc 2: Khong RS >100ms 1 trong cc
C trc tim:
- C NNT.
- Khng Bc 3.

TIU CHUN BRUGADA

Bc 3: Phn ly nh tht:

- C NNT.
- Khng Bc 4.

Bc 4: T/ch chn on NNT da hnh

dng QRS c V1-V2 v V6 :
- C NNT.
- Khng NNTT c DTLH.

TIU CHUN CHN ON NNT DA

VO HNH DNG QRS

TIU CHUN CHN ON NNT DA

VO HNH DNG QRS

Factor

NNT

NNTT c DTLH

Tui

>50

<35

Tin s

MI, CHF, CABG, MVR

MVR, WPW

Sng Cannon A

Present

Absent

Mch

Variation

No variation

Ting T1

Variable

Not variable

Fusion Beats

Present

Absent

iAV dissociation

Present

Absent

QRS

>0.14sec

<0.14sec

Axis

Extreme LAD (< -30)

Normal or slightly
abnl

Vagal Maneuvers

No response

Slows or terminates

QRS morphology
(RBBB-like
pattern)

V1 - R or qR
V6 - rS

V1 - rsR'
V6 - R(slurredS)

QRS morphology
(LBBB-like
pattern)

V1 or V2 - Broad R wave
(>40msec)
V6 - Any Q or QS

V1 - rS or QS
V6 - qRs

PHN LOI NHP NHANH THT

Da vo hnh dng:
- NNT n dng ( Monomorphic VT).

- NNT a dng ( Polymorphic VT): 2 dng.

- NNT n dng, nhiu loi ( Multiple
monomorphic VT).

NNT 2 HNG- Bidirectional VT

PHN LOI NHP NHANH THT

Da vo thi gian ko di:
- NNT khng bn b ( Nonsustained VT): t

ht trong vng <30s.

- NNT bn b ( Sustained VT): ko di 30s
hoc cn phi ct cn ngay ( sc in).

PHN LOI NHP NHANH THT

Da vo bnh tim thc tn:
- NNT BN c bnh tim thc tn.

- NNT v cn.

NNT V CN BN TRI

NNT V CN NG RA THT PHI

CC RI LON NHP THT KHC

Nhp tht <40ck/ph Nhp thot tht ( Ventricular

Escape)
Nhp thot tht xut hin khi TS pht xung ca nt xoang v/hoc ch
nhp trn tht qu chm. Km gim tnh t ng ca nt N-T.

40ck/ph < Nhp tht <100ck/ph Nhp t tht gia

tc ( Accelerated Ventricular Rhythm)

8-36% NMCT cp. 90% 24h sau ti ti mu c tim.

XON NH- Torsade De Pointes

L mt dng NNN ( NNT a hnh thi- Polymorphic VT), tuy

nhin c mt s c im khc vi cc dng thng thng v

cch x tr cng khc.
Thng lin quan n QT di.

a s cn X ngn, ko di vi chc giy ri t ht. Mt s

t chuyn thnh rung tht.

Chim 5% cc trng hp t t do tim.
Gp n nhiu hn nam ( 2-3 ln)

in tm trong cn:
Bin QRS tng dn n tr s ti a ri li

h dn xung tr s ti thiu.
nh ca QRS ang quay ln trn ng ng

in th li ln xung di, nh xon xung quanh

ng ng in.

Cc khong RR thay i ( khng u). TS

tht 150-300l/ph, trung bnh 200-250l/ph.

in tm ngoi cn:

Nhp tim bao gi cng chm.

QT thng kh di (>0,60s).
Khi pht cn thng do mt NTT/T n sm

(dng R/T) trn nn vi tim chm trc .

CUNG THT

-Tht kh u, nh dao ng hnh sin, kh phn nh QRS,

on ST v sng T.
- TS tht >200l/ph.

Rung tht
L tnh trng tht khng bp na m cc th

c tht b rung ln do nhng xung ng lon

x pht ra trn c tht.
Hu qu l BN b ngng tun hon, nu

khng cp cu kp thi th bnh nhn chc

chn s t vong.

3. in tm :
Khng cn thy du vt cc sng PQRST u c.

Ch thy nhng dao ng ngon ngho vi hnh

dng, bin , TS khng u khong 300-400ck/ph

xin chn thnh cm n

CHN ON PHN BIT

Phc Brugada.
Phc Vereckei aVR.
Phc Griffith.
Phc Niemann.