MUC LUC Tra Tih 0 OB heresy corr cree scree seseccncspeu seen rwerezyerevsnseveseunnenevenceses 5 Bang taf vidt tat 00... ccccccccceccsseseseeneneesseeseeeeesseesnees 7 Chuong 1 : Mot s6 khai niém vé Dién tam dé ............. 9 Chuong 2 : Day nhi — Day that 00.0.0. eee 19 Chuwong 3 : R6i loan dan truyén trong that ............... 29 Chuong 4: Suy déng mach vanh man. ........... ee 38 148 154 62 10 Chuong 5 : Nhéi mau co tim...........0...0. Chuong 6: Bléc xoang nhi-— Bléc nhi that .. Chuong 7: H6i ching kich thich sém... Chuong 8: Ngoai tam thu .......... Chuong 9: Dan truyén léch huéng Chuong 10: Nhip nhanh trén that Chuwong 11: Rung nhi — Cuéng nhi.. Chuong 12: Nhip nhanh that...........cceceeeerees Chuong 13: Chan dodn nhip nhanh QRS hep ......... 106 Chuong 14: Chan dodn nhip nhanh QRS réng hay Gi Mam onc... ec esse nestsdecdnvatecsntetuesetevecsedeles Chuong 15: Mé6t sé trudng hop khac : Chudong 16: Phu 1 .........cccecceeceeseeeteneeaeeeeseteeeeeseneesLOI NOI DAU Dién tam dé la phuong tién chdén dodn can lam sang kh6ng nhiing hitu ich cho bac si chuyén khoa Tim mach, ma cho ca cdc Bac si thuéc cdc chuyén khoa khac (gay mé hdi stic, néi khoa tong quat ...). Su ra ddi cia cdc phuong tién chdn dodn bénh tim mdi nhu siéu 4m tim, anh cOng huéng ti cing khéng bao gid gidm duge sy can thiét cia dién tam dé véi thay thuéc va ca sinh vién y khoa, diéu dudng. Mét kh6é khan déi véi diéu dudng, sinh vién y khoa, thay thuéc thuc hanh khi hoc dién tam dé 1a su phtic tap cia céc sch dién tam dé. C6 qué nhiéu chi tiét trong mot cudn sdch, nhiéu tir kh hiéu, nhiéu cdt nghia dai ddng. Cuén S6é tay dign tam dé chi nhkm muc dich don gidn 1a tom tat cdc diéu cén thiét cho déc gid dé c6 thé doc mé6t dién tam 4d, gép phan vao chan dodn lam sang cia bénh tim. Sé tay bao gém céc tiéu chudn chdn dodn va céc dién tam dé phi hgp cho ting loai bénh tim. Do dé sé khéng cé c&t nghia vé co ché ctia cdc bién déi dién tam dé. Mot khi doc gia cén hiéu sau, nén doc thém cac séch duge gi ¥ trong phan cudi ctia cuén sé tay nay. Lan xuat ban thi hai nay, Sé tay dién tam dé da duge sia chia mot sé thiéu sot cua lan xuat ban dau (1di chinh ta, hinh anh ro hon...). Tuy nhién, su thiéu s6t van cé thé cd, chting ti rét mong nhan duge sy gép y cla déc gia. Thang 9 nam 2003 Tac giaBANG TW VIET TAT CD HA DMV DMP LS NMCT NNT NNTT NT NP NTT TMCB TT TF Chuyén dao Huyét ap Déng mach vanh Dong mach phdéi Lién suén Nhéi mau co tim Nhip nhanh that Nhip nhanh trén that Nhi trai Nhi phai Ngoai tam thu Thiéu mau cue b6 That trai That phaiCHUONG 1 MGT SO KHAI NIEM CO BAN VE DIEN TAM 00 I. CHUAN HOA VA CHUYEN DAO | = : Td | | | [TT HH 0,20 gidy ml 5 mm Chudn hal : lmV=10mm Chudn hoa 2: ImV = 20 mm Chuan héa 0,5 : mV = 5mm * 12 chuyén dao Chuyén dao chi DI DIT DII aVR aVL aVF Chuyén dao ngue Vl V2 V3 V4 V5 V6 Doi khi co thé can cAc CD: V3R V4R V7 V8 V9" Vj tri cdc chuyén dao nguc Hinh 1.1: Vi tri cde chuyén dao ngue: (a) Duong trung don (b) Duéng nach trude (c) Duténg nach sau V1: LS4 P canh xuong te; V2; LS4 T canh xuong ute V4: LS5 duong trung don; V5: LSS dubng nach trude V6, LS5 duing nach gitta; V3: a diém gita V2 - V4 VSR, VAR: diém doi xting vdi V3 va V4 qua xuong ue. Hinh 1.2: So dé dign tim. ; - PR: Khodng PR | - QT: Khodng QT - PQ: Doan PQ - ST: Doan STIl. DIEN TAM DO BINH THUONG Méi mét dién tam dé, can khdo sat co hé thong 9 dae diém sau: . Tan sé va su déu dan Nhip Song P Khoang PR . Phitc hop QRS Doan ST . Song T Song U . Khoang QTc 1. TAN SO VA SU DIEU DAN PARARwOD © 60 Duge tinh bang : Tan sé / phut = RR (giay) Hoe 300 TAn 86/ phut = Sé quang 5 gida ede QRS 2. SONG P - Dang séng P: thudng tron lang, hode duong ho&c 4m toan b6 (don pha - monophasic) trén tat cd cdc chuyén dao tri V1 6 dang 2 pha (biphasic). - Bé rong < 0,12 s. - Bé cao < 2mm. - Truc séng P : tu 0° dén 75° - Binh thuéng séng P: * Duong GI, II, V4-6, aVF * Am 6 aVR3. KHOANG PR: - Thdi gian can thiét dé xung dong dién di chuyén tu vi tri co tam nhi canh nut xoang nhi dén ving co tém that gan cdc sdi cua hé thong Purkinje. - Thoi gian PR théng thudng tir 0,10-0,21 giay. - Khodng PR phan anh sy dan truyén xung déng cham lai khi qua nut nhi that, duoc diéu khién béi su can bang giifa 2 hé théng than kinh giao cdm va pho giao cam. Vi vay, khoang PR sé thay déi theo tan sé tim, sé ngdn hon khi nhip tim nhanh lén luc hé thong giao cam chiém uu thé va ngugc lai. Khoang PR cé khuynh huéng gia tang véi tudi tac. ¢ Gtré em ~ 0,10-0,12 giay ¢ Othanh thiéu nién 0,12-0,16 giay 6 ngudi lén 0,14-0,21giay - Thay déi PR: PR kéo dai: + Bléc nhi that (do suy DMV, thap tim..) + MOt vai truéng hop cudng gidp. + Bat thuong 6 ngudi binh thudng. ¢PR ngan lai: + Nhip bé néi hay nhip nhi thap (gan bé ni). + Héi chttng Wolff- Parkinson—White. + Héi chting Lown- Ganong — Levine + Bénh tu chat Glycogéne + Vai bénh nh4n cao huyét 4p. + Bénh Fabry + U tay thuong than, + Bat thudng 6 ngudi binh thudng.4, PHUC HOP QRS a. Dinh danh phic h¢p QRS - Song 4m dau ctia phic hop: Q - Song duong dau cia phite hgp: R - Song 4m sau R: S - Song duong tht hai: R’ hoac r’ b. Song Q - 6 vai chuyén dao (V;, Vo, Vs) su hién dién cia song Q 1a bat thudng. Trong khi dé 6 nhitng chuyén dao khac ngoai triv III, aVR, song Q binh thudng rat nho. - Gidi han trén binh thudng cia song Q 6 cdc chuyén dao duge néu ra 6 bang 1.1. Bang 1.1: Gidi han binh thudng cia song Q tai cde chuyén dao (TL: Circulation 1982; 65: 345) Chuyén dao Gidihantrén Chuyén dao Gidi han trén I < 0,03 gidy V1 Bat ky II <0,03 giay v2 Bat ky Ill khong V3 Bat ky aVR khong V4 <0,02 gidy aVL <0,03 gidy V5 <0,08 gidy aVF <0,03 gidy V6 <0,03 gidy ec. Song S - Séng S sdu 6 V1 va séu hon 6 V2, va nho dan tit V3-V6. Ciing nhu song R, hinh anh séng S sé thay déi khi cé day that hoac cé nhéi mau co tim. - Thoi gian cia phuc bd QRS tu 0,07- 0,llgiay. Thoi gian cla phic b6 QRS duge tinh tir lic bat dau cia séng Q hay song R dén luc két thc séng R, S, R’ hay S’.- Thoi gian xudt hién nhanh néi dién (intrinsicoid deflection: Ventricular activating time — VAT): dugc tinh tir luc xuat hién sém nhat cla song Q hay R, tinh dén dinh séng R_ trén cdc chuyén dao nguc. Thdi gian nay duge tinh tir lic xung déng dién di tiv néi tam mac cia hé théng Purkinje dén vung ngoai tam mac dudi ché dat dién cue. - Théi gian xudt hién nhanh néi dién cia that phai (do 6 V1- V2 ) téi da 1a 0,035 giay va cua that trai (do d V5- V6) toi da 1a 0,045 giay. Théi gian nay sé kéo dai khi co phi dai that hoac c6 su cham dan truyén trong that. So dé phite hop QRS - cach tinh thdi gian xudt higén nhanh néi dién. R Hinh 1.3: Thai gian xudt hién nhanh néi dién (tw hie bdt ddu phite b6 QRS dén dinh séng R). - Cach tinh truc QRS: cé nhiéu cach tinh. Dé nhanh chéng thudng xem gia tri QRS 6 2 chuyén dao DI va aVF dé co y niém truc QRS nadm trong 6 nao tit I dén IV. Sau dé xem 6 6 chuyén dao chi dé xem chuyén dao nao phic bé cé phan duong gan bang véi phan 4m nhat. Truc QRS sé vuéng géc véi chuyén dao nay. - Bénh ly: truc QRS léch phai (> 90°) hay léch trai (<0°) - Truc phe bé QRS: Thudng tir 0° dén 90°DI aVF +90 Hinh 1.4: Truc dién tim binh thuong. (Binh thusng- ving II: tit 0° dén +90°; léch phdi (RAD- right axis deviation)- vung III va IV: tw +90° dén +270°; léch trai (LAD-left axis deviation)-viing I: tw O'dén -90° Bang 1.2: Vi tri truc QRS tinh dua vdo truc cia QRS 6 chuyén dao DI va aVF ow | de +90°-+ 180° |-™ a -90°- + 180° y5. DOAN ST - ST: la thdi gian co that con trong tinh trang kich hoat hay duge khi cue, Doan ST thudng nim trén dudng dang dién néi vdi phite bd QRS 6 diém J va hop véi nhénh lén cia séng S mét géc 90°. - ST ¢6 thé c6 dang vom hay lém xuéng. Hinh 1.5: Doan ST (A) binh thuéng; (B) ST chénh xudng sau gdng sic 2 phut; (C)ST chénh xuéng dang ndm ngang; (D) ST chénh lén trong NMCT cdp; (E) * ST chénh lén- bién déi binh thusng & nam khoe manh. 6. SONG T: biéu hién thdi gian héi phuc tam that (tai cue) - Tuong tu séng P, song T c6 dang tron, tron lang. Thuong duong 6 moi chuyén dao trit aVR (4m) va dang 2 pha (4 V1). Song T c6 thé hoi nhon va c6 thé cé khae 6 tré em. - Bién d song T cé khuynh huéng gidm di theo tudi, song T thudng cao 6 nam hon ni. - Bién dé: Chuyén dao chi’ <5 mm Chuyén dao ngue < 10mm Hinh 1.6: Song T (A) song T binh thuéng; (B) sing T ¢ bénh nhdn suy DMV man cé dau nguc; (C) séng T déi xing ddo nguoc trén bénh nhén NMCT thanh tritéc; (D) sing T déi xung 6 NUCT thanh dust.7. SONG U - Thuong khong c6 hoac rat nhd. R6 nhat 6 V3. - Co ché: do tai cuc co tru, tai cuc hé Purkinje. - Séng U: thuéng nhé cao khi Kali mau ha, s6ng U dao khi thiéu mau co tim. (1) (2) Hinh 1.7: Song U (1) A: binh thuéng; (B,C,D): séng U cao do ha Kali mau. (2) A: séng U ddo nguoc don déc; B: U dao 6 bénh nhén cao RA; C: Séng U 6 bénh nhaén suy DM vanh man khéng cé cao HA; D: song T va U dado 6 bénh nhdn cao HA. 8. KHOANG QT: Khoang QT : do tit bat ddu cia phic hop QRS téi cudi séng T, biéu thi toan bé théi gian tam thu. Dé dai QT thay déi theo tan sé tim, do dé phdi tinh QTc (QT c6 stfa chita) QT QTc = \RR - QT tang: Khi bénh nhan suy tim, thiéu mau co tim, thap tim, viém co tim, bénh mach mau nao, réi loan dién gidi, thuéc (quinidine, procainamide, phenothiazine). QTc= 0,39 + 0,04gidy - QT gidm: Do Digitalis, Ca ** tang, K* tang.Bdng 1.3: Gidi han binh thuéng cia khodng QT Tan sé tim/ phut 40,0 43,0 46,0 48,0 50,0 52,0 54,5 57,0 60,0 63,0 66,5 70,5 75,0 80,0 86,0 92,5 100,0 109,0 120,0 133,0 150,0 172,0 L__——— QT BINH THUONG Nam vatréem Phu ni (gidy) (giay) 0,449 0,461 0,438 0,450 0,426 0,438 0,420 0,432 0,414 0,425 0,407 0,418 0,400 0,411 0,393 0,404 0,386 0,396 0,378 0,388 0,370 0,380 0,361 0,371 0,352 0,362 0,842 0,352 0,332 0,341 0,321 0,330 0,310 0,318 0,297 0,305 0,283 0,291 0,268 0,276 0,252 0,258 0,234 0,240 GIGI HAN TREN CUA BINH THUONG Namvatreem Phu ni (gidy) (giay) 0,491 0,503 0,479 0,491 0,466 0,478 0,460 0,471 0,453 0,464 0,445 0,456 0,438 0,449 0,430 0,441 0,422 0,432 0,413 0,423 0,404 0,414 0,395 0,405 0,384 0,394 0,374 0,384 0,363 0,372 0,352 0,360 0,338 0,347 0,325 0,333 0,310 0,317 0,294 0,301 0,275 0,282 0,255 0,262CHUONG 2 DAY NHI - DAY THAT Dién tam dé rat hiu ich trong chdén dodn day nhi, day that. Ty d6 gép phan trong chan dodn bénh tim. Tuy nhién, c6 thé day nhi, day that ma khéng cé bién déi trén dién tim. Théng thudng véch that trai day gp 3 lan vdch that phdi. Do dé, dé nhdy cam cua dién tam dé trong ddy that phai kém hon trong day that trai. 1. DAY NHI mae a a wr | NP f\ wr] NPOONT Hinh 2.1: So dé khit cuc nhi 6 trudng hop binh thuéng, déy nhi phdi, ddy nhi trai. (Theo Heart Disease 6" ed 2001, WB. Saunders, trang 94).1. DAY NHI TRAI VA DAY NHI PHAI Bang 2.1: Tiéu chudn chén dodn déy nhi trdi va nhi phdi. is DAY NHI TRAI - DII: Séng P > 0,11 gidy . Song P hinh lung lac da véi khodng c4ch 2 dinh > 0,04 giay. Ty 1é gitta d6 rong séng P va PR > 1.6 - Vi: Pt (P terminal force) > 0,04mm giay. - Truc sng P léch trai : -30°- + 45° DAY NHi PHAI | - DIL: Séng P > 2,5mm - V:: Pi (P initial force) > 0,06 mm-giay. - Truc séng P léch phai: > 70° (P phé) * Nhiing dau hiéu thay déi QRS gai ¥ 1én nhi phai: e Séng Q (dc hiéu 1a qR) / chuy&n dao nguc P, khéng la dau hiéu cia nhéi mau co tim. ¢ QRS bién dé thap/ V; (< 6mm) va cao dét ngot 6 V2(= 3 lan) 2. DAY 2 NHI e PII réng va cao. e =6PV;; *Pi>1,5 mm * Pt > 0,03 gidy Thudng gap trong: Hep van 2 la c6 tang 4p DMP, hep 2 la va ho van 3 14, hep 2 14 va hep 3 14, hdi ching Lutembacher.Hinh 2.2: Dién tam dé 12 chuyén dao trén bénh nhdn 33 tuéi hep 2 ld. Déy nhi trdi voi PDII > 0,11 gidy va Pt 6 VI > 0,04 mm gidy. Hinh 2.3: Dign tam dé 12 chuyén dao trén bénh nhén niz § tudi bj théng lién nhi. Hinh anh lén nht phai voi song P > 2,5mm @ DII. Hinh 2.4: Dién tam dé 12 chuyén doo trén bénh nhén nit 10 tudi bj théng lién nhi, he van 2 ld, tang dp DM phoi ngng. Ddy 2 nhi udi hinh anh song P > 2,5 mm 6 DII va Pt > 0,04mm-gidy.1. DAY THAT - Thanh tam that co thé dan ra dé dap tng véi tinh trang tang ganh thé tich trong thdi ky tam truong cing nhu tré nén phi dai dé dap tng vdi tinh trang tang ganh 4p luc trong thdi ky tam thu. Su l6n that trai va that phai thudng kém theo sy lén nhi trai hay nhi phai tuong tng. Vi thé, nhiing dau hiéu dién tam dé théa tiéu chudn chan dodn 16n nhi nén duge xem la dau hiéu goi y su lén that. - Khi cé su thay déi kich thuée that, sé cé sy thay déi hinh dang phtic b6 QRS, bién dé va hinh dang séng R, S, doan ST va T. Nhitng biéu hién nay ro nhat 6 chuyén dao DI va V1. Khi co su két hop su lén ca 2 that trai va phai, hinh dang phtic bo QRS 14 hinh dang phéi hgp (hinh 2.6). A. TANG GANH THE TICH B. TANG GANH APLUC Hinh 2.5: / Su thay doi kich (‘9 thue that & tréi (LV) va that THAT PHAI phdi (RV) gay ra bédi su tdng gdanh thé tich do hé van (A); va bdi su tdng génh dp luc do hep duong thoat (B).| oI vi —___} —_}_ ____ A. Binh thudng B. Dy that trdi , = | A C. Day that phai | AH j- Hinh 2.6: Nhing thay déi dién hinh cla phite b6 QRS 6 DI va V1 trén bénh nhdn ddy that 1. DAY THAT TRAI - Cée tiéu chudn chén doén: Bang 2.2: Hé théng thang diém Romhilt-Estes +e i4}4 D. Day 2 that Diém 1. Rhode S 6 chuyén dao chi = 20 mm 3 ho&ic S6V,, V2 hodc V3; = 25mm ho&e Rd Vs ho&c Ve 2 25mm 2. Thay 46i ST-T khong dac hiéu - khong uéng digitalis - 06 udng digitalis 3. Dau hiéu Ién nhi trai: Pt/ V, = 0.04 mm-giay 4. Truc léch trai = -30° 5. Phuc bd QRS 2 0,09 gidy 6. Thii gian xuit hién nhénh noi din/V; Ve. = 0,05 giay Téngcong: 13 ae ee) ® Day that tréi : = 5 diém C6 thé day that trai 4 diémBang 2.3: Tiéu chudn Sokolov-Lyon S Vi+ R (V; hodc Vs) > 35 mm hoac R Vs hoae Vz > 26mm Bang 2.4: Tiéu chudn dién thé Cornell Na RoaVL+S6éV3>20 mm Nam R6éaVL+S6V3>28mm Bang 2.5: D6 nhdy cém va chuyén biét cla 2 tiéu chudn chén dodn day that trai D6 nhay cam | Dé chuyén biét Sokolov-Lyon 22% 100% Cornell 42% 96% - Dau hiéu tang g4nh tam thu (phi dai) va tang ganh tam truong (dan) that trai: Tang ganh tam thu Tang ganh tam truong - Tang bién dé QRS 6 Vs, V;_ - Song R cao 6 Vs, Ve, DI, aVL - Tang thdi gian xudt hién = - Song S sau 6 Vo, Va nhénh ni dién Vs, Ve - Séng Q sau hep 6 Vs, Ve - ST chénh xuéng 6 Vs, V5 - ST chénh lén nhe (< 1mm) é Vs, - T dao é chuyén dao ngye ~—-V¢. trai - Song T cao, doi xtmg 6 chuyén dao nguc trai2. DAY THAT PHAI Bang 2.6: Tiéu chudn chdén dodn diy that phdi Tiéu chudn Dé nhé4y cm} Dé chuyén biét (%) (%) RgV,; = 7mm <10 - QRGV, <10 : RS 6V)>1 vi R> 5mm 25 89 {R/S 6 Vs hodc Vs <1 <10 - S 6 Vs hodc Ve = 7mm 17 93 RV; hodc V, # 4 mm véi <10 - S6V,# 2mm Truc léch phai (2 +90°) 14 99 S:Q 11 93 S,S,85 <10 ¥ P phé 11 97 Bang 2.7: Tiéu chudn Sokolov-Lyon chan dodn ddy that phdi RG V+ S (Vs ho&c Ve ) = 11 mm - Dau higu tang ganh t4m thu (phi dai) va tém truong (dan) that phai: Tang ganh tam thu Tang ganh tam trvong -R cao + T dao 6 chuyén dao ngyc phai. rSR’ 6 V, 3. DAY HAI THAT - Sy lén hay phi dai cia cd 2 that sé gay ra nhing thay déi dién tam dé phtc tap. Nguge lai vdi tinh trang lén 2 nhi, hinh anh dién tam dé chi 1a sy phéi hgp don gian cia ca lon nhi tréi va nhi phdi. Trong trudng hgp day thét, dau hiéu cia day that nay sé che dau hinh anh cia day thét kia.- Tiéu chun chén dodn day 2 that: 1. RS 2 pha kém dién thé cao 6 cdc chuyén dao nguc gitta 2. Tiéu chudn dién thé théa day that trdi trén cdc chuyén dao nguc + truc léch phai 6 céc chuyén dao chi. 3. s nhé 6 V,+ S rat sau 6 V2 4, Tiéu chudn dién thé théa day that tréi trén cdc chuyén dao nguc trai + R cao 6 cdc chuyén dao ngyc phai. 5. Dau hiéu 16n nhi trai + bat ky tiéu chudn nao cia 1én that phai. 6. Rao trén tat cd c&c chuyén dao nguc. Hinkh 2.7: Ddy thdt trdi, tang génh tam thu 6 bénh nhén nam 54 tuéi, bénh co tim phi dai. Truc QRS léch trai, S V;+R Vs > 35mm, thay déi ST-T thit cdp 6 DI, aVL, V-Ve.Hinh 2.8: Déy thdt trai tang ganh tam truong é bénh nhén na@ 26 tudi, hd van 2 1é nang. R cao & V;-Ve lam séng T cao. Hinh anh lon nhi trai voi Pt> 0,04 mm -gidy 6 V;. Hinh 2.9: Déy thdt phdi, tang génh tam thu 6 bénh nhadn nam 8 tuéi, hep van DMP nang. Truc QRS léch phdi, R rdt cao 6 V; kém theo thay déi ST-T 6 V,- V2. Hinh anh lén nhi phai vdéi séng P cao 6 DII.12 amet DIA “ir aur ah SITET he serotonin Hinh 2.10: Day that phdi, tang gdnh tam truong 6 bénh nhdn ni? 20 tudi, théng lién nhi cé tang ap DMP. Truc QRS léch phdi kem R cao 6 V; va c6 dang rSR’. 1 a em ae lis wy L Aatinae M AS ' AWN ‘ i ' i { fey E waif wig boca sf RH 1ava, fod cbt ied etal ate dad Pipi OWA AL i pla, fhe) 8 Coda f phd [ae fae + ae 1 ” Hinh 2.11: Day 2 that, 6 bénh nhan nam 15 thang tuéi, théng lién that cé tang dp DMP nang. Truc léch trai - 70°, RS dién thé cao trén tat cd cde chuyén dao ngucCHUONG 3 . . . ROI LOAN DAN TRUYEN TRONG THAT I. BLOC 1 BO (UNIFASCICULAR BLOCKS) - Bléc 1 b6 xdy ra khi dién tam dé chi c6 dau hiéu bléc nh4nh phai (RBB- right bundle block), blée phan nhanh trai truéc (LAF- left anterior fascicle), ho&c bléc phan nhaénh trai sau (LPF- left posterior fascicle). Bléc nhénh phai, bléc phan nhanh tréi truéc riéng lé thudng gap, nhung bléc phan nhanh trai sau riéng 1é thi hiém gap. 1. BLOC NHANH PHAI - That phai gop phan rat it vao hinh dang binh thudng cia phitc b6 QRS, nén hinh anh QRS it bi bién dang trong truéng hgp bléc nhanh phdi. Bang 3.1: Tiéu chudn chén dodn bléc nhanh phdi. - Chuyén dao V1 RSR’, théi gian xudét hién nhanh ndi dién tré, song R rong hodc gR. - Chuyén dao V6 Thdi gian xudt hién nhénh néi dién sém, séng S r6ng - Chuyén dao DI Song S réng. Blée nhanh phai * Khong hoan toan Dé réng QRS = 0,09 -0,10 giay * Hoan toan Dé réng QRS 2 0,12 giay. - ¥ nghia lam sang: 6 ngudi binh thudng (0,15%), bénh dong mach vanh, bénh co tim, bénh Ebstein, théng lién nhi, kénh nhi that, thuyén tadc phéi cap, héi chttng Brugada (bléc nhanh phai kém véi ST chénh lén trén c4c chuyén dao nguc phai).2. BLOC PHAN NHANH - Binh thudng, su khit cue thanh ty do cla that trai duge khéi phat déng thai ti 2 vi tri (gan ché g4n cia co try cia van 2 14). Song khtr cuc di tir ndi mac dén ngoai tam mac. Khi nhitng séng nay di theo nhiing huéng nguge chiéu nhau sé co hiéu qué lam mét tac dung cia nhau trén dién tam dé - hién tuong triét tiéu. Khi c6 bléc 1 phan nhanh trdi truéc hay trai sau, hién tugng kh cue chi xay ra tai 1 vi tri va hién tugng triét tiéu sé m&t di, do d6 sé c6 su bién déi cua phite b6 QRS (hinh 3.1). Binh thudng |Bléc phan nhénh|Bléc phan nhanh trai truéc trdi sau : Oe Hinh 3.1: So dé that trai nhin tit mém. (A) Khit cuc thdt binh thiténg. (B) Khit cuc that trong truéng hop bléc phan nhdnh tradi truée. (C) Khit cue that trong truong hop bloc phan nhdnh trdi sau. S: interventricular septum - vdch lién thét, FW: left ventricular free wall - thanh tu do thdt trdi, A-P: anterior and posterior regions of the left ventricle - vung truéc va sau thdt trai). (Theo Marriott’s Practical Electrocardiography 10" ed 2001, trang 103).Bang 3.2: Tiéu chudin chén dodn bléc phén nhanh tréi truée 1. Truc léch trai (thutng 2 - 60°) 2. q nhé 6 DI, aVL; r nhé ¢ DII, III, aVF. 3. D6 réng QRS binh thugng 4. Thdi gian xudt hign nhénh néi dién > 0,045 gidy 6 aVL. 5. Tang dién thé QRS 6 chuyén dao chi. Bang 3.3: Tiéu chudn chéin dodn bléc phan nhénh trai sau 1. True léch phai (thutng 2 + 120°) 2. rnhé 6 DI, aVL; q nhé ¢ DII, Ill, aVF. 3. D6 réng QRS binh thudng 4. Thai gian xu&t hién nhénh n@i dién > 0,045 gidy 6 aVF. 5. Tang dién thé QRS 6 chuyén dao chi. 6. Khong dau hiéu day that phai. II. BLOC 2 BO (BIFASCICULAR BLOCKS) - Bléc 2 b6 xay ra khi dién tam dé cé dau hiéu cda bléc nhénh tréi, bléc nhaénh phai kém theo bléc phan nhanh trai truéc hodc trai sau. - La 1 dang bléc nhénh 2 bén khéng hoan toan (incomplete bilateral bundle branch block) 1. BLOC NHANH TRAI Bang 3.4: Tiéu chudn chén dodn bl6c nhdnh trdi. -Chuyén dao V1 = QS hay rS - Chuyén dao V6 = Thai gian xudt hién nhdnh ni dién tré, khéng c6 séng Q, séng R don pha. - Chuyén dao DI Séng R don pha, khong séng QBléc nhénh trai * Khong hoan toan 6 rong QRS = 0,10-0,11 giay * Hoan toan Do réng QRS = 0,12 gidy. - Phan biét bléc nhaénh trai va day that trai: Sing Q 6 chuyén dao nguc trai chi cé trong day that trai. Bién do phtc hop QRS cang cao cang goi y day that trai. Nguoc lai, dé réng QRS cang réng cang goi ¥ bléc nhanh trai. - Theo Klein va cong su: chan doan blée nhanh trai + day that trai khi c6 1 trong 2 tiéu chudn sau: (1) S sau 6 V2 + RG V6 > 45mm. (2) Déu hiéu lén nhi trai + phtic b6 QRS rong > 0,16 giay. - Bién déi séng T trong truéng hop bléc nhénh: Song T thuong dao nguoce huéng véi phan cudi cua phttc b6 QRS (T thi phat). Thudng truc séng T hop véi phan tan cing cia phtic bé QRS géc lén # 180°; néu géc nay < 110° va séng T cing huéng véi phan cuéi phic bé QRS nén nghi dén su thay déi séng T nguyén phat cia bénh co tim. - Y nghia lam sang: Bléc nhaénh trai hoan toan goi y bénh co tim do thiéu m4u cuc bé hay tang huyét 4p; bléc nhanh trai + truc QRS léch phai gai y bénh co tim dan nd. 2. BLOC NHANH PHAI + BLOC PHAN NHANH TRAI TRUGC - Bléc phan nhanh trai trude xdy ra don thuan thuéng gap hon la bléc phan nhanh trai sau, thugng di kem véi bléc nhanh phai dé tao thanh bléc 2 bd. 3. BLOC NHANH PHAI + BLOC PHAN NHANH TRAI SAU - Bléc 2 b6 dang bléc nhanh phai + blac phan nhanh trai sau hiém xay ra. Ngay ca khi ma thay déi trén dién tam a6 théa tiéu chudn, chén dodn bloc 2 bé dang nay chi duge nghi dén khi khéng cé ching cit day that phai trén lam sang.Bang 3.5: Tiéu chudn chén dodn bléc nhdnh phdi + Bléc phan nhdnh trdi truéc 1. Hinh anh bléc nhaénh phai V1 2. Hinh anh bléec phan nhénh trdi truéc: rS 6 DII, DIII va aVF. 3. Dé rng QRS 2 0,12 gidy 4. Truc QRS -40° dén -120° Bang 3.6: Tiéu chudn chén dodn blée nhanh phdi + Bléc phan nhdnh trdi sau 1. Hinh anh bléc nhénh phai 6 V1 2. Hinh anh bléc phan nhénh trai truéc: rS 6 DI, va aVL 3. Dé rong QRS = 0,12 gidy 4. True QRS = +90° III. BLOC 3 BO - La tinh trang bléc déng thdi (khéng hoan toan / hoan toan) 3 trong 5 dudng d4n truyén that: b6 His, nhénh phai, nhanh trai, phan nhénh trai truéc va phan nhénh trdi sau. - Tuy nhién, bléc 3 bé thudng duge ding trong trudng hop bléc nhanh phai kém bléc phan nhénh trdi truée va phan nhénh trai sau. Va vi vay, bléc 3 bé duge xem 1a biéu hién cia bléc nhénh 2 bén (bang 3.7)Bang 3.7: Tiéu chuén chan dodn bléc nhanh 2 bén (bléc 2 bd va bléc 3 bd) 1. Blée nhaénh phai kém bléc phan nhanh trai truéc 2. Bléc nhénh phai kém bléc phan nhanh tréi sau. 3. Bléc nhaénh phai va nhanh trdi ludn phién. 4. Blée nhénh phai hodc nhénh tréi kém bléc nhi that dd 1 hodc dé 2. 5. Bléc nhanh trai hoc phai kém khoang HV kéo dai (khoang dan truyén dién thé ti b6 His xuéng that-ghi trong dién tam dé bé His) > 55 gidy. 6. Bléc nhénh tréi va nhénh phai ting lic. 7. Bléc nhi that d6 II, Mobitz 2. 8. Bléc nhi that hoan toan cé nhip thodt that (idioventricular). (Theo Pocket guide to ECG Diagnosis, 2" ed 2002, trang 72) ated eos, StUtOT | out Hinh 3.2: Bléc nhanh phdi khéng hoén toan kem voi lon 2 nhi trén bénh nhén 20 tudi, thong lién nhi.AT-aC1.27 + Hinh 3.3: Bléc nhdnh trai hodn todn trén bénh nhdan nam 50 tuéi, cao huyét dp. Hinh 3.4: Bléc nhanh phdi kem vdi bléc phan nhanh trai truée trén bénh nhén nam 27 tubi hd van DMC ngng.u mw SoSH coococertt hte Hinh 3.5: Bléc phan nhdnh trai trude Hinh 3.6: Bléc phdén nhanh trai sau trén bénh nhan nhoéi mau co tim thanh truéc.ee Hinh 3.7: Bléc nhanh trdi tung hic trén bénh nhdn nit 56 tuédi, cao HA. 7 ALIA s TUBER EEE gu eee ss aa AL PSOE er aoe 5 e + vee: eee tt ete es ee Wade i ea you vey i NIN Na ak dn i} ; ihe. LAA ey Sth 4a OTN a cay tlt A monk ong te Hinh 3.9: Bléc 2 b6 trén bénh nhaén NMCT thanh sau va ving hoanh.CHUONG 4 SUY OONG MACH VANH MAN Suy dgng mech vanh cé thé do t&c nghén 1 phén déng mach vanh (DMV), thutng do xo vita déng mach, c6 thé do co mach. Suy DMV sé dan dén thigu méu co tim. Biéu hién dién tam dé c6 thé la: - Bién déi tAi cc (repolarization). - Bién d6i khit cuc (depolarization). - Tuong quan bat thutng gitia tai cue va khit cuc. L BIEU HIEN BAT THUONG CUA TAI CYC (ST-T-U) - Doan ST - Séng T - Séng U 1. DOAN ST a. Sup xuéng (depression) - Biéu hién tén thuong duéi néi mac tim. - Biéu hién r6 nhat 6 V5-V6 - Cée dang ST: sup chdi xuéng, sup chéch lén, sup bing ngang, géc sic gitta ST-T (ST-T sharp angle) ** Tiéu chudn chan dodn thiéu mau duéi ni mac: (1) ST chénh xuéng >1 mm tai diém J. (2) ST chénh xuéng dang ngang hay chui xuéng, va sng T duong hay ngugc huéng véi phite b6 QRS (hinh 4.1). (3) ST chénh xuéng tit 1-2 mm tai diém J, theo sau béi sy chéch lén cia doan ST nhung van duéi du’ng dang dién 1mm va kéo dai 0,08 giay.Ho&ic 2 mm tai diém J, theo sau bé sf chéch 1én cia doan ST nhung vn duéi dutng dang dién 1mm va kéo dai 0,08 gidy. bale ol Hinh 4.1: Hinh anh ST trong trudng hop binh thudng (A), va thay i ST trong trudng hop thitu mdu dudi ndi mec. ST chénh zudng > 1mm tai diém J hem theo bién d6i séng T duong (B) va dédo (C). b. Chénh lén (elevation) trén dutng dang dién. C6 thé do tén thuong thyc thé nang DMV Binh thudng|ST syp xuéng] ST sup, chéch | ST chéh lén, T ST ngang- Géc ST-T sic Hinh 4.2: Cac dang thay déi ST -T. (Theo An introduction to Electrocardiography, 7th ed, 1990, Blackwell Scientific Publications, trang 159).Ngoai ra, ST chénh lén cén do: + Co thit DM vanh + Tui phinh thét trdi + Viém mang ngoai tim + Tén thuong chic nang thét tréi: thutmg gép d bénh nhan cé tién ai nhéi méu co tim. 2. SONG T - Binh thutng : khong déi xing - Bénh ly: eT nhon, déi xing hoe T dao, det. eT V6 Imm sau diém J va kéo dai 0,08 gidy kem T dédo. Hinh 4.4: Thay déi dién tam dé sau gdng ste 1:41 phiit, mute gdng suc toi 4 METS trén bénh nhdén nam 80 tudi. ST chénh xudng > 2mm 6 V5-V6 va > Imm 6 DI, DIL, aVF.Hinh 4.5: Thay doi dién tam dé sau khi ngung gdng suc 5 phut, trén bénh nhan nam 71 tuéi. ST chénh xuéng > Imm ¢é DIL, DIT, aVF hic gdng sue toi 7 METS va kéo dai sau ngung gdng site. Hinh 4.6: Thay déi dién tam dé gdng site 3,26 phut, trén bénh nhdn nam 56 tudi. ST chénh lén > 2mm 6 V2 vd V3 luc gang site toi 7 METS 0,26 gidy va kéo dai 2 phit 30 gidy 6 giai dogn hoi phuc. Hinh 4.7: Thay doi dién tam dé gang suc 8 phut, trén bénh nhén nam _66 tudi. ST chénh xudng nam ngang > 2mm_ 6 DII, DUI va aVF lie gdng suc téi 7 METS va kéo dai 2 phit 6 giai doan héi phuc.CHUONG 5 NHOI MAU CO TIM - ECG gop phan quan trong trong chdn dodn NMCT. Tuy nhién, c6 thé co NMCT ma ECG dau tién khéng thay bién déi. - Qué trinh nhéi mau dién ra qua 3 giai doan, duge ghi nhan trén dién tam dé: + Giai doan téi cap (hyperacute phase). + Giai doan cap dang tién trién. + Giai doan man én dinh. I. TIEU CHUAN CHAN DOAN NMCT GIAI DOAN TOL CAP (vai gid dau cha NMCT) 1) Thdi gian xuat hién nhénh néi dién kéo dai (VAT); > 0,45 giay "| Hink 6.1: So dé m6 té co ché va KR i hau qué eta tdée nghen mach vanh i || cdp. VAT kéo dai (khodng xy). 2) Tang bién dé séng R: - Do thii gian khit cuc that tang. M6 co tim bi tén thuong cap, chua bi hoai tt nén van con dan truyén dién, nhung 6 toc a6 cham hon. Do dé, khi khir cuc dén giai doan nay, vector khtr cue sé khéng chiu anh huéng cia xung déng khti cue cia vach tim déi dién tao nén hinh anh s6ng R cao cia ving co tim bi tén thuong.3) ST chénh lén, hinh vom: Cn chan doén phan biét véi nhiing nguyén nhan khéc (bang 5.1). Bang 5.1: Cac bénh ly cd ST chénh len. | 1. Bénh DM vanh: - Con dau that nguc Prinzmetal - Tdi phinh that - sau nhéi mau 2. Viém mang ngoai tim cap 3. Day that trai/ Bléc nhanh trdi (chi 6 V1,V2 , V3) 4. Thay doi binh thudng do téi cue sém. 5. Nguyén nhan hiém: - Viém co tim - Chan thuong co tim - Ha than nhiét - Sau sée dién chuyén nhip - Xuat huyét ndi so - Hdi chimg Brugada - Tang Kali, Calci mau (chi é V, va V2) - Thuéc chéng loan nhip nhém 1C (Tai ligu: Heart Disease 6** ed 2001 WB. Saunders, trang 115) 4) T cao va réng: Can chan dodn phan biét véi nhiing nguyén nhan gay song T cao nhon khac (bang 5.2). Bang 5.2: Cac bénh ly cé sing T cao rong 1. Thiéu mau duéi ndi mac, nhéi mau co tim 2. Nhéi mau co tim thanh duéi giai doan héi phuc 3. Giai doan téi c@p cua nhéi mau co tim thanh truée4, Con dau that nguc Prinzmetal 5. Nhéi méu co tim thanh duéi 6. Tang Kali mau (Tai ligu: An Introduction to Electrocardiography 1994, Blackwell Scientific Publications, trang 444) II. TEU CHUAN CHAN DOAN NMCT GIAI DOAN CAP Hinh 5.2: So dé mé ta cde giai doan trong NMCT cap. - Necrosis: hoai tit - Injury: tén thuong - Ischemia: thiéu mdu cuc b6 - Trong giai doan cap, xay ra 3 hién tuong: Hoai tt co tim, tén thuong co tim va thiéu mau co tim. Biéu hién trén ECG dac trung cua ting qué trinh. 1. HOAI TU CO TIM - Qs - Qr - Gidm bién dé RWI N f\ DQ Ving co tim hoai tu tao 4 A U nén 16 tréng dién = (electrical hole). Véc-to khu cuc cua QRS nguoc hudng vdi ving hoai tu (véctd 1 va 2) tao hinh anh séng Q sau réng. Cavity : buéng tim Muscle : ed Hinh 5.4: Qua trinh tao song R edt cut trong giai dogn edp nhoi mau co tim. A: Qua trinh khit cue binh thuéng B: Qué trinh khit cue binh thuong vé mat ly thuyét, cd ving hoai tit nhé dudi nédi mac C: Giam khit cuc QRS, séng Q bénh ly, hogi tit duci ndi mac quan trong. D: Mat khit cue QRS do hoai tit co tim xuyén thanh. E: Gidm khwt eve QRS do hoai tw duéi thuong tam mae.—+ Qc6¥nghia: - Rong > 0,04 giay - = % song R cing CD 2, TON THUONG CO TIM - ST chénh lén, hinh vom - Hinh anh soi guong 3. THIEU MAU CO TIM - T dado, nhon, déi xting - Hinh anh soi guong Antesran_Inrancriow Sar] vs Tertsion TWPARCTION ae A i fn dA ual Hinh 5.5: Cade giai doan cia NMCT ving trude va dui STAGE I (TL: Practical ln. electrocardiography, . 1 Williams & Wilkine, |"""lds tA ~ 8th ed, 1988, tr. 424). STAGE ML in ~ hh bly tv Tom tat: Dau hiéu cia Nhoi Mau Co Tim Cap Truée Duéi 1. Thay déi dinh vi 6/1, aVL II, IH, aVF cde chuyén dao CD nguc truéc |CD nguc sau (Q, STH, T dado) 2. Thay déi soi guong |II, III, aVF, I, aVL, 6 cdc CD CD nguc sau |CD nguc trude 3. Thay déi tién trién ting ngayII. NMCT GIAI DOAN MAN - ST tré lai dong dang dién - Séng T duong lai - Con song Q Tién trién cia cdc séng: - ST: sau vai ngay - Tvaitudn -> vai thing - Q: vinh vién IV. DINH VI NMCT - That trai - That phai - Tam nhi 1. THAT TRAI - Vach trude - Vach duéi - Vach sau * Nhéi mau co tim ving truée: - Trude rong: . IaVL . Tat ca chuyén dao nguc - Trudc vach (anteroseptal) . Vl-> V3 - Truéc bén (anterolateral) . IaVL . V4-> V6 - Mém tim (apical) . V8. V4Bang 6.3: Phan ving NMCT (Tai libu: Marriott's Practical Electrocardiography 10" ed 2001, Lippincott Williams & Witkins, trang 184) * Nhdi mau co tim ving hoinh (dudi): Bién déi céc chuyén dao II, WI, aVF (Q, ST chénh lén, T dao). * ¥ nghia cia Q @ DILL: Goi ¢ NMCT cd ving hoanh khi - QUI > 0,04 giay . QaVF > 0,02 gify . qhay QG DI . RIM & mm (hodc QIII cao > 2,6 mm) . P(+)¢ DI . Nhdi mau co tim ving sau: - ThuOng két hyp NMCT ving hoanh hay trudc bén, khéng cé CB khdo sat truc tiép ving sau. - Dya vao hinh anh soi gvong é V1 V2 V3 (nhét la V2) - Reao, rng. - T duong, nhon, ai xing.2. THAT PHAI 80% NMCT ving hoanh cé kem NMCT that phai - ST chénh lén V1, V4R> lmm hoa&c - ST chénh lén V1, + ST chénh xuéng V2 - Cé kém dau higu NMCT vang hoanh 3. TAM NHI Thudng ¢ NMCT ving hoanh Dau ggi y: - P-Ta chénh lén hodc sup xudng (da r&t it) (P-Ta: cudi séng P -> dau QRS) - Dang bat thutng cia P - Loan nhip nhi -- Bléc xoang nhi - Bléc nhi that d6 1 4. NM DUGI NOI MAC (Subendocardial infarction) Tiéu chudn : - Lam sang va sinh héa goi ¥ NMCT cép - ST chénh xuéng, T 4m 6 ede chuyén dao ngyc gitia va bén, I, II - Kéo dai vai ngay 5. NHOI MAU CO TIM / BLOC ana TRAI - Tiéu chudn chén dodn: (1) ST chénh lén kém T duong cao nhon 6 chuyén dao nguc phai. Hoae ST chénh lén 6 chuyén dao bén. ST chénh xuéng hodc T(-) sau V1-V3 ST chénh lén > 5mm 6 chuyén dao cé QS hay rS(2) QR 6 chuyén dao DI, V5-V6 hoae DII, DII, aVF. (3) Song S sau rong, nhdénh xudng cé méc 6 chuyén dao gitfa ngue —> NMCT cd (dau hiéu Cabrera). (4) Song R réng, nhénh lén c6 méc 6 V5-V6 —> NMCT ci (dau hiéu Chapman). 6) & A. Bléc nhanh trai. QO hy B. Nhéi mau co tim viing vach / bléc nhanh trai. Hinh 5.6: Hinh anh phitc b6 QRS trong blée nhanh trai (A) va NMCT trén bénh nhdn c6 bléc nhdnh trdi (B). Hinh 5.7; NMCT thanh truée | bl6c nhdnh trai. QR 6 DI, aVL, V5-V64 | ay ep | an Vr Vy Hinh 5.8: NMCT cui ving truée vdch trén bénh nhén nam 52 tuéi. QS 6 V2-V5, T (-) déi xing tit V2-V5. Hinh 5.10: NMCT cdp that phdi. ST chénh lén dang ké 6 V1-V3aoe ui a der Sea TITUT OU éoeuR Hinh 5.12: NMCT cap ving truée vach kém vdi blée nhanh phdi va rung nhi. Hinh 5.13: Bléc nhanh trai kem voi NMCT cdp thanh truéc.CHUONG 6 BLOC XOANG NHi- BLOC NHI THAT Réi loan dan truyén xung déng: - Bléc xoang nhi (sinoatrial block). - Bléc nhi that (atrioventricular block). - Nhip hé tuong (reciprocal rhythm). - Nhip nhanh trén that (supraventricular tachycardias). I. BLOC XOANG NHI - Sy din truyén xung déng bi tc ché 6 ving néi xoang nhi (SA junction). -ECG: Khéng P Khong QRS Sau nhat bi bléc, nhat sau cé thé: + Nhat xoang binh thuéng + Nhat thoat nhi-that + Nhat thodt that. - Blée xoang nhi: + Khéng hoan toan: d6 1, dé 2 + Hoan toan: dé 3 - Y nghia lam sang: + Thuéc: digitalis, quinidine, salicylate + Bénh DM vanh + R6i loan sinh ly: tang hoat tinh déi giao cam+ Uré mau cao + K' thap + Hi chting nut xoang bénh + Nhiém tring cap IJ. BLOC NHi THAT (Atrio-Ventricular Block) Hinh 6.1: So dé minh hoa duong dan truyén xung déng ti nhi dén thdt. A,B,C: tuong tng vdi cdc vi tri cé thé xdy ra bléc (nut nhi thét, b6 His, va nhdnh phdi-trdi); 1,2,3: nhung vi tri tai thdt ma khi bléc xdy ra tai nhitng vi tri nay, phite b6 QRS sé réng hon 0,12 gidy. (NP: nhanh phdi; NT: nhanh trai; PNTT: phan nhanh trdi trudc; PNTS: phan nhdnh trdi sau).Bléc nhi thét 1a tinh trang chém hay ngung dan truyén xung dng tit nhi xuéng that. Tuy theo mic dé nang hay nhe cia bléc, c6 3 mite dé: - Blée nhi that 46 1 - Blée nhi that 46 2 - Blée nhi that d6 3 (hay bléc nhi that hoan toan) . 1. BLOC NHi THAT BOI - Khoang PR binh thutng 0,12-0,21 giay. - Bléc nhi that 46 I khi thei gian ddn truyén nhi that (khoaéng PR) kéo dai > 0,21 gidy. - ¥ nghia lam sang: + Bénh DM vanh + Thap tim + Ding thuéc lam cham dan truyén nhi that: digitalis, ttc ché beta, tic ché Calci. + Ngudi binh thuéng (0,5- 2%). 2. BLOC NHI THAT BO I - Khi cé 2 1 (nhung khong phai tat cd) xung dong tir nhi khéng xuéng that duge. - Bléc nhi that 46 II c6é thé timg lic hay kéo dai. - Bléc nhi that d6 II dugc nhén biét khi c6 nhét roi (dropped beat) — tic 1a cé séng P ma khéng co phic b6 QRS theo sau. Ty lé d&n truyén (conduction rate) nay cé thé la 2:1, 3:2... Sé xung dong xoang (86 P) Ty 1 dan truyén (conduction rate)= S6é xung dong that (sé QRS)Ne PhAn loai blée nhi that 46 II: + Kiéu 1 (Wenckebech, Mobitz 1) PR dai dan dén khi cé 1 nhat roi Tén thuong thudng n&m tai nut nhi that + Kiéu 2: (Mobitz 2) PR cé dinh dén khi c6 1 nhét roi Tén thuong thudng nam tai bé His. Y nghia lam sang : + Bléc nhi that 46 2 tam thdi: do thap tim, nhéi mau eo tim vang duéi, ding thuéc (digitalis, tc ché béta, we ché Calci). +Bléc nhi that d6 2 vinh, vién: bénh van DMC, théng lién nhi, amylodosis, héi ching Reiter, u té bao cua nit nhi that (mesothelioma). 3. BLOC NHI THAT DO III - Khi kh6ng xung dng nao cia nhi dan truyén duge xuéng that. - Biéu hign dién tam dé: + Phan ly nhi that: Tén s6 nhi khéng lien quan dén tdn sé thdt (tdn s6 nhi > tan sé thét) + Tan s6 that cham (< 45 ldn/phit), thudng rat déu do khéng chiu anh huéng béi su cin bing gitia hé than kinh giao cém va phé giao cam. + Phiic hop QRS: binh thuéng hodc di dang. - Phan ly nhi that cdn do nhiéu nguyén nhan khée ngoadi bléc nhi that d6 III nhu gidm ty déng tinh cia nut xoang, tng tu déng tinh eda that va bé néi nhi that, va nhanh that do vong vao lai.Trong nhiing tru’ng hop nay, céc xung dong di xuéng (anterograde) déu gap phai thdi ky tro cia nut xoang, va vi thé tao diéu kién cho nhing xung dong nguoc chiéu (retrograde) kich hoat nut nhi that. - ¥ nghia 14m sang: + Bléc nhi that d6 3 tam thdi: bléc tai nét nhi that thutng do nhéi mau co tim ving duéi, ng6 déc digitalis, thép tim; bléc tai nhéanh thutng do nhdi mdu co tim ving truéc. + Bléc nhi_ that 49 3 vinh vin: thudng la do blée tai ca 2 nhénh (nhénh phdi va trdi) hon 1a bléc tai nut nhi that hay b6 His. Thutng do bénh Lenégre (xo héa hé théng dan truyén khéng ré nguyén nhan), bléc nhi that bém sinh, bénh tim bém sinh (bat tueng hgp nhi that va — that dai DM, théng lién that, thong lién nhi 16 tién phat). 4. MOT SO NHAN XET - X4c dinh vi tri bléc: Blée c6 thé xay ra tai nut nhi that, b6 His, nh4nh phai hoac trai. Sy phan biét nay r&t quan trong vi bléc tai nut va duéi nit cé nguyén nhén va tién lugng khée nhau. Vi bléc tai nhénh chung rat hiém nén vé mat lam sang chi xéc dinh bléc xdy ra tai nut nhi that hay tai cdc nhénh. Tiéu chudn x4c dinh dua vao khoang PR va thoi gian phic b6 QRS. + PR khéng déu: bl6c xay ra tai nut nhi that. + QRS< 0,12 gidy: bléc xdy ra tai nit nhi that. Tuy nhién, néu QRS> 0,12 gidy, khéng thé két ludn vi tri xay ra bléc vi c6 thé bléc nhi that di kém bléc nhénh hoac kém dan truyén Jéch huéng.+ Khoang PR: thay déi goi ¥ bléc tai nut nhi that, déu goi ¥ bléc tai nhanh (chi 4p dung cho bléc nhi that 46 1 va ID). + Khong thé két ludn vi tri xdy ra bléc trong truéng hgp bléc nhi that 46 III c6 QRS réng. Hinh 6.3: Bléc nhi that dé I, Mobitz II trén bénh nhén nit 45 tudi.eres ee Ym ly Mote i ta { Le atte tat Ta parent mi} iit f 1 1 i ree 3mm oa Pet At eee bik is MAG A aT ag fl ta ag a aly Hinh 6.4: Cuéng nhi voi bléc nhi that dé I, Mobitz I (Theo Pocket guide to ECG Diagnosis, 2"* ed 2001, trang 303) Hao arc as ari eis cee Pag MeN ok Pv iactrrea ere er teeny fey trek Hinh 6.5: Bl&c nhi thét d6 Hl, Mobitz I trén bénh nhan NMCT thanh sau duéi. Hinh 6.6: (A) Nhip nhanh xoang voi chu ky Wenckebach 3:2 tgo thanh nhip déi. (B) Nhip nhanh xoang vdi chu ky Wenckebach 3:2 cé xen ldn bléc nhi thét 2:1.(Theo Practical Electrocardiography 8 ed 1998, trang 365).Hinh 6.7: Nhip nhanh xoang vdi chu ky Wenckebach 4:3 tao thanh nhip 66 ba (Theo Practical Electrocardiography 8” ed 1998, trang 365). eget Hinh 6.9: Nhip xoang, bl6c nhi thét dé III cé nhip thodt that vdi tdn sé 33 ldn/phut.CHUONG 7 HOI CHUNG KICH THICH SOM (PREEXCITATION SYNDROME) I. DINH NGHIA - H6i chimg kich thich sém (H/c KTS) 1a bat thuong bam sinh cua tim, trong dé 1 phan co tam that sé duge nhén xung déng khit cuc sém tiv nhi trudc khi xung déng dugc truyén qua nut nhi that xuéng dén that. - H/c KTS cé thé xuat hién trong nhiing nam dau sau sanh hoac déi khi xuat hién tré. - Héi ching kich thich sém bao gém: + H6i ching W-P-W (Wolff - Parkinson - White). + H@i chttng Lown - Ganong - Levine. + H6i ching kich thich sém do sgi Mahaim. IL. CO CHE - Céc dung dan truyén phu: + Duéng nhi bo (Atrio fascicular connection): JAMES (H/c LGL). + Dudng tat trong nut (Intranodal bypass). + Duong b6é that (Fasciculo-ventricular connection): MAHAIM + Dung nut thét (Nodo ventricular connection): MAHAIM+ Dudng phu nhi that (Atrio ventricular accessory connection): KENT, PALADINO (H/c W-P-W). - Trong H/e KTS, co tam that sé duge kich hoat bdi 2 duong: (1) Qua duéng dan truyén phu (kénh gia nhi - that) phan khdi déu bat thuing cia phic b6 QRS. (2) Qua duéng dan truyén binh thudng cia nuit nhi that phan giifa va sau binh thudng cia phic bd QRS (hinh 7.1). Phtic bé QRS binh thuéng Phuc bé QRS khi c6 H/c KTS. Hinh 7.1: Hinh dang phic b6 QRS trong H/c KTS. {- Hinh 7.2: Cac duong dén truyén phu tao héi chung kich thich sém. 1: Duéng nhi bé (James). 2: Duéng tdt trong nut (intranodal bypass). 3: Duong b6é that (Mahaim) 4: Duong nut that (Mahaim). 5: Duong phu nhi thdt (Kent, Paladino).S068 Nii —— Nir Nai NT K NT NT That That ‘Tat Hinh 7.3: So dé miéu tad dén truyén bat thuéng & Hic Wolff-Parkinson-White. A: Bat thuong gidi phdu hoc can ban. B: Kich hoat nhi. C: Kich hoat thdt som. D: Kich hoat thdt sau cing. Il. BIEU HIEN 1. HOI CHUNG WOLFF-PARKINSON-WHITE (Bo Kent) - B6 Kent: Cau trac co méng nim 64 bat ctf ché nao cia vong sgi phan chia nhi that. a. Biéu hién ECG - PR ng&n < 0,12 giay - Cé séng delta - QRS réng > 0,10 gidy - Thay déi thi cp ST va T b. Dinh vi dudng tat (b6 Kent) - Rosenbaum va C/s: WPW loai A, loai B dua chi yéu vao hu6éng cua phitc bé QRS 6 V1 va V2.Dién tam dé Vi tri duéng dan truyén Loai A: QRS (+) V1- V2 |Nhi trai - That trai Loai B: QRS (-) V1-V2__ | Nhi phai - That phai - 90% bénh nhan H/c W.P.W co dudng phu nam 6 céc vi tri sau: Vi tri dung phu Tan suat (%) - Bung bén phai (Right Lateral) 18% - Dung bén trai (Left Lateral) 45% - Duong sau vach (Phai va Trai) (Postero septal) 26% - Dudng truédc vdch phai va trai (Antero septal) 9% Dé chAn doan cdc vi tri nay cin khdo sat: + Phan tich truce QRS + Phan tich séng Delta + Huéng cia phan chinh phitc hgp QRS 6 chuyén dao nguc Dudng bén trai Duong bén phai 45% 18% (giéng loai B Rosenbaum) - Truc Delta theo mat phng tran |- Truc Delta theo mat phang +90° -> +120° tran: -30° -> -60° (delta(-) DI, aVL; delta(+) II III aVF)| (delta (-) III, aVF; (+) I, aVL) - True QRS 6 khodng +60°-> +90° |- Truc QRS 6 khodng -30°-> -60° - QRS V2 = (+) - QRS V1V3 (-) - PR binh thugng hay gan binh|- Thudng 6 bénh nh4n Ebstein thuéngDudng sau vach (P) Duéng sau vach (T) - Truc Delta theo mat phAng tra4n|- Gidng loai A Rosenbaum & -30°-> -60° - Truc Delta > -60° (delta (-) III, aVF, (+) I, aVL) (delta(-) II, III , aVF) - Delta V1 = dong dién hay (-) - Song delta 6 V1 luén luén (+) - Truc QRS -30° - QRS V1(-)dang rS - QRS (+) 6 V1V2V3 QRS V2V3(+) dang Rs hay R c6 thé tat cd QRS chuyén dao nguc (+) ce. H6éi chiing W-P-W ting hic (Intermittent W-P-W syndrome) Hoi ching WPW cé thé xay ra thudng truc, cing cé thé- xay ra titng luc. Lic dé cé thé xay ra bat ky hay déu dan theo chu ky (TD: Dan truyén W-P-W 2:1). d. Bién ching WPW bao gém: - Nhip nhanh hé tuong: + Orthodromic: xung déng theo dudng chinh tré ngugc lai theo duéng phu + Antidromic: xung déng theo dudng phu tré ngugc lai theo duéng chinh do d6 QRS di dang - Rung nhi: khi dan truyén theo duéng phu qué nhanh, xung dong roi vao théi ky tro cia nhi sé tao ra rung nhi. Xung déng téi cua rung nhi cé thé theo duéng chinh hoac theo dung phu hoac theo ca hai cing luc.DA Hiching kichtich stm Ninth thin uy Hed tng Hinh 7.4: 3 co ché can nghi dén khi gap nhip nhanh cé QRS réng 2. HOL CHUNG LOWN-GANONG-LEVINE: B6 James. a. Tiéu chuan ECG - Song R binh thuéng. - PR ngan. - QRS binh thudng. b. Bién ching - Nhip nhanh hé tuong. Hinh 7.5: Héi chung Lown-Ganong-Levine trén bénh nhdn nam 47 tudi.3. HOI CHUNG KICH THICH SOM DO SOI MAHAIM a. Tiéu chuan ECG - Giéng W-P-W nhung PR binh thuéng. b. Bién chiing - Nhip nhanh hé tuong. Hinh 7.6: H6i chung WPW trén bénh nhan nam 21 tuéi WPW vdi duéng dan truyén phu sau vdch, PR ngdn 0,08 gidy, song delta trén cde chuyén dao, truc delta léch trai 2 60°, QRS (+) 6 tdt cd cde chuyén dao nguc. Hinh 7.7: H6i ching Wolff-Parkinson-White titng luc (X).BRAIN aur qa ae i Hinh 7.8: H6i ching WPW trén bénh nhdn ni 19 tuéi, théng lién nhi. H/c WPW cé duéng dan truyén phu bén phdi, vdi PR ngdn 0,06 gidy, séng delta trén cde chuyén dao, truc séng delta # -60°, true QRS khodng -45°, phic hop QRS co phan dm tréi 6 V1. i a UE i S hese 29 were 1S dente 25 ume S eecn2 Hinh 7.9: H6i ching WPW trén bénh nhdn nam 22 tudi, cd dusng dén truyén phu bén trai, vdi PR ngdn 0,08 gidy, true séng delta # +120°, true QRS khodng +120°, phitc hop QRS duong 6 V2.CHUONG & NGOAI TAM THU (PREMATURE BEAT) - Ngoai tam thu (NTT): nhat dén sém, duge nhan biét trén dién tam dé bang su dén sém cia phic bé QRS véi hinh dang binh thuéng hod&c bién dang, cé hoadc khéng kém séng P di truéc phtic b6 QRS. - Ngoai tam thu c6 thé xuat hién don déc, hodc bao hiéu 1 chuéi nhip nhanh sau dé. Tay theo sé NTT lién tiép va thoi gian xuat hién ma cé tén goi khde nhau. Bang 8.1: Dinh danh cdc loai nhip nhanh. S6 nhat NTT lién tiép Dinh danh 1 nhat NTT 2 nhat 1 cap (couplet) 3 nhat lién tiép, kéo dai dén|Con nhip nhanh khéng kéo dai 1 phut (nonsustained tachycardia) kéo dai > 1 phut Con onhip nhanh kéo dai (sustained tachycardia). - NIT nhip déi (bigeminy): NTT di sau mdi 1 nhat xoang binh thutng. - NTT nhip 3 (trigeminy): NTT di sau mdi 2 nhat xoang binh thuéng. - Phan loai NTT: duoc chia lam 2 loai trén that (supraventricular premature beats-SVPBs) va that (ventricular premature beats-VPBs).+ NTT trén that: hinh dang binh thuéng hodac réng phu thuéc vao dutng dan truyén xuéng that. Bao gdm: NTT nhi (atrial premature beats), va NTT b6 néi (junctional premature beats). BO néi nhi that bao g6m nut nhi that, duéng dan truyén chung va duéng dan truyén phu (b6 Kent). + NTT that: phic b6 QRS di dang > 0,12 giay. - Chan dodn phan biét NTT phic b6 rong: + NTT that binh thugng khéng anh huéng dén nhip xoang, vi khong dan truyén nguge Jén nut xoang. Déng thai di: nut xoang phat xung déu dan nhung van khéng dan truyén xuéng that duge vi gap thoi ky tro do NTT. Thdi gian tinh ti) NTT dén nhat xoang binh thudng sau dé duge goi la thdi gian nghi bu. Khoang thdi gian tit nhdt xoang truéec NTT dén nhat xoang ngay sau NTT bang 2 lan chu ky nhip xoang (RR)- thdi gian nghi bi hoan toan. + NTT trén that anh hudng dén nhip xoang, cé kha nang dan truyén ngugc vé nut xoang va kich thich nut xoang phéng xung truéc ky han, do d6 théi gian nghi bi sau NTT sé kh6éng hoan toan (< 2 RR). + Qué trinh tic ché do tdn sé cao (overdrive suppression): c6 thé lam chém xung dong nut xoang tiép theo NTT nhi gay nén thdi gian nghi bi: hoan toan hoac dai hon. - Co ché NTT: Do 2 co ché la vong vao lai va tang tu dong tinh. Khé xéc dinh co ché khi NTT xuat hién lé té. Thuong co ché chi cdn x4c dinh khi NTT xuat hién thanh tig chuéi lién tiép. Dua vao khoang cap (coupling intervals).[eo ché 1. Khoang cap gitta NTT- nhip xoang truéc dé déu Vao lai 2. Khodng cap gitta NTT - nhip xoang khong déu,|Tang ty nhung khoang cp gitfa cdc NTT lién tiép déu nhau |d6ng tinh 8. Khoang cap khéng déu gitta NTT-nhip xoang ciing| Ca hai nhu giita cde NTT. I. NTT NHI - Dac diém: + Song P dén sém, bat thudng. + QRS binh thutng + Nghi bi khéng hoan toan - Ngoai 1é: + Séng P khé nhan thay vi lan vao séng T truée dé. + Song P xuat hién qué sém trong lic nut nhi that cdn trong théi ky tro do dé sé khéng c6é phifc b6 QRS theo sau (NTT nhi khong d4n — nonconducted) + Phute bd QRS c6 thé di dang do dan truyén léch huéng + Théi gian nghi bi sau NTT nhi hoan toan hoac dai hon do hién tugng tic ché do tan s6 cao. —>Tuy nhién hiém khi cdc trudng hgp ngoai 1é nay xuat hién cing 1 lic, vi thé viéc nhan dang NTT nhi rat dé dang. - NTT nhi xuat hién qué sém khi ma nhi cdn trong thdi ky tro, c6 thé kich hoat cho con nhip nhanh nhi do vong vao lai. Lie nay NTT nhi tré thanh nhét dau tién cia chudi rung nhi hay cuéng nhi. Khi khodng PP < % khoang PP truéc d6, NTT nhi dugc xem 1a nguyén nhén khéi phat con rung/ cuéng nhi.Il. NTT BO NOI - Dac diém: + Séng P dén sém, truéc hodc sau hodc lan vao phic b6 QRS. Thudng dao 6 DII, aVF; duong 6 aVR, aVL; va det & DI, V5. + Phifc b6 QRS binh thudng. + Théi gian nghi bi khéng hoan toan. Ill. NTT THAT - Dac diém : + Khéng séng P di truéc. + Phuc b6 QRS di dang, r6ng (> 0,12 giay). + Théi gian nghi ba hoan toan. - Ngoai 1é: + C6 thé c6 séng P di truéc do NTT nhi va NTT that cing xuat hién. + Phitc bé QRS cé thé khong rong > 0,12 gidy, do phan dau ho&c phan cudi cia QRS dang dién, can quan sat trén nhiéu chuyén dao. + Théi gian nghi bi thay déi: c6 thé do: a) Loan nhip xoang: kh6 x4c dinh théi gian nghi bi hoan toan hay khéng. b) NTT that xen ké (NTT that di gitta 2 nhip xoang - interpolated VPB): * Khi NTT that xuat hién qué sém trén 1 nhip xoang binh thudng tuong déi cham, théi gian sau NTT di dé nut nhi that va that ra khdi thdi ky tro, cho phép xung dong ké tiép tiv nit xoang dan truyén binh thudng xuéng that.Do do, NTT that sé nam xen ké gidia 2 nhip xoang binh thudng, khéng cé khoang nghi bi. c) NTT that kich hoat lai nhip xoang (VPBs resets the sinus rhythm): * Khi NTT chi dén hoi sém, lic nay nut nhi that da ra khdi thdi ky tro dé chuan bi cho nhip xoang binh thudng ké tiép, NTT c6 thé duoc dan truyén nguge lén nut nhi that. Va sau d6 kich hoat lai nat xoang nhu trudng hop cua NTT nhi. Song P dan truyén ngude 6 thé sé 14n vao song T. Khodng nghi bi vi thé sé khong hoan toan. * NTT that phai-NTT that trai: Can chan dodn phan biét vi NTT that trai thugng di kém véi bénh tim thuc thé va c6 kha nang kich hoat con rung that trong giai doan nhdi mau co tim. Trong khi d6, NTT that phai thudng chi gap 6 ngu@i binh thudng khong bénh tim. NTT that trai NTT that phai vi R hoac qR 1S hoac rS/ QS v6 Dang RSr’ RS hoac QS R cao * NTT that da dang (multiform VPBs): thudng la do NTT that duoc thay déi dugng dan truyén hon la do NTT that xudt phat ti nhiéu 6 khdc nhau. * NTT that gay rung that: Ngoai tam thu that xudt hién sém trén dinh song T, sé gap giai doan dau cia thdi gian phuc héi that, gay vong vao lai tai that va kich hoat con cuéng that hay rung that song thé. Tuy nhién, khéng phai chi NTT that sém (R trén T) moi dua dén rung that, ma nhiing NTT that tré (xuat hién sau séng T) cing cé thé gay rung that. Theo cdc téc gid, NTT that sém (R trén T) cdkha nang gay rung that khi bénh nhan c6 cae yéu td nguy co sau: giai doan sém cua nhdi mau co tim, ha kali mau, c6 hdi chting QT dai. Hinh 8.1: NTT thdt nhip d6i voi khodng edp rat ngan, va khdi phat con cudng that. * Tién lugng cua bénh nhan nhdi mau co tim dua theo phan do NTT that cia Lown. Bang 8.2: Phan d6 cia Lown vé NTT thét. 2 nhaét NTT lién tuc 2 3 nhat NTT lién tuc R/T IS Pa Hinh 8.2: NTT nhi cé khodng nghi bu hoan toan, phitc b6 QRS hep.Hinh 8.3: NTT that phdi voi rS 6 V1 va R cao 6 V6. Phite b6 QRS > 0,12 gidy Hinh 8.4: NTT thdt xen ké. | (V: NTT that xen ké; X: NTT that thong thuéng). ERNE Hinh 8.5: NTT that da 6.Hinh 8.6: NTT thdét nhip déiCHUONG 9 DAN TRUYEN LECH HUONG I. DINH NGHIA Dan truyén that léch huéng (DTTLH) la tinh trang nhat trén that tam thdi dan truyén léch huéng trong that, xdy ra do su thay déi d6 dai cua chu ky. 1. HAI DAC DIEM CUA DTTLH - Thuéng gap, nhat 1a trong nhip nhanh kich phat - Dé lam lan véi nhip nhanh that, do d6 diéu tri sai. 2. PHUC HOP QRS DI DANG CO THE DO - Tu 6 ngoai vi that - Dan truyén léch huéng xung déng trén that 3. BA DANG CUA DTTLH - Kiéu A: Do thoi ky tro ctia bo. - Kiéu B: Do kich hoat trén that bat thutng (TD: H/e WPW). - Kiéu C: Do nhip nghiém trong nghich thudng (Paradoxical critical rate). II. CO CHE 1. CO CHE CUA DAN TRUYEN LECH HUGNG KIEU A - Bat ct nhat trén that nao khi t6i that c6 thé DTLH.- Réi loan tiy thuéc: + Thdi ky tro khéng déu cia 2 nhanh + Thdi diém tao thanh xung dong sém + Do dai cua RR truéc dé 1 | 2 ee ee A: Thdi ky tro (rp: refractory period) thai ky tro (rp) 2 nhdnh bang nhau . - Nhdnh 1 khong dan - Nhanh 2 dan binh thutng B: Théi ky tro 2 nhanh khong 1 2, 3 bang nhau errr - Nhanh 1 khéng dan Ha ky tro - Nhdnh 2 dn truyén léch huéng “\ . - Nhanh 3 dan truyén binh thuong Hinh 9.1: Biéu dé mé ta thoi ky tro. (Tai ligu: An Introduction to Electrocardiography 4‘ ed 1990, Blackwell Scientific Publications, trang 412). Xung déng bi DTLH cé thé c6 dang bléc nhanh phai hay bléc nhanh trai.2. CO CHE CUA DAN TRUYEN LECH HUONG KIBU B (hinh 9.2) 1 ae Hinh 9.2: So dé mé ta 4 kiéu DTLH kiéu B 1. Dan truyén theo b6 Kent 2. Nhat ti 6 ngoai vi b6 noi NT dan cing xuéng phia that 3. Nhdt tt 6 ngogi vi b6 néi Nnanhtréi ~~ NT ddn theo b6 Mahaim 4. Nhat tit 6 ngoai vi b6 néi NT dén qua phia bén xuéng , . that. 3. CO CHE CUA DITLH KIEU C 3 Mahaim Nhénh phai DTTLH chi xay ra vao cudi chu ky dai (nhip nghiém trong nghich thuéng) Ill. DAC DIEM DIEN TAM DO 1.DAC DIEM ECG CUA NHAT DTTLH 1. Dang 3 pha: e rSR’d6 V1 ¢ qRs 6 V6 2. Co nhat nhi 6 trudc 3. Pha dau tién tuong tu véi pha dau tién cia nhat dan (néu la bléc nhanh phai) 4. Dang bléc nhénh thay déi, phan cach béi nhat dan binh thuéng 5. Dang QRST tuong ty véi nhat c6 bléc nhanh tir trude 6. Nhat tha 2 cia mét chudi 1a nhat bat thudng.2. CAC DANG THUONG GAP CUA DTTLH - Dang bléc nhanh phai : 53% - Dang bléc nhanh trai : 15% - Dang bléc phan nhanh trai truée: 32% - Dang bléc phan nhanh trai sau ; 19% - Khong xép loai duge ‘ 10% 3. CHAN DOAN PHAN BIRT VOI NGOAI TAM THU THAT Dua vao 4 yéu té sau: a) Méi quan hé gitta phic bé QRS di dang véi nhip nhi trude dé: - Xung dng trén that dan truyén léch hudng thudng cé song P hay P’ di kém phia truéc. - Tuy nhién song P co thé khéng ré trong cdc truong hop sau: rung nhi, ngoai tam thu bé néi nhi that dan truyén léch huéng, nhip nhanh nhi kich phat. b) Su xuat hién cia nhat bat (capture beat): - Nhat bat cé hinh dang giéng hoac gan giéng hinh dang phtc b6 QRS binh thudng thudng goi y ngoai tam thu that. - Nhat hén hop (fusion beat) goi ¥ ngoai tam thu that. c) Hinh dang cua phtic bé QRS (Bang 9.1 trang 82). d) Co hay khong khoang nghi bi khi QRS di dang di kem rung nhi: - DTTLH thuodng khong co nghi bi. - Ngoai tam thu that thudng co nghi ba.Bang 9.1: Khdc biét vé QRS giita DTLH vé ngogi tam thu that Phiic bg QRS 1. Truc QRS : 2. Dang QRS 3. QRS dang tai thé 6V1 4, Song q/ Q6 V1 5. Su déng dang cia QRS 6. QS 6 V4: 7. QS 6 V6: 8. rS hoadc RS 6 V6 9. QS 6 DI 11. Thay déi hinh dang QRS 12. Théi gian phic bé QRS. DTTLH - tuong ty truc QRS binh thutng Dang Bléc nhénh P dién hinh: 3 pha (rsR’ 6 V1 va gRS 6 V6) - hiém gap - khi DTTLH co dang bléc nhanh trai, QS chi 6 V1-V3 - dang bléc nhénh trai: (+) 6 DI; dang bléc nhanh P: (-) & DI nhung cé séng r. - thutng da dang -< 0,14 gidy Ngoai tam thu that - thudng léch trai- ving tay bac Khong gidng dang bléc nhénh: Don pha hay 2 pha. Tai truée cao hon tai sau - thutng gap -egiy - QSGV4 - QS rong, c6 méc. - agiy - QS6DI - thuéng don dang. -> 0,14 giay (Theo Cardiac Arrythmias 1994, trang 246)Hinh 9.3: Séng P dén sém (mii tén), va ddn truyén léch huéng dang bléc nhdnh phdi (*) trén bénh nhdn nam 73 tuéi sau m6 cdt tui mat. Séng P thit 4 dén qua sém nén DTTLH, nguoc lai séng P thit 7 dén tré hon va cé dan truyén binh thudng. Mi i A oy \ SO ee \ Jr 4 pms yoy \oteter ay Hinh 9.4: Nhip nhanh ting luc duge khdi phat bang 1 NTT nhi (mui tén), QRS ddn truyén léch hudng cé dj dang, dang biéc nhdnh P, vd cé pha ddu tuong tu QRS dn truyén binh thuong. Hae See Ta RI eo Hinh 9.5: Nhip nhanh nhi voi dan truyén léch hubng dang bléc nhanh P trén bénh nhén kAt phé thing nang (mii tén—séng P dén sém). QRS cé dang 3 pha (triphasic) 6 chuyén dao V1 va V6.Hinh 9.6: Rung cuéng nhi ¢ bénh nhdn nam 81 tuéi, NMCT thanh trudc. Khodng cép cé dinh (fixed intervals coupling) (khodng cach ti QRS ddn truyén binh thuong dén QRS réng—miii tén) goi y NTT that. V SE] : r + ; t t + z al ne a te Gh mms Creve % oe ees jaziee: j j Sse SIRS i 4 BS ptt Hinh 9.7: (A) Dign tam dé ghi nhdn 6 bénh nhén n& 19 tuéi tang bach edu don nhén cé con héi hép; (B) Dién tam dé 6 bénh nhdn nam 64 tui, dau thdt nguc khong én dinh. Mui tén chi nhip nhi binh thuong, (*) chi nhip gia téc va cé dén truyén léch huéng dang bléc nhanh P (A) va nhanh T (B).Hinh 9.8: Dign tam dé ghi nhan 6 bénh nhdn 82 tuéi, cao HA vd suy tim. Binh thuéng chu kp la 100 mm gidy (tdn sé tim la 60 nhip/phit) va khi cé dén truyén léch huéng dang bléc nhdnh T, thoi gian dan truyén nhanh lén 91 mm gidy (66 nhip/phut) va sau dé tré vé binh thudng.CHUONG 9 NHIP NHANH TREN THAT I. DINH NGHIA - Nhip nhanh trén that (NNTT) 1a tiv nhi hay bé néi nhi that. - Bao gém 2 loai: nhip nhanh nhi nhip nhanh bat nguén va nhip nhanh bé néi nhi that. Nhip nhanh nhi khéng chiu anh huéng béi su dan truyén qua nut nhi that (déc lap véi nut nhi that - “AV node independent”). Nguge lai, nhip nhanh b6 néi nhi that phu thuéc vao sy dan truyén qua nut nhi that (phu thuéc nut nhi that — “AV node dependent”). Céc nhip nhanh xuat phat tiv nhi Cac nhip nhanh xuat phat tir bd ndi - Nhip nhanh xoang - Vao lai nut xoang - Nhip nhanh xoang man tinh - Nhip nhanh nhi - Cuéng nhi - Rung nhi - Vao lai nut nhi that - Vao lai nhi that - Nhip nhanh bé néi khong kich phat (nonparoxysmal junctional tachycardia) Il. PHAN LOAI A a. B a \ SX AX . Ne \ PU c @ a Q D \ VRS Hinh 10.1: Phan loai nhip nhanh dua theo co ché A: vao lai nit nhi that B: vao lai nhi that qua duéng phu C: nhip nhanh nhi do vao lai nhi hode tu déng tinh bat thuéng D: nhip nhanh bé6 noi khong hich phat