ry khoa cap nhat https://www.facebook.com/groups/489029" NHIP NHANH TREN THAT XUAT PHAT TU’ HOAC QUANH BO NOI 4. NHIP NHANH DO VONG VAO LAI TAI NUT NHI THAT Nhip nhanh do vong vao lai tai nut nht that (AVNRT: Atrioventricular Nodal Reentrant Tachycardia) la m6t dang nhip nhanh trén that, khéi phat thong do mét ngoai tam thu va duy tri do mét vong vao lai bén trong nut nhi that, la nguyén nhan gay héi hép — danh tréng ngye thuong gap nhat & bénh nhan khdng cd bénh tim cau truc. 4.1. Dac diém dién tam dd « Nhip déu, nhanh > 100 l&n/phut (thudng tir 150 — 250 lan/ phut) - Phtrc b6 QRS hep (< 0,12 giay), trv khi cd block nhanh trwoc dé hay dan truyén léch hung * Thuong khéng thay sdng P (do lan vao trong phtrc bd QRS) + Khi thay cé s6ng P thi khodng cach RP ngan (RP < PR va RP s 90 ms) Bang 11.1. So sanh d&c diém DTD dé phan biét cac dang vong vao lai cua AVNRT Dang AVRNT Dac diem DTD Cham—Nhanh 80-90% « Thudng khéng thay séng (Slow — Fast) P NN zalo nhom duy nhat 0528112107 4 493uy khoa cap nhat https://www.facebook.com/groups/48902. 104 || Sé tay dign tam dd Dang AVRNT | Tan suat Dac diém Cham-—Nhanh 80-90% + C6 thé thdy séng P sau (Slow — Fast) QRS tao nén song r’ gia & V1 hoadc séng S gia & Dil, DIIl, aVF Séng S gid \ ? Séng r gia Nhanh — Cham 10% * Thay duoc séng P dado (Fast - Slow) nguoc @ Dil, Dill, aVF, P duong @ V1; P dng phia sau phtrc b6 QRS tuong tng e RP 100 ldn/phut (thuéng 150 — 250 1n/phut) + Phirc bd QRS hep (< 0,12 giay), trv khi cé block nhanh truéc dé hay dn truyén léch hwéng va khéng cé séng Delta + Thwdng thay séng P dao ngugrc, di sau QRS twong tong + Khoang RP dai (RP > PR va/hoadc RP > 90 ms) yy | Wadd dll LLL ALLEL Mts |i il a ALA tc MAA hbhhbhbbbbbbbldabbbdds Hinh 11.4. DTD cla mét bénh nhan n& 47 tudi nhap vién vi hdi hép, DTD ghi nhan nhip nhanh phic bé hep, tan s6 180 lan/ phut, d&u; phirc bé QRS hep; mii tén dé chi sng P dao ngugc & V1 (nhip dau tién) va & Dill (khdc & doan dau séng T), voi doan RP dai = 128 ms. DTD nay ggi y orthodromic AVRT 2.1.2. Chan dodn phan biét + Nhip nhanh do véng vao lai tai nut nhi that * Nhip nhanh bé ndi + Nhip nhanh nhi don 6. zalo nhom duy nhat 0528112107u y khoa cap nhat https://www.facebook.com/groups/489 108 || Sd tay dién tam dd 2.2. AVRT dan truyén ngurge dong (Antidromic AVRT) Trong antidromic AVRT, dan truyén di qua duéng phy true, gay ra khir crc that theo chiéu bat thudng, sau d6 dan truyén nguwgc déng qua nut nhi that én nhi. 2.2.1, Dac diém dién tam dé + Nhip nhanh > 100 lan/phit (thueng 150 — 250 lan/phut) * Phtrc bé QRS gidn rdng (< 0,12 giay) * Thay duoc song Delta & phan dau cilia phic b6 QRS * Thwong khéng thay song P + Néu thy thi song P thuéng dao ngugc va di sau QRS twong rng MAMA Ay henna Mom - , KAA AAAS ol NANA | AMA AAA ai AL AAA AAA AA a ANY SAVVY AAA HT Hinh 14.5. BN nam 28 tudi, nhap vién vi hdi hép danh tréng nguc. DTD trong con ghi nhan nhip nhanh phtrc b6 QRS rdng, 6 séng Delta & phan dau phic b6 QRS (mii tén dé), kém séng P dao ngugc di sau QRS (mii tén den), RP > PR va RP = 120 ms > 90 ms. DTD nay goi y antidromic AVRT 2.2.2. Chan doan phan biét * Nhip nhanh that * Nhip nhanh trén that cé dan truyén léch hwéng ° Nhip nhanh trén that cd kém theo block nhanh cd san * Nhip may cd tao nhip that ¢ Rung nhi dap teng that nhanh kém hdi chng WPW. zalo nhom duy nhat 0528112107y khoa cap nhat https://www.facebook.com/groups/489 Nhip nhanh trén that xuat phat tir hoac quanh b6 ndi || 109 3. NHIP NHANH BO NOI Nhip nhanh bé néi (JET: Junctional Ectopic Tachycardia) la mét dang rdi loan nhip trén that it gdp, khéi phat tir khu vue nuit nht that va bo His. 3.1. Dac diém dién tam dé ¢ Nhip nhanh déu, tn sé > 100 lan/phut e Phtec b6 QRS hep (< 0,12 giay), try khi co block nhanh trwéc d6 hay dan truyén léch huéng ¢ Song P dao ngugc cé thé khéng xuat hién hoac xuat hién truwéc, trong hoadc sau phtrc b6 QRS + Song P dao di truéc QRS véi PR < 0,12 giay hodc P dao di sau QRS voi RP < 0,2 gidy \, eeu AAA I ZU OA A Abd I FSS 3 SHALL, il PMT f i SOULE a Sl BALI UII Il Hinh 14.6. Mét bénh nhan n& 81 tudi, nhap vién vi thay déi tri gidc, sau khi dung qua ligu Kyushin (mét thuéc tr¢’ tim) co chtra bufotoxin. DTD Itc nhap vién cho thay nhip nhanh déu, tan sé 142 l&n/phut. RBBB dién hinh (mai tén den), cé séng P dao di sau phic b6 QRS voi RP = 80 ms (mGi tén dd). DTD gai y dén JET sau ng6 déc bufotoxin? zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/48902 110 || Sé tay dién tam ad 3.2. Chan doan phan biét * Nhip nhanh nhi e AVNRT hoac orthodromic AVRT. 4. NHIP NHANH TREN THAT DAN TRUYEN LECH HUONG 4.1. Dac diém dién tam d6 + Nhip nhanh > 100 ln/phut « Phirc b6 ORS gin réng > 0,12 gidy; nhung < 0,16 giay * Co hinh anh dién hinh RBBB hoac LBBB * Tai V1, rSR’ véi sng R’ bén phai cao hon (tai thé bén phai cao hon) + Tai V6, R cao wu thé khdéng cé séng Q tai V6 + Hinh anh phirc b6 rong tuwong ty DTD nén ctla bénh nhan (dang RBBB hoac LBBB dién hinh) + Ghi cha: Nhip nhanh phirc bé réng cé thé la nhanh that, nhip nhanh trén that kém dan truyén léch huong hoac dan truyén ngwoc dong qua dong phy vdi ti Ié [An Iwot la 80%, 15% va 5%. Vi vay, chan doan so’ b6 nén la nhanh that dén khi bang chteng ngua’c lai. 4.2, Chan doan phan biét * Nhip nhanh that la chan doan phan biét quan trong nhat voi cc dac diém ggi y nhu sau: QRS réng > 160 ms * Truc v6 dinh Co phan ly nhi that — Nhip thoat — Nhat hén hop * QRS ddng duong hodc déng Am @ tat cd cdc chuyén dao trwdéc ngvc « Tai V1: Rsr’ voi tai thé bén trai cao hon, hoac Rdon pha hoac song R réng > 40 ms zalo nhom duy nhat 0528112107ry khoa cap nhat https://www.facebook.com/groups/489022" Nhip nhanh trén that xuat phat ti hodc quanh bé néi | 441 Khdi phat song R dén dinh song S > 100 ms ¢ Antidromic AVRT NIAAA AAAI narnrrinnnrAAdAAAddA a TAA A AAA aoa A ALAG genrenenneerd lbp} pe ed Hinh 11.7. DTD ca mét bénh nhan nam 22 tudi, nhap vién vi hdi hép. Ghi nhan nhip nhanh, déu, phirc bé réng, QRS co dang RBBB dién hinh (qR & V1, rsR’ & V2, S sau r6éng V6 DI aVL), khéng thay song P ma co song S gia & DIl, Dill, aVF. DTD nay ggi y AVNRT kém dn truyén léch huéng dang RBBB 5. TIEP CAN CHAN DOAN NHIP NHANH PHU'C BO HEP Tiép can chan doan cdc dang nhip nhanh phirc b6 hep, chan doan phan biét céc dang nhip nhanh trén that dwa vao cac yéu td: nhip déu hay khéng déu, co song P hay khéng, tan sé nhi/tan sé that, khoang RP (So dé 41.1). zalo nhom duy nhat 0528112107//www.facebook.com/groups/48902 t https: a uy khoa cap nhi én tam dé || $6 tay ai 12 rou og yueyu diy :(elpseohyoe, gidojoz jeuogounr) Jar FeyLiyu ypu 18} 18] OBA Buoa op yueyu diy :(elpseohyoe, juequecy Jepony Je/NOLQUEACLAY) LYNAY ‘IPY)LUU 18] OBA BuoA op yueyu diyny :(eIpse0hyoe) AnUeeYy JEINOUUSAOLIY) LYAV :4yoly] NYO eddy SHO Og onyd yueYU diyu Ue0p UgYD UBD den QP NNT |||) OP OS yury ugip Bueyuy LUNAV ¢@ “op lyu yueUN (up) Ley Ss LYuAY uuly UgID LYNAV ao ne . Pr ‘UN S g uop iyu yueUN Lanv qui INAV 7 i Pree = rier aire) ret trat % 0 (uigiy) yueuu og-3nu a (wigiu) LUNAY ‘Lar Re oe9 YORA 324} YUCYN = (wgi4u) LUNAW > g ueop iyu yueUN Z syu Bugnd 3 So @ ep luu queuu diuNn 4 lop Aeus 3g U3 1yWU UgKNa; UEP 194 5 1yu Bugno ogoy 9 uop yu yueUN 2 juu Buny gry khoa cap nhat https://www.facebook.com/groups/489022" NHIP NHANH THAT Nhip nhanh phitc bé QRS réng cé thé la: * Nhip nhanh that + Nhip nhanh trén thAt: dan truy&n qua duwong phy hoac dan truyén léch huwéng hodc cé kém block nhaénh truéc do ¢ Nhip may tao nhip 4. CHAN DOAN NHIP NHANH THAT 1.1. Cac dac diém dién tam dé ggi y manh nhip nhanh that Bang 12.1. Cac dac diém DTD ggi y manh mé nhip nhanh that ¢ Phan ly nhi that + Nhat bat (Capture beat) + Nhat hén hop (Fusion beat) * QRS dong dang, déng hung & cdc chuy&n dao trréc ngyre ¢ Thoi gian QRS > 160 ms * Truc QRS v6 dinh (+180° dén +270°) * R>R’OV1 (dau hiéu “tai thd” bén trai lon hon) + Dau hiéu Brugada + Dau hiéu Josephson 1.1.1. Phan ly nhi that Nhip nhanh phtec b6 réng voi hinh anh song P va QRS phan ly, d6c lap véi nhau thi gan nh dé la nhip nhanh that. Hinh 12.1. Hinh anh ih phan ly nhi that voi céc P-P > au nhau 1u (mdi én dd) zalo nhom duy nhat 0528112107] 113