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uy khoa cap nhat https://www.facebook.com/groups/4890: 114 || Sé tay dién tam ad 1.1.2. Nhat bat (Capture beat) Phtrc b6 QRS cé hinh dang tuong tw nhu phtrc b6 QRS ctla nhip xoang do nhat bop nay duoc kiém soat bi hé théng dan truyén binh thudng. | E M1 1.1.3. Nhat hén hgp (Fusion beat) Phtrc b6 QRS c6 hinh dang trung gian gitra nhip xoang va nhip that, xay ra khi mét xung déng xuat phat tlr that va mét xung déng tir trén tht kich hoat co that déng thdi. I \/ Nhat hén hop Nhat bat Hinh 12.3. Nhat hén hop va nhat bat 1.1.4. Phivc b6 QRS rat réng Z 1 Cac phtrc b6 QRS gian rat rong (thoi gian kéo dai > 160 ms) | thi kha nang cao [a nhip nhanh that. | 1.1.5. QRS déng dang, déng huéng « Phirc b6 QRS 6 cdc chuyén dao trvéc ngye ddng dang va ddng hwéng voi nhau goi y manh mé nhip nhanh that * C6 thé ding hudng am hoadc déng hudng dwong. Trong d6, déng huéng Am goi y manh mé nhip nhanh that hon zalo nhom duy nhat 0528112107ry khoa cap nhat https://www.facebook.com/groups/4890225 Nhip nhanh that || 115 Hinh 12.4. QRS déng hwong duong (A), hoac déng huéng am (B) goi Y manh mé nhip nhanh that 1.1.6. Truc QRS v6 dinh [ Truc QRS vé dinh (QRS 6 Di va aVF du Am) goi y rat manh mé la nhip nhanh that. 1.1.7. Déu higu R > R’ & V1 QRS 6 V1 cd dang block nhanh phai voi R > R’, tao nén hinh dang tai thé vdi tai trai lon hon. RoR NV AMM ada nvr A | WW Hi ui sin | yvy " 1 | M MM Pree mbjerrevish iy \ J ] YY Hinh 12.5. Dau hiéu tryc v6 dinh (QRS & DI va aVF déu am), kém dau hiéu tai thé vei tai trai lon hon tai phai 6 V1 (R>R’) goi y manh mé nhip nhanh that 1.1.8. Dau higu Brugada Thdi gian tir lic bat dau phtrc bé QRS dén day séng S > 100 ms 1.1.9. Dau higu Josephson C6 kh&c trén sudn xudng 6 gan day ctia song S tai V1 hodc V2 zalo nhom duy nhat 0528112107Se haa pan nhat httne://araray farsahanl eam /eraine/AQ0NI92 uy khoa cap nhat https://www.facebook.com/groups/489022: 116 || Sé tay aién tam ad _ 100 ms a — - ee | | | | | | Khac | D4u higu Brugada Dau hiéu Josephson Hinh 12.6. D4u hiéu Brugada va dau hiéu Josephson trong ggi y nhip nhanh that 1.2. Cac Iwu dé tiép can chan doan nhip nhanh that 1.2.1. Lwu d6 Brugada Luu dé tiép can gdm bén bude: ¢ Buoc 7: Tim su hién dién ctia phirc b6 RS tr V1 dén V6. Néu: khong cé — VT, néu cd > Bude 2. © Bue 2: Tinh thdi gian tl lic bat dau séng R dén day séng S. Néu: RS > 100 ms > VT, RS < 100 ms — Bu@c 3. * Buc 3: Tim ddu hiéu phan ly nhi that. Néu, cé > VT, khéng co — Buc 4. * Bue 4: Danh gid hinh dang QRS 6 V1-2, V6 cé dat tiéu chuan chan doan VT. * Chai thich: VT (Ventricular tachycardia): Nhjp nhanh that. zalo nhom duy nhat 0528112107oa cap nhat https://www.facebook.co: Nhip nhanh that | 447 CORS Khdéng cd RS Tiép tuc burec 2 RS s 100 ms Tiép tuc bur —_ ig Kh6ng phn ly nhi that C6 phn ly nhi that Tee tyc bude 4 Toco aa vi ae nhanh phai Dang block nhanh trai uM 4 i Mirena ol A, Hai pha R20,04 RS2007 S% khac ve aL bypy ha aka R a ae R a V6 co bat ky dang séng Qnao L___Théa V1 va V6 = VT Théa V1/V2 va V6 = VT Luu a6 12.1. Luu 40 Brugada chan doan nhip nhanh that 1.2.2. Luu d6 Basel Chan doan nhip nhanh thét khi co it nhat 2/3 tiéu chuan: * Tiéu chuan 1: Nguy co lam sang cao * Tién can NMCT * Tién cn suy tim EF giam * Tién cén dat ICD, CRT * Tiéu chuan 2: © chuyén dao Dil, thoi gian tir luc bat dau QRS dén dinh/day dau tién > 40 ms zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/4890: 118 || Sé tay dién tam dé |. Tiéu chudn 3: © chuyan dao aVR, thoi gian tir Itic bat dau QRS dén dinh/day dau tién > 40 ms. AWM * €6 0 hodc 1 tiéu chudn: Nhip nhanh trén that 1.2.3. Lu dé Vereckei Co phan ly nhi that? Khéng Séng R dau tién & aVR rene lent Hinh dang QRS khéng giéng dang block nhanh — phan nhanh? Vi/Vt S$ 1? | Khéng acacia svt Luu a 42.2. Luu dd Vereckei chan doan nhip nhanh that zalo nhom duy nhat 0528112107ry khoa cap nhat https://www.facebook.com/groups/489022" Nhip nhanh that | 119 Vi/Vt: Ti s6 van téc kich hoat tam that, véi: + Vi(VAn téc that ban dau): ting bién dé phan dau phic bo QRS trong 40 ms dau + Vt (Van téc that két thic): tang bién dé phan cudi phic bo QRS trong 40 ms cudi 40 ms dau tién c_40ms cudi cing LI cy EOITE 1 16nhd= 40ms 14 ||] +14mm 13 m 7mm 6mm ViNt> 1: Nhip nhanh trén that | Vit <4: Nhip nhanh that Hinh 12.7. Cach xa dinh Vi/Vt trong phan biét nhip nhanh that va nhip nhanh trén that 2. PHAN LOAI NHIP NHANH THAT zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/4890: 120 || Sé tay dién tam ad Bang 12.2. Phan loai nhip nhanh that Phan theo Loai nhip nhanh that * Nhip nhanh that khéng bén bi Thoi gian Lux ¢ Nhip nhanh that bén bi * Nhip nhanh that don dang ¢ Nhip nhanh that da dang Hinh ¢ Nhip nhanh that hai huéng dang + Xoan dinh ¢ Rung that * Cudng that ‘ Nhip nhanh that lién quan dén seo co tim Co’ ché P ¢ Nhip nhanh that v6 can ¢ Nhip nhanh that voi huyét déng khéng én Tinh trang éinh huyét dong : * Nhip nhanh that voi huyét dong 6n dinh Nhip nhanh that do seo co tim: RBLI, RBLS, RBRI, RBRS, LBLI, LBLS, LBRI, LBRS ° + Nhip nhanh that v6 c&n: nhip nhanh that Vi tri xuat phat tlr budng téng (that trai/that phai), nhip nhanh that tty bé nhanh, nhip nhanh tht tir vong van (2 14/3 1a), nhip nhanh that hén hop 2.1. Phan loai theo théi gian * Nhip nhanh that khéng bén bi: 2 3 — 4 ngoai tam thu that va kéo dai < 30 giay ¢ Nhip nhanh that bén bi: nhip nhanh that kéo dai > 30 gidy zalo nhom duy nhat 0528112107ny khoa cap nhat https://www.facebook.com/groups/489022" Nhip nhanh that || 121 Peete ceeccee seve cemraare Nhjp nhanh that khéng bén bi MANY Nhip nhanh that bén bi Hinh 12.8. Nhip nhanh that khéng bén bi va bén bi 2.2. Phan loai theo hinh dang 2.2.1. Nhip nhanh that don dang/da dang + Nhip nhanh that don dang: cdc phtrc bé QRS déu déng dang voi nhau ¢ Nhip nhanh that da dang: cac phtrc b6 QRS cé nhiéu hinh dang khac nhau (thay ddi vé bién dé, thoi gian, truc) AAA SV reer Hinh 12.9. Nhip nhanh that don dang (A), nhip nhanh that da dang voi nhidu hinh thai QRS khac nhau (B), nhip nhanh that da _ dang véi hai hinh thai QRS khac nhau (C) zalo nhom duy nhat 0528112107oa cap nhat https://www.facebook.com/groups/4890: 122 || Sé tay dien tam ad 2.2.2. Nhip nhanh that hai hvéng ¢ Nhip nhanh thAt da dang vdi truc ctia phirc b6 QRS theo mat phang tran va hinh dang chuyén ddi lién tuc theo tl:ng nhip tim Hiém gap, thong do ngé doc digoxin nang ALA Aer TTT | rep Il ryprppyeld tt, ‘i i rey ey uf mi) ry) yyw la I Popp yn rte Urry yy Hinh 12.10. Nhip nhanh that hai huong voi QRS thay déi tryc lién tuc (tryc chuyén 180° tir trai sang phai theo tng nhip tim) 2.2.3. Xodn dinh \ why Lala I + Xo4n dinh la mét dang nhip nhanh that da dang dac biét xay ra trén nén QT kéo dai + QRS bién dd khong déu xo4n quanh dung dang dién, tan s6 200 — 250 lAn/phut el tt iy ANA y Hinh 12.11. DTD cla mét bénh nhan nam 67 tudi nhap vién vi nhdi mau co tim cdp khéng ST chénh lén. DTD ghi nhan QT dai voi QTc = 668 ms, co hién tugng R/T (song R xuat hién trén stron xudng song T) va gay ra xo&n dinh vdi hinh anh QRS da dang xo&n quanh duéng dang dién : zalo nhom duy nhat 0528112107ry khoa cap nhat https://www.facebook.com/groups/48902% Nhip nhanh that || 123 2.2.4. Rung that + Nhip tim hén loan, khéng déu, bién dé séng khac nhau + Khéng xac dinh dugc séng P, phtvc b6 QRS, hay song T + Tan sé tir 150 d&n 500 lAn/phut * Bién a9 giém dan theo thoi gian (rung that song lén — rung thAt song nhé) PR arr BPA NAR AR AIA TI WY elie nel Hinh 12.12. DTD rung that voi nhip tim rat khong déu, hén loan, khéng phan biét duorc cc song 2.2.5. Cudng that * DTD la cdc séng hinh sin, tan s6 150 — 300 lan/phut * Khdng phan biét duoc P, QRS, hay song T AWWW Mrinal MN) Aw WA wy My AWWW mM 2 i { ARI yyyvyy | Hinh 12.13. DTD cudng that zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/4890: 124 || Sé tay dién tam ao 2.3. Phan loai theo co ché Bang 12.3. Phan loai nhip nhanh that theo co ché doseocotim| Nhipnhanh + Lién quan dén bénh tim cAu * Khéng lién quan dén tric bénh tim cau tric * Do vong vao lai * Do 6 phat nhip ngoai lai + Bénh nhan lon tudi + Bénh nhan tré tudi + Tién lvong twong déikém —- Tin Iwong tong déi tét 2.4. Phan loai theo tinh trang huyét déng Nhip nhanh that voi huyét dong khéng én dinh can séc dién pha rung ngay, khi co it nhat mot trong cac tinh trang sau: * Tut huyét ap (huyét ap tam thu < 90 mmHg) * Réi loan tri giac do nhip nhanh + Séc, giam tuoi mau + Suy tim cp ¢ Bénh nhan ngung tim Ca eA NAKKR, PV VY V~/ hte LW JA \\A Hinh 12.14. DTD cia mét bénh nhan nam 57 tudi, due chan doan nhdi mau co’ tim khéng ST chénh Ién. Huyét ap ghi nhan 80/50 mmHg, bénh nhan diy, bét rit. DTD ghi nhan nhip nhanh thdt don dang (c6 nhtrng nhat hén hop (vong tron dd) va truc vé dinh, QRS déng huéng 4m V1-6). Bénh nhan dugre sdc dién ddng bé voi nang lugng 220 J zalo nhom duy nhat 0528112107Dy khoa cap nhat https://www.facebook.com/groups/489022: Nhip nhanh that || 125 | Ph Rp 4 i Pryce pte ae pet ee ie Phe Hinh 12.15. DTD sau séc dién cla bénh nhan trén, ghi nhan khdi phuc vé nhip xoang 3. DINH VI VI TRI KHOI PHAT NHIP NHANH THAT 3.1. Nhip nhanh that do seo co tim (vong vao lai) Dinh vj vi tri khoi phat nhip nhanh that Bwée 1: Xem phitc bd QRS V1 dung (kiéu block nhanh phai) hay Am (kiéu block nhanh trai)? v1 That trai That phai hodc vach lién that Buw6e 2: Xem phirc b6 QRS @ DI duong hay 4m? Vach lién that Thanh bén hoac mom tim zalo nhom duy nhat 0528112107y khoa cap nhat https://www.facebook.com/groups/48902 126 || Sé tay dién tam ad Bue 3: Xem phtec b6 QRS @ DIl, Dill, aVF dwong hay 4m? Block nhénh pha QRS chuyén tir dung sang 4m (Vi tri cang gan day tim) QRS déng huréng durong QRS ddng huéng am Block nnanh trat: QRS chuyén tirdm sang duong (Vi tri cang gan mém tim) Hinh 12.16. Dinh vj vi tri tong déi khéi phat nhip nhanh that so vGi day tim va mdm tim, dya vao QRS @ cdc chuyén dao trwoc ngye V1-6 zalo nhom duy nhat 0528112107Py khoa cap nhat https://www.facebook.com/groups/480022" Nhip nhanh that || 127 Bang 12.4. Danh phap mé ta hinh dang QRS trong dinh vi vi tri khdéi phat nhip nhanh that do seo co’ tim Danh phap m6 ta hinh dang QRS (goi y chiéu vector dong dién) trong nhip nhanh that do seo co tim RB (Right bundle: Phirc b6 QRS —-Nhanh phai): QRS that trai V1 wu thé duong Goi y vi tri tai duong hodc LB (Left bundle: — Goi y vi tri tai am? nhanh trai): QRS tht phai hoac am vach lién that L (Leftward: léch — Goi y vi tri tai Phe bS ARS trai) QRS duong _vach lién that © Di wu thé durong hodic R (Rightward: Goi y vi tri ar léch phai): QRS tai thanh bén am hoac mém tim Phirc b6 QRS | (Inferior: dwéi): — Goi y vi tri tai @ Dil, Dill, avE QRS duong thanh trvéc wu thé duong —§ (Superior: tren): Goi y vitri tal hoac am? QRS 4m thanh dudi RAMAN patctcnn MAN \ AN MA Vann nol, NAMAAA VA AAAI A MANA CLM I Hinh 12.17. DTD nhanh that & bénh nhan 80 tudi cé ti&n can suy tim — bénh tim thiéu mau cuc b6. DTD ghi nhan nhip nhanh that RBLI: QRS dung dang block nhanh phai & V1 (RB); QRS duong © DI (L); QRS duong @ DIl, Dill, aVF (1); ngoai ra, QRS con déng huéng duong & cac chuyén dao truréc ngyc. Goi ¥ vi tri khéi phat tai phan day, truéc vach ctia that trai zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/4890228 128 || Sé tay dién tam dd AAAOEMW AAI \Roee AA YY BAIN WY Ny va fy TV VV VV Hinh 12.18. DTD nhanh that & bénh nhan 77 tudi cé tién cdn suy tim — bénh tim thiéu mau cuc bd. DTD ghi nhan nhip nhanh that LBRS: QRS 4m 6 V1 (LB); Am & DI (R); Am & DI, Dill, aVF (S); ngoai ra, QRS con déng hung dm @ cac chuyén dao trudc ngve. Goi y vi tri gan mém tim — vach — thanh duéi 3.2. Nhip nhanh that vé can Bang 12.5. Phan loai nhip nhanh that v6 can bdi vi tri ctla 6 phat nhip ngoai lai * Budng téng that phai (thuéng gap nhat) © Budng téng that trai » La van déng mach chu (vanh trai > vanh phai >> khéng vanh) = Ché néi van déng mach chii va van hai la = Mém that trai Buong tong + Nhanh that bo nhanh trai sau (thuong gap RETR eG nht trong nhanh that bé nhanh) eanieniie ° Nhanh that bé nhanh trai treéc * Nhanh that vach cao Nhanh that ¢ Vong van hai la WATE REIN) © Vong van ba la zalo nhom duy nhat 0528112107y khoa cap nhat https://www.facebook.com/groups/489 Nhip nhanh that || 129 + Nhanbh that tlr cor nhu (try sau gidra > trudc Nea eT bén >> that phai) aki) + Nhanh that tir dai digu hoa + Nhanh that tu thuong tam mac 3.2.1. Nhanh that tir buéng téng Nhanh that tir buéng téng: QRS duong & Dil, Dill, aVF; 4m @ DI, aVL, aVR * Bung téng that phai: QRS 6 V1 Am, dang block nhanh trai + Budng téng that trai: QRS & V1 duong, dang block nhanh phai lee Vy YY V' i wy A VY yyy iy) hu PHL AAA 2 y AMY V\ aN AM V uy A \V Pn Il lL Hinh 12.49. Nhip nhanh that tr budng tng that phai (QRS am 6 V1 dang block nhanh trai, goi y vi tri tai that phai; QRS dvong DIl, DIIl, AVF ggi y vi tri tty budng téng) zalo nhom duy nhat 0528112107u y khoa cap nhat https://www.facebook.com/groups/4890: 130. || Sé tay dign tam dd 3.2.2. Nhanh that tty bé nhanh « Nhanh that bo nhanh trai sau (90 — 95% trong hop nhanh thAt bé nhanh): block nhanh phai + truc Iéch trai * Nhanh that bé nhanh trai truée (10 — 15% trudng hop nhanh that bé nhanh): block nhanh phai + truc I6ch phai + Nhanh that trén vach cao (hiém): hinh thai khong dién hinh, thwong block nhanh phai nhung cé thé giéng block nhénh trai, cO thé cd QRS hep va truc binh thudéng bbabel Rett erie bebe elle POCA At Ate sie! mae Hinh 12.20. DTD nhanh that bo nhanh trai sau (co hinh anh phan ly nhi that, block nhanh phai hoan toan + truc léch trai) vy meee Utd Il ese ptani TCU ECU LW adeeereis j fet IU I AA, Hinh 12.21. DTD nhanh that bé nhanh trai tree (hinh anh phan ly nhi that, block nhanh phai hoan toan + truc léch phai) zalo nhom duy nhat 0528112107ny khoa cap nhat https://www.facebook.com/groups/489022: Nhip nhanh that || 134 3.2.3. Nhanh that tir co nha * QRS 6 V1 dang block nhanh phai * QRS réng > 130 ms * Séng R c6 khac 6 V1-3 ° Truc QRS: * Tw try sau gita: truc hung |én trén/léch trai « Tv tru truoc bén: truc hung xudéng dudi WAAR it 4! i veers | ri I “TERETE Pe ener Hinh 12.22. DTD nhanbh that xuat phat tir co’ tru sau gitra (block nhanh phai, QRS réng > 130 ms, R cd khdc & V1-3, truc QRS hwong lén trén/léch trai) zalo nhom duy nhat 0528112107u y khoa cap nhat https://www.facebook.com/groups/4890: ROI LOAN NHIP DI TRUYEN 4. HOI CHUNG QT DAI HOi chtrng QT dai l& mét dang réi loan nhip di truyén, co thé nhan biét trén DTD, lién quan dén réi loan tai circ co’ tim, lam tang nguy co’ réi loan nhip that ac tinh gay ngat hoc dét tte do tim. Trén DTD, QT dai khi QTe (tinh theo céng thir Bazett): | + > 450 ms 6 nam » >460 ms 6 ni | Bang 13.1. Thang diém Schwartz higu chinh (ESC 2022) Dac diem Dau hiéu trén dién tam d6* QTc (tinh theo céng thtrc Bazett) * 2480 ms 3,5 ° 460 —-479 ms 2 + 450 — 459 ms (6 nam gidi) f QTc phut tht tu giai doan phuc hdi tty nghiém 1 phap gang strc > 480 ms Xoan dinh 2 Séng T luan chuyén (T wave alternans)”” 1 Séng T cé kh4c & ba chuy&n dao 4 TAn sé tim th4p theo tudi 0.5 1.1. Dac diém dién tam dé 432 |) ~ zalonhom duy nhat 0528112107