Geleidingsstoornissen, bradycardie en PM€¦ · Sinus Aritmie • Presence of sinus P waves •...
Transcript of Geleidingsstoornissen, bradycardie en PM€¦ · Sinus Aritmie • Presence of sinus P waves •...
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Geleidingsstoornissen, bradycardie en PM
Rik Willems
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Intraventriculaire geleidingsstoornissen
• QRS-duur ≥ 100 ms– volledig ≥ 120 ms
– onvolledig 100 - 120 ms
• Rechter bundel• Linker bundel
• Aspecifiek
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DD/ breed QRS
• Geleidingsstoornissen• Atrioventriculaire extraverbinding (Kent-
bundel)• Ventriculair ritme• Elektrolietenstoornissen
– Hyperkaliëmie
• Hypothermie• Antiaritmica
– Klasse 1C (flecainide, propafenone)
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Linker bundeltakblock
• QRS duur ≥ 120ms• rS of QS beeld in V1
• Brede positieve QRS complexen metnotching of slurring zonder intiële q in I en V6
– afwezigheid normale septale activatie
• Diagnose van myocardinfarct enlinkerkamerhypertrofie kan niet gesteldworden !
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LBTB
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LBTB
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Rechter bundeltak block
• QRS duur ≥ 120ms
• rSR’ patroon of notched R in V1
– altijd hoge en brede terminale R of R’ ! DD/VT
• Brede S in I en V6
• ST daling en neg T in precordialen
• Diagnose van myocardinfarct blijft mogelijkomdat de initïele vectoren normaal verlopen
• Geen uitspraak over rechterkamerhypertrofie
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• • • • • •
normale variante bij kinderen en adolescentente hoge plaatsing V1pectus excavatumrechterkamerhypertrofielongembolie“True posterior” infarct
DD/ RSR’ in afleiding V1
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RBTB
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RBTB
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• ECG criteria– linker as <-30
– kleine q wave in lead I– diepe S in II en III
Linker anterior hemiblock
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• ECG criteria– Rechter as > +120– grote S in lead I
– qR in lead II, III en aVF• Grote R• Kleine q
Linker posterior hemiblock
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Gevorderde geleidingsstoornissen
• Bifasciculair block– VRBTB + LAH– VRBTB + LPH
• Trifasciculair block– 1e gr AV block + VRTBT + LAH of LPH
• CAVE: ontstaan vangeleidingstoornissen bij infarct
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Het normale geleidingssysteem
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Sinus knoop gerelateerde bradycardie
• Sinoatriaal (SA) block• Sinus arrest
• Sick sinus syndroom (SSS)
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Sino-atriale (SA) geleidingsstoornissen
• Minder frequent dan AVgeleidingsstoornissen
• Moeilijkere diagnose• Klinische relevantie?
• Ingedeelde in 1st, 2de, and 3de graad,maar enkel 2degraad SA block isdedecteerbaar op EKG.
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1st graads SA Block
• ECG geeft geen aanwijzing vanactiviteit van de sinusknoop, en daaromniet zichtbaar.
• EFO noodzakelijk voor diagnose, maarniet klinisch relevant
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Type 1 2de graads SA Block
• Progressive shortening of the PP interval until a pause inthe sinus rhythm appears.
• The pause will be less than the two preceding PP interval.• The PP interval following the pause is greater than the PP
interval just before the pause.
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
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Type 2 2de graads SA Block
• Abnormal pauses between 2 sinus P waves
• Length of pause is a multiple of the shortest PP interval(usually 2x)
• PP interval is otherwise constant.
• DD/ blocked AES!
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
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3de graads SA Block
• Niet te onderscheiden van sinus arrestop ECG.
• EFO noodzakelijk voor diagnose, maarniet klinisch relevant
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Sinus Aritmie
• Presence of sinus P waves
• Variation of the PP interval which cannot be attributed to either SA nodalblock or PACs
• When the variations in PP interval occur in phase with respiration, this isconsidered to be a normal variant. When they are unrelated to respiration,they may be caused by the same etiologies leading to sinus bradycardia.
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
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Sinusknoopziekte
• Characterized by a collection of symptoms and ECGfindings due to chronic dysfunction of the sinoatrial (SA)node:– Chronic and severe sinus bradycardia– Sinus pauses– Sinus arrhythmia– Complete sinus arrest– Progressive development of atrial arrhythmias (a-
flutter, a-fib, atrial tachycardia)• Patients are usually elderly and present with
lightheadedness and/or syncope, but it can also manifestas angina, dyspnea, and palpitations.
• About 50% of people with SSS also display some degreeof dysfunction of the AV node
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Sick Sinus Syndrome
Sinus bradycardia (rate of ~43 bpm) with a sinus pause
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Etiologie van SSSMore Common
Sinus node firbosis
Atherosclerosis of theSA arteryCongenital heartdiseaseExcessive vagal tone
Drugs
Less CommonFamilial SSS (due tomutations in SCN5A)Infiltrative diseases
Pericarditis
Lyme disease
Hypothyroidism
Rheumatic fever
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Tachycardia-Bradycardia Syndrome• Common variant of sick sinus syndrome
severe bradycardia alternates withparoxysmal tachycardias, most often atrialfibrillation.
• There is usually a prolonged pause in thecardiac rhythm following cessation of thetachyarrhythmia.
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Tachycardia-Bradycardia Syndrome
Abrupt termination of atrial flutter with variable AV block,followed by sinus arrest with a junctional escape beat.
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
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Spoedgevallensinusknoop gerelateerde brady
• Enkel spoedeisend zo symptomen vanhypotensie, draaierigheid of(pre)syncope
• Atropine 0.04 mg/kg iv
• Sluit onderliggende ischemie uit• Denk aan intoxicatie en
elektrolietenstoornissen
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AV block
• AV Block (relatively common)– 1st degree AV block: PR > 200 ms– Type 1 2nd degree AV block
– Type 2 2nd degree AV block
– 3rd degree AV block
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Plaats van AV block
his
infra-his of subnodaal
supra-his of nodaal
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Supra-his Infra-his
atropine
inspanning
carotismassage
beter
beter
slechter
slechter
slechter
beter
Niet invasieve methodes om de plaats vanblock te bepalen
• ECG– PR interval > 280 ms = supra-his
– Verbreed QRS = infra-his
• interventies
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EKG Characteristics: Prolongation of the PR interval, which is constant
All P waves are conducted
1st Degree AV Blockeigen geen echt block!
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
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2nd Degree AV BlockType 1
(Wenckebach)
EKG Characteristics:
EKG Characteristics:
Progressive prolongation of the PR interval until a Pwave is not conducted.
As the PR interval prolongs, the RR interval actuallyshortens
Type 2
Constant PR interval with intermittent failure to conduct
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EKG Characteristics: No relationship between P waves and QRS complexes
Relatively constant PP intervals and RR intervals
Greater number of P waves than QRS complexes
3rd Degree (Complete) AV Block
www.uptodate.com
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Wisselend bundeltakblock
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Paroxysmaal AV block
• • • • • •
Na kritische verlenging PP intervalLokalisatie is infra-his of subnodaal
Phase 4 block in conductiesysteem
Onbetrouwbaar escaperitme
Paroxysmaal karakter
Geen duidelijke AV geleidingsstoornissen
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Bradycardie afhankelijk block
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SpoedgevallenAV block
• Ernst afhankelijk van localisatie• Tijdelijke pacemaker
– Syncope– Hypotensie/Cardiogene shock– hartfalen
• CAVE ischemie– Inferior infarct: supra-his– Anterior infarct: infra-his
• Denk aan intoxicatie en elektrolietenstoornissen
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Reanimatie
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Reanimatiespecifieke aandachtspunten
• Atropine 0.5 mg iv/3-5 min– totale dosis 3 mg
• Isuprel 0.5 - 2 µg/min– als 1mg in 250 ml gluc 5% is dit 15 ml/u
• Transcutane pacing– pijnlijk
– misleiding door artefacten op ecg!
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Tijdelijke pacing
• Beste acces– Rechter Vena Jugularis Interna– Linker Vena Subclavia
• Blinde positionering met “drijvende”katheter– EGM
– Fluoroscopie
• Best niet > 72u
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PM Code1st Letter
Chamber(s) PacedA = atriumV = ventricle
D = dual (both atriumand ventricle)
2nd Letter
Chamber(s) SensedA = atrium
V = ventricle
D = dual
O = none
3rd Letter
Response to SensingI = inhibit
(Demand mode)T = triggered
D = dual
O = none (Asynch)
V V I
Chamber paced
Chamber sensed
Action or response to a sensed event
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Tijdelijke pacing
• VOO met hoge output tijdens plaatsing• Ken uw toestel !
• Dagelijks pacing en sensing drempelbepalen
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Andere dia
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