{"id":30865,"date":"2023-05-03T14:55:54","date_gmt":"2023-05-03T07:55:54","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=30865"},"modified":"2023-05-03T14:55:56","modified_gmt":"2023-05-03T07:55:56","slug":"dac-diem-can-lam-sang-va-chan-doan-nhip-nhanh-that","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/05\/03\/dac-diem-can-lam-sang-va-chan-doan-nhip-nhanh-that\/","title":{"rendered":"\u0110\u1eb7c \u0111i\u1ec3m c\u1eadn l\u00e2m s\u00e0ng v\u00e0 ch\u1ea9n \u0111o\u00e1n nh\u1ecbp nhanh th\u1ea5t"},"content":{"rendered":"

Nh\u1ecbp nhanh th\u1ea5t (Ventricular Tachycardia – VT) l\u00e0 r\u1ed1i lo\u1ea1n nh\u1ecbp nhanh khi c\u00f3 tr\u00ean 3 ph\u1ee9c b\u1ed9 th\u1ea5t li\u00ean ti\u1ebfp, c\u00f3 t\u1ea7n s\u1ed1 t\u1eeb > 100 c\/ph \u0111\u1ebfn 250 c\/ph, th\u01b0\u1eddng c\u00f3 ph\u1ee9c b\u1ed9 QRS r\u1ed9ng (\u2265120 msec) xu\u1ea5t hi\u1ec7n khi ho\u1ea1t \u0111\u1ed9ng kh\u1eed c\u1ef1c \u1edf th\u1ea5t ch\u1eadm b\u1ea5t th\u01b0\u1eddng, c\u00f3 ngu\u1ed3n g\u1ed1c ngo\u00e0i h\u1ec7 th\u1ed1ng d\u1eabn truy\u1ec1n b\u00ecnh th\u01b0\u1eddng.<\/strong><\/p>\n

1. C\u1eadn l\u00e2m s\u00e0ng nh\u1ecbp nhanh th\u1ea5t.\u00a0<\/strong><\/h2>\n

1.1 C\u1eadn l\u00e2m s\u00e0ng b\u1ed5 sung
\n<\/strong>– N\u1ed3ng \u0111\u1ed9 kali v\u00e0 magi\u00ea.
\n– N\u1ed3ng \u0111\u1ed9 digoxin, quinidine, ho\u1eb7c procainamide \u0111\u1ec3 l\u01b0\u1ee3ng gi\u00e1 nhi\u1ec5m \u0111\u1ed9c.<\/p>\n

– \u0110o n\u1ed3ng \u0111\u1ed9 TnI ho\u1eb7c T, Pro-BNP \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh MI v\u00e0 suy tim.
\n– X quang ng\u1ef1c, g\u1ee3i \u00fd b\u1ec7nh tim th\u1ef1c th\u1ec3, b\u1eb1ng ch\u1ee9ng \u0111\u00e3 ph\u1eabu thu\u1eadt tim, PM v\u00e0 ICD.
\n– Nghi\u00ean c\u1ee9u \u0111i\u1ec7n sinh l\u00fd<\/a> (EPs) cho ph\u00e9p ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh VT, nh\u01b0ng hi\u1ebfm khi c\u00f3 th\u1ec3 th\u1ef1c hi\u1ec7n trong tr\u1ea1ng th\u00e1i c\u1ea5p t\u00ednh.
\nSau c\u01a1n nh\u1ecbp nhanh c\u1ea7n EPs tr\u01b0\u1eddng h\u1ee3p sau:
\n+ <\/em>EPs trong b\u1ec7nh \u0111\u1ed9ng m\u1ea1ch v\u00e0nh: nh\u1eefng tr\u01b0\u1eddng h\u1ee3p nh\u1ed3i m\u00e1u c\u01a1 tim c\u0169 c\u00f3 c\u00e1c tri\u1ec7u ch\u1ee9ng nghi ng\u1edd VT, nh\u1eefng tr\u01b0\u1eddng h\u1ee3p b\u1ecb b\u1ec7nh \u0111\u1ed9ng m\u1ea1ch v\u00e0nh c\u00f3 c\u01a1n nh\u1ecbp nhanh ph\u1ee9c b\u1ed9 QRS d\u00e3n r\u1ed9ng m\u00e0 kh\u00f4ng r\u00f5 c\u01a1 ch\u1ebf ho\u1eb7c \u0111\u1ec3 ph\u00e2n t\u1ea7ng nguy c\u01a1 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n ti\u1ec1n s\u1eed b\u1ecb nh\u1ed3i m\u00e1u c\u01a1 tim, VT t\u1ea1m th\u1eddi v\u00e0 LVEF < 40%.
\n+ Trong BCT d\u00e3n, h\u1ed9i ch\u1ee9ng QT k\u00e9o d\u00e0i, h\u1ed9i ch\u1ee9ng Brugada, BCT ph\u00ec \u0111\u1ea1i, lo\u1ea1n s\u1ea3n th\u1ea5t ph\u1ea3i th\u00ec vai tr\u00f2 EPs ch\u01b0a r\u00f5 r\u00e0ng.
\n+ Trong VT \u0111\u01b0\u1eddng ra th\u1ea5t ph\u1ea3i: \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh, h\u01b0\u1edbng d\u1eabn \u0111i\u1ec1u tr\u1ecb b\u1eb1ng s\u00f3ng c\u00f3 t\u1ea7n s\u1ed1 Radio.
\n1.2. \u0110i\u1ec7n t\u00e2m \u0111\u1ed3:
\n<\/strong>ECG c\u00f3 th\u1ec3 cung c\u1ea5p kh\u1ea3 n\u0103ng ch\u1ea9n \u0111o\u00e1n VT \u1edf nhi\u1ec1u b\u1ec7nh nh\u00e2n.
\n– N\u1ebfu \u1ed5n \u0111\u1ecbnh huy\u1ebft \u0111\u1ed9ng c\u1ea7n: c\u1ea7n 12 chuy\u1ec3n \u0111\u1ea1o c\u01a1 b\u1ea3n v\u00e0 b\u0103ng ECG d\u00e0i 25 cm.
\n+ T\u1ea7n s\u1ed1: <\/em><\/strong>h\u1ea1n ch\u1ebf trong vi\u1ec7c ph\u00e2n bi\u1ec7t gi\u1eefa VT v\u00e0 SVT. Khi t\u1ea7n s\u1ed1 kho\u1ea3ng 150 l\/ph, cu\u1ed3ng nh\u0129 c\u00f3 d\u1eabn truy\u1ec1n l\u1ec7ch h\u01b0\u1edbng c\u1ea7n \u0111\u01b0\u1ee3c xem x\u00e9t, m\u1eb7c d\u00f9 ch\u1ea9n \u0111o\u00e1n n\u00e0y kh\u00f4ng \u0111\u01b0\u1ee3c ch\u1ea5p nh\u1eadn khi kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng \u1ee7ng h\u1ed9 kh\u00e1c.
\n+ T\u00ednh \u0111\u1ec1u \u0111\u1eb7n<\/em><\/strong>: VT th\u01b0\u1eddng \u0111\u1ec1u, m\u1eb7c d\u00f9 s\u1ef1 thay \u0111\u1ed5i nh\u1eb9 c\u00e1c kho\u1ea3ng RR \u0111\u00f4i khi \u0111\u01b0\u1ee3c nh\u1eadn th\u1ea5y. Kh\u00f4ng \u0111\u1ec1u ch\u00fat \u00edt g\u1ee3i \u00fd VT nh\u01b0 l\u00e0 ng\u01b0\u1ee3c l\u1ea1i v\u1edbi \u0111a s\u1ed1 SVT.
\n+ Tr\u1ee5c \u0111i\u1ec7n t\u00e2m \u0111\u1ed3<\/em><\/strong>:
\n\u2022 Tr\u1ee5c ph\u1ea3i m\u1ea1nh <\/em>(t\u1eeb -90 \u0111\u1ebfn \u00b1180\u00ba) g\u1ee3i \u00fd m\u1ea1nh m\u1ebd VT. Kh\u00f4ng \u00e1p d\u1ee5ng trong th\u1ec3 antidromic AVRT c\u1ee7a h\u1ed9i ch\u1ee9ng Wolff-Parkinson-White (WPW).
\n\u2022 So s\u00e1nh tr\u1ee5c trong qu\u00e1 tr\u00ecnh nh\u1ecbp xoang, n\u1ebfu ch\u00eanh l\u1ec7ch > 40\u00ba g\u1ee3i \u00fd VT.
\n\u2022 \u1ede b\u1ec7nh nh\u00e2n c\u00f3 RBBB, tr\u1ee5c QRS tr\u00e1i -30\u00ba g\u1ee3i \u00fd VT.
\n\u2022 \u1ede b\u1ec7nh nh\u00e2n c\u00f3 LBBB, tr\u1ee5c ph\u1ea3i +90\u00ba g\u1ee3i \u00fd VT.<\/p>\n

\"nhip-nhanh-that\"
LBBB v\u00e0 RBBB<\/figcaption><\/figure>\n

+ Kho\u1ea3ng th\u1eddi gian QRS<\/em><\/strong>.
\n\u2022 D\u1ea1ng RBBB, QRS >140 msec g\u1ee3i \u00fd VT, trong khi LBBB QRS >160 msec g\u1ee3i \u00fd VT.
\n\u2022 QRS <140 msec kh\u00f4ng lo\u1ea1i tr\u1eeb \u0111\u01b0\u1ee3c VT, do VT c\u00f3 ngu\u1ed3n g\u1ed1c t\u1eeb v\u00e1ch trong ph\u1ea1m vi h\u1ec7 His-Purkinje.
\n+Concordance:
\n<\/em><\/strong>\u2022 Khi c\u00e1c ph\u1ee9c h\u1ee3p QRS \u1edf t\u1ea5t c\u1ea3 6 chuy\u1ec3n \u0111\u1ea1o tr\u01b0\u1edbc tim (V1\u00f7 V6) l\u00e0 \u0111\u01a1n h\u00ecnh v\u1edbi s\u1ef1 kh\u1eed c\u1ef1c nh\u01b0 nhau, c\u00f3 th\u1ec3 \u00e2m to\u00e0n b\u1ed9 ho\u1eb7c d\u01b0\u01a1ng to\u00e0n b\u1ed9 (R m\u1ed9t pha).
\n\u2022 Concordance \u00e2m g\u1ee3i \u00fd m\u1ea1nh m\u1ebd VT.
\n\u2022 Concordance d\u01b0\u01a1ng th\u01b0\u1eddng nh\u1ea5t do VT nh\u01b0ng c\u0169ng c\u00f3 th\u1ec3 xu\u1ea5t hi\u1ec7n \u1edf ca t\u01b0\u01a1ng \u0111\u1ed1i hi\u1ebfm d\u1ea1ng antidromic AVRT c\u00f3 \u0111\u01b0\u1eddng ph\u1ee5 sau tr\u00e1i.
\n\u2022 Kh\u00f4ng c\u00f3 kh\u00f4ng lo\u1ea1i tr\u1eeb ch\u1ea9n \u0111o\u00e1n.
\n+Ph\u00e2n ly nh\u0129 th\u1ea5t : ph\u00e2n ly nh\u0129 th\u1ea5t \u0111\u01b0\u1ee3c \u0111\u1eb7c tr\u01b0ng b\u1eb1ng ho\u1ea1t \u0111\u1ed9ng c\u1ee7a nh\u0129 \u0111\u1ed9c l\u1eadp v\u1edbi ho\u1ea1t \u0111\u1ed9ng th\u1ea5t.
\nC\u00e1c nh\u1eadn \u0111\u1ecbnh ph\u00e2n ly AV.<\/strong>
\n\u2022 C\u00e1c s\u00f3ng P ph\u00e2n ly
\n\u2022 C\u00e1c kho\u1ea3ng PP v\u00e0 RR l\u00e0 kh\u00e1c bi\u1ec7t
\n\u2022 C\u00e1c kho\u1ea3ng PR thay \u0111\u1ed5i
\n\u2022 Kh\u00f4ng c\u00f3 s\u1ef1 k\u1ebft h\u1ee3p gi\u1eefa s\u00f3ng P v\u00e0 c\u00e1c ph\u1ee9c h\u1ee3p QRS
\n\u2022 C\u00f3 th\u1ec3 ph\u00e2n bi\u1ec7t r\u00f5 b\u1eb1ng chuy\u1ec3n \u0111\u1ea1o th\u1ef1c qu\u1ea3n ho\u1ea1t trong bu\u1ed3ng tim.
\n\u2022 Ph\u00e2n ly AV, t\u1ea7n s\u1ed1 nh\u0129 ch\u1eadm h\u01a1n t\u1ea7n s\u1ed1 th\u1ea5t g\u1ee3i \u00fd m\u1ea1nh m\u1ebd VT.<\/p>\n

2. Ch\u1ea9n \u0111o\u00e1n<\/h2>\n

2.1.Ti\u00eau chu\u1ea9n Brugada
\n<\/strong>Ngo\u1ea1i tr\u1eeb antidromic AVRT trong WPW syndrome.
\nTh\u1ef1c hi\u1ec7n c\u00e1c b\u01b0\u1edbc sau:
\n– Chuy\u1ec3n \u0111\u1ea1o V1-V6 \u0111\u01b0\u1ee3c xem x\u00e9t k\u1ef9 ph\u00e1t hi\u1ec7n h\u00ecnh th\u00e1i RS. N\u1ebfu kh\u00f4ng c\u00f3, c\u00f3 hi\u1ec7n di\u1ec7n concordance v\u00e0 ch\u1ea9n \u0111o\u00e1n VT \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh.
\n– N\u1ebfu c\u00f3 ph\u1ee9c h\u1ee3p d\u1ea1ng RS, x\u00e9t kho\u1ea3ng c\u00e1ch gi\u1eefa kh\u1edfi \u0111\u1ea7u s\u00f3ng R v\u00e0 \u0111i\u1ec3m th\u1ea5p nh\u1ea5t c\u1ee7a s\u00f3ng S. N\u1ebfu kho\u1ea3ng RS d\u00e0i nh\u1ea5t \u1edf b\u1ea5t k\u1ef3 chuy\u1ec3n \u0111\u1ea1o n\u00e0o >100 msec c\u00f3 th\u1ec3 ch\u1ea9n \u0111o\u00e1n VT.
\n– N\u1ebfu kho\u1ea3ng RS d\u00e0i nh\u1ea5t <100 msec, c\u00f3 hay kh\u00f4ng c\u00f3 ph\u00e2n ly AV c\u1ea7n \u0111\u01b0\u1ee3c xem x\u00e9t. N\u1ebfu c\u00f3 ph\u00e2n ly AV, ch\u1ea9n \u0111o\u00e1n cho VT.
\n– N\u1ebfu kho\u1ea3ng RS <100 msec v\u00e0 ph\u00e2n ly AV kh\u00f4ng th\u1ea5y r\u00f5, ti\u00eau chu\u1ea9n h\u00ecnh d\u1ea1ng c\u1ee7a QRS cho V1 d\u01b0\u01a1ng v\u00e0 nh\u1ecbp nhanh QRS r\u1ed9ng \u00e2m c\u1ea7n \u0111\u01b0\u1ee3c xem x\u00e9t.
\n– Ti\u00eau chu\u1ea9n h\u00ecnh d\u1ea1ng QRS ph\u00f9 h\u1ee3p v\u1edbi VT c\u1ea7n s\u1ef1 hi\u1ec7n di\u1ec7n \u1edf V1 ho\u1eb7c V2 v\u00e0 \u1edf V6 \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n VT. N\u1ebfu ho\u1eb7c ti\u00eau chu\u1ea9n V1-V2 ho\u1eb7c V6 kh\u00f4ng ph\u00f9 h\u1ee3p v\u1edbi VT lo\u1ea1i tr\u1eeb VT.
\n2.2. C\u00e1c ph\u01b0\u01a1ng ph\u00e1p thay th\u1ebf
\n<\/strong>– S\u1eed d\u1ee5ng ph\u01b0\u01a1ng ph\u00e1p b\u1eadc thang gi\u1ed1ng v\u1edbi ti\u00eau chu\u1ea9n Brugada (Ti\u00eau chu\u1ea9n Vereckei ):
\n-\u0110\u1ea7u ti\u00ean l\u00e0 xem c\u00f3 ph\u00e2n ly AV kh\u00f4ng? N\u1ebfu c\u00f3 l\u00e0 VT. N\u1ebfu kh\u00f4ng c\u00f3 qua b\u01b0\u1edbc 2.
\n-Nh\u00ecn v\u00e0o \u0111\u1ea1o tr\u00ecnh aVR: n\u1ebfu aVR b\u1eaft \u0111\u1ea7u b\u1eb1ng s\u00f3ng R ho\u1eb7c qR v\u1edbi R > 40 ms th\u00ec kh\u1ea3 n\u0103ng l\u00e0 VT. N\u1ebfu kh\u00f4ng c\u00f3 qua b\u01b0\u1edbc 3.
\n-Ph\u00e2n t\u00edch h\u00ecnh \u1ea3nh QRS xem c\u00f3 d\u1ea1ng RBBB hay LBBB \u0111i\u1ec3n h\u00ecnh hay kh\u00f4ng. N\u1ebfu c\u00f3 l\u00e0 nh\u1ecbp nhanh tr\u00ean th\u1ea5t. N\u1ebfu kh\u00f4ng c\u00f3 qua b\u01b0\u1edbc 4.
\n-Ph\u00e2n t\u00edch t\u1ec9 s\u1ed1 Vi\/Vt trong \u0111\u00f3 Vi l\u00e0 bi\u00ean \u0111\u1ed9 c\u1ee7a ph\u1ea7n l\u00ean s\u00f3ng R trong 40ms \u0111\u1ea7u ti\u00ean v\u00e0 Vt l\u00e0 bi\u00ean \u0111\u1ed9 ph\u1ea7n cu\u1ed1i s\u00f3ng S \u1edf 40 ms t\u1eadn c\u00f9ng. Ph\u1ea3i ch\u1ecdn \u0111\u1ea1o tr\u00ecnh m\u00e0 QRS c\u00f3 ph\u1ea7n kh\u1edfi \u0111\u1ea7u v\u00e0 k\u1ebft th\u00fac r\u00f5 nh\u1ea5t.<\/p>\n

– Ph\u00e2n bi\u1ec7t VT v\u1edbi AVRT.
\nCh\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t kh\u00f3, nh\u01b0ng kh\u00f4ng ph\u1ed5 bi\u1ebfn (6%). <\/strong>\u00a0N\u1ebfu nghi ng\u1edd k\u00edch th\u00edch s\u1edbm. M\u00f4 h\u00ecnh Brugada th\u1ee9 hai g\u1ed3m ba b\u01b0\u1edbc sau:
\n– Kh\u1eed c\u1ef1c chi\u1ebfm \u01b0u th\u1ebf c\u1ee7a QRS \u1edf V4 qua V6 \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh ho\u1eb7c l\u00e0 d\u01b0\u01a1ng ho\u1eb7c l\u00e0 \u00e2m. N\u1ebfu \u01b0u th\u1ebf \u00e2m, ch\u1ea9n \u0111o\u00e1n c\u00f3 nhi\u1ec1u kh\u1ea3 n\u0103ng VT.
\n– N\u1ebfu kh\u1eed c\u1ef1c c\u1ee7a QRS chi\u1ebfm \u01b0u th\u1ebf d\u01b0\u01a1ng \u1edf V4 qua V6, ECG c\u1ea7n \u0111\u01b0\u1ee3c xem x\u00e9t c\u00f3 d\u1ea1ng qR \u1edf m\u1ed9t hay nhi\u1ec1u chuy\u1ec3n \u0111\u1ea1o tr\u01b0\u1edbc tim t\u1eeb V2 qua V6. N\u1ebfu c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c nh\u1eadn th\u1ea5y qR, c\u00f3 th\u1ec3 ch\u1ea9n \u0111o\u00e1n VT.
\n– N\u1ebfu s\u00f3ng qR \u1edf V2 qua V6 kh\u00f4ng c\u00f3, m\u1ed1i li\u00ean h\u1ec7 AV sau \u0111\u00f3 c\u1ea7n l\u01b0\u1ee3ng gi\u00e1 (ph\u00e2n ly AV). N\u1ebfu qua h\u1ec7 AV l\u00e0 1:1 kh\u00f4ng c\u00f3 v\u00e0 c\u00f3 nhi\u1ec1u QRS h\u01a1n s\u00f3ng P, c\u00f3 th\u1ec3 ch\u1ea9n \u0111o\u00e1n VT.
\n+ N\u1ebfu ECG c\u1ee7a lo\u1ea1n nh\u1ecbp kh\u00f4ng bi\u1ec3u hi\u1ec7n b\u1ea5t k\u1ef3 \u0111\u1eb7c t\u00ednh h\u00ecnh th\u00e1i h\u1ecdc n\u00e0o ch\u1ea9n \u0111o\u00e1n VT sau khi s\u1eed d\u1ee5ng m\u00f4 h\u00ecnh n\u00e0y, ch\u1ea9n \u0111o\u00e1n antidromic AVRT c\u1ea7n \u0111\u01b0\u1ee3c xem x\u00e9t.<\/p>\n

T\u00e0i li\u1ec7u tham kh\u1ea3o<\/strong>: Ph\u00e1c \u0111\u1ed3 b\u1ec7nh vi\u00ean Nh\u00e2n d\u00e2n 115<\/p>\n","protected":false},"excerpt":{"rendered":"

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