電解質(zhì)與心律失常治療ppt課件

1、電解質(zhì)紊亂與心律失常處置電解質(zhì)紊亂與心律失常處置北京醫(yī)院北京醫(yī)院楊杰孚楊杰孚心肌動作電位的產(chǎn)生過程心肌動作電位的產(chǎn)生過程電解質(zhì)對心電及心律的影響電解質(zhì)對心電及心律的影響n主要影響心肌動作電位n對心肌應(yīng)激性及傳導(dǎo)性也有影響n嚴(yán)重電解質(zhì)紊亂n激動來源異常n傳導(dǎo)異常n心臟停搏n室顫電解質(zhì)紊亂對心肌動作電位的影響電解質(zhì)紊亂對心肌動作電位的影響工程工程 高鉀高鉀 低鉀低鉀 低鈉低鈉 高鈣高鈣 低鈣低鈣靜息電位靜息電位+-動作電位時程動作電位時程-+-+動作電位幅度動作電位幅度- 或或+ -傳導(dǎo)速度傳導(dǎo)速度-不應(yīng)期不應(yīng)期 -+-+閾電位閾電位應(yīng)激性應(yīng)激性+-+高鉀血癥高鉀血癥5.5mmol/L心電圖表心電

2、圖表現(xiàn)現(xiàn)nT波高尖波高尖nQRS波振幅降低、時間變寬、波振幅降低、時間變寬、S波加深波加深nST段下移段下移nP波減小，甚至消逝波減小，甚至消逝n各種心律失常緩慢型為主各種心律失常緩慢型為主n竇緩、竇性靜止；竇緩、竇性靜止；n傳導(dǎo)阻滯：房內(nèi)、房室、室內(nèi)傳導(dǎo)阻滯：房內(nèi)、房室、室內(nèi)n交界區(qū)心動過速、交界區(qū)心動過速、 心室自主心律、心室自主心律、 室顫室顫 、心、心室停搏室停搏 高血鉀的高血鉀的ECG改動改動高鉀的處置高鉀的處置n糾正原發(fā)病及誘發(fā)要素糾正原發(fā)病及誘發(fā)要素n促進(jìn)鉀排泄促進(jìn)鉀排泄n輸液輸液+利尿利尿n促進(jìn)鉀轉(zhuǎn)移促進(jìn)鉀轉(zhuǎn)移n葡萄糖葡萄糖+胰島素胰島素n對抗嚴(yán)重心律失常對抗嚴(yán)重心律失常n鈣劑

3、鈣劑n透析透析低鉀血癥低鉀血癥-心電圖表現(xiàn)心電圖表現(xiàn)nU波增高波增高nT波振幅降低、平坦或倒置波振幅降低、平坦或倒置nST段下移段下移n各種心律失常：以快速性心律失常為主各種心律失常：以快速性心律失常為主n竇性心動過速竇性心動過速n早搏，尤其是室早早搏，尤其是室早n交界區(qū)心動過速、交界區(qū)心動過速、 室速、室速、 室顫室顫低血鉀時心電圖低血鉀時心電圖U波改動波改動n隨著血鉀降低，隨著血鉀降低，U波不斷增大波不斷增大 低鉀血癥低鉀血癥-治療治療n糾正病因及誘因糾正病因及誘因n攝入缺乏攝入缺乏n喪失過多喪失過多n分布異常分布異常n補(bǔ)鉀補(bǔ)鉀n靜脈靜脈n口服口服鎂離子異常鎂離子異常-低鎂血低鎂血0.75

4、mmol/L)緣由大致同低血鉀緣由大致同低血鉀攝入減少攝入減少營養(yǎng)不良營養(yǎng)不良消化系統(tǒng)疾病消化系統(tǒng)疾病吸收不良吸收不良排除添加排除添加腎臟疾病腎臟疾病排泄添加排泄添加其它其它利尿劑的運(yùn)用等利尿劑的運(yùn)用等鎂離子異常鎂離子異常-低鎂血低鎂血0.75mmol/L)n直接效應(yīng)直接效應(yīng)n對竇房結(jié)有直接變速效應(yīng)對竇房結(jié)有直接變速效應(yīng)n降低細(xì)胞內(nèi)鉀降低細(xì)胞內(nèi)鉀n鎂是激活鎂是激活Na+-K+-ATP酶酶n缺鎂缺鎂該酶活性下降該酶活性下降細(xì)胞內(nèi)缺鉀細(xì)胞內(nèi)缺鉀n添加細(xì)胞內(nèi)鈣添加細(xì)胞內(nèi)鈣n鎂為鈣離子拮抗劑鎂為鈣離子拮抗劑鎂離子異常鎂離子異常-低鎂血低鎂血0.75mmol/L)n鎂離子異常通常合并鉀離子異常鎂離子異常

5、通常合并鉀離子異常n低鉀血癥低鉀血癥低鎂血癥低鎂血癥鎂離子異常鎂離子異常-低鎂血低鎂血3.0mmol/L)n緣由：少見緣由：少見n甲狀旁腺機(jī)能亢進(jìn)、骨髓瘤或骨轉(zhuǎn)移瘤甲狀旁腺機(jī)能亢進(jìn)、骨髓瘤或骨轉(zhuǎn)移瘤n心電圖表現(xiàn)：心電圖表現(xiàn)：nST段縮短或消逝段縮短或消逝R波后即出現(xiàn)忽然上升波后即出現(xiàn)忽然上升的的T波波nQT間期縮短間期縮短n嚴(yán)重時嚴(yán)重時nPR延伸延伸n房室阻滯房室阻滯n早搏、心動過速等早搏、心動過速等 高鈣血癥高鈣血癥3.0mmol/L)治療：治療：重點(diǎn)是原發(fā)病重點(diǎn)是原發(fā)病骨髓瘤、甲旁亢等骨髓瘤、甲旁亢等常合并低血鉀常合并低血鉀低鈣血癥低鈣血癥1.75mmol/L)n緣由緣由n慢性腎臟疾病：腎

6、衰、腎小管酸中毒等慢性腎臟疾?。耗I衰、腎小管酸中毒等n甲狀旁腺機(jī)能降低甲狀旁腺機(jī)能降低n心電圖異常及機(jī)制：心電圖異常及機(jī)制：n主要影響動作電位主要影響動作電位2相：延伸相：延伸2相復(fù)極時間相復(fù)極時間n心電圖表現(xiàn)心電圖表現(xiàn)nST段平直延伸段平直延伸nQT延伸：由延伸：由ST段延伸所致段延伸所致T波不寬波不寬血鈣異常的血鈣異常的ECG改動改動低鈣血癥低鈣血癥1.75mmol/L)n治療：原發(fā)病治療：原發(fā)病n慢性腎臟疾?。耗I衰、腎小管酸中毒等慢性腎臟疾?。耗I衰、腎小管酸中毒等n甲狀旁腺機(jī)能降低甲狀旁腺機(jī)能降低n補(bǔ)鈣補(bǔ)鈣n當(dāng)運(yùn)用洋地黃類藥物時不宜同時用鈣鹽當(dāng)運(yùn)用洋地黃類藥物時不宜同時用鈣鹽電解質(zhì)對心電

7、及心律的影響電解質(zhì)對心電及心律的影響臨床特點(diǎn)1多數(shù)非單一電解質(zhì)紊亂如低鉀常伴隨低鎂常伴有酸堿失衡高鉀酸中毒低鉀堿中毒摻雜要素多本身疾病肝腎功能藥物電解質(zhì)對心電及心律的影響電解質(zhì)對心電及心律的影響臨床特點(diǎn)2以鉀離子對心肌細(xì)胞影響最明顯其次鈣離子鎂離子鈉離子電解質(zhì)紊亂所致心律失常電解質(zhì)紊亂所致心律失常心電圖案例分析心電圖案例分析Case 1:Which electrolyte problem is this tracing suggestive of?HyperkalemianHyperkalemianDiscussionnAs the tracing shows, this patient ha

8、s a regular rhythm at a rate of 101/min. The QRSs are very wide; wider than those seen with ordinary bundle branch block. T-waves are tall in V1-3. These findings are all characteristic of hyperkalemia. The serum potassium level was 7.2 mEq/L. The rhythm may be sinus with the P-waves hidden in the S

9、T segment or sino-ventricular rhythm if P-waves are truly not present. Atrial muscle is more sensitive to hyperkalemia than the specialized conduction system is. At certain levels of hyperkalemia, the atrial muscle becomes inexcitable (paralyzed) while the special internodal conduction system is sti

10、ll excitable. Then, the sinus impulses will conduct to the ventricles through the conduction system without the atria being depolarized thus referred to as sino-ventricular rhythm.尿毒癥高鉀尿毒癥高鉀-竇室傳導(dǎo)竇室傳導(dǎo)竇室傳導(dǎo)竇室傳導(dǎo)ECG表現(xiàn)：表現(xiàn)：1.p波消逝波消逝 2.QRS寬大畸形寬大畸形 3.T波高尖對稱波高尖對稱 4.ECG表現(xiàn)為表現(xiàn)為QRS-T序序列列CASE 2:Anteroseptal Infarc

11、t or Pseudoinfarction Pattern From Hyperkalemia?nWhich of the following conditions is responsible for the ST elevation in leads V1-2? Choose from the list below.nA) Acute anteroseptal infarctB) Pseudoinfarction pattern from hyperkalemiaPseudoinfarction pattern from hyperkalemianPseudoinfarction patt

12、ern from hyperkalemia is correct.Sinus tachycardia at a rate of 130 beats per minute is present. The ST segment is elevated in V1 and V2, raising the possibility of acute anteroseptal myocardial infarction. However, the T wave is very tall, narrow, pointed, and tented; and the QRS is wide, measuring

13、 140 msec.nThese findings are characteristic of hyperkalemia. It is well known that hyperkalemia can cause ST-segment elevation (pseudoinfarction pattern or dialyzable current of injury).nThis tracing is from a patient with a serum potassium level of 7.5 mEq/L during diabetic ketoacidosis, who also

14、is in renal failure and taking an angiotensin-converting enzyme inhibitorCASE 4Hypocalcemia and hyperkalemianHypocalcemia and hyperkalemia is correct.nDiscussionnThe QT interval is long. When the long QT interval is due to a long ST segment with a delayed onset of the T wave, it is specific for hypo

15、calcemia. Besides, the T waves are tall, narrow, and pointed and are highly suggestive of hyperkalemia. This combination of electrolyte problems is common in patients with chronic renal failure, which this patient has. The serum potassium level was 8.2 mEq/L and calcium 5.4 mg/dL at the time.CASE 5n

16、病史患者病史患者 女女 26歲歲n全身緊縮感全身緊縮感12年，延續(xù)抽搐發(fā)作年，延續(xù)抽搐發(fā)作n以以“癲癇收住神經(jīng)科多次癲癇收住神經(jīng)科多次n查體：神經(jīng)肌肉應(yīng)激性查體：神經(jīng)肌肉應(yīng)激性 n緊張、恐懼、反射亢進(jìn)緊張、恐懼、反射亢進(jìn)n“面神經(jīng)征面神經(jīng)征+n“束臂實(shí)驗(yàn)束臂實(shí)驗(yàn)+nECG：QT明顯延伸明顯延伸n疑心長疑心長QT綜合征收住心內(nèi)科綜合征收住心內(nèi)科QT/QTc:528/561化驗(yàn)檢查化驗(yàn)檢查n生化：生化：nURIC:109umol/L nCK:1056u/L nLD：564u/L nHBDH：299u/L nCA:1.09mmol/L nIP:2.27mmol/L n余無異常余無異常 nCK-MB

17、TnT正常正常n血清血清Mg:0.7mmol/L化驗(yàn)檢查化驗(yàn)檢查n血清血清PTH3ng/mln24小時尿小時尿nCa 1.708mmol (2.5-7.5)n尿尿IP23.884mmol (16-42)診斷：甲狀旁腺功能減低診斷：甲狀旁腺功能減低確診規(guī)范：確診規(guī)范：臨床表現(xiàn)臨床表現(xiàn)神經(jīng)肌肉應(yīng)激性增高神經(jīng)肌肉應(yīng)激性增高“面神經(jīng)征面神經(jīng)征+，“束臂實(shí)驗(yàn)束臂實(shí)驗(yàn)+ECGQT延伸由延伸由ST段平直延伸所致段平直延伸所致化驗(yàn)化驗(yàn)血鈣降低血鈣降低血磷升高血磷升高治療治療n補(bǔ)充鈣劑補(bǔ)充鈣劑n一周后臨床病癥明顯改善一周后臨床病癥明顯改善n二周后臨床病癥根本消逝二周后臨床病癥根本消逝n典型的體征消逝典型的體征消逝n心電圖恢復(fù)慢心電圖恢復(fù)慢此病例閱歷及教訓(xùn)此病例閱歷及教訓(xùn)n誤診誤治誤診誤治12年年n誤診為癲癇誤診為癲癇