1. Lecturer: Prof.Rustamova M.T.
Differential diagnosis of arrhythmias. Clinical and ECG diagnosis. The principles of treatment and emergency care
Lecturer: Prof.Rustamova M.T.

2. Arrhythmias can occur in lesions of the heart and without it;
In the first case, they are more serious

3. Common causes of arrhythmias
1. Diseases of cardiovascular system (congenital, acquired)
2. Dysregulation at CVS noncardia pathological processes
-with the defeat of the gastrointestinal tract (GSD, diaphragmatic hernia)
-with the defeat of the CNS
-with endocrine diseases

4. 3. The physical and chemical influence
-Increased sensitivity to caffeine, nicotine, alcohol
    -hypoxia;
    -hypo-and hyperthermia;
    -injury, vibration
    -drug-effects;
    -ionizing radiation.
4.Idiopatiс rhythm disorders

5. Electro pathophysiological mechanisms of cardiac arrhythmias
1. Disturbance mechanisms of formation impulses
-violation of sinus node of automatism and latent centers of automatism
-formation of abnormal of automatism
-oscillatory mechanisms or start (trigger) activity

6. 2. Violation conduction of impulses
-elongation refractivity and damped (decremented) holding in the cardiac conduction system
-anatomical damage to the conduction system of the heart
-phenomenon re-entry
3. The combined mechanisms of formation and conduction of impulses

7. Clinical Electrocardiographic Classification of Arrhythmia

8. Normal sinus rhythm

9. Sinus bradycardia Right rhythm HR <60 in 1 minute Sinus P wave
The interval PQ - 0,12 sec.

10. Sinus bradycardia

11. Treatment
Carried out if it is proven that it causes angina, hypotension, syncope, heart failure, ventricular arrhythmias!
Atropine mg / in
Isoprenaline g / min. in /
ECS (atrial), in the absence of AV block.

12. The migration of the pacemaker
Right or wrong rhythm
HR <100 in 1 min.
Sinus and teeth nonsinus P
  PQ The interval varies and can be <0.12

13. The migration of the pacemaker

14. Sinus tachycardia Right rhythm
Normal sinus P wave configuration of (their amplitude is increasing on)
HR in 1 min., Young - up to 200 in 1 min.
Gradual onset and termination

15. Sinus tachycardia

16. Treatment Needed treatment basic disease
If tachycardia is in itself an pathogenetic factor (eg, stenocardia, myocardial infarction)
prescribed beta-blockers

17. Sick sinus syndrome
Sick sinus syndrome - a term coined by Lown (1966) to denote the aggregate signs, symptoms and electrocardiographic changes that define the sinus node dysfunction in clinical-cal conditions.

18. Sick sinus syndrome The syndrome is characterized by fainting or
other forms of cerebral dysfunction,
accompanied by:
sinus bradycardia,
stopping the sinus node (sinus arrest)
sinoatrial block, alternating bradyarrhythmias and tachyarrhythmias (syndrome tachybradii)
For determining tactics of treatment necessary
differential diagnosis:
between sinus syndrome and
autonomic dysfunction of the sinus node.

19. Sick sinus syndrome
The main criterion for differentiation is the result of the test with atropine.
The patient was given intravenously (or subcutaneous), a solution of atropine sulfate at a dose of mg / kg body weight of the patient.
Increase in heart rate after the administration of atropine, and the disappearance of clinical symptoms favor autonomic sinus node dysfunction.
Treatment of sick sinus syndrome SOS toit in pacemaker implantation.

20. Atrial Extrasystoles
Extraordinary non sinus teeth P, followed by a normal or aberrant QRS complex
Interval PQ - 0,12 - 0,20 sec.
Compensatory pause is usually incomplete (The interval between the pre-and post extrasystoles P wave less than twice the normal range PP).
Causes: There are healthy people with fatigue, stress, smoking, caffeine, and under the influence of alcohol, with organic heart disease, pulmonary heart.

21. Atrial Extrasystoles

22. AV nodal extrasystole
An extraordinary QRS complex with retrograde (negative in II, III, aVF) tooth P, which may be registered before or after the QRS complex or layered on it, common form of the QRS complex, with aberrant conduct can resemble ventricular beat. Compensatory pause may be complete or incomplete

24. Ventricular extrasystoles
An extraordinary, wide (> 0.12s) and deformed Bathrooms complex QRS,
ST segment and T teeth discordant complexes QRS,
teeth P may not be related to the beats (AV dissociation) or be negative and follow complex QRS (retrograde teeth P).
Full compensatory pause (the interval between the pre-and postextrasystolic wave P is equal to twice the normal interval PP).

25. Ventricular extrasystoles

26. Treatment
In most cases, specific antiarrhythmic therapy for arrhythmia is required.
Prognostically the most unfavorable ventricular extrasystoles for high grade B. Lown - Class 2 and up.
Preventative Treatment ventricular arrhythmia high grade appropriate treatment of ventricular tachycardia.

27. Diagnosis of tachyarrhythmias
When atrial tachyarrhythmia always identify the activity and the relationship between P wave and QRS complexes
The diagnosis can help you:
Twice the voltage of the ECG and increase the speed of roll of 50 mm / s help to identify the P wave

28. Atrial fibrillation rhythm "wrong incorrect." absence of teeth P,
irregular large-scale oscillations or small the wave isolines
the frequency of atrial waves min
untreated ventricular rate to -180 min.
electrical alternans (different height complexes QRS)

29. Atrial fibrillation

30. ECG criteria of Atrial flutter.
F saw tooth waveform wave with a frequency of in 1 min
F waves into one another without the isoelectric line in II, III, AVF absence of P wave
QRS complex is not changed
CHSZH usually about 150 in 1 min
Distinguish the regular and irregular form of TP

31. Diagnosis
When the AV conducting 1:1 ventricular rate may reach 300 min-1, in this case because conducting possible aberrant expansion of the complex QRS.
ECG as in ventricular tachycardia;
Observed when using class Ia antiarrhythmic drugs without simultaneous administration of AV-blockers,
WPW syndrome

33. Electro pulse therapy. Used for:
-Flutter, ventricular fibrillation
-Ventricular paroxysmal tachycardia, especially in patients with acute myocardial infarction Atrial flutter, 1:1
-Supraventricular paroxysmal tachycardia, atrial fibrillation tachiaritmias with hemodynamic deterioration (if ineffective AARP or having H / V)
-Constant atrial fibrillation after mitral commissurotomy, if AI is not more than 3 years

34. Ventricular fibrillation
Chaotic abnormal rhythm, QRS complexes and T waves are absent.

36. Wolff-Parkinson-White (WPW)
-Preexcitation syndrome
-Wave excitation is conducted from the atria to the ventricles by additional sheaf of Kent
On ECG:
-delta wave
-P-Q shortening of less 0.12sek
-extension of the QRS complex more 0.11 seconds

38. Sinoatrial block. Prolongation of the interval PP multiple of normal.
Reason: Some drugs (cardiac glycosides, quinidine, procainamide),
Hyperkalemia,
Sinus node dysfunction,
Myocardial infarction,
Increase of parasympathetic tone.
Sometimes marked the Wenckebach period (the gradual shortening of the interval PP up to the next cycle of fall).

40. AV block 1 degree. The interval PQ> 0,20 s.
To each tooth corresponds to complex P QRS.
The reasons:
observed in healthy individuals, athletes,
with an increase in parasympathetic tone,
taking certain drugs (cardiac glycosides, quinidine, procainamide, propranolol, verapamil)
rheumatic fever,
myocarditis,
congenital heart disease (atrial septal defect, patent ductus arteriosus).

41. Diagnosis
With narrow QRS complexes, the most probable level of the blockade - AV node.
If the QRS complexes are wide, a violation conducting is possible both in the AV node, well as in bundle of His.

43. AV block grade 2 Mobitts type I (with the Wenckebach period).
Increasing PQ prolongation up to falling complex QRS.
Causes: observed in healthy individuals,
athletes
When taking certain drugs (cardiac glycosides, beta-blockers, calcium channel blockers, clonidine, methyldopa, flecainide, encainide, propafenone and lithium)
At a myocardial infarction (especially the lower), rheumatic fever, myocarditis.

44. Diagnosis
With narrow QRS complexes, the most probable level of the blockade - AV node.
If the QRS complexes are wide, a violation of impulse conduction is possible in the AV node, well as in bundle of His.

46. AV block grade 2 Mobitts type II (with the Wenckebach period).
Periodic falling complexes QRS.
PQ intervals are the same.
The reasons: organic heart disease.
The delay the momentum going in the bundle of His.

48. Complete AV block.
The atria and ventricles are excited by independently of each other.
The frequency of atrial than ventricular.
Regular intervals and PP regular intervals RR, PQ intervals vary.

50. Paroxysmal supraventricular tachycardia
heart rate
P wave is inverted and sharpened in leads II, III, aVF
Sharply replaced by sinus rhythm
Maybe healthy and WPW
Tactics: The stimulation of the vagus nerve, and if there is no effect: adenosine, verapamil, beta-blockers, the drug group IA, cardioversion (150 J)

51. AV nodal PT QRS identical P is sometimes absent, can be a two-phase
R-R sharply reduced

52. Ventricular PT
Usually - the right rhythm with a frequency of min-1.
Complex QRS> 0,12 s, typically> 0.14 s.
ST segment and T teeth discordant complex QRS.

54. Restoration of sinus rhythm (phased approach):
1) vagotropic techniques (Valsalva maneuver, carotid sinus massage);
2) adenosine, verapamil or diltiazem. In heart failure, instead of calcium antagonists are introduced digoxin;
3) procainamide or propafenone.

55. Prevention of paroxysms:
1) sparse, short paroxysms occur without hemodynamic: only vagotropic techniques. Otherwise - catheter destruction or chronic administration conducting AV-blockers;
2) the ineffectiveness conducting AV-blocker class of drugs added Ia or Ic.

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