永久性心脏起搏器手术指征

永久性心脏起搏器手术指征 一 永久性心脏起搏器(Permanent Pacemakers) 心脏起搏器适应证主要是缓慢性心律失常，特别是心动过缓引起头晕、黑矇、晕厥或晕厥先兆，和有以此诱发的充血性心力衰竭、慢频率依赖性心肌缺血等症状者。此外，虽暂时无明显症状但有缓慢性心律失常导致潜在危险者，也是起搏器治疗的适应证。 [适应证] 1(房室传导阻滞 具有三度房室传导阻滞和进展性二度房室传导阻滞。有心动过缓症状的二度房室传导阻滞型。 2(慢性双束支和三束支阻滞 现为间歇性三度房室传导阻滞。表现为二度?型房室传导阻滞。交替出现的束支传导阻滞。 3(急性心肌梗死 急性心肌梗死后的持续性二度房室传导阻滞伴随双侧束支传导阻滞，或三度房室传导阻滞。 4(窦房结功能不全 包括频发性窦性停搏。有症状的窦房结 有心动过缓症状的窦房结功能障碍， 变时性功能不全患者。 其他相对适应证为: (1)特发性窦房结功能障碍，或由于必需陛药物治疗导致了窦房结功能障碍，心率<40次,分。症状和心动过缓之间有明确的关系。 (2)不能解释的晕厥，但窦房结功能不全已确诊，或在电生理检查时可被诱发。 (3)血管迷走性晕厥 由颈动脉刺激引起的复发性晕厥。在无抑制窦房结和房室传导药物治疗的情况下，很轻的颈动脉窦压迫可导致心室停搏>3s者。 临时心脏起搏手术 临时心脏起搏手术主要适用于紧急需要心脏起搏，病情可能恢复的患者。 (1)急性下壁心肌梗死伴有: 三度或二度?型房室传导阻滞。三束支阻滞或新出现的双束支阻滞。交替性左、右束支阻滞。心动过缓伴有胸痛、气促、头晕、晕厥以及低血压等循环不良症状者。 (2)急性心肌炎伴二度?型以上房室传导阻滞者。 (3)药物中毒或电解质紊乱引起二度二型以上房室传导阻滞或严重窦性心动过缓，伴有晕厥先兆等症状者。 (4)心脏外科手术、冠状动脉造影等手术时预防性应用，或术后出现心动过缓时进行临时治疗。 (5)在需做永久心脏起搏器手术前或在更换永久性心脏起搏器的紧急情况下做过渡起搏。 (6)顽固性快速性心律失常的超速起搏抑制治疗。 [永久性心脏起搏器手术术前准备] 停用凝血药物。摄X线胸片，检查12导联体表心电图和出、凝血时间，必要时测凝血酶原时间等。与家属交代病情及术中、术后可能发生的情况，由家属在术前谈话记录上签字。永久性起搏器手术需剃去双侧前胸及腋下的毛发。临时起搏应剃去会阴部毛发。患者术前3小时禁食。 rAt present, we have formed a "three-three" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of the Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to optimize government service. Low efficiency of government services, departments do not coordinate the views of businesses large, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilities 二 心力衰竭(Heart failer) 心力衰竭，简称心衰，是指由于心脏排血量减少及/或不能将静脉回心血量充分排出，引起静脉回流受阻，导致静脉系统瘀血及动脉系统血液灌注不足所出现的心脏循环衰竭的症候群。几乎所有的心脏疾病最终都会导致心力衰竭。《心力衰竭可分急性心力衰竭和慢性心力衰竭. 一、慢性心力衰竭 [诊断要点] (一)左心衰竭的诊断 1、临床表现 (1)病史，有较长的心脏病史。 (2)症状:呼吸困难:包括缓进型劳力性呼吸困难、夜间阵发性呼吸困难和端坐呼吸。咳嗽、咳泡沫痰，在活动或夜间平卧时加重，甚至甚至咯粉红色泡沫样痰。 (3)体征:心脏方面体征:心脏增大，心率常增快，心尖区舒张期奔马律，肺动脉瓣区第2心音亢进。肺脏方面体征:两肺底湿性哕音或全肺湿性啰音，伴或不伴哮鸣音及干啰音;呼气及吸气均感困难。交替脉:部分病例可见。 2(特殊检查 胸部X线。超声心动图(心脏彩色DOP)。血流动力学检查:应用有创性或无创性方法测定肺毛细血管楔嵌压、心排血量和心脏指数。 (二)右心衰竭的诊断 1(临床表现 (1)病史:有心脏病史。 (2)症状:由于各脏器淤血、水肿，可出现各种胃肠道症状，以及肝区不适、黄疸、少尿、浮肿、体重增加等。 (3)体征; 心脏体征:右室舒张早期奔马律。全身表现:颈静脉充盈、怒张或搏动，肝脏肿大和压痛，肝颈静脉回流征阳性，下垂性水肿，胸水，腹水甚至心包积液。 2(特殊检查 颈静脉压>1(5kPa(15cmHzO)。 (三)诊断 根据临床表现，结合某些辅助检查，一般不难做出心力衰竭诊断，临床诊断除病因诊断、病理解剖和病理生理诊断外，还需对心功能进行分级。 [治疗] (一)、一般治疗 1(去除或缓解基本病因。 2(去除诱发因素。 3(改善生活方式如戒烟、戒酒、减重、低盐饮食等;必要时限制饮水量等。适当的运动:心衰重度者，可床边小坐，较轻心衰可选择每日多次步行，但避免用力的等长运动。 (二)药物治疗 1、利尿剂:速尿20 iv 2、β受体阻滞剂 倍他乐克6.26-12.5mg bid 3、洋地黄制剂 西地兰0.4mg iv 地戈辛0.125mg-0.25mg/日 二急性左心衰竭 rAt present, we have formed a "three-three" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of the Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to optimize government service. Low efficiency of government services, departments do not coordinate the views of businesses large, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilities [诊断要点] (一)临床表现 1(症状 急性肺水肿表现为突发呼吸困难，端坐呼吸，频繁咳嗽，咳粉红色泡沫样痰，烦躁大汗，面色青灰，口唇发绀。 2(体征 典型体征为双肺满布湿性哕音和哮鸣音，心尖部闻及舒张期奔马律，心率快，脉搏可呈交替脉，早期可有血压升高，严重者可出现心源性休克甚至心跳骤停。 (二)特殊检查 胸部X线检查常有心影扩大，肺淤血肺间质水肿或肺水肿征象。 [治疗] 急性左心衰所导致的急性肺水肿是一种严重急症，必须争分夺秒地进行抢救，具体急救如下: (一)一般治疗 1(体位 患者取坐位或半卧位，双腿下垂。 2(纠正缺氧 鼻导管或面罩法给氧(10,20ml,m纯氧吸入)，湿化瓶内加入乙醇或有机硅消泡剂。 (二)药物治疗 1(吗啡 静脉推注3,5mg于3min内推完。 2(快速利尿剂 呋塞米20mg静脉推注。 (血管扩张剂的使用 可选用硝普钠或硝酸甘油静脉滴注。硝普钠初始剂 3 量20,40ug,m，每5分钟增加5ug,m;硝酸甘油初始剂量5,l0ug,m，每3分钟增加5ug,m，直至肺水肿缓解或动脉收缩压降到13(3kPa(100mmHg)。如有低血压，宜与多巴胺或多巴酚丁胺合用。 4(洋地黄制剂 可用毛花苷丙首剂0(4mg溶于10,20ml葡萄糖液内缓慢静脉注射， 5(氨茶碱 0.25g溶于20,40ml葡萄糖液内静脉注射，l0min推完，继以0(5ug,(kg?h)维持。 6(其他药物 可选用肾上腺皮质激素如地塞米松10,20mg静脉注射，可解除支气管痉挛，减少渗出，有利于肺水肿的治疗。 此外，同时尚需确定病因和诱因并积极予以相应处理。 三 晕厥(Syncope) 又称昏厥。一种突然发生的短暂的意识丧失,同时伴有姿势性张力丧失。 分类: 、血管抑制性晕厥 1 2、心源性晕厥 3、脑源性晕厥 4、直立性低血压性晕厥 5、反射性晕厥 6、神经心源性晕厥 7、代谢性晕厥，低血糖等。 8、病因不明性晕厥 [诊断] 晕厥为一过性的疾病，绝大多数患者就医时并无晕厥发作，因此详细的病史rAt present, we have formed a "three-three" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of the Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to optimize government service. Low efficiency of government services, departments do not coordinate the views of businesses large, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilities 在晕厥的诊断中就显得尤为重要。就医时的体征也可为正确的诊断，特别是病因诊断提供重要依据;某些实验室检查和特殊检查对部分晕厥的病因诊断具有决定性的意义。 (一)临床表现 1(病史 详细询问晕厥在何种情况下发生，发作时的体位、持续时间，发作时的面色、血压和脉搏，是否伴有抽搐、跌伤、大小便失禁、舌咬伤，晕厥发生前后的表现，晕厥与用药的关系，既往有无类似发作史，有无家族史等。 2(体征 仔细的体检常能对晕厥及其病因诊断提供重要线索。如直立位血压较卧位低2(67kPa(20mmHg)以上，表明有直立性低血压;如果两上肢之间血压差大于2(67kPa(20mmHg)，提示锁骨下动脉窃血综合征;新出现的单侧股动脉搏动减弱或消失，或上下肢血压差大于2(67kPa(20mmHg)，提示主动脉夹层;颈动脉脉搏上升速度减慢，提示存在主动脉瓣狭窄，但随着年龄的增大和动脉粥样硬化，这一体征可变得不明显;按摩颈动脉窦有助于确定有否颈动脉窦过敏，但应注意不能两侧同时按压，按压一侧后应至少间隔15s以上再按压另一侧颈动脉窦;大炮波提示房室分离或明显三尖瓣关闭不全;心脏听诊可明确主动脉瓣狭窄、二尖瓣脱垂或狭窄、左房黏液瘤(舒张期隆隆样杂音随时间和体位而明显改变为其特点，借此可与二尖瓣狭窄相鉴别)、肥厚性梗阻型心肌病等，并可了解病人的心率及节律情况;注意患者呼吸的频度及深度有助于过度通气所致晕厥的诊断;上肢运动试验对锁骨下动脉窃血综合征的诊断价值极大。此外，应做作详细的神经系统检查，以确定有否导致晕厥的神经系统疾病。 (二)实验室检查 所有晕厥病人均应查血电解质、血糖、血细胞比容等，特别是在晕厥发作期间。 (三)特殊检查 所有晕厥病人均应接受12导联标准心电图和24h长程心电图检查。 1(心电图 人工心脏起搏器者应注意有否起搏或感知失灵。 2(超声检查 超声心动图能明确显示心脏结构异常，彩色多普勒可显示颈动脉和椎—基动脉的循环状况。 3(导管检查和造影 心导管检查和造影对心血管结构的异常有重要的诊断意义，而脑血管造影能明确颈动脉和椎—基动脉粥样硬化。电生理检查能显示室性和室上性心律失常以及起搏传导系统病变。 4(脑电图 对鉴别癫痼发作与晕厥有很大价值。 5(胸片 胸片对主动脉夹层的诊断有较大价值，CT扫描或磁共振检查能确定主动脉夹层的诊断。 根据突然发生的短暂的意识丧失、跌倒、血压改变等临床表现，晕厥的诊断并不困难，但其病因诊断却较困难。此外，尚需将晕厥与其他意识障碍性疾病加以鉴别。 [治疗] (一)急性期的治疗 1(检查气道是否通畅。 2(检查呼吸、脉搏、血压。 3(速查心电图。 4(采血测定血细胞比容、电解质 5(检查有无外伤。 rAt present, we have formed a "three-three" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of the Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to optimize government service. Low efficiency of government services, departments do not coordinate the views of businesses large, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilities 6(对晕厥的病因进行治疗:心脏骤停者应立即行心肺复苏术，尽快用药物、起搏器或电转复纠正心律失常;低血糖者立即静脉推注50,葡萄糖溶液60ml;血压低者静脉注射低分子右旋糖酐等。 7(脑循环中断时间较长者，应给予激素和脱水治疗，如地塞米松lorn!静脉推注，甘露醇125—250ml静脉推注或快速滴注。 8(密切观察尿量和肾功能。 四 休克(Shock) 一种由于有效循环血量锐减、全身微循环障碍引起重要生命器官(脑、心、肺、肾、肝)严重缺血、缺氧的综合征。 [诊断要点] (一)临床表现 1(病史 对休克病人应首先进行处理，特别是呼吸和循环方面的紧急处理。处理的同时，尽快地收集病史，注意询问既往血压水平，有无心脏病、艾迪生病、黏液水肿病史，有无胸痛、气短、心悸发作史，有无引起低血容量的其他病因，近期有无外伤、烧伤或感染史，是否服用负性肌力药物、血管扩张剂和利尿剂。在老人和儿童，应特别注意不显性失水而未及时补充水分造成的血容量不足。 2(体征 休克的体征因病理阶段和病因的不同而有很大差异。 (1)休克早期:可无明显临床表现，或仅有焦虑、心悸。由于代偿的结果，此期血压正常或稍偏低，额部多有冷汗，尿量有所减少。 (2)休克期:此期可见患者面色苍白、表情淡漠、血压下降、四肢湿冷、脉搏细速、尿量明显减少等，有人称此种病人为“冷休克”。部分病人呈所谓“温休克”的临床经过，除无四肢湿冷外，其他临床表现同“冷休克”。 )休克晚期:嗜睡或昏迷、面色青灰、发绀明显、皮肤呈花纹状、脉细难 (3 以摸清、血压很低甚至测不出、呼吸困难、尿闭，伴DIC者可有皮肤、黏膜、呼吸道、消化道、泌尿道等多器官多脏器出血。 (二)实验室检查 休克早期实验室检查一般无特殊，休克期主要是尿比重增高，尿量减少，血液可呈高凝状态。晚期因凝血因子的消耗和酸中毒，可有血气异常和凝血因子的显著降低、凝血障碍等实验室检查异常。应注意原发病的实验室检查，如休克型肺炎时的胸片和血象，急性心肌梗死时的心电图和心肌酶谱，中毒性菌痢时的大便常规等对休克的病因诊断有决定性的意义。 根据血压和休克的其他临床表现，结合病史，诊断不难。 [治疗] (一)一般治疗 (二)纠正低血容量 任何休克均存在血容量的绝对或相对不足，故补充血容量是关键和首要措施。 (三)血管活性药物的使用 1(儿茶酚胺类药物 (1)多巴胺:多巴胺的使用剂量范围很大，一般用中等剂量2,10ug/(kg?min)，特别适用于心功能不全伴休克患者。 (2)阿拉明(间羟胺)常在单用多巴胺效果不理想时加用。 (3)多巴酚丁胺:用于心功能不全患者，休克明显时常与多巴胺合用，常rAt present, we have formed a "three-three" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of the Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to optimize government service. Low efficiency of government services, departments do not coordinate the views of businesses large, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilities 用剂量为2.5~10μg/(kg?min) 。 2、血管扩张剂 (1)硝普钠:在心功能不全或急性心肌梗死合并休克时常与多巴酚丁胺或多巴胺合用。 (2)硝酸甘油:适用于PWP增高而动脉压正常或轻度降低的低心排出量性休克或(和)心功能不全患者。 (3)酚妥拉明:如需同时扩张静脉血管，与硝酸甘油合用，可收到类似硝普钠的均衡扩张动、静脉的作用。 脑水肿的防治 急性肾功能不全的防治 主动脉内气囊反搏(IABP): 在心源性休克的病人，特别是AMI引起的心源性休克的病人，IABP可收到良好的治疗效果。 病因治疗 激素的应用 五 经食管心房调搏术(Transesophageal atrial pacing) 经食管心房调搏术是一项非创伤性心脏电生理检查技术。通过发出程序刺激来测定心脏窦房结及窦房传导功能、房室传导功能，明确心律失常的发生机理及诊断，以指导进一步治疗，如心脏电消融术、抗心律失常药物疗效的判定及调整。终止室上速发作及通过超速负荷试验诊断冠心病。 一、窦房结功能测定 [适应证] (用于窦性心动过缓或窦房阻滞及窦房停搏患者，以明确临床症状(胸闷、 1 晕厥等)和窦房结功能的关系。 2(用于病态窦房结综合征的诊断和鉴别诊断。 3(用于需要安装起搏器的患者，了解房室传导情况，以确定安装起搏器类型。 [窦房结功能测定参数] (一)窦房结恢复时间(SNRT) 结果判断 正常值为<1600ms，如>2000ms具有肯定性诊断意义。少数病人继发性抑制现象也具有诊断价值。 (二)窦房传导时间(SACT) 结果判断 SACT正常值<120ms，如>200ms为明显延长，SACT对窦房结功能判断的价值不如SNRT。 二、阵发性室上性心动过速 适应证:通过不同刺激方式诱发室上速以初步判断室上性心动过速(SVT)的类型。对预激旁路(包括隐匿性旁路)初步定位。 三、食管心房起搏的其他应用 宽QRS心动过速的鉴别诊断，抗心律失常药物的，食管心室起搏，心脏负荷试验 rAt present, we have formed a "three-three" Park. …… Industrial Park, according to ... ... The instructions of comrade, focus on development needs in the next decade, based on the original, and then extended the 6 square kilometers. Of the Park, to further improve the roads, power supply, communications, water supply and drainage and sewage pipe network and other infrastructure, to achieve full coverage of infrastructure and interconnection with the facilities and raise capacity. Each park to determine 1 leading industries, in particular stone Materials, cans, gloves, through guided, force and other measures to promote the "road company" Park, industrial agglomeration. Currently, to focus on building better ... ... Industrial Park, ... ... Wood Park as the starting area of the industrial park, planners need to take out plan, start construction as soon as possible, undertake in a timely manner ... ... Transfer of the wood industry. This opportunity slip by, so the timing must be tight. Second is to optimize government service. Low efficiency of government services, departments do not coordinate the views of businesses large, poor business environment, it is ... ... Short Board, decide to change. We will continue to deepen reform of the administrative examination and approval system, good digestion, implement the Government canceled, adjustment and devolution of administrative examination and approval matters, strengthen the existing supervision in matters of administrative power, has made it clear to cancel, are not allowed to keep or disguised approval. To do list list of administrative powers and responsibilities