เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care

2.46 rrtdrfninqardugru

lrregular narrow QRS complex tachycardia

1. Atrial fibrillation

rflunlxy arrhythmia fir,ruld:jou'lu'lofig''" {:ollrn sinus tachycardia) dnBruJ EKG
lvfi irregular QRS complex lerurtx'hl ons complex o:fin-nuruvuflud'r ttnl 6:Jd s1 lnriuiu

n:diifi ounote branch block aqjral r,riorflu rate dependent bundle branch block uonq'lnfl

{:-lrurr.r:ruortfi accessory pathway o'lclil'hi*r'n-nuruvtflu wide QRS complex lfi

{rJraiifi aviat fibritlation arcdosrntfitfinHatfiurda:: ul oliElulnfisrld1nulailrvlu

{rhufrfid'n:rnr:rdurlo'tf'rle t5r rnarod'rHa}i stroke volume ae'a.r1d uonoT nd{rhudfirur6-

RnTlnoefirh niu {rhufifi systolic LV dysJunction, hypertrophic cardiomyopathy, aortic stenosis,

chronic hypertension (eufi left ventricular hypertrophy) nr:tfio AF d'rnrnlfirfioolnoa'l{ lvld

fioua.rrdo,rqrn diastolic time fitun,: lla;flre' alrial contraction dr'lfifinrrilduTnfinsilLLn;

irrnl6ooluaoanqrnfi r'tttul1dtu1fi (cardiac output. Co) aqa.l'ld

qr:airuirnr:fnur {:h u nr lulofi grfunt:fi tr nfi r d n fn r :lrln ri uu lfi ao un sl YUY

norfi rfi n nr rfl urarind'.rd

t.t fl:Jruiirdtrfin Ar nrulurrnrlilrfiu 48 s'xlil'i

fi.r'ldnairrdr.:fiu fiLhs!r,r:'rufrfi Ap d{Hn tfiudornorofiSnrr'lvn riuulfiaer fns lar,Jr:

adrrEi,rll{rhaiifin'nritmuto.t left ventricle finilnfi vY.rtfio systolic dysfunction ua: diastolic

dysfunction tu r,ts!:,l{r nr't:nrrt.lfio n6to,tlnaroflSnr:Ivnrfiofi ttiu nll:6onernnr:nrn

cr:riruSorfiao tro:nrr;6anttnnr:n'ordalutt:.r orldtrunttir;uttl::erl6ulrtuGnltrlruurn

du nrrctrnoon6nulu16oo nrtrfiorJn6ao'rqnn:nrdr.tttn: tnda ttd un;nm:ri'rvirrr.Joo (pulmo-
nary edema) nrxJen. \:"i lun,JruRur:nn::{u1firfin nr ldrdurYu o-.rr?unr:inur nr tufl:Jrufio{

lulofig nr:binrrinuralrqfrrflld'rn::{u'hirfio nr du nrnlrjnl-ralttlqlra{ AF vialfinr:innr

nrilorrfiqufidli6du rT'rntfierrrln"ulnfinntr nr:1va liuuTnfirrlrirfiu,olrafiornr:lSuttironv?a

rirrirlr.lan nr:ficr:rurrir electrical cardioversion rfrarrJduu nr lfinailulflu sinus rhythm

In EJ railr; fi ilrfl fi rfi.: ufi o AF rrnr slunorlri urfi +a rirTr'r

drv:"u{r-hudfi nrr:nr:'lrnnriuulofi n! n6 uo: tfi n nr mnr utunarlrj rfi u qs drlu,:
ororior':rur}i medical cardioversion6 drusr dofetlide, flecainide, propafenone, ibutilide fiia

amiodarone rrsinr, vdnrdu,rnr:'lfisr flecainide, propafenone u6o ibutilide rrri{ilrufifi structural

heart disease fnuror'ry LV dysfunction uiaoreritr:rur'hin, :inurtfiuttfiontu4ra"nlnr:fl
or-rro.rr4'r'lc'lri1fir5T rfiul:i lounr:'tfiurtunqjr ueta-otockers rtiu meloprolol ttfl; propranolol

u6on non-dihydropyridine calcium channel blocker ldttri verapamil rnia dittiazem fi-ld

1.2 {rJrufifin,rt AF oijtdtJ (persistence AF) x50fi AF dn'!fi'! sinus rhythm

(paroxysmal AF)

firjrudlilldfi n'ruft n n6ro.:::u vo tiuulnfi ns ;tfi o AF 1iln?rldiunr::"nurtfi o

EKG: Cardiac Arrhydrrnias ain$ nand 247
ulduu AF'lfindljlflu sinus rhythm !fio{e']nom rnnnlx;rlflrndoueln thromboembolism ld a,l
axrt?inr:fnrl rfioffxrrn o'n:'ln1:rfiuflo.Jl4'xiolilhir5x rfiull lvitfu nrnfi:-hufinrtrri'uTafinsr:r
t5ofinrtrfto:Jnfirar:vu rnrluudu rdu fiorn'r: 16r uriuvriron niorirviu:loo arrficr:ru'r
rrRrmn6ul firiahirfinnrufinlnfin".rnnim ua:tfinr:fnurficlnqriu rfio.,rern1un:finiuii nr
fi1drfl uotnqvdntalnrrtlfi o, n6rar:ru rn rluulofi ndtn6ill

71fi s uan,t inegurar naffow QRs comptex tachycardia lu{tLtaiifi atiar fibilation with rapid

tventricular response #tnnitfr nrrotfi Sr-""grn"n etevation lu bads ll, Ill, aVF ixtJiu

reciprocat SI segment depless/on lu leads aVL, V,. V"

2. Mutlifocal atrial tachycardia (MAT)
{d'lan{rudo:fi0'omrnr:rfiulo.rfir'lcr5tnjr too ni.lsiaurfi Iosti.ror:rolrl p wave Id

fi.,r ufiira"or:rnr:rduro'lrirloe :lriorirra:rofinrll n"rdrfra.rorn p wave d'rnrirrfiritfinornrdariia
torrorsris luel'ruyrj.lri, .:niu nr:n:roer6ulvJflrri'rh6,rru e wave dfi;rJir.: rurer uo: fidyr.t

:rrlfr'rfi pn intervar sirrfiuunn'ir s rll,rfl*ulil lourfrb ons comorex frnrrrrn-nfin-nuruv lflu
eRS rl"xuol1 unriulufirhldii BBB dx dxu

v{:L MAT'ldiloulu{ilrrfrfinT ufinr.lnfiralrJoo Tcuranrtl:nq.onr.r1rl.:r,rolr!fliudaad
aonun0t{ (chronic obstructive pulmonary disease, COPD)

rrninur: lfio,ternn'trvdfi'ldriaturnno'usr:ruiruu:.tLrrifirhfl uaylri6i,rilarfiariounnronj
nrrlvnriflur6oer or"triunr:inurdtfidrutudl'r rflunrrinurl:nlrionrrcfinitrirfio tachycaroia r.r&u

248 rrtlhrioinqnfrugru

Wide QRS complex tachycardia
nrlr:nttriltflu regular rhythm lto! inegular rhytnm d'td

Regular wide QRS complex tachycardia

fio'lr{rhlfi wide QRS complex tfio QRS complex nir',,:njr tz0 findiurfi (3 do'':l6n)

6?1 fto nfiflo.I Eco dnuruvddru'lvd tfinlrn ventricular tachycardia ryI odr.ilrffmu'l"rrflu

fi o.rifi l{u uunl:n?1nnrr:oialild
1.1 Supraventricular tachycardia with pre-exisling bundle branch Utocf d+rduflr-hufifi

BBB Dglfiilrdxrno Psw du

1,2 Rate dependent bundle branch block fion1rd{dxutfionrr; bundle branch block
duriaa'n:rnrlduto.,rrir'lc rirn*u Toudru'lnr!u-nriu right BBB

1.3 Aberrant conduction f, xua'lafi bypass tract o{ (Wolff-Parkinson-White syndrome)
rdotfin tachycardia uruarfru bypass tract fJurduvn.:rirn::uolvlflrorn atrium nt{ ventricle

t cdaldu AV noce rilurr,:'hin:;rrob'{flrtiaudul qi atrium

Ventricular tachycardia (Vf)

eiru'hclr;rr w'lu{:-hufifinmc acute lvll loutanr;nrulu z+-+e frTil'ttt:nflia rnflfi
myocardial infarction lrriau vt'rlfifi myocardial scar rfiodurta:lfluor ruqdrir'hitfio re-entry

circuit tununirfio wo'ravu.r lu{rJrtfrfinrr; dilated cardiomyopathy n5o{ilrudfinm; lv
systotic dysfunction ornartuqdul ld drviu{rJrafiaqflula6g nr:iin,'r: severe hypoxemia

nl':tfio severe metabolic acidosis Ltn;n't't fio:.Jn6lo'rolqnn:orir.flnl tonrdvr rrflf,tfifl llso

whypokalemia rff: hyperkalemla r,t!'jrfinflufftJr{u6'rYlnr:rfio u"n"rnd4ilrudtd5lsr

antiarrhythmic drug type l, digoxin, urn::{unrrijuor"rrta.:rir'hlnutaurv dopamine nio adrenaline

r;ld nrr rdu{de;rfier w1d'
nr:$ursr 'lfinr:ifiodu'Jr{ilr1fi w ria'lri uanmnorrlutJ:;i6:ral{rhlo"':ndrrdrlfiu

rufi'l fi$idrfi'cpFo nr:fiqr:rurn?rrfio nfirat QRS complex ornnfiulliflrrirlq d'nuruvrirtl d':

'fiRruhun:neruirrnlvsir.{riul cirrtit-rrrnnrrl.rda:ootct utYrnoun'trfierrrurnduldffrnr'lq

'irr{rldrir w r.rio'lri d',rd
1. filr:rurnmrn{rwo.l QRs complex lntJ1nlfiunir t4o fiaiiurfi oriloquirrflu

VT

z. fidlnuru;rsr RS complex'tu precordial leads (v1 fi.'r vu1 n5o'hi fitrru'jrfirfiu.l QR

n6o QS wave orjr.:toodrtvdo'lu v, fi': vu riro:rflu w

3. ?rurelnlnd so\t R wave qufi{1ora'rqnto.r S wave tu precordial leads dunir,,rn'jr

too fiofiiurfi lflrldn-r w rYodrfiooernlun..c eea duludr'lrtrnflo.t QRS complex fltr!!f,

EKG: Cardiirc Arrhr,thmias f,ini nanai 249

'lvlflrti'rati,:mrr bundre branch firlnfirhtftrjdrmo.r eRS hd.r,r uingnd'1uiln6 0rau) LLeidlfif!

w rfun:;ua}4flr'lrild5wrl bundte branch d'.rriu ons i.,rnir.,rsYiusi6r,du
4. nlfll1 capture beats llnc/ fiio fusion beats iir:-i,llonnr.ldol.jrrfinfinrr; A_v

dissociation du najrr6o capture beats {lt,rfi::Jdre rvfiou eRS comprex rJnfi 1o-rucrul lfiorern p

wave dr l?ndlu AV node n\:!1n1 His-purkinje system un;n::dur?unir6n1dorililn6'ludr,l

d,,:rryfirurr:crl1ru:rfin Vr dlu fusion beats ?:firu1n eRS comptex a!i::rn.ir.: ORS JnfinTll
QRS d'?nil.J tfine1n ventricle :Jr{drunnn:cdudrun?srrfildfltdillc1n atrium r.i1u AV node Rn
qf rruer616a lurrurdrr,odrunnn:;6uernrruni16nla{,b*,rfirn un-nuru;r".rnorn"tnairrdrj.,ruan'jr

rflu w

5. ficr:rura"nsnrrra\r eFS complex'lu tead v, firfifinlr.:rfiulrn 6unir right bundle

branch type W fllflualrian'j'l teft bundte branch type W itt,tnt{oa{rfincvfi;rJdr,:n'trotn

lypical bundle branch btock aajr.,trfiulddo o-{nr:r,jfr 1

nrmrfi 1 uneln-nu yflo,i QeRRS comoplex vfiro'afriio:jourulunrr::ifi,i rii'u ventricular tachycardia

:,'. 'a- R/S <1
\ri'' ^,j i ,.,
Mono phastic i/\ \ QSoTQR - V

QRoTRS-. jri .._

,/,]/\\n

rflpnasltc -

F >30 msec

R >30 msec !r Ti'iil.'!\:,1t ' - , notched s

i

i I
> 60 msec to nadir S I

S tnotched

> 60 msec I
I
Snadir

250 rTtdrrininqorCrgru

druir tachycardla fifiri'nuru:ndra RBBB fi1n u QBS complex 'lu v, fidntcu:rflu
monophasic. QR, RS fiio triphasic fifi R wave nir,tn'jr r atjr.fleoEjr{vd.: :'rlfillu v6 vlu FV

s <1, Qs nia oR adrttood'r'tvd.r d1?:'hln'l:irilsi'u'irrflu w

dru tachycardia dfi QRS comptex ndTU Leee nrnnl'jr'lu Vl fi R wave n{ron'jr 30

fiafiiurfi ria::urlrnlotilr B wave frl1nn'rqmo.! s wave nir',:nir 60 fiodiurfi uiofi notcn
'lu s wave nialu QR vio as lu vu odr,tloodronfi,l arrr:n1finr:if,ldu'jrriiu w'[d

rnrirn: rim:rurnr vrnerceinr:l orirur6oarflun{nrnnnl'j'rndrivn:'hildi (pulseless
vf1 tfinr:fnurornr:tvfiou ventricular fibrillation grl ACLS guideline fl n.o, zoto lounrrrir
defibriffation (120-2Oo.t dlnf'u bipnasic defibrillator) iufiunr: CpR rirnfiurdarcnnnr:tfin

w',irlnulaur:1uf, xfldfi LV systolic dysfunction fiqr:mtfionld amiodarone 1u'lo 150 finAniil

nrnnoaorfronqh rnn.rornriulfiurluro t finfiniloiourfi ris6nrflurrnr o tirl .: nrl.rfiT uulturo

o.s fiahniusiaurfi 6n t e t'dr':riorr vioarcld lidocaine 0.5-0,75 finAnitJdorirrrinoi'T ndt

filnnir6qrr.rvnseriiaon'r dadruurtulo 1 -4 ft ni nitoiaurfi

lrregular wide QRS complex tachycardia
nrrlfiorlnfi'lun{ldl:w:L QRS comptex fi'rn{r,,rrrnl; iNttnndr.'tnli a'lorflu ventricular

fibriltation filrilfiufi'nurul ORS complex dnnu tlio polymorphic ventricular tachycardia ta':
diorctfiudn fu: QRS complex dtriunsjl polymorphic w. riunr:fie, rrur QT interval rd.:rir

cardioversion ouflo'ttlrtflu narrow QRS complex ttdlirorrn'jr:Jnfinio'lrj vrnvil.l'jr OT interval
urr nm}inr:inurtt'ultdurril Torsades de pointes

firhs ventrlcular fjbrillation nrrldfunr:li, CPR 6'ttJ ACLS guideline lnunrr'lfi d"i'*lialfuy
tta;tiru?nu'hir ri::nh chest compression rrn: delibrillation (120-200 J
management

biphasic defibrillator) rnti,i'hifl'r rrnl:Jduulfinfl':JtJrrflu sinus rhythm'ld fim:rurtfi epinephrine

1 6nvn,,:rnonrfiandruia vasopressin 40 Hfin dorr.ornon tfionrir rrnti, ridtr:o maintain
sinus rhythm ldorctfi amiooarone qt-l'ra soo finfni ltia lidocane o.s-o.zs finfinirldari'r

nrind'rufi.rfilnniuisyn.rraonrfioon'r unc'l'riurrt,rfioon tdaoriadrulurndtduotNli'tilnr:inur

pulseless W

Bradycardia

lnun-rlJda'lr{rJrafinrr;u''illrdudtdafio'n:rnr:tfiutorr.rrtoriaun'h oo nfioiourfi nrr:

dorqrfierdu'lunu:ln6dfinr:d'r,r'ruao{rv!:J rvf,1rlr1:rirlrrtnfin loiu Tnu ranr:tuu{rinfrrar
usofidoonrirn"rnrurfuJ:;oh Saarlrfisornn'r:ldiuurur,,:tfin ttiu beta-blocker ttlo calcium
channel blocker 16rrri Oittiatam Ltflc verapamil uonalndnl'lJfifinrrlfiot!nfito':':rl!Yl1{t6u
nrru6 vlflTlu'lurirtcq'rnlrurianlrdrrl lostour:nrr:ndrilrdort'r'lcmnrdao fiorodoarnlfi
rfio bradycaroia duld

I.IKG: CarcLiac ArrhyrhnrJas sin{ nlnad 251

drnir-r::ruvn'rr6unrvrrfllvJfl1n1u'lufrlo lcardiac conduction system) fltrinflLdxu

sinus node (AV node), His bundre rtnv His-purkinje system 6,:ttri,:rflu reft lrfl: right bundre

branches iunudrrtmqj sA node ocl6i:J 16ao:rrrdu,rernrdrrfioFrr!o,r1nT:uridruttriaua; ss

:o.rotrr-lduri circumflex coronary artery ?!rJ.truioun; ss neildrrfiol::lrruioso: to ld

rlulfraoqrnrdur6oovi'raorrdu dru AV node rfurr.ofi"roqjvrrrdrufifll?0,J interatriar seprum Infl

arjlvfia*n;rrjrrn'o coronary sinus drvfi AV node dq;ldi! rn'oocrnurutrouraaolfian un.r

lnT:ur56'rulrr Sauoy 85 rru:fi5ounv i 5 ldf:Jrfi oneln circumflex coronary artery'lunrr:
rlnF nv noce do;iunr:n:;{urrn sA node rfiocvdrnT :d.lsion::uolvJfirnjruor}Jrj,: His bundre

rrfl: His-Purkinje system rdolJ ror AV node fiqrunlf6ddrd'rp6onrrufirurruro,rnr: r

n:;uolr{flrrvrfjldurfroldfrlnr:n:rr{urioudu4ruor:j6o-eneiTrdfin?r*:qirfluaEjr{€j,rlnura rc

rfia{:J':ufint: atriar fibrillation iio fibri|ation impurse a'rn atrium al?fid'o?r l5urnfir ooo ni,r

oiaurfi {j.tnrncu1:0ij'tu AV node noqirrucrir6nldlsofiHo orcriBlfirfio ventricutar fibriIation fi*r

d dnfldfi d'un:r ufi r6i nld AV n od e n Aa : our: nfl o l n-u rrq nr:nid],: n

6f1fiiu His-purkinje system riurj:cno:Jdra bundle of His rioudl:utnrflu right *fl; teft

bundle branches Tau bundle ot uis r]suldiuraao 1tdu.,lflnffiu,,l anterior seplat perforators

orntdutfioq lefl anterior descending artery ua:o1n posterior septal perforators t",r rflurrgu*r

so.ltdurdon right coronary artery l,|io circumflex artery 6i?1r righl bundle branch futrrqr-.r

ad'lu intervenrricurar septum 'ldn'axrula.:ndrr rdo "nt"rio,. papilary muscre ii.l rnu.,r ,ighr

ounote fldilrfian?ln right coronary artery ahu AV nodal branch ,o:aln teft anterior descending

artery 'rum { arilerior septal perforaton tru:d left bundle branch rfufidnrru:n::erunfiruflJ -q

lou lrunaon lflundrur.rdruufr (anterior fasciclel vraodrunrldruudrsarndrurdo anterior

tapapillary muscle runitfio$ru uovndlyntdrunn",: (posterior fascicle) toofrrnhu ,tlt,t.l

dtuuo"'ttro't interventricular septum ufli posterior papillary muscle Tcg anterior lascicte lfi

:"rtfionornrHu,,r septal perforators ?a,J LAD d?lt posterior fascicle i!rdanqln septal perforators

lon LAD uazlr.:oilulo.r posterior descending artery

ecrfiuld'jrfi.,r sA mode unv AV node 16'i rfionqrnrfiurfioo ncn rfluoirutuqj nr:lfiot
n1?y acute myocardial infarction ?o,J RCA i,tfint?; bradycardialri'lro:tiu sinus bradycardia,
type lsecond degree AV block lllo comptete heart btock rfllnrr; ul:ndoufidrfi'ryd:rudra

R'r?i bradycardia irul6:t'at1u{:Jrulnqnriu oro rfinlrnraridnryrrar sA node yia

AV node o-rtd

1. Sick sinus syndrome (sinus node dysfunction)

6onrrd sn node fi nr:riruufi o:JnF loueyunnroonlun-nuuuro,rnltfl tl,0 imputse

generation kirfirrra drlfitfio sinus bradycardia, sinus arrest vio sinoatrial btock yiofr
n':rrfin nfiro.rnr:frn::ualulflrnrfl'tura rniu virtrirn'o atriat fibrilation of6nr:nilarnrr;d

rwg{rrulu{rhuq,roru uo;rfluorrrqfid'nfrdrlrtr{:-nurio,ildr-lnr:td permanent pacemaker

252 rrtdrriorinqnduSru

nr:'lfinr:ifirdunr?; sick sinus syndrome o1fu01n'l:to\r{rJruirrfiunr:r duutt al

:ra.ln6ulvlflrr{rl,erfludr6',r1 Inu{rJ':uoyfiornr:dou|r6uiiu,,r.: !flnufirfiq ;ofl ndfi (syncope)

iidr6'rp6o{l.run4r.rdo;fin.r1c sinus bradycardia ri.,:dir.rnroog'tunre:fifiarnr:nr:'lvn tlaulo.:
Tnfi nrfildu nju rarvaondrd.tnra nioiiliq.:

{rtru grarqiifiiiinmlulo6g fi lonrnda : ttde\to1n1T'il o{n1':; si nus node dvs{unction
lfirrnn.irnurlnfi diouorn{rJrufilon.rndc:ldi!urur,:tin niu digoxin, beta-blocker, calcium

:channet btocker LLfl amiodarone nr:fi nm;nd'rltdorirtqlrn rFao n6onr:fi nm:nruft orln6

to,rqan:ofi.t.,t leura 1:n1'ts hyperkatemia, severe metabolic acidosis {i.ltlee-fl tvdrdrfirTanra

fioctfionmv sinus bradycardia

n1li t1
t. tfinr:inurrfi orrfillnrlcarr fter:Jn6ao'torqnn:ooir.r

z. tqourfi orotfluarwqtfi tfi olnrrv bradycardia
3. tfiar inotrope ttiu dopamine t1i0 dobutamine triorfj t6|Jasr:rnr:tdu1o'1fi'rte
uiolfi atropinetu:radfinrtrfinr.lnfiao{vlaqroninr:boriuur6ontliofi{arirl'tun, :lsurdsnail

fi or:rur'lfi temporary pacemaker

2. AV conduction block

arerfiqcrnnttufiorlnata',r nV node [0{ His bundle io bundle-branch sy*em fild
srufin nfi1o.: AV node lanrin? riqno't rutfio complete heart block lulru;finrrlfinrjnfi
fr::or'u infranodal region a'nqnfl1 ?lfln'l?: second degree AV block-Mobitz tt rflu tniro

ldegree AV btock (comptete heart block) ldrioudrorjog 11snclnlf nlnff AV block 1 r:qu

infranodal btock rLd? escape beat frrfinq'tn?;d!n'1n'j1 AV junction l;fid'o:rrfrdfir (15-40 ni.t

riaurfil ai.:9,ra'fti:vuiltaritlulnfinlirfig.ivlo lru;fr escape bea't flo,In1: block t;o'l AV node

rfisorn AV junction [o,r fj,rfia'n:l5rrl:;lrfu 40-60 af.:oioutfi ritlo t'flu,:drtfinr:ltnriuu

lnfinaar{ilru

First degree AV block
nr:rjrn:; unllifirern sA node njru AV node a,:{rrun?l6ndrfiorjn6 oi{q'ra'h1fi:rl1'lu
pR intervat trrn.jrrlnfi (rfiu 200 finfiiurfi1 d'\:gr.ld O unxlJu n.rtdfin'j1'hjdoTiirnfri{atfiud
?uu?.rltri{ilxu unriulunrrfliiiltld'lr:fi'u bundle branch block fl;o fascicular btock 6,tarrtfio

complete AV block 9l11JtJ' d

Second degre AV hlock - MobiE type I Wenckehach paltem)
drulnqjtfiomnnrl fio nfirYdu supranodal [[ni nodal otocr ndu}iflrrirhfinnuru;

[o 1yfio nrfi PR interval du'trr,'u,{ou't riaud p *ave e;\riarm:n conduct lfirfiq ops

comptex 6'.lg11 6 un?fi 2 fi'mfio1? 1 PR interval !a{6dulv{fl'1fi11q rioufil:rfienr: block e;

nl,jtu.rtnir pB interval 1o,t QRS compbx m'rfrntUnd'lnr: block ad'lnt'o ra l'llril RR interval

FIKC: Cardiac Anhrrhmias aiafi naoati 253

1" degree
AV block

2"d degree
h/obitz ll

2d degree
Mobitz ll

3d degree
AV block

gli e uaatnlultlfrtth'lcdfi ev ttoct< uuuoi't,t1 uazd 1 uf,an 1" degree AV btock. unafr 2 uflas

2"2- degree uonit t, untd S uf,an degree MobiE It uazun?d't.,,qa udnn 3". degree AV

block (complete heaft block)

oyfianuru:#uo.lnurirnir.nnff.onr:rfin AV block n.t1rlfto nfirfio second degree AV btock type

r fiwlu{rhadfi acute inferior wa Mt, {iltsdldi:Ltr niu digoxin. beta-btocker nio catcium

channel btockers unynr:6ordolrwfio (!me disease) n.rtrdrinl*i*n*.,unnrarflu third degree
AV b tock 6.1.[ri fi a rfl u.fi arjdtunrrtd temporary pacem aker

n1:ifln1

1. rrJou1iiolqfl"hilnn AV btock

Z. rrfi'hntr; myocardial ischemia

Second degree AV block - Mobitz type
dnsrucna'u'tlhilrf?teetvr:l'jr pR interval Ft,rdrioufrqcfi AV btock o''.1;rlfi o unrii s
drulrrlufirvwrBcnrrfn rfinlu::d'lal"rn'jr nv node drarqrir'lfi eRS comptex rl'a-nsruyrflu
drnirt yiofinnu yflo{ intraventricular conduction detect

dtulnrlnt; second degree AV block-Mobitz tt #nrulufidru acute anterior wa ST-

elevation lvtt nrtrfiorrlnfirfiodour:oqnauriu complete AV btock'ld 0u 6.rrfludarjldlunr:
ld pacemaker nfioflo',rriunrr: third degree AV block

fl1tinn1

.'l Temporary pacemaker
Z. ufibnrr; myocardial infarction

254 rrttirfninqordlgru

Third deg,ee AV block
1r1r!'i1 QFS complex lrifi nrrrdlrr[ufn"l WAVE o{:llvt runx6iln louY'ixh

wave fnecfia'n:'rr5rn'jr QRS complex nio P-P interval #un'jr nn interval ttsivrndn:rt5rrta'l
P wave riarnit QRS complex qcliun'jl AV dissociation

nrxv third degree AV block q-otflun1'ltfifidus':'lu rn loutov'ttc rnvrurBanrlra$tu

!di;r6lfi4!rginfrrfaiunoadlqalatrdoo{ovoratnfll"d"n"5.pn"r:lbfienatitufuimtfilarnn:;d'utohiirrndirdengvreiuenAcVtiobnlorcTknfitof"loutn:rrm5rv1tritrnfil:,n,rdlTouo

iu{lhu nut lfiri.ldn anterior wall LLfl; posterior wall ST elevation Ml

fl'li?rlul

t . rtflhn'rr; acute myocardial inlarction lounr:'lfinr:tnurLL!! reperfusion therapy

2.'ld temporary pacemaker rd a nil o'or:rnr:il fi'rsa,rrir'il

Long QT syndrome (LOTS)''

QT inlerval 6otirr::u:::t'jr,:10 GrufiurLat Q wave oufi'r10fi'uqoljo\t T wave lstlvl'ln'l
6''rneirrfirilunrn:rlto,tt'l.l depolarization (QFS complex) ttfl; repolarization (ST segment)

?oenrfir rfIlor!iar'le LInuairu t[nr! rfroornnr:tfim'uta':dru ST-segment duration tfi0']?'tnt:u: tlfll
lunr:rfin repotarization n't'trlrr', rfufltc-u o'niid'tllnhirfin Qr prolongation luflc1liufinr:

znrrrrft lrf,Frrf,]rfi4go.t prolong QT-interval

d1$rq!ar Cardiac:
quinidine, disopyramide. procainamide, sotalol, ibutilide,
Electrolyte disturbances azimilide. amiodarone, phenylamine, bepridil
Severe bradycardia
Poisons and recreational drugs Noncardiac:
Cerebrovascular diseases erythromycin, grepafloxacin. moxilloxacin, pentamidine,
amantadine, chloroquine, trimethoprim-sulfamethoxazole,
I phenothiazines, haloperidol, lricyclic antidepressanls,
terfenadine, aslemizole. ketoconazole. itraconazole,
Other causes probucol. ketanserin, cisapride. papaverine. tacrolimus.
arsenic trioxide
IL
Hypokalemia. hypomagnesemia. hypocalcemia
Sick sinus syndrome, high-grade AV block
Cocaine. organophosphorus compounds
lntracranial and subarachnoid hemonhage, stroke. encephalitis
Hypothyroidism. hypothermja. myocardial ischemia. protein
sparing fasting. autonomic neuropathy. HIV disease

EKG: Cardiac Anh,vthmias qiaf nongi 255

ilnrrruljTiro repolarization riuarorfionruujduurujoordo.,lornnr:drm lon ion channel qir.r
Touto rc sodium lrflv potassium ion channers drhulNi'lua'r?fi6? r' duuurJo.rrrlr{uqn::r
Tas rov{r:1ufiufrn?ln n1rd5r{ sodium r?o potassium channel proteins miu lnn mutation
no{ potassium genes KVLQTI my HBKG dlrfudriunr:rfiom1?v LQT 1 ![ny LQT 2 rnrnern"u
uancrnnr:r duurr:Jo.rvrxr{uqn::rrrdr ri.':finrrvrir,:1 :uvr"ruruormf ordgrlrrnvrh'[fi et inter,rar
umduld 1or:rrd z1

uonoln QT interual IriR?1rJ lrnndrln'u'lu::rir.::1nnod,,:dua{rilrvlnrrnvors rrdr rj.,fi

nrr [cnsh ud'rqnnnror r*uo qjrYutir,,r nordrirnr:in. dn:rnr:rduto,:ri'rh un;nr:rirotura.l

::lr ryorn6'orlufh rfludu 61,rriulunr:fn eT intervat {.rnr:yrhnr:n'rurrumrir eTc rdoto,o

nrr:.rr:Jduuttrjo.rdurdo,:mlrno'nlnr:rduro,,:li'rlo lou

orc = or/GF

RR intervat 6o:yucrrnl'ludr.nln R wave ri'.1nfi,,:61 R wave drrior}l finrirarfuiurfi

(eTc fiillnnil 4S0 ms lu{tra u6omnn.j.r +zo ms 'lu{nrfu6o'jrnrrrurrftoJnfil
nr:fi Qt interval ul?fio nfifiorflunrryfirdu,lsionr:fin cardiac anhythmia lqurorlnc
n1?c lorsades de pointes ii.rfin"nr*ru:royrryfia finr:uldaurr nltugrldr.r amptitude (ljd 7)

uarfifiu'rwa,,l QRS complexes ogjnoonnor (ftf,r'r.r eRS complexes ruduurr:lnl}Jorlrrrnu
isoetectric) lnudn:rr5rra.: eRS comprexes ?yrJlru 100 fir zso nirsiaurfi 6,lrujnlln'o:Jnc'

d'ln6irrdcr r:o ruro.rld rd'luurl:rac: r duurflu ventricurar fibri arion d,,rarcrirtrl{dru rdu

fi ior'ldnr nlrildfu nr:fnrrlfi u-uvir.:fi
lnudilil Or intervat ?:!uj.rr.l'un.l t3fly FR interval i:r4.jt{ eRS complex m'rriouufr

rrovfirddrn, :in obiu$Jruo:fi eT intervat urrdurdafinrr: bradycardia riardai premature
QRS complex rfiodu 1rirlfi RR intervat u.r?nll eRS comptex dr n6 eT intervat so.r eRS

complex n"'ldrnrufl".J premature complex tiuc;ii,larrlru) nrnfi Dremature oea rfiotdu6nni.r
1fi,,:fnnno{tudrl ST-segmenr) fiq:d.rtirfiat Torsades de pointes duld 6yptcat short-tong-
short QRS complex) dr;r.lfi 8

gti z uanndublflnhhdfrfiawt o,9s complex oftdsuuJa,nouuuz isoerectric rine a$naaatzat

256 r'rtu?rriainqorCugru

+____-r,l -'iR-R--i-n-te-r-va-l--1:n*'r-"ri' . FR interval 2 |l

QTz'

Short RR interval rl :- -i Initiated ventricular a

Short RR interval

Short RR interval Initiated ventricular

ffgJd a uaa,tnnuflxtivitoJ QT interval RR inteval u z fnanvnnno ventricutar anhylhmh lu

{tlaafifi Qt interval prolongation

{anrr:vilrdaur{rJrufinrrr QTc prolongation.[duri

t. nurlnfiur.rnuii QTc 1nn'ir 5oo ms

e. nudfinrufinrlnfiuruiuqn::rro{ LQTs:J1n:1u ({ouny 6-12) fi QTc :Jn6ornn'r:
sFlr ECG

odr.i:finl.rrdaru{ilradfi orc prolongation n?fiv "erit't- unl:'hiurfifi:ru'rru'jrntrlfi
QTc undu un;nr:nrnr m4dudorqfihttfifi LQTs niu nrufio:Jn6tottn6otld'ludr.:nru nr:

fi ndrrrdarir'lomnrfi on ua:nrrrntrln"ulun;1nnn6:ustfildu

o:rnfu {ilrufi ii caroiac anhythmia dufiintt; QTc prolongation rdtnr:inutdla electrical

ttrerapy udrnr:rirri'rd

t. rqourdfi:ro.:ruirvhlfirfio QTc prolongation

z. ufil:rnrr:fi nrlnfrro,rorqnrndoud
g. inurIravianmvdr'rlfifi orc prolongation

4. lfi magnesium 1-4 nirrr.tvnaorfioorirorirtsia rdoolutrnr a-z+ rirllr nir'lrfio

arrhythmia

EKG: Cardiac Arrhythmias qiti nofsg 257

s. lfinr:fnurrfiauTuti.,rnrr: bradvcardia

5.1 overdrive pacing 1ers,,rdn:rr5? 8O-10o ni,ln'aurfi)
5.2 tfi isoproterenol tu'to 0.5-2 mcg/min

flfinrfiu.lnrrtliurfrrirtri orc amduTourorniod €i.r amiodarone ol?fior:rurtd tidocaine

ItvluntUnlfUaT;i nA{ 9r ; AnX!AXnt']; ventricular fibrillation
1ltfl
1lfl

lans1"d1{6.t
l Rubart l\4, Zipes DP. Genesis of cardiac arrh!'thmiasr Electrophysiological considerations. ln Ubby p, Bonow RO.

l\rann DL and Zipes DP. eds. Braunwald's Heart disease. 8'' eds. Philadeiphia: Saunders Elsevier 2008t722-62.

2. Antzelevitch C. eds. Mechanisms of cardiac arrhythmias and conduction disturbances. In Fuster V, O'Rourke. Walsh

FA Poole-Willson P. eds. Hurst's the Heart. 12r" eds. Intemational edition: Mccraw-Hi 200e:913-45.

3 iReinelt P. Karth GD. Geppe.t A. et al. Incidence and type of cardiac anh),thmias in critically patientsi a single

center experience in a medical-cardiological lCU. Intensive Care Med 2004.271466 73.

4. Trappe HJ- Brandts B. Weismueller P. Arfiythmias in the intensive care patient. Cunent Opinion in Critical Care

2003:9:345-55.

5. Goodman S, Weiss Y, Weissman C. Curent Update on cardiac anhythmias in the lCU. Opinion in Critical Care

2008J4:549-54.

6 Kanji S, Stewart R, Fergusson DA, et al. Trmtment ol new-onset alrial fibrillation in noncardiac intensiw care unit

patrents: A systematic review of randomized controlled trials. Crit Care Med 2008:36:1620 4.

7. Brugada P, Brugada J. Mont L, et al. A new approach to the differential diagnosis of a regular tachycardia with a

\ryide QRS complex. Circulation 1991j83:1 649-59.

8. SgaAossa EB. Birnbaum Y, Fbrillo JE. Elecvocardiographic diagnosis of acute myocafdial infarction: Curent

concepts for the clinician. Am Heart J 2001t141t507-17.

L Bayds de Luna A, Wagner G, Birnbaum Y, et al. A new tBrminology for lett vertricular walls and location of

myocardial infarcts that prssent Q wave based on th€ standard of cardiac magnetic resonance imaging. A staiement

for healthcare professionals from a committee appoint8d by the intemational society for holter and noninvasive

electrocardiography. Circulation 2006:114:1755-60.

10. Owens CG. Jennifer Adgey AA. Electrocardiographic diagnosis of non-ST-segment elevation acute coronary

syndromes: current concepts for the physician. Journal of Electrocardiology 2006t39:2lj- 4.

11. Scabossa EB, Pinskj SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction
in the presence of left bundle branch block. N Engl J Med 1996:334:481 7.

12. Ferai E,lmbert A, Chevalier T. et al. fhe ECG in pulmonary embolism. Predictive value of negative T waves in

precordial leads-80 case reports. Chest 1997J11:537-43.

13. lles S. Heron CJ. Davies G, et al. ECG score predicts those with the greatest perc€ntage of pertusion defects due
to acute pulmonary thromboembolic disease. Chest 2004:12S:16b1 -6.

14 Mieghem CV. Sabbe M. Knockaert D. The clinical value ot the ECG in noncardiac conditions Ch€sl 2004125j

'1561 76.

258 rrtrirrlnlnqnfirgru

'15. tuftam WA MeMirad AA Bi€rmann KM, et al- ttyp€*al€.ni8 ro\risibd. To,\ Hssrt Inst J 2006:33:4G7-
16. Ma G, Brady WJ, Pollack M, 6t al. Eloclrocadbgraphic manibstailons: DigitalF toxtlity. tha Jotmd ol EmoqEnc1

M€dicine 2m120145-52.

17. L8wintor MM. turicadial dis€48€. ln libby P, Bono$, RO, Mann DL and Zips DP.8ds. BnunvJald's Head ds€sa

8s eds PhlladelDhia: Saund€rs Els€visr 2008J829-53,

EKG: Non Cardiac Arrhvthmias

qiafi no,tog!

t . amlfi nr.ln6la'sadulrtihr?rlelrurrrcnfrlrrils#fleenntdon lAbnormal EcG
in acute coronary syndrome)
{:Jr'fiiunr:inurlulaigdruudl lflu{rhug,:arqdfiflrr-urdu,,rrianr:rfirnrrsnf,'r rdo

r{rlmrrnrfionrdurrd'uoqjrGr uonernflutruvfrir.:nrufinrrilfiniln6ral:c!ri}rnriiuu1nfin fufi
Ionrsdlvrfirrnrrvn'',rnritntuldiru d,,rn'rnldfunr:lilodud.lroriruoyldirnr:fnnrdrrurvsr
rycrrrrrnriruftJran{rdldlrn

nrufin n6ra.rndu}{flrrirlodffiru"udd:.rnr:lfiontvnfirrrdarirlorrn 16on 16uuvro'u
fuorrr:nu:-i.rrfl urJ:: mvrtuqjl 1d dtf

t. ntuftor.Jnfufindfinrrundutar ST-segment (acu.te ST-segmenr etevation myocardial

intarction)

z. nmnftorJn6rfinfilrjfint:unduto\r ST-segment (acute non-sT-segment elevation

myocardiat infarction or unstable angina)
1oufi:ruo:16und{d

Acute ST-segment elevation myocardial infarction
mndo4nlufln:iu{rJ.rudfinr:qnd'ulaunonfiorrlnlruriu :jriuuufl'ururirtiilnrry

ndrlriarfr'lelrnrfianrfluuirrsunrirmcfihifinrrrrilduuu:Jo.rroondu},lf,rn'rhntrdrdunnr

tillrnf, T ware q,n*u thyp"r"crt" T wavesl lurirl 15 urfiurn nn-.:ornriu sr-segment ocrd

unn-rdu nrurdru T wave'lu read dlnaungro;r duulflu T wave l-rflnu (sr-segment erevation

260 rrtrirrioinqnfiugrn

with inverted T wave) tdalrnrajlulj 3-4 txlil':11-lfit:cu;rrartflu?-u ST-segment o;ao::olno
rJ'rd? n-! R wave ovldunotutru:frrir.r lfin pathologic Q wave 6ndu inverted T wave c;riou'l

dlntu eulfrarrnrtj'ul:Jtfludilo1f sr-segment clnd! l6trrd'11rinfi T wave cvli"rsfudufinnio

6iru R wave oteovnlull v|o rd'sa.tn'jrrfil rLa:fi pathologic O wave rfiodu 1u{rhu!'l{l1uo1?

"JL;f'\*fi ST-segment lng,,:duo{ldrflurlarurud,rorcdtJfiudriunr:rfin left venlricular an"ury"m ld

;l^jh;

{r1,..-

trld usa,tnnuliiuuu awallrliiulvlf,'trta'lqlu acute sr-elevation Mt \au nnt e. uatsnadulvlf,t

#'fle1Jn6 ntn B. tdafi ptaque rupture vitlthfia hypencute T wave n1n c. ufron sT elevation
n1w D. LLfro,J sT elevation fifiadaxflu T wave inversion n1w E. ufl', sT elevation frafrrl;ffYfln
i'luiuntttfia T wave inversion uaz pathotogicat Q wave nltt F. uf,n t{nE z pathological Q

*tn lnsibifr T n ve invercion

finr:finurul'jrnr:rJ:rn4 sr-segment elevation ttnvtia o wave lu lead rir,:1 o'tlr:n

ronn"r*nr.i.rro.rndrilrdorir'lqdtLrFrrfroalfiu" rdo,rqrntuflclfufinrtorrcnrrrir,:rutotndurtdo
rirlevnrfli6 rdu nlrn:rqndulfiu,ig:fiouf'r'h (echocardiography) n'l?st:xltofltt?tinalfir rmai
(computer tomography, CT scan) nr:n:rodruRfiutrrirnfin'lvlflr (magnetic resonance imaging,
unD r"rlfifinrdrinhirrionrurdurrTr-rn'ruurisrornfiutdolununi16odrudutnrirdo'lfirvm;mr
un;a;nrn'lunr:uJiu:L rfiu!:vll ir.,,tDlnn'not:rldruiddr':1 {i.rarcfierrrtttnndr.torndarynfildrrn
nr:6nurrr,:ru'tiiruT oqjrirt lulunrrldqvtodrt6tol"rrrrrj.:lo.:ndr tdo truoi 16nfruortr
American Hearl Association (AHA) Cardiac lmaging Committee of the Council on Clinical
Cardiology d.rrni-rndr*rrdorrurltrfiasru Lflu q d'ru 6a anterior wall, septal wall, lateral wall

BnY inferior walt ri'od

EKG; \-on Cardiac Arrhyrhmias dinfi nslatj 261

1. Septal myocardial infarction

e:r! ST segment eleva on trd!11i0 e wave tu teads V, rrflt V, dr f:Jnrrfistlo,t

nlrnleraaFrl0,0ndlrrda'lurinrudrfioalnn"r:qndulo\:14floar6oo septal brun"h"" ra.': teft antlrio,
descending artery (LAD) niofinnaorfian LAD ro.l (fin,te1n1fi&iumt diagonat udr)

2. Mid-anterior myocardial infarction

llu ST elevation uio pathotogic e wave ii leads aVL un; | :rlfrrororl'lu 4 un:
v" ldTaur:birrnrufi oilno'd'.rneirrtu Vr, Vu nrrlfi o nfi drfl oqrnfi nonrfiofi diagonar branch

rfiuulnllo,r LAD qon"u

3. ApicaFanterior myocardial infarction

ST elevation tia e wave fi V,. Vo 1ua;arem.rlu %. V6 i?rJd.lu) udo;lriwlnttr

ftorjnfilu avL. t riolon'irndrr rdauirrru apex no{r? n;r6ndravrnrdonrdo{rrnnr:qnd'uto,,r

mid-LAD

4. Extensive anterior wall infarction

t,/! ST elevation y5o e wave'lu precordial leads (V, -VJ [nyorc Ulu leads aVL, I

li' 1;:jfi et.1 :j,rlon'irfinr:aon'unar proximat uo lrioudo:biunu{ septat branches r!fl;

diagonal branches) rlllifinfiil riior.r'ltoars rflulJirr ntr,,rrr.: septar wal. anterior wa lrfl:

mid-low lateral wall

5. Lateral myocardial infarction

ecytri R wave 4,rr,*uiu V. rrn; V, drlriu ST segment depression tu V, rrn: V, 'lu

tlarute;rfai1l ,wuaQll ?wroa1v6eouoftfli:o.S:eTrnsnerg:mqoe6n'tuteol,ervalteioftnchir.crutm, "flveLx rrfl; V5. V6 rir:_ronfitndrl ldorarh'lu
coronary artery (LCX) ttiorrsutto,:

LCX (marginal branches)

6. Inlerior myocardial infarction

o:uu O wave'lu teads [, t, aVF (g:Jni 2n.) .,]lonfifinTtrorfion*n; ST etevation

to,rndrr:rdodru in{erior wa rt,r rfiocrnnr:ooft'u1lo\r right coronary artery (RCA) iu{:Jruairu

lrd lsol'"1 lraonrfioo RcA crtliLLrurlnrurflu posterior descending artery o'r rda,rnfiurria

ritu inferior part ?,o,r septat wa dru 'lulr':ttunr:qooriufi Rcn arc6iiflahlrfin inferior wa tvll

iufii taterar wall Mrldrfio{?rnuru{ n1ufla'r RcA Ldurndrrrdadrt.ter',:nsilld?u (RcA dominant)

rirnirnfittdorirheirununir6omr ldfirdanmnuruldruduro,,,:rnoorfioq ncn
a'rtiuoronr RV infarction ilunitl inferior wall Mltourru sr erevation tu V, rtn;nia reads v. R,

drull)V4 R (fi',r Ao tead 1u:; ei! rfl ur ni! v,, v. uroi r:Jnrurur o'oiir:rron

luo#urioufiri'r 6un posrerior wafl infarction'fialdr-i,uannrrrfiondrilrdorirlerrn
lftanrirrru inferobasal part ro\rn erir6adru Tnun;virnrur duuu n*na,:afiulvirhrrirlo fi n

262 rtnirr.iainqnfru5ru

pli z uanlr,nunlyaduly'1fl't,ix'lqlJan$tJxu acute inferior wall ST-elevation myocardial infarction ilJ

7fl. ttu ST-segment elevation "lu tead" ll, lt! uflt avF'lurruzfinu pathotogic Q wave lu tt' lll.
avF LLaJ sT-segment deprcssion Iu t. avt, vs ua;t V6 #iffiaq-,lntvntzt6usatrtz'ls wuilfi

progressive PR intervat protongation riauii AnS complex fratandt P wave otntttltJ $econd

degree AV block: Mobitz t) ?J ltt. uga,tadulYlflTialem,$tln acute extensive anteiot wall

ST elevation Ml &ttnn ST segment an{ndu'lu V,-Vs

wave {,rlu v-, V, [LR: ST depression lu leads 4".]n6j1x :lqXflrqlnn'lr9t:xlTnuolfYu cardiac

magnetic resonance myocardral perfusion scan lt!'j1n?ltJ t:JduurrrJa.lla.lndulvJfiti'r'lqd',J
ndrr#rJfiufrir nr: Lfi o lateral wal I iniarction tJlnn'j']

uonflndn?r [ 6uuutlo.fla.]nduldflrri':lolunrr: STEMI ti.ld'ltl'nnronnrl'lmn:nfllo

ld Tau{rlrriifinn:rrtatnmrt duuudattu::o-laot srsT segment (riY.:fr rfin elevation !!o:
sr depression) tuusia: leads ii.rrrna;rtrfio'n:rnr:rdsfiin1u oo iuq.: tuaru:fi{ilrlfifio"n:r

nr:rdura.rrir'lo r5rfi QRS complex nir'urrn 1rfiu 120 findiulfr) viotfin bundle branch block

(vrs,r right rrnv left BBB) viafi palhologic Q wave ogt6r firudlrriudriuosl:16'luQ1n srElvl I i{.)

1lulhlflu

EKG: tron Cardiac Arrhydrmias sinti na,toE! 268

Non-ST-segment elevation acute coronary syndrome

iur]el:r"uv,ruq:r"6n1?nin1r!fiI acute coronary syndrome rfin sr-segment erevation no

atlutru:dvr:r non-sr-segment elevation acute coronary syndrome nv.:miofifi cardiac enzyme

gtr*u6o non-sr-segment elevation myocardial infarction (NSTElvll) trn;rfiofi cardiac enzvme
t.i tyltJg1jura0
unstable angina (UA)
[tJ

'lu:101:r"unr:1finr:tnur NSTeMt/Un riu:iuo{ri::arurdu,:lo,rfi r udc c rfionrr: rLyl:ndau
rua:o'n:rnrrrfiufiin1o{fi:huror Touiu{:Jrudfinrtrrdurq,l niu fiornr:urjurfiran?uu:,r?nl,

d'nvr",rfild:lrnr:inurTounr:lfiurodr.:16#udr {:Jrudfi::d'l cardiac enzyme g.odu {rhufifi::r,'..l
c-reactive protein q,'rdu unl {r-lrrLfrfinll r:jduuurjnrlo.rndilrdfirrirtorfin st-"eg,n"nt
depression nr:ldtrntiinurloranr:ri1nr:sururnonrfioorirle dryf!nrrt:Jdauurjnuro,rndu.lr,rlflr
ri'rlclunrr: UA,/NSTEMio nrirrlaaolrlddld

1, ST-segment depression

nTnt?ev,|! ST-segment or'rnjrrfiu basetine Fyfi.j lnduqo T *ru. fil|lorirdu e
wavel rfiu o.s finfinn: louranr:lirfinr:!:Jduuu:la,:u:.tu dynamic rnrd?,rlrorrir.ll arlr:n

rj,rdirdr-hufinrr: myocardiar iscnemia rfiqdu nrrnr'r?l,ru sr-depression fifinmnn.ir 1 finfiuq:
luynru lead {6 teads) d.tdur{uf,n-lnr:rfin myocardial intarction (specificiry 96_5%)

fi.,'ruinr:n:rlru ST depression tu teao drll q:hiarilr:nlddrulacthur ,rlto,,

ndurdav'T lodrn'onr:rro6ao'ldadl,u'a rou usiflinr:n:roulfrfid'nyru: rour:urrarirlfifin.:rn
ffrur{udrirnllfio n6rolnnaorfiaofnl:uri oiod

t.t nr:fi maximat ST depression 'lu lead v, uor V" dlnriufn-r_rnr:rfio Lcx occtusion

(sensitivity 70%. specificity 96%) lqulo 1:orirtEi,rdrfi tatt upright T ,""u" 'lu te.d V, u0: v,

der.rd'ra

41.2 nl:fn'teflu ST depression lu lead V4 fi.: dlniudriun.tifi subendocardial

ischemia rrnnr:rfinnl:andurarrdurfian Lno lnulor,rrsdrlr! upright r wave 'lu read rirniirr

1.3 n1:l/lJ ST depression lu tead l, aVL, Vsuny % d&filfdlnr:fiyoonr6oqTnT:uri
fiuf{ s rdu (trippre vessers disease) vio reft main coronary artery stenosis ttny rirlanfitnr:
lriro"n:r rfiutro,rnrl;rl'r'tcls nr:i!n-lao,l nuni16ndrunoor un:o-m:rnrud6,rdu

2, T-wave inversion

tn1?n??qu! T-wave inversion rioun.ir finFu.rq: lriuiro.n:rrfiu{?0,,rfi:JtE acute

coronary syndrome ttrinr:n:rtltll deep symmetrical r-wave inversion'lu tead v. rrac v. fi

nrrrdr.rr'udnilnr:aqm''uao.rdrufi urs.,rrdur6ooLAo

3. Lead aVR
Iour"rb reao avF *-nnnNo{{.trJiun:nid{rtrurrdlu STEMT uoidrrfi{rj.rrdfiornr:

264 rrrnjrriainqnfrugru

run:a1n1t[r6te\rlon NSTE[/l nllolt't?t{! ST elevation'lu aVR nl'irdlrrYuf,riun']lfi tripple vessels

disease l4iO left main coronary artery stenosis ( !fi.Iiguny 66 $A{{ilxufifi ST elevation 1

finFu.rn: 'lu avnl

nbru:nedfile"dbarannrcchnbdlorlckrdari"r'lenrq 6a aln uarf,u nduldfi rriele'tufl,:te uiifi nre v

iufirtrEriifi Rsee uia LBBB arfinxltJftollnfitotndu'h'lflti'r'lqlu1ru;fifi mvocardial
infarction ttonnl{?1nHlJlull.'l'! [!n,-{u!

r. firtruiifi naee

{:-6udfinrr:nfirllrdarirlenrolfiootduulti'uTourarr:luu?r'l septalwall t!fli anterior
watt filonrafrqcrfifrnr:rrotrfiaato,:nfirilriiarirlodru right bundle branch 14.1 His-Purkinje system

frvranmiraqjtumi,,rdurrunir6ald {:-hun{liie:findub{f,tr''rlc ttoo,,:dnE ;to\t intraventricular
conduction delay uia ngee Inufi QRS complex nir.rn'irr1n6 [dryfiflng1u;firrnndr.Jlrn

neee r"xber'.rd

t.t 4nr:fi ST-segment elevation lnu tqflr:'lu lead V, fil nio vn d'rrrnn.tirfi

seotal ttn; anterior wall infarction t'tio orqtu ST elevation'lu ll. lll, ttfi; aVF fif,ilfiudfiln1:fi

r-03 01-0? 0l-24

pl6 s u*atadul*fltrh'latta$rJlu acute sT-etevation Mt fifr BBBB itxdtu d,ttnnnzfi sr-seg-
ment elevation'lu rcaa v,, lt, ltt, 8a! avf iiouaa,titfr infeior watl infarction i'lutitt rignt

venticular infarction

EKG: \on C rdiac .{rrh}rhmia> ain{ na,tatj ?15

inferior warr infarcrion aiulfluar rvnbirfin BBBB ld uon?1ndfi{al .Dflnr.r?y{u pathorogic o

waue'ld"lu leads n"rnrlrr:?|Jri.'lu-{amnr'revr1j reciprocat sr depression ldryfioutu stEvt r:
fist

t.e fi:JrEJUr,i:1flfifindulr,,lflrrTriq Reeg od16rJ rfiorfin myocardial

ischemia e:finr:tl6uuLt a{fl0.,r T wave d,:16''ialqq:rfni s-neucorund; ary change rfio.,ntnn11: RBBB 0
wave tu RBBB nfiq;ifian:{dr ni! terminar portion rlo,, eRS comprex'lu teao r?u1 rtiu lu

V., V, terminal portion flo.t eRS rfluu?n n-.:rfu T wave l:tilunl; qulfinnl:t fiuurr at1o.,l

frfirt'na,r T wave rflufrqst:*ldu #unitfi pseudo-normatization rdutu v,. v, c;fi T wave fr

tJ vt 6 Hluu'r fl

z. {rteafin'leee
Tauvt''rll {:-nrlfilrul rrytrridruornr:flot acute coronary syndrome nrnq:ronfiu

bifitir'hnun"nuru; Leea nr:fi0'irfinl :uu:{rfiu:rryirrilfinm; srElfl uncnr:'ldiunr::*nrr

r'ra'ndrui6 earty reperfusion tnerapy d,:drdorornfilrn--n!ru'jr{rJrunni o-{nsjrrcyfio-n:rnrEJo,0

rvirn"rrSag,,rn'fi{rhu sTEMt odrrl:ficrlnr:filr:u.rndulv,lfirrhh 1u{rhodfin-nuru; Leee
odr.rn: rdunsrrr:nlfinr:ifimuld'jr{rJrufuinrr: myocardiar infarction nialrj Tnsardurnrud

dod" lsgarbosa criteria)

2.1 ST etevation t indrrln: 'lu teaos fifi eRS comptex lfiuuxn (Score = 5)
t2.2 ST depression fiofirr.rnr 'lu bads V, o'o % (Score = g)

2.3 ST etevation s fiafirun:'lu teads frfi ens comptex rfluol (Score =z;

r.rflr?rJ1ro\r ""or" yY,:3 do rrnlrnn.irnio lyirnil s o;riruoriuarlunr:ifieaanrr;
A[/l il-l{ilxuiifi LBBB 166 (specificity 90%) usir1.]n score rvirnju z c:fi specificiry rrnn.jr 80%

nhn:'r{rJerflld:"rnrr'ld pacemaker c:finduh'lflrfir'lcndru Lges n1:Fr:2evn sT

etevation rrnn'irniaMrrrl s fiofirilq:lu teacs dfi eFtS comptex rfluol rlan.irfi nn,lt

(specificity 88% r[Fi sensitivity S3%)

z. nrtrfi orJnfiroillil?nfi5ofl mc6il1 duuldriaalulafifl

fi:Jrudrdrirnr::"nurtulofigriu uancrnqcfin?r ld',:dc:rfianrr fin nfirora-n:r*n:
i,rnr:nr:rfiutory-rle uornrrynfirrJrdortrtclror6aorrdr ri,:fiTonrcde;r,rrn.:ufiarlnfira,rn6u

'[v'lflrrir'lq:iluu!6ul ldloudrurrnrflunrlrr:Jduuu:Jn,:lo,rnfiulilrnrri'riqfidruniuf,nirnur6onrrnr

oir'11 rriu nrtrr duuu o,rro{ndulviflrfi'rlcfivutu{r-rrrfifiarrlld'uynoor6aoua'.r:ro.'::Jaoo.:fi0

r.lnF uo:nfiu}iflti?'lflro.rfirhudrt'r6onatrtun:1ron6:u: rr,:n:eflnr:er:rqnfru}4flrr{rtcotrr:n

rfioulfiuruti{guonur:ntrinr:ifiedtntsnrrlfio nfilr.nj:vnr: Tnura r:nrr fioJn6,,oo

rnfiauilu16oo nr:fiqrurn4finrgc'rn^oin6 rSanrr:ur:ndoucrnnr:ldnruorunaas6an un,rJan

or".::rua;rdungialild

266 rrrrirrininqerdugru

Acute pulmonary embotism or acute pulmonary hypertension'a'"

{rJrutulafigoronufi't1: acute pulmonary hypertension.[dornvnruortvn nju acuie

pulmonary embolism (acute PEI, (acute) severe hypoxemia LLni acute respiratory distress

syndrome (nnos) rfludu n'rT loi,:neimai.lr.ra'tfifiarT l r:Jfiuurrilntlatndulvlflt'rr1a16d,:d
1- n'nm qr'ru S-Q,t louaur:no?lolru S wave'lu lead l. pathologic Q wave tu lead

lll !ro: inverted T tu lead ltt otirl't:finrlnllfiorJn6dfr,rrrfiq:ldilnr:nsirrfiflu5'lut classic

ECG abnormality lu{rJru acute pulmonary embolism rrrinduq:llnl'ldtfiu{5osn: 10-30 ?on
fi:-hufilfiiunr:ifiqdt acute pe rvirriu

2. Right bundle branch block
3. P-wave pulmonale
4. Right axis deviation
5. Sinus tachycardia
6. Inverted T in Vj-V4

Iptd uaar s wave lu lead I, Q wave 7u uaa ut ttflv 'tnvert T wave 'lu tead I &lllul1uifinnz

acute respintory distrcss syndrome t1n severe pneumonia fiuatv4'li6a acute pulmonary

hypertension

Acute subarachnoid hemorrhage (SAH)'"
rur-irnrrrufinln6ro'r Ece firutu sAH ldd'''rd

2.1 ECG morphological change

avnrq'r'ur!ilduuurlnwa'rnfiu'ldfirn"rle dtrirlriqnfirufinrr;ndtttdori'drtrrnlfioq'u

ndt6o urnrufiorJnfilu r wave losr:rflu large inverted T wave with prolong QT interval

ielriufi sr segment depression tiaorlfi ST segment elevalion fl'td t1lfi st

EKG: Nrrn Cardirc Arrlrrrhmia, qin{ nsnoli 267

Fr

snrt um,s cerebral T wave fianuayfiu T wave r\tnffi.t gtuni',uuflzfr eTc prolonged

2.2 Cardiac arrhythmia

fi:ru,lru'jroytu arrhythmia ldriou lioun: 3s; Inaravrr:1uri.:.rdrlorriu:nrfi.rrfin
seu' drulududrrflu sinus tachycardia uia sinus bradycardia drfnlrirfluiiurnrueiofirhu

urnrin drviu ventricular anhythmia (ventricular tachycardia,i fibrillation) [[fl; atrioventricular
ooct d,rrvdrlfifiikynrraoronfn, :horlaurfi oolrinrdua;rfluarrrqlrtrfia6inldriu vrild
::trruiaan: s

Hyperkalemials

nrrrftnUnGra.lndubifl'rririolufir-t.rfl hyperkalemia eynlcnrllr dluu n{ riu..rnr 6t'rd'u

qnu

(ilii1. Tall-peaked and narrow-based T waves dfin*nuru:d',rd 6n.)
- tdrulnqjufir duration :to,i waves dqcdu ?s lru 150-250 msec flrjrn'u o do,r
trfi n1 6.r rfl uo'naru:fi idu unqr n waves or'rhddrutunt y myocardial iniarcr ion

ttSo intracerebral hemorrhage

- riilru nv.: *si:;o!fu rmorir r'lu rd oor rrnn.jr 5.5 m Eq/L
- l,r"nrfiu'ldf'ntu tead t, uni v2 v4
- r'u1d:l::lrruiato: 22 lotfi rudfi hypert<atemia

2. Widened QRS complex and prolonged pR interval

- rfioo, nfin'nrrir{r'lunr:si.rairunr:rro'h4flr::n.j'r.r myocardiat ca 'lurruor?rfio uc;

AV node (intraventricular and atrioventricular conduction delayed)

268 remirrjainqnfiuSrrl

pli a uantntnldluiwulunttv hypetuatemia InsJtJ 6n. udo't hypencute T wave nuzfi 7) 6t.

ufron wide QR$ complex and absent P wave (sine wave)

- 6rnurfia::d'ulvrufld!8utflu!fiso rnn'jl 6.5 mEq/L
- rfroiio':trdrdrto,r intraventricular conduction rrndu QRs complex o:nirrdulu

fia-nuruvnd'ru LBBB u6o ReeB odr,:I:frfir n1lc hyperkalemia lYu QRS complex
e:nir,lfr.,rludrrrilduun:fi'uqoto.,r QRS {i*:riruornnrxv bundle branch block ldo
c vnir" rov{r:dr{filurl0.t QRS comolex trirriu

EKG: Non Cardiac .{rrhr.thmias tini van$ 269

3. Absence P wave activity

- riiar:d'lTvluyrcriaurnn.jr 8-9 mEq/L firufi sa node cyfl,rn.,rrfluff-?nhfi o

0"fl:tnrrLdu?o{r4-11oagj rSun.Jrri.n' sinoventricutar rhythm lleia:lri u p wave

orn surface ECG t?tJ?tv\t QRS complex o:nitoon fl,,:yr,rlrifin-nuru;nfi'tEJ ventricular

tachycardia

4. Classic sine-wave electrocardiogram (?ild 61.)

- rfio:cd':llflu orfiulurnflr '10 mEq/L q!t!u.j1 eFS comptex n{r.,rlrnou sr

segment nra}l rirtfirfiu QRS-T wave siordo,tfiulilafiru sine wave

- sinoventricular rhythm fi,tul adu'lv.tfiTirtcfiulfioqjrfiorrn acceretated junction

rhythm

- luiiqnc;rfin venrricutar fibriltation rrns asystole ntt6[rniu

uonrfifla?rnn'tl fi nrlnfr d.rnei1,lnrty hyperkatemia u"rRur:nrirtfi rfi nnrrrr frsuu:Jn,l

?a\: ECG 5u1 ld rrlu n1't: pseudomyocardiat infarction 10".r;:jn'z 6{or r:ouunernnT:

acute ST elevation ld lerun:rlvilnr:rrJduuu:Jnn?o\: ST segment rfrr'hlnr:inurRm: hyper-
kalemia) ianltfidn:T nr:rdutou,t, todrnl lsinus bradycardia. 1",, 2"o. uo: 3d-degree AV

block) lil du

talfi uaa,s eCG frfr Sr-segment etevation lafrniiuuluntzt acute ST-etevation MU ijnfr1l1ra

ataowlfflunnz severe hwetkalemia uaznfitfiuJnfitdaldiunttinatnttz hwerkalemia urtt

270 rrtrirfainqndugru

Hypokalemia
ridfifi oetayeo veniricular repolarization dlanlfifi ST-segment Prolongation n1'ltJg\:

nfl\: T wave nofl{ lrnrolQvllJ U wave ld'lUntll seuer" hypokalemia 1l]l! P wave $:, PH

inteNal ulxfie nfiuac QRs complex nir't1d tudqonrr; hypokalemia dtHn'lfilfin cardrac

anhythmialnu rarrvlu{r.tT ufrnldfuu'l digitalis d? 61u rdo{ernfrnr:rfjtJduto.rn'r?: automaticity

Galcium
tsn-u serum calcium do nsion'trut:ldautt nolo,l action potential duration lurirr phase

z t*rrvd.rnrntfifi QT interval #un,r tunm; hypercalcemia 'lutru;fi QT interval e;urrdu'tun'lrv

hypocalcemia

fl'r'|15nn:'l?1'lu QRS interval nirlua: PR prolongation lfflun'l1: severe hypercalcemia
uanqrndu-larlrfio 2"0 degree ria 3d degree AV bloctld arrvrua'nurulRfiru o"bom *aue d
ru'lu hypotnermia 1d

n1'ry severe hypocalcemia fnuldrrtriu hypokalemia lourolrvlu{:Jrufifinrdro'ru

lo,:1nfi0:Jn6 i{ore lldnl :druoron'.i 2 nrrv Isrufi tall "tent€d" T wave drrdl sr segment

prolongation

Magnesium
:;riuu*rnfi16ur.r'lu16aodftn:Jnfirfiu.rodr,r rdrrfinkidoruatr{rfionrtr ulduuu n,,ma,r Ecc

runirda{qrnu nfirfiu 'turfisninrr d vrTu6'lnfifion"lrvsYuh urortu! unvuna16ultu16ao drrir'lfi

fi nr:r:Jduuu a',iro.,r EcG nrrn'nuru;tatnruf o n6ta.r rn6o uisfi qdu"l ld

Digitalis effect and toxicity
{lr udtfiiuur d i g ital is rTnfi nxr fi n!nfi t o,o6'n:r nrr rdu *n:{.rrr vnr: lfiu1loorir'h1aru

tfln1r atrial fibrillation rdoldfuur cigitatis firunuiutY,: Na--K ATPase pump rirtri jntracellular

catcium tfrln8ud.rrualfi myocardium finr:nooYrldrr:,'rdu (increase myocardial contractility) d1l4fir

nnrio:rurnr:fr}lflrlurtrleriu oigitatis fiHnrir-ras.rnr:rirbiflr:ro.r AV node lum':rn.rdrt.triu
n::{u'lfirradh Purkinje fibers rfio automaticny ldi'rudu

nlrmila Ecc lar{rlrtrd'ldfi digitatis c! ln1lrr duuurlneo',:d'u
t, nrurrl6trulu:Jn,rto{ T wave olqv{u flattening T-wave nio inverted T-wave nl'tu

tr duuu:lnsto,l waue dvr d'luoiuo-r u:nrno.rldiru'r

2. n1:v{r QT-interval duno tfio\rmn digitalis rirbi ventricular depolarization time

flfifl{

EKC: Non Cardiac ,{rrh-lthmias qind nonti 271
3. n1fltru ST-segment depression firfio"nurwtaur:!fl reuerse check mark fl30

scooped tia sagging ndrr6o ST-segment fi downward slope 'lurir,lu:n nn:

ruJfiuurfu upward stope du1 turir*rn-.rriour*tdu r wave n-.T fi 8

an!fi urwinururnltotdsuutJanaor sr-segrnenf iinutu$l2flfi7di.u aigitatis

rirrilfirhudldfiu.t digitatis n1:olter,tun?.trJfio:jn6lo,r ece d:,rsioljd ri,'ddrfifiufi

nTtv digitalis toxicity

t. nrrtfin:lnfrto.,r ecc tuo'nurucdi increased automaticity ldLLri n1:}/tj premature

ventricular beats (PVcs) #rtfor unifocal !!ou multifocal pvc nr?nrxi u pVC fialflu earry
dcoymsrphleyxthmfi'linai'rlu.rnortxlrsflodcigrintanrris:fiinnrtotlxtfiicoart.ilonnfi'ulurnifri:,ufia:rfni,?rv:;ricr6luI1{:vJJrful1dffxilq"tr(ia"tbefirbrraifnlat tcioonndnulc?tyiorn:l)elRnSu
n1drfluern automariciry flld

2, Conduction btockTnflta rc'lu:;rr"tj AV node d,:orq tJrflu 1"','d fiio 3d degree AV
block fltd 1[oirlnlrirfluurr trobitz typ€ tt) uonrrnriuu',rar?n:?alw sinus bradycardia fild
fim:i'r1ufthffin' atriar fibriration ua:ldur oigitatis ori vrnnn:riflq:vion:'roafiu'lvlflrrirh
ld'jrfi6'n:rnr:ldutatrtr'hd.run;ntd }1::i.,t.ir{rlruaroarj'luntv digitatis roxicity n?1fi?1?ru..t
basetine na{ Ecc 12 teads 'hi6'irfin'nuruyta.o atrial librillation rio'lri

3. Paroxysmar atriar tachycardia with AV brock lucfiudoufiodlflu pathognomonic
EcG flo{ digitalis toxicitylounrtrftn nfigiadttorulrnnrfi increase automaticity ran subsidiary
pacemaker celb tu atrium rru:d sA node !ro: AV node qnflolrount:drrrudru digitatis d{1i

272 rrtrirrininqadu5ru

fi:r'i'rfi atrial iachyarhythmia dfiri'n:r rill:v1rru 150-250 nf1riaulfi tuffucdfi AV block tu

:ro'roirol ld.rdrulnrlo: lflu Wenckebach 2* degree AV block)
4. Junctional rhythm udaolrn digitalis n0n1l1i'1{1u110,J SA uflJ AV node lu1rucfi

n:r{ulfirfio aOnormal automaticity l;g\rlrfldl Purkinte fiber 6\tn:vfiu'lfirfio junctional escape
rnytnm dulrnlirrnufld'ld 6i{an1fi QRS complex fi:rurfinir,lttn:fiosn1r5? ':Y 'lru 40-60 ng'o

riourfi loudeutnqjfidnr+n-r;ndra right bundle branch block uriorc !finnufu:ofi1u left bundle
branch block 61d'lur-r,o:T uvru'j'Ifi QRS axis rrjduutt!o'l'Iil riun'j1 bidjrectional tachycardia fio
rrfio;vruldrjouuoi digitalis toxicity rfluor ruqdrioufi4afla{ bidirectional tachycardia

5. Ventricular tachycardia o']cfltl PVCS rjoul niofin"nunr; PVC 2 n? (bigeminy) vio

3 eT? (trigeminy) 6oriofiuniol'luns.r bigeminy. trigeminy uflv bidirectional ventricular tachycardia
iruni1fi a[ernating teft and right bundle branch block fr"ld o'ruir-rn'mrfin ventricular fibrillation

rLflc torsades de pointes flo rflunfllrfiq:Jn61on EcG l:u;fi'lr.l'i flo.i digitalis toxicity

EGG change in hypothermia'"

luieXfu{rJrudldfunr:inurlllofigfilonrog.:iir:rfionlxv hypothermia Yru,relnei'drnta.1

yioornuinn::l'lun1r:-nu1f, lu trju nr:rir therapeutic hypothermia 'tufl:-hl post cardiac

arrest o-.rtiu6rfinrrul"rrfufi rrvrttil:do.tr:ru6.lnr:r duu[:Jooso,,l ecc tunre;o',:noilr r'Y.rd
e cfi il:vIutillunrri o.tfl-un'r'r: ttr?nSoufi :u tt:tqrnnm: d't n rit r'ld

nr:r:l6uuur.ln.,:1s,J Ecc d6o'jlrfludnunrvdn:idr-jouto{n1'lv hypothermia ldrrri nr:
rfin osborn wave fir ritundu}lflrdo{rt}r'j1td1udu{o1ta,r QRs complex ua;XoG dwol sr-

segment (;:Jii o1loufinrr,tlo,r wave 6'.rndne;'lJlurl{[6uxniun-!fifiv]r'tun'nto.: oRS complex
ni?lna osbom wave o']qtfiaQlnn1?fi delayed depolarization, fin:;rrobiflr rdat?'Ifl myocardial

injury rio fi earty repolarization Rruftn nfin-lneimrfinduduirrru epicardium rrrdlrinunrrr

fio:Jndta.:nrudrrr1nti'lur?reru endocardium xl.l'trt1to'l osborn wave drvttri: nNiuri:.r:cd-:.l

qrul14fifl0'ld1{n1u u0nc'lndu-.lvtxi1 QT interval urrttu r,rrnqrulrqfinlunotl'''ln{1;?{u'itfi sinus

bradycardia, QRS interval n{1\tfl*u, PR interval umn*u:rilrY',irfin atrial fibrillation n€o ventricular

fibrillation ldtunrrv severe hypothermia (l'lu AF rdoqrun4finruriasn'ir gz'c, ill! VF rfia

qilfl{fi nlufiofl n'j'l 2S"C)

rda,rlrnnrrut duuu n.tto.t ecG o:Glrfindu riioqrunnfinruaodrn'jr go-ez'c !"',1
flo'jrrflu::o'r moderate hypothermia d.:tfunrrvt:lRtrrut dsutt:Jntto.t ecc i,rrflunr:r6ou1fi
uvimri:;i,,rnrrvurvr:ndoudarcrfiodu unvhjnT ::JiiauTriqrur4finruol"rnir ze'c d.rt: lflr{nm:

severe hypothermia

EKG: Non Cardia( Arrhfihnias qin{ nanad 273

trttii s u*ar osborn wave i,unaiti positive reftection iilaiuqntan e+s comptex'lu teaas t. tt, t ,
avL ttfrJ v6 tazfrfi negative reftection fiuinnttdaeriu'lu avn

nre; riio{lrirlean ra:.1 (acute pericard iti s)-,

fl1 1Tnmr?elr!oxr lrlduuu n',iloe nn'ulvifltirtelerurorr;'luairu sr seqments llfl:
-ldnr:r::u;
T wave rilfiornr: Touarlr:o urirnr:r duult:Jn,roon lflu q :ys: o-rri
lrarrn".r

nrl:yu# r riilfi 6uu[ oiratndu'lvlfl rrir"h rfio rirfi ornr:rSrmriro n louoyfl u sr-

segment elevation '[6'lur1n leads snr{ulu aVR rrfl: V, rroia-nuru;nr:un1o\] ST-segment ?:

sir.:qrnfi1r!'lun'rrynd'rr rdorir'hr.ror6oo rda,rqrn'lunrr; rdar{lrirTeo'nrare;fin'nuru;rruu

concave upward vsoTd,lulrlltmu tulnryfinrt;nfirr rdari'riotrn r6aacrrfiurula.ir iioh6'rg

donr:njdsuu nwo.r T wave lvtilnrrflurrn'lu tead dfi eRS comotex liullnua:r:1riu:t
nr:r duuulaora{ eRS complex LLn: T wave (;rJfi ro1 rfiorirnrrn:rendulilfirf?tar'hnru"lu

15 fi.i 30 !'rfi drrfinrr;nfi'urrdofirtetrnrfionev lnr:ulduuu nrranrr6-:l sT segment r[a;
T wave arlfifr6t1{m:.J{r rillyr'flrfirJuntty rtlrfiu e wave d,:u R wave q:fi amotitude flnn\:
tu nxr

1rru;d 2 rfi 0nr:rilfifluu!n{nnrcrnrilfiornrrr6rLyrirontT; 2-s fit lnawfi nr:nn

r:oiuo,l ST segment n.rei baseline rrfl; T wave q:no amplitude n.:eulfin T wave frniillu

lrnro{olr d{dr{o'rnnr:uiduuu a,Jernnrr;ndrrrdari'.:toarol6an6,: T wave qvfiflnuruylfr

ndldaufi sr segment ovooaod::n"r baserine llflJn'nuln'luulJnldrfiadulurrnrlurirh,ryo-.r

qrnri fiorn't:16:lyfiron

274 rrrr.irrinlnqodugru

.rL,LL$U"r,,t*vLvU-L!1.-..t^^ru1\.^t-\*i,\*r,.';v',.^u't^1,'q-L"L-.'JLL'!

npld uaoindulilfurtt1rwo,tfiihu acute peicarditis clntdouuafiis'luiuutniidufrointtdunri.rlrn

uanl?flu genentized ST elevation ttllu concave upward ttdz i'td,ttnwu PR segment
depression #iafiauiu TP segnent Iautfiuinlu lead vr, va

:cu# g T wave inversion Tqulilnu fi o wave tianr:t:Jdtuu:Jowo.t QRs complex

drrdru
:ca:d + reversion ol T wave changes to normal tflu:;g:d T wave no1:lrtflu nfiiir

c:ldrratiudilorrinSoorqrflur6oufild 1u{:Jrurt:ruarofi T wave inversion tfiu::uvtrcr

ururda.,rcrnrfionr?: chronic pericarditis louor nrEdvrlrlou niu irul:n nrl: uremia uio

neoplastic pericardial disease tiudu

nrevfi aT :frluriatriia{lri'r1e {pericardial effusion)
to'no:revr:J amplitude 1Jo.t QRS complex uo: wave rfinn.rlnuvr'r}l fi1n QRS complex

'lu timb teads drrfinn'jr 0.5 mv !!n:'tu chest teads n"rr6nn'jr t.o mV do'jrfinrrs low voltage
d.:uonlrnovlfioornnr.ifi pericardial effusion udrfiotrficr'lunrr:d{drufi tissue edema xlrn'l

lo

nr:ntrrvruenur:lfiuurr ago.l amplitude nio axis Ta'r QRs complex ttfl; T wave
orrrtdr{nr: r u'lq ris n'jr etectricat alternans rjwon'jrfiar:riro{lurioo rda{rrir'h:lirrrurrn
(massive pericardial eff usion) rla:olefr rfudnilnlx cardiac tamponade

EKG: Non Cardiac Arrhlthmias aiad nanti 275

gti tt niiulrlilttillcuan,trtnaruysat tow vottage frtwulfflu pericardiat effusion

, .vl

l:r

Ilt-i'ti].i.J:-

: vs.

zEtli t niiulvlf,ttfl?c uan,tnnuat etecticat atternans ii,muld'lu cardiac tamponade

276 remrhrjninqnduSlr

mn6['l:dfi6\r
1, Rubart M, Zipes DP. Genesis of cardiac arrhythmias: Electrophysiological considerations. In Libby P, Bonow RO,

lvlann DL and Zipes OP. eds. Braunwald's Heart disease. 8'" eds. Philadelphia: Saunders Elsevier 2008:727-62.

2. Antzelevitch C, eds. irechanisms of cardiac arrhythmias and conduction d istulbances. In Fuster V. o'Fourke, Walsh

BA toole-Wllson P, eds. Hurst's the Head. 12'- eds lnternational edition: Mccraw-Hill 2008913{5'

g. Reinelt p, Karth GD, Geppert A, et al. Incidence and type o, cardiac anhythmias in critically ill patients: a single

center experience in a medical-cardiological lCU. Intensive Care Med 2004:27:1466-73.

4. Traooe HJ. Brandb B, Weismueller P. Anhythrnias in the intensive care patient. Cunent Opinion in Citical Care

2003:9:345 55.

5. Goodman S. Weis$ Y, Weissman C. Current Update on cardiac arrhythmias in the lCU. Opinion in Critical Care

200814:549 54.

6. Kanii S. Slewan R. Fergusson DA et al. Treatmert of new-onset atrial flbrilla'tion in noncardiac irdensive care unit

patients: A systematic review of randomized controlled trials. Crit Care Med 2008:36:1620-4.

7. Brugada p, Brugada J, Mont L, et a!. A new approach to the differenlial diagnosis ol a regular tachycardia with a

wide QRS complex. Circulation 199'1 ;83:1649-59.

L sgarbossa EB, Birnbaum Y. Parillo JE. Electrocardiographic diagnosis of acute myocardial infarction: Curent

concepts for the clinician. Am Heart J 2001J 411507-17

g. Bayes de Luna A Wagner G, Bimbaum Y, et al. A new terminology for left ventricular walls and location of

myocardial infarctrs that present Q wave based on the standard of cardiac magnetic resonance imaging. A statement
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electrocardiography. Circulation 2006:1 14:1755-60.

10. O\'.i€ns CG, Jennifer Adgey AA Electrocardiographic diagnosis of non-ST-segment elevation acute coronary

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l l . Scarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction
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12. Fercri E.lmb€rt A Chevalier T, et al. The ECG in pulmonary embolism. Predictive value of negative T waves in

precordial leads-80 cas€ reports. Chest 1997:'11 1:537-43.

13. lles S. Heron CJ, Davies G, et al. ECG score predicls those with the greatest p€{centage of perfusion delects due
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'14, Mieghem CV, Sabbe M, Knockaert D. The clinical value of the ECG in noncardiac conditions. Chest 2004;125:

'1561-76.

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8' eds. Philadelphia: Saunders Elsevier 2m8:1829-53.

Septic Shock Approach and Management

nnn llauufi

gfnfi nangi
'lxafnfi fiiefina

Ssptic shock rflunrrvinqnfi inrudrd4rn:rvf,fnmnrug.o otnnr:fnsrlvfifllolilrru
o{rfunr;fifinurfinrurirhluuuriaS:lyrurad:n nr:n'rrfiuI:n nrrinur nnoneunr:rjrcrtu

unvrHrfi nnunrrn'rrilul.lnn"rsclfi ndrrdolil

*rirn-anrtr

Septic shock rflunrrufionfi rfinlrn systemic inflammatory r€sponsetrnnrr6ordoluu:.:,2

lu sepsis campaign Guideline finrrhlRrrmrmumrnh'fi sepsis, se'era sepsis, s€psis-induoed

hypotension, septic shock Uot sepsis related tissue hypop€rfu$ion

Sepels

Sepsis ulrufi.r nrrlu,jrfinloarsfinr.rfiordoitlrfuiolnltuf,e{ alulvuud.:riunolrn

nmlfierdo t6l sepsis l:ultufit systemic inftammatory response syndrome (S|RS) itilfr':J

nrrfinrdo 'lu sepsis campaign Guidotine a.fr. 2o1zldfinrrlfin'nrrurul ri toufisr:rurern
C?!ul: (variables) s firurl:fio

1. General variablas fimrrurrrn

o qru.!{finlu ,tnn.jr ge.o fiiodoun.J,t 06.0 o{o,tnntiuf,
.
iv*:mnn,ir so nioArfi ntomnn,ir z 'i'tloldrurdrlluJurJmlllu (standard

deviation) drnfitr,rriordrorrl
. rtru'lcrf')
. n?lilf6lndfiuJduultln{

278 rettirtial n q nfiunru

. firirrfiu1u6'rro.:{l-lxfl (positive fluid balance) rllnn'i1 20 n./nn trrdl,1 zn rirllt
. :;d'rrirnlrnrrnn'i1 1 40 n./na. lufir-trudlrildrfl uttl1fi'l"ltrtJlriou

2. Inflammatory variables

. .irulurfior6oq?1?tJ1nn'i1 12.000/tltr.3 niafiounir 4.000 /tJtr.3 Soiilfin6aotm

d'rdou limmature lorm) tJlnn'jl 1O%

. ::d'r.r c-reactive protein (cPR) tuL6onillnn'ir z tvirto*rnrirutfiu,t tuutt'to:gru
. :;eiu procalcitonin tut6anlrnn'ir 2 Mrlo,:vrirutiu.lt::ulrn:3.t.,

3. Hemodynamic variables n:rouu'j, fioruo'uTnfiogl"l (arterial hypotension) Inlfi
. Systolic blood pressure aun'ir 90 u.t. :al via
. z0nxl o''uTnfiotadl 1r""n arterial pressure, turAP) flounil
.:l:ar ttio

. Systotic blood pres.sure notatnl.irn'ir 40 tJ.tl?oYl 'luf,lnqi viaaoaoq"rnir z rvir

lOnd,J? tlru.rllJutJ'lo13'lu6I'1fi ltlt?{o'luuu'i

4. Organ dysfunction variables

. ::oraan6tculutfionnoat (arterial hypoxemia) Tnufr paolRo, rioln'ir goo
. :Jf,drr;oannqn.rfioufl'i1 0.5 trn,/nn./!'r. oti't{dosuru z fr1lruTout'ldar:ritr

rfiurrorrdr

. creatinine tutdan ntildunnr6r.ulnn'il 0.5 R-/nn.
. nrttt6{n?1o.t!6oofinrjnfi lotsfi international normalized ratio (lNR) lrnn'ir 1.s

tYil fi30 activated partial thromboplastin time (aPTT) 1nn'i'r 60 iu1fr

. fio,r6a Toucr:rqryirlrifi tfi rL.rnr:lndoulvtto,tdrld (absent bowel sound)
. rnfiordaofiaun'ir l oo.ooo /:ur.'
. ::n'lfinfigr-t'u'lur6on ltotal birirubin) mnnjr 4 ln./no.

5. Tissue perfusion variables

. ::Fr'r lactate 'lut6ongtnir t fin61lrnr6fl:

. Snr:rfi+,r,tr.roo,: capillary refilling time tr€ost-raru (skin mottling)

adT rl:fiqtr rnrurflunr:ifirdu sepsislrildrirnunirr:fioo ::nard'lurnrudn'lnsirrfido

dl,r u'ulunr:ifi edli.,:lfi fi or :rurm nnl'r :rr.r rfl u dr o'rp

Severe sepsis
Severe sepsis tllrufi ': n,l'); sepsis druriu{a'lofioru-.rsiolild
1- Sepsis induced organ dysfunction

2. Sepsis induced tissue hypoperfusion

u0nl1ndlunrifigii'tl severe sepsis arolfilauldernnr: rln'nn :tudalndofid,:siol:Jd

. Sepsis induced hypotension
. ::du hctate tutfiaorlrnnirdllnfi doantrl:.hrnnir + fiafillalfirn)

rniSeptic Shock: Approach and l\,tanagemenr i'la li, qiati nooafl uat btaiaf ftuft4a 279

. iof,rr;sonrioEln'ir o.s r.Jfl,/nn,iyrJ, aarrdoauru z tirTilo 1orudldor:riroeir,: rfia.o

ra ufir

. Acute rung injury 1:)oTiu6o mird AFDS) loudrir eaoyriq riaun.ir zso turir-rrud

lrifinr:ri'n lnurar:.Joo nio paoTFio, tioun'jr zoo tu{ilrufinr:o-nro:.n0,::_luro4riuu

. lyd':J creatinine 'lurfioolrnn,ir 2 ln./on.
. r;drJ biritubin lrnn.ir Z lnJnn.
. rnfiqrfianrioun.ir loo,ooo/rJ:r.!
. nllrt{nn'tra{!6anftcrln6 Toud:yril INR lrnn.ir t.s ryir

rfiafior:rurcrnrnzurilunr:ificduro.r severe sepsis lvrfiu.jrfi:.n.:dodrdaurirrnngflu

nr:ifiodtin'rr: sepsis niu floarrsoanonnrriaun'ir o.s a./nn.srt. ::cylrn6o rfiondriaun.ir
100.000 /rr.t :vn":l rNR mnndr 1.5 rir rfludu d.rriuntlifioda severe seosis da.,:onru:rr

rdur6urniu

Sepsis induced hypotension

f,rnrudnr:ifiedu 6a

. Systotic blood pressure fiauni.r 9O ll.:l:ot tio
. Rrud'uTafinrodu lmean arteriat pressure. MAp) fioun.j1 Z0 ur. :ar nia
. Systotic btood pressure ooo.:ol'rn.jr aO u.rJ:ovr 1ufluqJ' nioaoo.ro.rn.jr 2 rrirlo.r

siru rfi u.r ruulranXrudrnfurir.r orq riul

rfiuld'irrnrurflunrrified'u sepsis induced hvpotension finrudrdouffirnrurflunrr
ifiodunrrv sepsis ludrulo,,r hemodynamic variables !!a3'tfid{[nn,irn't mean arterial pressure

l(MAP) ldnililaun'i1 zo .:J:oyt rda'lfiatn:nifirdun.t?y sepsis induced hypotension t4io

severe sepsis ld:rnr5rii.'rdu adr.:'l':fiorurflrnvru?o\tfl1: resuscitation lufi .rrj severe sepsis

nia septic shock tu sepsis bundre ri'rR,rtd mean arterial pressure tJ'lnnfi 65 ur.:J:or n.,,:t6r

Septic shock

septic shock nlnufir sepsis induced hypotension df,in,,rfinrun'uTafinntioqjufi.fild
or:Jr o dr,r lfi u.:vra ud.r

fiod.rrnn6o rnrur{tunr:ifiodu septic shock d'lfisr:riratir.lfiu,rroudr lrild::uirdo.,,:
1fi ilSrrrunrrriur nria u rfi uolo

Sepsis induced tissue hypoperfusion

sepsis induced tissue hypopertusion firrufi.'t nr:6ordodrhtrir6frnrrrJn''ulnfinn'r ::rri!
tactate lu16ooR,:riu ?iaiaom:oonda!

280 r'nJ'fninqorfiugru

ils16ri1 [fi n $a;ils1if,t16nu1

rdo rfionr:6ordofr1ru:.ltuo:fi:JirrrurdoT:nd'ruru:lrn r:tfiont:tno.:dt: endotoxin vio

exotoxin rirtfifinr:nr{u monocyte, neutrophil ttflV endothelial cell 'tfiilfl'l mediators drll

firir;rgfio tumor necrotic factor C;NF) t[a: interleukin-1 (lL-1) dn TNF ttn; tt--t dci]J

n::{unr:fi6r'r cytokines oirtl niu TNF, lL-l , lL-2. lL-l2 la'l ix ri!nrln5;{u complement

pathway, coagulation system, platelet activating factors "'ln1 drr.rn}ifi inflammatory response

n'rr lil'luir,rnraua:ri, trioiur:eir,t1 drnrirdfinrlnfi rrasfinr:rdotJr 'ldto'l:vu tlntilut6on

drunu4id t"o

S.|rn
(actqit tn

',il:::,*, t W ]u.ltt'::r.

l*l$+trlriliff bi#tr'fii,,A::i:pi{:,r'-'j!i;)'-

lsnddox'xq r,6orieiiai ;:t:ififi*" tncreaxd tNCz ,til',Tilf .fj.**' tuwnr 0r

dFp,[o#glic,'*e'€ llEii*i{yUilhf6le$i,tna.i;'n-.'ltrt)rol.rct!,tsjh-,i,rxr' rt'5011?;v.;'tru*Yal

q MuHorlrrf
ti(d?fli,*" t"'"o' f*-""r y' /T:::,1Nd',to)"o-.opnneu'n*r"nr-isF,rdo.priins

DLE

rrtret dl'os

xin;n

ffT,

tuNugfrd umwutEittfrauatwatEgizinutta,t sepfic shock3

nr:rdarvrirfrlo,:::tL!'lnn riuurfioaoc rfiodu#,1'lu:;n''uXnnln (microcirculation) tta;

::ar}lrlntn (macrocirculation) lou1u:;n''llanraaYWl red cell deformability, disseminated
intravascular coagulation (DlC) LlAg vascular leakage drUlU::n"tllj nlnq;finre: vasodllatation
[ro: myocardial depression d'rlvaitfl alnunrrl:r tirfirinrrvfan'

'lu:J:vt6ura.r red blood cell6 fl 'j1n?1tJfl1rr:n'lunr::JilgtJir'ma-tffiatfioollo.tonal

(decrease red ce deformabirity) d,rnn}irfiordafrrro, votiruvaoa16ooclofl'ldnl:lrndurra: rfin
nr:qooYuluuoon16onnlawirtfirdorfialfiirloontteutta:f,t?a1v'rtflono' nlxi Dlc d,l[na?1nnlr
ni:q! coagulation cascade d{Nntlirfionrr: microthombosis tuvnooldooturn16nrir'ftinrr

lnariuu16anii.tana.,,:rrn;rirli microvascular permeability rdlduriolfirfielnr:tfiagr:riraonlrn

naanrdasua;nr:ul.njrnrror'ar:d1*1.t' '' ltju :Joo ln fi'lvri'r ndlr rdav"r'lc tta:d o0 td tnu

fida4nornnr:fintr'lufle1:iurl'ir n1rlfi activated protein C d,: tflu anticoagulant fl1tJ1rn

drlfinr:lnnrisur6ootu microcirculation firfincrnnr:rL{{fi'rla{u6oqdfio:JnAdduld"=' rroifleqfu

Septic Shock: Approach and \Ianagemem Enli ilalJurt, qiafi nangi uat fuaini $iafiqa 2g1,

!'j'rnr:}inlrinuldxu activated protein c hjld!flunr:inutnn:muufir ril1vrirlfifi nteeding

comptication unv'lrj'ldaoo'n:rnr:rfiu6isrlu seotic shock

septic shock ?'noul nr.lrJ distributive shoct< rn3,,rdrfja.,llrnnalnoiruun'womrrvfionrfioern
vasodilatation r!fl: vascurar leakage"o dr'lfi:;oiutt:.:drurtulatynon r6ondru nrunnn,: d,:orn
trl:vri'lnrrruriuTnfinnorn.'rodr,:un uanerndu-,ni!nr:rirmurorndurdoririqfinilnq'(rransient

myocardial suppressionllouranr:'lufirhufifint:6anfilrinolf,uaosianr:inrtflunaruru,u nr:
rr:mdruraio,r echocardiogram r;nunmlf,rrmn'tunr:fi:"rrr-rlorfir'hfia,:eirdrufinJn6'ldn'.t
tflua; 40 {ir{rJrutundfiir,vl,'jrfid'n:rnr:rfirdiorgtn'i'rfi:Jru6onornnrrfiardofilrirrnruftn

nfirornr:rir'rrura{ndtrrdortrle rrnaur:n:onfinlilldo:ur.irnr:rirrrurornfi.urdan-rlo
no'uurrflurlnn'n, u'lu z-ro iu uanmndti'lfi:rfl'Jrunr:na flua.,,rrianr:'ldfuornirgo.rrTr'lordil:l
d,::-i.,rf,rnr:rdalnrjrfito,:nr:nnrun-rro,rnd.r rdorirlq,' n''trranr4fifr z

-'- *^,r/
>40
,/

Sepsis t ith out €hock

aVp-o-lru--mc-e--iP-n|otuddon

80 s0 100 110 120

EDVI (ml/m2)

zttuugfri fln,t Frank-starting curves lu{tJzu se-ps/s, sepflc shock ttJiuutfruytiunsiu control'7 Iau

LVWI 6a teft ventricular work index uat EDVI 6fl end-diastotic volume index

lerua:illrflr6oi:i urccrdurflo,trYunrrlfio:Jn6lar macrocircutation Totfifi myocardial

suppression, vasodilatation lrfli vascular leakage i? fl"u microcirculation loufifinr:nnnr:

ha riaularrfian r{rdrnan rf,ooaurorfin uocnrrvnr:u6.:rl"rro,r lfianiifiorjnn'hj rirhirfinnm:

orlglobal tissue hypoxia ttns n1?c multiorgan dysfunction syndrome ltVOOSl 116

01n1Til1.tn6fifl1r

n,:l:;noufirr '[d r'ruldu 6vre:s5r firfl'le r5r ri'ulnfifiFr'rnr :;fi':rnrrrifindrnnn,r

dudrornr:unysrnr:lrfin,sro,onr:fin rd'atuuoio:aiuri s1n.r?yr1{:Juurirle In;ly"n riau16oo

282 rrmlrrininqnClSru

lu:ru:u:nll fJun'ntru: warm shock rrnlu{rlruu'lnllua'l?fifl'lfl1l1lot cold shock nsorrtititJ
fiu ornr:dr.,:1 rs6du1u e+-so rirTrl'lu{rhudna fluondanl:inur lu{rJrufifialnr fnole
utt'r?i60n?ult1\tduliuolnr:tol organ dysfunction o1n low perfusion rrn:l:rirl:J{ t'tOoS
ldtu{rhum,'rn{ildfinrr:.rfinrln6niafrI:n:J::drd'ro{rfiil $iu dilq:rr{of,r tlrvrru nut:r t6n
urnfi or }nn-ru6r lnr, ur{oit I:nl.t; r5l rrnl{rJrufrldiu corticosteroid ur tflutrnruru orl

lrifiornr:roonrr6ordoddnrlu {fnurr:fiolfind.cnrr;flu{r-trufrfi}n rrovnm tdu'rdtn6i'lr nr:

n:?e ln'nuruyo'"nnrroirr'1 ovdralunr:i0eii'uld triu stellate hemorrhagic skin irlrlu meningeal
hritation sign 'lu meningococcemia rio eschar tu scrub typhus

nT:ifirdtl

nrrifud'u'jr{rhufinl?r septic shock otduorntfla.rnrvf onuovrn'nXruta,t slRs d'ltJ
riurdn3'rurarnrrfia rdotu'ironru {:-nurfia.,,:tfrun-raai,t.tta.:6os fiuo0 rtiosrrdsr n'.tornoiurv
fr fi o rdo lunr:rirnrrr rc rdamn t6oonr: fi ud'radrl z-s ninluuirrrutirll riu

nr:rj:g tfi u6?1ltu !!i{na\tL6 "
nr:iinurtu{rhu sepsis tiuuariunr:'ld:vulnr:1fin;uuunda:J'l:6unr1 luut{ !!ni

nurn:nil:n (severity scoring system and prognostic mooerl ldfinr:1d;rJttllnr: ':vtfiuo{
nnrutfio uoidfiur'tdurndqn6o RpncHe ll score n6o Acute Physiologic and chronic Heath
Evatuation ll score" loa'ld te flo{unr',:vrurisi:inurd uJduurr:Jn,rlu z+ d'rlllrr:n niu orq
cn'rnornr:'tufl rluiu un:qtnrndugru Toufi nvttuua{'::n'fi.r o-zt

ruri'ir npacHe tt score f,'t 'nnljoflvrurn:oil:oldifirrrithfido,irrinlunr:rj:: fiunT;t6iol

uscroirrdet'oo,ilouiluurvnorh:l1:1:ddu1inl6rnrr4lunur::.'tnt oSlOTF:nAl"v"oour"r:fniiofioSeenpslnisr-rre:laalteudrvorr6giasnuFrfaiirludrelfiAfissensisomueonnt
morbidity lddn'j1 mortality riutoc nTr'ld SoFA score d tnoldrunr::J::rfiunfiT dla{oiarc

o rfirr

n11in''1
rdnnr:inur :vnar-rdrudrudrn'q g odrr f,o

t. nr:rirdorda unvundlfiarrda

2. 'lfi intensive lile support

g. ntilfinrrintr6ul dfinri'nXru'irrirurir'1fi ernnr':imfl septic sno* 6du

nrr'lfiutfi f, rwun cntrh{n uild.,tfi e ldo
nr:'lfilrrJ$6'ru:d tvrt:filoejlt:lot5':1u::u: tznro,t septic shock rsn"'l'lfidn:r:on

Septic Shock: Approach and !\{anagemenr Tn1, ilaxurt, qiart nooogf uat haiai fiiafiqa 2gJ

n4rdu" nr:r'n:vin'un:o:reir.,:nraodl,ro:r6uordorruusirro,,:nr:finrdo [o:nr:n:rcda
dratjrrc"r',:1 orndrhu (miu gram's stain, AFB) ecfrlfinr:6'o6iunr:1fiurrJ4'6.ruvjlnsu ur

rJ8firu:r''bflutie,,ru:nl:datR:arnqrrdadrflu}rdlulru:riuuocrdonnnrlrr:rdaoiror nn-lrrr ud.:
oT:rJirurrJg'f,rudfirfiurfiod,frrnrvoiadoriu uancrnfnr:nlro-ouueirfiordournrirld niu nr:
drain n15rola,t[rjon oo}l (foreign body) oan[a:nllairn'oovaru:noonrrc stRS ldodr,J6-"

Intensive life support

{rtr adldf',nr:inurrufiuornnr.:c6onatir,r:rn rirTnunr:lfior:rir arn:;{urirlcun:
uooo16on nnooounr:'lfirdanrfiafidorirdr:iri'q:r:oogon.irnalrdtdiunr:inursrrr nfi,' nr:lfi
tife support di:rnoilrjd'rl nr:'lfior:rir nr:ldurn:v{un-rleuavrnoc16an nr:'ld hemodynamic
monitoring nt:hi pulmonary support n.t:hi renal support rra;nr:liarrr:n-tl:nrirrda}J

nr:lfiar:rir {fl uid therapy)

nr:ril'lfisr:frriua'ua-uu:nlourir nia.rclnfirhuarco:finr:sroor:riradr.rmn airurfio
rator:rirriu 'lurir.'rrirfiunr:1d normat satine sotution (Nss) rdormnyrld,iru firj:;fininryr6

[oy?la1!n nr:ii 1fior:rirluo-rr:rr5r niu s00-1,000 uo.'lu ts-oo urfi udrueionrnto.,rfirJru

uo;I:nrrr::uutrto ua:unoordoodfia{ rfir nr:'lfior:fiare'tfitnar5rlnuarduua-nra,r frrio

challenge qrrnr:r.1fi r lrrudo mean arterial pressure (MAp. tri.rld?rnila:rma,mut r'luortlto.:
ul.systolic pressure duna.:'luorlra.,,: diastolic pressure) rrxlru 65
:oltflulnnlrtt

dr6'ry1u{rtrufi1ilfi rJ::ifi nrl.rdulnfi nc,r

ern[qrunr rt g uoa,rnr:1fio.r:rir'lutir.:u:n are o:drlinr:vrh.,nura,:rir'lc6duToufir
cardiac output rcniirdu uoi pulmonary capirary wedge pressure (pcwp) crdildulrilrn dr

l#or:ri, rialrj (laulo B) Fil pcwp rri dr.lodr,,rraqrie'lurnr;d cardiac output rfjrfiarula'hj

nrm# t uoo.,rttulvrtnrlit fluid cha enoe

Guided by c\rP lcmHp) PCWP (mmHgl 200 mU10 min --l
100 mL-/10 min
During infusion < 10 < 10 50 mV10 min I
After 10 min < 15
After waiting 10 min 2 15 < 14 Stop
>14
a>5 Continue
a>7
L, <z Wdt 10 min
A<3
2>a<5 3> A<7 Stop

A>5 L>z Stop
sti a>3 Repeat
sti > 2
a<3
L^<2

284 rrmirriainqndugrl

o

{!
3

E o-

=
=

e tnixnnllanitunup*fr twotlagaetn pulmonaty artery catheter A) Frank Stading relation

tznitt LV volume tlv cardiac output (CO) uflz B) pressure-wlume relationship"

rfrrms uaol'jr pretoad to.t{ lurjfi; !'iifl.,ivto lrfir nrnlfia, :rirrfjll, nnjllod {:Jrlarerfio
pulmonary edema ld*

dtrir:Jir,runr:ri,do'rrflufiotlfitu{t-hu septic shock 'lu'l:usu:ndri*rtrtrnr:inur {

r{uuuu:rjr1fi'lior':rlradr{rjou eoo uo. turirhr.rrr:n lerucrnnr:frnr,tto,tf,rmtrtrir:ininqn nrn

imarqrmcori nrulunrnunrsnSiii:'nnurlro lou :n. un. ltuinri rfilfiqn unvnru: tl'jr

Survival rate (o4)

'100

90
80
70

50 ; + !-Fa: : =1. : .raF _a

40 Received > 800 ml in 1" hr

30

Received < 800 ml in 1'' hr

10

01441256

Date atter treatment

uwgqi e uaotnttnliautfiaudmtnttflafiinlultnututan,$tlza septic shock lldfuanit

utnnimiasi'triv aoo xa.'lu r izlu,t nufi)tuiildiunnhfiaanhil?uluffinri'tt'o

Septic Shock: Approach and Managcment ?ffi1r 1laaui, tin$ na,toEj uaz lvaiai $efiqa 2gS

h{:Jrud'ldfinr:r.frrJlnnil SoMln- Bo0 rJn. r drf,uu.infia-or:'rnr,:rfirfiinn'rnir{drud'ld

iuor:rirrioun'ir eoo rro. lu?irTil{u:n 6o Saunc 4z rfiuun'uiorroc zz'o o'',,r unqolullerunil'i +

nr:ldurn:v{urTele ua ;unaa r6on

'lun:rifrn:rouu'jlJ?mnrqr:frluilaac16oo,uorfiirurfiurvloudr ruoi{:_huri.,ro{lunnl
6on unntiotrrirtfiuTn::{uridluorrnonr6oo flelriuln'ld norepinephrine rfluarriilfiu d1u
nrr'ld dopamine riu rio, :rur1fi'lu:rudlrirdurn'anr:rnn tachyanythmia nr:'td oopamine lu
mrooirl rfiovirorardr renat btood frow 'lufloliulrluu:ritdorernlilldrirlfifi renar perfusion
rrndu uioilo,,:n'unt;lnrruld'

nr:'ld norepinephrine firn'ngru'Jrorol:6n.Jr dopamin" rdooorn nor"pinephrine d1l1:n
ru,r'r::d'unrrrd'ulnfintrau1dr5'ln'jr dl arotfi sptancnnic perfusion rfilduldun: ri,r rfior)rgnr

tachycardia rlounir dopamine26 dlu epinephrine o.royr'r1finllei'uloficrrfrilld6oil rrshirhi

16an}Jrduraiurvnra'lunonr"' finr:flnurnr.linur{:Jrunm:6anornn116ordodru norepinephrine

dtrn"r dobutamine r:liu! rfiuuriunr:td epinephrine iltil.i1rlinl:hi norepinephrine d.:lriu
dobutamine i:lrjf,rlr:nnna'n:rnr:rdudina.ild usiiltuir{rhufi uurliln'?!ni?er^rl::riu serum
lactate ufly arteriat btood pH oirn'fi{ilrulunridlfiiu epinephrine niir.rodrlr6ur ii,ro.to

rj.ruan'jr norepinephrine irlriu dobutamine riru'lfi{fiuldfi rdoolil{druoirll lorir.rnru

:rilri,roirJrvnru'luldfin'i'r epinephrine rfimadrlrdur"' 'lunr:r,ld e ldalrlurn::{uri.:10!!o:

f rr.rnon rdoofildilou'lu seotic shock

nrrxd a unn.:urn::{urir'hun:nnonr6oordtdrjo u septic shock

Dose Cardiac Va3ocon- Vasodlla- Dopami- Indication
IMAP<€5, ad6quata
(g/kgfmin sdmulation sficdon tation notglc
p|€load,
or (gy'min*) Gr) (82)
Initial drug use
Norephine- 2-10' ++++ 0 0

phrine

Dopamine 1-10 ++ -} ++ +++

10-20 +++ +++ + 0

Epinephrine 1-8. ++++ ++++ 0 I co,

Initial drug failure

Dobutamine 1-10 ++++ ++ 0 I co.

combined with

'tlnorepinephrine therapy

286 rrmirrin1nqnduSru

g {oruurru4uamrinvt {cFc} 6t}?s4lflnJd!fi11! seyere seFbA€Fk strckt 0fl sticker {rhtl
d0?u €e{€r€ sepsis septc shftk (r}
':oid|Jrlal...,.-----.--.-,--.--!r ([cuu'|nd]
l€trDcLrlltte !?a1...............-..ta

ah MAP <65mmrg (2) source ldentification'' + control flrlr$r Organ ard mebbolic support
Adequate antjbiotickr narild---.--------u- . rntub€Uon !li: mechanical v€nfllabr
m! b€seline s€fum hcble
{rtbRmz respiratory hiture)
- $rEical dralnage tf Indlcat€d
. Renal replacemeflt tEftipy
ir'rstlrljEfiu lx ro
-ld iv fluld rate so-1000 cc utr]lr{nufl iE}rinEYentlon (5)

Iu v thrrYo es tr No

-tliaAu lntra\€scuhr vdumet2i
-ttraiu tntra\rdscular vdume{1)

L Adeqtlate r,olur|e - rh h'EslE rPmcrbJPd)rg- c\P l&15 dril:O
(cvP !1Ea pcvi9 1t18

2. Accepbue BP r.lh6:lilf;l* cw l&trnrr}i cw un:tlarnft1fii
c\P 1015 od+o
12al_.--.........._.....

2. l9 VaSOFeSSOt

trNorepinephrirE ao2-2 uEl kgr min

trLrine >osmf kc/ hr #d tloopartne 5-r5 ug/ kg/ mln }lia

c$r s€rum bcE; Gurn:ffi svc opagox) a *r MAP <65 mmr€ u{'rld wsopressc
fimreJfl
ts\,,c o$at r,llo mi)€d \ieno.ls osat to% - 4drccortisorE 2m mg (f,ip h 24 hr
(rnni'rx lirs5ldd) ttcae arl qa! $rtaqn urldmufu z
lu
fi4- tjtaix intrMlscular vdurne sbtr6

s. rh MAp <65 mfl€Ifi AdEEtne drF &Eb dce

3 Artquate pertrlslcn . fh MAp >gommr€ltlaoltlri \GsoFrespr
a'r (keep ft AFlsdrlo 65-90 mmf€)

. frt <3o%ldreoBadfi Hct>-%
. lEt >3oX lq Dobdamine 5.2o ugl€knin

- G€l achie\r€d : ad€qw*e ts$e UAP . ltlltn rrLr!€l 9r€asure
pertuston mdq e ihlltr .ivP r Juc|rl.r !€nouE pfl.$rrE, CVP . CenbE I v€rorE trc.slrr
Pt$? - F|\lir,on6ry clrlkry s*g! p..!!!t€
- FreoLreft as€ssnefil S\E 0: |.t - SlF.rior !.n3 r.v6 .ryEln 3ltul8tan
aBP * lrici6l bhod l'.slue

ar. !*8:rcte",-.rtirq.!(vh!r.,courkqrroE, l4udr?ndef'irulnntda.rrl{yahftdnb!!6!:sri1*tirrrr1hric.JrVt Pdi3i€-5*rc.,mrtu]pn3.l bfr/il!uE.temrlrnE!€
SAcccC.& P flr,atr r€t4rtr rne.n !t.ri!l p.EcslrE (MAPL65 rimHg
( ) nMl]lt! l.afi*.rni *{ (r) r|tJirismriarfulrlenrnfl:u *!r'. srp$ erE.€I*ic rlEck. (2) rt<lm:m:gulmrr{r}?!r{*r!di
4 (!0!i'E:riErtrtrrmrra6, (.1) crc
t1: !€.,/.f! 3oFs.,t ptb slFck (3) qtflrirtYtr_,nB&rrnt.d tltarlocutur.l lltl:rl1':tt1nn{ftt
m.mrfi|.ru{SE, G) lrrnmitniLlnYrt*rb!fls.;

' ljrqnliMul'inrifirE a:s&{t?.rF th#ift?rfl$ii?rr'ct +rtltufnn oGlli|EE. aP. Lad Ml't &rlitJM, €t€L tuoiring€Fc
campcign: htgndiqml Elidrin$ fra mEna€tmant gf sse:{e .ep$i rrd rcFlrc Ehcck: 2oo8 lilctFirc €ar. Mfd zQq 34: rr-60.

waan s

septic shock: Approach and Management zrn1i 17ni1ui, a{nd no,tatj uav'lxuind $ixftqa 2gT

:tTosnr ro,lnr:lfi hemodynamic support fifnnrdalinsr:;c'l tissue oxygenation

fnunr: r"u pretoad 'lfivlorrur; nr:tdurn::fiurirhun: oaqrfioolururnuad rdoinurfiq-
nrtro'uTnfinraatr'lfi.lilm'rnir os fiairrq: rau uoihirfiu go finfirrn: rar un:nr:ld invasive
monitorin g irr rilnr:fnur du1 r;r"'.1 uon,:'lu ru,ru4fi d s

flonr:fiqr:rur t;nornr:t$ul.runftfi s tunr:inurnrr; septic shock

t. lfi russ luo"mrrr5r ts-so la./nn.'lufi ruarrLfiau llnyoon,lrlroru lylr;n ufirhr

diorqniol:erirte arrrdr'lfi cottoid soturion lijokjnalouornia wSS
z. nlr.ro"uTnfindsolfild6o MAp oehj::urru 65 u.rj:oyr uotufi:hudfirj::.1:fintu

d'uTnfierp Mnp lrinr:riaunirerrud'urdlnldru 40 rr. ra

3. vasopressor riduturos{rufirniaul rdrtlroriiohicr:rir uri{r_harfiu.:naudr

4. Central venous oxygen saturation (ScvOr) ifilr; rfiil microcirculalion tfirirluonruii
dlirli'rn Scvo, firurnn'Jrria ryirn-l z0% rdrldril aoequate tissue oxygenation

5, n1tflo oxygen consumpton rirkilcrunrrtdrnio,:drEJfirfllq lfroflo worktoad to.t
nr:?rl u'lc n r:'l$ sedati on ua ;nr :nerarulrn fi nrulo unr:lfi uraF d riud'urn

o. fi,:::finlirora'jr:J:yFrEnuro,rnr::-nr+.rdua{nir:ys: rrnrdld'lunr::'nur?u:::.rr.r
'lnoriuuTafi ntar{r-hfl nniur{rdntc clqndnni,l

Hemodynamic monitoring

{ilr anr:Idilnr:g uafnurtunad:Jr ui n q ntt.,rfi nr: rilr:;i,r or nrr vitat sign s nltFlt.te

continuous EKG rda'rcrnfi rEJfinrr:.r ldu'rriav-rlq r6'uru'sro-.JvrvornT:an5ourn:cdufrlodlfi [rny
nrr:J::tftu intake llflJ outpd lurrFiasd?Tlr nr:lflr:y{,rdru centrat venous catheter rCVC)

tlSo pulmonary artery catheter (pAC) r[R! intra-arteriat catheter ludnrufiirirldq:fi:J:;Iflrf

'lu!'itrudinrrtd'ulnfinn'ryiorirri'.,rr:Jdsuurinr fuuriirda1afifiog1ufleo:r-uhjortr:nfigerildir
nr : rfi rt yi.,ro".r n dno ;dr'Ifi d'm:r: o or drh t d.rt{ur",'

rfia.:orndlhu septic shock fin'w hypoperfusion (niu nrril'1.r. n'uIafinntror. flaorry

nan'l) 'luodni-tfirrurfiofic;inurloufi rflrn rfltflu supemormal flo\r hemodynamic resuscitation
urinairrlirrfludun:ruilrnii*ulnukildri::TEslfo,, fleq!iuq-*lfirLurFofi r:J6auernrirdrflu supra-
normal tJ'trflurfifl{:infiLreifltfil5xfl5ulquriun.ir earty goat-directed therapy (EGD! druu;rir
b{yri nr:inprirlldrfl ryrr r a-t dol d'u'.,.

to1. lfi centrat venous pressure 10ve1 ::r.ir.l B-12 rr. (lo-ts rl.rir) lu{rl.rrfi

rnrulora.id ria:;y'jrr 12-15 ri.rhoyr 1rs-zo mr.rihy lu{rtrrdidrnCouirumulo

'hi uep fidrmnn'irn5o rvirnil 6s ll.rj:oyt
'Ifi:laorr:sio?i'illwnn'ir 0.5 uo./nn,rrirlll

288 rrtrirrintnqadugru

4. lfi Scvo, lrnn'irviotrirn-u zo%

EGDT ddo{n'n1fifurflrnlrud",,:noirrnru'lu o ri'ilur ndrmnifirdu septic shock lnu
nr:tfinrair n'r:'ldurn:;{uri'rtouncvnon lfios un:tdo scvo, fiauni't tovo {inurn,:o:'lfi
rfiaqrdolfi hematocrit lnniryiorvirrYu gOX rrncfir,ir lfluorqtfi dobutamine tfiotfilrir ScvO,

trilfinu6o,,:nrr

tunrrv6onfrlrinounuo,tsionl:inurldoufiu6o nr:tfiar:rirrro;nr:'ldurn:;{un-rlorra:

rnaorfionnfir {rJTurinli:1nr:lai cvc rfiorhsrfiuir cvp rirvfirrflurrurvrro'tun,:trior:rir

otiudr nr:n:mm scvo, 1{i dornnr:or:roita:r;f6aso'rorneru cvc) i',trfluiidirudqntu

nr:in:cuulfiotiu !6an microcirculation r[run1{d mixed venous blood oxygen saturation

nffriu,rdludllrrTnundrd:inru:fmi'uiotndrt'rt6;rdi6t-toosrcirvoor,n* 6*llufi'op*oulnmttounrrarruyu4afritfei ryo catheter) nia svq fi.rul'jrdrfifi

*a: z

nrrfinuroiorrruj, {rlrufioqj'lunrr;6onc:fidr scvo, fieiro.lnir svo, ?ctJlru 5% d{
rfudaruuvrirluflnliuTnutrfitsrir svo, 2659o u5o scvo, >70% lunrr resuscitation {rJru septic

shock"ttl'

aurnro.lfiffi rdamLnrJrufin:'lddrir scvo, < 70%

rt. lfirirnr:ntrlrio central venous pressure l11n CVP d1n'j1 8-12 tJx. roYl (10-15

ur.r"i"ry lou{-i,l,rufienrirloi ra{ I.rfvifi1r:rurdr tluid challenge test

z. rda cvp qrn'ir o-tz rJ . ?avr (10-15 tll.rirl vrnn:rot't hematocrit doun'jr so%
tfificr:ru{fi packed red cell transfusion trnlrififlorirr

60

o40

s

20

0 90 'l2o 150

180 210

time (min)

uwgii a uan,tnatadtniuizzniu svo, tta: scvo2 lufninnaailuantzttit't1'o

Septic Shock: Approach and luanagcmem Toli ilaauri, a{ni natati uaz lxaini tixfrqa Zg9

'100

90

=5e8o5

Ezo

a60

55

50 01234567 I I 10 11 121314 1516

Days

--.- SvO, -..a-. ScvO

una4ifr t ugannufxtluittnix Svo, uflr Scvo,'lu septic shock modet nuitfinlsnld uotat

dfia n a #u fiu fhl da s fuld fr"u

s. rfia cvp 4,rn'jr e-tz rrJ, ror (10-1s ff.,.rir1 un: hematocrit qlnir so% ufir

fi er:rurifi dobutamine rdorfil contractititv

Pulmonary suppod

fitJru septic shock ?:'tux tnc;fi acute lung injury mio acute respiratory distress
syndrome (ARDS) {inurnx:'hioonirqululufrurule'ld iu{nrtvt'fi respirarory faiture nr:ld

iiunr:tirflvrulqTnutd trng prorective strategy ndrtdo nr:ld lsr:o ruladr qo un.lnn.1

nrrld peep niohiffl':afi oxygenation fr ory rs (Sao. > so%) Iouldnrurirrjutalaoninu
(Fior) < 0.6 un:r:{rhitfi ptateau pressure rfiu so til.fr

Lung protective strategy dour:noaran:rqrulfti::Nr.u 1o% ludil?u ARDs dariatlft1

conventional ventilatory strategy"s

ernnr:6nuri',lludnHlu: randomized controlled trial'o rro; retrospective studyor vtt.r.it

lu{ilrufifi acute tung injury xia acute respiratory distress syndrome rfiar{ucrnnr.xfion trfir
nr:ldirar:riratir,rchfifi Iouvrurflrr'lfi:l3rrruor:u*rfifi:-hu.[6illuurinyiufi irrrurrirrTrrso
riounirrlSrrrunr:rltor:fraonrrnit.:nrsrniadtiunj't conservative fluid management lou

nuirnr:lfior:rirdreLi6ri'lndrrfidrurirulfi::e':roan6rculurfiomo,rf,:Jruo'du unyan.irurur"ud
flilrufio.rorrYurer{o.rdruurule Iofllrirfrllanrorfinnrr;lnrrr firo'ngru.lrnr:tfior:rirotir,l:rnl5r

'lurjrr u:ntotnr:inurnrr:6on (early rapid fluid resuscitationl ourfiu.,,:rrradrlfiunr:1fior:rir
firui6 conservative tate fluid management lurj.r.rrTufr z fi.riud z ta'rrilinurnm:fancrn

n'r :6or lda fi n r r il ffilr{uf ni:l ri'sr:rnr ud sl'r o,r o'

290 r'rtrirrinlnqndugru

Renal support
{rhud6ono{uruarofinrr:lnrrudrlriu hypercalabolic state rir'lfifita.rrflad,rurn fi

fnsrnr:u,fibnmvfio ntto;fiqentJjrfi f, or.irddevrir renal replacement therapy nialrj 1u

flllliuti.rlrifido4n'jrnr:inErrqrrvtunrird:ra.rlodrui6lno:firl:rfirninrrrrrnfion'iTdulu{ilru
nt;6oncrnnr:fi0ldo unn6{q uai.:r'rrfludo.:'l{iqrrruryrrulunrrt6oni6nr:fnsrn''.indrr'1fi
tvtnvflr.:flidntuao':{rlu trn;finnrr 6t'ttJ'tt01to.tfl0'tu urura ttda; ttvi.3

n1:lfia1r,n?

nr:liaur#nortln;finrrrdr6'r1 Inurtr}Jnr:tri enteral nutrition riuiidnrrr:ar.rdqor

ruoitun:fid{rhu'lrisurmil enteral nutrition ld nr:hi parenteral nutrition touri, nun'lfild

na'o,rru zs-eo kcat/nn./i'u dtrj:rnaudruTri:fiu t.a-z.o nfir/nn-rfu nr5lulatn:n 30-70% unr

ltfiu ts-gox no{ total non-protein calories

Innovative treatment

sepsis'l n?lvll']lld ' 2-. noo- \tIl
4w u.,

n?1:JR',t'1t1Ul
LUu!aA Uflo{n1TlnD1

t. urlunrjl corticosteroid firJ::Iuuilu{rJra refractory septic shock fi n'lduirfinrrc

critically ill related corticosteroid insufficiency (ClRCll nr:ti lututntfiurMriiu
"otticosteroid
hydrocortisonelri!fiu 300 n/'riu rflurrnr'lilriounir s iu rrri{rhu refractory septic shock43.44

fir,rdngrui'ra'rrr:nrsjllanranrrfnrrnT r:6onlddtiqnrutu z iuviir 6rlttrnrrr"nur uncaoan:r

nr:rfiu6iqd za riuorld orndornrartrrrrrmir:ioinqor nrnitroru:qrcni nru;*rvrEiqranS

fii:rrrEJr!rnlqB ra, vrry, :rfiugr inucio rrnsnru;" rujrfasn: +s tot{rJru refractory septic

snock fildi!nr:inr+r'lurta{r-huorq:n::rfinr:no:-rduo.:fi6oian'r:ldirur hydrocortisone flu1n

lrirfiu aoo n./?-u aufiM:0uunurn::fiunr:fiudrsa.,,:nnan 6aoua:ri'r'leldnru'lu +e srlilr

rnn,,rldfunr:insr rrn:{rJrufinarouo,rrdonr:inr*rdrr hydrocortisone rirfia'n:rnr:rfruiinnhn'jr

6ndru nr:n:ror:o''r.r baseline serum cortisol rrnrdrq'rn'iruiarrirnr ss r.rn,lon. dralunr:nurn:ni

nr:fia:Jduo'reiont:fnsrdrB corticosteroid lu{:-husrrliluldrioudrtd lnufinruh (sensitivity)

ioflav 85 llnvett d'tnlt: (specificity) Solns 6z turru:finlryrofloilnl:srorldua.:ro,:?vriu serum

cortisot Biofllrnr:{ufit corticotropnin zso lil:nnil nudrl firirurjrutunr: urn:ninr:sro!

ouatrianr:insrdru corticosteroid orndaXnd"rndrr nru:fir6uularcuabifinrrnrr'lfi nydro-

cortisone ruln 200-300 :Jn./iu yrl.ryaool6oooirlourr:ir'1fi e-+ ni,,r uri{rJru refractory septic

shock riur?nl 5 fi{ 7 iu Inuurnoqjtunnrudfrorm:ndrn:ror;a-u serum cortisot ld n?T

n:rnrroi.:rnmnr'.:nair':tto:'1fi hydrocortisone urifi.rJrufi:vcr'u baseline serum cortisol n"rn'ir 35

tn./9n.

Septic Shock: .{pproach and,\ranagemenr 21n1i,laauti, qiaf uang! uat'hainrt fiixfrqa 291

z. nr:'ld intensive insurin therapy orcrir'lfiHnnr:inur sepsis d{uTounalnfrl r-orcu*",

ornnt:finutto.r Van Den Berghe [lfl;n 96 :rrtru'l'rnrrnrrq :vriurjrs]raodr,lrn,j.,rniolou
inrrrvo''r:lid B0-ri0 n./nff. arrr:nnno'm:rnr ulu{ilrrLinqnnr,rrl'aun::uTou lolrvfiLrrufi

finr:fin rda rrn:fin'li; multiorgan taiture n,ilfifi.:yd,,rluo.ll urrr.rryr'r'hinor moroicity di.r1 tu
{rhuinqorvrr.:oru:n::r"'niu::g:rrnrnr,:ldradortirurlrulo nr:'l$ renat replacement therapy
nTl:ndurdoeiou!n\: ufl:n'lty bacteremia}i ori1,:l:fi6lrnnr:finurlufi:Jrsfrfinr:6oudo:uur,r
:trn"r4rhufrfinlr:6anrrnnr:6ordaohuru 53z mu Inu Brunkhorst'. lrflinru: no'rnu.jrnr:
nrunu:a-rnhorrnadr,,rrndlnfon:rfiont:::or'lnirsrraoirldr-iou Tndrinr r:nnna'nlnr:6!fii01
rianrtfionr:vrh,,:rufiq:infirar:::tlratuttoir.:1 n.r1d uonmnd nr:finur NtcE-sucAB5o ?.1u\,,ru
luil o.o. zoos ujiu'., rfiuueranr:nruql::o':LrirnrnlurfiontotftJrg"lunofiilrainqn'lfio{::rir.r
81 -108 rJnJan. lfiEruri:rn6i finrrnrtfi::n'::rJrrrrnlur6onlfioqj::r.r'r.r i 44-180 n,ftn. iifirhu

rild? tun1:flns'tfi"fir o.to+ :ru tu?'rurudfifi:J.tg severe sepsis ria sepric shock a4 izso
:rfl q{anr:finsrhifl!errr unnsirrro-: anrrinur:cv'ir.rri,:co,rnoi*r rrsinfl'rrnr:J'jrfiaffinrrnila.'r

nrryryfriudlqrnel"ruftr.rr*ulunajrfinrlqr::n-lurrnrn'lurFae:;yir.,r ,.t -t ou unrrul d'oriur{riuu
ruunirtfiinur;:(i'ilirj::rrru 140-180 rJn,/an, Mtiu lfiudurauio.Jrn'rufinrrnrrql:yri'lfrnro
turfiactor{rjruinqn uiaoirhufifinr:c'ordooejr.rluu:.r d.::rrrfofi'r]ruiifinrr:6anrrnnr:6qrda
c:ldarrr':onna"n:rnr:rdufiienorftJrun.,rld uoinr:nrlql:vo'lrirnrolur6aodlndrrndueur.in
onlonrgrfionr:n'ordoro{d runrrsinqorarvY.,ruarunarq:n::lua;dnun::ro, du'

f,r:J

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Engl J Med 2008:358:877-87-

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