v sao nt xoang (nt SA) li l ch nhp? nu n khng lm ch nhp na th sao?

T bo c tim c chia thnh 3 loi c chc nng khc nhau. T bo pht nhp, t bo dn truyn v t bo c Ch c duy nht t bo pht nhp c th to nhp m thi V phn b ca t bo ny th n c mt khp ni trong 2 nh, trong nt nh tht v trong h purkinje V mt in hc, cc t bo pht nhp c kh nng t kh cc, c biu th bi pha 4 trong chu trnh kh cc ca tim (a,b,c) dng in hc ca t bo pht nhp, phase 4 i ln dn

dng in hc ca t bo pht khng pht nhp, phase 4 khng i ln

Trong hnh trn, cc on a, b, c biu th phase 4 ng thi biu th c tnh t ng pht nhp ca t bo c tim. Nu ta gi s a l t bo pht nhp ca nt xoang, b l t bo pht nhp ti nt nh tht v c l t bo pht nhp ti mng purkinje ca tht, cc t bo ny u t tin hnh t kh cc nhng ti nt xoang th s t kh cc xy ra nhanh nht v kh cc trc tin, ti thi im ny, t bo pht ni khc vn ch ang t kh cc v cha kp pht nhp th b xung ng ca nt xoang hn lan truyn n gy kh cc. Sau khi cc t bo ny ti cc v li tin trnh li lp li t u v li tip tc b xung ng ca nt xoang gy kh cc trc khi n t kh cc. Nh vy, do tnh t ng ca nt xoang cao hn m biu th l phase 4 dc hn cc ni khc gy kh cc

t bo khc trc khi chng t kh cc do nt xoang s c vai tr dn nhp cho tim. Vy th vn bnh l s xy ra khi no. V d suy nt xoang, tnh t ng ca nt xoang gim xung hoc cng ph giao cm(thn kinh ph giao cm phn b nh nhiu hn tht) hay khi c c tng tnh t ng bt thng, gy c ch nt xoang, khi tim s b kh cc bi xung ng in t ni khc v nt xoang mt vai tr ch nhp. khi nt xoang khng hot ng th ln lt ti cc nt nh tht... v cui cng l c tim gi vai tr ch nhp duy tr nhp tim. cng c th hiu nm na nh sau: C 2 loi in th ng ca tim: -Loi p ng nhanh:... -Loi p ng chm: Nt xoang v nt nh tht. Xin ni qua v tc kh cc chm tm trng, y l mt tnh t ng ca t bo dn truyn ( khng c t bo co c tim). Vo k tm trng th ion Na+ dn dn i vo t bo v nng in th ln gn ng ng in v khi n nng ln t in th ngng----> th n cho ra mt xung ng. Loi p ng chm pht xung nhanh hn loi p ng nhanh v: Tc kh cc tm trng ca loi p ng chm nhanh hn (c th do loi ny ko c pha bnh nguyn); in th ngng ca loi p ng chm ch c -40mv trong khi loi p ng nhanh l -70mv. Nt xoang pht xung nhanh hn nt nh tht l v: Nt xoang (dy 2mm) mng hn nt nh tht (3mm) nn tc khuch tn ca cc ion nt xoang s nhanh hn=> Pht xung nhanh hn. Nh vy, nt xoang c li th l tc kh cc tm trng nhanh hn nn my thng kia in th cha ti ngng( tc l cha c cho ra xung m ht) th b nt xoang xa i. =>Nt xoang pht xung nhanh nht nn l nt ch nhp ca tim.

K+, Na+, Ca++ c vai tr trong in th ng ca c tim. i vi K+, iu kin bnh thng, nng ngoi mng t bo l vo khong 4mM. c tim, tnh thm ca K+ gim cn 1/5 so vi c khc nn K+ ra ngoi rt chm, khng ti kh cc ngay c nh hng n c tim khi nng K+ tng: khi K+ tng =>kh cc mng t bo =>m mt s knh Na+ nhng vn cha to ra in th hot ng => knh Na+ ng li v tr =>tng ngng kch thch. C tim mt tnh hng phn v ngng p trong k tm trng. Tng K+ xy ra khi K+ c to qu nhiu (n vo, li gii m) hoc khng c thi tr hu hiu (do thiu hormone aldosterone hoc do cc nguyn nhn t nhu m thn gy tn thng bi tit). chn on, c th cho o nng K+ nhiu ln (do c th c tng do tn huyt bnh phm u tin). in tm cng thng c thc hin sm xc nh nh hng ln tim. Sng T cao, hnh lu, P nh v phc hp QRS rng l du hiu cho tc ng ca lng K+ ln tim tng qu mc bnh thng. Khi nng K+ vt qu 6,5mM bt buc phi h khn cp v c th lon nhp dn n t vong. nh hng n c tim khi nng K+ gim: khi K+ gim dn n tng phn cc

in th mng trng thi ngh, t kch thch cn phi ln hn bnh thng c th gy kh cc mng nhm khi u mt in th ng. Ni chung, gim K+ ngoi t bo t gy nh hng trn kch thch v co c. Tuy nhin, h K+ nng c th gy ra ri lon nhp tim, nguy c h Na+ mu dn n ln ln, co git... Biu hin trn in tm : -Sng T dt (c kha) -Xut hin sng U i theo sau sng T. H kali mu nng sng U khng l c th nhm ln vi sng T, t c th biu hin nh QT di v thc ra l QU. Sng U c nn rng, phn bit vi sng T trong tng kali mu c nn hp, nh cao v nhn, QT bnh thng hoc ngn. -ST chnh xung -Ri lon nhp tht (nh ngoi tm thu tht, torsade de pointes, rung tht) -Ri lon nhp nh (nh ngoi tm thu nh, rung nh)

1.Cu trc m hc ca t bo c tim : Tim c cu to bi cc si c tim kt thnh mng. T bo c tim cng c cu to bi cc sarcomer t ng Z n ng Z k cn, bn trong cha cc si myosin v actin. Cc si c tim cha nhiu ty th v nhiu mao mch, mt mao mch cho mt si c tim. Do , khong cch khuych tn ngn v oxy, CO2, cc chtc th di chuyn nhanh gia cc t bo c tim v mao mach.

S dn truyn in ca c tim-nhm 2 swim or sink

2. S dn truyn in trong c tim Trong tm nh bn phi c mt hch - gi l nt xoang nh (SA, sinoatrial) - gm cc t bo c kh nng t to xung in (electric impulse). Xung in ny truyn ra cc c chung quanh lm co bp hai tm nh (to nn sng P trn in tm ). Sau c dng in tip tc truyn theo 1 chui t bo c bit ti mt hch khc gi l nt nh tht (AV, atrioventricular) nm gn khu gip gii gia cc tht ri theo chui t bo si Purkinje chy dc theo tng chia hai tm tht lan vo cc c chung quanh (lot sng QRS); lm hai tht ny co bp. Sau xung in gim i,tn tht trng ra lc tim ngh (to nn sng T). Vy dng in do tim pht ra v u m c? Ngy nay, khoa in sinh l hc hin i cho ta bit r: l do s bin i hiu th gia mt trong v mt ngoi mng t bo c tim. S bin i hiu th ny bt ngun t s di chuyn ca cc ion K+, Na+, t ngoi vo trong t bo v t trong t bo ra ngoi khi t bo c tim hot ng. Lc ny tnh thm thu ca mng t bo i vi cc ion lun lun bin i. Khi t bo bt u hot ng (b kch thch), in th mt ngoi mng t bo s tr thnh m tnh tng i (b kh mt cc dng) so vi mt trong: ngi ta gi l hin tng kh cc (dpolarisation).Sau , t bo dn dn lp li th thng bng ion lc ngh, in th mt ngoi tr li dng tnh tng i (ti lp cc dng): ngi ta gi l hin tng ti cc (rpolarisation). Cc qu trnh bin i in th c tim: - in th mng lc ngh: Bn trong t bo c nng ion K+ cao hn Na+, trong khi bn ngoi mng t bo, Na+ li cao hn v iu ny to nn mt hiu in th l -90 mV bn trong t bo.Nh vy khi ngh ngi t bo trang thi phn cc bn trong tch in m, bn ngoi tch in dng v mt cp m dng i nhau gi l dipole. - TM khi t bo b kh cc v cc giai on qu trnh kh cc: Khi t bo b kch thch, hin tng kh cc bt u. y l mt qu trnh in-ho v kt qu l bn trong mng t bo s tch in dng, bn ngoi tch in m. + KH CC NHANH - pha 0 : Tnh thm ca mng t bo tng cao, ion Na a vo bn trong t bo, in th hot ng tng ln n 20 mV. + HI CC : chia lm 3 pha oPha 1 : n th tr v nhanh chng n 0 mV sau khi b over shoot n 20 mV. oPha 2 : giai on plateau . Dng Ca+ bm chm t ngoi vo bn trong t bo. oPha 3 : hi cc nhanh . Dng K+ c bm ra khi t bo. in th tr li 90 mV. Chm dt thi k tm thu. + NGH NGI -pha 4 : T bo nm yn lng, n nh v mt in hc cho n khi c mt kch thch mi. Tuy nhin cc t bo c kh nng to nhp (pace maker), pha 4 s i dc dn ln, do Na+ c bm chm vo bn trong t bo. Khi t mt ngng in th, t bo s t ng kh cc v pht sinh xung ng. Hin tng ny gi l s kh cc tm trng hay kh cc chm . y chnh l nn tng ca tnh t ng v l mt c im ca tt c cc m to nhp trn tt c h dn truyn ca tim.

3.Cc bnh l do ri lon dn truyn in ca c tim Nu c thay i bt thng bt c mt phn nh no ca h thng trn, in s b xo trn, lan theo nhng hng ngc hay khng ng th t, lm co git cc c ca cc tht khng ng u - gy nn ri lon nhp tim. A.Ri lon nhp trn tht - Rung nh Rung nh (Atrial fibrillation) l ri lon dng in trong tm nh lm co git c thnh dng rung nhanh v khng u. Phn ln do in chy ngc tr ln t tm tht hay do in b cn v di li. Triu chng: Khi b rung nhanh tm nh s khng co bp c bnh thng, do s khng bm lng mu vo tm tht. Lng mu tim bm ra c th s gim em n nhng triu chng chng mt, kh th, xu (bt tnh), mt mi. in xo trn trong tm nh truyn xung tm tht lm hai tht ny co bp nhanh (to nh trng ngc), sau khi tim thiu mu tip t s lm tc ngc. - Cung nh Trong cung nh (atrial flutter) xung in tng bn lch tm nh atrial ectopic, sn sinh ra tc tm nh t 250 n 400 bmp. Tc tm tht thay i ph thuc vo s dn xut. Trn ECG, xc nh P-wave (c gi l sng run) xy ra chui k tip ng gia QRS complexes bnh thng. Ci ny cho dng sng c hnh rng ca. - Nhp nhanh vo li nt nh tht (AV node re-entry tachycardia) - Nhp nhanh vo li nh tht (AV re-entry tachycardia) - Hi chng Wolf-Parkinson-White y l mt bnh lin quan n si in th trong tim. Bnh thng, mt tnh hiu in th s bt u ti 1 phn ca tim (nt xoang nh phi) v b truyn bng qua vng gi tm nh v tm tht (nt nh tht), n nhng phn khc ca tim (tm tht). Trong bnh l ny, c 1 s bt thng v ni kt in th do s i qua nt nh tht, c th a n nhp tim nhanh hoc bt thng B.Cc ri lon nhp tht - Ngoi tm thu tht

(Ventricular extra-systole) Ngoi tm thu tht l cc xung lc ch xut pht t nhng vng nm xa h thng His Purkinje. Ngoi tm thu tht l mt ri lon nhp tht thng gp nht. - Nhp nhanh tht (Ventricular tachycardia) - Nhp nhanh tht (VT) l mt nhp tim p nhanh m bt u trong tm tht - Xon nh(Torsade de pointes) l cp cu tim mch. Thng do nhng nhm thuc chng lon nhp nhm 1 gy ra; gim kali mu cng l yu t thun li.Triu chng ch yu l ngt, try tim mch. in tim s thy sng kh cc bin dng ln tn, c ch nh v ch phnh to ty theo chu k. - Nhp t tht gia tc Nhp t tht gia tc l lon nhp thng gp sau khi ti ti mu, thng lnh tnh, khng cn phi iu tr. 4.ng dng s dn truyn in ca c tim trong lm sng Nhiu loi bnh tim thay i hot ng in hc ca tim theo nhng cch khc nhau v phng tin gip pht hin ra nhng thay i ny chnh l in tm (ECG). Trn ECG ta s ghi c cc sng: Sng P : s khc cc ca nt xoang. Phc b QRS : pha 0 v pha 1 ca in th hot ng. on ST v sng T : pha 2 v 3 ca in th hot ng.

in tm c s dng trong nhiu trng hp y hc: * Chn on nhi mu c tim khi c tim b thiu mu v dng kh, kh nng chuyn in ca c s thay i. S thay i ny c th ghi nhn c trn in tm . * Chn on v theo di ri lon nhp tim nhp tim p do mt h thng in rt tinh vi iu hnh. Khi c ri lon trong cc ng dn in, h thng thay i lm lon nhp. * Chn on cc chng tim ln khi tim ln v c tim dy ln hay mng i v dng

in i qua s thay i theo. * Chn on mt s thay i sinh ha mu v in tim l do s di chuyn ca cc ion nh natri, kali, calcium, v.v ... . Khi c thay i ln trong nng cc cht ny, in tm c kh nng thay i. * Chn on mt s ng c thuc Thuc digoxin lm thay i on ST ca mi cc. Thuc chng trm cm 3 vng lm di on QT.