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Wpw syndroom

WPW SYNDROOM

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1. Oorzaken

- ontstaat door stimulatie van de ventrikel via een accessoire AV-bundel = bundel van Kent
- geleiding kan anterograad, retrograad of in de 2 richtingen zijn
- er zijn 2-types:
- type A: meest frequent (70%) = orthodrome WPW.  Impuls gaat naar het ventrikel via de AV nodus en komt retrograad terug via de bundel van Kent. Hierdoor ontstaat een reëntry tachycardie.

- Type B: antidrome WPW.  De impuls loopt in omgekeerde richting.

 

2. Kliniek

- bij stabiele patient:
- asymptomatisch
- palpitaties
- dyspnee
- nausea
- duizeligheid
- bij instabiliteit
- hypotensie
- retrosternale pijn
- BWZ-daling
- reutels
- snelle pols

 

3. Diagnostiek

- bij elke supraventriculaire tachycardie moet je aan WPW denken
- ECG: diagnose op ECG na conversie tot sinusritme. 
- verlengd QRS (> 0,10 seconden = 2,5 kleine vakjes). 
- Delta golf (kleine opwaartse hoek bij het begin van het QRS. 
- verkort PR interval (< 0,12 seconden = < 3 kleine vakjes)
- poliklinische oppuntstelling: verder plannen ablatie Kent bundels, heelkundig of met radioablatie.

 

 

Eerste opvang

-IV lijn
- O2
- monitoring
- onstabiele patient
- indien hypotensie: opvullen, trendelenburg, cardioversie, ALS
- vermijd volgende producten: calciumantagonisten, betablokkers, digoxine!!!!

 

Spoeddienst

- is de patient stabiel?
- indien  neen: cardioversie, opvullen, trendelenburg, ALS
- indien ja:
- small complex tachycardie regelmatig
- vagale maneuvres
- adenosine: best alleen voor supraventriculaire tachycardie. Eerst snel 6 mg, zo nodig te herhalen na 2 minuten met 12 mg.
- bij slechte linker ventrikel functie
- cardioversie
- amiodarone (Cordarone) :eerst een bolus van 300 mg over 5 à 15 min, d.i. 2 amp opgelost in 20 cc glucose. Daarna het eerste uur 300mg/1u en de verdere 24 uur 900 mg/24u.
- bij een goede linker ventrikel functie
- amiodarone (Cordarone): eerst bolus 300mg/ 5-15 min opgelost in 20 cc glucose 5%.  Dan 300mg over 1 uur en daarna 900 mg over 24 u.
- alternatief: Flecainide (Tambocor): 2 mg/kg tegen 10mg/min IV of 2 x 100mg PO
- alternatief: propafenon (Rytmonorm): 1-2 mg/kg tegen 10 mg/min IV of 450 - 600 mg/d PO in 2-3 giften.
- alternatief: Sotalol (Sotalex): cave nierinsufficientie.  Bij opstarten is er een kans op torsades de Pointes dus goed monitoren.  Dosage: 80 - 160 mg 2x/d PO
- alternatief: Procainamide (Pronestyl): hogere dosis: 100mg IV elke 5 minuten en bij succes een infuus à 1-4 mg/min
- breed complex tachycardie onregelmatig
- farmacoconversie:
- Lidocaine
- Amiodarone (Cordarone): eerst een bolus van 300 mg over 5-15 min opgelost in 20cc glucose.  Daarna het eerste uur 300mg/1u gevolgd door 900mg/24u
- cardioversie:
- synchroon: 100J, 200J, 360J
- alternatieven voor farmacoconversie bij goede linker ventrikelfunctie
- alternatief: Flecainide (Tambocor): 2 mg/kg tegen 10mg/min IV of 2 x 100mg PO
- alternatief: propafenon (Rytmonorm): 1-2 mg/kg tegen 10 mg/min IV of 450 - 600 mg/d PO in 2-3 giften.
- alternatief: Sotalol (Sotalex): cave nierinsufficientie.  Bij opstarten is er een kans op torsades de Pointes dus goed monitoren.  Dosage: 80 - 160 mg 2x/d PO

- alternatief: Procainamide (Pronestyl): hogere dosis: 100mg IV elke 5 minuten en bij succes een infuus à 1-4 mg/min

 

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