Transcript
Lethal Arrhythmias
Kasus 1
• Laki-laki 55 th datang dibawa supir angkot karena ditemukan pingsan di angkot nya
• Tidak ada respons, tidak bernafas, tidak ada nadi
• Dipasang monitor dengan gambaran
Arrhythmia : What you need to know for ACLS?
Introduction
• Rhythm recognition is a key skill that one needs to demonstrate during cardiac arrest situation.
• This can be life saving.• Early defibrillation • Decision making on the right therapy
Lets Keep it Simple!
• Pulseless Rhythms• Tachyarrhythmias• Bradyarrhythmias
Pulse less Electrical Rhythm
Ventricular Fibrillation
• Uncoordinated contractions within the ventricles of heart.
• Due to multiple cardiac cells that function as pacemakers and discharge electrical impulses in a chaotic manner.
• Reduced / No cardiac output : No pulse• Will result in Asystole if not treated.
• Commonest cause : Hypoxia /Ischemia
• Types : Fine and Coarse
Therapy
Immediate DefibrillationCPRI/V Amiodarone after 3 shocks
Ventricular Tachycardia
• Broad Complex Tachycardia (QRS > 0.12s)• Heart rate > 180 beats /mt• Mono-morphic• Poly-morphic / Torsade Pointe• Pulse less vs with pulse
Mono morphic VT
Poly morphic VT
• Torsade Pointes if Prolonged QT interval on previous ECG
Treatment
• Pulseless : Defibrillation
• With pulse : stable = Amiodarone Unstable = DC Cardio version
No Pulse !
Pulse Less Electrical Activity (PEA)
• Organized electrical activity but without a pulse
• Usually has underlying treatable cause• Hypovolumea and Hypoxia are the
commonest causes.• If no underlying cause is identified, it will be
treated same as Asystole.
5 Hs and 5 Ts
5 Hs HypovolumiaHypoxiaHydrogen Ion (Acidosis)HyperkalemiaHypokalemiaHypoglycemia
5Ts
Toxins Tension Pneumothorax Tamponade Thrombosis : Coronary Thrombosis : Pulmonary Trauma
ASYSTOLE
Follow flat line protocol – check leads and gainNot a true rhythmState of no electrical activityTerminal event Very poor prognosis : ROSC extremely unlikely Possible underlying cause : 5Hs and 5Ts Treatment : CPR and Epinephrine
Bradiarrythmia
First Degree AV Block
• PR interval is prolonged > 200ms• No clinical significance if asymptomatic• May lead to higher degree AV Block
Second Degree AV Block
Mobitz Type 1• Progressive prolongation of PR interval.• Atrial impulse (P waves) may not be conducted
through AVN and gets blocked and hence no QRS.
• No clinical significance unless symptomatic. Mobitz Type 2• Non prolongation and fixed PR interval.• Non conducted p waves• No ventricular activity -Drop beats / No QRS Most times Infranodal
Third Degree AV Block (CHB)
P waves with a regular pp intervalQRS complexes with a regular RR intervalQRS complex may be narrow or wide (escape
rhythm) No relationship between P waves and QRS
complexes.
Treatment
• Trans cutaneous or Trans Venous pacemaker• Atropine (0.5 mg) may be tried Epinephrine 0.5 -1 mg /kg bw
Tachyarrhythmia
Atrial Fbrillation
• No p waves preceding QRS complexes as no coordinated atrial contractility
• Irregular (variable) RR intervals
Treatment
• Unstable : Synchronized DC Cardio version• Stable : Rhythm Control vs Rate Control
• Rhythm : Amiodarone, Sotalol, Flecainide• Rate control : Beta blocker, Calcium channel
blocker, Digoxin.• Anticoagulant if indicated.
Atrial Flutter
• Atrial rate 250 – 350 /mt• Saw Tooth Appearance• Ventricular rate depends on Degree of AV
block• Electrical foci usually in RA
Treatment
• Rate Control• Rhythm Control• Anti coagulant• DCC if unstable
Supra Ventricular Tachycardia
• Broad term for various supra ventricular arrhythmia
• Electrical impulses above the ventricular electrical conducting system.
• Inverted p waves preceding or following qrs complexes.
• Review old ECG – exclude WPW
Treatment
Vagal maneuver Adenosine •Drugs – Chemical Cardio version or Rate control.• Anti coagulant.
•If unstable : sync. DCC
Contoh Kasus
• Laki laki 54 tahun dibawa keluarga ke UGD karena tiba2 kejang
• Tidak ada respons, Tidak bernafas, tidak ada nadi
• 2 siklus RJP tidak ada respons• Alat defib datang, dipasang lead dengan
gambaran :
• Setelah 2 siklus RJP terdapat gambaran seperti berikut
Contoh Kasus
• Wanita 40 tahun datang ke UGD karena sesak nafas
• Setelah dipasang monitor tampak gambaran EKG
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