ACLSmodified by TAW

Asses responsivenessRespon (+)

1. 0bservasi2. Tx sesuai indikasi (di bawah ini):

Respon (-)

C all: - activated EMS (Emergency Respon System) - for defibL okL istenF eel

Breath (-) 2 kali hembusan

PULSE

(+)

Positif Negatif

O2 (termasuk intubasi)I v lineM onitor (12 lead)

CPR1 seri/1mnt=100x/mnt pola 15: 2 (unprotec airway)

5: 1 (protected airway)

Monitor

VT pulse(-)Atau VF

Non VT/VF

DC : 200-300-360PEA

ASISTOLE

SirkulasiKembalispontan

Persisten VT pulselessAtau VF

Observasi

ARITMIA

TAKIKARDI (>100)

BRADIKARDI

1. Serius simptom,sign2. HR >150

STABIL

AFA Fluter

PSVT VT

(<60)

Serius:-simptom:-nafas pendek - kesadaran turun - chest pain-sign:-T drop,pre/syock, -congestive pulmo -AMI,CHF

YA TDK -II0type2-III0

Klinis spt ASMA, ttp:-Retraksi (-)-Ronkhi basah s/d apec-Pucat, megap2,ala nasi lebar-EKG variatif:-sinus taki-T bisa > 140/90-PCO2 >> PO2 N<50) (N=85 – 90)

ACUTE LUNG OEDEM (ALO)

-Chest pain-Elevasi ST-dg/tanpa BBB: -QRS > 12 -Right=rsR’ di V1-V3 -left = RR’ di V5-V6

AMI

VTPulse (+)

cardioversi

precordial thump

I0 or II0 tipe-1

TCP, iv pacingA-T-D-E-I

ASISTOLE

TransCutaneousPacing (TCP), RJP

-Epinefrin 1 mg iv push or IO, (sediaan=1Amp1cc1mg lar 1:1,000) or 2 mg via ET IO=Intraoesophagus ulangi tiap 3 – 5 mnt, range 0.01 – 0.2 mg/kg-Atropin 1 Amp iv or IO (sediaan=1Amp1cc 0,25 mg), ulangi tiap 3 – 5 mnt pediatric: 0.02mg/kg s/d total 0,04 mg/kg (jika BB 50 kg=>0.04 mg x 50 kg= 2 mg => 8 Ampul bila IV sulit via ET: 2 mg atropin(Max.dose)+ flush 5 cc NaCl 0.9+baging 5x

Persisten Asistole VF atau lainnya

1. Cek apakah CPR sudah betul2. Atipical clinical feature present3. Support for cease-effort protocol in place

Akhiri Tx bila:1.2.

Tx sesuai kelainan

A cup of TEA

Flat line rhythm pd 2lead yg saling tegak lurus,Check another lead, and then:

EPINEPHRINE:-automatisitas impuls-coroner & cerebral flow pd CPR

ATROPIN:-reduce vagal tone via muscarinik reseptor blokade aktivasi SA node + konduksi SA-AV. (konduksi infra AV node : tdk efektif, justru dpt perburuk block 20 mjd 30)-<0.1 mg: centrally mediated paradoxical parasimpatomimetik effect-KI: pediatric dg bradiasistole (pakai saja epinefrin)

VASOPRESIN: pitresinR

-ADH activity:-resorb H2O distal ren tub-vasokonstric efect: splancnik, pulmonal cerebral, coronary-dose 40 IU iv, dpt 1x ulang.

Penyebab asistole:Primer: pacemaker cell tdk aktif-oklusi RCAinfark SA & AV node-degenerasi SA-AV node-congenital heart block,trauma jantung, lokal tumor-trauma listrik DCasistole via depolarisasi seluruh pacemaker. kalau arus ACbikin VFSkunder: hipoksia, asidosis met: berat, untreated VF, trauma: okuli, maksilofacial, carotid sinus left temporal lobe- complex partial seizure, HiperKalemia,

Sudden cardiac death (SDC):-kematian mendadak akibat jantung berhenti, onset simptom dlm 1 jam,-dgn atau tanpa didahului Dx fatal cardiac disease-trtm tjd didahului oleh aritmia(VT,VF)-underlying disease: a. kelainan struktural jantung: kongenital, CAD, kardiomiopati(dilated atau hipertrofi), miokarditis, valvular disease (stenosis mitral, aortal), coarctatio aorta, CHF (LV =EF 30-35) b. biomolekuler: ggn/disfungsi: - Ca channel - K (trtm pd kasus iskemi miokard) - mutasi(Na-channelopati)-Presipitator: iskemi berat, asidosis, hipoksemia, wall tension, drug, ggn met

VT pulseless atau VF

IntubasiIv line

1 mg epinefrin I flush 20 cc NaCl elevasi (bila iv sulit: intratraceal 2,5 mg atau 2.5x dose iv )

CPR – DC 360, pediatric:2 joule/kgCPR – DC 360 max 4 J/kgCPR – DC 360

1 mg Epinefrin II

CPR – DC 360CPR – DC 360CPR – DC 360

A / L / V

Amiodaron300 mg iv bolus 15 – 20 mntSediaan: Amp 150 mg

Lidocaine (Xylocard)1 – 1,5 mg/kgBBSediaan: amp 2cc.lar 2%=20 mg/cc

0,5 – 0,75 mg/kgBB, max.dose= 3 mg/kgBB maintenance: 2 – 4 mg/mnt 20 – 50 gr/kg/mnt (pediatrik)

Vasopresin 40 UI single doseSediaan: Amp pitresin 20 UI

-Precordial tumb: lbh efektif pd VT-Bila EKG kacau antara VT/VF atau SVT: HARUS dianggap saja VT/VF

3 menit

pertimbangkanRefracter (?)

No respon (?)

Dpt diulang tiap 3-5 mntMaintenance: 1 mg/mnt, selama 6 jam-I kmd 0.5 mg/mnt

Dpt diulang tiap 3-5 mnt Max.dose: 3 mg/kg

Kenali & koreksi kemungkinan:-hipoksia-hipovolemi-HiperK-hipoK, ggn met-tension pneumothoraks-tamponade-toxic/terapeutik substance-thromboemboli/mekanikal obstruksi

REFRACTORY VT-VF? :-procainamid 30mg/mnt. Max.dose 17 mg/kg-magnesium sulfat 1-2 gr iv ( 25-50 mg/kg iv) (MgSO4 juga drug of chois: - Torsade de pointes - hipoMg (< 1,4 mEq/L)-NaBiqnat 1 mg/kg, trtm,pd: -hiperK -toxic antidepresan trisiklik, phenobarbital-CaCl2 lar 10%, pd: -hiperK(>6): 2-4 mg/kg -hipoCa -toxic Ca chanel bloker pediatric: 0.2 ml/kg,lar10% (CaCl2 memperbaiki: action pot excitation threshold)

Pediatric: 0.1 gr/kg/mnt max 1.5 gr/kg/mnt

PEA(Pulseless Electrical Activity)

Tentukan causa utama:1. Hypovolemia 6. Obat (OD drug, kecelakaan)2. Hypoxia 7. tamponade, cardiac3. Asidosis 8. Tension pneumothorac4. Hyper/hypokalemia 9. Thrombosis coroner, ACS5. Hypertermia 10. Thrombosis DVT, pulmonary embolism

Tx sesuai causa, dan:1. PEA HR slow : atropin 1 mg iv ulangi tiap 3 – 5 mnt

max total 0,04 mg/kg2. PEA HR tdk slow: epinefrin 1 mg iv flush ulangi tiap 3 – 5 mnt

BRADICARDIA (<60)

NO SERIUSSign & simptom

- Block II0 type-2- Block III0

OBSERVASI - TCP- iv PACING

SERIUS:Simptom: nafas pendek, kes turun, chestpainSign: T turun, syock, ALO, CHF, AMI

Atropin 0,5 – 1 mg iv max 0,04 mg/kgBB ped: 0,02 mg/kg (sediaan=1Amp1cc 0,25 mg) hati2:- dg adanya infark (atropin=dangerous) - ES: ventrikular disritmia - tdk efektif pd block infranodal, wide compleks bradiaritmik, de-inervated heart(transplant)TCPDopamin 5 – 20 u gr/kg/mnt Sediaan: 200 mg/10 ml amp, 200mg/5cc flacon 200 mg dlm 50 lar 200.000 = 4.000 50 ml ml

Epinefrin 2 – 10 u gr/mnt Sediaan: 1 mg/ml (lar 1:1000) Pengenceran: 1.000 = 200 50 ml ml

(1 Amp + NaCl 500 1 – 5 cc/mnt)

Isoproterenol 2-10 µg/min.

All Trained Dogs Eat Iams

Oh Say It Isn't So O2 saturation monitorSuction equipmentIV lineIntubation equipmentSedation and possibly analgesics

LBBB and 2nd degree (II0)AV Block, Mobitz Type II(PR constan, P:QRS=X:Y=constan, mis:4P=3QRS4:3)

3rd Degree (III0)AV Block Rx'ed With a VentricularPacemaker

Block II0 atau III0

NO YES

Block II0 tipe-1dg QRS normal Block II0 tipe-1

tapi dg QRS lebar(lokasi block lbh distalyaitu di His-purkinye)

OBSERVASI KETATPertimbangkan vagolitik atropinAssesment iskemi, miokarditis; bila ada

Dg symptom:-light-headedness, dizziness, or syncope,(simtom yg tdk biasa)-chest pain (biasanya berhub dg adanya miocarditis or ischemia.

TAKIKARDI (>100)

-Serius simptom & sign: nafas pendek, kes turun, chest pain T turun, syock, ALO, CHF, AMI- HR > 150

-O2

-iv line-Siapkan suction O2 sat monitor intubasi set-sedatif-Dg/tanpa anastesi analgesi-Kemudian:

CARDIOVERSI Sincronize-AF : start 200 J-A Flutter & PSVT: start 50 J100200300360720 ? (utk refracter AF)Sedatif: - diazepam, - short act = midazolam - barbiturat - ketamin - etomidat - metohexitalAnalgetik: Antikoagulan: - fentanil -warfarin - morfin (s/d 4 mggu - meperidin post cardioversi)

Stabil atauSimptom & sign TDK serius

AFA Fluter

-Ca blocker: Diltiazem,Verapamil (menurunkan respon ventrikel)-B blocker (for case:simpatik ,tirotoxic)-Vagolitic:Prokainamid, Quinidin, disopiramide-antiaritmik lainnya: amiodaron,ibutilid, dofetilid azimilid-anticoagulan

PSVT

Bruit carotis (+) Bruit (-)

Vagal manouver

Adenosin 6 mg iv flush

1 – 3 mnt

Adenosin 6 mg iv flush

1 – 3 mntAdenosin 12 mg iv

Stop bila tjd Block II0

T makin turunSerius sign & simptom

Sincronize-cardioversimulai 50 J, dst.

Utk ped:0,5 J/kg

T, N membaik

Verapamil 2,5 – 5 mg iv pelanSambil lihat T & HR 2-3 mnt)

15 – 30 mnt

Verapamil 5 – 10 mg iv

Pertimbangkan :-digoxin - B block

- diltiazem

VT

Lidocain 1 – 1,5 mg/kg flush

Lidocain 0,5 – 0,75 mg/kg flush max total 3 mg/kg maintenance:1-4 mg/mnt (ped: 20-50 gr/kg/mnt)

5 – 10 mnt

Procainamid20 – 30 mg/mnt, max 17 mg/kgMaintenance: 1-4 mg/mnt

Bretilium

Sincronize-cardioversiStart: 50-100 J, kmd: 200 300 360 J

Tak peduli apapun penampilan EKG:mau AF atau lainnya, tindakannya sama yi:

Refracter ?

Amiodaron atau

Radiofrequent-cateter ablation