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  • Lethal Arrhythmias

  • Kasus 1Laki-laki 55 th datang dibawa supir angkot karena ditemukan pingsan di angkot nyaTidak ada respons, tidak bernafas, tidak ada nadiDipasang monitor dengan gambaran

  • Arrhythmia : What you need to know for ACLS?

  • IntroductionRhythm 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 RhythmsTachyarrhythmiasBradyarrhythmias

  • Pulse less Electrical Rhythm

  • Ventricular FibrillationUncoordinated 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 pulseWill 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 /mtMono-morphicPoly-morphic / Torsade PointePulse less vs with pulse

  • Mono morphic VT

  • Poly morphic VT Torsade Pointes if Prolonged QT interval on previous ECG

  • TreatmentPulseless : Defibrillation

    With pulse : stable = Amiodarone Unstable = DC Cardio version

  • No Pulse !

  • Pulse Less Electrical Activity (PEA)Organized electrical activity but without a pulseUsually has underlying treatable causeHypovolumea 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

  • ASYSTOLEFollow 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 > 200msNo clinical significance if asymptomaticMay lead to higher degree AV Block

  • Second Degree AV Block

  • Mobitz Type 1Progressive 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 2Non prolongation and fixed PR interval.Non conducted p wavesNo 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.

  • TreatmentTrans cutaneous or Trans Venous pacemakerAtropine (0.5 mg) may be tried Epinephrine 0.5 -1 mg /kg bw

  • Tachyarrhythmia

  • Atrial FbrillationNo p waves preceding QRS complexes as no coordinated atrial contractilityIrregular (variable) RR intervals

  • TreatmentUnstable : Synchronized DC Cardio versionStable : Rhythm Control vs Rate Control

    Rhythm : Amiodarone, Sotalol, FlecainideRate control : Beta blocker, Calcium channel blocker, Digoxin.Anticoagulant if indicated.

  • Atrial FlutterAtrial rate 250 350 /mtSaw Tooth AppearanceVentricular rate depends on Degree of AV blockElectrical foci usually in RA

  • TreatmentRate ControlRhythm ControlAnti coagulantDCC if unstable

  • Supra Ventricular TachycardiaBroad term for various supra ventricular arrhythmiaElectrical 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 KasusLaki laki 54 tahun dibawa keluarga ke UGD karena tiba2 kejangTidak ada respons, Tidak bernafas, tidak ada nadi2 siklus RJP tidak ada responsAlat defib datang, dipasang lead dengan gambaran :

  • Setelah 2 siklus RJP terdapat gambaran seperti berikut

  • Contoh Kasus Wanita 40 tahun datang ke UGD karena sesak nafasSetelah dipasang monitor tampak gambaran EKG