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