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AV node
Bisa mengeluarkan
impuls 40-60x/menit
Berkas His
Serabut Purkinje
Ventrikel
Bisa mengeluarkan impuls
20-40 x/menit
4
CAUSE OF CARDIAC ARRHYTHMIAS :
- sympathomimetic.
- Hypoximia, Hypercarbia.
- Acidosis
0 Endocrine abnormalities
-Thyrotoxicosis, Phaeochrocytoma.
Miscellaneous.
- Febrile illness
- Emotional stress
- Smoking
- Fatigue.
Symptoms
Palpitations: nontachycardiac; rapid and regular; rapid and
irregular (regularly irregular or irregularly irregular).
Abrupt or accelerating onset and termination?
Dyspnea
Chest discomfort
Syncope; “nearly blacked out”; syncope with spell
Polyuria
Cardiac arrest
Signs
Heart rate and pulses: regularity; amplitude; deficit
Hypotension
Hypoperfusion
Lebar gel. QRS
P wave ??
QRS sempit
Irama
Irama Teratur
Tidak teratur
Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia
Atrial Flutter
SVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
Atrial Fibrillation :
Irama
Irama Teratur
tidak teratur
Ventricular Ventricular
Tachycardia Fibrillation
Ventricular Tachycardia
VT
VT
Torsade de Pointes
Ventricular Fibrillation
VENTRIKEL EXTRA SYSTOLE
SR
VES
Sinus rhythm
with
Multifocal VES
VES VES
SR SR
SR SR SR SR
Sinus rhythm with VES couplet
Sinus Rhythm with VES, R on T
Atrial Fibrillation.
- Rate control :
1. Digoxin.
Digitalization dose : 0,03 mg x BW (Kg)
Maintenance dose : 0,125 – 0,25 mg /day,
depends on – renal function.
Route :oral tablet 0,25 mg or
Injection ampule 0,5 mg
- Propranolol
- Metoprolol
- Atenolol
- Bisoplrolol
- Carvedilol
Amiodaron
Tablet : 200 mg.
Injection : 150 mg
Loading dose : 3 x 200 mg ( 5 days)
Maintenance dose : 100 – 200 mg / day.
Contraindication : Thyroid and Lung
(fibrotic) dysfunction.
1. ATP injection ( 8 mg – 20 mg )
2. Verapamil injection ( 2,5 – 10 mg)
3. Amiodaron injection.
Vasopressor Medication
Epinephrine
1 mg 1:10,000 IVP
Repeat every 3-5 mins as long as arrest persists
Vasopressin (alternative to Epinephrine)
40 units IVP one time only
Shock @ 360 J after each medication given as long
as VF/VT arrest persists
Alternate epi-shock & antidysrhythmic-shock sequence
Antidysrhythmic Medication
amiodarone 300 mg IVP single dose
lidocaine 1-1.5 mg/kg IVP, q 5 min, max 3mg/kg total
procainamide 100 mg IV, q 5 min, max 17 mg/kg total
magnesium 10% 1-2 g IV
if hypomagnesemic or prolonged QT
Characteristics
The ultimate unstable bradycardia
A terminal rhythm
poor prognosis for resuscitation
best hope if ID & treat cause
No significant positive or negative deflections
Possible Causes
Hypoxia: ventilate
Preexisting metabolic acidosis: Bicarbonate 1
mEq/kg
Hyperkalemia: Bicarbonate 1 mEq/kg, Calcium 1
g IV
Hypokalemia: 10mEq KCl over 30 minutes
Hypothermia: rewarm body core
Possible Causes
Drug overdose
Tricyclics: Bicarbonate
Digitalis: Digibind (Digitalis antibodies)
Beta-blockers: Glucagon
Ca-channel blockers: Calcium
Primary ABCD
Confirm Asystole in two leads
Reasons to NOT continue?
Secondary ABCD
ECG monitor/ET/IV
Differential Diagnosis (5Hs & 5Ts)
TCP (if early)
Epinephrine 1:10,000 1 mg IV q 3-5 min.
Atropine 1 mg IV q 3-5 min, max 0.04
mg/kg
Consider Termination
Possibilities
Massive pulmonary embolus
Massive myocardial infarction
Overdose:
Tricyclics - Bicarbonate
Digitalis - Digibind
Beta-blockers - Glucagon
Ca-channel blockers - Calcium
Identify, correct underlying cause if possible
Possibilities:
Hypovolemia: volume
Hypoxia: ventilate
Tension pneumo: decompress
Tamponade: pericardiocentesis
Acute MI: vasopressor
Hyperkalemia: Bicarbonate 1mEq/kg
Preexisting metabolic acidosis: Bicarbonate
1mEq/kg
Hypothermia: rewarm core
ABCDs
ETT/IV/ECG monitor
Differential Diagnosis
Find the cause and treat if possible
Epinephrine 1:10,000 1 mg q 3-5 min.
If bradycardic,
Atropine 1 mg IV q 3-5 min, Max 0.04 mg/kg
TCP
In many systems, consider termination
of efforts
Hypovolemia Tablets (Drug
Hypoxia OD)
Tamponade
Hydrogen ions
(Acidosis) Tension
Pneumothorax
Hyper/hypo- Thrombosis,
kalemia Coronary
Hypothermia Thrombosis,
Pulmonary
Check pulse after any treatment
or rhythm change
If pulse present:
Assess breathing
Present?
Air moving adequately?
Equal breath sounds?
Possible flail chest?
If pulse present:
Protect airway
Position to prevent aspiration
Consider intubation
100% Oxygen via BVM or NRB
Vascular access
Assess perfusion
Evaluate
Pulses
Skin color
Skin temperature
Capillary refill
BP
Key is perfusion, not pressure
Management of Decreased Perfusion
Fluid challenge
Catecholamine infusion
Dopamine, or
Norepinephrine
Titrate to BP ~ 90 to 100 systolic
The
Deadly
Rhythms
PEA
VT VF (Pulse less
Electrical
Activity)
A systole
Treat the patient,
not the monitor . . . . . . . . .!!!