Aritmia dan DC Shock

TIM PELATIHAN KEGAWATDARURATAN

Anestesi dan Terapi Intensif

RSUD Saiful Anwar Malang/FK Univ.Brawijaya

Cardiac arrest = carotis (-)check ECG !

• VF / VT pulseless = ada gelombang khas• shockable rhythm, harus segera DC-shock

• Asystole = ECG flat, tak ada gelombang• UN-shockable

• PEA = EMD = ada gelombang mirip ECG normal• UN-shockable

SHOCKABLE RHYTHMS

1. Ventriculer fibrilation

Fine Ventriculer Fibrilation

Coarse Ventriculer Fibrilation

Fine VF :

If there is a doubt about whetherthe rhythm is asystole or fine-VFdo NOT attempt defibrilation,continuous chest compression andventilation

Fine Ventriculer Fibrilation

Coarse Ventriculer Fibrilation

Asystole

DC

chest compression

NO DC

chest compression

NO DC

SHOCKABLE RHYTHMS

2. Ventriculer tachycardia ( VT –pulseless )

NON-SHOCKABLE RYTHMS

1. Asystole

P-wave Asystole

Could be any form of waves, may mimic normal ECG but NO carotid pulse

• treatment similar to Asystole

P-ulseless

E-lectricalA-ctivity

E-lectro

M-echanicalD-issociation

NON-SHOCKABLE RYTHMS

2). P E A / E M D

Jika defib (biphasic) diberikan sebelum 5 menit, > 50-70% kemungkinan jantung berdenyut kembali

A E D Automatic Emergency Defibrillator

A E DAutomatic Emergency Defibrillator

• VF shock x 1

immediately begin chest

compression.

• Do NOT interrupt chest compressions to check rhythm or pulse until 5 cycles or 2 minutes of CPR are given.

• First shock efficacy of monophasic shock is lower than biphasic shock.

• Recommendations for higher energy (360J) when using monophasic waveform.

raba carotis

tidak ada

lihat EKG

ada

shockable un-shockable

CPR 30 : 2

2 menit

rosc

pertahankan jl nafas bebas

tetap beri oksigenraba arteri radialis

lihat EKG- ukur tensi nadi

pertahankan infus

hipotensi : beri inotropik

terapi aritmia

koreksi elektrolit & cairan single shock 360 J CPR

30:2 (2 menit)

VF / VT

lihat managemen

VT / VF

Asistol

PEA / EMD

CPR 30 : 22 menit

adrenalin

managemen asistol

Observasi di ICU

Waspada CA berulang

Adrenaline: 1 mg, iv, repeated

every 3-5 minutes

Defibrilation strategy-1

VF / pulseless VT

a single shockBiphasic 150-200 Joule

Monophasic 360 Joule

CPR 30 : 2

ROSC

NO

2 MINUTES, 30 : 2

Check ECGCheck pulse

a single shockBiphasic 150-360 Joule

Monophasic 360 Joule

AdrenalineCPR 30 : 2

YES

Recovery of

Spontaneous

Circulation

1).

2).

2 MINUTES, 30 : 2

3).

Defibrilation strategy - 2

VF / pulseless VT

ROSC

NO Check ECGCheck pulse

a single shock

Biphasic 150-360 Joule

Monophasic 360 JouleAdrenaline

CPR 30 : 2

2 MINUTES, 30 : 2

a single shock

Biphasic 150-360 Joule

Monophasic 360 JouleCPR 30 : 2

Check ECGCheck pulse

YESNo

YES

2).

3).

2 MINUTES, 30 : 2 Check ECGCheck pulse

Adrenaline: 1 mg, iv,

repeated every 3-5

minutes

a single shock1).

ROSC

Defibrilation strategy-3

VF / pulseless VT

ROSCa single shockBiphasic 150-360 Joule

Monophasic 360 Joule

CPR 30 : 2

Check ECGCheck pulse

YESNo

3).

Amiodarone 300 mg or

Lidocaine 1 mg/kg

A single shock

Biphasic 150-360 Joule

Monophasic 360 Joule

CPR 30 : 2

No YESCheck ECG

Check pulse

ROSC4).

2). a single shock

2 MINUTES, 30 : 2

Adrenaline: 1 mg, iv,

repeated

every 3-5 minutesa single shock

Biphasic 150 – 360 Joule

Monophasic 360 Joule

CPR 30 : 2 (2minutes)

• Adrenaline : 1 mg, iv, repeated every 3-5 minutes

• Amiodarone : 300 mg, bolus, if VF/VT persist after3 shocks.150 mg maybe given for recurrent orrefractory VF/VT, followed by an infusion of 900 mg over 24 hours

• Lidocain : 1 mg/kg, iv, if amiodarone is notavailable. Do not exceed a total dose of 3 mg/kg,during the first hour.Do not give lidocaine if amiodaronehas already been given

CPR -1

30 : 2

CALL

FOR

HELP

PASANG

MONITOR

VF / VT

a single shocka single shocka single shock

a single shock a single shock

2 menit 2 menit

2 menit 2 menit

adrenalinadrenalin

adrenalinCPR-3CPR-2 CPR-5CPR-4

Amiodaron

Adrenaline: 1 mg, iv,

repeated every 3-5

minutes

CPR-6

Cardiac

arrest

LIDOCAIN. Do not exceed

a total dose of 3 mg/kg,

during the first hour.

Amiodaron is the first choice

300 mg, bolus. Repeated 150 mg

for reccurrent VT/VF. Followed by

900 mg infusion over 24 hours

VF/ VT

Intubasi : as soon as possible, without stop CPR Pijat 100x/menit

Nafas 8x/menit

Evaluasi CPR : tiap 2 menit

Normal Electrocardiogram

SA node(pacemaker)

AV node

(relayer)

DC shock

Oles dulu paddles dengan jelly ECG tipis rata, baru kemudian :

1. Switch ON

Pasang paddles pada posisiapex dan parasternal

(boleh terbalik)

sternum

apex

DC shock2. Charge 360 Joules

(Non-synchronized)

Ucapkan dengan keras : Awas semua lepas dari pasien!• nafas buatan berhenti dulu• bawah bebas,

samping bebas, atas bebas, saya bebas!

3. Shock!!

(tekan dua tombol paddles bersama)

Lepas paddles dari dada, lanjutkanchest compression.

4. Segera pijat jantung lagi 2 menit

baru raba lagi/ baca lagi ECG

sternum

apex

Position of the paddles electrodeson thorax of an infant

Size of paddle electrode

- 4.5 cm diameter for infants and small children

- 8-12 cm diameter larger children

sternum

apex

VT / Ventricular Tachycardia|

| |

carotis (+) carotis (-)

Lidocain1 mg/kg iv cepat

atauAmiodaron 300 mg

a single shock360 Joules

CPR 30:2 - 5 SIKLUS

dst

Managemen VT/ VF

Cardiac arrest = carotis (-)

= ECG flat,

tak ada gelombang

• UN-shockableCPR + adrenalin

- ROSC < 10%( Recovery of Spontaneous Circulation )

Asystole

Asystole (ECG flat)PEA ECG ada gelombang tetapi carotis (-)

|CPR 2 menit

|Intubasi, iv line,

adrenalin 1 mg / 3-5 menit

|

| |

Asystole / PEA ROSC

| |

bradycardia normal

atropin 1-1-1 sp 3 mg / obat klas IIaCPR 2 menit30 : 2

30 : 2

obat klas IIa

• Lidocain 1-1.5 mg/kg tiap 3-5 menitmaksimal 3 mg/kg dlm 1 jam .

• MgSO4 1-2 gm u/ torsades des pointes

• Procainamide 30 mg/ menit

• Na-bicarb 1 mEq/kg

Adrenalin, Atropin, Lidocain

• Intra-venous

• Intra-tracheal / trans-tracheal• dosis 3-10 x intravena

• Intra-osseus

• TIDAK intra-cardial• menghentikan pijat jantung

• sukar pastikan intra-ventrikuler• kena miokard : nekrosis

• kena a. coronaria : infark

PEA = EMD

ada gelombang mirip ECG normal• TETAPI nadi carotis tidak teraba

• terapi sama seperti Asystole ( CPR + Adrenalin )

P-ulseless

E-lectrical

A-ctivity

E-lectro

M-echanical

D-issociation

BRADYARRHYTHMIA

HipoksiaHipovolemiaHiperkalemiaHipotermiaTamponade jantungTension pneumothoraxThromboemboli paruToxic overdose

B-block, Ca-blockDigitalis, Tricyclic AD

Massive MIAsidosis

4 H

4 T

MA

cardiac arrest membandel ???

Bila berhasil ROSC

• Lanjutkan oksigenasi, kalau perlu nafas buatan

(protap : ventilator )

• Hipotensi diatasi dengan inotropik dan obatvaso-aktif (adrenalin, dopamin, dobutamin, ephedrin)

• Tetap di infus untuk jalan obat cepat

• Terapi aritmia

• Koreksi elektrolit, cairan, gula darah dlsb

• Awasi di ICU

• awas: cardiac arrest sering terulang lagi

Bila setelah ROSC, lalu cardiac arrest lagi

• Ikuti algoritme semula.

• Bila perlu DC shock tetap diberikan 1 x 360

Joules dan disusul dengan CPR

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Questions