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

If there is a doubt about whether

the rhythm is asystole or fine-VF
do NOT attempt defibrilation,
continuous chest compression and
ventilation

Fine Ventriculer Fibrilation

Fine VF :

chest compression

NO DC
chest compression
Asystole

Coarse Ventriculer Fibrilation

NO DC
DC

SHOCKABLE RHYTHMS
2. Ventriculer tachycardia ( VT pulseless )

NON-SHOCKABLE RYTHMS
1. Asystole

P-wave Asystole

NON-SHOCKABLE RYTHMS
2). P E A / E M D
Could be any form of waves, may mimic normal ECG
but NO carotid pulse
treatment similar to Asystole

P-ulseless
E-lectrical
A-ctivity

E-lectro
M-echanical
D-issociation

AED
Automatic Emergency Defibrillator

Jika defib (biphasic) diberikan sebelum 5 menit,

> 50-70% kemungkinan jantung berdenyut kembali

AED

Automatic 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.

CPR 30 : 2
2 menit

raba carotis
ada

Adrenaline: 1 mg, iv, repeated

every 3-5 minutes

tidak ada
lihat EKG

rosc

pertahankan jl nafas bebas

tetap beri oksigen

shockable

un-shockable

raba arteri radialis

lihat EKG- ukur tensi nadi

pertahankan infus
hipotensi : beri inotropik
terapi aritmia
koreksi elektrolit & cairan

VF / VT

single shock 360 J CPR

30:2 (2 menit)

Asistol
PEA / EMD

CPR 30 : 2
2 menit

adrenalin
Observasi di ICU
Waspada CA berulang

lihat managemen
VT / VF

managemen asistol

VF / pulseless VT

1).
Defibrilation strategy-1

a single shock
Biphasic 150-200 Joule
Monophasic 360 Joule

CPR 30 : 2
2 MINUTES, 30 : 2

NO

2).

Check ECG
Check pulse

YES

a single shock
Biphasic 150-360 Joule
Monophasic 360 Joule

Adrenaline
CPR 30 : 2

ROSC
Recovery of
Spontaneous
Circulation

2 MINUTES, 30 : 2

3).

1). a single shock

VF / pulseless VT

Defibrilation strategy - 2
Check ECG
Check pulse

NO

2).

ROSC

a single shock

Biphasic 150-360 Joule

Monophasic 360 Joule
Adrenaline
CPR
30 : 2

2 MINUTES, 30 : 2
No

3).

Check ECG
Check pulse

a single shock

Biphasic 150-360 Joule

Monophasic 360 Joule
CPR

YES

30 : 2

Adrenaline: 1 mg, iv,

repeated every 3-5
minutes

YES
ROSC

2 MINUTES, 30 : 2

Check ECG
Check pulse

2). a single shock

Check ECG
Check pulse

No

3).

a single shock
Biphasic 150-360 Joule
Monophasic 360 Joule

CPR

4).

Check ECG
Check pulse

Amiodarone 300 mg or
Lidocaine 1 mg/kg
A single shock
Biphasic 150-360 Joule
Monophasic 360 Joule
CPR
30 : 2

Defibrilation strategy-3
YES
ROSC

30 : 2
2 MINUTES, 30 : 2

No

VF / pulseless VT

YES

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

a single shock

Biphasic 150 360 Joule

Monophasic 360 Joule
CPR 30 : 2 (2minutes)

 Adrenaline
Amiodarone

Lidocain

:
:

1 mg, iv, repeated every 3-5 minutes

300 mg, bolus, if VF/VT persist after

3 shocks.
150 mg maybe given for recurrent or
refractory VF/VT, followed by
an infusion of 900 mg over 24 hours
:

1 mg/kg, iv, if amiodarone is not

available.
Do not exceed a total dose of 3 mg/kg,
during the first hour.
Do not give lidocaine if amiodarone
has already been given

VF/ VT
Pijat 100x/menit
Nafas 8x/menit

Intubasi : as soon as possible, without stop CPR

Cardiac
arrest

CPR -1
30 : 2
CALL
FOR
HELP

PASANG
MONITOR

adrenalin
VF / VT

2 menit

adrenalin

2 menit
2 menit

a single shock

a single shock

a single shock

CPR-2

CPR-3

CPR-4

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

Evaluasi CPR : tiap 2 menit

Amiodaron

2 menit

a single shock
CPR-5

a single shock
CPR-6

Amiodaron is the first choice

300 mg, bolus. Repeated 150 mg
for reccurrent VT/VF. Followed by
900 mg infusion over 24 hours
LIDOCAIN. Do not exceed
a total dose of 3 mg/kg,
during the first hour.

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 posisi
apex dan parasternal
(boleh terbalik)

sternum

apex

2. Charge 360 Joules

DC shock

(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, lanjutkan

chest compression.
4. Segera pijat jantung lagi 2 menit
baru raba lagi/ baca lagi ECG

sternum

apex

Position

of the paddles electrodes

on thorax of an infant

sternum

apex

Size of paddle electrode

- 4.5 cm diameter for infants and small children
- 8-12 cm diameter larger children

VT / Ventricular Tachycardia
|
|

carotis (+)

carotis (-)

Lidocain
1 mg/kg iv cepat
atau
Amiodaron 300 mg

a single shock
360 Joules

CPR 30:2 dst

5 SIKLUS

Managemen VT/ VF

Cardiac arrest = carotis (-)

Asystole
= ECG flat,
tak ada gelombang

UN-shockable
CPR + adrenalin
- ROSC < 10%
( Recovery of
Circulation )

Spontaneous

Asystole (ECG flat)

PEA ECG ada gelombang tetapi carotis (-)
|
CPR 2 menit
| 30 : 2
Intubasi, iv line,
adrenalin 1 mg / 3-5 menit

|
|
Asystole / PEA
|
bradycardia
CPR 2 menit
30 : 2

|
ROSC
|
normal

atropin 1-1-1 sp 3 mg / obat klas IIa

obat klas IIa

Lidocain 1-1.5 mg/kg tiap 3-5 menit
maksimal 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

cardiac arrest membandel ???

4H
4T

MA

Hipoksia
Hipovolemia
Hiperkalemia
Hipotermia
Tamponade jantung
Tension pneumothorax
Thromboemboli paru
Toxic overdose
B-block, Ca-block
Digitalis, Tricyclic AD

Massive MI
Asidosis

Bila berhasil ROSC

Lanjutkan oksigenasi, kalau perlu nafas buatan
(protap : ventilator )

Hipotensi diatasi dengan inotropik dan obat

vaso-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

Questions

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