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LIFE THREATENING ARRHYTHMIAAND MANAGEMENT
Dr. Beny Hartono, SpJP
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Introduction
Cardiac arrhythmias are a common cause of sudden death.Symptomatic arrhythmia frequently observed in the ICU hemodynamic compromise
J. Intensive Care Med. 2007
ECG is the most important diagnostic tools !!!
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Life threatening Arrhythmia
Lethal:
VF, VT, PEA, ASYSTOLE
Non Lethal: TOO FAST or TOO SLOW
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ARRHYTHMIA
Tachyarrhythmias
Bradiarrhythmias
HR > 100 x/min
HR < 60 x/min
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Normal Conduction System
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Physiologic Basis of Pacemaker Cells
Pacemaking &Conduction System
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Mechanisms of Arrhythmia
AutomaticityReentryTrigger Activity
Slow pathway- hantaran konduksilambat- masa refraktercepat
Fast pathway- hantaran konduksicepat- masa refrakterlambat
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Treat the Patient ..., not the Monitor !!!!Evaluate the patient’s symptoms and clinical signs
Ventilation
OxygenationHeart rateBlood pressureLevel of consciousness
Look for signs of inadequate organ perfusion
Principles of Arrhythmia Recognition and Management
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QRS Complex ?
(-)
-Asystole-V F
(+)
Fast / Slow ? -Takikardia/-Bradicardia
Wide / Narrow complex -Wide ? (Ventricular ? )(Consult the expert is advice )
-Narrow ? (Supra ventricular)(Consult the expert is considered)
HOW TO READ ECG RHYTHM
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QRS regular /irregular ?
P wave ?
P wave and QRS complexConnection ?
Normal / abnormal P wave ?
-1 “P” followed by 1 “QRS” ? / more “P” than ”QRS”
-Appropriate distance betweenP wave and QRS complex
Irregular : A fib, A flutter, MAT,AF + WPW, multifocal VT,
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Tachy-Arrhythmia
The first step Determine if the patient’s condition is stable orunstable
The second stepObtain a 12-lead ECG to evaluate the QRSduration (ie, narrow or wide).
The third stepDetermine if the rhythm is regular or irregular
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TachyArrhythmia
If the patient becomes unstable at any time,proceed with synchronized cardioversion.If the patient develops pulseless arrest or is unstablewith polymorphic VT, treat as VF and deliver high-energy unsynchronized shocks (ie, defibrillationdoses).
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Tachycardia
Narrow –QRS-complex (SVT) tachycardias ( QRS
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ACC guidelines 2003
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Tachycardia
Wide –QRS-complex tachycardias ( QRS > 0.12second )
— Ventricular tachycardia (VT) — SVT with aberrancy — Pre-excited tachycardias ( advanced recognition
rhythms using an accessory pathway)
Most wide-complex (broad-complex) tachycardiasare ventricular in origin
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ACC guidelines 2003
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Tachycardia
Initial Evaluation and Treatment ofTachyarrhythmias The evaluation and management oftachyarrhythmias is depicted in the ACLSTachycardia Algorithm.
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Circulation 2010
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20/40Copyright ©2005 American Heart Association
Circulation 2005;112:IV-67-77IV-
ACLS Tachycardia Algorithm
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Synchronized Cardioversion andUnsynchronized Shocks
Synchronized cardioversion is recommended to treat(1) unstable SVT due to reentry(2) unstable atrial fibrillation(3) unstable atrial flutter(4) unstable monomorphic (regular) VT
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Synchronized Cardioversion andUnsynchronized Shocks
If possible, establish IV access beforecardioversion and administer sedation ifthe patient is conscious.Consider expert consultation.
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Syncrhronized Cardioversion
Initial recommended doses :Narrow regular : 50-100 JNarrow irregular : 120-200 J biphasic or 200 JmonophasicWide regular : 100 JWide irregular : defibrillation dose (NOT
synchronized)
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Cardioversion
Cardioversion is not likely to be effective fortreatment ofJunctional tachycardia
Ectopic or multifocal atrial tachycardia these rhythms have an automatic focus, arising from cellsthat are spontaneously depolarizing at a rapid rateshock delivery to a heart with a rapid automatic focus
may increase the rate of the tachyarrhythmia
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Brady-Arrhythmia
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Bradycardia
Defined as a heart rate of
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Bradycardia
Identify signs and symptoms of poor perfusion anddetermine if those signs are likely to be caused by thebradycardia
hypotensionacute altered mental statusChest paincongestive heart failure
seizuressyncopeother signs of shock related to the bradycardia
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Bradycardia
Bradycardia :Profound sinus bradikardia, SA blockJunctional rhythmAV block
Causes of bradycardia:medications
electrolyte disturbancesstructural problems resulting from acutemyocardial infarction and myocarditis.
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Copyright ©2005 American Heart Association
Circulation 2005;112:IV-67-77IV-
Bradycardia Algorithm
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Copyright ©2005 American Heart Association
Circulation 2005;112:IV-67-77IV-
Bradycardia Algorithm
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Therapy
Atropine First-line drug for acute symptomatic bradycardia(Class IIa)
Improved heart rate and signs and symptomsassociated with bradycardiaUseful for treating symptomatic sinus bradycardia
and may be beneficial for any type of AV block atthe nodal level .
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Therapy
Atropine The recommended dose for bradycardia is 0.5 mg IV every 3 to 5 minutes to a maximum total dose of3 mg.Doses
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Therapy
Atropine Use cautiously in the presence of acute coronaryischemia or myocardial infarction; increased heartrate may worsen ischemia or increase the zone ofinfarction.Atropine may be used with caution and appropriatemonitoring following cardiac transplantation . It willlikely be ineffective because the transplanted heart
lacks vagal innervation .
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Therapy
Pacing (Transcutaneous pacing, TCP )Class I intervention for symptomatic bradycardiasIndication : started immediately for patients
Unstable, particularly those with high-degree blockIf there is no response to atropineIf atropine is unlikely to be effectiveIf the patient is severely symptomatic
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Therapy
Pacing (Transcutaneous pacing, TCP )Can be painful and may fail to produce effectivemechanical captureUse analgesia and sedation for pain controlVerify mechanical capture and re- assess the patient’scondition
If TCP is ineffective (eg, inconsistent capture)prepare for transvenous pacing consider obtaining expert consultation
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Therapy
Alternative Drugs to Consider Second-line agents for treatment ofsymptomatic bradycardiaThey may be considered when thebradycardia is unresponsive to atropineand as temporizing measures whileawaiting the availability of a pacemaker.
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Epinephrine
Used for patients with symptomaticbradycardia or hypotension afteratropine or pacing fails ( Class IIb ).
Begin the infusion at 2 to 10 µg/min andtitrate to patient response.Assess intravascular volume and supportas needed.
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Dopamine
Both α - and ß-adrenergic actionsDopamine infusion (at rates of 2 to 10 µg/kg perminute) can be added to epinephrine or
administered alone.Titrate the dose to patient response.Assess intravascular volume and support as needed.
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Thank you for your attention !!