Management of Cardiac Arrhytmia in Advanced Cardiac Life Support (ACLS)

Causes of Cardiac Arrest and CPR Result

250
Cardiac arrests

200 150 100 50 0

220

Resuscitated; hospitalized Discharged alive

40%

108
23% 88% 67% 9%

87

51

24 21 16 Ventricular fibrillation Ventricular tacycardia

Bradycardia, asytole, PEA

Lethal Rhytms
VF (ventricular fibrillation) VT (ventricular tachycardia) Asystole PEAs (Pulseluss electrical activities)

Recognition and therapy of the major ACLS emergency conditions (core) :

Universal algorithm Ventricular fibrillation / pulselless ventricular tachycardia (VF / VT) Pulseless electrical activity (PEA) Asystole Bradycardia Tachycardias Acute myocardial infarction ( MI ) Hypotension / shock / acute pulmonary edema

Gambar Skematis Sistim Konduksi Jantung

Assess responsiveness

Responsive Observe Treat as indicated

Not

Responsive Activate EMS Call for defibrillator Assess breathing (open the airway, look, listen, and feel)

Breathing Place in recovery position if no trauma

Not Breathing Give 2 slow breaths Assess circulations

Rescue breathing Oxygen IV Vital signs

Pulse
Endotracheal intubation History Physical examination Monitor, 12-lead ECG

No Pulse
Start CPR

Suspected cause

Ventricular fibrillation/tachycardia (VF/VT) present on monitor/defibrillator ?

Hypotension/shock/ acute pulmonary edema Go to Fig 8

No
Intubate Confirm tube placement; consider end-tidal CO2 indicator Confirm ventilations Determine rhythm and cause

Yes
VF / VT Go to Fig 2

Acute MI Go to Fig 9

Arrhytmia

Yes
Too Slow Go to Fig 5 Too fast Go to Fig 6

Electrical activity ?

No
Asystole Go to Fig 4

Pulseless electrical activity (PEA) Go to Fig 3

Ventricular Fibrillation
Causes * Untreated ventricular tachycardia * Myocardial ischemia and infarction * Cardiomyopathy. * Severe electrolyte disturbances: hypokalemia and hypomagnesemia. * Drug toxicity may lead to VF, especially with digitalis, phenothiazines, and tetracyclic and tricyclic antidepressants. Criteria * Chaotic, wide, ventricular tachyarrhythmias with a grossly irregular morphology. * No consistent, identifiable QRS complex. * Rapid rate (at times more than 350 per minute).

Ventricular Fibrillation

VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA Defibrillate up to 3 times for persistent VF/VT: (200 Joules, 200-300 Joules, 360 Joules) Continue CPR, Intubate, IV Access Epinephrine, 1 mg IV Push; repeat q 3-5 min Defibrillate, 360 J within 30 to 60 sec

Epinephrine, increasing doses (?) Lidocaine: Amiodarone: Bretylium : Procainamide : Magnesium :

Intravenous antiarrhythmics 1,5 mg/kg; repeat in 3-5 min 150-300 mg over 10 min, 1 mg/min 5 mg/kg; 10 mg/kg in 5 min 30 mg/min, up to 17 mg/kg 1-2 gm IV (for polymorphic VT)

NaHCO3, 1 mEq/kg ( K+ )

(Drug

Defibrillate, 360 Joules Shock Drug Shock

.)

Venticular Tachycardia
Causes
VT is usually a manifestation of heart disease, particularly ischemic heart disease and cardiomyopathy. It may rarely occur in an apparently otherwise normal heart. Other causes are the same as for premature ventricular complexes.

Criteria
* Three or more consecutive premature ventricular complexes at a rate of 100 per minute or faster. * Rate is usually 100 to 250 per minute. * Evidence of AV dissociation is often present : * P waves at a different rate than ventricular rate * Supraventricular captures * Fusion complexes

Ventricular Tachycardia

Torsade De Pointes
Causes
Antiarrhythmic drugs, particularly the class IA drugs such as disopyramide, procainamide, and quinidine (quinidine syncope) are the most common causes of torsade de pointes (TDP). Hypokalemia and hypomagnesemia Psychotropic drugs such as phenothiazines and tetracyclic and tricyclic antidepressents Abnormal nutritional states including starvation and liquid protein diets may lead to long Q-T Severe bradyarrhythmias such as complete AV block and sick sinus syndrome

Criteria
* Rate greater than 100 per minute; usually 150 to 300 per minute. * Gradually shifting electrical axis (twisting of points) * Sinus rhythm prior to the onset demonstrates prolongation of the corrected Q-T interval. (In this ECG, the Q-Tc interval = 0.46 seconds) * Often starts as a short cycle following a long cycle.

Torsades de Pointes

Pulseless Electrical Activity

Pathophysiology: Cardiac conduction impulses occur in organized pattern, but this fails to produce myocardial contraction (former electromechanical dissociation); or insufficient ventricular filling during diastole; or ineffective contraction Common causes: 5 Hs and 5 Ts aid recall
Hypovolemia Hypoxia Hydrogen ion acidosis Hyperkalemia/hypokalemia Hypothermia - Tablets (Drug, Ingestions) - Tamponade (Cardiac) - Tension Pneumothorax - Trombosis, Coronary (ACS) - Trombosis, pulmonary (embolism)

ECG criteria:
Rhytm dyaplays organized electrical activity (not VF / pulseless VT) Seldom as organized as normal sinus rhytm QRS Can be narrow (<0,10mm) or wide (>0,12mm), beat can be fast (>100x/mnt) or slow (<60x/mnt) Most commonly fast and narrow (noncardiac) or slow & wide (cardiac)

Pulseless Electrical Activity (PEA)

Any organized pulse without detectable pulse is PEA

Pulseless Electrical Activity (PEA) Algorithm

Includes * Electromechanical dissociation (EMD) * Idioventricular rhythms * Bradyasystolic rhythms * Pseudo-EMD * Ventricular escape rhythms * Post defibrillation idioventricular rhythms

* Continue CPR * Assess blood flow using Doppler ultrasound, * Intubate at once end-tidal CO2, echocardiography, or arterial line * Obtain IV access

* * * * * *

Consider possible causes ( Parentheses = possible therapies and treatment ) Hypovolemia (volume infusion) * Drug overdoses such as tricyclics, digitalis, Hypoxia (ventilation) b-blockers, calcium channel blockers Cardiac tamponade (pericardiocentesis) * Hyperkalemiaa Tension pneumothorax (needle decompression) * Acidosisb Hypothermia (see hypothemia algorithm) * Massive acute myocardial infarction Massive pulmonary embolism (surgery, thrombolytics)

Epinephrine 1 mg IV push, a,c repeat every 3-5 min

If absolute bradycardia (<60 BPM) or relative bradycardia, give atropine 1 mg IV Repeat every 3-5 min to a total of 0.03 0.04 mg/kg

Asystole

Asystole Treatment Algorithm

Continue CPR Intubate at once Obtain IV access Confirm asystole in more than one lead Consider possible causes Hypoxia Hyperkalemia Preexisting acidosis Drug overdose Hypothermia

Consider immediate Transcutaneous pacing (TCP)

Epinephrine 1 mg IV push, repeat every 3-5 min

Atropine 1 mg IV, repeat every 3-5 min up to a total of 0.03 0.04 mg/kg

Consider termination of efforts

Stable Ventricular Tachycardia Monomorphic or Polymorphic ?

Monomorphic VT Is cardiac function Impaired ?

Note! May go directly to cardioversion

Polymorphic VT Is baseline QT interval prolonged?

Preserved Heart function

Poor ejection fraction

Normal baseline QT interval

Prolonged baseline QT interval (suggests torsades)

Normal baseline QT interval Treat ischemia Correct electrolytes Medications : any one Procainamide Sotalol Others acceptable Amiodarone Lidocaine Amiodarone 150 mg IV over 10 minutes or Lidocaine 0.5 to 0.75 mg/kg IV push Then use Synchronized cardioversion Medications : any one b-Blockers or Lidocaine or Amiodarone or Procainemide or Sotalol

Long baseline QT Interval Correct abnormal electrolytes Therapies : any one Magnesium Overdrive pacing Isoproterenol Phenytoin Lidocaine

Narrow-Complex Supraventricular Tachycardia, Stable

Attempt therapeutic diagnostic maneuver Vagal stimulation Adenosine
Preserved heart function

Junctional tachycardia

b-Blocker Ca2+ channel blocker Amiodarone NO DC cardioversion!

EF <40%, CHF

Amiodarone NO DC cardioversion! b-Blocker Ca2+ channel blocker Amiodarone NO DC cardioversion! Amiodarone Diltiazem NO DC cardioversion!

Ectopic or multifocal atrial tachycardia

Preserved heart function

EF <40%, CHF

Paroxysmal supraventricular tachycardia

Preserved heart function

Priority order : AV nodal blockade DC cardioversion Antiarrhythmics : consider procainemide, amiodarone, sotalol Priority order : DC cardioversion Digoxin Amiodarone Diltiazem

EF <40%, CHF

Tachycardia with Narrow QRS Complex

* * * * *

Assess ABCs Secure airway Administer oxygen Start IV Attach monitor, pulse oximeter, and automatic blood pressure

* * * * *

Assess vital signs Review history Perform physical examination Order 12-lead ECG Order portable chest x-ray

Bradycardia, either absolute (< 60 BPM) or relative

Too slow (<60 BPM)

Serious signs or symptoms ?

No

Yes

Type II second-degree AV heart block ? Or Third-degree AV heart block ? No Yes

Intervention sequence Atropine 0.5-1.0 mg TCP, if available Dopamine 5-20 mg/kg per min Epinephrine 2-10 mg/min Isoproterenol

Observe

Prepare for transvenous pacer Use TCP as a bridge device

Electrical Cardioversion Algorithm

Tachycardia With serious signs and symptoms related to the tachycardia

If ventricular rate is > 150 BPM, prepare immediate cardioversion. May give brief trial of medications based on specific arrhythmias. Immediate cardioversion is generally not needed for rates < 150 BPM

Check Oxygen saturation Suction device IV line Intubation equipment Premedicate whenever possible

Synchronized cardioversion VT PSVT 100 J, 200 J Atrial fibrillation 300 J, 360 J Atrial flutter

The Universal Algorithm for Adult Emergency Cardiac Death Assess responsiveness If not responsive, activate EMS system Call for defibrillator Assess breathing (open the airway, look, listen, and feel) If the patient is not breathing, give two slow breaths Assess the circulation

Includes

Electromechanical dissociation (EMD) Pseudo - EMD Idioventricular rhythms Ventricular escape rhythms Bradyasystolic rhythms Postdefibrillation idioventricular rhythms

Continue CPR Intubate at once Obtain IV access

* Assess blood flow using Doppler ultrasound, end-tidal CO2, echocardiolography, or arterial line

Hypovolemia (volume infusion) Hypoxia (ventilation) Cardiac tamponade (pericardiocentesis) Tension pneumothorax (needle decompression) Hypothermia (see hypothermia algorithm) Massive pulmonary embolism (surgery, thrombolytics)

* Drug overdoses such as tricyclics, digitalis, - blockers, calcium channel blockers * Hyperkalemiaa * Acidosisb * Massive acute myocardial infarction (go to Fig 9)

Epinephrine 1 mg IV Push,a,c repeat every 3-5 min

If absolute bradycardia (<60 BPM) or relative bradycardia, give atropine 1 mg IV Repeat every 3-5 min to a total of 0.03 - 0.04 mg/kgd

Key Points of Primary Survey In the primary survey, focus on basic CPR and defibrillation : First A - B - C - D Airway : open the airway Breathing : provide positive - pressure ventilations Circulations : give chest compressions Defibrillations : shock VF / pulseless VT In the secondary survey, focus on intubation, IV access, rhythms, and drugs and on why the cardiorespiratory arrest accurred : Second A-B-C-D Airway : perform endotracheal intubation Breathing : assess bilateral chest rise and ventilation Circulation : gain IV access, determine rhythm, give appropriate agents Differntial Diagnosis : search for, find and treat reversible causes

The Primary Survey : Focus on basic CPR and Defibrillation First A-B-C-D Airway : * Open the airway Breathing : * Provide positive - pressure ventillation Circulation : * Give chest compressions Defibrillation : * Shock VF/pulseless VT

The secondary Survey :

Reminds rescuer to perform in-depth interventions and assessments

Second A - B - C - D
Airway : * Establish advanced airway control * Perform endotracheal intubation Breathing : * Assess the adequacy of ventilation via endotraceal tube * Provide positive-pressure ventilations Circulation : * Obtain IV access to administer fluids and medications * Provide rhythm - appropriate cardiovascular pharmacology Differential Diagnosis : * Identify the possible reasons for the arrest. Construct a differential diagnosis to identify reversible causes that have a specific therapy

For Lone Rescuer With Immediate Access To Defibrillator

The recommended sequence is :

Assess responsiveness Call Fast Appropriately position the victim Appropriately position the rescuer