EKG - ARITMIA

Slide 1: 

My I Let it beat !

NARROW COMPLEX : 

NARROW COMPLEX (Supraventricular Tachycardia) BROAD COMPLEX TACHYCARDIA

NARROW COMPLEX TACHYCARDIA : 

NARROW COMPLEX TACHYCARDIA (Supraventricular Tachycardia)

Slide 4: 

NARROW COMPLEX TACHYCARDIA Vagal manouevres Atrial Fibrillation (>130 bpm) Adenosine lv Seek expert help Adverse signs ?  Esmolol or  Digoxin or  Verapamil or  Amiodarone or  Overdrive pacing Sedation Synchronized cardioversion Amiodarone lv No Yes

Slide 5: 

Adverse signs ?  Hypotension Systolic  Chest pain  Heart failure  Impaired consciousness  Rate  200 bpm BP  90 mmHG

Slide 6: 

Vagal manouvers : caution possible digitalis toxicity, acute ischaemia, or presence of carotid bruit.

Slide 7: 

Adenosine 3 mg by bolus injection repeat if necessary every 1-2 min. using 6 mg, then 12 mg, then 12 mg (ATP is an alternative)

Slide 8: 

If no adverse signs choose from : Esmolol : 40 mg over 1 min + infusion 4 mg/min (iv injection can be repeated with increments of infusion to 12 mg/min). Digoxin : max dose 500 g over 30 min x 2. Verapamil : 5 - 10 mg iv. Amiodarone : 300 mg over 1 hour (may be repeated once). Overdrive pacing (not AF).

Slide 9: 

Amiodarone 300 mg over 15 min then 300 mg over 1 hour if necessary, preferably by central line and repeat cardioversion.

Slide 10: 

BROAD COMPLEX TACHYCARDIA (Sustained Ventricular Tachycardia)

Slide 11: 

BROAD COMPLEX TACHYCARDIA Use VF protocol Seek expert help Adverse signs ?  Lidocaine iv Synchronised DC shock 100J: 200J: 360J Amiodarone iv Sedation No Yes Pulse ? No Yes If potassium low  Give K+  Give Mg+ + Seek expert help Synchronised DC shock 100J: 200J: 360J Sedation Start  Lidocaine +/-  Magnesium & potassium as opposite Further cardioversion as necessary consider other agents

Slide 12: 

Use VF protocol Adverse signs ?  Lidocaine iv Yes Pulse ? No Yes Seek expert help No Seek expert help

Slide 13: 

Adverse signs ?  Systolic BP  90 mmHG  Chest pain  Heart failure  Rate  150 bpm

Slide 14: 

 Lidocaine iv 50 mg over 2 min  Start infusion 2 mg/min after repeated every 5 min to total dose of 200 mg. first bolus dose.

Slide 15: 

 Give potassium chloride up to  Give magnesium sulphate iv 60 mmol, max rate 30 mmol/h. 10 ml 50 % in 1 hour. If potassium known to be low :

Slide 16: 

For refractory cases consider other pharmacological agents : amiodarone, procainamide, flecainide or bretylium, or overdrive pacing.

Slide 17: 

Amiodarone 300 mg over 5 - 15 min, preferably by central line then 300 mg over 1 hour.

Slide 19: 

Adverse signs ?  Clinical evidence of low cardiac  Hypotension : systolic BP  Heart failure  Rate < 40 bpm output.  Presence of ventricular arrhytmias requiring supression.  90 mmHg

Slide 20: 

Risk of asystole  History of asystole  Mobitz II AV Block  Any pause  3 seconds  Complete heart block, wide QRS

Slide 21: 

Interim measure  External pacing  iv isoprenaline or orciprenaline

Slide 22: 

Atropine IV 500 g initially to max 3 mg.

Slide 24: 

E M D Ventilate/Intubate 100 % oxygen IV/IO Access Adrenaline 10 mcg/kg Fluids 20 ml/kg CPR 3 min Adrenaline 10 mcg/kg Consider : Hypovolaemia Tension pneumothorax Cardiac tamponade Drug overdosage Hypothermia Electrolytic imbalance and treat appropriately

Slide 25: 

Consider :  pressor agents  calcium  alkalising agents  adrenaline 5 mg iv

Slide 26: 

Think of, and if indicated give specifik teratment for : If not already :  intubate  iv acces hypovolaemia tension pneumothorax cardiac tamponade pulmonary embolisme drug overdose/intoxication hypothermia electrolyte imbalance Adrenanline 1 mg iv 10 CPR sequences of 1:5 ventilation/compression

Slide 28: 

Precordial Thump Note : after 3 loops consider alkalising and/or antiaarhytmic agents

Slide 29: 

Precordial Thump Defibrillate 2 J/kg Defibrillate 2 J/kg Defibrillate 4 J/kg Ventilate/Intubate 100 % oxygen IV/IO Access Adrenaline 10 mcq/kg CPR 1 min Defibrillate 4 J/kg Defibrillate 4 J/kg Defibrillate 4 J/kg Adrenaline 100 mcq/kg Consider hypothermia drugs electrolytes

Slide 30: 

DC shock 200 J 1 DC shock 200 J 2 DC shock 200 J 3 Ventilate/Intubate 100 % oxygen IV/IO Access Adrenaline 10 mcq/kg CPR 1 min Defibrillate 4 J/kg Defibrillate 4 J/kg Defibrillate 4 J/kg DC shock 200 J 1 DC shock 200 J 2 DC shock 360 J 3 If not already  intubate  iv access Adrenaline 1 mg iv 10 CPR sequences of 1:5 ventilation/compression DC shock 360 J 4 DC shock 360 J 5 DC shock 360 J 6 Precordial Thump

Slide 31: 

Notes : The interval between shocks 3 and 4 should not be > 2 mins. Adrenaline given during loops approx. every 2-3 mins. Continue loops for as long as defibrillation is indicated. After 3 loops consider :  alkalising agents  antiarrhythmic agents

Silakan kunjungi kami di : : 

Silakan kunjungi kami di : http://www.jantunghipertensi.com Dr.H.M.Edial Sanif SpJP.FIHA

Slide 34: 

VF excluded ? no DC shock 200 J DC shock 200 J DC shock 360 J If not already  intubate  iv access Adrenaline 1 mg iv 10 CPR sequences of 1:5 ventilation/compression (Atropine 3 mg iv once only) Electrical activity evidence ? yes Pace Precordial Thump yes no

Slide 35: 

Ventilate/Intubate 100 % oxygen IV/IO Access Adrenaline 10 mcq/kg CPR 3 min Adrenaline 100 mcq/kg Fluids and/or alkalising agents Consider

Slide 36: 

Notes : If no response after 3 cycles, consider high dose adrenaline 5 mg iv