Lethal Arrhythmias

Kasus 1
Laki-laki 55 th datang dibawa supir
angkot karena ditemukan pingsan di
angkot nya
Tidak ada respons, tidak bernafas,
tidak ada nadi
Dipasang monitor dengan gambaran

Arrhythmia : What you

need to know for ACLS?

Introduction
Rhythm recognition is a key skill that
one needs to demonstrate during
cardiac arrest situation.
This can be life saving.
Early defibrillation
Decision making on the right therapy

Lets Keep it Simple!

Pulseless Rhythms
Tachyarrhythmias
Bradyarrhythmias

Pulse less Electrical Rhythm

Ventricular Fibrillation
Uncoordinated contractions within the
ventricles of heart.
Due to multiple cardiac cells that
function as pacemakers and
discharge electrical impulses in a
chaotic manner.
Reduced / No cardiac output : No pulse
Will result in Asystole if not treated.

 Commonest cause : Hypoxia

/Ischemia
Types : Fine and Coarse

Therapy
Immediate Defibrillation
CPR
I/V Amiodarone after 3 shocks

Ventricular Tachycardia
Broad Complex Tachycardia (QRS >
0.12s)
Heart rate > 180 beats /mt
Mono-morphic
Poly-morphic / Torsade Pointe
Pulse less vs with pulse

Mono morphic VT

Poly morphic VT

Torsade Pointes if Prolonged QT

interval on previous ECG

Treatment
Pulseless : Defibrillation
With pulse : stable = Amiodarone
Unstable = DC Cardio
version

No Pulse !

Pulse Less Electrical Activity

(PEA)
Organized electrical activity but
without a pulse
Usually has underlying treatable
cause
Hypovolumea and Hypoxia are the
commonest causes.
If no underlying cause is identified, it
will be treated same as Asystole.

5 Hs and 5 Ts
5 Hs
Hypovolumia
Hypoxia
Hydrogen Ion (Acidosis)
Hyperkalemia
Hypokalemia
Hypoglycemia

5Ts
Toxins
Tension Pneumothorax
Tamponade
Thrombosis : Coronary
Thrombosis : Pulmonary
Trauma

ASYSTOLE
Follow flat line protocol check leads and gain
Not a true rhythm
State of no electrical activity
Terminal event
Very poor prognosis : ROSC extremely unlikely
Possible underlying cause : 5Hs and 5Ts
Treatment : CPR and Epinephrine

Bradiarrythmia

First Degree AV Block

 PR interval is prolonged > 200ms

No clinical significance if
asymptomatic
May lead to higher degree AV Block

Second Degree AV Block

Mobitz Type 1
Progressive prolongation of PR interval.
Atrial impulse (P waves) may not be
conducted through AVN and gets blocked
and hence no QRS.
No clinical significance unless symptomatic.
Mobitz Type 2
Non prolongation and fixed PR interval.
Non conducted p waves
No ventricular activity -Drop beats / No QRS
Most times Infranodal

Third Degree AV Block

(CHB)

P waves with a regular pp interval

QRS complexes with a regular RR
interval
QRS complex may be narrow or wide
(escape rhythm)
No relationship between P waves and
QRS complexes.

Treatment
Trans cutaneous or Trans Venous
pacemaker
Atropine (0.5 mg) may be tried
Epinephrine 0.5 -1 mg /kg bw

Tachyarrhythmia

Atrial Fbrillation
No p waves preceding QRS
complexes as no coordinated atrial
contractility
Irregular (variable) RR intervals

Treatment
Unstable : Synchronized DC Cardio
version
Stable : Rhythm Control vs Rate Control
Rhythm : Amiodarone, Sotalol, Flecainide
Rate control : Beta blocker, Calcium
channel blocker, Digoxin.
Anticoagulant if indicated.

Atrial Flutter
Atrial rate 250 350 /mt
Saw Tooth Appearance
Ventricular rate depends on Degree
of AV block
Electrical foci usually in RA

Treatment

Rate Control
Rhythm Control
Anti coagulant
DCC if unstable

Supra Ventricular
Tachycardia
Broad term for various supra
ventricular arrhythmia
Electrical impulses above the
ventricular electrical conducting
system.
Inverted p waves preceding or
following qrs complexes.
Review old ECG exclude WPW

Treatment
Vagal maneuver
Adenosine
Drugs Chemical Cardio version or
Rate control.
Anti coagulant.
If unstable : sync. DCC

Contoh Kasus
Laki laki 54 tahun dibawa keluarga
ke UGD karena tiba2 kejang
Tidak ada respons, Tidak bernafas,
tidak ada nadi
2 siklus RJP tidak ada respons
Alat defib datang, dipasang lead
dengan gambaran :

 Setelah 2 siklus RJP terdapat

gambaran seperti berikut

Contoh Kasus
Wanita 40 tahun datang ke UGD
karena sesak nafas
Setelah dipasang monitor tampak
gambaran EKG