I

My

Let it beat !
Dr. Edial

TACHYCARDIA
NARROW COMPLEX
(Supraventricular Tachycardia)

BROAD COMPLEX

Dr. Edial

NARROW COMPLEX TACHYCARDIA

(Supraventricular Tachycardia)

Dr. Edial

NARROW COMPLEX TACHYCARDIA

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

Amiodarone lv

Dr. Edial

NARROW COMPLEX TACHYCARDIA

(Supraventricular Tachycardia)

Adverse signs ?

Hypotension Systolic BP 90 mmHG Chest pain Heart failure Impaired consciousness Rate 200 bpm

Dr. Edial

NARROW COMPLEX TACHYCARDIA

(Supraventricular Tachycardia)

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

Dr. Edial

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)

NARROW COMPLEX TACHYCARDIA

(Supraventricular Tachycardia)

Dr. Edial

NARROW COMPLEX TACHYCARDIA

(Supraventricular Tachycardia)

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). Dr. Edial

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

NARROW COMPLEX TACHYCARDIA

(Supraventricular Tachycardia)

Dr. Edial

BROAD COMPLEX TACHYCARDIA

(Sustained Ventricular Tachycardia)

Dr. Edial

BROAD COMPLEX TACHYCARDIA

Pulse ? Yes No
If potassium low Give K+ Give Mg+ +

No

Use VF protocol Yes

Adverse signs ?

Lidocaine iv

Seek expert help

Sedation Synchronised DC shock 100J: 200J: 360J Start

Seek expert help

Sedation
Synchronised DC shock 100J: 200J: 360J Lidocaine +/ Magnesium & potassium as opposite Further cardioversion necessary as

Amiodarone iv

Dr. Edial

consider other agents

BROAD COMPLEX TACHYCARDIA

(Sustained Ventricular Tachycardia)

Pulse ? Yes

No

Use VF protocol

Adverse signs ?
No Lidocaine iv

Yes Seek expert help

Seek expert help Dr. Edial

BROAD COMPLEX TACHYCARDIA

(Sustained Ventricular Tachycardia)

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

Dr. Edial

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

BROAD COMPLEX TACHYCARDIA

(Sustained Ventricular Tachycardia)

Dr. Edial

If potassium known to be low :

BROAD COMPLEX TACHYCARDIA

(Sustained Ventricular Tachycardia)

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

Dr. Edial

BROAD COMPLEX TACHYCARDIA

(Sustained Ventricular Tachycardia)

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

Dr. Edial

BROAD COMPLEX TACHYCARDIA

(Sustained Ventricular Tachycardia)

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

Dr. Edial

BRADYCARDIA

Adverse signs ?
BRADYCARDIA

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

Dr. Edial

BRADYCARDIA

Risk of asystole

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

Dr. Edial

Interim measure

BRADYCARDIA

External pacing iv isoprenaline or orciprenaline

Dr. Edial

BRADYCARDIA

Atropine IV 500 g initially to max 3 mg.

Dr. Edial

EMD
QRS without palpable pulse

QRS without palpable pulse

EMD

EMD
Ventilate/Intubate
100 % oxygen

IV/IO
Access

Adrenaline
10 mcg/kg 20 ml/kg

Fluids CPR

3 min

Adrenaline
10 mcg/kg

Consider : Hypovolaemia Tension pneumothorax Cardiac tamponade Drug overdosage Hypothermia Electrolytic imbalance and treat appropriately

Dr. Edial

QRS without palpable pulse

EMD

Consider : pressor agents calcium alkalising agents adrenaline 5 mg iv

Dr. Edial

QRS without palpable pulse

EMD

Think of, and if indicated give specifik teratment for :

hypovolaemia tension pneumothorax cardiac tamponade pulmonary embolisme drug overdose/intoxication hypothermia electrolyte imbalance If not already : intubate iv acces Adrenanline 1 mg iv 10 CPR sequences of 1:5 ventilation/compression

Dr. Edial

VF
PULSELESS VT

VF

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

Dr. Edial

Precordial Thump

VF

Defibrillate 2 J/kg Defibrillate 2 J/kg Defibrillate 4 J/kg Ventilate/Intubate

100 % oxygen

IV/IO Access

Adrenaline 10 mcq/kg
Adrenaline
100 mcq/kg Consider hypothermia drugs electrolytes

CPR 1 min Defibrillate 4 J/kg Defibrillate 4 J/kg Defibrillate 4 J/kg

Dr. Edial

VF

Precordial Thump DC shock 200 J 1 DC shock 200 J 2 DC shock 360 J 3 200

If not already Ventilate/Intubate oxygen intubate access IV/IO Access

Adrenaline 1 mg iv Adrenaline 10 mcq/kg

100 %

iv

10 CPRCPR 1 min of 1:5 sequences ventilation/compression Defibrillate 4 J/kg DC shock 360 J 4 Defibrillate 4 J/kg DC shock 360 J 5 Defibrillate 4 J/kg DC shock 360 J 6 Dr. Edial

PULSELESS VT

VF

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

Dr. Edial

ASYSTOLE

Silakan kunjungi kami di :

http://www.jantunghipertensi.com

Dr.H.M.Edial Sanif SpJP.FIHA

Precordial Thump

ASYSTOLE

VF excluded ? no DC shock 200 J DC shock 200 J DC shock 360 J If not already intubate access Adrenaline 1 mg iv

yes

iv

10 CPR sequences of 1:5 ventilation/compression (Atropine 3 mg iv once only)

no

Electrical activity evidence ? yes

Dr. Edial

Pace

ASYSTOLE

Ventilate/Intubate
100 % oxygen

IV/IO Access Adrenaline 10 mcq/kg CPR 3 min Adrenaline 100 mcq/kg

Dr. Edial Consider
Fluids and/or alkalising agents

ASYSTOLE

Notes : If no response after 3

cycles, consider high dose adrenaline 5 mg iv

Dr. Edial