You are on page 1of 47


Erwin Sukandi, SpPD, K-KV, FINASIM

Nama: Tn/Ny. Umur : tahun

Tanggal: ../../.... Pukul :

RSMH Palembang


Irama Aksis HR Gel. P Interval PR Gel. Q, R, S Interval QRS Interval QT Segmen ST Gel. T Gel. U

1500 RR (Ktk kecil) atau 300 RR (ktk sdg)

Common- 2.2 million Americans Prevalence increases with age Increased mortality secondary to



75,000 strokes/year in US First episode Recurrent (paroxysmal) Persistent

Causes Advancing age Uncontrolled htn CAD CHF Valvular heart disease

Acute pulmonary process (PE) Hyperthyroidism Acute alcohol intoxication Illicit narcotic abuse


of P waves IRREGULARLY IRREGULAR Atrial rates 350-750 Ventricular rate varies

Controlled versus rapid response

to 30% decrease in cardiac output

No atrial kick

Treatment Rate

Goals: rate control and anticoagulation


Beta-blockers and Ca channel blockers Metoprolol (Lopressor) 5mg IV q 5 min times 3 doses, then oral load Diltiazem (Cardizem) 10 to 20 mg SLOW IV push Digoxin may be used in chronic setting

Regular atrial activity Sawtooth pattern Single irritable foci in atria

initiates impulse Atrial rate 250-300


Slower than in a-fib No underlying cardiac disease CAD, Htn, MI, hypoxia, digitalis toxicity,

CHF, PE, COPD, thyrotoxicosis, alcohol


Ventricular rate control Beta Blockers or Ca channel blockers ER/admission Atrial overdrive pacing Ablation

may be helpful in

Transiently blocks AV node

Ventricular Fibrillation
Marquette Electronics Copyright 1996

Ventricular Asystole
Marquette Electronics Copyright 1996

Rhythm strip recording of ECG revealing that paroxysmal attacks of atrial fibrillation always terminated with a long ventricular asystole

ABCs HIGH QUALITY CPR Secure the airway, provide 02 IV or IO access Epinephrine 1 mg* (Repeat every 3 5 minutes) If the rhythm is Bradycardia, <60 Atropine 1.0 mg (Repeat every 3 5 min to a max of 3 mg)

The 5 Hs and the 5 Ts, while beginning drug therapy Hypoxia Toxins/overdose Hypovolemia Thromboemboli (coronary/pulmonary) Hyper/hypokalemia Trauma Hypothermia Tension pneumothorax Hydrogen ion/acidosis Tamponade (cardiac) Hypoglycemia Consider fluid bolus, 200-300cc; may repeat if lungs remain clear Once perfusing rhythm is restored, maintain adequate ventilations, and then stabilize Rate, Rhythm, and Blood Pressure Note: Repeated unsuccessful intubation attempts are not recommended. BVM support of the airway is acceptable until advanced airway can be placed. *You may consider Vasopressin instead of the first or second dose

ABCs, EFFECTIVE CPR SECURE AIRWAY IV/IO access Epinephrine 1.0 mg OR Vasopressin 40u (one time only instead of 1st or 2nd epi dose) Atropine 1 mg Epinephrine 1 mg Atropine 1 mg Epinephrine 1 mg

Several factors should be considered when making the decision to terminate resuscitation efforts on a patient in extended Asystole: Down Time Rigor Mortis Cold Water Drowning Chronic Medical Conditions Age Skin Temperature Blood Pooling Trauma And most importantly.quality of life!

ABCs Start HARD, FAST, EFFECTIVE CPR If un-witnessed code or down time > 4 minutes, 2 minutes of CPR prior to defibrillation Defibrillate 200 j biphasic (or device specific dose, 360j if monophasic) Continue CPR immediately w/o pulse rhythm check Secure the airway without prolonged intubation attempts And establish IV or IO with Saline or LR Vasopressin 40 Units I.V. DURING CPR

OR Epinephrine 1 mg I.V. (Repeat every 3 5 minutes) Defibrillate 200-360 joules (Repeat every 1 2 minutes) Amiodarone 300 mg I.V. OR Lidocaine 1 - 1.5 mg/kg I.V. (May repeat to a max of 3 mg/kg) Defibrillate 200-360 joules Consider Sodium Bicarbonate 1meq/kg (acidosis, tricyclic overdose, or hyperkalemia) Consider Magnesium Sulfate 1 2 grams I.V. (if Torsades is present) Upon return of spontaneous circulation (ROSC): Assess airway, breathing and vital signs. Provide medication appropriate for heart rate, rhythm and blood pressure. Consider hanging a maintenance anti-arrhythmic drip upon ROSC to prevent reoccurrence of V-Fib.

Assess ABCs Secure airway, provide oxygen, pulse oximetry Start IV Revised 9/2009 10 Obtain 12 lead EKG if possible, and review patients history, especially history of possible A-fib or A-flutter If determined a new onset, consider synchronized cardioversion @ 100, 200, 300, 360 joules (Consider Sedation) Cardizem 0.25 mg/kg OR Verapamil 2.5 5 mg

*Note: never delay cardioversion in lieu of sedation if the patient is unstable. (You can always apologize later) If AF has been present for >48 hours, a risk of systemic embolization exists with conversion to sinus rhythm unless patients are adequately anticoagulated for at least 3 weeks. Electrical cardioversion and the use of antiarrhythmic agents should be avoided unless the patient is unstable or hemodynamically compromised.

Which one is more tachycardic during this exercise test?