Electrophysiology and

Cardiac Arrhytmia Emergency

Zulfikri Mukhtar SpJP (K), FIHA

Dept. of Cardiology and Vascular Medicine
FK-USU / Adam Malik General Hospital
Medan
 SA node
Sumber impuls normal/
alamiah , 60 – 100 / menit

AV node
Bisa mengeluarkan
impuls 40-50x/menit

Berkas His
Serabut Purkinje

Ventrikel
Bisa mengeluarkan impuls
30 x/menit
ECG
 Arrhytmia
1.Ggn Pembentukan Impuls
1. Sinus : Sinus Takikardi 3. AV Node : Ekstrasistole AV
Sinus Bradikardi SVT
Sinus Aritmia Irama lolos
Henti Sinus 4. Ventrikel : Ventr Ekstrasistol
2. Atrium : Atrial Ekstrasistole VT & VF
Atrial Takikardi Henti Ventrikel
Atrial Fibrilasi Irama lolos Vent
Atrial Gelepar
2. Gangguan penghantaran : SA block, AV block
Lokasi dan mekanisme aritmia
Atrial fibrillation
SNRT Atrial flutter

AT AVRT
AVNRT

JT

VT

VF
 Arrhytmia

Tachyarrhythmia Bradyarrhytmia
(rate >100 x/min) (rate < 60 X/min)

• QRS sempit (<0.12 ms) • AV blok derajat 1, 2 & 3

• QRS lebar (>0.12 ms)
 The Tachycardias: Overview Algorithm
Evaluate patient
• Is patient stable or unstable?
• Are there serious signs or symptoms?
• Are signs and symptoms due to tachycardia?

Stable Unstable

Stable patient: no serious signs or symptoms
• Initial assessment identifies 1 of 4 types of
tachycardias
Unstable patient: serious signs or symptoms
• Establish rapid heart rate as cause of signs and
symptoms
• Rate-related signs and symptoms occur at many
rates, seldom < 150 bpm
• Prepare for immediate cardioversion (see Fig. 10)

1. Atrial 2. Narrow- 3. Stable wide-complex 4. Stable monomorphic VT

fibrillation complex tachycardia: unknown and / or polymorphic VT
Atrial flutter tachycardia type

Next slide 
Evaluation focus: 4 clinical
features
1. Patient clinically unstable?
2. Cardiac function impaired?
3. WPW present?
4. Duration <48 or >48 hours?
Attempt to establish a
Attempt to establish a
specific diagnosis
specific diagnosis
• 12-lead ECG
• 12-lead ECG
• Clinical information
• Esophageal lead
• Vagal maneuvers
• Clinical information
• adenosine

Treatment focus: clinical Diagnostic efforts yield

evaluation • Ectopic atrial tachycardia
1. Treat unstable patients • Multifocal atrial tachycardia
urgently • Paroxysmal supraventricular
2. Control the rate
tachycardia (PSVT)
3. Convert the rhythm
4. Provide anticoagulation

Treatment of Treatment of SVT Confirmed Wide-complex Confirmed Treatment of stable

atrial (see narrow-complex SVT tachycardia of stable SVT monomorphic and
fibrillation/ tachycardia unknown type polymorphic VT
atrial flutter algorithm) (see stable VT:
(see following Preserved cardiac Ejection fraction <40% monomorphic and
table) function Clinical CHF polymorphic
algorithm)
DC cardioversion DC cardioversion
or or
Procainamide Amiodarone
or
Amiodarone
 Classification of antiarrhythmic
Vw CHANNEL EFFECT EFFECT ON DRUG
CLASS ACTION POTENTIAL
1a Na channel blockers Phase 0 Procainamide
moderate Na influx Disopyramide
1b Na channel blockers Phase 0 lidocain
Weak Na influx

1c Na channel blockers Phase 0 Propafenon

strong Na influx Flecainamide

II b adrenergic blockers Decreased SA node Atenolol,Propanolol

automaticity ,metoprolol,esmolol
Slow av node conduction ,
labetolol
III K channel blockers Phase 3 Amiodaron,bretiliu
K efflux m,dofetilide,ibutilid
e,sotaol

IV ca channel blockers Phase 4 Diltiazem,verapamil

Ca influx
 QRS sempit : supraventricular origin

QRS sempit

Irama
Irama Teratur
Tidak teratur

Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia

Atrial Flutter
Atrial Fibrillation :

-from multiple area of re-entry within atria

-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical activity
(400-700 x/min).
-no uniform atrial depolarization
 DIGITALIS
• Atrial flutter, atrial fibrillation, mengembalikan
PSVT ke irama sinus.
• Sedikit peranannya pada tata laksana CHF akut.
• Baik pada CHF kronis
• meningkatkan kontraktilitas miokard.
• Mengontrol respon ventrikel pada atrial flutter
dan atrial fibrillation.
• Loading dose : 10 – 15 microgram/kg , IV.
• Dosis meintenance tergantung berat badan dan
fungsi ginjal.
 DIGITALIS

Intoksikasi:
• Atrial & ventricular premature complex,
ventricular bigeminy, VT
• Mual, muntah diare, ggn penglihatan dan
status mental.
• Lebih sering pada pasien dengan
hypokalemia, hypomagnesemia,
hypocalcemia
 b blockers (propanolol)
HWY WHEN HOW WATCH OUT
MOA indication dose precaution
Block b receptors ACS 0,1 mg/kg IV Bradicardia
push,divided 3 Hipotension
Tachyarrhithmas doses equal,2- Heart block
(control rate 3 min interval
AF,A flutter)
class 1
Narrow complex
tachycardia

Stable
polimorphic VT
class IIb
 Diltiazem,verapamil
HWY WHEN HOW WATCH OUT
MOA indication dose precaution
ca channel Diltiazem Wpw syndrome
blockers 0,25 mg/kg IV over
AF,A FLUTTER 2 min, repeat 15 AV block
Decreasing SA min LV dysfunction
nodal Narrow complex Maint 5-15 mg/Hr
outomaticity tachycardia
Verapamil
Prolong AV 2,5-5 mg IV
nodal refraktory 2nd doses 5-10mg
period Every 15 min
Max 20 mg
 Inotr.

Verapamil (=)
Diltiazem (-)
Beta blocker (=)
Digoxin (+)
Amiodarone ( )
 Tachycardia: Atrial Fibrillation and Flutter
Control of Rate and Rhythm (Continued from Tachycardia Overview)
Atrial fibrillation/ 1. Control Rate 2. Convert Rhythm
atrial flutter with
• Normal heart
• Impaired heart Heart Function Impaired Duration <48 Duration >48 Hours or
• WPW Preserved Heart EF Hours Unknown
<40% or CHF
Note: If AF>48 hours’ (Does not Consider • Avoid nonemergent
duration, use agents apply) • DC carioversion cardioversion unless
with potential to anticoagulation or clot
convert rhythm with precautions are taken (see
extreme caution in Use only 1 of the below).
patients not receiving following agents • Note: Conversion of AF to
adequate (see note below ): NSR with drugs or shock may
anticoagulation • Amiodarone cause embolization of atrial
because of possible (Class lla) thrombi unless patient has
embolic • Ibutilide (Class lla) adequate anticoagulation.
complications. • Use antiarrhythmic agents
• Flecainide
(Class lla) with extreme caution if AF >48
Use only 1 of the hours’ duration (see note
following agents (see • Propafenone above).
note below): (Class lla) or
• Calcium channel • Procainamide Delayed cardioversion
blockers (Class I) (Class lla) Anticoagulation x 3 weeks at
• ß-Blockers (Class I) proper levels
• Cardioversion, then
• Anticoagulation x 4 weeks
more
Next slide  or
 • For additional • For additional Early cardiovesrsion
drugs that are drugs that are • Begin IV heparin at once
Class IIb Class IIb • TEE to exclude atrial clot
recommendation recommendation
s, Then
s , see
see Guidelines Guidelines or • Cardioversion within 24 hours
or ACLS text ACSL text Then
• Anticoagulation x 4 more weeks

Impaired (Does not apply) Note: If AF>48 hours’ Consider • Aviod nonemergent
heart (EF duration, use agents • DC cardioversion unless
<40% or with potential to convert Cardioversion anticoagulation or clot
CHF) rhythm with extreme Or precautions are taken (see
caution in patients not above).
receiving adequate • Amiodarone
(Class IIb) • Anticoagulation as described
anticoagulation because above, follow by
of possible embolic • DC cardioversion
complications.

Use only 1 of the

following agents (see
note below):
• Digoxin (Class IIb)
• Ditiazem (Class IIb)
• Amiodarone (Class IIb)
 Use only 1 of the Class III
following agents (can be harmful)
(see note below): • Adenosine
• Amiodarone (Class • ß-Blockers
IIb)
• Calcium blockers
• Flecainide
• Digoxin
(Class IIb)
• Procainamide
(Class IIb) Impaired heart
• Profenone (EF <40% or CHF)
(Class IIb) • DC cardioversion
• Sotalol (Class IIb) • Amiodarone (Class
IIb)
Class III
(can be harmful)
• Adenosine
• ß-Blockers
• Calcium blockers
• Digoxin

WPW indicates Wolff-Parkinson-White syndrome: AF, atrial fibrillation; NSR, normal sinus rhythm; TEE, transesophageal
echocardiogram; and EF, ejection fraction.
Note: Occasionally 2 of the named antiarrithmic agents may be used, but use of these agents in combination may have
proarrhythmic potential. The classes listed represent the Class of Recommendation rather than the Vaughn-Williams
classification of antiarrhythmics.
SVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
 adenosine
HWY WHEN HOW WATCH OUT
MOA indication dose precaution
Depresed SA,AV 6 mg rapid IV AV block
nodal 12 mg rapid IV
Narrow complex 12 mg rapid IV
tachicardias Interval 1 min’fluh
20 ml saline
Narrow-Complex Tachycardia
Narrow-Complex SupraventricularTachycardia, Stable

Attempt therapeutic diagnostic maneuver

• Vagal stimulation
• Adenosine
Preserved
Heart function • b- Blocker
• Ca²+ channel blocker
• Amiodarone
Junctionalnct
tachycardia NO DC cardioversion!

EF <40%, CHF
• Amiodarone
NO DC cardiversion!

Next slide 
 Priority order:
• AV nodal blockade
– ß-Blocker
Preserved – Ca2+ channel blocker
heart function – Digoxin
• DC cardioversion
• Antiarrhythmics:
consider procainamide,
Paroxyamal supraventricular amiodarone, sotalol
tachycardia
Priority order:
• DC cardioversion
EF <40%, CHF
• Digoxin
• Amiodarone
• Diltiazem

Preserved • ß-Blocker
Heart function • Ca2+ channel blocker
• Amiodarone
NO DC cardioversion!
Ectopic or multifocal
atrial tachycardia
• Amiodarone
• Diltiazem
EF <40%, CHF NO DC cardioversion!
 QRS Lebar : Ventricular origin

QRS lebar

Irama
Irama Teratur
tidak teratur

Ventricular Ventricular
Tachycardia Fibrillation
Ventricular Tachycardia
 Amiodaron
HWY WHEN HOW WATCH OUT
MOA indication dose precaution
K channel Persisitent 300 mg IV Prolong QT
blockers VF/VT dilution on 20- Bradicardia
30 D5% Hipotension
Prolong action Stable VT Supp dose 150 Heart block
potential mg
Narrow compl.
Prolong Tachicardia An infusion 1
refraktory period mg/min for 6 hr
in allcardiac than
Prserved/impair
tissue,bypass ed 0.5 mg/min
tract vent.fungtion
Mav doses 2,2
mg/day
 lidocaine
HWY WHEN HOW WATCH OUT
MOA indication dose precaution
Decreasing Ventricular 1-1,5 mg/kg Myocardial
outomaticity arrhithmia depression
Reducing ( VT,VF) Add doses 0,5-
slope of 0,75/kg
phase 0 PVC’S ON MI Every 5-10 min
Total dose 3
Reentrant mg/kg
Reduces cond
velocity Ventricular Main doses 1-4
arrhithmia mg/min

Prolong
refraktory
period
 Stable Ventricular Tachycardia: Monomorphic and Polymorphic
Stable Ventricular Tachycardia
Monomorphic or Polymorphic?

Note!
Monomorphic VT Polymorphic VT
May go direcly to
• Is cardiac function impaired • Is Baseline QT interval prolonged?
cardioversion
Preserved Normal baseline Prolonged baseline
heart function Poor ejection fraction QT interval QT interval(suggests torsades)

Normal baseline QT Interval Long baseline QT interval

Medications: any one
• Procainamide • Treat ischemia • Correct abnormal electrolytes
• Sotalol • Correct electrolytes
Therapies: any one
Others acceptable Medications: any one • Magnesium
• Amiodarone • ß-Blockers or • Overdrive
• Lidocaine • Lidocaine or • Isoproterenol
• Procainamide or • Phenytoin
• Sotalol • Lidocaine

Next slide 
 Cardiac function
impaired
Amiodarone
• 150 mg IV over 10 minutes
or
Lidocaine
• 0.5 to 0.75 mg/kg IV push
Then use
• Synchronized cardioversion
Ventricular Fibrillation
ALGORITMA HENTI JANTUNG
Tidak sadar
UNTUK ORANG DEWASA Cek respon
Perhatikan tanda-tanda kehidupa
PERKI 2006 Cek pernafasann
Meminta bantuan
Tim resusitasi

CPR
Kompresi : Ventilasi = 30 : 2
sambil menunggu defibrilator/monitor terpasang

Tentukan jenis
Irama di monitor

Memerlukan terapi Tidak memerlukan terapi

syok listrik syok listrik
(VF/VT tanpa nadi) (PEA/Asystole)

Durante CPR
- Koreksi penyebab yang reversibel
Berikan segera 1 syok listrik - Periksa posisi elektroda dan perlekatannya
200 J (bifasik) - Pasang IV line, pertahankan patensi jalan napas
atau 360 J (monofasik) dan berikan oksigen
- Kompresi tak boleh terputus bila jalan nafas telah aman
- Berikan adrenalin tiap 3 – 6 menit
- Pertimbangkan pemberian amiodarone,atropin atau magnesium

Segera Lanjutkan
Segera Lanjutkan CPR 30 : 2
CPR 30 : 2 Penyebab reversibel Selama 2 menit
Selama 2 menit
Hipoksia, hipovolemi, hipo/hiperkalemi, hipotermi,
tension pneumotoraks, tamponade jantung,
toksin, trombosis (koroner/pulmoner)
A. Ventricular Fibrillation/Pulseless VT

Cardiac Defibrillator Give Consider

Arrest Arrives Vasopressor Antiarrhythmic

Go to

CPR CPR CPR CPR A

Rhythm Rhythm Rhythm

Check Check Check

CPR = 5 cycles or = CPR while = Shock

2 minutes of CPR defibrilator charging
II.Gangguan Penghantaran Impuls
1. Blok Sino-atrial
2. Blok Atrio Ventrikular
3. BlokIntraventrikular
Sick Sinus Syndrome
 1st degree AV block

Prolonged PR interval
 2nd degree AV block, type 1

Missing QRS Missing QRS

2nd degree AV block, type 2

Missing QRS
 Total AV Block /
3rd degree AV block

QRS QRS QRS

P P P P P P P
 BRADYCARDIAS
• Slow (absolute bradycardia=rate < 60 bpm
or
• Relatively slow (rate less than expected relative
to underlying condition or cause)

PRIMARY ABCD SURVEY

• Assess ABCs
• Secure airway noninvasively
• Ensure monitor / defibrillator is available

SECONDARY ABCD SURVEY

• Assess secondary ABCs (invasive airway
management needed?)
• Oxygen - IV access - monitor - fluids
• Vital signs, pulse oximeter, monitor BP
• Obtain and review 12-lead ECG
• Obtain and review portable chest x-ray
• Problem-focused history
• Problem-focused physical examination
• Consider causes (differential diagnoses)
Next slide 
 SERIOUS SIGNS OR SYMPTOMS ?
Due to the bradycardia?

No Yes

Type II second-degree AV block Intervention Sequence

or • Atropine 0.5 – 1.0 mg
Third-degree AV block? • Transcutaneous pacing if
available
• Dopamine 5-20 µg/kg per
minute
• Epinephrine 2-10 µg/min
• Isoproterenol 2-10 µg/min
No Yes

• Prepare for transvenous pacer

Observe • If symptoms develop, use
transcutaneous pacemaker until
transvenous pacer placed
 atropine
HWY WHEN HOW WATCH OUT
MOA indication dose precaution
Parasimpatolitic Bradicardia with 0,5-1 mg interval 5 tachicardia
simptoms min
Enhanced SA Av block
nodal
automaticity asistole 1 mg interval 5 min
AV conduction
VF
VT
SVT