ACLS

Peri-arrest
Arrhythmias

By: dr. Gagah Buana Putra

Fakultas Kedokteran dan Ilmu Kesehatan

Departemen Kardiologi dan Kedokteran Vaskular
Yogyakarta, 2018
OBJECTIVES
 Brady-arrhythmias
 Tachy-arrhythmias
 Stable (symptomatic) vs Unstable
 Management algorithm
 Pre-excitation
 ECG changes in electrolytes abnormality
 Lethal arrhythmias
Brady-arrhytmias
 HR < 60 beat / min
 Symptomatic if < 50 beat / min
 Hypoxemia is the common cause
 Sign & Symptoms of poor perfusion
 Needs immediate action :
 Provide supplementary O2, establish IV access
 Attach monitor & evaluate blood pressure
 Obtain 12 lead ECG
Treatment for brady-arrhytmias
Atropine
 1st line drug of choice (Class IIA, LOE B)
 Dose : 0.5 mg IV every 3-5 min, max 3 mg
 Use cautiously in the ACS settings
 Ineffective in 2nd degree type II or total AVB
Treatment for brady-arrhytmias
Transcutaneous Pacing (TCP)
 Unstable patients who do not respond to atropine
(Class IIA, LOE B)
 Usually needs sedation
Treatment for brady-arrhytmias
Alternative drugs :
 Unresponsive for atropine
 Waiting for TCP

IV Dopamin : 2 – 10 mcg / kg / min

IV Epinephrine : 2 – 10 mcg / min

Tachy-arrhytmias (reguler)
 HR > 100 beat / min
 Clinical significance if > 150 beat / min
 Hypoxemia is the common cause
 Sign & Symptoms of poor perfusion
 Needs immediate action :
 Provide supplementary O2, establish IV access
 Attach monitor & evaluate blood pressure
 Obtain 12 lead ECG
 Cardioversion shouldn’t be delayed if unstable
Treatment for reguler tachy-arrhytmias
If it’s stable,
Evaluate :
 QRS wide or narrow

If it’s narrow,
Do vagal maneuvers :
 Carotid sinus massage – if there is no carotid bruit
 Valsava maneuvers
 Modified valsava maneuvers
Treatment for reguler tachy-arrhytmias
If it’s failed,
Evaluate :
 Sinus rhythm ?  treat underlying cause
 SVT ?

Adenosin (Class I, LOE B)

 6 mg rapid IV push, followed with 20 mL saline flush
 Next dose 12 mg & 12 mg
 Be prepared for cardiac arrest
Treatment for reguler tachy-arrhytmias
Alternative drugs :
 If adenosine not avaiable
1. CCB (Class IIA, LOE B)
CONTRAINDICATED in  LV function or HF
IV bolus Verapamil : 2.5 – 5 mg over 2 min
Repeated doses of 5 – 10 mg q 15 – 30 min, max 20 mg
IV bolus Diltiazem : 15 – 20 mg over 2 min
Maintenance IV infusion 5-15 mg / hour
2. β-blocker (Class IIA, LOE C)
IV metoprolol, atenolol, propranolol, esmolol
Treatment for reguler tachy-arrhytmias
If it’s stable & wide,
Do adenosin chalenge (if monomorphic & reguler):
 Suspected SVT with abberancy

Or gives antiarrhytmic drugs infusion

 IV Amiodarone – 150 mg for 10 min
 Followed by maintenance 1 mg/min for the next 6 hour
 And another 0.5 mg/min for the next 18 hour
 Evaluate the ECG QTc interval (may prolonged)
Treatment for reguler tachy-arrhytmias
If it’s unstable,
Cadioversion :
 Establish IV line before cardioversion
 Sedation if patient is conscious
 Shock delivered with each QRS complexes
 Recommendation :
 Unstable SVT  50 – 100 J
 Unstable VT  start from 100 J
Tachy-arrhytmias (irreguler)
 HR > 100 beat / min
 Clinical significance if > 110 beat / min
 Sign & Symptoms of heart failure
 Needs immediate action :
 Provide supplementary O2, establish IV access
 Attach monitor & evaluate blood pressure
 Obtain 12 lead ECG
Treatment for AF
 > 48 hours are at  risk for cardiacembolic events
 AVOID electric or pharmacologic cardioversion
unless the patient is unstable
 IV β-blocker or CCB
 If not avaiable, rapid digitalization with digoxin
 If failed, amiodaron my be helpful
 AVOID medication if the QRS complex is wide
Suspected AF with pre-excitation, may lead to VT
Treatment for Polymorphic VT
 Same management for VF
 Sedate if patient is conscious
 Stop medication that may coused QT prolongation
 Correct electrolytes imbalance (hypomagnesemia)
Hypokalemia
ECG changes when K+ < 2.7 mmol / L
• Increased amplitude and width of the P wave
• Prolongation of the PR interval
• T wave flattening and inversion
• ST depression
• Prominent U waves (best seen in the precordial
leads)
• Apparent long QT interval due to fusion of the T
and U waves (= long QU interval)
• Usually associated with hypomagenesemia
Lethal arrhytmias
 Asystole
 PEA
 VT without pulse
 VF