life-threatening-arrhythmia-and-management.pdf

8/20/2019 life-threatening-arrhythmia-and-management.pdf

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LIFE THREATENING ARRHYTHMIAAND MANAGEMENT

Dr. Beny Hartono, SpJP


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Introduction

Cardiac arrhythmias are a common cause of sudden death.Symptomatic arrhythmia frequently observed in the ICU hemodynamic compromise

J. Intensive Care Med. 2007

ECG is the most important diagnostic tools !!!


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Life threatening Arrhythmia

Lethal:

VF, VT, PEA, ASYSTOLE

Non Lethal: TOO FAST or TOO SLOW


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ARRHYTHMIA

Tachyarrhythmias

Bradiarrhythmias

HR > 100 x/min

HR < 60 x/min


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Normal Conduction System


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Physiologic Basis of Pacemaker Cells

Pacemaking &Conduction System


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Mechanisms of Arrhythmia

AutomaticityReentryTrigger Activity

Slow pathway- hantaran konduksilambat- masa refraktercepat

Fast pathway- hantaran konduksicepat- masa refrakterlambat


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Treat the Patient ..., not the Monitor !!!!Evaluate the patient’s symptoms and clinical signs

Ventilation

OxygenationHeart rateBlood pressureLevel of consciousness

Look for signs of inadequate organ perfusion

Principles of Arrhythmia Recognition and Management


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QRS Complex ?

(-)

-Asystole-V F

(+)

Fast / Slow ? -Takikardia/-Bradicardia

Wide / Narrow complex -Wide ? (Ventricular ? )(Consult the expert is advice )

-Narrow ? (Supra ventricular)(Consult the expert is considered)

HOW TO READ ECG RHYTHM


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QRS regular /irregular ?

P wave ?

P wave and QRS complexConnection ?

Normal / abnormal P wave ?

-1 “P” followed by 1 “QRS” ? / more “P” than ”QRS”

-Appropriate distance betweenP wave and QRS complex

Irregular : A fib, A flutter, MAT,AF + WPW, multifocal VT,


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Tachy-Arrhythmia

The first step Determine if the patient’s condition is stable orunstable

The second stepObtain a 12-lead ECG to evaluate the QRSduration (ie, narrow or wide).

The third stepDetermine if the rhythm is regular or irregular


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TachyArrhythmia

If the patient becomes unstable at any time,proceed with synchronized cardioversion.If the patient develops pulseless arrest or is unstablewith polymorphic VT, treat as VF and deliver high-energy unsynchronized shocks (ie, defibrillationdoses).


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Tachycardia

Narrow –QRS-complex (SVT) tachycardias ( QRS


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ACC guidelines 2003


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Tachycardia

Wide –QRS-complex tachycardias ( QRS > 0.12second )

— Ventricular tachycardia (VT) — SVT with aberrancy — Pre-excited tachycardias ( advanced recognition

rhythms using an accessory pathway)

Most wide-complex (broad-complex) tachycardiasare ventricular in origin


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ACC guidelines 2003


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Tachycardia

Initial Evaluation and Treatment ofTachyarrhythmias The evaluation and management oftachyarrhythmias is depicted in the ACLSTachycardia Algorithm.


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Circulation 2010


20/40Copyright ©2005 American Heart Association

Circulation 2005;112:IV-67-77IV-

ACLS Tachycardia Algorithm


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Synchronized Cardioversion andUnsynchronized Shocks

Synchronized cardioversion is recommended to treat(1) unstable SVT due to reentry(2) unstable atrial fibrillation(3) unstable atrial flutter(4) unstable monomorphic (regular) VT


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Synchronized Cardioversion andUnsynchronized Shocks

If possible, establish IV access beforecardioversion and administer sedation ifthe patient is conscious.Consider expert consultation.


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Syncrhronized Cardioversion

Initial recommended doses :Narrow regular : 50-100 JNarrow irregular : 120-200 J biphasic or 200 JmonophasicWide regular : 100 JWide irregular : defibrillation dose (NOT

synchronized)


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Cardioversion

Cardioversion is not likely to be effective fortreatment ofJunctional tachycardia

Ectopic or multifocal atrial tachycardia these rhythms have an automatic focus, arising from cellsthat are spontaneously depolarizing at a rapid rateshock delivery to a heart with a rapid automatic focus

may increase the rate of the tachyarrhythmia


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Brady-Arrhythmia


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Bradycardia

Defined as a heart rate of


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Bradycardia

Identify signs and symptoms of poor perfusion anddetermine if those signs are likely to be caused by thebradycardia

hypotensionacute altered mental statusChest paincongestive heart failure

seizuressyncopeother signs of shock related to the bradycardia


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Bradycardia

Bradycardia :Profound sinus bradikardia, SA blockJunctional rhythmAV block

Causes of bradycardia:medications

electrolyte disturbancesstructural problems resulting from acutemyocardial infarction and myocarditis.


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Therapy

Atropine First-line drug for acute symptomatic bradycardia(Class IIa)

Improved heart rate and signs and symptomsassociated with bradycardiaUseful for treating symptomatic sinus bradycardia

and may be beneficial for any type of AV block atthe nodal level .


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Therapy

Atropine The recommended dose for bradycardia is 0.5 mg IV every 3 to 5 minutes to a maximum total dose of3 mg.Doses


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Therapy

Atropine Use cautiously in the presence of acute coronaryischemia or myocardial infarction; increased heartrate may worsen ischemia or increase the zone ofinfarction.Atropine may be used with caution and appropriatemonitoring following cardiac transplantation . It willlikely be ineffective because the transplanted heart

lacks vagal innervation .


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Therapy

Pacing (Transcutaneous pacing, TCP )Class I intervention for symptomatic bradycardiasIndication : started immediately for patients

Unstable, particularly those with high-degree blockIf there is no response to atropineIf atropine is unlikely to be effectiveIf the patient is severely symptomatic


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Therapy

Pacing (Transcutaneous pacing, TCP )Can be painful and may fail to produce effectivemechanical captureUse analgesia and sedation for pain controlVerify mechanical capture and re- assess the patient’scondition

If TCP is ineffective (eg, inconsistent capture)prepare for transvenous pacing consider obtaining expert consultation


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Therapy

Alternative Drugs to Consider Second-line agents for treatment ofsymptomatic bradycardiaThey may be considered when thebradycardia is unresponsive to atropineand as temporizing measures whileawaiting the availability of a pacemaker.


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Epinephrine

Used for patients with symptomaticbradycardia or hypotension afteratropine or pacing fails ( Class IIb ).

Begin the infusion at 2 to 10 µg/min andtitrate to patient response.Assess intravascular volume and supportas needed.


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Dopamine

Both α - and ß-adrenergic actionsDopamine infusion (at rates of 2 to 10 µg/kg perminute) can be added to epinephrine or

administered alone.Titrate the dose to patient response.Assess intravascular volume and support as needed.


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Thank you for your attention !!

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life-threatening-arrhythmia-and-management.pdf