dc shock + aritmia
DESCRIPTION
Tatalaksana aritmia dan dc shockTRANSCRIPT
Aritmia dan DC Shock
TIM PELATIHAN KEGAWATDARURATAN
Anestesi dan Terapi Intensif
RSUD Saiful Anwar Malang/FK Univ.Brawijaya
Cardiac arrest = carotis (-)check ECG !
• VF / VT pulseless = ada gelombang khas• shockable rhythm, harus segera DC-shock
• Asystole = ECG flat, tak ada gelombang• UN-shockable
• PEA = EMD = ada gelombang mirip ECG normal• UN-shockable
SHOCKABLE RHYTHMS
1. Ventriculer fibrilation
Fine Ventriculer Fibrilation
Coarse Ventriculer Fibrilation
Fine VF :
If there is a doubt about whetherthe rhythm is asystole or fine-VFdo NOT attempt defibrilation,continuous chest compression andventilation
Fine Ventriculer Fibrilation
Coarse Ventriculer Fibrilation
Asystole
DC
chest compression
NO DC
chest compression
NO DC
SHOCKABLE RHYTHMS
2. Ventriculer tachycardia ( VT –pulseless )
NON-SHOCKABLE RYTHMS
1. Asystole
P-wave Asystole
Could be any form of waves, may mimic normal ECG but NO carotid pulse
• treatment similar to Asystole
P-ulseless
E-lectricalA-ctivity
E-lectro
M-echanicalD-issociation
NON-SHOCKABLE RYTHMS
2). P E A / E M D
Jika defib (biphasic) diberikan sebelum 5 menit, > 50-70% kemungkinan jantung berdenyut kembali
A E D Automatic Emergency Defibrillator
A E DAutomatic Emergency Defibrillator
• VF shock x 1
immediately begin chest
compression.
• Do NOT interrupt chest compressions to check rhythm or pulse until 5 cycles or 2 minutes of CPR are given.
• First shock efficacy of monophasic shock is lower than biphasic shock.
• Recommendations for higher energy (360J) when using monophasic waveform.
raba carotis
tidak ada
lihat EKG
ada
shockable un-shockable
CPR 30 : 2
2 menit
rosc
pertahankan jl nafas bebas
tetap beri oksigenraba arteri radialis
lihat EKG- ukur tensi nadi
pertahankan infus
hipotensi : beri inotropik
terapi aritmia
koreksi elektrolit & cairan single shock 360 J CPR
30:2 (2 menit)
VF / VT
lihat managemen
VT / VF
Asistol
PEA / EMD
CPR 30 : 22 menit
adrenalin
managemen asistol
Observasi di ICU
Waspada CA berulang
Adrenaline: 1 mg, iv, repeated
every 3-5 minutes
Defibrilation strategy-1
VF / pulseless VT
a single shockBiphasic 150-200 Joule
Monophasic 360 Joule
CPR 30 : 2
ROSC
NO
2 MINUTES, 30 : 2
Check ECGCheck pulse
a single shockBiphasic 150-360 Joule
Monophasic 360 Joule
AdrenalineCPR 30 : 2
YES
Recovery of
Spontaneous
Circulation
1).
2).
2 MINUTES, 30 : 2
3).
Defibrilation strategy - 2
VF / pulseless VT
ROSC
NO Check ECGCheck pulse
a single shock
Biphasic 150-360 Joule
Monophasic 360 JouleAdrenaline
CPR 30 : 2
2 MINUTES, 30 : 2
a single shock
Biphasic 150-360 Joule
Monophasic 360 JouleCPR 30 : 2
Check ECGCheck pulse
YESNo
YES
2).
3).
2 MINUTES, 30 : 2 Check ECGCheck pulse
Adrenaline: 1 mg, iv,
repeated every 3-5
minutes
a single shock1).
ROSC
Defibrilation strategy-3
VF / pulseless VT
ROSCa single shockBiphasic 150-360 Joule
Monophasic 360 Joule
CPR 30 : 2
Check ECGCheck pulse
YESNo
3).
Amiodarone 300 mg or
Lidocaine 1 mg/kg
A single shock
Biphasic 150-360 Joule
Monophasic 360 Joule
CPR 30 : 2
No YESCheck ECG
Check pulse
ROSC4).
2). a single shock
2 MINUTES, 30 : 2
Adrenaline: 1 mg, iv,
repeated
every 3-5 minutesa single shock
Biphasic 150 – 360 Joule
Monophasic 360 Joule
CPR 30 : 2 (2minutes)
• Adrenaline : 1 mg, iv, repeated every 3-5 minutes
• Amiodarone : 300 mg, bolus, if VF/VT persist after3 shocks.150 mg maybe given for recurrent orrefractory VF/VT, followed by an infusion of 900 mg over 24 hours
• Lidocain : 1 mg/kg, iv, if amiodarone is notavailable. Do not exceed a total dose of 3 mg/kg,during the first hour.Do not give lidocaine if amiodaronehas already been given
CPR -1
30 : 2
CALL
FOR
HELP
PASANG
MONITOR
VF / VT
a single shocka single shocka single shock
a single shock a single shock
2 menit 2 menit
2 menit 2 menit
adrenalinadrenalin
adrenalinCPR-3CPR-2 CPR-5CPR-4
Amiodaron
Adrenaline: 1 mg, iv,
repeated every 3-5
minutes
CPR-6
Cardiac
arrest
LIDOCAIN. Do not exceed
a total dose of 3 mg/kg,
during the first hour.
Amiodaron is the first choice
300 mg, bolus. Repeated 150 mg
for reccurrent VT/VF. Followed by
900 mg infusion over 24 hours
VF/ VT
Intubasi : as soon as possible, without stop CPR Pijat 100x/menit
Nafas 8x/menit
Evaluasi CPR : tiap 2 menit
Normal Electrocardiogram
SA node(pacemaker)
AV node
(relayer)
DC shock
Oles dulu paddles dengan jelly ECG tipis rata, baru kemudian :
1. Switch ON
Pasang paddles pada posisiapex dan parasternal
(boleh terbalik)
sternum
apex
DC shock2. Charge 360 Joules
(Non-synchronized)
Ucapkan dengan keras : Awas semua lepas dari pasien!• nafas buatan berhenti dulu• bawah bebas,
samping bebas, atas bebas, saya bebas!
3. Shock!!
(tekan dua tombol paddles bersama)
Lepas paddles dari dada, lanjutkanchest compression.
4. Segera pijat jantung lagi 2 menit
baru raba lagi/ baca lagi ECG
sternum
apex
Position of the paddles electrodeson thorax of an infant
Size of paddle electrode
- 4.5 cm diameter for infants and small children
- 8-12 cm diameter larger children
sternum
apex
VT / Ventricular Tachycardia|
| |
carotis (+) carotis (-)
Lidocain1 mg/kg iv cepat
atauAmiodaron 300 mg
a single shock360 Joules
CPR 30:2 - 5 SIKLUS
dst
Managemen VT/ VF
Cardiac arrest = carotis (-)
= ECG flat,
tak ada gelombang
• UN-shockableCPR + adrenalin
- ROSC < 10%( Recovery of Spontaneous Circulation )
Asystole
Asystole (ECG flat)PEA ECG ada gelombang tetapi carotis (-)
|CPR 2 menit
|Intubasi, iv line,
adrenalin 1 mg / 3-5 menit
|
| |
Asystole / PEA ROSC
| |
bradycardia normal
atropin 1-1-1 sp 3 mg / obat klas IIaCPR 2 menit30 : 2
30 : 2
obat klas IIa
• Lidocain 1-1.5 mg/kg tiap 3-5 menitmaksimal 3 mg/kg dlm 1 jam .
• MgSO4 1-2 gm u/ torsades des pointes
• Procainamide 30 mg/ menit
• Na-bicarb 1 mEq/kg
Adrenalin, Atropin, Lidocain
• Intra-venous
• Intra-tracheal / trans-tracheal• dosis 3-10 x intravena
• Intra-osseus
• TIDAK intra-cardial• menghentikan pijat jantung
• sukar pastikan intra-ventrikuler• kena miokard : nekrosis
• kena a. coronaria : infark
PEA = EMD
ada gelombang mirip ECG normal• TETAPI nadi carotis tidak teraba
• terapi sama seperti Asystole ( CPR + Adrenalin )
P-ulseless
E-lectrical
A-ctivity
E-lectro
M-echanical
D-issociation
BRADYARRHYTHMIA
HipoksiaHipovolemiaHiperkalemiaHipotermiaTamponade jantungTension pneumothoraxThromboemboli paruToxic overdose
B-block, Ca-blockDigitalis, Tricyclic AD
Massive MIAsidosis
4 H
4 T
MA
cardiac arrest membandel ???
Bila berhasil ROSC
• Lanjutkan oksigenasi, kalau perlu nafas buatan
(protap : ventilator )
• Hipotensi diatasi dengan inotropik dan obatvaso-aktif (adrenalin, dopamin, dobutamin, ephedrin)
• Tetap di infus untuk jalan obat cepat
• Terapi aritmia
• Koreksi elektrolit, cairan, gula darah dlsb
• Awasi di ICU
• awas: cardiac arrest sering terulang lagi
Bila setelah ROSC, lalu cardiac arrest lagi
• Ikuti algoritme semula.
• Bila perlu DC shock tetap diberikan 1 x 360
Joules dan disusul dengan CPR
34
Questions