disritmia - dr.denny j
DESCRIPTION
materi ini mengenai disritmia (definisi, etiologi, patofisiologi hingga pengobatanTRANSCRIPT
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DisritmiaDisritmia
Denny JolandaDenny Jolanda
RSUD Dr Haulussy RSUD Dr Haulussy
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DisritmiaDisritmia
Penyebab:- Gangguan pembentukan rangsang
- Gangguan hantaran rangsang
Jenis:- Takhikardia : DJ > 100/menit
- Bradikardia : DJ < 60/menit.
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Takhikardia:Takhikardia:
Asal pembentukan rangsang:- SA (Sinoatriale) node- AV (Atrioventricular) node- Ventrikel.
+ Accessory pathway (WPW syndrome)
Perhatikan:- Kerteraturan jarak R-R- Frekwensi kompleks QRS- Gelombang P dan frekwensinya- Bentuk kompleks QRS
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EKG normalEKG normal
• P
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Takikardia SinusTakikardia Sinus
Letak kelainan: Perangsangan berlebih saraf simpatis pada SA node.
Penyebab klinis: ekstrakardial: demam, anemia, psikogenik.
Gambaran EKG:- Irama sinus, masih ada gel.P- R- R teratur.- Frekw. QRS > 100/menit- Bentuk QRS langsing/ spt. sebelumnya.
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Takhikardia atrialTakhikardia atrial
• Letak kelainan: fokus ektopi di atrium, kemudian disalurkan ke AV node – Ventr.
• Mekanisme reentry, atau automatisitas meningkat
• Penyebab klinis: IMA, PPOK, kafein, hipokaliemia, hipoksia,alkohol.
• Gambaran EKG:- R-R regular- Gel.P masih terlihat, tetapi tak jelas- Frekw. Gel.P 140-280/menit.
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Atrial takhikardia (SVT)Atrial takhikardia (SVT)
• P (+) QRS langsing
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Flutter atrialFlutter atrial
-Letak kelainan: di atrium-Mekanisme reentry, automatisitas meningkat,
triggered activity-Penyebab klinis: PJK, intoksikasi digitalis,
hipertensi.-Gambaran EKG: + Gel.P spt. mata gergaji + Frekw.gel.P 220-350/menit + R-R masih teratur + Kompleks QRS langsing
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Fibrilasi atrialFibrilasi atrial
• Letak kelainan: di atrium• Mekanisme reentry dg. Wavelet• Penyebab klinis: PJK, tirotoksikosis, hipertensi
lama, keracunan digitalis, idiopatik.• Gambaran EKG:
+ Gel.P tak ada/halus.
+ R-R tak teratur
+ Kompleks QRS langsing
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Takhikardia nodalTakhikardia nodal
• Sinonim: AVNRT, PAT• Letak kelainan di AV Node.• Penyebab klinis: SA node tertekan, krn. Digitalis
intoksikasi.• Gamb.EKG: + R-R teratur + Kompleks QRS langsing + Gel.P dpt. negatif, dibelakang QRS atau tak ada.
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Nodal rhytmeNodal rhytme
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AVNRT (PAT)AVNRT (PAT)
• P (-),reg.takhikardi
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Takhikardia ventrikel (VT)Takhikardia ventrikel (VT)
• Letak kelainan: rangsang dari ventrikel, VES consecutive• Penyebab klinis: IMA, aneurysma ventr.• Gambaran EKG: + Frekw. QRS 150-200/men. + Kompleks QRS melebar + Hubungan gel.P dan QRS tak tetap.
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Fluter ventrikelFluter ventrikel
• Penyebab klinis: IMA
• Gambaran EKG:
- Frekw. QRS 200-300/men.
- Amplitudo gel.R masih cukup tinggi
- Antara gel. QRS dan T tak terlihat batas
lagi
- Kompleks QRS melebar dan deformitas.
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Fibrilasi ventrikel (VF)Fibrilasi ventrikel (VF)
• Penyebab cardiac arrest
Biasanya karena IMA
• Gambaran EKG:
- Bentuk QRS sudah berubah sama sekali.
- Gel.R sudah mengecil sekali
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Algoritma diagnosis disritmia:
QRS langsing
Takhikardia
R-Rreguler
Ventrikel (V)Disosiasi P-QRS
R-R reguler
Frekw. QRS:<200/men=VT>200/men=VFl
VF
Gel.P: Normal: 1P-1QRS= ST P (N), bbrp.P-1QRS, frekw.P 140-280= At.TSaw teeth= At.fl.P (-) = AVNRT (PAT)
AF
No
Y
No
Y
mendatar
normal
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VES Bigemini VES Bigemini
• VES bigemini
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PENGOBATAN ARITMIAPENGOBATAN ARITMIA
• Class I : Sodium channel blocker I a: Ajmalin, Quinidine,Procainamide b. Xylocard, Mexiletine c: PropafenonClass II: Penyekat betaClass III: Amiodarone,SotalolClass IV: Ca channel blocker: verapamil,Diltiazem
- Defibrillator
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BradiaritmiaBradiaritmia
• Letak gangguan:- Pada SA node = Sick sinus syndrome- Konduksi atrioventrikular = AV Block.
SSS:- SA Block I, II, III (sinus arrest)
AV Block :- Grade I- Grade II: Wenckebach, Mobitz II, high grade (2:1- 3:1)- Grade III: AV block total.
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Sinus bradikardiaSinus bradikardia
• Letak kelainan: SA node.
• Penyebab klinis: vagal, obat misal digitalis
• Gambaran EKG:
- Denyut nadi: 40-50/men.
- Gel.P dan QRS normal, ada hubungan, reguler.
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Sinus bradikardiaSinus bradikardia
HR 50/men.SR
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SA Block derajat II.SA Block derajat II.
• SA Block der.I: tak terlihat pd. EKG
• SA block der.II:
terlihat P-P interval memendek, kemudian terlihat interval P-P yg. panjang (pause)
Secara praktis terlihat interval R-R memanjang, + = 2 R-R interval normal dan tidak ada gel. P diantaranya.
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SA Block 2SA Block 2ndnd degree degree
• RR pause <2 RR
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SA block derajat IIISA block derajat IIISA block total= Sinus arrestSA block total= Sinus arrest
• Kegagalan SA node untuk membentuk impuls.
• Banyak rangsang yang terblokade, shg. asistole lebih panjang dari 2 R – R interval normal.
• Gel. P tak terlihat.
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SA Block der.IIISA Block der.III
• RR pause>2RR
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AV Block 1AV Block 1stst degree. degree.
• Letak kelainan di AV node• Penyebab klinis: - Efek digitalis, PJK, usia tua
Gambaran EKG:- P-R interval > 0.21 sek- Semua impuls dari atrium dihantarkan ke
ventrikel.
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AV Block 1AV Block 1stst degree degree
• PR>
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AV Block 2AV Block 2ndnd degree degreeWenckebach (Mobitz type I)Wenckebach (Mobitz type I)
Letak kelainan sebagian besar di AV node.
Penyebab klinis: IMA, Digitalis, demam rema, degeneratif
Gambaran EKG:
P-R interval makin lama makin memanjang, kemudian diikuti oleh block dari gel.P, shg. terlihat 1 gel.P yang tak diikuti oleh kompleks QRS.
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AV Block 2AV Block 2ndnd degree Wenckebach degree Wenckebach
• PR memanjang, dan stop
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AV Block 2AV Block 2ndnd degree degreeMobitz type II.Mobitz type II.
• Letak kelainan: terutama didaerah His Purkinye• Penyebab klinis: IMA inf., miokarditis, demam
rema, vagal, kongenital, obat.• Gambaran EKG:
P – R interval konstant, tiba-tiba 1 impuls tidak dihantarkan ke ventrikel, shg. ada
1 gel. P yg. tak diikuti oleh kompleks QRS.
P-R interval bisa normal atau agak memanjang sedikit.
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AV Block 2AV Block 2ndnd degree Mobitz II degree Mobitz II
• PR konstant, lalu P stop
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AV Block 2AV Block 2ndnd degree degreeHigh grade (2:1; 3:1)High grade (2:1; 3:1)
• Letak kelainan bisa di AV node atau sistem His Purkinye
• Penyebab klinis: IMA inf., miokarditis, demam rema, vagal, kongenital, obat.
• Gambaran EKG: - 2:1= Didapatkan 2 gel.P dan 1 QRS.
Artinya dari setiap 2 impuls atrium, hanya 1 impuls yang diteruskan ke ventrikel.
- 3:1= 3 gel.P – 1 kompleks QRS.
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AV Block high grade 2:1AV Block high grade 2:1• 2:1
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AV Block 3AV Block 3rdrd degree degreeAV block totalAV block total
• Letak kelainan terutama di sistem His Purkinye.• Penyebab klinis: lebih sering pada PJK akut atau kronik.
Sebab lain spt. pd. AV Block 2nd degree.• Gambaran EKG:Impuls dari atrium tak ada yg diteruskan ke ventrikel, shg.
Pacemaker yg lebih rendah mengeluarkan rangsang (membentuk QRS sendiri).
Akibatnya P dan QRS tak ada hubungan.
Bila block diatas bifurcatio: QRS kompleks langsing, QRS rate 40-50/men.
Bila block dibawah bifurcatio: QRS melebar (M form), QRS rate< 40/men.
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Complete AV BlockComplete AV Block
• P-QRS disosiasi
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PenatalaksanaanPenatalaksanaan
• Farmaka:
- Sulfas Atropin
- Alupent
+ Pace maker:
Transient
Permanent
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Thank you