MALIGNANT ARRHYTHMIAS

dr. Abraham Ahmad Ali

Firdaus, SpJP

Universitas Nahdlatul Ulama Surabaya

Departemen Ilmu Penyakit Dalam
SISTEM KONDUKSI
THE H’S AND T’S ARE 12 REVERSIBLE CONDITIONS, 7
THAT START WITH H AND 5 THAT START WITH T.
 Hypovolemia
 Hypoxia
 Hydrogen ion excess (acidosis)
 Hypoglycemia
 Hypokalemia
 Hyperkalemia
 Hypothermia
 Tension pneumothorax
 Tamponade – Cardiac
 Toxins
 Thrombosis (pulmonary embolus)
 Thrombosis (myocardial infarction)
TACHYCARDIA
ATRIAL FLUTTER

 Causes : Toxic and metabolic conditions (thyrotoxicosis,

alcoholism, and pericarditis)
 Responds to carotid sinus massage
ATRIAL FIBRILLATION

 Most common arrhythmia

 Associated wth : ischemic heart disease, mitral valve
disease, hypertrophic cardiomyopathy, and dilated
cardiomyopathy
ATRIAL TACHYCARDIA
MANAGEMENT

 The ACLS Tachycardia Algorithm is used for patients who have marked
tachycardia, usually greater than 150 beats per minute, and a palpable pulse.
 Some patients may have cardiovascular instability with tachycardia at heart rate
less than 150 bpm. It is important to consider the clinical context when treating
adult tachycardia.
 If a pulse cannot be felt after palpating for up to 10 seconds, move immediately
to the ACLS Cardiac Arrest VTach and VFib Algorithm to provide treatment for
pulseless ventricular tachycardia.
 The immediate response to an adult patient with tachycardia and a
palpable pulse is:
• To maintain an open airway
• Assist breathing if necessary
• Apply monitors to assess cardiac rhythm, blood pressure, blood oxygenation
• Provide supplement oxygen to maintain O2 saturation between 94% and 99%
 The main assessment in adult patients with tachycardia is to determine
whether the patient is stable or not. Signs of cardiovascular instability are
hypotension, signs of shock or acute heart failure (flash pulmonary
edema, jugular venous distention), altered mental status, or ischemic
chest pain.
Unstable patients with tachycardia should be treated with synchronized
cardioversion as soon as possible

Cardioversion Rules

QRS narrow and regular 50-100 Joules

QRS narrow and irregular 120-200 Joules

QRS wide and regular 100 Joules

Turn off the synchronized mode and defibrillate

QRS wide and irregular
immediately
Stable patients with tachycardia with a palpable pulse can be treated with more
conservative measures first
 Attempt vagal maneuvers
 If unsuccessful, administer adenosine 6 mg IV bolus followed by a rapid normal saline flush
 If unsuccessful, administer adenosine 12 mg IV bolus followed by a rapid normal saline
flush
 Beta-blockers and calcium channel blockers may be considered for narrow QRS
tachycardia (QRS <0.12 sec)
 For stable, wide QRS complex tachycardia (QRS ≥0.12 sec)
 Strongly consider expert consultation
 Consider procainamide 20-50 mg/min IV, OR
 Amiodarone 150 mg IV over 10 minutes, OR
 Sotalol 100 mg (1.5 mg/kg) over 5 minutes
BRADYCARDIA
 Treatment for bradycardia should be based on controlling the symptoms and
identifying the cause using the H’s and T’s.
 Do not delay treatment but look for underlying causes of the bradycardia using
the H’s and T’s
 Maintain the airway and monitor cardiac rhythm, blood pressure and oxygen
saturation.
 Insert an IV or IO for medications.
 If the patient is stable, call for consults.
 If the patient is symptomatic, administer an atropine 0.5 mg IV or IO bolus;
Repeat the atropine every 3-5 minutes to a total dose of 3 mg.
 If atropine does not relieve the bradycardia, continue evaluating the patient to
determine the underlying cause and consider transcutaneous pacing.
 Consider an IV/IO dopamine infusion at 2-10 mcg/kg/minute
 Consider an IV/IO epinephrine infusion at 2-10 mcg/kg/minute
 Potential Cause How to Identify Treatments
Hypovolemia Rapid heart rate and narrow QRS on ECG; Infusion of normal saline or Ringer’s lactate
other symptoms of low volume
Hypoxia Slow heart rate Airway management and effective
oxygenation
Hydrogen Ion Excess Low amplitude QRS on the ECG Hyperventilation; consider sodium
(Acidosis) bicarbonate bolus
Hypoglycemia Bedside glucose testing IV bolus of dextrose
Hypokalemia Flat T waves and appearance of a U wave IV Magnesium infusion
on the ECG
Hyperkalemia Peaked T waves and wide QRS complex on Consider calcium chloride, sodium
the ECG bicarbonate, and an insulin and glucose
protocol
Hypothermia Typically preceded by exposure to a cold Gradual rewarming
environment
Tension Pneumothorax Slow heart rate and narrow QRS Thoracostomy or needle decompression
complexes on the ECG; difficulty breathing

Tamponade – Cardiac Rapid heart rate and narrow QRS Pericardiocentesis

complexes on the ECG
Toxins Typically will be seen as a prolonged QT Based on the specific toxin
interval on the ECG; may see neurological
symptoms
Thrombosis (pulmonary Rapid heart rate with narrow QRS Surgical embolectomy or administration of
embolus) complexes on the ECG fibrinolytics
Thrombosis (myocardial ECG will be abnormal based on the Dependent on extent and age of MI
infarction) location of the infarction
VENTRICULAR TACHYCARDIA AND
VENTRICULAR FIBRILLATION
VENTRICULAR TACHYCARDIA
VENTRICULAR FLUTTER AND FIBRILLATION

• Produce significant brain damage within 3 to 5

minutes
• Faintness, loss of consciousness, seizures, apnea
• Tx : Immediate nonsynchronized DC shock
1. Perform the initial assessment
Perform high-quality CPR
Establish an airway and provide oxygen to keep oxygen saturation > 94%
Monitor the victim’s heart rhythm and blood pressure
2. If the patient is in VTach or VFib, this is a shockable rhythm
3. Apply defibrillator pads (or paddles) and shock the patient with 120-200 Joules on a biphasic defibrillator or
360 Joules using a monophasic.
4. Continue high-quality CPR for 2 minutes (while others are attempting to establish IV or IO access).
5. After 2 minutes of CPR, check rhythm
6. If the monitor and assessment show asystole or PEA, move to Asystole/ PEA algorithm
7. Give epinephrine 1 mg every 3-5 minutes
8. Continue high-quality CPR for 2 minutes (while others are attempting to establish IV or IO access).
9. After 2 minutes of CPR, check rhythm
10. If needed, administer shock
11. Amiodarone IV 300 mg (preferable to lidocaine); May repeat 150 mg OR may use lidocaine 1-1.5 mg/kg
12. After 2 minutes of CPR, check rhythm
13. If needed, administer shock
14. If the patient attains Return of Spontaneous Circulation (ROSC), provide Post Cardiac Arrest Care