Tachy Arrhythmia

..
NO medication for sync
SEDATE pt before sync
NO sync/shock for stable patient
UNSTABLE

NARROW -

WIDE
-

REGULAR IRREGULAR REGULAR IRREGULAR

unsynchronized
sync sync sync shock
120-200J/200-220J 100J - 200J 200J - 360J
50-100J
-

SVT AFIB MONO VT TDP

Wide QRS complex, No P-waves Twisting of the point

R wave Invisible P wave High likelihood of rapid deterioration
near together to a state of VFIB

A Flutter

Saw tooth
pattern

STABLE

NARROW -

WIDE
- -

REGULAR IRREGULAR REGULAR IRREGULAR

SVT AFIB MONO VT TDP

Wide QRS complex, No P-waves Twisting of the point

R wave Invisible P wave High likelihood of rapid deterioration
near together to a state of VFIB

A Flutter
1. Vagal maneuvers Amiodarone Amiodarone
R Adenosine
2. in 100cc D50% in 100cc D50%
- 6mg/12mg/12mg 150mg/10mins
3. Beta blocker Saw tooth
150mg/10mins
pattern (infussion) (infussion)
- Metoprolol
- Propranolol While waiting for expert to come,
4. Calcium channel can repeat the same dose
blocker 1. Beta blocker
- Nife/Amlodipine - Metoprolol other option
- Atenolol
- Propranolol Adenosin
- 6mg usually only 1 dose
for diagnostic
2. Calcium channel - 12mg
Each side 10 sec
Not for >50 y/o
blocker
; can cause brady n hypotension - Nifedipine
>50 y/o apply ice pack 10 second on forehead - Amlodipine
- Felodipine
Left sided with big cannula - near to heart
Using 3 way technique - life time only 30sec to reach heart
Flush with 20cc NS n raise hand after
Explained : cause chest tightness

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 Adult Tachycardia with Pulse Algorithm

Assess appropriateness for clinical condition

(HR will be >150/min if tachyarrhythmia)
Anti-arrhythmic infusion for stable wide-QRS tachycardia :

Amiodarone IV 150mg/10mins, repeat if needed if VT recurs

maintain patten airway Follow by maintenance inf. 1mg/min for 1st 6hours
dont forget
BLS survey !!
identify & treat
u/L cause
oxemic
if hyp

To identify Left sided with big cannula - near to heart

Using 3 way technique - life time only 30sec to reach heart
Flush with 20cc NS n raise hand after
if regular narrow complex Explained : cause chest tightness
Adenosine
6mg/12mg/12mg
consider
sedation Follow with NS flushing

Persistent tachycardia causing

↓tension?
Acute alteredmental status?
Sign of shock?
T
if refractory, consider :
Is chemic chest discomfort?
Acute heart failure u/L cause
synchronized
cardioversion
^ level of cardioversion
if regular narrow complex
Adenosine &
monomorphic
+ anti arrhythmic
6mg/12mg/12mg
Follow with NS flushing
expert consultantion
Amiodarone infusion
, 1mg/min for 6H
Wide QRS? Consider
> 0.12 second

expert
consultantion
Each side 10 sec
Not for >50 y/o
; can cause brady n hypotension
>50 y/o apply ice pack 10 second on forehead

gular)
Vagal maneuvers (if re 1. Beta blocker
- Metoprolol
Adenosine Cif regular) - Atenolol
- Propranolol
I

B - blocker@ calcium channel blocker

2. Calcium channel
blocker
Consider expert consultation - Nifedipine
- Amlodipine
- Felodipine
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 Adult Cardiac Arrest Algorithm
CPR QUALITY
Minimal interruption : 10sec

i
immediately after if needed
100 -120/min, complete chest recoil know the rhythm • if no pulse, call for help, start with chest compression
Change each 2 mins/once fatigue dont forget • if pulses, but no spontaneous breathing, open the airway and give 2 breath 30:2
Deep : 2-2.5" (5cm) BLS survey !!
Quantitative capnography wave prepare
If no advance airway,
30:2 compression vent. ratio
Rescue breathing
will not having BP
V: 6-10/min (1:6sec)
None V : 10 - 12min
V Fib Asystole
pVT PEA NO shock
rhythm to be given !!
shockable?

dont delay ! 360J (mono phasic) if dilution

1 : 10 000
cpr while prepare defib,
shout for help manufacturer (biphasic)
Epinephrine 1mg
ASAP

better to
give 1 breath each 6sec (10breath/min)
treat cause earlier
intubated : 30:2
with continuous CPR Consider intubation
2 mins
check ETTplacement while CPR
while CPR Epinephrine 1mg if not inserted earlier
check quality CPR 2 mins
capnography
each 3-5 mins
35-45mmHg recommendated : 4mins
early intubation

check ETTplacement
rhythm check quality CPR give 1 breath each 6sec (10breath/min)

I
shockable? with continuous CPR
capnography
35-45mmHg

360J (mono phasic)

rhythm
manufacturer (biphasic) shockable?

give 1 breath each 6sec (10breath/min)

intubated : 30:2
with continuous CPR Consider intubation

check ETTplacement
2 min
check quality CPR Epinephrine 1mg 2 mins
capnography each 3-5 mins
35-45mmHg recommendated : 4mins hypotension difficult pulse

ting
palpitation
Tension pneumothorax Hypovolemia
desa
Hypoxia
Tamponade, cardiac treat
difficult pulse palpitation reversible causes Hydrogen ion (acidosis)
rhythm Toxins consider
Thrombosis, coronary TnH Hypokalemia/hyperkalemia
↑

shockable? difficult pulse

palpitation
Thrombosis, pulmonary Hypothermia

rhythm
shockable? go to
@
If no sign of ROSC, pulse & blood pressure
Abrupt sustained increase in PETCO2
go to @
(typically >40mmHg)
spontaneous arterial pressure waves with
only at 3rd and 5th shock intra arterial monitoring
only at 3rd and 5th shock Lidocaine
1st : 1-1.5mg/kg
Amiodarone IV PUSH 2nd : 0.5-0.75mg/kg If ROSC, go to U
admit pt to ICU/CC ECHO,EEG
300mg then 150mg Post-cardiac arrest care CT brain, blood ix, (32-36'c)
TT M/ 24H
For comatose
monitor
2 min Consider appropriateness
of continuous resuscitation
Tension pneumothorax Hypovolemia
Hypoxia A : o² supply
Tamponade, cardiac treat intubate - co2 detector, capno, cxr
reversible causes Hydrogen ion (acidosis) B : breathing 1:6sec
Toxins consider C : bp, ecg rhythm

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D : LOC, ecg, Ng, Folleys, extra IVC
Thrombosis, coronary TnH Hypokalemia/hyperkalemia

Thrombosis, pulmonary Hypothermia

 Adult Bradycardia Algorithm
Assess appropriateness for clinical condition
(HR will be <50/min if bradycardia) dont forget
if unconcious
BLS survey !!
check respiration for conscious patient
assist breathing if necessary
pt breath in their own ⑪ Consider possible hypoxic
maintain patten airway
&
toxicologic causes
identify & treat ^ insulin
Atropine
Digoxin
⑬ u/L cause ⑳ Cal. Gluconate
oxemic
Beta Blocker
if hyp 2%
<9
SPO²
⑳
⑥
dont delay ecg therapy

To identify

MAP >65mmHg
if < : ? decrease in perfusion
do not rely on Atropine for ;
mobitz T2
3rd degree AV block
3rd degree AV block with new wide QRS COMPLEX

Persistent brady arrhythmia causing

Monitor ↓tension?
Acute alteredmental status?
& Sign of shock?
Ischemic chest discomfort?
Observe Acute heart failure
if adequate perfusion
Atropine usually take time to increase the HR
so, prepare as well another option

Atropine
1mg/1mg/1mg (max 3x)
every 3-5min epinephrine
TCP 1-10mcg/min

if atropine not effective

Electrical impulse

dopamine
5-20mcg/kg/min

X respond?

Consider
&
CAUSES :

Myocardial ischemic
Drugs/toxicology
Hypoxia
Electrolyte imbalance
- hyperK

expert
consultantion transvenous pacing

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Heart Block Rhythm