Arrhythmia : What you

need to know for ACLS?

 Introduction
Rhythm recognition is a key skill that
one needs to demonstrate during
cardiac arrest situation.
This can be life saving.
Early defibrillation
Decision making on the right therapy
 Lets Keep it Simple!

Pulseless Rhythms
Tachyarrhythmias
Bradyarrhythmias
Pulse less Electrical Rhythm
 Ventricular Fibrillation
Uncoordinated contractions within the
ventricles of heart.
Due to multiple cardiac cells that
function as pacemakers and
discharge electrical impulses in a
chaotic manner.
Reduced / No cardiac output : No pulse
Will result in Asystole if not treated.
 Commonest cause : Hypoxia
/Ischemia

Types : Fine and Coarse

 Therapy
Immediate Defibrillation
CPR
I/V Amiodarone after 3 shocks
 Ventricular Tachycardia

Broad Complex Tachycardia (QRS >

0.12s)
Heart rate > 180 beats /mt
Mono-morphic
Poly-morphic / Torsade Pointe
Pulse less vs with pulse
Mono morphic VT
 Poly morphic VT
Torsade Pointes if Prolonged QT
interval on previous ECG
 Treatment
Pulseless : Defibrillation

With pulse : stable = Amiodarone

Unstable = DC Cardio
version
No Pulse !
Pulse Less Electrical Activity
(PEA)
Organized electrical activity but
without a pulse
Usually has underlying treatable
cause
Hypovolumea and Hypoxia are the
commonest causes.
If no underlying cause is identified, it
will be treated same as Asystole.
 5 Hs and 5 Ts
5 Hs
Hypovolumia
Hypoxia
Hydrogen Ion (Acidosis)
Hyperkalemia
Hypokalemia
Hypoglycemia
 5Ts
Toxins
Tension Pneumothorax
Tamponade
Thrombosis : Coronary
Thrombosis : Pulmonary
Trauma
 ASYSTOLE
Follow flat line protocol check leads and gain
Not a true rhythm
State of no electrical activity
Terminal event
Very poor prognosis : ROSC extremely unlikely
Possible underlying cause : 5Hs and 5Ts

Treatment : CPR and Epinephrine

Bradiarrythmia
First Degree AV Block
 PR interval is prolonged > 200ms
No clinical significance if
asymptomatic
May lead to higher degree AV Block
Second Degree AV Block
 Mobitz Type 1
Progressive prolongation of PR interval.
Atrial impulse (P waves) may not be
conducted through AVN and gets blocked
and hence no QRS.
No clinical significance unless symptomatic.
Mobitz Type 2
Non prolongation and fixed PR interval.
Non conducted p waves
No ventricular activity -Drop beats / No QRS
Most times Infranodal
Third Degree AV Block
(CHB)
P waves with a regular pp interval
QRS complexes with a regular RR
interval
QRS complex may be narrow or wide
(escape rhythm)
No relationship between P waves and
QRS complexes.
 Treatment
Trans cutaneous or Trans Venous
pacemaker
Atropine (0.5 mg) may be tried
Epinephrine 0.5 -1 mg /kg bw
Tachyarrhythmia
 Atrial Fbrillation
No p waves preceding QRS
complexes as no coordinated atrial
contractility
Irregular (variable) RR intervals
 Treatment
Unstable : Synchronized DC Cardio
version
Stable : Rhythm Control vs Rate Control

Rhythm : Amiodarone, Sotalol, Flecainide

Rate control : Beta blocker, Calcium
channel blocker, Digoxin.
Anticoagulant if indicated.
 Atrial Flutter
Atrial rate 250 350 /mt
Saw Tooth Appearance
Ventricular rate depends on Degree
of AV block
Electrical foci usually in RA
 Treatment
Rate Control
Rhythm Control
Anti coagulant
DCC if unstable
 Supra Ventricular
Tachycardia
Broad term for various supra
ventricular arrhythmia
Electrical impulses above the
ventricular electrical conducting
system.
Inverted p waves preceding or
following qrs complexes.
Review old ECG exclude WPW
 Treatment
Vagal maneuver
Adenosine
Drugs Chemical Cardio version or
Rate control.
Anti coagulant.

If unstable : sync. DCC

 Contoh Kasus
Laki laki 54 tahun dibawa keluarga
ke UGD karena tiba2 kejang
Tidak ada respons, Tidak bernafas,
tidak ada nadi
2 siklus RJP tidak ada respons
Alat defib datang, dipasang lead
dengan gambaran :
 Setelah 2 siklus RJP terdapat
gambaran seperti berikut
 Contoh Kasus
Wanita 40 tahun datang ke UGD
karena sesak nafas
Setelah dipasang monitor tampak
gambaran EKG