pulseless arrest, tachyarrythmia, bradyarrythmia

1. ALS Subcommittee 2010
ARRHYTHMIA
TREATMENT
ALGORITHMS

2. ALS Subcommittee 2010
OBJECTIVES
Upon completion of this session, you will be able
to:
List the 4 arrhythmias leading to cardiac arrest
State the treatment algorithms for VF/ pulseless
VT, PEA and Asystole
Understand the principles of management of
tachy and brady arrythmias

3. ALS Subcommittee 2010
Cardiac Arrest
Occurs with one of 4 arrhythmias:
ventricular fibrillation (VF)
pulseless ventricular tachycardia (VT)
pulseless electrical activity (PEA)
asystole

4. HYDROGEN ION
HYPOXIA
HYPOTHERMIA
HYPOVOLEMIA
HYPO/HYPERKALEMIA
HYPOGLYCEMIA
TAMPONADE, CARDIAC
TENSION PNEUMOTHORAX
THROMBOSIS, Pulmonary
THROMBOSIS, Coronary
TOXIN
•Danger
•Responsiveness
•Shout for help

5. 1. DANGER
2. RESPONSIVENESS
3. SHOUT FOR HELP AND DEFIBRILLATOR
4. AIRWAY OPENING
5. BREATHING
6. CHEST COMPRESSION
CARDIOPULMONARY RESUSCITATION
Push hard 5cm deep,
Push fast 100 per minute
Minimize interruption of chest compression
Allow complete chest recoil
Do NOT hyperventilate
Compression to ventilation ratio 30:2 if not intubated
DEFIBRILLATION
360J for monophasic, 120-200J for biphasic
IV or IO ACCESS
DRUGS
IV Adrenaline 1 mg push
IV Vasopressin 40 U (as first or second drug after Adrenaline
IV AMIODARONE 300mg bolus, 150 mg second dose

6. 1. DANGER
2. RESPONSIVENESS
3. SHOUT FOR HELP AND DEFIBRILLATOR
4. AIRWAY OPENING
5. BREATHING
6. CHEST COMPRESSION
CARDIOPULMONARY RESUSCITATION
Push hard 5cm deep,
Push fast 100 per minute
Minimize interruption of chest compression
Allow complete chest recoil
Do NOT hyperventilate
Compression to ventilation ratio 30:2 if not intubated
IV or IO ACCESS
DRUGS
IV Adrenaline 1 mg push
IV Vasopressin 40 U (as first or second drug after
Adrenaline
IV AMIODARONE 300mg bolus, 150 mg second dose
Hydrogen ion
Hypoxia
Hypothermia
Hypovolemia
Hypo/hyperkalemia
Hypoglycemia
Trauma
Tension pneumothorax
Thrombosis(coronary)
Thrombosis(pulmonary)
Tamponade

7. ALS Subcommittee 2010
Causes: H’s and T’s
• Hypoxia
• Hypokalemia/hyperkalemia
• Hypothermia
• Hypovolemia
• Hydrogen ions (acidosis)
• Hypoglycemia

8. ALS Subcommittee 2010
Causes: H’s and T’s ….cont
• Tamponade
• Thrombosis (pulmonary)
• Thrombosis (coronary)
• Toxins
• Tension pneumothorax

9. ALS Subcommittee
2010
Pericardial Tamponade
• Chest x-ray
–Widened mediastinum
–Pneumo- or hemothorax
• Electrical alternans
•Note rounded bottle
shape to left side of heart

10. ALS Subcommittee 2010
Right Left
A: Air under
tension in left
thorax
A
Pleural
margin;
partial
lung
collapse
Tension Pneumothorax

11. ALS Subcommittee 2010
Asystole Algorithm
Adrenaline 1 mg IV push,
repeat every 3 to 5 minutes,
Vasopression 40U may replace 1
dose of adrenaline
If Asystole persists
Withhold or cease resuscitation efforts?
•Consider quality of resuscitation?
•Atypical clinical features present?
•Search for DNR order

12. ALS Subcommittee 2010
Pulse Algorithm
• Bradycardia
• Tachycardia
– Narrow Complex
– Wide Complex

13. ATROPINE 0.5mg to 3mg OR
DOPAMINE 5 to 10mcg.kg.min OR
ADRENALINE 2-10 mcg/kg/min
Assess clinically
Identify and treat
underlying cause
Ensure airway patency
 Oxygen supplement
Cardiac monitor
Establish IV access
Perform 12 lead ECG
Hemodynamic instability
- Hypotension
- altered mental status
- signs of shock
- acute heart failure

14. ALS Subcommittee 2010
Tachyarrhythmia
Is patient stable or unstable?
Patient has serious signs or symptoms?
 Chest pain (ischemic? possible ACS?)
 Shortness of breath (lungs getting ‘wet’? possible CCF?)
 Low blood pressure (orthostatic? dizzy? lightheaded?)
 Decreased level of consciousness (poor cerebral perfusion?)
 Clinical shock (cool and clammy? peripheral vasoconstriction?)
Are the signs and symptoms due to the rapid
heart rate?

15. ALS Subcommittee 2010
Management of
Tachyarrhythmia
• Stable
– Treat with IV drugs
• Unstable
– Cardioversion

16. Unstable, with serious signs or
symptoms
ie : Heart failure, SBP<90, In shock
Tachycardia Algorithm
Immediate
synchronised
cardioversion
Narrow Complex
Tachycardia
•Assess: Responsiveness • ECG monitor
•Shout: Help/defibrillator • Assess vital signs
•Assess: ABC • Review history
•Administer oxygen • Perform physical exam
•Establish IV • Do 12 Lead ECG
Wide Complex
Tachycardia
Polymorphic VT
Yes
No

17. ALS Subcommittee 2010
Postresuscitation Stabilisation
• Support of `stunned’ myocardium - may
require vasoactive support
• Keep hypothermic (32-34°C) for VF or
non VF arrest for 12 to 24h
• Maintain strict glucose control (4 -
6mmol/l)
• Monitor clinical signs

18. ALS Subcommittee 2010
SUMMARY
• Effective ALS begins with high quality CPR
• Uninterrupted high quality chest compressions
improve outcome
– Rhythm check, rescue breath, even drug administration
should NOT interrupt compressions
• Early recognition & treatment of arrhythmias
give the best chance of survival
• Search for treatable causes of PEA
• Post-resuscitation period is important
• Know algorithms well

19. ALS Subcommittee 2010
THANK YOU
NATIONAL COMMITTEE ON RESUSCITATION TRAINING
SUBCOMMITEE FOR ADVANCED LIFE SUPPORT
 Dr Tan Cheng Cheng
 Dr Luah Lean Wah
 Dr Ismail Tan
 Dr Wan Nasrudin
 Dr Chong Yoon Sin
 Dr Priya Gill
 Dr Ridzuan bin Dato’ Mohd Isa
 Dr Thohiroh Abdul Razak
 Dr Adi Osman