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ACLS

modified by TAW

Asses responsiveness Respon (+) 1. 0bservasi 2. Tx sesuai indikasi (di bawah ini): Respon (-) C all: - activated EMS (Emergency Respon System) - for defib L ok L isten Breath (-) 2 kali hembusan F eel (+) PULSE Positif O2 (termasuk intubasi) I v line M onitor (12 lead) Negatif CPR 1 seri/1mnt=100x/mnt pola 15: 2 (unprotec airway) 5: 1 (protected airway) Monitor Non VT/VF VT VT pulse(-) Pulse (+) Atau VF
precordial thump

-Chest pain Klinis spt ASMA, ttp: -Elevasi ST -Retraksi (-) -dg/tanpa BBB: ARITMIA -Ronkhi basah s/d apec -QRS > 12 -Pucat, megap2,ala nasi lebar -Right=rsR di V1-V3 -EKG variatif:-sinus taki -left = RR di V5-V6 -T bisa > 140/90 -PCO2 >> PO2 BRADIKARDI AMI N<50) (N=85 90) (<60) Serius: -simptom:-nafas pendek - kesadaran turun ACUTE LUNG OEDEM (ALO) - chest pain -sign:-T drop,pre/syock, -congestive pulmo -AMI,CHF A-T-D-E-I YA TDK

PEA ASISTOLE

DC : 200-300-360 cardioversi Sirkulasi Kembali spontan Observasi Persisten VT pulseless Atau VF

TAKIKARDI (>100) 1. Serius simptom,sign 2. HR >150 I0 or II0 tipe-1 -II0type2 -III0 STABIL

AF PSVT A Fluter TCP, iv pacing

VT

Penyebab asistole: Primer: pacemaker cell tdk aktif Flat line rhythm pd 2lead yg saling tegak lurus, -oklusi RCAinfark SA & AV node Check another lead, and then: -degenerasi SA-AV node -congenital heart block,trauma jantung, A cup of TEA ATROPIN: lokal tumor -reduce vagal tone via -trauma listrik DCasistole via muscarinik reseptor blokade TransCutaneousPacing (TCP), RJP depolarisasi seluruh pacemaker. aktivasi SA node + konduksi SA-AV. kalau arus ACbikin VF (konduksi infra AV node : tdk efektif, Skunder: hipoksia, asidosis met: berat, justru dpt perburuk block 20 mjd 30) untreated VF, -<0.1 mg: centrally mediated paradoxical -Epinefrin 1 mg iv push or IO, (sediaan=1Amp1cc1mg lar 1:1,000) trauma: okuli, parasimpatomimetik effect or 2 mg via ET IO=Intraoesophagus maksilofacial, -KI: pediatric dg bradiasistole ulangi tiap 3 5 mnt, range 0.01 0.2 mg/kg carotid sinus (pakai saja epinefrin) -Atropin 1 Amp iv or IO (sediaan=1Amp1cc 0,25 mg), left temporal lobeulangi tiap 3 5 mnt pediatric: 0.02mg/kg R VASOPRESIN: pitresin s/d total 0,04 mg/kg (jika BB 50 kg=>0.04 mg x 50 kg= 2 mg complex partial seizure, HiperKalemia, -ADH activity:-resorb H2O distal ren tub => 8 Ampul -vasokonstric efect: splancnik, pulmonal bila IV sulit via ET: cerebral, coronary 2 mg atropin(Max.dose)+ flush 5 cc NaCl 0.9+baging 5x -dose 40 IU iv, dpt 1x ulang. Sudden cardiac death (SDC): -kematian mendadak akibat jantung berhenti, onset simptom dlm 1 jam, Persisten Asistole -dgn atau tanpa didahului VF atau lainnya Dx fatal cardiac disease -trtm tjd didahului oleh aritmia(VT,VF) -underlying disease: a. kelainan struktural jantung: 1. Cek apakah CPR sudah betul kongenital, CAD, kardiomiopati(dilated 2. Atipical clinical feature present Tx sesuai kelainan atau hipertrofi), miokarditis, valvular 3. Support for cease-effort protocol in place disease (stenosis mitral, aortal), coarctatio aorta, CHF (LVK =EF 30-35) b. biomolekuler: ggn/disfungsi: Akhiri Tx bila: - Ca channel 1. - K (trtm pd kasus iskemi miokard) 2. - mutasi(Na-channelopati) -Presipitator: iskemi berat, asidosis, hipoksemia, wall tension, drug, ggn met EPINEPHRINE: -Jautomatisitas impuls -Jcoroner & cerebral flow pd CPR

ASISTOLE

VT pulseless atau VF
-Precordial tumb: lbh efektif pd VT -Bila EKG kacau antara VT/VF atau SVT: HARUS dianggap saja VT/VF Intubasi

Iv line 1 mg epinefrin I flush 20 cc NaCl elevasi (bila iv sulit: intratraceal 2,5 mg atau 2.5x dose iv ) Pediatric: 0.1 mgr/kg/mnt max 1.5 mgr/kg/mnt CPR DC 360, pediatric:2 joule/kg CPR DC 360 max 4 J/kg 3 menit CPR DC 360 Kenali & koreksi kemungkinan: -hipoksia -hipovolemi -HiperK-hipoK, ggn met -tension pneumothoraks -tamponade -toxic/terapeutik substance -thromboemboli/mekanikal obstruksi 1 mg Epinefrin II Dpt diulang tiap 3-5 mnt Max.dose: 3 mg/kg CPR DC 360 CPR DC 360 CPR DC 360

No respon (?)

REFRACTORY VT-VF? : -procainamid 30mg/mnt. Max.dose 17 mg/kg -magnesium sulfat 1-2 gr iv ( 25-50 mg/kg iv) (MgSO4 juga drug of chois: - Torsade de pointes - hipoMg (< 1,4 mEq/L) -NaBiqnat 1 mg/kg, trtm,pd: -hiperK -toxic antidepresan trisiklik, phenobarbital -CaCl2 lar 10%, pd: -hiperK(>6): 2-4 mg/kg -hipoCa -toxic Ca chanel bloker pediatric: 0.2 ml/kg,lar10% (CaCl2 memperbaiki: action pot excitation threshold)

A/ L/V
Refracter (?) pertimbangkan

Amiodaron
300 mg iv bolus 15 20 mnt Sediaan: Amp 150 mg Maintenance: 1 mg/mnt, selama 6 jam-I kmd 0.5 mg/mnt

Lidocaine (Xylocard)
1 1,5 mg/kgBB Sediaan: amp 2cc.lar 2%=20 mg/cc Dpt diulang tiap 3-5 mnt 0,5 0,75 mg/kgBB, max.dose= 3 mg/kgBB maintenance: 2 4 mg/mnt 20 50 mgr/kg/mnt (pediatrik)

Vasopresin 40 UI single dose


Sediaan: Amp pitresin 20 UI

PEA
(Pulseless Electrical Activity)

Tentukan causa utama: 1. Hypovolemia 6. Obat (OD drug, kecelakaan) 2. Hypoxia 7. tamponade, cardiac 3. Asidosis 8. Tension pneumothorac 4. Hyper/hypokalemia 9. Thrombosis coroner, ACS 5. Hypertermia 10. Thrombosis DVT, pulmonary embolism

Tx sesuai causa, dan: 1. PEA HR slow : atropin 1 mg iv ulangi tiap 3 5 mnt max total 0,04 mg/kg 2. PEA HR tdk slow: epinefrin 1 mg iv flush ulangi tiap 3 5 mnt

BRADICARDIA (<60)

LBBB and 2nd degree (II0)AV Block, Mobitz Type II (PR constan, P:QRS=X:Y=constan, mis:4P=3QRS4:3)

NO SERIUS Sign & simptom Oh Say It Isn't So O2 saturation monitor Suction equipment IV line Intubation equipment Sedation and possibly analgesics

SERIUS: Simptom: nafas pendek, kes turun, chestpain Sign: T turun, syock, ALO, CHF, AMI

All Trained Dogs Eat Iams

3rd Degree (III0)AV Block Rx'ed With a Ventricular Pacemaker

Block II0 atau III0

NO
Block II0 tipe-1 dg QRS normal

YES
Block II0 tipe-1 tapi dg QRS lebar (lokasi block lbh distal yaitu di His-purkinye) - Block II0 type-2 - Block III0

Atropin 0,5 1 mg iv max 0,04 mg/kgBB ped: 0,02 mg/kg (sediaan=1Amp1cc 0,25 mg) hati2:- dg adanya infark (atropin=dangerous) - ES: ventrikular disritmia - tdk efektif pd block infranodal, wide compleks bradiaritmik, de-inervated heart(transplant) TCP Dopamin 5 20 u gr/kg/mnt
Sediaan: 200 mg/10 ml amp, 200mg/5cc flacon
200 mg dlm 50 lar 200.000 m = 4.000 m 50 ml ml

Dg symptom: -light-headedness, dizziness, or syncope,(simtom yg tdk biasa) -chest pain (biasanya berhub dg adanya miocarditis or ischemia.

Epinefrin 2 10 u gr/mnt
Sediaan: 1 mg/ml (lar 1:1000)
Pengenceran: 1.000 m = 200 m 50 ml ml

(1 Amp + NaCl 500 1 5 cc/mnt)

Isoproterenol 2-10 g/min. OBSERVASI - TCP OBSERVASI KETAT Pertimbangkan vagolitik atropin - iv PACING Assesment iskemi, miokarditis; bila ada

TAKIKARDI (>100)
Stabil atau -Serius Simptom & sign TDK serius simptom & sign: nafas pendek, kes turun, chest pain T turun, syock, ALO, CHF, AMI PSVT - HR > 150 AF VT Tak peduli apapun penampilan EKG: A Fluter Bruit carotis (+) Bruit (-) Amiodaron atau mau AF atau lainnya, tindakannya sama yi: -O2 Lidocain 1 1,5 mg/kg flush Vagal manouver -iv line 5 10 mnt -Ca blocker: Diltiazem,Verapamil -Siapkan suction (menurunkan respon ventrikel) Lidocain 0,5 0,75 mg/kg flush O2 sat monitor -B blocker (for case:simpatik J ,tirotoxic) Adenosin 6 mg iv flush max total 3 mg/kg intubasi set -Vagolitic:Prokainamid, Quinidin, Stop bila tjd maintenance:1-4 mg/mnt -sedatif 1 3 mnt Block II0 disopiramide (ped: 20-50 mgr/kg/mnt) -Dg/tanpa anastesi analgesi Adenosin 6 mg iv flush -antiaritmik lainnya: -Kemudian: Refracter ? amiodaron,ibutilid, dofetilid 1 3 mnt CARDIOVERSI Sincronize azimilid Adenosin 12 mg iv Procainamid -AF : start 200 J -anticoagulan 20 30 mg/mnt, max 17 mg/kg -A Flutter & PSVT: start 50 J Maintenance: 1-4 mg/mnt T, N membaik 100 T makin turun Radiofrequent- Serius sign & simptom 200 Verapamil 2,5 5 mg iv pelan cateter ablation 300 Sambil lihat T & HR 2-3 mnt) 360720 ? (utk refracter AF) Sincronize15 30 mnt Bretilium Sedatif: - diazepam, cardioversi - short act = midazolam Verapamil 5 10 mg iv mulai 50 J, dst. - barbiturat - ketamin Utk ped:0,5 J/kg SincronizePertimbangkan :-digoxin - etomidat cardioversi - B block - metohexital Start: 50-100 J, kmd: - diltiazem Analgetik: Antikoagulan: 200 - fentanil -warfarin 300 - morfin (s/d 4 mggu 360 J - meperidin post cardioversi)