Dr.

Ika Prasetya Wijaya SpPD-KKV, FINASIM, FACP

www.ipwijaya@gmail.com Samarinda: 5 Januari 1968

Pendidikan :
S1 : FKUI 1992
Spesialis 1 : FKUI 2003
Spesialis 2 : KIPD/FKUI 2011
Fellow INASIM : PAPDI 2010
FACP : 2015

Pekerjaan:
KETUA Divisi Kardiologi, Departemen Ilmu Penyakit Dalam FKUI-RSUPNCM 2014
Editor Acta Medica Indonesiana/Indonesian Journal of Internal Medicine
Penulis Buku Ajar Ilmu Penyakit Dalam bidang Kardiologi

Organisasi:
Kabid Humas, Publikasi dan Media PB PAPDI 2006-sekarang
Wakil Ketua PAPDI Cabang Jakarta 2010- sekarang
Ketua I PB IKKI 2013-sekarang

CRE/062/Aug10-Aug11/MF
Peneliti dan Pengembangan:
Tim Karotis FKUI RSCUPNCM
Anggota Tim Stem Cell FKUI RSUPNCM
Tim Transplan Ginjal RSCM
Kegawatan Jantung
Ika Prasetya Wijaya, dr. SpPD-KKV, FINASIM, FACP
Cardiac
Arrest
Epidemiology
Nearly 400,000 out-of-hospital sudden cardiac arrests occur
annually
88 percent of cardiac arrests occur at home
Failure to act in cardiac emergency can lead to unnecessary
deaths
Effective bystander CPR provided immediately after sudden
cardiac arrest can double or triple a victims chance of
survival.
Less than 8 percent of people who suffer cardiac arrest
outside the hospital survive.
Cardiac Arrest
Before conducting the BLS or ACLS survey,
look to make sure the scene is safe

Check responsiveness
Activate the emergency
response system/get AED
Circulation (CPR)
Defibrillation
Electrical
Therapies
 Early defibrillation is critical to survival from
sudden cardiac arrest
Purpose of defibrillation
Does not restart the heart
Defibrillation briefly terminates all electrical activity
(including VT and VF)

Principle of early defibrillation

A common initial rhythm in out-of-hospital witnessed
sudden cardiac arrest
Defibrillation Electrical defibrillation is the most effective way to
treat VF
The probability of successful defibrillation decreases
quickly over time

The earlier defibrillation occurs, the higher the

survival rate.
Shock 1st or CPR 1 st ?
 Healthcare provider who treat cardiac arrest in hospital
should provide immediate CPR until defibrillator is ready
for use
Use the defibrillator as soon as it is available.
AHA strongly recommends performing CPR while a
defibrillator or AED is readied for use and while charging
for all patients in cardiac arrest.
VF or
Pulseless VT
ACLS Cardiac Arrest Algorithm.
Managing VF/Pulseless VT

Robert W. Neumar et al. Circulation. 2010;122:S729-S767

Copyright American Heart Association, Inc. All rights reserved.
Managing VF/Pulseless VT
Managing VF/Pulseless VT
Managing VF/Pulseless VT
Managing VF/Pulseless VT
ACLS Cardiac Arrest Algorithm.
Managing VF/Pulseless VT

Robert W. Neumar et al. Circulation. 2010;122:S729-S767

Copyright American Heart Association, Inc. All rights reserved.
Application of the Cardiac Arrest Algorithm: VF/VT Pathway
Minimal Interruption of Chest Compression
Team member should continue to perform high-quality CPR until defibrillator arrives and attached to
patient
Chest compressions should ideally be interrupted only for ventilation (unless an advanced airway is
placed), rhythm checks, and shock delivery.

Deliver 1 Shock
The appropriate energy dose is determined by the identity of defibrillator monophasic or biphasic.
Monophasic: a single 360-J shock
Biphasic: use the manufacturers recommended energy dose (eg, initial dose 120 200 J)
Immediately after the shock, resume CPR. Give 2 minutes (about 5 cycles) of CPR.

Resume CPR
Application of the Cardiac Arrest Algorithm: Delivering Shock
Clearing for Defibrillation
To ensure safety during defibrillation, always announce the shock warning
State the warning firmly and in a forceful voice before delivering each shock
Clear. I am going to shock on three
Check to make sure you are clear of contact with patient with patient, the stretcher, or
other equipment.
Make a visual check to ensure that no one is touching the patient or stretcher.
One, two, three. Shocking
When pressing the SHOCK button, the defibrillator operator should face the patient, not
the machine.

Rhythm Check
Conduct a rhythm check after 2 minutes (about 5 cycles) of CPR
The pause in chest compressions to check the rhythm should not exceed 10 seconds.
Perform a pulse check -- preferably during rhythm analysis only if an organized rhythm
is present
Tachycardia Algorithm
Rhythms for Tachycardia
Atrial fibrillation
Atrial flutter
Reentry supraventricular tachycardia (SVT)
Monomorphic VT
Polymorphic VT
Wide-complex tachycardia of uncertain type
TACHYCARDIA

Unstable
Stable
 Approach to Unstable Tachycardia
Unstable tachycardia exists when the heart rate is too fast for the patients clinical
condition and the excessive heart rate causes symptoms or an unstable condition
because
The heart is beating so fast cardiac output is reduced
The heart is beating ineffectively cardiac output is reduced

Unstable tachycardia sign and symptoms

Hypotension
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute heart failure (AHF)
You must quickly determine whether the patients
tachycardia is producing hemodynamic
instability and serious signs and symptoms or
whether the signs and symptoms (eg, the pain
and distress of an AMI) are producing the
tachycardia

Expert suggest
- Instability with heart rate is <150/min unlikely caused by
tachycardia
- Heart rate >150/min unlikely caused by physiologic stress
Immediate Synchronized Cardioversion
If possible, establish IV access before cardioversion and administer sedation if the
patient is conscious
Do NOT delay cardioversion if the patient is extremely unstable
Synchronized cardioversion
Synchronized cardioversion uses a sensor
to deliver a shock that is synchronized with
a peak of the QRS complex (eg. The highest
point of the R wave)
Synchronization avoids the delivery of a
shock during cardiac repolarization (a
period of vulnerability in which a shock
can precipitate VF)
Synchronize cardioversion uses a lower
energy level than attempted defibrillation.
When to use synchronized cardioversion
Unstable AF

Unstable SVT

Unstable Atrial Flutter

Unstable regular monomorphic tachycardia with

pulses
 Energy dose for cardioversion
For unstable Atrial Fibrillation (AF)
Monophasic cardioversion: deliver an initial 200-J synchronized shock
Biphasic cardioversion: deliver an initial 120-200 J synchronized shock
In either case, increase the energy dose in a stepwise fashion for any subsequent
cardioversion attempts

For unstable Atrial Flutter and SVT

An initial energy dose of 50 J-100 J with a monophasic or biphasic waveform
If the initial dose fails, increase the dose in a stepwise fashion

For monomorphic VT
An initial energy dose of 100 J
If there is no response to the first shock, increase the dose in a stepwise fashion.

Polymorphic VT
Treat as VF with high energy shock (defibrillation dose)
When to use Unsynchronized Shocks
For patient who is pulseless
For patient demonstrating clinical deterioration (in
prearrest), such as those with severe shock or
polymorphic VT
When you are unsure whether monomorphic or
polymorphic VT is present in the unstable patient
Approach to
Stable
Tachycardia
 Approach to Stable Tachycardia
If the patient with tachycardia is stable, you have time to evaluate the rhythm and
decide on treatment options.

Narrow Regular
QRS

Wide Irregular
QRS
Wide Complex Tachycardia

Ventricular Atrial Fibrillation with

abberancy
Tachycardia Pre-excited atrial fibrillation
Supraventricular (AF with accessory pathyway)
Tachycardia with Polymorphic VT/Torsade de
pointes
abberancy

Regular Irregular
These are advanced rhythms requiring additional expertise or expert
consultation
Narrow Complex Tachycardia
Supraventricular Tachycardia
Atrial flutter
Ectopic atrial tachycardia
Junctional tachycardia
Atrial Fibrillation
Multifocat atrial tachycardia
Atrial flutter

Regular Irregular
These are advanced rhythms requiring additional expertise or expert
consultation
Narrow QRS, Regular Rhythm
The therapy for narrow QRS with regular rhythm is:
Attempt vagal maneuver
Give adenosine 6 mg as a rapid IV push in a large vein over 1 second follow with a 20
mL saline flush and elevate the arm immediately
If SVT does not convert within 1 to 2 minutes, give a second dose of adenosine 12 mg
rapid IV push following the same procedure above.
Adenosine is safe, but should not be given to patient with asthma.
IF the rhythm does not convert with adenosine, obtain expert consultation about
diagnosis and treatment.
AV Block high grade 2:1 dan 3 : 1
2:1
Complete AV Block
P-QRS disosiasi
 If at any point you become uncertain
or uncomfortable during the treatment
of a stable patient, seek expert
consultation. The treatment of stable
patients may await expert consultation
because treatment has the potential for
harm
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