Emergency

Aritmia Management
(Cardiac Arrest, Tachicardias, Bradicardias, STEMI)

Oleh :
Yudi Elyas
Disampaikan Pada Webinar Keperawatan MAHESA
13 Maret 2021
 Curiculum Vitae
Nama : Ns. Yudi Elyas, S.Kep
NIRA : 31730118302
Lama Bekerja : 16 Tahun
Riwayat Jabatan : 1. Ka. Ruang ICU bedah Jantung PJT RSCM
2. Supv. ICCU,ICU bedah jantung, RR PJT RSCM
Jabatan Saat ini : PJ Pelayanan Ruang Intensif RSCM Jakarta
Tlp / Instagram : 081316006831 / @YUDI ELYAS
Pendidikan :
• Ners FIK UI
• Pendidikan ICU Bedah Jantung (CCNP) Institute Jantung Negara (IJN) Malaysia
• Mahasiswa Magister Ilmu Keperawatan FIK UI
Pelatihan : Trainer : Organisasi :
• Kardiologi Dasar • BLS & ACLS Certified by AHA • PPNI
• Basic Trauma Cardiac Life Support • HIPERCCI DKI (Pengurus)
• Intensive Care Unit (ICU)
(BTCLS) • INKAVIN (Anggota)
• BLS & ACLS AHA 2015 • Pelatihan ICU (RSCM & HIPERCCI) • Provider BTCLS
• TOT BLS & ACLS AHA • Pelatihan Code Blue system di RS
• Asesor Keperawatan • Pelatihan Interpretasi EKG
• Seminar & Workshop Keperawatan
• TOT Keperawatan
 Lingkup Bahasan

Manajemen
Konsep Aritmia :
Sinus Aritmia : Aritmia : Artimia
dasar Cardiac
Rhythm Takikardia Bradikardi Pada Pasien
Aritmia Arrest
Covid-19
Gelombang EKG
 Karakteristik EKG Normal

• Impuls berasal dari SA Nodal

• Irama teratur
• Frekuensi jantung (HR) : 60 – 100 x/mnt
• Gel P Normal, setiap gel P diikuti gel QRS dan T
• Interval PR .0,12 – 0,20 detik
• Gel QRS 0.06 – 0,12 detik
• Semua gelombang sama

Irama EKG yang tidak memiliki kriteria diatas disebut

DISRITMIA atau ARITMIA
 Cardiac Rythm, How To Detec?

• Frekuensi HR (Cepat?,Normal?, Lambat?

Palpasi • Irama (Teratur?, Tidak Teratur?)

• Frekuensi HR (Cepat?,Normal?, Lambat?

Auskultasi • Irama (Teratur?, Tidak Teratur?)

• Frekuensi
EKG • Irama
• Jenis Aritmia
 Perhitungan
denyut nadi dilakukan
selama 1 menit

Arteri Karotis
Auskultasi
 Reguler
Irreguler

Tachicardi / Bradicardi
Interpretasi EKG ???

EKG
 ARHYTMIA
Gangguan Pada Sistem Konduksi Listrik jantung

1. Gangguan pembentukan impuls

2. Gangguan penghantaran impuls

 JENIS – JENIS ARITMIA
GANGGUAN PEMBENTUKAN IMPULS

SA NODE RHYTHM
SINUS BRADIKARDI

SINUS TAKIKARDI

SINUS ARITMIA

SINUS ARREST
ATRIAL RHYTHM
WANDERING ATRIAL
PACEMAKER (WAP)
PREMATUR ATRIAL
CONTRACTION (PAC)
ATRIAL TACHYCARDIA
SUPRAVENTRICULAR
TACHYCARDI (SVT)
ATRIAL FLUTTER

ATRIAL FIBRILASI (AF)

AV NODE RHYTHM

JUNCTIONAL RHYTHM

JUNCTIONAL TACHYCARDI
ACCELERATED
JUNCTIONAL RHYTHM
PREMATUR JUNCTIONAL
TACHYCARDI

JUNCTIONAL ESCAPE BEAT

 VENTRICULAR
ARRHYTHMIA

IDIOVENTRICULAR RHYTHM
ACCELERATED
IDIOVENTRICULAR RHYTHM
PREMATURE VENTRICULAR
CONTRACTION (PVC)
PVC BIGEMINY

PVC TRIGEMINY

VENTRICULAR TACHYCARDI

VENTRICULAR FIBRILASI
 JENIS – JENIS ARITMIA
GANGGUAN HANTARAN IMPULS

SA BLOCK

AV BLOCK DERAJAT 1
AV BLOCK DERAJAT 2
Type 1 & Type 2
AV BLOCK DERAJAT 3
Impuls yang berasal dari Inter Ventrikuler
 RBBB ( Right Bundle Branch Block )
 LBBB ( Left Bundle Branch Block )
- LPHB ( Left Posterior Hemi Block )
- LAHB ( Left Anterior Hemi Block )
 Bifasikuler Block
 Trifasikuler Block
Aritmia Emergency Management

Cardiac Arrest

Takikardia

Bradicardia
 Henti Jantung
Keadaan terhentinya aliran darah dalam sistem sirkulasi tubuh akibat
terganggunya efektivitas kontraksi jantung
 Cardiac Arrest / Henti Jantung
1. Pasien tidak sadar
2. Tidak ada nafas dan tidak teraba nadi
3. EKG:
Ventricular Fibrillation (VF)

Pulseless Ventricular Tachycardia (VT)

Pulseless electrical activity (PEA)

Asistole

Gbr EKG pada saat terjadi serangan jantung , sekitar 60%-70% adalah irama Ventricular Fibrilasi (VF)
 Henti Jantung
Shockable
DC Shock 360 J Not shockable
monofasik/200J bifasik Do chest compression
Chest compression

CPR
CPR
HIGH QUALITY CPR
 ANJURAN & LARANGAN
UNTUK CPR BERKUALITAS TINGGI

Anjuran Larangan
1. Kompresi dada dengan 1. Kompresi dada dengan
kecepatan 100 – 120x/ kecepatan < 100 x / mnt atau
menit
> 120 x/ menit
2. Kompresi dada dengan 2. Kompresi dada dengan
kedalaman minimal 2 inchi
(5 cm) kedalaman kurang dari 5 cm atau
lebih dari 6 cm
3. Dada rekoil penuh setelah 3. Bertumpu di atas dada di antara
setiap kali kompresi
kompresi yang dilakukan
4. Minimalkan jeda dalam 4. Kompresi berhenti lebih dari 10
kompresi
detik
5. Memberikan ventilasi yang 5. Memberikan ventilasi berlebihan
cukup (2 nafas buatan
setelah 30 kompresi, setiap (mis: terlalu banyak nafas buatan
1 nafas buatan (diberikan atau memberikan nafas buatan
dalam 1 detik inspirasi dan dengan kekuatan berlebihan)
1 detik ekspirasi ) cukup
sampai dada terangkat

Sumber: http://ecgguidelines.heart.org/wp-content/upload/2015-AHA-Guidelines-Highlights-Indonesia.pdf
Evaluasi High Quality CPR
Saat CPR Berlangsung...
1. Melihat kedalaman dan kecepatan kompresi
2. Perabaan nadi di arteri dorsalis pedis
3. Gelombang saturasi (Pulse Oximetry)
4. Gelombang arteri line (invasive Monitoring)

 .
Pulse Oximetry Waveform
X

Arterial waveform Probe saturasi

 SHOCK THERAPY
(Recommendation AHA 2015)

Patient Defibrilasi
(Asycronise)
Adult Bi phasic = 200 J
Monophasic = 360 J

Pediatrik 1st = 2 J/kg

2nd = 4 J / kg
Maks = 10 J/kg
Aba –aba saat akan melakukan
defibrilasi..Wajib.
 Shock First VS CPR First
 Henti jantung dewasa yang disaksikan / diketahui  Defibrillator
(AED) digunakan sesegera mungkin
 Henti jantung yang tidak diketahui / Defibrillator (AED)
belum siap Mulai CPR, jika indikasi dan alat sudah siap
maka lakukan defibrilasi sesegera mungkin
(Sumber: http://ecgguidelines.heart.org/wp-content/upload/2015-AHA-Guidelines-Highlights-Indonesia.pdf)

(Guidelines Update for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Care. Part 5-Circulation. 2015;132(suppl 2):S414–S435)
 DEFIBRILASI
Defibrilasi harus dilakukan dengan segera
dengan alasan:
1. Irama yang terjadi pada henti jantung
umumnya adalah VF
2. VF cenderung berubah menjadi asistol
dalam waktu beberapa menit
3. Pengobatan yang efektif untuk VF adalah
defibrilasi
4. Makin lambat defibrilasi dilakukan, makin
kurang kemungkinan keberhasilannya
DEFIBRILATION POSITION
SHOCK THERAPY
(AHA Recommendation )

Patient Defibrilasi
(Asyncronise)
Adult • Bi phasic = 200 J
• Monophasic = 360 J

Pediatrik • 1st = 2 J/kg

• 2nd = 4 J / kg
• Maks = 10 J/kg
 • Siapkan defibrilator
• Siapkan paddle
Langkah-Langkah • berikan Jelly
• Isi energi: CHARGE
• Stop CPR
• Tempel paddle
• I’m clear, you’re clear,
everybody’s clear
• Lakukan shock:
DISCHARGE
• Angkat paddle
• Lanjutkan CPR
• Evaluasi monitor
Tachicardias Rhythm
Contoh ….

VT

SVT

AF RR
Syncronized
Cardioversion
Doses
Sinus Bradikardia,
AV Nodal Bradikardia,
Block Rhythm
ST Elevasi Miokard
Infarct (STEMI)
Perubahan EKG : ST Changes

EKG Normal

STEMI
Lokasi Infark Miokard
 Management of Acute Myocardial Infarction

From: 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevationThe Task
Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of
Cardiology (ESC)
Eur Heart J. 2017;39(2):119-177. doi:10.1093/eurheartj/ehx393 Eur Heart J | © The European Society of Cardiology 2017.
 Manajemen Farmakologi

Anderson JL, et al. Circulation 2007;116(7):e148-e304; Gluckman TJ, et al. JAMA 2005;293(3):349-57; Hazinski MF, et al., editors. Handbook of emergency
cardiovascularcare for healthcare providers. Dallas: American Heart Association; 2008; Stringer KA, Lopez LM. Myocardial infarction. In: Wells BG, et al., editors.
Pharmacotherapyhandbook. 5th ed. New York: McGraw-Hill; 2003. p. 112-22.
AMI Management With STEMI

Balloning Stenting
 Reperfusion Strategy
According To Time From Symptoms Onset

2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation The Task Force for the
management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J.
2017;39(2):119-177.
AMI Management With STEMI
Terapi Fibrinolitik &
Kontraindikasi

Recomendation Class Level

Sumber :
2017 ESC Guidelines for the management of acute myocardial infarction in
patients presenting with ST-segment elevation The Task Force for the
management of acute myocardial infarction in patients presenting with ST-
segment elevation of the European Society of Cardiology (ESC). Eur Heart J.
2017;39(2):119-177.
Emergency Aritmia
Management
in Covid-19 Pandemic
 Cardiovascular
& Covid-19

Sumber :
European Society of cardiology. (2020). ESC Guidance for the Diagnosis
and Management of CV Disease during the COVID-19 Pandemic. European
Heart Journal, 1–115.
 Cardiovascular & Covid-19

Bansal, M. (2020). Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel
coronavirus COVID- 19 . The COVID-19 resource centre is hosted on Elsevier Connect , the company ’ s public news and information. 14(3), 247–250.
BLS & ACLS
In Covid-19.. ???

Edelson, D. P., Sasson,Topjian, A. A. (2020). Interim Guidance for Basic and Advanced Life
Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19: From
the Emergency Cardiovascular Care Committee and Get with the Guidelines-Resuscitation
Adult and Pediatric Task Forces of the American Heart Association. Circulation, E933–E943.
https://doi.org/10.1161/CIRCULATIONAHA.120.047463
 CPR in COVID-19 patients has a low
survival rate
• The overall 30-day survival rate for COVID-19 patients receiving CPR was 4 (2.9%)
patients, but only 1 (0.7%) had a favorable neurologic outcome at 30 days and just 18
(13.2%) patients achieved return of spontaneous circulation (ROSC). These figures are
from a study of 136 COVID-19 patients who received CPR at a hospital in Wuhan,
China.
• As is true in most studies of COVID-19, two-thirds of the patients were male, and 105
(77%) were greater than 60 years old. The arrest was due to respiratory issues in 119
patients, cardiac in 10, and other in 7.
• A rapid response team responded to all resuscitations—23 (17%) occurring in
intensive care units. In all, 132 had witnessed cardiac arrests. The initial rhythm
detected was asystole in 122 patients, ventricular fibrillation/tachycardia in 8, and
pulseless electrical activity (PEA) in 6;
• ROSC occurred in 11 (9%) with asystole, 6 (75%) with V fib/tach, and 1 (16.7%) with
PEA.
https://www.physiciansweekly.com/cpr-in-covid-19-patients-has-a-low-survival-rate/
CPR In Covid-19 Patient
With Mask
In Prone Position… How To Do CPR..??
 CPR in Prone Position

• 2010 AHA Guidelines (2015 AHA Not

Reviewed)
When the patient cannot be placed in the
supine position, it may be reasonable for
rescuers to provide CPR with the patient in
the prone position, particularly in
hospitalized patients with an advanced
airway in place
(Class IIb, LOE C-LD / Lemah,data terbatas).
 CPR in Prone Position
CPR
• 2 hands Together
• Put Hands on T 7 from scapula
• While performing a prone CPR, it is important to ensure high-
quality CPR

Defibrilator
• Defibrillator should be applied using maximum energy
discharge and should be shocked at the end of expiration
with the lowest positive end expiratory pressure to minimize
the chest impedance.
• One of which is the one electrode technique placed to the left
lower sternal border and the other posteriorly below the
scapula.
• Successful electrical defibrillation has been reported in
patients having spinal surgery in the prone position
Daftar Pustaka

Circulation. 2020;141:e933–e943. DOI:10.1161/CIRCULATIONAHA.120.047463

 Daftar Pustaka
1. Bansal, M. (2020). Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin
on the novel coronavirus COVID- 19 . The COVID-19 resource centre is hosted on Elsevier Connect , the company ’ s public news and
information. 14(3), 247–250
2. Bellomo R GD, Uchino S, Buckmaster J, Hart GK, Opdam H, et al. A prospective before-and-after trial of a medical emergency team.
MJA. 2003;179:283-7.
3. Chen J, Ou L, Hillman K, Flabouris A, Bellomo R, Hollis SJ Assareh H. Cardiopulmoary arrest and mortality trends and their association
with rapid response system expansion. MJA 2014; 201: 167-170
4. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms
5. Edelson, D. P., Sasson,Topjian, A. A. (2020). Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates
with Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get with the Guidelines-
Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation, E933–E943.
https://doi.org/10.1161/CIRCULATIONAHA.120.04746
6. European Society of cardiology. (2020). ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19
Pandemic. European Heart Journal, 1–115.
7. Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 5-Circulation. 2015;132 (suppl
2):S414–S435
8. http://ecgguidelines.heart.org/wp-content/upload/2015-AHA-Guidelines-Highlights-Indonesia.pdf
9. https://www.physiciansweekly.com/cpr-in-covid-19-patients-has-a-low-survival-rate/
10. M. SenthilVelou, E. Ahila (2020). Happy hypoxemia: What has been forgotten.IAIM, 2020; 7(8): 75-79.,
11. Tobin, M. J., Laghi, F., & Jubran, A. (2020). Why COVID-19 silent hypoxemia is baffling to physicians. American Journal of Respiratory
and Critical Care Medicine, 202(3), 356–360. https://doi.org/10.1164/rccm.202006-2157CP
TERIMAKASIH
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Email : yudielyas@gmail.com
IG : YUDIELYAS