PULSELESS VENTRICULAR

TACHYCARDIA & VENTRICULAR

FIBRILLATION (VT VF)

Dr. Abdul Hakim A SpJP

EKG: rekaman aktivitas listrik jantung
pada permukaan tubuh
PADA AKHIRNYA SETIAP KALI IMPULS YANG DITIMBULKAN OLEH
SA Node AKAN MENIMBULKAN DEPOLARISASI & KONTRAKSI
DARI KEDUA ATRIUM DAN KEDUA VENTRIKEL DAN TERBACA
SEBAGAI SATU GELOMBANG P-QRS-T YANG LENGKAP DAN
NORMAL
SISTEM KONDUKSI JANTUNG
 PEMBAGIAN ARITMIA
1. GANGGUAN PEMBENTUKKAN IMPULS / RANGSANG
A. G3 PEMBENTUKAN IMPULS DI ATRIUM
ST, SB, SINUS ARITMIA, SINUS ARREST
B. IMPULS ECTOPIC DI ATRIUM
PAT, AT, Af, AF
C. IMPULS ECTOPIC DI A-V JUNCTION : JUNCTIONAL
TACHY.
D IMPULS ECTOPIC DI VENTRIKEL
VES, VT, VF, VENTRICULAR ARREST
2. GANGGUAN PENGHANTARAN IMPULS/ GANGGUAN
KONDUKSI
A. SA BLOCK
B. AV BLOCK : FIRST ,SECOND, TOTAL AV BLOCK
C. INTRAVENTRICULAR BLOCK
RBBB, LBBB, LAHB, LPHB, BBBB
3. BENTUK-BENTUK CAMPURAN
 Causes Of Ventricular Tachycardias
Clinical Setting
Common Mechanisms
Structural heart disease
Reentry
Chroric ischemic heart disease
Acute ischemia and reperfusion Automatic, triggered activity, reentry
Dilated cardiomyopathy Reentry (bundle brunch), automatic, triggered
activity
Hypertrophic cardiomyopathy Triggered activity; reentry (?)
Right ventricular dysplasia Reentry ; triggered activity (?)
Congenital heart defects Automatic, reentry
Postsurgical correction of congenital heart defects Reentry

Channel abnormalities Triggered activity

Congenital long QT syndrome (torsades de Reentry ( ?: ventriculator refractory period
pointes) dispertion) ;triggered activity (?)
Brugadas syndrome (mono- or polymorphic VT)

Idiopathic Automatic
Right outflow tract VT
Automatic, reentry
Left posteroseptal VT Automatic
Other, less common locations

Drug induced Triggered activity

Acquire long QT (torsades de pointes) Triggered activity (?)
Digitalis toxicity (bidirectional tachycardia)
 VENTRICULAR TACHYCARDIA (VT)

SUATU ARITMIA YANG GAWAT

KRITERIA DIAGNOSIS :
- QRS lebar ( > 0.12 )
- QRS tidak berhubungan dengan gel P
- Rate biasanya 160 250 x/menit
Ventricular Tachycardia
Kompleks QRS

QRS SEMPIT

QRS LEBAR
+ ABBERANCY
 Broad Complex Tachycardia

REGULAR IRREGULAR

SVT WITH BBB AF WITH BBB

AF WITH AP
SVT WITH (PREEXCITED AF)
ABERRANT
TORSADES DE
SVT OVER AP POINTES

VT VF
Ventricular tachycardia,
all leads
 Wide Complex
Tachycardias: Stable
Must be regular and fast (>120)
Must be uniform (one QRS
morphology)
No signs of impaired perfusion
Mental status normal
No chest pain or CHF
Skin signs warm and dry
Systolic BP > 90 mm Hg

Obtain 12 lead ECG if stable

 Wide Complex
Tachycardias: Stable
Procainamide first line if ventricular function normal
(Sotalol) (IIa)
Amiodarone (IIb) (150mg over 10 minutes) or
Lidocaine (0.5-0.75mg/kg IV Push)if poor EF (<40%)
If ineffective:
Cardiovertion (100/200/300/360 joules)
No repeat drug doses recommended
Bottom line:
Normotensive: procainamide
Hypotensive: cardiovertion
 Evaluasi pasien
Apakah pasien stabil atau tidak stabil ?
Adakah keluhan/gejala serius ?
Apakah keluhan/gejala disebabkan oleh takikardi ?

STABIL : Tak ada keluhan/gejala serius TIDAK STABIL : Ada keluhan/gejala serius
Penilaian awal mengidentifikasi 1dari 4 Pastikan keluhan/gejala oleh karena
jenis takikardi takikardi
Keluhan/gejala serius jarang pada N < 150/1

1. Atrial fibrilasi 2. Takikardi dg 3. Takikardi dg QRS 4. VT monomorfik dan/

Atrial flutter QRS sempit lebar stabil : tipe tak polimorfik stabil
diketahui
 1. Atrial fibrilasi 2. Takikardi dg 3. Takikardi dg QRS 4. VT monomorfik dan/
Atrial flutter QRS sempit lebar stabil : tipe tak polimorfik stabil
diketahui

Fokus evaluasi 4 kondisi : Tegakkan dx spesifik : Tegakkan dx spesifik :

- Tidak stabil ? - EKG 12 lead - EKG 12 lead
- Fungsi jantung kurang ? - Informasi klinis - Lead esofageal
- Adakah WPW ? - Manuver Vagal - Informasi klinis
- Lamanya </> 48 jam ? - Adenosin

Fokus terapi tgt klinis: Hasil diagnosis : Terapi VT

- Bila tak stabil th/ segera - Ectopic atrial takikardi mono/polimorfik
- Kontrol kecepatan nadi - Multifokal atrial takikardi stabil (lihat
- Konversi ke irama sinus - Paroksismal supraventrikuler algoritme)
- Berikan antikoagulan takikardi (PSVT)

Dipastikan Taki dgn QRS Dipastikan

Terapi : Terapi : SVT SVT lebar tipe tak VT stabil
Atrial Fibrilasi jelas
Lihat Th/ takikardi
Atrial Flutter dgn QRS sempit
Lihat tabel
- DC kardioversi/ -DC kardioversi/
- Prokainamid/ -Amiodaron EF < 40%
Fungsi jantung normal
- Amiodaron
 Polymorphic V-tachycardia
Recurrent bouts
Usually terminate spontaneously, or
Degenerate into V-fibrillation
Stop offending meds that prolong QT
interval
Correct hypocalcemia/hypomagnesemia
Magnesium 2-4 grams IV Push (shortens QT)
Transcutaneous pacer (overdrive pacing)
Rate >100 if no ischemia
Shortens QT, reduces recurrence
 VENTRICULAR FIBRILLATION

Aritmia paling gawat

Klinis = cardiac arrest / tidak ada CO
Kriteria diagnosis
-QRS menjadi undulasi-undulasi yang tak
teratur konfigurasinya dan intervalnya
- rate sangat bervariasi , 150-500/menit
Ventricular fibrillation,
all leads
 V-fib/Pulseless V-tach

This is emergency situation

Defibrilation three times ASAP (200/300/360)
A B Cs
Epinephrine 1mg IV Push every 3-5 minutes,
or
Vasopressin 40 units IV Push, once
then Epinephrine same as usual
Amiodarone (IIb) 300mg IV Push
(second dose if recurrent V-fibrillation 150 mg)
 ECG distinction of VT from SVT with aberrancy

1. Absence of RS complexs in all prcordial leads ?

Yes VT No

2. R to S interval greater than 100 ms in all precordial leads ?

Yes VT No

3. AV dissociation ?

Yes VT No

4. Morphology criteria for VT if LBBB or RBBB in V1 and V6 ?

LBBB

RBBB