bradikardi, acs

7/25/2019 bradikardi, acs

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By: Varla Septrinidya Gharatri

(405090215)


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Occurs as a result of a ultitude ofcardio!ascular" eta#olic" infectious"neurolo$ic" inflaatory" % trauaticdiseases&

Se!eral specific causes: dru$ to'icity"yocardial ischeia" hyperaleia" torsadesde pointes" cardiac taponade"% tension

pneuothora'&


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cti!ate *+S or the desi$nated code tea&

,erfor #asic life support (-,.)&

*!aluate heart rhyth and perfor early

defi#rillation as indicated& /eli!er ad!anced life support (e&$&"

intu#ation" intra!enous access" transfer to aedical center intensi!e care unit)&


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-onduct a priary B-/ sur!ey,lace airay de!ice as soon as possi#le&

-onfir placeent" secure de!ice" and confiro'y$enation and !entilation&

*sta#lish V access" identify rhyth" andadinister dru$s appropriate for rhyth andcondition&

Search for and treat identified re!ersi#le causes"ith focus on #asic -,. and early defi#rillation&


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On arri!al to an unitnessed cardiac arrestor dontie lon$er than 4 inutes" fi!e

cycles (appro'iately 2 inutes) of -,. areto #e initiated #efore e!aluation of rhyth& f the cardiac arrest is itnessed or dontie is

shorter than 4 inutes" one shoc ay #eadinistered iediately if the patient is in

!entricular fi#rillation or pulseless !entriculartachycardia&


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f the patient is in !entricular fi#rillation or

pulseless !entricular tachycardia" shoc thepatient once usin$ 200 3 on #iphasic (oreui!alent onophasic" 60 3)&

.esue -,. iediately after attepted

defi#rillation" #e$innin$ ith chestcopressions&.escuers should not interrupt chest copression

to chec circulation (e&$&" e!aluate rhyth or

pulse) until fi!e cycles or 2 inutes of -,. ha!e#een copleted&


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f there is persistent or recurrent !entricular

tachycardia or !entricular fi#rillation despitese!eral shocs and cycles of -,." perfor asecondary B-/ sur!ey ith a focus on oread!anced assessents and pharacolo$ic

therapy&,haracolo$ic therapy should include

epinephrine (17$ V push" repeated e!ery to 5inutes) or !asopressin (a sin$le dose of 40 8 V"

one tie only)&


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-onsider usin$ antiarrhythics for persistentor recurrent pulseless !entricular tachycardiaor !entricular fi#rillation&hese include aiodarone" lidocaine" a$nesiu

(if there is a non hypoa$neseic state)" andprocainaide (class indeterinate for persistentand -lass # for recurrent)&

.esue -,. and attepts to defi#rillate&


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ssess the patient and conduct a priaryB-/ sur!ey&

.e!ie for the ost freuent causes of

pulseless electrical acti!ity" the fi!e s andfi!e s:ypo!oleia" hypo'ia" hydro$en ion (acidosis)"

hyperaleia (or hypoaleia)" and hypotheriaand ta#lets (dru$ o!erdose" accidents)

aponade (cardiac)" tension pneuothora'"thro#osis (coronary)" and thro#osis(pulonary e#olis)&


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dinister epinephrine (17$ V pushrepeated e!ery to 5 inutes) or atropine (1$ V if the heart rate is slo" repeatede!ery to 5 inutes as needed" to a totaldose of 0&04 $$)&

-onduct a secondary B-/ sur!ey&


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/eterine hether the #radycardia is slo(heart rate less than 60 #eatsin) orrelati!ely slo (heart rate less than e'pectedrelati!e to underlyin$ condition or cause)&

-onduct a priary B-/ sur!ey&

-hec for serious si$ns or syptos caused#y the #radycardia&

f no serious si$ns or syptos are present"

e!aluate for a type second7de$reeatrio!entricular #loc or third7de$reeatrio!entricular #loc&


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f neither of these types of heart #loc is

present" o#ser!e& f one of these types of heart #loc is present"

prepare for trans!enous pacin$& f syptos de!elop" use a transcutaneous

paceaer until the trans!enous pacer is placed&

f serious si$ns or syptos are present" #e$inthe folloin$ inter!ention seuence: tropine" 0&5 up to a total of $ V ranscutaneous pacin$" if a!aila#le

/opaine" 5 to 20 c$$in *pinephrine" 2 to 10 c$in soproterenol" 2 to 10 c$in



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-onduct a priary B-/ sur!ey&

,erfor transcutaneous pacin$ iediately

if needed&

-onsider trans!enous pacin$ if transcutaneouspacin$ fails to capture&

dinister epinephrine (17$ V push"

repeated e!ery to 5 inutes) or atropine (1

$ V repeated e!ery to 5 inutes" up to atotal of $)&


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f asystole persists" consider ithholdin$ or

ceasin$ resuscitati!e efforts&


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dia$nostic tool that is

routinely used to assessthe electrical anduscular functions of theheart&

he electrocardio$racan easure the rate andrhyth of the heart#eat&


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Raterefers to ho fast the heart #eats&


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he , a!e loos at the atria&

he =.S cople' loos at the !entricles

he a!e e!aluates the reco!ery sta$e of

the !entricles hile they are refillin$ ith#lood&

he tie it taes for electricity to tra!el

fro the S node to the V node is easured

#y the ,. inter!al&


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he =.S inter!al easures electrical tra!el

tie throu$h the !entricles

he = inter!al easures ho lon$ it taes

for the !entricles to reco!er and prepare to#eat a$ain&


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normal sinus rhythmeach P wave is followed by a QRS

P waves normal for the subject

P wave rate 60 - 100 bpm with


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normal P waveshei%ht < &'( mm in lead ))

width < 0'11 s in lead )) for abnormal P waves see ri%ht atrial hypertrophy*

left atrial hypertrophy* atrial premature beat*hyper+alaemia

normal PR interval

0'1& to 0'&0 s , - ( small s.uares/ for short PR se%ment consider

olff-Par+inson-hite syndromeorown-2anon%-evine syndrome,other causes -3uchenne muscular dystrophy* type )) %lyco%en

stora%e disease ,Pompe4s/* 578/ for lon% PR interval see first de%ree heart bloc+and

4trifasicular4 bloc+
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normal QRS comple$ < 0'1& s duration , small s.uares/

for abnormally wide QRS consider ri%htor leftbundlebranch bloc+* ventricular rhythm* hyper+alaemia* etc'

no patholo%ical Q waves no evidence of leftor ri%htventricular hypertrophy

normal Q9 interval 7alculate the corrected Q9 interval ,Q9c/ by

dividin% the Q9 interval by the s.uare root of the

preceedin% R - R interval' :ormal ! 0';& s' 7auses of lon% Q9 interval myocardial infarction* myocarditis* diffuse myocardial

disease hypocalcaemia* hypothyrodism subarachnoid haemorrha%e* intracerebral haemorrha%e

dru%s ,e'%' sotalol* amiodarone/ hereditaryRomano ard syndrome,autosomal dominant/ervill = an%e :ielson syndrome ,autosomal

recessive/ associated with sensorineural deafness
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normal S9 se%mentno elevation or depression

causes of elevation include acute 8) ,e'%' anterior*inferior/* left bundle branch bloc+* normal variants

,e'%' athletic heart* >dei+en pattern* hi%h-ta+e off/*acute pericarditis

causes of depression include myocardial ischaemia*di%o$in effect* ventricular hypertrophy*acute posterior 8)* pulmonary embolus*

left bundle branch bloc+
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normal 9 wave causes of tall 9 waves include hyper+alaemia*

hyperacute myocardial infarctionandleft bundle branch bloc+

causes of small* flattened or inverted 9 waves arenumerous and include ischaemia* a%e* race*hyperventilation* an$iety* drin+in% iced water* ?5*dru%s ,e'%' di%o$in/* pericarditis*P>* intraventricularconduction delay ,e'%' R@@@/and electrolyte

disturbance' normal A wave
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.efers to a spectru of clinical presentations

ran$in$ fro those for S7se$ent ele!ationyocardial infarction (S*+) topresentations found in non>S7se$entele!ation yocardial infarction (


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cute coronary syndroe (-S) is causedpriarily #y atherosclerosis&

he !ulnera#le plaue is typified #y a lar$e lipidpool" nuerous inflaatory cells" and a thin"

fi#rous cap& *le!ated deand can produce -S in the

presence of a hi$h7$rade fi'ed coronaryo#struction" due to increased yocardial o'y$enand nutrition reuireents" such as those

resultin$ fro e'ertion" eotional stress" orphysiolo$ic stress (e$" fro dehydration" #loodloss" hypotension" infection" thyroto'icosis" orsur$ery)&


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-?SS 1


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,ain occurrin$ at rest > duration E 20in" ithin one eeof first !isit

F -lass 2 se!erity" onset ith last 2onths

@orsenin$ of chest pain > increase #y at least 1 class"increases in freuency" duration

n$ina #ecoin$ resistance to dru$s that pre!iously $a!e$ood control&

noral" S depression(E0&5)" a!e chan$es


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*---- /*< >rise and fall in cardiac enHyes ith oneor ore of the folloin$: schaeic type chest painsyptos

*-G chan$es > S chan$es" patholo$ical = a!es

-oronary artery inter!ention data

,atholo$ical findin$s of an acute +


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/istruption of coronary arteryplaue 7E plateletacti!ationa$$re$ationacti!ation of coa$ulationcascade 7E endothelial

!asoconstriction 7Eintraluinalthro#use#olisation 7Eo#struction 7E -S

Se!erity of coronary !esselo#struction % e'tent of

yocardiu in!ol!eddeterines characteristics ofclinical presentation


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dentifyin$ those ith chest pain su$$esti!e of /-S&

horou$h history reuired:

-haracter of pain

Onset and duration

?ocation and radiation $$ra!atin$ and relie!in$ factors

utonoic syptos

A,-? VS A,-? SO.A ailure to reco$nise syptos other than chest pain 7E

appro' 2 hr delay in seein$ edical attention


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-.-*.S- S8GG*SV* O


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.SC -O.S O. /*V*?O,


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,alpitations

,ain" hich is usually descri#ed as pressure"sueeHin$" or a #urnin$ sensation across theprecordiu and ay radiate to the nec"shoulder" Na" #ac" upper a#doen" oreither ar

*'ertional dyspnea that resol!es ith pain orrest

/iaphoresis fro sypathetic dischar$e


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ypotension 7 ndicates !entricular dysfunctiondue to yocardial ischeia" infarction" or acute!al!ular dysfunction

ypertension 7 +ay precipitate an$ina or reflect

ele!ated catecholaine le!els due to an'iety orto e'o$enous sypathoietic stiulation /iaphoresis ,ulonary edea and other si$ns of left heart

failure *'tracardiac !ascular disease 3u$ular !enous distention -ool" clay sin and diaphoresis in patients

ith cardio$enic shoc


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he dia$nosis of acute yocardial infarctioncan #e ade if orup re!eals the typicalrise and fall of #iocheical arers ofyocardial necrosis alon$ ith either the

de!elopent of patholo$ic = a!es or thepresence (on *-G or in the settin$ of acoronary inter!ention) of ischeic S7se$ent chan$es


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-han$es that ay #e seen durin$ an$inal

episodes include the folloin$:ransient S7se$ent ele!ations

/ynaic 7a!e chan$es 7 n!ersions"

noraliHations" or hyperacute chan$es

S depressions 7 +ay #e Nunctional" donslopin$"

or horiHontal


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/*? +.C*.: i$h concentration in yocardiu

+yocardiu specific

.eleased early in inNury

,roportionate to inNury


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7hest radio%raphy helps in assessin$

cardioe$aly and pulonary edea" or it ay

re!eal coplications of ischeia" such as

pulonary edea&

>chocardio%ramsay play an iportant rolein the settin$ of -S&

Radionuclide myocardial perfusion ima%in%

has #een shon to ha!e fa!ora#le dia$nostic

and pro$nostic !alue in the eer$ent settin$"

ith an e'cellent early sensiti!ity in the

detection of acute yocardial infarction not

found in other testin$ odalities&


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7ardiac catheteriBation helps in definin$coronary anatoy and the e'tent of a

patients disease&

7omputed 9omo%raphy 7oronaryCn%io%raphy and 79 7oronary Crtery7alcium Scorin%his technolo$y allos for nonin!asi!e and early

dia$nosis of -/ and thus earlier treatent

#efore the coronary arteries #ecoe ore or

copletely occluded&


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n'iety ortic Stenosis stha -ardioyopathy" /ilated *sopha$itis Gastroenteritis ypertensi!e *er$encies in *er$ency

+edicine +yocardial nfarction +yocarditis ,ericarditis and -ardiac aponade


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nitial therapy for acute coronary syndroeshould focus on sta#iliHin$ the patientPscondition" relie!in$ ischeic pain" andpro!idin$ antithro#otic therapy to reduce

yocardial daa$e and pre!ent furtherischeia&

Pharmacolo%ic Cnti-ischemic 9herapy


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Pharmacolo%ic Cntithrombotic 9herapyspirin" -lopido$rel" ,rasu$rel" ica$relor"

#ci'ia#" *pitifi#atide" irofi#an"

Pharmacolo%ic Cnticoa%ulation 9herapy8nfractionated heparin" ?o olecular ei$ht

heparin" actor Da inhi#itors&

hro#olysis

-oronary nter!entions -oncoitant therapy


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*ducate patients a#out the dan$ers ofci$arette soin$" a aNor ris factor forcoronary artery disease (-/)&

,atients should #e infored a#out the#enefits of a lo7cholesterol" lo7salt diet&

n addition" educate patients a#out dietary $uidelines re$ardin$ a lo7fat" lo7cholesterol diet&


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he folloin$ eonic ay useful ineducatin$ patients ith -/ re$ardin$treatents and lifestyle chan$esnecessitated #y their condition: I spirin and antian$inals

B I Beta #locers and #lood pressure (B,)

- I -holesterol and ci$arettes

/ I /iet and dia#etes

* I *'ercise and education


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-oplications of ischeia include pulonaryedea" hile those of yocardial infarctioninclude rupture of the papillary uscle" left!entricular free all" and !entricular

septu&


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Si'7onth ortality rates in the Glo#al.e$istry of cute -oronary *!ents (G.-*)ere 1M for patients ith


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-ardiac arrest is the a#rupt loss of heart

function in a person ho ay or ay not

ha!e dia$nosed heart disease&

t occurs instantly or shortly after syptos

appear&


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he freuency of sudden cardiac arrest isrelated to the freuency of coronary arterydisease&

f pu#lic health initiati!es or to decrease

ris the factors for heart disease" the ris forsudden death should decrease as ell&


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bradikardi, acs