PREHOSPITAL

MANAGEMENT OF ACS
7th Surabaya Cardiology update

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Spectrum Acute Coronary Syndrome

Acute coronary
syndromes
• Unstable angina
• NSTEMI
• STEMI
Pathophysiology

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4
Reperfusion Therapy

Percutaneous Coronary
transluminal coronary artery bypass
Thrombolysis angioplasty
graft surgery
(PTCA)
(CABG)

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Primary angioplasty

Having a number of advantages over thrombolysis,

including lower risk of haemorrhagic incident and
improved conditions for coronary assessment

When time to in hospital treatment is short, PTCA

should be the treatment of choice

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Thrombolytic agents

Lysis of the occlusion, removal of the obstruction, and

restoration of blood flow to the ischaemic myocardium.

Thrombolytic agents

• streptokinase
• tissue plasminogen activator alteplase
• anistreplase
• urokinase

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 12 lead electrocardiography

Electrocardiography is the key diagnostic tool to determine

eligibility for acute reperfusion interventions

Ambulance service paramedics use 12 lead electrocardiography

to assist with early diagnosis of AMI, in one of two ways.
• The 12 lead electrocardiogram (ECG) is transmitted to a doctor who makes a
diagnosis (and may communicate this diagnosis back to the ambulance crew)
• Ambulance paramedics are trained to interpret the ECG themselves

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 Early reperfusion :
“Time is Muscle-muscle is life”
Time-Dependent
Time-Dependent Benefit
Benefit of
of Reperfusion
Reperfusion Therapy
Therapy Importance of Time-to-Treatment: Results of GUSTO-I

100 Reimer/Jennings 1977 12

Bergmann 1982
80

30-Day Mortality ( %)
GISSI-I 1986 10
% Benefit

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60
6
40 2=149 (1 df )
4
20 2

0 0
0 1 2 3 4 5 6 7 8 9 10 11 12
0 2 4 6 8 10 12
Reperfusion Time (hours) Time From Onset of Symptoms to Treatment (hours)
Ada pte d from Tiefenbr unn AJ, Sobel BE . Circu latio n. 1992 ;85 :231 1-2315 . Adapted fr om Lee KL , et al. Circulation. 1995;91:1659- 1668.

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 TIME IS MUSCLE, MUSCLE IS TIME

Prehospital provider play a

critical role
Vital link in the life line 24/7 PCI capable centre
What Does the Guideline says?
Pre Hospital Care Recommendation
 REPERFUSION STRATEGY

ESC STEMI 2012 13

Reperfusion Strategis within 12 hour of FMC
Pre-Hospital Management
Oxygen by nasal cannula  if hypoxemia is present
Aspirin : 160-325 mg
Sublingual nitroglycerine  followed by IV infusion if needed
Intravenous betablockers decrease myocardial oxygen demand,
control chest pain and reduce mortality)
Morphine for pain relief  given IV in small doses
Enhanced ACS management in dr ISKAK
Hospital Tulungagung

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What we have done now

TEMS
(Tulungagung Emergency Medical Service)
0355-320119

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 Demografis

luas wilayah 1.055,65

km2 memiliki 19
kecamatan yang terbagi
kedalam 257 desa dan
14 kelurahan.
31 Puskesmas itu ada
14 Puskesmas
perawatan
Fasilitas kesehatan
sekitar RS ISKAK

tulungagung.go.id
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 Proposed ACS
pathway Prehospital
management

Hospital
management

Model of ACS management in 19

Australia, 2009
Enhanced strategy Prehospital management of ACS
- Education (brochure,
counseling, on air radio
counseling, PHC and
clinic propagation)
Metropolitan: - Department of health
- Call for TEMS and hospital networking
- Directly to
hospital

Rural /teritorial :
- Consultation
using
phone/whatsapp
- Thrombolytic
prehospital

Model of ACS management in 20

Australia, 2009
 TRIAGE PRE-HOSPITAL PASIEN INFARK MIOKARD AKUT

TULUNGAGUNG CARDIOVASCULAR CARE UNIT NETWORK SYSTEM

Nama :

Tanggal lahir/usia :

Nama fasilitas pelayanan kesehatan primer :

SKA
(Waktu) (tanggal,jam : Menit) Keluhan utama : Riwayat Medis dan Pengobatan

Awal timbul gejala :

Meminta pertolongan medis :

Jam ambulans tiba/sampai di IGD :

Jam ambulans berangkat merujuk :

Team
Jam berangkat sendiri ke RS :

Jam pasien tiba di RS : Pemeriksaan Fisik : Kesadaran : TD : / mmHg

Jam mentransmit EKG : Denyut jantung : x/menit Laju nafas : x/menit

Irama : SR/Sinus Tachycardia/SB/AF/SVT/VT/VF/AV Block

was
Seorang pasien dengan keluhan nyeri dada /

rasa tidak nyaman di dada Heart Line :

Fax :

Rekam EKG 12 sandapan Email :

formed
BBM :

Transmit EKG ke Heart line WhatsApp :

di RSUD dr. Iskak Tulungagung Direct Line :

in jan
EKG normal atau Dijumpai elevasi segmen ST ; Dijumpai LBBB, RBBB

tanpa elevasi segmen ST inferior : II, III, aVF atau irama pacu jantung

lateral : I, aVL, V1-V6

anterior : V2-V4

Konsultasikan ke Heart Line anterior ekstensif : I, aVL,V1-V6

2016
Rujuk ke RS primer atau PCI Center posterior : V7-V9 atau ST depresi di V1-V2

Onset gejala </= 12 jam Onset gejala > 12 jam

O2 nasal 3-4 L/menit O2 nasal 3-4 L/menit

Tablet nitrat 5 mg SL Tablet nitrat 5 mg SL

Aspilet 160-320 mg dikunyah Aspilet 160-320 mg dikunyah

Clopidogrel 300-600 mg p.o Clopidogrel 300-600 mg p.o

Rujuk ke PCI center untuk primary PCI, jika Rujuk ke PCI center untuk evaluasi

estimasi waktu antara FMC sampai tindakan

kateterisasi ( balonisasi ) < 120 menit.

Jika tidak, diberi terapi fibrinolitik

Petugas :

Tanda tangan :

Keterangan :

IGD = instalasi gawat darurat,RS = rumah sakit,EKG = elektrokardiografi,TD = tekanan darah,SR = sinus rhytm,SB = sinus bradycardia,

AF = atrial fibrilation,SVT = supra-ventricular tachycardia,VT = ventricular tachycardia,VF = ventricular fibrillation,AV = atrioventricular,

RBBB = right bundle branch block, LBBB = left bundle branch, PCI = percutaneous coronary intervention, FMC = first medical contact,
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p.o = per os(oral), SL = sublingual. Lembar asli dikirim kre RS rujukan, lembar copy di tinggal di RS asal
 TRIAGE PRE-HOSPITAL PASIEN INFARK MIOKARD AKUT
TULUNGAGUNG CARDIOVASCULAR CARE UNIT NETWORK SYSTEM

Menit
(Waktu) (tanggal,jam : ) Keluhan utama : Riwayat Medis dan Pengobatan
Awal timbul gejala :
Meminta pertolongan medis :
Jam ambulans tiba/sampai di IGD :
Jam ambulans berangkat merujuk :
Jam berangkat sendiri ke RS :
Jam pasien tiba di RS : Pemeriksaan Fisik : Kesadaran : TD : / mmHg
Jam mentransmit EKG : Denyut jantung : x/menit Laju nafas : x/menit
Irama : SR/Sinus Tachycardia/SB/AF/SVT/VT/VF/AV Block

Seorang pasien dengan keluhan nyeri dada /

rasa tidak nyaman di dada Heart Line :
Fax :
Rekam EKG 12 sandapan Email :
BBM :
Transmit EKG ke Heart line WhatsApp :
di RSUD dr. Iskak Tulungagung Direct Line :
Continue
EKG normal atau
tanpa elevasi segmen ST
Konsultasikan ke Heart Line
Rujuk ke RS primer atau PCI Center
Dijumpai elevasi segmen ST ; Dijumpai LBBB, RBBB
inferior : II, III, aVF atau irama pacu jantung
lateral : I, aVL, V1-V6
anterior : V2-V4
anterior ekstensif : I, aVL,V1-V6
posterior : V7-V9 atau ST depresi di V1-V2
Onset gejala </= 12 jam Onset gejala > 12 jam
O2 nasal 3-4 L/menit O2 nasal 3-4 L/menit
Tablet nitrat 5 mg SL Tablet nitrat 5 mg SL
Aspilet 160-320 mg dikunyah Aspilet 160-320 mg dikunyah
Clopidogrel 300-600 mg p.o Clopidogrel 300-600 mg p.o
Rujuk ke PCI center untuk primary PCI, Rujuk ke PCI center untuk
jika evaluasi
estimasi waktu antara FMC sampai tindakan
kateterisasi ( balonisasi ) < 120 menit.
Jika tidak, diberi terapi fibrinolitik
 STEMI registry RS ISKAK jan-Aug 2016
25 300

250
20

200

15

150

10

100

5
50

0 0
jan feb mar apr may june july aug

thrombolytic door to needle nonthrombolytic PPCI door to device

Left vertical = patients number, right vertical number = time in second 24

CASE PASIEN STEMI DI RS DR. ISKAK
TULUNGAGUNG
Dr. Evit Ruspiono, SpJP
Jumlah Puskesmas: 31
Identitas Pasien

• Tn. M / 61 tahun
• Faktor resiko : smoker,
Hipertensi
• 06.00 : Nyeri dada kiri
tembus ke punggung dan
menjalar ke lengan kiri.
• Pasien ke Puskesmas
Ngunut pk 07.00 karena
nyeri dada tidak hilang
• 07.45 : ECG dan terapi
double antiplatelet
• 09.40 : Red Zone IGD
RSU Dr. Iskak,
Tulungagung
• 10.30 : Pasien diantar ke
Cathlab
• 11.00 : PCI dimulai
Red Zone IRD RS Dr. Iskak

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ECG tiba di RS Dr. Iskak
Cath Lab RS Dr. Iskak

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PRE PCI POST PCI
ICCU RS Dr. Iskak

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 Jumlah tindakan PCI
01 Januari 2016 s/d 31 September 2016

PCI PPCI
118 pasien 22 pasien

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Thank you

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