ASSALAMUALAIKUM WR WB

Pradik 12 April 2011

SEGI PRAKTIS PENANGANAN KEGAWAT DARURATAN DI BIDANG JANTUNG

Dr. Suryono, SpJP. FIHA

Departemen Kardiologi dan Kedokteran Vaskular FK Unej-RSD Dr Soebandi Jember

Penyakit Jantung Penyebab Kematian No. 1 di Dunia

Penyakit Paru Kecelakaan

6.3 9 9.7

AIDS
Kanker Penyakit Infeksi Peny. Jantung
0 5

12.6
19.3 22.3
10 15 20 25 30

Penyebab Kematian (%)

1

The World Health Report 2001. Geneva. WHO. 2001.

KELUHAN DI BIDANG JANTUNG

Nyeri dada Sesak Nafas ~ eodema Berdebar Syncope DLL

 PJK merupakan penyakit jantung yang sangat penting Diderita oleh jutaan orang & Penyebab kematian utama

Di AS IMA baru 1/20 detik (1,5 juta/tahun) Dana yang dikeluarkan 14 milyar $ Di Indonesia

Penyebab kematian no 1 (survey Rumah Tangga, Dep.Kes. 1992)

Tenaga medis sering berhadapan dengan ACS

APA YG KITA LAKUKAN ??

Vital sign

EKG

Oksigen Aspirin Clopidogrel Nitrat Morfin

Symptom Call to Recognition Medical System

Prehospital

ED

CCU

Cath Lab

PUSKESMAS

Delay in initiation of Pharmacologic Reperfusion

Adjusted RR [95% CI]: 1.075 [1.01-1.16]

7.5% increased risk of death for each 30-min delay

De Luca, Suryapranata et al Circulation 2004

Every minute delay counts : not only for thrombolysis, but also for primary PCI

Time is Myocardium

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis: Door-to-Needle within 30 min.

Not PCI capable

Onset of symptoms of STEMI 9-1-1 EMS Dispatch

EMS on-scene
Encourage 12-lead ECGs. Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.

InterHospital Transfer

PCI capable

GOALS
5 min. Patient

8 min.
EMS

EMS Transport
Prehospital fibrinolysis EMS transport EMS-to-needle EMS-to-balloon within 90 min. within 30 min. Patient self-transport Hospital door-to-balloon within 90 min.

Dispatch 1 min.

Golden Hour = first 60 min.

Total ischemic time: within 120 min.

MANAGEMENT
Anti Ischemic Nitrate Morphine Sulfate Beta Blocker Calsium Channel Blocker

Antithrombotic & Anticoagulation Therapy

Aspirin, Ticlopidine, Clopidogrel, Gp IIb/IIIa inhib UFH/LMWH

Revascularization Strategy

Trombolitik / PCI /CABG

Statin ACE Inhibitor

CARDIOGENIC PULMONARY EDEMA

NONCARDIOGENIC PULMONARY EDEMA

History
Acute cardiac event Physical Examination Cardiac output state S3 gallop Jugular venous distention Crackles Underlying noncardiac disease (e.g., peritonitis) Laboratory Tests Electrocardiogram Chest x-ray Cardiac enzymes Pulmonary capillary pressure Intrapulmonary shunting Edema fluid/serum protein Ischemia/infarction Perihilar distribution May be elevated >18 mm Hg Small <0.5 Usually normal Peripheral distribution Usually normal <18 mm Hg Large >0.7 Low-flow state (cool periphery) Present Present Wet Usually absent High-flow state (warm periphery, bounding pulses) Absent Absent Dry Present Usually Uncommon (but possible)

DIAGNOSTICS OF ALO
Physical findings :
Tachypnea

and tachycardia Sitting upright, agitated Central cyanosis Very anxious and diaphoretic Hypertension due to hyperadrenergic state Rales +, ronchi & wheezing also maybe + S3 +, jugular venous distension +

Hypotension severe LV sistolic

dysfunction / cardiogenis shock If murmur + acute valvular disorders Skin parlor or mottling Hepatomegaly, hepatojugular reflux, and peripheral edema right heart failure Change in mental status severe ALO

Evolution of cardiogenic pulmonary edema

Alveoli

Alveoli

Alveoli

Hydrostatic

Pressure 18 mmHg

Hydrostatic Pressure > 25 mmHg

Capillary

Lumen

Capillary Lumen

Systemic Vens Pressure

Hydrostatic Pressure > 28-30 mmHg

Capillary Lumen

A. Interstitial Edema

B. Early Alveolar Edema C. Complete Alveolar Flooding Stage III

Stage II

APA YANG KITA LAKUKAN ??

Oksigen Nitrat Furosemit Morfin

Acute Clinical signs of Hypoperfusion / Hypotensi, Shock, Cong Heart failure , acute pulmonary edema Start IV Assess vital signs Order 12-lead ECG Pulmonary Assess ABCs Secure airways Attach Monitor, pulse oximeter, Review history Edema / Administer oxygen and automatic blood pressure Perform physical examination Order portable chest x-ray Hypotension / Shock Algorithm
Volume problem Pump problem Rate problem Administer Fluids Blood transfusion Cause-specific interventious Consider vasopressors, if indicated Systolic BP
<70 mm Hg Signs and symptoms of shock

What is the Blood pressure [BP]

Too Slow

Too Fast

Systolic BP 70-100 mm Hg
Signs and symptoms of shock

Systolic BP 70-100 mm Hg

No Signs and symptoms of shock

Systolic BP >100 mm Hg

No signs and symptoms of shock

Norepinephrine
0.5-30 ug/min IV or

Dopamine
5-20 ug/kg per min IV

Dobutamin

2 - 20 ug/min IV or

Nitroglycerin start 10-20 ug/min IV Consider : Nitroprusside 0.1-5.0 g/kg per min IV

Consider Further actions, especially if the patient is in acute pulmonary edema

First-line actions Furosemide IV 0.5-1.0 mg/kg Morphine IV 2-4mg Nitroglycerin SL Oxygen /intubate PRN Second-line actions Nitroglycerin IV if BP> 100 mm Hg Nitroprusside IV if BP> 100 mm Hg Dopamine if BP70 - 100 mm Hg Dobutamine if BP>100 mm Hg Positive end-expiratory pressure (PEEP) Continuous positive airway pressure (CPAP)

Further diagnostic / therapeutic considerations Pulmonary artery catheter Intra-aortic balloon pump Angiography for AMI / ischemia

Additional diagnostic studies

HEART FAILURE
Maintenance

Furosemit

Spironolacton ACE Inhb / ARB B Bloker

Nitrat Digitalis

Palpitasi : Sinus Takikardia Extra Systole Atrial Fibrilasi Supraventrikular Takikardia Ventrikel Takikardia

APA YANG KITA LAKUKAN ??

A-B-C-D EKG Call Expert

PENYEBAB TERSERING

Sick Sinus Syndrome Bradikardia Blok Dll

APA YANG KITA LAKUKAN ??

A-B-C-D EKG Call Expert

SERIOUS SIGNS OR SYMPTOMS ? Due to the bradycardia?

No
Type II second-degree AV block or Third-degree AV block?

Yes

Intervention Sequence Atropine 0.5 1.0 mg Transcutaneous pacing if available Dopamine 5-20 g/kg per minute Epinephrine 2-10 g/min Isoproterenol 2-10 g/min

No
Observe

Yes
Prepare for transvenous pacer If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed

PENYEBAB TERSERING

Noncardiac ??? Asystole Ventrikel Fibrilasi

APA YANG KITA LAKUKAN ??

A-B-C-D Call

Take Home Messages

Penyakit CV penyebab kematian no 1 di dunia Sarana kesehatan : ujung tombak dalam menurunkan angka kematian Perlu penanganan segera dgn cepat dan tepat Pemahaman dan keterampilan KGD dlm bidang CV menjadi sangat penting

Take Home Messages THANK YOU

Penyakit CV penyebab kematian no TERIMA KASIH

1 di dunia Sarana NUWUN kesehatan : ujung tombak MATUR dalam menurunkan angka kematian Perlu penanganan segera dgn SAKALANGKONG cepat dan tepat Pemahaman dan keterampilan KASOON dibidang Kegawat daruratan dlm bidang CV menjadi sangat penting
Mba Marijan

A. Even, terutama basal dan homogen dari dinding dada ke jantung dan perihiler pada edema kardiak B. Central, pada overhidrasi atau gagal ginjal C. Peripheral, patchy, sudut kostofrenik bebas, air bronchogram + , pada gangguan permeabilitas kapiler