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SEGI PRAKTIS PENANGANAN

KEGAWAT DARURATAN DI BIDANG


JANTUNG

Dr. Suryono, SpJP. FIHA


DepartemenKardiologidanKedokteranVaskularFKUnejRSDDrSoebandi
Jember

Penyakit Jantung
Penyebab Kematian No. 1 di Dunia

Penyakit Paru

6.3

Kecelakaan

AIDS

9.7

Kanker

12.6
19.3

Penyakit Infeksi
Peny. Jantung

22.3
0

10

15

Penyebab Kematian (%)


1

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

20

25

30

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

sing
a
e
r
Inc

of
s
s
Lo

tes
y
c
Myo

Delay in initiation of Pharmacologic


Reperfusion

AdjustedRR[95%CI]:
1.075[1.011.16]

7.5%increasedriskofdeathforeach30mindelay

De Luca, Suryapranata et al Circulation 2004

Everyminutedelaycounts:notonlyforthrombolysis,butalsoforprimaryPCI

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.

GOALS

5
min.
Patient

8
min.
EMS

Dispatch
1 min.

InterHospital
Transfer

EMS
Triage
Plan

PCI
capable

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.

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

Usually

Uncommon (but possible)

Cardiac output state

Low-flow state (cool


periphery)

High-flow state (warm periphery,


bounding pulses)

S3 gallop

Present

Absent

Jugular venous distention

Present

Absent

Crackles

Wet

Dry

Underlying noncardiac disease


(e.g., peritonitis)

Usually absent

Present

Electrocardiogram

Ischemia/infarction

Usually normal

Chest x-ray

Perihilar distribution

Peripheral distribution

Cardiac enzymes

May be elevated

Usually normal

Pulmonary capillary pressure

>18 mm Hg

<18 mm Hg

Intrapulmonary shunting

Small

Large

Edema fluid/serum protein

<0.5

>0.7

Physical Examination

Laboratory Tests

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

Hydrostatic

Pressure
18 mmHg

Capillary

Lumen

A. Interstitial Edema

Alveoli

Stage II

Alveoli

Hydrostatic Pressure
> 25 mmHg

Capillary Lumen

Systemic
Vens
Pressure

Hydrostatic Pressure
> 28-30 mmHg

Capillary Lumen

B. Early Alveolar Edema C. Complete Alveolar Flooding


Stage III

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
airways
Attach Monitor, pulse oximeter, Review history
Order portable chest x-ray
Edema / Secure
Administer oxygen
and automatic blood pressure Perform physical examination
Hypotension /
Shock
Algorithm
Volume problem

Pump problem

Administer Fluids Blood transfusion


Cause-specific interventious
Consider vasopressors, if indicated
Systolic BP

<70 mm Hg
Signs and symptoms of shock

Norepinephrine
0.5-30 ug/min IV or

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

Dopamine
5-20 ug/kg per min IV

Systolic BP 70-100 mm Hg

No Signs and symptoms of shock

Dobutamin

2 - 20 ug/min IV or

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

What is the
Blood
pressure [BP]

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)

Rate problem

Too Slow

Too Fast

Systolic BP >100 mm Hg

No signs and symptoms of shock

Nitroglycerin start 10-20 ug/min IV


Consider :
Nitroprusside 0.1-5.0 g/kg per min IV

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

Yes

No
Observe

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

TERIMA KASIH