Acute Pulmonary Edema and

Emergency Arrhythmias in

ACS

Jetty RH Sedyawan SpJP KDepartemen Kardiologi dan Kedokteran Vaskuler FKUI

Edema Paru Akut(subset klinik dari gagal jantung akut)

• Distress pernafasan yang berat

• Crakles diseluruh lapang paru

• Orthopnoea

• Saturasi O2 < 90% pada udara kamar

Faktor pencetus

• Kepatuhan minum obat rendah

• Tatalaksana sub optimal

• Infeksi

• Surgery

• Lain-lain

IskemiaAritmia

How should I assess patients in acute heart failure?

1. Volume status and tissue perfusion:cold or warm, wet or dry. [IIa C]

2. A precipitating cause : complete blood count, serum creatinine, electrolytes, troponins,

ECG, chest x ray and an echocardiogram. [ I, C]

3. Blood brain Natriuretic Peptide (BNP) or N-terminal proBNP (NT-proBNP) if the diagnosis is in doubt. [I, A]

4. Monitor heart rate, BP and oxygen saturation . [IIa, C]

5. Monitor fluid balance, urine output, renal function and laboratory especially when the patient is in shock. [I, C]

6. Inserting an arterial line and a central venous pressure lineif the patient is in cardiogenic shock or for those who require pressors. [II b, C]

Assess the patient’s:

Canadian Journal of Cardiology, 23(1), 21-45. Dec, 2007

What are important acute heart failure treatment

considerations?

1. Correct precipitating causes of acute heart failure promptly. [I,B]

2. Oxygen. [I,C]

3. Support ventilation with (CPAP), bilevel positive airway pressure (BIPAP) or

endotracheal intubation if hypoxemia persists. [IIa,B]

4. Treat volume overload with i.v. diuretics. [I,B]

5. Vasodilators for patients with dyspnea at rest. [I,C]

6. Inotropes: cardiogenic shock or volume overload with diuretic resistance.[I,C]

7. ACE inhibitors until the patient is stabilized. [I,B]

8. Intra-aortic balloon pump (IABP) in patients with refractory heart failure despite

medical therapy. [IIb,B]

Arrhythmias

Canadian Journal of Cardiology, 23(1), 21-45. Dec, 2007

• Ventricular fibrillation

Or

Pulseless

ventricular

tachycardia

Defibrillate with 360J (preferably by biphasic defibrillation with a maximum of 200 J).

If refractory to initial shocks inject:

epinephrine 1 mg or

vasopressin 40 IU and/or

amiodarone 150–300 mg as injection

Bantuan ABC: beri Oksigen; pasang IV line.Monitor EKG, TD, Oksimetri

Rekam EKG 12 lead bila memungkinkan atau rekam irama di lead IIIdentifikasi dan obati penyebab yang reversibel

Probable re-entry PSVT:•Rekam EKG 12 lead saat irama sinus

•Jika timbul kembali; beri adenosin lagi dan pertimbangkan obat anti aritmia yg lain

Kembali ke Irama normal sinus ?

Takikardi QRS sempit irreguler•Probable Atrial fibrilasi, control rate dengan:B-bloker IV, digoxin IV atau diltiazem IV•Bila onset AF < 48 jam berikan :Amiodaron 300 mg IV selama 20-60 mnt, dilanjutkan 900 mg/24 jam

•Vagal manuver•Bolus cepat Adenosin 6 mg;

Bila tak berhasil berikan 12 mg;Bila tidak berhasil berikan 12 mg.

•Monitor EKG kontinu

QRS SempitApakah irregular?

Apakah QRS sempit (<0,12 det)?

Synchronnised DC shock Apakah pasien stabil?Tanda tidak stabil:

Kesadaran menurun, nyeri dada, TD sistolik<90 mmHg, gagal jantung(Gejala terjadi akibat laju nadi yang terlalu cepat > 150 beat/mnt)

•Amiodaron 300 mg IV lama pemberian10-20 mnt dan ulangi kejut listrik,

•amiodaron 900 mg/24 jam

Possible atrial flutterControl rate ( B-bloker)

Beberapa kemungkinan, a.l:•AF dgn bundle branch blockPengobatan spt QRS sempit

•Pre-excited AFPertimbangkan amiodaron

•VT Polimorfik (spt torsades de pointes = berikan magnesium 2 gr selama 10 mnt)

QRS lebarApakah QRS regular?

Jika VT (atau belum jelas)•Amiodaron 300 mg IV selama 20-60 mnt

dilanjutkan 900mg/24 jamJika sebelumnya confirmed SVT

dgn bundle branch block:•Berikan adenosin seperti

pada takikardi QRS sempit regularKonsultasi ke kardiolog

Stabil

Tidak Stabil

Tidak

irregular

regular

Ya

LebarSempit

regularirregular

Konsultasi ke kardiolog

Catatan :kardioversi harus dilakukan dalam sedasi atau anestesi umum

ALGORITMA TAKIKARDIA

Jetsed

ALGORITMA BRADIKARDI

pemasangan TPM

Obat-obatan alternatif :•aminofilin•Isoprenalin• dopamin

•Glucagon=pada overdosis BB atau CCB •glycopyrolate

Pengobatan sementara :•Atropin 0,5 mg IV dpt diulang sampai dosis maksimum 3 mg•Adrenalin 2 – 10 mcg/mnt

•Obat alternatif Atau

•Transcutaneous pacing

Adakah Risiko asistol?•Recent asystole

•Mobitz II AV block•Total AV block dengan QRS lebar

•Ventricular pause > 3 det.

Atropin0,5 mg IV

Yes

Observasi

No

Yes

No

Yes

No

Tanda-tanda:•TD sistolik < 90 mmHg•Nadi < 40 beat/mnt•Aritmia ventrikel dengan TD cukup•Gagal jantung

Respon memuaskan?

Jetsed