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Pradik 12 April 2011

ASSALAMUALAIKUM WR WB


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SEGI PRAKTIS PENANGANANKEGAWAT DARURATAN DI BIDANG

JANTUNG

Dr. Suryono SpJP. FIHADepartemen Kardiologi dan Kedokteran Vaskular FK Unej-RSD Dr Soebandi

Jember


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Penyakit Jantung

Penyebab Kematian No. 1 di Dunia

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

22.3

19.3

12.6

9.7

9

6.3

0 5 10 15 20 25 30

Peny. Jantung

Penyakit Infeksi

Kanker

Kecelakaan

Penyakit Paru

AIDS

Penyebab Kematian (%)


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KELUHAN DI BIDANG JANTUNG

Nyeri dada

Sesak Nafas ~ eodema Berdebar

Syncope

DLL


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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 RumahTangga, Dep.Kes. 1992)

Tenaga medis sering berhadapan dengan ACS


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APA YG KITA LAKUKAN ??

Oksigen

AspirinClopidogrel

Nitrat

Morfin

Vital sign

EKG


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Symptom

Recognition

Call to

Medical System

Prehospital ED CCU Cath Lab

Delay in initiation of PharmacologicReperfusion

PUSKESMAS


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Adjusted RR [95% CI]:

1.075 [1.01-1.16]

De Luca, Suryapranata et al Cir culation 2004

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

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


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Time is Myocardium


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Options for Transport of Patients With

STEMI and Initial Reperfusion Treatment

EMS Transport

Onset of

symptoms ofSTEMI

9-1-1

EMSDispatch

EMS on-scene

Encourage 12-lead ECGs. Consider prehospital fibrinolytic if

capable and EMS-to-needle within30 min.

GOALS

PCIcapable

Not PCIcapable

Hospital fibrinolysis:Door-to-Needle

within 30 min.

Inter-

Hospital

Transfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital fibrinolysis

EMS-to-needlewithin 30 min.

EMS transport

EMS-to-balloon within 90 min.Patient self-transport

Hospital door-to-balloonwithin 90 min.

Dispatch

1 min.

5min.

8min.


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MANAGEMENT

Anti IschemicNitrate

Morphine Sulfate

Beta BlockerCalsium Channel Blocker

Antithrombotic & Anticoagulation TherapyAspirin, Ticlopidine, Clopidogrel, Gp IIb/IIIa inhib

UFH/LMWH

Revascularization StrategyTrombolitik/ PCI /CABG


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Statin

ACE Inhibitor


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CARDIOGENIC

PULMONARY

EDEMA

NONCARDIOGENIC PULMONARY

EDEMA

History

Acute cardiac event Usually Uncommon (but possible)

Physical Examination

Cardiac output stateLow-flow state (coolperiphery)

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

Laboratory Tests

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


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DIAGNOSTICS OF ALO

Tachypnea and tachycardiaSitting upright, agitatedCentral cyanosisVery anxious and

diaphoreticHypertension due to

hyperadrenergic state

Rales +, ronchi & wheezingalso maybe +S3 +, jugular venous

distension +

Hypotensionsevere LV sistolicdysfunction / cardiogenis shock

If murmur +

acute valvulardisorders

Skin parlor or mottling

Hepatomegaly, hepatojugular reflux,and peripheral edemaright heartfailure

Change in mental statussevereALO

Physical findings :


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Evolution of cardiogenic pulmonary edema

A. Interstitial Edema B. Early Alveolar Edema C. Complete Alveolar Flooding

Stage II Stage III

Capillary Lumen Capillary Lumen Capillary Lumen

Alveoli Alveoli Alveoli

Hydrostatic Pressure Hydrostatic Pressure Hydrostatic Pressure 18 mmHg > 25 mmHg > 28-30 mmHg

Systemic

Vens

Pressure


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http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/3531med1955-02.jpg&template=izoom2


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APA YANG KITA LAKUKAN ??

Oksigen

Nitrat

Furosemit

Morfin

A


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AcutePulmonary

Edema /Hypotension /

ShockAlgorithm

Clinical signs of Hypoperfusion / Hypotensi, Shock, Cong Heart failure , acute pulmonary edemaAssess ABCs Start IV Assess vital signs Order 12-lead ECG Secure airways Attach Monitor, pulse oximeter, Review history Order portable chest x-rayAdminister oxygen and automatic blood pressure Perform physical examination

Volume problem Pump problem Rate problem

Too Slow Too Fast

Systolic BP 100 mm HgNo signs and symptoms of shock

Norepinephrine0.5-30 ug/min IV or

Dopamine5-20 ug/kg per min IV

Dobutamin2 - 20 ug/min IV or

Nitroglycerin start 10-20 ug/min IVConsider :

Nitroprusside 0.1-5.0 g/kg per min IV

Administer Fluids Blood transfusionCause-specific interventiousConsider vasopressors, if indicated

What is the

Blood

pressure [BP]

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

First-line actions FurosemideIV 0.5-1.0 mg/kg MorphineIV 2-4mg NitroglycerinSL Oxygen/intubate PRN

Second-line actions NitroglycerinIV if BP> 100 mm Hg NitroprussideIV if BP> 100 mm Hg Dopamineif 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


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HEART FAILURE

Maintenance

Furosemit

SpironolactonACE Inhb / ARB

B Bloker

NitratDigitalis


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Palpitasi :

Sinus Takikardia

Extra Systole

Atrial Fibrilasi

Supraventrikular Takikardia

Ventrikel Takikardia


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A-B-C-DEKG

Call Expert


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Sick Sinus Syndrome

Bradikardia Blok

Dll

PENYEBAB TERSERING


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A-B-C-DEKG

Call Expert


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SERIOUS SIGNS OR SYMPTOMS ?

Due to the bradycardia?

Type II second-degree AV block

or

Third-degree AV block?

Intervention Sequence

Atropine0.5 1.0 mg

Transcutaneous pacingif available

Dopamine5-20 g/kg per minute

Epinephrine2-10 g/min

Isoproterenol 2-10 g/min

No Yes

Prepare for transvenous pacer

If symptoms develop, use

transcutaneous pacemaker until

transvenous pacer placed

Observe

No Yes


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Noncardiac ???

Asystole

Ventrikel Fibrilasi

PENYEBAB TERSERING


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A-B-C-DCall


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Take Home Messages

Penyakit CV penyebab kematian no1 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 sangatpenting


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Take Home Messages

Penyakit CV penyebab kematian no1 di dunia

Sarana kesehatan : ujung tombak

dalam menurunkan angka kematian Perlu penanganan segera dgn

cepat dan tepat

Pemahaman dan keterampilan

dibidang Kegawat daruratan dlmbidang CV menjadi sangat penting

MATUR NUWUN

TERIMA KASIH

THANK YOU

SAKALANGKONG

Mba Marijan

KASOON


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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


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