Acute Pulmonary Edema

and

Emergency Arrhythmias

in
ACS

Jetty RH Sedyawan SpJP K

Departemen 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
Iskemiasub optimal
Tatalaksana

Aritmia
Infeksi
Surgery
Lain-lain

How should I assess patients

in acute heart failure?

Assess the patients:

1. Volume status and tissue perfusion:cold or warm, wet or dry.
2. A precipitating

[IIa C]

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 (NTproBNP) 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 line

if the patient is in cardiogenic shock or for those who require pressors. [II b, C]
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]

Arrhythmias

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

 Ventricular
fibrillation

Defibrillate with 360J

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

Or

Pulseless
ventricular
tachycardia

If refractory to initial shocks inject:

epinephrine 1 mg or
vasopressin 40 IU and/or
amiodarone 150300 mg as injection

ALGORITMA TAKIKARDIA
Bantuan ABC: beri Oksigen; pasang IV line.
Monitor EKG, TD, Oksimetri
Rekam EKG 12 lead bila memungkinkan atau rekam irama di lead II
Identifikasi dan obati penyebab yang reversibel

Synchronnised DC shock

Amiodaron 300 mg IV lama pemberian

10-20 mnt dan ulangi kejut listrik,
amiodaron 900 mg/24 jam

Tidak Stabil

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)
Stabil
Lebar

Konsultasi ke
kardiolog

Beberapa kemungkinan, a.l:

AF dgn bundle branch block
Pengobatan spt QRS sempit
Pre-excited AF
Pertimbangkan amiodaron
VT Polimorfik (spt torsades de pointes =
berikan magnesium 2 gr selama 10 mnt)

QRS Sempit

regular

QRS lebar
Apakah QRS regular?
irregular

Sempit

Apakah QRS sempit (<0,12 det)?

Apakah irregular?
irregular

Vagal manuver
Bolus cepat Adenosin 6 mg;
Bila tak berhasil berikan 12 mg;
Bila tidak berhasil berikan 12 mg.
Monitor EKG kontinu

regular

Kembali ke
Irama normal sinus ?
Jika VT (atau belum jelas)
Amiodaron 300 mg IV selama 20-60 mnt
dilanjutkan 900mg/24 jam
Jika sebelumnya confirmed SVT
dgn bundle branch block:
Berikan adenosin seperti
pada takikardi QRS sempit regular

Ya
Probable re-entry PSVT:
Rekam EKG 12 lead saat irama sinus
Jika timbul kembali; beri adenosin lagi dan
pertimbangkan obat anti aritmia yg lain

Catatan :kardioversi harus dilakukan dalam

sedasi atau anestesi umum

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

Tidak

Konsultasi ke
kardiolog

Possible atrial flutter

Control rate ( B-bloker)

Jetsed

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

Yes

No

Atropin
0,5 mg IV

Yes

Respon memuaskan?
No

Adakah Risiko asistol?

Yes

Pengobatan sementara :
Atropin 0,5 mg IV dpt diulang
sampai dosis maksimum 3 mg
Adrenalin 2 10 mcg/mnt
Obat alternatif
Atau
Transcutaneous pacing

pemasangan TPM

Recent asystole
Mobitz II AV block
Total AV block dengan QRS lebar
Ventricular pause > 3 det.
No

Observasi
Obat-obatan alternatif :
aminofilin
Isoprenalin
dopamin
Glucagon=pada overdosis BB atau CCB
glycopyrolate

Jetsed