MYOCARDIAL
INFARCTION :
MANAGEMENT
1.
Assessment of
Reperfusion Option for
Assess time
and risk
STEMI
Patients
Time since onset of symptoms
Risk of STEMI
Risk of fibrinolysis
Time required for transport to a skilled
PCI lab
Fibrinolysis is generally
preferred if :
An invasive strategy is
generally preferred if :
Contraindications and
Cautions for Fibrinolytic Use
Absolute
contraindication:
in
STEMI
Fibrinolytic therapi
Provisional Stent.
Stent positioning and deployment with prior
balloon dilatation of the stenosis.
Direct Stent.
Stent positioning and deployment without
prior balloon dilatation of the stenosis.
Primary Stenting.
Stent implantation as the first choice to
revascularize patients presenting with acute
myocardial infarction.
Emergency ward.
1.Oxygen 2 3 l /m
2.IV line
3.Nitrate 5 mg sublingual.
Nitrate intravenous
-ISDN (isosorbide dinitrate ) 1-2 mg /h (syringe
pump 10 mg or 1amp/50 cc)
- Nitroglycrine : 10 200 micro U/ m
(Nitrocine 10 mg / 50 cc-syringe pump)
Emergency ward.
5. Clopidogrel (75 mg/tab) : 600 mg (onset 1- 2 h) ;
300 mg (onset 4 hours), 75 mg/d
Aspirin : 300 mg (enteric coated- chewed)
80 , 100 , 0r 160 mg /d
Anticoagulant :
-UFH (unfractionated heparin) : bolus 5000
units, maintenance 750 1000 U/h
Controle :aPTT 2 3 normal.
Emergency ward.
6. - LMWH.
=Enoxaparine or dalteparine ( Porcine) 100 U/ kg,
twice daily or 60 mg / 12 h)
MANAGEMENT
ACUTE DECOMPENSATED HEART
FAILURE
1.
2.
I. GENERAL
1.
2.
3.
4.
5.
6.
7.
Emergency case
Intensive Care Unit
Up right position
O2 4 -6 l/min + pulse oximeter
( ABG if need,PO2 < 50 / PCO > 50 mmHg
Ventilator)
I. V. line D5W /0,9% Nacl (microdrip)
Negative fluid balances,normal electrolyte
Monitor Blood Pressure,Heart rate and rhythm
Small and frequent feeding. Diminish anxiety (Diazepam
2 mg tid) Diet reduced Nacl 1-2 g/day ( Eliminated
cheese,bread,cereals,canned vegetables and soup )
II.
Infection
Fever
tachycardia
2.
3.
4.
5.
Anemia
tachycardia
Thyrotoxicosis
tachycardia
Pregnancy
tachycardia
Drug discontinuation, high salt intake, chemotherapy, blood
transfusion, steroid and non steroid anti inflammation (NSAID)
IV.
MEDICAMENT
1. Furosemide : 0,5 1,0 mg / Kg BW/IV
Initial dose 20 mg / IV and max 80 mg/IV
For Acute Pulmonary Edema and CHF
Side effect hypo Na and hypo K
2. Dopamine : 2 -12 microgram/KgBW /IV/min
For symptomatic shock, BP 70 100 mmHg
Side effect : tachycardia,disrythmia
3. Dobutamine : 2 -12 microgram/KgBW /IV/min
For asymptomatic shock, BP 70 100 mmHg
Side effect : tachycardia,disrythmia
4. Nor epinephrine :0,04 -0,4 microgram / Kg BW / IV
For Systolic BP < 70 mmHg
Side effect : tachycardia, disrythmia
9.
Anti Coagulants
Heparin : 100 unit /Kg /IV /bolus
15 25 unit /Kg /hour /drips
check aPTT to 1,5 2,5 x N
Warfarin : Late effect ( 1 4 days )
Check INR to 1,5 2,5 x N
Dosis 5 10 mg / day for 2 days
Than titrated dose 1 2 mg/day
Indication for atriall fibrillation and high risk
thromboembolic patient
Acute
pulmonary
edema
Hypovolemia
Low outputcardiogenic
shock
Dysrhythmia
Bradycardia
1 st : Acute pulmonary edema
Furosemide
IV 0.5 to 1.0 mg/kgS
Morphine IV 2 to 4 mg
Nitroglycerin SL
Oxygen/intubation as needed
Administrter
Fluids
Blood transfusions
Cause-specific intervention
Consider vasopressors
Blood pressure?
Tachycardia
Systolic BP
BP defines 2d
line of action (see below)
Norepinephrine
0.5 to 30 g/min IV
Systolic BP
<70 mmHg
Signs/symptoms
of shock
Systolic BP
70 - 100 mmHg
Signs/symptoms
of shock
Dopamine
5 to 15 g/kg
per min IV
Systolic BP
70 - 100 mmHg
No Signs/symptoms
of shock
Dobutamine
2 to 20 g/kg
per min IV
Systolic BP
> 100 mmHg
Nitroglycerin
10 to 20 g/ min IV
Consider
Nitroprusside *
0.1 to 5.0 g/kg
per min IV