An Introduction
dr. David D Ariwibowo, Sp.JP
Fakultas Kedokteran
Universitas Tarumanagara
2011
Review of
Circulatory
System
Cardiovascular
Emergencies
1.
2.
3.
4.
5.
6.
7.
8.
Cardiorespiratory Arrest
Aortic dissection
Acute Limb Ischemic
Etc.
Acute Coronary
Syndrome
Kompetensi
3A
Mampu membuat diagnosis klinik berdasarkan pemeriksaan fisik dan pemeriksaan tambahan
Acute Coronary
Syndrome
1. Unstable Angina Pectoris (UAP)
2. Acute Non ST-Elevation Myocardial infarction
(NSTEMI)
3. Acute ST-Elevation Myocardial infarction
(STEMI)
Patophysiology
Atherosclerosis Timeline
Foam
cells
Fatty
streaks
Intermediate
lesion
Atheroma
Fibrous
plaque
Complicated
lesion rupture
Endothelial Dysfunction
From First Decade
Thrombosis
hematoma
Definition
Normal
Fatty
streak
Fibrous
plaque
Athero-
sclerotic
plaque
Plaque
rupture/
fissure &
thrombosis
Unstable
angina
NSTEMI
STEMI
Ischemic
stroke/TIA
Clinically silent
Critical
Stable angina
Intermittent claudication
Increasing age
Progressive Process
leg
ischemia
Cardiovascular
death
Diagnosis
Presentati
on
Working Dx
ECG
Cardiac
Biomarke
r
Final Dx
Ischemic Discomfort
Acute Coronray Syndrome
No ST
Elevation
UA
UA
ST
Elevation
NSTEMI
NQMI
QwMI
Presentation
Angina klasik
Rasa tidak nyaman / nyeri di daerah sternal > 20 menit.
Menjalar ke lengan kiri, leher, rahang, punggung.
Dapat bersifat tajam (ditusuk, terbakar) atau tumpul (seperti
ditekan, diperas).
Disertai keringat dingin, mual / muntah, kesulitan bernapas,
berdebar-debar.
Angina Equivalent
Tidak ada nyeri / rasa tidak nyaman di dada yang khas.
Gejala gagal jantung mendadak (sesak napas).
Aritmia ventrikular (palpitasi, presinkop, sinkop)
Presentation
Faktor Risiko :
Usia : Tua > Muda
Gender : Laki-laki > Perempuan
Riwayat Keluarga ( PJK )
Hipertensi
Diabetes Mellitus
Peningkatan Kadar Kolesterol Total dan LDL
Kadar Kolesterol HDL Rendah
Obesitas
Kurang Aktivitas Fisik
Diet : Tinggi Lemak Jenuh dan Kolesterol
Merokok
Differential Dx
Cardiac
1. Stable Angina
2. MVP
3. Aortic Stenosis
4. Hypertrophic cardio
myopathy
5. Pericarditis
.Lungs
1. Lung Emboli
2. Pnemonia
3. Pneumothorax
4. Pleuritis
Gastrointestinal
1.
2.
3.
4.
5.
Reflux esofagus
Ruptur esofagus
Gall bladder disease
Peptic Ulcer
Pancreatitis
. Vascular
1. Aortic dissection
. Others
1. Musculoskeletal
2. Herpes zoster
ECG
To detect ischaemic changes or arrhythmias.
Initial ECG has a low sensitivity for ACS.
A normal ECG does not rule out ACS.
ECG is the sole test required for emergency
ECG
Affecting all ECG featuring ventricles
ECG
T wave changes
A. Inverted T
Pada iskemia namun kurang
spesifik
Perubahan akhir pada
STEMI, terjadi setelah ST
elevasi kembali ke normal
B. Hyperacute T
Perubahan awal pada STEMI
ECG
ST Segment changes
A. With acute subendocardial ischemia the electrical forces (arrows) responsible for
the ST segment are deviated toward the inner layer of the heart, causing ST
depression in V5, which faces the outer surface of the heart
B. With acute transmural (epicardial) ischemia, electrical forces are deviated toward
outer layer of the heart, causing ST elevation in the overlying lead.
ECG
A. ST depresion
B.
C.
Horizontal
Spesifik untuk iskemia.
Down-sloping
Paling spesifik.
Up-sloping
Tidak spesifik
ECG
B. ST elevation
Occurs in the leads
facing the infarction
in the early stages
Slight ST elevation
may be normal in V1
or V2
ECG
Q wave
Q wave duration of more than 0.04 seconds (1
mm)
Q wave depth of more than 1/3 of ensuing R
wave
ECG
R
ST
1 hour or so
ST
A day or so
ST
A few hours
ST
Later changes
A few months
ECG
ECG
I
aVR
aVL
V2
V3
III
INFERIOR
V4
SEPTAL
LATERAL
II
V1
aVF
ANTERIOR
V5
LATERAL
V6
Laboratorium
10
0
Cardiac Biomarkers in
STEMI
Cardiac troponin-no
Multiples of
the URL
5
0
2
0
1
0
5
reperfusion
Cardiac troponin-reperfusion
CKMB-no reperfusion
CKMB-reperfusion
2
Upper reference
limit
1
0
8
Diagnosis Nomenclature
1. Timing at presentation :
.
.
.
2. Infarct location
.
.
.
Example
. UAP
. Acute NSTEMI
. Acute Anterior STEMI
. Recent inferolateral MCI
. Old Inferior MCI
I II III
Left
coronary
artery
V1 V2 V3
V4 V5 V6
I II III
Right
coronary
artery
V1 V2 V3
V4 V5 V6
I II III
Left
circumflex
coronary
artery
V1 V2 V3
V4 V5 V6
Management
Treatment Delayed is Treatment Denied
Symptom
Recognition
Call to
Medical
System
PreHospital
ED
Increasing Loss of
Myocytes
Delay in Initiation of Reperfusion
Cath Lab
Management
Onset of STEMI
- Prehospital issues
- Initial recognition and management
in the Emergency Department (ED)
- Reperfusion
MONA
Morphin 2- 5 q 5 min titrate to response and side
effects.
O2 Nasal cannula 4 L/mnt
Nitrat: ISDN 5 mg SL 3 times
Aspirin 160-320 mg
Call 9-1-1
EMS on-scene
Call fast
Onset of
symptoms
of STEMI
9-1-1
EMS
Dispatc
h
Not PCI
capable
EMS
Triag
e
Plan
GOALS
5
min.
Patient
InterHospital
Transfer
PCI
capable
8
EMS Transport
min.
EMS
Dispatc
h
1 min.
Prehospital
fibrinolysis
EMS-to-needle
within 30 min.
EMS transport
EMS-to-balloon within 90
min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Contraindications to fibrinolysis,
3B
Mampu membuat diagnosis klinik berdasarkan pemeriksaan
Definition
HF.
New or worsening of pre-existing chronic HF.
The European Society of Cardiology: Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2008
The European Society of Cardiology: Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2008
Clinical presentation
Usually characterized by pulmonary congestion
cardiac output & tissue hypoperfusion may dominate the clinical
presentation
Reflects a spectrum of conditions present in one of 6 clinical categories.
Figure demonstrates the potential overlap between these conditions
The European Society of Cardiology: Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2008
Clinical presentation
The European Society of Cardiology: Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2008
Diagnosis
Based on the presenting symptoms & clinical findings.
Confirmation by the history, physical examination, ECG, CXR,
The European Society of Cardiology: Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2008
Goals of treatment in
AHF
The European Society of Cardiology: Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2008
Immediate goals
tissue oxygenation & haemodynamics
Therapeutic Goal
Parameters
Clinical
1.
2.
3.
4.
Hemodynamic
1. SBP
2. SVRI
s-cm-5
3. PCWP
4. RAP
> 90 mm Hg
< 1200 dyne< 15 mm Hg
< 8 mm Hg
Specific treatment
strategy
based on distinguishing the clinical
conditions
The European Society of Cardiology: Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2008
haemodynamic characteristics.
Figure presents a modified from the Forrester classification.
Initial treatment
algorithm
The European Society of Cardiology: Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2008
The European Society of Cardiology, Guidelines on the diagnosis and treatment of acute heart failure, 2005
Loop diuretics
In the presence congestion & volume overload.
Class I, level of evidence B
The European Society of Cardiology, Guidelines on the diagnosis and treatment of acute heart failure, 2005
Vasodilators
The European Society of Cardiology, Guidelines on the diagnosis and treatment of acute heart failure, 2005
Inotropic agents
The European Society of Cardiology, Guidelines on the diagnosis and treatment of acute heart failure, 2005
Cardiorespiratory
Arrest
Kompetensi
3B
Mampu membuat diagnosis klinik berdasarkan pemeriksaan
Cardiorespiratory
Arrest
suatu keadaan dimana pasien:
tidak sadar
tidak bernafas
tidak ada denyut nadi
Fungsi
Pernapasan
Terganggu
Terganggu
Henti
Jantung
Henti Napas
Prevalensi
WHO (2004) 17,1 juta orang meninggal
angka Nasional
Chain of Survival
LANGKAH-LANGKAH
Pastikan penolong dan korban dalam kondisi
aman
Tempatkan korban di atas alas yang keras
dalam posisi telentang
Lakukan langkah-langkah algoritme.
Cek Respons
Carilah tanda-tanda
sirkulasi:
Bergerak
Bersuara
Bernapas
Dengan cara
menepuk dengan
cukup kuat
bahu/dada korban
sambil memanggil
korban
Kompresi Dada
Napas bantuan
Buka jalan
napas dengan
cara
menengadahkan
30
30x
TERIMA KASIH