samuel case 1b kgd

7/27/2019 Samuel Case 1B KGD

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Samuel S.S

Case 1B

Emergency Medicine


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RE Cardiovascular emergency

Classification Unconcious: cardiac arrest (VF, PVT, PEA, Asystole)

Concious : ACS

Risk factor Pathophysiology

SS

Diagnose

Treatment

Prognosis

Complication


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ACS

CAD

acute

NSTEMI

Unstable

angina

ACS

Stable

angina

acute

STEMI


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Risk factor

Smoking

DM

HT Obesity

Lack of exercise

Hiperlipidemia


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Pathophysiology


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Sign & Symptom

Pain localization : difficult to localized around retrosternal

Pain description : heaviness and squeezed feeling around the

chest

Referred pain : jaw, shoulder, arm Pain >20 minutes (>10 minutes)

Systemic symptoms: nausea, vomit, epigastric pain, sincope,

cold sweating

Dyspneu

ACLS indonesia IDI, ed.2011


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Diagnose

Based on Sign & Symptom

Based on physicalexamination

BP

HR

RRJVP

Gallop

Murmur

Rales


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ECG


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Cardiac marker

Troponin T Troponin I CKMB

3 h after onset

Peak hours 12-14 h

2-3 d

3-12 h after onset

Peak hours 12-24 h

T 8-21 d

I 7-14 d


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Treatment

ABC CPR and defibrilation

MONACO if necessary ECG

Call to hospital

Prehospital


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Emergency unit (initial assessment


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Initial treatment :

Morphin : 2-5 mg IV repeated every 5-30 minutes

O2 : 4L/minutes, O2 saturation >90% Nitroglycerin : 0,3-0,6 mg sublingual/buccal spray 3 times

in 3-5 minutes interval

Aspirin : 160-325 mg buccal, maintanance dose 75-100

mg/day Clopidogrel : 300 600 mg (75 mg @ tablet 4-8 tablet)

Streptokinase : 1,5 juta unit larutkan dalam dextrose

100 cc titrasi selama 60 menit

ACLS indonesia IDI, ed.2011


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Harrison Principle 18th

ed.


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STEMI Reperfution (onset


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Harrison Principle 18th

ed.


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Fibrinolysis

Streptokinase 1,5 million U in 100cc NaCl 0,9% or D5%

infused 30-60 m door-drug 75 years old12-24 h after onset or more

ST segment depression

High systolic pressure (>175 mmHg)


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Absolute CI Relative CI

Intracranial hemmorhage Uncontrolled BP (>180/>110 mmhg)

Ischemic stroke 3 hours-3 months Ischemic stroke > 3 months, dementia

Aorta dissectionCPR >10 minutes or major operation

Intracranial tumor Internal bleeding in 2-4 weeks

AVM Streptokinase in 5 days or more or allergicto streptokinsae

Active internal bleeding and blood

clotting dysfunctionPregnant

Trauma in the last 3 months

Active peptic ulcer

High INRUsing other anticoagulant


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PCI door to balloon 75 years old patients with STEMI

CI of fibrinolysis


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FIBRINOLYSIS PCI

Onset < 3 h Onset > 3 h

PCI isnt a choice (no access to PCIfacilities) Access to PCI facilities

Door-balloon > 90 min CI of fibrinolysis

No CI of fibrinolysis Syok cardiogenic

STEMI in >75 years old patients


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Cardiac Arrest

Ventricular fibrillation

Ventricular tachycardia without pulse

Pulseless electric activity

Asystole


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Pathophysiology


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AMERICAN RED CROSS FIRST AIDRESPONDING TO EMERGENCIES FOURTH EDITIONCopyright 2006 by The American National Red Cross All rights reserved.

Cardiopulmonary Resucitation

If cardiac arrest : Unconscious

Not breathing

Shows no signs of life

Then perform : CPR = 30 compressions and 2 breaths for an adult


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Unconscious ChokingAdult

The most common cause of obstruction in an

unconscious person is the tongue

The care for an unconscious choking adult is verysimilar to the skill of adult CPR

Chest compressions are used to help force air

from the victims lungs to dislodge a foreign

object


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Closing

When performing CPR on an adult, give 30 chest

compressions, followed by 2 breaths, at a rate of about

100 compressions per minute

The care for an airway obstruction for an unconsciousadult is to give CPR and check for an object in the mouth


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Adult AED(Automated External Defibrillation)


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Types of AEDs


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Citizen Responder and AED

Most victims of sudden cardiac arrest need an electric shock,

called defibrillation

Each minute that defibrillation is delayed reduces the victims

chances of survival by about 10 percent

The sooner the shock is administered, the greater the

likelihood of the victims survival


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Automated External Defibrillation

Disease or injury can disrupt the hearts electrical system and

damage the heart

An automated external defibrillator (AED) is a machine that

analyzes the hearts rhythm and, if necessary, tells you to

deliver a shock to a victim of a sudden cardiac arrest

This shock, called defibrillation, may help the heart

reestablish an effective rhythm

Defibrillation is not intended to restart a heart without any

electrical activity

f h


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Safety Precautions When Using an

AED

When using an AED, follow these precautions :

Do not touch the victim while the AED is analyzing

Do not touch the victim while defibrillating

Do not use alcohol to wipe the victims chest dry Do not defibrillate someone around flammable materials

Do not use an AED in a moving vehicle

Do not use an AED on a victim in contact with water

Do not use an AED and/or electrode pads designed foradult victims on an infant or a child under age 8 or

weighing less than 55 pounds


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Do not use an AED on a victim wearing a nitroglycerin

patch or other patch on the chest.

Do not use a mobile phone or conduct radio transmission

within 6 feet of the AED.

Do not place the pads directly over a pacemaker or other

implanted device.


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Skill Practice and Scenarios

Now it is time to practice!


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Potential AED Problems

Battery is dead

Patient is moving

Patient is responsive and has a rapid pulse


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AED Advantages

ALS providers do not need to be on scene

Remote, adhesive defibrillator pads are used

Efficient transmission of electricity


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Preparation

Make sure the electricity injures no one

Do not defibrillate a patient lying in pooled water

Dry a soaking wet patients chest first

Do not defibrillate a patient who is touching metal

Remove nitroglycerin patches

Shave a hairy patients chest if needed


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Using an AED (1 of 8)

Assess responsiveness

Stop CPR if in progress

Check breathing and pulse

If patient is unresponsive and not breathing adequately, givetwo slow ventilations


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If there is a delay in obtaining an AED, have your partner start

or resume CPR

If an AED is close at hand, prepare the AED pads

Turn on the machine


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Remove clothing from the patients chest area. Apply pads to

the chest

Stop CPR

State aloud, Clear the patient.


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Push the analyze button, if there is one

Wait for the computer

If shock is not needed, start CPR

If shock is advised, make sure that no one is touching the

patient Push the shock button


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After the shock is delivered, begin 5 cycles of CPR, beginningwith chest compressions

After 5 cycles, reanalyze patients rhythm

If the machine advises a shock, clear the patient and push

shock button If no shock advised, check for pulse


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If the patient has a pulse, check breathing

If the patient is breathing adequately, provide oxygen via

nonrebreathing mask and transport


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If the patient is not breathing adequately, use necessary

airway adjuncts and proper positioning to open airway

Provide artificial ventilations with high-concentration oxygen

Transport


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If the patient has no pulse, perform 2 minutes of CPR

Gather additional information on the arrest event

After 2 minutes of CPR, make sure no one is touching thepatient

Push the analyze button again (as applicable) If necessary, repeat alternating CPR/Analyze/Shock until ALS

arrives

Transport and check with medical control

Continue to support the patient as needed


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After AED Shocks

Check pulse

No pulse, no shock advised

No pulse, shock advised

If a patient is breathing independently :

Administer oxygen

Check pulse

If a patient has a pulse but breathing is inadequate, assist

ventilations


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Transport Considerations

Transport :

When patient regains pulse

After delivering six to nine shocks

After receiving three consecutive no shock advised messages

Keep AED attached

Check pulse frequently

Stop ambulance to use an AED


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Cardiac Arrest During Transport (1 of 2)

Check unconscious patients pulse every 30 seconds

If pulse is not present:

Stop the vehicle

Perform CPR until AED is available

Analyze rhythm

Deliver shock(s)

Continue resuscitation according to local protocol


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Cardiac Arrest During Transport (2 of 2)

If patient becomes unconscious during transport:

Check pulse

Stop the vehicle

Perform CPR until AED is available

Analyze rhythm Deliver up to three shocks

Continue resuscitation according to local protocol

samuel case 1b kgd

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