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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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AMERICAN RED CROSS FIRST AIDRESPONDING TO EMERGENCIES FOURTH EDITIONCopyright 2006 by The American National Red Cross All rights reserved.
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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AMERICAN RED CROSS FIRST AIDRESPONDING TO EMERGENCIES FOURTH EDITIONCopyright 2006 by The American National Red Cross All rights reserved.
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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Using an AED (2 of 8)
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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Using an AED (3 of 8)
Remove clothing from the patients chest area. Apply pads to
the chest
Stop CPR
State aloud, Clear the patient.
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Using an AED (4 of 8)
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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Using an AED (5 of 8)
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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Using an AED (6 of 8)
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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Using an AED (7 of 8)
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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Using an AED (8 of 8)
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