Aae ——- -. sree tas pret x» ioapemcatees nego deinarptmin soot 3 Sarena te 3 fxs evn pc pt a Silncsdenesans pena mael para Magne ‘oo don pret sovensee oS ees incre ene 2 Sib ieteeponpsaseia Oye ie Reomndgeey pin tc ne erga depts 6 fant SS scicepe rere mcr vnpe = TEE Rpt meric pee tsi tortor “Chowne se cronramer deCarasage meron ing hit Seam aber te tpn et ng mee Shove er Dente Seale nro in in pore prl coat mee inseam ‘eee ata ere rtd ‘Sine rpens mainte ‘necti wral iae ene ie ‘rns npr icc pace a ei ‘2nattanaaa hen poa evga Spree Osaramer sao narra ina Pe smile hon ps 1.29, Moatrare peer ipl amp tes Itasveaanars seercndogreh "2 ap rts ari e-Deptamel Qeaae ireweina (v 6| semana teal ee eS A ‘sl rn pas reg SU sl gale ‘pre etn Degree Cage nanan I22'Senart eor apn ose r PU ‘Sr dane in Derren o raoge aa i033 Seman nate chore de Nese seUant espe ars) all pune on Born desler IS. Senate or me a UP ‘Se hsp cen Dp ecg nal esteorace sagen st pace sat pce "Pc ose sc eae ‘ean oa nan ao ae 8 Tem preset Rezumat apa prespaleste cca malimportant taps in aberdarea unl pcint cu STEM, de cele mal multe or hotiatote sentra prognostelsevolia ueriead a acastla. Pe de o pat, istabltatea eect a nil ete mati in primele 4-6 dela debutul STEM, met penta care scl arti make (inspec file ventrculre este major. Pe de lth pate, esea! #6 prime oe repecnfereata de tip ldealé pena ealzarea repeal miocardce fi pin acest, 4 iin al de necro 9 sara de miocard vial Poin de a acest real binecunoscute obecvele majore ale ratamentul presptal al pacentul ‘uSTEMItebuiesae 1 blagnsticl pout precoce: 2. Apsara prompts a Servcluh de Assten Mescals de Urges (samy 3.tratamenulpromptalatilormalgne; | Repertuiamiocates Tndeptiniea cestorobectve se poste faeprin 1. Educa pubic larg in recunoatreasimptometoogel STEMI 5a spertimadatea SAM; 2. Aaliarea protoccaleor de esuctare, respec suport baz} al ‘ei (LS soprtlavanst al vei (ALS) rin care pot combate fitmile maligne. Potocoul BLS la care se adausd $i folosrea efibltorll eer semautomatzat (DEA) rebuleaplet de re esoaneleafatelnpeajmapacentuucuSTEMimedat up apaiia stopulcarlrespator Personal AMU trabules fe antenat in ALS sis alc iesiat aes rote in fat nul pant eu STEM alt in opearioespiator 3. Efectuarea reperfuie)miocardice fie interventional, fe prin fbrinais, fie farmacoinvadv (respec fbinolza continuatd cu ordre inervensonal. Altri de combatere aitmilor maligne, repertia micardis precoce uebule 3 fe o dominant a atc terapeute in prespital es! ghidutle actual ecomandéefectuarea reper micardicen primal 12 ore de la debut STEM, Senet/STEM prestal Reperfzia interventional prin angloplaste primar (PPC) este ‘modaltats idea de repertizi eat fina capactate el de ela desob- struiacoronarandinpeseoo%dn eat. clea PC esteinsaelatmitat dupa rime Gace princes sermnifeatvd incidental Fenomenulul de .no reflow”. Reperfuia farmacologd (rn fibrin 4) pate conducearecutatesiarecucle bint prin PPC dacs este tlatainpriele36 oe dele debut STEM ups atest inten de inp ecient Fu sce cemnifist. In algeren uae! dereperusie ator decional ete mpl. Superiotatea PPCl ‘supra FL seperde ac imp care se surge de pina contact mesa [PCM spnsiaPcidepaprt 1203 mine ‘rept imate FLTREBUIE EFECTUATA Ia toi acini Ia care se estimeaz un inp PCM-PPC de peste 120 de inate, La acest pain FL ‘eebue apleatinrmele 3d minute des Pru Contac Medial PM). Entree electat le pe Ambuln (fac mpl de a PM ip a spitauicelmalapropiat apeblldesefectuFLdepapeste30de mint) ela «cls apropiat sal (dc timpulrespecivestedesub 30 deine ‘acl tmp esimat de laPCM pla PCI esta de ub 1202 mite tune! pacientltrebule transport a Departmental de Cariloge Interverorals 00) ce ml apropiat. Pale cu agnor cert de STEM! In presptal NU rebuie mai afept a nous evalarein Unie de Primi Urgete cl rebule rim dec a Dr Sau tebe 8 se asinine Imada ofan de ttle desrzomal In absent contains, ty patent eu STEM! rela ttt In resp cu ancoaglante (heparin natacyonats sau encxaparns) cu ub antagregaeplchetar prin (150325 mg este un artiogregant ‘caretrabuleutaatabgstor, ‘Altri de asprin treble 8 se adauge Hagel sau lopidogre “Teaarlor (180 ma este prima ofune fa pacer wil pent PPCL.A ua opine este clopiorl Copdoprel (600 ma) ext anes ‘aretrebuie gat aspinellapacntlacaresepractes Lsaula arena Seintenyonenssoteapin cereperi ‘sinter. abrdinpresptalapacientlulcy STEM poate urmit fafgua STEN prespeals SS ge eco] ee at uo Atria prepa pcr ire moc sea “laura spent (STEM (ALS -suprl arta ‘iu ver 83 ipl az ie Odense de ‘loge nero DEA etry ersatomatt 6 okevocgra: NG lest Pc rgoplas pina: 502 Sturt cu ongoing srt) roti 8000d prec STEM aeesehanialinspasle intone anne (n2010a pound nealpert tat mere STEM tn nc orn eee 0 8 Inrange a ce pact (e138 20082 zona) Prin dela eps acum do nse sce osm Ieee fh W opine corte contr, 8 Poms evotfeipesenor STE pm snares gh odode storia1oysten psp Introducere: de ce STEMI PRESPITAL-2016? Bole cardovasclre sunt pina curd de deces In Romana, 60% tes Gace fd dalatector ba Aca pecan ee tal rare ‘ect media Europand de 6% (1}2gwa2)- Dept rare Roma ae “nadir cle ma eduse pean de viatdn Comunitats European) in randu bolo cardiovascular, acidntale vatulae cerebral 5 Gaaopatiaehomic sunt princaelecaunededeces Europa mania ‘dn Conant Een 42) narra cara acuta supradeivelr segment T (STEM st ‘problems major de sna in Romina. Acoimaty 1500 de pace {uSTEMI se ntereszé anal n spall i Roma (6), sara al fcenglorcusTeNilesteinssmultraimare S2%aite pcint decedied Inainte co pacental sa qjnga asp) ‘We sont caueleaspunitowe de mortaltatea mae apacenlor 4. Aritmile molgnesfibrilata venteculara (FV), tahicardla venti (7) forpus, cxtola (AS) ‘Actmile maligne (FTV 5 AS) sunt rspuitoare de moraltatea Prime 3-4 oe den debut infrt (10) terior cu de FY seade S162) STEMI pres 2 Ignoraree sv Interpretarea gresté 9 dfritelor spurt de Insabitete hemodinamed existent in primele oe dela debt, 5 ote conducelaattudniterapeutes eon 5 Weefctuares repel cranaiene fe pin angiglte primers (eh fe ponte Fol Rowa roars eas Ide aad nae, permite preserare mi bun afuneeleontatie ‘ri 1320) yiedace ernest cl ge (21.23). Prin uae, denteare rapid pacer cu STEM 5 insures at atvatamenusuntesengalen reverie dees sasiguares \ieieolptaniarefvorabie Cutoats acess leer afenomer asa pespal» STEMI conus fe cea ma slab vrgh in nul de Interven eapeutee in STEM est cr se rmares el pi te ipsa de educa popu! in recunoasereaprecoce a STEMI S12 Importone alert mediate a Serior de Astra Medead de Urgent SAM) (28.30) Dinca 8008 pace inriin rege RO STEM tell 1997-2006 a care a putt fidenteat tmp seus he a debut ori toracce pn a nijereartamentu numa $191(38,48) aufostatatin pele rede a debut TEN ) ipsa de educate populate in rsuscrea cardorespratol, ‘rote in intervene prompt in stopul care ganera de elme Imaine0 intervene prompts ls aes acen in conformtate cu Protocosele deresustar onstent suport debatdssportoanstal i(Seiplear ans de supravieure ae aestor pt reduce peste 50% rscl de denoare a Sechelelor newalogie post ressctare(32 ©) Grodul vari de tore thw! de anrenament specie al “chipelor Selo de Assent Medio de Urgent, lend rin vests ait Serv de Ambulantd de stat, erie Mable de Urgr, esusctareDescarcerare(SMURD) ts eferitele service gent pat up pubieare primulraportal Rept Roman pentru sTEN(RO- ‘38 sa hilt Romanese pentru managementul pacentor cu ‘inf prspal 3) Socitatea Romana de Craolople (SC) adepus yinvederea standard lrivelnajonalaatamentuupacenor {STE in Octombre 209, 0ecip fomats dn eprezetan af SACs Minster anata a neput seit In vederea resi una Progam Hjonal de Tatament ntevenional a STEMI Aes peogram a devert tional a1 August 2010 a2 August fos inegitat pri paient trina22/STEM pes Tn exert a fost cents o retea eu cle 10 Centre de Cadologie Interveonalé (Oc) capable la aces dat dea fetua PPC! in STEM, ‘respect tr ucure (nstutl 6 Bol Cardovaselre Cc ess" Spal ln de Urgent, Spall Universtor de Urgent al Munispa ‘Bucur Spall de Urgets Mitr Cena) dous aclu Napoca (cent e Carll cule Stroh, Spt udeean de Uren dou a ‘gu tres (stu de Bol Cadovasclare 9 Tanslat Spa Jadeteon de Urgent ul aa ns e808 Cardnaseutare Pro ‘e George M. Gorgas Toast de Bol Crosse) ‘Pacantl cu STEMI extn p are ncaretmpul de transport pa ce ‘mal propiat Desde nor dela pranulconact meal wa Be Iransprati ls cen respec in vedere eletle PCL Daca mul lvtnat de anspor depen 2 oe atu indeaa eae fri) dons ‘repaint eb trnserat a DL. Aces reomandi run dein ‘ancora curecomandacie dn hil European de management STM! In vegoare fa data respect (5)36) Prin aplcarea acest protocol se ‘eimste o acopane a4 din terri ri Agra 3) Intra in reat ‘eure aero corpu mesial in acest room a efescut asl net Un rum rescind de ace a incput etm cre DC oes dstane ‘inca nee maar nace tmp ate sse Dau nat in aes rogram ‘ste incl trl anu 2012 aceastreteaacoperea practi es, ‘ero Romane gure), (G urmare a acstl efor procenulpacienior cu STEM! trata irerverionalacresct 204 200813 apronimatv5%In2018 Imo “orespuneitormotltatea nepal sc3 pin Tels resus An ‘eelaintealde tp (Selo Sn 2009108 2%, 63%in2015, 2013). Tr dudaacestorrezutatencuajtoarerecutatel unui reir fuger ace ain to palette STEM! intra ne 130 Nem 20182 Ident cretere amoral 1% [gu 5). Oana a acestor date (ofectustsConfrina Grepursior deernle SRCIn Ml 2016) =identeat * easter nul numar mare de pacini cu STEM cite Oc 100 ba minut 62). Se amiistreao abet de 0 me sublingual. eek ders pas nai malt de 5 mine fr tev! EC tonsa sa inde STEMI tu ersana medial reble 3aplice edt masureerapeutie pects {contre misurnacare contro arto maligne s SI ‘ote de repett amaclog stu interventional} trebule priortare. NB. Nu este recomendetd repetoree admins! role Acest tune poate inserna, ped opt, perder nna preoose fn iniorea sroepet de repre pe deat ‘oate conde fo deterororee Memosioamid apace. in acl mote nese recomend utiaeanirolcerine traverse Goce adminstrarease fas pn peru sip alr deodmntro urtatecontrolatpeporearsltronporuu 1.2, Apelara prompts Service Urges 12. Recomandiepe ‘Sopecert service sistant Medias de Urgent La un povent cu seme cline de ft rere tora cau Iraiere nae nein andl sa nterscapaverteba, spe ‘reaitrasiaiamefel webu pest at servicldeurgonS 12 ‘peer ext overg ort portant in aul de nerve a pint STEM lsecer SAM srebule st fe pescanece a uno Frctcale (asstent redial, pram) care 8 actlonete pe Bata un protoeaie lose sere. Dspecerul bus * Sbecunoascaimptomel suesve de STEM {stmt a paler un ehia| cu dotares pegntrea act ‘Sestara complet aunupadencuSTEMIin espa 15h nce pacentull sha 0 bles de nogcarind de 05 sublingual + Snipes asin (dou 6 15-325 me de pro metab) 4 Shc copil at explce, do la cians, ele aft in prejna vicina od de sfctusre a manewrelr de essere (suporl debs a Vitiinstuasinareapaestoplcardoresprator. ‘ent pce ebule anspor las de cite Seri de Arter Medial de Uae sn uate ifloace de anspor. Set prespals 1.1.9 top cardorespatr Resusctarea adiovespatoreefectuots rt ‘depersonauinon medal Primele 45 oe de Ia debut sunt cre pnt paint cu STEM! Ste periods de instablat electrics maxim motv pens care Incidents arenllor magne, ganertoare de stop caroespator (Gen) 9 de moarte sub” Ronse ventas (FV), aicarde entice (TV), asitols (AS) sau acvtate electrics pus (canoe sub denotes de soci eletomecanic = DEM] este mains + itefeesarade impideal perruefectuarearepetuzel mio ‘set maior de ati magne im prime ore de i debut STEM! Ingame 0 montorizare sents 3 pacensulstsInterventia prompts 3 Suraj aetunn momenta apart SCR Sansa de supravine & Sint depinde de promprtucines eri manevrelr de rexsctare 3 1iepromptudinea apes unut a electric exten (8), Sansa cea ma fnweund pacenteuSTEMMaftinSCRde af resusctatexteca acest Sse Mein FV aan poco cy STEMI Fi dfbtarea elec efectut in Ive 90 de secunde dea debut amet psteaveasucoslsg0% inte Pen Acesaestematwal renal enrucaeesteincrajt are Ihlatarlr eterna semavtomatznte (OER) decitrepersoanelace cu tre mers inuizrator™™slampiasarenacstoraparatln cone Publ apomerate gt eroportar magainemar, et) Dept urmare, Fe urs pocenteuncicuteubolscarac scheme saucare sat un Ste rete 8 fe atrenate pnt Interest» maneweor de Fesusctore sentra ulzares DEA in conformtate cu protocalele Urs (Oe asenenes,slearea prompt 2 seri de Asstens Maal de Urgena(SAMU}exteeserna ch gol elacre mu poate f aminsatImedat atu tebuese \yteinelat monevele de reucetare char de ctepesoane ice. Prin iste manewese sper ne tt opie sre exemplaFV c meninerea Joint Fv ett ml ep ste net 8S tie timpul neces Ming ual deter lpn. ntervena pescaelrnon-medisle thie forte ingoreans pre exempl, 27% dnt pace cu SCR acre Fevvetaren fost init de eve mart eveniertli au supra Iran stud eect eat, compara curuma 13% nie ce acre Munctarennuatesiniatdoesrepescanleace™. Poni sordaes acl e debut» SCR apt n contort de TERA lusules se aple lori suport tal de bar (bas fe support”26(steM presi eaetenie 1.2.3. Suportl vita de bax (tsa unpacentcusTEMI = Prin tS eile arsamble do mr care au rep sop martina ‘uncial (espa crea aun pent aan SCR aa ase ‘weunutecipament cu exepia sipoutlor de pote. Organs ‘man ae nol Gun pore permanant de ogo I toate orgnele Stren petal eer ese afc sever de abn nigel pent ‘© peranda mei mare de 24 min, Manele de LS (pice crapres torace veri srticalé greg) pot asigura pentru opera Tima de ump un aport de oxigen minimal la nivel eelerlu mocrasa in atl In cae paclentl cu nfct de mora I plerde br ‘mostintapersaarale afte in edata sa vecinatetrebuie Sctonensinconformitatcourstarlerecarana: 1 Se air securtatea sahatoru, vce! 3 persoanelor dn Irespectv identifares perioelr potenile pent salvator ‘Maumatsma,acidente,lcrocuti et) 2e sit jut atx persoae Fgura 3). Mesa resusctar pref electustmaluger decir oud prsane, Una saat ‘apidepusatprnefecrea manewearderenzctrs 3.Seplaseanicimain debt dos {Severed starea de congens prin sl a (ctor jou ‘emeror cent everoa ce intbmplo? Sunt bine?) Oa persoaa ispundeinseamn cues in Svea va sat nace poste ie va pela SAMU. Deck rapunda te tect ln ea temitare 5:Seefctuear3 Npeestensia cpu pant Petru aceasta plaeats 0 ms pe funtes pacentul pst patel snd bre pert ensares raul acest lr vrurledegetclr cli sa plasend sb mentn, Dis aezat poate "basculac cp ‘cto pn com 9 ponte veda ura 30 Tr faces pot ‘esoise cle aerine levee. 65. Convlulespaties metidnd le eine deschis,shatoul {plese desta vite neers statease, docu de mat 1 secund, dad vcuma espa normal elles acroriml Pa (privet -ecat~sinta (gu 1 ‘ pevetemigeorepirtrialetoracll (seh acetone + asctevenunele gamete respirator Flea 9. soltareadeaistor Fgura 10, Hpeertensia apt Fgura 12 Conllespril Atentie! Inprimele minut dup ops cord a ms goateresprasib Shu powte sven "aep-ar rae,agomatoase.Acestea nu trebule (onfindstseuresptatanorma cree de a determina exten uae espa normale priv, tnd sind srtretuiss dren clmult 10secode stor nu ete sigur vitinaresp normal ature el rebule acionaeca cumeanuartespranorma.24(sTeM presotal 7. acd witina nu resp normal ature trebles consere aceastae ans nd robb prin FM Tn acetates ‘pave 3 pacer a dpinde de prmpttudnes defi ‘etre, in acest tv stator treble apelee media ser 12 18 slee erent meta SAMU. Wea apearea Sa ‘webu cu deo 2 dou pesca in timp sabato treble alice medat manele de 5 ack sao este sng atures trebles tec asap care lene dearest via unt pra ru daca aceasta na pri raidun SEE Din acest mote perm SShatoult si abandons, pnt moment vt pens ae Servi 112 pen cares sol trvntaSAMU dup care eto lavewmasinnatsts. 8 Se plea pod pale! pe central tarzan! (ews 12] Podul pam celese mini ve plasetd peste mina care staf ‘once se intropirund eget dior Potia minor vebin st fl net nu se ener presune pe reins elas au spendele fi incazeonrar a xroareacompresetrac se tea produce cu uring acu de cose Su de perder oi frapmantele de aturd pot produce len ale oeaelr inter (ptm, tomae epiplonete) Figura 12. Amplsarea mn pune de pes eras SEN prosptalo 8 Savtordseva poten vera dessoratoncell itera veers $id compres sree Compre tree bie Su practic Compre decamprea oa ete 8 fees ca mp. Fo ®pleare a compres ebule 58 condc la undarea cu 6 cm 3 Semler ms mul Ral esl comprstor rts 5 fice aprxmativ 00 pe mint Fg 13) Acs rim poste obra (ad saber ria hurt “Mu 9 te pt Dupe 2 30 de compre protic dus vent aris neblsgurconformteteich msoae (fev 18) seal constatnguravictine eumul eerie 0000 ro ting expr shator privet ridare peat trace aero sich ume mentnerearisess ascertain de sean 2 irareapae ara acnat represent cet + pd asasa, se repenenead raid mane in pox core pe ‘sacle prin afecunins ae compresses + spear compesie tack ele rons neal ldo pide ‘onal manlr cu tert compres decompesie secon cio Freer 10/rina. socominalectarea corral lace savetaiorinran apo he 302, inverupetea compress verllr pent reeves icine ee neat oar dc axa ncpe sb resp normal: ts, resets mtu ners pin sores eps abe ecuere poral asst akonediesippart™ AS) - ' Figwa 1 espatieResusctareacudoisahatort esses efectat de dol satan este mal pin salar pe sahator a impul un eel rsucrund dnt slats a 0 se comprsiatoracen inp ce a dae de vena aro ea 13 “rebuesublnatewemitoareleaspecte + slctreeSAMU to vederea defn elecice exe o prac 2st un ahatrincepe srgurresvctaeain pe aldoleaaelag ‘chip speci eer), + aporlconpreitraevenlai et to 20/2. La falleci Ser de 30 compres saatorl respecte f pres admits Cele dous ventas pantry 0 al bund coordonare, cl car fe omprerilepoatenunracu cee; + eareobirbio i extonsia capil vor 1 memtnute tt Hm resus se adminstreavd cele dous vents, tp inca ‘ompesile oases ner acest erly meat up» dou ‘sentat,ateptin doar ca sahstonsndepriere bce de eal Figures. Rescate 2st essere doarcucompresitorcce \a Congres dn mart 2008 al American Hoar Actaconon + proput lnunare Te respaiagurla-grd 1 efectuarea acestla st pen fomrest trace (6) Aces madifcare se ase. princi pe dos rate 1 tt ear a portato supra dents apace a care fsuctaren a contat numa In efecioes de compres oscee Compustves pacenilacares-aelectuatsiventi otal (7-72). 2. consaarea unulprocentredus de pesoane lace cre inand anes de reracitare, in special ator reine de 8 elects a gi 70-72). Prin aces nou inate AMA sper Into crete 3 numa de some eae nese rescore ardor pocent ai esucarenvficontout pln cn * ose ehip medical calc care ria enor 0 *sohatrl steep ee Sstematare algortmlu BS poate uma ine 16, 11.2.2. Uae dftatrua exter semiautomat (OFA). jue und pale eu STEM complist cu FV sau TV ata rare ste att nl mae eucBt SE exe adit ai aproope de omental acetnoty ata sper ext xe Us rd azole rey ace im arf comune rr (73.75), Lata poate inst mut ma bund In comune urbane. Asn Sete (Sut) pani x SR apd aaa pau primes un fc eee 157 rmiut a2) Tn ochester mean de imp petra ainsrarea desc electri 3 59 minute ups dotarea echpajeor de ple cu cera, lop are a wadus in eresteren pind a 49% arate! de pace eae au nue eare au putt 8 esterrai (76) Is 0 rth Boba go sweprelsan\ge Kt?42/STEM| postal aetna es CONSTIENTA tens = oS aa en mes ont Pia reverse 30 COMPRES! ree nn ECO Eat Figura 16. Suportal de baz al viet Recunoastereaimportantsimajoreaadministériiprecocea SSE ond nereareadeibrlatoareor extern semiautomate(OEA).O6A sto un dspoctvcomputerizt avind capactatea de a recunoaste Singur aritmile maine care otf opie promot prin SEE s de ado ivlatia de adminstrareaSEn aceste arti, Aceste deporte pot ( olosite practic de oriine (public larg, personal paramedic, personal medical) in prespital sin unele situa char in spit \litatea DEA 2 aparut imesiat dupa amplasare lor in locurile pulls. Asfl, un study prospect efecuat in aeroportrie ain ‘Chicago pe durata a2 ana arta faptul & amplasaea de DEA ari bine si marate a mod eorespunzitor a permisresusctarea cu sccesa 11 dncel 18 stopuricadiaelnregistateinacestntervalde limp, Zece dn ce 11 pacen esuscati eau in vi aed sechele nrologice dup tan (78). Defbrlares precoce este singura madaitate de reducere 3 octal pin stop erdorespiator pirat in contest de STEMI Dia 1 motvacualeleghiur incurajeazSutlizarea DEA de cit mal mul dintre cel care pat Interven! precoce In STEMI (frst ‘esponders") cum ar fi rudele pacientul, polit, pomper isotiton de bord ai vioanelor sau a vaselor de croair, et. DA seplaseard in cur publ (aeroportr gi sl de spectaco, woane) ncare exit un ric creset de producer 2 stopuli pin Agortmul de tizaea DEA este urmitorul ira 17): | seasigursecurtates svatorullsiapersoaneordin ju; 2. sahatorulincepe resusitarea cardiorespirtorie conform protocol Ls 3 medlat dupa sosrea defiorlatorl + se porestedefiriatorul se atayeazipadelele (modul lor de atasare este lstat in figura 18). acd exist mal mult de un seater, BLS tebulecontoust in mpl elect acestor + vor fl urmate comenale vocal sau cele afte; resuseltatorl se ‘va asigura imei nu tinge victim In imp ce DEA analizears itl pacientul‘bac ean apearea desoc alec *resuctatorlsevaaegura crimeninu tinge vicina “eapisbtonul de yocurmindnsteacinleDE ‘h Dacinuedstindeatiedoyaceectre: eno 02 a cons conform comenaar vole sau calor agate de cite Figura 17 Agormul de uizare a deibrzorul extern Semiatomatiat (084) (70) Sa on Drplsaen padeeor =} force 5 Resusctaravaconinuapindcind ‘itinaincepestresie normal *sohatorleteepuat ie 0 serene a modull de abordare 2 und pant cu STEM! pi a ul contact media estefactSin era, qu 9. nteprati' mod de abordre 3 infaret emieard (Moc sude debut SAMU seri de essen medical de wrgents; AE =deforiator emiutomatatste pres 11.2, Etapa prim contact medica extrasptalicese~ Unitatea. ‘de Primiei Urgente (PCM-UPU) 2. tdeiearea rp STEM Diagnosteul de STEMI te bzeatS in prespal pe aspactl ‘rocardograme’ orborat cu dtl neu reutatele tester rap ‘tava ge deptaresmarkesor(aptalllh 12:3. loregtrare eecrocordogromelstanderdi 12 deat) Ctrl Ec penrusTeMiaufospreenatoincapitll £6 standard tebe efectut in pimele 20 minute de 2 ootact mada! [PCM (casa vel de evden 8) (4). space Infarct miocardic (psteroiteriortrebuleefectuate fnvegisti "plimenare cu Inloerea derhatilor UR, VR pent agnosia narctulde verea rept asoeit 8). ‘nsaspalep amoral 302(73). Atentie! 1s gacej c cardosimuare permanent care 5 stilt veel 00%, rasel ECG de carsartimulare mash SemneleECGepicede STEM. trou ECG se po entific artmie ae ot compa STEMI cen. in azul In care electrocardiograma este sfectuats de 2s tentparamedel nesta pent deca agnosie gis tape Sauincade dub cde dignase ol medilor urges ls ster Ge telemedicind pentru transmiterea electrocarelograme! ct ‘depatamentul decardologiecs mal spropiat are poate preleapact NB. lecrcardigramd iia on dogmas pent STEM epctate dupe 1530 minute dacs tbl ci de STEMI ers. ‘east enol de np travel EC se poo modi deena ‘pent TEM 1.2.2. Anarmeza int de efectuatinparlelcuivegsvoreaC6). ‘Sevorclegeoblgtaraumstooree date: “amtecedented boslieardaschemic + factor de ic carsovscl: fama, Npertensune arterial, a {nara dpe Nedrocarogeati eogeresdateoranamnestee stem presi + erate duerttoracce ste dep anges) Intense {Ahpunstamtrogiern. eae bun modaltate de evalare a Intnl est dea oso seals ubectv dea absentia {lve pind lo 10 (duere aoc, superb). Paint va otto 53) een singe inenstaten dur (ce not da Suretpe osx dela0la107" ‘eaten fnoméneorinstitoae (tlburs digestive, dipnes, transpeaet) ‘honizates eventual contraindeatipertutoriaich~anuse tite neeidenele vaseulare cerebrale tate boli neuroogice reosstntelnlsvtamod cerebral 2.1.3 Tstul rapid cotati de depstre a marker de necoxd Inco troponina CF 8, mioglobn) TU este obiestorie pent agnosie de STEMI In prepa \ilote moterlor de ners pot formal In pimse 4-6 oe de Is nua STEN Ty pte ete de depstare a mater de Wh mioeah ma av senabiltaestetlor cntaive. Un tek UNSes pctv eonstie un element npn atestarea agnostic (nic untestcotatvnegsv NU exclade apostle ifr) 22, tecture aprotic erent Se face pe bata datelor anarestice, lactrocadografie i 8 wu le are tebe efectuat edit dupa Invegirares Iva Ato special pentru dsecinde ota! teniloconasacpencardtaasevedeacaptl. 2. Ieadrveapacientlinepurie hemodinamicede STEM, Incest op trebule fect exemenal ine complet inchs amenul neurlogie peru dpistares nor evetuale varie de fonts cetera aeutsau sec 2.2. eaharnclin tt) Strco de consent: pacenal poate agit, dezrientt, habit ern sigerenshipperurincerbralb)Aspecaltegmentlr: ‘nomaleneate cide ‘Ye curanspaidafores,eucanss pres sacha cas Inarmorat Tatacesteasugeensvasocostitisarterl pare Trains refi de redcarea dames debut INpoterstunea arterials, dean rtm cardiac thd de liu acestesere ne soaleasogen, aPutalpote ‘cu ampltutine reds hpoensne,desidatare, nae omea yoccartone. + cu amplitudine cescus (hipertensiune arterial, hiperto Sites). + prado (ul kussmaul amplitudes sa ine profund na spare semn aso farts vontri rept (8 Srest mn poate ft intsit tn tamponada perieardies 3 ‘rombembaismel pulmonar, ‘iterantinsuflen venta stngs sewers, Tail fin) Regula: third sna ‘weuar/venttr, ter) + Nereus Rist stil, Mute ail cu Boe atioventical vara + Brio eSOmi) Regu baicarie sural, ocatoventcuarcompt tahicariie parowsia (supra Neregul: Roa ari cx bloe atrovent degra na bocatoventrclardegradlit Atentie!iseniares une treme de ampltudine puss rmembreril supicuneadedsectede aor _Tenslunoorteiolebe isu fesvent eto parcursu pet 2surpindfatats prompt eventual sabi hemedinamie = hpotensuneo arterl8 terse soled 95 mn) ‘pareinutonsiestuai ‘+ Npertone vagal ca in care ete acompaniatd de brad Sinusala) De regula se invegistreass in infarctol miocard poserinfror ‘9 Tesunea atl tebe sure frecvent peta pac penis thurnd ata prompt svetunlelensaistnemodinames poten eer tesunea tac sa 9 me poate pare Inormatearee sua * biertonie gh (tn cae ete acompanits de badeare Sinusss) De regula se nvopietreatd In Infarct mioearde posteroierior. * deshiratare (pirat ea rental anspor prolate a “arstuni(arineareesteacompaniat details * nscin severed de pomp care (0 eager) state in remo iportensiunes oerlinde impreun cu third sinus stares hpedinamicsindusaprinhipertoasinpat eneleuguare ‘pectoral pind *infaret de vrtruldropt revrattperardiccu sar tmponadcardic + lnsufens venti sting’ cu perenne pulmonar 5 Secompensarevenetora creat ans + pneumotore sub tensa (omplestie ncaa mont un {atetervnoscenal *embolapumons ‘usc cord Aluraventrelorspoate Tahara 80/mn) Cu itm regula: taicardiesinusala,taicardieparoxstea (nopenventcaleerers, Nae * cu rtm naregult: Abie atrial, futer atrial eu bloc ‘overra vb radar (<50/min) ‘curt requatredicarde sus, ec atroventicularcomplet curt nee: Relay aera culoc atrovent de rad nat, Slocabsoveniculr degra.50/STEMpeespal Zo0motlecodice Binebotute Aur. Nene ‘ svometulde gap + retro percardc (perc din STEMI nu apare a deb bolic regu, dup 2-4 deo. rn uae supine ut ‘tecituri percardice n primele oe defo debutl une du recoaale sgerescé In primal rnd pericarp el, STEM pres. Profil Npersnamic se inegistreas maids I pacers canoe pene 1b NU rice higotensiune ata invegsrat I un pacient u STEN oreo preceis umd poe catiogeSocdlconfogen' ware It ‘proamatv 10% dre pacer eu STEM 5 este rrin prince ore de but se den rate ale dea itemre. Mal fever, eee a ee, ae; nena nes Heap aidan Be STE esse a a Be a | Be cele ‘+ spatiull parasternal drept:insuficientS aortic; as Lil on | a ara ele : ‘complicaté cu insuficienta aortc3}). 4: gobs sf seo | ow i eee = ‘pda el ll y Bienen Fee defi a hdd oa teeta ee tet ee + rare sad (sues penrunsfclnt vetoing) > ouens + normels/eligurie/onaie 1i.2.3.2.Proftulhemodinamica paint Datele obinute prin evalua cincd permit sabres peofl hemodnamic al pacertul apt impart penty mod de aborda twrapeuted abel 13} (4), Practptf dentist? pur hemodnami 50% din ra de usc a lamin) 1.24, stabiea gral dese values rscull valde evolu nefverabia a nul pacent cue poatefficutin aa prespta pe bara crterilorcc, etrcasigra Saunordstparacncs, 2.4. cttereinee de rise imbtoarele date cicesugerears un ictal ces, 80) ssapeste7Edean, reuatea sub 7h ‘+ semne de hipaperiie tur (eso caren tegument Imarmorate, extemal canotce, trnepiat tt, pu, oli eae psomatore, obese; ‘ohare peste 100/nin ou races 6 in preetrrdestae precetaagoratl Ta aust cord lesen prota ste asreadear paenicu routers deinen os pmeseact sae ceardog, 2.2. cre eecrocnogati dere a pant STEM sepa cca pt igre sd i cern pt aes pope ese ees Isa pone ae steep remanent psn cpt one ul ac ene descended cs sea tie adhgte space EC rato nrc do onde presen pare rece. 2.43. cher paracinee dere ccc suai gens rt Reducerea Saturajieloxgnull arterial su 90%, Identicat pe psonmaty in spect a pacer es dipae seve poate ana Spal | Mperatemio ‘Gicamia poate A detrminat rls or In prep ator pucotsalor portable. Nvlecrescte ale glcemil (pete 140 rg) vires pacier ey STEM scoreless cu un se dees ee mal re cama eu pact ser gleams ee normal Ln ae cent vo delet ee ma mre cl e oc adogen suena, vlarctare, evenmerte arose more ene este mat mare evan. |<) Nvele erescute de tropanind in primele 6 are de lo debutul sitomelrde STEM negara denivelecescute de toponin in primele 6 ore dela bul simptomatologielsugestive pnt un infaret anunf un rsc recut de deces (83). Reamintim foptu eB valor crescute ale bomarkerilor revelatori de necrozs miocardieS (creatinkina $i ltensima ef 8, troponinee | 7) Incep fe Tetra cel mal orem dup 3 oe dela debut infact. Oe cle mai mite orn lone lorsun normale primele Sor,SYSTEM pest Din acest mot, detecarea de nee crescte de troponin ‘male 6 rea un pacent cae a mal aw dre ine preced ‘verimentull nd fap epsoadele dureroase anterare au robeblinduse de ocualcovnarene de duaté mai sur sau |ungsinudoarepscade de angi pectoral stati (36), Figura 20snttizeadciterileclinicede stable gradu ‘aunuipacientcusTEMt (38) gura20. ctr nce de value rsp 2 sulla un pace cu STEM! (Av = ora venue = fensunea ore) 1.25. Tratamentul generalimediat 253.0300 Nu est recomandt cminitrarea de uns 2 igen n STEMI ar lapacenticusemne ehipove dspneesousutcetcardas ‘dminisrarea de ongen in exes, spacer cu satura normals oxigen a sangaul arena, poate A dsunitoae deourece determi vasoconsficie atari perercs cu cresteres petal 5. ‘ceasa aconsumulmiocarde de ge. Adminstraes de onenine ate f de ssermene,daunatoare i paint cv bromopneumo ‘true cronc. Di acest motive admintares de onion Ina patient nu teule st depsjensh orth de 2-31 pe min ir ta Seminisare webu restr Gore 68 ‘nian trebuie Ins adminsvat fe rrerve Ia to pace satura ater de oxigen sub 9% au dct au depne, seme Inston aude STEM press vl experiment au evident recon injil schaice (88) 32 jrodenveliet segmentls ST (85) sub aeminstare se oxigen in jigowene.Osgnl a dina 1S Vin ind ind $902 poste nase ol pumonae rons Iedupacentorcy STEMI Test (admins orgen 10%, 1 in, yn ind satura de ongen pote ore montorata pin pulsximetie, po dovavaWvaain ante de 02 (0496 sa 882%lacecubalpuimonarecaris. Sadaea duel poate contribu a educrea rc acti, poate ina arsette apap piborotai pin cet, conti a vicereaconsums marae degen ‘geocl de lal este mofin ($4) Doz: 35 mg admins vv nenouscoepeateepeiasinuncied cect dpsS 35min ATENTIE! + Morina WU reo adninertntamusse ‘+ Morina poate induce Mpotensiune arterials (prin arteriole # “nod stad gritos vigarimet) + Norra post cepime resp. Arto mere ete naan (rloona}.10.2 meh curepetaren dna evoiedi 5m * Date find eee adres mengonste mal ss, morina NU tebe mitra ire de cont trl ae verte (ie prefer lsat aterm cigen cae veda peste + Norfina poate induce greats, vest, motw pentru care exe csi agminstrarea de antiemetic enotzine, mtelopami) 2.82 nrogtcwna nse sdminsressce snl pacecuSTEMI yoga pote Ws us in al pacer ew infra 3 ipreniune ater sa inser aac (4). Ntroglaria poate 8 jn forma eats de 5 mg subg, do cre poate els eeu 20min sup admires ede 2) el rere persis pote recage perfec nitrogen dod it se 10 mer ene pate rem cs 20 en pa iia snptomeor sau pnd a reocerea tens ae cu 0% nor loses ais nometensh)soucu30%la peer (26)‘6/STEM peestal Atentie! Rispunsul antral paienior infarct poate igre a uni ne ace tonsunea arias poste scien nett de ups aminsrarea primal alee, mot perv care tnsunen at treule stent montonzat. in esas mot sdminstrres de nitropa Inperfsiein presptalbule eu prininarmedi unainectomat 3 al nui perfor but near eortrr In crs tanspart rim _tminstare al ntogcrine poate sea de sb con, fap care sve conseorfehemaiaanice somatic, irogicerna ioreare ane trodes nse adres + paclentcutensune arterials sub 90 mig sau cu redcerea tens rslecu al mut de30%anvaones nial) ‘apace infor miocard de venti rep (te a pac cuit poser stuaecaeseconpi rece ic vertiuldes) ‘apace cu brad sever (8 S0/min) cau tah pe {gin aa) 41s pacinp cate au flost inhibitor de forodesteaci pe sun erecl (de i snl nuts 24 de re sau chi 88 ‘or (preratandla (4) 2.54 Anicooguante 3} Motivate uti de ansoaguante preset {apacent cu sremt Aicoapulotele sunt atta pacenicuSTEMIindoul modal ‘ca mice ajar terapel de ropefue (armacsages interventional) + ca profane 2 acidentlor tromboembolle Ia paclenti oririncieai de erpiadeepertute, a paint a care se decd trap de reperfue, adminrares aninaplatsinpresitalarsurmstorele mote Foclitareadesobsructieicoronariene 15 becom waa cu fvininer hearing neraconss (N) ‘nu Ts cesetea rate de cebu cena entats Brno vite mal mare de recucre»supradehli segment (87) fe pin coronary Ansrarea de apace tah fiomotice bans ie oreduerc 18% 3 ora poco STEM prespta/s? a pein tata pin angioplase primar (PP dub antiapregare Plachetard#admiistrarea ni bol de HN iain de ante pinflor eitre Departament de Cardloge Itervefionalé (OC) poste crestatadedesobstructle coronaria’ sportand” pe arcu transporukpacentul etre OC. Ase, im stoi! PRAGUE.2 ‘orarima 0 teime dre pacino i Clin vedeea ‘feel Pct aveau dee desobstruclecorenariand cx TIMI3S2u2 Inaine de efectuareaaneopaste. To acest pacer usesed ins inca evaspins,copidoge suum bos de 200 were de visited transtr(2), Prevenrereoduielcoronariene dupa derbsructia ld upd debut STEM! apareo hpetcogulbtate sanguna.Acasts tend se acentvazd dips adminstraea de fibrin, Ric de cu tmp de numa scart (98, TNE, A) Din acest mot ext higtorica maine suid dips administrate una are ao lveitrombaltee maisusmentonate ss asinsvere anteoaglate [feheparindnefraconts, fe heparin cu reat oer mis) sae eden ajo gana geganteplchetae {apainpitrtaimtervenponal antoaeuatele sunt aénsratede ‘iio ace enti ec wet a tecture, eq oe is ‘resi fcomparatanccoagulantecyplaceblaacest pacien Estreacompikatiorromboembolce 2 fos moat invodvert ancoaguanelor in atamentul STEMI nite de ena reper intr penood in cae epasu rclungt a pat ea regu, incldena ‘romborslar vnoare profi in membre pane, oat mar. Deal srsculcesataetrombembolim pumonar Pe dea pae0 iararepertiaie infarct rae marimar pt cae condoe 2 ateraren importants a func sstaice a vere tng ezvotrea de anes venice tate conducted a apa de ‘womb itavetriuan. Aegta puteau &emboliati In ereustia stm fapt are conduceala accident vosuarechemca cereale Sau pire, Ata, ep aniccaglantle nu para ace benef ‘mporanelapaceni ik erapie viet, in conde ui de lin, betaslocntl, ita nibh enamel de conver, le pot Rute penta evtarea acidentalortomboemaic I pace sc reset ine anairnns, ombin vc stn, Mbriabe tril croniacienteemblcatn antecedent, suit veneass tones demembre elie).Sate preset 1 Antcoagulanteleathudinepractcnpresital Inaba contain, opie cu STEMI rebuie fet cu antcoaguante de indats ce dagnsticul de STEM! a fost stabi. presptalavemdealesinve Neparinanelracionat (HN): 56adminstea2 Ih bols 60 ul ge (rks se coisdora toad 4000 Bluse HN rebuieurmat ‘opetuiecu 2 /kg/or Heparne eu greutate molecular mled (HCN): Doud sunt HM nt ls pateni ea STEM enoxaparin oraaparin napa Hamble au avantjl uur! de adminstrare, efind noe de rls conn. Inplus corparatveuNenoxaparina esac cs 50 Fata renarctzare pain (33) Fondoprnu, 3 dove, {ssemenes,superiar in compart cu HN ls pacent tata ‘rnc (4). ATENTIE! Fondaparnax se adminsreaes NUMA pacing eu tratament vino sau la cil cae NU se tetone terapa de reperiue Fondaparinux NU se uaz, prin urmare, pacer la cafe se preconzearhrepefuna Interventional. [remenes ondoparina NU se admintres sla pacantieu insu ‘enalsevera (clearance acresln#sub30m/nin) Enoxparina apace sb 7S de anise administers 20 mes ‘bk 9 Lg/hgerpsubeuanat La pact peste 75 de ant NU dminsteard bolus, ar doze adminisratasubcutanat este Img/acor. Fondaparnut:25mglvsi2Sma-subcutnat.(bell18) STEN prespas9 125.5. Antogrgaete plachetare _angregat plata care ptf folstatn faa presptals STEM su: 2) Asin: Hochans eooupeana lahat cre mesa saa de Proglandne trombonni sn sed aden Wonboranal HAZ ete ‘puta stra lacheter 2) loan recep 2 bees lees adnan (ADP) Is recptrl spec 2%, nbd asl acthaesgheopotia Hh (85) bin aceasa pup oe pane doplogrel, copia, veagreor, rose arr Cider sprang sunt produ cae ect Sete forma ate leh te Forma 2th oe lag eves se reaptonlP2, rept urraeefeulanigregat pach laces Se taleard ml len in acext mot exe neve il deo xh de incdrete mare espact 600 mg. pent copogr 6D ma. peru rege) bone detrei sunt e 7S, respect de 10 ma Tiel este un hbo det de P2, I ae newie de atre heptel scare Bochea reves cet recep. Din acest mat debutant agrarian dps cou ore ce lnadnitore acta ss antipacheta age aa 0% 198. *) Motaile ws de anagem plachetare in prespal Is peu STEM ntagreanel achetare fe parte dn tap tana pacer srentaeonrece: * vomboctele sit implicate in womboairracoronran spusitaare este, * atogrepntelepachrtare pot induce esebrucicronarand precoce Tin combnal cu aongns) i stds PRAGUE sproape ores ‘dre pace randomanp pare wansr cite PCI eau aera ‘oronath desabamit cu Ase TM 2 s9u 3 In moment fui ‘oronrogafa a Ol pd adminstaes de asin’ i epiogre 3h epi ecjonat nate easter (2 1 reduce cl de reociale coronaria orecoce dup 0 desobstctie inal efecuat fe tarmacloge, fe marvel Dus fol rea ‘erect rath rest acs tu line lin spec [The ta) La pacer taal itervendonlraoduta treet oat Sparse rapes en tn east, deel n ple 30 el, fret de Sl do sent ant (278), Cau eo Intense mile dr eas ms importants de sestes te ‘esdminsarea de antapregarte sn ADP recs lachet(Sopy, ear suo, 98)aysteo press sev pest + rosuce motte sevenimentelecardace moje pacer «geen cin stile cde mau ota dence anda pens STEML na acest banficiv fest doves pent sspinin studi doe aos de 300m docs recomandatla aca dat degre 1352 (reducer cu 23% » moral ta cc siptoman, rtf praca mesa utero ora delndreaerecomandat usa heck ar 25m rn roll cn echinedll ot cee ogg dell AE ROOM ANN CORT. ros tiga ed supelaeet a conden redaredl > CODES alacant eteelce cet bpelogn ‘mortalitieu 42%). Uerior sudile au evidentiat un benetcll seq tratainterventina cele de 300 mg (34.35) prin educerea Spline pin adbuges unl atures placer dn se ge secesntncir/ abet vec cerealeccae ocnord receptor 2%, Aen COMMT/CES2 ata de deel oun fous combina! de doen ifrctare su cient sel rel fost ma esd peu peel Utah aptind Ml) Andogroarnepachtare-athude prc pep topo compare cae a pri urs 7.59] To pac ch STEM te at de dette ‘ers 81% fi respecty 9.3% vrs 103%), On ret UU sgegye pata seca pron oat err Ph, Se eer See EGA GLEN oe ee ree en ene ‘combinarea aspirinei cu clopidogrel la pacientitrataticufibrinolticel ...ctoe p2v, trebuie ficutd in functie de strategis de reperfuzie miocardicd ondus iat deeperfiecronaiancuTunTIMl-34667,041a4 ~ercaréa pleats atl l00Y Ge ore, semnieaty mat mare In comparaie cu cea de 60.89 (ase ecgafibeoleastnccelde-ldoesantagezant treble st fmrogarath i paclettrateh nua cu sokind cl OUHhal WIL” fe coaldeel peau ope eee nome de pad sor reducer cu 20% a riscli de decs,enaresizare sau de schemil csmpinai aspirin lus opioge) afst estat cu surces la pacient recur firdocrestereariscidehemoragimaiore(9<0021914f trap foenots 9900) pang pentuteagelor spasm erie Hegrelorncombinte cu asprin ra dove» superd exist Ind sta lo ea pacien. at find otens superiors 9 “lopdopeta In continaie cu aspirin a pacer cu singtoanl_tegrlor in apart eu dopdogrel este de prespus unr hemorap foronarene estat interven 3). al mae cu earl a pacer eu bl det cu piage ‘Teagrloraton sdministetniiat nto dat eincrcre de 180 i Acetic ete, naar mament dour igotetenefind Gerona rin per os urmat deo das de tenes de 90 mga 12 oe. ig Lsetage eas aa er Sater ee e EU MINGM aie eae na maa ee lan ck ork deinveynerece 75m: ‘tune pina opine comands este teapoor cae +2 dvedt cis tacit rca jacoent a nn eee ee Cereal fst connteatv mal radussipacengiuatajcatioereldl 3° tyarht ane ganar sdnattatapacemenvenmalare (Gi) compara cueitrttieu clopidogrel 1088109) ‘47S dean: lacicareavinantecndente unaexset vasa cereals slarindlsiu prasugrel (Go deincarare omg darhdeintetinetf scl ch greats 6D de Klograme dat find cul creseat de ddetoma/t)incombinaiecuasprinascondusla arth senna nemaraie cerebral Ia acy pace (0) ln absena earl imatvedd de deces enrivasulrrlforctare cident vascu]_i/snu pase an sl nar cea su contain Caebral (19.08) compart cu opidogrel (124%) aéminstat if ‘oltre copioee otk de ncreare de 300 ma rats deo doe de intretinere reat) 8 Aspina nav admin la pacienicanosctjea dad erieAdminisarea de bet locantelnpimeeore dela debut SEM es scant deoeece ee pot induce ntabitate hemodnamss, bad ‘Sermfatie stub de conducere atrovent In pls ia Iveta to pace STEM, beta loaner nu pare 836 beri semeative(10)05) sau poate ior reste inden soul ‘ardagen (10), Din acest motive attsineaceara prudent dea ‘iminstra in pesptal beteblocant IIa pacienh cu STEM (3 ‘dminstrare ral cde etalon exe nut in pest (ua np Ine nace nse de a ajnge asta poate desbia pact {tend probleme terapeutin dpsinernarea acest 1.2.6. Ttamental rior maligne (iba ventric went ra pls, asso, avn electric rd pls) Incident atmilor magne iia ventrelard (FM, thc venue rd ps (1V), atl (ss), soi elecomecanic 5 ‘etaten elects fd pul (AEP) este mas tn primele 4 ove de Gebutl STEM Cex mal bund abordare proces 2 srtmsior magne eprint algoritm per suport avaneat al et (ALS) publst Conslil Eropean de Ressctre (43),8)gur 21). Conform aces algo suceesoneamaneeloresteumstor: 1. Asie uportal de bali Apasiaechipajull SAMU nu nsearind abandonarea maneweor df Bisintiatedepersoanseaftelingt pace Incartinearemanel Ge BLS pu a fost inc nite ech SAMU vo tral Te ie imedatin sevens 30decompresitoacice/2 venta {2 atayeanhdefibltorl a malortateadetirtorlor ast stent ss apie cele do adele pe toracle arterial pcm (o pada per, cca Eublavicular erept) pentru ea vase ECG 58 apa pe ecran montoru 2.vauesn mata! (ats montt defirisor, e aber pe montreal adie alent, Post idenestsuna din umstoaee rasa Figura 2, Interven nati maine (suport suas vip -modieat dup (1368. RCP = esisctarecardopulmonaré *) atmie mata care ponte emis pein SEE ait socal Rbiele ‘ventricular (FV sa tala ventric (TV) fi pus, Se admisracimadat unyoc electrics (150-200) ans94360 sono. ‘Nena Socullecrc ear séminsvatin sin TVpoimarts rele SE fe nasinconzat In cau n care, in obi, medial sau Daramedil apse butonul de szorzare al deviates [NUA DECLANSA SOCUL ELECTRIC DEOARECE, IN CURSUL FSAI [VENTRICULAR PE TRASEUL ECG NU SE INREGISTREAZA UNDA "Rt, ‘nc pe care defiistora rebuie s."vad" pentru adelanga un got64/sTen preset STEMI pesos Inferential de ope cnias se adminitreh adrenalin, Ame lo sare 35 minute pint estbiien cele! sang spontane ‘ossa aca cd adrenaline este admin a fare 2 lt ae ‘iron Daehn engl ACP apar seme de Ways (misc, respale normal, use) Severed montrd: dac este prevent unt organs verifies pull ena aed acest eso prezet se ini aries pstressctre ‘hu tatamentulartmilorpostresuscare. Dac} nu ese preznt pul Cental scons REP asguravea unui aor comprese wi e202 ‘restate extent deacecasaotorcareeletueazi compres (rbuleseioclpaflecre2 minute ‘Civaneare eae trbule fectatein paral cu essctarea SStlorespatre ssdminsrarea de oe lete nabaiaor-abea 07) Pale abe intubat t ma repede vena cu blonl Ruben a ‘ores aapanh o srs oon cae Badmnttat cu un debit de 5 Win tbatia or tapels treble fetuts doa de ete un personal Sorat antl Init stn so Iterupscomresle traci Spl Isongostopil deci pena oSeurts pou trecerea onde deintubstie ror cra ven In pe personal cle, petra eva oce Sivriper 2 compres tore ino roraheas va eects “hind eubea crea spontanentubatia nu tebe dureze ol ult 30 de secunde; dca 2 fst fete in aes itera de timp se ‘ecomand3 vera cu mescd 5 alon fd Ineruperea comoresior Toate. Dups contemarea posal coreco 3 sonde de 1OT aceasta se ‘ts resale mull ssa prezeta unui pal palpbl medi foc ee font rar intiitea prods rin Incareaea de declr cesta va compromie spine micearl Dac este preent v ‘envenabi incl sna comoreiletorcce eres scl derecure 14 Tn prezena une! assole, upd aéminisrarea foculu let tomoresil oa otf tle in nducees une ari ere va pte Ulterior,convertts Ia ritm sinusal. Se continus resuscitar Cardorespiatarie RCP) pent 2 minute, mate de op set pe verre monitorl:dackpaietlcotnu en VV se pic oes soc elec 15020 besa 360} monotai). ACP serine ‘ups a doe go, tmp de 2 mite, uate doo scur pau pet verfearea monitorl Dac tal afat este tot FV, se ainstrea renaing melo uta imei dea eles oe lec (150200 bia Su 3601 monotone) reuares RCP (seeven: arenas ~ oe ~ RP ‘lure rtm). acd FV/TV pers 9! dup trl soe electric ‘dminstreer un bolus de 300mg amiodarond (5m cop), Imma de dnp necesar perry anal rut, naine de dina Celie a parle ore (37), Durata resus esto problems ect cine, india considerate creumstanelaindividal dental 1 stopull st percepts asnre probit de sere. Pact, RCP e Continua tits citpacentlestein FTV ) pocientl exten axa south otto eecics (ir pul (AE) rtm nonsocable Dac tiniest sola say AP slncape BLS compres trac si ventiiin apart 30:2] se adrinstear adrenal me nave ‘aud post de ston STEM (de gla incl postition poate tonusul vagal exces; din aest mot, se pot amine 3m. aro Iocest docs eigars bocads vagls matmals) dnc emul aft es seolsau AEP (C368) ‘up 2 minute de RCP se reevalunars ral das asso persis rete io Scimbare in aspectl let al AEP fat de mostra Inia, eres imesit ACP Dac tmpulresusti asiol sou AE es Incite se apd algorral@ FTV In eazcontayseconanus RCP seaiinstreasb adrenalin lafecare3 minute Accel venorHadministrarea de arenas, ‘esopresna yl antartmie ‘ezsu wena precce este etre de Important pent aes 0 ale de administrate» lets medeamente, Abra venos (de prefer ‘sind avend dela ive membre superioare trebles sereatzezein primle € minute dela agnostcarea stopull cardoresprator. COR comands, n eas impesttai abordulul venos,semiistarea ‘neicamentlor pe ale intaosaa dace aes abordneste pos, rene inatraheas (4368) Sustareleadmnstatzinpeifere webulest timate de un bos deh de cel pu 20 me ia entremii ‘nde #9 efectun injectarea entra 1020 de Secunde pent 2 fit ‘onsportsaubanalincrealtincetalacetic STEM prestas? Acrenlnarémnemedearentl ringgit intinpl resus Punconansadrnains se asminstreas soa F/T pert pal ol {ocelot rept lafeare3 Smite, eto pocsulRCP. ican incre ord venor nese pos adrenaina pote dint inatratel In acest stuatiedota trebles ede 3m bp ltr seings de 20 ml compltindse etl de vlum co flog, amestecl al obit re pinge” cu putere pe soda Intute rtanels up eae, eu outa alu Ren, ecu twelve energie al nest crenata 5 pt jung pnd ana rmemtraneaelo 90%); 18 nu se ute ok dmunstarn unataneteeitavonos fun paint ctr ‘espatoiimportante pate determina deprimareasevers espa estar apartunuistopresaatr nea adrinsvrepette de SE, tral de ng dre dus Ieareameardl(12). 1 ous ecomandS administra repeat de SEE pentrucpsodele de Feria avald parotid (avosmitate, epee. cast sua sta Ge obalilt Ispaclenl i stare acre ati este Indushdefatarpreptanhpesstny(decxempluacdrsmetabold ‘ausepi) Cadverianavapreveinolepsoadedetahicr 3) srinsrarea un SE nu este uma, in eal tatu pacer de ‘covering fl onl irs aria ahcwria rvke Peresa for pacantl contin 8 fe etablhemosnami In aeaet {Tua eva adie amodoron, nda deiner, 300mg ‘éminsvarea de goin ae pace inspec a cel culnseiens Cardiac, poate repezeta aferrat,scopl find rare aur etl My ebui tat apc eecaldgonul se istateaeh "ant sip 6 de minted seminar) elude concetaic ‘eatin abi dup 6 ore [gh 2008) Inccrea rp cu gon ‘nanos (6-15 mfg respect 05-10 mg pentru un paint care Cdntiresenjr de 7 detograme), cu junta de dou minstrath ‘pal aren curse doe, poste nice ea liveries pa sominute20re113).7oy/sTen psp “ehlcnifieiatabtatehemodinaied bain ari i ter atl la cre tensunes arterial srmat nu Se invepseaxd sere do isuicen adc. in aces ‘ont preacupare personal medal prespaese MU treble ‘conversia/cntroi arte cimai degra ansportulpacentllasital condense mais. Daciseinsst2ncontoulartiele poate ota pontureducere ‘venture sa pet conver elec. neal legsi prime! arian tensa laahrivenerlare ‘Administrarea Uebuie inert Ia cazul in care: 1-5 bri ‘eden convenaila alu venta; 2) tenstunes ater ade 100mg 3) uravetrlrscadesub 0/in i) Theaturlncate sinrare de beta locate et contain poste apt litazer (20mg administra introveosin2 inate su ‘Se operfse de dizem inrtm de 1Oma/or saul verapars 25-10 Intavenes in 2 minut c, eventual, repetarea nel doze de 5-10 Intvenor 82530 minte}(35) 28 Conversa elect» bli are sau» fate tial poste lua n consderare la pacini scareananens nu declearsastel. artim antcadentelepcint Thicarda parotid supraventricular (TPS) se Invest rar pacing eu inet de miocard. Oat find alura ventricular mare cue ‘olueaxt ceastdartmitreuiepromptopris ‘Adendna ete substantia de elec cca se poate bn cones rapid TPSV lat ssl Does de dna exe de 6m train adminstratefoarterapdn 2 secundo).Incaz de pes pot admins rmginravenos du? 2 mite de prema aminitrare. Aces dou de rmaposte repett 36) ‘ate medlement are pot lost sur beta blcanele (metop sau stall, item pepo! fn doze menjonate ma sus testament oie tal 26), Thicrdia ventricular monomodl stints (uatd peste 30 de sscunde) Sine toler eroinamie (pacer ranging, fra der umonaracutfraipotensiune ensue teal sila > 90m + comers electri ge electri exter neonzat incepind cu $01 (rota) (gid 2008 in eax de succes se poate peta oosné + Amiodarone este aternatva la conversa electrich, Dora de ‘Minsrare exe de 150 mg admins navenes in 20 minute 04S ‘malo Oakes nevoe dn de 150 mg poate Repeat 1015 Iminut. Amiodarone poate administra sn perf (Lin in Priel ore api0.S m/min pentru uendtowale 18 or) Dara tls ‘deamsodorons NU robles depresses 229/283, ‘finmtjnclonaccleret:nunecestsunratamen speci 42) + Tico ventric esi (ml oventralar acter) ru neces un trtament specie) Acst i de thicardieste recvert Init Ia pacing la care se realesrsreperuna coronaria, fe ‘macaloges fe interventional este nul ne teri cae indi cesltentatve de cebu coronariand. Airis rete pantan ‘Un etn de watament al tahini et rena in figura 22. radiata sinusals aparece (30-40%) 1 pace cu STEM! otra inferior date ipertane vga inde prin tarea receptor “a din aes eoriy (eel Berlaisc}. Aci mecanism ete "spunator 51 de agar braeariet In urma desostrucel artre Coroare deve, Be prin trombols fe prin snipe primed (130 Sradearda aru in atl de condi ve inset, de regl, 5 de gotnsune tera rental vase aterilare perfec aga Indie). Aeestangrom de radearie hpotersunentebieconundatea ‘ocularogen Tatamentl cont in dinars invaenoas de atropn 5-1 me oa are pate repetats pins ls maxi 2 mg (3648) de umpleres ‘olemied pi ves ma oa trate inti heradiamie Foster ete nao de stimula cardcd tempor, n stu nce sominirareadestropinieteinefsent (tt)TInacste suai sil oc este nvell nod aiowentraa, Incxt de ble ome, cert are pei actare ventclog se af sab ‘voll de Be, interior nod eter, suprahan, Diep lrmar,feevena de desccare a acer centr wef comvenabl (40 (aminatia complnle QRS vor Ings (212 secure) dooce ‘epolaiarea veel se face normal pe tic fac Mi cae rama deapa tng) Adminstare tropa lascsspacint poste Rurmat decrees flee desedreare a acestlcentrudatind apt ne asian ‘os terminate nervluvng Bloc clocalzaresuprasan sunt oe stable bine toaatehemodinamestrastor (2-3 conform (42) dr uneo dt se poate xine pn a 10-19 ca 2 de le Bret mare, pace cu acest tp de boc atrovent compet nu neces eit foarte ror stmulare caracl temporar (pace cu since sau Insel sevet pomp care) Tn STEM anterioare ocuna Intreeaehartero interventcularé oeioarfaptarese waduce prnanarea Mund sanguin ramus Sepa fn eas staf, seul locus se, de abc n barnes seroart a joneunhaoventicdar for contd cave pele area verre cla svbisian (36), pe rma stngh, pe unl are le dou fascial sau pe ara dea. Rata de descrare 9 acs rit este ma feds, de egls ub 30 pe minut a compote QRS sunt ligt in aeste motive pasetul poate deven stabi hemodinamic Cintrldeesadarma poste influenatde stops iereuncompertament ‘cones pate senda sed sau cia poate opr acta ot {or condice a aso) np, econ edu de escreare 3 cet ‘ene pate vor apart verry ate sd ‘oh! venice rin amare, paris uns ae de ce sr ‘atsprestiloescaacs feternetrnstenoos +e avo venta de raul nu necesitiun ratament (36) {boc atrowenticlor de gad sau il in contol un STEMI “terol ssimpund mortar nustmaator card, ‘bog atre venir de gral a i apiutn content de ifrce ‘mioeard non-anterlor hu necesit, de cele mal multe or ‘combina de bo stre-venelarcuboc ita veil de ‘regula 0 stein miocardled sever, inlerent de localiares Bnterioard sau non-anterioars 3 Infarct Din acest mot, ‘ardlostmolarea tebueelectuatleaceppacin (16) =m) ee Figure 22 Ago de bordare al aiartilor cu pls (7A frie ctr; TV= ahicarle veri) Socureatiowetrularsintrewentriuare Incdnf lou ati-ventclare in STEM tn jr cde 24 lar a blur intaventeaore de 10.20% (L155). Sema prognorte abociror aa ventrard desde de loesizaren STEM Tn ocalareanon-anteriarsecuis coronaria Inercenh at ‘oonar rapt (9) surterscreomfes (10%).7HySTEM peso ariostimulareatemporar(70) ote f relia cn peru sau prin ampasare un electro timuloreinvetil rept, etransctantiepecae dover Cardiostinularee tempore prin percutie este 0 manevit temparitare ce scorda timp fe revenir spontane a sstemul ‘Srctoondctar, fe neal una stem e pad vat au non Deeastd metods este capal 53 determine un debt cardiac ape ermal, cso raumatiare mini pacer. Tetnca pacing fercule cons In aémitraren uel ser de lout usoare Precordal, pe magines tng 91/3 inferior a sterul Bala cok {ela nual if centmetn a lotr webu 8 desl eu ental decatreunpacient consent pneu de contact peste suprtataprecrdal Focal in cae lovtura administra are ca recut simulates vent [complex orslouturoresfiredustpinslaun raglacarelotura fetermingunraspunsventiclr (8). Cardostmulorestemporar ansctanatd poste insta ond um minim de antzeramert poate eveettd ate med ct ‘ters. Osrvontal major A paagula transctanat ese icon produ paietull prin convactle muscbre getrminte cae "Seer. east poatinturat pn sedorea pacer, ‘ordostmidatonele tanscatanate sunt Integrate nl mon esbristr lar secon aden sunt capabll S enecute montor pacing carovesis debris cordasimultea poate fiat, ue para, fe aoncron et 3 “demand” In sOmularea ancora som ‘hei este admiitat independant de acttateacadach de ba nfo ate de desrare slse de mes sa aeitent. Din act mat ‘mull elect zneweat” ru prop al pace. Acasa Boat f peices dere osiulresectrch eects per “aneabil cord (roc pa unda Ta mi EC de ba) oat ‘ons verter rept mar, sant pe simular webu et ‘ums cturlor sos, del eaturor incre nu ent unm prop Th casostmultea demand” aparatl seizes activates sponta cord eres sul nna ate Sn rere propre 2 {ade sudo aut valoare (able de med sau de aise) au ‘Spar pau peangteln fal bar naertp destiulare simul ‘temerity peste”tmulearic pop, evn se asl esa ‘eaies3 ca" Inperioadvlnerblsacord. Pacingultransctaatimpunesucesuneautoaror acu ‘insepitaren exc dpe ald ure electro ‘sedaeapacen “pleas clecroaor de monitorze EC stata carcass tora este separate montordefbristr * veriieareaeletalor de pacing conectareacoret aloe ivesaea oven ducing ly neces stimuli sau la @ simular eu Smpitunetoatemare aplearen cectroror dpacing: ‘amplsareaclecvonr destnulce: ‘pois antervpoctrors (nu vo ipa aayrenpdeleoe de ‘instore a soul elec In az de cesta: eectroul ‘Sr se scr ave emoracsh stg, teapendele ‘of mamalon tng, supose corespunde cu patares ‘Seton V9 V3 el pater ee ane subeepuar Sting, aera de clouna verbal ls acl nile cel aterar (eur23) Figura. ‘amplsare ‘amterepasteroar ‘padelor toca pz aero ateal a electra alec prin wtermedl ora ve bowie st coricobondrea cit 9 edna Ge foe ‘ecr) se face atl slacrog laterals lees nell ne ular medi sting, ata de maelon crespunetor eectos \alE05) acelatriorseispunesubeaviulr drept.7a/sTen preset + legerea modal delet demand, dat este pon svertict ‘monitor invederesdetectrscomplecar ORS sponte Inca (are pe ecranapar © multtudine de afc, este ma bine 53 telecine odulds ur + ahem cosreiicinbrtide stirare, 1 alegre rate de stare care parr un alt af cups in yin 90/ont + cretre ites unt ler pla apart pe moni Imag de cpturd sie” urmat de complex ORS at und pote defocus, veranena EC) + pspaea pull perfec pentru confmarea capri mecanice ‘atk eadepoarareavertclrs Dac est necesar eibriarea unl pacer cre are insta eet de pacing. pall dfbriatorll vor fajerat la mii 23 cm faa cyt petra npldin paris unite actricintvepadelesilet Resse carBoresratrie se post execu cx electro dep staatipetoracee pce des nsenstrsculelecwoctii pra ‘arn fecteazi compre serra ene de stinulare ma ic de 1) ‘eeamanda inciderea carostmuatrll pen 3 proven stimu Iradeeatapacenu, Cardostimuloreatemporarvansvenoasd Stimularea cardiac trensrenoasa se pate raia prin plaarea ecto de simular, capt generator su, in veel rept cnt Ampasare se poate face pe ala veel subclavilre Saualveneuglre interne dete Teh nee tanevenoase a rondede tina respects wm satareaclecroaiordemonitoraare6; + slegeea cide aborstransvenossideinectategumentu: sanerenloaiicusin 1%: + punctionarea vena: ‘ser lectrodulu ein umenul au pi lanl VO. Poti rea corect a cectrodllla nivel pons VD sensei de pai pemenitors CG de complene RS giprecedte dsp Se presptal’77 + dersarea elecwodul endocaviar de dere + slgerea miu estimulace demand: + pore carostinulstrl co intensat inal a sill de 1020mAsicvofrecen\de60stmul/miut, + stbireapapuluide stinuaepinedcarea progress intent arena a precordis 9 Nivelal de intense a care icateassstimularea ventrculars ‘worecn prague stimuaresrebule i femal mie de 1 minded Dovel @ ponte eorespunatoae si un conse apm al electrode fndocardol ventrielar Uri se contnus elactrostimulres cv 0 nonstate acurentuu'de2socimaimoredecitapragul s exrageres auld pone *fnareaelecodulullategumen. 2.64. exrasitoee resto vorteuae si atrial surt foarte event in inet cari aut. St edoniete nu a veut ns demonstrere cb ‘stl anunsinstalareuroratmimai coer (36) Pe deat pre, tataentl extrasolar verti c li in lice prevent aacunlr de Rae vertu} sa dove manana In dr eunitor pen castarea mortal (3644). Di acestemotve imitate deantatice pentru contol etasstoler aval, alelor Ventricular al abril venture ness nu est ecomandts aa, 1.2.7. Tratamentul dezechilbrelor hemodinamice Diverse str hemodinamice pe are le poste preerta patent cu STevautos esrselacaptll 23 (abe 3). iptensunea arterial (defini cao redicere 2 tensile stoic sub 30 mmigsaucu peste 30 mmHgin apo cu valoare chins vo msurtoare precedent) et principal tuburaeheradinarich cares poate conirunta personal medical in fra prepa a STEMI E2 pooteaparin ueatoaelepatrucreunstante:DaySTEnt peso STEN prespay7 -hipeoniavagal (sndromulhpotnsune basa eshte ‘tahlatrsou bare ssoceatogen ‘eel Wu oie hpotensiune arterial negra debut STE Inseam soc cadogen Soc cardagen apres arin rele 15 debut STEM, a pacencu intact de mar dimen complica rim severe, int de veil rept, ete De eat mai me orca hipotesiuni este fe hpartona vagal We deshsatarea” interpreta [eid sre exp a une potest indus de hipovlei 20 da Frias str cu alr ventricular rapid dept 400 cadigen onduce In aéminstares eronat de sinpatcomimedic (debtor opaminieuconsecnt negative pentrupacent ‘Ate cauze de hpotensune pot § trombembolizml pulmo compli mecanie ae STE rita dest nerverredar rt ‘order sau a musznior ppl lve mitral navies mit ‘uth eecundars}, hemorapileiatragene (induse de Rina ntinaglot antogregnte laches complate ifecias Sepce). caste tine pat ccunstane sunt nite ss rr in espa 9 STEMI Ble apar ma event nate uematoace tena gue 24 Tater sti hperdnamice-mdat dus (34) ‘utlarea ly derun,a to pacer bets bocantlorin STEMI ns ares acd bane serene 104205) au pote ch cesta Insert oullcarogen 206). Din acest condi attucines ea mal prudent et de NU administra tetatlocant i apace cu STEMI de a aera pind cd area cient este dar sabi, momentincae spot admin beta lane pecsleos 12.7.2. Sindromulbracardepotesiune atrial (gua 25) Se va corer prin adminstare de atropin 05-1 mg, eventual ca ‘wpetarea dove pn dott 2 ms pen amintrare de soi fra sole soul Ringer, Veen). Fonte rar post neve ‘Secardosimulare cecil temporars[36)48) eu 25), 1.27. Starehiperinamis few 28) ‘area hperdinamiel (hiperensune~ care nu cadeat I media ipotensoare cum ar duretenitrgizering setcarae nur) Arata prin adminstarea de etsblocanteintavens, De ret ‘minsteat metoproo| 255 my doz ate pate repeat I fecare rinuteln fine de evolu tensinarerilia lr entare pind dossier 536) ‘sop 01 ent Oo 2a) “ee es ent! ‘ahaa sins poate expres unl sufrne more se ‘uregucere semen debited, stain cae adminis betablocatelor precip para yoru cadioge! Beta bocrtl treble odrinisvatenumain staan care pacino NU are zemne Insulent caraacs, seme se decries, ric crexet de ‘adogenauorkare at cntaingatie pentrabelsblocante ane tnt rs FD Figura 25. Tataentu sno hipotensune-bradcardle medieat 98 3) 12.73. Mpovlamia(ge 26) Hipovolemia va corectata prin adminsrarea rapide slut psf Volar, corres, ucrs 5% luor4 10M),sn/steeprespal erties ras Mn mn st "apn Bn hers nn -gura26,Tatamenl hipoolemll- mosis 9828) Howes ca recut lunar compat hemor inde tog (forint, anbcoagulante,andagrogante pachetare) este prac ‘rnpioalt face resi aSTEML ea necesitnd np penta nsal ‘Spin carpacentulainglasaia 12.74 neuseta de pomp hipotensoes necorecat prin ule oleic gra 27) ‘rast tnd pr ner ve que 27. Trtamentulnsfcene e pomp hpotnsunea ate ecoett| mode dup), Hipotensisnea pots severaacestpaclen La un pacent STEN ipoteane een ispundela adminsarea de ide (S00-000 ih Dra ecestaamiistrrea desenpaioimeice, Tracetscap seria spt neadrenaina dopa ebutai a pase cuhpotensune sever ub 780 mn] se poate aint rovedenling pert contelat pe netomat in dar de il SDrmea/nn eau02-4e3/min) STE peso och tensuea arterial este peste 80 mm se poate incerca sinstaen, in contuare, de dopomind nox Ge 2.55 meaPa/min co ‘estere regres pn ls 15 cgi. ln momenta ce ese ‘er eret pete 9mm poatelnersadminstrare, npr de Ubutomlgindoce de megaman cu ceteres utara» dae\ onan, 1.275. tfretumioearlede vents rept fs 28) a ipmtee se at et aa apse inh nse naa gua 2, Ttamentu derecho hemesirami nar venir deept- moat dupa), Infarct de verte rept compli apronimat 50% dine cane de yet psteoinfror (3) Maloy itersaea vet deep pare ret ater Trad inch suger de fret de vr deo est Notense pein enone erescut- plan fr seme de ts8 (36 DDegrosial Bevin evident dacS se inegstreach 91 dstesia veelor lve evertal pls pardon Kusmaul, dav acest serine pot pt (Dedpocentl ete dents 116)19} Tou maortateapacnpio cs ‘rt de vente et nu au simgtomel semelespetice interes ‘otic! dept. Oetetorreshemodinamic i simptomatie spel Inve de verve! dept apare la numal 10-15% dite pace [R2oyLD. On acest mt, dentiearen nfoctlu e vr dep se foe, de cole ma mule or pe Baza elecocardoprams, Prac 1 0 flew iret potrosnfrio, tele efectiste Inet EG Th Cia entreme dept (Um Va) ar apa sopradenvetirlor Stgnent Ti scesta dri certiicdagnos! de fart de venti tiepe De retin supradenvelarea de segment ST iV deriaie dep ftoetore de ifr de vena dept ete anctore. dpa ie inte ore dela debutl STEMI aprox Som dre pace (122,‘Tetamentiapresptal ‘Muse administreazdsubstante cae pot scidea presorcinal ventricululdreptnitroglicerind duretice)! 1. Reperfusio coronrians, de preleat prin angola prima ‘rebue feute toate efor perry ca un asf de paint au Intrun sta dott cv nlaborstr de caraoole terveonls care poatcecuareperfuacoronaran, Dai aes runueste posal Drmele 120 de minted Ia rut eontact mesial ature eb Inst erapafibnoticlrinpespital 2. Tatamentl bradordetsnsoe. Mult irre pace cu il posterior ompbeat unr de wer rept a brad Sinus cesta bul prompt atts atroins msi, da Dost repetts pn eo ds totals de 2 mg (0. eae n ‘feculatopinel vapor, pacentlvebulecardosomuiat 4. Cresteeapresrcin vec drept prin administra de ene ‘hele Important In tratamentl nara de vena dopt dminitrares de slut periable (ser blog) per eres presarcnvetrll rept 36468) “4 Asgurarevosincrnimul atrovent) 2) Fllaia art poste apare la pnd © weime doe pact Infarct de vente dept (123). La aces poien eariow lech tabu fectuatit evened sib ')Aorximat Sone pacieicu rt de ventral rept sb oven de grad avansat (erg ble compet) (128) cst con treble aigrtasincroismulativenticula ‘eostialare sever (psi numa in spitall mot pent ‘re pace ebuewarsponttit-un spa care poate fet acentprocedur 5, Administarea de inotrope simpavcomimetice (dopami obtains) in doe dese ma ss, webu fet dad tes teal ns edresea dp pri 00-1000 ml de hid peru (se STEMI presi 12.76, Siméromulde debit cardiac senuts soul crdogen gra 29) seep 2 be sl we nm er ne = pe Fiewe 28, Tatamenl soc cardogen-modieat dup 24) resent de pomp cara fore severe taboo ince oat emarator(@opnee sever iso} de sere de hpoperue sua ‘equmente rec, vans re, canara trent, lg, aptatie erematare, cone, cbmc. Smal Se debit carsac set exe Inorpntat en ted pregocin care ensure arr ee nesment 1b nivle normale (125) prin mecanisme periferce de compensare (osocrstie aero) I act earSogen tesa ate ete sk [tbh De fg rtrd di card sc pete Bent al ‘gab, eto fd conpenst a ecu caroge fn cae mca pane de compensa a prabul debt car mal ese mari Pert ambele tua lua opti este reper coronaria el in roast erearnapercutnat sau by pss aorecoronain (264127 Cptunan pen CIs CABG de grt dpe de petra tm 3 ots cornaine ee abreast 128). Intra SHOCK moras 30 de ae a 12 una fos ses mal elu a pacer cu joc eadogn revaculrznre precce (067% versus So 3153% versus 6) emput eu pacept eae inert, i, ‘tiarea medcarertons (126(129). Ol eeste motive trebule fete torte efor pert coun pain cu STE ome eu oe carogen 58 ton ian Stl cpab 8 efetuze revsclrearea moc 2 Fee stp angopas coronaria sub pas sot cnronron ‘wines maj suai nae cl apr peel 36 or a eottrctl sl roceaua tavernas poste fuss in peal 18 dela debt so).sre psp In sustain cre ordre interventional na ete pou se Inst fbvnoiza (44 cia in axa presptal. Rata de supraveu intaspiacansd a pacar vata finite pentuSTEMI compli cusocardogenavariatitre 20% 150% 130-133). ‘Atri de veperfciasornarna Wtametul ache se reticle (adrenalin, dopamin,dobutains) cine 51 modsl ‘ministre prezetaten pagal arterir. Balan de entrap rues eablinprespal ‘Digan mu este recomandst patra 3 notrop pout este el reds, determin vasoconstcia coronaria’ stoic (meat al renege) are potential aritage trial ef reds 120g (ay. eocardlografiaefectut in resptal poate atin sabes log indo de debt shat fret mari dimensun, nrc de veri rp ompicaticardacemecanic,revinatperiarde 12.2.2. pulmonar eat 335) Mine terapeutice penta un paint cu edem pulmonar api ‘canextde STEMI sunturmitoarl pose seriyentod sovigen pease soupesondinals24U/nin; «+ ventltia nonneai (VN) cu presse post (pon 5 mbulnl 8p BPAP folevel poste away pressure) sau (continuous postive away pessure et ncaa In EPACIapatient ‘recenarespatalor 925 rin, pO2 50 mig (685 KPa) stairs (pM 7.35), nu poate Imanagetnon vai 217, + tack edema puimonar ete sever acentl este intubat sven STEN prosotals In comtruare,trtamentu webu Judes perru wmstoarle stat s}ensunas strats ext noma ‘fursemiieO'5 mg/l tee lfopue est odstibupieacut3 2 hice npn cae aoc caoreraredceesoprtlt 4e fide pote Ince o dep navel In fza precoce ‘dretele pot accentua aceastd dele pot precited! ‘ardor ‘trogen sbrgul 05 me (otal) x repetare de so 10- 20 meg/nn pl pe mjectoma ac tensunea ari stole > 10 Meni! sdminisraresnerininatorsntoglesrne fir a vera Trane atodees ict moa de vet dep poate fea seversttslhemadinanc, + Mori. 2-4medin Sie cntiutl une foe 10 ml esau hears tunes arterials est ces pete 4D mn. ‘toate mise dela puncte ‘+ captopl2Smesub nga Ltensana serial stoi estesehut (ub 0 + Oobutoming 220 meg/tg/min ac TAS este 70200 mm feb Serme/smptome desoe das, ‘+ Dapaming 315 mea/rn dacs TAS 70-100 mig see de oe ste + Furosemid ha. acd tensiunea arterild este mentinutd cu Simptcomimetelaalerconvenadie(>90mng) + Wivopicerin in pertue pe Iectomat dock tenshnes aera ‘iolesererentintscusimposconimetelaalrconvesie(> 30 rol 4), Tle sever Riis arin lr vets api, ‘iter atl, tahiardle partes supraventir, tehicaaie vente ‘Toatemasul de masus, func evaore estuariessystem pres + Incandeapecalcaonersi Flas atvalé sau fter atl: dgoin 0.25 mg (o Tabard paroitcs supravenvilr denoising inbols 12 mpi dupsSminuteincar dese © Talal vertu parses suit: amlodarond 300 1 dou fol) adnan 20-0 mi, }sradaremsover: ‘Tontemasunledemaisusplus + orstimulve exparagrafulreertorlcardosmulre) 10.2.8 Stabila strategie de reperfunie miocardicd $1 ‘ransportl spre Unitatea de Primiri Urgente 1.2.8, Repertuia micardis precoce obec print at ‘ratamentllia STEMI epefuia micerdc frente tchnica ott, TREBLE SA ‘OBIECTVUL DOMINANT LA UN PRCIENT CU STEMI | Este extrem Important» se rte c dupd olin eoronaond trombotes toes useless instantaneuntoats aris dependent de at Corona respectna Nero debuears up apronmaty 20 deine tla coronarand ee dav’ progres ttn profursimas micadu Sinreendocrdspre epicard, ct sin spats. Dupa Gore es ch ‘eronarland necoa cringe spoumatv 70% dn micardul dependent foronaracstuat In umatoarele 6-24 reserva adap un rad red de necorh adorn 136) Orept urmare pn desobsuc corona presoce se poate obtinereperiamioearullameina u pcr proces exindees score se poste opr istarea sit de tt "eperuie exe cu at ml mare cy tl care se sear dea debi Clute ovnaien pid la desobsiruti i este mal sur. Pract benef pate putin primele Sore dela debut STEM. Duns. Interval decides ater coranare mal poate ae un bene di (ie efectunts pin a sarerea prialor 12 oe aa nu pin estrngo Sie fret mal drab pin amelorare proces de remodel tiocrespostnaret (13), vol lterioar a pacentull cu STEMI ir ideea dominant a atu teapeutice trebule 8 fle desobstrucia coronarind cit mal precoce. perl coronarandorecoceest, dup deseopeteadeirisilectice si erganitarea Uniti de Te “portant actin tatamentlpaienpr cu STEM econducinda smeliorarea major evolu jrognstulpacenoreu STEM! (13 2 y92)037-146, Stem pesos? Pen ure pele 46 oe dea debutl STEMI sunt captalepentre ie Itensivs Coronarians 93 mal Imporanta dezobsructe eoroarene pracoceapare cfd] mal + vombusul eave a ocuonat aera cavnar ete fab, wor de sizohatcusjtorl substan Rrinotice aude raversatmecanicay un cate in primele 3. Dap acest ines de tmp warbusl se contracts, devine tot mal coma. mal dr pn uae, sansa deaf Taatsereduce proses + schema mca post oclutecroraian inseam sun sera pent acSvarea polimorfonuleseor cclante. Odat activate 2cesza emi seudopode cu ajtorul cor pot ec, pn pede, (is ttn etna ttc de reap fasten necreata a6 ore def debut STE! poimororuleareleacthate ‘Met aarti de pert corral roe sped. Prezanlr reduce sels mai mult lamer intracroraan, alu de peezrta orto! intatoronaione sa tuner, pn Mpa,» Caller endo. In acest mod s poate produce, a desobstucia Coronal un enomen paral n cud intra rombor! Au! coronaran nu este reuat(fenomen de “no reflow corenarian”) Pardon post giml mare: umn coronas ipa pote rat ar reper nu 5 produce lin loc, a miroereuap (Fenomen de “oo reflow iocare") (145-147), a aes uti fenomen poste contrib apace trata intervenjoal, | emboiare dala cu fragmented tomb coronaan i wre stipunger acct de cdtve eateterulflost pentru desobstruci. In acest mod, del ovonarograta arth reluaren normals ¢ ull intracoronarian (reper coronaria’) lectrocadograma imine emedeat "no reflow nicer’) -asevedeamaljoslocteriledarepertueTen prepa 0.2.8.2. Strategiiderepertuzie epetuiamiocaricpomt resin pine modal ‘ armacslg, respec prin bil: restos oc Intocrenoran rin aanisares de ibarte Aaaise nc lantoapursartagreare place + interventional, respct prin angioplaste primard (‘pri ferctaneaus coronary teventon” [PCI deshieres meta Srtore ocusionate prin srapungerea .aspiarea trombusul inracornaran ahora wn eater mat (e rep) de on rset prince tara carnal tenors + Farmacia (armacinrvenfona) prin combines calor Frocerdematssindous modal eres © Anglo de sare (Yesue PPC): angle wfc ‘ae 2 oe de In deus smptomatsap au soc Ia ‘pera frmacloges nu sa ola cu descbacie coxa (respec duerea forse penists la pe vase ECG pe ‘pnenilareasegrertulisT) Ansipltiacronriand amtints soi efecto FHroredelvo tinal sounten ices Desobstructa coronarand indiferent de strates folosl Aeterenins,trmacloge su amc ete pcs 8) primate 12 or de Ia debut der trace su a simptome de infarc Ia fol pacintit a care Eco nregltea 2) Dp 32a pace cu semen sau £6 de posi a iecnemil (pace persed ures sa0 2 supradenvelh Segments. 2.8.3. Reperu fracas tina pentru Roma 2 Repetuafermacsinasi oresupane 0 state hi: fi matt de agioplte. Aesatssuatele este impuss de neces ecbsurelcorearen cits pecce, race setae FC Tnpina ‘ofan FCM te ess dari 20-50% cepa (10 dh mal + infaseucura deft, Uinteleimpus delnfrastructur es har {lin manle metopole sufocate de problemele de tate $1 de Supranlomerareaspalelor ‘ tmpul care pede de Innes pasertul pe pout cane de Pls pala efectuarea agiopastet (Zoot ned tne) Sore Semple date dn US National Carvesuor Data Rept” Indes {apt doar 51.3% dee pace transfer diet penta PPC a tun or oto tne sub 120 dente Pentru paceti la ‘are tipuldetransportadepasit 0 de minutedon 29,6%au bent {de Pr nt inte de 120 de minut mom 82,7 au pet Fiinoice(151) In Romi, in cnfomitate cy acule organza, pacer lunge sin Until de Pini Urgent (UU) in cae ela narra ‘eamenul cin; se repets elecarigrama fi se efcturaz test de tecros miocarde (cu toate cl este cunsc fptul cs acest teste {toooningcrestnkinas ME) sot, de requ normaein rimele Sore dela Sout STEMI Tot de regu mecel urgent cn UPU sole ulterior foodie carlo in sarc clase at deca de 2 tre S2U md picemtulstre dO, ‘east ip aes pede dea rrare pcienll in pitas pin Ia at (40010 eee te") na poate W estimate cre medic de pe ‘vlan su eer mesic in span rs DC eave ate ug, hil poet I oddeal pacertuleudlogostic de STEMI cl stain esl arrebuiss"by ase ~ene UUs etranspotat det OC Tmportant ese onatenare deere: majors cae exist nve tong PEM cq al de debut STEML-9PCI hire nde dept its te asim 2 ore penta Smpul PCM-PPCl penta dec inte PC! 5 ombola (44) Da una este un PM care ae len prime 23 ore de a seouuTEMsatalng0ore. op 8:0 or ifort a evolu proce complet, Rina ae sanse retuse de rest dec nu ste le problems dc se decide tansterl pent Pan lo ease feu bnolz. in scm unpocent {are PMC e rela, sre enrol npn 12 ore dela dabutul STEM! sesreaceor2o4e panda PCIpoats cela un nena debut STEM PPL estes bre Inacestconii inoleaar faut ansemar Gesuces. In pus inertarea PPI dncolo de 2 ore de a PEA 7 anulena acestela ‘uperirtatea asupa flvinole\52).Drept urmare,neefetuarea Forno = wanepotarea ect pacenull ce Oc pent electuares ctesteopreyeat.0/STEM pees STEN pep. rateaa formacoinssvk presupune abordresintervenyonald pacentlorreceatns eel component: 2) dul antapregare planeta ase vedeaparagtafull.25.5) )Rbenoapreanstr, 6) abordres interven erent paint in farce rezetesbsenacrterrscroargrae(ECG} erepetv ede poagraflll2.842 |aupseumumeazh + Anite esate” Lescoranglplsy"tespectv naop lectus la un pacint fare nae ivegsreadcrtrile CS. feperfucie dupa adminitrarea de fbrinoiie. La aces pace ‘ectuareaangopastie meloresrsprognostea 9 evolu uteral ‘nestor, Af o mataonlis a sures reducers mesons total compart tratamentl consent (73851, 0.08, 0 reducare la limita semnifeaie! statsice 2 Ice Inert! eatlace (12,7 versus 17.8%, 005) 9 0 rece ‘ofa a ted etoretare (6,18 versus 10.7% p= C0 iss “+ Angoplastia ant pert iterall3~24orelapacieieucr do repersi dup adminsrarea de finale Datel acum pina rent ini fat fecturenangiolastl imei THombo ruin adoce bene suplmetare 3 poste a ‘latin prognostulacestor paint in sped prin cove ‘rede eoraplor mars, acs a calor arbre wre Uni de ntoogulnt anagegateplachetare itaprocedu Imedat dup brnaliice [154)(155) 0 metaanali a surprns roytltate global mal mare la pace la care angoplt 2 etuats imedat dips nla compart cu pace taal PRC (5% versus 3% p00) (14) in aceste mote, eect Snpoplastel medit dups 0 wombolad lent ete conra fngoplsta este recomandata door dupa Wecees 4 316 de Ain intra 326 e813), epi trate farmacoisaie auessenalateiniinre ‘sel FASTA mortals Inteptalcesch fost de 33% pant packet fils presales urmat de abordre intervention mua cu 7% In pale trata sit prin PPI (56). 0 st taracoinaina pracicienteacuceameniont ma safest dont reteavregorals injure 87). Dereint apace cusemne de reperfcietrombolil abode lnorentonals a fort arnats ine 1 5 ale da debut STEM, © tordie care devent caret i ule centre in Roma ince In roma atonal de STEML 0 astel de stata 3 cond Ia resteren hum de pace att iteeronal 6 16H IneDX sla reducres roa inastalcer de 10% Io 95% (26). Important de eb, trois nraspiaasedla paca cfbrinatasn prime 2 Sore de Ib cebutu STEM a fot snr cu cea 4 paenor trata prin PPC ar Iroaltataintaeptaesees pain ata pin fina i primele {ore fs hin ma ress det cea legit Is pacieni tata prin cl (58), Aenea ending fost raportats in Ul ardomaat CAPT (6.5%ups trombola presptalcompartivev 48% cuPPC) (158 ntl fanaaian WEST (159). In-o analiza combina a clor dou tau Inoalfatstaun an afstdeslapocentcuibnl (260), lat recent, STREAM (statepe Reperfusion Eat ater Myocardial fren) sngrl al randomzat care a compart PPC! co strategie ‘armacoimaov (16) aie 1892 de pace aagnsts cu STEM Tn prima 3 oe dela debut ia care ngopasi era impostl de efetuat in ‘ecu pane oe a FEM, Palen a primi ove de nar cu ‘liar (300m) -euexcepta cor actor vt epi 75 de a5 ‘hon de ncreare de arprins (150325 ma) eecum sh eroxaparind (2 I/hgar a paces 75 dean 0,75 meegeor spin peste Soom wires) dud eave au fost randomlai fe pentru Rrinlics pretranser ey tnacepas (48 pace] fe pent transect pty Pct. important, upd rendomizaea 2 21% inte pacienti trata ‘romboli, dora detenecepata fost esc Ola pacer peste 75 Se ani ca mare 9 Inept uel tedinte de cresere 2 indore hearer carb este prim tl nce doa de Mini ete ‘hata fneied sta pacer, ‘sonresncanvl Ol practice angiopste esa” (3c3 sel E66 ra sues par epee scar) He argopasbe ‘dna pentruinterva 3-24 ere dup fibrin (dS rast ECGs ‘ops pent rperuie pest fla, 62% dntre pacien). Rats 6 ces rau soccadogen,refreinre auinutser cade 1s30dezHe3 lostsmirdeuambeleatuan terapeutee (24,38 bale PPCI12 8% (eleuwatametfarmacsiaih) Concu cetaaa sulla osc 0 "Words farmaconaaha precoce conduc larvae imac alae ‘poten pin PPO sana utero pubic in201, andeto tending pre ereteres sume de infarct .avortte fo pacer co stele farmacaaaa 3)(0 sts aban, put in mal 2015 (162) » fs sages noon ita de tp rn Sino precace apo x tran spre, As, atele de decesisuents cardiac eardlagen/ nf ‘egstat ls20 de pace ta amacoinvac su rn PPC a 103% vs 10.3% 9-090 pacers are tmp enter a fost Sx 55 mina, 12.9560 173% a pacer ca tnp dente ne into 48) ide 13516 86a paket eatin denier de 57 demir (p-0470, in concuia, pe matara erste impulul pnd a PC) abo umacoima te devind superar nape. cu pacer a ineral de tine depsete tpt recomandatl de pid, Prati enfcicresicuaae 10 minute de lunges polenta Tn conde Roms namic de 0, stare lng de tas pin la cl nest de rampart deta) svat frmacina ‘te state optims pet paces ox STEML La deschierea Progra Nato de rataentIteveniona a STEN in supst 2010, Ronde “spnes doar de 100 capable fete PCa epm7/24, de un 14.99% de repertuzie conc ls pcioni cu STEM in concordant cusstegatrpevicd abort. Reisnd Rawan panu STEM (RO STEN or 5,69% ‘Mortalitatea generalé: 8.31% 8.81% - A le salvare FibrinolizS Fars tratament PC amanat te vartr pacer ite OC suse dita mare de lola cre dagnosteat sTIa devant agronerepulsnspealincepndcu snl 01 ‘ase de atge a condus io estere api a num de pac sora nerve des 25% in 2050 63,35 203) 9 ee ‘moraines ela 135m 20513 8.2% anil anal Don? 3 2013 conform Regu Romsn pent incl mice set ‘radenvelre de opment TRO STEM comune Carges So Famine de cardoige) "Atel cea mal edu mortal rasta (348%) 3 fos isa lc 1478 pace care angigasa 2 fost nal, umare fap cet aea ca serine cnc EC de reper a ose ‘Det Acar mertatate 9 apiit sera ra resh dest cea acl 7334 pale trata pon PPC (635%, p01) Cum era de ante Iotaltjieitaspalcept au fst progresiv mai mar a pacent {reioplas de aka (569%) apace tats pn robot (8.813 Sapa ie proce de repetu14 99) (gu) Shuonasie PPCIangopiate primar N=1749312.8.4. Attudinipractce Angiplastin coronaria primaté ("percutaneous primary cron Intervention” = PPCi) este modaitaten optima de repertusie (4a Supeitatea PCtincmparaecurepertuafarmacologe constin ‘rata mare de desbstuctia coronaria (peste S08) compara tru 7273c ilies + posbitatea de rezolare Imetlats (prin stenare) 2 steno ‘otonarenerspunatooe deine + seu foarte reds de hemerapi majre (In speci de herr ‘arebae + postitatea evalu globle 2 acborell coronaria fat car Sarprinde a evn een cre pot abardate eds nt procedurdulerioa “Angloplasa primar (PPI abu cnsierat capri oplane ‘nratamentl paciantir cuSTEMIin prime 12ore dela debut ac poate efectatintran centr exprimentatnprimele 120 _demiute de april contact medlel PEM) practic lassen Armbulnte la pacent sau, in stuaia In eate pacentul se depiaseazt a spt prin ate lioace dela intrarea pacenullin Unitatea de Primi Urgent) (44). Aceast aude trebule doptts in speal la pose eu is reset, cum a feo cu femne de foceardogenaucuinsutientscardchsevers. Pentru pall care se pean a medi scr tmp dup debut STEM sauun STEMI dedimensian mai mad mpuldeefectuare IPPCttrebuietfledesub90 mite, aed angopatia primar nu poate efectuatnprmele 120 de minute dea POM tun in absent conrandcatilrRbrnoia treble instiutsin prime 30de minute dela PCM ao} pcm STEM preps ui2a4aScenariul 1 Pacentul umeaas f tanegartat aun spit cae dspune de un Departament de Cardiologie Inervenionals. Timp ertinat de ‘anspor ela rel eontaetmedea pins efectvren naopaste! ‘te de sub 120 de minute. Reperfua itervenonalé angplasta primadjesteoppuneadeales ota Aldus aningrogrplchetars ‘topir150 2250) ‘Un Bloat de receptor 2%. Prima epun: Hegre 180mg ous tablets de m2 aun opine coe e209 optabete Sm antcoaglre {HW bolus de 60 wi /kgcor fe a ded un total de 4000 wi) sa Enoraparind 30 mg. In bolus i plus Lmg/kgcorpsubcutanat; la clei peste 75 a MUS adits Bolsa numa mat ‘apsubeutanat (Q wansponat recta (4s), ‘Acca atu se breach pe dtl cave ates atl eb PPC te siperess Rone ac timp srs de le POM 9p eof reed deplete 120d mnt (43)52K063 165), in ls ent Sa cae au dems atu eb ant pen etn ila un pal care nu ete dota eu un obovate de argc Irareoné i un entry capa sb eect PP pire $0120 pate de penal ent medal exe 9 slue mai bund compat ‘focuares erirlesnspitallarea printnialpaceru ‘Ase sudl DANAM2 a eat eclupa 9 progasla 1562 de cle ta lo rin brn (eps) cu ce a pienioetanerti ‘nasal pet elecuaen PP Ostana min pris tan fo 6 Seen 3 se inp dean afor sim eo mee 17 ate). Tinpl seus el randomare pind le tatamert a fos de 30 rite in grup PP! de 20 mute n gpl watt a ne. 53 reps reducerecu 4% sala de morale, efor a ‘cen vse caer (0% v 10% p- 000), dr ma eit ores Samant cece vest morales adore 16) usimptome de fret afin pile 1 oredela debut ia care slecrocariogroms inrpistreasdsupradentlae de segment ST de peste 1mm (1 mV) cel putin dud deriva ECG corespon- demsavunbloc drama sting’ nouapint( 2).ysten psp Stal PRAGUE? a nomi pace STEMI peal 12 oe de eat ec rept 15 MU na ent wanterai ‘fet a PCA tiara ara benefil PPC pt pc ‘rot innerh 312 oe de debut TEM rotate dea pc ‘Yaa pen Pc compart cu 15% prin rombol), Perry pace wat rime oredr de moralatenuau ose) (ret umare hil european de ratrent a SER record, impuestiat ea FEM 5p la PC xe sub 120 de mnt, acral wel wanspott ec a CL Petr pn nes pret Inada scr trp op sb SEMI av unSTEMI de ers ‘inpulde ecture oPPClebuesS fede sub sO maui 8) izaa2.Scenariul2 Padentul ued 2 wonsprt a un spital cre pune de un Departament de Carole tereniiana. Timp esinat de anspor eis pl contact mel pi Infect snp denies 120de minute Reperunafaacoaa este options desks. edo: 1) dul antogregareplchetard *tapirin150-225%m6) + unblocantde captor 2. Pra pn lpidogr! 007m fsbeten7sdemg) 1) anteoaglare ‘HN bolus de 6 whan (te «dep! un total de 4000) Enoxapaina 30 mg In bolus Iw plus 1 mg/kaorp subeatanat, pale peste 75 de an NU se adminsvear3 Bolus Ivo numa Imehacorpsbeutanat riots D)tansportat rect act ‘Benepe reper fermacloic presse! Terapia rile [In azacere cu antagregante pachetare anenagulate) are citevapuncefor: ‘poste administration, corsa ocl de debual STEMI, ‘+ punecestsun prsonalmetalspecaprsitt; STEW prespal’7 seselting + est foarte efit ia termi de ath deepest cers sce ‘educore3 moti dc est floss n primal or de debutl STemi(2315(07)-Dat chiar nner acest interval inp ests © relate ives Ine timp scars de fa debut STEMI pn Ia Seminstrarea agent Amoi 5 martaltatea a 30 de ae: 4.3% Sach rombolan steels prime ZoredeladebutlSTEME 5 3a pcietratapinie 25i¢ore p38 9%intre4ore(1) “reperlusiintervenfoal repre scurtarea pull de a debt STEM pdnble dash storia coronaria fap cree truce sree ‘roca inreducereamoraltt rma seralare 3 Were Arinolielpespitaln STEM! dateans «in 1985 (167 Utero tll EMP a raporet un est med de 55 de innutecufbiole prespalfaptcaresatredusnt-o mertaltatedecauzd raed 8.3%, Series mal redusd comparaty cu pani cu Norio dp interare (8%, p04). an eg de tip de 90 de ‘minute att mortaltatea generis ts mortaltates de curs cardiac au testserniestv mai reuse apacentcu inl presptal(7273versus 1.35% p » 00475 respect, 646% versus 12.32%, p= 0.00) edna scene iascube cerebral fost dente (versus (168, Intrll ti pase atic notice n primele 70 de mite de le debut STEMI au arto veducere ou 59% aa de feo 850 3 ota (2% versus 7) oi de ti seria ma bund (csversus a9) comparative pent acare bola fost efectuatin Irena 7010 minute (195 In GREAT [sus randomiat, dla or) Irena 48.96 de ore (uberopul SSH) Csteu de tip prin fbn espa afost de 27 de minuto Rate de repre coronal detectate ‘ima a fost de B1,25% reASENON), 726% (ASENON 31 620% (SSHHER:p = 0025 pen preASENOX ws SSI 5 p= 0030 pentru InASENOM eS (O tenn spre 9 moraitateitasptatceneS mai redid a fost lovastatin subgrupurepreASENOK (312%) 51 MASENOK (5, 79%) ‘compara step (108) ar numa reuse pcieni a permis ineptrares ne:ferentesennfeatve ate Afonrgiraton seve arde accident vascular eb hemor subgrupl MASENON) sh ‘neandebemoragie major extracranians (177).0jsteM pes stem presptayon Pe bar datelor acute, side stale recamand inst inet it mai repede dupa sabia agnostic de STEM, pace primele 30 de minute de tabives primull contact medial cu pace Fespety dupa urea): Reperfziaformacologies presptol este indicat’ cu condita asinerta media de pe arbulan 8 fe asgurat Fe de medi Paramedic bine antrenst cae spun de posibitates inept ‘Secroarograme:standodia 2 dei tranamiterel att pesonalmedl artenatin watamertlpaienio cu STEM. confer Program de finlas presale abit In asenia entrain Farinolza presptaestindatsinstastileincare 4Langioplasta primar nupoatefelectat in prime 120de minute laprimal contacted; 2, nue un spl capa efcter rina in wmatwaree ‘deminte care reset prim conact media 4) 2, Potential hemerapi inns al sustonelor flbinltee in combine eu antisgregante sachets cu anicoagulnte. iis poteduce hemarapi minaret majore Ine teste heraragie cereale int redutabie Riel de here cerebral post Ronald waar te 0s pentustreptolinari 52s pentru reteplz 36) isc dehemarasle ‘eres est mn area pacer trata PA a cu deride 8 toate gupee dest 13)1427439)278) Real de hemorage cereals ext mai mare ls bol in vita de ste 65 dean a poset a crr greutate corpora este sub 70k, a Poona cor tensune artis iternare dopa 180/120 mien fone de acetate hemoragie arin ine 0.25% Gn abst orca ite ator a us rum 92.9 in presets 33x de is) (163). De nota la paceni care sped cuTA> 180-10 ne reccaea medicaments tendon arterial init administra oe ‘vmbolicenupareareduceisculdehemoraiecerebrai(279), 3. Nerespecarea dzelorecomandote pentru svstantl fiinltice frccam sl penta substan anteaaguante 5 antgrgante pachetre ‘late dept evant ae rombotz Sublozrea Rnoitelor ponte reste mortalitaten pen ceducerea ‘ted reperiiecornarieneSupradocare fxinoalor reer de hemorape cerebral InGUSTO regina de administra treptoinaes, respect al shop (tPA) nua fost respett a 13.5% respect 115% tre pacient (180. ‘rt urmar,moraltatea a 28 ore ost de 2,2 respect 1 a ecient cupretocolrespectats.a%respety35lacellcarepotoclla festineestp<@000. Dferenledemortltate ufos dasemenea semnifstvesila30e ie (6 versus 11.3% penta steepokina 9 spec, 5 Hers 77% pentru EPA. Ttran alt st, morass neers hemorator| ‘rae a fost serif mai mare Ia pace la caret a fost instr incor (595 versus 125%, p< 00001, respect 0.6% eu. 9<00001 (28). 4, Administrarea de tromboliice in Infactul miocardief8rd ‘peadeniveare de segment SI. ere bones nara pati (uSTEMN pe cna pacer supadenvelaedeSTepontetiau nara pute beneudr poste chiar sgrovaproeronul 82 scare reperfteformacloace preset! scrle adminis de fbxnoiie i prepa pot deriva urmitoarale ptrcauze: 1 Froare de alognoste.Adminstrarea de fbvioltce In stu pale eet lagnostcate dept STEMI poste urmat3 de acco hemoraelce fatale. Inte acestea, doud conf pot avea consecin dramance: 0 isc de ood ect de aot post i confundat cu STEMI ‘tun ara) ncareisecpaintresean una nr etree corona In aceasts tua trseee ECG pot invests supradenvls grent Tidentc cu celedn STEM. Din acest ot oe suspic te ducted ors rebvie ab conatite un moti serios penta Mk Se admins substanetombottc. by, Acldentele vorculore ceebrale hemoragice pot induce stecrocardopams supradeniveln de sapmant ST asamnateare cele fin ier de micah speci n pre 6 ore deo debut cclenuli(0), in acest mot, oe suspicune de aeident asa Cerebral care mimes, pe lecrocardogrm un infrt de i ‘rebule 58 conse un moti serios pentru 2 NU se ibaangatrombolice10sTEM press nae eape brine 368) 5) pace af! n prima 12 ore dof debutlsmptomatooi Inara cre cectrocarogramainveysea: “supradenivlae de seaman ST mal mare de 0 mVn cel putin derhatierespondentesau = blo de rama tng apa i content singtomelor de infret ‘rs aramneneisiadacumentelor medals pent) su spect suet pene att mica svc posterior: und Ra In dora V, el subdenivelare de angrent ST in dehatile Vu ‘eventual supradenvelare de Segment ST n derail (Aten ‘esrtinfrcteste desert corfu cu unifore ard suprodenieae coment ST lcolzarea anterior. De fop,subdenvlaeo Iegistrotbin Vv este mogne in oglndS asurodenvei de pertleposteror alent sting 5) pace eu smptomatooge supe pent inet de moc eta inners 12.28 de re, cre consis 8 ibs dere Sugestvd pen ischemia mlocardcd 51 la care elctrocadiogra inrpistren o supradenielar de epmet ST ai mare de 1 Ia utndoud rat corespondents Contranlctieterapeorinoiiee|3688) Comranaical abso: 10sec hemorapie cerebral stu accident vascular cerebral de cal necinoscatn antecedent paclentl 2Acientasclrearebelscarcnltinee lun | Boras erbrl xem malormatiaterovencse); “Neoplasm ceebralirimivsaumetst, SSuspleuneade dectiede aon, Gite hemoragie suhemorag actu (oteeeptia easter: 7Hemerapgastraintestaltn lun ‘Taumassmeanansilleteinultinete un. S raumassme major savintrvertichrurgalein tine 3n 11.Punci eecuate in zone non-comprensil (exemple: pun hepa, pancilombars. Contrandcaicttve: Trantecedente de hipertensune arterials conic sever, gre centrlatamedcamentas 2Hipertensine arterials severd (peste 180/110 mmM, grew contr, perntlsinternrea pacer ements sau patlogieintacraniant care na in sub indents contraieatior absolute: 4 Resusctarea eordorspatre aunate sau prolung (peste 10 ‘minut sauirtervennichrurgesiemajorelnulmele3s3ptiman, 5 Hemorgintererecentnultimele24sitimi ‘Pane stoptotnas yl anstrepan: dminitrave anterior a ear oud preporte in wre mai mt de 5 les rect aleree ‘document pentusceste substan; 7 Sarinasauprona siping post pau: {cru penticact 9Endocarta reco ‘Azenifrnoli bel 16) Agen Bono exert aciunes prin aetarea plasminogen cal pecare transom ediet einen plasingReestadin in elueaizaren nbs inracoroaran, ‘bell 6, nlc lat pace cy STEMI ieneasaengee! | eet oom mg tog Zee ices siete os OMe | ‘ete (-PAT Uh mata 3 mite eo pox bl de 1, sai a) Sia br fener eee04/TEM pes STEN pespan0s Fentrufzaprestal 2STENM! nl dele snk ele care seminsratein tain peiecontrs 2) bole ania inbolus 4 etepaa (PA, Rapin) ete un fgment de actor tle Diasminogaruu eR respect subarea foro atl) {ranform dret plsninogon in plasmed. Tipu si de ji ag adinsrare accptt in preset pent septoking cont In pert 3150000 UI In 30-80 mine}. Ieepnd a snl 199619 Fomaniaexstins so eperencaseminstrar sclera tetas, Sosbeum meas 1+ 150000011 peruatein numa 20de mine; + 75000011 admintatein 10 minute cus fr epetaes dst dust 50 de mite dacs ne inrgitesh eter CC deeper (83). ‘cet regis se bazar pe vomportametu etal septs concentra plasatice mar, respec fap el este concaieti epotnaa se combi aproape) to plasminogen cle. Orept lumare nu ma mine plasminogen ie. In conse exes 2 Srepokna complet plasritopenstrepnkinas an vor tag stick de plsminogendexstentin intel eo pe care ve ersform In plasind fr itevru womb (wombolis enogen, Wombola Endogedste mst napus deers xen (8), Find substan exgendsvepoknaa ae potential serge. De at sie adver comun pets steptokira ete potersiune arte, ingusd prin vasodlatae sterols perforics medaté de coking ‘salt fin spec brain) in ura cont epoknai ‘recess ptensnen arr paren aproumst 20% dre aden eae stepoknaza ee aint In eg ge 1500.00 UL a 0 mute da ete net ral Freeverse 45%) dock se utiass ‘pune eeterate[138)Orhpeersiues nuk de stepttna post ‘near, saver ait conrad in 15 minute pn sng admins Genetic ate ecolontalachvatorl! Suara pasminogenal] 48d er fel (851086) 20 de mute, admins fy boy cu 9 Specicate feapctte gare imamate scree ces lasenen nh ‘chat de pumingen erecta atv! plasminogen ‘nod dec. Fpl al fang de lumaere pert adm {enectepl!nrmsngr bor de 3050 me uni de ge ‘rps pace ) bole admirable inperile Folate amnisable perf psu 0 oe de prin al gents beats p ambulane te pot fh tot, ose ns Homa ‘tose asemenea pea cs asa sbane posts nt sal care prime pacer up cre cesta tree vapor nel etl de PPC. Pens evtarea complestor tebe agua conta rfc oneret zara de ecomate) ol a ate bate {or fadmnstetesub for de part sp, ase. ‘uu evn peer wansormsin asin Tp trams ‘te ns foarte set (5 minute, mot peu tebe acme rf ravens. eg uta a preetconst srntoel au 00 de migra te tour de 15mg uot de SO maperate $Sdeminateydeate3$mgpertusten ede mnt). + Suepokinaa (Steps) exe 0 substan alc prods Stretacoch beta-hemoiil de grup C) streptokinasa. ste Psmiroganul mos nde nto pina ap, repair = fest de plumingen rent vend wn comple sept Pesmipogen nad acest cogtexpasmineganulsufes0 mad 2 Srucur sale tdimensorle. n'a ous et acest erp “ane asmiogen modi clone aura paige a be cre comer plasmin Rest ain tomb ‘eoutens spasms exper ier dereperaiemioearSce pace rnold prespitel Succes so nsuccsu bin poate felt na 9 nese nluare ima 5 fa, dup ternarea part n tortor de Cada inerenioal, pon valves desobsruel ovnarene prin ‘ronarogate pin ae se poate cress ni eave esate ‘croaron acl repeats ln cle TM produ de 5") {a peso evalures cect a efecul teal rombotie nu ete posi Aceasa ponte ct nde pba douse 2) Cine (spare dre orca). xt © leer dec tre \isprtia sau redueresintensti duet tore vecaaliares ‘orenarand (129287(188. Oper ore arcs in nl tml fstenupumalun neta deeper coronrnd ar edi orld soos (43).STE prespal/i07 Departs dient none de admintrres finale ny tebule Consierat deep un erent de enurare ln acest tamer in spe {aru in cae spmenta ST mina sopradenivel (167/148). De ret Gurres toacies se poate acentu brsc In moment desotstuc ‘presi cnc 2 instal sdromull de repre (mri) miocr rcebare dure ponte avea dua dep la 10-5 minute pel Intenstatea ie reduce rappin la dipae b) etrocardiograe. Clecroargram este singura modal bet reinvzv care oat ofr pie, ran gator cu sues Insuecesut tentative de reperfune cronarans. Exist doud er slectocrdopace revesaarede reprise mio ‘ reducereasuprodnteailor segmental (957) eu ma mut 50% din veloorea invegistratd la debutulproedur de (tombold sa agioplane) et un orn sector ext de alors In aprecreasucesu teri de reer (90-19 Graal de reducers a supradenieliri este sugesv pare cla reper. Atel 870 80% inte pains care supradeniarea SST se reduce cu peste 70% In pimele 90 de mite dea ie Abrsalae me puter asep ca angiogrta covered fect Imedist dups iterare 8 indice suceeol oriole, resp ezostrutia coronaria cu fue nracoronarinekelent M3 copa TIMI2 Dae educere supradenielh SST est ne 3 Sams orobabl 3 numal SOX dice pacien av art Mux corona normal M3} Laoreducere minor asupradeniveli( sib 304) 1196)297) aduzores enki) supradenveie pS aro valareprognost leojebith Atl reducer ee este 7X a 10 de inate de ade Annas corel omaraltatla 21-35 dhe des Orda a supradenivelri irre 30% 70% corel uo mortal de 47 ‘ld sbrens, prac, @ moiesror de segment ST 3 fot wma ‘morale 356% (178197196). Expert cults Roms Conds a rentate iden reduere supodenivelr de SST cu es ‘Sthanuntdunproproste exert Figra 3 bustearsun cart de rezlatie compl asupaderiv de SST putenesugest pent ceperfute coronatind. De nat, Ssomenad, esotarerapids unde, feromon foarte gesinanlaac Daven ere este relat leeinlor[sndromull oe reper Coronainso morales sptaleatc3deaproimat 3.4199). Per navn 45min 20min Figur 31, Aspect ECG sageatv pot rpefic coronaria itt nun pcieat rate rptkinas pS ‘pment ST (eect. Gabriel Tote Chon) @ ACLAUI onl a VT « RETO APM : : 3 3STEMI presprayi09 retin Is en pacen, namic slectrocardogafcs ug pentru reperfine este precedati de ascensonaresuplmentars Uranatovie a Segmentll ST. Concomitet, durtea tras ts ectroardografcs 9 sincromul de repertsie (gua 32) Amb fenomene uo dat de 10-1 minute dup cre supradenilarea de Incape se euc piéconcomiten cu vedcarea/ dpe ntens erie de eperfate. Reducer supradenvli eS reveatoa se repertue coronrons, este inst, seer, ae etn ny cond ‘periment, inden aril reper vri8 inte 50852 rn cond lice incdens este de pid le 25% (201. ne ace tuber venrclrdneperoxsies (tml Kloventrclaracoeat) specal a paenieu nore moe ante baer ssl ‘ecia o pacino infares infro postin sunt cele ma re Ime. Fila vrtclré poate una site aie de reper Ineide ator derepetiziest cu att ma mare cc reper produce mal aproage de mamertleduze croraene. Experiment Inds fib! verre sau a tac! ventulave 2 fost 23poape 100% animale de eprint a care gar astre earn {or suprimts dupa 20 de mite do leche, Dacs drab ‘coronaria sefacea p20 deminutelncentclr dus arm ma Se reducea progresiv cu eresterea duratel de Ischemle. Aceas 25% 1.6% p=002 ‘rombotizsprosptalTromboies a spt Figura 33. Incidena fibrilayeiventriculare ls len tratap eu fibrinolitice in pre-spital sau dips Ineernare (159) 5% 4% Imolmare gortmilordereperfuseireitrate pe infarct experiment uk ‘reperfse moi mare deci eo cares iegistreor le paler ot shag 3313202208), radcarda sisal de reperfneet ara se poste inst potesiune arteri. Oach persist, ea s2 poate remite rap dminiseaeaa imgdeatopiease De retin: cu exept ria! vena event tai entice suse, fue ed ex arieGereee) 8 ase nan erupt eres ope hg ip radical siusalerestl arti de repertizie ru neces Ulta cinpeme reentarlcamerasepardd cemcantrte tratamentimesat Ele seremit ae santa, ‘mira canplaste eimara (160) =90 ‘90-180 > 180)20/stemprespal m2s43Scenariul3 cient pu poate f transport ls un sil cae dspune de un Departament de Carlole Interventional stan prea mae) farmscaapesesteoptunea le. etuine: A) dubibanagresaeplochetars ‘topic (50-225 a) ‘unbocant de receptor P2¥,. Prima opr copia! 60 ma ‘abletea75de ma slandcoaglre ‘HW ols de 60 wl/kgcorp (da dept! un ttl de 400) Enowaparing 30 min bolus i pls 2 ma/harorp subutanat alert peste 75 de ani NU se administra bolus bc noma Imahacorpsubeutnst. fino ‘dea np estima ea POM panda instr fibsinliel ns ‘xe de peste 30 dermiate, va electua inal Nnaaaprespal buona se vedea pavgratl ane upd cae pacer va traaporttspttlnon OC! + dah timpulestina ea POM pina ines file in ‘ete dsb 30demnutepacntlvafitransportt ezaspall ne ates 12.8, Montorzareapalntll cu STEMI tipul anspor sore Untatea de Primi Urgente Pe timp transport spre UPU painful tabu sf sent contuurmentorat en elecvocardogatcsiparacic. Storea de consent, intenstates durell toracice, aspect tegumenteloy, pulsul, tensiunen orev, aspectl venelor jug ‘secuiaconbli ss traci elu sake perriret pe 6 ‘eanspori nconforatcupecizriefeuteln pra 23. STEM prespal32 112.92. Montrereselectrocatiogris Montoriaralecrocarograflebuleistiut inpimulmomant slconartuui dire personal SAMUS paint Aceastamontoriatepoate ‘cfectuata utlainduse eran mento tay de drt #5 8 ‘ul montor ECG oral bac e utes devistorl manoriaes| pute aes prin oud modal 1. Printer pallor de debi) ‘cea mosaltate este uth pent 0 venta rap supra rhmal eadiae apacert Tn seat rap una Ste pode de elt Padela strum” sau ee oie func de tilde aprat ~ ea aplea ‘eave pastel dept in tp cel adel paces apo” ‘auceaverée~sevaapea sl ncn els corespun spatula intrest tng pe naar medi gra 35). Pon eetares pratt "asa ECG esto bie 8 se apc pe pdele aprons 20 ml de el 'erocandaor Totus nua de maxis urn etre eu ‘emul erin poate ont prin apesres pall det pe oracle pclentlasemaiperdetinp eu aplreadegel ‘Ovarantmai al acess! monte cont inuizare podlelor sxroclane, modaltate utlzats in special in caul defiristoarlor SSrigutamatiate. Ampaeres pdesor autostart se poate face ‘orale ante saben parasternal dept respect a nivel ‘patilr Intereastale WV pe a alars meaie~ Rgur 36) prin ‘rplasarea unl paele pe tree ater a elspa intros ‘itpetina sur medi ar acess dou pe orale porter (a m ‘entel Convento elected a unr tire surprinse prin Intermed adele de defloriore poate fr efecuet nual ‘modu ASINGRON! Acs! mod exe spec corioversielefecate Dent flrlepe verticals aor poste (a! induee file ‘entricsordocdestfolstpenrucrdovesa ator! 2 Prin intermedi lecroioramplastptoracsapactentul In aceasta stuate ual dnwe elec! webu amps pe uso! rept acetal ole elcrod pe umsrulstng el deal eal tahenteaclisting petina art orterar ou med ‘De regu, recomandinile cupinse In prospecele de Iiare 2 ontostlor sou deflistoarlr indies ampasare setrodi lore "oye pursue al eau de caloaregalbend pe und tngin tips ‘eco isorent clears ab, sa near au verde, Mine do "puldoporaieste dest pata dela tartare212/sTeM!prespal Figura 35 Montrzare ES prin intermedi adel denier Figuea36 Araasrea padelelrauzclate pe toracele ater STEM pespayiss “Tot rer eamplasarel lector webu eal yname cornered increunda Pest cea malampld penta ume ms ‘oar 2 mull sins (49d paint Se afl intra este de rm) cast imagine este obit n ervaiaD- Cel putin tore acess Achat poate obtain aplasaeaelcrodulirsupe ural dept lor aleegatbenls bazaherstorse tng lectrodundeent umd Fompssatpeumaltng ‘tent! 1. amplaaeselcroslr tei fi cu sunt de depart de ariledeampiasretorace apadleloderistor respect dea Subrleviuard~ paasternals reaps 5, respects aia apesan, ‘ubamelorard tng (gua) neat conta in stuart de Brim maligne care neces dminsarea medal de soe slocte ‘exter (firisie venta, ohare verter fe pl) v0 rei endepartare ectozlr demanitorzae de pe trae per 2 permite celnsarea soc, fot cae Seva va destin, pact, rmontorareaelecrocrogafes 2h stat de urgent ae presupun ierificarea rapid atm ‘adc mod de amare lecroior NU est inportar. Aes pot amplasat paca ore zon carl! 3. carl montorael ECG prin ntradllacroioe al eabla ‘ectiecorepuneitoro events carder poate elects ait n ‘modulasinron tinal eon 12.9.3, Montorare paracnes “Monitorzores sot! in geno sone arteril (S40) poate ‘fectuati cu prin pin floss pulser unele defbviatoare au in dotare stele peeve. Reduceres constants 2520, sub 90% ‘eprint un element erate 3c ul inte coterie dg eae ‘2 poate decide ttre paietul vliareaapartlr de verlag tats, ‘Determinaresaliemie prin wines ghcatestelorportabie este nprtant dat ind fptl cd pact cu gleam ma, ncarolt, ‘sbutlinfrctl chiar rs ie bese, avunrscoetwelorimaimacede ‘sees (205), La ate acer inelnoterapa poste apa hr in fun resi1 14sTEn presi 1.3. Etapa Unitatea de Primiri Urgente - Departamentul Cardiologie Interventionalé (UPU-DCl) maa. Scenariul 4 Paint este ads de tre Serva de Aste Medical de Urgent presptalcese(Ambulafa Ia UPU aun spl care dspune de un Departament Caroigielnervertioals noi 1. Pacint fr reperuneformacolol prespal + confmare agrostulldesTEn(aptllst) + daprossederentia + montoriare 6; + proflthemodinamc: + erduldenise + did ansogrgare chet docu fectust dein pee asprin pls dod delncircarecu eager 180mg sauprasgrel 60 Inlpsalorse lose dopiogrel 600 ma) + amcoagare (dc nu -efcust dea) -HN bolus de 60 {fad a pis un total de 400) sau Enoxaparind 30 in bls ‘las 1 ma/hgcorp subetonat; i pacient peste 75 de an) NU _minstreae bots xc numa Ime/kgcorpsubetanat, + trasportalaberatrldecarologieinerertionalgentruPPC. Foarte important! inveaga attsne deals rbuie 8 fe foarte rai asin impuldelaPCMn presi pinala PCL 58m depifeasca 120 de minuto stati in care Se dete ‘aptl eS efectuares Piva intra peste 120 minute de aM (evemplu: bortoal de caters este oeupat de ete un at pacer a efectua ibrinlss in UPUI Uteror sate de abordareitevemonldvaaeistinfunctie de elect reper ‘armacoogc, Osc po fibrin par serne ince ECG Se reperune micah tun eva recta angoplat de sare acd apar samne de epertre angola va adnatd pantry Interval 24 oredea rina. STEM prospayss 2. Pacanteurepertasafeemacloicprestal- + strate de abordare interventional af dein fancied fet ‘eperuse armacoogls Dac post inlad NU spar sere ie EG ge reparfue miocardch tun seve rates angi de salare.Dacéapar serine de reperfue anioplsa va W amdneta enruinterall3-24orede viol, ua.2.Scenariul 5, "cent jrge pi miloace propia UPU a unl pal care pune SeunDepartamentdeCardologelnerenionsl studies ‘confiareadgnostcullde TEN (aptlst), * dlagost erent smenitoraaetce; + prota hemodinam: saroduldorie: + dub ansgreare plchetad (ae nu ca efecunt dean prepa ‘pln pls zd deincreare cu eagle 280 mgs prasnrel 60 ng: nipsatrseflesestecoptogreleo0mg) + ancoage (ack mua lett dj) HN Bou de 60 corp (epi un otal de 4000 ui) su Enrapains 30 main blis us 1 mg/kgcorpsubcutanat; In pacen peste 75 2 ani NU Se msistenssblisix.oumal I meiarorpsvcuanat + tanportilabortorl decarololntervenionapentruPPCL Foarte important! nena attucine de mai us treble 8 Ae ‘foarte epi stone emp de a PCM in UPL pn PPOs nu depijeasca 90 de minute lnstunieincae se enti fap Gb focunren PCI af incr peste 99 minute de a PCM (exer bortarul de eaters este cept de cen alt acer eva efecua final in UPU I Uterorsratepa de Shordareintrvenponld af deci funcie ge efectulepertui: farmacologc, ack pst incss NU spa seme nies ECG reperfurie mio tunel se va practesangoplsta de share aed apr semne de reperfuve anpplstia af amSnat pent Intra 2¢deore dela fino.{16/STEMI pres! maa.Scenariul6. Pant ese aus Ge itr Servi de Asstt Medlal de Urgent presales Ambul} a UPU unl pal ere NU spine un Departament deCrdlei intervention 1 Paint fr repertutielarmacoope pres confirmare dagnstdeSTEMI (pital) dngrosesterenta profit hemodinaric; sedi + bls antipope placer (ck na fecit dejan resp Aspirin pls dove ere cu copdoyel 60 mg (dacs dc Fina) Su eageor 180 mesa raul 60 me (303m se fect inl sou pasentla ansteratlgunsp cs) + aicogulare (ack safest djl HN bolus 6D ug [res aopi un ttt e 4000) sau Enomparing 30 min bls us 1 ma/kcorp subctaat lo pacienb peste 75 de ani NU nisvead bls cima: mg/korscutanat + sno (dc inp estinat de wonspr ea POM in espa ind efetures ngiopastie pimareln celal apropiat spl cu Sapbers 120 mine srraniportdretiacempropit spl cx0Ci des inputs transport To PCM in pest! pnd la fectuarea angaplat pimareestedesub 120m 2 Paientearepertelamacologie presptal ‘coniemareadlagnsteu deSTEM! (apts) ign ieeni, ‘ * evuares sical /nsuecesu vino! pin eters ence cde repre; fear icel aproatap STEM prespayit? waa Scenariul?7. Pace june pin miloce pop la UPU a unl spa are NU ‘spunede on Departament Cadoge tervals + dgnotcpoiv de STEMI cpt) dograsteterentl, *prftalemodinami swratulde ie + dbl anigregare plahetar (dc pu 53 fectat dejan presi: spring pls oe de cere cy dopo 00 mg (cs se dee ‘orn Sau tegrelor 180mg Sau panel GO mg ach se ‘fectua flonan pace vatansestlounsptaleuDOI, coagulant fects de) HN bole de 60 Corp {ie eos un tal de 40004) 90 Enovaparnd 30 gin ols. ‘us 1 ma/keorp subctont a pacer peste 75 de ani MU ‘Smnstess ols cna mg/ecorubetanat, ‘+ frinoi(dacd mpl estat de wanspact a PEM pest ind efecurea argopase! pemarlncelmalaprgiat plc OC Aepisete120minate ‘anspor! lace agropit spl os 00 da tmp estima transport de a POM in prespal pan la efetuarea aril, primarestedosub 120 minute Hiestenpespta IVTratamentul fenomenelorinsotitoare Iv. Gest virtue. Apri Sena de greats 92 wrsturioe ontertu STEM! sunt conscia dure trace, 2 eareconsi si fin sstamul gastoitestnal (crcl splhais) gen eiterarea dena ator ateclomine precum jconscinaefetlor adverse reset Tnfza presi atamentlantemete poste Rfectut cl msi comod etocoprami Ix 10 mg (1-2 ma/gor]repetind dol tera be. de3.50 Miazlaml estes unantiemetiefcient(002reha/) Dlamorina indore de5-10mgactionezs cu unefct antiemetic v2. Ansetatea slaptaiapsinomatoce ‘Tatamentl anti ata po motor este important dat ‘apt ed acastea contribu a creterea vl relat de ctecolam pe seat cle, ot eseindent titi carice a dere femodnamice ‘ati seri demedicament adminisateln farsi STEMI Induce agitate pso-motor deli lin, mene, roca eopnametdina mepecina et Sedares avant Dindepitass eres; reduce anetates ag ‘reduce dssinconia dntepacient sl ventiatr (a pacientul ven reece faiitesaingricea pace ‘Sedatelepot rats nunc Riker Sedation Agitation Sele 8): 07-aghajeperieoas; 5-towteapat: (04-calmslcooperant; 02-foanesedat; 01 mupoate vent STEMI prespayiis algerie (gent nel). Debut acu ps administra 3 Iolopedouit este de 1030 minute. teeta modes minim Funct repatore conc cee ce fice sect perry ue i aa pacentl crite Nu are oet ane su amen ete medicament de ‘Sci n i de dl sau de sev ean Dele i dpi de acl de {otal 052mg pentru gta mis Sm pen spate mode 10-20rmg peat sia sevrs Senn ratomertl ch 2 mga are >More arco pte iain ca de fice fast 200i, ots ‘aan ainsi -50 mya Dale adriisrte po, fai 2 mes ‘Su 1D mg/m 1-5 mg fepete a8 or), dramas ind de 100 mf "isloperll poste determin preluges Inala GT ra als nea de state oraepam (besoin) ~ tip de inure intra (1020, ve, metabliathepate dar mu apre 0 acim sent, at radiant dele petu pacer non-vertistipetuceia cae et ‘opt veeliameancd pent 24ereSse Doe 12 mpbols repeat [eo adverse accra nga chert, sce renal a doe "ar Fumazeil fneate)~ un artagont campet = tus eee ‘spradamlor de berzodaepine(0.15me eetat ane) ‘lnepom berwatizepi semis ang metabolize patch Ee inadiamentl de eee pentru awoke pe tren ug. Daz 2-5 mg, reptat or. et abv ec reluga prin metabolic er Gracertareparadonal a agtaelo wil pdm parsurlvdrn ‘Midazolam besoin) sem scr (23 oe cu metablaare pti petra bers metabo ac cs acum substan dacs ‘somites ooze prea ar Saupe rege ma se apace oh nsf eral. madcarentulde eee env ansolape tin ct 2 pcr erly (rp anepot de verre su 24 oe) Ee peeat eines inert amma con uta oar pcs rite i/sau dnc equa achgareanratmenttloperola Propofol agent seat» Monat prof derisc cer care les ‘nso rez peerupacei eae ‘aepitsedre nl: ‘sectonecesaro are ap aun neuioge ‘ctepeent hipetensiunsinvacanians ropa determin un tmp de wena set, radice ames toed rare efecte anagete,tlecte adverse: Npotensune ares, sedor3 metabolic, hipertiieriemie (rise-de pancreatts, rabdomol, etherekbinerie ibrar ameristar.220(sTem presi V.STEMI~pacientiin situatii speciale A. PacintcuTEMsiacidnt vascular cerebral (AVE) Pacey AVCIn antecedent auuniscmal mare de ders in Imlocrde act (206) Paclenp cu store de AVC 9 care sur un ‘esol chiar co rpetarea unl nou aeeden ween, acca 3 Supmentarinsabitateahemodnamis selec, De asemanea sc sri ventricle male su stop cardrespator este mut ms mare ‘Stetpucan(207,Dessermenea bana tte de AC icre sed ‘afr rocardc uv isciatmared reorctarela 0 208 ‘borden pacint ev STEM! su @ unl pace u AVC da STeipote fel Lucruriedvin imal cindun STEMI coexist ‘unaVC Dielsesuntinguse dermal parent + preertaune oventiieataniponteface anarmnerafoat i padencusTeMt, + simptomatologa de tp neurologic poste mas sau mim sre Simptommsa unl infact mica (pretea, europt, locals ‘Suladreadrerete) ‘rather de necro mocardc pot erescu sn penn uu cut, pundnd probleme serosce de diagnostic diferent “roponina sac cetnal seal renstve Topol ‘Beresate neu uni AUC acm et rier moar (203) expat putes gat de wn tres macarae conor (einsba pote incerta) sermalanéastel paler c ‘eset Cesterea mare de necroxdmlocarde in az Ul ‘respect inssdinamicasogestpeninfret mica aut! “inaVChemoragie in speiinhemeagiaubarsnoiiand pot ol ‘modi EG fsupradenvlre de S57) etre aemsnaoare le cinsTEWI fr ca pacer abr! (210), ‘oniespcald seta de art ascendent5/Saude crs) poate Inducdconcomiten AV enemies STEMI (212)23) I cet studies pre-sptal este diets, dagnosteulcorect find per Dortate nainte de aca gst terapeute. Penta evar fonsecite catastae,svategia trope) tabu 53 nu con mediate cu rise hemorate(romboltc, anticoagulant) pana [anurreasaprostullearedeobclsfaceinspta) sre pespt.24 Tn consecis, in presptal trebule avuté permanent fo minte preocupareades nu conunda STEMI exo decade ort isu coun AVE Su coententa STEMI cu sete de aorta sau cum AVC. Oat ‘onus ratomentll pea pert STEMI fntievaguante, !nsagagonte placheare Aino) pote Neate seas acer Din acest mat a eric supe de dete de srt/AVe ma tebe smintratimedieatamenonat in ceea ce privet artes nad pest a botnavu cy STEMI -lcinantacedenta, srateaterapeates treble incon de bala bonefcluinprinarseuudehemoragl cerebral. Aa, + rnin esteabsolt otra lapaienpcuSTEMlcareauin Srocedenteun AVChemerage neers a aput act) sun [Nisehamicdcaacesssapirtinutinel Glan) + iol este ret contain a pace “tenaplat rater De asemenea: Tarlo este contrainte tre de hemo ‘og cerebral ar Prasipe este contandeat aes cv AVC de orc pn secede (40), a sub ataentsyste prespial V2. Pacienti cu STEMI aflatiin tratament anticoagulant STEM pest Probloma cea mal delet faci paint rime ine slegeren ‘wrapll de reperusie coronaran. 51 n acest eax prima algere este ‘nwoplstia primar, suspen care ech} SAMU tebe 3 ranaore Dicienul cite cel mat apropat cent cx pos de cadloge Interventions dad acest drum se posteface nai 120deriute dela Psluarea acest Ose ind nu est dbponl un abrator de ardooge Ina (sau este mult mai eparte de 2 or) se va a cll rapa Uombobes, eu prsetasctats de extents contingent rlave 3 soins de fone aun paint aft sb Watamentaneonant [onieAu exstat umeroase alu care au areist tit elena fn btnereareperiil ovnaree, ct ata de Singers, cele ma severe hindhemerailnrcrantene Duputineetiaturnemoregie cereale posttromboles spar 09-1 % ante pacent (29K), tar singrle Ijore no corerae (neces Wants sau sunt arenintoe de "9 Se produc a 413% dn eau (1710987) neal producer unr ‘cident voselare cererae, malonate sunt herocaice 3 par In primate 28 de or dupa vombolu, iar cle aprate maith sunt mal ‘eevee chenice. Ppa reditr de hemor cereale sun ta ans (peste 75 dean, potas scut 65 4] seal ei, TA ‘evil nceparea trata fibrin antecedent de boa ‘erebrovasclrd (213), Cas compart inte ert romboiti, 2 pare 'aefvatra plasminogen slr (- Ateplase] determi un nde tralmre de heroragl cerebral deed Tenecteplae (TMK A) (178) Sceptokinaza sau (Retplsn)suunec minor de scdentehemorge sraeraniene (17), ste cnoseut rscul de accidents heroraace Is sdminiraren de lwombolt, isa exists pune studi care st apreciers incidents compleailor Pemoraie la pale anteangl erie ce au primi ‘otementfenaaite ‘Unul ne acess contt chest erent mi aesernfitve ‘atti ft de cla Uatamentandcoaguant ol ane, marcind ‘scdmaimarelceicuINR reset (dea putes determin nal, Ineeipeste dean savev sito nial maimare de sO 238 ras colborterlrenarc un aun ma mare de Remora cereale tunel cd NR iil este peste (215) nr Pata Ober ric de “Sngeare crete cvs laren NR a debt antecedent de bea ore (216). Al autor remareb 0 crete de 3,7 on reel de hemor ntrecranian ia cei ce primeau anterior tatament Wading (217), ntimp ce un sual retrospect scandinyaperteash inden go 19% aherorallor majorelacsantcogua oral 218) Indicate actus ale traps antconguante orale (Rise ati rtrd protze value antecedent de vombemblsm pumas Sautromtoz} enous potun et) fcea un num mare de pace Me sub ratament cu antvtamine (Acenocumarl, Warfarin et) ‘1 node anscooguante orale (Dabigtan,Apaban, Rearosaban acini ancoaguo orl rank aun ec hemorape crest, ca te cesta sue un STEMI tebe nu con de ace re et ‘manera lagnostc sa teropets. Ate inch di fa preset, reba atric sports ore pn verons sure, petrrecatareéeanaze, pen adminis de medcamente injectable [rc de hematoma sahara prelonat ‘De asemenes in cau un sto cardi cet pace manele resusctare (mas adc eter) pot predispune a mai mule compli ~ hematoame toracie, hemotorax, hemopericar (in cot u ‘rauratsmecosaleperornipleweaupercrdlu), ATENTIE:presspoia la sngerae secundarstatamentulul annaglat ca NUcontand nina inte acete mane, fectuareatorcuaterispori Problema principal inst fa pacen ansenagulay cone ce suters STEN ete adintrarescancomitent de antagregante,aticongso Frio, wateeusedecompleati morc. ‘Aston pena trp! anipaenetare nf pre spl pace infarct migcardc aut poate prim dxa de Incicarepeferabl a ASP (150-325mgoral si Gopidgrl(300-500mg-, efertor Ia noe atigreante de fp inbitor de #2¥, (Pras ‘Teal la momertulacual au exsts eden cine eae 38 per sclera in sigan pe termen nga aeestor cu anticoagulntle ‘Nn vedere nd pace care a suet un fret mice ac ‘opt pentru moment terapia anticoagulant ora, considera iinisrarescudovdde ncicate) a Tegra sau Prasgrellpoa flutbincaeleaoptone cin tt deClopdore,STEM pespayi2s ns des trinlaapreispune la compat Nemorage, reduc emf 3 mortal pin aministrare presi! treble at ‘uate canine, carlin cae n 9 poate face anol ri dintrarea una emboli cuts me da hemrap Tenecepia Retpiase su char Septokinae) poate fut Ia anumite catego pacing cu rc mal mie de sSogerare: cel Sub 75 de an TA conoat ebutlratamentu INR <3 [dos poate determina), rd stoi bol cerebral, ‘sear pocani fos teatament anticoagulant rl ernie um net mloearte aes cu supradenivelare de ST repre un area curis crest sngerariiacaetratamentulin faa pres twebuieindidulaat} ind cont debalnfalschemie-hemorape + Biomarter Rocotarea pracoce a markerior de necroxs miocardies este ‘ecomandabl as ace et mi preeoce pon ste demn de meron ‘opulebrivollepabmasee de miog.obind, CK-MB pot Minuet ‘ames de prezegsconacilor wee pre deosetice de nivale asmatie de troponin ar nu depigesc vel rermae iia tmpu ‘tn souinperioads pengerum.Descee,bmarerl deste pert ‘rontoraarea cre micardagravietrebse fe oporin( 222). seocotowapo ‘xamiare ecocarsogaf in presptalfecotate portable) grids tre laaredeourec ext meted non-natginon sagan permite ‘scoperre arcane de dire torac decade aot, pec) Cfenndinacltinn date despre nepal VL3. Gravida cu STEMI Priorttea teapeut este repent in eal ravidlor de tre tsttirea tml precce trl derepetieTatamentu de lech STEMI ete angioeornarografia cu planted sen per-rimay, it ‘ccomandatea serene in cl emelor gravee STEM inde de Cast mel de evden), Se or lo de prefer bare ret! ent entry 9 reduce nevola adminstariiprelungte a torapet dale Spacer (23), isgnortcl MA ravi cuprine npn aaa clemente ca ne eave, ar rena anu partelr. ‘sSinptometaoae ‘Simptomele pce cum sunt dueres evosternal, afore, Palpsie senirsncps poate Wigeliteare ncaa nc fee ier fare acesea sunt fecvent considerate snptome generat de sri Semneiecniceprecim tahicari, agmetu I ergscena jure emee sunt comun ante ns [219) Atel suspiunea de MA‘ tte a de frocvet, ar nd ea est, se sermaea o retcenS Irerver(220, ‘ontorsoroC6 ‘efoca ala ne gravie, ct mal rocoe dup primul contact med umdind se at evel Segment ST et tal eave. Parl Sarin lal mest este posta pare a une evi alt secundar ascension dalagmul determinate restrain vlum ert Aesto modi pot gener aspect de und in derail inerioare (0, special Fj unde T negatvetn troller ter precumsin¥, Vl oesoralinfegatvin, 223) Tomboiea Aaminsvarea ombolielor este formal containdeats in srcing Scoarec sara repre un cite de excludere apap i tots Studie pe animal deexperen nua event ne ie teatgen ri tuburt ale deol postsale dupa aamnisvare de CPR Hat ‘reptoknaa, ct PR tavereeacplcentaln ant mime ce parent fuproduceectelt(228, ‘Complatia cea mal de temut ce apae la administrate trai wombs Ia gravie ese hemoraga, Rseul hamerage mater este Spectacle a6%. Pedal parte daciteapavomboliceste admins atlaopacents ust darter corona poate augntanemorap apa dc. rola tromboiic rebut sie esr doar prt ez lacare rusepoateefetusterapiade angonlaseprimar.126/sTeMI pes Terapia cdvonts + Sulft de mori. Incaeats in casa dere teratogen mrfna Goste adit pnt combsteren sure Ia paint cu find sornateefecteeratogenelat (225) “= Nitoglcrina sublingual trols est carat in catogoi fac teratoganc 8, sand Us exten management puta “rocatesarcini. Admiiatrarea de NTC sublngua sta permis, Imontoravea TA Sarcni, vind gi 38 nu produc hiptens tlic poate geera ipoperiiepacrtr (28), + Beta blocanteeratogenctatea bet blocantlr vari inunci Toi lor Adinitvarea unordore mic ebeta Soca pare ats een bei select find prefers! (sk nonselect pot ce enacts veri. + Anagzeganteplacetare area asin! a ferme rv, Sieur eel thenopdinsor ete deocamdts pup conor, ‘Sceeutlane clopdoprahiuiaevafocedoarinen denecestatel entre Nu erst date refentoare la ulinarea in sarod a nhibtorl _leoprtenlr bls, bvaruine, past 9 Seago lia {eestor medcamentneindrecmandsta teria bss (4) STEM prespta27 ‘odncngesapane ht U8 209. "sa a3 pfctl at ua ht eauepa seta bree ae 0 ‘tip ROSTON05 atm ct een Cnn eer ‘test mine Corse {Se moe cen isin dines i ge mm | ata i lin denon ear nec ‘aa tcrepeeroayarlc nagan n 2 7.75, etn en inn toe Oban ut RC OA. Fo ne pa ‘cenklrneianmosuhn onto syeons rie asa | "Oi tng aM per rg es Pgh 9539 ‘eet ee ean pry wa ete peel ‘ign sonmntn eee) 808 merece aca ya econ ins ak gt 53 ey blo 8 te i ‘ed fp pen onrepres henmenS “Scena an tn ene ar {he GINO mtr, A rail eid al epi renbc Sompsrosemenern Hina 2 iment anprenatonofs Row et nscangaen