Sixth Problem

Group 5
• Tutor: dr. Fifi, dr. Jimmy
• Group’s identity:
– Fransisca Novianti
– Shirley Lestari
– Jerry Setiawan
– Prematellie Jaya Leslie
– Kevin King
– Angeline Vincentia
– Jody Andrean
– Monica Pramana
– Andreas Adiwinata Then
– Mila Rizki Adila
– Sheren Regina
Problem: The Dangerous Heartbeat
• A 60-year-old man came to the Emergency Department with severe chest
pain extending to his jaw and left arm. He suddenly felt the chest pain 3
hours agowhile he was watching TV, accompanied by excessive cold sweat,
nausea and vomiting. He also felt shortness of breath since an hour ago.
He has a history of hypertension, diabetes mellitus and hypercholesterolemia
in the past 3 years. He is not taking his medication regulary, has been
smoking since the last 10 years and never exercises. Previously, he has
suffered an episode of mild chest pain but symptom disappeared after
resting. No history of stroke in the past.
Physical examinations result: compos mentis (GCS 15), looks in pain, agitated,
overweight and having mild-dyspneu. Blood pressure 170/90 mmHg, heart
rate 120 bpm (regular with enough volume and firmness), RR 30 bpm
(slow and superficial), afebrile and slight increase in JVP. Inspection,
palpation and percussion of the heart are in normal limits; S1 & S2 in
heart auscultation are normal, no murmur is found. Inspection, palpation
and percussion of the lungs are normal limits but fine rales at the basis of
the lungcan be heardin auscultation. Abdomen examination is normal. His
extremities are warm
 The image below is his 12 lead ECG result:

A few moments later, he suddenly experiences a seizure and falls unconscious. His
ECG monitor result is shown on the image below

Identify the problems in the case chronologically, discuss the problems and plan the
proper treatment while considering all possibilities!
 Learning Issues
Mampu memahami dan menjelaskan:
1. Klasifikasi kegawatdaruratan kardiovaskular
2. Patofisiologi
3. Tanda dan gejala kegawatdaruratan kardiovaskular
4. Diagnosis (history, hasil PF, pemilihan modalitas, PP)
5. Gambaran EKG DD kegawatdaruratan kardiovaskular
6. Tatalaksana kegawatdaruratan kardiovaskular
7. Komplikasi dan prognosis
8. Basic dan Advance CPR
LI 1: Klasifikasi kegawatdaruratan
kardiovaskular
UA
ACS STEMI
MI
Crisis
NSTEMI
hipertensi Narrow
Non-C.A
complex
Wide
complex
CV emerg Takiaritmia
Accesori
path
VF
Atrial
C.A
fibrilasi
VT
Lilly LS. Pathophysiology of Heart Disease, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
2011
 Klasifikasi Takiaritmia
Takikardia kompleks QRS-sempit
(QRS ≤ 0.12), terkait frekuensi
• Sinus takikardia
• Fibrilasi atrium
• Flutter atrium
• Re-entri nodus AV
• Takikardia dimediasi-jalur
aksesoris
• Takikardia atrium (termasuk
bentuk otomatisasi dan reentri)
• Multifocal atrial tachycardia
(MAT)
• Junctional tachycardia (jarang
pada dewasa)
Takikardia kompleks QRS lebar
(QRS ≥ 0.12)
• Takikardia ventrikular
(Ventricular tachycardia
[VT]) dan fibrilasi
ventrikular (ventricular
fibrillation [VF])
• SVT dengan aberan
• Takikardia pre-eksitasi
(Wolff-Parkinson-White
[WPW] syndrome)
• Irama pacu ventrikel
LI 2: Patofisiologi

Lilly LS. Pathophysiology of Heart Disease, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2011
Lilly LS. Pathophysiology of Heart Disease, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2011
ACLS.20
15.
LI 3: Tanda dan gejala kegawatdaruratan kardiovaskular
2016 ESC Guidelines for the diagnosis and management of Heart
Failure
LI 4: Diagnosis (history, hasil PF, pemilihan modalitas, PP)
 Sherman SC, Weber JM,
Schindlbeck MA, Patwari RG.
Clinical Emergency Medicine. USA:
McGraw-Hill; 2014.
LI 5: Gambaran EKG DD kegawatdaruratan kardiovaskular
Bradiaritmia

First Degree AV Block

• Delay at the AV node results in prolonged PR

interval
• PR interval>0.2 sec.
• Leave it alone
Second Degree AV Block Type 1
(Wenckebach)

• Increasing delay at AV node until a p wave is not

conducted.
• Often comes post inferior MI with AV node ischemia
• Gradual prolongation of the PR interval before a skipped
QRS. QRS are normal!
• No pacing as long as no bradycardia.
Second Degree AV Block Type 2

• Sudden loss of a QRS wave because p wave was

not transmitted beyond AV node. QRS are
abnormal!
• May be precursor to complete heart block and
needs pacing.
 Third Degree AV Block

• Complete heart block where atria and ventricles

beat independently AND atria beat faster than
ventricles.
• Must treat with pacemaker.
 Left Bundle Branch Block

• Left ventricle gets a delayed impulse

• QRS is widened (at least 3 boxes)
• Pacemaker if syncope occurs
 Right Bundle Branch Block

• Right ventricle gets a delayed impulse

• QRS is widened (at least 3 boxes)
• Pacemaker if syncope occurs.
Takiaritmia

SVT
• Reentrant arrhythmia at AV node that is
spontaneous in onset
• May have neck fullness, hypotension and/or
polyuria due to ANP
• Narrow QRS with tachycardia
 Atrial Flutter
• Atrial activity of 240-320 with sawtooth pattern. Usually
a 2:1 conduction pattern; if it is 3:1 or higher, there is AV
node damage
• Treatment is to slow AV node conduction with
amiodarone, propafenone or sotalol
• DC cardiovert if <48 hours or unstable
• You can also ablate the reentry pathway within the atrium
between the tricuspid and the IVC.
 Atrial Fibrillation
• Can be due to HTN, cardiomyopathy, valvular heart desease,
sick sinus, WPW, thyrotoxicosis or ETOH
• Therapy is either rate control via slowing AV node conduction
with stroke prophylaxis or rhythm control
 Ventricular Tachycardia

• Impulse is initiated from the ventricle itself

• Wide QRS, Rate is 140-250
 Torsades de Pointes

• “Twisting of the points” is usually caused by medication

(quinidine, disopyramide, sotalol, TCA), hypokalemia or
bradycardia especially after MI
• Has prolonged QT interval
 Ventricular Fibrillation

• Most common in acute MI, also drug overdose,

anesthesia, hypothermia & electric shock can
precipitate
• Absence of ventricular complexes
• Usually terminal event
Tintinalli's Emergency Medicine - A Comprehensive Study Guide 8th 2016
LI 6: Tatalaksana kegawatdaruratan kardiovaskular
 Terapi Reperfusi
 Terapi fibrinolitik  Streptokinase 1,5 juta U
dilarutkan dalam 100 cc NaCl 0.9% atau Dextrose
5%, diberikan secara infus selama 30-60 menit.

Fibrinolisis bermanfaat diberikan pada pasien :

1. ST elevasi atau perkiraan LBBB baru
2. Infark miokard luas
3. Pada usia muda dengan risiko perdarahan
intraserebral yang lebih rendah
 Kontraindikasi
Absolut
 Pendarahan intrakranial
kapanpun
 Stroke iskemik < 3 bulan, > 3 jam
 Kecurigaan diseksi aorta
 Adanya kelainan struktur
vaskular serebral (AVM)
 Perdarahan internal aktif atau
gangguan sistem pembekuan
darah
 Cedera kepala tertutup atau
cedera wajah dalam 3 bulan
terakhir
Relatif
 Tekanan darah tidak terkontrol
 TD sistolik > 180 mmHg, diastolik >
110 mmHg
 Riwayat stroke iskemik > 3 bulan,
demensia
 Trauma atau RJP lama (>10 menit)
atau operasi besar < 3 bulan
 Perdarahan internal dalam 2-4
minggu
 Hamil, ulkus peptikum aktif,
sedang menggunakan
antikoagulan dengan INR tinggi
LI 7: Komplikasi
LI 8: Basic dan
Advance CPR
Pediatric Chain of Survival.

• Injury prevention and safety

• Early CPR with an emphasis on chest compressions
• Early access to emergency care. In most communities, phone
911 accesses the EMS system.
• Early pediatric advanced life support.
• Comprehensive post-arrest care.