Acute Pulmonary Edema and
Emergency Arrhythmias in
ACS
Jetty RH Sedyawan SpJP KDepartemen Kardiologi dan Kedokteran Vaskuler FKUI
Edema Paru Akut(subset klinik dari gagal jantung akut)
• Distress pernafasan yang berat
• Crakles diseluruh lapang paru
• Orthopnoea
• Saturasi O2 < 90% pada udara kamar
Faktor pencetus
• Kepatuhan minum obat rendah
• Tatalaksana sub optimal
• Infeksi
• Surgery
• Lain-lain
IskemiaAritmia
How should I assess patients in acute heart failure?
1. Volume status and tissue perfusion:cold or warm, wet or dry. [IIa C]
2. A precipitating cause : complete blood count, serum creatinine, electrolytes, troponins,
ECG, chest x ray and an echocardiogram. [ I, C]
3. Blood brain Natriuretic Peptide (BNP) or N-terminal proBNP (NT-proBNP) if the diagnosis is in doubt. [I, A]
4. Monitor heart rate, BP and oxygen saturation . [IIa, C]
5. Monitor fluid balance, urine output, renal function and laboratory especially when the patient is in shock. [I, C]
6. Inserting an arterial line and a central venous pressure lineif the patient is in cardiogenic shock or for those who require pressors. [II b, C]
Assess the patient’s:
Canadian Journal of Cardiology, 23(1), 21-45. Dec, 2007
What are important acute heart failure treatment
considerations?
1. Correct precipitating causes of acute heart failure promptly. [I,B]
2. Oxygen. [I,C]
3. Support ventilation with (CPAP), bilevel positive airway pressure (BIPAP) or
endotracheal intubation if hypoxemia persists. [IIa,B]
4. Treat volume overload with i.v. diuretics. [I,B]
5. Vasodilators for patients with dyspnea at rest. [I,C]
6. Inotropes: cardiogenic shock or volume overload with diuretic resistance.[I,C]
7. ACE inhibitors until the patient is stabilized. [I,B]
8. Intra-aortic balloon pump (IABP) in patients with refractory heart failure despite
medical therapy. [IIb,B]
Arrhythmias
Canadian Journal of Cardiology, 23(1), 21-45. Dec, 2007
• Ventricular fibrillation
Or
Pulseless
ventricular
tachycardia
Defibrillate with 360J (preferably by biphasic defibrillation with a maximum of 200 J).
If refractory to initial shocks inject:
epinephrine 1 mg or
vasopressin 40 IU and/or
amiodarone 150–300 mg as injection
Bantuan ABC: beri Oksigen; pasang IV line.Monitor EKG, TD, Oksimetri
Rekam EKG 12 lead bila memungkinkan atau rekam irama di lead IIIdentifikasi dan obati penyebab yang reversibel
Probable re-entry PSVT:•Rekam EKG 12 lead saat irama sinus
•Jika timbul kembali; beri adenosin lagi dan pertimbangkan obat anti aritmia yg lain
Kembali ke Irama normal sinus ?
Takikardi QRS sempit irreguler•Probable Atrial fibrilasi, control rate dengan:B-bloker IV, digoxin IV atau diltiazem IV•Bila onset AF < 48 jam berikan :Amiodaron 300 mg IV selama 20-60 mnt, dilanjutkan 900 mg/24 jam
•Vagal manuver•Bolus cepat Adenosin 6 mg;
Bila tak berhasil berikan 12 mg;Bila tidak berhasil berikan 12 mg.
•Monitor EKG kontinu
QRS SempitApakah irregular?
Apakah QRS sempit (<0,12 det)?
Synchronnised DC shock Apakah pasien stabil?Tanda tidak stabil:
Kesadaran menurun, nyeri dada, TD sistolik<90 mmHg, gagal jantung(Gejala terjadi akibat laju nadi yang terlalu cepat > 150 beat/mnt)
•Amiodaron 300 mg IV lama pemberian10-20 mnt dan ulangi kejut listrik,
•amiodaron 900 mg/24 jam
Possible atrial flutterControl rate ( B-bloker)
Beberapa kemungkinan, a.l:•AF dgn bundle branch blockPengobatan spt QRS sempit
•Pre-excited AFPertimbangkan amiodaron
•VT Polimorfik (spt torsades de pointes = berikan magnesium 2 gr selama 10 mnt)
QRS lebarApakah QRS regular?
Jika VT (atau belum jelas)•Amiodaron 300 mg IV selama 20-60 mnt
dilanjutkan 900mg/24 jamJika sebelumnya confirmed SVT
dgn bundle branch block:•Berikan adenosin seperti
pada takikardi QRS sempit regularKonsultasi ke kardiolog
Stabil
Tidak Stabil
Tidak
irregular
regular
Ya
LebarSempit
regularirregular
Konsultasi ke kardiolog
Catatan :kardioversi harus dilakukan dalam sedasi atau anestesi umum
ALGORITMA TAKIKARDIA
Jetsed
ALGORITMA BRADIKARDI
pemasangan TPM
Obat-obatan alternatif :•aminofilin•Isoprenalin• dopamin
•Glucagon=pada overdosis BB atau CCB •glycopyrolate
Pengobatan sementara :•Atropin 0,5 mg IV dpt diulang sampai dosis maksimum 3 mg•Adrenalin 2 – 10 mcg/mnt
•Obat alternatif Atau
•Transcutaneous pacing
Adakah Risiko asistol?•Recent asystole
•Mobitz II AV block•Total AV block dengan QRS lebar
•Ventricular pause > 3 det.
Atropin0,5 mg IV
Yes
Observasi
No
Yes
No
Yes
No
Tanda-tanda:•TD sistolik < 90 mmHg•Nadi < 40 beat/mnt•Aritmia ventrikel dengan TD cukup•Gagal jantung
Respon memuaskan?
Jetsed