PRESENTED BY : IIN BANISWIRA C11108193

Supervisor : dr. Khalid Saleh, Sp. PD,KKV,FINASIM

BAGIAN ILMU ANESTESI, PERAWATAN INTENSIF, DAN MANAJEMEN NYERI

MR number

: 579492

Name

: Mr. J

Age

: 58 years old

Date administered

: November 20th 2012

Chief complaint: Chest pain The pain was felt a day ago after coming from the garden, before admitted to the hospital. The pain felt pressed by heavy things, radiated to left arm, but no penetrated to the back body. The pain was felt for more than 30

minutes and didnt relieved by rest. During the attack, patient feel
sweating, nausea, vomit (-), palpitations (-), shortness of breath (-). Cough (-), history of cough(-) Dizziness (-), Headache (-) , Fever (-) PND (-), DOE (-) Defecation and urination : normal

 History of heart disease ( - ) History of hypertension is (-) History of diabetes melitus (-) History of dyslipidemia is unknown History of smoking (+) +25years

 General status

Moderate illness/well nourished/conscious

Vital sign BP : 100/70 mmHg HR : 60 x/min RR : 24 x/min T

: 36.50 C

Head : Anemia (-) , Icterus ()

Neck : JVP R-2cm H20

Lung : Vesicular, Rhonchi -/- , Wheezing -/-

Cor :

I : Ictus cordis not visible

P : Ictus cordis not palpable P : Dull, normal heart size -Upper border : left 2nd ICS -Right border : right parasternalis line

-Left border : left medioclavicular line

A : Heart Sound I/II pure regular, murmur(-) Abdomen : Inspection Auscultation : flat and following breath movement : peristaltic sound (+) , normal

Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-) Extremities : Edema -/-

Right ECG

Posterior ECG

Rhythm P wave Heart Rate PR interval Axis

: Sinus rhythm : 0,08 s : 50 x/min, reguler : 0,24 s : +10

Duration QRS : 0,12 s

ST Segment

: ST elevation II,III, AvF

Conclusion: Cardiomegaly with dilatatio, elongatio et atherosclerosis aorta

Date of lab test

Types of test

Result

November 20th 2012

WBC: 13,78 x103 mm3 (4,0 10,0 x 103) PLT: 182 x103 mm3 ( 150 400 x 103) RBC: 4,72 x106 mm3 ( 4,0 6,0 x 106) HGB: 14,0 gr/dl ( 12 16 ) HCT: 39,8% ( 37 48 )
Blood chemistry Ureum : 26 mg/dl Creatinin : 0,9 mg/dl SGOT : 158 /l SGPT : 39 /l Chol Total: 189 mg/dl Chol HDL: 35 mg/dl Chol LDL: 116 mg/dl Triglyceride: 221 mg/dl GDS 131 mg/gl ( 10 50 ) ( < 1,3 ) ( < 38 ) ( < 41 ) ( 200 ) ( > 55 ) ( < 130 ) ( 200 ) (140)

Cardiac enzymes

CK : 2643 CKMB : 250 u/l Trop T : 0,98 ng/ml

( < 190 ) (<25) (<0,1)

Inferior STEMI onset >12 hours, Killip I

O2 2-4 lpm ( via nasal canule ) IVFD NaCl 0,9% 20 dpm Aspilet 80mg 0-1-0 Plavix 75mg 0-1-0 Simvastatin 20 mg 0-0-1 Lovenox 0,6 cc/12 h/ SC Fasorbid 5 mg/SL Alprazolam 0,5 0-0-1 Laxadyn syr 0-0-2 C

Yowler, C.J. Burn Injuries (Critical Care in Severe Burn Injury). In : Smith, C.E. Trauma Anesthesia. Cambridge : Cambridge University Press. 2008. p : 315

ST ELEVATION MYOCARDIAL INFRACTION

Myocardial infarction (MI) rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium.

This usually results from plaque rupture with thrombus formation in a coronary vessels, resulting in an acute reduction of blood supply to a portion of the myocardium.

 Occurs when coronary blood flow decreases

abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis. occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates.

In most cases, infarction

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from

unstable angina to myocardial infarction.

Non- Modifiable
Gender and Age Men, increased risk after age 45 Women, increased risk after age 55

Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia Obesity Lack of physical activity

Family History
Heart disease diagnosed before age 55 in father or brother

Heart disease diagnosed before age

65 in mother or sister

1. 2. 3.

Clinical history of ischaemic type chest pain lasting >20 minutes Changes in serial ECG tracings Rise and fall of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin

1. 2. 3. 4. 5.

Chest pain, >30 minutes Usually tight, crushing, and band like Location in retrosternal May radiate to left arm, throat, and jaw Associated features including palpitation, sweating, breathlessness, and nausea.

 ST segment elevation over area of damage ST depression in leads opposite infarction Pathological Q waves Reduced R waves Inverted T waves

Signs of myocardial ischemia ECG

Yes

ST segmen elevation ?
No

Acute Myocardial Infarction (STEMI) Yes NSTEMI ( Non ST-Elevation Myocardial Infarction )

Lab

Biochemical cardiac markers ?

No

Unstable Angina

Fixing the chest pain and fearness o Bed rest o Diet o O2 2-4 lpm o Nitrat sublingual/oral/IV o Antiplatelet : aspirin and clopidogrel o Morfin/petidine Diazepam 2-5mg/8 hour Stabilizing the hemodynamic ( blood pressure and pheripheral pulse control) o -blocker o Calcium chanel blocker (CCB) o ACE-Inhibitor Reperfusion of the myocard o Thrombolitik

Congestive heart failure Myocardial rupture Arrhythmia

Cardiogenic shock
Pericarditis

KILLIP CLASSIFICATION Class I II Description No clinical signs of heart failure Rales or crackles in the lungs, an S3, and elevated jugular venous pressure Acute pulmonary edema Cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction Mortality Rate (%) 6 17

III IV

30 - 40 60 80

Thank you for your attention