CARDIAC EMERGENCY

Rizki Amalia Gumilang

OUTLINE

Cardiac Arrest
Management Acute Coronary Syndrome
Tachycardia and Bradycardia
Hypertension Crisis
 CARDIAC ARREST

Cardiac arrest : sudden cessation of circulation due to

inability of heart to contract effectively

How to diagnose : unresponsive, no pulse

CHAIN OF SURVIVAL
HIGH QUALITY CPR

adequate rate and depth (100 x/mnt ; 2 inch or 5 cm depth)

Allowing complete recoil

minimize interruption : only for check rhythm and defibrillation

avoiding excessive ventilation

CARDIAC ARREST

NON SHOCKABLE : PEA/ASYSTOLE

SHOCK ABLE : VF/Pulseless VT

SHOCK/ DEFIBRILATION

Monophasic : 360 j

Biphasic : 120-200 j, or the highest energy according to device

DRUGS

Epinephrine : 1 mg every 3-5 min

Vasopressin : 40 units to replace first and second dose of

epinephrine
Amiodarone : 300 mg bolus ( 1st dose), 150 mg bolus (2nd dose)
Lidocaine : initial dose 1-1,5 mg/kgbb, additional dose 0,5-
0,75 mg/kgbb to max dose 3 mg/kgbb
AIRWAY SUPPORT

No definite recommendation pertaining to appropriate time of

airway support (ET/supraglotic advance airway ).

Study , airway support <5 min no significant correlation with

ROSC, but improved 24 h survival. Airway support < 12 min
better survival

Airway support should not interrupt

CPR
ROSC

Return Of Spontaneous Circulation

An adequate pulse

Secondary survey , post cardiac arrest care

Identify 5 H and 5 T
When to stop resuscitation ?

ROSC
no response to resuscitation for minimally 20 min
after optimal resuscitation according to guideline
Unwitness cardiac arrest
Sustained asistole > 10 min
 ACUTE CORONARY SYNDROME

Presentation
(Clinical, Initial ECG)

Working ST-Seg Elevation Non-STSeg Elevation

diagnosis Myocardial Infarction Acute Coronary Syndr

Time

Evolution of
ECG & Biomarker (+) Biomarker (-)
Biomarkers

Final ST-Seg Elevation Non-ST-seg- Unstable

diagnosis MCI Elevation MCI Angina
National Heart Foundation Australia &The Cardiac Society of Australia and New Zealand, MJA 2006
 Algorithm in Acute Coronary Syndrome

Admission CHEST PAIN

Performed in 10 min
Working Suspected ACS
diagnosis

Persistent No persistent {on serial

ECG
ST elevation ST elevation ECG}

Bio- Troponin, Troponin, - ACS unlikely

chemistry CKMB (+) - NSTEMI
CKMB (+)
- STEMI

Risk
Stratification
Risk: high / low

Initial management,
Management revascularization

Secondary Medical therapy,

prevention
coronary angiography Modified from ESC 2007
Diamond GA. J Am Coll Cardiol 1983;1:574
 ASSESSING CHEST PAIN
Character
Time of onset, duration, frequency
Changes in tempo
Exacerbating and alleviating factors
Pain during situation associated with increased myocardial O2 demand (e.g.
exertion, stress)
 CHARACTER OF ANGINAL
PAIN
Localized usually at precordium
Radiate to arm, neck, shoulder, back or
epicardium
Feels like being pressed by heavy object, or
constricting or crushing.
Concomitant systemic symptoms: dyspnea,
dizziness, nausea, diaphoresis
 CHARACTER OF ANGINAL PAIN
Some feels epigastrial pain, similar to gastritis
Only 54% report typical angina
34% burning, or indigestion
32% chest pain
20% stabbing, sharp pain
42% undescribable
Can be atypical in the elderly, diabetic
Patient without CAD: sharp localized pain,
pleuritic, positional, increased with tactile
pressure almost always not ischemia.
 Algorithm in Acute Coronary Syndrome

Admission CHEST PAIN

Performed in 10 min
Working Suspected ACS
diagnosis

Persistent No persistent {on serial

ECG
ST elevation ST elevation ECG}

Bio- Troponin, Troponin, - ACS unlikely

chemistry CKMB (+) - NSTEMI
CKMB (+)
- STEMI

Risk
Stratification
Risk: high / low

Initial management,
Management revascularization

Secondary Medical therapy,

prevention
coronary angiography Modified from ESC 2007
E K G

Ischemia : ST depression,
Tall T, T inverted
Injury : ST elevation
Infarction : Q pathologic
 EVOLVING ECG

A. Normal ECG
B. Tall T or Peaked T
waves
C. Injury, ST elevation
D. Inverted T waves
E. Q-abnormal
 Algorithm in Acute Coronary Syndrome

Admission CHEST PAIN

Performed in 10 min
Working Suspected ACS
diagnosis

Persistent No persistent {on serial

ECG
ST elevation ST elevation ECG}

Bio- Troponin, Troponin, - ACS unlikely

chemistry CKMB (+) - NSTEMI
CKMB ()
- STEMI

Risk
Stratification
Risk: high / low

Initial management,
Management revascularization

Secondary Medical therapy,

prevention
coronary angiography Modified from ESC 2007
 BIOMARKERS

Recommendation: Troponin upon admission and serial in 6-12

hours
LDH, SGOT/SGPT and other enzymes not recommended
Increase of TnI & TnT are more specific in diagnosing marker MI;
its level corresponds with prognosis (higher value, worse
prognosis).
 Biomarkers Early release myoglobin of
CKMB isoform

50 Cardiac troponin after

Multiple of the AMI cutoff limit

classical myocardial infarction

20 CK-MB after myocardial infarction

10 Cardiac troponin after microinfarction

5
2
1

0 1 2 3 4 5 6 7 8
Day after onset of AMI

Time-course of the different cardiac biochemical markers. From Wu AH et al. Clin Chem
1999 ; 45 : 1104, with permission
FIBRINOLYTICS VS PPCI
CONTRAINDICATION FIBRINOLYTIC
WHAT TO BE MONITORED DURING FIBRINOLYTICS

P : Perdarahan

A : Aritmia reperfusi

H : Hipotensi

A : Alergi
RISK STRATIFICATION

QUANTITATIVE RISK TIMI RISK SCORE AND GRACE RISK SCORE

TIMI RISK SCORE : Predict mortality and need for revascularization
TIMI FOR STEMI
GRACE SCORE
TACHYCARDIA AND BRADYCARDIA
Hypertensive Crisis

BP > 180/110
Emergency : with sign of target organ
damage
Urgency : without target organ damage
SIGN AND SYMPTOMS

headache
blurred vision
chest tightness
shortness of breath
anuria
Basic Principle of Management

Urgency : oral medication

BP lowering 24-48 h

Emergency : IV medication
target < 25% MAP for 1 h
160/100 in 2 -6 h
< 140/90 in 24-48 h
Exception
Intracranial hemmorhage : MAP 130 mmHg
Acute Ischemic stroke
Aortic Disection
Patient undergoing thrombolysis (<180/100 )
THANK YOU