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Ghidul de

conduita a
personalului
13 aprilie 2018 vineri
medical in caz
Sg de Padure de Infarct
miocardic acut
INIMA
Infarct miocardic = Szivinfarktus
Φ O2 distructie muschi >>> creier >>> durere ( umar epigastru )DZ-
Adrenalin ↑ frecventa cardiaca
dispnee
oboseala 15-20 minute ------5000 celule /sec
ameteala , sincopa
greata ,varsaturi
Localizare 2.5 mm in barbati < 40 ani, 2 mm in
2 TIPURI barbati peste 40 ani,sau
1.5 mm in femei in V2–V3 sau 1 mm in
celalte derivatii

 Subendocardic  Transmural = STEMI


=nonSTEMI Semn direct
Semn indirect de
oglinda
ECG
Semn direct

Semn indirect de
oglinda

Evolutia in timp a ECG


Infarc
miocardic
inferior
Infarc miocardic
inferoposterior
Infarct ventricul
drept
Infarct anterior
Infarct lateral
Examen de
laborator
BRS/BRD chiar daca este documentat prin ecg vechi
necesita PTCA primar , BRD prognostic rau
ST elevatio >8 derivatii =ocluzie de trunchi ACS
Alte investigatii:
colesterol, HDL ↓, TG, glicemie, homocisteine
functierenala, functie hepatica ,
hemoleucograma, , teste coagulare TS, TC, INR
ECO cord  Coronarografie
 hipokinezie FE%  Angio CT cardiac
 valve, papile,
cordaje, tromb,
anevrism VS,
pericardita, ruptura
SIV, perete VS
Complicatii : ŞOC
hipoTA cardiac
Primele saptamani:
Contractilitate ↓:
tromb
Instabilitate electrica EPA
ARITMII

Distructie celulara Bradicardie


Inflamatie pericardita IMA INFERIOR
 Cordaj mm papilar ;
insuficienta valvulara
 Sept interventricular
 Ruptura perete VS
tamponada
 Anevrism VS
 Mortalitate spital 4-12
Mortalitate la 1 an 10 %
ICC

Tratament :
 Recunoastere IMA
 Camera de garda : monitorizare ECG continua aritmii ,
cale venoasa , aspenter 500 mg Trombex 4x75 mg
 Tratamentul durerii : NG( ECG se norm coronarografie in
viitor apropiat ), Morfium, mialgin,
dispneei : Oxigen doar daca S02<90%
anxietatii benzodiazepina usoara
 SCR :FV defibrilator – Instruire personal
In caz de SCR coronarografie si PTCA primar obligatoriu in
2 h , pacientul se va aduce direct in laboratorul de
cateterism fara a se pierdere timp in UPU ----- UPU zona
rosie
Pacientul inconstient are o mortalitate mare si frecveta
mare a sechelelor neurologice
Non STEMI excludere alte dg ca stroke, insuf resp, TEP
intoxicatie si echo cardiac
 Tratamentul de reperfuzie NETWORK
PTCA
Fibrinoliza
By pass AO coronarian
PTCA primar  Fibrinoliza Bypass
 Simptome debut Anatomie
Prespital/salvare
sub 12 ore , trunchi
 abord radial  2-24 ore PTCA ACS,
 BRS/BRD/ SCR trivascular
In timpul procedurii Ptca

Aspenter + P2Y12 inhibitor + anticoagulant


150-300 mg Prasugrel D60-10 mg heparin 70-100ui/kg APTT
(500 mg) clopidogrel D300–75mg enoxaparin 0,5 mg/KG IVB
ticagrelor D180 =2x90 mg bivalirudin TR↓
Cangrelor IV abciximab
ANTICOAGULARA DE DURATA LG DOAR DACA Fa valve
mecanica, tromb VS, profilaxia TVP
Fibrinolizis debut <12 ore(2 ore )
 e. tenecteplase, alteplase, reteplase ½ doza la pacienti
peste 75 ani

 Antiagregant asociat cu fibrinoliz a aspenter clopidogrel


sau aspenter +p2Y12 inhib timp de un an
 anticoagulant asociat fibrinoliza aprox 8 zile
 contraindicatii absolute:hemoragie intracraniana in
antecedente, stroke ischemic in ult 6luni,noe intracranian
sau malform arteriovenoasa, traumatism cranian in ultima
luna , HDS in ultima luna, tulb hemostaza disectie aorta si
relative Tia in ult 6luni, sarcina, HTA refractar, endocardita,
hepatopatie, resuscitare prelungita, ulcer peptic activ
Tratamentul in cursul spitalizarii in
compartimentul de terapie
intenziva coronariana

 Fumat, dieta, alcool, glicemii , greutate


corporeala, control HTA
Antiagregant aspirina, clopidogrel, NEW
Betablocant
Statina
Nitrati
Inhibitor de enzima de conversie
antagonist aldosteron