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PREHOSPITAL

MANAGEMENT OF ACS
7th Surabaya Cardiology update

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Spectrum Acute Coronary Syndrome

Acute coronary
syndromes
• Unstable angina
• NSTEMI
• STEMI

Pathophysiology

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Reperfusion Therapy Percutaneous Coronary transluminal coronary artery bypass Thrombolysis angioplasty graft surgery (PTCA) (CABG) 5 .

including lower risk of haemorrhagic incident and improved conditions for coronary assessment When time to in hospital treatment is short.Primary angioplasty Having a number of advantages over thrombolysis. PTCA should be the treatment of choice 6 .

and restoration of blood flow to the ischaemic myocardium. removal of the obstruction. Thrombolytic agents • streptokinase • tissue plasminogen activator alteplase • anistreplase • urokinase 7 .Thrombolytic agents Lysis of the occlusion.

• The 12 lead electrocardiogram (ECG) is transmitted to a doctor who makes a diagnosis (and may communicate this diagnosis back to the ambulance crew) • Ambulance paramedics are trained to interpret the ECG themselves 8 . in one of two ways. 12 lead electrocardiography Electrocardiography is the key diagnostic tool to determine eligibility for acute reperfusion interventions Ambulance service paramedics use 12 lead electrocardiography to assist with early diagnosis of AMI.

Circulation. Circu latio n. Sobel BE . Early reperfusion : “Time is Muscle-muscle is life” Time-Dependent Time-Dependent Benefit Benefit of of Reperfusion Reperfusion Therapy Therapy Importance of Time-to-Treatment: Results of GUSTO-I 100 Reimer/Jennings 1977 12 Bergmann 1982 80 30-Day Mortality ( %) GISSI-I 1986 10 % Benefit 8 60 6 40 2=149 (1 df ) 4 20 2 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 0 2 4 6 8 10 12 Reperfusion Time (hours) Time From Onset of Symptoms to Treatment (hours) Ada pte d from Tiefenbr unn AJ. Adapted fr om Lee KL .1668.85 :231 1-2315 . 1992 . et al. 1995.91:1659. 9 .

TIME IS MUSCLE. MUSCLE IS TIME Prehospital provider play a critical role Vital link in the life line 24/7 PCI capable centre .

What Does the Guideline says? .

Pre Hospital Care Recommendation .

REPERFUSION STRATEGY ESC STEMI 2012 13 .

Reperfusion Strategis within 12 hour of FMC .

control chest pain and reduce mortality) Morphine for pain relief  given IV in small doses .Pre-Hospital Management Oxygen by nasal cannula  if hypoxemia is present Aspirin : 160-325 mg Sublingual nitroglycerine  followed by IV infusion if needed Intravenous betablockers decrease myocardial oxygen demand.

Enhanced ACS management in dr ISKAK Hospital Tulungagung 16 .

What we have done now TEMS (Tulungagung Emergency Medical Service) 0355-320119 17 .

31 Puskesmas itu ada 14 Puskesmas perawatan Fasilitas kesehatan sekitar RS ISKAK tulungagung.055.65 km2 memiliki 19 kecamatan yang terbagi kedalam 257 desa dan 14 kelurahan. Demografis luas wilayah 1.id 18 .go.

Proposed ACS pathway Prehospital management Hospital management Model of ACS management in 19 Australia. 2009 .

on air radio counseling. 2009 .Education (brochure.Department of health .Directly to hospital Rural /teritorial : .Consultation using phone/whatsapp . PHC and clinic propagation) Metropolitan: .Thrombolytic prehospital Model of ACS management in 20 Australia. counseling.Call for TEMS and hospital networking .Enhanced strategy Prehospital management of ACS .

jam : Menit) Keluhan utama : Riwayat Medis dan Pengobatan Awal timbul gejala : Meminta pertolongan medis : Jam ambulans tiba/sampai di IGD : Jam ambulans berangkat merujuk : Team Jam berangkat sendiri ke RS : Jam pasien tiba di RS : Pemeriksaan Fisik : Kesadaran : TD : / mmHg Jam mentransmit EKG : Denyut jantung : x/menit Laju nafas : x/menit Irama : SR/Sinus Tachycardia/SB/AF/SVT/VT/VF/AV Block was Seorang pasien dengan keluhan nyeri dada / rasa tidak nyaman di dada Heart Line : Fax : Rekam EKG 12 sandapan Email : formed BBM : Transmit EKG ke Heart line WhatsApp : di RSUD dr. LBBB = left bundle branch. jika Rujuk ke PCI center untuk evaluasi estimasi waktu antara FMC sampai tindakan kateterisasi ( balonisasi ) < 120 menit. aVF atau irama pacu jantung lateral : I. lembar copy di tinggal di RS asal . AF = atrial fibrilation.AV = atrioventricular. Dijumpai LBBB. 21 p. SL = sublingual.SVT = supra-ventricular tachycardia. Lembar asli dikirim kre RS rujukan.RS = rumah sakit. diberi terapi fibrinolitik Petugas : Tanda tangan : Keterangan : IGD = instalasi gawat darurat.VT = ventricular tachycardia.EKG = elektrokardiografi. V1-V6 anterior : V2-V4 Konsultasikan ke Heart Line anterior ekstensif : I. RBBB tanpa elevasi segmen ST inferior : II.o Clopidogrel 300-600 mg p. Iskak Tulungagung Direct Line : in jan EKG normal atau Dijumpai elevasi segmen ST . aVL.TD = tekanan darah. PCI = percutaneous coronary intervention.SB = sinus bradycardia.VF = ventricular fibrillation. FMC = first medical contact. RBBB = right bundle branch block.o Rujuk ke PCI center untuk primary PCI. aVL.o = per os(oral). TRIAGE PRE-HOSPITAL PASIEN INFARK MIOKARD AKUT TULUNGAGUNG CARDIOVASCULAR CARE UNIT NETWORK SYSTEM Nama : Tanggal lahir/usia : Nama fasilitas pelayanan kesehatan primer : SKA (Waktu) (tanggal.SR = sinus rhytm. III. Jika tidak.V1-V6 2016 Rujuk ke RS primer atau PCI Center posterior : V7-V9 atau ST depresi di V1-V2 Onset gejala </= 12 jam Onset gejala > 12 jam O2 nasal 3-4 L/menit O2 nasal 3-4 L/menit Tablet nitrat 5 mg SL Tablet nitrat 5 mg SL Aspilet 160-320 mg dikunyah Aspilet 160-320 mg dikunyah Clopidogrel 300-600 mg p.

TRIAGE PRE-HOSPITAL PASIEN INFARK MIOKARD AKUT TULUNGAGUNG CARDIOVASCULAR CARE UNIT NETWORK SYSTEM Menit (Waktu) (tanggal. Iskak Tulungagung Direct Line : .jam : ) Keluhan utama : Riwayat Medis dan Pengobatan Awal timbul gejala : Meminta pertolongan medis : Jam ambulans tiba/sampai di IGD : Jam ambulans berangkat merujuk : Jam berangkat sendiri ke RS : Jam pasien tiba di RS : Pemeriksaan Fisik : Kesadaran : TD : / mmHg Jam mentransmit EKG : Denyut jantung : x/menit Laju nafas : x/menit Irama : SR/Sinus Tachycardia/SB/AF/SVT/VT/VF/AV Block Seorang pasien dengan keluhan nyeri dada / rasa tidak nyaman di dada Heart Line : Fax : Rekam EKG 12 sandapan Email : BBM : Transmit EKG ke Heart line WhatsApp : di RSUD dr.

aVF atau irama pacu jantung lateral : I.o Rujuk ke PCI center untuk primary PCI. diberi terapi fibrinolitik .o Clopidogrel 300-600 mg p. RBBB tanpa elevasi segmen ST inferior : II.Continue EKG normal atau Dijumpai elevasi segmen ST . III. Jika tidak. Rujuk ke PCI center untuk jika evaluasi estimasi waktu antara FMC sampai tindakan kateterisasi ( balonisasi ) < 120 menit. Dijumpai LBBB. aVL.V1-V6 Rujuk ke RS primer atau PCI Center posterior : V7-V9 atau ST depresi di V1-V2 Onset gejala </= 12 jam Onset gejala > 12 jam O2 nasal 3-4 L/menit O2 nasal 3-4 L/menit Tablet nitrat 5 mg SL Tablet nitrat 5 mg SL Aspilet 160-320 mg dikunyah Aspilet 160-320 mg dikunyah Clopidogrel 300-600 mg p. V1-V6 anterior : V2-V4 Konsultasikan ke Heart Line anterior ekstensif : I. aVL.

STEMI registry RS ISKAK jan-Aug 2016 25 300 250 20 200 15 150 10 100 5 50 0 0 jan feb mar apr may june july aug thrombolytic door to needle nonthrombolytic PPCI door to device Left vertical = patients number. right vertical number = time in second 24 .

SpJP . Evit Ruspiono.CASE PASIEN STEMI DI RS DR. ISKAK TULUNGAGUNG Dr.

Jumlah Puskesmas: 31 .

00 : PCI dimulai .00 : Nyeri dada kiri tembus ke punggung dan menjalar ke lengan kiri. Iskak.Identitas Pasien • Tn.40 : Red Zone IGD RSU Dr.45 : ECG dan terapi double antiplatelet • 09.00 karena nyeri dada tidak hilang • 07. Hipertensi • 06. • Pasien ke Puskesmas Ngunut pk 07. Tulungagung • 10.30 : Pasien diantar ke Cathlab • 11. M / 61 tahun • Faktor resiko : smoker.

Iskak 28 .Red Zone IRD RS Dr.

Iskak .ECG tiba di RS Dr.

Cath Lab RS Dr. Iskak 30 .

PRE PCI POST PCI .

Iskak 32 .ICCU RS Dr.

Jumlah tindakan PCI 01 Januari 2016 s/d 31 September 2016 PCI PPCI 118 pasien 22 pasien 33 .

Thank you 34 .