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

before admitted to the hospital. palpitations (-). The pain was felt for more than 30 minutes and didn’t relieved by rest. history of cough(-) Dizziness (-). radiated to left arm. nausea. vomit (-). but no penetrated to the back body. Cough (-). The pain felt pressed by heavy things. Headache (-) . shortness of breath (-). patient feel sweating. DOE (-) • Defecation and urination : normal . Fever (-) • PND (-). During the attack.Chief complaint: Chest pain  The pain was felt a day ago after coming from the garden.

 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 .

Rhonchi -/. normal Palpation : liver and spleen unpalpable Percussion : tympani.. 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 (+) . ascites (-) Extremities : Edema -/- .      Lung : Vesicular.

.

Right ECG .

Posterior ECG .

AvF .24 s : +10° Duration QRS : 0.      Rhythm P wave Heart Rate PR interval Axis : Sinus rhythm : 0.III.12 s  ST Segment : ST elevation II. reguler : 0.08 s : 50 x/min.

elongatio et atherosclerosis aorta .Conclusion: Cardiomegaly with dilatatio.

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 ) ( < 1.0 x 106) HGB: 14.Date of lab test Types of test Result November 20th 2012 WBC: 13.1) .72 x106 mm3 ( 4.98 ng/ml ( < 190 ) (<25) (<0.3 ) ( < 38 ) ( < 41 ) ( 200 ) ( > 55 ) ( < 130 ) ( 200 ) (140) Cardiac enzymes CK : 2643 CKMB : 250 u/l Trop T : 0.78 x103 mm3 (4.0 gr/dl ( 12 – 16 ) HCT: 39.0 – 6.8% ( 37 – 48 ) Blood chemistry Ureum : 26 mg/dl Creatinin : 0.0 x 103) PLT: 182 x103 mm3 ( 150 – 400 x 103) RBC: 4.0 – 10.

 Inferior STEMI onset >12 hours. Killip I .

Burn Injuries (Critical Care in Severe Burn Injury). C. p : 315 . In : Smith. C. Trauma Anesthesia.• • • • • • • • • O2 2-4 lpm ( via nasal canule ) IVFD NaCl 0. Cambridge : Cambridge University Press.5 0-0-1 Laxadyn syr 0-0-2 C Yowler.E. 2008.9% 20 dpm Aspilet 80mg 0-1-0 Plavix 75mg 0-1-0 Simvastatin 20 mg 0-0-1 Lovenox 0.J.6 cc/12 h/ SC Fasorbid 5 mg/SL Alprazolam 0.

ST ELEVATION MYOCARDIAL INFRACTION .

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

infarction . occurs when an atherosclerotic plaque fissures. or ulcerates. ruptures.  In most cases. Occurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis.

.ACS describe a group of conditions resulting from acute myocardial ischemia (insufficient blood flow to heart muscle) ranging from unstable angina to myocardial infarction.

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 .Non.

3.1. 2. 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 .

breathlessness. 3.1. 5. and nausea. crushing. 2. sweating. . 4. and jaw Associated features including palpitation. and band like Location in retrosternal May radiate to left arm. throat. >30 minutes Usually tight. Chest pain.

 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 .

 o   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 β-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.40 60 – 80 . 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 . an S3.

Thank you for your attention .