Second Problem

Emergency Medicine Block

“Give Your Heart a Break”

Kelompok 09
October 2nd, 2019
Kelompok 09
• Tutor : dr. Gladys dan dr. Fifi
• Ketua : Monika Kristanti (405160128)
• Penulis : Elizabeth Novia (405160087)
• Sekretaris : Tania Vandarina (405160001)
• Anggota :
• Gracelya Esther Liwanto (405160020)
• Calvin Linardi Putra (405160031)
• Jennefer (405160040)
• Zamzammatun Nafiah (405160046)
• David Yohan (405160093)
• Vani Audrei (405160097)
• Shania Dwiputri Wibowo (405160110)
• Jonathan Edbert Afandy (405160200)
SECOND PROBLEM - "Give your heart a break"
A 45-year-old male came to the Emergency Department with chest discomfort and
shortness of breath since 8 hours ago. He also felt nauseous and had diaphoresis. He
has had a history of hypertension since 5 years ago, but he is not taking any
medicine. His daily blood pressure was around 160/100 mmHg.
On his initial physical examination, he appeared to be severely ill, agitated, blood
pressure 90/70 mmHg, heart rate 111 beats per minute and regular, respiratory rate
32 breaths per minute, temperature of 36 C. His first and second heart sounds were
regular. Inspection, palpation, and percussion of the lungs were in normal limits but
fine rales at the basis of the lung can be heard in auscultation. His extremities were
clammy.
Troponin examination was perfomed and was found increased. This image below
was his 12-lead ECG:
Ten minutes later, the patient suddenly falls unconscious and his carotid pulse is not
palpable, and he is not breathing. His ECG monitor result is shown below :

Identify and discuss the problems in this case chronologically, while considering
possibilities!
 Mind map
Cardiovascular Emergency

Non-cardiorespiratory Acute Coronary

Cardiorespiratory arrest
arrest Syndrome

Diseksi aorta

Acute cor Acute cardiac Angina Miokard

Aritmia
pulmonale failure pectoris infark

Supraventrikular Ventrikular Ventrikel Unstable angina

STEMI NSTEMI
takikardi takikardi fibrilasi pectoris
Learning Issues
Angina pectoris
1. Sign and symptoms Myocardial infarct
2. Pathophysiology Cardiorespiratory arrest
3. Physical and other examination for Tachycardia ventricular
diagnosis Acute cor pulmonale
4. Treatment Acute cardiac failure
5. Algorithm to save Tachycardia supraventricular
6. Complication and prognosis Ventricular fibrilation
Hypertensive Crisis
 Acute coronary syndromes (ACSs), are a group of conditions that are caused
by an abrupt reduction in coronary artery blood flow (Amsterdam, et al., 2014). Sequence :
myocardial ischemia (ie, unstable angina pectoris)  infarction (with or without associated ST
segment elevation [STE] on the electrocardiogram [ECG]).

https://ecgwaves.com/ecg-topic/acute-c
oronary-syndromes-acs-myocardial-inf
arction-ami/
Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.
Lilly LS. Pathophysiology of Heart Disease, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2011
• Cardiac Biomarkers

Harrison’s Principles of Internal Medicine. 18 th ed.

NSTEMI • Pemeriksaan fisik
• Disfungsi ventricular  terdapat S4
Iskemi atau infark miokard akibat reduksi dari • Split paradoksikal bunyi jantung kedua
Def aliran darah coroner tanpa elevasi segmen ST • Dapat ditemukan murmur regurgitasi mitral
inisi diikuti kenaikan biomarker (troponin maupun akibat disfungsi otot papilaris
CK-MB) • EKG
• Depresi segmen ST yg baru  iskemia akut
Ketidakseimbangan antara myocardial oxygen
Etio • New T-wave inversion
consumption (MVO2) dan demand yg
logi • 1-6% EKG normal
diakibatkan obstruksi arteri coroner
• Biomarker
• Histori gejala: • Troponin T atau I positif dalam beberapa jam
• Nyeri dada seperti ditekan saat istirahat setelah onset dan bertahan smpai 2 minggu
atau dengan minimal 10 menit • CK-MB kurang spesifik karna ada d otot
Dia
• Sering dimulai dari retrosternal dan dapat skeletl juga (beberapa jam sampai 48 jam)
gno
menjalar ke lengan kiri (sering) dan
sis
kanan, leher
• Disertai diaphoresis, dyspnea, nausea,
abdominal pain, atau syncope

2014 AHA/ACC Guideline for the Management of Patients

With Non–ST-Elevation Acute Coronary Syndromes
Tatalaksana Awal RS
Oksigen Bila saturasi O2 <90%, respiratory Beta IV Metoprolol 5 mg setiap 2-5 menit sampai 3
distress atau high risk hypoxemia blocker dosis
Nitrogli Sublingual 0,4 mg, dapat diberikan 3 jika HR >60, sistol >100, PR interval <0,24 dan
serin dosis interval 5 menit ronki <10cm dr diafragma
(NTG) (mengurangi nyeri dada dan dilatasi Lanjutan : oral metoprolol 50 mg tiap 6 jam
PD  ↓preload & ↑suplai  selama 48 jam dan dilanjutkan 100 mg tiap 12
↓kebutuhan O2 miokard jam
Analges Morfin  Mengurangi nyeri CCB Berikan bila:
ic 1-5 mg IV, dapat diulang interval 5- • Beta blocker tidak berhasil
therapy 30menit maks 20 mg • Reccurent iskemi, KI beta blocker, resiko
Aspirin Aspirin buccal 160-325 mg di ruang syok kardiogenik, PR interval >0,24
emergency Co: verapamil atau diltiazem
Lanjutan: oral 75-162 mg Cholesterol management

2014 AHA/ACC Guideline for the Management of Patients

With Non–ST-Elevation Acute Coronary Syndromes
 ANGINA PECTORIS
Definisi Sindroma klinik yang disebabkan oleh ketidakseimbangan antara kebutuhan dan suplai
aliran arteri koroner
Klasifikasi berdasarkan Canadian Kelas 1: keluhan angina terjadi saat aktifitas berat yang lama
Cardiovascular Society (CCS) Kelas 2: keluhan angina terjadi saat aktifitas yang lebih berat dari aktifitas sehari-hari
Kelas 3: Keluhan angina terjadi saat aktifitas sehari-hari
Kelas 4: keluhan angina terjadi saat istirahat
Anamnesis Nyeri dada: substernal saat aktifitas, dapat menjalar ke lengan kiri, punggung, rahang,
ulu hati
Terdapat salah satu/> faktor risiko: DM, kolesterol, hipertensi, dan keturunan
PF Umumnya dalam batas normal
PP Angina Pectoris Kelas 1-2: Treadmill test, atau Ekokardiografi Stress test
Angina Pectoris Kelas 3-4 atau riwayat infark miokard lama: angiografi koroner
perkutan
Terapi 1. Medikamentosa: Aspilet 1x80-160 mg, Simvastatin 1x20-40 mg, Bisoprolol 1x5-10
mg (Betabloker).
2. PCI: klo ada bukti iskemik

PPK dan CP Penyakit Jantung dan Pembuluh Darah. 2016. PERKI

Unstable Angina

http://calgaryguide.ucalgary.ca/unstable-anginaunstable-angina-pectoris-pathogenesis-and-clini
Stable Angina

http://calgaryguide.ucalgary.ca/stable-angina-pathogenesis-and-clinical-findings/
 Acute cor pulmonale
• Right ventricular hypertrophy (RVH) or dilation
caused by elevated pulmonary artery pressure.
(RVH due to a systemic defect or congenital heart
disease is not classified as cor pulmonale.)
• Acute cor pulmonale: • Etiologi: • Cystic fibrosis
• Chronic hypoxia • Severe anemia
• Right ventricle is dilated & muscle wall
• COPD • Obesity
stretched thin • Pulmonary veno-
• High-altitude dwellers
• Overload due to acute pulmonary hypertension • Sleep apnea occlusive disease,
(HTN) • Chest deformities vascular obstruction
• Most often caused by massive pulmonary • Kyphoscoliosis secondary to tumors or
embolism • Pulmonary embolism adenopathy
• Interstitial lung disease • Increased blood
• Chronic cor pulmonale: • Scleroderma viscosity:
• RVH with eventual dilation and right-sided heart • Systemic lupus • Polycythemia vera
failure erythematosus • Leukemia
• Increased intrathoracic
• Caused by an adaptive response to chronic pressure:
pulmonary HTN • Mechanical ventilation
• Predominately occurs as a result of alveolar with positive end-
hypoxia expiratory pressure
Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5TH EDITION 2015 by Wolters Kluwer Health • Idiopathic primary
Acute cor pulmonale: manifestasi klinis
• Tanda dan gejala: End-stage cor pulmonale • Physical-Exam
• Exertional dyspnea • Cardiogenic shock • Jugular venous distention
• Easy fatigability • Prominent A- and V-waves
• Oliguria
• Weakness • Increase in chest diameter
• Exertional syncope • Cool extremities
• Crackles and/or wheezes
• Cough • Pulmonary edema secondary to
intraventricular septum impairing • Left parasternal heave on
• Hemoptysis
left ventricular diastolic function cardiac palpation
• Exertional angina even in the
absence of coronary disease • Splitting of the 2nd heart
• Anorexia sound or murmurs of the
• Right upper quadrant
• Riwayat: pulmonary vasculature
discomfort • Exercise intolerance may be heard.
• Wheezing • Palpitations • Hepatojugular reflex and
• Hoarseness • Chest pain pulsatile liver
• Weight gain • Lightheadedness • Pitting edema of the lower
• Hepatomegaly • Syncope extremities
• Ascites • Swelling of the lower
• Peripheral edema extremities

Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5TH EDITION 2015 by Wolters Kluwer Health
Acute cor pulmonale: Pemeriksaan
Laboratorium:
• Pulse oximetry or ABG:
• Resting PO2 40–60 mm Hg
• Resting PCO2 often 40–70 mm
Hg
• Hematocrit:
• Frequently elevated
• B-natriuretic peptide:
• When elevated, is sensitive for
moderate to severe pulmonary
HTN, and may be an
independent predictor of
mortality
• Elevated level alone is not
enough to establish diagnosis
of cor pulmonale.
Other lab tests are not generally
useful.
Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5TH EDITION 2015 by Wolters Kluwer Health
1. CXR: Signs of pulmonary 3. MRI
HTN: • Superior to echocardiography for
• Large pulmonary arteries (>16–18 assessment of right ventricular
size & function
mm)
• An enlarged RV silhouette 4. Pulmonary function tests
• Pleural effusions do not occur in the • Impaired diffusion capacity due
setting of cor pulmonale alone. to pulmonary HTN
2. Echocardiography 5. Right-heart catheterization:
• The noninvasive diagnostic method • The most precise estimate of
of choice pulmonary vascular
• RV dilation or RVH hemodynamics
• Assessment of tricuspid • Gives accurate measurements of
regurgitation pulmonary arterial pressure and
pulmonary capillary wedge
3. Chest CT, ventilation/ pressure
perfusion scans, or pulmonary
angiography:
• Useful in the setting of acute cor
pulmonale
Acute cor pulmonale: Pemeriksaan & DD
6. EKG: • Small R-waves and deep S-waves DIFFERENTIAL
across the precordium
• Right-axis deviation DIAGNOSIS
• Right atrial enlargement; Tall,
• Right bundle branch block peaked P-waves (P pulmonale) • Primary disease of the left
• RVH • S1 Q3 pattern with acute cor side of the heart
• Dominant R-wave in V1 and V2 pulmonale
• Mitral stenosis
• Prominent S-wave in V5 and V6 • Transient changes due to hypoxia
• Right precordial T-wave flattening • Congenital heart disease
• Eisen menger syndrome
• Left to right shunt caused
by a congenital heart defect
in the fetal heart causes
increased flow through the
pulmonary vasculature,
causing pulmonary HTN
• Hypothyroidism
• Cirrhosis
Rosen
https://reference.medscape.com/features/slideshow/abnormal-ecg?pa=8nN9RPXta4tZ9RtmOofVGdBR4rzs%2FEqqnJ5hIz8dvPJ0JqBZYWZu%2Bl2yQYktlC1GJyGvMX%2Fu& Barkin’s 5-Minute Emergency Medicine Consult
%2BWdIXoARf%2FT0zw%3D%3D
5TH EDITION 2015 by Wolters Kluwer Health
Acute cor pulmonale: Tatalaksana
PRE HOSPITAL ED TREATMENT/PROCEDURES
Supportive therapy: • Supplemental oxygen sufficient to raise arterial
• Supplemental oxygen  To an endpoint of 90% saturation to 90%:
arterial saturation • Improving oxygenation reduces pulmonary arterial
vasoconstriction and RV afterload.
• IV access • The improved cardiac output enhances diuresis of
• Cardiac monitoring excess body water.

• Pulse oximetry • Care must be taken to monitor the patient’s

ventilatory status and PCO2, as hypercapnia may
• Treat bronchospasm from associated respiratory reduce respiratory drive and cause acidosis.
disease:
• Diuretics: furosemide  added cautiously to reduce
• β-Agonist nebulizers pulmonary artery pressure by contributing to the
reduction of circulating blood volume:
• Be wary of volume depletion and hypokalemia
INITIAL STABILIZATION/THERAPY
• Patients should be maintained on salt and fluid restriction.
• ED therapy is directed at the underlying disease • There is no role for digoxin in the treatment of cor
process and reducing pulmonary HTN. pulmonale.

Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5TH EDITION 2015 by Wolters Kluwer Health
Bronchodilators: MEDICATION
• Bronchodilator therapy is particularly helpful for • Furosemide: 20–60 mg IV
those patients with COPD • (peds: 1 mg/kg may increase by 1 mg/kg/q2h not to
• Selective β-adrenergic agents: terbutaline 0.25 exceed 6 mg/kg)
mg SC may be useful. • Terbutaline: 0.25 mg SC
• Bronchodilator affects and reduces ventricular DISPOSITION
afterload. • Admission Criteria
• Theophylline may play a role to improve • New-onset hypoxia
diaphragmatic contractility & << muscle fatigue. • Anasarca: extreme generalized edema
• Anticoagulation may be considered for those at • Severe respiratory failure
high risk for • Admission criteria for the underlying disease process
• thromboembolic disease. • Discharge Criteria
• Acutely decompensated COPD patients: • Patients without hypoxia or a stable oxygen requirement
• Early steroid therapy • Issues for Referral
• Antibiotic administration • Close follow-up as long as the underlying etiology has
responded to acute management
• The need for a sleep study to assess for sleep apnea
In general, improvement in the underlying should be coordinated by the patient’s physician.
respiratory disease results in improved RV
function.
Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5TH EDITION 2015 by Wolters Kluwer Health
Harrison's Principles of Internal Medicine 19th 2015.pdf
Arrhytmia Supraventricular
Tachyarrhythmias
• tachyarrhythmias that originate
in the atria or AV junction
• this term is used when a more
specific diagnosis of mechanism
and site of origin cannot be
made
• characterized by narrow QRS,
unless there is pre-existing
bundle branch block or aberrant
ventricular conduction
(abnormal conduction due to a
change in cycle length)
 Atrial Tachycardia
• AT terdiri dari denyut cepat regular dari
daerah atrium yg bermasalah dengan rate
>100 bpm
• Istilah paroksismal digunakan untuk
mendeskripsikan irama yg dimulai atau
berakhir mendadak  paroxysmal
supraventricular tachycardia (PSVT), dulu
disebut paroxysmal AT (PAT)
• PVST bisa bertahan dalam hitungan menit,
jam atau hari
• Jika onset atau akhir PVST tidak terlihat di
EKG, diaritmianya disebut SVT
• Focal AT dimulai pada area kecil didalam
atrium. Atrial rate biasanya antara 100-250
bpm

Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.

 Atrial Tachycardia (AT)
TATALAKSANA
• Irama sustained bertahan 3 beat hingga 30 detik, irama non-sustained bertahan lebih dari
30 detik
• Focal AT bisa berirama sustained atau non-sustained, AT non-sustained biasanya tidak
perlu penatalaksanaan
• AT sustained & asimptomatik karena takikardi: pasang pulse oksimeter & berikan oksigen
jika ada indikasi, periksa TTV, pasang IV access, pasang 12 lead EKG, vagal mauver jika
pasien tidak hipotensi, jika vagal mauver gagal berikan obat” an antiaritmia
• DOC untuk regular narrow QRS complex tachycardia  adenosisne
• Jika perlu dapat diberikan CCB atau Beta Blocker
• AT sustained dengan rate > 150 bpm & menyebabkan tanda” hemodynamic compromise
persisten  synchronized cardioversion

Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.

 Atrial Tachycardia (AT)

Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.

Advanced Cardiac Life Support (ACLS) Provider
Handbook. Karl Disque. 2016.
 Reentrant Tachycardias:
Reentrant Tachycardias Atrioventricular Nodal Reentrant
Tachycardia (AVNRT)
Tanda & Gejala
• Reentry merupakan penyebaran impuls
• Chest pain or pressure
melalui jaringan yg sudah di stimulasi oleh
• Dizziness
impuls yg sama
• Dyspnea
• Impuls listrik terlambat, dihambat atau
• Heart failure
keduanya pada satu atau lebih area system
• Lightheadedness
konduksi sementara impuls dihantarkan
secara normal melalui impuls yg dikonduksi • Nausea
• Nervousness, anxiety
• Reentry merupakan mekanisme umum
• Palpitations (common)
AVNRT  sirkuit atau loop listrik (reentrant
circuit) berada didalam AV node. Sirkuit atau • Signs of shock
loop terbentuk dari accessory conduction • Syncope
pathway dan AV node • Weakness

Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.

 Reentrant Tachycardias: Atrioventricular Nodal
Reentrant Tachycardia (AVNRT)
TATALAKSANA
• Pasien stabil, simptomatik krn takikardi 
suplemen oksigen jika ada indikasi, periksa
TTV, pasang IV access, vagal maneuver jika
tidak ada KI (biasanya responsif), jika vagal
maneuver gagal berikan adenosisn, CCb atau
Beta blocker
• Pasien unstable dengan gejala symptomatic
compromise (perubahan status mental, nyeri
dada, hipotensi, sesak napas, kongesti
pulmonal, gagal jantung, acute MI, tanda”
shock)  Pasang pulse oximeter, suplemen
oksigen jika ada indikasi, pasang IV access,
sedasi, synchronized cardioversion
Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.
 Reentrant Tachycardias: Atrioventricular
Reentrant Tachycardia (AVRT)
• Disebabkan abnormal TANDA & GEJALA
accessory pathway yg • Anxiety
mengahntarkan impuls dari
SA node secara cepat , • chest discomfort
melewati AV node saat • Dizziness
meuju ke ventrikel atau
kembali dari atrium sehingga • Lightheadedness
terjadi reentrant circuit • palpitations (common)
• Bentuk paling umum dari • shortness of breath during
preeksitasi yaitu: PR interval exercise
pendek, delta wave & wide-
• signs of shock
QRS complex
• Weakness
Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.
Reentrant Tachycardias: Atrioventricular
Reentrant Tachycardia (AVRT)

ACLS Study Guide

Reentrant Tachycardias: Atrioventricular Reentrant
Tachycardia (AVRT)
TATALAKSANA
• Delta wave + asimptomatik  tidak diperlukan
tatalaksana spesifik, hanya suportif
• Jika simptomatik, tatalaksana tergantung pada stabilitas
pasien, lebar QRS kompleks & regularitas irama ventrikel
• Periksa TTV
• Pasang pulse oximeter  suplemen oksigen jika ada
indikasi
• Pasang IV access
• Pasang 12 lead EKG
• Jika takikardi persisten, pasien stabil, QRS regular &
sempit  berikan adenosin
• Adenosin dapat mempresipitasi atrial fibrillation dengan
rapid ventricular rate pada pasein WPW  siapkan
defibrillator kardioversi sebelum memberikan adenosin

Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.

 TACHYCARDIA VENTRICULAR
• 3 or more consecutive ectopic ventricular complexes Signs and symptoms of
• ƒ rate >100 bpm (usually 140-200) hemodynamic instability
• ƒ ventricular flutter: if rate >200 bpm and complexes related to VT may include
resemble a sinusoidal pattern the following:
• ƒ “sustained VT” if it lasts longer than 30 s
• Acute altered mental status
• ƒ ECG characteristics: wide regular QRS tachycardia (QRS
usually >140 msec) • Chest pain or discomfort
• ƒ AV dissociation; bizarre QRS pattern • Hypotension
• ƒ also favor Dx of VT: left axis or right axis deviation, • Pulmonary congestion
nonspecific intraventricular block pattern, monophasic or • Shock
biphasic QRS in V1 with RBBB, QRS concordance in V1-V6
• ƒoccasionally during VT supraventricular impulses may be • Shortness of breath
conducted to the ventricles generating QRS complexes with
normal or aberrant supraventricular morphology (“ventricular
capture”) or summation pattern (“fusion complexes”)
Monomorphic VT
• ƒ identical complexes with uniform
morphology
• ƒ common than polymorphic VT
• ƒ typically result from intraventricular
re-entry circuit
• ƒ potential causes: chronic infarct
scarring, acute MI/ischemia,
cardiomyopathies, myocarditis,
arrhythmogenic right ventricular
dysplasia, idiopathic, drugs (e.g.
cocaine), electrolyte disturbances
Polymorphic VT
• ƒ complexes with constantly changing
morphology, amplitude, and polarity
• ƒ more frequently associated with
hemodynamic instability due to faster
rates (typically200-250 bpm)
• ƒ potential causes: acute MI, severe or
silent ischemia, and predisposing
factors for QT prolongation
Torsades de Pointes
• a variant of polymorphic VT that occurs in
patients with baseline QT prolongation –
“twisting of the points”
VENTRICULAR FIBRILLATION (VFib)
• chaotic ventricular arrhythmia, with very rapid
irregular ventricular fibrillatory waves of varying
morphology
• terminal event, unless advanced cardiac life-support
(ACLS) procedures are promptly initiated to maintain
ventilation and cardiac output, and electrical
defibrillation is carried out
• most frequent cause of sudden death
• refer to ACLS algorithm for complete therapeutic
guidelines
• http://calgaryguide.ucalgary.ca/ventricular-fibrillation-pathogenesis-and-clinical-findings/
Gagal jantung akut:
definisi dan etiologi
Gagal jantung adalah sindrom klinis yang
ditandai dengan gejala khas (misalnya
sesak napas, pergelangan kaki bengkak

uropean Heart Journal. ESC Guidelines for the diagnosis and treatment of
dan kelelahan) yang bisa disertai dengan
tanda-tanda (misalnya peningkatan
tekanan vena jugularis, crackles paru
dan edema perifer) yang disebabkan

acute and chronic heart failure.2012:33;1842-32

oleh kelainan jantung struktural dan /
atau fungsional, sehingga sebuah
penurunan curah jantung dan / atau
tekanan intrakardiak tinggi pada saat
istirahat atau selama stres.

Rosen’s Emergency Medicine, 9th ed.

Gagal jantung akut: Tanda dan gejala
• Cardinal symptoms  fatigue and shortness of breath
• In the early stages of HF, dyspnea is observed only during exertion;
however, as the disease progresses, dyspnea occurs with less
strenuous activity, and it ultimately may occur even at rest
• Cheyne-stokes respiration  caused by a diminished sensitivity of
the respiratory center to arterial Pco2
• Acute pulmonary edema
• Gastrointestinal symptoms
• Orthopnea  dyspnea occurring in the recumbent position, is
usually a later manifestation of HF than is exertional dyspnea
• Nocturnal cough
• Paroxysmal nocturnal dyspnea (PND)  refers to acute episodes
of severe shortness of breath and coughing that generally occur at
night and awaken the patient from sleep, usually 1–3 h after the
patient retires

Sumber: Harrison’s Cardiovascular Medicine, 2th ed.

Gagal jantung akut: Pemeriksaan
Pemeriksaan fisik Pemeriksaan lain
• General appearance and vital signs  patient appears to be in no distress at • Routine laboratory testing
rest except for feeling uncomfortable when lying flat for more than a few • Electrocardiogram (ECG)
minutes, systolic blood pressure may be normal or high in early HF, but
it generally is reduced in advanced HF because of severe LV dysfunction, • CXR
the pulse pressure may be diminished, reflecting a reduction in stroke • Assessment of LV function
volume, sinus tachycardia, cool peripheral extremities and cyanosis of the
lips and nail bed • Biomarkers
• Jugular veins  early stage : venous pressure may be normal at rest but • Exercise testing
may become abnormally elevated with sustained (∼1 min) pressure on
the abdomen (positive abdominojugular reflux).
• Pulmonary examination  pulmonary crackles (rales or crepitations)
• Cardiac examination  If cardiomegaly is present, the point of maximal
impulse (PMI) usually is displaced below the ffth intercostal space and/or
lateral to the midclavicular line, and the impulse is palpable over two
interspaces.
• Abdomen and extremities
• Cardiac cachexia
Sumber: Harrison’s Cardiovascular Medicine, 2th ed.
 Algoritma Diagnosis

European Heart Journal. ESC Guidelines for the diagnosis and

treatment of acute and chronic heart failure.2012:33;1842-32
Algoritma tatalaksana

European Heart Journal. ESC Guidelines for the diagnosis and treatment of acute
Rosen’s Emergency Medicine, 9 ed.
th and chronic heart failure.2012:33;1842-32
Gagal jantung akut: Tatalaksana Farmakologi

European Heart Journal. ESC Guidelines for the diagnosis and

treatment of acute and chronic heart failure.2012:33;1842-32
 Klasifikasi Management of patients with
acute heart failure based on

Klinis clinical profile during an early

phase

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
 Hypertensive
Crisis

Healthy and unhealthy blood pressure ranges recommended

by the American Heart Association.
https://www.heart.org/en/health-topics/high-blood-pressure/u
nderstanding-blood-pressure-readings

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the

Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in Adults
CCSAP 2018 Book 1. Medical Issues in the ICU Hypertensive
Emergencies. Scott T. Benken.
Cardiorespiratory
arrest

ACLS.2015.
Primary survey Ritme jantung pada henti jantung
• Pulseless ventricular tachycardia (pVT), Gambaran
• A: airway EKG lebar, kompleks QRS regular, HR >120x/min
• Ventricular fibrilation, EKG: defleksi kacau yang
• B: breathing tidak teratur bervariasi bentuk dan tingginya tetapi
• C: circulation tidak ada kontraksi ventrikel yang terkoodinasi
• Asistol : Tidak ada aktivitas listrik jantung
• D: disability/
• Pulseless electrical activity (PEA) : pada EKG
defibrilation terdapar aktivitas listrik tetapi tidak ada pulsasi
• E: exposure sentral

ACLS.2015.
ACLS.2
015.
ACLS.2
Etiologi PEA dan asistol

EIMED PAPDI. Buku

http://www.aed.com/blog/key-differences-between-a-heart-attack-sudden-cardiac-
arrest-and-a-stroke/
ACLS STUDY GUIDE. Barbara Aehlert. 2017
Conclusions and Suggestions
Conclusion :
We have learnt about : sign and symptoms,
pathophysiology, physical and other
examination for diagnosis, treatment,
algorithm to save and stabilize patient,
complication and prognosis of angina
pectoris, myocardial infarct,
cardiorespiratory arrest, tachycardia
ventricular, acute cor pulmonale , acute
cardiac failure, tachycardia supraventricular,
ventricular fibrilation, hypertensive crisis.
• Suggestions :
For patient : Recognize signs and
symptoms of cardiovascular emergency as
soon as posssible for diagnosis. Use the
cardiac arrest algorithm to patient in this
case, then look for the underlying
disease/etiology. It might due to the
uncontrolled hypertension for this case.
For students : learn about
pathophysiology, how to read ECG, and
algorithms for patient with cardiovascular
disease especially ones related to
emergency cases.
Daftar Pustaka
• EIMED PAPDI Kegawatdaruratan Penyakit Dalam. Buku 1 EIMED Dasar. Editor: Setyohadi B, Arsana PM,
Soeroto AY, Suryanto A, Abdullah M. 2015. Jakarta: Interna Publishing
• Harrison’s principal of internal medicine
• Rosen’s Emergency Medicine, 9th ed
• CCSAP 2018 Book 1. Medical Issues in the ICU Hypertensive Emergencies. Scott T. Benken.
• European Heart Journal. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
2012.
• Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5TH EDITION 2015 by Wolters Kluwer Health
• Aehlert, B. ACLS study guide; Elsevier: St. Louis, MO, 2017.
• ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation.
The European Society of Cardiology, 2015
• AHA/ACC Guideline for the management of patients with non ST-elevation acute coronary syndromes; 2014
• 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood Pressure in Adults