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Arrythmia Edema Paru Akut
Citation preview
Acute Pulmonary Edema and
Emergency Arrhythmias in
ACS
Jetty RH Sedyawan SpJP KDepartemen Kardiologi dan Kedokteran Vaskuler FKUI
Edema Paru Akut(subset klinik dari gagal jantung akut)
• Distress pernafasan yang berat
• Crakles diseluruh lapang paru
• Orthopnoea
• Saturasi O2 < 90% pada udara kamar
Faktor pencetus
• Kepatuhan minum obat rendah
• Tatalaksana sub optimal
• Infeksi
• Surgery
• Lain-lain
IskemiaAritmia
How should I assess patients in acute heart failure?
1. Volume status and tissue perfusion:cold or warm, wet or dry. [IIa C]
2. A precipitating cause : complete blood count, serum creatinine, electrolytes, troponins,
ECG, chest x ray and an echocardiogram. [ I, C]
3. Blood brain Natriuretic Peptide (BNP) or N-terminal proBNP (NT-proBNP) if the diagnosis is in doubt. [I, A]
4. Monitor heart rate, BP and oxygen saturation . [IIa, C]
5. Monitor fluid balance, urine output, renal function and laboratory especially when the patient is in shock. [I, C]
6. Inserting an arterial line and a central venous pressure lineif the patient is in cardiogenic shock or for those who require pressors. [II b, C]
Assess the patient’s:
Canadian Journal of Cardiology, 23(1), 21-45. Dec, 2007
What are important acute heart failure treatment
considerations?
1. Correct precipitating causes of acute heart failure promptly. [I,B]
2. Oxygen. [I,C]
3. Support ventilation with (CPAP), bilevel positive airway pressure (BIPAP) or
endotracheal intubation if hypoxemia persists. [IIa,B]
4. Treat volume overload with i.v. diuretics. [I,B]
5. Vasodilators for patients with dyspnea at rest. [I,C]
6. Inotropes: cardiogenic shock or volume overload with diuretic resistance.[I,C]
7. ACE inhibitors until the patient is stabilized. [I,B]
8. Intra-aortic balloon pump (IABP) in patients with refractory heart failure despite
medical therapy. [IIb,B]
Arrhythmias
Canadian Journal of Cardiology, 23(1), 21-45. Dec, 2007
• Ventricular fibrillation
Or
Pulseless
ventricular
tachycardia
Defibrillate with 360J (preferably by biphasic defibrillation with a maximum of 200 J).
If refractory to initial shocks inject:
epinephrine 1 mg or
vasopressin 40 IU and/or
amiodarone 150–300 mg as injection
Bantuan ABC: beri Oksigen; pasang IV line.Monitor EKG, TD, Oksimetri
Rekam EKG 12 lead bila memungkinkan atau rekam irama di lead IIIdentifikasi dan obati penyebab yang reversibel
Probable re-entry PSVT:•Rekam EKG 12 lead saat irama sinus
•Jika timbul kembali; beri adenosin lagi dan pertimbangkan obat anti aritmia yg lain
Kembali ke Irama normal sinus ?
Takikardi QRS sempit irreguler•Probable Atrial fibrilasi, control rate dengan:B-bloker IV, digoxin IV atau diltiazem IV•Bila onset AF < 48 jam berikan :Amiodaron 300 mg IV selama 20-60 mnt, dilanjutkan 900 mg/24 jam
•Vagal manuver•Bolus cepat Adenosin 6 mg;
Bila tak berhasil berikan 12 mg;Bila tidak berhasil berikan 12 mg.
•Monitor EKG kontinu
QRS SempitApakah irregular?
Apakah QRS sempit (<0,12 det)?
Synchronnised DC shock Apakah pasien stabil?Tanda tidak stabil:
Kesadaran menurun, nyeri dada, TD sistolik<90 mmHg, gagal jantung(Gejala terjadi akibat laju nadi yang terlalu cepat > 150 beat/mnt)
•Amiodaron 300 mg IV lama pemberian10-20 mnt dan ulangi kejut listrik,
•amiodaron 900 mg/24 jam
Possible atrial flutterControl rate ( B-bloker)
Beberapa kemungkinan, a.l:•AF dgn bundle branch blockPengobatan spt QRS sempit
•Pre-excited AFPertimbangkan amiodaron
•VT Polimorfik (spt torsades de pointes = berikan magnesium 2 gr selama 10 mnt)
QRS lebarApakah QRS regular?
Jika VT (atau belum jelas)•Amiodaron 300 mg IV selama 20-60 mnt
dilanjutkan 900mg/24 jamJika sebelumnya confirmed SVT
dgn bundle branch block:•Berikan adenosin seperti
pada takikardi QRS sempit regularKonsultasi ke kardiolog
Stabil
Tidak Stabil
Tidak
irregular
regular
Ya
LebarSempit
regularirregular
Konsultasi ke kardiolog
Catatan :kardioversi harus dilakukan dalam sedasi atau anestesi umum
ALGORITMA TAKIKARDIA
Jetsed
ALGORITMA BRADIKARDI
pemasangan TPM
Obat-obatan alternatif :•aminofilin•Isoprenalin• dopamin
•Glucagon=pada overdosis BB atau CCB •glycopyrolate
Pengobatan sementara :•Atropin 0,5 mg IV dpt diulang sampai dosis maksimum 3 mg•Adrenalin 2 – 10 mcg/mnt
•Obat alternatif Atau
•Transcutaneous pacing
Adakah Risiko asistol?•Recent asystole
•Mobitz II AV block•Total AV block dengan QRS lebar
•Ventricular pause > 3 det.
Atropin0,5 mg IV
Yes
Observasi
No
Yes
No
Yes
No
Tanda-tanda:•TD sistolik < 90 mmHg•Nadi < 40 beat/mnt•Aritmia ventrikel dengan TD cukup•Gagal jantung
Respon memuaskan?
Jetsed
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