cardiac emergencies

1. Cardiac emergenciesCardiac emergencies

3. Cardiac emergenciesCardiac emergencies
 BradycardiaBradycardia
 Acute CoronaryAcute Coronary
Syndromes and AcuteSyndromes and Acute
Myocardial InfarctionMyocardial Infarction
 Wide-ComplexWide-Complex
Tachycardias andTachycardias and
Ventricular TachycardiaVentricular Tachycardia
 Pericardial TamponadePericardial Tamponade
 Hypertensive CrisisHypertensive Crisis
 Cardiogenic ShockCardiogenic Shock
 Right Ventricle InfarctionRight Ventricle Infarction
 Acute Mitral RegurgitationAcute Mitral Regurgitation
 Acute Aortic InsufficiencyAcute Aortic Insufficiency
 Ventricular SeptalVentricular Septal
RuptureRupture
 Cardiac RuptureCardiac Rupture
 PseudoaneurysmPseudoaneurysm

4. BradycardiaBradycardia
 due to sinus node dysfunction or AV blockdue to sinus node dysfunction or AV block
Clinical PresentationClinical Presentation
 syncope, presyncope, fatigue, angina, andsyncope, presyncope, fatigue, angina, and
shortness of breathshortness of breath
 may be asymptomaticmay be asymptomatic

8. BradycardiaBradycardia
 sinus rate <60 bpm that does not increasesinus rate <60 bpm that does not increase
with activity.with activity.
 In sinus arrest, pauses of >3 secs areIn sinus arrest, pauses of >3 secs are
seenseen
 Severe Bradycardia (Heart Rate <40 bpm)Severe Bradycardia (Heart Rate <40 bpm)

9. Initial ManagementInitial Management
 Assess airway, breathing, and circulationAssess airway, breathing, and circulation
 Place a monitor/defibrillatorPlace a monitor/defibrillator

 adequate IV access and oxygenationadequate IV access and oxygenation

10. bradycardia with hemodynamicallybradycardia with hemodynamically
compromisedcompromised
1.1. atropineatropine
0.5–1.0 mg IV. Doses can be repeated q3–5mins up to a total0.5–1.0 mg IV. Doses can be repeated q3–5mins up to a total
dose of 0.04 mg/kgdose of 0.04 mg/kg
1.1. dopaminedopamine
2–20 mg/kg/min, to keep systolic BP >90 mm Hg2–20 mg/kg/min, to keep systolic BP >90 mm Hg
1.1. transcutaneous pacingtranscutaneous pacing
2.2. epinephrineepinephrine, 2–10 µg/min, 2–10 µg/min
3.3. transvenous pacingtransvenous pacing
4.4. have the patient monitored in an ICUhave the patient monitored in an ICU
5.5. Stop all medicines that may be causing bradycardia orStop all medicines that may be causing bradycardia or
hypotension (electrolytes, digoxin level, TSH)hypotension (electrolytes, digoxin level, TSH)

12. Acute Coronary SyndromeAcute Coronary Syndrome
 ST-segment–elevation MI (STEMI)ST-segment–elevation MI (STEMI)
 non–ST-segment MI (NSTEMI) andnon–ST-segment MI (NSTEMI) and
 unstable anginaunstable angina
Initial managementInitial management
 symptom recognitionsymptom recognition
 evaluation of the ECG, andevaluation of the ECG, and
 triaging to the appropriate reperfusion strategytriaging to the appropriate reperfusion strategy

14. Clinical PresentationClinical Presentation
 The classic symptoms of an MI include anThe classic symptoms of an MI include an
intense, left-sided, substernal chestintense, left-sided, substernal chest
discomfort radiating to the left arm and andiscomfort radiating to the left arm and an
impending sense of doom.impending sense of doom.
 Chest pain is often prolonged,Chest pain is often prolonged, lasting >20lasting >20
minsmins, and is not relieved with rest or NTG., and is not relieved with rest or NTG.
The pain may radiate to the jaw, right arm,The pain may radiate to the jaw, right arm,
both arms, or back.both arms, or back.

18. ACSACS
 Differentiating STEMI fromDifferentiating STEMI from
NSTEMI/unstable angina is important, asNSTEMI/unstable angina is important, as
it determines the type of therapy required.it determines the type of therapy required.
 Differentiating STEMI, NSTEMI, andDifferentiating STEMI, NSTEMI, and
unstable angina requiresunstable angina requires ECG and cardiacECG and cardiac
enzymes.enzymes.

19. The differential diagnosisThe differential diagnosis
aortic dissection,aortic dissection,
pericarditis,pericarditis,
esophagitis,esophagitis,
myocarditis,myocarditis,
..
pneumonia,pneumonia,
cholecystitis,cholecystitis,
pancreatitis, andpancreatitis, and
pulmonarypulmonary
embolismembolism

20. The ECGThe ECG
 The ECG triages patients in three groups: ST-The ECG triages patients in three groups: ST-
segment elevation, ST-segment depression, andsegment elevation, ST-segment depression, and
nondiagnostic or normal ECGnondiagnostic or normal ECG
 ST-segment deviation of at least 1 mm in twoST-segment deviation of at least 1 mm in two
contiguous leads is considered significant.contiguous leads is considered significant.
 A new left bundle-branch block should also raiseA new left bundle-branch block should also raise
concern of an acute MI.concern of an acute MI.
 ST-segment depression of 1 mm and T waveST-segment depression of 1 mm and T wave
inversions in two contiguous leads suggests aninversions in two contiguous leads suggests an
unstable angina/NSTEMI syndrome.unstable angina/NSTEMI syndrome.

22. ST segment depression or elevation (leads I, aVL, V4-V6), flattening of
the T wave (leads I, aVR, aVL, V5, V6), or T wave inversion (I, V2-V4).

23. ST segment and T wave changes that are consistent withST segment and T wave changes that are consistent with
subendocardial ischemiasubendocardial ischemia include ST segment depression (V3-V6), andinclude ST segment depression (V3-V6), and
T wave flattening or inversionT wave flattening or inversion

24. J point and ST segment elevation are the hallmarks ofJ point and ST segment elevation are the hallmarks of
acute myocardial infarctionacute myocardial infarction

25. Initial managementInitial management
 O2 and ASAO2 and ASA for all patientsfor all patients
 nitratesnitrates should be rapidly delivered for control ofshould be rapidly delivered for control of
chest discomfort.chest discomfort.
 If the heart rate is >65 bpm and the systolic BPIf the heart rate is >65 bpm and the systolic BP
is >110 mm Hg,is >110 mm Hg, beta blockersbeta blockers should be usedshould be used
as well.as well.
 MorphineMorphine may be given for analgesia as well asmay be given for analgesia as well as
relief from pulmonary congestion.relief from pulmonary congestion.
 Patients with STEMI or new left bundle-branchPatients with STEMI or new left bundle-branch
block benefit from early reperfusion withblock benefit from early reperfusion with
fibrinolytics or angioplastyfibrinolytics or angioplasty

26. Wide-Complec Tachycardia & VTWide-Complec Tachycardia & VT
 VTs are responsible for the majority of cases ofVTs are responsible for the majority of cases of
sudden cardiac death and are divided intosudden cardiac death and are divided into
sustained and nonsustained VTsustained and nonsustained VT
The differential diagnosisThe differential diagnosis
 bundle-branch blockbundle-branch block
 SVT with aberrant conductionSVT with aberrant conduction
 AF with preexcitationAF with preexcitation
 HyperkalemiaHyperkalemia

27. Findings suggestive of VT includeFindings suggestive of VT include
 (a) AV dissociation,(a) AV dissociation,
 (b) fusion/capture beats,(b) fusion/capture beats,
 (c) left bundle-branch block with right-axis(c) left bundle-branch block with right-axis
deviation, anddeviation, and
 (d) positive or negative concordance of QRS in(d) positive or negative concordance of QRS in
ECG leads V1–V6.ECG leads V1–V6.

28. symptomssymptoms
 Slow VT (rate, 100–Slow VT (rate, 100–
150) may be well150) may be well
tolerated with minimaltolerated with minimal
or no symptoms.or no symptoms.
 if it persists for hoursif it persists for hours
or longer, however,or longer, however,
they developthey develop HF and,HF and,
potentially,potentially,
cardiogenic shock.cardiogenic shock.
 At rates <200,At rates <200,
symptoms ofsymptoms of
decreased cardiacdecreased cardiac
output are generallyoutput are generally
present, includingpresent, including
dyspnea, light-dyspnea, light-
headedness,headedness,
syncope, orsyncope, or cardiaccardiac
arrest.arrest.

29. nonsustained ventricularnonsustained ventricular
tachycardia (VT)tachycardia (VT)

30. Treatment Pulseless VT or VFTreatment Pulseless VT or VF
 ACLS protocols immediate electrical defibrillation (360j)ACLS protocols immediate electrical defibrillation (360j)
 CPR should be started immediatelyCPR should be started immediately
 rapid assessment of the airwayrapid assessment of the airway
 the patient should be intubated, andthe patient should be intubated, and
 IV accessIV access
 The cardiac rhythm is briefly assessed between shocks.The cardiac rhythm is briefly assessed between shocks.
 Administer epinephrine, 1 mg IV q3–5 mins, orAdminister epinephrine, 1 mg IV q3–5 mins, or
vasopressin (Pitressin), 40 U IV once.vasopressin (Pitressin), 40 U IV once.
 Lidocaine (1.0–1.5 mg/kg IV, repeat in 3–5mins toLidocaine (1.0–1.5 mg/kg IV, repeat in 3–5mins to
maximum dose, 3 mg/kg)maximum dose, 3 mg/kg)

31. continued pulseless VTcontinued pulseless VT
 amiodarone (Cordarone, Pacerone) (300 mg IV,amiodarone (Cordarone, Pacerone) (300 mg IV,
repeat at 150 mg) Procainamide (Procan SR,repeat at 150 mg) Procainamide (Procan SR,
Procanbid, Pronestyl, Pronestyl-SR), 20–30Procanbid, Pronestyl, Pronestyl-SR), 20–30
mg/min, can also be considered.mg/min, can also be considered.
 If hyperkalemia is even suspected, calcium andIf hyperkalemia is even suspected, calcium and
bicarbonate should be administeredbicarbonate should be administered
immediately.immediately.

32. Treatment Stable VTTreatment Stable VT
divided into monomorphic and polymorphic VTdivided into monomorphic and polymorphic VT
 Polymorphic VT with a prolonged QT interval should raise concernPolymorphic VT with a prolonged QT interval should raise concern
of torsades de pointesof torsades de pointes
 administering 4 g MgSO4,administering 4 g MgSO4,
 overdrive pacing,overdrive pacing,
 isoproterenol (Isuprel), andisoproterenol (Isuprel), and
 LidocaineLidocaine
 Persistent torsades de pointes is usually unstable and may requirePersistent torsades de pointes is usually unstable and may require
defibrillation.defibrillation.
 Polymorphic VT with normal baseline QT interval and monomorphicPolymorphic VT with normal baseline QT interval and monomorphic
VT with a poor ejection fraction are both treated with amiodarone,VT with a poor ejection fraction are both treated with amiodarone,
150 mg IV over 10 mins, or lidocaine, 0.5–0.75 mg/kg IV push, as150 mg IV over 10 mins, or lidocaine, 0.5–0.75 mg/kg IV push, as
well as correcting electrolyte disorders and/or ischemia.well as correcting electrolyte disorders and/or ischemia.

33. Pericardial TamponadePericardial Tamponade
 Cardiac tamponade occurs with anCardiac tamponade occurs with an
increase in intrapericardial pressure dueincrease in intrapericardial pressure due
to accumulation of fluid in the pericardialto accumulation of fluid in the pericardial
space, which is characterized byspace, which is characterized by
 (a) elevation of intrapericardial pressure,(a) elevation of intrapericardial pressure,
 (b) limitation of RV diastolic filling, and(b) limitation of RV diastolic filling, and
 (c) reduction of stroke volume and cardiac(c) reduction of stroke volume and cardiac
output.output.

35. Clinical FindingsClinical Findings
 Beck's triad may be seen in this setting; itBeck's triad may be seen in this setting; it
consists ofconsists of
 (a) a decline in systemic arterial pressure,(a) a decline in systemic arterial pressure,
 (b) elevation of systemic venous pressure,(b) elevation of systemic venous pressure,
andand
 (c) a small, quiet heart.(c) a small, quiet heart.

36. ManagementManagement
 Percutaneous pericardiocentesisPercutaneous pericardiocentesis
 should be done by trained personnel withshould be done by trained personnel with
hemodynamic monitoring andhemodynamic monitoring and
echocardiographic guidance.echocardiographic guidance.

37. Hypertensive-CrisisHypertensive-Crisis
ClassificationClassification
 hypertensive emergencies, urgencieshypertensive emergencies, urgencies
 The distinction is important because itThe distinction is important because it
dictates how rapid BP should be lowered,dictates how rapid BP should be lowered,
whether the patient will need ICUwhether the patient will need ICU
monitoring, and whether parenteral or POmonitoring, and whether parenteral or PO
medications can be usedmedications can be used

38. Hypertensive EmergencyHypertensive Emergency
 accelerated or malignant HTN and hypertensiveaccelerated or malignant HTN and hypertensive
encephalopathyencephalopathy
 Accelerated or malignant HTNAccelerated or malignant HTN is characterized byis characterized by
severe elevation of BP with retinopathy, renal failure,severe elevation of BP with retinopathy, renal failure,
and other target organ damage. Retinal exudates,and other target organ damage. Retinal exudates,
hemorrhages, arteriolar narrowing, and spasm are seenhemorrhages, arteriolar narrowing, and spasm are seen
in accelerated HTN, whereas papilledema is seen inin accelerated HTN, whereas papilledema is seen in
malignant HTN.malignant HTN.
 Hypertensive encephalopathyHypertensive encephalopathy is a condition in whichis a condition in which
markedly elevated BP causes cerebral edema, resultingmarkedly elevated BP causes cerebral edema, resulting
in headache, papilledema, vision complaints, seizures,in headache, papilledema, vision complaints, seizures,
altered mental status, and other neurologic symptoms.altered mental status, and other neurologic symptoms.

39. Hypertensive UrgenciesHypertensive Urgencies
 Hypertensive urgencies present withHypertensive urgencies present with
markedly elevated BPmarkedly elevated BP without evidence ofwithout evidence of
acute end-organ damageacute end-organ damage

40. Management of HypertensiveManagement of Hypertensive
EmergenciesEmergencies
 The patient should be admitted to an ICUThe patient should be admitted to an ICU
setting.setting.
 In general, it is recommendedIn general, it is recommended to reduceto reduce
the mean arterial pressure by no morethe mean arterial pressure by no more
than 20–25%than 20–25% or to reduce the diastolicor to reduce the diastolic
pressure to 100–110 mm Hg withinpressure to 100–110 mm Hg within
minutes to several hours.minutes to several hours.

41. Drugs of choiceDrugs of choice
 Sodium NitroprussideSodium Nitroprusside
IV starting at doses of 0.25 µg/kg/min andIV starting at doses of 0.25 µg/kg/min and
titrated q5mins to 10 µg/kg/min.titrated q5mins to 10 µg/kg/min.
 NitroglycerinNitroglycerin
The usual initial dose is 5–15 µg/min.The usual initial dose is 5–15 µg/min.
Max 100 µg/minMax 100 µg/min

42. Hypertensive EncephalopathyHypertensive Encephalopathy
 The goal of treatment should be to lowerThe goal of treatment should be to lower
mean arterial pressure by approximatelymean arterial pressure by approximately
20% of diastolic pressure to 100 mm Hg20% of diastolic pressure to 100 mm Hg
(whichever is greater) in the first hour.(whichever is greater) in the first hour.
 The agents of choice are SNP andThe agents of choice are SNP and
labetalol.labetalol.
 CNS depressants, such as clonidineCNS depressants, such as clonidine
(Catapres), should be avoided.(Catapres), should be avoided.

43. acute stroke and intracranialacute stroke and intracranial
hemorrhage statehemorrhage state
 If systolic pressure is >230 mm Hg or diastolic pressureIf systolic pressure is >230 mm Hg or diastolic pressure
is >140 mm Hg on two separate readings 5 mins apart,is >140 mm Hg on two separate readings 5 mins apart,
startstart nitroprussidenitroprusside..
 If systolic pressure is 180–230 mm Hg, diastolicIf systolic pressure is 180–230 mm Hg, diastolic
pressure is 105–140 mm Hg, or mean arterial pressurepressure is 105–140 mm Hg, or mean arterial pressure
is 130 mm Hg, start IV labetalol, esmolol, or other easilyis 130 mm Hg, start IV labetalol, esmolol, or other easily
titratable IV antihypertensive.titratable IV antihypertensive.
 If systolic pressure is <180 mm Hg and diastolicIf systolic pressure is <180 mm Hg and diastolic
pressure is <105 mm Hg, defer antihypertensivepressure is <105 mm Hg, defer antihypertensive
treatment.treatment.
 If ICP monitoring is available, cerebral perfusionIf ICP monitoring is available, cerebral perfusion
pressure should be kept >70 mm Hg (cerebral perfusionpressure should be kept >70 mm Hg (cerebral perfusion
pressure = mean arterial pressure – ICP).pressure = mean arterial pressure – ICP).

44. Left Ventricular Failure withLeft Ventricular Failure with
Pulmonary EdemaPulmonary Edema
 LV failure with pulmonary edema requiresLV failure with pulmonary edema requires
rapid reduction in BP with SNP or NTG.rapid reduction in BP with SNP or NTG.
Small doses of loop diuretics may beSmall doses of loop diuretics may be
added.added.

46. Preeclampsia and EclampsiaPreeclampsia and Eclampsia
 IV hydralazine and labetalol are the mostIV hydralazine and labetalol are the most
common antihypertensives used.common antihypertensives used.
 NTGNTG
 ACE inhibitors are contraindicated inACE inhibitors are contraindicated in
pregnancy.pregnancy.

47. Management of HypertensiveManagement of Hypertensive
UrgencyUrgency
 Mean arterial pressure should not beMean arterial pressure should not be
decreased by more than 15–20%.decreased by more than 15–20%.
 Oral antihypertensives may be used toOral antihypertensives may be used to
control BP in 3–4 hrs.control BP in 3–4 hrs.
 Patients may be discharged to home withPatients may be discharged to home with
close follow-up.close follow-up.

48. MedicationsMedications Hypertensive UrgencyHypertensive Urgency
 Captopril (Capoten) at doses of 6.25–25 mg hasCaptopril (Capoten) at doses of 6.25–25 mg has
an onset in 15–30 mins and lasts 4–6 hrs.an onset in 15–30 mins and lasts 4–6 hrs.
 Clonidine at doses of 0.1 mg may be givenClonidine at doses of 0.1 mg may be given
every hourevery hour
 Short-acting nifedipine should be avoided inShort-acting nifedipine should be avoided in
treating hypertensive crises.treating hypertensive crises.
 Short-acting nifedipine (Procardia) has beenShort-acting nifedipine (Procardia) has been
shown to cause sudden severe hypotension,shown to cause sudden severe hypotension,
myocardial ischemia/MI, and decreased cerebralmyocardial ischemia/MI, and decreased cerebral
perfusion.perfusion.

49. Cardiogenic ShockCardiogenic Shock
 Cardiogenic shock is estimated to occur inCardiogenic shock is estimated to occur in
approximately 7.2% of patients whoapproximately 7.2% of patients who
present with an MI and has a mortality ratepresent with an MI and has a mortality rate
ranging fromranging from 50–80%.50–80%.

50. Management Cardiogenic ShockManagement Cardiogenic Shock
 diuresis with furosemide (Lasix) improvesdiuresis with furosemide (Lasix) improves
oxygenation. Start furosemide at 20 mg IVoxygenation. Start furosemide at 20 mg IV
 Vasopressors are very useful inVasopressors are very useful in
cardiogenic shockcardiogenic shock

51. Inotropes and VasopressorsInotropes and Vasopressors
 norepinephrinenorepinephrine
 If systolic BP is <70 mm Hg, start at 2 µg/min and titrate to 20If systolic BP is <70 mm Hg, start at 2 µg/min and titrate to 20
µg/min to achieve a mean arterial pressure of 70 mm Hg.µg/min to achieve a mean arterial pressure of 70 mm Hg.
 dopaminedopamine
 If systolic BP is 70–90 mm Hg, start At 2–5 µg/kg/min,If systolic BP is 70–90 mm Hg, start At 2–5 µg/kg/min,
dopamine increases cardiac output and renal blood flowdopamine increases cardiac output and renal blood flow
through beta- and dopamine-specific receptors, respectively.through beta- and dopamine-specific receptors, respectively.
At 5–20 µg/kg/min, dopamine has alpha-adrenergicAt 5–20 µg/kg/min, dopamine has alpha-adrenergic
stimulation leading to vasoconstriction.stimulation leading to vasoconstriction.
 dobutaminedobutamine
 With systolic BP >90 mm Hg, is the preferred agent.With systolic BP >90 mm Hg, is the preferred agent.
Dobutamine is started at 2.5 µg/kg/min and slowly titrated toDobutamine is started at 2.5 µg/kg/min and slowly titrated to
15 µg/kg/min (usual maximum dose is 10 µg/kg/min).15 µg/kg/min (usual maximum dose is 10 µg/kg/min).

52. Tip jantung sehatTip jantung sehat

53. Periksa Kolesterol (LDL-C ) SetiapPeriksa Kolesterol (LDL-C ) Setiap
6 bulan sekali6 bulan sekali

54. Aktivitas FisikAktivitas Fisik

55. Pola Makan yang SehatPola Makan yang Sehat

56. Berhenti / Jangan MerokokBerhenti / Jangan Merokok

57. TERIMAKASIHTERIMAKASIH