PRESENTED BY :IIN BANISWIRA C11108193

BAGIAN ILMU ANESTESI, PERAWATAN INTENSIF, DAN MANAJEMEN NYERI

Supervisor :dr. Khalid Saleh, Sp. PD,KKV,FINASIM

Chief complaint: Chest pain The pain was felt a day ago after coming from the garden,

before admitted to the hospital. The pain felt pressed by heavy things, radiated to left arm, but no penetrated to the back body. The pain was felt for more than 30 minutes and didn’t relieved by rest. During the attack, patient feel sweating, nausea, vomit (-), palpitations (-), shortness of breath (-).Cough (-), history of cough(-)Dizziness (-), Headache (-) , Fever (-)

• PND (-), DOE (-) • Defecation and urination : normal

History of heart disease ( - )History of hypertension is (-)History of diabetes melitus (-)History of dyslipidemia is unknownHistory 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

Lung : Vesicular, Rhonchi -/- , 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 : flat and following breath movement Auscultation : peristaltic sound (+) , normal Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-)• Extremities : Edema -/-

Right ECG

Posterior ECG

Rhythm : Sinus rhythm P wave : 0,08 s Heart Rate : 50 x/min, reguler PR interval : 0,24 s Duration QRS : 0,12 s Axis : +10° ST Segment : ST elevation II,III, AvF

Conclusion:

Cardiomegaly with dilatatio, elongatio et atherosclerosis aorta

Date of lab test Types of test Result

November 20th 2012 WBC: 13,78 x103 mm3 (4,0 – 10,0 x 103)PLT: 182 x103 mm3 ( 150 – 400 x 103)RBC: 4,72 x106 mm3 ( 4,0 – 6,0 x 106)HGB: 14,0 gr/dl ( 12 – 16 )HCT: 39,8% ( 37 – 48 )

Blood chemistry Ureum : 26 mg/dl ( 10 – 50 )Creatinin : 0,9 mg/dl ( < 1,3 )SGOT : 158 /l ( < 38 )SGPT : 39 /l ( < 41 )Chol Total: 189 mg/dl ( 200 )Chol HDL: 35 mg/dl ( > 55 )Chol LDL: 116 mg/dl ( < 130 )Triglyceride: 221 mg/dl ( 200 )GDS 131 mg/gl (140)

Cardiac enzymes CK : 2643 ( < 190 )CKMB : 250 u/l (<25)Trop T : 0,98 ng/ml (<0,1)

Inferior STEMI onset >12 hours, Killip I

Yowler, C.J. Burn Injuries (Critical Care in Severe Burn Injury). In : Smith, C.E. Trauma Anesthesia. Cambridge : Cambridge University Press. 2008. p : 315

• O2 2-4 lpm ( via nasal canule )• IVFD NaCl 0,9% 20 dpm• Aspilet 80mg 0-1-0• Plavix 75mg 0-1-0• Simvastatin 20 mg 0-0-1• Lovenox 0,6 cc/12 h/ SC• Fasorbid 5 mg/SL• Alprazolam 0,5 0-0-1• Laxadyn syr 0-0-2 C

ST ELEVATION MYOCARDIAL INFRACTION

Myocardial infarction (MI) rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply

and demand of the myocardium.

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.

Occurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis.

In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates.

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from

unstable angina to myocardial infarction.

Non- Modifiable Modifiable

Gender and Age

Men, increased risk after age

45

Women, increased risk after

age 55

Family History

Heart disease diagnosed

before age 55 in father or

brother

Heart disease diagnosed

before age 65 in mother or sister

Smoking

Hypertension

Diabetes Mellitus

Dyslipidemia

Obesity

Lack of physical activity

1. Clinical history of ischaemic type chest pain lasting >20 minutes

2. Changes in serial ECG tracings3. Rise and fall of serum cardiac

biomarkers such as creatinine kinase-MB fraction and troponin

1. Chest pain, >30 minutes2. Usually tight, crushing, and band

like3. Location in retrosternal4. May radiate to left arm, throat,

and jaw5. Associated features including

palpitation, sweating, breathlessness, and nausea.

ST segment elevation over area of damage

ST depression in leads opposite infarction

Pathological Q waves Reduced R waves Inverted T waves

No

Yes

YesNo

Acute Myocardial Infarction (STEMI)

NSTEMI( Non ST-Elevation

Myocardial Infarction )

Unstable Angina

Signs of myocardial ischemia

↑ Biochemical cardiac markers ?

ECG

Lab

ST segmen elevation ?

Fixing the chest pain and fearnesso Bed resto Diet o O2 2-4 lpmo Nitrat sublingual/oral/IVo Antiplatelet : aspirin and clopidogrelo Morfin/petidine

o Diazepam 2-5mg/8 hour Stabilizing the hemodynamic ( blood pressure and pheripheral pulse

control)o β-blockero Calcium chanel blocker (CCB)o ACE-Inhibitor

Reperfusion of the myocardo Thrombolitik

• Congestive heart failure• Myocardial rupture• Arrhythmia• Cardiogenic shock• Pericarditis

Class Description Mortality Rate (%)I No clinical signs of

heart failure6

II Rales or crackles in the lungs, an S3, and elevated jugular venous pressure

17

III Acute pulmonary edema

30 - 40

IV Cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

60 – 80

KILLIP CLASSIFICATION

Thank you for your

attention