classification of cardiovascular

emergency
1. Cardiac arrest
2. Acute coronary syndrome
1. Unstable angina pectoris
2. NSTEMI (Non- ST elevation miocard
infark)
3. STEMI (ST elevation miocard infark)

Cardiac arrest
Definition
Condition that the circulation of blood
stop because heart cant contraction
effectively
Etio:

ventricular fibrillation
Pulseless ventriculat tachycardia
Pulseless electrical activity (PEA)
Asistol

Ventricular fibrilation
Definisi :bentuk gambaran gelombang
yg naik turun dlm berbagai bentuk
amplitudo ( Tidak ada kompleks QRS
atau segmen ST )
Fibrilasi halus di tandai dengan
amplitudo < 0,2mv

Risk Factor

Smoking
Elevated Cholesterol serum
Elevated blood presure
Diabetes
Obesity
Lack of physical exercise
Family History
Age

etiologi

Coroner heart disease

Accumulation ion Ca
Free radikal
Disorder of cell metabolic
Modulation otonom
Hipokalium
Toksisitas obat-obatan

Clinical appreance
Henti jantung
Henti nafas

Ventriculer fibrilation
Heart is composed of several normal
myocardial regions interspersed by
regional ischemia myocardial, injury or
infarction were not synchronized and
chaotic.
Without regular ventricular depolarization
ventricles cant be contracted as a unit
& dont result in cardiac output (CO).
Heart "shaking / shivering" and does not
pump blood

Criteria for determining based

on ECG
Value / QRS complex: cant be
determined: no P wave, QRS or T that
can be known.
Rhythm: not determinable; deflection
pattern up (peak) & down (trough) sharp
Amplitude: measured from peak to
trough; Fine (2-4 mm), medium (5-9mm),
coarse (10-14mm), very coarse (>
15mm)

Clinical manifestation
Pulse disappeared with the onset of
VF. The pulse may disappear before
the onset of VF when a common sign
for VF (rapid VT) occurred before VF
Fainting, can not respond
Gasping, breathing very difficult
Begins an irreversible death /
irreversible

Etiology
Acute coronary syndrome that causes
myocardial ischemic areas
VT is stable to unstable, untreated
Premature ventricular complexes / premature
ventricular complexes (PVC) with R on T
phenomenon (R on T)
Some drugs, electrolyte or acid-base
abnormalities that prolong the refractory
period is relatively
QT prolongation primary or secondary
Death due to electricity, hypoxia and more

GAMBAR EKG

PEA (pulse less electric

activity)
A clinical situation there is no pulse,
while impulse conduction in the heart
is still there and should be able to
generate patterns that pulse
Because the electrical activity of the
heart does not result in myocardial
contraction / inadequate ventricular
filling at diastole

Determinants based on ECG

criteria:
Rhythm showed irregular electrical activity
(not VF / VT without pulse)
Generally noT irreguler a normal sinus
rhythm
Can narrow (QRS <0.10), wide (QRS> 0.12);
fast (> 100 per minute), slow (<60/menit)
Can narrow (non-cardiac etiology), wide
(often cardiac etiology), slow (cardiac
etiology), fast (non-cardiac etiology)

Clinical manifestations
Fainting can not respond
Gasping for breath, difficulty
breathing or apnea greatly
No pulse that can be detected by
palpation (a very low blood pressure
is still possible in the case of the socalled pseudo-PEA)

Etiology
6H & 5T (hypovolemia, hypotermia,
hypoglycaemia, H+ acidosis,
hypo/hyper kalemia, hypoksia,
Trauma, Toxin, Tamponade, Tension
pneumothorax, Trombosis)

PEA

Asistol
Determinants based on ECG criteria:
Published as a "flat line" heart stops
contracting

 Speed: no visible activity ventricular or 6

complexes per minute;"asystole P waves"
only possible with atrial impulse (P waves)
Rhythm: no visible activity of complex
ventricular or 6 per minute
PR: not specified, sometimes looks a P wave,
R wave but by definition should not appear
QRS complex: no visible deflection
consistent

clinical manifestations
gasping, breathing very hard (at the
beginning); unable to provide a
response
No pulse or blood pressure
cardiac arrest

etiology
End of life (death)
Ischemia / hypoxia from many causes
Acute respiratory failure (no oxygen,
apneu, asphyxiation)
Electroshock high level (eg, death due
to electrical, struck by lightning)
Can show "faint" of heart soon after
defiibrilasi, before the commencement
of the spontaneous rhythm

Differensial Diagnose of
Cardiac Arrest

Differensial Diagnose of
Cardiac Arrest
Sudden loss of consciousness with a
palpable pulse:
Syncope
Seizure
Acute stroke
Hypoglycemia
Acute airway obstruction
Head trauma, Toxins

Treatment (BCLS)
Melakukan survey primer ABCD &
lanjutkan RJP sambil menunggu alat
kejut listrik datang
Jika sudah datang pasang sadapan
pada pasien tnpa menghentikan RJP
Berhenti RJP (tidak boleh lebih dari
10 menit) Lihat ke monitor irama apa
yg terlihat

 Jika VT /VF ,kejut listrik unsynchronized

dengan energi 360 j (kejut listrik
monofasik)/200 J( kejut listrik bifasik)
RJP selama 5 siklus ( 2 menit) &lihat
monitor EKG
Jika msh VT,lakukan sama seperti di
atas & berikan EPINEPHRINE 1mg IV
/IO(ulang 3-5 menit) atau vasopresin 40
U IV/IO (hnya 1x smpai RJP selesai)

 Lakukan survey sekunder ,lakukan

intubasi

Acute coronary syndrome

UNSTABLE ANGINA
This is characterized by Pain that occurs
with less excertion , cumulating pain at rest.
platelet-fibrin thrombus associated
with a ruptured atheromatous plaque
without complete occulation of the
vessels.
The risk of infraction is
subtanial, and the main aim
of therapy is to reduce this.

Unstable angina

is that characterized by
rapidly worsening chest pain
on minimal exertion or at rest.
= ulcerated atheroma+
thrombus formation>>>
reduction of coronary blood
flow caused by thrombus>>
angina at rest

Unstable angina
Recent onset (less than 1 month).
Increase frequency and duration of
episode.
Angina at rest not responding readily
to therapy.
If the pain more than 30 min.????
MI

The Canadian Cardiovascular Society

grading scale
is used for classification of angina
severity, as follows:
Class I : Angina only during strenuous or
prolonged physical activity
Class II : Slight limitation, with angina only
during vigorous physical activity
Class III : Symptoms with everyday living
activities, ie, moderate limitation
Class IV : Inability to perform any activity
without angina or angina at rest, ie, severe
limitation
N.A.N 2009

The New York Heart Association

classification
is also used to quantify the functional limitation
imposed by patients' symptoms, as follows:
Class I : No limitation of physical activity (Ordinary physical
activity does not cause symptoms.)
Class II : Slight limitation of physical activity (Ordinary
physical activity does cause symptoms.)
Class III : Moderate limitation of activity (Patient is
comfortable at rest, but less than ordinary activities cause
symptoms.)
Class IV : Unable to perform any physical activity without
discomfort, therefore severe limitation (Patient may be
symptomatic even at rest.)

N.A.N 2009

Causes:

Decrease in myocardial blood supply

due to increased coronary resistance
in large and small coronary arteries:

1. Significant coronary atherosclerotic

lesion
2. Coronary spasm (ie, Prinzmetal
angina)

N.A.N 2009

Causes:
3. Abnormal constriction or deficient
endothelial-dependent relaxation of
resistant vessels associated with
diffuse vascular disease (ie,
microvascular angina)
4. Syndrome X
5. Systemic inflammatory or collagen
vascular disease, (scleroderma,
systemic lupus erythematous,
Kawasaki disease, polyarteritis
nodosa, and Takayasu arteritis)
N.A.N 2009

Risk factors:
Major risk factors for
atherosclerosis: like family history
of premature CAD, cigarette
smoking,DM,hypercholesterolemia(
Metabolic syndrome), or systemic
HTN
Other risk factors: These include LV
hypertrophy, obesity,
N.A.N 2009

Precipitating factors:
These include factors such as
severe anemia, fever,
tachyarrhythmias,
catecholamines, emotional
stress, and hyperthyroidism,
which increase myocardial
oxygen demand.

N.A.N 2009

Preventive factors:
Factors associated with reduced
risk of atherosclerosis are a high
serum HDL cholesterol level,
physical activity, estrogen, and
moderate alcohol intake (1-2
drinks/d).
???!! Plz Dont drink and smoke 4u
life.
N.A.N 2009

Stable Angina
Exercise Testing
The goal of exercise testing is to
induce a controlled, temporary
ischemic state during clinical and
ECG observation

N.A.N 2009

ECG
ST segment depression with or
without T wave inversion that
reverse after ischemia disappears.

N.A.N 2009

ECG
Elevation of ST segment in
prinzmentals angina.

N.A.N 2009

ECG
The resting ECG may be normal
between attacks however it may
show old MI, heart block or LVH

N.A.N 2009

Exercise Testing
Contraindications

MIimpending or acute
Unstable angina
Acute myocarditis/pericarditis
Acute systemic illness
Severe aortic stenosis
Congestive heart failure
Severe hypertension
Uncontrolled cardiac arrhythmias

N.A.N 2009

NON-ST ELEVATION
MYOCARDIAL
INFARCTION
a subtotally blockage in the coronary
artery in the first few hours and
disappear over time and there is
evidence myocardial infarction
(elevated cardiac biomarker)

Pathophysiology
oxygen supply or myocardial
oxygen demand superimposed on a
lesion (coronary arterial obstruction
atherothrombotic coronary plaque)

Myocardial
Infarction
RISK FACTOR:
1.Smoking
2.Hypertension
3.hypercholesterolemia
Myocardial Infarction
thrombus coronary artery

Coronary artery Occlus

Aggregasi platelet

Decrease coronary artery blood flow

Arterosklerosis plaque

Ruptur plaque

Tromboxan A2

Thrombosit activation
Agonis (kolagen, ADP, epinefrin dan serotonin)

Risk Factors
age > 65 years
three or more risk factors for CAD (carotid
artery disease),
documented CAD at catheterization,
development of UA/NSTEMI while on
aspirin,
more than two episodes of angina within
the preceding 24 h
ST deviation 0.5 mm, and an elevated
cardiac marker

Clinical manifestation
chest pain
located in the substernal region or
sometimes in the epigastrium, that
radiates to the neck, left shoulder,
and/or the left arm
dyspnea and epigastric discomfort

Clinical manifestation

Diaphoresis
cool skin
sinus tachycardia
a third and/or fourth heart sound
basilar rales (crackles) inflamation,
fluid or infection.
Hypotension resembling the
findings of large STEMI.

Diagnosis
clinical history
ECG
Cardiac markers (recognize or
exclude MI )
Stress testing (coronary imaging is
an emerging option).

Electrocardiogram
ST-segment depression, transient STsegment elevation, and/or T-wave
inversion occur in 30 to 50% of
patients

Cardiac Biomarkers
elevated biomarkers of necrosis,
such as CK-MB > 3 ng/ml and
troponin >0.4 ng/ml
High risk mortality if troponin
incrase.

Therapy

Prognosis
NSTEMI exhibit a wide spectrum of
early (30 days) risk of death, ranging
from 1 to 10%, and of new or
recurrent infarction of 35% or
recurrent ACS (5-15%).

AMERICAN HEART
ASSOCIATION

CHANGES IN THE 2010

GUIDELINES AFFECTING
ALL RESCUERS

AMERICAN HEART ASSOCIATION:

2010 GUIDELINES
Health Care Provider*
PUSH HARD AND PUSH FAST
At least 100 COMPRESSIONS / MINUTE*
Allow the chest to recoil -- equal compression and relaxation times
<10 seconds for pulse checks or rescue breaths
Compression Depth*
Adults 2
Child/Infant 1/3 depth of chest

Avoid excessive ventilations

1.5" infant

2" child

AMERICAN HEART ASSOCIATION:

2010 GUIDELINES
A-B-C changed to C-A-B*
Critical element is chest compressions
Delay in A-B
Avoidance of A & B

Early defib
If alone--call and retrieve AED
Exception asphyxial arrest

AMERICAN HEART ASSOCIATION:

2010 GUIDELINES
Cricoid pressure not recommended
Advanced airway = 1 every 6-8
seconds
Adult: 1 every 5-6

Peds: 1 every 3

With advanced airway- no pause

Dispatcher Identification
SCA = seizure & agonal gasps
Trained to ID ask if breathing is
normal
Only gasping???
Provide CPR instructions

AMERICAN HEART ASSOCIATION:

2010 GUIDELINES
AHA ECC Adult Chain of Survival - New

AMERICAN HEART ASSOCIATION:

2010 GUIDELINES

Simplified Universal
BLS algorithm

CPR

CPR
Combines external chest
compressions with artificial
ventilation
Provides 30% (or less) of normal
circulation
Only effective for short period of time

CPR 1 Rescuer
Assess
responsiveness
Summon EMS
Position the
patient

CPR 1 Rescuer
Open the airway

CPR 1 Rescuer
Look, listen, and
feel for
breathing

CPR 1 Rescuer
If there is no
breathing, give
two breaths, each
lasting 1 second

CPR 1 Rescuer
Check for a pulse
( 10 seconds)

CPR 1 Rescuer
If there is no
pulse, find your
landmarks, lower
half of the
sternum, between
the nipples

CPR 1 Rescuer
Begin chest
compressions

CPR 1 Rescuer
Perform 30 chest
compressions
Push hard
Push fast
Allow the chest
to recoil after
each
compression

CPR 1 Rescuer
Administer two
ventilations
then return to
compressions

CPR 2 Rescuer
1

CPR - Children

Use heel of one

hand
Keep airway open
with other hand
30
compressions:2
ventilations if
alone (2 rescuers
use 15:2)

CPR - Infant

Give chest thrusts

and puffs of air
30 compressions:2
ventilations if alone
15 compressions: 2
ventilations with 2
rescuers

AEDs

Safe, accurate &

lightweight
Easy to operate
What is public
access defibrillation?

PAD
AEDs in public
places
Training the public
in CPR/AED

Special Considerations

Implanted
Children
defibrillators or
Clothing
pacemakers
Body hair
Metal surfaces
Water
Jewelry and glasses
Transdermal
medication patches

AED

Assess

Check your
patient

Universal Steps

Power

Patient

Analyze

Shock

Power
Turn the power
on

Patient

Apply pads to
patient

Analyze

Stay clear while

patients heart
rhythm analyzed

Clear

Head to toe
and toe to
head:
everyone is
clear!

Shock
Defibrillate

Patient

Standard is set of
1 shock
Immediately
restart CPR for 2
minutes then
check pulse