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ACLS

Pembimbing :
Fakultas Kedokteran
Universitas Brawijaya dr. Ali Haedar, Sp.EM
Case Report
IDENTITY

Nama : Mrs. P
Age : 71 y.o
Address : Poncokusumo, Kab. Malang
Job : Farmer
Religion : Islam
Registration No : 11602991
Examination : April 4th 2017 at 11.40 AM
PRIMARY SURVEY

A : Patent, Additional breathing sound (-)


B : RR 28x/m, regular, simetrical chest expantion, retra
tion (-), SatO2 96%
C : BP 100/60 mmHg, PR 170 x/menit, regular stron
g, acral warm, CRT < 2 detik
D : GCS 456, pupil round isokor 3mm/3mm
E :Axilarry Temp 36C

Triage Priority : P1
INITIAL TREATMENT

A :-
B : O2 10 lpm via NRBM Sat O2: 9
6%
C : IVFD NaCl 0,9% 20 dpm
D :-
ANAMNESIS
Autoanamnesa
Chief Complain : Chest Pain
History of Present Illness :
Chest pain since 4 days before admission. Chest pain in middle section of
cest and spread to left shoulder (-), jaw (-), chin (+) for 30 minutes.
Patient felt like shooting pain when patient doing activity. Morning before
admission, patient felt her chest beat fast and sweated out. Nausea (-)
vomit (-) sweated out (-) out of breath when doing heavy activity, like
walking.

History of Past Illness:


History SVT since 1 year ago, and have monthly control in cardiology
department
ANAMNESIS
History Past Illness::
HT (+) since >10 years ago, DM (-), asthma (-), TB (-)
Medication :
Patient doesnt know drugs she routine use
Family Disease:
No family with HT, asthma (-), TB (-)
Social History:
Patient work as farmer
Physical Examination
Moderately ill Height: 150 cm Weight: 60 kg
GCS 456 Bmi 26,67 kg/m2
BP=100/60mm PR 170 x/m, regular, RR = 30 tpm Tax :360C
Hg

Head Conjunctiva Anemis (-) Pupil isokor 3/3mm


Sklera Ikterik (-)
Neck JVP R + 2 cm H20, semi Enlage of Lymph
Fowler Node (-)
Thoraks Ictus invisible & palpable at ICS VI MCL S
Cor RHM ~SL D, LHM ~ ictus
S1 S2 normal, Irregular, murmur (-), gallop (-)
Pulmo Simetris Stem fremitus Sonor + + v v Rh - - Wh - -
D=S
+ v v - - - -
+
+ v v - - - -
+
Abdomen Flat, soefl, bowel sound + N, liver span 8 cm. Traubes space timpani,
Shifting dullness -
EKG ( 11/ 01/2017)

Sinus takikardi, HR 125x/menit, poor R wave progression, LVH


LAB RESULTS ( 11/01/2017)
Lab Value Lab Value
Leucocyte 12.800 4700-11.300/L Na 142 136-145mmol/l
Diff Tell 1,2/0,4/6 0-4/0-1/51-67/25- K 4,0 3,5-5,0 mmol/l
3,3/27,4/ 33/2-5 %
7,7
Haemoglobin 15,4 11,4-15,1 g/dL Cl 103 98-106 mmol/l
MCV 93,9 80-93 fl

MCH 30,4 27-31pg CK-NAC 66 39-308 U/L


Hematokrit 47,6% 38-42 % CKMB 57 7-25 U/L
Thrombocyte 319.000 142000- Troponin I 0,015 Positif > 0,1
420000/L /L
SGOT 24 0-40 U/L Ureum 30 16,6 - 48,5
mg/dL
SGPT 31 0-41 U/L Kreatinin 1,36 < 1,2 mg/dL
GDS 146 <200
DIAGNOSIS

1. SVT
2. HF st C FC II
3. NSTEMI

DISPOSITION Cardiology Departement


PLANNING THERAPY
11.45
Semi-Fowler position
O2 10 lpm via NRBM
IVFD NaCl 0,9% 2500cc/24 jam
Inj : Diltiazem 15 mg bolus 2 minutes
next 1 mcg/kg/minutes
12.00
New Diltiazem inj. 5 mg Rhyme convert to synus rythm 95x
/minute
Re-ECG
Drip diltiazem 1 mcg/kg/minute
12.05
Re-SVT bolus 15 mg diltiazem
PLANNING THERAPY

14.07
NaCl 0.9% 100cc + Amiodarone 150 mg completed in 10 min
14.25
NaCl 0.9% 100cc + Amiodarone 300 mg completed in 6 hours
16.00
Per oral: ASA 320 mg
Clopidogrel 300 mg
Furosemid 20 mg
Spironolacton 25 mg
PLANNING MONITORING

Subjective
Vital Sign
Respiratory Distress
Urin Production
Discussion
ANAMNESIS
Case Theory (ESC, 2011)
Chest pain since 4 days b Pasien with typical ch
efore admission. Chest p est pain > 20 menit;
ain in middle section of c Angina de novo kelas
est and spread to left sho
II / III based on CCS
ulder (-), jaw (-), chin (+)
for 30 minutes when d Angina undergo dest
oing moderate activities. abilisation
chest beat fast and sweat Angina Pasca Infark
ed out. Miokard (2 weeks aft
er MI)
Physical Examination
Case Theory (ACLS 2015)

Pulse Rate 170 bpm reg


ular
TD: 100/60 mmHg
GCS 456 Tachycardia >100 bpm
Ictus invisible & palpable at Chest pain
1 cm lateral to ICS V MCL S
STABLE Tachycardia
ECG
SVT
ECG
T Inversion
Laboratory

Case Theory (ESC 2011)


Increase of Troponin I, C NSTEMI Diagnosis
KMB ECG:
ST segment Depression a
nd/or T inversion; with or
without ST segment eleva
tion (<20 minutes);
Persistent Q wave
Cardiac Marker:
Increase of troponin I/T le
vel 2-4 jam after onset.
Tachycardia Algorithm (ACLS 2
015)
ACS Algorithm (ACLS 2015)
Treatment
Case Theory (ACLS 2015)
Diltiazem 15 mg bolus iv
SVT
over 2 minutes
Initial: 0.25 mg/kg IV bol
Drip Diltiazem 1mcg/kg/mi
us over 2 minutes
nute
Maintenance: 5-10 mg/
Amiodarone 150 mg drip
h up to 15 mg/h
within 100cc NaCl in 10 mi
nutes Initial: 150 mg IV over 1
0 minutes
Amiodarone 300 mg drip
within 100 cc NaCl in 6 ho Maintenance: 360 mg or
urs 1 mg/minutes over next
6h
Treatment
Case Theory (PERKI 2014)
ACS
1.Bed rest (I-C)
O2 10 lpm NRBM
2.O2 supplementation for all patients with
ASA 320 mg ACS (IIa-C)
3.Anti Ischemia: Beta-Bloker (I-B); Nitrat (I
Clopidogrel 300 mg -C), CCB
Furosemid 20 mg 4.Anti platelet: Aspirin (I-A) + ADP Rec Inh
ibitor (I-A)
Spironolacton 25 mg 5.Anti coagulant suggested for all patients
with antiplatelet therapy. (I-A)
Patients transferred to Car 6.ACE Inhibitor to prevent remodelling (I-
diovascular Care Unit A)
7.Statin should give to all patients with U
AP/NSTEMI if contraindications not pres
ent (I-A)