PRESENTED BY :

IIN BANISWIRA C11108193

BAGIAN ILMU ANESTESI, PERAWATAN INTENSIF, DAN MANAJEMEN NYERI
Supervisor :
dr. Khalid Saleh, Sp. PD,KKV,FINASIM

MR number : 579492
Name : Mr. J
Age : 58 years old
Date administered : November 20
th
2012
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 didnt 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 unknown
History 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 : 36.5
0
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 2
nd
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 20
th
2012 WBC: 13,78 x10
3
mm
3


(4,0 10,0 x
10
3
)
PLT: 182 x10
3
mm
3


( 150 400 x 10
3
)
RBC: 4,72 x10
6
mm
3
( 4,0 6,0 x 10
6
)
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 tracings
3. Rise and fall of serum cardiac biomarkers
such as creatinine kinase-MB fraction and
troponin
1. Chest pain, >30 minutes
2. Usually tight, crushing, and band like
3. Location in retrosternal
4. May radiate to left arm, throat, and jaw
5. 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
Yes
No

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 fearness
o Bed rest
o Diet
o O
2
2-4 lpm
o Nitrat sublingual/oral/IV
o Antiplatelet : aspirin and clopidogrel
o Morfin/petidine
o Diazepam 2-5mg/8 hour
Stabilizing the hemodynamic ( blood pressure and pheripheral pulse control)
o -blocker
o Calcium chanel blocker (CCB)
o ACE-Inhibitor
Reperfusion of the myocard
o Thrombolitik


Congestive heart failure
Myocardial rupture
Arrhythmia
Cardiogenic shock
Pericarditis


Class Description Mortality Rate (%)
I No clinical signs of heart
failure
6
II Rales or crackles in the
lungs, an S
3
, 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