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    Role Play Electrocardiography: Dr. Ikhwan Handi Rosiyanto, SPJP

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    Rizky Adnanta
    This document provides an overview of electrocardiography in the context of a role play simulation involving a 29-year-old male who complained of chest pain after playing futsal for 30 minutes. It discusses the typical characteristics of angina pain, factors that may indicate a heart attack, physical exam findings, EKG placement and reading, classifications of acute coronary syndrome, treatment approaches, and post-treatment management. Reference materials are also provided to guide the role play scenario and evaluation.

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    Role Play Electrocardiography: Dr. Ikhwan Handi Rosiyanto, SPJP

    Uploaded by

    Rizky Adnanta
    84 views54 pages
    This document provides an overview of electrocardiography in the context of a role play simulation involving a 29-year-old male who complained of chest pain after playing futsal for 30 minutes. It discusses the typical characteristics of angina pain, factors that may indicate a heart attack, physical exam findings, EKG placement and reading, classifications of acute coronary syndrome, treatment approaches, and post-treatment management. Reference materials are also provided to guide the role play scenario and evaluation.

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    Role Play ECG

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    This document provides an overview of electrocardiography in the context of a role play simulation involving a 29-year-old male who complained of chest pain after playing futsal for 30 minutes. It discusses the typical characteristics of angina pain, factors that may indicate a heart attack, physical exam findings, EKG placement and reading, classifications of acute coronary syndrome, treatment approaches, and post-treatment management. Reference materials are also provided to guide the role play scenario and evaluation.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    84 views54 pages

    Role Play Electrocardiography: Dr. Ikhwan Handi Rosiyanto, SPJP

    Uploaded by

    Rizky Adnanta
    This document provides an overview of electrocardiography in the context of a role play simulation involving a 29-year-old male who complained of chest pain after playing futsal for 30 minutes. It discusses the typical characteristics of angina pain, factors that may indicate a heart attack, physical exam findings, EKG placement and reading, classifications of acute coronary syndrome, treatment approaches, and post-treatment management. Reference materials are also provided to guide the role play scenario and evaluation.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 54

    ROLE PLAY

    Electrocardiography

    dr. Ikhwan Handi Rosiyanto, SpJP

    Fakultas Kedokteran

    Universitas Muhammadiyah Malang


    REAL CASE
    • Laki-laki, 29 tahun mengeluh nyeri dada setelah kurang lebih 30 menit
    bermain futsal.
    Anamnesa
    • Typical chest pain ?
    Karakteristik Angina Tipikal pd ACS
    • Terlokalisir terutama (tapi tidak selalu) di daerah
    retrosternal
    • Menjalar ke lengan kiri, leher,area interskapuler, bahu
    atau epigastrium
    • Tidak berubah dengan posisi atau pergerakan
    • Sering terasa seperti tertekan atau berat,
    “constricting” atau “crushing”
    • Episode > 20 menit
    • Diikuti sesak, pusing, mual, atau berkeringat, sinkop
    Nyeri Dada Khas Infark
    1. Nyeri dada tipikal yang persisten >20 Menit (80%)
    2. Nyeri dada angina Pertama Kali (de Novo) dengan tingkatan CCS (The
    Canadian Cardiovascular Society) III
    3. Cresendo Angina (makin sering, lebih lama, atau menjadi makin berat,
    minimal CCS III
    4. Angina Paska Infark (terjadi 2 minggu setelah infark)
    Faktor risiko penyakit jantung koroner

    Non modifiable Modifiable


    •Sex •High blood pressure

    •Hereditary •High blood cholesterol

    •Race •Smoking

    •Age •Physical activity


    •Obesity
    •Diabetes
    •Stress and anger
    PHYSICAL EXAMINATION
    GENERAL APPEARANCE
    Anxious, considerable distress, restless, fist on chest (Levine sign)
    LV failure & symp. stimulation : cold perspiration, pallor, dyspnea, cough with frothy
    pink or blood-streaked sputum.
    Shock : cool, clammy skin, facial pallor, cyanosis, confusion or disorientation

    HEART RATE
    Variable depending on underlying rhythm and degree or ventr. failure
    Most commonly, HR 100 – 110/min; > 95% patients : VPB’s within first 4 hours

    8
    BLOOD PRESSURE
    Majority normotensive, but syst. BP may decline and diast. BP may rise
     Half of pts with inferior MI  parasympathetic stimulation : hypotension,
    bradycardia or both (Bezold – Jarisch reflex)
     half of pts with anterior MI,  sympathetic excess : hypertension, tachycardia or
    both

    TEMPERATURE AND RESPIRATION


    Most pts with extensive MI  fever within 24-48 hrs, fever resolves by 4th or 5th day
    Respiration  due to anxiety and pain, in LV failure : resp. rate correlates with degree
    of heart failure

    9
    JUGULAR VENOUS PULSE
    JVP usually normal
    RV infarction : marked jug. venous distension

    CAROTID PULSE
    Small pulse  reduced stroke volume
    Pulse alternans : severe LV dysfunction

    10
    ECG
    Limb Lead Placement

    Shirley A. Jones,2005
    Frontal Axis
    Precordial Lead Placement

    Lead Positive Electrode Placement View of Heart

    V1 4th Intercostal space to right of sternum Septum


    V2 4th Intercostal space to left of sternum Septum
    V3 Directly between V2 and V4 Anterior
    V4 5th Intercostal space at left midclavicular Anterior
    V5 line Lateral
    V6 Level with V4 at left anterior axillary line Lateral
    Level with V5 at left midaxillary line

    Shirley A. Jones,2005
    Right Ventricle Lead Placement

    Chest lead Position

    V1R 4th Intercostal space to left of sternum


    V2R 4th Intercostal space to right of sternum
    V3R Directly between V2R and V4R
    V4R 5th Intercostal space at right midclavicular line
    V5R Level with V4R at right anterior axillary line
    V6R Level with V5R at right midaxillary line

    Shirley A. Jones,2005
    Posterior Lead Placement

    Chest lead Position Heart views


    V4R 5th Intercostal space in right anterior Right ventricle
    midclavicular line
    V8 Posterior 5th intercostal space in left Posterior wall of
    midscapular line LV
    V9 Directly between V8 and spinal
    column at posterior 5th intercostal space Posterior wall of
    LV
    Shirley A. Jones,2005
    Observasi
    • Nyeri dada (+)

    • TDS 98-104 TDD 60-72, HR 68-72, RR 20, SPO2 98%, akral dingin

    • Monitor ECG : PAC occasional, PVC occasional


    Pendekatan Sistematis Pembacaan EKG
    ► Rate (frekuensi)
    ► Rhythm (irama)
    ► Axis
    ► Morfologi gelombang:
     P, T, and U waves and QRS complex
    ► Interval
     PR, QRS, QT
    ► ST Segment
    Elektrokardiografi

     The most important


     Serial EKG is routinely
     Classify ACS
     Determine severity and prognosis
     Elevasi Segmen ST pada J Point pada 2 lead yg berhubungan
     Sebagian besar sadapan ≥ 0,1 mv

    STEMI

     LBBB baru atau diduga baru (kriteria Sgarbossa)

    NSTEMI Depresi Segmen ST horizontal/downsloping baru ≥ 0.1 mV pada 2 lead yg


    /UAP berhubungan
    T Inverted ≥ 0.2 mV atau nonspesfik ST-T changes atau normal

    ESC Guidelines for the management of acute myocardial infarction in patients presenting
    with ST-segment elevation. 2011.
    Sandapan dengan ST Elevasi
    Infark miokardial anteroekstensif
    Infark miokardial
    lateral

    EVOLUSI
    Bayangan cermin
    Marka Jantung

    • Pada pasien dg SKA Peningkatan enzim Troponin terjadi 3-4 jam setelah
    onset gejala dan dapat bertahan 2 minggu
    • CKMB meningkat 4-6 jam mencapai puncak 12 jam, menetap 2 hari
    • Pemeriksaan serial harus dilakukan dlm 6-12 jam jika pemeriksaan pertama
    negative
    Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2018
    Klasifikasi SKA

    Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
    Tatalaksana
    Tindakan Umum & Langkah Awal

    Tirah Baring (Kelas 1C)

    Oksigen utk pasien dg hipoksemia (Saturasi < 90% atau Pa02<60


    mmHg) (I-C)

    Aspirin 160-320 mg pada semua pasien yang tidak diketahui toleransinya terhadap aspirin (Kelas l—
    A), dipilih sediaan tanpa salut (Kelas 1-C)

    Dosis awal ticagrelor 180 mg dilanjutkan 2 x 90 mg/hari kecuali pasien IMA-EST yang direncanakan
    untuk fibrinolitik (Kelas l-B). Atau clopidogrel dosis awal 300 mg dilanjutkan 75 mg/hari (Kelas I-C).

    Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2018
    Tindakan Umum & Langkah Awal..Lanjutan..

    Anti Iskemik: NTG spray/tab dapat diulang tiap 5 menit maks


    3 x(I-C), jk masih nyeri diberikan NTG/ISDN intravena (I-C)

    Morfin sulfat 1-5 mg IV dpt diulang setiap 10-30 menit (IIa-C)

    Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2018
    Strategi Reperfusi

    2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
    Pengobatan Pasca Perawatan Pasien SKA
     Obat-obat untuk mengontrol keluhan iskemia harus dilanjutkan
     Aspirin
     Beta-blocker
     ACE inhibitor
     Statin

    Modifikasi Faktor Risiko


     Berhenti merokok
     Pertahankan BB optimal
     Aktivitas fisik sesuai dengan hasil treadmill
     Diet
     Rendah lemak jenuh dengan kolesterol, bila perlu dengan target LDL
    < 100 mg/dL
     Pengendalian hipertensi
     Pengendalian ketat gula darah pada penderita DM 41
    REFERENSI

    • Pedoman Tata Laksana Sindrom Koroner Akut. Perhimpunan Dokter Spesialis Kardiovaskular Indonesia.
    Pedoman Tatalaksana Sindrom Koroner Akut. 2018

    • 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with
    ST-segment elevation

    • 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting
    without persistent ST-segment elevation

    • 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

    • 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the
    Management of Patients With Unstable Angina/Non −ST-Elevation Myocardial Infarction
    TERIMA KASIH
    CARA MENGHITUNG NADI
    Menentukan frekuensi jantung
    A. 300 = ( jml kotak besar dlm 60 detik )
    Jml kotak besar antara R – R

    B. 1500 = (jml kotak kecil dlm 60 detik )


    Jml kotak kecil antara R – R

    C. Ambil EKG strip sepanjang 6 detik, hitung jumlah QRS dan kalikan 10.

    RUMUS A/B UNTUK EKG YANG TERATUR.


    RUMUS C UNTUK YANG TIDAK TERATUR.
    Goldberger,2013
    Evolution of an Acute Myocardial Infarction
    Infarct Related Artery
    Infarct Related Artery
    Idioventricular rhythm
    Accelerated Idioventricular Rhythm (AIVR)

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