Emergency

Emergency
Cek kesadaran, vena jugular, tidak respon CPR,

A: airway harus bagus, head tilt, chin lift, jaw trush manouver, goedel,saturasi,
intubasi (caranya?)
B: breathing, saturasi, ventilator, bagging
C: sirkulasi, CPR, monitor, kardioversi, pasang akses vena, RL grojok
Post resusitasi:
1. ST elevasi Miokard infark (STEMI)
Penegakan diagnosis:
Nyeri dada khas jantung
Ekg: ST elevasi/lbbb
Penanganan:
Ke penanganan merah, monitoring EKG
Cek vital sign dan kesadaran
Morphin(2,5-10 mg iv), Oksigen (2-5 lt/menit, 3-5 jam), ISDN (asal pasien tidak
hipotensi)-SL, aspilet
Ambil darah lengkap
ICCU
2. Syok kardiogenik
3. NSTEMI dan UA
Penegakan diagnosis:
Nyeri dada, riwayat nyeri dada (ada peningkatan nyeri dada), rest angina
Lab: DL, kimia, enzim jantung, lipid profile
EKG: rule out STEMI
Thorax: edema pulmonal dan pembesaran jantung. Rule out mediastinal
abnormalities
Penanganan:
Bawa ke monitoring ekg
Bed rest
Oksigen, aspirin 300 mg (atau aspilet 80 mg), SL ISDN, jika tidak membaik : kasi
morfin 2,5-5 mg IV digabung dengan metoclopramide 10 mg iv
Periksa semua untuk penegakan diagnosis
Stratifikasi resiko:
Short-term risk of death non-fatal MI in patients with UA1
Feature
High risk (At least 1 Intermediate risk (No

Low risk (No high- or
of the following
high-risk feature but
intermediate-risk feature but
features must be
must have 1 of the
may have any of the following
present)
following)
features)
History Accelerating tempo of Prior MI, peripheral or
ischaemic symptoms cerebrovascular disease, or
in preceding 48 hours CABG, prior aspirin use
Character Prolonged ongoing (> Prolonged (>20 minutes) New-onset or progressive CCS
of pain
20 minutes) rest pain rest angina, now resolved, Class III or IV angina the past 2
with moderate or high
weeks without prolonged (>20
likelihood of CAD
minutes) rest pain but with
Rest angina (<20 minutes) moderate or high likelihood of
or relieved with rest or
CAD
sublingual NTG
Clinical Pulmonary oedema, Age>70 years
findings most likely due to
ischaemia
New or worsening
MR murmur S3 or
new/worsening rales
Hypotension,
bradycardia,
tachycardia
Age >75 years
ECG
Angina at rest with
T-wave inversions >0.2mV Normal or unchanged ECG during
transient
an episode of chest discomfort
ST-segment changes Pathological Q-waves
>0.05mV
Bundle-branch block,
new or presumed new
Sustained ventricular
tachycardia
Cardiac Elevated (e.g. TnT or Slightly elevated (e.g. TnT Normal
markers TnI >0.1ng/mL)
>0.01 but <0.1ng/mL)
1
Adapted from American College of Cardiology Practice Guidelines.
High Risk: ICCU
ASA(asetyl salisilik acid) aspirin 75-300 mg po, clopidogrel (75 mg od) selama 1
bulan, LMWH (UFH) enaxaparin 1mg/kg dibagi dua dosis perhari, IIb/IIIa
abciximab Bolus 250mcg/kg over 1 minute followed by iv infusion 125ng/kg/min
Anti-ischaemic therapy (first-line Beta-blocker. Ex: metoprolol 12.5-100mg po
tds), which if tolerated, may be converted to a longer-acting agent (e.g.
atenolol 25-1000mg od, GTN infusion (50mg in 50ml nitrate saline at
<=10ml/h) titrated to pain and keeping SBP >100mmHg )
Early invasive strategy (in-patient catheterization and PCI within 48 hours of

admission).
Intermediate risk/low risk:
ASA, clopidogrel, LMWH (UFH)

Anti-ischaemic therapy (first-line beta-blocker, GTN)
Undergoing a late risk stratification in 48-72 hours from admission
Takiaritmia. HR > 120
History: penyakit jantung sebelumnya, palpitasi, dizziness, nyeri dada, gejala gagal jantung dan
pengobatan sekarang. AF: alcohol, tirotoksikosis, penyakit katup mitral, IHD, perikarditis. VT:
MI sebelumnya, LV aneurisma.
Examination: BP, heart sounds and murmurs, signs of heart failure, carotid bruits
Penanganan:
Haemodynamically unstable patients

External defibrillation. The only exception is a patient in chronic AF with an uncontrolled
ventricular rate: defibrillation is unlikely to cardiovert to SR. Rate control and treatment
of precipitant is first line.
Sedate awake patients with midazolam (2.5-10mg iv)/ diamorphine (2.5-5mg iv +

metoclopramide 10mg iv) for analgesia. Beware respiratory depression and have an
anaesthetist, flumazenil, and naloxone to hand.
Formal anaesthesia with propofol is preferred, but remember the patient may not have an
empty stomach and precautions should be taken to prevent aspiration (e.g. cricoid
pressure, ET intubation).
Start at 200 J. synchronized shock and increase as required.
If tachyarrhythmia recurs or is unresponsive try to correct saPaO2, saPaCO2, acidosis, or

K+. Give Mg2+ (8mmol iv stat) and shock again. Amiodarone 150-300mg bolus iv may
also be used.
Give specific antiarrhythmic therapy (see P66).
Pasien stabil
o Admit and arrange for continuous ECG monitoring and 12-lead ECG.
o Try vagotonic manoeuvres (e.g. Valsalva or carotid sinus massage P78).
o If diagnosis is clear introduce appropriate treatment.
o If there is doubt regarding diagnosis, give adenosine 6mg as fast iv bolus followed by 5
ml saline flush. If no response, try 9, 12, and 18mg in succession with continuous ECG
rhythm strip.
o Definitive treatment should start as soon as diagnosis is known
Hipertensi emergency
Udem pulmonal
Atrial fibrilasi
Respirasi
1. Pneumonia akut
Diagnosis:
Panas, sesak, batuk, nyeri dada, ronkhi, wheezing, x-ray jelek. Cek RR, Saturasi O2, EKG.
Penanganan:
Cek ABC. Kasi O2, Jika ada tanda dehidrasi, pasang iv line. Darah, kimia lengkap.
Penghilang rasa sakit (paracetamol/NSAID kurang baik kasi codein)
2. Asthma berat
Diagnosis: sesak, batuk, wheezing.
Penanganan:
Suruh pasien duduk, kasi oksigen sesuai saturasi, nebul 2-3x setiap 15-30 menit jika tidak
membaik, hub dr nama(jika tidak bisa dihubungi), iv access. 200 mg hidrokortison iv,
lanjutkan 100 mg hidrokortison 3xsehari iv, atau metilprednisolon 30-50 mg perhari/oral.
Iv aminofilin: loading dose 250 mg (4-5 mg/kg) iv selama 20 menit. Maintenance: 250 mg pada
1 liter normal salin pada kecepatan 2-4 ml/kg/jam
3. COPD
Diagnosis: sesak, batuk berdahak, riwayat merokok, ronkhi, wheezing
Penanganan:
Sama dengan asma
4. ARDS
5. Pneumothorax
Chest Aspiration??
6. Tension pneumothoraks
Diagnosis: sesak tiba-tiba, riwayat pasang ventilator mekanik atau dilakukan CPR. Takipnea,
Takikardi, hipotensi. Suara paru menghilang. Deviasi trakea.
Penanganan:
Ambil kanul terbesar (18 G), tusukkan di ICS 2 midklavikula. Setelah stabil, ambil selang infuse,
tancapkan ke kanul dan taruh di bawah air. Tunggu sampai chest tube datang. Setelah chest tube
datang dan dipasang, cabut kanul dan tutup. Biarkan chest tube yang bekerja.
7. Hempotysis
8. Acute upper airway obstruction
Syok
Gangguan perfusi yang menyebabkan kerusakan organ. Ditandai: TD: <90 mmhg (tidak
terdeteksi)
Tindakan:
A: pastikan airway paten. (kasi O2)
B: pastikan ada nafas (look, listen, feel). Periksa saturasi berikan canul, mask rebreathing atau
intubasi (jika pasien tidak sadar) berdasarkan penurunan saturasi.
C: vena jugular, ekstrimitas, nadi. Segera pasang vena akses, CVP jika ada yang bisa
mengerjakan.
Monitoring: kesadaran, EKG, vital sign berkelanjutan, DL cito, x-ray,

Syok kardiogenik:
ABC primary survey
Jika ada aritmia kardioversi
Jika hipovolemia (tensi turun, nadi lemah, akral dingin) kasi cairan kristaloid (grojok).
Jika BP mengijinkan, kasi Gliseril trinitrate (5 mg/jam iv). Jika sangat hipotensif, kasi infuse
inotrop (epinephrine/adrenaline 1-10 mikrogram/menit hitung dosis adrenalin? atau
dobutamin 5-20 mikrogram/kg/menit inget. BB: 70 kg, dobutamin 250 mg. dalam infuse 500 cc
28 tetes/menit. Pake rumus perbandingan). Rumus siring pump dobutamin:
dosisxbb(kg)x60//5000
Untuk dopamine: BB: 70 kg, dopamine 200 mg, dalam infuse 500 cc 22 tetes/menit. Rumus
siring pump dopamine (dalam saline 50 cc) dosisxbb(kg)x60//4000.
Diamorphine 2,5 mg
Syok hipovolemik
Fluid replacement dengan cairan. Pasang DC
Tutup perdarahan.
Jika tetap hipotensi dengan cairan adekuat : untuk low cardiac output: adrenalin atau dobutamin
iv, Untuk high cardiac output: norepinephrine iv
Jika tetap oliguria dengan terapi cairan: kasi furosemid 10-20 mg iv
Syok anafilaksis
Presentasi: tubuh kemerahan, bengkak, wheezing, stridor, riwayat alergi
amankan jalan nafas, jika ada obstruksi, intubasi (selang 14g + oksigen 100%) atau
cricoidektomi
posisi kepala dibawah (kaki dinaikkan di bantal) jika hipotensi
injeksi epinephrine im 0,5-1 mg/adrenaline0,5-1ml dititrasi 1:1000, ulangi setiap 10 menit
sampai BP dan pulse tercapai
jika ada jalur iv, masukkan dosis epinephrine 0,1-0,2 mg (bolus atau drip?), liat respon.
Hidrokortison iv 100-200 mg dan chlorpheniramine (antihistamin) 10 mg iv

Jika stabil, kasih antihistamin 4x4mg selama 2 hari, sampai urtikaria menghilang
Tambah ranitidine 3x50 mg
Syok sepsis
Infeksi
Emergensi pada pasien HIV
Nefrologi
1. Acute renal failure
2. Anuria
3. Hematuria

Emergency

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Emergency

Cek kesadaran, vena jugular, tidak respon CPR,

1. ST elevasi Miokard infark (STEMI)

Short-term risk of death non-fatal MI in patients with UA1

High risk (At least 1 Intermediate risk (No

Early invasive strategy (in-patient catheterization and PCI within 48 hours of

Intermediate risk/low risk:

ASA, clopidogrel, LMWH (UFH)

Takiaritmia. HR > 120

Haemodynamically unstable patients

Sedate awake patients with midazolam (2.5-10mg iv)/ diamorphine (2.5-5mg iv +

Start at 200 J. synchronized shock and increase as required.

If tachyarrhythmia recurs or is unresponsive try to correct saPaO2, saPaCO2, acidosis, or

Give specific antiarrhythmic therapy (see P66).

Monitoring: kesadaran, EKG, vital sign berkelanjutan, DL cito, x-ray,

Hidrokortison iv 100-200 mg dan chlorpheniramine (antihistamin) 10 mg iv

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