INTERVENSI PADA ACS Nursing perspective Ns. Yuyun Yuniaty, SKep Emergency Department Staff Nurse National Cardiovascular Centre Of Harapan Kita

PRELIMINARY Cardiovascular disease today is a global problem and the cause of death in the world. World Health Organization (WHO) in 2008 there were 7.2 million deaths worldwide are caused by cardiovascular disease or 12.2% of all deaths world's population. In the United States despite the prevalence declined at least 1.5 million people have heart attacks each year and 400.000- 500,000 of them died, half of it died before reaching the hospital. Deaths caused by cardiovascular disease in Indonesia is still high even top the list of causes of death, according to the Household Survey MOH house in 2008 the mortality rate reached 25%.

Percentage of patient diagnosed with ACS admitted to emergency room 28% (35%) 28% 24% 22% Source: Jakarta Acute Coronary Syndrome Registry data base 2014, Emergency Unit NCCHK

DATA KUNJUNGAN PASIEN 10 KASUS TERBESAR INSTALASI GAWAT DARURAT RSJPDHK JULI – SEPTEMBER 2016 EMERGENCY DEPARTMENT- NCCHK

The case of health problems that often occur in people who may threaten the lives of sufferers are Acute Coronary Syndrome Someone who suddenly experiencing health problems, especially in life-threatening conditions, then the first thing to do is to seek help within easy reach for example seek help through the call center call center (119)

The pre-hospital emergency response system Management of pre-hospital in this case becomes very crucial, important and determines the success of subsequent treatment and a major effect on mortality The pre-hospital emergency response system

REGULATORY SYSTEM INTEGRATED EMERGENCY RESPONSE To realize the improving quality of care in the treatment emergency response at present the Ministry of Health has. Permenkes No.19 Tahun 2016 tentang Sistem Penanggulangan Gawat Darurat Terpadu. Accelerate the Emergence response time Pre hospital response system In hospital response system Interfacility response system INTEGRATED AND COMPREHENSIVE EMERGENCY RESPONSE SYSTEM

The system pre-hospital emergency response with a call center are a fundamental service in the healthcare system Nurses have an important role in the pre-hospital phase for the patients with chest pain suspected of having an acute coronary syndrome ( STEMI )

Pre-Hospital phase from the scene to EMS Patients in ED, A, B, C, Vital sign review..Triase Nursing interventions in order of priority issues Oksigen, aspirin, nitrat,morphin, IV acces Collaboration Asses and ECG monitoring Transport to hospital Pre-hospital phase EMS Quick response and transport . Asses A, B, C, vital sign Assesment focused, 12 lead of ECG

Selected Routine Medical Therapies Oxygen Start oxygen at 4 L/min In the prehospital, ED, and hospital settings, the withholding of supplementary oxygen therapy in normoxic patients with suspected or confirmed acute coronary syndrome may be considered. (Class IIb, LOE C-LD) Should administer oxygen if dypneic, hypoxemic, heart failure, arterial oxygen saturation less than 90%, or the oxygen saturation is unknown Titrate oxygen therapy

Selected Routine Medical Therapies Aspirin The recommended dose is 160 to 325 mg  Chewable or soluble Aspirin suppositories (300 mg)  with severe nausea, vomiting, or disorders of the upper gastrointestinal tract. If has not taken aspirin and has no history of true aspirin allergy and no evidence of recent GI bleeding

Selected Routine Medical Therapies Nitrogliceryn (Glyceryl Trinitrate) Ongoing symptoms and no contraindications exist Give 1 sublingual tablet (or spray “dose”) every 3 to 5 minutes until pain is relieved or low blood pressure limits indicated in the first 24 to 48 hours. Nitrates should not be given to patients with with inferior- wall MI and suspected RV MI, hypotension, marked bradycardia or tachycardia , taken a phosphodiesterase inhibitor (eg, sildenafil) for erectile dysfunction within 24 hours (48 hours if tadalafil use).

Selected Routine Medical Therapies Opiates (eg. Morphine) for chest discomfort unresponsive to nitrates The dose of morphine sulfate needed to achieve adequate pain control will vary depending on patient age, body size, BP, and heart rate

Diagnostic Interventions in ACS For patients presenting within 12 hours of symptom onset and electrocardiographic findings consistent with STEMI, reperfusion should be initiated as soon as possible – independent of the method chosen. (Class I, LOE A) The primary goal of initial treatment is early reperfusion therapy through administration of fibrinolytics (pharmacological reperfusion) or PPCI (mechanical reperfusion)

Reperfusion goals : Therapy defined by patient and centre criteria : Door-to-ballon inflation (PCI) goal of 90 minutes Door-to-needle (fibrinolysis) goal of 30 minutes

PRINCIPLES OF SUCCESS Early recognition Early acces The speed and quality of care services

STEMI Chain of Survival Door In Door Out Symptom to seek help Primary hospital/ Referral center Ambulance activation Reperfusion therapy in PCI Center

Importance “The Door in to door Out time “

“ The Door In To The Door Out ( DIDO ) Is within the time when the patient arrives at a service unit until the patient out of the service units are referred to the capable service unit. Highly recommended “the DIDO” is not less than 30 minutes.

Acute Coronary Syndromes (Risk of STEMI (Risk of fibrinolysis) Note: If presentation <3 hours and no delay for PCI, then no preference for either strategy. Fibrinolysis is generally preferred if : Early presentation (<3 hours from symptom onset) Invasive strategy is not an option (eg, lack of access to skilled PCI facility or difficult vascular access) or would be delayed Medical contact-to-balloon or door-balloon >90 minutes (Door-to-balloon) minus (door-to-needle) is >1 hour No contraindications to fibrinolysis An invasive strategy is generally preferred if : Late presentation (symptom onset >3 hours ago) Skilled PCI facility available with surgical backup Medical contact-to-balloon or door- to-balloon <90 minutes (Door-to-balloon) minus (door-to- needle) is <1 hour Contraindications to fibrinolysis, including increased risk of bleeding and ICH High risk from STEMI (CHF, Killip class is > 3) Diagnosis of STEMI is in doubt

Administration of fibrinolytics options Informed concern Rapid asses contraindications  absolute or relatives Start adjunctives therapies Aspirin loading dose is 160 mg  Chewable or soluble Clopidogrel loading dose is 300 mg Do not delay reperfusion

Administration of PPCI options Informed concern Start adjunctives therapies Aspirin loading dose is 325 mg  Chewable or soluble Clopidogrel loading dose is 600 mg Do not delay reperfusion

Summary PPCI is superior to fibrinolytic therapy in the management of STEMI The superiority of PPCI over fibrinolytic therapy is not absolute. For STEMI patients presenting to a : non–PCI capable hospital, the decision to administer fibrinolytic therapy at the initial facility as compared with immediate-transfer PPCI requires consideration of several factors including the location of the MI patient age the duration of STEMI at time of initial ED presentation, time required to complete transfer for and performance of PPCI the abilities of the PPCI cardiologist and hospital. the hemodynamic status of the patient is important; specifically, patients in cardiogenic shock are most appropriately managed with PPCI Patients with STEMI should use ambulance

REFERENCES ACC/ AHA (2015) : AHA Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 9: Acute Coronary Syndromes ACC/ AHA (2016) : Advanced Cardiovascular Life Support Provider Manual, AHA,USA ACC/ AHA (2014) : Guidelines for the Management of Patients With Non–ST- Elevation Acute Coronary Syndromes. ACC/ AHA (2013): Guidelines for the Management of ST-Elevation Myocardial Infarction Dracupss,K (1999). Intensive Cardiac Care, Lippincot William Lisa AB,Taletha Carter (2008) : Cardiovascular Care,Philadelphia Leslie Davis (2004) : Cardiovascular Nursing Secret,St Louis Moser & Riegel ( 2008 ) : Cardiac Nursing, Saunders, Canada. Mary Frans Hazinski RN, MSN & David MD (2008) : Handbook of Emergency Cardiovascular Care Sandra L et all ( 2005 ) : Cardiac Nursing, Lippincot Williams & Willkins. USA.

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