dr.

Ferdinand Wahyudi
ACUTE CORONARY SINDROME (ACS) RSUD Umbu Rara Meha
Waingapu, Sumba timur, NTT
IDENTITY
Name : HR
Date of Birth : 01 July 1932
Age : 84 y.o
Date of Admission : 01 December 2016
Time of Admission : 01.20 WITA
Address : Desa Tandula Jangga, Kec.Nggaha Ori Angu, Sumba Timur
Religion : Catholic
PRIMARY SURVEY
Circulation : Heart Rate 40 bpm, weak pulse, cold extremities
Airway : patent, no additional breath sounds
Breathing : RR 26 breathes per minute, SatO2 92%
Disability : Compos Mentis, GCS E4V5M6
Exposure : There is no wound and deformity
INITIAL TREATMENT
1. Transition to RED TRIAGE
2. O2 3 lpm nc
3. ECG  ST Elevation II,III,aVF; First Grade of AV block
4. IV-Line  Nacl 0,9% loading 500 mL
5. Draw Blood Sample
6. GDS Stick  89
ECG
 SECONDARY SURVEY (1)
Chief Compliant
Heartburn and vomiting more than 5 times for the last 6 hours

History of Present Illness

HR, 82 y.o man presents to the ED with heartburn and vomiting 6 hours before
admission. Patient felt burning sensation in his chest radiated to the throat and around
the neck for approximately 30 minutes. He felt weak, shortness of breath, loss of
appetite and began to sweat, he vomitted 5 times, vomitus was yellowish. Abdominal
pain and diarrhea were denied, He experienced a productive cough since 2 days
before admission, he has never had similar complaints and has no history of cardiac
disease.
SECONDARY SURVEY (2)
Past Medical History
Patient never checked his health, never hospitalized. A history of hypertension,
diabetes, cholesterol denied.
Drug and Treatment History
No significant drug history
Family History
There is no similar complaints in the family
Social History
Chronic smoker
No history of drinking
PHYSICAL EXAMINATION (1)
CM; GCS 15/15, patient’s alert and responsive
Vital Sign:
BP : 90/60 mmHg
HR : 40 beat per minute; regular
RR : 26 breathes per minute
Temp : 36,5oC
 PHYSICAL EXAMINATION (2)
Head Conjungtiva is not pale , Sclera is not jaundice
Neck JVP is in normal range, there was no carotid bruit present

Thorax Inspection:
On inspection, there is no deformity, no dilated vein, no surgical scar, and no visible
pulsation.
Palpation:
The apex beat is not palpable. There was no parasternal heave. Thrills were also absent.
Auscultation:
S1 and S2 were heard. There was no radiation, no murmur, no rubs and no
additional sounds. S3 and S4 were not heard..
Lung: Ves +/+, Rh +/+, Wh -/-
Abdomen •Epigastric tenderness (+), normal bowel sounds, Liver not palpable, spleen not palpable,
ascites not present

Extremitas Edema (-)

Genital Not Available

Kulit No remarkable findings

DIFFERENTIAL DIAGNOSIS
1. Inferior STEMI Killip I  Impending Syok
2. Community Aquired Pneumonia
INVESTIGATIONS - ECG
INVESTIGATIONS
ECG: Complete Blood Count
Hb : 14,1g/dL
Done within 10 mins of patient arrival Ht : 39,9%
Findings: Leu(/mm3 ) :11.100
Tromb(/mm3 ):440.000
Rate: 52
Electrolite
Rhythm: Sinus Rhythm
ST Segment Elevation in II, III and AvF Na 136 mol/L
Prolonged PR Interval K 3,5 mol/L
 Cardiac biomarkers Cl 101 mol/L
Not Available
INVESTIGATIONS
Lipid Profile Chest Xray
Total Cholesterol 260 mg/dl Cardiothoracic ratio increased showing LV
Dilatation
LDL 160 mg/dl
Infiltrate (+)
HDL 40 mg/dl
Sharp costophrenic angles
Ureum 40 mg/dl
creatinin 0,7 mg/dl
MANAGEMENT
Patient was immediately admitted in ICU. Within 10 mins, ECG was performed
and based upon diagnosis, following treatment was given.

Oxygen + Cardiac rhythm monitoring

MANAGEMENT
There is no no hospital with a PCI facility that can Inj Metocloperamide 10mg/8 h IV
be reached in under 2 hours
Inj Cefotaxim 1gr/12 h IV
There is no fibrinolytic agent available
Inj Heparin bolus 4000 unit IV, mainteneance
Nacl 0,9% loading 1000 mL, mainteneance 40 500unit/h sp IV
tpm IVFD
Dulcolax 1x10 mg po
02 3lpm nc
Alprazolam 1x0,5 mg po
Aspilet – clopidogrel loading 4 tab po
Insersi DC Catheter
Simvastatin 1x10 mg po
patient refused to be referred to a hospital in Bali
Inj SA 1 amp IV extra for economic reasons
LATE MANAGEMENT
Secondary Drug therapy:
Ace Inhibitor/ARB
Statin
FOLLOW-UP I
Wednesday, 01 December 2016
05.30 WITA Px apnoe, pulseless, monitor showed asystol
Tx : CPR + Bagging for 2 minutes, patient was intubated
05.32 WITA Asystol
Tx :Inj epinephrine 1 amp IV, CPR+ Bagging
05.34 Pulse palpable, spontaneous breath, (ROSC)
05.36 pulseless, no spontaneous breath,
Tx : CPR+Bagging, Inj epinephrine 1 amp IV
05.56 after performed CPR for 20 minutes, monitor showed asystol, maximum dilatation of the
pupil, Dolls eye (+), patient was declared dead.