Phác đồ cấp cứu tim mạch năm 2016

Trang

1.

`

3

2.

4

3.

5

4. Vô Tâm thu

có

6

5.

7

6.

8

7.

10

8.

13

9.

á

14

10.

Không ST Chênh Lên

15

11.

có ST chênh lên

17

12.

19

13.

21

14. Bóc Tách

24

15. Thuyên t

P

25

16. Chèn ép

27

17.

28

18.

30

19.

32

2

1-4

A-B-

-A-B

-

rung

phút

Không quá 6cm

100-120/ph
Không quá 140/ph
.
-

1.
2.
3.
4.

AHA Guidelines for CPR and ECC 2010. Circulation 2010 ;122;S640-S656.
International Consensus on CPR and ECC 2010. Circulation 2010.
2015 AHA Guidelines Update for CPR and ECC. Circulation. 2015;132(suppl 2):S414 S435.
2015 International Consensus on CPR and ECC Science With Treatment Recommendations. Circulation. 2015;132(suppl

1):S51 S83.

3


1,2

2

monitor/phá rung
Có

Không

RT/

VTT

HSTP 2 phút

Không

Có

HSTP 2 phút

HSTP 2 phút

Epinephrine/3-5ph
Epinephrine/3-5ph

Không

Có

Có
Không

HSTP 2 phút

HSTP 2 phút

Amiodarone

Không

1.
2.

Có

2015 AHA Guidelines Update for CPR and ECC. Circulation. 2015; 132(suppl 2):S444 S464.
2015 International Consensus on CPR and ECC Science With Treatment Recommendations. Circulation. 2015;132(suppl):S84
S145.
4


1,2

-

HSTP theo CAB

/200J*

HSTP 2ph (

)

1

Vô tâm thu
RT/NT

-

2ph

-

EPINEPHRINE 1mg/3-5 phút

AMIODARONE 300mg TM, 150mg TM sau 10-15ph
LIDOCAIN 1MAGNESIUM SULFATE 1-

1

1.
2.
3.

*

J

AHA Guidelines for CPR and ECC 2010. Circulation 2010 ;122;S640-S656.
International Consensus on CPR and ECC 2010. Circulation 2010.
2015 AHA Guidelines Update for CPR and ECC. Circulation. 2015; 132(suppl 2):S444 S464.
5


1-4

VÔ TÂM THU
Vô Tâm thu=

-Hypoxia
-Q
-

1

1.
2.
3.
4.

ADRENALINE 1 mg TM/ 3-5 phút

1

2010 AHA Guidelines for CPR and ECC. Circulation 2010 ;122;S640-S656.
2010 International Consensus on CPR and ECC. Circulation 2010.
2015 AHA Guidelines Update for CPR and ECC. Circulation. 2015; 132(suppl 2):S444 S464.
2015 International Consensus on CPR and ECC Science With Treatment Recommendations. Circulation. 2015;132(suppl
1):S84 S145.

6


1

LÂM SÀNG:

:

Monitoring ECG, HA, SpO2

Theo dõi
Dùng atropine trong

Toan máu
công

Chèn ép tim
Tràn khí màng

1.

TM

John M. Field et al. AHA Guidelines for CPR and ECC 2010. Circulation 2010 ;122;S640-S656

7


1-7
LÂM SÀNG:
ECG:
200 / ph.
220 / ph.

Monitoring ECG, HA, SpO2

TS tim <150/ph

HC chuyên khoa

Làm NP Valsalva
adenosine
-HC chuyên khoa
-

-amiodarone
N
dùng adenosin

không

-HC chuyên khoa

-không dùng adenosine,
digoxin, dilatiazem,
verapamil
-dùng amiodaron

NNKPTT không
,

thì
adenosine

, verapamil

magnesium

8


-2ph
VERAPAMIL TM
2,5PROPRANONOL TM
AMIODARONE TM

-

-

, sau
Ghi chú:
VERAPAMIL TM

2,5PROPRANONOL TM
AMIODARONE TM
150mg trong 10ph
MAGNESIUM SULFATE TM:
2-3g trong 2-3ph
1.
2.
3.
4.
5.
6.
7.

0.5mg/ph trong 18 gi

.

-

2015 AHA Guidelines Update for CPR and ECC. Circulation. 2015; 132(suppl 2):S444 S464.
2015 International Consensus on CPR and ECC Science With Treatment Recommendations. Circulation. 2015;132(suppl
1):S84 S145.
AHA Guidelines for CPR and ECC 2010. Circulation 2010 ;122;S640-S656
International Consensus on CPR and ECC 2010. Circulation 2010
Etienne Y, Blanc JJ, Boschat J, Le Potier J, Jobic Y, Le Grand O, Penther P. Anti-arrhythmic effects of intravenous magnesium
sulfate in paroxysmal supraventricular tachycardia. Am J Cardiol. 1992 Oct 1;70(9):879-85.
Joshi PP, Deshmukh PK, Salkar RG. Efficacy of intravenous magnesium sulphate in supraventricular tachyarrhythmias. J Assoc
Physycians India. 1995 Aug; 43(8):529-31.
2015 ACC AHA HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. J Am Coll Cardiol.
2015.

9


1-6

áp ngay
-

nv (HATT>180mmHg, HATTr>120mmHg)
trong 24quá nhanh

Dùng

,
-

-60 phút.
ông gây kém

,
V

không <120-125mmHg và HATTr không <70-75mmHg.
-

B
:
HATB<80mmHg

.

benzodiazepine
esmolol, nicardipine và fenoldopam

:
10


:
bn HA quá cao

15% trong 24h sau

não.
:

),

Tron

HATT <160mmHg
và làm loãng máu
-15mmHg

NMN và HA
ALTM

0mmHg
60 TT, <110 TTr

labetalol, methyldopa, nicardipine/nifedipine
NICARDIPINE TTM 3-

HA TTR=100 110 mmHg
100 mg.
50 mg.
50 mg.

thiazid, indapamide...
11


fedipine LA/LP, Diltiazem SR/LP, Cilnidipin...

Propranolol...
N
Hydralazine...
-

1.
2.
3.

4.

5.
6.

Philip B. Gorelick, Venkatesh Aiyagari. The management of Hypertension for an Acute Stroke: What is the Blood Pressure
Goal?. Curr Cardiol Rep 2013. 15:366

Edward C. Jauch, MD, MS, FAHA, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870 947
American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy.
Report of the American College of Obstetricians and Gy
2013;122(5):1122 31.
Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter, PharmD; William C. Cushman, MD; 2014 Evidence-Based Guideline
for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National
Committee (JNC 8). JAMA 2013.284427 Published online December 18, 2013.
D. P. Papadopoulos et al. Cardiovascular Hypertensive Emergencies. Curr Hypertens Rep (2015) 17: 5
Courtney Olson-Chen, MD, Neil S. Seligman, MD, MS. Hypertensive Emergencies in Pregnancy. Crit Care Clin 32 (2016) 29
41

12


1-8

02 4-

2

>90%

Có
Không

HATT >=100mmHg

HATT <100mmHg, có kém TMNB

HATT>80mmHg: dobutamin TTM
2Nitroglycerin NDL 0,4mg /3-5ph
h
3-5ph
00mcg/ph (400mcg/ph)
25-50mg

Furosemide TM 1mg/Kg/15-20ph
Thêm (n
:
Không nên dùng morphine
Diazepam, Midazolam 2,5-5mg TM

3-5ph

(

)

HATT<80mmHg: noradrenalin TTM
0,5<30mcg/p
Khi HATT >=100mmHg

thêm
dobutamin
(sau 30-45 ph):

1.
2.
3.

4.
5.
6.
7.
8.

Richard L. Summers and Sarah Sterling.Early Emergency Management of Acute Decompensated Heart Failure. Curr Opin Crit Care 2012,
18:301-307.
G. Michael Felker and John R. Teerlink. Diagnosis and Management of Acute Heart Failure. Braunwald's Heart Disease. A Textbook of
Cardiovascular Medicine, 10th ed 2015.
Jeremy M. Johnson, MS, RN, CEN, CCRN. Management of Acute Cardiogenic Pulmonary Edema. A Literature Review. Advanced Emergency
Nursing Journal. 2009. Vol. 31, No. 1, pp. 36 43.
John Bosomworth, MD et al. Rural treatment of acute cardiogenic pulmonary edema: applying the evidence to achieve success with failure.
Can J Rural Med 2008; 13 (3)
Levy P, et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis.
Ann Emerg Med 2007; 50(2): 144-152.
Javier Mariani, MD et al. Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema: A Meta-Analysis of Randomized Controlled trials.
Journal of Cardiac Failure Vol. 17 No. 10 2011
Pieter Martens, Petra Nijst, Wilfried Mullens. Current Approach to Decongestive Therapy in Acute Heart Failure. Curr Heart Fail Rep (2015)
12:367 378
Peacock WF et al. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emergency Med J 2008; 25: 205-209.

13


1-5

LÂM SÀNG:

-0,5mL/Kg/h)

2

ECG, X-

(

-Ganz)

Theo dõi oxy qua da
+

, Mg++, toan máu
/Prasugrel/clopidogrel cho NMCTC

NATRI CLORUA O,9% 250

HA tâm thu = 80
DOBUTAMINE TTM 2 15 ( 40)mcg/Kg/ph

1-

NORADRENALINE TTM 0,05 - 1 mcg/Kg/ph
:
ADRENALINE TTM 0,05 - 0.5 mcg/Kg/ph (tb=0,2 mcg/Kg/ph)
(
1.
2.
3.
4.

5.
6.

(tb=0.5-30mcg/ph),

)

Richard L. Summers and Sarah Sterling.Early Emergency Management of Acute Decompensated Heart Failure. Curr Opin Crit Care 2012,
18:301-307.
G. Michael Felker and John R. Teerlink. Diagnosis and Management of Acute Heart Failure. Braunwald's Heart Disease. A Textbook of
Cardiovascular Medicine, 10th ed 2015.
Vasopressor and Inotrope Usage in Shock. www.surgicalcriticalcare.net. Approved 04/19/2011.
Holger Thiele, M.D et al. Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock. N Engl J Med 2012; 367:1287-1296
Daniel De Backer, M.D et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. N Engl J Med 2010;362:779-89.
Carl V Leier, Garrie J Haas, Philip F Binkley. Positive Inotropic Drugs: A Limited but Important Role. Cardiac Drugs. 2013

14


KHÔNG ST CHÊNH LÊN1-7

LÂM SÀNG:

có

ECG:

30ng)
)

Troponin I và T và CK-MB
Troponin và CKTroponin và CK-

(Troponin hs
:

-1h
-

Theo dõi

Monitoring ECG
Nitroglycerine/isosorbide dinitrate
-10mcg
200mcg/ph) trong 48h
Morphine sulphate
Aspirin
162-

-T

-20mc
-

-15ph
),
15

.

Ticagrelor:
Prasugrel:
Clopidogrel:

Enoxaparin

Bivalirudin:
Fondaparinus:

-

-70s) trong 48h,

c
: dùng cho
-50mg/ng x 2/ng
các

Không dùng khi HATT < 100mmHg
Captopril: 6,25-

3/ng

hay EF

Statine:
Atorvastatin: 80mg/ng
Rosuvastatin: 20mg/ng

Ezetimibe/simvastatin 10/40mg

PCI/CABG (Không

khi:
)
16


Có

1.

2.
3.
4.
5.

6.

7.
8.
9.

Ezra A. Amsterdam, Nanette K. Wenger, Ralph G. Brindis, Donald E. Casey, Jr., Theodore G. Association Task Force on
Practice Guidelines Coronary Syndromes: A Report of the American College of ardiology/American Heart 2014 AHA/ACC
Guideline for the Management of Patients With Non-ST-Elevation Acute. Circulation. published online September 23, 2014.
Christian W. Hamm et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without
persistent ST-segment elevation. European Heart Journal (2011) 32, 2999 3054.
Paul A. James, MD et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From

the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520
Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline. Circulation. 2013;00:000 000.
Bellemain-P, Jacq L, Bernasconi F,
Montalescot G. Association of Clopidogrel Pretreatment With Mortality, Cardiovascular Events, and Major Bleeding Among
Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis. JAMA J Am Med Assoc.
2012;308:2507 2516.
Montalescot G, Bolognese L, Dudek D, Goldstein P, Hamm C, Tanguay J-F, Ten Berg JM, Miller DL, Costigan TM, Goedicke J,
Silvain J, Angioli P, Legutko J, Niethammer M, Motovska Z, Jakubowski JA, Cayla G, Visconti LO, Vicaut E, Widimsky P, the
ACCOAST Investigators. Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med
2013;369:999 1010
Marco Roffi et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without
persistent ST-segment elevation. European Heart Journal 2015 doi:10.1093/eurheartj/ehv320.
Antonio Eduardo P. Pesaro. Reduction of ischemic events in IMPROVE-IT: Intensive cholesterol lowering or ezetimibe
antithrombotic effects? American Heart Journal (2015), doi: 10.1016/j.ahj.2015.11.001
Sabina A. Murphy et al. Reduction in Total Cardiovascular Events With Ezetimibe/Simvastatin Post-Acute Coronary Syndrome.
The IMPROVE-IT Trial. J Am Coll Cardiol 2016;67:353 61

17


1-4

LÂM SÀNG:

ECG
i

-V3 và

t

)
-V4 = NMCTC thành sau
ST chênh lên aVR và V1
-

-T

Monitoring ECG
(xem phác
Nitroglycerine/isosorbide dinitrate:
-10mc

-20mcg

.

Morphine sulphate:
2-15ph
Aspirin
Aspirin 162-325 (150-

-100)mg,

Ticagrelor:
Prasugrel:

18


Clopidogrel:

BN không làm PCI:

làm PCI
-

-70s)

Enoxaparin

Bn suy

-50mg/6-12h, sau 2Carv

k
Captopril: 6,25Lisinopril:2,5-

.
Statin:
Rosuvastatin 20mg/ng
Ezetimibe/simvastatin 10/40mg
1.
2.
3.
4.

Patrick T. O'Gara et al. ACC/AHA Guidelines 2013 for the Management of Patients With ST-Elevation Myocardial Infarction. J
Am Coll Cardiol. 2013;61(4):e78-e140.
Ph. Gabriel Steg et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation. European Heart Journal (2012) 33, 2569 2619
Antonio Eduardo P. Pesaro. Reduction of ischemic events in IMPROVE-IT: Intensive cholesterol lowering or ezetimibe
antithrombotic effects? American Heart Journal (2015), doi: 10.1016/j.ahj.2015.11.001

Sabina A. Murphy et al. Reduction in Total Cardiovascular Events With Ezetimibe/Simvastatin Post-Acute Coronary Syndrome.
The IMPROVE-IT Trial. J Am Coll Cardiol 2016;67:353 61

19


1-4

LÂM SÀNG:
ECG: S

V5R, V1, V2, V3, II, III, aVF/(V7-

-

-T

Monitoring ECG
Nitroglycerine/isosorbide dinitrate:
-

-

Morphine sulphate:
2Aspirin
162-

-15ph
-

Ticagrelor:
Prasugrel:
,h
Clopidogrel:
Bn không làm PCI
75mg/ng

o aPTT 1.5-

-

Enoxaparin

Metoprolol tartrate

-50mg/6-12h, sau 220


Statin:
Rosuvastatin 20mg/ng
Ezetimibe/simvastatin 10/40mg

NATRICLORUA 0,9% TTM nhanh 500-1000ml

DOBUTAMINE TTM
NOREPINEPHRINE TTM

-1000

:

ATROPINE
DOPAMINE
ADRENALINE

1.
2.
3.
4.

Patrick T. O'Gara et al. ACC/AHA Guidelines 2013 for the Management of Patients With ST-Elevation Myocardial Infarction. J
Am Coll Cardiol. 2013;61(4):e78-e140.
Ph. Gabriel Steg et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation. European Heart Journal (2012) 33, 2569 2619
Antonio Eduardo P. Pesaro. Reduction of ischemic events in IMPROVE-IT: Intensive cholesterol lowering or ezetimibe
antithrombotic effects? American Heart Journal (2015), doi: 10.1016/j.ahj.2015.11.001
Sabina A. Murphy et al. Reduction in Total Cardiovascular Events With Ezetimibe/Simvastatin Post-Acute Coronary Syndrome.
The IMPROVE-IT Trial. J Am Coll Cardiol 2016;67:353 61

21


1-3

-V3 và
Sóng Q
)
-V4: NMCTC thành sau
-

Lúc
Chú ý

C

Bóng

PC

(B)
(B)
-

Aspirin 16212

Ticagrelor 180 mg
Prasugrel 60 mg
Clopidogrel 600 mg
12

Ticagrelor 90 mg X 2/ng
Prasugrel 10 mg/ng
Clopidogrel 75 mg/ng
aPTT 1.5-

-

70s)
22


Bivalirudin cùng hay ko cùng UFH

-

NMN trong vòng 3th

Có thai

Alteplase (rt> 60ph sau.
-60ph
Aspirin:
162-325mg l
81Clopidogrel:

23


-

50-70s) trong 48h

Enoxaparin:

Dùng trong
Fondaparinux:

-

1.
2.
3.

Patrick T. O'Gara et al. ACC/AHA Guidelines 2013 for the Management of Patients With ST-Elevation Myocardial Infarction. J
Am Coll Cardiol. 2013;61(4):e78-e140.
Ph. Gabriel Steg et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation. European Heart Journal (2012) 33, 2569 2619
2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal (2014) 35, 2541 2619

24


1-5

LÂM SÀNG:

LDH, CPK, CKX-

:
Týp A:

~60% :
tim

Týp B:

~40%

cao
HATT 100-

-70mmHg, và TS tim <70/ph

nicardipine
NICARDIPINE TTM 3-

ê

ùng

/
1.
2.
3.
4.
5.

Jip L. Tolenaar, MD et al. Update in the Management of Aortic Dissection. Current Treatment Options in Cardiovascular
Medicine 2013. DOI 10.1007/s11936-012-0226-1.
Christoph A. Nienaber et al. Management of acute aortic syndromes. European Heart Journal; 2012. 33:26 35.
Venu Menon et al. Optimal Management of Acute Aortic Dissection. Current Treatment Options in Cardiovascular Medicine
2009, 11:146 155.
Vinay Garga, Maral Ouzounianb, and Mark D. Peterson. Advances in aortic disease management: a year in review. Curr Opin
Cardiol 2016, 31:127 131
David M. Dudzinski1 & Eric M. Isselbacher. Diagnosis and Management of Thoracic Aortic Disease. Curr Cardiol Rep (2015) 17:
106

25


1-7

LÂM SÀNG:

(massive PE)
: HATT <
(nonmassive PE)
TTP trung bình, submassive PE
và ko có

-Q3-T3
X-

-

a
: TM 80
:
ENOXAPARINE, TDD 1mg/Kg

FONDAPARINUX, TDD 7,5mg/Kg (50-100Kg), 5mg/Kg (<50Kg), 10mg/Kg (>100Kg)

NATRICLORUA 0,9 % TTM.
DOBUTAMIN TTM 2 20 mcg/Kg/ph.

Khi ALTMT cao (>12có RLCNTP n ng, d
dùng
.
NORADRENALI
30 mcg/ph
DOBUTAMIN TTM 2 20 mcg/Kg/ ph.

ng, và nên

26