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DASAR PENANGANAN PENDERITA GAWAT
BASIC GENERAL EMERGENCYLIFE SUPPORT (B GELS)
TIM GELS
LAB./SMLAB./SMF Anestesiologi dan Reanimasi F Anestesiologi dan Reanimasi RSURSUP Dr. Hasan Sadikin BandungP Dr. Hasan Sadikin Bandung
T P U T P U
Peserta mampu menangani penderita gawat darurat dengan baik dan benar
T P K T P K
Peserta mampu :1. Mengenal penderita gawat darurat2. Mengetahui macam-macam penyebab kegawat daruratan3. Memahami sistematika penanganan penderita gawat darurat4. Mendiagnosa kegawatan jalan nafas / airway5. Menangani kegawatan jalan nafas / airway6. Mendiagnosa kegawatan nafas / breathing7. Menangani kegawatan nafas / breathing8. Memberikan terapi oksigen9. Mendiagnosa gangguan sirkulasi10. Menangani gangguan sirkulasi11. Mendiagnosa gangguan kesadaran12. Menangani gangguan kesadaran
Penderita Gawat DaruratPenderita Gawat Darurat
Penderita yang oleh karena suatu penyebab(penyakit, tindakan, kecelakaan) bila tidak segera ditolong akan cacat, kehilangan anggota tubuh atau meninggal
Silent epidemicSilent epidemic
Mass-casualties small scale disasterMass-casualties small scale disaster
Kecelakaan kereta api Man-made disasterMan-made disaster
Complex disasterComplex disaster
Complex disaster
Kerusuhan
Natural disasterNatural disaster
Triage dan evakuasiSiapa didahulukan dan siapa dikirim ke mana
Triage dan evakuasiSiapa didahulukan dan siapa dikirim ke mana
4 korban Ratusan korban
BILA TERJADI HENTI NAFAS DAN HENTI JANTUNGBILA TERJADI HENTI NAFAS DAN HENTI JANTUNG
Keterlambatan
1 menit
4 menit
10 menit
Kemungkinan berhasil
98 / 100
50 / 100
1 / 100
CHAIN OF SURVIVALCHAIN OF SURVIVAL
Early Activation of EMS
Early Basic of CPR
Early Defibrillation
Early Advanced Life Support
PENDERITA GAWAT DARURATPENDERITA GAWAT DARURAT
HIPOKSEMIAHIPERKARBIAHIPOKSEMIAHIPERKARBIA
HENTI JANTUNGHENTI NAFAS
HENTI JANTUNGHENTI NAFAS
SINDROMA IWRSINDROMA IWR
CONCEPTCONCEPT
• ABCDE – approach to evaluation / treatment
• Treat greatest threat to life first
• Definitive diagnosis not immediately important
• Time is of the essence
• Do no further harm
INITIAL ASSESSMENT / MANAGEMENTINITIAL ASSESSMENT / MANAGEMENT
Injury
Primary survey and adjuncts
Resuscitation
Reevaluation
Secondary survey and adjuncts
Reevaluation
Optimize patient status
Transfer
Primary survey and resuscitationof vital functions are done
simultaneously – a team approach
PENANGANAN PASIEN TIDAK GAWATPENANGANAN PASIEN TIDAK GAWAT
• Anamnesa• Pemeriksaan fisik
Inspeksi Palpasi Perkusi Auskultasi
• Pemeriksaan penunjang• Diagnosa• Terapi
Supportif Simtomatis Definitif / kausal
PENANGANAN PASIEN GAWAT DARURATPENANGANAN PASIEN GAWAT DARURAT
• Pem. Fisik awal (A-B-C-D) (Primary survey) + Lab. Awal
• Terapi suportif / resusitasi (life support)
Stabilisasi
• Pem. Fisik sekunder (Secondary survey) Anamnesa Dari kepala s/d kaki (B1 s/d B6)
• Pemeriksaan penunjang
• Diagnosa
• Terapi defenitif
CPCR / RJPO (Peter Safar)CPCR / RJPO (Peter Safar)
1. Basic life support emergency oxygenationA : AirwayB : BreatheC : Circulate
2. Advanced life support Restoration of spontaneous circulation
D : Drugs and FluidsE : EKGF : Fibrillations treatment
3. Prolonged life support post resuscitation brain – oriented therapy
G : GaugingH : Human mentationI : Intensive care
KONSEP ATLSKONSEP ATLS
• Primary SurveyA : Airway with C-spine controlB : Breathing with ventilationC : Circulation with hemorrhage controlD : Disability : neurologic statusE : Exposure/environment with temperature control
• Resuscitation
• Secondary SurveyHead – to – toe evaluation and history
• Reevaluation
• Definitive care
KEY POINTS ACLSKEY POINTS ACLS
In the Primary Survey, focus on basic CPR anddefibrillation
First A-B-C-D• Airway :
Open the airway• Breathing :
Provide positive – pressure ventilations• Circulation :
Give chest compressions• Defibrillation:
Shock ventricular fibrillation or pulselessventricular tachycardia (VF/VT)
KEY POINTS ACLSKEY POINTS ACLS
In the Secondary Survey, focus on intubation, intravenous (IV) access, and drugs and why the cardiorespiratory arrest occurred
Second A-B-C-D• Airway :
Perform endotracheal intubation• Breathing :
Assess bilateral chest rise and ventilation• Circulation :
Gain IV access, determine rhythm, give appropriate agents
• Defibrillation Diagnosis (Think): Search for, find, and treat reversible causes
PPGD (Penanggulangan penderita gawat darurat) Dokter umum
BLSALS
PLS
NLS
ACLS HIGH RISKHIGH FREQUENCYHIGH SUCCESSPROCEDURE
- PRIMARY PREVENTION- SECONDARY PREVENTION
LOCAL SPECIFIC- MALARIA- DHF- GE
BLS : Basic life support (A, B, C, BRAIN)ALS : Advance life supportATLS : Advance trauma life support (Trauma oriented L.S)ACLS : Advance cardiac life support (Cardiac oriented L.S.)NLS : Neonatal life supportPLS : Pediatric life supportOLS : Obstetric life support
PTC
OLSPTC : Primary trauma careA : AirwayB : BreathingC : CirculationDsan: Dokter spesialis Anestesi
PENANGGULANGAN PENDERITA GAWAT DARURATBasic General Emergency Life Support (GELS)
ATLS
LIFE SUPPORTLIFE SUPPORT
A : Airway Support
B : Breathing Support
C : Circulation Support
D : Disability / Brain Support
First responder
Life saver
Resusitasi – stabilisasi
AirwayBreathingCirculationBrain
SHOCKKARENA
PERDARAHAN1
2
3
ResusitasiStabilisasi
Definitif terapiawal
Definitif terapiakhir
Dr. Penyakit Perdarahan Dalam G.I.
Dr. Bedah
Perdarahantrauma
Dr. Obgyn
Perdarahan post partum
Dr.Umum
Dr.Spesislias
Pembagian Peran Dr. Umum – Dr. Spesialis
PROTECTION FROM COMMUNICABLE DISEASEPROTECTION FROM COMMUNICABLE DISEASE
• Water impermeable apron• Gown• Gloves• Face mask• Cap• Eye protection / goggles• Foot covers
To prevent contact with body fluids patientsTo prevent contact with body fluids patients
T P UT P U
Peserta mampu melakukan pengelolaan jalan nafas.
T P KT P K
Peserta mampu :-Mendiagnosa sumbatan jalan nafas/airway-Mengetahui penyebab sumbatan jalan nafas/airway-Mengelola sumbatan jalan nafas - tanpa alat - dengan alat
A (AIRWAY)A (AIRWAY)
PRIORITAS UTAMAPRIORITAS UTAMA
• Airway Bebas dan terjaga
• Breathing / ventilationAdekuat
• Supplemen oxygenAdekuat
PRIMARY SURVEYPRIMARY SURVEY
Establish patent airway
Caution sign :
Cervical spine injury
PRIMARY SURVEYPRIMARY SURVEY
Assume C-Spine Injury
• Multisystem trauma
• Altered level of consciousness
• Blunt injury above clavicle
SUMBATAN JALAN NAFASSUMBATAN JALAN NAFAS
Penyebab• Penurunan kesadaran
Tindakan anestesi Koma Trauma kepala Radang otak Obat / alkohol dll
• Suatu penyakit Laringitis Edema laring
………sumbatan jalan nafas………sumbatan jalan nafas
• Trauma / Kecelakaan Maksilofacial Jalan nafas dll
• Benda asing Darah Muntahan Makanan dll
• Macam Parsial
RinganBerat
Total
………sumbatan jalan nafas………sumbatan jalan nafas
SUATU SEBAB
PENDERITATAK SADAR
RELAKSASIOTOT
HILANG REFLEKSPERLINDUNGAN
LIDAH “KLEP”
SUMBATANJALAN NAFAS
MUNTAHREGURGITASI
ASPIRASI
SUMBATAN JALAN NAFASSUMBATAN JALAN NAFAS
• Look / Lihat Perubahan Status Mental
Agitasi / gelisah HipoksemiaObtundasi / teler Hiperkarbia
Gerak NafasNormalSee saw / rocking
Retraksi Deformitas Debris
Darah / sekretMuntahanGigi
Sianosis
SUMBATAN JALAN NAFASSUMBATAN JALAN NAFAS
• Listen / Dengar Bicara normal Tak ada sumbatan Ada suara tambahan
Snoring LidahGurgling CairanStridor / crowing Penyempitan
Suara parau (hoarseness / dysphonia)
• Feel / Raba Hawa nafas Krepitasi / fraktur (maxillofacial / laryngeal) Deviasi trakhea Hematoma Getaran di leher
MACAM SUMBATANMACAM SUMBATAN
SUMBATAN
BEBAS
PARSIAL RINGAN
PARSIAL BERAT
TOTAL
LOOK
GERAKNAFAS
NORMAL
NORMAL
SEE SAW
SEE SAW
LISTEN
SUARATAMBAHAN
⊝
⊕
⊕
⊝
FEEL
HAWAEKSHALASI
⊕
⊕
+
⊝
PENGELOLAAN PERLU :CEPAT, TEPAT, CERMAT
PENGELOLAAN PERLU :CEPAT, TEPAT, CERMAT
Sumbatan Total :
• FRC (Functional Residual Capacity) : 2500 ml
• Kadar O2 15% x 2500 ml : 375 ml
• Kebutuhan O2 permenit : 250 ml
• Bila ada sumbatan total O2 dalam paru habis dalam : 375 / 250 : 1,5 menit
PENYEBAB SUMBATANPENYEBAB SUMBATAN
• Lidah
• Epiglotis
• Benda asing / muntahan / darah / sekret
• Trauma jalan nafas
PEMBEBASAN JALAN NAFASPEMBEBASAN JALAN NAFAS
PENYEBAB LIDAH• Manual :
- Non trauma :Head tiltNeck liftChin liftJaw thrust
- Trauma :Chin liftJaw thrust
Dengan in-line manual immobilization” ataupasang cervical collar
• Bantuan Alat- Oropharyngeal airway- Nasopharyngeal airway
Pada pasien traumaPada pasien trauma
head tilt
neck lift
Don’t do Be carefulneck lift
chin lift
JAW THRUST
dianjurkan
JAW THRUST
dianjurkan
Oro-pharyngeal tubeOro-pharyngeal tube
Perhatikan ukuran
1 2
3 4
OROFARINGEAL TUBE
Naso-pharyngeal tubeNaso-pharyngeal tube
Tidak merangsang muntahUkuran u/ dewasa 7 mm atau jari kelingking kanan
Nasopharyngeal tube
NASOFARINGEAL TUBE
NASOFARINGEAL TUBE
PEMBEBASAN JALAN NAFASPEMBEBASAN JALAN NAFAS
PENYEBAB BENDA ASING• Manual
• Penghisap • Definitive airway
• Pada chocking : Back blows Abdominal thrust (Heimlich manuver) Thoracal thrust Cricothyroidotomy
Lima kali hentakanpada punggung,diantara dua scapula
CHOKING
Back blows
CHOKING
HeimlichAbdominal trust
Korban : sadar
Korban : Tidak sadar
Heimlich Abdominal trust
DEFINITIVE AIRWAY
• Cuffed tube in trachea
• Secure airway
• Ventilation
• Types :- Endotracheal intubation- Surgical airway - Cricothyrotomy
- Tracheotomy
Membrana cricothyroid
Pada keadaan gawat darurat
- Tempat injeksi transtracheal obat emergency
- Tempat untuk needle dan surgical
cricothyroidotomi
Bagaimana caranya ??Obat apa saja boleh masuk ??
DEFINITIVE AIRWAYDEFINITIVE AIRWAYIndications
1. Apnea
2. Risk of aspiration
3. Insecure airway
4. Poor oxygenation
5. Impending airway compromise
7. Closed head injury
TUJUAN INTUBASI ENDOTRAKHEALTUJUAN INTUBASI ENDOTRAKHEAL
1. Sebagai jalan nafas
2. Untuk oksigenasi
3. Untuk pemberian ventilasi
4. Mencegah aspirasi
5. Jalan pemberian obat (intra trakheal)
6. Bronchial toilet
MACAM INTUBASI ENDOTRAKHEALMACAM INTUBASI ENDOTRAKHEAL
• Orotrakehal Lewat mulut• Nasotrakheal Lewat hidung
ENDOTRACHEAL INTUBATIONENDOTRACHEAL INTUBATION
The trachea should be intubated by properly
trained personnel
PERALATAN INTUBASI ENDOTRAKHEHALPERALATAN INTUBASI ENDOTRAKHEHAL
• Laryngoscope dengan blade yang sesuai• Tube dengan ukuran yang sesuai• Jelly• Anestetik lokal / spray• Forceps – magill• Bite block / oropharyngeal airway• Adhesive tape / tali• Suction – metal yang kauer• Connectors• Synringe (20 cc)• Stylet• Stetoscope• End tidal CO2 monitor
INTUBASI
INTUBASI ENDOTRAKHEALINTUBASI ENDOTRAKHEAL
• Oksigenasi + ventilasi (5 menit)
• Alat dan obat siap
• Harus berhasil kurang 30 detik
• Bila > 30 detik belum berhasil oksigenasi + ventilasi ulang
• Penolong tak kuat tahan nafas
• Saturasi O2 menurun
• Monitoring :
Saturasi O2 (Pulse oxymeter)
End-tidal CO2 (Capnografi)
PEDIATRICPEDIATRIC
Airway Anatomy• Craniofacial diproportion• Large occiput cervical flexion• Obligate nasal breather• Narrow nasal passages• Small oral cavity• Large tongue• Adeno tonsillar hypertrophy• Horseshoe shaped epiglotis• Larynx anterior – cauded angle• Trachea short
T P UT P U
Peserta mampu menangani kegawatan nafas/breathing
T P KT P K
Peserta mampu :-Mendiagnosa kegawatan nafas-Mengetahui penyebab kegawatan nafas-Mengelola kegawatan nafas - tanpa alat - dengan alat
B (BREATHING)B (BREATHING)
GANGGUAN VENTILASIGANGGUAN VENTILASI
Penyebab• Tindakan anestesi• Penyakit• Kecelakaan trauma
Lokasi• Sentral
Pusat nafas• Perifer
Jalan nafas Dinding dadaParu Otot nafasRongga pleura Syaraf & jantung
GANGGUAN VENTILASI(penderita masih bernafas)
GANGGUAN VENTILASI(penderita masih bernafas)
Look / LihatSianosis TakhipneaStatus mental Distensi vena leherAsimetri dada Paralisis otot nafas
Listen / dengar Keluhan: “Tak bisa nafas!”
Stridor, wheeze atau hilang suara nafas
Feel / rabaHawa ekspirasiEmfisema subkutanKrepitasi / tenderness / nyeriDeviasi trakhea
AdjunctsPulse oximeterCO2 detectorGas darahX-ray dada
…………gangguan ventilasi(penderita masih bernafas)
…………gangguan ventilasi(penderita masih bernafas)
BEBERAPA ISTILAHBEBERAPA ISTILAH
• VentilationAliran (volume) udara keluar – masuk paru
• Tidal volumeVolume udara yang dihisap/dikeluarkan pada satu kali nafas biasa6 – 8 ml / kg bb 70kg: 400 – 55 ml
• Minute volumeTidal volume x freq.6 – 8 l / menit
• HipoventilationMinute volume berkurang
• HiperventilationMinute volume meningkat
• Parameter ventilasiPaCO2 N= 35 – 45 mmHg
Hipoventilasi PaCO2 Hiperventilasi PaCO2
………….beberapa istilah………….beberapa istilah
From: Pontoppidan,H.,Laver,M.B.,and Geffin,B,Acute respiratory failure in the surgical patient,in Welch.,C.E.(ed): Advances in surgery, volume 4,Chicago, Year.Book Medical Publishers,1970,p.163After 15 minutes of 100% O2
Except in chronic hypercapnia
Ventilation :•VD/VT•PaCO2 mm hg
Oxygenation :• A – a DO2 mm hg• PaO2 mm Hg
Mechanics :•Respiratory rate/Min•Vital capacity mml/kg
•Inspiratory force cm h2o
0,3 – 0,4
35 – 45
50 – 200
100 – 75
(air)
12 -25
70 – 30
100 - 50
0,4 – 0,6
45 – 60
200 – 350
200 – 70
(mask O2)
25 – 35
30 – 15
50 – 25
> 0,6
> 60
> 350
< 70
(mask O2)
>35, <10
< 15
< 25
Intubation Ventilation
tracheostomy
Close monitoring,oxygen,p
hysical TxNormalCriteria
DASAR PEMBERIAN VENTILASIDASAR PEMBERIAN VENTILASI
• Intermittent positive pressure ventilation (IPPV)
• Penderita tak bernafasNafas buatan (controlled ventilation)
• Penderita masih bernafas / tak adekuatNafas bantuan (assisted ventilation)Diberikan pada akhir ekspirasi
• Tekanan oropharing > 25 cm H2O udara masuk esophagus distensi lambung
………….dasar pemberian ventilasi………….dasar pemberian ventilasi
• Sellick’s maneuverMenekan cricoid kebelakang sehingga esophagusterjepit diantara cricoid dan corpus vertebra leher
Agar :Udara tak masuk lambungIsi lambung tak mengalir ke oropharingTak boleh pada cedera tulang leher
• Nafas buatan :Tidak volume 10-15ml/kgFrequensi 12-15 / m
CARA PEMBERIAN VENTILASICARA PEMBERIAN VENTILASI
Tanpa AlatMouth to mouthMouth to noseMouth to mouth and nose
Dengan AlatSafar airwayEsophageal obturator airwayFace mask / pocket maskLaryngeal maskBag-valve-maskBag-valve-tubeVentilator
Nafas buatan
Nafas berhenti
Nafas ada
SUPPLEMENTAL OXYGENSUPPLEMENTAL OXYGEN
1. Nasal cannula / prongLow – flow systemFlow O2 : 1-6 L/mFiO2 : 24-44% (1 L O2/M FiO2 4%)
2. Face maskLaw – flow systemFlow O2 : 8-10 L/mFiO2 : 40-60 %
3. Face mask with oxygen reservoirConstant – flowFlow O2 : 6-10 L/mFiO2 : 6L O2 / m + 60 % ((1 L O2/M FiO2 10%)
4. Venturi maskHigh gas flowFixed oxygen concentrationFlow O2 & FiO2 diatur24 %, 28%, 35% dan 40%
Terapi oksigen
NASAL PRONGO2 flow 1 – 6 lpmFiO2 : 24 – 44 %
BAG VALVE MASK (BVM) Dgn oksigen 8-10 lpm : 60%
Masker sederhanaDengan reservoir bagFlow O2 : 6-10 lpmFiO2 : 60%- 100%
BVM Dengan reservoir bagFlow O2 : 8-10 lpmFiO2 : 80%- 100%
Jackson ReesFlow O2 : 8-10 lpmFiO2 : 100%
BVM Dengan reservoir bagFlow O2 : 8-10 lpmFiO2 : 80%- 100%
FACE MASK O2 8-10 lpmFiO2 : 40-60%
TRACHEO BRONCHIAL SUCTIONING
TRACHEO BRONCHIAL SUCTIONING
• Preoksigenasi 100% 5 menit
• Alat hisap :
Setting suction: -80 -120 mmHg
Soft catheter (steril) + lobang pengatur
• Tindakan aseptis sesuai prosedur
• Tak lebih 15 detik
• Diselingi oksigenasi 100% 30-60 detik
• Komplikasi
Hipoksemia Cardiac arrest aritmia
Stimulasi simpatis Hipertensi takhikardia
Stimulasi vagal Hipotensi bradikardia
Batuk TIK
Perlukaan
Infeksi
T P UT P U
Peserta mampu mengelola kegawatan sirkulasi.
T P KT P K
Peserta mampu :-Mendiagnosa gangguan sirkulasi-Melakukan penanganan gangguan sirkulasi
C (Circulation)C (Circulation)
C (Circulation)C (Circulation)
Assessment of organ perfusion
- Level of conciousness
- Skin color and temperature
- Pulse rate and character
- Urinary output
SHOCKSHOCK
An abnormality of the circulatory system
that result in inadequate organ perfusion
and tissue oxygenation
GANGGUAN SIRKULASIGANGGUAN SIRKULASI
• Syok
• Disritmia
• Henti jantung
• dll
SHOCK RECOGNITION AND MANAGEMENTSHOCK RECOGNITION AND MANAGEMENT
• Recognize signs of inadequate perfusion and oxygenation• Identify probable cause• Restore perfusion• Re-evaluate patient response• Immediate involvement by specialists
CLINICAL SIGNSCLINICAL SIGNS
1. Tachycardia
2. Vasoconstriction
3. cardiac output
4. Narrow pulse pressure
5. MAP
6. blood flow
Remember :
Compensatory mechanisms
CLASSIFICATION OF SHOCKCLASSIFICATION OF SHOCK
Trauma :- Haemorrhagic- Non haemorrhagic
CardiogenicTension pneumothoraxNeurogenicSeptic
….. Classification of shock….. Classification of shock
Hypovolemic :- Haemorrhage- Diarrhoea- Burn
Distributive- Septic- Anaphylaxsis- Spinal cord injury
….. Classification of shock….. Classification of shock
Cardiogenik :- Arrytmias- Heart failure- Myocardial contusion / infarction
Obstructive- Tension pneumothorax- Cardiac tamponade- Haemopneumothorax
Disscociative- Profound anemia- Co poisoning
CO = SV X F
preload C after load EDV SVR VR
BP = CO X SVR
T P UT P U
Peserta mampu menilai gangguan kesadaran.
T P KT P K
Peserta mampu :-Menilai dengan menggunakan metode AVPU-Menilai dengan menggunakan metode GCS-Menilai reaksi pupil-Memahami bahaya penurunan kesadaran-Mengetahui penyebab penurunan kesadaran.
D (DISABILITY)D (DISABILITY)
Baseline neurologic evaluation
Level of consciousness- AVPU- GCS
Pupil
D (DISABILITY)D (DISABILITY)
GLASGOW COMA SCALEGLASGOW COMA SCALE
Variabels Score Eye opening (E) Spontaneous 4
To speech 3To pain 2None 1
Best motor response (M) Obeys commands 6Localizes pain 5Normal flexion (withdraws) 4Abnormal flexion (decorticate) 3Extension (decerebrate) 2Non (Flaccid) 1
Verbal response (V) Oriented 5Confused conversation 4Inappropriate words 3Incomprehensible sounds 2None 1
Verbal response ScoreAppropriate words or social smile, fixes and follows 5Cries, but consolable 4Persistently irritable 3Restless, agitated 2None 1
PEDIATRIC VERBAL SCOREPEDIATRIC VERBAL SCORE
GCS score = (E+M+V) Best possible score= 15 worst possible sore =3
