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