AIRWAY MANAGEMENTAIRWAY MANAGEMENTANDAND

FBAOFBAO

BAGIAN/ SMF ANESTESI FK UNISSULA/ RSI BAGIAN/ SMF ANESTESI FK UNISSULA/ RSI SULTAN AGUNG SULTAN AGUNG

20020088

DDr. Prabowo Wicaksono Y.P., SpAnr. Prabowo Wicaksono Y.P., SpAn

Dr. Wignyo Santosa, SpAnDr. Wignyo Santosa, SpAn

AIRWAY MANAGEMENTAIRWAY MANAGEMENT

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Apa ke-khusus-an penanganan pasien gawat darurat ?

Waktu untuk bertindak : terbatasData dasar untuk bertindak : terbatas

KonsepKonsep berfikir yang sederhanaberfikir yang sederhanaTindakan yang sistematikTindakan yang sistematik

Ketrampilan yang memadaiKetrampilan yang memadai

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PASIEN TRAUMAPASIEN TRAUMA/ NON TRAUMA/ NON TRAUMA

LIFE SUPPORTLIFE SUPPORTResusitasiResusitasiStabilisasiStabilisasi

A = airwayA = airwayB = breathingB = breathingC = circulationC = circulationD = disabilityD = disability

TERAPI DEFINITIF/ TERAPI DEFINITIF/ SPESIALISTIKSPESIALISTIK

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Life support

A ─B─ C─ DA ─B─ C─ DQuick Diagnosis – Quick Treatment

A= Airway, bebaskan jalan nafas, Lindungi C-spineB= Breathing, beri bantuan nafas, tambah oksigenC= Circulation, hentikan perdarahan, beri infusD= Disability/SSP, cegah TIK ↑

Pasien obstruksi (A) atau apneu (B) akan mati dalam 3-5 menitPasien shock berat (C) akan mati dalam 1-2 jamPasien coma (D) akan mati dalam 1 minggu

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Bagaimana mengamankan jalan nafas?

Intubasi trakea = Gold standard

??Bagaimana pendapat para ahli anestesiologi?1.Intubasi oleh bukan ahli dapat timbulkan trauma2.Resiko: hipoksia fatal/ secondary brain damage,

vagal reflex→ bradikardi berat, cardiac arrest3.TIK naik hanya dapat dicegah dengan obat-obatan4.Tidak semua fasilitas kesehatan dilengkapi peralatan untuk intubasi trakea

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Trauma wajah berat, dengan potensi obstruksi airwayIntubasi trakea ? SetujuSetuju

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Obstruksi airway karena lidah terdorong ke hipofaring, lebih sering terjadi.

Intubasi trakea ? Intubasi trakea ?

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Pasien mati karena hipoksiahipoksia, bukan karena tidak terpasang endotrakeal tube (ETT)

Tidak semua masalah airway harus Tidak semua masalah airway harus diselesaikan dengan intubasi trakeadiselesaikan dengan intubasi trakea

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Banyak Cara Mengamankan Jalan NafasBanyak Cara Mengamankan Jalan Nafas

A. Chin LiftA. Chin Lift

B.Jaw ThrustB.Jaw Thrust

1. Basic/ Manual1. Basic/ Manual

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C. Head tilt – Chin lift

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2. Airway (Alat Bantu Nafas) Dasar2. Airway (Alat Bantu Nafas) Dasar

A. Oropharyngeal Airway (OPA) / GuedelA. Oropharyngeal Airway (OPA) / Guedel

B. Nasopharnygeal Airway (NPA)B. Nasopharnygeal Airway (NPA)

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3. Advanced Airway3. Advanced Airway

A. Endotrakeal Tube (ETT)A. Endotrakeal Tube (ETT)

B. Laryngeal Mask Airway (LMA)B. Laryngeal Mask Airway (LMA)

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C. Combitube

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AirwayAirwayMenilai jalan nafas

Kesadaran (“ the talking patient”)Kesadaran (“ the talking patient”)Look, Listen and FeelLook, Listen and Feel

LookLook•Agitasi (hipoksia)/ tampak bodoh (hiperkarbia)•Sianosis •Retraksi •Accessory respiratory muscle

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ListenListen•Snoring•Gurgling•Stridor•Hoarness

FeelFeel•Trachea location

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Airway DefinitiveAirway Definitive

Pipa dalam trakea dengan balon (cuff) yang dikembangkan.3 macam:

•Orotrakeal (Intubasi Oral)•Nasotrakeal (Intubasi Nasal)•Surgical airway (Krikotiroidotomi/ trakeostomi)

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OBJECTIVEOBJECTIVE

Clear and protected airway

Oxygenation

Positive pressure ventilation

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Basic Airway ManueverBasic Airway Manuever

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1. Chin Lift1. Chin Lift

•Tidak boleh akibatkan hiperekstensi leher.•Aman untuk C-spine pada korban trauma

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2. Jaw Thrust2. Jaw Thrust•Pegang pada angulus mandibulae, dorong mandibula ke depan (ventral ).•Aman untuk C-spine pada korban trauma

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3. Head tilt – Chin lift

•Gabungan antara manuver Head tilt dan Chin lift.•Head tilt: meletakkan telapak tangan di dahi, kepala diekstensikan.•Pada pasien trauma: hati-hati cedera pada C-spine.

•Pada pasien multipel trauma dengan suspek cedera cervical, manuver yang paling aman : Jaw Thrust.•Bila dengan Jaw Thrust tidak bisa buka airway: lakukan Head Tilt – Chin Lift dengan ekstensi kepala minimal.•Airway tetap merupakan prioritas, meski terdapat cedera C-spine.

Jangan Lakukan !!Jangan Lakukan !!

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Airway DasarAirway Dasar

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1. Oropharyngeal Airway (OPA)1. Oropharyngeal Airway (OPA)•Menahan lidah tidak jatuh ke belakang .•Fasilitas suction.•Mencegah lidah/ ETT tergigit

•Merangsang muntah pada pasien sadar/ setengah sadar.

•Hati – hati pada anak dapat lukai jaringan lunak.

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Oropharyngeal Airway/GuedelOropharyngeal Airway/Guedel

NO: 0 1 2 3 4 5 6

How to mHow to measure the right size of easure the right size of Oropharyngeal Oropharyngeal AAirwayirway

Komplikasi– Obstruksi total– Laringospasme

– Muntah

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Cara Cara PPemasanganemasangan Oropharyngeal Airway Oropharyngeal Airway

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Dimasukkan mulut dg lengkungan menghadap palatum.Setelah masuk separuh panjangnya, putar 180° hingga lengkungan menempel pada lengkungan lidah.

1.

2.

3.

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2. Nasopharyngeal Airway (NPA)2. Nasopharyngeal Airway (NPA)

Jalan nafas buatan dengan ujung di belakang lidah.Hati hati pada fraktur basis cranii.Indikasi: Indikasi: Pasien setengah sadar dengan nafas spontan.Lebih dapat ditoleransi pasien daripada OPA, kecil kemungkinan rangsang muntah.

Nasopharyngeal AirwayNasopharyngeal AirwayKomplikasi Kerusakan mukosa nasal Laryngospasme

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Cara Pemasangan Cara Pemasangan Nasopharyngeal AirwayNasopharyngeal AirwayCara pemasangan: beri jelly pelicin, didorong memasuki

lubang hidung hingga ujung pipa terletak di orofaring. Arah ujungnya

datar menyusur dasar rongga hidung, arah menuju anak telinga

(tragus).

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1.1.

2.2.

3.

Keuntungan :Keuntungan : Menjaga jalan nafas terbuka Mengurangi risiko aspirasi Sebagai fasilitas ‘suction’ trakea Sebagai fasilitas pemberian oksigen

konsentrasi tinggi

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3. Advanced Airway3. Advanced Airway

A.A.Endotrakeal Tube (ETT)Endotrakeal Tube (ETT)

Endotrakeal Tube (ETT)Endotrakeal Tube (ETT)

KomplikasiKomplikasi Hipoksia Trauma Muntah-aspirasi isi

lambung Hipertensi Disritmia jantung Intubasi satu paru Intubasi esofagus Cardiac arrestCardiac arrest akibat akibat

vagal reflexvagal reflex35

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Persiapan Intubasi EndotrakealPersiapan Intubasi Endotrakeal1. Alat:1. Alat:A. LaryngoscopeA. Laryngoscope Terdiri dari : Blade (bilah) dan Handle (gagang). Pilih ukuran blade yg sesuai.

Dewasa : no 3 atau 4Anak : no 2Bayi : no 1Pasang blade dengan handleCek lampu harus menyala terang.menyala terang.

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LaryngoscopeLaryngoscope

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Menyiapkan LaryngoscopeMenyiapkan Laryngoscope

1. 2.

3. 4.

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Memegang LaryngoscopeMemegang LaryngoscopeMemegang laryngoscope selalu dengan tangan kiri

Posisi tangan yang betul adalah memegang pada handle, bukan pada pertemuan blade dan handle

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Melepas LaryngoscopeMelepas Laryngoscope

Memasang dan melepas laryngoscope selalu dengan sudut 45°

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B. Endotrakeal Tube (ET)B. Endotrakeal Tube (ET)Pilih ukuran yang sesuai: (ID: Internal Diameter)Dewasa : ID 6.5 , 7 atau 7.5 Atau ± sebesar

kelingking kiri pasienAnak : ID = 4 + (Umur : 4)

Bayi : Prematur : ID 2.5 Aterm : 3.0 – 3.5

Selalu menyiapkan satu ukuran dibawah dan diatas.Pilih ET yang High Volume Low Pressure (ETT putih/ fortex) Bila memakai yg re-useable, cek cuff dan patensi lubang ET.

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ETT dissposible (Low ETT dissposible (Low Pressure High Volume)Pressure High Volume)

ETT re-usable (High ETT re-usable (High Pressure Low Volume)Pressure Low Volume)Tidak dianjurkan.Tidak dianjurkan.

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C. Spuit 20 cc.C. Spuit 20 cc.D. Stylet (bila perlu).D. Stylet (bila perlu).E. Handsgloves steril.E. Handsgloves steril.F. KY jelly.F. KY jelly.G. Forcep Magill (bila perlu).G. Forcep Magill (bila perlu).H. AMBU Bag dg kantung reservoir dihubungkan denganH. AMBU Bag dg kantung reservoir dihubungkan dengan sumber oksigen.sumber oksigen.

I. Plester untuk fiksasi ETT.I. Plester untuk fiksasi ETT.J. Oropharngeal Airway.J. Oropharngeal Airway.H. Alat suction dg suction catheter .H. Alat suction dg suction catheter .K. Stetoscope.K. Stetoscope.

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2. Obat Emergency2. Obat Emergency- Sulfas Atropin (SA) dalam spuit- Adrenaline dalam spuit.

3. Pasien3. PasienInformed consent mengenai tujuan dan resiko tindakan.

Ingat resiko/komplikasi intubasi bisa berakibat Ingat resiko/komplikasi intubasi bisa berakibat fatal !!!fatal !!!

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Persiapan Intubasi EndotrakealPersiapan Intubasi Endotrakeal

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Langkah – langkah Intubasi EndotrakealLangkah – langkah Intubasi Endotrakeal

Ventilasi tekanan positif dan OksigenasiVentilasi tekanan positif dan Oksigenasi Harus dilakukan sebelum intubasi. Dada harus mengembang selama ventilasi diberikan. Oksigenasi dengan oksigen 100% (10 L/menit). Bila intubasi gagal (waktu >30 detik), lakukan ventilasi dan

oksigenasi ulang, bahaya hipoksia !!!bahaya hipoksia !!!

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Posisi Tangan Saat Ventilasi Tekanan PositifPosisi Tangan Saat Ventilasi Tekanan Positif

Ibu jari dan jari telunjuk menekan face mask ke bawah sambil mempertahankan sekat yg tidak bocor antara face mask dan penderita.

Jari tengah, jari manis dan kelingking pada ramus mandibula, mendorong ke atas sambil membuka airway.

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INTUBASI TRAKEAINTUBASI TRAKEA

Singkirkan lidah ke kiriSingkirkan lidah ke kiri

Cari EpiglotisCari Epiglotis

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POSITION OF THE TIP OF LARYNGOSCOPE BLADEPOSITION OF THE TIP OF LARYNGOSCOPE BLADE

VALEKULAVALEKULAEPIGLOTISEPIGLOTIS

LIDAH

Sniffing PositionSniffing PositionMambantu Visualisasi laringMambantu Visualisasi laring

TrakeaTrakea

Esofagus !!!Esofagus !!!

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ELEVASI LARINGOSKOP

Gunakan kekuatan tangan untuk mengangkat. Jangan diungkit dg menggunakan gigi seri atas sebagai titik tumpu (awas patah!!).

Arah elevasi laringoskopArah elevasi laringoskop Jangan diungkit !!!Jangan diungkit !!!

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INTUBASI TRAKEAINTUBASI TRAKEA

INTUBASI TRAKEAINTUBASI TRAKEA

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Plica VocalisPlica Vocalis TrakeaTrakeaEpiglotisEpiglotis

BURPBURP MANUEVERMANUEVER Menekan kartilago krikoid ke bawah, atas, kanan

(Back, Up, Right Pressure= BURP) Membantu visualisasi plika vokalis Dilakukan oleh asisten yg membantu intubator

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BURP

THYROIDTHYROID

CRICOIDCRICOID

ADAM’S APPLEADAM’S APPLE

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INTUBASIINTUBASI TRAKEA TRAKEAG. H.

Cara cegah intubasi endobronkhial:Masukkan ETT hanya sampai ujung distal cuff lewati plica vocalis

Ujung distal cuffUjung distal cuff

Intubasi endobronkhialIntubasi endobronkhial

TEKNIK TEKNIK INTUBASI TRAKEAINTUBASI TRAKEA Buka mulut dengan tangan kanan, gerakan jari menyilang (ibu jari

menekan mandibula, jari telunjuk menekan maksila) Pegang laringoskop dg tangan kiri, masukkan melalui sisi sebelah

kanan mulut, singkirkan lidah ke samping kirisingkirkan lidah ke samping kiri Cari epiglotisepiglotis. Tempatkan ujung bilah laringoskop di valekula

(pertemuan epiglotis dan pangkal lidah) Angkat epiglotis dg elevasi laringoskop ke atas (jangan menggunakan

gigi seri atas sbg tumpuan !!!) untuk melihat plika vokalisplika vokalis Bila tidak terlihat, minta bantuan asisten utk lakukan BURP manuverBURP manuver

(Back, Up, Right Pressure) pada kartilago krikoid sampai terlihat plika vokalis

Masukkan ETT, bimbing ujungnya masuk trakea sampai cuff ETT sampai cuff ETT melewati plika vokalismelewati plika vokalis

Kembangkan cuff ETT secukupnyasecukupnya (sampai tidak ada kebocoran udara) Pasang OPA Sambungkan konektor ETT dg ambu bag. Beri ventilasi buatan. Cek

suara paru kanan = kiri, Awas intubasi endobronkial !!Awas intubasi endobronkial !! Fiksasi ETT dengan plester

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Teknik OralTeknik Oral

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Teknik NasalTeknik Nasal

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MENCEGAH KOMPLIKASI MENCEGAH KOMPLIKASI INTUBASI TRAKEA INTUBASI TRAKEA

Dilakukan oleh tenaga terlatih Alat-alat intubasi lengkap : laryngoskop &

pipa trakea berbagai ukuran Intubasi dilakukan < 30 detik Dilakukan penekanan pada kartilago

krikoid (BURP Manuever) Pilih pipa trakea ‘high volume low pressure

cuff’

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RJP DENGAN RJP DENGAN PASIEN PASIEN TERPASANG ETTTERPASANG ETT

Pasien dengan intubasi trakhea, bantuan ventilasi tidak perlu sinkron dengan kompresi dada pada saat RJP

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3. Advanced Airway3. Advanced AirwayB. Laryngeal Mask AirwayB. Laryngeal Mask Airway

KeuntunganKeuntungan : : •Teknik pemasangan lebih mudahTeknik pemasangan lebih mudah•Trauma lebih sedikitTrauma lebih sedikit•Tidak membutuhkan laringoskopTidak membutuhkan laringoskop

KerugianKerugian :Tidak melindungi terhadap aspirasi:Tidak melindungi terhadap aspirasi

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Laryngeal Mask AirwayLaryngeal Mask Airway

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AIRWAY MANAGEMENT MOVIE

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AIRWAY ANATOMY BRONCHOSCOPY MOVIE

Foreign Body AirwayForeign Body AirwayObstruction Obstruction

(FBAO)(FBAO)

Conscious Adult ChokingConscious Adult Choking

1. To confirm that the victim is choking, ask: “Are you choking?” If the victim is choking, he will not be able to Speak, Breathe or Cough.

If “YES”, say “I am trained, can I help?”

2. If the victim is upright, the rescuer stands behind the victim. If the victim is sitting, the rescuer kneels down and positions himself behind the victim.

3. Put your arms around the victim’s abdomen.Place fist with thumb side against victim’s abdomen in the mid line about2 fingers’ breadth above the navel and well below the tip of the xiphoid.Give quick inward and upward thrusts in one motion into the victim’s abdomen until the foreign body is expelled or the victim becomes unconscious.

Steps Involved in Relief of FBAO ( Conscious)

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ADULT HEIMLICH MANEUVERLook for the Universal Sign of the victim's hand across their throat . . . . . . .

•if the victim is making sound or moving air, encourage them to cough. •If the victim is not making sound, or is turning color, intervene. •Announce to the victim that you know the Heimlich Manuver and can help! •Have someone activate emergency medical system - CALL 911.

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•Stand behind the victim with your arms wrapped around the victims chest. •Feel for the victim's xiphoid process with your right hand.

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Make a fist with your left hand and place it (THUMB IN) below the right hand.

•Wrap the right hand over the left hand.•Give inward and upward thrusts towards the shoulder blades. •Repeat this until either the obstruction is removed, or the victim becomes unconscious. •If the victim becomes unconscious, assist them to the ground and perform

•C.P.R. CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS AVAILABLE. 72

Subdiaphragmatic abdominal thrust (the Heimlich maneuver) administered to a conscious (standing) victim of foreign body airway obstruction.

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Subdiaphragmatic abdominal thrust (the Heimlich maneuver) administered to a conscious (standing)

victim of foreign body airway obstruction.

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ADULT CHOKING MOVIE75

CHILD HEIMLICH MANUVERLook for the Universal Sign of the victim's hand across their throat.

•If the victim is making sound or moving air, encourage them to cough. •If the victim is not making sound, or is turning color, intervene.•Announce to the victim that you know the Heimlich Manuver and can help!•Have someone activate emergency medical system - CALL 911.

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•If you are alone, perform Heimlich Manuver first, then call 911, because children need air !!!

•Stand behind the victim with your arms wrapped around the victims chest. •Feel for the victim's xiphoid process with your left hand.•Make a fist with your right hand and place it (THUMB IN)below the left hand.

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Wrap the left hand over the right hand. Give inward and upward thrusts towards the shoulder blades. Repeat this until either the obstruction is removed, or the victim becomes unconscious.

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•If the victim becomes unconscious, assist them to the ground and perform C.P.R.

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS AVAILABLE.

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CHILD CHOKING MOVIE80

INFANT HEIMLICH MANUVER

Intervene if the infant is turning color, or is not making sound !!!

•Place victim flat on his/her back with their head to your right, on a hard surface.

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With your left hand cupped in a "C" shape, grab the infant by the jaw and rest the remainder of your arm across the infant's body.

•Lift the infant with your left hand and invert the victim so their body is resting across the rescuer's left arm with the legs straddling your arm. •Lower the victim's head.

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Back blow in an infant.

•With the infant's back towards you, perform 5 back blows at the level of the infant's shoulder blades with the heel of your right hand.

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•Sandwich the infant between both arms, supporting the head with your right hand. •Invert the victim to the right arm, facing upwards with the legs straddling your right arm and move the victim to the level of your chest.

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•Take the left hand,and extend the middle 3 fingers. Place them on the infant's chest with the index finger in the center of the chest at the nipple-line. •Raise the index finger and depress sternum 1 inch using the remaining 2 fingers. •Perform 5 compresions (Chest Thrust)

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•Look in the infant's mouth to see if the foreign body has been displaced.

•If no air goes in, reposition the head and try again. •If no response after 1 minute, call emergency medical system dial-911 •Return to victim and continue the Heimlich Manuver.

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS AVAILABLE. 87

INFANT CHOKING MOVIE88

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1. Ask: “Are you choking?”

2. Perform abdominal thrusts (Heimlich maneuver) / For pregnant and very obese victims, perform chest thrusts.

If the victim becomes Unconscious,

3. Position the victim on his back and call “Help! Call 995”

4. Open the airway – Perform Head-Tilt-Chin Lift

5. Push chin down and check mouth for foreign body object

6. If foreign body is seen, If foreign body is seen, insert the index finger of the other hand down along the inside of the cheek and deeply into the throat. Use a hooking action to dislodge the foreign body and maneuver it out of the mouth./ Take precaution not to force the foreign body deeper into the throat. This maneuver is known as the finger sweep.

Steps Involved in Relief of FBAO ( Conscious to Unconscious)

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Finger Sweep

Use a hooking action to dislodge the foreign body and maneuver it out of the mouth./ Take precaution not to force the foreign body deeper into the throat. This man oeuvre is known as the finger sweep.

Check for Foreign Body – use Push chin downIf foreign body is seen, insert the index finger of the other hand down along the inside of the cheek and deeply into the throat.

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7. Check breathing – Look, Listen and See

8. If there is no breathing, attempt to ventilate (1st ventilation). If the chest does not rise, reposition victim’s head and reattempt to ventilate (2nd ventilation)

9. If the chest does not rise again, give 30 chest thrusts. The hand position for chest thrusts is the same as chest compression performed in CPR.

10. Repeat S/N 4 to 8 until there are 2 successful ventilations, and check the breathing.

Steps Involved in Relief of FBAO ( Conscious to Unconscious)

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1. To treat one’s own complete FBAO, make a fist with one hand, placethe thumb side on the abdomen above the navel (2 fingers breadth) andbelow the xiphoid process, grasp the fist with the other hand, and thenpress inward and upward toward the diaphragm with a quick motion.

2. If unsuccessful, the victim can also press the upper abdomen over any firm surface such as the back of a chair, side of table, or porch railing.Several thrusts may be needed to clear the airway.

The Self-Administered Heimlich Maneuver

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May be used as an alternative to Heimlich Maneuver. It is performed on obese or pregnant victim.

1. To confirm that the victim is choking, ask: “Are you choking?” If the victim is choking, he will not be able to Speak, Breathe or Cough.

If “YES”, say “I am trained, can I help?”

2. If the victim is upright, the rescuer stands behind the victim. If the victim is sitting, the rescuer kneels down and positions himself behind the victim.

Chest Thrust

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3. Place your arms under the victim’s armpits to encircle the chest. Place one fist with thumb side on the middle of the breastbone. Grasp fist with the other hand and give successive quick backward thrusts.. Deliver each thrust firmly and distinctly with the intent of relieving the obstruction until the foreign body is expelled or the victim becomes unconscious. When the victim becomes unconscious, the rescuer should activate emergency medical services by dialing 995 for an ambulance and begin CPR.

Chest thrust administered to a conscious victim (standing) of foreign body airway obstruction.

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Chest thrust administered to an unconscious victim (lying) of foreign body airway obstruction.

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Thank you.....Thank you.....

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