AIRWAY MANAGEMENTANDFBAOBAGIAN/ SMF ANESTESI FK UNISSULA/ RSI SULTAN AGUNG 2008Dr. Prabowo Wicaksono Y.P., SpAnDr. Wignyo Santosa, SpAn

AIRWAY MANAGEMENT*

*Apa ke-khusus-an penanganan pasien gawat darurat ?

Waktu untuk bertindak : terbatasData dasar untuk bertindak : terbatas

Konsep berfikir yang sederhanaTindakan yang sistematikKetrampilan yang memadai

*PASIEN TRAUMA/ NON TRAUMALIFE SUPPORTResusitasiStabilisasiA = airwayB = breathingC = circulationD = disabilityTERAPI DEFINITIF/ SPESIALISTIK

*Life supportA 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

*Bagaimana mengamankan jalan nafas?

Intubasi trakea = Gold standard?Bagaimana pendapat para ahli anestesiologi?Intubasi oleh bukan ahli dapat timbulkan traumaResiko: hipoksia fatal/ secondary brain damage, vagal reflex bradikardi berat, cardiac arrestTIK naik hanya dapat dicegah dengan obat-obatanTidak semua fasilitas kesehatan dilengkapi peralatan untuk intubasi trakea

*Trauma wajah berat, dengan potensi obstruksi airwayIntubasi trakea ? Setuju

*Obstruksi airway karena lidah terdorong ke hipofaring, lebih sering terjadi.Intubasi trakea ?

*Pasien mati karena hipoksia, bukan karena tidak terpasang endotrakeal tube (ETT)Tidak semua masalah airway harus diselesaikan dengan intubasi trakea

*Banyak Cara Mengamankan Jalan Nafas A. Chin Lift B.Jaw Thrust1. Basic/ Manual

*C. Head tilt Chin lift

*2. Airway (Alat Bantu Nafas) DasarA. Oropharyngeal Airway (OPA) / GuedelB. Nasopharnygeal Airway (NPA)

*3. Advanced AirwayA. Endotrakeal Tube (ETT)B. Laryngeal Mask Airway (LMA)

*C. Combitube

*AirwayMenilai jalan nafas

Kesadaran ( the talking patient)Look, Listen and Feel

LookAgitasi (hipoksia)/ tampak bodoh (hiperkarbia)Sianosis Retraksi Accessory respiratory muscle

*ListenSnoringGurglingStridorHoarness

FeelTrachea location

*

*

*

C-spine protection during airway management*

*Airway Definitive

Pipa dalam trakea dengan balon (cuff) yang dikembangkan.3 macam: Orotrakeal (Intubasi Oral)Nasotrakeal (Intubasi Nasal)Surgical airway (Krikotiroidotomi/ trakeostomi)

AirwayDEFINITIVESURGICAL: Krikotiroidotomy: TrakeostomyNON SURGICAL : Oral Intubation : Nasal Intubation

NON DEFINITIVEOROPHARYNGEAL AIRWAYNASOPHARNGEAL AIRWAY*

*

OBJECTIVEClear and protected airwayOxygenationPositive pressure ventilation*

Basic Airway Manuever*1. Chin LiftTidak boleh akibatkan hiperekstensi leher.Aman untuk C-spine pada korban trauma

*2. Jaw Thrust

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

*3. Head tilt Chin liftGabungan 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 !!*

Airway Dasar*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.

*Oropharyngeal Airway/GuedelNO: 0 1 2 3 4 5 6

How to measure the right size of Oropharyngeal AirwayKomplikasiObstruksi totalLaringospasmeMuntah *

Cara Pemasangan Oropharyngeal Airway*Dimasukkan mulut dg lengkungan menghadap palatum.Setelah masuk separuh panjangnya, putar 180 hingga lengkungan menempel pada lengkungan lidah.1.2.3.

*2. Nasopharyngeal Airway (NPA)

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

Nasopharyngeal AirwayKomplikasiKerusakan mukosa nasalLaryngospasme

*

Cara Pemasangan Nasopharyngeal AirwayCara pemasangan: beri jelly pelicin, didorong memasukilubang hidung hingga ujung pipa terletak di orofaring. Arah ujungnya datar menyusur dasar rongga hidung, arah menuju anak telinga (tragus).*1.2.3.

Keuntungan :Menjaga jalan nafas terbukaMengurangi risiko aspirasiSebagai fasilitas suction trakeaSebagai fasilitas pemberian oksigen konsentrasi tinggi *3. Advanced Airway

Endotrakeal Tube (ETT)

Endotrakeal Tube (ETT)KomplikasiHipoksiaTrauma Muntah-aspirasi isi lambungHipertensiDisritmia jantungIntubasi satu paruIntubasi esofagusCardiac arrest akibat vagal reflex*

*Persiapan Intubasi Endotrakeal1. Alat:A. 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.

*Laryngoscope

*Menyiapkan Laryngoscope1.2.3.4.

*Memegang LaryngoscopeMemegang laryngoscope selalu dengan tangan kiriPosisi tangan yang betul adalah memegang pada handle, bukan pada pertemuan blade dan handle

*Melepas LaryngoscopeMemasang dan melepas laryngoscope selalu dengan sudut 45

*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 3.5Selalu 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.

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

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

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

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

3. PasienInformed consent mengenai tujuan dan resiko tindakan.

Ingat resiko/komplikasi intubasi bisa berakibat fatal !!!

*Persiapan Intubasi Endotrakeal

*Langkah langkah Intubasi EndotrakealVentilasi 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 !!!

*Posisi Tangan Saat Ventilasi Tekanan PositifIbu 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.

*INTUBASI TRAKEASingkirkan lidah ke kiriCari Epiglotis

*POSITION OF THE TIP OF LARYNGOSCOPE BLADEVALEKULAEPIGLOTISLIDAHSniffing PositionMambantu Visualisasi laringTrakeaEsofagus !!!

*ELEVASI LARINGOSKOPGunakan kekuatan tangan untuk mengangkat. Jangan diungkit dg menggunakan gigi seri atas sebagai titik tumpu (awas patah!!).Arah elevasi laringoskopJangan diungkit !!!

*INTUBASI TRAKEA

INTUBASI TRAKEA*Plica VocalisTrakeaEpiglotis

BURP MANUEVERMenekan kartilago krikoid ke bawah, atas, kanan (Back, Up, Right Pressure= BURP)Membantu visualisasi plika vokalisDilakukan oleh asisten yg membantu intubator

*BURPTHYROIDCRICOIDADAMS APPLE

*INTUBASI TRAKEAG.H.

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

TEKNIK INTUBASI TRAKEABuka 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 kiriCari epiglotis. 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 vokalisBila tidak terlihat, minta bantuan asisten utk lakukan BURP manuver (Back, Up, Right Pressure) pada kartilago krikoid sampai terlihat plika vokalisMasukkan ETT, bimbing ujungnya masuk trakea sampai cuff ETT melewati plika vokalisKembangkan cuff ETT secukupnya (sampai tidak ada kebocoran udara)Pasang OPASambungkan konektor ETT dg ambu bag. Beri ventilasi buatan. Cek suara paru kanan = kiri, Awas intubasi endobronkial !!Fiksasi ETT dengan plester

*

*Teknik Oral12

*34

*5

*Teknik Nasal12

*34

*5

MENCEGAH KOMPLIKASI INTUBASI TRAKEA

Dilakukan oleh tenaga terlatihAlat-alat intubasi lengkap : laryngoskop & pipa trakea berbagai ukuranIntubasi dilakukan < 30 detikDilakukan penekanan pada kartilago krikoid (BURP Manuever)Pilih pipa trakea high volume low pressure cuff*

RJP DENGAN PASIEN TERPASANG ETTPasien dengan intubasi trakhea, bantuan ventilasi tidak perlu sinkron dengan kompresi dada pada saat RJP*

Intubation Movie*

*3. Advanced AirwayB. Laryngeal Mask Airway

Keuntungan: Teknik pemasangan lebih mudahTrauma lebih sedikitTidak membutuhkan laringoskop

Kerugian:Tidak melindungi terhadap aspirasi

*Laryngeal Mask Airway

*AIRWAY MANAGEMENT MOVIE

*AIRWAY ANATOMY BRONCHOSCOPY MOVIE

Foreign Body AirwayObstruction (FBAO)

Conscious Adult ChokingTo 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?

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.

Put your arms around the victims abdomen.Place fist with thumb side against victims 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 victims abdomen until the foreign body is expelled or the victim becomes unconscious.

Steps Involved in Relief of FBAO ( Conscious)*

ADULT HEIMLICH MANEUVER Look 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.

*

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

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.

*

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

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

ADULT CHOKING MOVIE*

CHILD HEIMLICH MANUVER Look 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.

*

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.

*

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.

*

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

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS AVAILABLE. *

CHILD CHOKING MOVIE*

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.

*

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.

*

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. *

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.

*

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)

*

*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. *

INFANT CHOKING MOVIE*

*Ask: Are you choking?

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

If the victim becomes Unconscious,

Position the victim on his back and call Help! Call 995

Open the airway Perform Head-Tilt-Chin Lift

Push chin down and check mouth for foreign body object

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)

*Finger SweepUse 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.

*Check breathing Look, Listen and See

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

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.

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)

*To treat ones 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.

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

*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

*3. Place your arms under the victims 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. *

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

Thank you.....*

**************************The theory and demo should last about 30 minutes and the practical about 70 minutes.*