Dasar2 Penanganan Px Gawat Oksigen Delivery Dr PG 2015
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Transcript of Dasar2 Penanganan Px Gawat Oksigen Delivery Dr PG 2015
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DASAR PENANGANAN PENDERITA GAWAT
BASIC GENERAL EMERGENCYLIFE SUPPORT (B GELS)
Puger Rahardjo
LAB./SMLAB./SMF Anestesiologi dan Reanimasi F Anestesiologi dan Reanimasi RSUD dr. Soetomo-FK Unair- SurabayaRSUD dr. Soetomo-FK Unair- Surabaya
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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
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Penderita Gawat DaruratPenderita Gawat Darurat
Penderita yang oleh karena suatu penyebabpenyakit, tindakan, kecelakaan) bila tidak segera ditolong akan cacat, kehilangan anggota tubuh atau meninggal
Jumlah pasien gawat darurat makin meningkat :– Indonesia rawan bencana – Perubahan pola penyakit
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Silent epidemic
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Mass-casualties small scale disaster
Kecelakaan kereta api Man-made disasterMan-made disaster
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Complex disaster
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Complex disaster
Kerusuhan
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Natural disaster
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Triage dan evakuasiSiapa didahulukan dan siapa dikirim ke mana
Triage dan evakuasiSiapa didahulukan dan siapa dikirim ke mana
4 korban Ratusan korban
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SURVAI KESEHATAN RUMAH SAKIT (SKRT) 1986, 1992, 1995
• Kematian jantung Urutan 2• Kematian trauma Urutan 4• Kematian jantung di Jakarta
1991 2535 orang 1992 2746 orang 1993 2961 orang 1994 3255 orang 1995 1283 orang (sampai maret)
• Kematian kecelakaan lalu lintas di Indonesia 1991 10.621 orang 1992 9.819 orang 1993 10.038 orang 1994 11.004 orang 1995 9.251orang
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No.1.2.3.4.5.6.7.8.9.
Macam KasusTrauma / kecelakaan lalu lintasDiareMalaria – panas – kejangISPA – batuk – sesakStroke – tidak sadarTBC – batuk darah – sesakJantung – hipertensi, infarkObsgyn – perdarahan, eklampsiaIntoksikasi – gigitan ular - peptisida
% Kasus20 %17 %
15,6 %12,2 %8,6 %7,7 %7,6 %6,4 %4,9 %
Trauma : 20 %Non trauma : 80 %
HASIL SURVEY DI 10 PROPINSI : KALBAR, SUMUT, NTT, SUMBAR, NTB, SULUT, KALSEL, KALTENG, JAMBI, BENGKULU
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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
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CHAIN OF SURVIVALCHAIN OF SURVIVAL
Early Activation of EMS
Early Basic of CPR
Early Defibrillation
Early Advanced Life Support
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CONCEPTCONCEPT
• ABCDE – approach to evaluation and treatment
• Treat greatest threat to life first
• Definitive diagnosis not immediately important
• Time is of the essence
• Do no further harm
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INITIAL ASSESSMENT / MANAGEMENTINITIAL ASSESSMENT / MANAGEMENT
Injury
Primary survey and adjuncts
Resuscitation
Reevaluation
Secondary survey and adjuncts
Reevaluation
Optimize patient status
Transfer
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Primary survey and resuscitationof vital functions are done
simultaneously – a team approach
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PENANGANAN PASIEN TIDAK GAWATPENANGANAN PASIEN TIDAK GAWAT
• Anamnesa• Pemeriksaan fisik
Inspeksi Palpasi Perkusi Auskultasi
• Pemeriksaan penunjang• Diagnosa• Terapi
Supportif Simtomatis Definitif / kausal
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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
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First responder
Life saver
Resusitasi – stabilisasi
AirwayBreathingCirculationBrain
Peranan Dokter Umum
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• Manusia memerlukan O2 supaya dapat hidup• Organ organ dalam tubuh memerlukan O2
supaya dapat berfungsi• O2 + cbh → H2O +CO2 + ATP
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. Penderita gawat :• Disebabkan oleh gagalnya O2 mencapai organ
organ dalam tubuh.• Misalnya pada penderita shock,gagal
napas ,anemia, obstruksi jalan napas .
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• Kegagalan O2 mencapai otot jantung dapat menyebabkan otot jantung tersebut kehilangan fungsinya ,demikian juga dengan organ tubuh yang lain.
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• O2 didapat dari udara luar 21% ( Fi O2 = 21%)• Di ruang gawat darurat kita dapat menambah
tekanan O2 ini menjadi > 21% bahkan dapat kita berikan 100% O2
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Org
anis
asi
Sis
tem
R
esp
i rasi
-
Kard
i ovask
ule
r
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Respiratory SystemRespiratory System
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2 Fungsi / tujuan : Mengembalikan kadar O2 yang berkurang
pada tingkat jaringan. Eliminasi CO2 pada darah vena.
2 Persyaratan agar tujuan tercapai : Udara membawa O2 dari luar ke dalam
alveoli. Darah menerima O2 dan melepas CO2.
Difusi Paru-paruDifusi Paru-paru
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Respiratory MembraneRespiratory Membrane
Pertukaran gas di alveoliPerbedaan tekanan parsial gas di alveoli dan dalam pembuluh
darah mencipatakan adanya perbedaan tekanan parsial diantara membran. Bila tekanan setara, tidak akan terjadi perpindahan.
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Oxygen Delivery (DO2)
Johnson’s conceptual model of oxygenation, Wagner, Johnson & Kidd (2006)
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Oxygen Delivery: DO2• Simplified Formula =
– D02 = CO X (Hgb X 1.34 X Sa02) X 10
• (Untuk tujuan praktis PaO2 dihilangkan?)
• Normal = 700 – 1400 ml/min.
• Bagaimana kita dapat mengerti hal ini ? (Kunci : Apa saja tiga komponen utama dalam formula ?)
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Oxygen Delivery: DO2
• DO2 tergantung pada :1. Kandungan oksigen/ oxygen content (faktor kualitas)
pada darah arteri (CaO2) & 2. Cardiac Output, (CO) (faktor kuantitas)
• FICK Formula for DO2: DO2 = CO X CaO2 X 10
– CaO2 = (Hgb x 1.34 x SaO2) + (PaO2 x .003)
Volume O2 (ml) yang dapat diikat oleh 1 gm Hgb
Koefisien kelarutan oksigen dalam plasma
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Oxygen Delivery: Apa saja komponennya ?
Oxygen DeliveryDO2
Cardiac Output
Heart Rate Stroke Volume
CaO2
PaO2 SaO2 Hgb
SynchronyPreload Afterload Contractility
CVPPCWP
PVRSVR
EF%
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Oxygen Delivery: Let’s break it down!
• DO2 = CO X CaO2 X 10• CaO2 =
– Normal = 20 mL O2/dL– PaO2– SaO2– Hgb
• CO =– HR– Preload– Afterload– Contractility
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Oxygen Delivery: DO2
• Jaringan yang paling terpengaruh terhadap penurunan DO2?– Cardiomyocytes– Neurons– Kidney & Liver (15-20 menit)– Sedikit terpengaruh :
• Skeletal muscle (60-90 menit)• Hair & Nails? (Leach & Treacher, 2002)
• Pengukuran DO2 masing-masing organ adalah yang paling ideal.
• “Optimizing DO2 EARLY = Better Outcomes”
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Contoh Penyakit yang mengganggu Oxygen Delivery (DO2)
Sumbatan jalan nafasGangguan mekanik pernafasan
Infeksi / PneumoniaEdema Paru ARDS
Penyakit darah : sickle cell disease, anemia, thalasemiaJantung : aritmiia, dekomp kordis kongenital (VSD)Vaskuler : PAPO, lesi vaskuler, Dengue Syok
Alkalosis, luka bakar, sepsis
Sepsis, cell death
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Komponen Sistem Transportasi Oksigen
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Terima Kasih