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Master emergency airway management
- 1. DASAR PENANGANAN PENDERITA GAWAT BASIC GENERAL EMERGENCY LIFE SUPPORT (B GELS)
- 2. T P U Peserta mampu menangani penderita gawat darurat dengan baik dan benar T P K Peserta mampu : 1. Mengenal penderita gawat darurat 2. Mengetahui macam-macam penyebab kegawat daruratan 3. Memahami sistematika penanganan penderita gawat darurat 4. Mendiagnosa kegawatan jalan nafas / airway 5. Menangani kegawatan jalan nafas / airway 6. Mendiagnosa kegawatan nafas / breathing 7. Menangani kegawatan nafas / breathing 8. Memberikan terapi oksigen 9. Mendiagnosa gangguan sirkulasi 10. Menangani gangguan sirkulasi 11. Mendiagnosa gangguan kesadaran 12. Menangani gangguan kesadaran
- 3. Penderita Gawat Darurat Penderita yang oleh karena suatu penyebab (penyakit, tindakan, kecelakaan) bila tidak segera ditolong akan cacat, kehilangan anggota tubuh atau meninggal
- 6. Mass-casualties small scale disaster Kecelakaan kereta api Man-made disaster
- 10. Triage dan evakuasi Siapa didahulukan dan siapa dikirim ke mana 4 korban Ratusan korban
- 11. SURVAI KESEHATAN RUMAH SAKIT (SKRT) 1986 DAN 1992 • 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
- 13. USA : TRAUMA • Trauma penyebab kematian ketiga setelah cancer dan atheroselerosis • Usia 1- 44 tahun (produktif) penyebab kematian pertama • Jumlah kecelakaan : 60 juta / tahun • 30 juta perlu perawatan medik • 3,6 juta perlu MRS • 9 juta cacat : 3000.000 permanen 8.700.000 temporer • Kematian 145.000 / tahun • Trauma – related costs > $ 100 milyar / year
- 14. HASIL SURVEY DI PROPINSI : NTT, KALBAR, KALTENG, SUMUT, BENGKULU No. 1. 2. 3. 4. 5. 6. 7. 8. 9. Macam Kasus Trauma / kecelakaan lalu lintas Diare Malaria – panas – kejang ISPA – batuk – sesak Stroke – tidak sadar TBC – batuk darah – sesak Jantung – hipertensi, infark Obsgyn – perdarahan, eklampsia Intoksikasi – gigitan ular - peptisida % Kasus 20 % 17 % 15,6 % 12,2 % 8,6 % 7,7 % 7,6 % 6,4 % 4,9 % Trauma : 25 % Non trauma : 75 %
- 16. BILA TERJADI HENTI NAFAS DAN HENTI JANTUNG Keterlambatan 1 menit 4 menit 10 menit Kemungkinan berhasil 98 / 100 50 / 100 1 / 100
- 18. CHAIN OF SURVIVAL Early Activation of EMS Early Basic of CPR Early Defibrillation Early Advanced Life Support
- 21. PENDERITA GAWAT DARURAT HIPOKSEMIA HIPERKARBIA HENTI JANTUNG HENTI NAFAS SINDROMA IWR
- 22. CONCEPT • 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
- 23. INITIAL ASSESSMENT / MANAGEMENT Injury Primary survey and adjuncts Resuscitation Reevaluation Secondary survey and adjuncts Reevaluation Optimize patient status Transfer
- 24. Primary survey and resuscitation of vital functions are done simultaneously – a team approach
- 25. PENANGANAN PASIEN TIDAK GAWAT • Anamnesa • Pemeriksaan fisik Inspeksi Palpasi Perkusi Auskultasi • Pemeriksaan penunjang • Diagnosa • Terapi Supportif Simtomatis Definitif / kausal
- 26. PENANGANAN 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
- 27. CPCR / RJPO (Peter Safar) 1. Basic life support emergency oxygenation A : Airway B : Breathe C : Circulate 2. Advanced life support Restoration of spontaneous circulation D : Drugs and Fluids E : EKG F : Fibrillations treatment 3. Prolonged life support post resuscitation brain – oriented therapy G : Gauging H : Human mentation I : Intensive care
- 28. KONSEP ATLS • Primary Survey A : Airway with C-spine control B : Breathing with ventilation C : Circulation with hemorrhage control D : Disability : neurologic status E : Exposure/environment with temperature control • Resuscitation • Secondary Survey Head – to – toe evaluation and history • Reevaluation • Definitive care
- 29. KEY POINTS ACLS In the Primary Survey, focus on basic CPR and defibrillation First A-B-C-D • Airway : Open the airway • Breathing : Provide positive – pressure ventilations • Circulation : Give chest compressions • Defibrillation: Shock ventricular fibrillation or pulseless ventricular tachycardia (VF/VT)
- 30. KEY 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
- 31. PPGD (Penanggulangan penderita gawat darurat) Dokter umum BLS ALS PLS NLS ACLS HIGH RISK HIGH FREQUENCY HIGH SUCCESS PROCEDURE - PRIMARY PREVENTION - SECONDARY PREVENTION LOCAL SPECIFIC - MALARIA - DHF - GE BLS : Basic life support (A, B, C, BRAIN) ALS : Advance life support ATLS : Advance trauma life support (Trauma oriented L.S) ACLS : Advance cardiac life support (Cardiac oriented L.S.) NLS : Neonatal life support PLS : Pediatric life support OLS : Obstetric life support PTC OLS PTC : Primary trauma care A : Airway B : Breathing C : Circulation Dsan: Dokter spesialis Anestesi PENANGGULANGAN PENDERITA GAWAT DARURAT Basic General Emergency Life Support (GELS) ATLS
- 32. LIFE SUPPORT A : Airway Support B : Breathing Support C : Circulation Support D : Disability / Brain Support
- 33. First responder Life saver Resusitasi – stabilisasi Airway Breathing Circulation Brain
- 34. SHOCK KARENA PERDARAHAN 1 2 3 Resusitasi Stabilisasi Definitif terapi awal Definitif terapi akhir Dr. Penyakit Perdarahan Dalam G.I. Dr. Bedah Perdarahan trauma Dr. Obgyn Perdarahan post partum Dr. Umum Dr. Spesislias Pembagian Peran Dr. Umum – Dr. Spesialis
- 35. PROTECTION FROM COMMUNICABLE DISEASE • Water impermeable apron • Gown • Gloves • Face mask • Cap • Eye protection / goggles • Foot covers To prevent contact with body fluids patients
- 37. T P U Peserta mampu melakukan pengelolaan jalan nafas. T 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)
- 38. PRIORITAS UTAMA • Airway Bebas dan terjaga • Breathing / ventilation Adekuat • Supplemen oxygen Adekuat
- 40. PRIMARY SURVEY Establish patent airway Caution sign : Cervical spine injury
- 41. PRIMARY SURVEY Assume C-Spine Injury • Multisystem trauma • Altered level of consciousness • Blunt injury above clavicle
- 42. SUMBATAN JALAN NAFAS Penyebab • Penurunan kesadaran Tindakan anestesi Koma Trauma kepala Radang otak Obat / alkohol dll • Suatu penyakit Laringitis Edema laring
- 43. ………sumbatan jalan nafas • Trauma / Kecelakaan Maksilofacial Jalan nafas dll • Benda asing Darah Muntahan Makanan dll
- 44. • Macam Parsial Ringan Berat Total ………sumbatan jalan nafas
- 45. SUATU SEBAB PENDERITA TAK SADAR RELAKSASI OTOT HILANG REFLEKS PERLINDUNGAN LIDAH “KLEP” SUMBATAN JALAN NAFAS MUNTAH REGURGITASI ASPIRASI
- 46. SUMBATAN JALAN NAFAS • Look / Lihat Perubahan Status Mental Agitasi / gelisah Hipoksemia Obtundasi / teler Hiperkarbia Gerak Nafas Normal See saw / rocking Retraksi Deformitas Debris Darah / sekret Muntahan Gigi Sianosis
- 48. SUMBATAN JALAN NAFAS • Listen / Dengar Bicara normal Tak ada sumbatan Ada suara tambahan Snoring Lidah Gurgling Cairan Stridor / crowing Penyempitan Suara parau (hoarseness / dysphonia) • Feel / Raba Hawa nafas Krepitasi / fraktur (maxillofacial / laryngeal) Deviasi trakhea Hematoma Getaran di leher
- 49. MACAM SUMBATAN SUMBATAN BEBAS PARSIAL RINGAN PARSIAL BERAT TOTAL LOOK GERAK NAFAS NORMAL NORMAL SEE SAW SEE SAW LISTEN SUARA TAMBAHAN ⊝ ⊕ ⊕ ⊝ FEEL HAWA EKSHALASI ⊕ ⊕ + ⊝
- 50. 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
- 52. PENYEBAB SUMBATAN • Lidah • Epiglotis • Benda asing / muntahan / darah / sekret • Trauma jalan nafas
- 53. PEMBEBASAN JALAN NAFAS PENYEBAB LIDAH • Manual : - Non trauma : Head tilt Neck lift Chin lift Jaw thrust - Trauma : Chin lift Jaw thrust Dengan in-line manual immobilization” atau pasang cervical collar • Bantuan Alat - Oropharyngeal airway - Nasopharyngeal airway
- 54. Pada pasien trauma head tilt neck lift Don’t do Be careful neck lift chin lift
- 58. Naso-pharyngeal tube Tidak merangsang muntah Ukuran u/ dewasa 7 mm atau jari kelingking kanan Nasopharyngeal tube
- 60. PEMBEBASAN JALAN NAFAS PENYEBAB BENDA ASING • Manual • Penghisap • Definitive airway • Pada chocking : Back blows Abdominal thrust (Heimlich manuver) Thoracal thrust Cricothyroidotomy
- 62. Lima kali hentakan pada punggung, diantara dua scapula CHOKING Back blows
- 65. Korban : Tidak sadar Heimlich Abdominal trust
- 67. DEFINITIVE AIRWAY • Cuffed tube in trachea • Secure airway • Ventilation • Types : - Endotracheal intubation - Surgical airway - Cricothyrotomy - Tracheotomy
- 68. Membrana cricothyroid Pada keadaan gawat darurat - Tempat injeksi transtracheal obat emergency - Tempat untuk needle dan surgical cricothyroidotomi Bagaimana caranya ?? Obat apa saja boleh masuk ??
- 69. DEFINITIVE AIRWAY Indications 1. Apnea 2. Risk of aspiration 3. Insecure airway 4. Poor oxygenation 5. Impending airway compromise 7. Closed head injury
- 70. TUJUAN 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 ENDOTRAKHEAL • Orotrakehal Lewat mulut • Nasotrakheal Lewat hidung
- 71. ENDOTRACHEAL INTUBATION The trachea should be intubated by properly trained personnel
- 72. PERALATAN 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
- 74. INTUBASI
- 79. INTUBASI 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)
- 88. PEDIATRIC 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
- 89. T P U Peserta mampu menangani kegawatan nafas/breathing T P K Peserta mampu : -Mendiagnosa kegawatan nafas -Mengetahui penyebab kegawatan nafas -Mengelola kegawatan nafas - tanpa alat - dengan alat B (BREATHING)
- 90. GANGGUAN VENTILASI Penyebab • Tindakan anestesi • Penyakit • Kecelakaan trauma Lokasi • Sentral Pusat nafas • Perifer Jalan nafas Dinding dada Paru Otot nafas Rongga pleura Syaraf & jantung
- 92. GANGGUAN VENTILASI (penderita masih bernafas) Look / Lihat Sianosis Takhipnea Status mental Distensi vena leher Asimetri dada Paralisis otot nafas Listen / dengar Keluhan: “Tak bisa nafas!” Stridor, wheeze atau hilang suara nafas
- 93. Feel / raba Hawa ekspirasi Emfisema subkutan Krepitasi / tenderness / nyeri Deviasi trakhea Adjuncts Pulse oximeter CO2 detector Gas darah X-ray dada …………gangguan ventilasi (penderita masih bernafas)
- 94. BEBERAPA ISTILAH • Ventilation Aliran (volume) udara keluar – masuk paru • Tidal volume Volume udara yang dihisap/dikeluarkan pada satu kali nafas biasa 6 – 8 ml / kg bb 70kg: 400 – 55 ml • Minute volume Tidal volume x freq. 6 – 8 l / menit
- 95. • Hipoventilation Minute volume berkurang • Hiperventilation Minute volume meningkat • Parameter ventilasi PaCO2 N= 35 – 45 mmHg Hipoventilasi PaCO2 Hiperventilasi PaCO2 ………….beberapa istilah
- 96. 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.163 After 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 Tx Normal Criteria
- 97. DASAR PEMBERIAN VENTILASI • Intermittent positive pressure ventilation (IPPV) • Penderita tak bernafas Nafas buatan (controlled ventilation) • Penderita masih bernafas / tak adekuat Nafas bantuan (assisted ventilation) Diberikan pada akhir ekspirasi • Tekanan oropharing > 25 cm H2O udara masuk esophagus distensi lambung
- 98. ………….dasar pemberian ventilasi • Sellick’s maneuver Menekan cricoid kebelakang sehingga esophagus terjepit diantara cricoid dan corpus vertebra leher Agar : Udara tak masuk lambung Isi lambung tak mengalir ke oropharing Tak boleh pada cedera tulang leher • Nafas buatan : Tidak volume 10-15ml/kg Frequensi 12-15 / m
- 99. CARA PEMBERIAN VENTILASI Tanpa Alat Mouth to mouth Mouth to nose Mouth to mouth and nose Dengan Alat Safar airway Esophageal obturator airway Face mask / pocket mask Laryngeal mask Bag-valve-mask Bag-valve-tube Ventilator
- 101. Nafas buatan
- 103. SUPPLEMENTAL OXYGEN 1. Nasal cannula / prong Low – flow system Flow O2 : 1-6 L/m FiO2 : 24-44% (1 L O2/M FiO2 4%) 2. Face mask Law – flow system Flow O2 : 8-10 L/m FiO2 : 40-60 % 3. Face mask with oxygen reservoir Constant – flow Flow O2 : 6-10 L/m FiO2 : 6L O2 / m + 60 % ((1 L O2/M FiO2 10%) 4. Venturi mask High gas flow Fixed oxygen concentration Flow O2 & FiO2 diatur 24 %, 28%, 35% dan 40%
- 104. Terapi oksigen NASAL PRONG O2 flow 1 – 6 lpm FiO2 : 24 – 44 % BAG VALVE MASK (BVM) Dgn oksigen 8-10 lpm : 60% Masker sederhana Dengan reservoir bag Flow O2 : 6-10 lpm FiO2 : 60%- 100% BVM Dengan reservoir bag Flow O2 : 8-10 lpm FiO2 : 80%- 100% Jackson Rees Flow O2 : 8-10 lpm FiO2 : 100% BVM Dengan reservoir bag Flow O2 : 8-10 lpm FiO2 : 80%- 100% FACE MASK O2 8-10 lpm FiO2 : 40-60%
- 105. 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
- 106. T P U Peserta mampu mengelola kegawatan sirkulasi. T P K Peserta mampu : -Mendiagnosa gangguan sirkulasi -Melakukan penanganan gangguan sirkulasi C (Circulation)
- 107. C (Circulation) Assessment of organ perfusion - Level of conciousness - Skin color and temperature - Pulse rate and character - Urinary output
- 108. SHOCK An abnormality of the circulatory system that result in inadequate organ perfusion and tissue oxygenation
- 109. GANGGUAN SIRKULASI • Syok • Disritmia • Henti jantung • dll
- 110. SHOCK RECOGNITION AND MANAGEMENT • Recognize signs of inadequate perfusion and oxygenation • Identify probable cause • Restore perfusion • Re-evaluate patient response • Immediate involvement by specialists
- 111. CLINICAL SIGNS 1. Tachycardia 2. Vasoconstriction 3. cardiac output 4. Narrow pulse pressure 5. MAP 6. blood flow Remember : Compensatory mechanisms
- 112. CLASSIFICATION OF SHOCK Trauma : - Haemorrhagic - Non haemorrhagic Cardiogenic Tension pneumothorax Neurogenic Septic
- 113. ….. Classification of shock Hypovolemic : - Haemorrhage - Diarrhoea - Burn Distributive - Septic - Anaphylaxsis - Spinal cord injury
- 114. ….. Classification of shock Cardiogenik : - Arrytmias - Heart failure - Myocardial contusion / infarction Obstructive - Tension pneumothorax - Cardiac tamponade - Haemopneumothorax Disscociative - Profound anemia - Co poisoning
- 115. CO = SV X F preload C after load EDV SVR VR BP = CO X SVR
- 116. T P U Peserta mampu menilai gangguan kesadaran. T 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)
- 117. Baseline neurologic evaluation Level of consciousness - AVPU - GCS Pupil D (DISABILITY)
- 118. GLASGOW COMA SCALE Variabels Score Eye opening (E) Spontaneous 4 To speech 3 To pain 2 None 1 Best motor response (M) Obeys commands 6 Localizes pain 5 Normal flexion (withdraws) 4 Abnormal flexion (decorticate) 3 Extension (decerebrate) 2 Non (Flaccid) 1 Verbal response (V) Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Verbal response Score Appropriate words or social smile, fixes and follows 5 Cries, but consolable 4 Persistently irritable 3 Restless, agitated 2 None 1 PEDIATRIC VERBAL SCORE GCS score = (E+M+V) Best possible score= 15 worst possible sore =3