kuliah MPDU

1. dr. Muhadi SpPD KKV M.Epid FINASIM
Divisi Kardiologi Dept IPD FKUI-KSM IPD RSCM
BLS ACLS IKKI ITC Coordinator
Focus on Adult Basic and Advanced Life Support

2. Introduction
The 2020 Guidelines are a
comprehensive revision of the AHA’s
guidelines for adult, pediatric,
neonatal, resuscitation education
science, and systems of care topics.
Overall, 491 specific
recommendations are made for
adult, pediatric, and neonatal life
support; resuscitation education
science; and systems of care

3. KeyIssuesand
MajorChanges
 Enhanced algorithms and visual aids.
 The importance of early initiation of CPR by lay
rescuers.
 Early epinephrine administration.
 Use of real-time audiovisual feedback is
suggested to maintain CPR quality.
 Continuously measuring arterial blood
pressure and endtidal carbon dioxide (ETCO2)
during ACLS resuscitation to improve CPR
quality.
 Routine use of double sequential defibrillation
is not recommended

4. KeyIssuesand
MajorChanges
 Intravenous (IV) access is the preferred route of
medication administration during ACLS
resuscitation. Intraosseous (IO) access is acceptable
if IV access is not available.
 Care of the patient after ROSC requires close
attention to oxygenation, BP control, evaluation for
PCI, targeted temperature management (TTM), and
multimodal neuroprognostication.
 Management of cardiac arrest in pregnancy focuses
on maternal resuscitation, with preparation for early
perimortem cesarean delivery if necessary to save
the infant and improve the chances of successful
resuscitation of the mother

5. Algorithmsand
VisualAids
IHCA and OHCA Chains of Survival
The Universal Adult Cardiac Arrest
New Opioid-Associated Emergency
Algorithms
The Post–Cardiac Arrest Care
Algorithm
A new diagram to guide and inform
neuroprognostication
A new Cardiac Arrest in Pregnancy
Algorithm

6. Asixth link,
Recovery,was
added totheIHCA
andOHCAChains
ofSurvival
AHA Chains of Survival for adult IHCA and OHCA

7. AdultBasicLife
Support

8. COVID-19
and
resuscitation
 Wabah infeksi SARS-CoV2 yang terus meningkat dan
menyebar luas tentu berdampak pada upaya resusitasi
dan memunculkan kebutuhan untuk memodifikasi
praktik resusitasi yang telah ada pada tatalaksana
kegawatan kardiovaskuler

9. COVID-19
andCardiac
arrest
 Sekitar 12-19% pasien yang positif COVID-19
membutuhkan perawatan di rumah sakit, dan 3-6%
berada pada kondisi kritis.
 Komplikasi seperti hipoksemia akibat gagal nafas akut,
jejas miokard, aritmia ventrikular, dan syok banyak
dijumpai pada pasien kritis dan menyebabkan pasien
tersebut lebih berisiko mengalami henti jantung.
 Tantangan yang dihadapi adalah bagaimana
memastikan pasien dengan atau tanpa COVID-19 yang
mengalami henti jantung mendapatkan kesempatan
untuk selamat tanpa membahayakan keselamatan
penolong

10. Riskof
resuscitation
duringCOVID-19
 Upaya resusitasi meningkatkan risiko penularan terhadap
tenaga kesehatan karena berbagai alasan :
1. RJP meliputi berbagai prosedur yang menghasilkan
aerosol, termasuk di dalamnya kompresi dada, ventilasi
tekanan positif, dan pemasangan alat bantu nafas lanjut
(advanced airway). Selama prosedur ini, partikel virus
dapat tersuspensi di udara dengan waktu paruh kurang-
lebih 1 jam dan dihirup oleh orang-orang yang ada di
sekitarnya.
2. Upaya resusitasi mengharuskan sejumlah penolong untuk
bekerja dalam jarak dekat baik satu sama lain maupun
dengan pasien.
3. Henti jantung merupakan kegawatdaruratan dimana
kebutuhan pasien untuk mendapat resusitasi dalam waktu
cepat dan hal ini berpotensi menurunkan kewaspadaan
standar untuk mengontrol infeksi.

11. PrinsipUmum
Resusitasipada
PasienTerduga/
PositifCOVID-19

12. BLSforCOVID-19
(April2020)

13. TheuniversalAdultCardiac
ArrestAlgorithmwas
modifiedtoemphasizethe
roleofearlyepinephrine
administrationforpatients
withnonshockablerhythms

14. ACLSforCOVID-19
(April2020)

15. Cardiopulmonary
ResuscitationAnd
Posterior
DefibrillationIn
ThePronePosition
 Prone position as treatment for acute respiratory distress
syndrome (ARDS) has been firstly described in 1976.
 During the current coronavirus disease 2019 (COVID-19)
pandemic, it has been widely used in both spontaneously
breathing and mechanically ventilated patients with acute
respiratory failure.
 An increasing number of cardiac arrests is expected
during COVID-19 era in the prone position.
 Since 2005, the American Heart Association (AHA)
Guidelines for CPR and Emergency Cardiovascular Care
recommended that CPR in the prone position might be
reasonable when the patient cannot be replaced in the
supine position without prejudice, particularly in
hospitalized patients with an advanced airway in place

16. Cardiopulmonary
ResuscitationAnd
Posterior
DefibrillationInThe
PronePosition
Untuk pasien dengan posisi pronasi saat henti jantung
 Pada pasien terduga/ positif COVID-19 yang berada
dalam posisi pronasi tanpa alat bantu nafas lanjut
(advanced airway), upayakan untuk reposisi pasien ke
dalam posisi supinasi untuk melanjutkan resusitasi
 Meskipun efektivitas RJP dalam posisi pronasi tidak
diketahui secara pasti, untuk pasien yang berada dalam
posisi pronasi dengan alat bantu nafas lanjut (advanced
airway), hindari reposisi ke supinasi kecuali tidak ada
risiko lepas alat bantu nafas dan aerosolisasi.
 Pertimbangkan untuk menempatkan bantalan
defibrilasi pada posisi anterior-posterior dan berikan
RJP dalam posisi pronasi dengan tangan di posisi
standar di atas korpus vertebra T7 atau T10

17. Cardiopulmonary
ResuscitationAnd
Posterior
DefibrillationInThe
PronePosition
a) antero-posterior placement
b) bi-axillary placement
c) postero-lateral placement.
a) midline position
b) lateral position
c) one-hand technique with sternal
counterpressure

19. Terminationof
Resuscitation

20. Tachycardia
Success rates for the Valsalva maneuver in terminating
SVT range from 19% to 54%.
Augmenting the Valsalva maneuver with passive leg raise
is more effective. (REVERT trial)

21. PSVT
Mnemonic

22. Postural modification to the standard Valsalva manoeuvre for
emergency treatment of supraventricular tachycardias
(REVERT) Performing the modified Valsalva maneuver
1. Position the patient in a semi-recumbent position (45º)
2. Instruct the patient to blow into the tip of a 10cc syringe
for 15 seconds. The patient should be targeting a
pressure reading on the manometer of 40mmHg, or
blowing hard enough to move the plunger tip*
3. Lower the patient flat and passively raise their legs to a
45º angle for 15 seconds
4. Return the patient to a semi-recumbent position for an
additional 45 seconds
5. Assess the rhythm
6. Repeat x1 if unsuccessful before moving on to
adenosine or electrical cardioversion (provided the
patient remains stable)
 *The REVERT trial used a manometer to measure 40mmHg of
pressure, however Smith and Boyle have demonstrated that
40mmHg of pressure is generated when a patient is instructed
to blow into a 10cc syringe until the plunger moves

23. IV Medications Commonly Used for Acute Rate Control in
Atrial Fibrillation and Atrial Flutter

24. Bradycardia

25. NewOpioid-Associated
EmergencyAlgorithms
havebeenaddedfor
trainedrescuers

26. NaloxoneDose
andRouteof
Administration

27. ThePost–CardiacArrest
CareAlgorithmwas
updatedtoemphasize
theneedtoprevent
hyperoxia,hypoxemia,
andhypotension

28. Anewdiagramhas
beenaddedtoguide
andinform
neuroprognostication
Recommended approach to multimodal neuroprognostication
in adult patients after cardiac arrest

29. AnewCardiacArrest
inPregnancy
Algorithm

30. Major Newand
Updated
Recommendations
 Early Initiation of CPR by Lay Rescuers
 Early Administration of Epinephrine (for cardiac arrest
with a nonshockable rhythm)
 Use audiovisual feedback devices during CPR for real-
time optimization of CPR performance
 Use physiologic parameters such as arterial blood
pressure or ETCO2 when feasible to monitor and
optimize CPR quality (This monitoring depends on the
presence of an ETT or arterial line, respectively).
Targeting compressions to an ETCO2 value of at least
10 mm Hg, and ideally 20 mm Hg or greater, may be
useful as a marker of CPR quality

31. Major Newand
Updated
Recommendations
 The usefulness of double sequential defibrillation for
refractory shockable rhythm has not been established.
 IV Access Preferred Over IO
 Post–Cardiac Arrest Care and Neuroprognostication
 Care and Support During Recovery
 Cardiac Arrest in Pregnancy (pregnant patients are
more prone to hypoxia, oxygenation and airway
management should be prioritized during resuscitation
from cardiac arrest in pregnancy)