Professional Documents
Culture Documents
Oral Airways
are designed to keep the
tongue from falling back
and blocking the upper
airway
easily available in six to
nine sizes
are only used in
unresponsive patients
without a gag reflex
do not eliminate the need
to monitor airway for
patency
Nasopharyngeal Airways
Curved, flexible rubber or plastic tubes
inserted into the patients nostril
Use on responsive patients who need an
airway assist
TOLONG !!!!
HUBUNGI DOKTER
ADA RESPON
TIDAK ADA
RESPON
ADA NAFAS
TIDAK ADA NAFAS
MENELUSURI SAMPAI
UJUNG TULANG DADA
PERGUNAKAN PANGKAL
TELAPAK TANGAN
JARI TIDAK MENYENTUH
PASIEN
Gerakan
Naik
Turun
Lengan tetap
lurus
TIUP 2 KALI
PIJAT JANTUNG 30 KALI
TIUP 2 KALI
PIJAT JANTUNG 30 KALI
TIUP 2 KALI
PIJAT JANTUNG 30 KALI
TIUP 2 KALI
PIJAT JANTUNG 30 KALI
RESUSITASI
JANTUNG PARU
SATU SIKLUS
TERABA NADI
TIDAK TERABA NADI
TERABA NADI
JANTUNG PASIEN BERDENYUT
HENTIKAN RESUSITASI JANTUNG PARU
POSISIKAN PASIEN DENGAN POSISI
MANTAP
PASIEN MEMERLUKAN PENANGANAN
LEBIH LANJUT
BAWA PASIEN KE PETUGAS KESEHATAN
ADA RESPON
PASIEN SADAR
PASIEN MEMERLUKAN
PEMERIKSAAN LEBIH
LANJUT
BAWA PASIEN KE
PETUGAS KESEHATAN
ADA NAFAS
TERABA NADI
JANTUNG MASIH BERDENYUT
PERTAHANKAN JALAN NAFAS TETAP
TERBUKA
BERIKAN NAFAS BANTUAN 16 20
KALI/PERMENIT
PASIEN MEMERLUKAN PENANGANAN
LEBIH LANJUT
TETAP BERIKAN NAFAS BANTUAN BILA
MEMUNGKINKAN
BAWA KE PETUGAS KESEHATAN
KAPAN RESUSITASI
DIHENTIKAN
PASIEN ADA TANDA-TANDA SADAR :
REFLEK BATUK, NADI TERABA
BANTUAN PETUGAS KESEHATAN
DATANG ; RESUSITASI DILANJUTKAN
OLEH PETUGAS KESEHATAN
YANG MELAKUKAN RESUSITASI
KELELAHAN DAN TIDAK ADA
PENGGANTINYA
TIDAK ADA TANDA TANDA PERBAIKAN
SETELAH DILAKUKAN LEBIH DARI 30
MENIT
Imobilisasi Tulang
Belakang
Spinal Board
Imobilisasi Tulang
Belakang
Kendriks Extrication
Device
Rapid Extrication
Mengangkat Tandu
1. Dekati tandu dan ketahui jumlah berat yang akan kita
angkat.
2. Bila jumlah berat yang kita angkat untuk berdua sesuai dengan
kemampuan kita maka kita akan lakukan. Tetapi kalau tidak maka
kita memerlukan teman yang lain.
3 . Mulai mengangkat dengan menjaga kelurusan tulang belakang
A. Gunakan gengaman yang kuat untuk menahan tekanan yang kuat Letakan kaki yang lemah pada bagian
depan
B. Letakan gengaman tangan pada jarak 10 inc (25 cm) dengan tangan yang lain.
C. Pada saat anda beridiri anda pastikan bahwa anda menjaga kelurusan tulang belakang
RAGAM TANDU
RAGAM TANDU
RAGAM TANDU
RAGAM TANDU
Memindah
Korban
Menarik Dengan
Selimut
SELALU JAGA KELURUSAN PUNGGUNG ANDA !!!
Memindah
Korban
Menarik Lengan
Memindah
Korban
Menarik Baju
Langkah 1. Rapatkan
tandu ke tempat tidur
Langkah 2. Raih &
pegang ujung sprei
Langkah 3. Geser
perlahan ke arah
stretcher
Langkah 4. Atur Pasien di
atas tandu
Kelurusan
Selalu Jaga
Punggung Anda !!!
The
EsophagealTracheal
Combitube
(ETC)
Class IIa
Combitube - Technique
100 ml of air
into blue cuff
Insert 15 ml of
air into white
cuff
Combitube - Technique
If ventilation is
inadequate
change to the
other port
Begin with
longer or port
closer to you
Bag-Valve-Mask (BVM)
Ventilation
Oxygen delivery
Bag-Valve-Mask (BVM)
Ventilation
Oxygen delivery
Bag-Valve-Mask (BVM)
Ventilation
Oxygen delivery
Stylet
ET Intubation Technique
If trauma is not
suspected, place
patients head in
sniffing position
Aligns axes of mouth, pharynx,
and trachea
ET Intubation Technique
Advance the laryngoscope
blade until the distal end
reaches the base of the
tongue
ET Intubation Technique
Lift the laryngoscope to
elevate the mandible without
putting pressure on the front
teeth
Visualize the epiglottis
Suction the
laryngopharynx as
necessary
Identify the vocal cords
Place the blade in proper
position
ET Intubation - Complications
Bleeding
Laryngospasm
Tube occlusion
Mucosal necrosis
Inability to talk
Barotrauma
Aspiration
Cuff leak
Dysrhythmias
Esophageal intubation
ET Intubation - Technique
Secure ET tube with
commercial tubeholder (preferred) or
tape
Provide ventilatory
support with
supplemental oxygen
After securing the tube,
observe and record
tube depth at the
patients teeth
What About?
Condensation within the tube as an indicator
In this model, condensation on the inner surface of the
endotracheal tube was common after placement within
the esophagus. If these results are confirmed in human
studies, the presence of a vapor trial should not be used
as a clinical indicator of correct endotracheal tube
placement
Ann Emerg Med. 1998 May;31(5):575-8.Related Articles, Links
Tube migration?
How to secure the tube?
Types of Solutions
CRYSTALLOIDS
Isotonic
Hypotonic
Hypertonic
COLLOIDS
Always hypertonic
Crystalloids
Solutions with small molecules that flow
easily from the bloodstream into cells and
tissues.
Crystalloid Solutions
Isotonic solutions have a concentration of
dissolved particles equal to that of intracellular
fluid.
Hypertonic solutions have a greater concentration
of dissolved particles than does intracellular
fluid.Fluid is pulled from cells
Hypotonic solutions have less particles than does
intracellular fluid.Fluid flows into cells
SO WHAT!!!!
The wrong fluid for the wrong patient
can make a critical difference in their
outcome. Dont depend on the
physician. KNOW YOUR FLIUDS
In Diffusion,
solutes(particles)
move from an area of
high concentration to
an area of lesser
concentration.
PARTICLES MOVE
ISOTONIC FLUIDS
Osmotic pressure is the same both inside
and outside the cell.
Cells neither shrink nor swell with fluid
movement.
Same tonicity as plasma
Hypotonic Solutions
Osmotic pressure is less than intracellular fluid
Water is drawn into the cells from the extracellular
fluid causing them to swell
Inappropriate use can result in increased ICP and
cardiovascular collapse from volume depletion.
May cause blood cells to burst
Volume Depletion?
Hypertonic Solutions
Osmotic pressure is greater than that of
intracellular fluid. Hypertonic solutions have a
large concentration of solutes(particles).
Water is drawn from the cells to equalize the
concentration, which causes the cells to shrink.
Inappropriate use can cause fluid overload and
pulmonary edema
Isotonic Fluids
0.9% Sodium Chloride ( Normal Saline )
Lactated Ringers
Dextrose 5% in Water (D5W)
Normal Saline
Uses
Shock
Resuscitation
Fluid challenges
Blood transfusions
Metabolic alkalosis
Hyponatremia
DKA
Special
considerations
Use with caution in
patients with heart
failure, edema, or
hypernatremia
Can lead to overload
Lactated Ringers
Uses
Dehydration
Burns
GI tract fluid loss
Acute blood loss
Hypovolemia
Special Considerations
Contains Potassium, can
cause hyperkalemia in
renal patients
Patients with liver disease
cannot metabolize lactate
Lactate is converted into
bicarb by liver
D5W
Uses
Fluid loss and
dehydration
Hypernatremia
Special Considerations
Solution becomes
Hypotonic when
dextrose is
metabolized
Do not use for
resuscitation
Use cautiously in renal
and cardiac patients
Hypotonic Solutions
0.45% Sodium Chloride (1/2 normal saline)
Special Considerations
Do not give to patients
at risk for ICP
Not for rapid
rehydration
Electrolyte
disturbances can occur
Hypertonic Solutions
5% Dextrose in 0.9% Sodium
Chloride(D5NS)
5% Dextrose in Lactated Ringers (D5LR)
5% Dextrose in 0.45% Sodium Chloride
(D51/2NS)
D5NS
Uses
Heat related disorders
Fresh water drowning
Peritonitis
Special Considerations
Should not be given to
patients with impaired
cardiac or renal
function
Draw blood before
administering to
diabetics
D5LR
Uses
Hypovolemic Shock
Hemorrhagic Shock
Certain cases of
acidosis
Special Considerations
Do not administer in
patients with cardiac
or renal dysfunction
Monitor for
circulatory overload
D5 1/2NS
Uses
Heat exhaustion
Diabetic disorders
TKO solution in
patients with renal or
cardiac dysfunction
Special Considerations
Not for rapid fluid
replacement
Colloids
Albumin
Plasma Protein fraction
Dextran
Hetastarch
Colloids are made up of much larger solutes
than are crystalloids
Colloids
Plasma Expander
Used if crystalloids do not improve blood
volume
Colloids pull fluid into the bloodstream,
remember they are always Hypertonic
Watch for increased BP, Dyspnea, and
bounding pulse
Tunneled Vs Nontunneled
Groshong, Broviac,
and Hickman
Single or multi lumen
Tunneled through
tissue for several
inches to the
cannulated vein
Used for intermittent
or continued therapy
Swan-Ganz Catheter
The Swan - Ganz is a long
plastic tube with several
openings.Its purpose is to
measure the pressures in
the heart and vessels going
to the lungs.After
placement, a monitor is
attached that displays
numbers and wave forms
that help to assess heart
and lung function.
Quinton Catheter
Temporary
hemodialysis access
2 lumens, one for
intake and one for
venous return
Infection risk is high.
Mid-Term Devices
Peripherally Inserted Central Catheter
Mid Line Catheter
PICC
Can be single or multi
lumen.
Used for extended home
TPN
Home health care use
Administration of meds
and fluids
Used when repeated IV
sticks would be necessary
Midline Catheter
Similar to a PICC but
not a true central line
Catheter is advanced
only into the upper
arm
Not used when caustic
agents such as chemo
will be needed
Hickman-Broviac
Tunneled from chest wall
to subclavian vein and
continues to superior vena
cava
Good as long as line is
patented and not
infected(months-years)
Commonly used for
oncology
Broviac is smaller and
generally used in peds
Groshong
Similar to Hickman
however catheter is closed
when not in use
Requires only a saline
flush weekly
Used in patients where
heparin is undesirable due
to low platlet count
Good for long periods
Groshong
IVADs
Portacath-Inserted in the
chest below the
clavicle.Access is gained
by puncturing the skin
then the synthetic port
Permacath-Lasts
longer.Up to a year
Passport-Placed in the arm
instead of chest.Cheapest
Hohn Catheter
Similar to Hickman
but it lies just under
the insertion point
rather than up the
subcutaneous portion
of the catheter body
REMEMBER
Many of these vascular access
devices are sealed with a heparin
solution. Some contain as much as
5000U - 7500U. You can
significantly anticoagulate your
patient if this heparin is not drawn
off before administering fluids or
medications
QUESTIONS
ACLS
ACLS
ACLS is mostly CPR, but with
extras:
drugs
electricity
ACLS
Dysrhythmias
Brady- or tachy- cardia
Asystole
Tachycardia
sudden onset of rapid heart rate
what do you do?
Tachycardia
ALWAYS CHECK THE PATIENT FIRST
1. Check for a pulse
2. Check the blood pressure
3. Make a diagnosis
Tachycardia
Case 1
On ward, sudden onset of palpitations
Does the patient have a pulse? Yes
2. What is the blood pressure? 60/20
1.
Definition of Unstable
presence of any one of:
1.
2.
3.
4.
5.
Unstable Tachycardia
DISCLAIMER: in the OR, it is different
Bleeding unstable tachycardia
treat with a blood transfusion!!
This algorithm is for non sinus rhythm
Unstable Tachycardia
Electrical Shock
defibrillation or
cardioversion (= synchronized)
action: resets all activity to zero
good for tachycardia (non-sinus)
good for ventricular fibrillation (VF)
Electrical Shock
defibrillation or
cardioversion (= synchronized)
NOT USED FOR:
sinus rhythm
bradycardia
asystole
Case #2
Alarm on ECG monitor makes noise!!
Case #2
Diagnosis?
ECG lead is disconnected
ECG shows artifact
Case #3
Alarm on ECG monitor makes noise!!
Case #2
VF
Drugs
improve success of defibrillation (the cure)
do NOT cure VF
lidocaine
procainamide
amiodarone
VF
What is the cardiac output in VF?
Zero. There is no circulation
What MUST occur at all times?
CPR unless defib. is happening.
How do you manage ventilation?
bag-mask and early intubation
VF Summary
VF Easy Algorythm:
CPR
Case #4
BP 60/30
Diagnosis?
Treatment?
Case #5
BP 60/30
Diagnosis?
Treatment?
Questions?
decrease HR
increase BP
check Hb
ABG INTERPRETATION
Marc D. Berg, MD DeVos Childrens Hospital
Rita R. Ongjoco, DO Sinai Hospital of Baltimore
ABG Interpretation
First, does the patient have an acidosis or an
alkalosis
Second, what is the primary problem
metabolic or respiratory
Third, is there any compensation by the
patient respiratory compensation is
immediate while renal compensation takes
time
ABG Interpretation
It would be extremely unusual for either the
respiratory or renal system to
overcompensate
The pH determines the primary problem
After determining the primary and
compensatory acid/base balance, evaluate
the effectiveness of oxygenation
Normal Values
pH 7.35 to 7.45
paCO2 36 to 44 mm Hg
HCO3 22 to 26 meq/L
Abnormal Values
pH < 7.35
Acidosis (metabolic
and/or respiratory)
pH > 7.45
Alkalosis (metabolic
and/or respiratory)
paCO2 > 44 mm Hg
Respiratory acidosis
(alveolar hypoventilation)
paCO2 < 36 mm Hg
Respiratory alkalosis
(alveolar hyperventilation)
HCO3 < 22 meq/L
Metabolic acidosis
HCO3 > 26 meq/L
Metabolic alkalosis
Compensation
The bodys attempt to return the acid/base
status to normal (i.e. pH closer to 7.4)
Primary Problem Compensation
respiratory acidosis metabolic alkalosis
respiratory alkalosis metabolic acidosis
metabolic acidosis
respiratory alkalosis
metabolic alkalosis respiratory acidosis
Expected Compensation
Respiratory acidosis
Acute the pH decreases 0.008 units for
every 1 mm Hg increase in paCO2; HCO3
0.1-1 mEq/liter per 10 mm Hg paCO2
Chronic the pH decreases 0.003 units for
every 1 mm Hg increase in paCO2; HCO3
1.1-3.5 mEq/liter per 10 mm Hg paCO2
Expected Compensation
Respiratory alkalosis
Acute the pH increases 0.008 units for
every 1 mm Hg decrease in paCO2; HCO3
0-2 mEq/liter per 10 mm Hg paCO2
Chronic - the pH increases 0.017 units for
every 1 mm Hg decrease in paCO2; HCO3
2.1-5 mEq/liter per 10 mm Hg paCO2
Expected Compensation
Metabolic acidosis
paCO2 = 1.5(HCO3) + 8 (2)
paCO2 1-1.5 per 1 mEq/liter HCO3
Metabolic alkalosis
paCO2 = 0.7(HCO3) + 20 (1.5)
paCO2 0.5-1.0 per 1 mEq/liter HCO3
Respiratory Alkalosis
Causes
Pain
Anxiety
Hypoxemia
Restrictive lung
disease
Severe congestive
heart failure
Pulmonary emboli
Drugs
Sepsis
Fever
Thyrotoxicosis
Pregnancy
Overaggressive
mechanical ventilation
Hepatic failure
Uncompensated Metabolic
Acidosis
Normal paCO2, low HCO3, and a pH less
than 7.30
Occurs as a result of increased production
of acids and/or failure to eliminate these
acids
Respiratory system is not compensating by
increasing alveolar ventilation
(hyperventilation)
Elevated AG
Metabolic Acidosis
Causes
Ketoacidosis - diabetic, alcoholic, starvation
Lactic acidosis - hypoxia, shock, sepsis,
seizures
Toxic ingestion - methanol, ethylene glycol,
ethanol, isopropyl alcohol, paraldehyde,
toluene
Renal failure - uremia
Diarrhea
Carbonic anhydrase
inhibitors
Acid administration
(HCl, NH4Cl, arginine
HCl)
Sulfamylon
Cholestyramine
Ureteral diversions
Effectiveness of Oxygenation
Further evaluation of the arterial blood gas
requires assessment of the effectiveness of
oxygenation of the blood
Hypoxemia decreased oxygen content of blood paO2 less than 60 mm Hg and the saturation is less
than 90%
Hypoxia inadequate amount of oxygen available
to or used by tissues for metabolic needs
Mechanisms of Hypoxemia
Inadequate inspiratory partial pressure of
oxygen
Hypoventilation
Right to left shunt
Ventilation-perfusion mismatch
Incomplete diffusion equilibrium
arterial-inspired O2 ratio
PaO2/FIO2
P/F ratio
*RQ=respiratory quotient= 0.8
ABG
PaO2
PaCO2
A-a grad
RA
100%
N*
N
N
N
/N/
N/
N/
N/
N/
Summary
First, does the patient have an acidosis or an
alkalosis
Look at the pH
Summary
Third, is there any compensation by the
patient - do the calculations
For a primary respiratory problem, is the pH
change completely accounted for by the change
in pCO2
if yes, then there is no metabolic compensation
if not, then there is either partial compensation or
concomitant metabolic problem
Summary
For a metabolic problem, calculate the expected
pCO2
if equal to calculated, then there is appropriate
respiratory compensation
if higher than calculated, there is concomitant
respiratory acidosis
if lower than calculated, there is concomitant
respiratory alkalosis
Summary
Next, dont forget to look at the
effectiveness of oxygenation, (and look at
the patient)
your patient may have a significantly increased
work of breathing in order to maintain a
normal blood gas
metabolic acidosis with a concomitant
respiratory acidosis is concerning
Case 1
Little Billy got into some of dads
barbiturates. He suffers a significant
depression of mental status and respiration.
You see him in the ER 3 hours after
ingestion with a respiratory rate of 4. A
blood gas is obtained (after doing the
ABCs, of course). It shows pH = 7.16,
pCO2 = 70, HCO3 = 22
Case 1
What is the acid/base abnormality?
1. Uncompensated metabolic acidosis
2. Compensated respiratory acidosis
3. Uncompensated respiratory acidosis
4. Compensated metabolic alkalosis
Case 1
Uncompensated respiratory acidosis
There has not been time for metabolic
compensation to occur. As the barbiturate
toxicity took hold, this child slowed his
respirations significantly, pCO2 built up in
the blood, and an acidosis ensued.
Case 2
Little Suzie has had vomiting and diarrhea for
3 days. In her moms words, She cant
keep anything down and shes runnin out.
She has had 1 wet diaper in the last 24
hours. She appears lethargic and cool to
touch with a prolonged capillary refill time.
After addressing her ABCs, her blood gas
reveals: pH=7.34, pCO2=26, HCO3=12
Case 2
What is the acid/base abnormality?
1. Uncompensated metabolic acidosis
2. Compensated respiratory alkalosis
3. Uncompensated respiratory acidosis
4. Compensated metabolic acidosis
Case 2
Compensated metabolic acidosis
The prolong history of fluid loss through diarrhea
has caused a metabolic acidosis. The mechanisms
probably are twofold. First there is lactic acid
production from the hypovolemia and tissue
hypoperfusion. Second, there may be significant
bicarbonate losses in the stool. The body has
compensated by blowing off the CO2 with
increased respirations.
Case 3
You are evaluating a 15 year old female in the ER who was brought in by
EMS from school because of abdominal pain and vomiting. Review of
system is negative except for a 10 lb. weight loss over the past 2
months and polyuria for the past 2 weeks. She has no other medical
problems and denies any sexual activity or drug use. On exam, she is
alert and oriented, afebrile, HR 115, RR 26 and regular, BP 114/75,
pulse ox 95% on RA. Exam is unremarkable except for mild
abdominal tenderness on palpation in the midepigastric region and
capillary refill time of 3 seconds. The nurse has already seen the
patient and has sent off routine blood work. She hands you the
result of the blood gas. pH = 7.21 pCO2= 24 pO2 = 45 HCO3 = 10
BE = -10 saturation = 72%
Case 3
What is the blood gas interpretation?
Uncompensated respiratory acidosis with severe
hypoxia
Uncompensated metabolic alkalosis
Combined metabolic acidosis and respiratory
acidosis with severe hypoxia
Metabolic acidosis with respiratory compensation
Case 3
Metabolic acidosis with respiratory compensation
This is a patient with new onset diabetes mellitus
in ketoacidosis. Her pulse oximetry saturation and
clinical examination do not reveal any respiratory
problems except for tachypnea which is her
compensatory mechanism for the metabolic
acidosis. The nurse obtained the blood gas sample
from the venous stick when she sent off the other
labs.