Management of Children in

Emergencies

Dr I Nyoman Budi Hartawan, MSC, SpAK

Pediatric Critical Care Division,

Child Health Department Sanglah
Hospital, Faculty of Medicine University
of Udayana
Introduction
Children's bodies respond to
significant injury and shock differently
than adults.

These differences may be subtle and

difficult to recognize.
providers
providers must
must recognize
recognize these
these differences
differences
in
in order
order to
to provide
provide the the best
best possible
possible care
care for
for
an
an illill or
or injured
injured child.
child.
Anatomical Differences
A childs anatomy differs in four significant
ways from an adults. They are:
Smaller airways
Less blood volume
Bigger heads
Vulnerable internal organs
Anatomical Differences, cont'd
Large tongue in relation
smaller
smaller airway
airway to a small oropharynx
Diameter of the trachea is
smaller
Trachea is not rigid and
will collapse easily
Back of the head is
rounder and requires
careful positioning to keep
airway open
Anatomical Differences, cont'd
Relatively smaller blood
smaller
smaller airway
airway volume
Approximately 70 cc of
less blood for every 1kg (2
less blood
blood volume
volume lbs) of body weight
A 20 lb child has about
700cc of bloodabout the
volume of a medium sized
soda cup
Anatomical Differences, cont'd
Head size is proportionally
smaller
smaller airway
airway larger
Prominent occiput and a
less relatively straight cervical
less blood
blood volume
volume spine
Neck and associated
bigger
bigger heads
heads support structures arent
well developed
Infants and small children
are prone to falling
because they are top
heavy
Anatomical Differences, cont'd
Internal organs are not
smaller
smaller airway
airway well protected
Soft bones and cartilage
less and lack of fat in the rib
less blood
blood volume
volume cage make internal organs
susceptible to significant
bigger
bigger heads
heads internal injuries
Injury can occur with very
internal little mechanism or
internal organs
organs
obvious signs
Segitiga Penilaian
Pediatrik (PAT)

an

Up
il

ay
mp

a
na

na
Pe

fas
Sirkulasi kulit
 Penampilan

Tonus

n
Interaksi

ila
mp
Cara melihat

na
Berbicara/menangis

Pe
Karakteristik Hal yang dinilai
Tone Apakah anak bergerak aktif atau menolak pemeriksaan
dengan kuat?
Apakah tonus ototnya baik atau lumpuh?
Interactiviness Bagaimana kesadarannya? Apakah suara mempengaruhinya?
Apakah ia mau bermain dengan mainan atau alat
pemeriksaan? Atau anak tidak bersemangat berinteraksi
dengan pengasuh atau pemeriksa?
Consolability Apakah ia dapat ditenangkan oleh pengasuh atau pemeriksa?
Atau anak menangis terus atau terlihat agitas sekalipun
dilakukan pendekatan yang lembut?

Look/gaze Apakah ia memfokuskan penglihatan pada muka atau

pandangan kosong?

Speech/cry Apakah anak berbicara atau menangis dengan kuat atau

lemah atau parau?
 Upaya napas

Suara napas
Up
yaa abnormal
Posisi tubuh abnormal
na
fas

Retraksi
Nafas cuping hidung
Tabel 2. Penilaian Upaya Napas
Karakteristik Hal yang dinilai

Suara napas yang tidak Mengorok, parau, stridor, merintih, mengi

normal
Posisi tubuh yang tidak tripoding, menolak berbaring
normal
Retraksi Supraklavikula, intekosta, substernal, head
bobbing
Napas cuping hidung Napas cuping hidung
TRIPOD position
 Sirkulasi Kulit
Mencerminkan kecukupan curah
jantung dan perfusi ke organ vital.

Fungsi kardiovaskular normal :

mukosa kuku, telapak tangan dan
telapak kaki berwarna merah muda.
Sianosis sentral akan tampak jika
lebih dari 5 g% Hb mengalami
desaturasi oksigen.
Kulit tubuh dan ekstremitas
berbercak/mottled pertanda
hipoksemia atau perfusi yang buruk.
Sirkulasi Kulit

Pucat
Mottling
Sianosis
Sirkulasi Kulit
 Tabel 3. Penilaian Sirkulasi
Karakteristik Hal yang dinilai

Pucat Kulit atau mukosa tampak kurang merah

karena kurangnya aliran darah ke
daerah tersebut

Mottling Kulit berbercak kebiruan karena

vasokonstriksi
Sianosis Kulit dan mukosa tampak biru
Mottling

Sianosis
Distres pernafasan Syok

N N
N

N N

Ggn primer SSP/ ggn Gagal Kardiopulmonal

metabolik

N N N /

N N
PENILAIAN ABCDE

A= Airway,
B= Breathing,
C= Circulation,
D= Disability,
E= exposure.
 AIRWAY
SAFE
Shout for help, Approach with care, Free from
danger, Evaluate ABC Are you alrightairway
manoeuvres look, listen, feel
 Bebas
Masih dapat
dipertahankan
Harus
Chin lift dipertahankan
dg intubasi
Head tilt Obstruksi

Look, listen, feel

 Chin lift in
infants Chin lift in children

Jaw thrust
jika cedera leher
 Sumbatan jalan nafas ~ benda asing

Pukulan dan hentakan

 Anak lebih besar

Heimlich manuver
 BREATHING
Melihat gerak napas,
Mendengar desah napas,
Merasakan aliran udara atau dengan
menggunakan stetoskop.
 Pernapasan cepat :
tidak selalu bermakna gangguan pada sistem
pernapasan
napas cepat juga dapat terjadi pada demam,
nyeri, ketakutan/cemas.
Pernapasan lambat anak yang kelelahan akibat
distres napas yang tidak ditolong segera atau akibat
penyakit pada sistem saraf pusat.
Tabel 5. Frekuensi pernapasan normal sesuai usia

Usia Frekuensi pernapasan

(pernapasan per menit)
<1 30-40
25 20-30
5 12 15-20
> 12 12-16
 Upaya napas

Tabel 4. Interpretasi suara napas abnormal

Suara Penyebab Contoh diagnosis
Stridor Obstruksi jalan napas Croup, benda asing,
abses retrofarings
Mengi Obstruksi jalan napas Asthma, benda asing,
bawah bronkiolitis
Merintih (grunting) saat Oksigenasi tidak adekuat Kontusi paru,
ekspirasi pneumonia, tenggelam
Ronkhi basah pada Cairan, lendir atau darah Pneumonia, kontusi paru
inspirasi dalam jalan napas
Suara napas tidak ada Obstruksi jalan napas Benda asing, asthma
dengan upaya napas total berat, pneumothotaks
yang meningkat Gangguan transmisi Efusi pleura, pneumonia,
suara pneumothoraks
 CIRCULATION
Denyut jantung
Perfusi sistemik
Denyut nadi perifer
Perfusi kulit
Penampilan
Produksi urin
Tekanan Darah
 Penilaian dengan memeriksa denyut nadi.
Pada anak sehat pembuluh nadi karotis, aksila,
brakial, radial, femoral, dorsalis pedis.
Raba nadi perifer, jika tak teraba alihkan ke nadi
sentral (femoral/karotis)
Hitung laju nadi dan perhatikan kualitasnya.
Kualitas nadi baik Jika curah jantung cukup.
Denyut nadi sentral (-) kegawatan
kardiovaskular dan perlu tindakan segera.
Perfusi Kulit
Suhu ektremitas
Waktu pengisian kapiler (CRT)
Warna
merah
Pucat
Biru
TD Sistolik minimal
berdasarkan umur

Umur TD sistolik
persentil-50
mmHg
0 1 bln 60
> 1 bln 1 th 70
> 1 th 70 + (2 x umur dlm
th)
 DISABILITY
(status neurologi)
Korteks Serebri
Batang Otak
Aktivitas motorik
Derajat Kesadaran
A = Awake, V = Responsive to voice, P =
Responsive to pain, U = Unresponsive
Glasgow coma scale (GCS)
Tabel 7. Penilaian dengan metode AVPU

Kategori Rangsang Tipe Respon Reaksi

Alert Lingkungan normal Sesuai Interaksi normal untuk

tingkat usia

Verbal Perintah sederhana atau ransang Sesuai Bereaksi terhadap

suara nama

Tidak sesuai Tidak spesifik/bingung

Painful Nyeri Sesuai Menghindari rangsang

Tidak sesuai Mengeluarkan suara

tanpa tujuan atau
dapat melokalisasi nyeri
Posture

Unresponsive Tidak ada respon yang dapat dlihat

terhadap semua rangsang
Skala koma Glasgow

Buka mata (E) Respons motorik

Spontan 4 (M)
Rangsang bicara 3
Spontan 6
Rangsang nyeri 2
Menarik tangan dng
Tidak ada respons 1
rangsang 5
Menarik tangan dengan
Respons Verbal (V) nyeri 4
Senyum sosial 5 Fleksi akibat nyeri 3
Menangis 4 Ekstensi akibat nyeri 2
Menangis terus 3 Tidak ada respons1
Agitasi / lemah 2
Tidak ada respons1
Batang Otak

Postur tubuh
Pola nafas sentral
Reaksi pupil
Saraf Kranialis
Dekortikasi
Pola napas sentral
Plum dan Posner (1982)
Aktivitas motorik
Gerakan asimetris
Kejang
Flasiditas
EXPOSURE/PAPARAN

Ruam
Hematoma
Ekskoriasi
etc.
KLASIFIKASI~ STATUS
Stabil
Disfungsi pernafasan

Syok
kompensasi
dekompensasi
Gagal kardiopulmonal
Gangguan dari perfusi jaringan yang terjadi akibat
adanya ketidakseimbangan antara suplai oksigen ke
sel dengan kebutuhan oksigen dari sel tersebut.

DO2 < VO2

IT IS NOT LOW BLOOD

PRESSURE !!!
IT IS HYPOPERFUSION..
PARAMETER HEMODINAMIK
 THE SHOCK TYPE
CaO2 = Cardiac
DO2 = Arterial OxygenHemorrhagic
Hypoxemia, Content
x Output
poisoning shock

SaO2 x 1.34 x Hb SV x HR

1. Quantitative Shock volume Afterload Contract

1. Decreased CaO2
2. Decreased Flow Hypovolemic
Cytophatic Cardiogenic
shockhypoxia shock
2. Distributive Shock

O2ER
Capillary Flow
recruitment redistribution
STADIUM SYOK

KOMPENSASI

DEKOMPENSASI

IREVERSIBEL (PRETERMINAL)

PERJALANAN KLINIS BERSIFAT PROGRESIF

FASE I: KOMPENSASI

KOMPENSASI TEMPORER
SIMPATIS, SVR, TEKANAN NADI
DISTRIBUSI SELEKTIF ALIRAN DARAH
RETENSI NA & AIR

KLINIS : * TAKHIKARDIA
* GADUH GELISAH
* KULIT PUCAT DINGIN
* PENGISIAN KAPILER >>
FASE 2: DEKOMPENSASI
KOMPENSASI MULAI GAGAL
HIPOPERFUSI HIPOKSIA JAR. METAB. ANAEROBIK
GGN. METAB. SELULER
PELEPASAN MEDIATOR :
* VASODILATASI
* PERMEABILITAS
* DEPRESI MIOKARD * GGN KOAGULASI

KLINIS : TAKHIKARDIA TEKANAN DARAH TAKIPNU

PERFUSI PERIFER ASIDOSIS (+) OLIGURI
(+)
TINGKAT KESADARAN
FASE 3: IREVERSIBEL
KOMPENSASI GAGAL
CADANGAN ENERGI TUBUH
KERUSAKAN/KEMATIAN SEL DISFUNGSI ORGAN
MULTIPEL

KLINIS : * T.D TAK TERUKUR

* NADI TAK TERABA
* TINGKAT KESADARAN
* ANURIA (+)
* GAGAL MULTI ORGAN
DAN KEMATIAN
TATALAKSANA RESUSITASI SYOK

RESUSITASI AWAL
OKSIGEN 100% + VENTILATORY SUPPORT
PASANG AKSES VASKULER (90 DETIK)
FLUID CHALLENGE (20 ml/kg BB)
SECEPATNYA < 10 MENIT
DPT DIULANGI 2-3 KALI
KRISTALOID/KOLOID
PEMANTAUAN AWAL
RESPON THD FLUID CHALLENGE
PANTAU PROD. URIN (KATETER)
STAT. LAB/PENUNJANG
 Monitoring

State of consiousness-Glasgow Coma Scale

Respiratory rate and character
Cardiovascular parameters
Skin and core temperature difference
Pulse rate and volume
Blood pressure
Capillary perfusion time
Central venous pressure - should be monitored in a patient
where there has been poor response to fluid therapy or
with established shock.
Urinary output - urine bag, or preferably catheter;
output should be 1-2 ml/kg body weight
Pulse oximetry
RESUSITASI LANJUT

BILA FLUID CHALLENGE NON

RESPONSIVE
INTUBASI & VENT. MEKANIK
PASANG CVP & LOADING HATI-HATI
KOREKSI EFEK INOTROPIK NEGATIF
Hb < 5 g/dl PRC 10 ml/kg BB (Ht 40-50 vol %)
OBAT INOTROPIK
PEMANTAUAN LANJUT

CARI PENYEBAB SYOK (CXR, KONSULTASI)

EVALUASI FUNGSI SIST. ORGAN LAIN :
ATN/PRE RENAL FAILURE
ARDS
CARDIAC FUNCTION
GGN. KOAGULASI/DIC
ORGAN-ORGAN LAIN
 Stadium syok septik dan manifestasi klinis

Stadium Tanda Klinis Gang fisiologis Biokimiawi

Warm Shock perfusi perifer (N) Smv O 2 hipokarbia

(Hiperdinamik) kulit hangat kering VO 2 hipoxia
HR nadi bounding CO kadar laktat
suhu / (tak stabil) SVR hiperglikemia
RR , gg. kesadaran
Cold Shock sianosis CO hipoxia
(Hipodinamik) kulit dingin lembab SVR asidosis
metab
nadi kecil, lemah CVP koagulopati
HR , Oliguria Smv O 2 hipoglikemi
shallow breathing
pe kesadaran
MOSF bergantung sistem Koma sesuai
yang terkena ARDS, CHF, RF jenis
Classifications

Hypovolemic or Hemorrhagic
Cardiogenic
Obstructive
Distributive
 Clinical features

Neurological: fluctuating mental status, sunken

fontanel
Cardio-pulmonary: tachypnea, tachycardia
Skin and extremities: cool, pallor, mottling,
cyanosis, poor cap refill, weak pulses
Renal: scant, concentrated urine
Respiratory emergency
Respiratory failure

The impaired ability of the respiratory

system to maintain adequate oxygen and
carbon dioxide homeostasis
Respiratory function

Two main categories:

Ventilation Oxygenation

Removal of waste CO2

Transfer of O2 from air in blood

Types of respiratory failure

Acute hypoxemic (Type I): pneumoni

Ventilatory (Type II): asthma
Principles of Management

Specific treatment vary according to the

underlying cause
Corrected hypoxemia
Reduced load on the respiratory muscle
Optimized ventilatory pump capacity
Specific measures

Administration of supplemental oxygen

Acute hypoxaemic or mixed respiratory failure
Simple mask, nasal cannulae, Venturi mask,
mask with rebreathing bag, oxygen tents
Physiological effects of oxygen therapy
Oxygen toxicity
Control of secretion
Hydration
Specific measures

Control of secretion
Mucolytic agents
Chest physiotherapy
Tracheal intubation and tracheostomy
Respiratory stimulants
Control of infection
Treatment of airways obstruction
-stimulants, ipratropium bromide, steroids
Specific measures
Control of lung water
Optimizing ventilatory pump capacity
Malnutrition, catabolism, immobility,
metabolic disturbance
Mechanical ventilatory support
Neurological emergency
Seizures
Seizure : transient, involuntary alteration of
consciousness, behavior, motor activity, sensation,
and/or autonomic function caused by an excessive
rate and hypersynchrony of discharges from a
group of cerebral neurons
Convulsion : seizure with prominent alterations of
motor activity
Initial Stabilization (ABC)

Ensure airway patency

Jaw thrust, suctioning of the oropharynx, use of
adjunctive airways
(oral or nasopharyngeal)
BREATHING
Considered intubation : hypoxia,
hypoventilation, GCS < 8
Supplemental oxygen provided and respiration
CIRCULATION

assisted as needed
Initial Stabilization (ABC)

Established intravena access or intraosseous

Hypotension or dehydration isotonoic fluid
resuscitation
Hypoglycemia dextrose intravenously
BREATHING
Electrolyte abnormalities replaced
appropirately
CIRCULATION
 Seizure Termination
Prehospital Diazepam 5-10 mg per rectal, max 2x, interval 5 mnt 0-10 min

Hospital/ED ABC Diazepam 0.25-0.5 mg/kg iv/io, max dose 20 mg, 10-20 min
rate 5mg/min
OR
Midazolam 0,2 mg/kg iv bolus
OR
Lorazepam 0,5-1 mg/kg iv, rate < 2mg/min

ICU/ED Phenytoin 15-20 mg/kg iv, max 30 mg/kg, 20-30 min

rate 20 min/50 ml NS
Additional 5-10 mg/kg iv

Phenobarbitone 20 mg/kg iv, max 1000 mg, 30-60 min

rate >5-10 min (100mg/min)
Additional 5-10 mg/kg iv

ICU/ED Refracter

Midazolam 0.2-0.5 mg/kg iv bolus,
followed by infusion 0.05-4 ,cg/kg/min
Pentotal 10-15 mg/kg iv then Propofol 2-5 mg/kg iv, followed by
2-5 mg/kg q 5 min to stop seizure, Infusion 25-65 mcg/kg/min
followed by infusion 1-3 mg/kg/hr
Tiopental 5 mg/kg iv then
1-2 mg/kg q 5 min to stop seizure,
followed by infusion 3-5 mg/kg/hr
Statler KD. Status epilepticus. 2007
Komisi Resusitasi Pediatrik. Konvulsi. 2006
Thank You for Listening
!!!