BLOK 24

KEGAWATDARURATAN MEDIK

KOORDINATOR:
DR. ERICA GILDA SIMANJUNTAK, SP.AN K I C
ADVANCE
LIFE
SUPPORT
BLOK 24
RESUME dr. Erica Gilda Simanjuntak, SpAn KIC

DEPARTEMEN ANESTESI & REANIMASI

PERIODE NOVEMBER 2016 – DESEMBER 2017
FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN INDONESIA
RESPIRATORY SYSTEM

BRAIN – PONS & PUMP & PIPE GAS EXCHANGE

MEDULLA

AIRWAY – LUNGS ALVEOLI

SURROUNDED
BY CAPILLARIES
AS PACEMAKER RESISTANCE

COMPLIANCE DIFFUSION
TRANSPORTATION
UPPER AND LOWER RESPIRATORY SYSTEM

UPPER AIRWAY

LOWER AIRWAY
Vagal reflex
TEKANAN DARAH

TEKANAN DARAH DIHASILKAN OLEH KOMPONEN :

① PRELOAD ( STATUS VOLUME )
② KONTRAKTILITAS JANTUNG
③ AFTERLOAD ( SYSTEMIC VASCULAR RESISTANCE )
④ LAJU JANTUNG
EGDT ?

?
 FLOW FLOW

CO SVR VASOPRESOR
BP
MENILAI TEKANAN DARAH PADA SHOCK

TEKANAN DARAH TURUN

NILAI SISTEMIC
NILAI CARDIAC OUTPUT
VASCULAR RESISTANCE

NILAI STROKE
NILAI HEART RATE
VOLUME
BAGAIMANA CARA MEMONITOR
EFEK TERAPI

MAP=CO X SVR CO = SV X HR

PRELOAD ( VOLUME ) -KONTRAKTILITAS-AFTERLOAD ( SVR )

ALAT MONITORING CARDIAC OUTPUT

▪ INVASIF : PAC
▪ SEMI INVASIF : PiCCO, LiDCO
▪ NON INVASIF : TTE, BIO REACTANCE, USCOM, ELECTRICAL
VELOCIMETRY ( ICON® )

① PRELOAD ( FTC )
② KONTRAKTILITAS ( ICON )
③ AFTERLOAD ( SVR )
④ THORACIC FLUID CONTENT
Chain of Prevention
System-specific Chain of Survival
Cardio Pulmonary
Resuscitation
Jones SA. ACLS, CPR, and PALS Clinical Pocket Guide. Philadelphia . 2014.
Every day around the world, cardiopulmonary resuscitation (CPR) is used in and out of the
hospital to save lives. CPR has saved the lives of children who are drowning or have
swallowed something accidentally, as well as those of adults suffering from a heart attack.

CPR encompasses a level of medical care that revives, resuscitates, or sustains a person
who is in cardiac or respiratory arrest. The person’s heartbeat and breathing may be
compromised or stopped by a heart attack, drowning, choking, or other emergency.

Healthcare personnel learn how to recognize emergencies, such as sudden cardiac arrest,
and know how to respond. Skills taught in this tab include performing CPR and relieving
choking (foreign-body airway obstruction) in all ages: adult, child, and infant. Also included
are use of a bag-mask device and an automated external defibrillator (AED).
Healthcare Provider Guidelines for CPR
CPR Compressio Rate of Depth of Pulse Check Hand Position for
Method n/ Compressions Compressions (artery) Compressions
Ventilation (min)
Ratio
Adult, 1 30:2 At least 100 At least 2.0 in Carotid Heels of 2 hands over
rescuer center of chest
between nipple line
Adult, 2 30:2 At least 100 At least 2.0 in Carotid Heels of 2 hands over
rescuers center of chest
between nipple line
Child, 1 30:2 At least 100 At least 2.0 in Carotid or Heel of 1 or 2 hands
rescuer Femoral over center of chest
between nipple line
Child, 2 15:2 At least 100 At least 2.0 in Carotid or Heel of 1 or 2 hands
rescuers femoral over center of chest
between nipple line
Infant, 1 30:2 At least 100 At least 2.0 in Brachial 2 fi ngers over center of
rescuer chest, just below
nipple line
Infant, 2 15:2 At least 100 At least 2.0 in Brachial 2 thumbs–encircling
rescuers hands technique over
lower third of sternum
What Is CPR?

CPR is performed when a person’s breathing or heart has stopped.

Its purpose is to move blood, and therefore oxygen, to the brain and
heart. CPR involves the following three steps:

C-A-B
C—Circulation Compressing the chest to keep the blood circulating
A—Airway Opening the airway (the passageway between the
nose/mouth and the lungs)
B—Breathing Giving rescue breaths that fi ll the lungs with air
How Can I Tell Whether CPR Is Needed?

If the person is conscious but cannot talk and appears to be choking, CPR is not
appropriate. Instead, follow the instructions for choking.

If the person appears to have lost consciousness:

■ Ask, “Are you OK?” Call out loudly. The person may be asleep or hard of
hearing.
■ If the person answers, ask how you can help.
■ If there is no answer, gently tap the person’s shoulder (or feet in an infant).
■ If there is still no response, begin the three steps (circulation, airway,
breathing) of CPR. The general technique for each step is described next.
See the step-by-step instructions for CPR for adults , children, and infants.
How to Perform Chest Compressions

ADULT
▪ Place the heel of one hand over the
center of the chest between the nipple
line (lower half of sternum).
▪ Place the heel of your other handover
the first.
▪ Keep your arms straight and locked at
the elbows.
▪ Firmly compress the chest at least 2.0
in (5 cm).
▪ Push hard and fast.
▪ Allow complete recoil after each
compression.
CHILD

▪ Place the heel of one or both hands

over the center of the chest between
the nipple line (lower half of
sternum). Keep your arm(s) straight
and locked at the elbows.
▪ Firmly compress the chest to at
least 1/3 its depth (about 2.0 in [5
cm]).
▪ Push hard and fast.
▪ Allow complete recoil after each
compression.
INFANT
▪ Place two fingers just below the
nipple line on the sternum.
▪ Firmly compress the chest to at
least 1/3 its depth (about 1.5 in
[4 cm]).
▪ Push hard and fast.
▪ Allow complete recoil after each
compression.
INFANT

Two thumbs–encircling hands technique:

▪ Encircle the infant’s chest with both of
your hands.
▪ Position your the thumbs just below the
nipple line.
▪ Firmly compress the chest, with your
thumbs, at least 1/3 the depth of the
chest (about 1.5 in [4 cm]).
▪ Push hard and fast.
▪ Allow complete recoil after each
compression.
How Do I Open the Airway?

You must ensure an open airway. This does not require looking in
the mouth, but instead requires straightening the angle of the head
and neck so that the path of airflow is unobstructed (e.g., by the
person’s tongue).
How to Open the Airway

Head tilt–chin lift method:

▪ Place the person face up on a
hard, flat surface.
▪ Lift the chin with one hand while
pushing down on the forehead
with the other hand. This aligns
the airway structures.
Jaw thrust method (if suspected
spinal injury):
▪ Place the person face up on a
hard, flat surface.
▪ Place the fingers of both your
hands on each side of the
person’s jaw.
▪ Lift the jaw with both hands.
▪ The jaw will be displaced forward,
opening the airway.
How Do I Locate a Pulse?

The pulse points used are carotid, femoral, and brachial.

Carotid (adult or child):
■ Locate the trachea.
■ Using 2 or 3 fi ngers, feel for a pulse between the trachea and the muscles
of the neck.

Femoral (child):
■ Locate the inner thigh.
■ Using 2 or 3 fi ngers, feel for a pulse midway between the pubic and hip bones.

Brachial (infant):
■ Locate the medial portion of the upper arm.
■ Using 2 or 3 fi ngers, feel for a pulse.
How Do I Perform Rescue Breathing?

Rescue breathing delivers oxygen to the victim’s lungs. The most

common technique for single-rescuer breathing is a face mask or
face shield. Use a bagmask device when performing two-rescuer
CPR.
Three Rescue Breathing Methods

Method 1, CPR face shield:

▪ Place the shield over the person’s
mouth with the airway tube
between the lips.
▪ Hold the airway open and pinch
the nose shut with your fingers.
▪ Give rescue breaths through the
breathing tube.
Method 2, CPR face mask:
▪ Put the mask over the person’s
nose and mouth as shown.
▪ Make sure the airway is open and
press the mask against the face
to create an airtight seal.
▪ Lift the jaw with one hand
holding the mask in place and
use your other hand to seal the
mask around the nose.
▪ Give rescue breaths through the
one-way valve.
Method 3, Bag-mask device:

▪ Put the mask over the person’s nose and mouth

as shown.

▪ Make sure the airway is open and press the mask

against the face to create an airtight seal.

▪ Lift the jaw with one hand using the E-C clamp
technique to hold the mask in place. Circle the
thumb and first finger around the top of the mask
(forming a C) while using the third, fourth, and fifth
fingers (forming an E).

▪ Use your other hand to squeeze the bag, giving

rescue breaths through the one-way valve.

▪ A bag-valve device has an attachment for

supplemental oxygen.
Do I Need an Automated External Defibrillator?

An automated external defibrillator (AED) can be used to “kick-start”

a heart that has stopped beating. If CPR does not revive the person
and an AED is available, you should use it.
What Is High-Quality CPR?

▪ Push hard and fast, delivering 30 compressions in less than 18 sec.

▪ Make sure you allow for complete chest recoil after each compression.
▪ Chest compressions should be interrupted infrequently and for no longer
than 10 sec. Pulse checks, even to determine return of spontaneous
circulation (ROSC), should be minimized during resuscitation.
▪ After every fifth cycle (2 min), rescuers should switch roles. This minimizes
rescuer fatigue, which can reduce compression rates and/or depth to an
inadequate level even if unrecognized. The switch should be accomplished
in less than 5 sec.
▪ Avoid excessive ventilations.
Basic Life Support
JONES SA. ACLS, CPR, AND PALS CLINICAL POCKET GUIDE.
PHILADELPHIA . 2014.
BLS Survey

■ Check patient responsiveness.

If the patient is conscious, proceed directly to the ACLS survey.
■ Activate the emergency response system and get an AED.
■ C–A–B
■ C—Circulation:
Check pulse (5–10 sec). If pulseless, start CPR, beginning with
compressions (30 compressions/2 ventilations).
■ A—Airway: Open the airway.
■ B—Breathing: Provide two breaths.
■ Defibrillation
If the rhythm is shockable, deliver shock pro
Advance Cardiac Life
Support
JONES SA. ACLS, CPR, AND PALS CLINICAL POCKET GUIDE. PHILADELPHIA . 2014.
ACLS Survey
A––Airway
■ Maintain patent airway.
■ Maintain proper head position.
■ Use oropharyngeal or
nasopharyngeal airway if indicated.
■ Use advanced airway if indicated
(laryngeal mask airway [LMA],
laryngeal tube, esophageal-tracheal
tube, endotracheal tube [ET]).
B––Breathing
■ Perform bag-mask ventilation.
■ Provide supplemental oxygen.
■ Monitor adequacy of ventilation and
oxygenation.
▪ Ensure adequate chest rise.
▪ Use CO2 detector or quantitative
waveform capnography.
▪ Measure oxygen saturation.
▪ Avoid excessive ventilation.
C––Circulation D––Differential Diagnosis
■ Provide high-quality CPR. ■ Identify and treat potentially
reversible causes. Assess Hs and Ts
■ Monitor cardiac rhythm.
■ Initiate prompt defi
brillation/cardioversion when
indicated.
■ Establish IV/IO access.
■ Administer medication when
indicated.
■ Administer volume resuscitation
when indicated.
■ Assess for ROSC.
Airway Management
Jones SA. ACLS, CPR, and PALS Clinical Pocket Guide. Philadelphia . 2014.
Oropharyngeal Airway
An oropharyngeal airway (OPA) is indicated for unconscious people who do not have a gag
refl ex and are at risk for developing airway obstruction from the tongue.

Emergency Actions

▪ Select an airway of the correct

size. This is done by measuring
from the earlobe to the corner of
the mouth.
▪ Insert the airway: rotate it 180
degrees as it approaches the
posterior wall of the pharynx, or
insert it sideways into the mouth
and turn it 90 degrees downward
so it angles toward the posterior
pharynx.
Nasopharyngeal Airway
A nasopharyngeal airway (NPA) is indicated for people who may have lockjaw,
are comatose with spontaneous respirations, or have a gag refl ex.

Emergency Actions

• Select an airway of the correct

size. Measure from the earlobe to
the tip of the nose.
• Never insert an NPA if the person
has facial trauma.
• Lubricate the airway with a
water-soluble lubricant.
• Insert the NPA by passing it
gently along the floor of the
nasopharynx with a slight rotation.
Laryngeal Mask Airway

An LMA is indicated for people who

have no spontaneous respiration. It
serves as an alternative to an ET
airway. Only experienced providers
should use this airway.
Laryngeal Tube Airway

A laryngeal tube airway, or King

tube, is indicated for people who
have no spontaneous respiration. It
provides an alternative to an ET
airway. Only experienced providers
should use this airway.
Esophageal–Tracheal Tube

An esophageal–tracheal tube, or
Combitube airway, is indicated for
people who have no spontaneous
respiration. It serves as an
alternative to an ET airway. Only
experienced providers should use
this airway.
Endotracheal Tube Airway

An ET airway is indicated for

people who have no spontaneous
respiration. It is the most effective
advanced airway and should only
be used by experienced providers.
Cardiac Arrest
Circular
Algorithm
Shout for Help/Activate Emergency Response
 Doses/Details for the Cardiac Arrest Algorithms

CPR Quality Drug Therapy Advanced Airway

• Push hard (2” to 2.4” or 5–6cm) • Epinephrine IV/IO Dose: 1 mg • Supraglottic advanced airway or
and fast (100–120/min) and every 3–5 minutes endotracheal intubation
allow complete chest recoil. • Amiodarone IV/IO Dose: First • Waveform capnography to
• Minimize interrruptions in dose: 300 mg bolus confirm and monitor ET tube
compressions. • Second dose: 150 mg placement
• Avoid excessive ventilation • 10 breaths per minute with
• Rotate compressor every 2 continuous chest compressions
minutes
• If no advanced airway, 30:2
compression-ventilation ratio
• Quantative waveform
capnography
• If PETCO2<10mm Hg, attempt to
improve CPR quality
• If relaxation phase(diastolic)
pressure<20mm Hg, attempt to
improve CPR quality.
 Return of Spontaneous
Shock Energy Reversible Causes
Circulation(ROSC)
• Pulse and blood • Biphasic: Manufacturer • Hypovolemia
pressure recommendation (eg. • Hypoxia
• Abrupt sustained initial dose of 120–200 • Hydrogen ion (acidosis)
increase in PETCO2 J): if unknown, use
• Hypo-/Hyperkalemia
(typically ≥ 40 mm Hg) maximum available.
• Hypothermia
• Spontaneous arterial • Second and
subsequent does • Tension pneumothorax
pressure waves with
intra-arterial should be equivalent, • Tamponade, cardiac
monitoring and higher doses may • Toxins
be considered • Thrombosis, pulmonary
• Monophasic: 360 J • Thrombosis, coronary
Tachycardia With a Pulse Algorithm
 Doses/Details

Synchronized Adenosine IV
Cardioversion Dose:
Initial recommended doses: - First dose : 6 mg rapid IV
push;
- Narrow regular : 50–100 J
follow with NS flush.
- Narrow irregular : 120–200 J
- Second dose : 12 mg if
biphasic or 200 J monophasic required
- Wide regular : 100 J
- Wide irregular : Defibrillation
dose (not synchronized)

Antiarrhythmic
Infusions
Amiodarone Sotalol IV
for Stable Wide-QRS
IV Dose: Dose:
Tachycardia 100 mg (1.5 mg/kg)
Procainamide IV Dose: First dose : 150 mg over 10 over 5 minutes.
minutes.
Repeat as needed if VT recurs.
Avoid if prolonged QT
20-50 mg/min until arrhythmia
Follow by maintenance infusion
suppressed, hypotension of 1 mg/min for first 6 hours.
ensues, QRS duration increases
> 50% or maximum dose 17
mg/kg given.
Maintenance infusion: 1–4
mg/min.
Avoid if prolonged QT or CHF.
Advance Trauma Life
Support
FIELD TRIAGE
DECISION SCHEME
Triage

▪ Triage involves the sorting of patients based on their need for

treatment and the resources available to provide that treatment.

▪ Treatmend is rendered based on the ABC priorities ( Airway with

cervical spine protection, Breathing, Circulation with hemorrhage
control).
Primary Survey

What is a quick, simple way to asses the patient in 10 seconds?

Patients are assessed, and their treatment priorities are established

based on their injury, vital sign, and the injury mechanism.
This proccess constitutes the ABCDEs of trauma care and identifies
life threatening conditions by adhering to the following sequence:

1. Airway maintenance with cervical spine protection

2. Breathing and ventilation
3. Circulation with hemorrhage control
4. Disability: Neurologic status
5. Exposure/Envireonmental control: completely undress the
patient, but prevent hypothermia
1. Airway maintenance with cervical spine protection

▪ Upon initial evaluation of a trauma patient, the airway should be

assessed first to ascertain patency.
▪ The rapid assessment for signs of airway obstruction should
include inspection for foreign bodies and facial, mandibular, or
tracheal/laryngeal fractures that may result in airway obstruction.
▪ Measures to establish a patient airway should be instituted while
protecting the servical spine.
▪ Initially, the chin-lift or jaw-thrust manuever is recommended to
achieve airway patency.
▪ Patients with severe head injuries who have an altered level of
consciousness or a Glasgow Coma Scale (GCS) score of 8 or less
usually require the placement of a definitive airway.
▪ Protection of the spine and spinal If mobilization devices must be
cord is a critically important removed temporarily, one person
management principle should manually stabilize the
patient’s head and neck using
inline immobilization techniques.
▪ Assume a cervical spine injury in
any patient with multisystem
trauma, especially those with an
altered level of consciousness or
a blut injury above the clavicle.
2. Breathing and ventilation

▪ Ventilation reqires adequate function of the lungs, chest wall, and

diaphragm.
▪ The patient’s chest should be exposue to adequately assess chest
wall excursion, and auscultation shuld be performed to ensure gas
flow in the lungs.
3. Circulation with hemorrhage control

Circulation issues to consider include blood volume and cardiac

output, and bleeding.

Blood Volume and Cardiac Output

Hemorrhage is the predominant cause of reventable deaths after
injury.
The elements of clinical observation that yield important
information within seconds are level of consciousness, skin color,
and pulse.
▪ Level of Consciousness
When circulating blood volume is reduced, cerebral perfusion may
be critically impaired, resulting in altered levels of consciousness.
However, a conscious patient also may have lost a significant
amount of blood.

▪ Skin Color
Can be helpful in evaluating the injured patient who has
hypovolemia. A patient with pink skin, especially in the face and
extremities, rarely has critical hypovolemia after injury. Conversely,
the patient with hypovolemia may have ashen, gray facial skin and
white extremiities.
▪ Pulse
Typically an easily accessible central pulse (femoral or carotid
artery), should be assessed bilaterally for quality, rate, and
regularity.

▪ Bleeding
External hemorrhage is identified and controlled during the primary
survey
4. Disability (Neurologic status)

▪ Neurologic evaluatin establishs the patient’s level of

consciousness pupillary size and reaction, lateralizing signs, and
spinal cord injury level.
▪ The GCS is a quick, simple method for determining the level of
cons iousness that is predictive of patient outcome-particularly the
best motor response.
5. Exposure/Envireonmental control

▪ After the patient’s cloting has been removed and the assessment
completed, cover the patient with warm blankets or an extenl
warming device to prevent hypothermia.
▪ The patient’s body temperature is more important than the
comfort of the health-care provides.
Secondary Survey

What is the secondary survey, and when does it start?

The secondary survey does not begin until the primary survey
(ABCDEs) is completed, resuscitative efforts are underway, and thee
normalization of vital functions has been demonstrated
The AMPLE history is a useful mnemonic for this purpose:

A- Allergies
M – Medications currently used
P – Past illness/Pregnancy
L – Last Meal
E – Events/Environment related to the injury
Bradycardia With a Pulse Algorithm
▪ Jones, SA. ACLS, CPR and PALS Clinical Pocket Guide. Davis
Company : Philadelphia. 2014
▪ American Heart Association. Highlights of the 2015 AHA
Guidelines Update for CPR and ECC. 2015.
▪ Soar, J. Advanced Life Support. Scientific Symposium 2015. 2015.
OBAT VASOACTIVE

VASOACTIVE

VASOPRESSOR INOTROPIC
VASOACTIVE DRUGS

BEBERAPA JENIS VASOPRESOR DAN INOTROPIK

SEBAIKNYA MEMAHAMI CARA KERJA OBAT VASOAKTIF
SECARA
JIKA KELIRU MEMILIH ATAU PENGGUNAAN TIDAK TEPAT
DPT MEMBAHAYAKAN PASIEN :
▪ Adrenergic menyebabkan aritmia
▪ Takikardia menyebabkan filling time berkurang sehingga stroke
volume berkurang
▪ Hati-hati dgn efek vasokonstriksi pada splanknik dan koroner
▪ Inotropik dapat menyebabkan hipotensi pada pasien tertentu
Clinical Application
1st Line Agent 2nd Line Agent
Septic Shock Norepinephrine (Levophed) Vasopressin
Epinephrine
Phenylephrine (Neosynephrine) (Adrenalin)
Heart Failure Dopamine Milrinone
Dobutamine
Cardiogenic Shock Norepinephrine (Levophed)
Dobutamine
Anaphylactic Shock Epinephrine (Adrenalin) Vasopressin
Neurogenic Shock Phenylephrine (Neosynephrine)
Anesthesia-
Hypotension induced Phenylephrine (Neosynephrine)
Following
CABG Epinephrine (Adrenalin)
 RESEPTOR OBAT VASOACTIVE DAN EFEK KLINIS

Drug Alpha-1 Beta-1 Beta-2 Dopaminergic Predominant Clinical Effects

(Neosynephrine)
Phenylephrine *** 0 0 0 SVR ↑ ↑, CO ↔/↑

(Levophed) Norepinephrine *** ** 0 0 SVR ↑ ↑, CO ↔/↑

(Adrenalin)
Epinephrine *** *** ** 0 CO ↑ ↑, SVR ↓ (low dose) SVR/↑ (higher dose)

(Intropin)
Dopamine (mcg/kg/min)
0.5 to 2 0 * 0 ** CO
5 to 10 * ** 0 ** CO ↑, SVR ↑
10 to 20 ** ** 0 ** SVR ↑ ↑

Dobutamine 0/* *** ** 0 CO ↑, SVR ↓

Isoproterenol 0 *** *** 0 CO ↑, SVR ↓

*** Very Strong Effect, ** Moderate effect, * Weak effect, 0 No effect.