9/29/17

Kegawatdaruratan Medis
(Anestesiologi dan Intensive Care)

dr. M. Helmi MSc, SpAn, KIC.

FAKULTAS KEDOKTERAN
UNIVERSITAS TARUMANAGARA
27 SEPTEMBER 2017

• Anestesi
• Resuscitation
• Critically ill
• Pain

1
 9/29/17

• Bayi dengan demam,

kejang
• Dewasa dengan mual
muntah
• Dewasa dengan luka
bakar luas
• Dewasa tak sadar
• Kecelakaan bermotor
• 1 orang lecet di kepala
• 1 orang meninggal

• Akses obat dan cairan ke dalam tubuh secara kontinyu atau sesaat
untuk mendapatkan efek pengobatan secara cepat.

• Indikasi
• Pemberian terapi intravena
• Transfusi
• Akses nutrisi parenteral
• Sampling darah

2
 9/29/17

• Lunak
• Di atas kanulasi sebelumnya
• Area non dominan
• Refills when depressed
• Dapat terlihat dengan baik
• Lumen yang cukup besar
• Lurus, tidak bercabang
• Dapat dipalpasi dengan mudah
• Bukan area akan dilakukan tindakan medis

• Tipis dan rapuh • Cairan rumatan • Tiang infus

• Mudah tergeser • Infus set • Perlak steril kecil
• Dekat dengan area tulang
• Pernah dilakuan puncture berulang sebelumnya
• Kateter intravena dg ukuran • Bidai, jika diperlukan (untuk
• Trombosis / sklerosis / fibrosis / inflamasi / peradangan / infeksi / edema /
(Gauge yang sesuai) pasien anak)
phlebitis • Desinfektan : kapas alkohol, • Sarung tangan steril Masker
larutan povidone iodine 10% • Tempat sampah medis
• Kassa steril, plester, kassa
pembalut
• Torniket
• Bengkok (kidney basin)

• Periksa kelengkapan alat • Suntikkan jarum dengan bevel menghadap ke atas dengan sudut 20-
• Sambungkan infus set dengan cairan, klem. 30o dari kulit (tergantung kedalaman vena).
• Hand hygiene, pakai gloves • Bila jarum berhasil masuk ke dalam lumen vena, akan terlihat darah
mengalir keluar.
• Posisikan pasien pilih ekstrenitas non dominan
• Beri bantalan di bawah area puncture (bila perlu)
• Pasang tourniquet
• Buka-tutup kepalan tangan
• Rendahkan posisi puncture di bawah ketinggian jantung

3
 9/29/17

• Turunkan kateter sejajar kulit. • Pasang infus set atau blood set yang
telah terhubung ujungnya dengan
kantung infus.
• Tarik jarum tajam dalam kateter vena (stylet) kira-kira 1 cm ke arah
luar untuk membebaskan ujung kateter vena dari jarum agar jarum • Longgarka fiksasi klem pada infus
set, untuk cek flow.
tidak melukai dinding vena bagian dalam.
• Jarum dan tempat suntikan ditutup
dengan kasa steril dan fiksasi
• Dorong kateter vena. dengan plester
• Cuci tangan
• Torniket dilepaskan.

Terapi Cairan Volume Replacement Therapy

RESUSITASI RUMATAN

Lactated Ringer's
Kristaloid Koloid Elektrolit NUTRISI
Normal Saline

Albumin Gelatin Dextran HES

Mengganti kehilangan 1. Kebutuhan normal
akut (hemorrhage, (IWL + urin+ feses) PPL solutions solutions solutions
distributif,) 2. Dukungan nutrisi

The gauge of an IV catheter refers to

A. Sharp point of needle
B. Bevel of needle
C. Length of needle
D. Diameter of lumen
E. All of the above

4

What is the first step in the insertion of a peripheral IV line?
A. Get permission from the patient/family member.
B. Indicated
C. Educate the patient about the need for IV access.
What step would you take if you have attempted IV access
and are unsure of proper placement?
A. Remove the catheter and try again.
B. Attempt to flush the catheter.
C. Pull the catheter back a few millimeters and check for
blood return
D. Go ahead and begin IV infusion.
9/29/17
Which of the following veins should be avoided when initiating
an IV?
A. Lower extremities of a diabetic patient
B. Previously used veins and sclerotic veins
C. Veins in the affected arm of a woman undergoing a mastectomy
D. Veins in the arm of a dialysis AV fistula
E. All of the above
What would be an indication that your IV insertion
attempt was not successful?
A. The insertion site begins to bruise
B. The insertion site does not flush easily
C. The site swells when fluids are flushed through
D. All of the above
5
 9/29/17

• Jaringan dan sel tidak mendapatkan pasukan O2 degan jumlah yang adekuat
• Klinis
• Awal : gelisah, iritabilitas, takikardid, cemas
• Lambat: : perubahan status mentalis, pulsasi melemah, sianosis

Efek hipoksia pada organ Pulse Oximetry

• Pulse oximeter: measures oxygen saturation of hemoglobin (Hb)
• Normal : SpO2 >95%
• COPD : SpO2 90-92%
• Used for:
• Monitoring oxygenation status during intubation attempt or suctioning
• Identifying deterioration in a patient with trauma or cardiac disease
• Assessing vascular status in orthopedic trauma

Pemantauan Suplementasi Oksigen Arterial Blood Gas Analysis

Pulse oximetry Interpretation Intervention
• Blood is analyzed for pH, PaO2, HCO3−, base excess, and SaO2.
95% - 100% Desired range O2 4 l/min – nasal canule • pH, HCO3−: acid-base status
• PaCO2: effectiveness of ventilation
• PaO2 and SaO2: oxygenation
90% - <95% Mild-moderate hypoxia Face mask

85% - <90% Moderate-severe hypoxia Face mask w/ O2 reservoir à

assisted ventilation

<85% Severe to life-threatening Assisted ventilation

hypoxia

6
 9/29/17

Oxyhemoglobin Dissociation Curve DEVICE FLOW RATE DELIVERY O2

Nasal cannula 1 L/min 21% - 24%
2 L/min 25% - 28%
• Acidosis and increased carbon dioxide 3 L/min 29% - 32%
4 L/min 33% - 36%
• Curve shifts to the right 5 L/min 37% - 40%
• Hemoglobin gives up oxygen faster 6 L/min 41% - 44%

• Alkalosis and decreased carbon dioxide Face mask w/ O2 reservoir

(nonrebreathing mask)
6 L/min
7 L/min
60%
70%
• Curve shifts to the left 8 L/min 80%
• Hemoglobin holds on to more oxygen 9 L/min 90%
10-15 L/min 95% - 100%

Nasal Cannula Rebreathing or non rebreathing mask

• Two small prongs
• 24% to 44% oxygen
• Best for patients who need long-
term therapy
• Ineffective with:
• Apnea
• Poor respiratory effort
• Severe hypoxia
• Mouth breathing

Nonrebreathing Mask Partial Rebreathing Mask

• Preferred in prehospital setting • Lacks one-way valve

• 90% to 100% oxygen • Residual exhaled air is
• Mask and reservoir bag
rebreathed
• Indications
• Spontaneously breathing patients
• Flow rates of 6 to 10 L/min
• Contraindications • 35% to 60% oxygen
• Apnea and poor respiratory effort

7
 9/29/17

What variable indicates the effectiveness of ventilation

A. pH
B. HCO3.
C. PaCO2
D. SaO2
E. PaO2

Which device will you take if the patient’s SpO2 is 89-

90% What differs NRM to RM?
A. Nasal cannula A. Size
B. Face mask B. Color
C. Bag Mask ventilation C. Valves
D. Intubation D. O2 container

A patient has been found unresponsive by a friend who

states that the patient has a problem with heroin abuse.
Which of the following is a normal PaO2? Upon his arrival at the hospital, the patient's blood gas
demonstrates a PaCO2 of 90. Which of the
a. 70 mm Hg following would be a possible cause of this
b. 90 mm Hg hypercarbia?
c. 110 mm Hg
d. 140 mm Hg a. Hyperventilation
b. Hypoventilation
c. Hypoxia
d. Metabolic acidosis

8
 9/29/17

Managemen Jalan Nafas

Cari tanda obstruksi jalan nafas!! Perbaiki segera dengan
• Kesulitan bernafas:nafas cuping manuver:
hidung, retraksi • Chin lift
• Pasien terlihat gelisah, melawan • Jaw thrust
• Suara tambahan Keluarkan debris/suction
Gunakan alat bantu jalan nafas:
• Nasal airway
• Oral airway

Manual Airway Maneuvers Head Tilt-Chin Lift Maneuver

• Indications: • Disadvantages
• Unresponsive • Hazardous to spinal injury
• If an unresponsive patient has a pulse • No spinal injury
but is not breathing, you must open the • No protection from aspiration
• Unable to protect airway
airway.
• Maneuver patient s head to propel the
• Contraindications:
tongue forward and open the airway. • Responsive
• Possible spinal injury
• Advantages
• No equipment
• Noninvasive

9
 9/29/17

Jaw-Thrust Maneuver Positioning

• Indications • Contraindications
• Unresponsive • Resistance to opening the mouth • Patient Positioning
• Possible spine injury • Advantages • Goal
• Unable to protect airway • Used with spine injury or cervical • Align 3 planes of view, so
collar
• Disadvantages • Vocal cords are most visible
• Cannot maintain if patient becomes • T - trachea
responsive or combative
• P - Pharynx
• Difficult to maintain for an extended time
• Difficult to use with bag-mask ventilation • O - Oropharynx
• No special equipment required
• Thumb must remain in place
• Requires second rescuer
• No protection against aspiration

Oropharyngeal Airway Nasopharyngeal Airway

Indikasi :
• Napas spontan • Napas spontan
• Tidak ada reflek muntah • Ada reflek muntah
• Contraindications • Kesulitan dg OPA
• Responsive patients • Insert through nose
• Patients with a gag reflex • Altered mental status with an intact
• Advantages gag reflex
• Noninvasive and easily placed • Better tolerated
• Prevents blockage by the tongue • Do not use with trauma to the nose or skull
fracture.
• Disadvantages • Lubricate the airway and insert gently.
• No prevention of aspiration

OPA & NPA Airway Assessment

• Cervical Spine
• Temporal Mandibular Joint
• Neck length, size and muscularity
• Mandibular size in relation to face
• Over bite
• Tongue size

10
 9/29/17

Difficult Airways The Lemon Law

• Difficult mask ventilation
• Difficult laryngoscopy •L Look externally
• Difficult tracheal intubation •E Evaluate the 3-3-2 rule
• Combinations of above •M Mallampati score
•O Obstruction?
•N Neck Mobility

Look externally Evaluate 3-3-2

• Temporal Mandibular Joint • Larynx
• Should allow 3 fingers between incisors • If higher, obstructive view of glottic
• 3-4 cm opening
• Two fingers from floor of mouth to
• Mandible thyroid cartilage
• 3 fingers between mentum & hyoid bone
• Less than three fingers
• Proportionately large tongue
• Obstructs visualization of glottic opening
• Greater than three fingers
• Elongates oral axis
• More difficult to align the three axis

Mallampati Score Obstruksi jalan nafas

• Evaluates ability to visualize glottic opening
• Patient seated with neck extended
• Open mouth as wide as possible • Bekuan darah, gigi
• Protrude tongue as far as possible
• Look at posterior pharynx • Jaringan lunak & Tulang
• Grade based on visual field
• Grades 1,2 have low intubation failure rates
• Bengkak
• Grades 3,4 have higher intubation failure rates • Trauma
• Benda asing

11
 9/29/17

Neck Mobility Bag-Mask

• Can deliver nearly 100% oxygen.
• Align axis to facilitate orotracheal • Can provide adequate tidal volume when
intubation used by an experienced paramedic
• Decreased mobility from • Depends on mask seal integrity
• C-Spine immobilization • Total amount of gas in an adult bag-mask device
• Rheumatoid arthritis is usually 1,200 to 1,600 mL.
• Volume of oxygen to deliver is based on visible
chest rise.
• Deliver each breath over a period of 1 second at the
appropriate rate.

Technique
Technique
• Hold the mask in place while your partner
squeezes the bag until the chest visibly rises.
• Above patient s head. • Place the mask on the patient s face. • If alone, hold your index finger over the lower
• Maintain neck in a • Bring the lower jaw up to the mask. part of the mask and your thumb over the
hyperextended position upper part.
• Connect the bag to the mask.
(unless spinal injury). • Observe for gastric distention, changes in
• Open the mouth, suction as compliance, and changes in status.
needed. • Squeeze every 5 to 6 seconds for adults, 3 to 5
• Insert an oral or nasal airway. seconds for infants and children.
• Squeeze bag as patient inhales.
• Slowly adjust rate and tidal volume.
• If patient is hyperventilating, first assist at the rate at
which the patient is breathing.
• Then slowly adjust rate and tidal volume.

Intubasi Endotrakea
Endotracheal Intubation Henti jantung,
Indikasi Patensi airway tdk bisa dipertahankan,
Ventilasi non invasif tdk adekuat

Kontra indikasi TIDAK ADA

mutlak Kecuali penolakan

M enjaga patensi & keamanan jalan napas

Kegunaan M embantu pemberian Fi O 2 tinggi
Jalur memasukkan obat resusitasi

Trauma
Komplikasi Intubasi esofagus
Intubasi endotrakea
Refleks vagal

12
 9/29/17

Persiapan alat Scope

Scope laringoskop dan stetoskop

Tube
Airways
• Blade sizes range from 0 to 4
Tape • 0, 1, and 2 appropriate for infants and children
• 3 and 4 considered adult sizes
I ntroducer • Miller: bayi dan anak
• Adults: based on experience, size of patient
Connectors *)
Suction *)

Tube Airway
Dewasa ukuran 7,0; 7,5 atau 8,0 OPA / NPA
Anak > 2 thn : Uk. Tube = 4 + (umur/4) Diukur dari sudut bibir sampai angulus mandibula
Siapkan 0.5 size up and down
Kinking vs non kinking

Tape Introducer / stylet

13
 9/29/17

Connector *) Suction *)

Lain-lain Intubation Technique

Jelly
Spuit cuff (5 – 10 mL)
Anestetik lokal (xylocain spray)
Handscoen

Blade Insertion
Sniffing position • Position yourself at the patient s head.
• Grasp laryngoscope n your left hand.
• If mouth is not open:
• Place thumb below bottom lip and
push open.
Preoxygenation • Scissor thumb and index finger
between molars
Critical before intubating • Open with tongue-jaw lift
2–3 minutes for apneic or hypoventilating patient
Prevents hypoxia during intubation • Insert blade into right side of mouth
Monitor SpO 2 and achieve as close to 100% saturation
as possible.
• Sweep tongue to the left while moving
blade into midline
• Slowly advance the blade.
Medication • Exert gentle traction at a 45° angle as
you lift the patient s jaw.

14
 9/29/17

Visualization of the Glottic Tube Insertion

• Continue lifting the laryngoscope
as you look down the blade. • Pick up preselected ET tube.
• Hold it near connector as you would a pencil.
• Work the tip of the blade into
• Insert tube from the right corner of mouth
position. through the vocal cords.
• The glottic opening should come • Continue until the proximal end of the cuff is 1 to 2
into view. cm past the vocal cords.
• The vocal cords lie within.
• Once tube is in the trachea:
• Inflate cuff.
• Remove stylet.
• Verify position of the ET tube.
• Secure the tube.
• Continue ventilations.

Komplikasi Post intubation

• Trauma langsung pada bibir, gigi, gusi
• Trauma pada jalan nafas à serak, nyeri menelan, nyeri tenggorok.
• Edema / trauma pita suara
• After you have seen the ET tube cuff pass roughly 1/2ʺ beyond the vocal
cords
• Gently remove the blade.
• Secure tube with right hand
• Remove stylet from tube
• Inflate the distal cuff with 5 to 10 mL of air
• Attach the bag-mask device to the ET tube; continue ventilation.
• Ensure that the patient s chest rises on both lungs with each ventilation.
• Listen to both lungs and to the stomach.
• You should hear equal breath sounds and a quiet epigastrium.
• Auscultate breath sounds with stethoscope.
• Should be clear and equal

Securing the Tube Medications

• Never take your hand off the ET tube • Sedative - hypnotic (diazepam and midazolam)
before securing with an appropriate • Provide muscle relaxation, mild sedation
• Used as anxiolytic and antiseizure medications
device.
• Provide anterograde amnesia
• Note the centimeter marking on the ET
tube.
• Analgetic (fentanyl / pethidine)
• Position the tube in the side of the
mouth. • Muscle relaxant
• Place the securing tape over the tube. • (rocuronium / atracurium / vecuronium)
• For uncooperative patient, good airway.
• Do not give before the airway is secured.

15
 9/29/17

Supraglotic Airway (SGA) /

Technique
Laryngeal Mask Airway (LMA)
A: The cuff should be deflated tightly. Apply
• Option for patients who: • Disadvantages lubricants along the cuff.
• Require more support than • No protection against B: The mask tip is pressed upward against the
bag-mask aspiration hard palate. The middle finger may be used to
• Do not require ET • Air may be insufflated into push the lower jaw downward. The mask is
intubation the stomach
• Predicted difficult • Not a primary airway in pressed forward as it is advanced into the
intubation emergency situations pharynx to ensure that the tip remains
• Not for long-term flattened and avoids the tongue.
ventilation C: Push the mask fully into position in one
• Surrounds larynx opening fluid movement.
with an inflatable cuff D: The hand holding the tube presses gently
downward until resistance is encountered.

Needle Cricothyrotomy
• Dilakukan hanya pada kondisi sangat emergency
• Menggunakan jarum iv line nomor 12G atau 14G
• Identifikasi landmark
• Sepsis-asepsis
• Inj. Anestesi lokal
• Isi spuit 10 mL dengan 5mL NaCl, ineksikan sesuai landmark
• Didapatkan gelembung udara setelah jarum melewati membran
crycothyroid.
• Tarik HANYA jarum dan spuit
• Ventilasi

A 27-year-old male patient has been found apneic behind a nightclub.

Bystanders suggest that the patient has overdosed on heroin. You are
attempting to initially ventilate the patient's lungs using a bag-mask
device, but the patient's color fails to improve and there is
difficulty squeezing the bag. A common reason for this includes:

a. Failure to properly tilt the head and lift the chin

b. Forcing the tongue into the throat with high-pressure breathing
c. Overly squeezing the bag and forcing too much air into the
patient
d. Pressing too tightly with the bag-mask device on the patient's face

16
 9/29/17

Which of the following is a structure of the upper airway? As you and your partner are assisting ventilations with a bag-mask
device, you notice significant distention of the stomach. Which
a. Alveoli of the following maneuvers will help prevent further dilation?
b. Bronchioles
c. Carina a. Gentle compression of the lateral neck
d. Pharynx b. Gentle pressure below the thyroid cartilage
c. Gentle pressure over nares
d. Gentle pressure superior to the thyroid cartilage

A patient has overdosed on narcotic medications. Upon your The purpose of the oropharyngeal airway is to:
arrival, the patient has no obvious gag reflex. Which of the
following conditions may this patient develop because of a. Keep the tongue from blocking the airway.
his lack of gag reflex? b. Lift the palate to further open the airway.
c. Open the nasopharynx to allow airflow.
a. Alkalosis d. Push the epiglottis away from the larynx.
b. Aspiration pneumonia
c. Hypertension
d. Hypocarbia

A patient who is conscious has a severe nosebleed. You

are having difficulty maintaining the airway. Which of
the following might help keep the airway patent?

a. Nasal airway
b. Nose plug
c. Oral airway
d. Suctioning

17
 9/29/17

Resusitasi Jantung - Paru

Critical steps Indicated

Stop
• heart too good to die
• Recognition of impending event • Three basic vital functions: • ROSC
• Activation of emergency response system • Breathing
• breathing, coughing, or movement
• Basic life support
• Circulation
• Consciousness
Not indicated and a palpable pulse or a
measurable blood pressure
• Defibrillation • biological death
• CPR has been performed for 20
• Ventilation • terminal stage disease minutes
• Pharmacotherapy
• trauma without chance to survive • rescuer is physically exhausted
• DNR - “Do not attempt • signs of biological death
resuscitation”

BLS sequence BLS sequence

Kneel by the side of the victim

Shake shoulders
Unresponsive
Ask “Are you all right?”
Shout for help

If he responds
• Leave as you find him
• Find out what is wrong
• Reassess regularly

18
 9/29/17

BLS sequence
BLS sequence

Unresponsive
Unresponsive
Shout for help
Shout for help
Open airway
Open airway
Check breathing
ØLook, listen and feel for
NORMAL breathing
ØNo breathing
ØGasps

BLS sequence
BLS sequence

Unresponsive
Unresponsive
Shout for help
Shout for help
Open airway Open airway

Check breathing Check breathing

Call emergency system

Call emergency system
30 chest compressions

Chest compression Chest compression

Ø Place the heel of one hand in the Ø Place the heel of one hand in the
centre of the chest centre of the chest
Ø Place other hand on top Ø Place other hand on top
Ø Interlock the fingers Ø Interlock fingers
Ø Compress the chest Ø Compress the chest
l Rate 100 min-1 l Rate 100 min-1
l Depth 4-5 cm l Depth 4-5 cm
l Equal compression : relaxation l Equal compression : relaxation
Ø When possible (2 or more Ø When possible (2 or more
rescuers) change CPR operator rescuers) change CPR operator
every 2 min. to prevent fatigue every 2 min. to prevent fatigue

19
 9/29/17

Chest compression Chest compression

Ø Place the heel of one hand in the

centre of the chest Unresponsive

Ø Place other hand on top Shout for help

Ø Interlock fingers
Open airway
Ø Compress the chest
l Rate 100 min -1 Check breathing
l Depth 4-5 cm
Call emergency system
l Equal compression : relaxation
Ø When possible (2 or more 30 chest compressions
rescuers) change CPR operator
every 2 min. to prevent fatigue 2 rescue breaths

2 rescue breaths Continue CPR

ØPinch nose
ØPlace and seal your lips
over the victim´s mouth
ØBlow until the chest rises
ØTakes about 1 second
ØAllow chest to fall
ØRepeat (10 – 12 times per
minute)
30 : 2

ØShockable: VT/VF Defibrilator

ØNonshockable : Asystole / PEA
ØShock:
ØBiphasic 120-200J
ØMonophasic 360J

20
 9/29/17

Give CPR every moment, when AED is not available,

Immediately resume CPR always if AED is not available within 5 minutes
Need new Need new
picture picture

30 : 2 30 : 2

If victim starts to breathe normally, or papable

pulse, place him in recovery position Pharmacology
• Gains IV access
Need new
• Gives 1 mg of Epinephrine every 3 – 5 minutes
picture • Gives a bolus of 300 mg Amiodarone IF the patient’s heart rhythm is
classified as shockable (MUST NOT be given at the same time as
epinephrine injection, it MUST be done separately)

Evaluation • ABC
• Overdose
• After every cycle ( every 2 minutes ) • Trauma
• If ECG Monitor/AED is attached, evaluates the rhythm first
• If there’s no ECG Monitor attached/AED, check pulse, If no carotid pulsation • Altered mental status
found: repeats compression ventilation cycle (30:2 ratio) • Diabetic emergencies
• If shockable, repeats defibrillation • Respiratory failure
• If pulse is found, no breathing, gives artificial breathing 10-12 • Airway obstruction
• breaths/minute for 2 minutes
• Respiratory Distress
• CAB
• Cardiac Arrest

21
 9/29/17

You attempt to deliver a rescue breath to an unconscious adult. The

breath does not go in. What is the next step in managing this case?
A. Perform abdominal thrusts
B. Begin CPR
C. Go call 911
D. Repeat the head tilt/chin lift maneuver and attempt the breath again

You are first on scene and the victim is unresponsive, pulseless and has The compression to ventilation ratio for one rescuer giving CPR to
vomited. You do not feel comfortable performing mouth-to-mouth individuals of ANY age is:
ventilation. What is the best approach? A. 30:1
A. Wipe off the face or cover with a shirt B. 30:2
B. Compression only CPR C. 15:1
C. Go and get help D. 15:2
D. Do not initiate resuscitation

Where should you attempt to perform a pulse check in a child who is The initial Basic Life Support (BLS) steps for adults are:
anywhere from one year to puberty?*Brachial artery A. Assess the individual, give two rescue breaths, defibrillate, and start
A. Ulnar artery CPR
B. Temporal artery B. Assess the individual, activate EMS and get AED, check pulse, and
C. Carotid or femoral artery start CPR
C. Check pulse, give rescue breaths, assess the individual, and
defibrillate
D. Assess the individual, start CPR, give two rescue breaths, and
defibrillate

22
 9/29/17

Follow my ig @ drhelm i

23