1922 - Ws Transport

Buku Materi Workshop 1st North Sumatera Conference on Emergency,
Anesthesia, and Critical Care 2018
TRANSPORT OF CRITICALLY ILL PATIENT
ISBN :
Editor : dr. Andriamuri P. Lubis, Sp.An, M.Ked(An)

dr. Sudirman
Steven Theo
Venue : RS USU, Medan
Perhimpunan Dokter Spesialis Anestesiologi dan Terapi Intensif (PERDATIN)

Cabang Sumatera Utara
1st North Sumatera Conference on Emergency, Anesthesia, and Critical Care 2018 1
Buku Materi Workshop 1st North Sumatera Conference on Emergency,
TRANSPORT OF CRITICALLY ILL PATIENT
Penerbit : Perhimpunan Dokter Spesialis Anestesiologi dan Terapi

Intensif (PERDATIN) Cabang Sumatera Utara
Redaksi : Panitia 1st North Sumatera Conference on Emergency,

Jln. Jamin Ginting, Perumahan Golden Vista 2 Blok C No.
7, Medan, Sumatera Utara, Indonesia
e-mail : perdatinsu@gmail.com
Hak cipta dilindungi oleh undang-undang

Dilarang memperbanyak karya tulis ini dalam bentuk dan cara apapun tanpa izin
tertulis dari penerbit
KATA SAMBUTAN
Assalamualaikum Wr.Wb
Sebuah kehormatan bagi kami untuk menyambut anda dalam acara 1st North
Sumatera Conference on Emergency, Anesthesia and Critical Care (NSEACC),
yang akan diadakan di Medan, 27 – 30 September 2018.
Di dalam acara ini kami akan mengkaji penerapan ilmiah dalam bidang Emergency,
Anesthesia and Critical Care. Kami akan menunjukkan bagaimana rancangan
penerapan keilmuan untuk kedepannya. Komite ilmiah kami mengerjakan program
yang atraktif dan ambisius. Refresher Courses, Plenary Lecturer, Workshop and
Poster Presentations akan memicu interaksi dan inspirasi antar partisipan. Pameran
industrial yang komprehensif, dan adanya sponsor satelit, akan melengkapi acara
ini dengan baik.
Pada akhirnya, kami memiliki tim yang handal untuk menjadikan konvensi ini
berkesan, dan kami menantikan untuk menyambut anda di Medan.
dr. Soejat Harto, SpAn, KAP

Ketua PERDATIN Cabang Sumut
KATA SAMBUTAN
Assalamualaikum Wr.Wb
Dengan memanjatkan puji dan syukur atas kehadirat Tuhan Yang Maha Esa
sehingga buku Materi Workshop Ultrasound Point of Care on Emergency and
Critical Care pada Pre-symposium Workshop 1st North Sumatera Conference on
Emergency,Anesthesia And Critical Care (NSCEACC) 2018 dapat terselesaikan.
First North Sumatera Conference on Emergency,Anesthesia And Critical Care

(NSCEACC) 2018 merupakan yang pertama sekali dilaksanakan oleh PERDATIN
Cabang Sumatera Utara melaui Bidang P2KB yang diharapkan menjadi kegiatan
rutin yang dilaksanakan sekali dalam dua tahun.
Dalam kegiatan 1st North Sumatera Conference on Emergency,Anesthesia And

Critical Care (NSCEACC) 2018 membahas hal-hal yang terkait di bidang
Emergency/kegawatdaruratan,bidang anestesi dan juga bidang Critical
Care/Penyakit Kritis dengan mengangkat tema “Handling Patietns Holistically
With All The Limitations”.Dengan disusunnya materi workshop menjadi sebuah
buku kami berharap dapat memberikan kontribusi dalam perkembangan di bidang
Emergency,Anesthesia dan Critical Care.
Kepada seluruh pihak yang turut membantu dalam terbitnya buku materi ini,
terutama kepada Instruktur/Pembicaradan Sponsor dalam Pre-symposium
Workshop 1st NSCEACC 2018 Transportation for Critical Ill Patient, kami
ucapkan banyak terima kasih. Semoga ini semua dapat menjadi ladang amal bagi
kita semua amin.
dr. Andriamuri P. Lubis, SpAn, MKed(An)

Ketua Panitia 1st NSCEACC 2018
KONTRIBUTOR
1. dr. Trisna H. Prasetyo, SpAn.,KIC Head Staff of ICU RS. Mitra Keluarga
Kelapa Gading, Jakarta
2. dr. Ahmad Irfan, SpAn.,KIC Head of Medic Committee RS Mitra,

Jakarta
3. dr. Eko Budi Prasetyo,

SpAn.,KIC
4. dr. Soejat Harto, SpAn.,KAP Staff of Department of Anesthesiology
and Intensive Care, RSUP Haji Adam
Malik / Faculty of Medicine, University
of North Sumatera, Medan
5. Ns. Purwani D. Kuntowati Flight Nurse Consultant and Medical

Team Member PT DA
DAFTAR ISI
Kata Sambutan Ketua PERDATIN Sumut ........................................................ 3

Kata Sambutan Ketua Panitia 1st NSCEACC 2018 ........................................... 4
Kontributor ......................................................................................................... 5
Daftar Isi ............................................................................................................. 6
Daftar Gambar .................................................................................................... 8
Daftar Tabel ........................................................................................................ 12
INTRA AND INTER-HOSPITAL TRANSPORT FOR CRITICALLY ILL ... 13

dr. Ahmad Irfan, SpAn.,KIC
Management of Patiet Transfer......................................................................... 28
Ns. Purwani D. Kuntowati
Patient Handling, Lifting, and Moving ............................................................. 38
dr. Eko Budi Prasetyo, SpAn.,KIC
Assessment & Stabilisasi Pretransfer .............................................................. 58
dr. Soejat Harto, SpAn.,KAP
Medical Equipments and Disposable Items ...................................................... 62
Emergency Drugs Patient Transfer .................................................................. 67
Air Ambulance and Experiences ....................................................................... 70
BASELINE DIAGNOSTIC STUDIES AND DOCUMENTATION ................................ 81
dr. Trisna H. Prasetyo, SpAn.,KIC
Guidelines for the Transport of Critically Ill Patients ............................................... 94
PRE-HOSPITAL TRANSPORT ................................................................................114
PHISIOLOGY of PATIENT TRANSPORT ..............................................................130
dr. Ahmad Irfan, SpAn.,KIC
INTRA-HOSPITAL TRANSFER ...............................................................................138
HOW TO CONDUCT A SAFE INTER-HOSPITAL TRANSFER OF PATIENTS ............146
STABILIZATION OF SPECIFIC PATIENT POPULATIONS........................................152
DAFTAR GAMBAR
Nomor Judul Halaman

Adverse clinical events during intrahospital
1 transport by a specialized team: a preliminary 14
report
Kondisi yang menyebabkan komplikasi serius
2 15
selama proses transportasi
Kondisi yang menyebabkan komplikasi serius
3 15
selama proses transportasi intrahospital
4 Incidents identified during Intra-Hospital Transport 16
Factors Contributing to Incidents During Intra-
5 17
Hospital Transportation
Incidents Identified During Inter-Hospital
6 18
Transport
Factors Contributing to Incidents During Inter-
7 18
Hospital Transport
8 Scoring untuk menentukan jenis ketenagaan yang 19

terlibat
Petunjuk untuk melakukan trasnportasi pasien ICU-
9 20
ruangan, diagnostik-ICU
10 Menentukan Tim yang Bertugas 21
11 Transporting critically ill patients : a checklist 22
Potensi bahaya selama proses transport
12 24
interhospital
13 Flowchart 28
14 Sample of Medical Assessment’s Form 30
15 Inform Concent 31
16 Sample Form 32
17 Land/Ground Transport 33
18 Work Order Form 34
19 Handover Form 36
20 Power Lift 39
21 Power Grip 39
22 Performing the Power Lift 40
23 Weight Distribution 41
24 Diamond Carry 41
25 One-Handed Carry 42
26 Carrying Backboard or Cot on Stairs 42

27 Stair Chair 43
28 Principles of Safe Reaching and Pulling 44
29 Clothes Drag 45
30 Blanket Drag 46
31 Arm Drag 46
32 Arm-to-arm Drag 46
33 Front Cradle 47
34 Fire Fighter Drag 47
35 One-person Walking Assist 47
36 Fire Fighter’s Carry 48
37 Pack Strap 48
38 Rapid Extrication 49
39 Direct Ground Lift 49
40 Extremity Lift 49
41 Direct Carry 50
42 Draw Sheet Method 50
43 Scoop Stretcher 50
44 Wheeled Ambulance Stretcher 51
45 Loading the Wheeled Ambulance Cot 51
46 Portable Stretcher 52
47 Flexible Stretcher 52
48 Backboard 52
49 Basket Stretcher 52
50 Scoop Stretcher 53
51 Stair Chair 53
52 Emergency Moves, Two Rescuers 53
53 Patient with Suspected Spine Injury 56
54 Patient Positioning 57
55 Prediction of In-flight PO2 59
56 Equipment Placement 65
57 Relative Contraindications to CCAT 73
58 Mnemonic I’M SAFE 74
59 Nitrogen and Decompression Sickness 75
Transfer of Patients with Acute Coronary
60 79
Syndromes
61 Gambaran EKG 83
62 Hematokrit dan Hb 85
63 Proses Protein menjadi B-type Natriuretic Peptide 86
64 Kaskade Kogulasi 87
65 Gas Darah 88
66 Pemeriksaan Urin 88
67 Guidelines 2011 94
68 Algoritme Transport 98
69 Risk Statification for Inter-Hospital Pation Transfer 103
70 Ventilator Mekanika Portabel 104
71 Defibrilator 104
72 Peralatan Transport 105
73 Obat-obat yang Disiapkan 107
74 Faktor Modaltas Evakuasi 108
75 Informasi yang Harus Diperoleh 115
76 Pengkajian dan Penanganan pada Pasien 115
77 ATLS Concept 117
78 Universal Meducal Care Protocol 119
79 Abdominal Trauma 120
80 Shock Protocol 120
81 Burn Protocol 121
82 Drowning/Near Drowning Protocol 122
83 Congestive Heart Failure Protocol 123
84 Asthma/COPD Protocol 124
85 Shock Protokol 125
86 Anaphilactic Shock Protokol 126
87 Protokol Penurunan Kesadaran 127
88 Protokol Hipertermia 128
89 Hubungan Ketinggian terhadap Tekanan Udara 131

90 Pre Transport Checklist 143
91 During Transport 144
92 Post Transport 144
93 Eclampsia 153
94 Burns 157
DAFTAR TABEL
Nomor Judul Halaman

1 Risk Score for Transport Patients 147
2 Medication for risk groups 149
3 Management of at risk patients 149
4 Comparison of ground and air transport 149
5 The Score 151
INTRA AND INTER-HOSPITAL TRANSPORT FOR CRITICALLY ILL
PATIENT
(dr. Ahmad Irfan, SpAn.,KIC)
SEJARAH
• Transportasi pasien bukan konsep baru
• Mulai berkembang Perang Prusia ( prajurit yg terluka dievakuasi melalui
balon udara ) dan perang dunia I-II
• Konsep awal : secepat mungkin mengevakuasi pasien ke rumah sakit
• Berkembang menjadi subspesialis dari emergency medicine
• Melibatkan banyak profesi dan spesialis ( dokter spesialis tertentu,
perawat, teknisi )
• GOAL : “ melakukan transfer pasien dengan aman dan efisien “
• Kebutuhan transportasi makin meningkat seiring kemajuan teknologi
• Berkaitan dengan bencana yang masif , perang dengan skala besar ( PD 1-
2, perang Vietnam, perang Korea, perang Teluk )
Makin berkembang:
1. Fisiologi transportasi
2. Teknik perawatan
3. Alat medis
4. Aspek mediko-legal
DEFINISI
• Primary Transport : Dari tempat kejadian ke fasilitas kesehatan
• Secondary Transport (Inter-Hospital) : Pasien dipindahkan antara dua
fasilitas kesehatan , biasanya karena memerlukan fasilitas dan oelayanan
kesehatan yang lebih tinggi
• Intra-Hospital Transport : Pasien dipindahkan dari satu fasilitas kesehatan
ke fasilitas kesehatan lain dalam suatu rumah sakit, dengan alas an untuk
tindakan medis atau diagnostic.
LATAR BELAKANG
Peneliti menemukan bahwa pada saat transport intrahospital pada pasien
sakit kritis kerap terjadi perburukan kondisi pasien walaupun tidak sampai
fatal.
Perburukan kondisi pasien ICU selama proses transpoertasi sering terjadi
dan dapat dicegah jika pasien didampingi intesivist atau tenaga medis yang
kompeten dan mengikuti guideline.
Gambar 1. Adverse clinical events during intrahospital transport by a

specialized team: a preliminary report
Insiden perburukan kondisi pasien lebih sedikir jika intrahospital transport

dilakukan oleh tim khusus yang sudah terlatih dan berpengalaman.
Gambar 2. Kondisi yang menyebabkan komplikasi serius selama proses
transportasi
Gambar 3. Kondisi yang menyebabkan komplikasi serius selama proses

transportasi intrahospital
Incidents Identified During Intra-Hospital
Transport
Equipment-related incidents 75 n = 191 incidents in 176 reports
(39%)
Monitors Drugs
• Battery supply problem 8 • Delayed administration/failure to
• Not available 2 deliver drug 14
• Faulty monitors 2 • Infusion interruption 4
Airway equipment • Emergency drugs unavailable 2
• Problem with intubation/airway Infusion pumps
equipment 7 • Battery supply problem 6
• Transport ventilator malfunction 4 • Not available 1
• Problems with oxygen supply 3 Other
• Emergency elevator access 18
• Bed-related problems 4
Beckmann et al. (2004) Incidents relating to the intra-hospital transfer of critically ill patients.
Intensive Care Medicine, 30(8), pg. 1579-85
Gambar 4. Incidents identified during Intra-Hospital Transport
Factors Contributing to Incidents During
Intra-Hospital Transportation
Human-based Factors - 488 n=900 selections in 176 reports
Knowledge-based error Skilled-based error

• Error of problem recognition 58 • Haste 42
• Error of judgment 50 • Distraction/inattention 20
• Lack of knowledge 22 • Stress 8
Rule-based error Technical error
• Failure to follow protocol 42 • Fault of technique 20
• Patient preparation inadequate 32 • Inexperience 23
• Patient assessment inadequate 26
• Failure to check equipment 24
• Misuse of equipment 13
• Unfamiliar equipment 12

Intra-Hospital Transportation
System-based Factors - 412 n=900 selections in 176 reports
Work practices Physical environment infrastructure

• Communication problem 47 • Lack of space 29
• Inadequate protocol 47 • High unit activity 20
• Inadequate training 31 • Lack of support staff 22
• Lack of supervision 14
• Insufficient staff 13
Equipment
• Equipment failure 34
• Inadequate equipment 22
• Poor design of equipment 20
• Poor maintenance 19
• Equipment not available 17
• Inadequate in-service 16
Gambar 5. Factors Contributing to Incidents During Intra-Hospital

Transportation
Incidents Identified During Inter-Hospital
Transport
n = 272 incidents in 125 reports n = 272 incidents in 125 reports
Harm 59% with one death
Equipment 37% Location

Patient Care 26% During transport 26%
Transport Operations 11% At patient origin 26%
Interpersonal Communication 9% During patient loading 20%
Planning or Preparation 9% At the retrieval service base 18%
Retrieval Staff 7% At receiving facility 9%
Tasking 2%
Flabouris et al. (2006) Incidents during out-of-hospital patient transportation.

Anaesth Intensive Care, 34(2), pg. 228-36
Gambar 6. Incidents Identified During Inter-Hospital Transport

Inter-Hospital Transport
n = 272 incidents in 125 reports n = 272 incidents in 125 reports
Harm 59% with one death
Contributing Factors Minimizing Factors

System-based 54% Good crew skills/teamwork 42%
Human-based 42% Checking equipment 17%
Haste 7.5% Checking patient 8%
Equipment malfunctioning 7.2% Patient monitors 15%
Equipment missing 5.5% Good luck 14%
Failure to check 5.8% Good interpersonal communication 4%
Pressure to proceed 5.2%
Flabouris et al. (2006) Incidents during out-of-hospital patient transportation.

Anaesth Intensive Care, 34(2), pg. 228-36
Gambar 7. Factors Contributing to Incidents During Inter-Hospital Transport
Scoring & Guidelines
Gambar 8. Scoring untuk menentukan jenis ketenagaan yang terlibat
Gambar 9. Petunjuk untuk melakukan trasnportasi pasien ICU-ruangan,
diagnostik-ICU
Gambar 10. Menentukan Tim yang Bertugas
Gambar 11. Transporting critically ill patients : a checklist
 Stabilisasi dan transportasi pasien untuk kebutuhan diagnostik atau

mendapatkan fasilitas pelayanan kesehatan makin meningkat
 Profesi kesehatan merupakan bagian tidak terpisahkan dari suatu proses
transport
 Tenaga kesehatan yang terlibat harus memastikan proses transportasi
berlangsung aman.
 Dibutuhkan pengetahuan tentang perubahan fisiologi, perawatan,
stabilisasi, safety serta masalah mediko-legal dalam proses transportasi
Transport pasien sakit kritis
• Meningkatkan resiko mortalitas dan morbiditas selama proses transportasi
• Insiden kejadian tidak diharapkan dari literatur 6-71%
• Pada intra-hospital transport kejadian mengancam nyawa 8% !!!
• Komplikasi sirkulasi-respirasi paling sering dilaporkan berkaitan dengan
peralatan
• Dapat diminimalkan dengan perencanaan yang matang, SDM yang terlatih
dan kompeten serta alat yang sesuai dan aman
• Literatur menemukan bahwa staf ICU kebanyakan meremehkan resiko
transport pasien dengan sakit kritis
• Terutama bila ruang emergensi dan radiologi sangat berdekatan dengan
ICU.
• Sehingga merasa aman dan percaya diri dapat mengatasi setiap masalah
sirkulasi dan respirasi yang timbul !!! “
Obyektif WS
TUjuan dari program ini adalah untuk :
1. memberikan informasi tentang jenis transportasi pasien yang tersedia,
2. perubahan fisiologi selama proses transportasi ,
3. peraturan transportasi,
4. upaya stabilisasi untuk transportasi,
5. perawatan selama transportasi, dan
6. prinsip-prinsip umum transportasi, termasuk keamanan dan masalah
medis-hukum , dalam rangka memfasilitasi perawatan pasien yang lebih
baik
Gambar 12. Potensi bahaya selama proses transport interhospital
Risiko vs Benefit
• Pertimbangan transport semata-mata untuk kebaikan pasien
• Jika terjadi perburukan selama transport, proses distabilkan di ICU
terdekat
• Walaupun ada perbedaan antara primary transport, intrahospital serta
interhospital transport, tetapi pertimbangan dan persiapannya sama saja.
Profesional
• Intra/interhospital transport sama seperti halnya memasang kateter vena
sentral, butuh training dan pengalaman
• Hanya staf yang sudah berpengalaman yang boleh terlibat di dalam proses
transport
Kasus
• Wanita, 24 TAHUN menderita Limfoma non-Hodgkins, mengalami
gangguan pernafasan yang progresif. Akibat limfomanya timbul
komplikasi amiloidosis sekunder yang berat sehingga menyebabkan
kardiomiopati, amiloidosis kulit dan rongga mulut. Laju napas lebih dari
30 kali/menit dan saturasi oksigen terbaca hanya 85%. Untuk perawatan
lebih lanjut, pasien ini dirujuk ke rumah sakit tipe A. estimasi waktu
transport diperkirakan 40 menit perjalanan. Dari komunikasi dengan
dokter UGD yang akan menerima pasien tersebut, dokter UGD RS tipe A
tersebut meminta agar pasien tersebut diintubasi dan masuk ventilator
terlebih dahulu sebelum berangkat. .
• Namun, dokter yang merujuk menyatakan ventilasi mekanis tidak perlu
seperti ini karena merupakan kondisi kronis, dan transportasi dilakukan
dengan dua paramedis. Namun, kondisi pasien cepat memburuk dan
meninggal selama transportasi.
Indikasi transport pasien sakit kritis

• Pasien memerlukan penanganan medis lebih lanjut seperti operasi bedah
syaraf tertentu, intervensi radiologi, PTCA, CRRT, transplantasi organ
atau intervensi ICU yang spesifik seperti terapi ventilasi mekanik dengan
posisi tengkurap
• Ketiadaan tempat di ICU RS pengirim pasien, keadaan khusus ( korban
bencana alam, kecelakaan moda transportasi besar, korban perang )
Pertimbangan etis
• Kurangnya sumber daya ICU sebagai alasan untuk transportasi antar-
rumah sakit dapat menimbulkan dilema etika untuk seluruh tim.
• Pertimbangan medikolegal misalnya “ last in first out “…
• Pertimbangkan untuk memindahkan pasien yang lebih stabil
• Pertimbangkan risk-benefit pada pasien untuk tindakan diagnostik yang
memerlukan intra hospital transport
Kasus
• Seorang pria 82 tahun itu dirawat di rumah sakit kecil dengan GCS 5,
pasien dengan CVDH dan mengarah ke perburukan ( MBO ). Oleh dokter
spesialis yang menangani pasien kemudian dirujuk ke rumah sakit
pendidikan yang juga merupakan rujukan nasional.
• Sesampainya di UGD RS rujukan, dokter spesialis bedah syaraf menolak
merawat dan melakukan tindakan pembedahan pada pasien tersebut
berdasarkan hasil CT-Scan, usia dan penampilan klinis. Pasien kemudian
diharuskan kembali ke RS yang merujuk.
Risiko transportasi pasien sakit kritis

• Komplikasi teknis : ETT bergeser posisi / tercabut, IVFD tercabut atau
clotting, drain tercabut
• Perburukan kondisi : peningkatan TIK sebagai akibat perubahan posisi
pada CT-Scan, pasien mengedan, batuk, gelisah atau berontak. Hipotensi,
desaturasi
• Monitoring kardiovaskular dan respirasi yang tidak adekuat karena
peralatan tidak lengkap / kurang canggih, interferesi pengukuran akibat
gerakan, space yang sempit
• Terapi yang tidak adekuat karena peralatan yang dibawa tidak sesuai
kondisi, misal ventilator portable kebanyakan tidak mempunyai MOV
selengkap Ventilator ICU ( saat ini sdh ada yg lengkap dan bisa dipakai
dalam ruang MRI )
• Adanya gerakan dari kendaraan pembawa ( gaya akselerasi dan deselerasi
ambulans / pesawat ), posisi pasien miring atau diangkat pada saat pindah
dari bed ke trolley ( dislokasi dari fraktur/ robek jahitan/ emboli vaskular
dll )
• Tidak adanya akses untuk melakukan diagnostik atau terapi segera
misalnya pada kondisi adanya dugaan spontaneous pneumothoraks atau
ketiadaan PRC pada perdarahan akut selama proses transportasi
• Sedikitnya personil yang terlibat pada proses transportasi berlangsung (
dalam ambulans / pesawat/ helikopter ). Jarang terlibatnya personil senior
yang berpengalaman dan trampil pada proses trasnportasi
• Space yang terbatas atau gangguan akibat gerakan kendaraan pengangkut
untuk melakukan tindakan medis
• Penelitian pada transportasi pasien dengan sakit kritis menemukan paling
tidak selalu atau lebih masalah selama proses berlangsung
• Sebagian besar insiden dapat dicegah dan bekaitan dengan peralatan,
kemampuan merawat pasien, komunikasi, perencanaan transportasi dll
Agar transportasi sesuai tujuan

• Tepat perencanaan & evaluasi pra transportasi
• Tepat dan lengkap alat & obat
• Tepat personal tim yang bertugas
• Tepat waktu
• Tepat tujuan
Management of Patiet Transfer
(Ns. Purwani D. Kuntowati )
Contents
1. BASIC PRINCIP
2. FLOWCHART
3. PREPARATION
3.1. Medical and non medical’s document
3.2. Destination ( decided by Triage )
3.3. Transportation’s mode
3.4. Human Resource
3.5. Medical Equipment and Emergency Drugs
3.6. Others
4. IMPLEMENTATION
5. EVALUATION
Basic princip of patients transport
• Recommended
• Fit to be transferred
• Worth to be treated (for further treatment only)
Gambar 13. Flowchart
Preparation
3.1. MEDICAL AND NON MEDICAL DOCUMENT
3.1.1. Medical Document
• Medical Summary and Diagnostic Results
o Patient Identity
o Patient History
o (Injury or Illness )
o Physical Assessment and Current Condition
o (General Impression, Mental Status, Airway,
o Breathing, Circulation)
o Indentify Priority of Patient
o (Critical, Unstable, Potensial Unstable, Stable)
o Laboratory and diagnostic
o Medical Equipment needs
o Drugs Administration List
o Family condition
• Medical Assessment
• Medical / MEDIF Approval
• Refferal and Recommendation Letter
3.1.2. Non Medical Document
• Transport Agreement
• Inform Consent
• ID of Patient and escorter
3.2. DESTINATION
3.2.1. Recommendation Note
( by Receiving Specialist )
3.2.2. Confirmation
 Name of Receiving Specialist
 Bed / Room Number
 PIC
- Name
- Phone / Mobile No
 Regulation of Admission
- Direct
- Non Direct
3.3. TRANSPORTATION’S MODE
3.3.1. LAND / GROUND TRANSPORT
3.3.2. SEA / RIVER TRANSPORT
3.3.3. AIR TRANSPORT
 COMMERCIAL / REGULAR FLIGHT
 CHARTER AIRCRAFT
- Jet Type
- Propeler / Fixed Wing
- Helicopter
Gambar 14. Sample of Medical Assessment’s Form
Gambar 15. Inform Concent
Gambar 16. Sample Form
Gambar 17. Land/Ground Transport
3.4. HUMAN RESOURCE
3.4.1. Person on Position
• Field coordinator
• Medical team : doctor and nurse
• Other supporting staff
3.4.2. Work Order Form
3.4.3. Approval’s team
• Reffering doctor
• Attending doctor
• Receiving doctor
3.5. MEDICAL EQUIP,EMT
3.5.1. Preparation must be based on
• Patient problem and condition
• Length of transport
• Enviroment of the transportation’s mode
• Medical procedures of during transport
• Special or other injury
Gambar 18. Work Order Form
Implementation
4.1. ORIGIN
4.1.1. Introducing
- Local Team
- Family
4.1.2. Reassessment
4.1.3. Inform Transport Planning
4.1.4. Handover
4.1.5. Patient Transfer procedure
4.1.6. Leaving Origin
4.2. ON THE WAY ( Medical Team )
4.2.1. Maintain Patient Condition
4.2.2. Maintain Communication
 Patient
 Family
 Call Centre / Field Coordinator
 PIC at Destination
4.2.3. Record all activities
 Patient Monitoring Forms
 Travel Report Form
 Resuscitation Report Form
4.2.4. Keep all pangangers as comfort as
possible
4.3. DESTINATION
4.3.1. Receiving Unit
 Received Pre Hospital Alert Form
 Prepare the medical equipment needed
 Communicate all patient’s details to receiving
specialist and team
4.3.2. Patient Transfer Procedure
4.3.3. Handover
 Make sure the patient is directed quickly to the most
appropriate acute treatment area
 The receiving team should be provided with a more
details and holistic handover which can be
supported by situation, background, assessment and
recommendation
 Acknowledged dan signed by attending medial team
and receiving medical team
4.3.4. Handover Form
Gambar 19. Handover Form
Evaluation
5.1. Patient
5.2. Human Resouces
5.3. Preparation
5.4. Procedure
5.5. Transportation Mode
5.6. Rerporting and Recording
References
1. Benson N, Hankins D, Wilcox D, Air Medical Dispatch: Guideline for
scene response [ positive paper]. Prehospital Disaster Med. 1992.
2. Mitsovich JJ, Karen KK. Pre Hospital Emergency Care.9th ed. Upper
Saddle River, NJ: Pearson; 2011
3. Brown JB, Stassen NA, Bankey PE, Sangosanya AT, Cheng JD, Gestrin
ML. Mechanism of injury andspecial consideration criteria still matter: an
evaluation of the National Trauma Triage Protocol. J Trauma 2011
4. Carruba C, Hunt R, Benson N. Criteria for air medical transport: non
trauma and pediatric consideration [ position paper]. Prehosp Disaster Med
1994.
Patient Handling, Lifting, and Moving
(dr. Eko Budi Prasetyo, SpAn.,KIC)
PROTECTING YOURSELF: BODY MECHANICS

Body mechanics refers to the proper use of your body to prevent injury and to
facilitate lifting and moving. Consider the following before lifting any patient :
 The object. What is the weight of the object
 Your limitations. What are your physical characteristics?
 Communication. Make a plan.Then communicate the plan for lifting and
carrying
 Position your feet properly
 Use your legs. Do not use your back to do the lifting
 Never turn or twist
 Do not compensate when lifting with one hand
 Keep the weight close to your body, or as close as possible
 Use a stair chair when carrying a patient on stairs whenever possible
Moving and Positioningthe Patient

1. Take care to avoid injury whenever a patient is moved.
2. Practice using equipment.
3. Know that certain patient conditions call for special techniques
 There are many kinds of patient-carrying devices, including

stretchers,backboards, and stair chairs
 When lifting a patient-carrying device, it is best to use an even number of
people
 To prevent injury when lifting a patient-carrying device, the general rules of
body mechanics mentioned earlier apply
 Two methods also can help to prevent injury :
1. power lift
2. power grip
Body Mechanics
• Shoulder girdle should be aligned over the pelvis.
• Lifting should be done with legs.
• Weight should be kept close to the body.
• Grasp should be made with palms up.
Gambar 20. Power Lift
Gambar 21. Power Grip

Performing power lift
 Tighten your back in normal upright position.
 Spread your legs apart about 5".
 Grasp with arms extended down side of body.
 Adjust your orientation and position.
 Reposition feet.
 Lift by straightening legs.
 A power grip gets the maximum force from your hands
 Arms and hands face palm up.
 Hands should be at least 10" apart.
 Each hand goes under the handle with the palm facing up and the thumb
extended upward.
 Curl fingers and thumb tightly over the top of the handle.
 Never grasp a litter or backboard with the hands placed palms-down over
the handle.
Gambar 22. Performing the Power Lift
Weight and Distribution
• Patient will be heavier on head end.
• Patients on a backboard or stretcher should be diamond carried.
Gambar 23. Weight Distribution
Diamond Carry
 Four EMT-Bs lift device while facing patient.
 EMT-B at foot end turns around to face forward.
 EMT-Bs at sides turn.
 Four EMT-Bs face same direction when walking.
Gambar 24. Diamond Carry
One-Handed Carry
 Face each other and use both hands.
 Lift the backboard to carrying height.
 Turn in the direction you will walk and switch to using one hand.
Gambar 25. One-Handed Carry
Carrying Backboard or Cot on Stairs

• Strap patient securely to the backboard
• Carry patient down stairs foot end first, head end elevated.
• Carry patient up stairs head end first.
Gambar 26. Carrying Backboard or Cot on Stairs
Directions and Commands
• Anticipate and understand every move.
• Moves must be coordinated.
• Orders should be given in two parts.
Additional Guidelines
• Find out how much the patient weighs.
• Know how much you can safely lift.
• Communicate with your partners.
• Do not attempt to lift a patient who weighs over 250 lbs with fewer than
four rescuers.
• Avoid unnecessary lifting or carrying.
Using a Stair Chair
• Secure patient to stair chair with straps.
• Rescuers take their places: one at head, one at foot.
• Rescuer at the head gives directions.
• Rescuer at the head gives directions.
Gambar 27. Stair Chair
When reaching:
• Keep your back in a locked-in position.
• Avoid twisting while reaching.
• Avoid reaching more than 15 to 20 inches in front of your body.
• Avoid prolonged reaching when strenuous effort is required
When pushing or pulling:

• Push, rather than pull, whenever possible.
• Keep your back locked-in.
• Keep the line of pull through the center of your body by bending your knees.
• Keep the weight close to your body.
• If the weight is below your waist level, push or pull from a kneeling position.
• Avoid pushing or pulling overhead.
• Keep your elbows bent and arms close to your sides.
Principles of Safe Reaching and Pulling

 Back should always be locked and straight.
 Avoid any twisting of the back.
 Avoid hyperextending the back.
 When pulling a patient on the ground, kneel to minimize the distance
 Elevate wheeled ambulance cot or stretcher before moving.
 Never push an object with your elbows locked.
 Do not push or pull from an overhead position.
Gambar 28. Principles of Safe Reaching and Pulling
General Considerations
• Plan the move.
• Look for options that cause the least strain.
Emergency moves
 Performed if there is some potential danger for you or the patient
 Performed if necessary to reach another patient who needs lifesaving care
 Performed if unable to properly assess patient due to location
 Three situations may require the use of an emergency move:
 The scene is hazardous. Hazards may make it necessary to move a
patient quickly in order to protect you and the patient
 Care of life-threatening conditions requires repositioning
 You must reach other patients
Urgent moves
 Urgent moves are required when the patient must be moved quickly for
treatment of an immediate threat to life
 unlike emergency moves, urgent moves are performed with precautions
for spinal injury
Examples in which urgent moves may be required :
1. The required treatment can only be performed if the patient is moved
2. Factors at the scene cause patient decline
Emergency Drags
Gambar 29. Clothes Drag
Gambar 30. Blanket Drag
Gambar 31. Arm Drag
Gambar 32. Arm-to-arm Drag
Gambar 33. Front Cradle
Gambar 34. Fire Fighter Drag
Gambar 35. One-person Walking Assist
Gambar 36. Fire Fighter’s Carry
Gambar 37. Pack Strap
When to Use Rapid Extrication Technique

• Vehicle or scene is unsafe.
• Patient cannot be properly assessed.
• Patient requires immediate care.
• Patient’s condition requires immediate transport.
• Patient is blocking access to another seriously injured patient.
Rapid Extrication
• Provide in-line support and apply cervical collar.
• Rotate patient as a unit.
• Lower patient to the backboard.
Gambar 38. Rapid Extrication
Nonurgent moves
Gambar 39. Direct Ground Lift
Gambar 40. Extremity Lift
Gambar 41. Direct Carry
Gambar 42. Draw Sheet Method
Scoop Stretcher
 Adjust stretcher length.
 Lift patient slightly and slide stretcher into place, one side at a time.
 Lock stretcher ends together.
 Secure patient and transfer to the cot.
Gambar 43. Scoop Stretcher
Geriatrics
 Emotional concerns
 Fear
 Skeletal concerns
 Osteoporosis
 Rigidity
 Kyphosis
 Spondylosis
 Pressure sores
 Use special immobilizing techniques.
 Be compassionate.
Bariatrics
 “Care of the obese”
 Increase in back injuries among EMTs
 Manufacturing of higher capacity equipment
 Use proper lifting techniques.
Wheeled Ambulance Stretcher

 Most commonly used device
 Has specific head and foot ends
 Has a folding undercarriage
 EMT-B must be familiar to specific features of cots used in the
ambulance.
Gambar 44. Wheeled Ambulance Stretcher
Loading the Wheeled Ambulance Cot

 Tilt the head of the cot upward.
 Place it into the patient compartment.
 Release the undercarriage lock and lift.
 Roll the cot into ambulance.
 Secure the cot to ambulance clamps.
Gambar 45. Loading the Wheeled Ambulance Cot
Patient-Moving Equipment
Gambar 46. Portable Stretcher
Gambar 47. Flexible Stretcher
Gambar 48. Backboard
Gambar 49. Basket Stretcher
Gambar 50. Scoop Stretcher
Gambar 51. Stair Chair
Gambar 52. Emergency Moves, Two Rescuers
Non-Urgent Moves
 When there is no immediate threat to life
 the patient should be moved when ready for transportation, using a non-
urgent move
 On-scene assessment and any needed on-scene treatments, such as
splinting, should be completed first
 Non-urgent moves should be carried out in such a way as to prevent
injury or additional injury to the patient
Wheeled Stretcher
 commonly referred to simply as the stretcher, cot, or litter
 their purpose is the same: to safely transport a patient from one place to
another, usually in a reclining position
 their purpose is the same: to safely transport a patient from one place to
another, usually in a reclining position
 The head of the stretcher can be elevated, which will be beneficial for
some patients, including cardiac patients
 the stretcher will have variable levels
 the safest level is closest to the ground
Stretcher
 Make sure to use proper body mechanics while placing the stretcher into
or taking it out of the ambulance
 There are two types of stretchers: manual stretchers and power
stretchers
 Manual stretchers are lifted by EMTs
 A power stretcher will lift a patient from the ground level to the loading
position or lower a patient from the raised position
 These stretchers use a battery-powered hydraulic system that
manufacturers state will lift patients
Bariatric stretchers
 Many services use bariatric stretchers.These are stretchers that are
constructed to transport obese patients—some rated for 800 pounds or
more
 Many ambulance services have ambulances specially equipped for the
loading and transport of the bariatric patient
 In addition, an increasing number of emergency departments are being
equipped with hydraulic lifts to transfer obese patients onto the hospital
cot
SELF-LOADING STRETCHER
 A stretcher can be carried by four EMTs, one at each corner
 This method can be useful on rough terrain because it helps keep the
wheels from touching the ground and provides greater stability
 The patient will stay on the stretcher during transport to the hospital
 Secure the patient to the stretcher before lifting or moving
 After placing the patient into the ambulance, secure the stretcher to the
ambulance
Stair Chair
 The stair chair has many benefits for moving patients from the scene to
stretcher
 The first benefit is that it is excellent for use on stairs
 The stair chair transports the patient in a sitting position
 It also has a set of wheels that allow the device to be rolled
 The stair chair must not be used for patients with neck or spine injury
Spine Boards
 There are two types of spine boards, or backboards: short and long
 They are used for patients who are found lying down or standing and who
must be immobilized
 Short spine boards are used primarily for removing patients from vehicles
when a neck or spine injury is suspected
 A short spine board can slide between the patient’s back and seat back
Other Types of Stretchers

 scoop stretcher, or orthopedic stretcher, splits into two pieces vertically,
allowing the patient to be “scooped” by pushing the halves together
under him
 The scoop stretcher does not offer any support directly under the spine
 it is not recommended for patients with suspected spinal injury
Basket stretcher
 A basket stretcher, or Stokes stretcher, can be used to move a patient
from one level to another or over rough terrain
 The basket should be lined with a blanket before positioning the patient
Flexible stretcher
 A flexible stretcher, or Reeves stretcher, is made of canvas or some other
rubberized or flexible material, often with wooden slats sewn into
pockets and three carrying handles on each side
 Because of its flexibility, it can be useful in restricted areas or narrow
hallways
Vacuum mattress
 Some services now use a vacuum mattress when transporting patients
 The patient is placed on the device and air is withdrawn by means of a
pump
 The mattress then becomes rigid and conforming, padding voids naturally
for greater comfort
 Vacuum mattresses reduce some of the discomfort associated with rigid
backboards
Patient Immobilizing Devices, Moving Patients onto Carrying Devices
Choose a move based on the position the patient is in when it is time to move
him to a carrying device and whether or not the patient is suspected of having a
spine injury
Patient with Suspected Spine Injury :
 A patient with suspected spine injury must have his head, neck, and spine
immobilized before being moved Perform manual stabilization, place a
rigid cervical collar, and maintain manual stabilization until the patient is
immobilized to a spine board
 Remember that immobilization is mandatory for any patient who has any
possibility of a spine injury
Gambar53. Patient with Suspected Spine Injury
Patient with No Suspected Spine Injury

 An extremity lift is used to carry a patient with no suspected spine or
extremity injuries to a stretcher or a stair chair
 A direct ground lift is performed when a patient with no suspected spine
injury needs to be lifted from the ground to a stretcher
 The draw-sheet method is one of two methods (along with the direct
carry method) that is performed during transfers between hospitals and
nursing homes, or when a patient must be moved from a bed at home to
a stretcher
 A direct carry is performed to move a patient with no suspected spine
injury from a bed or from a bed-level position to a stretcher
Patient Positioning
 Positioning the patient during transfer to the ambulance and during
transportation is a very important part of your care
 Lifting, moving, and transport must be performed as an integral part
 The position in which the patient is transported depends on his medical
condition and the device best designed to help this condition
 Unresponsive patients with no suspected spine injury should be placed in
the recovery position
 The position must be safe and not prohibit the proper use of any
transportation device.
 The position of comfort must be used cautiously in case the patient
vomits
 Always monitor the patient’s airway and level of responsiveness
 Place the patient in the recovery position at the first sign of a decreased
level of responsiveness.
Gambar 54. Patient Positioning
Positioning for Shock

 Patients who are believed to be in shock are placed in a supine position
 This allows maximum blood flow throughout the body with minimal
resistance from gravity
 It is important that all parts of the body—especially vital organs such as
the brain—remain perfused
Conclusion
 The process of lifting and moving patients is a task that requires planning,
proper equipment, and careful attention to body mechanics in order to
prevent injury to the patient and to EMTs
 Positioning the patient for transport should take into account the
patient’s comfort, medical needs, and safety
Assessment & Stabilisasi Pretransfer
(dr. Soejat Harto, SpAn.,KAP)
INTRODUCTION
• The process of transferring a patient from the scene or during
interhospital transfer causes additional physiological stresses to the
already compromise patient.
• Difficult to perform certain procedures while in transit.
• Minimum space in helicopter air ambulances.
• Essential that the patient is optimally prepared for the journey.
Considerations
• The urgency
• Mode of transportation
• Which intervention benefit the patient if done before transfer.
• Procedure which may necessary during transfer
• Special consideration of environment in which the patient will be placed
during transfer.
• The experience of the transport team.
Early vs late transfer? The need for stabilization

• Balans antara SPEED dan SAFETY
• Tidak banyak waktu stabilisasi (scoop & run philosophy):
• Pasien MCI  kateterisasi segera
• Pasien stroke hemoragik  tindakan segera di kamar operasi.
• Pasien ruptur aneurisma
• Cukup waktu untuk stabilisasi :
• Pasien AKI/CKD yang akan menjalani hemodialisis
EARLY vs LATE TRANSFER: What to stabilize

1. Jalan napas dan sistem respirasi
2. Hemodinamik
3. Sistem saraf pusat
4. Muskuloskeletal
AIRWAY & BREATHING

• Airway patency during transport is of primary importance.
• Potential airway compromise should be anticipated before transport, so
that proper intervention can be undertaken to ensure that the airway is
protected.
• Performing airway maneuvers in a transport vehicle : challenging & often
are unseccessful.
• Endotracheal intubation should be considered In patient who has the
potential to lose their airway due to aspiration, swelling or edema (facial
or neck burns, epiglotitis, facial fracture, or patient with altered level of
conciousness).
• Patient requiring mechanical ventilation and ventilatory support should
be intubated in a controlled environment prior to departure.
• Supplemental oxygen should be contemplated and is usually considered
to be standard therapy during transport.
• As a general rule, it is estimated that inspirred PO2 declines
approximately 5 mm/Hg per 1000 feet ascended. No formula exist as to
how much the oxygen percentage should be increased to combat this
drop in oxygenation.
• Transport team should rely their assessment of the patient’s color,
capillary refill, and oxygen saturation results to determine how the
patient is tolerating the transport.
• Chest tube placement may be accomplished prior to transport to
decompress pneumothorax.
• The patient who is being transported by air will have expansion of the
pneumothorax if it is not treated prior to departure.
• A close drainage system should be attached to the chest tube and a one
way valve should be in place to prevent complications.
Gambar 55. Prediction of In-flight PO2
Stabilisasi Pra Transport

• Pasang NGT pada pasien ileus atau obstruksi usus
• Pasang kateter urin pada pasien yang memerlukan restriksi cairan,
transport jarak jauh, dan pasien dengan diuretik
• Pasang WSD pada pasien dengan pneumotoraks
• Restrain pada pasien yang tidak kooperatif
Airway dan Breathing
• Patensi airway penting selama transport  Manuver airway saat
transport SULIT
• Intubasi endotrakeal
1. Pasien berpotensi gangguan airway:
• luka bakar wajah dan leher,
• epiglotitis,
• cedera kepala atau pasien dengan penurunan kesadaran.
2. Pasien dengan ventilasi mekanik (dapat disertai pemberian
sedatif, analgesia dan pelumpuh otot)
Hemodinamik
• Goal : normalisasi tanda vital dan normalisasi status sirkulasi.
• Pada pasien perdarahan, sebelum transport:
• kontrol perdarahan, dilanjutkan
• resusitasi cairan.
• Pressure dressing can be applied.
• Minimal 2 akses vena besar terpasang sebelum tindakan transport.
• Cairan infus lebih direkomendasikan dalam kemasan plastik.
• Ekspansi gas yang terjadi dapat menyebabkan pecahnya botol
infus.
• Produksi URIN : salah satu INDIKATOR status cairan dan hemodinamik
pasien yang baik.
• Kateter urin akan membantu team menilai status cairan.
• Irama jantung selalu dinilai melalui monitor kontinu.
Sistem saraf pusat

• Gangguan kesadaran diatasi dengan pemberian sedasi atau analgetik.
• Penilaian status neurologis (GCS) harus dilakukan sebelum transport.
• Pasien kejang diberikan anti kejang & atasi kemungkinan hipoksia.
• Pasien trauma medula spinalis dengan defisit neurologis:
• Backboard dan hard cervical collar.
• Methylprednisolon diberikan sebelum maupun dalam proses
transport
Stabilisasi Muskuloskeletal
• Penanganan mencakup : imobilisasi fraktur, perawatan luka dan
pemberian obat yang diperlukan.
• Selama transport, nilai deyut nadi distal.
• Traksi splint dapat digunakan selama transport. Traksi weights sebaiknya
dihindari.
• Extensive wound care is not possible in the transport environment.
• Transport crew should preserve integrity of a wound and prevent further
contamination.
• Wound should be dressed and the dressing reinforced as necessary.
Emotional Stabilization & Psychosocial Support

• After the physical needs of the patient who is about to be transported
have been met, the emotional and physchological aspects of transport
should be addressed.
• If the patient and his or her family have fears or questions, intervention
prior to the start of the transport can alleviate many of their worries.
• The use of interpreter should be considered when there is an obvious
disconnect in the communication proccess due to language problems.
Final Checklist
• Is the airway secure?
• Is the patient protected from aspiration ?
• Is the spine adequately immobilized (where necessary)?
• Has shock been treated?
• Does the patient have adequate IV access?
• Is a urinary catheter in place (where indicated)?
• Have all special environmental considerations been taken into account?
• Is appropriate monitoring in place including infusion pumps?
Medical Equipments and Disposable Items
( Ns. Purwani D. Kuntowati )
PURPOSES
 To provide initial treatment for life threatening
during patient transport
 To control the symptoms of the patient
 To save the life of the patient
 To reach the site of action as soon as possible
 To diverge the patient from the possible risk
PREPARATION
Based on:
 Patient Problem and Condition
 Length of Transport
 Environment of the transportation’s mode
 Medical Procedures during transport
 Special or other inquiry
DETAILS
 Stretcher , Basket Stretcher, Scoop Stretcher
 Transport Incubator
 Transport Monitor and / or Pulse Oxymeter
 Transport Ventilator and Oxygen Bottle
 Mobile Suction Pump
 Syringe Pump and Infuse Pump
 Temporary Pace Maker
 Oxygen Bottle / O2 Concentrate
 Vacuum Mattress
 Canvas Transfer Sheet
 Defibrillator / AED
 Trauma Life Support Equipments
 Disposable Blood Analyzer
 Responder Bag and Drugs Case
RESPONDER BAG’S DETAIL

 Assessment
- Stethoscope
- Reflex Hammer
- Penlight
 Airway
- Goedel
- Suction Catheter
- Manual Suction
 Breathing
- Ambubag
- O2 Nasal Canule
- O2 Mask ( Rebreathing and Non Reabreathing)
- Nebulizer Mask
- Intubation Set
* Laryngoscope + battery
* Mc Gill Forceps
* Mandrin or Bougie
* ETT
* Syringe 5 ml
* Sterile Gloves
* Xylocain Gel
* Tape for Fixation
- Ventilator Circuit
- Bacterial Filter
- Test Lung
 Circulation
- IV Catheter no 18, 20, 22, 24
- Needles
- Tourniquet
- Infuse Set
- Blood Set
- Micro drip
- Extension Tube
- Three way (with and without tail )
- Syringe ( 50 ml, 20 ml, 10 ml, 5 ml, 3 ml, 1 ml )
- Transparent Dressing
- Tape for fixation
- Alcohol Swab
- Water for injection
 Urinary Set and Bowel set
- Urine Catheter
- Syringe 20 cc
- Urine Bag
- Tape for Fixation
- Sterile Gloves
- Sterile Gauze
- Antiseptic Solution
- Sterile Forceps and Small Sterile Linen
- Xylocain Gel
- Water for injection
- Rectal Tube
- Plastic Reservoir
- Diapers
 GIT set
- NGT
- Xylocain Gel
- Gloves
- Syringe 50 ml Catheter Tip
- Reservoir Bag
- Tape for Fixation
-
 Temperature set
- Hot and Cold Pack
- Temperature
 Blood Glucose Test Pack
OTHERS
 Additional Savety Belt
 Meals and Beverages
 Linen ( Blanket, Pillow and Cover,
 Mattrass Cover, Patient Gown )
 Inverter or Battery
 Petty Cash
 Connecting Point
 Transit
 Refiil ( O2 )
 RON
EQUIPMENT PLACEMENT
Gambar 56. Equipment Placement
REFERENCES
1. Benson N, Hankins D, Wilcox D, Air Medical Dispatch Guideline for scene
response [ positive paper]. Prehospital Disaster Med. 1992.
2. Mitsovich JJ, Karen KK. Pre Hospital Emergency Care 9th ed. Upper Saddle
River, NJ: Pearson; 2011
3. Brown JB, Stassen NA, Bankey PE, Sangosanya AT, Cheng JD, Gestring ML.
Mechanism of injury andspecial consideration criteria still matter: an
evaluationof the National Trauma Triage Protocol. J Trauma 2011
4. Carruba C, Hunt R, Benson N. Criteria for air medical transport: non
trauma and pediatric considerations[ position paper]. Prehosp Disaster
Med 1994.
Emergency Drugs Patient Transfer
( Ns. Purwani D. Kuntowati )
PURPOSES
• To provide initial treatment for life threatening during patient transport
• To control the symptoms of the patient
• To save the life of the patient
• To reach the site of action as soon as possible
• To diverge the patient from the possible risk
Details
Drugs Class Drugs Name Route
• Analgesics
- Narcotics Tramadol IV/IM
Morphine IV
Pethidine IV
Fentanyl IV
Sufenta IV
- Non Narcotics Paracetamol IV
Diclofenac Na IM

• Anesthetics
- Topical Lidocain Gel 2% Topical
Licocain Spray 2% Topical
- Infiltrative Lidocain 2% Local
- Injection Midazolam IV
Propofol IV
Narcan IV
• Anti – bleeding Vitamin K IV
Transamin IV
Adona AC IV
• Anti - Coagulant Heparin IV
• Anti - Convulsions Diazepam IV

Phenytoin IV
Phenobarbitol IV
• Anti - Diabetic Inzulin R IM
• Anti – Dot Na Bicarbonat 4,2% IV
Ca Gluconate IV
Protamine Sulphate IV
Atropine IV
• Anti – Histamines Chlorphenaramine IV
• Anti – Invectives ( If needed ) IV

For Prophylaxis
• Anti - Inlammatories Hydrocortisone IV
Methyl Prednisolone IV

• Burn Preparation MEBO Topical
( Moist Exposure
Burn Ointment )
• CVS Agent
- ACE Inhibitor Captopril PO
- Adrenergic Stimulant
Nor Ephinephrine IV
Phenylephrine IV
Dobutamine IV
Dopamine IV
• CVS Agent
- α/β Blockers Propanolol IV
- Calcium Channel Blockers
Diltiazem IV
- Diuretics Furosemide IV
Manitol IV
- Vasodilator Nitroglycerine IV
• Electrolites Potasium Chloride IV
Magnesium Sulphate IV
Natrium Chloride IV
• Fluid Replacement Normal Saline IV
Dextrose IV
D5 NS IV
Ringer Lactat IV
( pediatric cases
must be provided fluid for pediatric only )
• GI Agents
- Antaside Mag Hydroxide PO
- Anti Emetic Ondansetron PO/IV
- Anti Spasmodic Hyocine IV

- buthylbromide
- H2 Antagonist Ranitidine IV
- Proton Pump Omeprazole IV
Inhibitor
Additional Drugs
Preparation of Additional Drugs must based on each condition of each patient
References
• Baynes, J., Doniniczak, M., Medical Biochemistry, Elsevier Limited; Third
Edition (2009 )
• Bryan E, Bledsoe; Robert S. Porter, Richard A. Cherry (2004). “Ch. 3”
Intermediate Emergency Care. Upper Saddle River, NJ: Pearson Prentice
Hill. pp.26
Air Ambulance and Experiences
Patient transportation is certainly a ‘Cinderella’ service

History :
• Rotary-wing and fixed wing aircraft are established modes of transport
for critically ill or injured patients
• In 1928 the first civilian aeromedical service was developed in Australia
• The Royal Flying Doctors Service was established to provide emergency
medical care to Australians living in remote locations
• The first helicopter evacuation was of combat casualties in Burma in 1944
Aeromedical transfer
• Modern aeromedical transfers can involve patients of any age who may
be critically ill or injured
• The patients can be moved from the scene of an incident to the most
suitable centre (primary transfer), between medical facilities for specialist
services (secondary transfer), or across international borders for
repatriation
Indications
 Aeromedical transfers are expensive and potentially dangerous (to the
patient and the team) and should not be undertaken unless necessary
 Unsafe patients (eg non-sedated confused patients, ‘unrestrained’,
psychiatric or potentially violent patients), terminal patients, patients
already in cardiac arrest, or patients likely to die en-route are unlikely to
benefit
 There is no rigid list of indications for an aeromedical flight
Topics
• physiologycal changing and disturbances
• communication and refferal
• priorities and time frames
• Preparation
• Documentation
• tips of specifics groups of patients ( cardiac, obstetrics, neonates, trauma)
Medical provision
 Rapid transfer for definitive care is an indication for aeromedical transfer
 Time-critical emergencies (eg patients requiring emergency
neurosurgery) are well suited to aeromedical transfer
 Having medically trained personnel on board the aircraft as part of the
transfer/ retrieval team may allow early intervention and management by
highly trained staff with specialist equipment
Time
• In a time-critical patient the distance travelled must be great enough to
offset the time taken for the planning, loading and unloading of a patient
and the possibility of a secondary transfer from landing site to final
destination
• helicopters are more routinely used for distances less than 250 miles
• Fixed wing aircraft transfer tends to be a more efficient process for
distances over 250 miles
• The decision to fly a patient may rest upon such variables as aircraft
availability, weather, and time of day
• Ultimately, the decisions on safety of the aircraft, crew and passengers
will rest with the Pilot in Command
TRANSFER DECISIONS
 The timing of transfer for certain groups of patients is critical
 For instance, in patients with multiple organ failure, the balance of risk
and benefit needs to be carefully considered
 The safe transfer of a patient by air relies on good planning and
organisation
 The safe transfer of a patient by air relies on good planning and
organisation
 personal planning should also include medico-legal cover and insurance
ORGANIZATION
 Designated consultant responsible for transfers,
 Guidelines for referral and for the transfer itself,
 Equipment specifically prepared and packed,
 Personnel nominated to check, replenish, clean, and recharge equipment
 Nominated medical and nursing transfer personnel,
 Good communication within and between hospitals,
 Proper routines for referral between hospitals,
 Regular audit.
 Mobilising a suitable team with adequate training is vital
 This team may vary depending upon the specialty of the patient and the
urgency of the transfer
 Having transport equipment that is safe to be used in aircraft and that is
available whenever required is essential
 Potential in-flight difficulties need to be identified and equipment to deal
with these anticipated
 Long battery life is essential
 Routine and emergency drugs (including those that require refrigeration)
should be available to collect prior to take off
 It is also important for medical staff to be familiar with the equipment
 Equipment should be dedicated transfer equipment which is tough and
reliable, lightweight and compact
 Carriage of spare equipment to provide backup in case of equipment
failure
 Suitable clothing needs to be worn
 Lace up boots or shoes are necessary, loose headgear is best avoided and
long hair should be tied back or tucked in
 Warm clothing, waterproof clothing, mobile phones and money should
also be considered.
Oxygen
 Oxygen needs to be available for transfer to and from the aircraft and
there should be sufficient supply on board for the transfer
 A portable cylinder will be needed for transfer to and from the aircraft
and is normally incorporated within the transfer trolley
 Sufficient oxygen should be carried in case of unexpected delay or
diversion
Communication
 Lines of communication must exist between the base hospital, the
destination hospital, the transporting service (air ambulance) and the
transfer team
 This is usually facilitated by a co-ordinator, who liaises between the
different parties
 It is helpful if the entire team are kept up-to-date with the progress of the
transfer
 Updates of estimated time of arrival (ETA) and any clinical changes can be
very helpful allowing ongoing planning to occur
Problems
Aircraft safety :
• All flight personnel should attend a safety briefing
• A full understanding of how to safely approach a helicopter, particularly
during ‘hot’ (rotors running) loading is essential
• Knowledge of the onboard emergency equipment and its use is
mandatory for flight crew
Gambar 57. Relative Contraindications to CCAT
Safe to fly
• The mnemonic I’M SAFE is often used to ascertain whether a pilot or
flight medic should be actively involved in flying
• Contravening any of the criteria is contraindication to flying
Gambar 58. Mnemonic I’M SAFE
Air in body cavities

• Boyle’s law states that under a constant temperature the volume of a
given mass of gas varies inversely with pressure
• As pressure falls with altitude thus the volume of a mass of gas will
increase and should this be enclosed in a body cavity THEN compression
of surrounding structures will occur
• sinus pressure, middle ear, gastrointestinal tract
• may cause life-threatening emergencies (pneumothorax, decompression
sickness or arterial gas embolism)
• Care must be taken with head injuries with suspected facial or base of
skull fractures
• Other examples relating to Boyle’s law are endotracheal
tube/tracheostomy cuff pressures
Nitrogen and decompression sickness (DCS)

 Nitrogen in solution within body tissues may come out of solution as
altitude is increased
 If a diver ascends to the water’s surface and shortly afterwards flies in an
aircraft then the diver will have increased risk of getting the bends
 A sensible ‘rule of thumb’ is not to plan to fly for 24 hours post-dive. For
multiple deep dives, requiring decompression stops, appropriate dive
tables must be consulted
Gambar 59. Nitrogen and Decompression Sickness
Pregnancy
 There is no known physiological reason why pregnant mothers should not
fly assuming that they and their fetus are in good health
 Although the PaO2 of the mother does fall at altitude, the fetus seems to
be relatively protected and there doesn’t seem to be any acute change in
fetal heart rate or variability
 It should be noted however, that babies born to women who are
chronically exposed to altitude hypoxia are, on average, of lower birth
weight
Defibrillation
• Each aircraft has its own individual characteristics but on many aircraft
with modern navigation systems defibrillation can be attempted without
interference to flight
• It is essential to communicate with the pilots to inform them that
defibrillation is about to take place
Noise
 Aircraft and especially helicopters generate considerable noise
 Auscultation for clinical signs become impossible
 Monitor alarms become inaudible and a visual alarm should be
incorporated
 Patients too require noise protection
Nausea and vomiting

 May occur when there is continual and changing body motion
 Any change in aircraft attitude, outside visibility, g-forces or speed may
exceed the limits of capability of the human orientation system
 This provokes a feeling of unwellness along with nausea, paleness and
sweating
 Antiemetics that have sedative properties are not to be recommended
Vibration and motion

 Many procedures are difficult to perform on aircraft (particularly
helicopters) due to the vibration and motion set up by the aircraft and
the weather conditions
 Affect the abilities of the flight medic to assess the patient
 Consideration for invasive arterial monitoring might be appropriate as
automated non-invasive blood pressure monitoring seldom works
Environment
 Vibration may be amplified with the patientlying on the aircraft floor and
pain from fractures may be exacerbated
 Suspected cervical spine fractures are immobilised
 an emergency requirement for intubation will prove challenging and as
such if these procedures are anticipated they should be performed pre-
flight
 For personnel and patients in fixed-wing vehicles, acceleration and
deceleration forces can be significant on take-off and landing
 Correct positioning of the patient to limit these stresses should be
considered
Cramped conditions
 All medics should be familiar with their aircraft and its safety briefing and
(to a limited extent) its flight characteristics.
 In most cases, the working environment will be small and access to the
patient may be limited
 Drip heights are limited by the low ceiling heights in most aircraft, limiting
flow rates
Limited staff numbers
 The staff available must deal with any emergency occurring in-flight.
 If the numbers in-flight cannot manage the emergency then options
include diverting to another closer centre or landing to allow better
access to the patient by all available crew members
 The pilots become a valuable medical resource
Distraction
 Ambulances and aircraft transfers alike require the medic to monitor a
critically ill patient constantly in less than ideal conditions
 However, the view from an aircraft can be spectacular whether by night
or day
 Noise, vibration, and motion sickness also provide significant distraction
Weather
• Turbulence, It is essential therefore to ensure that the patient is safely
secured within the aircraft and that equipment is stowed in such a
fashion that it cannot cause injury
• Humidity, high humidity may affect flight crew and patient comfort, its
effect on an aircraft is to reduce the load it can carry . The greater the
water content of air, the less its density. Aircraft performance will be
reduced as air density decreases
• Pressure lapse rate : A given reduction in pressure with height is known
as a pressure lapse rate. in the lower atmosphere the average pressure
lapse rate is considered to be 1hPa per 30ft. In a sick spontaneously
breathing patient, this reduction may need to be corrected for by
increasing supplemental oxygen
• Temperature lapse rate : the temperature lapse rate is 1.98°C per
1,000ft. Thus as in the example above at 5,000ft the temperature may be
10°C cooler than at sea level. maintenance of the patient’s core
temperature in these situations is vital, flight medics also need to remain
warm to avoid lapses in concentration and possibly air sickness
Flying
• Flight rules : aircraft fly under two sets of rules, the Visual Flight Rules
(VFR) and the Instrument Flight Rules (IFR). Should visibility and cloud
cover not allow VFR flight then generally flights must be under the IFR.
Distraction of the pilots under these conditions should be avoided
• Air accidents : The benefits of aeromedical transport must always be
weighed against the risk of death for patients. The overall risk of
accident-related patient death in Australia is about 1 in 50,000 helicopter
missions. A National Transportation Safety Board safety review found
that weather posed the single biggest danger to aeromedical transfers in
the US
Tips of specifics groups of patients

Obstetric :
• The goal is to optimize medical care during the transport of two patients
rather than one
• Differences in maternal anatomy and physiology : supine hypotension,
increase risk of venotrombosis and phlebitis, reduces tidal volume,
Increase in plasma volume, hypercoaguability, Prolonged gastric
emptying
• Foetal monitoring : USG
• The effect of altitude on the pregnant patient
Specific problems in obstetric transfers

• In utero transfers
• Vaginal bleeding : APH,PPH
• Pre-term labour
• Pre-eclampsia and eclampsia
Neonatal transfer
• It is usual for a paediatrician or neonatologist trained in neonatal
transportation to transfer the baby along with a neonatal intensive care
nurse
• These babies most commonly require transfer to a specialist unit for the
following reasons:
1. Complications associated with prematurity
2. Complications associated with delivery such as birth asphyxia or
meconium aspiration
3. Surgery – This includes problems such as diaphragmatic hernias, tracheo-
oesophageal fistulae, gastroschisis and necrotizing enterocolitis
4. Congenital heart disease
Most aeromedical transfers in
this category are patients with
Acute Coronary Syndromes
On clinical grounds give: Oxygen,Sublingualnitrates,

Aspirin, Narcoticanalgesia
Insert a single intravenous cannula and take bloods.
Monitor vital signs and
ECG continuously.
Obtain a 12-lead ECG
Gambar 60. Transfer of Patients with Acute Coronary Syndromes
Cardiac patient : arrhythmia

• General principles : Transport management will depend on the nature of
the arrhythmia and underlying cause
• Oxygen, Insert a single intravenous cannula and take bloods. Monitor
vital signs and ECG continuously.
• Obtain a 12-lead ECG. Fax us the ECG when referring patients for
transport
• Ensure continuous ECG monitoring and an escort to the airport
Trauma
• Mechanism of Injury
• Knowing and communicating the mechanism of injury helps to anticipate
injuries
• Primary Survey : Evaluate and treat immediately life-threatening
conditions in the standard order : Airway ( include spine ), breathing,
circulation, disability, exposure
• Early interventions may include airway manoeuvres, chest
decompression, IV fluid resuscitation
• Secondary survey : head, cervical spine, chest, abdomen, pelvis, limbs
• Treatment with : oxygen, analgetics, antibiotics, tetanus prophylaxis,
• Best transported on vacuum mattress
• Head Injuries : The aims of patient management in severe head injury are
to identify and treat life-threatening injuries and prevent further injury to
the brain and spinal cord
• Intubation in head injury : trauma patient with a GCS around 12-13/15
has significant risks of hypoxia, hypercarbia, and deterioration during
flight
• Avoid hypothermia
BASELINE DIAGNOSTIC STUDIES AND DOCUMENTATION
(dr. Trisna H. Prasetyo, SpAn.,KIC)
Tujuan
• Mengerti prinsip umum dalam analisis hasil laboratorium
• Mengenali pemeriksaan laboratorium yang paling umum diminta di IGD

dan ICU
• Mengerti pentingnya hasil pemeriksaan laboratorium yang abnormal

sebagaimana hal tersebut terkait kondisi pasien
• Membahas penyebab hasil laboratorium yang abnormal
• Mengenali pemeriksaan point-of-care (POCT) mana yang dapat dilakukan

pada saat transport.
PENDAHULUAN
• Hasil pemeriksaan laboratorium bermanfaat untuk:
1. mengetahui beratnya kondisi pasien

2. dalam menghadapi masalah potensial
Pemeriksaan meliputi darah, urin, CSF, atau cairan tubuh lain
Prinsip Analisis
1. Bagaimana nilai yang berlebih ini mempengaruhi pasien sekarang dan
bagaimana hal tersebut dapat mempengaruhi kondisi pasien dalam
perjalanan
2. Presisi dan akurasi sangat penting untuk penggunaan yang tepat suatu
pemeriksaan laboratorium
3. Presisi yang tinggi: setiap kali pemeriksaan dilakukan, nilainya akan selalu
sama
Nilai Laboratorium pada Sampel Darah

Natrium (Na)
 Penanda keadaan cairan pasien
 Tanda dan gejala berkaitan dengan neurologi
 Peningkatan Na: pada TBI mungkin terjadi akibat pemberian salin
hipertonis, mannitol dan diuretik untuk mengurangi edema serebri
 Hiponatremia: pada kondisi air bebas berlebih atau deplesi natrium
berlebih
 Dapat terlihat pada CHF, Gagal Ginjal, atau penyakit hati dan pada
pasien yang mendapatkan terapi diuretik
 Dapat terlihat pada CHF, Gagal Ginjal, atau penyakit hati dan pada
pasien yang mendapatkan terapi diuretik
 Koreksi: lebih lambat lebih baik (4-6 Meq/L per 24 jam) untuk
menghindari masalah neurologis
 Kadar natrium < 125 mEq/L: perubahan perilaku, kebingungan,
delirium, peningkatan RR, kedutan otot, peningkatan TIK & kelainan
jantung
 Peningkatan kadar natrium dapat menyebabkan retensi cairan dan
kelainan jantung
Kalium (K)
 Hiperkalemia: aritmia jantung, kelemahan dan paralisis.
 Akibat dari: suplementasi kalium, asidosis metabolik, AKI, CKD.
 Nilai yang tidak tepat: hemolisis
 Urgensi dalam koreksi tergantung gejala dan penyebab.
 Hipokalemia: artimia & perubahan EKG, nyeri otot, mual, muntah,
hipotensi ortostatik.
 Penyebab: cellular shift atau peningkatan ekskresi
Gambar 61. Gambaran EKG
Klorida (Cl)
 Hipokloremia: mendapatkan diuretik
 Hiperkloremia: baal & tingling, hipertonisitas otot, penurunan RR,
kegugupan.
Karbon Dioksida
 Dibawah normal : asidosis metabolik atau alkalosis respiratorik
 Meningkat : alkalosis metabolik atau asidosis respiratorik
Kreatinin
 Hasil metabolisme dari otot
 Meningkat pada kerusakan otot dalam jumlah besar
Laju Filtrasi Glomerulus

 GFR/LFG normal: 90-120 ml/min per 1.73 m2
 < 60 ml/min: kerusakan ginjal
 GFR/LFG menurun dengan usia
Glukosa
 Normal : 70-110 mg/dL
 Pasien dengan insulin  periksa GDS per jam
 Kadar yang tinggi : koma dan kematian
 Kadar yang rendah : pandangan buram, pusing, mual, muntah &
goyah.
Kalsium Total
 Fungsi : kontraksi otot hingga transduksi sinyal intrasel.
 Kalsium total normal : 8.5-10.2 mg/dL
 Hanya kalsium bebas yang aktif secara fisiologis.
 Kalsium terionisasi normal : 8.8-10.3 mg/dL
 Kadar kalsium terionisasi yang rendah : penurunan CO, hipotensi,
artimia.
Magnesium
 Normal 1.3-2.1 mEq/L
 Kadar yang tinggi disebabkan kelainan renal, dehidrasi berat,
pemberian berlebih.
 Kadar yang rendah : gangguan GI, muntah, diare, sirosis hepatis,
pankreatitis.
Hematocrit & Hb
Hematocrit
 Adalah persentase formed elements pada sebuah sampel darah vena.
 Kadar yang rendah mengindikasikan adanya penurunan kapasitas
darah dalam mengantarkan oksigen ke jaringan.
 Nilai normal: 41%-50%.
 Contoh: Pasien dengan nilai hematokrit 22%  kehilangan darah atau
kelebihan cairan.
Hemoglobin
 Membawa Oksigen dan CO2
 Nilai normal : laki-laki 14-17.5 g/dL, perempuan 12-16 g/dL
 Peningkatan : hemokonsentrasi (dehidrasi, luka bakar, muntah
berlebih)
Gambar 62. Hematokrit dan Hb
 RBC  Nilai kegunaan klinis sedikit

 WBC
• Normal : 4.500-11.000/mikroliter.
• Nilai yang rendah : anemia, defisiensi vitamin, sepsis
• Peningkatan terlihat pada inflamasi/infeksi, keganasan, kondisi

vascular, steroid, stress atau trauma.
 Hitung Trombosit
• Normal: 150-350.000
• Peningkatan terlihat pada kelainan mieloproliferatif, setelah

perdarahan limpa atau setelah splenektomi.
• Trombositopenia: sering karena DIC atau Splenomegali. Di ICU

sering terlihat pada HIT dan ITP
Protein
PROTEIN TOTAL
ALBUMIN
LAKTAT
LDH
CREATIN KINASE
TROPONIN
B-type Natriuretic Peptide

Gambar 63. Proses Protein menjadi B-type Natriuretic Peptide
Pemeriksaan Fungsi
Hati
 AST (SGOT)
• Meningkat pada kerusakan hati akut : hepatitis, obstruksi saluran

bilier, RHF, Hipoksia, Trauma ekstensif.
 ALT (SGPT)
• Lebih spesifik untuk kerusakan hati
• Durasi peningkatan lebih lama karena waktu paruh yang panjang

(36-60 jam)
 Bilirubin
• Indirek & Direk
• Disebabkan obstruksi saluran bilier & hemolisis sel darah merah
Pemeriksaan Fungsi Hati (Pankreas)
 Amilase, meningkat pada penyakit pankreas, obstruksi duktus bilier
dan trauma kepala
 Lipase, meningkat lebih lama daripada amilase pada pankreatitis akut
Fungsi Koagulasi
 Protrombin Time (Jalur Ekstrinsik)
• NORMAL : 10-13 detik
• Meningkat pada : Penyakit hati, terapi Warfarin, DIC & pasca

transfusi masif.
 APTT (Jalur Common & Intrinsik)
• NORMAL : 25-40
• Meningkat pada Hemofilia A, B & Von Willebrand
• Sering digunakan menilai DIC
 INR
• NORMAL : 0.8 – 1.2
• Meningkat sejalan dengan PT atau pada pasien yang

mendapat antikoagulan
• Nilai > 5 butuh terapi
Gambar 64. Kaskade Kogulasi
 Gas Darah
Status Status
Asam Basa Oksigenasi
Gambar 65. Gas Darah
Pemeriksaan Urin
Color
Appearance
Specific Gravity
pH
Glucose
Ketone Bodies
Protein
Blood and Hemoglobin
Electrolytes
Gambar 66. Pemeriksaan Urin
Pencitraan Diagnostik
Radiografi Standar
Khususnya pandangan lateral atau anteroposterior
Mengkonfirmasi letak tabung ETT, fraktur servikal, interpretasi daerah dada, dan
fraktur tulang mayor
Computed Tomography
Interpretasi CT Scan dapat menunjukkan diseksi aorta, cedera pada paru, cedera
organ abdomen, fraktur, emboli paru, efusi pleura, dan ARDS
Diagnostic Imaging
 MRI
• Gambaran jaringan lunak lebih baik daripada CT Scan
• Pasien tidak ter ekspose dengan radiasi.
• Kuatnya medan magnet  ventilator,monitor dan alat medis

yang menyertai pasien perlu spesifikasi khusus.
 USG
• Biasanya digunakan untuk menilai sistem kardiovaskuler
• FAST (Focused Assessment with Sonography for Trauma)

dapat dikerjakan bedside untuk membantu penilaian adanya
darah di kavitas abdomen.
• Membantu dalam memasukkan IV line atau CVC.
Tujuan Hasil Laboratorium untuk Tim Transport

• Membentuk sebuah gambaran klinis lengkap pasien.
• Analisis laboratorium memungkinkan klinisi untuk menilai dan

mengkonfirmasi keadaan organ atau sistem
• Tidak ada hasil laboratorium yang dapat dianalisis secara tersendiri :

trend penting dicermati, dikonfirmasi dengan metode lain.
Studi Kasus
• Laki-laki 37 tahun, gagal ginjal akut setelah transplantasi ginjal.
• Riwayat : Pasien dan temannya melakukan perjalanan hiking ke gunung

dan tersesat. Dia ditemukan 48 jam kemudian. Mereka ditemukan dalam
keadaan dehidrasi berat dan kebingungan.
• Pasien menjalani transplantasi ginjal kurang lebih 1 tahun lalu. Sebelum

hari ini, dia tidak memiliki masalah apapun terkait transplantasi tersebut.
Pasien sudah 2 hari tidak meminum obat antirejeksi-nya.
• Tim Evakuasi memasang jarum IV berukuran besar dan melakukan
resusitasi cairan terhadap pasien dengan 2000 mL normal saline sebelum
mengirimnya ke rumah sakit terdekat
• Pasien saat ini sadar dengan kelemahan generalisata.
• Dia telah mendapatkan intake total 2500 ml normal saline.
• Urin output 100 mL sejak kateter dipasang
• Tanda vital saat ini : 35.6 0C, HR 88x/min, RR 20x/min, SpO2 98% dengan
nasal cannula 4 lpm.
• EKG: normal SR, 88 detak/min, tall peaked T waves di lead precordial V1

hingga V6, QRS memanjang, RBBB inkomplit.
• Lab: Na 135 mEq/L, K 7.3 mEq/L, Cl 100 mEq/L, Total calcium 8.8 mg/dL,
BUN 70 mg/dL, Cr 3.0 mg/dL. Gula darah normal, CK dan myoglobin
meningkat.
1. Apa masalah utama pasien ini?

2. Apa langkah tatalaksana yang akan Anda lakukan?
3. Apakah Anda akan lakukan evakuasi ke RS Rujukan?
4. Jika Evakuasi dilakukan, apa tindak lanjut terapi dalam perjalanan ?
5. Apa tindakan setelah pasien sampai di RS rujukan?
Studi Kasus
• Pasien sedang dipindahkan ke rumah sakit tersier untuk HD emergensi
dan penanganan gagal ginjal
• Anda memberikan 1 g kalsium glukonas. Anda menilai EKG dan

mengamati bahwa QRS lebih sempit dan T wave tidak setinggi
sebelumnya.
• Anda memutuskan untuk mengirim pasien ini segera, sadar bahwa dia
masih membutuhkan penanganan emergensi, tetapi sisa obat-obatan
dapat diberikan di jalan.
• Dalam perjalanan, anda memberikan 50 mL 50% glucose IV, diikuti

dengan 10 Unit regular insulin, bikarbonat natrium 50 mEq IV dan 5 mg
albuterol dalam 3 mL normal saline via nebulizer.
1. Apa prioritas anda sebelum transport?
2. Apa prioritas anda pada saat transport?
3. Parameter penilaian ulang mana yang penting pada saat transport ini?
Analisis studi kasus

Saat evaluasi, didapat masalah pasien ini adalah acute kidney injury dan
hiperkalemia.
Acute kidney injury akibat dehidrasi, rejeksi atau rhabdomiolisis.
Namun, prioritas masalah adalah HIPERKALEMIA
Tanda-tanda hiperkalemia perlu segera diterapi :
1. Adanya kelemahan otot
2. Adanya perubahan gambaran EKG
Pada pasien ini didapat kelemahan umum dan perlambatan konduksi

intraventrikel, dan gelombang T yang meninggi.
• Intervensi yang terpenting adalah pemberian Calcium.
• Ada 2 sediaan: Calcium glukonas dan calcium chlorida.
• Calcium chlorida mengandung elemen calcium 3 kali lebih tinggi daripada

calcium gluconas, dan harus diberikan melalui CVC.
• Efek calcium akan terlihat dalam 3 hingga 5 menit, dan bertahan selama
30 sampai 60 menit.
• Dalam perjalanan, diberikan 10 U insulin bersamaan dengan 50 ml D50 @

IV. Efek keduanya akan terlihat dalam 15 menit, dan mencapai puncak
dalam 60 menit, bertahan untuk beberapa jam.
• Pasien diberikan BicNat 50 mEq IV. Bicnat akan menaikkan pH, melepas
ion hidrogen dari sel dan memasukkan kalium ke dalam sel. Efek terapi
ini akan terlihat dalam 30 menit dan bertahan beberapa jam.
Beta 2 adrenergic agonis akan mendorong kalium masuk ke sel dengan

meningkatkan aktivitas Na+/K= ATP ase yang diperlukan oleh pompa Na.
Albuterol yang diberikan secara nebulasi akan bekerja dalam 30 menit, dengan
durasi 2 sampai 3 jam
Review
Pemeriksaan laboratorium dapat sangat berguna dalam menentukan beratnya
kondisi pasien atau sebagai persiapan dalam menghadapi masalah potensial
dalam perjalanan ke rumah sakit.
Tim transport harus tau batas normal setiap pemeriksaan laboratorium, serta
makna fisiologis setiap pemeriksaan
Nilai setiap analisis laboratorium tergantung akurasi, presisi, sensitivitas dan
spesifisitas pemeriksaan
Nilai normal : hasil dari 95% of individu sehat terhadap pemeriksaan tersebut.
• Walaupun hasil lab abnormal tidak dapat diabaikan, sangat penting
bahwa hasil tersebut dinilai dalam konteksi gambaran klinis pasien secara
keseluruhan
• Laboratorium yang berbeda dapat memiliki rentang nilai normal yang

berbeda untuk suatu pemeriksaan yang sama.
• Natrium serum sodium adalah penanda yang mudah untuk menilai

keadaan cairan pasien dan merupakan salah satu komponen kunci
perhitungan osmolalitas serum. Hasil natrium yang abnormal tidak akan
menghasilkan perubahan EKG.
• Peningkatan kadar natrium dapat ditangani dengan pemberian diuretik

dan pembatasan intake cairan. Hasilnya yang diharapkan adalah
penurunan TIK
• Hiponatremia sering dijumpai pada CHF, Gagal ginjal, Penyakit hati dan
pasien yang mendapatkan diuretik.
• Hiperkalemia dapat menyebabkan aritmia jantung.
• Pasien yang lebih tua lebih mungkin mengalami aritmia dan perubahan
EKG dengan hipokalemia.
• Pasien dengan hipokloremia mungkin mengalami impending renal

dysfunction. Pasien yang mengkonsumsi diuretik juga mungkin memiliki
kadar klorida yang rendah abnormal.
• Untuk setiap pasien dengan riwayat penyakit jantung, perubahan fungsi

ginjal, penyakit hati, atau gangguan GI atau pasien yang menerima
insulin, kadar kalium terkini harus diperoleh sebelum transport.
• Kadar BUN cenderung meningkat seiring pertambahan usia sebagai akibat

penurunan fungsi ginjal.
• Kadar kreatinin dapat digunakan untuk menilai fungsi ginjal. Pasien

geriatric dengan peningkatan kadar kreatinin mungkin mengalami
kerusakan ginjal yang lebih daripada yang dikira.
• LFG adalah pengukuran laju filtrasi keseluruhan seluruh nefron

fungsional; perubahan pada LFG dapat memberi kesan perbaikan atau
perburukan fungsi ginjal
• GDS lazim dinilai di lapangan dengan alat point-of care testing (POCT).
GDS dinilai pada pasien tidak sadar atau setengah sadar
Kalsium total meningkat pada hiperparatiroidisme dan tumor pensekresi

paratiroid. Penurunan terjadi pada insufisiensi renal, hipomagnesemia dan
hiperfosfatemia dan pada pasien yang menjalani transfusi darah masif.
• Kadar kalsium terionisasi yang rendah dapat menyebabkan aritmia yang
serius dan henti jantung yang lama
• Kadar Mg yang rendah dapat terlihat pada keadaan gangguan GI, muntah,
diare, sirosis hepatis dan pankreatitis
• Kadar Mg yang rendah dapat terlihat pada keadaan gangguan GI, muntah,
diare, sirosis hepatis dan pankreatitis
• Kadar laktat adalah indikator global perfusi dan oksigenasi
• LDH dapat berguna dalam penentuan pankreatitis
• Peningkatan creatine kinase (CK) mengindikasikan kerusakan otot atau

IMA
• Peningkatan kadar troponin I digunakan untuk menilai AMI.
• BNP dikeluarkan oleh ventrikel sebagai respons terhadap tekanan

pengisian yang lebih tinggi  fungsi ventrikel abnormal atau Gagal
jantung.
• Uji fungsi pankreas : amilase dan lipase
• Bila pada pasien terpasang akses IV dan menerima cairan serta obat-
obatan, ekstremitas yang lain harus digunakan untuk mengambil sampel
darah.
Tim transfer harus familiar dengan pencitraan diagnostik dan dapat melakukan
interpretasi dasar : fraktur tulang panjang, massa, dan letak kateter
Guidelines for the Transport of Critically Ill Patients
• INTRODUCTION
• CATEGORIES OF TRANSPORT
• ADMINISTRATIVE GUIDELINES
• STAFFING
• MODE OF TRANSPORT FOR PREHOSPITAL AND INTERHOSPITAL
• EQUIPMENT
• PHARMACOLOGICAL AGENT
• MONITORING
• PRE DEPARTURE PROCESS
• PATIENT STATUS
• IN TRANSIT PROCEDURES
• ARRIVAL PROCEDURES
THE INTENSIVE CARE SOCIETY 2011

1. Transfer Decision and Ethics
2. Selection of Transport Mode
3. Accompanying personel and risk
assessment
4. Preparation for transport
5. Monitoring during transport
6. Safety during transport
7. Aero-medical considerations
8. Documentation and handover
9. Insurance and indemnity
Gambar 67. Guidelines 2011
Association of Anaesthetist of Great Britain & England (February 2009)

OUTLINE
• Keputusan transport pasien
• Perencanaan pemindahan pasien sakit kritis
• Early vs late transfer: perlunya stabilisasi
• Tim transport
• Peralatan
• Monitoring/pemantauan
1. The decision to transfer
2. Stabilization before transfer
3. Accompanying the patient
4. Monitoring drugs and equipment
5. The ambulance
6. Documentation and handover
Transport pasien sakit kritis

Keputusan melakukan Evakuasi/Transport
Ditentukan oleh Dokumentasi keputusan

 DPJP
 nama dokter dan jabatan
 Dokter penerima / personil di unit
INTRAHOSPITAL Cenderung  rincian kontak
INTERHOSPITAL meningkat
yang dituju
 waktu keputusan dibuat
 Tim evakuasi (attending doctor)
 alasan evakuasi
INGGRIS 1997:
KLINIS
11.000 PASIEN
&
TRANSPORT
NON-KLINIS
ANTAR ICU
Faktor yang mendasari tindakan transport pasien dalam kondisi

kritis
1. Kondisi penyakit
Adakah ada manfaat yang akan didapat?
Adakah ada perubahan tata laksana?
2. Tim Transport
3. Peralatan pendukung
4. Kondisi perjalanan
5. Modalitas transportasi yang tersedia
Proses transport: risiko pada pasien kritis ↑↑

 hanya dilakukan jika manfaat >> risiko
Pengaruh transport pasien terhadap sistem organ
Sirkulasi
• Pergerakan • hipotensi, aritmia
• Perubahan Respirasi
lingkungan • hipoksia
• Peralatan tidak • hipo/hiper ventilasi
berfungsi baik
Saat transport
SSP
• Kelalaian tim •Gangguan
peningkatan TIK
transport peralatan
• lead EKG lepas
• monitor tidak
menyala
• akses vena terlepas
• alat suction tidak
berfungsi
• terekstubasi
Akibatnya...
 Hipoksia  Imobilisasi lama

 Ekspansi gas  Motion sickness
 Dehidrasi  Noise
 Penurunan temperatur  Vibrasi
 Akselerasi & deselerasi  Decompression sickness
• Memastikan kesinambungan perawatan

• Memastikan pasien dipindahkan dengan selamat
• Saat memindahkan pasien ke fasilitas lain, pastikan:
Tersedia layanan yang memenuhi kebutuhan pasien
Mampu & bersedia menerima pasien
Sumber daya yang mendampingi perpindahan sesuai dengan keadaan pasien:
staf kompeten, peralatan, modalitas transport
Data medis lengkap diterima RS tujuan
PERENCANAAN
1. Komunikasi dan koordinasi pre-transport
2. Tim transport
3. Peralatan yang diperlukan
4. Monitoring selama transport
5. Persiapan / stabilisasi pasien
KOMUNIKASI DAN KOORDINASI
Transport Intra Hospital
1. Sesaat sebelum memberangkatkan pasien, pastikan unit penerima siap

2. Petugas lain diingatkan mengenai waktu transport dan kelengkapan yang
harus disiapkan
3. DPJP diinformasikan mengenai pemindahan pasien
4. Dokumentasikan dalam rekam medik
5. Jika tidak ada petugas berkompeten di unit tujuan, tim medis
mendampingi hingga kembali ke ICU
Transport Inter-Hospital
1. Komunikasi tim evakuasi dan dokter pengirim/penerima

2. Komunikasi dokter pengirim dan penerima
3. Komunikasi antar perawat
4. Modalitas transportasi yang digunakan
5. Persiapan rekam medik, pemeriksaan penunjang, dan dokumen
pasien lainnya
ALGORITME TRANSPORT INTER-HOSPITAL
Gambar 68. Algoritme Transport
1. Nama pasien, diagnosis & tujuan transfer
2. Dokumen: radiologi, laboratorium, rekam medis pasien
3. Tujuan transport
4. Kondisi cuaca dan alternatif rute
5. Nama, lokasi dan nomor telepon DOKTER PENGIRIM dan DOKTER
PENERIMA
6. Kelengkapan alat transport
7. Lama transfer dan kalkulasi jumlah oksigen, obat dan peralatan lainnya
8. Plan B

Akses intravena yang memadai
Jika tidak tersedia akses intravena, pasang akses vena sentral
Jika diperlukan: cairan dan support inotropik (pilih semua

cairan dan obat dengan kontainer plastik bukan kaca)
Pastikan patensi jalan napas  diprediksi tidak aman:

intubasi (LMA tidak dianjurkan)
Pada pasien trauma: lakukan imobilisasi tulang belakang

• Pasang NGT pada pasien ileus atau obstruksi usus
• Pasang kateter urin pada pasien yang memerlukan restriksi cairan,
transport jarak jauh, dan pasien dengan diuretik
• Pasang WSD pada pasien dengan pneumotoraks
• Restrain pada pasien yang tidak kooperatif
Early vs late transfer?

The need for stabilization
• Balans antara SPEED dan SAFETY
• Tidak banyak waktu stabilisasi (scoop & run philosophy):
Pasien MCI  kateterisasi segera
Pasien stroke hemoragik  tindakan segera di kamar operasi.
Pasien ruptur aneurisma
• Cukup waktu untuk stabilisasi :
Pasien AKI/CKD yang akan menjalani hemodialisis
What to stabilize
1. Jalan napas dan sistem respirasi
2. Hemodinamik
3. Sistem saraf pusat
4. Muskuloskeletal
Airway dan Breathing
• Patensi airway penting selama transport  Manuver airway saat
transport SULIT
• Intubasi endotrakeal
• Pasien berpotensi gangguan airway:
• luka bakar wajah dan leher,
• epiglotitis,
• cedera kepala atau pasien dengan penurunan kesadaran.
• Pasien dengan ventilasi mekanik (dapat disertai pemberian
sedatif, analgesia dan pelumpuh otot)
Hemodinamik
• Goal : normalisasi tanda vital dan status sirkulasi.
• Pada pasien perdarahan, sebelum transport:
kontrol perdarahan, dilanjutkan
resusitasi cairan.
• Minimal 2 akses vena besar terpasang sebelum tindakan transport.
• Produksi URIN : INDIKATOR status cairan dan hemodinamik pasien.
• Irama jantung selalu dinilai melalui monitor kontinu.
Sistem saraf pusat
• Gangguan kesadaran diatasi dengan pemberian sedasi atau analgetik.
• Penilaian status neurologis (GCS) harus dilakukan sebelum transport.
• Pasien kejang diberikan anti kejang & atasi kemungkinan hipoksia.
• Pasien trauma medula spinalis dengan defisit neurologis:
Backboard dan hard cervical collar.
Methylprednisolon diberikan sebelum maupun dalam proses transport
Stabilisasi Muskuloskeletal
• Penanganan mencakup : imobilisasi fraktur, perawatan luka dan
pemberian obat yang diperlukan.
• Selama transport, nilai deyut nadi distal.
• Traksi splint dapat digunakan selama transport. Traksi weights sebaiknya
dihindari.
STABILISASI PADA PASIEN-PASIEN KONDISI SPESIFIK:
1. Gangguan neurologi.
2. Gangguan sistem respirasi
3. Gangguan sistem kardiovaskular
4. Luka bakar
5. Multiple trauma
6. Pediatrik
7. Geriatrik
8. Obstetrik risiko tinggi
Pasien dengan gangguan neurologi

• Pertimbangkan intubasi pada pasien dengan gangguan kesadaran (GCS <8)
.
• Monitoring Saturasi oksigen dan end tidal CO2. Peningkatan PaCO2 akan
meningkatkan TIK  memperburuk kondisi pasien
• Pasang kateter urin pada pasien yang mendapat terapi manitol.
Pasien dengan gangguan respirasi

• Gangguan respirasi akan memicu hipoksia.
• Transport udara  penurunan suhu udara 2 meningkatkan konsumsi
oksigen 2 kali lipat  risiko hipoksia meningkat.
• Sekresi pulmonal akan meningkat pada lingkungan dengan kelembapan
rendah. Transport udara akan meningkatkan risiko terjadi mukus plug.
• Stabilisasi :
Suplementasi dan humidifikasi oksigen,
perbaikan volume darah,
kepala strecher dinaikkan untuk memperbaiki ekspansi paru,
pneumotoraks harus diatasi sebelum proses transport.
Pasien dengan gangguan kardiovaskular

• Risiko: Hipoksia  takikardia  demand oksigen jantung meningkat 
menurunkan fungsi miokard.
• Stabilisasi bertujuan memaksimalkan fungsi jantung tanpa menurunkan
cardiac reserve.
• Persiapan:
Antiemboli
Monitoring kontinus dan defibrilator
IABP pada kasus berat
Infus kontinus obat-obat support jantung
Pasien luka bakar
• Intubasi pada pasien yang mengalami edema jalan napas, beri oksigen
100%.
• Pasang jalur intravena, dan beri cairan IV atau oral.
• Monitoring tekanan darah dan produksi urin.
Pasien multiple trauma
• Risiko yang dapat terjadi pada pasien dengan multiple trauma:
Hipoksia akibat trauma jalan napas/paru
Hipovolemia akibat blood loss
Hipotermia akibat trauma SSP
• Trauma sistem muskuloskeletal  perlu pemasangan splint dan alat
stabilisasi lainnya.
• NGT untuk menghindari muntah akibat perpindahan.
Pasien pediatrik
• Berat badan relatif ringan  mobilisasi mudah, namun mudah terjadi
dekompensasi.
• Kapasitas vital lebih kecil  hipoksia terjadi lebih cepat.
• Rongga gaster yang lebih kecil, fungsi usus irregular  mudah terjadi
aspirasi
• Evaporasi lebih mudah terjadi.
Pasien geriatri
1. Compliance paru dan total luas permukaan paru menurun  risiko
hipoksia meningkat
2. Status cairan sulit dinilai. Mudah dehindrasi
3. Jaringan subkutan menipis  mudah hipotermia. Pasien diusahakan tetap
hangat dengan selimut
4. Imobilisasi pasien geriatri  risiko venous return buruk & edema. Pasang
stoking antiemboli
Pasien obstetri risiko tinggi

• Target: stabilisasi ibu dan bayi dalam kandungan
• Kontraindikasi transport: gawat janin, perdarahan peripartum tidak
terkontrol, imminent delivery
• Pasien obstetri : konsumsi oksigen meningkat  predisposisi hipoksia 
kelahiran prematur
• Peningkatan gas lambung  menekan diafragma  hipoksia. Pemasangan
NGT akan mengurangi tekanan dan mencegah vomiting
• Akselerasi-deselerasi  menurunkan aliran darah uterus. Tempatkan
pasien pada posisi dekubitus kiri
Stabilisasi obstetrik risiko tinggi

• Penilaian status pasien secara lengkap dan intervensi untuk optimalisasi
fungsi fisiologis.
• Oksigen high flow
• Manajemen status cairan
• Terapi pencegahan partus prematur
• Profilaksis kejang sudah diberikan sebelum berangkat.
• Tim transport memiliki kemampuan menolong proses persalinan.
Tim Evakuasi
• Minimal didampingi 2 orang
• Kapasitas pendamping tergantung level kegawatan pasien  diputuskan
dokter senior/ konsultan ICU
• Kategori pasien berdasarkan AAGBI:
Level 0: pasien ruangan (ward)
Level 1: risiko rendah  nurse atau paramedik
Level 2: gagal 1 sistem organ  dokter & nurse
Level 3: butuh support respirasi dan support min 2 sistem organ  dokter &
nurse
• Melakukan perawatan critical care di ruang terbatas dan situasi yang sulit
 berbeda dengan di ICU! Perlu pengalaman
• Evidence: tim transport yang berpengalaman lebih baik performanya
• Melakukan perawatan critical care di ruang terbatas dan situasi yang sulit
 berbeda dengan di ICU! Perlu pengalaman
Evidence: tim transport yang berpengalaman lebih baik performanya
Risk Stratification for the Inter-Hospital Patient Transfer

 Digunakan sebagai tools triase
 Membantu dalam menentukan
pilihan mode dan tim evakuasi
Gambar 69. Risk Statification for Inter-Hospital Pation Transfer
Peralatan Evakuasi
Gambar 70. Ventilator Mekanika Portabel
Gambar 71. Defibrilator

Ventilator mekanik portabel
 Minimal dilengkapi baterai internal, penyimpan data, alarm high
pressure dan diskoneksi, PEEP, pengaturan FiO2, I:E ratio, RR dan tidal
volume.
 Dianjurkan memiliki modus : PPV, PS dan CPAP.
Defibrilator
Alat penghangat portable
Syringe pumps
 Untuk pemberian sedatif, analgetik, inotropik atau vasopressor
 Sering digunakan karena semakin banyak obat dengan durasi pendek
dan pemberian secara titrasi
 Sebelum transport, periksa : apakah jumlah syringe pump memadai,
tubing cocok dengan pump, baterai power, dan jenis obat yang harus
diberikan selama perjalanan
Suction unit
 Untuk keperluan pasien sakit kritis, kecepatan suction setidaknya 25
l/menit
Emergency kit
 Alat-alat tambahan yang tidak memerlukan ruang banyak seperti alat-
alat intubasi, dapat disimpan di emergency kit
 Bawa alat-alat seperlunya, terutama alat untuk menjaga airway dan
membuat akses intravena
 Bila stabilisasi sebelum berangkat adekuat, alat ini jarang digunakan
Gambar 72. Peralatan Transport
Dasar (minimum requirement)
 EKG (min 3 lead)
 Pulse oksimetri kontinu
 Tekanan darah
 Frekuensi napas
Advanced
 Intra arterial BP
 Tekanan vena sentral (CVP)
 Tekanan arteri pulmonalis
 Tekanan intracranial
 Kapnograf
Persiapan Obat
• Sedatif/hipnotik
• Narkotik analgesik
• Pelumpuh otot
• Inotropik/vasopressor
• Antiaritmia
• Prostaglandin E1
• Surfaktan
Gambar 73. Obat-obat yang Disiapkan
Pemeriksaan Diagnostik Dasar
Radiologi:
servikal, dada, Lab: Hb, Ht,
EKG
pelvis, ekstremitas urinalisis, gol darah
yang trauma
Bawa semua hasil saat transport:

– nama pasien
– waktu pemeriksaan
– catatan hasil abnormal
– susulkan hasil pemeriksaan penunjang yang masih
dalam proses saat berangkat
Pilihan Modalitas Evakuasi
kondisi
penyakit
urgensi
cuaca
transfer
Faktor
lalu lintas waktu
faktor
geografis
Gambar 74. Faktor Modaltas Evakuasi
Keuntungan transportasi darat (ambulans)
• Biaya lebih murah
• Tidak tergantung cuaca
• Monitoring lebih mudah
• Tidak ada gangguan terkait ketinggian – masih ada efek akselerasi,
deselerasi dan imobilisasi
Ambulans Evakuasi
Pilihan Cara Evakuasi
Transportasi udara: untuk jarak jauh

1. Fixed wing transport (pesawat)
Tekanan kabin dapat dijaga
Efek ketinggian tetap ada
Ruang kabin >> helikopter
Membutuhkan ambulans sebagai penghubung
2. Rotor-wing transport (helikopter)
Ruang kabin sempit
Tekanan kabin helikopter tidak terjaga  antisipasi efek ketinggian: hipoksia & ekspansi
gas
Dapat terbang dan mendarat langsung di RS
Dokumentasi
Dokumentasi transfer antar fasilitas kesehatan

Dokumentasi pre-hospital
• Catatan pre hospital
• Mekanisme trauma atau riwayat
• Perawatan di UGD
penyakit
• Riwayat medis sebelumnya bila ada
• Waktu kejadian atau awal perjalanan
• Hasil pemeriksaan penunjang (lab dan radiologi)
penyakit
• Catatan evakuasi
• Waktu tiba di RS
• Protokol evakuasi
• Tindakan di lokasi kejadian
• Informed consent
• Tindakan selama perjalanan dari lokasi
• Informasi anggota keluarga dan contact person
ke RS
• Nama dokter pengirim & penerima
• Protokol selama transport
Hand Over (Operan)
Supplementary Equipments For Use During Transport
• Harus ada hand over formal antara tim transport dengan tim medis penerima dan perawat
• Mencakup:
riwayat penyakit
terapi dan kejadian selama transport
pemeriksaan penunjang yang telah dilakukan
Is The Patient Stable For Transport
Are You Ready For Departure?
PRE-HOSPITAL TRANSPORT
KATEGORI TRANSPORT
PRE HOSPITAL TRANSPORT
Transport pasien kritis dari lokasi (rumah atau tempat kecelakaan) ke rumah
sakit
Why is it important?
Early pre- Early Resuscitation Intervention

ICU
hospital care transport in ED in ED
 Jam pertama setelah terjadi trauma: resusitasi agresif dapat

meningkatkan kemungkinan survival dan mengembalikan fungsi seperti
sediakala
Sangat bermakna dalam mencegah kematian akibat trauma
KEBERHASILAN PENANGANAN PRE-HOSPITAL

 Pengenalan dini masalah klinis
 Pemberian BHD
 Keterampilan Tim transport
 Ketepatan Intervensi
 Metode transport cepat & efisien
 Kesiapan Unit Penerima
The Call Out

 Akses cepat ke layanan medis darurat sangat penting untuk penanganan
cepat
 Nomor kontak yang sama dan mudah diingat
 Ambulans 118 di Jakarta
Siapa yang
menelepon,
nomor
kontak
Tim
penyelamat Apa yang
selain terjadi
medis?
Informasi
Kapan Jumlah
terjadi, korban dan
akses ke jenis
sana cedera?
Siapa
korbannya
Gambar 75. Informasi yang Harus Diperoleh
Status pasien
(ABCDE)
Stabil Tidak Stabil
Scoop and
Stay and Play
Run
Gambar 76. Pengkajian dan Penanganan pada Pasien
SCOOP AND RUN!
• Curiga trauma pembuluh besar
• Luka tembak atau luka tusuk dada/abdomen
• Cedera otak dengan GCS < 8
• Trauma tumpul abdomen
PADA SEBAGIAN BESAR KEDARURATAN…

 Play and Run Approach  segera mengatasi masalah paling darurat dan
transport cepat ke pusat trauma tanpa menunda
 Contoh:
1. Balita dengan luka bakar derajat 3 akibat pemanas 

mendinginkan seluruh badan
2. Buruh pabrik dengan percikan larutan basa di mata  bilas mata

dengan air biasa
3. Pengendara motor dengan trauma crush injury  kristaloid dini

dalam jumlah banyak
 Bila waktu transport diperkirakan akan memanjang  penanganan

cedera yang mengancam nyawa harus dimulai di tempat dan dilanjutkan
selama transport
 Penelitian di Amerika Serikat:
1. Pasien cedera berat lebih mungkin selamat bila ditransport se

segera mungkin
2. Iskemia miokard  stay and play terbukti lebih efektif
PROSEDUR pre-hospital LAIN

• Imobilisasi setelah trauma
• Mencegah hipotermia
• Mengamankan jalan napas
• Unit yang menerima
• Operan/handover
• ABCDE untuk Primary Survey
• AMPLE (Alergy, Medications, Past History, Last Meal,Events)
untuk kejadian
TRAUMA
 Pedestrian trauma
 Fall from height
 Assault
 Firearm injuries
 Knife
 Industrial accidents
 Natural disasters
 Explosions
Gambar 77. ATLS Concept
PRIMARY SURVEY
Assessment and treatment of life threatening injuries
• A: Airway
• B: Breathing
• C: Circulation
• D: Disability
• E: Exposure
SECONDARY SURVEY
 History
 Complete physical examination
 Tubes and fingers in every orifice
 Neurological examination
 Re-evaluation
Pre hospital care of trauma

 Delivery to the hospital for definitive care as rapidly as possible (scoop
and run)
 Only critical interventions at the scene.
 Airway established, hard collar, spine board, control any external

hemorrhage.
 Infusion on way to the hospital
Gambar 78. Universal Meducal Care Protocol
Gambar 79. Abdominal Trauma
Gambar 80. Shock Protocol
Gambar 81. Burn Protocol
Gambar 82. Drowning/Near Drowning Protocol
Gambar 83. Congestive Heart Failure Protocol
Gambar 84. Asthma/COPD Protocol
Gambar 85. Shock Protokol
Gambar 86. Anaphilactic Shock Protokol
Gambar 87. Protokol Penurunan Kesadaran
Gambar 88. Protokol Hipertermia
PRIMARY TRANSPORT
Oksigen • Masker dan high flow
Pertahankan • kompresi lokasi perdarahan

volume darah • resusitasi cairan sesuai kebutuhan
• Pembidaian dasar untuk fraktur yang baik dan

Pembidaian mencegah perdarahan yang banyak
•Manusiawi - harus diberikan saat diperlukan

Analgesia
TRANSPORT SEGERA!
Penanganan di RS jauh lebih baik dibandingkan dengan yang bisa diberikan ‘di
jalanan, Kecuali bila tindakan pre-hospital bermanfaat, sadari bahwa ada
keterbatasan di lapangan  kirim pasien ke RS secara cepat dan aman
• Kamboja dan Irak: mortalitas trauma berat menurun 40% setelah ada
layanan ambulans dengan paramedik terlatih
PHISIOLOGY of PATIENT TRANSPORT
(dr. Ahmad Irfan, SpAn.,KIC)
The Problems….
1. Hypoxia
2. Gas expansion
3. Dehidrasi
4. Temprature
5. Acceleration & Decceleration
6. Prolonged Immobilisation
7. Motion sickness
8. Noise
9. Vibration
10. Decompression Sickness
Depends on
• Vehicle design and konfiguration
• Motion of transport vehicles
• Patient condition
1. HIPOKSIA
 HIPOKSIA : Kondisi yang menggambarkan konten oksigen yang rendah
di jaringan atau di sel.
 KAUSA: ketidakseimbangan DO2 dan VO2
 HIPOKSIA  PO2 mitokondria < 7 mmHg
 Manifestasi klinis :
a. takikardia
b. miosis
c. gangguan kesadaran
d. disorientasi
e. letargi
Kategori Hipoksia
• Hipoksik Hypoxia
• Anemic Hypoxia
• Stagnant Hypoxia
• Histotoxic Hypoxia
Hypoxic Hypoxia
 Disebabkan oleh turun nya PAO2
 Ketinggian  tekanan atmosfer menurun  menyebabkan PAO2

menurun.
 DIKENAL sebagai ALTITUDE HYPOXIA hipoksia yang timbul ketika ada

perubahan tekanan atmosfer
Gambar 89. Hubungan Ketinggian terhadap Tekanan Udara

Simple calculation of the difussion gradient:
(Atm Pressure – Water Pressure) x % Oxygen = PO2
Alveolar PO2 – Venous PO2 = Diffusion Gradient
 Assuming Water pressure = 47 mmHg
 Sea level PO2 = (760-47) x 0.21 = 150 mmHg
 6000 feet PO2 = (609-47) x 0.21 = 118 mmHg
 PO2 decrease 45 mm Hg in the resp tree
 Sea level: alv PO2 = 150 – 45 = 105 mmHg
 At 6000 feet : alv PO2 = 118 – 45 = 73 mmHg
 Vein PO2 = 40 mmHg.
 Diffusion Gradient at sea level = 105 – 40 = 65 mmHg
 Diffusion Gradient at 6000 ft = 73 – 40 = 33 mmHg \
STAGNANT HYPOXIA
Low Cardiac Output

Suplai
Hypothermic Oksigen dan
patient
hemoglobin
Hypovolemic shock
mencukupi,
namun
HISTOTOXIC HYPOXIA SIRKULASI
TIDAK
Kondisi adanya gangguan ambilan oksigen atau utilisasi oksigen oleh jaringan.
• CYANIDA POISONING => Disrupt cytochrome oxidase system (Responsible
ADEKUAT.
for O2 usage at the tissue level) => Disrupt cellular metabolism => DEATH
• KERACUNAN CARBON MONOKSIDA => Hemoglobin is bound by

molecules other than oxygen => Absence of oxygen at tissue level =>
SEVERE HYPOXIA
ANEMIC HYPOXIA
• When patient has inadequate amount of circulating Hb
• CAUSES: anemia & hemorrhage
• MONITORING : O2 Saturation
ANTISIPASI HIPOKSIA
• SUPLEMENTASI OKSIGEN
• Positioning Pasien secara optimal : Head Elevated.
• Transfusi PRC
• Mengatasi anxietas pasien
2. GAS EXPANSION
TAKE OFF  TEKANAN ATMOSFER MENURUN  EKSPANSI GAS
SEA LEVEL 100 cc

6000 ft 130 cc
18.000 ft 200 cc
34.000 ft 400 cc
Potential problems in all transport using unpressurized aircraft flying > 12.000 ft.
• Pemasangan NGT sebelum proses transport akan mengurangi risiko
muntah.
• Pasien dengan kolostomi atau ileostomi dilakukan pemasangan NGT ke

dalam stoma untuk mengurangi ekspansi gas di usus bagian bawah.
• Nyeri gigi akibat caries diberikan analgetik.
• Nyeri telinga akibat ekspansi gas dalam telinga tengah diberikan spray
vasokonstriktor melalui nasal.
 Pasien pediatri  child suck
 Vasalva maneuvre
• Sebagian besar ekspansi gas timbul saat transport dengan fixed wing
aircraft karena ketinggian yang dicapai lebih tinggi.
3. DEHIDRASI
• Ketinggian akan menurunkan kelembapan udara.
• Kelembapan akan semakin rendah pada pressurized aircraft.

Kelembapan pressurized aircraft setelah penerbangan 1 jam : <5%
RISIKO
1. Pasien Dehidrasi  gangguan volume sirkulasi
2. Pasien Saluran Pernapasan  risiko infeksi meningkat
ANTISIPASI
1. Hidrasi cukup
2. Humidifikasi sistem delivery oksigen
3. Cukupi volume intravaskular pasien sebelum transport
4. HIPOTERMIA
PENYEBAB :
KETINGGIAN: Tiap kenaikan 1000 kaki  penurunan suhu 2 derajat
hingga mencapai -55 derajat.
PERUBAHAN LINGKUNGAN sepanjang proses evakuasi
MASALAH:
PASIEN dengan gangguan kesadaran tidak dapat mengeluhkan penurunan
suhu, sehingga dapat mengalami hipotermia.
TIM EVAKUASI aktif bekerja  tidak menyadari penurunan suhu
lingkungan.
MEMICU: gangguan kesadaran & shivering.
• Risiko hipotermia meningkat pada
• Pasien luka bakar
• Pediatrik
• Geriatri
• Gunakan selimut penghangat untuk mengurangi terjadinya hipotermia.
5. AKSELERASI & DESELERASI
Terdapat pada seluruh mode transport.

Akselerasi : take off, menanjak atau panambahan kecepatan.
Menghasilkan positive G forces  memicu perpindahan cairan atau
darah menjauhi kepala.
Fenomena “grey-out” : Hilangnya pengelihatan sementara waktu.
Timbul jika sirkulasi area kepala tidak mencukupi.
Deselerasi: perlambatan, atau berhenti.
Menghasilkan negative G forces (“red-out”)  berpindahnya darah
ke area kepala.
Negative G forces berbahaya pada pasien dengan peningkatan TIK.
• Efek akselerasi dan deselerasi tergantung kecepatan, angle dan durasi
gaya yang diterima.
• Efek samping akselerasi dan deselerasi dikurangi dengan mengatur posisi
pasien:
• Di pesawat, stretcher diposisikan pada posisi kepala di depan.
• Elevasi kepala untuk mengatasi peningkatan TIK saat deselerasi.
• Menaikkan kaki pasien saat take off dapat mencegah akumulasi

cairan di tungkai saat akselerasi.
6. PROLONGED IMMOBILIZATION
• Evakuasi jarak jauh  Ruang gerak terbatas & sulit mengubah posisi
pasien.
• Pasien imobilisasi di stretcher berisiko:
 Terjadi pressure sore
 Stasis vena
RISIKO TINGGI:
• pasien trauma,
• geriatri dan pasien
• Pasien dgn gangguan kardiovaskular.
• Tanda-tanda gangguan perfusi sulit dinilai selama transport

• Penilaian berdasarkan KELUHAN PASIEN
• Sulit pada Pasien PENURUNAN KESADARAN
ANTISIPASI terjadinya PRESSURE SORE akibat PROLONG
IMMOBILIZATION:
 Pasien dengan cervical collar:
NILAI angulus mandibula dan oksipital.
 Sebelum berangkat :
splint, gips dan area tekanan harus diberi bantalan.
 Selama transport :
Posisikan pasien dengan baik. Range of motion dalam constrain dapat
dilakukan.
7. MOTION SICKNESS
Dalam evakuasi, Pasien maupun Tim Transport berisiko mengalami motion

sickness.
Penyebab:
 Perubahan equilibrium telinga dalam
 Hipoksia
 Stimulus visual
 Stress
 Suhu panas
 Bau tak sedap
 Ekspansi gas saat penerbangan
 Gejala : nausea & vomitting, sakit kepala.
 Antisipasi dan tatalaksana:
 Beri oksigen
 Pastikan pasien dalam posisi supine.
 Suhu ruang diturunkan (didinginkan).
 Profilaksis dengan patch transdermal.
 Pada kasus berat, lakukan pemasangan NGT.
8. NOISE
Constant noise dalam transport akan memicu stress  takikardia dan

hipertensi.
Noise di ambulans, helikopter dan pesawat, mungkin familiar bagi personil
transport, namun dapat menimbulkan kekhawatiran bagi pasien  perlu
dilakukan briefing sebelumnya.
Upaya mengatasi noise :
Penggunaan headset
9. VIBRASI
Gerakan menimbulkan vibrasi

Semua alat transportasi dipengaruhi oleh vibrasi
PROBLEM ?
Strap pengaman menjadi longgar  Pasien harus selalu dipastikan
rapat ke stretcher.
Perubahan setting alat  Setting harus sering diperiksa selama
transport.
10. Decompression sickness
Komplikasi yang dapat muncul pada pressurized aircraft adalah hilangnya

tekanan secara tiba-tiba. Akibatnya terjadi:
hipoksia,
ekspansi gas,
hipotermia
dehidrasi.
Semakin tinggi pesawat, semakin besar komplikasinya:
robekan membran timpani,
suhu tubuh turun drastis, dan
kemungkinan wind burn
• Decompression sickness ditandai dengan
 nyeri sendi, parestesia,
 perubahan pada SSP dan
 Chokes
 disebabkan oleh lepasnya gelembung nitrogen ke aliran darah.
• Gejala decompression sickness diatasi dengan
 terapi oksigen,
 pada kasus berat dengan terapi oksigen hiperbarik
KESIMPULAN
AWARENESS terhadap KOMPLIKASI, KESIAPAN INTERVENSI, STABILISASI Pre-

Transport dengan
Appropriate MENGURANGI bahaya & efek samping pada PASIEN yang menjalani
Transport
INTRA-HOSPITAL TRANSFER
Introduction
• Advancement in medical care have given caregivers the ability to prolong
patients’ lives, which has increased the acuity in the ICU.
• The safest place for these patient is in the ICU, attached to sophisticated
device and monitors, with close attention by the medical staff.
• Advancement in medical care have been facilitated by increased

diagnostic imaging and procedures such as CT Scan, MRI, nuclear
medicine imaging,
• Transfer from the ER to ICU and or OT, or from ICU to OT also occur with
great frequency.
• Transport within the hospital occur much more often than those outside
the hospital.
• Risk of transport must be weighed against the potential benefit for the
patient.
Intrhospital transport meningkatkan risiko:

1. Diskoneksi
2. Perpindahan pasien
3. Keterbatasan Alat
Kejadian Tidak Diharapkan

• INSIDEN TOTAL : sampai 70%
• Aritmia  84%. 44% perlu terapi.
• Perdarahan & hipotensi pada 7 dari 33 pasien transport dari OK ke ICU.
• Butuh intervesi vasoaktif, cairan bahkan RJP  8%
• EQUIPMENT Related 39%
• STAF Related 61%
Kejadian Tidak Diharapkan

• Related to Intensive Care
• diskoneksi lead EKG,
• baterai power mati,
• akses IV terlepas,
• terekstubasi,
• sumbatan pipa ETT,
• NGT terlepas,
• suplai O2 habis
• Related to critical illness
• hipotensi,
• hipoksemia,
• hipotermia
• aritmia,
• henti jantung,
• perubahan TD
• edema paru.
KOMPLIKASI
• human error
• malfungsi equipment
• hipotermia
• sistem respirasi
• sistem sirkulasi
Intervensi yang dilakukan

1. Suction ETT
2. Penggantian cairan intravena
3. Pemberian suplemen oksigen
4. Pemberian obat pelumpuh otot
5. Sedasi
6. Pemberian obat-obat inotropik atau vasoaktif
7. Pemberian sulfas atropine
8. Intubasi dan re intubasi
Tahapan
1. Decision
2. Identifikasi Pasien risiko tinggi
3. Persiapan Pasien
4. Koordinasi & Komunikasi pre-transport
5. Personil/ Tim transport
6. Peralatan, obat & monitoring
7. Care selama transport dan di tempat tujuan
1. The Decision
PERTIMBANGKAN :
– Oksigenasi dan ventilasi tidak adekuat
– Hemodinamik tidak stabil
– Tidak dapat dilakukan monitoring cardiopulmoner
– AIRWAY tidak aman
2. Identifikasi Pasien Risiko Tinggi
– FiO2 > 50%.
– Geriatri
– Cedera Kepala Berat
– Vasopressor & Inotropik dosis tinggi
3. Persiapan Pasien sebelum transport
– Optimalisasi hemodinamik dan parameter ventilasi.
– Pastikan jalan napas aman.
– Jalankan infus yang esensial.
– Sedasi cukup.
– Pengobatan khusus harus diantisipasi dan tersedia.
– Kantong drainase dikosongkan. Drainase diperiksa, ditutup jika
perlu.
– Rekam medik dan inform konsent.
– Persiapan darah dan komponen darah untuk pasien pro tindakan
operasi.
4. Komunikasi dan Koordinasi
– PRE- TRASPORT: pastikan unit penerima siap menerima pasien 
Prosedur segera dilakukan setelah pasien tiba
– Di Lokasi Prosedur: kontinuitas perawatan pasien dilanjutkan
melalui komunikasi dokter dengan dokter dan perawat dengan
perawat : REVIEW kondisi pasien dan rencana tatalaksana.
5. Tim Transport
– Transpor minimal didampingi oleh dua orang
– Bila unit penerima tidak memiliki staf terlatih, tim transpor terus
mendampingi hingga pasien kembali di ICU
– KOMPETENSI :
o masalah jalan napas (termasuk intubasi),
o resusitasi kardiopulmonal,
o inisiasi & maintenance obat-obat vasoaktif,
o ventilasi mekanik.
– Kewajiban Tim Transport:
Fase Stabilisasi
• Penilaian status pasien.
• Stabilisasi pasien:
– Airway
– Ventilasi
– Oksigenasi
– Hemodinamik
• Antisipasi masalah yang akan timbul.
• Mengamankan semua jalur obat
• Komunikasi dengan dokter/ paramedis unit yang dituju.
– Kewajiban Tim Transport

Fase Transport
• Memindahkan pasien secara aman.
• Monitoring sistem organ.
• Mengenali dan mengatasi masalah yang terjadi selama trasport.
• Memberikan laporan kepada personil penerima pasien.
• Mendokumentasikan prosedur tansport pasien secara detail.
6. Peralatan, obat dan monitoring
– Monitor :
a. Tekanan darah,
b. Pulse oksimetri
c. EKG/ defibrilator.
Jika ada : monitor yang memiliki kemampuan merekam dan
menyimpan data pasien selama transport dan prosedur.
• Peralatan manajemen airway dengan ukuran yang sesuai.
• Oksigen dengan kapasitas sesuai lama prosedur atau tindakan, ditambah
cadangan 30 menit.
• Untuk alasan kepraktisan: Bag-valve ventilation sering digunakan pada
transport intra hospital.
• Portable Mechanical Ventilator mulai populer  dapat memberikan
minute ventilation dan FiO2 dengan lebih terukur
• Obat-otatan dan cairan:
• Obat resusitasi dasar : epinefrin dan obat antiaritmia.
• Sedatif dan analgesik (opioid)
• Cairan dan obat-obat yang harus berjalan kontinu dengan infusion
atau syringe pump.
• Semua peralatan yang memerlukan batere dipastikan ter-charge secara

maksimal dan dapat berfungsi selama transport dan prosedur/tindakan
• Transport tanpa dokter pendamping: PROTOKOL mengenai pemberian

obat atau cairan oleh petugas paramedis yang mendampingi selama
transport/ kondisi emergency
Monitoring
• Monitoring pasien kritis yang dilakukan transport sama dengan
monitoring saat di ICU.
– Minimal mencakup : EKG kontinu, pulse oksimetri, NIBP, frekuensi

nadi dan frekuensi napas.
– Sebagai tambahan : kapnografi, ABP kontinu, PAP, atau

monitoring TIK, Hemodinamik monitoring.
Errors pada proses transport
• Inappropriate delegation of transport
• Problems in the identification of patiens
• Inappropriate preparation of patients
• Inappropriate control of infection
• Inappropriate vehicle for transportation
• Equipment failure
Gambar 90. Pre Transport Checklist
Gambar 91. During Transport
Gambar 92. Post Transport

MRI TRANSPORT
• The most challenging and potentially dangerous transport In terms of
logistics, specialized equipment and patient safety is the transport for
MRI.
• Death do to objects flying into the magnet have been reports.
• Caution must be taken when exposing a patient with implantable devices.

Also the use of other devices: reinforce endotracheal tube, pulmonary
artery catheter or cvc.
• MRI suites are often far away from patient care areas, and the
procedures performed typically more lenghty than other modalities.
• Therefore, iv pumps, monitors and ventilators must be capable on battery

power for extended periods If needed
• Equipment being considered for use in the MRI suite will fall under one of
3 categories:
• MRI safe: poses no hazards in an MRI environment.
• MRI conditional: suitable under certain specified conditions
• MR unsafe: not suitable for use in an MRI environment.
Kesimpulan
• Kejadian tidak diharapkan dapat terjadi pada saat transport maupun
setelah transport pasien kritis.
• KTD dapat berhubungan dengan alat maupun fisiologis pasien.
• FOKUS Transport Intrahospital : personil, peralatan dan monitor yang

digunakan saat tranport.
HOW TO CONDUCT A SAFE INTER-HOSPITAL TRANSFER OF PATIENTS
Back ground
 A large number of inter-hospital transfers already take place and the
number is likely to increase.
 Anesthetists/ intensivists are commonly involved in transferring the

sickest of these patients
IHT Goal
Optimal health and well being of the patient
 Decision : risk and benefit
 Choice of hospital : continuity treatment
 Transfer process initiated and completed ASAP
Well organized system with appropriate equipment is crucial for safe IHT
Think before you start…..
 Think before you start ...
 What's the level of the patient?
 Think before you start...
 Have we got the right staff and equipment?
 Always think of the patient –
 Safety / Comfort / Explanation
Risks Score
The Risk score for transport patients (RSTP) :
Etxebatteria et al :
based on patient’s physiological parameters
(hemodynamics, arrhythmia, respiration, GCS,
prematurity) and
the need for ECG monitoring, pacemaker, IV line,
Table 1. Risk Score for Transport Patients
Measurement Score
1. Haemodynamics
Stable 0
Moderately stable ( requires volume < 15 ml/min adults) 1
Unstable ( requires volume > 15 ml/min in adults) 2
2. Arythmia
No 0
Yes, not serious ( AMI after 48 hours) 1
Serious ( AMI in the first 48 hours) 2
3. ECG Monitoring
No 0
Yes 1
4. Intravenous line
No 0
Yes 1
Pulmonary artery catheter 2
5. Provisional pacemaker
No 0
Yes ( not invasive). Always AMI in the first 48 hours 1
Yes ( endocavity) 2
6. Respiration
Respiratory rate between 10 and 14 breaths/ min in adults 0
Respiratory rate between 15-35 breaths/min in adults 1
Apnoea (<10) or > 36 irregular breathing 2
7. Airway
No 0
Yes (guedel tube) 1
Yes ( intubation or tracheostomy) 2
8. Respiratory support
No 0
Yes (oxygen therapy) 1
Yes (mechanical ventilation) 2
9. Assesment
GCS = 15 0
GCS 8-14 1
GCS < 8 and/or neurological disorder 2
10. Prematurity
Newborn > 2000g 0
Newborn between 1200 and 2000g 1
Newborn < 1200 2
11. Technopharmacologist support (actual or en route)
None 0
Group I 1
Group II 2
Table 2. Medication for risk groups
(Etxebarria MJ et al)
Group I Group II
Inotropics Inotropic + vasodilator
Antiarrythmics Uterine relaxants
Bicarbonate Infant incubator
Analgesics General anesthetics
Antiepileptic
Steroids MAST
Manitol
Trombolytics
Naloxone
Thoracic tube
Risks Score
The score serves as a triage tool for assessing the risk of adverse event during IHT
Markaksi et al : RSTP > 7 were at significant risk and subsequent mortality
Table 3. Management of at risk patients
Ponts Group Vehicle Staff
0-2 0 Conventional None
ambulance
3-6 I Conventional Nurse
ambulance
Over 6 II Group ICU Doctor + nurse
Deciding the mode of transfer

1. Pt’s physiological status
2. Pt’s ilness of injury
3. Accessibility by road and air
4. Weather or Traffic conditions
5. Total transfer time
Table 4. Comparison of ground and air transport

Mode Advantages Disadvantages
Ground transport Low cost Longer transport time for
Rapid mobilization long distances
Less weather dependent Dependent on traffic
Easier patient condition
monitoring
Air transport Shorter response time to Slow to mobilize
patient and shorter Dependent on weather
transport time conditions
Can access patients in Landing site needed
topologically hard to Need for additional
reach areas ground transport
between landing site and
hospital
Limited availability in
comparison to ground
transport
More expensive
During transport……
Transient hypertension and dysrhythmia can occur to sudden
acceleration
Acceleration forces during acting on the body over long durations cause
shift in body organs and fluid compartments.
This may lead to venous pooling in lower limbs with fall cardiac output
with tachycardia.
There may be changes in intracranial blood volume and pressure
Altitude
Rotor ambulance fly between 2.000 ft to 5.000 ft, fixed wing fly 15.000 ft
to 40.000 ft
Flying more than 10.000 ft needs pressurized air cabin
The cabin pressure usually maintain equals atmospheric pressure at
altitude of 5.000-8.000 ft above sea level
In critically-ill patient it could fly 12.000 – 15.000 ft
Acceleration and gravitational forces
The body is exposed to linear and radial acceleration and deceleration
forces
The cardiovascular system of critically ill patients is more susceptible due
to their compromised physiological reserves (hypovolemic, dilated
peripheral vasculature).
The effect of these forces is greater during take off and landing
What it might be happened
(Adverse Event)
1. Cardiovascular : severe hypotension or hypertension, arrhytmia, cardiac
arrest.
2. Respiratory : hypoxia, aspiration, accidental extubation,, bronchospasm,

patient ventilator dyssynchrony.
3. Neurological: agitation, intracranial hypertension
4. HypothermiaTechnical failure : gas failure, oxygen or IV disconnection,

monitoring equipment malfunction
5. Human Error : drug error, patient mix up
6. Non medical factor
Table 5. The Score
Patient Disease Compication Age Sex Score
1 CVA Hypertension 72 F 5
2 Prematr Aspiration 0 F 4
3 Trauma Shock 20 M 12
5 Trauma Shock 75 F 17
7 Head tr/ Shock 36 F 8
8 Head tr/ Coma 18 M 12
9 Head tr/ Shock 19 M 11
11 AMI Shock 65 M 9
12 AMI APO 58 M 9
13 CVA Hypertension 59 M 12
14 CVA Hypertension 60 M 15
Conclusion
Inter-hospital transfer can be safe in the hands of experts
RSTP seems effective in differentiating critically ill patients prone to develop
major en route complication
Shock remains the most common problem encountered during transportation
STABILIZATION OF SPECIFIC PATIENT POPULATIONS
Cardiac : arrhythmias
• Transport management will depend on the nature of the arrhythmia and
underlying cause
• On clinical grounds give
• Oxygen
• Insert a single intravenous cannula
• take bloods
• Monitor vital signs and ECG continuously.
• Obtain a 12-lead ECG
Obstetrics
• The most common cases are preterm labour (PTL).
• Other transfer indications include preeclampsia
• antepartum haemorrhage (APH)
• postpartum haemorrhage (PPH)
Preterm Labour
• Commence tocolytics to suppress labour early
• Neonatal outcomes are superior if transferred in utero rather than

following delivery
• Salbutamol infusion
• Consider Celestone Chronodose and IV antibiotics if indicated
Preeclampsia & Eclampsia

• prevent convulsions and control blood pressure during transfer to an
appropriate hospital for delivery
• The severity of preeclampsia will determine the urgency of transfer
• avoid fluid overload
• Monitor urine output
• Magnesium Sulphate is the most effective prophylaxis against convulsions
• close monitoring (respiratory rate, blood pressure and tendon reflexes)
Eclampsia is a medical emergency with

significant maternal and fetal mortality
Treatment priorities are initial ABC

resuscitation
controlling seizures
controlling blood pressure
Gambar 93. Eclampsia
Antepartum Haemorrhage
• The major causes are placenta praevia and placental abruption
• APH is unpredictable and the woman’s condition may deteriorate at any

stage
• If haemodynamically unstable, commence ABC resuscitation
• All APH patients should have at least one large-bore IV line
• Consider cross-match of blood early
• Observe and monitor closely and notify any deterioration in maternal or

fetal status
Postpartum Haemorrhage
• Primary postpartum haemorrhage (PPH) is the main cause of maternal
mortality in developed countries
• Early recognition of PPH and institution of a treatment plan is important
• ResuscitatewithABCandattempttostop bleeding using standard protocols
• Cross-matchbloodearly,and check coagulation indices
• Treatment is based on the cause
• Transport requirements will depend on stability of the patient
Neonates
• The best way to transport the unborn fetus is in utero
• Specialized transport arrangements exist for transport of neonates,

particularly premature infants
• Initial resuscitation of the newborn includes oxygenation, respiratory

support and CPR if needed as per current protocols
• treatment aims are the prevention of hypoxia, hypothermia and

hypoglycaemia.
Trauma
Multi-Trauma
• Mechanism of Injury
• Knowing and communicating the mechanism of injury helps to anticipate

injuries
• Primary Survey : A, B, C, D, E ( include cervical spine )
• Early intervention ( airway manoeuvres, chest decompression, IV fluid

resuscitation, prior to the secondary survey )
• Two large bore IV lines should be inserted early in all multi-trauma

patients, Other options include intraosseous and central venous access.
Secondary survey
• The patient needs to be adequately exposed, examined “top to toe” and
log-rolled
• Head, Assess and monitor the GCS
• Cervicalspine
• Chest
• Abdomen
• Pelvis
• Limbs
• Further considerations :
• High flow oxygen is helpful for all major trauma patients
• Analgesia, antibiotic cover and tetanus prophylaxis
• Mostmulti-trauma patients are best transported on a vacuum

mattress with care to continue spinal precautions
• AMPLE History
Head Injuries
• identify and treat life-threatening injuries and prevent further injury to
the brain and spinal cord
• avoidance of hypotension, hypoxia and hypercarbia
• Airway management and cervical spine control take priority
• Spinal precautions (hard collar, sandbags or head blocks with tape)
• immediate treatment of life-threatening conditions.
• Assessment of conscious state ( AVPU ) and reassessment !!!
Intubation in head injury :

• Indications for intubation include deteriorating GCS, poor airway,
inadequate breathing, and the combative head-injured patient
• low threshold for intubation
• trauma patient with a GCS around 12-13/15 has significant risks of

hypoxia, hypercarbia, and deterioration during flight
• During ventilation maintain normocarbia
A_B_C_D_E
In acute presentation, cool the burnt area to prevent
further tissue damage
Adequate analgesia should be given early
assess the patient for other injuries such as fractures,

and for possible cyanide or carbon monoxide poisoning
Vascular access is extremely important in major burns
indwelling catheter should be inserted prior to transport
Gambar 91. Burns
• Tetanus prophylaxis should begiven
• careful asepsis and good dressings
• antibiotic prophylaxis.
• Be carefull with temperature
Acute Surgical Conditions
• Control haemorrhage before transport
• It is risky to transfer patients who continue to bleed, especially over

longer distances and long time frames
• Do not over-resuscitate patients
• Provide cross-matched blood if possible and if

likely to be required
• Reliable large bore intravenous access
Bowel Obstruction
• Trapped gases will expand at altitude
• Routine management includes intravenous infusion with maintenance

fluids
• A nasogastric tube helps decompress the stomach, to minimize vomiting
and gas expansion during flight
• Adequate analgesia should be given, with an antiemetic
Mental Health
Poisoning & Envenoming

Snake Bite
• First Aid should be started as soon as possible.
• Pressure immobilization bandage(PIB) along the whole limb.
• Splinting of thelimb.
• Immobilization of thepatient.
• Do not wash the bite site,as skin swabs can be used for venom detection
Initial Assessment and Care Prior to Transport

• Assist airway, breathing and circulation if indicated, and establish
intravenous access.
• Assess for symptoms and signs of envenoming
• Coagulopathy is a serious and common complication
• Antivenom is given if there is clinical or laboratory evidence of

envenoming
• Indications for immediate antivenom prior to transfer include unstable
cardiovascular system, seizures, proven coagulopathy, active bleeding
and paralysis.
Poisoning
• Follow an Airway, Breathing and Circulation approach, with particular
attention to the risk of aspiration and hypoventilation associated with a
GCS less than 12
• Risk assessment
• Supportive care & monitoring
• Decontamination
The following information will be required:

• Agents
• Doses
• Time since ingestion
• Clinical features and progress
• Patient factors such as weight and co-morbidities
Sepsis
• Severe sepsis is a common cause of critical illness in rural and remote
settings
• ensuring adequate oxygen delivery and tissue perfusion
• Identify and Treat the Cause
• Destination
Care of the Ventilated Patient

• General Principles
• Airway
• Ensure the ETT is well secured with tie and tape, and cuff inflated
appropriately.
• Record depth at the teeth and do a check chest x-ray if possible.
• Add a heat and moisture exchanger filter.
Breathing
• Record ventilator settings, taking note of respiratory rate, tidal
volume, minute volume, FiO2 and inspiratory pressures as a
minimum.
• Consider PEEP and I:E ratios. No PEEP for asthmatics.
• Check arterial blood gases and ensure adequate oxygenation.
• Aim for normocarbia and avoid excessive hyperventilation
Circulation
• Peripheral intravenous cannulae-have two good lines in case one fails
during transport.
• Central venousaccess-helpful if using inotropes, multiple drug infusions or

to monitor fluid status in sepsis or cardiac failure.
• Arterial line-for repeated arterial blood gas sampling and invasive blood
pressure monitoring in unstable and inotrope dependent patients.
• Fluids-give appropriate fluids in appropriate volumes.
• Maintain normotension.
• Urinary catheter with hourly measurement burette
Drugs
• Both sedation and paralysis are normally required for transport. See the
RFDS Drug Infusion Guidelines.
• Continuous infusion is usually morereliable in the transport setting than

episodic bolus doses.
• Manage pain and awareness
Protection and monitoring

Eye Protection
• Tape eyes closed to protect them and instil lubricant.
Gastric Decompression
• Insert a nasogastric or orogastric tube with drainage bag.
Monitoring
 Continuous ECG,
pulse oximetry,
blood pressure(non-invasiveorinvasive),
heartrate,
respiratory rate,
temperature
capnography

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1922 - Ws Transport

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Buku Materi Workshop 1st North Sumatera Conference on Emergency,

Anesthesia, and Critical Care 2018

TRANSPORT OF CRITICALLY ILL PATIENT

Editor : dr. Andriamuri P. Lubis, Sp.An, M.Ked(An)

Venue : RS USU, Medan

Perhimpunan Dokter Spesialis Anestesiologi dan Terapi Intensif (PERDATIN)

TRANSPORT OF CRITICALLY ILL PATIENT

Penerbit : Perhimpunan Dokter Spesialis Anestesiologi dan Terapi

Redaksi : Panitia 1st North Sumatera Conference on Emergency,

Hak cipta dilindungi oleh undang-undang

dr. Soejat Harto, SpAn, KAP

First North Sumatera Conference on Emergency,Anesthesia And Critical Care

Dalam kegiatan 1st North Sumatera Conference on Emergency,Anesthesia And

dr. Andriamuri P. Lubis, SpAn, MKed(An)

2. dr. Ahmad Irfan, SpAn.,KIC Head of Medic Committee RS Mitra,

3. dr. Eko Budi Prasetyo,

5. Ns. Purwani D. Kuntowati Flight Nurse Consultant and Medical

Kata Sambutan Ketua PERDATIN Sumut ........................................................ 3

INTRA AND INTER-HOSPITAL TRANSPORT FOR CRITICALLY ILL ... 13

Nomor Judul Halaman

8 Scoring untuk menentukan jenis ketenagaan yang 19

26 Carrying Backboard or Cot on Stairs 42

89 Hubungan Ketinggian terhadap Tekanan Udara 131

Nomor Judul Halaman

Gambar 1. Adverse clinical events during intrahospital transport by a

Insiden perburukan kondisi pasien lebih sedikir jika intrahospital transport

Gambar 3. Kondisi yang menyebabkan komplikasi serius selama proses

Gambar 4. Incidents identified during Intra-Hospital Transport

Knowledge-based error Skilled-based error

Factors Contributing to Incidents During

System-based Factors - 412 n=900 selections in 176 reports

Work practices Physical environment infrastructure

Gambar 5. Factors Contributing to Incidents During Intra-Hospital

Equipment 37% Location

Flabouris et al. (2006) Incidents during out-of-hospital patient transportation.

Gambar 6. Incidents Identified During Inter-Hospital Transport

Factors Contributing to Incidents During

Contributing Factors Minimizing Factors

Flabouris et al. (2006) Incidents during out-of-hospital patient transportation.

Gambar 7. Factors Contributing to Incidents During Inter-Hospital Transport

Gambar 8. Scoring untuk menentukan jenis ketenagaan yang terlibat

 Stabilisasi dan transportasi pasien untuk kebutuhan diagnostik atau

Indikasi transport pasien sakit kritis

Risiko transportasi pasien sakit kritis

Agar transportasi sesuai tujuan

Gambar 13. Flowchart

Gambar 14. Sample of Medical Assessment’s Form

Gambar 19. Handover Form

PROTECTING YOURSELF: BODY MECHANICS

Moving and Positioningthe Patient

 There are many kinds of patient-carrying devices, including

Gambar 20. Power Lift

Gambar 21. Power Grip

Gambar 22. Performing the Power Lift

Gambar 23. Weight Distribution

Gambar 24. Diamond Carry

Gambar 25. One-Handed Carry

Carrying Backboard or Cot on Stairs

Gambar 26. Carrying Backboard or Cot on Stairs

Gambar 27. Stair Chair

When pushing or pulling:

Principles of Safe Reaching and Pulling

Gambar 28. Principles of Safe Reaching and Pulling

Gambar 29. Clothes Drag

Gambar 31. Arm Drag

Gambar 32. Arm-to-arm Drag