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BIMBEL UKDI MANTAP

dr. Andreas W Wicaksono


dr. Anindya K Zahra
dr. Arius Suwondo
dr. M. Dzulfikar Lingga Q M
dr. Marika Suwondo
dr. Alexey Fernanda N
dr. Denise Utami Putri
dr. Aditya Wicaksana

Batch Agustus 2018


Content

Emergency
Airway Assessment
Foreign body obstruction
Breathing

Basic Life Support

Shock
• Hypovolemic shock
• Cardiogenic shock
• Distributive shock
• Obstructive shock

Triage
Acid Base Balance

Poisoning
Trauma, Primary Survey
Airway and C – Spine control
Pasien Berbicara Lancar -> airway baik
Curiga cedera cervical bila → pasien tidak
Trauma Maksilofasial sadar, high-velocity and high impact injury,
defisit neurologis, C spine tenderness

Problem Airway Adakah patensi jalan


Trauma Leher
nafas ?

Look : Agitasi, penkes,


Trauma Laryngeal retraksi, otot bantu nafas
Listen : suara nafas
abnormal Feel : lokasi trakea

Gurgling • liquid or semisolid foreign material in the main airway -> Suctioning

Snoring • pharyng is partially occluded by soft palate or epiglottis.

Crowing • sound of laryngeal spasm.

Inspiratory stridor • obsruction at laryngeal level or above.

Expiratory wheeze • obstruction of the lower airway.


NPA
Pengelolaan Jalan Nafas
Oksigenasi dan pasang pulse oxymetri
Open mouth dengan crossed-finger, bersihkan jalan nafas OPA
dari corpal, suctioning
Chin lift manuver atau jaw thrust manuver (pada
curiga C-spine terganggu)-> dipertahankan dengan
nasofaringeal airway atau orofaringeal airway

Dapat teroksigenasi Definitif airway Intubation


NO surgical
Assess airway anatomy -> Call assistance
LEMON Difficult or Awake
Intubation – drug – intubation
assistance Cricoid
pressure
unsuccesfull

Consider adjunct -> GEB/LMA/LTA

Definitif arway
surgical
Oropharingeal Airway
• Digunakan untuk ventilasi sementara pada pasien yang tidak
sadar sementara intubasi pasien sedang disiapkan
• Tidak boleh digunakan pada pasien yang sadar karena dapat
menyebabkan sumbatan, muntah dan aspirasi.

Nasopharingeal Airway
• Prosedur ini digunakan apabila pasien terangsang untuk
muntah pada penggunaan OPA
• Tidak boleh digunakan pada kecurigaan fraktur basis cranii

Laryngeal Mask Airway


• Digunakan untuk pertolongan dengan airway yang sulit untuk
intubasi endotracheal atau bag mask gagal. Ingat LMA bukan
definitif
Laryngeal Tube Airway
• Suatu alat airway diluar glotis untuk memberi ventilasi pasien
dengan baik.

Gum Elastic Bougie


• Diikenal dengan nama Eschmann tracheal tube introducer
(ETTI)
• Digunakan pada keadaan sulit intubasi

Multilumen Esophageal Airway (Combitube)


• Dapat digunakan apabila airway definit belum dapat
dilakukan.
• Alat ini memiliki lubang udara yang mengarah ke saluran
nafas, lubang lain mengarah ke esofagus.
Airway definitif ❑ Orotracheal Tube
❑ Nasotracheal Tube
❑ Airway surgical :
Adalah tabung yang terpasang di dalam trakea, dengan balon
❑ Krikotiroidotomi
yang dikembangkan di bawah pita suara. Tabung
dihubungkan ke sumber oksigen melalui alat bantu ventilasi ❑ Trakheostomi

Kebutuhan Untuk PERLINDUNGAN Kebutuhan Untuk VENTILASI


AIRWAY
Penurunan Kesadaran (GCS ≤ 8) Apneu :
-Paralisis neuromuscular
-Tidak sadar
Fraktur Maxilofacial berat Usaha Nafas tidak adekuat
-Takipneu
-Hipoksia
-Hiperkarbia
-Sianosis
Resiko Aspirasi : Perdarahan, muntah Cedera kepala tertutup berat yang
muntah membutuhkan hiperventilasi
Resiko Sumbatan : Hematoma leher, Kehilangan darah yang masif dan
cedera laring, trachea, stridor memerlukan resusitasi volume
Nasotracheal intubation

Cricothyroidotomy Tracheostomy
Memegang leher adalah tanda
universal bahwa korban
sedang tersedak
AHA Choking Algorithm
UPPER

LOWER
Bronchoscopy

is an endoscopic
technique of visualizing
the inside of the airways
for diagnostic and
therapeutic purposes.
Manual Assisted Ventilation
• Apply face mask
– Oro/naso-pharyngeal airway
adjuncts
– Mouth opening
– Hand positioning
• Elevate mandible and chin
• Resuscitation bag compression –
volume and frequency
• Frequency = 10-12 x/minute (apneu
without cardiac arrest), 8-10
x/minute (apneu with cardiac arrest)
• Ensure adequate chest wall
expansion everytime ventilation
given
Shock – Definition
A physiological state characterized by a
significant, systemic reduction in tissue
perfusion, resulting in decreased tissue oxygen
delivery and insufficient removal of cellular
metabolic products, resulting in tissue injury.
Classification of Shock

Hypovolemic Cardiogenic

Obstructive Distributive
Pathophysiology of Shock
Preload
Afterload Stroke Volume x Heart Rate
Contractility

O2 Content
Cardiac
Resistance
Output
x x

O2 Delivery Arterial Blood


Pressure
Pathophysiology
Shock CO SVR

Hipovolemik  (preload dan  sebagai


(termasuk perdarahan) afterload) kompensasi
Kardiogenik  (kontraktilitas)  sebagai
kompensasi
Distributif  sebagai 
(termasuk anafilaktik, kompensasi
septik, neurogenik/
spinal)
Characteristics of Shock

End organ Metabolic


dysfunction: dysfunction:
reduced urine
output acidosis
altered mental
status
altered metabolic
poor peripheral demands
perfusion
Management

Goal :  pengangkutan O2 &↓ kebutuhan O2

Cara : O2, cairan, kontrol suhu, antibiotik, koreksi kelainan metabolik, Inotropik

Airway : intubasi & kontrol ventilasi

Breathing :
• Awal : O2 100 %, monitor saturasi

Sirkulasi
• Akses IV scr cepat.
• Intra osseus: anak 4 – 6 th
• Kateter vena sentral
HYPOVOLEMIC SHOCK
Perkiraan Kehilangan Darah
Kelas I Kelas II Kelas III Kelas IV
Kehilangan darah <750 750-1500 1500-2000 >2000
(mL)*
Kehilangan darah <15% 15-30% 30-40% >40%
(% volume darah)
Nadi <100 >100 >120 >140
Tekanan darah Normal Normal Menurun Menurun
Tekanan nadi Normal atau naik Menurun Menurun Menurun
Frekuensi nafas 14-20 20-30 30-40 >35
Produksi urin >30 20-30 5-15 Tidak berarti
(ml/jam)
Status mental Sedikit cemas Agak cemas Cemas, bingung Bingung, letargis
Penggantian Kristaloid (3 for 1 Kristaloid (3 for 1 Kristaloid (3 for 1 Kristaloid (3 for 1
cairan rule) rule) rule)dan darah (1 rule)dan darah (1
for 1 rule) for 1 rule)

*) untuk laki-laki dengan berat badan 70kg


Estimated Blood Volume (EBV)

Laki –laki = 75 cc/kgBB

Perempuan = 65 cc/kgBB
Infant = 80 cc/kgBB

Neonatus = 85 cc/kgBB

Premature neonatus = 96 cc/kgBB


Therapy - Hypovolemic
PRINSIP TERAPI : CAIRAN

TUJUAN
• VOL. INTRAVASKULER TERCUKUPI
• KOREKSI ASIDOSIS METABOLIK
• OBATI PENYEBAB
REASSES PERFUSI, UO, TANDA VITAL

PILIHAN :
• KRISTALOID ISOTONIK : 1-2 LITER ATAU 20 CC/KG (ANAK) SECARA
BOLUS CEPAT BILA FUNGSI JANTUNG NORMAL
• NS DAPAT MENYEBABKAN ASIDOSIS HIPERCHLOREMIK
IV fluids
Crystalloid solutions (isotonic)
• Both 0.9% saline and RL are equally effective
• RL may be preferred in hemorrhagic shock because it
somewhat minimizes acidosis and will not cause
hyperchloremia.
• For patients with acute brain injury, 0.9% saline is preferred.

Colloid solutions (eg, HES, albumin, dextrans)


• also effective for volume replacement during major
hemorrhage.
• offer NO major advantage over crystalloid solutions, and
albumin has been associated with poorer outcomes in patients
with traumatic brain injury.
Sumber: Merck Manuals
IV Fluids Composition
End point and Monitoring

The actual end point of fluid therapy in shock is normalization of


DO2

Adequate end-organ perfusion is best indicated by urine


output of > 0.5 to 1 mL/kg/hour (1-2 mL/kg/hour for pediatric)

Central Venous Pressure

• is the pressure in the superior vena cava, reflecting right


ventricular end- diastolic pressure or preload.
• Normal CVP: 2 to 7 mm Hg (3 to 9 cm H2O)
• CVP > 12 to 15 mm Hg : fluid administration risks fluid
overload
CARDIOGENIC SHOCK
Therapy - Cardiogenic
• Terapi Inisial Dg. Pemberian Cairan
• Bila Tak Ada Perbaikan→ memburuk → susp.
Syok Kardiogenik → Inotropik
Anaphylactic – Septic – Neurogenic

DISTRIBUTIVE SHOCK
Distributive Shock
Inflammatory mediators → disruption of cellular metabolism →
peripheral vasodilation → decreased PVR

Etiology

• Anaphylaxis
• Septic
• Neurogenic
• Spinal

Sign & symptoms

• Febrile, tachycardia, clear lungs *, warm extremities, flat neck veins, oliguria
Anaphylactic Shock

Anaphylactic shock
• a type of distributive shock, which involves the immune system
(Hurst, 2008)

Type 1 hypersensitivity
• antigen binds to IgE antibodies on mast cells, which leads to
degranulation of the mast cells.

Sign & symptoms


• itching, hives, and swelling
• circulatory collapse (vasodilatation)
• suffocation (bronchial and tracheal swelling)
Tatalaksana Syok Anafilaksis
Septic Shock Tx
• O2
• Antibiotics
• Fluids
• Vasopressor
– Indication: persistent hypotension* once
adequate intravascular volume expansion has
been achieved
– DOC: NOREPINEPHRINE

*systolic blood pressure <90 mmHg or MAP<65 mmHg


OBSTRUCTIVE SHOCK

Obstructive Shock
CO↓akibat OBSTRUKSI FISIK terhadap ALIRAN DARAH

KOMPENSASI →SVR ↑

PENYEBAB :
• TAMPONADE PERIKARD
• TENSION PNEUMOTHORAX
• CRITICAL COARCTASIO AORTA
• STENOSIS AORTA

TERAPI
• CAIRAN
• ATASI PENYEBAB
START
Simple Triage and Rapid Treatment
• TRIASE
– proses pemilihan pasien berdasarkan beratnya kondisi pasien
• Situasi
– Multiple casualties (jumlah pasien/cedera >1, namun tidak melampaui
kemampuan dan fasilitas rumah sakit) → pasien dengan masalah yang
mengancam jiwa dan multi trauma akan dilayani terlebih dahulu
– Mass casualties (jumlah pasien dan beratnya cedera melampaui
kemampuan dan fasilitas rumah sakit → pasien dengan kemungkinan
bertahan hidup yang terbesar, serta membutuhkan waktu,
perlengkapan, dan tenaga paling sedikit
• Terdiri dari 4 prioritas penanganan:
– Merah → immediate care/life-threatening
– Kuning → urgent care/can delay up to 1 hour
– Hijau → delayed care/can delay up to 3 hours
– Hitam → dead/no care required
RPM
respirasi, perfusi, mental
- Semua proses evaluasi
dalam START harus
dilakukan dalam waktu
kurang dari 60 detik.
:
pH: 7,35-7,45
PCO2: 35-45 mmHg
HCO3: 22-26 mmol/L.

Tanda
Terkompensasi
(sebagian/sepe
nuhnya) →
ditandai dgn
ARAH panah
yang SAMA
Antara PaCO2
dengan HCO3
Step 1 Step 3 → Lihat
→ Lihat pH kompensasi
(<7,35 (uncompensate
Step 2 → d → arah tanda
panah PaCO2
Lihat kausa dan HCO3 tidak
(respiratorik searah; partially
→ PaCO2; compensated →
atau PaCO2 dan
metabolik → HCO3 searah
= asam HCO3), naik.turun, pH
masih
Gunakan
atau ROME
abnormal, fully
→ PaCO2 dan
>7,45 = HCO3 searah
naik.turun, pH
basa) sudah normal)
Organophosphate Poisoning
Sources

• Insecticides, herbicides

Mechanism

• Inhibit acethylcholinesterase
• ACh accumulates throughout the nervous system
• Overstimulation of muscarinic and nicotinic receptors

Characteristics

• SLUD + GEM
Organophosphate Poisoning
Sign and Symptom

• + GEM
• G : Gastrointestinal
• E : Emesis
• M : Miosis
Atropine
Competitive inhibitor at autonomic postganglionic cholinergic receptors (GI &
pulmonary smooth muscle, exocrine glands, heart, and eye)

Dosis awal → dewasa: 2 mg IM. Dosis dapat digandakan setiap 10 menit


sampai teratropinisasi.

“The main concern with OP toxicity is respiratory failure from


excessive airway secretions. The endpoint for atropinization
is dried pulmonary secretions and adequate oxygenation.
Tachycardia and mydriasis must not be used to limit or to stop
subsequent doses of atropine.”
CO Poisoning
Djengkolic Acid Poisoning
Sources

• JENGKOL bean

Mechanism

• poor solubility under acidic conditions


• the amino acid precipitates into crystals
• mechanical irritation of the renal tubules and urinary tract

Characteristics

• abdominal discomfort, loin pains, severe colic, nausea,


vomiting, dysuria, gross hematuria, and oliguria, occurring 2 to
6 hours after the beans were ingested.
Djengkolic Acid Poisoning
Supporting examination

• Urine analysis → erythrocytes, epithelial


cells, protein, and the needle-like crystals of
djenkolic acid.

Treatment

• Hydration to increase urine flow


• Alkalinization of urine by sodium
bicarbonate.
Cyanide Poisoning
Sources

• Naturally in foods (some fruits, lima beans, SINGKONG)


• Cyanide salts used in industry
• Produced in smoke of burning plastics/synthetics,
electroplating, metal polishing
Mechanism
Inhibits cellular respiration
• Tissue cannot utilize O2
• “Arterialization” of venous blood

Characteristics
Smells like “almonds”
Cyanide inhibit cellular respiration
Clinical Effects of Cyanide
• Headache • Hypertension,
bradycardia
• Dizziness
• Hypotension, later in
• Seizures course
• Coma • Cardiovascular
collapse

CNS Cardiovascular

• Dyspnea • Nausea,
• Tachypnea vomiting
• Pulmonary edema • Caustic effects
• Apnea

Pulmonary Gastrointestinal
Cyanide Diagnosis
• Clinical picture : sweet almond breath
• Lactic acidosis
• ABG:
– metabolic acidosis

”Arterialization of the
venous blood”
Treatment
• Remove from source
• Oxygen
• Cyanide antidote kit:
– Amyl nitrite perle (inhalation)
• until IV established
– Sodium Nitrite (300mg IV)
• Peds: 0.33 ml/kg of 10% solution)
– Sodium Thiosulfate (12.5gm IV)
• Peds: 1.65 ml/kg of 25% solution
Methanol Toxicity
• Methanol
– wood alcohol
– organic solvent that, because of its toxicity, can
cause metabolic acidosis, neurologic sequelae,
and even death, when ingested
• Complication
– Visual loss (optic nerve damage)
– Metabolic acidosis
– Movement disorder (damage in putamen >>) →
Parkinsonian motor impairment
Therapy
Therapy
• Hemodialysis can easily remove methanol and
formic acid.
Botulinum Toxin
Treatment
Monitoring
•Pulse oximetry
•Spirometry
•ABG
•Ventilation, perfusion, upper airway integrity

Antitoxin
•Equine serum heptavalen botulism antitoxin → children >1 year old and adult
•Human-derived botulism immune globin → infant ≤ 1 year old
Antibiotics
•Penicillin G (3 million units IV every four hours in adult)
•Metronidazole (500 mg IV every eight hours) is a possible alternative for penicillin-allergic
patients
Other treatments
•Laxatives, enemas