STEP 1

Primary survey : Survey yang selalu dilakukan pada saat ada kasus trauma dan
merupakan metode yang dilakukan scr cepat dalam waktu 5 menit. Dilihat dari airway,
breathing, circulation, defibrillation. Pemeriksaan dan tindakan untuk mengamankan
organ vital

Gurgling : suara seperti berkumur oleh karena adanya akumulasi cairan darah atau lendir
yang berada di sekitar orofaring.

Triple airway maneuver : tindakan untuk mengetahui adanya cedera cervical (head tilt,
chin lift, dan jaw thrust). Head tilt (mendorong kepala ke belakanhg), chin lift
(mengangkat dagu dan mendorong kepala ke belakang), jaw thrust (paling baik
dilakukan pada kasus trauma cervical, mempososikan kepala segaris linier untuk
menghindari dr cedera leher, dari os mandibular ditarik keatas oleh sudut jari)

Advanced airway : metode yg dilakuakn setelah triple airway apabila gagal.

Definitive airway : alat seperti pipa dalam trakea dengan balon yang dikembangkan
sebagai alat bantu pernapasan. Pipa akan dihunungkan dengan O2 agar pasien bisa
bernapas, kesadaran turun pada pasien akan dirangsang dengan rangsangan muntah.

Non surgical : Balon

Surgical airway : cricotiroidektomi, trakeostomi

Intubasi oral dan nasal : apabila tidak dapat dilakukan ini maka dilakukan surgical airway
(cricotiroidektomi, trakeostomi)

STEP 7

1. Apa saja tindakan yang diakukan dalam primary survey?

a. Airway (jalan nafas)
Apkah ada benda yang menghalangi? Dilakukan dalam waktu 3-5 menit. Ada 2
bagian
Protect airway : bersihkan terlabeih dahulu cairan yang menyumbat
Cervical spine control : dicek apakah ada fraktur  dipasang cervical polar
Ditanya apa ada nyeri leher?
2 komponen yang diperhatikan :
Px jalan nafas : adanya sumbatan cairan (gurgling)/benda asing. Adanya sumbatan
cairan dapat dilakukan oleh jari telunjuk dan ibu jari yang dilapisi kain. Kemudian
dapat dialkukan chin lift dan jaw thrust.
Dilihat responsif tidaknya
a. Look : sianosis, benda asing, kesadaran (GCS) apabila pasien sadar tetap
dilakukan airway tetapi tetap dilakuakn px scr berkala, nafas cuping hidung
(berkaitan dengan breathing/gangguan nafas), retraksi ICS (breathing), accesssoy
respiratory muscle
b. Listen : suara napas (gurgling/cairan/ lendir/darah), snoring (mengorok/ benda
padat setinggi faring/ lidah tertekuk ke belakang), stridor (tanda obstruksi di
bagian laring/ sumbatan di sal nafas, stridor terdengar di inspirasi kemungkinan di
laring, stridor terdengar di ekspirasi kemungkinan sumbatan di trakea), hoarsness
(serak/ gangguan plica vokalis setinggi faring, apabila afonia dengan kesadaran
merupakan pertanda buruk)
c. Feel : trakea (deviasi/-), dirasakan aliran udara dari mulut/hidung

b. Breathing
Dilihat di bagian thoraks : gerakan thoraks simetris/asimetris, deformitas, jejas,
palpasi (nyeri tekan), perkusi (sonor, hipersonor, pekak), auskultasi (dengarkan
suara jantung).
Bantuan napas : adanya hembusan nafas /- diperiksa dalam waktu 10 detik, diberi
bantuan napas dari mulut ke hidung, mulut ke mulut, mulut ke stoma.
c. Circulation
 Melihat di bagain pembuluh darah. Tanda- tanda yang dilihat : denyut jantung,
akral dingin, akral hangat, takanan darah, urin output.
Bantuan sikulasi : denyut jantung, denyut nadi kemudian dilakukan dengan triple
maneuver
Pentingnya melakukan circulation : pasien syok dapat mati dalam waktu 1-2 jam.
D. Disabilty
Menilai bagaian neuron : GCS, reflex pupil. Melakukan px neurologi scr cepat
apabila tidak bisa GCS bisa melakukan AVPU (Alert, Verbal, Pain, Unresponsive)
E. Exposure
Lepas seluruh pakaian dan asesories pasien.

2. Apa saja macam-macam pemeriksaan kesadaran dan bagaimana cara pemeriksaan

kesadaran pasien?

Penilaian AVPU

 AVPU
Cara menentukan kesadaran seseorang korban adalah dengan menilai respon korban terhadap
sentuhan atau panggilan dari penolong. Lakukan dengan metode AVPU, dimana pasien diperiksa
apakah sadar baik (alert), berespon dengan kata-kata (verbal), hanya berespon jika dirangsang nyeri
(pain), atau pasien tidak sadar sehingga tidak berespon baik verbal maupun diberi rangsang nyeri
(unresponsiv) .
A  Alert : Korban sadar jika tidak sadar lanjut ke poin V
V  Verbal : Cobalah memanggil-manggil korban dengan berbicara keras di telinga
korban ( pada tahap ini jangan sertakan dengan menggoyang atau menyentuh
pasien ), jika tidak merespon lanjut ke P.
P  Pain : Cobalah beri rangsang nyeri pada pasien, yang paling mudah adalah
menekan bagian putih dari kuku tangan (di pangkal kuku), selain itu dapat juga
dengan menekan bagian tengah tulang dada (sternum) dan juga areal diatas mata
(supra orbital).
U  Unresponsive : Setelah diberi rangsang nyeri tapi pasien masih tidak bereaksi
maka pasien berada dalam keadaan unresponsive
3.
Cara pemeriksaannya :
a. Dipanggil  kalau gak ada respon dirangsang nyeri, kemudian diihat
EMV
GCS : dilihat dari eye, verbal, motoric
 Eye
 Spontan terbuka : 4
Rangsang terhadap adanya suara : 3
Rangsang terhadap adanya nyeri : 2
Tidak ada respon : 1
 Verbal
Orientasi baik/ bisa bicara dgn jelas : 5
Bingung/ ngomng tapi tidak nyambung : 4
Hanya bisa membentuk kata : 3
Bergumam : 2
Tidak ada suara : 1
 Motorik
Bisa menuruti perintah : 6
Mampu melokalisir rangsang nyeri : 5
Menolak rangsang nyeri/withdrawal, hanya bisa narik tetapi belum bisa lepas : 4
Fleksi abnormal : 3
Ekstensi abnormal : 2
Tidak ada gerakan : 1

GCS
Skor komposmentis : 14-15
Skor apatis : 12-13
Skor somnolent : 11-12
Skor Stupor : 8-10
Skor koma :<5

GCS berdasar trauma kepala

Skor 13-15 : cedera kepala ringan
9-12 :cedera kepala sedang
<=8 : cedera kepala berat

Interpretasi dari skala Glasglow E3V4M5 = skor 12  cedera kepala sedang,

penurunan kesadaran apatis
E3 : membuka mata terhadap rangsang suara
V4 : bingung/disoriented. Ketika diberi pertanyaan jawabannya kacau
M5 : mampu lokalisir rangsang nyeri dan bisa narik sampai lepas
Dalam klinik dikenal tingkat-tingkat kesadaran : komposmentis, inkompos mentis (apati, delir, somnolen, sopor, koma)
a. Kompos mentis : Keadaan waspada dan terjaga pada seseorang yang bereaksi sepenuhnya dan adekuat terhadap
rangsang visuil, auditorik dan sensorik.
b. Apati : sikap acuh tak acuh, tidak segera menjawab bila ditanya.
 c. Delirium : kesadaran menurun disertai kekacauan mental dan motorik seperti desorientasi, iritatif, salah persepsi
terhadap rangsang sensorik, sering timbul ilusi dan halusinasi.
d. Somnolen : penderita mudah dibangunkan, dapat lereaksi secara motorik atau verbal yang layak tetapi setelah
memberikan respons, ia terlena kembali bila rangsangan dihentikan.
e. Sopor (stupor) : penderita hanya dapat dibangunkan dalam waktu singkat oleh rangsang nyeri yang hebat dan
berulangulang.
f. Koma : tidak ada sama sekali jawaban terhadap rangsang nyeri yang bagaimanapun hebatnya.

 Klasifikasi
 GSC Ringan (14-15)  penderita sadar namun dapat mengalami amnesia berkaitan dengan cedera yang dialaminya
 GCD Sedang (9-13)  penderita masih mampu menuruti perintah sederhana, namun biasanya tampak bingung atau mengantuk
dan dapat disertai deficit neurologis
 GCD Berat (3-8)  penderita dengan cedera kepala berat tidak mampu melakukan perintah sederhana walaupun status
kerdiopulmonernya telah stabil
 AVPU
Alert : kesadaran pasien (responsive/-), tanpa stimulus apapun dapat berbicara
dengan benar, dapat menjelaskan tempat dan kejadian
Verbal : dapat berkomunikasi, pasien dapat menjawab/-
Pain : nyeri di pangkal kuku atau intercostal, pasien dapat merasakan nyeri apabila
tubuh
Unresponsive : apabila nyeri tidak direspon, pasien tidak respon walu diberi
stimulus apapun

4. Bagaimana interpretasi dari pemeriksaan fisik yang ditemukan (laju pernafasan

28x/menit, SPO2 96%)?

Hasil TTV :
TD 100/60 mmHg (hipotensi)
HR 115x/menit (takikardi)
RR 28x/menit (takipneu)
SpO2 96% (normal)
5. Mengapa ditemukan epistaksis, edem periorbital, gurgling?
Epistaksis : pecahnya plexus kiesselbach
Gurgling : penumpukan cairan dan darah
Previous reviews have addressed airway management of trauma patients without
a detailed description of management of the traumatized airway. This clinical
commentary focuses on the approach to patients with upper airway trauma.
Airway injury is a major cause of early death in trauma.1,2 The incidence of
traumatic airway injuries is low, although it is recently increasing.3,4 In contrast,
mortality due to traumatic airway injuries is high, in part, because of associated
injuries to other organs, which are present in about one half of the cases of blunt
or penetrating airway trauma.1,2 Patients with a significant injury severity (scored
on a scale of 0 to 75,5 which accounts for the most severely traumatized body
systems) have a higher predicted mortality. In a retrospective review of 12,187
civilian patients treated at a regional trauma center in Toronto from 1989 to
2005, 36 patients (0.3%) had blunt airway trauma (injury severity score, 33;
mortality, 36%) and 68 patients (0.6%) had penetrating airway trauma (injury
severity score, 24; mortality, 16%).1 Among 24 deaths, airway injury was the
primary cause in 10 patients. Twelve patients had thoracic airway injury, 9 of
whom died. In another study including 44,684 trauma patients from Texas
between 1996 and 2003,2 there were 19 patients (12 died) with blunt trauma
and 52 patients (7 expired) with penetrating laryngeal–tracheal trauma. Traumatic
airway injury is rare (incidence < 1%); thus, assessment and management are not
well characterized because physicians rarely treat such cases.
Previous reviews of trauma care have addressed airway management, usually
without a detailed discussion of management of patients with a traumatized
airway.1,2,6–11 This clinical commentary will thus review the approach to
patients with airway trauma, particularly with injuries to the facial compartments
(i.e., maxillary and mandibular regions) and to the neck and glottis region. Care of
patients with lower airway trauma, which represents thoracic trauma, will not be
addressed in this review.
Anatomy of Trauma to the Airway
Airway injuries can be divided into three types: maxillofacial, neck, and laryngeal
injury.
Maxillofacial Trauma
Blunt or penetrating trauma to the face can affect the maxillary/mandibular or
mid-facial region and extend intracranially12–14 (table 1). Maxillofacial trauma
can result in life-threatening airway and hemorrhage problems and lead to
significant ocular, nasal, and jaw dysfunction. Bleeding may complicate airway
management. Swallowing of blood clears the airway and is facilitated with the
patient in the sitting position. However, gastric distension from swallowing of
blood may increase the likelihood of regurgitation and aspiration. Venous
bleeding can be controlled by packing and fracture reduction. Patients may not be
able to control their own airway due to brisk arterial hemorrhage. Arterial
bleeding may require angiographic embolization or may be resolved with surgical
intervention.

Table 1.
Selected Findings in Maxillofacial Trauma
In bilateral (bucket handle) or comminuted parasymphyseal mandibular fractures,
the tongue is no longer anchored anteriorly. This leads to posterior displacement
of tongue and periglottic soft tissue, causing airway obstruction. However, this
airway obstruction can be reduced by upright positioning, although a known or
suspected spinal cord injury could be worsened with upright positioning. Finally, a
condylar fracture fragment might be displaced through the roof of the glenoid
fossa to the middle cranial fossa, thus preventing mouth opening.
Mid-facial injury can cause unilateral or bilateral Le Fort I, II, and III, and
associated fractures (fig. 1). Le Fort II and III fractures may be associated with a
fractured skull base and leakage of cerebrospinal fluid (CSF). The cribriform plate
and sphenoid sinus may be damaged in patients with nasoorbito-ethmoid
fractures, Le Fort II and III fractures, or panfacial fractures. Mid-face fractures are
 generally associated with head and cervical spine (C-spine) injuries, whereas
zygomatic and orbital fractures are associated with eye injury.15

Fig. 1.
Le Fort fractures. (A, B) Le Fort I fracture. Drawings in lateral (A) and frontal (B)
projections show Le Fort I fracture runs horizontally above maxillary alveolar
process. Pterygoid plates are broken, as is true in all types of Le Fort fracture.
Walls of maxillary sinuses in this plane are broken, including point at anterolateral
margin of nasal fossa. Maxillary teeth would be movable on physical examination
relative to remainder of face. (C, D) Le Fort II fracture. Drawings show plane of Le
Fort II fracture in lateral (C) and frontal (D) projections. Le Fort II fracture is
pyramidal in shape with teeth at base of pyramid and nasofrontal suture at the
apex of pyramid. Pterygoid plates are broken, as is true in all types of Le Fort
fracture. Posterior and lateral walls of maxillary sinus are broken as fracture skirts
inferior in relation to body of zygoma. Fracture then crosses inferior orbital rim,
orbital floor, and medial wall of orbit before crossing midline near nasofrontal
suture. Maxillary teeth and nose as a unit would be movable relative to zygomata
and rest of skull. (E, F) Le Fort III fracture. Drawings show plane of Le Fort III
fracture in lateral (E) and frontal (F) projections. Le Fort III fracture separates the
bones of face from the rest of skull. Pterygoid plates are broken, as is true in all
types of Le Fort fracture. Upper posterior margins of maxillary sinuses fracture, as
does zygomatic arch, lateral orbital wall, and lateral orbital rim. There is a fracture
near junction of frontal bone and greater wing of sphenoid in posterior aspect of
orbit, fracture along medial orbital wall, and fracture across nasofrontal suture.
Maxillary teeth, nose, and zygomata as a unit would be movable on physical
examination relative to the rest of skull. Modified from the study by Rhea et al.16

Basilar skull fractures may involve the temporal, occipital, sphenoid, and ethmoid
bones. They may lead to “raccoon eyes,” i.e., periorbital ecchymosis; Battle’s sign,
i.e., retroauricular ecchymosis; CSF rhinorrhea; and cranial nerve palsy.

6. Apa saja penyebab sumbatan jalan nafas?

Klasifikasi
Sumbatan parsial : pasien masih bisa bernafas dapat muncul berbagai suara seperti
gurgling (suction), batuk

Sumbatan komplit/total : tidak bisa biacara, tidk bernafas, megang leher

Dapat ditemukan pada pasien sadar atau tidak sadar, tidak serta merta total
karena merupakan lanjutan dari obstruksi parisal,
 Akut : tertelan benda asing yang nyangkut di sal nafas

Penyebab
Trauma : Kecelakaan, gantung diri

Benda asing : laring (stridor/dispneu/apneu/sianosis), trakea (asfiksi), bronkus

(kanan lebih sering karena diameter lebih besar)

7. Apa saja pengelolaan sumbatan jalan nafas?

Primary/ awal : triple airway maneuver,
Advance/lanjutan : definitive (surgical/ cricotiroidektomi/trakeostomi atau non
surgical/intubasi oral/intubasi nasal), non definitive (orofaringeal airway)
 Alat dan cara penggunaan?

Keuntungan ETT :
Penuruann risiko aspirasi  lebih lancar
Jalan nafas terbuka
Alat bantu untuk pemberian O2 konsentrasi tinggi
Alat bantu suction

Pengelolaan Jalan Napas Dasar dengan Manuver Sederhana

Triple airway maneuver
 Chin Lift
Dilakukan dengan maksud mengangkat otot pangkal lidah ke depan. Caranya : gunakan jari tengah
dan telunjuk untuk memegang tulang dagu pasien kemudian angkat.
 Head Tilt
Dilakukan bila jalan nafas tertutup oleh lidah pasien, Ingat! Tidak boleh dilakukan pada pasien
dugaan fraktur servikal. Caranya : letakkan satu telapak tangan di dahi pasien dan tekan ke bawah
sehingga kepala menjadi tengadah dan penyangga leher tegang dan lidahpun terangkat ke depan.

Gambar 5. tangan kanan melakukan Chin lift ( dagu diangkat). dan tangan kiri melakukan head
tilt. Pangkal lidah tidak lagi menutupi jalan nafas.
 Jaw thrust
Caranya : dorong sudut rahang kiri dan kanan ke arah depan sehingga barisan gigi bawah berada
di depan barisan gigi atas


Pengelolaan Jalan Napas Dasar dengan Alat Sederhana
 Oropharyngeal Airway (OPA)
Indikasi :
Napas spontan
Tidak ada reflek muntah
Pasien tidak sadar, tidak mampu dilakukan maneuver manual
Kontraindikasi :
Pasien sadar atau setengah sadar
Reflek batuk dan muntah masih ada
Cara pemasangan :
Pemilihan ukuran OPA yg tepat :
- Mengukur jarak dari tengah bibir sampai angulus mandibula, ATAU
- Mengukur jarak dari sudut bibir sampai tragus
Memasukkan OPA dengan cara :
Mulut dibuka dengan teknik “crossed finger” lalu masukkan OPA ke dalam rongga
mulut, ketika mendekati dinding posterior faring, putarlah OPA sejauh 180 derajat
kearah posisi yg tepat.
 Nasopharyngeal Airway (NPA)
Indikasi :
Pasien sadar/ tidak sadar
Napas spontan
Masih ada reflex muntah
Kesulitan dengan OPA (karena trauma disekitar mulut dan trismus)
Kontraindikasi :
Fraktur wajah
Fraktur basis cranii
Cara pemasangan :
 Pemilihan ukuran NPA dilakukan dengan cara mengukur dari ujung hidung kea rah
tragus dan diameter internal NPA dengan jari kelingking
NPA diberi lubrikan
Masukkan NAP melalui lubang hidung dengan arah posterior membentuk garis tegak
lurus dengan permukaan wajah, masukkan dengan lembut sampai dasar nasofaring.
Bila mengalami hambatan, putar sedikit NPA untuk emmfasilitasi pemasangan pada
sudut antara rongga hidung dan nasofaring.

Advance/lanjutan : definitive non definitive

o Non surgical
 Endotrakeal intubasi
 Orotrakeal
 Nasotrakeal
 Indikasi :
Patensi jalan napas inadekuat
Keadaan oksigenasi inadekuat yg tidak dapat dikoreksi dengan pemberian
masker oksigen
Keadaan ventilasi inadekuat karena peningkatan pCO2
Henti jantung
Asfiksia
Penderita tidak sadar > 24 jam
Kontraindikasi :
Beberapa kasus trauma jalan napas atau obstruksi yg tidak emmungkinkan
untuk dilakukannya intubasi
Penolakan pada saat informed consent
Persiapan Intubasi Endotrakeal
1. Alat:
A. Laryngoscope
Terdiri dari : Blade (bilah) dan Handle (gagang).
Pilih ukuran blade yg sesuai.
Dewasa : no 3 atau 4
Anak : no 2
Bayi : no 1
Pasang blade dengan handle
Cek lampu harus menyala terang.

Pilih ukuran yang sesuai: (ID: Internal Diameter)

Dewasa : ID 6.5 , 7 atau 7.5 Atau ± sebesar kelingking kiri pasien
Anak : ID = 4 + (Umur : 4)
Bayi : Prematur : ID 2.5
Aterm : 3.0 – 3.5
 Selalu menyiapkan satu ukuran dibawah dan diatas.
C. Spuit 20 cc.
D. Stylet
E. Handsgloves steril.
F. KY jelly.
G. Forcep Magill (bila perlu).
H. AMBU Bag dg kantung reservoir dihubungkan dengan
sumber oksigen.
I. Plester untuk fiksasi ETT.
J. Oropharngeal Airway.
H. Alat suction dg suction catheter .
K. Stetoscope.
Obat Emergency
- Sulfas Atropin (SA) dalam spuit
- Adrenaline dalam spuit.
Pasien
Informed consent mengenai tujuan dan resiko tindakan.

Langkah – langkah Intubasi Endotrakeal

Ventilasi tekanan positif dan Oksigenasi
Harus dilakukan sebelum intubasi.
Dada harus mengembang selama ventilasi diberikan.
Oksigenasi dengan oksigen 100% (10 L/menit).
Bila intubasi gagal (waktu >30 detik), lakukan ventilasi dan
oksigenasi ulang, bahaya hipoksia !!!

•
• Buka mulut dengan tangan kanan, gerakan jari menyilang (ibu jari menekan mandibula, jari
telunjuk menekan maksila)
• Pegang laringoskop dg tangan kiri, masukkan melalui sisi sebelah kanan mulut, singkirkan lidah
ke samping kiri
• Cari epiglotis. Tempatkan ujung bilah laringoskop di valekula (pertemuan epiglotis dan pangkal
lidah)
• Angkat epiglotis dg elevasi laringoskop ke atas (jangan menggunakan gigi seri atas sbg tumpuan
!!!) untuk melihat plika vokalis
• Bila tidak terlihat, minta bantuan asisten utk lakukan BURP manuver (Back, Up, Right Pressure)
pada kartilago krikoid sampai terlihat plika vokalis

• Menekan kartilago krikoid ke bawah,

atas, kanan (Back, Up, Right Pressure=
BURP)
• Membantu visualisasi plika vokalis
• Dilakukan oleh asisten yg membantu
intubator
• Masukkan ETT, bimbing ujungnya masuk trakea sampai cuff ETT melewati plika vokalis
• Kembangkan cuff ETT secukupnya (sampai tidak ada kebocoran udara)
• Pasang OPA
• Sambungkan konektor ETT dg ambu bag. Beri ventilasi buatan. Cek suara paru kanan = kiri, Awas
intubasi endobronkial !!
• Fiksasi ETT dengan plester
o Surgical
 Krikotiroidotomi

 trakeostomi
Advance/lanjutan : non definitive
 Laryngeal Mask Airway

 Combitube
2. Manuever Sumbatan Jalan Nafas oleh Benda Asing pada Dewasa
A. Penderita sadar
  Sumbatan ringan
Penderita masih sadar  batuk tanpa melakukan tindakan dan terus
observasi
 Sumbatan berat
Penderita tak bisa bicara dan terlihat tercekik  abdominal
thrust/Heimlich manuever

B. Penderita tidak sadar

Aktifkan sistem Layanan Gawat Darurat, panggil bantuan  kompresi 30

kali tanpa cek arteri carotis communis  RJP

3. Manuver Sumbatan Jalan Nafas oleh Benda Asing pada Bayi dan Anak
A. Penderita sadar
 Back blows
  Chest thrust

 Abdominal thrust
Untuk anak > 1 tahun

B. Penderita tidak sadar

Aktifkan sistem Layanan Gawat Darurat, panggil bantuan  kompresi 30

kali tanpa cek arteri carotis communis  RJP
 1. Derajat2 (stadium) sumbatan jln napas

Sumbatan saluran napas atas dapat dibagi menjadi 4 derajat berdasarkan kriteria Jackson.

 Jackson I ditandai dengan sesak, stridor inspirasi ringan, retraksi suprasternal, tanpa
sianosis.
 Jackson II adalah gejala sesuai Jackson I tetapi lebih berat yaitu disertai retraksi supra
dan infraklavikula, sianosis ringan, dan pasien tampak mulai gelisah.
 Jackson III adalah Jackson II yang bertambah berat disertai retraksi interkostal,
epigastrium, dan sianosis lebih jelas. (Trakeostomi)
 Jackson IV ditandai dengan gejala Jackson III disertai wajah yang tampak tegang, dan
terkadang gagal napas.

(Kedaruratan Medik, Dr. Agus Purwadianto & Dr. Budi Sampurna)

Alat dan cara penggunaan?

► Assisting With Placement of Advanced Airways
Endotracheal (ET) intubation is the insertion of a tube into the trachea to
maintain and protect the airway. The ET tube can
be inserted through the mouth or through the nose. In either case, the ET tube
passes directly through the larynx between the
vocal cords and then into the trachea. You may also be asked to assist with
the placement of other advanced airway devices.
Patient Preparation
The first step in preparing a patient for ET intubation is oxygenation. Recall
from Chapter 10, Airway Management, that
oxygenation is the process of loading oxygen molecules onto hemoglobin
molecules in the bloodstream. Good oxygenation
often includes BVM ventilation (including the use of an oral or nasal airway)
and ensuring a proper seal, ventilation rate,
volume of ventilation, and time for patient exhalation. Oxygen enters the
bloodstream through the process of diffusion. The
more oxygen that is available in the alveoli, the longer the patient can
maintain adequate gas exchange in the lungs while the
intubation procedure is being performed Figure 41-4 . This critical phase of the
intubation procedure is called
preoxygenation.
Maintain a high-flow nasal cannula on the patient during the preoxygenation
phase and leave the nasal cannula in place
during the intubation attempt, a period of time when BVM ventilation and chest
rise and fall is not possible. This technique,
called apneic oxygenation, allows for continuous oxygen delivery down the
airways during all phases of the intubation
procedure.
Preoxygenation is a critical step in advanced airway management. Always follow
your local protocols regarding the
sequence of this procedure.
Equipment Set Up
Equipment sets vary depending on local protocols, provider preference, and
whether direct laryngoscopy or video
laryngoscopy will be used. (Direct laryngoscopy is visualization of the vocal
cords with a laryngoscope, while video
laryngoscopy is visualization of the vocal cords using a video camera and
monitor.) These differences emphasize why it is
important for team members to train and practice together. Typically,
intubation equipment sets include:
▪ Personal protective equipment (PPE), including face mask and eye shield
▪ Suction unit with rigid, tonsil-tip (Yankauer) and nonrigid, whistle-tip
(French) catheters
▪ Laryngoscope handle and blade (sized for the patient)
▪ Magill forceps
▪ ET tube (sized for the patient)
▪ Stylette or tube introducer (gum elastic bougie)
▪ Water-soluble lubricant
▪ 10-mL syringe
▪ Confirmation device(s), including waveform end-tidal CO2 monitors and/or
colorimetric device
▪ Commercial ET tube securing device
▪ Alternate airway management devices, such as a supraglottic airway and/or
cricothyrotomy kit

Words of Wisdom
When assembling the intubation equipment, you may have time to take extra steps, such as
opening the ET tube package, lubricating the end of
the ET tube with the water-soluble lubricant, attaching the 10-mL syringe, testing the cuff
and pilot balloon, and checking the laryngoscope’s
light source.

Performing the Procedure

While the details of endotracheal intubation may vary depending on available
equipment, difficulties encountered, and
provider preference, you can remember the six typical steps by using the BE
MAGIC mnemonic:
B Perform BVM preoxygenation.
E Evaluate for airway difficulties.
M Manipulate the patient.
A Attempt first-pass intubation.
GI Use a supraGlottic or Intermediate airway if unable to intubate.
C Confirm successful intubation/Correct any issues.
BVM preoxygenation. As discussed previously, it is crucial that you adequately
preoxygenate the patient before the
intubation procedure, especially critical patients Figure 41-5 . Do not
hyperventilate the patient during the preoxygenation
phase, because this may cause gastric distention and increase the risk of
aspiration. Hyperventilation may also cause
hypotension. Focus on maintaining a good seal, achieving chest rise and fall,
and delivering breaths at a rate appropriate for
the patient’s age (1 breath every 6 seconds for an adult, and 1 breath every
3 to 5 seconds for an infant or child).
Evaluate for airway difficulties. While you preoxygenate the patient, an ALS
provider should evaluate the patient to
identify any factors that will present difficulties during the procedure—for
example, trauma or anatomic deformities to the
airway. It is crucial that difficulties be identified before the procedure
begins. You may assist with this process, as well as the
preparation of any equipment that will be needed to address the problem(s).
Manipulate the patient. Before the procedure can begin, position the patient
so that the ALS provider can visualize the
vocal cords. Use towels, blankets, and pillows to ramp, position, and
otherwise manipulate the patient so that the first
attempted intubation will be successful. The ideal position is achieved when
the patient’s ear canal is on the same horizontal
plane as his or her sternal notch, known as the sniffing position Figure 41-6 .
Attempt intubation. When the ALS provider is ready to begin the intubation
attempt, remove the oral airway and
disconnect the mask from the bag in preparation for connecting the bag to the
ET tube. Always keep the mask and airway
within reach in case the first attempt is unsuccessful and you need to
ventilate the patient with the BVM once more.
Likewise, keep suction equipment at hand in case you need to suction the
patient’s airway. The ALS provider will begin by
inserting the laryngoscope blade into the patient’s mouth and will use it to
move structures in the airway, such as the tongue
and epiglottis, to gain a view of the vocal cords through which the ET tube
will pass Figure 41-7 .

Special Populations
It may be difficult for the ALS provider to visualize the vocal cords in bariatric and
pediatric patients or patients with suspected cervical spine
injuries. Expect to have particularly hands-on involvement with these patients. It is usually
necessary to open (undo) a cervical collar to perform
intubation. As the cervical collar is opened, you may be asked to maintain cervical spine
immobilization while an ALS provider attempts
intubation. Good communication and coordination between team members is critical during these
advanced procedures.
The ALS provider may ask you for assistance in manipulating the patient’s
larynx (external laryngeal manipulation) or
otherwise positioning the patient for a better view Figure 41-8 . You may also
be asked to hand over the ET tube, gum elastic
bougie, suction catheter, or other equipment to the ALS provider.
Supraglottic or intermediate airway. Should the intubation attempts fail, it
may be your responsibility to prepare and hand
over the supraglottic or intermediate airway device or, in systems where it is
allowed, you may place the airway devices
themselves Figure 41-9 .
Confirm intubation/correct issues. If the intubation procedure appears
successful, then work with your team to confirm
intubation success. You may attach the end-tidal waveform CO2 detector in line
between the ET tube and the bag. You may
also either ventilate the patient while another provider checks for positive
breath sounds in the absence of gastric sounds, or
you may listen while another team member ventilates Figure 41-10 . A
successfully intubated patient should have bilateral
breath sounds present and gastric (or epigastric) sounds should be absent.
Either absence of breath sounds or presence of
gastric sounds suggests the ET tube was improperly inserted into the
esophagus. If the intubation is confirmed as successful,
then you may assist in securing the ET tube Figure 41-11 . If the intubation
cannot be confirmed, or if the ET tube appears to
be properly placed but airway or breathing issues remain, then you may assist
other team members in correcting these issues.

Words of Wisdom
An ALS provider may place an oral airway back into the patient’s mouth after a successful
intubation attempt to prevent the patient from biting
down on the ET tube.
8. Apa indikasi dilakukan pemasangan NRM pada pasien ?
Cara pemberian O2 :
Aliran rendah / low flow
1. Low flow low consentration : saat pemberian nasal kanul 4 liter/menit dengan
konsentrasi maks 24-44%
 2. Low flow high consentration :
a. Sungkup / simple mask
Aliran 5-8 L/menit, konsentrasi maks 40-60%
b. NRM
Aliran 8-12 L/menit, konsentrasi maks 80-100%, masker memiliki katp yang
berfungsi untuk penukaran CO2
c. RM
O2 dan CO2 bercampur karena tak meiliki katup, aliran 8-12L/menit, konsentrasi
40-60%

Aliran tinggi / high flow

1. Low consentration
a. Venturi mask

2. High consentration
Diberikan pada orang sindrom dekompresi/orang tenggelam

CO2 tinggi, saturasi normal  High flow, low consentration

CO2 tinggi, saturasi rendah  high flow, high consentration

Indikasi : mencegah hipoksia

 S
9. Bagaimana diagnosis dan diagnosis banding dari kasus pada scenario?
A : Gangguan airway karena adanya suara gurgling
B : Gangguan breathing, adanya takipneu
C:
D:

10. Apa saja indikasi pemasangan definitive airway?

DEFINITIVE AIRWAY STRATEGY

This includes either ETI or a surgical airway. Indications for definitive airway strategy include the following:[10]
1. Presence of apnoea.
2. Need for airway protection form aspiration: vomitus, bleeding.
3. Unconsciousness: Glasgow Coma Scale <8.
4. Severe faciomaxillary fractures.
5. Risk for obstruction: neck haematoma, laryngeal/tracheal injury.
6. Impending or potential airway compromise: inhalation injury.
7. Inability to maintain SpO2> 90% by facemask oxygenation.
  Adanya patensi jalan nafas yang inadekuat


11. Mengapa dokter melakukan triple airway maneuver pada pasien ?
12. Apa saja tanda-tanda yang harus diidentifikasi apabila mengarah pada obstruksi
pernafasan akut?
a. Look : sianosis, benda asing, kesadaran (GCS) apabila pasien sadar tetap
dilakukan airway tetapi tetap dilakuakn px scr berkala, nafas cuping hidung
(berkaitan dengan breathing/gangguan nafas), retraksi ICS (breathing), accesssoy
respiratory muscle
b. Listen : suara napas (gurgling/cairan/ lendir/darah), snoring (mengorok/ benda
padat setinggi faring/ lidah tertekuk ke belakang), stridor (tanda obstruksi di
bagian laring/ sumbatan di sal nafas, stridor terdengar di inspirasi kemungkinan di
laring, stridor terdengar di ekspirasi kemungkinan sumbatan di trakea), hoarsness
(serak/ gangguan plica vokalis setinggi faring, apabila afonia dengan kesadaran
merupakan pertanda buruk)
c. Feel : trakea (deviasi/-), dirasakan aliran udara dari mulut/hidung
13. Apa saja komplikasi sumbatan jalan nafas?
Hipoksia
Macam hipoksia :
Ringan  tekanan O2 : 60-79 mmHg , SpO2 : 90-94%
Sedang : SpO2 75-89%, PaO2 : 40-60 mmHg
Berat : SpO2 : <75%, PaO2 : <40 mmHg
Indikasi penggunaaan pulse oximetry?
 15. Apa saja komplikasi organ vital akibat sumbatan jalan nafas?

T issues require oxygen for survival. Oxygen delivery (Do2)

depends on adequate ventilation, gas exchange and circulatory

distribution. Tissue hypoxia occurs within 4 minutes of
cardiorespiratory arrest because tissue, blood and lung oxygen
reserves are small. Causes of tissue hypoxia (Figure 13b) can be
classified into those resulting in: (a) arterial hypoxaemia, and (b)
failure of the oxygen–haemoglobin transport system without arterial
hypoxaemia.

Six pathophysiological mechanisms cause arterial hypoxaemia:

1 Low inspired oxygen partial pressure (Po2) occurs at high
altitude due to reduced barometric pressure, during fires due to O 2
combustion and after toxic fume inhalation.
2 Hypoventilation: failure to replenish alveolar O 2 as quickly as it
is removed by haemoglobin uptake.
3 Shunt refers to venous blood that bypasses lung gas-exchange
and passes directly into the systemic arterial system. Increasing
inspired O2 concentration (Fio2) has little effect on Pao2 when the
‘true’ shunt fraction is ≥30% (Figure 13d[i]).
4 Ventilation/perfusion (V/Q) mismatch is the most frequent
cause of hypoxaemia even in diseases like pulmonary fibrosis
where diffusion limitation might be expected to predominate.
Figure 13d(ii) illustrates that hypoxaemia due to venous admixture
from many lung units with mild V/Q mismatch (Figure 13d[ii]:
A) readily corrects with low-dose oxygen, whereas hypoxaemia
due to a few lung units with severe V/Q mismatch (Figure 13d[ii]:
B) (i.e. very poorly ventilated units) requires high-dose oxygen.
Unventilated lung units produce true shunt (i.e. resulting hypoxaemia
cannot be corrected with oxygen). Figure 13e illustrates the
calculation of venous admixture due to V/Q mismatch and true
shunt fraction. High V/Q units contribute to deadspace but not
hypoxaemia.
5 Impaired diffusion is rarely clinically significant but may
prevent equilibration of alveolar gas with capillary blood if capillary
transit time is reduced (e.g. high cardiac output [CO],
exercise).
6 Venous saturation: venous blood with a very low Sao2 returning
to the right heart usually has little effect on arterial Pao2, but in
patients with impaired gas exchange or low CO it may reduce Pao2.
 Clinical features of tissue hypoxia are non-specific (e.g. altered
mental state, dyspnoea, hyperventilation, arrhythmias, hypotension).
Nevertheless, early recognition is required for successful
therapy. Central cyanosis is detected when deoxygenated haemoglobin
is >1.5–5 g/dl. It is an unreliable sign of hypoxia because it
can be absent in hypoxic, anaemic patients but apparent in normoxic,
polycythaemic subjects.

RESPONSES TO HYPOXIA
Decreased O2 availability to cells results in an inhibition of oxidative
phosphorylation and increased anaerobic glycolysis. This switch
from aerobic to anaerobic metabolism, the Pasteur effect, maintains
some, albeit reduced, adenosine 5-triphosphate (ATP) production.
In severe hypoxia, when ATP production is inadequate to meet the
energy requirements of ionic and osmotic equilibrium, cell membrane
depolarization leads to uncontrolled Ca2+ influx and activation of
Ca2+-dependent phospholipases and proteases. These events, in turn,
cause cell swelling, activation of apoptotic pathways, and, ultimately,
cell death.
The adaptations to hypoxia are mediated, in part, by the upregulation
of genes encoding a variety of proteins, including glycolytic
enzymes, such as phosphoglycerate kinase and phosphofructokinase,
as well as the glucose transporters Glut-1 and Glut-2; and by growth
factors, such as vascular endothelial growth factor (VEGF) and
erythropoietin, which enhance erythrocyte production. The hypoxiainduced
increase in expression of these key proteins is governed by
the hypoxia-sensitive transcription factor, hypoxia-inducible factor-1
(HIF-1).

Komplikasi :

Otak  hipoksia, penurunan kesadaran

Jantung  peningkatan HR, tekanan perifer meningkat, vasokontriksi  gagal jantung

akut/cardiac aresst

Paru-paru  atelectasis, henti nafas

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