TATALAKSANA TERKINI

KEGAWATDARURATAN PEDIATRI
PADA PELAYANAN PRIMER

Ririe Fachrina Malisie

SUBBAGIAN  PEDIATRI  GAWAT  DARURAT
PEDIATRIC  INTENSIVE  CARE  UNIT
FAKULTAS  KEDOKTERAN  UNIVERSITAS  RIAU
RSUD  ARIFIN  ACHMAD
PEKANBARU
 PENDERITA GAWAT DARURAT

• Penderita yang memerlukan pertolongan segera

karena berada dalam keadaan yang mengancam
nyawa

• Pertolongan yang cepat, tepat dan cermat dapat

menghindarkan kematian dan mencegah kecacatan
 GAWAT DARURAT

• CRITICALLY ILL PATIENT: ancaman kematian

segera karena gangguan respirasi /sirkulasi
1.Immediately life threatening
2.Potentially life threatening

• EMERGENCY PATIENT: perlu mendapat

pertolongan yang jika tidak maka akan menyebabkan
kecacatan atau kematian karena gangguan
kesadaran, metabolisme dan disfungsi organ lain
Immediately Life Threatening

• Obstruksi total jalan napas

• Asfiksia

• Pnemotorak tension

• Henti jantung (cardiac arrest)

• Tamponade jantung
Potentially Life Threatening

• Ruptura trakeobronkial

• Kontusio jantung paru

• Perdarahan masif

• Koma
Kasus dengan ancaman kecacatan

• Fraktur tulang yang disertai cedera persyarafan

• Crush Injury

• Sindrom Kompartemen
 Prinsip Tatalaksana

• Penanganan cepat, tepat & cermat

• Pertolongan diberikan oleh siapa saja yang

available (dokter, perawat, kader kesehatan, orang
awam)

• Tindakan medis dan non-medis

Non-medis : meminta pertolongan, alat-alat
resusitasi, transportasi dan evakuasi
Medis : Upaya memberikan bantuan hidup dasar
(Basic Life Support) & bantuan hidup lanjut
(Advanced Life Support)
 Penilaian pasien gawat darurat

• PRIMARY SURVEY : pemeriksaan terhadap adanya

ancaman kematian segera (gangguan jalan napas,
usaha napas dan sirkulasi) tanpa dukungan alat
bantu diagnostik (look, listen & feel) ataupun dengan
alat bantu apabila tersedia

• SECONDARY SURVEY : pemeriksaan ulang

terhadap adanya ancaman kematian segera, dengan
alat bantu / alat resusitasi apabila tersedia
 TRIASE

• Tindakan melakukan seleksi atau memilah-milah pasien

sesuai tingkat kegawatannya untuk memperoleh
prioritas tindakan

• Penggunaan kode warna

• MERAH : GAWAT DARURAT yaitu pasien dengan

ancaman kematian segera karena gangguan ABC

• KUNING : DARURAT TIDAK GAWAT yaitu pasien

yang tidak ada ancaman kematian dengan segera tapi
mempunyai ancaman kecacatan karena gangguan ABC

• HIJAU : TIDAK GAWAT TIDAK DARURAT

• HITAM : meninggal / kematian

 ABCDE

Airway
Breathing
Circulation
Disability
Exposure
Pediatric Assessment Triangle

WU
orp
ilace
n

kaoy
rpan

faB
ema

nrea
pnpa

aptah
PAe

sing
Sirkulasi kulit
Skin Perfusion
 WU

WU
orp

orp
inlace

ne
n

inlac
kaoy

kaoy
arpa

arpa
fa

fa
paem

paem
Bnra

Bnra
eap

eap
pn

pn
PAe

PAe
tahs

tahs
ing

ing
Sirkulasi kulit
Skin Perfusion Sirkulasi kulit
Skin Perfusion

Respiratory Distress Shock

 WU

WU
orp

orp
inlace

ne
n

inlac
kaoy

kaoy
arpa

arpa
fa

fa
paem

paem
Bnra

Bnra
eap

eap
pn

pn
PAe

PAe
tahs

tahs
ing

ing
Sirkulasi kulit
Skin Perfusion Sirkulasi kulit
Skin Perfusion

Primary CNS/ Cardiorespiratory

Metabolic failure
Eye opening Motoric response
Spontaneous 4
Spontaneous 6
Verbal 3

Pain 2 Withdrawal with

5
tactile stimulus
No response 1
Withdrawal with
4
Verbal response pain stimulus
Social smile 5
Flexion with pain
3
Crying 4 stimulus
Non stop crying 3
Extension with
2
Agitation 2 pain stimulus
No response 1
No response 1
 Comparison between AVPU and GCS scales

Alert Voice Pain Unresponsive

Eye opening GCS 4 3 2 1

Motor response GCS 6 5 2-4 1

Verbal response GCS 5 3-4 2 1

Total Score GCS 15 11-12 6-8 3

Vascular Access
IO is a rapid, safe and
effective route
Central venous line does
not achieve higher drug
levels or more rapid
response than peripheral
administration
ET drugs administration →
lipid soluble drugs (LEAN)
epinephrine, atropine,
 Emergency Fluids

Use isotonic crystalloid solution to

treat shock
No benefit using colloid during
initial resuscitation
Glucose-containing solution only
for treating documented
hypoglycemia
Medication Dose
Adenosine 0.1 mg/kg (max 6 mg)
repeat 0.2 mg/kg (max 12 mg)
Amiodarone 5 mg/kg IV/IO; repeat up to 15 mg/kg
Maximum 300 mg
Atropine 0.02 mg/kg IV/IO; 0.03 mg/kg ET
Minimum dose 0.1 mg,
Maximum dose Child 0.5 mg; adolescent 1 mg
Calcium Chloride (10%) 20 mg/kg IV/IO (0.2 ml/Kg)
Epinephrine 0.01 mg/kg (0.1 ml/kg 1:10,000) IV/IO
0.1 mg/kg (0.1 ml/kg 1:1000) ET
Max.: 1 mg/kg IV/IO; 10 mg ET
Glucose 0.5-1 g/kg IV/IO
Lidocaine Bolus 1 mg/kg IV/IO; Max. 100 mg
Infusion 20-50 μg/kg per minutes
ET: 2-3 mg
Magnesium sulfate 25-50 mg/kg IV/IO; faster in torsades; Max 2g
Naloxone <5 y or ≤ 20 kg:0.1 mg/kg IV/IO/ET
≥5 y or >20 kg: 2 mg IV/IO/ET
Procainamide 15 mg/kg IV/IO over 30-60 min
Adult dose: 20 mg/min IV infusion up to total
maximum dose 17 mg/kg
Sodium bicarbonate 1 mEa/kg/ dose IV/IO slowly
Remarks
Monitor ECG
Rapid IV/IO bolus
Monitor ECG; give slowly when perfusing rhythm
present. Use caution when administering other drugs
that prolong QT (consider expert consultation)
Higher doses may be used with organophosphate
poisoning
Slowly; Adult dose: 5-10 mL
May repeat q 3-5 min
D10W: 5-10 ml/kg; D25W: 2-4 ml/Kg; D50W: 1-2 ml/kg
Use lower doses to reverse respiratory depression
associated with therapeutic opioid use (1-15μg/kg)
Monitor ECG and blood pressure; Use caution when
administering with other drugs that prologn QT
(consider expert consultation)
After adequate ventilation
 1 PULSELESS ARREST
• BLS algorithm: Continue CPR
• Give oxygen when available
• Attach monitor/defibrillator when available
3 2 9
Shockable Not Shockable
4
VF/VT Shockable rhythm?
10
Asystole/
Give 1 shock Resume CPR immediately
• Manual 2 j/kg Give epinephrine
• AED: >1 year of age 12 • IV/IO 0.01 mg/kg
Resume CPR immediately • ETT: 0.1 mg/kg
• If asystole go to box 10
• If electrical activity, check pulse Repeat every 3-5 min
5 5 cycles CPR
No if no pulse go to box 10 5 cycles CPR
Shockable rhythm? No 11
• if pulse present, begin
6 Yes Shockable rhythm?
post-resuscitation care
Continue CPR while defibrillator 8 13 Yes
is charging Continue CPR while defibrillator Go to
Give 1 shock No is charging box 4
• Manual 4 j/kg 7 Give 1 shock
• AED: >1 year of age Yes • Manual 4 j/kg
Shockable rhythm? • AED: >1 year of age
Resume CPR immediately

5 cycles CPR
Give epinephrine Resume CPR immediately
• IV/IO 0.01 mg/kg Consider antiarrythmics
• ETT: 0.1 mg/kg (e.g. amiodarone 5mg/kg or
Repeat every 3-5 min lidocaine 1 mg/kg)
After 5 cycles CPR go to box 5
 1 Bradycardia with a pulse
Causing cardiorespiratory compromise

2 • Support ABC
• Give oxygen
. Attach to monitor/defibrilator
4 Perform CPR if despite
No 3 Bradycardia still causing Yes oxygenation and ventilation
cardiorespiratory compromise? HR<60/min with
5a poor perfusion
. Support ABC
. Give oxygen if needed No 5 Persistent symptomatic
. Observe bradycardia?
. Expert consultation Yes
6 . Give epinephrine
- IV/IO: 0.01 mg/kg
- ET: O.1 mg/kg
Repeat every 3-5 minutes
. If increased vagal tone
7 If pulseless arrest develops, or primary AV block:
go to Pulseless Arrest Algorithm Give atropine, first dose:
0.02 mg/kg, may repeat.
(minimum dose: 0.1 mg;
maximum total dose for
child: 1 mg)
. Consider cardiac pacing
 1 Tachycardia
with Pulses and Poor Perfusion
. Assess and support ABCs as needed
. Give oxygen
. Attach monitor/defibrilator
3 Symptoms persist 9
Evaluate rythm 2 Possible
QRS < 0.08 sec QRS > 0.08 sec
with 12-lead Evaluate QRS duration Ventricular
ECG monitor Tachycardia
4 5 10
Probable Sinus Tachycardia Probable Supraventricular Tachycardia Synchronized cardioversion:
. Compatible history . Compatible history 0.5-1 J/kg; if not effective,
. P waves present/normal . P waves absent/abnormal increase to 2 J/kg
. Variable R-R; constant P-R . HR not variable Sedate if possible but don’t
. Infant rate < 220 bpm . History of abrupt rate changes delay cardioversion
. Children rate <180 bpm . Infant rate > 220 May attempt adenosine if it
. Children rate >180 bpm does not delay electrical
Search for and 8 Consider vagal
cardioversion
treat cause
. If IV access available: maneuvers 7 11
6 Give adenosine 0.1 mg/kg Expert consultation advised
(max first dose 6 mg) by rapid bolus - Amiodarone 5 mg/kg IV over 20-60 min
May double first dose and give once or
(max second dose 12 mg) - Procainamide 15 mg/kg IV
. Synchronized cardioversion: Do not routinely administer amiodarone
0.5-1 J/kg; if not effective 2 J.kg and prcainamide together
Sedate if possible but dont delay cardioveersion
why do children die?
will critical care change this?
 WHO, 2002

Part of the difficulty is that most 3rd world countries have some 1st and some 3rd world often living side by side with
very different types of conditions and very different expectations of management.
 what critical care
exists at the primary
health care level?
primary health care services
• equipment for pediatric emergency management
– IV fluid administration system
– IV fluids
– oxygen therapy

• NO triage system

• NO official pediatric resuscitation training for

undergraduate doctors

• NO official pediatric resuscitation training for nursing

basic training
 Pediatri Gawat Darurat / Pediatric Critical care

• critical care services for children

–services that provide for the care of critically ill or
injured children

• health services where critically ill or injured children

may present

• emergency medical services

• intensive care services

these exist in order to limit death and disability for children

“…PICU must provide multidisciplinary definitive care for a wide range of complex, progressive, and rapidly
changing medical, surgical and traumatic disorders occurring in pediatric patients of all ages, excluding premature
newborns.”

“Each … PICU should be able to address the physical, psychosocial, emotional, and spiritual needs of patients
with life-threatening conditions and their families”

“Level II PICUs may be necessary to provide stabilization of critically ill children before transfer to another center
or to avoid long-distance transfers for disorders of less complexity or lower acuity. It is imperative that the same
standards of quality care be applied to patients managed ….”

Rosenberg et al, 2004. Crit Care Med

Question ??
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