Pathophysiology of dying

Eddy Rahardjo
Guru Besar Anestesiologi dan Reanimasi
Fak Kedokteran Univ Airlangga
RS Dr Sutomo Surabaya

Seorang pasien dibawa ke IGD

Kita periksa
tidak bergerak
tidak bernafas
suara jantung tidak terdengar
pupil midriasis

Dx: DOA, dead on arrival

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Mengapa Anda memberi diagnose:

Mati?
Karena dulu di Fak Kedokteran diajarkan
tanda mati :
tidak sadar
tidak bergerak
tidak bernafas
tidak ada detak jantung

Apakah orang yang Sdr anggap mati itu

memang mati atau dianggap mati ?
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 Pada peradaban purbakala dulu ..

Orang tidak sadar, tidak bergerak,
tidak bernafas = mati

Orang purbakala ini berfikir:

Apakah memang mati?
Atau mungkin Dx saya salah?
Maka orang itu disimpan beberapa hari
Jika tetap tidak sadar, tidak bergerak,
tidak bernafas = benar-benar mati
Barulah orang itu dikubur
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sekarang tahun 2000 Masehi ini, kita

mencoba untuk menunda mati
Orang tidak bergerak, tidak bernafas =
belum tentu mati beri nafas buatan
Jika nadi carotis tidak berdenyut =
belum tentu mati pijat jantung
Disimpan beberapa hari (di ICU)

tetap tidak sadar, tidak bergerak,

nafas dipompa mesin
jantung berdenyut karena dibantu obat

Kapan pasien begini ini boleh dianggap mati ??

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The study of the critically ills

By understanding how people die
We can identify factors causing death

We then know how to stop the dying process

We can reverse the dying process = reanimation

Trauma
berat

Hidup
normal

Stroke, Infark

Hidup
normal kembali

Critically ill

Infeksi berat

Mati
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Basics for Life Support

Apakah pasien yang dinyatakan mati
itu benar mati?
Kenapa perlu Life Support ?
Agar pasien tidak mati prematur

Past experience
Assumption
Perception

influence

MINDSET
|
State of mind
which affects
the way people
THINK - FEEL - ACT
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sel otak
berhenti kerja
|
|
aliran darah
tidak sadar
terhenti

sel otak rusak

sel otak mati

limited reversibility

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 Setelah O2 untuk sel otak habis, pasien jatuh

tidak sadar, tetapi masih bisa diselamatkan
selama sel otak belum rusak
the viability of the brain defines human life.
When O2 supply stops:
dysfunction after 10-30 seconds
start of irreversible damage in 5-20 minutes
After 5 minutes brain glucose stores and ATP are
used up
Safar, 1986
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Process of anoxic brain injury

Deprivation of substrate plus deprivation of
oxygen injured neurons more than either
one separately
Injured neurons release cytotoxic
compounds into the extracellular fluid,
which might propagate injury
(Retinal) neurons tolerate up to 20 minutes
of complete ischemic anoxia
Safar, 1986

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Is there any exception,

that 20 minutes is maximum tolerance?

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Resusitasi

Tenggelam 30 menit,
tidak sadar, tidak bernafas,
dingin, biru

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Hidup
Recovery

|
Cardiac
Arrest

5 minutes

Vegetative
state

Mati
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Mati adalah proses yang perlu waktu

Kalau kita sigap, ada kematian yang
bisa dibatalkan

Alive
Vegetative
state

Clinical
death
Cerebral
death
Brain
death

Fungsi :
otak berfungsi
tubuh berfungsi

Biological
death

stop

rusak

mati

mati

berfungsi

berfungsi

berfungsi

mati

16 /63

Alive

1. Clinical death
Clinical
death

Apnea plus cardiac arrest, with

all cerebral activity suspended
but not irreversibly so

The early period of death, with

early optimal resuscitation
restoration of all vital organ
functions including normal
brain function is possible
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Alive

2. Cerebral death

Cerebral
death

Cortical death,
irreversible necrosis,
particularly the neocortex
Coma but spontaneous
breathing
Associated with deep
vegetative state

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Persistent Vegetative State

Social death (apallic syndrome)
Irreversible brain damage, remains
unconscious and unresponsive, but has
an active EEG and some intact reflexes
This is to be distinguished from
cerebral death (EEG is silent)
brain death (all cranial nerve reflexes and spontaneous
breathing are absent)

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3. Brain death

Alive

Brain
death

Most medical and legal

authorities define death in
terms of brain death, though
the heart is still beating and
artificial ventilation is
maintained.

Biological
death

4.

Biological death

Pan-organic death =
real death

Organ transplant
from cadaver

Cerebral death plus necrosis

of the rest of the brain

organ transplant from braindead-heart-beating donor

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Konsep-konsep dalam Life Support

Apnea mati
beri nafas buatan

Cardiac arrest mati

pijat jantung, DC shock
heart to good to die

Coma mati
brain resuscitation
brain to good to die

C
P
R

C
P
C
R

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Life Support (dulu)

A - airway
B - Breathing
C - circulation
Safar, Bircher et al 1968
A-B-C ATLS 1978
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Life Support (sekarang)

A - airway
B - Breathing
C circulation
D defibrillation, drug
E ECG, arrhythmia control

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Basics for Life Supports

CPR is to buy time
membeli waktu agar pasien masih sempat
hidup untuk diberi terapi definitif /causal

CPR must be provided by ALL medical

specialization
CPR for everyone, CPR by everyone

24 /63

30%
20%

5%

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Mengapa mengejar survival yang hanya 5% ?

Tehnologi yang berkembang menjanjikan hasil lebih baik

Extra corporeal membrane oxygenation

(ECMO)
Hypothermia

30%
20%

5%

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27

Decreasing level of ATP ----------------------

Ventricular fibrillation ------------------ Fine VF Asystole

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mmol/kg d-w

If you can not increase the production of ATP

Then try to reduce its usage

ATP

Hypothermia

* p<0.05 vs BL

30-20--

Base Line

VF
10 min

CC
6 min

Post Resusc
60 min
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The chain of Survival

Early
Access

Early
BLS

Early
Defib

Early
ALS

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Pijat jantung yang baik, hanya mencapai

30% dari Cardiac Output Normal

Push hard
- 4-5 cm
Push fast
-100 x pm

Pijat 30 x
Nafas 2 x
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 In sudden adult cardiac arrest, ventricular

fibrillation (VF) happens in 2/3 of all
VF is fatal unless defibrillation is given.
CPR does not stop VF but CPR extends the
window of time in which defibrillation can be
effective.
CPR provides a trickle of oxygenated blood to
the brain and heart and keeps these organs
alive until defibrillation can shock the heart into a
normal rhythm.

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 If CPR is started within 4 minutes of collapse

and defibrillation provided within 10 minutes
40% chance of survival.
CPR followed by defibrillation within 2 to 3
minutes of collapse up to 50% survival rates
With each minute of delay, chance of survival
decreases by 7 - 10 percent.

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Early defib / early DC shock meningkatkan

survival
Kalau ada Defib tersedia, segerakan
melakukan DC shock
Pijat jantung dikerjakan sambil menunggu
siapnya DC shock

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 Anda tidak harus jadi ahli Resusitasi / CPR

Tetapi Anda bisa berperan banyak untuk
mencegah agar pasien jangan sampai
perlu CPR

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Pathophysiology of Dying and Reanimation

(Safar, 1984)
mengajarkan Knowledge and Skill Proficiency
1. Primary Prevention:
Cegah jangan Cardiac Arrest
Pelajari Peri-arrest management
2. Secondary Prevention:
Jika Cardiac arrest, maka cepat aktifasi
Early BLS, Early Defib, Early ALS
ROSC in less than 5 minutes
3. Tertiary Prevention:
Setelah ROSC Prolonged Life Support di ICU
to bring recovery with good quality of life
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