ARTIFICIAL CIRCULATION

(CARDIAC MASSAGE)
( P I JAT JAN T U N G )

Dr. Tommy Sunartomo, SpAn K.IC

Lab / SMF Anestesiologi & Reanimasi

FK. Unair RSU Dr. Soetomo
Surabaya

Jude & Kouwenhoven (1961)

Closed chest resuscitation :
138 cardiac arrest in hospital
107 ROSC

People hearts stop beating everyday

For many people

Their hearts / brains should be

Too Good To Die

Resuscitative effort can restore these hearts

to spontaneous activity before the brain
has been permanently injured

K E S E H ATAN R U M A H S A K I T
1986, 1992 DAN 1995
Kematian jantung Urutan 2
Kematian trauma
Urutan 4
Kematian jantung di Jakarta
1991 2535 orang
1992 2746 orang
1993 2961 orang
1994 3255 orang
1995 1283 orang (sampai Maret)
Kematian kecelakaan lalu lintas di Indonesia
1991 10.621 orang
1992 9.819 orang
1993 10.038 orang
1994 11.004 orang
1995 9.251orang (sampai Maret)

CPCR / RJPO
(Peter Safar)

asic life support emergency oxygenation

A : Airway
B : Breathe
C : Circulate
dvanced life support Restoration of spontaneous
rculation
D : Drugs and Fluids
E : EKG
F : Fibrillation treatment
rolonged life support post resuscitation brain
riented therapy
G : Gauging
H : Human Mentation
I : Intensive care

KONSEP ATLS
Primary Survey
A : Airway with C-spine control
B : Breathing with ventilation
C : Circulation with hemorrhage control
D : Disability : neurologic status
E : Exposure / environment with temperature control
Resuscitation
Secondary Survey
Head to toe evaluation and history
Reevaluation
Definitive care

KEY POINTS ACLS

In the Primary Survey, focus on basic CPR and
defibrillation
First A-B-C-D
Airway
:
Open the airway
Breathing:
Provide positive pressure ventilations
Circulation :
Give chest compressions
Defibrillation :
Shock ventricular fibrillation or pulseless
ventricular tachycardia (VF/VT)

KEY POINTS ACLS

In the Secondary Survey, focus on intubation,

ntravenous (IV) access, and drugs and
why the cardio respiratory arrest occurred

Second A-B-C-D
Airway
:
Perform endotracheal intubation
Breathing:
Assess bilateral chest rise and ventilation
Circulation :
Gain IV access, determine rhythm, give
appropriate agents
Differential Diagnosis (Think):
Search for, find, and treat reversible causes

Reversible Cardiac Arr est

The clinical picture of overall cessation of
circulation
Unconsciousness
Apnea or gasp
Death like appearance (cyanosis or pallor)
Diagnosis Cardiac Arrest (No pulse)
Adult :
Carotid
Femoral
Infant small children :
Brachial
Femoral

Perabaan nadi carotis

dari tengah ke-lateral

Awam : tidak perlu

meraba carotis

Complete Cessation of Circ

15 second Unconsciousness
15 30
Isoelectric EEG
30 60
Agonal gasping
Apnea
Max pupillary dilatation
> 5 minute cerebral damage

TimesavingisLifesaving

Cardiac Arrest
Primary :
Ventricular Fibrillation
Asystole
Heart Block
Electric Shock
Drugs
Secondary :
Rapid :
Asphyxia
Exsanguination
Acute Pulmonary Edema
Oxygen Free Gas
Slow :
Hypoxemia
Shock
EMD

ARTIFICIAL CIRCULATION

CLOSED CHEST

THORACIC
PUMP

CARDIAC
PUMP

OPEN CHEST

ARTIFICIAL CIRCULATION

Heart Pump
Mechanism

Chest Pump
Mechanism

Squeezing the heart

Between sternum
and Spine

Overall intra-thoracic
Pressure fluctuation

Closed Chest CPR

Cardiac output
30% Normal
Carotid artery blood flow
Cerebral Blood Flow (CBF)
CBF :
Near zero without CPR
50% N Maintain consciousness
20% N Maintain cell Viability
Coronary P.P and blood flow Low
Right atrial pressure
Tungkai dibuat lebih tinggi

Closed Chest CPR

( Pijat Jantung Luar )

Titik tumpu
Teknik memijat
Monitoring
Komplikasi

Titik Tumpu
Pada tulang dada
Dewasa :
2 jari kranial proc. Xyphoideus (2000)
Tengah Toraks (2005)
Tengah sternum distal (2010)
Bayi :
Tengah sternum
Garis inter mammary

ILCOR
International Liaison Committee on Resuscitation
Guidelines 2005
Main changes in adult basic life support
Start CPR when victim is unresponsive and
not breathing normally
Place the hands on the centre of the chest
Two rescue breaths, 1 sec each rather than 2 sec
The ratio of compressions to ventilations is 30 : 2

ILCOR - Guidelines 2005 - 2010

CIRCULATION
Titik tumpu pijat jantung disternum ditengah
dada (2005)
Setengah sternum bagian distal (2010)
Pijat jantung 100x per menit,
diprioritaskan agar tidak ada sela.
- Pijat jantung 100x /men, nafas buatan 10x
/men
- Bila masih belum terintubasi :
Ratio pijat jantung dan nafas 30 : 2
- Dua atau satu penolong tidak dibedakan

Chest CompressionOnly
CPR
Treatment Recommendation

All rescuers should perform chest compressions for all patients in

cardiac arrest.
Chest compressions alone are recommended for untrained laypersons

Professional rescuers should provide chest compressions with

ventilations for cardiac arrest victims

Performing chest compressions alone is reasonable for trained

laypersons if they are incapable of delivering airway and breathing
maneuvers

There is insufficient evidence to support or refute the provision of chest

compressions plus airway opening and oxygen insufflation by
professional rescuers during the first few minutes of resuscitation

2010 ILCOR

Titik tumpu pijat

jantung adalah
disternum
Di tengah2 dada

titik tumpu
pijat jantung

Guidelines 2005 :
place the hands on the centre
of the chest

Using the rib margin method

is wasting time

Titik tumpu pijat jantung

Tumit 1 tangan
diletakkan diatas
sternum,
kemudian
tangan satunya
diletakkan diatas
tangan yang sudah
berada di-titik
pijat jantung
(di-tengah2 dada)

Jari-jari kedua tangan dirapatkan

dan diangkat pada waktu dilakukan tiupan nafas,
agar tidak menekan dada.

Pijat jantung
Penolong
mengambil
posisi
tegak
lurus
di atas dada
korban dengan
siku lengan lurus

Menekan tulang
dada sedalam
kira-kira4-5 cm.
etiap melepas 1 pijatan ,
ngan jangan masih menekan dada korban

100x per menit

4-5 cm

Pijat jantung nafas buatan

aat pijat jantung,

itung dengan suara keras

atu,dua,tiga,empat, SATU
atu,dua,tiga,empat, DUA,
atu,dua,tiga,empat,TIGA
atu,dua,tiga.empat,EMPAT
atu,dua,tiga,empat,LIMA
atu,dua,tiga,empat,ENAM

otal = 30 x pijatan
ang disela dengan 2 x tiupan nafas

30 : 2

Pijat jantung nafas buatan

30 : 2

Lakukan 30 kali pijat jantung

dengan diselingi
2 kali nafas buatan ini berulang
selama 2 menit
Setelah 2 menit (7-8 siklus) raba
nadi leher.
Bila masih belum teraba denyut
nadi leher, lanjutkan 30 x pijat
jantung dan 2 x nafas buatan
Lakukan tindakan ini terus sampai
datang bantuan atau ambulans

Teknik Memijat
Dewasa :
Tumit telapak tangan
Dua tangan
Anak :
Tumit telapak tangan
Satu tangan
Bayi : Dua jari ( Jari II + III )
Posisi tegak lurus
Kedalaman memijat :
Dewasa
: 1,5 2,0 inch (4 - 5 cm)
Anak
: 1,0 1,5 inch (2,5 4 cm)
Bayi
: 0,5 inch (1 2 cm )
Waktu memijat = waktu relaksasi
Frekwensi 100 / m (cepat dan kuat)

nasi Pijat Jantung + Nafas B

Guidelines 2000

1 Penolong :
15 pijat jantung (Frek. 80 100 / m)
2 nafas buatan (1-2 detik / nafas buatan)

2 Penolong :
15 pijat

jantung (frek.80 100 / m)

2 nafas buatan (1-2 detik / nafas buatan)
Setelah di intubasi Pijat Jantung 100x/menit Nafas
Buatan
12 - 20x/menit di sela sela pijatan.
Guidelines 2005 - 2010
1 atau 2 penolong = 30 : 2 Frek. 100 / m

Satu penolong
Tahun 2000 :

Tahun 2005,2010 :

30 : 2

Dua penolong
Tahun 2000 :

Tahun 2005,2010:

30 : 2

Korban tidak
sadar

1.

A.

bebaskan jalan
nafas

B.

jalan nafas bebas

tidak bernafas

2.

3.

C.

Call for help

2 x tiupan awal
raba nadi carotis

tidak teraba nadi

4.

beri pijatan
jantung
dan nafas buatan

awam
5.

Pasang
monitor EKG
( di RS )

Korban tidak sadar

A.

BLS

bebaskan jalan nafas

head tilt- chin lift- jaw thrust

Guideline 2010

Call for help

jalan nafas bebas

tidak bernafas

raba nadi carotis

B.

2 x tiupan awal
tidak teraba nadi

C.
B.

Beri pijatan jantung

dan nafas buatan
30 pijat + 2 nafas

pijat
jantung
(-)
30x

Bila
Karotis

= awam
2005 guideline

 CIRCULATION
Pijat dulu baru tiup
Pijat jantung yang pertama tanpa terlebih dahulu meraba karotis
Titik tumpu pijat jantung pada setengah bagian bawah sternum.
Bila belum di intubasi atau dipasang LMA, maka setiap 30 pijatan
jantung diselingi 2 kali tiupan nafas ( ratio 30 : 2 )

Bila sudah di-intubasi Pijat jantung 100x per menit, diprioritaskan

agar tidak ada sela. Push Hard, Push Fast
Pijat jantung 100x /men, nafas buatan 10x /men.
Beri kesempatan dinding toraks untuk re-coil setelah pijatan
Jika trachea sudah di-intubasi tak usah sinkronisasi antara pijat
dan nafas
Dua atau satu penolong tidak dibedakan

Monitoring
Nadi carotis oleh pemberi nafas
Intermitten
2 menit berikutnya ( 7 8 siklus )
Pupil
Ukuran
Refleks
Di RS.
EKG
Pulse oximetri
BGA
Tensi nadi
Perfusi organ
ETCO2

Komplikasi

Patah tulang iga

Patah tulang dada
Cedera jantung
Cedera paru
Cedera pembuluh darah
Cedera organ abdomen

New Techniques
IAC CPR =
Interposed Abdominal Compression CPR
Vest CPR =
Circumferential Vest Compression CPR
ACD CPR =
Active Compression Decompression CPR
Open Chest CPR

Drugs
Class I : Definitely Helpful
Class II a : Acceptable, Probably Helpful
Class II b : Acceptable, Possibly Helpful
Class III : Not Indicated, May be harmful

Adrenalin / Epinephrin
Obat Simpatomimetik
Vasokonstriktor
Vasopresor
Pilihan utama pada cardiac arrest (CPR)
Efek dan
=
Vasokonstriksi sistemik tidak pada koroner dan
otak
tahanan perifer
tekanan sistole dan diastole aliran ke otak dan
otot jantung
=
konstriksi otot jantung
irama jantung
Bronko dilatasi

Epinephrine / Adrenaline
Indications :
Cardiac arrest : VF, pulseless VT, asystole, PEA, (Class I)
Sympatomatic :
Bradycardia : after Atropine and transcutaneous pacing (class II b)
Dosage :
Cardiac arrest :
First dose : 1,0 mg / IV push repeat every 3 5 min
Alternative regimens for second dose (class II b)
Intermediate : 2 5 mg / IV push every 3 5 min
Escalating : 1 mg, 3 mg, 5 mg / IV push (3 min apart)
High : 0,1 mg / kg / IV push, every 3 5 min
Endotracheal route :
2,0 2,5 mg diluted in 10 ml normal Saline
Profound Bradycardia :
2 10 mg 1 min (1mg in 500 ml normal Saline 1 5 ml / min)

Atropine Sulfate
Indications
First drug for sympatomatic bradycardia (class II a)
Second drug (after Epinephrine) for Asystole or
Bradycardic PEA (class II a)
Dosage
Asystole or PEA
1 mg / IV push repeat every 3 5 min
Max dose 0,03 0,04 mg / kg
Bradycardia
0,5 mg 1,0 mg / IV every 3 5 min
Max dose 0,03 0,04 mg / kg
Endotracheal administration
2 3 mg diluted in 10 ml normal Saline

Lidocaine
Indications
Cardiac arrest from VF / VT (class IIa)
Stable VT, wide-complex tachycardias wide complex
PSVT (class I)
Cardiac arrest from VF / VT
Initial dose : 1,0 1,5 mg / kg IV
For refractory VF repeat 1,0 1,5 mg / kg IV in 3 5
min, total dose : 3 mg / kg
A single dose of 1,5 mg / kg IV in cardiac arrest is
acceptable
Endotracheal administration : 2 4 mg / kg

Sodium Bicarbonate
Indications
Class I :
If known pre existing Hyperkalemia
Class II a :
If known pre existing Bicarbonate Acidosis (EG. Diabetic
Keto Acidosis)
If overdose with tricyclic anti depressants to Alkalinize the
urine drug overdose
Class II b :
If intubated and continued long arrest interval
Upon return of spontaneous circulation after long arrest
interval
Class III :
Hipoxic Lactic Acidosis (EG. Cardiac arrest and CRP without
intubation
Dosage
1 mEq / kg IV bolus repeat half this dose every 10 min blood
gas analysis evaluation

DC shock
Oles dulu paddles
dengan jelly
ECG tipis rata,
baru kemudian :
1. Switch ON
Pasang paddles pada
posisi apex dan
parasternal
(boleh terbalik)

sternum

apex

2. Charge 360 Joules

(Non-synchronized)

DC shock

Ucapkan dengan keras :

Awas semua lepas dari pasien!

nafas buatan berhenti dulu
bawah bebas,
samping bebas,
atas bebas,
saya bebas!

3. Shock!!
(tekan dua tombol paddles bersama)

Lepas paddles dari dada,

lanjutkan chest compression.
4. Segera pijat jantung lagi 2 menit
baru raba lagi/ baca lagi ECG

sternum

apex

Position
of the paddles electrodes
on thorax of an infant

sternum

apex

Size of paddle electrode

- 4.5 cm diameter for infants and small children
- 8-12 cm diameter larger children

Jelly kurang rata, menekan paddles kurang kuat - luka bakar

VT / Ventricular Tachycardia
|
|

carotis (+)
Lidocain
1 mg/kg iv cepat
atau
Amiodaron 300 mg

carotis (-)

CPR 30:2 - 5 SIKLUS

a single shock
360 Joules
dst

Managemen VT/ VF

Defibrillation
Indications
VF
( class I )
Pulseless VT ( class I )
Guidelines 2000
Dosage
200 Joule : first shock
200 300 J
: second shock
360 J
: third shock
If fail to convert VF / VT continue at 360 J for future shock
If VF recours, shock again at the last successful energy level
Guidelines 2005 , 2010
Mono phasic 360 J
Bi phasic 150 J 200 J

 CPR dilakukan sambil menunggu datangnya DC shock

De-FIBRILLATION / DC shock
DC shock sedini mungkin (sebelum 5-10 menit)
360 Joules 1x (dulu 3x shock, repeated shock)
(Jika DC shock biphasic 150-200 Joules)

Setelah a single shock, segera CPR lagi 2 menit tanpa

check ECG sudah ROSC atau belum
Baru setelah 2 menit CPR, berhenti sebentar untuk
check ECG apakah sudah ROSC
76

Electrical Therapy
1. Simple chest thump
Witnessed VT / VF
2. Repetitive chest thumps
Heart block
3. Cardioversion
(synchronized electric counter shocks)
AF, PSVT
VT with pulse
4. Non synchronized electric counter shocks
VT without pulse
VF
5. Pacing
Heart block
Asystole

cardiac arrest membandel ???

4H
4T
MA

Hipoksia
Hipovolemia
Hiperkalemia
Hipotermia
Tamponade jantung
Tension
pneumothorax
Thromboemboli
paru
Toxic overdose
B-block, Ca-block
Digitalis, Tricyclic
AD

ASYSTOLE/ PEA/ EMD

Intubation
(LMA): as soon as possible, without stop compression
Cardiac
arrest

2 menit

CPR -1
30 : 2
CALL
FOR
HELP
PASANG
MONITOR
EKG

evaluasi

evaluasi

ASYST

CPR-2
Adrenalin-1

2 menit

CPR-3

Pijat 100x/menit
Nafas 10x/menit
evaluasi

2 menit

CPR-4
Adrenalin-2

Adrenaline: 1 mg, iv,

repeated every 3-5
minutes

evaluasi
2 menit

CPR-5

CPR-6
Adrenalin-3

Evaluasi CPR : tiap 2 menit

VF/ VT-pulseless
Intubation/
LMA : as soon as possible, without stop compression
Cardiac
arrest

adrenalin

a single shock-I

CALL
FOR
HELP
PASANG
MONITOR

CPR-2

adrenalin

2010

2 menit
CPR -1
30 : 2

adrenalin

VF / VT

Pijat 100x/menit
Nafas 10x/menit

2 menit

a single shock-II
CPR-3

2 menit

2 menit

a single shock-III - AMIODARON a single shock-V

- a single shock-IV
CPR-4

Adrenaline: 1 mg, iv,

repeated every 3-5
minutes

Evaluasi CPR : tiap 2 menit

CPR-5

CPR-6

Amiodaron is the first choice

300 mg, bolus. Repeated 150 mg
for reccurrent VT/VF. Followed by
900 mg infusion over 24 hours
Or LIDOCAIN 1mg/kg. Can be
repeated. Do not exceed a total dose of
3 mg/kg,during the first hour.

APRIL ANESTESI

TERIMA KASIH