TIK :

1. Cara mendiagnosis kejang demam

2. Algoritme penanganan kejang demam di fasilitas

layanan primer

3. Kriteria rujukan kasus kejang demam

4. Hal-hal yang perlu diperhatikan atau dipersiapkan

dalam merujuk kasus kejang demam
KEJANG DEMAM

Kejang Demam (KD): bangkitan kejang akibat pe suhu > 380

oleh karena proses ekstrakranium

Terbagi dua :

1. Simple Febrile Convulsion (KD sederhana)

2. Complex Febrile Convulsion (KD kompleks):

KD yg berlangsung > 15 menit, > 1 x kejang per episode demam

BUKU AJAR, NEUROLOGI ANAK, IDAI

 KRITERIA KD SEDERHANA
(KRITERIA LIVINGSTON)

1. Umur anak ketika kejang 6 bln- 4 thn

2. Kejang berlangsung < 15 menit
3. Kejang bersifat umum
4. Kejang terjadi dalam 16 jam pertama demam
5. Pemeriksaan neurologis normal
6. Pem EEG 1 mgg setelah suhu normal tidak ada kelainan
7. Frekuensi kejang dlm 1 tahun < 4 kali

BUKU AJAR, NEUROLOGI ANAK, IDAI

STATUS KONVULSIVUS

Kejang yang berlangsung > 30 menit atau kejang berulang

selama > 30 menit, selama kejang pasien tidak sadar.

Kasus rujukan rawat PICU

SPM Kesehatan Anak,2009

 TATALAKSANA
Prinsip terapi:
1. Pengobatan Fase Akut
2. Mencari dan mengobati penyebab
3. Pengobatan profilaksis terhadap berulangnya kejang
Indikasi Rawat Inap :
1. Kejang Demam Kompleks
2. Hiperpireksia
3. Usia dibawah 6 bulan
4. Kejang Demam pertama kali
5. Terdapat kelainan neurologis

SPM Kesehatan Anak,2009

 PENGOBATAN FASE AKUT
1. Tdk sesak Recovery Position

2. Bebaskan Airway

3. Oksigen 1-2 ltr/mnt

4. Awasi Tanda Vital

5. Demam kompres dan antipiretik

6. Mengobati Penyebab penyakit

7. Pilihan utama diazepam (rektal atau iv)

SPM Kesehatan Anak,2009

ALGORITME PENANGANAN KEJANG
KEJANG

PPREHOSPITAL Diazepam 5-10 mg rektal 0-10 menit

Max 2x jarak 5 menit

Monitor
Airway, Breathing O2, Diazepam 0,25-0,5 mg/kg/iv/io
HOSPITAL/ED 10- 20 menit
Circulation Kec 2 mg/mnt, mx dosis 20 mg

Tanda vital
EKG
Lorazepam 0,05-0,1 mg/kg/iv Gula Darah
NOTE : jika diaz rectal 1 x Atau
Kec : < 2 mg/mnt Elektrolit serum
prehospital, boleh rectal 1 x lagi (Na,K, Ca, Mg)
Analisa Gas Darah
Koreksi kelainan
Pulse Oxymetri
KEJANG (-)
5-7 mg/kg Kadar obat
12 jam kemudian 20- 30 menit
Fenitoin 20 mg/kg/iv dalam darah
(Kec 20 menit/50 ml NS)
Dosis max 1000 mg
NOTE :
PICU/ED Additional 5-10
mg/kg/i

Fenobarbital 20 mg/kg/iv 30- 60 menit

KEJANG (-) (Kecepatan > 5 10 menit, dosis
4-5 mg/kg 12 jam kemudian max 1 gr )

PICU/ICU REFRAKTER

Midazolam 0,2 mg/kg/iv bolus

Pentotal Tiopental 5-8 mg/kg/iv Propofol 1 5 mg/kg/infusion
Lanjut infus 0,02 0,4 mg/kg/jam

SPM Kesehatan Anak,2009

SESAK PADA ANAK
TIK :
1. Cara mendiagnosis sesak pada anak
2. Algoritme penanganan sesak pada anak di fasilitas
pelayanan primer
3. Kriteria rujukan kasus sesak pada anak
4. Hal-hal yang perlu diperhatikan atau dipersiapkan dalam
merujuk kasus sesak pada anak
IDENTIFIKASI ANAK DENGAN KESULITAN NAPAS
Anamnesis Umur Laju/menit
Pemeriksaan fisik :
1. Napas cepat ( takipnue)
2. Retraksi interkostal, subcostal, suprasternal Neonatus 30 60
3. Penggunaan otot napas bantu (head bobbing)
4. Posisi tripod
1-6 bulan 30 - 50
5. Pernapasan cuping hidung
6 12 bulan 24 - 46
6. Bunyi napas saat inspirasi dan expirasi
(stridor, wheezing, grunting, ronki)
1- 4 tahun 20 - 30

4 6 tahun 20 25

6 12 tahun 16 - 20

> 12 tahun 12 16
 PENYEBAB SESAK PADA ANAK

Laringomalasia

Aspirasi benda asing

Edema laring : anafilaksis, trauma inhalasi

Infeksi saluran napas atas : epiglotitis, croup, abses retrofaringeal

Penyebab di saluran napas bawah : asma, bronkiolitis, bronkitis, pneumonie, efusi

pleura, pneumotoraks dll

Penyebab di luar saluran napas : gagal jantung, anoksia jaringan, dll

TANDA TANDA BAYI DAN ANAK DENGAN RESIKO HENTI NAPAS :

Peningkatan laju napas, peningkatan usaha napas, menurunnya suara napas

Bila laju napas sangat rendah (bradipnue) tanda imminent respiratory arrest atau

keracunan obat narkotik

Agitasi, Penurunan kesadaran atau respon terhadap nyeri

Tonus otot rangka melemah

Sianosis
 ALGORITME PENANGANAN SESAK PADA ANAK

ACUTE BREATHING DIFFICULTY

Presence of pre-terminal sign YES Check :

Or signs requiring urgent attention Airway
(tabel 1 &2 ) Breathing
Circulation
NO

Measure respiratory rate for 60 sec

& oxygen saturation
Start Basic Life Support +
Call Appropriate team for advance
Life Support
If O2 sat 92%, give Oksigen and admit
Continue with algorithm whatever oxygen
Saturation level is recorded
Admit to HCU/PICU

Admit if severe distress

Sign of increase work (table 4)
YES
of breathing( Table 3) Stridor/wheezing YES
or cough?
NO
NO Mild/moderate distress (table 4)
Sign of serious illness? (table 5)/ YES Admit if complicating factors/serious
Complicating factors (table 6) Illness (table 5 &6)

NO
Upper respiratory tract infection
Home with GP follow up, Patient education
Call back instruction
Discuss with senior Dr
Consider alternative diagnoses (Table 10)
Arreange appropriate investigation
Admit
Table 1. Pre terminal sign
Table 2. Sign of severely ill child require
urgent attention
Bradycardia
Inappropriate drowsiness (difficult to rouse)
Silent Chest
Exhaustion Agitation
Significant apnoea Cyanosis

Table 3. Signs of increase work of breathing

Increase respiratory rate

Chest in drowing (retraction)
Nasal Flaring
Tracheal tug
Use of accesory muscles
Grunting
Table 4. Assessment of severity of breathing difficulty adapted from WHO
Management of acute respiratory infection in children.WHO, Geneva 1995
Assesment of severity (breathing difficulty)

Mild Moderate Severe

Oxygen saturation in air > 95% 92 95% < 92%

Chest wall in drawing None/mild moderate Severe

Nasal flaring Absent May be present Present

Grunting Absent Absent Present

Apnoea/pausing None Absent Present

Feeding history Normal Approximately half of Less than half normal

Normal intake intake

Behavior Normal Irritable Lethargic,

unresponsive, Flaccid
Decrease of
consciousness
Inconsolable
 Table 5. Symptoms of serious illness (adapted from Viral Upper Respiratory Tract Guideline by
Institute for Clinical System Improvement and the WHO recommendation on the management
of children with cough or breathing difficulty

< 3 months 3 months 3 years 4 years - adult

Responsiveness and activity : Responsiveness and activity : Responsiveness and activity :

Flaccid Unresponsive Decrease level of consciousness
Cant keep awake Cant keep awake Markedly decrease activity
Weak cry or weak suck Markedly decrease activity Cant keep awake
Inconsolable Inconsolable
Refuse feeding Weak suck or weak cry
Refuse feeding

Dehydration and Vomiting Dehydration and Vomiting Dehydration and Vomiting

Reduced wet nappies > 8 hours No urine > 6-8 hours if < 1 year No urine > 12 hours
No urine > 12 hours if > 1 year

Meningeal Sign Meningeal Sign

Stiff neck Stiff neck
Persistent vomiting Persistent vomiting
Severe headache
Other Other Other
Petechial or purpuric rash Petechial or purpuric rash Decrease urination with decrease
Convulsion Convulsion intake
Very high fever Very high fever un responsive to Petechial or purpuric rash
Hypotermia treatment Convulsion
Capillary refill < 3 sec Capillary refill < 3 sec Very high fever un responsive to
treatment
Capillary refill < 3 sec
 Table 6. Factors contributing to the clinicians decision regarding admission or discharge
Complication Factors

Co-morbidity e.g prematurity, congenital heart disease, any chronic lung disease, neurological disorder

Infants younger than 2 months of age

Special problems e.g previous non-accidental injury, ill parents, parents having difficulty coping

Table.10. Differential diagnosis of less obvious causes of respiratory distress

(Adapted from Fleischers Textbook of Emergency Medicine, Chapter 65)
Metabolic Disorder Central Nervous Neuromuscular Chest Wall Disorder
System Disfunction Disorder

Diabetes Mellitus Meningitis Spinal Cord injury Flail chest

Dehydration Encephalitis Infantile botulism Congenital Anomalies

Sepsis Tumour Guillian barre synd
Liver/Renal disease Intoxication Myopati
Intoxication Status Epilepticus
Inborn error of metabolism Trauma
Hydrocephalus
 BASIC LIFE SUPPORT

Unresponsive
Not breathing or only gasping
Send someone to activate emergency
Response system, get AED/defibrilator
Open Airway

AHA, 2010
DIARE DENGAN DEHIDRASI BERAT
TIK :
1. Cara mendiagnosis diare dehidrasi berat
2. Algoritme penanganan diare dehidrasi berat di
fasilitas pelayanan primer
3. Kriteria merujuk kasus diare dehidrasi berat
4. Hal-hal yang perlu diperhatikan atau
dipersiapkan dalam merujuk kasus diare
dehidrasi berat
 DIAGNOSIS DIARE DEHIDRASI BERAT
Tabel 1. Classification of the severity of dehydration in children with diarrhoea

Classification Sign or symptom Treatment

Severe Two or more of the following sign: Give fluid for severe
Dehydration Lethargy/unconsciousness dehydration (table 2)
Sunken eye
Unable to drink or drinks poorly
Skin pinch goes back very slowly ( 2
second)

Some Two or more of the following sign: Give fluid and food for some
Dehydration Restlessness, irritability dehydration
Shunken eyes After rehydration, advise
Drinks eagerly, thirsty mother on home treatment
Skin pinch goes back slowly and when to return
immediately
Follow up in 5 days if not
improving
No Dehydration Not enough sign to classify as some or Give fluid and food to treat
severe dehydration diarrhoea at home
Advise mother on when to
return immediately
Follow up in 5 days if not
improving

Pocket book of Hospital Care for Children, WHO

Table 2. Administration of IV fluid to a severely dehydrated child

First, Give 30 ml/kg in : Than, give 70 ml/kg in :

< 12 months old 1 hour 5 hours

12 months old 30 minutes 2 hours

Pocket book of Hospital Care for Children, WHO

ALGORITME DIARE DEHIDRASI BERAT
Can you give
Intravenous (IV)
Fluid immediately
NO
Start IV fluid immediately. If the child can drink give ORS by mouth while the drip set up.
Give fluid according table 2
Reassess the child every 15-30 minutes. If hydration status not improving, give the IV drip more rapidly
Also give ORS (about 5 ml/kg/hour) as soon as the child can drink, usually after 3-4 hours (infants)
or 1-2 hours (children)
Reassess an infant after 6 hours and a child after 3 hours. Classify dehidration. Then choose the
appropriate plan to continue treatment

YES Refer URGENTLY to hospital for IV treatment

Is IV treatment If the child can drink, provide the mother with ORS solution and show her how to give frequent sips
Available nearby during trip
(within 30 minutes)

NO

Are you trained to use Start rehydration by tube (or mouth) with ORS solution : give 20 ml/kg/hour for 6 hours
A nasogastric tube for (total 120 ml/kg)
Rehydration? YES Reassess the child every 1-2 hours
- if there is repeated vomiting or increasing abdominal distension, give the fluid more slowly
NO - if hydration status is not improving after 3 hours send the child for IV therapy
After 6 hours reassess the child. Classify dehydration. Then choose the appropriate plan to
Continue treatment
Can the child drink?

NO

Refer URGENTLY to
Hospital for IV
or NO treatment

Pocket book of Hospital Care for Children, WHO

TRANSPORTASI PASIEN
 Indikasi Transport Pasien
Indikasi medis
Penanganan di level yg lebih tinggi
Personil
Peralatan
Keahlian
Tindakan lain

Permintaan keluarga

Transport balik
 TRANSPORT PASIEN ANAK

Transport pasien terbagi 2 :

1. Intrahospital (transport dalam RS)

2. Interhospital (transport antar RS)

Resiko dapat dikurangi bila melakukan transport dengan :

1. Perencanaan transport yang matang

2. Menggunakan personil tim yang qualified

3. Penggunaan alat medis yang sesuai

4. Selama transportasi tanda vital pasien di awasi

Ad.1. Intrahospital Transport

Koordinasi dan komunikasi pretransport ( kesiapan menerima rujukan, hand over, dokumen
rekam medis)

Peralatan yang dibawa : monitor TD, pulse oxymetri, cardiac monitor, alat airway
management, oksigen, bag valve mask, obat-obat resusitasi dasar, cairan intravena, alat
dengan baterai harus sdh di charge

Bila dokter tidak bisa menemani maka dapat digantikan oleh personil yang telah dilatih
menangani kondisi emergency

Monitoring selama transport (tanda vital, pulse oxymetri, continues ECG bl tersedia)
Ad.2. Interhospital Transport
Mempertimbangkan risk and benefit dari transfer. Informed consent yg tlhg di tanda
tangani dalam rekam medis
Koordinasi Pretransport dan komunikasi (kontak dgn RS rujukan, memilih cara
transport, hand over kondisi pasien, pem penunjang lain)
Personil yang menemani : minimal 2 org tenaga kesehatan. Psn kondisi kritis team
leader adl dokter atau perawat, diharapkan yang mengetahui BLS
Peralatan medis minimal yang harus dibawa (tabel 1 dan 2)
Monitoring pasien selama transport continous pulse oxymetri, monitor tensi dan
tekanan darah, monitoring electrocardiographic
Mempersiapkan pasien utk transport interhospital : diperlukan evaluasi dan stabilisasi
pasien. Semua pasien kritis memerlukan akses intravena, resusitasi cairan dan
inotropik
Sblm transfer pasien evaluasi airway dan stabilisasi airway (orofaringeal tube,ETT).
NGT ileus atau intestinal obstruksi
Kateterisasi urin pada pasien yg restriksi cairan atau diberi diuretik
 Assess Patient Condition, is patient stable
NO
YES
Provide resuscitation and other measures as
Assess need fo transfer, Indicated & to degree possible :
Are resource at current facility a. Secure airway
adequate to adress patient needs b. Intravenous access
YES
NO c. Fluid resuscitation
d. Laboratory/ X-ray evaluation
Compare benefits and risk of transfer
is patient a candidate to transfer NO
YES Continue current management plan

Select receiving facility :

a. Distance
b. Resource NO
c. Bed availability
d. Patient preference
Idenify and communicate with receiving physician
Has transfer been accepted?
YES
Obtain informed consent/family notificaation
Select mode of transfer (air, or gound or river)
a. Cost
b. Patient acuity
c. Distance
d. Weather condition
Mobilize necessary personnel, transfer equipment & phamaceuticals
Nurse-to-nurse report to receiving facility
Copy Medical record for receiving facility

Initiate transport
Patient sedation as needed
Restraint as needed
Medical record keeping during transport
Follow protocol
Communications with medical command as needed
Figure 1. Interfacility transfer algorithm.
When completed, evaluate transfer for quality improvement
 Vehicle Advantages Disadventages

Ambulance Banyak tersedia Transit time meningkat

Hy 2 kali transfer pasien Macet, cuaca
Mampu utk beralih arah Peralatan kdg tdk lengkap
Lebih murah

Helicopter Cepat Butuh heliport

Dpt menjangkau daerah yg Kapasitas bahan bakar
sulit terbatas
Tempat kecil, ribut
Mahal
Fixed wing Cepat utk jarak jauh Empat kali transfer pasien
Gangguan cuaca Landasannya panjang
Ukuran cabin cukup besar Harga mahal
Jarak jauh > 150 miles