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 CLINICAL DEATH — a patient
is clinically dead the moment
breathing stops and the heart stops
patient is not breathing and the heart
is not circulating oxygenated blood,
potentially lethal changes begin to
take place in the brain within 4 to 6
minutes. Biological death occurs
when the patient's brain cells die.
Usually, brain cell death begins within
10 minutes after the heart stops
beating (this can be delayed by cold
temperatures, see p. 489). You may be
able to reverse clinical death, but
biological death is irreversible.
Respiratory System Anatomy
• The major structures of the airway include:
 NOSE — the primary pathway for air to enter and leave the system.
 MOUTH — the secondary pathway for air.
 PHARYNX — the throat.The common passageway for air and food.
 LARYNX — the neck structure that connects the pharynx and the
 TRACHEA — the windpipe.
 BRONCHIAL TREE — branching from the trachea to the
microscopic air sacs of the lungs. The first branches are the right and
left main stem (primary) bronchi. These branch into secondary
bronchi. The smaller branches coming off the secondary bronchi are
called the bronchioles
 LUNGS — the spongy, elastic organs containing alveoli, the
microscopic air sacs where oxygen and carbon dioxide exchange takes
Respiratory Function
 automatic function
 Involuntary
 automatically adjust the rate, depth,
and rhythm of breathing
 intercostal muscles
 inspiration
 expiration

 Simply stated, respiratory failure is  To determine the Signs of normal

either the cessation of normal breathing, you should:
breathing or the reduction of  LOOK for the even (bilateral) rise and
breathing to the point where oxygen fall of the chest associated with
intake is not sufficient to support life. breathing.
When breathing stops completely,  LISTEN for air entering and leaving the
nose or mouth. The sounds should be
the patient is in respiratory arrest.
typical, free of gurgling, gasping,
 Respiratory arrest can develop during crowing, and wheezing.
heart attack, stroke, airway  FEEL for air moving out of the nose or
obstruction, drowning, electrocution, mouth.
drug overdose, poisoning, brain  CHECK for typical skin coloration.
injury, severe chest injury, There should be no blue or gray
suffocation, and prolonged colorations.
respiratory failure.  NOTE that the rate and depth of
breathing should be typical for a
person at rest
• Chest movements are absent, minimal, or uneven.
• Movements associated with breathing are limited to the abdomen
(abdominal breathing).
• The use of neck muscles during respirations.
• No air can be felt or heard at the nose or mouth, or exchange is
evaluated as below normal.
• Breathing is noisy.
• The breathing rate is too rapid or too slow
• Breathing is very shallow or very deep and
• The patient's skin is blue or gray. This is called cyanosis.
• Inspirations are prolonged (possible upper airway obstruction) or
expirations are prolonged (possible lower airway obstruction).
• The patient is unable to speak or cannot speak in a normal fashion
• Opening the Airway
 Head-Tilt Maneuver

 Head-Tilt, Chin-Lift Maneuver

 Jaw-Thrust Maneuver
Mouth-to-Mouth Ventilation
Primarily, this procedure is used when the
patient is in respiratory arrest, that is, when he
is no longer breathing. The procedure may be
used when a patient's respiratory rate or depth
is not sufficient to sustain life
IMPORTANT: For artificial respirations provided
to the adult patient, you must deliver breaths •
to the patient at one every 5 seconds to give a
rate of 12 breaths per minute. To help establish
this rate, count, "One, one thousand; two, one
thousand; three, one thousand; four, one
thousand; five, one thousand.

adequately ventilating the patient if you:

 SEE the chest rise and fall.
 HEAR and FEEL air leaving the patient's lungs.
 FEEL resistance to your ventilations as the patient's lungs expand.
Airway Management
 Endotracheal Intubation
 Direct Laryngoscopy
 Stylet Guide (Introducer)
 Fibreoptic Bronchoscopic Intubation
 Blind Nasal Intubation
 Cricothyroidotomy
 Tracheostomy
Intubation difficulty can be anticipated or predicted by the following (although
the sensitivity and specificity, of individual features and classifications tends to
be low):
1. Anatomical or pathological features of difficult intubation in subjects who
otherwise appear normal:
 short neck, especially if obese or muscular (thyro-mental distance <6 cm)
 limited neck and jaw movements (e.g. as a result of trismus,
osteoarthritis, ankylosing spondylitis, rheumatoid arthritis or perioral
 protruding teeth, small mouth, long high curved palate, or receding lower
 space-occupying lesions of the oropharynx and larynx
 congenital conditions with any of the above features (e.g. Marfan's
2. Mallampatti classification of visualizing the oropharyngeal structures
(a co-operative sitting patient is required for this assessment):
a) Class 1: visible soft palate, uvula, fauces and pillars
b) Class 2: visible soft palate, uvula and fauces
c) Class 3: visible soft palate and base of uvula
d) Class 4: soft palate is not visible

3. The degree of difficult)' experienced visualizing the larynx by direct

laryngoscopy should be recorded and is commonly graded by the
classification of Cormack and Lehane:
a) Grade I: complete glottis is visible
b) Grade II; anterior glottis is not visible
c) Grade III: epiglottis but not glottis is visible
d) Grade IV: epiglottis is not visible
Clinical conditions associated with acute Laryngeal oedema
upper airway obstruction Allergic laryngeal oedema, angiotensin
Functional causes converting enzyme inhibitor associated,
Central nervous system depression hereditary angioedema, acquired CI
Head injury, cerebrovascular accident, esterase deficiency
cardiorespiratory arrest, siiock, hypoxia, Haemorrhage and haematoma
drug overdose, metabolic Postoperative, anticoagulation therapy,
encephalopathies inherited or acquired coagulation factor
Peripheral nervous system and deficiency ,
neuromuscular abnormalities Trauma
Recurrent laryngeal nerve palsy Burns
(postoperative, inflammatory or tumour Inhalational thermal injury, inger.tion of
infiltration), obstructive sleep apnoea, toxic chemical and caustic agents
laryngospasm, myasthenia gravis, Neoplasm
Guillain-Barre polyneuritis, Pharyngeal, laryngeal and
hypocatcaemic vocal cord spasm tracheobronchial carcinoma, vocal cord
Mechanical causes polyposis
Foreign body aspiration Congenital
Infections Vascular rings, laryngeal webs, laryngocele
Epiglottitis, retropharyngeal cellulitis or Miscellaneous
abscess, Ludwig's angina, diphtheria Cricoarytenoid arthritis, achalasia of the
and tetanus, bacterial tracheitis, oesophagus, hysterical stridor,
laryngotracheobronchitis myxoedema
Indikasi Manajemen Jalan Napas
Tujuan manajemen jalan napas adalah patensi dan proteksi
dengan memasang ETT dalam trakea dengan mengembangkan cuff
dan dihubungkan dengan sumber O2. Tindakan intubasi sering kali
menyebabkan komplikasi dan tergantung dari berbagai faktor. Ada 5
alasan mengapa pasien membutuhkan jalan napas :
• Gagal ventilasi atau oksigenasi
• Ketidakmampuan mempertahankan atau melindungi jalan napas
• Timbulnya gangguan yang disebabkan oleh penyakit pasien
• Delivery of treatment
• Keamanan dan perlindungan pasien (patient safety and protection)
Manajemen jalan napas
Immediate "crash" intubation
• Pasien dengan henti napas yang membutuhkan intubasi segera tanpa
medikasi tambahan. Keuntungan tindakan ini secara teknik mudah dan
cepat. Kerugiannya dapat meningkatkan tekanan intrakranial akibat stres
intubasi, muntah dan aspirasi.

Rapid sequence intubation

• Rapid sequence intubation (RSI) adalah serangkaian langkah tindakan
intubasi tanpa ventilasi BVM. Sebagian besar pasien yang dilakukan
intubasi darurat tidak dalam keadaan puasa dan dengan lambung terisi,
sehingga pemakaian BVM mungkin dapat menyebabkan distensi abdomen
dan meningkatkan risiko aspirasi. Untuk mencegah komplikasi pertama
kali dilakukan pemberian O2 100% agar O2 terpenuhi selama periode
apnea. Selanjutnya dilakukan induksi dan pemberian pelumpuh otot kerja
cepat agar pasien tidak sadar dan paralisis. Lalu pasien diintubasi tanpa
bantuan ventilasi BVM. Agar lebih mudah diingat, langkah-langkah RSI
disingkat dengan 9P
9 langkah P Rapid sequence intubation
Time Action
0 – 10 minutes Possibility of success
0 – 10 minutes Preparation
0 – 5 minutes Pre-oxygenation
0 – 3 minutes Pre-treatment
Time zero Paralysis (with induction)
0 + 20 – 30 seconds Protection and positioning
0 + 45 seconds Placement
0 + 45 seconds Proof
0 + 1 minute Post-intubation management