8. Protection fromProtection from
Communicable DiseasesCommunicable Diseases
Water impermeable apronWater impermeable apron
GownGown
GlovesGloves
Face maskFace mask
CapCap
Eye protection/gogglesEye protection/goggles
Foot coversFoot covers
To prevent contact with body fluids patientsTo prevent contact with body fluids patients
9. Multiple trauma :
50 th – perdarahan hebat, trauma kepala, scalp belakang kepala
terkelupas, trauma dada, open fracture Humerus Dextra.
Tidak sadar, pucat, dingin, basah,
Di UGD nafas ngorok kadang2 tersengal-2. Diberi O2 masker 6lpm
Kondisi yang paling cepat A. Trauma kepala
membuat korban meninggal B. Perdarahan hebat
adalah problem pada : C. Obstruksi (pembuntuan) jalan nafas
D. Gagal ginjal
E. Sepsis
10. • Jika jalan nafas tersumbatJika jalan nafas tersumbat
– 2-3’ kemudian2-3’ kemudian oksigen paruoksigen paru habishabis
• Jika oksigen paru habisJika oksigen paru habis
– 2-3’ kemudian2-3’ kemudian oksigen darah habisoksigen darah habis
• Jika oksigen darah habisJika oksigen darah habis
– 2-3’ kemudian2-3’ kemudian jantung berhentijantung berhenti
11. Pasien obstruksi (A) atau apnea (B)
akan mati dalam 6-9 menit
Pasien shock berat (C)
akan mati dalam 1-2 jam
Pasien coma (D)
akan mati dalam 1 minggu
12. Patient AssessmentPatient Assessment
• Level of consciousness
• Spontaneous efforts vs.
apnea
• Airway and cervical spine
injury
• Chest expansion
• Signs of airway obstruction
• Breath sounds
• Protective airway reflexes
Look, listen, and feel
13. Opening the Airway – theOpening the Airway – the
Triple Airway ManeuverTriple Airway Maneuver
• Slightly extend neckSlightly extend neck
(when cervical spine(when cervical spine
injury notinjury not suspected)suspected)
• Elevate mandibleElevate mandible
• Open mouthOpen mouth
• Consider adjunctiveConsider adjunctive
devicesdevices
14. ReassessmentReassessment
• Adequate spontaneous breathingAdequate spontaneous breathing
– Provide oxygen supplementationProvide oxygen supplementation
• Proceed to manual assisted ventilationProceed to manual assisted ventilation
– Apneic patientApneic patient
– Inadequate spontaneous tidalInadequate spontaneous tidal
volumesvolumes
– Excessive work of breathingExcessive work of breathing
– Hypoxemia with poor spontaneousHypoxemia with poor spontaneous
ventilationventilation
15. Manual AssistedManual Assisted
VentilationVentilation
• Open the airwayOpen the airway
• Apply face mask andApply face mask and
obtain sealobtain seal
• Deliver optimal minuteDeliver optimal minute
ventilation fromventilation from
resuscitation bagresuscitation bag
• Consider cricoid pressureConsider cricoid pressure
• Monitor with pulseMonitor with pulse
oximetryoximetry
16. Single-Handed MethodSingle-Handed Method
of Face Maskof Face Mask
ApplicationApplication
• Base of mask placedBase of mask placed
over chin and mouthover chin and mouth
openedopened
• Apex of mask overApex of mask over
nosenose
• Mandible elevated,Mandible elevated,
neckneck
extended (if no cervicalextended (if no cervical
spine injury), andspine injury), and
downward pressure bydownward pressure by
mask handmask hand
17. Two-Handed MethodTwo-Handed Method
ofof
Face Mask ApplicationFace Mask Application
• Helpful whenHelpful when
mask seal difficultmask seal difficult
• Fingers placedFingers placed
along mandiblealong mandible
on each sideon each side
• AssistantAssistant
providesprovides
ventilationventilation
18. Inadequate Mask-to-Face SealInadequate Mask-to-Face Seal
• Identify leakIdentify leak
• Reposition face maskReposition face mask
• Improve seal along cheek(s)Improve seal along cheek(s)
• Change mask inflation or sizeChange mask inflation or size
• Slightly increase downwardSlightly increase downward
pressure over facepressure over face
• Use two-handed techniqueUse two-handed technique
19. Sumbatan TotalSumbatan Total
FRC (Functional Residual Capacity) = 2500FRC (Functional Residual Capacity) = 2500
mlml
= 2300 ml= 2300 ml
Kadar OKadar O22 15% X 2500 ml = 375 ml15% X 2500 ml = 375 ml
Kebutuhan OKebutuhan O22 permenit = 250 mlpermenit = 250 ml
Bila ada sumbatan totalBila ada sumbatan total OO22 dalam parudalam paru
habis dalam: 375/250habis dalam: 375/250== 1,5 menit1,5 menit
Pengelolaan Perlu:
CEPAT, TEPAT, CERMAT
Pengelolaan Perlu:
CEPAT, TEPAT, CERMAT
AIRWAYAIRWAY
20. Jiwa terancamJiwa terancam
kematian jikakematian jika
• Jalan nafas tersumbatJalan nafas tersumbat
• OO22 tidak lancar masuk ke parutidak lancar masuk ke paru
• Nafas tidak membawa ONafas tidak membawa O22
• Nafas berhentiNafas berhenti
• Kehilangan darah banyakKehilangan darah banyak
• Jantung berhentiJantung berhenti
• Coma, kesadaranComa, kesadaran hilanghilang
dan otak cederadan otak cedera
Masalah pada :
A - Airway
B - Breathing
C - Circulation
D - Dissability
21. Cara membebaskanCara membebaskan
sumbatan jalansumbatan jalan
nafasnafas
• Tanpa alatTanpa alat
– Chin liftChin lift
– Jaw thrustJaw thrust
– (Head tilt)(Head tilt)
Cara yang tidak bolehCara yang tidak boleh
Neck lift pada semua kasusNeck lift pada semua kasus
Head tilt pada traumaHead tilt pada trauma
• Dengan alatDengan alat
– Oropharynx tubeOropharynx tube
– Nasopharynx tubeNasopharynx tube
– Endotracheal tubeEndotracheal tube
– Tracheostomy tubeTracheostomy tube
22. Semua penyebab kematianSemua penyebab kematian
berujung pada masalah A-B-Cberujung pada masalah A-B-C
dapat ditolong dengandapat ditolong dengan
tindakantindakan
A - B - CA - B - C
Jika cepat dikerjakan dengan tepat
besar kemungkinan korban dapat
terhindar dari kematian
Penanganan awal (survey primer,
stabilisasi,resusitasi), sangat menentukan
prognosa dan morbiditas.
23. Life SupportLife Support
A - B - C - DA - B - C - D
AA == airway, bebaskan jalan nafas,airway, bebaskan jalan nafas, lindungi C-spinelindungi C-spine
BB == breathing, beri nafas, tambah oksigenbreathing, beri nafas, tambah oksigen
CC == circulation, shock position, beri infusicirculation, shock position, beri infusi
hentikan perdarahanhentikan perdarahan
DD == disability / SSP, cegah TIK naikdisability / SSP, cegah TIK naik
Quick Diagnosis -- Quick TreatmentQuick Diagnosis -- Quick Treatment
Time saving is life savingTime saving is life saving
Primary Survey
26. Korban sadar atau tidak ?Korban sadar atau tidak ?
→→ ajak bicaraajak bicara
jika suara jelasjika suara jelas
= airway bebas= airway bebas
→→ bebaskan jalanbebaskan jalan
nafasnafas
- chin lift / head tilt- chin lift / head tilt
- jaw thrust- jaw thrust
lihat, dengar, raba nafaslihat, dengar, raba nafas
Tidak ada nafasTidak ada nafas
- berikan nafas buatan- berikan nafas buatan
- berikan oksigen- berikan oksigen
Ada suara tambahan?
Mendengkur, berkumur dll
Ada nafas
algorithm
A- airway
Tak sadarTak sadarSadarSadar
Ada nafas?Ada nafas?
27. Menilai jalan nafasMenilai jalan nafas
• LIHAT - LOOKLIHAT - LOOK
– Gerak dada & perutGerak dada & perut
– Tanda distres nafasTanda distres nafas
– Warna mukosa, kulitWarna mukosa, kulit
– KesadaranKesadaran
• DENGAR - LISTENDENGAR - LISTEN
– Gerak udara nafas denganGerak udara nafas dengan
telingatelinga
• RASA - FEELRASA - FEEL
– Gerak udara nafas dengan pipiGerak udara nafas dengan pipi
( Look - Listen - Feel )
A-AIRWAY
29. Pola NAFAS “ SEE SAW “ tanda ada obstruksi total
30. Sumbatan jalan nafas pasien takSumbatan jalan nafas pasien tak
sadarsadar
paling sering oleh pangkal lidahpaling sering oleh pangkal lidah
INFUS CEPAT 50% SISA “R”
31. head tilt
neck lift
Don’t do Be careful
neck lift
chin lift
Cara membebaskan jalanCara membebaskan jalan
nafasnafas
Pada pasien traumaPada pasien trauma
32. Cara paling amanCara paling aman
dan paling dianjurkandan paling dianjurkan
untuk membebaskanuntuk membebaskan
jalan nafas pada pasien traumajalan nafas pada pasien trauma
33. Chin LiftChin Lift
2 atau 3 jari tepat pada tulang2 atau 3 jari tepat pada tulang
mandibula, bukan padamandibula, bukan pada
jaringan lunakjaringan lunak
x
xSemua prosedure tindakan
Harus dengan cara yg benar
34. CERVICAL IN LINE
Immobilisasi leher sejak ditempat
kejadian.
In-line immobilisation dan collar brace
Perhatikan posisi tangan penolong
35.
36. Syarat untuk TRANSPORTASI pasien cervical
Fixasi dibantu bantal pasir dan pleister dahiFixasi dibantu bantal pasir dan pleister dahi
40. Indications forIndications for
Endotracheal IntubationEndotracheal Intubation
• Airway protectionAirway protection
• Relief of obstructionRelief of obstruction
• Need for mechanical ventilation/ONeed for mechanical ventilation/O22 therapytherapy
• Respiratory failureRespiratory failure
• ShockShock
• Need for hyperventilationNeed for hyperventilation
• Reduce the work of breathingReduce the work of breathing
• Facilitate suctioning/pulmonary toiletFacilitate suctioning/pulmonary toilet
41. PertimbangkanPertimbangkan
INTUBASIINTUBASI
TRACHEATRACHEA
• Bila cara-cara lain untuk AirwayBila cara-cara lain untuk Airway
gagalgagal
• Sukar memberikan nafas buatanSukar memberikan nafas buatan
• Risiko aspirasi ke paru besarRisiko aspirasi ke paru besar
• Mencegah pCOMencegah pCO22 naiknaik
(pada cedera kepala)(pada cedera kepala)
• GCS < 8GCS < 8
42. Airway AdjunctsAirway Adjuncts
• Laryngeal mask airwayLaryngeal mask airway
– Bowl-shaped cuff that fits inBowl-shaped cuff that fits in
hypopharynxhypopharynx
– Single or multiple use devicesSingle or multiple use devices
• Esophageal-tracheal combitubeEsophageal-tracheal combitube
– May be used in cardiorespiratoryMay be used in cardiorespiratory
arrestarrest
– Requires adequate trainingRequires adequate training
LMA
43. Indications forIndications for
Endotracheal IntubationEndotracheal Intubation
• Airway protectionAirway protection
• Relief of obstructionRelief of obstruction
• Need for mechanical ventilation/ONeed for mechanical ventilation/O22 therapytherapy
• Respiratory failureRespiratory failure
• ShockShock
• Need for hyperventilationNeed for hyperventilation
• Reduce the work of breathingReduce the work of breathing
• Facilitate suctioning/pulmonary toiletFacilitate suctioning/pulmonary toilet
44. Preparation for IntubationPreparation for Intubation
• Assess degree of difficulty for intubationAssess degree of difficulty for intubation
• Assure optimal ventilation andAssure optimal ventilation and
oxygenationoxygenation
• Consider gastric decompressionConsider gastric decompression
• Analgesia, sedation, amnesia,Analgesia, sedation, amnesia,
neuromuscular blockade as neededneuromuscular blockade as needed
45. Degree of DifficultyDegree of Difficulty
AssessmentAssessment
• Neck mobilityNeck mobility
• External faceExternal face
• MouthMouth
• Tongue and pharynxTongue and pharynx
• JawJaw
• Consider options for obtaining anConsider options for obtaining an
airway that maintain ventilationairway that maintain ventilation
• Obtain expert assistanceObtain expert assistance
46. Airway & Ventilation Methods: ALSAirway & Ventilation Methods: ALS
Assessing the Possibility of
Difficulty in Intubation
⇑ Difficulty
47. Airway & Ventilation Methods: ALSAirway & Ventilation Methods: ALS
• What effect wouldWhat effect would
the angle of thethe angle of the
mandible have onmandible have on
intubation difficulty?intubation difficulty?
51. Intubasi tracheaIntubasi trachea
juga membawa risikojuga membawa risiko
besarbesar
• Hipoksia karena spasme pita suaraHipoksia karena spasme pita suara
• Tekanan darah naikTekanan darah naik
• Aritmia, bradikardia sampai asistoleAritmia, bradikardia sampai asistole
• Tekanan Intra Kranial naikTekanan Intra Kranial naik
• Gerak leher memperberat cederaGerak leher memperberat cedera
cervicalcervical
Idealnya, intubasi dibantu obat anestesia danIdealnya, intubasi dibantu obat anestesia dan
obat pelumpuh otot (harus tenaga ahli)obat pelumpuh otot (harus tenaga ahli)
52. 1.1. Tulang leher mungkin cederaTulang leher mungkin cedera
2.2. Pasien meninggal karena kurangPasien meninggal karena kurang
oksigenoksigen
bukan karena tidak intubasi tracheabukan karena tidak intubasi trachea
3.3. Pasien hipoksik, trauma kepala + kejangPasien hipoksik, trauma kepala + kejang
→→ sering rahang terkatup eratsering rahang terkatup erat
Jika dipaksa laringoskopi berakibat :Jika dipaksa laringoskopi berakibat :
- TIK naik- TIK naik
- herniasi otak- herniasi otak →→ fatalfatal
I N G A T
58. • Jika pasien sadar, ajak bicaraJika pasien sadar, ajak bicara
– bicara jelasbicara jelas
= tak ada sumbatan= tak ada sumbatan
• Berikan oksigen (jika ada)Berikan oksigen (jika ada)
– masker 6 lpmmasker 6 lpm
• Jaga tulang leherJaga tulang leher
– baring datar, wajah ke depan, leher posisinetralbaring datar, wajah ke depan, leher posisinetral
• Nilai apakah jalan nafas bebasNilai apakah jalan nafas bebas
– adakah suara snoring, gargling, crowingadakah suara snoring, gargling, crowing
PRIORITAS UTAMA ADALAHPRIORITAS UTAMA ADALAH
JALAN NAFAS BEBASJALAN NAFAS BEBAS