dasar penanganan gawat darurat
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DASAR PENANGANANPENDERITA GAWATAnestesiologi dan Reanimasi
RSUD Tasikmalaya
Anestesiologi dan ReanimasiRSUD Tasikmalaya
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T P UPeserta mampu menangani penderita gawat darurat dengan baik danbenar
T P KPeserta mampu :1. Mengenal penderita gawat darurat
2. Mengetahui macam-macam penyebab kegawat daruratan3. Memahami sistematika penanganan penderita gawat darurat4. Mendiagnosa kegawatan jalan nafas / airway5. Menangani kegawatan jalan nafas / airway6. Mendiagnosa kegawatan nafas / breathing
7. Menangani kegawatan nafas / breathing8. Memberikan terapi oksigen9. Mendiagnosa gangguan sirkulasi10. Menangani gangguan sirkulasi11. Mendiagnosa gangguan kesadaran12. Menangani gangguan kesadaran
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Penderita Gawat DaruratPenderita yang oleh karena suatu penyebab
(penyakit, tindakan, kecelakaan)bila tidak segera ditolong akan cacat,kehilangan anggota tubuh atau meninggal
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Silent epidemic
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Mass-casualties small scale disaster
Kecelakaan kereta apiMan-made disaster
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Complex
disaster
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Complex disasterKerusuhan
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Natural disaster
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Triage dan evakuasiSiapa didahulukan dan siapa dikirim ke mana
4 korban Ratusan korban
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SURVAI KESEHATAN RUMAH SAKIT (SKRT)1986 DAN 1992 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
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USA : TRAUMA Trauma penyebab kematian ketiga setelah cancer
dan atheroselerosis
Usia 1- 44 tahun (produktif) penyebab kematian pertama
Jumlah kecelakaan : 60 juta / tahun
30 juta perlu perawatan medik
3,6 juta perlu MRS
9 juta cacat :
3000.000 permanen
8.700.000 temporer
Kematian 145.000 / tahun
Traumarelated costs > $ 100 milyar / year
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HASIL SURVEY DI PROPINSI :NTT, KALBAR, KALTENG, SUMUT, BENGKULUNo.1.2.3.
4.5.6.7.
8.9.
Macam KasusTrauma / kecelakaan lalu lintasDiareMalariapanaskejang
ISPAbatuksesakStroketidak sadarTBCbatuk darahsesakJantunghipertensi, infark
Obsgynperdarahan, eklampsiaIntoksikasigigitan ular - peptisida
% Kasus20 %17 %
15,6 %
12,2 %8,6 %7,7 %7,6 %
6,4 %4,9 %
Trauma : 25 %Non trauma : 75 %
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CHAIN OF SURVIVALEarly Activation of EMS
Early Basic of CPR
Early Defibrillation
Early Advanced Life Support
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PENDERITA GAWAT DARURAT
HIPOKSEMIAHIPERKARBIA
HENTI JANTUNGHENTI NAFAS
SINDROMA IWR
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CONCEPT ABCDEapproach to evaluation / treatment
Treat greatest threat to life first
Definitive diagnosis not immediately important
Time is of the essence
Do no further harm
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INITIAL ASSESSMENT / MANAGEMENT
Injury
Primary survey and adjuncts
Resuscitation
Reevaluation
Secondary survey and adjuncts
Reevaluation
Optimize patient status
Transfer
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Primary survey and resuscitationof vital functions are donesimultaneously a team approach
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PENANGANAN PASIEN TIDAK GAWAT Anamnesa Pemeriksaan fisik Inspeksi Palpasi
Perkusi Auskultasi
Pemeriksaan penunjang Diagnosa
Terapi Supportif Simtomatis Definitif / kausal
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PENANGANAN PASIEN GAWAT DARURAT Pem. Fisik awal (A-B-C-D)(Primary survey) + Lab. Awal
Terapi suportif / resusitasi (life support)
Stabilisasi
Pem. Fisik sekunder(Secondary survey) Anamnesa Dari kepala s/d kaki (B1 s/d B6)
Pemeriksaan penunjang
Diagnosa
Terapi defenitif
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CPCR / RJPO (Peter Safar)1. Basic life support emergency oxygenation
A : AirwayB : BreatheC : Circulate2. Advanced life support Restoration of spontaneouscirculationD : Drugs and FluidsE : EKGF : Fibrillations treatment
3. Prolonged life support post resuscitation brain oriented therapyG : GaugingH : Human mentation
I : Intensive care
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KONSEP ATLS Primary Survey
A : Airway with C-spine controlB : Breathing with ventilationC : Circulation with hemorrhage controlD : Disability : neurologic status
E : Exposure/environment with temperature control
Resuscitation
Secondary SurveyHeadtotoe evaluation and history
Reevaluation
Definitive care
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KEY POINTS ACLSIn the Primary Survey, focus on basic CPR anddefibrillation
First A-B-C-D
Airway :Open the airway
Breathing :Provide positivepressure ventilations
Circulation :Give chest compressions
Defibrillation:Shock ventricular fibrillation or pulselessventricular tachycardia (VF/VT)
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KEY POINTS ACLS
In the Secondary Survey, focus on intubation,intravenous (IV) access, and drugs andwhy the cardiorespiratory arrest occurred
Second A-B-C-D
Airway :Perform endotracheal intubation
Breathing :Assess bilateral chest rise and ventilation
Circulation :Gain IV access, determine rhythm, giveappropriate agents
Defibrillation Diagnosis (Think):Search for, find, and treat reversible causes
PENANGGULANGAN PENDERITA GAWAT DARURAT
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PPGD (Penanggulangan penderita gawat darurat) Dokter umum
BLSALS
PLS
NLS
ACLS HIGH RISKHIGH FREQUENCY
HIGH SUCCESS
PROCEDURE
- PRIMARY PREVENTION- SECONDARY PREVENTION
LOCAL SPECIFIC
- MALARIA
- DHF
- GE
BLS : Basic life support (A, B, C, BRAIN)
ALS : Advance life support
ATLS : Advance trauma life support (Trauma oriented L.S)
ACLS : Advance cardiac life support (Cardiac oriented L.S.)
NLS : Neonatal life support
PLS : Pediatric life supportOLS : Obstetric life support
PTC
OLS
PTC : Primary trauma care
A : Airway
B : Breathing
C : Circulation
Dsan: Dokter spesialis
Anestesi
PENANGGULANGAN PENDERITA GAWAT DARURAT
Basic General Emergency Life Support (GELS)
ATLS
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LIFE SUPPORTA : Airway SupportB : Breathing SupportC : Circulation SupportD : Disability / Brain Support
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First responder
Life saver
Resusitasi
stabilisasi
AirwayBreathing
CirculationBrain
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SHOCK
KARENA
PERDARAHAN1
2
3
Resusitasi
Stabilisasi
Definitif terapiawal
Definitif terapi
akhir
Dr. Penyakit PerdarahanDalam G.I.
Dr. Bedah
Perdarahantrauma
Dr. Obgyn
Perdarahan post partum
Dr.
Umum
Dr.
Spesislias
Pembagian Peran Dr. UmumDr. Spesialis
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PROTECTION FROM COMMUNICABLEDISEASE Water impermeable apron Gown
Gloves Face mask Cap Eye protection / goggles
Foot covers
To prevent contact with body fluids patients
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T P UPeserta mampu melakukan pengelolaan jalan nafas.
T P KPeserta mampu :-Mendiagnosa sumbatan jalan nafas/airway
-Mengetahui penyebab sumbatan jalan nafas/airway-Mengelola sumbatan jalan nafas- tanpa alat- dengan alat
A (AIRWAY)
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PRIORITAS UTAMA
AirwayBebas dan terjaga
Breathing / ventilationAdekuat
Supplemen oxygenAdekuat
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PRIMARY SURVEY
Establish patent airway
Caution sign :
Cervical spine injury
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PRIMARY SURVEY
Assume C-Spine Injury
Multisystem trauma
Altered level of consciousness
Blunt injury above clavicle
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SUMBATAN JALAN NAFASPenyebab
Penurunan kesadaran Tindakan anestesi Koma
Trauma kepala Radang otak Obat / alkohol dll
Suatu penyakit Laringitis Edema laring
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sumbatan jalan nafas
Trauma / Kecelakaan Maksilofacial Jalan nafas
dll
Benda asing Darah
Muntahan Makanan dll
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Macam
ParsialRinganBerat
Total
sumbatan jalan nafas
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SUATU SEBAB
PENDERITATAK SADAR
RELAKSASIOTOT HILANG REFLEKSPERLINDUNGAN
LIDAH KLEP
SUMBATANJALAN NAFAS MUNTAHREGURGITASI
ASPIRASI
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SUMBATAN JALAN NAFAS
Look / Lihat Perubahan Status Mental
Agitasi / gelisah HipoksemiaObtundasi / teler Hiperkarbia
Gerak NafasNormalSee saw / rocking
Retraksi Deformitas
DebrisDarah / sekretMuntahanGigi
Sianosis
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SUMBATAN JALAN NAFAS
Listen / Dengar Bicara normal Tak ada sumbatan Ada suara tambahan
Snoring LidahGurgling CairanStridor / crowing Penyempitan
Suara parau (hoarseness / dysphonia)
Feel / Raba Hawa nafas Krepitasi / fraktur (maxillofacial / laryngeal) Deviasi trakhea Hematoma
Getaran di leher
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MACAM SUMBATAN
SUMBATAN
BEBASPARSIAL RINGANPARSIAL BERAT
TOTAL
LOOKGERAKNAFAS
NORMALNORMALSEE SAWSEE SAW
LISTENSUARATAMBAHAN
FEELHAWAEKSHALASI+
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PENGELOLAAN PERLU :CEPAT, TEPAT, CERMATSumbatan Total :FRC (Functional Residual Capacity) : 2500 ml Kadar O2 15% x 2500 ml : 375 ml
Kebutuhan O2 permenit : 250 ml
Bila ada sumbatan total O2 dalam paru habis dalam: 375 / 250 : 1,5 menit
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PENYEBAB SUMBATAN Lidah
Epiglotis
Benda asing / muntahan / darah / sekret
Trauma jalan nafas
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PEMBEBASAN JALAN NAFAS
PENYEBAB LIDAH Manual :
- Non trauma :Head tiltNeck liftChin liftJaw thrust- Trauma :Chin liftJaw thrust
Dengan in-line manual immobilization atau
pasang cervical collar
Bantuan Alat- Oropharyngeal airway- Nasopharyngeal airway
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Pada pasien trauma
head tilt
neck lift
Dont doBe careful
neck lift
chin lift
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JAW THRUST
dianjurkan
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Oro-pharyngeal tube
Perhatikan ukuran
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1 2
3 4
OROFARINGEALTUBE
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Naso-pharyngeal tube
Tidak merangsang muntah
Ukuran u/ dewasa 7 mm atau
jari kelingking kanan
Nasopharyngeal tube
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NASOFARINGEAL
TUBE
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PEMBEBASAN JALAN NAFASPENYEBAB BENDA ASING
Manual
Penghisap
Definitive airway
Pada chocking :
Back blows Abdominal thrust (Heimlich manuver) Thoracal thrust Cricothyroidotomy
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Lima kali hentakanpada punggung,diantara dua scapula
CHOKING
Back blows
CHOKING
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CHOKING
HeimlichAbdominal trust
Korban : sadar
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Korban : Tidak sadar
Heimlich Abdominal trust
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DEFINITIVE AIRWAY
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DEFINITIVE AIRWAYCuffed tube in trachea
Secure airway
Ventilation
Types :
- Endotracheal intubation- Surgical airway - Cricothyrotomy
- Tracheotomy
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Membrana cricothyroid
Pada keadaan gawat darurat
- Tempat injeksi transtracheal
obat emergency- Tempat untuk
needle dan surgicalcricothyroidotomi
Bagaimana caranya ??Obat apa saja boleh masuk ??
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DEFINITIVE AIRWAYIndications
1. Apnea
2. Risk of aspiration
3. Insecure airway
4. Poor oxygenation
5. Impending airway compromise
7. Closed head injury
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TUJUAN INTUBASI ENDOTRAKHEAL1. Sebagai jalan nafas
2. Untuk oksigenasi
3. Untuk pemberian ventilasi
4. Mencegah aspirasi
5. Jalan pemberian obat (intra trakheal)6. Bronchial toilet
MACAM INTUBASI ENDOTRAKHEAL Orotrakehal Lewat mulut
Nasotrakheal Lewat hidung
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ENDOTRACHEAL INTUBATION
The trachea should be intubated by properlytrained personnel
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PERALATAN INTUBASI ENDOTRAKHEHAL Laryngoscope dengan blade yang sesuai Tube dengan ukuran yang sesuai Jelly Anestetik lokal / spray
Forcepsmagill Bite block / oropharyngeal airway Adhesive tape / tali Suctionmetal yang kauer Connectors Synringe (20 cc) Stylet Stetoscope End tidal CO2 monitor
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INTUBASI
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INTUBASI ENDOTRAKHEALOksigenasi + ventilasi (5 menit) Alat dan obat siap
Harus berhasil kurang 30 detik
Bila > 30 detik belum berhasil oksigenasi + ventilasi ulang
Penolong tak kuat tahan nafas Saturasi O2 menurun
Monitoring :
Saturasi O2 (Pulse oxymeter)
End-tidal CO2 (Capnografi)
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PEDIATRIC
Airway AnatomyCraniofacial diproportion Large occiput cervical flexion Obligate nasal breather Narrow nasal passages Small oral cavity Large tongue Adeno tonsillar hypertrophy
Horseshoe shaped epiglotis Larynx anteriorcauded angle Trachea short
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T P UPeserta mampu menangani kegawatannafas/breathing
T P KPeserta mampu :-Mendiagnosa kegawatan nafas-Mengetahui penyebab kegawatan nafas-Mengelola kegawatan nafas
- tanpa alat- dengan alat
B (BREATHING)
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GANGGUAN VENTILASIPenyebab
Tindakan anestesi Penyakit Kecelakaan trauma
LokasiSentral
Pusat nafas Perifer
Jalan nafas Dinding dadaParu Otot nafasRongga pleura Syaraf & jantung
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GANGGUAN VENTILASI(penderita masih bernafas)
Look / LihatSianosis Takhipnea
Status mental Distensi vena leherAsimetri dada Paralisis otot nafas
Listen / dengarKeluhan: Tak bisa nafas!
Stridor, wheeze atau hilang suara nafas
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Feel / rabaHawa ekspirasi
Emfisema subkutanKrepitasi / tenderness / nyeri
Deviasi trakhea
AdjunctsPulse oximeter
CO2 detectorGas darahX-ray dada
gangguan ventilasi(penderita masih bernafas)
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HipoventilationMinute volume berkurang
Hiperventilation
Minute volume meningkat
Parameter ventilasiPaCO2 N= 3545 mmHg
Hipoventilasi PaCO2
Hiperventilasi PaCO2
.beberapa istilah
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DASAR PEMBERIAN VENTILASI Intermittent positive pressure ventilation (IPPV)
Penderita tak bernafasNafas buatan (controlled ventilation)
Penderita masih bernafas / tak adekuatNafas bantuan (assisted ventilation)Diberikan pada akhir ekspirasi
Tekanan oropharing > 25 cm H2O udara masuk esophagus distensi lambung
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.dasar pemberian ventilasi
Sellicks maneuverMenekan cricoid kebelakang sehingga esophagusterjepit diantara cricoid dan corpus vertebra leher
Agar :Udara tak masuk lambungIsi lambung tak mengalir ke oropharingTak boleh pada cedera tulang leher
Nafas buatan :Tidak volume 10-15ml/kgFrequensi 12-15 / m
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CARA PEMBERIAN VENTILASITanpa Alat
Mouth to mouthMouth to noseMouth to mouth and nose
Dengan AlatSafar airwayEsophageal obturator airway
Face mask / pocket maskLaryngeal maskBag-valve-maskBag-valve-tube
Ventilator
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Nafas buatan
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Nafas berhenti
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Nafas ada
SUPPLEMENTAL OXYGEN
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1. Nasal cannula / prongLowflow systemFlow O2: 1-6 L/mFiO2 : 24-44% (1 L O2/M FiO2 4%)2. Face maskLawflow systemFlow O2: 8-10 L/m
FiO2 : 40-60 %3. Face mask with oxygen reservoirConstantflowFlow O2: 6-10 L/mFiO2 : 6L O2 / m + 60 % ((1 L O2/M FiO2 10%)
4. Venturi maskHigh gas flowFixed oxygen concentrationFlow O2 & FiO2 diatur24 %, 28%, 35% dan 40%
Masker sederhanaDengan reservoir bagFlow O2 : 6-10 lpmFiO2 : 60%- 100%
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Terapi oksigen
NASAL PRONGO2 flow 1 6 lpmFiO2 : 24 44 %
BAG VALVE MASK (BVM)
Dgn oksigen 8-10 lpm : 60%
BVM Dengan reservoir bagFlow O2 : 8-10 lpmFiO2 : 80%- 100%
Jackson ReesFlow O2 : 8-10 lpmFiO2 : 100%
BVM Dengan reservoir bagFlow O2 : 8-10 lpmFiO2 : 80%- 100%
FACE MASK O2 8-10 lpmFiO2 : 40-60%
TRACHEO BRONCHIAL SUCTIONING
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Preoksigenasi 100% 5 menit
Alat hisap :
Setting suction: -80 -120 mmHg
Soft catheter (steril) + lobang pengatur
Tindakan aseptis sesuai prosedur
Tak lebih 15 detik
Diselingi oksigenasi 100% 30-60 detik
Komplikasi
Hipoksemia Cardiac arrest aritmia
Stimulasi simpatis Hipertensi takhikardia
Stimulasi vagal Hipotensi bradikardia
Batuk TIK
Perlukaan
Infeksi
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C (Circulation)
Assessment of organ perfusion- Level of conciousness
- Skin color and temperature
- Pulse rate and character
- Urinary output
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SHOCK
An abnormality of the circulatory systemthat result in inadequate organ perfusionand tissue oxygenation
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GANGGUAN SIRKULASI Syok
Disritmia Henti jantung
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SHOCK RECOGNITION AND MANAGEMENT
Recognize signs of inadequate perfusionand oxygenation
Identify probable cause Restore perfusion Re-evaluate patient response Immediate involvement by specialists
CLINICAL SIGNS
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1. Tachycardia
2. Vasoconstriction
3. cardiac output
4. Narrow pulse pressure
5. MAP6. blood flow
Remember :
Compensatory mechanisms
CLASSIFICATION OF SHOCK
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Trauma :- Haemorrhagic- Non haemorrhagic
Cardiogenic
Tension pneumothoraxNeurogenicSeptic
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.. Classification of shock
Hypovolemic :- Haemorrhage- Diarrhoea- Burn
Distributive- Septic- Anaphylaxsis
- Spinal cord injury
.. Classification of shock
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Cardiogenik :- Arrytmias- Heart failure- Myocardial contusion / infarction
Obstructive- Tension pneumothorax- Cardiac tamponade- Haemopneumothorax
Disscociative- Profound anemia- Co poisoning
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CO = SV X Fpreload C after loadEDV SVRVR
BP = CO X SVR
D (DISABILITY)
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T P UPeserta mampu menilai gangguan kesadaran.
T P KPeserta mampu :-Menilai dengan menggunakan metode AVPU-Menilai dengan menggunakan metode GCS
-Menilai reaksi pupil-Memahami bahaya penurunan kesadaran-Mengetahui penyebab penurunan kesadaran.
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Baseline neurologic evaluation
Level of consciousness- AVPU- GCS
Pupil
D (DISABILITY)
GLASGOW COMA SCALEVariabels Score
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Eye opening (E) Spontaneous 4To speech 3To pain 2None 1Best motor response (M) Obeys commands 6Localizes pain 5Normal flexion (withdraws) 4Abnormal flexion (decorticate) 3Extension (decerebrate) 2Non (Flaccid) 1Verbal response (V) Oriented 5Confused conversation 4Inappropriate words 3Incomprehensible sounds 2None 1
Verbal response ScoreAppropriate words or social smile, fixes and follows 5
PEDIATRIC VERBAL SCOREGCS score = (E+M+V) Best possible score= 15 worst possible sore =3