RJPO
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Transcript of RJPO
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RJPORJPO(New Guidelines-2010)(New Guidelines-2010)
Dept. Anestesiologi & Terapi IntensifFK USU/RSUP H.Adam Malik Medan
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Historical Perspective• Modern CPR : since 50 yrs ago !• 1958 : ‘mouth to mouth’ ventilation (Peter Safar)• 1956 : defibrilator (reverse a fatal arrhythmia)• 1960 : chest compression (Kouwenhoven)
• 2000 : 1st International Guidelines Conference on CPR & ECC• 2005 : Guidelines on CPR & ECC• 2010 : New Guidelines on CPR & ECC
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Perkembangan baruRJPO/CPCR
New Guidelines 2010
revisi dariGuidelines 2005
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I L C O RInternational Liaison Committee on Resuscitation
E R C - European Resuscitation Council
The major contributor for ILCOR
A H A - American Heart Association
UK Resuscitation CouncilAustralian Resuscitation CouncilRCSA – Resuscitation Council of Southern AfricaRCA - Resuscitation Council of Asia
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CPCR / RJPO (Peter Safar)
1. Basic Life Support emergency oxygenationA : AirwayB : BreathingC : Circulation
2. Advanced Life Support Restoration of spontaneous circulation
D : Drugs and FluidsE : EKGF : Fibrillations treatment
3. Prolonged Life Support post resuscitation brain – oriented therapy
G : GaugingH : Human mentationI : Intensive care
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Istilah
• Basic Life Support = B L S = Jalan nafas + Nafas buatan + Pijat jantung
(A-B-C)• Advanced Life Support = A L S
= Drug (+fluid) + E K G + de-Fibrilasi (D-E-F)
• Cardio Pulmonary Resuscitation = CPR• Cardio Pulmonary Cerebral Resuscitation = CPCR = CPR = RJPO = BLS + ALS
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• Basic Life Support = B L S = Jalan nafas + Nafas buatan + Pijat jantung
(A-B-C)• Advanced Life Support = A L S
= Drug (+fluid) + E K G + de-Fibrilasi (D-E-F)
• Cardio Pulmonary Resuscitation = CPR• Cardio Pulmonary Cerebral Resuscitation = CPCR = CPR = RJPO = BLS + ALS
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Semua tindakan yang harus segera dilakukan dan bertujuan untuk menghentikan proses yang menuju kematian.
Basic Life Support
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DEFINISI KEADAAN
GAWAT DARURAT
KEADAAN YANG APABILA TIDAK MENDAPAT PERTOLONGAN CEPAT
KORBAN AKAN KEHILANGAN SEBAGIAN ANGGOTA TUBUH ATAU MENINGGAL
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A B C - bls
• A - airway : bebaskan jalan nafas• B - breathing : beri nafas bantuan,
(+oksigen)• C - circulation : pijat jantung, posisi shock
Harus dilakukan SEGERA di tempat kejadian
Kondisi gawat daruratPrioritas pertolongan pertama adalah :
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Peredaran darah (sirkulasi) yang berhenti 3 - 4
menit otak mulai mengalami kerusakan karena hipoksia.
Jika pasien mengalami kekurangan oksigen (hipoksia) sebelumnya, batas waktu itu jadi lebih
pendek.
BLS yang dilakukan dengan cara yang benarmenghasilkan cardiac out put
30% dari cardiac out put normal
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Aliran darah yang berhenti 6 - 9 menit
akan mengakibatkan kerusakan otak
yang permanen.
Jantung berhenti berdenyut
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Kapan Resusitasi Jantung Paru diperlukan ?
• Jika pasien Cardiac Arrest• Apa tanda Cardiac Arrest ?
– TIDAK TERABA nadi carotis
• Cardiac Arrest = Nadi Carotis tidak teraba• Cardiac Arrest ECG flat suara jantung
(-)
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Kunci keberhasilan CPR
• Early Access to BLS– Call for help
• Early (correct) CPR– to buy time
• Early Defibrillation– to restart the heart
• Early ALS– to stabilize
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ERC
uropeanesuscitationouncil
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
30 compressions are being given immediately (for adult)
Two rescue breaths, 1 sec each rather than 2 sec
The ratio of compressions to ventilations is 30 : 2
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Periksa kesadaran korban denganmenepuk bahu danmemanggil dengansuara keras
“Siapa namanya???!!!” “Coba buka mata!!!”
LANGKAH 1
Apakah korban sadar ?( Check kesadaran )
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LANGKAH 2
Panggil bantuanPanggil ambulans
1. Panggil bantuan dari orang sekitar, meminta mereka untuk ikut menolong dan
2. Tilpun 118-IGD atau Radio Medik minta bantuan medik/ Ambulans
Sebut lokasi kejadian dengan jelas
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LANGKAH 3
Posisi korban
Jika korban telungkup, balikkan pelan-pelan agar terlentang.
Korban harus ditolongdalam posisi terlentangdiatas alas keras.
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Korban tidak perlu diturunkandari tempat tidur
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LANGKAH 4
Bebaskan jalan nafasdari sumbatan pangkal lidah
Dengan satu tangan didahi korban. Doronglah dahikebelakang, agar kepalamenengadah dan mulut sedikit terbuka
head tilt
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Bebaskan jalan nafasdari sumbatan pangkal lidah
Dengan satu tangan didahi korban. Doronglah dahikebelakang agar kepalamenengadah dan mulutsedikit terbuka
head tilt
Pertolongan dapat ditambah denganmengangkat dagu.
chin lift
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Akibat fleksi ini, menyebabkan terjadinya sumbatan akibat pangkal lidah jatuh
kebelakang
Pada korban yang tidak sadar
posisi kepala cenderung fleksi
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Posisi kepala fleksi,jalan nafas buntu
Jalan nafas bebas karena kepala diposisikan ekstensi dengan Head tilt, Chin lift
fleksi
ekstensi
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head tilt
chin lift
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JAW THRUST
Tindakan lain untukmembebaskan jalan nafas bila Dengan head tilt dan chin lift , jalan nafas tetap obstruksi adalah :
Dengan kedua tangan kitadagu korban diangkat sehinggaderetan gigi rahang bawah beradadidepan deretan gigi rahang atas
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JAW THRUSTcara ini sebagai pilihan
terakhir jika cara lain tidak berhasil.
Untuk orang awam tidak dianjurkan
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Head tilt - Chin lift - Jaw thrustHead tilt chin lift in infant
Head tilt chin lift in child
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• AIRWAY– Jangan neck-lift semua pasien
– Head-tilt, juga untuk pasien trauma– Chin lift, juga untuk pasien trauma– Jaw-thrust, pilihan paling akhir
(untuk awam : TIDAK BOLEH )
– pasang oro/ naso-pharyngeal tube– pertimbangkan intubasi dini
ILCOR – New Guidelines
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Membebaskan jalan nafas
( manual )
head tilt
neck lift
chin lift
x
Head-tilt, juga untuk pasien traumaChin lift, juga untuk pasien traumaNeck lift, tidak boleh dilakukan sama sekali.
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Buka mulut korbanBersihkan benda asingyang ada didalam mulut korbandengan mengorek dan menyapukan dua jari penolong yang telah dibungkus dengan secarik kain
LANGKAH 5
Bebaskan jalan nafasdari sumbatan benda asing
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LANGKAH 1 Apakah korban sadar ?
LANGKAH 5
Panggil bantuanPanggil ambulans
LANGKAH 4 Bebaskan jalan nafasdari sumbatan pangkal lidah
head tiltchin liftjaw thrust
LANGKAH 2
LANGKAH 3 Posisikan korban terlentang
Bebaskan jalan nafasdari sumbatan benda asing
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LANGKAH 6
Periksa apakah korban bernafas
Dekatkan pipi penolongkemulut dan hidung korban.Mata penolong melihatke-arah dada .
LIHAT
DENGAR
RABA
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LANGKAH 7
Menentukan denyut nadi leher
Untuk awamtidak mutlak dilakukan,langsung langkah 8
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Perabaan nadi carotis
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Carotid pulse palpation- start at the middle, feel the trachea- move fingers sideways while pressing down into the groove lateral to the trachea - carotid pulsation should be felt there
Brachial pulse palpation in an infant
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LANGKAH 8
Menentukan lokasi pijat jantung.
Titik tumpu pijat jantung adalahditengah2 sternum
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Tumit 1 tangan diletakkan diatas sternum, kemudiantangan satunya diletakkan diatastangan yang sudah berada di-titik pijat jantung (di-tengah2 sternum)
Jari-jari kedua tangan dirapatkan dan diangkat pada waktu dilakukan tiupan nafas,
agar tidak menekan dada.
Titik tumpu pijat jantung
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Titik tumpu pijat jantung
Old Guidelines :
Using the rib margin method is wasting time
New Guidelines :
Place the hands on the centre
of the chest
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Penolong mengambil
posisi tegak lurus di atas dada korban dengan siku lengan lurus
Menekan tulang dada sedalam kira-kira4-5 cm.
LANGKAH 9
Pijat jantung
Setiap melepas 1 pijatan , tangan jangan masih menekan dada korban
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100x per menit
4-5 cm
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LANGKAH 10
Saat pijat jantung,Hitung dengan suara keras
Satu,dua,tiga,empat, SATUSatu,dua,tiga,empat, DUASatu,dua,tiga,empat, TIGASatu,dua,tiga.empat, EMPATSatu,dua,tiga,empat, LIMASatu,dua,tiga,empat, ENAM
Total = 30 x pijatanYang disela dengan 2 x tiupan nafas
Pijat jantung nafas buatan 30 : 2
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ILCOR – New Guidelines • CIRCULATION - Titik tumpu pijat jantung ditengah2 sternum - 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 - Jika trachea sudah intubasi tak usah sinkronisasi
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Pijat jantung nafas buatan
• Lakukan 30 kali pijat jantungdengan diselingi 2 kali nafas buatan ini berulangselama 2 menit
• Setelah 2 menit (7-8 siklus) rabanadi leher.
• Bila masih belum teraba denyut nadi leher, lanjutkan 30 x pijatjantung dan 2 x nafas buatan
• Lakukan tindakan ini terus sampaidatang bantuan atau ambulans
30 : 2
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Cara memberi nafas buatan
• Pertahankan posisi kepala tetap tengadah• Jepit hidung dengan tangan
yang mempertahankan kepala tetap tengadah• Buka mulut penolong lebar-lebar sambil menarik nafas
panjang Tempelkan mulut penolong diatas mulut korban dengan
rapat.• Hembuskan udara kemulut korban sampai terlihat
dada terangkat/ bergerak naik• Lepaskan mulut penolong, biarkan udara keluar dari
mulut korban, dada korban tampak bergerak turun.• Berikan hembusan nafas kedua dengan cara yang sama.
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child
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infant
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ILCOR – New Guidelines
• BREATHING
- 2 kali tiupan setelah jalan nafas bebas - Tiap kali hembusan 1 detik, disusul dengan
hembusan ke-dua, setelah ekshalasi- Nafas buatan 10 kali/ menit ( bila sudah
ter-intubasi )
- Usahakan dada terangkat.- @ 500-600 ml atau Volume Tidal 6-8 cc/kgBB- Beri oksigen 100% lebih dini
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Tiupan nafas yang berlebihan berakibat tekanan intra-thorakal
meningkat dan berdampakmenghambat aliran darahyang ditimbulkan akibat
pijatan jantung.
Tiupan nafas cukupasal dada mengembang
10 kali/ menit.
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Tehnik pemberian nafas buatan (1)
mouth to mouth mouth to mask
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Tehnik pemberian nafas buatan (2)
Ambu bag Jackson Rees
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LANGKAH 6
LANGKAH 9
LANGKAH 7
LANGKAH 8
LANGKAH 10
Periksa apakah korban bernafas
Menentukan denyut nadi leher( untuk awam, tidak perlu )
Tumit satu tangan langsung diletakkan ditengah2 dada.( diatas sternum )
Melakukan 30x pijatan jantung
Langsung disusul denganpemberian 2 x tiupan nafas
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?
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F B A OFForeign oreign BBody ody AAirway irway OObstructionbstruction
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Choking( tersedak )
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CHOKING
Back blows
Korban : sadar
Lima kali hentakan
pada punggung,diantara dua
scapula
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CHOKING
HeimlichAbdominal Trust
Korban : sadar
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Korban : Tidak sadar
Heimlich Abdominal trust
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?
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• Basic Life Support = B L S = Jalan nafas + Nafas buatan + Pijat jantung
(A-B-C)• Advanced Life Support = A L S
= Drug (+fluid) + E K G + de-Fibrilasi (D-E-F)
• Cardio Pulmonary Resuscitation = CPR• Cardio Pulmonary Cerebral Resuscitation = CPCR = CPR = RJPO = BLS + ALS
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Chain of Survival
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AUTOMATED AUTOMATED EXTERNAL EXTERNAL
DEFIBRILLATOR - DEFIBRILLATOR - AEDAED
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Now part of Basic Life Support (BLS)
AED now the first 3 links in Chain of Survival
EarlyAccess
EarlyCPR
EarlyDefibrillati
on
EarlyAdvanced
Care
Automated External Defibrillation
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Jika defib diberikan sebelum 5 menit, > 50% kemungkinan jantung berdenyut kembali
Public Access Defibrillation
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Emergency defibrillatorEmergency defibrillatorBandara Schipol di - Bandara Schipol di -
BelandaBelanda
Public Access Defibrilator (PAD) programmes are recommended for locations where the expected use of an AED for witness cardiac arrest exceeds once in two years
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Perubahan utama pada Automated External
Defibrillation
Segera berikan satu kali DC-Shock (paling sedikit 150 Joule biphasic atau 360 Joule monophasic) diikuti dengan RJP 2 menit yang tidak terputus , tanpa memeriksa apakah VF telah berakhir, atau memeriksa nadi, atau adanya tanda-tanda kehidupan.
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The need for defibrillation ventricular fibrillation:
80% of victims
survival decreases:
10% per minute
only treatment:
electrical defibrillation
this means: delivering an
electric shock with a
device called an
“Automated External
Defibrillator” (AED)
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Cardiac arrest = carotis (-) check ECG
VF / VT pulseless = ada gelombang khas- Shockable rhythm, harus segera DC-shock
Asystole = ECG flat, tak ada gelombang- UN-shockable
PEA /EMD = ada gelombang mirip ECG normal
- UN-shockable
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A-Systole
VT
VF
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Cardiac arrest = carotis (-)
Asystole = ECG flat,
tak ada gelombang
–
UNshockableCPR + adrenalin (+atropin?)ROSC < 10%(Return Of Spontaneous Circulation )
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PEA = EMD
ada gelombang mirip ECG normal TETAPI nadi carotis tidak teraba
–terapi sama seperti Asystole
P-ulselessE-lectricalA-ctivity
E-lectroM-echanicalD-issociation
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Perubahan utama pada Bantuan Hidup Lanjut dewasa
• RJP sebelum defibrillasi (DC-Shock)– Henti jantung diluar rumah sakit yang tidak
diketahui (unwitnessed) , bila ditolong oleh penolong terlatih dengan defibrillator manual, beri RJP 2 menit (6-7 siklus 30:2) sebelum DC-Shock.
– Jangan tunda defibrillasi (DC-Shock) bila henti jantung diluar rumah sakit didapati oleh petugas kesehatan (penolong) terlatih
– Jangan tunda defibrillasi (DC-Shock) bila henti jantung terjadi didalam rumah sakit.
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Perubahan utama pada Bantuan Hidup Lanjut
dewasa
• Strategi defibrillasi (DC-Shock)– Pada kasus dengan VF atau VT tanpa
pulse, beri 1 kali DC-Shock, segera diikuti RJP (30 kompressi : 2 nafas bantu). Tidak diperlukan penilaian kembali rhytme atau meraba nadi. Setelah 2 menit RJP, periksa rhytme dan beri DC-shock atas indikasi.
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Perubahan utama pada Bantuan Hidup Lanjut dewasa
• Strategi defibrillasi (DC-Shock)– Rekomendasi besarnya energi awal untuk
biphasic defibrillator adalah 150-200 Joule, berikutnya beri dengan energi 150-360 Joule.
– Rekomendasi besarnya energi untuk monophasic defibrillator baik awal ataupun berikutnya adalah 360 Joule.
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Perubahan utama pada Bantuan Hidup Lanjut
dewasa
• VF yang halus (fine-VF)– Bila ada keraguan apakah rhytme asystole
atau fine-VF, JANGAN berikan DC-shock, tetapi lanjutkan kompressi dada dan nafas bantu.
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Adrenaline (epinephrine)
VF/VT• Beri adrenaline 1 mg/iv bila VF/VT menetap
sesudah DC-shock yang kedua kali.• Ulangi pemberian adrenaline setiap 3-5 menit
bila VF/VT menetap.
Pulseless Electrical Activity (PEA) / Asystole
• Beri adrenaline 1 mg/iv segera jalur intra vena sudah didapat, dan ulangi setiap 3-5 menit sampai dengan kembalinya sirkulasi spontan (ROSC, return of spontaneous circulation)
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Obat-obat anti-arrhytmia
• Bila VF/VT bertahan setelah 3 kali DC-shock, beri Amiodarone 300 mg/iv, bolus. dosis selanjutnya 150 mg dapat diberikan bila VF/VT rekuren atau refrakter, diikuti dengan dosis 900 mg/iv-infusion/24-jam
• Bila amiodarone tidak tersedia, sebagai pengganti adalah Lidocaine 1 mg/kgBB/iv, tetapi jangan beri Lidocaine bila Amiodarone telah diberikan. Dosis total adalah 3 mg/kgBB dalam 1 jam pertama.
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Terapi thrombolitik pada henti jantung
• Diberikan pada kasus bila henti jantung diduga disebabkan oleh adanya emboli paru, atau pada kasus RJP yang gagal dengan dugaan henti jantung disebabkan thrombotik akut. RJP tidak merupakan indikasi kontra terhadap thrombolysis.
• Bila thrombolitik telah diberikan, RJP dilakukan sampai dengan 60-90 menit.
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Perawatan paska resusitasi – terapetik
hipothermia• Pasien dewasa tidak sadar, sirkulasi spontan,
pasca VF – henti jantung diluar rumah sakit, harus lakukan hipothermia terapi 320-340 C selama 12-24 jam
• Mild – Hipothermia juga mungkin memberikan hasil baik pada pasien dewasa yang tidak sadar, sirkulasi spontan, setelah henti jantung diluar rumah sakit dengan rhytme non-shockable atau sesudah henti jantung di dalam rumah sakit.
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HipoksiaHipovolemiaHiperkalemiaHipotermiaTamponade jantungTension pneumothoraxThromboemboli paruToxic overdose B-block, Ca-block Digitalis, Tricyclic AD
Massive MIAsidosis
4 H
4 T
MA
Cardiac Arrest membandel ???
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Bila berhasil ROSC
• Lanjutkan oksigenasi, kalau perlu nafas buatan( protap : ventilator )
• Hipotensi diatasi dengan inotropik dan obat vaso-aktif (adrenalin, dopamin, dobutamin, ephedrin)
• Tetap di infus untuk jalan obat cepat• Terapi aritmia• Koreksi elektrolit, cairan, gula darah dlsb• Awasi di ICU• Awas: cardiac arrest sering terulang lagi
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?
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slide bant
u1
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What is an AED ?
✔a device that delivers
electric shocks to victims
with cardiac arrest
✔ all AEDs share the same
operating principles
self-adhesive defibrillation electrodes
analyses the rhythm of the victim and
decides when a shock is needed
accuracy is almost 100%
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AED features
voice prompts
memory
analyzing
ECG
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Using an AED
☐ three steps:
1. decide to use the AED
2. activate the AED
3. follow instructions
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Check for signs of a circulation
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Switch on the AED
✔If NO signs of a circulation
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Attach the defib pads
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Analysis of the heart rhythm
✔ ensure that everyone
is clear during analysis
of the rhythm
☐☐ Follow the Follow the directionsdirections
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If a shock is advised
✔ensure that everybody is clear
✔push shock button or if no shock
button, allow AED to deliver shock
automatically
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If no shock is advised
check for signs of a circulation☐ if none present:
✔start CPR
✔continue CPR until the AED tells
you to stop
☐ if signs of circulation are present
(including normal breathing):
✔recovery position
✔check regularly
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Useful to know
✔wipe skin dry before attaching electrodes✔shave or cut excessive hair : only if necessary!✔remove plasters✔place electrodes away from pacemakers
✔ safety issues – risk to the rescuer– risk to the victim– risk to the bystanders
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Equipment
✔face shield
✔ face mask
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Using a face mask
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?
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slide bantu 2
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What is so important ….……….?
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DEFIBRILATION
DC shock
Un - Synchronized Synchronized
VF / VT PulselessAsystole-withness
AF - SVT
Kardioversi
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Pemberian tenaga listrik yang menyebabkan kejutan (shock) pada pasien aritmia menjadi suatu irama jantung yang menunjang hidup.
Indikasi : ✔ VF
✔VT-pulseless ✔(Asistol-witness)
Defibrilasi
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Kardioversi
Bentuk defibrilasi yang sinkron digunakan untuk menghentikan irama jantung yang mengancam jiwa, menjadi irama sinus
Indikasi : ✔ AF (atrial fibrilasi/ flutter) ✔VT yang membandel
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PERSIAPAN ALAT / OBAT
1. Mesin DC shock2. EKG – monitor3. Jelly elektrode4. Alat / obat resusitasi5. Oksigen6. Peralatan suction dengan kateter suction
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Perhatian
1. Defibrilasi segera dilakukan2. Pastikan diagnosa EKG- VT atau VF3. Paddle menempel dengan baik4. Discharge pada saat exhalasi penuh5. Interval waktu antara defibrilasi singkat6. Witnessed arrest segera defibrilasi sebelum cpr , tetapi segera cpr-abcd dalam waktu 30 – 60 detik.7. Jangan hentikan cpr-abc > 10 detik8. Periksa dan test defibrilasi secara teratur
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Tata Cara Defibrilasi
Monitor – VT atau VF
Raba a.carotis
Nyalakan defibrilator
Pilih Un-synchronized / synchronized mode
Beri jelly tipis pada “paddle” Tentukan energi (200 – 300 – 360 j)
Tekan tombol “charged control” Tekan kuat “paddle” kedada pada posisinya
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Evaluasi nadi dan irama jantung Jika defibrilasi tidak berhasil, naikkan
energi dan ulangi sampai 3 kali berturut2.
Jika tetap tidak berhasil, lakukan cpr – abc Ulangi defibrilasi setelah obat – obatan Cari penyebab kegagalan defibrilasi. Interupsi cpr-abc maksimal 20 detik.
….tata cara
Saat akan defibrilasi, beritahu semua menjauhTekan “ discharge control” bersama2
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Faktor yang mempengaruhi
Keberhasilan
1. Defibrilasi segera dilakukan
2. Pastikan diagnosa EKG
3. Penempatan paddle
4. Transthoracic impedence rendah
5. Paddle menempel dengan baik
6. Tekanan paddle ke dada
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7. Discharge pada saat exhalasi penuh 8. Defibrilasi awal 200 – 300 – 360 j 9. Interval waktu antara defibrilasi singkat10. Witnessed arrest segera defibrilasi sebelum cpr , tetapi segera cpr-abc dalam waktu 30 – 60 detik11. Jangan hentikan cpr-abc > 10 detik12. Periksa dan test defibrilasi secara teratur
…..keberhasilan
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DC shock
1. Switch ON
Oles paddles dengan jelly ECG tipis rata
Pasang paddles pada posisi apex dan
parasternal
(boleh terbalik)
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DC shock 2. Charge 200 Joules (Non-synchronized)
Perintahkan : Awas semua lepas dari pasien!
– nafas buatan berhenti dulu– bawah bebas, samping
bebas, atas bebas, saya bebas!
3. Shock !! (tekan dua tombol paddles bersama)
Biarkan paddles tetap menempel dada, baca ECG
sternum
apex
Siap charge lagi
bila iramamasih
Shockable
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?
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Terima kasih atas perhatian andaSemoga Tuhan selalu memberkahi kita semua
Amin
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To honour this gentleman, To honour this gentleman, wewe’’d extend the newestd extend the newest
knowledge of CPCR to more knowledge of CPCR to more and more providersand more providers
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RJPO Skill• Pijat jantung
– lokasi– kedalaman pijatan– lepas-tekanan pada “diastole”– frekwensi 100 x per menit– siku lurus, bahu pemijat diatas sternum
• Pijat jantung + nafas buatan– sinkronisasi 30 pijat : 2 nafas– bila 1 penolong pindah-pindah lokasi– dada terangkat, 2 x dengan sela
ekshalasi