dr. Mochamad Aleq Sander, M.Kes., SpB.

Bagian UPF Ilmu Bedah

Fakultas Kedokteran Universitas Muhammadiyah Malang
PROGRAM STUDI ILMU KEPERAWATAN (S1)
DEFINITIVE AIRWAY
Indications
1. Apnea
2. Risk of aspiration
3. Insecure airway
4. Poor oxygenation
5. Impending airway compromise
7. Closed head injury
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
TUJUAN INTUBASI ENDOTRAKHEAL
1. 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
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
ENDOTRACHEAL INTUBATION
The trachea should be intubated by properly
trained personnel
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
PERALATAN INTUBASI ENDOTRAKHEHAL
Laryngoscope dengan blade yang sesuai
Tube dengan ukuran yang sesuai
Jelly
Anestetik lokal / spray
Forceps magill
Bite block / oropharyngeal airway
Adhesive tape / tali
Suction metal yang kauer
Connectors
Syringe (20cc)
Stylet
Stetoscope
End tidal CO
2
monitor
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
INTUBASI
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
INTUBASI ENDOTRAKHEAL
Oksigenasi + ventilasi (5 menit)
Alat dan obat siap
Harus berhasil < 30 detik
Bila > 30 detik belum berhasil oksigenasi + ventilasi ulang
Penolong tak kuat tahan nafas
Saturasi O
2

Monitoring :
Saturasi O
2
(Pulse oxymeter)
End-tidal CO
2
(Capnografi)
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
GANGGUAN VENTILASI
Penyebab
Tindakan anestesi
Penyakit
Kecelakaan trauma
Lokasi
Sentral Pusat nafas
Perifer
Jalan nafas Dinding dada
Paru Otot nafas
Rongga pleura Syaraf & jantung
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
GANGGUAN VENTILASI
(penderita masih bernafas)
Look / Lihat
Sianosis Takhipnea
Status mental Distensi vena leher
Asimetri dada Paralisis otot nafas
Listen / dengar
Keluhan: Tak bisa nafas!
Stridor, wheeze
atau hilang suara nafas
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
Feel / raba
- Hawa ekspirasi
- Emfisema subkutan
- Krepitasi / tenderness / nyeri
- Deviasi trakhea
Adjuncts
- Pulse oximeter
- CO
2
detector
- Gas darah
- X-ray dada
gangguan ventilasi
(penderita masih bernafas)
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
BEBERAPA ISTILAH
Ventilation
Aliran (volume) udara keluar masuk paru
Tidal volume
- Volume udara yang dihisap/dikeluarkan pada
satu kali nafas biasa
- N: 6 8 ml / kg bb ex: 70kg 420 560 ml
Minute volume
- Tidal volume x freq./min
- N: 6 8 l / menit
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
Hipoventilation
Minute volume
Hiperventilation
Minute volume
Parameter ventilasi
PaCO
2
N= 35 45 mmHg
Hipoventilasi PaCO
2

Hiperventilasi PaCO
2

.beberapa istilah
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
DASAR PEMBERIAN VENTILASI
Intermittent positive pressure ventilation (IPPV)
Penderita tak bernafas
Nafas buatan (controlled ventilation)
Penderita masih bernafas / tak adekuat
- Nafas bantuan (assisted ventilation)
- Diberikan pada akhir ekspirasi
Tekanan oropharing > 25 cm H
2
O udara masuk
esophagus distensi lambung
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
.dasar pemberian ventilasi
Sellicks maneuver
Menekan cricoid kebelakang sehingga esophagus
terjepit diantara cricoid dan corpus vertebra leher
Agar :
- Udara tak masuk lambung
- Isi lambung tak mengalir ke oropharing
- Tak boleh pada cedera tulang leher
Nafas buatan :
Tidak volume 10-15ml/kg
Frequensi 12-15 / min
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
CARA PEMBERIAN VENTILASI
Tanpa Alat
- Mouth to mouth
- Mouth to nose
- Mouth to mouth and nose
Dengan Alat
- Safar airway
- Esophageal obturator airway
- Face mask / pocket mask
- Laryngeal mask
- Bag-valve-mask
- Bag-valve-tube
- Ventilator
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
Nafas buatan
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
Nafas berhenti
Nafas ada
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
SUPPLEMENTAL OXYGEN
1. Nasal cannula / prong
Low flow system
Flow O
2
: 1-6 L/m
FiO
2
: 20%
2. Face mask
Low flow system
Flow O
2
: 8-10 L/m
FiO
2
: 40 %
3. Face mask with O
2
reservoir
Constant flow
Flow O
2
: 6-10 L/m
FiO
2
: 60 %
4. Ventilatory mask
High gas flow
Fixed oxygen concentration
Flow O
2
& FiO
2
dapat diatur sesuai kebutuhan
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
Terapi oksigen
NASAL PRONG
O2 flow 1 6 lpm
FiO2 : 24 44 %
BAG VALVE MASK (BVM)
Dgn oksigen 8-10 lpm : 60%
Masker sederhana
Dengan reservoir bag
Flow O2 : 6-10 lpm
FiO2 : 60%- 100%
BVM Dengan reservoir bag
Flow O2 : 8-10 lpm
FiO2 : 80%- 100%
Jackson Rees
Flow O2 : 8-10 lpm
FiO2 : 100%
BVM Dengan reservoir bag
Flow O2 : 8-10 lpm
FiO2 : 80%- 100%
FACE MASK O2 8-10 lpm
FiO2 : 40-60%
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
TRACHEO BRONCHIAL SUCTIONING
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
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
C (Circulation)
Assessment of organ perfusion
- Level of conciousness
- Skin color and temperature
- Pulse rate and character
- Urinary output
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
SHOCK
An abnormality of the circulatory system
that result in inadequate organ perfusion
and tissue oxygenation
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
GANGGUAN SIRKULASI
Syok
Disritmia
Henti jantung
dll
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
SHOCK RECOGNITION AND MANAGEMENT
Recognize signs of inadequate perfusion and
oxygenation
Identify probable cause
Restore perfusion
Re-evaluate patient response
Immediate involvement by specialists
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
CLINICAL SIGNS
1. Tachycardia
2. Vasoconstriction
3. cardiac output
4. Narrow pulse pressure
5. MAP
6. blood flow
Remember :
Compensatory mechanisms
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
CLASSIFICATION OF SHOCK
Trauma :
Haemorrhagic
Non haemorrhagic
- Cardiogenic
- Tension pneumothorax
- Neurogenic
- Septic
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
.. Classification of shock
Hypovolemic :
- Haemorrhage
- Diarrhoea
- Burn
Distributive
- Septic
- Anaphylaxsis
- Spinal cord injury
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
.. Classification of shock
Cardiogenik :
- Arrytmias
- Heart failure
- Myocardial contusion / infarction
Obstructive
- Tension pneumothorax
- Cardiac tamponade
- Haemopneumothorax
Disscociative
- Profound anemia
- Co poisoning
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
CO = SV X F
preload C after load
EDV SVR
VR
BP = CO X SVR
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
Baseline neurologic evaluation
Level of consciousness
- AVPU
- GCS
Pupil
D (DISABILITY)
dr. Mochamad Aleq Sander, Sp.B., M.Kes.
GLASGOW COMA SCALE
Variabels Score
Eye opening (E) Spontaneous 4
To speech 3
To pain 2
None 1
Best motor response (M) Obeys commands 6
Localizes pain 5
Normal flexion (withdraws) 4
Abnormal flexion (decorticate) 3
Extension (decerebrate) 2
Non (Flaccid) 1
Verbal response (V) Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Verbal response Score
Appropriate words or social smile, fixes and follows 5
Cries, but consolable 4
Persistently irritable 3
Restless, agitated 2
None 1
PEDIATRIC VERBAL SCORE
GCS score = (E+M+V) Best possible score= 15 worst possible sore =3
dr. Mochamad Aleq Sander, Sp.B., M.Kes.