Lab / SMF Anestesiologi & Reanimasi

FK. Unair – RSU Dr. Soetomo

Surabaya
Jude & Kouwenhoven (1961)
– Closed chest resuscitation :
• 138 cardiac arrest in hospital
• 107 ROSC
 People hearts stop beating everyday

For many people

Their hearts / brains should be
“ Too Good To Die “

Resuscitative effort can restore these hearts
to spontaneous activity before the brain
has been permanently injured
• 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 (sampai Maret)
1. Basic life support  emergency oxygenation
A : Airway
B : Breathe
C : Circulate
2. Advanced life support  Restoration of spontaneous
circulation
D : Drugs and Fluids
E : EKG
F : Fibrillation treatment
3. Prolonged life support  post resuscitation brain –
oriented therapy
G : Gauging
H : Human Mentation
I : Intensive care
• Primary Survey
A : Airway with C-spine control
B : Breathing with ventilation
C : Circulation with hemorrhage control
D : Disability : neurologic status
E : Exposure / environment with temperature control

• Resuscitation

• Secondary Survey
Head – to – toe evaluation and history

• Reevaluation

• Definitive care
In the Primary Survey, focus on basic CPR and
defibrillation

First A-B-C-D
• Airway :
Open the airway
• Breathing :
Provide positive – pressure ventilations
• Circulation :
Give chest compressions
• Defibrillation :
Shock ventricular fibrillation or pulseless
ventricular tachycardia (VF/VT)
In the Secondary Survey, focus on intubation,
intravenous (IV) access, and drugs and
why the cardio respiratory arrest occurred

Second A-B-C-D
• Airway :
Perform endotracheal intubation
• Breathing :
Assess bilateral chest rise and ventilation
• Circulation :
Gain IV access, determine rhythm, give
appropriate agents
• Differential Diagnosis (Think):
Search for, find, and treat reversible causes
• The clinical picture of overall cessation of
circulation
• Unconsciousness
• Apnea or gasp
• Death – like appearance (cyanosis or pallor)
• Diagnosis Cardiac Arrest (No pulse)
– Adult :
• Carotid
• Femoral
– Infant small children :
• Brachial
• Femoral
 Perabaan nadi carotis

dari tengah ke-lateral

Awam : tidak perlu

meraba carotis
• 15 second – Unconsciousness
• 15 – 30 – Isoelectric EEG
• 30 – 60 – Agonal gasping
Apnea
Max pupillary dilatation
> 5 minute – cerebral damage
• Primary :
– Ventricular Fibrillation
– Asystole
– Heart Block
– Electric Shock
– Drugs
• Secondary :
– Rapid :
• Asphyxia
• Exsanguination
• Acute Pulmonary Edema
• Oxygen – Free Gas
– Slow :
• Hypoxemia
• Shock
• EMD
CLOSED CHEST OPEN CHEST

THORACIC CARDIAC
PUMP PUMP
Heart Pump Chest Pump
Mechanism Mechanism

Squeezing the heart Overall intra-thoracic

Between sternum Pressure fluctuation
and Spine
• Cardiac output
• Carotid artery blood flow 30% Normal
• Cerebral Blood Flow (CBF)
• CBF :
– Near zero  without CPR
– 50% N  Maintain consciousness
– 20% N  Maintain cell Viability
• Coronary P.P and blood flow  Low
 Right atrial pressure ↑
• Tungkai dibuat lebih tinggi
 • Titik tumpu
• Teknik memijat
• Monitoring
• Komplikasi
• Pada tulang dada
• Dewasa :
– 2 jari kranial proc. Xyphoideus
– Tengah sternum distal
• Bayi :
– Tengah sternum
– Garis inter mammary
 ILCOR
International Liaison Committee on Resuscitation
Guidelines 2005
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

• Two rescue breaths, 1 sec each rather than 2 sec

• The ratio of compressions to ventilations is 30 : 2

 ILCOR - Guidelines 2005
• CIRCULATION

– Titik tumpu pijat jantung ditengah dada di tulang

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
Titik tumpu pijat
jantung adalah
ditengah2 sternum
 titik tumpu
pijat jantung

Guidelines 2005 :

place the hands on the centre

of the chest

Using the rib margin method

is wasting time
 Titik tumpu pijat jantung
Tumit 1 tangan
diletakkan diatas
sternum,
kemudian
tangan satunya
diletakkan diatas
tangan 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.
 Pijat jantung
Penolong
mengambil
posisi tegak lurus
di atas dada
korban dengan
siku lengan lurus

Menekan tulang
dada sedalam
kira-kira4-5 cm.
Setiap melepas 1 pijatan ,
tangan jangan masih menekan dada korban
100x per menit

4-5 cm
Pijat jantung nafas buatan
30 : 2
Saat pijat jantung,
Hitung dengan suara keras

Satu,dua,tiga,empat, SATU
Satu,dua,tiga,empat, DUA,
Satu,dua,tiga,empat,TIGA
Satu,dua,tiga.empat,EMPAT
Satu,dua,tiga,empat,LIMA
Satu,dua,tiga,empat,ENAM

Total = 30 x pijatan
Yang disela dengan 2 x tiupan nafas
Pijat jantung nafas buatan
• Lakukan 30 kali pijat jantung
dengan diselingi 2 kali nafas buatan.
ini berulang selama 2 menit
30 : 2
• Setelah 2 menit (7-8 siklus) raba
nadi leher.

• Bila masih belum teraba denyut

nadi leher, lanjutkan 30 x pijat
jantung dan 2 x nafas buatan

• Lakukan tindakan ini terus sampai

datang bantuan atau ambulans
• Dewasa :
– Tumit telapak tangan
– Dua tangan
• Anak :
– Tumit telapak tangan
– Satu tangan
• Bayi : Dua jari ( Jari II + III )
• Posisi tegak – lurus
• Kedalaman memijat :
– Dewasa : 1,5 – 2,0 inch (4-5 cm)
– Anak : 1,0 – 1,5 (2,5 – 4 cm)
– Bayi : 1 – 2 cm (0,5 inch)
• Waktu memijat = waktu relaksasi
• Frekwensi 80 – 100 / m
Guidelines 2000
• 1 Penolong :
– 15 pijat jantung (Frek. 80 – 100 / m)
– 2 nafas buatan (1-2 detik / nafas buatan)
• 2 Penolong :
– 15 pijat jantung (frek.80 – 100 / m)
– 2 nafas buatan (1-2 detik / nafas buatan)
– Setelah di intubasi Pijat Jantung 100x/menit Nafas
Buatan
12 - 20x/menit di sela – sela pijatan.
Guidelines 2005
• 1 atau 2 penolong = 30 : 2
Satu penolong

Tahun 2000 :

Tahun 2005 :

30 : 2
 Dua penolong

Tahun 2000 :

1 2
Tahun 2005 :

30 : 2
 Korban tidak
1.
sadar
A. bebaskan jalan nafas Call for help

B. jalan nafas bebas

2.
tidak bernafas

2 x tiupan awal
3.
C. raba nadi carotis
tidak teraba nadi
4.
awam
beri pijatan jantung
Pasang
dan nafas buatan 5.
monitor EKG
30 pijat + 2 nafas ( di RS )
• Nadi carotis  oleh pemberi nafas
– Intermitten
– Menit pertama
– 2 – 5 menit berikutnya
• Pupil
– Ukuran
– Refleks
• Di RS.
– EKG
– Pulse oximetri
– BGA
– Tensi – nadi
– Perfusi organ
– ETCO2
 • Patah tulang iga
• Patah tulang dada
• Cedera jantung
• Cedera paru
• Cedera pembuluh darah
• Cedera organ abdomen
• IAC – CPR =
Interposed Abdominal Compression – CPR

• Vest – CPR =
Circumferential Vest Compression – CPR

• ACD – CPR =
Active Compression Decompression – CPR

• Open Chest – CPR

• Class I : Definitely Helpful

• Class II a : Acceptable, Probably Helpful

• Class II b : Acceptable, Possibly Helpful

• Class III : Not Indicated, May be harmful

• Obat Simpatomimetik
– Vasokonstriktor
– Vasopresor
• Pilihan utama pada cardiac arrest (CPR)
• Efek  dan 
=
• Vasokonstriksi sistemik tidak pada koroner dan
otak
• ↑ tahanan perifer
• ↑ tekanan sistole dan diastole  aliran ke otak dan
otot jantung ↑
=
• ↑ kontraksi otot jantung
• ↑ irama jantung
• Bronko dilatasi
• Indications :
– Cardiac arrest : VF, pulseless VT, asystole, PEA, (Class I)
– Sympatomatic :
– Bradycardia : after Atropine and transcutaneous pacing (class II b)

• Dosage :
– Cardiac arrest :
• First dose : 1,0 mg / IV push – repeat every 3 – 5 min
– Alternative regimens for second dose (class II b)
• Intermediate : 2 – 5 mg / IV push every 3 – 5 min
• Escalating : 1 mg, 3 mg, 5 mg / IV push (3 min apart)
• High : 0,1 mg / kg / IV push, every 3 – 5 min
– Endotracheal route :
• 2,0 – 2,5 mg diluted in 10 ml normal Saline
– Profound Bradycardia :
• 2 – 10 mg 1 min (1mg in 500 ml normal Saline 1 – 5 ml / min)
• Indications
– First drug for sympatomatic bradycardia (class II a)
– Second drug (after Epinephrine) for Asystole or
Bradycardic PEA (class II a)
• Dosage
– Asystole or PEA
• 1 mg / IV push – repeat every 3 – 5 min
• Max dose 0,03 – 0,04 mg / kg
– Bradycardia
• 0,5 mg – 1,0 mg / IV every 3 – 5 min
• Max dose 0,03 – 0,04 mg / kg
– Endotracheal administration
• 2 – 3 mg diluted in 10 ml normal Saline
• Indications
– Cardiac arrest from VF / VT (class IIa)
– Stable VT, wide-complex tachycardias wide complex
PSVT (class I)

• Cardiac arrest from VF / VT

– Initial dose : 1,0 – 1,5 mg / kg IV
– For refractory VF repeat 1,0 – 1,5 mg / kg IV in 3 – 5
min, total dose : 3 mg / kg
– A single dose of 1,5 mg / kg IV in cardiac arrest is
acceptable
– Endotracheal administration : 2 – 4 mg / kg
• Indications
– Class I :
• If known pre existing Hyperkalemia
– Class II a :
• If known pre existing Bicarbonate – Acidosis (EG. Diabetic
Keto Acidosis)
• If overdose with tricyclic anti depressants to Alkalinize the
urine drug overdose
– Class II b :
• If intubated and continued long arrest interval
• Upon return of spontaneous circulation after long arrest
interval
– Class III :
• Hipoxic Lactic Acidosis (EG. Cardiac arrest and CRP without
intubation

• Dosage
– 1 mEq / kg IV bolus – repeat half this dose every 10 min blood
gas analysis evaluation
 DC shock

Oles dulu paddles

dengan jelly ECG
tipis rata, baru
kemudian :

1. Switch ON sternum
Pasang paddles pada
posisi apex dan
parasternal apex
(boleh terbalik)
2. Charge 360 Joules DC shock
(Non-synchronized)
Ucapkan dengan keras :
Awas semua lepas dari pasien!
– nafas buatan berhenti dulu
– bawah bebas, sternum
samping bebas,
atas bebas,
saya bebas!
3. Shock!! apex
(tekan dua tombol paddles bersama)
Lepas paddles dari dada,
lanjutkan chest compression.
4. Segera pijat jantung lagi 2 menit
baru raba lagi/ baca lagi ECG
Position
of the paddles electrodes
on thorax of an infant sternum

apex

Size of paddle electrode

- 4.5 cm diameter for infants and small children
- 8-12 cm diameter larger children
Jelly kurang rata, menekan paddles kurang kuat - luka bakar
 VT / Ventricular Tachycardia
|
| |
carotis (+) carotis (-)

Lidocain
a single shock
1 mg/kg iv cepat 360 Joules
atau CPR 30:2 - 5 SIKLUS
Amiodaron 300 mg dst
Managemen VT/ VF
• Indications
– VF ( class I )
– Pulseless VT ( class I )

Guidelines 2000
• Dosage
– 200 Joule : first shock
– 200 – 300 J : second shock
– 360 J : third shock
– If fail to convert VF / VT continue at 360 J for future shock
– If VF recours, shock again at the last successful energy level

Guidelines 2005
– 1 X Shock
– Mono phasic 360 J
– Bi phasic 100 J – 200 J
1. Simple chest thump
– Witnessed VT / VF
2. Repetitive chest thumps
– Heart block
3. Cardioversion
(synchronized electric counter shocks)
– AF, PSVT
– VT with pulse
4. Non synchronized electric counter shocks
– VT without pulse
– VF
5. Pacing
– Heart block
– Asystole
 THANK YOU
For your attention