TIM KEDOKTERAN GAWAT DARURAT

RSU DR SOETOMO – FK UNAIR SURABAYA

 Pasien tidak sadar
|
bebaskan jalan nafas
Call for help
( head tilt , chin lift , jaw thrust )
|

bernafas • Gasping = tdk nafas tidak bernafas

• Untuk AWAM :
Tidak perlu
pertahankan jl nafas bebas meraba carotis beri nafas buatan
beri oksigen raba carotis
raba arteri radialis tidak ada ada

ada tidak ada CPR 30 : 2

2 menit
Posisi shock pasang monitor
Nafas
Pasang infus
Ekstra cairan buatan,
shockable un-shockable teruskan
lihat managemen shock
 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
Irama Sinus
SHOCKABLE RHYTHMS
1. Ventriculer fibrilation
Irama Sinus

Fine Ventriculer Fibrilation

Coarse Ventriculer Fibrilation

If there is a doubt about whether Irama Sinus
the rhythm is asystole or fine-VF
do NOT attempt defibrilation,
continuous chest compression and
ventilation

Fine Ventriculer Fibrilation chest compression+ adrenalin

NO DC
chest compression+adrenalin
Asystole
NO DC

Coarse Ventriculer Fibrilation DC

SHOCKABLE RHYTHMS
2. Ventriculer tachycardia ( VT –pulseless )
 VT / Ventricular Tachycardia
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carotis (+) carotis (-)

Lidocain
a single shock
1 mg/kg iv cepat 360 Joules
atau CPR 30:2 2 menit
Amiodaron 300 mg Managemen VT/ VF
AED
Automatic External Defibrillator
Jika defib (biphasic) diberikan sebelum 5 menit,
> 50-70% kemungkinan jantung berdenyut
kembali
AED
Automatic External Defibrillator

• VF  shock x 1
 immediately begin chest
compression.
• Do NOT interrupt chest compressions
to check rhythm or pulse until 5 cycles
or 2 minutes of CPR are given.

• First shock efficacy of monophasic

shock is lower than biphasic shock.
• Recommendations for higher energy
(360J) when using monophasic
waveform.
Biphasic : Mono
96 % vs 54 %
NON-SHOCKABLE RYTHMS
1. Asystole

P-wave Asystole
NON-SHOCKABLE RYTHMS
2). P E A / E M D
Could be any form of waves, may mimic normal ECG
but NO carotid pulse
– treatment similar to Asystole

P-ulseless E-lectro
E-lectrical M-echanical
A-ctivity D-issociation
CPR 30 : 2 raba carotis Adrenaline: 1 mg, iv, repeated
2 menit every 3-5 minutes

ada tidak ada

lihat EKG
rosc
pertahankan jl nafas bebas
tetap beri oksigen shockable un-shockable
raba arteri radialis
lihat EKG- ukur tensi nadi VF / VT Asistol
pertahankan infus PEA / EMD
hipotensi : beri inotropik
terapi aritmia
koreksi elektrolit & cairan single shock 360 J CPR 30 : 2
2 menit
CPR 30:2 (2 menit)
adrenalin
Observasi di ICU lihat managemen
Waspada CA berulang VT / VF managemen asistol
Defibrilation strategy VF / pulseless VT

- a single shock (I)

Biphasic 150-200 Joule
Monophasic 360 Joule
- CPR 30 : 2
2 MINUTES, 30 : 2

NO Check ECG
YES
Check pulse

-a single shock (II) ROSC

Biphasic 150-200 Joule
Monophasic 360 Joule Recovery of
2 MINUTES, 30 : 2 Spontaneous
- Adrenaline Circulation
- CPR 30 : 2 3).
VF / pulseless VT a single shock ( I )
Defibrilation strategy

NO Check ECG YES

Check pulse
- a single shock (II) ROSC
Biphasic 150-360 Joule
Monophasic 360 Joule
- Adrenaline
- CPR 30 : 2 Adrenaline: 1 mg, iv,
repeated every 3-5
2 MINUTES, 30 : 2 minutes
No Check ECG YES
Check pulse
- a single shock (III) ROSC
Biphasic 150-360 Joule
Monophasic 360 Joule 2 MINUTES, 30 : 2 Check ECG
- CPR 30 : 2 Check pulse
VF / pulseless VT a single shock ( II )
Defibrilation strategy

No Check ECG
YES
Check pulse

- a single shock ( III ) ROSC

Biphasic 150-360 Joule
Monophasic 360 Joule
- CPR 30 : 2
2 MINUTES, 30 : 2
No Check ECG YES
Check pulse
ROSC
- Amiodarone 300 mg
or Lidocaine 1 mg/kg Adrenaline: 1 mg, iv,
- A single shock ( IV ) repeated
every 3-5 minutes
- a single shock ( V )
Biphasic 150-360 Joule Biphasic 150 – 360 Joule
Monophasic 360 Joule Monophasic 360 Joule
- CPR 30 : 2 2 minutes - CPR 30 : 2 (2minutes)
 VF/ VT
Intubasi : as soon as possible, without stop CPR Pijat 100x/menit
Nafas 8x/menit

Cardiac 3’ 3’
adrenalin adrenalin adrenalin
arrest VF / VT

2 menit 2 menit 2 menit 2 menit

a single shock-III - AMIODARON a single shock-V

a single shock -I a single shock -II - a single shock-IV
CPR -1 CPR-2 CPR-3 CPR-4 CPR-5 CPR-6
30 : 2
Amiodaron is the first choice
CALL 300 mg, bolus. Repeated 150 mg
FOR Adrenaline: 1 mg, iv, for reccurrent VT/VF. Followed by
HELP repeated every 3-5 900 mg infusion over 24 hours
minutes
PASANG Or LIDOCAIN 1mg/kg. Can be
MONITOR repeated. Do not exceed a total dose of
Evaluasi CPR : tiap 2 menit 3 mg/kg,during the first hour.
ASYSTOL/PEA/EMD
Intubasi : as soon as possible, without stop CPR Pijat 100x/menit
Nafas 8x/menit

Cardiac
arrest evaluasi evaluasi evaluasi evaluasi
ASYST

2 menit 2 menit 2 menit 2 menit

CPR -1 CPR-2 CPR-3 CPR-4 CPR-5 CPR-6
30 : 2 Adrenalin-1 Adrenalin-2 Adrenalin-3
CALL
FOR Adrenaline: 1 mg, iv,
HELP repeated every 3-5
minutes
PASANG
MONITOR Evaluasi CPR : tiap 2 menit
 ILCOR - Guidelines 2005
DRUGS
• Adrenaline : 1 mg, iv, repeated every 3-5 minutes

• Amiodarone: 300 mg, bolus,

if VF/VT persist after 3 shocks.
Dose of 150 mg maybe given for recurrent
or refractory VF/VT, followed by an infusion
of 900 mg over 24 hours

• Lidocain : 1- 1,5 mg/kg, iv, repeated every 3 – 5 minutes, if

amiodarone is not available.
Do not exceed a total dose of 3 mg/kg,
during the first hour.
Do not give lidocaine if amiodarone has
already been given.
Adrenalin, Atropin, Lidocain, Na-Bikarb
• Intra-venous
• Intra-tracheal / trans-tracheal
dosis 3-10 x intravena
• Intra-osseus
• TIDAK intra-cardial !!!
– menghentikan pijat jantung
– sukar pastikan intra-ventrikuler
• kena miokard : nekrosis
• kena a. coronaria : infark
• Na-bikarb hanya 1 mEq/kg dan
paling akhir, hanya INTRAVENA
 Azas CPR

ROSC

Diagnosis cepat
adanya
Cardiac Arrest
 DC shock
1.Oles dulu paddles
dengan jelly ECG
tipis rata, baru
kemudian :

2. Switch ON sternum
Pasang paddles pada
posisi apex dan
parasternal apex
(boleh terbalik)
3. Charge 360 Joules DC shock
(Non-synchronized)
Ucapkan dengan keras :
Awas semua lepas dari pasien!
– nafas buatan berhenti dulu
– bawah bebas,
samping bebas,
atas bebas, sternum
saya bebas!
4. Shock!! apex 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
 Cardiac arrest = carotis (-)

Asystole

= ECG flat,
tak ada gelombang

– UN-shockable
CPR + adrenalin

- ROSC < 10%

( Recovery of Spontaneous
Circulation )
 Asystole (ECG flat)
PEA
|
CPR 2 menit 30 : 2
adrenalin 1 mg / 3-5 menit
Intubasi, iv line,
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Asystole / PEA ROSC
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bradycardia normal
dst

atropin 1-1-1 /
CPR 2 menit 30 : 2 obat klas IIa
 PEA = EMD
ada gelombang mirip ECG normal
– TETAPI nadi carotis tidak teraba
– terapi sama seperti Asystole ( CPR + Adrenalin )

P-ulseless E-lectro
E-lectrical M-echanical
A-ctivity D-issociation
cardiac arrest membandel ???

Hipoksia
4H Hipovolemia
Hiperkalemia
Hipotermia
Tamponade jantung
Tension pneumothorax
4T Thromboemboli paru
Toxic overdose
B-block, Ca-block
Digitalis, Tricyclic AD
MA Massive MI
Asidosis
 Bila berhasil ROSC
• Lanjutkan oksigenasi, kalau perlu nafas buatan
( di Surabaya, 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
Bila setelah ROSC,
lalu cardiac arrest lagi
• Ikuti algoritme semula.

• Bila perlu DC shock tetap diberikan 1 x 360

Joules dan disusul dengan CPR
Ada apa gerangan ?
Silahkan anda ceritakan