Bagian .

CRITICAL CARE
MEDICINE
Introduction, basic concept
ASSESSMENT
 Understand the importance of early identification of
patients at risk of life threatening illness.

 Recognize early signs of critical illness

FRAME WORK FOR ASSESSING THE
CRITICAL ILL PATIENTS
Phase I
Initial contact – first minute
(Primary survey)
What is the main
physiological problem ?
Phase II
Subsequent review
(secondary survey).
What is the underlying
cause?
Initial assessment of the citically ill patient
History (riwayat penyakit, anamnesis)
Keluhan utama, waktu datang, penyakit / operasi
sebelumnya, obat yang sedang dimakan, riwayat alergi,
riwayat keluarga,

Hal yg berhubungan dengan penyakit kritis yg belum

ditangani akan memperlihatkan a.l
 Pernafasan yg terganggu,
 Low cardiac out put,
 Penurunan kesadaran dan
 Gejala yang berhubungan dengan kelainan yang menjadi dasar
(underlying condition)
Phase I (primary survey)
1. History : gambaran utama kejadian atau keadaan
disekitarnya.
 Datadari keluarga atau orang disekitar yg mengetahui
 Keluhan utama : nyeri, sesak nafas
 Trauma atau nontrauma
 Operative atau nonoperative
 Obat2 an yg dimakan atau ada keracunan

2. Examination (pemeriksaan); Look, listen, feel

Airway, breathing & oxygenation, circulation, level of
consciousness
Phase I (primary survey)
3. Documentation, chart review: Heart rate, rhytm, blood
pressure, respiratory rate, pulse oximetry, level of
conciousness.

4. Investigations; Blood gas analysis, blood glucose.

5. Treatment (pararel dengan hal diatas): Oxygen,

intravenous access & cairan, assess response utk
immediate resuscitation, hubungi orang/ dokter yang
lebih berpengalaman
Phase II (secondary survey)
1. History : more detailed information.
 Keluhan saat ini
 Penyakit/ operasi sebelumnya
 Ketergantungan fisik atau psikososial
 Obat2 an atau riwayat alergi
 Riwayat keluarga
 Issue legal dan etik
 System review

2. Examination: structured review of organ system

 Respiratory, cardiovascular, abdomen & genitourinary tract, cebtral
nervous, musculoskeletal systems, endocrine & hematological
system
Phase II (secondary survey)
3. Documentation, chart review: Case records and note
keeping:
 Examine medical records is available
 Formulate spescific diagnosis
 Document current events

4. Investigation: laboratory blood tests, radiology, ECG,

microbiology.

5. Treatment: refine treatment, assess response, review

trends: provided specific organ system support as
required, choose most appropriate site of care, obtain
specialist advice/assistance
ASSESSMENT OF AIRWAY AND
BREATHING
AIRWAY PROBLEM
 Cause of obstruction
 blood,

 vomitus,

 foreign body,

 CNS depression,

 direct trauma,

 infection,

 inflammatin,

 laryngospasm.
AIRWAY ASSESSMENT
 LOOK for.
 Cyanosis
 Perubahan frekuensi dan pola pernafasan (Altered
respiratory pattern & rate)
 Bernafas dgn penggunaan otot pernafasan tambahan
(Use of accessory muscles)
 Trache tdk digaris tengah/ Tarikan pada trachea
(Tracheal tug)
 Perubahan derajat kesadaran (Altered level of
consciousness)
AIRWAY ASSESSMENT
 LISTEN for.
 Pernafasan berbunyi/ Noisy breathing (grunting, stridor,
wheezing, grunting).
 Tidak ada suara nafas (silence) pd obstruksi total

 FEEL for,
 Decreased or absent air flow
BREATHING PROBLEM
 Cause of inadequate breathing,
 Depressed respiratory drive : CNS depression

 Depressed respiratory effort : muscle weakness,

nerve/ spinal cord damage, debilitation, chest wall
abnormality, pain.

 Pulmonary disorders: pneumo/ hematothorax,

aspiration, COPD, asthma, pulmonary embolus, lung
contusion, acute lung injury, ARDS, pulmonary
edema,
BREATHING ASSESSMENT
• LOOK for,
• Cyanosis
• Altered respiratory pattern and rate
• Equility & depth of respiration
• Sweating
• Elevated JVP
• Use of accessory muscles
• Tracheal tug
• Altered level of consciousness
• Oxygen saturation
BREATHING ASSESSMENT
 LISTEN for.
 Dyspnea
 Inabilty to talk

 Noisy breathing

 Percussion

 Auscultation

 FEEL for
 Symmetri & extent of chest movement, position of trachea, crepitus,
abdominal distention
Frekuensi nafas atau Respiratory Rate (dewasa)
dapat dibagi menjadi:

 RR < 12 x/menit : sangat lambat

 RR 12-20 x/menit: normal
 RR 20-30 x/menit: sedang cepat
 RR > 30 x/menit: abnormal (menandakan hipoksia,
asidosis, atau hipoperfusi)

 Untuk lebih akurat kondisi breathing sebaiknya pasang

pulse oksimetri untuk mengetahuai jumlah saturasi
oksigen, normalnya > 95%.
ASSESSMENT OF CIRCULATION
CIRCULATION PROBLEM

 CAUSES OF CIRCULATORY INADEQUACY.

 Primary : directly involving the heart (ischemia, conduction

defect, valvular disorders, cardiomyopathy)

 Secondary: pathology originating elsewhere (drug, hypoxia,

electrolyte disturbances, sepsis)
CIRCULATION ASSESSMENT
 LOOK for,
 Menurunya perfusi perifer /Reduced peripheral perfusion
(palor, coolness)
 Perdarahan/ Hemorhage
 Perubahan derajat kesadaran/ Altered level of consciousness,
 sesak/ dyspnea,
 Decreased/ penurunan urine out put
CIRCULATION ASSESSMENT
 LISTEN for,
 additionalor altered heart sound
 Carotid bruit

 FEEL for,
 Precordial cardiac pulsation
 Pulses ( central & peripheral)
 Assesing rate
 Quality
 Regularity
 Symmetri
disability
Kita harus cek status kesadaran korban dengan menggunakan
konsep AVPU (trauma):
 A: Alert/Sadar (klien/korban dapat dikatakan sadar apablila dapat
berorientasi terhadap tempat, waktu dan orang)
 V: Verbal/respon terhadap suara (korban/klien dalam keadaan
disorientasi namun masih diajak bicara)
 P: Pain/resepon terhadap nyeri (korban/klien hanya berespon
terhadap nyeri)
 U: Unresponsive/tidak sadar (tentukan kesadaran korban apakah
berada dalam keadaan Alert, Verbal, Pain, Unresponsive)
 Eye opening (E)
4. Spontaneous
3. To speech
2. To pain
1. None

 Motor response (M)

6. Obeys command
5. Localizes pain
4. Normal flexion (Withdrawal)
3. Abnormal flexion
(Decorticate)
2. Abnormal Extension
(Decerebrate)
1. None
 Verbal response (V)
5. Oriented
4. Confused conversation
3. Inappropriate words
2. Incomprehensible sound
1. None
eksposure
 Lepaskan baju dan penutup tubuh pasien agar dapat
dicari semua cedera yang mungkin
ada.
 Jika ada kecurigaan cedera leher atau tulang belakang,
maka imobilisasi in-line harus
dikerjakan.