Artificial Circulation, Dr. TOMMY
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Transcript of Artificial Circulation, Dr. TOMMY
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Lab / SMF Anestesiologi & Reanimasi
FK. Unair – RSU Dr. Soetomo
Surabaya
A R T I F I C I A L C I R C U L ATI O N
( C A R D I A C M A S S A G E )( P I J AT J A N T U N G )
Dr. Tommy Sunartomo, SpAn K.IC
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Jude & Kouweno!en "#$%# –'losed (est resus(itation )
• #*+ (ardia( arrest in os,ital• #- RS'
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0eo,le earts sto, beating e!eryday
For many ,eo,le
1eir earts / brains sould be2 1oo 3ood 1o Die 2
Resus(itati!e e44ort (an restore tese eartsto s,ontaneous a(ti!ity be4ore te brain
as been ,ermanently in5ured
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• 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 kee!akaan !a!u !intas di "ndonesia
1991 1#$621 orang 1992 9$819 orang 1993 1#$#38 orang 1994 11$##4 orang
1995 9$251orang (sampai Maret)
K E S E H A TAN R U M A H S A K I T
1 9 8 6 , 1 9 9 2 D A N 1 9 9 5
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sic life support emergency oxygenationA : AirwayB : BreatheC : Circulate
vanced life support Restoration of spontaneousrculationD : Drugs and luids! : !"# : i$rillation treatment
olonged life support post resuscitation $rain 'iented therapy# : #auging( : (uman )entation
* : *ntensive care
C P C R / R J P O
( P ! " S # $ # " )
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• &rimary +urveyA : Airway with C-spine controlB : Breathing with ventilationC : Circulation with hemorrhage controlD : Disability : neurologic status
E : Exposure / environment with temperature control
• Resuscitation
• +econdary +urveyHead to toe evaluation and history
• Reevaluation
• De,nitive care
K O N S E P A TL S
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*n the &rimary +urvey- focus on $asic C&R andde,$rillation
irst ABCD
• Airway :/pen the airway
• Breathing:&rovide positive ' pressure ventilations
• Circulation :#ive chest compressions
• De,$rillation :+hoc0 ventricular ,$rillation or pulseless
ventricular tachycardia 345
K E % P O I N T S A C L S
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n the +econdary +urvey- focus on intu$ation-ntravenous *5 access- and drugs andhy the cardio respiratory arrest occurred
econd ABCD
• Airway :&erform endotracheal intu$ation
• Breathing:Assess $ilateral chest rise and ventilation
• Circulation :
#ain * access- determine rhythm- giveappropriate agents
• Di6erential Diagnosis 4hin05:+earch for- ,nd- and treat reversi$le cause
K E % P O I N T S A C L S
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• 1e (lini(al ,i(ture o4 o!erall (essation o4(ir(ulation
• Un(ons(iousness•
A,nea or gas,• Deat – li6e a,,earan(e "(yanosis or ,allor
• Diagnosis 'ardia( Arrest "7o ,ulse – Adult )
• 'arotid• Femoral
– 8n4ant small (ildren )
• 9ra(ial
• Femoral
R & " ' * C # " + # A " " ' !
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!erabaan nadi carotis
dari tengah "e-lateral
Awam : tida" perlumeraba carotis
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• #: se(ond – Un(ons(iousness
• #: – *- – 8soele(tri( ;;3
•*- – %- – Agonal gas,ing
A,nea
Ma< ,u,illary dilatation
= : minute – (erebral damage
C 0 * ! C ' ' # ! . $ C "
Time saving is Life saving
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• 0rimary ) –
>entri(ular Fibrillation – Asystole – ?eart 9lo(6 – ;le(tri( So(6 – Drugs
• Se(ondary ) – Ra,id )
• As,y<ia• ;<sanguination•
A(ute 0ulmonary ;dema• <ygen – Free 3as – Slow )
• ?y,o<emia• So(6
• ;MD
C # " + # A " " ' !
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%&'* %+, '-. %+,
,+'/0%"%-UM-
%0/*"0%-UM-
A R T I F I C I A L C I R C U L A TI O N
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+eart -ump
Meanism
%est -ump
Meanism
A R T I F I C I A L C I R C U L A TI O N
ueeing te eart
eteen sternumand pine
'era!! intratorai
-ressure !utuation
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• 'ardia( out,ut• 'arotid artery blood 4low• 'erebral 9lood Flow "'9F•
'9F ) – 7ear @ero → witout '0R – :- 7 → Maintain (ons(iousness – B- 7 → Maintain (ell >iability
•'oronary 0.0 and blood 4low → Low
→ Rigt atrial ,ressure C• 1ung6ai dibuat lebi tinggi
C * ' + C 3 ' ! C P R
*- 7ormal
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• 1iti6 tum,u
• 1e6ni6 memi5at• Monitoring
• Kom,li6asi
C * ' + C 3 ' ! C P R
( P 4 # ! J # . ! - . L - # " )
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• 0ada tulang dada
• Dewasa )
–
B 5ari 6ranial ,ro(. y,oideus "B--- – 1enga 1ora6s "B--:
–1enga sternum distal "B-#-
•9ayi ) –1enga sternum
–3aris inter mammary
T ! T -0 -
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*7C/R8nternational Liaison 'ommittee on Resus(itation
uide!ines 2##5 )ain changes in adult $asic life support
• tart %-/ en itim is unresponsie and
not :reating norma!!;
• -!ae te ands on te entre o te est
• ,o resue :reats< 1 se ea rater tan 2 se
• ,e ratio o ompressions to enti!ations is 3# = 2
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8L'R E 3uidelines B--: E B-#-
• C#$C%&A'#()
– 'iti" tumpu pi*at *antung disternum ditengahdada +,.
– 0etengah sternum bagian distal +,1
– !i*at *antung 1x per menit2
diprioritas"an agar tida" ada sela3- !i*at *antung 1x /men2 na4as buatan 1x
/men
- Bila masih belum terintubasi : $atio pi*at *antung dan na4as 5 : ,
- Dua atau satu penolong tida" dibeda"an-
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Treatment Recommendation
• All res(uers sould ,er4orm (est (om,ressions 4or all ,atients in
(ardia( arrest.• 'est (om,ressions alone are re(ommended 4or untrained lay,ersons
• 0ro4essional res(uers sould ,ro!ide (est (om,ressions wit
!entilations 4or (ardia( arrest !i(tims
• -erorming est ompressions a!one is reasona:!e or trained
!a;persons i te; are inapa:!e o de!iering aira; and :reating
maneuers
• 1ere is insu44i(ient e!iden(e to su,,ort or re4ute te ,ro!ision o4 (est
(om,ressions ,lus airway o,ening and o<ygen insu44lation by
,ro4essional res(uers during te 4irst 4ew minutes o4 resus(itation
Chest Compression–Only
CPR
2010 ILCOR
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'iti" tumpu pi*at
*antung adalah
disternum
Di tengah, dada
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titi0 tumpu
pi8at 8antung
uide!ines 2##5 =
p!ae te ands on te entre
o te est
Using te ri: margin metod
is asting time
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'umit 1 tangan
dileta""an diatassternum2"emudiantangan satunya
dileta""an diatastangan yang sudahberada di-titi"pi*at *antung
+di-tengah, dada 6ari-*ari "edua tangan dirapat"an
dan diang"at pada wa"tu dila"u"an tiupan na4as2agar tida" mene"an dada3
'iti" tumpu pi*at *antung
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!enolongmengambil
posisi tega"lurus
di atas dada"orban dengan
si"u lengan lurus
8ene"an tulangdada sedalam
"ira-"ira9-. cm3
Pijat jantung
tiap melepas 1 pi*atan 2
gan *angan masih mene"an dada "orban
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#--< ,er menit
45 m
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at pi*at *antung2
tung dengan suara "eras
tu2dua2tiga2empat2 0A'%tu2dua2tiga2empat2 D%A2
tu2dua2tiga2empat2'#A
tu2dua2tiga3empat2E8!A'
tu2dua2tiga2empat2Atu2dua2tiga2empat2E)A8
tal ; 5 x pi*atan
ng disela dengan , x tiupan na4as
Pijat jantung nafas buatan
30 : 2
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ijat jantung nafas buatan
• &a"u"an 5 "ali pi*at *antung
dengan diselingi
, "ali na4as buatan ini berulang
selama , menit
• 0etelah , menit +=-> si"lus raba
nadi leher3
• Bila masih belum teraba denyut
nadi leher2 lan*ut"an 5 x pi*at
*antung dan , x na4as buatan
• &a"u"an tinda"an ini terus sampai
datang bantuan atau ambulans
30 : 2
T M 4 !
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• Dewasa ) –
1umit tela,a6 tangan – Dua tangan• Ana6 )
– 1umit tela,a6 tangan –
Satu tangan• 9ayi ) Dua 5ari " Jari 88 888 • 0osisi tega6 – lurus• Kedalaman memi5at )
– Dewasa ) #G: – BG- in( "H E : (m – Ana6 ) #G- – #G: in( "BG: – H (m – 9ayi ) -G: in( "# – B (m
• Ia6tu memi5at wa6tu rela6sasi
• Fre6wensi #-- / m "(e,at dan 6uat
T . M 0 4 # !
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• # 0enolong ) – #: ,i5at 5antung "Fre6. +- – #-- / m
– B na4as buatan "#EB deti6 / na4as buatan
• B 0enolong ) – #: ,i5at 5antung "4re6.+- – #-- / m
– B na4as buatan "#EB deti6 / na4as buatan
– Setela di intubasi 0i5at Jantung #--</menit 7a4as
9uatan#B E B-</menit di sela – sela ,i5atan.
# ' P 4 # ! J # . ! - . 7 N # $ # '
uide!ines 2###
uide!ines 2##5 2#1#
• # atau B ,enolong *- ) B Fre6. #-- / m
S t l
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,aun 2### =
Tahun 2005,2010 :
3# = 2
Satu penolong
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21Tahun 2005,2010:
3# = 2
,aun 2### =
Dua penolong
Korban tidak
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Korban tidak
sadar
bebas"an *alan
na4as
*alan na4as bebastida" berna4as
tida" teraba nadi
Pasangmonitor EKG
( di RS )
13
,3
53
93
.3
Call for help
, x tiupan awalraba nadi carotis
beri pi*atan *antung
dan na4as buatan
A.
B.
C.
awam
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– 0i5at dulu baru tiu,
– 0i5at 5antung yang ,ertama tan,a terlebi daulu meraba 6arotis – 1iti6 tum,u ,i5at 5antung ,ada setenga bagian bawa sternum. – 9ila belum di –intubasi atau di,asang LMAG ma6a setia, *- ,i5atan
5antung diselingi B 6ali tiu,an na4as " ratio *- ) B
– 9ila suda diEintubasi 0i5at 5antung #--< ,er menitG di,rioritas6an
agar tida6 ada sela. -us +ard< -us >ast
0i5at 5antung #--< /menG na4as buatan #-< /men. – 9eri 6esem,atan dinding tora6s untu6 “re-coil” setela ,i5atan
– Ji6a tra(ea suda diEintubasi ta6 usa sin6ronisasi antara ,i5at
dan na4as – Dua atau satu ,enolong tida6 dibeda6an
• CIRCULATION
M !
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• 7adi (arotis → ole ,emberi na4as –
8ntermitten – B menit beri6utnya " – + si6lus
• 0u,il – U6uran –
Re4le6s• Di RS. – ;K3 – 0ulse o<imetri –
93A – 1ensi – nadi – 0er4usi organ – ;1'B
M . ! " .
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• 0ata tulang iga
• 0ata tulang dada
• 'edera 5antung
• 'edera ,aru
• 'edera ,embulu dara• 'edera organ abdomen
K 0 * # '
N T 3
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• 8A' – '0R 8nter,osed Abdominal 'om,ression – '0R
•>est – '0R 'ir(um4erential >est 'om,ression – '0R
• A'D – '0R
A(ti!e 'om,ression De(om,ression – '0R
• ,en 'est – '0R
N T 3 . : - '
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• 'lass 8 ) De4initely ?el,4ul
• 'lass 88 a ) A((e,tableG 0robably ?el,4ul
• 'lass 88 b ) A((e,tableG 0ossibly ?el,4ul
• 'lass 888 ) 7ot 8ndi(atedG May be arm4ul
D " - '
A + * / E 3
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•bat Sim,atomimeti6 – >aso6onstri6tor – >aso,resor
• 0ilian utama ,ada (ardia( arrest "'0R• ;4e6 α dan β
– α • >aso6onstri6si sistemi6 tida6 ,ada 6oroner dan
ota6• C taanan ,eri4er• C te6anan sistole dan diastole → aliran 6e ota6 dan
otot 5antung C – β
• C 6onstri6si otot 5antung• C irama 5antung•
9ron6o dilatasi
A + " . # * . / E . 3 " .
E . 3 " . / A + " . # * .
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•
8ndi(ations ) – 'ardia( arrest ) >FG ,ulseless >1G asystoleG 0;AG "'lass 8 – Sym,atomati( ) – 9rady(ardia ) a4ter Atro,ine and trans(utaneous ,a(ing "(lass 88 b
• Dosage )
– 'ardia( arrest )• First dose ) #G- mg / 8> ,us – re,eat e!ery * – : min
– Alternati!e regimens 4or se(ond dose "(lass 88 b• 8ntermediate ) B – : mg / 8> ,us e!ery * – : min• ;s(alating ) # mgG * mgG : mg / 8> ,us "* min a,art•
?ig ) -G# mg / 6g / 8> ,usG e!ery * – : min – ;ndotra(eal route )
• BG- – BG: mg diluted in #- ml normal Saline – 0ro4ound 9rady(ardia )
• B – #- mg # min "#mg in :-- ml normal Saline # – : ml / min
E . 3 " . / A + " . # * .
A ! " . S - * $ # !
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• 8ndi(ations – First drug 4or sym,atomati( brady(ardia "(lass 88 a – Se(ond drug "a4ter ;,ine,rine 4or Asystole or
9rady(ardi( 0;A "(lass 88 a•
Dosage – Asystole or 0;A• # mg / 8> ,us – re,eat e!ery * – : min• Ma< dose -G-* – -G-H mg / 6g
– 9rady(ardia
• -G: mg – #G- mg / 8> e!ery * – : min• Ma< dose -G-* – -G-H mg / 6g
– ;ndotra(eal administration• B – * mg diluted in #- ml normal Saline
A ! " . S - * $ # !
L + # .
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• 8ndi(ations – 'ardia( arrest 4rom >F / >1 "(lass 88a – Stable >1G wideE(om,le< ta(y(ardias wide (om,le<
0S>1 "(lass 8
• 'ardia( arrest 4rom >F / >1 – 8nitial dose ) #G- – #G: mg / 6g 8> – For re4ra(tory >F re,eat #G- – #G: mg / 6g 8> in * – :
minG total dose ) * mg / 6g – A single dose o4 #G: mg / 6g 8> in (ardia( arrest isa((e,table
– ;ndotra(eal administration ) B – H mg / 6g
L + # .
S + - 0 # " . # !
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• 8ndi(ations
– 'lass 8 )• 84 6nown ,re e<isting ?y,er6alemia
– 'lass 88 a )• 84 6nown ,re e<isting 9i(arbonate – A(idosis ";3. Diabeti(
Keto A(idosis• 84 o!erdose wit tri(y(li( anti de,ressants to Al6alini@e te
urine drug o!erdose – 'lass 88 b )
• 84 intubated and (ontinued long arrest inter!al• U,on return o4 s,ontaneous (ir(ulation a4ter long arrest
inter!al –
'lass 888 )• ?i,o<i( La(ti( A(idosis ";3. 'ardia( arrest and 'R0 witoutintubation
• Dosage – # m; / 6g 8> bolus – re,eat al4 tis dose e!ery #- min blood
gas analysis e!aluation
S + - 0 # " . # !
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DC shoc0
(les dulu paddlesdengan *ellyEC tipis rata2
baru "emudian :
1. Switch ON
Pasang paddles padaposisi apex danparasternal
(boleh terbalik
sternum
apex
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DC shoc"B. !harge 3"0 #o$les(Non%s&nchroni'ed
capkan dengan keras :)was sem$a lepas dari pasien* – na+as b$atan berhenti d$l$ – bawah bebas,
samping bebas,atas bebas,
sa&a bebas*
3. Shock**
(tekan d$a tombol paddles bersama-epas paddles dari dada,lan$tkan chest compression.
/. Segera piat ant$ng lagi 2 menitbar$ raba lagi baca lagi !
sternum
apex
!osition
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!ositiono4 the paddles electrodeson thorax o4 an in4ant
Size of paddle electrode- /. cm diameter +or in+ants and small children- 4%12 cm diameter larger children
sternum
apex
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#ell& k$rang rata, menekan paddles k$rang k$at % l$ka bakar
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56 5entric$lar 6ach&cardia|
| |
carotis +? carotis +-
&idocain
1 mg/"g iv cepatatau
Amiodaron 5 mg
C!$ 5:, - . 0#@&%0
a single shoc"5 6oulesdst
8anagemen '/
D $ " * * # ! .
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• 8ndi(ations
–>F " (lass 8
– 0ulseless >1 " (lass 8
uide!ines 2###
• Dosage
– B-- Joule ) 4irst so(6 – B-- – *-- J ) se(ond so(6
– *%- J ) tird so(6
– 84 4ail to (on!ert >F / >1 (ontinue at *%- J 4or 4uture so(6
– 84 >F re(oursG so(6 again at te last su((ess4ul energy le!el
uide!ines 2##5 < 2#1#
– Mono ,asi( *%- J
– 9i ,asi( #:- J – B-- J
D $ " * * # ! .
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76
• '0R dila6u6an sambil menunggu datangnya D' so(6
DeEF89R8LLA187 / D' so(6
– D' so(6 sedini mung6in "sebelum :E#- menit
– *%- Joules #< "dulu *< so(6G re,eated so(6
"Ji6a D' so(6 bi,asi( #:-EB-- Joules
• Setela a single so(6G segera '0R lagi B menit tan,a
(e(6 ;'3 suda RS' atau belum
• 9aru setela B menit '0RG berenti sebentar untu6
(e(6 ;'3 a,a6a suda RS'
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E * ! " # * T 3 " # ;
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#. Sim,le (est tum, – Iitnessed >1 / >F
B. Re,etiti!e (est tum,s – ?eart blo(6
*. 'ardio!ersion
"syn(roni@ed ele(tri( (ounter so(6s – AFG 0S>1 – >1 wit ,ulse
H. 7on syn(roni@ed ele(tri( (ounter so(6s –
>1 witout ,ulse – >F:. 0a(ing
– ?eart blo(6 –
Asystole
;
cardiac arrest membandel
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Hipo"sia
HipovolemiaHiper"alemiaHipotermia
'amponade *antung 'ensionpneumothorax
'hromboemboli
paru 'oxic overdoseB-bloc"2 Ca-bloc"Digitalis2 'ricyclicAD
9 (
9 4
)A
cardiac arrest membandel
ASS1L;/ 0;A/ ;MD
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ASYS
2 menit 2 menit 2 menit 2 menit
e7al$asie7al$asi
Adrenalin!1C"#!$C"#!2 C"#!5C"#!%
)drenaline: 1 mg, i7,
repeated e7er& 3%
min$tes
C"#!&
Cardiac
arrest
ASS1L;/ 0;A/ ;MD
8nt$bation
(-9): as soon as possible, witho$t stop compression
Piat 100xmenit
Na+as 10xmenit
7al$asi !P : tiap 2 menit
e7al$asie7al$asi
C"# !1
$0 ' 2
CA((
)*#
+,("
"ASA-G
.*-/*#
,G
Adrenalin!2 Adrenalin!$
>F/ >1 ,ulseless
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C"# !1
$0 ' 2
CA((
)*#+,("
"ASA-G
.*-/*#
)
a single shoc3!//a single shoc3!/! a single shoc3!/
a single shoc3!/// a single shoc3!2 menit 2 menit 2 menit 2 menit
adrenalinadrenalin
C"#!$C"#!2C"#!5
C"#!%
! A./*4A#*-
)drenaline: 1 mg, i7,
repeated e7er& 3%
min$tes
C"#!&
Cardiac
arrest
Or -8;O!)8N 1mgkg. !an be
repeated. ;o not exceed a total dose o+
3 mgkg,d$ring the +irst ho$r.
)miodaron is the +irst choice
300 mg, bol$s. epeated 10 mg+or recc$rrent 565<. <ollowed b&
=00 mg in+$sion o7er 2/ ho$rs
>F/ >1E,ulseless
8nt$bation
-9) : as soon as possible, witho$t stop compression
Piat 100xmenit
Na+as 10xmenit
7al$asi !P : tiap 2 menit
adrenalin3>
B-#-
3>
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A0R8L A7;S1;S8
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TERIMA KASIH