ii. modul 1 - dasar ppgd
DESCRIPTION
emergency medicineTRANSCRIPT
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DASAR PENGELOLAAN PENDERITA GAWAT DARURAT
Dept.Dept. Anestesiologi & Terapi Intensif Anestesiologi & Terapi Intensif FK-USU/RSUP H.Adam Malik- MedanFK-USU/RSUP H.Adam Malik- Medan
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Penderita Gawat Darurat
Penderita yang oleh karena suatu penyebab(penyakit, tindakan, kecelakaan) bila tidak segera ditolong akan cacat, kehilangan anggota tubuh atau meninggal
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The Golden HourThe Golden Hour is the time in which resuscitation of severely
injured patients must begin to achieve maximal survive
R. Adams Cowley, MD
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100
80
60
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0 30 60 90
THE GOLDEN THE GOLDEN HOURHOURProbability of SurvivalProbability of Survival
Survival is related to severity Survival is related to severity and durationand duration
minutes
% survival
R. Adams Cowley, MD
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The Trimodal Distribution of Traumatic Disease
The Trimodal Distribution of Traumatic Disease
IMMEDIATE : CNS injury or Heart and great vessel IMMEDIATE : CNS injury or Heart and great vessel injuryinjuryEARLY : Major EARLY : Major
hemorrhagehemorrhageLATE : Infection and Multi Organ failureLATE : Infection and Multi Organ failure
Perce
nt o
f trau
ma d
eath
s
50
40
30
20
10
0
Time after injuryTime after injury 0 1 2 3 4.hrs
// 1-2 5-6 weeks
. Anesthesiology Clin 1987;25:1-18
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PENDERITA GAWAT DARURAT
HIPOKSEMIAHIPERKARBIA
HENTI JANTUNGHENTI NAFAS
SINDROMA IWR
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• A = Airway
• B = Breathing
• C = Circulation
• D = Disability
• Sumbatan 3-5’
• Henti nafas 3-5’ • Shock berat 1-2 jam
• Coma 1 minggu
Gangguan Mati dalamPertolongan
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Korban bernafas tersengal-sengalNadi lemah, gelisah, Cedera berdarah di dada dan punggung
Apa pertolongannya?
• Ukur tek darah • Pasang infus • Konsultasi ke
Dokter Bedah• Beri Oksigen • Periksa Hb • Siap transfusi
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• Sumbatan jalan nafas 3-5 menit
• Henti nafas 3-5 menit
• Shock berat 1-2 jam
• Coma 1 minggu
mati dalam
• Bebaskan jalan nafas
• Beri Oksigen • Pasang infus
• Ukur tek darah• Periksa Hb
• Siap transfusi• Konsultasi ke
Dokter Bedah
•Ukur tek darah
•Pasang infus
•Konsultasi ke Dokter
Bedah
•Beri Oksigen
•Periksa Hb
•Siap transfusi
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PENANGANAN PASIEN TIDAK GAWAT
• Anamnesa• Pemeriksaan fisik
Inspeksi Palpasi Perkusi Auskultasi
• Pemeriksaan penunjang• Diagnosa• Terapi
Supportif Simtomatis Definitif / kausal
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PENANGANAN PASIEN GAWAT DARURAT
• Pem. Fisik awal (Primary survey) (A-B-C-D)+ Lab. Awal
Terapi suportif / resusitasi (life support)
Stabilisasi
• Pem. Fisik sekunder (Secondary survey) Anamnesa Dari kepala s/d kaki (B1 s/d B6)
• Pemeriksaan penunjang• Diagnosa• Terapi defenitif
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Primary survey and resuscitationof vital functions are done
simultaneously – a team approach
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KONSEP ATLS
• Primary SurveyA : Airway with C-spine controlB : Breathing with ventilationC : Circulation with hemorrhage controlD : Disability : neurologic statusE : Exposure/environment with temperature control
• Resuscitation• Secondary Survey
Head – to – toe evaluation and history• Reevaluation• Definitive care
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LIFE SUPPORT
A : Airway Support
B : Breathing Support
C : Circulation Support
D : Disability / Brain Support
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First responder
Life saver
Resusitasi – stabilisasi
Airway Breathing Circulation Disability/Brain
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SHOCKKARENA
PERDARAHAN1
2
3
ResusitasiStabilisasi
Definitif terapiAwal
Definitif terapiakhir
Dr. Penyakit Perdarahan Dalam G.I.
Dr. Bedah
Perdarahantrauma
Dr. Obgyn
Perdarahan post partum
Dr.Umum
Dr.Spesislias
Pembagian Peran Dr. Umum – Dr. Spesialis16
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PROTECTION FROM COMMUNICABLE DISEASE
• Water impermeable apron• Gown• Gloves• Face mask• Cap• Eye protection / goggles• Foot covers
To prevent contact with body fluids patients 17
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Time Saving is Life SavingTime Saving is Life Saving
• Waktu untuk bertindak terbatas
• Data dasar untuk bertindak terbatas
Konsep dasar berfikir yang sederhana, tindakan yang sistematik, dan ketrampilan yang memadai.
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Handling trauma patients requires different mindset
TIME SAVING is LIFE SAVING
Handling trauma patients requires different mindset
TIME SAVING is LIFE SAVING
Prognosis pasien trauma paling baik pada jam pertama.
Dalam waktu satu jam terapi definitip harus sudah dikerjakan
“The Golden Hour”19
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Initial Assessment !!
!!
Initial Assessment !!
!!
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TriageTriage
• Sorting of patients according to:– ABCDE’s– available resources
• Multiple casualties• Mass casualties
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TRIAGE & LABEL
MerahSegera Ditanggulangi terlebih dahulu : Mengancam Jiwa Cacat
Kuning
Boleh Ditangguhkan : Keadaan tidak mengancam Jiwa Segera ditangani bila yang mengancam Jiwa sudah teratasi
Hijau Boleh ditunda & Rawat Jalan :Tidak Membahayakan Jiwa
Hitam
Boleh Diabaikan & Ditinggalkan : Diurus paling akhir Sudah tidak ada tanda- tanda vital Usaha –usaha pertolongan amat sangat kecil keberhasilannya 25
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TRIASE Survei primer,
Survei sekunder
Terapi Definitif, Rujukan
Quick Dx, Quick RX
Resusitasi
& Stabilisasi
KLINIK
RUMAH SAKIT TERDEKAT
RUMAH SAKIT LENGKAP,
KAMAR OPERASI,
ICU
Hanya 50% pasien trauma yang perlu
operasi26
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Survei PrimerSurvei Primer
• Periksa cepat berurutan• Selesai dalam 2 menit
• Terapi segera apa yang ditemukan( treat as you find )
dewasa/pediatrik/ wanita hamil
prioritas yang sama
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ABCDE
ABCDE
Survei Primer
Airway
Breathing
Circulation
Disability
Exposure
Jalan nafas
Pernafasan
Sirkulasi
Kesadaran
Pemaparan
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Airwaymenilai jalan nafas
Airwaymenilai jalan nafas
• Bisa bicara ?• Look, listen, and feel
• Gerak dada• Gerak otot nafas tambahan• Warna kulit, mukosa, kuku
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AirwaywaspadaAirway
waspada
• Obstruksi jalan nafas• Cedera dada dengan gangguan nafas
• Cedera tulang leher
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Pasien tidak sadarPasien tidak sadar
Sumbatan jalan nafas paling sering oleh karena jatuhnya pangkal lidah
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AirwaywaspadaAirway
waspada
•Suspect C-spine injury– spinal protection– C-spine X-ray when appropriate
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Breathingmenilai pernafasan
Breathingmenilai pernafasan
• Apakah ada udara keluar masuk• Frekwensi nafas• Cuping hidung
• Cekungan sela iga
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Breathingwaspada
Breathingwaspada
ada jejas didada
• Tension pneumothorax• Open pneumothorax
• Fracture costa, Flail chest• Hematothorax• Kontusio paru
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Breathingmembantu pernafasan
Breathingmembantu pernafasan
• Beri oksigen ( jika ada )• Pernafasan buatan (AMBU)
• Dekompressi pneumothorax• Drain thorax
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Circulationmenilai sirkulasi
Circulationmenilai sirkulasi
• Cardiac output• Volume darah
• Perdarahan (external,internal)
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Circulationwaspada dan cari lokasi
perdarahan
Circulationwaspada dan cari lokasi
perdarahan
• Cedera intra abdominal• Cedera dada
• Patah tulang panjang• Patah tulang pinggul• Luka tusuk, tembus
• Luka kulit kepala38
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Circulationshock ?
Circulationshock ?
• Perfusi : pucat, dingin, basah, capillary refill time lambat
• Nadi >100x/m• Tekanan darah <100 mmHg
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Estimasi tekanan darahEstimasi tekanan darah
Jika teraba nadi di :•Radialis systolik > 80 mmHg•Femoralis systolik > 70 mmHg•Carotis systolik > 60 mmHg
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Disabilitymenilai kesadaran
Disabilitymenilai kesadaran
• Periksa pupil (besar, simetri, refleks cahaya)
• Periksa kesadaran A = Awake (sadar penuh) V = respond to Verbal command (ada reaksi terhadap perintah) P = respond to Pain (reaksi thdp nyeri) U = Unresponsive (tidak ada reaksi)
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ExposurepemaparanExposure
pemaparan
• Lepaskan semua pakaian untuk pemeriksaan teliti menyeluruh, ada jejas apa saja.
• Periksa punggung,(miringkan pasien dengan cara Log Roll)
• Cegah hypothermia (jangan kedinginan)
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X – foto(kalau ada)
X – foto(kalau ada)
•Tulang leher•Dada
•Panggul
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Survei SekunderSurvei Sekunder
• Lanjutan survei primer• Hanya bila ABC sudah stabil
• Teliti kepala sampai kaki• Kembali survei primer bila pasien
menjadi tidak stabil atau kondisi memburuk
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Setelah survei sekunder Setelah survei sekunder
• Pasien stabil
• Rujukan
• Definitive care
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Ingat !!!!Ingat !!!!
Periksa ulang ABCDE Jika pasien kembali tidak
stabil
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