*BANTUAN HIDUP DASARdr. Nasman Puar SpAnBagian Anestesiologi FKUA/RS. Dr. Djamil

*RESUSITASI OLD FASHION

*resusitasi = "resuscitare" = membangunkan lagi 1950-an : resusitasi nafas buatan (Safar & Elam)1960-an : resusitasi KJL (Kouwenhoven)1961 : nafas buatan + KJL (Safar)RJP RJPOSEJARAH RESUSITASI

*RESUSITASI MODERN

*untuk memberikan oksigenasi segeraA: airway control = pengendalian jalan nafasB: breathing support = pemberian nafas buatan dan oksigenasi paru-paruC: circulation support = pengenalan tanda-tanda henti jantung dan mempertahankan sirkulasi dengan kompresi jantung luar, pengendalian perdarahan dan syokBantuan Hidup Dasar (BHD)

*Bantuan Hidup Lanjut (BHL) untuk menimbulkan sirkulasi spontan kembali dan menstabilkan sistem kardiovaskuler D: drug and fluids = penggunaan obat-obatan dan cairan intravenaE: electrocardiography = pengenalan gangguan irama jantungF: fibrillation treatment = terapi kejut listrik sesuai gangguan irama jantung

*Bantuan Hidup Jangka Panjang (BHJP) G: gauging = menentukan penyebab dan terapi definitif serta menilai kemungkinan keselamatan pasienH: human mentation = menyelamatkan fungsi otak dengan cara resusitasi otakI: intensive care = resusitasi keseluruhan fungsi tubuh dalam jangka waktu panjang

*LATAR BELAKANGDi Eropa : kira-kira 700,000 kasus henti jantung (cardiac arrest) per tahunhanya 5-10% yg keluar RS dgn selamatDi Amerika + Kanada :angka kejadian henti jantung mendadak= 0,55 dari 1000330.000 kematian akibat serangan jantung250.000 diantaranya meninggal di luar RSBgmn di Indonesia ??8

*

*

*Resusitasi = ........??resuscitation = to revive from apparent death or from unconsciousnessmake (something such as an idea or enterprise) active or vigorous again

resusitasi berkonotasi Resusitasi Jantung Paru

*CPR (RJP) = a series of lifesaving actions that improve the chance of survival following cardiac arrest.BLS (BHD) = is the foundation for saving lives following cardiac arrest. Fundamental aspects of BLS include:immediate recognition of sudden cardiac arrest (SCA) and activation of the emergency response systemearly cardiopulmonary resuscitation (CPR)rapid defibrillation with an automated external defibrillator (AED). --AHA2010--Definisi dari AHA

*Basic life support (BLS) refers to maintaining airway patency and supporting breathing and the circulation,without the use of equipment other than a protective device--ERC 2005--Definisi dari ERCdoi:10.1016/j.resuscitation.2005.10.007

*Belum ada pernyataan apapun dari InaRC :istilah-istilah ?pedoman (guideline) resusitasi

Pada kenyataannya masing-masing disiplin ilmu dan tiap dokter berusaha untuk mendapatkan pedoman, bersumber dari literatur LN, untuk diterapkan di IndonesiaSumber yang populer : AHA dan ERCMasing-masing RS dapat membuat protokol sendiri untuk resusitasiDefinisi dari InaRC ?(Indonesian Resuscitation Council)

*ILCOR = International Liaison Comittee on ResuscitationAmerican Heart Association (AHA)European Resuscitation Council (ERC)Heart and Stroke Foundation of Canada (HSFC)Resuscitation Councils of Southern Africa (RCSA)Australian Resuscitation Council (ARC)Resuscitation Councils of Latin America (CLAR)New Zealand Resuscitation Council (NZRC)

*Didirikan th.1992 dgn misi :.......Its mission is to identify and review international science and knowledge relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and when there is consensus to offer treatment recommendations. Emergency cardiovascular care includes all responses necessary to treat sudden life-threatening events affecting the cardiovascular and respiratory systems, with a particular focus on sudden cardiac arrest.......ILCORKonferensi I (1999) menghasilkan konsensus : International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

*RANTAI KESELAMATAN (CHAIN OF SURVIVAL)a core set of actions provides a universal strategy for achieving successful resuscitation

200020052010Call for helpChest CompressionDefibrillationAdvanced Life SupportPost-Cardiac arrest Care

*Early recognition & EMS activation Early CPREarly defibrilationEarly ALS & post resuscitation careRANTAI KESELAMATAN (CHAIN OF SURVIVAL)

*Call for helpChest CompressionDefibrillationAdvanced Life SupportPost-Cardiac arrest Care

*Tanpa BHD (RJP) kemungkinan korban utk survive berkurang antara 7%-10% /menitDengan BHD (RJP) kemungkinan korban utk survive berkurang antara 3%-4% /menit sampai dilakukan defibrilasi

*When these links are implemented in an effective way, survival rates can approach 50% following witnessed out-of hospital ventricular fibrillation (VF) arrest. Unfortunately survival rates in many out-of-hospital and in-hospital settings fall far short of this figure. For example, survival rates following cardiac arrest due to VF vary from approximately 5% to 50% in both out-of-hospital and in-hospital settings.This variation in outcome underscores the opportunity for improvement in many settings.AHA 2010RANTAI KESELAMATAN (CHAIN OF SURVIVAL)

*The first link of this chain indicates the importance of recognising those at risk of cardiac arrest and calling for help in the hope that early treatment can prevent arrest. The central links depict the integration of CPR and defibrillation as the fundamental components of early resuscitation in an attempt to restore life.Immediate CPR can double or triple survival from VF OHCA. Performing chest-compressiononly CPR is better than giving no CPR at all.ERC 2010RANTAI KESELAMATAN (CHAIN OF SURVIVAL)

*Following VF OHCA, cardiopulmonary resuscitation plus defibrillation within 35 min of collapse can produce survival rates as high as 4975%.Each minute of delay before defibrillation reduces the probability of survival to discharge by 1012%.The final link in the Chain of Survival, effective post-resuscitation care, is targeted at preserving function, particularly of the brain and heartERC 2010RANTAI KESELAMATAN (CHAIN OF SURVIVAL)

*Immediate recognition of SCA based on assessing unresponsiveness and absence of normal breathing (ie, the victim is not breathing or only gasping)Look, Listen, and Feel removed from the BLS algorithmEncouraging Hands-Only (chest compression only) CPR (ie, continuous chest compression over the middle of the chest) for the untrained lay-rescuerKey changes and continued points of emphasis from the2005 BLS Guidelines include the following:AHA 2010

*Sequence change to chest compressions before rescue breaths (CAB rather than ABC)Health care providers continue effective chest compressions/CPR until return of spontaneous circulation (ROSC) or termination of resuscitative effortsIncreased focus on methods to ensure that high-quality CPR (compressions of adequate rate and depth, allowing full chest recoil between compressions, minimizing interruptions in chest compressions and avoiding excessive ventilation) is performedKey changes and continued points of emphasis from the2005 BLS Guidelines include the following:AHA 2010

*Continued de-emphasis on pulse check for health care providersA simplified adult BLS algorithm is introduced with the revised traditional algorithmRecommendation of a simultaneous, choreographed approach for chest compressions, airway management, rescue breathing, rhythm detection, and shocks (if appropriate) by an integrated team of highly-trained rescuers in appropriate settingsKey changes and continued points of emphasis from the2005 BLS Guidelines include the following:AHA 2010

*Dispatchers should be trained to interrogate callers with strict protocols to elicit information. This information should focus on the recognition of unresponsiveness and the quality of breathing.In combination with unresponsiveness, absence of breathing or any abnormality of breathing should start a dispatch protocol for suspected cardiac arrest.The importance of gasping as sign of cardiac arrest is emphasised.Summary of main changes since 2005 GuidelinesBasic life supportERC 2010

*All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. A strong emphasis on delivering high quality chest compressions remains essential. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions min1, to allow full chest recoil, and to minimise interruptions in chest compressions. Summary of main changes since 2005 GuidelinesBasic life supportERC 2010

*Trained rescuers should also provide ventilations with a compressionventilation (CV) ratio of 30:2. Telephone-guided chest compression-only CPR is encouraged for untrained rescuers.Summary of main changes since 2005 GuidelinesBasic life supportERC 2010

Rescuer Proficiency

*BLS keeps the brain alive until an automated external defibrillator (AED) or professional help is available

*CHAIN OF SURVIVAL

*Indikasi BHDHenti nafasHenti jantung(= mati klinis)

*

*

*Departemen Anestesiologi FKUI/RSCMERC 2010AHA 2010

*Adult BLS AlgorithmeAMERIKA

*Adult BLS AlgorithmeEROPA

*Do we still need to check pulse ???

*LANGKAH-LANGKAH BANTUAN HIDUP DASARPeriksa kesadaranPanggil bantuan / telpon ambulansBuka jalan nafas & nilai pernafasanBeri nafas buatan pertama 2xKompresi jantung + nafas buatan (30 : 2)Evaluasi setiap 2 menitJangan hentikan 30:2 sampai ada indikasi stop BHDPastikan keamanan

*JANGAN MENJADI KORBANBERIKUTNYA !

Lingkungan

Penolong

Korban

Orang2 disekitar

*PASTIKAN KORBAN TIDAK SADAR

*Guncangkan bahu dengan lembutTanya: apakah anda baik-baik saja?Jika ada respons: Jangan ubah posisi korban. Cari hal yang tidak beres. Ulangi pemeriksaan berkala.PERIKSA KESADARAN

*jika korban tidak responPanggil BANTUAN

*aktifkan sistem pelayanan emergensitelp. 118 (atau no. lokal lain)sebutkan: ID penelpon, lokasi, apa yg terjadi, jumlah korban, keadaan korban, apa yg sudah dilakukan, informasi penting lain

*BUKA JALAN NAFAS

*MENILAI PERNAFASAN

*Look, listen and feel (< 10 detik)Pastikan korban bernafas NORMAL atau tidakJangan keliru dengan nafas agonal/gasping (megap-megap)MENILAI PERNAFASAN49

*NAFAS AGONALTerjadi segera setelah jantung berhenti berdenyut pada lebih dari 40% kasus henti jantung

Tanda-tandanya: nafas pendek, berat, bunyi nafas terdengar keras atau megap-megap

Nafas agonal = tanda henti jantung !!50

*2X NAFAS BUATAN

*30x KOMPRESI JANTUNG

*Letakkan pangkal telapak tangan di pertengahan bawah tulang dadaLetakkan tangan yang lain diatas punggung tangan yang satunya Jari-jari boleh dikepal atau dibukaKompresi dadaLaju kompresi 100x per menitKedalaman 5 cmKompresi konstan diselingi relaksasiJika mungkin, bergantian kompresi setiap 2 menitKOMPRESI DADA

*

*KOMPRESI - DEKOMPRESIKompresiMenekan jantung dan paruMeningkatkan tekanan rongga dadaDekompresiPengisian jantung dan paruMenurunkan tekanan rongga dadaPengembangan penuh

*LANJUTKAN BHD

30256

*NAFAS BUATANPencet hidung korbanPenolong tarik nafas normalBibir penolong menutupi mulut korban dgn eratTiupkan udara nafas sampai dada korban bergerak terangkat1 tiupan = 1 detikBiarkan dada korban mengempis spontanUlangi57

*

*airway & breathing devices

*Periksa apakah ada tanda-tanda sirkulasi:

BergerakBernafas Batuk dll

*Kembalinya sirkulasi dan ventilasi spontanPasien dialihrawatkan kpd yg lebih berwenangBaru diketahui telah ada tanda-tanda kematian yang irreversibelPenolong lelah atau keselamatannya terancamAdanya perintah DNARJika 30 setelah ACLS yang adekuat tidak didapatkan tanda-tanda kembalinya sirkulasi spontan (asistole yang menetap), bukan intoksikasi obat atau hipotermia.STOP BHD JIKA .....

*tanda-tanda kematian yang irreversibel :Kaku mayatLebam mayatDekapitasiPembusukan

*

*JIKA KORBAN MULAI BERNAFAS NORMAL LAGI, TEMPATKAN DALAM POSISI RECOVERY

*

*

*BHD PADA ANAKTeknik BHD sama sepert pada dewasa

Kompresi sedalam 1/3 tebal dada

*

*

*Departemen Anestesiologi FKUI/RSCM

*BHD PADA ANAKTeknik dasar sama seperti pada dewasaKompresi dada dengan satu tangan pada anak usia 1-8 tahun

*BHD PADA BAYIBayi = usia 1 - 12 bulanKompresi dada menggunakan 2 jari, misal :jari telunjuk + jari tengahjari tengah + jari manisdua ibu jariNapas buatan : dari mulut ke mulut+hidung bayi

*BHD PADA BAYI

Napas buatan : dari mulut ke mulut+hidung bayi

*74

*?

*

*AHA 2010

*ERC 2010

*

*

*

ACLS Pulseless Arrest Algorithme

ACLS Pulseless Arrest Algorithme

ACLS Pulseless Arrest Algorithme

VF & VT pulseless = ada gelombang khasshockable, harus segera DC-shockAwas: ada VT yang nadi carotis (+) tak perlu DC-shock

Asystole = tak ada gelombang (ECG flat) UN-shockable

PEA = EMD = ada gelombang mirip ECG normalUN-shockableECG dalam cardiac arrest ada 4 pola(pada semuanya, nadi carotis tidak ada)

VF / VT pulselessBentuk gelombang khasshockable, harus segera DC-shockCPR sambil menunggu DC-shock, CPR saja sukar ROSC DC-shock < 5 mnt bisa mencapai > 50% ROSCtanpa DC-shock akan memburuk jadi asystole

123

Langsung DC shock 200 Joules

Langsung DC shock 360 JoulesVF / Ventricular fibrillation / flutter|

VT / Ventricular Tachycardia|| |carotis (+) carotis (-)Lidocain1 mg/kg iv cepat|Bila ragu,boleh DC shockDC shock360 Joules

DC shockOlesi paddles dengan jelly ECG tipis rata1. Switch ON

Pasang paddles pada posisi apex dan parasternal (boleh terbalik)

DC shock2. Charge (Non-synchronized)Perintahkan : Nafas buatan berhenti dulu Katakan dengan suara keras :Awas semua lepas dari pasien!Bawah bebas, samping bebas, atas bebas, saya bebas!3. Shock!! (tekan dua tombol paddles bersama)Biarkan paddles tetap menempel dada, baca ECGsiap charge lagi bila irama masih shockablesternumapex

Adrenalin, Atropin, Lidocain, VasopresinIntra-venousIntra-tracheal / trans-trachealdosis 2-3 x intravena Intra-osseusTIDAK intra-cardialmenghentikan pijat jantung sukar pastikan intra-ventrikulerkena miokard nekrosiskena a. koronaria infark

Jelly kurang rata, menekan paddles kurang kuat t luka bakar

AsystoleECG flat, tak ada gelombangUN-shockableCPR + adrenalin (+atropin?)ROSC < 10%

PEA = EMDada gelombang mirip ECG normalnadi carotis tidak terabaterapi sama seperti Asystole

HipoksiaHipovolemiaHiperkalemiaHipotermiaHydrogen ion (asidosis)

TraumaTamponade jantungTension pneumothoraxTrombosis (jantung, paru)Toxic overdoseB-blocker, Ca-blockerDigitalis, Tricyclic AD5 H5 TBila Cardiac Arrest membandel

Bila ROSCLanjutkan oksigenasi dan kalau perlu nafas buatanHipotensi diatasi dengan inotropik dan obat vaso-aktif (adrenalin, dopamin, dobutamin, ephedrin)Tetap di infus untuk jalan obat cepatTerapi aritmiaKoreksi elektrolit, cairan dsbAwasi di ICUawas: cardiac arrest sering terulang lagi

Bila setelah ROSC, lalu cardiac arrest lagiIkuti algoritme semulaDC shock dimulai dari 360 joules lagi

*?

*Departemen Anestesiologi FKUI/RSCM

*

*

*

*algoritme penata-laksanaan takikardia106

*107

*108

*109

*110bradikardiaAHA 2005

*algoritme bradikardia(ERC 2005)111

*once upon a time in heaven.............after resuscitation was invented....

*

TERIMA KASIH

terima kasih115

Tahun 2010 ERC tidak mengeluarkan definisi baru ttg BHD