Identifikasi Dini Pasien Kritis

Dr. Gatoet Soeseno, MARS

Objectives

Memahami pentingnya identifikasi dini

pada pasien-pasien yang beresiko menjadi
sakit kritis
Mengenali tanda-tanda awal sakit kritis
Mendiskusikan penilaian awal pasien sakit
kritis

Kenapa pasien mati ?

(atau mengapa terjadi mati otak?)

Kekurangan oksigen
Kehilangan energi (ATP)
Toksin
Kerusakan fisik

Proses terjadinya sakit kritis

Shock
Infection
Trauma

Early Sign &

Symptom

Compensation;
Preserve brain
and heart

Fail/ decomp Death

Onset of
illness

Compensatory phase

Tachypnea
Tachycardia
Hypertension
pH
Lactate
CRP
Leucocyte

Depends on;
Age
Severity of illness
Preexisting disease
Normal

Restlessness, anxiety, combativeness

Where were should we?

Bradycardia
Hypotension
Alkalosis
Severe
Acidosis

Dilihat dari penyebab-penyebab

terjadinya henti jantung, berapa
lama waktu yang kita miliki
sebelum terjadi henti jantung?

The Process of Dying*

Primary ventricular
fibrillation

0 min

Primary Asystole
Alveolar anoxia
Asphyxia:
(Airway Obstruction)
(Apnea)
Exsanguination
Pulmonary Failure
Shock
Brain Failure

2-3 min

5-12 min

Circulatory Arrest

?
?
?
?

*Safar P. Cerebral resuscitation after cardiac arrest: research initiatives and

future directions. Ann Emerg Med 22:324,1993

Berhentinya sirkulasi/ henti

jantung/cardiac arrest

10 detik

15-25 detik

Otak isoelektrik terjadi apnea

2 to 4 menit

Tidak sadar

Penyimpanan Glucose dan glycogen di otak habis

3 to 5 minutes

ATP habis
Pompa listrik otak mati total

Berapa lama waktu yang

kita miliki untuk
mengembalikan sirkulasi
setelah henti jantung?

The Process of Dying

*Safar P. Cerebral resuscitation after cardiac arrest: research initiatives and
future directions. Ann Emerg Med 22:324,1993

Mati klinis = henti sirkulasi total yang potensial reversibel sembuh

sempurna termasuk fungsi otak jika dilakukan resusitasi

Henti
sirkulasi

------5 min

10 min

15 min

Kembalinya sirkulasi

20 min

RESUSCITATION
NEED FOR SPEED

Slow
Fast
None
rate
rate
Resuscitation
% survival

Time

LV failure
contr

Compensation
Preload

Congestion

CO
Myocardial
work

CPAP

Early Stage

local control; dilatasi

Humoral; Anuria, Na
Sympathetic; HR

Signs of low CO;

Hypoperfusion

cool and clammy extrimitis, low

capillary refill, tachycardia,
narrow pulse pressure and low urine out put

Pulmonary

PaO2

Matching

edema

between Supply & demand

Redistribution blood flow
to vital organ (saving Heart & Brain)

Pulmonary

Diversi of blood flow, use respiratory

compliance

muscle
Dyspnea

Airway
resistance

Hyperventilation
PaCO 2

Late Stage
Consciousness
Dysritmia

Reduced
work of Breathing

The Process of Dying

*Safar P. Cerebral resuscitation after cardiac arrest: research initiatives and
future directions. Ann Emerg Med 22:324,1993

Mati klinis

Henti
sirkulasi

------5 min

10 min

15 min

20 min

Kembalinya sirkulasi
Bisa bernafas spontan
Bisa sadar penuh
Neurologi bisa normal

Bisa bernafas spontan

Bisa sadar atau stupor
Neurologi ada deficit

The Process of Dying cont

*Safar P. Cerebral resuscitation after cardiac arrest: research initiatives and
future directions. Ann Emerg Med 22:324,1993

Mati klinis

Henti
sirkulasi

------5 min

10 min

15 min

20 min

Kembalinya sirkulasi
Bisa nafas Spontan
Tidak sadar
Vegetative State
EEG Abnormal

Apnea
koma
Brain Death
Isoeletric EEG

Mengenal fase kompensasi

pasien sakit kritis

Fisilogis

Tanda aktivasi simpatis (HR,RR,HT,sweating)

Tanda inflamasi/peradangan sistemik (SIRS;Temp,
rush)
Tanda hipoperfusi sistemik
(cap.refill,confusing/agitation)

Biokimia

Base deficit/raised lactate

Leucocytosis/leucopenia
Thrombocytopenia
Raised urea and creatinine
Raised CRP

Assessing the patient

Basic investigations;

Tachypnoea (merupakan indikator sakit

kritis yang paling penting)
Tachycardia
Hypotension (gangguan kardiovaskular yg
tersering pada pasien sakit kritis yg akut,
penyebabnya ; hipovolemi/ sepsis)
Acidosis (adanya metabolic acidosis salah
satu dari indikator penting dari sakit kritis)

Dua faktor penting pada

peyelidikan awal

Arterial Blood Gases & Blood Lactate

Capillary Blood Glucose

Tachypnoea

(hyperventilation)

Minute ventilation

MV = RR x TV
Blood Gas Analysis

7.36/25/120/-10/99%

Remember 5 rules
1.

Kita sering menemukan pasien-pasien sakit kritis di

ruangan tidak selalu mempunyai proses yg sesuai ABC

2.

Kita tidak perlu mengetahui diagnosis pasti untuk menilai

pasien yg sakit kritis agar tetap hidup

3.

The patients is not sick just because he/she IS OLD

4.

Acute assesment is synonymous with RESUSCITATION

5.

DNR orders memerlukan suatu penilaian berdasarkan

kedokteran, dan tidak boleh digunakan sebagai upaya
menutupi kesalahan pengobatan atau keterbatasan
peralatan

The most important rule

Anamnesis, pemeriksaan fisik lengkap dan differential
diagnoses tidak akan menolong seseorang yang
sedang sakit kritis.
Assessment dan resuscitation
needs to proceed
hand in hand.

Some interesting facts

Banyak pasien rawat inap yg mengalami

kegawatan (actually many ICUs patient outside
the ICU)
Mayoritas pasien-pasien yang mengalami henti
jantung tiba-tiba (sudden cardiac arrest)
sebelumnya menderita gangguan yang
sebenarnya bisa dikenali
Kurang lebih sepertiga pasien yang dirawat di ICU
menerima pelayanan yg sub-optimal di ruangan
atau emergency room

Terima kasih

Definisi

Acidemia: arterial pH < 7.35

Acidosis: Reduced pH (tissue)
Alkalemia: arterial pH > 7.45
Alkalosis: Increased pH (tissue)
Anoxia: No Oxygen
Apnea: No breathing Movement
Asphyxia: Hypoxemia + hypercarbia (result of airway obstruction or
apnea)
Bradypnea: Decreased respiratory frequency (<6/mnt)
Dyspnea: subjective sensation of difficult or labored breathing
Hypercarbia=hypercapnea, PaCO2 > 45 mmHg; result of
hypoventilation
Hypocarbia=hypocapnea, PaCO2 < 35 mmHg; result of hyperventilation
Hypoxemia: Arterial PO2 < 75 mmHg
Hypoxia: reduced oxygen

Special Hospital
Considerations
Part II
Triage, Planning and Exercises

Hospital Triage

Use a triage system in an MCI

that parallels normal routine
Practice regularly to ensure
familiarity
Triage is a continual process
Re-triage all victims
transported by EMS
Set up triage area near the
ED entrance
Shielded and secure
Readily accessible

Triage

Greatest good for the greatest number of

casualties
Psychological impact
Classification:
Red
Yellow Green
Black
Limitations:
Time consuming
User variability
Lack of familiarity

START Triage
TRIAGE CRITERIA:

Respiratory status

Perfusion and pulse

Neurological status

TRIAGE CATEGORIES:
Walking wounded - Green or
minimal (relocate when told)
Normal findings - Yellow or
delayed (unable to relocated)
Abnormal - Red or immediate
Non-salvageable - Black or
expectant

START - Respiratory Status

Respiratory Status
No Respiratory Respirations
Effort
> 30
Expectant

Immediate

Normal
Respirations
Go to
Next Step

START - Perfusion
Perfusion Status

Radial Pulse
Absent

Cyanotic

Radial Pulse
Present

Immediate

Immediate

Go to
Next Step

START - Neurological Status

Neurologic Status
Change in
Mental Status

Unconscious

Immediate

Immediate

Normal
Mental Status

Move to
Next Victim

EMERGENCY ACTION
PRINCIPLES
SURVEY THE SCENE
PRIMARY SURVEY
ACTIVATE EMS
SECONDARY SURVEY

Survey The Scene

To determine if it is safe to proceed with

the rescue.
Avoid all dangerous situations.
If you are not properly trained and do not
have the necessary equipment do not
approach the victim.
Never risk your own life

Before You Approach The Victim

Check for unsafe conditions that will threaten

your safety and that of the bystanders
Look for clues and try to find out what happened
Dangers include downed power lines, traffic, fire,
unstable structures, deep or swift moving water
If conditions change, you may then be able to
approach the victim or victims
Ask bystanders for information or for help
Speak to victim in a calm reassuring manner

Primary Survey

This procedure takes a few seconds and is the

difference between life and death.
The Primary survey is also referred to as the
ABCs.
This principle is the basis of our class
You will be able to observe signs of life
threatening conditions

PATIENT ASSESSMENT

Check to see of the victim :

IS CONSCIOUS
HAS AN OPEN AIRWAY
IS BREATHING
HAS A HEARTBEAT
IS BLEEDING SEVERELY

The primary survey takes only seconds to perform

Check The Airway

A victim who can talk or cry is conscious and

has an open airway
If the victim is unconscious, open the victims
airway
Head Tilt/ Chin Lift
This action moves tongue away from the
airway
Check for Breathing
Airway may be obstructed by food, liquid, or
other objects

CHECK BREATHING

Look, listen and feel for signs of breathing

If victim is breathing chest will rise and fall
Position yourself so you can hear and feel air as it
escapes from victims nose and mouth
If victim is not breathing you must breathe for
the victim
This is called RESCUE BREATHING

CHECK CIRCULATION

Check for blood circulation or pulse

Check for severe bleeding
If the heart has stopped blood will not circulate
throughout the body
If the victim is breathing then their heart is beating and
circulating blood
On an infant check the pulse on the brachial artery
On a child or an adult check the carotid artery
Check the pulse for @5 - 10 seconds
If no breathing or pulse administer rescue breathing and
chest compressions

ACTIVATE EMS

Summon additional
help from advanced
medical personnel if
any of the following
conditions exists:

Unconsciousness
Breathing problems
Persistent chest or
abdominal pain

No pulse
Severe Bleeding
Vomiting or passing
blood
Suspected poisoning
Seizures, severe
headache, slurred
speech
Suspected or obvious
head or neck injuries
Suspected fractures
Severe burns

SECONDARY SURVEY

Once you are certain that the victim has no lifethreatening conditions, you can begin the secondary
survey
You will gather information about the victim and any
conditions that may become life-threatening
Interview the victim and bystanders
Check vital signs
Do a head-to-toe examination to check for signs and
symptoms
In some cases you may never have the opportunity or
need to conduct the secondary survey

INTERVIEW QUESTIONS

What happened?
Do you feel any pain anywhere?
Do you have any medical conditions?
Are you taking medications?
Do you have any allergies?
These questions may be asked to the parent or
responsible adult if you are working with an
infant or a child

CHECKING VITAL SIGNS;

PULSE

With every heartbeat a wave of blood moves through the

blood vessels
This creates a beat called the pulse
A pulse can be checked in arteries that circulate close to the
surface:

CAROTID:
BRACHIAL:
RADIAL

A normal pulse for an adult is @60-80BPM

An abnormal pulse may be sign of a potential problem:

Irregular pulse
Weak and hard to find pulse
Excessively fast or slow pulse

CHECKING THE VITAL SIGNS;

Breathing

A healthy person breathes regularly, quietly, and

effortlessly
Abnormal breathing may indicate a potential
problem such as:

Gasping for breath

Noisy breathing; whistling sounds, high pitched
wheezing, gurgling, or snoring
Excessively fast or slow breathing
Painful breathing

HEAD TO TOE EXAMINATION

Start at the head ending at the toes, checking for any

abnormal conditions
Use your senses to:

Smell unusual odors

Look for pale or bluish skin, bruises, deformed body parts
Palpate all tender areas

Continue to monitor vital signs

Observe any changes that indicate a life threatening
situation and provide necessary first responder care

Korban

RESUME OF
BASIC LIFE
SUPPORT

Cek kesadaran
Tidak sadar

Sadar

Cek
Nadi

Posisi mantap

Ada

Tidak ada

Kompresi

100 kali
permenit

ACLS

ROSC

Nilai irama dan cek pulse