MANAGEMEN JALAN NAFAS BANTUAN NAFAS suara tambahan Snoring Lidah Gurgling Cairan Stridor / crowing...
Transcript of MANAGEMEN JALAN NAFAS BANTUAN NAFAS suara tambahan Snoring Lidah Gurgling Cairan Stridor / crowing...
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MANAGEMEN JALAN NAFAS
&
BANTUAN NAFAS
Isrun Masari, dr. SpAn.
Bagian/SMF Anestesiologi & Perawatan Intensif
RSD Raden Mattaher Jambi
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T P U
Peserta mampu melakukan pengelolaan jalan nafas.
T P K
Peserta mampu :
-Mendiagnosa sumbatan jalan nafas/airway
-Mengetahui penyebab sumbatan jalan nafas/airway
-Mengelola sumbatan jalan nafas
- tanpa alat
- dengan alat
A (AIRWAY)
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…So I said “Hey Ya’ll…watch this”…………
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PRIORITAS UTAMA
• Airway
Bebas dan terjaga
• Breathing / ventilation
Adekuat
• Supplemen oxygen
Adekuat
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PRIMARY SURVEY
Assume C-Spine Injury
• Multisystem trauma
• Altered level of consciousness
• Blunt injury above clavicle
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SUMBATAN JALAN NAFAS
Penyebab
• Penurunan kesadaran Tindakan anestesi
Koma
Trauma kepala
Radang otak
Obat / alkohol
dll
• Suatu penyakit Laringitis
Edema laring
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………sumbatan jalan nafas
• Trauma / Kecelakaan Maksilofacial
Jalan nafas
dll
• Benda asing Darah
Muntahan
Makanan
dll
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• Macam
Parsial
Ringan
Berat
Total
………sumbatan jalan nafas
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SUATU SEBAB
PENDERITA
TAK SADAR
RELAKSASI
OTOT
HILANG REFLEKS
PERLINDUNGAN
LIDAH “KLEP”
SUMBATAN
JALAN NAFAS
MUNTAH
REGURGITASI
ASPIRASI
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In unconscious victim,
the muscles in the tongue
may relax, causing the
tongue to block the
airway
Head tilt and chin
lift may open airway
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SUMBATAN JALAN NAFAS
• Look / Lihat
Perubahan Status Mental
Agitasi / gelisah Hipoksemia
Obtundasi / teler Hiperkarbia
Gerak Nafas
Normal
See saw / rocking
Retraksi
Deformitas
Debris
Darah / sekret
Muntahan
Gigi
Sianosis
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SUMBATAN JALAN NAFAS
• Listen / Dengar
Bicara normal Tak ada sumbatan
Ada suara tambahan
Snoring Lidah
Gurgling Cairan
Stridor / crowing Penyempitan
Suara parau (hoarseness / dysphonia)
• Feel / Raba
Hawa nafas
Krepitasi / fraktur (maxillofacial / laryngeal)
Deviasi trakhea
Hematoma
Getaran di leher
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MACAM SUMBATAN
SUMBATAN
BEBAS
PARSIAL RINGAN
PARSIAL BERAT
TOTAL
LOOK
GERAK
NAFAS
NORMAL
NORMAL
SEE SAW
SEE SAW
LISTEN
SUARA
TAMBAHAN
⊝
⊕
⊕
⊝
FEEL
HAWA
EKSHALASI
⊕
⊕
+
⊝
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PENGELOLAAN PERLU :
CEPAT, TEPAT, CERMAT
Sumbatan Total :
• FRC (Functional Residual Capacity) : 2500 ml
• Kadar O2 15% x 2500 ml : 375 ml
• Kebutuhan O2 permenit : 250 ml
• Bila ada sumbatan total O2 dalam paru habis dalam
: 375 / 250 : 1,5 menit
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PENYEBAB SUMBATAN
• Lidah
• Epiglotis
• Benda asing / muntahan / darah / sekret
• Trauma jalan nafas
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PEMBEBASAN JALAN NAFAS
PENYEBAB LIDAH
• Manual :
- Non trauma :
Head tilt
Neck lift
Chin lift
Jaw thrust
- Trauma :
Chin lift
Jaw thrust
Dengan in-line manual immobilization” atau
pasang cervical collar
• Bantuan Alat
- Oropharyngeal airway
- Nasopharyngeal airway
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Pada pasien trauma
head tilt
neck lift
Don’t do Be careful neck lift
chin lift
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JAW THRUST
dianjurkan
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Oro-pharyngeal tube
Perhatikan ukuran
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1 2
3 4
OROFARINGEAL TUBE
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Naso-pharyngeal tube
Tidak merangsang muntah
Ukuran u/ dewasa 7 mm atau
jari kelingking kanan
Nasopharyngeal tube
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NASOFARINGEAL TUBE
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PEMBEBASAN JALAN NAFAS
PENYEBAB BENDA ASING
• Manual
• Penghisap
• Definitive airway
• Pada chocking :
Back blows
Abdominal thrust (Heimlich manuver)
Thoracal thrust
Cricothyroidotomy
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Lima kali hentakan pada punggung, diantara dua scapula
CHOKING
Back blows
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CHOKING
Heimlich Abdominal trust
Korban : sadar
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Korban : Tidak sadar
Heimlich Abdominal trust
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DEFINITIVE AIRWAY
• Cuffed tube in trachea • Secure airway • Ventilation • Types :
- Endotracheal intubation - Surgical airway - Cricothyrotomy - Tracheotomy
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Membrana cricothyroid
Pada keadaan gawat darurat - Tempat injeksi transtracheal obat emergency - Tempat untuk needle dan surgical cricothyroidotomi
Bagaimana caranya ?? Obat apa saja boleh masuk ??
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DEFINITIVE AIRWAY
Indications
1. Apnea
2. Risk of aspiration
3. Insecure airway
4. Poor oxygenation
5. Impending airway compromise
7. Closed head injury
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TUJUAN INTUBASI ENDOTRAKHEAL
1. Sebagai jalan nafas
2. Untuk oksigenasi
3. Untuk pemberian ventilasi
4. Mencegah aspirasi
5. Jalan pemberian obat (intra trakheal)
6. Bronchial toilet
MACAM INTUBASI ENDOTRAKHEAL
• Orotrakehal Lewat mulut
• Nasotrakheal Lewat hidung
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ENDOTRACHEAL INTUBATION
The trachea should be intubated by properly trained personnel
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PERALATAN INTUBASI ENDOTRAKHEHAL
• Laryngoscope dengan blade yang sesuai
• Tube dengan ukuran yang sesuai
• Jelly
• Anestetik lokal / spray
• Forceps – magill
• Bite block / oropharyngeal airway
• Adhesive tape / tali
• Suction – metal yang kauer
• Connectors
• Synringe (20 cc)
• Stylet
• Stetoscope
• End tidal CO2 monitor
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INTUBASI
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INTUBASI ENDOTRAKHEAL
• Oksigenasi + ventilasi (5 menit)
• Alat dan obat siap
• Harus berhasil kurang 30 detik
• Bila > 30 detik belum berhasil oksigenasi + ventilasi ulang
• Penolong tak kuat tahan nafas
• Saturasi O2 menurun
• Monitoring :
Saturasi O2 (Pulse oxymeter)
End-tidal CO2 (Capnografi)
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Ped and Adult Normal Trachea
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They Tend to look like This:
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And This (after failed ETT
attempt)
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Predisposing Factors for Difficult
Intubation
• Infection
• Endocrine
• Inflammatory diseases
• Congenital
• Trauma
• Foreign Body
• Tumours
• Physiologic
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Infections
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Endocrine Conditions
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Foreign Body
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Inflammatory Diseases
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PEDIATRIC
Airway Anatomy • Craniofacial diproportion
• Large occiput cervical flexion
• Obligate nasal breather
• Narrow nasal passages
• Small oral cavity
• Large tongue
• Adeno tonsillar hypertrophy
• Horseshoe shaped epiglotis
• Larynx anterior – cauded angle
• Trachea short
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T P U
Peserta mampu menangani kegawatan
nafas/breathing
T P K
Peserta mampu :
-Mendiagnosa kegawatan nafas
-Mengetahui penyebab kegawatan nafas
-Mengelola kegawatan nafas
- tanpa alat
- dengan alat
B (BREATHING)
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GANGGUAN VENTILASI
Penyebab
• Tindakan anestesi
• Penyakit
• Kecelakaan trauma
Lokasi
• Sentral
Pusat nafas
• Perifer
Jalan nafas Dinding dada
Paru Otot nafas
Rongga pleura Syaraf & jantung
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GANGGUAN VENTILASI (penderita masih bernafas)
Look / Lihat
Sianosis Takhipnea
Status mental Distensi vena leher
Asimetri dada Paralisis otot nafas
Listen / dengar
Keluhan: “Tak bisa nafas!”
Stridor, wheeze
atau hilang suara nafas
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Feel / raba
Hawa ekspirasi
Emfisema subkutan
Krepitasi / tenderness / nyeri
Deviasi trakhea
Adjuncts
Pulse oximeter
CO2 detector
Gas darah
X-ray dada
…………gangguan ventilasi (penderita masih bernafas)
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CARA PEMBERIAN VENTILASI
Tanpa Alat
Mouth to mouth
Mouth to nose
Mouth to mouth and nose
Dengan Alat
Safar airway
Esophageal obturator airway
Face mask / pocket mask
Laryngeal mask
Bag-valve-mask
Bag-valve-tube
Ventilator
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Nafas buatan
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Nafas berhenti
Nafas ada
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SUPPLEMENTAL OXYGEN
1. Nasal cannula / prong
Low – flow system
Flow O2 : 1-6 L/m
FiO2 : 24-44% (1 L O2/M FiO2 4%)
2. Face mask
Law – flow system
Flow O2 : 8-10 L/m
FiO2 : 40-60 %
3. Face mask with oxygen reservoir
Constant – flow
Flow O2 : 6-10 L/m
FiO2 : 6L O2 / m + 60 % ((1 L O2/M FiO2 10%)
4. Venturi mask
High gas flow
Fixed oxygen concentration
Flow O2 & FiO2 diatur
24 %, 28%, 35% dan 40%
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Terapi oksigen
NASAL PRONG O2 flow 1 – 6 lpm FiO2 : 24 – 44 %
BAG VALVE MASK (BVM) Dgn oksigen 8-10 lpm : 60%
Masker sederhana Dengan reservoir bag Flow O2 : 6-10 lpm FiO2 : 60%- 100%
BVM Dengan reservoir bag Flow O2 : 8-10 lpm FiO2 : 80%- 100%
Jackson Rees Flow O2 : 8-10 lpm FiO2 : 100%
BVM Dengan reservoir bag Flow O2 : 8-10 lpm FiO2 : 80%- 100%
FACE MASK O2 8-10 lpm FiO2 : 40-60%
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TRACHEO BRONCHIAL SUCTIONING
• Preoksigenasi 100% 5 menit
• Alat hisap :
Setting suction: -80 -120 mmHg
Soft catheter (steril) + lobang pengatur
• Tindakan aseptis sesuai prosedur
• Tak lebih 15 detik
• Diselingi oksigenasi 100% 30-60 detik
• Komplikasi
Hipoksemia Cardiac arrest aritmia
Stimulasi simpatis Hipertensi takhikardia
Stimulasi vagal Hipotensi bradikardia
Batuk TIK
Perlukaan
Infeksi
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Isrun Masari ,2007