penanganan kasus emergency pada anak
TRANSCRIPT
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Penanganan kasus gawat darurat
pada anak
Abdul Chairy
e-mail: [email protected]
Mobile: +6281329375575
@abdul_chairy
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Outline
Pediatric BLS + pediatric cardiac arrest
Primary assesment identify intervene
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approach to a
acutely-ill child
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Pediatric
cardiac arrest
Epinephrine IO/IV 0.01
mg/kg/dose repeat every3-5 minutes or
0.1 mg/kg ET
Defibrillation
1st shock 2 J/kg,
subsequent shock 4 J/kg,max. 10 J/kg or adult dose
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypoglycemia
Hypo-/hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiacToxins
Thrombosis
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Rationale for CAB vs ABC Chest compression must be started right away to support
circulation & algorithms too complex needed
simplification (only 30% of children receive bystander
CPR)
Provision of ventilation delays the initiation of chestcompressions & thus circulation often by minutes
CPR was done poorly too slow too shallow & with
excessive ventilations which can impede cardiac output Adults & children who suffer sudden cardiac arrest from V-
fib/V-tach benefit from rapid CPR & defibrillation
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Compression to ventilation
Health care provider if alone 30:2, otherwisecompression to ventilation rate 15:2
Push hard, push fast compress chest in infant 4 cmand 5 cm in children allow chest to recoil compress
at least 100 x/min
Breathe 8-10 x/min avoid excessive ventilation
Switch rescuers every 2 minutes to avoid fatigue whendoing chest compression
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Chest compressions
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BMV vs ET Intubation
LOE 1 study shows no
difference in survival or
neurological outcome
Recommendation is that
BMV recommended over
ET intubation for
ventilatory support in out-
of-hospital settings
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Minute ventilation Avoid excessive ventilation of infants & children
during resuscitation from cardiac arrest; insufficient data
to identify optimal tidal volume or rate
Animal studies show excessive ventilation decreasesCPP, ROSC & survival
Excessive ventilation increases intrathoracic pressureimpedes venous return, reduces CO &
cerebral/coronary blood flow
During CPR ventilate 8-10 times per minute for infants& children
TEKAN LEPAS LEPAS
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Rapid Sequence Intubation
Obtain AMPLE &examine patient
Prepare personnel, medication,
equipment
Monitor & pre-oxygenate
ECG, pulse oximeter
Pre-medicate Give atropine 0.02 mg/kg (min 0.1 mg) iv
Indicated for all children
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Sedate (choose one option based on condition of patient)
Normotensive
Midazolam 0.2 mg/kg
EtomidateThiopental
Propofol 1 mg/kg
Hypotensive/hypovolemic
Mild Severe
Etomidate or Etomidate orKetamine or Ketamine or
Midazolam none
Head injury or status epilepticus
Normotensive Hypotensive
Thiopental or Etomidate orPropofol or Low-dose thiopental
Etomidate
Status asthmaticus
Midazolam orKetamine
Rapid Sequence Intubation (contd ..)
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Apply cricoid pressure
when patient is unconscious
Paralyze
Rocuronium
Vecuronium
Succinylcholine
Intubate trachea
Evaluate & confirm tube placement (eg. exhaled CO2)
Secure tracheal tube
Observe & monitor Administer additional sedation & paralytics PRN
American Academy of Pediatrics /
American Heart Association
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CUFFED VS UNCUFFED ETT Cuffed tubes may be preferred in certain circumstances
poor lung compliance, high airway resistance, or large
glottic air leak, really any sick child (class IIa, LoE B)
Cuffed ETT will not cause pressure on the cricoidcartilage leading to pressure necrosis (class IIa, LoE B)
Reintubation rate in uncuffed ETT is 30.8% vs 2.1% incuffed ETT
Uncuffed (age (yr)/4) + 4 = mmIDCuffed (age (yr)/4) + 3.5 = mmID
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Rapid Sequence Intubation
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TroubleshootingDisplaced ET tube is not in trachea or has moved into a
bronchus (right mainstem most common)
Obstruction Consider secretions or kinking of the tube
Pneumothorax Consider chest trauma, barotrauma ornon-compliant lung disease
Equipment Check oxygen source, BVM and ventilator
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The PAT
Circulation to Skin
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Appearance
(TICLS)
Tone
InteractivenessConsolability
Look/Gaze
Speech/Cry
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Appearance
(AVPU)
Alert/Awake
VoicePain
Unresponsive
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Appearance
Seizure?
Exposure? Burns, causticingestion, CO, etc
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AppearanceSeizure management
Diazepam rectal 5-10 mg or IV/IM 0.3-0.5 mg/kg
Phenytoin IV 15-20 mg/kg in 20 minutes
2-3 times
Phenytoin IV 10 mg/kg in 20 minutes
Phenobarbital IV 15-20 mg/kg
Phenobarbital IV 10 mg/kg
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Work of Breathings Abnormal airway sounds
Abnormal positioning
Abnormal respiratory rate Retractions
Nasal flaring
SpO2
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Work of Breathings Upper airway obstruction
Lower airway obstruction
Lung tissue disease Disorder control of
breathing
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Upper Airway Obstruction
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Lower Airway Obstruction
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Intervention: Oxygen
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Oxygen (contd ..) Oxygen increasing evidence for harm limit
hyperoxemia start with 100% - later adjust to achieve
SpO2 >94%
The issues In reperfusion injury, hypoxic cells appear toundergo metabolic changes that prime them to create free
radicals when oxygen is reintroduced
Experimental resuscitation with 100% oxygen has beenassociated with a variety of concerning physiologic changes
when compared with room air resuscitation: increasedgeneration of oxygen radicals, decreased CNS sodium-
potasium ATPase function & decreased dopamine metabolism
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Pallor
Mottling
Cyanosis
Capillary refill timeCirculation to Skin
Circulation to Skin
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HYPOVOLEMI
C
SHOCK
DISTRIBUTIVE/SE
PTIC SHOCKCARDIOGENI
C
SHOCKMEDIATORS
Myocardial
Depression
Vasodilatation
Capilary
Leak
CARDIAC OUTPUT BLOOD PRESSURE
CONTRACTILITY
Sympathetic Discharge
Vasoconstriction
HR
Contractility
Improved
Cardiac Output
and
Blood Pressure
COMPENSATED
Myocardial Perfusion
Myocardial O2 Consumption
Myocardial PerfusionTISSUE ISCHEMIA
MEDIATOR
RELEASE
Cell FunctionLoss of
autoregulator
of microcirculationCell Death
DEATH OF ORGANISM
PRELOAD
UNCOMPENSATE
D
Figure 3.1.
Sequence of pathophysiologic
events in clinical shock states.From White MK, Hill JH, Blumer JL.
Shock in the pediatric patient. Act
Pediatr 1987:34:139-174
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SHOCKTypical signs of compensated
shock include
Tachycardia
Cool and pale distal extremities
Prolonged (>2 seconds)capillary refill (despite warm
ambient temperature)
Weak peripheral pulsescompared with central pulses
Normal systolic blood pressure
As compensatory mechanisms fail,
signs of inadequate end-organ
perfusion develop. In addition to the
above, these signs include
Depressed mental status
Decreased urine output
Metabolic acidosis
Tachypnea
Weak central pulses
Deterioration in color (eg,mottling, see below)
Circulation 2010;122;S876-S908
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Recognize decrease mental status & perfusion
Manage airway, breathing & IV/IO access
Initial resuscitation:
push boluses 20 cc/kg crystalloid or colloid up to 60 cc/kg
Correct hypoglycemia & hypocalcaemia. Begin antibiotics
Fluid refractory shock: Begin inotrope IV/IO
Reverse cold shock titrating dopamine up to 10 mcg/kg/min or, if
resistant, titrating central epinephrine 0.05-0,3 mcg/kg/min
Reverse warm shock titrating norepinephrine 0.5-3 mcg/kg/min
0 min
1 min
15 min
60 min Catecholamine resistant shock
Initial management
Lab work-up CBC, diff count, glucose (rapid), mixed venous GA,
blood culture, CRP/procalcitonin, ALT, SCr, PT/aPTT, electrolytes,
lactate, blood typeBrierley J et al. Crit Care Med 2009; 37:666-668
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EGDT (early target)
1. Regain of consciousness
2. Normal peripheral pulse (malleolus media or dorsalispedis), warm acral, CRT 1 ml/kg/hr
5. Broad-spectrum antibiotics (gram + & -)
6. ScvO2 >70%
7. Minimal Hb 7 (without shock) or 10 g/dL (shock orhypoxemia)
Goldsteinet al. Pediatr Crit Care Med 2005; 6(1):2-8
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Intervention: Vascular access
Peripheral vein
Intraosseus
Often difficult to obtain in small &/or
acutely-ill child
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Intraosseous IO access is a rapid, safe, effective, and acceptable route
for vascular access in children.
All intravenous medications can be administered
intraosseously, including epinephrine, adenosine, fluids,blood products and catecholamines.
Onset of action and drug levels for most drugs arecomparable to venous administration.
IO access can be used to obtain blood samples for analysis
including for type and cross match and blood gases duringCPR
Circulation 2010;122;S876-S908
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Intraosseous infusion
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Intraosseous infusion
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Summary
Primary care physician should be able to detect& manage emergency conditions in children
He/she should have the skill to perform CPR,manage CABs which consist of BMV/RSI,
oxygen therapy, intraosseus infusion