Artificial Circulation, Dr. TOMMY

7/25/2019 Artificial Circulation, Dr. TOMMY

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Lab / SMF Anestesiologi & Reanimasi

FK. Unair – RSU Dr. Soetomo

Surabaya

A R T I F I C I A L C I R C U L ATI O N

( C A R D I A C M A S S A G E )( P I J AT J A N T U N G )

Dr. Tommy Sunartomo, SpAn K.IC



Jude & Kouweno!en "#$%# –'losed (est resus(itation )

• #*+ (ardia( arrest in os,ital• #- RS'



0eo,le earts sto, beating e!eryday

For many ,eo,le

1eir earts / brains sould be2 1oo 3ood 1o Die 2

Resus(itati!e e44ort (an restore tese eartsto s,ontaneous a(ti!ity be4ore te brain

as been ,ermanently in5ured



• Kematian jantung Urutan 2• Kematian trauma Urutan 4• Kematian jantung di Jakarta 1991 2535 orang

1992 2746 orang 1993 2961 orang 1994 3255 orang 1995 1283 orang (sampai Maret)

• Kematian kee!akaan !a!u !intas di "ndonesia

1991 1#$621 orang 1992 9$819 orang 1993 1#$#38 orang 1994 11$##4 orang

1995 9$251orang (sampai Maret)

K E S E H A TAN R U M A H S A K I T

1 9 8 6 , 1 9 9 2 D A N 1 9 9 5



sic life support emergency oxygenationA : AirwayB : BreatheC : Circulate

vanced life support Restoration of spontaneousrculationD : Drugs and luids! : !"# : i$rillation treatment

olonged life support post resuscitation $rain 'iented therapy# : #auging( : (uman )entation

* : *ntensive care

C P C R / R J P O

( P ! " S # $ # " )



• &rimary +urveyA : Airway with C-spine controlB : Breathing with ventilationC : Circulation with hemorrhage controlD : Disability : neurologic status

E : Exposure / environment with temperature control

• Resuscitation

• +econdary +urveyHead to toe evaluation and history

• Reevaluation

• De,nitive care

K O N S E P A TL S



*n the &rimary +urvey- focus on $asic C&R andde,$rillation

irst ABCD

• Airway :/pen the airway

• Breathing:&rovide positive ' pressure ventilations

• Circulation :#ive chest compressions

• De,$rillation :+hoc0 ventricular ,$rillation or pulseless

ventricular tachycardia 345

K E % P O I N T S A C L S



n the +econdary +urvey- focus on intu$ation-ntravenous *5 access- and drugs andhy the cardio respiratory arrest occurred

econd ABCD

• Airway :&erform endotracheal intu$ation

• Breathing:Assess $ilateral chest rise and ventilation

• Circulation :

#ain * access- determine rhythm- giveappropriate agents

• Di6erential Diagnosis 4hin05:+earch for- ,nd- and treat reversi$le cause

K E % P O I N T S A C L S



• 1e (lini(al ,i(ture o4 o!erall (essation o4(ir(ulation

• Un(ons(iousness•

A,nea or gas,• Deat – li6e a,,earan(e "(yanosis or ,allor

• Diagnosis 'ardia( Arrest "7o ,ulse – Adult )

• 'arotid• Femoral

– 8n4ant small (ildren )

• 9ra(ial

• Femoral

R & " ' * C # " + # A " " ' !





!erabaan nadi carotis

dari tengah "e-lateral

Awam : tida" perlumeraba carotis



• #: se(ond – Un(ons(iousness

• #: – *- – 8soele(tri( ;;3

•*- – %- – Agonal gas,ing

A,nea

Ma< ,u,illary dilatation

= : minute – (erebral damage

C 0 * ! C ' ' # ! . $ C "

Time saving is Life saving



• 0rimary ) –

>entri(ular Fibrillation – Asystole – ?eart 9lo(6 – ;le(tri( So(6 – Drugs

• Se(ondary ) – Ra,id )

• As,y<ia• ;<sanguination•

A(ute 0ulmonary ;dema• <ygen – Free 3as – Slow )

• ?y,o<emia• So(6

• ;MD

C # " + # A " " ' !



%&'* %+, '-. %+,

,+'/0%"%-UM-

%0/*"0%-UM-

A R T I F I C I A L C I R C U L A TI O N



+eart -ump

Meanism

%est -ump

Meanism

A R T I F I C I A L C I R C U L A TI O N

ueeing te eart

eteen sternumand pine

'era!! intratorai

-ressure !utuation







• 'ardia( out,ut• 'arotid artery blood 4low• 'erebral 9lood Flow "'9F•

'9F ) – 7ear @ero → witout '0R – :- 7 → Maintain (ons(iousness – B- 7 → Maintain (ell >iability

•'oronary 0.0 and blood 4low → Low

→ Rigt atrial ,ressure C• 1ung6ai dibuat lebi tinggi

C * ' + C 3 ' ! C P R

*- 7ormal















• 1iti6 tum,u

• 1e6ni6 memi5at• Monitoring

• Kom,li6asi

C * ' + C 3 ' ! C P R

( P 4 # ! J # . ! - . L - # " )



• 0ada tulang dada

• Dewasa )

–

B 5ari 6ranial ,ro(. y,oideus "B--- – 1enga 1ora6s "B--:

–1enga sternum distal "B-#-

•9ayi ) –1enga sternum

–3aris inter mammary

T ! T -0 -





*7C/R8nternational Liaison 'ommittee on Resus(itation

uide!ines 2##5 )ain changes in adult $asic life support

• tart %-/ en itim is unresponsie and

not :reating norma!!;

• -!ae te ands on te entre o te est

• ,o resue :reats< 1 se ea rater tan 2 se

• ,e ratio o ompressions to enti!ations is 3# = 2



8L'R E 3uidelines B--: E B-#-

• C#$C%&A'#()

– 'iti" tumpu pi*at *antung disternum ditengahdada +,.

– 0etengah sternum bagian distal +,1

– !i*at *antung 1x per menit2

diprioritas"an agar tida" ada sela3- !i*at *antung 1x /men2 na4as buatan 1x

/men

- Bila masih belum terintubasi : $atio pi*at *antung dan na4as 5 : ,

- Dua atau satu penolong tida" dibeda"an-



Treatment Recommendation

• All res(uers sould ,er4orm (est (om,ressions 4or all ,atients in

(ardia( arrest.• 'est (om,ressions alone are re(ommended 4or untrained lay,ersons

• 0ro4essional res(uers sould ,ro!ide (est (om,ressions wit

!entilations 4or (ardia( arrest !i(tims

• -erorming est ompressions a!one is reasona:!e or trained

!a;persons i te; are inapa:!e o de!iering aira; and :reating

maneuers

• 1ere is insu44i(ient e!iden(e to su,,ort or re4ute te ,ro!ision o4 (est

(om,ressions ,lus airway o,ening and o<ygen insu44lation by

,ro4essional res(uers during te 4irst 4ew minutes o4 resus(itation

Chest Compression–Only

CPR

2010 ILCOR



'iti" tumpu pi*at

*antung adalah

disternum

Di tengah, dada



titi0 tumpu

pi8at 8antung

uide!ines 2##5 =

p!ae te ands on te entre

o te est

Using te ri: margin metod

is asting time



'umit 1 tangan

dileta""an diatassternum2"emudiantangan satunya

dileta""an diatastangan yang sudahberada di-titi"pi*at *antung

+di-tengah, dada 6ari-*ari "edua tangan dirapat"an

dan diang"at pada wa"tu dila"u"an tiupan na4as2agar tida" mene"an dada3

'iti" tumpu pi*at *antung



!enolongmengambil

posisi tega"lurus

di atas dada"orban dengan

si"u lengan lurus

8ene"an tulangdada sedalam

"ira-"ira9-. cm3

Pijat jantung

tiap melepas 1 pi*atan 2

gan *angan masih mene"an dada "orban



#--< ,er menit

45 m



at pi*at *antung2

tung dengan suara "eras

tu2dua2tiga2empat2 0A'%tu2dua2tiga2empat2 D%A2

tu2dua2tiga2empat2'#A

tu2dua2tiga3empat2E8!A'

tu2dua2tiga2empat2&#8Atu2dua2tiga2empat2E)A8

tal ; 5 x pi*atan

ng disela dengan , x tiupan na4as

Pijat jantung nafas buatan

30 : 2



ijat jantung nafas buatan

• &a"u"an 5 "ali pi*at *antung

dengan diselingi

, "ali na4as buatan ini berulang

selama , menit

• 0etelah , menit +=-> si"lus raba

nadi leher3

• Bila masih belum teraba denyut

nadi leher2 lan*ut"an 5 x pi*at

*antung dan , x na4as buatan

• &a"u"an tinda"an ini terus sampai

datang bantuan atau ambulans

30 : 2

T M 4 !



• Dewasa ) –

1umit tela,a6 tangan – Dua tangan• Ana6 )

– 1umit tela,a6 tangan –

Satu tangan• 9ayi ) Dua 5ari " Jari 88 888 • 0osisi tega6 – lurus• Kedalaman memi5at )

– Dewasa ) #G: – BG- in( "H E : (m – Ana6 ) #G- – #G: in( "BG: – H (m – 9ayi ) -G: in( "# – B (m

• Ia6tu memi5at wa6tu rela6sasi

• Fre6wensi #-- / m "(e,at dan 6uat

T . M 0 4 # !









• # 0enolong ) – #: ,i5at 5antung "Fre6. +- – #-- / m

– B na4as buatan "#EB deti6 / na4as buatan

• B 0enolong ) – #: ,i5at 5antung "4re6.+- – #-- / m

– B na4as buatan "#EB deti6 / na4as buatan

– Setela di intubasi 0i5at Jantung #--</menit 7a4as

9uatan#B E B-</menit di sela – sela ,i5atan.

# ' P 4 # ! J # . ! - . 7 N # $ # '

uide!ines 2###

uide!ines 2##5 2#1#

• # atau B ,enolong *- ) B Fre6. #-- / m

S t l



,aun 2### =

Tahun 2005,2010 :

3# = 2

Satu penolong



21Tahun 2005,2010:

3# = 2

,aun 2### =

Dua penolong

Korban tidak



Korban tidak

sadar

bebas"an *alan

na4as

*alan na4as bebastida" berna4as

tida" teraba nadi

Pasangmonitor EKG

( di RS )

13

,3

53

93

.3

Call for help

, x tiupan awalraba nadi carotis

beri pi*atan *antung

dan na4as buatan

A.

B.

C.

awam





– 0i5at dulu baru tiu,

– 0i5at 5antung yang ,ertama tan,a terlebi daulu meraba 6arotis – 1iti6 tum,u ,i5at 5antung ,ada setenga bagian bawa sternum. – 9ila belum di –intubasi atau di,asang LMAG ma6a setia, *- ,i5atan

5antung diselingi B 6ali tiu,an na4as " ratio *- ) B

– 9ila suda diEintubasi 0i5at 5antung #--< ,er menitG di,rioritas6an

agar tida6 ada sela. -us +ard< -us >ast

0i5at 5antung #--< /menG na4as buatan #-< /men. – 9eri 6esem,atan dinding tora6s untu6 “re-coil” setela ,i5atan

– Ji6a tra(ea suda diEintubasi ta6 usa sin6ronisasi antara ,i5at

dan na4as – Dua atau satu ,enolong tida6 dibeda6an

• CIRCULATION

M !



• 7adi (arotis → ole ,emberi na4as –

8ntermitten – B menit beri6utnya " – + si6lus

• 0u,il – U6uran –

Re4le6s• Di RS. – ;K3 – 0ulse o<imetri –

93A – 1ensi – nadi – 0er4usi organ – ;1'B

M . ! " .





• 0ata tulang iga

• 0ata tulang dada

• 'edera 5antung

• 'edera ,aru

• 'edera ,embulu dara• 'edera organ abdomen

K 0 * # '

N T 3



• 8A' – '0R 8nter,osed Abdominal 'om,ression – '0R

•>est – '0R 'ir(um4erential >est 'om,ression – '0R

• A'D – '0R

A(ti!e 'om,ression De(om,ression – '0R

• ,en 'est – '0R

N T 3 . : - '

















• 'lass 8 ) De4initely ?el,4ul

• 'lass 88 a ) A((e,tableG 0robably ?el,4ul

• 'lass 88 b ) A((e,tableG 0ossibly ?el,4ul

• 'lass 888 ) 7ot 8ndi(atedG May be arm4ul

D " - '

A + * / E 3



•bat Sim,atomimeti6 – >aso6onstri6tor – >aso,resor

• 0ilian utama ,ada (ardia( arrest "'0R• ;4e6 α dan β

– α • >aso6onstri6si sistemi6 tida6 ,ada 6oroner dan

ota6• C taanan ,eri4er• C te6anan sistole dan diastole → aliran 6e ota6 dan

otot 5antung C – β

• C 6onstri6si otot 5antung• C irama 5antung•

9ron6o dilatasi

A + " . # * . / E . 3 " .

E . 3 " . / A + " . # * .



•

8ndi(ations ) – 'ardia( arrest ) >FG ,ulseless >1G asystoleG 0;AG "'lass 8 – Sym,atomati( ) – 9rady(ardia ) a4ter Atro,ine and trans(utaneous ,a(ing "(lass 88 b

• Dosage )

– 'ardia( arrest )• First dose ) #G- mg / 8> ,us – re,eat e!ery * – : min

– Alternati!e regimens 4or se(ond dose "(lass 88 b• 8ntermediate ) B – : mg / 8> ,us e!ery * – : min• ;s(alating ) # mgG * mgG : mg / 8> ,us "* min a,art•

?ig ) -G# mg / 6g / 8> ,usG e!ery * – : min – ;ndotra(eal route )

• BG- – BG: mg diluted in #- ml normal Saline – 0ro4ound 9rady(ardia )

• B – #- mg # min "#mg in :-- ml normal Saline # – : ml / min

E . 3 " . / A + " . # * .

A ! " . S - * $ # !



• 8ndi(ations – First drug 4or sym,atomati( brady(ardia "(lass 88 a – Se(ond drug "a4ter ;,ine,rine 4or Asystole or

9rady(ardi( 0;A "(lass 88 a•

Dosage – Asystole or 0;A• # mg / 8> ,us – re,eat e!ery * – : min• Ma< dose -G-* – -G-H mg / 6g

– 9rady(ardia

• -G: mg – #G- mg / 8> e!ery * – : min• Ma< dose -G-* – -G-H mg / 6g

– ;ndotra(eal administration• B – * mg diluted in #- ml normal Saline

A ! " . S - * $ # !

L + # .



• 8ndi(ations – 'ardia( arrest 4rom >F / >1 "(lass 88a – Stable >1G wideE(om,le< ta(y(ardias wide (om,le<

0S>1 "(lass 8

• 'ardia( arrest 4rom >F / >1 – 8nitial dose ) #G- – #G: mg / 6g 8> – For re4ra(tory >F re,eat #G- – #G: mg / 6g 8> in * – :

minG total dose ) * mg / 6g – A single dose o4 #G: mg / 6g 8> in (ardia( arrest isa((e,table

– ;ndotra(eal administration ) B – H mg / 6g

L + # .

S + - 0 # " . # !



• 8ndi(ations

– 'lass 8 )• 84 6nown ,re e<isting ?y,er6alemia

– 'lass 88 a )• 84 6nown ,re e<isting 9i(arbonate – A(idosis ";3. Diabeti(

Keto A(idosis• 84 o!erdose wit tri(y(li( anti de,ressants to Al6alini@e te

urine drug o!erdose – 'lass 88 b )

• 84 intubated and (ontinued long arrest inter!al• U,on return o4 s,ontaneous (ir(ulation a4ter long arrest

inter!al –

'lass 888 )• ?i,o<i( La(ti( A(idosis ";3. 'ardia( arrest and 'R0 witoutintubation

• Dosage – # m; / 6g 8> bolus – re,eat al4 tis dose e!ery #- min blood

gas analysis e!aluation

S + - 0 # " . # !







DC shoc0

(les dulu paddlesdengan *ellyEC tipis rata2

baru "emudian :

1. Switch ON

Pasang paddles padaposisi apex danparasternal

(boleh terbalik

sternum

apex



DC shoc"B. !harge 3"0 #o$les(Non%s&nchroni'ed

capkan dengan keras :)was sem$a lepas dari pasien* – na+as b$atan berhenti d$l$ – bawah bebas,

samping bebas,atas bebas,

sa&a bebas*

3. Shock**

(tekan d$a tombol paddles bersama-epas paddles dari dada,lan$tkan chest compression.

/. Segera piat ant$ng lagi 2 menitbar$ raba lagi baca lagi !

sternum

apex

!osition



!ositiono4 the paddles electrodeson thorax o4 an in4ant

Size of paddle electrode- /. cm diameter +or in+ants and small children- 4%12 cm diameter larger children

sternum

apex



#ell& k$rang rata, menekan paddles k$rang k$at % l$ka bakar



56 5entric$lar 6ach&cardia|

| |

carotis +? carotis +-

&idocain

1 mg/"g iv cepatatau

Amiodaron 5 mg

C!$ 5:, - . 0#@&%0

a single shoc"5 6oulesdst

8anagemen '/

D $ " * * # ! .



• 8ndi(ations

–>F " (lass 8

– 0ulseless >1 " (lass 8

uide!ines 2###

• Dosage

– B-- Joule ) 4irst so(6 – B-- – *-- J ) se(ond so(6

– *%- J ) tird so(6

– 84 4ail to (on!ert >F / >1 (ontinue at *%- J 4or 4uture so(6

– 84 >F re(oursG so(6 again at te last su((ess4ul energy le!el

uide!ines 2##5 < 2#1#

– Mono ,asi( *%- J

– 9i ,asi( #:- J – B-- J

D $ " * * # ! .



76

• '0R dila6u6an sambil menunggu datangnya D' so(6

DeEF89R8LLA187 / D' so(6

– D' so(6 sedini mung6in "sebelum :E#- menit

– *%- Joules #< "dulu *< so(6G re,eated so(6

"Ji6a D' so(6 bi,asi( #:-EB-- Joules

• Setela a single so(6G segera '0R lagi B menit tan,a

(e(6 ;'3 suda RS' atau belum

• 9aru setela B menit '0RG berenti sebentar untu6

(e(6 ;'3 a,a6a suda RS'



E * ! " # * T 3 " # ;



#. Sim,le (est tum, – Iitnessed >1 / >F

B. Re,etiti!e (est tum,s – ?eart blo(6

*. 'ardio!ersion

"syn(roni@ed ele(tri( (ounter so(6s – AFG 0S>1 – >1 wit ,ulse

H. 7on syn(roni@ed ele(tri( (ounter so(6s –

>1 witout ,ulse – >F:. 0a(ing

– ?eart blo(6 –

Asystole

;

cardiac arrest membandel



Hipo"sia

HipovolemiaHiper"alemiaHipotermia

'amponade *antung 'ensionpneumothorax

'hromboemboli

paru 'oxic overdoseB-bloc"2 Ca-bloc"Digitalis2 'ricyclicAD

9 (

9 4

)A

cardiac arrest membandel

ASS1L;/ 0;A/ ;MD



ASYS

2 menit 2 menit 2 menit 2 menit

e7al$asie7al$asi

Adrenalin!1C"#!$C"#!2 C"#!5C"#!%

)drenaline: 1 mg, i7,

repeated e7er& 3%

min$tes

C"#!&

Cardiac

arrest

ASS1L;/ 0;A/ ;MD

8nt$bation

(-9): as soon as possible, witho$t stop compression

Piat 100xmenit

Na+as 10xmenit

7al$asi !P : tiap 2 menit

e7al$asie7al$asi

C"# !1

$0 ' 2

CA((

)*#

+,("

"ASA-G

.*-/*#

,G

Adrenalin!2 Adrenalin!$

>F/ >1 ,ulseless



C"# !1

$0 ' 2

CA((

)*#+,("

"ASA-G

.*-/*#

)

a single shoc3!//a single shoc3!/! a single shoc3!/

a single shoc3!/// a single shoc3!2 menit 2 menit 2 menit 2 menit

adrenalinadrenalin

C"#!$C"#!2C"#!5

C"#!%

! A./*4A#*-

)drenaline: 1 mg, i7,

repeated e7er& 3%

min$tes

C"#!&

Cardiac

arrest

Or -8;O!)8N 1mgkg. !an be

repeated. ;o not exceed a total dose o+

3 mgkg,d$ring the +irst ho$r.

)miodaron is the +irst choice

300 mg, bol$s. epeated 10 mg+or recc$rrent 565<. <ollowed b&

=00 mg in+$sion o7er 2/ ho$rs

>F/ >1E,ulseless

8nt$bation

-9) : as soon as possible, witho$t stop compression

Piat 100xmenit

Na+as 10xmenit

7al$asi !P : tiap 2 menit

adrenalin3>

B-#-

3>



A0R8L A7;S1;S8



TERIMA KASIH

Artificial Circulation, Dr. TOMMY

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