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Identifikasi Dini Pasien Kritis
Dr. Gatoet Soeseno, MARS.
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Objectives Memahami pentingnya identifikasi dini
pada pasien-pasien yang beresiko menjadisakit kritis
Mengenali tanda-tanda awal sakit kritis
Mendiskusikan penilaian awal pasien sakit
kritis
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Kenapa pasien mati ?Kenapa pasien mati ?
(atau mengapa terjadi mati otak?)(atau mengapa terjadi mati otak?)
Kekurangan oksigenKekurangan oksigen Kehilangan energi (ATP)Kehilangan energi (ATP)
ToksinToksin
Kerusakan fisikKerusakan fisik
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Proses terjadinya sakit kritisProses terjadinya sakit kritis
Onset ofOnset ofillnessillness
Early Sign &Early Sign &
SymptomSymptom
ShockShock
InfectionInfection
TraumaTrauma
Compensation;Compensation;
Preserve brainPreserve brain
and heartand heart Fail/ decompFail/ decomp DeathDeath
Depends on;Depends on;gege
Se!erity of illnessSe!erity of illness"ree#isting disease"ree#isting disease
TachypneaTachypnea
TachycardiaTachycardia
HypertensionHypertension
pHpHLactateLactate
CRPCRP
LeucocyteLeucocyte
BradycardiaBradycardia
HypotensionHypotension
AlkalosisAlkalosis
SevereSevere
AcidosisAcidosisor!alor!al
"here #ere should #e$"here #ere should #e$
C o ! p e n s a t o r y p h a s e
Restlessness, anxiety, combativeness
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Dilihat dari penebab!penebabDilihat dari penebab!penebabterjadina henti jantung" berapaterjadina henti jantung" berapa
lama #aktu ang kita milikilama #aktu ang kita miliki
sebelum terjadi henti jantung?sebelum terjadi henti jantung?
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The Process of Ding$The Process of Ding$
Asphy%ia&Asphy%ia&'Air#ay Obstruction('Air#ay Obstruction(
'Apnea('Apnea(
)%san*uination)%san*uination
Pul!onary +ailurePul!onary +ailure
ShockShock
Brain +ailureBrain +ailure
Circulatory ArrestCirculatory Arrest,-./ !in,-./ !in
$$
$$
$$
$$
0Safar P1 Cerebral resuscitation after cardiac arrest& research initiatives and0Safar P1 Cerebral resuscitation after cardiac arrest& research initiatives and
future directions1 Ann )!er* 2ed //&3/45.663future directions1 Ann )!er* 2ed //&3/45.663
Pri!ary ventricularPri!ary ventricular
fibrillationfibrillation
Pri!ary AsystolePri!ary Asystole
Alveolar ano%ia /-3 !in/-3 !in
7 !in
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%erhentina sirkulasi& henti
jantung&cardiac arrest 10 detik
idak sadar
1!-"! detik #tak isoelektrik terjadi apnea
" to $ menit %enyimpanan &lucose dan glycogen di otak habis
' to ! minutes
(% habis %ompa listrik otak mati total
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%erapa lama #aktu angkita miliki untuk
mengembalikan sirkulasi
setelah henti jantung?
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The Process of DingThe Process of Ding
HentiHentisirkulasisirkulasi
- - - - - - -- - - - - - -
2ati klinis 8 henti sirkulasi total yan* potensial reversibel se!buh2ati klinis 8 henti sirkulasi total yan* potensial reversibel se!buh
se!purna ter!asuk fun*si otak jika dilakukan resusitasise!purna ter!asuk fun*si otak jika dilakukan resusitasi
, !in, !in .7 !in.7 !in ., !in., !in /7 !in/7 !in
0Safar P1 Cerebral resuscitation after cardiac arrest& research initiatives and0Safar P1 Cerebral resuscitation after cardiac arrest& research initiatives and
future directions1 Ann )!er* 2ed //&3/45.663future directions1 Ann )!er* 2ed //&3/45.663
9e!balinya sirkulasi9e!balinya sirkulasi
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Ti!eTi!e
: survival: survival
+ast rate+ast rateSlo# rateSlo# rateoneone
ResuscitationResuscitation
'*+,TAT,O-'*+,TAT,O-
NEED FOR SPEEDNEED FOR SPEED
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LV failure Compensation Early Stage
contr Preload CO local control; dilatasi Humoral; Anuria, Na
Congestion Myocardial Sympatetic; HR!or"
CPAP Signs of low CO; Hypoperfusion cool and clammy e#trimitis, lo!
capillary re$ill, tacycardia,
narro! pulse pressure and lo! urine out put
Pulmonary Pa%& Matcing edema 'et!een Supply ( demand
Redistri'ution 'lood $lo!
to )ital organ *sa)ing Heart ( +rain -ate Stage
Consciousness
Pulmonary Di)ersi o$ 'lood $lo!, use respiratory Dysritmia
compliance muscle
Dyspnea Hyper)entilation Reduced
Air!ay PaC%& !or" o$ +reating
resistance
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The Process of DingThe Process of Ding
HentiHentisirkulasisirkulasi
- - - - - - -- - - - - - -
, !in, !in .7 !in.7 !in ., !in., !in /7 !in/7 !in
)%isa bernafas spontan%isa bernafas spontan)%isa sadar atau stupor%isa sadar atau stupor)-eurologi ada deficit-eurologi ada deficit
)%isa bernafas spontan%isa bernafas spontan)%isa sadar penuh%isa sadar penuh)-eurologi bisa normal-eurologi bisa normal
$$
0Safar P1 Cerebral resuscitation after cardiac arrest& research initiatives and0Safar P1 Cerebral resuscitation after cardiac arrest& research initiatives and
future directions1 Ann )!er* 2ed //&3/45.663future directions1 Ann )!er* 2ed //&3/45.663
2ati klinis2ati klinis
9e!balinya sirkulasi9e!balinya sirkulasi
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The Process of Ding cont.The Process of Ding cont.
- - - - - - -- - - - - - -
, !in, !in .7 !in.7 !in ., !in., !in /7 !in/7 !in
)%isa nafas pontan%isa nafas pontan)Tidak sadarTidak sadar)/egetative tate/egetative tate)0 Abnormal0 Abnormal
)ApneaApnea)komakoma)%rain Death%rain Death),soeletric 0,soeletric 0
$$
0Safar P1 Cerebral resuscitation after cardiac arrest& research initiatives and0Safar P1 Cerebral resuscitation after cardiac arrest& research initiatives and
future directions1 Ann )!er* 2ed //&3/45.663future directions1 Ann )!er* 2ed //&3/45.663
HentiHentisirkulasisirkulasi
2ati klinis2ati klinis
9e!balinya sirkulasi9e!balinya sirkulasi
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1engenal fase kompensasi
pasien sakit kritis *isilogis
anda aktivasi simpatis +R,RR,,sweating anda inflamasi.peradangan sistemik +/R/emp,
rush anda hipoperfusi sistemik
+cap2refill,confusing.agitation
3iokimia 3ase deficit.raised lactate 4eucocytosis.leucopenia hrombocytopenia Raised urea and creatinine Raised 5R%
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Assessing the patient
3asic investigations Tachpnoea+merupakan indikator sakit
kritis yang paling penting
achycardia
ypotension +gangguan kardiovaskular ygtersering pada pasien sakit kritis yg akut,penyebabnya hipovolemi. sepsis
(cidosis +adanya metabolic acidosissalahsatu dari indikator penting dari sakit kritis
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Dua faktor penting pada
peelidikan a#al
(rterial 3lood &ases 6 3lood 4actate 5apillary 3lood &lucose
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Tachpnoea(hyperventilation)
Minute ventilation M7 8 RR x 7
3lood &as (nalysis 92':.23.1"0.-10.;;(RE /@R7DE
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urve The cene
o determine if it is safe to proceed withthe rescue2
(void all dangerous situations2 f you are not properly trained and do not
have the necessary eFuipment do notapproach the victim2
?ever risk your own life
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%efore 6ou Approach The /ictim
5heck for unsafe conditions that will threatenyour safety and that of the bystanders
4ook for clues and try to find out what happened >angers include downed power lines, traffic, fire,
unstable structures, deep or swift moving water
f conditions change, you may then be able to
approach the victim or victims (sk bystanders for information or for help
/peak to victim in a calm reassuring manner
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Primar urve
his procedure takes a few seconds and is the
difference between life and death2 he %rimary survey is also referred to as the
(35As2
his principle is the basis of our class
Eou will be able to observe signs of lifethreatening conditions
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PAT,-T A1-T
5heck to see of the victim G
/ 5#?/5#@/ (/ (? #%D? (RH(E
/ 3RD(?&
(/ ( D(R3D(
/ 34DD>?& /D7DRD4E he primary survey takes only secondsto perform
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+heck The Air#a
( victim who can talk or cry is consciousandhas an open airway
f the victim is unconscious, open the victimAsairway ead ilt. 5hin 4ift his action moves tongue away from the
airway
5heck for 3reathing (irway may be obstructed by food, liFuid, or
other objects
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+7+K %'AT7,-0
4ook, listen and feel for signs of breathing
f victim is breathing chest #ill rise and fall
%osition yourself so you can hear and feel air as itescapes from victimAs nose and mouth
f victim is not breathing you must breathe forthe victim
his is called RD/5@D 3RD(?&
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+7+K +,'+*5AT,O-
5heck for blood circulation or pulse
5heck for severe bleeding
f the heart has stopped blood will not circulate
throughout the body
f the victim is breathing then their heart is beatingandcirculating blood
#n an infant check the pulse on the brachial arter
#n a child or an adult check the carotid arter 5heck the pulse for I! - 10 seconds
f no breathing or pulse administer rescue breathing andchest compressions
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(57(D DM/
/ummon additionalhelp from advanced
medical personnel ifany of the followingconditions existsG *nconsciousness
%reathing problems
Persistent chest orabdominal pain
-o pulse
evere %leeding
/omiting or passing
blood uspected poisoning
ei8ures" severeheadache" slurredspeech
uspected or obvioushead or neck injuries
uspected fractures
evere burns
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+O-DA'6 *'/6 #nce you are certain that the victim has no life!no life!
threateningthreateningconditions, you can begin the secondarsurve
Eou will gather information about the victim and any
conditions that ma become life!threateningma become life!threatening nterview the victim and bystanders
5heck vital signs
>o a head-to-toe examination to check for signs andsigns and
smptomssmptoms n some cases you may never have the opportunity or
need to conduct the secondar surve
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,-T'/,9 :*T,O-
Hhat happenedJHhat happenedJ
>o you feel any pain anywhereJ>o you feel any pain anywhereJ
>o you have any medical conditionsJ>o you have any medical conditionsJ (re you taking medicationsJ(re you taking medicationsJ
>o you have any allergiesJ>o you have any allergiesJ
hese Fuestions may be asked to the parent orresponsible adult if you are working with aninfant or a child
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5D5=?& 7(4 /&?/
P*5P*5 Hith every heartbeat a wave of blood moves through theblood vessels
his creates a beat called the pulse
( pulse can be checked in arteries that circulate close to thesurfaceG 5(R#>G
3R(5(4G
R(>(4
( normal pulse for an adult is I:0-K03%M (n abnormal pulse may be sign of a potential problemG
rregular pulse
Heak and hard to find pulse
Dxcessively fast or slow pulse
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5D5=?& D 7(4 /&?/
%reathing%reathing
( healthy person breathes regularly, Fuietly, andeffortlessly
(bnormal breathing may indicate a potentialproblem such asG &asping for breath
?oisy breathing whistling sounds, high pitched
wheeLing, gurgling, or snoring Dxcessively fast or slow breathing
%ainful breathing
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7AD TO TO ;A1,-AT,O-
/tart at the head ending at the toes, checking for anyabnormal conditions
@se your senses toG /mell unusual odors
4ook for pale or bluish skin, bruises, deformed body parts
%alpate all tender areas
5ontinue to monitor vital signs
#bserve any changes that indicate a life threateningsituation and provide necessary first responder care
RESUE !"RESUE !" (orban(orban
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RESUE !"BAS#$ %#"EBAS#$ %#"E
SU&&!R'SU&&!R'/e esadaran/e esadaran
adaradar
ida sadarida sadar
/e/e
NadiNadiosisi $antaposisi $antap
2da2daida adaida ada
6o$presi6o$presi
88 ali88 ali
per$enitper$enit
Nilai ira$a dan ce pulsNilai ira$a dan ce pulsRO/RO/2/92/9