Perawat DOKTER MengKegawatanAnak Dadang

MENGENAL KEADAAN EMERGENSI
SISTEM KARDIORESPIRASI
PADA BAYI DAN ANAK
KOMISI RESUSITASI PEDIATRI
UKK EMERGENSI DAN RAWAT INTENSIF
ANAK IDAI - PKGDI
UKK ERIA IDAI - PKGDI
RESPIRATORY
or
CIRCULATORY
SYSTEM
abnormality?
Cardiorespiratory Emergency
Many etiologies
Respiratory failure
Shock
Cardiopulmonary failure
Cardiopulmonary arrest
Outcome of
Respiratory vs Cardiopulmonary Arrest
in Children
100%
Survival rate
75 90 %
Cardiorespiratory Emergency
Core Knowledge and Skills:
1. Recognize respiratory distress and

potensial respiratory failure
2. Recognize shock
3. Describes priorities for management
of respiratory distress, failure, and
shock
75%
7 11 %
Respiratory arrest
3
PAT
ing
ath
re
ra
n
Ap
pe
a
fB
ko
or
W
ce
Pediatric Assessment Triangle

Hand off only <1 minute
Circulation
Followed by
ABCDE of Resuscitation
Hand on after 1 minute
Pediatric assessment triangle
Pediatric Chain of Survival

Pediatric Advance Life Support (PALS)
Prevention
Early CPR
Prompt Access to EMS
Rapid Pediatric Advanced Life Support (PALS)
Integrated Post-Cardiac Arrest Care
SYSTEMATIC APPROACH
Evaluate
Primary
Assessment
Identify
Secondary
Assessment
Focused Exam
SAMPLE History
Intervene
Diagnostic
Tests
Tertiary Assessment
Assessment
Airway & Respiratory Considerations
OPA NPA When do we use them
Signs of progressive Respiratory Failure

-Respirations decreasing and more lethargic
Following Breathing Treatments ABCs
Indications for needle decompression
Treatment options for allergic reactions
AIRWAY MANAGEMENT
Rescue Breathing
One (1) Rescue Breath every 3 5 Seconds

Pediatric Patient with a pulse but not
breathing
BVM = 1 Breath every 3 5 seconds
Has an ET Tube = 1 Breath every 3 5 seconds
CPR with advanced airway
Continuous Compressions and 1 breath every 6

8 seconds (8 10/minute)
ET Tube Sizes
UN-Cuffed
Age/4 + 4
Cuffed
Age/4 + 3.5
Listen------ Epigastric
Axilla
Lungs
breathing
Diminished breath sounds
Diminished rise of the chest on one side
Respiratory distress with stridor (possible

allergic reaction (Epi IM)
Barking cough (moderate stridor & retractions)

(Nebulized Epi)
Airway & Respiratory Considerations
Oxygen should be administered to patients with

low O2 saturations and increased work of
breathing
Nebulized Epinephrine is for stridor, mild to

moderate retractions, barking cough
Additional Information
Tracheal deviation absence of breath sounds

- Needle decompression
Following a seizure
ABCs manage airway/breathing
Equipment
Treat patient
Systolic Blood Pressure

Lower than 5th percentile
Estimate of Minimum Systolic Blood Pressure
Age
Minimum systolic blood pressure
0 to 1 month
60 mm Hg
>1 month to 1 year 70 mm Hg
1 to 10 years of age 70 mm Hg + (2 x age in years)
>10 years of age 90 mm Hg

(adolescence as in adult = 70 + 2x10 = 90 mmHg)
Rhythm disturbances
Hypovolemic Fluid boluses
SVT- Vagal Maneuvers Adenosine 0.1 mg/kg

Adenosine
0.2 mg/kg
Synchronized Cardioversion - 0.5 - 1 joules
Synchronized Cardioversion 2 joules/kg
Respiratory failure OR
Shock?
The Three Phases of

Rapid Cardiopulmonary Assessment
1. Physical examination
2. Classification of physiologic status
3. Initial management priorities
17
The PAT - ABCs

Normal Vital Functions Are Maintained
By
Airway
Breathing
Circulation
To Provide
Ventilation
Oxygenation
Perfusion
18
Primary Abnormalities in Respiratory Failure

Ventilation
Airway
And
Breathing
Oxygenation
Circulation
Perfusion
19
Anatomy of the Pediatric airway

Relatively larger head and tongue
More anterior larynx
Narrowest part of the airway: cricoid cartilage
Easily compressed trachea
Larynx: Adult
versus
Child
Bila edema, menebal 1 cm . . .
Bila pita suara edema, . . . . . .

Children vocal cord
Adult vocal cord
Bayi
Dewasa
20
Rapid Cardiopulmonary Assessment (30

seconds)
Evaluation of General Appearance
Color
Mental status, responsiveness
Activity, movement, muscle tone
Response to environmental stimuli
Airway, Breathing, Circulation

Airway
Clear
Maintainable with positioning and suctioning
Not maintainable without invasive intervention
Breathing
Respiratory rate
Effort and mechanics
Air entry/depth of respirations
Skin color
Circulation
Heart rate (tachycardia, bradycardia)

Pulses (volume, discrepancy between central and distal)
Capillary refill
Extremity temperature
Mental status
Pope, Consultation with the specialist Pediatrics in Review Vol.25 No.5 May
21
2004
Respiratory
distress or
Failure?
Alert pisan
Retraction & nasal flare
Sniffing position
ZZZ or ALOC?
Tripod position
Keep on the laps

Failure pisan
22
Gambaran Klinis Gagal Napas Akut

Lab. AGD diagnosis pasti
PaO2 < 60mmHg (FiO2 0,6)
PaCO2 > 60 mmHg
pH < 7,3
KLINIS
Sistem respirasi
Mengi
Merintih pada
fase ekspirasi
(grunting)
Suara napas
menurun
sampai hilang
Pernapasan
cuping hidung
Retraksi
dinding dada
Takipnea,
bradipnea, atau
apnea
Sianosis
Neurologis
Gelisah
Tidak stabil
Pusing, sakit
kepala
Kebingungan
Kejang
Koma
Keadaan umum
Kelelahan
Berkeringat
Jantung
Takikardia atau bradikardia
UKK ERIA
IDAI - PKGDI
Hipertensi
atau hipotensi
23
Pengenalan Dini Gagal Napas Akut
Distres napas
atau
Gagal napas?
24
Classification of Respiratory Failure

Potential respiratory failure
Theraphy
(eg, positioning, oxygen administration)
Improvement
Potential resp. failure
Deterioration
Probable resp. failure
25
Potential respiratory failure
P AT
ABCD
26
Penilaian Klinis Awal Gagal Napas Akut

Penilaian
Distres Pernapasan
Gagal napas
Henti napas
1. Status mental
Sadar, gelisah, agitasi,
Kurang responsif
/respons terhadap
rangsang sakit
Tidak responsif
2. Tonus otot
Normal
Normal atau hipotona
Lemas
3. Posisi tubuh
Posisi tripod
Posisi tripod, perlu

bantuan
mempertahankan posisi
duduk
Tidak bisa
mempertahankan posisi
tubuh (bayi >7-9 bulan)
4. Laju napas
Lebih cepat dari normal
Takipnea + periode
bradipnea
Tidak ada napa
5. Upaya napas
Retraksi interkostal
Napas cuping hidung
Pemakaian otot leher
Pernapasan paradoksik
Upaya napas tidak

adekuat, dinding dada
naik turun
Tidak ada upaya napas
6. Suara napas
Stridor, mengi, berdeguk
Stridor, mengi,
berdeguk, megapmegap
Tidak terdengar suara

napas
7. Warna kulit
Kemerahan atau pucat,

sianosis central yang
membaik dengan
pemberian O2
Sianosis central
walaupun telah diberi
O2, berbercak biru
Berbercak biru, sianosis

perifer dan sentral
(Aehlert 2007)
27
Care Crit Ill Child Bdg 3--5-15
Whatever your patients problem is, apply the PAT
ea
ra
n
PAT
ing
ath
re
Ap
p
fB
ko
or
W
ce
Pediatric Assessment Triangle

Hand off only <1 minute
Circulation
Followed by
ABCD of Resuscitation
Hand on after 1 minute
Pediatric assessment triangle
assessment
SYSTEMATIC APPROACH
Evaluate
Identify
Primary Assessment
Secondary Assessment
Focused Exam
SAMPLE History
Intervene
Diagnostic Tests
Tertiary Assessment
Dont forget PPE

Personal Protective Equipment.
SAMPLE
SAMPLE history
Signs and symptoms
Allergies
Medications
Past medical history
Last oral intake
Events leading to the
injury or illness
SYSTEMATIC APPROACH
Evaluate
Identify
Primary Assessment
Secondary Assessment
Focused Exam
SAMPLE History
Intervene
Diagnostic Tests
Tertiary Assessment
Initial Assessment: hands off < 60 seconds
r an
ea
B
of
re a
Ap
p
rk
Wo
ce
Pediatric Assessment Triangle (PAT) :
th i
ng
Circulation to Skin
34
Appearance (Tickles =TICLS)
ear
an
ce
Tonus
Interactiveness
Consolability
Look/Gaze
Speech/Cry
Ap
p
35
36
Work of Breathings
rk
Wo
gs
hin
eat
Br
of
Abnormal airway sounds

Abnormal positioning
Retractions
Nasal flaring
37
The sniffing position

The abnormal tripod position
Retractions
38
Circulation to Skin
Characteristic of Circulation to Skin
Pink
Pale
Mottling
Cyanosis
39
PAT: Potential Respiratory Failure
Increased
r ea
Ap
pe
a
fB
ran
ce
o
rk
Wo
Normal
thi
ng
Circulation to Skin
Normal
40
fB
r ea
Ap
pe
a
o
rk
Wo
Abnormal
ran
ce
PAT: Respiratory Failure
Increased
or
decreased
thi
ng
Circulation to Skin
Normal or abnormal
41

Physical Examination - Airway
1. Clear
2. Maintainable
3. Unmaintanable without intubation
4. Obstructed
42

Physical Examination - Breathing
1. Rate
2. Effort / mechanics (Retractions)
3. Air entry (VBS)
4. Skin color and temperature
43

Physical Examination : Breathing
44
EMERGENSI!
Gagal napas akut
Resusitasi segera:
Stabilisasi dan mencegah perburukan.
Berikan oksigenasi, kontrol saluran napas,
tatalaksana ventilasi,
stabilisasi sirkulasi dan terapi farmakologis.
Perawatan selanjutnya:
Melakukan diagnosis diferensial dan investigasi lanjut,
rencana terapi yang disesuaikan dengan diagnosis
(antibiotik, bronkodilator, nutrisi, fisioterapi,
pemantauan, radiologis).
45
OXYGEN !
Simple:
Nasal canule
Face mask
Oxyhood
Low Flow
vs
High Flow
Other airway adjuncts

Nasal trumpet
Awake
Oral airway
Unconscious
LMA
Need to be experienced in insertion
Not a stable airway
Needle cricothyrotomy
Tracheostomy
Non Invasive Positive Airway Pressure: CPAP (= PEEP)

BiPAP
Mechanical Ventilator
46
Bila pasien sadar:

Penanganan minimal, bayi dipangkuan orang tua,
dalam posisi yang nyaman,
jangan memaksakan pasien dalam posisi tidur,
berikan suplemen oksigen (aliran rendah atau tinggi),
pantau kardiorespirasi dan pulse oxymeter,
akses intravena bila perlu,
anamnesis dan pemeriksaan klinis singkat.
Bila pasien tidak sadar:
Buka jalan napas (manuver tengadah kepala, angkat dagu,
mengedapkan rahang), dan posisi pemulihan.
Isap lendir (10 detik),
ventilasi tekanan positif dengan O2 100%.
Intubasi endotrakea dan RJP bila diperlukan.
47
Primary Abnormalities in Shock
Ventilation
Airway
And
Breathing
Oxygenation
Circulation
Perfusion
48
PAT: Shock
Normal
r ea
Ap
pe
a
fB
ran
ce
o
rk
Wo
Abnormal
thi
ng
Circulation to Skin
Abnormal
49
TIPE dan STADIUM SYOK

Definisi Syok:
Stadium Syok
1. Syok Stadium Awal/Kompensasi
Tipe Syok
2. Syok Stadium Lanjut/Dekompensasi
1. Syok Hipovolemia
2. Syok Distributif
3. Syok Kardiogenik
4. Syok Distributif
5. Syok Disosiatif
3. Syok Stadium Akhir/Ireversibel

Perjalanan klinis progresif
50
STADIUM AWAL:
KOMPENSASI
KOMPENSASI TEMPORER
SIMPATIS, SVR, TEKANAN NADI
DISTRIBUSI SELEKTIF ALIRAN DARAH
RETENSI NA & AIR
KLINIS : * GADUH GELISAH (ALOC)

* TAKIKARDIA, TAKIPNEA
* KULIT PUCAT DINGIN
* PENGISIAN KAPILER >>
Belum terjadi hipotensi (kompensasi homeostasis)
Oliguria?
51
STADIUM LANJUT: DEKOMPENSASI

KOMPENSASI MULAI GAGAL
HIPOPERFUSI HIPOKSIA JARINGAN.
METAB. ANAEROB GGN. METAB. SEL
PELEPASAN MEDIATOR PROINFLAMASI :
* VASODILATASI
* PERMEABILITAS
* DEPRESI MIOKARDIUM
* GGN KOAGULASI
KLINIS :
KESADARAN (ALOC)
TAKIKARDIA, TAKIPNEA PERFUSI PERIFER , AKRAL
DINGIN (CRT >2 DETIK) OLIGURI (+)
HIPOTENSI
ASIDOSIS (+)
52
STADIUM AKHIR: IREVERSIBEL
KOMPENSASI GAGAL
CADANGAN ENERGI TUBUH
KERUSAKAN/KEMATIAN SEL
DISFUNGSI ORGAN MULTIPEL (MODS)
KLINIS : * TINGKAT KESADARAN
* NADI TAK TERABA
* Tekanan Darah TAK TERUKUR
* OLIGO-ANURIA
* GAGAL MULTI ORGAN (MOF) MATI
53
Basic Relationships of Cardiovascular Parameters

The Next Trend of Fluid Resuscitation in
Pediatric Shock
EARLY SHOCK . . .
Tachycardia and
prolonged capillary
refill time
( HR & SVR )
Preload - Hypovolemic
Myocardial - Cardiogenic
Stroke
contractility
Volume
Afterload - Obstructive
CO = HR x SV
Cardiac
Output
Blood
Pressure
Heart
Rate
Systemic
Vascular
Resistance
Compensated shock
Decompensated shock
Irreversible shock
- Distributive Shock
54
Blood Pressure: Cardiac Output >< SVR

Cardiac Output = Heart Rate X Stroke Volume
Inadequate
Compensation
Increased heart rate
Increased SVR
Possible increased SV
55
resistensi vaskular
Volume darah anak

85-65 mL/kgBB
140
100
60
25% x 80 mL = 20 mL
Curah
jantung
Tekanan darah
20
25
50
Resusitasi cairan:
20 mL/kgBB (5-30 menit)
Rata-rata dalam 15 menit
75
%tase kehilangan darah

Respons hemodinamik terhadap kehilangan darah
29
Syok awal/kompensata: kehilangan 25% volume darah

Syok lanjut/dekompensata:
50%
Syok ireversibel:
>50%
56

Physical Examination - Circulation
1. Heart rate
2. Systemic perfusion
Peripheral pulses
Skin perfusion
Level of consciousness
Urine output
3. Blood pressure
57
What information does blood pressure provide ?
What is inadequate blood pressure ?
58
Heart rates in Normal Children

Age
Range
Newborn 3 Mos
3 mos 2 yrs
85 200 bpm
100 190 bpm
2 10 yrs
60 140 bpm
5th Percentile of Systolic Blood Pressure

Neonate 60 mmHg
Infant
70 mmHg
> 1 year 70 + (2 x age in year)
Mean Arterial Blood Pressure: (1 systolic + 2 diastolic) : 3

Adolescent = adult
School age
Under 5 year
Under 1 year
Neonate
65 mmHg
60
50
45
40
Pulse Pressure: Systolic Diastolic = 2040 mmHg
59

Skin perfusion
Extremity temperature
Capillary refill
Color
Pink
Pale
Mottled
Blue
60
Normal capillary refill is < 2 seconds in a warm environment

61
Capillary refill
62
Child in shock with depressed mental status
63

Level of consciousness
A
V
P
U
= Awake
= Responsive to voice
= Responsive to pain
= Unresponsive
64
Renal perfusion
Urine output (Normal: 1 to 2 mL/kg/hour)

reflects
Glomerular filtration rate
reflects
Renal blood flow
reflects
Vital organ perfusion
65
Review of the Physical Findings in Shock

1.Early signs (compensated Shock)
Increased heart rate
Poor systemic perfusion
2. Late signs (decompensated Shock

Weak central pulses
Altered mental status
Decreased urine output
Hypotension
3. Irreversible Shock
66
Definition of Cardiopulmonary Failure
Deficits in
Ventilation
Oxygenation
Perfusion
Resulting in
Agonal respiration
Bradycardia
67

Ventilation
Airway
And
Breathing
Oxygenation
Circulation
Perfusion
68
The Three Phases of

1. Physical examination
2. Classification of physiologic status
3. Initial management priorities
69

Classification of Physiologic status
Stable
Respiratory failure
Potential
Probable
Shock
Compensated
Decompensated
Cardiopulmonary failure
70
Rapid Cardiopulmonary Assessment Priorities of Initial Management

Shock
Administer oxygen (FiO2 = 1.00) and ensure
adequate airway and ventilation
Establish vascular access
Provide volume expansion
Monitor oxygenation, heart rate, and urine output
Consider vasoactive infusions
71
Post Arrest Care
Goals
Preserve neurologic function
Prevent secondary organ injury
Diagnose & Treat cause of illness
Enable patient to arrive at Pediatric Tertiary-Care
facility in optimal physiologic state
Frequent assessment is necessary because of

risk of deterioration
Maintain Oxygen saturation between 94 and 99%

following ROSC

Pediatric Shock
THE BASIC MANAGEMENT OF SHOCK . . .

Stabilize the respiration
Assess perfusion
Access vascular: IV or IO
Fluid resuscitation
(crystalloids, colloids) which one?
Inotropes and Vasopressors
Transfusion: RBC
Electrolyte and Metabolic: hypoglycemia,
hypocalcemia
Steroid
73
TERIMA KASIH
74
HR/SBP
(shock index)
Fluid Resuscitation
HR
CR
BP
INTRAVASCULAR VOLUME LOSS

(-)20cc/kg
(-) 40cc/kg
(-) 60cc/kg
(After Carcillo JA)
75

Pediatric Shock
Fluid resuscitation volume expansion
Colloids
Crystalloids
Dextrose 5%
ICF = 28 L
40% BW
Interstitial = 9L
15% BW
RBCs
Plasma
5% BW
ECF = 14 L
TBW = 42 L
5L
76

Pediatric Shock
Fluid therapy and body compartment

Dehydration
Gastroenteritis
Extracellular fluid loss
Fluid
replacement
Isotonic crystalloid
Balanced solution
Hypovolemia/
Distributive shock
Intravascular fluid loss
(~ blood loss)
Volume
replacement
Isotonic crystalloid
Colloids
Hypertonic crystalloid
Balanced solution
77
77

Pediatric Shock
Assessment of volume status 1

Clinically, look at the patient:
Consciousness ALOC
Pulse
Blood pressure
Capillary refill
Mucous membranes
Cool extremity
Thirst
78

Pediatric Shock

Blood tests . . .
U & MEs
Hematocrit
Plasma/urine
osmolality
Arterial blood gases
Plasma lactate
Hypovolemic - Hypodynamic
79

Pediatric Shock

. . . more (non/minimally) invasive monitoring:
Urine output
Arterial line
Central venous line
PA catheter
Transesophageal/thoracic echo/doppler/TEE/TTE
Emergency/Critical Care Ultrasound
Passive leg raising
. . . and (non/minimally) invasive fluid

responsiveness monitoring . . .
80

Perawat DOKTER MengKegawatanAnak Dadang

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MENGENAL KEADAAN EMERGENSI

UKK ERIA IDAI - PKGDI

1. Recognize respiratory distress and

Pediatric Assessment Triangle

Pediatric assessment triangle

Pediatric Chain of Survival

Prompt Access to EMS

Rapid Pediatric Advanced Life Support (PALS)

Integrated Post-Cardiac Arrest Care

Airway & Respiratory Considerations

OPA NPA When do we use them

Signs of progressive Respiratory Failure

Following Breathing Treatments ABCs

Indications for needle decompression

Treatment options for allergic reactions

One (1) Rescue Breath every 3 5 Seconds

CPR with advanced airway

Continuous Compressions and 1 breath every 6

Diminished breath sounds

Diminished rise of the chest on one side

Respiratory distress with stridor (possible

Barking cough (moderate stridor & retractions)

Airway & Respiratory Considerations

Oxygen should be administered to patients with

Nebulized Epinephrine is for stridor, mild to

Tracheal deviation absence of breath sounds

Systolic Blood Pressure

Minimum systolic blood pressure

>1 month to 1 year 70 mm Hg

1 to 10 years of age 70 mm Hg + (2 x age in years)

>10 years of age 90 mm Hg

Hypovolemic Fluid boluses

SVT- Vagal Maneuvers Adenosine 0.1 mg/kg

The Three Phases of

UKK ERIA IDAI - PKGDI

The PAT - ABCs

UKK ERIA IDAI - PKGDI

Primary Abnormalities in Respiratory Failure

UKK ERIA IDAI - PKGDI

Anatomy of the Pediatric airway

Bila edema, menebal 1 cm . . .

Bila pita suara edema, . . . . . .

UKK ERIA IDAI - PKGDI

Rapid Cardiopulmonary Assessment (30

Airway, Breathing, Circulation

Heart rate (tachycardia, bradycardia)

Retraction & nasal flare

Keep on the laps

Gambaran Klinis Gagal Napas Akut

Pengenalan Dini Gagal Napas Akut

UKK ERIA IDAI - PKGDI

Classification of Respiratory Failure

UKK ERIA IDAI - PKGDI

Potential respiratory failure

Penilaian Klinis Awal Gagal Napas Akut

Sadar, gelisah, agitasi,

Normal atau hipotona

Posisi tripod, perlu

Lebih cepat dari normal

Tidak ada napa

Upaya napas tidak

Tidak ada upaya napas

Stridor, mengi, berdeguk

Tidak terdengar suara