Assessment of the Critically Ill Patients [Compatibility Mode]
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Penatalaksanaan Dini Penderita Penyakit Kritis
Frans JV PangalilaIntensivist
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mengidentifikasi gangguan fisiologimengidentifikasi cara yang tepat dalam mengatasigangguan fisiologismengidentifikasi penyebab dasar gangguan fisiologis
Tujuan Penatalaksanaan Dini Pada Penderita Kritis
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Pasien Kritis : definisi
mengalami dekompensasi fisiologis sehinggadiperlukan pemantauan terus menerus sertamelakukan intervensi sesegera mungkinuntuk mencegah timbulnya penyulit yanglebih fatal
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Penyakit kritis dimana fungsi sistem / organ dalam tubuh labil →....labil berarti mudah berubah dan berpengaruh terhadap organlain sehingga terjadilah gangguan fungsi organ multiple yang me-ngancam jiwa (Multi Organ Dysfunction Syndrome-Multi OrganFailure → mortalitas > 90%)
Penyakit kritis respon terhadap bantuan obat/intervensi sulit diduga dan berbeda satu sama lain (individual tailor)→pengelolaanberdasarkan respon terhadap intervensi (Therapy by Respondsand Titration)
Karakteristik Penderita Kritis dan Konsekwensinya
Axiom: Critically Ill PatientsTime is Everything : need an early intervention and anticipationsTreatment on day I is more more important than day 7, 15 or....etc
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Mengapa Penatalaksanaan Dini Penderita Kritis SeringTidak Sesuai Yang Diharapkan ??
Tanda tanda vital tidak dilakukan evaluasi secara optimal !
Petanda klinis yang ditemukan tidak di intepretasi secaraop mal → keterbatasan tenaga / staff terlatih
Identifikasi masalah terutama dipengaruhi oleh specializedhealth approach!
Terjadi perbedaan cukup besar antara diagnosa kerja denganrealitas status klinis penderita yang sebenarnya- evaluasi tanda vital tidak dilakukan teliti dan berulang !- contoh : nyeri dada posterior pada aneurisma aorta ataudelirium pada sepsis berat !
Terpenting mengevaluasi adakah ??• gangguan jalan napas dan pola napas• gangguan kesadaran dan sirkulasi
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Pendekatan awal dalam melakukan Assessment
mulai dengan pertanyaan sederhana dan evaluasi responsnya
bila memberikan respons jawaban normal menandakan →jalan napas / pernapasan serta perfusi otak baikbila jawaban tidak adekuat → kemungkinan ada gangguanperfusi otak (iskhemia) atau toksik otak (mis hipoglikemia)menjawab dengan kalimat pendek → ancaman gagal napastidak berespons → penyakit kritis
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Pemeriksaan Fisik Awal Pada Penderita Penyakit Kritis
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Tanda Klinis Penderita Penyakit Kritis
Ingat : perhatikan jalan napas , pernapasan dan sirkulasi !!!
Sistim Respirasi• ketidakmampuan membuatkalimat yang lengkap
• stridor dan retraksi dada• penggunaan otot sternocleidomastoideus (+)
• respirasi rate < 8 atau > 35 x/m• Sp02 < 90 dengan high flow 02• henti napas
Sistim Kardiovaskular• tekanan sistole < 100 mmHg• nadi < 8 atau > 140 permenit• capillary refill > 2 detik• hiperlaktatemia > 2 mmol• oligouria < 0.5 ml/jam• henti jantung
Sistim Kardiovaskular• Glasgow coma scale (GCS) < 10atau penurunan GCS < 2
• refleks batuk (-) ; gag refleks (-)• status kejang / kejang berulang
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Pendekatan Penderita Kritis
“ Melalui Primary Survey “
Pendekatan A – B – C – D
Adakah indikasi CPR* ??
* CPR : cardiopulmonary resuscitation
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CPR ??Apabila penderita TIDAK SADAR , TIDAK NAPAS , PULSASI ARTERI
TIDAK TERABA (pulsasi A.Carotis) ≈ CPR TRIAD
LAKUKAN CPR( kecuali : penyakit terminal , keadaan vegetatif )
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Pendekatan ABCDAirway & oxygenation
Breathing & ventilation
Circulation & shock management
Disability : neurological deterioration
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Berdasarkan Tampilan Klinis Penyakit Kritis dibagi dalam 3 kelompokBerdasarkan Tampilan Klinis Penyakit Kritis dibagi dalam 3 kelompok
Usia muda• karena mekanisme kompensasi sangat baik sering menutupi (masking effect)gejala - tanda yang disebabkan kelainan serius yang mendasarinya
• bila ditemukan gangguan fisiologis yang jelas menunjukan bahwa gangguanyang mendasarinya berada pada tingkat keparahan yang berat
Usia lanjut• karena respons tubuh menurun akibatnya gejala-tanda yang mendasari kelai-nan serius tersebut tidak tampak menonjol
• respons sistem kekebalan serta physiologic reserve sangat terganggu
Kasus Trauma• sering terlambat mengidentifikasi permasalahan utamanya karena kompleksitas trauma itu sendiri (kasus multitrauma), keluhan NYERI sering menutupikerusakan jaringan/organ yang sebenarnya menjadi prioritas penanganan
Assessment
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Airway : penilaian jalan napas sangat penting
Key points : Penyebab Utama Gangguan JalanNapas• perubahan tingkat kesadaran• benda asing• inflamasi - infeksi
• LOOK• LISTEN• FEEL
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Airway assessment
Keeping the airway open, look, listen and feel for normal breathing
• Look for chest movement (tachypnea , useof accessory muscle/tracheal tug , paradoxthoraco-abdomino respiration and sweating)
• Listen for gurgling, snoring, stridor(note : stridor maybe absent in severe case and thepresence of a normal oxygenation does not excludea compromised airway)
• Feel for air on your cheek
Key point : a patient with signs of airway obstruction should never be left alone
Bradypnea indicates Impending Cardiorespiratory Arrest
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Airway interventions(basic)
Manfaat :- mencegah pangkal lidah jatuhkebelakang
- fasilitas suction- mencegah tergigitnya lidah- Airway patency untuk penderita
“Oropharyngeal airway”
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Airway – interventions(basic)
“ Nasopharyngeal Airway “Indikasi : pasien setengah sadar dengan napas spontan
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Breathing assessment
“ Signs of Severe Respiratory Compromise ““ Signs of Severe Respiratory Compromise “•• tachypnoea > 25 bpmtachypnoea > 25 bpm••bradypnoea < 10 bpmbradypnoea < 10 bpm
•• accessory muscles of respirationaccessory muscles of respiration•• unable to complete sentencesunable to complete sentences
•• confusionconfusion•• cyanosiscyanosis
•• PaO2 < 8PaO2 < 800 , PaCO2 > 6, PaCO2 > 600
“ LOOK LISTEN FEEL “
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Breathing - interventions• Pemberian AMBU™ bag apabila
RR < 10 x/ menit• Posisi ½ duduk• Pengobatan spesifik
– i.e.: β agonist bila wheezing– Drain → pneumotoraks– Nebulized adrenalin bila stridor
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Circulation - assessment
“ Penting Identifikasi Tanda Tanda Hipoperfusi WalaupunTekanan Darah Normal “- penurunan tingkat kesadaran- skin mottling- akral dingin- capillary refill > 2 detik- serum laktat > 2 mmol/l- oligouria dan asidosis metabolik
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Circulation assessment
• Look :- berkeringat- pucat- takipnea / kussmaul
• Feel :- akral dingin- capillary refill time > 2s- takikardia- penempitan tekanan nadi- hipotensi
• Act : iv akses , terapi cairan ,inotropes/vasodilators
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Skin mottling
Tanda tanda Hipoperfusi - Syok
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“ Identifikasi Hipoperfusi dan Nilai Volume Intravaskular “
Hipovolemia (+)Akral dingin (+)
Kehilangan cairan (+)
Syok hipovolemik
Hipovolemia (+)Akral hangat (+)
Infeksi /Alergi (+)
Hipervolemia (+) / JVP ↑Riwayat sakit jantung (+)
Syok distributif Syok kardiogenik / obstruktif
LOOK LISTEN FEEL
Circulation-assessment
JVP : Jugular Venus Pressure
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Circulation-assessment“ LOOK LISTEN FEEL “
Kehilangan volume akibat akut hipovolemik
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Klasifikasi Syok Hemoragik menurut ATLS
Class I
Class II
Class III
Class IV
ATLS : Advance Trauma Life Support
Circulation-assessment
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Circulation-interventions
- perhatikan posisi penderita : kedua tungkai diangkat 30 cm→ autotransfusi (300-500ml darah) dari kaki ke sirkulasi sentral
- pemasangan infus jarum besar, 2 buah ; ukuran # 14 /18- pemberian kristaloid (Ringer lactate > Nacl 0.9%) dengan
dosis 2 liter bolus atau 40 – 60 ml/kgbb- pemberian koloid terutama pada syok yang berat atau bila
resusitasi memerlukan jumlah kristaloid yang banyak
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Disability
Penyebab tersering :• penurunan perfusi ke otak• efek samping obat sedasi• keracunan dan atau toksin• stroke• peningkatan tekanan intrakranial• metabolik : glukosa , elektrolit
Aspek klinis penurunan kesadaran terutama didasari :- Faktor kompensasi tubuh dalam keadaan sangat tertekan- Penyakit / kelainan neurologis !!
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Disability - assessment
The AVPU ( or GCS ) scale combined with assessment of the pupils
“ A V P U “- A lert- responds to V oice- responds to P ain- U nresponsive
“ Assessment of the pupils “- equal, size and do they responds to light?- un equal : alert intracranial SOL- pinpoint : opiate abuse or brain stem stroke
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Take Home PointDON’T BE PANIC !!!
• Lakukan evaluasi A B C D secara cermat (lakukan < 5 menit)• Lakukan intervensi sederhana tetapi bermakna , misalnya
- Head Tilt Chin Lift , maksimal oksigen (ambubag)- IV akses , fluid challenge
• Pembagian tugas bila berada dalam satu team• Terapi spesifik sedini mungkin melalui sistim rujukan• Lakukan reevaluasi A B C D terutama apabila klinis perburukan• Persiapkan moda transportasi yang tepat , dilakukan apabilapenderita lebih stabil
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Treatment of altered of conscious levelTreatment of altered of conscious level“ Recovery position ““ Recovery position “