a t l s-pdf

A T L S (Advanced Trauma Life Support)

Oleh: Agus Baratha Suyasa, dr. SpAn,KNA

Faculty of Medicine, Warmadewa University

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KEGAWATAN TRAUMA

Kepala, dada, abdomen, pelvis, luka bakar Primary Survey

A, B, C, D, E Secondary survey

Head to toe examination Pemeriksaan penunjang diagnostik FAST, CT Scan, X-Ray, DPL

NON TRAUMA

Metabolik, Jantung, Keracunan, Dehidrasi, dll A,B,C….D,E,F….G,H,I




PREPARATION PHASE

Pre Hospital Phase

Hospital Phase Preparing Area Preparing equipment




Introduction The leading causes of preventable or reversible sudden

death resulting from heart attacks, accidents, and other medical emergency

hypoxia or anoxia from: airway obstr. hypoventilation apnea blood loss pulselessness brain injury




Irreversible brain damage may occur when very low oxygen transport or no oxygen transport lasts longer than a few minutes.




Advanced Trauma Life Support

Airway control

Breathing support

Circulation support

Disability

Exposure & environment

With or without equipment




irway control




Airway control Cause of airway obstruction:

Base tongue and epiglottis fall to the posterior pharyngeal wall.

the most common. Foreign matter (vomitus, blood). Laryngospasm. in lightly comatous pasient.

Partial Complete




Complete:

if one can not hear or feel air flow at the mouth or nose.

Spontaneous breathing retraction (+) but chest expansion (-). Apnea when PPV to inflate the lung difficult.

Partial:

is recognized by noisy air flow




Patient Assessment Level of consciousness Spontaneous efforts vs. apnea Airway and cervical spine

injury Chest expansion Signs of airway obstruction Breath sounds Protective airway reflexes

Look, listen, and feel




AirwayControl APA YANG DILAKUKAN UNTUK KONTROL JALAN NAFAS ?

Menjaga jalan Nafas TANPA ALAT Head Tilt Chin Lift Jaw Thrust




Dengan Alat Orothracheal tube (mayo, guedel) Nasotracheal tube Endotracheal tube (ETT, NTT) Tracheostomi tube

Membersihkan Jalan Nafas Tanpa Alat Cross finger manuver Finger behind teeth manuver Gerakan jari memegang lidah Dengan Alat suction




Opening the Airway – the Triple Airway Maneuver

Slightly extend neck (when cervical spine injury not suspected) Elevate mandible Open mouth Consider adjunctive devices




Pharyngeal Airway Tube




Laryngeal Mask Airway




Endotracheal Tube




Endotracheal intubation - technique




Tracheostomy tube Translaryngeal O2 jet insufflation




reathing support




Breathing Support

Goal : Melakukan bantuan nafas, oksigenasi dan ventilasi

Tanpa Alat Nafas bantu buatan dgn: Mouth to mouth Mouth to nose or via pipe

How ?? Berapa kali dilakukan hembusan nafas bantu ??? 2 kali initial, dilanjutkan 2 kali hembusan setiap 30 x pijat jantung luar.




Dengan alat Ambu bag dengan face mask Ventilator




Breathing support

1. Position your cheek close to victims' nose and mouth, look toward victims' chest.

2.Look, listen, and feel for breathing (5-10 seconds).

3. If not breathing, pinch victim's nose closed and give 2 full breaths into victim's mouth.

4. If breaths won't go in, reposition head and try again to give breaths.




Manual Assisted Ventilation

Open the airway Apply face mask and obtain seal Deliver optimal minute ventilation from resuscitation bag Consider cricoid pressure




Single-Handed Method of Face Mask Application

Base of mask placed over chin and mouth opened Apex of mask over nose Mandible elevated, neck

extended (if no cervical spine injury), and downward pressure by mask hand




Two-Handed Method of Face Mask Application

Helpful when mask seal difficult Fingers placed along mandible on each side Assistant provides ventilation




irculation support




1. Control of external hemorrhage.

2. Position for shock.

3. Pulse checking.

4. Manual chest compressions.

Circulation support




BLEEDING

Apply direct pressure to the wound (at this time a direct pressure bandage may be used) Elevate (do not further harm) Pressure Point additional pressure may be applied to a pressure point to help reduce bleeding.




1. Check for carotid pulse by feeling for 5-

10 seconds at side of victims' neck.

2.If there is a pulse but victim is not breathing, give Rescue breathing at rate of 1 breath every 5-6 seconds Or 10-12 breaths per minute.

Circulation




Circulation

If there is no pulse, begin chest com-pressions as follows: Place heel of one hand on lower part of victim's sternum. With your other hand directly on top of first hand, Depress sternum 1.5 to 2 inches(4-5 cm)

Perform 100 x compression/ minute or about 30 x compression followed by 2 breath




Posisi penolong tegak lurus diatas dada pasien dengan siku lengan lurus menekan tengah-tengah

tulang dada , tekan sedalam 4-5 cm.

Pijat jantung 30 x disusul dg nafas 2 x

100x per menit

Push Hard and Push Fast




Tiupan nafas yang berlebihan berakibat tekanan intra-thoracal meningkat dan berdampak menghambat aliran darah yang ditimbulkan akibat pijatan jantung.

Tiupan nafas cukup asal dada mengembang 8-10 kali/ menit.




Synchronizing : 30 compressions - 2 breaths One or two rescuers

30 : 2




Saat pijat jantung, Hitung dengan suara keras Satu,dua,tiga,empat, SATU Satu,dua,tiga,empat, DUA Satu,dua,tiga,empat, TIGA Satu,dua,tiga.empat, EMPAT Satu,dua,tiga,empat, LIMA Satu,dua,tiga,empat, ENAM Total = 30 x pijatan, disela dengan 2 x tiupan nafas

Pijat jantung nafas buatan

30 : 2




A

C

B




isability




Disability Asessment of neurological status GCS (glagow coma scale E M V

Lateralisasi Bentuk pupil Impaired consciousness can be caused or aggravated by hypoxia or hypotension for which ABC stabilization is essential.




Xposure & nvironment




Exposure Environment and exposure represent hypothermia, burns, and possible exposure to chemical and radioactive substances. At the end of the primary survey, before continuing with the secondary survey, the ABCDEs should be re-evaluated and confirmed.




Korban tidak sadar bebaskan jalan nafas

jalan nafas bebas tidak bernafas

tidak teraba nadi

Pasang monitor EKG

1.

2.

3.

4.

5.

Call for help

2 x tiupan awal raba nadi carotis

Beri pijatan jantung dan nafas buatan 30 pijat + 2 nafas

A.

B.

C.

Awam ( 1,2,4)




raba carotis

tidak ada lihat EKG

ada

shockable un-shockable

CPR 30 : 2 2 menit

rosc pertahankan jl nafas bebas

tetap beri oksigen raba arteri radialis

lihat EKG- ukur tensi nadi pertahankan infus

hipotensi : beri inotropik terapi aritmia

koreksi elektrolit & cairan single shock 360 J CPR 30:2 (2 menit)

VF / VT

lihat managemen VT / VF

Asistol PEA / EMD

CPR 30 : 2 2 menit

adrenalin

managemen asistol Observasi di ICU

Waspada CA berulang

Adrenaline: 1 mg, iv, repeated every 3-5 minutes




Defibrilation strategy-1

VF / pulseless VT

a single shock Biphasic 150-200 Joule Monophasic 360 Joule

CPR 30 : 2

ROSC

NO

2 MINUTES, 30 : 2

Check ECG Check pulse


Adrenaline CPR 30 : 2

YES

Recovery of Spontaneous Circulation

1).

2).

2 MINUTES, 30 : 2

3).




Defibrilation strategy - 2 VF / pulseless VT

ROSC

NO Check ECG Check pulse


Adrenaline CPR 30 : 2

2 MINUTES, 30 : 2


CPR 30 : 2

Check ECG Check pulse

YES No

YES

2).

3).

2 MINUTES, 30 : 2 Check ECG Check pulse

Adrenaline: 1 mg, iv, repeated every 3-5

minutes

a single shock 1).

ROSC




Defibrilation strategy-3 VF / pulseless VT

ROSC a single shock Biphasic 150-360 Joule Monophasic 360 Joule

CPR 30 : 2

Check ECG Check pulse YES No

3).

Amiodarone 300 mg or Lidocaine 1 mg/kg A single shock Biphasic 150-360 Joule Monophasic 360 Joule CPR 30 : 2

No YES Check ECG Check pulse

ROSC 4).

2). a single shock

2 MINUTES, 30 : 2

Adrenaline: 1 mg, iv, repeated every 3-5 minutes a single shock

Biphasic 150 – 360 Joule Monophasic 360 Joule CPR 30 : 2 (2minutes)




CPR -1 30 : 2 CALL FOR HELP PASANG MONITOR

VF / VT

a single shock a single shock a single shock a single shock a single shock

2 menit 2 menit

2 menit 2 menit

adrenalin adrenalin

adrenalin CPR-3 CPR-2 CPR-5 CPR-4

Amiodaron


minutes

CPR-6

Cardiac arrest

LIDOCAIN. Do not exceed a total dose of 3 mg/kg, during the first hour.

Amiodaron is the first choice 300 mg, bolus. Repeated 150 mg for reccurrent VT/VF. Followed by 900 mg infusion over 24 hours

VF/ VT

Intubasi : as soon as possible, without stop CPR Pijat 100x/menit Nafas 8x/menit

Evaluasi CPR : tiap 2 menit




Asystole (ECG flat) PEA ECG ada gelombang tetapi carotis (-) |

CPR 2 menit |

+Intubasi, iv line, +adrenalin 1 mg / 3-5 menit

| | |

Asystole / PEA ROSC | |

bradycardia normal

atropin 1-1-1 / obat klas IIa CPR 2 menit

30 : 2

30 : 2




ASYST 2 menit 2 menit

2 menit 2 menit

• evaluasi • adrenalin

• evaluasi • adrenalin

adrenalin CPR-3 CPR-2 CPR-5 CPR-4


minutes

CPR-6

Cardiac arrest

ASYSTOL/PEA/EMD

Intubasi : as soon as possible, without stop CPR Pijat 100x/menit Nafas 8x/menit

Evaluasi CPR : tiap 2 menit

evaluasi evaluasi

CPR -1 30 : 2 CALL FOR HELP PASANG MONITOR




DRUGS • Adrenaline : 1 mg, iv, repeated every 3-5 minutes

• Amiodarone: 300 mg, bolus, if VF/VT persist after 3 shocks. Dose of 150 mg maybe given for recurrent or refractory VF/VT, followed by an infusion of 900 mg over 24 hours • Lidocain : 1 mg/kg, iv, if amiodarone is not available. Do not exceed a total dose of 3 mg/kg, during the first hour. Do not give lidocaine if amiodarone has already been given

ILCOR - Guidelines 2005




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