airway management [autosaved]
TRANSCRIPT
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AIRWAY MANAGEMENTAIRWAY MANAGEMENT
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Airway ManagementAirway Management
• Tetap terjaganya saluran yang menghubungkan paru dengan udara luar.
• Paru aman dari kemungkinan terjadinya aspirasi.
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AnatomiAnatomi
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Airway managementAirway management
Head Tilt / Ekstensi KepalaPasien tlentang & penolong di samping pasien, letakkn di
bwh leher & tlapak tgn yg lain di dahi.Ekstensikan kepala dgn mndorong dahi ke belakang
mengangkat leher.Indikasi : Obstruksi jaringan lunak jalan nafas atasKI : Fraktur bagian leher
Sindroma arteri basilerInfant
Komplikasi : Nyeri leherSyaraf terjepit
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Airway managementAirway management
Chin Lift / Angkat Dagu
Pasien terlentang & penolong meletakkan satu tangan di dahi dan ibu jari tangan yg lain di bwh dagu.
Dahi didorong & dagu diangkat scr bersamaan.
Indikasi : Alternatif head tilt
KI : sama dg head tilt
Komplikasi : sama dg head tilt
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Airway managementAirway management
Jaw Thrust / Dorong Rahang
Dr atas kepala pasien, ibu jari diletakkan di maksila & jari lain di angulus mandibula (bilateral), angkat & dorong rahang ke depan.
Indikasi : pasien KI atau tdk efektif dg head tilt
KI : fraktur rahang
dislokasi rahang
pasien sadar
Komplikasi : dislokasi rahang
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Airway managementAirway management
Buka mulut
Mulut di buka dgn menggunakan ibu jari
Indikasi : obstruksi ekspiratori setelah head tilt.
KI : -
Komplikasi : -
Head tilt, jaw thrust & open mouth dikenal sebagai Triple Airway Manuver
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Lateral xanogram of the head & neck in neutral position. Patient is awake & supine.Lateral xanogram of the head & neck in neutral position. Patient is awake & supine.
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Airway ManagementAirway ManagementHeimlich ManuverPada pasien berdiri, kaitkan kedua tangan
melingkari dada pasien dgn tangan kanan mengepal & tangan kiri dikaitkan di atas kepalan tangan kanan.
Dgn dorongan cepat & kuat, menekan ke atas, meningkatkan tekanan subdiagfragma & menimbulkan batuk artifisial.
Indikasi : Obstruksi total oleh benda asingKI : Fraktur iga (relatif)
Kontusio jantung (relatif)Obstruksi jalan nafas parsial
Komplikasi: fraktur iga, sternumtrauma hati atau limpa
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Airway ManagementAirway Management
• Jika anda sendiri dan anda tersedak, anda dapat melakukan manuver Heimlich sendiri.
• Sandarkan ke depan dan tekan abdomen anda secara cepat pada benda sekitar, seperti kursi, meja atau rel pada dinding.
• Tanpa oksigen, otak akan mulai mengalami kematian dalam waktu 4-6 menit.
• The Heimlich Maneuver merupakan metode terbaik untuk mengeluarkan benda asing dari jalan nafas pada pasien yang tersedak
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Airway ManagementAirway Management
Oropharyngeal Airway
Mencegah oklusi gigi, lbh sering utk memperbaiki jalan nafas.
Ukuran variasi 0-4
Terbuat dr plastik, metal, atau karet.
Dirancag pd bag gigitan keras, dan tepi proksimal bersirip utk mencegah overinsersi.
Bagian distal berbentuk semisirkuler sesuai bentuk lengkung mulut, lidan, dan faring posterior.
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Airway ManagementAirway Management
Nasopharyngeal airwayMerupakan silinder panjang yg berbentuk
lengkungan dan lentur.
Terbuat dr plastik atau karet lembut.
Panjang & lebar bervariasi.
Sirip proksimal mencegah overinsersi
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Jenis-jenis oropharyngeal airway
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Teknik pemasangan oropharyngeal airway
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Teknik pemasangan nasopharyngeal airway
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IntubasiIntubasi
Indikasi :• Menjamin jalan nafas bebas• Mencegah aspirasi• Memudahkan pengisapan sekret trakea• Memberikan O2 konsentrasi tinggi• Apnea• Trauma dinding dada berat• Shock berat• Jika diperlukan hiperventilasi dikontrol• Jika menggunakan obat sedasi yang dalam• Gagal nafas mengancam
Pemasangan : OralNasal
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Tahap intubasiTahap intubasi
• Persiapan
• Preoksigenasi
• Premedikasi
• Induksi
• Intubasi
• Penatalaksanaan pasca intubasi
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PersiapanPersiapan
Persiapan alat, Metode ‘STATICS’
S=Scope : Laringoskop, stetoskop
T=Tube : ETT
A=Airway : Oropharyngeal airway
T=Tape : Plester
I= Introducer : Mandrin, Ambu, Spuit, Jelly
C= Connector : Penghubung ETT ke Ambu
S=Suction : Multifungsi suction + oksigen
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PersiapanPersiapan
Persiapan pasien
• Kemungkinan kesulitan intubasi
• Buka mulut, trismus
• Mallampati class I-IV ?
• Leher pendek
• Mobilitas leher
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Mallampati class
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PreoksigenasiPreoksigenasi
• Berikan oksigen 100% dengan aliran 8 – 10 L/mnt
• Menggunakan sungkup muka (face mask) selama 5 menit
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PremedikasiPremedikasi
• Utk mengantispasi respon kardiovaskuler dan simpatis
• Mengurangi terjadinya peningkatan tekanan intrakranial
• Mencegah hipotensi dan hipoksia
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LaringoskopiLaringoskopi
Aktifitas simpatisAktifitas simpatisMean Arterial Pressure 25-58 mmHgMean Arterial Pressure 25-58 mmHg
Heart Rate 11-28 bpmHeart Rate 11-28 bpmICP 22 mmHgICP 22 mmHg
PerdarahanPerdarahanHerniasi Batang OtakHerniasi Batang Otak
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Obat premedikasi
• Lidokain
• Opioid
• Atropin
• Antagonis -adrenergik
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Lidokain
• Mengurangi respon batuk
• Memperbaiki stabilitas hemodinamik ?
• Mencegah meningkatnya ICP & IOP
• 1,5-2 mg/kgBB bolus IV, 2-3 mnt sblm intubasi
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Opioid
• Fentanil: 75-125 x lbh poten dr morfin
• Blokade takikardia & hipertensi
• 3-5 ug/kgBB ; 1-3 mnt sblm intubasi
• Potensial meningkatkan ICP
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Atropin
• Mencegah bradikardia, refleks vagal
• Efek mengurangi sekret
• 0,02 mg/kgBB, 1-2 mnt sblm intubasi
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Antagonis B-adrenergik
• Esmolol
• Mencegah peningkatan TD & HR
• 2 mg/kg bolus
• Bronkospasme
• Hindari utk anak2
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InduksiInduksi
• Obat induksi
Thiopentone
Propofol
Etomidate
Midazolam
Ketamin
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Thiopentone
• Onset cepat, durasi singkat
• 3-5 mg/kgBB IV bolus, kesdrn hilang dlm 30-45 dtk
• Serebroprotektif, baik utk cedera kepala
• Hindari pd pasien dg hipotensi
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Propofol
• Short acting hypnotic agent
• Mengurangi metabolisme serebral
• Bronkodilator
• Menurunkan MAP
• 2-3 mg/kgBB IV bolus
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Etomidate
• Onset cepat, durasi singkat
• Hemodinamik stabil
• 0,2-0,3 mg/kgBB IV
• Serebroprotektif
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Midazolam
• Effective anxiolytic & amnestic agent
• Onset cepat, durasi relatif singkat
• 0,1-0,2 mg/kgBB IV, sedasi dlm 1-2 mnt
• Hipotensi
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Ketamin
• Onset cepat, sedasi adekuat dlm 1 mnt
• 1-2 mg/kgBB IV
• Takikardia, hipertensi
• Meningkatkan ICP
• Pilihan utk psn dg asma bronkial
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Pelumpuh otot
• Suksinilkolin
• Rocuronium
• Vecuronium
• Atracurium
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IntubasiIntubasi
• Orotrakeal intubasi
• Nasotrakeal intubasi
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Identifikasi laringoskopik menurut Cormack-LehaneGrade 1. Glottis terlihat jelasGrade 2. Hanya bagian posterior glottis yg terlihatGrade 3. Hanya epiglottis yg terlihatGrade 4. Epiglottis tidak terlihat
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Pemasangan pipanasotrakeal
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Pemasangan pipa nasotrakeal dengan dibantu forsep Magill
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Penatalaksanaan Pasca IntubasiPenatalaksanaan Pasca Intubasi
• Inspeksi
• Auskultasi
• Kapnografi
• Foto torak
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Komplikasi intubasiKomplikasi intubasi
Trauma : Bibir, gigi, lidah, laring, faring, trakea
Salah masuk : Esofagus, Bronkus
Spasme : Laring, Bronkus
Stimulasi vagus : Henti jantung
Hipoksia : Henti jantung
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Intubasi di IGD vs OKIntubasi di IGD vs OK
IGD OK
Tujuan Utk mendptkn jln nafas definitif
Jln nafas dan ventilasi selama pasien dlm pembiusan
Karakteristik pasien Mendesak atau emegensi
Kemungkinan trauma servikal
Sering ggl nafas
Tidak puasa
Situasi elektif
Trauma servikal jarang
Gagal nafas, jarang
Puasa
Waktu persiapan Detik menit Jam hari
Alternatif jika gagal Jalan nafas definitif harus didapatkan
Jika gagal dapat dibatalkan
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Sungkup Laring (LMA)Sungkup Laring (LMA)
• Alternatif sungkup muka atau intubasi endotrakeal
• Penatalaksanaan jalan nafas pada tindakan anestesi
• Pada keadaan jalan nafas sulit
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Kontra Indikasi
• Puasa tidak cukup
• Obesitas berat
• Obstruksi atau lesi abnormal orofaring
• Pasien dg cedera multipel atau masif
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Keuntungan• Pemasangan cepat• Tidak memerlukan laringoskop• Tidak memerlukan pelumpuh otot• Dpt diberikan pd nafas spontan atau nafas
kendaliKerugian• Tidak melindungi dr kemungkinan terjadinya
aspirasi• Tidak dpt digunakan utk tekanan positif tinggi
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Teknik pemasangan LMA1. Klasik / standar2. Inverted / reserve / rotational approach3. Lateral approach
Index finger insertion techniqueIndex thumb insertion techniqueIntroducer insertion technique
Posisi ideal kepala pd pemasangan LMA‘Posisi netral atau sniffing position’
Ekstensi kepalaFleksi leher
Bantal dpt digunakan agar leher tetap fleksi
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Permasalahan pd saat pemasangan LMA
• Pembiusan tdk adekuat batuk, tahan nafas
• Posisi kepala kurang optimal
• Ukuran tdk pas
• Sungkup kempes, bocor
• LMA yg sdh usang / terlalu sering dipakai
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Komplikasi1. Mekanik
> Pemasangan salah> Kurang menutup rapat> Malposisi
2. Traumatik> Nyeri tenggorok> Disfagia> Disartria
3. Patofisiologik> Batuk> Muntah> Regurgitasi
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TrakeostomiTrakeostomi
Indikasi
1. Menjaga jalan nafas
2. Penggunaan ventilasi mekanik jangka panjang
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Komplikasi1. Segera
> Perdarahan> Hipoksia, hiperkapnia> Hipotensi> Pneumotorak,pnemuomediastinum, emfisema subkutan> Salah masuk> Cedera dinding trakea> Fraktur cincin trakea> Aspirasi> Kematian
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2. Dini ( 1 minggu )> Perdarahan> Infeksi stoma atau peristoma> Posisi kanul berubah> Obstruksi pipa trakeostomi
3. Lama ( > 1 minggu)> Perubahan suara> Fistula> Stenosis trakea> Trakeomalasia> Fistula arteri trakeoinnominata
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KrikotirotomiKrikotirotomi
Indikasi
• Trauma maxillofacial
• Obstruksi orofaring (edema, lesi massa)
• Intubasi oro/nasotrakeal gagal
• Anatomi sulit
• Regurgitasi atau perdarahan masif
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Kontra indikasi
• Penyakit laring (subglottik stenosis, striktur)
• Distorsi anatomi leher yang disebabkan penyakit atau cedera
• Koagulopati
Catatan: Sangat hati-hati pada anak dibawah 10 tahun
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KomplikasiDini :
Asfiksia, perdarahan, aspirasi, emfisema subkutan & mediastinum,perforasi mediastinal atau esogeal, cedera pita suara, disrupsi laring, dan fraktur kartilago tiroid.
Lama :Stenosis subglottis & trakeal, gangguan menelan, obstruksi pipa, fistula transesofageal, perubahan suara, infeksi, stoma persisten, dan trakeomalasia
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