1

General Concepts

lntroduction
Welcome to the BLS for Healthcare Providers Course. With the knowledge and skills you
learn in this course, you can save a life. You will learn the skills of CPR lor victims of all
ages and v/ill practice CPB in a team setting. You will learn how to use an automated
external defibrillator (AED) and how to relieve choking (loreigq-body airway obstruction).
The skills you learn in this course will enable you to rec,rgnize emergencies such as sud-
den cardiac arrest and know how to respond to them.

Despite important advances in preventron, cardiac arres: ren rains a substantial public
health problem and a leading cause of death in many prrls ef the world. Cardiac arrest
occurs both in and out of the hospital.

The Purpose of This manual focuses on what healthcare providers need to kitow to pefform CPFI in a wide
This Manual variety of in- and out-of-hospital settings. The manual details the information and skills
you will learn in this class:
. lnitiatrng the Chain of Survival
. Pedorming prompt, high-quality chest compressions for adult, child, and
infant victims
. lnitiating early use of an AED
. Providing appropriate rescue breaths
. Practicing 2-rescuer team CPR
. Relieving choking

Critical Concepts High-quality CPR improves a victim s chances of survival. The critical characteristics of
high-quality CPF include
. Start compressions within 10 seconds of recognition of cardiac arrest.
. Push hard, push fast: Compress at a rate of at least 100/min with a depth of at
least 5 cm (2 inches) for adults, approximately 5 cm (2 inches) for children, and
approximately 4 cm (1y2 inches) for infants.
. Allow complete chest recoil after each compression.
. Minimize interruptions in compressions (try to limit interruptions to <'10 seconds).
. Give effective breaths that make the chest rise.
. Avoid excessive ventilation.

at
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 1

The Chain of Survival

Leaming After reading this section you will be able to name the links in the American Hean
Objectives Association (AHA) adul't Chain of Survival and state ihe importance o, each link.

lntroduction to The AHA has adopted, supported, and helped develop the concept of emergency
the Adult Chain cardiovascular care (ECC) systems Ior many years.
of Survival fhe 1rm Chain of Suryiyai provides a useful metaphor for the elements ol the ECC
systems concepl (Figure 1). The 5 links in the adull Chain oI Survival are
. lmmediale recognition of cardiac arrest and activation of the emergency
response system
. Early cardiopulmonary resuscitation (CPR) with an emphasis on chest
compressions
. Fapid defibrillation
. Etfective advanced life support
. lntegrated post-cardiac arrest care

-l^

Figure 1. The adull Charn of Survrvat

Although basic life support is taught as a sequence of distinct sleps to enhance skills
retention and clarify priorities, several actions should be accomplis,hed simultaneously
(eg, begin CPR and activate the emergency response system) when multiple rescuers are
present.

lntroduction to Although in adults cardiac arrest is often sudden and results trom a cardiac cause, in
the Pediatric Ghain children cardiac arrest is often secondary to respiratory lairure and shock. ldentifying chil-
of Survival dren with these problems is essential to reduce the likelihood of pediatric cardiac arrest
and maximize survival and recovery. Therefore, a prevention link is added in the pediatric
Chain ol Survival (Figure 2):
. Prevention of arrest
. Early high-quality bystander CPR
. Rapid activation of the EMS (or other emergency response) system
. Effective advanced life support (including rapid stabilization and transport to
definitive care and rehabilitation)
. lntegrated post-cardiac arrest care

t-
Figure 2. The pecl atric Chain ol Surv vat

GD to9
 General Concepts

2OlO AHA Guidelines for CPR and ECC Science Update

Overview Ihe 2010 American Heaft Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care recommendations for healthcare providers include the
following key changes and issues:
. Changes in basic life support (BLS) sequence
. Continued emphasis on high-quality CPB, with minor changes in compression rate
and depth
. Additional changes regarding cricoid pressure, pulse check, and AED use
in infants

Learning After reading this section you will be able to name the major science updates in the
Objectives 2010 AHA Guidelines for CPR and ECC.

Change in fhe 2010 AHA Guidelines for CPR and ECC recommend a change in the BLS sequence of
Seguence.' steps from A-B-C (Airway, Breathing, Chest compressions) to C-A-B (Chest compressions,
Airway, Breathing) for adults, children, and infants. This change in CPR sequence requires
C-A-B, Not A-B-C
reeducataon of everyone who has ever learned CPR, but the consensus of the authors and
expefts involved in creating the 2010 AHA Guidelines for CPR and ECC is that the change
is likely to improve survival.

Chest
Compressions

Breathing

ln the A-B-C sequence, chest compressions were often delayed while the rescuer
opened the airway to give mouth-to-mouth breaths, retrieved a barrier device, or gathered
and assembled ventila'tion equipment. By changing the sequence to C-A-B, rescuers can
start chest compressions soone( and the delay in giving breaths should be minimal (only
the time required 10 deliver the lirst cycle of 30 chest compressions, or approximately
18 seconds or less; for 2-rescuer infant or child CPR, the delay will be even shorter).

106
 1

Emphasis on fhe 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-
High-Quality CPR quality CPFI, including
. A compression rate of at least 100/min (this is a change from "approximately"
'100/min).
. A compression depth o, at least 5 cm (2 inches) in adults and a compression depth
of at least one third of the anterior-posterior diameter oI lhe chest in infants and
children. This is approximately 4 cm (11/z inches) in infants and 5 cm (2 inches) in
children. Note that the range of 4 to 5 cm (l7, to 2 inches) is no longer used jor
adults, and the absolute depth specilied for children and infants is deeper than in pre-
vious versions ol lhe AHA Guidelines for CPR and ECC.
. Allowing complete chest recoil, minimizing interruptions in compressions, and avoid-
ing excessive ventilation continue to be important components of high-quality CpR.
To further strengthen the focus on high-quality CPR, the 2010 AHA Guidetines for CpR
and ECC stress the importance ol training using a team approach to CPR. The steps
in the BLS Algorithm have traditionally been presented as a sequence to help a sjngle
rescuer prioritize actions.

There is increased locus on providing CPB as a team because resuscitations in most

ElvlS and healthcare systems involve teams of rescuers, with rescuers performing several
aclions simultaneously. For example, one rescuer activates the emergency response
system while a second begins chest compressions, a third is either providing ventilations
or retrieving the bag-mask ior rescue breathing. and a fourth is retrieving a defibrillator
and preparing to use it.

No Look, Listen, Another key change is the removal of ',look, listen, and feel for breathing,,from the
and Feel assessment step. This step was removed because bystanders often failed to start CpR
when they observed agonal gasping. The heal.thcare provider Should not delay activating
th-. emergency response system but should check the victim for 2 things simultaneously:
response and breathing. With the new chest compression-firsl sequence, the rescuer
should activate the emergency response system and begin cpR if the adult victim is unre-
sponsive and not breathing or not breathing normally (only gasping) and has no pulse. For
the child or infant victim, cPR is performed if the victim is unresponsive and not breathing
or only gasping and has no pulse.

For victlms of all ages (except newborns). begin CpB with compressions (C-A-B
sequence). Aiter each set of chest compressions, open the airway and give 2 breaths.

o \o+
 General Concepts

Additional There are several additional cl]anqes in lhe 2010 AHA Guidelines for CPR and ECC
Changes
Change Details
The routine use of cricoid AlthoLrgh cricord pressure can prevent gastric infla-
pressure in cardiac arrest is tion and reduce the risk of regurEitation and aspira-
not recommended tion during bag-mask ventilation. it may also block
I

ventilation.

Several randornized studies have shown lhat cricoid

pressure can delay or prevent the placement of
an advanced airway and that some aspiration can
still occur despite the use of cricoid pressure. ln
addition, it is ditficult to appropriately train rescuers
how to do this

Therefore, the routine use of cricoid pressure in

Continued de-emphasis of
the pulse check
cardiac arrest is not recommended.
It can be difficult to determine the presence or
absence of a pulse within '10 seconds, especially in
an emergency and studies show that both health-
I

care providers and lay rescuers are unable to reliably

detect a pulse.

lf the victim is unresponsive and not breathing or

only gasping, healthcare providers may take up to
10 seconds to attempt to feel tor a pulse (brachial in
an infant and carotid or femoral in a child).
I
lf within 10 seconds you don't feel a pulse or are not
sure if you feei a pulse, begin chest compressions.
Use of an AED for infants For infants, a manual defibrillator is preferred to an
AED for defibrillation.

lf a manual defibrillator is not available. an AED

equipped with a pediatric dose attenuator is
preferred.

I lf neither is available, you may use an AED without a

pediatric dose attenuator

For more detalled information and references, read lhe 20lO AHA Guidelines for CpR
and ECC, including the Executive Summary, published online in Circulatlon in October
2010, or the Highlights ot the 201O AHA Guidelines for CPR and ECC, available at
www.heart.orgleccguidelines. You can also review the detailed summary of resuscita-
tion science in lhe 2010 lnternational Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science With Treatment Recommendations, published
simultaneously in Circu lation and Resuscltatlon.

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 BLS/CPR for Adults

BLS/CPR Basics for Adults

Overview This section describes the basic steps of CPR for adults. Adults include adolescents
(ie, alter the onset of puberty). Signs of puberty include chest or underarm hair in males
and any breast development in females.

Learning At the end of this section you will be able to

fibjectives . Tell the basic steps of CPF for adults
. Show the basic steps of CPF for adults

Understanding BLS consists of tnese main parts

the Basics of BI-S (Figure 3):
. Chest compressions
. Airway @
. Breathing
. Defibrillation
You will learn about each of these
11r $ @
throughout this course.

Distinct from the lone responder

approach, many workplaces and
most EMS and in hospital resusci-
@
tations involve teams of providers
who should perform several actions
,fi
simultaneously (eg, one rescuer
activates the emergency response
system while a second rescuer
begins chest compressions, a third
is either providing ventilations or
retrieving the bag-mask lor
@
Hepea( every 2 minutes

rescue breathing, and a fourth is

retrieving a delibrillator and prepar-
ing to use il). This course focuses on
team-based CPR.
Figure 3. The Simplified Adult BLS Algorithm for
Healthcare Providers.

10
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 2

Overview of lnitial Follow these initial BLS steps ior adults

BLS Steps
Step Action
1 Assess the victim for a response and look Ior normal or abnormal breath-
ing. lf there is no response and no breathing or no normal breathing (ie, only
gasping), shout for help.

2 lf you are alone, activate the emergency response system and get an AED
(or defibrillator) if available and return to the viclim.

3 Check the victim's pulse (take at least 5 but no more than 10 seconds)

4
I
tt you Oo not definrtely feel a pulse within 'lO seconds. perform 5 cycles ot
compressions and breaths {30:2 ratio), starting wrth compressions (C-A-B I

L
I sequencel. I

Step /; Issessment The first rescuer who arrives at the side of the victim must quickly be sure that the scene
and Scene Safety is safe. The rescuer should then check the victim Jor a response:

Step Action
I Make sure the scene is safe jor you and the viclim. You do not want to
become a victim yourself.

2 Tap the victim's shoulder and shout, "Are you all right?" (Figure 4)

3 Check to see if the victim is breathing. ll a victim is not breathing or not

breathing normally (ie. only gasping), you must activate the emergency
response system.

Caution Agonal gasps are not normal breathing. Agonal gasps may be present in the firsl min-
utes after sudden cardiac arrest.
Agonal Gasps
A person who gasps usually looks like he is drawing air an very quickly. The mouth may
be open and the jaw, head, or neck may move with gasps. Gasps may appear force-
ful or weak, and some time may pass between gasps because they usually happen at
a slow rate. The gasp may sound like a snort. snore, or groan. Gasping is not normal
breathing. lt is a sign of cardiac arrest in someone who doesn't respond.

a victrm is not breathing or there is no norrnal breathing (ie, only agonal gasps), you
I1
must activate the emergency response systern. check the pulse, and stad CPB.

o \o
 BLSICPR for Adults

Step 2.' Activate lf you are alone and find an unresponsive victirn not breathing, shout for help. lf no one
the Emergency responds, actl,"iate the emergency response system, ge1 an AED (or defibrillator) if avail_
Response System able, and then return to the victim to check a pulse and begin CpR (C A-B sequence).
and Get an AED A\
tr) f?
l-

! {.1 -

A B
Figure 4. Check for response and breathing and actrvate the emergency response system (assess ancl
act vate). A, Tap the victim's shoulder and shout, "Are you all r ght?" At the same time. look for breathing.
B, li the adult victim does not respond and has no breathing or no normal breathing (ie, is only gasping),
shout for he{p. lf another rescuer responds, send him or her to activate the emergency response system
and get lhe AED (or defibrillator) if available. lf no one responds, activate the emergency response system,
get the AED (or defibrillato4, and return to the victim to check a pulse and begin CPR (C A B sequence)-

Step 3; Pulse Check Healthcare providers shauld take no more than 10 seconds to check for a pulse

Locating the Carottd To perform a pulse chek in the adult, palpate a carotid pulse (Figure 5). lf you do not
Artery Pulse definitely feel a puise within 10 seconds, stad chest compressions.

Follow these steps to locate the carotid artery pulse:

Step
1 Locate the trachea, using 2 or 3 fingers (Figure 5A)

2 Slide these 2 or 3 fingers into the groove between the trachea and the mus-
cles at the side of the neck, where you can feel the carotid pulse (Figure 5B)

3 Feel for a pulse for at ieasf 5 but no more than 10 seconds. lf you do not
definitely ieel a pulse, begin CPR, starting with chest compressions (C-A-B
sequence).

AB
Figure 5. Finding the carotid pulse. A, Locate the trachea. B, Gently feel for the carotid pulse.

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 2

Step 4: Begin The lone rescuer should use the compression-ventilation ratio of 3O compressions to
Cycles ot 30 Chest 2 breaths when giving CPR to victims oi any age.
Compressions and When you give chest compressions, it is impodant to push the chest hard and fast, at
2 Breaths (CPB) a rate of at least 100 compressions per minute, allow the chest to recoil completely
after each compression, and minimize interruptions in compressions. Begin with chest
compressions.

Chest Compression The foundation of CPR is chest compressions. Follow these steps to perform chest com-
Technique pressions in an adult:

Step Action
I I Position yourself at the victim s side.

2 I\ilake sure the victim is lying faceup on a firm, flat surface. lf the victim rs
lying facedown, carefully roll him faceup. lf you suspect the victim has a
head or neck injury, try to keep the head, neck, and torso in a line when
ro'lirg the victrm to a faceup posrtion.
3 Put the heel of one hand on the center oI the victim's chest on the lower half
of the breastbone (Figure 64).

4 Put the heel of your other hand on top of lhe first hand

5 Straighten your arms and position your shoulders directly over your hands.

6 Push hard and Jast.

. Press down at least 5 cm (2 inches) with each compression (this requires
hard work). For each chesi compression, make sLrre you push straight
dowir on the vic'tim's breastbone (Figure 68).
. Deliver compressions in a smooth Jashion at a rare of at least
100/min-
7 A1 the end oI each compression, make sure you allow the chesl to recoil
(re-expand) completely. Chest recoil allows blood to flow into the heart and
is necessary for chest compressions to create blood flow. lncomplete chest
recoil is harmful because it reduces the blood flow created by chest com-
pressions. Chest compression and chest recoil/relaxation times should be
approximately equal.

a l,/l nim ze interrupt ons

IE \1
 BLSICPR for Adults

J,
I

:,

A B
Figufe 6. A, Place your hands on the breastbone in the center of the chest. B, Correct position cf the
rescuer durlng chest compress ons.

Fouhdational Facts Compressions pump the blood in the hearl to the rest of the body. lf aiirm sudace is
!' rl
under the victim, the force you use will be more likely to compress the chest and heart
The lmportance of a and creale blood flow rather than simply push the victim into the mattress or other soft
FirmjSurlace
surface.

Fouhditional Facla lf you have difficulty push

i!
ing deeply durinq compres-
Aherhatd Technique for sions, put one hand on the
Chedt Compressions
breastbone to push on the
chest. Grasp the wrist of that
hand with your other hand to
support the first hand as it
pushes the chest (Figure 7).
This technique is helpful for
rescuers with arthritis.

Figufe 7. Alternate technique for chest compressions

Moving the Victim Do not move the victim while CPB is in progress unless the victim is in a dangerous envi-
Only When ronment (such as a burning building) or if you believe you cannot pedorm CPR effectively
Illecessary in the victim's present position or location. CPR is better and has fewer interruptions when
rescuers perform the resuscitation where they find the victim.

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 2

Opening the Airway There are 2 methods for opening the airway to provide breaths: head tilt_chin lift and jaw
for Breaths: Head thrust. Two rescuers are generally needed to perform a jaw thrust and provide breaths
Tilt-Chin Lift with a bag-mask device. This is discussed in the ,,2-Rescuer Adult BLS/Ieam CpR
Sequence" section. Use a jaw thrust only if you suspect a head or neck injury, as it may
reduce neck and spine movement. switch to a head tilt-chin lift maneuver if the iaw thrust
does not open the aiMay.

Follow these steps to perform a head tilt*chin lift (Figure B):

Step Action
1 Place one hand on the victim's forehead and push with your palm to tilt the
head back.

2 Place the fingers of the olher hand under the bony part of the lower jaw near
the chin.

3 Ljft the jaw to br ng the chin forward

i \--
l *'

A B

Figure 8, The head lilt chin lifl relieves air\,,/ay obstruction in an unresponsive vrctim. A, Obstruciion by
the tongue. When a victim is unresponsive, the tongue can block lhe upper airway. B, The head t t-chin lift
maneuver lifts the tongue. relieving airway obstruclion.

Caution Do not press deeply into the soft tissue under the chin because this might block the
airway.
Things to Avoid With Do not Jse the thumb to lift tne chin.
Head Tilt-Chin Lift
Do not close the victim's mouth completely.

Adult Mouth-to- Standard precautlons include using barrier devices, such as a iace mask (Figure 9) or a
Barrier Device bag mask device, when giving breaths. Rescuers should replace face shields with mouth-
Breathing to-mask or bag-mask devices at the first opportunity. l\,4asks usually have a 1-way valYe
that divens exhaled air, blood. or bodily Jluids away from the rescuer.

i
Figure 9. Face mask

@
 BLS/CPR for Adults

Foundational Facfs The risk of infection from CPF is extremely low and limited lo a few case reports, but
I

the US Occupational Safety and Health Administration (OSHA) requires that healthcare
Low lnfection Risk workers use standard precautions in the workplace, including during CPR.

Giving Adult For mouth-to-mask breaths. you use a mask with or without a 1-way valve. The 1-way
Mouth-to-Mask valve allov/s the rescuer's breath to enter the victim's mouth and nose and diverts the vic-
Breaths tim's exhaled air away from the rescuer. Some masks have an oxygen inlet that allows you
to administer supplementary oxygen.

Effective use of the mask barrier device requires instruction and supervised practice.

Giving To use a mask, the lone rescuer is at the victim s side. This position is ideal when perform-
l\/louth-to-A,4ask ing 1-rescuer CPR because you can give breaths and perform chest compressions when
Breaths positioned at the victim's side. The lone rescuer holds the mask against the victim's face
and opens the airway with a head tilt-chin lift.

Follow these steps to open the airway with a head tilt-chin lift and use a mask to give
breaths to the victim:

'| Position yourself at the victim's side

2 Place the mask on the victim's face. using the brilge of the nose as a guide
for correct position
i
3 Seal the mask against the face:
. Using the hand that is closer to the top of the victim's head, place your
index Iinger and thumb along the edge ol the mask.
. Place the thumb of your second hand alc'ng the bottom edge of the mask

4 Place the remaining fingers of your second hand along the bony margin
of the jaw and lift the jaw. Pedorm a head tilt-chin lift to open the airway
(Figure 10).

5 While you lift the jaw. press firmly and completely around the outside edge of
the mask to seal the mask against the face.

6 Deliver air over 1 second to make the victim's chesl rise

Figure I O. N,4outh-to-mask breaths, 1 rescuer. The rescuer performs 1-rescuer CPR lrom a position
at the victim,s side_ Perform a head tilt-chln lift to open the airway while holding the mask tightly against
the face.

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 2

Bag-Mask Device Bag-mask devices consisl of a bag attached 1o a face mask. They may also include a
I -way valve. Bag-mask devices are the most common method that healthcare providers
use to give positive-pressure ventilation during CPB. The bag-mask ventilation technique
requires instruclion and practice and is not recommended by a lone rescuer during CPB.

Using Follow these steps to open the airway wilh a head tilt-chin lift and use a bag-mask to give
the Bag-Mask breaths 10 the victim:
During 2-Rescuer Step Actaon
CPR
1 Position yourself directly above the victim's head.

2 Place the mask on the victim's face, using the bridge of the nose as a guide
for correcl position.

3 Use the E-C clamp technique to hold the mask in place while you lift the iaw
to hold the airway open (Figure 11):

. Perform a head tilt.

. Place the mask on the lace wilh the narrow portion at the bridge of
the nose.
. Use the thumb and index finger of one hand to make a "C" on the side
oI the mask, pressing the edges of the mask to lhe face.
. Use the remaining fingers to lift the angles oI the jaw (3 fingers'form an
'E"), open the airway. and press the face to the mask
.for chest rise'
4 Squeeze the bag to give breaths (1 second each) while walching
Deliver all breaths over 1 second whether or not you use supplementary oxygen

,I

t I
d
\-
yourself
Figure I t. l\,4outh-to-mask E'C clamp technrque of holding mask while lifting the iaw Position
the mask (lorming a "C") while using
at ;e victim s head. place the thumb and Iirsl finger around the top of
jaw'
the third. founh, and lifth fingers (lorn'ring an 'E") lo lifl the

you will still deliver

Foundationat Facts l, you a|e using supplementary oxygen with a bag-mask device
{or any method of
each breath over I second lf you use only 1 second per breath
Giving Breaths.With rn chest compressrons needed for
delivery. you can help minimize the lnterruptrons
Supplementary Orygen brealhs and avoid excesstve ventilalion

@ \b
 BLSICPR for Adults

2-Rescuer Adult BLS/Team CPR Sequence

Overview This section explatns how to perform 2,rescuer team CPB for adults

Learning At the end of this section you n,ill be ab e to show hov,,to perform 2 rescuer team CpR
Objectives

When More When a second rescuer is available to help, that second rescuer should activate the emer-
Rescuers Arrive gency response system and get the AED. The first rescuer should remain with the victim
to start CPF immediately, beginning with chest compressions. After the second rescuer
returns, the rescuers should use the AED as soon as it is available. The rescuers will then
give compressions and breaths but should switch roles after every 5 cycles of CPR (about
every 2 minutes).

As additional rescuers arrive, they can help with the bag-mask ventilation, use of the AED
or defibrillatot and crash can.

Duties for ln 2-rescuer CPR (Figure 12), each rescuer has specific duties
Each Rescuer
Rescuer Locriiionl Duties
Rescuer 1 At the victim's side . Perform chest compressions.
- Compress the chest at least 5 cm
(2 inches).
- Compress at a rate of at least 1oo,imin.
- Allow the chest to recoil completely after
each compression.
M,nimize interruptrons rn compressrons
I
(try to limit any interruptions in chest
compressions to <10 seconds).
- Use a compressions-to-breaths ratio of
30:2.
- Count compressions aloud.
. Switch duties with the second rescuer
every 5 cycles or about 2 minutes, taking
<5 seconds to switch.

Rescuer 2 At the victim's head . l\,4aintain an open airway using either

- Head tilt-chin lift
- Jaw thrust
. Give breaths, watching for chest rise and
avoiding excessive ventilation.
. Encourage the first rescuer to perform
compressions that are deep enough and
Iast enough and to allow complete chest
recoil between compressions.
. Switch duties with the first rescuer
every 5 cycles or about 2 minutes, taking
<5 seconds to switch.

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 2

Figure 12. Two-rescuer CPR. The firsl

resclrer performs chest compressions.
The second rescuer pertorms bag-mask
venlilation using a mask with supplemen-
lary oxygen (when available). The second
rescuer ensures that the chest rises with
each breath. Bescuers should swtch \:
roles alter 5 cycles oJ CPR (about every
2 minules).
1-r,t

rfu t
4- I
I
l

Foundatiipnal Facts
Effective TAani,
Performanf,e td
Minimize tdterluptions in
Gompressigns
Effective teams communicate continuously. lf the compressor counts oul loud' the res-
cuer providing breaths can arrticipate when breaths will be given and prepare to givl
them efficiently to minimize i, ierruptions in compressions. The count will also help
both rescuers to know when the time for a switch is approaching.
11is hard work to deliver effective chest compressions. lI the compressor tires, chest
compressions won'l be as etiective. To reduce rescuer fatigue, switch compressor
roles every 5 cycles (about 2 minutes). To minimize interruptions, perform the switch
when the AED is analyzing the rhythm and take no more than 5 seconds to switch'

2 Rescuers Using When 3 or more rescuers are present,2 rescuers can provide more effective bag-mask
the Bag-Mask ventilation than 1 rescuer. When 2 rescuers use the bag-mask system' one rescuer opens
the airway with a head tilt-chin lilt lor jaw thrust) and holds the mask to the face while the
'13). All professional rescuers should learn both the
other rescuer squeezes the bag (Figure
'1- and 2-rescuer bag-mask ventilation techniques. When possible in the course, practice

wilh devices for both bag-mask and mouth-to-mask ventilation.

Figure 13. Two rescuer bag-mask L

ventilalion. The rescuer al the vicl m s

head lilis the victim's head and seals
\
the mask against the victlm s face wirll
lhe thurnb and firsl finqer ol each ha..i.
4
creating a "C" to provide a complele ',/. v
seal around the edges ol the mask. The
rescuer uses the remaining 3 iingers
t\
(the -E )to lrit the law (lhis ho{ds lhe
airway open) and hold the lace uP
agai,rst lhe mask. The second rescue,
slowly squeezes the bag (over 1 second)
until the chest rises. Both rescuers \
should watch for chesl rise.

ID u$
 BLS/CPR for Adults

Opening the lf the victim has a head or neck injury and you suspect a spine injury,2 rescuers may use
Airway for Breaths: another method to open the airway: a jaw thrust (Figure 14). Two people perform a jaw
Jaw Thrust thrust while holding the neck still and giving bag-mask ventilation. lf the jaw thrust does
not open the airway. use a head tilt-chin lift.

Figure 14. Jaw thrust withoul head lilt. The

jaw is lifted without lilting the head This is the
airway maneuver ol choice when the vrctrm has a
possible spine iniury.

Follow these steps to pedorm a iaw thrust

sfn Action
I Place one hand on each side of the victim's head, resting your elbows
on the surface on which the victim is lying.

2 Place your fingers under the angles of the victim's lower jaw and lift with
both hands, displaclng the jaw forward (Figure 14).

I tt tne tips close, push the lower lip with your thumb to open the lips.

q)
\s
 Automated External Defibrillator for Adults
and Children 8 Years of Age and OIder

Automated External Defibrillator for Adults

and Children 8 Years of Age and Older
Overuiew The interval from collapse to defibrillation is one of the most important determinants of
survival from sudden cardiac arrest with ventricular fibrillation (see Foundational Facts,
below) or pulseless ventricular tachycardia.

Automated external defibrillators (AEDs) are compu'erizel devices that can identify cardiac
rhythns that need a shock, and they can then deliv,-.r tht: shock. AEDS are simple to
operate, allo\ ring laypersons and healthcare providjrs to attempt defibrillation safely.

Learning At the end of this section you will be able to

Objectives . List the steps common to the operation of all /,.EDs
. Sl]ow proper placement of the AED pads
. Recall when to press the SHOCK button when usinJ an AED
. Explain why no one should touch the victim when prompted by the AED during
analysis and shock delivery
. Describe the proper actions to take when lhe AED gives a "no shock indicated" (or
"no shock advised") message
. Show coordination of CPF and AED use to minimize
- lnterruptrons in chest compressions
- Time between last compression and shock delivery
- Time between shock delivery and resumption of chest compressions

AED Arrival Once the AED arrives, place it at the victim's side. next to the rescuer who will operate
it. This position provides ready access to the AED controls and easy placement of AED
pads. lt also allows a second rescuer to perform CPR from the opposite side oI the victim
without interfering with AED operation.

Noter lf multiple rescuers are present, one rescuer should continue chest compressions
while another rescuer attaches the AED pads.

(9

$o
 3

Foundational Facta When ventricular fibrillation is present, the heart muscle fibers quiver and do not con-
tract together to pump blood. A defibrillator delivers an electric shock to stop the quiv-
Defibrillation ering of the heart fibers. This allows the muscle fibers oI the heart to "reset" so that
they can begin to contract at the same time. Once an organized rhythm occurs, the
heaft muscle may begin to contract etfectively and begin to generate a pulse (called
return of spontaneous circulation, or BOSC).

AEDS are available in ditferent models with a few differences from model to model, but all
AEDS operate in basically ihe same way. There are 4 universal steps for operating an AED

Note: To reduce the time to shock delivery, you should ideally be able to perform the first
2 steps withln 30 seconds after the AED arrives at the victim's side.

I POWER ON the AED (the AED will then guide you through the next steps).
. Open the carryinq case or the lop of the AED.
. Turn the power on (some devices will "power on" automatically when
you open the lid or case).

2 ATTACH AED pads to the victim's bare chest.

. Choose adult pads (nol child pads or a child s /sterrl) for victims B years
of age and clder.
. Peel the backing away from the AED pads.
. Attach the adheslve AED pads to the victim's L,are (:hest.
- Place one AED pad on ihe victim s upper-rig1t chest (directly below
the collarbone).
Place the other pad to the side of the left nipple /T ith the top edge of
the pad a few centimeters below the armpit (Figui-e 15).
. Attach the AED connecting cables to the AED bcx (so re are preconnected)

3 "Clear" the victirn and ANALYZE the rhythm.

. lf the AED prompts you, clear the victim during analysis. Be sure no one
is touching the victim, not even the rescuer in charge of giving breaths
. Some AEDS will tell you to push a bulton to allow the AED to begin ana-
yzing the heart rhythmi others will do that automatically. The AED may
take about 5 to 15 seconds to analyze.
. The AED then tells you if a shock rs needed.

4 lf the AED advises a shock, it will tell you to clear the victim.
. Clear the victim before de ivering the shock: be sure no one is touching
the victim.
. Loud y state a -clear the victim" message, such as "Everybody clear" or
I simply "Clear."
. Look to be sure no one is in conlact with the vlctim.
. Press the SHOCK button.
. The shock v., ll produce a sudden cor]traction of the victim's muscles.

lf no shock is needed. and after any shock delivery, immediately res ume
CPB. stanrng w th chest compressions.

6 After 5 cycles or about 2 minutes of CPR, the AED will prompt you to repeat
steps 3 and ,1.

lf "no shock advised." immediately restad CPB beginning v/ith chest

compressions.

@
\2\
 Auto m ated Extern a : Def i b ri ll ato r

a-
*

i,
\-'
\ i
{ J

l
Figure 15. AED pad #
placement on the victinr I

\\\ al,
'{ 11

,l

r.+ {. Analysis of thousands of rhythm strips recorded before and after shock delivery has
shovr'n that if rescuers can ke()p the time between the iast compression and shock
delivery to 10 seconds or Iess. the shock is much more likeiy to be effective (ie, to
eliminate ventricular fibrillation and result in return of spontaneous circulation).

Effectiveness of shock delivery decreases significantly for every additional 10 seconds

that elapses between last compression and shock delivery Minimizing this interval will
require practice and excellent team coordinalion, particularly between the compressor
and the rescuer operating the defibrillator.

Caution You may leave an AED attached while transporting the victim on a stretcher or in
an ambulance. Never push the ANALYZE button while moving the victim. Because
Moving the Victim movement can intedere with rhythm analysis and artifacts can simulate ventricular
fibrillation, the rescuer must bring the stretcher or vehicle lo a complete stop and
then reanalyze.

@
\xx
 Special The rollowing special situations may require the rescuer to take additional actions when
Situations using an AED:
. The victim has a hairy chest.
. The victim is immersed in waler or water is covering the victim's chest.
. The victim has an implanted delibrillator or pacemaker.
. The victim has a transdermal medication patch or other object on the surface of the
skin where the AED pads are placed.

Hairy Chest lf a teen or adult victirn has a lot of chesl hair, the AED pads may not properly stick to
the skin on the chest. lf this occurs, the AED will not be able to analyze the victim's heart
rhythm. The AED wlll then give a "check electrodes" or "check electrode pads" message.

Step Action i

I lf the pads stick to the hair instead of the skin, press down firmly on each
pad.

2 lf the AED contlnues to prompt you to "check pads" or "check electrodes,"

quickly pull off the pads. This will remove a large amount of hair and shoukj
allow tl-e pads to sticL to tl'e skin.

3 lf a large amouil of hair still remains where you will put the pads, shave the
area with Ihe ,a'o' rn the qFD carrying case.

4 Put on a new set of pads. Follow the AED voice prompts

Water Water is a good conductor of electricity. Do not use an AED in water. lf the victim s in
water, pull the viclim out oi the water. lf the victim is lying in water or the chest is covered
with water, the water may conduct the shock electricity across the skin of the victim's
chest. This prevents the delivery of an adequaie shock dose to the heart. lf water is cover-
ing the victim's chest, quickiy wipe the chest before attaching the AED pads.

lf the victim is lying on snow or in a small puddle, you may use the AED.

lmplanted Victims wilh a high risk for sudden cardiac arrest may have implanted defibrillators/pace-
Defibrillators makers that automaiically deliver shocks directly to the heart. You can immediately iden-
and Pacemakers tiiy these devices because iiley create a hard lump beneath the skin of ihe upper chest or
abdomen. The lump is half ine size o, a deck of cards, with an overlying scar. lf you place
an AED pad directly over a. implanted medlcal device, the device may block delivery of
rhe shock to lhe hean.

@ \?3
 Auto m ated E xtern al Def i b ri I lato r

lf you identify an implanted defibrillator/pacemaker:

. lf possible, avoid placing the AED pad directly over the implanted device.
. Follow the normal steps for operating an AED.
Occasionally the analysis and shock cycles of implanted defibrillators and AEDS will con-
flict. lf the implanted def br llator is dellvering shocks to the victim (the victim s muscles
contract in a manner like that observed after an AED shock), allow 30 to 60 seconds for
the implanted defibrillator to complete the treatment cycle be{ore delivering a shock from
thE AED,

T;:nsdermal Do not place AED pads directly on top of a medication patch (eg, a patch of nitroglycerin,
A/edication nicotine, pain medication, hormone replacement therapy, or antihypertensive medication).
Frlches The medication patch may lllock the transfer of energy from the AED paci to the hean and
may cause small burns to the skin.

lf it won't delay shock dellvery, remove the patch and wipe the area clean before attaching
the AED pad.

@
\ 4ll
 3

2-Rescuer BLS Sequence With an AED

2 Rescuers Follow these BLS steps ior 2 rescuers with an AED
With an AED

,|
Check for response and check breathing: lf the victim does not respond
and is not breathing or not breathing normally (ie, only gasping):
. The first rescuer stays with the victim and performs the next steps until
the second rescuer returns with the AED.
. The second rescuer activates the emergency response system and gets
the AED.

2 Check for pulse: lf a pulse is not definitely ,elt in 1O seconds:

. The first rescuer removes or moves clothing coverjng the victim's chest
(this will allow rescuers to apply the AED pads when the AED arrives).
. The first rescuer starts CPB, beginning with chest compressions.

Attempt defibrillation with the AED:

. When the AED arrives, place it at the victim's side near the rescuer who
will be operating it. The AED is usually placed on the side of the victim
opposite the rescuer who i.-s pefforming chest compressions (Figure 16).

4 POWER ON the AED (the AED will then guide you through the next steps)
(Figure 17).
. Open the carry ng case o|the top of the AED.
. Turn the power on (some cievrces wi I "power on" automatically when
you open the lid or case).

5 ATTACH AED pads to the victrm's bare chest (Figure 1B).

. Choose adult pads (not chiid pads or a child system) ior victims 8 years
of age and older.
. Peel the backing away from the AED pads.
. Attach the adhesive AED pads to the victim's bare chest.
- Place one AED pad on the victim's upper-right chest (directly below I

the collarbone).
- Place lhe other pad to the side of the left nipple, with the top edge oI
the pad a fe\,r' centjmeters below the armpit (Flgure I5).
. Attach ihe AED connectlng cables to the AED box {some are precon
nected).

6 "Clear" the victim and ANALYZE the rhythm (Figure I9).

. l.f the AED prompts you. clear the victim durlng analysis. Be sure no one
is touching the victim. nol even the rescuer in charge of giving breaths.
. Some AEDS will tell you to push a button to allow the AED to begrn ana
lyzing the heart rhythm: others will do that automatically. The AED may
take about 5 to 15 seconds to analyze.
. The AED then lells you f a shock is needed.

(cantinued)

@ \7!
 Automated External Defibrillator

(contnued)

Step Action
7 lf the AED advises a shock, it will tell you to clear the victim.
. Clear the victim before delivering the shock (Figure 20A): be sure no one
is touching the victim.
. Loudly state a "clear the victim mess"Ee, such as "Everybody clear" or
simply "Clear."
. Look to be sure no one is in contact with the victim.
. Press the SHOCK button (Figure 208).
. The shock will produce a sudden contraction ol the victim's muscles.

lf no shock is needed, and after any shock Celivery, immediately resume

CPR, starting with chest compressions (Figure 21).

9 After 5 cycles or about 2 minutes of CPH. ihe AED will prompt you to repeat
steps 6 and 7.

lf "no shock advised," immediately restan CPR beginning with

chest compressions.

@
\zb
 3

1t
lt
1l ,- ,e

\\
's
Figure 16. Second rescuer places AED beside victim Figure 17. AED operalor turns AED on

*{i

"I
I

t,
-_. j

Figure 18. Bescuer attaches AED pads to lhe vrctim ano then attaches Figure 19. The AED operator clears the victim betore
the electrodes to ihe AED. rhythm analysrs lf needed, the AED operator then activales
IhE ANALYZE TCATUTE OI IhC AED,

t a
\iU,
# rl
.1:
\r,

V-
G'

L'l
@
1

11
\
f'l \*_
A B

Figure 2(). A, The AED operalor clears the v clrm beJore delivenng Figure 21. ll no shock is indrcated and immediately after
a shock. B, When everyone rs clear cf the viclim the AED operator presses lhe any shock dehvered, rescuers stad CPR. beginnlng vr'iih chest
SHOCK button. compressrons (C_A-B sequence).

@ l2?
 Automated External )efibrt abr

BLS for Healthcare Providers Course American

1- and 2-Rescuer Adult BLS Wath AED Heart
Association.
Skills Testing Sheet
.See I .rrd 2 Eescuer Adi,rt BLS li/rt/l AED Skii/s lestr/)q CIrleil, irro I)csc .'tc/-s o/l ,e.,1 paEre

Student Name: Test Date: _

CPR Skills (circle one): Pass Needs Remediation
AED Skills (circle one): Pass Needs Remediation

skiI Crltical Pertonnance Crite# / if done

Step cornectly
I 1-Rescuer Adult BLS Skills Evaluation
During this first phase, evaluate the first rescuer's ability to initiate BLS an.l deliver high-quality CPR for 5 cycles
I ASSESSES: Checks for response and for no breathing or no rloina breathing. only gasping
(at least 5 seconds but no more than '10 seconds)

2 ACTIVATES emergency response system

:-
L14 Checks for PULSE (no more than 10 seconds)
IGH OUALITY CPR
Cycle 1:
t compression HAND PLACEMENT
L

t. ADEOUAIE RATE: At least 100/min (ie, delivers each set of 30 chest compressions rn Cycle 2 Tinie
i 18 seconds or less)
Cycle 3:
. ADECUATE DEPTH: Delivers compressions at least 5 cm (2 irrches) in depth (at least 23 out oi 30)
t- Cycle 4
ALL,fWS COIvIPLETE CHEST RECOIL (at least 23 out of 30)

. MIN'MIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds
Cycle 5

Second Rr:scu,irr AED Skills Evaluation and SWITCH

I
During this nexl Phase, evaluate the second rescuer's ability to use the AFD and both rescuers' abilities
to sv,/itch roles

5 DrJBll',G FIFTH SET OF COMPRESSIONS: Second rescuer arrives with AED and bag-mask
device. turns on AED, and applies pads
pads
6 First rescuer continues compressions while second rescuer turns on AED and applies

7 Second rescuer clears victim, allowing AED to analyze - RESCUERS SWITCH

a lf AED indicates a shockable rhythm, second rescuer clears victim again and delivers shock

First Rescuer Bag-Mask Ventilation

During this next Phase, evaluate the first rescuer's ability to give breaths with a bag-mask
Cycle Cycle 2
Both rescuers BESUME HIGH-QUALlry CPR immediately after shock delivery
1
9
. SECOND RESCUER gives 30 compressions immed ately after shock delivery (for 2 cycles)

. FIBST HESCUEH successfully delivers 2 breaths with bag-mask (for 2 cycles)

AFTER 2 CYCLES, STOP THE EVALUATION
lf the student completes all steps successfully (a / in each box to the right oI Critical Performance
. Criteria), the student
passed this scenario.
. lf the student does not complete all steps successlully (as indicated by a blank
box to the righl of any of the Critical
;;;;;;;; Criteria), give the form to ihe student for review as part of the student's remediation
. student will give the form to the in structor who is reevaluating the sludent. The student will
After reviewing the form, the
on this same form.
reperform the entire scenario, and the instructor will notate the reevaluation
. before the student leaves the classroom
lf the reevaluation is to be done at a different time, the instruclor should collect this sheet
Remediation (if needed):

lnstructor Signature lnstructor Signature:

I P,int lnstructor Name,- I

Print lnslructor Name:
--
Date Date
a
128
 3

BLS for Healthcare Providers Course

1- and 2-Rescuer Adult BLS With AED
Skills Testing Criteria and Descriptors
'1. Assesses victim (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival
at scene):
. Checks ror unresponsiveness (this t\4UST precede starting compressions)
. Checks lor no breathing or no normal breathing (only gasping)
2. Activates emergency response system (Steps'l and 2, assessment and activation, must be completed within
10 seconds ol arriual at scene):
. Shouls for help/directs someone to call ior help AND qet AED/defibrillator
3. Checks tor pulse:
r Checks carotid pulse
. This should take no more than l0 seconds
4. Delivers high-quality CPR (initiates compressions within 1o seconds of identifying cardiac arrest):
. Correct placement of hands/fingers in center of chest
- Adult: Lower half of breastbone
- Adult: 2-handed (second hand on top of the jirst or grasping the wrist oI the first hand)
. Compression rate of at ieast I00/min
Delrvers 30 compressions in 1B seconds or less
. ,ldeqLrate depth for age
. r.duit: at least 5 cn] i2 inches)
. :'cmplJte chest recoil after each compresston
. ' :n -r:es tntFfluDttcr]s .n co lp.ec3ions:
Less lnan l0 seconds betvveen last ccmpression of cne cycle and first compression oI next cycle
Compressions not interrupted until AED analyzing rhythm
Cori,oressions resumed tmmecjiaiely after shock/no shocl rndicated
5-8. lnregrates prompt and proper use of AED with CpR:
. rirrns AED on
. Piaces proper-sized pads for victim,s age in correct location
' Clears rescuers from victim for AED lo analyze rhythm {push3s ANALYZE button if required by devlce)
. Clears victim and delivers shock
. Flesumes chest compressions immediately after shock deljvery
. Dces NOT turn off AED during CpF
. j:i,ovides safe environment for
rescLlers during AED shock deltvery:
- Co|nr-irLrnicates c early to ail other rescuers to stop touching v'ctim
Delrvers shock to victim after all rescuers are clear of victirrl
. irwitcnes during analysrs phase oi AED
9. Pr,r,vides effective breaths:
. a-loens atrway adequately
. i-)elivers each breath over 1 second
. Jelivers brealhs that produce visible chest rise
. .: roids excessive ventilation

D
l29
 KONSEP DASAR REAKSI ANAFILAKSIS
DALAM RANGKA PATIENT SAFETY

BAGIAN ANESTESIOLOGI dan TERAPI

INTENSIF FKUB.RSSA
MALANG
2014
1

Epidemiologi
a The American College of Allergy, Asthma and
Immunology Epidemiology of Anaphylaxis Working
gloup ) international epidemiologicil studies: 30I
950 kasus per 100,000 orang peitahun
. Prognosis anafilaksis umumnya baik, dengan case
fatality ratio < lo/o pada
sebalian besar studi berbasis
populasi. Risiko kematian mehingkat pada pasien
dengan asma sebelumnya.

. Ada sekitar 20 kematian anafilaksis per tahun

di UK.

2
. The Clinical Indemnity Scheme (CIS), UK
menerima 751 laporan "reaksi alergik
terhadap allergen yang telah diketahui
sebelumnya" pada tahun 2A04-20rc.
peresepan co-amoxiclav pada pasien
dengan alergi penicilin meliputi 2Oo/o
kasus.

Time to cardiac arrest following exposure to

triggering agent
I
Nt{rrtrcr cl LlcaLhg

l_t

U
E'> qP 'P 5.<:
I@ .\
I

L6' \$ d' 1(r \CF

Tirr,e !o tirsr arrost (rftlnrrtFrsi
Contoh Kasus
1
$eorang pasien mengalami bronkospasme
berat didalam kamai operasi pada tahun
19.9.9 setelah injeksi cisatracurium, yang
akhirnya menydbabkan injury permanen.
Pasien tersebut mengalami reaksi serupa
pada tahun 1995 kar:ena atracurium.
Pengadilan menemukan bahwa reaksi
pertama seharusnya didokumentasikan
{gngaf benar sehihgga reaksi kedua dapat
dicegah.

DEFINISI

Ihe Eu.ropean Academy of Allergology

- and -
Clinical Immunology Nomenclature
Committee:

Anaphylaxis is a severe, life-threatening,

g e n e r a I i s e d o r t rrtJu"!!, yp e rs e n s i t i v i t y
lrnh

6
Definisi

. Reaksi anafilaksis merupakan bentuk

reaksi hipersensitifitas tipe 1 yang berat,
dimana kondisi syok dapat terjadi .

Patofisiologi
. Alergen + antibodi spesifik yang telah
terbentuk, ) degranulasi lisosom dari sel
mast (basofil), ) sekresi mediator
penting untuk reaksi anafilaksis, sepefti
histamin, bradikinin, prostaglandin, PAF
d[.

8
 i'-

YY

GEmbar l: patofisioloqi dari reaksi anafilaksis, pross terja dinya

degranulasi lisasom ddri sl .|last,

Patofisiologi
9

Patofisiologi
lryrocF i.p.n-

t
, C+t aat crkd ilb !G:d.ls
l.
r rd.h.+ <oq!!ah..rr't
Hrcir{|rdrbr For-t
. n'!,ftr.id r+ 'J; tt?fv'..1*"r

Cnrnbdr 2: bebcrnpn mcdlrtor h.19ll dcgranulnsl Iisoson dnri 5cl mrst

10
Fatalitas
o produk makanan ) 30-35 menit.
o sengatan serangga ) 10-15 menit.
. obat-obatan IV (intravena) ) < 5 menit.

. Sebalikoyo , bila sejak exposure sampai

manifestasi kliniknya > 6 jam, jarang
yang meninggal.

11

I I I

Fiiix! 2. Tirnc t. c.rrdi.c ar.6t tollo$ l.l .rForur* lo t,igg.rtng .g.fli ji

carrrlrar 3; olrset teriadinya reaksi anafilaksis yang fatal seteldlr kontak
dari beberapa alergen.

!2
Diagnosis
. Gejala mendadak dan cepat keluhan
penderita memberat.
. Terjadi masalah serius pada sistem
pernafasan dan sistem kardiovaskular,
. Bersamaan terjadi perubahan pada kulit
dan mukosa (f/ushing, uftikaria dan atau
angioedema).

13

7 -! rF

J
L j 1{

.,:{*-r .t'ir-...
tl
r
l,

.{rh
t
il L.- &
1 I
[,i

L4
Diagnosis lebih tepatr..
. Ada bukti bahwa sesaat sebelum terjadi
reaksi anafilaksis terjadi ekspos terhadap
alergen (obat, makanan, serangga
berbisa).

15

DIFFICUTTY BREATHIT{G TII{GLIHG & SWETLI}IG

16

THROAT NGHTEIIIIIG ITGHIIIO'RASH

Perhatian..
. Perubahan pada kulit dan mukosa saja
bukanlah gejala dari reaksi anafilaksis.
. Reaksi anafilaksis dapat terjadi tanpa
diikuti perubahan kutit dan mukosa'(20olo
-
dari reaksi anafilaksis hanya terjadi
gangguan pada sistem kardiovaskular,
sepeft i h i potensi/syok).
. Dapat pula disertai dengan gangguan
pada sistem gastrointestinal (muhtah,
sakit perut dan inkontinensia).

77

Lab
. Pemeriksaan hitung diferensial leukosit
sering hasilnya meningkat dan bergeser
ke kiri.
. Serum elektrolit, analisa gas darah, fungsi
ginjal (ureum dan kreatinin), EKG dan
foto rontgen dada.
. kadar triptase dari degranulasi lisosome
dari sel mast.

18
 t00 1
+
a
a

a
a
a

a
fr aa
ir
Trn'{: illl.r' } !l;!-'l iil -l!r;rl)l^yrilxrr, IrloL':r\
Flgurc a. Suegarlcd tirE cgurtc for tha 4Poatttc. o{ lryPaaro
ln 6erum or plaim. doring 3yal.mlc anaphylarls t'
FLDrodlEd .nC rdaDrd '^rlth p.r[*tCon ttgltr Elsaviar'
Ganrbar 4: profll triptase, onset. kadar pun(ak dan waktu paruhlrya.
19

Tatalaksana
Prinsip
. Eliminasi faktor penyebab.
. ABCD's
. Obat - obatan.

20
ABCD'S
. Airway ; simple sampai definitive.
. Breathing ; beri oksigen 100o/o.
. Circulation; kristaloid 500mL )
normotensi 1000mL ) hipotensi ,
250mL ) decomp cordis.
. Disability ; 50cc dekstrose 4Oo/o atau 5 -
10 cc dekstrose 10% pada anak/ bayi )
hypoglycemia . Ulangi bila perlu sp 3x )
pi kirka n hyd rocortison.

21

Obat - obatan
Adrenalin
. Usia >12 th: 0,3mL - 0,5mL (^, dewasa)
IM
. 6 th - L2 th: 0,3mL IM
.6 bl - 6 th: 0,15mL IM
o ( 6 bl: 0,15mL IM

22
 . Dosis adrenalin iv lqglkgBB, dengan
sediaan adrenalin yang sudah
diencerkan 1:1O.OOO.
. Kadang dibutuhkan dosis adrenalin
kontinyu IV selama fase akut dari
reaksi anafilaksis, (2 -
lOpg/menit).

T -\utrlu*rrnII f)osrs
Difenhi&^amn Delvlsr : 25 mg Ef/IV
Pediakrk 1mg/kgIl\;rff
Chlorphan:ramine 10 mg iIvOTl/
(hritcn; sebuah H1 -b lo*er)
Promethaane @henergan) Dewasa : 25 rng II'fiV
Anak > 6tahun : 12,5 mg IMTV
Anak < 6tahun : 6,25-l2,5mg II/IV

Tip : encerkan tiap ml dari 25 mg promethazine (phenergan) sampai 10 ml dengan NS

dan berikan tv pada kecepatan tidak lebih dari 2,5 m8/menit untuk menghindari efek
samping hipotensi transient.

24
. Glukagon : peftimbangkan
penggunaannya jika adrenalin merupakan
kontraindikasi relative, contoh : IHD,
hipotensi berat, kehamilan, pasien
pengguna beta blockeq atau yang tidak
berespon terhadap adrenalin.
. Dosis : 0,5-1,0 mg IV/IM; dapat diulang
sekali setelah 30 menit.

25

apelah lsrildi raslrC analfl*ds?

1- t{r.r rhfi,in.(dd
?. ta.!{lah lirt! yraf mrlihi*.E ri r 3trnrfrra
dri' !r.{lir*n&x!..,
1..*r & *rtrl s*i**a tril d*r lltllGra

?' Pqd
!- LiCrir I itr'

lEt !drcr}3trn

mor*torin6:
1.5,rtrrad 02.
). tltG, darr
l. Te*irla{ dard!
26

Alur pEnlgentn pE dtrit! yenP rrlndErits r:tbi anAlillk3ir,

 PENCEGAHAN

21

BAGAI MANA KESALAHAN TE RJADI?

Faktor yang paling sering berkontribusi terhadap
medication error tentang allergen obat yang telah
diketahui sebelumnya atlalah : -
7 Kegagalan untuk mempertimbanqkan alerqi saat
meresepkan, mengeluarkan, dan-memberikan obat.
2 Kurangnya pengetahuan atau informasi menqenai
cross-sensitivity, indikasikan atau digunakan-dengan
hati-hati bila ada riwayat alergi sebe'[umya
3 IKurangnya ketersediaan/a.kses untuk informasi yang
akurat mengenai riwayat alergi pasien saat
meresepkan, mengeluarkan, atau memberikan obat
4 Berasumsi bahwa sistem resep terkomputerisasi
akan menceqah oereseoan all'eroen vaho telah
diketahui sebel.umnya, iradahal Sistein tlOaf
orrancang demrKran.
5 Kegagalan mengenali, atau lambat dalam mengenali
alelgi- obat, saaf bendr-benar terjad i.

2a
BAGAIMANA PENCEGAHANNYA?
1. Cek status alergi obat
2. Pastikan staf memahami cross-allergies
3. Pastikan pasien mengetahui/memahami alergi yang
dimilikinya
4. Pastikan bahwa alergi obat terdokumentasi dengan jelas
5. Maksimalkan fungsi peresepan berbasis komputer
6. Atur agar basis data kesehatan merekam informasi alergi
7. Pastikan bahwa quidelines dan fasilitas untuk diaonosis.
terapi dan follow up alergi dan anafilaksis dapat diakses

29

Kenapa pemantauan perlu ?

eAnafi laksis dapat berulang

ePemicu perlu di ketahui
ePencegahan jangka paniang harus dilakukan

30
 Pendidikan terhadap anafi laksis

Sebelum Memberikan Obat

1. Adakah indikasi memberikan obat

2. Adakah riwayat alergi obat sebelumnya
3. Apakah pasien mempunyai risiko alergi obat
4. Apakah obat tsb perlu diuji kulit dulu
5. Adakah pengobatan pencegahan untuk mengurangi
reaksialergi

32
Et
lliohetata i tatpta| Atsbaiati on

MotionApproved by MHA Board

August 10,2007

Recognizing that cunent vanations in the use of color-coded "alert" wristbands may cause
confusion among caregivers, staff, and patients and can lead to patient harm, the Minnesota
HospitalAssociation's Patient Safety Committee proposes that the MHA board adopt the
following resolution:
The Minnesota HospitalAssociation recommends that all hospitals work toward reducing
reliance on and eventually eliminating the use of color wrist bands by collectively
developing more effective ways to communicate emergency information and patient risks.
ln the interim, if an organization uses colored wristbands to communicate patient
information or risks, the following colors should be used to indicate the respective alert:

*Red: allergy
*Yellow: fall risk
xPurple: DNR
* Pink: restricted extremity
xGreen: latex allergy
33

Color Coded Wristband

Standardization in Minnesota
Allergy
Reco m me n da tio n : Al le rgy
- Red Red means'Stop!'
The American National
It
is recommended that Sta nda rds Institute has
hospitals adopt the color designated red to
RED foT the ALLERGY ALERT communicate'Stop!' or
designation with the words 'Danger!'
embossed / printed on the
wristband, "ALLERGY."

a
Color Coded Wristband
Standardization in Minnesota
Recommendation - RED for the Attergy Atert
1. Wh v Red?
A ll 11 states to date have adopted red for allergy.
2. Any other reasons?
STOP!
jPn'fgn$f H?Rbl: ance/police
f,n:F'e[!*YJ'['"",'4"#'J
Do we write the allergies on the wristband too?
I1o_sg!g s .*j I t_ lS g{ Ig dete rqlt ne,E co n siste nt p' rocess
l

Ior co. m.muntcattng the specific allerqy. Some

nospltats may cho-se to riot write onthe band due to:
. Legibility issues
. Allergy list may change
. Patieirt chart should 6e the source for the specifics

Langkah-langkah Pencegahan

1. Riwayat alergi obat secara terperinci

2. Obat sebaiknya diberikan peroral
3. Observasi pasien selama 30 menit setelah pemberian
4. Memeriksa labelobat
5. Menanyakan riwayat obat secara telitijika ada faktor
predisposisi
6. Mengajarkan untuk dapat menyuntik adrenalin
7. Menggunakan preparat human antiserum
8. Lakukan uji kulit jika mungkin
9. Pemberian obat pencegahan reaksi alergi

36
Obat dan alat yang perlu dipersiapkan

1. Adrenalin
2. Antihistamin
3. Kortikosteroid injeksi
4. Aminofi lin, inhalasi beta2 I nebulizer
5. lnfus set
6. Cairan infus
7. Oksigen
B. Tensimeter
9. Alat bedah minor
10. Nomor telepon ambulans gawat darurat
37

Surat Keterangan

/Penting untuk pencegahan berulang

/Cantumkan daftar obat / alergen yang dicurigai
/Beritahu pasien untuk selalu memperlihatkan pada dokter
waktu berobat
/Tuliskan di status di tempat yang mudah dilihat
/Laporkan pada tim monitoring efek samping obat

38
 Sample Chef Card
To the Ghef :

WARNING ! I am allergic to peanuts. ln order to avoid a life{hreatening

reaction, I must avoid the following ingredients :
.Artificial nuts
.Beer nuts
.Cold pressed, expelled, or extruded peanut oil
.Ground nuts
.Mandelonas
.Mixed nuts
.Monkey nuts
.Nut pieces
.Peanut
.Peanut butter
.Peanut flour
Please ensure any utensils & equipment used to prepare my meal, as well as
prep surfaces, are thoroughly cleaned prior to use. Thanks for your cooperati
39

Munoz. Anaphylaxis 200,1, Wiley, Chachester. P. 265-75

REFERENSI
. Update: World Allergy Organization Guidelines for the
assessment and management of anaphylaxis.2012
. World Allergy Organization Guidelines for the
Assessment and Management of Anaphylaxis, WAO
Journal ZOLI; 4:L3-37
. Emerqencv treatment of anaohvlactic reactions.
GuideJinesfor healthcare providers. Working Group of
the Resuscitation Council (uf). ZOOS

40
. Briefihg Document: Reducing preventable
Harm to Patients with Known Drug
Allergies. The Irish Medication Saiety
Network (IMSN). Oct 2012

. Color Coded Wristband Standardization in

Minnesota.2007

TERIMA KASIH

42