AIRWAY MANAGEMENT

SMF Anestesi dan Reanimasi Rumah Sakit Persahabatan Jakarta

Elements of Basic Life Support

AB-C

Basic Life Support: Importance

The respiratory system is important because it is one of the primary systems that works to supply oxygen to the body. If breathing is not resumed, brain damage will result starting after four minutes.

RESUME OF BASIC LIFE SUPPORT

Sadar Posisi mantap

Korban Cek kesadaran Tidak sadar

Open airway
Cek nafas = Look, feel and listen Nafas Cek nadi Ada Tidak ada Tidak nafas 2-5 nafas buatan

Kompresi

Ventilasi dan oksigenasi

ACLS

ROSC

Nilai irama dan cek pulse

George, 2004

Airway Devices Oral Airways:

are designed to keep the tongue from falling back and blocking the upper airway are easily available in six sizes are only used in unresponsive patients without a gag reflex do not eliminate the need to monitor the airway for patency

Oral Airways Sizing

To choose the proper size, hold the airway against the side of the patients face. It should extend from the corner of the patients mouth to the angle of the jaw.

Oral Airways Insertion

open mouth with cross-finger technique. Insert airway with tip pointing up to avoid pushing tongue backward rotate airway tip slowly downward until its curve matches the curve of the tongue the flange of the airway should rest against the patients lips

Nasopharyngeal Airways Sizing

curved, flexible rubber or plastic tubes inserted into the patients nostril use on responsive patients who need an airway assist

Nasopharyngeal Airways Insertion

lubricate with sterile, water-soluble lubricant, and insert into nostril that appears most open insert until flange is against the nostril opening check to ensure airflow

Breathing Devices
There are several devices designed to make rescue breathing and similar treatments easier and safer for the rescuer. Common breathing devices:

Resuscitation Mask Bag Valve Mask

Breathing Devices: Resuscitation Mask

A resuscitation mask, also known as a pocket mask, is a device designed to separate the rescuers mouth from the victims. This prevents disease transmission

Breathing Devices: Resuscitation Mask

There are several criteria for a good mask:

Transparent, pliable One way exhalation valve Inlet for supplementary oxygen Resistant to extremes of heat or cold Easy to assemble and use.

Breathing Devices: Resuscitation Mask

To use a mask, place it over the victims mouth and nose, starting on the bottom and rolling it over the rest of the face. Tilt the head back and breath into it. A mask can also be used for the modified jaw thrust.

Breathing Devices: Bag Valve Mask

A Bag Valve Mask (BVM), also called an AMBU bag, is a device that allows artificial respiration without a rescuer to give breaths. It is much less tiring and safer to use. As the name implies a BVM needs a squeezeable bag, a one way valve, and a mask.

Breathing Devices: Bag Valve Mask

To use, place the mask over the victims mouth and nose, and grip the mask in one hand using a C shaped grip, finger on the victims jaw. Tilt the head back and squeeze the bag to administer respirations.

INTUBASI ENDOTRACHEAL

POLICY

PROSEDUR PENTING NAMUN BERESIKO TINGGI Darurat/waktu terbatas Diindikasikan untuk gagal nafas akut Ketidakstabilan hemodinamik (syok)/paska cardiac arrest Trauma servikal (leher) atau orofaring Beresiko muntah dan aspirasi Posisi sulit

POLICY

Harus familiar dengan trolley emergency, peralatan dan obat2 Asisten harus trampil Jika sendiri, harus memanggil staf anestesi, (penata atau dokter anestesi) Pada umumnya memakai teknik induksi cepat RAPID SEQUENCE INDUCTION

INDIKASI

Penggunaan ventilasi mekanik Mempertahankan fungsi jalan nafas (airway)

Sumbatan jalan nafas atas

Yang potensial EARLY BURNS Real EPIGLOTITIS, TRAUMA

TRANSPORTATION

Melindungi jalan nafas dari:

Resiko aspirasi Penurunan kesadaran Kehilangan refleks glotis Trakeal TOILET

TEKNIK

OROTRACHEAL metode STANDARD NASOTRACHEAL - jika; Pemakaian ventilator jangka pendek, trauma rongga mulut FIBREOPTIC Cedera kepala dan leher (servikal) Tidak mampu membuka mulut: fiksasi rahang, trauma Obstruksi jalan nafas atas: tumor di rongga mulut METODE DIRECT VISUALISATION - laringoskop FIBREOPTIC intubasi sadar (AWAKE INTUBATION) BLIND NASAL AWAKE INTUBATION

ENDOTRACHEAL TUBE

STANDARD TUBE: LOW PRESSURE HIGH VOLUME (PLAIN PVC)

Pria 8-9 MM: fiksasi pada 21-23 CM TO INCISORS (gigi taring) Wanita 7-8 MM: fiksasi pada 19-21 CM TO INCISORS

Jangan memotong tube dibawah 26 cm

DOUBLE LUMEN TUBES: jarang di ICU (kecuali CVVH) Tube dari OK/OT harus diganti jika diperkirakan ekstubasi > 48 HOURS

PROTOKOL
A. PERSON: 4 orang, asisten trampil sangat perlu TOP END INTUBATOR (yg melakukan intubasi) koordinator 1 orang pemberi obat 1 orang menekan cricoid 1 orang menjaga agar kepala dan leher segaris atau lurus (PROVIDE IN LINE CERVICAL SPINE IMMOBILISATION)

B. Jalur intravena harus dijamin lancar

PROTOKOL
C. Peralatan:
Lampu penerangan cukup Guedel/mayo Suction yg berfungsi AMBU BAG dan MASK 100% OXYGEN, 15 L/MIN 2 LARYNGOSCOPES yang berfungsi MAGILL FORCEPS INTRODUCER (kawat mandrain) dan PLESTER 2 tube (ETT):

NORMAL SIZE + 1 SIZE yang > kecil CHECK CUFF COMPETENC SCAPEL 15 ETT NO 6.0

Peralatan CRICOTHYROIDECTOMY:

PROTOCOL
D. MONITORING
PULSE OXYMETRY KAPNOGRAFI TEKANAN DARAH EKG

PROTOCOL
E. OBAT-OBATAN
Obat induksi (pentotal, propofol, fentanil/sufentanil, ketalar,dormicun) Obat pelumpuh otot; Suksinil kolin (1-2 MG/KGBB) merupakan obat pilihan

Kontraindikasi suksinil kolin:

Luka bakar > 3 DAYS CHRONIC SPINAL INJURY (SPASTIC PLEGIA) NEUROMUSCULAR DISEASE (Guillan Barre Syndrome) HYPERKALAEMIC STATE (K > 5.5)

Pertimbangkan Esmeron ROCURONIUM (1-2 mg/kgBB) Sulfas atropin (0.6 1.2 mg) ADRENALINE (10 ML 1:10.000)

PROCEDURE

Preoksigenasi 100% (NRM 15 l/m atau tempelkan mask ke hidung/mulut selama 3-4 menit) Loading cairan koloid 250-500 ml Obat induksi (dormicum + fentanil/petidin + S.kolin/esmeron/tracrium Tekan CRICOID Laringoskopi sampai melihat pita suara (VOCAL CORD) Intubasi Inflasi CUFF Cek : ET CO2 AND stetoskop Lepas CRICOID PRESSURE Plester tube Hubungkan dgn VENTILATOR Pastikan sedasi dan pelumpuh otot CHEST X-RAY Analisa gas darah 1 jam post intubasi dan sesuaikan FiO2

PROCEDURE
Sedasi POST INTUBATION:
Tidak perlu jika pasien koma atau hemodinamik tidak stabil MORPHINE+MIDAZOLAM, PROPOFOL, FENTANYL

Preoksigenasion

Pemberian O2 100% selama 2-5 menit Bagging mask selama 1-2 dgn 15 l/m KALAU PS MASIH BERNAFAS SPONTAN DAN SADAR, 3 kali tarik nafas dalam dgn baging mask Gunanya untuk membuang gas nitrogen udara bebas dalam paru Memberikan cadangan O2 dalam paru jika apne selama 3-5 min

Pretreatment

Defasiculation
Prevent increase ICP Pediatric patients 10% of neuromuscular blockade dose

ICP Concerns
Oxygenation Prevent fasiculations Lidocaine- 1.0mg/ kg

Bradycardia
Atropine 0.01- 0.02mg/ kg ALL children Dries secretions

Sedation
Prior to paralysis Immediately subsequent

You do not want a paralyzed awake patient!

Agents
Barbituates Benzodiazepines Dissociatives Opiates Other

Benzodiazepines
Midazolam (Dormicum) 0.1-0.2 mg/kg Diazepam (Valium) 0.25-0.4 mg/kg

Amnestic, anticonvulsant, Dose related hypotension

Dissociatives

Ketamine (Ketalar) 0.5-2mg/kg

Analgesic, amnestic, bronchodilator, Increased ICP, hypersecretion

Opiods
Morphine Sulfate 0.1-0.2 mg/kg Fentanyl (Sublimaze) 2-10mcg/kg

Analgesic

Others

Etomidate (Amidate) 0.2-0.4 mg/kg

Decreases ICP, little BP effect

Propofol (Diprivan)
1-2mg/kg Decreases ICP, anticonvulsant, antiemetic Hypotension

NMB

Depolarizing
Succinylcholine (Anectine) 1-1.5mg/kg

Nondepolarizing
Rocuronium (Esmeron) - 0.6-1.2mg/kg Vecuronium (Norcuron) - 0.1mg/kg Pancuronium Pavulon) - 0.1mg/kg

Sellecks Manuever

Prevents PASSIVE regurgitatioon Visualization

Suction

If you couldnt get it done before, you can now

Patient Positioning
Goal

Align the 3 planes of view, so that The vocal cords are most visible

T - trachea P - Pharynx O - Oropharynx

Complications

Inability to intubate Inability to ventilate Associated complications

Always have a back up plan and be prepared to use it!

Combitube LMA (Laringeal Mask Airway) Cricothyroidotomy

COMBITUBE

No . 2 15 ml

No .2 15 ml

No. 1 100 ml

Combitube
No. 1

. No 2

. No 2

No. 1

No. 1 100 ml

LARINGEAL MASK AIRWAY

POSITIONING OF THE AIRWAY FOR LMA

DEFLATION & INFLATION OF THE LMA

LMA Insertion Step 1

LMA Insertion Step 2

LMA Insertion Step 3

LMA Insertion Step 4

LMA Insertion Step 5

Fast-trach LMA

The Difficult or Failed Airway

Difficult to ventilate or oxygenate Difficult to intubate Difficult cricothyroidotomy candidate

Comprise 1- 3% patients Unpredictably difficult to intubate or ventilate with BVM 1:10,000