Principle of Emergency
Ventilasi Airway
O2
paru
breathing
difusi
Distribusi sirkulasi darah
O2
arteri
O2
CO2
CO2 MAKROSIRKULASI
jantung
cair
ginjal
ekskresi MIKROSIRKULASI
vena
Elektrolit + Plasma Saluran lymphe
darah
arteriole MIKROSIRKULASI
Eritrosit perfusi
ATP
mitochondria O2 Na +
Na+
K+ K+
Cl-
CO2 Cl-
sel perfusi
Na+ Na+
K + ATP
K+
Cl -
Cl-
End-venule
Saluran lymphe
Saluran lymphe
Perfusion
• Determined by Mean Arterial Pressure
• MAP
• Pulse Pressure = Systolic - Diastolic
AIRWAY
Definition
• Part of respiratory system through which air flows
• Divided into 2 parts
• Upper airway
• Lower airway
Anatomical review of Upper airway
• Start from nasal cavity
• End at carina
Functional review of Upper airway
• Air passage
• Warming
• Filtering
• Humidifying
• Protective reflex
• Vomit
Anatomical review of Lower airway
• Start from carina
• End at terminal bronchioles
• Contains
• Cartilage tissue
• Smooth muscle
• Secretory glands
Functional review of Lower airway
• Air passage
• Humidifying
• Filtering
• Protective reflex
• Cough
Total Upper Airway Obstruction
• Total Airway Obstruction
• Fatal
• Sudden cyanotic
• Restlessness, Agitated
• Rapid deterioration
• Strangulated
• Most common cause
• Foreign body (toys, food)
• Treat with
• Heimlich Maneuver
• Chest thrust
Partial Upper Airway Obstruction
• Usually non fatal, if recognized early
• Caused by:
• Fluid
• Foreign body
• Mass
• Treatment
• Open airway
• Maintain airway patency
Gurgling Fluid
Snoring Fall tongue
Upper
Mass
Stridor
Partial Foreign
body
Wheezing constriction
Lower
Rhonchi fluid
Open Airway
• Head Tilt and Chin Lift
• Jaw Thrust
• Trauma:
• Cervical collar
• Modified Jaw Thrust
• Fluid:
• Suctioning
• Leaning side
Cervical collar
• Airway Management step in Trauma
• Indication:
• Unconscious trauma victim
• Wound above clavicular
• High force MOI
• Unclear or not save cervical clearance
• Only for conscious victim
Cervical Clearance
1. Is there PAIN at the cervical
2. Pain when PALPATE
3. Pain when MOVED RIGHT or LEFT by 45
4. Pain when LOOKED UP and DOWN
IF there any YES answer, Attach Cervical Collar!!!
Maintain Airway Patency
• Simple Basic
• Oropharyngeal Tube
• Nasopharyngeal Tube
• Definitive Airway
• Orotracheal Tube
• Nasotracheal Tube
• Difficult Airway
• Jet Insufflation
• LMA
• Cricothyroidostomy
OROPHARYNGEAL AIRWAY
Oral Airway
• Indicated for unconscious ptx ( GCS <8).
Attachment technique:
• Direct methods/ Tounge Blade Methods
• Indirect methods / Up Sliding methods
Measurement
• Choose the size
• From the lip corner to
Tragus ipsilaterally
Indirect methods
NASOPHARINGEAL AIRWAY
• Size : 12F - 36F
• Complication :
• epistaksis
• aspirasi
• hipoksia
Orotracheal airway
Blind Nasotracheal Intubation
Laringeal Mask Airway
(LMA)
LMA Pro seal Fast
track
Lighted stylet Fiber
Optic
BREATHING
Definition
• A Process of moving air into and out of lung to facilitate gas exchange
• Diffusion process
• Bringing O2 into blood flow
• Flushing out CO2 from blood flow
Anatomical review of Breathing
• Controlled
• Pons
• Medulla Oblongata
• Sensor
• Central
• CO2
• O2
• Peripheral
• CO2
• pH
• Innervation
• Phrenic (XI branch)
• Diaphragm
• Spinothoracal
• Intercostal
Normal Breathing
What organ involved?
• Brain
• Controlling
• Central Sensor
• Vascular
• Peripheral Sensor
• Thoracic Wall
• Diaphragm
• Lung Parenchymal
Diffusion
• Equaling the pressure
• O2 blood vs O2 alveoli
• CO2 blood vs CO2
alveoli
Physiologic Breathing Parameters
• Volume and Rate
• Tidal Volume (6 – 8 cc/kg BW)
• Minute Volume (Tidal Volume x
Rate)
• Pattern
• Breathing effort
• Excursion
• Chest wall expanding
• Breathing sound
Cause of Breathing Disruption
• Control
• CVA and Herniation
• Sensor
• Acidosis
• CVA and Herniation
• Thoracic Wall
• Trauma
• Rib fractures
• Diaphragm
• Neural disruption
• Abdominal distension
• Lung Parenchymal
• Trauma
• Atelectasis
• ALO
• Etc.
Rescue Breathing in Apnea Victim
• Make sure the heart is beating
• Give 10 ventilation in a minute
• Counting
• One-n-a-thousand, two-n-a-thousand, three-n-a-thousand, four-n-a-thousand, five-n-a-
thousand, six-n-a-thousand
• Blow 600 cc of air
• Maximum exhalation for mouth to mouth
• Give 1/3 adult bag BVM volume
• Evaluate every minute
• Breathing effort
• Pulse
Supplemental O2
Spontaneous breathing
• Nasal cannula
• 1-6 liter/min
• Rebreathing Mask
• 6-15 liter/min
• Non Rebreathing Mask (with reservior)
• 6-15 liter/min
Non spontaneous breathing
• Bag-Valve-Mask
• 10 liter/min, full controlled breathing
• Jackson Rees
• Depending on breathing effort
• Full controlled and assisting
Mechanical Ventilation
Full controlled: Intermitten:
1. Pressure controlled Synchronized
2. Volume controlled Add necessary breathing rate
CMV SIMV
ASB CPAP non-invasive ventilation,
Spontaneous Breathing, inadequate:
Open alveolus with measured PEEP
Pressure support only
CIRCULATION
Haemoglobin
Blood Extravascular
fluid
and Fluid
Contraction
Pumping Blood and
Heart Vascular
Volume Dilatation
Rhythm
Circulation
Mean
Pulse
Arterial
Pressure
Pressure
Frank
Starling
Rule
SV determined by:
HR x SV
Preload
Contractility
Afterload
Starling's law of the heart
• Contraction energy from myocardium equal with it’s size
Circulatory Failure
Volume Lack of Fluid Adequate fluids or
Related Volume Blood products
Circulatory
Failure PUMPING FAILURE
caused by failed
Intravascular Abnormal Pumping myocardial
IMBALANCE Distribution Failure contraction or
DISTRIBUTION
Rhythm
disturbance
Solve the
Inotropes or
mechanical
antarrythmias
causes
Clinical evaluation
• Level of Consciousness
• Acral or extremity temperature
• Absence of extreme tachycardia
• Absence of extreme hypotension
• Urine Production
• Arterial Oxygen saturation
• Lactate level
• pH of gastric mucosa
Management of Circulation Failure
• Fluids
• Inotropes
• Vasoconstrictors
• Vasodilators
New Approach in Fluid Therapy
Drug.
Consider:
Osmolality
Tonicity
pH
electrolyte composition (chloride, sodium, potassium, etc)
metabolic active compound (lactate, acetate, malate,dll)
Clinical factors (disease, cardiac, renal and liver function, acid
base disorder, etc)
New Approach in Fluid Therapy: 4Ds
Drugs Dosing
De-
Duration
escalation
Osmolality
Tonicity
pH
Drugs,
consider
electrolyte composition
• Natrium, Potassium, Chloride
Active Metabolic compounds
• Lactate, Acetate, Malate
Clinical factors
• Disease, Cardiac renal liver fx, Acid base disorders
Dose
Frank Starling vs Marik -
Phillips
Duration
EA: Early Adequate; EC: Early Consercative; LC: Late Concervative; LL: Late Liberal
Maintain fluid
volume
De-escalating
Eliminate
unnecessary
volume
Terima Kasih
