ADULT CARDIOPULMONARY

RESUSCITATION

INDRIANTO, dr.,SpAn.KIC
Bagian Anestesiologi & Reanimasi
RSUD AL IHSAN BANDUNG

 CLINICAL

DEATH

a
patient is clinically dead the
moment breathing stops and
the heart stops beating.
BIOLOGICAL DEATH if a
patient is not breathing and
the heart is not circulating
oxygenated blood, potentially
lethal changes begin to take
place in the brain within 4 to
6 minutes. Biological death
occurs when the patient's
brain cells die. Usually, brain
cell death begins within 10
minutes after the heart stops
beating (this can be delayed
by cold temperatures, see p.
489). You may be able to

Respiratory System Anatomy

The major structures of the airway include:

NOSE the primary pathway for air to enter and leave
the system.
MOUTH the secondary pathway for air.
PHARYNX the throat. The common passageway for
air and food.
LARYNX the neck structure that connects the
pharynx and the trachea.
TRACHEA the windpipe.
BRONCHIAL TREE branching from the trachea to the
microscopic air sacs of the lungs. The first branches are
the right and left main stem (primary) bronchi. These
branch into secondary bronchi. The smaller branches
coming off the secondary bronchi are called the
bronchioles
LUNGS the spongy, elastic organs containing alveoli,
the microscopic air sacs where oxygen and carbon

Respiratory Function
automatic function
Involuntary
automatically adjust the
rate, depth, and rhythm of
breathing
intercostal muscles
inspiration
expiration

Collapse

Basic life
support of
the collaps
victim

Remove from immediate

danger (burning building,
etc.)
Check for
responsiveness
Call for help

a finger
sweep of
the
mouth
and jaw
lift

Clear

Airway
Yes

Assess breathing

Coma position check

pulse, BP, review
breathing

Open
No

Provide breathing
(EAR) 2 slow
breaths

slow
inspiratory
time and
low inflation
pressure

Assess circulation
Pulse
Present

Continue EAR
regularly assess pulse

Pulse
absent

Provide ECC at
100/min
Continue at 15:2
ECC:EAR Monitor
effectiveness

RESPIRATORY
FAILURE

Simply stated, respiratory

failure is either the cessation
of normal breathing or the
reduction of breathing to the
point where oxygen intake is
not sufficient to support life.
When breathing stops
completely, the patient is in
respiratory arrest.
Respiratory arrest can
develop during heart attack,
stroke, airway obstruction,
drowning, electrocution, drug
overdose, poisoning, brain
injury, severe chest injury,
suffocation, and prolonged
respiratory failure.

DIAGNOSTIC
SIGNS

To determine the Signs of

normal breathing, you should:
LOOK for the even (bilateral)
rise and fall of the chest
associated with breathing.
LISTEN for air entering and
leaving the nose or mouth.
The sounds should be typical,
free of gurgling, gasping,
crowing, and wheezing.
FEEL for air moving out of the
nose or mouth.
CHECK for typical skin
coloration. There should be no
blue or gray colorations.
NOTE that the rate and depth
of breathing should be typical
for a person at rest

Signs of Partial Airway

Obstruction
Unusual breathing sounds. Listen for:
Snoringprobably caused by the tongue obstructing
the pharynx. Gurglingoften due to a foreign object
or blood and other fluids in the trachea. Crowing
probably caused by spasms in the larynx.
Wheezingthis may not indicate any major
problems along the airway. However, wheezing
should not be treated lightly since it may be due to
serious edema or spasms along the airway.
Skin discoloration. The patient is breathing, but
there is a noticeable blue or blue-gray color to the
skin, lips, tongue, fingernail beds, or ear lobes. This
is recorded as cyanosis, and the patient is said to be
cyanotic.

PULMONARY
RESUSCITATION
Opening the Airway
Head-Tilt Maneuver

Head-Tilt, Chin-Lift
Maneuver

Jaw-Thrust Maneuver

SIGNS OF INADEQUATE
BREATHING
Chest movements are absent, minimal, or uneven.
Movements associated with breathing are limited to the abdomen
(abdominal breathing).
The use of neck muscles during respirations.
No air can be felt or heard at the nose or mouth, or exchange is
evaluated as below normal.
Breathing is noisy.
The breathing rate is too rapid or too slow
Breathing is very shallow or very deep and
labored.
The patient's skin is blue or gray. This is called cyanosis.
Inspirations are prolonged (possible upper airway obstruction) or
expirations are prolonged (possible lower airway obstruction).
The patient is unable to speak or cannot speak in a normal fashion

RESCUE BREATHING

Mouth-to-Mouth
Ventilation
Primarily, this procedure is used when the
patient is in respiratory arrest, that is, when
he is no longer breathing. The procedure may
be used when a patient's respiratory rate or
depth is not sufficient to sustain life
IMPORTANT:
For
artificial
respirations
provided to the adult patient, you must deliver
breaths to the patient at one every 5
seconds to give a rate of 12 breaths per
minute. To help establish this rate, count,
"One, one thousand; two, one thousand; three,
one thousand; four, one thousand; five, one
thousand.

adequately ventilating

the

patient if you:
SEE the chest rise and fall.
HEAR and FEEL air leaving the patient's lungs.
FEEL resistance to your ventilations as the
patient's lungs expand.

Airway Management
Techniques
NON-INVASIVE TECHNIQUES
BAG MASK VENTILATION
ORO- AND NASOPHARYNGEAL
AIRWAYS
LARYNGEAL MASK AIRWAY (LMA)

THE DIFFICULT AIRWAY

ASSISTANCE AND ENVIRONMENT
ANTICIPATING AND GRADING A DIFFICULT AIRWAY
Intubation difficulty can be anticipated or predicted by the
following (although the sensitivity and specificity, of individual
features and classifications tends to be low):
1. Anatomical or pathological features of difficult intubation in
subjects who otherwise appear normal:
short neck, especially if obese or muscular (thyro-mental
distance <6 cm)
limited neck and jaw movements (e.g. as a result of
trismus, osteoarthritis, ankylosing spondylitis, rheumatoid
arthritis or perioral scarring)
protruding teeth, small mouth, long high curved palate, or
receding lower jaw
space-occupying lesions of the oropharynx and larynx
congenital conditions with any of the above features (e.g.
Marfan's syndrome).

2. Mallampatti classification of visualizing the

oropharyngeal structures
(a co-operative sitting patient is required for this
assessment):
a)
b)
c)
d)

Class
Class
Class
Class

1:
2:
3:
4:

visible soft palate, uvula, fauces and pillars

visible soft palate, uvula and fauces
visible soft palate and base of uvula
soft palate is not visible

3. The degree of difficult)' experienced visualizing the larynx

by direct laryngoscopy should be recorded and is
commonly graded by the classification of Cormack and
Lehane:
a) Grade I: complete glottis is visible
b) Grade II; anterior glottis is not visible
c) Grade III: epiglottis but not glottis is visible

UPPER AIRWAY OBSTRUCTION

Clinical conditions associated with
acute upper airway obstruction
Functional causes
Central nervous system
depression
Head injury, cerebrovascular
accident, cardiorespiratory
arrest, siiock, hypoxia, drug
overdose, metabolic
encephalopathies
Peripheral nervous system and
neuromuscular abnormalities
Recurrent laryngeal nerve palsy
(postoperative, inflammatory or
tumour infiltration), obstructive
sleep apnoea, laryngospasm,
myasthenia gravis, GuillainBarre polyneuritis,
hypocatcaemic vocal cord
spasm
Mechanical causes
Foreign body aspiration

Laryngeal oedema
Allergic laryngeal oedema,
angiotensin converting enzyme
inhibitor associated, hereditary
angioedema, acquired CI esterase
deficiency
Haemorrhage and haematoma
Postoperative, anticoagulation
therapy, inherited or acquired
coagulation factor deficiency ,
Trauma
Burns
Inhalational thermal injury,
inger.tion of toxic chemical and
caustic agents
Neoplasm
Pharyngeal, laryngeal and
tracheobronchial carcinoma, vocal
cord polyposis
Congenital
Vascular rings, laryngeal webs,
laryngocele

INVASIVE TECHNIQUES

Endotracheal Intubation
Direct Laryngoscopy
Stylet Guide (Introducer)
Fibreoptic Bronchoscopic Intubation
Blind Nasal Intubation
Cricothyroidotomy
Tracheostomy

Indikasi Manajemen Jalan Napas

Tujuan manajemen jalan napas adalah patensi dan
proteksi dengan memasang ETT dalam trakea dengan
mengembangkan cuff dan dihubungkan dengan sumber
O2. Tindakan intubasi sering kali menyebabkan
komplikasi dan tergantung dari berbagai faktor. Ada 5
alasan mengapa pasien membutuhkan jalan napas :
Gagal ventilasi atau oksigenasi
Ketidakmampuan mempertahankan atau melindungi
jalan napas
Timbulnya gangguan yang disebabkan oleh penyakit
pasien
Delivery of treatment
Keamanan dan perlindungan pasien (patient safety
and protection)

Manajemen jalan napas

Immediate "crash" intubation
Pasien dengan henti napas yang membutuhkan intubasi segera tanpa
medikasi tambahan. Keuntungan tindakan ini secara teknik mudah dan
cepat. Kerugiannya dapat meningkatkan tekanan intrakranial akibat stres
intubasi, muntah dan aspirasi.
Rapid sequence intubation
Rapid sequence intubation (RSI) adalah serangkaian langkah tindakan
intubasi tanpa ventilasi BVM. Sebagian besar pasien yang dilakukan
intubasi darurat tidak dalam keadaan puasa dan dengan lambung terisi,
sehingga pemakaian BVM mungkin dapat menyebabkan distensi abdomen
dan meningkatkan risiko aspirasi. Untuk mencegah komplikasi pertama
kali dilakukan pemberian O2 100% agar O2 terpenuhi selama periode
apnea. Selanjutnya dilakukan induksi dan pemberian pelumpuh otot kerja
cepat agar pasien tidak sadar dan paralisis. Lalu pasien diintubasi tanpa
bantuan ventilasi BVM. Agar lebih mudah diingat, langkah-langkah RSI
disingkat dengan 9P

9 langkah P Rapid sequence

intubation
Time

Action

0 10 minutes

Possibility of success

0 10 minutes

Preparation

0 5 minutes

Pre-oxygenation

0 3 minutes

Pre-treatment

Time zero

Paralysis (with induction)

0 + 20 30
seconds
0 + 45 seconds

Protection and positioning

0 + 45 seconds

Proof

0 + 1 minute

Post-intubation management

Placement

Primary Survey
1

REPOSITIONING

The Techniques of CPR

ESTABLISH UNRESPONSIVENESSIs
the patient responsive? Gently shake the pa
tient's shoulder and shout, "ARE YOU
OKAY?" Patients requiring immediate CPR
will be unresponsive.
NOTE: If you are working by yourself, call out for help if the patient is
unresponsive.
REPOSITION THE PATIENT (see Chapter 4), if necessary.
ESTABLISH AN OPEN AIRWAYThis should be done by the head-tilt, chinlift, or jaw-thrust maneuvers. Usually at this time, you can easily check to
see if the patient is a neck breather.
CHECK FOR BREATHINGUse the LOOK, LISTEN, and FEEL method, taking
3 to 5 seconds to determine if the patient is breathing. A patient who is
breathing does not need immediate CPR. If the patient is in respiratory
arrest, you should . . .
DELIVER TWO BREATHSUse rescue breathing techniques. Allow for
deflation between breaths. If you note an upper airway obstruction, begin
the techniques used to clear the airway. If the patient's airway is clear
and he is still in respiratory arrest after you have provided two
breaths . . .

The CPR
Compression Site

Compression and Ventilations

COMPRESSIONS = a rate of 80 to
100 per minute, providing 15
compressions every 9
to 11 seconds
VENTILATIONS = 2 breaths after
every 15
compressions, delivered at 1
ventilation
every 1 to 1.5 seconds.

ONE RESCUER CPR

Effective CPR
Pupils constrict.
Skin color improves.
Heartbeat returns
spontaneously.
Spontaneous, gasping
respirations.
Arms and legs move.
Attempts are made to
swallow.
Consciousness
returns.

Once you have Started CPR,

youy must continue to
provide CPR until:

Spontaneous circulation
occurs .. then provide
artificial respiration as
needed.
Spontaneous circulation
and breathing occur.
Another trained rescuer
can take over for you.
You turn care of the
patient over to a
physician or a medical
facility.
You are too exhausted
and cannot continue.

Complication of CPR

TWO RESCUER CPR

CPR SUMMARY

CPR Techniques
for Infants and
Children
Establish unresponsiveness.
Correctly position the patient.
Open the airway (head-tilt,
chin-lift, or jaw-thrust).
Establish respiratory arrest (3
to 5 seconds).
Provide artificial ventilations
and clear the airway, if
necessary.
Establish the lack of pulse in 5
to 10 seconds.
Provide external chest
compressions and interposed
ventilations.
Do frequent assessments of
pulse and breathing. This is to
be done after every ten cycles

BLEEDING
Arterial Bleedingthe loss of
blood from an artery. The blood
loss is often rapid and profuse,
as blood spurts from the
wound. Usually, the spurting
blood pulsates as the heart
beats. The color of the blood is
bright red.
Venous Bleedingthe loss of
blood from a vein. The blood
loss is a steady flow and can be
quite heavy. The color of the
blood is dark red, often
appearing to be dark maroon.
Capillary Bleedingthe loss of
blood from a capillary bed. The
flow is slow, often described as

EXTERNAL BLEEDING

Direct pressure
Elevation
Pressure points
Splinting
Inflatable splints (air
splints)
Pneumatic anti-shock
garments or pneu
matic counterpressure
devices, (see Section
Two)
Applying a tourniquet.
Blood pressure cuff
(used as a tourniquet)

When bleeding is MILD, you should

1.Apply pressure to the wound,
preferably with a sterile dressing
held against its surface. (A clean
handkerchief or cloth can be used
if a sterile dressing is not
immediately available.)
2.Pressure held firmly on the wound
for 10 to 30 minutes will usually
stop the bleeding. Your role is to
control the bleeding and limit
additional significant blood loss.
3.Once bleeding is controlled, secure
the dressing in place with
bandaging.
4.NEVER remove a dressing once it is
in place. To do so may restart
bleeding or cause additional injury
to the site. Apply another dressing
on top of the blood-soaked one and

If bleeding is
PROFUSE, you
should:
NOT waste time
trying to find a
dressing.
Place your
gloved hand
directly on the
wound and exert
firm pressure.
Keep appl3dng
steady, firm
pressure until the
bleeding is
controlled.
Once bleeding is
controlled, a

INTERNAL BLEEDING

Wounds that have

penetrated the skull '
Blood or bloody fluids in
the ears or nose
Vomiting or coughing up
blood (cofFee-ground or
frothy red in appearance)
Bruises on the neck
Bruises on the chest or the
signs
possible rib
Wounds that have penetrated the chest
orof
abdomen
Areas of bruised or swollen abdomenfracture
Abdominal tenderness, rigidity, or spasms (the patient may
guard the abdomen)
Blood in the urine
Rectal or vaginal bleeding
Bone fractures, especially the pelvis and the long bones of the
arm and thigh.

American College of Surgeons Advanced Trauma

Life Support (ATLS) classification of blood loss
based on initial patient presentation
Class 1

Class II

Class III

Class IV

Blood loss* (ml)

Blood loss (% blood
volume)
Pulse rate

Up to750

750-1500

1500-2000

>2000

Up to 15%

15%-30%

30%^0%

>40%

<100

100-120

120-140

>140

Blood pressure

Normal

Normal

Decreased

Decreased

Pulse pressure (mmHg)

Normal or
increased

Decreased

Decreased

Decreased

Respiratory rate

14-20

20-30

30^0

>35

Urine output (ml/h)

>30

20-30

5-15

Negligible

Central nervous
system/mental status

Slightly
anxious

Mildly
anxious

Anxious,
confused

Confused,
lethargic

Fluid replacement

crystalloid

crystalloid

Crystalloid and Crystalloid and

blood
blood

American College of Surgeons Advanced Trauma

Ufe Support (ATLS) responses to initial fluid
resuscitation
Rapid
response
Vital signs

Return to
normal

Estimated blood
Minimal
loss
(10%-20%)

Transient response
Transient improvement, recurrence of
decreased blood pressure and
increased heart

Minimal or
no
response
Remain
abnormal

Moderate and ongoing (20%-40%)

Severe
(>40%)

hteed for more

crystalloid

Low

High

High

Need for blood

Low

Moderate to high

Immediate

Blood
preparation

Type and
crossmatch

Type-specific

Emergency
blood release

Need for
operative
intervention

Possibly

Likely

Highly likely

Early presence
of surgeon

Yes

Yes

Yes

TERIMA
KASIH