Hospital Palembang: Silvia Triratna Pediatric Critical Care Division Dept of Child Health RSUP Mohammad Husin

Silvia Triratna
Pediatric Critical Care division Dept of Child Health

RSUP Mohammad Husin Hospital Palembang
Copyright 2007 Seattle/King County EMS
2

Bayi dalam keadaan terbaring, tonus otot
lemah. Bila disentuh dan didekati gelisah,
suara tangisnya lemah. Tidak ada suara
nafas abnormal, tidak ada retraksi dan
nafas cuping hidung Tampak pucat dan
mottled.
Seorang ibu membawa anaknya usia 6
bulan ke IRD RSMH, keluhan muntah
> 10 kali sejak 1 hari sebelumnya
3
Laju nafas 30 kali /min, HR 180 kali / min,
dan TD 50 mm Hg / palp.
Gerakan aliran udara normal, pada
auskultasi suara nafas jelas, bersih.
Kulit terasa dingin, capillary refiil Time 4
detik. Denyut nadi brakialis lemah.
Abdomen meteorismus

4
What are the key
signs of illness in
this infant?

The first stage of which is quick
screening (triage) to identify

those who need emergency treatment
those who are at special risk and should be
given priority
Or.... those who are non-urgent cases
9
Not SICK
SICK

Stable
potential unstable.
UnStable
Level 1 Resuscitative
Level 2 Emergent
Level 3 Urgent
Level 4 Less urgent
Level 5 Non-urgent

Pearl of wisdom:
If patients look sick and you
are not sure,
triage them as Level I or II

11
Neurology Emergency
Respiratory emergency
Circulatory Emergency

12
PEMERIKSAAN
SULIT DILAKUKAN
KOMINIKASI SULIT
CENDRUNG KETAKUTAN
PENILAIAN KEGAWATAN
SULIT DILAKUKAN
You must recognize the SICK child within the
first minute of contact.
Much of the information you need to make a
decision can be obtained without touching
the patient.
dilema
Harus mampu meengenal
anak dalam keadaan sakit
pada menit pertama kontak
informasi harus dapat
diperoleh agar dapat membuat
keputusan Tanpa menyentuh
pasien
15
Penilaian Umum (General assessment )
Penilaian awal ( Initial assessment )
Bantuan Hidup Dasar
Penilaian Keparahan penyakit
Penilaian sekunder (ananmnesa,
pemeriksaan fisik lengkap, pulse
oksimetri, prosedur2
Intervensi lanjutan
Penilaian Ulang
Transport / Rujuk
Dokumentasi

17
MENENTUKAN
ANAK SAKIT GAWAT
PAT
MELIHAT KEADAAN ANAK
GENERAL ASSESSMENT

PENILAIAN ABCDE
INITIAL ASSESSMENT
18
19
Tiga elemen guna menentukan
sakit atau tidak sakit. Gawat atau
tidak
Pediatric Assessment Triangle
There are three elements that you need to
assess in a pediatric patient in order to
determine SICK or NOT SICK:
Appearance
Work of breathing
Circulation to the skin
These three clinical indicators reflect the
overall status of a childs cardiovascular,
respiratory and neurologic systems.
Normal
Appearance
Increased
Work of Breathing
MEANS RESPIRATORY DISTRESS
Normal Circulation
MEANS RESPIRATORY FAILURE
Normal circulation
Poor Circulation to Skin

MEANS SHOCK
Normal

MEANS CNS or Metabolic
Normal

Poor Circulation to Skin

MEANS OBSERVE
After completing the Triangle, begin a more
complete
pediatric primary survey.
AIRWAY
BREATHING
CIRCULATION
DISABILITY
29
circulation
Skin Signs
Feel for
temperature
and moisture.

Estimate
capillary refill.
FREKUENSI JANTUNG
TEKANAN SISTOLIK MINIMAL
70 + { 2 x umur (tahun) }
USIA FREKUENSI
< 3 bulan 85 - 200
3 bln 2 thn 100 - 190
3 10 tahun 60 -140
Normal Bood Pressure for
children
Age Systolic BP
0 28 day FT > 60
1 12 mo > 70
1 10 y 70 + 2 x age in y
> 10 y > 90
35
Pulse
In infants, feel over the brachial or femoral area.
In older children, use the carotid artery.

Count for at least 1 minute.
Note strength of the pulse.
STATUS NEUROLOGIK
A
ALERT
V
RESPONS TO VOICE
P
RESPONS TO PAIN
U
UN RESPONSIVE
A V P U
CARA CEPAT MENILAI KESADARAN
TINDAKAN LANJUT
MENERUSKAN RESUSITASI
PEMERIKSAAN /PEMANTAUAN
LEBIH LANJUT
MERUJUK
Respiratory Emergencies
Respiratory distress is a state where a child is
able to maintain adequate oxygenation of the
blood, but only by increasing his or her work
of breathing.

Respiratory failure occurs when a child
cannot compensate for inadequate
oxygenation and the circulatory and
respiratory systems begin to collapse.

Airway Obstruction
Croup
A viral infection of the airway below the level of
the vocal cords
Epiglottitis
Infection of the soft tissue in the area above the
vocal cords
Foreign body airway obstructions
Seizures
Seizures may be caused by:
Infection
Head trauma
Epilepsy
Electrolyte imbalance
Hypoglycemia
Toxic ingestion or exposure
Birth injury

Trauma
Use appearance, work of breathing and
circulation to the skin in your assessment.

Mechanism of injury may also play a
factor when deciding whether the child is
SICK or NOT SICK.
Drowning
The most important factors in drowning
are the duration and severity of hypoxia.

Restoring the ABCs is vital.

Hypothermia can occur in cold water
settings.
Burns
Check for possible involvement of the
airway.

Make a quick estimate of the burned
body surface area.

Take care to avoid further contamination
of burn injuries by wearing gloves and
carefully dressing the wounds.
47
For the purpose of resuscitation,
children are divided -somewhat
arbitrarily- into 3 age groups:

Infants: under one year of age
Small children: 1 to 8 years of age
Older children/adults: 9 years and over
Basic Life Support
Slide 49
S A F E approach
Shout for help
Aprroach with care
Free from danger
Evaluate ABC
Basic Life Support
Check for DANGER, stop and look
Check RESPONSE, verbal and tactile but
do not shake and shout
If conscious, assess carefully, patient may
still need urgent medical review

Continue to assess and manage
Airway
Breathing
Circulation

Slide 52
D
R
A
B
C
Slide 53
Basic Life Support Flowchart
Check for DANGER
Check for RESPONSE
CONSCIOUS
Make comfortable
Observe ABC
UNCONSCIOUS
Alert assistance
Clear airway
Apply head tilt and jaw support
Check for breathing
NOT BREATHING
2 rescue breaths
Check for pulse
Look for signs of life
BREATHING
Lateral position
Observe ABC
INADEQUATE PULSE
No signs of life
Commence CPR
Is The patient
able to
speak or cry ?

Airway Assessment
Slide 56
Observe for secretions and clear (suction)
Do not attempt a blind finger sweep
Open the airway
chin lift / jaw thrust
neutral position in infants
sniffing position in children

Slide 61
Airway Opening Manoeuvres
Chin lift/head tilt
Infants
Neutral head position
with chin lift
Smaller children
Sniffing position
with chin lift
Slide 62
Chin lift/head tilt

Older children/adults
Backward head tilt
with pistol grip
Slide 65
Jaw thrust
Jaw thrust
Use when concerned re
cervical spine injury
May also facilitate
bag and mask
ventilation
Slide 67
Foreign Body
Mild airway
obstruction
Effective Cough
Assess Severity
Severe airway
obstruction
Ineffective Cough
Unconscious
Call for
help
Commence
CPR
Conscious
Call for help
Give up to 5 back
blows
If not effective
Give up to 5 chest
thrusts
Encourage
coughing
Continue to check
victim until recovery
or deterioration
Call for help
Slide 68
Foreign Body
If there is an effective cough (mild
obstruction):
Encourage coughing
Continue to check victim until recovery or
deterioration
Call for help
Do not attempt any manoeuvres to remove
unless this is very easily done

Slide 69
Foreign Body
If there is an ineffective cough (severe
obstruction):
Unconscious
call for help, commence CPR
Conscious
call for help
give up to 5 back blows firm blows
between the shoulder blades using the heel
of the hand
Slide 70
Back blows infant

Back blows small child
Slide 71
Chest thrusts infant
Chest thrusts small child
Hand
position is
lower half
of the
sternum
Slide 72
Foreign Body
If 5 back blows unsuccessful:

Chest thrusts
identify same compression point as for CPR
give up to 5 chest thrusts
similar to compressions but sharper and delivered at a
slower rate
check to see if each thrust has relieved the airway
obstruction

Infant
place in a head down supine position across rescuers thigh

Child/ older child / adult
may be placed in sitting or standing position
Note: this is not the same as a Heimlich
manouvere this manouvere is on the chest
Airway Adjuncts
Slide 74
Oropharyngeal Airways

Use: to keep the airway open in an unconscious patient
and to facilitate bag and mask ventilation
Use with caution

If airway is able to
be maintained with
head positioning and
jaw support
dont use an
oropharyngeal airway

Slide 75

Use: to keep the airway open in an unconscious patient
and to facilitate bag and mask ventilation
Use of oropharyngeal airways:

size is imperative
measure from centre of
teeth/mouth to angle of
the jaw layed across the
face
In the infant and small
child insert the concave
side over the tongue
under direct vision. This
avoids damage to the
palate

Slide 76

Potential problems:
Trauma
Obstruction
Illicit a gag reflex
causing aspiration
Laryngospasm
Vagal response
Nasopharyngeal Airway
Evaluation of
Respiratory
Performance
Slide 86
Look, Listen & Feel
10 seconds
Breathing assessment
Respiratory Rate and
Regularity
Level of Consciousness
Color of the Skin and Mucous
Membranes
Respiratory Mechanics

The Need for Oxygen
0 1 minute: cardiac irritability
0 4 minutes: brain damage not likely
4 6 minutes: brain damage possible
6 10 minutes: brain damage very likely
> 10 minutes: irreversible brain damage

Initial assesment of the sick
child
Breathing
No
efective
breathin
g
Airway
Maintain
able
Un
maintain
able
Bag
mask
ventil
ation
NIPP
V
Intub
ation
s
oxyge
n
Airway
adjunc
t
Simple mask
partial rebreathing mask
low flow
nasal cannula.
simple oxygen mask.
high flow:

nonrebreathing masks.
Venturi masks.
oxygen hoods
oxygen tents.
aspirationfsh.swf
Slide 99
Breathing
If breathing is absent or inadequate:
Give 2 rescue breaths allowing about 1
second per inspiration
Sufficient breath to achieve gentle rise
and fall of chest, this means
puffs for an infant
breaths for a child
full breaths for an older
child/adult
Slide 100
Bag and Mask
Correct mask size: cover mouth and nose only
Holding the mask: C-grip
C
Slide 101
Bag and Mask
a few technicalities...
Mask size
Bridge of nose to cleft of chin and sufficiently wide to cover
mouth
If too big you may get an air leak and also potential damage
especially with pressure applied to the eyes
Self inflating bag
Connect to oxygen 10L/Min
Once reservoir bag full, delivering 95-100% oxygen
Pressure release valve prevents too high pressure
Self-inflating, so can be used to deliver room air
Slide 102
Self Inflating Bag Sizes

Child (500ml) 2.5 25kg

Preterm
Infant
(240ml)
<2.5kg
Adult
(1600ml)
>25kg
Slide 103
Checking Self Inflating Bags
Check that the self inflating bag compresses and
reinflates quickly and air is felt from patient outlet
Check the one way valve opens when self inflating
bag is compressed
Occlude patient outlet with hand and compress bag,
listen for the pressure release value to release
Take off oxygen reservoir bag and place over the
patient outlet. Inflate the reservoir bag checking for
holes
Bag mask ventilation

Bag to Mask Ventilation
Slide 107
Cricoid pressure:
Place two fingers on the level of the cricoid cartilage and apply
pressure (gently!)
Closes the oesophagus and straightens trachea
Dont release pressure until instructed or if the
patient actively vomits
Monitor the Effectiveness of
Ventilation
Monitor the Effectiveness of
Ventilation
Visible chest rise with each breath.
Oxygen saturation.
Heart rate.
Blood pressure.
Distal air entry.
Patient response.
Copyright 2000 American Heart Association
Circulation 2000;102:253I--290I-
Bag-mask
ventilation
for child
victim
Contraindicated if
gag-reflex is intact

Higher success rate

Does NOT protect
from aspiration

Difficult to maintain
during transport
Slide 119
Basic Life Support
Airway

Breathing

Circulation
Color of skin and capillary
refill
Strength of peripheral
and central pulses
Skin temperature
Obtain vascular access
(set IV lines)
Initiate volume
replacement
Perform chest
compressions
Defibrillate or provide
synchronized cardioversion
Initiate drug therapy
PULSE Check
Take no more than 10
seconds
Cardiac output in infancy and childhood largely
depends on heart rate.
No scientific data has identified an absolute heart
rate at which chest compressions should be
initiated;
the recommendation to provide cardiac
compression for a heart rate <60 bpm with
signs of poor perfusion
Slide 126
Pulse Check
the smallprint
Do not check for longer than 10 seconds
If the patient shows no sign of life and a pulse
cannot be palpated in 10 seconds presume it to
be absent!

Brachial is recommended in the infant as carotid pulse is
difficult to find and extension of the neck may compromise
the airway
Carotid pulse locate thyroid cartilage and feel to side, dont
feel too high due to the risk of inadvertently massaging the
carotid sinus, inducing bradycardia and hypotension

Locating and palpating carotid artery pulse
( > 1 year)
Locating and palpating brachial pulse
( < 1 year)
127
Slide 128
Look for signs of life

No signs of life =
unconscious
unresponsive
not moving
not breathing normally
No signs of life commence external cardiac
compressions

Slide 131
Circulation
Assess for pulse and
signs of life

If no pulse,
inadequate pulse or no
signs of life

commence ECC
CPR of the pediatric patient
132
PIJAT JANTUNG LUAR
If no pulse palpated,
begin
chest compression
134
Slide 135

Patient should be on a hard
surface eg. cardiac board
Rhythmic action, equal time for
compression and relaxation
Aim for a rate of 100
compressions per minute
Slide 136
CPR Ratio
CIRCULATION
Hand Position
Depth of
Compression
INFANT
1/3 depth of chest
OLDER
CHILD

30 compressions: 2 breaths
5 cycles / 2 min

SMALL
CHILD
Lower half of sternum
Ratio and Rate
1 rescuer
The ratio describes the number of
compressions in relation to breaths,
the rate is the number of
compressions/breaths given per
minute.
Ratio and Rate
2 rescuers
15: 2
5 cycles/min
30: 2
5 cycles/2 min
Slide 137
CPR Infant
Infant
Locate the lower half of the sternum
Two fingers one operator CPR
Two thumbs / two fingers if two operators
Ratio
Lone health care provider/ lay rescuer
30 compressions : 2 breaths (5 cycles per 2 minute)
Two health care providers
15 compressions : 2 breaths (5 cycles per 1
minute)
Aim for a rate of 100 compressions per
minute
Slide 138
CPR Infant
Finger/Thumb
position:
lower 1/2 of the sternum

Compression depth:
1/3 of the depth of the chest
Slide 139
CPR Ratio
CIRCULATION
Hand Position
Depth of
Compression
INFANT
1/3 depth of chest
OLDER
CHILD

5 cycles / 2 min

SMALL
CHILD
Ratio and Rate
1 rescuer
Ratio and Rate
2 rescuers
15: 2
5 cycles/min
30: 2
5 cycles/2 min
Slide 140
CPR Small Child
Child: Up to 8 years
Use the heel of one hand
Locate lower half of sternum
Ratio
Lone health care provider/ lay rescuer
Two health care providers
Aim for a rate of 100 compressions per minute

Slide 141
CPR Ratio
CIRCULATION
Hand Position
Depth of
Compression
INFANT
1/3 depth of chest
OLDER
CHILD

5 cycles / 2 min

SMALL
CHILD
Ratio and Rate
1 rescuer
Ratio and Rate
2 rescuers
15: 2
5 cycles/min
30: 2
5 cycles/2 min
Slide 142
CPR Older Child/Adult
Older child/adult i.e.>9years
Use two hands
Locate lower half of sternum
Ratio:
Lone health care provider/ lay rescuer or
two health care providers
30 compressions : 2 breaths (5 cycles per 2
minute)
Aim for a rate of 100 compressions per minute
Pressure is exerted through the heel of the hand,
with arm/s straight, using body weight as the
compression force
Slide 143
CPR
(Small and older child)
Compression depth: 1/3 of chest
CPR older child/ adult
1/3
CPR small child
Slide 144
CPR
ARC recommend minimum interruptions of
ECC and CPR should not be interrupted to
check for signs of life
Ineffective CPR:
too gentle
too slow
incorrect hand position
too many interruptions
Locating finger position for chest compressions in
infant (< 1 year)
Imagine a line drawn between the nipples
Place 2 fingers on sternum 1 fingers width below line.
Depress - 1 in.
At least 100 per min
1 breath to every 5 compressions
145
Locating hand position for chest compressions in
child (> 1 year)
Use 2-3 fingers to locate lower margin of rib cage.
Follow rib margin to base of sternum (xiphoid process)
Over 8 yr
Place other hand on top of hand on sternum
Depress 1 - 2 in
80-100 per min
2 breaths to every 15 compressions
146
1 ~ 8 yr
Use heel of one hand
Depress 1 1 in
100 per min
One-rescuer
1 breath to every 5 compressions
Two-rescuer
2 breaths to every 15 compressions
147
Brachial pulse check in infant
Carotid pulse check in child
One-hand chest compression
technique in child
After each compression
allow the chest to recoil
fully
because complete chest
reexpansion improves
blood flow into the heart
Slide 159
Can you identify 10 Things
wrong with this resus?
Slide 160
1. Incorrect
size bag &
mask

Slide 161
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique

Slide 162
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique
3. No cardiac
board
Slide 163
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique
3. No cardiac
board
4. Chair in way
Slide 164
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique
3. No cardiac
board
4. Chair in way
5. Monitor not
on or
connected
Slide 165
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique
3. No cardiac
board
4. Chair in way
5. Monitor not
on or
connected
6. Incorrect
pad
placement

Slide 166
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique
3. No cardiac
board
4. Chair in way
5. Monitor not
on or
connected
6. Incorrect
pad
placement
7. Incorrect
hand
placement

Slide 167
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique
3. No cardiac
board
4. Chair in way
5. Monitor not
on or
connected
6. Incorrect
pad
placement
7. Incorrect
hand
placement
8. No scribe

Slide 168
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique
3. No cardiac
board
4. Chair in way
5. Monitor not
on or
connected
6. Incorrect
pad
placement
7. Incorrect
hand
placement
8. No scribe
9. No drugs
prepared

?
Slide 169
1. Incorrect
size bag &
mask
2. Incorrect
mask & bag
technique
3. No cardiac
board
4. Chair in way
5. Monitor not
on or
connected
6. Incorrect
pad
placement
7. Incorrect
hand
placement
8. No scribe
9. No drugs
prepared
10.No oxygen
tubing

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