General Emergency Life Support

Departemen Anestesiologi & Reanimasi

FK Unair- RSUD dr.Soetomo Surabaya

ADVANCE LIFE SUPPORT

Defibrilation Strategy and Algorithm
April Poerwanto Basoeki
Kun Arifi Abbas
Prananda Surya Airlangga
Eddy Rahardjo
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Terminology

• Basic Life Support =BLS

= Airway + Breathing + Circulation/ Chest Compression
• Advanced Life Support =ALS
= Drug (+fluid) + E C G + Defibrillation
• Post Resuscitation Care, ICU

• Cardio Pulmonary Resuscitation = CPR

• Cardio Pulmonary Cerebral Resuscitation = CPCR
= CPCR = RJPO (Bhs Indonesia)
= CPR = RJP = RKP = Resusitasi Kardio Pulmoner
= BLS + ALS + Post CA Care 2
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Tujuan Pembelajaran
T.I.U :
MAMPU MELAKUKAN RJPO - RESUSITASI JANTUNG PARU
DENGAN BENAR

T.I.K :
1. MAMPU MENDIAGNOSA OSBTRUKSI JALAN NAFAS
2. MAMPU MELAKUKAN PEMBEBASAN JALAN NAFAS
3. MAMPU MENDIAGNOSA GANGGUAN NAFAS – HENTI NAFAS
4. MAMPU MELAKUKAN NAFAS BUATAN TANPA ALAT DAN DG ALAT BLS
5. MAMPU MENDIAGNOSA HENTI JANTUNG
6. MAMPU MELAKUKAN PIJAT JANTUNG LUAR

7. MAMPU MEMBACA GAMBAR EKG PASIEN HENTI JANTUNG

8. MAMPU MELAKUKAN DEFIBRILASI PADA PASIEN HENTI JANTUNG ALS
9. MAMPU MEMBERIKAN OBAT 2 RESUSITASI JANTUNG PARU
DENGAN TEPAT. 3
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 Consensus Guidelines

The major contributor for ILCOR

Resuscitation Council of
Southern Africa (RCSA)

Inter American Heart Foundation

Resuscitation Council of ASIA
(IAHF) (RCA) 4
 Cardio Pulmonary Resuscitation
Chain of survival
1. Immediate recognition and activation
of the emergency response system
2. Early CPR with an emphasis on chest compressions
3. Rapid defibrillation,
4. Effective advanced life support and
5. Integrated post-cardiac arrest care.

1 2 3 4 5

ICU
April_Surabaya BLS ALS POST C.A CARE5
 Kapan pijat jantung harus segera dilakukan??

Bila mendadak tidak sadar dan tidak bernafas

atau
Mendadak tidak sadar, nafas ter-sengal2 (gasping)

Treatment Recommendation

It is reasonable that lay rescuers and healthcare professionals use the combination
of unresponsiveness and absent or abnormal breathing to identify cardiac arrest.
Palpation of the pulse as the sole indicator of the presence or absence of cardiac
arrest is unreliable.
Agonal gasps are common during cardiac arrest and should not be considered
normal breathing.
2010 ILCOR 6
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BLS 1 atau 2 penolong atau lebih  pijat dan tiup
Pijat jantung 30 x Saat pijat jantung,
disela dg nafas 2 x dst hitung dengan suara keras:
1-2-3-4-5.....dst
30:2

Dua penolong

Satu penolong April_Surabaya

Bila anda tidak mampu memberi tiupan napas maka pijat saja.
Pijat jantung sampai bantuan datang atau korban sudah mulai bergerak
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Libatkan AED bila ada fasilitas didekat tempat kejadian
The new technique Chest Compression
Kecepatan pijat 100-120x/m
Kedalaman 5-6 cm

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 Korban mendadak tidak sadar
 Check kesadaran
Berteriak Code Blue
minta bantuan

Check Nafas
Kepala ditengadahkan

korban tidak bernafas

Bila anda tidak mau atau atau nafas tersengal-sengal
tidak mampu memberikan
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tiupan nafas

Lakukan pijat jantung saja

sd bantuan medis datang Pijat jantung 30 X
disusul dengan
Kecepatan pijat 100-120x/m
Kedalaman 5-6 cm 2 x tiupan nafas 9
Components of high-quality CPR

• Ensuring chest compressions of adequate rate

• Ensuring chest compressions of adequate depth
• Allowing full chest recoil between compressions
• Minimizing interruptions in chest compressions
and
• Avoiding excessive ventilation

AHA 2015_AP Surabaya 27

10
Key Points in 2015 CPR GUIDELINES
Adult basic life support (BLS).

1. Bystanders should initiate compression-only CPR.

2. Compression rate should be 100–120 per minute
(updated from “at least” 100 per minute).
3. Compression depth should be 2–2.4 inches (5-6cm),
upper limit added.
4. Compression time should be maximized.

5. Feedback devices may be used to optimize

compression rate and depth.
6. Social media may be used to summon rescuers
to perform CPR.
Push hard and fast — but not too hard or too fast
BLS – Basic Life Support
REVIEW
• Pijat jantung 30 x disela
5-6 cm
dg tiupan nafas 2 x BLS

• Bila sudah di –intubasi ALS

atau sudah dipasang LMA
maka :
• Pijat jantung
• Kecepatan100-120x/m
• Nafas buatan 10x/ menit dan
antara pijat jantung dan nafas
tidak usah sinkron

• Pijat Jantung, sedalam 5-6 cm. Sedini mungkin libatkan

• Beri kesempatan dinding toraks defibrilator sblm 5 menit
untuk “re-coil”
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The principle of CPR

ROSC ( Recovery of
Spontaneous Circulation )

Diagnosis cepat
adanya
Cardiac Arrest

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 Cardiac Arrest Call for help
Code Blue
|
belum intubasi sinkronisasi 30:2 BLS
(pijat & tiup 30:2 atau pijat saja)
sudah intubasi pijat jantung 100-120 x pm
Pijat & tiup
tidak usah sinkron
nafas 10 x pm
|
segera ECG
siap DC-shock
shockable | un-shockable
ALS
Asystole / PEA
VF/VT (non-VF / VT)

DC shock CPR terus

a single shock 2 menit
1515
ED_AP_Surabaya
un – shockable
Asystole
EKC = Flat
Tidak ada gelombang

P-ulseless
E-lectrical
ROSC < 10% A-ctivity
( Recovery of
Spontaneous
Circulation ) E-lectro
M-echanical
D-issociation

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 1. Ventriculer Fibrilation - VF
shockable 2. Ventriculer tachycardia ( VT–pulseless )

1. Ventriculer Fibrilation - VF

Coarse Ventricular Fibrillation

Fine Ventricular Fibrillation

Hati2 : ini termasuk UNshockable
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Cardiac Arrest
Tidak sadar, tidak nafas
Segera pijat jantung
Monitor EKG, Siap Defibrilator

• VF / VT pulseless = ada gelombang khas

– shockable rhythm, harus segera DC-shock

• Asystole = ECG flat, tak ada gelombang

– UN-shockable
• PEA = EMD = ada gelombang mirip ECG
normal
– UN-shockable
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 Asystole - PEA - EMD
UN-SHOCKABLE
Intubation (LMA):
as soon as possible, Pijat 100-120x/m
without stop compression Nafas 10x/menit

Cardiac evaluasi
Arrest evaluasi evaluasi evaluasi
ASYST = asistol = asistol = asistol = asistol

2 menit 2 menit 2 menit 2 menit

CPR -1 CPR-2 CPR-3 CPR-4 CPR-5 CPR-6
30 : 2 Adrenalin-1 Adrenalin-2 Adrenalin-3

CALL FOR HELP

….CODE BLUE
Adrenaline: 1 mg, iv, Evaluasi CPR : tiap 2 menit
PASANG repeated every 3-5
MONITOR EKG minutes
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 VF/ pulseless-VT
Intubation (LMA): Pijat 100-120x/m SHOCKABLE
as soon as possible, Nafas 10x/menit
without stop compression
3’ 3’
adrenalin adrenalin
Cardiac Evaluasi Evaluasi Evaluasi Evaluasi
arrest VF / p-VT = VF / p-VT = VF / p-VT = VF /p-VT = VF / p-VT

2 menit 2 menit 2 menit 2 menit

a single shock-I a single shock-II a single shock-III - AMIODARON a single shock-V
- a single shock-IV
CPR -1 CPR-2 CPR-3 CPR-4 CPR-5 CPR-6
30 : 2

CALL FOR Adrenaline: 1 mg, iv, Amiodaron is the first choice 300 mg, bolus.
HELP Repeated 150 mg for reccurrent VT/VF.
repeated every 3-5 Followed by900 mg infusion over 24 hours
PASANG minutes
Or LIDOCAIN 1mg/kg. Can be repeated.
MONITOR EKG Do not exceed a total dose of 3mg/kg, during
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Evaluasi CPR : tiap 2 menit the first hour.
 DRUGS - CPR
• Adrenaline : 1 mg, iv, repeated every 3-5 minutes

• Amiodarone : 300 mg, bolus, if VF/VT persist after

3 shocks.
150 mg maybe given for recurrent or
refractory VF/VT, followed by an
infusion of 900 mg over24 hours

• Lidocain : 1 mg/kg, iv, if amiodarone is not available.

Do not exceed a total dose of 3 mg/kg,
during the first hour.
Do not give lidocaine if amiodarone
has already been given

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Guidelines 2015 ILCOR/ ERC/ AHA April_Surabaya
Adrenalin, Lidocain
1.Intra-venous
(Intra-tracheal / trans-tracheal
dosis 3-10 x intravena, sejak Guideline
2010, ke-2 nya tidak direkomendasi)

2. Intra-osseus
• TIDAK intra-cardial
– menghentikan pijat jantung
– sukar pastikan intra-ventrikuler
• kena miokard : nekrosis
• kena a. coronaria : infark AP_ED_Surabaya
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2010 ILCOR
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Defibrilator Pengatur dosis Joules

Paddles

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DC - shock
1. Oles dulu paddles
dengan jelly ECG
tipis rata, baru
kemudian :

2. Switch ON
Pasang paddles
Para-
pada posisi apex sternum
dan parasternal Apex
(boleh terbalik) 25
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3. Tempelkan di dada, baru :
Charge 360 Joules DC shock
(Non-synchronized)
Ucapkan dengan keras :
Awas semua lepas dari pasien!
– nafas buatan berhenti dulu
– bawah bebas, Para-
samping bebas, sternal
atas bebas,
Apex
saya bebas!
apex
4. Shock!!
(tekan dua tombol paddles bersama)
Lepas paddles dari dada, lanjutkan chest compression.

5. Segera pijat jantung lagi.

Setelah 2 menit baru raba lagi/ baca lagi ECG 26
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 If there is a doubt about whether
the rhythm is asystole or fine-VF
Fine VF do NOT attempt defibrilation,
continuous chest compression and
ventilation

chest compression + adrenalin

Fine Ventriculer Fibrilation
NO DC
chest compression + adrenalin
Asystole
NO DC

Coarse Ventriculer Fibrilation DC 27

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2. Ventriculer tachycardia ( VT–pulseless )

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 VT / Ventricular Tachycardia
|

carotis (+) carotis (-)

check hemodinamik
buruk baik

Amiodaron 300 mg a single shock

Kardioversi bolus 360 Joules
50 – 100 – 150 atau
Joule Lidocain CPR 30:2 2 menit
ekskalasi 1 mg/kg iv cepat Managemen VT/ VF
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 Berhasil ROSC

• Lanjutkan oksigenasi, kalau perlu nafas

buatan
( di Surabaya, protap : ventilator, evaluasi 24 jam )
• Hipotensi.
Diatasi dengan inotropik dan obat vaso-aktif
(adrenalin, dopamin, dobutamin, ephedrin)
• Tetap di infus untuk jalan obat cepat
• Terapi aritmia
• Koreksi elektrolit, cairan, gula darah dlsb
• Awasi di ICU
• awas: cardiac arrest sering terulang lagi 30
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Cardiac Arrest Membandel ???

Hipoksia Intractable
Hipovolemia Cardiac Arrest
4H Hiperkalemia
Hipotermia
Tamponade jantung
Tension pneumothorax
4T Thromboemboli paru
Toxic overdose
B-block, Ca-block
Digitalis, Tricyclic AD
MA Massive MI
Asidosis
AP_ED_Surabaya
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Kapan CPR dihentikan?

• Jika sudah ROSC dan stabil

• Jika sudah muncul lebam mayat
• Jika sudah lebih dari 30 menit belum ROSC,
boleh dipertimbangkan untuk berhenti
• Jika tim sudah tidak kuat lagi melakukan CPR
(exhausted)

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 Key Points

New Guidelines 2015

Post Cardiac Arrest Care

After ROSC:

1. Consider lidocaine if arrest is due to ventricular fibrillation/

tachycardia.
2. In comatose patients, target temperature to 32–36 C for
at least 24 hours, and prevent fever.
(Post Resuscitation Care: Targetted Temperature Management)
3. There is a greater emphasis on the need for urgent
coronary_cath and percutaneous coronary intervention
(PCI)
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Bila setelah ROSC,
cardiac arrest lagi

• Ikuti algoritme semula.

• Bila perlu DC shock tetap diberikan 1 x 360

Joules (monophasic) atau 150 - 200 Joule 1x
(biphasic) dan disusul dengan CPR
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 Latihan tim work yang terjadual
sangat diperlukan untuk
setiap Center Code Blue

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Summary

4H
+ 2 MA
4T
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Key Points

New Guidelines 2015

ALS - Adult Avanced Life Support

1. Vasopressin is out; stick with epinephrine.

2. Extracorporeal CPR is an alternative to CPR in
patients for whom the suspected etiology is reversible.
3. Maximize oxygenation during CPR, but titrate down
after return of spontaneous circulation (ROSC).
4. After 20 minutes of CPR, a low end-tidal CO2 level
may be used to help determine whether to terminate
resuscitation in intubated patients.
5. Ultrasound may be used to confirm endotracheal tube
placement.
Capnography Waveforms

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Adult tachycardia
with a pulse
Adult tachycardia
with a pulse
Adult bradycardia
with a pulse
Kepustakaan.
American Heart Association Guidelines for Cardiopulmonal Resuscitation and Emergency
Cardiovascular Care. 2010. Circulation 2010;122;S676-S684 DOI:10.1161/ Circulation
AHA.110.970913
American Heart Association Guidelines for Cardiopulmonal Resuscitation and Emergency
Cardiovascular Care. 2015.
American Heart Association Hightligts of the 2015 Guidelines Update for CPR and ECC.
European Resuscitation Council. 2010. Published by Elsevier Ireland Ltd. All rights reserved.
Resuscitation 81 (2010) 1219–1276., doi:10.1016/j.resuscitation.2010.08.021
European Resuscitation Council. 20015., CPR Guidelines
General Emergency Life Support, 2015., Buku Ajar Kursus PPGD/ GELS., Ed.XIV., 2015.
Diklat IRD RSUD dr Soetomo – FK Unair., Surabaya
International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Science With Treatment Recommendations. 2010. Circulation 2010;122;S338-S344
DOI: 10.1161/ Circulation AHA.110.971036
International Liaison Committee on Resuscitation, European Resuscitation Council and American
Heart Association. 20015.

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