EMERGENCY EMERGENCY PEDIATRICPEDIATRIC

PICU Subdiv. Child Health DeptMedical Faculty, University of Hasanuddin

Dr. Wahidin Sudirohusodo Hospital Makassar

DEMAM BERDARAH DENGUEDEMAM BERDARAH DENGUE

ETIOLOGI :

Dengue Virus (Den 1, Den 2, Den 3,

Den 4)

PATOGENESIS :

Tidak jelas

1. Hipotesis Infeksi Heterolog Sekunder

2. Teori virulensi virus

Patokan WHOPatokan WHO

LABORATORIUMLABORATORIUM

DIAGNOSA

Klinis :Klinis :

• Demam 2- 7 hari

• Perdarahan

• Hepatomegali

• Renjatan

• Trombositopeni (< 100.000/mm)

• Hemokonsentrasi (Ht Akut - Konv > 20% )

• Ht konv

WHO CLASSIFICATION OF DHF (1975)

KLASIFIKASI DERAJAT DBD

MONITORING

TREATMENT DBD derajat III & IV

1. Oksigenasi (berikan O2 2-4 l/menit)2. Penggantian volume plasma (cairan kristaloid isotonis) Ringer laktat/NaCl 0,9 % / Asering Bolus 100 -200 ml (10-30 menit) DBD Grade IV

20 ml/kgBB/jam ( 1 jam) DBD Grade IIIEvaluasi 30 menit, apakah syok teratasi ?

Syok teratasi Syok tidak teratasiKesadaran membaikNadi teraba kuatTekanan nadi > 20 mmHgTidak sesak nafas sianosisEkstremitas hangatDiuresis cukup 1 ml/kgBB/jam

Kesadaran menurunNadi lembut / tidak terabaTekanan nadi < 20 mmHgDistres pernafasan / sianosisKulit dingin dan lembabEkstremitas dinginPeriksa kadar gula darah

Cairan dan tetesan disesuaikan 10 ml/kgBB/jam (4-6 jam)

Pantau tanda vital tiap 15 menitCatat balans cairan selama pemberian intravena

Lanjutkan cairan 20 ml/kgBB/jam

Evaluasi ketatTanda vitalTanda perdarahanDiuresisHb, Ht, trombosit

Tambahkan koloid/plasma Dekstran/FPP10-20 (max 30) ml/kgBB/jam

Stabil dalam 24 jam/Ht < 40Tetesan 5 ml/kgBB/jam

Syok teratasiSyok belum teratasi

Koreksi asidosis Evaluasi 1 jam

Ht turun Ht tetap tinggi/ naikTetesan 3 ml/kgBB/jam

Infus stop tidak melebihi 48 jamsetelah syok teratasi

Tranfusi darahSegar 10 ml/kgBBdiulang sesuai kebutuhan

Koloid 20 ml/kgBB

RENJATAN SEPTIK

ETIOLOGI

Patofisiologi terjadinya syok septikInfeksi Bakteri

Endorfin Produk Bakteri mis. endotoksin

Aktivasi Komplemen

Makrofag

SitokinFaktor JaringanAktivasi PMN.

Pelepasan PAF, produkArakidonat dan

Substansi toksik lainAktivasi koagulasi

fibrinolisis

Aktivasi kalikreinkinin

Vasodilatasi,Kerusakan endotel

kapilerSyok Septik

Kebocoran kapiler,kerusakan endotel

Kegagalan Organ Berganda

Menggigil, hipertermi Takikardi Takipneu Hipotensi Apatis Gelisah Manifestasi perdarahan (peteki, purpura) Neonatus tdk spesifik (letargi, muntah, hipotermi/hipertermia)

DIAGNOSIS

PENGOBATAN

DIARE DEHIDRASI

TIPE DEHIDRASI

DERAJAT DEHIDRASI

1. Jumlah kehilangan cairan (PWL,NWL,CWL)

PemeriksaanPemeriksaan

Angka PenilaianAngka Penilaian

11 22 33

Gambaran KlinikGambaran Klinik

Keadaan umumKeadaan umum

MataMata

MulutMulut

PernapasanPernapasan

TurgorTurgor

NadiNadi

BaikBaik

NormalNormal

NormalNormal

20-30 per menit20-30 per menit

BaikBaik

Kuat / kurangKuat / kurang

120 per menit120 per menit

Lemah/hausLemah/haus

CekungCekung

KeringKering

30-40 per menit30-40 per menit

KurangKurang

120-140120-140

per menitper menit

Gelisah/renjatanGelisah/renjatan

Sangat cekungSangat cekung

Sangat keringSangat kering

40-60 per menit40-60 per menit

JelekJelek

Lebih 140Lebih 140

per menitper menit

Derajat dehidrasiDerajat dehidrasi skor 6skor 6

diare tanpadiare tanpa

dehidrasidehidrasi

skor 7-12skor 7-12

diare dehidrasidiare dehidrasi

ringan/sedangringan/sedang

skor 13 / lebihskor 13 / lebih

diare dehidrasidiare dehidrasi

beratberat

2. Manifestasi klinis ( sistem skoring)

PENGOBATAN

UmurUmur

Cara PemberianCara Pemberian

PermulaanPermulaan LanjutanLanjutan

DiareDiare

InfantilInfantil- PWL 125 mlPWL 125 ml- NWL 100 mlNWL 100 ml- CWL CWL 25 ml25 ml

250 ml250 ml

KoleraKolera

PWL 100 ml/kgPWL 100 ml/kg

4 jam pertama4 jam pertama

60 ml/kg60 ml/kg

1 jam pertama1 jam pertama

30 ml/kg30 ml/kg

20 jam berikut20 jam berikut

190 ml/kg190 ml/kg

7 jam berikut7 jam berikut

70 ml/kg70 ml/kg

PWL 100 ml/kgPWL 100 ml/kg

Bayi kurang12 bulanBayi kurang12 bulan

Anak sama atau lebih 12 Anak sama atau lebih 12 bulanbulan

1 jam pertama1 jam pertama

30 ml/kg30 ml/kg

½ jam pertama½ jam pertama

30 ml/kg30 ml/kg

5 jam berikut5 jam berikut

70 ml/kg70 ml/kg

2 ½ jam berikut2 ½ jam berikut

70 ml/kg70 ml/kg

IVFD : 2 tahun : Asering/R. asetat sist 24

jam 4 jam I : 5 tetes/kgbb/menit 20 jam II : 3 tetes/kgbb/menit > 2 tahun : Ringer laktat sistem 8

jam 1 jam I : 10 tetes/kgbb/menit 7 jam II : 3 tetes/kgbb/menit

STATUS ASMATIKUS

ETIOLOGI

PATOGENESIS

Classification of Severity of Acute Asthma Exacerbations

ParametersParametersMildMild ModerateModerate SevereSevere Respiratory Respiratory

Arrest Arrest ImminentImminent

BreathlessnessBreathlessness While While walkingwalking

While talkingWhile talking While at restWhile at rest

TalksTalks SentencesSentences PhrasesPhrases WordsWords

PositionPosition Can lie Can lie downdown

Prefers sittingPrefers sitting Sits uprightSits upright

AlertnessAlertness May be May be agitatedagitated

Usually Usually agitatedagitated

Always Always agitatedagitated

Confused/ Confused/ drowsydrowsy

CyanoticCyanotic -- -- ++ ++++++

WheezeWheeze Moderate, Moderate, often only often only end end expiratoryexpiratory

Loud, Loud, throughout throughout expiratoryexpiratory± inspiratory± inspiratory

Extremely loud, Extremely loud, can be heard can be heard without without stethoscopestethoscope

Absence of Absence of wheezewheeze

Breathlessness Breathlessness MinimalMinimal ModerateModerate SevereSevere

Use of accessory Use of accessory musclesmuscles

Usually notUsually not CommonlyCommonly AlwaysAlways

RetractionsRetractions Shallow, Shallow, intercostalsintercostals

Moderate, + Moderate, + suprasternalsuprasternal

Deep, + Deep, + flare of alae flare of alae nasinasi

--

Respiratory rateRespiratory rate IncreasedIncreased IncreasedIncreased IncreasedIncreased DecreasedDecreased

Guide to rates of breathing in awake children:Guide to rates of breathing in awake children:Age:Age: Normal rate:Normal rate:< 2 month < 60 / minute< 2 month < 60 / minute2-12 months < 50 / minute2-12 months < 50 / minute1-5 years < 40 / minute1-5 years < 40 / minute6-8 years < 30 / minute6-8 years < 30 / minute

PulsePulse NormalNormal TachycardiaTachycardia TachycardiaTachycardia BradycardiaBradycardia

Guide to normal pulse rates in children:Guide to normal pulse rates in children:Age:Age: N Normal rate:ormal rate:

2-12 months < 160 / minute2-12 months < 160 / minute1-2 years < 120 / minute1-2 years < 120 / minute3-8 years < 110 / minute3-8 years < 110 / minute

Pulsus Pulsus ParadoksusParadoksus

None None < 10 mmHg< 10 mmHg

(+) (+) 10-20 mmHg10-20 mmHg

(+) (+) > 20 mmHg> 20 mmHg

NoneNone

PEFR or FEV1PEFR or FEV1-before b.dilator-before b.dilator-after b.dilator-after b.dilator

(% pedicted (% pedicted vavalue)lue)> 60%> 60%> 80% > 80%

(( % best value) % best value)40-60%40-60%60-80%60-80%

< 40%< 40%< 60 %< 60 %respons < 2 respons < 2 jamjam

SaO2SaO2 > 95%> 95% 91-95%91-95% ≤≤ 90%90%

PaO2PaO2 NormalNormal > 60 mmHg> 60 mmHg < 60 mmHg< 60 mmHg

PaCO2PaCO2 < 45 mmHg< 45 mmHg < 45 mmHg< 45 mmHg > 45 mmHg> 45 mmHg

GEJALA KLINIS

Acute asthma algorithm

Clinic/ERAsses attack severity

1st management• nebulitation -agonis 3x, 20 min interval

•3rd nebulitation + anticholinergic

Moderate attack (nebulization 2-3x,

partial response)• give O2

• asses: Moderate – ODC

• IV line

Mild attack

(nebulization 1x, complete response)

• persist 1-2 hr: discharge

• symptom reappear: Moderate attack

Severe attack (nebulization 3x,

no response)

• O2 from the start•IV line•asses: Severe -

hospitalized• CXR

One Day Care (ODC)• Oxygen therapy• Oral steroid • Nebulized / 2 hour• Observe 8-12 hours, if stable discharge• Poor response in 12h, admission

Admission room• Oxygen therapy• Treat dehydration and acidosis • Steroid IV / 6-8 hours• Nebulized / 1-2 hours• Initial aminophylline IV, then maintenance• Nebulized 4-6x good response per 4-6 h• If stable in 24 hours discharge• Poor response ICU

Discharge• give -agonist (inhaled/oral)• routine drugs• viral infection: oral steroid • Outpatient clinic in 24-48 hours

Notes:• In severe attack, directly use -agonist + anticholinergic• If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times •Oxygen therapy 2-4 l/min should be early treatment in moderate and severe attack

31

Figure. Jet nebulizer

32

Figure. Ultrasonic nebulizer

34

Dosis Obat untuk nebulizer

Obat NebulizerJet Ultrasound

NaCl 0.9% (ml) 5 10

2-agonist• Alupent sol. 2% (gtt)• Berotec 0.1% (gtt)• Ventolin nebule (mL)• Bricasma respule (mL)

3 – 5511

3-5511

Time (minutes) 10 - 15 3 - 5

PENANGANAN PICU

Obat di bgsl lanjut

Mechanical ventilator

STATUS EPILEPSI

NewbornNewborn 1-2 months1-2 months Infancy &childhoodInfancy &childhood

AcuteAcute CNS infectionCNS infection

Intracranial Intracranial HemorrhageHemorrhage

Hypoxic ischemicHypoxic ischemic

CNS infectionCNS infection

Subdural Subdural HemorrhageHemorrhage

AnoxiaAnoxia

CNS infectionCNS infection

Intracranial Intracranial HemorrhageHemorrhage

AnoxiaAnoxia

MetabolicMetabolic Electrolyte Electrolyte ImbalanceImbalance

Electrolyte Electrolyte ImbalanceImbalance

Electrolyte Electrolyte ImbalanceImbalance

MalformatiMalformationon

Neuronal Neuronal migrationmigration

Sturge-weber Sturge-weber

NeurofibromatosisNeurofibromatosis

OtherOther ToxinToxin

DrugsDrugsToxinToxin

DrugsDrugsFebrile ConvulsionFebrile Convulsion

DrugsDrugs

ETIOLOGI

PATOFISIOLOGI

KLASIFIKASI

PENGOBATAN

Tatalaksana status konvulsi

Kejang Diazepam rectal 0,5 mg/kgbb atau

BB < 10 kg :5 mg, BB > 10 kg :10mg Kejang (+)

Diazepam rectal 5 menit

Di Rumah Sakit

Pencarian akses venaLab: darah tepi, gula darah, elektrolit, ureum, kreatinin

Kejang (+) Diazepam IV 0,3 -0,5 mg/kgbb

Kecepatan 0,5-1 mg/menit (3-5 menit) (Hati-hati depresi nafas)

Kejang (+)

Fenitoin Initial dose bolus iv= 10 – 20 mg/kgbb/x dilarutkan dengan NaCl 0,9% dalam syringe pump sampai 50 cc dengan kecepatan 0,5-1 mg/kg/menit.

(Mulai dosis 10 mg bl tdk berespon naikkan jadi 20 mg)

Kejang (+) Kejang (-)

Phenobarbital 5-15mg/kg/hr/bolus iv Fenitoin maintanance dose : 5-7 mg/kg/hr

midazolam 0,2 mg/kg dilanjutkan (per 12 jam) dlm syringe pump 50 cc

Kejang (+) Ventilator mekanik

dilanjutkan 1-6 mg/iv/drips atau

dengan 0,1 – 4 mg/kg/jam

INTUSUSEPSI

PATHOFISIOLOGY Intussusceptions

Intususepsi ileoilealis, ileokolika, kolokolika

ETIOLOGI

GEJALA KLINIS

DIAGNOSIS

PENGOBATAN

HERNIA DIAFRAGMATIKA

Morgagni hernia

(Bochdalek Hernia)

(Hiatus esoph)

ETIOLOGI

GEJALA KLINIK

•Sesak•Takipnu•Sianosis

•Dinding torak yg tidak simetris•Takikardi

•Abdomen yg cekung•Bunyi nafas m’hilang di tempat defek•Bising usus dapat terdengar di paru

DIAGNOSIS

PENGOBATAN

SUDDEN INFANT DEATH SYNDROME

INSIDEN

PENYEBAB SIDS Belum diketahui Menidurkan bayi dgn posisi

tertelungkup Keterlambatan pada perkembangan sel

saraf dalam otak (aurosal/kewaspadaan thd hipoksia )

Rebreathing asphyxia: re-breathe carbon dioxide

Hypertermia

FAKTOR RESIKO SIDS

PEMERIKSAAN DAN TEST

PENANGANAN SIDS Saat di rumah (Telp RS /Call 911 for emergency medical

services, jika ada org tua atau pengasuh yg pernah diajarkan CPR bayi, mereka harus melakukan CPR sebelum paramedis datang)

Saat tiba Paramedis Oleh tim emergency sesuai pediatric

advanced life support protocols: Penanganan airway, breathing, nadi, gula darah. Pasang ETT, pasang infus, obat untuk memperbaiki denyut jantung.