KEGAWATAN PADA ANAK

Silvia Triratna
IDAI cabang Sumatera Selatan
Divisi Emergensi Rawat Intensif Anak
Departemen Kesehatan Anak RS Moh Hoesin Palembang/ FK UNSRI
Children are the most vulnerable
citizens in any society and the
Greatest of our treasures

(Nelson Mandela: Nobel Prize ceremony, Oslo,

Norway, 1993
• Pengenalan dini dan penatalaksanaan cepat
dan tepat pada kegawatan meningkatkan
kelangsungan hidup untuk anak-anak
• Kemampuan Menilai Kegawatan pada anak
mutlak harus dikuasai agar dapat segera
melakukan bantuan hidup dasar

3
 Outcome of cardiac arrest
in children
Arrive in ER in cardiac arrest
(N = 80)

Admit PICU Died in ER

(N=43) 54 % (N=37) 46%

Mod Deficit PVS at Dead at Died in ICU

(N=3) 12 mos 12 mos (N=37) 46%
(N=2) (N=1)
Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest
in children. N Engl J Med 1996;335:1473-1479
• RESPIRATORY EMERGENCY
• CIRCULATORY EMERGENCY
• NEUROGY EMERGENCY
• ENDOCRINE EMERGENCY
• TRAUMA
• POISONING/ INTOXICATION
• .......
Assessment: Key to Pediatric Management

Life threatening

Not life
threatening
AHA Pediatric Advanced Life Support Manual 2006
 Why treat children differently?

Child is not small adult

Children have unique
developmental
characteristics
require assessment and
management techniques
specific to the child’s age.

7
 Child is not small adult
 Gejala dan tanda
tidak jelas dan sulit dikenal, terutama pada anak
usia dibawah 1 - 2 tahun.
 Resiko Kematian dan kesakitan lebih besar
dibanding dewasa pada jenis penyakit yang sama

The key differences to consider in children are:

1. Weight
2. Anatomical –
3. Physiological
4. Psychological –
8
 Anatomical Differences
A child’s anatomy differs in four significant
ways from an adult’s. They are:

• Smaller airways
• Less blood volume
• Bigger heads
• Vulnerable internal organs
Anatomical Differences, cont'd
• Large tongue in relation to a
smaller airway small oropharynx
• Diameter of the trachea is
smaller
• Trachea is not rigid and will
collapse easily
• Back of the head is rounder
and requires careful
positioning to keep airway
open
• Tongue
Most common cause of airway obstruction is loss of
muscle tone with tongue falling back against posterior
pharynx
• Smaller radius:
results in marked increase in resistance to air flow
when edema or foreign body present
 Nasal obstruction, as with mucous or blood, may
result in severe respiratory distress
Anatomical Differences, cont'd
• Relatively smaller blood
smaller airway volume

less blood volume • Approximately 70 cc of

blood for every 1kg (2 lbs) of
body weight

• A 20 lb child has about

700cc of blood—about the
volume of a medium sized
soda cup
Anatomical Differences, cont'd
• Head size is proportionally
smaller airway larger
• Prominent occiput and a
less blood volume relatively straight cervical
spine
• Neck and associated
bigger heads support structures aren’t
well developed
• Infants and small children
are prone to falling
because they are top
heavy
The head is large and the neck is short,
tending to cause neck flexion and airway narrowing

OVER EKSTENSI

KOMPRESI TRAKHEA
.The head is large more prominent occiput , the
neck is short, relatively laxer cervical support,

tending to cause neck flexion and , making

the airway more vulnerable to obstruction
when supine
Anatomical Differences, cont'd
• Internal organs are not well
smaller airway protected
• Soft bones and cartilage and
less blood volume lack of fat in the rib cage
make internal organs
susceptible to significant
bigger heads internal injuries
• Injury can occur with very
internal organs little mechanism or obvious
signs
Narrowest point = cricoid cartilage
The airway is narrowest
at subglottic level. The
covering connective
tissue is loosely
attached

Inflammation can
rapidly cause
substantial narrowing of
airway calibre.
Effect Of Edema

Poiseuille’s law
The anatomy of the airway itself changes
with age, and consequently different
problems affect different age groups

Infants less than 6 months old are obligate

nasal breathers.
•  narrow nasal passages are easily obstructed
by mucous secretions,
• upper respiratory tract infections are common
in this age group, these children are at
particular risk of airway compromise
• In 3- to 8-year-olds, adenotonsillar hypertrophy may
be a problem. This not only tends to cause
obstruction, but also causes difficulty when the nasal
route is used to pass pharyngeal, gastric or tracheal
tubes.
• In all young children the epiglottis is horseshoe-
shaped, and projects posteriorly at 45◦,making
tracheal intubation more difficult. This, together with
the fact that the larynx is high and anterior
In children, the thoracic cage is more
compliant. Increased respiratory
effort in the presence of airway
obstruction leads to marked chest
wall recession, with decreases in the
efficiency of breathing.
A more compliant chest wall provides
less support for maintenance of lung
volume
Respiratory muscles in young children are less
efficient,

Their muscles are more likely to fatigue :

Fatigue of respiratory muscles may lead to decreased
respiratory effort as respiratory failure progresses

 fatigue can develop quickly, leading to

respiratoryfailure and " apnoea.
Use of diaphragm leads to characteristic ‘see-saw’
or abdominal breathing pattern
Intercostal, subcostal and suprasternal retractions are
prominent as work of breathing increases with airway
obstruction or lung disease

Their muscles are more likely to fatigue :

Fatigue of respiratory muscles may lead to decreased
respiratory effort as respiratory failure progresses
The ribs lie more horizontally in infants, and
therefore contribute less to chest expansion.

In the injured child, the compliant chest wall may

allow serious parenchymal injuries to occur without
necessarily incurring rib fractures.
For multiple rib fractures to occur the force must be
very large; the parenchymal injury that results is
consequently very severe and flail chest is tolerated
badly.
• Lung volume at end-expiration is similar to closing
volume in infants, increasing tendency to small airways
closure and hypoxia.
The body surface area (BSA) to weight
ratio decreases with increasing age.

Small children, with a high ratio, lose heat more

rapidly and consequently are relatively more
prone to hypothermia.

At birth the head accounts for 19% of BSA;

this falls to 9% by the age of 15 years
 Respiratory
• The infant has a relatively greater
metabolic rate and oxygen consumption.
 This is one reason for an increased respiratory
rate.
• However, the tidal volume remains relatively
constant in relation to body weight (5–7 ml/kg)
through to adulthood
Respiratory rate by age at rest

Age(Years) Respiratory rate/ MENIT

<1 30 -40
1-2 25 -35
2-5 25 - 30
5 -12 20 - 25
>12 15 -20
• Absolute size and relative body proportions
change with age.

• Observations on children must be related to

their age.

• Therapy in children must be related to their

age and weight.

• The special psychological needs of children

must be considered.
informasi harus segera
diperoleh agar dapat membuat
keputusan

 Tanpa menyentuh pasien

30
GENERAL ASSESSMENT
PAT
PRIMARY ASSESSMET
ABCDE
SECONDARY ASSESSMENT
S A M P L E
TERTIARY ASSESMENT
LABORATORY _ TEST

CATAGORIZE ILLNESS and SEVERITY

RESPIRATORY CIRCULATORY
Respiratory Distress Compensated Shock
Respiratory Failure Decompensated Shock
 KOMPONEN KEGAWATAN
• PAT
• PEMERIKSAAN A – B – C – D – E
• BANTUAN HIDUP DASAR
• PEMERIKSAAN/ PENILAIAN ULANG
• ANAMNESA YG BERHUBUNGAN
• LEVEL KEPARAHAN PENYAKIT
MENENTUKAN
ANAK SAKIT GAWAT
PAT Dilanjutkan ABCDE
SAVE-a-CHILD 32
 PEDIATRIC ASSESSMENT
TRIANGLE
• an objective tool that can be used to determine
the severity of illness in a child
• a rapid way to determine physiologic stability

• Appearance: the child’s mental status,

muscle tone, and body position
• Breathing : visible movement at the chest
or abdomen and work of breathing;
• Circulation: the child’s skin color
 S E G I T I G A P E N I L A I A N P E D I AT R I K
( PEDIATRIC ASSESSMENT TRIANGLE = PAT)

 T = Tonus  Suara nafas abnormal

 I = Interactiveness  Posisi abnormal
 C = Consolability  Retraksi
 L = Look/Gaze  Napas cuping hidung
 S = Speech/Cry

SIRKULASI KULIT
 Pucat  Mottled  Sianosis

34
 appearance

Indikator klinis
Status Sistem • TICLS
neurologis • AVPU

35
 work of breathing

Characteristics of Work of Breathing

Element Explanation
Abnormal airway Altered speech, stridor, wheezing or grunting
sounds

Abnormal Head bobbing, tripoding, SNIFFING,

positioning

Retractions Retraksi otot didnding dada, Supraclavicular,

intercostal or substernal

Flaring Nasal Flaring

36
 circulation
Characteristic of CIRCULATION
ELEMENT Explanation

Pallor White skin coloration from lack of

peripheral blood
Mottling Patchy skin discoloration, with
patches of cyanosis, due to vascular
instability or
Cyanosis Bluish discoloration of skin and mucus

37
SKIN COLOR

38
 Findings of the PAT Used to Form
a General Impression of the Physiologic State
General Appearance Work of Circulation to
Impression Breathing the skin
Stable Normal Normal Normal

Respiratory Normal Abnormal Normal

Distress Nasal flaring
Grunting
Stridor
Wheezing
Retractions
Respiratory abnormal abnormal Normal/
Failure abnormal
SHOCK
DISTRESS NAFAS GAGAL NAFAS

Circulation Normal Circulation Normal

 GANGGUAN SSP /
SYOK
KELAINAN METABOLIK

Circulation abnormal Circulation Normal

 CARDIO PULMONARY
FAilURE

Circulation Abnormal Circulation abnormal

• After completing the Triangle,
begin a more complete
 pediatric primary survey.
DISABILITY

CIRCULATION

BREATHING

AIRWAY
 INITIAL ASSESSMENT
• AIRWAY
Is The patient able to speak or cry ?
• Look for movement of the chest or
• Listen for breath sounds
Note specific sounds, such as gurgling, snoring,
grunting, or stridor (a high-pitched or low-pitched
sound as the child inhales

• Feel for air movement at the child’s mouth or

nose
 INITIAL ASSESSMENT
• AIRWAY

• Gurgling sounds may mean that there are

secretions or blood that must be
suctioned.
• Stridor or snoring may mean that the
tongue, secretions, or a foreign body are
partially blocking the airway
 INITIAL ASSESSMENT
• AIRWAY

• If you can see movement and hear

normal breath sounds, the airway is
patent (open).
• Vocalization, speech, crying, or coughing
indicates a patent airway, although partial
obstruction may be present.
 INITIAL ASSESSMENT
• AIRWAY

• If you see no chest or abdominal

movement and you cannot hear or feel
breathing,  the airway is completely
------------------ obstructed.
• Management as Respiratory Emergency
 Breathing assessment
• Evaluation of Respiratory Performance
Respiratory Rate and Regularity
Level of Consciousness
Color of the Skin and Mucous
Membranes
Respiratory Mechanics
If the child is able to breathe spontaneously,
evaluate
• Work of breathing and breath sounds
• Respiratory rate
• Respiratory depth and pattern
• Central color at the lips and tongue
• Breath sounds on auscultation with a stethoscope
• Signs of chest trauma, if present
• Work of breathing
Look and listen for signs that indicate
increased work of breathing
Visible signs Audible signs
􀂃 Retractions, 􀂃 Stridor, a high or low-pitched
􀂃 Nasal flaring 􀂃 Wheezing,
􀂃 Head bobbing 􀂃 Grunting,
􀂃 Gurgling,
• Work of breathing
 Stridor and wheezing are signs of respiratory
distress.
 Grunting is also a sign of severe respiratory
distress or respiratory failure.
 Crackles are caused by fluid in the lungs and
may accompany pneumonia or asthma.
 Gurgling may indicate secretions that require
suctioning
• Pain or fear can increase work of breathing in
children, causing noticeable wheezing or
stridor.

• RATE
• by counting the number of times the
chest or abdomen rises and falls
• over a 30-second period, then doubling
the number to find the rate per
minute.
• RATE
• RATE
 In children, pain, fear, or fever can increase the respiratory
rate;
 in neonates, exposure to cold can increase the respiratory
rate and may cause respiratory distress.
 Respiratory rates that are very fast or very slow can lead to
low blood-oxygen levels .

• Depth and pattern

 Note shallow depth, which indicates decreased work of
breathing.
 Watch for irregularities in the breathing pattern, including
apnea, in which breathing pauses for at least 15 seconds.
 Watch the chest wall for equal movement on both sides
and equal time spent inhaling and exhaling .
• COLOR
 Check the color of the lips and tongue.
 Pink is normal.
 A pale color at the lips and tongue is a sign
of respiratory distress or respiratory failure.
 A cyanotic color indicates low blood
oxygen, and is a sign of respiratory failure
or respiratory arrest In children
• Auscultation
 compare breath sounds of the right and left lungs to
see if they are equal.
 Since children have small chests, you should place the
stethoscope near the armpits rather than the nipples
when listening for breath sounds.
 This minimizes the possibility that sounds are being
transmitted from one side of the child’s chest to the
other
• CHEST INSPECTION
• During auscultation, check for life-threatening
chest injuries that may interfere with
ventilation and oxygenation.
 RATE BRADIPNU, TAKIPNU

RHYTHM REGULER, IREGULER

QUALITY DANGKAL, DALAM,

NAFAS HEMBUS
Respiratory Mechanics
 Head Bobbing
 Nasal Flaring
 Retractions
 Grunting
 Stridor
 Wheezing or Prolonged
Exhalation
 CIRCULATION
Perfusion
Perfusion is evaluated by assessing

• peripheral pulse,
• skin color and temperature,
• capillary refill time

60
 peripheral pulse
• Compare the peripheral pulse to the central
pulse.
• A peripheral pulse that is weak, irregular, or
difficult to palpate
may indicate
 poor peripheral perfusion,
 a sign of shock or bleeding
• the radial pulse (inside the wrist)
• the pedal pulse (on the top of the foot)
61
 Skin Signs
• Feel for temperature
and moisture
• Estimate capillary
refill.
 FREKUENSI JANTUNG
USIA FREKUENSI
< 3 bulan 85 - 200
3 bln – 2 thn 100 - 190
3 – 10 tahun 60 -140

• HEART RATE
Rate = 150 − ( 5 × age in
years )
Normal Blood 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

TEKANAN SISTOLIK MINIMAL

70 + { 2 x umur (tahun) }
65
 Pulse
• In infants, over the brachial or femoral area.
• In older children, carotid artery
• Count for at least 1 minute.
• Note strength of the pulse.
STATUS NEUROLOGIK
 AVPU
CARA CEPAT MENILAI KESADARAN

A ALERT

V RESPONS TO VOICE

P RESPONS TO PAIN

U UN RESPONSIVE
 Glasgow Coma Score
• Modified Glasgow Coma Score
(3-15): Patient's best response.
EYE OPENING
INFANT CHILDREN, ADULTS
4. Spontaneous Spontaneous
3 To speech To verbal stimul
2 To pain To pain
1 No response No response
 Glasgow Coma Score

MOTOR RESPONSE
INFANT CHILDREN, ADULTS
6 Normal spontaneous Follows commands
5 movement Localizes pain
4 Withdraws to touch Withdraws to pain
Withdraws to pain Abnormal flexion to
3 Abnormal flexion pain
2 Abnormal extension Abnormal extension
1 No response No response
 Glasgow Coma Score

MOTOR RESPONSE
INFANT CHILDREN, ADULTS
5 Coos and babbles Oriented
4 Irritable cries Confused
3 Cries to pain Inappropriate
2 Moans to pain words
1 No response Non-specific sound
No response
 TINDAKAN LANJUT
• MENERUSKAN RESUSITASI
• PEMERIKSAAN /PEMANTAUAN
LEBIH LANJUT
• MERUJUK
Secondary Assessment
• Focused History & Physical Exam
• Perform on all responsive patients following
the initial assessment. Focus on the history
and signs and symptoms of the present
illness/injury.
 Secondary Assessment
 Focused history
• Signs and symptoms
• Allergies
• Medications
• Past Medical History
• Last Meal
• Events
Focused medical hx using
 Detailed PE SAMPLE mnemonic and a
thorough head-to-toe P.E.
AHA Pediatric Advanced Life Support. 2010
Patient History
acquire during/incorporate into physical exam

• S = Signs & Symptoms

as they relate to chief complaint. Will be different
for medical as opposed to trauma patients.
• A = Allergies
medications, foods, environmental
• M = Medications
prescribed, over-the-counter, compliance with
prescribed dosing regimen, time, date and
amount of last dose.
Patient History
acquire during/incorporate into physical exam

• P = Past Pertinent Medical History

Pertinent medical or surgical problems
Preexisting diseases/chronic illness
Previous hospitalizations
Currently under medical care
For infants, obtain a neonatal history (gestation,
prematurity, congenital anomalies, was infant
discharged home at the same time as the
mother)
Patient History
acquire during/incorporate into physical exam

• Last oral intake

/liquid/food ingested; adolescent females: LMP;
sexually active?
• E = Events surrounding current problem
a. Onset, duration and precipating factors
b. Associated factors such as toxic inhalants,
drugs, alcohol
c. Injury scenario and mechanism of injury
d. Treatment given by caregiver.
 Diagnostic Tests

• Assessment of respiratory and circulatory abnormalities

ABG, VBG, Hb, Blood sugar

Pulse oximetry, CXR
Capnography (ETC02), exhaled C02
Sv02 saturation, arterial lactate
CVP, 2DEcho, ECG, PEFR
Invasive arterial pressure monitoring
 The E-I-I Sequence: IDENTIFY
Type Severity
Respiratory Upper Airway Obstruction Respiratory Distress
Lower Airway Obstruction Respiratory Failure
Lung Tissue Disease
Disordered Control of
Breathing
Circulatory Hypovolemic Shock Compensated Shock
Distributive Shock Hypotensive Shock
Cardiogenic Shock
Obstructive Shock
Cardiopulmonary Failure
Cardiac Arrest
 RESUME
• ANAK Bukan Miniatur Orang Dewasa
• PAT nerupakan alat bantu menilai kegawatan
pada anak
Once cardiac arrest occurs, even with optimal
resuscitation efforts, the outcome is generally
poor. For this reason, one needs to know the
important concepts of pediatric assessment, as
it is the key to pediatric management.
Assessment identifies life threatening
situations which need rapid systematic
intervention to prevent progression to cardiac
arrest.

80