primary survey fk umsu
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Primary Survey Assessment
(Penilaian dan Penanganan
Survei Primer)
Departemen Anestesiologi dan Reanimasi
FK UMSU2014
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Initial Assessment
• Preparation
– Prehospital Phase
– Hospital Phase
• Triage: – Multiple casualty incidents
– Mass casualty events
• Primary survey (ABCDE)
• Resuscitation
• Adjuncts to the primary survey and resuscitation
• Consideration of need for transfer
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Preparation
• The preparatory phase is an integral
component of trauma care and occurs in two
different clinical settings:
– Prehospital
– Hospital
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Prehospital Phase
• Occurs before patient involvement and concerns
the establishment of protocols the safe
transport of the right patient to the appropriatetrauma center at the earliest possible time using
the ideal transport method
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• Physicians involved in trauma care should be familiar
with these protocols, and should optimally be
involved in their establishment, review, and revision
• When an actual patient is injured, care is provided
according to protocol by the personnel who receive
initial notification of the trauma and are first torespond at the scene
• All events are ideally coordinated with the physicians
at the receiving hospital to ensure adequate time to
prepare personnel and resources in the emergency
department (ED).
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GOALS
• Maintenance of airway
• Control of external bleeding and shock
• Patient immobilization
• Transport to the closest appropriate facility preferably a trauma center.
• Obtaining important information concerning the
mechanism of injury, related events, and past medical
history of the patient alert the receiving team to the
possibility of particular injuries and their severity to
enable faster diagnosis and treatment.
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Hospital Phase
• The hospital phase of preparation is initiated withadvance notice of the arrival of the injured patient.
• Ideally, there should be a designated arrival area
with adequate space to accommodate the personneland equipment needed to carry out a trauma
resuscitation
• All trauma evaluations require proper personnel
ensuring that all personnel understand their roles and
have received any information communicated by the
prehospital personnel.
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• For example, patients who are hypotensive
(systolic blood pressure <90 mm Hg), bradycardic or tachycardic (heart rate <50
beats/min or >130 beat/min), or intubated in
the field or with respiratory compromise
meet criteria for the highest level of activation
which requires the presence of the full trauma
team consisting of trauma surgery faculty,
surgical residents, emergency medicine
faculty and residents, and ED nurses
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The Teams
• Physicians and nurses• Respiratory therapists
• Radiology technician
• Social workers (for family issues)
• Resources such as the laboratory, x-ray,
• Bedside diagnostic equipment such as an
ultrasound machine for FAST (FocusedAssessment Sonography in Trauma)
examination should be present
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Precaution
• Last but definitely not least is the safety of the
hospital team caring for the patient.
• All personnel who will be in close contact with
the patient should wear universal precautions
including hair covers, facemasks, eye
protection, appropriate length gowns, shoe
and/or leg coverings, and gloves to minimizeexposure to communicable diseases.
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Standard Precautions
• Cap
• Gown
• Gloves• Mask
• Shoe covers
• Goggles/face• Shields
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TRIAGE
• The word triage derives from the French
word meaning “to sort.”
• Medical context, triage involves the
initial evaluation of a casualty and the
determination of the priority and level ofmedical care necessary for the victim.
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• There are two typical triagesituations encountered:
– Multiple casualty incidents
– Mass casualty events.
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Multiple casualty incidents
• Multiple patients whose injuries do not
exceed the capabilities of the receiving
facility.
• Patients with lifethreatening or multiple
injuries are transported and treated first.
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Mass casualty events
• The number of patients and the severity of
their injuries exceed the equipment,
supplies, and personnel limitations of thereceiving facility.
• Patients with the greatest chance of survival
and requiring the least use of resources aretransported and treated first
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T r i
a g e D e c
i s i on S c
h e m e
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PRIMARY SURVEY
• The primary survey is a sequence of stepsto identify immediately life-threatening
but treatable injuries.
• Assessment and management proceed
simultaneously,and life-threatening
situations are managed as they are
encountered during the course of
resuscitation.
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Philosophy
“treat as you go”
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PRIMARY SURVEY
• A: airway maintenance with cervical spine
protection,
• B: breathing and ventilation,
• C: circulation with hemorrhage control,
• D: disability with respect to neurologic status
• E: exposure/environmental control, where the patient is completely undressed but kept warm
to prevent hypothermia.
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Special Populations
Pregnant women The anatomic and physiologic changes of
pregnancy can be a challenge, and the response of
the pregnant patient may be modified. Knowledge
of pregnancy and early monitoring of the fetus are
important in maternal and fetal survival.
Unnecessary x-ray exposure should be avoided, but treatment of the mother takes precedence.
Obese patients Their anatomy can make procedures such as
intubation difficult and hazardous. Obese patients
typically have cardiopulmonary disease limitingtheir ability to compensate for injury and stress.
Treatment of these patients may exacerbate their
underlying comorbidities.
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Pediatric patients the size of the child and specific injury patterns must
be kept in mind. Serious pediatric trauma is usually
blunt trauma, often involving the brain. Brain injuries
can lead to apnea, hypoventilation, and hypoxia, and protocols for pediatric trauma patients stress
aggressive management of the airway and breathing
to prevent these consequences. These physiologic
derangements occur more often than hypovolemia
with hypotension in seriously injured children.Geriatric patients The geriatric patient has overall less physiologic
reserve to withstand injury. Their response may also
be altered or blunted by comorbidities and chronic
medication use. Resuscitation of these patients must
take into account possible preexisting cardiac,
pulmonary, and metabolic diseases. Minor injuries
can cause serious complications due to multiple
medications, especially anticoagulant use.
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Airway Maintenance with
Cervical Spine Protection
• Maintenance of the airway is the most important
priority in caring for the trauma patient.
• Inadequate ventilation leads to hypoxia andinadequate oxygen delivery to tissues.
• Particularly important in patients with head
injury, as hypoxia contributes to secondary braininjury and hypoventilation may increase
intracerebral pressure.
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• In acute trauma, upper airway obstruction is the
most common cause of inadequate ventilation.
• Structures of the upper airway such as the
tongue, edematous soft tissues, blood, foreign
bodies, teeth, and vomitus are common causes
of obstruction.
• Quick assessment of the airway begins by
“asking the patient his or her name”.
• A normal response implies the airway is not inimmediate jeopardy, but frequent reassessment
is required.
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• Breathlessness, weak or absent voice, or
hoarseness suggests airway compromise.• Objective signs of potential airway problems
include noisy breathing, cyanosis, and the use of
accessory muscles.• Unconscious and obtunded patients with a
Glasgow Coma Score (GCS) of less than 8
should have their airway protected with anendotracheal tube to provide oxygenation and
ventilation, and reduce the chance of aspiration.
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• When airway compromise occurs, initial
maneuvers to maintain the airway are performed.
• The first involves opening the mouth and
inspecting for foreign bodies or otherobstructive causes.
• Either a chin lift or jaw thrust in conjunction
with an oral or nasal airway can relieveobstruction caused by the tongue
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X
Neck lift
Head tilt
Chin-lift
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Previously recommended hand
positions for manual in-line
stabilisation of the cervical
spine.
Currently recommended hand
positions for manual in-line
stabilisation of the cervical
spine.
Lindungi leher dari gerakan
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Breathing and Ventilation
• After securing the airway, attention may be
turned to breathing and ventilation.
• This includes both oxygenation and adequate
exchange of carbon dioxide
• Pulse oximetry is an effective noninvasive
means of measuring arterial blood saturation
• A patent airway does not ensure adequate
ventilation
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• Evaluation of breathing begins by looking at,
listening to, and feeling the chest wall.
• Inspection of the chest wall can reveal
asymmetry in chest expansion, accessory
muscle use, contusions, penetrating chest
wounds, open or sucking chest wounds, anddistended neck veins.
• Auscultation of breath sounds can help
diagnose pneumo- or hemothorax by detectingdifferences in breath sounds between the left
and right chest
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• Palpation of the chest wall can be used to
diagnose an unstable chest wall, tenderness,crepitance, deformity, or subcutaneous air.
• Percussion has been suggested to identify
hyperesonance, dullness, or tympany.• Due to an often noisy resuscitation area, it is
rarely helpful in diagnosing or differentiating
chest trauma
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Breathing problems can be life-
threatening
• Tension pneumothorax air continuously
enters the pleural space from the trachea,
bronchi, or chest wall causing the lung to
collapse
• A flail chest:
– three or more consecutive ribs broken in at least two
places each,
– or one or more rib fractures along with a
costochrondral separation
– or fracture of the sternum 35
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Dekompresi pneumotoraks (tension)
harus dikerjakan dalam Primary Survey
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• Open pneumothorax a chest wall defect
greater than two thirds the diameter of thetrachea. This is also known as a “sucking chest
wound”
• Massive hemothorax (>1,200 mL of bloodevacuated initially) can cause mediastinal shift,
respiratory distress, and hypovolemic shock,
which must be managed immediately.
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Ci l ti ith H h
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Circulation with Hemorrhage
Control
• Hemorrhage is the leading cause of preventable
death after injury.
• Shock is the result of inadequate oxygen
delivery to tissues.
• Although hypovolemic shock from bleeding is
the most common form of shock in trauma
victims, other types of shock can occur in these
patients, and occasionally a combination of
several types of shock are simultaneously
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• Treatment for shock begins with placement of
two large-bore peripheral IV (16-gauge orlarger) and appropriate isotonic fluid
replacement
• STOP THE BLEEDING!!! – direct pressure on the bleeding vessel
– Tourniquets
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• Hemorrhage in the adult trauma patient
comes from one of five places:
– the thoracic cavity
– abdominal cavity – pelvic fracture
– long bones
– obvious external bleeding
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Disability: Neurologic Status
• The neurologic examination includes the
APVU/GCS and pupil examination
including size, symmetry, and reaction tolight.
• A complete and detailed neurologic
examination is not accurateor warranteduntil the patient is hemodynamically
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Exposure and Environmental
Control
• The patient’s clothing must be
completely removed for complete andadequate evaluation, while ensuring the
patient does not become hypothermic
• Clothing is cut when there is severe
injury or risk of injury to the spine.
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• During exposure of the patient, prevention of
hypothermia with warmed air, fluids, oxygen,and blankets is necessary.
• The temperature of the patient should be
obtained as soon as possible and reassessedfrequently
• The best way to avoid hypothermia in the
trauma patient is to stop bleeding
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Adjuncts to Primary Survey
Vital sign
ECG ABGs
Urinary Adjuncts Pulse
Output oximeter
and CO₂
Urinary/gastric catheters
unless contraindicated
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© ACS
Adjuncts to Primary Survey
Diagnostic Tools• Chest and pelvic
x-ray
• DPL
• Ultrasound
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Decision for Early Transfer
Consider Early Transfer
Do not delay transfer for diagnostic
tests
Use time before transfer for
resuscitation
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