CHAPTER I

PRELIMINARY

A. Problem Background
Treatment of trauma generally aims to save lives, prevent further organ damage, prevent
body disability and heal. As we know, in the handling of trauma in the known primary survey
rapid resuscitation followed then secondary survey and finally definitive therapy. During the
primary survey, life-threatening circumstances should be identified and resuscitation is done
at that time. In the primary survey is known sisitem ABCDE (Airway, Breathing,
Circulation, Disability, Exposure / Enviromental control) arranged in order of priority
handling. So the main priority of handling is the state of ensuring adequate airway breathing.
Therefore, airway trauma is a condition that requires a fast and effective way to avoid
unintended consequences.
The management of patients with severe injuries requires rapid and precise assessment.
This initial assessment includes the preparatory phase, trease, primary survey, resuscitation,
adjunct, secondary survey, reevaluation, and definitive therapy. There are many
circumstances that will cause death in a short time, but all end up in one final result of cell
oxygenation failure, especially to the brain and heart. Prevention of hypoxemia requires a
protected, open airway and adequate ventilation which is a priority for other priorities
Preparation of the patient lasts from the pre-hospital phase to the hospital phase. In the
pre-hospital phase, emphasis is placed on airway maintenance, bleeding and shock control,
immobilization of the patient, and immediately to the nearest hospital with adequate
facilities. Preparations to the hospital phase include the preparation of the human resources,
facilities and infrastructure needed for resuscitation.
B. Formulation Of The Problem
1. What is the definition primery survey?
2. What is the management primery survey (A-B-C-D)?
C. The Purpose Of The Problem
1. Knowing about the definition primery survey
2. Knowing about management primery survey (A-B-C-D)

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 CHAPTER II

BODY

A. Definition
Primary surveys are preliminary assessments of patients, aiming to identify quickly and
systematically and take action on any life-threatening issue. Primary surveys should be
conducted in no more than 2-5 minutes. Simultaneous treatment of trauma can occur when
there are more than one life-threatening situation
B. Menagement Primery Survey (A-B-C-D)
1. Airway Management
The main priority is to create or maintain a free airway.
a. Talking to the patient
A patient who can speak clearly must have a free airway. Unconscious patients
may require airway and ventilation assistance. The cervical vertebrae should be
protected during endotracheal intubation in case of head, neck or chest trauma.
Airway obstruction is most commonly caused by tongue obstruction in unconscious
patients.
b. Check response shout for help
Open airway check breathing
1) Assessment
After assessing consciousness, the helper must be able to assess the airway
function promptly. In conscious and voiced victims, airway biasas are said to be
free or no disturbance. In nonvoice or unconscious victims, the assessment of the
airway may be performed by:
a) Look (see)

Looking directly into the oral cavity is the absence or obstruction of the
airway.

b) Listen (hear)
Listen to the victim's breath. The existence of snoring or gurgling.

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 c) Feel (feel)
Feel with the cheek or the back of the hand the breath from the victim.
2) Airway obstruction
Airway obstruction is the quickest killer, faster than breathing and
circulation. Moreover breathing improvement is not possible if there is no airway
patent. Total or partial airway obstruction.
a) Total Obstruction
In total obstruction may be found the patient is still conscious or
unconscious. In an acute total obstruction, it is usually caused by ingestion of
a foreign object which is then caught and clogged in the larynx (choking).
When the total obstruction arises slowly it will start from partial obstruction
which then becomes total.
b) Partial Obstruction
Partial obstruction can be caused by various things. Usually the sufferer
can still breathe so that various sounds arise, depending on the cause:
- Liquids (blood, secret, gastric aspiration) : Arise sound "gurgling", sound
breathing fluid-filled sound. In this situation the suction must be
performed.
- The tongue is falling backward: This condition can occur due to
unconscious or broken bilateral jaw. Snoring sounds that must be overcome
by Airway repair, either manually or by means.
- Refinement in the larynx or trachea: Can be caused by udema due to
various things (burns, inflammation, etc.) atapun neoplasm insistence.
Rising sounds "crowing" or stridor respiratori. This situation can only be
resolved by the distal airway repair of the blockage, eg by tracheostomy.
c. Management of the airway
Efforts that can be made to maintain and liberate the airway due to falling back
tongue are as follows:
1) Head Tilt (head extension)

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 By pressing the head (forehead) down the airway will be in a straight and
open position. This action is not recommended anymore because of the magnitude
of movement caused by the cervical.
2) Chin Lift (lift chin)
Lifting the chin using the finger with the intent of the tongue that clog the
airway can be lifted so that the airway is open. If done in a way this will not cause
much movement in the cervical.
3) Jaw Thrust (pushing the jaw)
Pushing the victim's mandibulan (jaw) to the front with the same intention as
the chin lift. The mandible is lifted up by the middle finger at the angle of the jaw
(mandibular angulus), the thrust on the chin is performed by the thumb, and the
index finger as a counterweight in the mandibular ramus.
4) Orofaringeal Airway (Guedel)
This tool serves to keep the airway to remain free from blockages.
Oropharygeal Airway inserted into the mouth and placed behind the tongue.
2. Breathing and Ventilation-Oxygenation
Good airway does not guarantee good ventilation. Good ventilation includes good
function of the lung. Thoracal walls, and diaphragms. The shrub that covers the victim's
chest should be opened to see the victim's breathing.
a. Assessment
1) Normal breathing.
The speed of human breathing is:
- Adult: 16-24 x / i
- Children: 15-45 x / i
- Baby: 30-50 x / i
In adults abnormal when breathing> 30 x / min or <10 x / min. Breathing is
generally torako-abdominal while in children the abdominal breathing is more
dominant. If always have to think about the possibility of spinal cord injury.
2) Shortness of breath
Shortness of breath may or may not be noticeable. When it looks it will
probably be found:

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 - Patients complain of tightness
- Breathing fast
- Respiratory Nose Breathing
- Use of additional breathing muscles:
Suprastrenal retractions
Intercostal retraction
Internal retraction
Infrasternal retraction
- There may be cyanosis
b. Physical examination :
1) Inspection (Look) of respiratory frequency is important. Is there one of the
following:
- Cyanosis
- Trauma puncture
- The presence or absence of chest wall movement
- Injuries to the chest
- Is there any use of additional breathing muscles
2) Palpation (Feel)
- Tracheal shift
- Fracture costae
- Subcutaneous emphysema
- Pneumothoracic
3) Auscultation (Listen)
- Pneumothorac (breath sounds decreased in the trauma area)
- Detection of abnormal sounds to the chest
c. Management
1) Administration of high concentration oxygen (nonrebreather mask 11-12 liters /
min)
2) Ventilation with Bag Valve Mask
3) Eliminates tension pneumothorax

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 4) Closes open pneumothorax
5) Installed a pulse oximeter
3. Circulation management
After handling the respiratory system, the circulatory system can be assessed by:
a. Checking the pulse (radialis or carotis)
In adults and children, the pulse is touched in the radial artery and the caritis
artery (medial of M. Sternocleidomastoideus). While in infants, feel the pulse is on A.
Brachialis, ie on the medial side of the upper arm. The frequency of heart rate in adults
is 60-100 times / min. When less than 50 times / min is called bradycardia and more than
100 times / min is called tachycardia. A normal bradycardia is often found in trained
athletes. In infants the heart rate frequency is 85-200 times / min while in children is 60-
140 times / min. In shock if found bradycardia is a bad diagnostic sign.
- Assess skin color
- Feel the temperature of acral and capillary refill
- Check for bleeding
Circulation with bleeding control
a. Assessment
1) Know the source of fatal external bleeding
2) Know the source of internal bleeding
3) Check the pulse: speed, quality, regularity, pulsus paradoxus. The absence of
pulsation from large arteries is a sign of the need for immediate massive
resuscitation.
4) Check the skin color, recognize the signs of cyanosis.
5) Check the blood pressure
b. Management
1) Direct emphasis on external sources of bleeding
2) Recognize internal bleeding, the need for surgical intervention and consultation
with the surgeon.
3) Install 2 large-sized IV catheters and take blood samples for routine examinations,
blood chemistry, pregnancy tests (in women of childbearing age), blood type and
cross-match and Blood Gas Analysis (BGA).

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 4) Give liquid crystalloid that has been warmed with fast droplets.
5) Install PSAG / pneumatic splints for bleeding control in patients with life-
threatening pelvic fractures.
6) Prevent hypothermia.
4. Disability
Towards the end of the primary survey, a rapid evaluation of the neurological state
was performed. What is considered here is the level of consciousness, as well as the size
and reaction of the pupil. A simple way to assess awareness is the AVPU method.
A : Awake (full awake)
V : responds to Verbal command (no reaction to the command)
P : responds to Pain (no reaction to pain)
U : Unresponsive (no reaction)
Glasgow Coma Scale (GCS) is a simple scoring system that can predict patient
outcomes. This GCS can be done in place of AVPU. If not done in the primary survey,
should be done in the secondary survey at the time of neurological examination
Decreased consciousness can be due to decreased oxygenation and / or decreased
brain perfusion, or due to direct trauma to the brain. Decreased awareness demands
reevaluation of the state of oxygenation, ventilation and perfusion. Alcohol and drugs can
disrupt the level of awareness of the patient. However, when hypoxic or hypovolemic is
excluded as a cause of consciousness decline, capitis trauma is thought to be a cause of
consciousness, not alcoholism, until proven otherwise.

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 CHAPTER III
END

A. Conclision
Primary surveys are preliminary assessments of patients, aiming to identify quickly and
systematically and take action on any life-threatening issue (European Resusitasion, 2005).
Primary surveys should be conducted in no more than 2-5 minutes. Simultaneous treatment
of trauma can occur when there are more than one life-threatening situation
These include:
1. Airway
2. Breathing
3. Circulation
4. Disability

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 REFERENCE

American College of Surgeons. (1997). Advanced trauma life support for doctors. instructor
course manual book 1 - sixth edition. Chicago.