Primary and Secondary

Survey Pre Hospital

Hariyono
Nursing Staff, Institute of Health
Science Jombang

Tujuan Pembelajaran
Umum
Setelah mengikuti mata kuliah ini mahasiswa
akan dapat melakukan primary survey dan
secondary survey pre hospital

Khusus
Menjelaskan langkah langkah dalam
primary survey & secondary survey pre
hospital
Menjelaskan prioritas pemeriksaan
Menjelaskan intervensi yang harus dilakukan
dalam primary survey & secondary survey
pre hospital

Scene Survey
Is scene safe?
Protect Self/Team (Universal
Precautions).
Protect your patient.
Find Clues for Mechanism of injury/history.

Number of patients.

PRIMARY SURVEY
Adult / Pediatric priorities same
Identified the life-threatening conditions and
simultaneously managed
A: Airway maintenance with cervical spine
protection
B: Breathing and ventilation
C: Circulation with hemorrhage control
D: Disability ( Neurologic status )
E: Exposure / Environmental control: Undress the
patient & prevent hypothermia

Airway
Assesment of the airway is always the
initial step in trauma patient care,
because of the potential for cervical
spine injury in this population
Maintain head and neck in a neutral
position while placing a rigid cervical
collar and immobilizing the patient on a
long spine board

Listen for spontaneus vocalisation

indicating air movement across the
cords
If vocalisation absent, opent the patient
airway using a chinlift or modified jaw
thrust manuever
The airway may be partially or entirely
obstructed by fluid ( blood, saliva,
emesis ) or debris such as teeth, food
or foreign bodies

Intervensi
Bila airway aman tidak ada masalah
- Amankan jalan nafas, stbilkan dan
imobilisasi tulang leher
- Stabilisasi dan mobilisasi setiap
pasien maupun bila mana ditemukan
cedera yang dicurigai kearah cedera
spinal

Pada korban yang jalan nafasnya tersumbat

total / sebagian
Letakkan pasien pada posisi telentang
Bilamana posisi pasien tidak dalam posisi ini
sebelumnya balikkan pasien dengan metode
Logroll
Stabilkan tulang leher Cervical Collar
Bila tulang leher korban blm distabilkan,
stabilkan kepala secara manual dgn
memegang / menahan kepala dlm posisi
netral

 Buka jalan nafas dan bersihkan Jaw

thrust, chin lift
Pertahankan tlg leher pd posisi netral
jgn hiper ekstensi, fleksi, memutar
leher waktu melakukan tindakan
Suction harus dilakukan perlahan
agar tdk merangsang muntah shg bisa
mengakibatkan aspirasi

 Memasang oro / naso pharingeal tube

Mempertimbangkan pemasangan
intubasi endo trakea
Ventilasi BVM sesaat menjelang
dilakukan intibasi endotrakea
Pemasengan intubasi endotrakea
dilakukan dgn posisi tlg leher pada
posisi netral
Pada beberapa kasus perlu
dipertimbangkan penggunaan obat
penghambat neuro muskuler /
kombinasi obat lain untuk memudahkan
intubasi

Cervical Spine Injury

Include in airway management.
Suspect in all blunt trauma
victims, unconscious patients.
Stabilize and immobilize neck.
Dont use head-tilt.

Breathing
Kondisi kondisi pernafasan yang
mengancam jiwa dpt diketahui bila
ditemukan hal hal :
- Trauma dada
- Korban menghantam setir mobil
- Energi akselerasi, deselerasi
maupun gabungan keduanya

Breathing
Bila mana jln nafas sdh diamankan,
lakukan penilaian :
Pernafasan spontan atau tidak
Naik turunnya dada
Warna kulit
Jumlah pernafasan
Pola/ciri pernafasan
Integritas jaringan lunak dan struktur
dinding dada yang keras
Pengunaan otot bantu pernafasan
Suara nafas
Konsisi vena jugularis

Tindakan Intervensi
Korban bernafas dengan efektif
Berikan oksigen mll masker non
rebreathing dgn kecepatan aliran cukup
untuk mengembangkan kantong udara,
waktu inspirasi biasanya membutuhkan
12 L-15 L

Korban bernafas tapi tdk efektif

Kriteria :
1. Status mentak berubah buruk
gelisah, agitasi
2. Sianosis
3. Pengembangan dada tidak simetris
4. Penggunaan otot bantu nafas
5. Sucking chest wound
6. JVD
7. Suara nafas melemah

Tindakan :
Berikan nafas mll masker no rebreathing
( oksigen konsentrasi tinggi ) atau bantu
ventilasi menggunakan ambubag
Kalau perlu lakukan intubasi

Korban tidak bernafas

Beri segera ventilasi pakai alat ambubag
dgn sistem pengantaran oksigen
Segera pasang intubasi endotrakeal lalu
beri ventilasi mll sistem reservoar oksigen
yang terpasang
Bila dijumpai gg pernafasan yang potensial
mengancam nyawa segera atasi, bilasdh
berhasil baru melanjutkan cirkulasi

Circulation
Assess circulatory function:
Central & peripheral pulse
Pulse rate and character
Skin color, moisture & temp

Circulation
Identify life-threatening hemorrhage:
Rapid , Arterial , Massive amount
Control hemorrhage:
Direct pressure , Splint and elevate,
Tourniquet
Identify internal hemorrhage.

Pasang kanula ukuran besar 14 dan

16
Gunakan cairan yang masih hangat
Pakai lat khusus AS untuk
mempercepat aliran infuse
Gunakan NS bila akan digunakan untuk
tranfusi
Bila perlu pasang CVP
Ambil sampel darah

Bila tidak ada sirkulasi

Mulailah CPR
Lanjutkan dengan ACLS

Disability
Identify level of consciousness
A-alert
V-verbal commands
P-pain
U-unresponsive

Pupil response and size

Intervensi
Bila ada penurunan tkt kesadaran
lakukan pemeriksaan yang lebih
berfokus pada saat penilain sekunder
Bila pasien tidak sadar / tdk bereaksi
teruskoan monitor airway, breathing dan
sirkulasi

Expose
Remove clothing as needed .
Maintain body temperature.
Inspect/palpate the entire
body.
Log roll to expose back.

Full vital sign, Five Intervention

Monitor denyut dan ritme jantung EKG
Pasang pulse oksimetri
Pasang indwelling kateter monitor out
urine
Pasang NGT
Lakukan px lab Gol darah, ureum,
elektrolit, glukosa, AGD, faktor pembekuan

Give Comfort
Intervensi
Beri obat analgetik
Meletakkan pasien pd posisi yang benar
Distraksi dan relaksasi
Menghibur klien

History / Head to toe

Kepala
Cedera pada jaringan lunak
Perubahan bentuk tulang
Ekpresi wajah waktu bicara
Rinorhoe
Otorhoe
Battle sign
Raccon Eye

The rapid Assessment

Neck
Inspect/palpate : DCAP BLS, JVD, Trache
deviation, pain
Chest
Inspect/palpate : DCAPP BLS, Auscultate
for breath sounds, Percuss
Abdomen
Inspect/palpate : DCAP BLS, Tenderness

The rapid Assessment

Pelvis
Inspect/palpate DCAP
BLS, TIC
Musculoskeletal
Inspect/palpate DCAP
BLS, TIC, PMS
Load and Go

Kriteria Load and Go

Obstruksi jalan nafas yg tdk dpt diatasi scr mekanik(suction,
forceps atau intubasi)
Henti jantung karena trauma
Keadaan yg menimbulkan pernafasan tdk adekuat (open
pneumothotax, flail chest, tension pneumothorax, trauma
dada yg luas
Shock
Trauma kepala tdk sadar, pupil anisokor/penurunan
kesadaran
Nyeri abdomen
Pelvis tdk stabil
Fraktur femur bilateral

SECONDARY SURVEY
History
A. Allergies
M. Medications currently used
P. Past illness / pregnancy
L. Last meal
E. Events / Environment related to injury

HISTORY
Mechanisms of injury
Blunt

Automobile collisions

Seat belt usage

Steering wheel deformation
Direction of impact
Ejection of passenger form the vehicle

Burns and Cold injury

Inhalation injury and CO. intoxication in fire field

Hazardous environment
Penetrate
Anatomy factors
Energy transfer factor

Velocity and caliber of bullet

Trajectory
Distance

SECONDARY SURVEY
Physical Examination

Head and Maxillofacial

Inspect and palpate head and face (DCAP
BLS, TIC)
Battles sign
Pupils and LOC
Raccoon eyes
Ears and nose for CSF
Mouth
Skin : pale, cyanosis, diaphoresis

SECONDARY SURVEY
Reassess ABCs
Vital sign
Physical Examination
C-spine and Neck

Inspect for signs of injury, tracheal deviation

- Palpate for tenderness,DCAP - BLS,
subcutaneous emphysema
- Auscultate for carotid bruits

SECONDARY SURVEY
Physical Examination
Chest
Inspect ant, lat and post chest for injury, use of
accessory
- Auscultate for breath sounds
- Palpate for DCAPP BLS, TIC
- Percuss

SECONDARY SURVEY
Physical Examination
Abdomen

- Inspect & palpate for signs of injury or

bleeding DCAP - BLS
- Auscultate for bowel sounds
- Percuss

SECONDARY SURVEY
Physical Examination
Musculoskeletal
- Inspect & Palpate extremities for signs of
injury (DCAP BLS, TIC, PMS)
- Assess pelvis (DCAP BLS, TIC)

SECONDARY SURVEY
Physical Examination
Neurologic

Determine GCS score

Re-evaluate pupils
Sensory / motor evaluation
Maintain immobilization
Prevent secondary CNS injury
Early neurosurgical consultation

Reassessment Survey
The level of Consciouss
Reassess ABCs
Neck, chest, abdomen, pelvis, ekstremitas
Focused Assesment of Injuries
Check Intervention
( patient is not stable every 5 minute, patient
is stable every 15 minute)

SUMMARY
Initial assessment & management of multiply
injured patient
Primary survey ( ABCDEs )
Resuscitation & monitor ( life-threatening problems
)
Secondary survey ( head-to-toe, history )

Questions?

Referrence
1. Lanros & Barber (1997) Emergency Nursing :
with Certification, Preparation, & Review.USA :
Appleton & Large
2. Springhouse corporation book division (1985).
Nurses Reference Library : Emergencies.
Pennsylvania : Springhouse corporation
3. _____ (1998) Pertolongan Dasar Gawat Darurat
Trauma : Malang.RSUD Dr Saiful Anwar
4. http://www.adhb.govt.nz/trauma/T_guidelines/pr
imary_survey.htm
5. Suhttp://sprojects.mmi.mcgill.ca/trauma/educ/
tutorials/surveys.htmrvey