INITIAL ASSESMENT

MANAGEMENT

Dr. Resiana Karnina, Sp.An

Departemen Anestesiologi dan Terapi Intensive

RS. Pertamina Jaya Jakarta
INTRODUCTION
The main role of the doctor is
 SAVING LIFE

 ALLEVIATE SUFFERING

Any doctors should have these

competences.
The main tool of saving life is
“BASIC LIFE SUPPORT “
ACCIDENTS OR DISASTERS

Accidents or disasters may occur to :

 ANY WHERE

 ANY TIME

 ANY ONE

Well preparedness is very important

( soft-ware and hard-ware ) harus tau
bagaimana mempersiapkan dengan
baik
 What is “EMERGENCY” in Medicine ?

A medical condition that starts suddenly and

requires immediate care (membutuhkan
pertolongan segera)

A life or limb threatening medical condition

resulting from an injury or sickness that
requires immediate treatment and, if left
untreated, could result in permanent harm
to the person.
 Some Example of Emergency Conditions

Conditions such as:

heart attack, uncontrollable bleeding, loss

of consciousness, convulsions, severe
allergic reactions, poisoning, severe
shortness of breath or difficulty
breathing, or severe or multiple injuries,
including obvious fractures.
The Cause of Death in US

 Traffic accidents are the third cause of

mortality after CVS and Cancer
 Disease of the young, leading cause
death age 1 to 40 years
 > 100,000 death /year in US
 Loss of productive work years
 Trauma management is expensive
Epidemiology of Trauma Death

 Trimodal patterns
 Donald Trunkey ATLS
50%
Death 30%
20%
%

sec hr days/week
 Trauma Death

 First Peak
 Death that occurs at
impact or soon after the
accident
 50 % death

 Not preventable

 severe head

laceration, massive
bleeding, heart injury
etc.
 Prevention of accidents

 enforcement,

education &
awareness
(pencegahan)
 Trauma Death
 Second Peak
 Death within minutes

to hours after injury

 “ Golden Hours ”

 30 % of death

 Life threatening

injuries involving
airway, breathing ,
circulation
 Trauma Death

 Airway
 obstruction: tongue(lidah jatuh kebelakang

ngikutin jalur napas), secretion &

blood(tergigit jadi berdarah), vomitus
 difficult airway management

 Breathing & Ventilation

 pneumothorax,heamothorax, penetrating

chest injuries(luka tusuk), flail chest

 Circulation
 hemorrhage, cardiac tamponade
Second Peak
 Preventable
 Reflect
 adequacy, efficiency of EMS

(emergency medicine start) in

prehospital resuscitation
 hospital emergency department

resuscitation
 definitive therapy
 Third peak

 Third Peak
 Death within days or week

after injury
 20 % death

 Sepsis or multiorgan failure

 Reflects again efficiency at

resuscitation, definitive
care, aggressive ICU care,
prevention of infection and
rehabilitation
 INITIAL ASSESMENT

Initial assessment include :

1. Preparation( siap diri apd, pasien posisi, alat ,
obat adrenalin dll)
2. Triage ( label kuning merah item)
3. Primary Survey ( ABCDE )
4. Resuscitation
5. Secondary Survey ( Head to toe evaluation )
6. Definitive Care(operasi)
Initial assesment
 Mentreatmen nilailah pasien dengan
cepat
 Waktu sangat krusial dalam penaganan
pasien trauma
 Kerja tim yang baik
1. PREPARATION
Preparation of the trauma patient occurs
in two different clinical settings

1. PRE-HOSPITAL PHASE
2. IN HOSPITAL PHASE
 Kita suruh pihak rs untuk persiapkan
sblm pasien datang
 PRE HOSPITAL

Transportation is very important

Prehospital Trauma Resuscitation

 Definitive care ? GOALS

 A clear airway, effective ventilation,

hemorrhage control & restoration of

adequate blood volume, external
bleeding di control, imobilisiasi supaya
tdk permanen harm, cari rs yang deket
Pre hospital Care

 Ambulance Response
Time: Standard
 50 % of all calls are

responded within 8
min. (harus direspon
cepat dlm 8 mnt)
 95 % of calls within 14

min. (urban)
 95 % of calls within 19

min. (rural )
 Nolan JP, Pars. BJA
1997;79,226-240
 Pre hospital Communication

 Communication

 Vital between prehospital & in-hospital

trauma patient resuscitation
 Prepare ED personnel well ahead
 Activation of TRAUMA TEAM / DISASTER
PLAN into action
Hospital phase
 Mempersiapkan
operasi, anastesi ,
dll udah siap.
Tes2 in alatnya.
Cairan jg siapin.
Protokol hrs di
tempat
dokter2nya
2. Triage

 ‘trier’ sorting out

(menelaah pasien),
berdasarkan ABCD

 Is the sorting of patient

based on the need for
treatment

 Triage
 Resuscitation Room

 Activation of trauma

team
 Trauma Team-work
 Efficient method
 Trained doctors & nurses
 Variety of tasks taken
simultaneously(ngga perwat
dulu atau dokter dulu,
semua hrs kerja sma)
 horizontal organization

 reduced time to life-

saving procedure by 50
%
Trauma Team at Work

 “ Pit stop in a formula

1 motor race ”

 Managing trauma in a
smooth and efficient
manner

 Do no further harm
3. The Primary Survey
 Airway & cervical spine
control
 Breathing & ventilation
 Circulation & haemorrhage
control
 Disability(kesadaran)
 Exposure/Environment
 Di ident, tanya
aja namanya, apa
yg terjadi kalo
bisa jawab, berati
airway klir, dan
breathing ga
masalah kalo dia
bisa bicara dia
cukup sadar(abcd
aman )
 Airway & Cervical Spine Control

 Difficult Airway
 Goal
 Keep airway patent

 protect

compromised
airway
 provide airway if

none( pasien
trauma muka ,
gamungkin napas ,
bikin jalan napas
midle ,
 Cervical spine Fracture

 Suspect:

 Unconscious patients
 Injury above clavicles
 Neck pain
 Weakness or
neurological deficit
 History of fall > 6 m
 Multipel trauma
Breathing & Ventilation

 Patient in increasing respiratory distress, BLUE,

BLUE, BLUE, BP DOWN, Not Recordable…...

 Think :Tension Pneumothorax, haemotothorax,

Flail chest, lung contusion, cardiac tamponade

 Goals: Avoid Hypoxia, Hypercarbia.

Bad for the Brain
TENSION PNEUMOTHORAX
Circulation
Haemorrhage Control with Fluid therapy
 First Priority : Restore volume with fluid (RL/NaCl
0.9% ) kemabaliin cairannya
 Second Priority :

Restore blood with WB and PRC transfusion

to restore oxygen carrying capacity, ganti cioran
dg darah, darah mngikat oksigen sehingga tdk
hipoxia
 Remember : did not die of anemia but die of
hypovolemic shock
 Third Priority : Normalize coagulation status

 FFP, Platelet, blood products

Disability
( Neurologic Evaluation )

 Rapid Neurologic evaluation is perform at the

end of primary survey

 Simple Neurologic evaluation is AVPU method,

selain GCS
 A  Alert

 V  Responds to Vocal stimuli disentuh ,

dipanggil
 P  Responds only to Painful stimuli dicubit

 U  Unresponsive to all stimuli, ga berespon

di apa2in
4. Resuscitation
 Aggressive resuscitation and the management of life
threatening injuries

 Essential to maximize patient survial

 Airway should be protect and secure

 Jaw thrust or Chin lift maneuver

 Definitive airway if needed

 Breathing/ventilation and oxygenation

 Injured patient should received supplemental O2
 Circulation
 Controlled bleeding by direct pressure or operative
intervention
End- Points of Resuscitation
 Traditional:
 Achieved definitive care

 Blood Pressure/ cerebral perfusion

pressure/ ICP
 Heart rate

 Urine output
5. Secondary Survey
 Not begin until the Primary Survey is completed

 Is Head to Toe evaluation(kalo BCDE udah kelar)

 Head

 Maxillofacial

 Cervical spine and Neck

 Chest( pneumothorak)

 Abdomen (jejas)

 Perineum / rectum / vagina

 Musculoskeletal

 Neurologic
6. Definitive Care

 Surgical intervention
 Transfer to higher trauma center
Conclusion

 Trauma continues to be the most common

cause of death
 BLS(basic life suport) playing a big role in
saving life in pre-hospital phase or in
hospital
 “Do No Further Harm” is the basic
principle of BLS
 ABCDE is a good guide to take action.