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.

Don’t 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)
Battle’s 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).
Nurse’s 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/pri
mary_survey.htm
5. Suhttp://sprojects.mmi.mcgill.ca/trauma/educ/
tutorials/surveys.htmrvey