Primary Survey Assessment (Penilaian dan Penanganan Survei Primer)

Departemen Anestesiologi dan Reanimasi FK USU 2010

Emergency Medicine
TRIAGE PRIMARY SURVEY SECONDARY SURVEY STABILISATION TRANSFER DEFINITIVE CARE TRIASE SURVEI PRIMER SURVEI SEKUNDER STABILISASI RUJUKAN TERAPI DEFINITIF

Tujuan Survei Primer

Secepat mungkin menemukan kelainan yang mengancam jiwa (cepat mematikan)
di sektor A - B - C - D

Memberikan pertolongan yang memadai untuk menyelamatkan jiwa Pertolongan meliputi : Resusitasi Stabilisasi

Concepts of Primary Survey

Rapid Primary survey Resuscitation Adjuncts to primary survey /resuscitation Detailed secondary survey Adjuncts to secondary survey Reevaluation Definitive care

Korban ledakan tabung elpiji Muka hangus Pneumotoraks (blast injury) Luka bakar luas Fraktura betis kiri

Jangan terpukau kelainan yang jelas terlihat

Ikuti Sistematika A - B - C - D

Derajat kegawatan korban berbeda-beda Survei primer Triage Survei sekunder

Terapi definitif / rujukan RS lain Kamar Operasi

RESUSITASI & STABILISASI

ICU
Emergency Medicine Hanya 50% pasien trauma perlu operasi

Triage
Sorting of patients according to : ABCDEs Available resources Multiple casualties Mass casualties

 ACS

Primary Survey
Primary survey and resuscitation of vital functions are done simultaneously a team approach

Preparation
Prehospital System

Transport guidelines /protocols On-line medical direction Mobilization of resources Periodic review of care Closest appropriate facility

Preparation
Inhospital

Preplanning essential Equipment, personnel, services Standard precautions Transfer agreement

Standard Precautions
Cap Gown Gloves Mask Shoe covers Goggles/face Shields

Survei Primer

Periksa cepat berurutan Selesai dalam 2 menit Terapi segera apa yang ditemukan ( treat as you find )

Survei Primer
Airway Breathing Circulation Disability Exposure Jalan nafas Pernafasan Sirkulasi Kesadaran Pemaparan

Mulai dengan Survei Primer

Mencari dengan cepat gangguan fungsi vital di sektor A-B-C-D Memberi terapi suportif dengan cepat pada fungsi yang terganggu

Setelah fungsi vital stabil Survei Sekunder

Mencari gangguan fungsi vital dengan teliti Memberi terapi definitif pada fungsi yang terganggu

Resuscitation
Protect and secure airway Ventilate and oxygenate Stop the bleeding Vigorous shock therapy Protect from hypothermia

Survei Primer
Airway Breathing Circulation Disability Exposure

Sumbatan jalan nafas pasien tak sadar paling sering disebabkan pangkal lidah

Airway
menilai jalan nafas

Kesadaran (bisa bicara?) Look, Listen and Feel Gerak dada Gerak otot nafas tambahan Warna kulit, mukosa, kuku

Airway
mengatasi obstruksi / sumbatan jalan nafas

Lakukan chin lift / jaw thrust Bersihkan rongga mulut (suction?) Pasang jalan nafas oro / nasopharynx Lindungi tulang leher Intubasi trachea

20

JN NasopharynxJaw thrust

JN Oropharynx

Walaupun tanpa intubasi masih banyak pasien dapat ditolong

JN Nasopharynx

21

Head tilt

Neck lift

Chin-lift

22

Airway
waspada

Obstruksi (sumbatan) jalan nafas Cedera dada dengan gangguan nafas Cedera tulang leher

Lindungi leher dari gerakan

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.

24

Primary Survey
Establish Patent Airway C-spine injury Pitfalls
Caution

Equipment failure Inability to intubate Occult airway injury Progressive loss of airway

Primary Survey
Suspect C-Spine Injury Spinal protection C-spine X-ray when appropriate

Survei Primer
Airway Breathing Circulation Disability Exposure

Breathing
menilai pernafasan

Adakah udara keluar masuk

Look, Listen, Feel

Frekwensi nafas Gerak cuping hidung Cekungan sela iga

Breathing
membantu pernafasan

1. Oksigen (jika ada) 2. Pernafasan buatan 2. 2.

1.

29

Jejas di dada:

Breathing
waspada
- Pneumotoraks tension - Fr costa / Flail chest - Hemotoraks berat - Kontusio paru

- Pneumotoraks terbuka

30

Dekompresi pneumotoraks (tension) harus dikerjakan dalam Primary Survey

Survei Primer
Airway Breathing Circulation Disability Exposure

Circulation
mengatasi perdarahan

Hentikan perdarahan Posisi shock Pasang infus besar x 2 Ambil sampel darah

u/ darah donor dan periksa Hb

Beri infus cairan, 1000 ml cepat

Circulation
mengatasi perdarahan

Beri infus cairan, 1000 ml cepat

RL (Ringer Laktat) NaCl 0.9% (Garam Fisiologis) RA (Ringer Asetat) Hypertonic Saline Dextran 250 ml

Shock ?
Perfusi :
pucat - dingin - basah cap. refill time lambat (kuku, telapak)

Nadi > 100 Tekanan darah < 100 (atau 90) mmHg
Nadi masih teraba di :
radialis > 80 mmHg femoralis > 70 mmHg carotis > 60 mmHg

Circulation
waspada & cari lokasi perdarahan

Cedera intra-abdominal Cedera dada Patah tulang panjang Patah tulang pinggul Luka tusuk / tembus Luka kulit kepala

Primary Survey
Circulatory Management Control hemorrhage Restore volume Reassess Pitfalls Elderly Athletes Caution

Children Medication

Survei Primer
Airway Breathing Circulation Disability Exposure

Disability
menilai kesadaran

Periksa Pupil (besar, simetri, refleks cahaya) Periksa kesadaran A = Awake (sadar penuh) V = responds to Verbal command
(ada reaksi terhadap perintah)

P = responds to Pain (ada reaksi terhadap nyeri) U = Unresponsive (tak ada reaksi)

A- V - P - U Pupil

Primary Survey
Disability Baseline neurologic evaluation GCS scoring Pupillary response Observe for neurologic deterioration

Caution

Survei Primer
Airway Breathing Circulation Disability Exposure

Exposure
pemaparan

Lepaskan semua pakaian untuk pemeriksaan teliti menyeluruh, ada jejas apa saja Periksa punggung!

miringkan pasien cara Log-roll

Cegah hipotermia (kedinginan)

Primary Survey
Exposure / Environment Completely undress the patient
Prevent hypothermia
Caution

Survei Primer
Foto Dada sinar-X / Chest X-Ray ( jika ada) Tulang leher / C - Spine(lateral) Panggul ( Pelvis ) Abdominal USG

Adjuncts to Primary Survey

Vital sign ECG Urinary Output Adjuncts ABGs Pulse oximeter and CO

Urinary/gastric catheters unless contraindicated

Adjuncts to Primary Survey

Diagnostic Tools Chest and pelvic x-ray DPL Ultrasound

ACS

Adjuncts to Primary Survey

Consider Early Transfer Do not delay transfer for diagnostic tests Use time before transfer for resuscitation

Special Considerations
Trauma in the Elderly th leading cause of death 5 Physiologic reserve Comorbidities : Diseases/medications Outcome depends on early, aggressive care

Survei Sekunder

Lanjutan dari survei primer Hanya bila ABC sudah stabil Teliti kepala sampai jari kaki Kembali ulang survei primer jika pasien tidak stabil / kondisi memburuk

Reevaluate
Proceed to Secondary Survey After :

Primary survey completed ABCD Es are reassessed Vital functions are returning to normal