INITIAL ASSESSMENT FOR TRAUMA

ByRossi M I Sebayang

PENDAHULUAN

KEMAJUAN LALU LINTAS - PENGGUNA JALAN- JUMLAH KENDARAAN- JARINGAN JALAN- KECEPATAN KENDARAAN

ANGKA KEJADIAN KECELAKAAN LALIN / TRAUMA ME ↑

KECELAKAAN / TRAUMA

-TAK DIKETAHUI

- KAPAN

- DIMANA

- KENAPA

PERLU PERTOLONGAN !!!

CEPAT BENAR

-TEMUKAN PENDERITA GAWAT DARURAT

- MINTA PERTOLONGAN / TEAM

- KUALITAS PERTOLONGAN

- PRASARANA / PRASARANA

BASIC PRINCIPLES

TRAUMA

DEATH MORBIDITY

PRE HOSPITAL

- Transport guidelines/protocolsOn-line

medical direction

- Mobilization of resources

- Periodic review of care

PHASES OF TRAUMA CARE

INHOSPITAL

- TRIAGE

- PRIMARY SURVEY

- RESUSCITATION

- SECONDARY SURVEY

- CONTINUED MONITORING

- DEFENITIVE TREATMENT

PHASES OF TRAUMA CARE

CHILDREN YOUNGER

ADULT ELDERLY

PREGNANT WOMEN

PRIORITIES ARE THE SAME

TRAUMA IN

OBJECTIVE

Identifikasi prioritas managemen

Aplikasi prinsip2 primary dan secondary survey

Lakukan resusitasi & monitoring

Perhatikan riwayat kejadian & biomekanik injury

Antisipasi bahaya/kesulitan2 yang tersembunyi

In general, trauma triage and initial care is based on a step-wide evaluation of both anatomic

injury and physiologic stability.

PRIMARY SURVEYElderly, adult, younger, children, pregnant women : Priorities are the same

A : Airway + C-spine protectionB : BreathingC : Circulation + hemorrhage controlD : DisabilityE : Exposure/Environment

PRIMARY SURVEY

A = AIRWAY / C – SPINE ≈ JALAN NAFAS /TL BELAKANG CERVIKAL• PASTIKAN BAHWA JALAN NAFAS BERSIH

- BENDA ASING- MANUVER

• KASUS SPESIAL• IN LINE TRACTION = TRAKSI SEGARIS• RESIKO TINGGI CEDERANYA C – SPINE • PITFALLS (HAL2 YG TERSEMBUNYI)

PRIMARY SURVEY

• B = BREATHING AND VENTILATION≈ BERNAFAS DAN VENTILASIBERSIHNYA JALAN NAFAS SAJA TDK MENJAMIN VENTILASI YANG ADEKUAT

PASIEN TRAUMA MEMBUTUHKAN PERTUKARAN GAS YANG ADEKUAT

EVALUASI DINDING DADAAUSKULTASI PARU-PARUPERKUSI ADANYA CAIRAN / DARAH

PRIMARY SURVEY

• B = BREATHING AND VENTILATION

≈ BERNAFAS DAN VENTILASIMAJOR INJURIES :

TENSION PNEUMOTHORAXFLAIL CHESTMASSIVE HAEMOTHORAXOPEN PNEUMOTHORAX

MINOR INJURIES : RIB FRACTURES

SIMPLE HAEMO / PNEUMOTHORAXPULMONARY CONTUSION

PRIMARY SURVEY

• B = BREATHING AND VENTILATION≈ BERNAFAS DAN VENTILASI

THE PATIENT IS DYSPNOE, TACHYPNOE RR = 35 X/i

YOU DECIDE TO INTUBATE / VENTILATE

PRIMARY SURVEY

• C = CIRCULATION AND CONTROL OF BLOOD LOSS≈ SIRKULASI DAN KONTROL PERDARAHAN

STATUS HAEMODYNAMIC PENDERITA DI ASSESS SECARA CEPAT

HYPOTENSION YG MENYERTAI TRAUMA ADALAH HYPOVOLEMIC KECUALI KENYATAAN SEBALIKNYA

HAEMORRHAGE ADALAH PENYEBAB KEMATIAN KE-2 PASCA TRAUMA

PRIMARY SURVEY

• C = CIRCULATION AND CONTROL OF BLOOD LOSS

CLINICALLY, ASSESS

1. LEVEL OF CONSCIOUSNESSBLOOD LOSS

C.V.P.

2. SKIN COLOUR

3. PULSE

PRIMARY SURVEY

• CONTROL BLEEDING

DIRECT PRESSURE BEFORE

USING TOURNIQUETS

BEFORE USING CLAMPS

PRIMARY SURVEY• CONTROL BLEEDING

≈ KONTROL PERDARAHAN

THINK OF THE SITE THORAX

ABDOMEN

RETROPERITONEUM

FRACTURE SITE

PENETRATING THORAX

PRIMARY SURVEY

• PITFALLS REGARDING BLOOD LOSS

BEWARE OF THE ELDERLY AND CILDREN

BEWARE THOSE ON BETA – BLOCKERS

BEWARE FIT MALES (ATLIT)

The Lethal Triad

• SHOCK Prolonged hypotension

Coagulopathy

Metabolic Acidosis

Hypothermia

DEATH

Rotondo MF, Zonies DH. Surg Clin North Am 1997; 77(4): 761-777

PRIMARY SURVEY

• D = DISABILITY → NEUROLOGICAL EVALUATIONDONE AT THE END OF THE PRIMARY SURVEY

DROP IN LVL. OF CONSCIOUSNESSRE – EVALUATE OXYGENATION, VENTILATION, AND PERFUSIONIS IT A DIRECT CEREBRAL INJURY ?ARE THERE ALCOHOL OR DRUGS INVOLVED ?

AVPU GCS

PRIMARY SURVEY

E = EXPOSURE / ENVIRONMENT

EXPOSURE IS IMPORTANT

LOGROLL THE PATIENT

MAINTAIN THE CORE TEMPERATURE

THE RESUSCITATION PHASE

• AGGRESSIVELY RESUSCITATE PATIENTS TO INCREASE SURVIVAL

AIRWAY BERSIHKAN, BEBASKAN, LINDUNGI IF THE PATIENT CAN’T MAINTAIN AIRWAY INTEGRITY

PLACE A DEFINITIVE AIRWAYINTUBATE WITH CONTINUOUS C – SPINE PROTECTION !!!

THE RESUSCITATION PHASE• BERIKAN CAIRAN – CRYSTALLOID OR COLLOID ??

• ATASI HYPOVOLEMIA DAN HAEMORRHAGE !!!

• HAMPIR SEMUA SHOCK PD TRAUMA ADALAH HYPOVOLEMIC !!!!

• HENTIKAN PERDARAHAN, BUKAN BERIKAN CAIRAN

• PULIHKAN VOLUME INTRAVASCULAR

MONITORING DURING RESUSCITATION

• ECG MONITORING SINUS TACHYCARDIAST CHANGESATRIAL FIBRILLATIONPEA (Pulseless Electrical Activity) BRADYCARDIA

• TUBESURINARY CATHETERSNASOGASTRIC DECOMPRESSION

MONITORING DURING RESUSCITATION

• TUBES

INSTRUMENT THE UNCONSCIOUS PATIENT CAREFULLY

BEWARE OF URETHRAL TRANSECTION

MONITORING DURING RESUSCITATION

• MONITORINGRESUSITASI YG ADEKUAT DI ASSESS DENGAN PARAMETER FISIOLOGIS- HR- BP- PULSE PRESSURE- RR- ABG ANALYSIS- URINE OUTPUT

MONITORING DURING RESUSCITATION

RE – EVALUATE ALL PARAMETERS

ALL THE TIME

SECONDARY SURVEY

• JANGAN DIMULAI SAMPAI ABCDE’s (PRIMARY SURVEY) TERSELESAIKAN

• JANGAN DIMULAI SAMPAI KEADAAN PASIEN MEMBAIK

• JANGAN DIMULAI SAMPAI FASE RESUSITASI MEMBAIK

SECONDARY SURVEY

• HISTORY AMPLEMECHANISM OF INJURY

• FULL EXAMINATIONHEAD AND FACENECKCHESTABDOMENMUSCULOKELETALNEUROLOGICAL

• IMAGING

IMPORTANT POINTS IN TRAUMA

• FULL ASSESSMENT

• EVALUASI BERKELANJUTAN DAN SELALU

DIULANGI

• MULTIDISCIPLINARY APPROACH

IMPORTANT EXAM POINTS IN TRAUMA

• BERPEGANG PD BASIC PRINCIPLES

• SETIAP PERMASAALAHAN TRAUMA SECARA GLOBAL DI ASSESSMENT DENGAN MENGGUNAKAN ATLS / ACLS PROTOCOLS