Primary Survey Assessment(Penilaian dan Penanganan

Survei Primer)Departemen Anestesiologi dan Terapi Intensif

FK – USU2011

TRIAGEPRIMARY SURVEYSECONDARY SURVEYSTABILISATION TRANSFERDEFINITIVE CARE

TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF

Emergency Medicine

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

Jangan terpukaukelainan yang jelas terlihat

Ikuti Sistematika A - B - C - D

Korban ledakan tabung elpiji

Muka hangusPneumotoraks (blast injury)

Luka bakar luasFraktura betis kiri

Triage

RESUSITASI & STABILISASI

Survei primerSurvei sekunder

KamarOperasi

ICU

Hanya 50%pasien traumaperlu operasi

Terapi definitif/ rujukan

Emergency Medicine

RS lain

Derajat kegawatankorban berbeda-beda

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

AirwayBreathingCirculationDisabilityExposure

Jalan nafasPernafasan SirkulasiKesadaran 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

AirwayBreathingCirculationDisabilityExposure

Sumbatan jalan nafas pasien tak sadar paling sering disebabkan pangkal lidah

Airwaymenilai jalan nafas

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

Airwaymengatasi obstruksi / sumbatan jalan nafas

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

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Walaupun tanpa intubasi masih banyakpasien dapat ditolong

JN OropharynxJN NasopharynxJaw thrust

JN Nasopharynx

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X

Neck lift

Head tilt

Chin-lift

Airwaywaspada

• Obstruksi (sumbatan) jalan nafas• Cedera dada dengan gangguan

nafas• Cedera tulang leher

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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.

Lindungi leher dari gerakan

Primary Survey

C-spine injury Pitfalls

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

Establish Patent Airway

Caution

Primary Survey

Suspect C-Spine InjurySpinal protection C-spine X-ray when appropriate

Survei Primer

AirwayBreathingCirculationDisabilityExposure

Breathingmenilai pernafasan

• Adakah udara keluar masuk– Look, Listen, Feel

• Frekwensi nafas• Gerak cuping hidung• Cekungan sela iga

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Breathingmembantu pernafasan

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

2.2.

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

- Pneumotoraks terbuka

Jejas di dada:

Breathingwaspada

Dekompresi pneumotoraks (tension)harus dikerjakan dalam Primary Survey

Survei Primer

AirwayBreathingCirculationDisabilityExposure

Circulationmengatasi 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

Circulationmengatasi 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

Circulationwaspada & 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 Children

Athletes Medication

Caution

Survei Primer

AirwayBreathingCirculationDisabilityExposure

Disabilitymenilai 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

AirwayBreathingCirculationDisabilityExposure

Exposurepemaparan

• Lepaskan semua pakaian untuk pemeriksaan teliti menyeluruh, ada jejas apa saja

• Periksa punggung!– miringkan pasien cara Log-roll

• Cegah hipotermia (kedinginan)

Primary SurveyExposure / Environment • Completely undress the patient

Prevent hypothermiaCaution

Survei Primer

Foto Dada sinar-X / Chest X-Ray ( jika ada)

Tulang leher / C - Spine(lateral)Panggul ( Pelvis )Abdominal USG

Adjuncts to Primary SurveyVital sign

ECG ABGs Urinary Adjuncts Pulse Output oximeter

and CO₂

Urinary/gastric catheters unless contraindicated

© ACS

Adjuncts to Primary Survey Diagnostic Tools• Chest and pelvic x-ray• DPL• Ultrasound

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 5th leading cause of death ↓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

END

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