EMERGENCY SCENARIO.

CASE 1
Emergency call traffic accident by policeman to By pass Ngurah Rai Kuta.
Patient, male 30+, lay on his chest on the road, active bleeding from his face, spontaneous
breathing, deformity on the left thigh. Open wound on left calf.
IN ER:
ER nurse received the phone.
Ask: - caller name
- Contact number
- Location
- Event/evident
- Patient (consciousness, age, casualty number)
ON SCENE:
Check for danger + universal precaution (gloves, google, apron, facemask).
Check respon responsive, eyes closed respons to call, in pain.
BP: 110/60, Pulse: 110x/min, RR: 22.
Log roll patient with spine control, put on spine board.
AIRWAY.
No foreign body.
Seen Maxillofacial deformity with active bleeding on the mouth. suction, Chin lif and jaw
thrust unable to performed put OPA.
Attach hard collar neck and sands bag.
Air way controlled with OPA and succion.
BREATHING
Attach oxygen supp, attach pulse oxymetri. RR:26x/min, saturation: 88%
Spontaneous breathing. Regular pattern. right side no movement, right neck vein distended,
trachea deviated to the left.
O ow. Patient is vomiting. positioned lying to the side succion.. want intubation???
Chest: assimetric rise and fall decreased on the right, assismetric breathsounds, bruis on the right
mid axilla +subcutan emphysema. -------- needle thoracostomy. (midclavicle ICS 2) oxygen
sat: 95%.
Patient develop unresponsive, no respond to call and pain.
Back to A.. want intubation?? Or check the tube, fixation, etc
Intubation:
. preoxygenation
.remove the collar neck and sands bag
. insert laryngoscope, move the tongue to the left side. - patient
struggling midazolam 0.2mg/kgbw or propofol 1-2mg/kgbw
. preoxygenation
. insert laryngoscope, insert the tube (size?), depth?
. auscultated the breath sounds. less on the right side pull up the tube.

. fixation. Intubation success.

. attach collar neck
Repeat to check breathing breathing controlled with bag valve, still unequal movement,
trachea in the middle, no neck vein distension. Needle thoracostomy in the good place
CIRCULATION:
Skin pale, cold clammy extremities attach IV line 2 large bores, rapid infusion.
BP: 80/palpation, pulse: 122x/min, RR: controlled. Oxygen sat: 95%.
Direct pressure on the wound site, apply wood splint on the femur.
Abdomen: bruis on the right upper abdomen call surgeon to hospital.
Pelvic: stable.
DISABILITY
GCS: E1V1M1 (with SRI). Pupil : PERRL, glukocheck: 119mg/dl
Exposure: deformity on left antebrachii. Bruis on Lumbar spine.
SECONDARY SURVEY.
AMPLE
Scalp: no cephal hematoma, no wound
Facial: unstable, active bleeding
Ear: no bleeding
Nose: severe injury, active bleeding
Jaw/teeth: unstable
Neck: on hard collar neck and sands bag
Chest: with needle thoracostomy, assimetric movement and breath sounds
Abdomen: bruis on right upper quadran
Pelvic: stable, no bruis/bleeding from perineum and urethra
Extremities: immobilized with wood splint. Cold, good pulse.
EVACUATION.
REPEAT THE PRIMARY SURVEY SIMULTANEOUSLY DURING TRANSFER.

CASE 2

EMERGENCY CALL OUT TO A HOTEL

Patient fell off the 2nd floor, unconscious on the ground, was stabbed by the fence on his back
chest.
IN ER:
ER nurse received the phone.
Ask: - caller name
- Contact number

- Location
- Event/evident
- Patient (consciousness, age, casualty number)
ON SCENE:
Patient Female 20+, unconscious laying on his back with open wound on the head, whistling
sounds from her back. Cold clammy extremities.
Check for danger + universal precaution (gloves, google, apron, facemask).
Check respon responsive, eyes closed respons to call, in pain.
GCS E1V1M1 BP: 70/Palpation, Pulse: 120x/min, RR: 36 x/min, shallow. Sat: 60%
AIRWAY.
Secret (+),No foreign body succion OPA? Intubation?
Attach rigid collar neck, sands bag.
BREATHING
Attach oxygen 100% via mask/positive pressure
No neck vein distension, trachea in the middle.
RR: 36x/min oxygen sat: 64%
Whistling sounds from the wound on the right posterior side of the chest, assimetric breath
sounds and movement. occlusive dressing valve like.
PATIENT SUDDENLY STOP BREATHING.
Saturation drop to 30%.
Back to evaluate the airway. Check OPA/intubation..--> intubation pipe pulled reintubate.
Give positive pressure oxygen 80%
CIRCULATION
BP: 60/palpation. Pulse: 140x/minute, palpated diminished. Cold clammy extremities
IV catheter 2 large bores Fluid with cristaloid 1000ml, up to 3x.
Actve bleeding from the scalp direct pressure, wound on the chest.
Abdomen: no bruis, no wound
Pelvic: unstable wrap with PASG.
Extremities: no deformity, open wound on popliteal.
DISABILITY:
GCS: 3
PUPIL: pupil anisokor, responsive to light call hospital toprepare CT scan
Glukocheck: 155mg/dL
Deformity on thoracal, no open wound
Bruis on perineum.
SECONDARY SURVEY
AMPLE
Scalp: wound on right parietal
Ear: bleeding from right ear

Nose: no bleeding, no hematome

Facillomaxial: stable, raccoon eyes
Jaw and teeth: intac, ETT: intac, fixated.
Neck: on collar neck/sands bag
Chest: check the tape, check the breath sounds.
Abdomen:no distension, no bruis
Pelvic: with PASG
Extremities: cut wound on right poplitea, bleeding has stopped.
REMOVE TO STRETCHER WITH LOG ROLL, EVACUATION TO HOSPITAL.
REMEMBER TO DO CONTINUOUS EVALUATION FOR ABCD