INITIAL

ASSESSMENT AND
MANAGEMENT
1
 OBJECTIVES
 MENENTUKAN PRIORITAS PENILAIAN.
 MENERAPKAN PRINSIP PRIMARY SURVEY DAN SECONDARY
SURVEY.
 MENERAPKAN CARA DAN TEKNIK TERAPI PADA FASE RESUSITASI.
 MENGENAL RIWAYAT DAN MEKANISME CEDERA DALAM
MEMBANTU DIAGNOSIS.
 CONCEPTS OF INITIAL ASSESSMENT

 RAPID PRIMARY SURVEY

 RESUSCITATION
 ADJUNCTS TO PRIMARY SURVEY /RESUSCITATION
 DETAILED SECONDARY SURVEY
 ADJUNCTS TO SECONDARY SURVEY
 REEVALUATION
 DEFINITIVE CARE
 INITIAL ASSESSMENT

PRIMARY SURVEY DAN RESUSITASI

DILAKUKAN SECARA SIMULTAN – TEAM
 PREPARATION

PREHOSPITAL SYSTEM
 TRANSPORT GUIDELINES /PROTOCOLS
 KOORDINASI YANG BAIK ANTARA DOKTER RS DAN PETUGAS LAPANGAN
 MOBILIZATION OF RESOURCES
 DIKIRIM KE RS TERDEKAT DENGAN FASILITAS YANG SESUAI
 PREPARATION

INHOSPITAL
 PERENCANAAN SEBELUM PENDERITA TIBA
 EQUIPMENT, PERSONNEL, SERVICES
 STANDARD PRECAUTIONS
 STANDARD PRECAUTIONS

• CAP
• GOWN
• GLOVES
• MASK
• SHOE COVERS
• GOGGLES/FACE SHIELDS

7
 TRIAGE

 SORTING OF PATIENTS ACCORDING TO :

• ABCDES
• AVAILABLE RESOURCES
 MULTIPLE CASUALTIES
 MASS CASUALTIES
 PRIMARY SURVEY

 ADULT, CHILDREN, PREGNANT WOMEN –

PRIORITIES ARE THE SAME !
A AIRWAY WITH C-SPINE PROTECTION
B BREATHING
C CIRCULATION WITH HEMORRHAGE CONTROL
D DISABILITY
E EXPOSURE/ENVIRONMENT
 SPECIAL CONSIDERATIONS

TRAUMA IN THE ELDERLY

 5TH LEADING CAUSE OF DEATH
  PHYSIOLOGIC RESERVE
 COMORBIDITIES : DISEASES/MEDICATIONS
 OUTCOME DEPENDS ON EARLY,
AGGRESSIVE CARE
 PRIMARY SURVEY
Establish Patent Airway
C-SPINE INJURY
PITFALLS
• EQUIPMENT FAILURE
• INABILITY TO INTUBATE
Caution
• OCCULT AIRWAY INJURY
• PROGRESSIVE LOSS OF
AIRWAY
 PRIMARY SURVEY
SUSPECT C-SPINE INJURY
 SPINAL PROTECTION
 C-SPINE X-RAY WHEN APPROPRIATE
 PRIMARY SURVEY

BREATHING
 ASSESS
 OXYGENATE
 VENTILATE

PITFALLS
• AIRWAY VS VENTILATION PROBLEM
?
• IATROGENIC PNEUMOTHORAX
/TENSION PNEUMOTHORAX
 PRIMARY SURVEY

ASSESSMENT OF ORGAN PERFUSION

 LEVEL OF CONSCIOUSNESS
 SKIN COLOR AND TEMPERATURE
 PULSE RATE AND CHARACTER
 PRIMARY SURVEY

CIRCULATORY MANAGEMENT
 CONTROL HEMORRHAGE
 RESTORE VOLUME
 REASSESS
PITFALLS
ELDERLY CHILDREN
Caution ATHLETES MEDICATION
 PRIMARY SURVEY

DISABILITY
 BASELINE NEUROLOGIC EVALUATION

• GCS SCORING
• PUPILLARY RESPONSE

OBSERVE FOR NEUROLOGIC

DETERIORATION
Caution
 PRIMARY SURVEY

EXPOSURE / ENVIRONMENT
• COMPLETELY UNDRESS THE PATIENT

Caution
PREVENT HYPOTHERMIA
 RESUSCITATION

 PROTECT AND SECURE AIRWAY

 VENTILATE AND OXYGENATE
 STOP THE BLEEDING
 VIGOROUS SHOCK THERAPY
 PROTECT FROM HYPOTHERMIA
 ADJUNCTS TO PRIMARY SURVEY
VITAL SIGN

ECG ABGS

URINARY ADJUNCTS PULSE

OUTPUT OXIMETER
AND CO2

URINARY/GASTRIC CATHETERS
UNLESS CONTRAINDICATED
 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
 REEVALUATE

PROCEED TO SECONDARY SURVEY AFTER :

 PRIMARY SURVEY COMPLETED

 ABCDES ARE REASSESSED

 VITAL FUNCTIONS ARE RETURNING TO NORMAL
 SECONDARY SURVEY

THE COMPLETE

HISTORY AND

PHYSICAL

EXAMINATION

23
 SECONDARY SURVEY
KEY COMPONENTS
 HISTORY
 PHYSICAL EXAMINATION : HEAD-TO-TOE
 “TUBES AND FINGER IN EVERY ORIFICE”
 COMPLETE NEURO EXAM
 SPECIAL DIAGNOSTIC TESTS
 REEVALUATION
 SECONDARY SURVEY

HISTORY
A ALLERGIES
M MEDICATIONS
P PAST ILLNESSES
L LAST MEAL
E EVENTS/ENVIRONMENT
© ACS 25
 SECONDARY SURVEY

MECHANISMS OF INJURY

26
 SECONDARY SURVEY
HEAD
 COMPLETE NEUROLOGIC EXAMINATION
 GCS SCORE DETERMININATION
 COMPREHENSIVE EYE/EAR EXAM
PITFALLS
 UNCONSCIOUS PATIENT
 PERIORBITAL EDEMA
 OCCLUDED AUDITORY CANAL
 SECONDARY SURVEY

MAXILLOFACIAL
 BONY CREPITUS/STABILITY
 PALPABLE DEFORMITY
PITFALLS

• POTENTIAL AIRWAY OBSTRUCTION

• CRIBRIFORM PLATE FRACTURE
• FREQUENTLY MISSED INJURY
 SECONDARY SURVEY
CERVICAL SPINE
 PALPATE FOR
 PITFALLS
TENDERNESS • ALTERED LOC FOR ANY
 COMPLETE MOTOR/ SENSORY REASON
EXAMS • OTHER SEVERE,
 REFLEXES PAINFUL INJURY
 C-SPINE IMAGING
 SECONDARY SURVEY

NECK (SOFT TISSUES)

 MECHANISM : BLUNT  PITFALLS
VS PENETRATING • DELAYED SYMPTOMS
 SYMPTOMS : AIRWAY
AND SIGNS
OBSTRUCTION ,
• PROGRESSIVE AIRWAY
HOARSENESS
OBSTRUCTION
 FINDINGS :CREPITUS

HEMATOMA ,STRIDOR • OCCULT INJURIES

BRUIT
 SECONDARY SURVEY
CHEST
 INSPECT
 PALPATE
 PITFALLS
 PERCUSS
• ELDERLY
 AUSCULTATE
• CHILDREN
 X-RAY
 SECONDARY SURVEY

ABDOMINAL EVALUATION

BLUNT TRAUMA PENETRATING TRAUMA

 SECONDARY SURVEY
ABDOMEN
 INSPECT, AUSCULTATE, PALPATE, AND PERCUSS
 REEVALUATE FREQUENTLY
 SPECIAL STUDIES
 PITFALLS
• HOLLOW VISCUS AND RETROPERITONEAL INJURIES
• EXCESSIVE PELVIC MANIPULATION
 SECONDARY SURVEY
PERINEUM CONTUSIONS, HEMATOMAS,
LACERATIONS, URETHRAL BLOOD

SPHINCTER TONE , HIGH –RIDING

RECTUM PROSTATE, PELVIC FRACTURE,
RECTAL WALL INTEGRITY, BLOOD

BLOOD, LACERATIONS

VAGINA URETHRAL INJURY IN WOMEN,

PREGNANCY

PITFALLS
 SECONDARY SURVEY

MUSCULOSKELETAL : EXTREMINITIES
 CONTUSION , DEFORMITY
 PAIN
 PERFUSION
 PERIPHERAL NEUROVASCULAR STATUS
 X- RAYS AS NEEDED
 SECONDARY SURVEY

MUSCULOSKELETAL : PELVIS
 PAIN ON PALPATION
 SYMPHYSIS WIDTH ↑
 LEG LENGTH UNEQUAL
 INSTABILITY
 X-RAYS AS NEEDED
 SECONDARY SURVEY

MUSCULOSKELETAL
 PITFALLS
• POTENTIAL BLOOD LOOS
• MISSED FRACTURES
• SOFT-TISSUE OR LIGAMENTOUS INJURY
• OCCULT COMPARTEMENT SYNDROME (ESPECIALLY WITH ALTERED LOC
/ HYPOTENSION)
 SECONDARY SURVEY
NEUROLOGIC
SPINE / CORD
CNS
 COMPLETE MOTOR
AND SENSORY EXAMS  FREQUENT
 IMAGING AS REEVALUATION
INDICATED  PREFENT SECONDARY
 REFLEXES BRAIN INJURY
EARLY NEUROSURGICAL CONSULTATION
 ADJUNCTS TO SECONDARY SURVEY

 SPECIAL DIAGNOSTIC TEST AS INDICATED

 PITFALLS
• PATIENT DETERIORATION
• DELAY OF TRANSFER
 SECONDARY SURVEY

NEUROLOGIC
 PITFALLS
• INCOMPLATE IMMOBILIZATION
• SUBLE ↑ IN ICP WITH MANIPULATION
• RAPID DETERIORATION
 REEVALUATION

MINIMIZING MISSED INJURIES

 HIGH INDEX OF SUSPICION
 FREQUENT REEVELUATION AND
MONITORING
 REEVALUATION

PAIN MANAGEMENT
 RELIEF OF PAIN /ANXIETY AS APPROPRIATE
 ADMINISTER INTRAVENOUSLY
 CAREFUL MONITORING IS ESSENTIAL
 DEFINITIVE CARE

LOCAL FACILITY

??
TRANSFER AGREEMENTS
?? LOCAL RESOURCES ??
??

TRAUMA SPECIALTY
CENTER FACILITY
QUESTIONS
 SUMMARY

 PRIMARY SURVEY
 RESUSCITATION
ADJUNCTS
• SECONDARY SURVEY
ADJUNCTS
• DEFINITIVE CARE