CASE II

A 48 year old man was taken to PUSKESMAS in a lost of

consciousness condition. After laid on the bed and undergone
some examinations, the patient was not giving any response
and remained snoring with breathing frequency of 32 times
per minute, weak pulse 100 bpm. According to the family
who took him to the PUSKESMAS, the patient was not in any
trauma preceding the condition.

*keyword

CLARIFICATION WORD
Snoring Trauma-

The patient was unconscious? Not giving any

response??
Refer to GCS!

Why snoring? tachypnea? weak pulse?

Dont panic, do the

emergency action
immediately and
you can find the
reason for these
signs!!!

ACTION IN EMERGENCY?
WHAT WE HAVE TO DO???

INITIAL ASSESSMENT
Preparation

Triage

Primary Survey ( ABCDE )

Resuscitation

Secondary Survey ( Head to toe evaluation )

Definitive Care

PRIMARY SURVEY
A.
B.
C.
D.
E.

Airway & cervical spine control

Breathing & ventilation
Circulation & hemorrhage control
Disability
Exposure/Environment

PRIMARY SURVEY
Head tilt
Chin lift method
Jaw thrust method

Manual stabilization of C-Spine

Noisy breathing = Obstructed breathing
allobstructs
obstructed
breathing
is NOT noisy)
Case: snoring due to base of(But
tongue
the airway
( suggesting
partial airway obstruction) Assume airway problems with:
Decreased LOC
Head, face, neck, thorax trauma

OPEN - CLEAR - MAINTAIN

PRIMARY SURVEY
Repiratory Rate
Normal respiration 12 - 20
Bradypnea

Tachypnea

Apnea

Give O2 immediately if:

Change in LOC
Possible shock
Possible severe hemorrhage
Chest pain
Chest Trauma
Rythm
commonly
Dyspnea seen in shock
tachypnea,
Regular
Case:
is rapid and shallow respiration
Irregular
Respiratory Distress

Quality:
Shallow
Full
Deep

If you think about giving O2,

GIVE IT!

LOOK - LISTEN - FEEL

PRIMARY SURVEY
Heart Rate
Normal HR
Bradycardia
Tachycardia
Quality

60 - 90

Weak (Thready)
Case:
weak
Full pulse with 100bpm, might be shock from loss of blood
Bounding

Rhythm

Regular
irregular

Pulses present?
Radial => BP > 80 systolic
Femoral => BP > 70 systolic
Carotid => BP > 60 systolic

PRIMARY SURVEY
Mental status Glasgow Coma Scale
Pupils
Extremities

Eye opening

Spontaneously
To Speach
To Pain
None

Verbal response
Level of consciousness = Best indicator
of brain perfusion
Pupils-Eyes are windows of CNS
Decreased LOC:
Head injury
Hypoxia
Hypoglycemia
Shock

Orientated
Confused
Inappropriate words
Incomprehensible sounds
None

Motor response

4
3
2
1
5
4
3
2
1

Obeys verbal commands 6

Localising pain
5
Withdraws from pain stimuli 4
Flexing to pain
3
Extension to pain
2
No response
1

PRIMARY SURVEY
Mental status Glasgow Coma Scale
Pupils
Extremities

Shape
Equality
Response to light

PEARL
Pupils Equal And Reacting to Light

PRIMARY SURVEY
Mental status Glasgow Coma Scale
Pupils
Extremities

CSM
Circulation
Sensation
Movement

PRIMARY SURVEY
Victims history
Physical exam

Head to toe examination

DOTS

You cant treat what you dont find

Remove clothing from critical patients ASAP!
But do NOT delay resuscitation to remove clothing
Cover patient with blanket after exam is complete

Deformity
Open wounds
Tenderness
Swelling

PRIMARY SURVEY
SAMPLE history

Symptoms
Allergies
Medications
Past medical history
Last oral intake
Events leading up to the illness or injury

Initial resuscitation!!

Immobilize C-spine (rigid collar)

Removal of blood or foreign bodies by suctioning with gentle techniques
Keep airway open
Administration of supplemental oxygen, 100% oxygen by highflow mask
Use of oropharyngeal or nasopharyngeal airways
Aggressively correct hypoxia, hypovolemia
Begin assisted ventilation with BVM
Apply and inflate PASG
Reassess and report in route

Minimum Time On Scene

Maximum Treatment In Route

SECONDARY SURVEY
To detect medical and injury-related problems that do not
pose an immediate threat to survival but if left untreated,
may do so!
You WILL get here with MOST trauma patients
Perform ONLY after initial assessment is completed and life
threats corrected
Do NOT hold critical patients in field for detailed exam
Head and toe examination:

Organized, systematic
Superior to Inferior
Proximal to Distal
Look - Listen - Feel - Smell

Extremity assessment must include:

Pulse
Skin color, temperature
Capillary refill
Motor, sensory function

Definitive care
Stable patients can receive attention
for individual injuries before
transport
Bandaging
Splinting

Reassess carefully for hidden

problems
Surgery intervention
If patient becomes unstable at any
time, refer to higher trauma center!

Reevaluation

Ventilation and perfusion status

Repeat vital signs
Continued stabilization of identified problems
Continued reassessment for unidentified problems
Go for supporting diagnosis eg. CT-scan and blood
evaluation.

References:

National Safety Council; FIRST AID AND CPR.

Lecture notes of INITIAL ASSESMENT MANAGEMENT, SYAFRI K.ARIF, Dept.of
Anesthesiology,Pain Management and Intensive Care Faculty of Medicine
Hasanuddin University
Chapleau, W., Pons, P. (2007) EMERGENCY MEDICAL TECHNICIAN. St. Louis:
Elsevier
Caroline, N. (2007) EMERGENCY CARE IN THE STREET. 6th ed. London: Jones and
Bartlett
Trauma Critical Care-volume 1
First aid, lecture notes, Charles University in Prague, 1st Faculty of Medicine,
Initial Assessment and Management of Trauma, Temple College EMS Professions

Any Question??