Primary Survey FK UMSU

8/10/2019 Primary Survey FK UMSU

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Primary Survey Assessment

(Penilaian dan Penanganan

Survei Primer)

Departemen Anestesiologi dan Reanimasi

FK UMSU2014



Initial Assessment

• Preparation

– Prehospital Phase

– Hospital Phase

• Triage: – Multiple casualty incidents

– Mass casualty events

• Primary survey (ABCDE)

• Resuscitation

• Adjuncts to the primary survey and resuscitation

• Consideration of need for transfer



Preparation

• The preparatory phase is an integral

component of trauma care and occurs in two

different clinical settings:

– Prehospital

– Hospital

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Prehospital Phase

• Occurs before patient involvement and concerns

the establishment of protocols the safe

transport of the right patient to the appropriatetrauma center at the earliest possible time using

the ideal transport method

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• Physicians involved in trauma care should be familiar

with these protocols, and should optimally be

involved in their establishment, review, and revision

• When an actual patient is injured, care is provided

according to protocol by the personnel who receive

initial notification of the trauma and are first torespond at the scene

• All events are ideally coordinated with the physicians

at the receiving hospital to ensure adequate time to

prepare personnel and resources in the emergency

department (ED).

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GOALS

• Maintenance of airway

• Control of external bleeding and shock

• Patient immobilization

• Transport to the closest appropriate facility preferably a trauma center.

• Obtaining important information concerning the

mechanism of injury, related events, and past medical

history of the patient alert the receiving team to the

possibility of particular injuries and their severity to

enable faster diagnosis and treatment.

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Hospital Phase

• The hospital phase of preparation is initiated withadvance notice of the arrival of the injured patient.

• Ideally, there should be a designated arrival area

with adequate space to accommodate the personneland equipment needed to carry out a trauma

resuscitation

• All trauma evaluations require proper personnel

ensuring that all personnel understand their roles and

have received any information communicated by the

prehospital personnel.

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• For example, patients who are hypotensive

(systolic blood pressure <90 mm Hg), bradycardic or tachycardic (heart rate <50

beats/min or >130 beat/min), or intubated in

the field or with respiratory compromise

meet criteria for the highest level of activation

which requires the presence of the full trauma

team consisting of trauma surgery faculty,

surgical residents, emergency medicine

faculty and residents, and ED nurses

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The Teams

• Physicians and nurses• Respiratory therapists

• Radiology technician

• Social workers (for family issues)

• Resources such as the laboratory, x-ray,

• Bedside diagnostic equipment such as an

ultrasound machine for FAST (FocusedAssessment Sonography in Trauma)

examination should be present

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Precaution

• Last but definitely not least is the safety of the

hospital team caring for the patient.

• All personnel who will be in close contact with

the patient should wear universal precautions

including hair covers, facemasks, eye

protection, appropriate length gowns, shoe

and/or leg coverings, and gloves to minimizeexposure to communicable diseases.

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Standard Precautions

• Cap

• Gown

• Gloves• Mask

• Shoe covers

• Goggles/face• Shields



TRIAGE

• The word triage derives from the French

word meaning “to sort.”

• Medical context, triage involves the

initial evaluation of a casualty and the

determination of the priority and level ofmedical care necessary for the victim.

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• There are two typical triagesituations encountered:

– Multiple casualty incidents

– Mass casualty events.

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Multiple casualty incidents

• Multiple patients whose injuries do not

exceed the capabilities of the receiving

facility.

• Patients with lifethreatening or multiple

injuries are transported and treated first.

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Mass casualty events

• The number of patients and the severity of

their injuries exceed the equipment,

supplies, and personnel limitations of thereceiving facility.

• Patients with the greatest chance of survival

and requiring the least use of resources aretransported and treated first

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T r i

a g e D e c

i s i on S c

h e m e



PRIMARY SURVEY

• The primary survey is a sequence of stepsto identify immediately life-threatening

but treatable injuries.

• Assessment and management proceed

simultaneously,and life-threatening

situations are managed as they are

encountered during the course of

resuscitation.

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Philosophy

“treat as you go”

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PRIMARY SURVEY

• A: airway maintenance with cervical spine

protection,

• B: breathing and ventilation,

• C: circulation with hemorrhage control,

• D: disability with respect to neurologic status

• E: exposure/environmental control, where the patient is completely undressed but kept warm

to prevent hypothermia.

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Special Populations

Pregnant women The anatomic and physiologic changes of

pregnancy can be a challenge, and the response of

the pregnant patient may be modified. Knowledge

of pregnancy and early monitoring of the fetus are

important in maternal and fetal survival.

Unnecessary x-ray exposure should be avoided, but treatment of the mother takes precedence.

Obese patients Their anatomy can make procedures such as

intubation difficult and hazardous. Obese patients

typically have cardiopulmonary disease limitingtheir ability to compensate for injury and stress.

Treatment of these patients may exacerbate their

underlying comorbidities.

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Pediatric patients the size of the child and specific injury patterns must

be kept in mind. Serious pediatric trauma is usually

blunt trauma, often involving the brain. Brain injuries

can lead to apnea, hypoventilation, and hypoxia, and protocols for pediatric trauma patients stress

aggressive management of the airway and breathing

to prevent these consequences. These physiologic

derangements occur more often than hypovolemia

with hypotension in seriously injured children.Geriatric patients The geriatric patient has overall less physiologic

reserve to withstand injury. Their response may also

be altered or blunted by comorbidities and chronic

medication use. Resuscitation of these patients must

take into account possible preexisting cardiac,

pulmonary, and metabolic diseases. Minor injuries

can cause serious complications due to multiple

medications, especially anticoagulant use.

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Airway Maintenance with

Cervical Spine Protection

• Maintenance of the airway is the most important

priority in caring for the trauma patient.

• Inadequate ventilation leads to hypoxia andinadequate oxygen delivery to tissues.

• Particularly important in patients with head

injury, as hypoxia contributes to secondary braininjury and hypoventilation may increase

intracerebral pressure.

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• In acute trauma, upper airway obstruction is the

most common cause of inadequate ventilation.

• Structures of the upper airway such as the

tongue, edematous soft tissues, blood, foreign

bodies, teeth, and vomitus are common causes

of obstruction.

• Quick assessment of the airway begins by

“asking the patient his or her name”.

• A normal response implies the airway is not inimmediate jeopardy, but frequent reassessment

is required.

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• Breathlessness, weak or absent voice, or

hoarseness suggests airway compromise.• Objective signs of potential airway problems

include noisy breathing, cyanosis, and the use of

accessory muscles.• Unconscious and obtunded patients with a

Glasgow Coma Score (GCS) of less than 8

should have their airway protected with anendotracheal tube to provide oxygenation and

ventilation, and reduce the chance of aspiration.

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• When airway compromise occurs, initial

maneuvers to maintain the airway are performed.

• The first involves opening the mouth and

inspecting for foreign bodies or otherobstructive causes.

• Either a chin lift or jaw thrust in conjunction

with an oral or nasal airway can relieveobstruction caused by the tongue

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X

Neck lift

Head tilt

Chin-lift



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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



Breathing and Ventilation

• After securing the airway, attention may be

turned to breathing and ventilation.

• This includes both oxygenation and adequate

exchange of carbon dioxide

• Pulse oximetry is an effective noninvasive

means of measuring arterial blood saturation

• A patent airway does not ensure adequate

ventilation

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• Evaluation of breathing begins by looking at,

listening to, and feeling the chest wall.

• Inspection of the chest wall can reveal

asymmetry in chest expansion, accessory

muscle use, contusions, penetrating chest

wounds, open or sucking chest wounds, anddistended neck veins.

• Auscultation of breath sounds can help

diagnose pneumo- or hemothorax by detectingdifferences in breath sounds between the left

and right chest

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• Palpation of the chest wall can be used to

diagnose an unstable chest wall, tenderness,crepitance, deformity, or subcutaneous air.

• Percussion has been suggested to identify

hyperesonance, dullness, or tympany.• Due to an often noisy resuscitation area, it is

rarely helpful in diagnosing or differentiating

chest trauma

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Breathing problems can be life-

threatening

• Tension pneumothorax air continuously

enters the pleural space from the trachea,

bronchi, or chest wall causing the lung to

collapse

• A flail chest:

– three or more consecutive ribs broken in at least two

places each,

– or one or more rib fractures along with a

costochrondral separation

– or fracture of the sternum 35



Dekompresi pneumotoraks (tension)

harus dikerjakan dalam Primary Survey



• Open pneumothorax a chest wall defect

greater than two thirds the diameter of thetrachea. This is also known as a “sucking chest

wound”

• Massive hemothorax (>1,200 mL of bloodevacuated initially) can cause mediastinal shift,

respiratory distress, and hypovolemic shock,

which must be managed immediately.

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Ci l ti ith H h



Circulation with Hemorrhage

Control

• Hemorrhage is the leading cause of preventable

death after injury.

• Shock is the result of inadequate oxygen

delivery to tissues.

• Although hypovolemic shock from bleeding is

the most common form of shock in trauma

victims, other types of shock can occur in these

patients, and occasionally a combination of

several types of shock are simultaneously

present 38



• Treatment for shock begins with placement of

two large-bore peripheral IV (16-gauge orlarger) and appropriate isotonic fluid

replacement

• STOP THE BLEEDING!!! – direct pressure on the bleeding vessel

– Tourniquets

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• Hemorrhage in the adult trauma patient

comes from one of five places:

– the thoracic cavity

– abdominal cavity – pelvic fracture

– long bones

– obvious external bleeding

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Disability: Neurologic Status

• The neurologic examination includes the

APVU/GCS and pupil examination

including size, symmetry, and reaction tolight.

• A complete and detailed neurologic

examination is not accurateor warranteduntil the patient is hemodynamically

normal44



Exposure and Environmental

Control

• The patient’s clothing must be

completely removed for complete andadequate evaluation, while ensuring the

patient does not become hypothermic

• Clothing is cut when there is severe

injury or risk of injury to the spine.

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• During exposure of the patient, prevention of

hypothermia with warmed air, fluids, oxygen,and blankets is necessary.

• The temperature of the patient should be

obtained as soon as possible and reassessedfrequently

• The best way to avoid hypothermia in the

trauma patient is to stop bleeding

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Adjuncts to Primary Survey

Vital sign

ECG ABGs

Urinary Adjuncts Pulse

Output oximeter

and CO₂

Urinary/gastric catheters

unless contraindicated



Decision for Early Transfer

Consider Early Transfer

Do not delay transfer for diagnostic

tests

Use time before transfer for

resuscitation



END

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Primary Survey FK UMSU

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