INITIAL ASSESSMENTS

Dwi Prihatiningsih, M.Ng.

Dua before Studying

“I’ve accepted Allah as my Lord And Islam as my way of life

And Muhammad As Allah’s Prophet and Messenger. O Allah! Advance
me in Knowledge and true understanding”
Learning Outcome

At the end of this topik, students will be able to show understanding of

initial assessment in trauma:
1. Primary survey
2. Secondary survey
Initial Assessment

Primary survey
Secondary survey
Primary Survey

The primary survey should conducted in the following sequences:

A Airway maintenances with cervical spine control
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability: Neurological Status
E Exposure and temperature control
Airway and cervical spine stabilization

TOP Priority
The goal of airway and ventilation assessment are to:
1. Secure a patient airway
2. Ensure adequate oxygenation
3. Provide adequate ventilation
4. Monitor ongoing status of airway patency and ventilatory status
5. Maintain in-line spinal immobilization
Using “Look, Listen & Feel
Breathing and Ventilation Assessment

LOOK closely and examine the patient’s chest wall integrity for:
• Fracture, lacerations and/or bruising
• Paradoxical chest movement
• Tachipnoea and/or abnormal respiratory rate
• Use of accessory and/or abdominal muscle
• Further assessment of patient colour
LISTEN for absent or decreased breath sound and unequal air entry
FEEL for subcutaneous air, chest wall instability and or crepitation,
position of trachea, dullness and/or hyperresonance
Circulation & Haemorrhage Control

The goal:
• Identify sign and sources of haemorrage
• Assess mental status
• Assess pulses
• Assess skin colour, temperature and moisture
Circulation & Haemorrhage Control

LOOK for:
• Obvious sign of external bleeding
• Skin colour for pallor and/or cyanosis
• Level of consciousness
• Neck vein (collapsed or distended)
• Abnormalities underneath the hard collar
LISTEN for muffled heart sounds that indicate pericardial tamponade
FEEL
• Assess skin for moisture and temperature
• Palpate pulses for presence, quality, rate and rhythm
 Classification of Hypovolemic Shock
CLASS I CLASS II CLASS III CLASS IV
Blood loss (mL) < 750 750-1500 1500-2000 > 2000
Blood loss < 15% 15% - 30% 30% - 40% > 40%
Pulse (beats per minute) < 100 100 - 120 120 - 140 > 140
Blood pressure Normal Normal Decreased Decreased
Respiratory rate 14 - 20 20 - 30 30-40 > 35
Urinary output (mL/hour) > 30 20 - 30 5 - 20 Negligile
Central nervous system Slightly Mildly Anxious, Confused,
anxious anxious confused lethargic
Fluid replacement Crystalloid Crystaloid Crystaloid & Crystaloid &
Blood Blood
Disability (Neurological)

• Brief and focused neurological assessment

• Glasgow Coma Scale (GCS) score
• AEIOU

A Alcohol and drugs

E Endocrine, encephalopathy
I Insulin
O Opiates and oxygen
U Uremia
If one of the above is not the cause of the decreased GCS
score, it should be considered traumatic
Exposure and Temperature Control

• Final step of the primary survey

• Completely and rapidly, remove the patient’s clothing to assess for
injuries, haemorrhage or other abnormalities
• This step should not be completed until the patient reaches an
environment where active warming can replace the patient’s cloting
Hypothermia prevention and management

• Remove all wet, blood soaked clothes, linen and covers

• Keep patient covered
• Apply blanket (external active rewarming temperature regulated
blanket)
• Warm all fluid and blood product before transfusion
• Increase room temperature
• Humidify inspire gases
• Control haemorhage
• Reverse shock
• Be aware of causes of heat loss such as drugs, long operative events
such as exploratory laparotomies, ongoing exposure
The five most important rules to remember

• The patient should be repeatedly reassessed, particularly if clinical

sign change
• Any immediately life threatening condition diagnosed should be
rectified without delay
• Penetrating wounds and implements must be left for formal surgical
exploration
• Any external bleeding should be stopped by using direct pressure
• The patient must be kept warm
Adjuncts to the primary survey

• Monitoring
• Urinary catheters and gastric tubes
• Laboratory tests
• Primary survey X-rays
Secondary Assessment

Four main elements to the secondary survey:

F = Full set of vital signs monitoring/five intervention
G = Give comfort measure
H = History
H = Head-to-toe assessment
Vital Signs

• Complete vital sign

• Cardiac monitor
• Pulse oxymeter (SpO2)
• Urinary Catether if nor contraindicated
• Gastric tube (oral or naso)
• Laboratory studies
• Facilitate family presence
History