INITIAL ASSESSMENT

By
Dr. HARDY, SpB
INITIAL ASSESSMENT
PENILAIAN / EVALUASI AWAL SECARA CEPAT &
BENAR SERTA SEGERA MELAKUKAN RESUSITASI
SEGERA BILA DIPERLUKAN PADA PENDERITA YANG
MENGALAMI TRAUMA

CEDERA / TRAUMA
- TAK DIKETAHUI
- KAPAN
- DIMANA
- KENAPA
KEMAJUAN LALU LINTAS
- PENGGUNA JALAN
- JUMLAH KENDARAAN
- JARINGAN JALAN
- KECEPATAN KENDARAAN

ANGKA KEJADIAN KECELAKAAN LALIN /

TRAUMA ME ↑
 PENDERITA TRAUMA

PERLU PERTOLONGAN !!!

CEPAT BENAR

 TEMUKAN PENDERITA GAWAT DARURAT

 MINTA PERTOLONGAN / TEAM
 KUALITAS PERTOLONGAN
 SARANA / PRASARANA
 BASIC PRINCIPLES

TRAUMA

DEATH MORBIDITY
 TRAUMA

INITIAL CARE EVALUATION

BASED ON

ANATOMIC INJURY PHYSIOLOGIC STABILITY

 PHASES OF TRAUMA CARE

PRE HOSPITAL IN HOSPITAL

 PRE HOSPITAL
- INITIAL ASSESSMENT
- PRIMARY SURVEY + RESUSITASI
- SECONDARY SURVEY + CONTINUED
MONITORING
- TRIAGE
- STABILIZATION
- TRANSPORTATION / MOBILIZATION OF
RESOURCES  MEDICAL DIRECTION /
HOSPITAL
- PERIODIC REVIEW OF CARE
 INHOSPITAL
- INITIAL ASSESSMENT
- PRIMARY SURVEY + RESUSITASI
- SECONDARY SURVEY +
CONTINUED MONITORING
- TRIAGE
- DEFENITIVE TREATMENT
 TRAUMA IN
CHILDREN
YOUNGER
ADULT
ELDERLY
PREGNANT WOMEN

PRIORITIES ARE THE SAME

INITIAL ASSESSMENT
 IDENTIFIKASI PRIORITAS MANAGEMEN
 APLIKASI PRIMARY DAN SECONDARY SURVEY
 RESUSITASI & MONITORING
 RAPID ASSESSMENT : RIGHT TIME, RIGHT
PLACE, RIGHT MAN
 PERHATIKAN RIWAYAT KEJADIAN &
BIOMEKANIK INJURY
 ANTISIPASI PITFALL
PRIMARY SURVEY
A : AIRWAY + C – SPINE PROTECTION
B : BREATHING + OKSIGEN
C : CIRCULATION + HEMORRAGE CONTROL
D : DISABILITY
E : EXPOSURE

RAPID, SIMULTANEOUSLY & PRIORITY

 PRIMARY SURVEY
A = AIRWAY + C – SPINE PROTECTION

PASTIKAN BAHWA JALAN NAFAS BERSIH

- TERTEKUK LIDAH
- DARAH / BENDA ASING
- GIGI PALSU
- EDEMA LARING : CEDERA INHALASI
GANGGUAN JALAN NAFAS
- NGOROK (SNOORING)
- GARGLING
- SERAK / PARAU (HOARNESS)
- PENURUNAN KESADARAN
RESUSITASI
 BEBASKAN JALAN NAFAS + CERVICAL
PROTECTION
- CHIN LIP & HEAD TILT
- JAW THRUST
- SUCTION, MANUAL BY FINGER
- OPA (OROPHARYNGEAL AIRWAY)
- NPA (NASOPHARYNGEAL AIRWAY
- INTUBASI (ETT)
• B = BREATHING AND VENTILATION
BERSIHNYA JALAN NAFAS SAJA TDK MENJAMIN VENTILASI
YANG ADEKUAT

PASIEN TRAUMA MEMBUTUHKAN PERTUKARAN GAS YANG

ADEKUAT

EVALUASI
- FP : DYSPNOE, TACHYPNOE, APNOE
- DINDING DADA : IPPA (INSPEKSI, PALPASI, PERKUSI,
AUSKULTASI
MASALAH
MAYOR INJURIES :
- TENSION PNEUMOTHORAX
- FLAIL CHEST
- MASSIVE HAEMOTHORAX
- OPEN PNEUMOTHORAX
- TAMPONADE JANTUNG
RESUSITASI
- OKSIGEN
- ATASI KEGAWATDARURATAN PADA CEDERA
DADA
- INTUBATE / VENTILATE
 C = CIRCULATION AND CONTROL OF BLOOD LOSS
≈ SIRKULASI + KONTROL PERDARAHAN
PENILAIAN : STATUS HAEMODYNAMIC PENDERITA
- SYOK : ADA / TIDAK
- PERDARAHAN : ADA / TIDAK

CARA :
- PERIKSA AKRAL : DINGIN / HANGAT, WARNA KULIT
- FREK. NADI
- TEK. DARAH / MEAN ARTERIAL PRESSURE
- TINGKAT KESADARAN
- TEK. VENA CENTRAL (CVP)
- URINE OUTPUT
- EKG
KONTROL PERDARAHAN
- DIRECT PRESSURE BEFORE
- TOURNIQUETS
- CLAMPS
- LIGASI
- SURGERY

SUMBER PERDARAHAN : EXTERNAL BLEEDING /INTERNAL BLEEDING

- CEDERA THORAX : HEMATOTHORAX MASSIVE
- CEDERA ABDOMEN : LIVER, SPLEEN, GINJAL, RUPTURE P.DARAH
- CEDERA PELVIK
- FX : FEMUR, CRURIS
- CEDERA PEMBULUH DARAH
 KLASIFIKASI SYOK AKIBAT PERDARAHAN
CLASS I II III IV

BVL < 15% 15 - 30% 30 - 40% > 40%

AMOUNT 750 cc 750 - 1500 cc 1500 - 2000 cc > 2000 cc

PULSE <100 > 100 >120 >140

BP No change Narrowed pulse Consistent decrease Decreased SBP and narrowed

pressure in SBP pulse pressure or no DBP

RESP No change 20-30 30-40 >35

CNS No change Anxiety Anxious, confused Confused. lethargic

Urine >30cc per hr 20-30cc per hr 5-15cc per hr negligible

TX Replace fluid 2L RL, NS IV 2 L RL, NS IV, usually Rapid transfusion of blood

loss requires blood transfusion and RL, NS, requires
immediate intervention to
stop hemorrhage
 RESPON PASCA RESUSITASI

Rapid Response Transient No Response

Response
Vitals Return to normal Transient Remain Abnormal
improvement with
return to previous
Estimated Blood 10-20% 20-40% with Severe >40%
loss ongoing likely
Need for more Low High High
Fluid
Need for Blood Type and cross Type specific O neg
Need for surgery Possible Likely Highly likely
 PITFALLS REGARDING BLOOD LOSS

- BEWARE OF THE ELDERLY AND CILDREN

- BEWARE THOSE ON BETA – BLOCKERS

- BEWARE FIT MALES (ATLIT)

- INCIDIOUS BLEEDING / ON GOING BLEEDING

 LETHAL TRIAD
SHOCK PROLONGED HYPOTENSION

METABOLIC ACIDOSIS

DEATH

COAGULOPATHY HYPOTERMIA
 D = DISABILITY → NEUROLOGICAL EVALUATION
PENILAIAN TINGKAT KESADARAN + MINI NEUROLOGI

CARA :
- AVPU
- GCS
- REFLEKS PUPIL

PENURUNAN TINGKAT KESADARAN

- GANGGUAN OKSIGEN KE OTAK  SECONDARY BRAIN
INJURY
- CEDERA KEPALA : EPIDURAL HEMORRAGE, SUBDURAL
HEMORRAGE
- ALKOHOL / OBAT2AN

RE – EVALUATE OXYGENATION, VENTILATION, AND PERFUSION

 E = EXPOSURE / ENVIRONMENT
BUKA PAKAIAN PENDERITA / LOG ROLL
- PERIKSA CEDERA PD SLRH TUBUH  HEAD TO
TOE)
- JAGA SUHU TUBUH / CEGAH TERJADINYA
HIPOTERMI
 THE RESUSCITATION PHASE
RESUSITASI : RAPID, SIMULTANEOUSLY & PRIORITY
- AIRWAY + C - PROTECTION
- BREATHING + OKSIGEN
- CIRCULATION + BLEEDING CONTROL
- DISABILITY
- EXPOSURE
 INCREASE SURVIVAL
MONITORING DURING RESUSCITATION
• MONITORING
RESUSITASI YG ADEKUAT DI ASSESS DENGAN PARAMETER
FISIOLOGIS
- HR
- BP
RE – EVALUATE ALL PARAMETERS
- PULSE PRESSURE
- RR ALL THE TIME
- PULSE OXYMETER
- EKG
- ABG ANALYSIS
- URINE OUTPUT (PEMASANGAN KATETER)
- NGT
 SECONDARY SURVEY

• JANGAN DIMULAI SAMPAI ABCDE’s

(PRIMARY SURVEY) TERSELESAIKAN

• JANGAN DIMULAI SAMPAI KEADAAN

PASIEN MEMBAIK

• JANGAN DIMULAI SAMPAI FASE RESUSITASI

MEMBAIK
 SECONDARY SURVEY

HISTORY / ANAMNESA :
- AMPLE
- MECHANISM OF INJURY

FULL EXAMINATION : HEAD TO TOE

- HEAD AND FACE
- NECK
- CHEST
- ABDOMEN
- MUSCULOKELETAL
- NEUROLOGICAL

LABORATORIUM
IMAGING
IMPORTANT POINTS IN TRAUMA

• FULL ASSESSMENT

• EVALUASI BERKELANJUTAN DAN SELALU

DIULANGI

• MULTIDISCIPLINARY APPROACH
 IMPORTANT EXAM POINTS IN
TRAUMA

• BERPEGANG PD BASIC PRINCIPLES

• SETIAP PERMASAALAHAN TRAUMA SECARA

GLOBAL DI ASSESSMENT DENGAN
MENGGUNAKAN ATLS / ACLS PROTOCOLS