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Primary and Secondary Survey Pre HospitalNs. Mohammad Ali Hamid


Tujuan PembelajaranUmumSetelah mengikuti mata kuliah ini mahasiswa akan dapat melakukan primary survey dan secondary survey pre hospitalKhususMenjelaskan langkah langkah dalam primary survey & secondary survey pre hospitalMenjelaskan prioritas pemeriksaan Menjelaskan intervensi yang harus dilakukan dalam primary survey & secondary survey pre hospital

Scene SurveyIs scene safe? Protect Self/Team (Universal Precautions).Protect your patient.Find Clues for Mechanism of injury/history.Number of patients.

7*Entering a scene before it is safe to do so puts the medical team at risk and, in doing so, can jeopardize the entire mission. Medical providers at all levels of training are expected to be brave and selfless; they are not expected to be reckless or foolish. Be aware of fuel leaks, ordnance, traffic, hostile bystanders, downed power lines, etc.*Ensure that you and the other members of your team are using universal precautions. Remember, HIV is the only blood-borne pathogen for which we screen and then only in our own troops. Hepatitis is a major source of morbidity and mortality for medical personnel and is very common throughout the world. Your patients will not always be US military personnel. Develop good habits from day one.*Remaining in the scene to treat your patient may put them at risk due to the above considerations or because of environmental factors (cold, rain, smoke, etc.). It may be necessary to move the patient before or during initiating treatment.*There may be clues in the vicinity of the patient that give you some idea of the mechanism of injury, especially if the patient is not able to provide that information. A cracked windshield or bent steering wheel in MVAs; smoke or fire in vicinity of unconscious (potentially hypoxic) patients; evidence of explosions can help focus your search for blast injuries; taking note of environmental factors (patient was laying in snow)all these and more will help you and the other providers in the chain of medical care.*Search the area for other victims. Especially at night it can be difficult to find an unconscious patient. Military personnel seldom operate individually, and given that teams are usually employed, search the area for other patients before leaving the area.PRIMARY SURVEYAdult / Pediatric priorities sameIdentified the life-threatening conditions and simultaneously managedA: Airway maintenance with cervical spine protectionB: Breathing and ventilationC: Circulation with hemorrhage controlD: Disability ( Neurologic status )E: Exposure / Environmental control: Undress the patient & prevent hypothermia

AirwayUpper airway obstruction kills.Talking patients have an open airway.Common causes of obstruction: tongue, foreign objects, swelling, direct traumaSigns & Symptoms: impaired speech, cyanosis, irregular breathing, stridor, coughing.9*If your airway is obstructed, you will be unconscious before I finish this slide. *The simplest way to assess the airway is to ask the patient to speakWhats you name soldier? if answered correctly and in a normal voice tells you that, in addition to the airway being open, the patient is pumping enough oxygenated blood to the brain to be able to comprehend the question. That is, it tells you something about A, B and C.*When a patient becomes unconscious, the musculature of the floor of the mouth and throat relaxes sufficiently to allow the tongue to slide back and obstruct the airway. Of course, foreign objects, secretions, vomitus, and direct trauma to the larynx can also obstruct the airway.*The Signs and Symptoms of an obstructed airway include: apprehension, agitation, impaired speech, clutching at the throat, stridor, coughing.

Airway ManeuversHead tilt, chin lift (Caution!)Jaw thrustLeft lateral positionHeimlich Artificial airways : oropharyngeal, nasopharyngeal 10*What do you do about an obstructed or partially obstructed airway? It does, to some extent, depend upon the context. *In the context of battlefield trauma, all patients must be assumed to have a cervical spine injury. The most common maneuver for opening the airway, as taught in BLS and ACLS, is the Head Tilt, Chin Lift. This maneuver will hyperextend the spine and may cause serious damage in the presence of an unstable cervical spine injury.*The Jaw Thrust is performed with two hands and a modified jaw thrust can be performed with one. It is a quick and effective way to open the airway temporarily. It is impractical to use this maneuver for extended periods of time.*The left lateral position can be used to aid a patient in draining secretions and in overcoming the effects of gravity in order to keep the airway open. It is particularly useful if the patient must be left unattended for a while as in a mass casualty incident.*The Heimlich maneuver is used when a foreign body is suspected to be in the airway, particularly if, after opening the airway, one is still not able to get air to enter the lungs.*Mechanical adjuncts can also be used to help maintain an open airway. The Oropharyngeal airway can only be used in an unconscious patient. Attempting to use it in a conscious patient will cause gagging and vomiting. Remember that neither device protects the airway against aspiration, and that both, particularly the oropharyngeal airway, are considered temporary measures: either the patient improves and does not need one, or the patient does not improve and needs to be intubated. You will be taught how to determine the correct size of mechanical airway device and how to insert them during the patient assessment lab.Cervical Spine InjuryInclude in airway management.Suspect in all blunt trauma victims, unconscious patients.Stabilize and immobilize neck.Dont use head-tilt. 11*First Do No Harm is a useful principle to apply to the discussion of possible cervical spine injuries. It is not possible to image the cervical spine or to exclude cervical spine injuries on the battlefield. For this reason, the most prudent thing to do is to PROTECT the cervical spine while continuing with the examination and stabilization.*Cervical spine trauma is much more likely to occur in victims of blunt trauma. Unconscious patients, and particularly those with injuries above the clavicle, are also at particularly high risk for occult cervical spine injuries. Cervical spine injuries are relatively uncommon with penetrating neck injuries, unless there are signs of neurological compromise.*In the Patient Immobilization and Transport Section, you will be taught methods of immobilizing the spine in addition to the standard civilian approach of using a cervical collar and long spine board. Boots, sandbags, canteens and other pieces of gear can be used as effective field-expedient aids to immobilization.*As was mentioned earlier, the head-tilt/chin-lift maneuver is dangerous in the presence of suspected cervical spine injuries and should not be done in the context of battlefield medicine.BreathingBreathing is different from airway.Look ListenFeelAcute Respiratory Insufficiency: abnormal respiration , use of accessory muscles, nasal flaring, cyanosis

12*As soon as you encounter a patient you should be in the process of assessing their vital functions. Part of this is to assess their respiratory rate, rhythm and effort. Under battlefield conditions it may be impossible to hear the breath sounds. The only way to determine respiratory status might be through touch. In addition to determining rate, the sense of touch can alert you to the presence of crepitus from subcutaneous emphysema which might indicate a pneumothorax or damage to the airway.*In addition to rate and rhythm you should observe the patient for signs of acute respiratory insufficiency. These would include: gasping, accessory muscle usage, intercostal or supraclavicular retractions, nasal flaring, or cyanosis.BreathingSupplemental Oxygen is a drug! Spontaneous respiration:Nasal cannula, face masks, rebreather and non-rebreather masksNon-breathing patients:Mouth to mask ventilation, Bag- Valve-Mask

13*Not only is oxygen a drugwith specific indications, dosage and contraindications, but, apart from the approximately 21% that is found in the atmosphere, it is also hard to come by on the battlefield. Until you are at echelon three or higher, oxygen will be hard to obtain.*The spontaneously breathing patient can be assisted, where indicated, by nasal cannula, face masks, rebreather and non-rebreather masks.*The NON-breathing patient will require you to perform the actual act of breathingi.e., it is necessary to have a means of supplying the inhaled gases under pressure: mouth to mask, bag-valve-mask, etc. People normally get air into their lungs by creating negative intra-thoracic pressure. Since that is not possible, you will have to supply positive extra-thoracic pressure. Patients who are not breathing do not have intact gag reflexes and will need to be intubated expeditiously to protect their airways. It is easier to bag an intubated patient because it can be done with one hand, and it can be done by personnel who are not medically trained.*Failure to recognize impending respiratory arrest in a major cause of morbidity and mortality in the trauma patient.CirculationAssess circulatory function:Central & peripheral pulsePulse rate and characterSkin color, moisture & temp

CirculationIdentify life-threatening hemorrhage:Rapid , Arterial , Massive amountControl hemorrhage:Direct pressure , Splint and elevate, MAST, TourniquetIdentify internal hemorrhage.DisabilityIdentify level of consciousnessA-alertV-verbal commandsP-painU-unresponsivePupil response and sizeExposeRemove clothing as needed .Maintain body temperature.Inspect/palpate the entire body.Log roll to expose back.

The rapid AssessmentNeckInspect/palpate : DCAP BLS, JVD, Trache deviation, painChestInspect/palpate : DCAPP BLS, Auscultate for breath sounds, PercussAbdomenInspect/palpate : DCAP BLS, Tenderness

The rapid AssessmentPelvisInspect/palpate DCAP BLS, TICMusculoskeletalInspect/palpate DCAP BLS, TIC, PMS

Load and Go

Kriteria Load and GoObstruksi jalan nafas yg tdk dpt diatasi scr mekanik(suction, forceps atau intubasi)Henti jantung karena traumaKeadaan yg menimbulkan pernafasan tdk adekuat (open pneumothotax, flail chest, tension pneumothorax, trauma dada yg luasShockTrauma kepala tdk sadar, pupil anisokor/penurunan kesadaranNyeri abdomenPelvis tdk stabilFraktur femur bilateral

SECONDARY SURVEYHistory A. AllergiesM. Medications currently usedP. Past illness / pregnancyL. Last mealE. Events / Environment related to injury

HISTORYMechanisms of injuryBluntAutomobile collisionsSeat belt usageSteering wheel deformationDirection of impactEjection of passenger form the vehicleBurns and Cold injuryInhalation injury and CO. intoxication in fire fieldHazardous environmentPenetrateAnatomy factorsEnergy transfer factorVelocity and caliber of bulletTrajectoryDistance

SECONDARY SURVEYPhysical ExaminationHead and Maxillofacial Inspect and palpate head and face (DCAP BLS, TIC) Battles sign Pupils and LOC Raccoon eyes Ears and nose for CSF Mouth Skin : pale, cyanosis, diaphoresis

SECONDARY SURVEYReassess ABCsVital sign Physical ExaminationC-spine and Neck Inspect for signs of injury, tracheal deviation- Palpate for tenderness,DCAP - BLS, subcutaneous emphysema- Auscultate for carotid bruitsSECONDARY SURVEYPhysical ExaminationChestInspect ant, lat and post chest for injury, use of accessory- Auscultate for breath sounds- Palpate for DCAPP BLS, TIC- PercussSECONDARY SURVEYPhysical ExaminationAbdomenInspect & palpate for signs of injury or bleeding DCAP - BLSAuscultate for bowel soundsPercussSECONDARY SURVEYPhysical ExaminationMusculoskeletalInspect & Palpate extremities for signs of injury (DCAP BLS, TIC, PMS)Assess pelvis (DCAP BLS, TIC)SECONDARY SURVEYPhysical ExaminationNeurologicDetermine GCS scoreRe-evaluate pupilsSensory / motor evaluation Maintain immobilizationPrevent secondary CNS injury Early neurosurgical consultation

Reassessment SurveyThe level of Consciouss Reassess ABCsNeck, chest, abdomen, pelvis, ekstremitasFocused Assesment of InjuriesCheck Intervention( patient is not stable every 5 minute, patient is stable every 15 minute)SUMMARYInitial assessment & management of multiply injured patient

Primary survey ( ABCDEs )

Resuscitation & monitor ( life-threatening problems )

Secondary survey ( head-to-toe, history )

Questions?ReferrenceLanros & Barber (1997) Emergency Nursing : with Certification, Preparation, & Review.USA : Appleton & LargeSpringhouse corporation book division (1985). Nurses Reference Library : Emergencies. Pennsylvania : Springhouse corporation_____ (1998) Pertolongan Dasar Gawat Darurat Trauma : Malang.RSUD Dr Saiful Anwarhttp://www.adhb.govt.nz/trauma/T_guidelines/primary_survey.htmSuhttp://sprojects.mmi.mcgill.ca/trauma/educ/tutorials/surveys.htmrvey