CHAPTER 1

INISIAL ASSESSMENT

Elemen inisial asesment :

1. Preparation
2. Triage
3. Primary survey (ABCDEs) with immediate resuscitarion of patients with life threatening injuries
4. Adjuncts to primary survey and resuscitation
5. Consideration of the need for patient transfer
6. Secondary survey (head to toe evaluation and patient history)
7. Continued post resuscitation monitoring and reevaluation
8. Definitive care

PREPARATION :
1. Prehospital phase
2. Hospital phase

- Prehsopital phase : GUNAKAN CONCEPT “FIELD TRIAGE DECISION Of SCHEME)

 Emphasize airway maintenance
 Control of external bleeding and shock
 Immobilization of patient
 Immediate transport to the closest appropiate facility

Memberikan informasi yg dibutuhkan di rumah sakit :

 Time of injury
 Events realted to the injury
 Patient history
 The mechanisms of injury

- Hospital phase :
 A resuscitation area is avalaible for trauma patients
 Properly functioning airway equipment (laryngoscopes and ETT) is organized, tested, and
strategically placed to be easily accessible
 Warmed IV Crystalloid solutions are immediately available for infusion
 A protocol to summon additional medical assistance is in place, as well as means to ensure
prompt responses by laboratory and radiology personnel
 Transfer agreements with verified trauma centers are established and operational.

TRIAGE :
 Triage involves the sorting of patients based on the resources required for treatment and the
resources that are actually available.
 ABC priorities (airway with cervical spinte protection, breathing, circulation with hemorrhage
control)
 Other factors that can affect triage and treatment priority (the severity of injury, ability to
survive, available resources)
 Categorized :

1. Multiple casualties : the number of patients and the severity of their injuries do not exceed the
capability of the facility to render care. Patients with life threatening problems and those sustaining
multiple system injuries are treated FIRST.
2. Mass casualties : the number of patients and the severity of their injuries does exceed the
capability of the facility and staff. Patients having the greatest chance of survival and requiring the
least expenditure of time, equipment, supplies, and personnel are treated FIRST.
PRIMARY SURVEY WITH SIMULTANEOUS RESUSCITATION
 AIRWAY maintenance with restriction of cervical spine motion
 BREATHING and ventilation
 CIRCULATION with hemorrhage control
 DISABILITY (Assessment of neurologic status)
 EXPOSURE / Environmental control

 Do quickly assess (10 second) by identifying themselves, Asking the patient for his name and
asking what happened.
 AIRWAY MANAGEMENT :
 Clearing the airway
 Suctioning
 Administering oxygen
 Opening and securing the airway

 Airway maintenance with restriction of cervical spine motion :

 Assess the airway for signs of airway obstruction :
 Inspecting for foreign bodies : identifying facial, mandibular and/or tracheal fracture
 Suctioning to clear accumulated blood or secretion
 Begin measures to establish a patent airway while restricting cervical spine motion
 Prevent excessive movement of the cervical spine with a cervical collar. When airway
managament is necessary, the cervical colar is opened and a team member manually
restrict motion of the cervical spine.

 Breathing and ventilation :

 Breathing is maximize oxygenation and carbon dioxide elimination
 Ventilation requires adequate function of the lungs, chest wall, and diaphragm.
 Injuries that significantly impair ventilation include :
 Tension pneumothorax
 Massive hematothorax
 Tracheal or bornchial injuries

 Circulation with hemorrhage control

 Major issues to consider :
 Blood volume
 Cardiac output
 Bleeding
 Blood volume and cardiac output, The elements of clinical observation that yield important
information within seconds are :
 Level of consciousness : When circulating blood volume reduces, cerebral perfusion
may be critically impaired, resulting in an altered level of consciousness
 Skin perfussion : patient with hypovolemia may have ashen, gray facial skin and pale
extremities
 Pulse : Assess a central pulse (femoral or carotid) bilaterally for quality, rate, and
regularity
 Bleeding :
 Identifty the source of bleeding external or internal.
 External bleeding :
 Direct manual pressure on the wound
 Tourniquets are effective in massive exsanguination but carry a risk of ischemic
injury to thar extremity. Use only when direct pressure is not efective and the
patient’s life is threatened
 Internal bleeding :
 Major area : chest, abdomen, retroperitoneum, pelvis, long bones
 Diagnosed by : X-Ray, FAST, DPL
 Immediate management : chest decompression, pelvic stabilizing device,
extremity splints.
  Definitive management : surgical, interventional radiologic treatment, pelvic and
long bone stabilization
 Typically two large peripheral venous catheters are palced administer fluid, blood, and
plasma, if peripheral sites cannot be accessed, Intraosseus, CVC, or Venous cutdown
may be used.
 Baseline hematologic studies are obtained : Pregnancy test for all females of
childbearing age, Blood type and cross matching.
 Assess the presence and degree of shock : Blood gases, Lactat level
 All iv solutions should be warmed (37-40 C). A bolus 1 L isotonic solution may be
required in initial therapy to achieve an appropiate response in an adult patient.If the
patient is inresponsive, he should receive blood transfusion.
 Fluids are administered judiciously, as aggressive resuscitation before control of
bleeding has been demonstrated to increase moratlit and morbidity.
 Severely injured trauma patients are at risk for coagulopathy, which can be further
fueled by resuscitative measures.
 Studies demonstrate improved survival when tranexamic acid is administered within 3
hours of injury. When bolused in the field follow up infusion is given over 8 hours in
the hospital.

 Disability (neurologic evaluation)

 Neurologic evaluation establishes :
 Level of consciousness : GCS is quick simple. A decreases GCS may indicate decreased
cerebral oxygeantion and/or perfussion, or may be caused by direct cerebral injury.
Other conditions like hypoglycemia, alcohol, narcotics and other drugs can also alter a
patinet’s level of consciousness.
 Pupillary size and light reaction
 Lateralizing signs
 Spinal cord injury level
 Prevention of secondary brain injury by maintaining adequate oxygenation and perfussion
are the main goals of initial management, which is crucial to repeat the examination.

 Exposure and environmental control

 Undress the patient to do examination and assessment, after completing, cover the patient
with warm blankets or an external warming device to prevent him hypothermia
 Warm IV Fluid before infusing them, and maintain a warm environment, the use of a high
flow fluid warmer to heat fluids to 39 C is recommended, if not available, amicrowave can
be used to warm crystaloid fluids.
ADJUNCTS TO THE PRIMARY SURVEY WITH RESUSCITATION

1. ECG
2. Pulse Oximetry
3. CO2 monitoring
4. Ventilatory rate
5. Arterial blood gas measurement
6. Urine catheters to monitor urine output and assess for hematuria
7. Gastric Catheters to decompress distention
8. Blood lactat
9. X-Ray
10. FAST and eFAST
11. DPL

 ECG
 Dysrhytmia : Unexplained tachycardia, AF, PVC, ST Segments changes (can indicate blunt
cardiac injury, or extreme hypothermia)
 PEA : can indicate cardiac tamponade, tension pneumothorax, profound hypovolemia
 Bradycardia, aberrant conduction, premature beats : Hypoxia and hypoperfusion should be
suspected imeediately
 ABG :
 Provide acid base information
 Low PH and base Excess levels indicate shock, trending these values can reflect
improvemnets with resuscitation.
 Urine catheheters :
 Indicator of volume status and reflects renal perfusion.
 Contraindicate for patients who may have urethral injury, suspect with the presence of
either blood at the urethral meatus or perineal ecchymosis
 Gasrtric Catheters :
 Is indicated to decompress stomach distention, decrease the risk of aspiration, and check
for upper GIT hemorrhage from trauma.
 X-Ray :
 Blunt trauma : AP Chest and AP Pelvic
SECONDARY SURVEY (head to toe evaluation and patient history)
 Complete history and physical examination : reassessment of all vital sign
 Each region of the body is completely examined
 For adult patients, maintenance of urinary output at 0.5 ml/kg/hour is desirable
 For pediatric patients who are older than 1 year, an output of 1 ml/kg/hour is typically adequate
 Effective analgesia usually requires the administration of opiates or anxiolytics IV.
 Interhospital guidelines : ACS COT’s Resources for Optimal Care of the Injured Patient)

 HISTORY :
 AMPLE :
 Allergies
 Medications currently used
 Past illnesses / Pregnancy
 Last Meal
 Events / environment related to the injury

 Mechanism of injury :
1. Blunt trauma
2. Penetrating trauma
3. Thermal injuries
4. Those caused by hazardous environments.

BLUNT TRAUMA
 Often results from automobile collisions, falls, and other injuries related to transportation,
interpersonal violence.
 Ask about seat-belt use, steering wheel deformation, presence and activation pf air-bag
devices, direction of impact, damage to the automobile, patient position in the vehicle.

PENETRATING TRAUMA
 Think organs in the path of the penetrating object and velocity of the missile.
 In gunshot vitcims, ask the velocity, caliber, presumed path of the bullet and distance from
the weapon to the wound can provide important clues

THERMAL INJURY
 Burning automobile, explosion, falling debris, patient attempt to escape a fire can risk
inhalation injury and carbon monoxide poisoning.
 Acute or chronic hypothermia without adequate protection against heat loss produces
either local or generalized cold injuries. Can occur at moderate temperatures (15-20 C)

HAZARDOUS ENVIRONMENT
 History of exposure to chemicals, toxins, and radiation is important to obtain for two main
reasons, these agents can produce a virety of pulmonary, cardiac, an internal organ
dysfunctions in injured patients.

 PHYSICAL EXAMINATION :
 Head :
 Identify all related neurologic injuries and any other significant injuries (laceration,
contusion, fracture)
 Evaluate eye for : Visual acuity, pupillary size, hemorrhage of the conjunctiva,
penetrating injury, contact lenses, dislocation of the lens, ocular entrapment
 Maxilofacial structure :
 Palpation of all bony structure, assessment of occlusion, intraoral examination, and
assessment of soft tissue
 If there fractures of the midface may also have a fracture of the cribriform plate, so
gastric intubation should be perform via the oral route.
 Cervical spine and neck
  Patients with maxillofacial or head trauma should be presume to have a cervical spine
injury and cervical spine motion must be restricted.
 Evaluation may include Radiographic series and CT
 Examination of neck : inspection, palpation, auscultation : cervical spine tenderness,
subcutaneous emphysema, tracheal deviation, and laryngeal fracture
 Carotid arteries should be palpated and auscultated for bruits
 Chest :
 Visual evaluation of the chest both anterior and posterior : open pneumothorax and
large flail segments, contusion and hematoma.
 Palpation of the entire chest cage (clavicles, ribs, and sternum) and x-ray.
 Significant injury can manifest : pain, dyspnea, and hypoxia.
 Distand heart sounds, distended neck veins and decreased pulse pressure can
indicate cardiac tamponade.
 Percussion : hyperresonace (tension pneumothorax)
 Abdomen and Pelvis :
 Abdominal injuries must be identified and treated aggressively.
 Close observation and frequent reevaluation of the abdomen preferably by the same
observer are important in managing blunt abdominal trauma.
 Pelvic fractures can be suspected by identification of ecchymosis over the iliac wings,
pubisa, labia, or scrotum.
 Pain on palpation of the pelvic ring is an important finding in alert patients.
 Assessment in peripheral pulses can identify vascular injuries.
 Candidates for DPL, USG Abdomen, CT Abdomen if hemodynamic are normal
considered by : Unexplained hypotension, neurologic injury, impaired sensorium
secondary to alcohol and/or other drugs, equivocal abdominal findings.
 Perineum, rectum, and vagina :
 The perineum shoulb be examined for contusions, hematomas, lacerations, and
urethral bleeding
 A rectal examination may be performed to assess for the presence of blood within the
bowel lumen, integrity of the rectal wall, and quality of sphincter tone.
 Vaginal examination should be performed in patients who are at risk of vaginal injury,
presence of blood in the vaginal vault and vaginal lacerations.
 Pregnancy tests should be performed on all females of childbearing age.
 Musculoskeletal system :
 Inspection : Contusions and deformities
 Palpation : tenderness and abnormal movement aids in the identification of occult
fractures
 Ligament ruptures produce joint instability
 Muscle tendon unit injuries interfere with active motion of the affected structures.
 Impaired sensation and/or loss voluntary muscle contraction strength can be caused
by nerve injury or ischemia, including that due to compartment syndrome
 Neurological System :
 A comprehensive neurologic examination includes motor and sesnsory evaluation of
the extremities : reevaluation of the patient’s level of consciousness and pupillary size
and response.
 If theres is head injury early consultation with a neurosurgeon is required, monitor of
an intracranial injury, reassess oxygenation, the adequacy of ventilation and perfusion
of the brain.
 Any evidence of loss of sensation, paralysis, or weakness suggest major injury to the
spinal column or peripheral nervous system.
 Protection of the spinal cord is required at all times until a spine injury is excluded.
 Early consultation with a neurosurgeon or orthopedic is necessary if a spinal injury is
detected.
TEAMWORK
 The trauma team typically includes a team leader, airway manager, trauma nurse, trauma
technician. :
 Team leader : supervises, checks, and directs the assessment, assigns roles and tasks to the
team members, assignss some of the possible roles, depending on the size and composition
of the team :
 Assessing the patient, including airway assessment and management
 Undressing and exposing the patient
 Applying monitoring equipment
 Obtaining intravenous access and drawing blood
 Serving as scribe or recorder of resuscitation activity
 On arrival of the patient : MIST
 Mechanism and time of injury
 Injuries found and suspected
 Symptoms and signs
 Treatment initiated