INITIAL ASSESMENT

Farly Ihsan, S.Kep,.Ners

Phone/wa : 087808986733
Email : nabhanelihsan@gmail.com

International
Seminar dan Workshop
28 Juni 2020
Tujuan Instruksional
Umum

PESERTA MAMPU MEMAHAMI INITIAL

ASSESMENT PADA PASIEN TRAUMA
Tujuan Instruksional Khusus

Update manajemen Trauma

Mensimulasikan manajemen trauma

• Seorang laki – laki berusia 50 tahun mengalami kecelakaan
lalu lintas terpental sejauh kurang lebih 10 meter. Pasien tiba
di IGD dalam kondisi tidak sadar, akral dingin, tampak keluar
darah dari lubang hidung dan telinga, frekuensi nafas 10 x /
menit, frekuensi nadi 110x/menit , GCS 8, tampak fraktur
femur terbuka dextra dengan pendarahan massif

• Apa tindakan Prioritas yang saudara lakukan jika menemukan

pasien sperti ini ?
PENGERTIAN

INITIAL ASSESMENT

Menilai hal – hal yang

mengancam nyawa penderita
dan bagaimana menanganinya
dengan cepat dan benar
 PRINSIP

• Kenali terlebih dahulu keadaan yang mengancam nyawa

Terdiri dari :
1. Primary Survey (Survei Primer)
2. Secondary Survey (Survei Sekunder)

Terapi Definitip
Sebelum Kontak Dengan Pasien

1.Alat Pelindung Diri (APD)

2. Identifikasi Keadaan Umum

cek respon APVU :
ALERT – PAIN – VERBAL -
UNRESPONSIVE
SURVEY PRIMER

A.AIRWAY (+ Cervical Spine Control)

B.BREATHING (+Ventilation)
C.CIRCULATION ( + Kontrol Pendarahan)
D.DISABILITY (Kesadaran, Lateralisasi)
E.EXPOSURE
REVISI
American College OF Surgeons. 2018. Advanced Trauma
Life Support. Student Course Manual. Tenth edition
 AIRWAY MAINTENANCE WITH
RESTRICTION OF CERVICAL SPINE
Update istilah/terminologi
 SPINAL IMMOBILIZATION
and
SPINE MOTION RESTRICTION

• Spinal motion restriction is defined as attempting to maintain the spine in

anatomic alignment and minimizing gross movement irrespective of adjuncts
or devices. NREMT’s use of the term, spinal immobilization is defined as the
use of adjuncts (i.e cervical collar, long board, etc.) being applied to minimize
movement of the spinal column. (Sumber: National Registry of EMT's Resource
Document on Spinal Motion Restriction/Immobilization )
• Participants experienced greater transverse plane cumulative integrated
motion during TSI compared to SMR (F1,57 = 4.05; P = 0.049), and greater
transverse peak range of motion during participant loading/unloading in TSI
condition compared to SMR (F1,57 = 17.32; P < 0.001). Pain was reported by
40% of our participants during TSI compared to 25% of participants during SMR
(χ2 = 1.29; P = 0.453). ()
 AIRWAY MAINTENANCE
WITH RESTRICTION OF
CERVICAL SPINE

Penanganan
Curiga Fraktur Cervical bila
Bila Curiga Fraktur Cervical

 Trauma kepala  Bila curiga fraktur

servikal
 Multi trauma
 Fiksasi kepala secara
 Ada luka (tumpul) manual
di atas klavikula  Pasang cervical collar
 AIRWAY MAINTENANCE WITH
RESTRICTION OF CERVICAL SPINE
• PERIKSA KEPATENAN JALAN NAFAS
• Head Tilt – Chin Lift / jaw Thrust
• Look, Listen and Feel

• Melihat pengembangan Dada

• Mendengar suara nafas
• Merasakan hembusan nafas
GURGLING SNORING STRIDOR
- Miringkan/Logroll - Head tilt,chin lift - Therapi definitip
- Finger Swap - Jaw thrust - Trakeostomi
- Suction - OPA - NPA - Ett
Mempertahankan jalan napas dengan
OPA dan NPA

OPA

NPA
Mempertahankan jalan napas dengan
Laringeal Mask Airway (LMA)
Lanjutan
Mempertahankan jalan napas dengan Endotracheal Tube
(ETT)

Persiapan alat
- Selang endotrakeal (ETT), terbagi
2 jenis yaitu king king dan non
king king,
- Laringoskop (laryngoscope)
dengan 2 jenis, yaitu laringoskop
Macintosh dan Miller
- BVM
- Stetoskop
- Cuff inflator atau spuit 10 cc
- Mandrin / Stylet
- Jelly
- Sarung tangan
- Plester
BREATHING AND VENTILATION
BREATHING AND VENTILATION

BREATHING AND VENTILATION

INSPEKSI PALPASI PERKUSI AUSKULTASI

BERIKAN OKSIGEN
BANTU VENTILASI DENGAN BAG VALVE MASK
VENTILASI MEKANIK
KEPERAWATAN GAWAT DARURAT DAN BENCANA, 2016
BAG VALVE MASK
1 PENOLONG 2 PENOLONG
Primary survey

life-threatening thoracic injuries

 Update Trauma Thorax

• Modifikasi kondisi trauma

thorax yang mengancam
nyawa (life-threatening
thoracic injuries)
• Flail chest tidak masuk
kategori, dan digantikan
oleh tracheobronchial tree
injury
 BREATHING (lanjutan)
Update primary survey thoracic Injuries :
1. Airway Obstruction
2. Tracheobronchial injury
3. Open Pneumothorak
4. Tension Pneumothorak
5. Masif Hemathothorak
6. Tamponade Jantung
7. Traumatic circulatory arrest
BREATHING (Lanjutan)
• Tindakan Pada Gangguan Breathing
1. Airway Obstruction
2. Open Pneumothorak
3. Tension Pneumothorak
4. Masif Hematothorak
5. Flail Chest
6. Tamponade Jantung
7. Traumatic circulatory arrest
8. Tracheobronchial injury
kassa 3 sisi
Needle Thorakosentesis
Thorakotomi Cito/WSD
Analgetik,Kompres
Pericardiosintesis
OPERATIF
Tamponade Jantung

Pericardiosintesis
Open Pneumothorak Tension Pneumothorak
 UPDATE
Needle Decompression
 UPDATE
Needle Decompression
• Dewasa: ICS 4 atau 5, antara garis mid-
axila dan axila anterior
• Anak: tetap, ICS 2 garis mid-clavicular

American College OF Surgeons. 2018. Advanced Trauma

Life Support. Student Course Manual. Tenth edition
Traumatic
Circulatory Arrest

American College OF Surgeons. 2018. Advanced Trauma

Life Support. Student Course Manual. Tenth edition
 Secondary Survey
Potensially LIFE THREATENING INJURIES
1. Simple Pneumothorak
2. Hemothorax
3. Flail chest
4. Pulmonary contusion
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Blunt esophageal rupture
American College OF Surgeons. 2018. Advanced Trauma
Life Support. Student Course Manual. Tenth edition
 CIRCULATION
WITH HEMORRAGHE CONTROL
 CIRCULATION WITH
HEMORRAGHE CONTROL

PEMERIKSAAN PENUNJANG MEDIS

 IDENTIFIKASI SUMBER TES LABORATORIUM DARAH

PERDARAHAN RONTGEN
 KAJI STATUS SIRKULASI, CT SCAN
HEART RATE,WARNA KULIT, MRI
PULSASI, CAPILARRY REFILL USG
TIME, TEKANAN DARAH.
 NILAI AKRAL
 ESTIMAS KEHILANGAN DARAH AKIBAT CEDERA
NO CEDERA PERKIRAAN KEHILANGAN CAIRAN DARAH
1 FRAKTUR PELVIS 3000ML
2 FRAKTUR FEMUR 1000ML
3 FRAKTUR TIBIA 650ML
4 CEDERA INTRA ABDOMEN 2000ML
5 CEDERA OTAK 2000ML

DATA DARI EMERGENCY NURSES ASSOCIATION (2009), Sheehy’s emergency

nursing. Principle and Practice (6th ed). St. Louis, MO : Mosby
 The definition of shock an abnormality of the
circulatory system theat result in inadequate organ
perfusion and tissue oxygenation

The second step in

The first step managing managing shock is to
shock in trauma patients is identity the probable
to recognize its presence cause of shock and adjust
treatment accordingly
 The element of Clinical observation that yield important
information within seconds are level of consciousness, skin
perfusion, and pulse
1. Level Of consciousness
When circulating blood volume is reduce, cerebral perfusion may be critically
impaired, resulting in an altered level of consciousness
2. Skin Perfusion
This sign can be helpful in evaluating injured hypovolemic patiens. A patients with pink
ski, especially in the face and extremities , rarely has critical hypovolemia after injury.
Conversely, a patient with hypovolemia may have ashen, gray facial skin and pale
extremities
3. Pulse
A rapid, thread pulse is typically a sign of hypovolemia, assessa central pulse (e.g
femoral or carotid artery) bilaterally for quality, rate and regularity. Absent central
pulses that cannot be attributed to local factors signify the need for immediate
resuscitative action
American College OF Surgeons. 2018. Advanced Trauma
Life Support. Student Course Manual. Tenth edition
AKRAL DINGIN + NADI CEPAT

SYOK
CIRCULATION (lanjutan)
TINDAKAN
• Mengatasi ABC
• Cek tanda – tanda vital
• Pasang IV line 2 jalur
• Tinggikan Ekstremitas Bawah
(Posisi Syok)
• Cari sumber Pendarahan dan
Hentikan
• Resusitasi cairan untuk
meningkatkan volume Intravaskular
• Tekhnik penekanan langsung
(direct pressure) dengan
tujuan menghentikan
pendarahan
• Kaji seberapa luas luka
pendarahan
• Sesuaikan dengan
perlengakapan yang ada
Direct Pressure On Hemorrage
 KESADARAN
A.V.P.U

DISABILITY LATERALISASI

RESPON
PUPIL :
ISOKOR/ANISOKOR

Tentukan tingkat Kesadaran dengan GCS, hati – hati menjadi perhatian bila pasien GCS turun 2 atau
lebih
Revisi GCS

• Skor tetap tapi memudahkan

interpretasi

• NT, jika tidak dapat dilakukan

pemeriksaan
Revisi GCS

• Area stimulasi yang disarankan:

• ujung kuku
• trapezius
• supraorbital

• Area stimulasi yang TIDAK disarankan:

• sternum
• retromandibular
EXPOSURE
• Buka pakaian pasien tapi cegah hipotermia
• Periksa seluruh permukaan tubuh
PERIKSA DOTS:
•D DEFORMITY (Deformitas)
•O OPEN WOUND (luka Terbuka)
•T TENDERNESS (nyeri Tekan)
•S SWELLING (Bengkak)
Tambahan Survei Primer
• F = FOLLEY CATHETER
Kateter urine untuk penilaian produksi urine
• G = GASTRIC TUBE
NGT untuk dekompresi lambung
meminimalkan aspirasi
• H = HEART MONITOR
Monitor EKG Untuk mengetahui adanya
gangguan irama jantung
 SECONDARY SURVEY

• Setelah survey primer selesai

• Pemeriksaan dari ujung rambut sampai kaki
(head to toe) termasuk neurologi
• Balut dan bidai (Jika ada)
• Monitor terus menerus
• Pemeriksaan tanda vital
• Periksa tiap lubang tubuh (Finger In Orifice)
 SECONDARY SURVEY

Tidak lupa untuk menanyakan riwayat

KOMPAK AIUEO SAMPLE
K = KELUHAN A = ALKOHOL S = SIGN AND SYMPTOM
O = OBAT I = INSULIN A = ALLERGY
M = MAKANAN U = UREMIA M = MEDICATION
P = PENYAKIT E = EPILEPSI P = FAST HISTORY
A = ALERGI O = OVER DOSIS L = LAST MEDICATION/MEAL
K = KEJADIAN E = EVENT LEADING
 SECONDARY SURVEY
(lanjutan)

FOTO RONTGEN
1. SERVICAL (LATERAL)
2. THORAKS (AP) HANYA BILA STABIL
3. PELPIS (AP)

PEMERIKSAAN LABORATORIUM
Pemeriksaan H2TL,creatinine kinase, elektrolit dan
serum serta pemeriksaan urine
 TAHAPAN - TAHAPAN
PERSIAPAN
PRA RS DAN
RS
PRIMARY SURVEY :
APD & CEK RESPON
AIRWAY AND CERVICAL SPINE CONTROL SECONDARY SURVEY :
BREATHING AND VENTILATION HEAD TO TOE
CONTROL PEMERIKSAAN TTV
CIRCULATION AND BLEEDING CONTROL FINGER IN ORIFICE
DISABILITY GCS R/ KOMPAK – AIUEO
EKSPOSURE LAB. FOTO
FOLLEY CATHETER LABORATORIUM
GASTRIC TUBE
HEART MONITOR
HIGH PERFORMANCE TEAM

TIMER DOCUMENT
AIRWAY

PATIENT

COMPRESSOR DEFIB

LEADER MEDICATION
 5H 5T

HIPOVOLEMIA TENSION PNEUMOTHORAK

HYPOXIA TAMPONADE JANTUNG
HIDROGEN ION (ACIDOSIS) TOXINS
HIPO-/HIPERKALEMIA THROMBOSIS PULMONARY
HIPOTERMIA THROMBOSIS CORONARY
 Referrences
• Kurniati, A, Trisyani,Y, dkk. 2018. Keperawatan Gawat Darurat dan Bencana Sheehy.
Edisi Indonesia I
• American College of Surgeons. ATLS Advanced Trauma Life Support Tenth Edition.
2018. Chicago
• Ooi, S, Manning, P. 2017. Guide to The Essential in Emergency Medicine. Second
edition
• National Registry of EMT's Resource Document on Spinal Motion
Restriction/Immobilization
• Erik E Swartz et al. 2018 . Prehospital Cervical Spine Motion: Immobilization Versus
Spine Motion Restriction. PMID: 29452031 DOI: 10.1080/10903127.2018.1431341
• Inaba, K., et al. Optimal Positioning for Emergent Needle Thoracostomy: A Cadaver-
Based Study. J Trauma, 2011; 71; 1099-1103.
• Inaba, K., et al. Optimal Positioning for Emergent Needle Thoracostomy: A Cadaver-
Based Study. J Trauma, 2011; 71; 1099-1103.
HATURNUHUN