Primary survey approach

(Penderita gawat darurat)

Dr.Irfan Hamdani,Sp.An
Dept.Anestesiologi FK UMSU
1
Medan

Penderita Gawat
Darurat

Penderita yang oleh karena suatu penyebab

(penyakit, tindakan, kecelakaan)
bila tidak segera ditolong akan cacat,
kehilangan anggota tubuh atau meninggal
2

Silent epidemic

Bencana akibat ulah manusia

Kecelakaan kereta api

Bencana
Kompleks

Kerusuhan

Alam

Triage dan evakuasi

Siapa didahulukan dan siapa dikirim ke mana

4 korban

Ratusan
10 korban

USA :
TRAUMA
Trauma penyebab kematian ketiga setelah cancer
dan atheroselerosis
Usia 1- 44 tahun (produktif) penyebab
kematian pertama
Jumlah kecelakaan : 60 juta / tahun
30 juta perlu perawatan medik
3,6 juta perlu MRS
9 juta cacat :
3000.000 permanen
8.700.000 temporer
Kematian 145.000 / tahun
Trauma related costs > $ 100 milyar11/ year

HASIL SURVEY DI PROPINSI :

NTT, KALBAR, KALTENG, SUMUT,
BENGKULU
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.

Macam Kasus
% Kasus
Trauma / kecelakaan lalu lintas
20 %
Diare
17 %
Malaria panas kejang
15,6 %
ISPA batuk sesak
12,2 %
Stroke tidak sadar
8,6 %
TBC batuk darah sesak
7,7 %
Jantung hipertensi, infark
7,6 %
Obsgyn perdarahan, eklampsia
6,4 %
Intoksikasi gigitan ular - peptisida
4,9 %

Trauma
Non trauma

: 20 %
: 80 %
12

BILA TERJADI HENTI NAFAS DAN

HENTI JANTUNG
KeterlambatanKemungkinan berhasil
1 menit

98 / 100

4 menit

50 / 100

10 menit

1 / 100

13

14

The Golden Hour

is the time in which resuscitation of severely injured
patients must begin to achieve maximal survive
R. Adams Cowley, MD

The lethal factor in shock is inadequate cellular oxygen

delivery, leads to irreversible anoxic cellullar injury that
kills a critical mass of cells

15

THE GOLDEN
Probability
of Survival
HOUR

R. Adams Cowley, MD

100
80
%
survival

60
40
20
0

30

60

90

Survival is related to severity

and duration
16

minutes

Percent of trauma deaths

The Trimodal Distribution of

Traumatic Disease
50

40
30
20
10
//
0
1
2
3
4.hrs 1-2
5-6
Time after injury
weeks
IMMEDIATE : CNS injury or Heart and great vessel
injury
EARLY : Major
hemorrhage
LATE : Infection and Multi Organ failure
0

17

PENDERITA GAWAT DARURAT

HIPOKSEMIA
HIPERKARBIA

HENTI JANTUNG
HENTI NAFAS

SINDROMA IWR
18

Pertolongan

A = Airway
B = Breathing
C = Circulation
D = Disability

Gangguan

Mati dalam

Sumbatan 3-5
Henti nafas
3-5
Shock berat
1-2 jam
Coma
1 minggu

19

 Ukur tek darah

Pasang infus
Konsultasi ke
Dokter Bedah
Beri Oksigen
Periksa Hb
Siap transfusi

Korban bernafas tersengal-sengal

Nadi lemah, gelisah,
Cedera berdarah di dada dan punggung

Apa pertolongannya?
20

mati dalam
Bebaskan jalan
nafas
Beri Oksigen
Pasang infus
Ukur tek darah
Periksa Hb
Siap transfusi
Konsultasi ke
Dokter Bedah

Ukur
Sumbatan
3-5 menit
tek darahjalan nafas
infus
Pasang
Henti nafas
3-5 menit
Konsultasi ke Dokter

Bedah
Shock berat
Beri Oksigen
Periksa Hb

Siap
Coma
transfusi

1-2 jam
1 minggu

21

CONCEPT
ABCDE approach to evaluation / treatment
Treat greatest threat to life first
Definitive diagnosis not immediately important
Time is of the essence
Do no further harm
22

INITIAL ASSESSMENT /
MANAGEMENT
Injury
Primary survey and adjuncts
Resuscitation
Reevaluation
Secondary survey and adjuncts
Reevaluation
Optimize patient status
Transfer

23

Primary survey and resuscitation

of vital functions are done
simultaneously a team approach

24

PENANGANAN PASIEN TIDAK

GAWAT
Anamnesa
Pemeriksaan fisik

Inspeksi
Palpasi
Perkusi
Auskultasi

Pemeriksaan penunjang
Diagnosa
Terapi
Supportif
Simtomatis
Definitif / kausal
25

PENANGANAN PASIEN GAWAT

DARURAT
Pem. Fisikawal (A-B-C-D)
(Primary survey) + Lab. Awal
Terapi suportif / resusitasi (life support)
Stabilisasi
Pem. Fisik sekunder(Secondary survey)
Anamnesa
Dari kepala s/d kaki
Pemeriksaan penunjang
Diagnosa
Terapi defenitif

26

CPCR / RJPO (Peter

Safar)

sic life support emergency oxygenation

A : Airway
B : Breathe
C : Circulate
vanced life support Restoration of spontaneous
culation
D : Drugs and Fluids
E : EKG
F : Fibrillations treatment
olonged life support post resuscitation brain
ented therapy
G : Gauging
H : Human mentation
27
I : Intensive care

KONSEP ATLS
Primary Survey
A : Airway with C-spine control
B : Breathing with ventilation
C : Circulation with hemorrhage control
D : Disability : neurologic status
E : Exposure/environment with temperature control
Resuscitation
Secondary Survey
Head to toe evaluation and history
Reevaluation
Definitive care
28

KEY POINTS
ACLS

In the Primary Survey, focus on basic CPR and

defibrillation
First A-B-C-D
Airway
:
Open the airway
Breathing :
Provide positive pressure ventilations
Circulation :
Give chest compressions
Defibrillation:
Shock ventricular fibrillation or pulseless
ventricular tachycardia (VF/VT)
29

KEY POINTS ACLS

In the Secondary Survey, focus on intubation,
intravenous (IV) access, and drugs and
why the cardiorespiratory arrest occurred
Second A-B-C-D
Airway
:
Perform endotracheal intubation
Breathing :
Assess bilateral chest rise and ventilation
Circulation :
Gain IV access, determine rhythm, give
appropriate agents
Defibrillation Diagnosis (Think):
Search for, find, and treat reversible
causes
30

PENANGGULANGAN PENDERITA GAWAT DARURAT

Basic General Emergency Life Support (GELS)
PPGD (Penanggulangan penderita gawat darurat) Dokter umum

PTC
ACLS

ATLS

BLS
ALS

- PRIMARY PREVENTION
- SECONDARY PREVENTION

PLS
NLS
OLS

HIGH RISK
HIGH FREQUENCY
HIGH SUCCESS
PROCEDURE

LOCAL SPECIFIC
- MALARIA
- DHF
- GE

BLS : Basic life support (A, B, C, BRAIN)

ALS : Advance life support
ATLS: Advance trauma life support (Trauma oriented L.S)
ACLS
: Advance cardiac life support (Cardiac oriented L.S.)
NLS : Neonatal life support
PLS : Pediatric life support
OLS : Obstetric life support

PTC : Primary trauma care

A
: Airway
B
: Breathing
C
: Circulation
Dsan: Dokter spesialis
31 Anestesi

LIFE SUPPORT
A : Airway Support
B : Breathing Support
C : Circulation Support
D : Disability / Brain Support

32

First responder
Life saver
Resusitasi stabilisasi
Airway
Breathing
Circulation
Brain

33

Dr. Bedah

Dr. Obgyn

Perdarahan
trauma

Perdarahan post partum

SHOCK
KARENA
PERDARAHAN

1
2

Dr. Penyakit
Dalam

Resusitasi
Stabilisasi

Dr.
Umum

Definitif terapi
Awal
Definitif terapi
akhir

Perdarahan
G.I.

Pembagian Peran Dr. Umum Dr. Spesialis

34

Dr.
Spesislias

PROTECTION FROM COMMUNICABLE

DISEASE

Water impermeable apron

Gown
Gloves
Face mask
Cap
Eye protection / goggles
Foot covers

To prevent contact with body fluids

35
patients

Time Saving is Life Saving

Waktu untuk bertindak terbatas
Data dasar untuk bertindak terbatas

Konsep dasar berfikir yang sederhana,

tindakan yang sistematik, dan
ketrampilan yang memadai.
36

Handling trauma patients requires

different mindset

TIME SAVING is LIFE SAVING

Prognosis pasien trauma paling baik pada jam pertama.

Dalam waktu satu jam terapi definitip harus sudah dikerjakan

The Golden Hour

37

Pasien Trauma
Life Support
Resusitasi,
Stabilisasi

A = airway
B = breathing
C = circulation
D = disability

Terapi Definitif,
Spesialistik
38

Initial
Assessment !!!!
39

Triage
Sorting of patients according to:
ABCDEs
available resources

Multiple casualties
Mass casualties

41

> 200 DEAD & more than 500 INJURED

42

43

TRIAGE & LABEL

Merah

Segera Ditanggulangi terlebih dahulu :

Mengancam Jiwa
Cacat

Kuning

Boleh Ditangguhkan :
Keadaan tidak mengancam Jiwa
Segera ditangani bila yang
mengancam Jiwa sudah teratasi

Hijau

Hitam

Boleh ditunda & Rawat Jalan :

Tidak Membahayakan Jiwa
Boleh Diabaikan & Ditinggalkan :
Diurus paling akhir
Sudah tidak ada tanda- tanda vital
Usaha usaha pertolongan amat
sangat kecil keberhasilannya44

TRIASE

Survei primer,
Surveisekunder

Terapi Definitif,
Rujukan

KLINIK

RUMAH SAKIT
TERDEKAT

Quick Dx, Quick RX

RUMAH SAKIT
LENGKAP,

Resusitasi

KAMAR OPERASI,

& Stabilisasi

ICU

PTC

Hanya 50% pasien

trauma
yang perlu
45
operasi

Survei Primer
dewasa/pediatrik/ wanita hamil
prioritas yang sama

Periksacepatberurutan
Selesaidalam 2 menit
Terapisegeraapa yang ditemukan
( treat as you find )
46

A
B
C
D
E

Survei Primer
Airway

Jalan nafas

Breathing

Pernafasan

Circulation

Sirkulasi

Disability

Kesadaran

Exposure

Pemaparan

47

Primary Survey
A airway with C-spine protection
B breathing
C circulation with hemorrhage
control
D disability
E exposure/environment
48

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure
49

Primary Survey
A
Establish patent airway
assume C-spine trauma

Pitfalls

equipment failure
inability to intubate
occult airway injury
progressive loss of airway
50

Airway
menilai jalan nafas
Bisa bicara ?
Look, listen, and feel
Gerak dada
Gerak otot nafas tambahan
Warna kulit, mukosa, kuku
51

Airway
waspada
Obstruksi jalan nafas
Cedera dada dengan gangguan nafas
Cedera tulang leher

52

Primary Survey

Suspect C-spine injury

spinal protection
C-spine X-ray when appropriate

53

54

Pasien tidak sadar

Sumbatan jalan nafas paling

sering oleh karena jatuhnya
pangkal lidah
55

Airway

mengatasi sumbatan jalan nafas

Chin lift, jaw thrust

Bersihkan rongga mulut
Oro atau nasopharyngeal tube
Lindungi tulang leher
Intubasi trakhea
56

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure
57

Primary Survey
B

Assess
Oxygenate
Ventilate
Pitfalls:
Airway vs ventilation problem
iatrogenic pneumothorax/tension
pneumothorax
58

Breathing
menilai pernafasan
Apakah ada udara keluar masuk
Frekwensi nafas
Cuping hidung
Cekungan sela iga

59

Breathing
waspada
ada jejas didada

Tension pneumothorax
Open pneumothorax
Fracture costa, Flail chest
Hematothorax
Kontusio paru
60

Breathing

membantu pernafasan

Beri oksigen ( jika ada )

Pernafasan buatan (AMBU)
Dekompressi pneumothorax
Drain thorax
61

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure
62

Primary Survey
C
Assessment of organ perfusion
Level of Consciousness
Skin color and temperature
Pulse rate and character

63

Primary Survey
C
Circulatory Management
Control Hemorrhage
Restore Volume
Reassess

Pitfalls:

elderly, athletes, children

medications
64

Circulation
menilai sirkulasi
Cardiac output
Volume darah
Perdarahan (external,internal)

65

Circulation

waspada dan cari lokasi

perdarahan

Cedera intra abdominal

Cedera dada
Patah tulang panjang
Patah tulang pinggul
Luka tusuk, tembus
Luka kulit kepala
66

Circulation
shock ?
Perfusi : pucat, dingin, basah,
capillary refill time lambat
Nadi >100x/m
Tekanan darah <100 mmHg
Jika shock(+) posisi shock
67

Estimasi tekanan darah

Jika teraba nadi di :

Radialissystolik> 80 mmHg
Femoralissystolik> 70 mmHg
Carotissystolik> 60 mmHg

68

Circulation

mengatasi perdarahan
Hentikan perdarahan
Posisi shock
Pasang infus besar (2)
Ambil sampel darah crossmatch & periksaHb
Beri infus cairan :
RL, RA, NaCl 0.9% 1000 ml
guyur cepat, hangat
69

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure
70

Primary Survey
D
Disability
Baseline neurologic evaluation
GCS Scoring
Pupillary response

Continuously reassess for

deterioration/changes

71

Disability
menilai kesadaran
Periksa pupil (besar, simetri, refleks cahaya)
Periksa kesadaran
A = Awake (sadar penuh)
V = respond to Verbal command (ada reaksi
terhadap perintah)
P = respond to Pain (reaksi thdp nyeri)
U = Unresponsive (tidak ada reaksi)

72

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure
73

Primary Survey
E
Exposure
Completely undress the patient

Environment
core temperature
prevent hypothermia

74

Exposure
pemaparan

Lepaskan semua pakaian untuk pemeriksaan

teliti menyeluruh, ada jejas apa saja.
Periksa punggung,(miringkan pasien dengan
cara Log Roll)
Cegah hypothermia (jangan kedinginan)

75

X foto
(kalau ada)

Tulang leher
Dada
Panggul

76

Alur Pasien

Pasien datang
Survei primer

stabil

Survei sekunder

Tidak stabil

Survei primer &

stabilisasi

stabil

Tidak stabil lagi

77

Survei primer lagi

Survei Sekunder

Lanjutan survei primer

Hanya bila ABC sudah stabil
Teliti kepala sampai kaki
Kembali survei primer bila pasien
menjadi tidak stabil atau kondisi
memburuk
78

Setelah survei sekunder

Pasien stabil
Rujukan
Definitive care

79

ingat !!!!
Periksa ulang ABCDE
Jika pasien kembali
tidak stabil
80

81