INITIAL

ASSESMENT
MANAGEMENT

Faisal Sommeng
INTRODUCTION

The main role of the doctor is

SAVING LIFE
ALLEVIATE SUFFERING
Any doctors should have these
competences.

The main tool of saving life is

BASIC LIFE SUPPORT
ACCIDENTS OR
DISASTERS
Accidents or disasters may occur to :
ANY WHERE
ANY TIME
ANY ONE

Well preparedness is very important

(soft-ware and hard-ware )
What is EMERGENCY in Medicine ?

A medical condition that starts suddenly and

requires immediate care

A life or limb threatening medical

condition resulting from an injury or
sickness that requires immediate
treatment and, if left untreated, could
result in permanent harm to the person.
Some Example of Emergency Conditions

Conditions such as:

heart attack, uncontrollable bleeding, loss of
consciousness, convulsions, severe allergic
reactions, poisoning, severe shortness of
breath or difficulty breathing, or severe or
multiple injuries, including obvious fractures.
The Cause of Death in US

Traffic accidents are the third

cause of mortality after CVS and
Cancer
Disease of the young, leading
cause death age 1 to 40 years
> 100,000 death /year in US
Loss of productive work years
Trauma management is expensive
Epidemiology of Trauma Death

Trimodal patterns
Donald Trunkey

ATLS
50%
Death 30%
20%
%

sec hr days/week
Trauma Death

First Peak
Death that occurs at
impact or soon after the
accident
50 % death
Not preventable
severe head laceration,
massive bleeding,
heart injury etc.
Prevention of accidents
enforcement,
education & awareness
Trauma Death

Second Peak
Death within
minutes to hours
after injury
Golden Hours
30 % of death
Life threatening
injuries involving
airway, breathing ,
circulation
Trauma Death
Airway
obstruction: tongue, secretion & blood,
vomitus
difficult airway management

Breathing & Ventilation

Pneumothorax,heamothorax, penetrating
chest injuries, flail chest

Circulation
hemorrhage, cardiac tamponade
Second Peak

Preventable
Reflect
adequacy, efficiency of EMS in
prehospital resuscitation
hospital emergency department
resuscitation
definitive therapy
 Third peak

Third Peak
Death within days or
week after injury
20 % death
Sepsis or multiorgan
failure
Reflects again
efficiency at
resuscitation,
definitive care,
aggressive ICU care,
prevention of infection
and rehabilitation
INITIAL ASSESMENT

Initial assessment include :

1. Preparation
2. Triage
3. Primary Survey ( ABCDE )
4. Resuscitation
5. Secondary Survey ( Head to toe
evaluation )
6. Definitive Care
1. PREPARATION

Preparation of the trauma patient occurs

in two different clinical settings

1. PRE-HOSPITAL PHASE
2. IN HOSPITAL PHASE
 PRE HOSPITAL

Transportation is very
important
Continous Training
Medical First Responder.
Indonesian MFR
EMS in F1
EMS
Prehospital Trauma
Resuscitation

Definitive care ? GOALS

A clear airway, effective
ventilation, hemorrhage control &
restoration of adequate blood
volume
Pre hospital Care
UE

Ambulance Response
Time: Standard
50 % of all calls are
responded within 8
min.
95 % of calls within
14 min. (urban)
95 % of calls within
19 min. (rural )
Nolan JP, Pars. BJA
1997;79,226-240
Pre hospital Communication

Communication
Vital between prehospital & in-
hospital trauma patient
resuscitation
Prepare ED personnel well ahead
Activation of TRAUMA TEAM /
DISASTER PLAN into action
2. Triage

trier sorting out

Is the sorting of
patient based on the
need for treatment
Triage
Resuscitation Room
Activation of
trauma team
Trauma Team-work

Efficient method
Trained doctors &
nurses
Variety of tasks taken
simultaneously
horizontal organization
reduced time to life-
saving procedure by 50 %
Trauma Team at Work

Pit stop in a formula 1

motor race
Managing trauma in a
smooth and efficient
manner
Do no further harm
3. The Primary Survey

Airway & cervical spine

control
Breathing & ventilation
Circulation & haemorrhage
control
Disability
Exposure/Environment
 Airway & Cervical Spine Control

Difficult Airway
Goal
Keep airway patent
protect compromised
airway
provide airway if none
Difficult Airway Management .
 Cervical spine Fracture

Suspect:
Unconscious patients
Injury above clavicles
Neck pain
Weakness or
neurological deficit
History of fall > 6 m
 Breathing & Ventilation
Patient in increasing respiratory distress,
BLUE, BLUE, BLUE, BP DOWN, Not
Recordable...
Think :Tension Pneumothorax,
haemotothorax, Flail chest, lung
contusion, cardiac tamponade

Goals: Avoid Hypoxia, Hypercarbia.

Bad for the Brain
TENSION PNEUMOTHORAX
Flail Chest

Segmental ribs fracture

of multiple ribs
Panel moves in with
inspiration and out with
expiration
Cardiac Tamponade
Treatment of Cardiac
Tamponade
 Hematothorax

Chest tube
Massive : > 1500 ml blood
Drainage: . 200 ml/hr
CLAMPED CT
Urgent thoracotomy
 Circulation
Haemorrhage Control with Fluid therapy

First Priority : Restore volume with fluid

(RL/NaCl 0.9% )
Second Priority :
Restore blood with WB and PRC transfusion
to restore oxygen carrying capacity
Remember : did not die of anemia but die of
hypovolemic shock
Third Priority : Normalize coagulation status
FFP, Platelet, blood products
Disability
( Neurologic Evaluation )

Rapid Neurologic evaluation is perform

at the end of primary survey
Simple Neurologic evaluation is AVPU
method
A Alert
V Responds to Vocal stimuli
P Responds only to Painful stimuli
U Unresponsive to all stimuli
4. Resuscitation

Aggressive resuscitation and the

management of life threatening injuries
Essential to maximize patient survial
Airway should be protect and secure
Jaw thrust or Chin lift maneuver
Definitive airway if needed
Breathing/ventilation and oxygenation
Injured patient should received supplemental O2
Circulation
Controlled bleeding by direct pressure or operative
intervention
 End- Points of Resuscitation

Traditional:
Achieved definitive care
Blood Pressure/ cerebral perfusion
pressure/ ICP
Heart rate
Urine output
 5. Secondary Survey
Not begin until the Primary Survey is
completed
Is Head to Toe evaluation
Head
Maxillofacial
Cervical spine and Neck
Chest
Abdomen
Perineum / rectum / vagina
Musculoskeletal
Neurologic
6. Definitive Care

Surgical intervention
Transfer to higher trauma
center
Conclusion
Trauma continues to be the most
common cause of death
BLS playing a big role in saving life in pre-
hospital phase or in hospital
Do No Further Harm is the basic
principle of BLS
ABCDE is a good guide to take action.