INITIAL ASSESMENT

MANAGEMENT

SYAFRI K.ARIF

Dept.of Anesthesiology,Pain Management and Intensive Care Faculty

of Medicine Hasanuddin University
Makassar-Indonesia
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

 Prehospital Trauma
Resuscitation

Definitive care ? GOALS

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

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
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.