em - 1 & 2 kuliah anestesiologi kbk blok emergency 1

8/7/2019 EM - 1 & 2 KULIAH ANESTESIOLOGI KBK BLOK EMERGENCY 1

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Initial Assessment andManagement

(Primary Survey assessment)

Departemen Anestesiologi dan ReanimasiFK-USU/RSUP Haji Adam Malik, Medan


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Objectives

Indentify Management Priorities.

Apply principles of primary andsecondary survey.

Institute appropriate resuscitation andmonitoring.

Recognize value of patients history and

biomechanics of injury. Anticipate pitfalls.


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Concepts of Initial Assessment

Rapid Primary Survey

Resuscitation

Adjuncts to primary survey /resuscitation Detailed secondary survey

Adjuncts to secondary survey

Reevaluation

Definitive care


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Initial Assessment

Primary survey and

resuscitation of vital

functions are donesimultaneously

a team approach


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Preparation

Prehospital System

Transport guidelines /protocols

On-line medical direction

Mobilization of resources

Periodic review of care

Closest appropriate facility


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Preparation

Inhospital

Preplanning essential

Equipment, personnel, services

Standard precautions

Transfer agreement


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Standard Precautions

Cap

Gown

Gloves Mask

Shoe covers

Goggles/face

Shields


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Triage

Sorting of patients according to :

ABCDEs Available resources

Multiple casualties

Mass casualties


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Primary Survey

Adult, children, pregnant women

Priorities are the same !

A Airway with c-spine protectionB Breathing

C Circulation with hemorrhage control

D Disability

E Exposure/Environment


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Special Considerations

Trauma in the Elderly

5th leading cause of death

Physiologic reserve

Comorbidities : Diseases/medications

Outcome depends on early, aggressivecare


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Primary Survey

C-spine injury

Pitfalls Equipment failure

Inability to intubate

Occult airway injury

Progressive loss of airway

Establish Patent Airway

Caution


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Primary Survey

Suspect C-Spine Injury

Spinal protection

C-spine X-ray when appropriate


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Primary Survey

Breathing

Assess

Oxygenate

Ventilate

Pitfalls

Airway vs ventilation problem ?

Latrogenic pneumothorax

/tension pneumothorax


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Primary Survey

Assessment ofOrgan Perfusion

Level of consciousness

Skin color and temperature

Pulse rate and character


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Primary Survey

Circulatory Management

Control hemorrhage

Restore volume

Reassess

Pitfalls

Elderly Children

Athletes MedicationCaution


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Primary Survey

Disability

Baseline neurologic evaluation

GCS scoring

Pupillary response

Observe for neurologic

deteriorationCaution


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Primary SurveyExposure / Environment

Completely undress the patient

Prevent hypothermiaCaution


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Resuscitation

Protect and secure airway

Ventilate and oxygenate

Stop the bleeding

Vigorous shock therapy

Protect from hypothermia


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Adjuncts to Primary Survey

Vital sign

ECG ABGs

Urinary Adjuncts Pulse

Output oximeter

and CO

Urinary/gastric catheters

unless contraindicated


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Diagnostic Tools

Chest and pelvic x-ray

DPL

Ultrasound


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Consider Early Transfer

Do not delay transfer for diagnostic tests

Use time before transfer for resuscitation


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Reevaluate

Proceed to Secondary Survey After :

Primary survey completed

ABCD Es are reassessed Vital functions are returning to

normal


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Secondary Survey

The complete

history and

physical

examination


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Secondary Survey

Key Components

History

Physical examination : Head-to-toe

Tubes and finger in every orifice

Complete neuro exam

Special diagnostic tests Reevaluation


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Secondary Survey

History

A Allergies

M Medications

P Past Illnesses

L Last mealE Events/Environment


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Secondary Survey

Mechanisms of Injury


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Secondary Survey

Head

Complete neurologic examination

GCS score determination

Comprehensive eye/ear exam

Pitfalls

Unconscious patient

Periorbital edema Occluded auditory canal


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Secondary Survey

Maxillofacial

B

ony crepitus/stability Palpable deformity

Pitfalls

Potential airway obstruction

Cribriform plate fracture

Frequently missed injury


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Secondary SurveyCervical Spine

Palpate for

tenderness Complete motor/

sensory exams

Reflexes C-spine imaging

Pitfalls

Altered LOC forany reason

Other severe ,

painful injury


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Secondary Survey

Neck (soft tissues)

Mechanism : Blunt

vs penetrating Symptoms : Airway

obstruction ,

hoarseness

Findings :Crepitushematoma ,stridor

bruit

Pitfalls

Delayed symptomsand signs

Progressive airway

obstruction Occult injuries


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Secondary SurveyChest

Inspect

Palpate

Percuss

Auscultate

X-ray

Pitfalls

Elderly

Children


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Secondary SurveyAbdominal Evaluation

Blunt trauma Penetrating trauma


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Secondary Survey

Abdomen

Inspect, auscultate, palpate, and percuss

Reevaluate frequently Special studies

Pitfalls

Hollow viscus and retroperitoneal injuries Excessive pelvic manipulation


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Secondary Survey

Perineum

Rectum

Vagina

Pitfalls

Contusions, hematomas,lacerations, urethral blood

Sphincter tone , high riding

prostate pelvic fracture,rectal wall integrity, blood

Blood lacerations

Urethral injury in women,

pregnancy


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Secondary Survey

Musculoskeletal : Extreminities

Contusion , deformity

Pain

Perfusion

Peripheral neurovascular status

X- rays as needed


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Secondary SurveyMusculoskeletal : Pelvis

Pain on palpation

Symphysis width

Leg length unequal

Instability

X-rays as needed


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Secondary Survey

Musculoskeletal

Pitfalls

Potential blood loos Missed fractures

Soft-tissue or ligamentous injury

Occult compartement syndrome (especiallywith altered LOC / hypotension)


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Adjuncts to Secondary Survey Special diagnostic test as indicated

Pitfalls

Patient deterioration

Delay of transfer


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Secondary SurveyNeurologic

Pitfalls Incomplete immobilization

Suble in ICP with manipulation

Rapid deterioration


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Reevaluation

Minimizing Missed Injuries

High index of suspicion

Frequent reeveluation and monitoring


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ReevaluationPain Management

Relief of pain /anxiety as appropriate Administer intravenously

Careful monitoring is essential


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Definitive Care

Local Facility

??Transfer agreements

?? Local resources ??

??

Trauma Specialty

Center Facility


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Record , Legal Considerations Concise, chronologic documentation

Consent for treatment Forensic evidence


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Questions


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Summary Primary Survey

Resuscitation

Adjuncts

Secondary Survey

Adjuncts

Definitive care

em - 1 & 2 kuliah anestesiologi kbk blok emergency 1

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