em i k2 an secondary survey assessment
DESCRIPTION
secondary survey assesmentTRANSCRIPT
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Secondary Survey Assessment( Penilaian dan Penanganan
Survei Sekunder )
Departemen Anestesiologi dan ReanimasiFK – USU
2010
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Sistematika Emergency Medicine
TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF
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Survei sekunder
• Mencari cedera yang mengancam jiwa atau cacad ekstremitas (life or limb)
• Pemeriksaan teliti dari kepala sampai kaki
• Dikerjakan setelah survei primer selesai• Dikerjakan jika ABC sudah stabil• Segera kembali ke survei primer jika ABC
memburuk lagi
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Pemeriksaan kepala
• Kulit kepala (robekan, memar, laserasi) • Tengkorak (nyeri tekan, depresi tulang)• Mata (pupil, fundus, lensa, conjunctiva)• Cairan CSF / darah dari telinga, hidung,
mulut
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Ada darah mengalir, tetapi dari mana ?
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• Glasgow Coma Score• Pupil
– ukuran, simetri, refleks cahaya• Fungsi motorik• Fungsi sensorik• Refleks-refleks
Periksa kesadaran dan syaraf
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Secondary SurveyHead Complete neurologic examination GCS score determination Comprehensive eye/ear examPitfalls Unconscious patient Periorbital edema Occluded auditory canal
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Secondary Survey
The complete history and physical
examination
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Secondary SurveyKey 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
HistoryA Allergies M MedicationsP Past IllnessesL Last meal E Events/Environment
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© ACS
Secondary SurveyMechanisms of Injury
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Pemeriksaan leher (1)
• Lihat / inspeksi • Palpasi (nyeri tekan, deformitas)• Anggap leher cedera• Imobilisasi pada posisi netral
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Pemeriksaan leher (2)
• Cari Luka tembus• Cari Emfisema subkutis• Apakah trachea ditengah ?
– raba di supra-sternal notch• Apakah Vena leher distended ?
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Periksa posisi trachea: palpasi di suprasternal notch
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Secondary SurveyCervical Spine Palpate for
tenderness Complete motor/
sensory exams Reflexes C-spine imaging
Pitfalls • Altered LOC for any reason• Other severe , painful injury
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Secondary Survey
Neck (soft tissues) Mechanism : Blunt
vs penetrating Symptoms :
Airway obstruction , hoarseness
Findings :Crepitus hematoma ,stridorbruit
Pitfalls • Delayed symptoms and signs• Progressive airway
obstruction• Occult injuries
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Secondary Survey
Maxillofacial Bony crepitus/stability Palpable deformityPitfalls
• Potential airway obstruction • Cribriform plate fracture • Frequently missed injury
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Pemeriksaan dadamencari ulang kerusakan
• Lihat / inspeksi• Palpasi• Perkusi• Auskultasi• Foto sinar-X dada (jika ada)• ECG ( jika ada)
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Secondary SurveyChest Inspect Palpate Percuss Auscultate X-ray
Pitfalls • Elderly • Children
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• Cari perdarahan tersembunyi (Internal hemorrhage)– ketegangan otot perut– nyeri tekan– cairan bebas (USG / DPL)
• Inspeksi / palpasi / auskultasi• Jangan test gerakan panggul
bila diduga ada fr. pelvis• Periksa rektum (rectal toucher)
Pemeriksaan perut (1)
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Perlukaan organ padat / pemb darah besarPerlukaan organ berongga (usus)
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Pemeriksaan perut (2)
• Trauma tembus = pembedahan eksplorasi• Trauma tumpul = pasang pipa naso/ orogastric
dan observasi lanjut• Pasang kateter buli jika tak ada darah di
meatus ext. • Periksa ulang berkali-kali
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Secondary Survey
Abdominal Evaluation
Blunt trauma Penetrating trauma
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Secondary SurveyAbdomen Inspect, auscultate, palpate, and percuss Reevaluate frequently Special studies Pitfalls
• Hollow viscus and retroperitoneal injuries• Excessive pelvic manipulation
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Secondary SurveyPerineum
Rectum
Vagina
Pitfalls
Contusions, hematomas,lacerations, urethral blood
Sphincter tone , high –ridingprostate pelvic fracture,rectal wall integrity, blood
Blood lacerations
Urethral injury in women, pregnancy
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Ekstremitas / anggota gerak
• Inspeksi – deformitas, robekan, memar, laserasi
• Palpasi• Palpasi nadi arteria distal• Ingat compartment syndrome• Jangan lupa periksa punggung
Log-roll
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Cari luka, robekan, memar, nyeri tekan, deformitas tulang belakang
4 orang
Pemberi komandoinstruksiyang jelas
Log-roll
Digulingkan serentak pelan-pelan
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Foto sinar-x
• Dikerjakan waktu survei sekunder• Dada• Tulang leher - 7 segmen vertebra• Pelvis / panggul• Lokasi lain sesuai indikasi
– (misal fr tulang paha dll)
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Secondary Survey
Musculoskeletal : Extreminities Contusion , deformity Pain Perfusion Peripheral neurovascular status X- rays as needed
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Secondary Survey
Musculoskeletal : 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 (especially
with altered LOC / hypotension)
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Secondary Survey
Neurologic Spine / Cord Complete motor
and sensory exams Imaging as
indicated Reflexes
Early neurosurgical consultation
CNS Frequent
reevaluation Prefent secondary
brain injury
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Adjuncts to Secondary Survey
Special diagnostic test as indicated Pitfalls
• Patient deterioration • Delay of transfer
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Secondary Survey
Neurologic 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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Reevaluation
Pain 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 SpecialtyCenter Facility
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Record , Legal Considerations
Concise, chronologic documentation Consent for treatment Forensic evidence
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