PREHOSPITAL

Priyo mukti
Emergency depth
Fakultas keperawatan dan kebidanan
winoto@unusa.ac.id
OUT HOSPITAL
SERVICES Prehospital Equipment
 ITLS Primary Survey

■ Perform a scene size-up

■ Perform initial assessment
■ Perform a rapid trauma survey or focused exam
■ Make critical interventions and transport decision
 SCENE SIZE UP
Dimulai saat panggilan ambulans masuk dan penolong mengantisipasi kemungkinan yang
akan ditemui di tempat kejadian.
Penolong harus memikirkan peralatan apa saja yang dibutuhkan
Apakah sumber daya yang lain dibutuhkan (unit bantuan lain, peralatan spesifik, protokol
insiden massal)
Steps of the Scene Size-up

■ Standard precautions (personal protective equipment)

■ Scene safety
■ Initial triage (total number of patients)
■ Need for more help or equipment
■ Mechanism of injury
Steps of the Scene Size-up

■ Standard precautions (personal protective equipment)

– Emergency care providers are at significant risk of exposure to blood or other
potentially infectious material (OPIM) when caring for trauma patients.
– Not only are trauma patients often bloody, but they may also require active
airway management under adverse conditions
– Personal protective equipment (PPE) is necessary at trauma scenes. Protective
gloves are always needed, and many situations will also require eye and face
protection. It is wise for the emergency care provider in charge of airway
management to don a face shield or eye protection and a mask
 Mechanism of Injury
be predicted by a mechanism of injury (MOI)
 Mechanism of Injury
Frontal impact
■ Potential Injury Patterns
– Traumatic brain injury
– Cervical spine fracture
– Facial injuries
– Myocardial contusion
– Pneumothorax/hemothorax
– Aortic disruption
– Spleen or liver laceration
– Posterior hip dislocation
FILOSOFI
■ GOLDEN HOUR dimulai saat pasien dengan cedera serius mengalami
cidera hingga mampu memperoleh akses ke ruang operasi (estimasi
waktu 1 jam).
■ Pada setting prehospital : “10 MINUTES PLATINUM” untuk
mengidentifikasi korban yang hidup, membuat keputusan terapi, dan
memindahkan korban ke fasilitas medis yang sesuai
 Memperpanjang hidup.
 Melindungi korban yang tidak sadar.
 Mencegah cedera atau sakit lebih parah atau timbulnya
cedera baru.
 Membantu pemulihan.
First Aid
▪Consent
 Conscious victim
 Unconscious victim
 Children
 Mentally incompetent victim

 Refusing help
ACTION IN AN EMERGENCY

▪Primary Survey (Initial assessment)

▪Get help
▪Secondary Survey (assessment)
▪Provide first aid
▪Reassess regularly
▪Transport to health care facility
ACTION IN AN EMERGENCY

▪Primary Survey (assessment)

▪ Get help
▪ Secondary Survey (assessment) ▪ D
▪ Provide first aid ▪ R
▪ Reassess regularly ▪ s
▪ Transport to health care facility ▪ A
▪ B
▪ C
ACTION IN AN EMERGENCY

▪Primary Survey (assessment)

▪ Get help
▪ Secondary Survey (assessment) ▪ Dangers
▪ Provide first aid ▪ R
▪ Reassess regularly ▪ s
▪ Transport to health care facility ▪ A
▪ B
▪ C
ACTION IN AN EMERGENCY

▪Primary Survey (assessment)

 AVPU scale
▪ Dangers
 Alert and aware
▪ Response
 Responds to Verbal stimuli
 Responds to Painful stimuli
▪ s
 Unresponsive ▪ A
▪ B
▪ C
ACTION IN AN EMERGENCY

▪Primary Survey (assessment)

▪ Get help
▪ Secondary Survey (assessment) ▪ Dangers
▪ Provide first aid ▪ Response
▪ Reassess regularly ▪ shout for help
▪ Transport to health care facility ▪ A
▪ B
▪ C
ACTION IN AN EMERGENCY

▪Primary Survey (assessment)

▪ Get help
▪ Secondary Survey (assessment) ▪ Dangers
▪ Provide first aid ▪ Response
▪ Reassess regularly ▪ shout for help
▪ Transport to health care facility ▪ Airway
▪ Breathing
▪ Circulation
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪Get help
▪ Secondary Survey (assessment)
▪ Provide first aid
▪ Reassess regularly
▪ Transport to health care facility
ACTION IN AN EMERGENCY
▪ Europe 112
▪Get help ▪ Local 155

▪ Helth care facility 4444

▪ What happened
▪ How many victims
▪ Where
▪ Who
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪ Get help
▪Secondary Survey (assessment)
▪ Provide first aid ▪ A
▪ Reassess regularly ▪ B
▪ Transport to health care facility ▪ C
▪ D
▪ E
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪ Get help
▪Secondary Survey (assessment)
▪ Airway
▪ B
▪ C
▪ D
 Head tilt – chin lift method
 Jaw thrust method ▪ E
ACTION IN AN EMERGENCY

▪Secondary Survey (assessment)

▪ Airway
 Rate
 Normal respiration 12 - 20 ▪ Breathing
 Bradypnea  ▪ C
 Tachypnea 
 Apnea ▪ D
 Depth
 Ease
▪ E
 Noise
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪ Get help
▪Secondary Survey (assessment)
▪ Provide first aid ▪ Airway
▪ Reassess regularly ▪ Breathing
▪ Transport to health care facility ▪ Circulation
▪ D
▪ E
ACTION IN AN EMERGENCY

▪Secondary Survey (assessment)

 Rate ▪ Airway
 Normal HR
 Bradycardia
60 - 90
 ▪ Breathing
 Tachycardia  ▪ Circulation
 Strength
 Rhythm ▪ D
 Arrythmia
 Skin colour
▪ E
ACTION IN AN EMERGENCY

▪Secondary Survey (assessment)

▪ Airway
▪ Breathing
 Systemic BP
 Normal BP 120–140 / 60-80 ▪ Circulation
 Hypertension  ▪ D
 Hypotension 
▪ E
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪ Get help
▪Secondary Survey (assessment)
▪ Provide first aid ▪ Airway
▪ Reassess regularly ▪ Breathing
▪ Transport to health care facility ▪ Circulation
▪ Disability
▪ E
ACTION IN AN EMERGENCY
▪ Mental status
▪ Pupils
▪ Extremities

▪Secondary Survey (assessment)

▪ Airway
▪ Breathing
▪ Circulation
▪ Disability
▪ E
 ACTION IN AN EMERGENCY
▪ Mental status: Glasgow Coma Scale  Eye opening
 Spontaneously 4
▪ Pupils  To Speach 3
 To Pain 2
▪ Extremities  None 1

▪Secondary Survey (assessment)

 Verbal response
 Orientated 5
▪ Airway
 Confused 4


Inappropriate words
Incomprehensible sounds
3
2
▪ Breathing
 None 1
▪ Circulation
 Motor response ▪ Disability
 Obeys verbal commands 6


Localising pain
Withdraws from pain stimuli
5
4
▪ E
 Flexing to pain 3
 Extension to pain 2
 No response 1
ACTION IN AN EMERGENCY
▪ GCS
▪ Pupils
▪ Extremities

▪Secondary Survey (assessment)

 Shape ▪ Airway
 Equality ▪ Breathing
 Response to light
▪ Circulation
 PEARL ▪ Disability
 Pupils Equal And Reacting to Light
▪ E
ACTION IN AN EMERGENCY
▪ GCS
▪ PEARL
▪ Extremities

▪Secondary Survey (assessment)

 CSM ▪ Airway
 Circulation ▪ Breathing
 Sensation
▪ Circulation
 Movement
▪ Disability
▪ E
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪ Get help
▪Secondary Survey (assessment)
▪ Provide first aid ▪ Airway
▪ Reassess regularly ▪ Breathing
▪ Transport to health care facility ▪ Circulation
▪ Disability
▪ Exposure, Everything Else
ACTION IN AN EMERGENCY
▪ Physical exam
 Victim‘s chief complaint
 Head to toe examination
▪ Victim‘s history

▪Secondary Survey (assessment)

▪ Airway
▪ Breathing
▪ Circulation
▪ Disability
▪ Exposure, Everything Else
ACTION IN AN EMERGENCY
▪ Physical exam
 Victim‘s chief complaint
 Head to toe examination
▪ Victim‘s history

▪Secondary Survey (assessment)

▪ Airway
▪ Breathing
 DOTS
 Deformity
▪ Circulation
 Open wounds ▪ Disability
 Tenderness
 Swelling ▪ Exposure, Everything Else
ACTION IN AN EMERGENCY
▪ Physical exam
 Victim‘s chief complaint
 Head to toe examination
▪ Victim‘s history (SAMPLE history)

▪Secondary Survey (assessment)

▪ Airway
 Symptoms ▪ Breathing
 Allergies ▪ Circulation
 Medications
 Past medical history ▪ Disability
 Last oral intake ▪ Exposure, Everything Else
 Events leading up to the illness or injury
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪ Get help
▪ Secondary Survey (assessment)
▪Provide first aid
▪ Reassess regularly
▪ Transport to health care facility
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪ Get help
▪ Secondary Survey (assessment)
▪ Provide first aid
▪Reassess regularly
▪ Transport to health care facility

 Recovery position
ACTION IN AN EMERGENCY

▪ Primary Survey (assessment)

▪ Get help
▪ Secondary Survey (assessment)
▪ Provide first aid
▪ Reassess regularly
▪Transport to health care facility
RESOURCES

▪ National Safety Council; FIRST AID AND CPR.

▪ Chapleau, W., Pons, P. (2007) EMERGENCY MEDICAL

TECHNICIAN. St. Louis: Elsevier
▪ Caroline, N. (2007) EMERGENCY CARE IN THE STREET.
6th ed. London: Jones and Bartlett
The Role of Prehospital Care

■ Minimizing the poor outcomes, mortality and long term morbidity

■ Proper wound care, immobilization of fractures, availability of oxygen, IV fluids,
prompt recognition of life threatening condition, and transport to definitive care

45
SPGDT

■ Sistim koordinasi multisektor dan multiprofesi dalam pelayanan gawat darurat

sehari-hari maupun bencana yang meliputi pelayanan pra rumah sakit, pelayanan di
rumah sakit dan pelayanan antar rumah sakit

46
■ Diperlukan penguatan sistem pelayanan gawat darurat dan penataan kewenangan
layanan gawat darurat yang mampu memberikan pelayanan secara komprehensif
dan terpadu serta efisien dan efektif , sehari-hari, mencakup prarumah sakit, di
rumah sakit dan antar rumah sakit, yang ditunjang oleh komponen; SDM pada
semua jenjang pelayanan, fasilitas sarana dan prasarana termasuk transportasi
dan komunikasi

47
■ The EMS system is the entire system in place to provide care to emergency patients
from the initial call to definitive care
■ Extension of emergency medical care into the community

48
The EMS System
1. Personnel
2. Training
3. Communication 10. Transfer to care

4. Transportation 11. Standardization of

5. Facilities patients records

6. Critical care unit 12. Public information and

7. Public savety agency education

8. Consumer participation 13. Independent review

9. Acces to care and evaluation

14. Disaster linkage
15. Mutual aid agreement

49
Personnel

Urban area
■ Public savety
■ Ambulance personal
■ Rural area
■ Citizen volunteers
■ Park rangers
■ Ski patrols

50
Training

■ First Responder
■ Emergency Medical Technician (EMT) Basic
■ EMT intermediate (EMT-I)
■ EMT paramedic (EMT-P)

51
First responder

■ CPR
■ Automated external defibrilator (AED)
■ Safe extrication
■ Immobilization
■ Transportation

52
EMT-B

■ Nitroglycerine
■ Epinephrine
■ Inhaler
■ Advance airway technique; endotracheal intubation, advanced airway adjunct

53
EMT-I

■ Patient assessment
■ Intravenous therapy
■ Defibrillation
■ Basic ECG interpretation
■ Some cardiac medication

54
EMT-P

■ Understanding of the pathophysiology and pharmacology needed for intervention in

various medical condition

55
Communication

■ The universal emergency telephone number

■ Is the essential front door of the EMS system
■ To obtain initial medical information properly
■ Dispatch appropriate personal
■ Offer first aid information

56
Call center

■ Public access
■ Dispatch of the appropriate vehicles and personnel
■ Hospital notification
■ Online medical control

57
Transportation

■ Basic life support ambulances, EMT-B level

■ Advanced life support ambulances, EMT-P or other health care personnel

58
Facilities

■ Emergency patients should be transported to the closest appropriate hospital

59
Critical Care Units

Tertiary care facilities

■ Trauma
■ Neonatal intensive care
■ High-risk obstetrics
■ Burn
■ Spinal cord injury
■ Neurosurgical
■ Cardiac care

60
Public savety agency

■ The EMS system should have strong ties with police and fire department

61
Consumer participation

■ Public support; political and financial

■ Lay public first aid training and the implementation of a universal telephone number
system

62
Access to care

■ All individuals have access to emergency care regardless of their ability to pay or
type of insurance coverage
■ The EMS system is a patients only point of entry into the emergency care system

63
Transfer of care

■ Transferring and receiving facilities

■ Transfer agreement

64
Patient records

■ Use a similar reporting form

■ The record systems should facilitate data extraction for trauma registries, severity
scoring, and cardiac arrest outcome studies

65
Public information and education

■ The benefit from excellent EMS system

■ Prepared to first aid care
■ Know how to quikly access the EMS system
■ Understands that patients may not be delivered to the hospital of their choice under
life threathening condition

66
Independent review and evaluation

■ Review of EMS system

■ Review of communication
■ Review of response time
■ Review of patient care and quality control
■ Review of outcome studies of several entities as cardiac arrest, multiple trauma etc.
■ Hospital participation

67
Disaster linkage

■ The EMS system is an integral part of disaster preparedness

■ Should be involved in planning and practice drill
■ The EMS system informed of potential disaster situation and hazards
■ The EMS system informed of hospital capacity to recieve certain kinds of pastients
under disaster condition

68
Mutual aid agreements

■ Uninterrupted emergency care is available when local agencies are overwhelmed or

unable to provide services

69
Research

■ Is needed to determine which therapeutic interventions are beneficial and which are
not
■ Is the key to improve EMS practice

70
Medical Control

A save and effective EMS system requires considerable physician input and surveylance
■ Development of protocol (medical treatment, the use of medical devices and
equipment)
■ Development of medical accountability
■ Development of ongoing education

71
Medical basis for EMS

■ Emergency cardiac care

■ Trauma care
■ Adult medical care
■ Pediatric care

72
Peralatan

■ Began as hospital equipment that was extrapolated to the field

■ Did not always perform under the more rigorous conditions of out-of-hospital care
■ Scrutinized for effectiveness
■ Adapted to field use in term of size, weight, and durability

73
Communication

■ Wireless communication
■ Use specific frequency
■ Cellular/personal communication system

74
Patient record

■ Electronic medical record

■ Software specific
■ Essential for prehospital research

75
Universal precautions

■ Protected against exposure to blood and other body fluids from patient

76
Personal protective equipment

■ When personnel are exposed to hazardous material or biologic or chemical weapons

77
Resuscitation equipment

■ Defibrillators
■ Airway and ventilatory adjuncts
■ Vascular access equipment
■ MASTs

78
Spinal immobilization

■ Spinal boards and cervical collars

79
Extremity immobilization

■ Traction splint

80
Pharmaceutical equipment

■ Nitroglycerine for chest pain

■ Inhaled beta agonist for bronchospasm
■ Glucagon for hypoglycemia
■ Epinephrine preloaded injection for anaphylaxis

81
The drug that can make difference

■ Oxygen for hypoxia

■ Glucose for hypoglycemia
■ Nitroglycerine for chest pain
■ Inhaled beta agonist for bronchospasm
■ Naloxone for narcotic overdose
■ Morphin for pain
■ Benzodiazepines for seizures, extreme agitation, or intubation

82
■ Furosemide for fluid overload
■ Epinephrine for cardiac arrest and anaphylaxis
■ Lidocaine, magnesium, and amiodarone for cardiac arrest
■ Adenosine and diltiazem for rate control of the various tachycardias
■ Calcium and sodium bicarbonate for hyperkalemia
■ Paralytic drug are used for RSI

83
■ The equipment used in prehospital care includes the vihicles

84
Sistem Rujukan

■ Klasifikasi RS / Klasifikasi IGD RS

■ RS Khusus

■ The right patient on the right time to the right hospital

■ Closed appropriate hospital

85
Transportasi

■ Ground ambulances
■ Helicopters
■ Fixed-wing aircraft
■ First-response vehicle

86
The ground ambulance

■ Type I, a standard truck chassis with a separate a modular box

■ Type II, an enlarged van-type vehicle
■ Type III, a van chassis with an integrated modular box
Have warning devices (lights and siren)

87
88
89
4. Transportasi medis udara

■ Helicopter (rotor-wing)
■ Air-plane (fixed-wing)

Fast-speeds
100-200 miles/h for helicopter
500 miles/h for airplane
Not limited by traffic or road quality

90
91
92
93
Transportasi neonatal, pediatric dan
lansia
■ Intensive care in neonatology and pediatric care are expensive and high technology
■ The interfacility transport is conducted by specialized transport services

94
Special problem

■ Hypothermia
■ Hypoxemia (RDS, PPHN, CHD)
■ Hypoglycemia
■ Vascular access
■ Infection
■ Viability (gestational age, weighing)

95