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Oleh:TEAM
EMERGENCY UMM
2014
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General Trauma Assessment
Scene size up Initial assessment/
primary survey


Rapid trauma survey or
focus assessment/
secondary survey


1. Find life threats
2. life threat present, CORRECT
IT!
3. If life threat cant be corrected
a. Support ABCs
b. TRANSPORT!!


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Scene size up
Universal precaution?
Lihat keadaan sekitar
Prioritas utama: keselamatan penolong
lingkungan yang aman untuk bekerja
Initial triage. Berapa jumlah korban?
Mekanisme cedera?
Rapid extrication?
Aktifkan EMS
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Equipment
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Dressing and Bandages
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Scoop stretcher
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BTLS
A
Airway
B
Breathing
C

circulation
D
dissability
E
Environment & Exposure
F
Full Vital Sign & Five Intervention
G
Give Comfort
H
Head to Toe & History
I
Inspect Back Posterior
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Primary Survey
Merupakan pemeriksaan cepat
untuk menentukan kondisi yang
mengancam nyawa.
Diselesaikan dalam waktu 2
menit atau kurang.
Stop Primary Survey: gagal
nafas dan henti jantung
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Airway with C-Spine Control
Anticipate airway problems with
Decreased level of consciousness
Head trauma
Facial trauma
Neck trauma
Upper chest trauma
Open, Clear, Maintain
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Orofaringeal Airway
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Nasopharyngeal airway
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Intubation Naso-trachea :
Jika pasien apnea
Dengan sedasi
Dengan atau tanpa
pelumpuh otot
Perhatikan
pengembangan
paru
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Breathing



Oxygenate
immediately

Decreased level of
consciousness
? Shock
? Severe
hemorrhage
Chest pain
Chest trauma
Dyspnea
Respiratory
distress
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Breathing
If respirations
compromised:
Expose chest
Inspect front and back
Palpate front and back
Auscultation front and
back
LOOK, LISTEN, FEEL
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Breathing
Ventilasi Tambahan :
Mulut Ke Mulut
Mulut Ke Mask
Bag Valve & Mask
Ventilator
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Circulation
Is heart beating?
Kuat lemahnya
Frekuensi
Is there serious external
bleeding?
Lakukan control bleeding
Pasang jalur IV
(infuse)menggunakan IV
catheter
(abocath/venflon)
no.14/16 dan blood set
dengan cairan RL/NS
Is the patient perfusing?
Periksa akral, warna
dan temperatur
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The Load and Go Situations
Head injury with decreased cconsciousness
Airway obstruction unrelieved by mechanical
methods
Conditions resulting in inadequate breathing
Shock
Conditions that rapidly lead to shock
Tender, distended abdomen
Pelvic instability
Bilateral femur fractures
Traumatic cardiopulmonary arrest
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Disability (CNS Function)
1. Level of Consciousness =
Best brain perfusion
indicator
2. AVPU initially
Check pupils The eyes
are the window of the CNS
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EXPOSURE & ENVIRONMENTAL
FULL VITAL SIGN & FIVE
INTERVENTION
Complete blood count with differential
Serum chemistries
Other chemistries ,
Liver function tests
Amylase , Lipase, Cardiac markers
PT, PTT, INR
D-dimer (ELISA)
Arterial blood gas
Urinalysis
Pregnancy tests
Rh factor
Type and screen
Type and crossmatch
Erythrocyte sedimentation rate
Toxicology screen
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GIVE COMFORT


Berikan tindakan
kenyamanan utk klien

Personal religious,
KIE
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Secondary survey

HEAD TO TOE & HISTORY

Kepala : DCAP-BTLS, Battles Sign atau Raccoon Eyes, perdarahan pada
hidung dan telinga.
Leher : DCAP-BTLS, JVD, Deviasi trakhea
Dada : DCAPP-BTLS, TIC, Suara napas, Perkusi
Abdomen : DCAP-BLS, Nyeri?, Supel?, Kaku?
Pelvis : DCAP-BLS, TIC
Tungkai bawah dan atas : DCAP-BLS, TIC, PMS
Bagian posterior : DCAP-BLS (Log roll/Log Up)

S = symptom
A = Allergies
M = Medications
P = Past medical history
L = Last oral intake
E = Events leading up to incident

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Reevaluation
Ventilation and perfusion status
Repeat vital signs
Continued stabilization of identified
problems
Continued reassessment for unidentified
problems
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Daftar Pustaka
Bresler, Michael Jay, et all. (2000). Manual Kedokteran Darurat. Edisi 6. USA:
Mosby, Inc.
Dochterman, et all. (2004). Nursing Interventions Classification (NIC). USA:
Mosby
Emergency Nurses Association. (2006). Sheehys Manual of Emergency Care, 6th
edition.
Herdman, Heather. (2009). Nursing Diagnoses: Definitions and Classification.
United Kingdom: Wiley-Blackwell
Johnson, et all. (2000). Nursing Outcomes Classification (NOC). USA: Mosby
Koeshartono, dkk. (2011). Materi Pelatihan GERH (General Emergency Life
Support). Surabaya: RSUD Dr. Soetomo
Lanros, Nedel, (1997). Emergency Nursing: With Certification Preparation and
Review. 4
th
Edition. Connecticut: Appleton & Lange
Liverpool Hospital Trauma Department, (2002), Hand Book of Trauma Care: The
Liverpool Hospital Trauma Manual. 6
th
Edition. Sydney: Trauma Department
Liverpool Hospital Selfridge, Thomas Judy (1995). Manual of Emergency Nursing.
USA: WB. Saunders Co.

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