SPGDT HOSPITAL

DR I KETUT WIARGITHA,SPB(K)TRAUMA, FINACS

SYSTEM PENANGGULANGAN GAWAT
DARURAT TERPADU ( SPGDT ) • Emergency Nurse
(BTLS, BCLS, )
• Emergency physician
(BLS) (ATLS, ACLS)
Layman • HOPE
• Surgeon
(Paramedic , (ATLS, ATLS,BSS, DSTC, Peri OPE
(MFR, CSSR)
CSSR) CC, HOPE)
Police
118 Emergency DISASTER MANAGEMENT
Fire Brigade
Ambulance
Security Guard
Service
Civil Defense
Scouts
Red Cross
ED 

Access
OK
Emergency

ICU
Telephone Number
112,113,118

WARD
AMBULATOIR

PRE-HOSPITAL HOSPITAL
 KA. DINKES PROP. DIR.UT. RSUP
SANGLAH DENPASAR
AKTIFKAN DISASTER
PLAN.

DIR.
RS. WANGAYA
MASY. AWAM KA.DINKES. KAB./KODIA
MENGAKTIFKAN
DISASTER PLAN
RS.

DIR.
RSUD. LAINNYA
AMBULANCE MENGAKTIFKAN
DISASTER PLAN
PSC PROP. BALI DIR.
RS.
RSU TNI/POLRI
PUSKESMAS
MENGAKTIFKAN
AKSES KLINIK2 SWASTA DISASTER PLAN
RS.
PMI
RS. PEM./SWASTA DIR.
POLISI 112 RS. SWASTA
MENGAKTIFKAN
DIN.KEB. 113 DISASTER PLAN
RS.
AMBULANCE ? ( 000 )
AGD 118
 1. HIJAU
2. KUNING 1. HIJAU
1. KUNING
3. MERAH 2. KUNING
TRIAGE 2. MERAH
4. HITAM 3. MERAH
4. HITAM

R.OP. R. ICU WORD POLIKLINIK

FORENSIK

REGISTRASI/data
 DIREKTUR UTAMA

MANAGEMENT SUPPORT MEDICAL SOPPORT

1. DEVISI RESOURCES/SUMBER DAYA 1. DEVISI PRA-HOSPITAL.

A. UNIT KEAMANAN/LALU-LINTAS A. TEAM AMBULANCES
B. UNIT KEPERAWATAN B. TEAM SDM ( DOKTER/NURSE )
C. UNIT KAMAR OPERASI
D. UNIT FARMASI DAN ALKES C. TEAM PENUNJANG
E. UNIT CSSD/STERILISASI
F. UNIT LABORATORIUM KLINIK/PA
G. UNIT GIZI
2. DEVISI HOSPITAL
H. UNIT RELAWAN
I. UNIT AMBULANCE.
J. UNIT RUANG JENASAH
K. UNIT DIKLAT. 2.1. UNIT MEDIK
A. TEAM SERGAP
2. DEVISI KOMUNIKASI/INFORMASI/ B. TEAM KORBAN/TRIAGE
HUMAS C. TEAM KAMAR OPERASI
A. UNIT DATA D. TEAM RUANG ICU
B. UNIT MEDIA E. TEAM INTERMEDIATE
C. UNIT HUBUNAN NASIONAL/ INTERNASIONAL F. TEAM RAWAT JALAN
D. UNIT VISIT
E. UNIT KOMUNIKASI
2.2. UNIT FORENSIK

3. DEVISI FINANCIAL/KEUANGAN
4. DEVISI KONTRUKSI/BANGUNAN
Trimodal Death Distribution
Time Phases of Death Following Trauma

 Within 1 hour (Immediate Death) : Nearly 50%

of deaths occur within an hour of the
traumatic event.
 Within 1-4 hours (Early Death) : These constitute
30% of the deaths due to disaster
 More than week (Late Death) : The remaining
20% of trauma related deaths occur more
than a week.
Disaster

 In our context in a disaster, the patients may

arrive at the hospital
 without receiving any previous first-aid
 without proper stabilization
 by private means
 In such situation resuscitation will have to be
done entirely in hospital.
 Early management of respiration,
circulation, bleeding and also fractures the
victims
Complications

 Delay in diagnosis and consequently therapy

 Inadequate restoration of blood volume & the
haemodynamics of circulation
 Lack of attention to the possibility of
contamination and lack of prophylactic
treatment
 Severity of multiple trauma and severe damage
to spine & brain
Fill in the Blank
The Team
 The team required for
resuscitation and immediate
care must consist of :
 one surgeon ready to
coordinate and take over
his duties when required
 one anesthetist
 five nurses or trained
technicians
 This number is usually sufficient
to deal with a five bed unit.

Fill in the Blank

TEAM MEDIS

TEAM 1. TEAM 2
TEAM 3
KOORDINATOR
TEAM 4
DR. Spesialis Bedah.
Dr. Spesialis Anesthesi TEAM 5
TEAM 6

Dokter Umum Dokter Umum Dokter Umum

Nurse Nurse
Nurse
Nurse Nurse
Nurse
Nurse Nurse
Nurse
Nurse Nurse
Nurse
Nurse Nurse
Nurse
Basic goal of emergency care

 Save life

 Prepare for definitive care in

a prompt and timely manner

 In a situation of mass
Casualty Incidents it is to
address for maximum
number of victims.
Common scheme of assessment

 Critical
 Immediate
 Urgent
 Deferred
Procedures of Triage

 TRAGE DILAKUKAN SEBELUM MELAKUKAN

PENANGANAN
 < 60 DETIK
 Menentukan prioritas penanganan
pasien dan prioritas evakuasi korban ke
Emergency Departement yang
mempunyai fasilitas yang lebih baik
untuk penanganan difinitif
Single Patient Triage

 Single patient triage – penting di ruang

emergency terutama pada keadaan dimana
ruang emrgency sangat sibuk dan fasilitas kamar
operasi yang keseluruhan terpakai.
 Single patient triage – dengan mengadakan
skala prioritas di ruang emergency, maka kita
dapat menurunkan morbiditas dan mortalitas.
 Katagori Triage, termasuk.
a) Emergent
b) Urgent
c) Non-urgent
KATAGORI EMERGENT
 Major trauma
 Airway obstruction
 Tension pneumothorax
 Flail Chest
 Hypovolemic shock (Class III and IV)
 Burns with inhalation injury
management should begin upon arrival
Urgent

 Vertebral and Spine Injury

 Femoral shaft fracture
 Closed head injury
 Burns

They all are at risk if not treated in a few hours

Non-urgent

Skinlacerations
Contusions
Abrasions
Upper extremity fractures
Fever
Associated medical conditions
THE GOLDEN HOUR

 Amount of time from injury to the definitive care.

 Care given within the first hour, mortality and
morbidity is favorably reduced
Mass casualty triage

 Mass casualty triage – pada musibah massal

yang mengakibatkan jumlah korban yang
banyak seperti keadaan bencana.
 Pada level tersebut tidak dapat dilakukan
penanganan secara bersamaan maka
diperlukan suatu prioritas.
 Katagori Triage an.
a) Immediate
b) Delayed
c) Walking wounded
d) Dead and dying
START Triage

Simple Triage And Rapid Treatment

Dengan menilai :
1. Respiration
2. Circulation
3. Mental Status
START

Tujuan dari triage memakai

START untuk mengatasi
1.Sumbatan Jalan nafas
2.Pernafasan
3.Perdarahan
KATAGORI
1. Meningga(l BLACK)
No ventilations present after
clearing airway
2. Berat/kritis (RED)
RR >30/min
delayed capillary refill(>2
secs)
unable to follow simple
commands
3. Sedang (YELLOW)
4. Ringan(GREEN)
“Walking wounded”
Prosedur Dari START
(time <60 seconds / patient)
 Frekwensi Pernafasan
 assess for RR and adequacy
 not breathing – check for foreign body
obstruction; remove loose dentures; reposition
head with C-spine precautions
 Tidak bernafas – HITAM
 Frekwensi Nafas > 30/min – MERAH
 Frekwensi Nafas < 30/min – Jangan diberi
label, tapi
 Nilai Perfusi
Prosedure dari START

 Perfusi
 assess capillary refill (> atau < 2 detik)
 >2 detik – MERAH
 <2 detik – jangan diberi label tapi nilai
status mental
 Kontrol Perdarahan.
Prosedure dari START

 Status Mental
Perintah sederhana
“open and close your eyes”
“squeeze my hands”
Tidak bisa dilakukan – MERAH
Bisa dilakukan -- KUNING
 HOspital Preparedness for
Emergencies

RESUSCITATION AND EMERGENCY CARE

Resuscitation and Emergency care

 Resuscitation at the site of incident

 Resuscitation during transportation
 Management at the nearest hospital
 Management at the referral hospital

Fill in the Blank

Resuscitation

 Procedures at the site and

during transportation are:
 Establish and maintain a
clear airway
 Provide and maintain
adequate oxygenation
 Control external bleeding
 Stabilize the fracture by
Splint/collar
Resuscitation and Emergency Care
Management at nearest medical care facility

 Modern field hospitals should be well equipped and

able to perform any urgent surgery.
 Surgery performed in field hospitals situation should
be for immediate life-saving only, for example:

 Airway Obstruction
 Tension pneumothorax / mehothorax massif / cardiac
tamponade, etc.
 Penetrating heart wounds
 Rupture spleen, kidneys vena cava tears
 Intracranial hemorrhage
Management at the referral
hospital
 From the field hospital, victims may be referred to a large
referral centre
 Abdominal contusions & stabs, gun shot wounds, crush injuries
 Cardiovascular injuries or suspected myocardial contusions,
severe thoracic injuries
 Head injuries with loss /deteriorating LOC
 Acute spinal cord injuries & suspected vertebral fractures
 Nose, ear and fascio-maxillary injuries
 Eye injuries
 Multiple injuries requiring urgent resuscitation and treatment
Fill in the Blank
Primary Survey (PS)

 The primary survey, requiring no more than

several minutes, is done by assessing the
following :
 Airway
 Breathing
 Circulation
 Disability
as judged by
neurological examination
 Exposure
Fill in the Blank
Resuscitation Phase

 Occurs simultaneously
with the primary survey
 Resuscitation is
continued
 throughout stabilization
of the patient
 the diagnostic workup
 until
procedures and
surgeries are complete
Resuscitation Phase

 This includes:
 monitoring the patient’s vital signs
 protecting the airway
 oxygenation

 volume replacement
 IV fluids and blood products as needed
Secondary Survey

 Begins after the completion of the primary

survey and initiation of the resuscitation phase.
 Complete head to toe physical exam,
 Time to identify all injuries and to perform
necessary diagnostic studies as indicated
 Often,
time is only wasted by using the classic
diagnostic methods while the patient's condition is
gradually deteriorating to the point where irreversible
damage has occurred
Secondary Survey

 CNS examination should be performed

with particular attention to the
protection the spine.
 Log roll the patient with an in-line
stabilization of the head and neck.
 Inspectthe entire spine for tenderness and
deformity.
 Chest examination is carried out with
palpation for tenderness, crepitance
and instability.
Secondary Survey

 A thorough search for entry and exit

wounds is penetrating trauma is
involved.
 The abdomen should be assessed
carefully as the general condition of the
patient does not necessarily match the
extent of the damage.
 Abdominal injuries could be liver wounds,
perforation and rupture of the bowel or
ruptured spleen.
Trauma Scoring
& Anatomic Criteria

 The type and severity of injury are the basic

factors predicting mortality and morbidity.
Different scoring systems based on the criteria
used are as follows :
 Abbreviated Injury Scale (AIS)
 Injury Severity Score (ISS)
 Anatomic Index (AI)
Abbreviated Injury Scale (AIS)

 This scale is derived by assigning a score of 1 through 6

to each of six body areas, head or neck, including
CNS, face, thorax, abdomen, extremities, and external
genitals

Score Type of Injury

1 Minor injury
2 Moderate injury
3 Severe but not life threatening
4 Severe life threatening injury
5 Critical injury
6 Fatal injury specific to region
Injury Severity Score (ISS)

 This system assigns a numerical value based on number

and severity of anatomical injuries.
 It ranges from 1 (minimum injury) to 75 (maximum
anatomical injury)
 ISS >25 is critical and >16 is serious injury
 It is derived by summing the squares of each of three
highest single AIS rating.
Physiological Criteria

 Glasgow Coma Scale (GCS)

 Trauma Score (TS)
 Crams Scale (Circulation, respiration, abdomen, motor,
speech scale)
Anatomical and Physiological Criteria

 Pre-hospital Index (PI)

 It grades systolic blood pressures, pulse, respiration and level of
consciousness along with scores for the presence or absence of
penetrating chest/abdominal wound.
 Paediatric Trauma Score (PTS)
 It was developed as a physiological and anatomic scoring
system specific for paediatric patients.
 Parameters
Anatomical and Physiological Criteria

 Paediatric Trauma Score (PTS)

 degree of airway maintenance
 invasive or non-invasive procedure
 CNS grading as lethargic/comatose
 systolic BP measurement
 absence or presence of fracture/minor or major
penetration
 closed/open being factors which increase severity
 HOspital Preparedness for Emergencies

Management Of The
Deceased
Objective

 Identify issues related to management of the deceased

 Examine the effects of mass deaths upon workers
 Identify the resources required to manage the
deceased
Issues

 Cultural
 Religious
 Mental trauma,
Funeral Pyres,
Undisposed,
Uncollected Bodies
 Unceremonious
Disposal
Bali Bombing: Ambulance carrying more than one
patient (stacked)
Safety Issues

 Dead Bodies & Body

Parts Communicable
Disease
 Blood & Body Fluids
 Normal Safety
Measures
 Protective Clothing,
Gloves Routine
Decontamination Of
Clothing
Psychological Issues
 Psychological Effect On
Response & Hospital
Personnel, Other Victims,
People on The Disaster Site
 Large numbers Of The
Deceased
 Body Bags & Evacuate
 Severely Injured
 Field Hospital
 Evacuate
 Cordon  Yellow Police
Line
Psychological Trauma

Post Traumatic Stress Disorder

 Regular Rest Breaks
 Opportunities &
Encourage To Ventilate
Feelings
 Reasonable Limits To Shifts
 Follow up personnel
surveys & care
 Use Trained Support &
Counseling Staff
 Adequate Training &
Exercising Fill in the Blank
Legal Issues
 Legal System-
Management Of The
Deceased
 Police (Forensic & Coroner
Responsibilities)
Hospital Preparedness
Committee
 Vary Country To Country
 Legal & Forensic Process
 Photography
 Other Agencies (Aircraft
Crash)
 International Disaster Victim
Identification (DVI) System
Disaster Victim Identification

 At Scene
 The Mortuary
 Ante Mortem
Information
Retrieval
 Reconciliation
 Debriefing
Disaster Victim Identification

 Documentation
 Equipment and
Personnel
 Chain of
Command
 Identification
Condition at the make up morgue 13 Oktober
2002 14.00 pm. The corridor is fenced with linen.
Documentation

 A thorough means of documentation should be

instituted
 Interpol has published its own DVI Forms
 Documentation must be clear, concise, accurate, and
comply with the coding system of the internationally
approved Interpol forms.
Resources At A Disaster

 Protective Clothing
 Markers  Location
Of Bodies & Body
Parts
 Litters & Stretchers
 Body Bags
 Transport
Resources At A Disaster

 Mortuary Overloaded
 Cool Storage Facilities
 Multi Purpose
Container
 Policlinic, Field
Hospital, Morgue
 Bags / Containers 
Personal Articles On /
To View / Identify
Bodies Volunteers activities: Indonesian Red Cross, Medical Faculty
Udayana Univ students, and foreign volunteers
Chain of Command
Identification
 Obtaining of ante- Volunteers from medical students, Faculty
mortem information on of medicine, Univ of Udayana, Bali

possible victims (AM)

 Recovery and
examination of victim
remains to identify
post-mortem evidence
(PM)
 Comparison of AM and
PM data to identify
each victim
Fill in the Blank
Conclusion

Resuscitation and Emergency care provided in

the pre-hospital and the hospital situation along
with the proper transportation of the victims is the
key issue in any mass casualty situation.

Outcome for achieving the reduction in mortality

and disability is much depend upon how
coordinated is the effort, how timely is the
initiation of management and how optimally and
rationally available resources are used.
 Disaster
 Difficult & Complex Operation
 Limited Resources
 Management Of The
Deceased
 Health
 Safety
 Legal
 Forensic
 Cultural & Religion
Ambulance 118 Pertama
Jam 19.55
TRIAGE/ REEVALUATION