Secondary Survey Assessment( Penilaian dan Penanganan

Survei Sekunder )

Departemen Anestesiologi dan ReanimasiFK – USU

2010

Sistematika Emergency Medicine

TRIASESURVEI PRIMERSURVEI SEKUNDERSTABILISASI RUJUKANTERAPI DEFINITIF

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

Pemeriksaan kepala

• Kulit kepala (robekan, memar, laserasi) • Tengkorak (nyeri tekan, depresi tulang)• Mata (pupil, fundus, lensa, conjunctiva)• Cairan CSF / darah dari telinga, hidung,

mulut

Ada darah mengalir, tetapi dari mana ?

• Glasgow Coma Score• Pupil

– ukuran, simetri, refleks cahaya• Fungsi motorik• Fungsi sensorik• Refleks-refleks

Periksa kesadaran dan syaraf

Secondary SurveyHead Complete neurologic examination GCS score determination Comprehensive eye/ear examPitfalls Unconscious patient Periorbital edema Occluded auditory canal

Secondary Survey

The complete history and physical

examination

Secondary SurveyKey Components History Physical examination : Head-to-toe “Tubes and finger in every orifice” Complete neuro exam Special diagnostic tests Reevaluation

Secondary Survey

HistoryA Allergies M MedicationsP Past IllnessesL Last meal E Events/Environment

© ACS

Secondary SurveyMechanisms of Injury

Pemeriksaan leher (1)

• Lihat / inspeksi • Palpasi (nyeri tekan, deformitas)• Anggap leher cedera• Imobilisasi pada posisi netral

Pemeriksaan leher (2)

• Cari Luka tembus• Cari Emfisema subkutis• Apakah trachea ditengah ?

– raba di supra-sternal notch• Apakah Vena leher distended ?

Periksa posisi trachea: palpasi di suprasternal notch

Secondary SurveyCervical Spine Palpate for

tenderness Complete motor/

sensory exams Reflexes C-spine imaging

Pitfalls • Altered LOC for any reason• Other severe , painful injury

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

Secondary Survey

Maxillofacial Bony crepitus/stability Palpable deformityPitfalls

• Potential airway obstruction • Cribriform plate fracture • Frequently missed injury

Pemeriksaan dadamencari ulang kerusakan

• Lihat / inspeksi• Palpasi• Perkusi• Auskultasi• Foto sinar-X dada (jika ada)• ECG ( jika ada)

Secondary SurveyChest Inspect Palpate Percuss Auscultate X-ray

Pitfalls • Elderly • Children

• 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)

Perlukaan organ padat / pemb darah besarPerlukaan organ berongga (usus)

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

Secondary Survey

Abdominal Evaluation

Blunt trauma Penetrating trauma

Secondary SurveyAbdomen Inspect, auscultate, palpate, and percuss Reevaluate frequently Special studies Pitfalls

• Hollow viscus and retroperitoneal injuries• Excessive pelvic manipulation

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

Ekstremitas / anggota gerak

• Inspeksi – deformitas, robekan, memar, laserasi

• Palpasi• Palpasi nadi arteria distal• Ingat compartment syndrome• Jangan lupa periksa punggung

Log-roll

Cari luka, robekan, memar, nyeri tekan, deformitas tulang belakang

4 orang

Pemberi komandoinstruksiyang jelas

Log-roll

Digulingkan serentak pelan-pelan

Foto sinar-x

• Dikerjakan waktu survei sekunder• Dada• Tulang leher - 7 segmen vertebra• Pelvis / panggul• Lokasi lain sesuai indikasi

– (misal fr tulang paha dll)

Secondary Survey

Musculoskeletal : Extreminities Contusion , deformity Pain Perfusion Peripheral neurovascular status X- rays as needed

Secondary Survey

Musculoskeletal : Pelvis Pain on palpation Symphysis width ↑ Leg length unequal Instability X-rays as needed

Secondary Survey

Musculoskeletal Pitfalls

• Potential blood loos • Missed fractures • Soft-tissue or ligamentous injury• Occult compartement syndrome (especially

with altered LOC / hypotension)

Secondary Survey

Neurologic Spine / Cord Complete motor

and sensory exams Imaging as

indicated Reflexes

Early neurosurgical consultation

CNS Frequent

reevaluation Prefent secondary

brain injury

Adjuncts to Secondary Survey

Special diagnostic test as indicated Pitfalls

• Patient deterioration • Delay of transfer

Secondary Survey

Neurologic Pitfalls

• Incomplete immobilization• Suble ↑ in ICP with manipulation • Rapid deterioration

Reevaluation

Minimizing Missed Injuries High index of suspicion Frequent reeveluation and monitoring

Reevaluation

Pain Management Relief of pain /anxiety as appropriate Administer intravenously Careful monitoring is essential

Definitive Care

Local Facility

??Transfer agreements?? Local resources ??

??

Trauma SpecialtyCenter Facility

Record , Legal Considerations

Concise, chronologic documentation Consent for treatment Forensic evidence

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