approaching trauma patient in pre hospital
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Transcript of approaching trauma patient in pre hospital
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Approach to truma case in prehospital care
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Bagaimana Anda Rawat Mangsa Trauma???
Adakah semua mangsa trauma dirawat menggunakan prosedur yang sama????
Atau dirawat mengikut spesifikasi triage???
Bagaimana ?????
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• Primary adjunt
• Secondary adjunt
Primary survey
Secondary survey
Definitive treatment
Definitive care
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Primary survey
• Untuk Apa????
• Bila???
• Bagaimana???
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• Primary survey dilakukan untuk mengesan “life threatening”
• Untuk mencegah pesakit daripada menjadi lebih parah atau teruk.
• Supaya dapat membuat pemeriksaan atau perawatan yang tepat terhadap “life threatening”
• Primary survey perlu di ulang beberapa kali untuk mengesan sebarang keabnormalan kepada status pesakit yang mana akan mengenalpasti keperluan intervensi tambahan.
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“Six life threatening”Airway obstruction
Tension pneumothoraxOpen pneumothoraxMassive hemothorax
Flail chestCardiac temponade
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Hidden potential “life threatening”
• Pulmonary contusion• Aortic disruption• Tracheabronciol fistula• Myocardial contusion• Esophageal ruptured• Traumatic diaphram hernia• Simple pneumothorax• Simple hemothorax
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Apa yang perlu anda lakukan????
• Siapkan satu kerja sebelum pergi kepada kerja seterusnya…..
• Sentiasa ikut turutan “step by step”
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Primary survey • Danger• Response• Shout for help• Airway and servical collar• Breathing and oxygen administration• Circulation and hemorrhage control • Disability and neurology• Exposure and enviroment control
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danger• 3 pekara perlu diambil kira1. Diri sendiri (self) : pakai “PPE”
2. Persekitaran (area) : pastikan persekitaran selamat.
3. Pesakit (patient) : dalam kondisi yang bersesuaian.
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Response• Periksa respon pesakit dengan
menepuk kedua bahu pesakit• Berhati-hati supaya pesakit tidak
bergerak tiba-tiba. (sudden move)
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Shout for help• Call for help or dail 999
• Shout for equipment such as AED or first aid kits
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Airway and servikal collar
• Gunakan kaedah “look, listen and feel”• Look: lihat mimik muka, lihat kecederaan pada
muka dan sekitar bahagian luar salur penafasan.• Listen: dengar sebarang bunyi,( guggling, stridor,
normal, absent, and wheezing)• Feel: palpate bahagian leher. Rasa sebarang
keabnormalan di sekitar ruang luar penafasan. Pasang servikal collar untuk protect bahagian servikal pesakit.
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• Jika ada sebarang sekatan pada airway, gunakan manual in line stabilisation (MILS) atau sebarang peralatan airway termasuk intubation atau surgikal airway.
• Selalunya sekatan berlaku akibat direct injury, edema, atau foreign bodies dan penutupan salur penafasan oleh lidah atau anggota pesakit sendiri kerana kehilangan tahap kesedaran, atau tahap kesedaran yang rendah.
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Breathing and oxygen administration
• Kondisi “potential life threatening” selalu dijumpai semasa memeriksa penafasan.
• Periksa kondisi “ATOMFC”• Periksa penafasan menggunakan look, listen dan
feel.• Look : kadar penafasan 12-16/min, agonal
breathing/gasping (start cpr), lihat chest wall(contusion, bruise, leseration, puntured, abrasion, unequal chest rise, silent chest dan flail. Lihat juga distended neck vein.
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• Feel: rasakan apex beat, palpate traekea pesakit dan dada, lakukan percussion samada dullness atau hyperresonan.
• Listen: dengar kemasukan udara. ( air entry). Pesakit politrauma perlu diberikan oksigen yang banyak.
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• Pemeriksaan penafasan adalah untuk mengesan keupayaan pesakit untuk ventilate dan oxygenate. Penemuan kritikal termasuklah kehilangan spontaneous breathing, asymmetric breath sound(konsisten dengan pneumothorax atau endotrackeal tube malposition), dyspnea, hyperresonan atau dullness apabila percussion (kemungkinan ada tension pneumothorax atau hemothorax), dan gross chest wall instability atau defects yang compromise ventilation.
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Circulation and hemorrhage control
• Pemeriksaan sirkulasi boleh dilakuakan dengan memeriksa nadi(pulse), capillary time refill(crt), tone kulit (sainosis, pale atau pink) dan pedarahan (active bleed).
• Ingat “4 and the floor” :thorax :abdomen :pelvic :long boneAnd the floor (external hemorrhage)
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• Untuk pedarahan (active bleeding), cuba hentikan dengan memberi tekanan (direct pressure) di tempat berdarah selama 5 minit guna tangan. Jika masih belum berhenti, gunakan bandage, atau tonique atau kedua-duanya. (jika anda perlu jimatkan masa, trus compress guna gauze tebal atau gamgee dan bandage.
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• Pemeriksaan sirkulasi dilakukan untuk mengesan dan mencegah hipovolemia, cardiac tamponade dan sebarang external hammorhage. Perhatikan neck vein distension atau neck vein collapse, kerana ia akan kenalpasti tona jantung (heart tone) ascultated, dan mengenalpasti samada hipovolemia mampu di kawal.
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Untuk hypovolemia,, apa perlu anda lakukan ???
Apa langkah pengawalan???
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• Pasang 2 Branula saiz besar (2 large bore, pheripheral, iv catheter)
• Pasang di bahagian limb atas.• Hypovolemic shock bole dikelaskan dan setiap
pengkelasan perlukan kadar cecair yang berbeza.
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Class I Class II Class III Class IV
Blood Loss (mL) Up to 750 750-1500 1500-2000 >2000
Blood Loss (% blood volume) Up to 15% 15-30% 30-40% >40%
Pulse Rate < 100 >100 >120 >140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure (mm Hg) Normal or increased Decreased Decreased Decreased
Respiratory Rate 14-20 20-30 30-40 >35
Urine Output (mL/h) >30 20-30 5-15 Negligible
CNS/Mental Status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic
Fluid Replacement (3:1 rule) Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood
Table. Estimated Fluid and Blood Losses Based on Patient’s Initial Presentation [4]
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Disability and neurology • Pemeriksaan menggunakan AVPU (alert,
verbal, pain dan unresponsive)• Alert : periksa kadar kesedaran pesakit.• Verbal: periksa melalui percakapan pesakit.• Pain: pemeriksaan melalui kesakitan. Respon
pesakit kepada kesakitan.• Unresponsive: periksa respon pesakit.
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• Pemeriksaan keupayaan(disability) adalah untuk mengenalpasti kecederaan kepala yang serius atau kecederaan spinalcord.
• Ini dilakukan dengan membuat gross mental status dan motor examination.
• Selain dari AVPU, penggunaan GCS juga bole digunakan, tetapi ia tidak sesuai dalam keadaan kritikal.
• Pemeriksaan pupils, rangsangan terhadap cahaya juga penting untuk kenalpasti spinalcord injury dan intracranial injury.
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Exposure and environment control
Ini merupakan langkah terakhir dalam primary survey.Tanggal pakaian pesakit, untuk membuat pemeriksaan
fizikal.Disamping itu, perhatikan keadaan pesakit untuk
mengelakan daripada hypotermia.Check head to toe. Perhatikan sebarang keabnormalan
dan diformities(kecacatan)Lakukan log roll untuk pemeriksaan belakang pesakit.
Hentikan pedarahan dengan segera jika ada.
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Primary adjunt• Pemeriksaan semula pesakit sekali imbas.
(reassesment, ABCDE)• Periksa vital sign pesakit, blood pressure, pulse,
respiration, pain score, temperature dan spo2.• Pemeriksaan yang bersesuaian. Ecg atau cardiac
monitoring leads. Oximetry monitoring perlu dilakukan berterusan.
• Sebarang keabnormalan perlu di rawat segera dengan memerhatikan semula ABCD.
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• Semua pesakit trauma dirawat dengan cara yang sama tanpa mengikut spesifikasi triage……. Semua mengikut “drsABCDE” dan dilakukan mengikut turutan…….
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Thank you