The document discusses the steps for initial assessment of trauma patients. It describes the initial scene assessment, primary survey using ABCDEFGHI methodology, and secondary survey. The primary survey focuses on assessing the airway, breathing, circulation, disability, exposure, and identifying any life-threatening injuries that need immediate treatment. The secondary survey involves a full head-to-toe examination to identify and treat all injuries when the patient is stabilized. Proper history taking using SAMPLE format and ongoing vital sign and Glasgow Coma Scale monitoring are also emphasized. The goal is to quickly identify and manage life-threatening injuries while preparing for transport to a higher level of care.

1. Initial Assessment
Yunus Elon, S.Kep., Ns, MSN
Fakulty of Nursing
Adventist University of Indonesia
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2. Definition
O Initial Assessment adalah suatu cara atau langkah-
langkah yang digunakan untuk menilai hal-hal yang
mengancam nyawa penderita pada kasus trauma dan
bagaimana kita menanganinya dengan cepat dan benar.
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3. WHEN YOU REACH THE VICTIM
O Once you reach the scene of the accident, you
will have to carry out four steps as expeditiously
as possible:
1) INITIAL SCENE ASSESSMENT
2) THE PRIMARY SURVEY
3) THE SECONDARY SURVEY
4) COMMUNICATION WITH CD, CLINIC OR
HOSPITAL
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4. INITIAL SCENE ASSESSMENT
Whether there are any hazards to the victim
or rescuers
The number of causalities
Whether you will need backup
The mechanism of Injury
Whether you will need any special
equipment to gain access to the victim
Establish Priorities
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5. PRIMARY SURVEY
The Role of the primary survey is to
identify any life-threatening problems or
injuries.
Whenever possible, treatment of any life
–threatening problem is carried out as
soon as that problem is identified.
The primary survey follows the simple
system of “ABCDEFGH”.
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6. Airway and Cervical Control #1
As always, first priority goes
to the airway.
Is the airway open now?
Will it stay open?
IF THE VICTIM IS
UNCONSCIOUS, OPEN THE
AIRWAY by HEAD TILT-CHIN
LIFT or JAW TRUST.
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7. Airway and Cervical Control
That is maneuvers that will not move
the head out of neutral position.
A little bit of extension of the head
probably won’t hurt, but flexion of
the head may be catastrophic, so
AVOID FLEXING THE HEAD at all cost.
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8. Airway and Cervical Control
Inspect the victims' mouth
quickly and suction out
secretion, blood or vomits.
If the victim is unconscious,
use an ORAPHARYNGEAL
(OPA) or NASOPHARYNGEAL
AIRWAY to help keep the
airway Patent.
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9. If Suspected Cervical Injury
APPLY CERVICAL
COLLAR
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10. AIR WAY MANAGEMENT
1. Gurgling
a. Logroll
b. Suction
c. Finger Sweep
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11. AIR WAY MANAGEMENT
2. Snoring
a. Head tilt-chin lift
b. Jaw Trust
c. OPA/NPA
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12. AIR WAY MANAGEMENT
3. Crowing
a. Airway definitive
b. Intubation
c. Needle cricothiroidotomi
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13. BREATHING #2
If the victim is conscious,
listen to the TALK. Are they
able to speak in full
sentences without gasping
for breath.
 If the victim is unconscious,
expose the chest, in order to
LOOK, LISTEN, AND FEEL
FOR BREATHING. 8/28/2016Emergency and Kritis 13

14. Breathing #2
If the Victim is not
breathing, give (2) two full
breaths, cheek for a
carotid pulse, and start
CPR.
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15. Breathing #2
If they are breathing, however, cheek the
adequacy of breathing by noting:
Respiratory RATE
DEPTH of respiratory
The NECK (Look & Palpate) is the trachea in
the midline)
The CHEST: Look for open wounds, bruises,
deformity, and flail segments.
Listen with a Statoscope in each axilla for
presence and equality of breath sounds.
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16. Cases in Breathing
 Tension Pneumothorax: Treatment=Needle
thoracosisntesis Intercostal 2 mid claviculaline.
Open Pneumothorax: Kasa 3 sisi (Adhesive
dressing)
Massive Hematothorax: IV 2 Line with big
needle with warm NACL.
Flail Chest: Strong Analgetik
Cardiac Tamponade: Pericardio Synthesis.
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17. CIRCULATION#3
O Assessment of the circulation begin as soon as
you encounter the victim and place a hand on
the forearm. If it is pale, cold and sweaty the
victim is in shock .
O Cheek the CAROTID PULSE, FEMORAL PULSE,
RADIAL PULSE once you’ve cheeked radial
pulse , cheek the finger nail For CAPILLARY
REFIL. Normal <2 second.
O External bleeding must be controlled during
the primary survey by direct pressure. 8/28/2016Emergency and Kritis 17

18. CIRCULATION#3
O When the victim shows signs of
hypovolemic shock and the source of
bleeding is not obvious, Consider the 3
AREAS OF HIDDEN BLOOD LOSS: The
Chest, The Abdomen and The Thigh.
O Traumatic blood loss is correctly by
placing 2 Line Cannula 14-16 gauge. 2
Liters of Hartman Solution..(crystalloid sol)
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19. DISABILITY#4
O The primary survey, only the briefest
Neurologic Evaluation is undertaken
especially:
O Assessment of pupil size and Reaction to
light .
O Level of Consciousness AVPU scale :
O A=Alert (Victim know his name, where he is)
O V=Verbal (responds to vocal stimuli)
O P=Pain (Responds only to painful stimuli)
O U=Unresponsive to any stimuli.
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20. EXPOSE#5
OThe principle of
exposure to find out
bleeding and the
wounds
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21. FOLLEY CATETHER#6
O To observe Intake-Output .
O Contra-Indication of Inserting folley catheter
O Present of blood in the urethra
O Scrotum hematoma
O Normal Urine
Adult : 0,5-1cc/Kg BW(30-50 cc/hrs
Child : 1-2 cc/Kg BW/hrs
Baby :2-3 cc/kg BW/hrs
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22. GASTRIC TUBE#7
O It is Advice to insert NGT in order to
prevent
O Gastric distention
O Avoid vomiting
O Medication route
O Warning: In fracture Basis cranial
Inserting NGT through mouth
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23. HEART MONITOR#8
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24. SECONDARY SURVEY
OA secondary survey should only be
performed when all life –
threatening condition have been
treated.
OSecondary survey is HEAD TO TOE
EXAMINATION
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25. Head to Toe Examination#1
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Secondary survey of multitrauma Victim
HEAD Depressed fracture, scalp laceration, Cerebrospinal fluid leak from ears
or Nose: Battle sign; Maxillofacial injury.
EYES Penetrating injury, Extraocular motion; Pupils and visual acuity
MOUTH Foreign bodies; loose or avulsed teeth. Broken dentures, blood, vomits,
secretions.
NECK Open wounds, tracheal deviation, jugular distention, tenderness or
bruises over cervical spine (assume in any case that cervical injury is
present)
CHEST Bruises, open injuries, equality of breath sounds; dullness or hyper
resonance
ABDOM
EN
Contusions and seat belt marks, open wounds, evisceration, distention,
rebound tenderness
PELVIS Stability on compression of iliac wings
EXTRE
MITIES
Deformity, Swelling, Collor, Temperature Pulses sensation and motion

26. TAKING THE HISTORY IN
TRAUMA (SAMPLE)#2
O S= Sign & Symptoms
O A= Allergies
O M= Medications (that the victim takes regularly
or has taken today
O P= Past Medical History (Operations, Prev
hospitalization, other serious illnesses.
O L=Last Meal (the last time the victim had any
oral intake
O E= EVENTS (Mechanism of injury)
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27. VITAL SIGN#3
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28. GCS#4
EYE OPENING
4=Spontaneous When the victim is approached he
opens his eyes
3=Opening to
Speech
When the victim open his eyes to
speech
2=Opening to
Pain
When the victim open his eyes to
pain applied to the nail beds
1=No eye
opening
Neither open his eyes to painful
stimuli 8/28/2016Emergency and Kritis 28

29. GCS#4
VERBAL RESPONSE
5=Oriented Give accurate answer to who they are, where
they are
4=Confused Unable to give accurate answer to the above,
but produce meaningless phrases
3=Inapropriate words Says only one or two words unrelated to the
question.
2=Incomprehens
ible
Groans, Moans or mumbles
1=No verbal
Response
No verbal response 8/28/2016Emergency and Kritis 29

30. GCS#4
MOTOR RESPONSE
6= Obeys command Accurately respond to instruction such as
raise your right hand
5=Localize to Pain Can move an arm to locate the pain in an
effort to remove it
4=Withdraws from
pain
Pulls away from painful stimuli
3=Abnormal
Flexion
After painful stimuli at fingertips the
victim bends an arms at the elbow
2=Extensor
Response
when painful stimuli is applied the
elbow straightens
1=No response to
pain
No detacble motor response
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