FIRST INITIAL ASSESSMENT

Disasters either originating from nature or as a result of human acts in Indonesia are very likely to occur due to one of the countries located in a meeting of 5 Earth Plates. In addition Indonesia is also located in a series of volcanoes ranging from the tip of Aceh to Maluku. While human activities such as logging, many end up with disasters such as floods, landslides and so forth.

Lately various disasters such as chemical plant fire, flood. Landslides, forest fires, volcanic eruptions, earthquakes and tsunamis have hit Indonesia. Busung lapar, diarrhea, dengue fever, aviant flu inevitable to contribute to the form of disaster in Indonesia and even polio that has been declared free in Indonesia re-emerged as a disaster. Disasters that occur can be large or small, can be local or national, can lead to damage both infrastructure and materials owned by the population, often even the disaster can threaten his helper.

One of the impacts of such damage has a direct impact on the health of the affected communities, as well as the deterioration of health facilities and their supporting facilities, affecting the disruption of community accessibility to health services that ultimately affects the health status of the affected communities.

The ability of disaster-affected communities to cope with sudden and life-threatening difficulties is a key asset in the emergency response effort to the above-mentioned disaster threat before getting outside assistance. The community's ability, preparedness and maturity demonstrate the benefits of community-based disaster management.

Patients who are seriously injured require rapid, appropriate and easy assessment and management to avoid death and disability. Understanding the area of ​​the initial assessment is the process of rapid evaluation in emergency patients directly followed by resuscitation measures. Assessment and resuscitation are based on the priority of emergency on the patient based on airway, breathing and circulation. The patient's care must be quickly recognized in the Primary Survey and immediate resuscitation action to save the patient. Complete and supplementary checks are performed on the Secondary Survey. Both the Primary Survey and the Secondary Survey are conducted repeatedly to be able to recognize the decline in the patient's condition, and to provide therapy if necessary. This action is done systematically and sequentially (sequentially) but in practice in everyday events this can be done simultaneously.

Component

The overall Initial assessment process includes:

1) Preparation of the patient2) Triage3) Primary survey4) Resuscitation5) Investigations for primary servey6) Secondary survey7) Investigations for secondary surveys8) Monitoring and re-evaluation9) Definitive therapy

While the initial understanding of the assessment is limited to include the action of triage up to the secondary survey.

Initial assessment should be done in the correct order to obtain maximum results, though in practice every day can take place simultaneously.

The steps in the initial assessment include:

1. Preparation of the patient

Good coordination between doctors in hospitals and field workers will benefit patients. The hospital should be notified before the patient is transported from the scene so that the hospital can prepare the equipment and the trauma team at the time the patient arrives at the hospital. There are 2 stages of preparation of the patient: the pre-hospital stage and the intra-hospital stage. In the pre-hospital phase is a decisive phase for patient safety, ranging from initial treatment to patient referral to appropriate hospital.

At the pre hospital stage things to consider include:

• Coordination with destination hospitals tailored to the patient's condition and type of injury
• Airway maintenance, control of bleeding and immobilization of the patient.
• Coordinate with other field officers
• In the intra-RS stage should be prepared officers and equipment before the patient arrives. These preparations include:
• Personal protective equipment
• Preparedness of equipment and room for resuscitation
• Preparation for more complex resuscitation measures
• Preparation for definitive therapy

2. Triage

Triage (triage) is an action to classify sufferers based on the severity of injuries that are prioritized based on the presence or absence of interference on A (airway), B (breathing) and C (circulation).Patients with airway problems should receive first priority treatment because airway disturbance is the fastest cause of death in patients.Triage also includes the notion of organizing referrals in such a way that the sufferer gets proper care. Two types of triage state may occur:

1. Mass calamity with the number of patients and the severity of injury does not exceed the ability of the hospital. In these circumstances patients with emergency and multi trauma problems will be treated first.
2. Mass calamities with the number of patients and the severity of the injuries exceeded the ability of the hospital. Under these circumstances the first treatment will be the sufferer with the greatest survival probability, and will require the least amount of time, equipment and energy.
3. Triage action can be done on a group of patients, in disaster or mass casualties, or in a single patient to determine the diagnosis.

3. Primary survey, resuscitation, and investigation

The primary survey or primary survey is a rapid examination of vital function in patients with severe injury with priority on ABCD, this phase must be done in a short time and the gravity of the patient should be enforced in this phase. Resuscitation action to save lives should be done immediately if the emergence of emergency in patients. Actions on the primary survey include assessment:

A Or Airway maintenance is to maintain the airway, this can be done by manual technique) or use aids (oropharynx, endotracheal pipes etc). This action may be a lot of manipulation of the neck so it must be considered to maintain stability of the collar bone.

 B or Breathing is to keep breathing / ventilation work well. Every person with severe trauma requires additional oxygen to be given to the patient in an effective way. The presence of gravity  C or Circulation is maintaining the circulation along with the action to stop the bleeding. Early recognition of signs of hemorrhagic shock and an understanding of the principles of fluid administration are very important to do so avoid the patient from delayed treatment.D or Disability is the examination to obtain the possibility of neurological disorders. E or Environment or Exposure is the examination of the whole body of the patient to see clear or visible signs of emergency that may not be visible by keeping hypotermic.During this primary survey the life-threatening circumstances should be identified and the resuscitation is done on the spot. Aggressive resis- titation and the rapid management of life-threatening circumstances are essential if the patient is to survive. Priority of emergency treatment is done based on the above sequence, but if possible it can also be done simultaneously. Priority handling for young and old age patient is same. One difference is that at a young age the size of the organ is relatively smaller, and its function has not developed optimally.

In pregnant women the priority remains the same, it's just that the process of pregnancy makes the physiological process change because of the fetus. In the elderly, due to the aging process the body's function becomes more susceptible to trauma due to the reduced power of body adaptation.

Airway + Cervical control

The smoothness of the airway is the priority of the examination. This examination includes airway obstruction that can be caused by foreign bodies, facial bone fractures, laryngeal trauma, trachea and other causes.

In this case airway maintenance can be initiated by manually opening the airway by the technique of chin lift or jaw thrust maneuvers. In addition to the need to check whether there is a blockage of airway by foreign objects / blood / and others. During the course of action, care should be taken to stabilize the collarbone, especially in multiple trauma or upper trauma. Neck bone injuries should be properly anticipated until proven to be non-existent.

In certain circumstances where the airway is difficult to maintain by regular measures it must be prepared to install a definitive airway if necessary.

Breathing + Ventilation

Good breathing and ventilation require good chest, lung and diaphragm work. Interference with one of these organs can cause respiratory and ventilation problems. The patient's chest should be opened to see chest wall expansion. Perform auscultation, percussion and palpation techniques to see any abnormalities in the patient's breathing. Every trauma patient should be given oxygen. Some acute conditions due to trauma that can cause fatal respiratory distress are: tension pneumothorak, flail chest accompanied by pulmonum contusions, massive hematothorac and open pneumothorac. This should be recognized in this phase, in the pneumothorac tension should be done immediately to save lives in the form of drain thorak for decompression purposes.

Circulation + Hemorhage control

Bleeding is a major cause of death in traumatized patients who may be treated if they receive prompt and appropriate therapy. Rapid circulation function assessment can be done by assessing awareness, skin color and pulse. Stopping external bleeding can be done during primary surveys with pressure techniques on the wound or by surgery. The body's reaction to fluid loss (bleeding) may differ:

• In the elderly the ability of compensation is much reduced so that resuscitation action should be immediately given.
• At an early age the compensation is so great that signs of circulatory failure appear slow.
• On exercise the power of compensation is greater than that of an ordinary person with a marked characteristic of less tachycardia even in hypovolemia.

Fluid resuscitation is given on the basis of the degree of shock occurring, from the degree of shock and its response to fluid resuscitation, it can be predicted whether a bleeding (especially internal bleeding) requires surgical resusitation.

Disability

Rapid neurological examination can be done by AVPU method (Allert, Voice response, Pain response, Unresponsive).

Periodic GCS checks can be performed for more detailed results in the secondary survey. Decreased consciousness can be due to decreased oxygenation or decreased perfusion to the brain, or due to direct trauma to the brain. If hypoxia and hypovolaemia in patients with impaired consciousness can be excluded, consider CNS damage to the point.

Exposure

Examination of all parts of the body should be accompanied by measures to prevent hypothermia. Installation of splints or vacuum mats to stop bleeding can also be done in this phase.

Investigations are generally not conducted on the primary survey. The primary surveys are: oxygen saturation check with pulse oxymetry, cervical photo, thoracic photo, and plain abdominal photo. Other actions that can be done in the primary survey are the installation of ECG, catheter and NGT monitors. Examination done without stopping / delaying the primary survey process.

Definitive therapy and referrals

Definitive therapy is generally the job of a surgeon. The duty of the physician who performs the first treatment is to perform resuscitation and stabilization as well as prepare the patient for the conduct of definitive actions or to be referred. The referral process should have started when the reasons for referring are found, because delaying referrals will elevate the patient's morbidity and mortality. The decision to refer the patient is based on the patient's ata or physiology, anatomical injury, injury mechanisms, comorbidities and factors that may alter prognosis. Ideally selected the nearest hospital that matches the condition of the patient.