中国初级创伤救治课件学员英文

PTCPTC Primary TraumaPrimary Trauma CareCare 1 PTCPTC What is PTC?What is PTC? Primary Trauma Care is a 2 day course followed by a one day instructors course, training doctors and nurses in the acute management of the severely injured patient 2 PTCPTC PTC Mission Statement PTC Mission Statement To train doctors & nurses to treat severely injured patients quickly & systematically To use what equipment is available, to prioritise and treat patients safely To train clinicians to teach PTC principles in their hospitals 3 PTCPTC The PTC 2 day courseThe PTC 2 day course Objectives Demonstrate the systematic assessment & treatment of the severely injured patient To train you in the knowledge, skills and attitudes of the PTC principles To consider how these PTC principles can be adapted to your hospital 4 PTCPTC PTC SystemPTC System PreventionPrevention TriageTriage Primary surveyPrimary survey Secondary surveySecondary survey Stabilisation Stabilisation TransferTransfer Definitive careDefinitive care 5 PTCPTC PTC SystemPTC System PreventionPrevention 6 PTCPTC PTC SystemPTC System TriageTriage Sorting patients according to prioritySorting patients according to priority Priority depends on experience resources severity of injury 7 PTCPTC PTC SystemPTC System Primary & Secondary SurveyPrimary & Secondary Survey History Examination Look (Inspection) Listen (Auscultation) Feel (Palpation) Special Investigations if available 8 PTCPTC PTC SystemPTC System Stabilisation Includes Re-assessment Optimisation Documentation Immunisation When stable Transfer for definitive care 9 PTCPTC PTC SystemPTC System ? ? 10 PTCPTC PTC SystemPTC System SummarySummary PTC offers a systematic approach rapid assessment and treatment of the injured patient adaptability to all healthcare environments 11 PTCPTC Primary SurveyPrimary Survey Objectives To introduce the elements of the Primary Survey To understand when to perform the Primary Survey 12 PTCPTC Primary SurveyPrimary Survey Rapid sequential look 2 minutes Treat as you find Repeat if at any time unstable 13 PTCPTC Primary SurveyPrimary Survey Airway Breathing Circulation Disability Exposure 14 PTCPTC AirwayAirway AssessmentAssessment Look, listen, feel Colour Conscious state Accessory muscle use 15 PTCPTC AirwayAirway BewareBeware Airway obstruction Chest injuries with breathing difficulties Cervical spine injury 16 PTCPTC AirwayAirway ManagementManagement Clear mouth Chin lift/jaw thrust Guedel / Nasopharyngeal airway Intubation Cervical spine care 17 PTCPTC BreathingBreathing AssessmentAssessment Air movement Respiratory rate 18 PTCPTC BreathingBreathing BewareBeware Tension pneumothorax Massive haemothorax Open pneumothorax Flail chest Lung contusion 19 PTCPTC BreathingBreathing ManagementManagement Oxygen (if available) Artificial ventilation Decompress pneumothorax Drain haemothorax 20 PTCPTC CirculationCirculation AssessmentAssessment Cardiac output Blood volume External haemorrhage 21 PTCPTC CirculationCirculation BewareBeware Intra-abdominal injury Intra-thoracic injury Long bone fracture Pelvic fracture Penetrating injury Scalp wounds 22 PTCPTC CirculationCirculation ManagementManagement Stop bleeding Large bore intravenous access x 2 Blood for crossmatch and Hb Administer IV fluid 23 PTCPTC DisabilityDisability Pupils Check awareness AAwake VResponds to verbal command PResponds to pain UUnresponsive 24 PTCPTC ExposureExposure Undress for thorough assessment Prevent hypothermia 25 PTCPTC Primary SurveyPrimary Survey X-Rays (if available)X-Rays (if available) Cervical spine (lateral) Chest Pelvis 26 PTCPTC Reassessment of Reassessment of ABCDEABCDE If patient is, or becomes, unstable 27 PTCPTC ? ? Primary SurveyPrimary Survey 28 PTCPTC Primary SurveyPrimary Survey SummarySummary Rapid sequential look 2 minutes Treat as you find Repeat at any time if unstable 29 PTCPTC Airway and Airway and Breathing Breathing Objectives To understand the structured approach to airway and breathing To recognise and manage common airway and breathing problems 30 PTCPTC Airway ManagementAirway Management First priority is a patent airway Talk to the patient Give oxygen (if available) Assess the airway Cervical spine 31 PTCPTC Airway AssessmentAirway Assessment Look Listen Feel Colour Respiratory distress Conscious state Chest movement Breath sounds Respiratory distress 32 PTCPTC Airway Assessment Airway Assessment Signs Of ObstructionSigns Of Obstruction Snoring or gurgling Stridor Agitation (hypoxia) Use of accessory muscles Paradoxical chest movement Cyanosis 33 PTCPTC Airway ManagementAirway Management Basic TechniquesBasic Techniques Chin lift Jaw thrust 34 PTCPTC Airway ManagementAirway Management AdjunctsAdjuncts Oropharyngeal airway Nasopharyngeal airway 35 PTCPTC Airway ManagementAirway Management Advanced TechniquesAdvanced Techniques LMA Endotracheal intubation Surgical Cricothyroidotomy 36 PTCPTC Endotracheal IntubationEndotracheal Intubation if:if: Failure to maintain an airway by other means Failure of ventilation by other means Consider: iRisk of aspiration iControl CO2 (eg head injury) 37 PTCPTC RememberRemember 1. Cervical spine1. Cervical spine 2. Patients die from lack 2. Patients die from lack of oxygen not lack of a of oxygen not lack of a endotracheal tubeendotracheal tube 38 PTCPTC Surgical CricothyroidotomySurgical Cricothyroidotomy Consider if: Intubation attempted and failed and still needed Patient cannot be ventilated 39 PTCPTC BreathingBreathing (Ventilation)(Ventilation) 40 PTCPTC BreathingBreathing AssessmentAssessment Inspection (LOOK) Palpation (FEEL) Auscultation (LISTEN) Resuscitate 41 PTCPTC Breathing Breathing LookLook Respiratory rate Accessory muscle use Cyanosis Penetrating injury Flail chest Sucking chest wound 42 PTCPTC Breathing Breathing FeelFeel Tracheal shift Rib fractures Subcutaneous emphysema Percussion 43 PTCPTC BreathingBreathing ListList e en n Breath sounds Heart sounds Bowel sounds 44 PTCPTC Tension PneumothoraxTension Pneumothorax SignsSigns Respiratory distress Tachycardia Hypotension Distended neck veins Resonant percussion note Tracheal deviation Air entry 45 PTCPTC Tension Pneumothorax Tension Pneumothorax ManagementManagement Immediate decompression Large bore needle Second intercostal space Mid clavicular line Formal chest drain must follow 46 PTCPTC Tension PneumothoraxTension Pneumothorax Should be a clinical diagnosis Treat before X-ray 47 PTCPTC BreathingBreathing ManagementManagement High flow oxygen if available Assist ventilation if necessary Treat pneumothorax + haemothorax 48 PTCPTC ? ? Airway and BreathingAirway and Breathing 49 PTCPTC Airway and BreathingAirway and Breathing Summary Open the airway Consider intubation Do not forget cervical spine Oxygen if available Assist ventilation as required 50 PTCPTC CirculationCirculation Objectives To understand the structured approach to circulation problems To recognise and manage shock 51 PTCPTC CirculationCirculation AssessmentAssessment Blood pressure Heart rate Capillary refill Peripheral temperature Peripheral colour Urine output 52 PTCPTC ShockShock Inadequate organ perfusion and tissue oxygenation Most often due to hypovolaemia in trauma 53 PTCPTC Circulation Circulation Types of shockTypes of shock iHypovolaemic iCardiogenic iNeurogenic iSeptic iAnaphylactic 54 PTCPTC ShockShock Sites of blood lossSites of blood loss Closed Femoral #1.5-2 litres Closed Tibial # 500 ml Pelvic # 3 litres Rib # (each)150 ml Haemothorax 2 litres Hand sized wound 500 ml Fist sized clot500 ml 55 PTCPTC ShockShock Concealed blood lossConcealed blood loss Abdominal Cavity Pleural Cavity Femoral Shaft Pelvic Fractures Scalp (children) 56 PTCPTC Types of BleedingTypes of Bleeding Compressible - usually peripheral Non-compressible - e.g. intra-abdominal - Surgery required 57 PTCPTC ShockShock Clinical SignsClinical Signs Altered mental state : anxiety to coma Pulse present ? - radial systolic 80 mmHg - femoral systolic 70 mmHg - carotid systolic 60 mmHg Tachycardia Pulse pressure narrowed 58 PTCPTC ShockShock Clinical SignsClinical Signs Skin - cold, pale, sweaty, cyanosed Capillary refill time 2 seconds Blood pressure JVP Urine output 1500mlBlood loss 1500ml 63 PTCPTC Cardiogenic ShockCardiogenic Shock Myocardial contusion Cardiac tamponade Tension pneumothorax Penetrating wound of heart Myocardial infarction 64 PTCPTC Circulation Circulation ManagementManagement A + B, oxygen (if available) Two large bore i/v cannulae Stop obvious bleeding Fluid replacement Maintain temperature Analgesia 65 PTCPTC CirculationCirculation Stop bleedingStop bleeding Chest Drain tube and re-expand lung Emergency thoracotomy rarely Abdomen Laparotomy if hypotensive after fluids Limbs Pressure dressing Tourniquet last resort 66 PTCPTC CirculationCirculation Fluid replacementFluid replacement Warm fluids if possible Colloids or crystalloids? Consider hypotensive resuscitation if haemostasis not secure Consider oral resuscitation 67 PTCPTC CirculationCirculation Fluid replacement - How much?Fluid replacement - How much? 1000-2000ml 0.9% Saline or Ringers Reassess 1000-2000ml 0.9% Saline or Ringers Reassess Consider blood Consider surgery Aim for systolic BP90 + HR 200-300 ml/hr 97 PTCPTC Chest InjuriesChest Injuries Pulmonary ContusionPulmonary Contusion Potentially life threatening Occurs with blunt and penetrating trauma Suspect if rib fractures Onset often slow and progressive over 24 hours 98 PTCPTC Chest InjuriesChest Injuries Rib FracturesRib Fractures Associated with pulmonary contusion Associated with pneumothorax May result from simple trauma in the elderly Remember analgesia 99 PTCPTC Chest InjuriesChest Injuries Flail ChestFlail Chest Unstable segment Paradoxical movement with ventilation May severe respiratory distress Adequate analgesia vital Give oxygen (if available) Consider intubation and IPPV 100 PTCPTC Chest InjuriesChest Injuries Myocardial ContusionMyocardial Contusion Common in blunt trauma May mimic myocardial infarction Can cause sudden death ECG monitoring (if available) 101 PTCPTC Chest InjuriesChest Injuries Other InjuriesOther Injuries Pericardial tamponade Great vessel injury Airway rupture Oesophageal trauma Diaphragmatic injury 102 PTCPTC ? ? Chest InjuriesChest Injuries 103 PTCPTC Chest InjuriesChest Injuries Summary Management is ABC Recognise life threatening problems in primary survey Surgical intervention rarely needed 104 PTCPTC Abdominal TraumaAbdominal Trauma Objectives Recognise common life threatening abdominal injuries Understand principles of management of abdominal injuries 105 PTCPTC Abdominal TraumaAbdominal Trauma Initial AssessmentInitial Assessment Airway Breathing Circulation 106 PTCPTC Abdominal TraumaAbdominal Trauma Common site of injury Assessment can be difficult Site of “hidden haemorrhage” Continual reassessment important Early surgical consultation if possible 107 PTCPTC Abdominal TraumaAbdominal Trauma Mechanism of injuryMechanism of injury Penetrating (gunshot, stabbing) -Entry/exit wounds may not be obvious -Surgical opinion / laparotomy Non-penetrating -Good history important -Compression, crush, seat belt, acceleration, deceleration 108 PTCPTC Abdominal TraumaAbdominal Trauma Site of injurySite of injury Liver Spleen GIT Pancreas Kidney and urinary tract 109 PTCPTC Abdominal TraumaAbdominal Trauma RememberRemember Intra-peritoneal cavity extends up to 4th intercostal space in thorax 110 PTCPTC Abdominal TraumaAbdominal Trauma LookLook Lacerations Penetrating injury Distension Bruising may indicate significant injury External urethral meatus 111 PTCPTC Abdominal TraumaAbdominal Trauma FeelFeel Be gentle (especially children) Tenderness Rigidity Rectal examination (blood, tone, prostate) 112 PTCPTC Abdominal TraumaAbdominal Trauma ManagementManagement Airway Breathing Circulation IV access Fluid resuscitation ? Laparotomy 113 PTCPTC Abdominal TraumaAbdominal Trauma ManagementManagement Gastric decompression and aspiration - Especially in children - Look for blood Urinary catheterisation - After exclusion of urethral trauma 114 PTCPTC Abdominal TraumaAbdominal Trauma Laparotomy?Laparotomy? Penetrating trauma Haemodynamic instability with - obvious intra-abdominal injury - no other obvious cause Seek Early Surgical Advice 115 PTCPTC Abdominal TraumaAbdominal Trauma Pelvic InjuriesPelvic Injuries Potential for massive haemorrhage Consider urological injury Feel for tenderness, crepitus, abnormal movement, pulses X-ray essential (if available) Immobilisation will help stop bleeding 116 PTCPTC Abdominal TraumaAbdominal Trauma Special InvestigationsSpecial Investigations Diagnostic peritoneal lavage CT scan Ultrasound scan Intravenous urography Urethrography 117 PTCPTC ? ? Abdominal TraumaAbdominal Trauma 118 PTCPTC Abdominal TraumaAbdominal Trauma Summary Common site of injury Assessment can be difficult Site of “hidden haemorrhage” Continual reassessment important Early surgical consultation if possible 119 PTCPTC Head TraumaHead Trauma Objectives To understand the structured approach to the patient with head trauma To learn how to identify serious and life-threatening head injuries 120 PTCPTC Head TraumaHead Trauma 1/3-1/2 of trauma deaths Good outcomes possible without CT scans and neurosurgeons Aim to avoid secondary brain injury Hypoxia and hypotension double mortality 121 PTCPTC Head TraumaHead Trauma ApproachApproach Airway Breathing Circulation 122 PTCPTC Head TraumaHead Trauma PhysiologyPhysiology CPP = MAP - ICP CPP = cerebral perfusion pressure MAP = mean arterial pressure ICP = intracranial pressure 123 PTCPTC Cerebral Blood FlowCerebral Blood Flow Depends on:Depends on: CPP (MAP-ICP) PaCO2 PaO2 Local metabolites 124 PTCPTC Head Trauma Pathophysiology Primary Injury occurs at time of injury Secondary Injury occurs after injury may be preventable 125 PTCPTC Head Trauma Primary injury Diffuse axonal injury -Acceleration -deceleration Cerebral contusion Penetrating injury 126 PTCPTC Head Trauma Secondary injury Hypoxia Hypoperfusion ( ICP, MAP) Hypoglycaemia Hyperthermia (fever) Seizures 127 PTCPTC Head Trauma Head Trauma Initial assessmentInitial assessment Airway (+ C-spine) Breathing Circulation Disability (AVPU, pupils) Exposure 128 PTCPTC Head TraumaHead Trauma ExaminationExamination Glasgow Coma Score Pupils Corneal reflex Eye position Fundi 129 PTCPTC Head TraumaHead Trauma ExaminationExamination Tympanic membrane Scalp and skull Respiratory Pattern Muscle tone Posture Tendon reflexes 130 PTCPTC Head Trauma Head Trauma Glasgow Coma Score (GCS)Glasgow Coma Score (GCS) Grades severity of head injury Score out of 15 Subject to inter-observer variation Trend of GCS over time very useful Also important to describe responses 131 PTCPTC Head Trauma Head Trauma GCS Eye openingGCS Eye opening Open spontaneously4 Open to command3 Open to pain2 None1 132 PTCPTC Head Trauma Head Trauma GCS Best Verbal Response GCS Best Verbal Response Oriented5 Confused4 Inappropriate words3 Inappropriate sounds2 None1 133 PTCPTC Head TraumaHead Trauma GCS Best Motor ResponseGCS Best Motor Response Obeys command6 Localises to pain5 Withdraws to pain4 Abnormal flexion3 Extensor response2 None1 134 PTCPTC Head Trauma Head Trauma Severity of Head InjurySeverity of Head Injury SevereGCS 8 ModerateGCS 9-12 MinorGCS 13-15 135 PTCPTC Head Trauma Head Trauma Pupillary SignsPupillary Signs Size Reactivity Equality 136 PTCPTC Head Trauma Head Trauma Pupillary ResponsesPupillary Responses Signs Fixed Dilated Unresponsive Causes Severe hypoxia Hypothermia Seizures 137 PTCPTC Head Trauma Head Trauma Pupillary ResponsesPupillary Responses Signs Unilateral Dilated Unresponsive Causes Expanding lesion on same side Tentorial herniation Seizures 138 PTCPTC Head TraumaHead Trauma Acute extradural or subduralAcute extradural or subdural Potentially life-threatening Immediate recognition essential Require burr-hole decompression 139 PTCPTC Head TraumaHead Trauma Acute extraduralAcute extradural LOC lucid interval deterioration Middle meningeal artery bleed Overlying skull fracture Contralateral hemiparesis Fixed pupil on side of injury 140 PTCPTC Head TraumaHead Trauma Acute subduralAcute subdural Tearing of bridging vein between cortex and dura Underlying brain injury Usually no lucid interval Worse prognosis than extradural haematoma 141 PTCPTC Head TraumaHead Trauma Other injuriesOther injuries Base-of-skull fractures Cerebral concussion Depressed skull fracture Intracerebral haematoma Usually do not require neurosurgery 142 PTCPTC Airway Breathing (ventilation) Circulation + Avoid ICP Aim to prevent secondary injury Head TraumaHead Trauma ManagementManagement 143 PTCPTC Head TraumaHead Trauma Severe (GCS 2 seconds Tachypnoea Agitation Drowsiness Urine output 178 PTCPTC Trauma in ChildrenTrauma in Children Circulation DifferencesCirculation Differences Hypotension may be a late sign in children 179 PTCPTC Trauma in Children Trauma in Children Intraosseous AccessIntraosseous Access Relatively safe + effective Anteromedial aspect of tibia below tibial tuberosity Other long bones Avoid epiphyseal growth plate Intraosseous needle or spinal needle 180 PTCPTC Trauma in Children Trauma in Children Fluid ResuscitationFluid Resuscitation Initial bolus 20ml/kg Second bolus 20ml/kg If no response give blood Aim for urine output 1-2 ml/kg/hour in infant Warm fluids if possible 181 PTCPTC Trauma in ChildrenTrauma in Children Psychologic