《处理原则》PPT课件.ppt

1,Blunt Thoracic Injury,Chao-Wen Chen Attending Surgeon Trauma Service, KMUH,2004-July,Trauma Conference,2,Preface,2/3 of victims of major blunt trauma suffer from thoracic injury. Thoracic injuries account for 20-25% of deaths due to trauma. Major thoracic trauma is associated with multisystem injuries in 70% of cases.,2004-July,Trauma Conference,3,Common Injuries Develop After Blunt Chest Trauma,Thoracic cage fractures Lung contusion and tears Myocardium contusion Aortic rupture,2004-July,Trauma Conference,4,Initial Survey,Assume the existence of C-spine injury ABCs Gerneral evaluation: PE, PH, ECG, or ABG Chest x-ray Administer oxygen,2004-July,Trauma Conference,5,處理原則,謹記ABC 順序與原則 初級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理： 張力性氣胸 （Tension Pneumothorax） 連枷胸 （flail chest） 開放性胸壁傷口 （open chest wound） 大量血胸 （massive hemothorax） 心包填塞 （cardiac tamponade）,2004-July,Trauma Conference,6,如何處理？,張力性氣胸 連枷胸 開放性胸壁傷口 大量血胸 心包填塞,2004-July,Trauma Conference,7,如何處理？,張力性氣胸 Needle decompression/ Chest Tube 連枷胸 Pain control/ O2 / MV 開放性胸壁傷口 Wound coverage/Chest tube 大量血胸 Chest tube / Thoracotomy 心包填塞 Pericardial window,2004-July,Trauma Conference,8,Imaging Survey,Chest x-ray : serve as a screening rather than a definite test repeat radiography should be ordered if suspicious Computed tomography : highly sensitive in detecting injuries and superior to routine chest x-ray recommended in patients with multiple trauma and suspected chest trauma Angiogram : for suspicious great vessel injuries Chest ultrasound : detect hemothorax, FAST,2004-July,Trauma Conference,9,處理原則,二級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理： 主動脈破裂（contained aorta rupture） 氣管或支氣管破裂（rupture of tracheobronchial tree） 食道破裂（perforation of esophagus） 橫膈破裂（rupture of diaphragm） 心肌挫傷（myocardial contusion） 肺部挫傷（pulmonary contusion）,2004-July,Trauma Conference,10,Contained aortic tear,2004-July,Trauma Conference,11,Pneumothorax,2004-July,Trauma Conference,12,Hemothorax,2004-July,Trauma Conference,13,Troublesome Injuries,Sternal fracture More serious injuries may accompany If suspected, a lateral CXR may be diagnostic Operative reduction is usually unnecessary Hospitalization is not mandatory if the ECG is normal and the patients vital sign is stable,2004-July,Trauma Conference,14,Troublesome Injuries,Flail chest Fracture of 2 or more consecutive ribs in at least 2 places each About 30-40% of patients need mechanical ventilation ARDS is increased 20-30% in the presence of flail chest,2004-July,Trauma Conference,15,Troublesome Injuries,Flail chest Close monitoring of respiratory performance Adequate analgesic therapy Provide oxygen therapy and ventilatory support Aggressive pulmonary toilet,2004-July,Trauma Conference,16,Troublesome Injuries,Lung contusion CxR finding may range from minimal interstitial infiltrate to extensive lobar consolidation Chest CT is accurate diagnostic tool but not always mandatory Tx : same as flail chest, but pay attention to avoid overhydration; use of steroid and prophylactic antibiotic are still controversial,2004-July,Trauma Conference,17,Pulmonary contusion,2004-July,Trauma Conference,18,Troublesome Injuries,Blunt Cardiac Trauma - spectrum Asymptomatic myocardiac contusion Symptomatic myocardiac contusion Free wall or septal wall rupture Valvular tears Coronary artery thrombosis,2004-July,Trauma Conference,19,Troublesome Injuries,Blunt Cardiac Trauma risk factors Chest impact 15 mph Marked precordial tenderness, ecchymosis or contusion PH of cardiac disease Fractured sternum Thoracic spine or ribs fractures Hemodynamic instability, or multiple injuries Age 50,2004-July,Trauma Conference,20,Troublesome Injuries,Blunt Cardiac Trauma - assessment Most are asymptomatic; severe cases die before arrival Common manifestation : arrhythmia, hemo-dynamic instability Evaluation : CxR, ECG, cardiac enzymes, echo-cardigram, MUGA,2004-July,Trauma Conference,21,Troublesome Injuries,Blunt cardiac trauma - management Most cases do not require Tx; Symptomatic arrhythmia (2-5%) antiarrthythmics Abnormal ECG and cardiac enzymes almost return to normal within one week. Patients with abnormal cardiac echo finding or MUGA keep hospitalization till a repeat test show acceptable finding Cardiac rupture prompt surgical repair,2004-July,Trauma Conference,22,Troublesome Injuries,Blunt cardiac trauma - Guideline (USC+LAC) Obtain admission ECG and CPK-MB/TnT in patient with suspect BCI Repeat ECG 8-12 hours after admission For unexplained hemodynamic instability, abnormal ECG, and abnormal cardiac enzyme levels perform cardiac echogram If no suspect symptomatolgy, lab tests or ECG finding discharge after 12 hours,2004-July,Trauma Conference,23,胸部鈍傷處理流程,PE Survey,2004-July,Trauma Conference,24,X-ray,2004-July,Trauma Conference,25,胸部鈍傷病患住院照護準則,Admission Order Day 1 Consider ICU admission for elderly patients, or if other complicating factors exist. NPO Chest tube to suction, follow chest tube output Follow-up CXR Analgesia ( oral epidural PCA) Pulmonary toilet OOB to chair,2004-July,Trauma Conference,26,胸部鈍傷病患住院照護準則,Day 2 Advance diet Chest tube to suction, follow chest tube output Morning CXR Analgesia ( oral epidural PCA) Pulmonary toilet OOB to chair,2004-July,Trauma Conference,27,胸部鈍傷病患住院照護準則,Day 3 if no air leak, chest tube to water seal, otherwise to suction. follow output Morning CXR Analgesia ( oral epidural PCA) Pulmonary toilet Ambulate tid once chest tube is off suction,2004-July,Trauma Conference,28,胸部鈍傷病患住院照護準則,Day 4 Check CXR after 6-8 hours on water seal, if lung expanded and output150ml remove chest t