儿童创伤急救

Chapter 17Trauma in Children,Trauma in Children,Trauma in Children儿童创伤,Overview,Effective techniques to gain confidence有效增加信心的技巧Injuries based on mechanisms of injury受伤机理ITLS Primary and Secondary Surveys初步及进一步检查 Consent and the need for immediate transport家长同意及需实时运送Pediatric equipment needs适合儿童之器材Various methods of SMR on child儿童脊椎固定方法EMS involvement in prevention programs参与预防意外计划,2,Trauma in Children -,Trauma in Children,Different from adults与成人不同Different patterns of injuries不同伤势模式Different responses to those injuries不同反应Special equipment required需要特别器材 Assessment equipment and treatment equipment检查及冶疗用的器材Difficult to assess and communicate 较难评估及沟通Come with caregivers and other family members与家人或照顾者同行,3,Trauma in Children -,Communicating沟通,Family-centered care is critical.以家庭为中心Caregiver not always parent.照顾者未必是父母Involve caregivers as much as possible in care.尽量让照顾者参与Give explanations and careful instructions.必需详加解释及指示Inclusion and respect will improve stabilization.包容及尊重可稳定伤者Keep caregivers in physical and verbal contact.与照顾者保持接触Demonstrate competence and compassion.,4,Trauma in Children -,Assessing Mental Status捡查精神状态,Consoled or distracted可按抚或转注意力Most sensitive indicator of adequate perfusion 能准确反映组织灌注是否足够Caregivers best at detecting subtle changes 照顾者会较易分辩出伤者微小改变,5,Trauma in Children -,Assessing Mental Status,Initial level of consciousness最初清醒程度Preschool child : sleeping vs. unconscious 幼儿:疲倦vs人事不醒Most will not sleep through arrival of ambulance大部份沿途不会睡觉Ask caregivers to wake child着照顾者弄醒伤者Suspect hypoxia, shock, head trauma, seizure 怀疑缺氧、休克、头部受伤、癫痫,6,Trauma in Children -,Communicating,Interaction strategies使用适龄的语言Appropriate language for developmental level合适的语言Speak simply, slowly, clearly说话要慢及简溸Be gentle and firm必需肯定Avoid “no” questions避免说”不”Get a favorite belonging 利用其喜爱的玩具/随身物品Get on childs level 降下身段至与伤者视线平衡Explain SMR necessity 解释脊椎固定之需要Allow caregiver to accompany child 让照顾者与伤者同行,7,Trauma in Children -,Caregiver Consent照顾者”同意”,Critical care shouldnotbe delayed.切勿延医冶理Emergency care needed如需进行急救Consent not available未能取得”同意”Transport before permission, document why, notify medical direction记录,速送医院,通知医五Consent denied不同意Try to persuade, document actions, obtain signature 尝试说服、记录、签署Notify law enforcement and appropriate authorities 行使有关法例Report suspected abuse 如怀疑儿童受虐待,通知警方,8,Trauma in Children -,Pediatric Equipment儿科器材,Length-based tape身长尺Weight estimate大约体重Fluid and medication doses precalculated 输液及药物剂量Common equipment size estimates 常用器材尺码,9,Trauma in Children -,Photo courtesy of Kyee Han, MD,Mechanisms of Injury受伤机理,Falls高处下堕Usually land on head通常头先着地Serious head injury unusual from 27 inches严重头部受伤并不常见于身长27吋Protective gear保护装备MVCs交通意外Seat-belt syndrome安全带综合症Liver, spleen, intestines, lumbar spine 肝、脾、小肠、腰椎Auto-pedestrian crashes路人被撞,10,Trauma in Children -,Mechanisms of Injury,Burns烧伤Airway obstruction气道受阻Foreign body异物Child abuse虐待儿童Suspect if history does not match injury 受伤经过与伤势不吻合Story keeps changing经常改变说法,11,Trauma in Children -,Airway in Children儿童气道,Signs of obstruction呼吸受阻征状Apnea无呼吸Stridor吸气时有喘鸣声“Gurgling” respiration有杂声的呼吸Contribute to obstruction诱因Hyperextension过度舒张Hyperflexion过度屈曲,12,Trauma in Children -,Courtesy of Bob Page, NREMT-P,Airway in Children,Opening airway张开气道Tongue is large; tissue soft舌大,组织软Jaw-thrust下颔上提法Oropharyngeal airway口咽气道Nasopharyngeal airways鼻咽气道Too small to work predictably 因鼻孔太少未必有效Neonate obligate nose breather 新生婴儿用鼻孔呼吸Clear nose with bulb syringe用球状泵吸走分泌,13,Trauma in Children -,Breathing in Children儿童呼吸,Work of breathing呼吸方法Retractions, flaring, grunting 肋间收缩、鼻翼扩张、咕噜声 Persistent grunting requires ventilatio n持续咕噜声需要施行助呼吸Respiratory rate呼吸次数Fast, then periods of apnea or very slow 先后短暂停止或转慢Minor blunt neck trauma can be critical.轻微头部挫伤可引起严重伤势,14,Trauma in Children -,20, 15, 10,Ventilation Rate换气次数,15,Trauma in Children -,10 per minute for adolescent如为中童, 10次/分钟,20 per minue for 1 year如1 year如 1岁, 15次/分钟,Breathing Management呼吸处理,16,Effective BVM ventilation有效BVM换气intubation is elective.可考虑插喉,Trauma in Children -,Endotracheal Intubation 气管内导管,Oral endotracheal intubation从口腔插入No blind nasotracheal intubation for 130 usually shock in all ages except neonates脉搏130多为休克,新生婴儿除外Prolonged capillary refill and cool extremities微血管回流时闭迟及肢体冰冷Level of consciousness清醒程度Circulation can be poor even if child is awake 血循环衰竭的儿童仍可完全清醒Low blood pressure is sign of late shock.血压低是休克的后期征状BP 80 mmHg in child; 70 mmHg in young infant,19,Trauma in Children -,Shock in Children,Strong compensatory mechanisms生理的补尝机制较强Appear surprisingly good in early shock 早期休克可有效发挥“Crash” when deteriorate但情况会急转直下Be prepared必需有心理准备Fluid administration 20 mL/kg in each bolus输液补充每次20 mL/kgConsider intraosseous infusion骨髓输液法Frequent Ongoing Exams持续检查,20,Trauma in Children -,Pediatric Trauma Center 儿童创伤中心,Criteria条件Obstructed airway气道阻塞Need for airway intervention处理气道Respiratory distress呼吸困难Shock休克Altered mental status意识紊乱Dilated pupil曈孔扩大Glasgow Coma Scale score 13Pediatric Trauma Score 10 feet高处堕下Motor-vehicle collisionMVC with fatalities车祸中有人死亡Ejection from an automobile in a MVC 车祸中弹离车厢In MVC, significant intrusion into compartment 车祸中受困于车厢中Hit by a car as a pedestrian or bicyclist行人被撞Fractures in more than one extremity多边一条肢体骨抑Significant injury to more than one organ system多过一个器官受伤,22,Trauma in Children -,Pediatric Trauma Center,Recommended建议送院Burns烧伤Near-drowning遇溺Head injuries with loss of consciousness 人事不醒的头部受伤Notify hospital as early as possible.尽早知会医院,23,Trauma in Children -,Life-Threatening Injuries 危害生命伤势,Head injury头部受伤Most common cause of death最常见死亡原因Level of consciousness change best indicator 清醒程度之改变为最有效的征状Pupil assessment important检查瞳孔,24,Trauma in Children -,Life-Threatening Injuries,High-flow oxygen高浓度氧气Hyperventilate only with cerebral herniation syndrome 加快换气只适用于出现脑疝征状Fluid administration titrated to systolic BP 控制输液速度至可维持基本收缩压Preschool child: 80 mmHg; older child: 90 mmHg幼儿: 80 mmHg,小童: 90 mmHgBe prepared to prevent aspiration 预防气道吸入异物,25,Trauma in Children -,Life-Threatening Injuries,Chest injury胸部创伤Respiratory distress common最常见的征状为呼吸困难Pneumothorax or tension pneumothorax气胸或张力性气胸Difficult to assess较难分别Needle thoracostomy can be life-saving剌胸膜腔穿刺Pulmonary contusion胸部挫伤Rare injuries较少发生伤势Rib fractures, flail chest, aortic rupture, pericardial tamponade 肋骨折、槤架胸、主动脉撕裂、心胞膜填塞,26,Trauma in Children -,Life-Threatening Injuries,Abdominal injury腹部创创Liver and/or spleen rupture肝、脾撕裂Second leading cause of traumatic death 伤第二致死伤势Bleeding often contained within organ 出血通常局限于器官之内Difficult to diagnose难以诊断Severe injury with minimal signs 严重伤势可只有轻微征状Suspect with any abnormal abdominal assessment 若有任何异常腹部征状当作严重伤势处理Be prepared to prevent aspiration. 预防气道吸入异物,27,Trauma in Children -,Life-Threatening Injuries,Spinal injury脊椎创伤Uncommon before adolescence青少年以下较少发生9 years usually lower cervical-spine injuries头椎下受伤Higher incidence of SCIWORAspinal-cord injury without radiographic abnormality 可无X-光片异常,28,Trauma in Children -,Life-Threatening Injuries,SMR脊椎固定Pad under torsofor neutral position 于天然屈曲位下放置较垫May have to secure wi