《儿童创伤急救》

1、International Trauma Life Supportfor Prehospital Care ProvidersSixth Edition Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEPDonna Hastings, EMT-PJohn Emory Campbell, MD, FACEPand Alabama Chapter,American College of Emergency PhysiciansCampbell, International Trauma Life Support, 6th Ed. 2008

2、Pearson Education, Inc., Upper Saddle River, NJChapter 17Trauma in ChildrenCampbell, International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJTrauma in ChildrenTrauma in Children儿童创伤儿童创伤Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education,

3、Inc., Upper Saddle River, NJ2整理课件OverviewEffective techniques to gain confidence有效增加信心的技巧有效增加信心的技巧Injuries based on mechanisms of injury受伤机理受伤机理ITLS Primary and Secondary Surveys初步及进一步检查初步及进一步检查 Consent and the need for immediate transport家长同意及需家长同意及需实时运送实时运送Pediatric equipment needs适合儿童之器材适合儿童之器材Va

4、rious methods of SMR on child儿童脊椎固定方法儿童脊椎固定方法EMS involvement in prevention programs参与预防意外计划参与预防意外计划Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ3整理课件Trauma in ChildrenDifferent from adults与成人不同与成人不同 Different patterns of injuries不同伤势模式 Diffe

5、rent 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Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, I

6、nc., Upper Saddle River, NJ4整理课件Communicating沟通沟通Family-centered care is critical.以家庭为中心以家庭为中心 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

7、 Keep caregivers in physical and verbal contact.与照顾者保持接触Demonstrate competence and compassion.Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ5整理课件Assessing Mental Status捡查精神状态捡查精神状态Consoled or distracted可按抚或转注意力可按抚或转注意力 Most sensitive indicato

8、r 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Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ整理课件Assessing Mental StatusInitial level of consciousness最初清醒程度最初清醒程度 Preschool child : sleeping vs

9、. 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6Trauma in Children -Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle Riv

10、er, NJ7整理课件CommunicatingInteraction strategies使用适龄的语言使用适龄的语言Appropriate language for developmental level合适的语言合适的语言 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

11、固定之需要 Allow caregiver to accompany child 让照顾者与伤者同行Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ8整理课件Caregiver Consent照顾者照顾者”同意同意”Critical care shouldnotbe delayed.切勿延医冶理切勿延医冶理Emergency care needed如需进行急救如需进行急救 Consent not available未能取得”同意” Tr

12、ansport 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Campbell,International Trauma Life Support, 6th

13、 Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ9整理课件Pediatric Equipment儿科器材儿科器材Length-based tape身长尺身长尺 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Photo courtesy of Kyee Han, MDCampbell,International Trauma Life Support, 6th Ed

14、. 2008 Pearson Education, Inc., Upper Saddle River, NJ10整理课件Mechanisms of Injury受伤机理受伤机理Falls高处下堕高处下堕 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-p

15、edestrian crashes路人被撞路人被撞Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ11整理课件Mechanisms of InjuryBurns烧伤烧伤Airway obstruction气道受阻气道受阻 Foreign body异物Child abuse虐待儿童虐待儿童 Suspect if history does not match injury 受伤经过与伤势不吻合 Story keeps changing经常改

16、变说法Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ12整理课件Airway in Children儿童气道儿童气道Signs of obstruction呼吸受阻征状呼吸受阻征状 Apnea无呼吸 Stridor吸气时有喘鸣声 “Gurgling” respiration有杂声的呼吸Contribute to obstruction诱因诱因 Hyperextension过度舒张 Hyperflexion过度屈曲Courtesy of

17、 Bob Page, NREMT-PCampbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ13整理课件Airway in ChildrenOpening airway张开气道张开气道 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

18、 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Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ14整理课件Breathing in Children儿童呼吸儿童呼吸Work of breathing呼吸方法呼吸方法 Retractions, flaring, grunting 肋间收缩、鼻翼扩张、咕噜声 Pe

19、rsistent grunting requires ventilatio n持续咕噜声需要施行助呼吸Respiratory rate呼吸次数呼吸次数 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轻微头部挫伤可引起严重伤势Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ15整理

20、课件20, 15, 10Ventilation Rate换气次数换气次数10 per minute for adolescent如为中童如为中童, 10次次/分钟分钟 20 per minue for 1 year如如1 year如如 1岁岁, 15次次/分钟分钟Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ16整理课件Breathing Management呼吸处理呼吸处理Effective BVM ventilation有效有效B

21、VM换气换气intubation is elective.可考虑插喉可考虑插喉Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ17整理课件Endotracheal Intubation 气管内导管气管内导管Oral endotracheal intubation从口腔插入从口腔插入 No blind nasotracheal intubation for 130 usually shock in all ages except neon

22、ates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 infantCampbell,International Trauma Li

23、fe Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ20整理课件Shock in ChildrenStrong compensatory mechanisms生理的补尝机制较强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

24、/kg Consider intraosseous infusion骨髓输液法 Frequent Ongoing Exams持续检查 Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ21整理课件Pediatric Trauma Center 儿童创伤中心儿童创伤中心Criteria条件条件 Obstructed airway气道阻塞 Need for airway intervention处理气道 Respiratory distres

25、s呼吸困难 Shock休克 Altered mental status意识紊乱 Dilated pupil曈孔扩大 Glasgow Coma Scale score 13 Pediatric Trauma Score 10 feet高处堕下 Motor-vehicle collision MVC 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 pedestri

26、an 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Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ23整理课件Pediatric Trauma CenterRecommended建议送院建议送院 Burns烧伤 Near-drowning遇溺 He

27、ad injuries with loss of consciousness 人事不醒的头部受伤Notify hospital as early as possible.尽早知会医院尽早知会医院Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ24整理课件Life-Threatening Injuries 危害生命伤势危害生命伤势Head injury头部受伤头部受伤 Most common cause of death最常见死亡原因 L

28、evel 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Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ整理课件Life-Threatening Injuries High-flow oxygen高浓度氧气 Hyperventilate only with cerebral herniation syndrome 加

29、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 mmHg Be prepared to prevent aspiration 预防气道吸入异物25Trauma in Children -Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Sadd

30、le River, NJ26整理课件Life-Threatening InjuriesChest injury胸部创伤胸部创伤 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 rupt

31、ure, pericardial tamponade 肋骨折、槤架胸、主动脉撕裂、心胞膜填塞Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ27整理课件Life-Threatening InjuriesAbdominal injury腹部创创腹部创创 Liver and/or spleen rupture肝、脾撕裂 Second leading cause of traumatic death 伤第二致死伤势 Bleeding ofte

32、n 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Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., U

33、pper Saddle River, NJ28整理课件Life-Threatening InjuriesSpinal injury脊椎创伤脊椎创伤 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Campbell,International Trauma Life Support, 6th Ed. 2008 Pearson Education, Inc., Upper Saddle River, NJ整理课件Life-Threatening Injuries SMR脊椎固定脊椎固定 Pad under torsofor neutral position 于天然屈曲位下放置较垫 May have to secure without cervical collar 可不使用颈圈固定颈椎 Do