创伤与战伤 中山大学 外科学ppt课件

1、Trauma & Weapon InjuryQing-Tang Zhu, M.D., Ph.D.Department of Microsurgery & Orthopedic TraumaThe First Affiliated HospitalSun Yat-Sen University Aims of this lecture Know the physiological responses of our bodies following trauma Know the features of different types of trauma Learn how to c

2、are an acutely injured patient based on the priority Know some general knowledge about weapon injuryOutline Part I: Basic scientific knowledge about trauma Pathophysiology of trauma Wound healing Part II: Trauma Epidemiology & injury prevention Classification & triage Initial assessment &

3、; care Part III: Weapon Injury Blast injury Nuclear weapon injury Chemical weapon injury Combined injuryPart I: Basic scientific knowledge about trauma Pathophysiology of trauma Immune response to trauma Changes in organ function following trauma Wound healingImmune Response to TraumaDynamic stages

4、in the immune response to traumaChanges in organ function Cardiovascular system Blood loss, hypovolemia, shock, hear failure Lung Hypercapnia Hypoxia Adult Respiratory Distress Syndrome (ARDS) Acute Lung Injury (ALI) Kidney Hypovolemia, renal hypoperfusion, Toxin-mediated (radiocontrast, antimicrobi

5、als) renal parenchymal injury Rhabdomyolysis Liver Gastrointestinal tract: bleeding BrainWound Healingi in nf fl la am mm ma at to or ry y p ph ha as se ep pr ro ol li if fe er ra at ti io on n p ph ha as se er re em mo ol ld di in ng g p ph ha as se ep ph ha as se es s o of f h he ea al li in ng gA

6、: inflammatory phase B. proliferation phaseC. Remodeling phasePrimary healingSecondary healingPart II: Trauma Epidemiology & injury prevention Classification & trauma triage Initial assessment and care of the injured patient Prehospital phase In-hospital phaseThe Facts about Trauma Leading c

7、ause of death Over all ages: Rank 4 Aged 1 to 44: Rank 1 Aged 1-34: more than to all other causes of death combined Nonfatal Injuries (USA, 2019) 8% of all hospital discharges 37% of all emergency department visits The highest rate of injury In developing areas/countries Rapid economic change and ur

8、banization Road traffic incidence caused Global: 1.18 million deaths; 30 million injuries USA: 45,000 deaths; 357,000 hospitalization China: 120,000 deaths; 550,000 injuresLifetime Cost of Injury$406 Billion (USA, 2000)Is Trauma Preventable? Trauma Occurs randomly, unpredictably? Does not occur by a

9、ccident! Primary prevention Prevent the occurrence of the trauma itself Secondary prevention Limit energy transfer to the individual Minimize the severity of trauma Tertiary prevention Institute optimal care for the injured patient Improve outcome following traumaPart II: Trauma Epidemiology & i

10、njury prevention Classification & trauma triage Initial assessment and care of the injured patient Prehospital phase In-hospital phaseClassification Base on the integrity of skin Closed injury Open injury Base on the injury site Base on the mechanism of injury (MOI) Base on the severity Related

11、to the features, treatment options, and prognosis of traumaClosed InjuryOpen InjuryClassification based on the injury siteHeadFaceNeckChestAbdomen& pelvisSpineUpper limbExternal structure (Skin)Lower limbMultiple injuriesClassification based on MOI Mechanical injury Blunt injury: motor vehicle a

12、ccident (MVA), fall, crush Penetrating injury: stab, impale, firearm Blast injury Temperature-associated injury Burns, cold injury Firearm-associated injury Special injury Chemical, biological, radiation injury Combined injuryClassification based on the severityDisaster Triage Parameters Ability to

13、ambulate Respiratory function Systemic perfusion Level of consciousness Green Walking wounded Red: immediate transport RR30 RR2 RR30,CR2, unconscious Yellow: delayed transport Black: unsalvageable Simple Triage And Rapid Transport (START)Part II: Trauma Epidemiology & injury prevention Classific

14、ation & trauma triage Initial assessment and care of the injured patient Prehospital phase In-hospital phaseAlgorithm for prehospital careTrauma-related incidentScene assessmentPrimary survey (ABCDE), treat as neededLife-threatening or multisystem injuriesYesManage injuries as appropriateNoSecon

15、dary survey, AMPLE historySpinal immobilization as indicatedInitiate transportReevaluate primary surveySecondary survey if appropriateReevaluate primary surveyEn route interventions and continued assessment Initiate rapid transport (closest appropriate facility) Scene Assessment Safety Dangerous env

16、ironments Standard precautions Blood and body fluid may contain pathogens Situation Number of patients and their ages Need for additional assistances Kinematics - MOI MVA Falls Occupational/recreational injury Penetrating injuryInitial Assessment Primary survey Airway Breathing Circulation Disabilit

17、y (neurologic evaluation) Expose/environment control Secondary surveyImmediate Measures at the Scene(Basic Life Support, BLS) Basic airway management Supplemental oxygen Rescue breathing Cardiopulmonary resuscitation (CPR) Control of external hemorrhage Fluid therapy Spinal immobilization C-collar L

18、ong backboard Golden Principles of Prehospital Trauma Care Ensure the safety of the prehospital care providers and the patientAssess the scene situation to determine the need for additional resourcesRecognize the kinematics that produced the injuriesUse the primary survey approach to identify life-t

19、hreatening conditionsProvide appropriate airway management while maintaining cervical spine stabilizationSupport ventilation and deliver oxygen to maintain an SpO2 95%Control any significant external hemorrhageProvide basic shock therapy, including restoring and maintaining normal body temperature a

20、nd appropriately splinting musculoskeletal injuriesGolden Principles of Prehospital Trauma Care Consider the use of the pneumatic antishock garment for patients with decompensated shock (SBP 90 mm Hg).Maintain manual spine stabilization until the patient is immobilized on a long backboardFor critica

21、lly injured trauma patients, initiate transport to the closest appropriate facility within 10 min of arrival on sceneInitiate warmed, intravenous fluid replacement en route to the receiving facilityAscertain the patients medical history and perform a secondary survey when life-threatening conditions

22、 have been satisfactorily managed or have been rule outAbove all, do no further harmPart II: Trauma Epidemiology & injury prevention Classification & trauma triage Initial assessment and care of the injured patient Prehospital phase In-hospital phaseIn-hospital Phase Primary survey Resuscita

23、tion Secondary survey Monitoring and investigation Definitive carePrimary Survey Airway maintenance with cervical spine protection Breathing and ventilation Circulation with hemorrhage control Disability, neurologic status Expose/environment control completely undress prevent hypothermiaPrimary surv

24、ey and resuscitation are all taking place simultaneouslyPrimary Survey- Airway Inspection Foreign body Facial, mandibular, tracheal/laryngeal Fx Asking a simple question normal voice Signs of possible airway compromise weak voice breathlessness, noisy breathing, labor breathing hoarseness absent res

25、ponse agitation combativeness cyanosisPrimary Survey- Airway Common causes of airway obstruction Tongue Edematous soft tissues Blood Foreign bodies Teeth VomitusPrimary Survey- Breathing & Ventilation Expose the neck & chest Physical examination Inspection: chest wall injury, respiratory mov

26、ement Palpation: chest wall, tracheal deviation, crepitus Percussion: air (heperresonance) or blood (dullness) in the chest Auscultation: bilateral breath sounds Pulse oximeter (SpO2) Immobilization of the head and neckPrimary Survey- Circulation Level of consciousness Skin Color: Pink VS ashen, gra

27、y and white Temperature Pulse Full, slow, regular Rapid, thready, irregular, absent Blood pressure (often misleading)Primary Survey- Circulation Hemorrhagic shock External bleeding Internal bleeding (occult blood loss) Cardiogenic shock Cardiac tamponade Cardiac contusion Air embolus Myocardial infa

28、rction Neurogenic shock Early septic shockPrimary Survey- Disability Neurologic Status Glasgow coma scale (GCS) score = E + M + V (3-15) Pupils Size Symmetry Reaction to light Frequent reevaluationEye opening (E)spontaneous 4To speech 3To pain 2None 1Best motor response (M) Obeys commands 6 Localize

29、s to stimulus 5 Withdraws to stimulus 4 Flexer posturing 3 Extensor posturing 2 None 1Verbal response (V)Oriented 5Confused conversation 4Inappropriable words 3Incomprehensiable phonation 2None 1Primary Survey-Exposure and Environmental Control Exposure Completely undress Identify all external injur

30、ies (back, perineum) Environmental control Monitor temperature (core temperature) Keep warmPrimary Survey Airway: loss of airway Breathing/ventilation Tension pneumothorax Flail chest with pulmonary contusion Open pneumothorax Massive hemothorax Circulation Massive bleeding Open wound Thorax, abdome

31、n, pelvis Cardiac tamponade Disability Intracranial massImmediately identify and treat life-threatening conditionsIn-hospital care Primary survey Resuscitation Secondary survey Monitoring and investigation Definitive careResuscitation Lifesaving measures are initiated when the problem is identified,

32、 rather than after the primary survey Reevaluate frequentlyEssential PrinciplesResuscitation-AAirway Maintenance with C-spine Protection Establish a patent airway Chin lift or jaw thrust maneuver Clear of foreign body (suctioning) Oropharyngeal/nasopharyngeal airway Definitive airway Orotracheal/nas

33、otracheal intubation Surgical cricothyroidotomy Cervical spine protection Oxygenation Tight-fitting oxygen reservior face mask Nasal catheter Nasal cannula Nonrebreather mask Ventilation Tension pneumothorax Flail chest with pulmonary contusion Open Pneumothorax Massive HemothoraxResuscitation-BResu

34、scitation-CHemorrhage Control: Direct Compression Resuscitation-C Hemorrhage control: compress the artery proximally Resuscitation-CHemorrhage Control: TourniquetResuscitation-CHemorrhage Control Pneumatic splint Pneumatic antishock garment (PASG) Surgical intervention Thoracotomy Celiotomy (laparot

35、omy) Surgical pelvic fixation Sure the scalpResuscitation-CFluid Replacement Vascular access lines Intraosseous needle insertion to the proximal tibia ( 6y) Initial fluid resuscitation Warmed balanced salt solution 1 to 2 boluses (2 L to the adult, 20 ml/kg to the child) Blood replacement Fully cros

36、smatched blood Type-specific blood Type O packed cells AutotransfusionResuscitation- D & E Disability (neurologic status) ABC: adequate perfusion and oxygen supply to the brain Spine protection Environment control: keep warm! Warm rooms Warm blankets Warm resuscitation fluids Warm inspired airIn

37、-hospital care Primary survey Resuscitation Secondary survey Monitoring and investigation Definitive careSecondary Survey Timing Primary survey is completed Resuscitation efforts are well established Patient with normal vital functions Complete history Head-to-toe evaluation Reassessment of all vita

38、l signs Complete physical examinationSecondary Survey AMPLE history Allergies Avoid allergic reactions Medications currently used Chronic conditions Physiological responses to the shock Past illness and operation/Pregnancy Last meal Potential for vomiting and aspriation Patient with diabetes Events/

39、Environment related to the injurySecondary Survey AMPLE history Blunt trauma Penetrating trauma Burns and cold Hazardous materials Chemicals Toxins Radiation Biological agentsEvents: mechanism of injury (MOI)Secondary SurveyHead-to-toe examination Head Face Neck Thorax Abdomen Perineum/Rectum/Vagina

40、 Spine & extremity Neurological assessmentIn-hospital care Primary survey Resuscitation Secondary survey Monitoring and investigation Definitive careMonitoring & Investigation Monitoring Vital signs: HR, RR, T, BP Oxygenation and ventilation Circulation Investigation X-ray: chest, pelvis, sp

41、ine, extremity CT: head, chest, abdomen, pelvis, spine Ultrasonography: abdomen, pericardial sac Lab testIn-hospital care Primary survey Resuscitation Secondary survey Monitoring and investigation Definitive careDefinitive Care Injured site management Wound irrigation and debridement Repair & re

42、construction: fracture fixation et al. Systemic management Fluid, electrolyte management and nutritional support Prophylaxis and treatment of complications, such as infection, organ disfunction (failure) RehabilitationSummary Immediate management of the injured patient Prehospital care In-hospital care Assess the patients condition rapidly and accurately Primary survey: ABCDEs Secondary survey: AMPLE history, head-to-toe exami