创伤Advanced Trauma Life Support.ppt

1、1/00,1,Advanced Trauma Life Support Patrick Cheah, MD Li-Shin Hospital Emergency Department,1/00,2,1. Preparation 2. Triage 3. Primary Survey (ABCDEs) 4. Resuscitation 5. Adjuncts to primary survey & resuscitation 6. Secondary Survey (head to toe evaluation & history) 7. Adjuncts to secondary survey

2、 8. Continued post-resuscitation monitoring & re-evaluation 9. Definite care.,1/00,3,1. PREPARATION A Pre-hospital phase Receiving hospital is notified first. Send to the closest, appropriate facility. B In Hospital Phase Advanced planning for the trauma pt arrival. Method to summon extra medical as

3、sistance Transfer agreement with verified trauma center established. Protect from communicable disease.,1/00,4,2. TRIAGE A Multiple Casualties no of severity & pt do not exceed the ability of the facility. B Mass Casualties no & severity of pt EXCEED the capability of the facility & staff.,1/00,5,3.

4、 PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing C : Circulation -control external bleeding. D : Disability or neurological status E : Exposure (undress) & Environment (temp control),1/00,6,PRIMARY SURVEY Priorities for the care of Adult , Pediatrics & Pregnancy women are all th

5、e same. During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.,1/00,7,A. Airway Maintenance with Cervical Spine Protection. * GCS score of 8 or less require the placement of definite airway. *Protection of the spine & spinal cord is the impo

6、rtant management principle. *Neurological exam alone does not exclude a cervical spine injury. *Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or blunt injury above the clavicle.,1/00,8,B. Breathing & Ventilation * Airway p

7、atency does not assure adequate ventilation. C. Circulation with Hemorrhage Control. 1. Blood Volume & Cardiac Output a. level of consciousness. b. skin color c. Pulse. 2. Bleeding *external bleeding is identified & controlled in the primary survey. *Tourniquets should not be use.,1/00,9,D. Disabili

8、ty ( Neurological Evaluation) Simple Mnemonic to describe level of consciousness A : Alert V : Responds to Vocal stimuli P : Responds to Painful stimuli U : Unresponsive to all stimuli Not forget to use also Glascow Coma Scale.,1/00,10,E. Exposure / Environmental Control *It is the pts body temp tha

9、t is most important, not he comfort of the health care provider. *Intravenous fluid should be warm. *Warm environment (room tem) should be maintained. *early control of hemorrhage.,1/00,11,4. RESUSCITATION A. Airway *definite airway if there is any doubt about the pts ability to maintain airway inte

10、grity. B. Breathing /Ventilation/Oxygenation *every injured pt should received supplement oxygen C. Circulation *control bleeding by direct pressure or operative intervention * minimum of two large caliber IV should be established *pregnancy test for all female of child bearing age. * Lactated Ringe

11、r is preferred & better if warm.,1/00,12,5. ADJUNCT TO PRIMARY SURVEY & RESUSCITATION A. Electro-cardiographic Monitoring B. Urinary & Gastric Catheter 1. Urinary catheter. Urethral injury should be suspected if *Blood at the penile meatus *Perineal ecchymosis *Blood in the scrotum *High riding or n

12、onpalpable prostate *Pelvic fracture,1/00,13,C. Monitoring 1. Ventilatory rate & ABG 2. Pulse oximetry does not measure ventilation or partial O2 pressure 3. Blood pressure poor measure of actual tissue perfusion. D. X-Ray & Diagnostic Studies C-spine, CXR, Pelvic film Essential x-ray should not be

13、avoid in pregnant pt. * Consider the need for patient transfer.,1/00,14,6 SECONDARY SURVEY Does not begin until the primary survey (ABCDEs) is completed, resuscitative effort are well established & the pt is demonstrating normalization of vital sign. * Head to Toe evaluation & reassessment of all vi

14、tal signs. * A complete neurological exam is performed including a GCS score. * Special procedure is order.,1/00,15,History A : Allergies. M: Medication currently used. P : Past illness/ Pregnancy. L : Last Meal E: Events/Environment related to the injury. *blunt trauma/penetrating trauma/injuries d

15、ue to cold & burn/hazardous environment?,1/00,16,PHYSICAL EXAMINATION 1. Head Visual acuity Pupillary size Hemorrhage of conjunctiva and fundi Penetrating injury Contact lenses(remove before edema occurs) Dislocation of lens Ocular movement,1/00,17,2. Maxillofacial Injury no NG tube, definite airway

16、? 3. Cervical Spine & Neck *Pt with maxillofacial or head trauma should be presumed to have and unstable cervical spine. 4. Chest *elderly pt are not tolerant of even relatively minor chest injury. *Children often sustain significant injury to the intrathoracic structure without evidence of thoracic

17、 skeletal trauma.,1/00,18,5. Abdomen *excessive manipulation of the pelvic should be avoided. 6. Perineum/rectum/vagina 7. Musculoskeletal 8. Neurologic * Protection of spinal cord is required at all times until a spine injury excluded, especially when the pt is transfer.,1/00,19,7. ADJUNCT TO THE S

18、ECONDARY SURVEY include additional x-ray and all other special procedure. 8. RE-EVALUATION Adult urine output 0.5ml/kg/hr Pediatric urine output 1mg/kg/hr *Pain relief - IM should be avoid. 9. DEFINITE CARE,1/00,20,Indication For Definite Airway * Unconscious * Severe maxillo-facial fracture * Risk

19、for aspiration : Bleeding/ vomiting * Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor * Apnea : Neuromuscular paralysis/unconscious * Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis * Severe closed head injury need for hyperventilation,1/00,21,Normal Blo

20、od Amount: Normal adult blood volume : 7% of body weight Normal blood volume for child : 8-9% of body weight Hemorrhage Classification : Class I Hemorrhage : up to 15% loss Class II Hemorrhage : 15-30% loss Class III Hemorrhage : 30-40% loss Class IV Hemorrhage : 40% loss,1/00,22,3 for 1 Rule a roug

21、h guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial & intracellular space,1/00,23,Initial Fluid Therapy Lactated Ringer is preferred * For adult 1-

22、2 liters bolus * For child 20ml/kg bolus,1/00,24,Intraosseous Puncture/Infusion Children less than 6 y/o for IV access is impossible due to circulatory collapse or for whom percutaneous peripheral venous cannulation had failed on two attempt.,1/00,25,Head Injury Classification: Mild : GCS 14-15 Mode

23、rate : GCS 9-13 Severe : GCS 3-8 Coma = GCS score of 8 or less,1/00,26,Diagnostic Peritoneal Lavage Indication A. Change in sensorium-Head injury/alcohol/drug. B.Change in sensation-Spinal cord injury. C.Injury to adjacent structure-lower ribs/pelvic/lumbar spine. D.Equivocal physical examination. E

24、.Prolong loss of contact with patient anticipated. * Positive Test: 100,000 RBC/mm3, 500 WBC/mm3 or Gram Stain with bacteria,1/00,27,Determining the level of quadriplegia a. Raise elbow to level of shoulder - Deltoid C5 b. Flexes the forearm - Biceps C6 c. Extend the forearm - Triceps C7 d. Flexes w

25、rist & finger - C8 e. Spread finger - T1,1/00,28,Determine the level of paraplegia a. Flexes the hip - Iliopsoas L2 b. Extend knee - Quadriceps L3 c. Dorsiflexes ankle - Tibialis anterior L4 d. Plantar flexes ankle - Gastrocnemius S1,1/00,29,Thoracic Trauma 8 lethal Injury 1. Simple pneumothorax 2. Hemothorax 3. Pulmonary contusion 4. Tracheo-bronchial tree injury 5. Blunt cardiac injury 6. Traumatic aortic disruption 7. Traumatic diaphragmatic injury 8. Mediastinal traversing wounds.,1/00,30,Fluid Therapy in