创伤Advanced Trauma Life Support.ppt

Advanced Trauma Life SupportPatrick Cheah,MDLi-Shin Hospital Emergency Department 1/0011.Preparation2.Triage3.Primary Survey(ABCDEs)4.Resuscitation 5.Adjuncts to primary survey&resuscitation6.Secondary Survey(head to toe evaluation&history)7.Adjuncts to secondary survey8.Continued post-resuscitation monitoring&re-evaluation9.Definite care.1/0021.PREPARATIONA 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 assistance Transfer agreement with verified trauma center established.Protect from communicable disease.1/0032.TRIAGEA A Multiple CasualtiesMultiple 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.1/0043.PRIMARY SURVEYA:A:Airway with cervical spine protect.B:B:BreathingC:C:Circulation-control external bleeding.D:D:Disability or neurological statusE:E:Exposure(undress)&E Environment (temp control)1/005PRIMARY SURVEYPriorities for the care of Adult,Pediatrics&Pregnancy women are all the same.During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.1/006A.Airway Maintenance with Cervical Spine A.Airway Maintenance with Cervical Spine Protection.Protection.*GCS score of 8 or less require the placement of definite airway.*Protection of the spine&spinal cord is the important 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.1/007B.Breathing&VentilationB.Breathing&Ventilation*Airway patency does not assure adequate ventilation.C.Circulation with Hemorrhage Control.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.1/008D.Disability(Neurological Evaluation)D.Disability(Neurological Evaluation)Simple Mnemonic to describe level of consciousnessA:AlertV:Responds to Vocal stimuliP:Responds to Painful stimuliU:Unresponsive to all stimuliNot forget to use also Glascow Coma Scale.1/009 E.Exposure/Environmental ControlE.Exposure/Environmental Control*It is the pts body temp that 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.1/00104.RESUSCITATIONA.Airway*definite airway if there is any doubt about the pts ability to maintain airway integrity.B.Breathing/Ventilation/Oxygenation*every injured pt should received supplement oxygenC.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 Ringer is preferred&better if warm.1/0011 5.5.ADJUNCT TO PRIMARY SURVEY&ADJUNCT TO PRIMARY SURVEY&RESUSCITATION 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 nonpalpable prostate *Pelvic fracture 1/0012 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 avoid in pregnant pt.*Consider the need for patient transfer.1/00136 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 vital signs.*A complete neurological exam is performed including a GCS score.*Special procedure is order.1/0014History 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 due to cold&burn/hazardous environment?1/0015PHYSICAL EXAMINATION1.Head Visual acuity Pupillary size Hemorrhage of conjunctiva and fundi Penetrating injury Contact lenses(remove before edema occurs)Dislocation of lens Ocular movement1/00162.Maxillofacial Injury no NG tube,definite airway?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 skeletal trauma.1/00175.Abdomen *excessive manipulation of the pelvic should be avoided.6.Perineum/rectum/vagina7.Musculoskeletal8.Neurologic *Protection of spinal cord is required at all times until a spine injury excluded,especially when the pt is transfer.1/00187.7.ADJUNCT TO THE SECONDARY SURVEYADJUNCT TO THE SECONDARY SURVEY include additional x-ray and all other special procedure.8.8.RE-EVALUATIONRE-EVALUATION Adult urine output 0.5ml/kg/hr Pediatric urine output 1mg/kg/hr *Pain relief-IM should be avoid.9.DEFINITE CARE9.DEFINITE CARE 1/0019Indication For Definite Airway*Unconscious*Severe maxillo-facial fracture*Risk 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 hyperventilation1/0020Normal Blood Amount:Normal adult blood volume:7%of body weightNormal blood volume for child:8-9%of body weightHemorrhage Classification:Class I Hemorrhage:up to 15%lossClass II Hemorrhage:15-30%lossClass III Hemorrhage:30-40%lossClass IV Hemorrhage:40%loss1/00213 for 1 Rulea rough 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 space1/0022Initial Fluid TherapyLactated Ringer is preferredLactated Ringer is preferred *For adult 1-2 liters bolus *For child 20ml/kg bolus1/0023Intraosseous Puncture/InfusionChildren 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.1/0024Head Injury Classification:Mild :GCS 14-15 Moderate:GCS 9-13 Severe :GCS 3-8 Coma =GCS score of 8 or less1/0025Diagnostic Peritoneal Lavage IndicationA.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.Prolong loss of contact with patient anticipated.*Positive Test:100,000 RBC/mm3,500 WBC/mm3 or Gram Stain with bacteria1/0026Determining the level of quadriplegiaa.Raise elbow to level of shoulder-Deltoid C5b.Flexes the forearm-Biceps C6c.Extend the forearm-Triceps C7d.Flexes wrist&finger-C8e.Spread finger-T11/0027Determine the level of paraplegiaa.Flexes the hip-Iliopsoas L2b.Extend knee-Quadriceps L3c.Dorsiflexes ankle-Tibialis anterior L4d.Plantar flexes ankle-Gastrocnemius S11/0028Thoracic Trauma8 lethal Injury1.Simple pneumothorax2.Hemothorax3.Pulmonary contusion4.Tracheo-bronchial tree injury5.Blunt cardiac injury6.Traumatic aortic disruption7.Traumatic diaphragmatic injury8.Mediastinal traversing wounds.1/0029Fluid Therapy in 2nd or 3rd Degree BurnTotal amount of first 24 hours:4 ml of Ringer lactate x BW(kg)x BSA*give 1/2 in first 8 hrs*1/2 in remaining 16 hrs 1/0030Referral to Burn Center*2nd or 3rd degree burn 10%BSA,pt under 10 or over 50y/o*2nd or 3rd degree burn 20%BSA in other age group*2nd or 3rd degree burn of face/eye/ear/hands/feet/genitalia/perineum or major joints*3rd degree burn 5%in any age group*Significant electrical/lightning injury*Significant chemical burn*Inhalation injury1/0031Color Codes Triage Tag RED:Most critical injury YELLOW:Less critical injured GREEN:No life or limb threatened injury BLACK:Death or obviously fatal injury1/0032Priorities with multiple injuries1.Thoracic trauma or tamponade2.Abdominal hemorrhage3.Pelvic Hemorrhage4.Extremity Hemorrhage5.Intra-cranial Injury6.Acute Spinal Cord Injury1/0033