hvorfor og hvordan · occurrence of errors by phase of trauma management (gruen et al. ann surg...
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Traumemodtagelse
Hvorfor og hvordan
Carsten Fladmose MadsenTraumesektorenOrtopædkirurgisk afdelingOdense Universitetshospital September 2013
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• Hvad er traumemodtagelse?
– Traumeteam
– Traumemanual
– Traumeteam-aktivering
Traumemodtagelse
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præhospitalt forløb
transport
modtagelse
transport internt
undersøgelsebilleddiagnostik
akut behandlingoperation
interventionsradiologi
observation/behandlingintensiv afdeling
sengeafdeling
udskrivelse
rehabilitering
ambulant forløb
- kun en del af et samlet traumesystem
Traumemodtagelse
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Traumemodtagelse
Fundament
• Fagligt– ABC; ATLS
• Organisatorisk– makro: region, hospital
– mikro: traumestuen, teamet» samarbejde
» kommunikation
» ledelse
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O2 og cirkulation
• Unacceptable delay before treatment
• Most initial care by junior doctors
Brit.Med.J. 1992;305:737-40
undgåelige dødsfald
Traumemodtagelse
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The golden hour
Traumemodtagelse
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Det er vanskeligt at håndtere en tilskadekommen patient!
Traumemodtagelse
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Det er vanskeligt at håndtere en tilskadekommen patient!
patienterne er ikke ens
• forskellige personer
– alder
– køn (herunder graviditet)
– komorbiditet (herunder fedme)
– medicinforbrug
Traumemodtagelse
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Det er vanskeligt at håndtere en tilskadekommen patient!
patienterne er ikke ens
• forskellige traumemekanismer
– skarp, ofte lokaliseret til kun én region
– stump, ofte lokaliseret til flere regioner
– hypotermi/drukning
– forurening (kemisk, biologisk, nuklear)
– m. fl.
Traumemodtagelse
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Det er vanskeligt at håndtere en tilskadekommen patient!
patienterne er ikke ens
• forskellige læsioner
– brækket ben
– leverkontusion
– rygfraktur
– osv. osv.
Traumemodtagelse
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Det er vanskeligt at håndtere en tilskadekommen patient!
prioriteringen
• hvad skal man behandle først
• hvad ser - diagnosticerer - man først
• undersøgelse / behandling - rækkefølge
Traumemodtagelse
symptombehandling før undersøgelse
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Det er vanskeligt at håndtere en tilskadekommen patient!
altid tilstede
• tidspres
• dynamik
Traumemodtagelse
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Det er vanskeligt at håndtere en tilskadekommen patient!
erfaring og rutine
• relativt få konfrontationer for hver enkelt
Traumemodtagelse
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Det er vanskeligt at håndtere en tilskadekommen patient!
U-ha…- det er noget værre noget
• U-vished
• U-overskuelighed
• U-forudsigelighed
• U-sikkerhed
• U-beslutsomhed
• U-klarhed
Traumemodtagelse
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• Fejl i traumesystemer
– Fejl* i 2,5 % af døde ved traumemodtagelser(Gruen et al. Ann Surg 2006;244:371–380)
– Fejl* i 9,9 % af døde ved traumemodtagelser(Ivatury et al. J Trauma. 2008;64:265–272)
*): fejl målt ved ”maximal impact” = død.
En endnu større del udgør non-maximal impact
Traumemodtagelse
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Major Patterns of Errors Contributing to Trauma Mortality(Gruen et al. Ann Surg 2006;244: 371–380)
Hemorrhage control• Delayed control of intrathoracic/abdominal/pelvic hemorrhage• Failure to rewarm and/or correct coagulopathy
Airway management• Unsuccessful intubation and delayed surgical airway• Failure to secure or protect airway
Management of unstable patients• Unduly long initial operative procedure in unstable patient• Inappropriate interhospital transfer of unstable patient• Unstable patient sent to CT scanner
Missed or delayed diagnoses• Intracranial hemorrhage• Intraabdominal injury• Pericardial tamponade
Traumemodtagelse
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Occurrence of Errors by Phase of Trauma Management(Gruen et al. Ann Surg 2006;244: 371–380)
• 34% of errors occurred in the ED (20% during initial assessment and resuscitation, 14% during the secondary survey and initial diagnostictests)
• 8% during stabilization and interhospital transport
• 11% during initial interventions (surgery and/or angiography)
• 37% during the intensive care unit stay
• 9% during the general or rehabilitation ward
Traumemodtagelse
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• Dårlige traumemodtagelser
– Manglende eller uklart lederskab
Traumemodtagelse
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Hvordan optimeres den tidlige indsats?
• kendt viden
• kendte (simple) håndgreb
• struktureret og ensartet tilgang
• lederskab
• træning
• evaluering
Traumemodtagelse
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Håndtering af traumepatienten
• forud-fastlagte retningslinier for modtagelsen
• forud-fastlagte opgaver for personalet
• behandle alle ens i den primære fase
Traumemodtagelse
Traumemanual
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Håndtering af traumepatienten
• primær gennemgang
• primær behandling af manifeste eller potentielt livstruende tilstande
• vekslen mellem gennemgang og behandling
• sekundær gennemgang
• plan for videre undersøgelse/behandling
Traumemodtagelse
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Traumepatienten
• Den ”klassiske opfattelse”
– Seneste 20 – 30 år (siden midt-firserne)
– ”Definition”
– Hvem er / hvor er traumepatienten?
• Triage
• En anden (nyere) opfattelse?
– Højst små justeringer
• Triage
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Traumepatienten
• Triagekriterierne
– Mekanisme
• tiltagende mindre betydning
– Anatomi
– Fysiologi
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Traumemekanisme - højenergi
• stor energi (herunder acceleration eller deceleration) påvirker kroppen
• indikatorer for stor energi er (bl. a.) stor masse
eller stor hastighed
Traumepatienten
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Traumemekanisme - højenergi- eksempler
− person i samme (eller modkørende) bil er dræbt
− person fastklemt
− bil er svært deformeret
− person kastet ud af bil
− bil er kastet rundt
− fodgænger er kastet gennem luften
− fodgænger er påkørt med mere end 30 km/t
− person er faldet mere end 5 meter
Traumepatienten
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Anatomisk lokalisation
• store luftveje – hals, thorax
• respiratorisk væv – thorax
• store blodkar – hals, thorax, abdomen, lyske, axil
• mange blodkar – bækken, skalp, ansigt
• centralnervesystem – kranie, nakke
gælder synlig skade
- eksempler
Traumepatienten
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Fysiologisk status
• påvirket luftvej?
• påvirket oxygenering?
• påvirket cirkulation?
• påvirket centralnervesystem?
Traumepatienten
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Fysiologisk status - tegn på dårlig patient
• dyspnø
• fugtig hud
• cyanose
• bleg
• bevidstløs
Traumepatienten
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Fysiologisk status - tegn på dårlig patient
• respirationsfrekvens < 10 eller > 30
• hjertefrekvens < 50 eller > 120
Normal fysiologi ?
Traumepatienten
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Prætraumatisk status
• komorbiditet - medicinforbrug
• alder
børn
unge atlet-typer
ældre
• graviditet
• overvægtSkærpet opmærksomhed!
Traumepatienten
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Traumepatienten
• Diagnostisere– Alt / mest muligt som patienten fejler
»Undgå undertriage
• Udelukke– Det ”vigtige”, det ”farlige”
»Undgå undertriage
– Det som patienten alligevel ikke fejler
»Undgå overtriage
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Traumepatienten
• Redskaber
– Klinisk undersøgelse (se-føl-lyt)
• Dårlig
• Ufarlig
• Kræver få ressourcer (og dog: rutine og erfaring er en ressource!)
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Traumepatienten
• Redskaber
– Paraklinisk undersøgelse
• Invassiv
– God eller ikke-god
– Komplikationer/bivirkninger
– Ressourcekrævende
• Non-invassiv
– God eller ikke-god
– Komplikationer/bivirkninger
– Ressourcekrævende
Man skal ikke være tilbageholdende og
defensiv, men man skal tænke sig (godt) om!
Røntgenundersøgelse er en strålebelastning!
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BilleddiagnostikRtg. thorax
UL abdomen
Rtg. bækken
Rtg. / CT columna cervicalis
CT cerebrum
CT thorax-abdomen
Angiografi (CT-angio)
Knogle rtg. / CT / CT-scout
Traumepatienten
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TraumeteamTraumeteam
Ortopædkirurg
Anæstesiolog
Anæstesisygeplejerske x 2
Skadestuesygeplejerske x 2
Radiolog
Radiograf
Bioanalytiker
Sekretær
Serviceassistent
Abdominalkirurg
Neurokirurg
Plastikkirurg
Thoraxkirurg
Urolog
Kæbekirurg
Gynækolog
PædiaterBestemt af lokale forhold.
– teamleder?
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Patientens ankomst
Tilstand (ABC)?
Vitalparametre?
Skal der handles straks?
Dokumentér fra begyndelsen!
- så handl!
TraumeteamTraumeteam
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•ambulance-behandler•præhospital-læge•helikopter-læge•læge fra overflyttende sygehus•(pårørende/vidner)
The MIST handoverMechanism of injuryInjuries observed (erkendt eller mistænkt)Vital SignsTherapy instituted (og effekt heraf)
traume-team
Overlevering af patient
TraumeteamTraumeteam
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Primær og sekundær gennemgang
TraumeteamTraumeteam
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Primær gennemgang
ABCDE
TraumeteamTraumeteam
Sikre en luftvej.
Sikre en ventilation.
Sikre en cirkulation.
Vurdere dysfungerendenervesystem.
”Afdække” patienten i erkendelse af det miljøpatienten kom fra og under hensyntagen til det miljøpatienten nu er i.
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Sekundær gennemgang
TraumeteamTraumeteam
Systematisk
– anamnese
– undersøgelse
– observation
Sekundær billeddiagnostik
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Afslutning
TraumeteamTraumeteam
Plan for videre undersøgelse og behandling.
Aflevering af patienten.