initial management of trauma patientmed.swu.ac.th/surgery/images/sar54/atls medical student .pdf ·...
TRANSCRIPT
Initial management of
Trauma patient
นพ.ธวชชย ตลวรรธนะ ภาควชาศลยศาสตร คณะเเพทยศาสตร มศว
ADVANCED TRAUMA LIFE SUPPORT
• (ATLS)
Advanced Trauma Life support
(ATLS)
Preparation ( Prehospital and hospital care)
Triage
Primary survey (ABCDE)
Resuscitation
Adjuncts to Primary survey and Resuscitation
Consider need for transfer patient
Secondary survey ( Head to toe evaluation and patient history)
Adjuncts to Secondary
Continued postresuscitation monitoring and reevaluation
Definite care
Prehospital phase
การประเมนผปวยและใหการรกษาในเบองตน รวมถงการเคลอนยายผปวยจากทเกดเหต
Airway maintenance
Control of external bleeding and management of
shock
Immobilization
Immediate transport
Hospital phase
Airway equipment
Intravenous crystalloid solution
Monitoring : Vital sign ,EKG , O2 sat.
Laboratory and Radiology
Universal precaution
Triage
การคดแยกผปวย เพอใหผปวยทอยในภาวะวกฤตไดรบการรกษาอยางทนทวงท
• โดยเรยงล าดบความส าคญตามหลกการ ABC ไดแก
• - Airway with cervical spine protection
• - Breathing
• - Circulation and Hemorrhage control
Measurement of vital sign and level of conciousness
GCS < 14 Systolic BP < 90 mmHg RR < 10 , > 29 /min
Assess Anatomy of Injury
Fail chest Limb paralysis
≥ 2 long bone fracture Pelvic fracture
Traumatic amputation of wrist , ankle Combination of Trauma and burn
All penetrating trauma to head , neck, Torso extremities
Evaluation for Mechanism of injury and High energy impact
High speed auto crash > 20 mile/hr Fall > 20 ft
Evaluation Age and Associated Condition
Age < 5 or > 55 years
Pregnancy
Immunosuppressed patient
Cardiac disease , Respiratory disease
DM, Cirrhosis, Morbid obesity , coagulopathy
Transport to Highest level trauma center
TRAUMA TEAM
Primary survey
• A : Airway and cervical spine protection
• B : Breathing
• C : Circulation
• D : Disability
• E : Exposure
A : Airway and cervical spine protection
• Airway problem ????????????
• Good consciousness
• No abnormal voice
• No stridor
• >> C –spine Injury ????????
• Multiple injury : blunt injury above clavicle with
loss of conscious
Airway
• Airway problem in traumatic patient can
be cause of death
• failure to recognize the need for airway intervention
• Inability to establish an airway
• Failure to recognize incorrectly airway
• Displacement of previous established airway
• Failure to recognize the need of ventilation
• Aspiration of gastric content
• “ Supplement oxygen must be administered
to all trauma patients”
Airway
• Problem Recognition
• altered level of conciousness
• maxillofacial trauma
• neck trauma
• laryngeal trauma
Sign of airway obstruction
• Agitation , Cyanosis = hypoxia
• Obtundation = hypercarbia
• Retraction / Use of accessory muscle =
Airway compromise
• Stridor / Hoarsness = Laryngeal
obstruction
• Position of trachea
airway maintenance technique
Chin-Lift Maneuver
The fingers of one hand are
placed under the mandible
with gently lifted upward the
chin anterior.
The thumb placed behind
lower incisors and depresses
lower lip to open the mouth
airway maintenance technique
Jaw-Thrust Maneuver
Grasping of the lower jaw, one hand
on each side and displacing the
mandible forward
Care must be taken to prevent neck
extension
oropharyngeal airway
INDICATION FOR DEFINITE AIRWAY
MANAGEMENT
• Presence of apnea
• Inability to maintain a patent airway
• Need for protect airway from aspiration of blood or vomitus
• Impending or potential compromise airway (Inhalation injury,Retropharyngeal hematoma,Sustained seizure
• Severe Head injury (Glasgow coma scale <8)
• Inability to maintain oxygenation by facemask oxygen supplementation
Helmet removal
1 2
3 4
Rapid sequence intubation technique
• Preparation for “ surgical airway “
• Ensure suction and positive pressure ventilatiion are ready
• Preoxygenate with 100% oxygen
• Apply pressure over cricoid cartilage
• Administer induction drug ( Etomidate 0.3 mg/kg or 20 mg )
• Administer 1-2 mg/kg of Succinylcholine IV
• Intubation after patient relaxes then inflate the cuff and confirm tube
placement
• Release cricoid pressure and ventilate patient
Surgical airway
emergency cricothyroidotomy
B :BREATHING AND VENTILATION
• EMERGENCY LIFE THREATENING CAUSING INADEQUATE VENTILATION
• TENSION PNEUMOTHORAX
• OPEN PNEUMOTHORAX
• FAILED CHEST AND PULMONARY CONTUSION
• MASSIVE HEMOTHORAX
Tension pneumothorax
one way valve air leak
from lung through
thoracic cavity
Respiratory distress and
hypotension
Trachea deviation
Decrease breath sound
Needle Thoracocentesis
Angiocatheter needle No.16-18
second Intercostal space , Midclavicular line
Intercostal chest drainage (ICD)
Open pneumothorax
• “ Sucking chest
wound”
• Full thickness loss of
chest wall --> free
communication
between pleural
space and
atmosphere
• Prevent lung inflation
and alveolar
ventilation
Management of open pneumothorax
Failed chest and pulmonary contusion
• 3 or more contiguous ribs are fractured in at least 2 locations.
• paradoxical movement of free floating segment and pain --> compromise ventilation
• Pulmonary contusion --> decrease lung compliance and increase shunt (often progress during first 12 hours)
Management
• Adequate pain control (
epidural anesthesia )
• Oxygenation
• Optimal hydration
• Intercostal chest drainage
• Respiratory support
• Chest physical therapy
Chest Physical therapy
• Respiratory
training
• Breathing
exercise
• Clear airway
secretion
Massive hemothorax
- Compromised respiration by compressing lung and prevent adequate
ventilation
- Bleeding > 1500 cc
- Continuous bleeding > 200 cc/hr for 2-3 hr
C : Circulation and Hemorrhage
control
• Hemorrhagic shock : Most common
cause of shock in traumatic patient
• Evaluated by level of consciousness,
pulse, skin color
ADVANCED TRAUMA LIFE SUPPORT CLASSIFICATION OF HEMORRHAGIC SHOCK
RESPONSE TO INITIAL FLUID
RESUSCITATION
• Rapid response ผปวยกลมนจะมการเสยเลอดนอยกวา 20% ของ blood
volume เเละจะม vital sign เปนปกตดภายหลงไดรบ initial fluid
resuscitation ท าใหมเวลาพอทจะตรวจสบคนเพมเตมส าหรบหาสาเหตของ Shock ตอไป
• Transient response ผปวยกลมนจะมการเสยเลอดประมาณ 20-40%
ของ blood volume โดยจะมการตอบสนองตอการให initial fluid
resuscitation ดในชวงเเรก เเลวกลบม Unstable vital sign อกครงมกมสาเหตมาจาก Inadequate resuscitation หรอ ม Ongoing blood loss
ผปวยกลมนมความจ าเปนตองไดรบการท า surgical intervention เพอหามเลอดอยางทนทวงท
• Minimal or No response ผปวยกลมนจะไมมการตอบสนองตอ Initial
fluid resuscitation เเละมความจ าเปนตองไดรบ Blood transfusion
group O, Rh-negative ทนท เพอใหม adequate circulation เเละน าผปวยเขาหองผาตดเพอท าการผาตดหามเลอดโดยรบดวน
Hemorrhage control
• Direct manual compression
• Ballon tamponade
• Immobilization : Long bone fracture
• Pelvic splint : Pelvic fracture
Cardiogenic shock
• Blunt/ penetrating injury to Heart or Great vessel --> Blood in pericardial sac
• Decrease cardiac output
• Clinical : Muffle heart sound,engorged neck vein,Hypotension ( Beck's triad),Kussmaul 's sign (increase venous pressure during spontaneous inspiration)
• Diagnosis : FAST
• Managenent : Pericadiocentesis
NEUROGENIC SHOCK
• Occur in spinal cord injury patient --> Loss of sympathetic tone
• Clinical : Hypotension without tachycardia ,cutaneous vasoconstriction or narrowed pulse pressure as in Hemorrhagic shock patient
• CVP Monitoring
• Management : Intravenous fiuid resuscitation + vasopressive drug
Pulse oximetry
TO BE CONTINUE ....