Transcript การดูแลรักษาผู้บาดเจ็บฉุ

การดูแลรักษาผ้ ูบาดเจ็บฉุกเฉินที่
ทรวงอก
ประวัติ
พบ. วิทยาลัยแพทยศาสตร์ พระมงกุฎเกล้ า
 แพทย์ ใช้ ทุน รพ. สก.พร.
 วุฒิบต
ั รสาขาศัลยศาสตร์ ทวั่ ไป
 วุฒิบต
ั รสาขาศัลยศาสตร์ ทรวงอก หัวใจ และหลอดเลือด
 อนุมต
ั ิบตั รสาขาเวชศาสตร์ ครอบครัว
 ศัลยแพทย์ รพ. สก.พร.
 หลักสู ตรเสนาธิการทหารเรือ
 นกพ.พร. และ หน.แผนกศัลยกรรม รพ.ทร. กรุ งเทพ
 ผบ.พัน พ. กรม สน. สอ.รฝ.
 นยก.พร. และ หน.แผนกศัลยกรรม รพ.ทร. กรุ งเทพ
หน.แผนกศัลยกรรมทรวงอก รพ.ปก.พร. และ รรก.รอง หก. กวตบ. พร.
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Introduction
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Trauma is leading cause of death, long-term
disability for all ages from first –forty
years.
25% of all trauma death due to chest
injuries
20-33% death preventable.
Deaths occur within first 4 hours trauma.
85% of pt with life threatening injuries can
be managed simple interventions easily
mastered by physicians and ER service
personnel
Most life-threatening injuries identified in
primary survey
Trimodal Death Distribution
CAUSES OF THORACIC TRAUMA:
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Falls
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3 times the height of the patient
Blast Injuries
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overpressure, plasma forced into alveoli
Blunt Trauma
 PENETRATING TRAUMA
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6 Immediate Life Threats
1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax
“sucking chest wound”
4. Flail chest
5. Massive hemothorax
6. Cardiac tamponade
ADVANCE TRAUMA LIFE SUPPORT
CONCEPT
• The most important was to treat
the greatest threat to life first.
• The definitive diagnosis should
never impede the application of an
indicated treatment.
•A
detailed
history
was
not
essential to begin the evaluation of
an acutely injured patient
• ABCDE-approach to evaluation and
treatment
GOALS
• Rapid, accurate, and physiologic
assessment
• Resuscitate, stabilized and monitor
by priority
• Determine needs, and capabilities
• Prepare to transfer to definitive
care
• Assure optimal, safe patient care
“The primary focus of ATLS is on the first hour
of trauma management , rapid assessment and resuscitation”
ADVANCE TRAUMA LIFE SUPPORT
1. Preparation
2. Triage
3. Primary survey ( A B C D E )
4. Resuscitation
5. Adjuncts to primary survey and
resuscitations
6. Secondary survey (head‐to‐toe)
7. Adjuncts to the secondary survey
8. Continued post‐resuscitation
monitoring and resuscitation
9. Definitive care
Initial assessment and
management
Primary Survey
(ABCDE's)
Resuscitation
Secondary Survey
Data / Information /
Response to Therapy
Definitive Care
Standard precaution
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Cap
Gown
Gloves
Mask
Shoe covers
Goggles/face shield
Primary survey: Airway
•Assess for airway patency
•Airway obstruction
•Snoring
•Gurgling
•Stridor
•Rocking chest wall movement
•Maxillofacial injury/ laryngeal injury
• Things to remember...
C-Spine Protection
Assessment: Breathing
• Inspection RR, paradoxical ,symetrical motion of
the chest wall, or obvious chest wounds.
• Palpation should seek pain, crepitus or
subcutaneous emphysema as clues to underlying
pathology.
• Auscultation of the lung fields may detect a
pneumothorax or hemothorax before a chest x-ray
is performed, as well as assessing the adequacy of
air entry.
• Percussion theoretically of use in differentiating
between pneumo and hemothorax
Resuscitation :Breathing
• Supplemental oxygen
• Ventilate as needed
• Tension pneumothorax
-Needle decompression
• Open pneumothorax
-Occlusive dressing
• Reassess frequently
TENSION PNEUMOTHORAX
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Air within thoracic cavity that cannot exit
the pleural space
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Fatal if not immediately identified, treated,
and reassessed for effective management
Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Tension Pneumothorax
The trachea is
pushed to
the good side
Heart is being
compressed
EARLY S/S OF TENSION
PNEUMOTHORAX
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ANXIETY!
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Increased respiratory distress
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Unilateral chest movement
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Unilateral decreased or absent breath
LATE S/S OF TENSION
PNEUMOTHORAX
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Jugular Venous Distension (JVD)
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Tracheal Deviation
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Narrowing pulse pressure
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Signs of decompensating shock
JVD & TRACHEAL SHIFT
Decreased input and output
from the heart with
compression of the great
vessels
JVD & TRACHEAL SHIFT
Increased pressure moves
mediastinum and compresses
the lung on the uninjured side
MANAGEMENT OF TENSION
PNEUMOTHORAX
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Asherman Chest Seal
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Needle Decompression
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High flow oxygen (If available)
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Chest Tube
Tension Pneumothorax
Pleural Decompression
• 2nd intercostal
space in midclavicular line at
TOP OF RIB
• Consider multiple
decompression sites
if patient remains
symptomatic
• Large over the
needle catheter: 14ga
• Create a one-wayvalve: Glove tip or
Heimlich valve
Needle Decompression
NEEDLE THORACENTESIS
Tension Pneumothorax
􀁺 Respiratory distress
􀁺 Distended neck veins
􀁺 Tracheal deviation
􀁺 Hyperresonance
􀁺 Cyanosis (late)
􀁺 Unilateral decrease in
breath sounds
• Tension pneumothorax
is not an x-ray
diagnosis – it MUST be
recognized clinically
• Treatment is
decompression – needle
into 2nd intercostal
space of mid-clavicular
line followed by
thoracostomy tube
OPEN PNEUMOTHORAX
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Develops when penetration injury to the chest
allows the pleural space to be exposed to
atmospheric pressure - “Sucking Chest
Wound”
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Q- WHAT MAY CAUSE A SCW?
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Examples Include:
 GSW,
Stab Wounds, Impaled Objects, Etc...
LARGE VS SMALL
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Severity is directly proportional to the size
of the wound
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Atmospheric pressure forces air through the
wound upon inspiration
S/S: OPEN PNEUMOTHORAX
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Shortness of Breath (SOB)
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Pain
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Sucking or gurgling sound as air moves in and
out of the pleural space through the wound
Open Pneumothorax
• Dyspnea
• Subcutaneous Emphysema
• Decreased lung sounds on affected side
• Red Bubbles on Exhalation from wound
(Sucking chest wound)
Open Pneumothorax
Open Pneumothorax
Inhale
Open Pneumothorax
Exhale
Open Pneumothorax
Inhale
Open Pneumothorax
Exhale
Open Pneumothoarx
Inhale
Open Pnuemothorax
Inhale
Open Pneumothorax
Initial management
• High flow O2
• Cover site with
sterile occlusive
dressing taped on
three sides
• Progressive
airway management
if indicated
MANAGEMENT OF SCW
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Apply an Asherman Chest
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Seal
Occlusive dressing with a release valve
Observe for development of a
Tension Pneumothorax
Hemothorax
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Occurs when pleural space fills with blood
Usually occurs due to lacerated blood vessel in
thorax
As blood increases, it puts pressure on heart and
other vessels in chest cavity
Each Lung can hold 1.5 liters of blood
Hemothorax
Hemothorax
Hemothorax
Hemothorax
Hemothorax
Hemothorax
May put pressure on the heart
Hemothorax
Where does the blood come from.
Lots of blood vessels
S/S of Hemothorax
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Anxiety/Restlessness
Tachypnea
Signs of Shock
Frothy, Bloody Sputum
Diminished Breath Sounds on Affected Side
Tachycardia
Flat Neck Veins
Treatment for Hemothorax
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ABC’s with c-spine control as indicated
Secure Airway assist ventilation if necessary
General Shock Care due to Blood loss
Consider Left Lateral Recumbent position if not
contraindicated
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RAPID TRANSPORT
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Contact Hospital and ALS Unit as soon as possible
Flail chest
• “Free-floating” chest
segment, usually from
multiple ribs fractures
• Pain and restricted
movement
• Paradoxicalmovement
of chest wall with
respiration
• Clinical diagnosis
• Pulmonary contusion
is the major problem
Flail chest
Flail chest
Flail chest
􀁺 Oxygen
􀁺 Aggressive pulmonary physiotherapy
􀁺 Definitive treatment: reexpand the lung
􀁺 Effective analgesia, intercostal nerve
blocks,high segmental epidural analgesia
􀁺 Intubation
• RR > 35 /min or < 8 /min
• PaO2 < 60 mm Hg at FiO2 >= 0.5
• PaCO2 > 55 mm Hg at FiO2 >= 0.5
• Alveolar-arterial oxygen gradient > 450
• Severe shock
• Severe head injury
• Requiring surgery
• Internal splint
Massive Hemothorax
􀁺 Hypovolemia &
hypoxemia
􀁺 ≥ 1500 mL BL; 1/3 of
blood volume
􀁺 Neck veins may be:
Flat: hypovolemia
Distended: intra thoracic blood
􀁺 Shock with no
breath sounds and / or
percussion dullness
Intercostal Drainage
The “safe triangle”for
insertion of ICD
Cross-section of the intercostalspace
Assessment: Circulation
􀁺 Hemorrhagic Shock
• External bleeding
• Internal bleeding
􀁺 Non-hemorrhagic shock
• Cardiac tamponade
• Tension pneumothorax
• Neurogenic
Resuscitation :Circulation
􀁺Stop bleeding !
􀁺Restore circulating volume
• RLS 1-2 L
• Colloid / Blood component
􀁺Reassess frequently
􀁺Venous access
Things to remember…
Direct pressure
Avoid blinding clamp
Resuscitation :Circulation
Hypotension in thoracic trauma is
usually associated with hypovolemia
it should be aggressively treated
initially with volume expansion with
crystalloids while other possible
etiologies, i.e. pneumothorax, cardiac
tamponade and blunt cardiac injury
are assessed.
Arrhythmia should raise suspicion of
blunt cardiac injury
Cardiac tamponade
1.
2.
Usually from penetrating injuries
Classic “Beck’s triad”
•
elevated venous pressure neck veins
•
decreased arterial pressure BP
•
muffled heart sounds
3. Blood in sac prevents cardiac
activity
4. May find “pulsus paradoxus” - a
decrease of 10 mm Hg or greater in
systolic BP during inspiration
5. Systolic to diastolic gradient of
less than 30 mm Hg also suggestive