外科急診創(chuàng)傷之脊椎損傷.ppt

1、Spinal Cord Injuries,L. Barnes, BS, CCEMT-P, NREMT-P,Among all neurologic disorders, the cost to society of automotive SCI is exceeded only by the cost of mental retardation.” National Institutes of Health,33 bones comprise the spine Function Skeletal support structure Major portion of axial skeleto

2、n Protective container for spinal cord Vertebral Body Major weight-bearing component Anterior to other vertebrae components,Spinal Anatomy and PhysiologyVertebral Column,Size of Vertebrae C-1 cricoid ring compress esophagus against spinal column sudden increased intratracheal pressure against closed

3、 glottis (seatbelt), crush bruise (clothesline tackle) rapid acceleration/ deceleration results in tracheal injury,Strangulation,Hanging ligature suffocation manual choking postural asphyxiation children with neck over object and body weight produces compression,Hanging,Significant c spine/ SCI occu

4、r only with fall body height simple asphyxia rarely cause death c spine disruption subsequent to strangulation,Pathophysiology of Hanging,Venous obstruction Hypoxia Cerebral stagnation Arterial spasms Decreased cerebral blood flow Vagal collapse Increased parasympathetic tone,Statistics,5 - 10% trau

5、ma neck injuries cervical injuries initially missed mortality 15% Zone 1 injuries associated with increased morbidity and mortality,Hx MOI question patient and bystanders clarify events drug/ ETOH abuse establish time of injury baseline condition blood loss/ LOC,MVC,Seatbelt use patient location air

6、bag deployment magnitude of vehicle damage,Penetrating,Weapon used caliber gun size knife,Hanging,Suspension time drop height ligature Hx drug/ ETOH use Hx suicide attempts Pain- OPQRST,CV manifestations,Bleeding Sx associated with CVA,Aerodigestive,Dyspnea hoarseness dysphonia dysphagia,CNS,Parasth

7、esia weakness plegia paresis,Physical,Airway loss may be percipitous ABCs expose and disability,Arterial Injury,Hard Signs expanding hematoma severe active /pulsatile bleeding shock unresponsive to fluids Sx cerebral infarction presence bruit diminished distal pulses require operative repair,Soft Si

8、gns nonexpanding henatoma paresthesias not predictive,Esophageal Perforation,Rarely occurs most serious and rapidly fatal trauma induced perforation of GI,Sx SCI or Brachial plexus injury,Tend to involve upper nerve root C5- C7 diminished capacity of upper arm while sparing lower arm Quadriplegia co

9、mplete transection of SC absence of all motor, sensory, reflex below injury bilateral neuro findings imply SCI untilproven otherwise,Pathological reflexes,Babinski extension of big toe Hoffmann ovvewractive stretching reflex,Sx larynx or tracheal injury,Voice alterations hemoptysis stridor drooling

10、sucking, hissing,air frothing through neck wound sub Q emphysema/ crepitus hoarseness dyspnea deformity,Sx penetrating injury to heart, aorta, great vessels,Hemorrhage massive hemothorax hypotension tamponade weak/ absent carotid pulse paradoxical pulse bruit,Cervical or supraclavicular hematoma com

11、a hemiparesis resp distress,Sx trachebronchial or lung injury,Sub Q emphysema cough hemoptysis tension pneumo persistent air leak mediastinal crunch,IC retractions decreased BS tachypnea agitation hypotension hypoxia deviation,Sx carotid injury,Decreased LOC contralateral hemiparesis hemorrhage hema

12、toma,Dyspnea thrill bruit pulse deficit,Sx jugular injury,Hematoma external hemorrhage hypotension,Sx CN injuries,Facial nerve - CN VII drooping corners of mouth glassopharyngeal nerve CN IX dysphagia vagus nerve CN X hoarseness spinal accessory nerve CN XI inability shrug and laterally rotate chin

13、hypoglossal nerve CN XII deviation of tongue with protrusion,Sx esophageal and pharynx injuries,Dysphagia bloody saliva sucking neck wound bloody nasogastric aspirate pain/ tenderness to neck resistance with passive motion crepitus bleeding from mouth/ NGT ligature marksa,Treatment,Caution with intu

14、bation occlussive dressing c spine/ LBB defer helmet removal until stabilized Football vs motorcycle direct pressure stabilize impaled objects,Structure Covered with skin Flexible and thin Highly vascular Minimal layer of subcutaneous tissue Circulation External carotid artery Supplies facial area B

15、ranches Facial, Temporal & Maxillary Arteries,Anatomy & Physiology of the Face,Nerves Trigeminal (CN-V) Facial Sensation Some eye motor control Enables chewing process Facial (CN-VII) Motor control for facial muscles Sensation of taste,Anatomy & Physiology of the Face,Nasal Cavity Upper Border Bones

16、 Junction of Ethmoid, Nasal, & Maxillary Bones Bony Septum Right & Left Chamber Turbinates Vascular mucosa support Warm, Humidify, and Filter incoming air Lower Border Bony Hard Palate Soft Palate Moves upward during swallowing Nasal Cartilage Forms Nares,Anatomy & Physiology of the Face,Oral Cavity

17、 Formed Structures Maxillary bone Palate Upper teeth meeting the mandible and lower teeth Floor Tongue Connects to hyoid bone Free-floating U-shaped bone inferior & posterior of the mandible Mandible Articulates with the TMJ joint,Anatomy & Physiology of the Face,Special Structures Salivary Glands F

18、irst stage in digestion Location Anterior and inferior to the ear Under tongue Inside the inferior mandible Tonsils Posterior wall of the pharynx,Anatomy & Physiology of the Face,continued,Sinuses Hollow spaces in cranium and facial bones Function Lighten head Protect eyes and nasal cavity Produce r

19、esonant tones of voice Strengthen area against trauma,Anatomy & Physiology of the Face,Cranial Nerves CN-XII (Hypoglossal) Swallowing & tongue movement CN-IX (Glossopharyngeal) Saliva production & taste CN-V (Trigeminal) Sensations from facial region & aids in chewing CN-VII (Facial) Muscles of faci

20、al expression & taste,Anatomy & Physiology of the Face,Pharynx Posterior & Inferior to the oral cavity Aids in swallowing Bolus of food propelled back & down by tongue Epiglottis moves downward Larynx moves up Combined effect seals airway Peristaltic wave moves food down esophagus,Anatomy & Physiolo

21、gy of the Face,Ear Function Hearing Positional sense Structures Pinna Outer visible portion Formed of Cartilage & has Poor blood supply External Auditory Canal Glands that secrete cerumen (wax) Middle & Inner Ear Structures for hearing and positional sense,Anatomy & Physiology of the Face,Special In

22、jury Care,Scalp Avulsion Cover the open wound with bulky dressing Pad under the fold of the scalp Irrigate with NS to remove gross contamination Pinna Injury Place in close anatomic position as possible Dress and cover with sterile dressing,Ear Structures for Hearing Tympanic membrane Ossicle bones

23、Cochlea Auditory Nerve Structures for Proprioception Semicircular canals Sense position & motion Present when eyes are closed Vertigo Continuous movement sensation,Anatomy & Physiology of the Face,Eye Structures Sclera Cornea Conjunctiva Anterior Chamber Aqueous humor Iris Pupil Lens Posterior Chamb

24、er Vitreous humor Retina Lacrimal Fluid Bathes, protects, and nourishes cornea,Anatomy & Physiology of the Face,Eye Innervation CN-III (Oculomotor) Pupil dilation Conjugate movement Movement of eyes together Normal range of motion CN-IV (Trochlear) Downward & inward movement CN-VI (Abducens) Abducti

25、on (outward) gaze,Anatomy & Physiology of the Face,Facial Injuries,Soft tissue Excessive bleeding Deformity Fractures Eyes, ears, nose,Facial Injury,Facial Soft Tissue Injury Highly vascular tissue Contribute to hypovolemia Superficial injuries rarely life threatening and rarely involve the airway D

26、eep Injuries can result in blood being swallowed and endanger the airway Soft tissue swelling reduces airflow Consider likelihood of basilar skull fracture or spinal injury,Facial Injury,Ear Injury External Ear Pinna is frequently injured due to trauma Poor blood supply Poor healing Internal Ear Wel

27、l protected from trauma My be injured due to rapid pressure changes Diving, Blast, or Explosions Temporary or permanent hearing loss Tinnitus may occur,Facial Injury,Eye Injury Penetrating trauma can result in long term damage Suspect small foreign body if patient complains of sudden eye pain and se

28、nsation of something on the eye DO NOT REMOVE ANY FOREIGN OBJECT Corneal Abrasions & Lacerations Common & usually superficial Hyphema Blunt trauma to the anterior chamber of the eye Blood in front of iris or pupil Sub-conjunctival Hemorrhage Less serious condition May occur after strong sneeze, seve

29、re vomiting or direct trauma,Facial Injury,Eye Injury Acute Retinal Artery Occlusion Non-traumatic origin Painless loss of vision in one eye Occlusion of retinal artery Retinal Detachment Traumatic origin Complaint of dark curtain/obstruction in the field of view Possibly painful depending on type o

30、f trauma Soft Tissue Lacerations,Special Injury Care,Eye Injury General Injury Cover injured and uninjured eye Prevents sympathetic motion Consider sterile dressing soaked in NS Corneal Abrasion Invert eyelid and examine eye for foreign body Remove with NS moistened gauze or Morgans Lens Avulsed or

31、Impaled Eye Cover and Protect from injury General Care Calm & reassure patient,Facial Injury,Nasal Injury Rarely life threatening Swelling & Hemorrhage interfere with breathing Epistaxis Most common problem AVOID NASOTRACHEAL INTUBATION Passage of ET tube into the cerebral cavity,Epistaxis,Epistaxis

32、 without Fx one of the most common emergencies encountered Usually associated with disruption of Kiesselbachs plexus located anteriorly Posterior epistaxis may be associated withdisruption of sphenopalatine artery More difficult to control,Epistaxis,Children Easily controlled Direct pressure Pressure upper gum,Elderly More severe Associated with HTN Often originates posteriorly Posterior nasal packing may be required Massive posterior bleed may be life threatening,Special Injury Care,Dislodged Teeth Rinse in NS Wrap in NS soaked gauze Impaled Objects Secure with bulky dressing Stabiliz