2022醫(yī)學課件兒童創(chuàng)傷急救

1、Chapter 17Trauma in Children第一頁，共三十五頁。Trauma in ChildrenTrauma in Children兒童創(chuàng)傷第二頁，共三十五頁。OverviewEffective techniques to gain confidence有效增加信心的技巧Injuries based on mechanisms of injury受傷機理ITLS Primary and Secondary Surveys初步及進一步檢查 Consent and the need for immediate transport家長同意及需實時運送Pediatric equipme

2、nt needs適合兒童之器材Various methods of SMR on child兒童脊椎固定方法EMS involvement in prevention programs參與預防意外方案3Trauma in Children -第三頁，共三十五頁。Trauma in ChildrenDifferent from adults與成人不同Different patterns of injuries不同傷勢模式Different responses to those injuries不同反響Special equipment required需要特別器材 Assessment equi

3、pment and treatment equipment檢查及冶療用的器材Difficult to assess and communicate 較難評估及溝通Come with caregivers and other family members與家人或照顧者同行4Trauma in Children -第四頁，共三十五頁。Communicating溝通Family-centered care is critical.以家庭為中心Caregiver not always parent.照顧者未必是父母Involve caregivers as much as possible in ca

4、re.盡量讓照顧者參與Give explanations and careful instructions.必需詳加解釋及指示Inclusion and respect will improve stabilization.包容及尊重可穩(wěn)定傷者Keep caregivers in physical and verbal contact.與照顧者保持接觸Demonstrate competence and compassion.5Trauma in Children -第五頁，共三十五頁。Assessing Mental Status撿查精神狀態(tài)Consoled or distracted可按撫

5、或轉注意力Most sensitive indicator of adequate perfusion 能準確反映組織灌注是否足夠Caregivers best at detecting subtle changes 照顧者會較易分辯出傷者微小改變6Trauma in Children -第六頁，共三十五頁。Assessing Mental StatusInitial level of consciousness最初清醒程度Preschool child : sleeping vs. unconscious 幼兒:疲倦vs人事不醒Most will not sleep through arri

6、val of ambulance大部份沿途不會睡覺Ask caregivers to wake child著照顧者弄醒傷者Suspect hypoxia, shock, head trauma, seizure 疑心缺氧、休克、頭部受傷、癲癇7Trauma in Children -第七頁，共三十五頁。CommunicatingInteraction strategies使用適齡的語言Appropriate language for developmental level適宜的語言Speak simply, slowly, clearly說話要慢及簡溸Be gentle and firm必需肯

7、定Avoid “no questions防止說不Get a favorite belonging 利用其喜愛的玩具/隨身物品Get on childs level 降下身段至與傷者視線平衡Explain SMR necessity 解釋脊椎固定之需要Allow caregiver to accompany child 讓照顧者與傷者同行8Trauma in Children -第八頁，共三十五頁。Caregiver Consent照顧者同意Critical care shouldnotbe delayed.切勿延醫(yī)冶理Emergency care needed如需進行急救Consent not

8、 available未能取得同意Transport before permission, document why, notify medical direction記錄,速送醫(yī)院,通知醫(yī)五Consent denied不同意Try to persuade, document actions, obtain signature 嘗試說服、記錄、簽署Notify law enforcement and appropriate authorities 行使有關法例Report suspected abuse 如疑心兒童受虐待,通知警方9Trauma in Children -第九頁，共三十五頁。Pe

9、diatric Equipment兒科器材Length-based tape身長尺Weight estimate大約體重Fluid and medication doses precalculated 輸液及藥物劑量Common equipment size estimates 常用器材尺碼10Trauma in Children -Photo courtesy of Kyee Han, MD第十頁，共三十五頁。Mechanisms of Injury受傷機理Falls高處下墮Usually land on head通常頭先著地Serious head injury unusual from

10、27 inches嚴重頭部受傷并不常見于身長27吋Protective gear保護裝備MVCs交通意外Seat-belt syndrome平安帶綜合癥Liver, spleen, intestines, lumbar spine 肝、脾、小腸、腰椎Auto-pedestrian crashes路人被撞11Trauma in Children -第十一頁，共三十五頁。Mechanisms of InjuryBurns燒傷Airway obstruction氣道受阻Foreign body異物Child abuse虐待兒童Suspect if history does not match inj

11、ury 受傷經過與傷勢不吻合Story keeps changing經常改變說法12Trauma in Children -第十二頁，共三十五頁。Airway in Children兒童氣道Signs of obstruction呼吸受阻征狀Apnea無呼吸Stridor吸氣時有喘鳴聲“Gurgling respiration有雜聲的呼吸Contribute to obstruction誘因Hyperextension過度舒張Hyperflexion過度屈曲13Trauma in Children -Courtesy of Bob Page, NREMT-P第十三頁，共三十五頁。Airway

12、in ChildrenOpening airway張開氣道Tongue is large; tissue soft舌大,組織軟Jaw-thrust下頷上提法Oropharyngeal airway口咽氣道Nasopharyngeal airways鼻咽氣道Too small to work predictably 因鼻孔太少未必有效Neonate obligate nose breather 新生嬰兒用鼻孔呼吸Clear nose with bulb syringe用球狀泵吸走分泌14Trauma in Children -第十四頁，共三十五頁。Breathing in Children兒童呼

13、吸Work of breathing呼吸方法Retractions, flaring, grunting 肋間收縮、鼻翼擴張、咕嚕聲 Persistent grunting requires ventilatio n持續(xù)咕嚕聲需要施行助呼吸Respiratory rate呼吸次數(shù)Fast, then periods of apnea or very slow 先后短暫停止或轉慢Minor blunt neck trauma can be critical.輕微頭部挫傷可引起嚴重傷勢15Trauma in Children -第十五頁，共三十五頁。20, 15, 10Ventilation Ra

14、te換氣次數(shù)16Trauma in Children -10 per minute for adolescent如為中童, 10次/分鐘 20 per minue for 1 year如1 year如 1歲, 15次/分鐘第十六頁，共三十五頁。Breathing Management呼吸處理17Effective BVM ventilation有效BVM換氣intubation is elective.可考慮插喉Trauma in Children -第十七頁，共三十五頁。Endotracheal Intubation 氣管內導管Oral endotracheal intubation從口腔插

15、入No blind nasotracheal intubation for 130 usually shock in all ages except neonates脈搏130多為休克,新生嬰兒除外Prolonged capillary refill and cool extremities微血管回流時閉遲及肢體冰冷Level of consciousness清醒程度Circulation can be poor even if child is awake 血循環(huán)衰竭的兒童仍可完全清醒Low blood pressure is sign of late shock.血壓低是休克的后期征狀BP

16、 80 mmHg in child; 70 mmHg in young infant20Trauma in Children -第二十頁，共三十五頁。Shock in ChildrenStrong compensatory mechanisms生理的補嘗機制較強Appear surprisingly good in early shock 早期休克可有效發(fā)揮“Crash when deteriorate但情況會急轉直下Be prepared必需有心理準備Fluid administration 20 mL/kg in each bolus輸液補充每次20 mL/kgConsider intra

17、osseous infusion骨髓輸液法Frequent Ongoing Exams持續(xù)檢查 21Trauma in Children -第二十一頁，共三十五頁。Pediatric Trauma Center 兒童創(chuàng)傷中心Criteria條件Obstructed airway氣道阻塞Need for airway intervention處理氣道Respiratory distress呼吸困難Shock休克Altered mental status意識紊亂Dilated pupil曈孔擴大Glasgow Coma Scale score 13Pediatric Trauma Score 10

18、 feet高處墮下Motor-vehicle collisionMVC with fatalities車禍中有人死亡Ejection from an automobile in a MVC 車禍中彈離車廂In MVC, significant intrusion into compartment 車禍中受困于車廂中Hit by a car as a pedestrian or bicyclist行人被撞Fractures in more than one extremity多邊一條肢體骨抑Significant injury to more than one organ system多過一個器

19、官受傷23Trauma in Children -第二十三頁，共三十五頁。Pediatric Trauma CenterRecommended建議送院Burns燒傷Near-drowning遇溺Head injuries with loss of consciousness 人事不醒的頭部受傷Notify hospital as early as possible.盡早知會醫(yī)院24Trauma in Children -第二十四頁，共三十五頁。Life-Threatening Injuries 危害生命傷勢Head injury頭部受傷Most common cause of death最常見

20、死亡原因Level of consciousness change best indicator 清醒程度之改變?yōu)樽钣行У恼鳡頟upil assessment important檢查瞳孔25Trauma in Children -第二十五頁，共三十五頁。Life-Threatening InjuriesHigh-flow oxygen高濃度氧氣Hyperventilate only with cerebral herniation syndrome 加快換氣只適用于出現(xiàn)腦疝征狀Fluid administration titrated to systolic BP 控制輸液速度至可維持根本收縮

21、壓Preschool child: 80 mmHg; older child: 90 mmHg幼兒: 80 mmHg,小童: 90 mmHgBe prepared to prevent aspiration 預防氣道吸入異物26Trauma in Children -第二十六頁，共三十五頁。Life-Threatening InjuriesChest injury胸部創(chuàng)傷Respiratory distress common最常見的征狀為呼吸困難Pneumothorax or tension pneumothorax氣胸或張力性氣胸Difficult to assess較難分別Needle t

22、horacostomy can be life-saving剌胸膜腔穿刺Pulmonary contusion胸部挫傷Rare injuries較少發(fā)生傷勢Rib fractures, flail chest, aortic rupture, pericardial tamponade 肋骨折、槤架胸、主動脈撕裂、心胞膜填塞27Trauma in Children -第二十七頁，共三十五頁。Life-Threatening InjuriesAbdominal injury腹部創(chuàng)創(chuàng)Liver and/or spleen rupture肝、脾撕裂Second leading cause of tr

23、aumatic death 傷第二致死傷勢Bleeding often contained within organ 出血通常局限于器官之內Difficult to diagnose難以診斷Severe injury with minimal signs 嚴重傷勢可只有輕微征狀Suspect with any abnormal abdominal assessment 假設有任何異常腹部征狀當作嚴重傷勢處理Be prepared to prevent aspiration. 預防氣道吸入異物28Trauma in Children -第二十八頁，共三十五頁。Life-Threatening I

24、njuriesSpinal injury脊椎創(chuàng)傷Uncommon before adolescence青少年以下較少發(fā)生9 years usually lower cervical-spine injuries頭椎下受傷Higher incidence of SCIWORAspinal-cord injury without radiographic abnormality 可無X-光片異常29Trauma in Children -第二十九頁，共三十五頁。Life-Threatening InjuriesSMR脊椎固定Pad under torsofor neutral position 于天然屈曲位下放置較墊May have to secure without cervical collar 可不使用頸圈固定頸椎Do not restrict chest movement 切勿緊束胸部30Trauma in Children -第三十頁，共三十五頁。Child Restraint Seats兒童汽車平