晚期創(chuàng)傷生命支持的創(chuàng)傷

Advanced

Trauma

Life

Support1/001Patrick

Cheah,

MDLi-Shin

Hospital

Emergency

DepartmentPreparationTriagePrimary

Survey(ABCDEs)ResuscitationAdjuncts

to

primary

survey

&

resuscitationSecondary

Survey

(head

to

toe

evaluation

&

history)Adjuncts

to

secondary

surveyContinued

post-resuscitation

monitoring

&

re-evaluationDefinite

care.1/0021.

PREPARATION1/003A

Pre-hospital

phaseReceiving

hospital

is

notified

first.Send

to

the

closest,

appropriate

facility.B

In

Hospital

PhaseAdvanced

planning

for

the

trauma

pt

arrival.Method

to

summon

extra

medical

assistanceTransfer

agreement

with

verified

trauma

center

established.Protect

from

communicable

disease.2.

TRIAGE1/004A

Multiple

Casualtiesno

of

severity

&

pt

do

not

exceed

the

ability

ofthe

facility.B

Mass

Casualtiesno

&

severity

of

pt

EXCEED

the

capability

ofthe

facility

&

staff.3.

PRIMARY

SURVEY1/005A

:

Airway

with

cervical

spine

protect.B

:

BreathingC

:

Circulation

--control

external

bleeding.D

:

Disability

or

neurological

statusE

:

Exposure

(undress)

&

Environment (temp

control)PRIMARY

SURVEY1/006Priorities

for

the

care

ofAdult

,

Pediatrics&

Pregnancy

women

are

all

the

same.During

the

primary

survey

life

threateningconditions

are

identified

and

management

isinstituted

SIMULTANEOUSLY.A.

Airway

Maintenance

with

Cervical

SpineProtection.1/007*

GCS

score

of

8

or

less

require

the

placementof

definiteairway.*Protection

of

the

spine

&

spinal

cord

is

the

importantmanagement

principle.*Neurological

exam

alone

does

not

exclude

a

cervical

spineinjury.*Always

assume

a

cervical

spine

injury

in

any

pt

with

multi-system

trauma,

especially

with

an

altered

level

of

consciousnessor

blunt

injury

above

the

clavicle.B.

Breathing

&

Ventilation1/008*

Airway

patency

does

not

assure

adequate

ventilation.C.

Circulation

with

Hemorrhage

Control.

1.

Blood

Volume

&

Cardiac

Outputlevel

of

consciousness.skin

colorPulse.

2.

Bleeding*external

bleeding

is

identified

&

controlled

in

theprimary

survey.*Tourniquets

should

not

be

use.D.

Disability

(

Neurological

Evaluation)Simple

Mnemonic

to

describe

level

of

consciousnessA

:

alert1/009V

:

Responds

to

Vocal

stimuliP

:

Responds

to

Painful

stimuliU

:Unresponsiveto

all

stimuliNot

forget

to

use

also

Glascow

Coma

Scale.E.

Exposure

/

Environmental

Control1/0010*It

is

the

pt’s

body

temp

that

is

most

important,

not

hecomfort

of

the

health

care

provider.*Intravenous

fluid

should

be

warm.*Warmenvironment(room

tem)

should

be

maintained.*early

control

of

hemorrhage.4.

RESUSCITATION1/0011Airway*definite

airway

if

there

is

any

doubt

about

the

pt’s

ability

tomaintain

airway

integrity.Breathing

/Ventilation/Oxygenation*every

injured

pt

should

receivedsupplement

oxygenCirculation*control

bleedingbydirect

pressure

or

operative

interventionminimum

of

two

large

caliber

IV

should

be

established*pregnancy

test

for

all

female

of

child

bearing

age.Lactated

Ringer

is

preferred

&

better

if

warm.5.

ADJUNCT

TO

PRIMARY

SURVEY

&RESUSCITATION1/0012Electro-cardiographic

MonitoringUrinary

&

Gastric

Catheter1.

Urinary

catheter.Urethral

injury

should

be

suspected

if*Blood

at

the

penile

meatus*Perineal

ecchymosis*Blood

in

the

scrotum*High

riding

or

nonpalpable

prostate*Pelvic

fractureC.

MonitoringVentilatory

rate

&

ABGPulse

oximetrydoesnot

measure

ventilation

or

partial

O2

pressureBlood

pressurepoormeasure

of

actual

tissue

perfusion.D.

X-Ray

&

Diagnostic

StudiesC-spine,

CXR,

Pelvic

filmEssential

x-ray

should

not

be

avoid

in

pregnant

pt.***

Consider

the

need

for

patient

transfer.1/00136

SECONDARY

SURVEY1/0014Does

not

begin

until

the

primary

survey

(ABCDEs)is

completed,

resuscitative

effort

are

well

established&

the

pt

is

demonstrating

normalization

of

vital

sign.Head

to

Toe

evaluation

&

reassessment

of

all

vital signs.A

complete

neurological

exam

is

performedincluding a

GCS

score.Special

procedure

is

order.History1/0015A

:

Allergies.M

:

Medication

currently

used.P

:

Past

illness/

Pregnancy.L

:

Last

MealE

:

Events/Environment

related

to

the

injury.*blunt

trauma/penetrating

trauma/injuries

dueto

cold

&

burn/hazardous

environment?PHYSICAL

EXAMINATION1/00161.

HeadVisual

acuityPupillary

sizeHemorrhage

of

conjunctiva

and

fundiPenetrating

injuryContactlenses(removebefore

edema

occurs)Dislocation

of

lensOcular

movementMaxillofacial

Injuryno

NG

tube,

definite

airway?Cervical

Spine

&

Neck*Pt

with

maxillofacial

or

head

trauma

should

be

presumedto

have

and

unstable

cervical

spine.Chest*elderly

pt

are

not

tolerant

of

even

relatively

minorchest

injury.*Children

often

sustain

significant

injury

to

theintrathoracic

structure

without

evidence

of

thoracicskeletal

trauma.1/0017Abdomen*excessive

manipulation

of

the

pelvic

should

be

avoided.Perineum/rectum/vaginaMusculoskeletalNeurologic*

Protection

of

spinal

cord

is

required

at

all

times

until

aspine

injury

excluded,

especially

when

the

pt

is

transfer.1/00187.

ADJUNCT

TO

THE

SECONDARY

SURVEY1/0019include

additional

x-ray

and

all

other

special

procedure.RE-EVALUATIONAdult

urine

output

0.5ml/kg/hrPediatric

urine

output

1mg/kg/hr*Pain

relief

--

IM

should

be

avoid.DEFINITE

CAREIndication

For

Definite

Airway1/0020UnconsciousSevere

maxillo-facial

fractureRisk

for

aspiration

:

Bleeding/

vomitingRisk

for

obstruction

:

neck

hematoma/laryngeal,tracheal injury/

stridorApnea

:

Neuromuscular

paralysis/unconsciousInadequate

respiratory

effort: tachypnea/hypoxia/hypercapnia/cyanosisSevere

closed

head

injury

need

for

hyperventilationNormal

Blood

Amount:1/0021Normal

adult

bloodvolume:

7%

ofbodyweightNormal

blood

volume

for

child

:

8-9%

of

body

weightHemorrhage

Classification

:Class

I

Hemorrhage

:Class

II

Hemorrhage

:Class

III

Hemorrhage

:Class

IV

Hemorrhage

:up

to

15%

loss15-30%

loss30-40%

loss>40%

loss3

for

1

Rule1/0022a

rough

guideline

for

the

total

amount

ofcrystalloid

volume

acutely

is

to

replace

eachML

of

blood

loss

with

3

ML

of

crystalloidfluid,

thus

allowing

for

restitution

of

plasmavolume

lost

into

the

interstitial

&

intracellularspaceInitial

Fluid

Therapy1/0023Lactated

Ringer

is

preferredFor

adult

1-2

liters

bolusFor

child

20ml/kg

bolusIntraosseous

Puncture/Infusion1/0024Children

less

than

6

y/o

for

IV

access

isimpossible

due

to

circulatory

collapse

orfor

whom

percutaneous

peripheral

venouscannulation

had

failed

on

two

attempt.Head

Injury

Classification:1/0025Mild

:Moderate

:Severe

:GCS

14-15GCS

9-13GCS

3-8Coma =

GCS

score

of

8

or

lessDiagnostic

Peritoneal

Lavage

Indication1/0026Change

in

sensorium--Head

injury/alcohol/drug.Change

in

sensation--Spinal

cord

injury.

Injury

to

adjacent

structure--lowerribs/pelvic/lumbar

spine.Equivocal

physical

examination.Prolong

loss

of

contact

with

patient

anticipated.***

Positive

Test:>100,000

RBC/mm3,

>500

WBC/mm3or

Gram

StainwithbacteriaDetermining

the

level

of

quadriplegia1/0027Raiseelbow

to

level

of

shoulder

--

Deltoid

C5Flexes

the

forearm

--

Biceps

C6Extend

the

forearm

--

Triceps

C7Flexes

wrist

&

finger

--

C8Spread

finger

--

T1Determine

the

level

of

paraplegiaFlexes

the

hip

--

Iliopsoas

L2Extend

knee

--

Quadriceps

L3Dorsiflexes

ankle

--

Tibialis

anterior

L4Plantar

flexes

ankle

--Gastrocnemius

S11/0028Thoracic

Trauma1/00298

lethal

InjurySimple

pneumothoraxHemothoraxPulmonary

contusionTracheo-bronchial

tree

injuryBlunt

cardiac

injuryTraumatic

aortic

disruptionTraumatic

diaphragmatic

injuryMediastinal

traversing

wounds.Fluid

Therapy

in2nd

or

3rd

Degree