Download - 頸部創傷的評估和處置
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頸部創傷的評估和處置
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機 轉
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頸部頓挫傷
頸部穿刺傷
窒息和上吊
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大 綱
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案例
解剖
初級評估: A B C D
4 次級評估:診斷檢查
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案例 1
55 歲男性,在工廠被飛出機具擊中頸部。
到達急診時意識清楚,生命徵象穩定,初級評估大致正常。
下一步?
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案例 2
22 歲男性,機車事故,左側頭頸部鈍挫傷。到達急診時意識清楚,生命徵象穩定,初級評估大致正常。於急診時主訴右側手腳麻木,感覺異常頭部和臉部電腦斷層:左側下顎骨骨折,無顱內出血下一步?
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鎖骨
環狀軟骨
下顎角
Zone I
Zone II
Zone III
Roon & Christensen Classification.
J trauma, 1979
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頸部創傷的 “ Hard” & “Soft” Signs
Soft Signs • 咳血、吐血• 口咽出血• 呼吸困難• 無法發聲• 皮下或縱隔腔氣腫• 胸管氣漏• 非擴散性血腫• 局部神經缺損
Hard Signs• 擴散性血腫• 嚴重持續出血• 頑固性休克• 橈動脈脈搏微弱或消失• 血管雜音• 大腦缺血• 呼吸道阻塞
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處置原則
• 盡快插管A
• 治療氣胸、血胸B
• 檢查脈搏,壓迫止血C
• 檢查脊髓損傷或大腦缺血D
根據高級創傷救命術流程
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Airway
氣管或咽喉損傷:– 呼吸困難,嘯喘,聲音沙啞,發聲困難,咳血,
皮下氣腫,頸部疼痛,壓痛,氣管偏移…
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Airway
早期氣管插管– 意識改變– 嚴重呼吸困難– 呼吸道阻塞– 嚴重皮下氣腫或氣管偏
移
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Breathing
治療氣胸,血胸
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Circulation
持續大量出血立即壓迫止血
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Disability
神經學缺損可能起因於脊髓損傷或血管損傷導致腦部缺血
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初步影像檢查胸部、頸部 X 光:
– 血腫,皮下氣腫,喉部損傷,後咽部血腫,氣胸,血胸,縱隔腔積氣
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Complete Evaluation
• 血管損傷– 動脈攝影
• 咽喉,氣管損傷– 咽喉鏡,氣管鏡
• 消化道損傷– 食道鏡或食道攝影
• 神經損傷
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頸部穿刺傷發生率
部位 數量 (1275 total)
百分比 (%)
動脈靜脈咽喉、氣管食道脊髓大腦胸管
320281253240
768520
12.811.310.1
9.63.03.4
0
From McConnel DB, Trunkey D: Management of penetrating trauma to the neck. Adv Surg 27:97, 1994
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Blunt Carotid & Vertebral Vascular Injuries (BCVI)
Early recognition and treatment of blunt carotid and vertebral vascular injuries may reduce the risk of stroke.
Suggested criteria for screening include: a) C1–3 fracture
b) C -spine fracture with subluxation
c) Fractures involving the foramun transversarium
Approximately 1/3 of these patients will have BCVI when imaged with CT angiography of the neck
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頸部穿刺傷之處置生命徵象不穩定持續動脈出血傷口冒泡
手術 CTA
可看清楚完整彈道
觀察
檢查結果不確定彈道靠近重要結構病患有無法解釋的症狀
Zone I Zone II
動脈攝影食道攝影或食道鏡喉鏡或氣管鏡
手術
Zone III
動脈攝影
是 否
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重要觀念• 頸部創傷最主要之立即死因是血管損傷。• 頸部創傷最主要之延遲死因是食道損傷。
此種傷害並不常見,症狀不明確,容易延誤診斷造成高死亡率。
• 頸圈可能造成呼吸道外部壓迫,並且可能阻礙頸部之系列評估 ( 例如擴散中之血腫 ) 。
• 若無禁忌症,儘可能由有經驗者儘快做氣管內插管。
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96 年 急診醫學科專科醫師甄審考題
25 歲男性業務員騎機車過馬路時,不慎和對方來車相撞,119送他到醫院時,發現他下巴中間有凹陷,臉部和口腔都在流血,右側脖子腫脹,血壓 80/50 mmHg 、心跳 120/min 、呼吸 32/min ,下列何種醫囑要先執行?
( A)臉部和口腔壓迫止血( B)下巴固定( C)輸林格氏液 2000ml( D)口咽氣管插管( E)環甲軟骨切開術 ( cricothyroidotomy)✔