Upload File

hvorfor og hvordan · occurrence of errors by phase of trauma management (gruen et al. ann surg...

  • Home
  • Documents
  • Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment
41
Traumemodtagelse Hvorfor og hvordan Carsten Fladmose Madsen Traumesektoren Ortopædkirurgisk afdeling Odense Universitetshospital September 2013

Upload: others

Post on 17-Feb-2020

2 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumemodtagelse

Hvorfor og hvordan

Carsten Fladmose MadsenTraumesektorenOrtopædkirurgisk afdelingOdense Universitetshospital September 2013

Page 2: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

• Hvad er traumemodtagelse?

– Traumeteam

– Traumemanual

– Traumeteam-aktivering

Traumemodtagelse

Page 3: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

præhospitalt forløb

transport

modtagelse

transport internt

undersøgelsebilleddiagnostik

akut behandlingoperation

interventionsradiologi

observation/behandlingintensiv afdeling

sengeafdeling

udskrivelse

rehabilitering

ambulant forløb

- kun en del af et samlet traumesystem

Traumemodtagelse

Page 4: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumemodtagelse

Fundament

• Fagligt– ABC; ATLS

• Organisatorisk– makro: region, hospital

– mikro: traumestuen, teamet» samarbejde

» kommunikation

» ledelse

Page 5: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

O2 og cirkulation

• Unacceptable delay before treatment

• Most initial care by junior doctors

Brit.Med.J. 1992;305:737-40

undgåelige dødsfald

Traumemodtagelse

Page 6: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

The golden hour

Traumemodtagelse

Page 7: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Det er vanskeligt at håndtere en tilskadekommen patient!

Traumemodtagelse

Page 8: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Det er vanskeligt at håndtere en tilskadekommen patient!

patienterne er ikke ens

• forskellige personer

– alder

– køn (herunder graviditet)

– komorbiditet (herunder fedme)

– medicinforbrug

Traumemodtagelse

Page 9: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Det er vanskeligt at håndtere en tilskadekommen patient!

patienterne er ikke ens

• forskellige traumemekanismer

– skarp, ofte lokaliseret til kun én region

– stump, ofte lokaliseret til flere regioner

– hypotermi/drukning

– forurening (kemisk, biologisk, nuklear)

– m. fl.

Traumemodtagelse

Page 10: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Det er vanskeligt at håndtere en tilskadekommen patient!

patienterne er ikke ens

• forskellige læsioner

– brækket ben

– leverkontusion

– rygfraktur

– osv. osv.

Traumemodtagelse

Page 11: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Det er vanskeligt at håndtere en tilskadekommen patient!

prioriteringen

• hvad skal man behandle først

• hvad ser - diagnosticerer - man først

• undersøgelse / behandling - rækkefølge

Traumemodtagelse

symptombehandling før undersøgelse

Page 12: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Det er vanskeligt at håndtere en tilskadekommen patient!

altid tilstede

• tidspres

• dynamik

Traumemodtagelse

Page 13: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Det er vanskeligt at håndtere en tilskadekommen patient!

erfaring og rutine

• relativt få konfrontationer for hver enkelt

Traumemodtagelse

Page 14: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Det er vanskeligt at håndtere en tilskadekommen patient!

U-ha…- det er noget værre noget

• U-vished

• U-overskuelighed

• U-forudsigelighed

• U-sikkerhed

• U-beslutsomhed

• U-klarhed

Traumemodtagelse

Page 15: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

• Fejl i traumesystemer

– Fejl* i 2,5 % af døde ved traumemodtagelser(Gruen et al. Ann Surg 2006;244:371–380)

– Fejl* i 9,9 % af døde ved traumemodtagelser(Ivatury et al. J Trauma. 2008;64:265–272)

*): fejl målt ved ”maximal impact” = død.

En endnu større del udgør non-maximal impact

Traumemodtagelse

Page 16: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Major Patterns of Errors Contributing to Trauma Mortality(Gruen et al. Ann Surg 2006;244: 371–380)

Hemorrhage control• Delayed control of intrathoracic/abdominal/pelvic hemorrhage• Failure to rewarm and/or correct coagulopathy

Airway management• Unsuccessful intubation and delayed surgical airway• Failure to secure or protect airway

Management of unstable patients• Unduly long initial operative procedure in unstable patient• Inappropriate interhospital transfer of unstable patient• Unstable patient sent to CT scanner

Missed or delayed diagnoses• Intracranial hemorrhage• Intraabdominal injury• Pericardial tamponade

Traumemodtagelse

Page 17: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Occurrence of Errors by Phase of Trauma Management(Gruen et al. Ann Surg 2006;244: 371–380)

• 34% of errors occurred in the ED (20% during initial assessment and resuscitation, 14% during the secondary survey and initial diagnostictests)

• 8% during stabilization and interhospital transport

• 11% during initial interventions (surgery and/or angiography)

• 37% during the intensive care unit stay

• 9% during the general or rehabilitation ward

Traumemodtagelse

Page 18: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

• Dårlige traumemodtagelser

– Manglende eller uklart lederskab

Traumemodtagelse

Page 19: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Hvordan optimeres den tidlige indsats?

• kendt viden

• kendte (simple) håndgreb

• struktureret og ensartet tilgang

• lederskab

• træning

• evaluering

Traumemodtagelse

Page 20: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Håndtering af traumepatienten

• forud-fastlagte retningslinier for modtagelsen

• forud-fastlagte opgaver for personalet

• behandle alle ens i den primære fase

Traumemodtagelse

Traumemanual

Page 21: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Håndtering af traumepatienten

• primær gennemgang

• primær behandling af manifeste eller potentielt livstruende tilstande

• vekslen mellem gennemgang og behandling

• sekundær gennemgang

• plan for videre undersøgelse/behandling

Traumemodtagelse

Page 22: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumepatienten

• Den ”klassiske opfattelse”

– Seneste 20 – 30 år (siden midt-firserne)

– ”Definition”

– Hvem er / hvor er traumepatienten?

• Triage

• En anden (nyere) opfattelse?

– Højst små justeringer

• Triage

Page 23: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumepatienten

• Triagekriterierne

– Mekanisme

• tiltagende mindre betydning

– Anatomi

– Fysiologi

Page 24: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumemekanisme - højenergi

• stor energi (herunder acceleration eller deceleration) påvirker kroppen

• indikatorer for stor energi er (bl. a.) stor masse

eller stor hastighed

Traumepatienten

Page 25: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumemekanisme - højenergi- eksempler

− person i samme (eller modkørende) bil er dræbt

− person fastklemt

− bil er svært deformeret

− person kastet ud af bil

− bil er kastet rundt

− fodgænger er kastet gennem luften

− fodgænger er påkørt med mere end 30 km/t

− person er faldet mere end 5 meter

Traumepatienten

Page 26: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Anatomisk lokalisation

• store luftveje – hals, thorax

• respiratorisk væv – thorax

• store blodkar – hals, thorax, abdomen, lyske, axil

• mange blodkar – bækken, skalp, ansigt

• centralnervesystem – kranie, nakke

gælder synlig skade

- eksempler

Traumepatienten

Page 27: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Fysiologisk status

• påvirket luftvej?

• påvirket oxygenering?

• påvirket cirkulation?

• påvirket centralnervesystem?

Traumepatienten

Page 28: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Fysiologisk status - tegn på dårlig patient

• dyspnø

• fugtig hud

• cyanose

• bleg

• bevidstløs

Traumepatienten

Page 29: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Fysiologisk status - tegn på dårlig patient

• respirationsfrekvens < 10 eller > 30

• hjertefrekvens < 50 eller > 120

Normal fysiologi ?

Traumepatienten

Page 30: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Prætraumatisk status

• komorbiditet - medicinforbrug

• alder

børn

unge atlet-typer

ældre

• graviditet

• overvægtSkærpet opmærksomhed!

Traumepatienten

Page 31: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumepatienten

• Diagnostisere– Alt / mest muligt som patienten fejler

»Undgå undertriage

• Udelukke– Det ”vigtige”, det ”farlige”

»Undgå undertriage

– Det som patienten alligevel ikke fejler

»Undgå overtriage

Page 32: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumepatienten

• Redskaber

– Klinisk undersøgelse (se-føl-lyt)

• Dårlig

• Ufarlig

• Kræver få ressourcer (og dog: rutine og erfaring er en ressource!)

Page 33: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Traumepatienten

• Redskaber

– Paraklinisk undersøgelse

• Invassiv

– God eller ikke-god

– Komplikationer/bivirkninger

– Ressourcekrævende

• Non-invassiv

– God eller ikke-god

– Komplikationer/bivirkninger

– Ressourcekrævende

Man skal ikke være tilbageholdende og

defensiv, men man skal tænke sig (godt) om!

Røntgenundersøgelse er en strålebelastning!

Page 34: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

BilleddiagnostikRtg. thorax

UL abdomen

Rtg. bækken

Rtg. / CT columna cervicalis

CT cerebrum

CT thorax-abdomen

Angiografi (CT-angio)

Knogle rtg. / CT / CT-scout

Traumepatienten

Page 35: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

TraumeteamTraumeteam

Ortopædkirurg

Anæstesiolog

Anæstesisygeplejerske x 2

Skadestuesygeplejerske x 2

Radiolog

Radiograf

Bioanalytiker

Sekretær

Serviceassistent

Abdominalkirurg

Neurokirurg

Plastikkirurg

Thoraxkirurg

Urolog

Kæbekirurg

Gynækolog

PædiaterBestemt af lokale forhold.

– teamleder?

Page 36: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Patientens ankomst

Tilstand (ABC)?

Vitalparametre?

Skal der handles straks?

Dokumentér fra begyndelsen!

- så handl!

TraumeteamTraumeteam

Page 37: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

•ambulance-behandler•præhospital-læge•helikopter-læge•læge fra overflyttende sygehus•(pårørende/vidner)

The MIST handoverMechanism of injuryInjuries observed (erkendt eller mistænkt)Vital SignsTherapy instituted (og effekt heraf)

traume-team

Overlevering af patient

TraumeteamTraumeteam

Page 38: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Primær og sekundær gennemgang

TraumeteamTraumeteam

Page 39: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Primær gennemgang

ABCDE

TraumeteamTraumeteam

Sikre en luftvej.

Sikre en ventilation.

Sikre en cirkulation.

Vurdere dysfungerendenervesystem.

”Afdække” patienten i erkendelse af det miljøpatienten kom fra og under hensyntagen til det miljøpatienten nu er i.

Page 40: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Sekundær gennemgang

TraumeteamTraumeteam

Systematisk

– anamnese

– undersøgelse

– observation

Sekundær billeddiagnostik

Page 41: Hvorfor og hvordan · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during initial assessment

Afslutning

TraumeteamTraumeteam

Plan for videre undersøgelse og behandling.

Aflevering af patienten.


Sara Gruen - Apa pentru elefanti.pdf - Romana

Antidote to the errors of Universalism

CHAPTER 2 Caselette - Correction of Errors

Chapter 7 Correction of Errors [II]: Errors Affecting …proxy.flss.edu.hk/~flssmcwong/S5 Notes/Chapter 7...1 Chapter 7 Correction of Errors [II]: Errors Affecting Trial Balance Agreement

Fileshare.ro_apa Pentru Elefanti-Sara Gruen

Ronda - Cousins UK · Ronda No 1171 Gruen 1172 Gtuen 1173 Gruen 1174 Sltallord 1 175 Gruen 1176 Gruen 1177 As 1 178 Gruen "1 179 Gruen 1180 Gruen 1 1 81 Eberhard ""1182 Gruen 1 1

A Freundschaft Gruen (1)

© 2007 Thomas W. Gruen Thomas W. Gruen, Ph.D. A Ruptura na Indústria do Varejo: Buscando uma Solução

Notification Errors & Omissions Excepted Revised Result of

James Tam Psychology of Everyday Things Pathological designs Many human errors result from design errors Human factors

Scrutinizing bit-and symbol-errors of IEEE 802.15.4 Communication in Industrial Environments

Journal of Inborn Errors of Metabolism & Screening · Diagramação e XML SciELO Publishing Schema: [email protected] 2 Journal of Inborn Errors of Metabolism Screening

Compensation for Dynamic Errors of CMMs

An Analysis of Errors Caused by Omani EFL Learners in

Shakespeare - The Comedy Of Errors

Traumemodtagelse · 2018-08-20 · Occurrence of Errors by Phase of Trauma Management (Gruen et al. Ann Surg 2006;244: 371–380) • 34% of errors occurred in the ED (20% during

Estimation of 3D reconstruction errors in a stereo-vision ... · Estimation of 3D reconstruction errors in a stereo-vision system ... the quality of the 3D reconstruction depends

ME EN 7960 – Precision Machine Design Topic 21 ME EN 7960 – Precision Machine Design – Fundamentals of Errors 2-1 Fundamentals of Errors ME EN 7960 – Precision Machine Design

Sheet1Volvo VOL136 Gruen,M.,2C Volvo 169 Gruen/Vert,M.,2C Volvo 531 Gruen/Vert,M.,2C Volvo 69 Gruen/Vert,M.,2C Volvo VOL9111 Gruen/Vert,M.,2C Volvo 115 Gruenblau,M.,2C Volvo VOL115

Sara Gruen - Apa Pentru Elefanti

gruen A1services

gruen - mehr kommunikation und sicherheit

FACTORS OF DEVIATION CAUSES IN TAFSIR (Causes of Errors

Numerical Simulations of Multipole Errors and Fringe Fields in ......2011/09/08  · Numerical Simulations of Multipole Errors and Fringe Fields in the 1.5-TeV Muon Collider Lattice

A Study on the Characteristics of Global Errors …...identify unique errors at certain levels of overall writing ability. The result was that learners at any level can make global

deutschebahn.com/gruen Deutsche Bahn. · deutschebahn.com/gruen W.. Nr. 05 deutschebahn.com/gruen Das ist grün. V O₂.. Nr. 06 deutschebahn.com/gruen Das ist grün. Nr. 07 deutschebahn.com/gruen

gruen A1 Cloud

Gruen opicja%20hisa300dpi

Common Sentence Errors - Saddleback College am taking English, ... Are these errors? Fragments can be acceptable in certain types of writing ... Common Sentence Errors Author:

Errors in Rational Number Operations: A Case of DEBESMSCAT Preservice Teachers

Dr. Prabhakar Singh SEM-IV_Inborn Errors of Metabolism

The Effect of Errors of Fragmentation Functions on the Analysis of Parton Helicity Distribution

Inborn errors of metabolism

Apa Pentru Elefanti Sara Gruen

Goldloeckchen gruen