initial management in trauma patient - chiang mai …...initial management in trauma patient...
TRANSCRIPT
Initial Management
in
Trauma Patient
ผศ.นพ.ก ำธน จนทรแจม
หนวยศลยศำสตรอบตเหตและวกฤต ภำควชำศลยศำสตร
คณะแพทยศำสตร มหำวทยำลยเชยงใหม
OVERVIEWS
• Initial assessment and resuscitation for trauma
patient
• Advanced Trauma Life Support (ATLS) 10th
Edition
Advanced Trauma Life Support (ATLS)
• หลกสตรมำตรฐำนส ำหรบ
ผปฏบตงำนดแลผบำดเจบ
กอนทหองฉกเฉนในชวงแรก
• เพอลดอตรำกำรเสยชวตจำก
กำรบำดเจบ
• Edition 10 (update 2017)
Trimodal Death Distribution
Preparations
• Universal precaution
• Cap
• Mask / Shield / Goggles
• Gown
• Gloves
• Shoes / Shoes cover
กำรคดแยกผบำดเจบ (Triage)
• Multiple Casualties จ ำนวน
ผบำดเจบไมมำก สำมำรถรกษำ
ไดทกคนดวยทรพยำกรทม รกษำ
ผทมอนตรำยตอชวตมำกทสด
กอน
• Mass Casualties ทรพยำกร
จ ำกด เมอเทยบกบจ ำนวน
ผบำดเจบ รกษำผทมโอกำสรอด
ชวตกอน
Concepts of ATLS
Adjunct to primary survey
Consider need for transfer
Secondary survey (head to toe evaluation and history)
Adjunct to secondary survey
Primary survey and simultaneous resuscitation
Continue monitoring & Re-evaluation
Definitive care VS Transfer
Primary Survey
• A : Airway maintenance with restriction C-spine motion
• B : Breathing and Ventilation
• C : Circulation and Hemorrhagic control
• D : Disability (Assessment of neurological status)
• E : Exposure and Environmental control
Airway & Restriction C-spine motion
• First priority !!!
• Quick assessment : ถำมผปวย
• ตรวจรำงกำย : Signs of airway obstruction (stridor, เลอด
secretion, FB เปนตน
• Protection of C-spine ตลอดเวลำทประเมนและดแลทำงเดน
หำยใจ
• Severe Maxillo-facial injury
Potential Airway Compromise
• Inhalation injury (Facial burn)
Potential Airway Compromise
• Neck injury (blunt & penetrating)
Potential Airway Compromise
Exclusion of C-spine injury
NEXUS
criteria
• MILS, remove collar
• Palpation for
tenderness
• Rotation
• Neck flexion
Restriction of C-spine
• สวม Philadelphia's collar และ
ใหผปวยนอนบน Long spinal
board
• ตด Head immobilizer และม
Straps รด
• Further investigation
Airway Maintenance Techniques
Basic or Temporary airway
maintenance
• Chin lift / Jaw thrust
• Suction and removal of FB
• Oropharyngeal /
Nasopharyngeal airway
• Restriction of C-spine with MILS
!!
Basic Airway Maintenance
Chin Lift
• With Manual in line stabilization (MILS)
Jaw thrust
Basic Airway Maintenance
• Oropharyngeal Airway
Basic Airway Maintenance
• Nasopharyngeal
Airway
Airway Maintenance
Advance or Definitive airway maintenance
• Endotracheal Intubation : Orotracheal / Nasotracheal
Intubation
• Surgical Airway : Surgical Cricothyroidotomy /
Tracheostomy
Indications for Definitive Airway
• Apnea
• Airway compromise
• Protection from
aspiration
• Potential or Impending
airway compromise
• GCS < 9 (severe head
injury)
• Obtunded due to cerebral hypoperfusion
• Failed face mask
ventilation
Definitive Airway
• สวนมำกจะท ำเปน Orotracheal Intubation with Manual-in-
line Stabilization (MILS)
Definitive Airway
• Surgical Cricothyroidotomy
• ไมสำมำรถใสทอชวยหำยใจได
• ในผปวยทม Difficult airway เชน
severe maxillofacial injury
Surgical Cricothyroidotomy
Adjuncts Airway Maintenance
• Laryngeal Mask Airway (LMA)
• Laryngeal Tube Airway (LTA)
• Multi-lumen Esophageal tube
• Gum Elastic Bougie (GEB)
• Needle cricothyroidotomy with jet insufflation
• Video laryngoscopes
Laryngeal Mask Airway (LMA)
i-gel�supraglottic airway
Laryngeal Tube Airway (LTA)
Multi-lumen Esophageal Tube
Multilumen Esophageal Tube
Gum Elastic Bogie (GEB)
• แนะน ำใหใช GEB เมอใส orotracheal intubation ไมส ำเรจใน first
attempt หรอมองเหน vocal cords ไดยำก
• Needle Cricothyroidotomy with Jet Insufflation
Needle Cricothyroidotomy
Video Laryngoscope
Breathing & Ventilation
Evaluation by Physical Examinations
• ด (Look) : chest movement, แผล, neck vein
• คล ำ (Palpation) : trachea
• เคำะ (Percussion)
• ฟง (Auscultation)
Breathing & Ventilation
• Oxygen supplement
• Mask with reservoir bag at least 11 L/min
• Nasal cannula
• ET-tube with Mechanical ventilator
• ชวยหำยใจ (assist ventilation) กอน ระหวำง และ หลงกำรท ำ
definitive airway ในผปวยทม respiratory failure
Breathing & Ventilation
• ตรวจหำภำวะทเปน Immediate life-threatening injury ไดแก
Tension pneumothorax
Massive hemothorax
Open pneumothorax
Flail chest
Tension Pneumothorax
• Most treatable
• Dyspnea / abnormal chest
expansion
• Tracheal deviation, decrease
BS
• Hyperresonance on
percussion
• Hypotension, neck vein
distension
Tension Pneumothorax
Management
• Needle thoracocentesis
• 2nd ICS Midclavicular line
(ATLS ed9)
• ICD : no. 28-32, 5th ICS just anterior to midaxillary lineImmediately after needle
Management (ed 10)
• Needle thoracocentesis at 4-5th ICS slightly anterior to Midaxillary line : success rate มากกวา (แนะน าใหใชในAdult)
• Children : 2nd ICS MCL
• Finger decompression ถาใชเขมแลวไมส าเรจ
Massive Hemothorax
• Massive bleeding in pleural cavity / Shock
• Immediately drain > 1,500 cc from ICD
• Diagnosis (Clinical)
Dullness on percussion
Decrease breath sound
S/S of Shock
Massive Hemothorax
• Fluid resuscitation / blood
transfusions
• ใส ICD ประเมนวำมเลอดออกปรมำณ
เทำไหร
• ER thoracotomy / Emergency
thoracotomy
• Autotransfusion
Open pneumothorax
• Sucking chest wound
• Diagnosis : ทลมผำนเขำ-
ออก จำกแผลททรวงอก
• One-way valve : develop
tension pneumothorax
• Air pass through defect :
hypoventilation
Open pneumothorax
Management
• 3-sided sterile occlusive
dressing
• ICD หำงจำกแผล
• Temporary closure of
defect
Flail Chest
• เกดเมอม Segmental ribs fracture
ตดกน 2 ซหรอมำกกวำ
• Paradoxical chest movement
• เหนไดชดถำอยทำงดำน Anterior or
lateral part of chest wall
• อำกำรอน ๆ : Dyspnea,
subcutaneous emphysema,
decrease breath sound
Paradoxical chest
movement
Flail Chest
สำเหตของ Respiratory failure ใน flail chest
• Pain
• Hemothorax / pneumothorax
• Lung contusion
• Loss of lung mechanics (paradoxical
chest movement)
Flail Chest
Management
• ให Oxygen supplement
• ใส ICD ถำพบวำม Pneumothorax / Hemothorax
• ระวงไมให crystalloid fluid overload
• Control pain
• พจำรณำ intubation with mechanical ventilation (PaO2 < 60
mmHg or O2 sat < 90%)
Circulation & Hemorrhagic
control
• Identify patient's circulation : Shock ?
• หำสำเหตของ shock
• ให Fluid resuscitation
• Control hemorrhage แกไขสำเหตของ shock
Symptoms/Signs of Shock
• Blood pressure, Pulse rate, Respiratory rate
• Consciousness
• Peripheral pulse and perfusion : capillary refill,
temperature, sweating
• Urine output
• Base deficit
Causes of Shock
• Hypovolemic shock (most common) :
• External bleeding, chest, abdomen, pelvis and long
bone fracture
• Cardiogenic shock : cardiac tamponade, tension
pneumothorax, blunt myocardial injury, MI
• Neurogenic shock
• Septic shock
Management of Shock
• Control of hemorrhage
• แกไขสำเหตอน ๆ ของ shock
• Resuscitation
Control External bleeding
• Manual compression
• Splint and traction
• Elastic bandage
• Full thickness suture
• Tourniquet
• Others : Nasal packing
Direct pressure
&
Bandaging
Tourniquet
Pelvic Exam
Pelvic Binder for Pelvic Fracture
Pelvic Sheet Wrapping
Traction Splint for Femur Fracture
Cardiac tamponade
FAST (subxiphoid)
กำรรกษำ
• Pericardiocentesis
• Median sternotomy / Thoracotomy
Neurogenic shock
• Loss sympathetic tone เกดจำก spinal cord injury ระดบสง
กวำ T6
• Hypotension, no tachycardia, warmed skin
• กำรแกไขเบองตน :ใหสำรน ำใหเพยงพอ (Euvolumia), พจำรณำ
ให vasopressor
• Support ventilation ในรำยทมกำรบำดเจบสงกวำ C6 level
Resuscitation
Venous Access
• Large size angiocatheter (peripheral vein) - 18G
• Vital sign stable : 1 extermity
• Vital sign unstable : 2 extermities
• Upper > Lower extremity
Resuscitation
• Central venous access
Cut down (Saphenous vein)
Femoral / Subclavian vein
• Intraosseous cannulation :
ใชไดทกอำย / ใชช วครำวหลงจำกเปด peripheral line ไมได
• Obtain blood for LAB/Crossmatching
Intraosseous Cannulation
Femoral vein catheterization
Types of Fluid resuscitation
• Isotonic crystalloid solution (Warmed LRS, NSS, Acetar)
• Initial : 1 L bolus or 20 cc/kg (ถำ นน. > 40 kg) , without
aggressive resuscitation, frequent re-evaluation
• Precaution : Penetrating injury “permissive
hypotension” กอนจะท ำกำรผำตดในรำยท shock
Evaluation of Response
Transient / No Response
• Early blood and blood products
transfusion (hemostatic
resuscitation)
• PRC, FFP, platelets
• Exsanguination : PRC type O,
FFP type AB มไวท ER
• MTP (Massive transfusion
protocol)
MTP
• Protocol เพอทจะไดเลอดอยำง
รวดเรว - แตกตำงกนในแตละ
โรงพยำบำล
• แนะน ำ Low ratio (FFP:PRC
ระหวำง 1:1 ถง 1:2)
• รพ.มหำรำช MTP 1 box
ประกอบดวย PRC:FFP:platelet
อยำงละ 4 units
Transient / No Response
• Correct coagulopathy อยำงตรง
จด
• Thromboelastogram (TEG) or
Rotational
Thromboelastometry (ROTEM)
• Transamine 1 g IV in 10 min
then 8 hours (มประโยชนถำให
ภำยในเวลำ 3 ชม.)
Thromboelastogram (TEG)
Coagulation factors Fibrinogen Platelets
Disability (Neurological assessment)
• Brief baseline neurological assessment
Level of consciousness (new GCS)
Pupillary size and reaction
• ประเมนซ ำบอย ๆ
• Limbs movement
Exposure and Environment
control
• Completely undress in severe injured patient
• Logrolling : Exam back and Per-rectal examination
• Keep warm : ปองกนภำวะ hypothermia
Warm blanket, warm IV, external warming device
Adjuncts to Primary survey
Monitoring
• Vital signs
• Pulse oximetry, RR, ABG
• EKG
• End tidal CO2 : monitor adequate
ventilation, confirm ET tube in
trachea, ประมำณคำ cardiac output
และ predict ROSC ในกรณท ำ CPR
Adjuncts to Primary survey
Radiography
• CXR
• Pelvic X-ray
• FAST, eFAST
• should be performed in resuscitation area
CXR Interpretation
• D : Detail
• R : Rotation, Inspiration, Picture,
Exposure
• S : Soft tissue & Bone
• A : Airway
• B : Breathing
• C : Circulation
• D : Diaphragm
• E : Extra (tube & line)
FAST (Focused Assessment
Sonography in Trauma)
e-FAST (extended FAST)
Pneumothorax Hemothorax
Adjuncts to Primary survey
• Gastric tube : decompress
stomach (avoid NG tube in
patient with base skull
fracture)
• Urinary catheter :
precaution in BPH,
stricture
Bleeding per meatus Scrotal & Perineal ecchymosis
• contraindication for Foley's catheter
• Palpation of the prostate gland is not a reliable sign of
urethral injury
Suspected Urethral Injury
Retrograde Urethrogram
Consider need for Transfer
• ไมควรท ำ diagnostic investigation ทไมจ ำเปน ซงจะท ำให
delay transfer
• ท ำเฉพำะทชวยในเร อง resuscitate เพอใหผปวยมอำกำรคงท และ
ปลอดภยทจะ transfer ได
• Communication
Secondary Survey
• Perform after
Primary survey is completed
Resuscitation has been performed
Re-evaluation vital signs
• Complete history taking and Physical Examination
Secondary Survey
Essential Historical Element "AMPLE"
• A : Allergies
• M : Medications
• P : Past illness, Previous operation, Pregnancy
• L : Last meal
• E : Events & Environment related to injury
Secondary Survey
• Complete Physical Examination
• "Head to Toe"
• Prevent "Missed" injury
• รวมทงกำรท ำ PV ใน female patient with pelvic fracture
Adjuncts to Secondary survey
• กำรตรวจวนจฉยเพมเตม ส ำหรบกำรบำดเจบทตรวจพบทงหมด
X-rays for spine and extremities
CT scan
Contrast studies
Other diagnostic intervention
• ควรท ำเมอผปวยมสญญำณชพคงทเทำนน
Adjuncts to Secondary survey
C-spine clearance
• MDCT
• Plain X-ray ถำไมม MDCT
• Normal X-ray (adequate &
good interpreter) : remove
collar ท ำ flexion-extension
film
• Inadequate X-ray : MDCT
Adjuncts to Secondary survey
TL-spine clearance
• GCS 15, no pain or
tenderness, no neuro deficit
• ถำมไมครบ : MDCT
• ถำไมม MDCT : plain X-ray
with good quality &
interpreter
• Long spinal board : not more
than 2 hours
DEFINITIVE CARE
VS
TRANSFER