special consideration of pre-hospital trauma …...• monitor ventilatory rate, spo 2, and etco 2...
TRANSCRIPT
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Department of Trauma and
Emergency Medicine
Phramongkutklao Hospital
Special Consideration ofPre-Hospital Trauma Patient Care
Thanananan Isarangura na Ayutthaya MD EPNat Krairojananan MD FRCST
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Department of Trauma and Emergency
Medicine
• Traumatic brain injury• Burn• Confined space medicine
Scope
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Department of Trauma and Emergency
Medicine
Traumatic Brain Injury
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Department of Trauma and Emergency
Medicine
Pathophysiology of CNS Injury
Primary injury• Direct damage to the brain
Secondary injury• Systemic causes• Intrinsic causes
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Department of Trauma and Emergency
Medicine
Pathophysiology of secondary CNS injury
Systemic causes Intrinsic causesHypoxiaHypotensionAnemia (blood loss)Increased or decreased CO2
Increased or decreased blood glucose
Increased intracranial pressure (ICP)EdemaHematomasSeizures
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Department of Trauma and Emergency
Medicine
CNS Injury Management
• A-B-C• Spinal motion restriction• D-E• Transport and destination decisions
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Department of Trauma and Emergency
Medicine
Airway
• Open AW under spinal motion restriction: Jaw thrust or chin lift• Clear AW: suction • Maintain AW: need of definitive AWo Protection: tongue, FBo Ventilation
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Department of Trauma and Emergency
Medicine
BreathingProvide 100% oxygen
• Goal 95% oxygen saturation or higherAssist ventilations (as needed)
• Maintain normal ETCO2 at 35 to 40 mm Hg• Ventilation rateso Adults : 10 to 12 breaths/mino Pediatric : 12 to 20 breaths/min
No routine hyperventilation
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Department of Trauma and Emergency
Medicine
Hyperventilation indicated for:• Bilateral dilated and unresponsive pupils or Unequal pupils (with altered LOC)• Abnormal posturing• Neurologic deterioration Decreased GCS > 2 points in patient with initial GCS < 9
Ventilatory rate Hyperventilation target• Adult : 20 breaths/min ETCO2 30–35 mm Hg• Child : 25 breaths/min• Infant : 30 breaths/min
Hyperventilation
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Department of Trauma and Emergency
Medicine
Circulation
• Control hemorrhage• Prevent secondary brain injury• Maintain adequate BP by hypotensive resuscitation,
maintain SBP 90-100 mmHg
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Department of Trauma and Emergency
Medicine
Neurologic assessment for disability
Conduct in the ambulanceThe complete neurologic examinations
• Level of consciousness• Pupillary reaction• Motor function• Sensory function
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Department of Trauma and Emergency
Medicine
AVPU
• Alert
• Responds to Verbal stimulus
• Responds to Painful stimulus
• Unresponsive
Glasgow Coma Scale (GCS)
• scored after the A-B-C assess and correct
• Mild-Moderate-Severe
• modified GCS for pediatrics
Level of Conscious Assessment
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Department of Trauma and Emergency
Medicine
Pupils Assessment
• Determine increasing of intracranial pressure• Normally equal, round, and 3 to 5 mm in size• Light in one pupil should constrict both• Consensual light reflex tests CNs II and III
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Department of Trauma and Emergency
Medicine
Motor Function
upper extremities • Move the hands and arms• Squeeze your fingers
lower extremities • Wiggle the toes• Push and pull their feet against resistance
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Department of Trauma and Emergency
Medicine
Sensory Function
in conscious patient:• light touch perception in both upper and lower extremities
in unconscious patient• deep pain responseo Forehead rubo Nailbed compression
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Department of Trauma and Emergency
Medicine
Transport and destination
• Minimal scene time < 10 minutes• Supine position• Appropriate receiving facility• Reassessment
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Department of Trauma and Emergency
Medicine
Burn
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Department of Trauma and Emergency
Medicine
Spectrum of disease
• All severity of burns are not related in size
• Large burns might cause multiple organ systems
• Smoke inhalation can be life-threatening
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Department of Trauma and Emergency
Medicine
Burn Assessment: Depth
• Superficial (first-degree)
• Partial-thickness (second-degree)
o Superficial
o Deep
• Full-thickness (third- and fourth-degree)
Burn depth may progress over time
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Department of Trauma and Emergency
Medicine
Burn Assessment: extension
Burn size estimation
• Percent of body surface area (BSA)
• Rule of nines
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Department of Trauma and Emergency
Medicine
Primary Assessment in : A & B
Airway• swelling in smoke inhalation• Consider early intubation / surgical airway
Breathing• compromised from chest wall eschar• toxic pulmonary injury• Monitor ventilatory rate, SpO2, and ETCO2
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Department of Trauma and Emergency
Medicine
Circulatory
• fluid leaks into damaged tissue causing swelling
• Hypotension
• Concomitant injury
• IV access and fluid replacement by Parkland’s formula
Primary Assessment in Burn: C
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Department of Trauma and Emergency
Medicine
Disability
• Altered mentation indicated hypotension or hypoxia
Expose
• loss of body temperature
• Cover patient upon completion of assessment
Primary Assessment in Burn: D & E
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Department of Trauma and Emergency
Medicine
Burn Management: Specific burn therapy
• Stop ongoing burning: remove cloth• Cover with dry, sterile dressing • Do not apply ice• Do not use any ointments or topical antibiotic
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Department of Trauma and Emergency
Medicine
Burn Management: fluid administration
Parkland formulaTotal fluid in 1st 24 hrs (2–4 ml)(body weight: kg)(% BSA burned)
• First ½ given in the first 8 hours after burn
• Second ½ given in the next 16 hours after burn
• Adults: RLS
• Pediatric: 5% dextrose in RLS
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Department of Trauma and Emergency
Medicine
Burn Management: transfer to definitive care
• Analgesia• Transport to burn center as indicated• Monitor for hyperventilation, fluid overload, heat loss• Reassess the patient
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Department of Trauma and Emergency
Medicine
Confined Space Medicine
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Department of Trauma and Emergency
Medicine
Cause
• Natural: earthquake, storm, flood
• Manmade: explosion, accident
• Collapsed structure / building
• Rocks, trees
• Trapped in vehicle
Confined space
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Department of Trauma and Emergency
Medicine
• To rescue casualties trapped in confine space
• 35% of casualties are still alive
Confined Space Medicine (CSM)
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Department of Trauma and Emergency
Medicine
• Low lighting• Bad ventilation• Temperature• Tight space• Hazardous material• Risk for exposure to body fluids
Factors influence CSM
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Department of Trauma and Emergency
Medicine
Environment
• O2 deficit
• CO2 and other toxic gas from fire
Risk of secondary collapse
Scene sized up in CSM
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Department of Trauma and Emergency
Medicine
• Might spend hours in limited space along with patient
• Preventing sudden death from hyperkalemia and metabolic acidosis
• Prevent morbidity from infection and compartment syndrome
Principle of care in CSM
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Department of Trauma and Emergency
Medicine
• Decubitus ulcer• Infection from contaminating own urine and feces• Animals and insects bite• Hypothermia• Dehydration• Bleeding
Prolonged management in CSM
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Department of Trauma and Emergency
Medicine
• ‘Remote assessment’
• Assess and treat only exposed/ accessible part
Limited access
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Department of Trauma and Emergency
Medicine
• Rapid stabilize and extricate
• Immobilize as necessary
• Pain control
• Restrain for incorporate / unmovable patient
Increase patient outcome in CSM
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Department of Trauma and Emergency
Medicine
• Airway obstruction from impacted dust
• Crush syndrome
• Traumatic amputation
• Hypothermia / burn
• HAZMAT and blast injury
Spectrum of symptoms
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Department of Trauma and Emergency
Medicine
• Mostly from impacted dust• #1 cause of death in Kobe earthquake• Building components: plaster, tiles, silica• Block ventilation and gas exchange
• Rarely from blood, vomitus or tooth
Airway obstruction
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Department of Trauma and Emergency
Medicine
Increased mortality due to explosion in close space
• Primary blast injury: PTX, PE, ruptured TM, ARDS (sequelae)• Secondary blast injury: rare• Tertiary blast injury: crush injury, blunt injury, traumatic
asphyxia• Quaternary blast injury: burn• Quinary blast injury: toxic
Blast injuries in CSM
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Department of Trauma and Emergency
Medicine
• Open wound with delayed treatment wound infection• Contamination with dirty water, own urine and stool• Animals and insects bite
• Decontamination, wound cleansing• Prophylaxis antibiotics
Infection
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Department of Trauma and Emergency
Medicine
• Clean and cover all wounds• Immobilize all fractures / dislocation with non-compressive splint• High index of suspicious for compartment syndrome, neurovascular
injuries• Adequate pain control• Field amputation only for entrapped extremity with sign of ischemia
Extremities injury
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Department of Trauma and Emergency
Medicine
• Initiate treatment before extrication / lifting the overlay object
Cause of death• Early: cardiac arrhythmia and hypovolemia• Late: renal failure and infection
Crush and Reperfusion Syndrome
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Department of Trauma and Emergency
Medicine
• Before extrication / lifting the overlay object • Initiate IV fluid: NSS load• connected with T-way• Syringe filled with calcium gluconate, Sodium bicarbonate, RI and glucose• ECG monitoring
Prevention of EARLY death from crush syndrome
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Department of Trauma and Emergency
Medicine
• Treatment of traumatic rhabdomyolysis• IV fluid load• Alkalinizing urine?
Prevention of LATE death from crush syndrome
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Department of Trauma and Emergency
Medicine
Question