Presentation is loading. Please wait.

Presentation is loading. Please wait.

การดูแลรักษา ผู้บาดเจ็บฉุกเฉินที่ ทรวงอก ประวัติ พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า แพทย์ใช้ทุน รพ. สก. พร. แพทย์ใช้ทุน.

Similar presentations


Presentation on theme: "การดูแลรักษา ผู้บาดเจ็บฉุกเฉินที่ ทรวงอก ประวัติ พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า แพทย์ใช้ทุน รพ. สก. พร. แพทย์ใช้ทุน."— Presentation transcript:

1

2 การดูแลรักษา ผู้บาดเจ็บฉุกเฉินที่ ทรวงอก

3 ประวัติ พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า แพทย์ใช้ทุน รพ. สก. พร. แพทย์ใช้ทุน รพ. สก. พร. วุฒิบัตรสาขาศัลยศาสตร์ทั่วไป วุฒิบัตรสาขาศัลยศาสตร์ทั่วไป วุฒิบัตรสาขาศัลยศาสตร์ทรวงอก หัวใจ และหลอดเลือด วุฒิบัตรสาขาศัลยศาสตร์ทรวงอก หัวใจ และหลอดเลือด อนุมัติบัตรสาขาเวชศาสตร์ครอบครัว อนุมัติบัตรสาขาเวชศาสตร์ครอบครัว ศัลยแพทย์ รพ. สก. พร. ศัลยแพทย์ รพ. สก. พร. หลักสูตรเสนาธิการทหารเรือ หลักสูตรเสนาธิการทหารเรือ นกพ. พร. และ หน. แผนกศัลยกรรม รพ. ทร. กรุงเทพ นกพ. พร. และ หน. แผนกศัลยกรรม รพ. ทร. กรุงเทพ ผบ. พัน พ. กรม สน. สอ. รฝ. ผบ. พัน พ. กรม สน. สอ. รฝ. นยก. พร. และ หน. แผนกศัลยกรรม รพ. ทร. กรุงเทพ นยก. พร. และ หน. แผนกศัลยกรรม รพ. ทร. กรุงเทพ หน. แผนกศัลยกรรมทรวงอก รพ. ปก. พร. และ รรก. รอง หก. กวตบ. พร. หน. แผนกศัลยกรรมทรวงอก รพ. ปก. พร. และ รรก. รอง หก. กวตบ. พร.

4 Introduction Trauma is leading cause of death, long-term disability for all ages from first –forty years. 25% of all trauma death due to chest injuries 20-33% death preventable. Deaths occur within first 4 hours trauma. 85% of pt with life threatening injuries can be managed simple interventions easily mastered by physicians and ER service personnel Most life-threatening injuries identified in primary survey

5 Trimodal Death Distribution

6 CAUSES OF THORACIC TRAUMA: Falls Falls  3 times the height of the patient Blast Injuries Blast Injuries  overpressure, plasma forced into alveoli Blunt Trauma Blunt Trauma PENETRATING TRAUMA PENETRATING TRAUMA

7

8 6 Immediate Life Threats 1.Airway obstruction 2.Tension pneumothorax 3.Open pneumothorax “sucking chest wound” 4. Flail chest 5. Massive hemothorax 6. Cardiac tamponade

9 ADVANCE TRAUMA LIFE SUPPORT CONCEPT The most important was to treat the greatest threat to life first. The definitive diagnosis should never impede the application of an indicated treatment. A detailed history was not essential to begin the evaluation of an acutely injured patient ABCDE-approach to evaluation and treatment

10 GOALS Rapid, accurate, and physiologic assessment Resuscitate, stabilized and monitor by priority Determine needs, and capabilities Prepare to transfer to definitive care Assure optimal, safe patient care “The primary focus of ATLS is on the first hour of trauma management, rapid assessment and resuscitation”

11 ADVANCE TRAUMA LIFE SUPPORT 1. Preparation 2. Triage 3. Primary survey ( A B C D E ) 4. Resuscitation 5. Adjuncts to primary survey and resuscitations 6. Secondary survey (head ‐ to ‐ toe) 7. Adjuncts to the secondary survey 8. Continued post ‐ resuscitation monitoring and resuscitation 9. Definitive care

12 Initial assessment and management

13 Standard precaution Cap Cap Gown Gown Gloves Gloves Mask Mask Shoe covers Shoe covers Goggles/face shield Goggles/face shield

14 Primary survey: Airway Assess for airway patencyAssess for airway patency Airway obstructionAirway obstruction SnoringSnoring GurglingGurgling StridorStridor Rocking chest wall movementRocking chest wall movement Maxillofacial injury / laryngeal injuryMaxillofacial injury / laryngeal injury Things to remember... C-Spine Protection

15 Assessment: Breathing Inspection RR, paradoxical,symetrical motion of the chest wall, or obvious chest wounds. Palpation should seek pain, crepitus or subcutaneous emphysema as clues to underlying pathology. Auscultation of the lung fields may detect a pneumothorax or hemothorax before a chest x-ray is performed, as well as assessing the adequacy of air entry. Percussion theoretically of use in differentiating between pneumo and hemothorax

16 Resuscitation :Breathing Supplemental oxygen Supplemental oxygen Ventilate as needed Ventilate as needed Tension pneumothorax Tension pneumothorax -Needle decompression -Needle decompression Open pneumothorax Open pneumothorax -Occlusive dressing -Occlusive dressing Reassess frequently Reassess frequently

17 TENSION PNEUMOTHORAX Air within thoracic cavity that cannot exit the pleural space Air within thoracic cavity that cannot exit the pleural space Fatal if not immediately identified, treated, and reassessed for effective management Fatal if not immediately identified, treated, and reassessed for effective management

18 Tension Pneumothorax Each time we inhale, the lung collapses further. There is no place for the air to escape..

19 Tension Pneumothorax Each time we inhale, the lung collapses further. There is no place for the air to escape..

20 Tension Pneumothorax Heart is being compressed The trachea is pushed to the good side

21 EARLY S/S OF TENSION PNEUMOTHORAX ANXIETY! ANXIETY! Increased respiratory distress Increased respiratory distress Unilateral chest movement Unilateral chest movement Unilateral decreased or absent breath sounds Unilateral decreased or absent breath sounds

22 LATE S/S OF TENSION PNEUMOTHORAX Jugular Venous Distension (JVD) Jugular Venous Distension (JVD) Tracheal Deviation Tracheal Deviation Narrowing pulse pressure Narrowing pulse pressure Signs of decompensating shock Signs of decompensating shock

23 JVD & TRACHEAL SHIFT Decreased input and output from the heart with compression of the great vessels

24 JVD & TRACHEAL SHIFT Increased pressure moves mediastinum and compresses the lung on the uninjured side

25 MANAGEMENT OF TENSION PNEUMOTHORAX Asherman Chest Seal Asherman Chest Seal Needle Decompression Needle Decompression High flow oxygen (If available) High flow oxygen (If available) Chest Tube Chest Tube

26 Tension Pneumothorax Pleural Decompression 2nd intercostal space in mid-clavicular line at 2nd intercostal space in mid-clavicular line at TOP OF RIB Consider multiple decompression sites if patient remains symptomatic Consider multiple decompression sites if patient remains symptomatic Large over the needle catheter: 14ga Large over the needle catheter: 14ga Create a one-way-valve: Glove tip or Heimlich valve Create a one-way-valve: Glove tip or Heimlich valve

27 Needle Decompression

28 NEEDLE THORACENTESIS

29 Tension Pneumothorax Tension pneumothorax is not an x-ray diagnosis – it MUST be recognized clinically Treatment is decompression – needle into 2nd intercostal space of mid-clavicular line followed by thoracostomy tube  Respiratory distress  Distended neck veins  Tracheal deviation  Hyperresonance  Cyanosis (late)  Unilateral decrease in breath sounds

30 OPEN PNEUMOTHORAX Develops when penetration injury to the chest allows the pleural space to be exposed to atmospheric pressure - “Sucking Chest Wound” Develops when penetration injury to the chest allows the pleural space to be exposed to atmospheric pressure - “Sucking Chest Wound” Q- WHAT MAY CAUSE A SCW? Q- WHAT MAY CAUSE A SCW? Examples Include: Examples Include: GSW, Stab Wounds, Impaled Objects, Etc... GSW, Stab Wounds, Impaled Objects, Etc...

31 LARGE VS SMALL Severity is directly proportional to the size of the wound Severity is directly proportional to the size of the wound Atmospheric pressure forces air through the wound upon inspiration Atmospheric pressure forces air through the wound upon inspiration

32 S/S: OPEN PNEUMOTHORAX Shortness of Breath (SOB) Shortness of Breath (SOB) Pain Pain Sucking or gurgling sound as air moves in and out of the pleural space through the wound Sucking or gurgling sound as air moves in and out of the pleural space through the wound

33 Open Pneumothorax Dyspnea Dyspnea Subcutaneous Emphysema Subcutaneous Emphysema Decreased lung sounds on affected side Decreased lung sounds on affected side Red Bubbles on Exhalation from wound (Sucking chest wound) Red Bubbles on Exhalation from wound (Sucking chest wound)

34 Open Pneumothorax

35 Inhale

36 Open Pneumothorax Exhale

37 Open Pneumothorax Inhale

38 Open Pneumothorax Exhale

39 Open Pneumothoarx Inhale

40 Open Pnuemothorax Inhale

41 Open Pneumothorax Initial management High flow O2 High flow O2 Cover site with sterile occlusive dressing taped on three sides Cover site with sterile occlusive dressing taped on three sides Progressive airway management if indicated Progressive airway management if indicated

42 MANAGEMENT OF SCW Apply an Asherman Chest Seal Apply an Asherman Chest Seal  Occlusive dressing with a release valve Observe for development of a Observe for development of a Tension Pneumothorax Tension Pneumothorax

43

44

45 Hemothorax Occurs when pleural space fills with blood Occurs when pleural space fills with blood Usually occurs due to lacerated blood vessel in thorax Usually occurs due to lacerated blood vessel in thorax As blood increases, it puts pressure on heart and other vessels in chest cavity As blood increases, it puts pressure on heart and other vessels in chest cavity Each Lung can hold 1.5 liters of blood Each Lung can hold 1.5 liters of blood

46 Hemothorax

47 Hemothorax

48 Hemothorax

49 Hemothorax

50 Hemothorax

51 Hemothorax May put pressure on the heart

52 Hemothorax Lots of blood vessels Where does the blood come from.

53 S/S of Hemothorax Anxiety/Restlessness Anxiety/Restlessness Tachypnea Tachypnea Signs of Shock Signs of Shock Frothy, Bloody Sputum Frothy, Bloody Sputum Diminished Breath Sounds on Affected Side Diminished Breath Sounds on Affected Side Tachycardia Tachycardia Flat Neck Veins Flat Neck Veins

54 Treatment for Hemothorax ABC’s with c-spine control as indicated ABC’s with c-spine control as indicated Secure Airway assist ventilation if necessary Secure Airway assist ventilation if necessary General Shock Care due to Blood loss General Shock Care due to Blood loss Consider Left Lateral Recumbent position if not contraindicated Consider Left Lateral Recumbent position if not contraindicated RAPID TRANSPORT RAPID TRANSPORT Contact Hospital and ALS Unit as soon as possible Contact Hospital and ALS Unit as soon as possible

55 Flail chest “ Free-floating” chest segment, usually from multiple ribs fractures Pain and restricted movement Paradoxicalmovement of chest wall with respiration Clinical diagnosis Pulmonary contusion is the major problem

56 Flail chest

57

58  Oxygen  Aggressive pulmonary physiotherapy  Definitive treatment: reexpand the lung  Effective analgesia, intercostal nerve blocks,high segmental epidural analgesia  Intubation RR > 35 /min or < 8 /min PaO2 = 0.5 PaCO2 > 55 mm Hg at FiO2 >= 0.5 Alveolar-arterial oxygen gradient > 450 Severe shock Severe head injury Requiring surgery Internal splint

59 Massive Hemothorax  Hypovolemia & hypoxemia  ≥ 1500 mL BL; 1/3 of blood volume  Neck veins may be: Flat: hypovolemia Distended: intra - thoracic blood  Shock with no breath sounds and / or percussion dullness

60 Intercostal Drainage The “safe triangle”for insertion of ICD Cross-section of the intercostalspace

61 Assessment: Circulation  Hemorrhagic Shock External bleeding External bleeding Internal bleeding Internal bleeding  Non-hemorrhagic shock Cardiac tamponade Tension pneumothorax Neurogenic

62 Resuscitation :Circulation  Stop bleeding !  Restore circulating volume RLS 1-2 L Colloid / Blood component  Reassess frequently  Venous access Things to remember… Direct pressure Avoid blinding clamp

63 Resuscitation :Circulation Hypotension in thoracic trauma is usually associated with hypovolemia it should be aggressively treated initially with volume expansion with crystalloids while other possible etiologies, i.e. pneumothorax, cardiac tamponade and blunt cardiac injury are assessed. Arrhythmia should raise suspicion of blunt cardiac injury

64 Cardiac tamponade 1.Usually from penetrating injuries 2.Classic “Beck’s triad” elevated venous pressure - neck veins decreased arterial pressure - BP muffled heart sounds 3.Blood in sac prevents cardiac activity 4.May find “pulsus paradoxus” - a decrease of 10 mm Hg or greater in systolic BP during inspiration 5.Systolic to diastolic gradient of less than 30 mm Hg also suggestive


Download ppt "การดูแลรักษา ผู้บาดเจ็บฉุกเฉินที่ ทรวงอก ประวัติ พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า แพทย์ใช้ทุน รพ. สก. พร. แพทย์ใช้ทุน."

Similar presentations


Ads by Google