创伤与战伤 中山大学 外科学PPT文档.ppt

,Aims of this lecture,Know the physiological responses of our bodies following traumaKnow the features of different types of traumaLearn how to care an acutely injured patient based on the priorityKnow some general knowledge about weapon injury,Outline,Part I:Basic scientific knowledge about traumaPathophysiology of traumaWound healing Part II:TraumaEpidemiology&injury preventionClassification&triage Initial assessment&care Part III:Weapon InjuryBlast injuryNuclear weapon injuryChemical weapon injuryCombined injury,Part I:Basic scientific knowledge about trauma,Pathophysiology of traumaImmune response to traumaChanges in organ function following trauma Wound healing,Immune Response to Trauma,Dynamic stages in the immune response to trauma,Changes in organ function,Cardiovascular systemBlood loss,hypovolemia,shock,hear failureLungHypercapnia Hypoxia Adult Respiratory Distress Syndrome(ARDS)Acute Lung Injury(ALI)KidneyHypovolemia,renal hypoperfusion,Toxin-mediated(radiocontrast,antimicrobials)renal parenchymal injuryRhabdomyolysis LiverGastrointestinal tract:bleedingBrain,Wound Healing,A:inflammatory phase B.proliferation phaseC.Remodeling phase,Primary healing,Secondary healing,Part II:Trauma,Epidemiology&injury preventionClassification&trauma triageInitial assessment and care of the injured patientPrehospital phaseIn-hospital phase,The Facts about Trauma,Leading cause of deathOver all ages:Rank 4 Aged 1 to 44:Rank 1Aged 1-34:more than to all other causes of death combined Nonfatal Injuries(USA,2003)8%of all hospital discharges 37%of all emergency department visitsThe highest rate of injuryIn developing areas/countriesRapid economic change and urbanizationRoad traffic incidence causedGlobal:1.18 million deaths;30 million injuriesUSA:45,000 deaths;357,000 hospitalizationChina:120,000 deaths;550,000 injures,Lifetime Cost of Injury$406 Billion(USA,2000),Is Trauma Preventable?,Trauma Occurs randomly,unpredictably?Does not occur by accident!Primary preventionPrevent the occurrence of the trauma itselfSecondary preventionLimit energy transfer to the individualMinimize the severity of traumaTertiary preventionInstitute optimal care for the injured patient Improve outcome following trauma,Part II:Trauma,Epidemiology&injury preventionClassification&trauma triageInitial assessment and care of the injured patientPrehospital phaseIn-hospital phase,Classification,Base on the integrity of skinClosed injury Open injuryBase on the injury site Base on the mechanism of injury(MOI)Base on the severityRelated to the features,treatment options,and prognosis of trauma,Closed Injury,Open Injury,Classification based on the injury site,Classification based on MOI,Mechanical injuryBlunt injury:motor vehicle accident(MVA),fall,crushPenetrating injury:stab,impale,firearmBlast injury Temperature-associated injuryBurns,cold injuryFirearm-associated injury Special injuryChemical,biological,radiation injuryCombined injury,Classification based on the severityDisaster Triage,ParametersAbility to ambulateRespiratory functionSystemic perfusionLevel of consciousness,GreenWalking woundedRed:immediate transportRR30RR2RR30,CR2,unconscious Yellow:delayed transportBlack:unsalvageable,Simple Triage And Rapid Transport(START),Part II:Trauma,Epidemiology&injury preventionClassification&trauma triageInitial assessment and care of the injured patientPrehospital phaseIn-hospital phase,Algorithm for prehospital care,Scene Assessment,SafetyDangerous environmentsStandard precautionsBlood and body fluid may contain pathogensSituationNumber of patients and their agesNeed for additional assistancesKinematics-MOIMVAFallsOccupational/recreational injuryPenetrating injury,Initial Assessment,Primary surveyAirwayBreathingCirculationDisability(neurologic evaluation)Expose/environment controlSecondary survey,Immediate Measures at the Scene(Basic Life Support,BLS),Basic airway managementSupplemental oxygenRescue breathingCardiopulmonary resuscitation(CPR)Control of external hemorrhageFluid therapySpinal immobilization C-collarLong backboard,Golden Principles of Prehospital Trauma Care,Ensure the safety of the prehospital care providers and the patientAssess the scene situation to determine the need for additional resourcesRecognize the kinematics that produced the injuriesUse the primary survey approach to identify life-threatening conditionsProvide appropriate airway management while maintaining cervical spine stabilizationSupport ventilation and deliver oxygen to maintain an SpO2 95%Control any significant external hemorrhageProvide basic shock therapy,including restoring and maintaining normal body temperature and appropriately splinting musculoskeletal injuries,Golden Principles of Prehospital Trauma Care,Consider the use of the pneumatic antishock garment for patients with decompensated shock(SBP 90 mm Hg).Maintain manual spine stabilization until the patient is immobilized on a long backboardFor critically injured trauma patients,initiate transport to the closest appropriate facility within 10 min of arrival on sceneInitiate warmed,intravenous fluid replacement en route to the receiving facilityAscertain the patients medical history and perform a secondary survey when life-threatening conditions have been satisfactorily managed or have been rule outAbove all,do no further harm,Part II:Trauma,Epidemiology&injury preventionClassification&trauma triageInitial assessment and care of the injured patientPrehospital phaseIn-hospital phase,In-hospital Phase,Primary surveyResuscitationSecondary surveyMonitoring and investigationDefinitive care,Primary Survey,Airway maintenance with cervical spine protectionBreathing and ventilationCirculation with hemorrhage controlDisability,neurologic statusExpose/environment controlcompletely undressprevent hypothermia,Primary survey and resuscitation are all taking place simultaneously,Primary Survey-Airway,InspectionForeign bodyFacial,mandibular,tracheal/laryngeal FxAsking a simple questionnormal voiceSigns of possible airway compromiseweak voicebreathlessness,noisy breathing,labor breathinghoarsenessabsent responseagitationcombativenesscyanosis,Primary Survey-Airway,Common causes of airway obstructionTongueEdematous soft tissuesBloodForeign bodiesTeethVomitus,Primary Survey-Breathing&Ventilation,Expose the neck&chest Physical examinationInspection:chest wall injury,respiratory movementPalpation:chest wall,tracheal deviation,crepitusPercussion:air(heperresonance)or blood(dullness)in the chestAuscultation:bilateral breath soundsPulse oximeter(SpO2)Immobilization of the head and neck,Primary Survey-Circulation,Level of consciousnessSkinColor:Pink VS ashen,gray and whiteTemperaturePulseFull,slow,regularRapid,thready,irregular,absentBlood pressure(often misleading),Primary Survey-Circulation,Hemorrhagic shockExternal bleedingInternal bleeding(occult blood loss)Cardiogenic shockCardiac tamponadeCardiac contusionAir embolusMyocardial infarctionNeurogenic shockEarly septic shock,Primary Survey-Disability Neurologic Status,Glasgow coma scale(GCS)score=E+M+V(3-15)PupilsSizeSymmetryReaction to lightFrequent reevaluation,Eye opening(E)spontaneous 4To speech 3To pain 2None 1,Best motor response(M)Obeys commands 6 Localizes to stimulus 5 Withdraws to stimulus 4 Flexer posturing 3 Extensor posturing 2 None 1,Verbal response(V)Oriented 5Confused conversation 4Inappropriable words 3Incomprehensiable phonation 2None 1,Primary Survey-Exposure and Environmental Control,ExposureCompletely undressIdentify all external injuries(back,perineum)Environmental controlMonitor temperature(core temperature)Keep warm,Primary Survey,Airway:loss of airwayBreathing/ventilationTension pneumothoraxFlail chest with pulmonary contusionOpen pneumothoraxMassive hemothorax,CirculationMassive bleedingOpen woundThorax,abdomen,pelvisCardiac tamponadeDisabilityIntracranial mass,Immediately identify and treat life-threatening conditions,In-hospital care,Primary surveyResuscitationSecondary surveyMonitoring and investigationDefinitive care,Resuscitation,Lifesaving measures are initiated when the problem is identified,rather than after the primary surveyReevaluate frequently,Essential Principles,Resuscitation-AAirway Maintenance with C-spine Protection,Establish a patent airway Chin lift or jaw thrust maneuverClear of foreign body(suctioning)Oropharyngeal/nasopharyngeal airwayDefinitive airwayOrotracheal/nasotracheal intubationSurgical cricothyroidotomyCervical spine protection,OxygenationTight-fitting oxygen reservior face mask Nasal catheter Nasal cannula Nonrebreather maskVentilationTension pneumothoraxFlail chest with pulmonary contusionOpen PneumothoraxMassive Hemothorax,Resuscitation-B,Resuscitation-CHemorrhage Control:Direct Compression,Resuscitation-C Hemorrhage control:compress the artery proximally,Resuscitation-CHemorrhage Control:Tourniquet,Resuscitation-CHemorrhage Control,Pneumatic splint Pneumatic antishock garment(PASG)Surgical interventionThoracotomyCeliotomy(laparotomy)Surgical pelvic fixationSure the scalp,Resuscitation-CFluid Replacement,Vascular access linesIntraosseous needle insertion to the proximal tibia(6y)Initial fluid resuscitationWarmed balanced salt solution1 to 2 boluses(2 L to the adult,20 ml/kg to the child)Blood replacementFully crossmatched bloodType-specific bloodType O packed cellsAutotransfusion,Resuscitation-D&E,Disability(neurologic status)ABC:adequate perfusion and oxygen supply to the brain Spine protectionEnvironment control:keep warm!Warm roomsWarm blanketsWarm resuscitation fluidsWarm inspired air,In-hospital care,Primary surveyResuscitationSecondary surveyMonitoring and investigationDefinitive care,Secondary Survey,TimingPrimary survey is completedResuscitation efforts are well establishedPatient with normal vital functionsComplete history Head-to-toe evaluationReassessment of all vital signsComplete physical examination,Secondary Survey AMPLE history,AllergiesAvoid allergic reactionsMedications currently usedChronic conditionsPhysiological responses to the shockPast illness and operation/PregnancyLast mealPotential for vomiting and aspriationPatient with diabetesEvents/Environment related to the injury,Secondary Survey AMPLE history,Blunt traumaPenetrating traumaBurns and coldHazardous materialsChemicalsToxinsRadiationBiological agents,Events:mechanism of injury(MOI),Secondary SurveyHead-to-toe examination,HeadFaceNeckThoraxAbdomenPerineum/Rectum/VaginaSpine&extremityNeurological assessment,In-hospital care,Primary surveyResuscitationSecondary surveyMonitoring and investigationDefinitive care,Monitoring&Investigation,Monitoring Vital signs:HR,RR,T,BPOxygenation and ventilationCirculationInvestigationX-ray:chest,pelvis,spine,extremityCT:head,chest,abdomen,pelvis,spineUltrasonography:abdomen,pericardial sac Lab test,In-hospital care,Primary surveyResuscitationSecondary surveyMonitoring and investigationDefinitive care,Definitive Care,Injured site managementWound irrigation and debridementRepair&reconstruction:fracture fixation et al.Systemic managementFluid,electrolyte management and nutritional supportProphylaxis and treatment of complications,such as infection,organ disfunction(failure)Rehabilitation,Summary,Immediate management of the injured patientPrehospital careIn-hospital careAssess the patients condition rapidly and accuratelyPrimary survey:ABCDEsSecondary survey:AMPLE history,head-to-toe examinationAdjuncts:monitoring,imaging study,lab testResuscitate and stabilize the patient according to priorityABCDEsLifesaving followed by limb/organ salvageIntensive care&definitive care,Part III:Weapon Injury,Blast injuryNuclear weapon injuryChemical weapon injury,Blast Injury,Primary injuryA result of the physical properties of the blast wave Secondary injuryA result of projectiles resulting in penetrating injury Tertiary injuryInjuries caused from deceleration and structural collapse Quaternary injuryByproducts of that explosion,including burns,and chemical,and radiological exposure,Primary Blast Injury,Ear and eye injuryEardrums perforationEye contusionChest injuryPneumothoraces&lung injuryHeart injury Air emboli(pulmonary/coronary vessels)Abdomen injuryLiver&spleen injuryHollow viscus injury,Nuclear Weapon Injury,Blast waveFireball of the explosionThermal burnBlindnessRadiationGamma raysNeutrons,Chemical Weapon Injury,Nerve agentsBlister agentsSystemic agentsAsphyxiant agentsIncapacitating agentsIrritants,Take Home Messages,Trauma is a disease coupling with modernization,it is preventable.Primary injury,individual response and medical interventions are the major determinants of the patients outcome.Keep in mind!ABCDE for primary survey and resuscitation.Life-saving takes the first priority,followed by limb/organ salvage,Thank You for Your Attention!,