美国重症医学（FCCM）的基础教程 创伤和烧伤的处理

nullTrauma and Burn Management Trauma and Burn Management TRA * ®ObjectivesObjectivesReview initial assessment of the trauma patient Outline treatment of life-threatening injury Discuss use of radiography to identify injury Outline response to changes in patient’s status Discuss early burn managementTRA * ®Trauma Care PrinciplesTrauma Care PrinciplesSimultaneous assessment and treatment through a standardized approach If no improvement or decline in status, start over at primary assessment Early surgical involvementTRA * ®Primary Assessment – Airway / BreathingPrimary Assessment – Airway / BreathingAssume cervical spine injury Airway assessment and management Effects of facial/mandibular fracture Laryngeal/tracheal injury – ecchymosis, hoarseness, edema, subcutaneous air Flail chest from rib fractures Pneumo- / hemothoraces TRA * ®Primary Assessment – CirculationPrimary Assessment – CirculationHemorrhage is most common cause of shock Establish large-bore venous access Initiate fluid resuscitation with lactated Ringer’s solution Follow with packed red blood cells after 2–3 L of crystalloid Control external hemorrhage by compression Monitoring – data flow sheet, vital signs, ECG, pulse oximetry, CVP, arterial lineTRA * ®Hemorrhage ClassificationHemorrhage Classification Hemorrhage Blood Blood class loss loss (mL) (%) I <750 <15 II 750–1500 15–30 III 1500–2000 30–40 IV >2000 >40 Hemorrhagic ShockHemorrhagic ShockChest – hemothorax; drain and monitor Abdominal Intraperitoneal (lavage or sonography) Retroperitoneal (CT scan) Operative intervention Pelvis – usually venous; consider embolization, external stabilization TRA * ®Nonhemorrhagic ShockNonhemorrhagic ShockTension pneumothorax Tube thoracostomy Cardiac tamponade Consider mechanism of injury Venous hypertension with shock Pericardial window preferred over needle pericardiocentesisTRA * Nonhemorrhagic ShockNonhemorrhagic ShockBlunt cardiac injury Consider mechanism of injury ECG nonspecific Cardiac enzymes rarely helpful Monitor at least 4 hours Neurogenic shock Cervical/thoracic spinal cord injury Associated bradycardia Secondary AssessmentSecondary AssessmentIdentify potentially life-threatening injuries History of event, medical history, drugs, allergies, tetanus immunization Head to toe examination Fully expose patient Correct and prevent hypothermia Assess for signs of urethral injury Neurovascular integrityTRA * ®Secondary AssessmentSecondary AssessmentLaboratory data – arterial blood gas, blood counts, electrolytes, coagulation studies, type and cross-match, urinalysis, toxicology, etc Radiograph review Cervical spine – complete survey Chest – mediastinal evaluation; tubes/catheters Pelvis – major fractures Cystogram/urethrogram Skeletal exam Secondary AssessmentSecondary AssessmentCT scan of head CT scan of abdomen if indicated Other issues Nasogastric tube Tetanus prophylaxis Antibiotic indications Specialty consultationTertiary AssessmentTertiary AssessmentDetailed examination to detect all injuries Serial examinations over time to detect change and occult injuries Return to primary/secondary survey strategies for worsening status Surgical consultation/transfer planningTRA * ®Compartment SyndromesCompartment SyndromesAbdomen Compromise of venous return due to high intra-abdominal pressure Secondary to free blood, fluid, edema of abdominal contents Evaluate with measure of intrabladder pressure Surgical decompressionCompartment SyndromesCompartment SyndromesExtremity Serial examinations Pain, pallor, pulselessness, paresthesias, paralysis Fasciotomy Burn Injury – Primary AssessmentBurn Injury – Primary AssessmentAirway/breathing Upper and lower airway injury Carbon monoxide exposure Bronchoscopy for evaluation Consider early intubation Avoid succinylcholine TRA * ®Burn Injury – Primary AssessmentBurn Injury – Primary AssessmentCirculation Establish intravenous access Crystalloid resuscitation based upon extent and severity of burns Assess for circumferential injury Evaluate for other injuriesTRA * ®Assessment of Burn SeverityAssessment of Burn SeverityFirst-degree Erythema and pain Second-degree (partial-thickness) Red, swollen, blisters, weeping, painful Third-degree (full-thickness) White, leathery, painlessRule of NinesResuscitation – Burn ShockResuscitation – Burn ShockPrimary fluid loss from wound Secondary nonburn edema Principles Avoid excess fluid resuscitation but maintain organ perfusion Replace components of fluids lost as well as volume Replace blood as neededTRA * ®Resuscitation – Burn ShockResuscitation – Burn ShockLactated Ringer’s solution – crystalloid of choice Various formulae for amount and type of crystalloid and colloid resuscitation Parkland formula: 4 mL/kg  % of second- and third-degree burn estimates  body weight in first 24 hrs; deliver one-half calculated volume in first 8 hrs Aim for urine output 0.5-1 ml/kg/hr Cautious use of analgesiaBurn Wound CareBurn Wound CareGently wash and cover prior to transport Remove rings, bracelets Burn dressings controversial before transfer Consultation for specific wound care TRA * ®Chemical BurnsChemical BurnsInjury is caused by concentration of agent and duration of exposure Remove patient from source Remove clothing Brush off dry agent Irrigate copiously with waterElectrical InjuryElectrical InjuryEntry and exit wounds Secondary skin burns Flame burns from clothes Cardiac arrest Secondary injury – falls, muscle contraction, etc. Rhabdomyolysis and compartment syndromesPediatric ConsiderationsPediatric ConsiderationsSame general principles as for adults Orotracheal intubation with in-line stabilization Greater risk of injury after cricothyrotomy Diagnostic peritoneal lavage used less frequently Body surface area/body mass so higher risk of hypothermiaTRA * ®Pediatric ConsiderationsPediatric ConsiderationsInitial crystalloid bolus 20 mL/kg Hypotension is late finding of severe hypovolemia Blood added when crystalloid infusion >40 mL/kg Initial blood transfusion = 10 mL/kgTRA * ®Pediatric ConsiderationsPediatric ConsiderationsConsider child abuse when discrepancies exist between history and physical examination Laboratory Skull and skeletal radiographs Fundoscopic exam for hemorrhageTRA * ®Key PointsKey Points