การดูแลผู้ป่วยอุบัติเหตุที่ห้องฉุกเฉิน

. Why is Trauma Care Important? Leading cause of death in those <40 y 3rd leading cause of death in all ages Significant loss of work force productivity Background Trimodal distribution of death

50% die at scene What do they die of? 50% survive to hospital but then die 30% die during golden hour 20% die after prolonged hospital course In ER Patients in their Golden Hour must: Be recognized quickly Have only immediate life threats

managed Be transported to an APPROPRIATE facility In ER Survival depends on assessment skills Good assessment results from An organized approach Clearly defined priorities Understanding available resources Preparation yourself

1.Knowledge 2.Skill, 3.Healthy 4.Equipment,area 5.Adjunct 1. 2.,,

3. 4., 5. STANDARD PRECAUTIONS

-CAP - MASK - GOWN - SHOE COVERS - GLOVES - GOGGLES / FACE SHIELDS -*

- Mask - - - , -

1. (Primary Primary Survey) 2. (Primary Resuscitation) 3. (Primary Secondary Survey) 4. (Primary Definite Care) Looking

Listening Smelling Touching Feeling

1./ 2. 3. 4. Rectal exam, back 5. (, ,) 6.

Primary survey Airway Maintenance with Cervical Spine Protection Signs of airway obstruction Inspection for foreign bodies Chin lift or jaw thrust

GCS of 8 or less definitive airway management Prevent excessive movement of the cervical spine Inline immobilization techniques Breathing and Ventilation Assess chest wall excursion Auscultation Visual inspection and palpitation B : Breathing and Ventilation

Objective sign Look : Symmetrical expansion Paradoxical movement Location and depth of the wound Listen : Breath sound Pulse oximeter :

Measure oxygen saturation. B : Breathing and Ventilation Objective sign Pulse oximetry Pa O22 level O22 Hbg Saturation levels 90 90 mm

mm Hg Hg 100 100 % % 60 60 mm mm Hg Hg

90 90 % % 30 30 mm mm Hg Hg 60 60 % %

27 27 mm mm Hg Hg 50 50 % % Circulation with Hemorrhage Control 1. blood volume and cardiac output

Level of consciousness : impaired cerebral perfusion Skin color : gray skin of face, white skin of extremities Accessible central pulse (Primary Radial = 80 mmHg., femoral=70 mmHg., carotid=60 mmHg) Absent central pulses : immediate resuscitation Circulation with Hemorrhage Control 2. bleeding External hemorrhage is identified

and controlled in the primary survey Direct manual pressure Pneumatic splinting devices Tourniquets hemostat Disability (Primary Neurologic Evaluation ) Alert Verbal Pain Unresponse Pupillary size and reaction Lateralizing signs

Spinal cord injury level GCS Exposure/Environment Control Completely undressed Prevent hypothermia Warm blanket Warmed IV Warmed environment (Primary room temperature) What should you do

ET tube or not C spine protection

ICD or ET-tube ICD single or both Oxygen saturation 3 sides coverage NG tube or OG tube foley catheter Hemorrhage control FAST DPL Unseen wonud What should you do

Secondary survey A allergy M Medication P past illness / pregnancy L last meal E event / environment

Physical examination (trauma system) 1. Head 2. Maxillofacial 3. Neck 4. Chest 5. Abdomen 6. Perineum (Primary back , axilla) 7. Extremity 8. Neuro - exam Film x-ray

A airway trachea R L main bronchus ET tube position tube carina 2-3 cm. B breathing lung parenchyma pleural line costophrenic angle C cardiac shadow heart ratio 0.5 mediastinum 8 cm. D diaphragm , E emphysema subcutaneous emphysema

F Fracture rib Film C-spine A alignment 4 -anterior , posterior , spinolamina , spinous process B bone 2-7 C cartilage and disc prevertebral soft tissue swelling Film pelvis AP 6

Un corrected ER triage Uncontrolled Management system Medical personnels

Visitors and press Pitfall in primary survey and c-spine control Delay or inadequate airway control

Delay or undetection of c-spine injuries Delay or undetected chest injuries

Inappropiate fluid resuscitation Undetected wound of back or perineal wounds A blood pressure or an exact respiratory or pulse rate is NOT necessary to tell that your patient is critical !!!!!

If the patient looks sick, hes sick!!! primary survey c-spine chest injuries pelvis perinium rectal examination long bone

Investigation CT abdomen angiogram vascular Investigation injuries film chest, pelvis, c-spine multiple trauma investigate coma score

angiogram knee dislocation, fracture first rib widening mediastinum investigate hematocrit/blood pressure emergecy Investigation thoracotomy stable investigate

Common miss injury above clavicle

1. Open depressed skull fracture 2. Fracture Zygoma 3.Fracture maxilla 4.Nasal fracture 5.Bilateral mandibular fractures 6.Fracture of C-6 vertebra 7.Unequal pupils 8.Hemotympanum 9.Deviated Trachea

,

? Thank you

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