การดูแลรักษาผู้บาดเจ็บฉุกเฉินที่ทรวงอก

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

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

Trimodal Death Distribution

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

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

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

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”

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

Initial assessment and management

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

Primary survey: Airway Assess for airway patency Airway obstruction Snoring Gurgling Stridor Rocking chest wall movement Maxillofacial injury/ laryngeal injury Things to remember... C-Spine Protection

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

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

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

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

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

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

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

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

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

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

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

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

Needle Decompression

NEEDLE THORACENTESIS

Tension Pneumothorax 􀁺 Respiratory distress 􀁺 Distended neck veins 􀁺 Tracheal deviation 􀁺 Hyperresonance 􀁺 Cyanosis (late) 􀁺 Unilateral decrease in breath sounds 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

OPEN PNEUMOTHORAX 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? Examples Include: GSW, Stab Wounds, Impaled Objects, Etc...

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

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

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

Open Pneumothorax

Open Pneumothorax Inhale

Open Pneumothorax Exhale

Open Pneumothorax Inhale

Open Pneumothorax Exhale

Open Pneumothoarx Inhale

Open Pnuemothorax Inhale

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

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

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

Hemothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax May put pressure on the heart

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

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

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

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

Flail chest

Flail chest

Flail chest 􀁺 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 < 60 mm Hg at FiO2 >= 0.5 PaCO2 > 55 mm Hg at FiO2 >= 0.5 Alveolar-arterial oxygen gradient > 450 Severe shock Severe head injury Requiring surgery Internal splint

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

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

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

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

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

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