INITIAL APROACH TO THE TRAUMA Pt

 

212. INITIAL APROACH TO THE TRAUMA Pt

1. Notification by prehospital personnel

    airway patency

    pulse & respiration

    level of consciousness

    immobilization

    mechanism of injury & blood loss at the scine

2. preparation for receiving the trauma victim

    assign tasks to team members

    check & prepare vital equipment

    summon surgical consultant & other team members not present

3. primary survey

  1) airway

    clear airway : chin lift, suction, finger sweep

    protect airway :

     depressed level of consciousness or bleeding,

      tracheal intubation without neck movement

    surgical airway

    very agitated trauma patient :

      paralyzing agent ( succinylcholine or midazolam or vecuronium bromide)

      with a small dose of diazepam or midazolam

      emergency brain CT에 필수지만 neurologic evaluation에 장해

  2) breathing

    ventilate with 100% O₂

    check thorax and neck

      deviated trachea

      tension pneumothrax ( intervention - needle decompression )

      chest wounds & chest wall motion

      sucking chest wound ( intervention - occlusive dressing )

      neck & chest crepitation

      multiple broken ribs

      fractured sternum

      pneumothorax

    listen for breath sounds

      correct tracheal tube placement ?

      hemopneumothorax ?

       chest tube - 38 F : 1500 - 2000 ml blood가 나올때에는

         thoracotomy의 Ix.

       collect blood for autotransfusion

  3) circulation

    apply pressure to sites of external bleeding

    assure that two large - bore IVs established

     begin with rapid infusion of warm erystalloid solution ( 2 L )

     if arm sites unavailable insert a large central line or perform

       a saphenous cutdown at the ankle

    assess for blood volume status

     radial & carotid pulse, BP determination

     jugular venous filling

     quality of heart tones

     만일  radial pulse 가 촉지된다면 최소한 80 mmHg 임을 알 수 있다.

    Beck's triad present ? ( low BP, ↑venous pressure, muffled heart sound )

      : cardiac tamponade 의심

       Beck's triad positive 이고    

       tension pneumothorax 배제되고

       rapid volume infusion 에 반응이 없는 환자에게는

        pericardiocentesis를 시행해 볼수 있다.

   hypovolemia

     after 2 L of crystalloid begin blood infusion if still hypovolemic :

               chidren - use two 20 ml /kg

     then 10 ml /kg blood boluses if still unstable

   near term pregnant pt - place roll under right hip

 4) disability

     brief neurological examination

      pupil size & reactivity

      limb movement

      GCS

 5) continuing resuscitation

     moniter fluid administration

      consider central line for CVP monitoring :

       large volume infusion 할때에는 반드시 CVP monitor.

     use fetal heart rate as indicator in pregnant women

     record all events : vol, fluid, BP, PR, CVP, U/O, gastric suction vol.

                           neurologic status

4. secondary survey : a thorough search for injuries is carried out in order to

                        set further priorities

   trauma series X-ray : lateral cervical spine, supine chest, AP pelvis

   head-to-toe examination looking & feeling : quickly breng problems

        scalp wound bleeding controlled with Rancy clips

        hemotympanum

        facial stability

        epistaxis tamponaded with balloons if severe

        avulsed teeth, broken jaw

        penetrating injuries

        abdominal distension & tenderness

        pelvic stability

        perineal laceration / hematoma

        urethral meatus blood

        rectal examination for tone, blood, & prostate position

        bimanual vaginal examination

        peripheral pulses

        deformities, open fractures

        reflexes, sensation

   large gastric tube ( 32F )

    * facial trauma : basilar skull Fx. 위험성--> mouth로 insertion 한다.

   foley catheter inserted

    blood in urethra

    rectal exam상 prostate의 위치의 이상이 있을때에는

     urethra 의 손상을 의미하기 때문에 foley catheter insert 하지 않는다.

   pregnancy test

   deflate the MAST sequentially beginning with the abdominal

    MAST의 압력은 100mmHg으로 하되 2-3 시간이 지나면 skin의 necrosis를

          방지하기 위하여 20-30 mmHg 정도의 감압이필요하다

   portion if the BP is near normal :

    5-10 min 이상의 shock : bicarbonate therapy를 생각해 볼 수있다.          

   log-roll the pt to feel & see the back, flanks, & buttocks

   splint unstable fx / dislocations

   assure that tetanus prophylaxis is given

   consult with surgeon regarding further tests or immediate need for surgery or

        preferred IV medications : consider

        emergency thoracotomy to provide aortic compression or cross- clamping

        aortogram or upright chest x-ray to r/o ruptured aorta

        cystogram if pelvic fracture present or blood in urine

        IVP or cnhanced CT scan of the abdomen

        diagnostic peritoneal lavage : open or closed

        head CT scan

        IV mannitol for neurologic decompensation

        IV steroids for possible ruptured abdominal vescus

        IV antibiotics for possible ruptured abdominal viscus

        IV antibiotics for perineal, vaginal, or rectal laceration

        pelvic arteriogram and embolization for pelvic hemorrhage