美国重症医学(FCCM)的基础教程 创伤和烧伤的处理

TraumaandBurnManagement

TRA1

®ObjectivesReviewinitialassessmentofthetraumapatientOutlinetreatmentoflife-threateninginjuryDiscussuseofradiographytoidentifyinjuryOutlineresponsetochangesinpatient’sstatusDiscussearlyburnmanagementTRA2

®TraumaCarePrinciplesSimultaneousassessmentandtreatmentthroughastandardizedapproachIfnoimprovementordeclineinstatus,startoveratprimaryassessmentEarlysurgicalinvolvementTRA3

®PrimaryAssessment–

Airway/BreathingAssumecervicalspineinjuryAirwayassessmentandmanagementEffectsoffacial/mandibularfractureLaryngeal/trachealinjury–ecchymosis,

hoarseness,edema,subcutaneousairFlailchestfromribfracturesPneumo-/hemothoracesTRA4

®PrimaryAssessment–CirculationHemorrhageismostcommoncauseofshockEstablishlarge-borevenousaccessInitiatefluidresuscitationwithlactatedRinger’ssolutionFollowwithpackedredbloodcellsafter2–3L

ofcrystalloidControlexternalhemorrhagebycompressionMonitoring–dataflowsheet,vitalsigns,ECG,pulseoximetry,CVP,arteriallineTRA5

®HemorrhageClassification Hemorrhage Blood Blood

class loss loss

(mL) (%) I <750 <15 II 750–1500 15–30 III 1500–2000 30–40 IV >2000 >40HemorrhagicShockChest–hemothorax;drainandmonitorAbdominalIntraperitoneal(lavageorsonography)Retroperitoneal(CTscan)Operativeintervention

Pelvis–usuallyvenous;considerembolization,externalstabilizationTRA7

®NonhemorrhagicShockTensionpneumothoraxTubethoracostomyCardiactamponadeConsidermechanismofinjuryVenoushypertensionwithshockPericardialwindowpreferred

overneedlepericardiocentesisTRA8

NonhemorrhagicShockBluntcardiacinjuryConsidermechanismofinjuryECGnonspecificCardiacenzymesrarelyhelpfulMonitoratleast4hoursNeurogenicshockCervical/thoracicspinalcordinjuryAssociatedbradycardiaSecondaryAssessmentIdentifypotentiallylife-threateninginjuriesHistoryofevent,medicalhistory,drugs,

allergies,tetanusimmunizationHeadtotoeexaminationFullyexposepatientCorrectandpreventhypothermiaAssessforsignsofurethralinjuryNeurovascularintegrityTRA10

®SecondaryAssessmentLaboratorydata–arterialbloodgas,bloodcounts,electrolytes,coagulationstudies,typeandcross-match,urinalysis,toxicology,etcRadiographreviewCervicalspine–completesurveyChest–mediastinalevaluation;tubes/cathetersPelvis–majorfracturesCystogram/urethrogramSkeletalexamSecondaryAssessmentCTscanofheadCTscanofabdomenifindicatedOtherissuesNasogastrictubeTetanusprophylaxisAntibioticindicationsSpecialtyconsultationTertiaryAssessmentDetailedexaminationtodetectallinjuriesSerialexaminationsovertime

todetectchangeandoccultinjuriesReturntoprimary/secondarysurveystrategiesforworseningstatusSurgicalconsultation/transferplanningTRA13

®CompartmentSyndromesAbdomenCompromiseofvenousreturndue

tohighintra-abdominalpressureSecondarytofreeblood,fluid,

edemaofabdominalcontentsEvaluatewithmeasureofintrabladderpressureSurgicaldecompressionCompartmentSyndromesExtremitySerialexaminationsPain,pallor,pulselessness,paresthesias,paralysisFasciotomyBurnInjury–PrimaryAssessmentTRA16

Airway/breathingUpperandlowerairwayinjuryCarbonmonoxideexposureBronchoscopyforevaluationConsiderearlyintubationAvoidsuccinylcholine®BurnInjury–

PrimaryAssessmentCirculationEstablishintravenousaccessCrystalloidresuscitationbaseduponextentandseverityofburnsAssessforcircumferentialinjuryEvaluateforotherinjuriesTRA17

®AssessmentofBurnSeverityFirst-degreeErythemaandpainSecond-degree(partial-thickness)Red,swollen,blisters,weeping,painfulThird-degree(full-thickness)White,leathery,painlessRuleofNinesResuscitation–

BurnShockPrimary