儿童创伤急救

Chapter17TraumainChildren第一页，共三十五页。TraumainChildrenTraumainChildren

儿童创伤第二页，共三十五页。OverviewEffectivetechniquestogainconfidence有效增加信心的技巧Injuriesbasedonmechanismsofinjury受伤机理ITLSPrimaryandSecondarySurveys初步及进一步检查Consentandtheneedforimmediatetransport家长同意及需实时运送Pediatricequipmentneeds适合儿童之器材VariousmethodsofSMRonchild儿童脊椎固定方法EMSinvolvementinpreventionprograms参与预防意外方案3TraumainChildren-第三页，共三十五页。TraumainChildrenDifferentfromadults与成人不同Differentpatternsofinjuries不同伤势模式Differentresponsestothoseinjuries不同反响Specialequipmentrequired需要特别器材Assessmentequipmentandtreatmentequipment检查及冶疗用的器材Difficulttoassessandcommunicate较难评估及沟通Comewithcaregiversandotherfamilymembers与家人或照顾者同行4TraumainChildren-第四页，共三十五页。Communicating沟通Family-centeredcareiscritical.以家庭为中心Caregivernotalwaysparent.照顾者未必是父母Involvecaregiversasmuchaspossibleincare.尽量让照顾者参与Giveexplanationsandcarefulinstructions.必需详加解释及指示Inclusionandrespectwillimprovestabilization.包容及尊重可稳定伤者Keepcaregiversinphysicalandverbalcontact.与照顾者保持接触Demonstratecompetenceandcompassion.5TraumainChildren-第五页，共三十五页。AssessingMentalStatus

捡查精神状态Consoledordistracted可按抚或转注意力Mostsensitiveindicatorofadequateperfusion

能准确反映组织灌注是否足够Caregiversbestatdetectingsubtlechanges照顾者会较易分辩出伤者微小改变6TraumainChildren-第六页，共三十五页。AssessingMentalStatusInitiallevelofconsciousness最初清醒程度Preschoolchild:sleepingvs.unconscious幼儿:疲倦vs人事不醒Mostwillnotsleepthrougharrivalofambulance大部份沿途不会睡觉Askcaregiverstowakechild着照顾者弄醒伤者Suspecthypoxia,shock,headtrauma,seizure疑心缺氧、休克、头部受伤、癫痫7TraumainChildren-第七页，共三十五页。CommunicatingInteractionstrategies使用适龄的语言Appropriatelanguagefordevelopmentallevel适宜的语言Speaksimply,slowly,clearly说话要慢及简溸Begentleandfirm必需肯定Avoid“no〞questions防止说〞不〞Getafavoritebelonging利用其喜爱的玩具/随身物品Getonchild’slevel降下身段至与伤者视线平衡ExplainSMRnecessity解释脊椎固定之需要Allowcaregivertoaccompanychild让照顾者与伤者同行8TraumainChildren-第八页，共三十五页。CaregiverConsent照顾者〞同意〞Criticalcareshouldnotbedelayed.切勿延医冶理Emergencycareneeded如需进行急救Consentnotavailable未能取得〞同意〞Transportbeforepermission,

documentwhy,notifymedicaldirection记录,速送医院,通知医五Consentdenied不同意Trytopersuade,documentactions,obtainsignature尝试说服、记录、签署Notifylawenforcementandappropriateauthorities行使有关法例Reportsuspectedabuse如疑心儿童受虐待,通知警方9TraumainChildren-第九页，共三十五页。PediatricEquipment儿科器材Length-basedtape身长尺Weightestimate大约体重Fluidandmedicationdosesprecalculated

输液及药物剂量Commonequipmentsizeestimates

常用器材尺码10TraumainChildren-PhotocourtesyofKyeeHan,MD第十页，共三十五页。MechanismsofInjury受伤机理Falls高处下堕Usuallylandonhead通常头先着地Seriousheadinjuryunusualfrom<27inches严重头部受伤并不常见于身长<27吋Protectivegear保护装备MVCs交通意外Seat-beltsyndrome平安带综合症Liver,spleen,intestines,lumbarspine肝、脾、小肠、腰椎Auto-pedestriancrashes路人被撞11TraumainChildren-第十一页，共三十五页。MechanismsofInjuryBurns烧伤Airwayobstruction气道受阻Foreignbody异物Childabuse虐待儿童Suspectifhistorydoesnotmatchinjury

受伤经过与伤势不吻合Storykeepschanging经常改变说法12TraumainChildren-第十二页，共三十五页。AirwayinChildren儿童气道Signsofobstruction呼吸受阻征状Apnea无呼吸Stridor吸气时有喘鸣声“Gurgling〞respiration有杂声的呼吸Contributetoobstruction诱因Hyperextension过度舒张Hyperflexion过度屈曲13TraumainChildren-CourtesyofBobPage,NREMT-P第十三页，共三十五页。AirwayinChildrenOpeningairway张开气道Tongueislarge;tissuesoft舌大,组织软Jaw-thrust下颔上提法Oropharyngealairway口咽气道Nasopharyngealairways鼻咽气道Toosmalltoworkpredictably

因鼻孔太少未必有效Neonateobligatenosebreather

新生婴儿用鼻孔呼吸Clearnosewithbulbsyringe用球状泵吸走分泌14TraumainChildren-第十四页，共三十五页。BreathinginChildren儿童呼吸Workofbreathing呼吸方法Retractions,flaring,grunting

肋间收缩、鼻翼扩张、咕噜声

Persistentgruntingrequiresventilation持续咕噜声需要施行助呼吸Respiratoryrate呼吸次数Fast,thenperiodsofapneaorveryslow

先后短暂停止或转慢Minorbluntnecktraumacanbecritical.轻微头部挫伤可引起严重伤势15TraumainChildren-第十五页，共三十五页。20,15,10VentilationRate换气次数16TraumainChildren-10perminuteforadolescent如为中童,10次/分钟

20perminuefor<1year如<1岁,20次/分钟15perminutefor>1year如>1岁,15次/分钟第十六页，共三十五页。BreathingManagement呼吸处理17EffectiveBVMventilation—有效BVM换气

intubationiselective.可考虑插喉TraumainChildren-第十七页，共三十五页。EndotrachealIntubation

气管内导管Oralendotrachealintubation从口腔插入Noblindnasotrachealintubationfor<8years

少于8岁不可施行鼻入插喉法Uncuffedtube无气袋式喉管Length-basedtapesystem身长尺Samediameterastipofchild’slittlefinger与小童尾指头直径相同Frequentlyreassessplacement需经常捡查喉管位置18TraumainChildren-4+ageinyears=sizeoftube(mm)4第十八页，共三十五页。CirculationinChildren儿童血循环19Persistenttachycardiaismostreliableindicatorofshock.最有效显示伤者休克的征状为持续的脉搏过快TraumainChildren-第十九页，共三十五页。CirculationinChildrenEarlyshockmoredifficulttodetermine.较难于休克初期预测Persistenttachycardia持续的脉搏过快Rate>130usuallyshockinallagesexceptneonates脉搏>130多为休克,新生婴儿除外Prolongedcapillaryrefillandcoolextremities微血管回流时闭迟及肢体冰冷Levelofconsciousness清醒程度Circulationcanbepoorevenifchildisawake

血循环衰竭的儿童仍可完全清醒Lowbloodpressureissignoflateshock.血压低是休克的后期征状BP<80mmHginchild;<70mmHginyounginfant20TraumainChildren-第二十页，共三十五页。ShockinChildrenStrongcompensatorymechanisms生理的补尝机制较强Appearsurprisinglygoodinearlyshock早期休克可有效发挥“Crash〞whendeteriorate但情况会急转直下Beprepared必需有心理准备Fluidadministration20mL/kgineachbolus输液补充每次20mL/kgConsiderintraosseousinfusion骨髓输液法FrequentOngoingExams持续检查

21TraumainChildren-第二十一页，共三十五页。PediatricTraumaCenter

儿童创伤中心Criteria条件Obstructedairway气道阻塞Needforairwayintervention处理气道Respiratorydistress呼吸困难Shock休克Alteredmentalstatus意识紊乱Dilatedpupil曈孔扩大GlasgowComaScalescore<13PediatricTraumaScore<822TraumainChildren-第二十二页，共三十五页。PediatricTraumaCenterMechanismthatpredictssevereinjury预期严重伤势Fallfromheight>10feet高处堕下Motor-vehiclecollisionMVCwithfatalities车祸中有人死亡EjectionfromanautomobileinaMVC

车祸中弹离车厢InMVC,significantintrusionintocompartment

车祸中受困于车厢中Hitbyacarasapedestrianorbicyclist行人被撞Fracturesinmorethanoneextremity多边一条肢体骨抑Significantinjurytomorethanoneorgansystem

多过一个器官受伤23TraumainChildren-第二十三页，共三十五页。PediatricTraumaCenterRecommended建议送院Burns烧伤Near-drowning遇溺Headinjurieswithlossofconsciousness

人事不醒的头部受伤Notifyhospitalasearlyaspossible.尽早知会医院24TraumainChildren-第二十四页，共三十五页。Life-ThreateningInjuries

危害生命伤势Headinjury头部受伤Mostcommoncauseofdeath最常见死亡原因Levelofconsciousnesschangebestindicator

清醒程度之改变为最有效的征状Pupilassessmentimportant检查瞳孔25TraumainChildren-第二十五页，共三十五页。Life-ThreateningInjuriesHigh-flowoxygen高浓度氧气Hyperventilateonlywithcerebralherniationsyndrome加快换气只适用于出现脑疝征状FluidadministrationtitratedtosystolicBP控制输液速度至可维持根本收缩压Preschoolchild:80mmHg;olderchild:90mmHg幼儿:80mmHg,小童:90mmHgBepreparedtopreventaspiration预防气道吸入异物26TraumainChildren-第二十六页，共三十五页。Life-ThreateningInjuriesChestinjury胸部创伤Respiratorydistresscommon最常见的征状为呼吸困难Pneumothoraxortensionpneumothorax气胸或张力性气胸Difficulttoassess较难分别Needlethoracostomycanbelife-saving剌胸膜腔穿刺Pulmonarycontusion胸部挫伤Rareinjuries较少发生伤势Ribfractures,flailchest,aorticrupture,

pericardialtamponade肋骨折、槤架胸、主动脉撕裂、心胞膜填塞27TraumainChildren-第二十七页，共三十五页。Life-ThreateningInjuriesAbdominalinjury腹部创创Liverand/orspleenrupture肝、脾撕裂Secondleadingcauseoftraumaticdeath伤第二致死伤势Bleedingoftencontainedwithinorgan出血通常局限于器官之内Difficulttodiagnose难以诊断Severeinjurywithminimalsigns严重伤势可只有轻微征状Suspectwithanyabnormalabdominalassessment假设有任何异常腹部征状当作严重伤势处理Bepreparedtopreventaspiration.预防气道吸入异物28TraumainChildren-第二十八页，共三十五页。Life-ThreateningInjuriesSpinalinjury脊椎创伤Uncommonbeforeadolescence青少年以下较少发生<9yearsusuallyuppercervical-spineinjuries头椎上受伤>9yearsusuallylowercervical-spineinjuries头椎下受伤HigherincidenceofSCIWORA

spinal-cordinjurywithoutradiographicabnormality可无X-光片异常29TraumainChildren-第二十九页，共三十五页。Life-ThreateningInjuriesSMR脊椎固定Padundertorsoforne