การดูแลรักษาผู้บาดเจ็บฉุกเฉินที่ทรวงอก

1. การดูแลรักษาผู้บาดเจ็บฉุกเฉินที่ทรวงอกการดูแลรักษาผู้บาดเจ็บฉุกเฉินที่ทรวงอก

2. 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.

3. 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

4. Trimodal Death Distribution

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

7. 6 Immediate Life Threats • Airway obstruction • Tension pneumothorax • Open pneumothorax • “sucking chest wound” • 4. Flail chest • 5. Massive hemothorax • 6. Cardiac tamponade

8. 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

9. 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”

10. 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

11. Initial assessment and management

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

13. 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

14. Assessment: Breathing • Inspection RR, paradoxical ,symetricalmotion 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

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

16. TENSION PNEUMOTHORAX • Air within thoracic cavity that cannot exit the pleural space • Fatalif not immediately identified, treated, and reassessed for effective management

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

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

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

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

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

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

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

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

25. 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

26. Needle Decompression

27. NEEDLE THORACENTESIS

28. 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

29. 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...

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

31. 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

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

33. Open Pneumothorax

34. Open Pneumothorax Inhale

35. Open Pneumothorax Exhale

36. Open Pneumothorax Inhale

37. Open Pneumothorax Exhale

38. Open Pneumothoarx Inhale

39. Open Pnuemothorax Inhale

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

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

44. 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

45. Hemothorax

46. Hemothorax

47. Hemothorax

48. Hemothorax

49. Hemothorax

50. Hemothorax May put pressure on the heart