What is new in trauma management?
本帖最后由 shenxiu2 于 2011-5-21 21:10 编辑Notes from lecture in Combined scientific meetingby Ken Harrison
What is new in trauma management?
6 points:
1. Airway devices
2. Hyperoxaemia
3. Stop the bleeding
4. Following the patient
5. Induction drugs
6. Analgesia
1.New airway devices for use in the field :
a. Various types of LMA( Supreme, igel )
b. Various types of Videolaryngoscopes ( Airtraq, McGrath)
2. Hyperoxaemia
Hypoxaemia & hyperoxaemia are bothharmful in neurotrauma .
High flow O2 may kill a patient with COAD.
3.Stop the bleeding
Damage control resuscitation:
Primary survey
Airway+ Cervical spines control
Breathing+Ventilation
Circulation +control bleeding
Disability+Neurological evaluation
Exposure + But keep warm
• Repeat primary survey until stable.
• Give volume by boluses.
• Give warm normal Saline 20ml/kg as bolus , as an assessment of blood loss estimation , watch the heart rate & blood pressure.
• After the 2ndbolus , start to give blood.
• Reassess often, do ABGs, FBC,Coags.
There is a paradigm shift ( EMA Article 2008) :
• Haemorrhage control
• Contamination containment
• Definitive surgery to be delayed 24 to 72 hours.
Remember the Lethal triads :
Coagulopathy + Hypothermia+ Acidosis.
Methodsused to stop bleeding:
Tourniquet, Novel Topical hemostatics, Permissive hypotension.
Methods used to prevent hypothermia ( Temperature <35’C):
1. Use 2 Bair- huggers (hot air blower warmers)—one above and one below the patient.
2. Keep the patient dry
3. Warm all fluids.
Blood & products Transfusion:
Study showed that the ratio of FFP : PRBC near to 1:1 is ideal .
Increasing the ratio of FFP: PRBC , the survivor rate is increased.
Hypotensive resuscitation/Permissive hypotension:
Definition:Keep blood pressure low to reduce bleeding until bleeding point is controlled.
4 groups of patients:
1. Penetrating injury
2. Blunt non head injury
3. Blunt head only injury
4. Blunt both head & body injury
1. Management of Penetrating injury :
• Keep radial pulse present is enough , put a pulse oximeter probe on the finger , if can pick up , it is enough perfusion. (Systolic BP about 60mmHg.)
• Most important priorityis to stop the bleeding .
• Go either to OR or Angio room to locate the bleeding point and stop it.
• After the bleeding is stop , can replace the volume with 1/1/1 blood /FFP/Platelet.
2. Management of blunt non head injury :
Same as for penetrating injury.
3. Management of blunt head injury:
• Give blood /fluids to keep MAP=90mmHg until bleeding is controlled.
• MAP=90mmHg is equal to Systolic BP about 110mmHg.
• CPP=MAP-ICP. To keep CPP about 60 mmHg , and ICP is <30mmHg ( ICP above 30mmHg, brain is not salvageable ) , the MAP need to be 90mmHg.
4. Management of both head & body injuries:
Decide which one is going to kill the patient first, then treat that one first.
4.Following the patient around until stablewill improve his/her outcome.
5.Induction agents:
Use less of Midazolam , more of Ketamine is the recent trend in the European countries & USA.
Reasons:
• Recent study had declared that for Ketamine, the effect onICP is not an issue.
• Need to add a small dose of midazolam to prevent bad dreams.
• It gives more stable hemodynamics.
6.Analgesia:
Adequate analgesia is important to reduce post traumatic stress disorder. Can use IV morphine or PCAs. 外伤管理新进展是什么？
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