ATLS Student Course Manual: Advanced Trauma Life Support [9 ed.] 1880696029, 9781880696026

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∣NINTHEDITION】 ﹄←＿﹦＝﹦＝＝﹦＝＿－﹦逵一﹦＿＝﹦＝＝︹』

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STUDENTCOURSEMANUAL

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C／mrO／Comm㎡eeo〃Tmαmα:MichaelF.Rotondo,MD,FACS Mbd﹠cα／D”αorO／?γmαmαPmgm加:JohnFildes’MD,FACS AIγLSα加加㎡t2eChα加KarenJ.Brasel’MD’MPH’FACS AILSPmgmmM【mαge㎡WillChapleau,EMT﹣P’RN,TNS P叼ectMα几αgeⅣClaireMerrick Deue!Op加e几rEd肱or『NanCyPeterson P”dαc此o〃Seru!cesfAnneSeitzandLauraHorowitz,HearthsidePublishingServices M它dtαSeru』ces『SteveKiddandAlexMenendez,DelveProductions Des唔〃e㎡TerriWrightDesign AJ.t!st『DragonflyMediaGroup Boo虎Lαyoαtα几dαmpos蛐o几:GregJohnson／TextbookPer比ct NinthEdition

Copyright◎2012AmericanCollegeofSurgeons 633N.SaintClairStreet Chicago,IL60611﹣3211 Previouseditionscopyrighted1980,1982’1984,1993,1997,2004,and2008bythe AmericanCollegeofSurgeons.

CopyrightenfbrceableinternationaⅡyundertheBernConventionandtheUnifbrm CoⅣrightConvention·Allrightsreserved.Thismanualisprotectedbycopyright.No partofitmaybereproduced,storedinaretrievalsystem,ortransmittedinanyfbrm orbyanymeans,electronic,mechanical’photocopymg’recording’or0therwise,without writtenpermissionfTomtheAmericanCollegeofSurgeons.

TheAmericanCollegeofSurgeons’itsCommitteeonTrauma,andcontributingauthors havetakencarethatthedosesofdrugsandrecommendationsfbrtreatmentcontained hereinarecorrectandcompatiblewiththestandardsgenerallyacceptedatthetimeof publication.However,asnewresearchandclinicalexper1encebroadenourknowledgB, changesintreatmentanddrugtherapymaybecomenecessaryorappropriate.Readers andparticipantsofthiscourseareadvisedt0checkthemostcurrentproductinfbrma﹣ tionprovidedbythemanufacturerofeachdrugtobeadministeredtoverifytherecom﹣ mendeddose’themethodanddurationofadministration’andcontraindications.Itis theresponsibilityofthelicensedpractitionertobeinfbrmedinallaspectsofpatientcare anddetermmethebesttreatmentfbreachindividualpatient.Notethatcervicalcollars andspinalimmobihzationremainthecurrentPHTLSstandardintransportingspine injurypatients.Ifthecollarsandimmobilizationdevicesaretoberemovedincontrol﹣ ledhospitalenvironments,theyshouldberemovedonlywhenthestabilityoftheinjuⅣ isassured.Cervicalcollarsandimm0bilizationdeviceshavebeenremovedinsomeof thephotosandvideostoprovideclarityfbrspecificskilldemonstrations.TheAmerican CollegeofSurgeons’itsCommitteeonTrauma,andcontributmgauthorsdisclaimany liabihty,loss’ordamageincurredasaconsequence’directlyorindirectly’oftheuseand applicationofanyofthecontentofthisNinthEditionoftheATLSProgram. AdvancedTraumaLifbSupport﹫andtheacronymATLS﹫areregisteredtrademarksof theAmericanCollegeofSurgeons·

PrintedintheUnitedStatesofAmerica·

AdumzcedZγmα加αLi／bSUpp0㎡·S加de〃／αα”eMα几αα／ LibraryofCongressControlNumber:2012941519 ISBN13:978﹣1﹣880696﹃02-6

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Dedication ToPau∣〃Skip卯CoⅡicott『ⅢD‘「ACS Weallleavetracksinthesandaswepassthroughlifb.Occasionallywepauseand lookbackatthosetracks.ThisNinthEditionoftheATLS﹫manualistrulythesum ofthec0ntributionsofmanywhohavemadetracks,directlyandindirectly·But therearenotrackswiderormorefirmlyplantedthanthosemadebyPaulE.“Skip’’ Collicott,MD》FACS’ It’shardtorememberthe‘《badol,days’,whenanmjuredpatientwasevalu﹣ atedintheEmergenCyDepartmentbyaninternormedicalstudent’Theevaluation startedwithacompletehistoryandphysical.Unlessthepatientwascrashing,the ABCswerenotgivenanyparticularpriority.Imagmeaninternquestioningthe ihmilyofapatientwithagunshotwoundtothechestaboutchildhoodillnessesas thepatientwasinsignificantrespiratorydistress!Yet,ithappened.Howdiffbrently suchapatientismanagedtoday· Today》asthenewsmediabroadcastsvar1ousconflictsandothertraumatic eventsfTomaroundtheworld,onethingthatbecomesobviousisthatfirstrespond﹣ ersandphysicianscaringibrtheiUjuredareusingtheprinciplesandmethodsof ATLS.Why?Becausetheprinciplesandmethodswork. Weandtheinjuredpatientswetreatoweyouadebtofgratitude,Skip＿you andyoursmallgroupoforiginalauthors.Ifweweretobesoluc坷tohavethe opportunitytotouchasmanylivesaroundtheworldasyourvisionandefIbrthave throughthebirth,adolescenceandnowmaturi叮ofATLS﹫,thenwecouldfbeljus﹣ tifiablyproudofouraccomplishments.Itseemsinadequatetosaybut⋯thankyou fbryourvision.ATLSworks! ThistributetoSkipandthelegaCyhewillleavegoesfhrbeyondthededication ofthiseditionofthemanualtohim.Welldone,myFriend.

MaxL·Ramenofsky,MD,ⅢnCS PJD／bssorO／Smg它γ:y RobertWoodJohnsonCoⅡegeofMedicine NewBrunswick,NJ RichardM。BelI,MD,InCS PrO／bsso咚D叩α㎡〃』e〃﹠O／Sα唔eU／ Universi叮ofSouthCarolina Columbia,SC

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Foreword lb『firstexposurewithATLSwasinSanDiegoin1980 whⅡeIwasaresident.Theinstructorcoursewascon﹣ ductedbyPaulE.‘‘Skip’,Collicott,MD’FACS’andfbl﹣ lowstudentsincludedayoungsurgeoninSanDiego, A.BrentEastman,MD,FACS,andonefromSanFrancisco’DonaldDTrunkey,MD’FACS.Overthenext yearortwo’wetrainedeveryoneinSanDiego’and thisbecamethelanguageandgluefbrtheSanDiego Trauma斷stem.Theexperiencewasenlightemng,in﹣ spiring’anddeeplypersonal.Inaweekend’Iwasedu﹣ catedandhadmyconfidenceestablished;Iwasadept andskiⅡedinsomethingthathadpreviouslybeena causeofanxietyandconfhsion·Forthefirsttime,Ihad beenintroducedtoan“organizedcourse,’》standards fbrquality,validatededucationandskillstraining’and verificationoftheseskills.Itwasalifb﹣transfbrming experienceandIchoseacareerintraumainpartasa result.Duringthatweekend,Ialsowasintroducedto theAmericanCoⅡegeofSurgeons－atitsverybest. ThetraditionofATLSandthenewestcourse＿the NinthEdition－camyonthispowerfhltradition.This typeofeducationfhlfillsourresponsibilitywithour patientsandthepublicatlarge＿wearecommitted toconsistencyinpracticeandexcellenceindelivery aboveallelse. ThefbllowcreatorsoftheNinthEditionunder theleadershipofDr.KarenBrasel’MD,FACS’Will Chapleau’EMT﹣P》RN’TNS,andthewonderihlC0l﹣ legestaffhavefhrtheredthetradition,theexperience, andbroadenedtheglobalimpact.ATLShasbeenand remainsoneofthefinestachievementsoftheAmeri﹣ canCoⅡegeofSurgeonsanditsFellows.TheNinth Editiontakesthisachievementtoanevenhigherlevel. DavidB·Hoyt,MD,InCS 陬ecα㎡ueD﹠爬αo／· AmericanCollegeofSurgeons Chicago’IlⅡnois UnitedStates

Remembe『aⅢdCe!eb『ate! TheAdvancedTraumaLifbSupport（ATLS）Course arosefromthezealandpassionofasmallgroupofsur﹣ geonsintentonimprovingpatientcare.In1976,when orthopedicsurgeonDr.JamesSbmerencountereda woefhⅡyinadequateresponsetotheneedsofhischil﹣ dreninjuredinalightplanecrashinruralNebraska’ hewascompelledtotakeaction.Hespurredthedevel0pmentofanorganizedsystematicapproachtothe evaluationandcareoftheinjuredpatient.Recent】y retiredDirectorofMemberServicesfbrtheAmerican CollegeofSurgeons’Paul‘‘Skip,’Collic0ttMD,FA0S》 joinedfbrceswithhisthen﹦colleagueDr.Stynerand themovementcalled“AdvancedTraumaLifbSup﹣ port”wasborn.Inshortorder’itwasadoptedbythe CommitteeonTraumaandsincethen’thecoursehas beendevelopedandrefinedyearafteryear’decadeaf. terdecade,inthatsamespiritofdedicationkindled byitsfbunders.Sinceitsinception’ATLShastrained morethanonemillionphysiciansin63countriesand nodoubthassavedcountlesslives.Inrecentyears’ severalindividualscentraltothedevelopmentand promulgationofATLShavebeenlost.Whilewemiss them’theirspiritlivesonaswecelebratethelaunchof theNinthEditi0nofAⅢLS TheNinthEditionrepresentsthelatestineⅥ﹣ dence﹣basedcarefbrtheiIUured.Thecoursemateri﹣ alswerethoroughlyvettedbyagroupofinternational expertsandthecontentwasⅥgorouslydebatedfbrboth itsscientificmeritandpracticalapplication.Theresult isavibrantofIbringfbrhealthcareprovidersacrossthe worldwhoseekaneasilyrememberedframeworkto carefbrpatientswithcomplexmjures.Thenewedition hasmanychangesincludingthelatesttechmquesinim﹣ tialassessment’abalancedstrategyfbrresuscitation’ andaninteractiveapproachtolearnmg. Sothen,ontheoccasionofthis’theNinthEdi﹣ tionofATLS’werememberthespiritinwhichitwas fbundedandwecelebrateourworkaswecarryoutthe missionofthe0ommitteeonTrauma·Wehopeyou willfindthecoursestimulatingandinteresting.Above all,wehopeitwillhelpyousaveahfb. Michae1F.Rotondo’MD’FnCS αjα《乃α〃｝〃咖鮑eoJ】乃u叨mα AmericanCollege0fSurgeons Chicago,Illinois UnitedStates

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Preface RoⅡeoftheAme『icanCoIIegeof Su『geonsCommitteeonT『auma TheAmericanCollegeofSurgeons（ACS）wasfbunded toimprovethecareofsurgicalpatients’andithaslong beenaleaderinestabhshingandmaintainingthehigh qualityofsurgicalpracticemNorthAmerica.Inac﹣ cordancewiththatrole,theACSCommitteeonTrau﹣ ma（COT）hasworkedtoestablishguidelinesfbrthe careofinjuredpatients· According】y’theCOTsponsorsandcontributesto thecontmueddevelopmentoftheAdvancedTraumaLifb Support（ATLS）Program·TheATLSStudentCourse doesnotpresentnewconceptsinthefieldoftrauma care;rad1er,itteachesestablishedtreatmentmethods·A Systematic’conciseapproachtotheearlycareoftrauma patientsisthehalhnarkoftheATLSPr0gram. ThisNinthEditionwasdevelopedfbrtheACSby membersoftheATLSCommitteeandtheACSCOT’ othermdividualFeⅡowsoftheCollege,membersofthe internationalATLScommunity,andnonsurgicalcon﹣ sultantstotheCommitteewhowereselected｛brtheir specialcompetenceintraumacareandtheirexpertise mmedicaleducation.（Pleaseseethelistingattheend OfthePrefaceandtheAcknowledgementssectionfbr namesandafIiliationsoftheseindividuals.）TheCOT behevesthatthoseindividualswhoareresponsiblefbr carmgfbrimuredpatientswillfindtheinfbrmation extremelyvaluable.Theprinciplesofpatientcarepre﹣ sentedmthismanualmayalsobebeneficialfbrthe c砥eofpatientswithnontrauma﹣relateddiseases. Injuredpatientspresentawiderangeofcomplex problems.TheATLSStudentCoursepresentsacon﹣ ciseapproachtoassessingandmanagmgmultiply injuredpatients.Thecoursepresentsproviderswith knowledgeandtechmquesthatarecomprehensiveand easⅡyadaptedtofittheirneeds.Theskillsdescribed mthismanualrepresentonesafbwaytoperfbrmeach technique.TheACSrecognizesthatthereareother acceptableapproaches.However’theknowledgeand skiⅡstaughtmthec0urseareeasilyadaptedtoallven﹣ uesfbrthecareofthesepatients· TheATLSProgramisrevisedbytheATLSC0m﹣ mitteeapproximatelyeveryfburyearstorespondto changesinavailableknowledgeandincorporatenewer andperhapsevensafbrskills.ATLSCommitteesin othercountriesandregionswheretheProgramhas beenintroducedhaveparticipatedintherevisionproc﹣ ess’andtheATLSCommitteeappreciatestheirout﹣ standingc0ntributions·Nationalandinternati0nal

educatorsreviewtheeducationalmaterialstoensure thatthecourseisconductedinamannerthat色cili﹣ tateslearning·Allofthecoursecontentisavailable motherresources’suchastextbooksandjournals. However’theATLSCourseisaspecificentity,and themanuals’shdepresentations,skillprocedures’and otherresourcesareusedfbrtheentirec0urseonlyand cannotbefragmentedintoseparate,freestandinglec﹣ turesorpracticalsessions·MembersoftheACSCOT andtheACSRegionalandState／ProvincialCommittees’asweⅡastheACSATLSProgramOfficestaff members’areresponsiblefbrmaintaimngthehigh qUali↑yoftheprogram.Byintroducingthiscourseand maintainingitshighquality,theCOThopestoprovide anotherinstrumentbywhichtoreducethemortality andmorbidityrelatedtotrauma.TheCOTrecom﹣ mendsthatprovidersparticipatingintheATLSStudentCoursereveriiytheirstatuseveryfburyearsto maintainboththeircurrentstatusintheprogramand theirknowledgeofcurrentATLScorec0ntent·

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ⅡewtothisEdition

ThisNinthEditionoftheAduα／Ⅱced乃m﹠mαL旋S【《p﹣ po『㎡S卹de㎡αM炤eMα〃Mα!reflectsseveralchanges designedtoenhancetheeducationalcontentandits visualpresentation.

Co㎡e㎡Updates Allchapterswererewrittenandrevisedtoensureclear coverageofthemostup-to﹣datetechnicalcontent’ whichisalsorepresentedmupdatedrefbrences·New tothiseditionare; 卜卜CoⅡceptofbaIanced『esⅡs【itatioⅡ 〉卜EmphasisoⅡthepeMsasasou『ceofbIoodIos5 〉卜05eofmo『eadvancedai『waytechⅡique5fo『the difficultai『way 卜〉0ptioⅡa∣DPlandpe『ica『dioceⅡtesis 卜卜ⅡewFASTSkiIlStatioⅡ 〉〉Newm凹ltiple﹣choiceq凹estions『o『p『e.testaⅡd post﹦test 卜〉0ptionaIeXpaⅡdedcoⅡteⅡtonheatinjⅡ『y 卜卜NewiⅢitiaIassessme㎡sCeⅡa『ios ）〉Manynewimages 〉卜New!Ⅱst『ucto『Co凹『seCoⅢteⅡt PbNewSkilIsVideos 〉》NewAT【SApp 』x

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懿濰繃繃蘿籮鴛鯊鯊 fbrretrievalatthebedsideandfbrreviewatyourlei﹣ sure.Contentincludes: ■Interactivevisuals’suchastreatmentalgorithms andx﹣rayidentification ■JustinTimevideosegmentscapturingkeyskills ■Calculators,suchaspediatricburncalculator andtheParklandFormulatodeterminefluid administration ■Animations,suchasairwaymanagementand surgicalcricothyroidotomy Students’instructors’coordinators,andeducatorscan accesstheappthroughtheMyATLS.comwebsite.

SkⅢsVideo Aspartofthecourse,videoisprovidedviathe 】叮ATLS.comwebsitetoshowcriticalskiⅡsthat providersshouldbefamiharwithbefbretakingthe course.SkⅡ1StationsduringthecoursewiⅡallowpro﹣ viderstheopportumtytofinetuneskiⅡperfbrmance

inpreparationfbrthepracticalassessment.Reviewof thedemonstratedskillspriortoparticipatinginthe skillsstationswillenhancethelearner’sexperience.

Edito『iaIⅡoteS TheACSCommitteeonTraumaisrefbrredtoasthe ACSCOTorf／jeα／〃加肋加e’andtheState／Provincial Chair（s）isrefbrredtoasS／PC〃α〃、（S）’ Theinternationalnatureofthiseditionofthe ATLSStudentManualmaynecessitatechangesin commonlyusedtermstofhcilitateunderstandingby allstudentsandteachersoftheProgram. AdvancedTraumaLifbSupport＠andATLS＠are proprieta】Vtrademarksandservicemarksowned bytheAmericanCoⅡegeofSurgeonsandcannotbe usedbyindividualsorentitiesoutsidetheACSCOT organizationfbrtheirgoodsandserv1ceswithoutACS approval·Accordingly,anyreproductionofeitheror bothmarksindirectconjunctionwiththeACSATLS ProgramwithintheACSCommitteeonTrauma organizationmustbeaccompaniedbythecommonlaw symboloftrademarkownership·

TextbookFeatu『es Thepedagogicalfbaturesofthetex｛jbookhelptoimprovestudentcompre﹣ hensionandknowledgeretention·Lookfbrthefbllowingfbatures: LinkS

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P R E F A C E X i

Ame『icanColIegeo『Su『geons tt Committeeon丁『auma ■

MichaeIF·Rotondo,MD,ⅢnCS CommitteeonITauma,Chair P『U／bssoγ㎡Smg它肌α!αZJD／DePαJ.／〃﹟e㎡O／Sα｝ge『:y’歐Ⅵs㎡ αnD／t〃αU〉m）eJqs叼 C／jie／o／SαJg它秘D岫αoγo／Cb〃te『.o／陬ce〃e況ce／bγ乃α叨mα α〃αSα『gtcα／α蛻cα／∞『℃ PittCoun叮MemorialHospitalUniversityHealthSystems ofEasternCarolinR GreenviⅡe,NorthCarolina UnitedStates JohnFildes,MD,InCS 乃ααmαP『唔）um’M它d【cα』αJ、ec／Or

Pm／bssorO／SαJgEJ:y’ⅥCeC／iα〃DGPα㎡〃!e㎡o／Sα｝召它Jy’ RDgynmD舵cm乃Ge几e妒α』S【〃gUJjResfde〃CyC〃』e／Dtu【sio〃 o／Trααmα＆α㎡Cα／Cm℃ Umversi叮ofNevadaScho0lofMedicine LasVegas’Nevada UnitedStates

CommitteeonAdvancedT『auma t 【i『eSuppo『toftheAme『ican CoⅡegeofSu『geonsCommittee onT『auma KarenBraseI,MD,MPH,InCS AⅡLSα加m㎡ftce’Chαz了 PrO／bssorZ〉nαmαSα咱它Jj＆Cr㎡cα』Oαγe

RaphaelBonvin,皿,PhD C〃αZ乃AnjSS它㎡o｝.Ed【zcαtorAduZsoUrGJm!p Facult白debiologieetdem白decine,UnitedeP色dagogie m色dicale,Lausanne SwitzerlRnd

MarkW。Bowyer,MD,FnCS,DMCC Col（Ret）’USAF’MC PrO／bsso妒O／Sα『gU／y C／㎡e／;αu!s『o几O／乃ααmαα〃dαmbα﹠Sα『gC『y D岫αo『·O／Sα唔﹠cα』Stmα／α㎡o几 TheNormanM·RichDeptofSurge叮 UnifbrmedServicesUniversiby Bethesda,Maryland UnitedStates

Mary﹣MargaretBrandt,MD,FACS Assis』α〃ZPrO／bssoJ. Ge〃em／Sα『gCJ弘D【Utsfo〃o／?〉Uα加α’Bαr几α几dEn﹩e『gC几Cy smgu『:y UniversityofMichigan AnnArbor,Michigan UnitedStates ReginaIdA.Burton’MD’FACS DZ疋c／o門Ⅲγuαmαα几dSu唔【cα／α㎡cα／α!γ·e BIyanLGHMedicalCenter Lmcoln,Nebraska UmtedStates

JulieA·Dunn,MD,InCS Medicα／D『祀αo八Reseα加／tα冗d風fucα㎡o）』 TraumaandAcuteCareSurgica1Services PoudreValleyHealthSystem Loveland,Colorado UnitedStates

FroedtertHospital＆MedicalCollegeofWisconsin,Trauma SurgeⅣDivision Milwaukee,Wisconsin UnitedStates

LesleyDunstall EMS?γAILS』W肱o几α／Cbord加α加F’Aαs㎡m〃α ROyalAustralasianCollegeofSurgeons NorthAdelaide,SouthAustralia Aush、RⅡR

eIohnB。Kortbeek,MD,ⅢRCSC,E洫CS ATLSα加〃㎡ff它e’血／eJ·〃α㎡o〃α』αα｝·seD〃℃c／or PJU／bsso／D叨αJ㎡me〃拓O／Sα唔e｝:yα几dO恤cα／m『℃ Universi叮ofCalga】yandCalgaryHealthRegion Calgary’Alberta Canada

GregoryM.Georgiadis,MD’FACS O㎡〃叩αed【c乃UαmαSeFU【ce TheToledoHospital Toledo,Ohio UnitedStates

SaudA1ⅡmPki,MD,mtCS,ODTS,ⅢnCA,FACS C〃!e／;COTR嚀o几Z7 Ⅸ沱c／o乃TmM加αα【〃沮esO／γ:“』Pbs唔｝uαMα皰EdMcα㎡o几＆ Acαde／㎡cA〃htJB KingAbdulazizMedicalCi叮 Riyadh KingdomofSaudiArabia

SharonM·Henry,MD,rnCS A几〃eScα／eαPJD／bssorO／乃αα加α UniversityofMarylandSch0olofMedicine D【reαo『·WbM〃dHbα』加gα几dM﹫rαbo／﹩s加Seru!ce RAdamsCowleyShockTraumaCenter Baltimore》MaMand UnitedStates

JohnL。D·Atkinson,MD,ⅢnCS D叩αJtme㎡O／Ⅳeαmsα）召它『:y MayoClinic Rochester,Minnesota UnitedStates

Michae1Hollands,MBBS’ⅢRACS’FACS Hmαo／H印α¢ob毗α｝:yα几dGαs向D﹣oesOp〃αgm／SMJg它nI WestmeadHospital Sydney,NewSouthWales A】】息trR】R i

■■

x】I

PREFACE

ClausFaIckLarsen,MD,dr。med·,MPA,ⅢnCS MMiCα／DZ沱αor TheAbdominalCentre’UniversiⅣofCopenhagen, RigshopitaletDenmark Copenhagen DenmRTk DouglasW。Lundy,MD,FnCS Or仇Opαed』cZ〉mz加αS叨唔e叮 ResurgensOrthopaedics Marietta,Ge0rgia UnitedStates R。ⅡoddMaxson,MD,ⅢnCS Chief,TraumaProgram DellCM】dren,sMedicalCenter LittleRock,Arkansas UnitedStates

DanieIB·MiChaeIMD,PhD,FACS C／jte／;Ⅳbα｝mmMmαα〃dα㎡cα!印沱 BeaumontHospita1 ROyalOak’Michigan UnitedStates

KimberlyK·Nagy’MD,InCS Ⅵce﹣Chα!『mα几,Depαrrme㎡o／乃m〃冗α CookCoun叮TraumaUmt Chicago’IⅡinois UnitedStates

RenatoSergioPoggetti,MD,FHCS Direc／o『oO／EmeJg它〃qySα唔!cα【Seru〔ce HospitaldasClinicasUniversidaddeSdoPaulo Brazil RaymondR·Price,MD,FACS A叮叨几αα加!cα／ASs!S／α㎡Pm／bsSOr UniversityofUtah Murray,Utah UnitedStates JeffreyP·Sa1omone,MD,FACS Ass0c『α／ePm／bssoJ.O／SαγgeUbD『uts:o〃㎡乃αα〃zα／Sα喱cα／ Cr㎡cα／α】杷 EmoIyUniversi勺SchoolofMedicine Atlanta,Georg1a UnitedStates ◆

R·StephenSmith,MD,RDMS,EACS 助ste加Chte／;Acα』e∞『它Sα唔eⅣ WestPennA1leghenyHealthSystemPittsburgh,Pennsylvania UnitedStates ROberteJ·WincheⅡ,MD,ⅢnCS Hmd’乃αα加αα冗dBα派几Sα唔它『y MaineMedicalCenter Portland’Maine UnitedStates

JayA·Yelon,MD,ⅢACS C〃α!『wm〃’Depαr加e几／O／Sα『gEJ:y LincolnMedicalCenter PJD／bsso妒O／α加tcα／Sα『gGUI WeillCorneⅡMedicalCoⅡege Bronx,NewYork UnitedStates

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GuyF。Brisseau,MD,IhCS Ass『stα㎡Deα几’Pos／GrαdMαteMM』cα／歐!邸cα瓦o几 DalhousieUniversi叮 Halifhx’NovaScotia Canflda ReginaSuttonChennau1t,MD,FACS 仍.α凹mαM它dicα／D力℃ctoJ、 AlaskaRegiona1Hospital Anchorage,Alaska UnitedStates

KimberIyA·Davis,MD,fnCS 乃α叨加αM它dZcα／D!沱c加r S泓唧cα／D『reαo乃Qαα／蚵α『Jd此J允『7冗α〃ceD7!p『DUe加e〃﹠ Yale﹣NewHavenHospital NewHaven,Connecticut UnitedStates

GlenA·Fhpank1in,MD,FACS AssoααtcPmgrαmD:recfo門Ge〃em』SmgcJy Progrα加D舵αo乃SM唔icα』Cr㎡cα【αJ爬 UniversityofLouisvilleDepartmentofSurge】y Louisville》Kentucky UnitedStates LewisE·JacObson,MB,CHB’InCS M它dtcα』D加cto乃TrαM〃｝αP『oogm加 St.VincentIndianapolisHospital Indianapolis,Indiana UnitedStates

SarveshLogsetty’Ⅷ,FnCS D【reαorO／Mα〃加bαⅣre／Jg〃tersBαr几U》u肋 AssoααrePm／bssoγ DepartmentofSurgeIyandChildren,sHea1th Universi叮ofManitoba Wmnipeg,Manitoba CahRdH GeorgeE·McGee,MD,EnCS ForrestGeneralHospital TraumaSurgeryClinic Hattiesburg,Mississippi UmtedStates

DrewW。McRoberts,MD,ⅢACS Ge〃erα』S〃｝g它o〃 PortneufMedicalCenter Pocatello’Idaho UnitedStates CharlesE·Morrow,Jr,卹,ⅢnCS ProgrαmD岫αo『〕G它〃eγα』Sα唔e『y MbdfCα／Di把αo乃TmMmαSα『gCⅣ

DepartmentofTrauma’SpartanburgRegionalMedicalCenter Spartanburg’S0uthOarolma UnitedStates

PREFACE NeilG·Parry,MD,IRCSC,InCS Assoαα陀Pm／bsso妒 VictoriaHospital London,Ontario Canada

MartinA·Schreiber,MD,FACS Pm／bssorO／Sα『gu『:y DZ｝℃αo乃乃U皿〃】αSbr㎡ce OregonHealth＆ScienceUniversi叮）Trauma＆CriticalCare Section Portland,Oregon UmtedStates GustavoJ·TisminetzIW,MD,MAAC,ⅢⅦCS An』SPmg『m施D〃℃ctoγ JefbUnidadUrgenciaHospitalJ.A.Fernandez BuenosAires Argentina

SpeciaIMembe『stotheCommittee onAdvancedT『aumaIj『eSuppo『t oftheAme『icanCo∣Iegeof Su『geonsCommitteeonT『auma JameelA1i,卹,M·Med·Ed,ⅢRCS,ⅢACS R㎡bsso）、O／S【αge／:y UniversilyofToronto St·Michael,sHospital,DivisionofGeneralSuγge】y／Trauma Toronto,Ontario C8hRdR ChristophR·Kaufmann,MD,FACS Mbd【cα』D舵ctoJ》TmumαSe｝u!ces ForbesRegionalHospital MonroeviⅡe,Pennsylvama UmtedStates

■ ■ ■

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Consu∣tanttotheCommitteeon AdvancedT『aumaIjfeSuppo『tof theAme『icanCoⅡegeofSu『geons ▲ CommitteeonT『auma 』 可

ArthurCooper,MD,MS,ⅢnCS,InAP,FCCM Pm／bsso了O／S【〃琛J:y ColumbiaUniversiWMedicalCenter AifiliationatHarlemHospital

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Ame『icanSocietyo『AnesthesioIogy LiaisoⅡtotheCommitteeon ｝ ｝AdvancedT『aulhalifeSuppo『tof theAme『icanCoⅡegeofSu『geons CommitteeonT『auma

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PeterJ·Dunbar,MD Assoαα花PrO／bsso『》A〃est〃esZo【咽「 Harb0rviewMedicalCenter Seattle’Washington UnitedStates

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RobertR·Bass,MD,FACEP 陬它cαtiueDb杷αo｝. MarylandInstitutefbrEmergen叮MedicalServicesSystems Baltimore,Ma叮land UmtedStates

RobertE。O,Connor,MD,rnCEP P『D／bso妒α〃dC／』αZ『’ DepartmentofEmergenCyMedicine UniversityofVirginiaScho0lofMedicine Charlottesville’Virginia UnitedStates

xivPREFACE

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RaphaelBonvin,MD,PhD Fhcα／t﹫dbbZo／ogteαdem“eα几e’U〉﹩蛇d它F白dαgog!em錮tcα／e LR】】sanne Switzerland

WesamAbuznadah’MD,Med,IHCS（C）’RPVI AssJsm㎡P『D／bsso乃Cb冗sα〃α㎡Vhscu／αJ.＆E〃d0uαscα／αr S叨唔eU／ M它d﹩Cα／Educα﹠or加﹣C〃α唔e’D叨αr咖e㎡O／M它㎡cα／EdⅨcα㎡o／』 KingSaudBinAbdulazizUniversiWForHealthSciences JeddRh KingdomofSaudiArabia JoeAcker,n1,MS,MPH,EMr·P 陬eCα／／ueD!爬αor

Birmin帥amRegionalEMS Birmingham,Alabama UmtedStates PeggyChehardy,EdD’CHES NewOrleans’Louisiana UnitedStates

DebbiePaltridge C0几／bderα〃o〃O／几s唔『。αdααfeMbdicα／Edαcαtio几αα〃α【s M﹫加be乃AⅡ】LSSemo『·歐』ucα／orAdu!so／:yGJ·o吻 Victoria AⅦStrH】iH

ElizabethdeIasMercedesValI酊odeSolezio’MA,PhD M它加be／》AⅡLSSe几torEdαcα／orAdu『so）yGro叩 α〃sα〃OrαI〃ter〃αc!o〃α／e几Ed叨cααd几’EUα／α“!d〃J α!pαc肋ααd几 Quito,Pichincha Ecuador ClausDieterStrobaus Mb加be乃ATLSSe几ZorEducα』oγAdu『soJyGro叩 DepartamentodePdsGraduagaoemEduca﹫且o PontihciaUniversidadeCat0licadoRioGrandedoSu】 PortoAllegre Brazil

KumYingTham’MBBS,ⅢRCS（Edin）,FAMS Mb〃!be乃AZ!LSSe㎡oJEdαcα／orAdu:so｝:yG／.o叩 SeniorConsultant’Climca1AssociateProfbssor TanTockSengHospital SingaporeCity Smgapore

DonnaAⅡerton,RN Cr洫cα』印／.e’αo㎡加αto乃AILSPJDg了α〃﹫ McMasterUniversityMedicalCentre Hamilton,Ontario CRhn刊R

Vil】naCabading AI!LSⅣt﹩〃o几α／Cbo｝﹃d加αto乃SααdiA『·αb㎡α AcademicAffairsDepartment KingAbdulazizMedicalCity﹣NGHA Riyadh Kingd0mofSaudiArabia

CristianedeAlencarDomingues,RN αo『de几αdbmⅣhCi0几α／AILS／PH?】LS／ATOM Dfre／orαⅣααo几α』ATCN UniversityofSaoPaulo SaoPaulo BrR叨Ⅱ

LesIeyDunstaII EMSIγAⅡLS』W瓦o〃α【Cbo｝.d加αtoJ）Aαs力.α／㎡α RoyalAustralasianCollegeofSurgeons NorthAdelaide,SouthAustralia Australia

RuthDyson,BA（hons） 陬皰r〃α』Pmgrα加加esαoFd加αtoJ）EUαcα㎡o几D叩α『·t加e〃』 TheROyalCollegeofSurgeonsofEngland London UnitedKingdom ChadMcIntyre’NHEMT·P,FPC AZLSα0rd加αtor ShandsJacksonvilleMedicalCenter Jacksonville’Florida UnitedStates

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AckⅡowledgⅡ1ents ATLSp『og『amOfficeStaff WhⅡeitisclearthattherearemany peopleresponsiblefbrtheNinth Edition,theoutstandingstaffinthe ATLSProgramOfficedeservesspecialmention.Itistheirdedication andhardworkthatnot0nlypro﹣ ducestheneweditionwhileensur﹣ ingthateachoneisbetterthanthe last,butfacilitatesitsuseinhun﹣ dredsofcoursesaroundtheworld eachandeveryyear. WiⅡChapIeau,EMr羼P,RN,TNS A?LSPmg7u加Mmmgcγ AmericanCollegeofSurgeonsATLS ProgramO伍ce Chicago,Illinois UnitedStates BiⅡJen肘hS Ad加加【S向u㎡ueS吻αu』8oγ AmericanCollegeofSurgeonsATLS ProgramOfHce Chicago,Illinois UmtedStates

Jagm可neA】M】巫ib COTRCg『o〃α』R·ogmmαo㎡加α『oγ α劣1玩IaI〃 AmericanCollegeofSurgeons Chicago,Illinois UnitedStates SⅢ和】·onE·BorⅢm COTRCgio几α』P『吧rα〃!αo㎡加α㎡o了（a9） AmericanCollegeofSurgeons Chicago,Illinois UnitedStates

GerardoCuauht色m＠cAlvizoCdrden巫 COTAd〃㎡〃istm〃ueAss!s／α〃tα〃d 印eciα』Rn／cc蚶αOrd加α／Oγ AmericanCollegeofSurgeons Chicago,Illinois UnitedStRt2s

DanielIeS。Haskin,MSW COTCME＆α【』炤eDeu2／op〃te『㎡ 印eαα〃SZ AmericanCollegeofSurgeons Chicago,Illinois UnitedStates PascaleLeblHnc COTR嚀o〃α』RDgm加α0㎡加㎡o｝、（am） AmericanCoⅡege0fSurgeons Chicago,Illinois UnjtQdStates

HichardH。SR0Iee COTR唧o『m』R唔ynmαo㎡加α加rα’m） AmericanCollegeofSmgeons Chicago,Illinois UnitedStates

CeliaAMRn田 A?LSαo㎡t〃αtor Santiago Chile

FreddieL。Scruggs COTR唔『o〃α』P『Dg｝qαmαo㎡!〃α』oJ 但’風8） AmericanCollegeofSuIgeonsATLS ProgramOHice Chicago》Illinois UnitedStates

JameelA1i,MD,M。Med。Ed,rRCS, FACS P／.o／bsso『.o／S邸唔它J:y UniversityofToronto St’Michael’sHospital,Divisionof GeneralSurge】W／Trauma Toronto,Ontario Canada

NataIieM·Torres COTReg!o〃α／PmgmmCbo㎡Z〃αto『。 α’Kn’』2） AmericanCollegeofSurgeons Chicago,Illinois UnitedStates

Cont『ibuto『s Duringdevelopmentofthisrevision’ wereceivedagreatdealofassistance fiyommanyindividuals-whether reviewinginfbrmationatmeetmgs, submittingm1ages’orevaluatingre﹣ search.ATLSthanksthefbⅡowing contributorsfbrtheirtimeHⅥdek brtinthedevelopmentoftheNmth Edition: GeorgesAbiSaad AⅢ】LSProg『n加D向℃croγ Beirut Lebanon

OmarAlGha㎡mi A?】LSEd【﹠cα﹠or Taif KingdomofSaudiArabia

Abdu1IahAl·Harthy α〃sM〃α〃!’奶.α【』mαSα『gCo〃’α几d 〉 I !／e〃sⅡU!SZ SultanQabo0sUniversi叮Hospital AlKhod Oman

SaudAlTurki,MD,FRCS,ODTS, FACA,FnCS D〃℃αo｝》乃αα加αα叨滔es昕fcq 几s咱『,αdααteEd皿cα㎡O〃＆Acαde｝｝㎡c A〃h〃沿 KingAbdulazizMedicalCi叮 Riyadh KingdomofSaudiArabia

DonnaA1lerton,RN CJ、尬cα』∞『它,αo㎡加αto片AnJS Pr唔γα加 McMasterUniversi叮MedicalCentre Hamilton,Ontario Cah月dR

JohnA。AndrouIakis,MD,FACS Eme／.肋MsRD／它ssorO／Sm君E｝:y Universi叮HospitalofPatras Patras Greece

Ma】jorieJ.Arca’MD’FACS ASsistα〃／P／D／bSso了 Children’sHospitalofWisconsin Milwaukee,Wisconsin UnitedStates JohnH。Armstrong,MD,FACS M它d【cα』DZ杷c加r CenterfbrAdvancedMedicalLearning andSimulation,Universi叮ofSouth Florida Tampa’Florida UnitedStates

JohnL。D。AtMnson,MD,ⅢnCS DCpα『W〃e／㎡O／ⅣbαmsαJgE『:y MayoClinic Rochester,Minnesota UnitedStates

MahmoodAyyaz’Ⅷ Pro／bSSo『·O／Sα唔它『y Lehore,Punjab Pakistan AndrewBaker,MD An』SPJngJ.α加DZ沱αoJ. Durban SouthAfipica

DavidP。BIake,MD,FACS α／’USAEMUFB αmmα〃de『;88毗S皿嚀cα／OPerα㎡o〃s SqααdJ.o〃 WrightPattersonAirForceBase,Ohio UnitedStates x v

XviACKNOWLEDGMENTS MarkW·Bowyer,MD,r泠CS,DMCC α【（ReU’USAF＼MC Pm／bsso「O／Sα唔它U／ C／M叭D『u㎡s【o〃O／乃m‘mαα〃dαmbαt Sα咱eU／ D【陀αorO／Sα嚀cαSi加α／㎡to几 TheNormanM.RichDeptofSurgeⅡy Uni｛brmedServicesUniversity Bethesda,Ma】yland UnitedStates Mary·MargaretBrandt,MD,FnCS Ass!stα〃『Pm／bssor Ge几em／Sα咱eJy’αuis『o〃O／Tmαmα’ Bαr〃α〃dEmeJgc『﹫叼／Sα唔eU／ UniversityofMichigan AnnArbor,Michigan UnitedStates

FrankJ·Branicki,MBBS,DM,FRCS, FRACS,FCS（HK）,FHKAM（Surg） Pm／bssorα〃dChαjr㎡Sα唔eU／ UAEUniversity’Al-AinFaculbyof Medicine＆HealthServices Al﹣Ain UnitedArabEmirates KarenBrasel,崆H,MD,FACS A7LSαm加尬ee’Chα亦 Pm／bssormm皿加αSα『g它Jy＆C「㎡cα』 ∞爬 FroedtertHospital＆MedicalCo】legeof Wisconsin,TraumaSurgeIyDivision Milwaukee,Wisconsin UnitedStates

GeorgeBrighton’MD Cb爬SαJgicα』I》m〃ee TraumaandOrthopaedics NorthDevonDistrictHospital Bamstaple UnitedKingdom

JamesBrown,MA ATLSEdαcαtor MaⅣlandInstituteibrEmergency MedicalServicesSystem Baltimore,MaIyland UnitedStates LauraBruna,RN I』α〃α〃Ⅳα〃O几α』αOrdmα／Or ASsitrauma Torino Italy

ReginaldA·Burton洫,FACS Di施αo門Iγmαmαα〃dSα唔tCα／Cr㎡Cα／ Cm℃ BⅣanLGHMedicalCenter Lincoln,Nebraska UnitedStates

JacquelineBustraan,MSc Ei皿cα〃O兇α／α〃sα〃α㎡α〃dReseαJ℃〃er PLATO,Centre｛brResearchand Developmento『Educationand Training’LeidenUniversity Leiden Netherlandg

EmmanUelChrysos,MD,PhD,rnCS Associα¢eR℃允ssorO／Sα『gCⅣ DepartmentofGeneralSurgeIy, UniversityHospitalofCrete Heraklion,Crete Greece

VilmaCabading A】γLSⅣα㎡o〃α』Cbo㎡!几α／o門Sααdi A｝ubZα AcademicAiIairsDepartment KingAbdulazizMedicalCity﹣NGHA Riyadh KingdomofSaudiArabia

RaulCoimbra,洫,PhD,FACS C版e／O／7丫uα加α／Bαm／Sα唔㎡cα』Cr㎡cα／ “祀D!U』S!o〃 Depα冗me〃tO／Sα唔eyy UniversityofCalifbrnia’SanDiego MedicalCenter SanDiego,Cali｛brnia UnitedStates

CarlosCarv薊alHafemann’MD’ FACS Chα『叩e炤o〃’Ch〃eαⅧ加㎡eeo〃】γmαmα ProfbssorofSurgeIy DirectorofSurge叮o『theEastCampus UniversidaddeChile Santiago Chile

FranciscoColleteSiIva,卹,FACS, PhD（med｝ MCd!cα／Doαor﹣E加e『g巴〃旬／SM咱tcα／ Seru〔ces HospitaldasClinicasoftheUniversityof SaoPaulo S且oPaulo Brazil

Gusta▼oH·Castagneto,MD,FnCS Pm／bssoro／Sα唔cⅣ BuenosAiresBritishHospital, DepartmentofSurgeⅣ BⅡ】enosAires Argentina

ArthurCooper,MD,MS,FACS, FAAP,FCCM Pm／bssorO／Sα唔它Ⅳ ColumbiaUniversityMedicalCenter Al刪iationatHarlemHospital NewYork,NewYork UnitedStates

CandiceL·Castro,MD,FACS COL’MαUSA ATLSα【』『qseD／祀αor SanAntonio,Texas UnitedStates ZafarUllahChaudhry,MD,FRCS, FCPS,FACS Pm允ssorO／Sα唔en／ NationalHospitalandMedicalCenter R℃si咋㎡ CoⅡegeofPhysiciansandSurgeons Paki息tRh K且rRchi PHkistR肋

PeggyChehardy,EdD’CHES NewOrleans,Louisiana UnitedStates ReginnSuttonChenn扭ult,MD,FACS I》uαmαM它d【cα』Di祀αOr AlaskaRegionalHospital Anchorage,Alaska UnitedStates

WeiChongCHUA,MD Ch吋A｝。mJM它d!cα』O版c2r SingaporeArmedForces SingaporeCity Singapore

JaimeCortesqeda,卹 C〃e i ／;Ge〃em【Sα｝習cⅣ NationalChildren’sHospital Pm／bsSOr UniversityofCostaRica SanJose CostaRica ClayCothrenBurlewMD,rnCS D蛇αor’Sα唔icα』加蛇J!StUe∞『它U〃〃 Pmgm加Di陀αo門乃ⅦMmαα冗dAcαte αreSα』g它U／Fb〃o卹sh叩 DenverHealthMedicalCenter Denver’Colorado UnitedStates DianeChetty ATLSαo㎡加α加r TawamHospital AlAin,AbuDhabi UnitedArabEmirates

KimberlyA。Da吭s,MD,FACS Tmα加αM它d!cα／D!沱c如r Sα唔icα／α陀αo乃Qα〔M叼α几d 几朮mm〃c2I〃Jp”Ueme〃t Yale·NewHavenHospital NewHaven,Connecticut UnitedStates

ACKⅡOWLEDGMENT5 CristianedeAlencarDomingues,RN αo㎡它Jm㎡OmⅣ“Zo〃α／A7LS／PH】LS／ ATOM DZ祀mmⅣαc!o〃α／ATCⅣ UniversityofSaoPaulo S且oPaulo Bmzil

Abdelh啦mTalaatElkholy,MBBCh A】ZSPmgm加Di祀αor Cairo E田pt

OscarD·GuiⅡamondegu’,泗,FACS Assoαα』eR℃／bssorO／SαJ召它Ⅳ’D﹟uZs﹟o〃 o／Tmα加α＆Sα唔／∞／C㎡〃cα／∞疋 VanderbiltUniversityMedicalCenter Nashville,Tennessee UnitedStates

MauricioDiSil㎡o·Lopez,MD,FACS Chα加ME卯tcuα加m尬e2o〃乃Uα〃m HospitalRegional20deNoviembre’ ISSSTEMexicoCity,DistrictoFederal Mexico

CIausFalckLarsen,MD,dr·med。, MPA,FACS C／tZe／;ComJm㎡eeo几仍nu加αHegZo〃15 M它d﹟cα』D㎡J℃c!o尸 TheAbdominalCentre’Universityof Copenhagen,RigshopitaletDenmark Copenhagen Denmark

JayJ.Doucet’MD,EHCS Di爬c加門SαJgicα』ImeⅡs!U2α陀U》J㎡ UniversityofCalifbrnia’SanDiego MedicalCenter SanDieg0,Califbrnia UmtedStates

Ⅲ廿oi1anA·Fernandez,卹 A】YLSPmgm加α陀αor M它d『cα』D㎡爬c如了Eme『習c〃叼Seγu』ce HospitaldelTrabajador Santiago Chile

HermanusJacobusChristoffel DuPlessis,蛔’ChB,MMed（Surg）, FCS（SA）,FnCS C脈㎡Sα唔它o几’α／o〃e／ SAMHS（SouthAiricanMilitaIyHealth Services） Hb“O／t肱D叩α㎡me㎡o／Sα『習它U／α〃d 血蛇J2SZUe“沱 1Milita1yHospital A匈α〃αRU／bSSorO／Sα唔2『y UniveIBityofPretoria Pretoria SouthAmca

EstebanFoianini,MD’FACS Ge〃e尸α／S邸Jg它o〃 Di爬αo尸 FoianimClinic SRntHCruz Bolivia

RichardHenn,RN,BSN,M·ED D岫c加門Educα〃o〃D叩α㎡me㎡ NorthernArizonaHealthcare FlagStaff;Arizona UnitedStates

JoanFoerster AZLSCoo㎡mα加r UBCHealthSciencesHospital Vancouver,BritishColumbia

WalterHenny,MD FbJw﹩e叼O／Erαs加αsMbd!cα／α〃蛇r RotterdRm Nether】Fm刊R

GJulieA。Dunn,MD,Ⅲ洫CS Med『cα／DZ爬αo尸Reseαγc／tα〃d Ⅲf皿cα戊O冗 Z】mαmαα〃dAcαteCnreSα唔﹟cα／SerU』ces ●

PoudreValleyHealthSystem Loveland,Colorado UmtedStates RuthDyson,BA（hons） E冗皰mα』Pmgmm加esαO尸di〃α／o『●﹣ 風fαcα／tO〃D叩α㎡加e〃／T／!eRαyα／ α〃唔它O／Sα『g它o碼O／England London UmtedKingdom

MartinEasonMD,GJD Ass『sm几『P『D允ssor EastTennesseeStateUniversity JohnsonCity,Tennessee UnitedStates

EnriqⅢeA·GuzmanCottal】at,MD, FACS C〃α叱﹠αααOrαm加㎡eeo〃 】】mα加αD加／omαti〃PαMcHbα〃〃 D!疋cto乃Ⅳbαγosα『君它U／SerU!Ces GuayaquilHospital Guayaquil,Guayas Ecuador

BettyJeanHancock,MD,InCS Sec〃o几Hmd）几dm㎡CGe〃em【SαJgCb／ UniversityofManitoba Winnipeg,Manitoba CanHdR

CanadR

HeidiFrm】kel,MD’FACS Assistα㎡Pm允ssorO／SαJgeUI UniversityofMaMandMedicalCenter Baltimore’MaIyland UnitedStates SubashC·Gautam’MD’MBBS, FRCS,FACS A7LSP『吧7u加D舵αor SeniorConsultantandHeadof DepartmentofSurge】y FUjairahHospital Fhjairah UnitedArabEmm·ates GerardoA.Gomez,MD’F沙CS M它d﹟cα／D『咫Ctor IU／WiShardLevelITraumaCenter Indianapolis’Indiana UnitedStates HugoA1fredoGomezFernandez,

A·BrentEastman,MD,FACS PJ℃sⅡ叱㎡’Ame㎡∞几α』』咱eO／Sα『g它o〃s Chie／M它αic㎡o版ceF 凡比皿』W乃肱〃erC〃αⅡr㎡Tmαmα’ Sc『V】psM它〃m㎡α／Hbsp〃α／’Lαc／b〃α ScrippsHealth SanDiego,Cali允rnia UnitedStates

●■

xvⅡ

泗,FACS AZLSPγ吧『UmDZ『℃Cro『· SociedadParaguayadeCirugia Asuncion Paraguay

SharonM·Henry,卹,FACS A〃〃eSCα!eαPro允ssorO／乃uαmα UniversityofMarylandSchoolof Medicine αJ℃αo了Wb邶況dHbα／!〃gα〃dMααbo【!s沉 SerU／“ RACowleyShockTraumaCenter Baltimore,Maryland UnitedStates

GraceHerrera·FernR■同＠正 AILSαo㎡mαfoγ CollegeofPhysiciansandSurgeonsof CostaRica SanJose CostaRica

MichaelHoⅡands,MBBS,FRACS, FACS HmdO／H臼Pα『oα〃m:yα〃dGαS2”﹣ oeSqPhαg它α／S酩『g它U／ WestmeadHospital Sydn叮’NewSouthWales AustT且】iR RoxolanaHorbowW’MD’FACS ATLSI兀Stmαo听 Holmes,Pennsylvania UnitedStates

■ ■ ●

xvⅡI

ACKNOWLEDGMENTS

ChristopherM·Hu】ts,MD,FACS CDR,USN Tmα肌αα几dSα唔﹟cα／Cr㎡cα／∞祀 UniversityofSouthFlorida Tampa,Florida UnitedStates

Chong﹣JehLo,MD,FACS Assoαα『eDeα几／brS『αde〃／A﹟ht稻 NationalChenKungUniversityCollege ofMedicine T日ihan Taiwan

RandeepS·Jawa,MD,ⅢⅦCS Ass!sfα㎡Pm允ssorO／Sα唔eU「 UniversityofNebraskaMedicalCenter Omaha,Nebraska UnitedStates

Sar▼eshIcgsetty,MD,FnCS D亦ecmro／MmmobαFh℃／:g／t陀炤Bαr〃 U〉z肱 Assoα㎡ePm佗ssor DepartmentofSurgeIyandChildren,s Health UniversityofManitoba Winnipeg,Manitoba Can2dH

JoseMariaJo▼erNa▼al◎n,MD,FACS A】LSP尸ogJUmD〃它C加r HospitalUniversitariodeGetaib, DepartmentofGeneralSurge叮 Madrid Spain

GregoryJ·Jurko㎡ch卹,FACS P”／bssoγO／SαJgc刁 HarborviewMedicalCenter Seattle,Washington UnitedStates ChriStophR。Kaufn1ann,泗,FACS M它diCα』DZ爬αo門】〉uαmαSerU／CeS ForbesRegionalHospital Monroeville,Penn可lvania UnitedStates

PeggyKnudson’MD,FACS Pm允ssorO／Sα『g它Ⅳ UniversityofCalifbrnia,SanFrancisco GeneralHospital’Departmentof SurgeIy SanFrancisco,Califbrnia UnitedStates JohnB·Kortbeek’MD’FRCSC,FACS ATLSCbm加ittCe’m蛇mα〃o〃α／αα涵e D〔『eαor Pm／bssorD叨α㎡memsO／Sα唔e叮α㎡ Cr㎡cα∞沱 UniversityofCalgaryandCalgmyHealth Region Calga叮,A1berta CanRdR

RomanKosir,MD A7?LSPmgmmDt祀αoF Ass【s!α㎡O／SαJg它Jy UniversityClinicalCenterMaribor, DepartmentofTraumatolo田 Maribor Slovenia

EricJ。KunCir,MD,FACS Umuers吻O／α﹩／吮m!α’Sα〃D㎡ego SanDiego’Califbrnia UnitedStates RoSlynLadner A?LSαo㎡mαmr BritishColⅡ】mb面a CanRdR

K且KRI』㎡ A?LSαo㎡i〃α如r

DepartmentofNeurosurgery,Queen MaryHospital HongKong China Siew·KheongLum ATLSP『唔m加α祀αor SungaiBulohHospital KualaLumpur Malaysia

DougIasW.Lundy,卹’ⅢnCS O冗〃αpαedZcT〉nα加αSαJgeⅣ ResurgensOrthopaedics Marietta,Georgia UnitedStates FernandoMaChado,MD U）3加e『qs㎡“de【αR叩αMcα Montevideo Uruguay

PatrimoMao,泗,FACS ReSPo〃sαb!／eU》ge〃Z2C脈rα嚀che ChirurgiaGeneraleUniversitaria,A.S.O SanLuigiGonzagadiOrbassano T0rino Italy

DanielBMichael,卹,PhD,FACS C版e／;Ⅳ它αm『mα加αα〃αCr尬Cα』Cαre BeaumontHospital ROyalOak,Michigan UnitedStates

MaheshC·Misra,泗,FACS AILSR吧m加D〔疋ctDr AllIndiaInstituteofMedicalSciences, NewDelhi Ind』n ForrestO·Moore,MD,FACS 7γmα加αSα咱eo〃 St·Joseph,sHospitalandMedicalCenter Phoenix,Arizona UnitedStates

Newton叨inMori,泗 G它几em／Sα｝gCo〃 EmergenCySurgicalServices, HospitaldasClinicasUmversidaddeS且o PaulO SaoPaulo Brazil CharlesE。Morrow,GJr,洫,FACS P『唔mmα『℃C如乃Ge几em』sα唔e刁 M它dicα／D舵c如乃乃nα〃mSαJg它Jy DepartmentofTrauma’Spartanburg RegionalMedicalCenter Spartanburg,SouthCarolina UnitedStates

StephenG.Murphy’MD DivisionofPediatricGeneralSurge叮 Wilmington,Delaware UnitedStates

KimberlyK。Nagy,洫,FACS Ⅵce﹣C／α j『 i wm几’D叩mty7ue〃『O／》 I m』mα CookCountyTraumaUmt Chicago,Illinois UnitedStates NicolaosNicolau,MD,FACS

Ⅸ出月】迅MasoodGondal

ATLS血sfrααor LRrnR∞ Cyprus

AⅥLSDtsrγαctor LRhore PaMStnh

凹且nBoonOh A】LSI〃s／rααor

R·ToddMa巫on,MD,FACS Ch蠅I｝m〃〃αR吧m加 DellCM!dren,sMedi∞lCenter LittleRock,Arkansas UnitedStates ChadMcIntyre,NHEMT·P,FP·C ATLSαo㎡mα』oγ ShHhdsJacksonvilleMedicalCenter Jacksonville,Florida UnitedStates

SingaporeCity Singapore

OsamaAliOmari’洫 A】LSIJ】s仃ααor SRl】diARAMCOMedicalServices Organization DhRhmn KingdomofSaudiArabia

HockSooOng,MD,FnCS Se〃iorα〃sα〃α㎡加GeJ﹫em／Sα唔e『y SingaporeGeneralHospital Singap0reCity Singapore

ACKNOWLEDGMENT5xix GiorgioOlivero,MD,FACS RD允ssorO／SαJ吾C『y UniversityofTorino,Departmentof MedicineandSurgeIy,St.Johnthe BaptistHospital Torino Italy GonzaloOStria,卹 A7LS﹣Bo〃㎡ααα〃 Bolivia Chile

RattapleePak.Art,MD A】LsP『吧m加D﹟爬αor Bangkok TbHi】ahd

SoniaPriⅡuuPR皿 AZLSαo㎡加α㎡or MontrealGeneralHospital Montreal,Quebec C月h匆da

PatrickSehoettker,MD,M。E·R· ATLS加s／mαor

CristinaQuintana A】LSαo㎡mα』or

Switzerlnhd MartinA·SChreiber,MD,rnCS RD／bssOr㎡Sα『g它Jy Di咫C如昀】牠α加α鈍rU【ce OregonHealth＆ScienceUniversity, Trauma＆CriticalCareSection Portland,Oregon UnitedStates

SociedadParaguayadeCirugia Asuncion Paraguay

TarekS·A·Razek,MD,FACS DZ沱Cto阿TmαmαU〃肱 MontrealGeneralHospital Montreal,Quebec CaⅥRda

NeilG.Parry’MD,FRCSC,FACS Assoαα花RD允ssor VictoriaHospital London,Ontario C8h且dR

C〃α亦’AZLSSt2e冗〃gGm叩 TheRoyalCollegeofSmgeons London UnitedKingdom

BiPinchandraR·Patel,MD,ⅢnCS A?LSαα淹eDi沱ctor Vestal,NewYOrk UnitedStates

JakobRoed,MD AILSPmgmmD!陀αor Copenhagen DeⅥmHrk

JasmeetS·Paul,卹 A】LSh』St『t』αor MedicalCollegeofWisconsin Milwaukee,Wisconsm UnitedStates

MarthaRomero A?ZSCoo㎡m㎡or AMDABolivia SHⅥtaCruz Bohvia

PedroMonizPereira,MD A】LSR昭m加D舵Cfo『 GeneralSurgcon LisboaPortugal

MichaeIF·Rotondo’MD,FnCS α加m㎡陀eo几】1mα加α’Chα／「

RosalindRoden,FFA酗

PJD／bss0rO／Sα『g2n／’C〃α﹩r㎡D2pα㎡me㎡

RenatoSergioPoggetti’MD,FACS αi叭COTR嚀o冗I4 α咫αorO／E加e『g它〃叮SαJg!Cα』生ru!Ce HospitaldasClinicasUniversidaddeS包o Paulo R下巫il

o／Sα『g2U／’EαsZ“m〃〃αU㎡Ue稻叼 CⅡt㎡o／Sα｝g它『y’D!爬c加rO／α㎡erO／ E冗c2』／e“e允rT》uαmαα〃dSα唔【c㎡ αγ肱cα／“爬 PittCountyMemorialHospital,Umver﹣ sityHealthSystemsofEasternCarolina Greenville,NorthCarolina UnitedStateS

AlexPoole,MD,FACS ATLSαα『它eD!沱αor Nelson,BritishColumbia C巳nRd2

M匈idSabahi,MD ATLSI〃s¢rααor Tehmn Iran

Marce】oReca1deHidrobo,MD,FACS ATLSαα滴eD【爬cmr UniversidadSanFranciscodeQuito Quito EαⅡHd㎡

NicoIeSchaapveld’RN MmmgZ『】gDi陀αor／Ⅳα〃o〃α／ αo㎡加㎡orA?匹SNL AdvancedLifbSupportGrou防NL Riel TheNetherlands

RaymondR·Price,MD,rnCS A叼α〃ααm『cα!Ass【sm㎡Pm允ssor UniversityofUtah Murray,Utah UnitedStat2s

IngerB·SChipper,卹,PhD,FACS Pmgy·α加D舵αo月A?LSⅣb毗er』α〃ds H它α〔』’Depα㎡加e〃／㎡】〉nαmαsα唔eⅣ LeidenUniversityMedicalCenter LeidenTheNetherlandS

Responsab】eAnesth色sieNeurochirurgicale, ORLetUrgenceService d,Anesth怠siologie 『丑Ⅱ】RHnne

EstrellitaC·Serafico AZLSαo㎡mαmr KingAbdu】azizMedica』City Riyadh KingdomofSaudiArabia

JuanCarlosSerrano,MD,FACS AZLSαα咫eD﹩沱αoγ Dir2ct叱Depαrt加e〃tO／乃uαmα HospitalSantaIn色s CuenCa EcⅡ2dor BrianSiegel,洫’FACS ATLSαα施eD!陀c如r Stα〃助）幅iαα冗 DepartmentofSurge叮 MorristownMemorialHospital Morristown,NewJersey UnitedStates

PreechaSiritongtaworn,MD,FACS C／j﹟e／;αuisio〃O／刃m邸mαS凹』geb／ DepartmentofSurgeIy,Facultyof MedicineSirirajHospital,Mahidol University Bangkok Tb且ilRnd n;■UnRsk㎡f A】LSαo㎡i『mtor AmericanUniversityofBeirutMedical Centre Beirut Lebanon

R·StephenSmith,MD,RDMS,FACS Syste加Chi叭Acαtc∞爬Sα『g它｝y WestPennAⅡeghenyHealth司stem Pittsburgh,Penn可lvania UnitedStates RicardoM·Sonneborn,MD,FACS Santiago Ch】 i e

AⅥⅥeSorvari AⅢLSαo㎡mα!or St;Michael,sHospital Toronto,Ontario CanadR

xxACKNOWLEDGMENT5 Paul﹦MartinSutter,MD DepartmentofSurgeIy,Spitalzentrum Biel Switzer】and

JohnSutyak,MD,FACS AssoααfeD!reαor SouthernIllinoisTraumaCenter SpringHeld,Illinois UnitedStates

LarsBoS▼endsen,卹,DMSci AssoααtePm允ssorSα唔e刁 CopenhagenUniversity’Department ofAbdominalSurgeIyand Transplantation,Rigshospitalet Copenhagen Denmark

PhilipIhpuSkett,MBBS,IRACS TheUniversityofNewSouthWales PrinceofWalesHospital,Randwick Cr0nulla,NewSouthWales Aust丫aⅡa

JeffreyUpperman,MD,IⅦCS AsSZsm㎡Pm／bssor Children,sHospitalofLosAngeles LosAngeles’Califbrnia UnitedStates YVonne▼巳ndenEnde O版CeMα〃喀它r StichtingAdvancedLifbSupportGroup Riel TheNetherlandg

NicholasM.Wetjen,疝 Ass【Sm几rPm／bssorO／Ⅳ它M”S皿JgU刁α几d AdZαh·㎡cS MayoClimc Rochester,Minnesota UnitedStates RichardL·Wigle,MD,FACS Assism几『Pm／bssor LSUHea!thSciencesCenter Shreveport,Louisiana UnitedStates StephenWilkinson,MBBS,MD, FHACs Ge〃em【Sα｝gm几 TasmaniaAntiobesitySurgeIyCentre Hobart AⅡ】昌t『nm I

AⅡnnven㎡ke

Wa,eIS。Taha,MD Ass﹟s!α㎡Pm／bssorO／Sα『g它刁 KingAbdulazizMedicalCity NationalGuardHealthA恤irs Riyadh Kingd0mofSaudiArabia

KathrynTchorz’洫,FACS AssoααtePm／bssor WrightStateUmversi叮SchoolofMedicine Dayton,Ohio UnitedStates WeiTingLee AILSI〃s／rααor SingaporeCity Singapore

Gusta▼oTisminet盆y,MD’FACS’ MAAC ATγLSProgmmDt沱cmr Pm允ssorO／Sα唔eⅣ UniversidaddeBuenosAires BuenosAjres Argentina JulioL·Trostchansky,MD,FACS AⅢLSPr唔yu加D硿c』or SociedaddeCirugiadelUruguay Montevideo Uruguay

A7LSⅣα〃o几α』Edα∞加r N鋁stved Denmark

T◎reVikStr6m,MD,PhD D『reαo了α〃dHm〔fα几sα〃α㎡’G2几em／ S腮唔eU／Pm／bssorO／DZsαs蛇rMed!c加e ＆Tmα加α』o／Ogy CentrefbrTeaching＆Researchin DisasterMedicineandTraumatolo田 UniversityHospital Link0ping Sweden

EricVoigIio,MD,PhD,IⅦCS,FRCS Se几／orLectM祀內α几sα〃α㎡Sα唔eo〃 DepartmentofEmergen叮SurgeIy’ UniversityHospitalsofLyon CentreHospitalierUon﹣Sud Pierre﹣Benite France

I£onardJ·WeiretereJr·,卹,FACS Pm允ssorO／Sα唔e刁 EasternVirginiaMedicalSchool Norfblk’Virginia UnitedStates

RobertJ·WinCheⅡ,洫,FACS Hmd’乃Ⅶαmαα〃dBαr〃SαJg它刁 MRiheMedicalCenter Portland’Maine UnitedStates

RObertWinter,PRCP,ⅡRCA’DM α〃Sα／tα㎡加Cr㎡cα／∞爬M它dic加e MidTrentCriticalCareNetworkand NottinghamUniversityHospitals Nottingham UnitedKingdom

eIayA·Yelon,MD,FACS C几α『r加α〃’D叩α㎡加e㎡O／Sα唔cⅣ LincolnM2di哩lCenter P｝D／bssorO／α加／cα』Sα『ge〃 WeillCornellMedicalCollege Bronx,NewYOrk UnitedStates

AhmadM·Zarour,MD,FACS D叩α㎡me〃『㎡Sα｝吾它Ⅳ HamadGeneralHospital Doha Qatar

ACKNOWLEDGMENTSxxi

Ⅱoho『RoII Overthepast30years’ATLShas grownhomalocalcoursetraining Nebraskadoctorstocarefbrtrau﹣ mapatientstoaf白mi】yoftrauma specialistsfrommorethan60coun﹣ trieswhovol1mteertheirtimeto ensurethatourmate而RisreⅡect themostcurrentresearchandthat ourcourseisdesignedt0nnprove patientoutcomes.TheNmthEdi﹣ tionofATLSreHectsthee任brtsof thefbⅡowingindividualswhocon﹣ tributedtothefirsteighteditions’ andwehonorthemhere. Hono『RoIIMembe『s SabasF·Abuabara,MD,FACS JoeE.Acker,II,MS,MPH,EMT RaymondH.Alexander,MD,FnCS FatimahAlbarracin,RN JameelAli,MD,MMedEd’FRCS（C）, FACS HeriAminuddin,MD CharlesAprahamian,MD,FACS GuillermoArana’MD,FACS AnaLuisaArgomedoManrique IvarAustlid GonzaloAvil﹫s RichardBaillot》MD BarbaraA·Barlow,MA’MD,I性CS JamesBarone,MD,InCS JohnBarrett,MD,FACS PierreBeaumont,MD MargaretaBehrbohmFallsberg,PhD,BSc RichardM.Bell’MD’FHCS EugeneE.Berg,MD’FACS RichardBergeron’MD FrangoisBertrand,MD RenatoBessadeMelo’MD MikeBetzner,MD EmidioBianco’MD,JD KenBoifhrd’MBBCh’FRCS,FRCS（Ed）’ FACS BertilBouillon,MD DonEBoyle,MD,FACS MHrianneBrandt FredBrenneman,MD,FIlCSC,FACS SusanMBriggs,MD,FACS AseBrinchmann﹣Hansen,PhD PeterBrink,MD,PhD KarimBrohi,MD ReaBr0wn,MD,FACS AllenF.Browne,MD,FACS GerIyBunting,MD AndrewR·Burgess,MD,FACS RichardE.Burney,MD,FACS DavidBurris’MD,FACS 財lviaCampbell,MD’FACS C.JamesCarrico’MD,FACS C·GeneCayten,MD’FACS JUneSau·HungChan

RobertA’Cheny,MD,FACS Chin-HungChung’MBBS,FACS DavidE’Clark’MD,FACS PaulE.Collicott’MD,FACS ArthurCooper,MD,FACS RonaldDCraig,MD DougDavey,MD ElizabethdeSolezio’PhD SubratoJ.Deb,MD AlejandroDeGracia,MD,FACS’MAAC LauraLeeDemmons,RN,MBA RonaldDenisjMD JesusDiazPortocarrero,MD,FACS FrankX·Doto,MS Anne﹣Mich白leDroux MargueriteDup1’色jMD CandidaDura0 BrentEastman’MD’FACS FrankE·Ehrlich,MD,FACS MartinR.Eichelberger,MD,FACS DavidEduardoEskenazi》MD,IⅦCS VagnNorgaardEskesen’MD DenisEvOy,MOH’FRCSI WilliamF.Fallon,Jr,MD,FACS DavidV.Feliciano,MD’FACS FroilanFernandez,MD CarlosFernandez﹣Bueno,MD JolmFildes’MD,InCS RonaldP.Fischer’MD’FACS StevensonFlanigan》MD’FACS LewisMFlint’Jr,MD,FACS Co1,neliaRitaMariaGetrudaFluit》MD, MEdSci J0rgeE·Foianini,MD’FACS SusanneFristeen,RN KnutFredriksen,MD》PhD RichardFuehling’MD ChristineGaarder’MD SylvainGagn0n’MD RichardGamelli’MD,FACS PaulGebhard JamesA’Geiling’MD,FCCP ThomasA.Gennarelli,MD,FACS Jo】mHGeorge,MD AggelosGeranios,MD MichaelGerazounis,MD RogerGilbertson’MD RobertW.Gillespie,MD,EACS MarcGiroux,MD JavierGonzdlez﹣Uriarte,MD,PhD, EBSQ,FSpCS JohnGreenwood RussellL.Gruen’MBBS’PhD’FRACS NielsGudmundsen﹣Vestre J·AlexHaller,Jr’,MD,FACS BurtonH.Harris,MD,FACS M i ch ae l LH a w kins,MD,FA CS IanHayw0od,FRCS（Eng）’MRCS,LRCP JamesDHeckman,MD,FACS JuneE.Heilman’MD,FACS DavidMHeimbach’MD’FACS DavidN.Herndon,MD’FACS FergalHickey,FRCS’FRCSEd.（A＆E）, DA（UK）’FCEM ErwinF.Hirsch,MD’FACS FranciscoHolguin,MD

ScottHolmes DavidB·Hoyt,MD’FACS ArthurHsieh,MA,NREMT﹣P IrveneK.Hughes’RN RichardC·Hunt,MD,FACEP JohnE·Hutton’Jr,MD,FACS MilesH.Irvin呂FHCS（Ed）’FRCS（Eng） Jos色MariaJoverNavalon,MD,FACS RichardJUdd,PhD,EMSI Grego1yJ.JUrkovich,MD,FnCS AageWKarlsen ChristophR.Kaufinann,MD’FACS HowardB.Keith,MD,FACS JamesF.KeⅡam,MD,FRCS’FACS StevenJ·Kilkenny,MD,FnCS DarrenKihOy,FRCSEd’FCEM,M.Ed LenaKlarin,RN AmyKoestner,RN,MSN RadkoKomadina,MD,PhD DignaR·Kool,MD JohnB.Kortbeek,MD’FACS BrentKrantz,MD,FACS JonR·Krohmer,MD,FACEP AdaLaiYinKwok MariaLampi,BSc’RN KatherineLane,PhD FrancisG.Lapiana,MD,FACS PedroLari0sAznar AnnaMLedgerwood,MD,FACS DennisG·Leland,MD,FACS FrankLewis,MD’FACS WilsonLi,MD He】enLivanios,RN NurRacl】matLubis,MD EdwardB.Lucci,MD,FACEP EduardoLuck,MD,FACS ThomasG·Luerssen’MD,FACS J·S.K.Luitse’MD ArnoldLuterman,MD,FACS LAMSuk﹣0hin呂BN,MHM LEOPienMing,MBBS’MRCS（Edin）’ MMed（Orthopaedics） JaimeManzano,MD,FACS FernandoMagallanesNegrete’MD DonaldW·Marion,MD,FACS MichaelR.Marohn,DO,FACS BanyD·Martin,MD SalvadorMartmMandUjano’MD,FACS KimballI.Maull’MD,FnCS MaryC.McCarthy’MD,FACS GeraldMcCullough,MD’FACS JohnE.M山ermott,MD,FACS JamesA.McGehee’DVM’MS WilliamF·MCManus,MD,FACS NormanE·McSwain,Jr.,MD,FACS PhilipS.Metz,MD,FACS CynthiaL.M叮er’MD SalvUusMila苜ius’MD FrankB.MⅢer,MD,FACS SidneyF.MⅢer’MD’FACS SoledadMonton,MD ErnestE·Moore,MD,FACS JohanneMorin,MD DavidMulder,MD’FACS RajKNarayan,MD,FACS JamesB.NiChols,DVM,MS

● ■

x x Ⅱ

ACKNOWLEDGMEⅡTS

MartinOdriozola,MD,FACS FranklinCOlson,EdD SteveA·Olson,MD,FACS GonzaloOstriaP.,MD,FACS ArthurPa唉,MD JosePaizTejada FatimaPardo,MD StevenNParks,MD,FACS Chester（Chet）Paul,MD AndrewPearce,BScHons,MBBS, FACEMPGCertAeromedretrieval MarkD·Pearlman,MD AndrewB。Peitzman,MD,FnCS NicolasPeloponissios,MD JeanPeloquin,MD PhilipW·Perdue,MD,FACS J·W.RodneyP叮ton’FRCS（Ed）’MRCP LawrenceH·Pitts’MD,FACS GalenV.Poole,MD’FACS DaniellePoretti,RN EmestPregent,MD RiChardR.Price,MD,FACS HerbertProctor,MD,FACS JacquesProvost,MD PaulPudimat,MD MaxL.RamenofBky’MD,FACS JesperRavn,MD MarceloRecalde,MD’FACS JohnReed,MD MarletaR鉚nolds,MD,FACS StuartA·Reynolds,MD,FACS PeterRhee,MD,MPH’FACS’FCCM, DMCC BernardRiley,FFARCS MartinRichardson BoRichter CharlesRinker,MD,FACS AvrahamRiVkind,MD

DiegoRodriguez’MD VicenteRodriguez,MD OlavIMse,MD’PhD RonaldE.Rosenthal,MD,FACS GraceRozycki,MD,FACS DanielRuiz,MD,FACS J.OctavioRuizSpeare,MD,MS,FACS JamesM.Ryan’MCh,FRCS（Eng）, RAMC JamesM·Salander,MD’FACS GueiderSalas,MD Je臉叮P.Salomone,MD,FACS RocioSanchez﹣AedoLinares,RN M﹠rtinSandberg,MD,PhD ThomasG·Saul,MD,FACS DomenicScharplatz,MD,FACS WⅢiamP.Schecter,MD,FACS KariSchr¢derHansen,MD Thom軀E.Scott,MD,FACS StuartR·SeiⅨMD,FACS BohvarSerrano,MD’FACS StevenR·Shack允rd,MD,FACS MarcJ·Shapiro,MD,FACS ThomasE·Shaver,MD,FACS MarkSheridan,MBBS,MMedSc,FRACS RichardC.Simmonds,DVM’MS RichardK.Simons,MB,BChir,FRCS, FRCSC,FACS NilsOddvarSkaga,MD PeterSkippen’MBBS’FRCPC’FJFICM, MHA DavidV.Skinner’FRCS（Ed）,FRCS （Eng） AmoldSladen’MD,FACS ToneS】蝕巳 BirgitteSoehus RicardoSonneborn’MD,FACS MichaelStavropoulos’MD,FACS

SpyridonStergiopoulos,MD GeraldαStrauch’MD,FACS LutherMStrayer,III,MD JamesKStyner’MD VassoTagkalakis JosephJ·Tepas,III,MD,FACS StephaneTetraeault,MD GregoIyA.Timberlake,MD’FACS PeterG.Traiton,MD,FACS StanleyTrooksin,MD,FACS DavidTuggle,MD,FACS WolfgangUmmenhofbr,MD’DEAA JayUpright ArmandRobertvanKanten,MD EndreVarga,MD,PhD EdinaV訌konyi PanteleimonVassiliu,MD,PhD Eug已niaVassilopoulou,MD AntigoniVavarouta AntonioVeraBolea AlanVerdant’MD J·LeonelVil】avicencio,MD,FACS EricVoiglio,MD’PhD,FACS,FRCS FranklinC·Wagner,MD,FACS RaymondL·Warpeha,MD,FACS ClarkWatts,MD,FACS JohnA·Weigelt,MD,FACS JohnWest,MD,FACS RobertJ·White,MD,FACS Da】ylWilliams,MBBS,FANZCA’ GDipBusAd,GdipCR FremontP·Wirth,MD,FACS BradleyD.Wong,MD,FACS NopadolWora﹣Urai,MD,FACS PeterHWorlock,DM’FRCS（Ed）’FRCS （Eng） BangWai﹣KeyYuen,MBBS’FRCS’ FRACS,FACS

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CoⅡrseOverview:Tl1ePurpose,HistorV, andConceptsoftheATLSPrograⅢ oftheATLSPrograⅢ ∣P p『og『amGoaIs

∣

TheAdvancedTraumaLifbSupport（ATLS）course providesitsparticipantswithasafbandreliablemethodfbrtheimmediatetreatmentofinjuredpatientsand thebasicknowledgenecessa1yto; 1.Assessapatient’sconditionrapidlyand accurately.

3·Determinewhetherapatient’sneedsexceedafa﹣ cⅡity,sresourcesand／0raprovider’scapabilities·

3·Initiateprimaryandsecondarymanagementnec﹣ essarywithinthegoldenhourfbrtheemergency managementofacutelifb﹣threateningconditions.

a.Prima1yandsecondaryassessmentofapatient withsimulated’multipleinjuries

4Arrangeappropriatelyfbrapatient’sinterhospi﹣ talorintrahospitaltransfbr（what,who’when’ andhow）.

hEstablishmentofapatentairwayandinitia﹣ tionofassistedventilations· c。Orotrachealintubati0nonadultandinfhnt mEmiMnS

5’Ensurethatoptimalcareisprovidedandthat thelevelofcaredoesnotdeteriorateatanypoint duringtheevaluation’resuscitation’ortransfbr

d·Pulseoximetryandcarbondioxidedetectionin exhaledgas

processes.

participantwⅢbeableto:

Z.Establishmanagementprioritiesinatrauma situation.

practicum’demonstratethefbllowingskills’ whichareoftenrequiredintheimtialassessment andtreatmentofpatientswithmultipleinjuries:

priority.

Thecontentandskillspresentedinthiscoursearede﹣ signedtoassistdoctorsinprovidingemergenCycare fbrtraumapatients.Thec0nceptofthe“goldenhour” emphasizestheurgenCynecessaryfbrsuccessh1ltreat﹣ mentofinjuredpatientsandisnotintendedtorepre﹣ senta“fixed’》timeperiodof60minutes.Rather,itis thewindowofopportumtyduringwhichproviderscan haveap0sitiveimpactonthemorbidi叮andmortal﹣ ityassociatedwithi叮mV.TheATLScourseprovides theessentialinfbrmationandskiⅡsfbrprovidersto identi叮andtreathfb﹣threateningandpotentiallyhfb﹣ threateninginjuriesundertheextremepressuresasso﹣ ciatedwiththecareofthesepatientsinthefhst﹣paced environmentandanxietyofatraumaroom.TheATLS courseisapplicabletochmciansinavarietyofclimcal situations.Itisjustasrelevanttoprovidersinalarge teachingfacⅢtyinNorthAmericaorEuropeasitisin adevelopingnationwithrudimentaryfacilities. UponcompletionoftheATLSstudentcourse’the

primaryandsecondarypatientassessments.

4·Inag1vensimulatedclinicalandsurgicalskiⅡs

Z·Resuscitateandstabilizepatientsaccordingto

Cou『se0b】ectv i es

1.Demonstratetheconceptsandprmciplesofthe

e.Cricothy1·oidotomy

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↑tAssessmentandtreatmentofapatientin shock’particularlyrecognitionofhfb﹣threaten﹣ inghemorrhage g·Venousandintraosseousaccess h·Pleuraldecompressionv1aneedlethoracentesis andchesttubeinsertion i·Recognitionofcardiactamponadeandappro﹣ priatetreatment i.Clinicalandradiographicidentificationoftho. raclc1IUur1es G

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k.Useofperitoneallavage’ultrasound（FAST）, andcomputedtomography（CT）inabdominal evaluation l.Evaluationandtreatmentofapatientwith braininjury’includinguseoftheGlasgow ComaScalescoreandCTofthebmin mAssessmentofheadandfacialtraumaby physicalexamination n·Protectionofthespinalcord’andradiographic andclimcalevaluationofspineinjuries o·Musculoskeletaltraumaassessmentand management

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xxⅡI

xxivCOURSEOVERVlEW

Othe「

p.Estimationofthesizeanddepth0fburnimury fmdvolⅡ】meresuscitation q。RecognitionofthespecialproblemsofiIUuries ininfhnts,theelderly,andpregnantwomen 脫Understandingoftheprinciplesofdisaster management

TheNeed AccordingtothelatestinfbrmationfromtheWHOand CDC’morethannmepeopledieeve】yminutefTomm﹣ juriesorviolence’and5.8millionpeopleofallagesand economicgroupsdieeve叮year仕omunintentionalinjuriesandviolence（Figure1）.TheburdenofiIUu】yiseven moresignificant’accountmgfbr12℅oftheworld’sbur﹣ den0fdisease·Motorvehiclecrashes（roadtrafficimuries’mFigure2）alonecausemorethan1milliondeaths annua1lyandanestimated20milliont050millionsignif icantiIUuries;theyaretheleadingcauseofdeathdueto inju1yworldwide.Improvementsminju叮controleffbrts arehavingan1mpactinmostdevelopedcountries,where traumaremainstheleadingcauseofdeathmpersons1 through44yearsofage.Significantly’morethan90℅ ofmotorvehiclecrashesoccurinthedevelopingwodd. Injmy巨relateddeathsareexpectedtorisedramaticaⅡyby 2020’withdeathsduetomotorvehiclecrashesprqjected toincreaseby80℅fromcurrentratesinlow﹣andmiddle﹣

Se【f﹣inf【icted vio【ence 16﹪ n

g

∣nte「pe vio【e 10

■FlGUREZDiSt『ibutionofGlobaIIniu『yMo『taIityby Cause。 Rep『0ducedwtihpe『msiso i n『『om肪e〃W『yCha㎡BookfaG／aph／ca／0肥戶 呢wof叻eC／bba／Bu『d白ncf〃W爬s.Geneva:Wo『∣dHea∣thO「ganziato in Depa『tmento↑∣niu『iesandViolenceP『evention.Noncommunic己bIeDisease5 andMentaIHeaIthαuste『;Z00之·

mc0mecountries.By2020itisestimatedthatmorethan 1in10peoplewiⅡdiefrominjuries‘ Globaltrauma﹣relatedcostsaIeestimatedto exceed＄500billionannually.Thesecostsaremuch

■FlGURE1GlobaIIn】u『y﹣ReIatedMo『talityb Rep「0ducedwtihpe『msis0 i n↑『omγhe〃u』yCha付B0ok:aG眉phka／0veMewoftheGbba／Bu／旋nof〃!／U〃自5.Geneva:Wo『d I He己∣thO「ganziato i nDepa『tmentof∣nu i 『e i 5andVo ie I nceP「evento i n.Ⅱoncommunc i abe l Dsiea5esandMenta∣He己∣thC∣u5te『;2002

COURSEOVERVlEWxxv

higherifoneconsiderslostwages’medicalexpenses, insuranceadmimstrationcosts’propertydamage, fireloss’employercosts’andindirectlossfTomwork relatediIUuries.Despitethesestaggermgcosts’less than4centsofeachfbdera1researchdoⅡarinthe UmtedStatesarespentontraumaresearch.Asmonu﹣ mentalasthesedataare,thetruecostcanbemeas﹣ uredonlyWhenitisrealizedthattraumastrikesdown asociety’syoungestandpotentiallymostproductive members.Researchdollarsspentoncommumcable diseasessuchaspolioanddiphtheriahavenearlyelim﹣ inatedtheincidenceofthesediseasesintheUhited States.Unfbrtunatelythediseaseoftraumahasnot capturedthepublicattentioninthesameway. Inju】yisadisease.Ithasahost（thepatient）and ithasavectoroftransmission（eg,motorvehicle,firearm’etc）.Manysignificantchangeshaveimprovedthe careoftheinjuredpatientsincethefirsteditionofthe ATLSProgramappearedin1980.Theneedfbrthe

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■FIGURE3乃imodaIDeathDist『ibution.

programandfbrsustained’aggressiveeffbrtstopre﹣ ventinjuriesisasgreatnowasithaseverbeen·

∣P T『imodaIDeathDist『ibution Firstdescribedin1982’thetrimodaldistribution0f deathsimpⅡesthatdeathduetoiIUuIyoccursinone ofthreeperiods,orpeaks（Figure3）.ZⅥe亢｝駝peα陀occurswithinsecondstominutesofinjury.Duringthis earlyperiod,deathsgeneraⅡyresultfromapneadue toseverebrainorhighspinalcordinjuryorruptureof theheart,aorta’orotherlargebloodvessels.Ve】yfbw ofthesepatientscanbesavedbecauseoftheseverity oftheiri叼uries.Onlypreventioncansignificantlyre﹣ ducethispeakoftrauma﹣relateddeaths. Theseco氾dpeα陶occurswithinminutestosev﹄ eralhoursfbllowingimury.Deathsthatoccurduring thisperiodareusuallyduetosubduralandepidural hematomas’hemopneumothorax’rupturedspleen, lacerationsofthehver,pelvicfractures,and／ormultipleotheri叮uriesassociatedwithsignificantbloodloss· Thegoldenhourofcareaftermjuryischaracterizedby theneedfbrrapidassessmentandresuscitation’which aretheh1ndamentalprinciplesofAdvancedTrauma LifbSupport. The炕【㎡peα几’whichoccursseveraldaystoweeks aftertheinitialmju叮,ismostoftenduetosepsisand multipleorganSystemdysihnctionCareprovideddur﹣ ingeachoftheprecedingperiodsimpactsonoutcomes duringthisstage.ThefirstandeverysubseqUentper﹣ sontocarefbrtheinjuredpatienthasadirecteffbcton long﹄termoutcome. ThetemporaldistnbutionofdeathsrefIectslocal advancesandcapabilitiesoftraumaSystems.Thedevelopmentofstandardizedtraumatrainin呂betterprehos-

pitalcare’andthedevelopmentoftraumacenterswith dedicatedtraumateamsandestablishedprotocolsto carefbriIUuredpatientshasalteredthepicture.

∣P Ⅱisto『y Thedelive】yoftraumacareintheUnitedStatesbe﹣ fbre1980wasatbestinconsistent.Atragedyoccurred inFebrua1y1976thatchangedtraumacaremthe “firsthour”fbrimuredpatientsintheUnitedStates andinmuchoftherestoftheworld.Anorthopedic surgeonwaspilotinghisplaneandcrashedinarural Nebraskacornfield.Thesurgeonsustainedser1ousinjuries,threeofhischildrensustainedcriticaliIUuries’ andonechⅡdsustainedmmorinjuries.Hiswifbwas killedinstantly.Thecarethatheandhisfamilysub﹣ seqUentlyreceivedwasinadequatebytheday,sstand﹣ ards.Thesurgeon,recognizmghowinadequatetheir treatmentwas,stated:‘‘WhenIcanprovidebettercare inthefieldwithlimitedresourcesthanWhatmychil﹣ drenandIreceivedattheprima1ycarefacility’there issomethingwrongwiththesystem,andthesystem hastobechanged.” Agroupofprivate﹣practicesurgeonsanddoctors inNebraska’theLmcolnMedicalEducationFounda﹦ tion）andtheLincoln﹣areaMobileHeartTeamNurses’ withthehelpoftheUmversityofNebraskaMedical Center,theNebraskaStateCommitteeonTrauma （COT）oftheAmericanCollegeofSurgeons（ACS）,and theSoutheastNebraskaEmergen叮MedicalServices identifiedtheneedfbrtrainingmadvancedtrauma lifbsupport.Acombinededucationalfbrmatoflectures,lifbsavingskiⅡdemonstrations,andpractical

xxviCOURSEOVERVIEW

laboratoryexper1encesfbrmedthefirstprototype ATLScourse. Anewapproachtotheprovisionofcarefbrindi﹣ vidualswhosuf【brm勾or’li佗﹣threatemnginjurypre﹣ mieredin1978’theyearofthefirstATLScourse.This prototypeATLScoursewasfield﹣testedincon】unc﹣ tionwiththeSoutheastNebraskaEmergencyMedical Services.Oneyearlater,theACSCOT’recognizing traumaasasurgicaldisease,enthusiasticaⅡyadopted thecourseundertheimprimaturoftheCollegeand incorporateditasaneducationalprogram. Thiscoursewasbasedontheassumptionthat appropriateandtimelycarecouldsignificantly improvetheoutcomeofinjuredpatients·Theorigi﹣ nalintentoftheATLSProgramwastotraindoctors whodonotmanagem匈ortraumaonadailybasis,and theprimaryaudiencefbrthecoursehasnotchanged. However,todaytheATLSmethodisacceptedasa standardfbrthe“firsthour’》oftraumacarebymany whoprovidecarefbrtheinjured,Whetherthepatient istreatedinanisolatedruralareaorastate﹣ofthe-art traumacenter.

Cou『seDeve∣opmentand Dissemination TheATLScoursewasconductednationallyfbrthe firsttimeundertheauspicesoftheAmericanCollege ofSurgeonsinJanuary1980.Internationalpromulga﹣ tionofthecoursebeganin1980. Theprogramhasgrowneachyearinthenumber ofb0thcoursesandparticipants.Todate’thecourse hadtrainedmorethan1.5millionparticipantsinmore than75,000coursesaroundtheworld.Currently,an averageof50,000cliniciansaretrainedeachyearin over3’000courses.Thegreatestgrowthinrecent yearshasbeenintheintemationalcommunity’and thisgroupcurrentlyrepresentsapproximatelymore thanhalfofallATLSactivity. Thetextfbrthecourseisrevisedapproximately every4yearsandincorporatesnewmethodsofevalu﹣ ationandtreatmentthathavebecomeacceptedparts ofthearmamentarium0fproviderswhotreattrauma patients·Courserevisionsincorporatesuggestionsfrom membersoftheSubcommitteeonATLS;membersof theACSCOT;membersoftheinternationalATLSfhm﹣ Ⅱy;representativestotheATLSSubcommitteefrom theAmericanCollegeofEmergenCyPhysiciansand theAmericanC0ⅡegeofAnesthesiologists,andcourse instructors’coordinators’educators,andparticipants. Changesthataremadetotheprogramreflectaccepted, verifiedpracticepatterns,not“cuttingedge,,technology0rexpernnentalmethods.Themternationalnature

oftheprogrammandatesthatthecoursebeadaptable toavarie叮ofgeographic’econonuc,s0cial’andmedi﹣ calpracticesituations.Toretainacurrentstatusinthe ATLSProgram’anindividualmustreveri月『withthe latesteditionofthematerials. AparallelcoursetotheATLScourseisthePre﹣ hospitalTraumaLifbSupport（PHTLS）course’which issponsoredbytheNationalAssociationofEmergency MedicalTechnicians（NAEMT）.ThePHTLScourse, developedincooperationwiththeACSCOT’isbased ontheconceptsoftheACSATLSProgramandiscon﹣ ductedfbremergenCymedicaltechnicians’paramedics, andnurseswhoareprovidersofprehospitaltrauma care.Othercourseshavebeendevelopedwithsimilar conceptsandphilosophies.Forexample’theSocietyof TraumaNursesof比rstheAdvancedTraumaCare允r Nurses（ATCN）,whichisalsodevelopedincoopera﹣ tionwiththeACSCOT.TheAⅢCNandATLScourses areconductedparalleltoeachotherwiththenurses auditingtheATLSlecturesandthenparticipatingin skillstationsseparatefTomtheATLSskillstations conductedfbrdoctors.Thebenefitsofhavingbothpre﹣ hospitalandin-hospitaltraumapersonnelspeaking thesame‘‘language”areapparent.

!ⅡtematioⅡa!DissemiⅡatioⅡ Asapilotpmject’theATLSProgramwaseXported outsideofNorthAmericain1986t0theRepublicof TrinidadandTobago.TheACSBoardofRegentsgave permissionin1987fbrpromulgationoftheATLSPro﹣ graminothercountries.TheATLSProgrammaybe reqUestedbyarecognizedsurgicalorgamzationor ACSChapterinanothercount】ybycorresponding withtheATLSSubcommitteeChairperson’careofthe ACSATLSProgramOfHce’Chicago’IL.Atthetimeof publication》63countrieswereactivelyprovidingthe ATLScoursetotheirtraumaproviders.Thesecoun﹣ triesinclude: 1·Argentina（ACSChapterandCommitteeon Trauma） Z。Australia（RoyalAustralasianCollegeof Surgeons） 3.Bahrain（KingdomofSaudiArabiaACSChapter andCommitteeonTrauma） 4·Bolivia（BolivianSurgeonsS0ciety） 5·Brazil（ACSChapterandCommitteeonTrauma） 6.Canada（ACSChaptersandProvincialCommitteesonTrauma） 7·Chile（ACSChapterandCommitteeonTrauma） 8.C0lombia（ACSChapterandCommitteeon Trauma）

COURSEOVERVlEWXXVii 9。CostaRica（CollegeofPhysiciansandSurgeonsof CostaRica） I0.Cyprus（ACSChapterandCommitteeonTrauma’ Greece） 11.CzechRepublic（CzechTraumaSociety） 12.Denmark（DanishTraumaSociety） 13·Ecuador（ACSChapterandCommitteeon Trauma） Ⅲ·Egypt（EgyptianSocietyofPlasticandRecon﹣ structiveSurgeons） ↑5.FijiandthenationsoftheSouthwestPacific 〔ROyalAustralasianC0llegeofSurgeons） 16·France（SocieteFrancaisedeChirurgie d’Urgence） 17.Germany（GermanSocietyfbrTraumaSurgeIy andTaskForcefbrEarlyTraumaCare） l8.Greece（ACSChapterandCommitteeonTrauma） 19·Greenland（DanishTraumaSociety） 20.Grenada（SocietyofSurgeonsofTrinidadand Tobago） Z1.HongKong（ACSChapterandCommitteeon Trauma） Z2.Hungary（HungarianTraumaSociety） Z3.India（AssociationfbrTraumaCareofIndia）

36·Netherlands,The（DutchTraumaSociety） 37.NewZealand（RoyalAustralasianCollegeof Surgeons） 38.Nigeria（NigerianOrthopaedicAssociation） 39.Norway（NorwegianSurgicalSociety） 』0·Oman（OmanSurgicalSociety） 刎.Pakistan（CollegeofPhysiciansandSurgeons Pakistan） 4Z.Panama（ACSChapterandCommitteeon Trauma） 43·PapuaNewGuinea（RoyalAustralasianCollege 0fSurgeons） 』4Paraguay（SociedadParaguayadeCirugia） 45.Peru（ACSChapterandCommitteeonTrauma） 46.Portugal（PortugueseSocietyofSurgeons） ¢7.Qatar（KingdomofSaudiArabiaACSChapter andCommitteeonTrauma） 』8.RepublicofChina,Taiwan（SurgicalAssociation 0ftheRepublicofChina,Taiwan） 49·RepublicofSingapore（ChapterofSurgeons, AcademyofMedicine） 50·Samoa（ROyalAustralasianCoⅡegeofSurgeons） 51·Slovenia（SlovenianSocietyofTraumaSurgeons）

Z¢.Indonesia（IndonesianSurgeonsAssociation）

5Z.RepublicofSouthAfiPica（SouthAh?icanTrauma Society）

25·Iran（PersianOrthopedicandTrauma Association）

53·Spain（SpanishSocietyofSurgeons）

Z6.Ireland（RoyalCollegeofSurgeonsinIreland） Z7·Israel（IsraelSurgicalSociety）

54’Sweden（SwedishSocietyofSurgeons） 55·Switzerland（SwissSocietyofSurgeons）

Z8·Italy（ACSChapterandCommitteeonTrauma）

56.Syria（CenterfbrContinuingMedicalandHealth Education）

Z9·Jamaica（ACSChapterandCommitteeon Trauma）

57.Thailand（RoyalCollegeofSurgeonsofThailand）

30.KingdomofSaudiArabia（ACSChapterandCommitteeonTrauma） 3↑.Kuwait（KingdomofSaudiArabiaACSChapter andCommitteeonTrauma） 3Z·Lebanon（LebaneseChapteroftheAmericanCol﹣ legeofSurgeons） 33.Lithuania（LithuanianSocietyofTraumatolo盯 andOrthopaedics） 3』.Malaysia（CollegeofSurgeons’Malaysia） 35·Mexico（ACSChapterandCommitteeonTrauma）

58.TrinidadandTobago（SocietyofSurgeonsof TrinidadandTobago） 59.UnitedArabEmirates（SurgicalAdvisoIy Committee） 60UnitedKingdom（ROyalCollegeofSurgeonsof England） 61.UnitedStates,U·S。territories（ACSChaptersand StateCommitteesonTrauma） 6Z·Uruguay（UruguaySocietyofSurge】y） 63·Venezuela（ACSChapterandCommitteeon Trauma）

XXviiiCOURSEOVERVlEW ﹁

TheConcept 」

TheconceptbehindtheATLScoursehasremained simpleHistorically’theapproachtotreatinginjured patients,astaughtinmedicalschools,wasthesame asthatfbrpatientswithapreviouslyundiagnosed medicalcondition;anextensivehisto1yincludingpast medicalhistory’aphysicalexaminationstartingatthe topoftheheadandprogressingdownthebody,the developmentofadifIbrentialdiagnosis’andalistof adjunctstoconhrmthediagnosis.Althoughthisap﹣ proachwasadequatefbrapatientwithdiabetesmellitusandmanyacutesurgicalillnesses’itdidnotsatis句 theneedsofpatientssuffbringlifb﹣threateninginju﹣ ries.TheapproachrequiredChange. ThreeunderlyingconceptsoftheATLSProgram wereinitiallydifficulttoaccept: 1·Treatthegreatestthreattohfbfirst’ Z’Thelackofadefinitivediagnosissh0uldnever mpedetheapplicationofanindicatedtreatment. 3.Adetailedhistoryisnotessentialtobeginthe evaluation0fapatientwithacuteinjuries. TheresultwasthedevelopmentoftheABCDEap﹣ proachtotheevaluationandtreatmentofi叼ured patients.Theseconceptsarealsoinkeepingwiththe observationthatthecareof呵uredpatientsmmany circumstancesisateameffbrt’allowingmedicalper﹣ sonnelwithspecialskiⅡsandexpertisetoprovidecare simultaneouslywithsurgicalleadershipoftheprocess. TheATLScourseemphasizesthatinjurykiⅡsin certainreproducibletimeframes.Forexample’the lossofana1rwaykillsmorequicklythandoestheloss oftheabilitytobreathe.Thelatterkillsmorequickly thanlossofcirculatingbloodvolume·Thepresenceof anexpandingintracranialmasslesionisthenextmost lethalproblem.Thus,themnemonicABCDEdefines thespecific,orderedevaluationsandinterventions thatshouldbefbllowedinallinjuredpatients: Airwaywithcervicalspmeprotection Breathing Circulation’stopthebleeding Disabili叮orneurologicstatus Exposure（undress）andEnvironment （temperaturecontrol）

﹥TheCou『se TheATLScourseemphasizestherapidimtialas﹣ sessmentandprima1ytreatmentofinjuredpatients’ startmgatthetimeofimmyandcontinuingthrough

imtialassessment’lifbsavingintervention,reevalu﹣ ation,stabilizati0n,and’whenneeded,transfbrtoa traumacenter.Thecoursec0nsistsofprecourseand postcoursetests’corecontentlectures》interactivecase presentations’discussions’developmentoflifbsaving skills’practicallaboratoryexperiences’andafinalper﹣ fbrmanceproficienCyevaluation.Uponcompletionof thecourse,participantsshouldfbelconfidentinimple﹣ mentingtheskiⅡstaughtintheATLScourse.

∣

The!mpact

ATLStraimnginadevelopingcount1yhasresultedin adecreaseini叼urymortali叮·Lowerpercapitarates ofdeathsfrominjuriesareobservedinareaswhere providershaveATLStraining.Inonestudy,asmall traumateamledbyachnicanwithATLSexperience hadequivalentpatientsurvivalwhencomparedwitha largerteamwithmoreprovidersinanurbansetting. Inaddition,thereweremoreunexpectedsurv1vors than通talities.ThereisabundantevidencethatATLS traimngimprovestheknowledgebase’thepsychomo﹣ torskiⅡsandtheiruseinresuscitation,andtheconfi﹣ denceandperfbrmanceofparticipantswhohavetaken partintheprogram.Theorganizationandprocedural skillstaughtinthecourseareretainedbycoursepar﹣ ticipantsfbratleast6years,whichmaybethemost significantimpactofa1l.

I now∣edgments 】 ∣PAc《

∣

TheCOToftheACSandtheATLSSubcommittee grateMlyaCknowledgethefbⅡowingorganizations fbrtheirtimeandeffbrtsindevelopingandfieldtest﹣ ingtheAdvancedITaumaLifbSupportconcept:The LincolnMedica1EducationFoundation’S0utheastNe﹣ braskaEmergenCyMedicalServices,theUniversi叮of NebraskaCollegeofMedicine》andtheNebraskaState C0mmitteeonTraumaoftheACSThecommitteealso isindebtedtotheNebraskadoctorswhosupportedthe developmentofthiscourseandtotheLincolnArea MobileHeartTeamNurseswhosharedtheirtimeand ideastohelpbuildit.Appreciationisextendedtothe organizationsidentifiedpreviouslyinthisoverview fbrtheirsupportoftheworldwidepromulgationof thecourse.Specialrecognitionisgiventothespouses’ significantothers’children,andpracticepartnersof theATLSinstructorsandstudents.Thetimethatpro﹣ vidersspendawayfromtheirhomesandpracticesand effbrtaffbrdedtothisvoluntalyprogramareessential componentsfbrtheexistenceandsuccessoftheATLS Program.

C0URSEOVERVIEWxxix

Summa 『 y TheATLScourseprovidesaneasilyrememberedap﹣ proachtotheevaluationandtreatmentofinjured patientsfbranyprovider’irrespectiveofpracticespe﹣ cialty,evenunderthestress’anxie叮,andintens呵 thataccompaniestheresuscitationprocess.Inaddi﹣ tion,theprogramprovidesacommonlanguagefbr allprovidersWhocarefbrinjuredpatients·TheATLS courseprovidesafbundationfbrevaluation’treatment’education’andqualityassurance-inshort’a Systemoftraumacarethatismeasurable,reproduc﹣ ible’andcomprehensive. TheATLSPr0gramhashadapositiveimpacton thecareprovidedtoiIUuredpatientsworldwide.This hasresultedfromtheimprovedskillsandknowledgeof thedoctorsandotherhealthcareproviderswhohave beencourseparticipants。TheATLScourseestablishes anorganizedandSystematicapproachfbrtheevalu﹣ ationandtreatmentofpatients’promotesmimmum standardsofcare,andrecognizesinjuryasaworld healthcareissue.Morbidityandmortalityhavebeen reduced,buttheneedtoeradicateiUjuryremains. TheATLSProgramhaschangedandwillcontinueto changeasadvancesoccurinmedicineandtheneeds andexpectationsofoursocietieschange·

8.AndersonID,AndersonIW,CliifbrdP,etal.Advanced TraumaLifbSupportmtheUK:8yearson.BrJHOSp Mbd1997;57:272﹣273. 9.AprahamianC,NelsonKT,ThompsonBM,etal.The relationshipoftheleveloftrainingandareaofmedi﹣ calspecializationwithregistrantperfbrmanceinthe AdvancedTraumaLifbSupportcourse.JE加e咱M﹫d 1984;2:137﹣140. 10.BenAbrahamR,SteinM,KlugerY’etal.ATLScourse inemergenCymedicinefbrphysicians·Hα／它／吻α〃 1997i132:695﹣697,743· 11BenAbrahamR’SteinM’ⅢugerY,etalTheimpact ofAdvancedTraumaLifbSupportCourseongraduates withnon﹣surgicalmedicalbackground.Eα｝.JE〃﹟e唔 M它d1997;4:11﹣14· 12.BergerLR’MohanD:I〉VαU／α〃向D／『AG／obα／Ⅵeu）. Delhi,India:OxfbrdUnivers蚵Press;1996. 13.BlumenheldA’BenAbrahamR’StemM,etal.Cognitive knowledgedeclineafterAdvancedTraumaLifbSupport courses.c／乃α【↓mα1998;44:513﹣516. 14.BurtCW’InjuIy﹣relatedvisitstoh0spitalemergenCy departments:UnitedStates’1992·AduDαtα1995;261:1.20. 15.DemetriadesD’KimbrellB,SalimA’etal.Traumadeaths 1namatureurbantraumasystem:is‘‘trimodal’》distribu﹣ tionavalidconcept?JA〃｝Cb〃S叨咱2005;201:343﹦348· 16.DeoSD》KnottenbeltJD,PedenMMEvaluation0f asmalltraumateamfbrm則orresuscitation·蚵M／y 1997;28:633﹣637. 17.DireccaoGeraldeVicao,Lisboa’Portugal,dataprovided byPedroFerreiraMonizPereira’MD,FACS

Bibliog『aphy 1.AliJ,AdamR’ButlerAK》etal.Traumaoutcomeimproves ibllowingtheAdvancedTraumaLifbSupportprogramin adevelopingcount】yJ乃α叨mα1993;34:890﹣899· 2’AliJ,AdamR’JosaD,etal.Comparisonofmterns completingtheold（1993）andnewinteractive（1997） AdvancedTraumaLifbSupportcourses·J乃αumα 1999;46:80﹣86· 3.AliJ,AdamR,StedmanM’etal.AdvancedTraumaLifb Supportprogram1ncreasesemergen叮roomapplication oftraumaresuscitativeproceduresinadevelopmgcoun﹣ try·J乃αα加α1994;36:391﹣394. 4.AliJ,AdamR,StedmanM’etal.CognitiveandattitudinalimpactoftheAdvancedTraumaLifbSupp0rtCourse inadevelopingcountry·J仍uαmα1994;36:695﹣702. 5.AliJ,CohenR’AdamB,etalTeachingef【bctivenessof theAdvancedTraumaLiibSupportpr0gramasdemon﹣ stratedbyanohjectivestructuredclinicalexaminationfbr practicingphysicians.Wb『.／dJSα／g1996;20:1121﹣1125. 6.AliJ,CohenB,AdamsR,etal.Attritionofcognitiveand traumaskiⅡsaftertheAdvancedTraumaLifbSupport （ATLS）course.JZ》mzmα1996;40:860﹣866. 7.AliJ’HowardMTheAdvancedTraumaLifbSupport ProgrammManitoba:a5﹣yearreⅥew.αmJSα唔 1993;36:181﹣183.

18.FingerhutLA’CoxCS,WarnerM,etal.International comparativeanalysisofinjurymortality:hndingslrom theICEoninjurystatistics·AduDαrα1998;303:1﹣20 19.FirdleyFM,CohenDJ,BienbaumML,etal·Advanced TraumaLifbSupport:Assessmentofcognitiveachieve. ment·MM肋Mbd1993;158:623﹣627. 20.GautamV’HeyworthJ.Amethodt0measurethe valueoffbrmaltraimngintraumamanagement:com﹣ parisonbetweenATLSandinductioncourses.In／α『:y 1995;26:253﹣255. 21.GreensladeGL’TaylorRH.AdvancedTraumaLifbSup﹣ portaboardRFAArgus.JRMⅥuMbdSeru1992;78:23﹣26. 22.LeiboviciD,FedmanB,GofTitON’etal.Prehospital cricothyroidotomybyphysicians.AmJEme咱M﹫d 1997515;91﹣93. 23.MockCJ。Internationalapproachestotraumacare. 乃αMmαQ1998;14:191﹣348. 24.MurrayCJ,LopezA.Z1／jeg／obα／bl〃、de〃o／d／seαsαZA co〃Ⅱpre／je几sZueαssess加e㎡O／mo㎡α／吻α〃dd』sαM蚵 加加d!seαseS’α〃d”M冗esα冗drZs〃／hc加J1s加I990α〃d pJn／eαed㎡o2020.Cambridge,MA:HarvardUniversity Press;1996· 25.NationalCenterfbrHealthStatistics:Injmyvisitsto emergenCydepartments· 26.NationalSafbtyCouncil.呵m:yFhc拓（1999）.Itasca’IL: NationalSalbtyCouncⅡ.

xxxCOURSEOVERVIEW 27.NouIjahP.NationalhospitalambulatoIymedicalcare surv叮:1997emergen叮departmentsummary.AduDαtα 1999;304:1﹣24. 28.OldenvanGDJ,MeeuwisJD,BolhuisHW’etal·Chm﹣ calimpactofadvancedtraumali｛bsupport·A〃﹩JE加e唔 M它d2004;22;522﹣525· 29.RutledgeR,Fakh叮SM,BakerCC’etal·Apopulationbasedstudyoftheassociationofmedicalmanpowerwith countytraumadeathratesintheUnitedStates·A几几 Sα咱1994;219:547﹣563. 30.WalshDP,LammertGR,DevollJ.TheeHbctivenessof theadvancedtraumalifbsupportsysteminamasscasualtysituationbynon﹣traumaexperiencedphysicians: Grenada1983.JE〃﹫e唔Mbd1989;7:175.180 31.WⅡhamsMJ’LockeyAS,CulshawMCImprovedtrauma managementwithAdvancedTraumaLifbSupport （ATLS）training.JAcc!de㎡E加eJgMed1997;14:81﹣83.

32.WorldHealthOrganization.Ⅳ﹟eI叮MⅣChα㎡Boo陀fα Gmp加cα』OuemZe山o／仇eG』obα!Bα『丫!e几㎡蚵αr!es. Geneva:WorldHealthOrganizationDepartmentofInju﹣ riesandViolencePrevention·Noncommlmi哩bleDisea﹣ sesandMentalHealthCluster;2002 33.WorldHealthOrgamzation.Ⅵo』e几ceα〃dhVαn／Preue〃﹣ 〃o〃mtdD／sαb【／妳（ⅥP）.http:〃www.who.mt／Violence injury＿prevention／Publicati0ns／other＿injury／Chartb／en／ index‘htmlAccessedJanua1y9,2008. 34.WorldHealthOrganization.Wbr!dRepo㎡o冗Roαd 仍U茄c蚵α刁P疋u2几肱o〃·Geneva:WorldHealth Organization. 35.WorldHealth0rganization（WHO）.In／α㎡esα〃du【o﹣ ／e〃“f仇2／hc／s.Geneva,Switzerland:WHO;2010. 36.WorldHealthOrganization（WHO）.Ⅷeg!obα／bαrde〃o／ d!seαsα2004叩dα／它.Geneva,Switzerland:WHO;2008.

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一

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Contents 「o『ewo『d p『efaCe AcknowIedgement5 CoⅡ『se0veⅣiew

VⅡ ∣ X XV XXⅡI

CⅡAPTER1 lⅡitia』ASSeSSmeⅢta肋dⅢanageme㎡ P『epa『ation Ⅳiage p『m i a『ySⅡ『vey Resuscitation Ad】l』nctstoP『ima『ySu『veyandResuscitation Conside『Needfo『patieⅡtⅣansfe『 Seconda『ySu『yey Ad】unctSt0theSeConda『ySu『vey ReevaIuation DefinitiveCa『e DiSaste『 Reco『dSandLega∣Conside『ations 呃amwo『k CⅡAPTERSUⅢMARγ BIBLI0GRApⅡγ 〉》S∣《I【【S『八『IOⅡI:lnitiaIAssessmentand Management SkiⅡ∣·A:p『ima『ySⅡⅣeyRe5usdtation S∣《ⅢI.B:Sec0nda『y5uⅣeyandMaⅡagement Sl《iIⅢ·CPatientReevaluati0n SkⅡⅢD:WaⅡ5↑e『t0De↑initiveCa『e S∣《iⅡl·E:Afte『Acti0nReview

CⅡAPTER2 Ai『wayaⅢdVe㎡Ⅱato『yManagemeⅡt Ai『way VentiIati0n Ai『wayMaⅡagement Management0f0xygenation ManagementofVentilatioⅡ CⅡAPTERSUMMARγ BIBU0GRAPⅡγ ）卜S!《!皿Sγ八『I0ⅡⅢ目Ai『wayaⅡdVeⅡtilato『y MaⅡagement Scena『ios S!《ⅢⅢ﹣A:0『0pha『yngeaIAi『wayinse『tion SkiI∣Ⅱ﹦B8Ⅱa5opha『yⅡgeaIAiⅣvayIn5e『ti0n SkiⅡⅡ·CBag﹣MaskVentiIatioⅡ:】WoPe晦0n『bchniqⅡe SkiⅡⅡ﹣D:AduIt0『0t『a〔heaIIntubati0n

Z 4 6 6 10 11 13 13 18 19 19 Z0 Z0 Z0 Z2 ZZ

Z3 M Z5 Z8 Z8 Z8

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CⅡAPTER3 shock Shocl《pathophysiology lnitiaIpatientAssessment Ⅱemo『『hagicShock ∣nitiaIManagementofⅡemo『『hagicShocI《 Evaluationof『IuidResuSCitationand 0『ganpe『fusion 『he『apeuticDecisionsBasedonResponseto !nitiaI『luidReSu5（itation BIoodRepIacemeⅡt SpedalConside『ations ReassessiⅡgpatientReSponseand AvoidingCompIications CⅡAPTERSUMMARγ BIB〔I0GRAPⅡγ 》卜Sl《!l【S『八『!0Ⅱ∣V:ShocI《Assessmentand Management SceⅡa『ios S!《iⅡ!MA:pe『iphe『aIVen0usAccess S∣《iⅡIVB目「emo『aIVenipunctu『e:SeIdinge『Ibchnique SkiⅡ!MCSubclavianVenipunctu『e:Inf『acIavicuIa『 App『oach SkiⅡ】VD弓IntemaI」uguIa『Venipunctu『e:Middleo『 Cent『aIR0ute SkiⅡIME:lnt『ao55eouspunctu『e／In｛usion;P『oximaI TibialRoute SkiIl∣MF:Identi↑icationandMaⅡagemento｛ Pelvic「『adu『es:AppIicati0nofPeIvic8inde『

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XXXiiCONTENTS

ChAP丁ER4 Tho『acicT『auma P『ima『ySu『vey:【ife﹣Th『eateningInlu『ies ResuscitativeTho『acotomy Seconda『ySⅡ『vey:PotentiaIIyLife﹣Th『eatening ∣nu i 『e iS 0the『MaⅡifestationsofChestInju『ies CⅡApTER5UMⅢARγ BlB〔I0GRApⅡγ 〉〉5KIUS『八『!0NV!:X﹣RayIdentificatioⅡof Tho『a〔icIⅡjⅡ『ies SceⅡa『ios SI《iⅡV!﹦A:P『oce55fo『Initia∣Reviewo↑ChestX﹣Rays 卜卜SK!USγ八『!OⅡVⅡ;ChesthaumaManagement SiⅡVⅡ.A:ⅡeedleTh0『acentesi5 SkiⅡV!!﹣B8Che5tⅦbeln5e『ti0n SkiⅡVⅡ.CPe「ica『di0cente5i5（0ptionaI） C惻AP丁ER5 AbdomihalaⅡdpeMcT『aⅡma AnatomyoftheAbdomeⅡ MechanismofIn】u『y Assessment lndiCationsfo『Lapa『otomyinAduItS SpeCifiCDiagnoses CⅡApTERSUMⅢARγ 8I8LI0GRApⅡγ 〉》S!《肌【Sγ八『∣0NVⅢ:「ocusedAssessment Sonog『aphyilmauma（趴ST） SceⅡa『ios SI《iⅡVIⅡ:Focu5edA5se55mentS0n0g『aphyin T「auma（趴S『） 卜卜SK!LLSγ八『∣ON!X:DiagnosticPe『itoneaI 【avage（0ptional） SkiⅡ∣X﹣A:Diagno5i5ticPe『it0neaI【avage－ 0pen爬chnique SkiⅡ∣X﹣B:Diagn0siticPe『tioneaI【avage＝ Cl05ed爬chnique

CⅡAP『ER6 ⅡeadT『a凹ma

AnatomyReview PhySi0logy CIassificationsofⅡeadln】u『ies ⅢanagemeⅡt0fMino『B『ainIniu『y （GCSSco『e13＝15） Ⅲanagement0fMode『ateB『ainIn】u『y （GCSSc0『e9＝1Z）

94 96 10Z

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ManagementofSeve『eB『ainlⅡ】u『y （GCSSco『e3－8） MedicaIThe『apiesfo『8『ainIn】u『y Su『gicalManagement P『ognosis B『ainDeath CⅡAPTERSUMMARγ BlB【I0GRAPⅡγ ）卜SKlUS『八『∣ONX目ⅡeadandⅡeckⅣauma: ASseSSmentandMaⅡagement SceⅡa『ios Ski!!X﹣A:P『ima『ySuⅣey SkⅢX﹦B;5econda『y5u『veyandⅢanagement SI《ⅢX﹣CEvaluati0n0fCTScan5oftheⅡead SkiⅡX.D:HeImetRem0vaI

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CⅡAPTER7 SpiⅡeaⅢdSpma∣Co『dT『auma Anatomyandphy5ioIogy Cla55ificationsofSpinaICo『dIniu『ies SpecificⅣpesofSpinaIIn】u『ies X﹣RayEvaIuatioⅢ Gene『aIManagement CⅡApTERSUMMARγ BIBU0GRApⅡγ 》〉S∣《IUS『八『I0NXI:X﹣RayIdentificationof Spinelniu『ies SceⅡa『ios SI《iⅡXI.A:CeⅣicalSpineX﹣RayAs5es5ment SI《iⅡXI·B:AtIant0﹣0ccipitaIj0iⅡtAssessment SkiⅡXI.CTh0『acicand【umba『X︻RayA55es5ment SkiⅡX∣.D:ReviewSpineX﹣Rays p》S!《IUSγW『!ONXⅡ:Spina∣Co『dIniu『y ASSesSmentandManagement SceⅡa『ios Sl《il∣XⅡ.A:P『ima『y5uⅣeyandResu5citation－ A5seSSingSpineln】u『ies SkⅡ i XⅡ﹣B呂Sec0nda『ySu『vey－Ⅱeu『oI0gc i ASSeSSment S∣《ⅢXⅡ.CExamIⅡationf0『【eveI0fSpinaI Co『dInu l 『y S∣《iⅡXI!.D:TiPatmentp『indpIe5↑o『patients withSpinaICo『dIn】u『ies Skil∣XⅡ﹣E:p『incipIe5o↑SpineImm0biIizati0n and【og『0lIing

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CONTENTSxxxiii

CⅡAPTER8 ⅢⅡscuIosI《eletaIⅣa凹ma

P『ima『ySu『veyaⅡdResuscitation Adlunctstop『ima『ySu『ve『y Seconda『ySu『vey Life﹃Th『eateningIniu『ies 0the『Ext『emity∣n】u『ies P『inCipIeSofImmobiIization PainCont『oI Associatedln】Ⅱ『ies 0ccuItSI《eIetalIn】u『ies CⅡApTERSUMMARγ 8IB【I0GRAPⅡγ 卜〉S∣《I皿S『八『IONX!Ⅱ目MuscuIosl《eIetamauma: AssessmentandManagement SceⅢa『ios SkiⅡXIⅡ囈A:physicaIExamination SkiⅡXⅢ·B:p『indples0fExt『emityImm0biIizati0n SI《iI!XII∣﹦CReaIigniⅡgaDe｛0『medExt『emity SkiⅡXⅢ﹄D:AppIicati0nofaⅡactioⅡSp∣int SkiⅡXⅢ巨E8C0mpa『tmentSynd『0me:Asses5ment andⅢanagement S∣《iⅡXIⅡ·F:∣dentification0↑A『te『ialInlu『γ

Z06 Z08 Z08 Z09 Z13 Z18 Z19 ZZ0 ZZ0 ZZ1 ZZZ ZZZ

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CⅡAPTER9

The『maIⅡ l Ⅱ i 『e iS Immediate【ifesavingⅢeasⅡ『esfo『Bu『nIⅡ】u『ies AssesSmentofPatientswithBu『ns p『ima『ySu『veyandReSusCitationofPatients withBu『ns Ci『cuIation＿8u『nShocl《Resuscitation SecoⅡda『ySu『veyandReIatedAdiun仁ts ChemicaIBums EIect『icaIBums PatientⅣan5fe『 CoIdin】u『y:【ocalTissueEffects CoIdIn】u『y:SystemicⅡypothe『mia CHAPTERSUMMARγ 8I8【l0GRApⅡγ

CⅡAP『ER10 pediat『icⅣaⅡma ⅣpesandPatte『nsoflniu『y UniqueCha『acte『isticsofpediat『icPatients Ai『way:EvaIuationandMaⅡagement B『eathing:EvaluationandManagement Ci『cⅡIationandSh0cI《:EvaIuationand Management Ca『diopuImona『yResⅡscitation CheSt『iauma AbdominaIFauma ⅡeadⅣauma

Z30 Z3Z Z33

Z35 Z36 Z37 Z39 Z40 Z40 Z¢1 Z4Z Z43 Z“

Z46 Z47 Z48 Z50 255 z56 Z60

5pinalCo『dln】u『y MuscuIosketamauma ChiIdMalt『eatment CⅡApTERSUMMARγ BIBU0GRApHγ

CHApTER11 Ge『iat『icT『auma Ⅳpesandpatte『nsofIniu『ies Ai『way B『eathingandVentiIation α『cuIation DisabiIity:B『ainandSpinalCo『dlⅡju『y Exposu『eandEnvi『onment 0the『5ystems 5pecialα『cumstanceS CⅡAP『ER5UMMARγ 8l8【I0GRApⅡγ

CⅡAPTER1Z T『aumaiⅡP『egⅡaⅢCyandIⅡtimate Pa『tⅡe『VioIeⅡ叵e AnatomicandPhy5ioIogicAIte『ationsofP『egnancy MeChanismSofIniⅡ『y Seve『ityofIniⅡ『y Asses5mentand】Teatment Pe『imo『temCesa『eanSe〔ti0n ∣ⅡtimatePa『tne『VioIence CⅡAPTERSUMMARγ BIB〔I0GRApⅡγ

CⅡAPTER13 ⅣaⅡsfe『toDefiⅡitiveCa『e Dete『miningtheⅡeedfo『patiehtⅣansfe『 Ⅳansfe『Resp0nsibilities Ⅱansfe『P『otocoIS ⅢodesofⅡanspo『tation haⅡsfe『Data CⅡAPTER5UMMARγ BIB【I0GRApⅡγ

APPENDICES

264 Z65 266 Z68 Z68

Z72 Z73 Z75 275 Z76 277 278 Z79 Z80 28Z Z83

Z86 Z88 Z91 Z91 Z92 194 Z9¢ 295 296

Z98 300 302 303 303 306 307 307

309

AppeⅡdixA:0cula『】iauma（0pti0naI【ectu『e） AppendixB:Ⅱypothe『miaandⅡeatlnIu『ie5 AppeⅢ刨ixCAu5te『eandA『medC0n↑lict Env『 i onment5（0pt0 i naI【ectu『e） AppeⅡdixD:0isaSte『ⅢanagemeⅡtandEme『gency p『epa『edne55（0pt0ina【 l ectu『e） AppeⅢdixE呂Fiage5cena『i0s

321

INDEX

355

3ll 317

3Z5 339

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P『ima『ySu『vey ·5pedaIPopuIati0ns ·Ai『wayMaintenancewithCeⅣicaISpineP『0tection ·8『eathingandVentilati0n ·Ci「culati0nwithⅡem0『『hageCont『0I ·0i5abiIity（Ⅱeu『0I0gicEvaIuati0n） ·Exposu『eandEnvi「0nmentaIC0nt『oI ReS凹sdtatioⅢ ·A『 i way ·B『eathing『VentiIati0n!and0xygenati0n ·α「cuIationandⅡem0『「hageC0nt『0I

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回Identifytheco『『ectsequenceofp『io『itiesfo『assess﹣ mentofaseve『eIyin】u『edpatient 圃App∣ythep『incipIesoutlinedinthep『ima『yandsec﹣ 0nda『ysuⅣey5t0thea5se5sment0famuItip∣yinlu『ed patient.

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timingiscrucial’asystematicapproachthatcanbe rapidlyandaccurate】yappliedisessential.Thisapproach istermedthe‘‘mitialassessment,’andincludesthe fbⅡowingelements:

圃AppIyguideIinesandtechniquestotheinitiaI『esusd﹣ tativeanddefinitive﹣ca「ephasesofthet『eatmento↑a mu∣tiplyiniu『edpatient.

■Preparation

回ExpIainhowapatient’smedica∣histo「yandthe meChanismofin】u『yCont『ibutetotheidentlficationof n I」u『e I 5.

■Primarysurvey（ABCDEs）

圃Identi↑ythepitfaIIsasso亡iatedwiththeinitiaIassess﹣ mentandmanagemento↑anin】u『edpatientand de5c「ibe5tep5tominimlzethei「impact. 囝ConductaninitiaIa5se5smentsu「veyonasimuIated muItipIyln】u『edpatient’u5Ingtheco『『ectsequenceof p『io『itiesandexp∣ainingmanagementtechnique5fo『 p『m i a『yt『eatmentandstab∣ i ziato i n. 圓ReevaIuateapatientwhoisnot「espondingapp「op「i﹣ ateIyto『esuscitationandmanagement’ 回ExpIaintheimpo「tanceofteamwo『kintheinitiaI asseSsmentofat『aumapatient. ⅢRecognizepatientswhowil∣『equi『et「ansfe「fo「de↑ini﹣ tv i emanagement·

■Triage

■Resuscitation

■Adjunctstopr1marysurveyandresuscitation ■Considerationoftheneedfbrpatienttransfbr ■Secondarysurvey（head﹣to﹣toeevaluationand patienthistory） ■A句unctstotheseconda1ysurvey ■Continuedpostresuscitationmomtoringand reevalⅢation ■Definitivecare Thep『ima『yahdsecoⅡda『ysu『veysshou∣dbe爬peated f『equeⅡtIytoideⅡtiⅣanychangeihthepatient,sstatus thatindicatestheneed佗『additiohaliⅡteⅣehtioh.The

﹃

3

4CHAPTER1■InitiaIAssessmentandManagement assessmentsequencepresentedinthisChapterreflects ahnear,orlongitudinal,progressionofevents’Inan actualclinicalsituation’manyoftheseactivitiesoc﹣ curinparallel,orsimultaneous】y.Thelongitudinal progressionoftheassessmentprocessallowsclinicians anopportumtytomentallyreviewtheprogressofan actualtraumaresuscitation. ATLS＠p『incipIesguidetheassessmentahd『esusci. tatioho「iniu『edpatients.ludgmehtis『equi『edtodete『﹣ minewhichp『ocedu『esa『enecessa『y,becausehotalI patients『equi『eaIIofthesep『ocedu『es·

p『eba『ati on ∣ ﹥ p『epa『ati

Duringtheprehospitalphase’emphasisshould beplacedona1rwaymaintenance’controlofexternal bleedingandshock’immobilizationofthepatient,and immediatetransporttotheclosestappropriatefhcil﹣ i勺,prefbrablyaverifiedtraumacenter.Everyeffbrt shouldbemadetominimizescenetime’aconceptthat i s s u p p o r t e d b y t h e F i e l d T r i a g e D e c i s i o n Scheme, shownin■「lGURE1﹣Z.

Emphasisalsoshouldbeplacedonobtainingand reportinginfbrmationneededfbrtriageatthehos﹣ pital,includingtimeofinjury,eventsrelatedtothe injury’andpatienthistory.Themechanismsofinjmy cansuggestthedegreeofinjuryaswellasspecificinju﹣ riesfbrwhichthepatientmustbeevaluated· TheNationalAssociationofEmergencyMedical Techmcians’PrehospitalTraumaLifbSupportCom﹣ mittee’incooperationwiththeCommitteeonTrauma （COT）oftheAmericanCoⅡegeofSurgeons（ACS）,has developedacoursewithafbrmatsimⅡartotheATLS Coursethataddressestheprehospitalcareofinjured patients,whichiscalledPrehospitalTraumaLifbSup﹣ port（PHTLS）. Theuseofprehospitalcareprotocolsandtheabili叮 toaccessonhnemedicaldirection（directmedicalcon﹣ trol）canfHcⅢtateandimprovecareinitiatedinthefield. Periodicmultidisciphnaryreviewofthecareprovided throughqUalityimprovementactjvitiesisessential·

∣

7●fγα〃s㎡O〃介o加仇epy劍e〃Osptrα【fO肋e HO叨dOp I 妒epα爬伽αsⅧoo毗 〃Osp㎡αJeJz㎡γo刃加e〃輝 Preparationibratraumapatientoccursmtwodif fbrentClinicalsettings·First,duringtheprehospital phase,alleventsmustbec0ordinatedwiththeClimciansatthereceivinghospital.Second’duringthe hospitalphase》preparationsmustbemadetorapidly facilitatethetraumapatient,sresuscitation·

pREⅡ0SP∣TAlPⅡASE Coordinationwithprehospita1agenciesandpersonnel cangreat】yexpeditetreatmentmthefield（■FIGuRE1﹣1）. Theprehospitalsystemshouldbesetuptonoti句the receivinghospitalbefbrepersonneltransportthepa≡ tientfromthescene.Thisallowsfbrmobihzationofthe hospital,straumateammemberssothatallnecessary personnelandresourcesarepresentintheemergen叮 department（ED）atthetimeofthepatient’sarrival.

■「IGURE1﹣1P『ehospitalPhase·Thep「eho5pitaI5ystem sh0uIdbe5etuptonotifythe「eceivingho5pitaIbefo「e pe『s0nneIt「anspo「tthepatientf『omthe5cene.

Ⅱ0sP∣TAlPⅡAsE Advanceplanningfbrthetraumapatient’sarrivalises﹣ sential.Aresuscitationareash0uldbeavailablefbrtrau﹣ mapatients.Proper】yfUncti0ninga1rwayequipment （e.g.’la】yngosc0pesandtubes）shouldbeorganized’ tested’andstrategicaⅡyplacedwhereitisimmediately accessible·Warmedintravenousc1ystalloidsolutions shouldbeimmediatelyavailablefbrinftlsi0n’asshould appropriatemonitoringdevices.Aprotocoltosummon additionalmedicalassistanceshouldbeinplace,as weⅡasameanstoensurepromptresponsesbylabo﹣ rato1yandradiolo盯personnel.Transfbragreements withverihedtraumacentersshouldbeestabhshedand operational.SeeAmericanCollegeofSurgeons00mmit﹣ teeonTrauma（ACSCOT）,ResourcesfbrOptimalCare oftheInjuredPatient’2006）（electromcversiononly）’ Periodicreviewofpatientcarethroughthequali叮im﹣ provementprocessisanessentialcomponentofeach hospital’straumaprogram. AⅡpersonnelwhoarelikelytohavecontactwith thepatientmustwearstandardprecautiondevices· Duetoconcernsaboutcommunicablediseases,par﹣ ticularlyhepatitisandacqUiredimmunodeficiency syndrome（AIDS）》theCentersfbrDiseaseControland Prevention（CDC）andotherhealthagenciesstrongly recommendtheuseofstandardprecautions（e.g.,face

PREPARATION5 ■F!GURE1﹣ZFieldTiiageDecisionScheme

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帕ketot『aumacente脫TSteps1andZattempttoidentifythemostse「iously inju「edpatients·Thesepatientsshou!dbet「anspo「tedp『efe「entia!【ytothe highest【eve【ofca『ewithinthedefinedt「aumasystem.

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AssessanatomyofinjuⅣ

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·A【【penet『atinginju「iestohead’neck’to『soand ext『emitiesp「oxima【toe【bowandknee（e.g·’f∣ai 【chest） ·TWoo「mo「ep「oxima【【ong﹣b0nef「actu『es ·C「ushed,deg【oved,mang【ed,o「puIse【essext「emi ext「emity

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Taketot「aumacente脫Steps1andZt「iag Iaketot「aumacente胝5teps1andZt「iageattemptstoidentiⅣthemost

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。Chi【d『enⅢ:﹥10fto「Zto3timestheheighto「thechi【d ·High·「iskautoc『ash 。Int「usion’尚勵inc【uding「oof:﹥1Zin》occupantsite:﹥18in,anysite

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Assessspecia【patiento『 systemconside「ations

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·0∣de「adu【tsⅧ ·Riskofinju『y／deathinc「easesafte「age55yea『s ·SBP﹤110might「ep「esentshockafte「age65yea「s ·Lowimpactmechanisms（e.g·g「ound【eve!fa【【s） might「e5u【tinseve「einju『y ·Ch【 i d『en ·Shou【dbet「iagedp『efe「entiaⅡyto pediat「ic﹣capab!et「aumacente『s

Step4 勺

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·Anticoagu【ationandb【eedingdiso「de「s ·Patientswithheadinju「ya「eathigh「isI《fo『 『apiddete「io『ation ·Bu『ns ·Withoutothe「t「aumamechanism:TTiagetobumfaci∣ity☆侖鴦 。Witht「aumamechanism:TTiagetot「aumacente「俞向尚 ·P「egnancy﹥Z0weekB 。EⅡ5p「ovide「judgemeⅡt

鏈【 I 刪辮唧耐 〕 .

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TTanspo「ttoat「aumacente「o「hospita【capab【eoftimelyandtho「ougheva【uat『onand initia∣managementofpotentia【【ysenousinju『ies.Conside「consu【tationwithmedica【cont『o【.

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Whenindoubt,t「anspo「ttoat『aumacente『

Abb「eviati0n:EⅢS﹦eme『2encymedica【seMces· ·Theuppe『Ⅱmito『『e5pi甩to『y『ateiⅡinfaⅡtsig﹥Ⅱ9b『已ath■pe「mmutetomain【ainahi2he「【eve【◎『ove『Uiage『o「infan岱· Th已umace們te店a『ede5ignatedLeveⅡ.IMALev2!】cente「hasth巳g『eate5tamDunto『祀gou『ce5己ndpe店onne!fo『ca尼◎『theinjt』『edpat『entandp『ovide5『Bgiona（Ieade『ghipineducati0n’ 『esea『ch0andp『eventionp『oS『am5.ALevelⅡ『acⅧtyof佗店5imⅡa『「esou「c“to己Leve!If己叵Ⅲt叭p◎已已ib【ydi『帕而ng◎nlyincontinuo叩avai【己bⅢⅣo「ce「tainsubspeciaMeso『sⅡ「『忙ient p『eventi◎n,education,and『啟ea『chactMt『啟化『Leve｛Ide5ignat『0n;Leve｛IⅡacⅡ『tiesa『enot『equi『edtobe『e5ident◎『佗Ⅱoweducat『oncente巧令ALeve【Ⅲcente『iscapabIeo『 a5蛉5sment,『e5uscitation’andeme『Eehcygu『ge肌withgeve『e【y﹟nju『edpatien匕bem2【『an5『e「『edt◎a【eve｛﹟o「Ⅱfac﹩!i以A【£ve【Ⅳt『aum己cente『iscapabIeo『p「oWdm2Z▲·h0u「 phWiciancove『age,『e5uscitati◎n’andstabi（izationt◎呵u『edpat『ent5bef0『et『ans爬「toa偭旬【itythatp『ov『degahighe「【eve｛oft『aumaca「e. 5Anyin】u『ynotedinStepTWoo『mechanismidenti『iedm5tepTh『巴e㎡gSe『sa“ye5”「espoⅡse· ⅥAse﹤I5yea店· ··Int『u5i0n『e『e屆tointe『↑o「compa『tment『nt『u5ioⅡ’asoppo5edtode『b『mationwhich『e『e底【oexte『io『damaSe· 甘lnc【ude5pede5t巾nso「bicyc【iststh『Dwho『『unove「byamoto『vehideo『thosewi【he5timatGdimpact﹥10mp0uⅧthamoto「veiWc｛e· 卵L◎ca【◎「『2Siona【p『ot0co【5s加u【dbeusedtodete「m『ne【hem醃tapp呃p『i己te【eve!o『t甩umacentc『wi【hinthedefinedt『auma5Wtem;neednotbetheh虺he5t.【eve【【『3umacente『E Ⅷ人ge﹥55yea『5· ⋯Patien匕wi【hbothbumsandconcomi陋nt【『auma『o「whomthebummju『yp◎5e5Uue日「e己test『isMO「mo「bidityandmo『ta｛可ty5ho叭dbet甩Ⅱs『e「『edtoabumcente呃I「thenonbu「n t『aumap「esent5ag「eate「immediaten日k,thepatientmaybe5tabi!iZedinat「aumaceⅡte「andthent甩n5陀Ⅳedt◎abum仁eⅡte【 ∣T『Patient5whodonotmeetanyo『thet「iagec『itenainStepsOneth『ou8h「Ou「sh0u｛dbet『己nspo「tedto【hemo5tapp「cpnatemedica【『aci【ityasout【inedin∣oca【E胝p『utoc0｛s·

〕

6CHAPTER1■∣nitiaIAssessmentandManagement

∣PP『p ima『ySu『vey

mask’eyeprotection,water﹣imperv1ousgown,and gloves）whencomingintocontactwithbodyfluids.The ACSCOTc0nsidersthesetobeminimumprecautions andprotectionfbrallhealthcareproviders·StandardprecautionsarealsoanOccupationalSafbtyand HealthAdministration（OSHA）requirementinthe UnitedStates.

∣ ﹥ 『『ai ge

∣

Patientsareassessed’andtheirtreatmentprioritiesare established,basedontheirinjuries,vitalsigns’andthe m】mymeChanisms.Inseverelyinjuredpatients,logical andseqUentia1treatmentprioritiesmustbeestabhshed basedonoverallpatientassessment（■「lGuRE1-3）.The patient,svitalfi1nctionsmustbeassessedqUick】yand efficiently.Managementconsistsofarapidprimarysur﹣ v叮,resuscitation0fvitalhmctions）amoredetailedsec﹣ onda】ysurvey,and,finaⅡy,theinitiationofdefimtive care.ThisprocessconstitutestheABCDEsoftrauma careandidentifieslifb﹣threateningconditionsbyadher﹣ ingtothefbllowingsequence:

∣

Triageinvolvesthesortingofpatientsbasedontheir needsfbrtreatmentandtheresourcesavailableto providethattreatment·Treatmentisrenderedbased ontheABCpriorities（Airwaywithcervicalspinepr0﹣p tection’Breathing,andCirculationwithhemorrhage controD.OtherfhctorsthatmayafIbcttriageand treatmentpriorityincludeinju】yseveri叮,salvageabⅡ﹣ ity’andavailableresources. Triagealsoincludesthesortingofpatientsinthe fieldsothatadecisioncanbemaderegardingtheappr0﹣ priatereceivingmedicalfacility.Itistheresponsibility ofprehospitalpersonnelandtheirmedicaldirectorsto ensurethatappropriatepatientsarriveatappropriate hospitals。Forexample,itisinappropriatetodelivera patientWhohassustainedseveretraumatoahospital otherthanatraumacenterwhensuchacenterisavail﹣ able（see■FIGuRE1﹣z）.Prehospitaltraumascoringmay behelpfhlinidenti句ingseverelyinjuredpatientswho shouldbetransportedtoatraumacenter·See.Trauma Scores:RevisedandPediatric（electronicversiononly） andAppendixD:TriageScenariosinthistextbook. Triagesituationsarecategorizedasmultiplecasu﹣ HItiesormHsscasualties·

MULTIPlECASUALT∣ES Inmultiple﹣casualtyincidents,althoughthereismore thanonepatient’thenumberofpatientsandthese﹣ verityoftheiriIUuriesdonotexceedthecapabⅡityof thefacilitytorendercare.InsuChsituations’patients withli企﹣threatemngproblemsandthosesustainmg multiple﹣Systeminjuriesaretreatedfirst.

MASSCASUA【TIES Inmass﹣casual叮events,thenumberofpatientsand theseverityoftheirin】uriesexceedthecapabilityof thefacⅢtyandstaffJnsuchsituations’thepatients havingthegreatestchanceofsurvivalandrequiring theleastexpenditureoftime,eqUipment,supplies’

andpersonnel’aretreatedfirst.（SeeAppendixC: DisasterManagementandEmergencyPreparedness·）

Airwaymaintenancewithcervicalspinepr0tection Breathingandventilation Circulationwithhemorrhagecontrol Disability:Neurologicstatus Exposure／Environmentalcontrol:Completely undressthepatient,butpreventhypothermia

7●刪 α〃sα甽c〃’s卹Je”咖oαss﹫ssα pα跎e㎡加I0secO〃伽β AquickassessmentoftheA,B,C,andDinatrauma patientcanbeconductedbyidenti觔ngoneself;asking thepatientfbrhisorhername’andaskingwhathap﹣ pened.Anappropriateresponsesuggeststhatthereis n0ma】ora1rwaycompromise（abilitytospeakclearly）’ breathingisnotseverelycompromised（abilitytogen﹣ erateairmovementtopermitspeech）’andthereisno majordecreaseinlevelofconsciousness（alertenough todescribewhathappened）.Failuretorespondto thesequestionssuggestsabnormalitiesinA’B’orC thatwarranturgentassessmentandmanagement· Duringtheprimarysurvey’lifb﹣threateningcondi﹣ tionsareidentifiedinaprioritizedseqUencebasedon theeffbctsoftheinjuriesonthepatient’sphysiolo盯 becauseitisfreqUentlynotpossibletoinitiaⅡyidenti句 thespecificanatomicinjuries·Forexample,airwaycompromisecanoccursecondarytoheadtrauma,injuries causingshock,ordirectphysicaltraumatotheairway. Regardlessoftheinjurycausmga1rwaycompromise’ thefirstpriorityisairwaymanagement,mcludingclear﹣ mgtheairway,suctioning,admimstermgo唧gen’and securmgtheairway.TheprioritizedseqUenceisbased onthedegreeoflifbthreatsothattheabnormalitythat posesthegreatestthreattolifbisaddressedfirst· Theprioritizedassessmentandmanagementpro﹣ ceduresdescribedinthischapterarepresentedas seqUentialstepsinorderofimportanceandfbrthe purposeofclarity.However,thesestepsarefrequently

PRIMARYSURVEY7

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■『lGURE1﹣3p『imaⅣSu『veyblnseve「eIyin】u「ed patient5’Iogica∣andsequentiaIt「eatmentp『i0『itiesmust beestabIishedbasedonove「allpatientassessment·

accomplishedsimultaneous】ybyateamofhealthpro﹣ fbssionals.Toperfbrmeffbctively,themembersofsuch ateammustconstantlycommumcatewitheachother underateamleader（seeTeamwork,below）.

SpEαAlP0PUlATI0ⅡS Patientpopulationsthatwarrantspecialconsideration arechildren’pregnantfbmales’olderadults,athletes’ andobesepatients. Prioritiesfbrthecareofpediatricpatientsarethe sameasthosefbradults.Althoughtheanatomicand physiologicdiffbrencesfromtheadult;thequantitiesof bl0od’fluids,andmedications;sizeofthechⅡd;degree andrapidi叮ofheatloss;andinjurypatternsmaydiffbr, theassessmentandmanagementprioritiesareidenti﹣ cal·SpecifIcissuesrelatedtopediatrictraumapatients areaddressedinChapter1 0:Pediatric T r a n m a

Prioritiesfbrthecareofpregnantfbmalesaresimi﹣ lartothosefbrnonpregnantfbmales,buttheanatomic andphysiologicchangesofpregnanCycanmodib／the patient’sresponsetoinjury.Earlyrecognitionofpreg nancybypalpationoftheabdomenfbragraviduterus andlaboratorytesting（e’g.,humanChoriomcgonadotro﹣ pin,orhCG）andearlyfbtalassessmentareimportant fbrmaternalandfbtalsurvival.Specificissuesrelatedto pregnantpatientsareaddressedinChapter12:Trauma inPregnanCyandIntimatePartnerⅥolence. Traumaisacommoncauseofdeathintheelderly, althoughcardiovasculardiseaseandcancerovertake theincidenceofinjuryastheleadingcausesofdeath inthispopulation·Resuscitationofolderadultswar﹣ rantsspecialattention.Theagmgprocessdimimshes thephysiologicreserveofelderlytraumapatients, andchroniccardiac,respirato1y,andmetaboⅡcdis﹣ easescanimpairtheirabⅢtytorespondtoinjuryin thesamemannerasyoungerpatients.Comorbidities

suchasdiabetes,congestiveheartfailure》coronary arterydisease’restrictiveandobstructivepulmonaIy disease,coagulopathy,liverdisease,andperipheral vasculardiseasearemorecommonin0lderpatients andmayadverselyaffbctoutcomesfbllowinginjury. Inaddition’thelongtermuseofmedicationscanalter theusualphysiologicresponsetoinjuryandfrequently leadstoover-resuscitationorunder﹣resuscitationm thispatientpopulationDespitethesefhcts’mosteld﹣ erlytraumapatientsrecoverifappropriatelytreated· Prompt’aggressiveresuscitationandtheearlyrecogni﹣ tionofpreexistingmedicalconditionsandmedication usecanimprovesurvivalinthispatientgroup’Early use0finvas1vemomtormgmaybeavaluableadjunct tomanagement SeeChapter1 1:GeriatricTra】】mH ObeseDati〔 Obesepatientsposeaparticularchallengeinthe traumasetting’astheiranatomycanmakeprocedures suchasintubati0ndifIicultandhazardous。Diagnostic tests’suchasultrasound’diagnosticperitoneallavage （DPL）,andcomputedtomography（CT）arealsomore difficult.Inaddition,obesepatients旬『picaⅡyhave cardiopulmonarydisease’which比nitstheirabili叮to compensatefbri叮uryandstress.RapidfIuidresuscitationmayexacerbatetheirunder】yingcomorbidities. BecauseoftheirexceⅡentconditioning,athletes maynotmanifbstearlysignsofshock’suchastachy﹣ cardiaandtachypnea·Th叮mayalsohavenormally lowsystolicanddiastohcbloodpressure.

A!RWAγⅢA∣ⅡTEⅡAⅡCEWlTⅡCERV∣CAl SpIⅡEpROTECTI0Ⅱ Uponinitialevaluationofatraumapatient’theairway shouldbeassessedhrsttoascertainpatenCy.Thisrapid assessmentfbrsignsofairwayobstructionshouldin﹣ cludesuctioningandinspectionfbrfbreignbodiesand facial’mandibular’ortracheal／laryngealfTacturesthat canresultinairwayobstruction.Measurestoestablish apatentairwayshouldbeinstitutedwhileprotecting thecervicalspine.Initially,thechin﹣liftorjaw﹣thrust maneuverisrecommendedtoachieveaiIwaypatenCy. Ifthepatientisabletocommunicateverbally’the a1rwayisnotlikelytobeinimmediatejeopardy,h0wever’repeatedassessmentofairwaypatenCyispru﹣ dent.Inaddition’patientswithsevereheadinjuries whohaveanalteredlevelofconsciousnessoraGlasgow ComaScale（GCS）scoreof8orlessusual】yreqUirethe placementofadehmtiveairway（i.e.’cuffbd,secured tubeinthetrachea）.Thefindingofnonpurposeh1l motorresponsesstrong｝ysuggeststheneedfbrdefini﹣ tiveairwaymanagement.Managementoftheairway inpediatricpatientsrequiresknowledgeoftheumque anatomicfbaturesofthepositionandsizeofthelarynx inchildren,asweⅡasspecialequipment.SeeChapter 10:PediHtTicTrHⅧma

8CHAPTER】■lnitiaIA5se5smentandManagement

Whileassessingandmanagingapatient’sairway, greatcareshouldbetakentopreventexcessivemove﹣ mentofthecervicalspine.Thepatient,sheadandneck shouldnotbehyperextended’hyperflexed’orrotated toestabhshandmaintaintheairway.Basedonthe historyofatraumaticincident’lossofstabilityofthe cervicalspineshouldbeassumed.Neurologicexami三 nationalonedoesnotexcludeadiagnosisofcervical spmeinju】y·ImtiaⅡy’protectionofthepatient,sspinal cordwithappropriateimmobilizationdevicesshould beaccomplishedandmaintained.Evaluationand diagnosisofspecificspmalinjury’mcludingimaging’ shouldbedonelater.Ifimmobi】i究ationdevicesmustbe removedtemporarily,onemember0fthetraumateam shouldmanuaⅡystabilizethepatient,sheadandneck usinginhneimmobilizationtechniques（■FIGuRE1﹣q）· Cervicalspineradiographsmaybeobtainedto confirmorexcludeinjuryonceimmediateorpoten﹣ tial】ylifb﹣threateningconditionshavebeenaddressed, althoughitisimportanttorememberthatalateral filmidentifiesonly85℅ofalli叮uries‘AssumeaceM. calspineiniu『yinpatientswithbluntmultisystemt『auma, especiaIlythosewithanaIte『edIevelo「consciousnesso『 abluntiniu『yabovethecIavicIe.iSeeChapter7:Spine andSpinalCordTrauma. Everyeffbrtshouldbemadetorecognizea1rway compromisepromptlyandsecureadefinitiveairway. Equallyimportantisthenecessitytorecognizethe potentialfbrprogressiveairwayloss.Frequentreeval﹣ uationofairwaypatencyisessentialtoidenti吋and treatpatientswhoarelosingtheabili叮tomaintainan adeqUateairway·

≡ 二 ﹄

J

■

■ b

尸 ■

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＿

▼ 一

﹣

＿

歹 b

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■FIGURE1﹣4『nIineImmobilizationTbChniques.lf immobiIizati0ndevice5mu5tbe「emovedtempo「a「iIy｝ onemembe「ofthet『aumateamshouIdmanuaIIy stabiIizethepatientbheadandneckusinginIine immobilizationtechniques·

▲▲

PIⅡFA『Ⅱ』S L

∣

■Despitetheeffo「ts0feventhemostp『udentand attentiveclinician『the「ea「eci「cumstance5inwhich ai『waymanagementisexceptionallydi什icuItand occasionaIIyevenimp05sibIetoachieve.Equipment faiIu「eoftencannotbeanticipated’fo「exampIe’ theIightontheIa『yngoscopebu『nsouto「thecuff ontheendot『achealtubethatwasplacedwithex﹣ ceptionaIdi什icuIⅣleaksbecauseitwasto「nonthe patient’steethdu「ingintubation. ■The5eincludepatientsinwhomintubationcannot bepe『fo『medafte『neu『omuscuIa『bIockadeand

patient5inwhomasu『gicaIai『waycannotbeestab﹣ Iishedexpedientlybecauseofthei「obeSiW. ■Endot『acheaIintubationofapatientwithanun﹣ kn0wnla「yngealf「actu「eo『incompIeteuppe『 ai『wayt『ansectioncanp「ecipitatetotaIai『wayoc﹣ cIusiono「compIeteai『wayt「ansection.Thiscan oc〔u「intheabsenceofcIinicalfindingsthatsugge5t thep0tentiaIfo『anai『wayp『obIem’o『whentheu「﹣ gencyofthesituationdictatestheimmediateneed fo「a5ecu『eai『way0『ventiIation. ThesepitfaII5cannotalway5bep『evented·Howeve「’ they5houIdbeanticipated’andp「epa『ationsshould bemadetominimizethei『impact·

BREATⅡIⅡGAⅡDVEⅡTllATIOⅡ Airwaypatencyalonedoesnotensureadequateventi﹦ lation.Adequategasexchangeisrequiredtomaximize oxygenationandcarbondioxideelimination.Venti﹣ lationrequiresadequatehmctionofthelungs’chest wall,anddiaphragm.Eachcomponentmustberapidly examinedandevaluated. Thepatient,sneckandchestshouldbeexposedto adequatelyassessjugularvenousdistention,position』 ofthetrachea’andchestwallexcursion.Auscultation shouldbeperfbrmedtoensuregasflowmthelungs. Visualinspectionandpalpati0ncandetectinjuriesto thechestwallthatmaycompromiseventⅡation.Per﹣ cuss1onofthethoraxcanalsoidentifyabnormalities’ butduringanoisyresuscitationthismaybedifficultor produceunreliableresults. InjuriesthatseverelyimpairventⅡationintheshort』 termincludetensionpneumothorax’Ⅱailchestwithpul﹣ monarycontusion,massivehemothorax,andopenpneu﹣ mothorax.Theseinjuriesshouldbeidentifiedduringthe prima】ysurveyandmayreqUireinnnediateattention fbrventⅡato】yeffbrtstobeeHbctiveSimplepneumo﹣ thoraxorhemothorax’fracturedribs,andpulmonary contusioncancompromiseventilationtoalesserdegree andareusuaⅡyidentifieddurmgtheseconda】ysurvey.

pRIMARYSURVEY9

L PITFA『』『』S

sessedbilaterallyfbrquali叮,rate,andregulari叮.FuⅡ, slow’andregularperipheralpulsesareusuaⅡysignsof relativenormovolemiainapatientwhoisn0ttaking β﹣adrenergicblockingmedications.Arapid,thready

∣

Di什e「entiatingbetweenventilationp「obIemsandaiF waycomp『omisecanbedi什icult: ■Patientswhohavep「ofounddyspneaandtachypnea appea「a5thoughthei『p「ima「yp『obIemis「eIatedto aninadequateai『way.Howeve『’iftheventiIation p「obIemiscausedbyapneumotho「axo『ten5ion pneumotho『ax’intubationwithvigo「ousbag﹣mask ventiIationcan「apidIyIeadtofu「the「dete「io『ation 0fthepatient. ■Whenintubationandventilationa「enecessa『yin anunconsciouspatient’thep『ocedu「eitseIfcan unmasko『agg「avateapneumotho「ax’andthe patient’schestmu5tbe「eevaluated.Chestx﹣『ays shouIdbeobtainedasso0nafte「intubationandini﹣ tiationofventilationasisp「acticaI.

CIRCUlATl0ⅡWlTⅡⅡEM0RRⅡAGEC0ⅡTR0【 Circulatorycompromiseintraumapatientscanresult fr0mmanydiffbrentinjurles.Bloodvo】ume,cardiac output’andbleedingaremaJorcirculatoryissuesto consider.

B∣oodVolumeandCa『diacOutput Hemorrhageisthepredominantcauseofpreventable deathsaftermjmy.Identiiyingandstoppinghemor﹣ rhagearetherefbrecrucialstepsintheassessment andmanagementofsuchpatients·Oncetensionpneu﹣ mothoraxhasbeenehminatedasacauseofshock’hy﹣ potensi0nfbllowinginju1ymustbeconsideredtobe hypovolemicinoriginuntilprovenotherwise.Rapid andaccurateassessmentofanimuredpatient’shemo﹣ dynamicstatusisessentia1.TheelementsofcⅡmcal observationthatyieldimportantinfbrmationwithin secondsarelevelofconsciousness,skincolor,andpulse.

pulseistypiCaⅡyasignofhypovolemia’butthecondi﹣ tionmayhaveothercauses.Anormalpulseratedoes notnecessarilyindicatenormovolemia’butanirregu﹣ larpulsedoeswarnofpotentialcardiacdyshmction. Absentcentralpulsesthatarenotattributabletolo﹣ calfactorssigni坷theneedfbrimmediateresuscitative actiontorestoredepletedbloodvolumeandeffbctive cardiacoutput·

Bleeding Thesourceofbleedingshouldbeidentifiedaseither externalorinternal·Externalhemorrhageisidentified andcontrolledduringtheprimarysurvey.Rapid’ex﹣ ternalbloodlossismanagedbydirectmanualpressure onthewound.TourniquetsareeHbctiveinmassive exsanguinationfromanextremity’butcarryariskof ischemicinjmVtothatextremityandshouldonlybe usedwhendirectpressureisnoteffbctive.Theuseof. hemostatscanresultindamagetonervesandveins. Them句orareasofinternalhemorrhagearethe chest,abdomen,retroperitoneum’pelvis’andlong bones.ThesourceofthebleedingisusuaⅡyidentifiedbyphysicalexaminationandimaging（e.g.’chest x-ray,pelvicx﹣ray,orfbcusedassessmentsonography intrauma〔FAST】）.Managementmayincludechest decompression,pelvicbinders,sphntapplication,and surgicalintervention.

T「auma『e5pect5nopatientpopuIati0nba「「ie『.TheeI﹣ de「ly’chiId『en’athIetes’andindividuaIswithch『onic medicaIconditi0nsdonot「espondtovoIumeIossina simiIa「o「evenina〃no『maI〃manne「.

EIde「IypatientshaveaIimitedabiIitytoinc「ease thei『hea「t『atein「esponsetobIo0dlo5s》which ob5cu『e5oneoftheea『IiestsignsofvoIumedepIe﹣ tion一tachyca『dia.BIoodp「e5su『eha5IittIeco『﹣ 『eIationwithca「diacoutputinoIde「patients. AnticoaguIationthe「apyfo『medicaIconditionssuch asat『iaIfib「iIlation’co『ona『ya「te『ydisease’and t『ansientischemicattackscaninc『ea5ebloodIoss.

LevelofCon5ciou5ne5sWhencirculatingbloodvol﹣ umeisreduced’cerebralperfhsionmaybecritically impaired,resultinginalteredlevelsofconsciousness· However’aconsciouspatientalsomayhavelostasig hi問cantamnuntofblood·

Sl《inCoIo『Skincolorcanbeahelpfhlsigninevaluat﹣ inginjuredhypovolemicpatients.Apatientwithpmk skin’especiaⅡyinthefhceandextremities’rarelyhas criticalhypovolemiaafterimury.Conversely,thepa﹣ tientwithhypovolemiamayhaveashen’grayfhcial skinandpaleextremities. PuIseThepulse,typicallyaneasilyaccessiblecentral pulse（e.g.’fbmoralorcarotidarte1y）’shouldbeas﹣

∣

PITFA『刀』s L

ChiId「enusuaIIyhaveabundantphysioIogic「eseⅣe andoftenhavefewsignsofhypovoIemia’evenafte「 seve『evoIumedep∣etion.Whendete「io「ationdoes ocCu阡itisp「ecipitousandcata5t『ophic. ∣

WeII﹣t『ainedathIeteshavesimiIa「compensato『y mechanisms’mayhaveb「adyca「dia‘andmayn0t havetheu5uaIIeveIoftachyca「diawithbIoodIos5.

（tonUhued）

10CHAPTER1■lnitiaIAssessmentandManagement 日

■Often’theAMPLEhisto『y’de5c「ibedlate『inthis chapte「〃isnotavailabIe‘5otheheaIthca「eteami5 notawa「eofthepatient’suseofmedicationsfo『 ch「onicconditions·

▲」

Despitep「ope『attentiontoaIIaspectsoft「eatinga patientwithacIosedheadin】u『y》neu『oIogicdete『io﹣ 「ationcanoccu『﹂often「apidIy.TheIucidinte「va∣cIas﹣ sicaIIyassociatedwithacuteepidu『alhematomaisan exampIeofasituationinwhichthepatientwiII〃taIk anddie.〃F「equentneu『oIogic『eevaIuationcanmini﹣ mizethisp「obIembyaIIowingfo「ea『Iydetectiono↑ changes·Itmaybenece5sa『yto「etu「ntothep「ima『y su『veyandtoconfi『mthatthepatienthasasecu『e ai『way’adequateventiIationandoxygenation’and adequatece「eb『aIpe『fusion.Ea「ly∞nsuItationwith aneu『osu「geonaIsoisnecessa『ytoguideadditionaI managementeffo「tS.

Anticipationandanattitudeofskepticism「ega「ding thepatient’s〃no「maI〃hemodynamicstatusa『eap. p「op『a i te·

DISAB∣UTγ（ⅡEUR0L0GICEVAⅢATI0Ⅱ） Arapidneurologicevaluationisperfbrmedattheend oftheprimarysurv叮.Thisneurol0gicevaluationes﹣ tablishesthepatient,slevel0fconsciousness’pupⅢary sizeandreaction,lateralizmgsigns’andspinalcord iIUmylevel. TheGCSisaquick’simplemethodfbrdeter﹣ miningthelevelofconsciousnessthatispredic﹣ tiveofpatientoutcome’particularlythebestmotor

● ︵ 仃

＿

patient,slevelofconsciousness.However’ifthesefactorsareexcluded,changesmthelevelofconsciousness shouldbeconsideredtobeoftraumaticcentralnerv﹣ ousSystemoriginuntilprovenotherw1se. Primarybraininjuryresultsfromthestructural effbctoftheinjurytothebrain.Preventionofsec﹣ onda】囝ybraini叮urybymaintai㎡ngadequateo汀﹣ genationandperfbsionarethemaingoalsofinitial management.

EXP0SUREAⅡDEⅡV∣R0ⅡMEⅡTALC0ⅡTR0l Thepatientshouldbecomplete】yundressed,usu﹣ aⅡybycuttingoffhisorhergarmentstofhcilitatea thor0ughexaminationandassessment.Aiterthepa﹣ tient’sclothinghasbeenremovedandtheassessment iscompleted,thepatientshouldbecoveredwithwarm blanketsoranexternalwarmingdevicetopreventhy﹣ pothermiainthetraumareceivingarea·Intravenous fIuidsshouldbewarmedbefbrebeinginh1sed’anda warmenv1ronment（i.e.’roomtemperature）shouldbe maintained·Thepatie盹t,sbodytempe『atu『eismo『eim· po『tantthahthecom↑b㎡oftheheaIthca『ep『ovide『s.

＿

v

＝

『

－

4

response.See C h a p t e r 6 : H e a d T r a u m a i n t h i s t e x t

andTraumaScores:RevisedandPediatric（electronic versiononly）. Adecreaseinthelevelofconsciousnessmay indicatedecreasedcerebraloxygenationand／orper﹣ fhsion’oritmaybecausedbydirectcerebralinjmy. Analteredlevelofconsciousnessindicatestheneedfbr immediatereevaluationofthepatient,so叮genation, ventⅡation’andperfUsionstatus.Hyp0glycemiaand alcohol,narcotics’andotherdrugsalsocanalterthe

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PITFAIJ」 L S

SceⅢa『io■∞nt↑huedC0nside『0u『patient【 wh0was『ep0『tedun『esp0n5iveand『equi『ed assistedventi∣ati0nsaf【e『ahead﹣0nc「ashWhat abn0『ma∣itiesinthep『ima『ysuⅣeyd0y0ususped? Ⅱ0wcany0ubestasses5thi5patientqui〔k∣y? ＿

∣P Res uscitatio

n

Resuscitationandthemanagemento「life﹣th『eatening iniu『iesastheya『eidenti伺eda『eessentiaItomaximize patientsu『vival·ResuscitationalsofbⅡowstheABCse﹣ quenceandoccurssimultaneouslywithevaluation.

A∣RWAγ Theairwayshouldbeprotectedmallpatientsandse﹣ curedwhenthereisapotentialfbrairwaycompromise. Thejaw﹣thrustorchin﹣lifijmaneuvermaysufIiceasan initialintervention·Ifthepatientisunconsciousandhas nogagreflex,theestabhshmentofan0ropharyngealair﹣ waycanbehelpfi1ltemporarily.Ade伽itiveaiIway（i.e.｝ intubation）shouIdbeestabIishedi「the『eisanydoubt aboutthepatient,sabilitytomaintaiⅡai『wayinteg『ity. DefimtivecontroloftheairwaympatientsWhohave compromisedairwaysduetomechanicalfactors,have ventⅡatoⅣprOblems,orareunconsciousisachievedby endotraChealmtubation.Thisprocedureshouldbeper﹣ fbrmedwithcontinuousprotectionofthecervicalspme. AnairwayshouldbeestabhshedsurgicaⅡyifintubation iscontraindicatedorcannotbeaccomplished.

AD」UNCTSTOPRIMARYSURVEYANDRESUSCITATION11

BREATⅡlNGⅡVENTI叭TlOⅡANDOXγGEⅡATl0Ⅱ Atensionpneum0thoraxcompromisesventilationand circulationdramaticaⅡyandacutely;ifoneissuspect﹣ ed,chestdecompressionshouldfbllowimmediately. EveryiIUuredpatientshouldreceivesupplementalox﹣ ygenIfnotintubated’thepatientshouldhaveoXygen deliveredbyamask﹣reservoirdevicetoachieveopti﹣ maloxygenati0n.Thepulseoximetershouldbeused tomonitoradequacyofo唧genhemogl0binsaturation. SeeChapter2 AirwayandVentilatoryManagement

αRCULATI0ⅡANDⅡEMORRⅡAGEC0ⅡTR0【 DehnitivebIeedingcoht『oIisessentiaIaIongwithapp『o· p『iate『epIacemehtofint『avascuIa『voIume·Aminimum oftwolarge-caliberintravenous（Ⅳ）cathetersshould beintroduced.Themaximumrateoffluidadminis﹣ trationisdeterminedbytheinternaldiameterofthe catheterandinverse】ybyitslength－n0tbythesizeof theveininwhichthecatheterisplacedEstablishment ofupper﹣extremilyperiphera1Ⅳaccess1sprefbrred. Otherperipherallines’cutdowns,andcentralvenous linesshou1dbeusedasnecessaryinaccordancewiththe skiⅡlevelofthecⅡmcianwhoiscaringfbrthepatient. See SkiⅡStationⅣ:ShockAssessmentandManage﹣ ment,andSkiⅡStationV VenousCutdown’mChapter 3Shock.AtthetimeofⅣinsertion,bloodshouldbe drawnfbr勺peandcrossmatchandbaseⅡnehematolog icstudies,mcludingapregnancytestfbra1lfbmalesof childbearingage.Bloodgasesand／orlactatelevelshould beobtainedtoassessthepresenceanddegreeofshock· Agg『essiveahdcoⅡtinuedvoIume『esuscitationisnot asubstitute｛b『de伺nitivecont『oIo「hemo『『hage.Defimtive controlmcludessurgeⅣ’ang1oembolization,andpelvic stabⅡization.Ⅳfluidtherapywithc1ystalloidsshouldbe initiated·Abolusof1to2Lofanisotomcsolutionmay berequiredtoachieveanappropriateresponseinthe adultpatient.AⅡⅣsolutionsshouldbewarmedeither bystorageinawarmenv1r0nment（i·e·’37。Cto40。C,or 98·6。Fto104。F）orfluid﹣warmingdevices.Shockassoci﹣ atedwithinjmyismostoftenhypovolemicinoriginIf thepatientisunresponsivetoinitialcrystalloidtherapy》 bl0odtransfhsionshouldbegiven.

Hypothermiamaybepresentwhenthepatient arrⅣes,oritmaydevelopqUicklyintheEDifthe patientisunc0veredandundergoesrapidadmimstra﹣ tionofroom﹣temperaturefluidsorrefTigeratedbl0od. HypothermiaisapotentiaⅡylethalcomplicationin injuredpatients,andaggressivemeasuresshouldbe takentopreventthelossofbodyheatandrestorebody temperaturetonormal.Thetemperatureoftheresusci﹣ tationareash0uldbemcreasedtomihimi弭ethelossof bodyheat·Theuseofahigh﹣flowfIuidwarmerormicro﹣ waveoventoheatcrystalloidⅡuidsto39。C（1022。F）is

recommended.Howeverblo0dproductsshoUldnotbe warmedinanncrowaveoven.SeeChapter3:Shock.

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PIrFA『』I」S L

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Iniu「edpatient5cana「『iveintheEDwithhypothe「mia’ andhypothe『miacandeveIopinsomepatientswho 「equi『emassivet「ansfusion5andc『ystaIIoid「esuscita﹣ tiondespiteagg「essivee什o『tstomaintainb0dyheat. Thep『oblemisbestminimizedbyea「lycont「oIo↑ hemo「「hage.Thiscan「equi「eope『ativeinte「vention o「theappIicationofanexte「nalcomp「eSsiondevice to「educethepeIvicvoIumeinpatientswithce「tain type5ofpelvicf『actu『e5.E什o「tsto『ewa「mthepatient andp『eventhypothe「miashou∣dbeconside「edasim﹣ po『tantasanyothe「componentofthep『ima『ysuⅣey and『esuscitati0nphase.

Ad】unctstoP『in】a『ySu『veyand Resuscitation Adjunctsthatareusedduringtheprimarysurveyin﹣ cludeelectrocardiographicmomtoring;urinaIyand gastriccatheters;othermomtoring,suchasventⅡato﹣ Iyrate’arterialbloodgas（ABG）levels,pulseoximetry’ bloodpressure,andx﹣rayexammations（e.g.’chestand pelvis）（■FIGURE1﹣5）.

ElECTR0CARDl0GRApⅡICM0Ⅱ∣T0R∣ⅡG Electrocardiographic（ECG）momtoringofalltrauma patientsisimportant.Dysrhythmias＿includingunex﹣ plainedtachycardia,atrialfibrⅢation’prematureventricularcontractions’andSTsegmentchanges＿can indicatebluntcardiacinjmy.Pulselesselectricalac﹣ tivity（PEA）canindicatecardiactamponade’tension pneumothorax’and／orprofbundhypov0lemia.When bradycardia,aberrantconduction,andprematurebeats arepresent,hypoxiaandhypo﹣perfhsionshouldbe suspectedimmediately.Extremehypothermiaalsopro﹣ ducesthesedysrhythmias.SeeChapter3;Shock. URIⅡARγANDGASTRICCATⅡETERS Theplacementofurinaryandgastriccathetersoc﹣ cursduringtheresuscitationphase.Aurinespec1men shouldbesubmittedfbrroutinelaboratoryanalysis·

U『ina『yCathete『s Urina1youtputlsasensitiveindicatorofthepatient,s volumestatusandreflectsrenalperh1sion.Momtoring ofurinary0utputisbestacc0mpliShedbytheinsertionof

1ZCHApTERI■InitiaIAssessmentandManagement

properly,beattachedtoappropriatesuction,andbe hmctional.Bloodinthegastricaspiratecanbeindica﹣ tiveoforopharyngeal（swallowed）bl0od’traumaticin﹣ sertion,oractualinjurytotheupperdigestivetract’ IfthecribrifbrmplateisknowntobefiPacturedora fTactureissuspected,thegastrictubeshouldbein﹣ sertedorallytopreventintracramalpassage·Inthis situation’anynasopharyngea1mstrumentationispo﹣ tentiallydangerous. 0TⅡ朋M0ⅡlT0RIⅡG Adequateresuscitationisbestassessedbyimprove﹣ mentinphysiologicparameters,suchaspulserate》 bloodpressure’pulsepressure,ventilato1yrate,ABG levels’bodytemperature’andurinaryoutput,rather thanthequalitativeassessmentdoneduringthepri﹣ marysurvey.Actualvaluesfbrtheseparameters shouldbeobtainedassoonasispracticalaftercom﹣

■FlGURE1﹣5Radi0g「aphicStudiesa「eimp0「tant adiunct5t0thep『ima「ysu「vey.

pletingtheprimarysurvey,andperiodicreevaluation isimportant.

anindwellmgbladdercatheter.Transurethralbladder catheterizationisc0ntraindicatedinpatientsinwhom ured1ralinju】y1ssuspected.Urethralmju叮shouldbe suspectedinthepresenceof0neofthefbllowing:

VentiIato『yRateahdA㎡e『ialBIoodGases VentilatoryrateandABGlevelsshouldbeusedto monitortheadeqUacyofrespirations·Endotracheal tubescanbedislodgedwheneverthepatientismoved. Acolorimetriccarbondioxidedetectorisadevicecapableofdetectingcarbondioxideinexhaledgas.Color﹣ imet1y,orcapnography,isusefUlinconfirmingthat theendotrachealtubeisproperlylocatedintherespi﹣ ratorytractofthepatientonmechanicalventⅡation andnotintheesophagus.However’itdoesnotconfirm

■BloodattheuretbTalmeatus ■Perinealecchymosis ■High﹣riding0rnonpalpableprostate Accordmg】y,aurinarycathetershouldnotbe insertedbefbretherectumandgemtaliahavebeen examined,ifurethralmju】yissuspected·Urethral integrityshouldbeconfirmedbyaretr0gradeurethro﹣

properplacementofthetubemthetrachea.SeeChap﹣ ter2:AirwayandVentilatoryManagement

grambefbrethecatheterisinserted.

▲▲

PulseOximet『y

PITFA『几S

∣

5ometimesanatomicabno「maIitie5（e.g.!u『eth『aI5t『ic﹣ tu『eo『p「ostatichype「t「0phy）p「ecIudepIacementof anindwelIingbIadde「cathete「’despitemeticuIous te〔hnique.NonspeciaIist55houIdavoidexce5sivema﹣ nipuIationoftheu『eth「ao『useofspecializedin5t『u﹣ mentation.ConsuItau『oIogistea「Iy·

Gast『icCathete『s Agastrictubeisindicatedtoreducestomachdisten﹣ tion’decreasetheriskofaspiration,andassessfbr uppergastrointestinalhemorrhagefromtrauma. Decompressionofthestomachreducestheriskof aspiration’butdoesnotpreventitentirely.Thickor semisolidgastricc0ntentswiⅡnotreturnthroughthe tube’andactualpassageofthetubecaninducevomit﹣ ing.Forthetubetobeeffbctive’itmustbepositioned

Pulseoximet1yisavaluablea叮unctfbrmomtoring oxygenationini呵uredpatients.Thepulseoximeter measurestheoXygensaturationofhemoglobmcolori﹣ metrically’butitdoesnotmeasurethepartialpres﹣ sure0foXygen‘Italsodoesnotmeasurethepartial pressureofcarbondioxide’Whichreflectstheadequa﹣ cyofventilation.Asmallsens0risplacedonthefinger, toe,earlobe’oran0therconvenientplace.Mostdevices displaypulserateando叮gensaturationcontinuously. Hemoglobinsaturationfromthepulseoximeter shouldbecomparedwiththevalueobtainedfromthe ABGanalysis.Inconsistencyindicatesthatatleastone ofthetwodeteTminationsisinerror.

BIoodP『essu『e Thepatient’sblo0dpressureshouldbemeasured,al﹣ thoughitmaybeapoormeasureandlateindicatorof actualtissueperfUsion·

SECONDARYSURVEY13

▲▲

PITFA『Ⅱ』s L

FASTandDPLareusefhltoolsfbrtheqUick detectionofoccultintraabdominalblood.Theiruse dependsontheskiⅡandexper1enceofthechmcian. Identihcationofthesourceofoccultintraabdomin2l bloodlossmayindicatetheneedfbroperativecontrol ofhemorrhage·

∣

■PIacementofagast『iccathete「caninducevomiting o「gaggingandp「oducethespecificp『oblemthatit5 pIacementisintendedtop『even﹄aspi『ation.FunctionaIsuctionequipmentshouIdbeimmediate∣y avaiIabIe. ■Combativet「aumapatientscanoccasionalIyex﹣ tubatethemseIves.TheycanaIs0occIudethei『 endot『acheaItubeo「defIatethecu什bybitingit. F「equent『eevaluationoftheai『wayisnecessa『y· ■Thepul5eoximete『senso「shouldnotbepIaceddis﹣ taItothebIoodp『essu「ecu什.Misleadinginfo『mation「ega『dinghem0gIobinsatu『ationandpuIsecan begene『atedwhenthecu什isinfIatedandocCIudes bIo0dfIow· ■I＼lo「maIizationofhemodynamicsinin】u「edpatients 「equi「esm0「ethansimpIyano『maIbIo0dp『essu『e﹩ a「etu『ntono「malpe『iphe『alpe『fu5ionmustbe estabIished.Thiscanbep「obIematicintheeIde「Iy『 andconside『ationshouIdbegiventoea『Iyinvasive monito『ingofca「diacfunctioninthesepatients。

X﹣RAγEXAⅢ!ⅡAT∣0ⅡSAⅡD DIAGⅡOSTICSTUDIES X﹣rayexaminationshouldbeusedjudiciouslyand shouldnotdelaypatientresuscitation.Anteroposterior （AP）chestandAPpelvichlmsoftenprovideinfbrma﹣ tionthatcanguideresuscitationeffbrtsofpatientswith blunttrauma.Chestx﹣rayscanshowpotentiallylifb﹣ threatemnginjuriesthatrequiretreatment,andpeMc filmscanshowfracturesofthepelvisthatindicatethe needfbrearlybloodtransfbsion.Thesefilmscanbetak﹣ enintheresuscitationareawithaportablex﹣rayumt’ butshouldnotinterrupttheresuscitationprocess. Essentialdiagnosticx﹣raysshouldbeobtained, eveninpregnantpatients.

PⅡFA『J』S L Technicalp「oblem5maybeencounte『edwhenpe「fo「minganydiagnosticp「ocedu『e’incIudingthose necessa「ytoidentifyint「aabdominaIhemo『『hage. Obesityandint『aIuminaIboweIgascan∞mp「omise theimagesobtainedbyabdominaIuIt『asonog『aphy. Obesity’p『eviousabdominalope「ations’andp「eg﹣ nancyalsocanmakeDPLdi什icuIt.Eveninthehandsof anexpe『iencedsu「geonJthee什Iuentvolumef「omthe lavagemaybeminimaIo『ze『o.Inthe5eci『cum5tances’ analte『nativediagnosticto0l5houIdbechosen.Asu「﹣ geonshouIdbeinvoIvedintheevaIuationp「oces5and guidefu「the「diagnosticandthe『apeuticp「ocedu「es·

SceⅢa『io■con劬uedHaving〔0mpleted thep『ima「ysuⅣeⅡthepatientn0whasade↑initive aI『wayandchesttubeinpIace.St0pt0〔0nside『 whethe『theabn0『maIitie5y0uhaveidenti｛iedindi﹣ catetheneedf0『t『ansfe『t0de↑n i tiv i eca『ebe↑b『e p『0ceedingwithadlunctsandthesec0nda『ysu『vey’ －

∣ ﹥ Conside『Ⅱeedfo『patientT『ansfe『 Duringtheprimarysurveyandresuscitationphase, theevaluatingphysicianfrequentlyobtainsenough infbrmationtoindicatetheneedtotransfbrthepa﹣ tienttoanotherfhcility.Thistransfbrprocessmay beinitiatedimmediatelybyadministrativepersonnel atthedirectionoftheexaminingdoctorwhileaddi﹣ tionalevaluationandresuscitativemeasuresarebeing perfbrmed·Oncethedecisiontotransfbrthepatient hasbeenmade,communicationbetweentherefbrring andreceivingdoctorsisessential.■FIGuRE1﹣6shows apatientmonitoredduringcriticalcaretransportby groundambulance·

y ∣ ﹥ Seconda『ySu『vey

∣

?腳翼辮·。⋯⋯⋯腿d咖” Thesecohda『ysu『veydoesnotbegihuntiIthep『ima『y suⅣey（ABCDEs）iscompIeted’『esuscitativeenb『tsa『e undeIway,andtheno『malizationofvita∣fi』nctionsluas beendemonst『ated.Whenadditionalpersonnelare available,partofthesecondarysurveymaybecon﹣ ductedwhiletheotherpers0nnelattendtotheprimary survey.Inthissettmgtheconductionoftheseconda】y surveyshouldnotinterfbrewiththeprima1?ysurvey’ whichtakesfirstpriori叮. Thesecondarysurv叮isahead﹣to﹣toeevalua﹣ tionofthetraumapatient,thatis’acompletehisto叮

1』CHAPTER1■Initia∣Asses5mentandManagement

Thepatient,sconditionisgreatlyinHuencedby themechanismofmjury’andsomei1Uuriescanbe predictedbasedonthedirectionandamountofenergy behindthemechanismofi叮ury.Injuryusuallyisclas﹣ sifiedintotwobroadcategories:bluntandpenetrating trauma.Prehospitalpersonnelcanprovidevaluable infbrmationonsuchmechanismsandshouldreport pertinentdatat0theexaminingdoctor.SeeBiome﹣ chamcsofInjur】【（electronicversiononly）.Othertypes ofinjuriesfbrwhichhistoricalinfbrmationisimpor﹣ tantincludethermaliIUuriesandthosecausedbyhaz﹣ ardousenvironmehts.

BIuntT『auma

■FIGURE1﹣6Ca『efuIpatientmonito『ingdu『ingc『iticaI ca「et『ansp0「tise5sentialtop「eventand／0「manage compIicationsandanydete「io「ationinpatientstatus.

andphysicalexamination,includingreassessmentof allvitalsigns’Eachregionofthebodyiscompletely examined·Thepotentialfbrmissinganinjuryorfhil﹣ uretoappreciatethesignificanceofaninjuryisgreat’ especiallyinanunresponsiveorunstablepatient.See TableI﹣1SecondarySurvey’inSkillStationI:Initial AssessmentandManagement

Duringtheseconda】Vsurv叮,acompleteneurologic examinationisperfbrmed》includingarepeatGCSscore determination.X戶raysarealsoobtained’asindicated bytheexamination’Suchexaminationscanbeinterspersedintothesecondarysurveyatappropriatetimes. Specialprocedures》suchasspecificradiographicevalu﹣ ationsandlaborato叮studies,alsoareperfbrmedatthis time.CompletepatientevaluationreqUiresrepeated physicalPx月mih㎡ions.

HistoⅣ Everycompletemedicalassessmentincludesahis﹣ toryofthemechanismofi叼ury.Often,suchahisto1y cannotbeobtainedhomapatientwhohassustained trauma;therefbre,prehospitalpersonnelandf白mⅡy mustbeconsultedtoobtninin允rmationthatcanen﹣ hancetheunderstandingofthepatient,sphysiologic state.TheAMPLEhistoryisausefi1lmnemomcfbr thispurpose; Allerg1es ●

Medicationscurrent】yused Pastillnesses／Pregnancy 『」astmeal Events／Environmentrelatedtothem】ury

Blunttraumao仕enresultsfromautomobilecollisions, falls’andotherinjuriesrelatedtotransp0rtati0n’rec﹣ reation,andoccUpations. Importantinfbrmationtoobtainaboutautomobile collisionsmcludesseat﹣beltuse’steeringwheeldefbr﹣ mation’directionofimpact’damagetotheautomo﹣ bⅡemtermsofm匈ordefbrmationormtrusioninto thepassengercompartment’andwhetherthepatient was句ectedfromthevehicle·EjectionfTomthevehicle greatlyincreasesthepossibilityofm匈ormjury. IIUu】ypatternscanoltenbepredictedbythe mechanismofinjury.Suchinjurypatternsalsoare influencedbyagegroupsandactivities（Table1·1: MechanismsofInjuryandRelatedSuspectedInjury Patterns）.

Penet『atingT『auma Theincidenceofpenetratingtrauma（e.g.’injuries fTomfirearms,stabbings,andimpalement）isincreas﹣ ing.Factorsthatdeterminethetypeandextentof inju】yandsubsequentmanagementincludethere﹣ g1onofthebodythatwasinjured’theorgansinthe path0fthepenetratmgohject,andthevelocityofthe missile.Therefbre’ingunshotvictims’thevelocily’ caliber’presumedpathofthebuⅡet’anddistancefTom theweapontothewoundcanprovideimportantclues regardingtheextentofinjmy.SeeBiOmechanicsof

InjurI（electronicversiononly）

The『maIn】u『y Burnsareasignificanttypeoftraumathatcanoccur aloneorbecoupledwithbluntandpenetratingtrau﹣ maresultingfrom,fbrexample’aburningautomobile, explosion’fhllingdebris》andapatient,sattemptto escapeafire.Inhalationinjuryandcarb0nmonoxide poisoningoftencomplicateburniIUuries·Therefbre’it isimportanttoknowthecircumstancesoftheburn iIljury’suchastheenv1ronmentinwhichtheburnin﹣ ju1y0ccurred（openorclosedspace）’thesubstances consumedbythefIames（e.g.’plasticsandchemicals）,

SEC0NDARYSURVEY15

--】

■叭BLE1口1

Ⅲecha㎡smsof!Ⅱju『yaⅡdS凹spected !Ⅲiu『yPatte『ns SUSPEcTED IⅡ』0RγPATTERⅡ5

MECⅡAⅡ∣sⅢ 0FIⅡ川Rγ

『『ontaIimpactaut0mobiIe C0IIiSi0n ·Bentstee『ingwheel oKneeimp『int’dashboa『d ·Bu∣∣’s﹣eyef『actu「e’wn i d﹣

Ce『vical5pine↑「actu「e Ante『io『flailchest Myoca『diaIcontusion Pneumotho『ax T「aumatica0『ticdis『uption F「actu『edspleeno『Iive『 Poste「io『f「adu『e／di5∣ocation ofhipand／b『knee

■ ● ● ● ● ■

sc『een

■

sideimpactaut0m0bile C0lIiSi0n

Cont『aIate「a∣necksp「ain CeⅣicalsplnef「actu『e 【ate『aIfIaiIchest pneumotho『ax T『aumatica0『ticdis『upti0n Diaph『agmatic『uptu「e F『actu『edspleen／Iive「and／O『 kidney〃dependingon5ide 0fImpact F『actu『edpelvis0「acetabulum

● ● ● ● ● ● ●

■

theseagentscanproduceavarietyofpuhnonary’car﹣ diac,andinternalorgandysfhnctionsini叮uredpa﹣ tients·Second,thesesameagentsmayalsopresenta hazardtohealthcareproviders.Frequently,thecⅡni﹣ cian,sonlymeansofpreparationistounderstandthe generalprinciplesofmanagementofsuchc0nditions andestablishimmediatecontactwithaRegionalPoi﹣ sonControlCenter.

PⅡγSICALEXAMlⅡATI0Ⅱ Duringthesec0ndarysurvey,physicalexamination fbllowsthesequenceofhead,maxⅢofacialstructures’ cervicalspineandneck,chest’abdomen’perineum／ rectum／Vagina,musculoskeletalsystem’andneuro﹣ logicsystem.

Head Thesecondarysurveybeginswithevaluatmgthehead andidentifyingallrelatedneurologici叼uriesand othersignificantinjuries.Theentiresca】pandhead shouldbeexaminedfbrlacerations,c0ntusions,and evidenceoffTactures SeeChapter6 HeadTraI】mH·

Rea『impactaut0m0biIe C0lIi5i0n

·Ce『vc i aslpn i en i 】u「y ·Softtissueiniu「yt0neck

Ee i cto i n↑「omvehc i Ie

o日ection↑「omthevehicIe p『ecIudesmeaningfuIp『e﹣ dictionofin】u『ypatte『ns’ butpIa﹤espatientatg「eate『 『sik↑『0mv『 i tuaIya∣ l n i 】u『y meChaniSms

Ⅲoto『vehMeimpactwith pedest『ian

HeadinIuⅣ T『aumaticao『ticdi5『uption AbdominaIviSCe『aIin】u『ies 「『actu『edIowe「ext「emtie i s／ pelvis

● ● ● ●

－

＿

－

＿

andanypossibleassociatedinjuriessustained·These factorsarecriticalfbrpatientmanagement. Acuteorchromchypothermiawithoutadequate protectionagainstheatlossproduceseitherlocalor generalizedcoldinjuries.Significantheatlosscan occuratmoderatetemperatures（15。Cto20。Cor 59。Fto68。F）ifwetclothes’decreasedactivily,and／ 0rvasodilationcausedbyalcoholordrugscompromise thepatient’sabili｛ytoconserveheat.Suchhistorical infbrmationcanbeobtainedfromprehospitalperson﹣ nel.Thermaliniuriesareaddressedinmoredetailin

Chapter9:ThermalIniuries H囿za『dousEnvi『onment Ahistoryofexposuretochemicals,toxins’andradia﹣ tionisimportanttoobtainfbrtwomainreasons:first’

Becauseedemaaroundtheeyescanlaterpreclude anin﹣depthexamination’theeyesshouldbereevalu﹣ ated允r:

■Visualacuity ■Pupillarysize ■Hemorrhageoftheconjunctivaand／orfimdi ■Penetratinginjury ■Contactlenses（removebefbreedemaoccurs） ■Dislocationofthelens ■Ocularentrapment Aquickvisual﹣acuityexaminationofb0theyescanbe perfbrmedbyaskingthepatienttoreadprintedmate﹣ rialsuchasahandheldSneⅡenChart,orwordson anⅣcontainerordressingpackage.Ocularmobility shouldbeevaluatedtoexcludeentrapmentofextraoc﹣ ularmusclesduetoorbital仕actures.Theseproceduresfrequentlyidentilyocularinjuriesthatarenot 0therwiseapparent SeeAppendixA Ocular Trauma.

MaxiIIofacia∣St『uctu『es Examinationofthefhceshouldincludepalpationofall bonystructures,assessmentofocclusion’intraoralex﹣ amination,andassessmentofsofttissues. Maxillofhcialtraumathatisnotassociatedwith a1rwayobstructionormajorbleedingshouldbetreated onlyafterthepatientisstabilizedc0mpletelyand

16CHAPTER1■lnitialAssessmentandManagement

▲▲

PITFAI刀』S L

ProtectionofapotentiaⅡyunstablecervicalspine injuryisimperativefbrpatientswhoarewearingany typeofprotectivehelmet’andextremecaremustbe takenwhenremovingthehelmet·Helmetremoval isdescribedinChapter2:AirwayandVentilato】,y Management。 Penetratinginjuriestotheneckcanpotentially iUjureseveralorgansystems.Woundsthatextend throughtheplatysmashouldnotbeexploredmanu﹣ ally’probedwithinstruments,ortreatedbyindividu﹣ alsintheEDwhoarenottrainedtomanagesuch injuries.EDsarenottypicallyequippedtodealwith theproblemsthatmayarisewiththeseinjuries, theyrequireevaluationbyasurgeonoperativelyor withspecializeddiagnosticproceduresunderthe directsupervisionofasurgeon.Thefindingofactive arterialbleeding,anexpandinghematoma,arterial bruit,orairwaycompromiseusuallyrequiresopera﹣ tiveevaluation·Unexplainedorisolatedparalysisof anupperextremityshouldraisethesuspicionofa cervicalnervero0tinjuryandshouldbeaccurately documented

∣

■Facialedemainpatientswithma5sivefacialinju『yo『 incomatosepatientscanp「ecIudeacompIeteeye examination.Suchdi什icuItiesshouldnotdete『the cIinicianf「ompe『fo「mingthecomponentsofthe ocuIa「examinationthata「epossible. ■SomemaxiIIofaciaIf「actu『es’suchasnasaIf「actu「e’ nondi5pIacedzygomaticf『actu『es〃ando『bitaI『im f「actu『es’canbedi什icuIttoidentifyea『Iyinthe evaluationp「ocess.The「efo『e’f「equent「eassess﹣ mentisc「uciaI.

lifb﹣threateningi1Uurieshavebeenmanaged.Atthe discretionofappropriatespecialists’definitivemanagementmaybesafblydelayedwithoutcompromis﹣ ingcare.Patientswith仕acturesofthemidfacemay alsohaveafractureofthecribrifbrmplate.Forthese patients,gastricintubationshouldbeperfbrmedvia theoralroute.SeeChapter6:HeadTrauma,andSkiⅡ StationⅨ:HeadandNeckTrauma2AssessmentHhd Management·

Ce『vica∣SpineandNeck patientswithmaxiIlo陌cialo『headt『aumashouIdbe p『esumedtohaveahuⅡstablece『vicaIspiⅡeihiu『y（e.g.’ 仃actu『eand／o『ligamehtiniu『y）’andthenecI《shouIdbe immobiIizeduntiIaIIaspectso「theceMcalspinehave beenadequateIystudiedandaniniu『yhasbeenexcIuded’ Theabsenceofneurologicdeficitdoesnotexcludeinjurytothecervicalspine,andsuchinjuryshouldbe presumeduntilacompletecervicalspineradiographic seriesandCTarerev1ewedbyadoct0rexperiencedin detectingcervicalspinefracturesradiographically. Examinationoftheneckincludesinspection,pal﹣ pation’andauscultation.Cervicalspinetenderness, subcutaneousemphysema,trachealdeviation,and laryngealfTacturecanbediscoveredonadetailedexammation.Thecarotidarteriesshouldbepalpatedand auscultatedfbrbruits.Evidenceofb】untiIUuryover thesevesselsshouldbenotedand’ifpresent’should arouseahighindexofsuspicionfbrcarotidartery in】u1y.Acomm0nsignofpotentialinjuryisaseat﹣ beltmark.Occlusionordissectionofthecarotidarte】y can0ccurlatemtheinjuryprocesswithoutanteced﹣ entsignsorsymptoms.Angiographyorduplexultra﹣ sonographymayberequiredtoexcludethepossibihty ofm則orcervicalvascularinjurywhenthemechanism ofinjurysuggeststhispossibili叮·Mostm匈orcervical vascularinjuriesaretheresultofpenetratinginjury; however’bluntfbrcetotheneckoratractioninjury 仕omashoulder-harnessrestraintcanresultinmtimal disruption,dissection’andthrombosis.SeeChapter7: SpineandSpinalCordTrauma.

▲▲ PITFAI『』s L

▼

「

■BIuntin】u『ytotheneCk〔anp『oduceinju『ie5in whichthecIiniCaIsignsandsymptom5developIate andmaynotbep「esentdu『ingtheinitialexamina﹣ tion.In】u「yt0theintimaoftheca『otida「te『iesi5an exampIe. ■TheidentificationofceⅣicaIne『ve「ooto「b『achiaI plexusin】u『ymaynotbepossibleinacomatose patient.Conside「ati0nofthemechanismofin】u「y mightbetheCIinician,s0nIyclue. ■In5omepatient5『decubitusuIce『5candevelopquickIy ove『thesac『umandothe「a「easf「omimmobilization ona『igidspineboa「dandf『omthece『vicalc0IIa『·E卜 fo「t5toexcIudethepo5sibiIityofspinaIin】uIyshouId beinitiatedas5oonasisp「actical』andthesedevices shouldbe『emoved·Howeve『’『esuscitationandef﹄ f0『﹣tstoidentifyIifeth『eateningo『potentiaIIyIife﹣ th『eateninginiu「iesshou∣dnotbedefe『『ed.

Chest Ⅵsualevaluationofthechest,bothanteriorandpos﹣ terior,canidenti吋conditionssuchasopenpneumo﹣ thoraxandlargeHailsegments·Acompleteevaluation ofthechestwallrequirespalpationoftheentirechest cage,includingtheclavicles’ribs,andsternum.Ster﹣ nalpressurecanbepainfUlifthesternumishactured orcostochondralseparationsexist.Contusionsandhe﹣ matomasofthechestwallshouldalertthec】ihicianto thepossibilityofoccultinju1y.

SECONDARYSURVEY17

SignihcantchestimuⅣcanmaniibstwithpam》 dyspnea,andhypoxia·Evaluationmcludesauscultation ofthechestandachestx﹣ray.Auscultationisconducted highontheanteriorchestwa1lfbrpneumothoraxand attheposteriorbasesfbrhemothorax·Althoughaus﹣ cultatoryfindingscanbedi筮culttoevaluateinanoiSy environment,th叮maybeextremelyhelpfhlDistant heartsoundsanddecreasedpulsepressurecanindicate cardiactamponade.Inaddition,cardiactamponadeand tensionpneumothoraxaresuggestedbythepresence ofdistendedneckvems’a1thoughassociatedhypovo﹣ lemiacanm1n1m1zeoreliminatethisfindingDecreased breathsounds’hyperresonancetopercussion,andshock maybetheonlymdicationsoftensionpneumoth0rax andtheneedfbrimmediatechestdecompression. Achestx﹣raymayc0nfirmthepresenceofahemot﹣ horaxorsimplepneumothorax.Ribfracturesmaybe present’buttneymayno【 present’buttheymaynotbevisibleonthex﹣ray.A widenedmediastinumor0↑ widenedmediastinumor0therradiographicsignscan s u g g e s t a n a 0 r t i c r u p t u r e . See Chapter4:Thoracic Trauma·

PⅡFAⅡ刀」S 」

■ExcessivemanipuIationofthepelvisshouIdbe avoided’becauseitcanp『ecipitateadditionaI hem0「『hage·TheAPpelvicxP「ayexamination’pe『fo「medasanad】uncttothep「ima『ysu『veyand 「esuscitation’canp「ovidevaIuabIeinfo『mation「e﹣ ga「dingthep「esenceofpeIvicf「actu『es’whicha「e potentiaIIyas50ciatedwithsignificantbIoodIoss。 ■∣n】u『ytothe「et『0pe『itoneaIo「gansmaybedi什icuIt toidenti↑y’evenwiththeuseofCT·CIassicexampIe5 incIudeduodenaIandpanc『eaticin】u「ies. ■l﹤nowIedgeofin】uⅣmechanism’identificationof associatedin】u『ies’andahighindexofsuspiciona『e 『equ『 i ed. ■FemaIeu「eth「aIinju『y’aIthoughuncommon’does occu『inassociationwithpeIvicf『actu『esandst「ad﹣ dlein】u「ies·Whenp『esent’suchin】u『iesa「edi什icuIt todetect.

Pe『ineum’Rectum’andVagina

PITFA『几S

∣

■EIde『IypatientsmaynottoIe「ateeven『eIatively mino『chestinju「ies。P『og『essiontoacute『espi『a﹣ to『yinsu什iciencymustbeantidpated『andsuppo『t shouIdbeinstitutedbefo『ec0IIapseoccu『5. ■ChiId『enoftensu5tainsignificantin】u『ytotheint『a﹣ tho「aciCst「uctu『eswithoutevidenceoftho「acicskeI﹣ etaIt『auma’5oahighindexofsuspiCioniSe55entia∣.

Abdomen Abdominalinjuriesmustbeidentifiedandtreatedag﹣ gressively.Thespecificdiagnosisisnotasimportantas recognizingthataninjuryexiststhatrequiressurgical intervention.AnormH『initialexaminationoftheab﹣ domendoesnotexcludeasignificantintraabdominal injury.Closeobservationandfrequentreevaluation oftheabdomen,prefbrablybythesameobserver,is importantinmanagingbluntabdominaltrauma’be﹣ causeovertime,thepatient,sabdominalfindingscan change.Earlyinvolvementofasurgeonisessential. Patientswithunexplainedhypotension,neuro﹣ logicinjury,impairedsensoriumsecondarytoalcohol and／orotherdrugs,andeqUivocalabdominalfindings shouldbeconsideredcandidatesfbrperitoneallavage, abdominalultrasonography,or’ifhemodynamicfind﹣ mgsarenormal,CToftheabdomen.Fracturesofthe pelvisorlowerribcagealsocanhinderaccuratediag﹣ nosticexaminationoftheabdomen’becausepalpat﹣ ingtheabdomencaneⅡcitpam仕omtheseareas·See Chapter5?AbdominalandPelvicTrauma·

Theperineumshouldbeexaminedfbrcontusions’ hematomas’lacerations’andurethralbleeding.See 0hapter5:AbdominalandPelvicTrauma。

Arectalexaminationmaybeperfbrmedbefbre placingaurinarycatheter·Ifarectalexaminationis required,theclinicianshouldassessfbrthepresenceof bloodwithinthebowellumen,ahigh﹣ridingprostate, thepresenceofpelvicfTactures,theintegri叮ofthe rectalwall’andthequali叮ofsphinctertone. VaginaIexaminationshouIdbepe『｛b『medinpatients whoa『eat『iskofvaginaliniu『y,includihgalIwomenwith apelvic忖actu『e·Theclinicianshouldassessfbrthe presenceofbloodinthevaginalvaultandvaginallac﹣ erations·Inaddition’pregnanCytestsshouldbeperfbrmedonallfbmalesofchildbearingage. MuscuIoske∣etaISystem Theextremitiesshouldbeinspectedibrcontusions anddefbrmities.Palpation0fthebonesandexamina﹣ tion比rtendernessandabnormalmovementaidsin theident↑鬥cationofocculthactures. PelvicfracturescanbesuspectedbytheidentificationofecchymosisovertheⅢacwings,pubis’ labia,orscrotum·Painonpalpationofthepelvicring isanimportantfindingmalertpatients.Mobilityof thepelvisinresponsetogentleanterior﹣to﹣posterior pressurewiththeheelsofthehandsonbothanterior ihacspinesandthesymphysispubiscansuggestpel﹣ vicringdisruptioninunconsciouspatients.Because suchmanipulationcaninitiateunwantedbleeding’it shouldbedoneonlyonce（ifatall）’andprefbrablyby theorthopedicsurgeonresponsiblefbrthepatient,s

18CHAPTER1■InitiaIAs5essmentandManagement

care.Inaddition’assessmentofperipheralpulsescan identi旬vascularinjuries. SigniiicantextremityiI』uriescanexistwithoutiTac﹣ turesbeingevidentonexaminationorx﹣rays·Ligament rupturespr0ducejointinstability.Muscle﹣tendonunit injuriesinterfbrewithactivemotionoftheafIbctedstruc﹣ tures·Impairedsensationand／orlossofv0luntarymus﹣ clec0ntractionstrengthcanbecausedbynerveinjmyor ischemia,includingthatduetocompartmentSyndrome. Thoracicandlumbarspinalfracturesand／orneu﹣ rologicinjur1esmustbeconsideredbasedonphysical findingsandmechanismofmjury.Otherinjuriescan maskthephysicalfindingsofspinalmjuries,andth叮 canremamundetectedunlessthec】ihicianobtafhsthe appropriatex﹣rays. Themusculoskeletalexamination正notcomplete withoutanexaminationofthepatient’sback.Unless thepatient’sbackisexamined,significantinjuries

brainandadequa叮ofventilation（i.e.,theABCDEs） mustbereassessed·Intracrania1surgicalintervention ormeasuresfbrreducingmtracranialpressuremay benecessary·Theneurosurgeonwilldecidewhether conditionssuchasepiduralandsubduralhemato﹣ masrequireevacuation’andwhetherdepressedskull fTacturesneedoperativeintervention.SeePhapter6: HeadTrauma,andChapter7;SpineandSpinalCord Trauma﹣

Anyevidenceoflossofsensation’paralysis,or weaknesssuggestsm酊orinjurytothespmalcolumnor peripheralnervoussystem.Neurologicdeficitsshould bedocumentedwhenidentified,evenWhentransfbrto anotherfacilityordoctorfbrspecia1tycareisneces﹣ saryP『otectionoftlTespihal∞『dis『equi『edataIItimes untilaspihemiu『yisexcluded.Ea『Iyconsultationwitlu aneu『osu『geoho『o『thopedicsu『geonisnecessa『yifa spinaliniu『yisdetected.

canbemissed.See Chapter7:SpineandSpinalCord Trauma’andChap dChapter8 MusculoskeletalTraⅥm月﹣

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■BIoodlo5sf「ompeIvicf「a〔tu「esthatinc『ea5epeIvic voIumecanbedi什icuIttoCont「ol’andfataIhemoF 「hagecan「e5uIt.ASenseofu『gencyshouIdaccom﹣ panythemanagementoftheSein】u「ies. ■F「actu『esinvoIvingthebonesofthehands’w『ists’ andfeeta「eoftennotdiagnosedintheseconda『y su『veype『fo「medintheEDSometimes’itisonIy afte「thepatienthas「egainedconsciousnessand／ 0『othe「ma】0「in】u『ieSa「e「esoIvedthatpaininthe a「eaofanoccuItin】u『yisn0ted. ■lnju『iestothesofttissuesa「oundjointsa「ef「e﹣ quentIydiagnosedafte『thepatientbeginsto「e﹣ cove「.The『efo『e『f『equent「eevaIuationisessential. ■AhighIeveIofsuspicionmu5tbemaintainedtop「e﹣ ventthedeveIopmentofcompa「tmentsynd「0me.

■Anyinc『easeinint「ac『aniaIp『essu『e（ICP）can「educe ce「eb「aIpe「fu5ionp「essu「eandIeadtoseconda「y b『ainin】u『y.Mo5tofthediagno5ticandthe「apeutic maneuve『sneces5a『yfo『theevaIuationandCa『eof patientswithb『ainin】u『ywiIIinc「easelCP.T『acheal intubationisacIassicexampIe;inpatientswithb「ain in】u『y’itshouIdbepe『fo「medexpeditious∣yandas smoothIyaspossibIe.Rapidneu「oIogicdete『io『ation ofpatientswithb『ainin】u「ycanoccu「despitethe appIicationofaIImeasu『estocont『oIICPandmain﹣ tainapp「op『iatesuppo「t0fthecent「aIne「voussys﹣ tem· ■ImmobiIizationoftheenti「epatient’usingalong 5pineboa「d’semi『igidce「vi亡aIcoIIa「『and／o『othe『 ceⅣicaIimmobiIizationdevices’mustbemaintained unti∣spinaIin】u『ycanbeexcIuded.Thecommonmis﹣ takeofimmobilizingtheheadbutf「eeingtheto『so aIIowstheceⅣicaIspinetoflexwiththebodyasa fuc l 「um·

Neu『ologicaISystem Acomprehensiveneurologicexaminationincludesnot on】ymotorandsens0ryevaluationoftheextremities’ butreevaluationofthepatient’slevelofconscious﹣ nessandpupillarysizeandresponse。TheGCSsc0re fRcilitatesdetectionofearlychangesandtrendsinthe neurologicstatus.SeeTraumaScores:RevisedandPe﹣

∣P AdjunctstotheSecoⅡ da『yS u『vey ∣

diatric（electronicversiononly）. Earlyconsultationwithaneurosurgeonisrequired fbrpatientswithheadinjmy.Patientsshouldbemom﹣ toredfTequentlyfbrdeteriorationinlevelofconscious﹣ nessandchangesintheneurologicexamination,as thesefindingscanreflectworsemngoftheintracranialinjmy.Ifapatientwithaheadimurydeterio﹣ ratesneurologicaⅡy,oxygenationandperfhsionofthe

Missedinjuriescanbeminimizedbymaintaininga highindexofsuspicionandprovidingcontinuousmon﹣ itoringofthepatient’sstatus.Specializeddiagnostic testsmaybeperfbrmedduringthesecondarysurvey toidenti句specificinjuries.Theseincludeadditional x-rayexaminationsofthespineandextremities;CT scansofthehead’chest’abdomen’andspine,contrast urographyandang1ography;transesophagealultra﹣

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sound,bronchoscopy;es0phagoscopy;andotherdiagnosticprocedures（■FlGuRE1﹣7）. Duringtheseconda1ysurvey’completecervical andthoracolumbarspineimagmgmaybeobtained withaportablex-rayumtifthepatient’scareisnot compromisedandthemechanismofinjurysuggests thepossibilityofspmalmjury.Inapatientwithobtun﹣ dationwhorequiresCTofthebrain,CTofthespine maybeusedasthemethodofradiographicassess﹣ ment·Manytraumacentersibregoplainfilmsanduse CTinsteadibrdetectingspinei叼ury.Spinalcordpro﹣ tectionthatwasestablishedduringtheprimarysurvey shouldbemaintained.AnAPchestfilmandadditional filmspertinenttothesite（s）ofsuspectedm】uryshould beobtained. O仕entheseproceduresrequiretransportationof thepatienttootherareasofthehospital’whereequip﹣ mentandpersonneltomanagelifb﹣threateningcontingenciesmaynotbeimmediatelyavailable.Therefbre》 thesespecializedtestsshouldnotbeperfbrmeduntil thepatienthasbeencareiUllyexaminedandhisorher hemodynamicstatushasbeennormalized.

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SceⅡa『io■contfnuedThepatientbec0mes ta〔hyca『dicandhyp0ten5Ive’withapuI5e0↑l20 andasy5t0∣i〔b∣00dp『essu『e0↑90mmHg‘What d0y0ud0?

Thereliefofseverepainisanimportantpartof thetreatmentoftraumapatients·Manyinjuries’espe﹣ ciallymusculoskeletalinjuries’producepainandanxi﹣ e叮inconsciouspatients·Effbctiveanalgesiausually requiresthe曰dmihistrationofopiatesoranxiolytics intravenously（intramuscularinjectionsshouldbe avoided）.Theseagentsshouldbeusedjudiciouslyand msmalldosestoachievethedesiredlevelofpatient comfbrtandreⅡefofanxiety’WhⅡeav0idingrespira﹣ torydepression’themaskingofsubtlemjuries,and changesinthepatient,sstatus.

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T『aumapatientsmustbe『eevaluatedconstantIytoensu『e thatnewhndingsa『enotove「Iookedandtodiscove『dete『io. 『atiohinp『eviouslynotedhⅡdings.Asimtiallifb﹦threaten﹣ inginjuriesaremanaged》0therequallylifb﹣threatening problemsandlesssevereinjuriesmaybecomeapparent. Underlyingmedicalproblemsthatcansignificantlyafk fbcttheulthnateprognosisofthepatientmaybecome evident.Ahighindexofsuspicionfacilitatesearlydiag﹄ n0sisandmanagement. Continuousmomt0ringofvitalsignsandurinary outputisessential.Foradultpatients,maintenanceof urinaryoutputat0.5mL／kg／hisdesirable.Inpediatric patientswhoareolderthan1year,anoutputof1mL／ kg／histypicaⅡyadequate.ABGanalysesandcardiac momtoringdevicesshouldbeused.Pulse0ximetryon criticaⅡymjuredpatientsandend﹣tida1carbondioxide monitormgonmtubatedpatientsshouldbeimtiated.

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Transfbrshouldbeconsideredwheneverthepatient’s treatmentneedsexceedthecapabili叮ofthereceiving institution.Thisdecisionrequiresadetailedassessment ofthepatient’sinjuriesandthecapabⅢtiesoftheinsti﹣ tution’includingequipment,resources,andpersonnel. Interhospitaltriagecriteriawillhelpdetermine thelevel,pace,andintensityofimtialtreatmentofthe multiplyinjuredpatient·SeeACSCOT’Resourcesfbr

OptimalCareoftheIniuredPatient,2006 （electronic versiononly）.Thesecriteriatakeintoaccountthe patient,sphysi0logicstatus’obviousanatomici叼ury, mechanismsofm】ury’concurrentdiseases,andother fhctorsthatcanalterthepatient,sprognosis.EDand surgicalpersonnelshouldusethesecriteriatodeter﹣ minewhetherthepatientreqUirestransfbrtoatrauma center0rtheclosestappropriatehospitalcapableof

Z0CHAPTER1■InitiaIA55essmentandManagement

「0REⅡSlCEVlDENCE

providingmorespecializedcare·TheclosestappropriatelocalfRcililyshouldbechosenbasedonitsoverall capabilitiestocarefbrtheiIUuredpatient.SeeChapter 13TransfbrtoDefinitiveCareandFigure1﹣2.

IfcriminalactivityissuspectedincoIUunctionwitha patient’sinjury’thepersonnelcaringfbrthepatient mustpreservetheevidence.Allitems,suchascloth﹣ ingandbullets,mustbesavedfbrlawenfbrcement personnel.Laboratorydeterminationsofbloodalcohol concentrationsandotherdrugsmaybeparticularly

∣ ﹥ DiSaSte『

∣

pertinentandhavesubstantiallegalimplications.

Disastersfrequentlyoverwhelmlocalandregional resources.Plansfbrmanagementofsuchconditions mustbedeveloped’reevaluated’andrehearsed丘e﹣ quentlytoenhancethepossibilityofsavingthemax1﹣ mumnumber0finjuredpatients。ATLSproviders shouldunderstandtheirrolemdisastermanagement withihtheirhealthcareinstitutionsandremember theprinciplesofATLSrelevanttopatientcare.See AppendixC;DisasterManagementandEmergenCy Preparedness.

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Inmanycenters,traumapatientsareassessedbya team,thesizeandcompositionofwhichvariesfrom institutiontoinstitution.lno『de『tope『lb『me跪ctive∣y, oⅥeteammembe『shouldassumethe『oleo「teamIeade『· Theteamleadersuperv1ses’checks’anddirectsthe assessment;ideaⅡyhe／sheisnotinvolvedhands﹣on intheassessmentitsel£Theteamleaderisnotnecessarilythemostseniorpersonpresent.He／shesh0uld betrainedinATLSandwhatisinvolvedinleadinga medicalteam. Theteamleadersupervisesandcheckstheprepa﹣ rationstagetoensureasmoothtransitionfiPomthe

∣

Specificlegalconsiderations’includingrecords’c0n﹣ sentfbrtreatment’andfbrensicevidence’arerelevant toATLSproviders.

RECORD5 Meticulousrecordkeepingduringpatientassessment andmanagement’includingdocumentingthetime fbrallevents,isveryimportant.O仕enmorethanone cliniciancaresfbranindividualpatient,andprecise recordsareessentialfbrsubsequentpractitionersto evaluatethepatient’sneedsandclinicalstatus.Accu﹣ raterecordkeepingduringresuscitationcanbefacⅢtatedbyamemberofthenursingstaffwhoseprimary responsibili叮istorecordandcollateallpatientcare ih釦rmabion’ Medicolegalproblemsarisefrequently,andpre﹣ c1serecordsarehelpfhlfbrallindividualsconcerned. Chronologicreportingwithflowsheetshelpsboththe attendingdoctorandtheconsultingdoctortoassess

changesinthepatient,sconditionquickly.SeeSample TraumaFlowSheet（electromcversiononly）’andChap﹣ ter13:TransfbrtoDefinitiveCare,inthistextbook C0ⅡSEⅡT『0RTREATⅢEⅡT Consentissoughtbefbretreatment’ifpossible·Inhfb﹣ threateningemergencies’itisoftennotpossibletoob﹣ tainsuchconsent。Inthesecases,treatmentshouldbe providedfirst’withfbrmalconsentobtainedlater.

∣ ﹥ Teamwo『l《

prehospitaltohospitalenvironment,assigningtasks totheothermembersoftheteam.Teamhmctionis relatedtoteamtraining;duringtrainin呂dutiesare assignedtoaparticularrole’whichisreviewedwith individualteammembersbytheteamleaderasthe teampreparesfbraspecificpatient·Dependingon thesizeandcompositionoftheteam,itishelpfhlto haveteammembersassignedtothefbllowingroles: patientassessment;undressing／exposingthepatient andapplyingmonitoringequipment;andrecording theresuscitationactivi叮. Onarrivalofthepatient’theteamleadersuper﹣ visesthehand-overbyEMSpersonnel,makingcertain thatnoteammemberbeginsworkingonthepatient unlessimmediatelifb﹣threateningconditionsareobvi﹣ ous（‘‘hands﹣offhand-over”）.Auseh1lfbrmatisthe MISTacronym: Mechanism（andtime）ofinju】y !njuriesfbundandsuspected SymptomsandSigns Treatmentinitiated Asassessmentof‘‘A,,》‘‘B’”and“C》’proceed,itisex﹣ tremelyimportantthateachmemberknowswhatthe othermembershavefbundand／oraredoing·Thisis facilitatedbyverbalizingeachactionandeachfinding outloudwithoutmorethanonememberspeakingat thesametime·Requestsandordersshouldnotbestat﹣ edingeneralterms）butinsteadsh0uldbedirectedto

TEAMWORl﹤Z1

anindividual,byname.Thatindividualthenrepeats thereqUest／order,andlaterconfirmsitscompletion and’ifapplicable,itsoutcome. Theteamleadercheckstheprogressionofthe assessment,atintervalssummarizesthefindingsand theconditionofthepatient,callsfbrconsultantsas required,ordersadditionalexaminations,andsug﹣

SceⅡa『io■coⅡcIⅡsioⅡThe叫﹣yea卜0∣d patientIwh0wasinv0∣vedinahead·0nMVC!was initia∣∣yun「esp0nsiveatthesceneHewasintu﹣ bated0na「「ivaIattheh05pita∣andachesttube

gests／directstransfbrofthepatient. Duringtheentireprocess,allteammembersare e泖ectedtomakeremarks,askquestionsandmake suggestions,whenappropriate.Inthatcase’allother teammembersshouldpayattentionandthenactas directedbytheteamleader. WhenthepatienthaslefttheED’itisoptimalfbr theteamleadertoconductan‘‘AfterAction”session’ durmgWhichthetechmcalandemotionalaspectsof theresuscitationareaddressed.

pIaced｛0『a∣e｛tpneum0th0『ax·C0『『edp05ti0 in 0fthetubewa5c0n↑i『medwithchestx﹣『ay｝anda peIvicf『actu『ewa5identified0npeIvi〔x﹣『ay·The patient『eceivedZunit50fbI00df0『ta〔hyca『dia andhyp0tensi0n!andisn0wn0『m0ten5ive·Ⅱis GC5is6了AceⅣicalc0I∣a「『emainsinpIace.Ⅱe wiIlneedfu『the『evaIuati0nf0『p0ssib∣ehead iniu『yandabd0mIna∣inIu『y. ■■■

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ⅢThecorrectsequenceofprioritiesfbrassessmentofamultiplyinjuredpatientis preparation;triage;primarysurv叮;resuscitation;adjunctstoprimarysurvey andresuscitation〕considerneedfbrpatienttransfbr;secondarysurvey’a財uncts toseconda1ysurv叮;reevaluation;anddehnitivecare. 回Theprinciplesoftheprimaryandsecondarysurveysareappropriatefbrtheas﹣ sessmentofallmultiply蚵uredpatients. 圃Theguidehnesandtechmquesincludedintheinitia1resuscitativeanddeHmtive﹣ carephasesoftreatmentshouldbeappliedtoa11mu1tip】ymjuredpatients· 囤Apatient’smedicalhistoⅣandthemeChanismofinjmyarecriticaltoidentib／ing ●

◆

●

1IUur1es.

回Pitfallsassociatedwiththeinitialassessmentandmanagementofi叮uredpa﹣ tientsmustbeanticipatedandmanagedtominimizetheirimpact. 圓Theprimarysurv叮shouldberepeatedfrequently’andanyabnormalitiesshould promptathoroughreassessment· 囝EarlyidentificationofpatientsreqUiringtransfbrtoahigherlevelofcareim﹣ provesoutcomes. －

■BⅡoGRAⅢ 1.AmericanCoⅡegeofSurge0nsCommitteeonTrauma. Resoα加es／b／Op瓦mα』Cm它O／靦eI7Vu杷dPα㎡e㎡.Chicago,IL:AmericanCoⅡegeofSurgeonsCommitteeon Trauma;2006. 2.BattisteⅡaFD.EmergenCydepartmentevaluationofthe patientwithmultipleinjuries·In:WilmoreDW,Cheung LY,HarkenAH,etal.’eds.Sαe几峨cA加e／、』cα〃Sα／配／y. NewYOrk’NY:ScientificAmerican;198＆2000.

7.McSwainNEJr.’Sa1omoneJ,etal.,eds·PHILS﹩P｝℃／jo叩z﹣ rα／T／、α叨mαL旋S【《ppo尬7thed.St.Louis,MO:MosbyUems; 2011.:Isittimet0refbcus?cm｝mz加α1995;39:929＿934. 8.MorrisJA,MacKinzieEJ’DaminsoAM,etal·Mort血叮 intraumapatients目interactionbetweenhostfhctorsand severi叮.JT／.α叨mα1990;30:1476-1482. 9NahumAM’MelvinJ.eds.ⅧeBfomec力α〃ZcsO／Ⅱ】m叨mα. Norwalk,CT:Appleton﹣Century﹣Crofts;1985·

3LubbertPH,KaasschieterEG,Hoorn叮eLE,etal.Video registrationoftraumateamper比rmanceintheemer﹣ genCydepartment:theresultsofa2﹣yearanalysisina level1traumacenter.J乃α叨mα.2009j67:1412＝1420

10RhodesM,BraderA’LuckeJ’etal:Directtransportto theoperatingro0mfbrresuscitationoftraumapatients· J奶u叨〃』α1989;29:907﹣915·

4.EndersonBL’ReathDB’MeadorsJ,etal.Thetertia】y traumasurvey:aprospectivestudyofmissedinjury·J TrαM加α1990;30:666-670.

11.HolcombJB、DumireRD,CrommettJW’etalEvalua﹣ tionoftraumateamperfbrmanceusinganadvanced humanpatientsimulatorfbrresuscitationtraining.J 刃u泓mα2002;52:1078＿1086·

5.EspositoTJ,IngrahamA’LuchetteFA’etalReasonsto omitdigitalrectalexammtraumapatients:nofingers, norectum,nousemladditi0nalinfbrmation·JTJ.αM加α 2005;59（6）:1314＝1319.

12·ManserT.Teamworkandpatientsalb叮indynamic domainsofhealthcare:areviewoftheliterature.Aαα A几αes仇eS㎡o／Scα〃d2009;53:143－151·

6.EspositolIU’KUbyA’Unfred0’etal.Generalsurgeons andtheAdvancedITaumaLifbSupportcourse.Chicago, IL:AmericanCoⅡegeofSurgeons’2008.

13.KappelD,RossiD,PolackE,AvtgisT,MartinMTimeto decisiontotransfbrmtheruralsystem.Paperpresented at:39thAnnualWTAMeetmg;2009;CrestedButte.

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圓Usingthep『ima『ysuⅣeyasse5Smenttechniques『dete「mineand demonst『ate ·Ai『waypatencyandceⅣicalspinecont『oI ·B「eathingandventilation ·Ci『culato『ystatuswithhemo『『hagecont『oI

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圃Estabsilh「esusdtato i n（management）p「o i 『tiesn i amu∣tp iy In i 】u『ed patientba5edonfindingsf『omthep『ima『y5uⅣey.

囚Integ「ateapp「op『iatehisto『ytakingasaninvaIuabIeaidinpatient aSseSsment·

固Identifythein】u「y﹣p『odudngmechanismanddesc「ibethein】u「ies thatmayexistand／b「maybeanticipatedasa『e5uItofthemecha﹣ nsimofn i 】u『y. 圓Usingseconda『ysuⅣeytechniques’assessthepatient↑「omhead totoe

因Usn i gthep『m i a「yandseconda「ysu「veytechnq i ues’『eevau I atethe patient〃sstatu5and『esponsetothe『apyinstItuted.

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ⅢInthe「oIeof「efe『『ingdocto「’communicatewiththe「eceiving docto『（inst『ucto『）inalogicaI!sequentia∣manne『: ·patient’shisto「y’indudingmechanismo↑in】u『y ·Phy5iCaIfinding5 ·T「eatmentinstituted ·PatientⅢs「esponset0the『apy 。Diagnosticte5tspe㎡o『medand『esults ·NeedfO『t『an5po「t ·Methodoft『anspo「tation ·Antidpatedtimeofa『『ivaI ■

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〉5kiⅢ﹣A:P『ima『ySu『veyandResuscitation Thestudentshould:（1）outlinepreparationsthatmust bemadetofhcilitatetherapidprogressionofassess﹣ mentandresuscitationofthepatient;（2）indicatethe needtowearappropriateclothingtoprotectboththe careg1versandthepatientfromcommunicablediseas﹣ es;and（3）indicatethatthepatientistobecompletely undressed’butthathypothermiashouldbeprevented. V I btαS㎡α〃dα｝、dP／它cα叨㎡o几sα／它／、eq岫.ed山／e j 几eue｝.cα／﹄ Z唔／b『、力,αα加αPα沉e〃拓·

卜卜AIRWAγIVWⅡTEⅡAⅡCEW∣TⅡCERVICAl SpⅢEPR0TECTl0N

sTEPZ·

AAdministerhigh﹣concentrationoxygen B·Ventilatewithabag﹣maskdevice. C.Alleviatetensionpneumoth0rax. D·Seal0penpneumothorax. E.AttachaCO2monitoringdevicetothe endotrachealtube. 『。Attachapulseoximetertothepatienti

b〉αRCUlATI0ⅡWITⅡⅡEM0RRⅡAGE COⅡTR0L STEP1.

STEP1.Assessment A.Ascertainpatency. B.Bapidlyassessfbrairwayobstruction.

ⅡnHneuver.

procedure STEP3.Maintainthecervicalspineinaneutra1 positionwithmanualimmobilizationas necessarywhenestablishinganairway. STEP4Reinstateimmobilizationofthec-spmewith appropriatedevicesaiterestablishingan a1rway.

）〉BREATⅡlⅡG:VEⅡTIlATI0ⅡAⅡD 0XγGEⅡATI0Ⅱ 5TEP1.AsSessment A·Exposetheneckandchest’andensure immobiIi叨ationoftheheadandneck. B·Determinetherateanddepthof respirations· CInspectandpalpatetheneCkandchest fbrtrachealdeviation,unilateralandbi﹣ lateralchestmovement’useofaccesso】y muscles,andanysignsofinjury. D·Percussthechest允rpresenceofduⅡ﹣ nessorhyperresonance. E·AuscultatethechestbⅡateraⅡy.

ASSeSSment AIdentifysourceofexternal,exsanguinat﹣ inghemorrhage. B.Identifypotentialsource（s）ofmternal hemorrhage. C·Assesspulse:Quali叮’rate’regularity》 andparadox。 D·EvalⅢateskfncolor. E.Measurebloodpressure’iftimepermits·

STEP2·Management-Establishapatentairway APerfbrmachin﹣liftorjaw﹣thrust B.Cleartheairwayoffbreignbodies. C.Insertanoropharyngealairway. D·Estabhshadefinitiveairway. 1）Intubation 2）Surgicalcricothyroidotomy E·Describejetinsufflationoftheair﹣ way,notmgthatitisonlyatempora】y

Management

STEp2·

Management AApplydirectpressuretoexternalbleed﹣ ingsite（s）. B.Considerpresenceofinterna1hemorrhage andpotentialneedfbroperativeinterven﹣ tion’andobtainsurgicalconsult. CInserttwolarge﹣caliberⅣcatheters. D·Simultaneouslyobtainblood允rhemato﹣ logicandchemicalanalyses;pregnanCy test’whenappropriate;typeandcrossmatch;andABCs. E’InitiateⅣfluidtheraⅣwithwarmed crystalloids0lutionandblo0dreplacement. 『.Preventhypothermia·

卜卜DISABⅢTγ:BRIE『ⅡEUR0l0GI〔 EXAMlⅡATI0Ⅱ S『Ep1.Determinethelevelofconsciousnessusing theGCS. 5TEP2·CheckpupⅡsfbrsizeandreaction. 5『EP3·Assessfbrlateralizingsignsandspinalcord ●

●

1II】ury.

b〉EXP0SURE／EⅡV∣R0NⅢEⅢALC0ⅢR0【 5TEP1·Completelyundressthepatient,butprevent hypothermia.

∣

SKILLSTATIONI■InitiaIAssessmentandManagement25

P卜AD』UⅡCTST0PR∣MARγSURVEγAⅡD RESUSαTAT∣0N S『EP↑.ObtainABGanalysisandventilatoryrate· STEP2·Monitorthepatient,sexhaledCO2withan appropriatemonitoringdevice. STEp3·AttachanECGmonitortothepatient·

STEp5·

ConsidertheneedfbrandobtainAPchest andAPpelvicx﹦rays.

STEp6.

ConsidertheneedfbrandperfbrmFASTor DPI」.

rrREASSESSPAT∣EⅡT〃SABCDEsAⅡD C0ⅡSIDERⅡEED『0RpAT∣EⅡTTRAⅡSFER

STEp4Inserturinaryandgastriccathetersunless contraindicated,andmonitorthepatient,s hourlyoutputofurine·

卜SI《i∣lI﹦B:Seconda『ySu『veyandManagement （n七o5ee乃b／e／Ⅵ . 5econ巾／ySun／eM） P卜SAMPlEⅡIST0RγAⅡDMECⅡAⅡISⅢ OFlⅡ』URγ 5TEP1.ObtainAMPLEhistoryfTompatient’fam﹣ ily,orprehospitalpersonnel·

STEP2.Obtainhistoryofinjury﹣producingevent andidenti句iniurymechanisms·

b卜ⅡEADAⅡDMAXIlL0『AαAl sTEP3·ASSPSSment A.Inspectandpalpateentireheadandfhce fbrlacerations’contusions’fTactures, andthermalinjuIy. B·Reevaluatepupils· C.Reevaluatelevelofconsciousnessand GCSscore. D.Assesseyesfbrhemorrhage’penetratmg nUmy,visualacui叮,dislocationoflens’ andpresenceofcontactlenses. E.EvaluatecrahiHl﹣nervehmction. F·Inspectearsandnosefbrcerebrospinal fluidleakage. G·Inspectmouthfbrevidenceofbleed﹣ ingandcerebrospinalfluid）soft﹣tissue lacerations’andlooseteeth S丁EP4·Management AMaintainairway’andcontinueventila﹣ tionando叮genationasindicated B·Controlhem0rrhage. C.Preventsecondarybraininjmy. D.Rem0vecontactlenses.

rPCERVICAlSPINEAⅡDⅡECl《 S『EP5。Assessment AInspectfbrsignsofbluntandpenetrat﹣ inginju】y’trachealdeviation’anduseof accesso1yrespirato】:ymuscles. B.Palpatefbrtenderness,defbrmity,swell﹣ ing,subcutaneousemphysema’tracheal deviation’andsymmetryofpulses· C.Auscultatethecarotidarteries允rbrl】itsI D·ObtainaCTofthecervicalspmeora lateral,cross﹣tablecervicalspmex-ray. STEP6.Management:MaintainadeqUatein-hneim﹣ mobilizationandprotectionofthecervical ●

sp1ne.

卜卜CⅡEST STEP7·Assessment A·Inspecttheanterior’lateral’andpos﹣ teriorchestwallfbrsignsofbluntand penetratinginjury’useofaccesso1y breathingmuscles’andbⅡateralresp1ratoryexcursions. B·Auscultatetheanteriorchestwalland posteriorbases〔brbilateralbreath soundsandheartsounds. C·PalpatetheentirechestwallfbreⅥ﹣ denceofbluntandpenetratinginju】V’ subcutaneousemphysema,tenderness’ andcrepitation. D·Percussfbrevidenceofhyperresonance ordullness.

Z6Sl﹤ILLSTATI0Nl■lnitialAssessmentandManagement STEp8·

Management APerfbrmneedledecompressionofpleural spaceortubethoracostomy’asindicated. B·Attachthechesttubetoanunderwater seal﹣drainagedevice· CCorrectlydressanopenchestwound. D·Perfbrmpericardiocentesis》asmdicated. E.Transfbrthepatienttotheoperating room,ifindicated.

b卜ABD0M甽 STEp9·Assessment AInspecttheanteriorandposteriorabdo﹣ menfbrsignsofbluntandpenetratmg injuryandmternalbleeding. B.Auscultatefbrthepresenceofbowel sounds≡ C.Percusstheabdomentoelicitsubtle rebmmdtenderness. D·Palpatetheabdomenfbrtenderness,m﹣ volunta1ymusCleguarding）uneqUivocal reboundtenderness’andagraviduterus. E·Obtainapelvicx﹣rayfilm. 『·PerlbrmDPL／abdominalultrasound’if warranted. G·ObtainCToftheabdomenifthepatient ishemodynamicallynormal· STEP10·Management ATransfbrthepatienttotheoperating room’ifmdicated. B.Wrapasheetaroundthepelvisorapply apelviccompressionbinderasindicated toreducepelvicvolumeandcontrolhem﹣ orrhagefromapelvicfracture.

P》PERⅢEUM／RECT0Ⅲ／VAGⅢA 5TEp11·Perinealassessment. Assess允r: A·Contu】SinnsRhdhem月tom月貝 B.LaEerations C.Urethralbleeding STEp1Z·Rectalassessmentmselectedpatients. Assess允r: ARectalblood B·Analsphinctertone C.Bowelwallintegrity D.Bonyhagments E·Prostatep0sition STEP13·Vaginalassessmentmselectedpatients· AsRess允r: APresenceofbloodmvaginalvault B·Vaginallacerations

bbMUSC0l0Sl《ElETAl STEP14Assessment AInspecttheupperandlowerextremities fbrevidenceofbluntandpenetrating injury,includingcontusions,lacerations’ anddefbrmi叮· B·Palpatetheupperandlowerextremities fbrtenderness’crepitation’abnormal movement,andsensation. CPalpateallperipheralpulsesfbrpres﹣ ence’absence》andequa1ity. D.Assessthepelvisfbrevidenceoffracture andassoci帥edhemorrhage. E·Inspectandpalpatethethoracicand lumbarsp1nesfbrevidenceofbluntand penetratingiIUu】y,mcludingcontusions, lacerations’tenderness’defbrmity’and sensHtion. 『·Evaluatethepelvicx-rayHlmfbreⅥ﹣ denceofa仕acture. G·Obtainx﹣rayfilmsofsuspected丘acture sitesasindicated. STEP↑5·Management A’Applyand／Orreadjustappropriate splintingdevicesfbrextremityfractures asindicated. B·Maintainimmobihzationofthepatient,s thoracicandlumbarspines. C·Wrapasheetaroundthepelvisorapply apelviccompressionbinderasindicated toreducepelvicvol11meandcontrolhem﹣ orrhageassociatedwithapelvicfTacture. D.App】yasplinttoimmobilizeanextrem﹣ i叮i1Uury. E·AdmihistertetanusimmⅥhization. 『.AdmihistermediCationsasindicatedor asdirectedbyspecialist. G·Considerthepossibilityofcompartment Syndrome. Ⅱ·Perfbrmacompleteneurovascularex﹣ HmihHtionoftheextrem沘ies·

b》NEUR0l0GlC 5TEP16·ASSeSSment AReevaluatethepupⅡsandlevelof consc1ousness· B·DeterminetheGCSscore· C·Evaluatetheupperandlowerextremi﹣ tiesfbrmotorandsensoryhmctions. D·Observefbrlateralizmgsigns. STEP17·Management A.Continueventilationandoxygenation. B·Maintainadequateimmobilizationofthe entirepatient.

SKILLSTATIONl■lnitialAssessmentandManagement27

卜bAD』UNCTST0SEC0NDARγS0RVEγ STEP18’Coh臼idertheneed允randobtainthese diagnostictestsasthepatient）scondition permitsandwarrants: ■Spinalx﹣rays ■CTofthehead’chest’abdomen’and／or

■Contrasturography ■Angiography ■Extremityx﹣rays ■Transesophagealultrasound ■Bronchoscopy ■Esophagoscopy

●

sp1ne

■TABLEMSECONDARγSURVEγ I『EMT0AsSEs5

ESTABL﹟5ⅡE5／』DEN『I「lES

AssEss

FⅢDlNG

CON『IRM8γ

【eveIof C0nsciousneSS

·Seve「V i 0「headn iu l 『y

oGCSSCO『e

·8!Seve『ehead叮 i u『y ·9＿Zl’M0de『atehead n 】 iⅡ 『 y ·3 l －5 l 〃ⅢⅡ i o『headn iu l 『y

●CTs〔an ·Repeatwithoutpa『aIyzing

·Ⅳpe0h l eadn i 】u『y ·P『e5en〔e0e fyeni｝Ⅱ『y

pⅡpilS

● ● ■

·Scap In iu i 『y ·SkuIIiniu『y

Ⅱead

ⅢaxiⅡofacia∣

● ● ● ●

ⅡeC 《 I

● ● ● ■ ■

S0↑t﹣5 tisuen iⅡ I 『y 80nen iu l 『y ⅡeⅣe Ⅱ i uI『y Teeth／m0uthn iu i 『y 【a『yngean iIu l『y C﹣5pnieni】u『y Va5〔ua I 『n iu i『y E50phagean il】u『y Ⅱeu『o0lgc i de↑（ i ti

siZe Shape Reactivity

·n l sped↑o『∣ace『ato i ns and5ku∣ I ↑『actu『es ·Palpablede↑ed5 ■ ● ●

● ● ●

V5 i uaIde｛0『mtiy ⅢaI0cdusi0Ⅱ Pa∣pat0 i n↑0『c『eptiat0 in

VisuaIin5pedi0n paIpati0n Au5cultati0n

● ● ●

● ● ●

● ● ■ ● ● ●

『ho「ac〔 i ﹣wan iIu I 『y Subcutane0u5emphyseⅢa pneum0tho「ax／hemotho『ax B『0n〔ha iⅡ iI u l 『y pum I 0Ⅱa「ycoⅡtus0 in Th0『adca0『tc i d5 i 『upt0 iⅡ

● ● ● ● ●

● ● ■

VisuaIinspeCti0n Pa∣pat0 in Au5cu∣tat0 in

●

●

● ● ● ●

Abdomen／FIanl《

● ● ■

Abd0mn i a﹣ l wan iIlu i 『y n lt『ape『to i nean iI】u「y Ret「ope『to i nean iIu i 「y

● ● ● ●

Visualinspedion Palpati0n AⅡscu∣tat0i Ⅱ Dete『minepath0↑ peⅡet『at0 in

Masse肫d D肋 i seb『an in iⅡ l 『y 0phthalmiciniU『y

●CTScan

Scap I ∣a〔e『at0 in Dep「e5sedsku↑ I 『adu『e 8a5a li 『sk』 l ∣fI『adu『e

●〔『sCan

·『aCa if『 I aCtu『e 。50↑t﹣ti5sueiniuⅣ

●

Tho『ax

ageⅡt5

●

● ● ●

a l 【yngead l e↑0『mtiy 5ub〔utane0u5emphy5em日 Ⅱematoma 8『uti pIaW5ma∣penet『at0 in Pain!tende『nes5of G5pⅢe

B『u5in ig〃de↑o「mⅣ i ’0『 pa『ad0xicaIm0ti0n Chest﹣waI∣tendeme55! c『epitati0n Dimini5hedb『eaths0und5 Mu什∣edhea『t0Ⅱe5 MediastiⅡaI〔『epitati0n Seve『eba〔kpan i

Ab〔0 l mn i a﹣ l waIp l an i／ teⅡde『ne5s pe「it0neaIi「『itati0n V5i ce『an il】uⅢ Ret『0Pe『t0 i nea∣o『gan ●

·「a〔a i﹣ I b0nex﹣『ay ·CTsCan0「↑adaIb0nes

● ● ● ■

● ● ● ● ● ● ■

C﹣5pn i ex﹣『ay0「CT Angi0g『aphy／dupIexexam ESoPhag0Sc0Py 【a『yng05〔0py

Che5tx﹣「ay CT5Can Ang0 i g『aphy B『0nch05〔0py Tubeth0『ac05t0my pe『C i a『d0 i CenteSsi TEⅡIt「a50und

·Dpl／ult『asound ·d5（an ·【apa『0t0my ·C0nt「a5t6∣x﹣『ay5tudies ·Angi0g「aphγ

■

∣ n 】 u Ⅳ peMS

·Gent0i0『n ia「y（GU）t『ad 川 I u『e ls ·Pevlc i↑『adu『e（5） ●

●

■

·paIpate5ymphy5ispubi5 扣『widening ·PaIpateb0Ⅱype∣vis↑0『 teⅡde『ne5s ·0ete「minepeIvic stabiIitγon∣yon〔e ·∣Ⅱ5pectpe『n i eum ·Recta∣／Vagn i aIexam

。GUt『adn iu i 『y （hemau t「 a i） ·PevIc i ｛「adu「e ·RedalivaginaI!and／0『 pe『n i ean iI u i 『γ

● ● ● ● ● ■

Peγ lc i x﹦『ay GUcont『a5tstudies U『e【h『og『am 〔y5t0g「am IVP C0nt『a5t﹣enhanCedCT

28SKILLSTATIONI■InitiaIAssessmentandManagement

■

■TABLE!.1（contiⅡued） ITEMT0ASsEs5

E5TABUSHES／IDENTIFlES

5piⅡaICo『d

● ● ●

C『aⅡ a i∣ n u i『y 〔o『d 叫 i u『y Pe『 pihe『a∣ⅡeⅣe（5） Ⅱ iui『y

FIND!NG

AS5ESS

·M0to『『e5p0nse ●pain「e5p0nse

■

● ● ●

Ve『teb『aICo∣umn

● ● ●

Ext『emities

● ● ■ ●

Cou l mnn iu l 『y Ve『teb『aⅡ iI stabq iI ⅡeⅣen iu I 『y

·Ve『baI『e5p0nset0

S0ft﹦tsisuen i 】u『y B0nyde｛b『mtie5 」0n i tabn0『ma∣tie5 Ⅱeu『0vas〔ua I 『de佗ds

·Vi5ualin5peCti0n 。『alpati0n

UniIate『aI〔『anialmaSs e付ed 0uad『p i Iega i Pa『ape l ga i ⅡeⅣe『00tn iu i 『y

●F『a〔tu『eve『su5disl0〔ati0n

C0NFIRMBγ

·Plainspinex﹣『ays ●CT5〔an ●ⅢRl

● ●

painlate「aIizingsign5 ·Pa∣pate「0「tende『ne55 ·Deb『mity

●

● ● ■

● ●

■

SweI∣n i g『b『usin i g’pa0 l「 Malalignment pan i ’tende『ne5S’ 〔「eptiat0 in Ab5ent／dimini5hedpuI5e5 「ensemu5（Ⅱa I「 compa『tment5 Ⅱeu「oo I gc i de↑〔 i ti5

● ● ● ●

P∣an i x﹣『ays CT5CaⅡ MRl

Sped↑c i x﹣『ays D0pp∣e『examn i at0 in C0mpa『tmentp『e55u『e5 Ang0 i g『aphy

『

bSkiIlI﹦CpatientReevaIuation Reevaluatethepatient’noting,reporting’anddocu﹣ mentinganychangesinthepatient,sconditionand responsestoresuscitativeeffbrts.JUdicioususeofan﹣

algesicsmaybeinstituted.Continuousmonitoringof vitalsigns’urinaryoutput’andthepatient’sresponse totreatmentisessential.

）SkiⅢ﹣D:T『ansfe『toDefinitiveCa『e Outlinerationalefbrpatienttransfbr’transfbrproce﹣ dures,andpatient,sneedsdurmgtransfbr,andstate theneedfbrdirectdoctor﹣to﹣doctorcommumcation.

I

卜SkiⅢ.E:Afte『﹦ActionReview Outhnetherationalefbrconductinganafter﹣actionre﹣ view’andident吋whatwentwellandwhatcouldhave beenimproveduponmedicaⅡyAttentionshouldbe

paidtobreakdownsinintra﹣teamcommunication andinteractionsthatmayhaveoccurred.

AirwayandVCntilatoⅣ ManageⅡ1ent Pyw）e㎡加兀Of

『

■

■

〃Ⅵ〕O如e加Ⅱαy℃qⅢⅡy。es αpy嘲O扼e蛇【J,

＝

︼

■

■

＝

◆

叨〃Obs〃叨cf巴【Jα亦砂α9）

「 ﹦

歹

p

■

【 ·夕·」『 ■

＜

G

α】“Jα〔!cq叨α跎

伊;簿’▽.』 ■ m ﹄■

凸 包 P

Uc肥川α㎡O兀,叨觔叻 勺 ﹃ 〃

如隘ep沉o了t咖OUeγ

蚶

﹄

加α〃αg它加e咖ofα〃 o涉胞CγcO犯αt跎O〃s·

膨

＼

夕

↙

∣

I

珊 鄱 汍

『·∼釗

●

●

■

■ ■ ■ ■ 0 ﹦ ■ ■

P β

∣

F O ℃ o G 幼 o b ∼

● n

﹦

伊 ● L ● 、 ＿ ＝

●

『∼l ■ · I 舜

嶇

●● ■ ∞

／

尸 ‘ ＝

『 ●

』

＝﹁∣ ﹄h● ■

『

」

↓

d

■＼·汀

／︽﹣、 ↙ 一

－

﹃

OutⅡⅥe

0

Obiective5 Ai『way ·p『0bIemRec0gnition ·0biectiveSigns0fAi『way0b5t『uction VeⅡti∣atioⅡ ·P『oblemRec0gnition ·0b】ective5ignsofInadequateVentiIati0n LI

ⅢaⅡageme㎡ofOXygeⅢatioⅡ lVIaⅢagemeⅡtofVehtⅡatio刑 Chapte『Summa『y Bib!iog『aphy

30

0

0↑speed·Hewasn0twea『ingaheImetand has0bvi0Ⅱs↑adalt『auma.ThepatientsmeIls0↑ aIc0h0I·HewasC0mbativeandbel∣ige『entatthe scene!aIth0ughheisn0wletha『gi〔andn0tc0m﹣ municating.Ⅱi5b『eath50und5a『es0n0『0u5PuIse 0ximete『『eadingiS85℅’

∣Ⅱt『o【Ⅱ I Co tiⅢ

Ai『wayⅢaⅡagemeⅡt ·p『edictingDi付icⅡ∣tAiⅣvays ·Ai『wayDeci5i0nScheme ·Ai『wayMaintenan〔eTechniques ·DefinitiveAi『way5

q﹩4∞vP月F0Idmn『c

〔0nt『0∣and C『aSI〕edint0a↑enCeatahigh『ate

L

了∼顫

pk﹄令

!

｝

↙

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﹂

﹦ 「

r

zz

p

叮

回 』∼﹣ ﹣

■

﹂

＝

F

O坷ectives

－

Ⅲ

Identi↑ythecIinicaIsituationsinwhichai『waycomp『o﹣ miseislikelyt0occu『.

回

Recognizethe5ignsandsymptomsofacuteai『way ob5t『uction.

圃

RecognizeventiIato『ycomp『omiseandsignsofinad﹣ equateventiIation

囤

Desc『ibetheteChniquesfo『estab∣ishingandmaintain﹣ lngapatentai『way.

回

Desc『ibethetechniquesfo『con↑i『mIngtheadequacy ofventilationandoxygenationlincIudIngpuIseoxim﹣ et『yandend﹣tida∣CO2monito「ing.

回 固 圃

Definethete『mdefinitiveai「way. Listtheindicati0nsfo『『apid5equenceintubation. OutIinethe5tepsnecessa『yfo『maintaining0xygen﹣ ati0nbefo『e’du「ing’andafte「estabIishingadefinitive aI『way.

T

T若繃:蟹緇腳鹽繃譙:跚

quickestkiⅡerofinjuredpatients.Preventionof hypoxemiarequiresaprotected’unobstructedairway andadequateventilation’whichtakepriorityover managementofallotherconditions.Anairwaymust besecured,oxygendelivered,andventilatorysupport provided.SuppIemehta∣oxygenmustbeadmmiste『edto allt『aumapatients· Earlypreventabledeathsfromairwayproblems aftertraumaoftenresulthom: ■Failuret0recognizetheneedfbrana1rway intervention ■Inabilitytoestablishanairway ■Inabilitytorecognizetheneedfbranalterna﹣ tivea1rwayplaninthesettingofrepeated failedintubationattempts ■Failuret0recognizeanincorrectlyplaced a1rway ■Displacementofaprevious】yestablished a1rway ■Failuretorecognizetheneedfbrventilation ■Aspirationofgastricc0ntents Ai『wayandventiIationa『ethe伺『stp『io『ities.

31

3ZCHAPTERZ■Ai「wayandVentiIato『yManagement

■A『 i wway ay ?鰓勰:yⅧ⋯叼 ■

Thefirststepstowardidentifyingandmanagmgpo﹣ tentiallylifb﹣threatemngairwaycompromiseareto recognizetheproblemsinvolvingmaxillofacial》neck, andlaryngealtrauma,andtoidentifyohjectivesigns ofairwayobstruction. PR0BlEMREC0GⅡITlOⅡ Airwaycompromisecanbesuddenandcomplete’m﹣ sidiousandpartial’and／0rprogressiveandrecurrent· Alth0ughitisoitenrelatedt0pamoranxie｛y’orboth’ tachypneacanbeasubtlebutearlysignofairwayor ventilatorycompromise.Therefbre,assessmentand freqUentreassessmentofairwaypatencyandadequa﹣ cyofventilationarecritical· Duringimtialassessmentoftheairway,the “talkingpatient”providesreassurance（atleastfbr themoment）thattheairwayispatentandnotcom﹣ promised.Therefbre’themostimportantearlymeas﹣ ureistotalktothepatientandstimulateaverbal resp0nse.Apositive’appropriateverbalresponseindi﹣ catesthattheairwayispatent’ventⅡationisintact’ andbrainperfhsionisadeqUate.Failuretorespond oraninappropriateresponsesuggestsanalteredlevel ofconsciousness’airwayandventilatorycompromise, orb0th. Patientswithanalteredlevelofconsciousness areatparticularriskfbra1rwaycompromiseand oftenrequ1readefinitiveairway.Adefinitivea1r﹣ wayisdefinedasatubeplacedinthetracheawith thecuffinflatedbelowthevocalcords’thetubecon﹣ nectedtosomefbrmofo叮gen﹣enrichedassistedven﹣ tⅡation,andtheairwaysecuredinplacewithtape. Unconsciouspatientswithheadmjuries,patients whoareobtundedbecauseoftheuseofalcoholand／ orotherdrugs,andpatientswiththoracicinjuriesall canhaveacompromisedventilatoryef【brt.Inthese

▲▲ P I T F A 『 几 S L

Aspi『ationisadange『fo「t「aumapatients.FunctionaI SuctionequipmentmustbeimmediatelyavaiIablet0 aidcliniciansinensu「ingasecu「e『patentai『wayinaII t『aumapatients·

MaxiIlofacia∣T『auma Traumatothe炫cedemandsaggressivebutcarefhl airwaymanagement（■F∣GuREE﹣1）.Themechanism fbrthisinjuryisexemplifiedbyanunbeltedautomo﹣ bilepassengerwhoisthrownintothewindshieldand dashboardTraumatothemidfhcecanproducefrac﹣ turesanddislocationsthatcompromisethenasophar﹦ ynxandoropharynx.FacialhPacturescanbeassociated withhemorrhage,increasedsecretions,anddislodged teeth,whichcauseadditionaldifficultiesinmaintainingapatentairway.Fracturesofthemandible’especiallybilateralbodyhactures’cancauselossofnormal a1rways向、αcmm／support.Airwayobstructioncan resultifthepatientisinasupmepositi0n.Patients whorefhsetoliedownmaybeexperiencmgdifficulty inmaintaimngtheirairwayorhandlingsecretions. Furthermore,providinggeneralanesthesia’sedation’ ormusclerelaxationcanleadtothetotalloss0fairway

duetodimimshedorabsentmuscletone’SeePhapter 6:HeadTrauma. NeckT『auma Penetrating1njurytotheneckcancausevascularin﹣ jurywithsignificanthematoma,Whichcanresultin

patients》thepurposeofendotrachealintubationis toprovideana1rway,deliversupplementaryoxygen） supportventilation’andpreventaspiration.Maintain. ihgoxygehatioⅡandp『eventinghype『ca『biaa『ec『iticaI ihmahagingt『aumapatiehts,especiaIIythosewhohave sustainedheadiniu『ies. Itisimportanttoanticipatevomitinginallinjured patientsandbepreparedtomanagethesituation.The presenceofgastriccontentsintheoropha1ynxrepre﹣ sentsasignificantriskofaspirationwiththepatient,s nextbreath.Therefbre,immediatesucti0ningand rotationoftheentirepatienttothelateralpositionare ihdicated.

■「IGUREZ﹣1TiBumatothefacedemandsagg「essive butca『efuIai「waymanagement.

A I R W A Y 3 3

displacementandobstructionoftheairway.Emergen﹣ Cyplacementofasurgicalairwaymaybenecessaryif thisdisplacementandobstructionmakeendotracheal mtubationimpossible.HemorrhagefTomadjacentvas﹣ culariIUu叮canbemassive,andoperativecontrolmay bereqUired. Bluntorpenetratinginjurytotheneckcancause disruptionofthelarynxortrachea’resultingina1rway obstructionand／Orseverebleedingintothetracheobronchia1tree.Adefinitiveairwayisurgentlyrequired 1nthissituation. NeckiIUuriesinvolvingdisruptionofthela1ynx andtracheaorcompressionoftheairwayfromhemor﹣ rhageintothesofttissuesoftheneckcancausepartial a1rwayobstruction.Initially,apatientwiththistype ofseriousa1rwayinjurymaybeabletomaintaina1r﹣ waypaten叮andventilation.However,ifairwaycom﹣

thatcompleteobstructionalreadyensts·Whenthe patient’slevelofconsciousnessisdepressed’detectionofsignificantairwayobstructionismoresubtle. Laboredrespirato叮effbrtmaybetheonlycluetoairwayobstructionandtracheobronchialinju】y. IfafTactureofthelarynxissuspected’basedon themechanismofinju1yandsubtlephysicalfindings, computedtomography（CT）canhelptoidentifythis 1IUury.

0B』ECT∣VESlGⅡS0『A∣RWAγ0B5TR0CT∣0Ⅱ Severalohjectivesignsofairwayobstructioncanbe identifiedbytakingthefbllowingsteps: 1.Observethepatienttodeterminewhetherhe0r sheisagitatedorobtunded.Agitationsuggests hypoxia’andobtundationsuggestshypercarbia’ Cyanosisindicateshypoxemiaduetoinadequate oxygenation;itisidentifiedbyinspectionofthe nailbedsandcircumoralskin.However’cyano﹣ sisisalatefindingofhypoxia.Pulseoximetry isusedearlyintheairwayassessmenttodetect inadequateoxygenationpriortothedevelop﹣ mentofCyanosisLookfbrretractionsandthe useofaccessorymusclesofventilationthat,when

promiseissuspected’adefinitiveairwayisrequired· T0preventexacerbatinganexistinga1rwayinjury, anendotrachealtubemustbeinsertedcautiouslyand prefbrablyunderdirectvisualization.Lossofairway patencycanbeprecipitous,andanearlysurgicalairwayusuallyisindicated’SeeSkillStationIX:Head

andNeckTrauma;AssessmentandManagement la『yngea∣T『auma

present,provideadditionalevidenceofairway comprom】se.

Althoughfractureofthela】?ynxisararemjury’itcan presentwithacuteairwayobstruction.Itisindicated bythefbllowingtriadofclinicalsigns:

Z.Listenfbrabnormalsounds.Noisybreath﹣ ingisobstructedbreathing.Snoring,gurgling’ andcrowingsounds（stridor）canbeassociated withpartialocclusionofthepharynxorlarynx. Hoarseness（dysphonia）implieshmctional,laryn﹣

1·Hoarseness 2.Subcutaneousemphysema 3·PalpablefTacture

gealobstruction. 3·FeelfbrthelocationofthetracheaandqUickly determinewhetheritisinthemidlmeposition.

Completeobstructionoftheairwayorsevereres﹣ piratorydistresswarrantsanattemptatintubation. Flexibleendoscopicintubationmaybehelpfhlinthis situation’buton】yifitcanbeperibrmedpromptly.If intubationisunsuccessfhl,anemergencytracheos﹣ tomyismdicated,fbⅡowedbyoperativerepair.How﹣ ever’atracheostomyisdifIiculttoperfbrmunder emergenCyconditions’canbeassociatedwithprofhse bleeding’andcanbetime﹣consuming.Surgicalcrico﹣ thyroidotomy’althoughnotprefbrredfbrthissitua﹣ tion,canbealifbsavingoption. Penetratmgtraumatothelarynxortracheais overtandreqUiresimmediatemanagement.Com-

4Evaluatepatientbehavior.Abusiveandbe∣lige『ent patientsmayin伯cthavehypoxiaandshouIdnotbe p『esumedtobeintoxicated·

＝ ﹁

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SceⅡa『io■cont『huedThepatient似sb『eath 50und5bec0mem0『eIab0『ed!andhe『emains un『esp0nsiveUsingIn∣inece『vicaIimm0biIizati0n!

pletetraChealtransectionorocclusionoftheairway withbloodorsofttissuecancauseacuteairwaycom﹣ promisethatrequ1resimmediatecorrection.These iIjuriesare0灶enassociatedwithtraumatothe es0phageus,carotidartery’orjugularvein,asweⅡas extensivetissuedestruction·Noisybreathingindicates partialairwayobstructionthatcansuddenlybecome complete’whereastheabsenceofbreathingsuggests

∣ y0upe『↑0『mthechn i ﹣∣↑ i tmaneuve『andbag﹣mask venti∣a【i0n﹟inc「easinghis0xygenati0n5atⅡ『ati0n ｛『0m85℅t09Z℅.

﹣

34CHAPTERZ■Ai「wayandVentiIato「yManagement

∣PVeⅡa tIi tioⅡ

∣「 b 、 「 PITFA『几S Patientswhoa『eb「eathinghighconcent「ationsofox﹣

Ensuringapatentairwayisanimportantstepinpro﹣ vidingoXygentothepatient,butitisonlythefirst step.Anunobstructedairwayisnotlikelytobenefit thepatientunlessthereisalsoadequateventilation. Theclinicianmustlookfbranyobjectivesignsofinad﹣ equateventilation·

pR0BLEMREC0GⅡlT∣0Ⅱ Ventilationcanbecompromisedbyairwayobstruc﹣ tion,alteredventilatorymechanics’and／Orcentral nerv0usSystem（CNS）depression·Ifapatient,s breathingisnotimprovedbyclearingtheairway’oth﹣ ercausesoftheproblemmustbefbundandmanaged. Directtraumat0thechest,especiallywithribfrac﹣ tures’causespainwithbreathingandleadstorapid’ shallowventilationandhypoxemia.Elderlypatients andindividualswithpreexistingpulmonarydyshmc﹣ tionareatsignificantriskfbrventilatoryfhilureunder thesecircumstances.Intracranialinjurycancauseab﹣ normalbreathingpatternsandcompromiseadequa叮 ofventⅡation.Cervicalspinalcordinjurycanresultin diaphragmaticbreathingandinterfbrewiththeability tomeetincreasedoxygendemands.Completecervical cordtransection’whichsparesthephrenicnerves（C3 andC4）,resultsinabdominalbreathingandparalysis oftheintercostalmuscles;assistedventilationmaybe required.

∣

ygencanmaintainthei『oxygen5atu『ationaIthough b『eathinginadequateIy.Measu『ea「te『iaIo「end﹣tidaI ca『bondioxide.

∣

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Sceha『io■cont『huedγ0ua『eunablet0 vi5uaIizethev0calc0『ds0ndi『ectIa『yng0sc0py’ A｛te『sⅡdI0ningiy0useethep0ste「i0「a「yten0∣ds andattemptintubati0nC0n↑i『matI0n0↑C0z pIacementd0esn0tc0n↑i『mc0『『e〔tp∣acemen﹂ the『eisn0c0I0『Chang巳 ■■■■

∣ ﹥ Ai『wayManagement 叨 H0叨αo〃 I ‘α腮αg僭咖α﹠γ叨叼O／α ●fγα叨〃』αpα㎡e肥fβ AirwaypatencyandadeqUaCyofventilationmustbe assessedquicklyandaccurately.Pulseoximetryand end﹣tidalCOomeasurementareessential.Ifproblems ︼

08』ECTIVESIGⅡS0『INADE0UATEVEⅢI【AT∣0Ⅱ

叨 HmMo肋 I o叨ue劂蹦α ! 魷o腮 ●『sααeq〃α花β SeveralohjectivesignsofmadeqUateventilationcan beidentifIedbytakingthefbllowingsteps: 1·LookfbrSymmetricalriseandf白llofthechest andadequatechestwallexcursion·Asymmetry suggestssphntingoftheribcageorailailchest. Laboredbreathingmayindicateanimminent threattothepatient’sventⅡation. 2·Listenfbrmovementofaironbothsidesof thechest.Decreasedorabsentbreathsounds 0veroneorbothhemith0racesshouldalertthe examinertothepresenceofthoracicinjury.See 0hapter4;Thoracic Trauma. Bewareofarapid respiratoryrate＿tachypneacanindicaterespira﹣ torydistress· 3·Useapulseoximeter.Thisdeviceprovidesinfbr﹣ mationregardingthepatient’soxygensaturation andperipheralperfhsion,butdoesnotmeasure theadequacyofventilation.

areidentifIedorsuspected’measuresshouldbeinsti﹣ tutedimmediatelytoimproveoxygenationandreduce theriskoffbrtherventilato】ycompromise.These measuresincludeairwaymaintenancetechmques’de﹣ fimtivea1rwaymeasures（includingsurgicalairway）, andmethodsofprovidingsupplementalventilation. BecauSeaIIoftheseactionscaⅡ『equi『esomeneckmo· tioh’itisimpo『tanttomaintaiⅡce『vicaIspine（c﹣spine） p『otectioⅡinalIpatients）especiaⅡypatientswhoa『e l《nowntohaveahunstabIe。spiheiniu『yandthosewho havebeenihcompletelyevaluatedanda『eat『isl《·The spinalcordmustbeprotecteduntⅡthepossibilityofa spinalinjuryhasbeenexcludedbyclimcalassessment andappropriateradiographicstudies High﹣flowo河genisrequiredbothbefbreand immediatelyaftera1rwaymanagementmeasures areinstituted.Arigidsuctiondeviceisessentialand shouldbereadilyavailable.Patientswithfacialinju﹣ riescanhaveass0ciatedcribrifbrmplatefTactures’and theinsertionofanytubethroughthenosecanresult inpassageintothecranialvault· Patientswhoarewearingahelmetandrequire airwaymanagementneedtheirheadandneckheldin aneutralpositionwhilethehelmetisremoved.Thisis

AIRWAYMANAGEMENT35

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■FlGUREZ﹣ZHelmetRemovaI.Removingahelmetp『ope「lyisatwo﹣pe「sonp「ocedu「e.WhiIe 0nepe『5onp「ovide5manua∣’inIinestabiIizationoftheheadandneck（A）’thesecondpe「son expand5theheImetIate「aIly·The5econdpe『s0nthen『emovestheheImet（B）’withattention paidtotheheImetcIea「ingtheno5eandocciput·Once「emoved!thefi「stpe『son5uppo「tsthe weight0fthepatient’shead（C）’andthe5ec0ndpe「sontake50ve「inIine5tabiIization（D）.

atwo-personprocedure:Onepersonprovidesmanual inlinestabihzationfTombelow）whilethesecondper﹣ sonexpandsthehelmetlaterallyandremovesitfipom above（■F!GuRE2﹣2）.Then》inlinestabilizationisrees﹣ tablishedfromabove,andthepatient》sheadandneck aresecuredduringa1rwaymanagement·Removalof thehelmetusingacastcutterwhilestabilizingthe headandneckcanminimizec﹣spinemotioninpatients withknownc﹣spinein】ury.

PREDlCTlⅡGDl『『ICULTAlRWAγS

叨 HmMbp I 7℃伽c態αpo﹩e劂鯨甽 ●d圻:c叨Jfαtγ叨叼β Itisimportanttoassessthepatient,sairwaypriorto attemptingmtubationinordertopredictthelikelydif ficulWofthemaneuver.Factorsthatmaypredictdif

ficultieswithairwaymaneuversincludec﹣spineinjmy’ severearthritisofthec﹣spine,significantmaxillofacial ormandibulartrauma,limitedmouthopening,obesity’ andanatomicalvariations（e.g.’recedingchin,overbite） andashort’muscularneck）.Insuchcases’skilledclini﹣ ciansshouldassistintheeventofdifficul叮. ThemnemonicLEMONishelph1lasaprompt whenassessingthepotentialfbradifficultintubation （Box2﹣1）.Severalcomp0nentsofLEMONareparticu﹣ larlyusefhlintrauma.Lookfbrevidenceofadifficult a1rway（smallmouthorjaw,largeoverbite,or炮cial trauma）.Anyobviousairwayobstructionpresentsan immediatechallenge。AⅡblunttraumapatientsneces﹣ sitatec﹣spineimmobiⅡzation’whichincreasesthedi慍 ficultyofestablishingana1rway.Clinicaljudgment andexperiencewiⅡdeterminewhethertoproceed immediate】ywithdrug-assistedintubationortoexer﹣ c1secaution.

36CHAPTERZ■Ai『wayandVentilato『yManagement ■

Box2﹦1【EMONAssessⅢentfo『Di冊icult∣ntubation O A 冊 L﹦LookExte『nalIy:【00k↑0『〔ha『ade『i5ticstI】ata「ekⅡ0wn t0causedi什icultintubati0n0『ventiIati0n

E﹦EvaIuatethe3﹦3﹣ZRuIe;T0al∣ow↑0「aIignment0↑the pha「yngeaI!∣a『yngeaa il nd0『aIaxesandthe『e↑0『esm i p∣en i tuba﹣ ti0nlthe↑0∣I0wing『elati0nshipssh0u∣dbe0bse『ved ■「hedistan〔ebetweenthepatientl5ind50『teeth5h0uldbe atIeaSt3↑n i ge「b『eadth5（3） ■Thedistan〔ebetweenthehy0idb0neandthechin5h0uldbe at∣ea5B｛n i ge『b『eadth5（3） ■Thedi5tan〔ebetweenthethy『0idn0tchand｛l00『0｛the m0uth5h0uldbeatlea5t2finge『b「eadth5（Z） M﹦MaIIampati:Thehyp0pha『ynx5h0uldbevi5ualized adequateIy.Thishasbeend0net『aditi0nalIybyasse5singthe Ⅲa∣IampaticIas5i↑i〔ati0n.Whenp0s5ib∣e!thepatientisa5ked t0situp『ight’openthem0uth↑u∣Iyiandp『0t『udethet0Ⅱgueas ↑a『asp0ssib∣eTheexamiⅡe『then∣00ksintothem0Ⅱthwitha

∣ightt0『cht0a5se5sthedeg「ee0↑hyp0pha『ynxvisib∣e·∣n5upine patient5!theⅢaIIampatisc0『ecanbee5timatedbyaskingthe patientt00penthem0uth↑u∣∣yandp『0t『udethet0ngue】aIa『yn﹣ g05c0py∣ighti5thenshoneintotI】ehyp0pha『ynx↑『0mab0ve· O﹦Obst『uction:Anyconditi0nthatcan〔ause0bst『udi0n 0↑theai『waywiIImakeIa『yng05c0pyandventiIati0ndiⅡicuIt. Such〔0nditi0n5in〔ludeepigI0ttiti5!pe「it0n5iIIa『ab5ce55land t『auma

N﹦NeckMobiIity:ThisIsavital『equi『ement↑0『suc（e5s﹣ ｛u∣Intubati0n.∣t〔anbea55e55edeasiIybya5kingthepatient t0p∣acehis0『he『〔hin0Ⅱt0the〔he5tandthenextendingthe ne〔k50thathe0『sheisI00kingt0wa「dthecei∣ing.Patientsin ha『dcoⅡa『neckimmobiIizationobviousIyhavenonecI《 m0vementanda『ethe『efo『emo『edi什icuIttointl』bate. M0di↑iedwi【hpe『mi55i0n↑『0m:M』ReedIM』GDunnandDWMc氏e0wn‘ Cananai『wayas5e5s『nentsc0『ep『edictdi↑↑icuItyatintubati0nintIle eme『0encydepa「tment?Em叩Ⅲedj2005l22l99﹣I0Z

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The3﹣3﹣ZRule.TbaIlowf0「aIignmentof thepha『yngeaI『la「yngeaI’ando『alaxe5’and the『ef0『esimpIeintubation’thefoIIowing 「eIationshipssh0u∣dbeobse『ved:Thedistance betweenthepatient!sinciso『teethshouIdbeat least3finge『b「eadths（A）｝Thedistancebetween thehyoidboneandthechin5hou∣dbeatIeast3 finge「b『eadths（B）;andthedi5tancebetweenthe thy『oidnotchandfloo「ofthemouthshouIdbe atIeastZfinge「b『eadths（C）.

︼

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AIRWAYMANAGEMENT37 ■■

I

Box2曰1（Co〃加ued）

C∣assI:softpa【ate,uvu∣a） fauces,pi【∣a「svisib∣e

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C∣assⅢ:softpa【ate》 baseofuvu【avisib∣e

αasslV:ha「dpa【ate on【yvi5ib!e

MaIIampatiCIassifications·ThesecIassification5a『eusedtovisua∣izethehypopha『ynx. CIassI:5oftpaIate!uvuIa!fauce5『piIIa「svisibIe;CIassⅡ:softpaIate’uvuIa〃faucesvi5ible｝ αassⅢ:softpalate’ba5e0fuvuIavisibIe;CIasslV:ha「dpaIateonlyvi5ibIe·

﹃

AIRWAγDEαS∣0NSCⅡEME

AlRWAγMAIⅢEⅡAⅡCETECⅡⅡI0UES

■FlGuRE2﹣3providesaschemefbrdecidingtheappro﹣

Inpatientswhohaveadecreasedlevelofconsciousness, thetonguecanfhllbackwardandobstructthehyp0pharynx.ThisfbrmofobstructioncanbecorrectedreadⅡyby thechin﹣liftorjaw.thrustmaneuvers·Theairwaycan thenbemaintainedwithanoropha】yngealornasopha﹣ 】yngealairway.Maneuve『susedtoestablishanai『way canp『oduceo『agg『avatec﹦spiheiniu『y,soMiheimmobi﹦ Iizationo「thec.spineisessentiaIdu『ingthesep『ocedu『es·

priaterouteofairwaymanagement.Thisalgorithm appliesonlyt0patientswhoareinacuterespiratory distressorwhohaveapnea’areinneedofanimmediateairway’andinwhomac﹣spineinjmyissuspected becauseofthemechamsmofinjuryorsuggestedby thephysicalP玄月h1ination.Thefirstpriorityistoen﹣ surecontinuedoxygenationwithmaintenanceofc﹣ spineimmobilization.Thisisaccomplishedimtially byposition（i.e.’chin﹣liftorjaw﹣thrustmaneuver）and theprehmina1ya1rwaytechniques（i·e‘,oropharyngeal airwayornasopharyngealairway）.Anendotracheal tubeisthenpassedwhileasecondpersonprovides inlineimmobilization.Ifanendotrachealtubecann0t beinsertedandthepatient）srespiratorystatusisin jeopardy,ventilationviaala】yngealmaskairwayor otherextraglotticairwaydevicemaybeattemptedasa bridgetoadefinitivea1rway.Ifthisfhils,acricothyroi﹣ dotomyshouldbeperfbrmed.Allofthesemethodsare describedbelow. OXygenationandventilationmustbemaintained befbre’during,andimmediatelyuponcompletionof insertionofthedefinitivea1rway.Prolongedperiods ofinadequateorabsentventilationandoxygenation shouldbeav0ided·

Chin﹣LiftManeuve『 Inthechin﹣liftmaneuver,thefingersofonehandare placedunderthemandible》whichisthengentlylifted upwardtobringthechinanteri0r.Thethumbofthe samehandlightlydepressesthelowerliptoopenthe mouth（■FIGuRE2﹣4）.Thethumbalsomaybeplacedbe﹣ hindthelowerincisorsand’simultaneously’thechinis gentlylifted.Thechin﹣liftmaneuversh0uldnothyper﹣ extendtheneck·Thismaneuverisuseh1lfbrtraⅢma victimsbecauseitcanpreventconvertingacervical fracturewithoutcordinjuryintoonewithcordmjury.

jaw﹣Th『uStManeuve『 Thejaw﹣thrustmaneuverisperfbrmedbygrasping theangles0fthelowerjaw’onehandoneachside,and

38CHAPTERZ■Ai「wayandVentiIato『yManagement

Bep『epa『ed Equipment: Suction’Oz’o「opha「yngea【andnasopha『yngea【aiIways’ bag.masI《,【a『yngosc0pe’gume【asticbougie（GEB）’ ext「a﹣g【otticdevices’su「gica【o「need【ec「icothy「oidotomy kit’endot「achea【tube’pu【seoximet「﹪COZdetection device’d「ugs P「otectC﹣Spine! 」

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De v ntife i a「 i way∣Su『gc ia【a「 i way ∣ l ﹀

■『IGURE2﹣3Ai『wayDeci5ioⅡSchemeUsedfo「decidingtheapp「op「iate『outeofai『way management·／Vo扭『TheA兀SA〃wayDe亡店／onScbemep／bv／desagene眉／app「oachtoa／）way management／n妯uma·Manycente店havedeve／opeddeta／／eda〃w日ymanagementa／go〃thms ／tk／mpo／Tantto「eⅥewand／eamthestand白「dusedbyteam5／nyou「t佃umaS｝x5tem·

displacingthemandiblefbrward（■『IGuREZ﹣5）.When thismethodisusedwiththefacemaskofabagmask device,agoodsealandadeqUateventilationcanbe achieved.Caremustbetakentopreventneckextension.

O『opha『yngea∣Ai『way Oralairwaysareinsertedintothemouthbehindthe tongue.Theprefbrredtechmqueistouseatongue bladetodepressthetongueandtheninserttheair﹣

wayposteriorly,takingcarenottopushthetongue backward,whichwouldblock＿ratherthanclear－the a1rway.Thisdevicemustnotbeusedinc0nsciouspa﹣ tientsbecauseitcaninducegagging’vomiting’and aspiration.Patientswhotolerateanoropharyngeal a1rwayarehigh】ylikelytorequireintUbation. Analternativetechniqueistoinserttheoralair﹣ wayupsidedown’soitsconcavityisdirectedupward’ untilthesoftpalateisencountered.Atthispoint’

AIRWAYMANAGEMENT39

■F!GUREZ﹣4TheChin﹣LiftManeuve『toEstabIishan Ai『waybThi5maneuve『isu5efuIfo『t『aumavictims becau5eitcanp「eventconve「tingaceⅣicaIf「actu「e withoutco『din】u『yint0onewithco「din】uly·

二 ■

一

■

＼ ■FIGURE2﹣5The」aw﹣Th『uStManeuve『toEstab!ishan Ai『waybCa「emustbetakentop「eventneckextension.

■FlGUREZ﹣6A∣te『nativeTechniquefo『lnse『tingO『aI Ai『waybInthistechnique’theo『alai『wayi5inse『﹣ted upsidedown（A）untiIthesoftpaIateisencounte『ed’ atwhichp0intthedeviceiS「otated180deg『eesand 5lippedint0pIace0ve「thetongue（B）.Thismeth0d shouIdnotbeusedinchiId「en.

withthedevicerotated180degrees,theconcavityis directedinfbriorly,andthedeviceisslippedintoplace overthetongue（■「IGuRE2﹦6）.Thisalternativemethod shouldnotbeusedinchildren’becausetherotationof thedevicecandamagethemouthandpha1ynx.See SkillStationII:AirwayandVentilatoryManagement’ SkillII﹣A:Oropha1yngealAirway Insertion.

bewelllUbricatedandinsertedintothenostrilthatap﹣

Nasopha『yngeaIAi『way

Ext『ag∣otticahdSup『agIotticDevices

Nasopha】3mgealairwaysareinsertedinonenostrⅡand

Thefbll0wingextraglottic,orsupraglottic,deviceshave ar0leinmanagingpatientsWhorequireanadvanced

passedgentlyintotheposteriororopharynx.Th可should

pearstobeunobstructed.Ifobstructionisencountered duringintroductionoftheairway,stopandtrytheother nostrⅡ.Thisp『ocedu『eshouIdⅡotbeattemptedinpatiehts withsuspectedo『poteⅡtiaIc『ib『i化『mpIate什actu『e·See SkiⅡStationII:AirwayandVentilato1yManagement’ SkiⅡII﹣B:Nasopha1yngealAirwayInsertion.

40CHAPTERZ■Ai『wayandVentiIato『yManagement

▲

■ 」↘k

P

MuItilumenEsophageaIAi『wayMultilumenes﹣ ophagealairwaydevicesareusedbys0meprehospi﹣ talpersonneltoachieveanairwaywhenadefinitive a1rwayisnotfbasible（■FIGuRE之﹣9）.Oneoftheports communicateswiththeesophagusandtheotherwith thea1rway·Thepersonnelwhousethisdeviceare trainedtoobservewhichportoccludesthees0phagus andwhichprovidesairtothetrachea.Theesophageal portisthenoccludedwithaballoon’andtheotherport isventⅡated.ACO2detectorimprovestheaccuraCyof thisapparatus.Themultilumenesophagealairwayde﹣ vicemustberemovedand／oradefimtiveairwayprovidedafterappropriateassessment.

AIRWAγ5

■F』GUREZ﹣7ExampleofaIa『yngeaIma5kai『way

a1rwaya叮unct,butinwhomintubationhasfailed0r isunlikelytosucceed:laryngealmaskairway》multi﹣ lumenesophagealairway’andla】yngealtubeairway· Othersupraglotticdevicesusedintraumapatientare currentlybeinginvestigated· La『yngeaIMaskAi『wayandlntubatingLMAThere isanestablishedrolefbrthelaryngealmaskairway （LMA）andtheintubatinglaryngealmaskairway （ILMA）’mthetreatmentofpatientswithdifIicultair﹣ ways,particularlyifattemptsatendotrachealintuba﹣ tionorbagmaskventilationhavefhiled（■FlGuREz﹣7）. TheLMAdoesnotprovideadefinitiveairway,and properplacementofthisdeviceisdifIicultwithoutap﹣ propriatetraining.TheILMAisanevolutionofthede﹣ vicethatallowsfbrintubationthrou帥theLMA·When apatienthasanLMAoranILMAinplaceonarrivalin theemergencydepartment（ED）,cliniciansmustplan fbradefimtiveairway.SeeSkillStationII:Airwayand

Adefinitiveairwayrequiresatubeplacedinthetra﹣ cheawiththecuffinflatedbelowthevocalcords’the tubeconnectedtosomefbrmofoxygen﹣enrichedas﹣ sistedventⅡation,andthealrwaysecuredinplace withtape‘Therearethreetypesofdefinitiveairways: 0rotrachealtubes’nasotrachealtubes’andsurgical airways（cricothyroidotomyortracheostomy）.Thecri﹣ teriafbrestablishingadefinitiveairwayarebasedon clinicalfindingsandinclude（seeTable2.1）: ■Airwayproblems＿Inabilitytomaintaina patentairwaybyothermeans,withimpending orpotentialcompromiseoftheairway（e.g.’ fbllowinginhalationinjury’fhcialfTactures,or retropharyngealhemat0ma）

VentilatoryManagement’ S k i l l I I ﹣ E : L a r y n g e a l M a s k

Airway（LMA）andIntubatingLMA（ILMA）Insertion La『yngeaITubeAi『wayThelaryngealtubeairway （LTA）isanextraglotticairwaydevicewithcapabih﹦ tiessimilartothoseoftheLMAinprovidingsuccess﹣ h1lpatientventilation（■FlGuREz﹣8）.TheLTA1snota definitiveairwaydevice’andplanstopr0videadefimtiveairwayarenecessary.AswiththeIMA,theLTA isplacedwithoutdirectvisualizationoftheglottisand doesnotrequiresignificantmanipulationofthehead andneckibrplacement.SeeSkillStati0nII:Airway andVentⅡato】yManagement’SkillII﹣F;Laryngeal TubeAirway（LTA）Insertion.

■FlGURE2﹣8Exampleofala『yngeaItubeai『way

AIRWAYMANAGEMENT41

■T八BLEZ·1 !ndiC日tioⅡSfo『De伽itⅣeAi『Way ⅡEEDF0RA【RWAγ pR0TECTlOⅡ

ⅡEED『0RVEⅡTlLA『I0Ⅱ 0R0XγGEⅡATI0Ⅱ

Seve「emaxIl∣ofada∣f『actu『es

Inadequate『e5pi『ato『ye什o「t5 。Tachypnea ●Hyp0xia ·Hype「ca「ba i ●Cyanosis

Ri5kfo「obst『ucti0n ·Neckhematoma ·La「yngea∣0「t「achea∣ n I〕u「y oSt『ido「

MassivebloodlosSandneedfo『 volume「esu5citation

Ri5kfo「a5pi「ati0n ·Bleeding oVOmiting

Seve「e叵IosedheadInlu『ywith needf0「b「iefhypeⅣentiIation i↑acuteneu『0I0gicdete『io「ation

∣

0cCu『S

unc0nsci0us

Apnea oNeU『OmUSCUIa「Pa「alySiS ●Unconsdous

Endot『aCheaI∣ntubation

■FIGUREZ﹣8ExampIeofamultiIumenes0phageaI ai『way.

■Breathmgproblems－Inabililytomaintain adeqUateo汀genationbyfhce﹣maskoxygen supplementation,andpresenceofapnea ■Disabilityproblems＿Presenceofaclosedhead injuryreqUiringassistedventⅡation（Glasgow ComaScale〔GCS】scoreof8orless）’needto protectthelowera1rwayfromaspirationof blo0d0rvomitus’orsustainedseizureactivity TheurgenCyofthesituationandthecircum﹣ stancesindicatingtheneedfbrairwayintervention dictatethespecificrouteandmethodtobeused.ContinuedassistedventⅡation1saidedbysupplemental sedation’analgesics’ormusclerelaxants’asindicated· Assessmentofthepatient,schnicalstatusandtheuse ofapulseoximetercanbehelpfhlindeterminingthe needfbradefinitivea1rway’theurgen叮oftheneed’ and,byinfbrence’theeffbctivenessofairwayplace﹣ ment.Thepotentialfbrconcomitantc﹣spineimuryis ofm匈orconcerninthepatientrequiringana1rway.

Althoughitisimportanttoestablishthepresenceor absenceofac﹣spineiracture,obtainingradiological studies（CTscanorc﹣spinex﹃rays）shouldnotimpede ordelayplacementofadelinitivea1rwaywhenoneis clearlyindicated.patientswIthCCSsco『eso「8o『IeSs 『equi『ep『omptintubatioh·I「the『eisnoimmediateheed ↑b『intubation｝『adioIogicalcIea『anceo「thec﹣spinemay beobtained.However’anormallateralc﹣spinefilm doesnotexcludethepossibilityofac﹣spineinjury. Themostimportantdeterminantsofwhetherto proceedwithorotrachealornas0trachealintubati0n aretheexperienceoftheclimcianandthepresenceofa spontaneouslybreathingpatient.BothteChniquesare safbandeffbctivewhenperlbrmedproperly,although theorotrachealrouteismorecommonlyusedandhas fbwerintensivecareumt（ICU）﹣relatedcomplications （e.g.’sinusitisandpressurenecrosis）.I「thepatienthas apⅡea,o『ot『acheaIintubationisihdicated· BlindnasotrachealintubationreqUiresapatient whoisspontaneouslybreathingandiscontraindi﹣ catedinpatientswithapnea·Thedeeperthepatient breathes,theeasieritlstofbⅡowtheairflowthrough thelarynx.Facial,frontalsinus’basilarskuⅡ’andcrib﹣ rifbrmplatefracturesarerelativecontraindicationsto nas0trachealintubation.EvidenceofnasalfTacture’ raccooneyes（bilateralecChymosisintheperiorbital region）’Battle,ssign（postauricularecchymosis）’and possiblecerebrospinalfluid（CSF）leaks（rhin0rrheaor oto1Thea）areallsignsofthesemjuries.Precautions regardingc﹃spineimmobⅡizationshouldbefbⅡowed’ aswithorotrachealintubation.

4ZCHAPTERZ■Ai『wayandVentiIato『yManagement Ifthedecisiontoperfbrmorotrachealintubation ismade’thetwo﹣persontechniquewithmanualinline stabihzationisnecessa1y（■F!GuREz﹦10）· Laryngealmanipulationbybackward,upward, andrightwardpressure（BURP）onthethyroidcarti﹣ lagecanaidinvisualizingthevocalcords·Additional handsarereqUiredfbrdrugadministrationandthe BURPmaneuver. A1ternativeintUbationdeviceshavebeendeveloped overtheyearswiththeintegrationofvideoandoptic imagingtechniques.Theiruseintraumapatientsmay bebenehcialmspecificcasesbyexperiencedproviders· CarefUlassessmentofthesituation,equipment’andper﹣ sonnelavailableismandatory’andrescueplansmustbe available.SeeSkiⅡStationⅡ:Ai1wayandVentⅡatoⅣ Management’SkiⅡII﹣D:AdultOrotrachealIntubati0n

（withandwithoutGumElasticBougieDevice,andSkill

▽ -

■F∣GURE2﹣11E5chmannTTacheaITUbe!nt『oduce『 （ETTI）·Thi5isaIsokn0wnasthegumeIasticbougie

-

II﹣G:InfhntEndotrachealIntubation.

AnexcellenttoolWhen色cedwithadifHcultair﹣ wayistheEschmannTrachealTubeIntroducer （ETTI）’alsokn0wnasthegumelasticbougie（GEB） （■F∣GuRE2﹣11）.TheGEBisusedwhenvocalc0rds cannotbevisualizedondirectla1yngoscopy.With thelaryngoscopeinplace,theGEBispassedblindly beyondtheepiglottis,withtheangledtippositioned anteriorly（■F!GuRE2﹦1zand■FIGuREⅡ﹣13）.Tracheal positionisconfirmedbyfbelingclicksasthedistaltip rubsalongthecartilaginoustrachealrings（presentin 65℅＝90℅ofGEBplacements〔■FIGuRE2﹦14】）’when thetuberotatestotherightorleftwhenenteringthe bronchus,orwhenthetubeisheldupatthebronchial tree（10℅＝13﹪）’WhichisusuaⅡyatab0utthe50﹣cm mark·NoneoftheseindicationsoccuriftheGF｝Bhas enteredtheesophagus. ﹦

A D ■ ﹦

▼ ∞

I

∣ ﹣ ＝

尸

「 ■ 顯 ﹂

■FlGUREZ﹣10O『0t「achealintubationu5ingtwo﹣pe「son techniquewithinlineceⅣicaI5pineimmobiIization.

G＞HmO‘JO肋 I o卹痂e劬etS加 ●炕eγ唔觔pJαce2 Followingdirectlaryngoscopyandinsertionofthe orotrachealtube’thecuffisinfl㎡ed,andassistedven﹣ tilationisinstituted.Properplacementofthetube issuggested一butnotconfirmed＿byhearingequal breathsoundsbilaterallyanddetectingnoborborygmi （i·e。,rumblingorgurglingnoises）intheepigastrium· Thepresenceofborbo叮gmiintheepigastriumwith inspirationsuggestsesophagealintubationandwar﹣ rantsrep0sitioningofthetube.Acarbondioxidedetec﹣ tor（ideallyacapnograph,but,ifthatisnotavailable, acolorimetricCO◎momtoringdevice）isindicatedt0 helpconfirmproperintubationoftheairway.The presenceofCOoinexhaledairindicatesthattheair﹣ wayhasbeensuccessh1llyintubated’butdoesnot ensurethecorrectpositionoftheendotrachealtube IfCO2isnotdetected’esophagealmtubationhasoc﹣ curred.Properpositionofthetubeisbestconfirmed bychestx﹣ray’oncethepossibiⅡtyofesophagealintu﹣ bationisexcluded·ColorimetricCO,indicatorsarenot usefhlfbrphysiol0gicmonitoringorassessingthead﹣ equacyofventilation,whichrequiresarterialbloodgas analysisorcontinualend﹣tidalcarbondioxideanalysis. SeeSkillStationII:AirwayandVentilat0ryManage﹣ ment’SkillII﹣H PulseOximetryMonitoring, a n d S k i l l II﹣I:CarbonDioxideDetection. Whentheproperpositionofthetubeisdeter﹣ mined,itissecuredinplace.Ifthepatientlsmoved’ tubeplacementisreassessedbyauscultationofboth laterallungfieldsfbrequali叮ofbreathsoundsandby reassessmentfbre】d1aledCO,· Iforotrachealintubationisunsuccessh1lonthe firstattemptorifthecordsaredifficulttovisualize,a

gumelasticbougieshouldbeused,andfhrtherprepa﹣ rationsfbrdifficultairwaysh0uldbeundertaken·

AIRWAYMANAGEMENT

43

八

B ■『IGUREZ﹣1ZCe『vicaIspineimmobiIizationneedsto happenbutha5beeneIiminated↑『omtheimagef0『 Ca I 「tiy·

C

B

k

, ,

■FlGUREZ﹣14Inse『tionoftheGEBdesignedtoaid indifficuItintubations.（A）TheGEBisIub『icatedand di『ectedposte「i0「totheepigIo㎡iswiththetip己ngIed ante「io「Iy.（B）ItsIidesunde『theepigIotti5andis maneuve『edinasemibIindo『bIindfashionante『io「Iy intothet『achea·（C）PlacementoftheGEBintothe t「acheamaybedetectedbythepalpable〃cIicks〃asthe tippas5es0ve『theCa「tiIagin0us「ingsofthet「achea.

■『IGUREZ﹣13!ntubationth『oughan“intubating La『yngeaIMask.〃OncetheIa『yngealmaskisint『oduced〃 adedicatedendot『acheaItubeisinse「tedint0it’ allowingthe「efo「ea〃bIind〃intubati0ntechnique·

44CHAPTERZ■Ai『wayandVentiIat0『yManagement GumEIasticBougie Oncethepositionisconfirmed’theproximalendis lubricated,anda6.0﹣cminternaldiameterorlarger endotrachealtubeispassedovertheGEBbeyond thevoca1cords.Iftheendotrachealtubeisheldupat thea1ytenoidsoraryepiglotticfblds’thetubeiswith﹣ drawnshghtlyandturned90degreestofacilitatead﹣ vancementbey0ndtheobstruction.TheGEBisthen removed’andtubepositionisconfirmedwiththeaus﹣ cultationofbreathsoundsandcapnography‘ UseoftheGEBhasall0wedfbrtherapidintuba﹣ tionofnearly80percentofprehospitalpatientsin whomdirectlaryngoscopyisdifIicult.

RapidSequenceIhtubation Theuseofanesthetic’sedative,andneuromuscular blockingdrugsfbrendotrachealintubationintrauma patients,lspotentiaⅡydangerous.Incertaincases’the needfbranairwayjustifiestheriskofadministering thesedrugs,butitisimportanttounderstandtheir pharmacology’beskilledinthetechniqUesofendotra﹣ chealintubation,andbeabletosecureasurgicalair﹣ wayifnecessa1y.Inmanycasesinwhichana1rwayis acutelyneededdurmgtheprimarysurv叮’theuseof paralyzingorsedatingdrugsisnotnecessa】y. Thetechniquefbrrapidsequencemtubation（RSI） isas允llows: 『 Haveaplanintheeventoffhilurethatmcludesthe

p0ssibilityofperfbrmingasurgicalairway.Know whereyourrescuea1rwayequipmentislocated. 2 EnsurethatsuctionandtheabiliWtodehver

positivepressureventⅡationareready. a

Preoxygenatethepatientwith100﹪oxygen.

4

App】ypressureoverthecricoidcartⅡage.

a

Administeraninductiondrug（e.g.’etomidate,0.3 mg／kg）orsedate,accordingtolocalpractice.

caretoavoidlossoftheairwayasthepatientbecomes sedated.Then,succinylcholine,whichisashort﹣acting drug’isadministered.Ithasarapidonsetofparalysis （＜1minute）andadurationof5minutesorless. Themostdangerouscomplicationofusmgseda﹣ tionandneuromuscularblockingagentsistheinabilitytoestabhshanairway·Ifendotrachealintubation isunsuccessfbl,thepatientmustbeventilatedwith abag﹄maskdeviceuntiltheparalysisresolves;long﹣ actingdrugsarenotroutinelyusedfbrRSIfbrthis reason.Because0fthepotentialfbrseverehyperkale﹣ mia’succinylcholinemustbeusedcarefhllyinpatients withseverecrushinjuries,m匈orburns,andelectri﹣ calinjuries.Particularattentionmustbepaidincases ofpreexistmgchronicrenalfhilure’chronicparalysis, andchronicneuromusculardisease. Inductionagents’suchasthiopentalandseda﹣ tives,arepotentiaⅡydangerousintraumapatients withhypovolemia.Smalldosesofdiazepamormida﹣ zolamareappropriatetoreduceanxietyinparalyzed patients·Flumazenilmustbeavailabletoreverse thesedativeeffbctsafterbenzodiazepineshavebeen 月別mihisteredPracticepatterns’drugprefbrences’ andspecificproceduresfbrairwaymanagementvary amonginstitutions.Thecriticalprmcipleisthatthe individualusmgthesetechmquesneedstobeskilledin theiruse,lmowledgeableoftheinherentpitfhllsasso﹣ ciatedwithrapidseqUenceintubation,andcapableof managmgthepotentialcomplications.

∣▼ P I T F A I J 』 s Equipmentfailu『ecanoccu「atthemostinoppo「tune timesandcannotaIwaysbeanticipated.Fo「exampIe’ theIightontheIa『yngoscopebu『nsout’theIaIyngo﹣ scopebatte『iesa『eweak’theendot『acheaItubecu什 leaks’o『thepulseoximete『doesn0tfunctionp『op﹣ e『Iy.Havespa「esavaiIable·

6. Administer1to2mg／kgsuccinylchoⅡneintrave﹣

nously（usualdoseis100mg）. ’ 7 Afterthepatientrelaxes’intubatethepatient

orotracheally· · 8 Inflatethecuffandconfirmtubeplacementby

auscultatingthepatient’schestanddetermining thepresenceofCO2inexhaledair. 9 1

0

■

■

Releasecricoidpressure‘ Ventilatethepatient.

Thedrugetomidate（Amidate）doesnothaveasig﹣ nificantefIbctonbloodpressureorintracramalpres﹣ sure,butitcandepressadrenal拉nctionandisnot umversallyavailable.Thisdrugdoesprovideadequate sedation,whichisadvantageousinthesepatients.Eto﹣ midateandothersedativesmustbeusedwithgreat

Su『gicaIAi『way Theinabilitytointubatethetracheaisaclearindica﹣ tionfbranalternateairwayplan,includinglaryngeal maskairway’intubatingla1,yngealmaskairway,ora surgicalairway.Asurgicalairway（i.e.’cricothyroi﹣ dotomyortracheostomy）isestabhshedwhenedemaof theglottis,fTactureofthelarynx,orsevereoropharyn﹣ gealhemorrhageobstructstheairwayoranendotra﹣ chealtubecannotbeplacedthroughthevocalcords‘ Asurgicalcricothyroidotomyisprefbrabletoatrache﹣ ostomyfbrmostpatientswhorequ1reestablishment ofanemergenCysurgicalairway,becauseitiseasier toperfbrm’associatedwithlessbleeding’andrequires lesstimetoperfbrmthananemergenCytracheostomy.

MANAGEMENTOFOXYGENATI0N45

NeedIeC『icothy『oidotomyNeedlecricothyroid0to﹣ myinv0lvesinsertionofaneedlethroughthecricothy﹣ roidmembraneorintothetracheainanemergency situationtoprovideoxygenonashort﹣termbasisuntⅡ adefinitivea1rwaycanbeplaced·Needlecricothyroi﹣ dotomycanprovidetemp0rary’supplementaloxy﹣ genationsothatintubationcanbeaccomplishedonan urgentratherthananemergentbasis. Thejetinsufflationtechniqueisperfbrmedby placingalarge﹣caliberplasticcannula’12﹣to14﹣gauge fbradults,and16-to18﹣gaugeinchildren,through thecricothyroidmembraneintothetracheabelowthe leveloftheobstruction（■FIGuREZ﹣15）.Thecannulais thenconnectedtooxygenat15L／min（40to50psi） withaY﹣connectororasideholecutinthetubing betweentheoxygensourceandtheplasticcannula. Intermittentinsufflation’1secondonand4seconds o鎚canthenbeachievedbyplacingthethumboverthe openendoftheY﹄connect0rorthesidehole. ThepatientcanbeadequatelyoXygenatedfbr30 to45minutesusingthistechnique’andonlypatients withnormalpulmonaryfhnctionWhodonothavea significantchestinju叮maybeoxygenatedinthis

■

﹠ ﹄

■■

k﹁

■「lGUREZ﹣15NeedIeC『icothy『oidotomybThisp『oce﹣ du「eispe「fo『medbypIadngaIa『ge﹣caIibe『pla5tic cannuIath「oughthec『icothy『oidmemb『aneintothe t「acheabeIowtheleveloftheobst『ucti0n.

manner.Duringthe4secondsthattheo汀genis notbeingdeliveredunderpressure’someexhalation 0ccurs.Becauseoftheinadequateexhalation’CO, slowlyaccumulates’limitingtheuseofthistechnique’ especiallyinpatientswithheadiIUuries.SeeSkill StationIII;Cricothyroidot0my,SkillIII﹣A;Needle Cricothyroidotomy. JetinsufIlationniustbeusedwithcautionwhen completefbreign﹣bodyObstructionoftheglotticarea issuspectedAlthoughhighpressurecanexpelthe impactedmaterialintothehypopha】ynx’Whereitcan beremovedreadny,significantbarotraumacanoccur, includingpulmonaryrupturewithtensionpneumot﹣ horax.Therefbre,particularattentionmustbepaid toeffbctiveairflow’andlowflowrates（5to7L／min） shouldbeusedwhenpersistentglotticobstructionis present·

L ∣ ▲ ▲ PITFA『』『』S TheinabiIitytointubateapatientexpediently’p「ovide atempo「a『yai『waywithasup『agIotticdevice’o『es﹣ tabIishasu「gicaIai「way『esuItsinhypoxiaandpatient dete『io『ation.Remembe『thatpe「fo「minganeedIe c「icothy「oidotomywith】etinsu什Iationcanp『ovide thetimenecessa『ytoestabIishadefinitiveai『way·

Su『gicaIC『iCothy『oidotomySurgicalcricothyr0i﹣ dotomyisperfbrmedbymakingaskinincisionthat extendsthroughthecricothyroidmembrane.Acurved hemostatmaybeinsertedtodilatetheopening’and asmallendotrachealtubeortraCheostomytUbe （prefbrab｝y5to7mmOD）canbemserted.SeeSkill StationIII:Cricothyroidotomy,SkiⅡⅡI-B:Surgical Cric0thyroidotomy. Whenanendotrachealtubeisused’thecervical collarcanbereapplied·Itispossiblefbrtheendotrachealtubetobecomemalpositionedandtherefbre easilyadvancedintoabronchus.Caremustbetaken’ especiallywithchildren’toavoiddamagetothecricoid cartilage,whichlstheonlycircumfbrentialsupportfbr theuppertrachea·Therefbre’surgicalcricothyroidot﹣ omyisnotrecommendedfbrchildrenunder12years ofage SeeChapter 10PediatricTra1】ma. Inrecentyears,percutaneoustracheostomyhas beenreportedasanalternativetoopentracheos﹣ tomy.Thisisnotasafbprocedureintheacutetrauma situation’becausethepatient’sneckmustbehyper﹣ extendedtoproperlypositiontheheadtoperfbrmthe proceduresafbly.Percutane0ustrache0stomyrequires theuseofaheavyguidewireandsharpdilator,ora guidewireandmultipleorsinglelarge﹣boredilators‘ Thisprocedurecanbedangerousandtime-consuming’ dependingonthetypeofequipmentused.

Man agement

mosttraumapatients,pulseoximetryisusefhl,asthe continuousmonit0ringofo唧gensaturationprovides animmediateassessmentoftherapeuticinterventions·

SceⅢa『io■cont／huedγ0ua『eabIet0 inc『ease0xygenati0nsatⅡ「ati0nt09Z℅agaIn usIngbag﹣maskventi∣ati0n.Whid〕advanced a『 i waγted】nq i ueswI∣∣y0uuSe?

∣VIanagemento mentofVentiIatioⅡ ∣﹥V Ia IⅡage mentoW fⅡ a Itio tiⅡ

?鰓勰繆⋯⋯”

﹂

y ∣﹥V Ia I nageme to il↑Oxygenation

叨 Hb”咖 陀 I 涊o叨o‘剛g檀〃α㎡o〃 ●面Sααeq叨αfCβ Oxygenatedinspiredairisbestprovidedviaatight﹣ Ettingo汀genreservoirfacemaskwithaflowrateof atleast11L／min.Othermethods（e.g.’nasalcatheter’ nasa1cannula’andnonrebreathermask）canimprove 1nspiredoxygenconcentration. BecausechangesinoXygenationoccurrapidlyand areimpossibletodetectclimcally’pulseoximetrymust beusedatalltimes.Itisinvaluablewhendi笛culties areanticipatedinintubationorventilation,including duringtransportofcriticallyinjuredpatients·Pulse oximetryisanoninvasivemethodofcontinuously measuringtheoxygensaturation（O,sat）ofarterial blood·Itdoesnotmeasurethepartialpressureof oxygen（PaO2）and’dependingonthepositionofthe o汀hemoglobindissociationcurve’thePaO2canvary widely（seeTable2.2）.However’ameasuredsatura﹣ tionof95℅orgreaterbypulseoximetryisstrongcor﹣ rob0ratmgevidenceofadeqUateperipheralarterial o叮genation（PaO2＞70mmHg’or9.3kPa）. Pulseoximetryrequiresintactperipheralpermsion andcannotdistinguishoxyhemoglobinfromcarboxyhe﹣ moglobmormethemoglobm,whichhmitsitsuseh1lness mpatientswithseverevasoconstrictionandthosewith carbonmonoxidepoisoning.Profbundanemia（hemo﹣ globm＜5創dL）andhypothermia（＜30。C’or＜86。F） decreasethereⅡabili叮ofthetechnique.However,in

Effbctiveventilationcanbeachievedbybagmask techniques.However,one﹣personventilationtech﹣ mquesusingabag﹄maskarelesseffbctivethantwopers0ntechmquesinwhichbothhandscanbeused toensureagoodseal.Bagmaskventilati0nshouldbe perfbrmedbytw0peoplewheneverpossible.SeeSkiⅡ Stati0nII:AirwayandVentilatoryManagement’Skill II﹣C:BagMaskVentilation:Two﹣PersonTechmque. Intubationofpatientswithhypoventilationand／or apneamaynotbesuccessfUlimtiallyandmayreqUire multipleattempts.Thepatientmustbeventilated periodicallyduringprolongedeffbrtstointubateThe climcianshouldpracticetakingadeepbreathandhold﹣ ingitwhenintubationisfirstattempted.Whenthe individualperfbrmingtheintubationmustbreathe’ theattemptedintubationshouldbeabortedandthe patientventilated. Withmtubationofthetracheaaccomplished’assisted ventilationfbllows,usingp0sitive﹦pressurebreathing techniques·Avolume﹣orpressure﹣regulatedresp】ra﹣ torcanbeused,dependingonavailabili叮0ftheequ1p﹣ ment.Thechmcianshouldbealerttothec0mplications 0fchangesinintrathoracicpressure’whichcanconvert asimplepneumothoraxtoatensi0npneumothorax’or evencreateapneumothoraxseconda1ytobarotrauma.

▲▲ P I T F A 『 几 S Gast『icdistentioncanoccu「whenventiIatingthepatientwithabag﹣maskdevice〃whichcan「esuItinthe patientvomitingandaspi「ating·ItaI5ocancausedis﹣ tenti0nofthestomachagain5tthevenacava﹟「esuIting inhypotensionandb『adyca「dia.

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CHAPTERSUMMARY47

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Chapter S un1n1ary 皿Clinicalsituationsinwhichanwaycompromiseishkelytooccurincludemaxil﹣ lofacialtrauma’necktrauma’laryngea1trauma,andairwayobstruction· 回Actualorimpendinga1rwayobstructionshouldbesuspectedinallinjuredpaP tients.Objectivesignsofairwayobstructionincludeagitation’presentationwith obtundation’cyanosis’abnormalsounds’andadisplacedtrachea. 固RecognitionofventilatorycompromiseandensurmgaccuraCyofventⅡationsisof prima1yimportance. 囤Techmquesfbrestablishingandmaintainingapatentairwaymc】udetheChin﹣ hftandjaw﹣thrustmaneuvers,0ropharyngea1andnasopha】yngealairways’laryngealmaskairway’multilumenesophagealairway’andlaryngealtubeairway. TheselectionoforotrachealornasotrachealroutesfbrintUbationisbasedonthe experienceandskiⅡlevelofthecⅡmcian·Asurgicalairwayisindicatedwhenever ana1rwayisneededandmtubationisunsuccessfi1l. 回Withallairwaymaneuvers,thecervicalspinemustbeprotectedbyinⅡne fmmobiIi究ation. 圃TheassessmentofairwaypatencyandadequaCyofventⅡationmustbeper﹣ fbrmedquicklyandaccurately.Pulseo】dmet1yandend﹣tidalCO2measurement areessential ⅢAdefinitivea1rwayrequiresatubeplacedmthetracheawiththecuffinflated belowthevocalcords,thetubeconnectedt0somefbrmofoxygen﹣enrichedas﹣ sistedventilation,andtheairwaysecuredmplacewithtape.Examplesofdefinitiveairwaysincludeendotrachealintubationandsurgica1airways（e.g.’needle cricothyroidotomyandsurgicalcricothyroidotomy）.Adefinitivea1rwayshould beestabhshedifthereisanydoubtabouttheintegrity0fthepatient,sairway.A definitivea1rwayshouldbeplacedear】yafterthepatienthasbeenventⅡatedwith oxygen﹣enrichedair’topreventprolongedperiodsofapnea. 圃Rapidsequenceintubationorotherpharmacologicassistancemaybenecessary inpatientswithactivegagrefIex· 回Tomaintainapatient’soxygenation’o叮genatedinspiredairisbestprovided Ⅵaatight﹣fittingoXygenreservoirfhcemaskwithaflowrateofgreaterthan11 L／min·Othermethods（e·g.）nasalcatheter,nasalcannula’andnonrebreather mask）canimproveinspiredoXygenconcentration. ﹂

48CHAPTER2■Ai『wayandVentiIato『yManagement

■B∣肌o l GⅢⅢ 1.AlexanderR’HodgsonP’LomaxD,BullenC.Acompari﹣ sonofthela1yngealmaskairwayandGuedelairway,bag andfhcemaskfbrmanualventilationfbllowingfbrmal training.A〃αes﹠／les﹩α1993;48（3）:231﹣234. 2.AoiY’InagawaG,HashimotoK’TashimaH,TsuboiS, TakahataT,NakamuraK》GotoT.Airwayscopelaryn﹣ goscopyundermanualinlinestabilizationandcervical collarimmobilization:acrossovermvivocmehuorosco﹣ picstudy.J乃αα／川α2010;Aug27. 3.AprahamianC’ThompsonBM’FingerWA,etal·Emerimentalcervicalspineinjurymodel:evaluationofairway managementandsplintingtechniques.Am】E／〃e／gMbd 1984;13（8）:584﹣587. 4.ArslanZI’YildizT’BaykaraZN’SolakM,TokerK.Tra﹣ chealintubationinpatientswithrigidcoⅡarimmobilisationofthecervicalspine:acomparisonofAirtraqand LMACTrachdevices·A〃αest〃es【α2009Dec;64（12）:1332﹣ 6·Epub2009;Oct22· 5.AsaiT’ShinguK.Thelaryngealtube.BrJAJmes／〃 2005;95（6）:729﹣736. 6·BathoryI,FrascaroloP’KernC,SchoettkerP.Evalua﹣ tionoftheGlideScopefbrtrachealintubationinpatients withcervicalspineimmobilisationbyasemi﹣rigidcoⅡar. A〃αest／jes﹠α2009Dec;64（12）:1337﹣41. 7.BergenJM’SmithDOAreviewofetomidatefbrrapid sequenceintubationintheemergencydepartment.J E加e／gM﹫d1997｝15（2）;221﹣230. 8.BrantiganCO,GrowJBSr.Cricothyroidotomy:elective useinrespiratoryproblemsrequiringtracheotomy.J Ⅷo／.αcCα／、αtouαscSα／g1976;71:72﹣81. 9.CombesX’DumeratM’DhonneurG.Emergen叮gum elasticboug1e.assistedtrachealintUbationmfbur patientswithuppera1rwaydistortion.Cα几eJAJmes仇 2004;51（10）:1022﹣1024. 10.CrosbyET,CooperRM’DouglasMJ’etal.Theunan﹣ ticipateddifficultanwaywithreconⅡnendationsfbr management.Cα几JA｝MJes洫1998;45（8）:757﹣776.

16·FrameSB,SimonJM,KersteinMD’etalPercutane0ustranstrachealcatheterventilation（PTCV）in completeairwayobstructionscaninemodel·e／T『.αα加α 1989;29（6）:774﹣781. 17.FremstadJD’MartinSH.Lethalcomplicationhom insertionofnasogastrictubea仳erseverebasilarskull hacture.J仍u【』mα1978;18:820﹣822 18.GataurePS’VaughanRS’LattoIP.Simulateddiificult intubation:comparisonofthegumelasticb0ug1eandthe stylet.A〃αes／〃es㎡α1996;1:935﹣938. 19.GreenbergRS,BrimacombeJ,BerryA’GouzeV》Pian﹣ tadosiS,DakeEM.Arandomizedcontrolledtrialcompa﹣ ringthecuffbdoropharyngealairwayandthelaryngeal maskairwayinspontaneouslybreathinganesthetized adults.A〃es仇esio／o呂y1998;88（4）:970﹣977. 20.GreinAJ.WeinerGM.Laryngealmaskairwayversus bagmaskventilationorendotrachealintubationfbr neonatalresuscitation.αc／jrα〃eDαmbαseSyStReu 2005;（2）:CD003314. 21.GrmecS,MaⅡyS.Prehospitaldeterminationoftracheal tubeplacementinsevereheadinjmy·Eme咱MedJ 2004;21（4）:518﹣520· 22.GuildnerCV.Resuscitation－openingtheairway:a comparativestudyoftechmquesfbropeninganairway obstructedbythetongue.JAmα〃E〃』e／gP／Ⅳstαα〃s 1976;5:588﹣590. 23.HagbergC,BogomolnyY’GilmoreC,GibsonV,Kait﹣ nerM,KhuranaS.Anevaluationoftheinsertionand hmctionofanewsupraglotticairwaydevice,theKing LT,duringspontaneousventilation‘A〃es〃﹠A〃α唔 2006;102（2）:621﹣625· 24.IsersonKV.Blindnasotrachealintubation.A／z几EJ〃e／g M它d1981,10:468. 25.JabreP,CombesX,LerouxB,AaronE,AugerH,Mar﹣ genetA’DhonneurGUseofthegumelasticboug1e fbrprehospitaldifficultmtubation.A〃JJE／兀e『gM它d 2005;23（4）:552﹣555. 26.JordenRC,MooreEE’MarxJA’etal.Acomparisonof PTVandehdotrachealventilationinanacutetrauma model.J?｝mzmα1985;25（10）:978﹣983.

11DanzlDF,ThomasDMNasotraChealmtUbationmthe emergenCydepartment·α肱Cm.eMed1980;8（11）:667﹣682.

27.KiddJF’DysonA,LattoIP.SuccessiUldifficultintu﹣ bation.Useofthegumelasticbougie·A〃αes／／jesiα 1988;43:437﹣438.

12.DaviesPR,TigheSQ’GreensladeGL,EvansGH.Laryn﹣ gealmaskairwayandtrachealtubeinsertionbyunskil﹣ ledpersonnelLα〃cα1990;336（8721）:977﹣979

28.KressTD’etal.Cricothyroidotomy.A几〃E／〃e｝召M它d 1982;11:197.

18.DograS,Falc0nerR’LattoIP.SuccessfUldifficultintu﹣ bationTrachealtubeplacementoveragum﹣elasticbou﹣ gie.A〃αest／!esiα1990;45（9）:774﹣776. 14·DorgesV’OckerH,WenzelV’SauerC’SchmuckerP. Emergencyairwaymanagementbyn0n﹣anaesthesia houseo｛Hcers＿acomparisonofthreestrategies.Eme｝g MbdJ2001;18（2）:90﹣94. 15.El﹣OrbanyMI,SalemMR’JosephNJ.TheEschmann trachealtubeintroducerisnotgum,elastic,orabou﹣ gie.A｝】est／ies【o／Ogy2004,101（5）;1240;authorreply1242﹣ 1240;authorreply1244.

29.LattoIP,StaceyM’MecklenburghJ,VaughanRS.Sur﹣ veyoftheuseofthegumelasticbougieinclinicalprac﹣ ticeA几αest／』esfα2002;57（4）;379﹣384· 30.LevinsonMM,ScuderiPE,GibsonRL’etal.EmergenCy percutaneousandtranstrachealventilation·JA／几Oo〃 E〃』e『gP／吵stαα〃S1979;8（10）:396﹣400. 31.LevitanR,OchrochEA.Airwaymanagementanddirect laryngoscopy.Areviewandupdate·C／·肋Cα『它α加 2000;16（3）:373﹣88,v. 32.LiuEH,GoyRW,TanBH,AsaiT.Trachealintubation withvideolaryngoscopesinpatientswithcervicalspine

∣ ∣

BIBUOGRAPHY49 immobilization:arandomizedtrialoftheAirwayScope andtheGlideScope.BrcJA几αes『〃2009Sep;103（3）:446﹣51.

43.ReedMJ’DunnMJ,McKeownDW·Cananairwayassess﹣ mentscorepredictdifficultyatintubationintheemer﹣

33.MacintoshRR.Anaidtooralintubation.BMJ1949;1:28.

gen叮department?E加eJgMedJ2005;22（2）:99﹣102’

34.M匈ernickTG,BieniekR,HoustonJB’etal:Cervical spinemovementduringorotrachealintubation·A兄〃 E加e唔M它d1986;15（4）:417-420.

44.ReedMJ,RennieLM,DunnMJ’GrayAJ’Robertson CE,McKeownDW·Isthe“LEMON,,methodaneasily appliedemergenCyairwayassessmenttool?EαrJE加e唔 M它d2004;11（3）;154-157·

35·MortonT,BradyS,Cl旦n叮M.Di伍cultairwayequip﹣ mentinEnglishemergenCydepartments.A〃αest加s〔α 2000;55（5）:485﹣488.

45.RussiC,MillerL.Anout﹣o低hospitalcomparisonofthe KingLTtoendotrachealintubationandtheEsopha﹣

36.NoceraA.AflexiblesolutionfbremergenCyintubation difHculties.AJmE加eJgM它d1996;27（5）:665﹣667.

geal﹣TrachealCombitubemasimulateddiHicultairway patientencounter【inprocesscitation】.AcαdE加e咱Med 2007;14（5Suppl1）:S22.

37.NoguchiT’K0gaK,ShigaY,ShigematsuA·Thegum elasticbougieeasestrachealintubationwhileapplying cricoidpressurecomparedtoastylet.Cα〃JA〃αesf〃 2003;50（7）;712﹣717.

46·SeshulMBSr’SinnDP,GerlockAJJr.TheAndyGump fractureofthemandible:acauseofrespiratoIyobstruc﹣ tionordistress.J7】mα加α1978;18:611﹣612.

38.NolanJP’WilsonME.Anevaluationofthegumelastic bougie.Intubationtimesandincidenceofsorethroat. A）tαes姚2stα1992;47（10）:878﹣881. 39.NolanJP,WilsonME.Orotrachealintubationinpatients withpotentialcervicalspmeinjuries·Anindicationfbr thegumelasticbougie.A〃αesthes!α1993;48（7）:630﹣633. 40.OczenskiW,KrennH,DahabaAA’etalComplicationsfbl﹣ lowingtheuseoftheCombitUbe,trachealtubeandlaryn﹣ gealmaskairway.AJmes炕esiα1999;54（12）:1161﹣1165. 4LPennantJH’PaceNA,G可rajNM·Roleofthelaryn﹣ gealmaskairwayintheimmobilecervicalspine.Jα加 A〃est〃1993;5（3）:226-230. 42.PhelanMP.Useoftheendotrachealbougieintroduceribr diHicultmtubations.AmcJEm2JgMbd2004;22（6）:479﹣482.

47.SilvestriS’RallsGA,KraussB,etal.Theeffbctiveness 0fout﹣o﹩hospitaluseofcontinuousend﹣tidalcarbondio﹣ xidemonitoringontherateofunrecognizedmisplaced mtubationwithinaregionalemergen叮medicalservices system.A〃〃E加e唔Mbd2005;45（5）:497﹣50a 48.SmithCE,DejOySJ.Newequ1pmentandtechniquesfbr airwaymanagementintrauma〔InProcessCitation】. C凹rr印mA〃αest／jes／o／2001;14（2）:197﹣209. 49.WalterJ,DorisPE,ShaffbrMA·Clinicalpresentati0n ofpatientswithacutecervicalspineinjuIy.AJJ冗E加e唔 M它d1984;13（7）:512﹣515. 50.YestonNSNoninvasivemeasurementofbloodgases· I几／b㎡Sα咱1990;90:18﹣24.

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AirwayandVentilatoryManageIⅡent TⅡEF0LL0WINGPR0CEDURESARE INC山DEDIⅡTⅡISSI《lUSTATI0N:

■

Objectives

〉〉Ski∣IⅡ·A:Oropharyngeal AirwayInsertion

∣

pe『fo『manceatthisskillStationwilIaIlowpa『ticipantstoevaIuatease「ies 0fc∣inicaI5ituationsandacqui『ethec0gnitiveski∣Isf0『decis∣0nmakingin

〉卜SkiⅡⅡ·B:Nasopharyngeal AirwayInsertion

aiⅣvayandventiIato『ymanagement.Studentswillp『acticeanddemonst『ate thefoIl0wingskiIIs0naduItandInfantintubationmanikins:

〉〉SkiⅡIl﹣CBag﹄Mask Ventilation:Two﹣Person TechniqUe

ⅢInse『to『opha「yngeaIandnasopha『yngealai「ways. 圓Usingbotho『alandnasaI『outes’intubatethet「acheaofanadu∣t intubationmanikin（withintheguidelineslisted）〃p『ovideeffective venti∣ation’andu5ecapnog『aphytodete『minep『ope『p∣acementof theendot「acheaItube

〉卜SkiⅡⅡ·D:AdultOrotracheal Intubati0n（withandwithout GEBdevice）

）〉SkiⅡⅡ﹣E:La】yngealMask Airway（LMA）andIntUbating 『』MA（ILMA）Insertion

圓Desc『ibeanddemon5t『atemethods↑o『managingdi什iculto『failed a∣『ways’n i dudn i gIa『yngeaIma5ka『 i way（LMA）』n i tubatn i g∣a『yngea∣ maska「 i way（I【MA）!Ia『yngeatlubea「 i way（L『八）’andgume∣astc i bouge i （GEB）.

〉〉Ski!IⅡ﹣F:LaryngealTube Airway（LTA）Insertion

囚lntubatethet「acheaofaninfantIntubationmanikinwithanendo﹣ t『achealtube（withintheguide∣inesIisted）andp『ovideeffective ventilation.

r卜Ski!∣Ⅱ﹣G:Ih估htEndotracheal IntUbation

圓Desc「ibehowt「aumaaffectsaiⅣvaymanagementwhenpe「「o「ming o『alendot『achealintubationandnasot『achealintubation

卜〉SkiⅡⅡ·Ⅱ:PulseOximetHy Monitoring

圃Usingapulseoximete「: ·Statethepu『poseofpuI5eoximet『ymonito『ing ·Demonst「atethep『ope『useofthedevice ·De5c『ibetheindicationsfo『itsuse’itsfunctionalIimitsofaccu「acy! andpo5sib∣e『easonsfo『maIfunctiono『inaccu『acy ·Accu『ateIyinte『p『etthepuIseoximete『monito『『eadingsand 『elatethei『significancetotheca『eoft『aumapatients.

卜﹥S!《ⅡIⅡ.I目CarbonDioxide Detection

ⅢDesc「ibetheindicationsfo『anduseofend﹣tidalCO2detecto「 deviceS. ﹃

50

SKILLSTATlONII■Ai『wayandVentilato『yManagement51

卜sCEⅡARIOS SCENARI0Ⅱ﹦1

ScEⅡARI0II﹣3

A22﹣year﹣oldmaleisanunrestrainedpassengerina motorvehiclethatcoⅡideshead﹣onintoaretaining wall·Hehasastrongodorofalcoholonhisbreath.At thetimeofthecollision’hehitsthewindshieldand sustainsascalplaceration.Attheinjuryscene,heis combative’andhisGCSscoreis11.Hisbloodpres﹣ sureis120／70mmHg’hisheartrateis100beats／min》 andhisrespirationsare20breaths／minAsemirigid cervicalcoⅡarisapplied’andheisimmobilizedona longbackboard.Heisreceivingo叮genviaahigh﹣flow oxygenmask.ShortlyafterhisarrivalintheED,he beginstovomit.

A3.year﹣old’unrestrained》fTont﹣seatpassengerisin﹣ juredwhenhercarcrashesintoastonewall·Thechild isunconsciousattheinju1yscene.IntheED》bruises toherfbrehead’face’andchestwallarenoted,and thereisbloodaroundhermouthThepatient’sblood pressureis105／70mmHg’heartrateis120beats／ minute,andrespirationsarerapidandshallow.Her GCSscoreis8.

sCEⅡAR∣0Ⅱ﹣Z ThepatientdescribedinScenarioII﹣1isnowunre﹣ sponsiveandhasundergoneendotrachealintubation. Ventilationwith100﹪o唧genisbeingapphed.Partof hisevaluationincludesaCTscanofhisbrain.A灶er heistransportedtoradiologyfbrthescan,thepulse oximeterreveals82﹪SaO2.

SCEⅡAR∣0Ⅱ﹣4 A35﹣year﹣oldmalesustainsbluntchesttraumaduring asingle﹣motor﹣vehiclecoⅡision.IntheED’heisalert withevidenceofarightChest﹣wallcontusion.Hehas pointtendernessandfracturecrepitationofseveral rightribs.HisGCSscoreis14.HeisimmobⅢzedwith asemirigidcervicalspinec0Ⅱarandsecuredtoalong backboard.High﹣flowo可genisbeingadministeredvia a色cemask

I

rSkiⅢI﹣A:O『opha『yngeaIAi『wayInse『tion Ⅳbfe:Z】／Z㎡sp加cedM沱zs皿sed／brte〃!p0m｝:yue冗㎡／α㎡o几 u）／j:／ep／,印）α『w!g㎡O加tMbαteα几叨几cO〃sαOαspα㎡e〃t.

untilthedevice’sflangerestsontopofthe patient’shps.Theairwaymustn0tpushthe tonguebackwardandblocktheairway.An alternatetechniquefbrairwayinsertion’ termedtherotationmethod’involvesinsert﹣ ingtheoropharyngea1airwayupsidedown soitstipisfhcingtheroofofthepatient’s mouth.Astheairwayisinserted’itisro﹣ tated180degreesuntiltheflangecomesto restonthepatient’slipsand／orteethThis maneuvershouldnotbeusedincMIdren.

STEP1.Selecttheproper﹣sizea1rway.Acorrectly sizedairwayextendsfTomthecornerofthe patient,smouthtotheearlobe· STEP2·Openthepatient,smouthwiththechin﹣hft maneuverorcrossed﹣fingertechnique（scis﹣ sorstechnique）. STEP3‘Insertatonguebladeontopofthepatient’s tonguefarenoughbacktodepressthe tongueadequately.BecarefUlnottocause thepatienttogag. STEP4·Inserttheairwayposteriorly,gentlyshding theairwayoverthecurvatureofthetongue

5TEP5·

Removethetongueblade.

5TEp6.

Ventilatethepatientwithabag﹣mask devc i e·

52SI﹤ILLSTATI0NII■Ai『wayandVentilato『yManagement I

卜Sl《iIIⅡ﹣B:Ⅱasopha『yngeaIAi『way∣nse『tion 』VO／αIⅧsp｝℃cedz〃它zs叨seα山九e〃仇epα肋e㎡山oM／d

STEP4.

Insertthetipoftheairwayintothenostril anddirectitposteriorlyandtowardtheear

sTEP5.

Gent】yinsertthenasopharyngealairway throughthenostrilintothehypopharynx withaslightrotatingmotionuntilthe flangerestsagainstthenostril·

sTEP6·

Ventilatethepatientwithabag-mask device.

gαgo川α／】o／Dp／jα／:y／啗eα／αir山叼. STEP1·Assessthenasalpassagesfbranyappar﹣ entobstruction（e.g·,polyps,fiPactures,or hemorrhage）· STEP2·Selecttheproper﹣sizea1rway,whichwill easilypasstheselectednostril· STEP3·Lubricatethenasopha1yngealairwaywitha water﹣solublelubricantortapwater.

I

〉SI《i∣Ⅲ﹦CBag﹣MaskVentiIation:TWo﹦Pe『s0nTechnique STEp1.

Selecttheproper﹣sizemasktofitthepa﹣ tient,sfHce.

sTEPZ.

Connecttheoxygentubingtothebag﹣mask deviceandadjusttheflowofoXygento 15L／min.

STEp3·

Ensurethatthepatient,sairwayispatent andsecuredaccordingtopreviouslyde﹣ scribedtechniques.

STEP4.

maneuverandascertainingatightsealwith bothh月hds. STEp5.

Thesecondpersonappliesventilationby squeezingthebagwithbothhands.

STEP6·

Assesstheadequacyofventilationbyob﹣ servmgthepatient,schestmovement·

sTEP了.

Ventilatethepatientinthismannereve1y5 seconds.

Thefirstpersonappliesthemasktothe patient’sfhce,perfbrmingajaw-thrust

b5I《iIIⅡ﹣D:Adult0『ot『acheaIIntubation （W﹟t／jα〃d咖t〃o叨tGMmE／αs戊cBo【』gZedeufce）

5TEP5.

Infl㎡ethecuffoftheendotrachealtubeto ascertainthattheballoondoesnotleak,and thendehatethecu紐

STEP6·

Connectthelaryngoscopebladetothehan﹣ dleandchecktheli帥tbulbfbrbrightness.

sTEP7.

Assessthepatient）sairwayfbreaseofintu﹣ bation,usingtheLEMONmnemonic.（Box 2﹣1,page36.）

STEp8.

Directanassistanttomanuallyimmobilize theheadandneck·Thepatient’sneckmust notbehyperextendedorhyperflexedduring theprocedure·

S『EP1。Ensurepropersterihzation. STEPZ·Inspectallcomponentsfbrvisibledamage. STEp3·ExaminetheinterioroftheairwaytUbe toensurethatitisfiPeefromblockageand looseparticles. STEP4·EnsurethatadequateventⅡationandoxygenati0nareinprogressandthatsuctioning equipmentisimmediatelyavailableincase thepatientvomits.

SKILLSTATl0NII■Ai『wayandVentiIato『yManagement53

5TEP9’Holdthelaryngoscopeinthelefthand. STEP10.InsertthelaryngoscOpeintotheright sideofthepatient,smouth,displacingthe tonguetotheleft· STEPⅧ·ⅥsuaⅡyidenti句theepiglottisandthenthe vocalcords·Externallaryngealmanipula﹣ tionwithbackward’upward,andrightward pressure（BURP）maybehelpfUlfbrbetter visualizHtion. STEP1Z·Gentlyinserttheendotrachealtubeintothe tracheawithoutapplyingpressureonthe teethororaltissues. STEP13·Inflatethecuffwithenoughairt0provide anadequateseal.Dohotove『innatethecu硫 STEP↑4Checktheplacementoftheendotracheal tubebyapplyingbag﹄to﹦tubeventilation. STEP↑5·ⅥsuaⅡyobservechest﹣valve（bagwalve） excursionswithventilation· STEP16’Auscultatethechestandabdomenwith astethoscopetoascertaintubeposition.

Placementofthetubemustbechecked carefhlly.Achestx﹣rayexamishelp血lto assessthepositionofthetube,butitcannot excludeesophagealintubation. 5TEP17·Ifend0trachealintubationisnotaccom﹣ phshedwithinsecondsormthesametime requiredtoholdyourbreathbefbreexhahng, discontinueattempts’applyventilationwitha bag﹣maskdevice）andt】yagamusingaGEB SγEP18·Securethetube.Ifthepatientismoved’the tubeplacementshouldbereassessed· STEP19oAttachaCO2detectortotheendotracheal tubebetweentheadapterandtheventilat﹣ ingdevicetoconfirmthepositionofthe endotrachealtubeintheairway. S『EPZ0·Attachapulseoximetertooneofthepa﹣ tient,sfingers（intactperipheralperfUsion mustexist）tomeasureandmomtorthepa﹣ tient,so叮gensaturationlevelsandprovide animmediateassessmentoftherapeutic interventions.

卜SkiII∣﹣E:la『yngealMaskAi『way（lMA）andlntubatinglMA（llMA）Inse『ti0n 5TEP1·

Ensurepropersterilization.

sTEP2·

Inspectallcomponentsfbrvisibledamag巳

sTEP3·

Examinetheinterioroftheairwaytube toensurethatitisfreefr0mblockageand looseparticles·

STEP4

EnsurethatadequateventilationandoXy﹣ genationareinprogressandthatsuctioning equipmentisimmediatelyavailableincase thepatientvomits.

STEp5.

InⅡatethecu任oftheLMA／ILMAtoascer﹣ tainthattheballoondoesnotleak.

STEp6.

Directanassistanttomanuallyimmobilize theheadandneck·Thepatient,sneckmust notbehyperextendedorhyperflexedduring theprocedure.

sTEP7.

Befbreattemptinginsertion’completelyde﹣ flatetheLMA／ILMAcuffbypressingitfirmly ont0aflatsurfhce,andthenlubricateit.

STEP8

Cho0sethecorrectsizeLMA／ILMA:3fbra smallfbmale’4fbralargefbmaleorsmall male,and5fbralargemale.

5TEP9·HoldtheLMA／ILMAwiththedominant handasyouwouldapen,withtheindexfin﹣ gerplacedatthejunctionofthecuffandthe shaftandtheLMA／ILMAopeningoriented overthetongue· STEp10·PasstheLMA／ILMAbehindtheupperinci﹣ sors’withtheshaftparalleltothepatient’s chestandtheindexfingerpointingtoward theintubator. STEP11。PushthelubricatedLMA／ILMAintopositionalongthepalatopharyngealcurve’with theindexfingermaintainingpressureon thetubeandguidingtheLMA／ILMAinto thefinalposition. STEP12.InⅡatethecuffwiththecorrectvolumeofair （indicatedontheshaftoftheIMA／IIMA）· STEP13·ChecktheplacementoftheLMA／ILMAby applyingbag﹄mask-to﹣tubeventⅡation· S『Ep14Visuallyobservechestexcursionswith ventiIRtion.

54SKILLSTATIONIl■Ai「wayandVentilat0『yManagement

A

B

■FIGURE∣l﹣1∣ntubatiohth『oughan〃1htubatingLa『yngealMask〃OncetheIa『yngeaImasl《 isint『oduced『adedicatedendot『achealtubeisin5e『tedint0it’aIIowingthe『efo『ea〃bIind〃 intubationtechnique

S『EP15·IfILMAisavailable,carefhlintUbation throughtheILMAmaybeattempted （■F!GuREⅡ﹣1）.Inflatethecu任oftheendotrachealtubetoascertainthattheballoon doesnotleak,andthendeHatethecuff: STEP16·LubricatetheendotrachealtUbewitha water﹣solublelubricant. STEP17.Careh1llymsertthelubricatedtubeintothe 『 『 』 M A ﹦ STEP18’InfIatethecuffwithenoughairtoprovide anadequateseal.Donotove『ih｛latethecu厭 STEP19·Checktheplacementoftheendotra﹣ chealtubebyapplyingbag﹄mask﹣to﹣tube ventilation.

STEPZ0·ⅥsuaⅡy0bservechestexcursionswith ventiIHt↑on· STEP21.Auscultatethechestandabdomenwitha stethoscopetoascertaintubeposition· STEP2Z·Ifendotrachea1intI】bationisnotaccom﹣ phshedwithinsecondsorinthesametime requiredtoholdyourbreathbefbreexhal﹣ ing,discontmueattemptsandapplyventilationwithabagmaskdeviceconnectedto theILMA. STEPZ3.Securethetube.Ifthepatientismoved’ tubeplacementshouldbereassessed. Ⅳb蛔Remouα』o／炕eILMA㎡deα／!ys〃o叨／dbePe『允／、加ed 加α〃oSP古tα／’ααe／o仇e／.;s陀O／αcαde〃m／0e㎡αbα瓦唔 仇epα肋e／㎡d叨）w】gt〃emα〃e叨Uer·

Sl﹤ILLSTATI0NⅡ■Ai『wayandVentiIato『yManagement55

）S《 l Ⅲ i I﹣『:a l 『yngea『 l ubeA『 i way（TlA）∣nse『to in sTEP1.

Ensurepropersterihzation.

STEPZ·

Inspectallcomponentsfbrvisibledamage.

STEp3·

Examinetheinterioroftheairwaytube toensurethatitis仕eefromblockageand looseparticles.

STEP4

InfIatethecu錐byimectingthemaximum recommphdedvolumeofairintothecu雌.

STEP5.

Selectthecorrectlaryngealtubesize.

STEp6·

Applyawater-solublelubricanttothebeveleddista1tipandposterioraspectofthetube, takingcaretoavoidintroductionoflubricant into0rneartheventilato1yopenings·

S『EP7·

Preo叮genatethepatient.

S『Ep8·

Achievetheappropriatedepthofanesthesia’

s『EP9o

Directanassistanttomanuallyimmobilize theheadandneck.Thepatient,sneckmust notbehyper﹣extendedorhyperfIexeddur﹣ mgtheprocedure·

STEP10’ HoldtheLTAattheconnect0rwiththe

domih2nthand.Withthenondomihant hand》holdthemouthopenandapplythe chin﹣liftmaneuver. S T E P 1 1 . WiththeLTArotatedlaterally45to90de﹣

grees’introducethetipintothemouthand advanceitbehindthebaseofthetongue.

S『EP1Z·RotatethetUbebacktothemidlineasthetip reaChestheposteriorwallofthepha1ynx. STEP13·Withoutexertingexcessivefbrce,advance theLTAuntⅡthebaseoftheconnectoris alignedwiththepatient’steethorgums. S丁EP14IhfIatetheLTAcu躂tothemihim『】m volumenecessarytosealtheairwayatthe peakventⅡatorypressureused（justseal volume）. STEP15·WhⅡegentlybaggingthepatienttoassess ventilation’simultaneouslywithdrawthe airwayuntilventilationiseasyandfree ilowing（largetidalvolumewithminimal a1rwaypressure）. STEP16·Refbrencemarksareprovidedattheproxi﹣ malendoftheLIH;whenalignedwiththe upperteeth,thesemarksindicatethedepth ofinsertion. STEP17.Confirmproperp0sitionbyauscultation, chestmovement’andverificationofCO2by capnography. STEP18’Rea叮ustcuffinfIationtosealvolume. STEP19.SecureLⅢAtopatientusingtapeorother acceptedmeans·Abiteblockcanalsobe used,ifdesired.

卜S∣《iIⅢ﹃G:InfantEndot『acheaI!ntubation STEP1·

Ensurepropersterilization·

s『EP2.

Inspectallcomp0nents允rvisibledamage.

STEp3·

Examinetheinterioroftheairwaytube

STEP6·

ConnectthelaIyngosc0pebladeandhandle; checktheⅡghtbulb允rbrightness.

sTEp7‘

Directanassistanttomanuallyimmobihze theheadandneCk.Thepatient’sneckmust notbehyper﹣extendedorhyperflexeddur﹣ ingtheprocedure.

5TEP8’

Holdthelaryngoscopeinthelefthand.

5TEp9’

Insertthelaryngoscopebladeintotheright sideofthemouth,movingthetonguetothe left.

toensurethatitisfreefromblockageand looseparticles. S『Ep4

EnsurethatadeqUateventilationando可﹣ genationareinprogressandthatsuctioning equipmentisimmediatelyavailableincase thepatientvomits.

sTEp5.

Selecttheproper﹣sizetube’whichshouldbe thes8mesizeasthein色nt’snostrilorlittle finger.

5TEP10.Observetheepiglottisandthenthevocal cords.Externa1laryngealmanipulationwith

56SKILLSTATI0NII■Ai『wayandVenti∣ato『yManagement BURPmaybehelpfUlfbrbetter visua】i叨ation.

discontinueattempts’ventⅡatethepatient withabag﹣maskdevice’andtryagam.

STEP11.InserttheendotrachealtUbenotmorethan 2cmpastthecords·

STEPⅧ·Securethetube·Ifthepatientismoved’ tubeplacementshouldbereassessed·

STEp12.Checktheplacementofthetubebyapply﹣ ingbag﹄mask﹣to﹣tubeventilation’observing lunginflations,andauscultatingthechest andabdomenwithastethoscope.Place﹣ mentofthetubemustbecheckedcareihlly. Chestx.rayexaminationmaybehelpfhlto assessthepositionofthetube,butitcann0t excludeesophagealintubation’

STEP15·AttachaCO2detectortothesecureden﹣ dotrachealtubebetweentheadapterand theventilatingdevicetoconfirmtheposi﹣ tionoftheendotrachealtubeinthetrachea

STEP13·Ifendotrachealintubationisnotaccom﹣ plishedwithin30secondsorinthesametime reqUiredtoholdyourbreathbefbreexhaling’

STEP16·Attachapulseoximetertooneofthepa﹣ tient’sfingers（intactperipheralper血sion mustexist）tomeasureandmonitorthepa﹣ tient’soxygensaturationlevelsandprovide animmediateassessmentoftherapeutic interventions.

I

卜SkiIIⅡ﹣Ⅱ:PuIse0ximet『yⅢonito『ing Thepulseoximeter1sdesignedtomeasureo叮gensatura﹦ tionandpulserateinperiphera1circulati0n.Thisdevice isamicroprocessorthatcalculatesthepercentagesaturation0fo呵genmeaChpulseofarterialbloodthatflows pastasens0r.ItsimultaneouS】ycalculatestheheartrate. Thepulseoximeterworksbyalow﹣intensi叮light beamedfromalight﹣emittingdiode（LED）toalightreceivingphotodiode.Twothinbeamsoflight,onered andtheotherinfrared,aretransmittedthroughblood andbodytissue,andaportionisabsorbedbytheblood andbodytissue.Thephotodiodemeasurestheportionof thelightthatpassesthroughthebloodandb0dytissue. TherelativeamountoflightabsorbedbyoXygenated hemoglobindi雌rshomthatabsorbedbynonoxygen﹣ atedhemoglobin.Themicroprocessorevaluatesthese diffbrencesinthearterialpulseandreportsthevalues ascalculatedo呵hemoglobinsaturation（℅SaO’）.Meas﹣ urementsarereliableandcorrelatewellwhencompared withacooximeterthatdirectlymeasuresSaO’· However,pulseoximetryisunreliablewhenthe patienthaspoorperipheralperfUsion’acondition thatcanbecausedbyvasoconstriction,hypotension’ abloodpressurecuffthatlsinflatedabovethesen﹣ sor’hypothermia’andothercausesofpoorbloodHow. Severeanemiacanlikewiseinfluencethereading·Sig﹂ nificantlyhighlevelsofcarbo叮hemoglobinormeth﹣ emoglobincancauseabnormalities’andcirculating dye（e.g.,indocyaninegreenandmethyleneblue）can interfbrewiththemeasurement’Excessivepatient movement,otherelectricaldevices’andintenseambi﹣ entlightcancausepulseoximeterst0malhmction·

Usingapulseoximeterrequiresknowledgeofthe particulardevicebeingused.Differentsensorsare appropriatefbrdifferentpatients.Thefingertipand earlobearecommonsitesfbrsensorapphcation,how﹣ ever,bothoftheseareascanbesuhjecttovasoconstric﹣ tion·Thefingertiportoetipofaninjuredextremityor belowabloodpressurecuffshouldnotbeused. Whenanalyzingpulseoximetryresults,evaluate theinitialreadings.Doesthepulseratecorrespondto theelectrocardiographicmonitor?Istheo汀gensatu﹣ rationappropriate?Ifthepulseoximeterisgivinglow readingsorverypoorreadings,lookfbraphysiologic cause,notamechanicalone· Therelationshipbetweenpartialpressureofo叮gen inarterialblood（PaO2）and℅SaO2isshownin■『lG uREⅡ.z.Thesigmoidshapeofthiscurveindicatesthat therelationshipbetween℅SaO2andPaO2isnonlinear. Thisisparticularlyimportantinthemiddlerangeof thiscurve’wheresmallchangesinPaO2wiⅡeffbctlarge changesinsaturation·Remember’thepulseoximeter measuresarterialo叮gensaturation,notarterialo叮gen partialpressure.AlsoseeTable2·2:ApproximatePaO2 versusO2HemoglobinSaturationLevelsinChapter2: AirwayandVentilatoryManagement. StandardbloodgasmeasurementsreportbothPaO, and℅SaO2.Wheno呵gensaturationiscalculatedfrom bloodgasPaO2,thecalculatedvaluecandiffbrfromthe o叮gensaturationmeasuredbythepulseoximeter·This diffbrencecanoccurbecauseano唧gensaturationvalue thathasbeencalculatedhomthebloodgasPaO,has notnecessarilybeencorrectlyadjustedfbrtheeffbctsof

SKILLSTATlONII■Ai『wayandVentiIato『yManagement57

variablesthatshifttherelationshipbetweenPaO2and saturation.Thesevariablesincludetemperature,pH, PaCO·（partialpressureofcarbondioxide）’2’3﹣DPG

U

（diphosphoglycerates）,andtheconcentrationoffbtal hemoglobin

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PaOz（mmHg）andHemogIobinSatu「ationRelationship

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I

卜Sl《il∣Ⅲ:Ca『boⅡDioxideDetection Whenapatientisintubated’itisessentialtocheck thepositionoftheendotrachealtube.Ifcarbondiox﹣ ideisdetectedintheexhaledair’thetubeisinthe airway.Methodsofdeterminingend﹣tidalCO2should bereadilyavailableinallemergencydepartmentsand anyotherlocationswherepatientsrequireintubation· Theprefbrredmethodisquantitative’suchascapnog﹣ raphy,capnomet1y,ormassspectroscopy. Colorimetricdevicesuseachemicallytreatedindi﹣ catorstripthatgenerallyreflectstheCO2level。Atvery lowlevelsofCO,’suchasatmosphericair,theindicator turnspurple.AthigherCO21evels（e.g’,2℅－5℅）,the indicatorturnsyellow.Atancolorindicatesdetection ofCO。levelsthataregeneraⅡylowerthanthosefbund intheexhaledtrachealgases. Itisimp0rtanttonotethat,onrareoccasion, patientswithgastricdistentioncanhaveelevatedCO2

levelsintheesophagus.Theseelevatedlevelsclearrap﹣ idlyafterseveralbreaths,andtheresu】tsofthecolori﹣ metrictestshouldnotbeusedunti】a仕eratleastsix breaths.IfthecolorimetricdevicestⅢshowsanmter﹣ mediaterange’sixadditionalbreathsshouldbetakenor g1ven·Ifthepatientsustainsacardiacarrestandhasno cardiacoutput’CO2isnotdeliveredtothelungs.Infact, withcardiacasystole,thiscanbeamethodofdetermin﹣ ingwhethercardiopulmona1yresuscitationisadeqUate. Thecolorimetricdeviceisnotused允rthedetecti0n ofelevatedCO2levels·Similar】y,itisnotusedtodetect amainstembronchialintubation.Physicalandchest x﹣rayexaminationsarerequiredtodeterminethatthe end0trachealtubeisproperlypositi0nedmtheairway. InanoisyEDorWhenthepatientistransportedseveral times,thisdeviceisextremelyreliableindiffbrentiatmg betweentrachealandesophagealintubation.

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Objectives

r卜Ski】lIⅡ﹣A:Needle Cricothyroidotomy

pe『↑o『manceatthisskiIlstationwi∣Ia∣Iowstudentstop『acticeanddemon﹣ st「atethetechnique5ofneedIec『icothy『oidotomyandsu「gicalc『icothy「oid﹣ otomyonalive『anesthetizedanimal!↑『e5hhumancadave『『o『anatomic humanbodymanikin’

b卜SkillIII﹣B:Surgical Cricothyroidotomy

Ⅲldenti↑ythesu『facema『kingsandst「uctu「es『elevanttope『fo「mIng need∣eandsu『gc i a∣﹤『c i othy『od i otome i s. 圃StatetheIndicationsandcompIicationso↑need∣eandsu「gical c『c i othy「od i otome i s’ 圃Pe「fo「mneedleandsu『gicaIc「icothy「oidotomiesonalive’anesthe﹣ tizedanima∣lf『eshhumancadave「｝o『anatomichumanbodymani﹣ kln’asoutIinedinthisskiIlstation ﹂

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SKILLSTATIONIII■C「icothy「0idotomy

59

bSkiⅢⅡ﹣A:ⅡeedleC『icothy『oidotomy STEP1·Assembleandprepareoxygentubingby cuttmgaholetowardoneendofthetubing. Connecttheotherendoftheoxygentubing toano汀gensourcecapableofdeⅡvermg50 ps1orgreateratthempple,andensurethe freeflowofoxygenthroughthetUbing. STEPZ’Placethepatientinasupmeposition’ STEp3·Assemblea12-or14﹣gauge’8·5﹣cm,over﹣ the﹣needlecathetertoa6﹣to12﹣mLSyringe STEP4Surgicallypreparetheneck,usmgantisep﹣ ticswabs· STEP5·Palpatethecricothyroidmembraneante﹣ riorlybetweenthethyroidcartⅡageand thecricoidcartⅡage.Stabilizethetrachea withthethumbandfbrefingerofonehand topreventlateralmovementofthetrachea duringtheprocedure. S『EP6·Puncturetheskininthemidhnewitha 12﹣or14﹣gaugeneedleattachedtoaSyrmge, directlyoverthecricothyroidmembrane （i.e.’midsagittaⅡy）（■FIGuREⅡ!﹣1）.

5TEP7.Directtheneedleata45﹣degreeanglecau﹣ daⅡy,whⅡeapplyingnegativepressureto thesyringe· STEP8·Carefhllymserttheneedlethroughthe lowerhalfofthecricothyroidmembrane’ aspiratingastheneedleisadvanced· STEP9·Notetheaspirationofair,whichsignifies entryintothetracheallumen. STEP10.BemovetheSyringeandwithdrawthe stylet,Whilegentlyadvancingthecatheter d0wnwardintoposition’takingcarenotto perfbratetheposteriorwal1ofthetrachea （■nGUREⅢ﹣2）. SγEP11.Attachtheoxygentubingoverthecatheter needlehub,andsecurethecathetertothe patient,sneck. STEP12·Applyintermittentventilationbyoccluding theopenholecutintotheo叮gentubing withyourthumbfbr1secondandreleasing itfbr4seconds.Afterreleasingyour thumbfromtheholemthetubing,passive

頭 ﹃ 旦

■FlGUREⅡ!﹣1Punctu「ethe5kininthemidIinewitha 1Z﹣o「14﹣gaugeneedIeattachedtoasy『inge’di『ectIy ove『thec『icothy「oidmemb「ane.

＝

▽

■「lGUREⅡI﹣ZRemovethesy「ingeandwithd「awthe 5tylet’whiIegentlyadvandngthecathete『downwa「d int0position’takingca「enottope「「o「atetheposte『io「 waIIofthet「achea

60SKILLSTATIONIII■C「ic○thy『oidot0my exhalationoccurs.Note:AdeqUatePaO,can bemaintainedfbronly30to45minutes, andCO2accumulationcanoccurmore rapidly·

〉卜C0MPUCA『∣0ⅡS0FⅡEEDlE CRIC0TⅡγR0ID0T0Mγ ■InadeqUateventilation’leadingto hypoxiaanddeath ■Aspiration（blood） ■Esophageallaceration ■Hematoma ■PerfbrationoftheposteriortrachealwaⅡ ■Subcutaneousand／Ormediastmal emphysema ■Thyroidperfbration ■Pneumotho】、Hx

STEP13·ContinuetoobservelunginflationandauscultatethechestfbradeqUateventilation. Payspecialattentiontolungdeflationin ordertoavoidbarotrauma’whichcanlead topneumoth0rax.Iflungdeflationisnotob﹣ served’gentlemanualribcagecompression toaidexhalationmaybenecessary.

卜SkiIIⅡI﹣B:Su『gicaIC『icothy『oidotomy STEp1.

Placethepatientinasupinep0sitionwith theneckinaneutralposition.

STEp2·

Palpatethethyroidnotch’cricothyroid interval’andsternalnotchfbrorientation （■FG I URE∣Ⅱ﹣3A）.

number5or6）intothecricothyroidmem﹣ braneincision’directmgthetubedistaⅡy intothetrachea（■『lGuREⅢ﹣3D）. STEP9·Inflatethecuffandapplyventilation.

STEP3·

Assemblethenecessaryequipment·

S『EP10·Observelunginflationandauscultatethe chestfbradequateventilation’

STEP4·

Surgicallyprepareandanesthetizethearea locally’ifthepatientisconscious·

STEPⅢ·Securetheendotrachealortracheostomy tubetothepatienttopreventdislodging·

s『EP5·

Stabilizethethyroidcartilagewiththeleft handandmaintainstabilizationuntilthe tracheaismtUbated.

sTEp6·

sTEp7.

5TEp8.

Makeatransverse呂kinincisionoverthe cricothyroidmembraneandcarefUllyincise throughthemembranetransversely （■FIGuREⅡI﹣3B）·Caution:Donotcutor removethecricoidand／orthyroidcartilages Inserthemostatortrachealspreaderinto themcisionandrotateit90degreestoopen theairway（■FlGUREⅡl﹣3C）. Insertaproper﹣size’cuffbdendotracheal tubeortracheostomytube（usuaⅡya

）卜C0ⅢPUCATI0ⅡS0『SⅢG∣CAl CR∣C0TⅡγR0∣D0T0Ⅲγ ■ ■

■ ■ ■ ■ ■ ■ ■

Aspiration（blood） Creationofafhlsepassageintothe tissues Subgl0tticstenosis／edema Laryngealstenosis Hem0rrhageorhematomafbrmation Lacerationoftheesophagus Lacerationofthetrachea Mediastinalemphysema VOcalcordparalysis’hoarseness

SK!LLSTATlONIII■C『icothy「oid0t0my

61

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圓Recognzieshockandco「「e∣ateapate i nt’sacutecn Ic i a∣ signswiththedeg『eeofvolumedefidt.

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囤Compa『eandcont『astthecIinicaIp『esentationof patientswithva『iousc∣as5ification5ofhemo『『hage. 回Desc「ibetheinitiaImanagementofhemo「『hagic5hock andtheongoingevaIuationoffIuid『esuscitationand o『ganpe『fusion 圃Recognizethephy5ioIogic『esponsesto『esu5citation in0『de「t0continuaIIy「ea5se5sthepatient’s『esponse andavoidcomplication5. ⅢExpIainthe「oIeofbIood『epIacementinthemanage﹣ ment0fshock 圓Desc「ibethespedaIconside『ationsinthediagnosis andt『eatmentof5hock’includingequatingblood p「e5su『ewithca「diacoutput〃advancedage’athIetes’ p「egnancy’medication5〃hypothe「mia!andpace﹣ make『S. ＝

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T離鸛饕置織讓韉黷! shock;rather,theinitialdiagnosisisbasedoncⅡnical recognitionofthepresenceofinadequatetissue perihsionando叮genation.Thedefinitionofshock－an abnormalityofthecirculatorysystemthatresultsin inadequateorganperh1sionandtissueoxygenation＿ alsobecomesanoperativetoolfbrdiagnosisand treatment· ThesecondstepintheinitiaImanagemehto「shocl《

istoidentilythep『obabIecaⅡseo「theshocl《state.In traumapatients’thisprocessisdirectlyrelatedtothe mechanismofinju】y·Mostinjuredpatientsinshock havehypovolemia,buttheymaysuffbrfTomcardio﹣ genic,obstructive’neurogemc’and’rarely,septicshock. Tensionpneumothoraxcanreducevenousreturnand produceobstructiveshock,andcardiactamponadealso producesobstructiveshock’asbloodmthepericardial sacinhibitscardiacc0ntractilityandcardiacoutput. Thesediagnosesshouldbec0nsideredmpatientswho mayhaveinjuriesabovethediaphragm.Neurogen1c shockresultsfromextensiveinjurytothecervicalor upperthoracicspinalcord·F0rallpracticalpurposes, shockdoesnotresultfromisolatedbraininjuries· Patientswithspinalcordi咖】:ymayimtiaⅡypresent mshockresultingfrombothvasodilationandrelative 63

64CHAPTER3■ShoCk

hypovolemia.Septicshockisunusual,butmustbecon﹣ sideredinpatientswhosearrivalattheemergenCyfacil﹣ i叮hasbeendelayedfbrmanyhours. PatientmanagementresponsibⅡitiesbeginwith recognizingthepresenceofshoCk’andtreatment shouldbeinitiatedsimultaneouslywiththeidentifica﹣ tionofaprobablecause.Theresponsetoinitialtreat﹣ ment’coupledwiththefindingsduringtheprimary andsecondarypatientsurveys,usuaⅡyprovidessuf ficientinfbrmationtodeterminethecauseofshoCk· Hemo『『hageisthemostcommoncauseo「shocl《iⅡthe in】u『edpatient.

pressureandrightatrialpressure（■「IGuRE3﹣1）.This pressurediffbrentialdeterminesvenousflow.The venoussystemcanbeconsideredareservoirorcapaci﹣ tancesysteminwhichthevolumeofbloodisdivided intotwocomponents: 1.Thefirstc0mponentdoesnotcontributetothe meansystemicvenouspressureandrepresents thevolumeofbloodthatwouldremaininthis capacitancec1rcuitifthepressureinthesystem w a s z e r o

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AnoverⅥewofbasiccardiacphysiologyandblo0d losspathophysiologyisessentialtounderstandingthe shockstate.

BAS∣CCARDIACPⅡγS∣0L0Gγ Cardiacoutput,whichisdefinedasthevolumeof bloodpumpedbytheheartperminute,isdetermined bymultiplyingtheheartratebythestrokevolume. Strokevolume,theamountofblo0dpumpedwith eachcardiaccontraction,isclassicallydeterminedby preload’myocardialcontractility,andafterload. Preload,thevolumeofvenousreturntotheheart’ isdeterminedbyvenouscapacitance’volumestatus’

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Z.Thesecondandm0reimportantcomponent representsthevenousvolumethatcontributes tothemeansystemicvenouspressure·Nearly 70℅ofthebody,stotalbl0odvolumeisestimated tobelocatedinthevenouscircuit·Therelation﹣ shipbetweenvenousvolumeandven0uspres﹣ suredescribesthecomplianceofthesystem.It isthispressuregradientthatdrivesvenousflow fmdtherefbrethevolumeofvenousreturntothe heart·Bloodlossdepletesthiscomponentofve﹣ nousvolumeandreducesthepressuregradient; asaconsequence’venousreturnisreduced·

Thevolumeofvenousbloodreturnedtotheheart determinesmyocardialmusclefiberlengthafterven﹣ tricularfillingattheendofdiastole.Musclefiber lengthisrelatedtothecontractilepropertiesofmyo﹣ cardialmuscleaccordingtoStarling,slaw.Myocardial contractili叮isthepumpthatdrivesthesystem.After﹣ loadissystemic（peripheral）vascularresistanceor） simplystated’resistancetothefbrwardflowofblood

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INITIALPATlENTASSESSMENT65 Bl00DLOSSPATⅡ0pⅡγSI0L0Gγ Earlycirculatoryresponsestobloodlossarecom﹣ pensatoryandincludeprogressivevasoconstriction ofcutaneous’muscle’andviscera1circulationtopre﹦ servebloodnowtothekidneys,heart’andbrain.The usualresponsetoacutecirculatingvolumedepletion associatedwithiIUmyisanincreaseinheartratein anattempttopreservecardiacoutput.Inmostcases’ tachycardiaistheearⅡestmeasurablecirculato】ysign ofshock.Thereleaseofendogenouscatecholamines increasesperipheralvascularresistance’whichin turnincreasesdiastolicbloodpressureandreduces pulsepressure,butdoeslittletoincreaseorganper﹣ h1sion·Otherhormoneswithvasoactivepropertiesare releasedintothecirculationduringshock,including histamine’bradykimn’β-endorphins’andacascade ofprostanoidsandotherCyt0kines·Thesesubstances haveprofbundeffbctsonthemicrocirculationandvas﹣ cularpermeabⅢty· Venousreturnmeanyhemorrhagicshockispreservedtosomedegreebythecompensato1ymechamsm ofcontractionofthevolumeofbloodinthevenousSys﹣ tem,whichdoesnotcontributetomeansystemicvenous pressure.However’thisc0mpensato1ymechanismis limited·Themoste碓ctivemethodo「『esto『ingadeqⅡate ca『diacoutputandend·o『ganpe『fi』sioⅡisto『esto『evenous 『etumtono『malbylocatingandstoppingthesou『ceo「 bIeeding’aloⅡgwithapp『op『iatevolume『epIetioh. Atthecellularlevel’inadequatelyperfhsedand o汀genatedceⅡsaredeprivedofessentialsubstrates fbrnormalaerobicmetabolismandenergyproduction. Initially,compensationoccursbyshiftingtoanaero﹣ bicmetabolism,whiChresultsmthefbrmationoflac﹣ ticacidandthedevelopmentofmetabolicacidosis.If shockisprolongedandsubstratedelive】yfbrthegen﹣ erationofadenosinetriphosphate（ATP）isinadequate’ theceⅡularmembranelosestheabⅢtytomaintainits integri勺’andthenormalelectricalgradientislost. Proinflammato叮mediators,suchasinduciblemtric o泣desynthase（iNOS）’tumornecrosisfhctor（TNF）, andotherCytoldnesarereleased’settingthestageibr subseqUentend-organdamageandmultipleorgan dysfhnction. Iftheprocessisnotreversed,progress1veceⅡular damage,a1terationsmendothelialpermeability’addi﹣ tionaltissueswelling’andceⅡulardeathcanoccur· Thisprocesscompoundstheimpactofbloodlossand hypoperfhsion,potentiaⅡyincreasingthevolumeof fluidrequiredfbrresuscitation. Theadministrationofanappropriatequantity ofisotomcelectrolytesolutionsandbloodhelpscom﹣ batthisprocess.Patienttreatmentisdirectedtoward reversingtheshockstatebyprovidingadequateoxy﹣ genation,ventilation’andappropriatefluidresuscita﹦ tion’asweⅡasst0ppmgthebleeding.

Theimtialtreatmentofshockisdirectedtoward restoringceⅡularandorganper血sionwithadequately oxygenatedblood.De伺nitivecont『oIofhemo『『hage and『esto『ationo「adequateci『cu∣atingvolumea『ethe goaIso「t『eatmento「hemo『『luagicshocl《.Vasopressors arecontraindicatedfbrthetreatmentofhemorrhagic shockbecausetheyworsentissueperfhsion.Frequent momtoringofthepatient,sindicesofperihsionisnec﹣ essalytoevaluatetheresponsetotherapyanddetect anydeteriorationmthepatient’sconditionasear】yas possible·Reassessmentwillhelptoidentib『patientsm compensatedsh0ckorthosewhoareunabletomounta compensatoryresponsepriortocardiovascularcoⅡapse. Mostinjuredpatientswhoaremhypovolemic shockrequireearlysurgicalinterventionorang1oem﹣ bolizationtoreversetheshockstate.Thep『esence o「shocl《inaniniu『edpatientwa『『antstlTeimmediate invoIvementofasu『geon.

Initia ∣PIⅡ itial patientASseSSment Optimally,clinicianswillrecognizetheshockstate duringtheinitialpatientassessment·Todoso’itis importanttobefhmiliarwiththeclinicaldiffbrentia﹣ tionofthecausesofshock－chiefIy,hemorrhagicand nonhemorrhagic·

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Profbundcirculatoryshock－asevidencedbyhemody﹣ namiccollapsewithinadequateperfUsionoftheskin, kidneys,andcentralnervousSystem＿issimpletorecognize.However,aftertheairwayandadequateventilationhavebeenensured’careh1levaluationofthe patient,scirculatorystatusisnecessarytoident呵the earlymanifbstationsofshoCk’includingtachycardia andcutaneousvasoconstriction. Reliancesolelyonsystolicbloodpressureasan indicatorofshockcanresultindelayedrecogmtionof theshockstate.Compensat0rymechanismscanpre﹣ cludeameasurablefhllinSystohcpressureuntⅡupto 30℅ofthepatient》sbloodv0lumeislost.Specificatten﹣ tionshouldbedirectedtopulserate,pulsecharacter’ respiratoryrate,skincirculation’andpulsepressure （i·e.,thedilfbrencebetweenSystolicanddiastolicpres﹣ sure）.Tachycardiaandcutaneousvasoconstrictionare thetypicalearlyphysiologicresponsestovolumeloss inmostadultsAnyiniu『edpatientwhoiscooIaⅡdhas taclWca『diaisconside『edtobeihshoCl《untiIp『ovenoth﹣ e『wise.Occasionally’anormalheartrateorevenbrady﹣ cardiaisassociatedwithanacutereductionofblood

66CHAPTER3■Shock

volume,otherindicesofperfUsionmustbemomtored inthesesituations. Thenormalheartratevarieswithage.Tachycar﹣ diaisdiagnosedwhentheheartrateisgreaterthan160 beatsperminutes（BPM）inaninfant’140BPMinapre﹣ school-agedchild,120BPMinchⅡdrenfTomschoolage topuberbγ’and100BPMmadultsElderlypatientsmay noteXhibittaChycardiabecauseoftheirlimitedcardiac responsetocatecholaminestimulationortheconcur﹣ rentuseofmedications,suchasβ﹣adrenergicbloCking agents.TheabⅢlVofthebodytoincreasetheheartrate alsomaybelimitedbythepresenceofapacemaker·A narrowedpulsepressuresuggestssignificantbloodloss andmvolvementofcompensato】ymechanisms. Laboratoryvaluesfbrhematocritorhemoglobin concentrationmaybeunreliablefbrestimatingacute bloodlossandshouldnotbeusedtoexcludethepres﹣ enceofshock·MassivebIoodlossmayp『oduceonIya minimaIacutedec『easeinthehematoc『ito『hemogIo· binconcent『ation·Thus,averylowhemat0critvalue obtainedshortlyafterinjurysuggestseithermassive bloodlossorapreexistinganemia,whereasanormal hematocritdoesnotexcludesignificantbloodloss·Base deficitand／orlactatelevelscanbeusefhlindetermin﹣ ingthepresenceandseverityofshock。Serialmeasure﹣ mentoftheseparametersmaybeusedtomonitora patient,sresponsetotherapy.

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叨 ●W／jα㎡s肋ecα叨seO／s〃oe臃 Shockinatraumapatientisclassifiedashemorrhagic ornonhemorrhagic.Apatientwithinjuriesabovethe diaphragmmayhaveevidenceofinadequateorgan perfUsionduetopoorcardiacperfbrmancefiyomblunt myocardialmjury,cardiactamponade,oratension pneumothoraxthatproducesinadequatevenousreturn（preload）.Ahighindexofsuspicionandcarefhl observationofthepatient,sresponset0initialtreat﹣ mentwillenableclinicianstorecogn1zeandmanage allfbrmsofshock· Initialdeterminationofthecauseofshockdepends ontakinganappropriatepatienthistoⅣandper﹣ fbrminganexpeditious’carefhlphysicalexamination· Selectedadditionaltests,suchasmonitoringcentral ven0uspressure（CVP）,chestand／orpelvicx﹣rayexami﹣ nations》andultrasonography,canprovideconfirmato1y evidencefbrthecauseoftheshockstate,butshouldnot delayappropriateresuscitation.

Ⅱemo『『hagicShock Hemorrhageisthemostc0mmoncauseofshockaf terinjury,andvirtuallyallpatientswithmultiplein﹣

■F∣GURE3﹦2U5inguIt「asoundinthesea「chf0「the cau5eofshocl﹤·

jurieshaveanelementofhypovolemia·Inaddition’ mostnonhemorrhagicshockstatesrespondpartially orbrieflytovolumeresuscitation.Therefbre,ifsigns ofshockarepresent’treatmentusuallyisinstitutedas ifthepatientishypovolemic（■FIGuRE3﹣z）.However, astreatmentisinstituted,itisimportanttoidentify thesmallnumberofpatientswhoseshockhasadi低 fbrentcause（eg·,asecondaryconditionsuchascar﹣ diactamponade,tensionpneumothorax,spinalcord mjury,orbluntcardiacmjury’whichcomplicateshy﹣ povolemic／hemorrhagicshock）.Specificinfbrmation aboutthetreatmentofhemorrhagicshockisprovided inthenextsectionofthischapter’Theprimaryfbcus inhemorrhagicshockistopromptlyidentifyandstop hemorrhage.Sourcesofpotentialbloodloss－chest》 abdomen,pelvis,retroperitoneum’extremities,andex﹣ ternalbleeding－mustbequicklyassessedbyphysical examinationandappropriatea財unctivestudies.Chest x-ray,pelvicx﹣ray,abdominalassessmentwitheither fbcusedassessmentsonographyintrauma（FAST） ordiagnosticperitoneallavage（DPL）,andbladder catheterizationmayallbenecessarytodeterminethe sourceofbloodloss（■FIGURE3﹣3）. Nonhemo『『hagicShock Nonhemorrhagicshockincludescardiogenicshock, cardiactamponade,tensionpneumothorax’neurogen﹣ icshock,andsepticshock.

Ca『diogenicShoCk岫『ocardialdysfhnctioncanbe causedbybluntcardiacmIury’cardiactamponade,an

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airembolus’or,rarely,amyocardialiniarctionassociat﹣ edwiththepatient,siIUmyBluntcardiacinjuryshould besuspectedwhenthemechanismofiIUuⅣtothetho﹣ raxisrapiddeceleration.AⅡpatientswithblunttho﹣ racictraumaneedconstantelectrocardiographic（ECG） m0nitoringtodetectinju1ypatternsanddysrhythmias. Bloodcreatinekinase（CK;fbrmerly,creatinephos﹣ phokinase【CPIq）isoenzymes’andspecificisotope studiesofthemyocardiumrarelyassistindiagnosingor treatinginjuredpatientsintheemergenCydepartment

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（ED）.Echocardiographymaybeusefhlinthediagnosis oftamponadeandvalvularrupture》butitisoftennot practicalorimmediatelyavailablemtheEDFASTin theEDcanidenti句pericardialfluidandthelikeliho0d ofcardiactamponadeasthecauseofshock.Bluntcar﹣ diacmjurymaybeanmdicationfbrearlyCVPmomtor﹣ ingtoguidefluidresuscitationinthissituation. Ca『diacTamponadeCardiactamponadeismost commonlyidentifiedinpenetratingthoracictrauma,

68CHAPTER3■Shock

butitcanoccurastheresultofblunti呵urytothetho﹣ rax.Tachycardia’muffledheartsounds’anddilated, engorgedneckveinswithhypotensionresistanttoflu﹣ idtherapysuggestcardiactamponade.However’the absenceoftheseclassicfindingsdoesnotexcludethe presenceofthiscondition·Tensionpneumothoraxcan mimiccardiactamponade,butitisdiffbrentiatedfrom thelatterconditionbythefindmgsofabsentbreath sounds’trachealdeviation,andahyperresonantper﹣ cussionnoteovertheaHbctedhemithorax·Cardiac tamponadeisbestmanagedbythoracotomy.Pericar﹣ diocentesismaybeusedasatemporizmgmaneuver Whenthoracotomyisnotanavailableoption.SeeSkiⅡ StationⅥIChestTraumaManagement’SkillⅥI﹣C Pericardiocent巴SiS

TensionPneumotho『axTensionpneumothoraxis atruesurgicalemergenCythatreqUiresimmediatedi﹣ agn0sisandtreatment·ItdevelopsWhena1rentersthe pleuralspace’butaflap﹣valvemechanismpreventsits escape·Intrapleuralpressurer1ses’causingtotallung coⅡapseandashiftofthemediastinumtotheopposite sidewiththesubsequentimpa1rmentofvenousreturn andiallincardiacoutput·Thepresenceofacuterespira﹣ toⅣdistress》subcutaneousemphysema,absentbreath sounds’hyperresonancetopercussion’andtrachealshift supportsthediagnosisandwarrantsimmediatethoracic decompressionwithoutwaitingfbrx﹣rayconfirmation ofthediagnosis.Appropriateplacementofaneed1emto thepleuralspaceinacaseoftensionpneumothorax temporarilyrelievesthislifb﹣threateningcondition.See SkiⅡStationⅥI;ChestTraumaManagement）SkiⅡVII﹣

sustainedaspinalinjuryoftenhaveconcurrenttorso trauma;therefbre,patientswithknownorsuspected neurogenicshockshouldbetreatedmitiallyfbrhypo﹣ volemia.The炮ilureofⅡuidresuscitationtorestoreor﹣ ganperh1sionsuggestseithercontinuinghemorrhage orneurogemcshock.CVPmonitoringmaybehelpfhl inmanagingthiscomplexproblem.SeePhapter7: SpineandSpinalCordTrauma

SepticShockShockduetoinfbctionimmediatelyaf terinjuryisuncommon;however,ifapatient’sarrival atanemergen叮fhcilityisdelayedfbrseveralhours,it canoccur.SepticshoCkcanoccurinpatientswithpen﹣ etratmgabdominaliIUuriesandcontaminationofthe peritonealcavi勺byintestinalcontents.Patientswith sepsiswhoalsohavehypotensionandareaibbrileare clinicallydifIiculttodistinguishfromthosemhypovo﹣ lemicshock》asbothgroupscanmanifbsttachycardia, cutaneousvasoconstriction,impairedurina1youtput, decreasedsystolicpressure,andnarrowpulsepressure. Patientswithearlysepticshockcanhaveanormalcir﹣ culatingvolume,modesttachycardia,warmskin,systo﹣ licpressurenearnormal’andawidepulsepressure’

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Neu『ogenicShockIsolatediht『ac『ahiaIiniu『iesdonot causeshock·Thepresenceofshockinapatientwitha headi叼urynecessitatesthesearchfbracauseother thananintracranialinjury.Cervical0ruppertho﹣ racicspinalcordmjurycanproducehypotensiondue tol0ssofsympathetictone·LossofSympathetictone compoundsthephysiologiceffbctsofhypovolemia, andhypovolemiacompoundsthephysiologiceffbctsof sympatheticdenervation.Theclassicpictureofneuro﹣ gemcshockishyp0tensionwithouttachycardiaorcu﹣ taneousvasoconstriction’Anarrowedpulsepressure isnotseeninneurogenicshock.PatientsWhohave

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∣P Ⅱemo『『 hagicShocI《 C

∣

Hemo『『hageisthemostcommoncauseofshockint『au. mapatients.Thetraumapatient’sresponsetobloodloss ismademorecomplexbyshiftsoffluidsamongthefluid compartmentsinthebody－particularlyintheextracel﹣ lularfluidcompartment.Theclassicresponsetoblood lossmustbeconsideredinthecontextoffluidshiftsas﹦ sociatedwithsofttissuem〕my.Inaddition’thechanges associatedwithsevere,prolongedshockandthepatho﹣ physiologicresultsofresuscitationandrepermsion mustalsobeconsidered,aspreviouslydiscussed.

DEFINITI0Ⅱ0FⅡEM0RRⅡAGE Hemorrhageisdefinedasanacuteloss0fcirculating bloodv0lume.Althoughthereisconsiderablevariabil﹣

HEMORRHAG∣CSHOCI﹤69

ity’thenormaladultbloodvolumeisapproximately 7℅ofbodyweight.Forexample’a70﹣kgmalehasa circulatingbloodvolumeofapproximately5L.The bloodvolumeofobeseadultsisestimatedbasedon theiridealbodyweight,becausecalculationbasedon actualweightcanresultinsignificantoverestimation. Thebloodvolume允rachildiscalculatedas8﹪to9﹪ ofbodyweight（80－90mL／kg）.SeeChapter10:Pediat﹣ ricTraumR.

andresuscitationofinjuredpatientswhoareatriskfbr hemorrhagicshoCk.Thesefhctorsinclude: ■Patient,sage ■Severityofinjury’withspecialattentionto typeandanatomiclocationofinjury ■Timelapsebetweeninjmyandinitiationof treatment ■Prehospitalfluidtherapy ■Medicati0nsused仇rchronicconditions

D∣RECTE『「ECTS0「ⅡEM0RRⅡAGE

Itisdange『oustowaituntiIat『aumapatient伺tsa

Theclassilicationofhemorrhageintofburclassesbased onclinicalsignsisauseMtoolfbrestimatingtheper﹣ centageofacutebloodloss·Thesechangesrepresenta continuumofongoinghemorrhageandserveonlyto guideinitialtherapy.SubsequentvoIume『epIacement isdete『minedbythepatient,s『esponsetoinitiaIthe『apy· ThisclassificationSystemisusefhlinemphasizingthe earlysignsandpathophysi0logyoftheshockstate. ClassIhemorrhageisexemplifiedbythecondi﹣ tionofanindividualwhohasdonatedaunitofblood ClassIIhemorrhageisuncomplicatedhemorrhage ibrwhichcrystalloidfluidresuscitationisrequired· ClassIIIhemorrhageisacomplicatedhemorrhagic stateinwhichatleastcrystalloidinfhsionisrequired andperhapsalsobloodreplacement.ClassIVhemor. rhageisconsideredapreterminalevent;unlessvery aggressivemeasuresaretaken,thepatientwilldie withinminutes’Table3.1outlinestheestimatedblood lossandothercriticalmeasuresfbrpatientsineach classihcationofshock· Severalconfbundingfhctorsprofbundlyalterthe classichemodynamicresponsetoanacutelossofcircu﹣ latingbloodvolume,andthesemustbepromptlyrecog﹣ mzedbyaIlindividualsinvolvedintheinitialassessment

p『ecisephysioIogiccIass而cationo「shocI《be｛b『einitiatiⅡg app『op『iatevoIume『esto『atioⅡ·Hemo『『hagecont『o∣and baIanced｛luid『esuscitationmustbeiⅡitiatedwhenea『Iy signsandsymptomso「bIoodIossa『eappa『ento『sus. pected＿notwhenthebIoodp『essu『eis陌Ilingo『absent’ BIeedingpatientsneedb∣ood!

CIass∣Ⅱemo『『hage＿Upto15℅ BIoodVoIumeLoss TheclinicalsymptomsofvolumelosswithclassIhe﹣ morrhageareminimal.Inuncomplicatedsituations, minimaltachycardiaoccurs.Nomeasurablechanges occurinbloodpressure’pulsepressure）orrespiratory rate’Forotherwisehealthypatients’thisamountof bloodlossdoesnotrequirereplacement’becausetrans﹣ capillaryrefillandothercompensatorymechanisms willrestorebloodvolumewithin24hours》usually withouttheneedfbrbloodtransfhsion.

CIassⅡHemo『『hage＿15℅to30℅ BloodVo∣ume∣﹣oss Ina70﹣kgmale,volumelosswithclassIIhemor﹣ rhagerepresents750to1500mLofblood.Clinical

■TABLE3』EstimatedBlood【oss1BasedoⅡPatieⅡt,sI㎡tiaIp『esehtatioh αAssl

αA5sⅡ

CLA5SⅡ∣

C儿ASs∣V

BI0odI0ss（m【）

Upto750

750一1500

∣500＝Z000

＞Z000

BIoodIoss（℅bl0odvoIⅡme）

Upt015℅

↑5℅︼30％

30℅＝▲0％

﹥40℅

Pulse『ate（BPM）

＜100

100﹦1Z0

】Z0﹦140

＞1▲0

SystoIicbp『essu『e

No『ma∣

No『mal

Dec「eaSed

DeC『eaSed

pusIep『essu『e（mmⅡg）

Ⅱo『maIo『inc『eased

Dec『eased

Dec『eaSed

Dec『eased

Respi『ato『y『ate

M－20

Z0＿30

30＝q0

＞35

U『Ⅱ i eoutput（m／ l】 l 『）

﹥30

Z0-30

5＿15

ⅡegligibIe

CⅡS／mentaIstatus

S∣ightlyanxious

Mi∣d∣yanxIous

Anxiou5’c0nfused

C0nfused‘Ietha『gi〔

lnitiaIf∣uid『epIaCement

C「y5taI∣oid

C「yStaIloid

CⅣstalloidandblood

C「y5taI∣oidandb∣00d

∣「o『a70﹣kgman

70CHAPTER3■Shock

signsincludetachycardia（heartrateabove100m anadult）,tachypnea’anddecreasedpulsepressure》 thelattersignisrelatedprimarilytoariseinthedi﹣ astoliccomponentduetoanincreaseincirculating catecholamines.Theseagentsproduceanincreasein peripheralvasculartoneandresistance.Systolicpres﹣ surechangesminimaⅡymearlyhemorrhagicshock; therefbre,itisimportantt0evaluatepulsepressure ratherthansystolicpressure.Otherpertinentclimcal findingswiththisamountofbloodlossincludesubtle centralnervoussystem（CNS）changes,suchasanxi﹣ ety,fright,andhostility.Despitethesignificantblood lossandcardiovascularchanges,urma】,youtputisonly mildlyaffbcted.Themeasuredurineflowisusually20 to30mL／hourinanadult. Accompanyingfluidlossescanexaggeratethe clinicalmamfbstationsofclassIIhemorrhage.Some patientsinthiscategorymayeventuaⅡyrequireblood trans血sion’butm0starestabilizedinitiallywithcIys﹣ tHⅡoidsolutions.

C∣assⅢHemo『『hage－30℅to40℅ B∣oodVolumeLoss ThebloodlosswithclassⅡIhemorrhage（approximate﹣ ly1500＝2000mLinanadult）canbedevastating.Patientsalmostalwayspresentwiththeclassicsignsof inadeqUateperfhsion,mcludingmarkedtachycardia andtaChypnea’significantchangesinmentalstatus’ andameasurablefhllm叮stolicpressure.Inanuncom﹣ pⅡcatedcase,thisistheleastamountofbloodlossthat consistentlycausesadropin可stolicpressure.Patients withthisdegreeofbloodlossahnostalwaysrequ1re transfhsion.However’thepriⅢi叮ofinitialmanagementistostopthehemo】Thage’byemergencyopera﹣ tionorembohzationifnecessa1y·M0stpatientsinthis categorywiⅡrequ1repa止edredbloodceⅡs（pRBCs） andbloodproductresuscitationinordertoreversethe shockstate.Thedecisiontotrahslhsebl0odisbasedon thepatient,sresponsetoinitialfluidresuscitation·

CUⅡICAlU5E「UlⅡESSO「 αASS∣『∣CAT∣ONSCⅡEME ThecIinicalusefhlnessoftbisclassihcationscheme1s illustratedbythefbllowingexample:A70﹣kgpatient withhypotensionwhoarrivesatanEDortrauma centerhaslostanestimated1470mLofblood（70kg x7℅x30℅﹦1.47L,or1470mL）.Resuscitationwill likelyreqUirecrystalloid,pRBCs’andblo0dproducts. Nonresponsetofluidadministrationalmostalwaysin﹣ dicatespersistentbloodlosswiththeneedfbropera﹣ tiveorang1ographiccontrol.

『山IDCⅡAⅡGESSEC0ⅡDARγT0 S0『TTISSUE∣Ⅱ』URγ M勻orsoittissueiIUuriesandfiPacturescompromisethe hemodynamicstatusofiIUuredpatientsmtwoways: 1’First’bloodislostmtothesiteofinjury,particu﹣ larlymcasesofm可orfractures.Forexample,a fTacturedtibiaorhl】me】yuscanbeassociatedwith thelossofasmuchas1·5units（750mL）ofblood· Twicethatamount（upto1500mL）iscommonly associatedwithfbmurfractures’andseveralliters ofbloodcanaccumulatemaretroperitonealhema﹣ tomaassociatedwithapelvichacture. Z·Thesecond兔ctortobeconsideredistheedema thatoccursininjuredsofttissues.Thedegree ofthisadditionalvo】1】melossisrelatedtothe magnitudeofthesofttissueimu1y.Tissueinjmy resultsmactivationofasystemicin日ammatory responseandproductionandreleaseofmultiple Cytokines.ManyoftheselocaⅡyactivehormones haveprofbundeffbctsonthevascularendothe﹣ lium’whichmcreasespermeability.Tissueedema istheresultofshiftsinfluidprimarilyfromthe plasmaintotheextravascular’extracellularspace duetoalterationsinendothelialpermeability. Suchshiftsproduceanadditionaldepletionin intravascularvolume.

C∣a5sIVHemo『『hage＿Mo『ethan』0℅ BIoodVoIumeLoss ThedegreeofexsanguinationwithclassⅣhemor﹣ rhageisimmediatelylifb﹣threatening.Symptomsin﹣ cludemarkedtachycardia,asignificantdecreasein systolicblo0dpressure’andaverynarrowpulsepres﹣ sure（oranunobtainablediastolicpressure）.Urinary outputisnegligible,andmentalstatusismarkedlyde﹣ pressed.TheskiniscoldandpalePatientswithclass Ⅳhem0rrhagefrequentlyreqU1rerapidtransh1sion andimmediatesurgicalmtervention.Thesedecisions arebasedonthepatient’sresponsetotheinitialman﹣ agementtechmquesdescribedinthischapter.Lossof morethan50℅ofbloodvolumeresultsml0ssofconsciousnessanddecreasedpulseandbloodpressure.

﹥

∣nitiaIIVianagementof Ⅱemo『『hagicShod《

?刪⋯Ⅷ⋯⋯: Thediagnosisandtreatmentofshockmustoccural﹣ mostsimultaneously.Formosttraumapatients’treat﹣ mentisinstitutedasifthepatienthashyp0volemic shock）unlessthereisclearevidencethattheshock statehasadifIbrentcause.TlTebasicmanagemeⅡtp『in. cipleistostopthebleedingand『eplacethevolumeIoss.

lNITIALMANAGEMENTOFHEMORRHAGICSHOCK71

pHγSICAlEXAMlNATl0N Thephysicalexaminationisdirectedtowardtheim﹣ mediatediagnosisofhfb﹣threateninginjuriesandincludesassessmentoftheABCDEs·Baselinerecordings areimportanttomonitorthepatient,sresponseto therapy’andmeasurementsofvitalslgns,urmaryout﹣ put’andlevelofconsciousnessareessential.Amore detailedexaminationofthepatientfbⅡowsasthesitu﹣ ationpermits·SeeChapter1InitialAssessmentand Management.

Ai『wayandB『eathing Establishingapatentairwaywithadequateventila﹣ tionandoxygenationisthefirstpriority.Supplemen﹣ taryoxygenisprovidedtomaintainoXygensaturation atgreaterthan95﹪.SeeChapter2;AirwayandVenti﹣ latoryManagement.

Whenund『essingthepatient｝itisessentialtop『event hypothe『mia·Theuseoffluidwarmersandexternal passiveandactivewarmingtechmquesareessentialto preventhypothermia.

Gast『icDi∣ation－Decomp『ession GastricdⅡationoftenoccursmtraumapatients’especiaⅡyinchⅡdren,whichcancauseunexplainedhypo﹣ tensionorcardiacdysrhythmia,usuaⅡybradycardia fTomexcessivevagalstimulation.lnuncoⅡsciouspa﹣ tiehts’gast『icdistentioninc『easesthe『iskofaspi『ationof gast『iccontents’whichisapotehtiaⅡy伯talcompIication. Gastricdecompressionisaccomplishedbyintubating thestomachwithatubepassednasallyororallyand attachingittosuctiontoevacuategastriccontents. However’properpositioningofthetubedoesnotcom﹣ pletelyobviatetheriskofaspiration.

U『ina『yCathete『ization α『cuIation＿Hemo『『hageCont『oI Prioritiesfbrmanagmgcirculationincludecontrolling obvioushemorrhage’obtainingadequateintravenous access’andassessingtissueperfhsion.Bleedingfrom externalwoundsusuallycanbecontrolledbydirect pressuretothebleedingsite,althoughmassiveblood lossfromanextremitymayrequireatourniquet.A sheetorpelvicbinderfromanextremilVmaybeused tocontrolbleedingfTompelvic仕actures.Theadequa﹣ cyoftissueperfUsiondictatestheamountoffIuidre﹣ suscitationrequired·Surgicalorangiographiccontrol mayberequiredtocontrolinternalhemorrhage.The priorityistostopthebleeding,nottocalculatethe volⅦmeofHuidlost.

DisabiIity－Ⅱeu『oIogicExamination Abriefneurol0gicexaminationwilldeterminethepa﹣ tient’slevelofconsciousness,eyemotionandpupillary response,bestmotorh1nction,anddegreeofsensa﹣ tion.Thisinfbrmationisusefblinassessingcerebral perfhsion’fbllowingtheevo】utionofneurologicdis﹣ abⅢly,andpredictmg血turerecove】yAlterationsin CNShmctionmpatientsWhohavehypotensionasa resultofhypovolemicshoCkdonotnecessarilyimply directintracranialinjmyandmayreflectinadequate brainperfUsion.Restorationofcerebralperfhsionand o叮genationmustbeachievedbefbreascribingthese findingstointracranialiIUmy.SeeChapter6:Head Tra】】ma.

Exposu『e＿CompIeteExamination Afterlifbsavingprioritiesareaddressed,thepatient mustbecomplete】yundressedandcarefi1llyexam﹣ inedfromheadt0toetosearChfbrassociatedmluries·

Rl月ddercatheterizationa1lows允rassessmentofthe urinefbrhematuria（indicatingtheretr0peritoneum maybeasignificantsourceofbloodloss）andcon﹣ tinuousevaluationofrenalperfUsionbymonitoring urinaryoutput.Bloodattheurethralmeatusora high﹣riding,mobile,ornonpalpableprostateinmales isanabsolutecontraihdicationtotheinsertionofa transurethralcatheterpriortoradiographicconfirma﹣ t i o n o f a n i n t a c t u r e t h r a . S e e 0hapter5;Abdominal HhdPelvicTrauma.

VASC0lARACCESSⅡNES Accesstothevascularsystemmustbeobtained promptlyThisisbestaccomplishedbyinsertingtwo large﹣caliber（minimumof16-gaugeinanadult）pe﹣ ripheralintravenouscathetersbefbreplacementofa centralvenouslineisconsidered.TherateofHowis proportionaltothefburthpower0ftheradiusofthe cannulaandinverselyrelatedtoitslength（PoiseuⅡle,s law）.Hence’short,large﹣caliberperipheralintrave﹣ nouslinesareprefbrredfbrtherapidmfUsionoflarge volumesoffluid.FluidwarmersandrapidinfUsion pumpsareusedinthepresenceofmassivehemor﹣ rhageandseverehyp0tension. Themostdesirablesitesfbrperipheral’percuta﹣ neousintraven0uslinesmadultsarethefbrearms andantecubitalveins.Ifcircumstancespreventthe useofperipheralvems’large-ca1iber’centralvenous （i.e,fbmoral’jugular’orsubclavianvein）access usingtheSeldingertechniqueorsaphenousveincut﹣ downisindicated,dependingontheclinician’sskill andexperience.SeeSkillStationIV:ShockAssess﹣ n 1 e n t a n dManagement, a n d S k i l l S t a t i o n V : V e n o u s Cutdown

7ZCHAPTER3■Shock Frequentlyinanemergencysituation’central venousaccessisnotaccomplishedundertightlycon﹣ trolledorcompletelysterileconditions·Therefbre, theselinesshouldbechangedinamorecontrolled environmentassoonasthepatient,sconditionper﹣ mits.Considerationalsomustbegiventothepotential fbrseriouscomplicationsrelatedtoattemptedcentral venouscatheterplacement,suchaspneumothoraxor hemothorax’inpatientswhomayalreadybeunstable. Inchildrenyoungerthan6years,theplacement ofanintraosseousneedleshouldbeattemptedbefbre insertingacentralline·Theimportantdeterminant fbrselectingaprocedureorroute｛brestablishing vascularaccessistheclinician,sexperienceandskill. Intraosseousaccesswithspeciallydesignedequipment isp0ssiblemα〃αg它g／D吻s’andisbeingusedwith increasingfTequenCy.Asinthepediatricpopulation’ thisaccessmaybeusedin﹃hospitaluntilintravenous accessisobtained· Asintraven0uslinesarestarted,blo0dsamplesare drawnfbrtypeandcrossmatch’appropriatelabora﹣ to叮analyses,toxicologystudies,andpregnancytest﹣ ingibrallfbmalesofchildbearingage.Arterialblo0d gas（ABG）analysisisperfbrmedatthistime·Achest x﹣raymustbeobtainedafterattemptsatinsertinga subclavianorinternaljugularCVPmonitoringlineto documentthepositionofthelineandevaluatefbra pneumothoraxorhemothorax’

IⅡITlAL「LUIDTⅡERAPγ Warmedisotomcelectrolytesolutions’suchaslactated Binger,sandnormalsaline,areusedfbrinitialresus﹣ citation.This｛ypeofiluidprovidestransientintra﹣ vascularexpansionandfbrtherstabilizesthevasculaI volumebyreplacingaccompanyingfluidlossesintothe interstitialandintracellularspaces. AninitiaI’wa『med｛Iuidbo∣usisgiven·Theusualdose is】to2【fb『aduItsahd之omL／I《g｛b『pediat『icpatieⅡts. AbsoIutevoIumeso「『esuscitation｛luidsshou∣dbebased onpatient『esponse·Itisimpo㎡antto『emembe『thatthis initiaI↑IuidamountincIudesany｛Iuidgiveninthep『ehos.

theseestimates,acareh1lreassessmentofthesituationandsearchfbrunrec0gnizedinjuriesandother causesofshockarenecessary· Thegoalofresuscitationistorestoreorganper﹣ fhsion.Thisisaccomplishedbytheuseofresuscitation fluidstoreplacelostintravascularvolume.Note,how﹣ ever,thatifbloodpressureisraisedrapidlybefbrethe hemorrhagehasbeendefinitivelycontrolled,increased bleedingcanoccur.pe『sistentinfi』siono「Ia『gevoIumes o「｛Iuidandb∣oodihanattempttoachieveano『malbIood p『essu『eisnotasubstitute化『de偷nitive∞nt『oIo「bIeed. ing·Excessivefluidadministrationcanexacerbatethe lethaltriadofcoagulopathy,acidosis》andhypothermia withactivationoftheinf】ammatorycascade. Fluidresuscitationandavoidanceofhypoten﹣ sionareimportantprinciplesintheinitialmanage﹣ mentofblunttraumapatients,particularlythosewith traumaticbrainmjury（TBI）.Inpenetratingtrauma withhemorrhage,delayingaggressivef】uidresuscita﹣ tionuntildefinitivecontrolmaypreventadditional bleeding.Althoughcomphcationsassociatedwith resuscitationinju1yareundesirable’thealternative ofexsanguinationisevenlessso.Acare血l,balanced approachwithfrequentreevaluationisrequired Balancingthegoaloforganperfhsionwiththe risksofrebleedingbyacceptingalower﹣than﹣normal bloodpressurehasbeentermed“controlledresuscita﹣ tion’”（‘balancedresuscitation’,’‘‘hypotensiveresus﹣ citation,”and“permissivehypotension.’,Thegoalis thebalance’notthehypotension.Sucharesuscitation strategymaybeabridgeto,butisnotasubstitutefbr’ definitivesurgicalcontrolofbleeding.

▲▲

Rec0gnizethesou『ceofoccuIthemo『『hage.Remem﹣ be「!〃BIoodonthefIoo『＋fou「mo「e.〃Che5t『peIvis （『et『0pe「itoneum）『abdomen’andthigh.

pitaIsetting·Thepatient,sresponseisobservedduring thisinitialfluidadministration,andfhrthertherapeu﹣ ticanddiagnosticdecisionsarebasedonthisresponse· Theamounto「｛IuidandbIood『equi『ed↑b『『esus· citationisdi侃culttop『edictoninitia∣evaIuationo「the

疝。■■■■■■■■■■■■■■■■■■■■■

遭

1

▽

『

﹀

一

V

■

5ceⅡa『io■con觔huedThepatie㎡SCheSt x﹣「aysh0wsawIdemediastinumandseve『aI 「b i ↑「actu『es0nthe∣e↑tsd i e’Ⅱe『peIvc i x﹣『ayIs n0『ma∣Ⅱe『「ASTexamsh0w5n0ca『diacabn0r maIities’The『eis↑IuidlnM0『『is0n!sp0uchHe「 『espi『at0『y『atels36!puI5eI40!andbI00dp『e5﹣ 5u「e80／pap I’

patient.Table31providesgeneralguidelinesfbrestab﹣ lishingtheamountoffluidandbloodlike】yrequiredIt ismostimpo『tanttoassessthepatient,s『espoⅡseto↑Iuid 『esuscitationandidentifyevidenceofadequateeⅡd氬o『gan pe伽sionandoxygelTation（i.e.’viau「ina『youtput’IeveI ofcoⅡscioushess’andpe『iphe『aIpe『fi』sion｝·If｝during resuscitation,theamountoffluidrequiredtorestore ormaintainadequateorganperfhsiongreatlyexceeds

∣

PIⅡFA『」『』S

﹂

THERApEUTlCDECISI0NSBASED0NRESPONSETOlNITIALFLUIDRESUSCITATlON73

Eva∣uationof『∣uidResuscitation and0『ganPe『fusion

?Ⅷ⋯卹α繃⋯罈⋯.; ThesamesignsandSymptomsofinadequateperfUsion thatareusedtodiagnoseshockareusefUldetermi﹣ nantsofpatientresponse.Thereturnofnormalblood pressure,pulsepressure’andpulseratearesignsthat suggestperibsionisreturningtonormal.However, theseobservationsg1venoinfbrmationregardingor﹣ ganperfhsion.ImprovementsintheCVPstatusand skincirculationareimportantevidenceofenhanced perfhsion,butaredifficulttoquantitate.Thevolume ofurinaryoutputisareasonablysensitiveindicator ofrenalperfhsion,normalurinevolumesgenerally implyadequaterenalblo0dflow,ifnotmodifiedby theadministrationofdiureticagents.Forthisreason’ urinaryoutputisoneoftheprimemonitorsofresus﹣ citationandpatientresponse.ChangesinCVPcan pr0videusefhlinfbrmation’andtherisksincurredin theplacementofaCVPlinearejustifiedfbrcomplex cases·

determimngthepresenceandseverityofshock.Se﹣ rialmeasurementoftheseparameterscanbeusedto momtortheresponsetotherapy.Sodiumbicarbonate shouldnotbeusedtotreatmetabolicacidosissecond﹣ a1ytohypovolemicshock.

▼ 」

The『apeuticDecisionsBased onResponseto∣nitiaI『Iuid Resusdtation

Thepatient,s『esponsetoinitialfIuid『esuscitationisthe l《eytodete『mmingsubsequentthe『apy.Havingestab﹣ lishedapreliminarydiagnosisandtreatmentplan basedontheinitialevaluation,thecliniciannowmodi﹣ fiestheplanbasedonthepatient’sresponse.Observ﹣ ingtheresponsetotheinitialresuscitationidentifies patientswhosebloodlosswasgreaterthanestimated andthosewithongoingbleedingwhorequireoperative controlofinternalhemorrhage.Resuscitationinthe operatingroomcanaccomplishsimultaneouslythedi﹣ rectcontrolofbleedingbythesurgeonandtherestora﹣ tionofintravascularvolume.Inaddition,itlimitsthe probabili叮ofovertransfhsionorunnecessarytrans｛h﹣ sionofbloodinpatientswhoseinitialstatuswasdis﹣

URINARγ0UTPUT Withincertainlimits’urinaryoutputisusedtom0ni﹣ torrenalbloodflow.Adequateresuscitationvolume replacementshouldproduceaurinaryoutputofap﹣ proximately0.5mL／kg／hrinadults’whereas1mL／kg／ hrisanadequateurinaryoutputfbrpediatricpatients· Forchildrenunder1year0fage,2mL／kg／hourshould bemaintainedTheinabilitytoobtainurina】youtput attheselevelsoradecreasingurinaryoutputwithan increasingspecificgravitysuggestsinadequateresus﹣ citation.Thissituationshouldstimulateh1rthervol﹣ umereplacementanddiagnosticendeavors.

proportionatetotheamountofbloodloss. Itisparticularlyimportanttodistinguishpatients whoare“hemodynamical】ystable”fromthosewhoare “hemodynamicallynormal·’,Ahemodynamicallystable patientmayhavepersistenttachycardia,tachypnea, andoliguria;thispatientisclearlyunderresuscitated andstillinshockIncontrast】hemodynamicallynormal patientsexhibitnosignsofinadequatetissueperfUsion· Thepotentialpatternsofresp0nsetoinitialfluid administrationcanbedividedintothreegroups; rapidresponse,transientresponse’andminimalor noresponse.Vitalsignsandmanagementguidelines fbrpatientsineachofthesecategoriesareoutlinedin Table3.2.

AαD﹦BASEBAlAⅡCE Patientsinearlyhypovolemicsh0ckhaverespiratory alkalosisduet0tachypnea.Respirato】yalkalosisisfTe﹣ quentlyfbⅡowedbymⅡdmetabolicacidosismtheearly phasesofshockanddoesnotrequiretreatment·Se﹣ veremetabolicacidosiscandevelopfTomlongstanding orsevereshock.Metabolicacidosisiscausedbyanaer﹣ obicmetabolism,Whichresultsfrominadequatetissue perfhsionandtheproductionoflacticacid.Persistent acidosisisusuaⅡycausedbyinadequateresuscitation orongoingbl0odlossand’innormothermicpatients mshock,itshouldbetreatedwithfluids’blood’and considerationofoperativeinterventiontocontrolhe﹣ morrhage.Basedeficitand／orlactatecanbeusefhlin

RAP∣DRE5P0ⅡSE Patientsinthisgroup,termed“rapidresponders’”re﹣ spondrapi砠ytotheinitialfluidbolusandremainhe﹣ modynamicallynormalaftertheimtialfIuidbolushas beeng1venandthefluidsareslowedtomaintenance rates.Suchpatientsusuallyhavelostminimal（less than20℅）bloodvolume.NofUrtherf】uidbolusorim﹣ mediatebloodadministrationisindicatedfbrpatients inthisresponsegroup.Typedandcrossmatchedblo0d shouldbekeptavailable.Su『gicaIconsuItatiohandevaI. uationa『enecessa『ydu『ihginitiaIassessmentandt『eat· ment,asope『ativeihteⅣentiohmaystiIIbenecessa『y.

7』CHAPTER3■ShocI﹤

■TABLE3。2Respon5estolⅡitial「!uMResⅡscitatioⅡ 1 RApIDRESp0ⅡSE

TRAⅡsIEⅡTRESp0NsE

MIMMAl0RⅡ0RESP0ⅡsE

VitaIsigns

Retu『ntono「maI

T『ansientimp『ovement’『ecu『「ence ofdec「easedbIoodp『e5su『eand InC『eaSedhea『-t「ate

Remainabn0『ma∣

Estimatedb∣oodIoss

Mn i Ima∣ （10℅－Z0℅）

Mode『ateandongoIng（20％＝q0℅）

Seve「e（﹥40℅）

Ⅱeedfo『mo『ec『y5taIloid

Low

Lowtomode『ate

Mode『ateasab『idget0t『ansfusion

Ⅱeed『o『blood

LOw

Mode「atetohig∣1

Immediate

8Ioodp『epa『ation

Typeandc「osSmatCh

Type﹣5pecifiC

Eme『gencybIood『eIease

Ⅱeedfo『0pe『ativeinte『veⅡtion

pos5ibIy

Uke∣y

Highly∣ike∣y

Ea『Iyp『esenceofsu『geon

Yes

YeS

YeS

II5otonicc『ysta∣lo∣dso∣ution’Z000m【inaduIt5﹩20mL／kginchild『en

TRAⅡSIEⅡTRESp0ⅡSE Patientsinthesecondgroup,termed“transientre﹣ sponders,”respondtotheinitialfluidbolus.However》 theybegintoshowdeteriorationofperfhsionindices astheinitialfluidsareslowedtomaintenancelevels, indicatingeitheranongoingbloodlossorinadequate resuscitationMostofthesepatientsinitiallyhave lostanestimated20℅to40℅oftheirbloodvolume. Translhsionofbloodandbloodproductsisindicated, butmoreimportantistherecognitionthatthispatient requiresoperativeorang1ographiccontrolofhemor﹣ rhage.Atransientresponsetobloodadministrati0n shouldidentifypatientswhoarestillbleedingandre﹣ quirerapidsurgicalintervention.

lVⅡⅡIMAl0RⅡORESP0ⅡSE FaiIu『eto『espondtoc『ystalIoidandbIoodadminist『ation ihtl1eEDdictatestheneedfb『immediate,dennitiveinte『﹦ vention（e.g.,ope『ationo『aⅡgioemboIization）tocont『oI exsanguiⅡatinghemo『『hage·OnveⅣrareoccasions’ fhiluretorespondmaybeduetopumpfhilureasa resultofbluntcardiacmjury’cardiactamponade’or tensionpneumothorax·Nonhemorrhagicshockalways shouldbeconsideredasadiagnosisinthisgroupof patients·CVPm0nitoringandcardiacultrasonogra﹣ phyhelptodiffbrentiatebetweenthevariouscauses ofshock.

PITFAI』『』S ■DeIayindefinitivemanagementcanbeIetha∣ ■D0notove「Io0kasou『ceofbIeeding.

∣三 BIoodRepIacement Thedecisiontoinitiateblo0dtransfhsionisbased onthepatient’sresponse’asdescribedintheprevi﹣ oussection.Patientswhoaretransientrespondersor nonresponders－thosewithClassIIIorClassⅣhem﹣ orrhage－willneedpRBCsandbloodproductsasan earlypartoftheirresuscitation（■F∣GuRE3﹣q）·

CR0SSMATCⅡED『TγP巳SPEα『ICl AⅡDTγpE0Bl00D Themampurposeofbloodtransfhsionistorestore theo叮gen﹃carryingcapacityoftheintravascularvol﹣ ume.Ful】ycrossmatchedbloodisprefbrable’However》 thecompletecrossmatchingprocessrequiresapproxi﹣ mately1hourinmostbloodbanks·Forpatients whostabilizerapidly,crossmatchedbloodshouldbe obtainedandmadeavailablefbrtransfhsionwhen ihdicated. Type﹣specificbloodcanbeprovidedbymostblood bankswithin10minutes.Suchbloodiscompatible withABOandRhbloodtypes,butincompatibilities ofotherantibodiesmayexist.Type﹣specificbloodis prefbrredfbrpatientswhoaretransientresponders, asdescribedintheprevioussection.Iftype-specific bloodisrequired,completecrossmatchingshouldbe perfbrmedbythebloodbank. Iftype﹣specificbloodisunavailable’typeOpacked cellsareindicatedfbrpatientswithexsanguinating hemo】rhage.Toavoidsensitizationandfhturecompli﹣ cations,Rh-negativecellsareprefbrredibrfbmalesof childbearingage.Assoonasitisavailable,theuseof unmatched,叮pe﹣specificbloodisprefbrredovertype Oblo0d.Thisistrueunlessmultiple’unidentifiedcas﹣

BLO0DREPLACEMENT75

ofshedblood.CoⅡectionofshedblood允rautotrans﹣ fhsionshouldbeconsideredfbranypatientwithama﹣ jorhemothorax. MASS∣VETRAⅡS『US∣0N AsmallsubsetofpatientswithshockwⅡlrequiremas﹣ sivetransfhsion’mostoftendefinedas＞10units0f pRBCswithinthefirst24hoursofadmission’Early administrationofpRBCs,plasma’andplatelets,and minimizingaggressivec1ystalloidadmimstrationin thesepatientsmayresultinimprovedsurvival.This approachhasbeentermedbalanced’hemostaticor damagecontrolresuscitation.Concomitanteffbrtsto rapidlycontrolbleedingandreducethedetrimental efIbctsofcoagulopathy,hypothermia’andacidosis inthesepatientsareextremelyimportant.Amas﹣ sivetransfhsionprotocolthatincludestheimmediate availabilityofallbloodcomp0nentsshouldbeinplace inordertoprovideoptimalresuscitationfbrthese patients》astheresourcesrequiredaretremendous. Theseprotocolsa1soimproveoutcome.

C0AGUl0PATⅡγ ■「∣GURE3﹣4Ma55ivet「ansfusion0fbIoodp『oductsin at『aumapatient.

ualtiesarebeingtreatedsimultaneouslyandtherisk ofinadvertently月dmihisteringthewrongunitofbl0od toapatientisgreat.

Severeinjuryandhemo1Thageresultmtheconsumptionofcoagulationfactorsandearlycoagulopathy. Suchcoagulopathyispresentmupto30℅ofseverely injuredpatientsonadmission.MassiveHuidresuscita﹣ tion,withtheresultantdiluti0nofplateletsandclottmg factors’alongwiththeadverseeffbctofhypothermiaon

Hypothermiamustbepreventedandreversedifa patienthashypothermiaonarrivalatthehospital. TheuseofbloodwarmersmtheEDiscritical’evenif cumbersome.Themostefficientwaytopreventhypo﹣ thermiainanypatientreceivingmassivevolumesof crystalloidistoheatthefluidto39。C（102·2。F）befbre infUsingit.Thiscanbeaccomplishedbystoringc1ys﹣ ljalloidsinawarmerorwiththeuseofamicrowave ovenBloodproductscannotbewarmedinam1cro﹣ waveoven,buttheycanbeheatedbypassagethrough intravenousfluidwarmers·

plateletaggregationandtheclottingcascade’contrib﹣ utestocoagulopathyini叮uredpatients.Prothrombin time,partialthromboplastintime’andplateletcount arevaluablebaseⅡnestudiestoObtaininthefirsthour’ especiallyifthepatienthasahisto】yofcoagulationdis﹣ ordersortakesmedicationsthataltercoagulation,or areliablebleedinghisto】ycannotbeobtained.Inpa﹣ tientswhodonotrequiremassivetransh1sion,theuse ofplatelets’c】y0precipitate,andfresh﹣frozenplasma shouldbeguidedbythesec0agulationparameters’in﹣ cludingfibrinogenlevels. Patientswithm則orbraininjuryareparticu﹣ larlypronetocoagulationabnormalities.Coagula﹣ tionparametersneedtobecloselymonitoredinthese patients;theearlyadministrationofplasmaand／0r plateletsimprovessurvivaliftheyareonknownanti﹣ coagulantsorantiplateletagents.

AUT0TRAⅡS『U5∣0N

CAlC∣UMADM∣Ⅱ∣STRATI0Ⅱ

Adaptationsofstandardtubethoracostomycollection devicesarecommerciallyavailable;theseallowfbr sterilecoⅡection’anticoagulation（generallywithso﹣ diumcitratesolutions’notheparin）,andretransfhsion

Mostpatientsreceivingblo0dtransfhsionsdonotneed calciumsupplements.Whennecessary,ndmihistrati0n shouldbeguidedbymeasurementofiomzedcalcium. Excessive’supplementalcalciummaybeharmh1l.

WARM∣ⅡG『lUlDS－PlASMAAⅡD CRγSTAU0ID

76CHApTER3■Sh0ck

﹥SpeciaⅡConside『ations

meetthemcreaseddemandsfbrgasexchangeimposed

∣balreadyproducedbyareductioninlocal0xygendeliv﹣ yiIUury.Thiscompoundsthecellularhypoxia

Specialconsiderationsinthediagnosisandtreatment ofshockincludethemistakenequationofbloodpres﹣ surewithcardiacoutput,advancedage’athletesin shock,pregnancy’patientmedications’hypothermia’ andthepresenceofpacemakers·

E0UAT∣ⅡGBl00DPRESSURE WITⅡCARDIACO0TpUT Treatmentofhypovolemic（hemorrhagic）shockre﹣ quirescorrectionofmadequateorganperfhsionby increasingorganbloodflowandtissueoXygenati0n. Increasingbloodflowrequiresanincreaseincardiac output.Ohm’slaw（V﹦IxR）appliedtocardiovas﹣ cularphysiologystatesthatbloodpressure（V）ispro﹣ portionaltocardiacoutput（I）andSystemicvascular resistance（R）（afterload）.Aninc『easeinbloodp『essu『e shouldnotbeequatedwithacoⅡcomitantinc『easeinca『﹣ diacoutputo『the『ecove『y什omshocl《·Anincreasein peripheralresistance－fbrexample’withvasopressor therapy－withnochangeincardiacoutputresultsin increasedbloodpressure,butnoimprovementintis﹣ sueperfhsionoro叮genation.

ADVAⅡCEDAGE Elder】ytraumapatientsrequirespecialconsidera﹣ tion.Theagmgprocessproducesarelativedecrease insympatheticactivitywithrespecttothecardiovas﹣ cularsystem.Thisisthoughttoresultfromadeficitin thereceptorresponsetocatecholamines,ratherthan fromareducti0nincatecholaminepr0duction·Car﹣ diaccompliancedecreaseswithage’andolderpatients areunabletoincreaseheartrateortheefIicienCyof my0cardialcontractionwhenstressedbybloodvolume loss,asareyoungerpatients. Atheroscleroticvascularocclusivediseasem2kes manyvitalorgansextremelysensitivetoeventheslightestreductioninbloodflow.Manyelderlypatientshave preexistingvolumedepletionresultingfTomlong﹂term diureticuseorsubtlemalnutrition.Forthesereasons, hypotensionsecondarytobloodlossisp0orlytolerated byelderlytraumapatients.β﹣adrenergicblockadecan masktachycardiaasanearlyindicatorofshock.Other medicationscanadverselyaffbctthestressresp0nseto 1nJuryorblockitcompletely.Becausethetherapeutic rangefbrvolumeresuscitationisrelativelynarrowin elderlypatients,itisprudenttoconsiderearlyinva﹣ sivemonitoringasameanstoavoidexcessiveorinad﹣ equatevolumerestoration. Thereductionmpulmonarycompliance,decrease indiffhsioncapacity’andgeneralweaknessofthemus﹣ clesofrespirationlimittheabihlyofelderlypatientst0

ery.Glomerularandtubularsenescenceinthekidney reducestheabih↑yofelderlypatientstopreservevol· umeinresponsetothereleaseofstresshormonessuch asaldosterone’catecholamines’vasopressin’andcorti﹣ sol.Thekidneyalsoismoresusceptibletotheeffbcts ofreducedbloodfl0wandnephrotoxicagentssuchas drugs’contrastagents,andthetoxicproductsofcel﹣ lulardestruction. Forallofthesereasons’mortalityandmorbidity ratesincreasedirectlywithageandlongtermhealth statusfbrmⅡdandmoderatelyseveremjuries.Despite theadverseeffbctsoftheagmgprocess,comorbidi﹣ tiesfiPompreexistingdisease’andageneralreduction inthe‘‘physiologicreserve”0fgeriatricpatients’the m可ori勺ofthesepatientsmayrecoverandreturnto theirpreinjurystatus。Treatmentbeginswithprompt’ aggressiveresuscitationandcarefhlmonitoring.See Chapter11?Geriatric T r a u m a

ATⅡ止ETES Rigorousathletictrainingroutineschangbthecardio﹣ vasculardynamicsofthisgroupofpatients·Bloodvol﹣ umemayincrease15℅to20℅’cardiacoutputsixfbld） strokevolume50℅,andtherestingpulsecanaverage 50.Theabili叮ofathletes》bodiestocompensatefbr bloodlossistrulyremarkable.Theusualresponsest0 hypovolemiamaynotbemanifbstedinathletes,even whensignificantbloodlosshasoccurred. pREGⅡAⅡCγ

Physiologicmaternalhypervolemiarequiresagreater bloodlosstomanifbstperfhsionabnormalitiesinthe mother’whichalsomaybereflectedindecreasedfbtal perihsion.See Chapter12:TraumamPregnancyand IntimatePartnerVoilence

MED∣CAT∣0NS β﹣adrenergicreceptorblockersandcalcium﹃channel blockerscansignificantlyalterapatient,shemody﹣ namicresponsetohemorrhage.Insulinoverdosing mayberesponsible允rhypoglycemiaandmayhave contributedtotheinjury﹣producingevent.Long﹂term diuretictherapymayexplainunexpectedhypokalemia’ andnonsteroidalantiinflammato叮drugs（NSAIDs） mayadverselyaffbctplateletfUnction. Ⅱγp0TⅡERMIA PatientssuffbringfTomhyp0thermiaandhemorrhagic shockdonotrespondnormallytotheadministration

REASSESSINGPATIENTRESpONSEANDAVOIDINGCOMPUCATIONS77

ofbloodandfluidresuscitation’andcoagulopathymay developorworsen.Bodytemperatureisanimportant vitalsigntomomtorduringtheinitialassessment phase.Esophagealorbladdertemperatureisanac﹣ curateclimcalmeasurementofthecoretemperature. AtraumHvictimⅡ】ndertheinfluenceofalcoholfmd exposedtocoldtemperatureextremesismoreⅡkely tohavehypotherm1aasaresultofvasodilation·Bapid rewarminginanenvironmentwithappropriateexter﹣ nalwarmingdevices’heatlamps’thermalcaps,heated respiratorygases’andwarmedintravenousfluidsand bloodwillgeneraⅡycorrecthypotensionandmildto moderatehypothermia.Corerewarmmg（irrigation oftheperitonealorthoraciccavitywithcrystalloid solutionswarmedto39。C〔102.2。F〕orextracorporeal bypass）isindicatedfbrseverehypothermia·Hypother﹦ miaisbesttreatedbyprevention.SeeChapter9:Ther﹣ malIniuries.

pRESENCE0『pACEMAl《ER Patientswithpacemakersareunabletorespondto blo0dlossintheexpectedfashion,becausecardiacout﹣ putisdirectlyrelatedtoheartrate·Inthesignificant numberofpatientswithmyocardialconductionde﹣ fbctswhohavesuchdevicesinplace》CVPmonitoring isinvaluabletoguidefluidtherapy.

｝ons e ReassessingPatientRespon andAvoidingCompIication! onS

Monitoringtheresponsetoresuscitationisbest accomplishedfbrsomepatientsinanenvironmentin whichsophisticatedtechniquesareused.Earlytrans﹣ fbrofthepatienttoanintensivecareunitshouldbe consideredfbrelderlypatientsandpatientswithnon﹣ hemorrhagiccausesofshock· CVPmonitoringisarelativelysimpleprocedure usedasastandardguidefbrassessingtheabⅢ叮ofthe rightsideofthehearttoacceptafluidload.Properly interpreted’theresponseoftheCVPtoHuidadmin﹣ istrationhelpsevaluatevolumereplacement·Several pointstorememberare: 1·Theprecisemeasureofcardiachmctionisthe relationshipbetweenventricularenddiastolic volumeandstrokevolume.Rightatrialpres﹣ sure（CVP）andcardiacoutput（asreflectedby evidenceofperfhsionorbloodpressure）oreven bydirectmeasurement）areindirectand’atbest, insensitiveestimatesofthisrelationship.Remem﹣ beringthesefhctsisimp0rtanttoavoidoverde﹣ pendenCyonCVPmomt0ring. Z·TheinitialCVPlevelandactualbloodvolumeare notnecessarilyrelated.TheinitialCVPissome﹣ timeshigh’evenwithasignificantvolumedehcit, especiallyinpatientswithchronicobstructive pulmonarydisease’generalizedvasoconstriction） andrapidfIuidreplacement.Theinitialvenous pressurealsomaybehighbecauseoftheinappro﹣ priateuseofexogenousvasopressors·

■

Inadequatevolumereplacementisthemostcommon complicationofhemorrhagicshock.Immediate,ap﹣ propriate,andaggressivetherapythatrestoresorgan perfUsionminimizessuchcomplications.

C0ⅡTlNUEDⅡEM0RRⅡAGE Anundiagnosedsourceofbleedingisthemostcom﹣ moncauseofpoorresponsetofluidtherapy.Patients withthisconditionaregenerallyincludedinthetran﹣ sientresponsecategory’asdefinedpreviously.Imme﹣ diatesurgicalinterventionmaybenecessary.

『LUlD0VER【0ADANDCVPM0N∣T0R∣ⅡG Afterapatient’simtialassessmentandtreatment havebeencompleted,theriskoffIuidoverloadismini﹣ mizedbycarefhlmonitoring·Remember’thegoalof therapyisrestorationoforganperh1sionandadequate tissueo酊genation,confirmedbyappropriateurinary output,CNShmction,skincolor,andreturnofpulse andbloodpressuretowardnormal.

3·AminimalriseinaninitiallylowCVPwithⅡuid therapysuggeststheneedfbrhlrthervolume expansion（useanappropriatefluidresuscitation category）andarenewedsearchfbrthesourceof bleeding. 4AdecliningCVPsuggestsongoingfIuidlossand theneedfbradditionalfluidorbloodreplacement （i·e·,transientresponsetofluidresuscitation category）. 5.AnabruptorpersistentelevationinCVPsuggeststhatvolumereplacementisadequateortoo rapid’orthatcardiacfhnctionisc0mpromised. 6.PronouncedelevationsofCVPmaybecausedby hypervolemiaasaresultofovertransfhsion’car﹣ diacdyshmction,cardiactamp0nade’orincreased intrathoracicpressurehomatensionpneumo﹣ thorax.Cathetermalpositioncanpr0duceerrone﹣ ouslyhighCVPmeasurements. Aseptictechniquesmustbeusedwhencentral venouslinesareplaced.Multiplesitesprovideaccess tothecentralcirculation’andthedecisionregarding whichroutetouseisdeterminedbytheclimcian’s skiⅡandexperience.Theidealp0sitionfbrthetipof

78CHAPTER3■Shock

thecatheterisinthesuperiorvenacava’justproxi﹣ maltotherightatrium.Techmquesfbrcatheterplace﹣ mentarediscussedindetailinSkiIlStationIV:Shock AssessmentandManagement Theplacementofcentralvenouslinescarries theriskofpotentiallylifb﹣threateningcomphcations· Infbctions’vascularinjmy’nerveinjury,emboliza﹣ tion,thrombosis,andpneumothoraxcanresult·CVP momtoringrefIectsrightheartfUnction.Itmaynotbe representativeofleftheartfhnctioninpatientswith

primarymyocardialdysfUnctionorabnormalpulmo﹣ narycirculation。

REC0GⅡITI0Ⅱ0『0TⅡERPR0BLEⅢS Whenapatientf白ilstorespondtotheraW’considerun﹣ diagnosedbleeding,cardiactamponade’tensionpneu﹣ mothorax,ventilato】yproblems’unrecognizedfluid loss’acutegastricdistention,myocardialinfhrction’dia﹣

beticacidosis’hypoadrenalism,andneurogemcshock· Constantreevaluation’especiallyWhenpatients’condi· tionsdeviate仕omexpectedpatterns’isthek叮torecog mzmgsuchproblemsasear】yaspossible

●

vLUJ∣八﹣一︶』

﹢

SceⅡa『io■coⅡcIusioⅡThepatientistaken immediateIyt0the0pe『ating「00mf0『0pe『ative 〔0nt『0I0｛hem0『『hageBI00dandpIasmaa『e given’andthemassivet『ansfusi0np『0t0c0∣is initiated

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∣

CHAPTERSUMMARY79

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C h a p t e r S u m m a r yy ChapterSum ⅢShockisanabnormalityofthecirculato叮Systemthatresultsininadequateor﹣ ganperfUsionandtissueoxygenation.Shockmanagement’basedonsoundphysi﹣ ologicprmciples,isusuaⅡysuccessfh1. 圓Hypovolemiaisthecauseofshockmmosttraumapatients.Treatmentofthese patientsrequ1resimmediatehemorrhagecontrolandfluidorbloodreplacement. Operativecontrolofthepatient’scontinuinghemorrhagemaybenecessary. 圃Thediagnosisandtreatmentofshockmustoccuralmostsimultaneously.For mosttraumapatients’㎡eatmentisinstitutedasifthepatienthashypovolemic shock’un1essthereisdearevidencethattheshockstatehasadiffbrentcause. Thebasicmanagementprmcipleistostopthebleedingandreplacethevo】ume lOSS. 囤Imtialassessmentofapatientmshockrequ1rescarefhlphysicalexamination’ lookingfbrsignsoftensionpneumothorax’cardiactamponade’andothercauses oftheshockstate’ 圓Themanagementofhemorrhagicshockincludesrapidhemostasisandbalanced resuscitationwithcrystalloidsandblood.Earlyidentificationandcontrolofthe sourceofhemorrhageisessential. 圃Theclassesofhemorrhageserveasanearlyguidetoappropriateresuscitation. CareiUlmomtoringofphysiologicresponseandtheabⅡitytocontrolbleedingwill dictateongoingresuscitationeffbrts. ■Bloodisadministeredtoresumetheo】qrgen﹣canymgcapacityoftheintravascu﹣ larvol1】mP. 圃0hallengesinthediagnosisandtreatmentofshockmcludeeqUaijingbloodpres﹣ surewithcardiacoutput’extremesofage,athletes,pregnancy,medications’hy﹣ potherm1a,andpacemakers. －

∣

80CHAPTER3■Sh0ck

■BsluoGRAⅢ

18’DentD,AlsabrookG’EricksonBA’etal.Bluntsple﹣ nici叮uries:highnonoperativemanagementratecan beachievedwithselectiveembohzation.JI】mMmα 2004;56（5）:1063﹣1067.

1’Abou﹣KhalilB,ScaleaTM,TrooskinSZ’etal.Hemodyna﹣ micresponsestoshockinyoungtraumapatients:needibr invasivemonitoring.O·肋Cm℃Mbd1994;22（4）;633.639.

19.DuttonRP,MackenzieCF’ScaleaTMHypotensive resuscitationduringactivehemorrhage:impactonin﹣ hospitalmortali叮.JTrααmα2002;52（6）:1141﹣1146.

2.AlamHB,RheeP·Newdevelopmentsinfluidresuscita﹣ tion.S【【唔α加Ⅳb㎡〃Am2007;87（1）:55﹣72’vi·

20.DzikWH,KirkleySA.Citratetoxicityduringmassive bloodtransfUsion.乃α肥S／hsMbdReu1988Jun;2（2）;76-94.

3·AsensioJA’MurrayJ,DemetriadesD,etal.Penetrating cardiaci叮uries:aprospectivestudyofvariablespredic﹣ tingoutcomes.JA加α〃S叨唔1998,186（1）:24﹣34.

21.EastridgeBJ’SalinasJ,McManusJG’BlackburnL’Bug lerEM,CookeWH,ConvertmoVA’WadeCE,Holcomb JB.Hypotensionbeginsat110mmHg:redefining‘‘hypo﹣ tension”withdata.J乃α泓mα2007Aug;63（2）:291﹣9.

4.BickellWH,WallMJ’PepePE,etal.Immediate versusdelayedfluidresuscitationfbrhypotensive patientswithpenetratingtorsoinjuries.ⅣE｝咱／JMbd 1994;331（17）:1105﹣1109. 5’BrohiK,CohenMJ,GanterMT’etal·Acutecoagulopathy 0ftrauma:hypoperh1sioninduces可stemicanticoagula﹣ tionandhyperfibrinolysis.JTrαumα2008;64:1211﹣7. 6·BrunsB’LmdseyM’RoweK’BrownS’MineiJP’Gen﹣ tilelloLM,ShafiS.HemoglObindropswithinminutes ofinjuriesandpredictsneedfbraninterventiontostop hemorrhage.JTm【』加α2007Aug;63（2）:312﹣5. 7.BunnF,RobertsI’TaskerR’AkpaE.Hypertonicver﹣ susnearisotoniccrystalloidfbrfIuidresuscitation incritical】yⅢpatients.αc〃m〃eDαtαbαse緲s㎡Reu 2004,（3）:CD002045· 8’BurrisD,RheeP,KaufinannC,etal.Controlledresusci﹣ tationfbruncontrolledhemorrhagicshock.JTrαα加α 1999;46（2）:216﹣223. 9.CarricoCJ’CamzaroPC,ShiresGT.Fluidresuscitation fbllowinginjury:rationaleibrtheuseofbalancedsalt solutions.C㎡『Cα沱Mbd1976;4（2）:46﹣54. 10.ChernowB’RaineyTG,LakeCR·Endogenousandexo﹣ genouscatecholamines.Cr肱“爬Med1982;10:409 11.CogbillTH,BlintzM,Johns0nJA’etal.Acutegastricdila﹣ tationaitertrauma.JI〉nⅢmα1987;27（10）;1113﹣1117. 12.CookRE’KeatingJF’GⅢespieI.Theroleofangiography mthemanagementofhaemorrhagefTomm勻or丘actures 0fthepelvis·JBo几eJb加rSmgBr2002;84（2）:178﹣182 13.CooperDJ,WalleyIⅡ《’WiggsRB,etal.Bicarbonatedoes notimprovehemodynamicsincriticaⅡyillpatientswho havelacticacidosis.A｝m血陀『7】Mbd1990,112:492. 14.Cott0nBA’AuBK’NunezTC,GunterOL’Roberts0n AM,YoungPP.PredefinedmassivetransfUsionproto﹣ colsareassociatedwithareductioninorganihilureand postinjurycomplications.cm】mα刀』α2009;66i41﹣9. 15·CottonBA’DossettLA’AuBK’NunezTC’Robertson AM’YoungPP.Roomfbr（perfbrmance）improvement: provider﹣relatedfhctorsassociatedwithpooroutcomes inmassivetransh1sion.J乃α叨『几α2009;67:1004﹣1012·

22.FangioP,AsehnouneK’EdouardA,SmailN,Benhamou D.Earlyembohzationandvasopressoradministrationfbr managementoflifb﹣threateninghemorrhagefTompeMc fracture.J?〉u泓mα2005;58（5）’978﹣984;discussion984. 23FerraraA’MacArthurJD,WrightHK,etal.Hypo﹣ thermiaandacidosisworsencoagulopathyinpatients requiringmassivetransh1sion.AmJSMJg1990;160:515. 24’GloverJL’BroadieⅢA.Intraoperativeautotransfbsion. Wb／。』dJS叨Jg1987;11:60﹣64. 25.GrangerDN.Roleofxanthineoxidaseandgranulo﹣ cytesmischemia﹣reperfUsionmjury.A加JPhJsfo／ 1988;255:H1269﹣H1275. 26’GreavesI,PorterKM,RevellMP.Fluidresuscitation inpre﹣hospitaltraumacare:aconsensusview.JRα／／ S【〃gEd加b2002;47（2）:451﹣457. 27.GuytonAC,LindseyAW’KaufinanBN.Effbctof meancirculato叮fⅢingpressureandotherperiphe﹣ ralcirculatory炮ctorsoncardiacoutput.A〃JJP／Us:o』 1955,180:463﹣468. 28.HakDJ.Theroleofpelvicangiographyinevaluationand managementofpelvictrauma.O㎡九Opα加lVb『沈Am 2004;35（4）:439﹣443,v. 29.HarriganC,Lucas0E’LedgerwoodAM’etal.Serial changesinprimaIyhemostasisa仇ermassivetransm﹣ si0n.Sα『gen／1985;98:836﹣840. 30HolcombJB,WadeCE,MichalekJE’ChisholmGB’ ZarzabalLA,SchreiberMA’GonzalezEA,PomperGJ, PerkinsJG,SpinellaPC,WilliamsKL’ParkMS.Incre﹣ asedplasmaandplatelettoredblo0dceⅡratiosimpro. vesoutcomein466massivelytrans血sedciviliantrauma patients.A冗几S叨Jg2008Sep;248（3）:447-58. 31.HoytDB.Fluidresuscitation:thetargethomananaly﹦ sisoftraumaSystemsandpatientsurvival’JZm叨加α 2003;54（5Suppl）:S31-35· 32.JurkovichQJ.Hypothermiainthetraumapatient.In: MaullKI,ed.Aduα冗cesZ〃仍m｛mα.Chicago:Yearbook; 1989:111﹣140·

16.DavisJW,KaupsKL’ParksSNBasedeficitissuperior topHinevaluatingclearanceofacidosisaftertraumatic shock.J乃αumα1998Jan;44（1）:114﹣118.

33.KaplanLJ,KellumJA‘InitialpH,basedeficit’lactate’ aniongap’strongiondiiIbrence’andstrongiongappre﹦ dictoutcomefTomm叮orvascularinju叮.Cr肱Cm·eMbd 2004;32（5）:1120-1124.

17DavisJW’ParksSN,KaupsKL,etal.Admissionbase deficitpredictstransh1sionrequirementsandriskof complications.JTrααmα1997Mar;42（3）;571﹣573’

34.Karmy﹣JonesR,NathensA,JurkovichGJ,etal·Urgent andemergentthoracotomyfbrpenetratingcheSttrauma. JTrα【【加α2004;56（3）:664﹣668;discussion668.669.

BlBLIOGRAPHY81 35.KnudsonMM,MaullKI.Nonoperativemanagementof solidorganmjuries.Past,present,andmture.Sα唔αm Ⅳb冗hAm1999;79（6）:1357﹣1371.

trans血sionprotocols:theroleofaggTessiveresuscitation versusproductratioinmortalityreduction.cJAmα〃 Sα唔2009（2）:198﹣205.

36.KraghJFJr’WaltersTJ,BaerDG,FoxCJ’WadeCE’ SalinasJ）HolcombJB·SurvivalwithemergenCytour﹣ niquetusetostopbleedinginm可orlimbtrauma.A〃几 SαJg2009Jan;249（1）:1﹣7.

50.RobackJD’CaldwellS,CarsonJ’DavenportR’Drew MJ’EderA’FungM’HamiltonM’HessJR’LubanN, PerkinsJG’SachaisBS,ShanderA,SilvermanT,Snyder E,TormeyC,WatersJ,DjulbegovicB.Evidence﹣based practiceguidelinesfbrplasmatransfUsion·Tm〃s／hsio〃 2010.

37.KruseJA’VyskocilcU’HauptMT.Intraosseous:af】exi﹣ bleoptionfbrtheadultorchildwithdelayed,difficult,or impossibleconventionalvascularaccess·α㎡“爬M﹫d 1994;22;728﹣735· 38.LowrySF,FongY.CytokinesandtheceⅡularresponse toinjuIyandinlbction.In:WⅡmoreDW,BrennanMF, HarkenAH’etal.’eds.αJ沱O／t〃eSα唧cα／R孤㎡2〃t.New York:ScientilicAmerican;1990. 39.LucasCE,LedgerwoodAM.Cardiovascularand renalresponsetohemorrhagicandsepticshock.In; ClowesGHAJr’ed.T》uαmα’S叩s』sα〃dS〃oc您Ⅷe P〃Jsm／ogtcαBαstsO／ZⅥemny·NewYork:Marcel Dekker;1988:87﹣215. 40.MandalAK’SanusiM.Penetratingchestwounds:24 years’experience·i『b〃dJSαJg2001;25（9）:1145﹣1149· 41.MansourMA’MooreEE’MooreFA）ReadRR.Exigent postinjuIythoracotomyanalysisofbluntversuspenetra﹣ tingtrauma.Sα咱叼〃eco／Obs加f1992;175（2）:97﹣101. 42.MartinMJ’FitzSullivanE,SalimA,etal.Discordance betweenlactateandbasedeficitinthesurgicalinten﹣ sivecareunit:whichonedoyoutrust?AmeJSα咱 2006;191（5）;625-630. 43.McManusJ’YershovAL’LudwigD,HolcombJB,Salinas J’DubickMA,ConvertinoVA,HindsD,DavidW’Flana﹣ ganT,DukeJH.RadialpulsecharacterrelationshipSto systolicblo0dpressureandtraumaoutcomes.P沱〃oSp E加e唔∞γe2005Oct﹣Dec;9（4）:423﹣8· 44.MizushimaY,TohiraH’MizobataY’MatsuokaT’Yokota J.Fluidresuscitationoftraumapatients:howfhstisthe optimalrate?AmJE加e唔Med2005;23（7）:833﹣837. 45.NovakL,ShackfbrdSR’BourguignonP’etal.Compari. sonofstandardandalternativeprehospitalresuscitation inuncontrolledhemorrhagicshockandheadi叼uIy.J I〉nαmα1999;47（5）:834﹣844. 46.NunezTC,YOungPP,HolcombJB’CottonBA.Creation, implementation’andmaturationofamassivetransfh﹣ siOnprotocolfbrtheexsanguinatingtraumapatient.J 乃αM加α2010Jun;68（6）:1498﹣505.

51.RhodesM,BraderA,LuckeJ,etal.Adirecttransportto theoperatingroomfbrresuscitationoftraumapatients. J乃Ⅶα加α1989;29:907﹣915. 52.RohrerMI,NataleAM.Effbctofhypothermiaonthe coagulationcascade.Cr肱“祀M它d1992;20;490· 53.RotondoMF,SchwabCW,McGonigalMD,et洫. “Damagecontrol”:anapproachfbrimpr0vedsurvivalin exsanguinatingpenetratingabdominalinjmy.J乃uα加α 1993;35:375﹣382. 54.SadriH,Nguyen-TangT’SternR,HoffineyerP’Peter R.ControlofseverehemoIThageusingC﹣clampandarte﹣ rialembolizationinhemodynamicallyunstablepatients withpelvicringdisruption.A爬〃O㎡／jOpTrαα加αSα唔 2005;125（7）:443﹣447. 55.Sarno｛fSJ.蛐ocardialcontractilityasdescribedbyventricularfhnctioncurves:observationsonStarling’slaw oftheheart.P〃Jsio／Reu1988;35:107﹣122 56.SawyerRW）BodaiBI.ThecuITentstatusofintraosseous infi1sion.JAmα〃Sα唔1994;179:353﹣361. 57.ScaleaTM’HartnettRW,DuncanAO,etal.Centralven﹣ ouso刈gensaturation:ausefUlchnicaltoolintrauma patients.JZ1mαmα1990;30（12）:1539﹣1543· 58.ThouraniVH,FelicianoDV’CooperWA’etal.Penetra﹣ tingcardiactraumaatanurbantraumacenter:a22·year perspective.A加Sα唔1999;65（9）:811﹣816;discussi0n 817﹣818· 59.TyburskiJG,AstraL’WilsonRF’DenteC’StefIbsC. Factorsaffbctingprognosiswithpenetratingwounds oftheheart·J乃Ⅶαmα2000;48（4）:587.590;discussion 590﹣591. 60.vonOUO’BautzP’DeGM.Penetratingthoracicinjuries:whatwehavelearnt.Ⅲ】homcα㎡!ouαscSα唔 2000;48（1）:55﹣61 61.WerwathDL,SchwabCW’ScholterJR,etal.Microwave oven:asafbnewmethodofwarmingcIystalloids·AmJ Sα唔1984;12:656﹣659.

47·PeckKR,AltieriM.IntraosseousinfUsions:anold techniquewithmodernapplications.RdmtrMzrs 1988;14（4）:296-298.

62.WilliamsJF,SeneffMG,FriedmanBC,etal·Useof fbmoralvenouscathetersincriticaⅡyⅢadults:prospec﹣ tivestudy·C冗t∞沱Mbd1991;19:550.553·

48.RevellM,GreavesI’PorterK·Endpointsfbri】uid resuscitationinhemorrhagicshock.JTm邸加α2003;54（5 Suppl）!S63﹣S67.

63·YOrkJ,ArrilagaA,GrahamR’etal.Fluidresuscitation ofpatientswithmultipleiniuriesandsevereclosedhead injuⅣ:experiencewithanaggressivefluidresuscitation strate田.J?】mMmα2000;48（3）:376﹣379.

49.RiskinDJ’TsaiTC,RiskinL’Hernandez﹣BoussardT, PurtillM,MaggioPM,SpainDA,BrundageSI.Massive

l

V

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SⅨⅦ」『』STAⅡION

LⅡV

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Sl1ockAssessInentandManageInent ■

〉〉IⅡTERACTlVESl《ILl PR0CEDUREs

Objectives

／VotefAccompanying5omeo↑theski∣Is InthisSki∣IStationisase『ieso↑5cena『ios fo「youto「eviewandusetop『epa『efo『 thisstation.Tab∣espe『tainingtotheini﹣ tialassessmentandmanagementofthe

∣

Pe㎡o『manceatthisskiIIstationwiIlalIowthepa『ticipanttop『acticetech﹣ niquesnecessa『yt0t『eatapatientinshock’dete『minethecauseofthe 5hockstate’pe『fo「mtheinitiaImanagemento↑shock’andmanagethe patient’s「esp0nsetot『eatment.SpecificaIly’thestudentwiIlbeabIeto:

patientinshocka「ea∣sop『ovided↑o『you『 「eviewStanda『dp『ecautionsa『e『equi「ed wheneve『ca『ingfo「t『aumapa（ients.

ⅢRecognizethe5hockstate 固Identi↑ythecau5e5oftheshockstate 圃Ident↑ i ythesu「facema『kn i g5anddemonst『atethetechnq i ue5of

TⅡE『0Ll0WlNGPR0CEDURE5ARE lNαUDEDIⅡ『ⅡlS5l《IUSTA『l0Ⅱ:

vascuIa「acce5sfO『thefol∣owing; ·Pe『iphe『aIvenoussystem

卜〉SkiⅡIV·A目PeripheralVenousAccess

·「emo『aIvein ·Inte『naIluguIa『vein ·SubcIavianvein ·lnt『a05seousinfuSion

〉〉SkiⅡIV.B:FemoralVenipuncture: SeldmgerTechnique 卜卜SkiⅡlV.CSubclavianVenipuncture:InfTaclavicularApproach

囚Identfiytheapp「op「a i tesu「faceIandma『ksfo『pIadngapev lc i bn i de「 andsuccessfullyplaceacomme『daIbinde「o『sheetw『ap

卜卜SkⅡⅢV·D;Interna1Jugular Venipuncture:MiddleorCentra1 Route

圃ExplainthevaIueoftheante『oposte『io『（Ap）pelvicx﹣「ayexamina﹣ tiontoidentifythepotentiaIfO『masslvebIoodIoss』anddesc『ibe themaneuve『sthatcanbeusedto『educepelvicvolumeandcont『o∣ b∣eedn i g.

〉〉Ski∣∣∣V.E:IntraosseousPuncture／ Inlhsion:ProximalTibialRoute

圃Selecttheapp『op『iateequipmentfo「pediat「icpatientsbasedonage （8「o5eo l WTMtape）

〉bS∣《iⅡlV·「﹠Identihcationand ManagementofPeMcFractures ApplicationofPelvicBinder

ⅢU5ea叮unct5intheasse5smentandmanagementoftheshockstate’ induding: ·X﹣「ayexamination（che5tandpeIvic↑iIms） 。Diagnosticpe『itonea∣Iavage（DPL） ·Focu5edassessments0nog『aphyInt『auma（FAST） ·Computedtomog「aphy（CT） 圃Identi↑ypatien芯who「equI『edefinitivehemo「「hagecont「oIo『t「ans﹣ fe『toanintensiveca『eunit. 圃ldentifywhichadditionalthe『apeuticmeasu「esa『eneCessa「ybased onthepatient似5『esponsetot『eatmentandthecIinicaIsigni↑icanceo↑ the「esponsesofpatients’ascIassifiedby: ·Rapid『esponse ·T『ansient『e5ponse ·Non『e5p0nSe ■

82

㎡ 錨 △

■ ﹃

﹂

5l﹤lLLSTATIONIV■ShockAsse55mentandManagement83

卜SCEⅡARIOS heartratehasdecreasedto90beats／min;theblood

SCENARIO∣V﹣1 A42-year﹣oldfbmalewasejectedfromavehicledur﹣ inganautomobilecoⅢsion。EnroutetotheemergenCy department（ED）’prehospitalpersonnelreportthat herheartrateis110beats／min,herbloodpressureis 88／46mmHg’andherrespiratoryrateis30breaths／ min.Thepatientisconfhsed’andherperipheralcapil﹣ la】,yrefillisreduced.（SeeTableIV.1.）Herairwayis patent.Sheisinrespirat0rydistresswithneckvein distention’absentbreathsoundsontheright,andtra尸 chealdeviationtothele仕·

SCEⅡARI0∣V﹣2（CDnt／nua甘onofP『Pv／ou5Scena〃o） Afterneedledecompressionandchest﹣tubeinsertion’ thepatient’sheartrateis120beats／min’theblood pressureis80／46mmHg’andtherespiratoryrateis30 breaths／min.Herskinispale》cool’andmoisttotouch· Shemoanswhenstimulated.（SeeTableIV﹄2.） SCEI＼lARI0IV﹣3（（bn〃nuat／onofp伯Ⅵousscena〃o） AftertheinitiationofvascularaccessandinfUsionof 2000mLofwarmedc1ystalloidsolution’thepatient’s

pressureis110／80mmHgandtherespirato1yrateis 22breaths／min.Thepatientisnowabletospeak,her breathingislesslabored,andherperipheralpermsion hasimproved.（SeeTableⅣ2.）

SCEⅡARI0IV﹣』（（bnt／nuat／onofp「eⅥousscena〃o） Thepatientrespondsinitial】ytotherapidinfhsion0f 1500mLofwarmedcrystalloidsolutionbyatransient increasembloodpressureto110／80mmHg’adecrease intheheartrateto96beats／min’andimprovementsin level0fconsciousnessandperipheralperfUsion·Fluid in允sionisslowedtomaintenancelevels·FivemihⅦtes later’theassistantreportsadeteriorationintheblo0d pressureto88／60mmHg,anincreaseintheheartrate to115beats／min,andareturninthedelayofthepe﹣ ripheralcapilla】yrefill.（SeeTableⅣ.3.） A1ternativeScenario8Therapidinfhsionof 2000mLofwarmedcrystalloidsolutionproducesonly am0destincreaseinthepatient,sbloodpressureto 90／60mmHg,andherheartrateremamsat110beats／ min.Herurina1youtputsincetheinsertionoftheuri﹣ narycatheterhasbeenonly5mLofverydarkurine

■TABLEIVu1lMTlA【ASSESSMENTANDSⅡOCKMANAGEMENT

COⅡDI『IOⅡ

TensionpⅡeum0tho『ax

ASSE5SMENT （PⅡγSICA【EXAMINATI0N） ● ● ● ●

Ⅲassivehemotho『ax

● ● ● ●

Ca『diactamponade

● ● ●

T「a〔heaIdeviati0n Di5tendedneckveins Ⅳmpany Ab5entb『eaths0undS 『『achead l eva i t0 iⅡ 「latne〔kveins pe『（u5s0 i ndu∣Ine55 Ab5eⅡtb『eaths0unds Di5tendedne〔kveiⅡ5 M咐ledhea『tt0neg UIt甩s0und

ⅢAⅡAGEMEⅡT

·Ⅱeede l de〔0『np『es50 in ·Tubeth0『a〔05t0my

● ● ● ●

■ ● ● ■

∣nt『aabdominaIhemo『『hage

● ● ● ●

0bviousexte『naIbIeeding

0i5tendedabdomen Ute『n i e↑ Ii t〃↑ i p『egnant DP【／utl『a50n0g『aphy Vaginalexaminati0n

。d l ent↑ i y50u『ce0↑0bv0 i u5 exte『Ⅱab le l edn ig

■ ● ● ■

● ■ ●

Venousa〔〔esg V0Iume『epIacement 5u『gc i aI（0n5u∣tat0 i n／th0『ac0tomy Tubeth0『a〔0st0my Ven0usacce5s V0∣ume『epa I 〔ement 『h0『a〔ot0my pe『c i a『d0 i 〔enteS5 i

Ven0u5a〔〔e5s V0u I me『ep∣a〔ement Su『gical〔0n5ultati0n Di5placeute「u5仃0mvenacava 0『 i ectp『e5su『e 5pIint5 Cl05Ⅱ『eo↑adiveIyb∣eedingsca∣pw0und5

84Sl﹤lLLSTATI0NIV■ShockAssessmentandManagement

■ T A B l EIV.ZPElV【C『RAC丁URES IⅡTERVENTl0Ⅱ

CONDITI0Ⅱ

IMAGEFIⅡDINGs

5IGⅢFIcAⅡCE

peM仁f『actu『e

peMCx﹣『ay ·Pub〔 i 「amu5「『actu『e

·【essbl00dI05sthan0the『types ·〔ate『aIc0mp『e5si0nmechani5m

·0peⅡb00﹟

·pe∣vc i vou I men i 〔「eased ·Ⅲa0i『5ou『ce0↑b∣00d∣05s

V0u I me『ep∣a〔ement P『0babe I t『an5h』50 in 0ec「ea5edpeIvicv0lⅡme pev l〔 i bn i de『 Exte『naIfixat0『 Ang0 i g『aphy skeletalt『adi0n 0『th0pedicconsuItati0n

■ ● ● ● ● ■ ● ●

oMa0 l 「sou『〔eo↑b0 I od0 l ss

·Ve『C ti a∣shea『

Vsc i e『a∣o『gann i】Ⅱ『y

CTscan ·Int『aabd0minalhemo『『hage

● ●

p0tentia∣↑o『continuingbI00dlo55 pe『↑0『med0nIyinhem0dynami（aIly n0『malpatients

■ ● ●

Vo∣uⅢe「epa I cement po5siblet『an5｛usion Su「gi〔aI〔0nsuItati0n

■TABLEIV·3丁RANS!EⅡ丁RESPOⅡDER

ETI0l0Gγ

ADDIT∣0ⅡAL DIAGⅡ0STICsTEPs

pⅡγS∣CALEXAⅢ

0nde『estimationofbloodIosso『 continuingblood∣oss

● ■ ■ ●

Ⅱonhemo『『hagic ·Ca『da i 〔tamp0nade

■ ● ●

INTERVENTI0Ⅱ

Abd0mina∣di5tenti0n pev IC i f『actⅡ『e Ext『e『ntyi↑『actu「e 0bvi0u5exte『naIb∣eeding

。DP【0『ult『ason0g『aphy

0i5tendedneckveins 0ec『easedhea『ts0unds Ⅱo『maIb『eaths0unds

·ECh0Ca『d0 i g「am ●「AS『

Distendedne〔kvein5 『「aChealshift Absentb『eathsouⅡds Ⅱype『「es0nant〔hestpe『cⅡ55∣0n

。C∣iniCaldiagn05i5

● ● ● ●

5u『gicaIcon5uItati0n V0lumeiⅡ「u5i0n BI00dt『aⅡs↑u5i0n App∣yapp『0p『a i tespⅡ il t5

·Th0『a〔0t0my ·T『an乖「

·RecⅡ『『eⅡt／pe『55 i tentten50 in pⅡeum0th0『ax

● ● ● ■

● ● ●

ReevaIuate（hest Ⅱeedledec0mp『e55i0n Tubeth0『a〔0st0my

-

■TABLEIV·4NONRESp0NDER

E『l0【0Gγ

pⅡγSICAlEXAⅢ

ADDITI0ⅡA【 DIAGN0ST∣CSTEPS

MassivebIoodIosS （Ca I∣ sI 0『∣V） ·Int『aabd0minaIbleeding

·Abd0minaIdiStenti0n

·DpL0『uIt『as0n0g『aphy

Ⅱonhemo『『hagic 。TeⅡ5i0npneum0tI〕0『ax

■ ● ● ■

·Ca『diactamponade

● ● ●

·B∣Ⅱntca『da i cn iu i 『y

0i5tendedneckvein5 『『a〔hea5Ih↑ i t Ab5entb『eath50ⅡndS Ⅱype『『e50naⅡtchestpe『cus50 in

。CIini〔aIdiagn0si5

0i5teⅡdedne〔kvein5 0e〔『easedhea『t50uⅡds Ⅱo「malb『eaths0unds

·「A5T ·pe『ica「diocentesiS

·『 l 『egua I 『hea『t「ate ·∣nadequatepe『↑u5o in

lN『ERVENTI0N

·ImmediateinteⅣenti0nbysu『ge0n ·V0IⅡme『esto『ati0n

■ ■ ●

·lsChemiCECGChange5 ●E〔G

Reevaluate〔he5t Ⅱeede l de〔0mp『e5s0 in 「ubeth0『a〔0t0my

·「h0『aC0t0my

● ● ●

Ensu『eno5ou『仁eo「hem0「『ha9em5 i 5ed ∣n0t「0p〔 i 5upp0忱 ∣nva5v i emoⅡti0『n ig

SKlLLSTATIONIV■ShockAssessmentandManagement85

SCEⅡARI0lV﹣5

SCENARIOIV﹣6

A42﹣year﹣oldfbmale’ejectedfromhervehicleduring acrash’arrivesintheEDunconsciouswithaheart rateof140beats／min’abloodpressureof60mmHg bypalpation,andpale,c0ol,andpulselessextremi﹣ ties·Endotrachealintubationandassistedventilation areinitiated.Therapidvolumeinfi1sionof2000mL ofwarmedcrystalloidsolutiondoesnotimproveher vitalsigns’andshedoesnotdemonstrateevidenceof improvedorganper血sion.（SeeTableⅣ·4.）

An18﹣month﹣oldboyisbroughttotheEDbyhismoth﹣ er,whoapparentlyexperiencesspousalabuse.The childhasevidenceofmultiplesoft﹣tissueinjuriesabout thechest,abdomen’andextremities.Hisskincoloris pale’hehasaweak’threadypulserateof160beats／ min》andherespondson】ytopainh1lstimuliwitha weakcry·

I

I

卜SkiⅢV﹣A:Pe『iphe『aIVenousAccess STEp1·

Selectanappropriatesiteonanextremity （antecubital’fbrearm,orsaphenousvein）.

5TEpZ。

Applyanelastictourmquetabovethepro﹦ posedpuncturesite.

5TEP3·

Cleanthesitewithantisepticsolution.

sTEp4.

Puncturethevemwithalarge﹣caliber’ plastic’over﹣the﹣needlecatheter‘Observe 允rblo0dreturn.

STEP5.Threadthecatheterintotheveinoverthe needle·

sTEP6·

Removetheneedleandtourniquet.

STEP7.

Ifappropriate’obtainbloodsamplesfbr laboratorytests.

STEp8·

Connectthecathetertotheint】、avenous infhsiontubingandbegintheinfhsionof warmedcrystalloidsolution.

S『Ep9。

Observefbrpossibleinfiltrationoffluids intothetissues.

S『EP10.Securethecatheterandtubingtotheskin oftheextremity·

I

bSkiⅢV.B:Femo『aIVenipunctu『e:SeIdinge『Technique Ⅳb加:S花㎡』e花ch㎡qαes／jo叨／dbe叨sedu／／je〃pe肋了m﹣ 加g仇:sp加ced叨泥.

5TEP5.

Makeasmallskinmcisionattheentry pointofwireordilatationofcentralveint0 insertlargeborecatheter.

5TEp6·

Introducealarge﹣caliberneedleattachedt0 a12﹣mLSyrmgewith0.5to1mLofsaline· Theneedle’directedtowardthepatient’s head）shouldentertheskindirect】yoverthe 允moralvein（■FIGuRE』v巳1A）Holdthenee﹣ dleandsyrmgeparalleltothefTontalplane.

STEp7.

Directingtheneedlecephaladandposterior﹣ ly’slowlyadvanceitwhilegentlywithdraw﹣ ingtheplungerofthesyringe·

5TEp8.

WhenafreefIowofbloodappearsinthe Syringe,removethesyringeandoccludethe needlewithafingertopreventairembo﹣ lism.Ifthevemisnotentered》withdraw theneedleandredirectit.Iftwoattempts

STEP1.Placethepatientinthesupineposition. S『EPZ·Cleansetheskinaroundthevempuncture siteweⅡanddrapethearea. STEP3·Locatethefbmoralveinbypalpatingthe fbm0ralarte】V.Theveinliesdirectlyme﹣ dialtothefbmoralartery（rememberthe mnemomcNAVEL’fiPomlateraltomedial: nerve’arte】y,vein》emp叮space’lymphatic） KeepafingeronthearterytofHcilitateana﹣ tomicallocationandavoidinsertionofthe catheterintothearte】y·Ultrasoundcanbe usedasanadjunctfbrplacementofcentral venouslines. STEP4Ifthepatientisawake,usealocalanes﹣ theticatthevenipuncturesite.

86SKILLSTAT∣0NIV■Sh0ckAssessmentandManagement

d【e

e「 nous

A

B（Step8）

■「IGURE∣V己1Femo『aIVenipunctu『e:SeIdinge『Tbchnique· （A）lnt「oduceaIa「ge﹣calibe「needIeattachedtoa1Z﹣mL sy『ingewith0.5to1mLofsaline.TheneedIe’di「ected towa『dthepatient’shead’shouldente「theskindi『ectIyove『 thefemo「alvein·（B）∣n5e「ttheguidewi「eand「emovethe needIe.Useanint「oduce「if『equi「ed·（C）∣nse「tthecathete「 0ve『theguidewi『e.

C（Step9）

SKILLSTATIONIV■Sh0ckAsse55mentandManagement87 areunsuccessfhl’amoreexperienced clinicianshouldattempttheprocedure’if avai】Hble.

STEP9·Inserttheguidewireandremovetheneedle∣ Useanintroducerifrequired（■FlGuRE∣v﹄1B）·

S丁EP13’Tapetheintravenoustubmginplace. STEp14ObtainChestandabdominalx﹣rayfilmsto conHrmthepositionandplacementofthe intravenouscatheter. 5TEP15.Changethecatheterassoonasitis

STEP10’Insertthecatheterovertheguidewire （■FlGUREIV﹄1C）. STEP11.Removetheguidewireandconnectthecath﹣ etertotheintravenoustUbmg·

practica1.

〉卜MA』0RC0∣VlPllCATl0ⅡS0『『EM0RAl VEⅡ0USACCESS ■Deep-veinthrombosis ■ArterialorneurologiciIUmy ■In生ction ■Arteriovenousfis恤la

S『Ep1Z·Aifixthecatheterinplace（withasuture）, applyantibioticointment,anddressthe area·

pSl《iIlIV.CSubc∣avianVenipⅢctu『e:I㎡『aclavicu∣a『App『oach 』Vb花fS㎡er〃etec〃㎡q叨es〃oα／dbeαsedu）／ie〃pe痂『w3﹣ 面γJgt／j古sp加cedα沱.

STEp8.

Slowlyadvancetheneedlewhilegently withdrawingtheplungerofthesyringe·

STEp1’Placethepatientinthesupineposition’ withtheheadatleast15degreesdown todistendtheneckveinsandpreventair embolism.Onlyifacervicalspinei叮ury hasbeenexcludedcanthepatient’sheadbe turnedawayhomthevenipuncturesite.

sTEP9·

WhenafreeflowofbloodappearsintheSy﹣ ringe,rotatethebeveloftheneedlecaudal】y, removetheSyringe,andoccludetheneedle withafingertopreventairembohsm.Ifthe veinisnotentered’withdrawtheneedleand redirectit.Iftwoattemptsareunsuccessfhl, amoree泖eriencedchnicianshouldattempt thepr0cedure’ifavailable·

STEP2’Cleansetheskinaroundthevenipuncture sitewellanddrapethearea. S丁EP3·Ifthepatientisawake’usealocalanesthet﹣ icatthevempuncturesite. SγEP4·

Intr0ducealarge﹣caliberneedle》attachedto a12﹣mLSyringewith0.5to1mLofsaline’ 1cmbelowthejunctionofthemiddleand medialone-thirdoftheclaviCle.Ⅲtrasound canbeusedasanadjunctfbrtheplacement ofcentralvenouslines

STEP5·Aitertheskinhasbeenpunctured’withthe beveloftheneedleupward,expeltheskin plugthatcanoccludetheneedle. S『EP6.Holdtheneedleandsyrmgeparalleltothe fTontalplane. S『EP7·DirecttheneedlemediaⅡy’slightlyc印ha﹦ lad,andposteriorlybehindtheclavicle towardtheposterior,superiorangleofthe sternalendoftheclavicle（towardthefinger placedinthesuprasternaln0tCh）·

5TEp10.InserttheguidewireWhⅡemomtoringthe electrocardiogramfbrd〕ythmabnormalities STEp11·Removetheneedlewhileholdingthe guidewireinplace.

5TEP1Z。Insertthecatheterovertheguidewiretoa predetermineddepth（thetipofthecatheter shouldbeabovetherightatriumfbrfluid admimstration） STEpγ3·Connectthecathetertotheintravenous tubing. STEpM.Affixthecathetersecurelytotheskin（with asuture）’applyantibioticointment,and dressthearea.

SγEP15.Tapetheintravenoustubinginplace· SγEP16’Obtainachestx﹣rayfilmtoconfirmthe positionoftheintravenouslineandidentify apossiblepneumothorax·

88SKlLLSTATI0NIV■Sh0ckAs5essmentandManagement I

bS∣《iⅢV.D;Inte『naI』ugu∣a『Venipunctu『e:Midd∣eo『Cent『a∣Route IVOtefZγj:sp／Dced【〃它／s加q叨e几叼d哪cα〃tope）允｝wJ 加力咖γedpα㎡e㎡sbecα凹set／j6yα／它O／》e几咖加oM綞d top｝,o蛇c㎡〃ece｝.u;Cα／Sp』〃e.Stcr〃etec／z㎡qαes〃oM／dbe 叨sed叨几e）』pe／允／7冗力咱仇ZspJUced叨rC· STEp1.Placethepatientinthesupineposition, withtheheadatleast15degreesdown todistendtheneckveinsandpreventan airembolism·Onlyifthecervicalspine hasbeenclearedradiographicaⅡycanthe patient’sheadbeturnedawayfTomthe vempuncturesite. 5TEPZ·Cleansetheskinaroundthevenipuncture siteweⅡanddrapethearea.

sTEP8·

WhenafTeeiIowofbloodappearsinthe syringe’removethesyrmgeandoccludethe needlewithafingertopreventairembolism Iftheveinisnotentered,withdrawthenee﹣ dleandredirectit5to10degreeslateraⅡy.

sTEP9·

Inserttheguidewirewhilemonitoring theelectrocardiogram（ECG）允rrhythm abnormalities.

5TEP10·Removetheneedlewhilesecuringthe guidewireandadvancethecatheteroverthe wire.Conhectthecathetertotheintrave﹣ noustUbing.

5TEP3·Ifthepatientisawake’useal0calanesthet﹦ icatthevenipuncturesite.

5TEpⅢ.Affixthecatheterinplacetotheskinwith suture,applyantibi0ticointment,anddress thearea.

STEP4·

STEP1Z.Tapethemtravenoustubinginplace.

STEP5.

Introducealarge﹣caliberneedle,attaChedto a12-mLSyrmgewith0.5to1mLofsaline’ int0thecenterofthetrianglefbrmedbythe twolowerheadsofthesternomastoidandthe clavicle.Ⅲtrasoundcanbeusedasanadjunct fbrtheplacementofcentralvenoushnes· Aftertheskinhasbeenpunctured’withthe beveloftheneedleupward’expeltheskin plugthatcanoccludetheneedle.

STEp6·

Directtheneedlecaudally’paralleltothe sagittalplane’atanangle30degreesposte﹣ riortothefiPontalplane.

sTEp7.

Slowlyadvancetheneedlewhilegently withdrawingtheplungeroftheSyringe·

STEP13.Obtainachestfilmtoconfirmtheposition oftheintravenouslineandidentifyapos﹣ siblepneumothorax.

卜卜C0MPLICATl0NS0『CEⅢRAlVEⅡ0US pUⅡCTURE ■Pneumothoraxorhemothorax ■Venousthrombosis ■Arterialorneurologicimury ■Arteriovenoushstula ■Chylothorax ■In企ction ■Airembolism

I

卜SkiIIIV﹣E:Int『aosseousPunctu『e／Infusion:P『oximaITibiaIRoute IVbtαS花｝.Z／e花c／”qαes／joM【dbeαsedu）／te几pe肋rm﹣ z／﹩gt／Msp／Uced叨re· Thisprocedureisappropriatefbrallageswhen venousaccessisimpossiblebecauseofcirculatorycol﹣ lapseorwhenpercutaneousperipheralvenouscan﹣ nulationhasfailedontwoattempts.Intraosseous infhsions（bloodandcrystalloids）shouldbehmitedto emergenCyresuscitationdiscontinuedassoonasother venousaccesshasbeenobtained.

Methylenebluedyecanbemixedwiththesaline orwaterfbrdemonstrationpurposesonchickenor turkeybonesonly.Whentheneedleisproperlyplaced withinthemedullarycanal》themethylenebluedye／ salinesolutionseepsfTomtheupperendofthechicken orturkeybonewhenthesolutionisinjected（seeStep 8）.Swellingaroundtheintraosseousneedleshould promptdiscontinuationoffluidinfbsionandremoval oftheintraosseousdevice.

SKILLSTATIONIV■ShockAs5essmentandManagement89

5TEP1·

Placethepatientinthesupineposition. Selectanuninjuredlowerextremity,place sufficientpaddingunderthekneetoef｛bct appr0ximate30﹣degreeflexionoftheknee’ andallowthepatient’sheeltorestcomfbrt﹣ ablyonthegurn叮orstretcher.

STEp2.

Identi句thepuncturesite－theanterome﹣ dialsurfaceoftheproximaltibia’approxi﹣ matelyonefingerbreadth（1to3cm）bel0w thetubercle.

STEP3’

Cleansetheskinaroundthepuncturesite wellanddrapethearea.

S『Ep4

Ifthepatientisawake’usealocalanesthet﹣ icatthepuncturesite.

sTEP5·

Imtiallyata90﹣degreeangle》introducea short（threaded0rsmooth）,large﹣caliber, bone﹣marrowaspirationneedle（orashort, 18﹣gaugespmalneedlewiths叮let）intothe skinandperiosteum,withtheneedlebevel directedtowardthefbotandawayfromthe epiphysealplate·

sTEP6·

Aftergainingpurchaseinthebone》direct theneedle45to60degreesawayfTomthe epiphysealplate（■FIGuRE∣v旨z）.Usinga gentletwistingorboringmotion’advance theneedlethroughthebonecortexandinto thebonemarrow.

sTEP7o

Rem0vethestyletandattachtotheneedle a12.mLSyringewithapproximately6mL ofsterilesaline.Gentlydrawontheplunger

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﹣ r〉 ／ ■FlGURE!VZInt『aosseousPunctu『e／lnfusion:P『oximaI TibiaIRoute·Afte「gainingpu「chaseinthebone’di『ect theneedIe45to60deg「eesawayf「omtheepiphyseaI pIate.

ofthesyringe.Aspirationofbonemarrow intothesyringesignihesentranceintothe medullarycavity. STEp8.

InjectthesalineintotheneedletoeXpel anyclotthatcanoccludetheneedle.Ifthe salineflushesthroughtheneedleeasⅡyand thereisnoevidenceofsweⅢng,theneedle islikelylocatedintheappropriateplace·If bonemarrowwasnotaspiratedasoutlined inStep7’buttheneedleflusheseasily wheninjectingthesalineandthereisn0 evidenceofswelling,theneedleislikelyin theappropriateplace·Inaddition’proper placementoftheneedleisindicatedifthe needleremamsuprightwithoutsupportand intravenoussolutionflowsheelywithout evidenceofsubcutfmeousin鬥ltration.

STEP9.Connecttheneedletothelarge﹣caliber intravenoustubingandbeginf】uidinh1sion. Carefhllyscrewtheneedleihrtherintothe medullarycavityuntiltheneedlehubrests onthepatient’sskinandfreeflowcontin﹣ ues.Ifasmoothneedleisused’itshouldbe stabilizedata45-to60﹣degreeangletothe anteromedialsurfhceofthepatient’sleg. STEP10·Applyantibioticointmentanda3x3sterile dressing·Securetheneedleandtubingin pa l ce· STEp11·Routinelyreevaluatetheplacementof theintraosseousneedle,ensuringthatit remainsthroughthebonecortexandmthe medullarycanal.Remember’intraosseous infUsi0nshouldbeⅡmitedtoemergenCy resuscitationofthepatientanddiscontin﹣ uedassoonasothervenousaccesshasbeen obtained.

卜rC0MpUCAT∣0ⅡS0『IⅢRA0SSE0US pUⅡCTURE ■In也ction ■Through﹣and-throughpenetrationofthe bone ■Subcutaneousorsubperiosteal infiltration ■Pressurenecrosisoftheskin ■Physealplateinjury ■Hematoma

90SKILLSTATI0NIV■ShockAssessmentandManagement I

〉SI《iⅢV﹣『:∣dentificationandManagementofPelvic『『actu『es: AppIicationofPelvicBiⅡde『 sTEp1

STEpz.

Identi句themechanismofiInury’whiChcan suggestthepossibih叮ofapelvicfiPacture＿ fbrexample,ejectionfromamotorvehiCle’ crushingimury,pedestrian﹣vehiclecoⅢsion’ ormotorcyclecolⅡsion·

S丁EP↑0· Interpretthepelvicx﹣rayfilm’g1vmgspecial

considerationtohacturesthatarefTequent﹣ lyassociatedwithsignificantbl0odloss－fbr example’fracturesthatincreasethepelvic volume. A·Confirmthepatient,sidentifIcationon thefi】m﹣ B.Systematica1lyevaluatethefilmfbr:

Inspectthepelvicareafbrecchymosis’peri﹣ nealorscrotalhematoma’andbloodatthe ureth】、aImeah1s﹦

STEp3.

Inspectthelegsfbrdiffbrencesinlengthor asymmetⅣinrotationofthehips.

STEp4.

Peribrmarectalexamination’notingthe

·WidthoftheSymphysispubis＿greater thana1﹣cmseparationmaysignify significantpelvicmjury ·Integrityofthesuperiorandinfbrior pubicramibilaterally ·Integrityoftheacetabula’asweⅡas

positionandmobⅡi叮oftheprostategland, anypalpablefTacture,orthepresenceof grossoroccultbloodinthestool. STEp5·

允mora1headsandnecks 。Symmet】VoftheⅡiumandwidthof thesacroiliacjoints ·Symmetryofthesacralfbraminaby

Perfbrmavaginalexamination,noting palpablehactures,thesizeandconsist﹣ enCyoftheuterus’orthepresenceofblood· Remember,fbmalesofchildbearingagemay bepregnant·

sTEP6·

IfSteps2through5areabnormal,orif themechanismofinjurysuggestsapelvic fracture’obtainanAPx﹣rayhlmofthe patient,spelvis.（Note:Themechanismof injurymaysuggestthetypeoffiPacture.）

sTEp7·

IfSteps2through5arenormal’palpatethe bonypelvistoident均painfhlareas.

sTEP8·

Determinepelvicstabilitybygentlyap﹣ plyinganterior-posteriorcompressionand lateral.to﹣medialc0mpression0verthe anterosuperioriliaccrests.Testfbraxial mobilitybygentlypushingandpulhngon thelegstodeternnnestabilitymacranial﹣ caudaldirection.Immobilizethepelvis properlybyus1ngasheetand／Oracommer﹣ ciallyavailablebinder（e.g·’T-pod）

sTEP9’

Cautiouslyinsertaurinarycatheter,ifnot contraindicated,orperfbrmretrogradeure﹣ thrographyifaurethralinjuryissuspected.

evaluatingthearcuatelines ·Fracture（s）ofthetransverseprocesses ofL5 CRemember,thebonypelvisisaringthat rarelysustainsaninjuryinonlyone location.Displacementofringedstruc﹣ turesimpliestwofracturesites. D·Remember’fracturesthatincreasethe pelvicvolume－fbrexample’vertical shearandopen﹣bookfTactures’areoften ass0ciatedwithmassivebloodloss.

卜卜TECⅡⅡI0UEST0RED0CEBl00D【0SS 『R0MPElVIC『RACT0RES 5丁EP1·Avoidexcess1veandrepeatedmanipulation ofthepelvis. ●

sTEPZ·

Internallyrotatethelowerlegstoclosean open﹣booktypefracture.Padbonypromi﹣ nencesandtietherotatedlegst0gether. Thismaneuvercanreduceadisplaced Symphysis’decreasethepelvicv0lume,and serveasatempora1ymeasureuntⅡdefini﹣ tivetreatmentcanbeprovided·

SKILLSTATlONlV■Sh0ckAsses5mentandManagement91

STEP3·Applyapelvicexternalfixationdevice（early orthopedicconsultation） STEP4Applyskeletallimbtraction（earlyortho﹣

sTEP7·

Placesandbagsundereachbuttockif thereisnoindicationofspinaliUjuryand othertechmqUestoclosethepelvisarenot avai】Hble.

pedicconsultation） STEP5·Emb0lizepelvicvesselsviaangiography· STEP6.Obtainearlysurgicalandorthopedicconsul﹣ tationtodeterminepriorities.

STEP8.App】yape】vicbinder. STEP9·Arrangefbrtransfbrtoadefinitive﹣care fhcili叮iflocalresourcesarenotavailableto managethisinjury.

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SKILLSTATIONV■VenousCutd0wn

93

I

卜SkiIIV﹣A:VenousCutdown STEP1.

CleansetheskinaToundthevenipuncture sitewellanddrapethearea.

STEPz

Ifthepatientisawake,usealocalanesthet﹣ icatthevempuncturesite.

5TEP3o

Makea血ll﹣thickness,transverseskin incisionthroughtheanesthetizedareatoa lengthof2.5cm.

5TEp4·

STEP5n

sTEP6.

Bybluntdissection’usingacurvedhemo﹣ stat’identi句theveinanddissectitfTee 仕omanyaccompanyingstructures. Elevateanddissecttheveinfbradistanceof approximate】y2cmtofTeeitfromitsbed. Ligatethedista1mobilizedvein’leavingthe sutureinplacefbrtraction.

5TEp9·

5『EP10·Attachtheintravenoustubingtothecan﹣ nulaandclosetheincisionwithinterrupted sumTes.

STEPⅧ.Applyasteriledressingwithatopica1anti﹣ bioticointment.

卜卜C0MPLICATI0ⅡS0『PERIPⅡERAlVEⅡ0US CUTD0WⅡ ■Celh】】itiS ■Hematoma ■Phlebitis ■Per比rationoftheposteriorwallofthe

STEP7·Passatiearoundtheveminacephalad direction· STEP8’

Makeasmall,transversevenotomyand gentlydilatethevenotomywiththetipofa closedhemostat.

A

■FIGUREV■1VenousCutdown

Introduceaplasticcannulathroughthe venotomyandsecureitinplacebytyingthe upperligaturearoundtheveinandcan﹣ nula（■FIGuREv﹄1B）·Thecannulashouldbe insertedanadequatedistancetoprevent dislodging.

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囫ldentifyandinitiatet「eatmentofthefo∣∣owingpo﹣ tentiaIyli↑e﹣th『eateninginlu『iesdu『ingtheseconda『y suⅣey: ·SimpIepneumotho『ax ·Hemotho『ax ·PuImona『ycontusion ·T『acheob「oncha i tl『eeIn】u『y ·8Iuntca『diacIn】u『y ·T「aumaticaov「ticdis『uption ·T『aumaticdiaph「agmaticin】u『y ·Bluntesophageal『uptu『e 圃Desc「ibethesignificanceandt「eatmentofthefoIIow﹣ !ngIn】u「Ies: ·Subcutaneousemphy5ema ·Tho「acicc「ushin】u『ies ·Stema’ l 『b i ’andc∣avc i uIa『f『actu「es ﹃

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T繃繃藍繃襬蠻譏

ofthesedeathscouldbepreventedwithprompt diagnosisandtreatment·Lessthan10﹪ofblunt chestmjuriesandonly15℅to30℅ofpenetrating chestinjuriesrequireoperativeintervention（typically thoracoscopyorthoracotomy）.Infact’mostpatients whosustainthoracictraumacanbetreatedbytechnical procedureswithinthecapabⅡitiesofclinicianswho takethiscourse.Manyoftheprinciplesoutlinedin thisChapteralsoapplytoiatrogemcth0racicinjuries’ suchashemothoraxorpneumothoraxwithcentralⅡne placementandesophagealmjurydurmgendoscopy. Ibpoxia,hypercarbia,andacidosisoftenresult 仕omchestinjuries.Tissuehyponaresultshomthe inadeqUatedelive1yofo汀gentothetissuesbecauseof hyp0volemia（blo0dloss）,pulmonaryventilation／Per﹣ h1si0nmismatch（eg·’contusion’hematoma,andalveo﹣ larcollapse）’andchangesintheintrath0racicpressure relationships（e.g.’tensionpneumothoraxandopen pneumothorax）·Thishypoperh1sionleadstometabolic acidosis.I汀percarbiawithresultantrespirat01yacido﹣ sismostoftenfbⅡowsmadequateventⅡati0ncausedby 95

96CHAPTER4■Tho「acicT『auma

changesintheintrathoracicpressurerelationshipsand depressedlevelofconsciousness.Theinitialassessment andtreatmentofpatientswiththoracictraumaconsists oftheprimarysurvey’resuscitationofvitalhmctions, detailedsecondarysurv叮,anddefimtiveca】?e.Because hyp0xiaisthemostseriousaspectofchestiIUmy’ thegoalofearlyinterventi0nistopreventorcorrect hypoxia.Injuriesthatareanimmediatethreattolifbare treatedasquiCklyandsimp】yasispossible.Mostlifb﹣ threateningthoracicinjuriescanbetreatedwithairway controloranappropriatelyplacedchesttubeorneedle. Theseconda1ysurveyismfluencedbythehisto1yofthe inluryandahighindexofsuspicionfbrspecificinjuries.

P『ima『ySu『vey:Ijfe﹣Th『eatening n I 】u『e is

G＞W｝α j 莎⋯咖pα肋qp咖toJ唧c ●eO〃seq叨e列cesOf妣esec〃esf蚵叨㎡esβ TheprimarysurveyofpatientswiththoraciciUjuries beginswiththeairway,fbⅡowedbybreathingand thencirculation.Maio『p『obIemsshou∣dbeco『『ectedas theya『eidenti而ed·

BREATⅡING Thepatient’schestandneCkshouldbecompletely exposedtoallowfbrassessmentofbreathingandthe neckveins.ThismayreqUiretemporarilyreleasingthe ffontofthecervicalcollarfbllowingblunttrauma·In thiscase’cervicalspineimmobilizationshouldalways beactivelymaintainedbyholdingthepatient’shead whilethecoⅡarisloose.Respiratorymovementand quali叮ofrespirationsareassessedbyobserⅥng,pal﹣ pating,andlistening. Important’yetoftensubtle,signsofchesti叼ury orhypoxiaincludeanincreasedrespiratoryrate andchangeinthebreathingpattern’whichisoften manifbstedbyprogressivelyshallowerrespirations. Cyanosisisalatesignofhyp0xiaintraumapatients. However’theabsenceofcyan0sisdoesnotnecessarily indicateadequatetissueo叮genationoranadeqUate a1rway·Them可orthoracicinjuriesthataffbctbreath﹣ ingandthatmustberecognizedandaddresseddur﹣ ingtheprimarysurveyincludetensionpneumothorax, openpneumothorax（suckingchestwound）’flailchest andpulmonarycontusion,andmassivehemothorax.

L F PITFAI瓜』S FTPⅡFⅢS 「

AIRWAγ Itisnecessarytorecognizeandaddressma】orinju﹣ riesaffbctingtheairwayduringtheprimarysurve）／. AirwaypatenCyandairexchangeshouldbeassessed byhsteningfbrairmovementatthepatient’snose’ mouth,andlungHelds;mspectmgtheoropharynxfbr fbreign﹣bodyObstruction;andobservingfbrintercostal andsupraclavicularmuscleretractions. Laryngealmjurycanaccompanyma】orthoracic trauma.Althoughtheclimcalpresentationisoccasion﹣ aⅡysubtle,acuteairwayobstructionfromla1yngeal traumaisalifb﹣threatemnginjury.SeeChapter2:Air﹣ wayandVentilatoryManagement

Injurytotheupperchestcancreateapalpable defbctinthereg1onofthesternoclavicularjoint’with posteriordislocationoftheclavicularhead,which causesuppera1rwayobstruction.Identificationofthis injuryismadebylistening允rupperairwayobstruc﹣ tion（stridor）oramarkedChangeintheexpectedvoice qUaliW’ifthepatientisabletotalk.Management consistsofaclosedreducti0noftheinjury’whichcan beperfbrmedbyextendingtheshouldersorgrasping theclaviclewithapointedinstrument,suchasatowel clamp,andmanuallyreducmgthefracture.Once reduced’thisinjuryisusuaⅡystableifthepatient remainsinthesupineposition. Otherinjuriesaffbctingtheairwayareaddressed inChapter2 AirwayandVentⅡatoryManagement

Afte『intubation’0neofthecommon「easonsfo「Ioss ofb『eathsoundsinthelefttho『axisa『ightmain5tem intubation.Du「ingthe「ea5se55ment’besu「etocheck thep0siti0noftheendot「achealtubebefo『eassum﹃ ingthatthechangeinphy5icalexaminationisdueto apneumotho『axo『hemotho『ax.

TensionPneumotho『ax Atensionpneum0thoraxdevelopswhena‘‘one﹣way valve’,airleakoccursfTomthelungorthroughthe chestwall（■F!GuRE¢﹣1）.Airisfbrcedintothepleural spacewithoutanymeansofescape’eventuallycom﹣ pletelycollapsingtheafIbctedlung·Themediastinum isdisplacedtotheoppositeside,decreasingvenousre﹦ turnandcompressingtheoppositelung.Shockresults homthemarkeddecreaseinvenousreturncausinga reductionincardiacoutputandisoftenclassifiedas obstructiveshock· Themostcommoncauseoftensionpneumothorax ismechanicalventilationwithpositive﹣pressureventⅡa戶 tioninpatientswithvisceralpleuralmjmy.However’a tensionpneumothoraxcancomplicateasimplepneu﹣ mothoraxfbⅡowingpenetratingorbluntchesttrauma inwhichaparenchymallunginju1yf白ilstoseal,orafter amisguidedattemptatsubclavianorinternaljugularvenouscathetermsertion.OccasionaⅡy’traumatic defbctsinthechestwallalsocancauseatensionpneu﹣ mothoraxifmcorrectlycoveredwithocclusivedressings

PRlMARYSURVEY:LIFE﹣THREATENlNGIN」URlES97

pne

■F∣GURE¢﹣1TbnsionPneumotho『ax· Atensionpneumotho「axdeveIopswhen a〃one﹣wayvalve〃ai『leakoccu「sf「om theIungo「th「oughthechestwaIl.Ai『is f0『cedintothepIeu『alspace『eventualIy c0mpIeteIycoIIap5ingthea什ectedlung.

orifthedeibctitselfconstitutesailap﹣valvemecha﹣ msm·Tensionpneumothoraxrare】yoccursfrommark﹣ edlydisplacedthoracicspinefiPactures. Tehsionpneumotho『axisacIihicaldiagnosis『e｛Iect﹣ ingai『uhde『p『ess凹『eiⅡthea碓ctedpleu『aIspace· T『eatmehtshouIdhotbedeIayedtowait↑b『『adioIogiG con伺『matiohjTensionpneumothoraxischaracterized bysomeorallofthefbⅡowingsignsandSymptoms: ■Chestpain ■Airhunger

insertingalarge.caliberneedleintothesecondinter﹣ costalspacemthemidclavicularlineoftheaf｛bcted hemithorax（■「∣GuRE4富2）.However）duetovariable thicknessofthechestwall,kinkingofthecatheter andothertechnicaloranatomiccomphcations,this maneuvermaynotbesuccessfhl.SeeSkillStationⅥI: ChestTraumaManagement ’SkillⅥI﹣A:NeedleTho﹣ racentesis.WhensuccessfUl,thismaneuverconverts

theinjmytoasimplepneumothorax;however,the possibihtyofsubsequentpneumothoraxasaresultof

■Respiratorydistress ■Tachycardia ■Hypotension ■Trachealdeviationawayfromthesideof 1叨ury ■

●

■Unilateralabsenceofbreathsounds ■Elevatedhemithoraxwithoutrespiratory movement ■Neckveindistention ■Cyanosis（latemanifbstation） Becauseofthesimilarityintheirsigns》tensioIi pneumothoraxcanbeconfUsedinitiaⅡywithcardiac tamponade﹩Diffbrentiationismadebyahyperreso﹣ nantnoteonpercussion;deviatedtrachea’andabsent breathsoundsovertheaffbctedhemithoraX,whichareo signsoftensionpneumothorax‘ TensionpneumothoraxreqUiresimmediate decompressionandmaybemanagedimtiallybyrapidly

■FlGURE4﹣ZNeedIeDecomp『e5sio向’Tbnsi0npneumo﹣ tho『axmaybemanagedinitiaIIyby『apidIyinse「tinga Ia『ge﹣caIibe「needIeintothesecondinte「costaIspacein themidclavicuIa「Iineofthea什ectedhemitho「ax··

98CHAPTER4■Th0「acicT「auma

■﹃﹣眇■■

theneedlesticknowexists’sorepeatedreassessment ofthepatientisnecessa】y ChestwalltMcImessinfluencesthelikPliho0dof successwithneedledecompression·!Recentevidence suggeststhata5cmneedlewillreachthepleuralspace ＞50℅ofthetime’whereasan8cmneedlewillreach thepleuralspace＞90﹪ofthetime.Evenwithaneedle oftheappropriatesize,themaneuverwillnotalwaysbe successfhl·DefinitivetreatmentreqUnestheinsertion ofachesttubeintothefifthintercostalspace（usually atthenipplelevel）,justanteriortothemidaxⅡlaryhne.

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OpenPneumotho『ax（SuckingChestWound）∣ Largedefbctsofthechestwallthatremamopencan resultinanopenpneumothorax’whichisalsoknown asasuckingchestwound（■FlGuRE4﹣3）.Equilibration betweenintrathoracicpressureandatmosphericpres﹣ sureisimmediate.AirtendstofbⅡowthepathofleast resistance,assuch,iftheopeninginthechestwallis0 approximatelytwo-thirdsofthediameterofthetra﹣ cheaorgreater,airpassesprefbrentiaⅡythroughth9 chestwa1ldefbctwitheaChrespiratoryeffbrt.Effbctive ventilationistherebyimpaired’leadingtohypoxiaand0 hypercarbia.0 Imtialmanagementofanopenpneumothorax isaccompⅡshedbypromptlyclosingthedefbctwitha sterileocclusivedressmg·Thedressingshouldbelarge enoughtooverlapthewound,sedgesandthentaped secure】yonthreesidesinordertoprovideaflutter﹣typd valveeffbcto（■「lGuRE4﹣4）.Asthepatientbreathesm, thedressingoccludesthewound’preventmgairfrom

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■FIGURE4﹣4D『e5singfo『Ti.eatmehtofOpenⅡ Pneumotho『ax』﹩P『omptIycIo5ethedefectwithaste『iIe occIusived『essingthati5la『geenought0ove「∣ap thewound『sedges·Tapeitsecu「eIyonth『eesidesto p「ovideaf∣utte『﹣typevaIvee什ect.

entermg.Duringexhalation’theopenendofthedressmgallowsmrtoescape廿omthepleuralspace.AChest tuberemotefromthewoundshouldbeplacedassooq aspossibledSecurelytapmgalledgesofthedressingcan causeairtoaccumulateinthethoraciccavity’result﹣ mginatensionpneumothoraxunlessachesttUbeisin place?Anyocclusivedressmg（e.g.,plasticwraporpet﹣

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■『IGUREq﹣3OpenPneumotho『ax· La『gedefectsofthechestwalIthat 「emainopencan『e5ultinanopen pneumotho「ax!o「suckingchestwound

pRIMARYSURVEY:LIFE﹣THREATENINGINjURIES99

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■FlGUREq﹣5『IaiIChest.（A）Thep「esenceofaflailchestsegment「e5uIt5in di5『uptionofno『maIchestwalImovement.AIthoughChestwaIIin5tabilitycan leadt0pa「adoxicaIm0tionoftheche5twaIIdu「inginspi「ationandexpi「ation’ thi5defectaIoned0esnotcausehypoxia.（B）Radiog『aphview0fflaiIchest.

rolatumgauze）maybeusedasatempora】ymeasureso thatrapidassessmentcancontinue·Subsequentd或ni﹣ tivesmgicalclosureofthedefbctisfTeqUentlyreqUired· S e e S k i l l S t a t i 0 n Ⅵ I ChestTramhaM月h月 呂ement,Skill ⅥI﹣B:ChestTubeInsertion.

『lailCheStandpulmona『yContusion AfIailchestoccurswhenasegmentofthechestwall doesnothavebonycontinuitywiththerestofthetho﹣ raciccage（■F∣GuRE4﹣5）.Thisconditi0nusuaⅡyresults· fromtraumaassociatedwithmultipleribfiPactures－ thatis’twoormorea叮acentribs仕acturedintw0or moreplaces.· Thepresenceofaflailchestsegmentresultsindis﹣ ruptionofnormalchestwallmovement.Althoughchest wallmstabili叮canleadt0paradoxicalmotionofthe Chestwalldurmginspirationandexpiration,thisde允ct alonedoesnotcausehypoxia.Them盯ordifficulWin· flailcheststemsfromthei叮mytotheunderlyinglung （pulmonarycontusion）.Iftheinjuryt0theundedying lungissignificant’serioushypoxiacanresult·Restricted Chestwallmovementassociatedwithpainandunderly﹣ inglungmju】yarem句orcausesofhyp0xia. FlailchestmaynotbeapparentinitiaⅡyifa patient,schestwallhasbeensphnted,inwhichcase heorshewillmovea1rp0orly,andmovementofthe thoraxwiⅡbeasymmetricalanduncoordinated’PalpaD tionofabnormalrespiratorymotionandcrepitationof riborcartilagefracturescanaidthediagnosis.Asatis﹣ facto1ychestx﹣raymaysuggestmultipleribfractures’ butmaynotshowcostochondralseparation.

h1itialtreatmentofHailchestmCludesadequateven﹣ tilation,administrationofhumidiⅡedo汀gen,and日uid resuscitationJntheabsenceofsystemichypotension,the administrati0nofc叮stall0idintravenouss0lutionsshould becareh1llyc0ntroⅡedtopreventvolume0verload,which canfhrthercompromisethepatient,srespirato1ystatus. Thedefimtivetreatmentistoensureadequate o汀genation,administerfluidsjudicious】y’andprovide ana1gesiatoimproveventilation.Thelattercanbe achievedwithintravenousnarcoticsorlocalanesthetic administration’whichavoidsthepotentialresp1ra﹣ to】ydepressioncommonwithSystemicnarcotics.The optionsfbradmimstrationoflocalanestheticsinclude intermittentintercostalnerveblock（s）andintrapleu﹣ ral’extrapleural’orepiduralanesthesia.Whenused properly,localanestheticagentscanprovideexcellent analgesiaandpreventtheneedfbrintubation.How﹣ ever’preventionofhypoxiaisofparamountimportance fbrtraumapatients,andashortperiodofintubati0n andventilationmaybenecessaryuntildiagnosisofthe entireinjmypatterniscomplete.Acareihlassessment oftherespiratoryrate’arterialo叮gentension,and workofbreathingwillindicateappropriatetimingfbr intubationandventiIation.

MassiveHemotho『ax Accumulationofblo0dandfluidmahemithoraxcansig﹄ niHcantlycompromiserespirato】yeHbrtsbycompress﹣ mg恤elungandpreventingadeqUateventilation·Such massiveacuteaccumulationsofbloodmoredramatical】y presentashypotensionandshock（seepage100）.

100CHApTER4■Th0「acicT「auma

PITFA『』『」s Bothtensionpneumotho『axandmassivehemotho﹣ 「axa『eassociatedwithdec「easedb「eathsoundson auscuItation.Di什e「entiationonphysicaIexamination canbemadebype「cussion;hype「『esonance5uppo「ts apneumotho「ax『whe「easduIIness5uggest5amassive hemotho「ax.Thet「acheaisoftendeviatedinatension pneumotho『ax〃andthea什ectedhemitho『axcanap﹣ pea「eIevatedwithout『espi「ato『ymovement.

shouldbemanagedaccordingtostandardprotocols Pulselesselectricactivity（PEA）ismanifbstedbyan electr0cardiogram（ECG）thatshowsarhythmwhⅡethe patienthasnoidentihablepulse.PEAcanbepresentin cardiactamponade,tensionpneumothorax,profbund hypovolemia’andcardiacrupture. Themajorthoracicinjuriesthataffbctcirculation andshouldberecognizedandaddressedduringthe primarysurveyaretensionpneumothorax,massive hemothorax,andcardiactamponade. MassiveHemotho『ax

C∣RCUlATI0N Thepatient’spulseshouldbeassessedfbrqUali叮, rate,andregularity.Inpatientswithhypovolemi禺the0 radialanddorsalispedispulsesmaybeabsentbecause0 ofvolumedepletion.『Bloodpressureandpulsepres﹣ surearemeasuredandtheperipheralcirculationis assessedbyobservingandpalpatmgtheskinfbrcolor andtemperature.Neckveinsshouldbeassessedfbr distention,however’keepinmindthatneckvemsmay notbedistendedinpatientswithconcomitanthypovo﹣· lemiaandeithercardiactamponade,tensionpneumo鎮 thorax’oratraumaticdiaphragmaticimu】yP Acardiacmonitorandpulseo血netershouldbe attachedtothepatient·PatientsWhosustainthoraciC traumaespeciallymtheareaofthesternumorfroma0 rapiddecelerationimu】V’arealsosusceptibletomyo﹣∣、 cardia1imu】y’whichcanleadtodys】l】ythmias.∣Hypo亙a andacidosisenhancethispossibility.Dysrhythmias

Massivehemothoraxresultsfromtherapidaccumulai; tionofmorethan1500mLofbloodorone﹣thirdor尸 moreofthepatient,sbloodvolumeinthechestcavity （■F【GuREq·6）.Itismostcommonlycausedbyapen﹣ etratingwoundthatdisruptstheSystemicorhilar vessels.However,massivehemothoraxcanalsoresult hombhmttra1】ma Inpatientswithmassivehemoth0rax,theneCkveins maybeflatasaresultofseverehypovolemia’orth叮 maybedistendedifthereisanassociatedtensionpneu﹣ moth0rax·Rarelywillthemechanicaleffbctsofmassive mtrathoracicbloodshiftthemediastinumenoughto caⅡsedistendedneckveins·Amassivehemothoraxis suggestedWhenshoCkisassociatedwiththeabsenceof breathsoundsordullnesstopercussionononesideof theChest.Thisbloodlossiscomplicatedbyhyp0xia. Massivehemothoraxisimtiallymanagedbythe simⅡltaneousrestorationofbloodvolumeanddecom﹣ pressionofthechestcavityLarge-calibermtravenous

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■F【GURE4﹦6MaSSiveHemotho『axo Thi5condition『esuItsf「omthe「apid accumuIationofmo『ethan1500mL ofbI00do「one﹣thi『d0『mo『eofthe patient’sbIo0dvoIumeinthechest cavity.

PRIMARYSURVEY:LIFE﹣THREATENINGIN」URIES

hnesandarapidcrystall0idinfhsionarebegun’and type﹣specificbloodis剽dh1inisteredassoonasp0ssi﹣ ble’BloodfiDmthechesttubeshouldbecollectedin adevicesuitablefbrautotransfhsion.Asinglechest tUbe（36or40French）isinserted,usuaⅡyatthempple level,justanteriqrtothemidaxiⅡaryline’oandrapid restorationofvolumecontinuesasdecompressionof thechestcavityiscompleted.Whenmassivehemotho﹣· raxissuspected’preparefbrautotransfUsion.If1500. mLoffluidisimmediatelyevacuated,earlythoracot﹣ omyisalmostalwaysrequired. Patientswhohaveanimtialoutputoflessthan 1500mLoffIuid’butcontinuetobleed,mayalso requirethoracotomy·Thisdecisionisnotbaseds0lely ontherateofcontinuingbloodloss（200mL几1rfbr2to 4hours）;butalsoonthepatient’sphysiologicstatuS. Thepersistentneedfbrbloodtransfhsionsisanindi﹣ cationfbrthoracotomy.Duringpatientresuscitation’ thevolumeofblo0dinitial】ydrainedfromthechest tubeandtherateofcontinuingbloodlossmustbefHc﹣ toredintotheamountofintravenousfluidrequired fbrreplacement.Thecoloroftheblood（indicatmgan arterialorvenoussource）isapoorindicatorofthe

101

A

B

racotomy. anteriorchestwoundsmedialtothe osteriorwoundsmedialtothescapula

shouldalertthepractitionertothepossibleneedfbr thoracotomybecauseofpotentialdamagetothegreat vessels,hilarstructures’andtheheart’withtheasso﹦ ciatedpotentialfbrcardiactamponade.Tho『acotomyis hotindicatedunIessasu『geoⅡ’quali而edbyt『ainingahd expe『iehce’isp『eseⅡt.. pe「c i a『

Ca『diacTamponade CardiactamponademostcommonlyresultsfTompen﹣ etratinginjuries.However,bluntinjuryalsocancause thepericardiumtofillwithbloodfromtheheart’great vessels,orpericardialvessels（■FIGuRE4﹣7）.Thehuman pericardialsacisafixedfibrousstructure;arelatively smallamountofbloodcanrestrictcardiacactivityand interfbrewithcardiacfilling·Cardiactamponademay developslowly》allowingfbralessurgentevaluation,or. mayoccurrapidb『）reqUirmgrapiddiagnosisandtreat: ment‘ThediagnosisofcardiactamponadecanbedifH﹣ cultinthesettmgofabusytraumaoremergenCyr0om. Cardiactamponadeisindicatedbythepresence oftheclassicdiagnosticBeck,stria比venouspressure elevation,declineinarterialpressure’andmuffled hearttones.However’muffledhearttonesarediffi﹣ culttoassessinthenoisyexamarea,anddistended neckveinsmaybeabsentduetohypovolemia.Addi﹣ tionally,tensionpneumothorax’particularlyonthe leftside,canmimiccardiactamponade.Kussmaul’s sign（ariseinvenouspressurewithinspirationwhen breathingspontaneously）isatrueparadoxicalvenous

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■FIGURE4﹣7Ca『diaCTamponade‘（A）N0『malhea『﹣t. （B）Pe「ica「diaItamponadecan「e5uItf「ompenet『ating o『bIuntin】u『iesthatcausethepe「ica『diumtofiIIwith bloodf『omthehea「t‘g『eatvesselsJo『pe『ica「dialvesseIs （C）UIt「asoundimage5howingca『diactamponade.

10ZCHAPTER4■Tho「acicT「auma

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pressureabnormalityassociatedwithtamponade. PEAissuggestiveofcardiactamponade,butcan haveothercauses’aslistedabove.Insertionofacen﹣ tralvenoushnewithmeasurementofcentra1venous pressure（CVP）mayaiddiagnosis,butCVPcanbe elevatedfbravarie叮ofreasons. AdditionaldiagnosticmethodsincludeeChocar﹣ diogram’fbcusedassessmentsonographyintrauma （FAST）’orpericardialwindow.Inhemodynamically abnormalpatientswithbluntorpenetratingtraumaand suspectedcardiactamponadeanexaminationoftheperi﹣ cardialsacibrthepresenceoffluidshouldbeObtainedas partofafbcusedultrasoundexaminationperfbrmedbya properlytrainedproviderintheemergen叮department （ED）.FASILisarapidandaccuratemethod0fimagmg theheartandpericardium.Itis90－95℅accuratefbrthe· presenceofpericardialfluidfbrtheexperiencedoper缶 tor.DConcomitanthemothoraxmayacc0untfbrb0th fhlsep0sitiveandfhlsenegativeultrasoundexams.See Chapter5:AbdommalandPelvicTrauma. Promptdiagnosisandevacuationofpericardial bloodisindicatedfbrpatientswhodonotrespondto theusualmeasuresofresuscitationfbrhemorrhagic shockandinwhomcardiactamponadeissuspected. ThediagnosiscanusuaⅡybemadewiththeFAST exam’Ifaqualifiedsurgeonispresent’surgeryshoUld beperfbrmedtoreⅡevethetamp0nade.Thisisbestper﹣ fbrmedintheoperatingroomifthepatient’scondition allows.lfsu『gicaIihteⅣentiohisnotpossible,pe『ica『dio﹣ centesiscahbediagnosticasweIIasthe『apeutic,butitis notde伺nitivet『eatment↑b『ca『diactamponade.SeeSkiⅡ StationⅥI:ChestTraumaManagement ,Ski1lⅥI﹣C Pericardiocentesis.

Althoughcardiactamponademaybestronglysus﹣ pected’theimtialadmimstrationofmtravenousfIuid willraisethevenouspressureandimprovecardiac outputtransientlywhilepreparationsaremadefbr surgery.Ifsubxyphoidpericardiocentesisisusedasa temporizingmaneuver’theuseofaplastic﹣sheathed needleortheSeldingerteChmquefbrmsertionofa flexiblecatheterisideal’buttheurgentpriorityisto aspiratebloodfTomthepericardialsac.Ifultrasound imagingisavailable’itcanfhcilitateaccurateinsertion oftheneedleintothepericardialspace. Becauseofthepropensityofinjuredmyocardium toselfkseal,aspirationofpericardialbloodalonemay temporarilyrelievesymptoms·Howeverallpatients withacutetamponadeandapositivepericardiocente﹣ siswillrequiresurgerytoexaminetheheartandrepa1r theinjury.Pericardiocentesismaynotbediagnosticor therapeuticwhenthebloodinthepericardialsachas clotted.Preparationtotransfbrsuchapatienttoan appropriatefhcilityfbrdefinitivecareisalwaysneces﹣ sary.Pericardiot0myviathoracotomyisindicatedonly whenaqualifiedsurgeonisavailable.p

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SceⅡa『io■cont／huedThepatienthas distendedneckvein5andadeviatedt『acheawith ab5entb「eath50unds0nthe『ight· ■■■■■

∣P ReSuscitativeTho『acotomy ClosedheartmassagefbrcardiacarrestorPEAisin﹣ effbctiveinpatientswithhypovolemia.Patientswith penetratingthoracicinjurieswhoarrivepulseless,but withmyocardialelectricalactivity’maybecandidates fbrimmediateresuscitativethoracotomy.AquaIi伺ed su『geonmustbep『esentatthetimeo「thepatient,sa『匐 『ivaltodete『minetheneedandpotehtialfb『successo「ad 『esuscitativetho『acotomyintheeme『geⅡcydepa『tmeht （ED）jlBestorationofmtravascularvolumeshouldbe continued,andend0trachealintubationandmechani﹣ calventilationareessentiRl Apatientwhohassustainedapenetratingwound似 andrequiredcardiopulmonaryresuscitation（CPR）in theprehospitalsettingshouldbeevaluatedfbrany signsoflifb.Iftherearenone》andnocardiacelectricalactivityispresent,nofUrtherresuscitativeeffbrt shouldbemade.Patientswhosustainblunti叼uries口 andarrivepulselessbutwithmyocardialelectri﹣ calactivity（PEA）arenotcandidatesfbremergency departmentresuscitativethoracotomy.Signsoflifb■ mcludereactivepupils,spontaneousmovement,or orgamzedECGactivity.⋯ Thetherapeuticmaneuversthatcanbeeffbctive】y accomplishedwitharesuscitativethoracotomyare: ■Evacuationofpericardialbloodcausing tamponade ■Directcontrolofexsanguinatingintrathoracic hemorrhage ■Opencardiacmassage ■Cross﹣clampingofthedescendingaortatoslow bloodlossbelowthediaphragmandincrease perfhsiontothebrainandheart Despitethevalueofthesemaneuvers）multi﹣ plereportsconfirmthatthoracotomyintheEDfbr patientswithblunttraumaandcardiacarrestisrarely e睦ctive. Oncetheseandotherimmediatelylifb﹣threatenmg mjurieshavebeentreated,attentionmaybedirected totheseconda】ysurvey.

SECONDARYsURVEY:POTENTIALLYUFE﹣THREATENINGlNjURIES103

Seconda『ySu『vey:PoteⅡtiaIly li『e﹣Th『eateningIniu『ies

叨 W／α j 『α咖Ⅷc跎Ue陀s妁α⋯seα伽伽 ●f〃esecO〃〔!α咖s叨y·UCy加α〃O叨COmpJe加 euαJ叨α㎡o〃／bγPo加〃跎α川魔允﹣ 毗γeα㎡e㎡yⅡg毗O】錮αctc:叮Iz㎡esβ Theseconda1ysurveyinvolvesfUrther,in﹦depthphysi﹣ calexamination,anuprightchestx﹃rayexamination ifthepatient’sconditionpermits,arterialbloodgas （ABG）measurements,andpulseoximetryandECG monitoring.Inadditiontolungexpansionandthe presenceoffluid’thechestfilmshouldbeexamined fbrwideningofthemediastinum’ashiftofthemid﹣ line,andlossofanatomicdetail.MultipleribfTactures andfTactures0fthefirstorsecondrib（s）suggestthat asignificantfbrcehasbeendeliveredtothechestand underlyingtissues.Ultrasoundhasbeenusedtodetect bothpneumothoracesandhemothoraces·However’ otherpotentiallylifb﹣threateninginjuriesarenotwell﹣ visualizedonultrasound,makingthechestradiograph anecessarypartofanyevaluationaftertraumaticin﹣ jury.SeeSkillStationⅥ:X﹣RayIdentificationofTho﹣ racicIniuries· Thefbllowingeightlethalimuriesaredescribed below: ■Simplepneumothorax ■Hemothorax ■Pulmona1ycontusion ■Tracheobronchialtreein】ury ■Bluntcardiacinjury ■Traumaticaorticdisruption ■Traumaticdiaphragmaticinjury ■Bluntesophagealrupture Unhkeimmediatelylifb﹣threateningconditions thatarerecognizedduringtheprimarysurvey,these injuriesareoftennotobviousonphysicalexamination.

SceⅡa『io■con劬uedAneedIehasbeen

pIacedinthe5ec0ndinte「c05ta∣space!atthe midc∣avIcuIa『∣ineinthe『ighthemith0「ax’The patienti5「espi『at0『y『atelsZ8﹟hea『t『atelI0l andb∣00dp『e5su『ell0／70· ＝

Diagnosisrequiresahighindexofsuspicionandappropriateuseofa叮unctivestudies·Thesei叼uriesaremo】e oftenmissedthandiagnosedduringtheimtialposttrau﹣ maticperiod;however’ifoverlooked’hvescanbelost.

SIMplEpⅡEUM0TⅡ0RAX Pneumothoraxresultshomairenteringthepotential spacebetweenthevisceralandparietalpleura（■F∣G. uRE4﹣8）.Bothpenetratingandnonpenetratingtrauma cancausethisinju叮.Lunglacerationwithairleakage isthemostcommoncauseofpneumothoraxresulting fTomblunttraⅥm月﹣ Thethoraxisnormallycompletelyfilledbythe lung,beingheldtothechestwallbysurfhcetension betweenthepleuralsurfhces.Airinthepleuralspace disruptsthecohesivefbrcesbetweenthevisceraland parietalpleura’whichallowsthelungtocollapse.A ventⅡation／perfhsiondefbctoccursbecausetheblo0d thatperfUsesthenonventilatedareaisnoto叮genated. Whenapneumothoraxispresent’breathsounds areoftendecreasedontheaffbctedside’andpercus﹣ sionmaydemonstratehyperresonance.Thefindingof hyperresonanceisextremelydifIiculttodeterminein abuSyresuscitationbay.Anupright’expiratoryx﹣ray ofthechestaidsinthediagnosis. Anypneum0thoraxisbesttreatedwithachest tubeplacedinthefburthorlifthintercostalspace》just anteriortothemidaxillaryline·Observationandaspi﹣ rationofasmall,asymptomaticpneumothoraxmay beappropriate,butthechoiceshouldbemadebya qualifieddoctor,otherwise,placementofachesttube shouldbeper｛brmed‘Onceachesttubeisinsertedand connectedtoanunderwatersealapparatuswithor withoutsuction》achestx﹣rayexaminationisneces﹣ sarytoconfirmreexpansionofthelung‘Neithe『gen﹣ e『alanesthesiano『positive﹦p『essu『eventi∣ationshouId beadmiⅡiste『edinapatiehtwhohassustaihedat『au﹣ maticpneumotho『axo『whoisat『isl《↑b『uⅡexpected int『aope『ativetensionpneumotho『axunti∣achesttube hasbeenihse『ted.Asimplepneumothoraxcanreadily converttoahfb﹣threateningtensionpneumothorax’ particular】yifitisinitial】yunrecognizedandpositive﹣ pressureventilationisapplied· Thepatientwithapneumothoraxshouldalso undergochestdecompressionbefbretransportviaair ambulanceduetotheexpansionofthepneumothorax ataltitude’eveninapressurizedcabin.

■ A5impIepneumotho「axinat「aumapatientshouId notbeigno「edo「ove『I0oked’Itmayp『og「esst0aten﹣ sionpneum0tho『ax·

104CHAPTER4■Tho『acicT「auma

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■FlGURE4﹣85imp｛ePneumotho『ax·Pneumo. SimpIePneumotho『ax·Pneumotho「ax『esult5f『omai『ente「ingthep0tential spacebetweenthevisce「aIandpa「ietaIpleu『a

ⅡEM0TⅡ0RAX Theprimarycauseofhemothorax（＜1500mLblood） islunglacerationorlacerationofanintercostalvessel orinterna1mammaryarteryduetoeitherpenetratmg orblunttrauma·ThoracicspinefTacturesmayalsobe associatedwithahemothorax.BleedingisusuaⅡyselfk limitedanddoesnotrequireoperativeintervention. Anacutehemothoraxlargeenoughtoappearon achestx﹣rayfilmisbesttreatedwithalarge-caliber （36or40French）chesttube.Thechesttubeevacu﹣ atesblood,reducestheriskofaclottedhemothorax, and’importantly,providesamethodfbrcontinuous monitormgofbloodloss.EvacuationofbloodandfIuid alsofhcilitatesamorecompleteassessmentofpoten﹣ tialdiaphragmaticinjury.Althoughmanyfhctorsare involvedinthedecisiontooperateonapatientwith ahemothorax’thepatient》sphysiologicstatusand thevolumeofblooddrainagefTomthechesttubeare majorfhctors·Asaguideline,if1500mLofbloodis obtainedimmediatelythroughthechesttube’ifdrain﹣ ageofmorethan200mL／hr｛br2to4hoursoccurs,

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PITFA『』I』S I T L

AsimpIehemotho「axthatisnotfuIlyevacuatedcan『e﹣ 5ultina『etained’cIottedhemotho「axwithIungent『ap﹣ mento叼ifinfected!itcandevelopintoanempyema.

orifbloodtransh1sionisreqUired,operativeexplora﹣ tionshouldbeconsidered.The1】ltimatedecisionfbr operativeinterventionisbasedonthepatient’shemo﹣ dynamicstatus.

PUlM0ⅡARγC0ⅡTUS∣0N Pulmonarycontusioncanoccurwithoutribfractures orflailchest,particularlyinyoungpatientswithout completelyossifiedribs.However,inadultsitismost commonlyseenwithconcomitantribfractures,andit isthemostcommonpotentiallylethalchestinjury.The resultantrespirat0ryfhilurecanbesubtle,developing overtimeratherthanoccurringinstantaneously.The planfbrdefimtivemanagementmaychangewithtime andpatientresponse,warrantingcarefhlmonitoring andreevaluation0fthepatient· Patientswithsignificanthypoxia（i.e.’PaO2＜65 mmHg【8.6kPa】orSaO2＜90℅）onro0ma1rmay requireintubationandventilationwithinthefirst hourafterinjmy.Associatedmedicalconditions,such aschronicobstructivepulmonarydiseaseandrenal failure,increasethelikelihoodofneedingearlyintuba﹣ tionandmechanicalventilation. PulseoximetIymonitoring,ABGdeterminations, ECGmomtoring’andappropriateventilatoryeqUip﹣ mentarenecessaryfbroptimaltreatment·Anypatient withtheafbrementionedpreexistingconditionsWho needstobetransfbrredshouldundergointubationand ventilation.（SeeFigure4﹣8.）

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SECONDARYSURVEY:POTENTIALLYLIFE﹣THREATENINGINjURIES105

BLUNTCARDIAC∣Ⅱ』URγ

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Ⅱeve「unde『e5timatetheseve「ityofbIuntpulmona『y inju『y.Pulmona「ycontu5ionmayp「esenta5awide spect「umofcIinicaIsignsthata「e0ftennotweIIco『『elatedwithchestx＝「ayfindings.Ca「efuImonito「ing0f ventiIation’0xygenation’andfluid5tatusis『equi「ed’ oftenfo「seve『aIdays.Withp『ope『management’me﹣ chanicaIventiIationmaybeavoided.

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縿﹦︼﹄u︼﹂﹄室 Scena『io■cont『huedAchesttⅡbeha5 beenp∣aced0nthe『ight.〔he5tx-「ay『eveaIsa widemedia5tinumwithmultipIe『ibf『actu「es0n the『ightwithapu∣m0na『yc0ntusi0n’ ﹄

TRACⅡE0BR0ⅡCⅡ∣ALTREElNjURγ I叮u叮tothetracheaorm酊orbronchusisanunusual andpotentiallyf白talc0nditionthatisoftenoverlooked onimtialassessment.Inblunttraumathem勻orityof suchmjuries0ccurwithin1inch（2.54cm）oftheca﹣ rina.Mostpatientswiththismjurydieatthescene. Thosewhoreachthehospitalalivehaveahighmortal﹣ ityratefromassociatediIUuriesordelayindiagnosis oftheairwayinjury. Iftracheobronchia1iILjuryissuspected,immedi﹣ atesurgicalc0nsultation1swarranted.Suchpatients typicallypresentwithhemoptysis,subcutaneous emphysema,ortensionpneumothorax.Incomplete expansionofthelungafterplacementofachesttube suggestsatracheobronchialmjmy’andplacementof morethanonechesttubeoftenisnecessarytoover﹣ comeasignificantairleak.Bronchoscopyconfirms thediagnosis. Temporaryintubationoftheoppositemainstem bronchusmaybereqUiredtoprovideadequateo唧﹣ genation.However’mtUbationofpatientswithtracheobronchialimuriesisfrequentlydifficultbecause ofanatomicdistortionfromparatrachealhemat0ma’ associatedoropharyngealinjuries’and／orthetracheobronchialinjuryitself店Forsuchpatients,immediate operativeinterventionismdicated.Inmorestable patients,operativetreatmentoftracheobronchialinju﹣ riesmaybedelayeduntⅡtheacuteinflammationand edemaresolve.

Bluntcardiacinju叮canresultinmyocardialmuscle contusion,cardiacchamberrupture’coronaryarte】y dissectionand／orthrombosis’orvalvulardisrUption. CardiacrupturetypicaⅡypresentswithcardiactam﹣ ponadeandshouldberecognizedduringtheprimary surveyHowever’occasi0nallythesignsandsymptoms oftamponadeareslowtodevelopwithanatrialrup﹣ tureEarlyuseofFASTcanfacilitatediagnosis. PatientswithbluntmyocardialiIUurymayreport chestdiscomfbrt’butthissymptomisoftenattributed tochestwallcontusionorhPacturesofthesternum and／orribs.Thetruediagnosisofbluntmyocardial 1n】u1ycanbeestablishedonlybydirectinspectionof theinjuredmyocardium.ClimcaⅡyimportantseque﹣ laearehypotension’dysrhythmias’and／0rwall﹣motion abnormalityontwo﹣dimensionalechocardiography. Theelectrocardiographicchangesarevariableand mayevenindicatefrankmyocardialinfarction.Mul﹣ tipleprematureventricularcontractions,unexplained sinustachycardia’atrialfibrⅢation’bundle﹣branch block（usuallyright）’andST﹣segmentchangesare themostcommonECGfindings.Elevatedcentral venouspressureintheabsenceofanobviouscause mayindicaterightventriculardysh1nctionseconda1y tocontusion·Italsoisimportanttorememberthatthe traumaticeventmayhavebeenprecipitatedbyamyo﹣ cardialischemicepisode. Thepresenceofcardiactroponinscanbediag﹣ nosticofmyocardialinfhrction.However’theiruse indiagnosingbluntcardiaci呵u】yisinconclusiveand offbrsnoadditionalinfbrmationb叮ondthatavailable 仕omECG.Patientswithabluntinjurytotheheart diagnosedbyconductionabnormalities（anabnormal ECG）areatriskfbrsuddendysrhythmiasandshould bemomtored允rthehrst24hours.A仕erthismterval’theriskofadysrhythmiaappearstodecreasesub﹣ stantially.ThosewithoutECGabnormalitiesdonot requirefhrthermonitoring.

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TRAIjMATIcA0RT!CD∣SRUPTI0N Traumaticaorticruptureisacommoncauseofsuddendeatha仳eranautomobⅡecoIIi曰ionor炮llhoma greatheight（■F!GUREq﹣9）.Forsurv1vors,recoveryis fTequentlypossibleifaorticruptureispromptlyidentifiedandtreatedinnnediately. PatientswithaorticruptureWhohaveachance ofsurvivaltendtohaveanincompletelacerati0nnear theligamentumarteriosumoftheaorta.Continui叮is maintainedbyanintactadventitiallayerorcontained mediastinalhematomaandpreventsimmediateexsan﹣ guinationanddeath.Bloodmayescapeintothemedi﹣ astinum,butonecharacteristicsharedbyallsurv1v0rs isthattheyhaveacontainedhematoma.Persistent

106CHAPTER4■Th0「acicT「auma

■Widenedmediastinl】m ■Obhterationoftheaortickhnb 「e

■Deviationofthetracheatotheright ■Depressionoftheleftmainstembronchus ■Elevation0ftherightmainstembronchus ■Obliterationofthespacebetweend1epulmo﹣ naryarteryandtheaorta（obscurationofthe aortopulmonarywindow） ■Deviationoftheesophagus（nasogastrictube） totheright ■Widenedparatrachealstripe ■Widenedparaspinalinterfhces ■Presenceofapleuralorapicalcap ■Lefthemothorax ■Fracturesofthefirst0rsecondriborscapula

■FlGUREq﹣9Ao『ticRuptu『e.T『aumaticao「tic「uptu『e isac0mmoncau5e0fsuddendeathafte「anautomobiIe CoIIisi0no「faIIf「omag『eatheight·

orrecurrenthypotensionisusuallyduetoaseparate, unidentifiedbleedingsite.Althoughfreeruptureofa transectedaortaintothele仕chestdoesoccurandcan causehypotension’itusual】yisfatalunlessthepatient undergoesrepairwithinafbwminutes. Specificsignsandsymptomsoftraumaticaortic disruptionareiiyequentlyabsent.Ahighindexofsus﹣ picionpromptedbyahistoryofdeceleratingfbrceand characteristichndingsonchestx﹣rayfilmsshouldbe maintained,andthepatientshouldbefhrtherevalu﹣ ated.Adjunctiveradiologicsignsonchestx﹣ray,which mayormaynotbepresent,indicatethelikelihoodof maIorvascularinjmyinthechestandinclude:

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Penet「atingob】ectsthatt『ave『sethemediastinum mayinju『ethema】o「mediastinaIst『uctu「es’suchas thehea「t’g「eatvesseIs〃t「acheob「onchiaIt『ee『and esophagu5·Thediagnosisismadewhenca『efuIex﹣ aminationandachestx-『ayfiIm「eveaIanent「ance woundinonehemitho『axandanexitwoundo「amis﹣ siIelodgedinthecont「aIate「aIhemitho『ax·Woundsin whichmetaIIicf「agmentsf『omthemissiIea「einp「ox﹣ imiⅣt0mediastinaIst『uctu「esalsoshouId「aisesuspi﹣ cionofamediastinaIt「ave『singinju「y.5uchwounds wa「「antca「efulconside『ation’andsu「gicaIconsuIta﹣ tionismandato『y·

FalsepositiveandfHlsenegativefindingscan occurwitheachx﹣raysign’and’infrequently（1﹪13℅）,nomediastinalorimtia1chestx﹣rayabnormali叮 ispresentinpatientswithgreat﹣vesseli叼my.Ifthere isevenaslightsuspicionofaorticinjmy,thepatient shouldbeevaluatedatafhcihlycapableofrepairinga diagnosedinjury. Helicalcontrast﹣enhancedcomputedtomography （CT）0fthechesthasbeenshowntobeanaccurate screeningmethodfbrpatientswithsuspectedblunt aorticinjmy.CTscanningshouldbeperfbrmedliber﹣ ally》becausetheHndingsonchestx﹣ray,especiallythe supineview,areunreliable.Iftheresultsareequivocal’ aortographyshouldbeperfbrmed.Ingeneral,patients whoarehemodynamicallyabnormalshouldnotbe placedinaCTscanner.Thesensitivityandspecificity ofhelicalcontrast﹣enbancedCThavebeenshownto becloseto100﹪’butthisresultisverytechnology﹣ dependent.IfenhancedhelicalCTofthechestisnega﹣ tivefbrmediastinalhematomaandaorticrupture’no fhrtherdiagnosticimaging0ftheaortaisnecessary. WhentheCTispositivefbrbluntaorticrupture’the extentoftheinjurymaybefhrtherdefinedwithCT ang1ogramoraortography.Transesophagealechocar﹣ diography（TEE）alsoappearstobeausefhl,lessinvasivediagnostictool.Thetraumasurgeoncaringfbrthe patientisinthebestpositiontodeterminewhich,if any’otherdiagnostictestsarewarranted. Inhospitalsthatlackthecapabilitytocarefbrcar﹣ diothoracicinjuries,thedecisiontotransfbrpatients withp0tentialaorticinjmymaybedifficult.Aproperly perfbrmedandinterpretedheⅡcalCTthatisnormal mayobviatetheneedfbrtransfbrtoahigherlevelof caret0excludethoracicaorticinjury· Aqualiiiedsurgeonsh0uldtreatpatientswith blunttraumaticaorticinjuryandassistinthediagno﹣ sis.Thetreatmentiseitherprnnaryrepa1rorresection

SECONDARYSURVEY:POTENTIALLYLIFE-THREATENINGIN」URlES107

Lung

A

Abdomina∣ contents

Hemia 0iaph「agm

■FIGURE4-10Diaph『agmaticRuptu『e.（A）Radiog「aphview·（B）BIuntt『aumap「oducesIa「ge 『adialtea「sthatIeadtohe「niation’whe『ea5penet「atingt「aumap「oducessmaIIpe『fo「ations thatcantaketime’5ometimesevenyea『5〃todeveI0pintodiaph「agmatiche『nias·

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DeIayedo「extensiveevaIuationofthewidemedias﹣ tinumwithoutca「diotho「acicsu「ge『ycapabiIitiescan 「esuItinanea『Iyin﹣hospital「uptu『eofthecontained hematomaand『apiddeathf「omexsanguination.AII patient5withamechanismofinjulyandsimplechest x﹣「ayfinding55uggestiveofao「ticdis『uptionshouId bet「ansfe『「edtoafaciIitycapabIeof『apiddefinitive diagnosisandt「eatmentofthisiniu『y·

ofthetornsegmentandreplacementwithaninterpo﹣ sitiongrait.Endovascularrepairisnowanacceptablealter﹣ nativeapproach.

TRA0MATICDIApⅡRAGMATIC∣NjURγ Traumaticdiaphragmaticrupturesaremorecommon﹣ lydiagnosedontheleftside’perhapsbecausetheliver obliteratesthedefbctorprotectsitontherightside ofthediaphragm’whereastheappearanceofdisplaced bowel’stomach’andnasogastric（NG）tubeismoreeas﹣ Ⅱydetectedintheleftchest.Blunttraumaproduces largeradialtearsthatleadtoherniation（■FIGuRE q﹣10）,whereaspenetratingtraumaproducessmallper﹣ fbrationsthatcantaketime,sometimesevenyears’to developintodiaphragmatichernias·

DiaphragmaticinjuriesarefreqUentlymissedimtiaⅡywhenthechestfilmismisinterpretedasshowing anelevateddiaphragm’acutegastricdilatation’locu﹣ latedhemopneumothorax’orsubpUhnonaryhematoma· Theappearance0fanelevatedrightdiaphragmonchest x﹣raymaybetheonlyfindingofaright﹣sidedimury·If alacerationoftheleftdiaphragmissuspected,agastric tubeshouldbemserted.Whenthegastrictubeappears inthethoraciccavi叮onthechesthlm,theneedfbr specialcontraststudiesiseliminated.OccasionaⅡy,the conditionisnotidentifiedontheinitialx﹣rayfilm0r subseqUentCTscan.Anuppergastrointestinalcon﹣ traststudyshouldbeperfbrmedifthediagnosisisnot clear.TheappearanceofperitoneallavagefIuidmthe chesttubedrainagealsoconfirmsthediagnosis.Mim﹣ mallyinvasiveendoscopicprocedures（e.g.,laparoscopy 0rthoracoscopy）maybehelp｛hlinevaluatingthedia﹣

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phragminindeterminatecases. Operationibrotherabdominalinjuriesoftenreveals adiaphragmatictear.Treatmentisbydirectrepair.

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Diaph「agmin】u「iesmaybemisseddu「ingtheinitiaI t「aumaevaIuation.Anundiagno5eddiaph「agminju『y can「esuItinpuImona「ycomp『omiseo『ent「apment andst「anguIationofpe「itoneaIcontent5·

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108CHAPTER4■Tho「acicT『auma

BⅢⅡTES0PⅡAGEALRUPTURE EsophagealtraumamostcommonlyresultsfTompen﹣ etratmginjury·Bluntesophagealtrauma,although veryrare’canbelethalifunrecognized·Bluntinjury oftheesophagusiscausedbythefbrcefhlexpulsionof gastriccontentsintotheesophagusfromasevereblow totheupperabdomen.Thisfbrcefhlejectionproduces alineartearintheloweresophagus,allowingleakage intothemediastinum﹦Theresultingmediastinitisand immediateordelayedruptureintothepleuralspace causeempyema. Theclinicalpictureofpatientswithbluntesopha﹣ gealruptureisidenticaltothatofpostemeticesopha﹣ gealrupture·Esophagealinjuryshouldbeconsidered inanypatientwhohasaleftpneumothoraxorhemo﹣ thoraxwithoutaribfracture﹩receivedasevereblow tothelowersternumorepigastriumandisinpamor shockoutofproportiontotheapparentinjury;andhas particulatematterinthechesttubeafterthebl0od beginstoclear·Thepresenceofmediastinalairals0 suggeststhediagnosis’whichoftencanbeconfirmed bycontraststudiesand／oresophagoscoⅣ. Treatmentconsistsofwidedrainageofthepleural spaceandmediastinumwithdirectrepairoftheinjury viathoracotomy,iffbasible.Repairsper〔brmedwithin afbwhoursofinjuryleadtoamuChbetterprognosis.

﹥

0the『Mani『estationsof Chestlniu『ies

Othersignificantthoracicinjuries,includingsUbcuta﹣ neousemphysema;crushinginjury（traumaticasphyx﹣ ia）;andrib》sternum,andscapularfractures,shouldbe detectedduringtheseconda】另ysurvey.Althoughthese injuriesmaynotbeimmediatelylifb﹣threatening,they havethepotentialtodosignificantharm. SUBCUTANEOUSEMpⅡγSEMA Subcutaneousemphysemacanresulthoma1rway injuIy,lunginjury,or,rarely’blastinjury.Although itdoesnotrequiretreatment,theunderlyinginjury mustbeaddressed.Ifpositive﹣pressureventilationis required’tubethoracostomyshouldbec0nsidered0n thesideofthesubcutaneousemphysemainanticipa﹣ tionofatensionpneumothoraxdeveloping. CR05ⅡIⅡG∣Ⅱ」URγT0TⅡECⅡEST

（TRAUMAT∣CASPⅡγX∣A） Findingsassociatedwithacrushm〕mytothechest includeuppertorso’facial,andarmplethorawithpe﹣

techiaesecondarytoacute’temporaIycompression ofthesuperiorvenacava.Massiveswellingandeven cerebraledemamaybepresent·Associatedinjuries mⅥstbetreated.

R!B’STERⅡUM『AⅡDSCAPULAR「RACTURES TheribsarethemostconⅡnonlyiIUuredcomponentof thethoraciccage’andmjuriestotheribsareoftensig mficant。PainonmotionlⅣpicallyresultsinsplintingof thethorax,whichimpairsventilati0n,o叮genati0n’and effbctivecoughing.Theincidenceofatelectasisandpneu. moniarisessignificantlywithpreexistinglungdisease. Theupperribs（1to3）areprotectedbythebony frameworkoftheupperlimb.Thescapula’humerus） andclavicle’alongwiththeirmuscularattachments, provideabarriertoribinjury.Fracturesofthescap﹣ ula,firstorsecondrib’orthesternumsuggestamag﹣ mtudeofinjurythatplacesthehead’neck’spinalcord’ lungs,andgreatvesselsatriskfbrseriousassociated m〕ury.Becauseoftheseverityoftheassociatedinju﹣ ries’mortalitymaybeashi助as35﹪. Sternalandscapularfracturesaregenerallythe resultofadirectblow.Pulmonarycontusionmay accompanysternalfTactures,andbluntcardiacimury shouldbeconsideredwithallsuchfractures.Operative repairofsternalandscapularfTacturesoccasionaⅡyis indicated·Rarely,posteriorsternoclaviculardisloca﹣ tionresultsmmediastinaldisplacementofthecla尸 vicularheadswithaccompany1ngsuper1orvenacaval obstruction.ImmediatereductionisreqUired. Themiddleribs（4to9）sustainthem鉚orityof blunttrauma.Anteroposteriorcompressionofthetho﹣ raciccagewillbowtheribsoutwardwithafTacture mthemidshaft.Directfbrceappliedtotheribstends tohacturethemanddrivetheendsofthebonesinto thethorax,increasingthepotentialfbrintrathoracic injury’suchasapneumothoraxorhemothorax’ Asageneralrule,ayoungpatientwithamore flexiblechestwallislesslikelytosustainribfTactures. Therefbre,thepresenceofmultipleribfTacturesin youngpatientsimpliesagreatertransfbroffbrcethan inolderpatients.Fracturesofthelowerribs（10to12） shouldincreasesuspicionfbrhepatosplenicinjury. Localizedpain’tendernessonpalpati0n’andcrep﹣ itationarepresentinpatientswithribi叼ury.Apalpa. bleorvisibledefbrmitysuggestsribfTactures.Achest x﹣rayfilmshouldbeobtainedprimarilytoexclude otherintrathoracicinjuriesandnotjustt0identifyrib fiPactures.Fracturesofanteriorcartilagesorsepara﹣ tionofcostochondraljunctionshavethesamesigmfi﹣ canceasribfractures,butwillnotbeseenonthex﹣ray examinations.Specialrib-techniquex﹣raysarenotcon﹣ sideredusefUlbecausetheymaynotdetectallribiUju﹣ riesandaddnothingtotreatmentdecisions,whereas

0THERMANIFESTATIONS0FCHESTINjURIES109

theyareexpensiveandrequirepainfhlpositioningof thepatient‘SeeSkillStati0nⅥ:X﹣RayIdentification ofThoracicIniuries. ThepresenceofribfTacturesintheelderlyshould raisesignificantconcern’astheincidenceofpneumo﹣ niaandmortali叮isdoublethatinyoungerpatients See Chapter11:GeriatricTrauma Taping,ribbelts, andexternalsplintsarecontraindicated.Reliefofpain isimportanttoenableadequateventilation.Intercos﹣ talblock’epiduralanesthesia’andsystemicanalgesics areeffbctiveandmaybenecessa1y.Earlyandaggres﹣ sivepaincontrol,includingtheuseofsystemicnarcot﹣ icsandlocalorregionalanesthesia’improvesoutcome inthispopulation. IncreaseduseofCThasresultedmtheidentifi﹣ cationofiUjuriesnotpreviouslyknownordiagnosed, suchasminimalaorticinjuriesandoccultpneumot﹣ horacesandhemothoraces.Appropriatetreatmentof theseoccultmjuriesshouldbediscussedwiththerela﹣ tivespecialtyconsultant·

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PITFA『』『』S

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ⅢThoracicinju1yiscommonm恤epoly﹣traumapatientandcanposeⅡfb﹣threatening problemsifnotpromptlyidentifiedandtreatedduringthepr1ma1ysurvey.These patientscanusuaⅡybetreatedortheirconditionstemporarilyreⅡevedbyrela﹣ tive】ysimplemeasures,suChasintubation,ventilation,tUbethoracostomy’and huidresuscitation·Theabili叮torecognizetheseimportanti叼uriesandtheskill toperfbrmthenecessaryprocedurescanbelifbsav1ng.Thepr1marysurveyin﹣ cludesmanagementofthefbⅡowingconditions: ﹥AirwayObstruction ﹥Tensionpneumothorax ﹥Openpneumothorax ﹥Flailchestandpuhnonarycontusion ﹥Massivehemothorax ﹥Cardiactamponade

圍Thesecondarysurv叮includesidentificationandimtialtreatmentofthefbⅡow﹣ 1ngpotentiaⅡyhfb﹣threateninginjuries’utⅢzmgadjunctivestudies,suchasx﹣ rays,laboratorytests’andECG: PSimplepneumothorax ﹥Hemothorax ﹥Pulmonarycontusion ﹥TracheobronChialtreei呵ury ﹥Bluntcardiac呵ury ﹥Traumaticaorticdisruption ﹥ITaumaticdiaphragmaticimury PBluntesophagealrupture 固Severalmanifbstationsofthoracictraumaareindicativeofagreaterriskofas﹣ s0ciated坷uries: ﹥Subcutaneousemphysema ﹥CrushiIUuries0fthechest ﹥Imuriestotheupperribs（1＿3）,scapula,andsternum ＝

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BIBUOGRAPHY111

■BⅢlocRAⅢ LBallCG,KirkpatrickAW,LauplandKB,etal·Incidence, riskfhctors’andoutcomesfbroccultpneumothoracesin victimsofmajortrauma.J乃αMmα2005;59（4）:917﹣924; discussion924﹣925. 2.BallCG,WilliamsBH,WyrzykowskiAD’NicholasJM’ RozyckiGS,FelicianoDV·Acaveattotheperfbrmance ofpericardialⅢtrasoundinpatientswithpenetrating cardiacwounds.J乃.αM加α2009;67（5）1123﹣4. 3BraselKJ,StaffbrdRE,WeigeltJA’TenquistJE’ BorgstromDOTreatmentofoccultpneumothoraces fTomblunttrauma.J乃α叨mα1999j46（6）,987﹣990; discu釁sion990﹣991. 4.BulgerEM,EdwardsT,KlotzP,JurkovichGJ.Epidural analgesia1mprovesoutcomeaftermultipleribfTactures. S皿咱它Jy2004,136（2）:426﹣430. 5.CallahamMPericardiocentesisintraumaticand nontraumaticcardiactamponade.A〃〃Eme唔Mbd 1984;13（10）:924﹣945. 6.CookJ,SalernoC,KrishnadasanB,NichoⅡsS’Meiss﹣ nerM’Karmy﹣JonesR.Theeffbct0fchangmgpre﹣ sentationandmanagementontheoutcomeofblunt ruptureofthethoracicaorta.JⅣjo／.αcCm.d!ouαscSα／g 2006;131（3）:594﹣600. 7DemetriadesD’VelmahosG,etal.Diagnosisandtreatmentofbluntaorticinjurieschangingper5pectives.J 乃αα加α2008;64:1415﹣1419. 8.DemetriadesD’VelmahosG’etal.Operativerepairor endovascularstentgraltinblunttraumaticthoracicaortic imuries:resultsofanAmericanAssociationfbrtheSurge】y ofITaumamulticenterstudy.J乃αumα2008;64:561﹣571. 9.DulchavskySA’SchwarzKL’KirkpatrickAW,etal.Pro﹣ spectiveevaluationofth0racicultrasoundinthedetec﹣ tionofpneumothorax.J?／.αα／〃α2001,（Feb50）:201﹣5. 10DunhamCM’BarracoRD,ClarkDE,etal.Guidelines fbremergenCytrachealintubationimmediatelyfbⅡowing traumatici叼ury:anEASTPracticeManagementGuide﹣ linesWOrkgroup.JⅡγJu【↓mα2003;55:162﹣179 11.DyerDS,MooreEE’IlkeDN’McIntyreRC,Bernstein SM’DurhamJD,MestekMF,HeinigMJ,RussPD, SymondsDL,HomgmanB,KumpeDA’RoeEJ’EuleJ Jr.Thoracicaortic1mu】y:howpredictiveismechanism andischestcomputedtomographyareliablescreening tool?Aprospectivestudyof1’561patients.J乃α叨mα 2000;48（4）:673﹣82;discussion682﹦3. 12EkehAP’PetersonW’etal·Ischestx﹣rayanadequate screeningtoolfbrthediagnosisofbluntthoracicaortic injury?J奶Ⅶα加α2008;65:1088﹣1092. 13’FlagelB,LuchetteFA’ReedRL,etal.Halfadozenribs: thebreakp0intfbrmortali叮.Sα／郡『y2005;138;717﹣725. 14’GrahamJG’MattoxKL,BeallACJr.Penetratingtrauma ofthelung.J乃m』加α1979;19:665. 15.HarckeHT’PearseLA’LevyAD,GetzJM,RobinsonSR. Chestwallthicknessinmilitarypersonnel;implications fbrneedlethoracentesisintensionpneumothorax.MM Med2007;172（120）:1260﹣1263.

16.HenifbrdBT,CarrⅢoEG’SpainDA’etal.Therole ofthoracoscopyinthemanagementofretainedtho﹣ raciccollectionsaitertrauma.A〃〃Zγjo『ncSMJg 1997;63（4）:940﹃943. 17.HershbergerRC,BernadetteA,etal.Endovascualar grafts｛brtreatmentoftraumaticinjurytotheaortic archandgreatvessels。J乃α【〃〃α2009;67（3）:660﹣671. 18.HopsonLR,HirshE’DelgadoJ,DomeierRM’McSwain NE,KrohmerJ.Guidehnesfbrwithholdingortermina﹣ tionofresuscitationinprehospitaltraumaticcardiopul﹣ mona】:yarrest:ajointpositionpaperfromtheNational AssociationofEMSPhysiciansStandardsandClinical PracticeCommitteeandtheAmericanCollegeofSur﹣ geonsCommitteeonTrauma·PJ它／ioSpEme／gCα『、e 2003;7（1）:141﹣146. 19.HopsonLR’HirshE’DelgadoJ’etal.GuideⅡnesfbr withholdingorterminationofresuscitationmprehospi﹣ taltraumaticcardiopuhnonaryarrest·JAmα〃SαJg 2003,196（3）’475﹦481 20.KenjiInaba,MD’FRCSC,FACS’BernardinoC.Branco’ MD,MarcEckstein,MD’DavidV·Shatz,MD’Mat﹣ thewJ.Martin’MD,DonaldJ.Green,MD,ThomasT. Noguchi’MD’andDemetriosDemetriades,MD,PhD. 0P放況α／肋s尬o／泌吧／bJ·E〃』e／ge㎡1Vbed／eⅧomcosfo〃?y﹩ ACαdαue／.﹣BαsedS如叼.J乃αMmα2011;71;1099﹣1103. 21.HuntPA,GreavesI》OwensWA.EmergenCythoracotomy inthoracictrauma－areview.In／Ⅸ／:）I2006;37（1）;1﹣19. 22.KaralisDG’VictorMF,DavisGA,etal.Theroleofecho﹣ cardiographyinbluntchesttrauma:atransthoracicand transesophagealechocardiographystudy.JT『.α叨／〃α 1994;36（l）:53﹣58. 23.K印?my﹣JonesR,JUrkovichGJ,NathensAB,ShatzDV, BrundageS,WallMJJr’EngelhardtS’HoytDB,HolcroftJ’KnudsonMM·Timingofurgentthoracotomyfbr hemorrhageaftertrauma!amulticenterstudyA祀加ues O／S皿｝ge／:y2001j136（5）:513﹣8. 24.LangLazdunskiL’MouroxJ,PonsF,etal.Roleof videothoracoscopyinchesttrauma.A〃几ThomcSmg 1997;63（2）:327﹣333· 25.Lock叮D,CrewdsonK,DaviesG凸aumaticcardiacarrest: whoarethesu1.vivors?A／B〃E〃』eJgMed2006;48（3）:240﹣244. 26.MarnochaKE’MaglinteDDT,WoodsJ,etal·Bluntchest traumaandsuspectedaorticrupture:reliabilityofchest radiographfIndings.A〃〃E加e唔Mbd1985;14（7）:644﹣649. 27.MeyerDM,JessenME,WaitMA.Earlyevacuationof traumaticretainedhemothoracesus1ngthoracoscopy: Aprospectiverandomizedtrial.A几〃T／io尸αcSM『g 1997;64（5）:1396﹣1400 28.MirvisSE,ShanmuganthamK,BuellJ,etal.Useofspi﹣ ralcomputedtomographyfbrtheassessmentofblunt traumapatientswithpotentialaorticinjmyJ乃.αα加α 1999;45922.930 29.MoonMR,LuchetteFA’GibsonSW,etal.Prospec﹣ tive,randomizedcomparis0nofepiduralversusparen﹣ teralopioidanalgesiainthoracictrauma.A几几Sα唔 1999;229:684﹣692· 30PoweⅡDW’MooreEE,CothrenCC’etal.Isemergencydepartmentresuscitativethoracotomy血tile

11ZCHAPTER4■Tho「acicT「auma carefbrthecriticallyinjuredpatientrequiringpre﹣ hospitalcardiopulmonaryresuscitation?JAmα〃SαJg 2004;199（2）:211﹣215·

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31.RamzyAI’RodriguezA,TurneySZ.Managementof m匈ortracheobronchialrupturesinpatientswithmultiplesystemtrauma.JTrαM加α1988;28:914﹣920.

40.S¢reideK’S¢ilandH,LossiusHM,etal.Resuscitative emergen叮thoracotomyinaScandinaviantraumahospi﹣ tal＿isitjustified?I叮α『y2007;38（1）:34﹣42.

32.ReedAB’ThompsonJK’CraltonCJ’etal.Timingof endovascularrepairofblunttraumaticthoracicaortic transections.JⅦscSu唔2006;43（4）:684﹣688.

41·StalfbrdRE’LinnJ,WashingtonL.Incidenceand managementofocculthemothoraces.AmJSα咱 2006;192（6）:722﹣726.

33·RheePM’AcostaJ,BridgemanA’WangD,JordanM, RichNSurvivalafteremergen叮departmentthora﹣ cotomy:reviewofpubhsheddatafTomthepast25years. JAmα〃Sα唔2000;190（3）:288﹣298.

42.SwaaenburgJC,KlaaseJM,DeJongsteMJ’etal.Tro﹣ poninI,troponinT,CI甽B﹣activityandCKMG﹣mass asmarkersfbrthedetectionofmyocardialcontusionin

34.RichardsonJD’AdamsL’FlintLM.Selectivemanage﹣ mentoff】ailchestandpulmona1ycontusion.AJmSα唔 1982;196（4）:481﹣487’ 35.RosatoRM’ShapiroMJ,KeeganMJ’etal.Cardiac injuIycomplicatingtraumaticasphyxia·J】》nαmα 1991;31（10）:1387﹣1389. 36.RozyckiGS’FelicianoDV,OschnerMG,etal.Therole ofultrasoundinpatientswithpossiblepenetratingcar﹣ diacwounds:aprospectivemulticenterstudy.J】粒α加α 1999;46（4）:542﹣551. 37.SimonB,CushmanJ’BarracoR,etal·Painmanagement inbluntthoracictrauma:anEASTPracticeManagement GuidehnesWorkgroup.JTmα加α2005;59:1256-1267· 38.SisleyAC,RozyyckiGS,BallardRB,NamiasN,Salo﹣ moneJP,Fe】icianoDV·Rapiddetectionoftraumatic effhsionusingsurgeon﹣perfbrmedultrasonography·J T『江αmα1998;44:291﹣7.

patientswhoexperiencedblunttrauma.αmC加mAcm 1998;272（2）:171﹣181 43.TehraniHY,PetersonBG’KatariyaK’etalEndova﹣ scularrepairofthoracicaortictears·Am』ⅣjomcSα唔 2006;82（3）:873﹦877. 44.WeissRL,BrierJA’O,ConnorW’etal.TheusefUlnessof transesophagealechocardiographyindiagnosingcardiac contusions.C／jes』1996;109（1）:73﹣77· 45.WilkersonRG,StoneMB.Sensitivityofbedsideultra﹣ soundandsupineanteroposteriorchestradiographsfbr theidentificationofpneumothoraxafterblunttrauma. 〔Review】〔24re始】AcαdE加e咱M它d2010;17（1）:11﹣7. 46.WoodringJH.Anormalmediastinuminblunttrauma ruptureofthethoracicaortaandbrachiocephalicarte﹣ ries.JE加e咱M它d1990;8:467﹣476·

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／VotefThisSkilIStationincIudesasystem﹣ aticmethodfo『evaluatingchestx﹣「ay films.Ase『ie5ofx﹣『ayswith『eIatedsce﹣ na『iosis5hownt0studentsfO『thei「evaIuationandmanagementdeci5i0nsba5ed onthefinding5.Standa『dp『ecaution5 a『e『equi『edwheneve『ca「ingfo『t『auma patients·

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113

114SKILLSTATI0NVI■X﹣Rayldentificati0nofTh0「acicIn】u「ies I

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pATlENTVl﹣7

X尸rayfilmofa33﹣year-oldbiCyclistwhowashitbyacar

XPrayfilmofa36﹣year﹣oldmaleaitertreatmentofanob· viouspneumothoraxontheri即tside,stⅢdesaturated

PAT∣ENTVI﹣Z X﹣rayfilmofayoungfbmalewithasmaⅡstabwound abovethemppleontherightsidewithipsilateraldi﹣ mihishedbreathsounds.

PAT!ENTVl﹣8

pAT∣EⅡTVI﹣3

Xrayfilmofa45﹣year﹣oldmalemotorcyclistwhohit atreeathighspeedHewasintubatedbyemergenCy medicalserv1ces（EMS）andpresentsashemodynami﹣ caⅡynormal.

X﹣rayfilmofa56曰year﹣oldtruckdriverwhohitan abutmentandreportedleft﹣sidedChestpainandres﹣

pATIEⅡTVI﹣9

piratorydistress.

pATlEⅡTV∣﹄4 X﹣rayfilmofa22﹣year﹣oldmaleindistressafterafight inabar（stabwoundintheback’fburthintercostal spaceonle仕）.

pATIENTVI﹣5 X﹣rayfilmofa42﹣year﹣oldmaleinrespiratorydistress aftersustainingagunshotwoundmajewelryshop robbery·

pATIEⅡTV∣﹣6

Xrayhlmofa56﹣year-oldmotorcyclistwhosustained acollisionwithatruck.Hewasintubatedandreceived athoraxdrainintheprehospitalsetting.

pATIEⅡTVI﹣10 Xrayfilmofan18﹣year﹣oldgangleaderwhowasas﹣ saulted.Hehasmultiplecontusions,analteredlevel ofconsciousness,andasmallentrancewoundonthe righthemithorax.Hehasreceivedimtialresuscitation.

pATIENTVI﹣11 X≡rayfilmofa56﹣year-oldmalewhofblloffaladder （6morapproximately20fbet）withsevereheadlnju叮·

X﹣rayfilmofamotorcyclistwithsevereheadtrauma onBdmission.

卜5l《iI∣VI﹦A:P『ocessfo『lnitiaIReviewofChestX﹣Rays 卜pI.0vERvIEW S『Ep1.Confirmthattheiilmbeingviewedisof yourpatient. STEP2’Quicklyassessfbrsuspectedpathology. STEP3·Usethepatient,sclmicalfindingstofbcus thereviewofthechestx-rayhlm’anduse thex﹣rayfindingstoguidemrtherphysica」 evaluation（TableⅥ·1）.

pbII.TRACⅡEAA∣＼』DBR0NCⅡI STEp1·Assessthepositionofthetubeincasesof endotracbealmtubation. s丁EP2·

Assessibrthepresenceofinterstitialor pleuralairthatcanrepresenttracheobron﹣ chialinjury.

5TEP3·

Assess允rtrachea1lacerationsthatcan presentaspneumomediastinum,pneumo﹣ thorax》subcutaneousandinterstitialemphy﹣ semaoftheneck’orpneumoperitoneum.

5KILLSTATIONVI■X-RayIdentification0fTho「acicIn】u「ies115

■TABLEVI.1C閒ES丁X﹦RAγSUGGEST!ONS FlNDⅧGS

DIAGⅡOSESTOCONSlDER

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pneum0tI｝0『axipu∣mona「y（0ntusi0n

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STEP4

Assessfbrbronchialdisruptionthatcan presentasa丘eepleuralcommunication andproduceamassivepneumothoraxwith apersistentairleakthatisunresponsiveto tubethoracostomy.

r卜ⅢPLEⅢAlSPACESAⅡD川ⅡG pAREⅡCⅡγMA STEp1.

Assessthepleuralspacefbrabnormal coⅡectionsofⅡuidthatcanrepresenta hemothorax.

5TEPZc

Assessthepleuralspacefbrabnormalcol﹣ lecti0nsofairthatcanrepresentapneumo﹣ thorax一usuaⅡyseenasanapicallucentarea withoutbronchia1orvascularmarkings·

sTEP3·

s『EP4.

Assessthelungiieldsfbrinfiltratesthatcan suggestpuhnonarycontusion’hematoma’ aspiration’andsoon.Pulmonarycontusion appearsasa1r﹣spaceconsolidationthatcan beirregu1arandpatchy,homogeneous’dif h1se’orextensive.

Assesstheparenchymafbrevidenceoflaceration.Lacerationsappearashematomas, va1yaccordingtothemagnitudeofinjury, andappearasareasofconsohdation.

卜P∣V.MED!ASTIⅡUⅢ sTEP1·

Assessfbrairorbloodthatcandisplaceme﹣ diastmalstructures’blurthedemarcation betweentissueplanes’orouthnethemwith radiolucenCy.

5TEpZ

Assessfbrradiologicsignsassociatedwith cardiacormajorvasculari1Umy. AAirorbloodinthepericardiumcan resultmanenlargedcardiacsilhouette. Progressivechangesmcardiacsizecan representanexpandingpneumopencardiumorhemopericardium. B·Aorticrupturecanbesuggestedby: oAwidenedmedi3stinum－mostreli﹣ ablehnding ·FTacturesofthe行Tst月hdsecondribs ·Obliterationoftheaorticknob ·Deviationofthetracheatotheright ·Presenceofapleuralcap ·Elevationandrightwardshiftofthe rightmainstembronchus ·Depressionoftheleftmainstem bronehⅢs ·Obliterationofthespacebetweenthe pulmonaryarteryandaorta ·Deviationoftheesophagus（nasogas﹣ tric〔NG】tube）totheright

116SKILLSTATlONVI■X﹣RayIdentificationofTh0『acicIn】u『ie5

卜〉V·DIAPHRAGM Ⅳb／e『Diaphragmaticrupturerequiresahighindex ofsuspicion’basedonthemechanismofinjury,signs andsymptoms’andx-rayfindings.Initia1chestx-ray examinationmaynotclearlyidenti句adiaphragmatic injury.Sequentialfilmsoradditionalstudiesmaybe required. STEP1·CareiUllyevaluatethediaphragmfbr; AElevation（mayrisetofburthintercostal spacewithfhllexpiration） B·Disruption（stomach’bowelgas》orNG tubeabovethediaphragm） C.Pooridentification（irregularorobscure） duetooverlyingfluidorsoft﹣tissue 】nasses

STEP2·X﹣raychangessuggestinginjuryinclude: AElevation,irregulari叮’orobliterationof thediaphragm＿segmentalortotal B·Amass-Ⅱkedensi叮abovethediaphragmthatcanbeduetoafluid﹣filled bowel’omentum’hver’kidn叮,spleen’ orpancreas（mayappearasa‘‘loculated pneumothorax”） C.Airorcontrast﹣containingstomachor bowelabovethediaphragm D·ContTalateralmed珀stinalsh↑仕 E·Wideningofthecardiacsilhouetteifthe peritonea1contentshermateintothe pericardia1sac 『.Pleurale飭】sion

STEP4Assessribs4through9fbrevidenceoB AFracture’especiallyintwoormorecon﹣ tiguousribsintwoplaces（flailchest） B·Associatedi叼ury,suchaspneumotho﹣ rax,hemothorax,pulmonarycontusion STEp5·Assessribs9through12fbrevidenceof! AFracture,especiallyintwoormore places（flailchest） B’Associatedmjury,suchaspneumotho﹣ rax,pulmona】ycontusion’spleen’liver, and／orkidney STEp6’Assessthesternomanubrialjunctionand sternalbodyfbrevidenceof仕actureor dislocation.（Sternalhyacturescanbemis﹣ takenontheanteroposterior【AP】filmfbr amediastinalhematoma.Afterthepatient isstabⅢzed’aconed﹣downview,over﹣ penetratedfilm’lateralview’orcomputed tomography〔CT〕maybeobtainedtobetter identifysuspectedsternal丘acture.） 5TEP7.

卜bVⅡ。S0FTTISS0ES sTEP1·

STEP1.

STEpZ。

s丁EP3’

AsSesstheclavicle允revidenceoB AFracture B·Associatedi叮ury,suchasgreat﹣vessel 1mu1y Assessthescapulafbrevidenceof﹩ AFracture B·Associatedinjmy,suchasa1rwayor great﹣vesseliIUmy’pulmonarycontusion Assessribs1through3fbrevidenceof﹩ AFracture B·Associatedmjury’suchaspneumotho﹣ rax,m則orairway,orgreat﹣vesselinju1y

Assessfbr: A·Displacementordisruptionoftissue

5『EP3·AssessfbrassociatediIUuries’suchas splenic’pancreatic’renal’andliver.

b卜VI.B0ⅡγTⅡORAX

Assessthesternumfbrassociatedinjuries’ suchasmyocardialcontusionandgreat﹦ vesselinju1y（widenedmediastinum）’ althoughthesecombinationsarerelatively infreqUent.

planes B·Evidenceofsubcutfmeousair

卜卜VⅡI.TUBESANDlIⅡES STEp1·

Assessfbrplacementandpositionmgof A·Endotrachealtube B·Chesttubes CCentralaccesslines D·NGtube E’Othermonitoringdevices

〉P∣X·X﹣RAγREASSESSⅢEⅡT Thepatient,sclinicalfindingsshouldbecorrelated withthex﹣rayfindings’andviceversa.Aftercarefhl, systematicevaluationoftheinitialchestfilm,addition﹣ alx﹣raysorradiographicand／orimagingstudiesmay benecessaryashistoricalfhctsandphysicalfindings

∣

SKILLSTAT∣ONVI■X﹣RayIdentificationofTho『acicln】u「ies117 dictate·Remember,neitherthephysicalexamination northechestx﹣rayfilmshouldbeviewedinisolation. Findingsonthephysicalexaminationshouldbeused tofbcusthereviewofthechestx﹣rayfilm’andfind﹣ ingsonthechestx﹣rayfilmshouldbeusedtoguidethe physicalexammationanddirecttheuseofancillarydi﹣

agnosticprocedures·Forexample,rev1ewofthepreⅥ﹣ ousx﹣rayfilmandrepeatchestfilmsmaybeindicated ifsignificantchangesoccurinthepatient’sstatus. ThoracicCT,thoracicarteriography,orpericardia1ul﹣ trasonography／echocardiographymaybeindicatedfbr specificityofdiagnosis.

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Pe『fo『manceatthi55kiIlstationwillaIIowthe5tudenttop『adiceanddem﹣ onst「ateonaIive’anesthetizedanimaI;af「e5h〃humancadave『｝o『an anatomichumanbodymanikinthetechniquesofneedIetho『adcdecom﹣

TⅡE『0Ll0WINGPR0CEDURESARE ∣NαUDEDlNTⅡISSK!LLSTA『l0Ⅱ:

p『essionofatensionpneumotho『ax’chesttubeinse「tionf0『theeme『gency managemento↑hemopneumotho『ax’and〃i↑indicatedbythecou『5edi『ec﹣ to『』pe『ica『diocentesisSped｛ica∣Iy’thestudentaI5owiIlbeab∣etα

〉卜SkiⅡVⅡ﹣A:Needle Thoracentesis 卜〉Sl《iI!VⅡ﹣8:ChestTube Insertion

Ⅲldentifythesu「facema「kingsandtechnlque5fo「pleu「aIdecomp「es﹣ Sionwithneed∣eth0『acente5is’chesttubeIn5e㎡ion’andneedIe pe「c i a「do i centessi.

〉卜S∣《i∣∣V!I巨CPericardiocentesis （Opto i na） l

圓Desc『ibetheunde「∣yingpathophysio∣ogyoftensionpneumotho『ax andca『diactamponadeasa『esuIto↑t「auma 圃Desc「ibethecompIicationsofneedletho『acentesis’chesttubeinse『﹣ ti0nⅡandpe『ica『di0centesis ＝

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ChestTrauInaManageInent 〉卜IⅡTERACTIVE5KlU pR0CEDURES ／Vote:Standa『dp『ecautionsa『e「equi『ed wheneve『ca『ingfo『t『aumapatients.

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Sl﹤lLLSTATI0NVlI■ChestT『aumaManagement119

bSl《ilIVⅡ.A:Need∣eTho『aceⅡtesis Ⅳb雄ZⅧsp『Dced叨疋】s〔取p）Dp㎡α花／bJpα㎡e几妁加c湔戊cα／ cO冗d㎡O几叫仇mpfdde陀㎡Om㎡O几叨〃O／jαUeM／b﹣炕γeαf﹣ e几／唔花〃S㎡o〃P〃e叨加o仇o『m℃α几d加叨ho〃﹩P／αceme〃／O／ α〃e唧）ed㎡oMsc九est加beJs几ofposs『b』e.SMccess／、α花加 仇ep沱se几ceO／αte『唧o几p几e叨mo炕o｝m:Zs5仆乃℅dMe m／e｝!gt／O j ／?几eed／eα几dcα仇e／e｝》s﹩zeO／c／e j s／山α〃’α〃d 〃加腕吧O／﹠／jecα毗e花汎〃咖s／ec〃㎡qMe』s叨sedα冗d㎡／je pα肋e／㎡dOes〃0t／jαUeα花〃sfO几p〃e皿m0〃﹟O／n如’αp几eα﹣ 〃﹩0仇o／,α卵α〃d／b／.dαmαg它fo炕e』α唔mqyoccM／、. STEP1.Assessthepatient’schestandrespirato1y status. S丁EP2·Administerhigh.ilowo唧genandapply ventⅡationasnecessa1y. STEp3.

Ident吋thesec0ndmtercostalspace,inthe midclavicu】a了hneonthesideofthetension pneumothorax.

STEP4’

SurgicaⅡypreparethechest.

STEP5·

L0caⅡyanesthetizetheareaifthepatientis consciousandiftimepermits.

STEp6·Placethepatientinanuprightpositionifa cervicalspineinjuryhasbeenexcluded. STEP7·KeepingtheLuer﹣Lokmthedistalend ofthecatheter’insertanover﹣the﹣needle

catheter（2in.【5cm〕long）intotheskinand directtheneedlejustover（i.e.,superiorto） theribintotheintercostalspace· STEP8·Puncturetheparietalpleura. S『EP9·RemovetheLuer﹣LokhomthecatheterEmd listenibrthesuddenescapeofairwhenthe needleenterstheparietalpleura,indicating thatthetensionpneumothoraxhasbeen relieved 5『EPⅡ0.RemovetheneedleandreplacetheLuer﹣ Lokinthedistalendofthecatheter.Leave theplasticcatheterinplaceandapp】ya bandageorsmalldressmgovertheinserti0n site.

5『EPⅢ·Preparefbrachesttubemsertion.The chesttubeistypicaⅡyinsertedatthenipple leveljustanteriortothemidaxillarylmeof thea錐ctedhemithorax. 5『Ep1Z·ConnecttheChesttubetoanunderwater﹣ sealdeviceora日utter﹣叮pevalveapparatus andremovethecatheterusedtorelievethe tensionpneumothoraxinitiaⅡy. STEp13·ObtainaChestx﹣rayfilm

卜Sl《ilIVⅡ﹃B:ChestTuhelnse『tion P卜C0ⅢPlICATI0ⅡS0『NEEDLE TⅡ0RACENTESlS ■Localhematoma ■Pneumothorax ■Lunglaceration

STEp4’

Makea2﹣to3﹣cmtransverse（horizontal） incisionatthepredeterminedsiteand bluntlydissectthroughthesubcutaneous tissues’justoverthetopoftherib.

STEp5。

Puncturetheparietalpleurawiththetip ofaclampandputaglovedfingerintothe incisi0ntoavoidinjurytootherorgansand toclearanyadhesions’clots,andsoon. Oncethetubeintheproperplace,remove theclampfTomthetube.

STEp6·

Clamptheproximalendofthethoracos﹣ tomytubeandadvanceitintothepleural spacetothedesiredlength.Thetubeshould bedirectedposteriorlyalongtheinsideof theChestwall.

S丁EP1·Determinetheinsertionsite,usuallyatthe nipplelevel（fifthintercostalspace）’justan﹣ teriortothemidaxiⅡaryhneontheaffbcted side·AsecondchesttUbemaybeusedfbra hemothorax≡ STEpz·

SurgicaⅡyprepareanddrapethechestat thepredeterminedsiteofthetubeinsertion

STEP3n

LocaⅡyanesthetizetheskinandrib periosteum.

1Z0SKILLSTATIONVII■Che5tT『aumaManagement

sTEp7·

■Damagetotheintercostalnerve,artery, orveuns ·Convertmgapneumothoraxtoa hemopneumothorax ·Resultinginintercostalneuritis／

Lookfbr‘‘fbgging,’ofthechesttubewith expirationorhstenfbrairmovement.

sTEp8·

Connecttheendofthethorac0stomytube toanunderwater-sealapparatus.

STEp9·

Suturethetubeinplace.

neuralgia ■Incorrecttubeposition’extrathoracicor intrathoracic ■Chesttubekinking,clogging,ordislodg﹦ ingfTomthechestwall,ordisconnection 仕omtheunderwater﹣sealapparatus ■Persistentpneumothorax: oLargeprima1yleak ·Leakattheskinaroundthechest

5TEP10·Applyanocclusivedressingandtapethe tubetothechest·

5TEP11.Obtainachestx﹣rayfilm STEP1Z’Obtainarterialbloodgasvaluesand／or institutepulseoximetrymonitoringas necessa1y.

tube;suctionontubetoostrong ·Leakyunderwater﹣sealapparatus ■Subcutaneousemphysema,usuallyat tubesite ■Recurrenceofpneumothoraxuponre﹣ movalofchesttUbe;sealofthoracostomy woundnotimmediate ■Lungfailstoexpandbecauseofplugged bronchus;bronchoscopyreqUired ■Anaphylacticorallergicreactiontosur﹣

卜bC0MpUCAT∣0NS0『CⅡESTTUBE IⅡSERTION ■Lacerationorpunctureofintrathoracic and／orabdominalorgans’WhiChcanbe preventedbyusingthefingertechnique befbreinsertingthechesttube ■Introductionofpleuralinfbction－fbr example’thoracicempyema

gicalpreparationoranesthetic

〉SkiIlVⅡ﹣CPe『ica『diocentesis（0ptionaI） sTEP1。

Monit0rthepatient,svitalsignsandelec﹣ trocardiogram（ECG）befbre’durmg》and aftertheprocedure.

STEP8·

Iftheneedleisadvancedtoofar（i.e.,into theventricularmuscle）,aniIUurypattern knownasthe“currentofinjury,,appears ontheECGmomtor（e.g.’extremeST﹣T wavechangesorwidenedandenlarged QRScomplex）.Thispatternindicatesthat thepericardiocentesisneedleshouldbe withdrawnuntilthepreviousbaselineECG tracingreappears.Prematureventricular contractionsalsocanoccur’secondaryto irritationoftheventricularmyocardium·

sTEp9·

Whentheneedletipenterstheblood﹣filled pericardialsac’withdrawasmuchnonclot﹣ tedbloodasp0ssible

S『EP2·Surgicallypreparethexiphoidandsubxi﹣ phoidareas’iftimeallows. STEP3·

Locallyanesthetizethepuncturesite,if necessary.

5丁EP4·

Usinga16﹣to18﹣gauge,6﹣in.（15﹣cm）or longerover﹣the﹣needlecatheter’attach a35﹣mLemptySyringewithathree﹣way stopcock.

sTEp5·

STEp6·

Assessthepatientfbranymediastinalshih thatmayhavecausedthehearttoshi仕 significantly. Puncturetheskin1to2cmin比riorto theleftofthexiph0chondraljunction,ata 45﹣degreeangletotheskin.

STEP7.Carefhllyadvancetheneedlecephaladand aimtowardthetipoftheleftscapula·

STEp10·Duringtheaspiration’theepicardium approachestheinnerpericardialsurface agam’asdoestheneedletipSUbsequently’ anECGcurrentofinjurypatternmayreappear.Thisindicates恤atthepericardiocentesisneedleshouldbewithdrawnslightly. Shouldthisinjurypatternpersist’withdraw theneedlecompletely.

Sl﹤ILLSTATIONVlI■ChestT「aumaManagement121

sTEp11· Afteraspirationiscompleted,removethe

syringeandattachathree﹣waystopcock, leavingthestopcockclosed.Securethecath﹣ etermplace. S T E p 1 Z . Op㎡0〃:ApplyingtheSeldingertechnique’

passaflexibleguidewirethroughtheneedle intothepericardialsac,removetheneedle, andpassa14﹣gaugehexiblecatheterover theguidewire.Removetheguidewireand attachathree﹣waystopcock. sTEP13o Shouldthecardiactamponadesymptoms

persist,thestopcockmaybeopenedand thepericardialsacreaspirated.Thismay berepeatedasthesymptomsoftamponade recur,priortodefimtivetreatment·The plasticpericardi0centesiscathetercanbe suturedortapedinplaceandcoveredwith asmalldressmgtoallowfbrcontinuedde﹣ compressionenroutetosurgeryortransfbr toanothercare通cility

pb

COMPUCATIONS0『 pERICARDl0CEⅡTESIS ■Aspirationofventricularbloodinstead0f pericardialblood ■Lacerationofventricularepicardium／ myocardium ■Lacerationofcoronaryartely0rvein ■Newhemopericardium,secondaryto lacerationsofthecoronaryarte1yor vein,and／orventricularepicardium／ my0cardium ■Ventricularfibri】】Rtion ■Pneumothorax,seconda】ytolung puncture ■Punctureofgreatvesselswithworsening ofpericardialtamponade ■Punctureofesophaguswithsubsequent mediHStinitiS ■PunctureofperitoneumwithsubseqUent peritonitisorf白lsepositiveaspirate

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Objectives Ⅲldenti↑ythekeyanatomic『egionsoftheabdomen 固Recognizeapatientat「isk↑o「abdomInaIandpeIvic n i 】u『e i sbasedonthemechansimo↑In】u『y. 圍AppIytheapp『op『a i teda i gnostc i p『ocedu「e5tod i en﹣ t｛ i yongon i ghemo『『hageandIn】u『e l sthatcancause deIayedmo『bidityandmo「tality. 囚∣denti↑ypatientswho『equi『esu「gIcaIconsuItationand possiblelapa『0tomy. 回Desc『ibetheacutemanagementofabdominaland pe∣vc in i ｝u「e i s. ＿

叨 W／㎡ j p㎡o喲tsαbdO〃‘加αJα胭dpeJ㎡c ●〃α叨mα加炕e〃』α肥αg它加e〃fof加α〃ZpJy t叮叨γeαpα〃e肥fSβ

Ⅳ繃墨蟲齲縣撇緇朧盅孟

ofi叼uredpatientsTheassessmento「ci『culatioh du『ingthep『ima『ysu『veyihcIudesea『IyevaIuation ofthepossibiIityofhemo『『hageintlTeabdomehaⅡd pelvisinanypatiehtwhohassustamedbluntt『auma· Penetratingtorsowoundsbetweenthenippleand perineumalsomustbeconsideredaspotentialcauses 0fintraperitonealin】ury.Themechanismofmju1y, injuryfbrces,locationofinjury,andhemodynamic statusofthepatientdeterminethepriorityandbest methodofabdominalandpelvicassessment. Un『ecognizedabdomiⅡaIahdpelviciniu『ycoh. tinuestobeacauseo「p『evehtabledeatha仕e『t『unCaI t『auma·RuptureofahoⅡowviscus’bleedingfToma solidorgan’andbleedingfromthebonypelvismaynot beeasilyrecognized,andpatientassessmentisoften compromisedbyalcoholintoxication’useofillicit drugs,mjurytothebrainorspinalcord’andiIUury toadjacentstructuressuchastheribsandspine. Signi伺cantbloodIosscanbep『esentintheabdomiha∣ cavitywithoutanyd『amaticchahgeihappea『anceo『

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dimensionsahdwithoutobvioussignsofpe『it◎neal i『『itation.Anypatientwhohassustainedsignificant blunttorsoinjuryfromadirectblow,deceleration,or apenetratingi叼urymustbeconsideredtohavean abdominalvisceral’vascular,orpelvicinjuryuntil provenotherwise.

∣ ﹥ AnatomyoftheAbdomeⅡ

∣

Theanatomyoftheabdomenisillustratedbelowin ■FlGURE5旦1· Theabdomenispartiallyenclosedbythelower thorax·Theα几tcJ.Joγαbdo加e〃isdefinedasthearea betweenthecostalmarginssuperiorly’theinguinal ligamentsandsymphysispubismfbriorly,andthe anterioraxillaryhneslateraⅡy·Them勻orityofthe hollowvisceramaybeinvolvedwhenthereisanmju1y totheanteriorabdomen. The仇omco﹣αbdo加e〃istheareain企riortothe trans﹣nipplelineanteriorlyandtheinfra﹣scapularline posteriorly’andsuperiortothecostalmargins.This area,althoughs0mewhatprotectedbythebonythorax’ includesthediaphragm’liver,spleen’andstomach. Becausethediaphragmrisestothefburthintercostal spaceduringfhllexpiration’fracturesofthelowerribs orpenetratingwoundsbelowthempplelinecaninjure abd0minalviscera. Theβα几陶istheareabetweentheanteriorand posterioraxillarylineshomthesixthintercostalspace totheⅡiaccrest·Thethickmusculatureoftheabdomi﹣ nalwallinthislocation,ratherthanthemuChthinner aponeuroticsheathoftheanteriorabdomen’actsas

（A）Ante「io『abdomen Tho「aco﹣abdomen

（B）FIank

apartialbarriertopenetratingwounds’particular】y stabwounds. Thebαc月isthearealocatedposteriortotheposterioraxiⅡarylinesfromthetipofthescapulaetothe iliaccrests.SimiIRrtotheabdominalwallmusclesin thefIank’thethickbackandparaspinalmusclesactas apartialbarriertopenetratingwounds·ThefIankand backcontainthe｝它trOper㎡o〃eα／o『gtms.Thispotential spaceistheareaposteriortotheperitonealliningof theabdomen.Itc0ntainstheabdominalaorta;infbrior venacava;mostoftheduodenum’pancreas’kidneys andureters;theposterioraspectsoftheascending anddescendingcolons;andtheretroperit0nealcompo﹣ nentsofthepelviccavi叮.∣Ⅱiu『iestothe『et『ope『itoneal visce『aIst『uctu『esa『edi倆cuItt◎『e∞gnizebecausetITe a『eais『emote什omphysicaIexamination’andiniu『ies maynotinitiaIIyp『eseⅡtwithsighso『symptomsofpe『i. tohitis.Inaddition,thisspaceisnotsampledbydiag﹄ nosticperitoneallavage（DPL）orweⅡvisualizedwith fbcusedassessmentsonographyintrauma（FAST）. ThepeMccαu叼’surroundedbythepelvicb0nes, isessentiaⅡythelowerpartoftheretroperitonealand mtraperitonea1spaces.Itcontainstherectum,blad﹣ der’iliacvessels,and’infbma1es,internalreproduc﹣ tiveorgans.SigⅡi而caⅡtbIoodIosscanoccu『什omeithe『 iht『apelvico『ganso『thebonypelvisitse脈

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MECHANISMOFIN」URY125

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MechanismofIIniu 『 y

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叨 刪㎡s毗e加ec〃α㎡s加Oft咖叮 ●JmpO㎡α川fβ UnderstandingthemechanismofmjuryfaciⅡtatesthe earlyidentificationofpotentialinjuries.Thisinfbrma﹣ tiondirectswhatstudiesmightbenecessaryfbrevalu﹣ ationandthepotentialneedfbrpatienttransfbr.See BiomechanicsofIniury （electronicversiononly）

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8lUⅡTTRAUMA AdtJ﹃ec㎡b／o山’suchascontactwiththelowerrimofa steeringwheeloranintrudeddoorinamotorvehicle crash’cancausecompressionandcrushinginjuriesto abdominalvisceraandpelvis.Suchfbrcesdefbrms0lid andhollow0rgansandcancauserupture,withsecond﹣ aryhemorrhage’contaminationbyvisceralcontents’ andassociatedperitonitis. S／jeα㎡唔叼α｝、／esareafbrmofcrushinginjury thatcanresultwhenarestraintdeviceiswornimprop﹣ erly（■FIGuRE5﹣zA）.Patientsinjuredinmotorvehicle crashesmaysustaindece／e／·α瓦o〃z叼叨JⅥes’inwhich thereisadiffbrentialmovementoffixedandnonfixed partsofthebody.Examplesincludelacerationsofthe hverandspleen’bothmovableorgans,atthesitesof theirfixedsupportingligaments·Buckethandleinju﹣ riestothesmallbowelarealsoexamplesofdecelera﹣ tioninjuries（■F∣GURE5.囪B）. Inpatientswhosustainblunttrauma’theorgans mostfTequentlyinjuredarethespleen（40﹪to55﹪）’ liver（35℅to45℅）’andsmallbowel（5﹪to10℅）. Additionally,thereisa15℅incidenceofretroperito﹣ nealhematomainpatientswhoundergolaparot0my fbrblunttrauma.Althoughrestraintdevicesprevent m0remajori叮uries,theycanproducespecifIcpatterns ofmju1y’asshowninTable5.1onpage126.Ai『bag depIoymentdoesnotp『ecludeabdomihaIiniu『y. pEⅡETRATIⅡGTRAUMA Stabwouhdsandlow巨velocitygunshotwo凹hdscausetis﹦ suedamagebyIace『atihgandcutting.High.veIocityguⅡ﹣ shotwoundst『ansfb『mo『el《iⅡeticene『gytoabdominal visce『a·Thesewoundscancauseincreaseddamage surroundingthetrackofthemissileduetotempora1y cavitation. Stabwounds（■「lGuRE5﹣3）traversea句acent abdominalstructuresandmostcommonlymvolvethe liver（40﹪）,smallbowel（30﹪）,diaphragm（20﹪）,and colon（15℅） Gunshotwoundsmaycauseadditionalintraabdominalinjuriesbaseduponthetr鉚ectory’cavitation

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■FlGURE5﹣2LapBeltandBuCketHahdIe【niu『ie5· （A）ln】u「iescan『esuItwhena『e5t「aintdevicei5wom imp「ope『lyb（B）5maIIboweIbuckethandIein】u「y·

effbct,andpossiblebulletfiPagmentation.Gunshot woundsmostcommonlyinvolvethesmallbowel （50℅）,colon（40﹪）’hver（30℅）’andabdominalvas﹣ cularstructures（25℅）.Injuriesincurredbyshotgun blastareaffbctedbythetypeofshotusedandthedis﹣ tancefromtheguntothepatient. Explosivedevicescauseinjuriesthroughseveral mechanisms’includingpenetratingfragmentwounds andbluntinjuriesfromthepatientbeingthrownor struck.Combinedpenetratingandbluntmechanisms mustbeconsideredbythetreatingclinician.Patients closetothesourceoftheexplosioncanincuraddi﹣ tionalpulmona1yandhollowviscusinjuriesrelated toblastoverpressure,whichmayhavedelayedpresentation.ThepotehtiaIfb『ove『p「essu『eihiu『ysh◎uId notdist『actthecIiniciahfibmasystematicapp『oachto ideⅡti而catiohandt『eatmento「the∞mmonbIuntand penet『atiⅡgihiu『ies.

126CHAPTER5■AbdominaIandPeIvicT「auma

■γABLE5·1T『mca!aⅧCe『vica!!Ⅱju『iesf『omRest『a加tDevi叵e曰 RES『RAIN『DEVICE

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Tea『0『avuIsion0fmesente『y（BucketHandIe） Ruptu『eof5maIIbowe∣o「coIon Th「0mb0sis0fiIiaca『te『yo『abdomina∣a0『ta Chancef「actu『eof∣umba『ve『teb『ae panc「eatic0『duodenaIiniu『y ∣ntimaItea『o『th『0mbosisininn0minatei叵a『otid’subc∣avian’o「ve「teb『ala「te『ies F『actu『e0『dislocation0fce『viCaIspine Ribf『actu『e5 puImona「ycontusi0n Ruptu『e0↑uppe『abdominaIvIsce「a

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ASSESSMENT127

∣P Assessment

∣PⅡγSICALEXAM∣ⅡATI0N

G＞HO叨‘JO 陀 I 腮o叨沁〃oc紅s妣⋯s迦／蔽 ●㎡α肥加力﹃ααbdO〃E加αJo了pe／u㎡C ㎡叮叨yy? InhypotehsivepatieⅡts’thegoaIisto『apidIydete『mine ifanabdominaIo『peIviciⅡiu『yisp『esentandwhethe『 itisthecauseo「hypoteⅡsioⅡ.Thepatienthistorymay predict,andthephysicalexam,alongwithrapidly availablediagnostictools,mayconfirmthepresence ofabdominalandpelvicimuriesthatrequireurgent hemorrhagecontrol.HemodynamicaIIyno『malpatients withoutsignsofpe『itohitismayunde『goamo『edetaiIed evaIuationtodete『minewhethe『speci伺ciniu『iesthat cancausedeIayedmo『bidityandmo『talitya『ep『esent. Thismayincluderepeatedexaminati0ntodetermine whethersignsofbleedingorperitomtisdevelopover time.

ⅡISTORγ

Whenassessmgapatientinjuredinamotorvehicle crash’pertinenthistoricalinfbrmationincludesspeed ofthevehicle’typeofcoⅡision（eg.’frontalimpact, lateralimpact’sideswipe’rearimpact’orrollover）,ve﹦ hicleintrusionintothepassengerc0mpartment,types ofrestraints’deploymentofairbags,patient,sposition inthevehicle,andstatusofpassengers,ifany.Forpa﹣ tientsinjuredbyfalⅡn呂theheightofthefhllisimpor﹣ tanttodetermineduetothepotentialfbrdeceleration injuryfromgreaterheights.Historicalinfbrmation canbeprovidedbythepatient,otherpassengers,the police’oremergen叮medicalpersonnel.Infbrmation ab0utvitalsigns’obviousinjuries,andresponseto prehospitaltreatmentshouldalsobeprovidedbythe prehospitalcareproviders. Whenassessingapatientwhohassustainedpenetratingtrauma’pertinenthistoricalinfbrmation includesthetimeofinjury’typeofweapon（eg·,knifb’ handgun’rifle,orshotgun）’distancefromtheassail﹣ ant（particularlyimportantwithsh0tgunwounds, asthelikelihoodofm匈orvisceralinjuriesdecreases beyondthe10﹣fb0tor3﹣meterrange）’numberofstab woundsorshotssustained’andtheamountofextemal bleedingfTomthepatientnotedatthescene.Ifpos﹣ sible’importantadditionalinfbrmationtoobtainfrom thepatientincludesthemagmtudeandlocationofany abdominalpain· Wheninjuriesarecausedbyanexplosivedevice, thelikelihoodofvisceraloverpressureinjuriesis increasediftheeXplosionoccurredinanenclosed spaceandwithdecreasmgdistanceofthepatientfrom theexplosion.

叨 HmodbMe呵m加e㎡咖｝℃t⋯ ●αbdo加加α／OγpeJUict叮叨Ⅳβ

TheabdomihalexRminationshouldbeconductedin ameticulous,systematicfhshioninthestandardse﹣ quence;inspection’auscultation’percussion,and palpation.Thisisfbllowedbyassessmentofpelvic stabililV;urethral’perineal,andrectalexam;vaginal exam,andglutealexam.Thefindings,whetherposi﹣ tiveornegative,shouldbedocumentedcareMlyinthe patient’smedicalrecord. Inspection Inmostcircumstances’thepatientmustbefhllyun﹣ dressedtoallowfbrathoroughinspection.Theanteriorandposteri0rabdomen’asweⅡasthelowerchest andperineum’shouldbemspectedfbrabrasions,con﹣ tusi0nsfTomrestraintdevices’lacerations,penetrat﹣ ingwounds’impaledfbreignbodies,eviscerationof omentumorsmallbowel’andthepregnantstate.The patientshouldbecautiouslylogr0lledtofhcilitatea completeexamination· Theflank,scrotum,andperianalareashouldbe inspectedquicklyfbrbloodattheurethralmeatus, swellingorbruising;orlacerationoftheperineum, vag1na’rectum’orbuttocks,whichissuggestiveofan openpelvicfracture. Attheconclusiono「the『apidphysicaIexam,the patientshou∣dbe∞ve『edwithwa『medbIanl《etstohe∣p p『eventhypothe『mia·

【▼

PITFAIJ」

∣

Hyp0the「miacont『ibute5tocoaguIopathyandongo﹣ ingbIeeding.

AuscuItation AuscultationoftheabdomenmaybedifficultinanoiSy emergenCydepartment’butitcanbeusedtoconfirm thepresenceorabsenceofb0welsounds.Freeintraperi﹣ tonealbloodorgastrointestinalcontentsmayproduce anileus,resultinginthelossofb0welsounds;however’ thisfindingisnonspecific,asⅡeuscanalsobecausedby extraabdominalinjuries.These伺ndingsa『emostusefi』I whentheya『eno『maIinitiaIlyahdthenchangeove『time· Pe『cussionandPa!pation Percussioncausesslightmovementofthepe㎡toneumand mayehcitsignsofperit0nealimtation.Whenp『esent’ho additionaIevidenceof『ebouhdtende『nessshouldbesought’ asitmaycausethepatientfi』『the『uhⅡecessa『ypain.

128CHAPTER5■Abd0minaIandPeIvicT「auma

Voluntaryguardingbythepatientmaymakethe abdominalexaminationunrehable.Inc0ntrast’invol﹣ unta1ymuscleguardingisareliablesignofperitonea1 irritation.Palpationmayalsoehcitanddistinguish superficial（abdominalwall）anddeeptenderness·The presenceofapregnantuterus’aswellasestimationof fbtalage,alsocanbedetermined. Palpationofahigh﹣ridingprostateglandisasign ofasignificantpelvicfracture.

AssessmentofPelvicStabiIity M叮orpelvichemorrhageoccursrapidly’andthedi﹣ agnos1smustbemadequick】ysothatappropriatere﹣ suscitativetreatmentcanbeinitiated.Unexplained hypotensionmaybetheonlyinitialindicationofmajor pelvicdisruptionwithinstabilityintheposteriorhga﹣ mentouscomplex·Mechanicalinstabilityofthepelvic ringshouldbeassumedinpatientswhohavepelvic fractureswithhypotensionandnoothersourceofblood loss.Physicalexamfindingssuggestiveofpelvichac﹣ turemcludeevidenceofrupturedurethra（high﹣riding prostate’scrota1hematoma,bloodattheurethralmea﹣ tus）’hmblengthdiscrepancy,orarotationaldefbrmi叮 ofthelegwithoutobviousfTacture·Inthesepatients’ manualmanipulationofthepelviscanbedetrimental’ asitmaydislodgeabloodcl0tthathasalreadyfbrmed’ therebyprecipitatingfhrtherhemorrhage. Whennecessary’mechanicalmstabⅡi叮ofthepeMc ringmaybetestedbymanualmampulationofthepelvis. Thisp『ocedu『eshou∣dbepe『fb『medo〃／γo〃cedu『ingthe physicaIexamination,astestiⅡg｛b『pelvicinstabilitycan 『esuItinfi』『the『hemo『『hage.ltshouIdⅡotbepe朮『med inpatieⅢtswithshocI《andahobviouspelvic什actu『e. Theunstablehemipelvismigratescephaladbecauseof muscularfbrcesandrotatesoutwardsecondarytothe effbctofgravity0ntheunstablehemipelvis.Becausethe unstablepelvisisabletorotateexternal】y,thepelviscan

beclosedbymanuaⅡypushmgontheiliaccrestsatthe leveloftheanteriorsuperiorⅢacspme（■FlGuRE5﹣4）. MotioncanbefbltiftheⅢaccrestsaregraspedandthe unstablehemipelvisispushed／rotatedinward（inter﹣ naⅡy）andthenoutward（externaⅡy）,whichisrefbrred toasthecompressiondistracti0nmaneuver. Withposteriorligamentousdisruption,the involvedhemipelviscanbepushedcephaladaswell aspulledcaudally.Thistranslationalmotioncanbe fbltbypalpatingtheposterioriliacspineandtubercle whilepushingandpullingtheunstablehemipelvis· Theidentificationofneurologicabnormalitiesor openwoundsintheflank’perineum’andrectummay beevidenceofpelvicringinstabihty.Whenappropri﹣ ate,ananteroposterior（AP）x﹣rayofthepelviscon﹣ 鬥】、mstheclinicalexHm﹩nation·SeeSkillStationⅣ; Sh0ckAssessmentandManagement.

PITFAI」 L RepeatedmanipuIationofaf「actu『edpeIviscan agg「avatehemo「「hage.

U『eth『a∣〃Pe『ineal『andRectaIExamination Thepresenceofbloodattheurethralmeatusstrongly suggestsaurethralmjmy.Inspectthescrotumand perineumfbrecchymosisorhematoma’a1sosuggestive ofurethralimury.Inpatientswhohavesustainedblunt trauma’goalsoftherecta1examinationaretoassess sphinctertoneandrectalmuc0salintegrity’deteImine thepositionoftheprostate（high﹣ridingprostateindi﹣ catesurethraldisruption）,andidentiiyanyfTacturesof thepelvicb0nes.Inpatientswithpenetratingwounds’ therectalexaminationisusedtoassesssphinctertone andl0okfbrgrossbloodfTomab0welperfbration.FoIey

■F∣GURE5﹣4 EvaluationofPeIvic StabiIitybGentIe p『essu「eove「the iIiacwing5ina downwa「dand mediaIfa5hion may『eveaIIaxityo『 inStability·

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ASSESSMENT1Z9

cathete『sshouIdh◎tbeplacedihpatientswitITape『ineaI hematomao『high氬『idihgp『ostate·

VagihaIExamination Lacerationofthevaginacanoccurfrombonyfragments frompelvicfracture（s）orfiPompenetratingwounds’ Vaginalexamshouldbeperfbrmedwheninjmyissus﹣ pected（e.g.’inthepresenceofcomplexperineallacera﹣ tion’pelvicfracture,ortrans﹣pelvicgunshotwound）. GIuteaIExamination Theglutealreg1onextends仕omtheihaccreststothe glutealfblds.Penetratmginjuriestothisareaareas﹣ sociatedwithuptoa50℅incidence0fsignificantin﹣ traabdominalinjuries,mcludingrecta1injuriesbelow theperitonealreflection.Gunshotandstabwounds areassociatedwithintraabdominalinjuries,these w0undsmandateasearchfbrsuchinjuries.

toringofurinaryoutputasanmdexoftissueperh1sion. Grosshematuriaisasignoftraumatothegenitouri﹣ na1ytractandnonrenalintraabdominalorgans.Theab. senceo「hematu『ia》howeve『》doesnot『uIeoutaniniu『y tothegenitou『ina『yt『act·Theinabilitytovoid’unstabIe peIvic什actu『e’bloodatthemeatus,sc『otaIhematomao『 pe『inea∣eccIWmoses,o『alTigh.『idihgp『ostateon『ectaIex· aminationmaⅡdatea『et『og『adeu『eth『og『amtoconh『m anintactu『eth『abe｛b『einse『tihgau『iⅡa『ycathete『。Adis﹣ ruptedurethradetectedduringthepr1maryorsecond﹣ arysurveymayreqUiretheinsertionofasuprapubic tubebyanexperienceddoctor.

PⅡFA『刀」 『 Ⅲ AsingIephysicaIexamo「adjunctshouIdnotaIIay cIinicaIsuspicionbasedonthemechanismofin】u『y. RepeatedexamsandcompIementa「yad】unctsmaybe neCeS5a『y.

AD」UⅡCTST0pⅡγSICA【EXAMIⅡATl0Ⅱ GastricandurinarycathetersarefTequentlyinserted aspartoftheresuscitationphase’onceproblemswith theairway,breathing’andcirculationarediagnosed andtreated.

Gast『icTube Thetherapeuticgoalsofinsertinggastrictubesearly intheresuscitationprocessaretoreheveacutegastric dilation’decompressthestomachbefbreperlbrminga DPL’andremovegastriccontents.Gastrictubesmay reducetheincidenceofaspirationinthesecases,how﹣ ever,inanawakepatientwithanactivegagreflexthey mayactuaⅡypromotevomiting.Thepresenceofblood inthegastriccontentssuggestsaniIUurytotheesopha﹣

Othe『Studies Withpreparationandanorganizedteamapproach’the physicalexaminationcanbeperfbrmedveryquickly. lnpatientswithhemodynamicabno『maIitIes,『apidevaIu· ationisnecessa『y;thiscahbedoⅡewitheithe『fbcused assessmentsohog『aphyint『auma（FAST）o『DPL’The onlycontraindicationtoperfbrmingthesestudiesisan existingindicationfbrlaparotomy.Inaddition’hemo﹣ dynamicaⅡynorma1patientswithanyofthefbⅡowing signsreqUireadditionalstudies: ■Changemsensorium（potentialbrainmjmy, alcoholint0xication’0ruseofiⅢcitdrugs） ■Changeinsensation（potentialiUjurytospinal cord） ■Injurytoadjacentstructures,suchaslower ribs’pelvis’lumbarspine

gusoruppergastrointestina1tractifnasopharyngeal and／Ororopharyngealsourcesareexcluded.l「seve『e 伯ciaI什actu『esexisto『basila『sl《uIl什actu『eissuspected, thegast『ictubeshouldbeinse『tedth『oughthemouthto

■Equivocalphysicalexamination

p『eventpassageo「thetubeth『oughthec『ib『ifb『mpIate intotheb『ain.

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pated,suchasgeneralanesthesiafbrextraab﹣ dominalinjuriesorlengthyx﹣raystudies ■Lap﹣beltsign（abdominalwallcontusion）with suspicionofboweli叮ury

Whenint『aabdominaIiniuⅣissuspected!anumbe『 o「studiescanp『ovideusefi』Iin化『mation;howeve『,these studiesshouIdnotdelaythet『ahsfb『o「apatienttode｛ini﹣ tiveca『e.

U『ina『yCathete『 Thegoalsofmsertingurinarycathetersearlyinthere﹣ suscitationprocessaretoreheveretention’decompress thebladderbefbreperfbrmmgDPL,andallowfbrmoni﹣

X﹣Raysfo『AbdomihaIT『aumaAnAPchestx﹣rayis recommendedintheassessmentofpatientswithmul﹣ tiSystemblunttrauma.Hemodynamicallyabnormal

130CHAPTER5■Abdomina∣andPelvicT「auma

patientswithpenetratingabdominalwoundsdonot requirescreemngx﹣raysintheemergenCydepartment （ED）.IfthepatientishemodynamicaⅡynormalandhas penetratingtraumaabovetheumbilicusorasuspected thoracoabdominalinjury,anuprightchestx﹣rayisuse﹣ fhltoexcludeanassociatedhemothoraxorpneumo﹣ thorax,ortodocumentthepresenceofintraperitoneal air.Withmarkerrmgsorchpsapphedt0allentrance ande】dtwoundsites,asupineabdominalx﹣raymaybe obtainedmhemodynamicaⅡynormalpatientstodeter﹣ minethetrackofthemissileorpresenceofretroperito﹣ nealair.Ananteroposteriorpelvicx﹣raymaybehelpfhl inestabⅡshingthesourceofbloodlossmhemodynami﹣ caⅡyabnormalpatientsandmpatientswithpelvicpam ortenderness.Thealert’awakepatientwithoutpain0r tendernessdoesnotneedapelvicradiograph.

rapid,nomnvasive,accurate’andinexpensivemeans ofdiagnosinghemoperitoneumthatcanberepeated 仕equently. Ultrasoundscanmngcanbedoneatthebedsidein theresuscitationroomwhilesimultaneouslyperfbrm﹣ ingotherdiagnosticortherapeuticprocedures.The indicationsibrtheprocedurearethesameasfbrDPL.

SeeSkillStationⅥII:FocusedAssessmentβonogra﹣ phyinTrauma（FAST）. Furthermore,ultrasoundcandetectoneofthe nonhypovolemicreasonsfbrhypotension:pericardial tamponade.Scansareobtainedofthepericardialsac （1）,hepatorenalfbssa（2）,splenorenalfbssa（3）,and pelvis（4）orpouchofDouglas（■FIGURE5﹣6A）.After theimtialscaniscompleted,asecondscanmaybeper﹣ fbrmedafteranintervalof30minutes.Thisscancan detectprogressivehemoperitoneum（■F∣GuRE5﹣6B）.

「ocusedAssessmentSonog『aphyinT『aumaFASTis one0ftworapidstudiesutilizedtoidentifyhemorrhage‘ InFHST,ultrasoundtechnologyisusedbyproperly trainedindividualstodetectthepresenceofhemoperi﹣ toneum（■「IGuRE5昌5）.Withspecificequipmentand 1nexperiencedhands,ultrasoundhasasensitivity, specificity’andaccuraCyindetectingintraabdominal fluidcomparabletoDPL.Thus,ultrasoundprovidesa

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ju1y.DPLcansignificantlyaltersubseqUentexamina﹣ tionsofthepatientandisconsidered98﹪sensitive fbrintraperitonealbleeding（■FIGuRE5﹣7）.Itshould beperibrmedbyasurgicalteamcaringfbrapatient withhemodynamicabnormalitiesandmultipleblunt injuries,andmaya1sobeusefi1linpenetratingtrauma. DPLalsoisindicatedinhemodynamicaⅡynormal patientswithbluntinjurywhenultrasound0rc0m﹣ putedt0mography（CT）isnotavailable.Insettmgs witheitherorbothofthesemodalitiesavailable’DPL israrelyused’asitisinvasiveandrequiressomesurg1﹣ calexpertise. RelativecontraindicationstoDPLincludepreviousabdominaloperations,morbidobesity’advanced cirrhosis,andpreexistingcoagulopathy·Eitheran openorclosed（Seldinger）inhaumbilicaltechnique isacceptableinthehandsoftrainedclinicians.In patientswithpelvicfractures’anopensupraumbⅡi﹣ calapproachisprefbrredtoavoidenteringapelvic hematoma·Inpatientswithadvancedpregnancy,an opensuprafUndalapproachshouldbeusedtoavoid damagingtheenlargeduterus·F『eeaspi『atioⅢo『bIood, gast『ointestinaI∞ntents,vegetable伺be『s,o『bileth『ough theIavagecathete『inpatientswithhemodyhamicabno『﹣ malitiesmahdatesIapa『otomy· Ifgrossblood（＞10mL）orgastrointestma1con﹣ tentsarenotaspirated’lavageisperfbrmedwith1000 mLofwarmedisotomcc1ystalloidsolution（10mL／kg inachild）. Afterensuringadequatemixingofperitonealcon﹣ tentswiththelavagefluidbycompressingtheabdo﹣ menandmovingthepatientbylogrollingortilting himorherintohead﹣d0wnandhead﹣uppositions, theeⅢuentissenttothelaborato1yfbrquantitative analysisifgastrointestinalcontents,vegetablefibers, orbilearenotobviouslypresent.Apositivetestis indicatedby＞100,000redbloodcells（RBC）／mm3,500 whitebloodcells（WBC）／mm3,oraGramstainwith bacteriapresent.SeeSkillStationⅨ:DiagnosticPeri﹣ tonealLavage.

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DiagnosticPe『itoneaILavageDPLisanotherrapid studytoidenti句hemorrhage.Althoughinvasive,it alsoallowsinvestigationofpossiblehollowviscusin﹣

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■nGURE5﹣7DiagnosticPe『itoneaILavage（DPL）·DPL i5a『apidlype「fo「med’invasivep『0cedu「ethatis c0nside『ed98℅5ensitivefo「int「ape「itoneaIbleeding.

andpelvis.ltisatime﹣consumiⅡgp『ocedⅡ『ethatshouId beusedo〃／γi〃hemodγ〃αmi叵α〃γ〃oγmα／PαtieⅡf5ih whomthe『eisnoappa『entindicationfb『aneme『gency lapa『otomy·TheCTscanpr0videsinfbrmationrelative tospecificorganinjuryanditsextent’andcandiag﹣ noseretroperitonealandpelvicorganinjuriesthatare difficulttoassesswithaphysicalexamination,FAST, andperitoneallavage.Relativecontraindicati0nsto theuseofCTincludedelayuntilthescannerisavail﹣ able,anuncooperativepatientwhocannotbesafbly sedated’anda1lergytothecontrastagentwhennonioniccontrastisnotavailable.CTcahmisssomegast『o. iⅡtestinal,diaplwagmatic’andpanc『eaticiniu『ies·!nthe absehceofhepatico『spleniciniu『ies’thep『esehceomee ｛luidintheabdominaIcavitysuggestsaniniuⅣtothegas﹣ t『ointestinaIt『actand／o『itsmesente『y,andmanyt『auma su『geons伺ndthistobeanindication｛b『ea『∣yope『ative ihtewention. Cont『astStudiesAnumberofcontraststudiescan aidinthediagnosisofspecifica1lysuspectediIVuries】 buttheyshouldnotdelaythecareofpatientswhoare hemodynamicaⅡyabnormal.Theseinclude: ■Urethrography ■Cystography ■Intraven0uspyelogram

ComputedTomog『aphyCTisadiagnosticproce﹣ durethatrequirestransportofthepatienttothescan﹣ ner’admimstrationofcontrast’andscann1ngofthe upperandlowerabdomen,asweⅡasthelowerchest

■Gastrointestinalcontraststudies U〉W〃mgmphJshouldbeperfbrmedbefbre insertinganmdweⅢngur1narycatheterwhenaure﹣

132CHAPTER5■Abd0minaIandPeIvicT『auma

thra1injuryissuspected.Theurethr0gramisper﹣ fbrmedwithan8Fi.enchurinarycathetersecuredin themeatalfbssabyballooninflationto1·5to2mL. Approximately30to35mLofundilutedcontrast materialisinstⅢedwithgentlepressure.Inmales,a radiographistakenwithananterior﹣posteriorprq〕ec﹣ tionandwithslightstretchingofthepemstowardone ofthepatient’ssh0ulders.Anadequatestudyshows re』Ⅱxofcontrastintothebladder. Anintraperitonealorextraperitonealbladderrup﹣ tureisbestdiagnosedwithacystogramorCTCysmgmp腳.AsyringebarrelisattachedtotheindweⅢng bladdercatheter’held40cmabovethepatient,and 350mLofwater﹣solUblecontrastisallowedtoⅡow intothebladderuntil（1）flowstops,（2）thepatient voidsspontaneously,or（3）thepatientisindiscomfbrt· ThisisfbllowedbyinstiⅡati0nofanadditional50mL ofc0ntrasttoensurebladderdistension.Anterior﹣pos﹣ teriorandpostdrainagev1ewsareessentialtodefim﹣ tivelyexcludeinjury·CTevaluationofthebladderand pelvis（CTcystogram）isanalternativestudythatis particularlyusefhlmprovidingadditionalinfbrmation aboutthekidneysandpelvicbones. Suspectedurinarysysteminjuriesarebesteval﹣ uatedbycontrast﹣enhancedCTscan.IfCTisnot available’加㎡αue几oⅨsRye／0gm加（ryF）providesan altemative.Ahigh﹣dose’rapidmjectionofrenalcon﹣ trast（《‘screeningIVP,,）isbestperfbrmedusingthe recommendeddosageof200mgofi0dine／kgbody weight.Thisinvolvesabolusinjectionof100mL （standard1.5mL／kgfbra70﹣kgindividual）ofa60℅ iodinesolutionperfbrmedthroughtwo50mLsyringes over30to60seconds.Ifonly30℅iodinesolutionis available,theidealdoseis3.0mL／kg.Visualizati0n ofthecalycesofthekidn叮sonaflatplatex﹣rayof theabdomenshouldappear2minutesaftertheinjec﹣ tioniscompleted.Unilateralnonfhnctionindicates anabsentkidn叮,thrombosis’avulsionoftherenal

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SceⅡa『io■cont／nuedThepatienthas ↑『actu『e50↑the∣0we『『ib50ntheIeftSideidenti↑ied0nchestx﹣『ayand｛『actu『es0｛theleft supe『i0「andinfe『i0『『amiidenti「ied0npeIvic x﹣『ay·Because0↑thesefinding5!a5weIIa5hi5 abd0minaItende『nessⅡthepatientunde「g0esan abd0min0peIvIc〔T5can.

artery,ormassiveparenchymaldisruption.NonfUnc﹣ tionwarrantsfhrtherradiologicevaluationwitha contrast﹣enhancedCTorrenalarteriogram’orsurg1﹣ calexploration,dependingonmechanismofinjuryand localavailabilityorexpertise. Isolatedinjuriestoretroperitonealgastrointesti﹣ nalstructures（e.g.’duodenum’ascendingordescend﹣ ingcolon’rectum,biliarytract’andpancreas）maynot causeperitonitisandmaynotbedetectedonDPL Wheninjurytooneofthesestructuresissuspected, CTwithcontrast’specificupperandlowergαstJD加／es﹣ t加α／co／㎡rαs『s／αd㎡es,andpancreatico﹣biliaryimaging studiescanbeusefhl.However’thesestudiesshould beguidedbythesurgeonwhowillultimate】ycarefbr thepatient· EVALUATl0Ⅱ0『ABD0MⅢAI﹣TRAUMA Ifthe『eisea『lyo『obviousevidencethatthepatientwiII bet『ans佗『『edtoahothe『伯ciIity,time.cohsumiⅡgtests） lⅡcludiⅡgabdominalCT’should仃o亡bepe『｛b『med.Table 52comparestheuseofDPL’FAST,andCT’including theiradvantagesanddisadvantages’intheevaluation ofblunttramhR﹦

■TABLE5凰ZCompa『isoⅡofDPL,FAST『aⅡdCTmBluⅡtAbdom咖aiT『auma aⅥS ﹟ 『 ■ 丁 ■ ︼ ■ 仃

DPl

Advantages

● ● ● ● ●

Ea「lydiagno5is Pe「fb『med『apidly 98℅sensitive Detect5bowe∣in】u『y T「anspo「t:No

FAST ● ● ● ● ● ●

Disadvantages

●

■

■

Ea『∣ydiagnosis N0ninva5ive Pe「fo「med『apd i ∣y Repeatable 86℅＿97℅sensitive T『anspo「t:Ⅱo

CT5CAⅡ ●

●

●

MostspecificfO『in】u『y 9Z℅﹣98℅sensitive N0n﹦invasive

∣nva5ive 5peCifidty:Low

oOpe「ato『︼dependent ·Bowelgasandsubcutane0usai『

●Costandtime oMissesdiaph『agm’bowe!‘and5ome

MI55e﹩in】u「ie5todiaph「agm and『et『ope『tioneum

di5to「tion oMissesdiaph『agm’boweI’and

panc『eaticiniu『ies oT『anspo『t:Requi『ed

panc「eaticin】u『ies Indications

oUn5tablebluntt『auma ●Penet『atingt「auma

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·5tabIebluntt「auma oPenet「atingbad《／f∣ankt『auma

ASSESSMENT133

anteriorperitonealpenetrationcanbeconfirmed orstrong】ysuspectedbylocalwoundexploration, approximately50℅eventuallyrequireoperation. Laparotomyrema1nsareasonableoptionfbrallsuch

Theevaluationofpenetratingtraumainvolves specialconsiderationtoaddresspenetratingwounds totheabdomenandthoracoabdominalreg1on.Options includeserialphysicalexaminationorDPLinthora﹣ coabdomihRloranteriorabdominalstabwounds.Dou﹣ ble﹣ortriple﹣contrastCTscansareusefhlinflankand backinjuries.Surgerymayberequiredfbrimmediate diagnosisandtreatment·

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EvaluationsshouIdnotde∣aythet「ansfe『ofthepa﹣ tienttoamo「eapp「op「iateIeveIofca「efo「seve『e in】u「iesthathaveaI「eadybeenidentified.

Mostgunshotwoundstotheabdomena『emaⅡaged byexpIo『ato『y∣apa『otomy）astheincidenceo「signi而caⅡt int『ape『itoⅡealihiu『yapp『oaches98％whehpe『itoneaI penet『ationisp『eseⅡt.Stabwoundstotheabdomen maybemanagedmoreselective】y,butapproximately 30℅docauseintraperitonea1i叨ury.Thus’indications fbrlaparotomympatientswithpenetratingabdominal w0undsmclude: ■Anyhemodynamical】yabnormalpatient ■Gunshotwoundwithatransperitoneal tr句ectory ■Signsofperitonealirritation ■Signsoffasciapenetration

▼ F

patients.Lessinvasivediagnosticoptionsfbrrela﹣ tivelyasymptomaticpatients（whomayhavepainat thesiteofthestabwound）includeserialphysicalex﹣ aminationsovera24﹣hourperiod’DPL】ordiagnostic laparoscopy. AIthoughapositiveFASTmaybeheIpfUIinthis situation,anegativeFASTdoesnotexcludethepos﹣ sibiIityofasignificantiht『aabdominaIiniu『yp『oducing smaⅡvoIumeso「nuid·Serialphysicalexaminations arelaborintensive,buthaveanoverallaccuracyrate of94℅.DPLmayallowfbrearlierdiagnosisofinjury inrelativelyasymptomaticpatients.TheaccuraCy rateisgreaterthan96℅whenspecificcellcounts’ ratherthangr0ssinspectionofthefluid,areused. Useoflowerthresholdsfbrpenetratingtrauma increasessensitivityanddecreasesspecificity.Diag﹣ nosticlaparoscopycanconfirmorexcludeperitoneal

▲

PITFAⅡⅡ」

Tangentia∣gunshotwoundsoftena『enott「uIytan﹣ gentiaI’andconcu55iveandbIastin】u「iescancause int「ape「itoneaIin】u「ywith0utpe「itoneaIpenet『ation.

Tho『acoabdominaIWoundS Diagnosticoptionsinasymptomaticpatientswithpos﹣ sibleinjuriestothediaphragmandupperabdominal structuresincludeserialphysicalexaminations,serial chestx﹣rays’DPL,thorac0scopy,laparoscopy’andCT （fbrrightthoracoabdominalwounds）. LocaIWoundExplo『ationandSe『ialPhysical AbdomihalExamination Approximately55℅to60﹪ofallpatientswithstab woundsthatpenetratetheanteriorperitoneumhave hypotension’peritonitis,oreviscerationofomentum orsmallbowel.Thesepatientsrequireanemergen﹣ Cylaparotomy.Intheremainingpatients,inwhom

penetration,butitislessusefUlinidenti句ingspe﹣ cificinjuries.

Se『iaIPhysicaIExaminationsVe『sus Double﹣o『T『ipIe﹣Cont『astCTScansin 「∣ankandBackIn】u『ies Thethickness0ftheflankandbackmusclesprotects theunderlyingv1scerafrominjuryfrommanystab woundsandsomegunshotwoundstotheseareas.Althoughlaparotomyisareasonableoptionfbrallsuch patients,lessinvasivediagnosticoptionsinpatients whoareinitiaⅡyasymptomaticmcludeserialphysical examinations’double-ortriple﹣contrastCTscans’and DPL.Serialphysicalexaminationinpatientswhoare initiaⅡyaSymptomaticandthenbecomesymptomatic isve】yaccurateindetectingretroperitonealandintra﹣ peritoneali叼urieswithwoundsposteriortotheante﹣ rioraxillaryline. Double﹣（intravenousandoral）ortriple﹣（intrave﹣ nous’oral,andrectal）contrastenhancedCTistime consumingandmaymorefhllyevaluatetheretroperi﹣ tonealcolononthesideofthewound.TheaccuraCyis comparabletothatofserialphysicalexaminations,but shouldallowfbrearlierdiagnosisofinjuryinrelatively asymptomaticpatientswhentheCTisperfbrmed properly. Onrareoccasions,theseretroperitonealinjuries canbemissedbyserialexaminationsandcontrast CT·Earlyoutpatientfbllow.upismandatoryafterthe 24﹣hourperiodofinhospitalobservationbecauseofthe subtlepresentationofcertaincolonicinjuries. DPLalsocanbeusedinsuchpatientsasanearly screemngtest.ApositiveDPLisanindicationfbran urgentlaparotomy.

∣

134CHAPTER5■AbdominaIandPeIvicT「auma ■Bluntabdominaltraumawithhypotension

PITFA『』『」S 日 I TheseevaIuationsa『eseekingtop「ovethe『eisno inju「yinthehemodynamicaIIyno『maIpatient.They shouIdnotdeIayaIapa『otomyinhemodynamicalIyab﹦ no「maIpatientswholikeIyhaveanabdominaIsou『ce 0「inpatientswith0bviouspe『itonitis·

withapositiveFASTorclinicalevidenceof intraperitonealbleeding ■Bluntorpenetratingabdominaltraumawitha positiveDPL ■Hypotensionwithapenetratingabdominal wolmd ■Gunshotwoundstraversingtheperitoneal cavityorvisceral／Vascularretroperitoneum ■Evisceration

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■Bleedingfromthestomach,rectum’orgen1﹣

SceⅡa『io■contfnuedTheCTs〔anfu『the『 de∣n i eatesthe『b i f「adu『esandpe∣vc i ↑『adu『es andsh0wsaG『adeIl（m0de『ateIyseve『e）sp∣enic n i ｝u『ywtiha5ma∣ I am0unt0↑↑『een I t『ape『ti0nea∣ ｛Iud i ·Thepate i nt’5b∣00dp『essu『e『eman i 5n0『mal hi5hea『t『atei5ll0〃hiSba5edefidtiS3.Z!and hiSladateiSl.7mm0I／L ﹂

tourinarytractfrompenetratmgtrauma ■Peritomtis ■Freeair’retroperitonea1air,orruptureofthe hemidiaphragm ■Contrast-enhancedCTthatdemonstrates rupturedgastrointestinaltract,intraperitoneal bladderinjury》renalpediclei叮ury,orsevere visceralparenchymalinjuryafterbluntor penetratingtrauma

∣P SpecificDiag

In伽 cations『o『alapa『otomy n S o『al I nA

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?躂辮耀⋯⋯ Inindividualpatients,surgicaljudgmentisreqUiredto determinethetimingandneedfbrlaparotomy（■FlG﹣ uRE曰﹣8）ThefbⅡowingindicationsarecommonlyused tofhcihtatethedecision-makingprocessinthisregard. ＝

noses

Theliver,spleen,andkidneyaretheorganspredomi﹣ nantlyinvolvedafterblunttrauma,althoughtherela﹣ tiveincidenceofhollowvisceralperibration’lumbar spinalmjuries’andutermeruptureincreaseswith incorrectseatbeltusage（seeTable5.1）.Difficulties indiagnosiscanoccurwithinjuriestothediaphragm, duodenum’pancreas,genitourinarySystem,orsmall b0wel·Mostpenetratingi叼uriesarediagnosedat laparotomy.

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DIAPⅡRAGMIⅡjURIES 匡f﹦、品寺

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Blunttearscanoccurinanyportionofeitherdia﹣ phragm;however,thelefthemidiaphragmismore c0mmonlyi叮ured·Themostcommoninjuryis5to10 cminlengthandinvolvestheposterolaterallefthe﹣ midiaphragm·Abnormalitiesontheinitialchestx﹣ray includeelevationor“blurring,）ofthehemidiaphragm’ hemothorax’anabnormalgasshadowthatobscures thehemidiaphragm’orthegastrictubepositionedin thechest.However’theimtialchestx﹣raycanbenor﹣ malinasmallpercentageofpatients·Thediagnosis shouldbesuspectedwithanywoundofthethoracoab﹣ domenandmaybeconfirmedwithlapar0tomy’thora﹣ coscopy,orlaparoscopy.

SPECIFICDIAGNOSES135

PITFA『Ⅲ

abdominalpainWitheither呵ury,anIVP’CT’orre﹣ nalarteriogramcanbeusefblindiagnosis. Ananteriorpelvicfractureusuallyispresentin patientswithurethralinjuries·Urethraldisruptions aredividedintothoseabove（posterior）orbelow（ante﹣ rior）theurogenitaldiaphragm.Aposteriorurethral iIUu1yusuallyoccursinpatientswithmulti取stem injuriesandpelvicfTactures.Incontrast,ananterior urethralinjuryresultshomastraddleimpactandcan beanisolatedi叼ury.

∣

Penet「atingwoundsofthediaph『agmmaybeasymp﹣ t0maticonp「esentation.

D00DEⅡALIⅡjURIES Duodenalruptureisclassicallyencounteredinunre﹣ straineddriversinvolvedinfrontal﹣impactmotorve﹣ hiclecoⅡisionsandpatientswhosustaindirectbl0ws totheabdomen’suchasfrombicyclehandlebars.A bloodygastricaspirateorretroperitonealaironaflat platex﹣rayoftheabdomenorabdominalCTshould ra1sesuspicionfbrthisinjury.Anuppergastrointesti﹣ nalx﹣rayseriesordouble﹣contrastCTisindicatedfbr high﹣riskpatients.

pAⅡCREATICIⅡ』URIES Pancreaticmjuriesmostoitenresultiromadirectepigastricblowthatcompressestheorganagainstthevertebralcolumn.AⅡea『Iyno『maIse『umamyIaseIeve∣does hotexcIudemaio『panc『eatict『auma.Conve『seIy,theam. yIaseIevelcanbeeIevatedfiomnonpanc『eaticsou『ces’ H0wever,persistentlyelevatedorrisingserumamylase levelsshouldpromptfhrtherevaluationofthepancreas andotherabdominalviscera.Double﹣contrastCTmay notidenti句signihcantpancreatictraumaintheim﹣ mediatepostmjmyperiod（upto8hours）,itshouldbe repeatedlaterifpancreaticinjmyissuspected.Should therebeconcernafteranequivocalCT,surgicalexplo﹦ rationofthepancreasiswarranted.

GEⅡIT0URIⅡARγIⅡ』URIES Directblowst0thebackorⅡankthatresultincontusions’hematomas’orecchymosesaremarkersofpoten﹣ tialunderlyingrenalinjmyandwarrantanevaluation （CTorIVP）oftheurina】ytract.Additionalindications fbrevaluatingtheurina1ytractincludegrosshematuriaormicroscopichematuriainpatientswith（1）a penetratingabdominalwound’（2）anepisodeofhypo﹣ tension（Systolicbloodpressurelessthan90mmHg） inpatientswithbluntabdominaltrauma,and（3）as﹣ sociatedintraabdominalinjuriesinpatientswithblunt trauma.Grosshematuriaandmicroscopichematuria inpatientswithanepisodeofshockindicatetheyare atrisk允rnonrenalabdominalmjuries.Anabdominal CTscanwithⅣcontrastcandocumentthepresence andextentofabluntrenalimury,95℅ofwhichcanbe treatednonoperatively.Thrombosisoftherenalartery ordisruptionoftherenalpedicleseconda1ytodecel﹣ erationisarareuppertractmjurymwhichhematuria maybeabsent’althoughthepatientcanhavesevere

Ⅱ0ll0WVlSCUSIⅡ』uR∣ES BluntinjurytotheintestinesgeneraⅡyresults丘omsuddendecelerationwithsubseqUenttearingnearahxed p0intofattachment,especiaⅡyifthepatient’sseatbelt wasappliedincorrectly.Theappearanceoftransverse, hnearecchymosesontheabdominalwall（seabbeltsign） orthepresenceofalumbardistractionfracture（Chance fTacture）onx﹣rayshouldalertthechniciantothepos﹣ sibili叮ofintestinalinjury.Althoughsomepatientshave ea『lyabdominaIpainaⅡdtende『ness》diagnosiscanbedif 伺cultinothe『s’especialIybecauseiⅡiu『edintestinaIst『uc· tⅡ『esmayohIyp『odⅡceminimaIhemo『『hage·

PITFAI』『」 I T Ea『IyuIt「asoundandCTa『eoftennotdiagnosticfo『 thesesubtIeiniu『ies·

S0UD0RGAⅡIⅡjURIES Injuriestotheliver’spleen,andkidneythatresultin shock’hemodynamicinstability,orevidenceofcon﹣ tinuingbleedingareindicationsfbrurgentlaparotomy. SolidorganinjuryinhemodynamicaⅡynormalpatients canoftenbemanagednon0peratively.Suchpatients shouldbeadmittedtothehospitalfbrcareh1lobserva﹣ tion,andevaluationbyasurgeonisessential.C◎h∞mi. taⅡthoIIowviscusiⅡiu「yoccu『sinIessthan5％o「patiehts iⅡitiaIIytlioughttohaveisoIatedsoIido『gahihiu『ies·

pELVlC「RACTURESAⅡDA5S0αA『ED IN』UR∣ES Patientswithhypotensionandpelvicfiactureshavea highmortality,andsounddecisionmakingiscrucial· Pelvicfiyacturesassociatedwithhemorrhagecommon﹣ lyexhibitdisruptionoftheposteriorosseoushgamen﹣ tous（sacroiliac’sacrospinous’sacrotUberous,andthe fibromuscularpelvicfloor）complexfTomasacroiliac fractureand／ordislocation,orfromasacralfTacture. Disruptionofthepelvicringtearsthepelvicvenous plexusandoccasionallydisruptstheinternaliliac

136CHAPTER5■AbdominaIandPeIvicT「auma

arterialsystem（anteroposteriorcompressioninjury）· Verticaldisplacementofthesacroihacjointmayalso causedisruptionoftheiliacvasculaturethatcancause uncontrolledhemorrhage.Pelvicrmgmjurymaybe causedbymotorCyclecrashesandpedestrian﹣vehicle collisions’directcrushing1n】mytothepelvis,and fallsfTomheightsgreaterthan12fbet（3.6meters）. Mortalityinpatientswithalltypesofpelvic仕actures isapproximatelyonemsix（5℅＿30℅）.Mortali叮rises toapproximate】yoneinibur（10℅－42﹪）inpatients withclosedpelvicfracturesandhypotension,andto approximately50℅inpatientswithopenpelvicfrac﹣ tures.Hemo1Thageisthem酊orpotentiallyreversible contributing趙ctortomortali勺. InmotorvehiclecoⅢsions’acommonmechanism ofpelvicfractureisfbrceappⅡedtothelateralaspect ofthepelvisthattendstorotatetheinvolvedhemi﹣ pelvisinternaⅡy,closingdownthepelvicvolumeand reducingtensiononthepelvicvascularsystem（lateral compressioninjury）.Thisrotationalmotiondrivesthe pubisintothelowergemtourinarysystem,potentially creatinginjurytothebladderand／orurethra.Hemor﹣ rhagefromthisimu】y,oritsseqUelae,rarelyresultsin death.SeeSki】lStationX『『I:MusculoskeletalTrauma:

AssessmentandManagement ,SkillXIII﹣F:Identifica﹣ tionandManagementofPelvicFractures

Mechanismof!n】uIy／CIassification Thefburpatternsoffbrceleadingtopelvicfractures include（1）APcompression’（2）lateralcompression’ （3）verticalshear’and（4）complex（combination）pat﹣ tern.AnAPcompressioniIUurycanbecausedbyan auto﹣pedestriancoⅢsionormotorCyclecrash,adirect crushingimurytothepelvis’oraihllfTomaheight greaterthan12fbet（3.6meters）.Withdisruption ofthesymphysispubis’thereoftenistearingofthe

posteriorosseoushgamentouscomplex,represented byasacroiliachactureand／ordislocationorsacral fracture.Withopeningofthepelvicring,therecanbe hemorrhagefromtheposteriorpeMcvenouscomplex and’occasionaⅡy,branchesofthemternalⅡiacarteIy· LateralcompressioniIUuriesoftenresulthom motorvehiclecrashesandleadtointernalrotationof theinvolvedhemipelvis.ThepelvicvolumeisactuaⅡy compressedinsuchanimu】y’solifb﹣threateninghem﹣ orrhageisnotcommon. Ahi助﹣energyshearfbrceapphedinavertical planeacrosstheanteriorandposterioraspectsofthe ringdisruptsthesacrospinousandsacrotuberousliga﹣ mentsandleadstom幻orpelvicinstability.Thiscom﹣ monlyresultsfTomafall.■FlGURE5﹣9iⅡustratestypes ofpelvicfractures·

Management Initialmanagementofam可orpelvicdisruptionas﹣ sociatedwithhemorrhagerequireshemorrhagecon﹣ trolandfluidresuscitation.Hemorrhagecontrolis achievedthroughmechanicalstabilizationofthepel﹣ vicringandexternalcounterpressure.Patientswith theseinjuriesmaybeinitiallyassessedandtreatedin hospitalsthatdonothavetheresourcestodefinitively managethedegreeofassociatedhemorrhage’Insuch cases’simpletechniquescanbeusedtostabilizethe pelvisbefbretransfbrringthepatient.Longitudinal tracti0nappliedthroughtheskinortheskeletonis afirst﹣linemethod.Becausetheseinjuriesexternally rotatethehemipelvis,internalrotationofthelower limbsalsoreducesthepelvicvolume.Thisprocedure maybesupplementedbyapp】yingasupportdirectly tothepelvis.Asheet,peIvicbinde『,o『othe『devicecan appIysu冊cientstabiIity↑b『theuhstablepeIvisattheIeveI o「theg『eate『t『ochante『so「the佗mu『（■FlGuRE5﹣10）.

■FlGURE5﹣9PeIvic「『actu『es.（A）CIosedf『actu「巳（B）OpenbooI（f『actu『e.（C）Ve「ticaI5hea「f「actu「e 】8

A

Late「a【comp「e5sion （c【osed）60﹣70﹪f「equency

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爬「tica【shea『 5﹣15﹪f『equency

SPECIFICDIAGNOSES137

『 0

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■『IGURE5﹣10PeIvicStabiIization.（A）peIvicbinde伋（B）PelvicstabiIizationusingasheet·（C）Befo「eappIication ofpelvicbinde脫（D）Afte「appIicati0nofpelvicbinde阬

Thesetemporarymethodsaresuitabletogainearly pelvicstabilization·Thebindersareonlyatemporary pr0cedure,andcautionisnecessary,astightbinders cancauseskinbreakdownandulcerationoverthe bonyprominences.Asaresult,patientswithpelvic bindersneedt0becarefhllymomtored. Defimtivecareofpatientswithhemodynamic abnormalitiesdemandsthecooperativee肋rtsofa teamthatincludesatraumasurgeon’aninterventional radiologistifavailable,andanorthopedicsurgeon. Angiographicembohzationisoitenthebestoptionfbr defimtivemanagementofpatientswithongoinghem﹣ orrhagerelatedtopelvichactures. Althoughdefinitivemanagementofpatientswith pelvicfracturesvaries,onetreatmentalgorithmbased onthehemodynamicstatusfbremergencypatients isshownin■FIGURE5﹣11.SiⅡcesigni伺cant『esou『ces a『e『equi『edtoca『e｛b『patientswithseve『epeIvic抒ac. tu『es,ea『ly∞nside『ationoft『aⅡsfb『toat『aumacehte『 isessentia∣.

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皿Thethreedistinctregionsoftheabdomenaretheperitonealcavity’retroperito﹣ nealspace’andpelviccavity.Thepelviccavi叮containscomponentsofboththe peritonealcavityandretroperitonealspace. 回EarlyconsultationwithasurgeonisnecessaryWheneverapatientwithpossible intraabdominalinjuriesisbroughttotheEDOncethepatient,svitalhmctions havebeenrestored）evaluationandmanagementvariesdependingonthemecha﹣ nismofi叫my 圃HemodynamicaⅡyabn0rmalpatientswithmultiplebluntinjuriesshouldberap﹣ i出yassessedfbrmtraabdomina1bleedingorcontaminationfTomthegastrointestmaltractbyperfbrmingaFASTorDPL· 回IndicationsfbrCTscaninhemodynamicaⅡynormalpatientsincludeanunevalu﹣ ableabdomen’pain’ortenderness.ThedecisiontooperateisbasedontheSpecific organ（s）mvolvedandthemagnitudeofi呵ury. 回AⅡpatientswithpenetratingwoundsmproximi叮totheabdomenandassociated hypotension,peritomtis,orev1scerationrequireemergentlaparotomy·Patients withgunshotwoundsthatobvious】ytraversetheperitonealcavi叮orvisceral／ vasculararea0ftheretroperitoneumonphysicalexaminationorroutinex﹣rays a1sorequirelaparotomy.ASymptomaticpatientswithanteriorabdominalstab woundsthatpenetratethefhsciaorperitoneumonlocalwoundexplorationre﹣ qUire血rtherevaluation;thereareseveralacceptablealternatives. 圃Asymptomaticpatientswithflankorbackstabwoundsthatarenotobviously superficialareevaluatedbyseria1physicalexaminationsorcontrast﹣enhanced CT.Explorato叮laparotomyisanacceptableoptionwiththesepatientsaswell· ＝

∣

BIBLIOGRAPHY139

＝

Ch apterSunⅢnary（Co〃f加叨c叫

∣

ⅢManagementofbluntandpenetratingtraumatotheabdomenandpelvisincludes; ﹥Reestabhshingvita1hmctionsandoptimizingoxygenationandtissueperfUsion ﹥Promptrecognitionofsourcesofhemorrhagewitheffbrtsathemorrhagecontrol ·Laparotomy ·PelvicstabiIi叨a垃on ·AngiographicemboⅡzation ﹥Dehneatmgthe呵mymechanism ﹥Meticulousmitialphysicalexamination,repeatedatregularmtervals ﹥Selectmgspecialdiagnosticmaneuversasneeded’perfbrmedwithaminimal lossoftime ﹥Maintainingahighmdexofsuspicionrelatedtooccultvascularandretroperi﹣ tonealinjuries ﹂

■ ﹥

BIBlI0GRApⅡγ

8·DemetriadesD’RabinowitzB’SolianosO’etal.The managementofpenetratinginjuriesoftheback:apro﹣ spectivestudyof230patients’A几〃S【〃g1988;207:72﹣74.

1.AgoliniSEShahK,JaffbJ,etal.Arterialembolization isarapidandelIbctivetechniquefbrcontrollingpelvic hyacturehemorrhage.J乃αM〃】α1997;43（3）:395﹣399.

9.DischingerPαCushingBM’KernsTJ‘Injurypatterns associatedwithdirectionofimpact:driversadmittedto traumacenters.J仍m【〃﹩α1993;35:454詹459.

2.AndersonPA’RivaraFP,MaierRV｝etal.Theepide﹣ miologyofseatbelt﹣associatedinjuries.JZ〉nMmα 1991;31:60﹣67.

10.FabianTC’CroceMA·Abdominaltrauma’including mdications｛b1.laparotomy’In:MattoxLK,FelicianoDⅥ MooreEE,eds·仍nα／几α·EastNorwalk,CT:Appleton＆ Lange;2000:583﹣602.

3·AquⅡeraPA’ChoiT,DurhamBH.Ultrasound﹣aided supra﹣pubiccystostomycatheterplacementintheemer﹣ gencydepartment.JE〃』eJgM它d2004;26（3）:319﹣321. 4.BallardRB’RozyckiGS,NewmanPG,etal.Analgorithm toreducethemcidenceoffhlse﹣negativeF牲STexamma﹣ tionsinpatientsathighriskfbroccultinjurybJAmα〃 SM／g1999;189（2）:145﹣150 5.BoyleEM’MaierRV》SalazarJD,etal:Diagnosisofinju﹣ riesalterstabwoundstothebackandfIank.J乃.α〃mα 1997;42（2）:260﹣265. 6.CryerHM,MiⅡerFB,EversBM,etal.Pelvicfracture classi固cation:correlationwithhemorrhageJⅡ｝mz加α 1988;28:973﹦980 7.DalalSA,BurgessAR’SiegelJH,etal.Pelviciracturein multipletrauma:classificationbymechamsmiskeyto patternoforganinjury,resuscitativerequ1rements,and outcomeJ仍nα〃』α1989;29:981﹦1002·

11.HolmesJEHarrisD,BattistellaFD.Perfbrmanceof abdominalultrasonographyinblunttraumapatients without﹣of巳hospitaloremergenCydepartmenthypoten﹣ sion.A〃〃Eme唔Mbd2004;43（3）:354﹣361. 12.HuizingaWK,BakerLW》MtshaliZWSelectivemanage﹣ mentofabdominalandthoracicstabwoundswithestab﹣ lishedperitonealpenetration:theevisceratedomentum. AJ〃JSα唔1987,153:564﹣568. 13.KnudsonMM,McAninchJWGomezR.Hematuriaasa predictorofabdominalinjuryafterblunttrauma.AmJ S叨唔1992,164（5）:482﹃486. 14.KoraitimMM.Pelvicfractureurethralinjuries:theunre﹣ solvedcontroversy.JU〉D／1999;161（5）:1433﹣1441· 15.LiuM’LeeC,VbngEProspectivecomparisonofdiagnos﹣ ticperitoneallavage’computedtomographicscanning’ andultrasonographyfbrthediagnosisofbluntabdomi﹣ naltrauma.JZ〉uαmα1993;35267﹣270.

1q0CHAPTER5■AbdominaIandPeIvicT『auma 16·McCarthyMC,LowdermilkGA’CanalDEetal.Predic﹣ tionofinjurycausedbypenetratingwoundstotheabdo﹣ men’f】ank,andback.AJ℃〃Sα咱1991;26:962﹣966.

24·RouttMLJr’SimonianPT,SwiontkowskiMRStabih. zationofpelvicringdisruptions.O㎡hOpα加Ⅳb㎡几Am 1997;28（3）:369﹣388·

17·MendezC’GublerKD’MaierRV;Diagnosticaccura叮 ofperitoneallavageinpatientswithpelvicfTactures. AJ℃〃Sα唔1994;129（5）:477-481.

25.RozyckiGS,BallardRB,FelicianoDV﹩etal.Su吧eon. per｛brmedultrasoundfbrtheassessmentoftruncal injuries:lessonslearnedfium1540patients.AmzS泓唔 1998;228（4）;557-565.

18.MeyerDM,ThalER’Weigelt‘〕A’etal.Theroleofabdo﹣ minalCTintheevaluationofstabwoundstotheback· J仍uα加α1989;29:1226﹣1230. 19.MillerKS,McAnnichJWRadiographicassessmentof renaltrauma:our15yearexper1ence.cJU》D／1995;154（2 Pt1）:352﹣355. 20NordenholzKE’RubmMA,GularteGG’etal.Ultra﹣ soundmtheevaluationandmanagementofbluntabdo﹣ minaltrauma.AJ!〃Eme唔M﹫d1997;29（3）:357﹣366. 21·PhillipsⅢSclafaniSJA’GoldsteinA,etal.Useofthe contrast﹣enhancedCTenemainthemanagementof penetratingtraumatotheHankandback.J?》mz加α 1986;26:593-601· 22ReidAB,LettsRM’BlackGB.PediatricChancefi.actu﹣ res:associationwithintraabdominalinjuriesandseat beltuse.JT〉uαmα1990;30:384﹣391. 23’RobinAP,AndrewsJR,LangeDA’etalSelective managementofanteriorabdominalstabwounds.J 『〉uαmα1989;29:1684﹣1689.

25.RozyckiGS.Abdominalultrasonographyintrauma’ Sα唔α加Ⅳb㎡〃Am1995;75:175﹣191. 21.ShackfbrdSR,RogersFB,OslerTM,etal.Focusedabdo﹣ minalsonographyfbrtrauma:thelearningcurveofnon﹣ radiologistcⅡmciansindetectinghemoperitoneum.c／ 仍uαmα1999;46（4）:553﹣562. 22.IhkishimaT,SugimotaLHirataM’etal.Serumamylase levelonadmissioninthediagnosisofbluntinjurytothe pancreas:itssignificanceandlimitations.AJt〃Sα咱 1997;226（1）:70﹣76. 24.UdobiKERoderiquesA,ChiuWC’ScaleaTM.Roleof ultra﹣sonographyinpenetratingabdominaltrauma;a prospectiveclinicalstudy.cJⅢ》nα加α2001;50（3）:475﹣479. 25.ZantutLF’IvatuIyRR’SmithRS’etal.Diagnosticand therapeuticlaparoscoⅣfbrpenetratingabdominaltrauma﹩ amulticenterexpenence.cJT牠αmα1997;42（5）:825﹣829·

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SCENARI0V∣Ⅱ﹣1 A45﹣year﹣oldrestraineddriverisinvolvedinahead﹣ onmotorvehiclecoⅢsion.Sheiscomplainingofse﹣ vereabdomina1pam,butdoesnothaveanytrouble breathing·Herheartrateis115’bloodpressure85／60’ respiratoryrate24,andGCS15.Intravenousaccess isobtained》andcrystalloidfluidresuscitationisimti﹣ ated.Achestx﹣rayshowslowerleft﹣sidedribfractures’ andapelvicx﹣rayisnormal·

SCENAR!0VⅡl﹣Z A57year﹣oldconstructionw0rkerfRllsfromasecond sto1y.Hecomplainsofbackpainandhasnosensation ormovementinhislowerextremities·Hisheartrate is100,bloodpressure100／60,respirato1》yrate20,and GCS15.Chestandpe】vicx﹣raysarenormal.

SCENARI0VⅡ∣﹣3 A23year﹣oldmotorCyclististhrownfromhisCycle.He isunresponsive,withdecreasedbreathsoundsonthe right’aheartrateof130’andbloodpressure70／40.His tracheaismidlineandhedoesnothavejugularvenous distention.Asheisbeingmtubated,chestandpelvic radiographsareobtained’alongwithFASTimages.

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〉SkilIVⅡ!:『ocusedAssessmentSonog『aphyinT『auma（『AST） TheFASTexamisatoolfbrtherapidassessmentof atraumapatient·Inordert0developproficienCywith thisassessment,moretimethanisavailableinthe ATLSskillstationisrequired·However,thisskillsta﹣ tionwillprovideyouwithabasichPameworkfbriden﹣ ti觔ngthecorrectwaytoperfbrmtheFASTexam, andtointerpretFASTimagesinthecontextofseveral cases.FASTincludesthefbllowingv】ews:

atefbrchildrenorextremelythinadults.Evenlower fTequenCytransducersmaybenecessaryfbrthemor﹦ bidly0bese.

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thediaphragm,spleen’andkidney（■FlGuRE vⅢ﹣4）.Theentiresplenorenalfbssashould bevisualized.Airarti趙cts丘omthestomach andcolon’inadditiontothesmalleracous﹣ ticwindow’makethisthemostdifficult viewtoobtain,itmaybenecessarytomove thetransducerposteriorly.

parasternalview· STEPZ·

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TheRUQviewisasagittalviewinthe midaxillaryline’atapproximatelythe10th or11thribspace.Structurestovisualize includethediaphragm’hver’andkidney （■『!GuREvIⅡ﹣3）.Theentirehepatorenalfbssa （Morris0n’sp0uCh）shouldbevisualized. TheLUQviewisasagittalviewinthe midaxⅢaryline’atapproximatelythe8thor 9thribspace.Structurestovisualizeinclude

sTEp4

Thesuprapubicviewisatransverseview optimallyobtainedpriortoplacementofa Foleycatheter（■F∣GuREvⅢ5）.Artifhctsmay beintroducedduetoposteriorenhance﹣ ment;ifareasoff】uiddisappearwithside﹣ to﹣sidemovementofthetransducer,they arelikelyartifact.

144SKILLSTATlONVⅡl■F0cusedAsse55mentS0nog『aphyinT『auma（FAST）

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PITFA『Ⅱ」S ■AnegativeFASTexamdoesnot「uIeoutint『aab﹣ dominaIin】u『y·Itdoes『howeve「’makeanabdominaI sou「ceIessIikeIyasthe〔auseofhemodynamicaIIysig﹣ nificanthemo「『hage.

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■ThepeIvicviewisbestpe㎡o『medp『io『t0inseI﹣tionof aFoIeycathete『』asadistendedbIadde「isheIpfuIin seeingf『eepeIvicfIuidonFAST.

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Pe『fo『manceatthisstationwiIlalIowpa「ticipant5top「acticeanddem﹣ onst『atethetechniqueofdiagnosticpe『itoneaIIavage（DPL）onaIiv巳 anesthetlzedanima∣jaf『e5h〃humancadave『;0『ananatomichumanbody manikin.

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145

146SKILLSTATI0NIX■Diagno5ticPe「it0neaILavage

卜S∣《iⅢX﹦A:DiagnosticPe『itoneaIlavage－0penTechnique STEp1·Obtaininfbrmedconsent’iftimepermits. STEP2·DecompressthestomaChandurinaryblad﹣ derbyinsertingagastrictubeandurinary catheter. sTEP3.

sTEp4.

Afterdonmngmask’sterilegown,and gloves’surgicaⅡypreparetheabdomen （costalmargintothepubicareaandflank toflank,anteriorly） IIUectlocalanestheticmidlinejustbelow theumbilicus,downtothelevelofthe 角Scia.

STEp5·Vertical】yincisetheskinandsubcutaneous tissuestothe姐scia. STEP6·

Graspthefhscialedgeswithclamps’and elevateandincisethefhsciadowntothe peritoneum.Makeasmallmckintheperi﹣ toneum’enteringtheperitonealcavi叮.

S『EP7·Insertaperitonealdialysiscatheterintothe peritonealcavity· S『EP8·Advancethecatheterintothepelvis S『EP9·ConnectthedialysiscathetertoaSyringe andaspirate.

STEP10.Ifgrossbloodisaspirated,thepatient shouldbetakentolaparotomy·Ifgross bloodisnotobtained’instiⅡ1Lofwarmed isotoniccrystalloidsolution／normalsaline （10mL／kginachild）intotheperitoneum throughtheintravenoustubingattachedt0 thedialysiscatheter. STEP11。Gentlyagitatetheabdomentodistribute thefluidthroughouttheperitonealcavity andincreasem1xmgwiththeblood.

5TEP1Z.Ifthepatient’sconditi0nisstable,allowthe fluidtoremainafbwminutesbefbreplacing thec1ystalloidcontaineronthefloorandallowingtheperitonealfluidtodrainfromthe abdomen.Adequatefluidreturnis＞20℅of thein血sedvolume.

5TEP13·Aitertheiluidreturns,sendasampletothe laboratoryfbrGramstainande】ythroCyte andleukocytecounts（unspun）.Apositive testandthustheneedfbrsurgicalinterven﹣ tionisindicatedby100’000redbloodcells （HBCs）／mm3ormore’greaterthan500 whitebloodceⅡs（WBCs）／mm3’oraposi﹣ tiveGramstain允r允odfibersorbacteria. Anegativelavagedoesnotexcluderetro﹣ peritonealinjuries’suchaspancreaticand duodenalinjuries.

P卜C0ⅢplICATl0ⅡS0『PERIT0ⅡEAlLAVAGE ■Hemorrhage’secondarytoi叼ection0f localanestheticorincisionoftheskinor subcutaneoustissues,whichproduces fhlsepositiveresults ■Peritonitisduet0intestinalperfbration fromthecatheter ■Lacerationofurinarybladder（ifbladder notevacuatedpriortoprocedure） ■Injurytootherabdominalandretroperi﹣ tonealstructuresrequiringoperative care

■Woundinfbctionatthelavagesite（late complication）

Sl﹤ILLSTATIONIX■Diagn05ticPe『it0neaILavage147 I

bSI《iⅢX﹦B:DiagnosticPe『itoneaIlavage＿ClosedTechnique STEP1.Obtaininfbrmedconsent’iftimepermits· STEP2.Decompressthestomachandurinaryblad﹣ derbyinsertingagastrictubeandurinary catheter. sTEp3·

Aiterdonningmask,sterilegown,and gloves,surgicaⅡypreparetheabdomen （costalmargintothepubicareaandflank toflank’anteriorly）

STEP4·Injectloca1anestheticmidlinejustbelow theumbilicus. STEp5.

Insertan18﹣gaugebeveledneedleattached toasyringethroughtheskinandsubcu﹣ taneoustissue.Besistanceisencountered whentraversingtheskin,fascia’andagam whenpenetratingtheperitoneum·Aspirate Ifgr0ssbloodisnotobtained’continueto step6·Ifgrossblo0disaspirated’thepa戶 tientshouldbetakentolaparotomy.

STEP6·

Passtheflexibleendoftheguidewire throughthe18﹣gaugeneedleuntilresist﹣ anceismetor3cmisstillshowingoutside theneedle.Thenremovetheneedlefrom theabdominalcavitysothat0nlythe guidewireremams’

STEP7.

STEp8·

MBkeasm月】】skinmcisionattheentrance siteoftheguidewireandinserttheperito﹣ neallavageca」Jheterovertheguidewireinto theperitonealcavity.Removetheguidewire fromtheabdommalcavitys0thatonlythe lavagecatheterremams.Reattemptaspira戶 tionofthecathetertolookfbrgrossblood. Ifgrossbloodisaspirated’thepatient shouldbetakentolaparotomy.

Instill1Lofwarmedisotonicc1ystalloid solution（10mL／kginachild）intothe peritoneumthroughtheintravenoustubing attachedtothelavagecatheter.

STEP9’Gentlyagitatetheabdomentodistribute thefluidthroughouttheperitonealcavity andincreasemixingwiththeblood. STEP10·Ifthepatient）sconditionisstable,allowthe fluidtoremainafbwminutesbefbreplacing thecrystalloidcontaineronthefloorandal﹣ lowingtheperitonealfluidtodrainfromthe abdomen.AdeqUatefluidreturnis＞20﹪of theinh1sedvolume.

5TEPⅢ.Aiterthefluidhasreturned,sendasample tothelaboratoryfbrGramstainande】Vth﹣ rocyteandleukocytecounts（unspun）’A positivetestandthustheneedibrsurgical mterventionisindicatedby100’000RBCs／ mm30rmore’greaterthan500WBCs／mm3 orapositiveGramstainfbrfbodfibersor bacteria·Anegativelavagedoesnotexclude retroperitonealinjuries’suchaspancreatic andduodenalinjuries.

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O吋ectives ⅢDesc『b i ebasc in i t『ac『ana ip l hy5o i ∣ogy. 圍Evaluatepatientswithheadandb『ainin】u『ies. 圃Pe「「o「mafocusedneu『oo l gc i examn i ato in 囤ExpIaintheimpo『tanceofadequate「esuscitationin m iI tingseconda「yb『an in i 】u『y. 回Givenapatientscena「i0〃dete「minetheneedfo『 pate i ntt「ansfe「’admsiso i n〃consutIato i n〃o『dsicha『ge ＿

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departments（EDs）.Manypatientswithsevere brainimuriesdiebefbrereaChingahospital,withahnost 90﹪ofprehospitaltrauma﹣relateddeathsinvolving brainmjury.About75﹪ofpatientswithbraininjuries whoreceivemedicalattentioncanbecategorizedas havingminorinjuries’15﹪asmoderate,and10﹪ asseverd.MostrecentUnitedStatesdataestimate 1,700,000traumaticbraini叼uries（TBIs）annually, including275’000hospitalizationsand52,000deaths. SurvivorsofTBIareoftenleftwithneuropsycho﹣ logicimpairmentsthatresultmdisabⅡitiesaffbcting workandsocialactivity.Everyyear’anestimated 80,000to90’000peopleintheUnitedStatesexperiencelongtermdisability廿ombraininjury.Inone averageEuropeancountry（Denmark）’approximately 300individua1spermilhoninhabitantssuffbrmoder﹣ atetosevereheadinjuriesannuaⅡy,withmorethan one-thirdoftheseindividua1srequiringbraininjmy rehabⅢtation.Giventhesestatistics,itisclearthat evenasmallreductioninthemortali叮andmorbidity resultingfrombrainmjurycanhaveam勻orimpact0n publichealth. Theprimarygoaloftreatmentfbrpatientswith suspectedTBIistopreventsecondarybrainiIUmy Providingadequateoxygenationandmaintaimng 149

150CHAPTER6■HeadT『auma

bloodpressureatalevelthatissufficienttoperfhse thebrainarethemostimportantwaystolimitsecondarybraindamageandtherebyimprovethepatient’s

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outcome.SubseqUenttomanagingtheABCDEs’ identificationofamasslesionthatrequiressurg1﹣ ●α冗αfoyy』0／α冗dp〃0靨㎡oJO部bα〃α〃o叨dO c a l e v a c u a t i o n i s c r i t i c a l ’ a n d t h i s i s b e s t a c h i e v e d b y · · . 炕eJα旅㎡Pαf㎡cγ〃sOfbJum』叼叨叮2 immediatelyobtainingacomputedtomograPhic（CT） scanofthehead.Howeve『,obtainingaCTscanshould』 AreⅥewofcranialanatomymcludesthescalP,skuⅡ’ notdelaypatientt『an乖『t◎at『aumacente『thatiscapabIemeninges,brain’ventricularsystem’andintracranial o「immediateandde伺nitiveheu『◎su『gicaIiⅡte『ventioⅡ.《comPartments.（■『IGuRE6﹣1）. ThetriageofapatientwithbraininjurydePends ontheseveri｛yoftheinjmyandthefhcilitiesavailable SCAlP withinaparticularcommunity.Forfacilitieswithout neurosurgicalcoverage’prearrangedtransfbragree﹣ Becauseofthescalp’sgenerousbloodsuPPly,scalPlac﹣ mentswithhigher﹣levelfacilitiesshouldbeinplace.erationscanresultinm匈orblo0dloss,hemorrhagic Consultationwithaneurosurgeonearlyinthecourseshock’andevendeath.Thisisparticula】lytrueinpa﹣ oftreatmentisstronglyrecommended（Box6﹣1） tientswithalongtransporttime

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Thebaseoftheskullisirregular,Whichcancontribute tomjuryasthebrainmoveswithintheskuⅡdurmgac﹣ celerationanddeceleration·Theanteriorfbssahouses thefrontallobes’themiddlefbssathetemporallobes, andtheposteriorfbssathelowerbrainstemandthe cerebellⅢm﹣

Themeningescoverthebrainandconsistofthreelay﹣ ers:theduramater,arachnoidmater,andpiamater （■FlGuRE6﹣Z）.Theduramaterlsatough,hbrousmem﹣ branethatadheresfirmlytotheinternalsurfhceofthe skull.Atspecificsites’thedurasphtsintotwoleaves thatenclosethelargevenoussinuses,whichprovide

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15ZCHAPTER6■HeadT『auma

them勾orvenousdrainagefromthebrainThemidline superiorsagittalsinusdrainsintothebilateraltrans﹣ verseandsigmoidsinuses’whichareusuallylargeron therightside.Lacerationofthesevenoussinusescan resultinmassivehemorrhage. Meningealarteriesliebetweentheduraandthe internalsurfhceoftheskull（theepiduralspace）.Over﹣ lyingskullfracturescanlaceratethesearteriesand causeanepiduralhematoma‘Themostcommonly injuredmeningealvesselisthemiddlemeningeal artery）whichislocatedoverthetemporalfbssa·An expandinghematomafromarterialinjmyinthisloca. tionmayleadtorapiddeteriorationanddeathEpi﹣ duralhematomascanalsoresultfrominjmytothe duralsinusesandfromskuⅡfractures,whichtendto expandslowlyandputlesspressureontheunderlying brain.However,mostepiduralhematomasrepresenta h佗﹣threateningemergenCyandmustbeevaluatedby aneurosurgeonassoonaspossible. Beneaththeduraisasecondmeningeallayer’the thin》transparentarachnoidmater.Becausethedura isnotattachedtotheunderlyingarachnoidmem﹣ brane,apotentialspacebetweentheselayersexisbs （thesubduralspace）,intowhichhemorrhagecan occur.InbrainiIUury,bridgingveinsthattravelfrom thesur炮ceofthebraintothevenoussinuseswithin theduramaytear’leadingtothefbrmationofasUb﹣ duralhematoma﹦ Thethirdlayer,thepiamater’isfirmlyattachedto thesurfaceofthebrain.Cerebrospinalfluid（CSF）fills thespacebetweenthewatertightarachnoidmaterand thepiamater（thesubarachnoidspace）,cushioning thebrainandspinalcord·Hemorrhageintothisfluid﹣ filledspace（subarachnoidhemorrhage）isfrequently seeninbraincontusionorinjmytom勻orbloodvessels atthebaseofthebrHfh﹣

BRA∣Ⅱ Thebrainconsistsofthecerebrum’brainstem,and cerebellum（seeFigure6.1）.Thecerebrumiscomposed oftherightandlefthemispheres,whichareseparated bytheftllxcerebri.Theleithemispherecontainsthe languagecentersmvirtuallyallright﹣handedpeople andinmorethan85℅ofleft﹣handedpeople.Thefron﹣ tallobecontrolsexecutivehmction’em0tions,motor h1nction’and,onthedominantside,expressionof speech（motorspeechareas）.Theparietallobedirects sens0ryfhnctionandspatial0rientation·Thetemporal loberegulatescertainmemoryfhnctions.Theoccipital lobeisresponsiblefbrvision. Thebrainstemiscomposedofthemidbrain,p0ns, andmeduⅡa·Themidbrainandupperponscontain thereticularactivatingSystem,whichisresponsible fbrthestateofalertness·Ⅵtalcardiorespirato叮cen﹣

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tersresideinthemedulla,whichcontinuesontofbrm thespinalcord.Evensmalllesionsinthebrainstem maybeassociatedwithsevereneurologicdeficits. Thecerebellum,responsiblemainlyfbrcoordi. nationandbalance’prqjectsposteriorlymtheposte﹣ riorfbssaandfbrmsconnectionswiththespinalcord, brainstem,and,ultimately,thecerebralhemispheres.

VEⅡTRICULARSγSTEM TheventriclesareasystemofCSF-filledspacesand aqueductswithinthebrain.0SFisconstantlypro﹣ ducedwithintheventriclesandisabsorbedoverthe surfaceofthebrain.Thepresence0fbloodintheCSF mayimpairCSFreabsorption’resultinginincreased intracranialpressure.Edemaandmasslesions（e·g., hematomas）cancauseeffhcementorshiftingofthe usuallysymmetricventriclesthatcanbeeasilyidenti﹦ fiedonCTscansofthebrain· IⅡTRACRAⅡ∣AlC0MPARTⅢEⅡTS Toughmeningealpartitionsseparatethebraininto reg1ons·Thetentoriumcerebellidividestheintra﹣ cranialcavityintothesupratentorialandinfTatento﹣ rialcompartments.Themidbrainpassesthroughan openingcalledthetentorialhiatusornotch.Theocu﹣ lomot0rnerve（cranialnerveIII）runsalongtheedge ofthetentoriumandmaybecomecompressedagainst itduringtemporallobeherniation.Parasympathetic fibersthatconstrictthepupillieonthesurfhceofthe thirdcranialnerve.Compressionofthesesuperiicial fibersduringherniationcausespupⅢa】ydilationdue tounopposedsympatheticactivity,oitenrefbrredtoas a‘‘blown,,pupil（■F』GuRE6-3）.

pHYSIOLOGY153

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■FIGURE6﹣4丁heLate『al（UncaI）Ⅱemiationf『oma 呃mpo『aIEpidu『alHematomaCau5edbyaLesiohofthe MiddIeMeningea!A『te『yf『omaF『actu『eintheTbmpo『al Bone’Theuncusc0mp「essestheuppe「b『ain5temwith the『eticuIa「system（dec「easingGCS）〃theocuIomoto『 neⅣe（pupiIIa『ychange5）!andtheco「ticospinaIt「actin themidb「ain（cont『aIate『aIhemipa「e5i5）.

INTRACRAⅡIAlPRESSURE Elevationofintracranialpressure（ICP）canreduce cerebralperfUsionandcauseorexacerbateischemia. ThenormalICPmtherestingstateisapproximately 10mmHg.Pressuresgreaterthan20mmHg’particu﹣ larlyifsustainedandrefractorytotreatment,areas﹦ sociatedwithpooroutcomes.

Thepartofthebrainthatusuallyhermates throughthetentorialnotchisthemedialpartofthe temporallobe,knownastheuncus（■F∣GuRE6﹣4）· Uncalherniationalsocausescompressionofthecor﹣ ticospinal（pyramidal）tractinthemidbrain.The motortractcrossestotheoppositesideatthefbramen magnum,socompressionatthelevelofthemidbrain resultsinweaknessoftheoppositesideofthebody （contralateralhemiparesis）.IpsiIate『alpupiIla『ydiIation associatedwithcont『aIate『aIhemipa『esisistheclassic signo「uncaIhe『niation.Barely’themasslesionmay pushtheoppositesideofthemidbrainagainstthe tentorialedge’resultinginhemiparesisandadilated pupilonthesamesideasthehematoma.

∣ ﹥ physio∣0gy Physiologicconceptsthatrelatetoheadtraumam﹣ cludeintracranialpressure,theMonro﹣KeⅢedoctrine’ andcerebralbloodflow（CBF）.

M0NR0﹣∣《Eu∣ED0CTRIⅡE TheMonro﹣KeⅢeDoctrineisasimple’yetvitaⅡyim﹣ portantconceptrelatedtotheunderstandingofICP dynamics.Thedoctrinestatesthatthetotalvolume oftheintracranialcontentsmustremamconstant’ becausethecraniumisarigid’nonexpansilecon﹣ tainer.Venousbloodandcerebrospinalfluidmaybe compressedoutofthecontainer,providingadegree ofpressurebuffbring（■F∣GuRE6﹣5and■F∣GuRE6﹣6）. Thus】veryearlyafterinjury’amasssuchasablood clotmayenlargewhⅡetheICPremainsnormal·How﹣ ever,oncethelimitofdisplacementofCSFandintra﹣ vascularbloodhasbeenreached,ICPrapidlyincreases.

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154CHAPTER6■HeadT『auma

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■FlGURE6﹣6TheMon『o﹣KeIIieDoct『ineRega『dingint『ac『anialCompensationfo『ExpandingMass. Thevolumeoftheint『ac『aniaIcontents「emainsc0n5tant·Iftheadditionofamasssuchasa hematoma「esuItsinthe5queezingoutofanequalvoIumeofC5FandvenousbI0od’theICp「emain5 no「maI.HoweveI｝whenthiscompensato「ymechani5misexhausted〃the『eisanexp0nentialinc『ease in∣CPfo『evenasmalladditionaIinc「easeinthevoIumeofthehematoma.

malfbrdaysorweeksafterinjmy.Thereisincreasing evidencethatlowlevelsofCBFaremadeqUatetomeet themetabohcdemandsofthebraineadyaiteriIUmy. Regi0nal,evengl0bal,cerebralischemiaiscomm0nafter severeheadi叼uryfbrknownandunknownreasons. TheprecapⅡla1ycerebralvasculaturenormal】yhas theabih叮toreflexivelyconstrictordilateinresponse tochangesinmeanarterialbloodpressure（MAP）.For chmcalpurposes’cerebralperfhsionpressure（CPP）is definedasmeanarterialbloodpressureminusintracranialpressure（CPP＝MAP－ICP）.AMAPof50to 150mmHgis‘‘aut0regulated’’tomaintamaconstant

CBF（pressureautoregulation）.SevereTBImaydisrupt pressureautoregulationsuchthatthebrainisunable toadeqUatelycompensatefbrchangesinCPP.Inthis setting’iftheMAPistoolow,ischemiaandinfhrction willresult·IftheMAPistoohigh,markedbrainswell﹣ ingwilloccurwithelevatedICP.Cerebralbloodvessels alsoconstrictordilateduetochangesinthepartial pressureofo汀gen（PaO2）andthepartialpressureof carbondioxide（PaCOo）levelsintheblood（chemical ︼

regulation）. Therefbre’secondaryinjmymayoccurdueto hypotension’hyp0xia,hypercapma’andiatrogenic

CLASSIFlCATIONS0FHEADIN」URlES155

hypocapnia.Eve『yef『b『tshouIdbemadetoenhaⅡce ce『eb『aIpe『fhsionaⅡdbIood｛Iowby『educihgeIevated ICp,maintainingno『malint『avascuIa『voIume,maintain. ingano『malmeana怵e『ia∣bloodp「essu『e（MAp）!and 『esto『ingho『maloxygenatiohandno『mocaphia·Hema. tomasandothe『Iesionsthatihc『easeint『ac『aniaIvol. umeshouldbeevacuatedea『ly·Maintaininganormal cerebralperihsionpressuremayhelptoimproveCBF, however,CPPdoesnoteqUatewithorassureadequate CBF.Oncecompensato1ymechamsmsareexhausted andthereisanexponentialincreasemICP,brainper﹣ fhsioniscompromised·

SEVERITγ0『IⅡ」URγ TheGCSscoreisusedasanohjectiveclimcalmeasure oftheseveri叮ofbraininjury（Table6.2）.ACCSsco『e of8o『Iesshasbecomethegene『alIyacceptedde侃hition ofcomao『seve『eb『aininiu『y.Patientswithabrain inju】ywhohaveaGCSscoreof9to12arecategorized as“moderate,’’whereasindividualswithaGCSscore of13to15aredesignatedas“minor.”Inassessingthe CCSsco『e,whenthe『eis『ight／le仕o『uppe『／!owe『asym. met『y,itisimpoItanttousethebestmoto『『esponse tocaIcuIatethes∞『e）becausethisisthemost『eIiable p『edicto『o「outcome·However,onemustrecordthe actualresponse0nbothsidesofthebody’face’arm, andleg.

M0RpⅡ0L0Gγ

SceⅡa『io■cont／huedThepatIentisintu﹣ batedandgivena5ec0ndIite「0↑n0『maI5aIine. Hishea『t『ateimp「0vest0l00bpm﹟and0xygen satu『ati0nImp『0ve5t09¢℅·HisbI00dp「essu「e 『emainSI00／70. ＝

∣ ﹥ CIassi↑icationsoⅢeadIniu『ies Headinjuriesareclassifiedinseveralways.F0rpracti. calpurp0ses,theseverityofinjuryandmorphologyare usedinthischapter（Table6.1）.

Headtraumamayincludeskullfracturesandintra﹣ craniallesions’suchascontusions》hemat0mas’diffhse mjuries,andresultantswelling（edema／hyperemia）.

SkuⅡF『actu『es Skullfracturesmayoccurinthecranialvaultor skullbase.Theymaybelinearorstellate’andopen orclosedBasilarskulliiyacturesusuallyrequireCT scanningwithbone﹣windowsettingsfbridentification. Theclinicalsignsofabasilarskullfractureinclude periorbitalecchymosis（raccooneyes）,retroauricu﹣ larecchym0sis（Battle’ssign）,CSFleakagefromthe nose（rhinorrhea）orear（otorrhea）’andseventh﹣and eighth﹣nervedysfUnction（facialparalysisandhearing

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Epidu『aI Subdu「aI nlt『aCe『eb『a∣

C0ncussion Multiplecontusions Hyp0xic／ischemicin】u「y Ax0na∣lnIu『y

Adaptedwithpe『missi0nf『0mValadkaAB‘l＼Ia『ayanRI﹤.Eme『gency『oommanagement0↑t∣〕ehead﹣inlu『edpatient｝∣nI＼Ia『ayanRI﹤’Wilbe『ge『」E’Pov∣isho（k』T’ ed5’／Veu『o〔『Buma·NewYo『k’NY:McG『aw﹣H∣ i ’ l 】996:I20

156CHApTER6■HeadT「auma

■TABLE6絢2G!asgowComaS叵a!e（GCS） A55E5sⅢEⅡTAREA

Eyeopening（E） Sp0ntaneous Tbspeech 1bpaIn None

Ve『baI『esponse（V） O「iented ConfusedConve『sation Inapp『op「iatewo『ds lnc0mp『ehensibles0unds None

Bestmoto『『esponse（M） Obeyscommand5 【ocaIize5pain Flexionwithd「awaltopain Abno『maIfIexion（deco『ticate） Extenso i n（dece『eb『ate） None（f∣acdd）

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loss）’whichmayoccurimmediatelyorafbwdaysafter theinitialiIUury.Thepresenceofthesesignsshould increasetheindexofsuspicionandhelpidentiiybasi﹣ larskT】IIhactures·Those仕acturesthattraversethe car0tidcanalsmaydamagethecarotidarteries（dis﹣ section’pseudoaneurysm,orthrombosis）,andconsid﹣ erationshouldbegiventocerebralarteriography（CT angiography〔CT﹣A〕orcatheter﹣based）. Openorcompoundskullfracturescanprovidea directconnnumcationbetweenthescalplaceration andthecerebralsurfhce,becausetheduramaybetorn· Thesigni伺canceo「asku∣Ifiactu『eshouIdnotbeunde『﹣ estimated,siⅥceittal《esconside『abIe｛b『ceto什actu『e tlTes∣《uII·Ahnearvaultfractureinconsciouspatients increasesthelikelihoodofanintracranialhemHtoma byabout400thnes. ∣nt『ac『anialLeSions IntracraniallesionsmaybeclassifiedasdiffUseorfb﹣ cal,althoughthesetwofbrmsfrequentlycoexist。

Di什useB『ainln】u『iesDiffUsebraininjuriesrange frommildconcussions’inwhichtheCTscan0fthe headisnormal,toseverehypoxicischemicmjuries. Withaconcussion’thepatienthasatransient’n0nfbcalneurologicdisturbancethato仕enincludesloss ofconsciousness.Severediffhseinjuriesoftenresult fromahypoxic,ischemicinsulttothebrainduetopro﹣ longedshockorapneaoccurringimmediatelyafterthe trauma.Insuchcases,theCTscanmayimtiaⅡyappearnormal,orthebrainmayappeardiffhselyswol﹣

＼

len’withlossofthenormalgray﹣whitedistinction. AnotherdiffUsepattern’oftenseeninhigh﹣veloci叮 impactordecelerationmjuries’mayproducemultiple punctatehemorrhagesthroughoutthecerebralhemi﹣ spheres’whichareoftenseenintheborderbetween thegraymatterandwhitematter.These（‘shearingin﹣ juries,’’refbrredtoasdiffhseaxonalinjmy（DAI）’have definedaclimcalsyndromeofseverebraininju】ywith variablebutoitenpooroutcome. FocaIB『ainIn】u『ieSFocallesionsincludeepidural hematomas’subduralhemat0mas’contusions’andin﹣ tracerebralhematomas（■FIGuRE6﹣7）. 陬〕面dαγα』Hb〃2α加刃】αsEpiduralhematomasare relativelyuncommon,occurringinab0ut0.5﹪of patientswithbraininjuriesandin9℅ofpatientswith TBIwhoarecomatose.Thesehematomasb／picaⅡy becomebiconvexorlenticularinshapeasth叮push theadherentduraawayfiyomtheinnertableofthe skull.Theyaremostoftenlocatedinthetemporalor temporoparietalreg1onandoftenresultiromatearof themiddlemeningealarteryastheresUltofafTacture. Theseclotsareclassicallyarterialmorigin;however, theyalsomayresulthomdisruptionofam勻orvenous sinusorbleedingfromaskullhacture.Alucidinterval betweentimeoflnjuryandneurologicdeteriorationis theclassicpresentationofanepiduralhematoma. S叨bαMγαJHb加αfomαsSubduralhematomH屬 aremorecommonthanepiduralhemat0mas,occurringinapproximately30℅ofpatientswithsevere braininjuries.TheyoftendevelopfTomtheshearmgof smallsurfaceorbridgingbloodvesselsofthecerebral cortex·Incontrasttothelenticularshapeofanepi﹣ duralhematomaonaCTscan’subduralhematomas moreoftenappeartoconfbrmtothecontoursofthe brain.Braindamageunderlyinganacutesubdural hematomaistypicallymuchmoreseverethanthat ass0ciatedwithepiduralhematomasduetothepresenceofconcomitantparenchymali叮my· CO刃fⅢs面o〃sαⅦdI加fγαceγeb7αJHemαfo加αs Cerebralcontusionsarefhirlycommon（presentin approximately20℅to30℅0fseverebraini叼uries）. Themajori叮ofcontusions0ccurinthefrontaland temporallobes’althoughtheymayoccurinanypart ofthebrain.Contusionsmay’inaperiodofhours ordays,evolvetofbrmanintracerebralhematoma oracoalescentc0ntusionwithenoughmasseffbctto requireimmediatesurgicalevacuation.Thisoccursin asmanyas20℅ofpatientspresentingwithcontusions onimtialCTscanofthehead.Fo『this『easoh,patients withcontusionsgene『a∣Iyuhde『go『epeatCTscahning toevaIuate｛b『chahgesinthepattemo「ihiu『ywithin24 lTou『so「theinitiaIscan.

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158CHAPTER6■HeadT「auma

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ManagementofMino『B『ainIniu『y （GCSSco『e13-15） ＿

Minortraumaticbrainimury（MTBI）isdefinedbya historyofdisorientation’amnesia,ortransientlossof consciousnessinapatientwhoisconsciousandtalk﹣ ing·ThiscorrelateswithaGCSscorebetween13and 15·Thehistoryofabriefl0ssofconsci0usnesscanbe difficulttoconfirm’andthepictureoftenisconfbund﹣ edbyalcoholorotherintoxicants.Howeve『,aIte『atiohs ihmeⅡtaIstatusmustneve『beasc『ibedtoconfbundiⅡg 伯cto『suntilb『ainihiuⅣcaⅡbede伽itivelyexcluded.The managementofpatientswithmmorbraininjuryisde﹣ scribedin■「IGuRE6﹣8. Mostpatientswithminorbraininju1ymakeune﹦ venth1lrecoveries.Approximately3﹪haveunexpected deterioration’potentiallyresultinginsevereneuro﹣ logicdyshmctionunlessthedeclineinmentalstatus isdetectedearly· Thesecondarysurveyisparticularlyimportantin evaluatingpatientswithMTBI.Notethemechanism ofi叮ury’withparticularattentiontoanylossofcon﹣ sciousness,includingthelengthoftimethepatient wasunresponsive’anyseizureactivity’andthesub﹣ sequentlevelofa1ertness·Determinetheduration ofamnesiabothbefbre（retrograde）andaiter（ante﹣ grade）thetraumaticincident.Serialexamination anddocumentationoftheGCSscoreisimportantin allpatientswithaGCSscore＜15.CTscanningis theprefbrredmethodofimagmg.ACTscaⅡshouldbe obtainediⅡalIpatieⅡtswithsuspectedb『aininiu『ywho haveacIihicaIlysuspectedopeⅡs∣《uI∣什actu『e,anysign o「basiIa『sl《uII冊actⅡ『e,mo『ethahtwoepisodesofvomit. ing’o『ihpatieⅡtswhoa『eoIde『than65yea『s（Table63）. CTshouldalsobeconsideredifthepatienthashada lossofconsciousnessfbrlongerthan5minutes,retro﹣ gradeamnesiafbrlongerthan30minutes,adanger﹣

■TABlE6·3!Ⅱdi叵atioⅢsfo『CTScaⅢⅢmgMT8l

pea『neu『oIogicallyno『maIbutcontinuetobesymp﹣ tomaticfo「sometime.Besu『ethatthe5epatients av0idanyunnecessa『y「iskofa〃5econdimpact〃du『ing thesymptomaticpe「iodthatcouId「esu∣tindevastat﹣ ingb『ainedema’Emphasizetheneedfo「competent foIIow-upandcIea『ancebefo『e『esumingno「maI activities’especia∣Iycontactspo「ts.

ousmechamsmofinjury’severeheadaches’orafbcal neurologicdeficitattributabletothebrain. ApplyingtheseparameterstopatientswithaGCS scoreof13’approximately25﹪wⅢhaveaCTfinding indicativeoftrauma’and1.3℅willreqUireneurosurg1﹣ calintervention.ApplyingthistopatientswithaGCS scoreof15’10℅willhaveCTfindingsindicativeof trauma,and0.5℅willrequ】reneurosurgicalinterven﹣ tion.Basedoncurrentbestevidence,nopatientwith clinical】ysignificantbraininjuryorreqUiringneuro﹦ surgicalinterventionwillbemissed· ObtaiⅡihgCTscahsshouIdhotdelayt『ahs佗『o「the patient. IfabnormalitiesareobservedontheCTscan’orif thepatientremamsSymptomaticorcontinuestohave neurologicabnormalities,heorsheshouldbeadmitted tothehospital,andaneurosurgeonshouldbeconsulted. IfpatientsareaSymptomatic’arefhl】yawakeand alert’andhavenoneurologicabnormalities,theymay beobservedfbrseveralhours’reexamined,and’ifstill normal,safblydischarged.Ideally,thepatientisdis﹣ chargedtothecareofacompanionwhocanobserve thepatientcontinuallyoverthesubsequent24hours. Aninstructionsheetdirectsboththepatientandthe companiontocontinueclose0bservationandtoreturn totheEDifthepatientdevelopsheadachesorexpe﹣ riencesadeclineinmentalstatus0rfbcalneurologic deficits.Inallcases,writtendischargemstructions shouldbesuppliedtoandcarefhllyrev1ewedwiththe

,乳灘﹩嚨 緻 鱟 筑 、 ’

HeadCTis『equi『edfo『patient5withmino『headin】u『ieS（i.e’witnessedIosso↑consciousness’definiteamne5Ial o『witnesseddiso『ientationinapatientwithaGCSsc0「e0f13＝l5）andanyoneofthe↑oIlowingfacto『s: Ⅱigh『iskfo『neu『osu『gicaIinte『vention oGCSsc0『e∣essthan】5atZhou『5afte「In】u「y ●Su5peCtedopeno『dep「essedskuI∣f『actu『e 。Any5∣gno↑basiIa「sku∣lf「actu『e（e·g.’hemotympanum! 『accooneye5〃C5「0t0『『heao「『hn i 0『『hea’BattIe’ssg i n） oVomiting（m0『ethantwoepis0des） oAgemo『ethan65yea『s

Mode『ate『iSI《fo『b『aininiu『yonCT ·Lossofconsciousness（mo『ethan5minutes） ·Amnesiabefo『eimpact（mo「ethan30minutes） ·Dange「ousmechanI5m（e.g.’pedest『ianst『uckbym0to「vehicIe’ occupanteiectedf『ommoto『vehicIe’falIf『omheightmo『ethan3 feeto『↑v i esta『 i s）

Adaptedf「omStieⅡ∣G’Wel∣5GAVandeml】een∣﹤’eta∣.TheCanadianCTHeadRulefo『patient5withmino『headiniu「ylancetZ00】;357;】Z94

MANAGEMENTOFMINORBRAlNlNjURY（GCSSCORE13－15）

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■F∣GURE6﹣8AIg0「ithmfo『ManagementofMin0「B「ainIn】u『y. （Adaptedwtihpe『msiso i n↑『omVa∣adkaA8’Ⅱa『ayanRK:Eme『gen〔y『oommanagementofthehead﹣n iu i 「ed pae tint∣ . nN : a『ayanRK’Wb Il e「ge『」E’pov5ilhod﹤』T’（ed5） . Wbu『ot佃umaN . ewYo『k’『＼』YM : cG『aw﹣H∣ i M996） .

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159

160CHAPTER6■HeadT「auma

patientand／orcompanion（■FlGuRE6﹣9）.Ifthepatient isnotalertororientedenoughtoclearlyunderstand thewrittenandverbalinstructions.thedecisionibr disChargeshoUldbereconsidered.

ManagementofMode『ateB『aiⅢ IⅢu i『 『 yy（ GG CC SSScSo e9 121） （ c『 o『 e＿ 9＿ Z Approximately15﹪ofpatientswithbraininjurywho areseenintheEDhaveamoderatemjmy.Theystill areabletofbll0wsimplec0mmands’butusuaⅡyare confbsedorsomnolentandcanhavefbcalneurologic deficitssuchashemiparesis.Approximately10℅to

20℅ofthesepatientsdeteriorateandlapseintocoma. Forthisreason,serialneurologicexaminationsare criticalinthetreatmentofthesepatients. Themanagementofpatientswithmoderatebrain injuryisdescribedm■FlGuRE6﹣10. OnadmissiontotheED,abriefhistoryisobtained’ andcardiopulmona1ystabilityisensuredbefbreneuro﹣ logicassessment.ACTscanoftheheadisobtained’and aneurosurgeoniscontacted.AⅡofthesepatientsrequ1re admissionfbrObservationmanintensivecareunit（ICU） orasimⅡarumtcapableofclosenursmgobservationand fTequentneurologicreassessmentfbratleastthehrst12 to24hours.AfbⅡow﹣upCTscanwithin24hoursisrec. ommendediftheimtialCTscanisabnormalorifthereis deteriorationofthepatient’sneurologicstatus.

MiIdⅣaumatiCB『a洫!hju『y Wa『hihgDischa『ge!nst『uctioⅡs PatientI＼lame

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Wehavefoundnoevidencetoindicatethatyou「headinju『ywasse『ious. HoweveI〕newsymptomsandunexpectedcomp【icationscandeve【ophou『s o「evendaysafte『theinju『ybThefi『stZ4hou「sa『ethemostc「ucia【and youshou【d『emainwitha「e【iab【ecompanionat【eastdu「ingthispe「iod. Ifanyofthef0I【owingsignsdeve【op’ca【【you「docto「o「comebacI《tothe hospitaI.

■FlGURE6﹣9ExampleofHead ∣nju『yWa『ningDi5cha『ge Inst『uctions.

ⅢDlDwsinesso「inc「eαsingdi〃icu【tyinαwαken『ngpαt『ent 囚Nαuseαo「vomti『ng 回Convu【so i nso「／tis 圃B【eedingo「wotelydminαgehbmthenoseo「2α「 回5eve「eheαdαches 回雌αknesso「【osso／／be【『ng『ntheα「mo「【eg 固Co㎡usiono「stIungebehαvio「 圃OnepupⅡ（b【αckpα「to／eye）much【αg l e「thαntheothe「;pecu【α i「 mov臼mentsO／theeyes’doub【evsio j n’o「othe「vsiuα【dsitu「bαnces 回Ave「ys【owo「ve「y「dpd i pu【se’o「αnunusuα【b「eαthn i gpαte「n lfthe『eissweIIingatthesiteoftheinju『y》app【yanicepacI《’makingsu『e thatthe「ei5acIotho『towe【betweentheicepacl《andthesl《in.lf swe【【inginc『easesma『l《ed【yinspiteoftheicepacl《app【ication’ca【【uso「 comebacI《t0thehospita【· γbumayeato「d「inkasusua【ifyousodesi『e.HoweveI;youshou【dN0T d『inI《a【coho【icbeve『agesfo「at｛east3daysafte「you「inju『yb DonottaI《eanysedativeso「anypain『e【ieve「sst「onge『than acetaminophen’atIeastfo「thefi『stZ4hou「s.Donotuseaspi「in﹣ containingmedicines. ∣fyouhaveanyfu「the『questions’o『incaseofeme『gency）wecanbe 「eachedat:﹤te【ephonenumbe「＞ physician’sSignatu「e

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MANAGEMENTOFMODERATEBRAlNINjURY（GCSSC0RE9＝1Z）161

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Patientswithmode「ateb「ainin】u『ycanhave「apid dete『io『ationwithhypoventiIationo「asubtIeIoss ofthei「abilitytop「otectthei「ai「wayf『omdecIining mentaI5tatu5.Na「coticanaIgesicsmustbeusedwith cauti0n.Avoidhype「capniawithcIosemonito『ingo↑ 『e5pi『ato『ystatusandtheabi∣ityofpatientstoman﹣ agethei『ai「way.U「gentintubationmaybecomea necessityunde『theseci『cumstances.

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·lfthepatientstops fo【【owingsimp【e commands’「epeat CTscanandmanage pe「se「ve「eb「ain injuIyp『otoco【

■「IGURE6﹣10AIgo『ithmfo『Managementof Mode『ateB『ainln】u『yb （Adaptedwtihpe『msiso i n↑「omVaa I dkaABⅡⅡa『ayanRk:Eme『gency『oom managemento『theheadn .i】u『edpae ti nt.∣n:Ⅱa「ayanR∣《’Wb Ii e『ge『」E’ Pov∣5 i hock」T’（ed5）’咋um岫uma＼ .I e l wYo『【’W I :MCG『aw.H’ Ii 9 I 96.）

∣

Approximately10℅ofpatientswithbraininjurywho aretreatedintheEDhaveaseverebrainmjury.Pa﹣ tientswhohavesustainedaseverebrainmjuryare unabletofbⅡowsimplecommands,evenaltercardi﹣ opulmonarystabilization.Althoughthisdefimtion includesawidespectrumofbraininjury’itidentifies thepatientswhoareatgreatestriskofsuffbringsig﹣ nificantmorbidityandmortalilyA‘‘waitandsee”ap﹣ proachinsuchpatientscanbedisastrous’andprompt diagnosisandtreatmentareextremelyimportant.Do hotdelaypatientt『aⅡsfb『toobtaiⅡaCTscah· Theinitialmanagementofseverebraininjuryis out】inedin■FIGURE6﹣11.

Definition:PatientisunabIetofb∣【oweven5imp【e commandsbecauseofimpai「edconsciousness （GCSSco「e3﹣8） ■F』GURE6﹣11Algo『ithm fo『lnitiaIManagementof

ASSeSSmentandmanagement

Seve『eB『ain∣n】u『yb

·ABCDEs·Neu『o【ogic『eeva【uation: 。p『ima「ysu『veyand「esuscitation·GCS 。Seconda『ysu「veyandA川PLE一Eyeopening h i s t o 『 y ＿ M o t o 『 『 e s p o n s e 。Admittoafaci【itycapab【eof-Ve『ba【『esponse definitiveneu「osu「gica【ca「e。pupi【【aIy【ight『esponse ·The「apeuticagents（usua【【y·Foca【neu『o【ogicexam administe「edafte「consu【tation withneu「osu「geon） －川annito【 一川ode「atehypeIventi【ation（PCOZ3Z-35mmHg） ＿Hype「tonicsa【ine

（Adaptedwtihpe『m5 i so i n『「om Vaa I dkaAB‘Na『ayanR∣﹤:Eme『gency 『00mmanagementofthehead﹦inlu「ed pae ti nt’∣n;Ⅱa『ayanR∣﹤’Wb Ii e『ge『」Ei pov5 il h0ck」T’（ed5）.川eu／o”um己＼ l e lw Yo『k’NY:McG『aw﹣H’ li 】996·）

＼

」少

I

﹀

CTscan

l

16ZCHAPTER6■HeadT「auma

PRIMARγS0RVEγAⅡDRESUSαTATI0N

Ci『cu∣ation

Braininjmyoftenisadverselyaffbctedbysecondary insults.Themortalityratefbrpatientswithsevere braininjurywhohavehypotensiononadmissionis morethandoublethatofpatientswhodonothave hypotension.Thepresenceofhypoxiainadditionto hypotensionisassociatedwithanincreaseintherela﹣ tiveriskofmortalityof75℅.The『efb『e,itisimpe『ative thatca『diopulmona『ystabiIizationbeachieved『apidIyin patientswithseve『eb『aininiu『y.SeeBox6·zfb『tl】ep『io「. itiesoftheinitiaIevaIuationandt『iageo「patientswithse. ve『eb『aihiniu『ies.SeeSkillStationX:HeadandNeck

HypotensionusuaIIyisnotduetotheb『ainihluIyitseIf exceptinthete『minaIstageswhehmedulIa『yfaiIu『esu﹣

Trauma:AssessmentandManagement,SkillX﹣A;Pri﹣ marySurvey’andSkillX﹣D:HelmetRemoval·

Ai『wayandB『eathing Transientrespiratoryarrestandhypoxiaarecom﹣ monwithseverebraininjuryandmaycausesecond﹣ a1ybrainmjmy.Ea『Iyehdot『acheaIihtubationshouIdbe pe『｛b『medincomatosepatients· Thepatientshouldbeventilatedwith100℅o汀﹣ genuntilbloodgasmeasurementsareobtained,after whichappropriateadjustmentstothefTactionof inspiredoXygen（FIO2）aremade.Pulseoximetryisa usefnladjunct,andoxygensaturationsof＞98℅are desirable.Ventilationparametersaresettomaintain aP0O2ofapproximately35mmHg.Hyperventila﹣ tion（PCO2＜32mmHg）shouldbeusedcautiouslym patientswithseverebraininjuryandonlywhenacute neurologicdeteriorationhasoccurred.

pe『veneso『the『eisa∞hcomitantspinaIco『diⅡ】u『y. Intracranialhemorrhagecannotcausehemorrhagic shockEuvolemiashouldbeestablishedassoonaspos﹣ sibleifthepatientishypotensive,usingbloodprod﹣ ucts,wholeblood’orisotonicfluids’asneeded· Itmustbeemphasizedthattheneurologicexami﹣ nationofpatientswithhypotensionisunreliable· Patientswithhypotensionwhoareunresponsiveto anyfbrmofstimulationmayrecoverandsubstan﹣ tiallyimprovesoonafternormalbloodpressureis restored.Theprimarysourceofthehypotensionmust beurgentlysoughtandtreated.

Ⅱeu『oIogicExamination

叨 W iα j 〃sα／bc豳se伽e叨淤oJogtcα』 ●e㎡α加加α觔O几? Asso0nasthepatient,scardiopulmonarystatusis managed’arapidanddirected（fbcused）neurologic examinationisperfbrmed·Itconsistsprimarilyofde﹣ terminingtheGCSscore,pupillarylightresponse’and fbcalneurologicaldeficit. Itisimportanttorecognizeconfbundingissuesin theevaluationofTBI,includingthepresenceofdrugs’ alcohol,intoxicants’andothermjuries.Donotover. lookaseverebraininjurybecausethepatientisalso intoxicated.

∣

■■

Box6﹄2p『io『ities『o『theInitiaIEvaluationandT『iage p t e n ts o『 『 □a ■ 一 ■ ■ ■

W

■ ■ ■ ■

t h

Seve『eB『an i In】Ⅲe is

↑.AI∣〔0mato5epate i nt5wtihb『an in iu l 『e i 55h0u∣dunde『g0『e﹣ 5u5dtati0n（A8C0Es）0na『『iva∣IntheED.

h0Ies0『〔『ani0t0mymaybeunde『takeniⅡthe0Rwhilethe （eI0 i t0my5 i ben i gpe『↑0『med

Z·Ass00nasthebl00dp『essu『e（8p）isn0『ma∣ized〃aneu『0﹣ 0 l g〔 i exam5 i pe『↑0『med（GCS5c0「eandpupa lI 『y『eact0 i n） I↑theBpcann0tben0『maIizedltheneu『0l0gicexaminati0n I5stI∣pe『↑0「meda l ndthehyp0tens0 i n『ec0「ded’

4.Ilthepatient!55yst0lic8Pi5＞l00mmⅡga↑te「『e5uscitati0n andt∣）epate i nthasc∣Ⅱ i c i ae l vd i en〔e0↑ap055b i ∣en i t『a〔『ana i∣ ma5s（unequa∣pup∣ i sa l 5ymmet『c i 『esuIts0nm0t0『exam）﹟the ↑i『5tp『i0『ityist00btainaC「headscan·ADP【0「「ASTexam maybepe『↑0『medintheEDiCTa『ea!0「0Rlbutthepatientls Ⅱeu「0∣0g〔 i eva∣uat0 i n0『t『eatmeⅡt5h0ud I n0tbede∣ayed·

3.I↑thepatient’55y5t0lic8pcann0tbeb『0ughtupt0＞l00mm Hgithep「i0『∣tyi5t0estab∣ishthe〔au5e0｛thehyp0tensi0n’ withtheneu「0su『gicaleva∣uati0ntakingsec0ndp『i0『ity·ln 5u〔h〔a5e5lthepatientunde『g0esadiagn05ticpe『it0nea∣ lavage（Dp【）0『u∣t『as0undintheEDandmayneedt0g0 di「eαIγtothe0pe『ating『00m（0R）「0『a∣apa「0t0my·d 5cans0↑theheada『e0btan i eda↑te『thea l pa『0t0my.I↑the『e i5dinicaIevidence0↑anInt『a〔「anialma5s!diagn05ticbu『『 可■

5·lnb0『de「∣inecases-i.e.!whenthesy5t0∣ic8pcanbetem﹣ p0『a『Iiyc0『『ectedbuttendst0s0 l wy l de〔『ea5e－eve『ye付0『t 5h0u∣dbemadet0getahead〔「p『i0『t0takiⅡgthepatient t0the0R↑0『aIapa『0t0my0『th0『a〔0tomy.Su（h〔a5e5caI∣ ↑0『s0undcIini〔alIudgmentand〔00pe「ati0nbetweenthe t『auma5u『ge0nandneu「05u「ge0n.

MEDICALTHERAPIESFORBRAlNINjURY163

Thepostictalstateaiteratraumaticseizurewill勺p﹣ icallyworsenthepatient,sresponsivenessfbrminutes0r hours.h1acomatosepatient,motorresponsesmaybe ehcited叮pmchingthetrapeziusmuscleorwithnailbed orsupraorbitalridgepressure·I「apatientdemonst汨tes va『iabIe『esponsestostimuIation’thebestmoto『『espohse eIicitedisamo『eaccu『atep『ognosticihdicato『thanthe wo『st『espoⅡse.Testingfbrdoll’seyemovements（oculo﹣ cephalic）’thecalorictestwithicewater（oculovestibular）, andtestingofcornealresp0nsesaredefbrredtoaneuro﹣ surgeon.DoIl,seyetestingshouIdneve『beattempteduntiI aceMcaIspineiniu『yhasbeeⅡ『uIedout. Itisimpo『tantto◎btaintheCCSsco『eandtope朮『m apupilIa『yexamiⅡationp『io「tosedatingo『pa『alyzingthe patieht）becausel（nowIedgeofthepatieht,scIinicalcondi. tionisimpo『taht化『dete『miningsubsequentt『eatmeht. Long﹣actingparalyticandsedatingagentsshouldn0t beusedduringtheprima1ysurv叮.Sedationshould beavoidedexceptwhenapatient,sagitatedstatecould

themidline（masseffbct）andobliterationofthebasal cisterns（seeFigure6﹣7）.Ashiftof5mmo『g『eate『is oftenindicativeo「theneed｛b『su『ge『ytoevacuatethe bloodcIoto『cohtusioncausingtheshiR.SeeChapter7: SpineandSpinalCordTraumafbrrelevancetospine’ andthediscussionofbasilarskullfracture’above’fbr relevancetocranialinjury. Cautionsh0uldbeappliedinassessingpatients withTBIwhoareanticoagulatedoronantiplatelet therapy.Theinternationalnormalizedratio（INR） shouldbeobtainedandaCTshouldbeperfbrmed expeditiouslyinthesepatientswhenindicated·Rapid normalizationofanticoagulationisthegeneralrule· Table6·4providesanoverviewofthemanagement ofTBI.

P I T F A LL Evenpatientswithappa『entlydevastatingTBIonp『e﹣ sentati0nmayhave5ignificantneu『oI0gic『ecove『y· Vigo「ou5managementandimp『ovedunde『standing ofthepathophy5ioIogyofseve「eheadin】u『Ⅱe5pe﹣ ciaIIythe『oIeofhypotension’hypoxia’andce『eb『aI

placehimorheratrisk.Theshortest﹣actingagents availablearerecommendedwhenpharmacologicparal﹣ ysisorbriefsedationisnecessaryfbrsafbendotracheal intubationor0btaininggoodqualitydiagnosticstudies.

pe「fusion’havemadeasignificantimpactonpatient outcome5·

SEC0ⅡDARγSURVEγ Serialexaminations（e·g·,GCSscore,lateralization, andpupⅢaryreaction）shouldbeperfbrmedtodetect neurologicdeteriorationasearlyaspossible.AweⅡknownear】ysignoftemporallobe（uncal）herniationis dilationofthepupilandlossofthepupilla1yresp0nse tohght·Directtraumatotheeyealsoisapotentia1 causeofabnormalpupilla1yresponseandmaymake

』 ■

SceⅡa『io■contfnuedThepatient!5 abd0m∣naI〔Tscandidn0tsh0wanyinlu『y.Due t0hiSint「aC「aniaIleSi0nanddete『i0『ati0nin GCSsc0「e!heistakent0the0pe『ating『00m↑0『 Ⅱ『gentdec0mp『e55i0n0｛hissubdu『aIhemat0ma

pupilevaluati0ndifficult·However,inthesetting0f braintrauma’braininjuryshouldbeconsideredfirst. SeeSkiIlStationX:HeadandNeckTrauma?Assess﹣ mentandManagement, SkillX﹣B:SecondarySurv叮

andManagement.

DlAGⅡ0STICPR0CEDURES AheadCTscanmustbe0btainedassoonaspossible afterhemodynamicnormalization·CTscanningalso shouldberepeatedwheneverthereisachangeinthe patient,sclinicalstatusandroutinelywithin24h0urs afterinjuryfbrpatientswithacontusionorhemat0ma ontheinitialscan.SeeSkillStationX:HeadandNeck

Trauma:AssessmentandManagement , S k i Ⅱ X ﹣ C Evah】RtionofCTScansoftheHead FindingsofsignificanceontheCTimagesinclude scalpsweⅡmgandsubgalealhematomasatthereg1on ofimpact.Skullfracturesmaybeseenbetterwith bonewindows’butareoftenapparentevenonthe

soft﹣tissuewindows.ThecrucialfindingsontheCT scanareintracranialhematoma’contusions,shiftof

∣

■■■■■

l he『ape i sfo『B『an i ∣nu i 『y ∣ ﹥ Vl Iedci a『 Theprimaryaimofintensivecareprot0colsistopre﹣ ventseconda1ydamagetoanalreadyinjuredbrain.The basicp『incipleisthati「iniu『edneu『altissueisp『ovided anoptimaImi∣ieuinwhichto『ecove『’itmay『ecove『and 『egainno『maIfi』nction·Medicaltherapiesfbrbrainin﹣ juryincludeintravenousfluids,temporaryhyperventi﹣ lation,mannitol,hypertomcsaline,barbiturates’and Hn﹠iconⅥ】I醞hts.

IⅡTRAVEⅡ0US『lU∣DS Intravenousfluids》blood’andbloodproductsshould beadmimsteredasrequiredtoresuscitatethepatient

164CHAPTER6■HeadT「auma

■叭BLE6.』MaⅡageme㎡Ove『viewo仃『aⅡmaticB『a『n!hiu『y AUPATIEⅡTS:PERF0RMABCDEsWlTⅡSPECIA【ATTENTI0ⅡT0Hγp0XIAANDⅡγp0TEⅡS∣0Ⅱ

GCS ClASSIF∣CATl0Ⅱ

13-15 ⅢllDTRAUⅢA『IC BRAIMⅡ』0Rγ Maydischa『geifadmis﹣ sionc「ite『ianotmet

∣ntia∣ Management

Admitfo『Indications beIow:

＊AMPLEhist0『yandneu『oIogicaIexam

Dete「minemeChanISm↓ time0fInlu『y’Initia∣GCS〃 confusion’amnesticin﹣ teⅣaI’seizu「e’headache 5eve『ity’etc. 索Seconda『ySu『veyindud﹣

N0CTavaiIabIe’CTab﹣ no『maI’5ku↑ Il 『actu『e’ CSF∣eak FocaIneu「0logicdefidt GCSd0esnot『etumto ↑5within2h0u「s

9＝1z M0DERATETMUMATI〔 BRAIⅡIN川Rγ

3－8 SEVERETRAUMA『I〔 BRAlⅡIⅡ」URγ

Neu『osu『ge『yevaIuati0n 『equ『 i ed

U『gentneu『0su『ge『y Consu∣tation「equi「ed

＊P「ima「ysu『veyand

＊P『ima『ysuⅣeyand

『esuscitation 熊A「『ange↑o『t「an5fe『to definitiveneu『oSu「gica! evaluationandmanage﹣ ment 鸞F0cu5edneu「ologica∣ exam ＊Se〔ondaⅣ5uⅣeyand

ingfocusedneu『ologIcaI exam

AMPLEhistoⅣ

「esuscitation ＊∣ntubationandventiIa﹣ tionfo『ai「wayp「otec﹣ ti0n ＊T「eathypoten5ion〃hy﹣ povolemiaandhypoxia ＊「0cuSedneu「ologica∣ exam

＊Sec0nda『ysuⅣeyand AMP【EhiSto『y

Diagnostic

＊CTScanningaSdete『minedbyheadCT「u∣es （TabIe6.3） 燾B∣ood／U『ineEtOHand

CTnotavaIlabIe’CTab﹣ no『mal『5kulIf「a﹤tu『e Signi↑icantlntoxication （admito『obseⅣe）

toxiC0IogySC『eens 5econda『y Management

豫CTscaninalI〔ases

＊CT5CanIna∣Icases

澱EvaIuateCa「efu∣∣yf0「

＊Eva∣uateca『efuy I ↑o『

othe『iniu『ie5 ☆Typeandc『0ss’coagu∣a﹣

othe『inlu「ies 蓑Typeandc「os5’c0agu∣a﹣

ti0nstudieS

tionstudies

★5e「ialexaminati0nsuntil

＊pe㎡o『m5e『IaIexamina﹣

★Se『ia∣exams

＊F「equentse『ialneu『o﹣

GCSisI5andpatient hasnope「seve「ationo「 memo「yde『icit 蟲RuIeoutindication↑o「

tionS ☆Pe『fo「m↑olIow﹣upCT

☆Conside『foI∣ow﹣upCT

∣0gicaIexaminations withGC5 ★PCoz3S﹢／巳3

CT（Table63）

in↑Z＝18h

scaniffi『stisabno『maI o『GCS『emainsIes5 than15 辦RepeatCTifneu『ologi﹣

★∣VIannitoI〃pCqZ8﹣32 fO『dete『i0「ation ＊AvoidPCO2＜Z8

ca∣examdete『io『ateS

鴦Add「eSSn i t『aC『ana i∣ ∣e5ionsapp『op「iately

Disposition

＊Homeifpatientd0es notmeetc『ite『iaf0「 admission ＊Discha『gewithhead in】u『ywa『ningsheetand foll0w﹣upa『『anged

Obtainneu『osu『gical evaIuationifCTo『neu『o﹣ ∣ogC i aIexam∣5abn0『ma∣ o「patientdete『i0『ates ＊A『「angefo「medc i a∣ folIow﹣upandneu「opsy﹣ chologiCaIeva∣uationas 『equi「ed（maybed0ne asoutpatient）

＊RepeatCTimmediate∣y

＊T『ans↑e『ass0onaspos﹣

fo「dete『lo「ationand manageasIn5eve『e b「an in i 】u『y（10℅） ☆Discha『gewithmedical

sib∣et0de↑initiveneu『o﹣ su『giCaIca『e

andneu『op5ychoI0gi﹣ ca∣foIow﹣upa『『anged whenstableGCS（90℅）

☆A5te『iskdenote5action『equi『ed

andmaintainnormovolemia·Hypovolemiainthesepa. tientsisha『mfi』I·Careshouldalsobetakennottoover﹣ loadthepatientwithfluids’Hypotonicfluidsshould notbeused.Furthermore,theuseofglucose﹣contain﹣ ingfluidsmayresultinhyperglycemia’whichhasbeen showntobeharmh1ltothei叮uredbrain.Therefbre, itisrecommendedRinger’slactatesolutionornormal salinebeusedhrresuscitation.Serumsodh】mlevels

needtobeverycarefUllymonitoredinpatientswith headinjuries.Hyponatremiaisassociatedwithbrain edemaandshouldbeprevented.

ⅡγPERVENTIlATI0Ⅱ Inmostpatients,normocarbiaisprefb1Ted·Hyperven﹣ tilationactsbyreducingPaCO2andcausingcerebral

SURGICALMANAGEMENT165

vasoconstriction.Aggressiveandprolongedhyperven﹣ tilationmaypromotecerebralischemiainthealready injuredbrainbycausingseverecerebralvasoconstric﹣ tionandthusimpairedcerebralperfnsion.Thisispar﹣ ticularlytrueifthePaCO2isallowedtofallbelow30 mmHg（4.0kPa）.However’hypercarbia（PCO2＞45 mmHg）wiⅡpromotevasodilationandincreaseintra﹣ cranialpressure,andthusitshouldbeavoided. HypeⅣenti∣ationshouIdbeusedon!yinmode『ation andfb『asIimitedape『iodaspossibIe.Ingeneral,itis prefbrabletokeepthePaCO,atapproximately35mm Hg（4·7kPa）,thelowendofthenormalrange（35mm Hgto45mmHg）.Briefperiodsofhyperventilation （PaCO,of25to30mmHg〔3.3to4.7kPa】）maybe necessaryfbracuteneurologicdeteriorationwhile othertreatmentsareinitiated.Hyperventilationwill lowerICPinadeterioratingpatientwithexpanding intracranialhematomauntⅡemergentcraniotomycan beperfbrmed. ∞

MAⅡⅡIT0【 MannitolisusedtoreduceelevatedICP.Theprepara﹣ tionmostcommonlyusedisa20℅solution（20gof mannitolper100mlsolution）.Mannitolshouldnot begiventopatientswithhypotension’becausemannitoldoesnotlowerICPmhypovolemiaandisapotent osmoticdiuretic.Thiscanfhrtherexacerbatehypotensionandcerebralischemia.Acuteneurologicdete﹣ rioration’suchasthedevelopmentofadilatedpupⅡ’ hemiparesis,orlossofconsciousnesswhilethepatient isbeingobserved’isastrongindicationfbradmimster﹣ ingmanmtolinaeuvolemicpatient.Inthissetting’a bolusofmannitol（1g／kg）shouldbegivenrapidly（over 5minutes）andthepatienttransportedimmediatelyto theCTscannerordirectlytotheoperatingro0mifa causativesurgicallesionisalreadyidentified·

ⅡγpERT0ⅡICSAUⅡE

IDpertonicsalineisalsousedtoreduceelevatedICP. Concentrationsof3℅to234℅areused’andthismay betheprefbrableagenttouseinpatientswithhypo﹣ tension’asitdoesnotactasadiuretic·However’there isnodiffbrencebetweenmannitolandhypertonicsa﹣ lineinloweringICP,andneitherwⅡladequatelylower ICPinhypovolemicpatients.

BARB∣TURATES BarbituratesareeffbctiveinreducingICPrefractoryto othermeasures·Theyshouldnotbeusedinthepres﹣ enceofhypotensionorhypovolemia.Furthermore’ hypotensionoftenresultsfromtheiruse.Therefbre’ barbituratesarenotindicatedintheacuteresus（Yita﹣

tivephase.Thelonghalfklifbofmostbarbiturateswill alsoprolongthetimetobraindeathdetermination,a considerationinpatientswithdevastatingandlikely nonsurvivablemjuIy.

ANTlC0ⅡVU【SAⅡTS Posttraumaticepilepsyoccursinabout5﹪ofpatients admittedtothehospitalwithclosedheadinjuriesand in15℅ofindividualswithsevereheadinjuries·Three mainfhctorslinkedtoahighincidenceoflateepilepsy areseizuresoccurringwithinthefirstweek’anintra﹣ cranialhematoma’andadepressedskullfracture. Acuteseizuresmaybecontr0lledwithanticonvulsants, butearlyantic0nvulsantusedoesnotchangelong﹄ termtraumaticseizureoutcome.AnticohvuIsantsmay alsoinhibitb『ain『ecove『y,sotheyshouldbeusedonIy whenabsolutelynecessa『y·Currently,phenytomand fbsphenytoinaretheagentsgenerallyusedinthe acutephase.Foradults’theusualloadingdoseis1g ofphenytoing1venintravenouslyataratenofaster than50m創min.Theusualmaintenancedoseis100 m創8hours’withthedosetitratedtoachievetherapeu﹣ ticserumlevels.Diazepamorlorazepamisfrequently usedinadditiontophenytoinuntiltheseizurestops. Controlofcontinuousse1zuresmayrequiregeneral anesthesia·Itisimperativethatacuteseizuresbecon﹣ trolledassoonasp0ssible,becauseprol0ngedseizures （30to60minutes）maycauseseconda1ybraininjury.

【」 PITFA『』『』S FAL

∣

■ltisimpo「tanttom0nito『theICpifactiveICPm己n﹣ agementi5beingunde「taken·Fo『example『mannitoI mayhaveasignificant『eb0unde什ectonICBand additionaIthe「apie5maybeindicatedifong0ing managementis「equi『ed. ■Itisimpo「tantto『emembe「thatSeizu「esa『enot cont「olIedwithmuscle「eIaxant5.P『oIongedseizu『e5 inapatientwhosemuscIesa『e「eIaxedpha「macolog﹣ icaIIycansti∣Ibedevastatingtob「a∣nfunction!and maygoundiagnosedandunt「eatediftonic﹣clonic mu5cIecont『actionsa「emaskedbyaneu『omuscuIa『 bIocke『suchasvecu『oniumo『succinyIch0Iine.Ina patientwithawitnessedseizu『e’makesu『eapp「o﹣ p『iateantiseizu『ethe『apyi5beinginitiatedandthat theseizu「eisunde『cont『oIbefo『einitiatingneu『o﹣ mu5cuIa「bI0ckadeifataIIpossibIe.

∣P Su 『g∣Ca I Management Surgicalmanagementmaybenecessa1yfbrscalp wounds,depressedSkullfractures’intracramalmass lesi0ns,andpenetratingbraininjuries.

166CHAPTER6■HeadT『auma

SCALpW0UⅡDs Itisimportanttocleanandinspectthewoundthor﹣ oughlybefbresuturing.Themostcommoncauseof infbctedscalpwoundsisinadequatecleansingand debridement.Bloodlossfromscalpwoundsmaybe extensive》especiallyinchildren（■FIGuRE6﹣1z）.Scalp hemorrhageusuallycanbecontrolledbyapplying directpressureandcauterizingorhgatinglargeves﹣ sels.Appropriatesutures,clips’orstaplesmaythen beapplied.Carefhllyinspectthewoundunderdirect visionfbrsignsofaskullhactureorfbreignmaterial· CSFleakageindicatesthatthereisanassociateddural tear.Aneurosurgeonshouldbeconsultedinallcases ofopenordepressedskuⅡfractures.Notinfrequently, asubgalealcollectionofbloodcanfbelhkeaskullfrac﹣ ture.Insuchcases’thepresenceofafracturecanbe confirmedorexcludedbyplainx﹣rayexaminationof thereg1onand／oraCTscan.

DEPRESSEDSl《UⅡ「RACTURES Generally,adepressedskullfTactureneedsoperative elevationifthedegreeofdepressionisgreaterthan thethicknessoftheadjacentskull,orifitisopenand grosslycontaminated·Lesssignificantdepressed丘ac﹣ turescanoftenbemanagedwithclosureoftheoverly﹣ ingscalplaceration’ifpresent·ACTscanisvaluable inidentib『ingthedegreeofdepression,butmoreim﹣ portantlymexcludingthepresenceofanintracrania1 hRmHtomaorcontl1sion.

∣ⅡTRACRAMAlMASSlES∣0NS Intracramalmasslesionsaremanagedbyaneurosur﹣ geon’Ifaneurosurgeonisnotavailableinthefacil﹣

■『!GURE6﹣1ZBloodIos5f『om5caIpwoundsmaybe exten5ive’e5pecialIyinchi∣d『en.

ityimtiallyreceivmgthepatientwithanintracranial masslesion,earlytransfbrtoahospitalwithaneu﹣ rosurgeonisessential·Inve1yexceptionalcircum﹣ stances,arapidlyexpandingintracranialhematoma maybeimminentlylifb﹣threatemngandmaynotallow timefbrtransfbrifneurosurgicalcareissomedistance away.Althoughthiscircumstanceisrareinu1banset﹣ tings’itmayoccurinaustereorremoteareas.Emer﹣ genCycraniotomyinarapidlydeterioratingpatientby anon﹣neurosurgeonshouldbeconsideredonlyinex﹣ tremecircumstances,andtheprocedureshouldbeper﹣ fbrmedbysurgeonsproper】ytrainedintheprocedure onlyafterdiscussionandadviceofaneurosurgeon. Theindicationsfbracramotomyperibrmedbya n0n﹣neurosurgeonarefbw,anditsuseasadesperation maneuverisneitherrecommendednorsupportedby theCommitteeonTrauma.Thisprocedureisjustified onlywhendefinitiveneurosurgicalcareisunavailable. TheC0mmitteeonTraumastron劊yrecommendsthat individualswhoanticipatetheneedfbrthisprocedure receivepropertraimnghomaneurosurgeon·

pEⅡE『RATIⅡGBRA!N∣Ⅱ』URIES CTscanningoftheheadisstronglyrecommendedto evaluatepatientswithpenetratingbrainmjury.Plain radiographsoftheheadcanbehelpfhlinassessing buⅡettr勻ecto1yandfTagmentation’andthepresence oflargefbreignbodiesandintracranialair.However, WhenCTisavailable,plainradiographsarenotes﹣ sential.CTand／orconventionalangiographyisrecom﹣ mendedwithanypenetratingbraininju】V,orwhen atr匈ectorypassesthroughorneartheskullbaseor am可orduralvenoussinus·Substantialsubarach﹣ noidhemorrhageordelayedhematomashouldalso promptconsiderationofvascularimagmg.Patients withapenetratinginju1yinvolvingtheorbitofRcial orpterionalregionsshouldundergoangiographyto identi句atraumaticintracranialaneurysmorarterio﹣ venous（AV）fistula.WhenananeurysmorAVfistula isidentified’surgicalorendovascularmanagementis recommendedMRIcanplayaroleinevaluatingin﹣ juriesfrompenetratingwoodenorothernonmagnetic objects.ThepresenceonCToflargecontusions’he﹣ matomas’orintraventricularhemorrhageisassoci﹣ atedwithincreasedmortality,especiallywhenboth hemispheresareinvolved. Prophylacticbroad-spectrumantibioticsare appropriatefbrpatientswithpenetratingbrainmjmy. EarlyICPmonitoringisrecommendedwhenthecli﹣ nicianisunabletoassesstheneurologicexaminationaccurately’theneedtoevacuateamasslesionis unclear,orimagingstudiessuggestelevatedICP. Itisappropriatetotreatsmallbulletentrance wol】hdstotheheadwithlocalwoundcareandclosure

BRAINDEATH167

inpatientswhosescalpisnotdevitalizedandwhohave nom鉚orintracranialpathology. Ohjectsthatpenetratetheintracranialcompart﹣ mentorinfratemporalfbssaandrema1npartially exteriorized（e.g.,arrows’knives,screwdrivers）must beleftinplaceuntilpossiblevascularinju】yhasbeen evaluatedanddefinitiveneurosurgicalmanagement establishedDisturbingorremovingpenetrating ohjectsprematurelycanleadtofhtalvascularinjuryor intracranialhemorrhage

■GlasgowComaScalescore＝3 ■NonreactivepupⅡs ■Absentbrainstemreflexes（e.g.’oculocephalic’ corneal’andDoⅡ’s叮es’andnogagreflex） ■Nospontane0usventilatoryeffbrtonfbrmal apneatesting AnciⅡarystudiesthatmaybeusedtoconfirmthe diagnosisofbraindeathinclude:

∣

PITFA『J』S Bu「「h0Iec「aniostomy／c「aniotomy＿pIacinga10﹣to﹣ 15﹦mmd「iIIhoIeintheskuII＿hasbeenadvocatedas amethodofeme「gentlydiagno5ingacCessibIehema﹣ toma5inpatientsinauste『eo『「emote「egionswith 『apiddete「io「ationwhenneu「0su「geonsandimag﹣ inga『enot「eadilyavailabIe.Unfo「tunateI叭evenin ve『yexpe「iencedhands’thesed「iIIhoIesa『eeasiIy

Certainreversibleconditions,suchashypother﹣ miaorbarbituratecoma,maymimictheappearance ofbraindeath;therefbre,thisdiagnosisshouldbe consideredonlyafterallphysiologicparametersare normalizedandcentralnervoussystem（CNS）fhnc﹣ tionisnotpotentiaⅡyaffbctedbymedications.The remarkableabilityofchildrentorecoverfromseem﹣ inglydevastatingbraininjuriesshouldbecarefUlly consideredpriortodiagnosingbraindeathinchil﹣ dren.Ifanydoubtexists’especiallyinchildren’multi﹣ pleserialexamsspacedseveralhoursapartareusefhl inconfirmingtheinitialclinicalimpression.Local organ﹣procurementagenciesshouldbenotifiedabout allpatientswiththediagnosisorimpendingdiagnosis ofbraindeathpriortodiscontinuingartificiallifbsup﹣ portmeasures.

Allpatientsshouldbetreatedaggressivelypending consultationwithaneurosurgeon.Thisisparticularly trueofchildren’whohavearemarkableabihtyt0re﹣ coverfTomseeminglydevastatinginjuries.

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pIacedinco「「ectIy｝andtheyseIdom『e5uItind『ain﹣ ingenoughofthehemat0matomakeacIinicaldif﹣ fe『ence.Inpatientswhoneedanevacuation’bone fIapc『aniotomy（andnotasimpIebu『「hoIe）isthe definitiveIife5avingp『ocedu『etodecomp『essthe b「ain’andeve「yattemptshouIdbemadetohave ap「actitione『t『ainedandexpe「iencedindoingthe p『oCedu「epe『f0「mitinatimeIyfashion。

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Thediagnosisofbraindeathimpliesthatthereisno possibilityfbrrecoveryofbrainfUnction.Mostexperts agreethatthefbllowingcriteriashouldbesatisfiedfbr thediagnosis0fbraindeath

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SceⅢa『io■coⅡdⅡ5ioⅡThepatientunder wentsuccess｛uIevacⅡati0n0fhissubdu『aI hemat0maand5ubsequentt『eatment0｛a↑emu『 f『adu『e↑0und0n5ec0nda『ysuⅣeyp05t﹣evacuati0n Hewa5ultimateIydischa『gedt0a『ehabi∣itati0n cente『f0『0ng0Ingphy5icaIi0ccupati0na∣iand 5peechthe『apy·

168CHAPTER6■HeadT「auma

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C h a p t e r S u1nmary ummary ⅢUnderstandingbasicintracranialanatomyandphysiologyisk叮tothemanage﹣ mentofheadi叼ury. 回Learntoevaluatepatientswithheadandbraininjuriesef【iciently.Inacomatose patient,secureandmaintaintheairwaybyendotrachealintubation.Perfbrma neurologicexaminationafternormalizingthebloodpressureandbefbreparalyzingthepatient.Searchfbrassociatedi叼uries. 圖Practiceperfbrmingarapidandfbcusedneurologicexamination.Becomefamiliar withtheGlasgowComaScale（GCS）andpracticeitsuse.FTeqUent】yreassessthe patient’sneur0logicstatus. 囚AdequateresuscitationisimportantinlimitmgsecondarybraininjuIV.Prevent hypovolemiaandhypoxemia.Treatshockaggressivelyandlookfbritscause.Be﹣ suscitatewithRinger,slactatesolution’normalsaline,0rshnⅡarisotonicsolu﹣ tionswithoutdextrose.Donotusehypotomcs0lutions.Thegoalinresuscitating thepatientwithbraininjuriesistopreventseconda1ybraini叮u1V. 回Determinetheneedfbrtransfbr,admission’consultation’ordischarge.Contacta neurosurgeonasearlyaspossible.Ifaneurosurgeonisnotavailableatthefacil﹣ i叮,transfbrallpatientswithmoderateorsevereheadinjuries. －

■8Ⅲ l OGⅢⅡγ 1.AmhjamshidiA’AbbassiounK,BahmatHMinimal debridementorsimplewoundclosureastheonlysurgicaltreatmentmwarvictimswithlow﹣velocitypenetra﹣ tingheadinjuries.Indicationsandmanagementprotocol baseduponmorethan8years’fbllow﹣upof99cases fTomIran﹣Iraqconflict.Sα唔Ⅳ﹫mD／2003;60（2）,105﹦110; discussion110-111. 2.AndrewsBT’ChⅡesBW,OlsenWL’etal.Theeffbctof intra﹣cerebralhematomalocationontheriskofbrain﹣ stemcompressionandonclinicaloutcome.JⅣbM／Dsα／g 1988;69:518.522‘ 3.AtkinsonJLD.Theneglectedprehospitalphaseofhead injury:apneaandcatecholaminesurge.MtU／oα加P）Dc 2000,75（1）:37﹣47. 4.AubryM,CantuR,DvorakJ’etal.Summaryandagree﹣ mentstatementofthehrstInternationalConibrence onConcussioninSport’Ⅵenna2001.PhjsSpo／、／s﹣ med2002;30:57﹣62（copubhshedinB／.J印o㎡sM它d 2002;36:3﹣7andα加J助o㎡Mbd2002,12:6﹣12）

5.BoyleA,SantariusL’MaimarisCEva1uationofthe impactoftheCanadianCTheadruleonBritishpractice. EJ九e唔MbdJ2004;21（4）;426﹣428. 6.BrainTraumaFoundation.Earlyh1dicatorsofProg nosisinSevereTraumaticBrainImu1y.http:〃Www2. braintrauma.org／guidelines／downloads／btLprognosis guidelines.pdf?BrainTraumaSession﹦1157580cb4d126 eb381748a50424bb99.AccessedMay4,2012. 7.BrainTraumaFoundation.GuidehnesfbrtheManage﹣ mentofSevereTraumaticBrainI叼ury.http:〃Www2 braintrauma·org／guidelines／downloads／JON≡24＿Supp1 pdⅣBrainTraumaSession＝1157580cb4d126eb381748a 50424bb99.AccessedAccessedMay4’2012 8‘ChestnutRM,MarshallLF’KlauberMR,etal·Therole 0fsecondarybraininjuⅣindetermining0utcomehom severeheadinjury.J奶uα加α1993;34:216﹣222. 9ChibbaroS,TaccomL.Orbito﹣cranialin】urlescausedby penetratingnon﹣missilefbreignbodies·Experiencewith eighteenpatients.AααⅣeⅢJDc／iZγ（Wien）2006,148（9）’ 937﹣941jdiscussion941﹣942. 10.ClementCM’StiellIG’SchullMJ’etal.CⅡnicalfbatures ofheadinlurypatientspresentmgwithaGlasgowComa

卜

BIBUOGRAPHY169 Scalescoreof15andwhorequireneurosurgicalinter﹣ vention.AmJE加e唔Med2006;48（3）:245﹣251. 11·EisenbergHM,FrankowskiRF,ContantCR,etal·High﹣ dosebarbituratescontrolelevatedintracranialpres﹣ sureinpatientswithsevereheadinjuIy.JⅣbαmsαJg 1988;69:15﹣23· 12·EelcoF.MWijdicks,PanayiotisNVarelas,GaryS. GronsethandDavidM.Greer.Evidence﹣basedguideⅡne update:Determiningbraindeathinadults.Reportofthe QualityStandardsSubcommitteeoftheAmericanAca﹣ demyofNeurolo田.Ⅳbα徊』ogy.2010;74:1911﹣1918. 13·GiriBK’KrishnappaIK,BIyanRMJ’etal.Regionalcere﹣ bralbloodflowaftercorticalimpactinju叮complicated byasecondaryinsultinrats.St”陀e2000;31:961﹣967· 14.GonulE’Erd0ganE,TasarM,etal.Penetratingorbitocranialgunshotinjuries.Sα唔Ⅳbα”／2005;63（1）;24﹣30; discⅢSSinn31. 15·http:〃www·cdc.gov／traumaticbraimnjuIy／.AccessedMay 4,2012‘ 16·JohnsonU,NilssonP’Ronne﹣EngstromE’etal.FavorableoutcomeintraumaticbraininjuIypatientswith impairedcerebralpressureautoregulationwhentreated atlowcerebralperfUsionpressurelevels.N它αmsαJgFⅣ 2011;68:714-722· 17’MarionDW,SpiegelTP.Changesinthemanagementof severetraumaticbrainmjuIy:1991﹣1997.O.肱“沱Med 2000;28:16﹣18. 18.McCroⅣ’P,Johnston,K,Meeuwisse’W,etal.Sum﹣ maryandagreementstatementofthe2ndInternational ConfbrenceonConcussioninSport,Prague2004.BrJ 印o㎡sM它d2005;39:196﹣204. 19MowerWR,etal.Devel0pingaDecisionInstrumentto GuideComputedTomographicImagmgofBluntHead Patients· http:〃www.ncbi.nlm.nih·gov／Pub﹣ InjuIy med／16374287.JTmαmα2005;59:954﹣9. 20.MuizelaarJP,MarmarouA’WardJD,etal.Adverse eHbctsofprolongedhyperventilationinpatientswith severeheadmjuIy:arandomizedclinicaltrial.cJⅣ它α加﹣ sα唔1991;75:731﹣739·

23.RobertsonCS’ValadkaAB,HannayHJ’etal.Prevention ofsecondaryischemicinsultsaftersevereheadinju】y. Cr肱“沱M它d1999;27:2086﹣2095. 24.RosengartAJ,HuoD,TolentinoJ,NovakovicRL,Frank JI,GoldenbergFD’MacdonaldRL.Outcomempatients withsubarachnoidhemoIThagetreatedwithantiepilep﹣ ticdrugs.JⅣ﹫α”sα唔2007;107:253﹣260. 25.RosnerMJ,RosnerSD,JohnsonAH.Cerebralperh1sion pressuremanagementprotocolsandclinicalresults.J Ⅳeαmsα唔1995;83:949﹣962. 26.SakellaridisN,PavlouE,KaratzasS,ChroniD,Ⅵachos K’ChatzopoulosK,DimopoulouE,KelesisC’Kara﹣ ouliV.Comparisonofmannitolandhypertomcsaline inthetreatmentofseverebraininjuries.JⅣ它Ⅱrosα唔 2011;114:545﹣548. 27.SmitsM,DippelDW’deHaanGG,etalExternalvalida﹣ tionoftheCanadianCTHeadRuleandtheNewOrleans CriteriafbrCTscanmnginpatientswithminorhead injury.c仄AMA2005;294（12）:1519﹣1525· 28.StiellIG,ClementCM’RoweBH,etal.Compar】son oftheCan2diHnCTHeadRuleandtheNewOrIeHns CriteriainpatientswithminorheadinjuIy.‘仄AMA 2005;294（12）:1511﹣1518. 29.StiellIG’LesiukH,WellsGA’etal·CanadianCThead rulestudyfbrpatientswithmmorheadi叮ury;methodo﹣ lo田fbrphaseII（validationandeconomicanalysis）·AJm Eme唔Med2001;38（3）:317﹣322 30.StiellIG,LesiukH,WeⅡsGA,etalTheCanadianCT HeadRuleStudyfbrpatientswithminorheadinju】y: rationale,ohjectives,andmethodolo盯fbrphaseI（derivation）.A冗〃Eme唔M它d2001;38（2）:160﹣169. 31.StiellIG’WellsGA,VandemheenK,etal.TheCanadian CTHeadRulefbrpatientswithminorheadinjuIy·L〔m﹣ cα2001;357（9266）:1391﹣1396. 32.SultanHY,BOyleA,PereiraM’AntounN’MaimarisC. ApplicationoftheCanadianCTheadrulesinmanagmg minorheadmjuriesinaUKemergen叮department: implicationsfbrtheimplementationoftheNICEguidelines.E加e咱MeαcJ2004;21（4）:420﹣425.

21.Part1:Guidelinesfbrthemanagementofpenetrating braininjmy·Introductionandmethodolo盯.J?1mMmα 2001;51（2Suppl）:S3﹣S6.

33.TemkinNR’DikmanSS,WilenskyAJ’etal.Arandom﹣ ized’double﹣blindstudyofphenytoinfbrthepreventionof post﹣tI.aumaticseizures.NE『Jg／JM它d1990;323:497﹣502.

22Part2:PrognosisinpenetratingbraininjuIy.JTγmαmα 2001;51（2Suppl）:S44﹣S86.http川ournals.lww.com／ jtrauma／toc／2001／08001

34.ValadkaAB.Injmytocranium.InMoore’Feliciano, Mattox,eds·仍uα加α,2008,pp385﹣406.

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Pe『f0『manceatthi5stationwiIIaI∣owpa『ticipant5top『actiCeanddemon﹣ st『atethefoIIowingactivitiesIna5imuIatedcIinicaIsituation:

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團Identifydiagnosticaidsthatcanbeusedtodete「mlnethea『eaof in】u『ywithintheb『ainandtheextentofthein】u『y.

〉〉SkiIIX﹦CEvaluationofCT ScansoftheH＠ad

回Demonst「atep『ope『helmet『emovalwhilep「otectingthepatient’s CeⅣlcaI5plne 圃Pe「fo『macompleteseconda『ya5sessmentanddete『minethe patient『sGIasgowComaScaIe（GCS）sc0『eth『0ughtheuseofsce﹣ na『iosandinte『activediaIoguewiththeinst『uct0『.

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SI﹤ILLSTATIONX■HeadandNecI﹤T『auma:AssessmentandManagement171 I

pSCEⅡARl0s SCENAR∣OX﹣1 A17﹣year﹣oldhigh﹣schoolfbotbaⅡplayer’involvedin acrushingtacklewithabrieflossofconsciousness’ reportsneckpainandparesthesiainhisleftarm.He isimmobⅡizedonalongspineboardwithhishelmet inplaceandtransportedt0theemergenCydepartment （ED）.Heisnotinrespiratorydistress,talkscoherent﹣ ly’andisawakeandalert. 5CEⅡAR∣0X﹃Z A25﹣year﹣0ldmaleistransportedtotheEDafteracar crashwhiledrivinghomehDmatavem·Hisairwayis clear,heisbreathingspontaneous】ywithoutdifficul叮, andhehasnohemodynamicabnormalities·Hehasa scalpcontusionovertheleftsideofhishead.Thereis astrongodorofalcoholonhisbreath,butheisable toanswerquestionsappropriately.Hiseyesareopen’ butheappearsconh1sedandpushesawaytheexam﹣ iner,shandswhenexaminedfbrresponsetopain.Heis thoughttohavesuffbredaconcussionandtohavealco﹣ holintoxication.HeiskeptintheEDfbrobservation. Onehourlater》thepatientismoresomnolent, brieflyopenshiseyestopainfUlstimuli,anddemon﹣

stratesanabnormalflexionresponsetopainfUlstimuli ontherightandwithdrawalontheleft·Hisleftpupilis now2mmlargerthanhisright.Bothpupilsreactslug gishlytolight·Hisverbalresponseconsistsofmcom﹣ prehensiblesounds.

SCENARI0X﹣3 A21﹣year﹣oldmalewasthrownfromandthenkickedin thefacebyahorse.HewasimtiaⅡyunconsciousfbrat least5minutes.Henowopenshiseyestospeech,moves onlytopainfUlstimuhbywithdrawinghisextremities’ anduttersinappropriatewords.Hisbloodpressureis 180／80mmHg,andheartrateis64beats／min. SCENAR∣0X﹦4 A40﹣year﹣oldmotorCyclistisbroughtt0theEDwith obviousheadtrauma.Theprehospitalpersonnelre﹣ portthathehasunequalpupilsandrespondsonlyto painfhlstimulibyabnormallyflexinghisarms,open﹣ inghiseyes,andspeakingincomprehensibly.When notstimulated’hisrespirationsareverysonorous.

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Examinethecervicalspine. APalpatefbrtenderness／painandapplya semirigidcervica1coⅡar’ifneeded. B·Per允rmacross﹣tablelateralcervical spinex﹣rayexamination,ifneeded

sTEp6.

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Reassessthepatientcontinuously,observ﹣ 1ngfbrsignsofdeterioration· A·FrequenCy B·Parameterstobeassessed C.SerialGCSscoresandextremi叮motor assessn1ent D·Remember,reassessABCDEs

Documenttheextentofneurologicinjury.

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卜Ski∣IX﹣CEvaIuationofCTScanso『theHead ThediagnosisofabnormalitiesseenonCTscansofthe headcanbeve1ysubtleanddifficult·Becauseofthe inherentcomplexilyininterpretingthesescans’early reviewbyaneurosurgeonorradiologistisimportant‘ ThestepsoutⅡnedherefbrevaluatingaCTscanof theheadprovideoneapproachtoassessingfbrsignili﹣ cant’lifb﹣threateningpathology.Remember’obtaining aCTscanoftheheadshouldnotdelayresuscitationor transfbrofthepatienttoatraumacenter’ STEp1

Fo llo wth ep roces s fb ri ni ti a l revi ew of0T scans0fthehead A·Confirmthattheimagesbeingreviewed areofthecorrectpatient· B·EnsurethattheCTscanoftheheadwas donewithoutanintravenouscontrast agent. C·USethepatient,sclimcalfindingsto fbcustherev1ewoftheCTscan’anduse theimagefindingstoenhancefhrther physicalevaluation·

sTEPZ。

Assessthescalpcomponentfbrcontusionor swelhngthatcanmdicateasiteofexternal tramna

5TEp3.

Assess允rskuⅡhPactures.Keepinmindthat ASuturehnes（joimngofthebonesof thecranialvault）maybemistakenfbr 仕actures. B.DepressedskuⅡfractures（thicknessofskuⅡ）reqUireneur0surgical cons1】ItRtion. COpenfracturesrequ1reneurosurgical consulta位on. D·MissⅡewoundtractsmayappearas Iih田rareasoflowattenuation.

STEP4Assessthegyriandsulcifbrsymmetry.If asymmet叮exists’considerthesediagnoses

A·Acutesubduralhematomas: ·Typicallyareareasofincreasedden﹣ sitycoveringandcompressingthegyri andsulciovertheentirehemisphere ·Cancauseashiftoftheunderlying ventriclesacrossthemidline ·Occurmorecommonlythanepidural hematomas oCanhaveassociatedcerebralcontu﹣ sionsandintracerebralhematomas B·Acuteepiduralhematomas: ·Iypicallyarelenticularorbiconvex areasofincreaseddensity ·Appearwithintheskullandcompress theunderlyinggyriandsulci ·Cancauseashiftoftheunder】ying ventriclesacrossthemidIine oMostoftenarelocatedinthetemp0ral ortemporoparieta1reg】on STEp5·Assessthecerebralandcerebella】. hemispheres. A·Comparebothhemispheresfbrsimilar densityandSymmet】V. B·Intracerebralhematomasappearas areasofhighdensi叮· C’Cerebralcontusionsappearaspunctate areasofhighdensi叮. D·Diffhseaxonalinjurycanappearnormal orhavescattered,sma1lareasofcerebral contusionandareasoflowdensity. STEP6·AssesstheventriCles. AChecksizeandSymmetry. B·Significantmasslesionscompressand distorttheventriCles’especiaⅡythe lateralventricles· C。Significantinbracranialhypertensionis o仳enassociatedwithdecreasedventricu﹣ larsize.

SKlLLSTATI0NX■HeadandNeckT『auma:AssessmentandManagement173 D.Intraventricularhemorrhageappears asreg1onsofincreaseddensity（bright spots）intheventricles. STEp7.

Determinetheshifts.Mid1ineshiftsmay becausedbyahematomaorswellingthat causestheseptumpeⅡucidum,betweenthe twolateralventricles’toshiftaway仕om themid】ine.Themidlineisalineextend﹣ ingfTomthecristagalhanteriorlytothe tentlikeprαjectionp0steriorly（imon）·After measuringthedistancefTomthemidlineto theseptumpeⅡucidum’theactualshi仕is determinedbycorrectmgagainstthescale ontheCTprint.Ashiftof5mmormoreis consideredindicativeofamasslesion曰nd theneed允rsurgicaldecompression.

5TEP8.

As日essthemaxiIlo色巴i日lstructures. AAssessthe趙cialbones允rhactures. B.Assessthesim】sesand】hHstoidairceⅡs 允rair-』1】idlevels. CFacialbonefractures,sinusfractures, andsmusormastoidair﹣fluidlevelsmay indicatebasilarskullorcribrifbrmplate fiPactures.

STEP9.

LookfbrthefburCsofincreaseddensity: AContrast B·Clot CCeⅡularity（tumor） D.Calcihcation（pinealgland’choroid plexus）

I

bSkiⅡX﹦D:Ⅱe∣metRemoval Anypatientwearingahelmetshouldhavethehead andneckheldinaneutralpositionwhilethehelmet isremovedusingthetwo﹣personprocedure·Note:A

removesthehelmet.Ifthehelmethasa色ce cover,thisdevicemustberemovedfirst·If thehelmetprovidesfhll炮cialcoverage’the

posterentitled“TechniquesofHelmetRemovalfTom InjuredPatients’,isavailablefromtheAmericanCol﹣ legeofSurgeons（www.fhcs.org／trauma／Publications／ helmet.pdf）.Thisposterprovidesapictorialandnar﹣ rativedescriptionofhelmetremoval.Alsoseephoto﹣ graphsofthisprocedurein』igure2﹣2ofChapter2: AirwayandVentⅡatoryManagement.Somevarieties ofhelmetshavespecialremovalmechanismsthat shouldbeusedinaccordancewiththespecifichelmets.

patient’snosewillimpedehelmetremoval· Toclearthenose’thehelmetmustbetilted backwardandraisedoverthepatient,s

STEP1.Onepersonstabilizesthepatient,sheadand neckbyplacing0nehandoneithersideof thehelmetwiththefingersonthepatient’s mandible.Thispositionpreventsslippageif thestrapisloose· STEP2·Thesecondpers0ncutsorlo0sensthehel﹣ metstrapattheD﹣rings. sTEP3o

Thesecondpersonthenplacesonehandon themandibleattheangle,withthethumb ononesideandthefingersontheother. The0therhandappliespressurehom undertheheadattheoccipitalreg1on.This maneuvertransfbrstheresp0nsibih叮fbr inlineimmobihzationtothesecondperson.

SγEP4·Thefirstpersonthenexpandsthehelmet lateral】ytocleartheearsandcarefhlly

nose·

STEP5.

Duringthisprocess,thesecondpersonmust maintaininhneimmob﹟I肱2tionhombelow topreventheadtⅡt.

sTEP6.

Afterthehelmetisremoved,inhneman﹣ ualimmobilizationisreestablishedhom above,andthepatient,sheadandneckare secured·

sTEP7·

Ifattemptstoremovethehelmetresultin painandparesthesia’thehelmetshould beremovedwithacastcutter.TheheImet alsoshouldberemovedwithacastcutterif thereisevidenceofacervicalspineinjury onx﹣rayfilm.TheheadandneCkmustbe stabⅢzedduringthisprocedure’whichis accomplishedbydividingthehelmetinthe coronalplanethroughtheears.Theouter, rigidlayerisremovedeasⅡy,andtheinside layeristhenincisedandremovedanteri﹣ orly.Maintainingneutralalignmentofthe headandneck’theposteriorportionsare removed.

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withbrainmjuryhaveanassociatedspinalinjury, whereas25℅ofpatientswithspinalmjuryhave atleastamildbraininju】y·Approximately55℅of spinalinjuriesoccurinthecervicalregion’15℅mthe tho】acicreg1on,15℅atthethoracolumbarjunction, and15﹪inthelumbosacralarea.App『oximately1o％ o「patientswithacewicaIspihefi·actu『ehaveasecond’ Ⅱohcohtiguousve『teb『aIcoIumh行actu『e. D0ctorsandothermedicalpersonnelwhotreat patientswithspineinjuriesmustbeconstantlyaware thatexcessivemampulationandinadeqUateimmobili﹣ zationofsuchpatientsmaycauseadditionalneurologic damageandworsenthepatient’soutcome.Atleast5℅ ofpatientswithspineinjuryexperiencetheonsetof neurologicSymptomsortheworsemngofpreexisting symptomsafterreachingtheED.Thisisusuallydue toischemiaorprogressionofspmalcordedema,but itmayalsoresulthominadequateimmobilization. AsIongasthepatient,sspineisp『otected,evaIuatioⅡ ofthespiⅡeandexcIusiohofspinaIihiu『ymaybesafb∣y de佗『『ed,especiaIlyinthep『esehceofsystemicinstabil﹣ ity,suchashypotensionand『espi『ato『yinadequacy. Cervicalspineinjuryinchildrenisarelativelyrare event,occurringinlessthan1﹪ofcases·Additionally, 175

176CHAPTER7■SpineandSpinaICo『dT「auma

anatomicaldiffbrences’emotionaldistress’andinabil﹣ itytocommumcatemakeevaluationofthespineeven morechallenginginthispopulation（seeChapter10: PediatricTrauma）. Inapatient叨肋／joα／neurologicaldeficit’pam0r tendernessalongthespine,evidenceofintoxication’ ordistractingiIjury’excludingthepresenceofaspi﹣ nali叮uryisstraightfbrward.Inaneurol0gicallyintact

patient’theabsenceofpainortendernessalongthe spinevirtuallyexcludesthepresenceofasignificant spma1imury.H0wever’inapatientwhoiscomatose orhasadepressedlevelofconsciousness,theproc﹣ essisnotassimple.Inthiscase’itisincumbenton theClimcianto0btaintheappropriatex﹣rayfilmsto excludeaspinalinjury·Ifthex﹣raysareinconclusive, thepatient’sspineshouldremainprotecteduntilh1rthertestingcanbeperfbrmed. Althoughthedangersofinadequateimmobiliza﹣ tionhavebeenweⅡdocumented·therealsoissome dangerinprolongedimmobilizationofpatientsona hardsur色cesuchasabackboard.Inadditiontocaus﹣ mgseverediscomfbrtinanawakepatient,prolonged immobilizationmayleadtothefbrmationofserious decubitusulcersinpatientswithspinalcordi叮uries. Therefbre,thelongbackboardshouldbeusedonlyasa

patienttransportationdevice,andeveryeffbrtshould bemadetohavethepatienteva1uatedbytheappro﹣ priatespecialistsandremovedfromthespineboa】Pd asquicklyaspossible.Ifthisisnotfbasiblewithin2 hours’thepatientshouldberemovedfromthespine boardandthenlogrolledevery2hours,whilemain﹣ tainingtheintegrityofthespine,toreducetheriskof the仇】.mationofdecubitusulcers·

tomvandp andphysioI ogy ∣P Anatomy ThefbⅡowingrev1ewoftheanatomyandphysiologyof thespmeandspinalcordincludesthespinalcolumn, spinalcordanatomy’sensoryexamination》myotomes》 neurogenicandspinalshock’andeffbcts0notherorgansystems.

SplNAlC0【UⅢN Thespinalcolumnconsistsof7cervical’12thoracic’ and5lumbarvertebrae,aswellasthesacrumandthe cocq／x（■『IGuRE7.1）.Thetypicalvertebraconsistsof ananteriorlyplacedvertebralb0dy’whichfbrmsthe

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■FlGURE7﹣1TheSpine.（A）ThespinaI coIumn’「ightIate「aIandp05te「io「view5 （B）Atypi（aItho「acicve「teb「a’supe『io『 vIewb

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ANATOMYANDPHYSIOLOGY177

mainweight﹣bearingcolumn.Thevertebralbodies areseparatedbyintervertebraldisks,andareheldto﹣ getheranteriorlyandposteriorlybytheanteriorand posteriorlongitudinalligaments’respectively.Postero﹣ laterally’twopediclesfbrmthepillarsonwhichthe roofofthevertebralcanal（i.e·,thelamina）rests·The fhcetjoints’interspinousligaments’andparaspinal musclesallcontributetothestabilityofthespine· Thecervicalspineisthemostvulnerabletoi叫u】y, becauseofitsmobⅡityandexposure.Thecervical canaliswideintheuppercervicalregion’orfromthe fbramenmagnumtothelowerpartofC2·Them則orityofpatientswithimuriesatthislevelWhosurv1ve areneurologicallyintactonarrivalatthehospital· However,approximatelyone﹣thirdofpatientswith uppercervicalspmeinjuriesdieattheinjuryscene fromapneacausedbylossofcentralinnervationof thephren1cnervescausedbyspinalcordmjuryatC1. BelowthelevelofC3thediameterofthespinalcanal ismuchsmallerrelativetothediameterofthespinal cord,andvertebralcolumninjuriesaremuchmore likelyt0causespmalcordinjuries.Thecervicalspine inchildrenhasmarkeddiffbrencesfTomthatofadⅥ】ts untilapproximately8yearsofage.Thesediffbrences includemoreflexiblejointcapsulesandinterspinous ligaments,aswellasflatfhcetjointsandvertebral bodiesthatarewedgedanteriorlyandtendtoslide ｛brwardwithflexion.Thediffbrencesdeclinesteadily untilapproximatelyage12’whenthecervicalspineis moresimilartoanadult,s（see Chapter10:Pediatric Trauma） Themobili叮ofthethoracicspineismuchmore restrictedthanthatofthecervicalspine,andithas additionalsupportfromtheribcageHence’themci﹣ dence0fthoracicfracturesismuchlower.Mosttho﹣ rac1cspinefracturesarewedgecompressionfractures thatarenotassociatedwithspinalcordinjmy.How﹣

ever,whenairacture﹣dislocationinthethoracicspme doesoccur,italmostalwaysresultsinacompletespi﹣ nalcordinjury（seebelow）becauseoftherelative】y narrowthoraciccanalThethoracolumbarjunctionis afhlcrumbetweentheinflexiblethoracicregionand thestrongerlumbarlevels·Thismakesitmorevulner﹣ abletoinjmy’and15℅ofallspinalinjuriesoccurin thisregion.

5p∣NAlC0RDAⅡATOMγ ThespinalcordoriginatesatthecaudalendofthemeduⅡaoblongataatthefbramenmagnum.Inadults,it usuallyendsneartheL1bonylevelastheconusmeduⅡaris·Belowthislevelisthecaudaequina’whichis someWhatmoreresilienttoiIUu1y.Ofthemanytracts inthespinalcord,onlythreecanbereadilyassessed climcaⅡy:thelateralcorticospinaltract’spmothalam﹣ ictract,anddorsalcolumns（■FlGuRE7﹣z）.Each1sa pairedtractthatcanbei叼uredononeorbothsides ofthecord.Thelocationinthespinalcord’fUncti0n, andmethodoftestingfbreachtractareoutlinedin Table71 Whenapatienthasnodemonstrablesensoryor motorfhnctionbelowacertainlevel’heorsheissaid tohaveaco〃!p／e花SP加α／co／.d卹M／:y·Duringthefirst weeksafterinjury’thisdiagnosiscannotbemadewith certainty’becauseofthepossibilityofspinalshock‘ An加co〃叩／e加Sp加α／co『、d加卹:yisoneinwhichany degreeofmotororsensoryihnctionremains;thepr0g﹣ nosisfbrrecoveryissignificantlybetterthanthatfbr completespinalcordinjury.Sparing0fsensationin theperianalregion（sacralsparing）maybetheonly signofresidualfhnction.Sacralsparingcanbedemon﹣ stratedbypreservationofsomesensoryperceptionin theperianalreg1onand／orv0luntarycontractionofthe rectalsphincter.

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178CHAPTER7■SpineandSpinaICo「dT「auma

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7●兀eⅢγoJOg㎡esm加sβ HO卹doα I sse⋯〃epα赫e㎡’s Adermatomeistheareaofskininnervatedbythesen﹣ soryaxonswithinaparticularsegmentalnerveroot. Knowledgeofthem匈ordermatomelevelsisinvalu﹣ ableindeterminingthelevelofnUuryandassessing neurologicimprovementordeterioration.Thesenso】:y levelisthelowestdermatomewithnormalsensory hmctionandcanoftendiffbronthetwosidesofthe body.Forpracticalpurposes》theuppercervicalder﹣ mat0mes（C1toC4）aresomewhatvariableintheir cutaneousdistributionandarenotcommonlyusedfbr localization.However》itshouldberememberedthat thesupraclavicularnerves（C2throughC4）provide sens0ryinnervationtothereg1on0verlyingthepecto﹣ ralismuscle（cervicalcape）.Thepresenceofsensation inthisreg1onmayconfhsetheexaminerwhenheor

sheist】yingtodeterminethesensorylevelmpatients withlowercervicalinjuries.ThekeysensoIypointsare oI】tIinedmTable7.2andillustratedin■FlGuRE7﹣3. Mγ0T0MEs Eachsegmentalnerve（root）innervatesmorethanone muscle’andmostmusclesareinnervatedbymorethan oneroot（usuallytwo）.Nevertheless,fbrthesakeof simplicity,certainmusclesormusclegroupsareiden﹣ tifiedasrepresentingasinglespinalnervesegment. Thekeymyotomesareshownin■FIGuRE7﹣4. Thekeymusclesshouldbetestedfbrstrengthon bothsides.Eachmuscleisgradedonasix﹣pointscale hPomnormalstrengthtoparalysis（Table7·3）·Docu﹣ mentationofthestrengthinkeymusclegroupshelps toassessneurologicimprovementordeteriorationon subsequentexaminations.Inaddition’theexternal analsphinctershouldbetestedfbrvoluntarycontractionbydigitalexamination.

ANATOMYANDPHYSIOLOGY179

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∣叨Hb砌do妣 I 刎姍α胭d蕨Feα蔽〃e囫mge㎡c ⅡEUR0GENlCSⅡOCI《VERSUSSPIⅡA【SⅡ0Cl《 ●αⅦdSP加α【s〃oc臃

Ⅳ它α『Dgemcs／zoc陀resultsfromimpairmentofthede﹣ scendingsympatheticpathwaysinthecervicalorup﹣ perthoracicspinalcord.Thisconditionresultsinthe lossofvasomot0rtoneandinsympatheticinnervation totheheart·Neurogemcshockisrareinspinalcord mjurybelowthelevelofT6;ifshockispresentinthese patients,analternativesourceshouldbestronglysus﹣ pected.Lossofvasomotortonecausesvasodilationof

i80CHAPTER7■SpineandSpinaICo「dT『auma

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visceralandlower-extremitybloodvessels’pooling0f blood,and,consequently’hypotension.L0ssofSympa﹣ theticinnervationtotheheartmaycausethedevelop﹣ mentofbradycardiaoratleastafhilureoftachycardia mresponsetohypovolemia·Inthiscondition’the bloodpressuremaynotberestoredbylluidinfhsion alone,andmassivefluidresuscitationmayresultin fluidoverloadandpulmonaryedema.Thebloodpres﹣ suremayo仕enberestoredbythejudicioususeofvasopressorsaitermoderatevolumereplacement.Atropine maybeusedtocounteracthemodynamicaⅡysignifi﹣ cantbradycardia. Sp加α／s〃oc〃refbrstotheflaccidi叮（lossofmusCle tone）andlossofreflexesseenafterspinalcordinjury. The“shock,’totheinjuredcordmaymakeitappear completelynonfhnctional’althoughthecordmayn0t necessarilybedestroyed.Thedurationofthisstateis variable.

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E「FECTS0Ⅱ0TⅡER0RGANSγSTEMS Hyp0ventilationduetoparalysisoftheintercostal musclesmayresultfTomaninjuryinvolvingthelower cervicalorupperthoracicspinalcord.Iftheupperor middlecervicalcordisinjured,thediaphragmalsois paralyzedbecauseofinvolvementoftheC3toC5seg﹣

The几eα／.o／og﹠c／eue／isthemostcaudalsegmentofthe spinalcordthathasnormalsensoryandmotorfhnctiononbothsidesofthebodyWhenthetermse〃so／》y ／eue／isused,itrefbrstothemostcaudalsegmentofthe spinalcordwithnormalsensoryfhnction.The｝冗oto／. ／eUe／isdefinedsimilarlywithrespecttomotorfhnc﹣

CLASSIFlCATIONSOFSPINALC0RDlNjURIES181

tionasthelowestkeymusclethathasagrade0fat least3／5（seeTable7.3）.Incompleteinjuries,when s0meimpairedsenso】Vand／ormotorhmctionisfbund justbelowthelowestnormalsegment,thislsrefbrred toasthezoneofpartialpreservation.Asdescribed above》thedeterminationofthelevelofiIUuIyonboth sidesisimportant· Abroaddistinctionmaybemadebetweenlesions aboveandbelowT1.Injuriesofthefirsteightcervi﹣ calsegmentsofthespinalcordresultinquadriplegia, andlesionsbelowtheT1levelresultinparaplegia.The b0甽／eue』o／刎m:yisthevertebraatwhichthebones aredamaged,causinginjurytothespinalcord.The 几e泓ro／OgZc』eue／O／叼m:yisdeterminedprimarilyby clinicalexamination.Frequently,thereisadiscrep. ancybetweenthebonyandneurologiclevelsbecause thespinalnervesenterthespinalcanalthroughthe fbraminaandascendordescendmsidethespinalcanal befbreactuaⅡyenteringthespmalcord.Thefhrther caudaltheinjuryis’themorepronouncedthisdiscrep﹣ anCybecomes.Apartfromtheinitialmanagementto stabilizethebonyinjury,allsubsequentdescriptions ofthelevelofiniuryarebasedontheneurologiclevel.

upperextremitiesthaninthelowerextremities,with varyingdegreesofsensoryloss.UsuaⅡythissyndrome occursafterahyperextensi0ninjuryinapatientwith preexistingcervicalcanalstenosis（oftenduetodegen﹣ erativeosteoarthriticchanges）,andthehistoryiscom﹣ mon】ythatofafbrwardfallthatresultedinafhcial impact·Centralcordsyndromeisthoughttobedue tovascularcompromiseofthecordinthedistribution oftheanteriorspinalartery.Thisarterysuppliesthe centralportionsofthecord.Becausethemotorfibers tothecervicalsegmentsaretopographicallyarranged towardthecenterofthecord’thearmsandhandsare themostseverelyaffbcted. Centralcordsyndromemayoccurwithorwithout cervicalspinefractureordislocation·Recoveryusually fbllowsacharacteristicpattern’withthelowerextremitiesrecovermgstrengthfirst’bladderhmctionnext, andtheproximalupperextremitiesandhandslast.The

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preserved.Usually,anteriorcordsyndromeisdueto infhrctionofthecordintheterrit0Iysuppliedbythe anteriorspinalartery.ThisSyndromehasthepoorest

Spinalcordinjurymaybecategorizedas: ■Incompleteparaplegia（incompletethoracic iIUury） ■Completeparaplegia（completethoracicinjmy） ■Incompletequadriplegia（incompletecervical injury） ■Completequadriplegia（completecervicalinjmy） Itisimportanttoassessfbranysignofpreserva﹣ tionoffUnctionofthelongtractsofthespinalcord. Anymotororsensoryfhnctionbelowthelevelofthe injuryconstitutesanmcompleteiIUury.Signsofan incompleteiIUmyincludeanysensation（including positionsense）orvoluntarymovementinthelower extremities’sacralsparing’voluntaryanalsphincter contraction’andvoluntarytoefIexion.Sacralreflexes’ suchasthebulbocavern0susreflexoranalwink,do notquali圩assacralsparing· sPINAlC0RDSγNDR0MES CertainCharacteristicpatternsofneurologici叼u】yare fTeqUentlyencounteredmpatientswithspinalcordm﹣ juries,suchascentralcordSyndrome,anteriorcordsyn﹣ drome’andBr0wn﹣S色qUardsyndrome.Thesepatterns shouldberecognizeds0th叮donotconh1setheexammer’ Cb几向、α』c0㎡Sy氾d加meischaracterizedbyadis﹣ proportionatelygreaterl0ssofmotorstrengthinthe

prognosisfbrrecove】yincentralcordinjuriesissome﹣ whatbetterthanwithotherincompleteiIUuries· A／㎡e／、!oJ.co㎡Sy〃d／Dmeischaracterizedbyparaplegiaandadissociatedsensorylosswithalossof pamandtemperaturesensation.Dorsalcolumnfhnc﹣ tion（position’vibration,anddeeppressuresense）is

prognosisoftheincompleteiIUuries. B｝Du）几﹣S勿αα㎡Sy／Ⅱd加｝〃eresultsfromhemisec﹣ tionofthecord’usuallyasaresultofapenetratmg trauma.A1th0ughthissyndromeisrare】yseen,variationsontheclassicpicturearenotuncomm0n.Inits purefbrm’thesyndromeconsists0fipsilateralmotor loss（corticospinaltract）andlossofpositionsense（dorsalcolumn）’associatedwithcontralaterallossofpain andtemperaturesensationbeginningonetotwolevels belowthelevelofinjury（spinothalamictract）Even whenthesyndromeiscausedbyadirectpenetrating injmytothecord’somerecoveryisusuallyseen.

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SpinalinjuriescanbedescribedasfTactures’fracture﹣ dislocations’spinalcordinjurywithoutradiographic abnormalities（SCrWORA）,andpenetratinginjuries. Eachofthesecategoriesmaybefhrtherdescribedas stableorunstable.However’determiningthestability ofaparticulartypeofinjuryisnotalwayssimpleand’ indeed,evenexpertsmaydisagree.The『efb『e,especial. IyintheinitiaIt『eatment,aIlpatIehtswith『adiog『aphic evideⅡceo「iniu『yanda∣IthosewithⅡeu『oIogicde伺cits shouIdbeconside『edtohaveahunstabIespinaliniu『y. ThesepatientsshouldbeimmobilizeduntⅡaftercon﹣ sultationwithanappropriatelyqualifieddoctor）usu﹣ allyaneurosurgeonororth0pedicsurgeon.

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Thei叮uriesidentifiedinthischapterallinvolve thespinalcolumn.Theyarelistedinanatomicsequence （notinorderoffTequenCy）’progressingfromthecra﹣ nialtothecaudalendofthespine.Ofnote,upper cervicalspineinjuriesinchildren（C1＝C4）arealmost twiceascommonaslowercervicalspineiniuries·

ATLAⅡT0﹣0Cαp∣TALDISL0CAT∣0Ⅱ Craniocervicaldisruptionmjuriesareuncommonand resulthomseveretraumaticflexionanddistraction. Mostpatientswiththismjurydieofbrainstemdestruc﹣ tionandapneaorhavepr0〔bundneurologicimpa1r﹣ ments（e.g.’areventilator-dependentandquadriplegic）. Patientsmaysurviveifpromptresuscitationisavail﹣ ableatthemjmyscene·Atlanto.occipitaldislocation maybeidentifiedinupto19℅ofpatientswithfhtal cervicalspineiIUuriesandisacommoncauseofdeath mcasesofshakenbabySyndromeinwhichtheinfhnt diesimmediatelya仕ershaking.Spinalimmobilization isrecommendedimtiaⅡy·Aidstotheidentihcationof atlanto﹣occipitaldislocationonspinefilms’including Power,sratio,areincludedinSkillStationXI:X﹣Ray IdentificationofSpme Iniuries‘ ATlAS（α）「RACTⅢE Theatlasisathin,bonyringwithbroadarticularsur﹣ fhces.Fracturesoftheatlasrepresentapproximately 5℅ofacutecervicalspinefTactures.Approximately 40℅ofatlas仕acturesareassociatedwithhacturesof theaxis（C2）.ThemostcommonC1fTactureisaburst hacture（Jeffbrs0nfracture）.Theusualmechanismof inju】yisaxialloading’whichoccurswhenalargeload fhllsverticaⅡy0ntheheadorapatientlandsonthetop ofhisorherheadinarelativelyneutralposition.The Jeffbrsonfractureinvolvesdisruptionofboththean﹣ teriorandposteriorringsofC1withlateraldisplace﹣ mentofthelateralmasses·Thefractureisbestseenon anopen﹣mouthviewoftheC1toC2reg1onandaxial computedtomography（CT）scans（■F∣GuRE7﹣5）.

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Inpatientswithanatlasfracturewhosurvive,the fTacturesusuallyarenotassociatedwithspinalcordinju﹣ ries.H0wever,theyareunstableandshouldbeinitia1ly treatedwithacervicalcoⅡar.Unilateralrmgorlateral masshPacturesarenotuncommonandtendtobestable injuries·However,theyaretreatedasunstableuntilthe patientisexaminedbyanappropriate】yqUaliheddoctor, usuallyaneurosurgeonororth0pedicsurge0n.

C1R0TARγSUB山XATI0Ⅱ C1rota】?ysubluxationin】uryismostoftenseenin children（■FIGURE7﹣6）.Itmayoccurspontaneously, afterm則ororminortrauma’withanUpperrespira﹣ to】yinfbction’orwithrheumatoidarthritis·Thepa尸 tientpresentswithapersistentrotationofthehead （tortic0llis）.Thisinjmyisbestdiagnosedwithan open﹣mouthodontoidview》althoughthex﹣rayfInd﹣ 1ngsmaybeconh1sing·Inthisinjury,theodontoidis notequidistantfromthetwolateralmassesofC1.The patientshouldnotbefbrcedtoovercometherotation’ butshouldbeimmobilizedintherotatedpositionand refbrredfbrfUrtherspecializedtreatment.

AX∣S（CZ）『RACTURES Theaxisisthelargestcervicalvertebraandisthemost unusualinshape.Therefbre,itissusceptibletovari﹣ ousfracturesdependingonthefbrceanddirectionof

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■Anteriorwedgecompressioninjuries ■Burstinjuries ■Chancehactures ■Fracture﹣dislocations

Othe『C2F『actu『es Approximately20℅ofallaxisfracturesarenonodon﹣ toidandnonhangman,s.Theseincludefractures throughtheb0dy’pedicle,lateralmass,laminae,and sp1nousprocess.

「RACTURESAⅡDDIS【0CAT∣0ⅡS （C3TⅡR00GⅡC7） AhactureofC3isveryuncommon,possiblybecauseit ispositionedbetweenthemorevulnerableaxisandthe moremobile‘‘relativefhlcrum,》ofthecervicalspine＿ thatis,C5andC6,wherethegreatestflexionandextensionofthecervicalspineoccur.Inadults’themost commonlevelofcervicalvertebralfractureisC5’and themostcommonlevelofsubluxationisC5onC6.The mostcommoninju1ypatternsidentifiedattheselevels arevertebralbodyfTactureswithorwithoutsubluxa﹣ tion;subluxationofthearticularprocesses（including unⅡateralorbilatera1lockedfhcets）,andfractures ofthelaminae’spinousprocesses’pedicles,orlateral masses.Rarely’ligamentousdisruptionoccurswithout 仕acturesor通cetdislocations· Theincidenceofneurologicinjmyincreasesdra﹣ maticaⅡywithfacetdislocations.Inthepresenceof unilateralfacetdislocation’80﹪ofpatientshavea neurologicinjury;approximately30℅haverootinjuriesonly,40﹪mcompletespinalcordinjuries,and30﹪ completespma1cord蚵uries·Inthepresenceofbilat﹣ erallockedfacets’themorbidityismuchworse,with 16℅mcompleteand84﹪completespinalcordinjuries.

Axialloadingwithflexionproducesanα／】花r㎡o『。 叨edg它co〃!p／℃ssio川〃V!〃:y.Theamountofwedging usuallyisquitesmall’andtheanteriorportionofthe vertebralbodyrarelyismorethan25℅shorterthan theposteriorbody.Becauseoftherigidityoftherib cage,mostofthesefracturesarestable. B【〃B觔｝VM／:yiscausedbyvertical﹣axialcompression. C／jα〃ce介αc戊〃℃saretransversefracturesthrough thevertebralbody（■FIGuRE7﹣9）·Theyarecausedby

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X﹣RAYEVALUATION185

flexionaboutanaxisanteriortothevertebralcolumn andaremosthequent】yseenfbllowingmotorvehicle crashesinwhichthepatientwasrestrainedbyonlya lapbelt。Chancefracturesmaybeassociatedwithret﹣ roperitonealandabdominalvisceralimuries. 扔、αc卹『它﹣d『S／ocα瓦o／』sarerelativelyuncommonin thethoracicandlumbarspinebecauseoftheorienta﹣ tionofthefHcetjoints.TheseiUjuriesalmostalways areduetoextremeflexionorsevereblunttraumato thespine,whichcausesdisruptionoftheposteriorele﹣ ments（pedicles,fhcets,andlamina）ofthevertebra. Thethoracicspinalcanalisnarrowinrelationtothe spinalcord,sofTacturesubluxationsinthethoracic spinecommonlyresultincompleteneurologicdeficits. SimplecompressionfracturesareusuaⅡysta﹣ bleandoftentreatedwitharigidbrace.Burstfrac﹣ tures,Chancefractures,andfracture﹣dislocationsare extremelyunstableandalmostalwaysrequireinternal fixHt↑on.

plainx-rayiilms,andCTscans.Ifthepathofinjury passesdirectlythr0ughthevertebralcanal,acomplete neurologicdeficitusuallyresults.Completedeficits alsomayresultfTomenergytransfbrassociatedwitha high﹣velocitymissⅡe（e·g·,bullet）passingclosetothe spinalcordratherthanthroughit。PenetratingiIUu﹣ riesofthespineusuallyarestableinjuriesunlessthe missⅡedestrOysalargeportionofthevertebra. B山ⅡTCAR0TIDANDVERTEBRAL VASCULAR∣Ⅱj0RIES BhmttraⅡ】matotheheadandneckisariskfactor比r carotidandvertebralarterialiIUuries.Earlyrecogni﹣ tionandtreatmentoftheseinjuriesmayreducethe riskofstroke.Indicationsfbrscreeningareevolving, butsuggestedcriteriafbrscreeninginclude: ■C1－C3hacture ■CervicalspinefiPacturewithsubluxation ■Fracturesinvolvingthefbramen trHhsversariⅡ】m

TⅡ0RAC0lUMBAR』UⅡCTI0N『RACTURES （T11TⅢ0UGⅡL1） Fracturesatthelevelofthethoracolumbarjunction areduetotherelativeimmobiⅡtyofthethoracicsp1ne ascomparedwiththelumbarspine.Th叮mostoften resultfromacombinationofacutehyperflexionand rotation’and,consequently,theyareusuallyunstable. Peoplewhofallfromaheightandrestraineddrivers whosustainsevereflexionenergytransfbrareatparticularriskfbrthis｛ypeofi叼my. Thespinalcordterminatesastheconusmed﹣ ullarisatapproximate】ythelevelofL1,andinjury tothispartofthecordcommonlyresultsinbladder andboweldysfhnction’aswellasindecreasedsensa﹣ ti0nandstrengthinthelowerextremities.patiehts withtho『acoIumba『仆actu『esa『epa『ticu∣a『lyvulne『able to『otationaImovement.The『efb『e’Iog『oIIihgshouIdbe pe『｛b『medwtihext『emeca『e·

【0MBAR『RACTURES Theradiographicsignsassociatedwithalumbarfrac﹣ turearesimilartothoseofthoracicandthoracolumbar 仕actures.However’becauseonlythecaudaequinais involved,theprobabiⅡtyofacompleteneurologicdefi﹣ citismuchlesswiththeseinjuries.

pENETRATIⅡGIⅡ』URIES Themostcommontypesofpenetrating1njuriesare thosecausedbygunshotwoundsorstabbings.Itis importanttodeterminethepathofthebulletorkmfb. Thiscanbedonebyanalyzinginfbrmationfromthe histo1y’climcalexamination（entryandexitsites）’

Approximatelyone﹣thirdofthesepatientswillbe showntohavebluntcarotidandvertebralvascular injuⅣ（BCⅥ）onCTangiographyoftheneck（■FIGuRE 7.10）Thetreatmentofthesemjuriesisevolving,with eitheranticoagulationorantiplatelettherapycurrent】y recommendedinpatientswithoutcontraindications.

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叨 HmMoc I o涮伽﹠咖p’e . Se劂Cep’: ●αbse〃eeOfαs唔犯娥cα】㎡sp加e〃叨mw Bothcarefhlclinicalexaminationandthoroughra﹣ diographicassessmentarecriticalinidentifyingsig﹣ nificantspinelIUu1y.SeeSkillStati0nXI;X﹣Ray IdentificationofSpineIniuries. CERV∣CAlSpIⅡE Cervicalspineradiographyisindicated｛bralltrauma patientswhohavemidlineneckpain,tendernesson

186CHAPTER7■SpineandSpinalCo「dT『auma

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戡 palpation’neur0logicdeficitsrefbrabletothecervical spine’analteredlevelofconsciousness’orasignifi﹣ cantmechanismwithadistractinginjmyorinwhom intoxicationissuspected.Twooptionsfbrx﹣rayevalu﹣ ationexist.Inlocationswithavailabletechnology’the primaryscreemngmodalityismulti-detectoraxialCT 仕omtheocciputtoT1withsagittalandcoronalre﹦ constructions.Wherethisisnotavailable,plainfilms consistmgoflateral,anteroposterior（AP）’andopen﹣ mouthodontoidviewsshouldbeobtained. Inplainfilms’thebaseoftheskuⅡ,allsevencerv1﹣ ca1vertebrae）andthefirstthoracicvertebramustbe visualizedonthelateralview.Thepatient’sshoulders mayneedtobepuⅡeddownwhenobtainingthelateral cervicalspinex﹣rayfilmtoavoidmissmg廿actures0r 仕acture﹣dislocationsinthelowercervicalspine·Ifall sevencervicalvertebraearenotvisualizedonthelat﹣ eralx﹣rayfilm’asw1mmer,sviewofthelowercervical andupperthoracicareashouldbeobtained Theopen﹣mouthodontoidviewshouldinclude theentireodontoidprocessandtherightandleftC1, C2articulations·TheAPviewofthec﹣spineassistsin theidentihcationofaunilateralfhcetdislocationin casesinwhichlittleornodiSlocationisidentihedon thelateralhlm.Thin﹣cutaxialCTscansshouldalso beobtainedthroughsuspiciousareasidentifiedonthe plainfilmsorthroughthel0wercervicalspineifitis notadequatelyvisualizedontheplainfilms.AxialCT imagesthroughC1andC2mayalsobemoresensi﹣

■FIGURE7﹣10NeckCTangiog「amwith aG「adellca「otidin】u「y（a「「ows）.

tivethanplainiilmslbrdetectionoffracturesofthese vertebrae. Whenthesefilmsareofgoodqualityandareprop﹣ erlyinterpreted’unstablecervicalspinei叼uriescanbe detectedwithasensitivityofgreaterthan97℅.The ∞mpletese『iesofce『vica∣spihe『adiog『aphsmustbe 『eviewedbyadocto『expe『iencedinthep『ope『inte『p『eta﹣ tiono「thesefilmsbe｛b『ethespineisconside『edno『ma∣ ahdtheceMcaIcolIa『is『emoved.CTscansmaybeused inIieuo「pIaihimagestoevaluatetlTeceMcaIspine. Itispossiblefbrpatientstohaveapurelyligamen﹣ tousspmei叼mythatresultsmmstabili叮without associatedfiPacture.However,somestudiessuggest that,ifplainthree﹣viewcervicalspineradiographsor CTfilmsaretrulynormal（i.e·’noanteriorsoft-tissue swellingandnoabnormalangulation）,significant instabⅢtyisunlikely.Patientswithneckpainand normalfilmsmaybeevaluatedbymagneticresonance imaging（MRI）orfIexion﹣extensionx﹣rayfilms’or treatedwithasemirigidcervicalcoⅡaribr2＿3weeks withsubsequentrepeatexaminationandimagingif necessary.Flexion﹣extensionx﹃rayfilmsofthecerⅥ﹣ calspinemaydetectoccultinstabili叮ordeterminethe stabilityofaknownfTacture’suchasalaminarorcompressionfracture.Unde『hoci『cumstaⅡcesshouIdthe patieⅡt》snecI《be化『cedi佣toapositionthateIicitspaih· AIImovemehtsmustbevolu㎡a『y·ThesehImsshouId beobtaiⅡeduhde『thedi『ectsupeMsioⅡandcont『oIof adocto『expe『iehcedintheiⅡte『p『etationo「such伺lms·

GENERALMANAGEMENT187

Insomepatientswithsignificantsoft﹣tissueinjury’ paraspinalmusclespasmmayseverelyhmitthedegree offlexionandextensionthatthepatientallows.Insuch cases,thepatientistreatedwithasemirigidcervical collarfbr2to3weeksbefbreanotherattemptismade toobtainflexion﹣extensionv1ews·MRIappearst0be mostsensitivefbrsofttissueinju叮ifdonewithin72 hoursofiIUury.However’dataregardingcorrelation ofcervicalspineinstabili叮withpositiveMRIfindings arelacking. App『oximately】o％ofpatientswithacewicaIspine 什actu『ehaveasecond’nohcontiguousve『teb『al∞I. umn什actu『e·Thiswarrantsacompleteradiographic screemngoftheentirespineinpatientswithacervical spinefracture.Suchscreeningalsoisadvisableinall comatosetraumapatients. Inthepresenceofneurologicdeficits,MRIisrec﹣ ommendedtodetectanysofttissuecompressivelesion, suchasaspinalepiduralhematomaortraumatized herniateddisk’thatcannotbedetectedwithplain films.MRImayalsodetectspinalcordcontusionsor disruption,andparaspinalligamentousandsofttis﹣ suemjury.However,MRIisfrequentlynotfbasiblem

p『etedasno『malbyanexpe『ienceddocto『be｛b『espiⅡe p『ecautionsa『ediscontinued·However,duetothe possibilityofpressureulcers’remova1ofthepatient fromalongboardshouldNOTwaitfbrfinalradio﹣ graphicinterpretation.

▲」 PITFA『J』S ■AninadequateseConda『yasseSsmentmay「esuItin thefaiIu『eto「ecognizeaspinaIco『din】u「y’pa「ticu. la「IyanincompIetespinaIco「din】u『y. ■PatientswithadiminishedIeveIofconsciousness andthosewhoa「『iveinshocka「eo仕endi什icuItt0 assessfo『thep「esenceofspinaIco「din】u「y·These patients「equi「eca「efuI「epeatassessmentonceini﹣ tialIife北h「eateninginiu『ieshavebeenmanaged.

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patientswithhemodynamicinstability.WhenMBIis notavailableorappropriate,CTmyelographymaybe usedtoexcludethepresenceofacutespinalcordcom﹣

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pressioncausedbyatraumaticherniateddiskorepi﹣ duralhematoma.ThesespecializedstudiesusuaⅡyare perfbrmedatthediscretionofaspmesurgeryconsult﹣ ant.Box7-1presentsguidelinesfbrscreeningtrauma

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patientswithsuspectedspinei叼my.

TⅡ0RAαCAⅡD山MBARsPINE Theindicationsfbrscreeningradiographyofthetho﹣ racicandlumbarspinearethesameasthosefbrthe cervicalspineWhereavaⅡable’CTscanningofthe thoracicandlumbarspinecanbeusedastheinitial screeningmodality.APandlateralplainradiographs withthin﹣cutaxialCTscansthroughsuspiciousareas candetectmorethan99﹪ofunstableinjuries.Onthe APviews’theverticalalignmentofthepediclesand distancebetweenthepediclesofeachthoracicand lumbarvertebrashouldbeobserved.Unstablehac﹣ turescommonlycausewideningoftheinterpedicular distanceThelateralfilmsdetectsubluxations’com﹣ pressionfTactures,andChancefractures.CTscan﹣ ningisparticularlyusefhlfbrdetectingfracturesof theposteriorelements（pedicles,lamina,andspinous processes）anddeterminingthedegreeofcanalcom﹣ promisecausedbyburst丘actures.Sagittalrecon﹣ structionsofaxialCTimagesorplaintomography maybeneededtoadequatelycharacterizeChance fractures.AswiththeceⅣicalspine,acompletese『ies ofgoodquaIity『adiog『aphsmustbep『ope『Iyihte『﹣

∣ ﹥ Gene『aIManagement 叨 玫【MoIf⋯pα㎡e㎡s叨觔sp加αJco㎡ ●】叼ⅨyyαⅦd〃〃㎡fsecO刃ααyy蚵叨Ⅳβ Generalmanagementofspineandspinalcordtrauma includesimmobilization》intravenousfluids’medica﹣ tions’andtransfbr’ifappropriate·SeeSkillStation

XII;SpinalCordInⅡ1Ly:AssessmentandManagement. lMM08IUZAT∣0Ⅱ

叨 Hb”dop I m酋ec觔〃eSp加eα“胛岫 ●eUα伽α㎡O犯’〃』α〃αg它｝〃e甽α砌d力α〃spO㎡β Prehospitalcarepersonnelusuallyimmobilizepatients be允retheirtransporttotheED.Anypatientwitha suspectedspinemjmyshouldbeimmobilizedabove andbelowthesuspectedinjurysiteuntila丘acture isexcludedbyx﹣rayexamination.Remember’spinal protectionshouldbemaintaineduntⅡacervicalspine iIUuryisexcluded.Properimmobilization1sachieved

188CHAPTER7■SpineandSpinalCo『dT『auma ■

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Box7覃1GuideIines『o『5c『eeniⅡgpatientswith SuspectedSpineIniⅢy SuspectedCe『vicaISpiⅡeln】u『y 1·Thep『esehceofpa『apIegiao『quad『iplegiaisp『e﹣ sumptiveevidenceofspinaIinstabiIity. Z.陶旋n佔wh0a「eaw日k巳a／e「﹟50b則and〃eU／U／0gk日／Ⅱ／n0尸 ma↓andhaV白n0ne砍pa〃 i 0「md i ／〃）etendeme颺0『a此﹣ 〃m↑hg／甽MThesepatient5a「eext『eme∣yun∣ikeIyt0have anacutec﹣5pine↑『adu『e0「instabiIityWiththepatieⅡtIna 5upn i epo5ti0 i n〃「em0vethec﹣〔0∣∣a『andpa∣patethespn i eIf the『eisn05igni↑i〔anttende『nessiaskthepatientt0voIⅡnta『﹣ iIymovehi50『he『ne〔k↑『0m5idet05ide.Neve『｛b『cethe patieht,snecI《.Whenpe『↑0『medv0Iunta「i∣ybythepatienti the5emaneuve『sa『egene『aIIysa↑e.I↑the『eIsn0paInihave thepatientv0∣unta『iIy｛lexandextendhis0『he「ne〔k.Again’ ↑ i the『esin0pan i〔 l ﹣5pn i e｛m li 5a『en0tne〔essa「y’ 3.尸ate i 〃佔wh0a尼awakeanda／e「﹟neu「0／0g〔 i a／〃n0『maL ∞0pe佃加e〃andd0〃0Mal／白adk加αing叮u／yanda尼 ab佗m（0n田〃帕傯0nt／｝e〃sph i 巳bu〔d0ha∣／e〃e砍pah i 0『 m刎inete〃deme55／Thebu『den0↑p『00↑is0nthedinidan t0excIudeaspina∣Inlu『y.Whe『eavailab∣eiaIsuchpatients 5h0uldunde「g0mu∣ti﹣deted0『axiaICT↑『0mthe0cαput t0「lwith5agittaIandc0「0naI『ec0n5t『ucti0ns.Whe『en0t avaiIabIe’patient5sh0u∣dunde『g0Iate『a∣!APland0pen﹣ m0uth0d0nt0idx﹣『ayexaminati0ns0↑thec﹣5pinewithaxial CTimage50↑sⅡspid0Ⅱsa『eas0『0↑theI0we『ce『vicaI5pine i↑n0tadequate∣yvisuaIized0nthepIain｛iIms.Assessthe c﹣spn i e↑m Ii 5↑0『: ·b0nyde｛0『mtiy ·｛『adu『e0↑theve『teb『ab I 0dy0「p『0ces5es ·l0550｛a∣ignment0「thep0ste『i0『aspe〔t0↑thevelteb『aI b0de i s（ante『0 i 「extent0↑theve『teb『aIcanaI） 。iⅡc『ea5eddistancebetweenthespin0u5p「0〔e5sesat0ne IeveI ·na『『own i go↑theve「teb「ac I anaI ·Ⅱ i 〔『ea5edp『eve『teb『a5 I 0｛tsisⅡespace flthese↑m Ii sa「en0『ma∣’『em0vethec﹣c0a I 「.Unde『the〔a『e 0fakn0wledgeabIec∣inidan!0btaIn｛∣exi0nandextensi0n’ andIate『a∣〔e『vi〔a∣5pine↑i∣m5withthepatientv0∣unta『ily 【lexingaⅡdextendinghis0『he「ne〔kI↑the↑iIm55h0wn0 5ubluxati0n﹟thepatient’sc﹣spine〔aⅡbec∣ea『edandthe

〔﹣c0∣∣a『『em0vedⅡ0weve『｛ iI any0↑thesef∣ i msa『e5u5p﹣ i 〔i0u5o『undea『!『epIacethe〔0I∣a「and0btaIn〔0Ⅱ5ultati0n ↑『omaspIne5peciali5t. 4P日旎n店whoha爬a〃a／iB把d佗爬／0f∞n5oousnes50「a『P 加oy0ung加db5o↑be叻e「 i 勻yn】pr0m5『Whe『eavaa li bIe’a∣I su〔hpatient5sh0uIdunde『g0mu∣ti﹣detect0『axialCT↑『om the0cciputt0Tlwith5agitta∣andc0『0naI『ec0nst『udi0n5· Whe『en0tava∣ i ab∣e’a∣∣suchpate i nt5sh0ud I unde『g0a I te『a’ I AP『and0pen﹣m0uth0d0nt0id｛iImswithCT5upplementa﹣ ti0nth『0ugh5uspici0usa『eas（巳glαandCZlandth『0ugh the∣0we『ce『vi〔aIspinei｛a『easa『en0tadequatelyvi5ua∣﹣ ized0nthepIain↑i∣m5）.∣n〔hI∣d「eniCTsupp∣ementati0nis 0pti0na∣I↑theenti『ec﹣5pinecaⅡbevi5ualizedandis｛0und t0ben0『maIithec0∣Ia『canbe「em0veda↑te『app『op『iate evaluatI0nbyad0〔t0「／〔0nsuItaⅡtski∣∣edintheevaIuati0n／ management0↑patientswithspineinlu『ies.CIea『an〔e0↑the c﹣spn i esipa『tc i uIa『Iym i p0『tant「 i puIm0Ⅱa『y0『othe『ca『eo↑ thepatienti5c0mp『0misedbytheInabi∣ityt0『n0bilizethe patient. 5.Whehindoubt｝IeavethecoIIa『on· 6。（0nsu／t／D0ct0『swh0a「eskiI∣edintheevaluati0nand management0↑patientswithspineinlu『ie5sh0uIdbe 〔0nsuItedinaI∣ca5esinwhichaspineinlu『yisdeteded 0「5u5pected. 7’8ackb0a「dS:Patientswh0haveneu『o∣0gicde↑idts（eg.’ quad『ipIegia0「pa『aplegia）5h0uIdbeevaIuatedqui（k∣yand 『em0ved↑『0mtheba〔kb0a『dass00na5p0ssibIeApa『a· !yzedpatientwhoisaI∣owedtoIieonaha『dboa『d ↑b『mo『ethan之hou『sisathigh『isI《fb『p『essu『e uc I e『s· 8’EmeUenqs伽atibns／『「aumapatient5who『equi『eeme『﹣ gency5u『ge『ybe「0『eac0mpIetew0『kup0↑thespinecan beacc0mp∣sihedsh0ud l bet「an5p0『ted〔a『e↑u∣y I ’a5sⅡm∣ng thatanun5tab∣e5pIneInIu『yisp『esent.Thec﹣c0l∣a『sh0uId beIe↑tonandthepatient∣0g『0l∣edwhenm0vedt0and↑『0m theope「atingtabIe.「hepatientsh0uldn0tbeIe｛t0na『igid backb0a『ddu『n i gsu『ge『y.『he5u『g（ i atleam5h0uIdtakepa『﹣ ticu∣a『ca『et0p『0tectthene〔ka5mu（ha5p0ssib∣edu『Ing the0pe『ati0n’Theane5thesi0∣0gistsh0u∣dbein↑0『『ned0｛ the5tatus0↑thew0『《up’

（ton加ued）

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GENERALMANAGEMENT189

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BOX7﹦1（continued）

SuspectedTho『acoIumba『SpineIn】u『y 1.Thep『esenceo「pa『apIegiao『aIeveIo「sehso『yloss onthechesto『abdomehisp『esumptiveevidehce o「spinaIinstabiIity· Z.Patien芯wh0a「eaw日k巳a／e「“0b即〃eu』D／0gkal!yno尸 ma﹟andhaVen0mid／ine【h0佃oCo「／umba「ba吠paino『 tendbme55:TheeⅡti『eextent0↑thesp∣neshouIdbepaI﹣ patedandin5pe〔tedIfthe『eIsn0tendemess0npaIpation 0『e（chym05i50ve『the5pin0u5p『0〔e5se5’aⅡun5table5pine ↑『adu『eisunIikeIylandth0『a〔olumba『『adi0g『aph5mayn0t beneCeSSaⅣ.

3.Patien芯wh0have叩川ePa川0「rendbme55onpa巾a加n〃 neu『o／Ogkdb加固ana／re「ed∣eI／e／ofmn5d0u5ne5另o「／n wh0mintoxit日加〃／s5u叩eded:Apand∣ate『aI『adi0g『aph5 0↑theenti『eth0『adcandIumba『spine5h0uIdbe0btained. ThIn﹣CutaxiaIC「5h0uIdbe0btainedth『0ugh5uspIci0u5 a『easidenti｛iedonthepIain↑iIm5.AIlimagesmustbeof goodquaIityandinte『p『etedasno『malbyanexpe﹣ 『ienceddocto『befb『ediscontinuihgspinep『ecau﹣ tions.

¢·C0n5uItad0d0『5kiIediⅡtheeva∣uationandmanagement 0↑5pineinlu『ie5i「a5pIne∣nIu『yisdetected0『5u5peded

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withthepatientintheneutralposition－thatis,su﹣ pinewithoutrotatingorbendingthespinalcolumn. NoefIbrtshouldbemadetoreduceanobvious de｛brmi叮·Childrenmayhavetorticolhs’andtheeld﹣ erlymayhaveseveredegenerativespinediseasethat causesthemtohaveanontraumatickyphoticorangu﹣ lationdefbrmi叮ofthespine.Suchpatientsshouldbe immobilizedonabackboardinapositionofcomfbrt. Supplementalpaddingisoftennecessary·Attemptsto aIighthespinefb『thepu『poseo「immobiIizationonthe bacl《boa『da『enot『ecommendedi「theycausepain. ImmobilizationoftheneCkwithasemirigidc0Ⅱar doesnotensurecompletestabilizationofthecervical spine.Immobilizationusingaspineboardwithappro﹣ priatebolsteringdevicesismoreeffbctiveinlimiting certainneckmotions.Theuseoflongspineboardsis recommendedCewicaIspineihiuⅣ『equi『escontiⅡuous immobilizatioⅡo「theeⅡti『epatientwithasemi『igidce『﹣ vicaI∞I∣a『,headimmobiIizatioh,bacI《boa『d,tape,and st『apsbe化『eanddu『ingt『ansfb『toade偷nitive.ca『e伯Cility （■FlGuRE7﹣11）.Extensionandflexionoftheneck shouldbeavoidedbecausethesemovementsarethe mostdangeroustothespinalcord.Theairwayisof criticalimportanceinpatientswithspinalcordinjury’ andearlyintubationshouldbeaccomplishedifthere isevidenceofrespiratorycompromise.Duringintuba﹣ tion’theneckmustbemaintainedinaneutralp0sition. Ofspecialconcernisthemaintenanceofadequate immobilizationofrestless’agitated’orviolentpatients. Suchbehaviorcanbeduetopain’confhsionassociated withhypoxiaorhypotension,alcoholordruguse’or apersonalitydisorder·Theclinicianshouldsearch fbrandcorrectthecauseofthebehavior’ifpossible.

■FlGURE7﹣11ImmobiIizatioⅡ.Ce「vicalspinein】u「y 『equi「e5continuousimmobiIizationoftheenti『epatient withasemi﹣「igidce「vicaIcoIlaI》headimmobilization‘ backboa「d’tape’andst『apsbefo『eandafte「t『ansfe『to adefinitive﹣〔a『efadIity.

Ifnecessary’asedativeorparalyticagentmaybe administered’whileensuringadeqUateairwayprotec﹣ tion,control,andventilation.Theuseofsedativesor paralyticagentsinthissettingrequ1resconsiderable clinicaljudgment’skiⅡ’andexperience.Theuseof short-acting,reversibleagentsisadvised. OncethepatientarrivesattheED,everyeffbrt shouldbemadetoremovetherigidspineboardas earlyaspossibletoreducetheriskofpressureulcer fbrmation。Rem0valoftheboardisoftendoneaspart ofthesecondarysurv叮whenthepatientislogrolled

190CHAPTER7■SpineandSpinaIC0『dT『auma fbrinspectionandpalpationoftheback‘Itshouldnot bedelayedsolelyfbrthepurposeofobtainingdefini﹣ tivespineradiographs,particularlyifradiographic evaluationmaynotbecompletedfbrseveralhours. Thesaibmovement,orlogrolling’ofapatient withanunstableorpotentiallyunstablespinerequires planningandtheassistanceoffburormoreindividu﹣ als,dependingonthesizeofthepatient（■「lGuRE7﹣1Ⅱ）. Neutralanatomicalignmentoftheentirevertebral columnmustbemaintainedwhilerollingandlifting thepatient·Onepersonisassignedtomaintainin﹣line immobilization0ftheheadandneck·Otherindividu﹣ alspositionedonthesamesideofthepatient,storso manuaⅡypreventsegmentalrotation,flexion’extension,lateralbending,orsagg1ngofthechestorabdo﹣ menduringtransfbrofthepatient·Anotherindividual isresponsiblefbrmovingthelegsandremovingthe spineboardandexaminmgthepatient,sback.

∣ ▼ 」 PITFA『』『』 ▼

Patient5beingt『anspo「tedtoa t「aumacente「may haveun「ecognizedspinaIin】u『ies· SuchpatientsshouId bemaintainedincompletespinal immobiIization.

lⅡTRAVEⅡOUS『LUIDS Inpatientsinwhomspineinjuryissuspected,intra. venousfluidsare月dmihisteredastheywouldusu﹣ allybefbrresuscitationoftraumapatients.Ifactive hemorrhageisnotdetectedorsuspected’persistent hypotensionshouldraisethesuspicion0fneurogenic shock.Patientswithhypovolemicshockusuallyhave tachycardia,whereasthosewithneurogenicshock classicallyhavebradycardia·Ifthebloodpressuredoes

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■F!GURE7﹣1ZFourPe『sonLog『o!I·Log『oIIingapatientto『emovea5pineboa『dand／o「examine theback5houIdbeacc0mpIishedusingatIeastfou『people.（A）Onepe『sonstandsatthepatienfs headt0cont「oItheheadandc-spine〃andtw0a『eaIongthepatient’ssidestocont『oIthebody andext『emities·（B）Asthepatientis「olled〃th『eepe0pIemaintainaIignmentofthespine’whiIe （C）thef0u『thpe『s0n『emove5theboa『dandexamine5theback.（D）Oncetheboa『dIs『em0ved’ thepatientis「etu「nedtothe5upineposition『whiIemaintaininga∣ignmentofthe5pine·

GENERALMANAGEMENT191

notimproveafterafluidchallenge’thejudicioususe ofvasopressorsmaybeindicated.Phenylephrinehy﹣ drochloride,dopamine,ornorepinephrineisrecom﹣ mended.Overzealousfluidadmimstrationmaycause pulmonaryedemainpatientswithneurogenicshock. Whenthefluidstatusisuncertain,theuseofinvasive momtoringmaybehelpfhl.Aurinarycatheterisin﹣ sertedtomomtorurinaryoutputandpreventbladder distention.

MED∣cATI0Ns

ephoneconsultationwithaspinespecialist.Avoidunnecessarydelay.Stabihzethepatientandapplythe necessarysphnts,backboard,and／0rsemirigidcervical coⅡar.Remembe『,ceMcaIspiⅡeihiu『iesaboveC6cah『e. sultinpa『tiaIo『tota!∣osso「『espi『ato『yfUnction·Ifthere isanyconcernabouttheadequa叮ofventilation’the patientshouldbeintubatedpriortotransfbr.

Atpresent’thereisinsufficientevidencetosupport theroutineuseofsteroidsmspmalcordiIUu1V.

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SceⅡa『io■coⅡclusioⅢThepatIentwas admittedt0theinten5iveca『eunit!unde『went ｛ixati0n0fhisceⅣicaI5pIne／andwasuItimateIy t『an5fe『『edt0aspinaIc0『d「ehabiIitati0ncente『

TRANSFER Patientswithspmefracturesorneurologicde丘cit shouldbetransfbrredtoadefinitive﹣carefhcih叮.The safbstprocedureistotransfbrthepatientaftertel-

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ChapterSunnnary ⅢThespinalcolumnconsistsofcervical,thoracic’andlumbarvertebrae.Thespma1 cordcontainsthreeimportanttracts:thecorticospinaltract’thespinothalamic tract’andthedorsa1cohnnns. 圍Obtainimages’Whenmdicated’assoonaslifb冒threatemngmjuriesaremanaged. Documentthepatient’shisto】yandphysicalexaminationsoastoestablisha baselinefbranychangesmthepatient,sneurologicstatus. 圓Spmalcordinjuriesmaybecompleteormcompleteandmaymvolveanylevelof thespina1cord. 四Attendtohfb﹣threateninginjuriesfirst’minimizingmovementofthespmalcol﹣ umn.EstabhshandmaintainproperimmobilizationofthepatientuntⅡvertebral fracturesandspinalcordmjurieshavebeenexcluded·Obtaineanyconsultation withaneurosurgeonand／ororthopedicsurgeonwheneveraspinalinjuryissus﹣ pectedordetected· 回TransfbrpatientswithvertebralfracturesorspinalcordhUuriestoadefinitive﹣ carefhcⅢty. ﹂

■BⅡOGⅢⅡγ 1.BachCM,SteingruberIE’PeerS,etal.Radiographic evaluationofcervicalspinetrauma.Plainradiography andconventionaltomographyversuscomputedtomog raphy﹣AJ℃〃O㎡几Op乃αα加αSα唔2001;121（7）:385﹣387. 2BachulisBL’LongWI,HynesGD,etal.Clinicalmdica﹣ tionsibrcervica1spmeradiographsmthetraumatized patient.AmJS皿J召1987,153:473﹣477. 3.BerneJD’ReulandKS’VillarrealDH,etal.Sixteen﹣ sⅡcemulti﹣detectorcomputedtomographicangiography improvestheaccura叮ofscreeningfbrbluntcerebrovas﹣ cularinjmy.J乃αMmα2006;60（6）:1204﹣1209;discussion 1209﹣1210· 4.BifIIWL,EgglinT,BenedettoB,etal.Sixteen﹣slicecom﹣ putedtomographicang1ographyisareliablenoninvasive screeningtestfbrclinicallysigniiicantbluntcerebrovas﹦ cularinjuries.JT／.α叨加α2006;60（4）:745﹣751jdiscussion 751﹣752. 5·BrackenMB,ShepardMJ,CollinsWF,etal·Arandom﹣ ized,controⅡedtrialofmethylprednisoloneornaloxone inthetreatmentofspinalcordinjmy;resultsofthe secondNationa1SpinalCordInjuⅣStudy·IVE／咱MM﹫d 1990;322:1405﹣1411.

Ⅱ

＝

6.BrackenMB’ShepardMJ,HolfbrdTR,etal.Methyl﹣ prednisoloneortirlazadmesylateadmimstrationaiter acutespinalcordi呵ury:1﹣yearibllowup:resultsofthe thirdnationalAcuteSpmalCordInjuryRandomized ControlledTrial.JⅣm加sαJg1998;89:699﹣706. 7.BrownCV,AntevilJL’SiseMJ,etal.Spiralcomputed tomographyfbrthediagnosisofcervical,thoracic,and lumbarspmefractures:itstimehascome.eJTmα加α 2005;58（5）:890·895;discussion895-896. 8.ColemanWP,BenzelD’CahillDW,etal.Acriticalappra1﹣ salofthereportingoftheNationalAcuteSpmalCord Inju】yStudies（IIandIII）ofmethylprednisolone1nacute spinalcordinju1y.JSp加α／D方so㎡2000;13（3）:185﹣199. 9ComoJ’etal.Practicemanagementguidelinesfbriden﹦ tificationofcervicalspineiUjuriesfbllowingtrauma: updatefTomtheEasternAssociationfbrtheSurgeⅣof TraumaPracticeManagementGuidelinesCommittee·J Trα【【mα2009;67:651﹣659· 10.CooperC’DunhamCM,RodriguezA·Fallsandm可orinju﹣ riesareriskfhct0rslbrthoracolumbarfractures:cognitive impairmentandmultipleinjuriesimpedethedetectionof backpainandtenderness’J奶uα〃】α1995;38:692﹣696. 11.CothrenCC,BiHlWL’MooreEE,etal.Treatmentfbrblunt cerebrovascularmjuries:eqUivalenceofanticoagulation andantiplateletagents·A『℃／jSα唔2009;144（7）:685﹣90.

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BIBLIOGRAPHY193 12CothrenCC,MooreEE,Biff】WL’etal.Anticoagulati0n isthegoldstandardtherapyfbrbluntcarotidinjuries toreducestrokerate.A｝℃〃Sα唔2004;139（5）:540﹣545; discussion545﹣546 13.CothrenCC,MooreEE,RayCE’etal.Cervicalspine fracturepatternsmandatingscreeningtoruleoutblunt cerebrovascularinjmy·Sα『g它U／2007;141（1）:76﹣82. 14.DaifherRH,SciulliRL,RodriguezA’etal.Imagmgfbr evaluationofsuspectedcervicalspinetrauma:a2﹣year analysis.I）VαJ:y2006;37（7）:652﹣658 15.DziurzynskiK,AndersonPA,BeanDB,etal.Ablinded assessmentofradiographiccriteriafbratlanto﹣occipital dislocation.劬加e2005;30（12）:1427-1432. 16.EastmanAL’ChasonDP’PerezCL,etalComputed tomographicang1ography｛brthediagnosisofbluntcer﹣ vicalvascularinjuIy:isitreadyfbrprimetime?JTmαmα 2006;60（5）:925﹣929;discussion929. 17.GhantaMK,SmithLM,PolinRS,etal.Ananalysisof EasternAssociationfbrtheSurgeIyofTraumaprac﹣ ticeguidelinesfbrcervicalspineevaluationinaseries ofpatientswithmultipleimagingtechniques·AmSα唔 2002;68（6）:563﹣567;discussion567﹣568. 18.GoodwinRB’BeeIyPRII’DorbishRJ’etal.Computed tomographicang1ographyversusconventionalangiog raphyfbrthediagnosisofbluntcerebrovascularinjuIy intraumapatients·JTrααmα2009;67（5）:1046﹣50. 19·GroganEL’MorrisJA’DittusRS’etal.Cervical spineevaluationinurbantraumacenters:lowering institutionalcostsandcomplicationsthroughhelicalCT scan.cJAmα〃Sα唔2005;200（2）:160﹣165. 20.GulyHR,BouamraO’LeckyFE,Theincidenceofneuro﹣ genicshockinpatientswithisolatedspinalcordinju】yin theemergen叮department·Resαsc肱α匝o几2008;76:57﹣62 21.HarrisJH’CarsonGC,WagnerLK,etal.Radiologic diagnosisoftraumaticoccipitovertebraldissociation:2. Comparisonofthreemethodsofdetectingoccipitoverte﹣ bralrelationshipsonlateralradiographsofsupinesub﹣ jects.A慮／RA加JRoe〃咱e〃o!1994;162（4）:887﹣892. 22’HoffinanJR’MowerWR’WolfbonAB’etal.Validityof asetofclinicalcriteriatoruleoutinjuIytothecervi﹣ calspineinpatientswithblunttrauma,ⅣE唔JMed 2000;343:94﹣99. 23HolmesJF,AkkinepalliR.Computedtomographyversus plainradiographytoscreenfbrcervicalspineinjuIy:a meta﹣analysis.cJTrααmα2005;58（5）:902﹣905. 24HurlbertHIStrategiesofmedicalinterventionin themanagementofacutespinalcordmjuIy·Spi〃e 2006;31（11Suppl）:S16﹣S21;discussionS36. 25.HurlbertRJ.Theroleofsteroidsinacutespinalcord injuIy:anevidence﹣basedanalysis.Sp加e2001;26（24 Suppl）:S39﹣S46. 26·血陀mα肱o几α／Stα〃dαrds／brⅣbα”／Og!cα／α〃dF｝mc肱o〃α! ααss帆cα〃o〃O／SPmα／α㎡I）VαUl·Atlanta’GA:Ameri﹣ canSpinalInjuryAssociationandInternationalMedical SocietyofParaplegia（ASIA／IMSOP）;1996.

27.KrassioukovAV,KarlssonAK’WechtJM’etal.Assess﹣ mentofautonomicdyshmctionfbllowingspinalcord injuIy:rationalefbradditionstoInternationalStan﹣ dardsfbrNeurologicalAssessment·JRe力αbt』ResDeu 2007;44:103﹣112· 28.MarionDW,PIyzybylskiG.InjuIytothevertebraeand spinalcord.In:MattoxKL’FelicianoDV’MooreEE,eds. 7?mα加α.NewYork’NY:McGraw﹣Hill;2000:451﹣471. 29.McGuireRA,NevilleS,GreenBA,etal.SpineinstabⅡity andthelog-rollingmaneuver·EJTrααmα1987;27:525-531. 30.MichaelDB,GuyotDR’DarmodyWR.Coincidenceofhead andcervicalspineinjmy.cJⅣbα巾fmα加α1989;6:177﹣189. 31.MowerWR’HoffmanJR,PoⅡackCV,etal.Useofplain radiographytoscreenfbrcervicalspineimuries.Am2 E加e唔Med2001;38（1）:1-7. 32.PatelJC’TepasJJ’MoⅢttDL’etal.Pediatriccerv1﹣ calspineinjuries:defimngthedisease.J几dtα仃S皿唔 2001;36:373﹣376. 33.PerettiVanmarckeR,etal.Chnicalclearanceofthe cervicalspineinblunttraumapatientsyoungerthan3 years:amulti﹣centerstudyoftheAmericanAssociation ｛brtheSurge】yofTrauma.Jγm叨mα200967:543﹣550· 34.SanchezB,WaxmanK,JonesT’etal.Cervicalspineclear﹣ anceinblunttrauma:evaluationofacomputedtomog raphy﹣basedprotocol.J乃uαmα2005;59（1）:179﹣183. 35.SayerFT’KronvallE’NⅡssonOG·Methylprednisolone treatmentinacutespinalcordinjury:themythchal﹣ lengedthroughastructuredanalysisofpublishedlitera﹣ ture.助加eJ2006;6（3）:335﹣343· 36.SchenartsPJ’DiazJ,KaiserC’etal.Pmspectivecompar﹣ isonofadmissioncomputedtomographicscanandplain lilmsoftheuppercervicalspineintraumapatientswith alteredmentalstatus·cJTmα加α2001;51（4）:663﹣668; discⅢssion668﹣669. 37.ShortDJ’ElMWS’JonesPW.Highdosemethylpred﹣ nisoloneinthemanagementofacutespmalcordinjury＿ aSystematicreviewfromacⅡnicalperspective.助mα』 α㎡2000;38（5）:273﹣286. 38.SteinDM’BosweⅡS,ShkerCW’etal.Bluntcerebr﹣ ovascularinjuries:doestreatmentalwaysmatter?J T】mα加α2009﹩66（1）:132﹣42;discussion143﹣4. 39.StieⅡIG’ClementCM’GrimshawJ’et·al’Implementa﹣ tionoftheCanadianC﹣SpineRule;prospective12centre clusteI.randomisedtrial.BMJ2009;339:b4146· 40.StiellIG,WellsGA’VandemheenKL,etalTheCanadianC-Spineruleofradiographyinalertandstable traumapatients.c／AMA2001;286:1841﹣8· 41.TatorCH,FehlingsMG.Reviewofthesecondarymjury theoIyofacutespinalcordtraumawithspecialemphasis onvascularmechanisms.JⅣeαrosα唔1991;75:15﹣26. 42·ⅥcellioP’SimonH’PressmanB’etal.Aprospective multicenterstudyofcervicalspineinjuIyinchildren. 几diα〃!cs2001;108（2）.

∣

h■ 涵 ∣ l

SK叮Ⅱ』S叨ATION

L 一 ﹣

X·RayIdentificationofSpineI叮Ⅲies ＝

卜﹥∣NTERACT!VESI《IU pR0「FDURES

O吋ectives

／Vote:Thi5SkillStationindudesasystem﹣ aticmethodfo「evaIuatingsplnex﹦『ayfiIm5’ Ase『iesofx﹣『ayswith「elatedscena『iosis sh0wntostudent5fo『thei『evaluationand managementdecision5basedonthefind﹣ ings.Standa『dp『ecautionsa『e『equi『ed wheneve『ca『ingfo『t『aumapatients.

pe「↑o『manceatthis5killstationwi∣IaIlowthepa「ticipantto:

ⅢIdentifyva『iousspinein】u「lesbyu5ingspedficanatomicguideIines fo『examinlnga5e『∣esofspinex﹣『ays.

圓Gv i enase「e i sofspn l ex﹣『aysandscena『o i s: ·DefineIimitationSofexamination ·Diagnosef「actu『es. ·Delineateassociatedin】u「ies. ·ldentifyothe『a『easofpoSsibIeinIu『y

『ⅡE『0LL0WINGPR0CEDURESARE IⅡα0DED!ⅡTⅡIssl《luSTATI0Ⅱ:

〉卜SkiⅡX!﹦A:CervicalSpineX﹣Ray Assessment 卜卜SkiⅡXI﹣B:Atlanto﹣Occipital JointAssessment

〉卜S!《iⅡX!·CThoracicand LumbarX﹣RayAssessment ）卜SkiIIXI·D;ReviewSpineX戶Rays

194

■

▽↗ ∣

SKlLLSTATI0NX∣■X-RayIdentificati0n0fSpineIn】u『ie5195 I

卜SCENAR!0s PATlENTXI﹣1

PATIEⅡTXI﹣8

28-year﹣oldma1efbⅡwhilemountainbiking.Noneurologicdeficit.

45-year-oldfbmaleattemptedtohangherself＼GCS scoreof7.

pATIEⅡTXI﹣Z

pATIEⅡTXI﹣9

54﹣year﹣oldmalehitatreewhiledrivinghiscar.Symp﹣ tomsareonlyslightdiscomfbrtofhisneckandsome numbnessinhisdigitV’leftside.

30-year-oldmaleinmotorvehiclecraShversustree. Patientwasrestrained,buttherewasnoairbag.GCS sc0reof15;neurologicexamintact;patientreports neckpain.

PATIEⅡTX∣﹣3 8﹣year﹣0ldchildfblldownthestairsandiscrymg·No neurologicdeficit.

pATlEⅡTXl﹣10 36﹣year﹣oldmalefbllfromaheightgreaterthan3me﹣ tersandhasbackpain.

PATIEⅡTX∣﹣4 62﹣year﹣oldmalehitanabutmentwhiledrivinghis car·Thereisnoneurologicdeficit,thepatientisun﹣ abletoactivelymovehisneckbecauseofpain·

pAT∣EⅡTX∣﹣5 19﹣year﹣oldfbmalewithheadandnecktraumaasthe resultofanassault. PATIEⅡTX!﹣6

pATlEⅡTXI﹣11 30﹣year﹣oldmaleinvolvedinmotorcyclecrash.Onex﹣ amination,heappearstohaveasens0ryandmotor deficitinvolvingbothlegs.Deep﹣tendonreflexesa】?e absent·

pATIEⅡTXI﹦1z 25﹣year﹣oldfbmaleinvolvedinmotorvehiclecrash.Pa﹣ tientwaswearingalapbeltwithoutshoulderharness. Noneurologicdeficit.

22-year﹣oldmalestruckatreewhileridinghismotor﹣ cycle·Noneurologicdeficit.

pATIEⅡTXI﹦7 44﹣year-oldmale;boxfbllonhead.Painfhlneck,no neurologicdeficit.

I

卜SI《illXl﹦A:Ce『vicaISpineX昌RayAssessment STEP1·

AssessadequaCyandalignment（■FlGuRExI﹣1） AIdentiiythepresenceofall7cervical vertebraeandthesuperioraspectofT1. B·Identifythe; ·Anteriorvertebralline ·Anteriorspinalline ·Posteriorspinalline ·Spinouspr0cesses

STEPz

Assessthebone（■「IGuRExI﹣2）. AExamineallvertebraefbrpreservationof heightandintegrityofthebonycortex· B·R文月mihP炮cets. CExaminespinousprocesses.

5TEp3·

Assessthecartilage’includingexamining thecartilaginousdiskspacesfbrnarrowing orwidening（see■F!GUREXI﹣Z）.

196SKILLSTATIONXI■X-RayIdentificationofSpIneIn】u『ies sTEp4

AExaminetheouthneofthedens. B·Examinethepredentalspace（3mm）. C·Examinetheclivus;itshouldpointto thedens.

B

C ＼ 巳 ＼

Assessthedens（■FIGuRExl3）

A

5TEP5·

AssesstheextraaxialsofMissues. AExaminetheextraaxialspaceandsoft tissues ·7mmatC3 ·3cmatC7

＼

B·Examinethedistancesbetweenthe sp1nousprocesses·

l

l

／

／ ■『IGUREXl.1A5sessadequacyandalignment.LineA; Ante「io『ve「teb『aIIine;LineB:Ante『io「spinaIline﹩Line Cposte『io『spinaIIine;UneD:Spinousp「0cesses.

■F∣GUREX】﹣3AsSessthedens

■FIGUREXl﹣2Asse5stheb0ne（blacl﹤lines）『ca「tiIage〃 anddisl﹤space（whitedottedIines）.

SKILL5TATIONXI■X-RayldentificationofSpineInju『ies197 I

〉SI《i∣IXI﹣B:At∣anto﹦0ccipital』ointAssessment Detectionofanatlanto﹣occipitaldislocationcanbe challenging.OneusefhlfindingisaPower,sratio＞1 （BC／OA’whereBCisthedistancefiyomthebasion 【B〕totheposteriorarch〔C】ofC1’andOAisthedis﹣ tancehomtheanteriorarchofC1【A】totheopisthion 【O’theposteriormarginofthefbramenmagnum】）. Wackenheim’sline,drawnalongtheclivus,doesnot

intersectthedensonanormallateralcervicalspine radiograph.Ifanatlanto.occipitalinjuryissuspected, spinalimmobilizationshouldbepreserved》andexpert radiologicmterpretationshouldbeobtained·■「IGuRE Xl.4AshowsanormalPower）sratio,and■F∣GUREXMB showsanabnormalPower,sratio.

C0﹣C1INST汍BlLITγ

NOR川AL

Wackenheim’s【ine

Wackenheim,s【ine 0 0

BC／AO（powe『,s「ato i ）≦1

8C／AO（Powe「,s「ato i ）﹥1

BC

BC

AO

Ao

■『IGUREXI﹣4AtIanto﹣occipitaI】ointa55e55ment.（A）No『maIpowe『’s『atio;（B）Abno『maIPowe『’s『atio

198SKlLLSTATIONXl■X﹣RayIdentificationofSpineIn】u『ies I

rSl《iⅡXI﹦CTho『acicandlumba『X﹣RayAssessment 卜rANTER0p0STERI0RVIEW sTEP1.

AsSeSS允r: AAhgnment B·Symmetryofpedicles C·Contourofbodies D.Hei卯tofdiskspaces 巳Centralpositionofspinousprocesses

rSkⅡIXI﹣D:ReviewSpineX﹣Rays TheinstructorwⅡldisplayaseriesoffilmstobeinter﹣ pretedanddiscussedwithstudents.

卜卜lATERAlVIEW sTEp2’

ASsess比r: AAlignmentofb0dies／angulationofspine B·Contourofbodies CPresenceofdiskspaces D.Encroachmentofbodyoncanal

瓩 SⅨ『『J』SIHTION

■ ＝

︼

盯

■ 步 ＼已 ⅥE

︸ ﹂

↖

∣ I

SpinalCordInjⅡryAssessInentandManageInent ﹦

b）∣ⅡTERAC『lVES∣《ILL PR0CEDURES

Objectives

／Vote:Standa『dp『ecautionsa『e『equi『ed wheneve『ca『Ing↑o『t『aumapatients‘Thi5 SkiIIStationinc∣ude5scena『∣o5and『elated x﹣『aysfo「useinmakingevaIuationandman﹣ agementdecisionsbasedonthe↑indings.

Pe『fo『manceatthisskillstati0nwiIIaIIowthepa『ticipantt0:

ⅢDemonst「atetheexaminationofapatientinwhomspineand／o『 spinaIco『dinlu『iesa『esuspected 圓Explainthep「inciplesfo「immobilizIngandIog「oIlingpatientswith neckand／b『5pn i a∣n iu l 『e i s’n i cIudn i gthen i dIcato i ns↑o『『emovn ig p『otectivedevices. 圓pe「fo『maneu『oIogicexaminationanddete『minetheIevelofspInal co『dni】u『y.

TⅡE『0UOWINGPR0CEDURESARE IⅡα0DEDlNTⅡlSSl《IlLSTAT∣0Ⅱ:

b〉Ski∣IXⅡ﹣A:PrimarySurvey andResuscitation＿Assessmg SpineI叮uries

圍Dete『minetheneedfo『neu『osu『gicaIconsuItation. 圃Dete「minetheneedfo『inte「hospitalo『int『ahospitaIt「ansfe「’ anddesc『ibehowthepatientsh0uldbep「0pe『IyimmobiIizedfo『 「 t anSe f『·

〉〉SkiⅡX!!﹣B:Seconda】ySurvey＿ NeurologicAssessment 卜卜SkiIIXⅡ.CExHminHtionfbr LevelofSpmalCordInju】y

＝

卜卜SkiⅡX!l﹣D:Treatment PrmciplesfbrPatientswith Spina1CordIIUuries 〉卜SkiI!XⅡ﹣E:PrinciplesofSpme ImmobilizationandLogrolling

199

200SKILLSTATlONXlI■SpinaIC0「dln】u『yAssessmentandManagement

）SCENARl0S SCEⅡARIOXlI﹣1 A15﹃year﹣oldmaleisridinghisbiCyclethroughapark﹣ inglot.Heisdistractedandhitsacaratlowspeed whenitbacksoutofaparkingspace.Heisthrown fromhisbiCycleacrossthetrunkofthecarandsus﹣ tainsamⅡdabrasionandanangleddefbrmityofthe leftwrist.HeisbroughttotheemergenCydepartment （ED）immobⅡizedonalongspineboardwithasemi﹣ rigidcervicalcoⅡarinplace.Heisalertandcoopera﹣ tiveandhasnohemodynamicabnormalities.

5CEⅡARI0XI∣﹣Z A75﹣year-oldmaleiswalkingtothestorewhenhe tripsandfhllsfbrward’strikinghischinonaparked car.HeistransportedtotheEDimmobilizedonalong spineboardwithasemirigidcervicalcollarapplied· Hehasanabrasiononhischinandisalertandappro﹣ priatelyresponsive.Physicalexaminationrevealspa﹣ ralysisofhishands’withverylittlefingermotion.He hassomeupper﹣extremitymovement（grade2／5）’but isclearlyweakbilaterally.Examinationofthelower extremitiesrevealsweakness,butheisabletoflexand extendbothhislegsatthehipandknee·Hehasvari﹣ ousareasofhypesthesiaoverhisbody.

SCEⅡARI0XⅡ﹣3 A25year﹣oldmalepassengersustainsmultiplei叮uries inacarcolhsion.Thedriverdiedatthescene.Thepa﹣ tientistransp0rtedtotheEDimmobilizedonalong

spineboardwithasemirigidcervicalcoⅡarapplied· O汀genisbeing日dmihistered’andadmimstrationof warmedcrystalloidfluidswithtwolarge﹣caliberintravenouslinesisinitiated.Hisbloodpressureis85／40mm Hg’hisheartrate130beats／min,andhisrespirato1y rate40breaths／min.Hisrespirationsaresha1low’and theIeisacontusi0n0verthechestwall.His叮esare open’andhisverbalresponseisappropriate.Heisable t0Shrughisshoulders’butisunabletoraisehiselbow totheshoulderlevelormovehislegs.

SCEⅡARl0XII﹣4 ThisscenarioisessentiallythesameasScenarioXII﹣3, buttheinstructorwⅡlmakechangesinthepatient》s neurologicstatusasthestudentexaminesthepatient. A25﹣year﹣oldpassengersustainsmultipleinjuriesin acarcoⅢsion·Thedriverdiedatthescene.Thepas﹣ sengeristransportedtotheEDimmobilizedona longspineboardwithasemirigidcervicalcollarap﹣ plied.Oxygenisbeingadministered,administrationof warmedcrystalloidfluidswithtwolarge﹃caliberintra﹣ venouslinesisinitiated.

SCEⅡARI0XⅡ﹣5 A6﹣year﹣oldmalefbⅡoffhisbiCycleandhitthebackof hishead.IntheED’hisheadandneckareinaflexed positi0n,andhereportspaininhisneck·Heisimmo﹣ bilizedonanunpaddedlongspineboardwithoutacer﹣ vicalcoⅡHT﹣

SKILLSTATIONXII■SpinaICo『dIniu『yA5se55mentandManagementZ01

》SI《iIXⅡ﹣A:P『ima『ySu『veyandResuscitation－AssessingSpinelⅡiu『ies B·Replacefluidsfbrhypovolemia. C.IfspinalcordiIUuryispresent’fluid resuscitationshouldbeguidedbymom﹣ toringcentra1venouspressure（CVP）. （Ⅳbtc:Somepatientsmayneedinotropic support.） D·Whenperfbrmingarectalexamination befbremsertingtheurinarycatheter’ assessfbrrectalsphinctertoneand sensation.

IVb花『Thepatientshouldbemaintainedmasupine,neu﹣ tra1p0sitionusmgproperinnnobilizationtechniques· STEP1.Airway: AAssesstheairwaywhⅡeprotectmgthe cervicalspine. B.EstablishadeⅡmtiveairwayasneeded. S丁EP2·Breathing:Assessandprovideadequate oxygenationandventⅡatorysupportas needed. STEP3·

Circulation:

STEP4

A·Ifthepatienthashypotension,dif〔bren﹣ tiatehypovolemicshock（decreasedblood pressure’increasedheartrate’andcool extremities）lromneurogemcshock（de﹣ creasedbloodpressure’decreasedheart rate’andwarmextremities）.

Disability－BriefNeurologicExamination: ADeterminelevelofconsciousnessand assesspupⅡs. B.DetermineGlasgowComaScale（GCS） score·

C.Recognizeparalysis／Paresis.

I

〉SI《iIIXⅡ﹣B:Seconda『ySu『vey－Ⅱeu『oIogicAssessment STEP1.ObtainAMPLEhistory.

B‘Assessfbrpam》paralysis,and

AHistoryandmechanismofi叫u1y B·Medicalhistory CIdenti句andrecorddrugsg1venpriorto thepatient’sarrivalandduringtheas﹣ sessmentandmanagementphases

paresthesia: ·Presence／absence ·Location ·Neurologiclevel CTestsensationtopinprickinallder﹣ matomesandrecordthemostcandal dermatomethatfbelsthepinprick. D·Assessmotorfhnction. E·Measuredeeptendonreflexes（least infbrmativemtheemergenCysetting）. 『·Documentandrepeat＿rec0rdthere﹣ sultsoftheneurologicexaminationand repeatmotorandsensoryexamm月忖nh只 regularlyuntilconsultationisobtained.

5TEP2·Beassesslevelofconsciousnessandpupils· 5『EP3·ReassessGCSscore. SγEP4’Assessthespine（SeeSkillXII﹣C:Examina﹣ tionfbrLevelofSpinalCordI叮ury） APalpatetheentirespineposteriorlyby carefhllylogroⅡingthepatientandas﹣ sessingfbr; ·Defbrmityand／0rswelling ·Crepitus ·Increasedpainwithpalpation 。Contusionsandlacerations／penetrat﹣ ingwounds

STEp5·

Reevaluate－Assess允rassociated／occult ●

●

●

mJur1es·

Z0ZSl﹤ILLSTATIONXII■SpinaIC0『dInju「yAssessmentandManagement

卜Sl《ilXⅡ﹣CExaminationfo『leve∣ofSPina∣Co『dIniu『y ·Flexesknee＿hamstrings’L4﹣L5toS1 ·Dorsiflexesbigtoe＿extensorhallucis

Apatientwithaspinalcordmjurymayhavevarying levelsofneurologicdeficit·Thelevelofmotorhmcti0n andsensationmustbereassessedfTequentlyandcare﹣ fhllydocumented,becausechangesintheleveloffhnc﹣ tioncanoccur· STEP1.BestM0torE文Hmihation

longus,L5 ·PlantarfIexesankle＿gastrocnem1us, S1 5TEP2.

ADeterminingthelevelofquadriplegia, nerverootlevel: ·Raiseselbowtolevelofshoulde1﹂

SensoryR文月mih月付◎n:Determihih口the levelofsensationisdoneprimarilyby assessmgthedermatomes.SeeFigure 7·3inChapter7 SpineandSpina1Cord Trauma.Remember,thecervicalsensory dermatomesofC2throughC4fbrmacerv1﹣ calcapeormantlethatcanextendd0wnas fhrasthenipples.Becauseofthisunusual

deltoid,C5 ·Flexesfbrearm－biceps,C6 。Extendsfbrearm－triceps,C7 ·Flexeswristandfingers’08 ·Spreadsfingers,T1

pattern,theexaminershouldnotdependon thepresenceorabsenceofsensationinthe neckandclaviculararea,andthelevelof

B·Determiningthelevelofparaplegia, nerverootlevel ·Flexeship＿iliopsoas,L2 ·Extendsknee＿qUadriceps,L3﹣L4

sensationmustbecorrelatedwilhthemotor responselevel.

I

卜SkiIlXⅡ.D:T『eatmentP『incipIesfo『PatieⅡtswithSpina∣Co『dlniu『ies sTEP1·

Patientswithsuspectedspineinjmymust beprotectedfromfUrthermjury.Such protectionincludesapplyingasemirigid cervicalcollarandlongbackboard’per﹣ 允rmingamodifiedlogroⅡtoensureneutral alignmentoftheentirespine’andremovmgthepatientfTomthelongspineboard assoonaspossible.Paralyzedpatients whoareimmobihzedonalongspineboard areatparticularriskfbrpressurepoints anddecubitusulcers·Therefbre,para】yzed patientsshouldberemovedfromthelong spmeboardassoonaspossibleafteraspine injuryisdiagnosed’i.e.,within2hours·

STEpZ·

FluidResuscitationandMonitoring: A·CVPmonitoring:Intravenousfluids usuallyarelimitedtomaintenance levelsunlessspecificallyneededfbrthe managementofshoCk·Acentralvenous cathetershouldbeinsertedtocarefUlly monitorfluidadmihistration. B·Urinarycatheter:Aurmarycatheter shouldbeinsertedduringtheprima1y surveyandresuscitationphasestomoni﹣ torurina1youtputandpreventbladder distenti0n. C.Gastriccatheter:Agastriccatheter shouldbeinsertedinallpatientswith paraplegiaandqUadriplegiatoprevent gastricdistentionandaspiration.

SI﹤ILLSTATIONXII■Spina∣C0『dIn】u『yAssessmentandManagementZ03

〉SI《iIIXⅡ﹣E:P『incipIesofSpinelmmobiIizationandlog『o∣Iing andneck’cautiouslylogroⅡthepatient asaunittowardthetwoasSistantsatthe

）bADUlTpATIEⅡT Fourpeopleareneededtoperfbrmthemodifiedlog rollingprocedureandtoimmobilizethepatient＿fbr example,onalongspineboard: ■onepersontomaintainmanual,inline nnmobilizationofthepatient,sheadand neck ■onefbrthetorso（includingthepelvis andhips） ■onefbrthepelvisandlegs ■onetodirecttheprocedureandmovethe spineboard Thisproceduremaintainsthepatient’sentirebodyin neutralalignment’therebyminimizinganyuntoward movementofthespine.Thisprocedureassumesthat anyextremi叮suspectedofbeinghacturedhasalready beenimmobi】ized.

STEP↑.Placethelongspineboardwithstrapsnext tothepatient’sside.Positionthestrapsfbr fasteninglateracrossthepatient,sth0rax’ justabovetheiliaccrests》acrossthethighs’ andjustabovetheankles.Strapsortape canbeusedtosecurethepatient,sheadand necktothelongboard. 5TEPZ·App】ygentle,inlinemanualimmobilization tothepatient’sheadandapplyasemirigid cervicalcollar.

S『EP3.Gentlystraightenandplacethepatient,s arms（palmin）nexttothet0rso· STEP4

CarefUllystraightenthepatient,slegsand placetheminneutralalignmentwiththe patient’sspme.Tietheanklestogetherwith aroller﹣typedressingorcravat.

STEP5·

Whilemaintainingalignmentofthepatient,s headandneCk,anotherpersonreaChes acrossandgraspsthepatientattheshoul﹣ derandwrist·Athirdpersonreachesacross andgraspsthepatient》shipjustdistalto thewristwithonehand,andwiththeother handfirmlygraspstherollerbandageor cravatthatissecuringtheanklestogether.

S『EP6·Atthedirectionofthepersonwhoismain﹣ taimngimmobilizationofthepatient,shead

patient,sside,butonlytotheleastdegree necessarytopositiontheboardunderthe patient.Maintainneutralalignmentofthe entirebodyduringthisprocedure. 5TEP7·

Placethespineboardbeneaththepatient andcarefhllylogroⅡthepatientmone smoothmovementontothespmeboard. Thespineboardisusedonlyfbrtransfbr﹣ ringthepatientandshouldnotbeleft underthepatientfbranylengthoftime.

5TEp8.

Considerpaddingunderthepatient’shead toavoidhyperextensionoftheneckandfbr patientcomfbrt.

STEP9.

Placepadding,roⅡedblankets’orsimilar bolstermgdevicesonbothsidesofthepa戶 tient,sheadandneck,andfirmlysecurethe patient,sheadtotheboard.Tapethecerv1﹣ calcollar,fUrthersecuringthepatient’s headandnecktothelongb0ard.

卜rPEDIATRICPATIEⅢ Apediatric﹣sizedlongspineboardisprefbrablewhen immobilizingasmallChild.Ifonlyanadult﹣sizedboard isavailable’placeblanketroⅡsalongtheentiresidesof thechildtopreventlateralmovement.Achild’sheadis proportionate】ylargerthananadult,s.Therefbre’pad﹣ dingshouldbeplacedundertheshoulderstoelevatethe torsosothatthelargeocciputofthechild,sheaddoes notproduceflexionofthecervicalspme;thismaintains neutralaligmnentoftheChⅡd’sspme.Suchpaddinge西 tendsfiPomtheChⅡd’slumbarspmetothet0pofthe shouldersandlaterallytotheedgesoftheboard.

bbC0ⅢPUcATI0ⅡS Ifleftimmobilizedfbranylengthoftime（approx1﹣ mately2hoursorlonger）onthelongspineboard’ pressuresorescandevelopattheocciput,scapulae’ sacrum》andheels’Therefbre,paddingshouldbeap﹣ phedundertheseareasassoonaspossible’andthe patientshouldberemovedhPomthelongspineboard ass0onashisorherconditionpermits.

Z04SKlLLSTATIONXlI■SpinaIC0『dIniu『yAssessmentandManagement portingsurface.Thetransfbroptionslisted belowmaybeused’dependingonavailable

P〉REM0VAlFR0MAl0ⅡGSPⅡ＼』EB0ARD Movementofapatientwithanunstablevertebral spineinjurycancauseorworsenaspinalcordinjury. Toreducetheriskofspinalcorddamage,mechanical

personnelandequipmentresources. STEP¢·

ModifiedLogrollTechnique:Themodified logrolltechnique,previouslyoutlined’isre﹣ versedtoremovethepatientfromthelong spineboard.Fourassistantsarerequired: onetomaintainmanual’inlineimmobiliza﹣ tionofthepatient,sheadandneck;onefbr thetorso（includingthepelvisandhips）; onefbrthepelvisandlegs;andoneto directtheprocedureandremovethespine b0ard.

sTEP5·

ScoopStretcher:Thescoopstretcherisan alternativetousmgthemodifiedlogrolling techniquesfbrpatienttransfbr.Theproper useofthisdevicecanproviderapid,safb transfbrofthepatientfTomthelongspine boardontoafirm’paddedpatientgurney· Forexample’thisdevicecanbeusedto transfbrthepatientfromonetransportde﹣ vicetoanotherortoadesignatedplace（e.g., x﹣raytable）. Thepatientmustremainsecurelyim﹣ mobilizeduntilaspineiIUmyisexcluded. Afterthepatientistransfbrredfromthe backboardtothegurn叮（stretcher）and thescoopstretCherisremoved’thepatient mustagambeimmobⅡizedsecurelyonthe gurney（stretcher）.Thescoopstretcheris notadeviceonwhichthepatientisimmobi﹣ lized.Inaddition,thescoopstretcherisnot usedtotransportthepatient,norshould thepatientbetransfbrredtothegurn叮by

protectionisnecessa】yfbrallpatientsatrisk.Such protectionshouldbemaintaineduntilanunstable spineiIUmyhasbeenexcluded. S『EP1·Asprevious】ydescribed’propeHysecurethe patienttoalongspineboard,whichisthe basictechniquefbrsphntingthespine.In general’thisisdoneintheprehospitalset﹣ tingandthepatientarrivesatthehospital alreadyimmobilized.Thelongspineboard providesaneffbctivesplintandpermits safbtransfbrsofthepatientwithaminhnal numberofassistants.However’unpadded spmeboardscansoonbecomeuncomfbrtable fbrconsciouspatientsandposeasignificant riskfbrpressuresoresonposteriorbony pronunences（occiput,scapulae’sacrum, andheels）.Therefbre,thepatientshouldbe transibrredfromthespmeboardtoafirm’ well﹣paddedgurneyorequivalentsurfaceas soonasitcanbedonesafbly.Befbreremov﹣ ingthepatientfromthespineboard’c﹣spine, chest’andpelvisx﹣rayfilmsshouldbeob﹣ tainedasmdicated’becausethepatientcan beeasi】yⅡftedandthex﹣rayplatesplaced beneaththespmeboard·WhⅡethepatient isimmobⅢzedonthespmeboard,itisve】y importanttomaintainimmobilizationofthe headandthebodycontinuously·Thestraps usedtoimmobⅡizethepatient0ntheboard shouldnotberemoved仕omthebodywhⅡe theheadremainstapedtotheupperportion ofthespineboard. STEPZ

Bemovethepatienthomthespineboardas earlyaspossible·Preplanningisrequired.A goodtimetoremovetheboardfTomunder thepatientisWhenthepatientislogroⅡed toevalⅢatetheback.

STEP3.

pickinguponlythefbotandheadendsof thescoopstretcher.Withoutfirmsupport underthestretcher’itcansaginthemiddle andresu1tmlossofneutralalignmentof thespine.

P卜∣MM0BⅢZATI0N0FTⅡEPATIEⅢWlTⅡ p0SS∣BlESpⅢEIⅡ』uRγ

Saibmovement0fapatientwithanunsta﹣ bleorpotentiallyunstablespinerequires contimmusmRintenEmceofanatomic a1ignmentofthevertebralcolumn.Rota﹣ tion,flexion’extension’lateralbending,and shearing﹣typemovementsinanydirection mustbeavoided.Manual,in﹣lineimmobili﹣ zationbestcontrolstheheadandneck.No

PatientsheqUentlyarriveintheEDwithspmalpro﹣ tectivedevicesinplace.Thesedevicesshouldcause theexaminertosuspectthatac﹣spineand／orthoraco﹣ lumbarspinei叮u】ymayexist’basedonmechanismof injury‘Inpatientswithmultipleinjurieswithadimin﹣ ishedlevelofconsciousness’protectivedevicesshould beleftinplaceuntilaspineimuryisexcludedbyclini﹣

partofthepatient,sbodyshouldbeallowed tosagasthepatientishftedoffthesup-

calandx﹣rayPx日mihations·See Chapter7;Spineand SpinalCordTrauma

SKILLSTATIONXII■SpinalCo「dIn】u『yAssessmentandManagementZ05 Ifapatientisimmobilizedonaspineboardandis paraplegic’spmalinstabili叮shouldbepresumedand allappropriatex﹣rayfilmsobtainedtodeterminethe siteofspina1injury.However,ifthepatientisawake, alert,sober,neurologicallynormal,isnotexperienc﹣ ingneckorbackpain,anddoesnothavetendernessto spinepalpation,spinex﹣rayexaminationandimmobi﹣ l｛zationdevicesarenotneeded·

Patientswhosustainmultipleinjuriesandare comatoseshouldbekeptimmobilizedonapaddedgur﹣ ney（stretcher）andlogroⅡedtoobtainthenecessary x﹣rayfilmstoexcludeafracture.Then,usingoneofthe afbrementionedprocedures）theycanbetransfbrred care血llytoabed.

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O吋ectives ⅢExpIainthesignificanceofmuscuIoskeIetaIin】u「iesin patientswithmu∣tipIein】u『ies. 回OutIinep『io「itiesintheassessmentofmuscuIoske∣etaI t『aumatod i entfiyIfie﹣th『eatenn i gandIm i b﹣th『eatenIng∣n」u『Ie5.

圃Explainthep「ope「p『incipIesoftheinitiaImanagement ofmuscuIoske∣etan Ii 】u『e i S. ﹂

H鸛鵝辮騾臘鯊籮

threattolifborlimb.However’musculoskeletal iIUuriesmustbeassessedandmanagedproperlyand appropriatelysolifbandlimbarenotjeopardized· Cliniciansneedtorecognizethepresenceofsuch injuries,befamiliarwiththeanatomyoftheiIUury’ protectthepatientfromfhrtherdisability,and anticipateandpreventcomplications. M匈ormusculoskeletalinjuriesindicatethatsig﹣ nificantfbrcesweresustainedbytheb0dy.F0rexam﹣ ple,apatientwithlong﹣bonehacturesaboveand belowthediaphragmhasanincreasedlikelihoodof ass0ciatedinternaltorsoinjuries.UnstablepelvicfiPac﹣ turesandopenfbmurfiPacturesmaybeaccompanied bybriskbleedingSeeChapter5:AbdominalandPel﹣ vicTraum旦·Severecrushmiuriescausethereleaseof myoglobin’whichmayprecipitateintherenaltubules andresultinrenalfailure.SweⅡingintoanintactmus﹣ culofhscialspacemaycauseanacutecompartment syndromethat’ifnotdiagnosedandtreated’maylead tolastmgimpa1rmentandlossofuseoftheextremity. FatemboⅡsm,anuncommonbuthighlylethalcomph﹣ cati0noflong﹄bonefTactures’mayleadtopulmonary failureandimpairedcerebralfi1nction.

Z07

Z08CHAPTER8■MuscuIoskeleta∣T『auma

Musculoskeletaltra】】madoesnotwarrantareor﹣ dermgoftheprioritiesofresuscitation（ABCDEs）. However’thepresenceofsignificantmusculoskeletal traumadoesposeaChallengetoclinicians.Musculoskel﹣ etali叮uriescannotbeignoredandtreatedatalater time·ThecⅡnicianmusttreatthewholepatient’mcludmgmusculoskeletalinjuries’toensureanoptimalout﹣ come·Despitecarefhlassessmentandmanagementof multipleiIUuries’fracturesandso仳tissueinjuriesmay notbeinitiaⅡyrecognized.Continued『eevaIuationoftlTe

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叨 W／α j 游卹αcMo加肱sc豳o !咖／e刎 ●刎m.i2s〃αUeOⅦ毗epyw〃αyyS卹、Ueyβ

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Durmgthepnmarysurv叮’itisimperativetorecognize andcontrolhemorrhagehommusculoskeletali叼uries （■FlGuRE8﹣1）.Deepsofttissuelacerationsmayinvolve m則orvesselsandleadtoexsanguinatinghemorrhage. Hemorrhagecontrolisbesteffbctedbydirectpressure. Hemo『『hage什omIohg.bohefi‘actu『esmaybesig. ni伺cant,ahdce『tainfbmo『al什actu『esmay『esultinsig. nihcantbIoodIossintothethigh·Appropriatesplinting ofthefTacturemaysignificantlydecreasebleedingby reducingmotionandenhancingatamponadeeffbct ofthemuscle.IfthefTactureisopen’applicationofa sterilepressuredressingusuallycontrolshemorrhage. Appropriateiluidresuscitationisanimp0rtantsupple﹣ menttotheseme「hfmicalmeasures.

aspossibleandtopreventexcessivefracture﹣sitemo﹣ tion·ThisisaccomplishedbytheappⅡcationofin-hne tractiontorealigntheextremityandmaintainedby animmobihzationdevice（■『∣GuRE8﹣2）.Theproper applicationofasplinthelpscontrolbloodloss,reduce pam,andpreventfhrthersofttissueinju】y.Ifanopen fTactureispresent,theclinicianneednotbeconcerned aboutpullingexp0sedbonebackintothewoundbe﹣ causeopenfTacturesrequiresurgicaldebridement. SeeSkillStationX『ⅢMusculoskeletalTrauma:As﹣ sessmentandManagemenLSkillXIII﹣C:Bealigninga DefbrmedExtremity· Jointdislocationsmayrequ1resplintmginthe

positioninwhichtheyarefbund.Ifaclosedreduc﹣ tionhassuccessM】yrelocatedthejoint’immobiliza﹣ tioninananatomicpositionmaybeaccomphshedin anumberofways:prefhbricatedspⅡnts’pⅢows’or plaster.Thesedeviceswillmaintaintheextremi叮in itsreducedposition.

P IⅦ I T F A LL Mu5cuIo5keletalin】u『ie5a『eapotentiaI5ou『Ceof bI0odIossinpatientswithhemodynamicabno『maIi﹣ ties.Site5ofhemo「『hageincIudethethighf「omfem﹣ o『aIf『actu『e5andanyopenf「actu『ewithma】o『soft tissueinvoIvement.

Ad unctstop『ima『ySu『vey ∣ ﹥ M 】

∣

A叮unctstotheprimarysurveyofpatientswithmus﹣ culoskeletaltraumaincludefractureimmobilization andx﹣rayexaminationifthehacturesaresuspected asacauseofshock.

FRACTURE∣MⅢ0BⅢZATI0Ⅱ Thegoalofinitialfractureimmobilizationistorealign theiniuredextremityinasclosetoanatomicposition

■F∣GURE8﹣ZAppIicationof1）in﹣Iinet「action’and thenZ）「0tation0fthedistalIegtono『malanatomi〔 po5iti0n.

SECONDARYSURVEYZ09

Splintsshouldbeappliedassoonaspossible,as theycancontrolhemorrhageandpain·Howeve『,spIint appIicationshouIdhottal《ep『ecedeⅡceove『『esuscitation·

X﹣RAγEXAMIⅡA丁I0N X﹣rayexaminationofmostskeletalinjuriesoccursas thepartofthesecondarysurvey.Thedecisionsregard﹣ ingwhichx﹣rayfilmstoobtainandwhentoobtain themaredeterminedbythepatient,sinitialandobvi﹣ ousclinicalfindings’thepatient,shemodynamicsta﹣ tus,andthemechanismofiniury.

I

■

Scena『io■contmuedThepatienthasn0 abn0『ma∣tie i 5d i ent↑ i e i d0np『Ima『ysuⅣeyandc0n﹣ tinue5t0c0mpIain0↑paint0hisIeg·Ⅱisdista∣pu∣se5 a『en0『maI’hei5abIet0m0vehi5t0e5!andheha5 n0『maIseⅡsati0nAnx﹣「ay0fthel0we『ext「emityiS 0btaineda∣0ngwithIadi0g『aphicevaIuati0n0↑the 〔eⅣI〔alspineduet0hisdi5t『adinginlu『y. ■■■■

∣ ﹥ Seconda『ySu『vey

passenger?Thisfactcanindicatethetypeoffracture－fbrexample’lateralcompressionfTacture ofthepelvisresultinghPomasideimpactina vehiclecollision. Z。Whatwasthepostcrashlocationofthepatient＿ insidethevehicleor句ected?Wasaseatbeltor airbaginuse?Thisinfbrmationmaymdicate patternsofinjury.Ifthepatientwasejected, determinethedistfmceheorshewasthrownEmd thelandingconditions.EjectiongeneraⅡyresults inincreasedinjuryseveri叮andunpredictable patternsofinjmy. 3.Wasthereexternaldamagetothevehicle’such asde允rmationtothehontofthevehiclefiPom ahead﹣oncnlⅡsion?Thisin允】、mHtionraisesthe suspicionofahipdislocation. 4Wasthereinternaldamagetothevehicle’such asbentsteeringwheel）defbrmationtothe dashboard,ordamagetothewmdscreen?These findingsindicateagreaterlikeliho0dofsternal’ clavicular,orspinalfiPacturesorhipdislocation. 5.Wasthepatientwearingarestraint?Ifso’what type（laporthree-pointsafb叮belt）?Wasthe restraintappliedproperly?Faul叮apphcation ofsafb叮restraintsmaycausespinalfTactures andassociatedintraabdominalvisceralinjuries （■F∣GuRE8﹣3）Wasanairbagdeployed?

Elementsoftheseconda】ysurvey0fpatientswith musculoskeletalinjuriesarethehistoryandphysical exHmiⅥRtion.

ⅡIST0Rγ

Keyaspectsofthepatienthisto1yaremechanismofin﹣ jury’enⅥronment’preinjurystatusandpredisposing fhctors’andprehospitalobservationsandcare.

Mechanismofln】u『y Infbrmationobtainedhomthetransportpersonnel,the patient,relatives,andbystandersatthesceneofthein﹣ juryshouldbedocumentedandincludedasapartofthe patient,smedicalrecord.Itisparticularlyimportantto determinethemechanismofinju】y,whichmayarouse suspicionofi叮uriesthatmaynotbeimmediate】yap﹣ parent·SeeBiomechanicsofInjmy（electronicversion only）.ThecⅡnicianshouldmentaⅡyreconstructthe mjuryscene’identi句otherpotentialiIUuriesthatthe patientmayhavesustained,anddetermineasmuchof thefbllowinginibrmationaspossible? 1.Inamotorvehiclecrash’whatwastheprecrash locationofthepatientinthevehicle＿driveror

■FIGURE8﹣3SafetyRest『aint5.Whenw0mco『「ectIy（A）〃 Sa↑etybeltscan『educein】u『ies.Whenwo『ninc0『『ect∣y （B）〃asshownhe「e’bu『5tiniu「iesando『ganIace『ation5can occu脫Hype「flexi0n0ve「aninco『『ectlyappIiedbeltcan p「oduceante『io「comp『essionf『actu『esoftheIumba「5pine

Z10CHAPTER8■MuscuIoskeIetalT『auma

6.Didthepatientfall?Ifso’whatwasthedistance 0fthefall’andhowdidthepatientland?Thisin﹣ fbrmationhelpsident吋thespectrumofinjuries. Landingonthefbetmaycausefbotandankle injurieswithassociatedspinalfractures·

ercisetoleranceandactivitylevel’ingestionofalcohol and／orotherdrugs,emotionalproblemsorillnesses, andprev1ousmusculoskeletalinjur1es.

叭Wasthepatientcrushedbyanohject?Ifso,iden﹣ tifytheweightofthecrushingohject’thesiteof theinjury,anddurationofweightappliedtothe site.Dependingonwhetherasubcutaneousbony surfhceoramuscularareawascrushed’diffbrent degreesofsofttissuedamagemayoccur’rangmg fromasimplecontusiontoaseveredeglovingex﹣ tremityiUjurywithcompartmentsyndromeand tissueloss.

Findingsattheincidentsitethatmayhelptoidenti句

8.Didanexplosionoccur?Ifs0’whatwasthemag﹣ nitudeoftheblast’andwhatwasthepatient’s distancehomtheblast?Anihd『vidualclosetothe explosionmaysustainprimaryblastmjuryfrom thefbrceoftheblastwave.Asecondaryblast injmymayoccurfromdebrisandotherohjects acceleratedbytheblasteffbct（e.g.,fragments）, leadingtopenetratingwounds’lacerations,and contusions.Thepatientalsomaybeviolently throwntothegroundoragainstotherohjectsby theblasteffbct’leadingtobluntmusculoskeletal andother1muries（tertia1yblasteffbct）. 9.Wasthepatientinvolvedmavehicle﹣pedestrian collision?Musculoskeletalinjuriesmayfbllow predictedpatterns（e.g.’bumperm】urytoleg） basedonthesizeandageofthepatient. Envi『onment Askprehospitalcarepersonnelfbrinfbrmationabout theenvironment’including: ■Whetherthepatientsustainedanopen fTactureinacontaminatedenvironment ■Patientexp0suretotemperatureextremes ■BrokenglassfiPagments（whichmayalsomjure theexaminer） ■S0urcesofbacterialcontamination（e.g.,dirt, animalfbces’fTeshorsaltwater） Thisinfbrmationcanhelpthecliniciananticipatep0﹣ tentialproblemsanddeterminetheinitialantibiotic treatment·

P『einiu『yStatusandP『edisposihgFacto『s Itisimportantt0determinethepatient,sbaselinecon﹣ ditionpriortoiUjury’becausethisinfbrmationmay altertheunderstandingofthepatient》scondition, treatmentregimen,andoutcome.TheAMPLEhistory alsoshouldincludeinfbrmationaboutthepatient,sex﹣

p『ehospitaIObse『vationsandCa『e potentialinjuriesinclude: ■Positioninwhichthepatientwasfbund ■Bleedingorpoolingofbloodatthescene, includingtheestimatedamount ■Boneorfractureendsthatmayhavebeen exposed ■Openwoundsinproximi叮to0bviousor suspectedfTactures ■Obviousdefbrmi勺ordislocation ■Presenceorabsenceofmotorand／orsensory fhnctionineachextremity ■Delaysinextricationproceduresortransport ■Changesinhmbfhnction’perfhsion’orneurologicstate’especiaⅡyafterimmobihzationor duringtransfbrtothehospital ■Reductionoffractures0rdislocationsdurmg extricationorsplintingatthescene ■Dressingsandsphntsapplied’withspecial attentiontoexcessivepressureoverbony prominencesthatmayresultinperipheral nervecompressionmjuries’compartment syndromes’orcrushsyndromes. Thetimeoftheinjuryalsoshouldbenoted’espe. ciallyifthereisongomgbleedingandadelayinreach﹣ ingthehospital.Allprehospitalobservationsandcare mustbereportedanddocumented.

PⅡγSICALEXAⅢIⅡAT∣0Ⅱ Thepatientmustbe∞mpIeteIyuhd『essed｛b『adequate examination·Obviousextremityimuriesareoften splintedpriortothepatient’sarrivalintheemergency department（ED）·Therearethreegoalsfbrtheassess﹣ mentoftraumapatients,extremities: 1.Identificationofhfb﹣threateninginjuries（primary survey） Z.Identificationoflimb﹣threatemnginjuries（secondarysurvey） 3.Systematicreviewtoavoidmissinganyother musculoskeletalinjmy（continuousreevaluation） Assessmentofmusculoskeletaltraumamaybe achievedbylookingatandtalkingtothepatient’as

SEC0NDARYSURVEYZ11

wellasbypalpationofthepatient,sextremitiesand perfbrmanceofalogical’Systematicrev1ewofeach extremity.Thefburcomponentsthatmustbeassessed are:skin,whichprotectsthepatientfromexcessive fluidlossandinfbction;neuromuscularfUnction;cir﹣ culato1ystatus;andskeletalandligamentousinteg riby.Usingthisevaluationprocessreducestheriskof missinganinjury.SeeSkiⅡStationXIII:Musculoskel﹣ etalTrauma:AssessmentandManagement ’SkillXIII﹣ A:PhysicalExamination

LookandASk VisuaⅡyassesstheextremitiesfbrcol0randperh1sion, wounds’defbrmity（angulation,shortening）’swellin呂 anddiscolorationorbruising. Arapidvisua1inspectionoftheentirepatientis necessa】ytoidentifysitesofm可orexternalbleeding. ApaleorWhitedista1extremityisindicativeofalack ofarterialinHow.Extremitiesthatareswolleninthe reg1onofmajormusclegroupsmayindicateacrush injurywithanimpendingcompartmentsyndrome. Swellingorecchymosisinoraroundajointand／orover thesubcutaneoussurfhceofaboneisasignofamus﹣ culoskeletalinjury.Extremitydefbrmi叮isanobvious signofm匈orextremi∣Vinjury·Table8.1outlinescom﹣ monjointdislocationdefbrmities. Inspectthepatient’sentirebodyfbrlacerati0nsand abrasions.Openwoundsareobviousunlesstheyare locatedonthedorsumofthebody;therefbre,patients mustbecarefUllylogrolledtoassessfbranimu】yor skinlaceration.Ifaboneprotrudesorisvisualizedin thewound’anopenfiPactureexists·Anyopenw0undto aIimbwithanassociated仕acturealsoisconsideredan openfiPactureuntⅡprovenotherwisebyasurgeon. Observethepatient,sspontaneousextremitymotor fUnctiontohelpident耐anyneurologicand／ormuscu﹣ larimpairment.Ifthepatientisunc0nscious,absent spontaneousextrenntymovementmaybetheonlysign ofimpairedfbnction.Withacooperativepatient’active voluntarymuscleandperipheralnervehmctionmaybe

assessedbyaskingthepatienttocontractm勾ormuscle groups.Theabili叮tomoveallmajorjointsthrougha 血Ⅱrangeofmotionusuallyindicatesthatthenerve﹣ muscleunitisintactandthejointisstable. FeeI Palpatetheextremitiestodeterminesensationtothe skin（neurologicfhnction）andidenti均areasoften﹣ derness,whichmayindicatefiPacture.Lossofsensa﹣ tiontopa1nandtouchdem0nstratesthepresenceofa spinalorperipheralnerveinjury.Areasoftenderness orpa1novermusclesmayindicateamusclecontusion orfTacture.Pain’tenderness,swelling’anddefbrmity overasubcutaneousbonysurfRceusuallyconfirmthe diagnosisofafTacture.Ifpainortendernessisassociatedwithpainfhlabnormalmotionthroughthebone’ fTactureisdiagnosed.Attemptstoelicitcrepitationor demonstrateabnormalmotionarenotrecommended. Atthetimeoflogrollingpalpatethepatient’sback toidentifyanylacerations,palpablegapsbetweenthe spinousprocesses’hematomas’ordefbctsintheposteriorpelvicreg1onthatareindicativeofunstableaxial skeletalinjuries. Closedsofttissuemjuriesaremoredifficultto evaluate.SoiMissueavulsionmaysheartheskinfrom thedeepfascia’allowingfbrsignificantaccumulation ofblood.Alternatively）theskinmaybeshearedfTom itsbloodsupplyandundergonecrosisoverafbwdays. Thisareamayhavelocalabrasionsorbruisedskin, whicharecluestoamoreseveredegreeofmuscledam﹣ ageandpotentialcompartmentorcrushSyndromes· Thesesofttissueinjuriesarebestevaluatedwith knowledgeofthemechanismofmjuryandbypalpat﹣ ingthespecificcomponentmvolved. J0intstabilitycanbedeterminedonlybyclinical examination.Abnormalmotionthroughajointseg mentisindicativeofaligamentousrupture.Palpate thejointtoidentifyanyswelhngandtendernessof thehgamentsasweⅡasintraarticularfluid.FoⅡowing this,cautiousstressingofthespecificligamentscanbe

■TABlE8·1Common』ointD﹟5!o叵ationDefo『m耐es 』0IⅡT

D】RECT!0Ⅱ

0EF0RⅢITγ

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Ante『io「 poste『i0『

Squa『edoff L0Ckedininte『naI『otation

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Poste『io『

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Ante「io『 Poste『i0「

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Knee＊

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Late「allydisplacedosca∣dS

☆Kneedi5Iocation5can5ometimes『educespontaneous∣yandmaynotp『esentwithanyobviousg『ossextema∣o「『adiog『aphicanomaIiesunti∣aphy5ica∣examo↑ theiointispe『fo『medandinstabi∣ityisdetededdini（aⅡy

Z1ZCHAPTER8■MuSCuI0skeIetaIT「3uma

︵

∣

perfbrmed.Excessivepainmaymaskabnormalliga﹣ mentmotionbecauseofguardingofthejointbymus﹣ cularcontractionorspasm;thisconditionmayneedto bereassessedlater.

Ci『CuIato『yEvaluation Palpatethedistalpulsesineachextremityandassess capⅢaryrefill0fthedigits·Ifhypotensionlimitsdigit﹣ alexaminationofthepulse’theuseofaDopplerprobe maydetectbloodflowtoanextremity.TheDoppler signalmusthaveatriphasicqualitytoensurenoproxi﹣ mallesionLossofsensationinastockingorglovedis﹣ tributionisanearlysignofvascularimpairment. Inpatientswithnohemodynamicabnormalities’ pulsediscrepancies’coolness,pallor,paresthesia’and evenmot0rhmctionabnormalitiescansuggestanarte﹣ rialiIUury.Openwoundsandfracturesinproximi叮to arteriescanbecluestoanarterialinjury.ADoppler ankle／brachialmdexoflessthan0.9isindicativeofan abnormalarterialflowsecondarytoi叼uryorperipheralvasculardisease·Theankle／brachialindexis determinedbytakingthesystolicbloodpressurevalue asmeasuredbyDopplerattheankleoftheinjured leganddividingitbytheDoppler﹣determinedsysto﹣ hcbloodpressureoftheumnjuredarm.Auscultation canrevealabruitwithanassociatedpalpablethriⅡ. ExpandinghematomasorpulsatⅡehemorrhagefTom anopenwoundalsoareindicativeofarterialinjury.

SceⅡa『io■cont『huedRadi0g『aphsc0nfi『m ac0mmInuted｛『adu「e0fthe柏mu吼 ＿

﹥

potentia Ⅱ y l i∣『e﹣Th『eatenⅡ i g Ext『emi↑tyy Ⅱ 『 』 e s Ⅱ I∣ i ■

G＞跚α涉α妒e”p冗oy伽e⋯α加α〃αgeme孤! ●pⅣ〃e加』esβ ExtremitymjuriesthatareconsideredpotentiaⅡylifb﹣ threatemngincludemajorarterialhemorrhageand crushsyndrome.（Pelvicdisruptionisdescribedin Chapter5:AbdominalandPelvic Trauma·）

MA』0RARTERIALⅡEⅢ0RRⅡAGE Inju『y Penetratingextremitywoundsmayresultinm匈orarteria1vasculariIUuryBlunttraumaresultmginanex﹣ tremilyfractureorjointdislocationincloseproximity toanarteⅣalsomaydisrupttheartery.Thesei叼uries mayleadtosignificanthemorrhagethroughtheopen woI】ndorintothesofttissues.

X﹣RayExamination Thechnicalexaminationofpatientswithmusculoskel﹣ etalmjuriesoftensuggeststheneedfbrx﹣rayexamina﹣ tion.Anyareaoverabonethatistenderanddefbrmed likelyrepresentsafTacture.InpatientsWhohaveno hemodynamicabnormalities,anx﹣rayfilmshouldbe obtained·JointeffUsions’abnormaljointtenderness’ orjointdefbrmi叮representajointinju1yordisloca﹣ tionthatalsomustbex﹣rayed.Theonlyreasonfbr electingnottoobtainanx﹣rayfilmpriortotreatment ofadislocationorafractureisthepresenceofvascu﹣ larcompromiseorimpendingskinbreakdown.Thisis seencommonlywithfracture﹦dislocationsoftheankle. Ifthereisgomgtobeadelayinobtainingx﹣rays, immediatereductionorrealignmentoftheextremi叮 shouldbeperlbrmedtoreestablishthearterialblo0dsup﹣ plyandreducethepressureontheskin.Alignmentcan bemaintainedbyappr0priateimmobilizationtechmqUes.

PITFA『』I」 NotIog『oIIingthepatienttoIookfo『additiona∣po﹣ tentiaIIylifeth『eateningin】u『ieso『faiIu『etope「fo『m atho『oughseconda『ysu「veycan『esultinmi5singpo﹣ tentiaIIife﹣andIimb﹣th『eateninginiu『ies·

ASSeSSment Assessinjuredextremitiesfbrexternalbleeding,lossof apreviouslypalpablepulse’andchangesinpulsequal﹣ ity’D0pplertone,andankle／brachialindex.Acold, pale,pulselessextremityindicatesaninterruptionin arterialbloodsupply.Arapidlyexpandinghematoma suggestsasignificantvascularmjury·SeeSkillStation XIII;MusculoskeletalTrauma:AssessmentandMan﹣ agement ’SkillXIII﹣F

IdentificationofArterialIniury

Management Ifam匈orarterialmjuryexistsorissuspected’im﹣ mediateconsultationwithasurgeonisnecessary. Managementofm則oraIterialhemorrhageincludes applicationofdirectpressuretotheopenwoundand appropriatefluidresuscitation· Theiudicioususeo「atoⅡ『niquetmaybeheIp伽Iahd li佗saving（■FIGuRE8.q）·Itisnotadvisabletoapply vascularclampsintobleedingopenwoundsWhilethe patientisintheED,unlessasuperficialvesselisclearly identified·IfafTactureisassociatedwithanopenhemorrhagingwound,itshouldberealignedandsplinted whiledirectpressureisappliedtotheopenwound.A j0intdislocationshouldbereducedifpossible;ifthe

LIMB﹣THREATENINGIN」URIES213

toprotectingthekidneysandpreventingrenalfhilure inpatientswithrhabdomyolysis.Myoglobin﹣induced renalfRiluremaybepreventedbyintravascularfIuid expansionandosmoticdiuresistomaintainahigl1 tubularvolumeandurineflow.Itisrecommendedto maintainthepatient》surmaryoutputat100mL／hr untilthemyoglobinuriaiscleared.

b﹣Th『eatenin g n I 】u『e is ∣ ﹥ Limimb﹣Th『eate

﹃

吋

－

■FIGURE8﹣qⅣaumapatientwithmanuaItou「niquet inpIace.

∣

Extremi叮injuriesthatareconsideredpotentially limb﹃threateningincludeopenfracturesandjointinjuries,vascularinjuries,compartmentSyndrome,and neurologicinjurysecondarytoffacturedislocation. 0PEN「RACT0RESAⅡD』0∣ⅡTIⅡ』URIES !niu『y

jointcannotbereduced’emergenCyorthopedicinter﹣ ventionmayberequired.Theuseofarteriography andotherinvestigationsisindicatedonlyinresusci﹣ tatedpatientswhohavenohemodynamicabnormali﹣ ties;otherpatientswithclearvascularinjuryrequire urgentoperation.Consultationwithasurgeonskilled invascularandextremitytraumamaybenecessary.

CRUSⅡ5γⅡDR0ME（TRAUMATIC RⅡABD0∣V∣γ0【γS∣S） n l 】u『y CrushsyndromerefbrstothecⅡmcaleHbctsofinjured musClethat’ifleftuntreated,canleadtoacuterenal 角i】l】Te.Thisconditionisseeninindividualswhohave sustainedacrushinjuryofasigniⅡcantmusclemass’ mostoftenathighorcalkThemuscularinsultisa combinationofdirectmusclemjmy’muscleischemia’ andcelldeathwithreleaseofmyoglobin.Muscular traumaisthemostcommoncauseofrhabdomyolysis, whichrangesfTomanasymptomaticillnesswitheleva﹣ tionofthecreatinekinaseleveltoahfb﹣threatemng conditionassociatedwithacuterenalfailureanddis﹣ seminatedintravascularcoagulation（DIC）.

Openfracturesrepresentacommumcationbetween theexternalenv1ronmentandthebone（■FlGuRE8﹣5） MuscleandskinmustbeiIUuredfbrthistooccur.The degreeofsofttissueinjmyisproportionaltotheen﹣ ergyappⅡed.Thisdamage,alongwithbacterialcontamination,makesopenfracturespronetoproblems withinfbction,healing,andfUnction. ASSeSSment DiagnosisofanopenfTactureisbasedonthehistoryof theincidentandphysicalexaminationoftheextremity thatdemonstratesanopenwoundonthesamelimb segmentwithorwithoutsignificantmuscledamage, contamination,andassociatedfTacture.Management

ASSeSSment Themyoglobinproducesdarkamberurinethattests positivefbrhemoglobin.Themyoglobinassaymustbe specificallyreqUestedtoconfirmthepresenceofmy﹣ oglobin’Rhabdomyolysismayleadtometabolicacido﹣ sis,hyperkalemia’hypocalcemia,andDIO

刈

Managemeht Theinitiationofearlyandaggressiveintravenousflu﹣ idtherapyduringtheperiodofresuscitationiscritical

■F!GURE8﹣5ExampIe0fanopenf『actu『e

Z14CHAPTER8■Mu5cuI0sI﹤eIetaIT「auma

decisionsshouldbebasedonacompletehistoryofthe incidentandassessmentoftheinjury. Documentationregardingtheopenwoundbegins duringtheprehospitalphase’withtheinitialdescrip﹣ tion0ftheinjuryandanytreatmentrenderedatthe scene.Atnotimeshouldthewoundbeprobed.Ifa 仕actureandanopenwoundexistinthesamelimb segment’thefTactureisconsideredopenuntilproved 0therwise. Ifanopenwoundexistsoverornearajoint,it shouldbeassumedthatthisinju1yconnectswithor entersthejoint,andsurgicalconsultationshouldbe obtained.Theinsertionofdye,saline’oranyother materialmtothejointtodeterminewhetherthejoint cavitycommunicateswiththewoundisnotrecom﹣ mended·Theonlysafbwaytodeterminecommunica﹣ tionbetweenanopenwoundandajointist0surgicaⅡy exploreanddebridethewound. Management ThepresenceofanopenfiPactureorajointmjmy shouldbepromptlydeterminedApplyappropriate immobilizationafteranaccuratedescriptionofthe woundismadeandassociatedsofttissue,circulato】y’ andneurologicinvolvementisdetermined.Prompt surgicalconsultationisnecessary.Thepatientshould beadequatelyresuscitated,withhemodynamicstabil﹣ ityachievedifpossible.Woundsthenmaybeopera﹣ tivelydebrided’fTacturesstabilized,anddistalpulses confirmed.Tetanusprophylaxisshouldbeadmin﹣ istered（seeTetanus『mmunization〔electronicver﹣ siononly】）.AIIpatieⅡtswithopeⅡ忖actu『esshouidbe t『eatedwithint『avenousantibioticsassoonaspossible· Currentlyfirst﹣generationcephalosporinsaregiven toallpatientswithopenfracturesandaminoglyco﹣ sidesorotherGram-negativeappropriateantibiotics maybegiveninmoreseveremjuries.Antibioticsare usedonlyafterconsultationwithasurgeon.

VASCUlARIⅡ川RIES『lⅡαⅡDIⅡG TRAUMATlCAMP0TAT∣0Ⅱ ∣nu i 『y Avascularinjuryshouldbestrong】ysuspectedinthe presenceofvascularinsufficiencyassociatedwitha historyofblunt,crushing,twisting,orpenetratingin﹣ jurytoanextremity· ASSeSSment Thehmbmayimtial】yappearviablebecauseextremi﹣ tiesoftenhavesomecollateralcirculationthatprovides enoughflow.Partialvascularinjuryresultsincoolness andprolongedcapⅡlaryrefillinthedistalpartofan extremity’aswellasdiminishedperipheralpulsesand

anabnormalankle／brachialindex.A1ternatively’the distalextremitymayhavethecompletedisruptionof flowandbecold’pale,andpulseless.

Management AhaCuteIyavascuIa『ext『emitymustbe『ecognized p『omptIyaⅡdt『eatedeme『gentIy.Theuseo「atoumiqⅡet mayoccasionaIIybeIifbsavingand／o『Iimb·savihginthe p『esenceo「ongoinghemo『『hageuhcont『olIedbydi『ect p『essu『e·Aproperlyappliedtourmquet’whⅡeendan﹣ geringthelimb,maysaveahfb.Atourniquetmust occludearterialinflow’asoccludingonlythevenous systemcanincreasehemorrhage.Therisksoftourni﹣ quetuseincreasewithtime.IfatourniqUetmustremaininplacefbraprolongedperiodtosaveahfb’the climcianmustbecognizantofthefHctthechoiceoflifb overlimbhasbeenmade. Muscledoesnottoleratealackofarterialblood flowfbrlongerthan6hoursbefbrenecrosisbegins. Nervesalsoareverysensitivetoanan0xicenviron﹣ ment.Therefbre,earlyoperativerevascularizationis requiredtorestorearterialflowtotheimpaireddistal extremi叮.IfthereisanassociatedfTacturede允rmity, itshouldbecorrectedquicklybygentlyrealigningand splintingtheinjuredextremity. IfanarterialiIUmyisassociatedwithadiSlocation ofajomt,aclimcianwhoisskiⅡedmjointreduction mayattemptonegentlereductionmaneuver·Otherw1se’sphntingofthedislocatedjomtandemergency surgicalconsultationarenecessary·Arteriography mustnotdelayreestablishingartenalblood且ow,andis indicatedonlyafterconsu】tationwithasurgeon.Computedtomography（CT）angiographymaybehelpfhlm institutionsinWhicharteriographyisnotavailable· Thepotentialfbrvascularcompromisea1soemsts wheneveraninjuredextremi叮issphnted0rplacedina cast.Vascularcomprom1secanbeidentiiied叮theloss oforchangeinthedistalpulse,butexcessivepainafter castapplicationalsomustbeinvestigated.Thesphnt’ cast,andanyothercircumfbrentialdressmgsmustbe releasedpromptlyandthevascularsupplyreassessed· Amputationisatraumaticeventfbrthepatient, bothphysicallyandemotional】y.Traumaticamputa﹦ tion’aseverefbrmofopenfracturethatresultsinloss ofanextremity,maybenefitfTomtourniquetuseand requiresconsultationwithandinterventionbyasur﹣ geon.CertainopenfTactureswithprolongedischemia, neurologicinjury,andmuscledamagemayrequire amputation·AmputationofaniIUuredextremitymay behfbsavinginpatientswithhemodynamicabnormal﹣ itieswhoaredifHculttoresuscitate. Alth0ughthepotentialfbrreplantationshouldbe considered’itmustbeputintoperspectivewiththe patient,sotherinjuries.ApatieⅡtwithmultipleihiu﹣ 『ieswho『equi『esiⅡtehsive『esuscitationahdeme『gency

【IMB﹣THREATENINGIN」URIESZ15

su『ge『yishotacandidatefb『『epIantation.Replanta﹣ tionusuaⅡyisperfbrmedwithaninjuryofanisolated extremity.Apatientwithclean’sharpamputations offingersorofadistalextremity’belowthekneeor elbow’shouldbetransportedtoanappropriatesurgi﹣ calteamskilledinthedecisionmakingfbrandman﹣ agementofreplantationprocedures. Theamputatedpartshouldbethoroughlywashed inisotomcsolution（e.g.’Ringer,slactate）andwrapped insterⅡegauzethathasbeensoakedinaqueouspeni﹣ cillin（100’000umtsin50mLofBinger,slactate solution）.Theamputatedpartisthenwrappedina simⅡarlymoistenedsteriletowel,placedmaplastic bag,andtransportedwiththepatientinaninsulated co0hngChestwithcrushedice.Caremustbetakennot tofreezetheamputatedpart.

asa『est『ictingmemb『aneince『tainci『cumstaⅥces·｝ Commonareasfbrc0mpartmentSyndromemcludethe lowerleg’fbrearm’fbot,hand’glutealreg1on,andthigh （■FIGURE8﹣6）. TheendresultsofuncheckedcompartmentSyn﹣ dromearecatastrophic.Theyincludeneurologicdefi. cit’musclenecrosis’ischemiccontracture’infbction’ delayedhealingofafracture,andpossibleamputation.

AsSeSSment Anyinjurytoanextremityhasthepotentialtocausea compartmentSyndrome.However’certaininjuriesor activitiesareconsideredhighrisk,including: ■Ti｝〕ialand允rearmhactures ■InjuriesimmobⅢzedintightdressmgsorcasts ■Severecrushinjuryt0muscle

c0MPARTⅢEⅡTSγNDR0ME

■Localized,prolongedexternalpressuretoan extremity

In】u『y CompartmentSyndromedevelopswhenthepressure withinanosteofhscialcompartmentofmusclecauses ischemiaandsUbsequentnecrosis.Thisischemiamay becausedbyanincreaseincompartmentsize（e.g.’ swellingsecondarytorevascularizationofanischemic extremi叮）orbydecreasingthecompartmentsize（e’g., aconstrictivedressing）.Compa『tmentsynd『omemay occu『ihahysiteiⅡwhichmuscIeiscontainedwithiha cIosedfhscialspace.（Remembe『!thesI《inaIsomayact

■IncreasedcapillarypermeabⅢtysec0ndaryto reperfhsionofischemicmuscle ■Burns ■Excessiveexercise Thesignsandsymptomsofcompartmentsyn﹣ dromearelistedinBox8﹦1.Thekeytothesuccess﹣ fhltreatmentofacutecompartmentSyndromeisearly diagnosis·Ahighdegreeofawarenessisimportant’

B

A Ante「io「 tment

Tib Late『a【 compa『tment

Fib

a

Supe「ficia【poste「io『 compa「tment

■FlGURE8﹣6Compa『tmentSynd『ome.Thisconditi0ndeveIopswhenthep「essu「e withinanosteofasciaIcompaItmentofmuscIecause5ischemiaandsubsequentnec『05is （A）No「malcaIf·（B）CaIfwithcompa「tmentsynd『ome·

216CHAPTER8■Mu5cuIoskeletalT『auma

Box8﹦15ignsandSyIhptomsofCoⅢpa『tⅢent5ynd『oⅢe 而 ■∣nc「ea5ingpaing『eate『thanexpectedand0ut0「p『0p0『﹦

■Asymmet『y0↑themu5cIe〔0mpa『tments

ti0nt0thestimuI〔』s

■PaiⅡ0npassive5t『etch0↑tI】ea↑「e〔tedmuscIe

■Palpab∣etenseness0↑thec0mpa『tment

■A∣te『edSenSati0n

﹃

especiallyifthepatienthasana1teredmentalsenso﹣ riumandisunabletorespondappropriatelytopam. SeeSkillStationXIII:MusculoskeletalTr8】】mB:

AssessmentandManagement’SkiⅡXIII-E;Compart﹣ mentSyndromeAssessment andManagement.

Theabsenceo「apaIpabIedistaIpulseusualIyisan uⅡcommoⅡo『∣atefindingIncompa仕mehtsynd『omeahd shouIdnotbe『eIiedupontodiagⅡose∞mpaItmeITtsyn﹣ d『ome·Weaknessorparalysisoftheinvolvedmuscles andlossofpulses（becausethecompartmentpressure exceedsthesystoⅡcpressure）intheaffbctedlimbare latesignsofcompartmentsyndrome.Ifpulseabnor﹣ malitiesarepresent’thepossibilityofaproximalvas﹣ cularmjurymustalsobeconsidered. Remember,changesindistalpulsesorcapillary refilltimesarenotreliableindiagnosingcompartment syndrome.Clinicaldiagnosisisbasedonthehisto】yof injuryandphysicalsigns,coupledwithahighindexof susp1c1on. Intracompartmentalpressuremeasurements maybehelpfUlindiagnosingsuspectedcompartment syndrome.Tissuepressuresthataregreaterthan 30to45mmHgsuggestdecreasedcapillaryblood flow,whichmayresultinincreasedmuscleandnerve damagecausedbyanoxia.Manysurgeonsusethe ‘‘delta﹣P,,methodofcalculatingtissuepressures.The ●

tientmustbecarefhⅡymomtoredandreassessedclini﹣ caⅡyfbrthenext30to60minutes.Ifnosignificant changesoccur,fhsciotomyisreqUired（■F!GuRE8﹣7）. Compartmentsyndromeisatime﹦dependentcondi﹣ tion.Thehigherthecompartmentpressureandthe longeritremainselevated,thegreaterthedegreeof resultingneuromusculardamageandfimctionaldefi﹣ cit.Adelayinperfbrmingafhsciotomymayresultin

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compartmentpressureissubtractedfromthediastolicbloodpressure,yieldingthe‘‘delta-P.”Ifthisvalue is30mmHgorless’thissuggeststhatthepatient mayhaveacompartmentsyndrome.Systemicblo0d pressureisimp0rtant:thelowerthesystemicpressure’thelowerthecompartmentpressurethatcauses acompartmentsyndrome·Pressuremeasurementis indicatedinallpatientswhohaveanalteredresponse topain. Thephysicianmust『ealizethatcompa『tmentsyn· d『omeisaclinicaIdiagnosisaⅡdisnotonethatissoIely dete『mihedbyp『essⅡ『emeasu『ements·CompaltmeⅡt measu『ementsa『eoⅡlyinteⅡdedtoaidthephysicianih thediagⅡosiso「compa『tmentsynd『ome·

Management Allconstrictivedressings,casts’andsplintsapphed overtheaffbctedextremitymustbereleased.Thepa﹣

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LIMB-THREATENINGINjURIES217

myoglobinuria’whichmaycausedecreasedrenalhmc﹣ tion.Su『gicaIcohsuitationfb『diagnosedo『suspected compaItmentsynd『omemustbeobtainedea『Iy.

shoulderdislocation.Optimalmnctionaloutcomeis jeopardizedunlessthisinjmyisrecognizedandtreat﹣ edearly· ASSeSSment

PITFA『」『」 Compa「tmentsynd「omeislimbth「eatening.CIinicaI findingsmustbe『ecognizedandsu「gicaIconsuIta﹣ tionobtainedea『Iy.Remembe『thatinunc0n5cious patientso「thosewithseve『ehypovoIemia’thecIas﹣ sicfindingsofacutecompa「tment5ynd「omemaybe maSked.

ⅡEUR0∣DG∣CIⅡjURγSEC0ⅡDARγT0 FRACTURE﹣D∣S止0CATI0Ⅱ ∣n】u『y Fracturesandparticularlydislocationsmaycause significantneurologicmjurybecauseoftheanatomic relationshipandproximityofthenervetothejoint＿ fbrexample’sciaticnervecompressionfromposterior hipdislocationoraxillmynervemjuryfTomanterior

Athoroughexaminationoftheneurologic可stemises﹣ sentialinpatientswithmusculoskeletalinju1y.Deter﹣ minationofneurologicimpairmentisimportant,and progressivechangesmustbedocumented. AssessmentusuaⅡydemonstratesadefbrmityof theextremity.Assessmentofnervefhnctionusually reqUiresacooperativepatient.Foreachsignificant peripheralnerve’voluntarymotorfhnctionandsensa﹣ tionmustbeconfirmedsystematicaⅡy.Table8.2and Table8.3outlineperipheralnerveassessmentofthe upperextremitiesandlowerextremities’respectively. Muscletestingmustincludepalpationofthecontract﹣ ingmuscle. Inmostpatientswithmultipleinjuries,itisdiffi﹣ culttoimtiallyassessnervefhnction.However,assess﹣ mentmustbecontinuallyrepeated’especiaⅡyafterthe patientisstabihzed.Progressionofneurologicfind﹣ ingsisindicativeofcontinuednervecompression.The

■TAB【E8·2Pe『iphe『a!ⅡeⅣeAssessmeⅢtofUppe『Ext『emities ⅡERVE

M0T0R

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IndexandIittlefinge『abduction

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None

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MuscuIocutaneous

Elbow↑lexion

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RadiaI

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MedIan’ante『i0「Inte「0S﹣ se0us

■丁AB【E8·3pe『iphe『alNeⅣeAssessmeⅢtoⅡowe『Ext『emities ⅡERVE

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Ante『io「knee

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Foot

poste『io『hipdis∣ocation

Supe「io『gIutea∣

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Uppe「buttock5

AcetabuIa「f「actu『e

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AcetabuIa『f「actu『e

Z18CHAPTER8■MuscuIo5keIetaIT『auma mostimportantaspectofanyneurologicassessmentis thedocumentationofprogressionofneurologicfind﹣ ings.Italsoisanimportantaspectofsurgicaldecision making.

Management Theinjuredextremityshouldbeimmobihzedinthe dislocatedposition’andsurgicalconsultationobtained immediately.Ifindicatedandifthetreatingclimcian isknowledgeable,acarefblreductionofthedisloca﹣ tionmaybeattempted·Afterreducingadislocation, neurologichmctionshouldbereevaluatedandthe hmbsplinted.Iftheclimcianisabletoreducethedis﹣ location,thesubseqUenttreatingphysicianmustbe notifiedthatthejointwasdislocatedandsuccessmlly reduced.

∣ ﹥

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Othersignificantextremityinjuriesincludecontusions andlacerations,jointinjuries,andhactures. C0ⅡTUSI0NSAⅡDlACERAT∣0NS Simplecontusionsand／orlacerationsshouldbeas﹣ sessedt0ruleoutvascularand／orneurologicinjury. Ingeneral’lacerationsrequiredebridementandclo﹣ sure.Ifalacerationextendsbelowthefhsciallevel,it requiresoperativeinterventiontomorecompletelyde﹣ bridethewoundandassessfbrdamagetounderlying structures. ContusionsusuaⅡyarerecognizedbypaminthe areaanddecreasedfhnctionoftheextremity.Palpa﹣ tionconfirmslocalizedsweⅢngandtenderness·The patientusuaⅡycannotusethemuscleorexperiences decreased血nctionbecauseofpainmtheaifbcted extremi叮.Ifthepatient1sseenearly,contusionsare treatedbylimitmghmctionoftheinjuredpartand applyingcoldpacks. Smallwounds’especiaⅡythoseresultingfrom crushiIUuries,maybesignifIcant·Whenaverystrong fbrceisapphedve1yslowly0veranextremity’signiiicantdevascularizationandcrushingofmusclemay occurwithonlyasmallskinwound.Crushanddeglov﹣ inginjuriescanbeverysubtleandmustbesuspected basedonthemechanismofinju叮· Theriskoftetanusisincreasedwithwoundsthat aremorethan6hoursold,arecontusedand／orabraded’ aremorethan1cmindepth,resulthomhigh﹣veloci叮 missiles,areduetoburnsorcold,andhavesignificant c0ntamination（especiallyburnwoundsandwounds withdenervatedorischemictissue）.SeeTetanus Immunization（electronicversiononly）

j0lNTINjURIES In】u『y Jointmjuriesthatarenotdislocated（i.e.,thejointis withinitsnormalanatomicconfigurationbuthassus﹣ tainedsignificantligamentousinjury）usuallyarenot limb﹣threatening·However,suchjointinjuriesmayde﹣ creasethefhnctionofthe】imb. ASSeSSment Withjointinjuries,thepatientusuallyreportssome fbrmofabnormalstresstothejoint,fbrexample,im﹣ pacttotheanteriortibiathatsubluxatestheknee posteriorly’impacttothelateralaspectofthelegthat resultedinavalgusstraintotheknee’orafallontoan 0utstretchedarmthatcausedahyperextensionmjury totheelbow. Physicalexaminationrevealstendernessthrough﹣ 0uttheafIbctedligament·AhemarthrosisusuaⅡyis presentunlessthejointcapsuleisdisruptedandthe bleedingdiffhsesintothesofttissues.Passivehgamen﹣ toustestingoftheaffbctedjointrevealsinstability.X-ray examinationusuallyrevealsnosignificantimury·How﹣ ever’somesmallavulsioniTacturesfTomligamentous insertionsororiginsmaybepresentradiographicaⅡy.

Management Jointinjuriessh0uldbeimmobilized.Thevascular andneurologicstatusofthelimbdistalt0theinjury shouldbereassessed·Surgicalconsultationusuallyis warranted.

FRAC『URES !n】u『y Fracturesaredefinedasabreakmthecontinui叮of thebonecortex.Theymaybeassociatedwithabnor﹣ malmotion,some｛brmofsofttissueiIUury,bonycrepitus,andpain·AfTacturecanbeopenorclosed. ASSeSSment F｝x月minationoftheextremi∣ydemonstratespam, swelling’de｛brmity,tenderness,crepitation’andabnormH】motionatthefracturesite.Theevaluation fbrcrepitationandabnormalmotionatthefiPacture sitemayoccasionallybenecessarytomakethediag nosis’butthisispainfhlandmaypotentiallyincrease softtissuedamage’Thesediagnostictestsmustnotbe doneroutinelyorrepetitively.Usuallytheswelling, tenderness,anddefbrmi叮aresufficienttoconfirma fracture.ItisimportanttoperiodicaⅡyreassessthe neurovascularstatusofalimb,especiallyifasphntis inplace·

PRlNαPLES0FIMM0BlLIZATlONZ19

X﹣rayfilmstakenatrightanglestooneanother confirmthehistoryandphysicalexaminations （■F∣GuRE8﹣8）.Dependingonthehemodynamicsta﹣ tusofthepatient,x﹣rayexaminationmayneedto bedelayeduntilthepatientisstabilized.X﹣rayfilms throughthejointaboveandbelowthesuspectedfTac﹣ turesitemustbeincludedtoexcludeoccultdislocation andconcomitantinjury.

1 l 1 』 0 0 d ■ 』 ■ ■ ■ ■ 】 ■ ■ ■ ■ ■ ■ ∣

Management Immobilizationmustincludethejointaboveandbelow thefracture.Aftersphntmg’theneurologicandvascu﹣ larstatusoftheextremitymustbereassessed‘Surgi﹣ calconsultationisrequiredfbrfhrthertreatment.

∣ ﹥ p『incip∣esofImmobilization Splintingofextremi叮injuries,unlessassociatedwith hfb﹣threatemngiIUuries’usuallycanbeaccomplished duringtheseconda1ysurvey.However,allsuchinju﹣ riesmustbesplintedbefbreapatientistransported Assessthelimb,sneurovascularstatusafterapplying splintsorrealigningafTacture· Specifictypesofsplintscanbeappliedibrspecific hactureneeds. Alongspineboardprovidesatotalbodysplint fbrpatientswithmultipleinjurieswhohavepossi﹣ bleorconfirmedunstablespmeinjuries.However, itshard,unpaddedsurfacemaycausepressuresores onthepatient’socciput’scapulae,sacrum,andheels. Therefbre,assoonaspossible,thepatientshouldbe m0vedcarefUllytoanequallysupportivepaddedsur﹣ face’usingascoop﹣stylestretcheroranappropriate logrollingmaneuvertofhcilitatethetransfbr.The patientshouldbefbllyimmobilized,andanadequate numberofpersonnelshouldbeavailableduringthis transfbr.SeeSkillStationXII;SpinalCordInjulyy: AssessmentandManagement’SkillXII﹣E!Principles ofSpineImmobⅡizationandLogrolhng,andSkill﹣Sta﹣ tionXIII:MusculoskeletalTrauma:Assessmentand

Management’SkillXIII﹣B:PrinciplesofExtremity ImmobiIi叨H忖on. 「EM0RAl「RACTURES FemoralfiPacturesareimmobihzedtemporarilywith tractionsplints（■「lGuRE8﹣9）.Thetractionsplint,s fbrceisappheddistallyattheankleorthroughthe skin.Proxhnally,thesplintispushedintothethigh andhipareasbyaringthatappliespressuretothe buttocks,perineum,andgrom.Excessivetractioncan causeskindamagetothefbot’ankle,orperineum. Neurovascularcompromisecanresultfromstretching

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■FlGURE8﹣8X-『ayfiImstakenat「ightang∣est0one anothe『confi「mthehist0「yandphy5icaIexamination5. （A）APviewofthedistaIfemu傀（B）Late「aIviewofthe dista∣femu倪Sati5facto「yx﹣『aysofanin】u『edIongbone shouldincIudetwo0「thogonaIviews’buttheenti「e b0ne5houldbevisuaIized.Thustheaboveimage5 aIonewouIdbeinadequate.

theperipheralnerves·Hipiracturescanbesimilarly immobilizedwithatractionsplint,butaremoresuita﹣ blyimmobilizedwithskintractionorafbamboottractionwiththekneeinslightfIexion.Asimplemethodof splintingistobindtheinjuredlegtotheoppositeleg. SeeSkillStationX『『I:MusculoskeletalTra】】ma;As﹣ sessmentandManagement,SkiⅡXIII﹣D:Application ofaTractionSplint

∣《NEEIN』URIES Theuseofcommerciallyavailablekneeimmobilizers ortheapplicationofalong﹂legplastersphntisve1y helpfhlinmaintainingcomfbrtandstability.Theknee shouldnotbeimmobilizedincompleteextension,but shouldbeimmobilizedwithabout10degreesofflexion toreducetensionontheneurovascl】I田?structures.

ZZ0CHApTER8■MuscuI0skeIetalT「aum3

UPPER﹣EX『REMITγANDⅡAⅡDⅢjUR∣ES ThehandmaybetemporarilyspⅡntedinananatomic’ fhnctionalposition,withthewristslightlydorsifIexed andthefingersgentlyfIexed45degreesatthemeta﹣ carpophalangealjoints.Thispositionusuallycanbe achievedbygentlyimmobⅡizingthehandoveralarge rollofgauzeandusingash0rt﹣armsplint. The允rearmandwristareimmobiIi究edHaton

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paddedorpillowsplints.Theelbowusuallyisimmo﹣ bilizedinaflexedposition,eitherbyusingpadded splintsorbydirectimmobilizationwithrespecttothe bodyusingaslingandswathdevice.Theupperarm usuallyisimmobilizedbysplintingittothebodyor applyingaslingorswath’whichcanbeaugmentedby athoracobrachialbandage.Shoulderinjuriesareman﹣ agedbyasling﹂and-swathdeviceoraVelcro﹣typeof dressing.

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T「actionspIintofafemu「f『actu『eshouIdbeavoided ifthe『eisaconcomitantipsiIate『aIIowe「Iegf『actu「e·

TIBIAFRACTURES TibiafTacturesarebestimmobihzedwithawell﹣pad﹣ dedcardboardormetalgutterlong﹣legsplint’Ifreadilyavailable,plastersplintsimmobilizingthelower thigh’theknee’andtheanklemaybeused·

AⅡI《lEFRACTURES Anklefracturesmaybeimmobilizedwith apⅢow splintorpaddedcardboardsplint,thereby avoiding pressureoverb0nyprominences·

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AnalgesicsaremdicatedfbrjomtiIUuriesandfractures. Theappropriateuseofsplintssignihcantlydecreases thepatient’sdiscomfbrtbycontrollingtheamountof motionthatoccursattheinjuredsite. Patientswhodonotappeartohavesignificant painanddiscomfbrtfromamajorhacturemayhave otherassociatedinjuries－fbrexample’intracranial lesionsorhypoxia－ormaybeundertheinfluenceof alcoh0land／Orotherdrugs· EfIbctivepa1nreliefusuallyreqUirestheadmin﹣ istrationofnarcotics’Whichshouldbegiveninsmall dosesintravenouslyandrepeatedasneeded.Muscle rela文2ntsandsedativesshouldbe月】m↑nisteredcau﹣ tiouslyinpatientswithisolatedextremityinjuries＿ fbrexample,reductionofadislocation·Regionalnerve blockshavearolempa1nrehefandthereductionof appropriatefTactures.Itisessentialtoassessanddoc﹣ umentanyperipheralnervemjurybefbreadnnmster﹣ inganerveblock· Wheneveranalgesics,musclerelaxants’orseda﹣ tivesare日dmihisteredtoaninjuredpatient’the potentialexistsfbrrespirato】yarrest·Consequently’ appropriateresuscitativeequipmentmustbeimmediatelyavailable.

∣ ﹥ Associat ednI 】u『ei s Certainmusculoskeletalinjuries’becauseoftheircom﹣ monmechanismofiIUuIy’areoftenassociatedwith otheriniuriesthatarenotimmediatelyapparentor

OCCULTSKELETALINjURIESZZ1

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maybemissed（Table8.4）.Stepstoensurerecognition andmanagementoftheseinjuriesinclude: 1.ReviewtheiIUuryhist01y’especiaⅡythemecha﹣ nismofmjury’todeterminewhetheranother injuryispresent. 2·Thoroughlyreexamineallextremities’plac﹣ 1ngspecialemphasisonthehands’wrists’fbet’ andthejomtab0veandbelowafTactureor dislocation.

siveorthereareothersevere叫uries.Itisimportant torecogmzethatinjuriesarecommonlydiscovered daysafterthemjurymcident＿fbrexample,whenthe patientisbeingmobilized.Therefbre’isitimportant toreassessthepatientroutinelyandtorelatethispos﹣ sibilitytoothermembersofthetraumateamandthe patient,sfhmily·

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3.ⅥsuaⅡyexaminethepatient,sdorsum’includ﹣ ingthespineandpelvis.Openmjuriesandclosed softtissueinjuriesthatmaybeindicativeofan unstableinjmymustbedocumented

Despiteatho「oughexamination『occultassociatedin﹣ 】u『ie5maynotbeidentifieddu「ingtheinitiaIevaluation.Itisimpe「ativeto『epeatedIy『eevaIuatethe

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Remember’notallmjuriescanbediagnosedduring theinitialassessmentandmanagementofinjury. Jointsorbonesthatarecoveredorwellpaddedwithin muscularareasmaycontainoccultinjuries.Itcanbe difficulttoidentibmondisplacedfiPacturesorjointliga﹣ mentousinjuries,especiaⅡyifthepatientisunresp0n﹣

﹂

SceⅡa『io■coⅢcIⅡsioⅡAt『aCti0nsp∣int isappliedt0thepatientisext『emity.Ⅱeisglven int『aven0uspainmedicati0nandt『an5↑e『『edt0 thenea『estt『aumacente『withan0『th0pedic su『ge0n「0『ea『Iyfixati0n0↑hisfem0『alf『adⅡ『e

Z22CHAPTER8■MuscuIoskeIetaIT『auma ︼

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ChapterSunnnary ⅢMusculoskeletalinjuries’althoughgenerallynotlifb﹣threatening’mayposede﹣ layedthreatstohfbandlimb. 圓Thegoaloftheimtialassessmentofmusculoskeletaltraumaistoidenti匈inju﹣ riesthatposeathreattolifband／orlimb.Althoughuncommon,lifb﹣threatemng musculoskeletalinjuriesmustbeproperlyassessedandmanaged.Mostextremity injuriesareappropriatelydiagnosedandmanagedduringlhesecondarysurvey. 圃ItisesSentialtorecognizeandmanageinatimelymannerarterialinjuries’com﹣ partmentsyndrome’openfractures’crushimuries’andfracture﹣dislocations. KnowledgeofthemeChanismofiIUuryandhisto】yoftheinjury﹣producmgevent enablesthecliniciantobeaware0fWhatassociatedconditionspotentiaⅡyexist withtheinjuredextremib『· 囚EarlysphntingoffTacturesanddislocationsmaypreventseriouscomplications andlatesequelae. ﹂

10.KostlerW,StrohmPC,SudkampNP.Acutecompartment Syndromeofthelimb·I〉Vα）:y2004;35（12）:1221﹣1227. 1.BeekleyAC’StarnesBW,SebestaJA.Lessonslearned hPommodernmilitarysurgeⅣ.SM唔α加』Vbrf〃A〃】 2007;87（1）:157﹣84,vii. 2.BrownCV》RheeP’ChanL’EvansK’DemetriadesD’ VelmahosGC.PreventingrenalfHilureinpatientswith rhabdomyolysis:dobicarbonateandmannitolmakea diffbrence?JT／.α【〃川α2004;56:1191 3·CliifbrdCC.Treatingtraumaticbleedinginacombatset﹣ ting’Mi／Mbd2004;169（12Suppl）:8.10,14. 5’ElliotGB’JohnstoneAJ.Diagnosingacutecompartment syndrome·JBo〃ec／b加／Sα『gB『.2003;85:625﹣630. 6’GustiloRB,MendozaRM’WiⅡiamsDN.Problemsin themanagementof∣ypeIII（severe）openfTactures:a newclassificationof∣ypeIIIopenfTactures.c／?】mM／〃α 1985;24:742· 9.KingRB’FilipsD’BlitzS’LogsettyS.Evaluationofpos﹣ sibletourniquetSystemsibruseintheCanadianForces. J仍m↓／川α2006;60（5）:1061﹣1071.

12.LaksteinD,BlumenfbldA,SokolovT’etal.Tourmquetsfbrhemorrhagecontrolonthebattlefield;a 4﹣yearaccumu】atedexperience.J乃αα／〃α2003;54（5 Suppl）:S221﹣S225. 13·Mab】HyRL.Tourniquetuseonthebattlefield.Mj／Mbd 2006;171（5）:352-356. 14.OdodehM·Theroleofreperhlsion﹣inducedi叫uryin thepathogenesisofthecrushsyndrome·NE几g』JM它d 1991;324:1417﹣1421 15.OkikeK’Bhattacha】:yyaT.Trendsinthemanagementof openfTactures.Acriticalanalysis·JBo〃eJb〃㎡Su）gA加 2006;88:2739﹣2748. 16.OlsonSA,GlasgowRR.AcutecompartmentSyndrome mlowerextremitymusculoskeletaltrauma.JAmAcαd O㎡／jOpSM唔2005;13（7）;436﹣444· 17.UlmerT.TheclinicaldiagnosisofcompartmentSyn﹣ dromeofthelowerleg:areclinicalfindingspredictiveof thedisorder?JO㎡／jOpTrαM加α2002;16（8）:572﹣577.

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18·WaltersTJ’MabryRL.Issuesrelatedtotheuseoftourmquetsonthebattlefield·Mγ』M它α2005;170（9）:770﹣775. 19。WaltersTJ,WenkeJC,KauvarDS,M甽anusJG’Hol﹣ combJB,BaerDGEffbctivenessofself巴appliedtour﹣ mquetsmhumanvolunteers.R它ho”E加e唔“沱 2005;9（4）:416-422.

20·WellingDR,BurrisDG,HuttonJE,MmkenSL,Rich NM.Abalancedapproachtotourniquetuse:lessonslear﹣ nedandrelearned·JA加α』』Sα唔2006;203（1）:106﹣115.

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／Vote:Standa『dp『ecauti0nsa『e『equi『ed whenca『ingfo『t『aumapatients·A5e『ie5 ofx﹣『aySwith『e∣atedscena『iosi5p「ovided fo『u5edu『ingthlsSki∣IStationinmaking evaluationandmanagementded5Ion5 basedonthe『adiog「aphlcfindings.

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ⅢPe「fo『ma「apidassessmentoftheessentialcomponentsofthe mu5cuIo5keIetaIsy5tem.

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Thegoal0fspIintinglstop「eventfu『the『 softtissuein】u『yandcont『oIbIeedingand

圃Identifypatientswhoa「eat『iskfo『compa「tmentsynd『ome 囤ExpIaintheIndicationsfo『andthevaIueofapp『op「iatesplintingof muscuo l 5keIetaIn i 】u「e i 5.

paIn、Conside『theimmobiIizationof↑『ac﹣ tu『edext「emitieswiththeu5eo↑5pIintsa5 〃seconda『y『esuscitationdeviCes〃thataid inthecont『oIofbleeding

回Applystanda「dsplintstotheext『emities〃incIudingat『action5pIint. 圃Listthecomplicationsassodatedwiththeuseofsplints.

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〉卜SkiIIXⅡ【.B目Principlesof ExtremityImmobⅡization 卜卜SkiIIXIⅡ.CRealigninga DefbrmedExtremity 〉〉SkiⅡXⅢ﹣D:Applicationofa TractionSphnt 〉》SkiⅡXⅢ﹦E:Compartment Syndrome:Assessmentand Management 卜卜S!《ⅢXIⅡ﹣RIdentificationof ArterialInju】y

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〉5CENARI0s SCEⅡARIOXⅢ﹣1 A28-year-oldmaleisinvolvedinahead﹣onmotorcycle coⅢsionwithacar.Atthescene,hewascombative’ hissystohcbloodpressurewas80mmHg’hisheart rate120beats／min,andhisrespirato1yratewas20 breaths／min.Intheemergencydepartment（ED）’his vitalsignshavereturnedtonormal’andthepatientre﹣ portspaininhisrightupperextremityandbothlower extremities.Hisrightthighandleftlowerextremity aredefbrmedPrehospitalpersonnelreportalargelacerationtotheleftleg’towhichtheyappliedadressing.

SCEⅡARI0XIⅡ﹣Z ScenarioA:A20﹣year﹣oldfbmaleisfbundtrappedin heraut0mobile.Severalhoursarerequiredtoextricate herbecauseherlefMegwastrappedandtwistedbe﹣ neaththedashboard‘Inthehospital,shehasnohemo﹣ dynamicabnormalitiesandisalert‘Shereportssevere

ScenarioB:A34﹣year﹣oldmaleissh0tintheright legWhilecleaninghishandgun.Heisunabletowalk becauseofkneepa1nandstatesthathislowerextrem﹣ ityispainfUl,weak’andnumb·

SCEⅡAR∣0XⅡI﹣3 A16﹣year﹣oldmaleisthrownapproximately100fbet （33meters）fTomthebackofapiCkuptruck.IntheED hisskiniscool,andheisletharg1candunresponsive. Hissystolicbloodpressureis75mmHg’hisheartrate is145beats／min,andhisrespirationsarerapidand shallow.Breathsoundsareequalandclearonauscul﹣ tati0n.Twolarge-caliberⅣcathetersareimtiated, and1500mLofwarmedcrystalloidsolutionisinfhsed· However,thepatient’shemodynamicstatusdoesnot improvesignificantly‘HisbloodpressuIenowis84／58 mmHg’andhisheartrateis135beats／min.

paininherleftleg,whichissplinted·

bSkiIIXlⅡ﹣A:PhysicalExamination 》〉L00K’GEⅡERAl0VERV∣EW Externalhemorrhageisidentifiedbyobviousexternal bleedingfr0manextremi叮’poolingofbloodonthe stretcherorfloor’blood﹣soakeddressings’andbleed﹣ ingthatoccursduringtransporttothehospital.The exHminershouldaskaboutcharacteristicsofthein﹣ juryincidentandprehospitalcare.Remember’open w0undsmaynotbleed,butmaybeindicativeofan openfTacture.

5TEp3‘

Notetheposition0ftheextremily,which canbehelpfhlindetermimngspecific injmypatterns·Certainnervedeficitslead tospecificpositionsoftheextremi叮.Forex﹣ ample’injurytotheradialnerveresultsin wristdrop,andiIUurytotheperonealnerve resultsmibotdrop.

sTEp4

Observespontaneousactivitytohelp determinetheseverityofinjury.Obse『vmg whethe『thepatieⅡtspohtaneouslymovesan ext『emitymaysuggesttotlTeexamine『othe『 obviouso『occultiniu『ies.Anexampleisa patientwithabraininjurywhodoesnot fbllowcommandsandhasnospontaneous lower﹣extremi叮movement;thispatient couldhaveathoracicorlumbar仕acture·

sTEp5·

Notegenderandage,whichareimportant cluestopotentialmjuries·Childrenmay sustaingrowthplate叫uriesandfractures thatmaynotmanifbstthemselves（e.g., bucklehacture）·

STEP1.Splintdefbrmedextremities’whicharein﹣ dicativeofafractureorjointinju1y,befbre patienttransportorassoonasissafbly possible. STEpZ·Assessthecoloroftheextremity.Thepres﹣ enceofbruismgindicatesmusclemjmy orsignificantsoittissuemju1yoverbones orjoints.Thesechangesmaybeassoci﹣ atedwithswelhngorhematoma·Vascular impairmentmaybefirstidentifiedbyapale distalextremity.

226SKILLSTATI0NXIII■MuscuIoskeIetaIT「auma:AssessmentandManagement

indicatedbythepatient’sclinicalcondition· Testsensationbyhghttouchandpinprick ineachoftheextremities.Progressionof theneurologicfindingsindicatesapotential problem’ A·C5－Lateralaspectoftheupperarm （alsoaxiⅡarynerve） B·C6－Pahnaraspectofthethumband indexfinger（mediannerve） C.C7-PahnaraspectofthelongfInger D·C8＿Palmaraspectofthehttlefinger

〉卜『FFI Lifb﹣andlimb﹣threateninginjuriesareexcludedfirst. STEP1.Palpatepulsesinallextremitiesandd0cu﹣ mentthefindings.AnyperceivedabnormalityordifIbrencemustbeexplained.Normal capilla1yrefill（＜2seconds）ofthepulp spaceornailbedprovidesago0dindication ofsatisfhctorybloodflowtothedistalparts oftheextremity·Lossordiminishmentof pulseswithnormalcapiⅡa】yrefillindicates aviableextremity;however,surgicalcon﹣ sultationisrequired‘I「anext『emitylTasno pulsesandnocapiIIa『y『e伺lI,asu『gicaIeme『﹣ gehcyexists·ADopplerdeviceisuse血lto assesspulsesanddeterminetheankle／arm systolicpressureratio.Bloodpressureis measuredattheankleandonanumnjured arm·Thenormalratioexceeds0.9.Ifthe ratioisbelow0.9’apotentialinjuryexists andsurgicalconsultationisrequired. STEP2·Palpatethemusclecompartmentsofallthe extremitiesfbrcompartmentSyndromes andfiPactures.Thisisdonebygentlepalpa﹣ tionofthemuscleandbone.Ifahactureis present,thepatientreportspain.Acom﹣ partmentSyndromeshouldbeconsidered ifthemusclecompartmentisveryfirmor tender.CompartmentSyndromesmaybe associatedwith仕actures. STEp3.

STEp4

Assessjointstabilitybyaskingthecoopera﹣ tivepatienttomovethejointthrougha rangeofmotion.Thisshouldnotbedoneif thereisanobvioushactureordefbrmi叮’ orifthepatientcannotcooperate.Palpate eachjointfbrtenderness’swelling’and intraarticularfluid.Assessjointstabili叮 byapp】yinglateral｝medial’andanterior﹣ posteriorstress·Anydefbrmedordisl0cated jointshouldbesplintedandx﹣rayedbefbre testingfbrstabⅡity. Peribrmarapid》thoroughneurologicex﹣ aminationoftheextremitiesanddocument thefindings.Repeatandrecordtestingas

（ulnarnerve） E·T1＿Medialaspectofthefbrearm F·L3＿Medialaspectofthethigh G·L4－Medialaspectofthelowerleg’especiaⅡyoverthemedialmalleolus Ⅱ.L5－Dorsumofthe比otbetweenthe firstandsecondtoes（commonperoneal） I.S1－Lateralaspectofthefbot 5丁EP5.

Per比rmmotorexaminationofthe extremi↑ies. A·Shoulderabduction－AxiⅡarynerve,C5 B·Elbowflexion－Musculocutaneousnerve, C5andC6 C.Elbowextension＿Radialnerve’C6’C7, andC8 D.Handandwrist－Powergriptestsdor﹣ siflexionofthewrist（radialnerve’C6） andflexionofthefingers（medianand ulnarnerves’C7andC8） E·Fingeradd／abduction－〔Ⅱnarnerve,C8 RndT1 『.Lowerextremity－Dorsiflexionofthe greattoeandankleteststhedeeppero﹣ nealnerve’L5’andplantard0rsiflexion teststheposteriortibialnerve’S1 G.Musclepowerisgradedinthestandard fbrm.Themotorexammationisspecific toavarietyofvoluntarymovementsof eachextremity SeeChapter7 Spine andSpinalCordTrauma.

5TEP6·Assessthedeeptendonreflexes STEP7·Assessthepatient’sback.

SKILLSTATIONXIⅡ■MuscuIoskeletaIT『auma:AssessmentandManagementZZ7 I

bSI《iⅡXⅢB:p『incip∣esofExt『emity!mmobiIization SγEP1·AssesstheABCDEs’andtreatlifb﹣threaten﹣ ingsituationsfirst’

STEp6·

Applypaddingoverbonyprominencesthat willbecoveredbythesplint.

STEPZ·Removeallclothingandcomplete】yexpose thepatient’includingtheextremities· Bemovewatches’rings’bracelets,andother

STEp7。

Placetheextremityinasplintifnormally aligned·Ifmalaligned,theextremi叮needs toberealignedandthensplinted.Donot fbrcerealignmentofadefbrmedextremi叮 withanormalpUlse.Carefhlrotationand realignmentmaybereqUiredifcirculation iscompromised;thisisbestd0nebyan experiencedprovider.

potentiaⅡyconstrictingdevices.Remember topreventthedevelopmentofhypothermia· STEP3·Assesstheneurovascularstatusofthe extremi叮befbreapplyingthesplint.Assess fbrpulsesandexternalhem0rrhage,Which mustbecontrolled,andperfbrmamotor andsensoryexaminationoftheextremity。 S『EP4Coveranyopenwoundswithsterile dressings S丁EP5·

Selecttheappropriatesizeandtypeof splintfbrtheiILjuredextremity.Thedevice shouldimmobilizethejointaboveandthe jointbelowtheinju1ysite.

STEp8·Obtainorthopedicconsultation. 5TEp9·Documenttheneurovascularstatusofthe extremitybefbreandaftereverymanipula﹣ tionorsplintapplication.

STEP10.Administerappropriatetetanusprophylaxis SeeTetanusImmunization（electromc

versiononly）

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）SkiIlX∣Ⅱ﹣CReaIigningaDefo『medExt『emity Physicalexaminationdetemuneswhetheradefbrmityis fTomahactureoradislocation.Theprincipleofrealign﹣ mganextremityfractureistorestorelengthbyapplying gentlelongitudinaltractiontocorrecttheresidualangu﹣ lationandthenrotationa1de允rmities.WhⅡemaintain﹣ mgrealignmentwithmanualtraction’asplintisapphed andsecuredtotheextremitybyanassistant.

STEp2·Secureasplinttothefbrearmandelevate thei叮uredextremity.

卜卜FEMUR STEp1·

RealignthefbmurbymanuaⅡyapplying tractionthroughtheankleifthetibiaand fibulaarenot仕actured.

STEp2’

Asthemusclespasmisovercome’theleg willstraightenandtherotationaldefbrmi｛y canbecorrected.Thismaneuvermaytake severalminutes’dependingonthesizeof thepatient.

卜bⅢMERUS 5TEP1·Grasptheelbowandmanuallyapplydistal traction.

sTEpZ

Afteralignmentisobtained’applyasplint andsecurethearmtothechestwallwitha slingandswath

卜卜『0REARⅢ 5TEP1·

ManuaⅡyapplydistaltractionthroughthe wristwhileholdingtheelbowandapplying countertraction.

卜卜TIBlA sTEp1.

Manuallyapplydistaltractionattheankle andcountertractionjustabovetheknee, providedthatthefbmurisintact.

2Z8SKILLSTATlONXIII■MuscuI0skeIetalT『auma:AssessmentandManagement

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Fracturesassociatedwithneurovasculardeficitsre﹣ quirepromptrealignment·Immediateconsultation withasurgeonisnecessaⅡy.Ifthevascularorneuro﹣

logicstatusworsensafterrea1ignmentandsplinting） thesplintshouldberemovedandtheextremityre﹣ turnedtothepositioninwhichbloodflowandneu﹣ rologicstatusaremaximized.Theextremi叮isthen immobilizedinthatposition.

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卜SkiIIXⅡl﹣D:App∣icationofa『『actionSpIint 』VbfαApp／Zcαtio几0f炕Zsdeu『cereq叨zres卹opeOp／e－ o〃epersO〃Zo〃α几d／e靦e呵叨杷α鉚『rem姒α〃dt／jesec﹣ O几αtOqpp〃炕esp／tγ㎡.

STEp7。

Reassesstheneurovascularstatusofthe distalinjuredextremityafterapp】ying traction.

S丁EP1‘Removeallclothing’includingfbotwear,to exposetheextremity.

sTEp8.

Positiontheanklehitcharoundthepa﹣ tient,sankleandfbotWhⅡetheassistant maintainsmanualtractionontheleg·The bottomstrapshouldbeslightlyshorter than,oratleastthesamelengthas’thetwo uppercrossingstraps.

sTEp9·

Attachtheanklehitchtothetractionhook whiletheassistantm月intainsmanualtrac﹣ tionandsupport.Applytractioninincre﹣ mentsusingthewindlassknobuntilthe extremityappearsstable’oruntilpainand muscularspasmarerelieved·

STEP2.Applysteriledressingstoopenwounds. STEP3·Assesstheneurovascularstatusofthe extremi叮. STEP4’Cleanseanyexposedboneandmuscleof dirtanddebrisbefbreapp】yingtraction. Documentthattheexposedbonefragments werereducedintotheso仕tissues. S『EP5.

STEP6·

Determinethelengthofthesplintby measuringtheuninjuredleg·Theupper cushionedringshouldbeplacedunderthe buttocksanda甸acenttotheischialtuber﹣ osity.Thedistalendofthesplintshould extendb叮ondtheanklebyapproximately 6inches（15cm）.Thestrapsonthesplint shouldbepositionedtosupportthethigh 2ndcal企 Aligntheibmurbymanuallyapp】yingtrac﹣ tionthroughtheankle.Aiterrealignment isachieved,gentlyelevatethelegtoallow theassistanttoslidethesplintunderthe extremilysothatthepaddedportion0fthe splintrestsagainsttheischialtuberosity.

STEP10’Reassesstheneurovascl】】m、statusofthein﹣ juredextremity.Ifperfhsionoftheextrem﹣ itydistaltotheinjuryappearsworseafter applyingtraction,graduallyreleasethe traction. STEP11’Securetheremainingstraps’

ST匱p12。FreqUent】yreevaluatetheneurovascular statusoftheextremi叮.Documenttheneurovascularstatusaftereverymanipulation oftheextremity. STEP13·Admimstertetanusprophylaxis,asindicat﹣ ed·SeeTetanusImmunization（electronic

versiononly）

SI﹤∣LLSTATlONXIII■Mu5cuI05keIetalT「auma:AssessmentandManagement229

〉SkiIIXⅡl﹦E:Compa『tmentSynd『ome:AssessmentandManagement STEp1·

■LossofpulsesandotherclassicHndings ofischemiaoccurlate,aiterirreversible damagehasoccurred.

ConsiderthefbⅡowingimportantfacts: ■CompartmentSyndromecandevelop insidiously. ■CompartmentSyndromecandevelopin anextremityastheresultofcompres﹣ sionorcrushingfbrcesandwithoutObvi﹣ ousexternaliIUmyorfracture. ■Frequentreevaluationoftheinjured extremityisessential. ■Thepatientwhohashadhypotension orisunconsciousisatincreasedrisk允r compartmentsyndrome. ■PainistheearliestSymptomthather﹣ aldstheonsetofcompartmentischemia, especial】ypainonpassivestretchof恤e involvedmusclesoftheextremity. ■Unconsciousormtubatedpatients cannotcommumcatetheearlysignsof extremityisChemia.

STEp2.

Pa1patethemuscularcompartmentsofthe extremities,comparingthecompartment tensionintheiIUuredextremitywiththat inthenoninjuredextremity· AASymmetrymaybeasignificantfinding. B·Frequentexaminationfbrtensemuscu﹣ larcompartmentsisessential. C·Measurementofcompartmentpressures maybehelpfhl.

5丁EP3·

Obtainorthopedicorgeneralsurgicalcon﹣ sultationearly.

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Rec0gnizethatischemiaisalimb﹣threat﹣ eningandpotentiallylifb﹣threatening condition.

5TEPZ‘

Palpateperipheralpulsesbilaterally（dor﹣ salispedis,anteriortibial,fbmoral,radial’ andbrachial）fbrquali叮andsymmetry.

STEP3’Documentandevaluateanyevidenceof aSymmetryinperipheralpulses.

s丁Ep4

ReevaluateperipheralpulsesfTequent】y’ especiallyifasymmet1yisidentified.Use Dopplerandmeasurementofankle／brachial indextoassessthepresenceandqualityof distalpulses·

STEP5·Obtainearlysurgicalconsultation

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Objectives ⅢGivenapatientwithbuminlu「y’eStimatethebu『n 5zieanddete『mn i ethep『esen仁eofassodatedn i 】u「e i 5∣ 固Demonst「atetheinitialassessmentandt「eatmentof pate i ntswtihthe『maIn】u『e i s· 圃ldentifytheuniquep「oblemsthatcanbeencounte『ed inthet『eatmentofpatientswiththe『maIin】u『ies〃and expIainhowto『esoIvethem. 囫Listthec「ite『iafo「t『ansfe『「ingpatientswithbum n i 】u『e i 5t0bu『ncente『s. ﹂

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apphcationofsimpleemergen叮measurescanhelpto mimmizethemorbidibyandmortali叮oftheseiIUuries· Theseprinciplesincludeahighindexofsuspici0n fbrthepresenceofairwaycompromisefbllowing smokeinhalation’identificationandmanagementof associatedmechanicalinjuries,andmaintenanceof hemodynamicnormalitywithvolumeresuscitation. Cliniciansalsomusttakemeasurestopreventandtreat thepotentia1complications0fthermali叮uries’suchas rhabdomyolysisandcardiacdysrhythmias,whichcan beseeninelectricalburns·Temperaturecontroland removalfTomtheinjury﹣pr0vokingenv1ronmentalso arem盯orprinciplesofthermaliIUurymanagement. Ⅳbfc:HeatiIUuries,includingheatexhaustion andheatstroke,areexplainedinAppendiXB:Hypo﹣ thermiaandHeat Iniuries.

Z31

Z32CHAPTER9■The「maIIn】u「ies

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Liibsavingmeasuresfbrpatientswithburninjuriesin﹦ cludeestablishinga1rwaycontrol’stoppmgtheburn﹣ ingprocess’andgainingintravenousaccess.

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AlRWAγ Becauseburnscanresultinmassiveedema,theupper airwayisatriskfbrobstruction.Signsofobstruction mayinitiallybesubtleuntⅡthepatientisincrisis; therefbre,ear】yevaluationoftheneedfbrendotra﹣ chealintubationisessential·Factorsthatihcreasethe riskfbrupperairwayobstructionaremcreasingburn sizeanddepth’burnstotheheadandface’inhala﹣ tioninjury’andburnsinsidethemouth（■F!GuRE9﹣1）. Burnslocalizedtothe色ceandmouthcausemorelo﹣ calizededemaandposeagreaterriskfbrairwaycom﹣ promise·Becausetheirairwaysaresmaller,chⅡdren areathigherriskfbra1rwayproblems.

叨 Hb鯽αo㎡ I e涮劬加〃α【α㎡o〃t咖M ● AlthoughthelarynxprotectsthesUbglotticairwayfrom

directthermali咖1y,theairwayisextremelysuscepti﹣ bletoobstructionasaconsequenceofe聊osuretoheat. Climcalindicationsofinhalationinjmyinclude: ■Faceand／orneckburns ■Singeingoftheeyebrowsandnasalvibrissae ■Ca1bondepositsinthemouthand／Ornoseand carbonaceoussputum ■Acuteinf】ammato1ychangesintheorophar﹣

■P』GURE9﹣1Facto「sthatinc「easethe『iskfo「uppe『 ai「wayobst「ucti0na『einc「easingbu「nsizeand depth’bu『nstotheheadandface’inhaIationin】u『y｝ a5sociatedt「auma’andbu「nsinsidethemouth.

tialbu『nso「thehecl《canIeadtosweIlingo「thetissues a『oundtheai『way;the『efb『e,ea『lyintubationisa∣soindi· catedfb『theseiniu『ies.

ST0PTⅡEBURⅡ∣NGPR0CESS Allclothingshouldberemovedtostoptheburning process（■「IGuRE9﹣2）;however’donotpeeloffadher﹣ entclothing.Syntheticfabricscanignite’burnrapidly athightemperatures’andmeltintohotresiduethat continuestoburnthepatient·Anyclothingthatwas burnedbychemicalsshouldberemovedcarefhlly.D1y Chemicalpowdersshouldbebrushedfromthewound, withthemdividualcarmgfbrthepatientavoidingdi﹣ rectcontactwiththechemical.Thentheinvolvedbody﹣ surihceareasshouldberinsedwithcopiousamountsof warmtapwater.Thepatientthenshouldbecovered withwarm’clean’drylinenst0preventhypothermia.

ynx,includingerythema ■Hoarseness ■Historyofimpairedmentationand／orconfine﹣ mentinaburningenvironment ■Explosionwithburnstoheadandtorso ■Carboxyhemoglobinlevelgreaterthan10﹪in apatientwhowasinvolvedinafire

-

Any0ftheabovefindingssuggestsaninhalationinjury andtheneedfbrintubation·T『aⅡs佗『toabu『nCente『 isindicatedi「the『eisinhaIatiohiniuⅣ,buti「thet『a例s﹣

叨

po『ttimeisp『oIonged,intubationshouldbepe『fb『med p『io『tot『anspoIt’St『ido『occu『slateandisanihdication fb『immediateendot『acheaIintubation.Ci『cum佗『en﹣

■FlGURE9﹣ZAlIcIothingand】ewel「y5houIdbe 『emovedf「omthepatientto5topthebu「ningp『ocess andtop『eventcon5t『ictionf『omedema.

﹄

ASSESSMENTOFPATlENTSWlTHBURNS233

INTRAVEⅡOUSACCESS Anypatientwithburns0vermorethan20﹪ofthe bodysurfhcereqUiresfluidresuscitation.Afterestab﹣ lishinga1rwaypatenCyandidentifyingandtreatmgim﹣ mediatelylifb﹣threateninginjuries,intravenousaccess mustbeestabhshedLarge﹣caliber（atleast16-gauge） intravenoushnesshouldbeintroducedimmediatelyin aperipheralvein.Iftheextentoftheburnprecludes placementofthecatheterthroughunburnedskin,the Ⅳshouldbeplacedthroughtheburnedskinmtoan accessiblevein.Theupperextremitiesareprefbrable tothelowerextremitiesasasiteibrvenousaccess becauseoftheincreasedriskofphlebitisandseptic phlebitisWhenthesaphenousveinsareusedfbrve﹣ nousaccess.BegininfUsionwithanisotoniccrystalloid solution,prefbrablylactatedRinger,ssolution.Guide﹣ linesfbrestablishingtheflowrateare0utlinedlaterm thischapter.

繆︶JLL八／LL一︵」

SceⅡa『io■cont加uedThepatientisintu﹣ bated!andint「aven0usaccessis0btainedinthe antecubitaI↑055aeth『0ughbu『nedskln’

－

and／Ordrugsensitivities.Somepatientsattemptsui﹣ cidethroughselfimmolation’sotheclimcianshould beawareofthispossibili叮.Inaddition,thepatient historyshouldbematchedwiththeburnpattern·If the‘‘story,,issuspicious,theclinicianshouldbeconcernedaboutthepossibilityofmaltreatment.The patient’stetanusimmunizationstatusalsoshouldbe ascertHined

B0Dγ﹣SUR「ACEAREA

叨 Hb叨刨oe I s緬刎α加b“⋯’ze ●α〃ααcp紕? TheBuleofNinesisausefUlandpracticalguidefbr determmingtheextentofabum（■FlGuRE9﹣3）.The adultbodyconfigurationisdividedint0anatomicre﹣ g1onsthatrepresent9℅’ormultiplesof9℅’ofthetotal bodysurface.Body﹣surfacearea（BSA）diffbrsconsiderablyfbrchildren’Theinfhnt,soryoungchild’shead representsalargerproportionofthesurfacearea,and thelowerextremitiesrepresentasmallerproportion thananadult,s·Thepercentageoftotalbodysurface ofaninfhnt,sheadistwicethatofthenorm月Iadult· ThepaIma『su脆ce（incIudingthe伽ge『s）ofthepatient’s hand『ep『esehtsapp『oximate∣y1％o「thepatieht,sbody su脆ce·TheRuleofNinesguidelinehelpsestimatethe extentofburnswithirregularoutlines0rdistribution andisconsideredtheprefbrredtoolfbrcalculatingand documentingtheextentofaburninjury.

∣ ﹥ AssessmentofpatientswithBums ∣DEp『Ⅱ0FBURⅡ Theassessmentofpatientswithburni叼uriesbegins withthepatienthistoryandisfbllowedbyestimation ofthebody-surfaceareaburnedandthedepthofthe burninjury.

ⅡIST0Rγ Theinjmyhistoryisextremelyvaluableinthetreat﹣ mentofpatientswithburns’Associatedinjuriescan besustainedwhⅡethevictimattemptstoescapethe fire’andinjuryfromexplosionscanresultininternal mjuriesorfractures（e.g·’centralnerv0ussystem,my﹣ ocardial’pulmonary’andabdominali叮uries）.Itises﹣ sentia1thatthetimeoftheburnmjurybeestabhshed. Burnssustainedwithinanenclosedspacesuggestthe potentialfbrinhalationimmyandanoxicbraini1Uury ifthereisanassociatedlossofconsciousness· Thehistory’fromthepatientorarelative,should includeabriefsurveyofpreexistingillnesses（e·g.,dia﹣ betes,hypertension’cardiac,pulmonmy’and／orrenal disease）anddrugtherapy,aswellasanyallergies

Thedepthofburnisimportantinevaluatingthese﹣ verityofaburn,planningfbrwoundcare,andpredict﹣ ingfhnctionalandcosmeticresults. FhBt-deg／、eeb叨／、〃s（e·g·’sunburn）arecharacter﹣ izedbye】ythema,pain）andtheabsenceofblisters. Theyarenotlifb﹣threateningandgenerallydonot reqUireintravenousfluidreplacementbecausethe epiderm1sremainsintact。Thistypeofburnisnotdis﹣ cussedfUrtherinthischapterandisnotmcludedm theassessmentofburnsize. Pα／.㎡α!﹣仇方c陬eSSb叨γ几sarecharacterizedbyared ormottledappearancewithassociatedswellingand blisterfbrmation（■「IGuRE9﹣4AandB）.Thesur兔ce canhaveaweeping’wetappearanceandispainfhlly hypersensitive’eventoaircurrent. FM』-炕fc虎〃essbMr几susuaⅡyappeardarkand leathery（■FIGURE9﹣4CandD）.Theskinalsomayappear translucentorwaXywhite.Thesurfhceispainlessand generallyd1y,itmaybered,butdoesnotblanchwith pressure.ThereislittlesweⅢngofthefUll﹣thickness burnedtissue,althoughthesurroundingtissuemay sweⅡasignificantamount.

.％6｝osBId∣﹟In山」osuo!Pe」｝」0／puB Ⅱ〕23％6﹢0sB3』e3〕目｝」nsoJu!p3p!八!p八IIe」3u36s!人p0q】InpeBq上·】uB山36eue山p!nIj3u!u』」3】Bp Pu目su」nq」o血!』B八es3q﹟3﹟enIe八3o｝pBsn5!3p!n6Ie〕!pe」d5!q上·s3u!N』oBInUE﹣6司UnD!」■

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■FIGURE9﹣4DepthofBu『ns·（A）ShaIlowpa『tiaI﹣ thc i knessbu『nn i 】u『y·（B）Pa『ta i﹣ l thC i knessbu『n.（C） Deeppa「tiaI’fuⅡ﹣thicknessbu『nin】u『y·（D）FulI﹣thickne55 bu「nin】u「yonapatient’suppe『a『mandback·

department（ED）necessitatesevaluationofthea1rway withdefimtivemanagement.Pharyngealthermalin﹣ juriescanproducemarkeduppera1rwayedema’and earlyprotectionoftheairwayisimportant.Theclini﹣ calmanifbstationsofinhalationinjurymaybesubtle andhequentlydonotappearinthefirst24hours.If theproviderwaitsfbrx﹣rayevidenceofpulmonary injmyorchangeinbloodgasdeterminations,airway edemacanprecludeintubation,andasurgicalairway mayberequired· 8REATⅡlⅡG

P『m i a『y』Su『veya∣ndResuscitation 0『pati a 【e Ie n】tswith n【swI Bu『ns Theprimarysurveyandresuscitati0nofpatients withburnimuriesfbcusesonairway,breathing’and circulation.

AIRWAγ AhistoⅣofconfinementinaburmngenvironmentor earlysignsofairwayinjmy0narrivalintheemergenCy

Directthermalmjmytothelowerairwayisve1yrare andessentiaⅡyonlyoccursafterexposuretosuper﹣ heatedsteamorignitionofinhaledflammablegases. Breathingconcernsarise仕omthreegeneralareas:hypoxia’carbonmonoxidepois0ning,andsmokeinhala﹣ tioniUjmy. HyponamayberelatedtoinhalationiIUury,inad﹣ eqUateventⅡationduetocircumfbrentialchestburns, ortraumaticthoracici叼uryunrelatedt0thethermal iIUury.Supplementaloxygenwithorwithoutintuba﹣ tionshouldbeadmihistered

Z36CHAPTER9■The『maIIn】u「ie5 Alwaysassumecarbonmonoxide（CO）exposurein patientswhowereburnedinenclosedareas·Thediag﹄ nosisofCOpoisoningismadeprimarⅡyfromahisto】y ofexposureanddirectmeasurementofcarbo汀hemo﹣ globin（HbCO）.PatientswithCOlevelsoflessthan 20℅usuallyhavenophysicalsymptoms.Higher0O levelscanresultin: ■headacheandnausea（20℅-30﹪） ■confUsion（30﹪＿40℅） ■coma（40℅－60﹪） ■death（＞60℅） Cherry﹣redskincolorisrare,andmayonlybe seeninthemoribundpatient.Becauseofthemcreased affini勺ofCOfbrhemoglobin,240timesthatofoxy﹣ gen’itdisplaceso唧genfTomthehemoglobinmolecule andshiftstheoxyhemoglobindissociationcurvetothe left.COdissociatesveryslowly,anditshalflifbis250 mmutes（4hours）whenthepatientisbreathingroom a1r’comparedwith40minutesWhenbreathing100﹪ oxygen.Therefbre’anypatientmwhomCOexposure couldhaveoccurredshouldreceivehigh﹣flowo叮gen viaanon﹣rebreathingmask. EarlymanagementofinhalationiIUurymay requireendotrachealintubationandmechanicalventi﹣ lation.Priortointubation’thepatientshouldbepre﹣ o汀genatedwithcontinuousadministrationofo叮gen. Intubationshouldbeperfbrmedearlyinpatientswith suspectedairwayi呵u】V.BecausethereisahighprOb﹣ abilityoftheneedfbrbronchoscopyinburnpatients withairwayinjury’anendotrachealtUbeofsufficient sizeshouldbechosenfbradefinitiveairway.Arterial bloodgasdeterminationsshouldbeobtainedasabasehnefbrtheevaluationofthepatient’spulmona】ysta﹦ tus.However,measurementsofarterialPaO’donot reliablypredictCOpoisomng,becauseaCOpartial pressureofonly1mmHgresultsinanHbCOlevelof 40﹪orgreater.Therefbre,baselineHbCOlevelsshould beobtained’and100℅o汀genshouldbe曰Nmih｛stered. Inhalationofproductsofcombustion,includ﹣ ingcarbonparticlesandtoxicfhmes,isimportantto diagnose’becauseitdoublesthemortahtyofburn patientswhencomparedwithpatients0fasimilarage andburnsizewhodonothaveinhalationinjury.The pathophysiologyinvolvessmokeparticlessettlinginto thedistalbronchioles,leadmgtodamageanddeathof themucosalcells.Damagetotheairwaysthenleads toanincreasedinnammat0ryresponsethat’inturn’ leadstoanincreaseincapiⅡaryleakage’whichresults inano叮gendiffhsiondefbct.Thenecroticcellstendto sloughandobstructtheairways.Thispluggingofthe a1rwaysandanimpairedabilitytofightinfbctionlead toanincreasedriskofpneumon1a. TheAmericanBurnAssociationhasdefinedtwo reqU1rementsfbrthediagnosisofsmokemhalation

1n】ury:（1）exposuretoacombustibleagent,and（2）signs ofexposuretosmokeinthelowerairway,belowthevocal c0rds,bybronchosc0Ⅳ.Thep0ssibilityofsmokeinhala﹣ tioninjmyismuchhigheriftheinjmyoccurredwithin anencl0sedplace·Prolongede卹osurealsoincreasesthe likelihoodfbrsmokeinhalationiIUury. Aninitialchestx﹣rayandarterialblo0dgasdeter﹣ minationshouldbeobtainedasabaselinefbrevaluatmgthepatient’spulmona】ystatus.Althoughthe imtialx﹣rayandbloodgasmaybenormal’theymay deteriorateovertime·Thetreatmentofsmoke｛nhR】2﹣ tioninjuryissupportive.Apatientwithahighlikehhoodofsmokeinhalationinjuryassociatedwitha signiiicantburnshouldbeintUbated.Ifthepatient,s hemodynamicconditionpermitsandspinalmjmyhas beenexcluded’elevationoftheheadandchestby30 degreeshelpstoreduceneckandchestwalledema·If a仇】Il-thickhessburnoftheanteriorandlateralchest wallleadstosevererestrictionofchestwallmotion, evenintheabsenceofacircum允rentialburn’chest wallescharotomymayberequired·

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﹄I

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α『cu∣ation＿Bu『nShoc∣《 Resuscitation

G＞『Wm㎡s咖mfeαM聊eof伽α ●ααy㎡㎡sfcγeαfOpα〃e〃加叨㎡〃伽γ砌sβ Evaluationofcirculatingbloodvolumeisoftendifficult inseverelyburnedpatients.Inaddition,thesepatients mayhaveaccompanyingi叮uriesthatcontributetothe hypov0lemicshock.Shockshouldbetreatedaccording totheresuscitationprinciplesasouthnedinChapter 3:Sh0ck.Burnresuscitationfluidsalsoshouldbepro﹣ vided（■「IGuRE9﹣5）.Bloodpressuremeasurements canbedifficulttoobtainandmaybeunreliablein

patientswithsevereburninjuries,butmonitoringof hourlyurinaryoutputcanreliablyassesscirculating bloodvolumeintheabsenceofosmoticdiuresis（e.g, g】ycosuria）.Therefbre,anindwellingurinarycatheter shouldbeinserted.

SECONDARYSURVEYANDRELATEDADjUhICTSZ37

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■「lGURE9﹣5Patientswithbu「ns「equi「eZto4mLof Ringe『’slactate5oIutionpe『kiI0g『amofbodyweight pe「pe『centage8SA0fdeeppa「tiaI﹣thiclme5sandfuIIthicknessbu「nsdu「ingthefi「stZ4hou「st0maintain anadequateci「cuIatingbI0odvoIumeandp『ovide adequate「enaIpe「fusi0n.

rate,thefluidrateshouldbeincreaseduntiltheurine outputisappropriateIfthepatienthasalesssevere burn’alowerstartingratecanbeimtiated.Likewise’if theurineoutputisatorabovethe0.5mL／kg／hrtarget’ theⅣrateshouldbedecreased·TheⅣrateshould几ot bedecreasedbyone﹣halfat8hours,reductioninⅣ fluidrateshouldbebasedonurineoutput. Similarly’fluidratesshould〃ofbebasedonthe timeoftheactualmjury.Rather’startthefluidsbased ontheinitialcalculationandadjustbasedonurine outputirrespectiveofthetimefrommjury.Inve】y smallchildren（i.e.,＜10kg）’itmaybenecessarytoadd glucosetotheirⅣfluidstoavoidhypoglycemia· Cardiacdysrhythmiasmaybethefirstsignof hypoxiaandelectrolyteoracid﹣baseabnormalities. Electrocardiography（ECG）shouldbeperfbrmedfbr cardiacrhythmdisturbances.Persistentacidemiamay becausedbyCyanidepoisomng·Consultationwitha burncenterorpoisoncontrolcentershouldoccurif thisdiagnosisissuspected.Cyanideisanaturally occurringtoxinthatmaybeinhaledinaconfined﹣ space固re.

▲▲

■FaiIu「eto「ecognizetheinc「easedfIuid「equi『ement fo「patientswithinhaIationin】u『yandthosewith con﹤omitantblunto「c「usht「auma’andfo「pediat『ic bu『npatients. ■Failu『et0ad】ustthefIuidadminist『ation『atebased onapatient『sphysioIogic『esponse.

Theinitialfluidratefbrburnpatientsisbased onseveralwell﹣knownfbrmulas:Patientswithburns require2to4mLofRinger’slactatesolutionperlnlo﹣ gramofbodyweightperpercentageBSAofdeeppar﹣ tial﹣thicknessandfUll﹣thicknessburnsduringthehrst 24hourstomaintainanadequatecirculatingblood volumeandprovideadequaterenalpermsion.Thecal﹣ culatedfluidvolumeisinitiatedinthefbⅡowingmanner!one-halfofthetotalfluidisprovidedinthefirst 8hoursaftertheburninjulV.（Forexample’a100kg manwith80℅totalBSAburnsrequires2to4x80x 100＝16’000to32,000mLin24hours.One﹣halfof thatvolume’8,000to16’000mLshouldbeprovidedin thefirst8hours’sothepatientshouldbestartedata rateof1,000＝2,000mL／hr·）Theremaimngone﹣halfof thetotalf】uidis月刷mihisteredduringthesubsequent 16hours. Itisimportanttounderstandthatfbrmulasare onlyfbrprovidingastartingtargetrate.Mterstarting atthistargetrate,theamountoffluidsprovidedshould beadjustedbasedontheurineoutputtargetof0.5mL／ k創hrfbradultsand1mL／kg／hrfbrchildren＜30kg. Theactualfluidratethatapatientrequires dependsontheseverityofinjury.Ifthetargeturine outputisnotreachedwiththeimtialresuscitation

PITFAγ』『」S L

Scena『io■∞nt／hued「Iuid『esusdtati0nis begunandthepatientha5mInIma∣u『ine0utput｝ the↑luid『ateisinc『ea5ed’andthepatientis evau I ated↑0『↑u『the「t『aumatc in Iu I 『y. －

Seconda『y5u『veyandReI 『 y ated Ad】uncts Keyaspectsoftheseconda1ysurveyanditsrelated adjunctsincludephysicalexamination,documenta﹣ tion’basehnebl0odlevelsandx﹣rays’maintenance ofperipheralcirculationincircumfbrentialextremity burns’gastrictubeinsertion’narcoticanalgesicsand sedatives’woundcare,andtetanusimmunization.

Z38CHAPTER9■The「maIIniu「ies PⅡγS!CALEXAMINATI0Ⅱ Inordertoplananddirectpatienttreatment,thepro﹣ vidermustestimatetheextentanddepthoftheburn, assessfbrassociatedinjuries,andweighthepatient.

D0C0MENTATl0N Aflowsheetorotherrep0rtthatoutlinesthepatient,s treatmentshouldbeinitiatedwhenthepatientisad﹣ mittedtotheEDThisflowsheetshouldaccompany thepatientwhentransfbrredtotheburnunit·

BASElINEDETERMⅢATI0ⅡS『0RPAT∣EⅡTs W∣TⅡMA』0RBURNS Obtainsamplesfbracompletebloodcount（CBC）, typeandcrossmatch／screen,anarterialbloodgaswith HbCO,serumglucose,electrolytes,andpregnancytest inallfbmalesofchⅡdbearmgage.Achestx﹣rayshould beobtainedfbrthosepatientswhoareintubatedor haveasuspectedsmokeinhalati0ninjury’withrepeat filmsasnecessary.Otherx﹣raysmaybeindicatedlbr appraisalofassociatedinjuries.

pERIPⅡERALαRCULATI0ⅡIⅡ αRCUM「EREⅡTIAlEXTREMITγBⅡRNS Thegoalfbrassessingperipheralcirculati0ninapa﹣ tientwithburnsistoruleoutcompα㎡加e〃﹠ay川dro加e· CompartmentSyndromeresultsfTomanincreasein thepressureinsideacompartmentthatinterfbreswith perfUsiontothestructureswithinthatcompartment· Foranextremity,perfhsiontothemusclewithinthe compartmentisthemamconcern.Althoughacompartmentpressuregreaterthansystolicbloodpressure isrequiredtoloseapulsedistaltotheburn’apressure of＞30mmHgwithinthecompartmentmayleadto musclenecrosis.Oncethepulseisgone,itmaybetoo latetosavethemusCle.Thus’cⅡmciansmustbeaware ofthesignsofacompartmentsyndr0me:increased pamwithpassivemotion,tightness’numbness,and, eventually,decreaseddistalpulses.Iftherearec0n﹣ cernsaboutacompartmentSyndrome’thecompart﹣ mentpressureiseasⅡymeasuredbyinsertinganeedle connectedtopressuretubing（arterialorcentralpres﹣ suremonitor）intothecompartment·Ifthepressureis ＞30mmHg,escharotomyisindicated. CompartmentSyndromesmayalsopresentwith c】rcumfbrentialchestandabdominalburns,leading toincreasedpeakinspiratorypressures.Chestand abdominalescharotomiesperfbrmeddowntheante﹣ rioraxillarylineswithacross﹣incisionatthejunction ofthethoraxandabdomenusuaⅡyrehevetheprob﹣ lem（■FIGuRE9﹣6）.Withaggressivefluidresuscitation’

■『lGURE9﹣6Escha『otomybCompa「tmentsynd「omes mayp『esentwithci『cum↑e『entiaIchestandabd0minal bu「ns〃Ieadingtoinc『easedpeakinspi『ato「yp『essu「es. ChestandabdominaIescha「otomiespe「fo「meddown theante『io『axilIa「yIineswithac『o5s﹣incisionatthe 】unctionofthetho『axandabdomenusuaIIy『eIievethe p「obIem.

abdominalcompartmentsyndromemayoccur,sothe cliniciansshouldwatchfbrthispotentialproblem. Inordertomaintainperipheralcirculationin patientswithcircumfbrentialextremityburns,thecli﹣ nicianshould: ■Removealljewelryonthepatient,s extremities. ■Assessthestatusofdistalcirculation,check﹣ ingfbrcyanosis’impairedcapillaryrefill,and progressiveneurologicsigns’suchaspares﹣ thesiaanddeep﹣tissuepain.Assessmentof peripheralpulsesinpatientswithburnsis bestperfbrmedwithaDopplerultrasomcflow meter. ■Relievecirculato1yc0mpromiseinacircumfbr﹣ entiallyburnedlimbbyescharotomy,always withsurgicalconsultation.Escharotomies usua1lyarenotneededwithinthefirst6hours afteraburnmjury. ■Althoughfhsciotomy正seldomreqUired’itmay benecessarytorestorecircu1ationfbrpatients withassociatedskeletaltrauma,crushmjury, high﹣voltageelectricalinjury’andburns involvingtissuebeneaththeinvestingfHscia.

CHEMICALBURNSZ39

GASTRICTUBE∣ⅡSERTIOⅡ

TETAⅡUS

Insertagastrictubeandattachittoasuctionsetup ifthepatientexperiencesnausea’vomiting’orabd0minaldistention,orifburnsinvolvemorethan20﹪ totalBSA.Priortotransfbr,itisessentialthatagas﹣ trictubebeinsertedandfhnctiomngmpatientswith theseSymptomsinordertoavoidvomitingandpos﹣ sibleaspiration.

Determinationofthepatient,stetanusimmunization statusisve叮important.SeeTetanusImmunization （electronicversiononly） ＝ ﹁

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SceⅡa『io■contfnuedThepatientⅡsu『ine 0utputindeaseSt00·5mUkgwithlnc『eased↑∣uid 『eSusdtati0niandhi5chestx﹣『ay『eveaIsmu∣tip∣e 『ib↑『actu『esandapuIm0na『yc0ntu5i0n.A↑te『 discus5i0nwiththeacceptingphysician’hei5 t『ans↑e『『edt0a『eg0 i na∣bumcente吼

ⅡARC0TICS’AⅡALGESlCS’AⅡDSEDATlVE5 Severelyburnedpatientsmayberestlessandanxious lromhypoxemiaorhypovolemiaratherthanpain. ConseqUently,hypoxemiaandinadequatefluidre﹣ suscitationshouldbemanagedbefbreadministration ofnarcoticanalgesicsorsedatives,whichcanmask thesignsofhypoxemiaandhypovolemia.Narc0tic analgesicsandsedativesshouldbe月dmihisteredin small’fTequentdosesbytheintravenousrouteonly. Rememberthatsimplycoveringthewoundwillim﹣

▼

﹂

∣P ChemicaIBu『ns ChemicalinjurycanresultfTomexposuretoacids,al﹣ kalies’andpetroleumproducts.Alkaliburnsaregener﹣ allymoreseriousthanacidburns,becausethealkalies

W0UNDCARE Partial﹣thicknessburnsarepainfhlwhena1rcurrents passovertheburnedsurfhce·Gentlyc0veringtheburn withcleansheetsrelievesthepainanddeflectsair currents.Donotbreakblistersorapplyanantiseptic agent.Anyappliedmedicationmustberemovedbefbre appropriateantibacterialtopicalagentscanbeapplied Applicationofcoldcompressescancausehypothermia. Donotapplycoldwatertoapatientwithextensive burns（＞10﹪totalBSA）·

penetratemoredeeply.Rapidremovalofthechemical andimmediateattentiont0woundcareisessential· Chemicalburnsareinfluencedbythedurationofcon﹣ tact,concentrationofthechemical,andamountofthe agent.Ifdrypowderisstillpresentontheskin,brush itawaybefbreirrigatingwithwater.Otherwise’im﹣ mediatelyflushawaythechemicalwithlargeamounts ofwater,fbratleast20to30minutes,us1ngashower orhose（■FIGuRE9﹣7）.Alkaliburnsrequirelongerir﹣ rigation.Neutralizingagentso睦rnoadvantageover waterlavage,becausereactionwiththeneutraliz﹣ ingagentcanitselfproduceheatandcausefhrther

AⅡTIBIOTlCS ThereisNOindicationfbrprophylacticantibioticsin theear】ypost﹣burnperiod.Antibioticsshouldbere. servedfbrthetreatmentofin企ction.

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Z40CHAPTER9■The『maIlniu「ies tissuedamage.Ajkaliburnstothe叮erequirecontinu﹣ ousirrigationduringthefirst8hoursaitertheburn. Asmall﹣calibercannulacanbefixedinthepalpebral sulcusfbrirrigation.Therearespecificchemicalburns （suchashydrofluoricacidburns）thatrequirespecializedburnunitconsuItRtion.

∣ ﹥ EIect『icaIBu『ns

generatedresultsinthermalinjurytotissue.Diffbrent ratesofheatlossfTomsuperficialanddeeptissuesallow fbrrelativelynormalover】yingskintocoexistwithdeep﹣ musclenecrosis.Assuch’electricalburnsfrequent】yare moreseriousthanth叮appearonthebodysurfhce’and extremities’especiaⅡydigits,areparticular】yproneto i叮u】y.Inaddition,thecurrenttravelsinsideblo0dves﹣ selsandnervesandthusmaycauselocalthrombosis andnerveinjmy.Patientswithelectricali叼uries仕e﹣ quentlyneedfhsciotomiesandshouldbetransfbrredto burncentersear】yintheircourseoftreatment. Immediatetreatmentofapatientwithasignificant electricalburnmcludesattentiontotheairwayand breathing,establishmentofanintravenouslineinan umnvolvedextremi叮’ECGmonitoring’andplacement ofanindwellingbladdercatheter.Electrici叮maycause cardiacarrhythmiasthatmayrequirechestcompres﹣ sions.Iftherearenoarrhythmiaswithinthefirstfbw hoursofi叼ury,prolongedmomtormgisnotnecessa】y. Sinceelectricitycausesfbrcedcontractionofmus﹣ cles》cliniciansneedtoexaminethepatientfbrasso﹣ ciatedskeletalandmusculardamage’includingthe p0ssibili叮ofspinalhUuries·Bhabdomyolysisresultsin myoglobinrelease’whichcancauseacuterenalfhilure. Donotwaitfbrlaboratoryconfirmationbefbrem﹣ stitutingtherapyfbrmyoglobinuria.Ifthepatient,s urineisdark,assumethathemochromogensareinthe urine·Fluidadmihistrationshouldbeincreasedtoensureaurina1youtputof100mL／hrinadultsor2mL／ kg／hrinchildren＜30kg.Metabohcacidosisshouldbe correctedbymaintaimngadeqUatepermsion.

叨W／o j do⋯ I 咖蔽oαb“⋯e涮加’.β ●

Thecriteriafbrtransfbrmustbemetandprocedures mustbefbllowedinthetransfbrofpatientstoburn centers.

TheAmericanBurnAssociationhasidentifiedthefbllowingtypesofburninjuriesthattypicallyrequirere﹣ fbrraltoaburncenter: Partial﹣thicknessandh1ll-thickhessburnson greaterthan10﹪oftheBSAinanypatient 2 Partial﹣thicknessand血Ⅱ﹣thicknessburnsinvolv﹣ ingtheface’eyes’ears,hands,fbet’genitalia’ andpermeum,aswellasthosethatinvolveskin overlyingmajorjoints

· 1

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Electricalburnsresultwhenasourceofelectricalpower makescontactwithapatient,sbody.Thebodycanserve asavolumeconductorofelectricalenergy’andtheheat

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5 ●

6 ■

7

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Significantchemicalburns Inhalationinjury Burninjuryinpatientswithpreexistingillness thatcouldcomplicatetreatment’prolongrecov﹣ ery,orafIbctmortali叮

· 8

Anypatientwithaburninjurywhohasconcomi﹣ tanttraumaposesanincreasedriskofmorbidity ormortality,andmaybetreatedinitiallyina traumacenteruntilstablebefbrebeingtrans﹣ 比rredtoaburncenter

· 9

Childrenwithburninjurieswhoareseeninhos﹣ pitalswithoutqualifiedpersonnelorequipment tomanagetheircareshouldbetrans｛brredtoa burncenterwiththesecapabilities

10

Burnin】ury1npatientsWhowillreqUirespecial socialandemotionalorlong﹄termrehabilitative support,mcludingcasesinvolvingsuspectedchild maltreatmentandneglect

TRANSFERPROCEDURES Transfbrofanypatientmustbecoordinatedwiththe burncenterstaf£AⅡpertinentinfbrmationregardmg testresults,temperature’heartrate’fluidsadmims﹣ tered’andurinaryoutputshouldbedocumentedon theburn／traumaflowsheetandsentwiththepatient. Anyotherinfbrmationdeemedimportantbytherefbr﹣ rmgorreceivingdoctoralsoissentwiththepatient.

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COLDINjURY:L0CALTISSUEEFFECTSZ41

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Theseverityofcoldinjurydependsontemperature’du﹣ rationofexposure’environmentalconditions’amount ofprotectiveclothing’andthepatient’sgeneralstate ofhea1th·Lowertemperatures’inⅢnobⅢzation’pro﹣ longedexposure,moisture’thepresenceofperipheral vasculardisease’andopenwoundsallmcreasetheseveri叮oftheinjury. TγpES0「C0止DIⅡjURγ

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■FIGURE9﹣8F『ostbite.F「0stbiteisduetof『eezing oftis5uewithint「aceIIuIa「icec『ystalfo『mation’ mic「ovascuIa『occIu5ion『andsubsequenttis5ueanoxia 5omeofthetis5uedamageaIsocan『esuItf『om 「epe㎡usi0nin】u『ythatoccu『son『ewa『ming.

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Threetypesofcoldmjuryareseenintraumapatients frostnip,丘ostbite’andnonfTeezingmjmy.

3。Third﹣degreehyostbite:FuⅡ﹣thicknessandsubcutaneoustissuenecrosisoccurs,commonlywith hemorrhagevesiclefbrmation

F『ostnip

4Fourth﹣degree丘ostbite:Full﹣thicknessskinnecro﹣ sis’includingmuscleandbonewithgangrene

Frostmpisthemildestfbrmofcoldin】u1y·Itischaracter﹣ izedbyinitialpain,pallor’andnumbnessoftheaffbcted b0dypart.Itisreversiblewithrewarnnnganddoesnot resultmtissueloss’unlesstheinjuryisrepeated0ver manyyears’whichcausesfhtpadlossoratrophy· F『oStbite Fr0stbiteisduetoheezingoftissuewithintracellu﹣ laricecrystalfbrmation）microvascularocclusi0n,and subsequenttissueanoxia（■『IGuRE9.8）.Someofthe tissuedamagealsocanresultfTomreperh1sioninjmy thatoccursonrewarming.Frostbiteisclassifiedinto first﹣degree’second﹣degree’third﹣degree,andfburth﹣ degreeaccordingtodepthofinvolvement. 1.First﹣degreefTostbite:I均『peremiaandedema without屬Mnnecrosis Z.Second-degreefrostbite;Large,clearvesicle fbrmationaccompaniesthehyperemiaandedema withpartial-thicknessskinnecrosis

AlthoughtheaffbctedbodypartistypicaⅡyini﹣ tiaⅡyhard,cold’white’andnumb,theappearance 0fthelesionchangesfrequentlyduringthecourseof treatment.Inaddition’theinitialtreatmentreg1menis applicablefbralldegreesofinsult’andtheinitialclas﹣ sificationisoftennotprognosticallyaccurate.Hence’ someauthoritiessimplyclassi句frostbiteassuperiicial ordeep

Nonf『eezinglniu『y Nonheezingi叼uryisduetomicrovascularendothelial damage’stasis,andvascularocclusion.Trenchfbotor coldimmersionfbot（orhand）describesanonfiPeezing inju】yofthehandsorfbet,typicaⅡyinsoldiers’sailors, andfishermen,resultingfromlong﹄termexposureto wetconditionsandtemperaturesjustabovefTeezing （1.6。Cto10。C’or35。Fto50。F）.Althoughtheentire fbotcanappearblack,deep﹦tissuedestructionmay notbepresent·Alternatingarterialvasospasmand

Z4ZCHAPTER9■The『maIln】u『ies vasodilationoccur,withtheaffbctedtissuefirstcold andnumb’thenprogressingtohyperemiam24to48 hours·Withhyperemiacomesintense’painfhlburn. inganddysesthesia,asweⅡastissuedamagecharac﹣ terizedbyedema’blistering,redness’ecchymosis’and ulcerations.Comphcationsoflocalinfbction’ceⅡuⅡtis, lymphangitis,andgangrenecanoccur·Properatten﹣ tiontofbothygienecanpreventtheoccurrenceofmost suchiniuries.

MAⅡAGEMEⅡT0『『R0STB∣TEAⅡD Ⅱ0Ⅱ『REEZ∣ⅡGC0lD∣Ⅱ川RlES

叨Hb”do吻 I 潛α〃ocα!coM伽咖:es; ●

TreatmentshouldbeimmediatetodecreasethedmPa﹣ tionoftissuefreezing,althoughrewarmmgshouldn0t beundertakenifthereistheriskofrefreezing.Con﹣ stricting’dampclothingshouldbereplacedbywarm blankets’andthepatientshouldbegivenhotfluidsby mouth,ifheorsheisablet0drink.Placetheinjured partincirculatingwaterataconstant40。C（104。F） untⅡpinkcolorandperfhsionreturn（usuaⅡywithm 20to30minutes）.Thisisbestaccomplishedman inpatientsettinginalargetank,suchasawhirlpool tank·Avoidd】yheat,anddonotrubormassagethe area.Rewarmingcanbeextremelypainfbl,andade﹣ quateanalgesics（intravenousnarcotics）areessential. Cardiacmomt0ringduringrewarmingisadvised.

LocaIWoundCa『eofF『ostbite Thegoalofwoundcarefbrfrostbiteistopreservedam﹣ agedtissuebypreventinginfbction,avoidingopening uninfbctedvesicles’andelevatingtheimuredarea, whichisleftopentoair.Theaffbctedtissueshould beprotectedbyatentorcradle’andpressurespots shouldbeavoided· Onlyrarelyisfluidlossmassiveenoughtorequire resuscitationwithintravenousfluids,although patientsmaybedehydrated.Tetanusprophylaxis dependsonthepatient’stetanusimmunizationsta﹣ tus.Systemicantibioticsarenotindicatedempirically, butarereserved允ridentihedin比ctions·Thewounds shouldbekeptclean,anduninfbctedblebsleftintact fbr7to10daystoprovideasterilebiologicdress﹣ ingtoprotectunderlyingepithelialization.Tobacco,

mcotme’andothervasoconstrictiveagentsmustbe withheld·Weightbearingisprohibiteduntiledemais resolved·Numerousadjuvantshavebeenattempted inanefIbrttorestorebloodsupplyt0cold﹣injuredtis﹣ sue.Unfbrtunately,mostareineffbctive.Sympathetic blockade（sympathectomy,drugs）andvasodilating agentshavegeneraⅡynotprovenhelpfhlinaltering thenaturalhisto1yoftheacutecoldinjury.Heparin andhyperbaricoxygenalsohavefhiledtodemonstrate substantialtreatmentbenefit’Low﹣molecularweight dextranhasshownsomebenefitduringtherewarm﹣ ingphaseinanimalmodels.Thrombolyticagentshave alsoshownsomepromise. Withallcoldinjuries）estimationsofdepthofmjury andextentoftissuedamagearenotusuallyaccurate untⅡdemarcationisevident·Thisoftenrequiressev﹣ eralweeksormonthsofobservation.EarⅡersurgi﹣ ca1debridement0ramputationisseldomnecessary’ unlessinfbctionwithseps1soccurs.

∣L▲ PIFFA『』『』S L

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Traumapatientsalsoaresusceptibletohypothermia, andanydegreeofhypothermiaintraumapatients canbedetrhnental.Intraumapatients,hypother﹣ miashouldbeconsideredtobeanycoretemperature below36·C（96.8。F）’andseverehypothermiaisany coretemperaturebelow32。C（89.6。F）Hypothermia iscommonintheseverelyinjured’butfhrtherloss ofcoretemperaturecanbelimitedwiththeadminis﹣ trationofonlywarmedintravenousfluidsandblood’ judiciousexposureofthepatient’andmaintenanceof awarmenvironment·Avoidingiat『ogehichypothe『mia du『ingexposu『eandⅡuidadminist『ationisimpoItant,as hypothe『miamaywo『sencoagulopathy。 Thesignsofhypothermiaanditstreatmentare explainedinmoredetail i n A p p e n d i x B Hypothermia

andHeatIniuries

CHAPTERSUMMARY243

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ChapterSunnnary

∣

ⅡTheRuleofNinesisauseh1landpractica1guidetodeterminetheextentofthe burn·Bodysurfaceareadiffbrsconsiderablyfbrchildren.Theinf白nt’soryoung child,sheadrepresentsalargerproportionofthesurfhcearea’andthelowerex﹣ tremitiesrepresentasmallerprop0rtionthananadult’s. 圓Associatedinjuriescanbesustainedwhilethevictimattemptstoescapethefire》 andi叮uryfromexplosionscanresultminternalinjuriesor仕actures（e·g.,cen﹣ tralnervousSystem’myocardial’pulmonary,andabdominali叼uries）. 圃Immediatelifbsa凡『ingmeasuresfbrpatientswithburninjuryincludetherec﹣ ognitionofinhalationimu】yandsubseqUentendotrachealintUbation,andthe rapidmstitutionofintravenousfluidtherapy.Earlymanagementofcold﹣iIUured patientsmcludesadheringtotheABCDEsofresuscitation;ident坩ingthetype andextentofcoldimury;measuringthepatient’scoretemperature;initiatinga patient﹣carefIowsheet;andimtiatingrapidrewarmingtechniques. 囚Attentionmustbepaidtospecialproblemsuniquetothermalinjuries.Carbon monoxidepoisomngshouldbesuspectedandidentified·Circumfbrentialburns mayrequireescharotomy.Chemicalburnsrequireimmediateremovalofclothing topreventfmtherinjury’asweⅡascopiousirrigation.Electricalburnsmaybe associatedwithextensiveoccultmyonecrosis·Patientssustainingthermalinjury areatriskfbrhypothermia.JUdiciousanalgesiash0uldnotbeoverlo0ked. 回TheAmericanBurnAssociationhasidentifiedb『pesofburni叮uriesthattypical﹣ lyrequirerefbrraltoaburncenter:Transfbrprinciplesaresimilartonon﹣bumed patientsbutincludeanaccurateassessment0fthepatient,sburnsizeanddepth ＝

Z44CHAPTER9■The『maIIn】u『ie5

1.CiofHWG,GravesTA,McManusWF,etal.Highfre﹣ quenCypercussiveventilationmpatientswithinhalation mjury.JⅡ】mαmα1989;29:350﹣354. 2.DanzlD,PozosR,AuerbachP’etal.Multicenterhypo﹣ thermiasurvey·AmbE加e唔Mbd1987;16:1042﹣1055. 3·DemⅡngHR.Burncaremtheimmediateresuscitation period.SectionIⅡ,Thermalmjury·In:WilmorDW’ed. Sαe兀餓cAme『γcα〃SM唔它｝:y.NewYOrk:ScientificAme﹦ ncan,1998.

14·JUrkovichGJ’GreiserW’LutermanA,etal.Hypothermiamtraumavictims:anommouspredictorofsurvival· J乃ααmα1987;27:1019﹣1024. 15.LundT,Go0dwinCW’McManusWF,etal.UPpera1rway sequelaeinburnpatientsrequirmgendotrachea1mtuba﹣ tionortracheostomy·Am】Smg1985;201:374﹣382. 16·MiⅡsWJJr·Summa】yoftreatmentofthecoldinju﹣ redpatient:frostbite〔1983classicarticle〕.A／αMbd 1993;35（1）:61﹣66. 17.MossJ.Accidentalseverehypothermia·Sα唔句〃eco／ Obsfα1986;162:501﹣513.

4.EdliChR’ChangeD,BirkK,etal·Coldinjuries·CbJ7zp｝· ?γie／、1989;15（9）:13﹣21.

18·MozmgoDW,SmithAA,McManusWF’etal.Chemical burns.J乃.α叨加α1988;28:642﹣647·

5.GentⅡeⅡoLM,CobeanRA’OffherPJ,etal.Continuous arteriovenousrewarming:rapidreversalofhypothermia incriticallyillpatients.JZ】mαmα1992;32（3）:316﹣327

19.O,MalleyJ’MiⅡsW’KappesB’etal.Frostbite:general andspecifictreatment,theAlaskanmethodA／αMbd 1993;27（1）:pullout.

6.GentilelloLM’JurkovichGJ’MoUjaesS‘I均『pothermia andinjmy:thermodynamicprinciplesofpreventionand treatment.In:LevineB,ed‘几／qSpec觔uesmS【〃群『y.St. Louis:QualityMedical;1991.

20‘PemyRJ,MooreCA’etal.Determiningtheapproximate areaofburn:aninconsistenCyinvestigatedandreevalu﹣ ated.BM／1996;312:1338.

7·GravesTA’CioffiWG,McManusWF,etal.Fluidresusci﹣ tationofinihntsandchildrenwithmassivethermnI injury’JT／、α泓mα1988;28:1656﹣1659 8·GunningK,ed.BαmsZ〉uMmαHtmdb0o陶·5thed.Liver﹣ pool,UK:LiverpoolHospitalDepartmentofTrauma Services;1994. 9.HalebianP,RobinsonN’BarieP,etal.Wholebodyo叮﹣ genutilizationduringcarbonmonoxidepoisoningand isocapneicnitrogenhypoxia.J乃αu加α1986;26;110﹣117. 10.HaponikEF’MunsterAM,eds·ReSp〃α加｝y蚵α『y: S加o〃e加／jα／α〃o〃α〃dB皿J7ls.NewYork:McGraw﹣Hill; 1990· 11.HerndonD.ed·乃fα』B【〃ⅥCαJ℃.3rded。Philadelphia’ PA:Saunders;2007. 12.JacobJ’WeismanM,RosenblattS,etal.0hronicpernio: ahistoricalperspectiveofcold﹣inducedvasculardisease. A『.c﹠血／er几Mbd1986;146:1589﹣1592.

21PruittBAJr·Theburnpatient:I.mitialcare·C【〃7、PJDb／ S叨／g1979;16（4）:1﹣55. 22.PruittBAJr·Theburnpatient:Ⅱ.Latercareand complicationsofthermaliUjmy.Cαr／.P／ub!Sα／g 1979j16（5）;1﹦95· 23·ReedR’BraceyA’HudsonJ,etal.Hypothermiaand bloodcoagulation:dissociationbetweenenzymeactivi叮 andclotting炮ctorlevels.α｝℃S／joc陀1990;32:141﹣152· 24’SaffleJR,CrandallA’WardenGD.Cataracts;alon曾 termcomplicationofelectricalmjury.JT／·α叨加α 1985;25?17﹣21· 25·SchallerM’FischerA’PerretC.Hyperkalemia:aprog nosticfhctorduringacuteseverehypothermia·cMMA 1990;264:1842﹣1845. 26.SheehyTW,NavariRM.Hypothermia.A／αJMbdSb面 1984;21（4）:374﹣381. 27.StrattaRJ,SaffleJR,KravitzM,etal.Managementof tarandasphaltinjuries.AJ〃JS皿Jg1983;146:766﹣769.

13.JUrkovichGJ.Hypothermiainthetraumapatient.In: MaullKI,ClevelandHC,StrauchGO,etal.,eds’AdDα〃﹣ ces加Trααmα·Vol.4·Chicago:Yearbook;1989:11-140.

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requireemergencydepartmentcarefbrthetreatment 0finjuries,representingnearly1ofevery6children. Eachyearmorethan10,000childrenintheUnited Statesdiefromseriousmjury·Injurymorbidityand mortalitysurpassallm匈ordiseasesinchildrenand youngadults’makinginjurythemostseriouspubhc healthandhealthcareprobleminthispopulation. Becausefhiluretosecuretheairway’supportbreathing, andrecognizeandrespondtointraabdominaland intracranialhemorrhageareknowntobetheleading causesofunsuccessfUlresuscitationinseverepediatric trauma,applicationofATLS＠principlestothecare ofinjuredchildrencanhaveasigmficantimpacton u】timatesurviva1.

﹃ □

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叨 W】α j﹩卹eso／㎡咖㎡esdoc腕J〔γ !e翩 ●s叨s㎡α加β Mot0rvehicle﹣associatedinjuriesarethemostcom﹣ moncauseofdeathsinchildrenofallages’whether thechildisanoccupant’pedestrian,or叮clist.Deaths

﹃

Z47

Z48CHAPTER10■Pediat「icT「auma

duetodrownmg’housefires’homicides,andfhllsfbl﹣ lowmdescendingorder·Childmaltreatmentaccounts ibrthegreatm匈ori叮ofhomicidesininfants（children youngerthan12monthsofage）’whereasfirearmmju﹣ riesaccountfbrthemajori叮ofhomicidesinchildren andadolescents。Fallsaccountfbrthemajori叮ofall pediatricinjuries,butinfTequentlyresultindeath. Bluntmechanismsofinju】yandchildren,sphysi﹣ calcharacteristicsresultinmultiSysteminjurybeing theruleratherthantheexception.Table10.1outlines commonmechanismsofinjulVandassociatedpatterns ofi叮uryinpediatricpatients.Itshouldbepresumed’ therefbre’thataⅡorgansystemsmaybeinjureduntil provenotherwise.A∣thoughtheconditiono「themaio『ity ofiniu『edchild『enwilInotdete『io『ate’alTdmostiniu『ed chiId『enhavenohemodyⅡamicabho『ma∣ities,the陌ct 『emaihsthatthecohditiono「somechiId『enwithmulti. systemihiu『ieswilI『apidlydete『io『ate,andse『iouscom﹣ plicatiohswiIIdeveIop·The『efb『e,suchpatientsshouIdbe

t『ans佗『『edea『lytoa佰cilitycapableo「t『eatingchiId『en withmuItisystemiⅡiu『les. The TriageDecisionScheme（seeFigure1﹣2） and PediatricTraumaScore（Table10.2）arebothusefhl toolsibrtheearlyidentificationofpediatricpatients withmultiSysteminiuries.

﹥

UniqueCha『acte『isticso『 pediat『icPatients

?腳緇;雲緇鷥。·α⋯唧 Theprioritiesofassessmentandmanagementofinju﹣ riesinchildrenarethesameasfbradults.However, theuniqueanatomicandphysiologiccharacteristicsof pediatricpatientscombinewiththediffbrentmecha﹣

■TABLE10』CommoⅡMecha㎡smsofln】u『yaⅡdAssociatedPatteⅧsof!nju『y iⅡPediaMcpatiehts MECⅡAⅡISM0FIⅡ』URγ

COMM0ⅡPATTERNS0『∣N』URγ

pedest『a i nSt『【』C∣《

·【0wspeed:Lowe「ext『emityf「actu『es ·Highspeed;Multiplet『auma’headandneckinlu『ies!Iowe「ext「emity↑『a〔tu『e5

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Un「est「alned:MuItipIet『aumaiheadandneckin】u「ies’scalpandfacia∣∣ace『ations Re5t『ained:Che5tandabdomeniniu「ies’Iowe『spinef『actu「e5 Low:Uppe『ext「emⅣ i ↑『actu『es Medium:Headandneckin】u『ies‘uppe「andIowe「ext『emiⅣf「actu『es High:MuItipIet「auma’headandneckinlu「ies’uppe『and∣owe「ext「emiⅣf「actu「es Withouthe∣met;Headandneckin】u「ies’scaIpandfada∣Iace『ations!uppe「ext「emiWf「actu『es Withhelmet:Uppe『ext『emity↑「actu『es St『ikinghand∣eba「;∣nte『na∣abd0minaIinlu『ies

msmsofmjurytoproducedistmctpatternsofi叮uIy. Forexample’mostseriouspediatrictraumaisblunt traumathatinvolvesthebrain.Asaresult,apnea, hyp0ventilation’andhypoxiaoccurfivetimesmore oftenthanhypovolemiawithhypotensioninseriously injuredChildren·Therefbre,treatmentprotocolsfbr pediatrictraumapatientsemphasizeaggressiveman﹣ agementoftheairwayandbreathing.

SIZEAⅡDSⅡAPE Becauseofthesmallerbodymassofchildren,theener盯 impartedfrom,fbrexample,fbnders’bumpers,andfalls resultsinagreaterfbrceappliedperunitofbodyarea. Thismoreintenseenergyistransmittedtoabodythat haslessfht,lessconnectivetissue·andcl0serproximi叮 ofmultipleorgans.ThesefhctorsresultinthehighfTe﹣ quen叮ofmultipleinjuriesseenmthepediatricpopula﹣

tion.Inaddition,theheadisproportionate】ylargerin youngChildren,resultmginahigher丘equenCyofblunt braininjuriesmthisagegroup.

Sl《ELET0Ⅱ Thechild’sskeletonisincompletelycalcified.c0ntains multipleactivegrowthcenters’andismorepliable thananadult,s.Forthesereasons’internalorgan damageisoftenn0tedwithoutoverlyingbonyfracture. Forexample,ribfracturesinchildrenareuncommon》 butpulmonarycontusionisnot.Others0仳tissuesof thethorax,heart,andmediastinumalsomaysustain significantdamagewithoutevidenceofbonyinjury. Theidentihcationofskullorrib仕acturesinachild suggeststhetransfbrofamassiveamountofenergy’ andunderlyingorganinjuries》suchastraumaticbrain injuryandpuhnona1ycontusion,shouldbesuspected.

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50RFACEAREA Theratioofachild,sbodysurfhceareatobodyvolume ishighestatbirthanddiminishesasthechildmatures· Asaresult’thermalenergylossisasignificantstress fhctorinchildrenHypothermiamaydevelopquickly andcomplicatethetreatmentofthepediatricpatient withhypotension.

pSγCⅡO【OGICAlSTATUS TheremaybesignificantpSychologicalramifications ofi叼uriesinchildren·Inyoungchildren’emoti0nal instabilityfrequentlyleadstoaregress1vepsychologicalbehaviorwhenstress,pain,andotherperceived threatsinterveneinthechild,senvironment·The chⅡd,sabⅢ叮tointeractwithunfhmiliarindividuals instrangeanddifficultsituationsislimited,making historytakingandcooperativemanipulation,especial﹣ lyifitispainh1l’extremelydifficult.Chmcianswho understandthesecharacteristicsandarewillingto c可oleandsootheaninjuredchildaremorelikelyto establishagoodrapport’Whichfacilitatesacomprehensiveassessmentofthechild’spsychologicaland physicalinjuries·Inaddition’thepresence0fparents orguardiansduringevaluationandtreatment,includ﹣ ingresuscitation’mayassisttheclinicianduringearly careofpediatrictraumapatientsbyminimizingthe iniuredchⅡd’snatural佗arsandanxieties。

L0ⅡG﹣TERME『『ECTS Am匈orconsiderationintreatingmjuredchildrenis theeffbctthatinjurycanhaveontheirsubsequent gr0wthanddevelopment·Unhkeadults,chⅡdren mustnotonlyrecoverfromtheeffbctsofthetrau﹣ maticevent’butalsomustcontinuethenormalproc﹣

essofgrowthanddevelopment.Thephysiologicand psych0logicalefIbctsofinjuryonthisprocessshould notbeunderestimated,particularlyincasesinvolving long﹣termfhnction’growthdefbrmi叮,0rsUbsequent abnormaldevelopment.ChildrenWhosustainevena minorinjurymayhaveprolongeddisabili叮incerebral hmction）psychologicala叮ustment,ororgansystem’ S0meevidencesuggeststhatasmanyas60℅of childrenwhosustainseveremultiSystemtraumahave residualpersonalitychangesatoneyearafterhospitaldischarge,and50℅showcognitiveandphysical handicaps·Social’afIbctive,andlearmngdisabⅢties arepresentinone﹣halfofseriouslyimuredchildren·In addition,childhoodiIUurieshaveasignificantimpact onthefamily’withpersonalityandemotionaldis﹣ turbancesfbundintwo﹣thirdsofun1nJuredsiblings. Frequent】y,achild,siIUuriesimposeastrainonthe parents,maritalrelationship’includingHnancialand sometimesemplOymenthardships.Traumamayaffbct notonlythechⅡd,ssurvival,butalsothequali勺ofthe Child’slifbfbryearstocome. Bonyandsolidvisceralinjuriesarecasesinpoint: Injuriesthroughgrowthcentersmayresultingrowth abnormalitiesoftheimuredbone.Iftheimuredbone isafbmur,aleglengthdiscrepanCymayresult,caus﹣ ingalifblongdisabihtyinrunmngandwalking.Ifthe fractureisthroughthegrowthcenter0foneormore thoracicvertebra’theresultmaybescoⅡosis’kypho﹣ sis,orevengibbus·Inaddition’massivedisruption0f achild,sspleenmayrequireasplenectomy.Theloss 0fthespleenpredisposesthechildtoalifblongriskof overwhelmingp0stsplenectomysepsisanddeath. Ionizingradiation,usedcommonlymtheevalua﹣ tionofinjuredpatients’isknowntoincreasetherisk 0fcertainmalignanciesandshouldbeusedonlyinthe fbⅡowingcircumstances:

Z50CHAPTER10■Pediat『icT「auma

■Theinfbrmationneededcannotbepractically orexpeditiouslyobtainedbyothermeans ■Theinfbrmationgainedwillchangetheclinical managementofthepatient ■Theinfbrmationisobtainedatthelowest possibleradiation‘‘cost’’tothepatient ■Obtaimngtheinfbrmationwillnotdelaythe transfbrofpatientswhorequirehigherlevels ofcare Neve『theless,theIongte『mquaIityo「lⅡb｛b『chiId『en whohavesustaiⅡedt『aumaissu『p『isiⅡgIy『obust,even thoughinmanycasestheywillexpe『ienceli佗∣ohgphysicaI chaIIenges·MostsuChpatients『epo『tagoodtoexceIlent qualityo「Ii佗and伺ndgainfi』lemploymentasadu∣tsiius. ti0ingagg『essive『esuscitatioⅡattemptsieven化『pediat. 『icpatientswhoseinitialphysioIogicstatus,e.g.,C∣asgow ComaScale（CCS）sco『e,mightsuggestothelwise.

pediatricpatientsbasedonlength（■F∣GuRE10﹣1）.Chni﹣ ciansshouldbef白miliarwithlength﹣basedresuscitation tapesandtheiruses. TheAmericanCoⅡegeofSurgeonsCommitteeon Trauma,AmericanCollegeofEmergenCyPhysicians, NationalAssociationofEMSPhysicians,thePediatric EquipmentGuidelinesCommitteeoftheEmergency MedicalServicesfbrChildren（EMSC）Partnershipfbr ChildrenStakeholderGroupandtheAmericanAcad﹣ emyofPediatricsissuedapoliCystatementregarding requiredequipmentfbrambulancesintheJuly2009 issueofAdiα廿rics.

∣▼

PIⅡFAI几 L S

■TheuniqueanatomicandphysioI0giccha『acte『istics ofchiId『enocca5i0naIIyIeadtopi廿alI5inthei「t「eat﹣ ment’ ■Theneces5ityoff『equent『ea5se5smentmu5tbeem﹣ phasized.

E00IPMEⅡT Immediate】yavailableeqU1pmentoftheappropriatesiz﹣ esisessentialfbrthesuccessMinitialtreatmentofin﹣ juredChildren（Table10·3）.Alength﹣basedresuscitati0n tape》suchastheBroselow＠PediatricEmergenCyTape, isanidealadjunctfbrtherapiddeterminationofweight basedonlengthfbrappropriatefluidvolumes’drugdos﹣ es’andequipmentsize.Bymeasuringtheheightofthe chⅡd,thechild,sestimatedweightcanbedetermined readⅡy·Onesideofthetapeprovidesdrugsandtheir recommendeddosesfbrthepediatricpatientbasedon weight·Theothersideidentifiesequipmentneedsfbr

﹁ 」

Ai『way:Eval uationandManag ement

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7Hb吵donLpp妙AⅡSp咖呶⋯o ●炳G向,eα力〃e〃㎡Ofc觔〃yw﹩β The‘‘A”oftheABCDEsofimtialassessmentisthe sameinchildrenasfbradults.Establishmgapatent a1rwaytoprovideadequatetissueoxygenati0nisthe

■『lGURE10﹣1Re5uscitation陌pe.AIength-based「esu5citati0ntape’suchastheB「oseIow＠ Pediat「icEme『gencyTBpe’i5anideaIad】unctf0『the「apiddete「minationofweightbasedon Iengthfo「app「op『iatefluidvoIumes’d「ugdose5『andequipment5ize.0nesideofthetape p『ovidesd『ugsandthei『『ecommendedd05esfo『thepediat「icpatientbasedonweight.The othe「sideidentifiesequipmentneedsfo「pediat『icpatientsba5edonIength.

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ynx（i·e.,thetongueandtonsils）arerela﹣ tivelylargecomparedwiththetissuesinthe oralcavi叮’whichmaymakevisualizationof thelarynxdifIicult·Achild’slarynxishmnel﹣ shaped’allowingsecretionstoaccumulatein theretropharyngealarea·Thela】ynxand vocalcordsaremorecephaladandanterior intheneck’Thevocalcordsarefrequently moredifficulttovisualizewhenthechild,s headisinthenormal,supme’anatomical positiondurmgintubationthanwhenitisin theneutralpositionreqUiredfbroptimalcer﹣ vicalspineprotecti0n.Themfhnt,stracheais approximately5cmlongandgrowsto7cm byabout18months.Failuretoappreciate thisshortlengthmayresultinintubation oftherightmainstembronchus,madequate ventilation,accidentaltubedislodgment》 and／ormechanicalbarotrauma.Optimal endotrachealtube（ETT）depth（incm）can bedeterminedtobethreetimestheappr0﹣ priatetubesize.Forexample,a4.0ETT wouldbeproperlypositionedat12cmfTom thegums.

MANAGEMENT InaspontaneouslybreathingchⅡdwith apartiallyobstructedairway,theairway

Z5ZCHAPTER10■Pediat「icT『auma

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■FIGURE10﹣2Positioningfo『Ai『wayMaintenance·（A）Imp『0pe「positioning0fachiId tomaintainapatentai『way·Thedi5p「opo「tionbetweenthesi2eofthechiId〃sc「anium andmidfaceIead5t0ap「opensityfo『thepo5te『i0『pha「ynxtobuckIeante「io「Iy·TheIa「ge 0cciputcausespassivefIexionofthece「vicaIspine（B）P『ope「positioningofachi∣dto maintainapatentai「waybAvoidpassivefIexi0nofthece『vicaIspinebykeepingthepIane ofthemidfacepa「alIeItothespineboa『dinaneut「aIposition’『athe『thaninthe〃5niffing p0sition.〃Placementofa1﹣inch﹣thickIaye「ofpaddingbeneaththeinfant’so「toddIe「『s enti『eto『sowiIIp「eseⅣeneut「aIaIignmentofthespinaIc0Iumn.

shouldbeoptimizedbykeepmgtheplaneofthefhce paralleltotheplaneofthestretcherorgurney,while maintainingneutrala1igmnentofthecervicalspme. Thejaw﹣thrustmaneuvercombinedwithbimanualin﹣ linespinalimmobilizationisusedtoopentheairway. Afterthemouthandor0pharynxareclearedofsecre﹣ tionsordebris,supplementalo叼genisadmimstered· Ifthepatientisunconscious,mechanicalmethodsof maintainingtheairwaymaybenecessary.Befb『eat. temptsa『emadetomechanicaⅡyestablishanai『way’the chiIdshouldbefi』Ilyp『eoxygenated.

O『a∣Ai『way An0ralairwayshouldon】ybeinsertedifachildisuncon﹣ scious’sincevomitingislikelyifthegagreflexisintact’ Thep『acticeo「inse『tihgtheai『waybac∣《wa『dand『otating it】8odeg『eesisnot『ecommehdedfb『child『eh,ast『auma with『esultanthemo『『hageihtoso丘tissuest『uctu『esofthe o『ophaIynxmayoccu『.Theoralairwayshouldbegen﹣

tlyinserteddirectlymtothe0ropha1ynx·Theuseofa tonguebladetodepressthetonguemaybehelpfUl.

O『ot『aCheaIIntubatioh Endotrachealintubationisindicatedfbrinjuredchil﹣ dreninavarietyofsituations’including: ■achildwithseverebrainimurywhorequires controⅡedventilation ■achildinwhomana1rwaycannotbe mRintained ■achildwh0exhibitssignsofventilatoryfhilure ■achildwhohassuffbredsignificanthypo﹣ volemiawhohasadepressedsensoriumor requ1resoperativeintervention Orotrachealintubationisthemostrdiablemeans ofestablishingana1rwayandadministeringventⅡa﹣ tiontoachⅡd.Thesmallestareaoftheyoungchild,s

AlRWAY:EVALUATIONANDMANAGEMENT

∣

D「ug﹣AssistedIntubation（DAl）fO「Pediat「icpatients

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a1rwayisatthecricoidrmg’whichfbrmsanatural sealaroundanuncuHbdendotraChealtube.Uncuf比d endotrachea1tUbesarecommonlyusedininfants becauseoftheanatomicdiffbrences.However’theuse ofcuffbdendotrachealtubes’evenintoddlersandsmall children,providesthebenefitofimproⅥngventilation andCO2management,whichhasap0sitiveimpacton cerebralbloodⅡow.PreviousconcernsaboutcuHbd endotrachealtubescausmgtrachealnecrosisareno longerrelevantduetoimprovementsmthedesignof thecuffb.IdeaⅡy’cuffpressureshouldbemeasuredas soonasisfbasible,and＜30mmHgisconsideredsafb’ Asimpletechniquetogaugethesizeofthe endotrachealtubeneededistoapproximatethediameterofthechild,sexternalnaresorthetipofthechⅡd’s smalliingeranduseatubewithasimilardiameter.A length﹣basedpediatricresuscitationtape,suchasthe Broselow＠PediatricEmergen叮Tape,alsolistsappro﹣ priatetubesizesofendotrachealtubes.However’be suretohavetubesreadⅡyavailablethatareonesize largerandonesizesmallerthanthepredictedsize.If astyletisusedtofacilitateendotrachealmtubation’ besurethatthetipdoesnotextendbeyondtheendof thetube· Mosttraumacentersuseaprotocolfbremergency intubation’refbrredtoasdrugassistedintubation （DAI）’prev1ouslyknownasrapidsequenceintubation （RSI）.CarefUlattentionmustbepaidtothechild’s

∣

weight’vitalsigns（pulseandbloodpressure）’and levelofconsciousnesstodeterminewhichbranchof theAlgorithmfbrDrug﹄Ass珀tedIntubation（■F∣GuRE 10﹣3）touse. Preo汀genationshouldbeperfbrmedinchildren whorequireanendotrachealtUbefbrairwaycon﹣ trol.Infhntshaveamorepronouncedvagalresponse toendotrachea1intubationthanchⅡdrenandadults’ andmayexperiencebradycardiawithdirectlaryngeal stimulation.Bradycardiainchildren（＞1yearofage） ismuchmorelikelytobeduetohypoxia.Atropine sulfhtepretreatmentshouldbeconsideredfbrinfhnts requ1ringDAI,butitisnotreqUiredfbrchildren. Atropinealsodriesoralsecretions’permittingeasier visualizationoflandmarks允rmtubation.Thedoseof atropineis0.01to0.03mg／kggivenatleast1to2min﹣ utesbefbreintubation,withamaximumsmgledose of0.5mg.Appropriatedrugsfbrmtubationsedation includeetomidate（0.3mg／kg）ormidazolam（0＠3mg／ kg）ininfantsandchildrenwithnormovolemia’and etomidate（0.1mg／kg）ormidazolam（0.1mg／kg）in childrenwithhypovolemia.Thespecificantidotefbr midazolamisfIumazenⅡ,whichshouldbeimmediately available. ThisisfbⅡowedbytemp0ra〕ychemicalparalysis. Ideally’ashort﹣acting’dep0larizing,neuromuscular blocking（chemicalparalytic）agentshouldbeused’ suchassuccinylchohne（2mgkgmchildren＜10kg;

Z54CHAPTER10■Pediat『icT『auma

1m曰kginchⅡdren＞10kg）.Succinylchohnehasa rapidonset’ashortdurationofacti0n,andmaybethe safbstdrugofchoice（unlessthepatienthasaknown spinalcordinju】y）.Ifalongerperiodofparalysisis needed＿fbrexample’inachildwhoneedsacomputed tomographic（CT）scanfbrfUrtherevaluation＿a longer﹣acting’nondepolarizing,neuromuscularblockingagent,suchasrocuronium（06m創kg）,orvecuronium（0.1m曰kg）maybemdicated. Aftertheendotrachealtubeisinserted’itsposi﹣ tionmustbeassessedchnicaⅡy（seebelow）and’ifcor﹣ rect,thetubecare拉Ⅱysecured.Ifitisnotpossibleto placetheendotrachealtubeafterthechⅡdischemicallyparalyzed,thechⅡdmustreceiveventilationwith 100℅oxygenadmimsteredwithaselfLinflatingbag﹣ maskdeviceuntiladefinitiveairwayissecured. O『ot『acheaIintubationunde『di『ectvisionwithade.

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■FlGURE10﹣4O「ot『acheaIintubationunde「di『ect visionwithadequateimm0bilizationandp『otectionof thece『vicaIspinei5thep『efe「「edmethodofobtaining initiaIai「wayc0nt「oI.

quateimmobilizati◎而andp『otectiono「theceⅣicaIspine isthep『e佗『『edmethodofobtaiⅡinginitiaIai『waycont『oI （■FIGuRE10﹣4）.Nasotrachealintubationshouldnotbe per｛brmedinchildren’asitrequiresblindpassage aroundarelativelyacuteangleinthenasopharynx towardtheanterosuperiorlylocatedglottis）making intubationbythisroutedifIicult·Thepotentialfbr penetratingthechild,scranialvaultordamagingthe moreprominentnasopharyngeal（adenoidal）softtis﹣ suesandcausinghemorrhagealsodiscouragestheuse ofthenasotrachealroutefbrairwaycontrol· Oncepasttheglotticopening,theendotracheal tubeshouldbepositioned2to3cmbelowthelevel ofthevocalcordsandcarefnllysecuredinplace.A ruleofthumbfbrthecorrectendotrachealtubeposi﹣ tionatthegumsis3timestheETTsize.Primary confirmationtechmques’suchasauscultationofboth hemithoracesintheaxiⅡae’shouldthenbeperfbrmed toensurethatrightmainstembronchialintubation h2snotoccurredandthatbothsidesofthechestare beingadequate】yventⅡated·Aseconda1yconfirmation device,suchasareal﹣timewave﹣fbrmcapnograph’a colorimetricend﹣tidalcarb0ndioxide（ETCO2）detec﹣ tor’oranesophagealdetectordevice（EDD）,should thenbeusedt0documenttrachealintubation’anda chestx﹣rayshouldbeobtainedtoaccuratelyidentify thepositionoftheendotrachealtUbe. Becauseoftheshortlengthofthetracheain youngchⅡdren（5cmininfants,7cmintoddlers）’any movementoftheheadcanresultindisplacementof theendotrachealtUbe,madvertentextUbation’right mainstembronchialintUbation’orv1gorouscoughing duetoirritationofthecarinabythetipoftheendotra﹣ chealtube.Theseconditionsmaynotberecognized climcallyuntilsignificantdeteriorationhasoccurred· Thus,breaths0undsshouldbeevaluatedperiodically toensurethatthetuberemamsmtheappropriate positionandtoidenti句thepossibⅡity0fevolvingven﹣ tilato叮dyshmction.Ifthereisanyd0ubtaboutcor﹣

rectplacementoftheendotrachealtubethatcannotbe resolvedexpeditiously,thetubeshouldberemovedand replacedimmediately.Useofthemnemonic,“Donjtbe aDOPE’,》（Dfbrdislodgment,Ofbrobstruction,Pfbr pneumothorax’Efbrequipmentfailure）mayserveas auseMreminderofthec0mmoncausesofdeteriora﹣ tioninintubatedpatients·SeeChapter2:Airwayand VentilatoryManagement,andSkillStationII:Airway andVentilatoryManagement’SkillII﹣G:InfantEndo· trachealIntubation.

C『icothy『oidotomy Whenairwaymaintenanceandcontrolcannotbeaccom﹣ plishedbybagmaskventilationor0rotrachealintuba﹣ tion,arescuea1rwaywitheitherla】yngealmaskairway （LMA）’intubatingIMA’orneedlecricothyroidotomyis necessa』y.Needlejetinsufflationviathecricothyroid membrane1sanappropriate’temporizingteChniqUe fbroXygenation’butitdoesnotprovideadeqUateven﹣ tilation,andprogressivehypercarbiawilloccur.La﹣ ryngealmaskairwaysareappropriatea叮uncta1rways fbrinfhntsandchildren,buttheirplacementreqUires experience,andtheairwaymaydistendthestomachif ventilationisoverlyvigorous.IMAsizesrangehom1 （appropriatefbrinfants＜6.5kg）’1.5（fbr5to10kg）’ 2（fbr10to20kg）’2·5（fbr20to30kg）,and3（fbrbe﹣ tween30and70kg）;inpatientsover70kg,adultsizing isappropriate.SeePhapter2:AirwayandVentilatolUI Management,andSkiⅡStationIII:Cncothyroidotomy’ SkillIII﹣A:NeedleCricothyroidotomy· Surgicalcricothyroidotomyisrarelyindicatedfbr infhntsorsma1lchildren.Itcanbeperfbrmedinolder childreninwhomthecricothyroidmembraneiseas﹣ ilypalpable（usuallybytheageof12years）.Seeβkill StationIII:Cricothyroidotomy,SkillIⅡ﹣B:Surgical Cricothyroidotomy.

CIRCULATIONANDSHOCI﹤:EVALUATIONANDMANAGEMENT255

duringtheresuscitationofinjuredchildren.Withade﹣

■Un「ecognizedinadve「tentdislodgmentoftheen﹣ dot『acheaItube＿whichmostoftenoccu『sasthe patientist「ansfe「「edf『omanambuIancest「etche『 toahospitaIgu『neyintheeme「gencydepa「tment’ o「f「omgu「neytogant「y’andviceve『sa’intheCT Suite＿islikeIythemostCommoncauseofsudden dete「io「ationintheintubatedpediat「icpatient’ emphasizingtheneedfo『u5eoft「anspo「tmonit0『s wheneve「achiIdmu5tbet「ansfe「「edf「om0neca『e envi『onmenttoanothe「. ■Desatu『ationmayaIso『esultf「omob就『uctionofthe endot「aCheaItubebyclottedbIoodo「inspissated 5ec「etion5’wo『seningoftensionpneumotho『ax withpositive﹣p「e5su『eventilation（pa「ticuIa『Iyifdiagnosticfindingswe「eabsentoninitiaIevaIuation）『 andequipmentfaiIu『e＿eithe『kinkingofthesofte『’ na『「owe『endot『acheaItubesusedinchiId『eno「an emptyoxygentank· ■Useofthemnemonic’〃D0n’tbeaDOPE／’（Dfo『 disI0dgment’Ofo「obst「uction’Pfo「pneumotho﹣ 「axiEfo『equipmentfaiIu『e）mayhe∣pto『emindthe t「eatingcIinicianofthemostlikeIycaIamitieswhen theconditionofanintubatedchiIdbeginstodete﹣ 「Io「ate

8『eathing:Eva∣uationaⅡd Management

quateventilationandperh1sion,achildshouldbeable tomaintainarelativelyn0rmalpHIhtheabsehceof adequateventilationaⅡdpe伽sioh,attemptihgtoco『『ect ahacidosiswithsodiumbica『bohatecan『esultinfi』忱l1e『 hype『ca『biaandwo『senedacidosis·

ⅡEEDlEAND『UBETⅡORACOSTOMγ Injuriesthatdisruptpleuralapposition－fbrexample’ hemothorax,pneumothorax’andhemopneumothorax’ havesimilarphysiologicconseqUencesinchildrenand adults.Thesemjuriesaremanagedwithpleuralde﹣ compression’precededinthecaseoftensionpneumo﹣ thoraxbyneedledecompressionjustoverthetopofthe thi〕dribinthemidclavicular】｛he.Careshouldbetak﹣ enduringthisprocedurewhenusing14﹣to18﹣gauge over﹃the﹣needlecathetersininfhntsandsmaⅡchil﹣ dren,sincethelongerneedlelengthmaycause,rather thancure’atensionpneumothorax.Chesttubesneed tobeproportionallysmaller（seeTable10.3）andare placedintothethoraciccavity叮tunnelingthetube overtheribab0vetheskinincisionsite,anddirect﹣ ingitsuperiorlyandposteriorlyalongtheinsideofthe chestwall.However’thesizemustbelargeenought0 drainhemothoraces.TunneⅡngisespeciallyimportant inchildrenbecauseofthethinnerchestwall·Thesite ofchesttubeinsertionisthesameinchildrenasin adults:thefifthintercostalspace,justanteriortothe midaxillaryline SeeChapter4 Thoracic Trauma,and SkillStationⅥI:ChestTraumaManagement

BREATⅡIⅡGANDVEⅡTI【ATI0N Therespiratoryrateinchildrendecreaseswithage.An infantbreathes30to40timesperminute,whereasan olderchildbreathes15to20timesperminute.Nor﹣ mal’spontaneoustidalvolumesvaryfrom4to6mL／kg fbrinfhntsandchⅡdren’althoughslightlylargertidal volumesof6to8mL／kg,andoccasionallyashighas 10mL／kg’mayberequiredduringassistedventilation. A1thoughmostbag﹂maskdevicesusedwithpediatric patientsaredesignedtolimitthepressureexerted manuallyonthechⅡd’sairway’excessivevolumeor pressureduringassistedventilationsubstantiallyin﹣ creasesthepotentialfbriatrogenicbarotraumabecause ofthefragilenatureoftheimmaturetracheobronchial treeandalveoli·Ifanadultbag-maskdeviceisusedto ventilateapediatricpatient,theriskofbarotraumais significantlymcreased.Useofapediatricbagmaskis recommendedfbrChⅡdrenunder30kg. Hypoxiaisthemostcommoncauseofcardiacarrest inthechild.However,befbrecardiacarrestoccurs, hypoventilationcausesrespiratoryacidosis’whichis themostcommonacid／baseabnormalityencountered

C『 i cu』 a ∣ I tionan刨ShocI《:Eva∣uation and『Ma】nagement

?●Wα｝ g i ﹩p咖﹠oJog!cd樅了e〃ces㎡ I Ⅲαue 〃ⅡmpααO肥y唧fγeα向加C㎡O加ediα㎡c 向、α巫〃』αpα㎡c〃fSβ Keyfact0rsintheevaluationandmanagementof circulation1npediatrictraumapatientsincluderec﹣ ognitionofcirculatorycomprom1se’accuratedetermi﹣ nationofthepatient’sweightandcirculato1yvolume, fluidresuscitation,bloodreplacement,venousaccess’ assessmentsofadequaCyofresuscitationsuchasur1ne output,andthermoregulation·

REC0GNITI0Ⅱ0FαRCUlAT0RγC0MpR0lVlISE InjuriesinchⅡdrenmayresultinsignificantblood loss.Achild,sincreasedphysiologicreserveallowsfbr maintenanceofsystolicbloodpressureinthenormal range’eveninthepresenceofshock（■FlGuRE10﹣5）.

Z56CHAPTER10■Pediat『icT『auma

【

Physiologiclmpact:HemodynamicChanges

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45

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Uptoa30℅diminutionincirculatingbloodvolume mayberequiredtomanifbstadecreaseinthechild’s systolicbloodpressure.Thismaybemisleadingto medicalprofbssionalswhoarenotfamiliarwiththe subtlephysiologicchangesmanifbstedbychildrenin hypovolemicshock.Tachycardiaandpoorskinper﹣ fhsi0noftenaretheonlykeystoearlyrecognitionof hyp0volemiaandtheearlyinitiationofappropriate fluidresuscitation.WhenpossibIe,ea『Iyassessment byasu『geonisesseⅡtiaItotheapp『op『iatet『eatmeht o「iⅡiu『edchiId『en. AlthoughachⅡd’sprimaryresponsetohypovo﹣ lemiaistachycardia,thissignalsomaybecausedby pain,fbar’andpsychol0gicalstress·Othermoresub﹣ tlesignsofbloodlossinchildrenincludeprogressive weakemngofperipheralpulses,anarrowingofpulse pressuretolessthan20mmHg’skinmottling（which substitutesfbrclammyskinininfantsandyoungchil﹣ dren）,coolextremitiescomparedwiththetorsoskin, andadecreaseinlevelofc0nsciousnesswithaduⅡed responsetopain·Adecreaseinbloodpressureand otherindicesofinadeqUateorganperfUsion’suchas urinaryoutput,shouldbemonitoredclosely,butgen﹣ erallydeveloplater.Changesinvital0rganhmction areol】t】inedinTable10.4. ThemeannormalsystoⅡcbloodpressurefbrchil﹣ drenis90mmHgplustwicethechild,sageinyears. ThelowerlimitofnormalSystolicbloodpressurein childrenis70mmHgplustwicethechild,sage1nyears.

Thediastolicpressureshouldbeabouttwo﹣thirdsof theSystolicbloodpressure.（Normalvitalhmctions byagegrouparehstedinTable10.5.）Hypotension machⅡdrepresentsastate0fdecompensatedshock andmdicatesseverebloodlossofgreaterthan45℅of thecirculatmgbloodvolume.Tachycardiachanging tobradycardiao仕enaccompaniesthishypotension’ andthischangemayoccursuddenlyininfhnts.These physiologicchangesmustbetreatedbyarapidinfh﹣ sionofbothisotonicc1ystalloidandblood’

DETERMIⅡATI0ⅡO「WE∣GⅡTAⅡD CIRCUlAT∣NGB【00DV0ⅢME Itis0ftenverydifficultfbremergencydepartment （ED）personneltoestimatetheweightofachild,par﹣ ticularlyifthesepersonneldonottreatmanychildren. Thesimplestandquickestmethodofdetermininga child,sweightinordertoaccuratelycalculatefluid volumesanddrugdosagesistoaskacareg1ver.Ifa careg1verisunavailable,alength﹣basedresuscita﹣ tiontape,suchastheBroselow＠PediatricEmergency Tape’isextremelyhelpihl.Thistoolrapidlyprovides thechild’sapproximateweight’respiratoryrate,fluid resuscitationvolume,andavarietyofdrugdosages·A finalmethodfbrestimatingweightinkilogramsisthe fbrmula（（2xage）＋10）. Thegoaloffluidresuscitationistorapidlyreplace thecirculatingvolume.Aninfhnt’sbloodvolume

ClRCULATIONANDSHOCK:EVALUATIONANDMANAGEMENT257

■TABLE10·4System忙Re5poⅡsestoB!oodloss加Pediat『kPatiehts M∣lDBLO0D V0【UMEL0SS （＜30℅）

M0DERATEBL00D VO山MEL0SS （30℅＝45℅）

SEVEREBL0OD v0山MEL0ss （＞45℅）

Ca『diova5cula『

∣nc「easedhea「t「ate﹩weak, th『eadype『iphe『a∣pulses;no『ma∣ 5ysto∣icbloodp『essu「e（80﹣90＋ 2xageinyea『5）﹩no「ma∣pulse p『es5u「e

Ma「kedlyinC『easedhea『t『ate; weak’th『eadycent『aIpu∣ses; absentpe『iphe『aIpuI5es;∣ow no『maIsystoIicb∣o0dp「e55u『e （70﹣80﹢zxageinyea『S）;na『﹣ 『owedpuI5ep『essu『e

TachyCa『da i fo∣∣owedbyb「ady﹣ ca「dia;ve『yweako「absent cent「aIpuIse5;ab5entpe『iphe「aI puIses;hypoten5ion（＜70＋Zx ageinyea『s）;na「『0wedpuIse p『essu「e（o『undetectable diasto∣icbIoodp『essu『e）

Cent『aIⅡe『vousSystem

Anxlous;i『「itab∣e】Confused

Letha『giC;dulIed『esponseto painl

Comat0se

Skin

Cool’mottled;p『o∣onged capa Ii 『y『e↑∣ i I

Cyan0tic;ma『kedlyp『oIonged cap∣ i a l 『y『e↑Ii

PaIeandCo∣d

U『ine0utput丑

Lowtove「yIow

Minima∣

None

5γSTEM

lThechi∣d’5dulIed『e5ponsetopainwiththi5deg「eeofbIo0dl0s5（30％﹣45℅）maybeindicatedbyadec『ea5ed『e5pon5eto∣Vcathete『inse『tion. 2A↑te『n i tiad I ecomp『e5so i nbyu『n i a『ycathete『.Lowno「ma5 il Zm／ l kg／h「（n i f己nt）’.I5m∣／kg／h「（younge『chd Ii ）’m I ／ l kg／h『（o∣de「Ch∣ i d）〃and0.5mVhg／h『 （adoles仁ent）』Vcont『astcan↑a∣seIyeIevateu「Ina『youtput

■丁ABLE10篁5VitaInmCtioⅡs AGEGR0UP （∣NM0Ⅱ丁ⅡS0R γEARs）

（ⅢMⅡG）

RE5PlRA『0Rγ RATE （BREATⅡS／MIⅡ）

0RINARγ 0uTPuT （M ／ l（ l G／ⅡR）

＞60

＜60

Z 0

＜150

＞70

＜40

I 5

I』＿I8

＜M0

﹥75

＜35

l.0

SchooIAge 6＝1Zyea『5

I8－36

＜1Z0

＞80

＜30

1.0

Adolescent ≧13yea『S

36＝70

＜100

﹥90

＜30

0 5

WElGⅡTRANGE （!NKG）

ⅡEARTRATE

8L00D PRESSURE

（BEATs／MⅡ I ）

∣㎡ant 0＝1Zmonths

0﹃10

＜160

Toddle『 l＿Zyea『S

l0－M

P『eschool 3＿5yea『s

canbeestimatedat80mL／kg,andachild,sat70ml／ kg.Whenshockissuspected’abolusof20mL／kg0f warmedisotoniccrystalloidsolutionisneeded.Ifit weretoremaininthevascularspace,thiswouldrepre﹣ sent25℅ofthechild’sbloodvolume·

VEⅡOUSACCESS Severehypovolemicshockusuallyoccursasthere﹣ sultofdisruptionofintrathoracicorintraabdominal organsorbl0odvessels.Venousaccessisprefbrab】y estabhshedbyaperipheralpercutaneousroute·Ifper﹣ cutaneousaccessisunsuccessfhlaftertwoattempts, considerationshouldbegiventointraosseousinfh﹣ sionviaabonemarrowneedle（18gaugeininfhnts’15 gaugeinyoungchildren）（■FlGuRE10﹦6）orinsertionof afbmoralvenouslineusingtheSeldingertechnique

orathrough﹣the﹣needlecatheterofappropriatesize. Iftheseproceduresf白il,ad0ctorwithskiⅡandexper﹣ tisecansafblyperfbrmdirectvenouscutdown.How﹣ ever,thisshouldbedoneonlyasalastresort’since thisprocedurecanrarelybeperfbrmedinlessthan10 minutes’eveninexperiencedhands’whereasanin﹣ traosseousneedlecanreliablybeplacedinthebone marrowcavitymlessthan1minute’evenbyproviders withhmitedskillandexpertise.SeeSkiⅡStationⅣ:

ShockAssessmentandManagement Theprefbrredsitesfbrvenousaccessmchildrenare ■Percutaneousperipheral（twoattempts）－ Antecubitalfbssa（e）’saphenousvein（s）atthe anldR

■Intraosseousplacement＿（1）Anteromedial tibia,（2）distalfbmur

Z58CHApTER10■Pediat「icT「auma

－

∼ ■

＝

A

Intravenousaccessinyoungchildrenwithhypovo﹣ lemiaisachallengingproblem,eveninthemostexpe﹣ riencedhands.Intraosseousinfbsion’cannulatingthe marrowcavi句γofalongbonemanuninjuredextrem﹣ ity’isanappropriateemergencyaccessprocedure.The intraosseousrouteissafbandefIicacious,andrequires fhrlesstimethanvenouscutdown.Intraosseousinfh﹣ sionshouldbediscontinuedwhensuitablevenous accesshasbeenestablished. Indicationsfbrintraosseousinfhsionarelimitedto childrenfbrwhomvenousaccessisimpossiblebecause ofcirculatoIycollapseorfbrwhomtwoattemptsat percutaneousperipheralvenouscannulationhave fhiled‘Complicationsofthisprocedureincludecel﹣ lulitis,osteomyelitis’compartmentsyndrome’and iatrogenicfracture.Theprefbrredsitefbrintraosseous cannulationistheproximaltibia’bel0wthelevelofthe tibialtuberosity.Analternativesiteisthedistalfbmur, althoughthecontralateralproximaltibiaisprefbrred. Intraosseouscannulationshouldnotbeperfbrmedin anextremitywithaknownorsuspectedfracture.

『LUIDRESUSαTATI0Ⅱ Fluidresuscitationinthechildisbasedonthechild,s weight’andanisotomcso】utionistheappropriateflu﹣ idfbrrapidrepletionofcirculatingbl0odvolume.Be﹣ causethegoalistoreplacelostintravascularvolume, itmaybenecessa〕Vtogivethreebolusesof20mL／ kg,oratotalof60mL／kg’toachieveareplacementof thelost25℅.SeeChapter3;Shock.Whenconsidering thethird20mL／kgbo】us’theuseofpackedredblood cells（pRBCs）shouldbeconsidered·ThepRBCsaread﹣ ministeredasabolusof10mL／kg.Oncebloodproduct administrationisbegun’considerationshouldbegiven totheneedfbradditionalpr0ductssuchasplasmaand platelets· IUjuredchⅡdrenshouldbemonitoredcarefUllyfbr responsetofIuidresuscitationandadequacyoforgan

B

■FlGURE10﹣6∣nt『aosseousInfusion〃（A）DistaIfem叫 （B）P『oximaltibia.Ifpe「cutaneousaccessisunsuccessful afte『twoattempts’conside『ationshouIdbegivento int「aosseousinfusionviaabonema『『owneedIe（18 gaugeininfants『15gaugeinyoungchiId『en）.

perfhsion.Areturntowardhemodynamicnormalityis indicatedby: ■Slowingoftheheartrate（＜130beats／min’ withimprovementofotherphysiologicsigns》 thisresponseisage﹣dependent） ■Clearingofthesensorium

■Percutaneousplacement＿Femoralvein（s） ■Percutaneousplacemen﹄Externaljugular vein（s）（shouldbereservedfbrpediatric experts;donotuseifthereisairwaycompro﹣ mise,oracervicalcollarisapplied） ■Venouscutdown－Saphenousvem（s）atthe Emlde

■Returnofperipheralpulses ■Returnofnormalskihcolor ■Increasedwarmthofextremities ■Increasedsystolicbloodpressure（normalis approximately90mmHgplustwicetheagein years）

CIRCULATIONANDSHOCK:EVALUAT∣ONANDMANAGEMENTZ59

tiono「asecondandpe『lTapsathi『d2○mL／l《gboIusof isotonicc『ystaIIoidfluid,and『equi『esthep『omptinvolve﹣ mehto「asu『geon.Whensta『tmganadditionaIbolusof isotonicc『ystaIIoid｛Iuido『ifatanypointdu『ihgtlTevoI. ume『esuscitationthechild,sconditiohdete『io『ates’con﹣ side『ationmustbegiventotheea『lyuseo「TomL／l《go「 type﹦specinco『O﹣negativewa『medpRBCs.

■Increasedpulsepressure（＞20mmHg） ■Urinaryoutputof1to2mL／kg／hour （age﹣dependent） Childrengeneral】yhaveoneofthreeresponsesto fluidresuscitation.Theconditionofmostchildrenwill bestabilizedbytheuseofcrysta1loidfluidonly,and bloodwillnotbereqUired;thesechildrenareconsid﹣ ered‘‘responders.”Somechildrenrespondtocrystal﹣ loidandbloodresuscitation;thesechildrenarealso considered“responders.,》InsomechⅡdrenthereis animtialresponsetoc叮stalloidfluidandblood’but thendeteriorationoccurs）thisgroupistermed“tran﹣ sientresponders·’,Otherchildrendonotrespondat aⅡtocIystalloidfluidandbloodinfhsion〕thisgroupis refbrredtoas“nonresponders.”Thetwolattergr0ups ofchildren（transientrespondersandnonresponders） arecandidatesfbrpromptinfhsionofadditionalblood

ⅡR∣ⅡE0UTpUT Urineoutputvarieswithage.Theoutputgoalfbrmfhntsupto1yearofageis2mL／kg／hr,fbryounger children1.5mL／kg／hr’andfbrolderchildren1mL／kg／ hr.Thelowerlimitofurinaryoutputdoesnotachieve thenormaladultvalueof0’5mL／kg／hruntiltheadolescenthasstoppedgrowmg· Urineoutputcombinedwithurinespecificgravily isanexcellentmethodofdeterminingtheadequaCyof volumeresuscitationOncethecirculatingbloodvolume hasbeenrestored’theurinaryoutputshouldreturnto normal。Insertionofaurmarycatheterfacihtatesaccu﹣ ratemeasurementofthechⅡd’surina1youtputfbr

productsandconsiderationfbrearlyoperation Theresuscitationflowdiagramisausefhlaidm theinitialtreatmentofinjuredchildren（■F∣GuRE10﹣7）.

patientsreceivingsUbstantialvolumeresuscitation.A straightcatheter,ratherthanonewithaballoon,may beusedininfhnts,butitisnotappropriateintoddlers andChⅡdren.Catheterscontainingtemperatureprobes areav8iI白blefbr¢bildTenWhoneedmtensivecare.

BID0DREPlACEMEⅡ『 FaiIu『etoimp『ovehemodynamicabno『maIities｛bIlowing tI1e偷stbolusof『esuscitation冊uid『aisesthesuspicionof cohtiⅡuinghemo『『lTage,p『omptstlTeneedfb『admihist『a﹣

＼

／

Su『gica【ConSuItation Z0mL／kgRinge「’s【actateso【utionasbo｛us

」 ＼ 上

「

Hemodynamics No「ma【

Hemodynamics Abno「ma【

Fu『the「 eva【uation

10m【／kg pRBCs

﹄

﹀

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Abno「maI

Fu『the「 eva∣uation

Ope「ation

Wansfe『as necessaly

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】

﹀

Obse『ve

Ope「ation

·nansfe『as necessa「y ﹀

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｝

l ■『∣GURE10﹣7Resuscitation 「IowDiag『amfo『Pediat『iC Patientswithno『maland abn0「malhemodynamic5.

Z60CHAPTER10■Pediat「icT「auma

TⅡERM0REGUlAT!0N Thehighratioofbodysurfhceareatobodymassin childrenincreasesheatexchangewiththeenv1ron﹣ mentanddirectlyaffbctsthebody,sabⅢtytoregu﹣ latecoretemperature.Increasedmetabolicrates,thin skin’andthelackofsubstantialsubcutaneoustissue contributetoincreasedevaporativeheatlossandca﹣ loricexpenditure.Hypothermiamayrenderthechild’s injuriesrehPacto1ytotreatment’prolongcoagulation times,andadverselyafIbctcentralnervoussystem （CNS）hmction.Whilethechildisexposedduringthe initialsurveyandresuscitationphase,overheadheat lamps,heaters,orthermalblanketsmaybenecessary topreservebodyheat.Itisadvisabletowarmtheroom aswellastheintravenousfluids’bloodproducts’and inhaledgases.Onceexaminedduringtheinitialresus﹃ citationphase,itisimportanttocoverthechild’sbody withwarmblanketstoavoidunnecessaryheatloss·

▲▲ PITFAI刀』 p「eCipitous.

色

vLUJL4﹣一﹦」

Eightpercentofallinjuriesinchildreninvolvethe chest.ChestiIUuryalsoservesasamarkerfbrother organSysteminjury’sincemorethantwo﹣thirdsof childrenwithchestinjurywillhavemultipleinju﹣ nes.Themechanismofmjuryandtheanatomyofthe child,schestaredirectlyresponsiblefbrthespectrum ofinjuriesseen. Thevastmajorityofchestmjuriesmchildhoodare duetobluntmechanisms,causedprincipaⅡybymotor vehicles.Thepliability’orcompliance’ofachild,s chestwallallowsimpactingfbrcestobetransmitted totheunderlyingpulmona】yparenchyma’causing pulmonarycontusion.RibiTacturesandmediastinal injuriesarenotcommon,but’ifpresent,th叮indicate asevereimpactingfbrce.Thespecifici1Uuriescaused byth0racictraumainchⅡdrenaresimilartothose encounteredinadults,althoughthefreqUenciesof theseinjuriesaresomewhatdiffbrent. Mobilityofmediastihalst『uctu『esmal《esthechiId mo『esusceptibIetotensionpneumotho『ax,themost commonimmediate∣yIifbth『eateninginiu『yihchiId『en Pneumomediastinumisrare,andbemgnintheover﹣ whelmingm匈ori叮ofcases.Diaphragmaticrupture, aortictransection’m可ortracheobronchialtears,flail chest,andcardiaccontusionsarealsoseldomencoun﹣ teredinchildhood.Whenidentified,treatmentfbr theseinjuriesisthesameasfbradults.Significant i叼uriesrarelyoccuraloneandarefrequentlyacom﹣ ponentofm可ormultiSystemi叼ury.Mostpediatric thoracicinjuriescanbesuccessfhllymanagedusingan appropriatecombinationofsupportivecareandtube thoracostomy.Thoracotomyisnotgenerallyneededin children. Theincidenceofpenetratingthoracicinjury increasesafter10yearsofage.Penetratingtraumato thechestinchildrenismanagedthesamewayasfbr

∣

SceⅡa『io■p『bg尼驅／onThepatientisintu﹣ batedwith0utdiffi〔uItyandint『aven0u5acce5s is0btainedⅡei5giveni50t0nicc『y5taII0idand 0﹣negativebI00dwithg00d『e5p0n5elhispul5els I00andhisbl00dp『es5u「el00／60. ﹂

∣ ﹥ Ca『d iopuImona『yResuscitati

∣﹥c heStT『auma

∣

TheabiIityofachiId’sbodytocompensateinthe ea『Iyphase5ofbIo0dIossmayc『eateanillusionof hemodynamicno『maIi軏『e5uItingininadequatefIuid 『eSuscitationand「apiddete「io「ation’whichisoften

凸■

withcontinuedCPRoflongduration’prolongedresus﹣ citativeeffbrtsaretypicallynotbeneficial

on

Childrenwhoundergocardiopulmonaryresuscitation （CPR）inthefieldwithreturnofspontaneouscircula﹣ tion（ROSC）pri0rtoarrivalmthetraumacenterhave roughlya50℅chanceofneurologicallyintactsurvival. Childrenwhopresenttoanemergencydepartment stillintraumaticcardiopulmonaryarresthaveauni﹣ fbrmlydismalprognosis·ChildrenreceivingCPRfbr morethan15minutespriortoarrivalinanEDorwith fixedpupilsonarrivalumfbrmlypredictnonsurvival. Incasesinwhichchildrenarriveinthetraumabay

adults SeeChapter4 Thoracic Trauma, andSkillSta﹣

tionⅥI:ChestTraumaManagement

∣P AbdominalT『auma MostpediatricabdominaliIUuriesoccurastheresultof blunttrauma,primarⅡyinvoMngmotorvehiclesand falls·Seriousintraabdominalinjurieswarrantprompt involvementbyasurgeon’andhypotensivechildren Whosustainbluntorpenetratingabdommaltrauma requ1repromptoperativeintervention.

ABDOMINALTRAUMAZ61

ASsE55ⅢEⅡT ConsciousinfantsandyoungchildrenaregeneraⅡy frightenedbytheeventsprecedingadmissiont0an emergencydepartment,whichmayaffbcttheabdomi﹣ nalexamination.Whiletalkingquiet】yandcalmlyto thechild,askquestionsaboutthepresenceofabd0mi﹣ nalpainandgentlyassessthetoneoftheabdommal musculature.Deep,painfUlpalpationoftheabdomen shouldbeavoidedattheonsetoftheexaminationto preventvoluntaryguardingthatmayconfhsetheabdominalfindings.AlmostallinfRntsandyoungchil﹣ drenwhoarestressedandc1y1ngwillswallowlarge amountsofair.Iftheupperabdomenisdistendedon examination,insertingagastrictubetodecompress thestomachshouldbeapartoftheresuscitation phase.Orogastrictubedecompressionisprefbrredin inmnts.Tensenessoftheabdominalwallo仕ende﹣ creasesasgastricdistentionisrelieved’allowingfbr morecarefhlandreliableevaluation·Thepresenceof shoulder﹣orlap﹣beltmarksincreasesthelikehho0d thatintraabdominalinjuriesarepresent’especiaⅡy iflumbarfTacture’intraperitonealfluid’orpulserate ＞120arealsodetected. Abdominalexaminationinunconsciouspatients doesnotvarygreatlywithage.Decompressionof theurinarybladderfhcilitatesabdominalevaluation. Sincegastricdilationandadistendedurinarybladder maybothcauseabdominaltenderness,abdominalten﹣ dernessmustbeinterpretedwithcaution,unlessthese organshavebeenfhllydecompressed‘

DIAGN0STICAD」UⅡCTS Diagnosticadjunctsfbrassessmentofabdominaltrau﹣ mainchildrenincludeCT,fbcusedassessmentsonog raphyintrauma（FAST）,anddiagnosticperitoneal a l vage’ ComputedTomog『aphy TheadventofhelicalCTscanmngallowsfbrextremely rapidandpreciseidentificationofinjuries.CTscan﹣ ningisoftenusedtoevaluatetheabdomenofChildren whohavesustainedblunttraumaandhavenohemo﹣ dynamicabnormalities·CTscahningshouIdbeimmedi. ateIyavaiIabIe’shouIdbepe『｛b『medea『ly’ahdmusthot deIayfUIthe『t『eatmeht·Theidentificationofmtraab﹣ dominali呵uriesbyCTscaninpediatricpatientswith nohemodynamicabnormalitiescanallowfbrnonop﹣ erativemanagementbythesurgeon.Earlyinvolve﹣ mentofthesurgeonisessentialtoestablishabasehne thatwⅡlallowthesurgeontodeterminewhether’and when,operationisindicated.Centersthatlacksurg1﹣ calsupportandwheretransfbrofinjuredchildrenis

plannedarejustifiedinfbregoingtheCTevaluation priortodefimtivetransport. I叮uredchildrenwhorequireCTscann1ngasan adjunctivestudyoftenrequiresedati0ntoprevent movementduringthescanningprocess.Thus,an injuredchildrequiringresuscitationorsedationwho undergoesCTscanshouldbeaccompaniedbyaclimcianskilledinpediatrica1rwaymanagementand pediatricvascularaccess.CToftheabdomenshould routinelybeperfbrmedwithⅣcontrastagentsaccord﹣ ingtolocalpractice. However,CTscann1ngisnotwith0utrisk.Fatal cancersarepredictedtooccur1nasmanyas1in1,000 patientsundergoingCTaschⅡdren.Thus,theneedfbr accuratediagnosisofinternalinjurymustbebalanced againsttheriskoflatemalignancy.Certainlyevery effbrtshouldbemadetoavoidCTscanmngpriorto transfbrtothedefinitivetraumacenter,ortoav0id repeatCTuponarrivalatthetraumacenter,unless deemedabsolutelynecessary.WhehCTevaIuationis necessa『y,『adiationmustbeI《eptAsLowAsReasonabIy AchievabIe（ALARA｝.lⅡo『de『toachieve∣owestdosespos· sible’pe『fb『mCTscansonIywhenmedicalIynecessa『y’ scanonIywhenthe『esultswiIIchangemanagement’scan onlythea『eao「inte『est’andusetheIowest『adiationdose possibIe.Criteriaarenowavailabletoidentifypatients atlowriskfbrhead》cervicalspine,andabdominal injury,whothe1’efbredonotrequireCT.

FocusedAssessmentSonog『aphyinT『auma AlthoughFASThasbeenwidelyavailablefbrmany years,comparativelyfbwstudiesontheefficacyoful﹣ trasoundinchildrenwithabdominali叮uryhavebeen reported’andithasonlym0destsensitivityfbrthede· tectionofhemoperitoneummyoungchildrenwhenthe mostmethodol0gicallyrigorousstudiesareanalyzed. However,itsuseasanextensionoftheabdominalex﹣ aminationminjuredchildrenisrapidlyevolving’and itoffbrstheadvantagethatimagingmayberepeated. FASThasbeenshownbysomeinvestigat0rstoiden﹣ tih『evensmallamountsofintraabdominalbloodin pediatrictraumapatients,afindingthatisunⅡkelyto beassociatedwithsignificantinjury.Iflargeamounts ofintraabdominalbloodarefbund’significantiIUury1s morehkelytobepresent.However,eveninthesepa﹣ tients’operativemanagementisindicatednotbythe amountofintraperitonealblood,butbyhemodynamic abn0rmalityanditsresponsetotreatment.FASTis mcapableofidenti句ingisolatedintraparenchymalin﹣ juries’whichaccountibruptoone﹣thirdofsohdorgan injuriesinchildren.Insummary,FASTshouldnotbe relieduponasthesolediagnostictestt0ruleoutthe presenceofintraabdominalinjury.Ifasmallamount ofmtraabdominalfluidisfbundandthechildishemo﹣ dynamicaⅡynormal’CTshouldbeobtained.

Z6ZCHAPTER10■Pediat「icT『auma

DiagnosticPe『itonealLavage Diagnosticperitoneallavage（DPL）maybeusedtode﹣ tectintraabdominalbleedinginchildrenwithhemody﹣ namicabnormalitieswhocannotbesafblytransported totheCTscanner,orwhenCTandFASTarenotread﹣ ilyavailableandthepresenceofbloodwiⅡleadtoim﹣ mediateoperativeintervention.Thisisanuncommon occurrence.Mostpediatricpatientshaveselflimited intraabdominalinjuriesandnohemodynamicabnor﹣ malities.Therefbre》bloodibundonaDPLwouldnot mandateoperativeexplorati0ninachildwhois0ther﹣ wisestable. Warmedcrystalloidsolutioninvolumesof10mL／ kg（upto1000mL）isusedfbrDPL.Becauseachild’s abdominalwallisrelativelythincomparedwiththat ofanadult,uncontrolledpenetrationoftheperitoneal cavitymayproduceiatrogeniciIUu】ytotheabdominal contents,evenwhenanopentechmqueisused.DPL hasutilityindiagnosinginjuriestointraabdominal visceraonly;retroperitonealorganscannotbeevalu﹣ atedreliab】ybythistechnique.Theevaluation0fthe effluentfTomtheDPListhesameinchiIdrenasitis inadults. Onlythesu『geonwhowillca『efb『thechildshould pe『lb『mtheDpL】becauseDpLmayinte旋『ewithsub﹣ sequentabdominaIexaminatiohso『imagihgupoⅡwhich thedecisioⅡtoope『atemayinpa㎡bebased·

Ⅱ0Ⅱ0PERATIVEMAⅡAGEⅢEⅡT

Selective’nonoperativemanagement0fsolidorgan injuriesinchildrenwh0arehemodynamicaⅡynormal isperfbrmedinmosttraumacenters’especiallythose withpediatriccapabilities·Thepresenceofintraperi﹣ tonealbloodonCTorFAST’thegradeofmjury,0r thepresenceofavascularblushdoesnotnecessar﹣ ilymandatealaparotomy.IthasbeenwelldemonstratedthatbleedingfTomaninjuredspleen’liver’ orkidneygenerallyissel低limited·Therefbre’aCTor FASTthatispositivefbrbloodalonedoesnotman﹣ datealaparotomyinachildwhoishemodynamically normalorwhostabilizesrapidlywithfluidresuscita﹣ tion.l「thechiId’shemodynamic∞nditiohcannotbe no『maIizedandifthediaghosticp『ocedu『epe『fb『med ispositive｛b『bIood,ap『omptlapa『otomyt◎∞ht『◎l hemo『『hageisindicated· Whennonoperativemanagementisselected,chil﹣ drenmustbetreatedinafhcilitythatoffbrspediatric intensivecarecapabilitiesandunderthesupervisi0n ofaqualifiedsurgeonwhospecializesinthecareof mjuredchildren.Intensivecaremustincludecon﹣ tinuouspediatricnursingstaffcoverage’continuous monitoring0fvitalsigns,andimmediateavailability ofsurgicalpers0nnelandoperatingroomresources.

Nonoperativemanagementofconfirmedsolid organmjur1esisasurgicaldecisionmadebysurgeons, justas1sthedecisiontooperate.Therefbre’thesur﹣ geonmustsupervisethetreatmentofpediatrictrauma patients.

SpEα『∣CV∣SCERALIⅡ』URIES Anumberofabdominalvisceralinjuriesaremorecom﹣ moninchildrenthaninadults.Injuriessuchasthose causedbyabicyclehandlebaroranelbowstrikingthe childintherightupperquadrantorthoseassociated withlap﹣beltinjuriesarecommonandresultwhen thevisceralcontentsarefbrciblycompressedbetween theblowontheanteriorabdominalwallandthespine posteriorly.Thisinjuryalsomaybecausedbychild mRltreatment. Bluntpancreatici叮uriesoccurfromsimilarmech﹣ an1sms’withtheirtreatmentdependentontheextent ofmjury.Smallbowelperfbrationsatorneartheliga﹣ ment0fTreitzaremorecommonincMdrenthanm adults,asaremesentericandsmallbowelavulsion injuries.Theseparticularinjuriesareoftendiagnosed latebecauseofthevagueearlySymptoms. Bladderruptureisalsomorecommoninchildren thaninadults,becauseoftheshallowdepthofthe child,spelvis. Childrenwhoarerestrainedbyalapbeltonlyare atparticularriskfbrentericdisruption,especiallyif theyhavealap﹣beltmarkontheabdominalwallor sustainafIexion﹣distraction（Chance）fTactureofthe lumbarspine.Anypatientwiththismechanismof injuryandthesefindingsshouldbepresumedtohave ahighⅡkeⅡhoodofinjurytothegastrointestinaltract untⅡprovenotherwise.Penetratinginjuriesofthe penneum,orstraddleinjuries’mayoccurwithfalls ontoaprominentobject,andmayresultmmtraperi﹣ tonealmjuriesbecauseoftheproximi叮oftheper1﹣ toneumtotheperineum·Buptureofahollowviscus requiresearlyoperativeintervention.

「▼

P I TFAI」『』

DeIaysinthe『ecognitionofabdominaIhoⅡowvi5cus in】u「ya「epossibIe’especiaIIywhenthedecisioni5 madetomanagesoIido「ganin】u「ynonope「ativeIy. Suchanapp『oachtothemanagementofthesein】u『ies inchiId「enmustbeaccompaniedbyanattitudeofan﹣ ticipation!f『equent「eevaIuation’andp『epa「ationfo『 immediatesu「gica∣inteⅣention·ThesechiId「enshouId aIIbet「eatedbyasu『geoninafaciIityequippedt0 handIeanycontingenciesinanexpeditiousmanne『.

HEADTRAUMAZ63

■ReadT『auma Theinfbrmationprovidedi nChapter6 HeadTrauma

alsoappliestopediatricpatients·Thissectionempha﹣ sizesadditionalpointsspecifictochildren· Mostheadinjuriesinthepediatricpopulationare theresultofmotorvehiclecrashes,childmaltreatment, bicyclecrashes’andfhlls.Datafromnationalpediatric traumadatarepositoriesindicatethatanunderstand﹣ mgoftheinteractionbetweentheCNSandextracra﹣ malmjuriesisimperative,becausehypotensionand hypoxiafromass0ciatedinjurieshaveanadverseeffbct ontheoutcomeiTomintracranialinjuryLackofatten﹣ tiontotheABCDEsandassociatedinjur1essignificantly increasesmortality仕omheadmjury.Asmadults’hypo﹣ tensionisinfTeqUentlycausedbyheadinjuryalone’and otherexplanationsfbrthisfindingshouldbeinvesti﹣ gatedaggressively.Inrareoccasions’however,infhnts maylosesignificantamountsofbloodinthesubgaleal, subdural’ormtraventricularspaces· Thebrainofthechi1disanatomicaⅡydiffbrentfiyom thatoftheadult.Itdoublesmsizemthefirst6months oflifbandachieves80℅oftheadultbrainsizeby2years ofage.Thesubarachnoidspaceisrelative】ysmaller’ andhenceoffbrslessprotectiontothebrainbecause thereislessbuOyanCy.Thus’headmomentumismore likelytoimpartparenchymalstructuraldamage·Nor﹣ malcerebralbloodflowincreasesprogressivelytonearly twicethatofadultlevels叮theageof5years,andthen decreases.Thisaccountsmpartfbrchildren’ssevere susceptibilitytocerebralhypoxiaandhypercarbia.

ASSESSMENT ChⅡdrenandadultsmaydiHbrintheirresponseto headtrauma’whichmayinfIuencetheevaluationof theinjuredChild.Theprmcipaldiffbrencesinclude: 1·TheoutcomeinchildrenwhosufIbrseverebrain 1n〕u1yisbetterthanthatinadults·However’ theoutcomeinchildrenyoungerthan3years ofageisworsethanasimilarmjuryinanolder child.ChⅡdrenareparticularlysusceptibletothe effbctsofthesecondarybraininju】ythatmaybe producedbyhyp0volemia’withattendantreduc﹣ tionsincerebralperfhsion’hypoxia,seizures,0r hyperthermia.Thee蹤ctofthecombinationof hypovolemiaandhyp0xiaontheinjuredbrainis devastating,buthypotensionfromhypovolemia istheworstsingleriskfactor.Adequateahd『apid 『esto『atioⅡo「aⅡapp『op『iateci『cuIatihgbIoodvol﹣ umeandavoidanceofhypoxiaa『emandato『y· 2’Althoughaninfrequentoccurrence’hypotension mayoccurininfhntsastheresult0fbloodloss

intoeitherthesubgaleal’intraventricular,orepi﹣ duralspace.Thishypovolemia’duetointracra﹣ maliIUury,occursbecauseofopencramalsutures and允ntanellesininf白nts.I＼?eatmentisdirected towardappropriatevolumerestoration’asisap﹣ propriatefbrbloodlossfromotherbodyreg1ons. 3.Theinfantwithanopenfbntanelleandmobile cranialsutureshasmoretoleranceibranexpand﹣ 1ngintracranialmasslesionorbrainswelling’ andsignsoftheseconditionsmaybehidden untilrapiddecompensationoccurs.The『e↑b『e,an ih伯htwhoisnotiha∞mabutwhohasbulgiⅢg 化Ⅱtahelleso『sutu『ediastasesshouIdbet『eatedas havingamo『eseve『einiu『y.Earlyneurosurgical cons1】ltRtionisessenti月l

4.Vomitingandevenamnesiaarecommonafter braininjuryinchildrenanddonotnecessarily implyincreasedintracranialpressure.However, persistentvomitingorvomitingthatbecomes morefTequentisaconcernandmandatesCT oftheheadGastricdec0mpressionisessential, becauseoftheriskofaSpiration. 5.Impactseizures（seizuresthatoccurshortly afterbraininjury）aremorecommoninchildren andareusuallyselBlimited.Allseizureactivi叮 requiresinvestigationbyCTofthehead. 6.Cbildrentendtohave比werfbcalmasslesions thandoadults,butelevatedintracranialpres﹣ sureduetobrainswellingismorecommon.Rapid restorationofnormalcirculatingbl0odvolume isnecessary.Ifhypovolemiaisnotcorrected promptly,theoutcomeiTomheadinju1yismade worsebecauseofsecondarybrainiIUury.Emer﹣ genCyCTisvitaltoident吋childrenwhorequire emergencyoperation. 7.TheGCSisusefhlwhenappliedtothepediatric agegroup.However,theverbalscorecomponent mustbemodifiedfbrchildrenyoungerthan4 years（Table10.6）. 8.Becauseincreasedintracranialpressurefrequent﹣ lydevelopsinchildren’neurosurgicalconsulta﹣ tiontoconsiderintracranialpressuremonitoring shouldbeobtainedearlyinthecourseofresusci﹣ tationfbrchildrenwith: ·AGCSsc0reof8orless,ormotorscoresof1 or2 ·Multipleinjuriesassociatedwithbrainmjury thatrequirem則orvolumeresuscitation’imme﹣ diatelifbsavingthoracicorabdominalsurge1y》 orfbrwhichstabihzationandassessmentis prolonged

264CHAPTER10■Pediat「icT『auma

·ACTscanofthebrainthatdemonstratesevidenceofbrainhemorrhage’cerebralswelling’ ortranstentorialorcerebeⅡarherniation

■TABLE10·6Ped同at『kVe『balS仁o『e VERBALRESp0ⅡSE

v﹣sC0RE

App「0p『iatewo『dso『s0dalsmile’fixesandfOⅡow5

5

C『ies’butcons0∣abIe

q

pe『SiStent∣yi『『itabIe

3

·Phenobarbital’10to20mg／kg／dose

ReStIeSSiagitated

2

·Diazepam,0.1to0.2mg／kg／dose;slowⅣbolus

hlone

1

9.Medicationdosagesmustbeadjustedasdictated bythechild,ssizeandinconsultationwitha neurosurgeon.Drugsoftenusedinchildrenwith headmjuriesinclude:

·Phenytomorfbsphenytoin’15to20mg／kg, 月dmih↑steredat0·5to1.5mL／kgminas aloadingdose’then4to7m創k創dayfbr m瓠htenRn旺e

·Hypertomcsaline3﹪（BrainTraumaFounda﹣ tionguidelines）3to5mL／kg ·Mannitol,05toL0刨kg（rarelyrequired）; diuresiswiththeuseofmanmtolmayworsen hypovolemiaandshouldbewithheldearlyin theresuscitationofchildrenwithheadinjury unlessthereareincontrovertiblesignsoftran. stent0rialherhiRtion

MAⅡAGEMEⅡT Managementoftraumaticbraininjmyinchildren involves: 1.Rapid,earlyassessmentandmanagementofthe ABCDEs

Z·Appropriateneurosurgicalinvolvementfromthe beginningoftreatment 3·Appropriatesequentialassessmentandmanage﹣ mentofthebrainiILjmywithattentiondirected towardthepreventionofseconda1ybrainm﹣ ju〕Ⅳ－thatis,hypoxiaandhypoperfhsion·Early endotrachealintubationwithadequateoxygenationandventilationisindicatedtoavoidprogres﹣ siveCNSdamage.Attemptstoora1lyintubatethe tracheainanuncooperativechⅡdwithabrain injurymaybedifficultandactuaⅡyincrease intracranialpressure.Inthehandsofclinicians whohaveconsideredtherisksandbenefitsof intubatingsuchchildren,pharmacologicseda﹣ tionandneuromuscularblockademaybeusedt0 fhcilitateintubation. Hypertonicsalineandmannitolcreate hyperosmolali叮andincreasedsodiumlevelsin thebrain,decreasingthebrainedemaandthe pressurewithintheinjuredcranialvault.They havetheaddedbenefitofbeingrheostaticagents thatimprovebloodflowanddown﹣regulatethe inflammato】yresp0nse.

4ContinuousreassessmentofallparametersSee SkillStationX:HeadfmdNeckTral】ma:Assess﹣ mentandManagement·

P

● ■ ■ ■

S p Ⅱa

∣

︻ L o 『d

I

n

■ ■ ■ ■ ■

Ⅱ『 y

TheinfbrmationprovidedinChapter7:Spineand SpinalCor d T r a u m a a l soapphestopediatricpatients

Thissectionemphasizespointsspecifictopediatric spinalinjury. Spinalcordinjuryinchildrenisfbrtunatelyuncom﹣ mon＿only5℅ofspinalcordi叼uriesoccurinthepedi﹣ atricagegroup.Forchildrenyoungerthan10years ofage》motorvehiclecrashesmostcommonlyproduce thesem】uries·Forchildrenaged10to14years’motor vehiclesandsportingactivitiesaccountfbranequal numberofspinalinjuries. AⅡAT0MICDI「『ERENCES TheanatomicdiffbrencesinChfMrentobeconsidered withregardtospinalinjuryinclude: ■Interspinousligamentsandjointcapsulesare moreⅡexible. ■Vertebralbodiesarewedgedanteriorlyand tendtoslidefbrwardwithhexion. ■Thefacetjointsareflat. ■Thechildhasarelativelylargeheadcompared withtheneck.Therefbre,theangularmomen﹣ tumisgreater】andthefhlcrumexistshigher inthecervicalspine,whichaccountsfbrmore injuriesattheleveloftheocciputtoC3. ■Growthplatesarenotclosed,andgrowth centersarenotcompletelyfbrmed. ■Forcesappliedtotheupperneckarerelatively greaterthanintheadult.

MUSCULOSl﹤ELETALTRAUMAZ65

RAD∣OL0G∣CCONSlDERATI0NS Pseudosubluxationfrequentlycomplicatestheradio﹣ graphicevaluationofachild’scervicalspine.About 40﹪ofchildrenyoungerthan7yearsofageshowan﹣ teriordisplacementofC2onC3’and20℅ofchildren upto16yearsexhibitthisphenomenon.Thisradio﹣ graphicfindingisseenlesscommonlyatC3onC4.Up to3mmofm0vementmaybeseenwhenthesejoints arestudiedbyflexionandextensionmaneuvers Whensubluxationisseenonalateralcervical spinex﹣ray’theclimcianmustascertainwhetherthis isapseudosubluxationoratruecervicalspineiUjury. Pseudosubluxationofthecervicalve1.tebraeismade morepronouncedbytheflexionofthecervicalspine thatoccurswhenachildliessupineonahardsurfhce’ Tocorrectthisradiographicanomaly,placethechild,s headmaneutralpositionbyplacinga1﹣inch﹣thick layerofpaddingbeneaththeentirebodyfromshoulders tohips,butnotthehead,andrepeatthex﹣ray（seeFig ure10.2）.Truesubluxationwillnotdisappearwiththis mHneuverandmandatesfhrtherevaluation’Cervical spineinjmyusuallycanbeidentifIedfromneurologic examinationfindingsandbydetectionofanareaofsoft tissuesweⅡing）musclespasm,orastep﹣offdefbrmityon carefUlpalpationoftheposteriorcervicalspine. Anincreaseddistancebetweenthedensandthe anteriorarchofC1occursinappro泣mately20℅of youngchildren.Gapsexceedingtheupperlimitofnor﹣ malfbrtheadultpopulati0nareseenfrequently. SkeletalgrowthcenterscanresemblefTactures· Basilarodont0idSynChondrosisappearsasaradiolucentareaatthebaseofthedens,especiallyinchil﹣ drenyoungerthan5years.Apicalodontoidepiphyses appearasseparationsontheodontoidx﹣rayandare usuallyseenbetweentheagesof5and11years.The growthcenterofthespinousprocesscanresemble fTacturesofthetipofthespinousprocess. Childrensustain“spinalcordinju1ywithoutradio﹣ graphicabnorma1ities’,（SCIWORA）morecommon】y thanadults·Anormalcervicalspineseriesmaybe fbundinuptotwo﹣thirdsofchildrenwhohavesufk fbredspinalcordinjmy.Thus’ifspinalcordinjuryis suspected’basedonhistoryortheresultsoftheneu﹣ rologicexamination,normalspinex﹣rayexamination doesnotexcludesignificantspinalcordin】ury·When indoubtabouttheinteg『ityo「thece『vicaIspineo『spi﹣ naIco『diassuIhethatanunstabIeihluⅣexists》maihtain immobiIizationo「thechiId’sheadandnecI《,andobtain app『op『iateconsuItation· TheindicationsfbrtheuseofCTscanfbrevaluationofthecervicalspineinchildrenarenotdiffbrent thaninadults.CTscanmaynotdetecttheligamentousinjuriesthataremorecommoninthisagegroup. SpmalcordnUuriesinchildrenaretreatedinthe samewayasspinalcordinjuriesinadults·Consultation

withaspmesurgeonshouldbeObtainedearly.SeeChap﹣ ter7:SpineandSpinalCordTrauma’SkillStationXI X﹣RayIdentificationofSpine Iniuries’ a n d S k i l l S t a t i o n

XII!SpinalCordIniury!AssessmentandManagement.

∣ ﹥ Muscu∣os∣《e∣etaIT『auma

∣

Theinitialprioritiesinthemanagementofskeletal traumainthechildaresimilartothosefbrtheadult, withadditionalconcernsaboutpotentialmjmytothe growthplates SeeChapter8 MusculoskeletalTrauma

Ⅱ∣ST0Rγ Thepatient》shistoryisofvitalimportance.Inyounger children’x﹣raydiagnosisoffracturesanddislocations isdiHicultbecauseofthelackofmineralizationaround theepiphysisandthepresenceofaphysis（growth plate）.Infbrmationaboutthemagnitude,mechamsm’ andtimeofthemjuryfacilitatesbettercorrelationof thephysicalandx﹣rayfindings.Radiographicevidence offTacturesofdifIbringagesshouldalertclimciansto possiblechildmaltreatment》asshouldlower-extremityfracturesinchildrenwhoaretooyoungtowalk.

Bl00DL0SS Bloodlossassociatedwithlong﹣boneandpelvicfiPac﹣ turesisproportionatelylessinchⅡdrenthaninadults. Bloodlossrelatedtoanisolatedclosedfbmurhacture thatistreatedappropriatelyisassociatedwithanav﹣ eragefRllinhematocritof4percentagepoints’which isnotenoughtocauseshock.Hemodynamicinstability inthepresenceofanisolatedfbmurfTactureshould promptevaluationfbrothersourcesofbloodloss, whichusuallywillbefbundwithintheabdomen.

SPEαAlCOⅡS∣DERAT∣0ⅡS0『TⅡE ∣ⅢⅢATURESI《ElET0Ⅱ Boneslengthenasnewboneislaiddownbythephysis nearthearticularsurfhces.Injuriesto,oradjacentto, thisareabefbrethephysishasclosedmaypotentially retardthenormalgrowthoralterthedevelopmentof theboneinanabnormalway.Crushinjuriestothe physis’whichareoftendifficulttorecognizeradio﹣ graphical】y,havetheworstprognosis. Theimmature’pliablenatureofbonesinchildren mayleadtoaso﹣calledgreenstickfTacture.SuchfTacturesareincomplete,withangulationmaintainedby corticalsplintersontheconcavesurface。Thetorus’ or“buckle,,’fTacture,seeninsmallchildren,involves angulationduetocorticalimpactionwitharadiolu﹣ centfTactureline.Bothtypesoffracturesmaysuggest

Z66CHAPTER10■Pediat『icT『auma maltreatmentinpatientswithvague,inconsistent, orconflictinghistories.Supracondylarhacturesat theelboworkneehaveahighpropensityfbrvascular injuIyaswellasinjurytothegrowthplate.

ormaltreatedchild.Homicideisthemostcommon causeofmjurydeathinthefirstyearoflifb.Therefbre’ ahistoryandcarefhlevaluationofthechildinwhom maltreatmentissuspectediscriticaⅡymportantto preventeventualdeath,especiallyinchⅡdrenwhoare youngerthan2yearsofage.Climciansshouldsuspect cbildmaltreatmentiB

PRINαPLES0FIMM0BⅢZATION Simplesphntingofhacturedextremities1nchⅡdren usuallyissufficientuntildefinitiveorthopedicevaluationcanbeperfbrmed.Injuredextremitieswithevidence ofvascularcompromiserequireemergenCyevaluation topreventtheadversesequelaeofischemia.Asingle attempttoreducethehPacturetorestorebloodflowis appropriate,fbⅡowedbysimplesplintingortraction splintmgoftheextremity·SeeSkiⅡStationXⅡI;Mus﹣

■Adiscrepancyexistsbetweenthehisto】yand thedegreeofphysicalinjury-fbrexample, ayoungchildlosesconsciousnessorhas significantinjuriesafterfHllingfTomabedor sofh’fTacturesanextremityduringplaywith siblingsorotherchildren,orsustainsalower﹣ extremityfracturebutistooyoungtowalk.

culoskeletalITauma:AssessmentandManagement

■刀

PITFAI』『』S L

■Aprolongedintervalhaspassedbetweenthe timeoftheiUjuryandpresentationfbrmedical

∣

■Manyo「thopediciniu「iesinchild『enp「oduceonIy subtIesymptoms‘andp0sitivefinding5onphysica∣ examinati0na「edi什icuIttodetect. ■AnyevidenceofunusuaIbehavio﹟︺fo「exampIe’a Childwho「efusestouseana『mo『bea「weighton anext『emity’mustbeca『efuIIyevaluatedfo『the possibilityofanoccuItb0nyo「softtis5uein】u『y. ■Theca「egive「sa「eoftentheoneswhon0tebehav﹣ i0「thatisoutoftheo『dina『yf0『thechiId ■ThecIinicianmu5t「emembe『thepotentiaIl:o『chiId maIt『eatment·Thehisto「y0fthein】u『yeventsh0uId beviewedsuspiciouslywhenthefindingsdonotco『﹣ 『obo「atethepa「ent’sst0『y.

care.

■Thehistoryincludesrepeatedtrauma’treated inthesameordif也rentEDs. ■Thehistoryofmjurychangesorisdiffbrent betweenparentsorguardians· ■Thereisahistoryofhospitalordoctor “shoppn i g·》’ ■Parentsrespondinappropriatelytoordonot complywithmedicaladvice＿fbrexample’ leavingachildunattendedintheemergenCy fhcility. ■Themechanismofinjuryisimplausiblebased onthechild,sdevelopmentalstage（Table 107）

Thefbllowinglindings,oncarefUlphysicalexami﹣ nation’shouldsuggestchildmaltreatmentandindi﹣ catemoreintensiveinvestigation: F

■Multicoloredbruises（bruisesindi蹤rent stagesofhealing）

SceⅡa『io■cont／huedThepatientis t『ans↑e『『edt0thenea『estt『aumacente『a↑te『 intubati0nandstabiIizati0n0↑hi5hem0dynamic5 Chestx-「ay『evea∣5puIm0na『yc0ntusi0ns』anda peIvi〔x﹣『ayisn0『maI.

fiedbyoldscarsorhealedfracturesonx﹣ray examination ■Perioralmjuries ■Injuriestothegenital0rperiana1area ■Fractures0flongb0nesinchⅡdrenyounger

＿

∣﹥Ch d IiMat『 I eat

■Evidenceoffrequentpreviousinjuries,typi﹣

than3yearsofage

ment

叨 Hb刎伽『 I ecOg『豳ze奩咖㎡eS伽呱c腕M ●〃Jα肋℃αrme犯癬 AnychildWhosustainsanintentionali叼uryasthere﹣ sultofactsbycaregiversisconsideredt0beabattered

■Rupturedinternalviscerawithoutantecedent majorblunttrauma ■Multiplesubduralhematomas’especially withoutafTeshskullhacture ■Retinalhemorrhages ■Bizarrei巧uries,suchasbites,cigaretteburns’ orropemarks

CHILDMALTREATMENT267

■丁ABLE10·7BabyMilestoⅡeS AGE

TγplCALsKIlLS

】month

li↑tsheadwhensupine.Respondsto5ound5 Sta「eSatfaCeS·

Zmonths

VocaIizes.F0IIowsob】ectsac『ossfie∣dofvi5ion Ho∣dsheadupfo『5ho『tpe『iods.

3monthS

Rec0gnize5famiIia「facesH0Idshead5teady.Visu﹣ al∣yt「acksmovingob】ects.

¢mont∣】s

SmiIesLaughs·Canbea『weightonIeg5.Voca∣izes whenspokento.

5months

DistinguishesbetweenboIdcolo「s·PIay5with h日ndSandfeet·

6montI】s

Tumstowa『ds0und5o「voIces·Imitates5ounds Rollsove「inbothdi『ections·

7months

Sitswith0utsupp0『tD『agsob】eCtstowa『d55el↑

8months

Says〃mama〃o『〃dada〃t0pa『ents.Passes0qect5 f「omhandtohand.

9months

5tandSwhi∣eho∣dingont0thing5

10montI】s

Pi〔k5thingsupwith〃pince「”g『a5p.C『awl5weI∣ withbeI∣yo什theg『ound.

↑1months

pIay5game5∣ike〃pattycake’’and〃peek﹣a﹣b0o.〃 Standswithoutsuppo『tfo「a↑ewseconds.

↑2months

lmitatestheactions0fothe「s.Indicate5wantswith

place.Upto80℅ofchildhoodinjuriescouldhavebeen preventedbytheapplicationofsimplestrategiesin thehomeandthecommunity.TheABCDEsofinjury preventionhavebeendescribed,andwarrantspecial attentioninapopulationamongwhomthelifbtime benefitsofsuccessh1lmjurypreventionareselBevident （Box10﹣1）.Notonlyisthesocialandfhmilialdisrup﹣ tionassociatedwithchildhoodinjuryavoided,butfbr everydollarinvestedininjuryprevention’fburdollars aresavedinhospitalcare.

■

BoX1O﹣1ABCDEsof A D In】Ⅲyp『evention ■AnaIyzein】u「ydata －【0〔aliniu『γsuⅣeIIlance ■BuiIdI0〔aI〔0a∣iti0n5 -Ⅱ0spitaIcommunitypa『tne『5hip5 ■Communicatethep『0blem －Inu i 『e i 5a『ep『eventabe l ■Developp『eventi0nactivitie5 －C『eate5a拒『env『 i 0nment5

gestu「es‘

■EvaIuatetheinteⅣeⅡti0Ⅱs ＿0ng0n i gn i 】u『γ5u『veIian〔e

■Sharplydemarcatedsecond﹣andthird﹣degree burns ■Skulliracturesorrib仕acturesseeninchiIdren lessthan24monthsofage Inmanynations,cliniciansareboundbylawto reportincidentsofchildmaltreatmenttogovernmen﹣ talauthorities’evencasesinWhichmaltreatmentis onlysuspected.Maltreatedchildrenareatincreased riskfbrfhtalinjuries,andnooneisservedbyfRilingto report.Thesystemprotectscliniciansfromlegalhabil﹣ ityfbridenti觔ngconfirmedorevensuspiciouscases ofmaltreatment.Althoughthereportingprocedures mayva1y》theyaremostcommonlyhandledthrough localsocialserviceagenciesorthestate》shealthand humanservicesdepartment·Theprocessofreporting childmaltreatmentassumesgreaterimportancewhen onerealizesthat50℅ofmaltreatedchildrenwhodie oraredeadonarrivalatthehospitalwerevictimsof

Sou『ce:p『essIeyjC8a『I0w8『Du『kinM」ack0SA00minguez DR」ohns0nL／U『banⅡea／叻2005;8Z:389﹣』0ii ■

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ChapterSunnnary ⅢUniquecharacteristicsofchildrenincludeimportantdiffbrencesinanatomy, bodysurihcearea,chestwallcompliance,andskeletalmaturity.Normalvital signsvarysignificantlywithage. 圓Imtialassessmentandmanagementofseverelyinjuredchildrenisguidedbythe ABCDEapproach·Earlymvolvementofageneralsurgeon0rpediatricsurgeonis imperativeinthemanagementofi呵uriesinachⅡd.Nonoperativemanagement ofabdominalvisceralinjuriesshouldbeperfbrmedonlybysurgeonsinfhcilities equippedtohandleanycontingen叮inanexpeditiousmanner. 固0hⅡdmaltreatmentshouldbesuspectedifsuggestedbysuspiciousfindingson histo】yorphysicalexamination.Thesemcludediscrepanthistory’delayedpres﹣ entation’fTeqUentpriorinjuries,andperinealmjuries· 團Mostchildhoodinjuriesarepreventable.DoctorscaringfbrinjuredChⅡdrenhave aspecialresponsibih叮topromotetheadoptionofeffbctive蚵urypreventionpro﹣ gramsandpracticeswithintheirhospitalsandcommunities. ＿

●BⅢIoGRAⅢ 1A1nericanCollegeofSurgeonsCommitteeonTrauma, AmericanCollegeofEmergenCyPhysicians,National AssociationofEMSPhysicians’PediatricEquipment GuidelinesC0mmittee＿EmergencyMedicalServicesibr Children（EMSC）PartnershipfbrChildrenStakeholder GroupandAmericanAcademyofPediatricsBabyCen﹣ ter.（n·d.）Mnestonechart:1to6monthsandMilestone chart:7to12months.http:〃www.babycenter.com／baby﹣ milestones·Accessed. 2.BrattonSL’ChestnutRM,Gh鉚arJ,etal·Guidelines 〔brthemanagementofseveretraumaticbraininjury.II. Hyperosmolartherapy.JⅣbαγoZrαM加α2007;24Suppl 1:S14﹣20.BrainITaumaFoundation;AmericanAssocia﹣ tionofNeurologicalSurgeons;CongressofNeurological Surgeons;JointSectiononNeurotraumaandCritical Care,AANS／CNS,PEDIATRICSVol·124Nα1July 2009’pp.e166﹣e171（doi:10.1542／peds.2009﹣1094）. 3.CapizzaniAR’DrognonowskiR’EhrlichPF.Assessment ofterminationoftraumaresuscitationguidehnes:are chⅡdrensmalladults?JHd㎡α力、SαJg2010;45;903﹣907.1. 4.CarneyNA’ChesnutR,KochanekPM,etal.Guidelines fbrtheacutemedicalmanagementofseveretrauma﹣

ticbrainin】u1yininfants’chⅡdren’andadolescents.J Tm【〃川α2003,54:S235﹣S310. 5.ChesnutRM,MarshallLF,etal.Theroleofsecondary braininjmyindeterminingoutcomefTomseverehead injuIy.c／乃α叨〃｝α1993;43:216﹣222. 6.ChwalsWJ,RobinsonAV,SivitCJ’etal.Computed tomographybefbretrans｛brtoalevelIpediatrictrauma centerrisksduplicationwithassociatedradiationexpo﹣ sure.JPed㎡α㎡SαJg2008;43:2268﹣2272. 7.ClementsRS’SteelAG,BatesAT,etal。CuHbdendo· trachealtubeuseinpaediatricpreh0spitalintubation: challengmgthedoctrine?E〃!e『gMbdJ2007;24（1）: 57﹦58· 8·CloutierDR,BairdTB,GormleyP,etal·Pediatricsplenic in】urieswithacontrastblush:successmlnonoperative managementwithoutangiographyandembolization. c／P它d㎡α﹠『.Sα唔2004;39（6）:969﹣971. 9.CookSH,FieldingJR,PhillipsJDBepeatabdominal computedtomographyscansafterpediatricbluntabdomi﹣ naltrauma;missedinjuries》extracosts,andunnecessary radiationexposure.JAdZα向.Sα『習2010;45:2019﹣2024. 10.C0operA,BarlowB,DiScalaC’etal·Mortalityand truncalinjmy:thepediatricperspective.JP它d古αtγSα唔 1994;29:33·

BlBUOGRAPHY269

11.CooperA’BarlowB,DiScalaCVitalsignsandtrauma mortality:thepediatricperspective.Rd㎡α』rEme唔Cm℃ 2000;16:66· 12.CorbettSW’AndrewsHG’BakerEM,etalEDevaluationofthepediatrictraumapatientbyultrasonography· A加cJEmeJgMbd2000;18（3）:244﹣249. 13iDaviesDA,EinSH’PearlR,etal.Whatisthesignifi﹣ canceofcontrast‘‘blush’,inpediatricbluntsplenic trauma?JAd〔α〃Sα唔2010;45:916﹣920. 14.DiScalaC,SageR,LiG’etalChildmaltreatment andunintentionalimuries.A『℃hRdiα』rAdO!escMbd 2000;154:16﹣22· 15.EmeIyKH,McAneneyCM,RacadioJM,etal.Absent peritonealfluidonscreenmgtraumaultrasonography inchildren:aprospectivecomparisonwithcomputed tomography.J几dtα〃Sα咱2001;36（4）:565﹣569· 16.FastleRKRobackMG.Pediatricrapidsequenceintu﹣ bation:incidenceofreflexbradycardiaandeffbcts ofpretreatmentwithatropine.PedtαtrEme唔Cα沱 2004;20（10）:651-655.

27.LutzN,NanceML,KallanMJ’etal.Incidenceandclini﹣ calsignilicanceofabdominalwallbruisinginrestrained childreninvolvedinmotorvehiclecrashes.cJRdmfr SαJg2004;39（6）:972﹣975· 28.McAuliffbG’BiSsonnetteB,BoutinC·Shouldtherou﹣ tineuseofatropinebefbresuccinylcholineinchildrenbe reconsidered?Cα〃cJA冗αes毗1995;42（8）:724﹣729. 29.MCVayMR,KokoskaER,JacksonRJ,etal.Throwmg outthe“grade,,book:managementofisolatedspleen andⅡverinjuIybasedonhemodynamicstatus.JRd』α』r Sα咱2008;43:1072﹣1076. 30.MurphyJT,JaiswalK’SabellaJ’VinsonL,etal.Pre﹣ hospitalcardiopulmonaryresuscitationinthepediatric traumapatient·j代㎡α〃助唔2010Jul;45（7）:1413﹣1419’ 31.MutabaganiKH,ColeyBD,ZumbergeN’etal.Prelimi﹣ naryexperiencewithfbcusedabdominalsonographyfbr trauma（FAST）inchildren:isituseh1l?JRdmZrSαJg 1999;34:48﹣54. 32.NationalSafbtyCouncil.I）Vα刁Fhc／s.Itasca,IL: NationalSafbtyCounci】;2007.

17·HannanE’MeakerP’FaweⅡL’etal·Predictinginpatientmortality｛brpediatricblunttraumapatients:abet﹣ teralternative.JRdmtrSα咱2000;35:155﹣159.

33.NealMD,SippeyM,GainesBA,etal·Presenceofpneu﹣ momediRstinumafterblunttral】maincbi】dren:what doesitreallymean?JPediα㎡Sα唔2009;44:3122﹣1327.

18·HaricharanRN,GriffinRL,BarnhartDC,etal.Injmy patternsamongobesechildreninvolvedinmotorvehicle collisions.cJ几d【αfrSα唔2009;44:1218﹣1222.

34.PaddockHN,TepasJJ,Rameno比kyML.Management ofbluntpediatrichepaticandsplenicinjuIy:similarpro. cess,diffbrentoutcome.AmSMJg2004;70:1068﹣1072·

19.HarrisBH’SchwaitzbergSD’SemanTM,etal.The hiddenmorbidityofpediatrictrauma.JAdtα仃Sα唔 1989;24:103.106.

35.ParisC,BrindamourM,OuimetA,etal.Predictiveindi﹣ catorsfbrbowelinju叮inpediatricpatientswhopresent withapositiveseatbeltsigna｛termotorvehiclecoⅢsion. cJAd『α仃Sα唔2010;45:921﹣924.

20HerzenbergJE,HensingerRN’DedrickDE’etal.Emer﹣ gen叮transportandpositioningofyoungchildrenwho haveaninjuIyofthecervicalspine.JBo〃eJb加tSα唔 Am1989;71:15﹣22. 21·HolmesJF,BrantWE,BondWF’etal.Emergency departmentultrasonographyintheevaluationofhypo﹣ tensiveandnormotensivechildrenwithbluntabdominHl trauma.cJAdiαfrSα唔2001;36（7）:968﹣973. 22.HolmesJF,LondonKL’BrantWE,etal.Isolatedintra. peritonealⅡuidonabdominalcomputedtomographyin childrenwithblunttrauma.AcαdE加eJgMbd2000;7（4）: 335﹣341. 23·HolmesJF,GladmanA,ChangCH.Perfbrmance ofabdominalultrason0graphyinpediatricblunt traumapatients:ameta﹣an刨ysis.JAd【α¢rSα唔 2007;42:1588﹣1594·14· 24.HolmesJ,LillisK,MonroeD,etal.Identifyingchildren atverylowriskofintra﹣abdominalinjuriesundergoing acuteintervention.AcαdE加e唔Mbd2011;18:S161. 25.KuppermannN’HolmesJF’DayanPS,etal,fbrthe PediatricEmergencyCareAppliedResearchNetwork （PECABN）:IdentificationofchildrenatveⅣlowriskof climcaⅡy﹣importantbraininjuriesalterheadtrauma:a prospectivecohortstudy·Lα几cet2009;374:1160-1170. 26.LeonardJC,KuppermannN,OlsenC,etal,fbrthe PediatricEmergenCyCareAppliedResearchNetwork. Factorsassociatedwithcervicalspineinju叮in childrenfbllowingblunttrauma.A〃〃Eme咱MCd 2011;58:145﹣155.

36.PatelJC,TepasJJ.TheefficaCyof｛bcusedabdomi﹣ nalsonographyfbrtrauma（FAST）asascreenmgtool intheassessmentofinjuredchildren.JAd『α〃Sα唔 1999;34:44﹣47. 37.PershadJ’GilmoreB.Serialbedsideemergencyultra﹣ soundinacaseofpediatricbluntabdominaltrauma withsevereabdominalpam.RdtαtrEmG唔Cα「e 2000;16（5）:375-376. 38.Pieretti≡VanmarckeR’VehmahosGC,NanceML,etal. Chnicalclearanceofthecervicalspineinblunttrauma patientsyoungerthan3years:amulti-centerstudyof theAmericanAssociationfbrtheSurgeIyofTrauma.J ?〉uαmα2009;67:543﹣550. 39.PigulaFA,WaldSL,ShackfbrdSR’etal.Theeffbctof hypotensionandhypoxiaonchildrenwithseverehead mjuries.cJ凡dtα〃Sα咱1993;28:310﹦316. 40.PressleyJ,BarlowB,DurkinM,etalAnationalpro﹣ gramfbrinjuIypreventioninchildrenandadolescents; theInjuIyFreeCoalitionfbrKids.JU〉bα〃Hm!仇 2005;82;389﹣402. 41.RanaAR,DrogonowskiR,BrecknerG’etal·Traumatic cervicalspineinjuries:characteristicsofmissedinjuries. eJ几d〔α／rSα唔2009;44;151-155. 42.RathausV,ZissinR’WernerM,etal.Minimalpelvic fluidinbluntabdominaltraumainchildren:thesig﹣ nificanceofthissonographicfinding.J几dm／rSα唔 2001;36（9）:1387-1389·

Z70CHApTER10■Pediat『icT『auma 43.RetzlaffT,HirschW,TillH’etal.Issonographyreliable fbrthediagnosisofpediatricbluntabdominaltrauma?J AdZαtrSα唔2010;45（5）:912﹣915.

51.StylianosS.Compliancewithevidence﹣basedguidelines inchildrenwithisolatedspleenorliverinjuⅣ:aprospec﹣ tivestudy.JAd!α／rSα唔2002;37:453﹣456.

44.RiceHE’FrushDP’FarmerD,etal,APSAEducation Committee.Reviewofradiationrisks仕omcomputed tomography:essentialsfbrthepediatricsurgeon.c／Ped【﹣ α〃Sα咱2007;42:603﹣607.

52.SuthersSE,AlbrechtR’FoleyD,etalSurgeon﹣directed ultrasoundlbrtraumaisapredictorofintra﹣abdomina】 injuIyinchildren.AmSα唔2004;70（2）:164﹣167;discus﹣ sion167﹣168·

45.RogersCG,KnightV,MacUraKIHigh﹣graderenalinju﹣ riesinchildren＿isconservativemanagementpossible? U》℃』咽／2004;64:574-579.

53.Tepas《LJ,DiScalaC,Ramenofb坷ML,etal.Mortality andheadinjuIy:thepediatricperspective·JRdi㎡r Sα咱1990;25:92﹣96.

46.RothrockSG,PaganeJ.Pediatricrapidsequenceintubation incidenceofreHexbradycardiaandefIbctsofpretreatment withatropine.几dm』rEmeJgαn它2005;21（9）:637﹣638.

54.TepasJJ’Rameno｛SkyML’MollittDL,etal.ThePedi﹣ atricTraumaScoreasapredictorofmjmyseverity:an ohjectiveassessment·eJⅥmαmα1988;28:425﹣429.

47.SasserSM,HuntRC》SulliventEE,etal·Guidelinesfbr heldtriageofinjuredpatients:recommendationsofthe NationalExpertPanelonFieldTriage.M0JbMbr／α／ W弗!yRep2009;58（RR-1）:1-35.

55‘TolleiSenWW,ChapmanJ,FrakesM’etal.Endotra. chealtubecu任pressuresinpediatricpatientsintubated befbreaeromedicaltransport.AdtαZrE加e咱“疋2010 May;26（5）:361-3.

48.SchwaitzbergSD,BeIgmanKS,HarrisBW·Apediatric traumamodelofcontinuoushemorrhage.J几d』α』rSα唔 1988;23:605﹣609.

56.T0urtierJP,AuroyY’BorneM,etal.Focusedassess﹣ mentwithsonographyintraumaasatriagetool.JAd!﹣ αrSα唔2010;45（4）:849;authorreply849.

49.SoudackM’EpelmanM’MaorR,etal.Experiencewith fbcusedabdominalsonographyfbrtrauma（FAST）in313 pediatricpatients.Jα加αfmsoα〃d2004;32（2）:53﹣61·

57.vanderSluisCK’KingmaJ,EismaWH,etal·Pedi. atricpolytrauma:short﹣termandlongtermoutcomes.J Trααmα1997;43（3）:501﹣506.

50.SoundappanSV,HollandAJ,CassDT’etal.Diagno﹣ sticaccura叮ofsurgeon-perfbrmedfbcusedabdominal sonography（FAST）inbluntpaediatrictrauma.I叮αⅣ 2005;36（8）:970﹣975.

58.WeissM,DullenkopfA,FischerJE,etal,European PaediatricEndotrachealIntubationStudyGroup.Pro. spectiverandomizedcontroⅡedmulti﹣centretrialofcufL fbdoruncu健dendotrachealtubesinsmallchildren.BrJ Ames炕2009;103（6）:867-873·

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populationhashadasignificanteconomicimpact becauseoftheiruniquemedicalrequirementsandthe 也ctthattheseindividualsconsumem0rethanone﹣ thirdofthecountry,shealthcareresources.Currently, traumaistheseventhleadingcauseofdeathinthe elderly’surpassedonlybyheartdisease’cancer,chronic obstructivepulmonarydisease’stroke,diabetes’and pneumon1a·

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outcome.Milzmanetal·reportedthatpreexistingdis﹣ easewasmorecommonintheolderagegroup（mean age’49·2）thanintheyoungeragegroup（meanage》 30.0）,andthemortalityratewasthreetimesgreat. erinolderpatientswithpreexistingdisease（9.2℅vs 3.2﹪）.However’morethan80℅ofinjuredolderadults canreturntotheirpreexistinglevelofindependentlivmgafteraggressiveresuscitationandfbll0w﹣upcare. Fallsarethemostcomm0nmechanismofinjury encounteredinolderadultsseenintraumacenters andarethemostcommoncauseofunintentional injuryanddeathamongtheelderly.Fallsaccountfbr 40﹪ofthedeathsmthisagegroup.Boththeinci﹣ denceoffhllsandtheseverityofcomplicationsrise withage’andlargenumbersofemergencydepartment visitsandsubsequenthospitaladmissionsoccurasa resultoffalls·FallsaremostfTequentlycausedbythe accumulatedeffbctsoftheagmgprocessandenviron﹣ mentalhazards.Changesinthecentralnervousand musculoskeletalsystemsmakeolderpeoplelessflex﹣ ibleandlesscoordinatedthanyoungeradults.Geriat. ricpatientsaremorelikelytohavegaitdisturbances.

BREATHINGANDVENTILATION275

Ⅵsual’hearing’andmem01yimpairmentsplaceolder adultsathighriskfbrhazardsthatcancausefh1ls. FallsresultingfiPomdizzmessorvertigoareextremely comnTnn·

Inaddition,drugs－includingalcohol-cause orcontributetomanyfalls.SeemingIymino『mecha﹣ nismso「iniu『ycahp『oducepotentiallyIetha∣iniu『yand compIicationsbecauseo「thee促cto「muItip∣emedica﹣ tiohs,especiaIIyanticoaguIahts·Warfhrin（Coumadin） andclopidogrel（Plavix）arehequentlyprescribedto olderpatients.Thepresenceofthesemedicationswith traumaticbraininjuryincreasesthelikelihoodofpoor outcomes.Betablockerscanbluntthecardiovascular responsetohypovolemia. Theeffbctsoftheagmgprocessaream旬orinflu﹣ enceontheincidenceofinjuryanddeathinolder adultsfrommotorvehiclecrashes.O仳en’theelderly havedimimshedvisualandauditoryacuity.Dayhght acuity,glareresistance,andnightvisiondecrease markedlywithage.Medicalconditionsandtheirtreat﹣ mentsmayalterattentionandconsciousness.Because ofsenescentchangesinthebrain’judgmentmaybe altered.FihaIIy,the『eo儡ehisdec『easedabilitytoavoid iITluⅣbecauseo「impai『ment什omconditiohssuchas aItlT『itis,osteopo『osis,emphysema）heaItdisease,and dec『easedmuscIemass. Thermalmjuryisthethirdleadingcauseofdeath duetoinjuryintheelderly,accountingfbrahnost 2000deathsannuaⅡyintheUnitedStates·One﹣third ofthesemdividualsarefataⅡyinjuredwhⅡeunderthe inf1uenceofalcohol’whⅡesmokinginbed,orWhen exposedtoheatandtoxicproductsofcombustionwhen trappedinabuⅡdingfire.Oftheremainder’themajoritysustaininjurybecausetheirclothingisignited0r th叮haveprolongedcontactwithhotsubstances· Aswithfhlls,fhctorsassociatedwithdegenerative diseaseandphysicalimpa1rmentappeartocontribute substantiaⅡytotherateoftherma1injuryintheelder】y. OlderadⅢtswhocomemtocontactwithhotsurfacesor hqUidsorareexposedtofireoftenarenotabletoremove themselvesbe｛breextensiveiIUuryoccurs·FinaⅡy’pre﹣ existingcardiovascular,respirato1y》andrenaldiseases oftenmakeitimpossiblefbrthemjuredpersontoover﹣ comeserious,butpotentiaⅡysurvivableburns.

『a way ■A『 i Aiw y 叨 Hb鯽doα IPPZyA皿Sα砌叨 . 叼P㎡’’CPie !S ●fo炕c打eα力〃e〃fOfeJαey.腳Pα㎡e〃加β The“A,’oftheABCDEmnemonicoftheprimarysur﹣ v叮isthesameintheelderlyasfbranyotheri叮ured patient.EstablishingandmaiⅡtainingapatentai『wayto p『ovideadequateoxygenatiohistheh『stobiective。Sup﹣

plementalo汀genshouldbeadministeredassoonas p0ssible’eveninthepresenceofchromcpulmonary disease.Becauseoftheelderlypatient,slimitedcar﹣ diopulmonaryreserve,earlyintubationshouldbecon﹣ sideredfbrelderlytraumapatientspresentinginshock andthosewithchestwalliIUuryoralterationinthe levelofconsciousness. FeaturesthatafIbctmanagementoftheairwayin theelderlyincludedentition’nasopharyngealfragility’ macroglossia（enlargementoftongue）,microstomia （smalloralaperture）’andcervicalarthritis.Lessthan fUlldentitioncaninterfbrewithachievingaproperseal onafhcemask·ConsequentIy,whe『easb『ol《eⅡdentu『es shouIdbe『emoved,intactweII.伺tteddehtu『esa『eoften bestIeftinpIaceuntiIaRe『ai『waycont『oIisachieved.Care mustbetakenwhenplacingnasogastricandnasotra﹣ chealtubesbecauseofnasopharyngealfriability,espe﹣ ciallyaroundtheturbinates’ProfUsebleedingcan ensue.Theoralcavitymaybecompromisedbyeither macroglossia’associatedwithamyloidosisoracrome﹣ galy,ormicrostomia,suchastheconstricted,birdlike mouthofprogressivesystemicsclerosis.Arthritiscan affbctthetemp0romandibularjointsandthecervical spine’makingendotrachealintubationmorediffi﹣ cultandincreasingtheriskofspinalcordi叼mywith mampulationoftheosteoarthriticsp1ne.Degenerative changesandcalcificationinlaryngealcartilageplace theelderlypopulationatincreasedriskofinjuryfrom minorblowstotheneck· Theprinciplesofairwaymanagementremainthe same’withendotrachealintubati0nastheprefbrred methodfbrdefinitivea1rwaycontrol.Ifacutea1rway obstructionexistsorthevocalcordscahhotbevisual﹣ ized,surgicalcricothyroidotomyshouldbeconsidered asanoption.SeeChapter2AirwayandVentilatory Management’andSkillStationIII:Cricothyroidot﹣ omⅡ,SkillⅢ﹦BiSUrgicalCricothyrOjdotomy.

∣P 8『eathingandVentilation Manyofthechangesthatoccurinthea1rwayand lungsofelderlypatientsaredifIiculttoascribepurely totheprocessofagingandmaybetheresult0fchronic exp0suretotoxicagentssuchastobaccosmokeand otherenvironmentaltoxinsthroughoutlifb·Thelossof 『espi『ato『y『eseⅣeduetothee碓ctsofagingandch『ohic diseasesmakesca『efi』Imohito『ihgo「thege『iat『icpa. tient,s『espi『ato『ysystemimpe『ative（■FIGURE11﹣2）. Administrationofsupplementalo叮genismandatory, althoughcautionshouldbeexercisedwithitsusebe﹣ causesomeelderlypatientsrelyonhypoxicdriveto maintainventilationOxygenadmimstrationcanre﹣ sultinlossofthishypoxicdrive,causingCOoretention andrespiratoryacidosis.Inanacutetraumasituation’

Z76CHAPTER11■Ge『iat「iCT「auma

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however,hypoxemiashouldbecorrectedbyadminis﹣ teringo可genwhileacceptingtheriskofhypercarbia. Inthesesituations,ifrespiratoryfailureisimminent’ intubationandmechanicalventilation1snecessaIy· ChestiIjuriesoccurinpatientsofallageswith simⅡarfreqUenCy,butthemortalityratefbrelderly patientsishigher.Chestwallinjurieswithribhactures orpuhnona】ycontusionsarecommonandnotwelltol﹣ erated·Patientsolderthan65yearsofagewithmultipleribhactureshaveincreasedratesofmorbidityand mortali叮.Simplepneumothoraxandhemothoraxalso arepoorlytolerated,andgeriatricpatientswiththese iIUuriesshouldbeconsideredfbrintensivecareumt （ICU）observation’asrespiratoryfHilurecanbegradual orprecipitous.Respiratoryfhiluremayresultfromthe increasedwork0fbreathingcombinedwithadecreased energyreserve.Adequatepamcontrolandvigorous pulmonmytoⅡetareessentialfbrasatis趙ctoryout﹣ come.Thebalancebetweenadequatepamcontroland narcoticsideeHbctscanbedifficultintheelderly,and theuseofepiduralcathetersmayimproveoutcome inthesepatients.Pulmona】ycomphcations＿suchas atelectasis,pneumonia）andpulmonaryedema＿occur intheelderlywithgreatfrequency.Marginalcardio﹣ pulmonaryreservecoupledwithoverzealouscrystalloid infhsionincreasesthepotentialfbrpulmona】yedema andworsemngofpuhnonarycontusions·Admissionto thehospitalusuaⅡyisnecessary,evenwithapparently nunor1IUur1es·

Astheheartages,thereisprogressivelossoffUnction· Bytheageof65years’nearly50℅ofthepopulation hasc0ronaryarterystenosis·Thecardiacindexfalls offlinearlywithage,andthemaximalheartratealso beginstodecreaseafter40yearsofage.Thefbrmula fbrmaximalheartrateis220minusthemdividual,s ageinyears.Althoughtherestingheartratevaries little’themax1mumtachycardicresponsedecreases withage. ThecauseofthisdiminutionofhmctionismⅡltifaceted.Withaging’totalbloodvolumedecreasesand circulationtime1ncreases·Thereisincreasingmyo﹣ cardialstiffhess,slowedelectrophysiologicconduc﹣ tion,andlossofmyocardialcellmass.Theresponse toendogenouscatecholaminereleasewithstressis alsodiffbrent,whichislikelyrelatedtoareductionin respons1venessofthecellularmembranereceptors. Thesechangespredisposetheagedhearttoreentry dysrhythmias.DiastolicdysfUnctionmakestheheart moredependentonatrialfillingtoincreasecardiac Output. Thekidneylosesmassaftertheageof50years. Thisl0ssinvolvesentirenephronunitsandisaccom﹣ paniedbyagradualdeclineintheglomerularfiltration rateandrenalbloodflow.Levelsofserumcreatihine usuallyremainwithinnormallimits,presumably becauseofareductionincreatinineproductionby muscles·Theagedkidneyislessabletoresorbsodium andexcretepotassiumorhydrogenions.Themaxi﹣ mumconcentratingabili叮ofthekidneyofanindividualbetween80and90yearsoldisonly850mOsm／ kg,whichis70℅oftheabilityofa30﹣year﹣oldindi﹣ vidual,skidney.Adecreaseintheproductionof）and responsivenessofthekidneyto,ren1nandangiotensin occurswithage.Asaresult’creatinineclearanceinthe elderlyisreduced,andtheagedkidn叮ismoresus﹣ ceptibletoinjuryfTomhypov0lemia》medications,and othernephrotoxins.

CIRCULATION277

EVAlUAT∣0ⅡAⅡDMAⅡAGEIViEM Acommonpitf白IIintheevaluationofge『iat『ict『auma patientsisthemistakenimp『essionthat‘‘no『maI,）blood p『essu『eandhea『t『ateindicateho『movolemia·Ea『ly monito『ingo「theca『diovascuIa『systemmustbe﹟nstitut﹣ ed.Bloodpressuregenerallyincreaseswithage.Thus, asystolicbloodpressureof120mmHgcanrepresent hypotensioninanelderlypatientwhosepreinjury systolicbloodpressurewas170mmHgEarlystagesof shockcanbemaskedbytheabsenceofearlytaChycar﹣ dia.Theonsetofhypotensionalsomaybedelayed.In addition,thechromchighafterloadstateinducedby elevatedperipheralvascularresistancecanlimitcar﹣ diacoutputandultimatelycerebral,renal,coronary’ andperipheralperfhsion. Geriatricpatientshaveahmitedphysiologic reserveandmayhavedifficul叮generatinganadeqUate responsetoinjury.Severelyinjuredelderlypatients withhyp0tensionandmetabohcacidosisfrequently die,especiallyiftheyhavesustainedbraininjmy.Fluid requirements－oncecorrectedfbrthelesser,leanbody mass－aresimilartothoseofyoungerpatients·EIde『Iy patientswithhype『tensiohwhoa『eoⅡch『ohicdiu『etic the『apymayhaveach『onicaIlycont『actedvascuIa『voI. umeandase『umpotassiumde而cit;the『e化『eca『efi』I monito『ingo「tlTeadminist『ationo「c『ystaIIoidsolutions isimpoItanttop『eventeIect『oIytediso『de『s. Geriatricpatientsshouldberesuscitatedinaman﹣ nersimil㎡toyoungerpatients.However,theymay bemoresensitivetovolumeoverloadduetoahigher incidenceofcardiacdisease.SeeChapter3:Shock. Theoptimalhemoglobinlevelfbrani叮uredelderly patientisapointofcontroversy.Manyauthorssuggest that,inpeopleovertheageof65years,hemogl0bin concentrationsofover10g／dLshouldbemaintained tomaximizeoXygen﹣carryingcapacityanddelivery. Thereislittlesupportintheliteraturefbrthisp0sition. 『hdiscriminatebloodtransfhsionshouldbeavoided becauseoftheattendantriskofbloodborneinfbctions, impairmentoftheimmunehostresponseandresult﹣ ingcomplications,andtheef【bctofahighhemat0crit onbloodviscosi叮’whichcanadverselyaffbctmyocar﹣ dialfUnction.TheiⅡdication化『bloodt『ansfi』sionshouId bethesameasinyouhge『patients.Ea『Iy『ecognitiohand ∞『『ectionofcoaguIationdefbctsisc『uciaI,ihcIudihg 『eve『saIo「d『ug·inducedanticoaguIation. Becauseelderlypatientsmayhavesignificant limitationincardiacreserve》arapidandcomplete assessmentfbrallsourcesofbloodlossisnecessary. Thefbcusedassessmentsonographymtrauma（FAST） examinationisarapidmeansofdetermimngthepresenceofabnormalintraabdominalandpericardial fluidcollections·Nonoperativemanagementofblunt abdominalsolidviscusiIUuriesinelderlypatients mustbedonebyanexperiencedsurgeon.The『isl《of

Ⅱonope『ativemaⅡagementmaybeg『eate『thanthe『isI《 ofahea『Iyope『ation. Theretroperitoneumisanoften﹣unrecognized sourceofbloodloss·Exsanguinatingretroperitoneal hemorrhagemaydevelopmelderlypatientsafterrel﹣ ativelymmorpelvicorhiphactures·Apatientwith pelvic,hip,orlumbarvertebralfractureswhodem0nstratescontinuingbloodlosswithoutaspecificsource shouldbeconsideredfbrpr0mptangiographyandcon﹣ trolwithtranscatheterembolization. Theprocessofagmgandsuperimposeddisease statesmakeclosemomtoringmandato1y,especially incasesofinjurywithacuteintravascularvolumel0ss andshock.ThemortalityrateinpatientsWhoonini﹣ tialassessmentappeartobeuni叮uredortohaveonly minorinjuriescanbesignificant（upto44﹪）.Approxi﹣ mately33℅ofelderlypatientsdonotdiefromdirect consequencesoftheirmjury’buthom‘‘inexplicable,, sequentialorganfailure,Whichmayreflectearly, unsuspectedstatesofhypoperfhsion.Failuretorec0g﹣ mzeinadequateo叮gendeliverycreatesanoXygendelk icitfTomwhichthegeriatricpatientmaynotbeable torecover.Becauseofassociatedcoronaryarterydis﹣ ease’hypotensionandhypovolemiafrequentlyresults inimpairedcardiacperfbrmancefrommyocardial ischemia.Thus,hypovolemicandcardiogemcshock maycoexist.Earlyinvasivemonitoringwithapulmo﹣ na】yarterycathetermaybebeneficial.Hemodynamic resuscitationmayrequiretheuseofinotropesafter volumerestorationinthesepatients.Prompttransfbr toatraumacentermaybelifbsaving·

PITFAⅡⅡ』S ■Equatingno「maIbIoodp「essu『ewithno『movo﹣ Iemia. ■FaiIu「eto『ecognizemetaboIicacid0sisa5ap『edicto「 ofmo「tality· ■FaiIu『etoinstituteea『lyhemodynamicmonito『ing. ■FaiIu「eto『ecognizethee什ect5ofindisc「iminate bloodt「ansfuSion.

Disabi∣ty ity:B『ainaⅡdSpinaI Co『dn I】u『 『 y CⅡAⅡGESWITⅡAGlNG Brainmassdecreasesapproximately10℅by70years ofage.Thisloss1sreplacedbycerebrospinalfluid. Concomitantly,thedurabecomestightlyadherentto theskuⅡ.Althoughtheincreasedspacecreatedaround

278CHAPTER11■Ge『iat「icT「auma thebrainmayservetoprotectitfromcontusion’italso causesstretchingoftheparasagittalbridgingve1ns, makingthemmorepronetoshearimu叮.Thislossof brainvolumealsoallowsfbrmorebr月inmovementin responsetoangularaccelerationanddeceleration.Sig mficantamountsofbloodcancoⅡectaroundthebmin lnthesubduralspaceofanelderlymdividualbefbre overtSymptomsbecomeapparent. Cerebralbloodflowisreducedby20℅bytheageof 70years.Thisisfhrtherreducedifatheroscleroticdis﹣ easeoccludescerebralarteries.Peripheralconduction velocityslowsasaresultofdemyehnization.Reduced acquisitionorretentionofinfbrmationcancause clinicallysubtlechangesinmentalstatus.Ⅵsualand audito】yacuitydeclines’vibratoryandpositi0nsensa﹣ tionisimpaired’andreactiontimeincreases.Inaddi﹣ tiontocomplicatingtheevaluationprocessofinjured elderlypatients,thesechangesplacetheindividualat greaterriskfbrinjury.Finally,preexistingmedical conditionsortheirtreatmentmaycauseconfhsionin theelderly. Inthespine,themostdramaticchangesoccurin theintervertebraldisks.Lossofwaterandprotein affbcttheshapeandcompressibili叮ofthedisks.These changesshifttheloadsonthevertebralcolumntothe fhcets,ligaments’andparaspinalmusclesandcontrib﹣ utet0degenerationofthefhcetjointsanddevelopment ofspinalstenosis。Thesealterationsplacethespine andspinalcordatincreasedriskfbriUjuryingeriatric patients·Thisriskisincreasedinthepresenceofoste﹣ opor0sis》whetherornotitisapparentradiographi﹣ cally.Finally’osteoarthritismaycausecanalstenosis andsegmentalimmobility,makingcordiIUurymore likely（■FIGuRE11﹣3）·

EVA山AT∣0ⅡAⅡDMAⅡAGEMEM Elderlypatientswithbrainmjuryhavefbwersevere cerebralcontusi0nsthandoyoungerpatients·How﹣ ever,theelderlyhaveahigherincidenceofsubdural andintraparenchymalhematomas.SUbduralhemato﹣ masarenearlythreetimesashPequentmtheelderly, inpartbecauseelderlyindividualsaremorehkelyto betakinganticoagulantmedicationsfbrcardiacorcer﹣ ebrovasculardisease.Rapidsc『eenihg允『anticoagulaⅡt useandsubsequentco『『ectionwithbIoodcompo刷eht the『apymayimp『oveoutcomes·Subdura1hematoma mayproduceagradualonsetofneurologicdecline’es﹣ pecial】yinelderlypatients.Chromcsubduralhematomaresultingfromanearlierfhllmaybethecauseofa subsequentfhllthatleadstoadmissiontothetrauma bay·Acomputedtomography（CT）scanofthehead providesrapid’accurate,anddetailedinfbrmationon structuraldamagetothebrain,skuⅡ,andsupporting elements.Liberaluseofthisimagingtechnologyis

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appropriateinelderlypatientswithbraininjury.See Chapter6:HeadTrauma

Cervicalspineinjuriesappeartobemorecom﹣ moninelderlypatients,althoughtheymaybeoccult anddifficulttodiagnoseifosteoporosisandosteoar﹣ thritisarepresent.Severeosteophyticdiseasemakes thediagnosisofcervicalfracturechallenging.Degen﹣ erationofintervertebralligamentscanincreasethe degreeofsubluxationthatisphysiologic.Preexisting spinalcanalstenosisduetoanterioroste0phytesand posteriorligamentoushypertrophyincreasestherisk fbrcentralandanteriorcordSyndromes.Theseinju﹣ riesoftenresultfT0mrelativelymildextensioni叮uries afterfhllsorrear﹣endmotorvehiclecrashes.Magnetic resonancennaging（MRI）isparticularlyuseh1lfbr diagnosmgligamentousinjuries.SeeChapter7:Spine andSpmal C o r d T r a u m a

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Theskinandconnectivetissuesofelderlyindividuals undergoextensivechanges’includingadecreaseincell numbers,lossofstrength,andimpairedfUnction.The epidermalkeratinoCytesloseasignificantproportion oftheirprolifbrativeabilitywithaging.Thedermis losesasmuchas20℅ofitsthickness’undergoesasig﹣

0THERSYSTEMSZ79

mficant.lossofvasculari叮’andhasamarkeddecrease inthenumberofmastceⅡs.Thesechahges『esultinthe losso「the『maI『eguIato『yabiIity,dec『easedba『『ie『fimc﹣ tionagaiⅡstbacte『ialinvasioh’andsigni伺cahtimpai『. mento「woundheaIing. Injuredelderlypatientsmustbeprotectedfrom hypothermia.Hypothe『mianotatt『ibutabIetoshocko『 exposu『eshouIdale『ttheplTysiciantothepossibiIityof occultdisease-iⅡpa『ticula『,sepsis’endoc『ihedisease, o『pha『maco∣ogiccauses. Thepotentialfbrinvasivebacterialinfbction throughinjuredskinmustberecognized.Appropriate care’includingassessmgtetanusimmumzationstatus’ topreventinfbction’mustbeinstitutedearly.SeeⅢet﹣ anusImmunization（electronicversion0nly）.

SceⅡa『io■∞nt『huedThepatientistaking wa『fa『inandabetab∣0〔ke『f0『hype『tensi0n·His chest『adi0g『aphsh0w5muItipIe『ibf『adu『es!and hishead〔T5h0w5a5ubdu『aIhemat0mawitha ｛ewsmalIint『ace『eb『aIc0ntusi0ns‘ －

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levelofgrowthhormones.Aitertheageof25years’ musclemassdecreasesby4℅eve】y10years.Afterthe ageof50years’therateis10﹪perdecadeunlessthe levelsofgrowthfactorsarelow,mwhichcasetherate ofdecreaseapproaches35℅.Thisismanifbstedbya reductioninthesizeandtotalnumberofm】】sclecells. Thedecreaseinmusclemassisdirectlycorrelatedto thedecreaseinstrengthseenwiththeagmgprocess. Osteoporosisresultsmadecreaseofhistologic normalbonewithaconsequentlossofstrengthand resistanceto丘actures.Thisdisorderisendemicinthe elderlypopulation,affbctmgahnost50﹪oftheseindi﹣ viduals。Thecausesofosteoporosisincludedecreaseof estrogen’lossofbodymass,decreasinglevelsofphysicalactivity’andinadequateintakeandutilizationof dietarycalcium. TheconsequencesoftheseChangesonthemus﹣ culoskeletalsystemarefrequentlydisablingandat timesdevastating.I叮uriestoligamentsandtendons af｛bctjointsandadjacentsofttissues.Osteoporosis contributest0theoccurrenceofspontaneousvertebral compressionfTacturesandthehighincidenceofhip fracturesintheelderly.Theyea1lyincidenceofthese fracturesapproaches1℅fbrmenand2℅允rwomen overtheageof85years.TheeasewithwhichfiPactures occurintheelderlypatientmagniHestheeffbctof fbrceappliedduringinjmy. Elderlyindividualsareparticularlysusceptibleto hacturesofthelongbones’withattendantdisabili叮 andassociatedpulmonarymorbidityandmortali｛V. Earlystabilizati0nofhacturesmaydecreasethisrisk. Resuscitationshouldbetargetedatnormalizingtissue

∣

Othersystemsthatwarrantspecialattentionwithre· gardtothetreatmentofelderlytraumapatientsin﹣ cludethemusculoskeletalsystem’nutritionalstatus, alteredmetabohsm,andtheimmunesystem.

MUSCUl0SKElETA1SγSTEM DisordersofthemusculoskeletalsystemarefTequent﹣ lythecauseofpresentingSympt0msinthemiddle﹣ agedandgeriatricpopulation.Thesedisorderscause restrictionsindailyactivitiesandarekeycomponents inthelossofindependence.Agingresultsinstiffbn﹣ ingofligaments’cartⅡage’intervertebraldisks’and jointcapsules.Deteriorationoftendons’ligaments, andjointcapsulesleadstoanmcreasedriskofmjury’ sp0ntaneousrupture’anddecreasedjointstabihty. Theriskofinjuryincreasesnotonlyfbrthemuscu﹣ loskeletalSystem’butalsofbrtheadjacentsofttissues. AgingcausesadeclineinresponsⅣenesstomany 月haboⅡchorm0nesHndanabsolutereducti0ninthe

perh1sionasearlyaspossibleandbefbrehacturefixa﹣ tionisperfbrmed. Themostcommonlocationso「仃actu『esiⅡelde『Iy patientsa『ethe『ibs,p『oximaI佗mu『’hip,hume『us,and w『ist·IsolatedhipfracturesdonotusuaⅡycauseclassIII orⅣshock·Neurovascularintegri叮shouldbeassessed andcomparedwiththatoftheoppositeextremi叮. FracturesofthehumerususuaⅡyarecaused byfhllsonanoutstretchedextremi叮.Theresulting injmyisafractureofthesurgicalneckofthehumerus· Usual】y,thereispamandtendernessintheshoulder orupperhumerusarea. Ofma】orimportanceintheevaluationofthese patientsisthedeterminationofwhetherthe仕actureis impactedornommpacted·I〉γLpαc花d斤ααM祀sdemon﹣ stratenofhlsemotionofthehumeruswhentheshoul﹣ derisrotatedgentlyfTomafIexedelbow.Patientswith 〃o㎡mpαcted加c虹疋sgeneraⅡye迦eriencepainon movementofthearm.Theselatterfiyacturesrequire hospitalizationfbrorthopedicconsultationandoften operation. CoⅡes’fractureresultsfTomafhIIontheout﹣ stretched,dorsiflexedhand,causingametaphyseal

Z80CHAPTER11■Ge『iat「icT『auma

仕actureofthedistalradius.Theclassicfindingofa fractureatthebaseoftheulnars叮loidprocessoccurs in69℅ofcases.Evaluationshouldmcludecareh】】 testingofthemediannerveandmotorfhnctionofthe fingerflexors·Thewristshouldbeexaminedradiographically’andallofthecarpalbonesshouldbevisu﹣ alizedtoexcludeamorecomplexiUjury. Theaimo「t『eatment｛b『musculoskeletalin】u『ies shouIdbetounde『taketheleastinvasive,mostde而nitive p『ocedu『ethatwi∣lpe『mitea『Iymobilization·Prolonged inactivi叮anddiseaseoftenhmittheultimatehmc﹣ tionaloutcomeandimpactsurvival.

■ SceⅡa『io■con㎡nuedThepatientisgiven f『e5h｛『0zenpIasmat0『eve「5etheantic0agu∣ant e什ects0↑wa『fa『inandadmittedt0theintensive 〔a『eunitf0『puIm0na『yca『eandm0nit0『ing.Ⅱi5 paini5c0nt『0∣Iedwithna『c0tic5and!0ncehis c0agu∣ati0nstatu5isn0『maI!anepidu『aIcathete『 5 i p∣aced. L

ⅡUTRITI0ⅡAⅡDMETAB0USⅢ Caloricneedsdeclinewithage,asleanbodymassand metabolicrategraduallydecrease.Pr0teinrequire﹣ mentsactuaⅡymayincreaseasaresultofinefficient utilization.ThereisawidespreadoccuITenceofchroni﹣ callyinadequatenutritionamongtheelderly,andpoor nutritionalstatuscontributestoanincreasedcom﹣ plicationrate·Ea『Iyahdadequatenut『itionaIsuppoIt o「iniu『edeIde『lypatientsisaco『ne『stoneo「successfUl t『aumaca『e。

∣ ﹥ Specia∣Ci『cumstances

∣

?腳:勰鰓;辮繃緇:辮 Specialcircumstancesthatrequireconsiderationin thetreatmentofelderlytraumapatientsincludemedi﹣ cations’eldermaltreatment’andend﹣ofklifbdecisions.

MEDICATI0NS ∣MⅢ0ⅡESγSTEMAⅡDIⅡ『ECTI0Ⅱ5 Mortali叮hommostdiseasesincreaseswithage.The lossofcompetenceoftheimmunesystemwithagecer﹣ tainlyplaysarole.Thymictissueislessthan15℅of itsmaximumby50yearsofage.Liverandspleensize alsodecrease.CeⅡ﹣mediatedandh1】m0ralimmunere﹣ sponsetofbreignantigensisdecreased’whereasthe responsetoautologousantigensisincreased.Itisnot clearwhetheragmgaltersgranulocytehmction’but chronicdiseasesoftheelderly,suchasdiabetesmeⅡi﹣ tus’maydoso.Asaconsequence,elderlypatientshave animpairedabilitytorespondtobacteriaandviruses, areducedabilitytorespondtovaccination,andalack ofreliableresponsetoskinantigentesting.Elderlyin﹣ dividualsarelessabletotoleratein佗ctionandmore pronetomultipleorganSystemfhilure·Theabsence offbver,leukoCytosis,andothermanifbstations0fthe ihflammatoryresponsemaybeduetopoorimmune fhnction.

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■Failu「eto「ecognizethatminimaIt『aumamay『esult inf『actu『esandse「iouSdi5abiIiⅣ· ■Poo「hemodynamic『ese『vecombinedwithunde『﹣ estimationofbIoodIos5f「omf「actu『esmaybe IethaI.

Concomitantdiseasefrequentlymandatestheuseof medications,andelderlypatientsareoftentakingsev﹣ eralpharmacologicagentsevenbefbreaninjuryoccurs’ D『uginte『actiohsa『e什equent∣yencounte『ed》andsidee雁 佗ctsa『emuchmo『ecommoⅡbecauseo「thena『『owthe『. apeutic『angeinthee!de『∣y·Adversereactionstosome medicationsmayevencontributetotheinju】y﹄producmgevent·侶.ad『ene『gicblocl《ingagentsmaylimitch『ono· t『opicactMty’andcalcium﹦channelb∣oc∣《e『smayp『event pe『iphe『aIvasoconst『ictionandcont『ibutetolWpotension。 Nonsteroidalantiinflammato1yagentsmaycontribute tobloodlossbecauseoftheiradverseeffbctsonplatelet h1nction·Steroidsandotherdrugsmayfhrtherreduce theinⅡ月mmato叮andimmuneresp0nse.Long﹄terman﹣ ticoagulantusemaymcreasebloodlossandincreases theincidenceoflethalbrainiIljury.Long﹄termdiuretic usemayrenderelder】ypatientschromcaⅡyhypovo﹣ lemicandleadtototalbodydeficitsofpotassiumand sodium.Hypoglycemicagentsmaycontributetodiffi﹣ cul叮mcontrolofserumgluc0se.psychot『opicmedica· tiohs,commonIyp『esc『ibedfb『eIde『lypatients,maymasl《 iniu『ieso『becomep『obIematici「discontinuedab『uptly. ChangesincentralnervousSystem（CNS）hmction resultingfr0mtheuseofthesemedicationsalsomay contributetotheimu叮.Elder】yindividualsfrequently neglecttomaintaintetanusimmunization. Painreliefingeriatrictraumapatientsshouldnot beneglecteda此erresuscitation.Narcoticsaresafband eifbctiveandshouldbegiven1nsmall,titratedintra﹣

SPECIALCIRCUMSTANCESZ81

■Abrasionstotheaxillaryarea（fromrestraints） orthewristandankles（fromhgatures）

venousdoses.Antiemeticagentsshouldbegivenwith cautiontoavoidextrapyramidaleffbcts‘Potentially nephrotoxicdrugs（e.g.,antibioticsandradiographic dyes）mustbegivenindosesthatrefIecttheelderly

■Nasalbridgeandtempleinjmy（eyeglasses） ■Periorbitalecchymoses

patient’sdecreasedrenalfhnction,contractedintra﹣ vascularvolume,andcomorbidconditions.

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■Unusualalopeciapattern ■Untreatedpressureulcersorulcersinnon﹣ lumbar／sacralareas ■Untreatedfractures ■Fracturesnotinvolvingthehip》humerus,or vertebra ■Injuriesinvariousstagesofevolution ■Injuriestotheeyesornose

FIDERMALTREATMENT Whenevaluatinganinjuredelderlypatient,consider thatthei叮urymayhavebeeninflictedintention﹣ ally·Maltreatmentoftheelderlymaybeascommon aschildInHItreatment.Maltreatmentisdehnedas anywillh1linⅡictionofinjury’unreasonableconiine﹣ ment’inthnidation’orcruelpunishmentthatresults inphysicalharm,pam’mentalanguish,orotherwill﹣ fhldeprivationbyacaretakerofgoodsorserv1cesthat arenecessarytoavoidphysicalharm,menta1anguish’ OrmentaliⅡTleSS. F｝】dermHltreatm色ntcanbeclassifiedintosix categories: 1.Physicalmaltreatment Z’Sem】almaItreatment

■Contactbu丫nSands∞MS ■Scalphemorrhageorhematoma Thep『eseⅡceo「these伽dingsshouIdp『ompta detaiIedhisto『ythatmaybeatva『iancewiththeplWsicaI nndiⅡgsandmayuhcove『ahihtentionaIdelayint『eat. ment·These伺ndingsshouIdp『ompt『epo『tingtoapp『op『i. ateautho『itiesahdfU『the『investigation·l「malt『eatment issuspectedo『con伺『med,app『op『iateactionshouldbe tal《eh,inc∣uding『emovaloftlTeeIde『Iypatient抒omthe abusivesituation·AccordingtotheNationalCenter0n ElderAbuse,morethan1m10olderadultsmayexperi﹣ encesometypeofmaltreatment,butonly1in5casesor fbwerarereported.Thisstatisticholdstrueeventhough eve】ystateinUnitedStatesmandatesreportingofelder maltreatment.Amultidisciphna】yapproachisrequired

3·Neglect 4PSychologicalmaltreatment 5’Financialandmateriale翔loitation 6’Ⅵolation0frights Often,several叮pesofmaltreatmentoccursimul﹣ taneously.Multifacetedincause’eldermaltreatment oftenisnotrecognizedandisunderreportedMany casesofmaltreatedelderlypersonsinvolveonlysub﹣ tlesigns（eg.,poorhygieneanddehydration）andhave greatpotentialtogoundetected·Physicalmaltreat﹣ mentoccursinupto14℅ofgeriatrictraumaadmis﹣ sions》resultinginahighermortalitythaninyounger patients. Physicalfindingssuggestingeldermaltreatment include: ■Contusi0nsaffbctingtheinnerarms,inner thighs,palms,soles,scalp,ear（pinna）,mastoid area’buttocks’ormultipleandclustered contusions

END﹣0「﹣【I『EDEαSI0ⅡS Manygeriatricpatientsreturntotheirprei叼mylevel offhnctionandindependenceafterrecoveringfTom injuIy.Agesigni同cantIyinc『easesmo『taIity什ominiu『yl butmo『eagg『essiveca『e,especiaIlyea『Iyintheevalua. tionahd『esuscitationo「eIde『Iyt『aumapatients,hasbeen showntoimp『ovesuⅣivaI。Attemptstoidentifywhich elderlytraumapatientsareatgreatestriskbrmortal﹣ ityhavefbundlittleutilityinchnicalpractice. 0ertainlytherearecircumstancesinwhichthe doctorandpatient,orfhmilymember（s）,maychoose towithdrawlifb﹃sustainingtreatmentandprovidepal﹣ liativecare.Thisdecisionisparticularlyclearinthe caseofelderlypatientswhohavesustainedextensive burnsorseverebraininjmyorWhensurvivalfTom themjur1essustainedisunlikely.Thet『aumateam shouIdt『ytodete『minethepatieht,swishesasevideⅡced byaIivingwiIl’advancedi『ective,o『simiIa『document. Althoughnoabsoluteguidelinescanbegiven’thefbl﹣ lowingobservationsmaybehelpfhl:

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itismthepatient,sbestinterests. ■Medica1therapyisappropriateonlywhen itslikelybenefitsoutweighitsadverse consequences. ■Theethicalissueofappropriatenessofcare inanenvironmentofdeclininghospital resourcesandrestrictionsonfinancesismore challenging.

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ChapterSu皿1ary 皿ThenumberofelderlypersonsisincreasingglobaⅡy.A」thoughtheelderlyare lesslikelytobei1叮uredthanyoungerpeople,themortali叮ratefbrthegeriatric populationishigher.Manygeriatrictraumapatientscanbereturnedtotheir prei叼urymedicalstatusandindependence·KnowledgeoftheChangesthatoc﹣ curwithaging,anappreciationoftheiIUu1ypatternsseenmtheelderly’andan understandingoftheneedfbraggressiveresuscitationandmomtormgofi叼ured geriatricpatientsarenecessaryfbrimprovedoutcome. 回Anatomicandphysiologicchangesmtheelderlyareassociatedwithmcreased morbidityandmortali叮fbⅡowingtrauma.Comorbidi句γmcreaseswiljhage.Fre﹣ qUentuseofmedicationsincludingbetablockersandanticoagulantscomplicate assessmentandmanagement. 固TreatmentofthegeriatrictraumapatientfbⅡowsthesamepatternasthatfbr youngerpatients,butcautionandahighindexofsuspicionfbriI叮uriesspecificto thisagegr0uparereqUiredfbroptimaltreatment.Comorbiditiesandmedications maynotonlycause,butalsocomplicate坷uriesintheeldeny.Careh1lvolume resuscitationwithclosehemodynamicmonitoringshouldguidetreatment. 囚Increasedawarenessofeldermaltreatment,includingthepatternsofinjuly’is necessarysothatreportingcanbeimproved.Thisshouldleadtoearlierdiagnosis andimprovedtreatmentofelderlyi叮uredpatients· －

嘯 . 」 ■

BlBU0GRAPHYZ83

20.LachsMS,PⅢemerK.Abuseandneglectofelderlyper﹣ sons·ⅣE／Jg／JM它d1995;332:437﹣443· 1.AlexanderBH’RivaraFP）WolfME.ThecostandfTe﹣ quenCyofhospitalizationfbrfhll﹣relatedinjuriesinolder adults.AmJPαb』tcHbα〃／』1992;82:1020﹣1023.

21.LotfipourS’KakuSK’VacaFE’etal·Factorsassociated withcomplicationsinolderpatientswithisolatedblunt chesttrauma.Wbste／Eme唔Mbd2009;10:79﹣84·

2.BergeronE’LavoieA,ClasD,etal.Elderlytrauma patientswithribfracturesareatgreaterriskofdeath andpneumoma.J乃α【《mα2003;54:478﹣485.

22MackenzieEJ,MorrisJA,EdelstemSL·Effbctofpre﹣ existmgdiseaseonlengthofstayintraumapatients.J T／·αMmα1989;29:757﹣764·

3.BouchardJA’BareiD,CayerD’etal·Outcomeof fbmoralshaitfracturesintheelderly.α加O／、仇Op 1996;332:105﹣109·

23MacKenzieEJ,RivaraFP,JUrkovichGJ,etal·Anational evaluationoftheeffbctoftrauma﹣centercareonmortality· NE〃gMM它d2006;354（4）:366﹣78.

4.BulgerEM’JurkovichGJ,FarverCL,etal.Oxandrolone dosenotimproveoutcome｛brchromcallyventilatedsur﹣ gicalpatients.AmzSM｝g2004;240（3）:472-8.

24.MantonDKVaupelJW.Survivalaftertheageof80in theUmtedStates’Sweden,France,England’andJapan. NE〃g』JM它d1995;333:1232﹣1235.

5.CoIIinsKM.Eldermaltreatment－areview.A／、c／jR】t〃o／ Lαb2006;130:1290﹣1296‘

25.McGwinGJr.,MacLennanPA,FifbJB,etal.Preexisting conditionsandmortalityinoldertraumapatients·c／ TrαMmα2004;56:1291﹣1296

6.CoⅡinsKA,BennettAT,HanzhckR.Elderabuseand neglect.A｝℃／jI〉E花】勺J乙Mbd2000;160;1567﹣1568. 7.CorwinHL’GettmgerA’PearlRG,etal.TheCRIT study:anemiaandbloodtransfhsionmthecriticallyiⅡ－ currentchnicalpracticeintheUnitedStates.CJ㎡Cα沱 M它d2004;32:39. 8.CouncilReport.Decisionsneartheendoflifb.cIAMA 1992;267:2229﹄2233. 9.DeGoedeKM’Ashton﹣MiⅡerJA’SchultzAB.F皿﹣related upperbodymjuriesmtheolderadult:areviewofthe biochemicalissues·JB㎡o加ec〃2003;36:1043-1053 10.DeLaetCE,PolsHA·Fracturesintheelderly:epide﹣ miologyanddemography.Bαt／』fe｝它sBestRncfResα加 E〃docr加o／Mbmb2004;14:171﹣179. 11DemetriadesD,SavaJ’AloK,eta1.Oldageasacriterion fbrtraumateamactivation.J乃ααmα2001;51:754﹣756. 12.GillespieLD’RobertsonMC’GⅢespieWJ,eta1Inter﹣ ventionsibrpreventinglhllsinolderpeoplelivinginthe commumty.EuidBαsedM它d2009;14:176· 13.GublerKD,MaierRV,DavisR,etal.Traumarecidivism intheelderly.J乃α叨mα1996;41（6）952﹣956. 14.HebertPC,WeⅡsG’BlajchmanMA’etal.Amulticen﹣ ter’randomized,controlledclinicaltrialoftransfhsion requirementsincriticalcare.NEHg／JMbd1999;340:409.

26.McKevittEC,CalvertE’NgA,etal.Geriatrictrauma: resourceuseandpatientoutcomes.釦〃JSmg 2003;JUn;46（3）:211﹣215. 27.McKinleyBA,MarvinRG,CocanourCS,etal·Blunt traumaresuscitation;theoldcanrespond·AJ℃hS叨『g 2000;135（6）:688﹣693,discussion694﹣695. 28.McMahonDJ,SchwabCW,KauderDR.Comorbi﹣ dityandtheelderlytraumapatient.Wb了／dJSu唔 1996;20:1113﹣1119 29.MilzmanDP’BoulangerBR’RodriguezA,etal.Pre﹣ existingdiseaseintraumapatients:apredictoroffhte independentofageandinjmyseverityscore·JⅡ】Jmz加α 1992;31:236﹣244. 30.MinaAA,BairHA,HoweⅡsGA’etal.Comphcationsof preinjurywar炮rinusemthetraumapatient.JZ】mα〃』α 2003;54:842﹣847 31MorrisJA’MackenzieEJ,EdelsteinSL:Theeffbctof pre﹣existingconditionsonmortali叮intraumapatients. eIAMA1990:263:1942﹣1946. 32.MosenthalAC,LivingstonDH,LaveⅣRF,etal.TheeHbct ofageonhmctionaloutcomeinmildtraumaticbrain iUjury:6﹣monthreportofaprospectivemulticentertrial. J刃uαmα2004;56:1042﹣1048.

15’HebertPC）YetisirE’MartinC,etal.Isalowtransh1sion thresholdsafbincriticallyillpatientswithcaIdiovascu. lardiseases?Cr肱“『它Mbd2001;29:227.

33.NationalCenteronElderAbuse.WhyShouldICare AboutElderAbuse?http:〃Www.ncea·aoa·gov／ncear00t／ Main－Site／pdf／publication／NCEAWhatIsAbuse﹣2010. pd咀AccessedMarch,2010.

16.HoranMA,ClagueJE.Injmyintheaging:recoveryand rehabilitation.BγMbdBM〃1999;55:895氧909

34·0slerT,HalesK,BaackB,etal·Traumaintheelderly· Amc／SM唔1988;156:537﹣543.

17.IvascuFA,HoweⅡsGA’JtlnnFS,BairHA’BendickPJ, JanczykRJ·Predictorsofmortali｛yintraumapatients withintracranialhemorrhageonpreinjuryaspirinorclo﹣

35.Ott0chianM,SalimA’DuB0seJ,TeixeiraPG,etal.Does agematter?Therelationshipbetweenageandmortality inpenetratingtrauma.DVα／y2009;40:354﹣357.

pidogrel.J乃αMmα2008Oct;65（4）:785.8. 18.KarmakarMK,HoAM﹣HAcutepa1nmanagement ofpatientswithmultiplefTacturedribs·J刃.αα）施α 2003;54:615﹣625· 19KoepsellTD’WolfME’McClosk叮L’etal.Medicalcon﹣ ditionsandmotorvehiclecollisionsinolderadults.JA加 Ge㎡αr／.Soc1994;42:695﹣700.

36.PenningsJL’BachulisBL,SimonsCT,etal·Survi﹣ valafterseverebraininju】yintheaged.A）℃／iSα／g 1993;128:787﹣794. 37.PhillipsS’RondPC,KellySM’etal.Thefnilureoftri﹣ agecriteriatoidentiiygeriatricpatientswithtrauma! resultsfTomtheFloridatraumatriagestudy.J乃ααmα 1996;40:278﹣283.

Z84CHAPTER11■Ge『iat「icT「auma 38.ScaleaTM,SimonHM’DuncanAO’etal.Geriatricblunt multipletrauma:improvedsurvivalwithearlymvasive monitoring.cJmmαmα1990;30:129﹣134. 39.SchwabCW,KauderDR.Tmumainthegeriatricpatient. A加﹠Sα唔1992;127:701﹣706. 40·ShabotMM’JohnsonCL.Outcomefi·omcritical careinthe‘‘oldestold”traumapatients.J乃ααmα 1995;39:254﹣259. 41.TimberlakeGA.Elderabuse.In:KaufinanHH,edThe P叼s㎡αα〃慈R『qSpec戊ueo兄Medfcα』Lα卹.ParkRidge,IL: AmericanAssociationofNeurologicalSurgeons;1997.

42.UtomoWK,GabbeBJ’SimpsonPM’CameronPA.Pre﹣ dictorsofm﹣hospitaland6﹣monthfhnctionaloutcomes inolderpatientsaftermoderatetoseveretraumatic brainmjuIy.hVα刁2009;40:973﹣977. 43‘vanderSluisCK,KlasenHJ’EismaWH’etal.Major t r a um a i n y oun g a n d ol d :wh a t i s t h e d i f f b r e n c e ? c ／ 乃αα加α1996;40:78﹣82. 44.WardleTD.Co.morbidfhctorsintraumapatients.Br MedB叨〃1999;55:744﹣756. 45.ZietlowSP,CapizziPJ’BannonMP,etal.Multi盯stem geriatrictrauma.J?】mαmα1994;37:985﹣988.

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instructureandfUnctioncaninhuencetheevaluation ofinjuredpregnantpatientsbyalteringthesigns andsymptomsofinjury,theapproachandresponses toresuscitation,andtheresultsofdiagnostictests. PregnanCyalsocanaffectthepatternsandseverity ofinjury. Clinicianswhotreatpregnanttraumapatients mustrememberthattherearetwopatients:mother andfbtus‘Nevertheless,initialtreatmentprioritiesfbr aninjuredpregnantpatientremainthesameasfbr thenonpregnantpatient.ThebestiⅡitiaIt『eatmentfb『 the佗tusisthep『ovisionofoptimal『esuscitationo「the mothe『·Monitoringandevaluationtechniquesshould allowfbrassessmentofthemotherandthefbtus·If x﹣rayexaminationisindicatedduringcriticalmanage﹣ ment’itshouldnotbewithheldbecauseofthepreg﹄ nanCy.AquaIi伺edsu『geonandanobstet『icianshouId beconsuItedea『IyiⅡtlTeevaluatiohofp『egnantt『auma patieⅡts.

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叨 W／α tc f〃α腮geo scc“妒刎㎡〃 ●py?egy﹩α兀cyβ Anunderstandingoftheanatomicandphysiological﹣ terationsofpregnancy,aswellasofthephysiologicre﹣ lationshipbetweenapregnantpatientandherfbtus’ isessentialtoservethebestinterestsofbothpatients. Suchalterationsincludediffbrencesinanatomy’blo0d volumeandcomposition’andhemodynamics,aswell aschangesintherespiratory,gastrointestinal,uri﹣ nary,musculoskeletal’andneurologicsystems·

AⅡAT0ⅢICD∣『「EREⅡCES Theuterusremamsanintrapelvicorganuntilapproxi﹣ matelythe12thweekofgestation,whenitbeginsto riseoutofthepelvis.By20weeks’theuterusisatthe umbⅢcus,andat34to36weeks,itreachesthec0s﹣ talmargm（■FlGuRE12-1）.Duringthelast2weeksof

■「∣GURE12﹣1ChangesinFundaI Heightinp『egnancybAstheute「u5 enIa『ges’theboweIi5pushed cephaIad’sothatitliesmostIyin theuppe『abd0men.Asa『esultJ theboweIi5somewhatp「otectedin bluntabdominalt『auma,whe「eas theute『usanditsc0ntents（fetu5 andpIacenta）becomemo『e vuIne『abIe.

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gestation’thehmdusfrequentlydescendsastheibtal headengagesthepelvis.Astheuterusenlarges,the bowelispushedcephalad’sothatthebowelⅡesmostly intheupperabdomen.Asaresult’thebowelissome﹣ whatprotectedinbluntabdominaltrauma’whereas theuterusanditscontents（fbtusandplacenta）be﹣ comemorevulnerable.However,penetratingtrauma totheupperabdomenduringlategestationmayresult incomplexintestinalinjurybecauseofthiscephalad displacement· Duringthefirsttrimester,theuterusisathiCk﹣ walledstructureoflimitedsize,confinedwithinthe bonypelvis.Duringthesecondtrimester’itenlarges beyonditsprotectedintrapelviclocation,butthe smallfbtusremamsmobⅡeandcushionedbyagen﹣ erousamountofamnioticfluid·Theamnioticfluid maycauseamnioticfluidembolismanddisseminated intravascularcoagulationfbllowingtraumaifthe fluidgainsaccesstothematemalintravascularspace. Bythethirdtrimester’theuterusislargeandthin﹣ walled.Inthevertexpresentation,thefbtalheadis usuallywithinthepelvis’withtheremainderofthe fbtusexposedabovethepelvicbrim（■FIGuRE12﹃z）.

ANAT0MICANDpHYSIOLOGICALTERATIONS0FPREGNANCYZ89

Pelvicfracture（s）inlategestationmayresultinskull fTactureorseriousmtracranialinjmytothefbtus. Unhketheelasticmyometrium’theplacentahaslittle elasticity.Thislackofplacentalelastictissueresults invulnerabilitytoshearfbrcesattheuteroplacental interface’whiChmayleadtoabruptioplacentae· Theplacentalvasculatureismaximallydilated throu助outgestation,yetitisexquisitelysensitive tocatecholaminestimulation.Anab『uptdec『easein matemaIint『avascula『voIumecan『esuItinap『ofbund inc『easeihute『inevascuIa『『esistaⅡce,『educihg佗taIoxy· genationdespite『easohablyⅡo『maImate『naIvitaIsigns.

31﹪to35﹪isnormal.Healthypregnantpatientscan lose1200to1500mLofbloodbefbreexhibitingsigns andSymptomsofhypovolemia.However,thisamount ofhemorrhagemaybereflectedbyfbtaldistressev1﹣ dencedbyanabnormalfbtalheartrate· Thewhite﹣blood﹣ceⅡ（WBC）countincreasesdur﹣ ingpregnanCy.ItisnotunusualtoseeWBCcounts of12’000／mm3duringpregnanCyorashighas25’000／ mm3duringlabor·Levelsofserumfibrinogenandother clottingfhctorsaremildlyelevated‘Prothrombinand partialthromboplastintimesmaybeshortened’but bleedingandclottingtimesareunchanged.Table12.1 outlinesnormallaboratoryvaluesduringpregnanCy.

Bl00DV0UjMEAⅡDC0Ⅲp0SlTI0Ⅱ PlasmavolumeincreasessteadⅡythroughoutpregnancyandplateausat34weeksofgestation.Asmaller increase1nred﹣blo0d﹣ceⅡ（RBC）volumeoccurs,resulting1nadecreasedhematocritlevel（physiologicanemia ofpregnan叮）.Inlatepregnancy,ahematocritlevelof

ⅡEM0DγⅡAMICS

Importanthemodynamicfact0rstoconsiderinpreg﹣ nanttraumapatientsincludecardiacoutput,heart rate,bloodpressure,venouspressure’andelectrocar﹣ diographicchanges

p【acenta

Wa【【of ute『uS

Umbi【ica【 co『d

sed） Fetus

U「inaIyb【ad

（comp「esed） X

pubicsymphysis

△ U「eth「a

Vagina

∣

pe「ineum

＼ Anus

■『∣GURE1Z﹣ZFuII﹣L『m「etusinVe『texP『esentation.Notethedi5pIacementandcomp「e5sion oftheabdominalvisce『a.Mostofthevisce『aisdispIacedcephaIad!whichcannotbeshownin thiSiIIust『ation.

290CHAPTER1Z■T『aumainP『egnancyandIntimatePa『tne『Vi0Ience

■TABLE12·1No『malLabo『ato『yVa』凹es DuⅧgP『egna0xy Ⅱematoc『it

3Z℅－4z％

WBCcount

5’000＿1Z’000Ⅱ【

A『te『iaIpⅡ

7·40＿745

Bica『bonate

↑7-ZZmEq／【

PaC0】

Z5＿30mmHg（33-4kPa）

Fib『inogen

3.79g／L（3『dt『m i este『）

Ca『diacOutput Afterthe10thweekofpregnanCy,cardiacoutputcan increaseby1.0to1.5L／minbecauseoftheincrease inplasmavolumeanddecreaseinvascularresistance oftheuterusandplacenta,whichreceive20℅ofthe patient,scardiacoutputduringthethirdtrimesterof pregnancy.ThisincreasedoutputmaybegTeatlyinflu﹣ encedbythemother’spositionduringthesecondhalf ofpregnanCy.Inthesupmeposition’venacavacom﹣

AVFandtheprecordialleadsmaybenormal·Ectopic beatsareincreasedduringpregnanCy.

RESP!RAT0RγSγSTEM Minuteventilationincreasesprimarilyasaresultofan increaseintida1volume.Hypocapnia（PaCO2of30mm Hg）istherefbrecommoninlatepregnancy.ApaC○2 o「35t◎4ommHgmayindicateimpending『espi『ato『y 佗ilu『edu『ingp『egnancy·Anatomicalterationsinthe thoraciccavityappeartoacc0untfbrthedecreased residualvolumethatisassociatedwithdiaphragmatic elevation,withincreasedlungmarkingsandpromi﹣ nenceofthepuhnonaryvesselsseenonchestx﹣ray examination.O呵genconsumptionisincreaseddur﹣ ingpregnanCy.Therefbre’itisimportanttomaintain andensureadeqUatearterialoxygenationduringthe resuscitationofi叮uredpregnantpatients.

GASTROIⅡTESTlⅡAlSγSTEM GastricemptyingisdelayedduringpregnanCy,soearly

pressioncandecreasecardiacoutputby30℅because ofdecreasedvenousreturnfromthelowerextremities.

gastrictubedecompressionmaybeparticularlyimpor﹣ tantt0avoidtheaspirationofgastriccontents’Thein﹣ testinesarerelocatedtotheupperpartoftheabdomen

Hea『tRate

andmaybeshieldedbytheuterus.Thep0sitionofthe

Heartrateincreasesgraduallyby10t015beats／mm duringpregnancy’reaChingamaximumratebythe thirdtrimester.Thischangeinheartratemustbecon﹣ sideredwheninterpretingatachycardicresponseto hypovolemia.

patient’sspleenandliverareessentiallyunchangedby pregnan叮.

BIoodP『essu『e PregnanCyresultsma5to15mmHgf白llinSystohc anddiastolicpressuresduringthesec0ndtrimester. Blo0dpressurereturnstonear-normallevelsatterm. Somepregnantwomenexhibithypotensionwhen placedinthesupineposition’causedbycompression oftheinfbriorvenacava.Thishypotensioniscorrected byrelievinguterinepressureontheinfbriorvenacava’ asdescribedlaterinthischapter·IDpertensioninthe pregnantpatientmayrepresentpreeclampsiaifac﹣ companiedbyproteinuria.

VenousP『essu『e Therestingcentralvenouspressure（CVP）isvari﹣ ablewithpregnancy’buttheresponsetovolumeis thesameasinthenonpregnantstate.Venoushyper﹣ tensioninthelowereXtremitiesispresentduringthe thiTdtrimeSter.

EIect『oca『diog『aphicChanges Theaxismayshiftleftwardbyapproximately15degrees.FlattenedorinvertedTwavesinleadsIIIand

URINARγ5γSTEⅢ Theglomerularfiltrationrateandrenalbloodflow mcreasedurmgpregnancy’whereaslevelsofserum creatmineandureanitrogenfalltoapproximatelyone. halfofnormalprepregnanCylevels.Glycosuriaiscom﹣ monduringpregnanCy.

MUSCUL0SI《ElETALSγSTEⅢ TheSymphysispubiswidensto4to8mm,andthesac﹣ roiliacjointspacesincreasebytheseventhmonthof gestation.Thesefactorsmustbeconsideredininter﹣ pretingx﹣rayfilmsofthepelvis. Thelarge’engorgedpelvicvesselsthatsurround thegraviduteruscancontributetomassiveretroperi﹦ tonealbleedingafterblunttraumawithassociatedpel﹣ vichyactures.

ⅡEUR0lOG∣CSγSTEⅢ EclampsiaisacomphcationoflatepregnanCythatcan mimicheadinjury.Itshouldbeconsideredifseizures occurwithassociatedhypertension,hyperreflexia’pro﹣ teinuria’andperipheraledema.Expertneurologicand obstetricconsultationfTequentlyishelpfhlindiffbren﹣ tiatingbetweeneclampsiaandothercausesofseizures.

SEVERITYOFINjURYZ91

∣

■TABlE12風2lⅡcideⅡceofVa『iousTypesof BluntT『auma加P『egⅡaⅡCy

■Notunde『standingtheanatomicandphysioIogic changesthatocCu「du『ingp『egnancy ■N0t『eCognizingthatano『maIPaCO2mayindicate

impending『espi『ato『yfaiIu「edu「ingp『egnancy ■MistakingecIampSiafo「headiniu『y

⋯

叮

＝

SceⅡa『io■contmuedThepatientisgiven high﹣↑∣0w0xygen.Shel5unabIet0『e5p0ndt0 questi0nsiha5a「e5pi『at0『y『ate0fZ8!hea『t『ate0↑ I30!andbI00dp『e5su『e0f】l0／50.Ⅱe『GIasg0w C0maScae I （GC5）5〔0『e5 i 7（日’VZ’M4）. ﹄

﹥MechansimsoⅡ fI u i 『y

TγPEo『 B【ⅡⅡTTRAUⅢA

T0TAL ⅡuMBER

pERcEⅡTAGE

Ⅲot0『vehicIe c『ashes／pedest『ians

l098

59。6

Fa∣IS

411

Z2.3

Di『ectaSsauItS

308

I6.7

0the『

zq

α 1

5ou『ce:ShahA」’Kilc∣ineBAT『aumainp『egnancy·EmepMedqh川Am z003;z1:6】5﹦629

missionofdirectfbrcetotheuterusonimpact.The useofshoulderrestraintsinconjunctionwiththelap beltreducestheⅡkelihoodofdirectandindiTectfbtal injmy,presumablybecauseofthegreatersurfacearea overwhichthedecelerationfbrceisdissipated’aswell asthepreventionoffbrwardflexionofthemotherover thegraviduterus.Therefbre’determinationofthe typeofrestraintdevicewornbythepregnantpatient’ ifany》isimportantinthe0verallassessment.There doesnotappeartobeanymcreaseinpregnanCy﹣spe﹣ cificrisksfromthedeplOymentofairbagsmmotor vehicles.

∣

o＞W｝ α j嗾α祀肋e酗吶“e妒蛐s加 ●pγegyEα〃fpα㎡e肥fsβ Mostmechanismsofi叼u1yaresimilartothosesus﹣ tainedbynonpregnantpatients’butcertaindiffbr﹣ encesmustberecognizedinpregnantpatientswho sustainbluntorpenetratinginjury. BlUⅡT∣Ⅱ』URγ

Theincidence0fvarious｛ypesofblunttraumainpreg﹣ nancyisouthnedmTable12.2·Theabdominalwall’ uterinemyometrium’andammoticfluidactasbuffk erstodirectfbtali叮ury仕omblunttrauma.Nonethe﹣ less,fbtalinjuriesmayoccurwhentheabdominalwall strikesanohject,suchasthedashboardorsteering wheel》orwhenapregnantpatientisstruckbyablunt instrument·Indirecti叼mytothefbtusmayoccurfrom rapidcompression’deceleration,thecontrecoupefIbct, orashearmgfbrceresultinginabruptioplacentae. Comparedwithrestrainedpregnantwomen involvedincoⅢsions’unrestrainedpregnantwomen haveahigherriskofprematuredelive叮andfbtal death.Thetypeofrestraintsystemaffbctsthefrequencyofuterineruptureandfbtaldeath.Theuse ofalapbeltaloneallowsfbrwardfIexionanduterine compressionwithpossibleuterineruptureorabrup﹣ tioplacentaeAlapbeltworntoohighovertheuterus mayproduceuterinerupturebecauseofthetrans﹣

pEⅡE『RATlⅡG∣Ⅱ」URγ

Asthegraviduterusincreasesinsize,theothervis﹣ ceraarerelativelyprotectedfrompenetratinginjury, whereasthelikelihoodofuterineinjuryincreases. Thedenseuterinemusculatureinearlypregnancy canabsorbagreatamountofenergyfrompenetrating missiles’decreasingmissilevelocityandlesseningthe likelihoodofinjurytootherviscera.Theamnioticfluid andfbtusalsoabsorbenergyandcontributetoslowing ofthepenetratingmissile.Theresultinglowincidence ofass0ciatedmaternalvisceralinjuriesaccountsfbr thegenerallyexcellentmaternaloutcomeincasesof penetratingwoundsofthegraviduterus.However’the fbtusgenerallyfhrespoorlywhenthereisapenetrat﹣ inginjurytotheuterus.

∣ ﹥ Seve『tiyofIn】u『y Theseverityofmaternalinjuriesdeterminesmaternal andfbtaloutcome.Therefbre,treatmentmethodsalso dependontheseverityofmaternali叮uries.Allpreg nantpatientswithm句orinjuriesrequ1readmissionto afhcilitywithtraumaandobstetriccapabilities.Even pregnantpatientswithminorinjuriesshouldbecare﹣

Z92CHAPTER1Z■T『aumainP「egnancyandIntimatepa「tne『Vi0∣ence

fhllyobserved’sinceoccasionallyminorinjuriesareas﹣ sociatedwithabruptioplacentaeandfbtalloss.

volemiaofpregnancy.Vasopressorsshouldbean absolutelastresortinrestoringmaternalbloodpres﹣ sure’becausetheseagentsfhrtherreduceuterine bloodflow,resultinginfbtalhypoxia.Baselinelabora﹦ to叮evaluationinthetraumapatientsh0uldincludea fibrinogenlevel’asthismaydoubleinlatepregnancy﹩ anormalfibrinogenlevelmayindicateearlydissemi﹣ natedintravascularcoagulati0n（DIC）.

「

SceⅡa『io■con加uedThepatientunde『g0es 「apidsequenceintubati0nduet0he『GCSsc0『e· Ⅱe『hea『t『ateisn0wI30!andb∣00dp『essu『eis 90／60·Int『aven0usacces5is0btaInedlandsheis

Fetus

gv I en∣ I tie「0↑c「ysta∣0 Id I· ＝

∣ ﹥ ASSesSmentandT『eatment

TheabdominalexaminationduringpregnanCyis criticallyimportant）asrapididentificati0nofserious maternalinjuriesandfbtalwell﹣beingdependona thorou即evaluationThemaincauseoffbtaldeathis matemalshockandmaternaldeath·Thesecondmost commoncauseoflbtaldeathisplacentalabruption· Abruptioplacentaeissuggestedbyvaginalbleeding （70℅ofcases）’uterinetenderness’fTequentuterine contractions,uterinetetany,anduterineirritabili叮 （uteruscontractswhentouched）.In30﹪ofabruptions fbllowingtrauma,vaginalbleedingmaynotoccur. Uterineultrasonographymaybehelpihlmdiagnosis, butisnotdefinitive·Lateinpregnan叮,abruptionmay occurfbllowingrelativelyminorinjuries. Uterinerupture,arareinjury’issuggestedby findingsofabdominaltenderness’guarding,rigidity’ orreboundtenderness’especiaⅡyifthereisprofbund

∣

叨 HmodoJeU咖α加α砲毗’e .α㎡叨o ●pα㎡e〃Zs; Fo『optimaloutcomeo「mothe『ahdfetⅡs,c∣iniciansmust assessand『esuscitatethemothe『伺『st’andthenassessthe 佗tusbe｛b『econductihgaseconda『ysuweyo「themothe『· PRIMARγ5URVEγANDRESUSαTAT∣0N Mothe『 Ensureapatentairway,adequateventⅡationando叮﹣

﹄

genation’andeffectivecirculato叮volume.Ifventila﹣ torysupportisreqUired’mtubationisappropriatefbr pregnantpatients,andconsiderationshouldbegiven tomaintaimngtheappropriatePCO2fbrherstage ofpregnancy（e.g.,approximately30mmHginlate pregnanCy）.SeeChapter2:AirwayandVentilatory Management. Uterinecompressionofthevenacavamayreduce venousreturntotheheart’therebydecreasingcar﹣ diacoutputandaggravatingtheshockstate.The ute『usshouldbedispIacedmanuaIlytotheIe什sideto 『eIievep『essu『eohtheinfb『io『venacava·Ifthepatient requ1resimmobilizationinasupineposition’the

﹃

郃」 ∣

夕

patientorspineboardcanbelogrolled4to6inches（or 15degrees）totheleftandsupportedwithabolster﹣ ingdevice’thusmaintainingspinalprecautionsand decompressingthevenacava（■FIGuRE1z﹣3）. Becauseo「thei『iⅡc『easedint『avascuIa『voIume, p『egnantpatientscaⅡIoseasigni倫cantamounto「blood be｛b『etaclWca『dia,hypoteⅡsioh’andothe『signso「hypo﹣ volemiaoccu『.Thus,thefetusmaybeindist『essandthe placentadep『ivedo「vitaIpe『fi』sionwhiIethemothe『,s conditionandvitaIsigⅡsappea『stable.Crystalloidfluid resuscitationandearlytype﹣specihcblo0dadmimstra﹣ tionareindicatedtosupportthephysiologichyper﹣

■FiGURE1Z﹣3P『ope『∣mmobiIizationofap『egnant Patient.Ifthepatient「equi『esimm0biIizationina supineposition’thepatiento『spineboa『dcanbe Iog「oIled4to6inches（o「15deg「ee5）totheleftand 5upp0『tedwithabol5te『ingdevice妒thusmaintaining 5pinaIp『ecaution5anddecomp『essingthevenacava.

ASSESSMENTANDTREATMENT293

shock·Frequently’peritonealsignsaredifficultto appreciateinadvancedgestationbecauseofexpansion ahdattenuationoftheabdominalwallmusculature. Otherabnormalfindingssuggestiveofuterineruptureincludeabdominalfbtallie（e.g.,obliqUeortrans﹣ versehe）’eaSypalpationoffbtalpartsbecauseoftheir extrauterinel0cation,andinabili勺toreadi】ypalpate theuterinefhndusWhenthereis血nda1rupture.X﹣ray evidenceofruptureincludesextendedfbta1extremities’abnormalfbtalposition’andfiPeemtraperitoneal air.OperativeeXplorationmaybenecessa】ytodiag noseuterinerupture. Inmostcasesofabruptioplacentaeanduterine rupture,thepatientreportsabdominalpainorcramp﹣ 1ng.Signsofhypovolemiacanaccompanyeachofthese mJur1es. Initialfbtalhearttonescanbeauscultatedwith Dopplerultrasoundby10weeksofgestation.Contihu﹣ ousfetaImoⅧto『iⅥgwithatocodyhamomete『shouldbe ●

◆

◆

pe『1b『medbeyohd2oto24weeI《so「gestation·Patients withnoriskfhctorsfbrfbtallossshouldhavecontim】﹣ ousmomtoringfbr6hours,whereaspatientswithrisk fhctorsfbrfbtallossorplacentalabruptionshouldbe momtored允r24hours.Therisk色ctorsarematernal heartrate＞110,anInjurySeverityScore（ISS）＞9, evidenceofplacentalabruption,fbtalheartrate＞160 or＜120,ejectionduringamotorvehiclecrash,and motorCycleorpedestriancoⅡisions.

AD川ⅡCTS『0PRIMARγSURVEγ AⅡDRESUSαTAT∣0Ⅱ Mothe「 Ifpossible’thepatientshouldbemomtoredonherleft sideafterphysicalexamination.Momtormgofthepatient’sfIuidstatusisimportantinordertomaintain therelativehypervolemiareqUiredinpregnan叮.Monitormgshouldalsoincludepulseoximet】yandarterial bloodgasdeterminations.Remember’maternalbicarbonatenormallyislowdurmgpregnan叮asacompen﹣ sationfbrrespirato】yalkalosis. 「etuS Obstetricconsultationshouldbeobtained’sincefbtal distresscanoccuratanytimeandwithoutwarning.Fe﹣ talheartrateisasensitiveindicatorofbothmaternal bloodvolumestatusandfbtalweⅡ﹦bemg.Feta1heart tonesshouldbemomtoredineveryinjuredpregnant woman.Thenormalrangefbrfbtalheartrateis120to 160beats／min.Anabnormalfbtalheartrate,repetitive decelerations’absenceofaccelerationsorbeat﹣to﹦beat variabⅢty,andfTequentuterineactivi勺canbesigns ofimpendingmaternaland／orfbtaldecompensation （e.g.,hypoxiaand／oracid0sis）andshouldpromptim﹣ mediRteobstetricconsultation.

Indicatedradiographicstudiesshouldbeper﹣ fbrmed,becausethebenefitscertainlyoutweighthe potentialrisktothefbtus.

5EC0NDARγAssESSMENT Thematernalseconda1ysurv叮shouldfbⅡowthesame

patternasfbrnonpregnantpatients.SeeChapter1: 1mtialAssessmentandManagemenl·Indicationsfbr abd0minalcomputedtomography’fbcusedassessment sonographyintrauma（FAST）,anddiagnosticperito﹣ neallavage（DPL）arealsothesame.However,ifDPL isperfbrmed’thecathetershouldbeplacedabovethe umbilicususmgtheopentechnique.PaycarefUlat﹣ tenti0ntothepresenceofuterinecontractions’which suggestearlylabor,ortetaniccontracti0ns,whichsug gestplacentalabruption·Evaluationoftheperineum shouldincludeafbrmalpelvicexamination》ideally perfbrmedbyaclinicianskilledinobstetriccare.The presenceofammoticfluidinthevag1na,evidencedbya pHof7to7.5’suggestsrupturedChorioammonicmem﹣ branes.Cervicaleffacementanddilation’fbtalpresentation,andtherelationshipofthefbtalpresentmgpart totheischialspinesshouldbenoted. Becausevaginalbleedinginthethirdtrimester mayindicatedisruptionoftheplacentaandimpendmgdeathofthefbtus,avaginalexaminationisvital. Repeatedvaginalexaminationsshouldbeavoided. Thedecisionregardinganemergen叮cesareansecti0n shouldbemadewithadvicefTomanobstetrician﹦ Admissiontothehospital1smandato1yinthe presenceofvaginalbleeding,uterineirritability, abd0minaltenderness,painorcrampmg,evidence ofhypovolemia’changesinorabsenceofibtalheart tones’orleakageofamnioticfIuid.Careshouldbepro﹣ videdatafacili叮withappr0priatefbtalandmaterna1 momtoringandtreatmentcapabihties.Thefbtusmay beinieopa『dyevenwithappa『entIymino『mate『naIiniu「y.

DE『INIT∣VECARE Obstetricconsultationshouldbeobtainedwhenever specificuterineproblemsexistoraresuspected.With extensiveplacentalseparationoramnioticfIuidemboli﹣ zation,widespreadintravascularclottingmaydevelop’ causingdepletionoffibrinogen,otherclottingfactors, andplatelets.Thisconsumptivecoagulopathycan emergerapidly.Inthepresenceoflifb﹣threateningam﹣ moticfluidembolismand／Ordisseminatedintravascular coagulation,uterineevacuationshouldbeaccomphshed onanurgentbasis’alongwithreplacementofplatelets’ fibrinogen,andotherClottingfactors’ifnecessary. Consequencesoffbtomaternalhemorrhageinclude notonlyfbtalanemiaanddeath,butalsoisoimmuni﹣ zati0nifthemotherisRh﹣negative.Becauseaslittle

Z94CHAPTER1Z■T『aumainP『egnancyandIntimatepa「tne「VioIence

as0.01mLofRh﹣positivebloodwillsensitize70﹪of Rh﹣negativepatients’thepresenceoffbtomaternal hemorrhageinanRh-negativemothershouldwar﹣ rantBhimmunoglobulintherapy.Althoughapositive Kleihauer﹣Betketest（amaternalbloodsmeara1low﹣ ingdetectionoffbtalRBCsinthematernalcirculation） indicatesfbtomaternalhemorrhage,anegativetest doesnotexcludeminordegreesoffbtomaternalhem﹣ orrhagethatarecapableofsensitizingtheRh-negative mother.AIIp『egnahtRh.negativet『aumapatientsshouId 『eceiveRhimmunog∣obulinthe『apyuhlesstheihiu『yis 『emote什omtheute『us（e.g·,isoIateddistaIext『emity iniu『y｝.Immunoglobulintherapyshouldbeinstituted within72hoursofimury.

∣ ﹥ Intimatepa『tne『 VioIence

▲」 PITFAI」I」S

partnerviolenceoccurperyear’andalmostone﹣half ofallwomenovertheirlifbtimesarephysicallyand／ orpsychologicaⅡyabusedinsomemanner.Worldwide, between10℅－69℅ofwomenreporthavingbeenas﹣ saultedbyanintimatepartner. Suspicionofintimatepartnerviolenceshouldbe documented’andreported·Theseattackscanresultin deathanddisabihty.TheyalsorepresentanincreasingnumberofEDvisits.Althoughthem匈orityofvic﹣ timsarewomen’menmakeupapproximately40℅of allreportedcasesofintimatepartnerviolenceinthe UnitedStates. Indicatorsthatsuggestthepresenceofintimate

「 F

■FaiIu『eto『ec0gnizetheneedtodispIacetheute『us totheleftsideinahypotensivep『egnantpatient. ■FaiIu『eto『ecognizeneedfo「RhimmunogI0buIin the『apyinanRh﹣negativemothe『. ＝ ﹁

■

∣

?勰勰妒‘‘聊⋯⋯p⋯『 Intimatepa『tne『vioIehceisamaio『causeo「iⅡiu『yto womeⅡdu『ingcohabitation,ma『『iage,andp『egnancy 『ega『dlesso「etlmicbacI《g『ouⅡd,cultu『aIin｛luehces,o『 socioeConomicstatus.Seventeenpercentofinjured pregnantpatientsexperiencetraumainflictedbyan﹣ otherperson’and60℅ofthesepatientsexperience repeatedepisodesofintimatepartnerviolence.Ac﹣ cordingtoestimatesfromtheU.S.Departmentof Justice’2miⅡionto4millionincidentsofintimate

partnerviolenceinclude:

SceⅢa『io■cont／huedTheute『usisdis-

■Injuriesinconsistentwiththestatedhistory

pIacedt0theIeft;thepatientd0e5n0t『esp0nd t0c「ysta∣∣0id『esusdtati0nlandhe『hea『t『ate inc『easest0l40.A趴STexami5d0ne〃whi〔h sh0w5int『aabd0mina∣↑∣uidSheisgivenRh immun0gI0buIinthe『apyandantibi0tics!andis takeneme『gent∣yt0the0pe『ating『00m.

■Dimimshedsel世image’depression’orsuicide attempts ■Selfabuse

■FrequentEDordoctor’sofficevisits ■Symptomssuggestiveofsubstanceabuse

﹃

■SelfLblamefbrinjuries ■Partnerinsistsonbeingpresentfbrinterview

■ ＞ pe『imo『temCesa『eanSection

∣

Thereare佗wdatatosupportpenmortemcesareansec﹣ tioninpregnanttraumapatientswhoexperiencehyp0﹣ volemiccardiacarrest·Remember,fbtaldistresscanbe presentwhenthemotherhasnohemodynamicabnor﹣ malities,andprogressivematernalinstabili叮compro﹣ misesfbtalsurvival·Atthetimeofmaternalhypov0lemic cardiacarrest,thefbtusalreadyhassuffbredprolonged hypona.Forothercausesofmaternalcardiacarrest’pe﹣ nmortemcesareansectionoccasionaⅡymaybesuccess﹣ fhlifperfbrmedwithin4to5minutesofthearrest.

andexaminationandmonopohzesdiscussion

Theseindicatorsraisethesuspicionofthepoten﹣ tiallbrintimatepartnerviolenceandshouldserveto initiateihrtherinvestigation.Thethreequestionsin Box12﹣1,whenaskedinanonjudgmentalmannerand withoutthepatient,spartnerbeingpresent’caniden﹣ ti句65℅to70℅ofvictimsofintimatepartnerviolence. Suspectedcasesofintimatepartnerviolenceshouldbe handledthroughlocalsocialserv1ceagenciesorthe statehealthandhumanserv1cesdepartment.

CHAPTERSUMMARYZ95

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SceⅢa『io■coⅡcIusioⅡThepatientundeI﹄ g0e5eme『gentspIened0my｝andanint「a0pe『ative cesa「eansedi0nispe『↑0『med.Sheunde『g0e5a headc0mputedt0m0g『aphy（CT）p0st0pe『atv i e∣y｝‘ whichidenti↑iessma∣Iint『apa『enchymaIc0ntusi0ns witham0de『ateam0unt0fsuba『achn0idbl00d She『ec0ve『5afte『ap『0I0ngedintensiveca『eunit

2D0y0u↑eelsafeiny0u『cu『『ent『eIati0n5hip? 3l5the『eapa『tne『｛『0map『evioⅡs『eIation5hipwh0is makingy0u↑eeIun5a↑en0w? Rep『intedwithpe『mi55i0n『『0m『e∣dhau5kMl〈0zi0l.Ⅲdain」i AmsbuⅣⅡbetal.A〔〔u『aq0｛3b『ie｛s〔『eenIngquesti0ns｛0『 detectingpa「tne『vi0∣enceintheeme『gencydepa『tmenMM｛A I997;Z77:B57﹣B6l

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ChapterSunnnary ChapterSunnnary ⅢImportantandpredictableanatomicandphysiologicChangesoccurduringpreg﹣ nanCythatcaninfluencetheassessmentandtreatmentofinjuredpregnantpa﹣ tients.Attentionals0mustbedirectedtowardthefbtus’thesecondpatientofthis un1qUeduo,afteritsenv1ronmentisstabⅢzed.Aqualifiedsurgeonandanobste﹣ tricianshouldbeconsultedearlyintheevaluationofpregnanttraumapatients. 圓Theabdominalwall’uterinemyometrium’andamnioticfluidactasbuffbrsto directfbtalinjuryfromblunttrauma.Asthegraviduterusmcreasesinsize’the remainderoftheabdominalvisceraarerelativelyprotectedhompenetratingin﹣ jury’whereasthelikelihoodofuterineinjuryincreases. 圃Appropriatevolumeresuscitationshouldbegiventocorrectandpreventmater﹣ na1andfbtalhypov0lemicshock.Assessandresuscitatethemotherfirst’and thenassessthefbtusbefbreconductingasecondarysurv叮ofthemother. 囤Asearchshouldbemadefbrconditionsuniquetotheinjuredpregnantpatient》 suchasbluntorpenetratinguterinetrauma’abruptioplacentae,ammoticf】uid embolism,isoimmunization’andprematureruptureofmembranes. 回MinordegreesoffbtomaternalhemorrhagearecapableofsensitizmgtheRh﹣ negativemother.AllpregnantRh﹣negativetraumapatientsshouldreceiveRh mⅢnunoglobulintherapyunlesstheinju1yisremotefromtl1euterus. 圃Presenceofindicatorsthatsuggestintimatepartnerviolenceshouldservetoini﹣ tiatefhrtherinvestigationandprotectionofthevicthn. ﹂

∣

Z96CHAPTER1Z■T「aumainp「egnancyandIntimatePa「tne『VioIence

■SB IⅡOCRAⅢ 1·ACEPChmcalPoliciesCommitteeandCli㎡calPolicies SubcommitteeonEarlyPregnancy.AmericanCollege ofEmergenCyPhysicians·ClimcalpoliCy:criticalissues intheinitialevaluationandmanagementofpatients presentingtotheemergenCydepartmentinearlypreg﹣ nanCy‘A〃〃Eme唔Mbd2003;41:122﹦133. 2·AdlerG,DuchinskiT’JasinskaA’etal.Fibrinogenhac﹣ tionsinthethirdtrimesterofpregnancyandinpuerpe﹣ rium.IγjJDmbRes2000;97:405－410· 3’BenyMJ’McMurrayRG,KatzVL.Pulmona叮andven﹦ tilato】yresponsestopregnan叮,1mmersion’andexer﹣ cise.JARp【PhJs【o』1989;66（2）:857﹣862· 4.BuchsbaumHG,StaplesPPJr.Selfinflictedgunshot woundtothepregnantuterus:reportoftwocases.Obsfα 句几eco!1985;65（3）:32S﹣35S. 5.ConnollyAM,KatzVL,BashKL,etal.Traumaandpreg nanCy.A刀﹩JR㎡ⅦαroJ1997,14:331﹣336. 6.CuretMJ,SchermerCR’DemarestGB,etal.Predictors ofoutcomemtraumaduringpregnanCy:identification 0fpatientswhocanbem0nitoredfbrlessthan6h.J 乃αMmα2000;49:18﹣25. 7.DahmusM’SibaiB.Bluntabdominaltrauma:are thereanypredictivefactorsfbrabruptionplacen﹣ taeormaternal﹣fbtaldistress?A加JObs螂Gy〃eco／ 1993;169:1054﹣1059. 8·EisenstatSA,SancroftL.Domesticviolence·ⅣE唔／J Med1999;341:886﹣892. 9.EspositoTJ·TraumaduringpregnanCy.E〃te嘈Mbdα加 』V0㎡／jA加1994,12:167﹣199. 10.EspositoT,GensD,SmithL,etal·Traumaduringpreg﹣ nanCy.A加／iS【』咱1991,126:1073﹣1078. 11.FeldhausKM’Koziol-McLainJ,AmsburyHL’etal· AccuraCyof3briefscreemngquestionsibrdetecting partnerviolencemtheemergencydepartment.c／AMA 1997;277:1357﹣1361. 12.GeorgeE,VanderkwaakT,ScholtenDFactorsinflu﹦ encingpregnanCyoutcomeaftertrauma.AmSα唔 1992;58:594-598. 13.GoodwinT’BreenM.Pregnancyoutcomeandfbtoma﹣ ternalhemorrhageafternoncatastrophictrauma·A加J Obs㎡叼氾cco』1990;162:665﹣671 14.GrissoJA,SchwarzDF’HirschingerN’etal·Ⅵolent injuriesamongwomenmanurbanarea’lVEJtg!JMM 1999;341:1899﹣1905. 15·HamburgerKL’SaundersDG,HoveyMPrevalenceof domesticviolenceincommunitypracticeandrateofphy﹣ sicianinquiry·Fh加Mbd1992;24:283·287.

18.HoifW’D’AmelioL’Tmko任G’etal.Maternalpredictors offbtaldemisemtraumadurmgpregnanCy·S【〃g叼〃e﹣ co／Obs皰㎡1991;172:175﹣180. 19.HydeLK,CookLJ’OlsonIMetal·EHbctofmotor vehiclecrashesonadversefbtaloutcomes.Obs﹠αqyⅧeco／ 2003;102;279﹣286. 20.IkossiDG’LazarAA,MorabitoD,etal·Prohleofmothers atrisk:ananalysisofinjuryandpregnanCylossin1’195 traumapatients.JAmCo〃Sα唔2005;200:49﹣56· 21.KissingerDP’RozyckiGS,MorrisJA,etal.Traumain pregnancy＿predictmgpregnanCyoutcome.A加／jSM｝習 1991j125:1079﹣1086. 22KlinichKD’SchneiderLW,MooreJLetal.Investiga. tionsofcrashes1nvolvingpregnantoccupants.A〃〃α P／ocAssocAduA㎡o加otM它d2000;44:37-55. 23.KyriacouDN,AnglinD,TaliafbrroE’etal.Riskfactors fbrinjmytowomenfromdomesticviolence·NE〉』g』J Mbd1999;34L1892﹣1898. 24.LeeD,ContrerasM,RobsonSC,etal.Recommendations fbrtheuseofanti﹦DimmunoglObuhnfbrRhprophylaxis. BritishBloodTrans血sionSocie叮andRoyalCollege ofObstetriciansandGynaecologists.?〉u几S／hsMed 1999;9:93﹣97. 25MattoxKL,GoetzlL.Traumainpregnancy.C）㎡“祀 Mbd2005;33S385﹣S389 26‘MetzTD,AbbottJT.Uterinetraumainpregnancyafter motorvehiclecrasheswithairbagdeployment;a30﹦case series·JTrα叨加α2006;61:658﹣661. 27.MinowMViolenceagainstwomen＿achallengetothe SupremeCourt·ⅣEJ』g』JMbd1999;341:1927﹣1929 28.MollisonPL·ClimcalaspectsofRhimmunization·A加J α加.Pαt〃o／1973;60:287. 29.NicholsonBE’ed.Familyviolence.JSoαt／jCα”／㎡〃α M它dAssoc1995;91:409﹣446· 30’PearlmanMD,TmtinalliJE’LorenzRP.Blunttrauma durmgpregnanCy.ⅣE刀g』JMbd1991;323:1606-1613 31PearlmanM’TmtmalliJ,LorenzR.Aprospectivecon﹣ troⅡedstudyof0utcomeaftertraumaduringpregnancy. A／施JObstαGy几eco／1990;162:1502﹣1510. 32.RosePG’StrohmPL’ZuspanFP.Fetomaternal hemorrhagefbllowingtrauma.AmJObs『αGy氾eco／ 1985;153:844宮847· 33‘RothenbergerD,QuattlebaumF,PerryJ’etalBlunt maternaltrauma:areviewof103cases·J乃αM加α 1978;18:173﹣179. 34.SchoenfbldA’ZivE’StemL’etal.Seatbeltsinpreg﹣ nancyandtheobstetrician·Obs／e﹠Gy〃eco／Sαru1987; 42:275﹣282.

16.HellgrenMHemostasisduringnormalpregnanCyand puerperium.Sem加IⅥ”mbHbmos﹠2003;29（2）:125﹣130。

35。Sc0rpioR》EspositoT,SmithG,etal.Blunttrauma duringpregnanCy;fHctorsa｛fbcting【btaloutcome·J 乃αα加α1992;32:213﹣216.

17.HigginsSD,GariteI＼J.Lateabruptioplacentaintrauma patients:imphcationsfbrmonitoring.Obs螂Gy〃eco』 1984;63;10S﹣12S.

36.SelaHY》Weimger,CF,Hersch’etal.Thepregnantmotor vehicleaccidentcasualty.Adherencetobasicworkupand admissionguidelines.AJu几Sα唔2011;254（2）·

BIBU0GRAPHYANDRESOURCEZ97

37.ShahAJ,KⅡclineBA.Traumainpregnancy.Eme唔Med α加Ⅳb㎡hAm2003;21:615氬629

44.WembergL,SteeleRG,PughB’etal.Thepregnant traumapatient.A〃αes﹠／jD㎡Cα疋2005;33;167﹣180.

38.SimsCJ,B0ardmanCH,FuⅡerSJ.Airbagdeployment fbⅡowingamotorvehicleaccidentinpregnancy.Obstα 劻几eco』1996;88:726.

45.WolfME,AlexanderBH,RivaraFP,eta1.Aretrospec﹣ tivecohortstudyofseatbeltuseandpregnan叮outcome afteramotorvehiclecrash.J介αα加α1993;34:116﹣119.

39.SisleyA’JacobsIM’PooleG,etal.ViolencemAmerica: apubⅡchealthcrisis＿domesticviolence.J?】mα加α 1999;46:1105﹣1113.

46·www.who.int／violence－1nJury＿prevention／violence／ world-report／炮ctsheets／en／ipvfacts.pdftAccessed5／14／12.

40.StatementonDomesticⅥolence’B叨〃A加α〃Smg 2000;85:26· 41.TimberlakeGA,McSwainNE.Trauma1npregnanCy,a ten﹣yearperspective·AmSmg1989;55?151﹣153. 42.Towe叮RA,EnglishTP,WisnerDW.Evaluationofpregb nantwomenaiterbluntimu1y·JTrα叨加α1992;35:731﹣736. 43.TsueiBJ.ASsessmentofthepregnanttraumapatient. I7vαnl2006;37:367﹣373.

■REsoⅢc贗 NationalCoalitionAgainstDomesticⅥolence,POBox18749, Denver,CO80218﹣0749,303﹣839﹣1852;303﹣831﹣9251（fhx）.

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T鑾玀繃籥鑒濰籮 patientsfbrdefinitivecare.Definitivecare,whether supportandmomtormginanintens1vecareumt（ICU） oroperativeintervention’requiresthepresenceand activeinvolvementofasurgeonandtraumateam·If definitivecarecannotbeprovidedatalocalhospital’ thepatientrequirestransfbrtoahospitalthathas theresourcesandcapabilitiestocarefbrhimorher. Ideally,thisfhcilityshouldbeaverifiedtraumacenter, thelevelofwhichdependsonthepatient’sneeds· Thedecisiontotransfbrapatienttoanotherfacil﹣ i叮dependsonthepatient,sinjuriesandthelocal resources.Decisionsast0whichpatientsshouldbe transfbrredandwhentransfbrshouldoccurarebased onmedicaljudgment.Evidencesupp0rtsthev1ew thattraumaoutcomeisenhancedifcriticaⅡyinjured patientsaretreatedintraumacenters.The『e｛b『e｝ t『aumapatientsshouIdbet『ahsf它『『edtothecIosest app『op『iatehospita!,p『e佗『ablyave『i伺edt『aumaceⅡte『· SeeAmericanCollegeofSurgeons（ACS）Committee onTrauma,ResourcesfbrOptimalCareoftheIniured Patient;GuidelinesfbrTraumaSystemDevelop﹣ mentandTraⅢmaCenterVerihcationProcessesand mentand -

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Am匈orprincipleoftraumamanagementistodo noh1rtherharm.Indeed’thelevelofcareoftrauma patientsshouldconsistentlyimprovewitheachstep, fTomthesceneoftheincidenttothefacihtythatcan providethepatientwiththenecessa1y’propertreat﹣ ment.Allproviderswhocarefbrtraumapatientsmust ensurethatthelevelofcareneverdeclineshomone steptothenext·

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thedoctoroncallcanreachtheED.Consequently, effbctivecommumcationwiththeprehospitalSystem shouldbedevelopedtoidenti叮patientswhorequ1re thepresenceofadoctorintheEDatthetimeofarrival （■「!GuRE13﹣1）.Inaddition’theattendingdoctormust becommittedtorespondtotheEDpriortothearrival ofcriticallyinjuredpatients·Identificationofpatients whoreqmrepromptattentioncanbebasedonphysi﹣ ologicmeasurements,specificidentifiableiIUuries’and mechanismofinjury· Thetimingofinterhospitaltransfbrvariesbased onthedistanceoftransfbr’theavailableskilllevels fbrtransfbr’circumstancesofthelocalinstitution’and interventionthatisnecessarybefbrethepatientcan betransfbrredsafbly.Iftheresourcesareavailable andthenecessaryprocedurescanbeperfbrmedexpe﹣ ditiously,lifb-threateningmjuriesshouldbetreated befbrepatienttransport.Thistreatmentmayrequire oPerativeinterventiontoensurethatthepatientism thebestpossibleconditionfbrtransfbr.lnte『ventioh p『io『tot『ahsfb『isasu『gicaldecision.

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Toassistchniciansindeterminingwhichpatientsmay requirecareatahigher﹣levelfhcility’theACSCommit. teeonTraumarecommendsusingcertainphysiologic indices,injurymechanismsandpatterns’andhistori﹣ calinfbrmation·Thesefactorsalsohelpclimciansde﹣ cidewhichstablepatientsmightbenefitfromtransfbr· Criteriafbrinterhospitaltransfbrwhenapatient’s needsexceedavailableresourcesareol】t】inedmTable 13·1.Itishnportanttonotethatthesecriteriaareflex﹦ ibleandmusttakeintoaccountlocalcircumstances· Certainclinicalmeasurementsofphysiologicsta﹣ tusareusefhlindeterminingtheneedfbrtransfbr toaninstitutionthatprovidesahigherlevelofcare· Patientswhoexhibitevidenceofshock’significant physi0logicdeterioration,orprogressivedeteriora. tioninneurologicstatusrequirethehighestlevel ofcareandwilllikelybenefitfTomtimelytransfbr （■FIGUR曰3﹣且） Stablepatientswithbluntabdominaltraumaand documentedliverorspleeninjuriesmaybecandidates fbrnonoperativemanagement.Implicitmsuchprac﹣

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fraughtwithhazards.Thesepatientsareo仳enimmo﹣ bilizedinthesupinepositionwimwrist／legrestraints· Ifsedationisrequired,thepatientshouldbemtubated· Therefbre,befbreadministeringanysedation’thetreat﹣ mgdoctormust:

paredfbrurgentoperativemtervention;theyshould betrans允rredtoatraumacenter. Patientswithspecificinjuries,combinationsof imuries（particularlythoseinvolvingthebrain）,or historicalfindingsthatmdicatehigh﹣energy-transfbr injmymaybeatriskfbrdeathandarecandidatesfbr earlytransfbrtoatraumacenter.High﹣riskcriteria suggestmgthenecessityfbrearlytransfbrarealsooutI﹩hedinTable13.1. Treatmentofcombativeanduncooperativepatients withanalteredlevelofconsciousnessisdifficultand

1.Ensurethatthepatient’sABCDEsareappropriatelymanaged. Z·Behevethepatient’spainifpossible（e.g.’splint fracturesandadministersmalldosesofnarcotics intravenous】y） 3.Attempttocalmandreassurethepatient. Remember,benzodiazepmes’fbntanyl（Subhmaze）, propofbl（Diprivan）’andketamine（Ketaset）areall hazardousinpatientswithhyp0volemia’patientswho

30ZCHAPTER13■T『ansfe『toDefinitiveCa「e

∣P 『『ansfe『Responsibi∣ities e

Specifictransfbrresponsibilitiesareheldbyboththe refbrringdoctorandthereceivingdoctor.

RE「ERRIⅡGD0CT0R

叨 W ie j ’℃s〃o叨Mse I 腮d ●毗epα㎡e〃㎡β Therefbrringdoctorisresponsiblefbrinitiatingtransfbrofthepatienttothereceivinginstitutionandselect﹣ mgtheappropriatemodeoftransportationandlevelof carerequiredfbroptimaltreatmentofthepatienten route.Therefbrrmgdoctorshouldconsultwiththereceivingdoctorandshouldbethoroughlyfamiliarwith thetransportingagencies,theircapabilities’andthe arrangementsfbrpatienttreatmentduringtransport‘ Stabilizingthepatient,sconditionbefbretransfbr t0an0therfacilityistheresp0nsibilityoftherefbrring d0ctor’withinthecapabihtiesofhisorherinstitution. Imtiationofthetransfbrprocessshouldbeginwhile resuscitativeeffbrtsaremprogress. Transfbragreementsmustbeestablishedtopro﹣ videfbrtheconsistentande筮cientmovementof

■FlGURE13﹣2Patientswhoexhibitevidence0fshock’ 5ignificantphy5iologicdete「io『ati0n!o「p「og『es5ive dete「i0「ationinneu『0l0gicstatus『equi「ethehighest ∣eveIofca「eandwiIIIikeIybenefitf『omtime∣yt「ansfe『

patientsbetweeninstitutions·Theseagreementsallow fbrfbedbacktotherefbrringhospitalandenhancethe efficienCyandqualityofthepatient’streatmentdur﹣ ingtransfbr（■FIGuRE13.3）.

areintoxicated’andpatientswithheadmjuries.pain management,sedation’andintubationshouIdbeaccom﹣ pIishedbytheindMduaImostski∣Iedinthesep『oCedu『es. SeeChapter2 AirwayandVentilato1yMana臼ement

Abuseofalcoholand／orotherdrugsiscommonto allibrmsoftraumaandisparticularlyimportantto identi句,becausethesesubstancescanalterpainper﹣ ceptionandmasksignificantphysicaliindings.Altera﹣ tionsinthepatient,sresponsivenesscanberelatedto alcoholand／ordrugs’buttheabsenceofcerebralinjmy shouldneverbeassumedmthepresenceofalcoholor drugs.Iftheexaminingdoctorisunsure,transfbrt0a higher﹣levelfaciⅡtymaybeappropriate. Deathofanotherindividualinvolvedintheinci﹣ dentsuggeststhepossibilityofsevere,occultinjuryin surv1vors.Inthesecases’atho『oughandca『efUlevaIua﹣ tioⅡoftlTepatient,evenintheabsenceo「obvioussignsof seve『einiuⅣ,ismahdato『y.

▲▲ P I 叨 F A L

L

Inadequatep「epa『ationf0『t『anspo「t’inc「easingthe IikeIihoodthatdete「io「ationofthepatientwiIloccu「 du「ingt「ansfe『·

▲P I T F A L L lnadequateo「inapp『op「iatecommunicationbetween 『efe「『ingandacceptingca「ep「ovide『s『esuItinginIoss 0finfo『mationc「iticaltothepatient『sca『e·

RECElVlⅡGD0CT0R Thereceivingdoctormustbeconsultedwithregard tothetransfbrofatraumapatient.Heorshemust ensurethattheproposedreceivinginstitutionisqUali﹣ fied’able’andwiⅢngtoacceptthepatient,andisin agreementwiththeintenttotransfbr.Thereceiving doctorshouldassisttherefbrringdoctorinmaking arrangementsfbrtheappropriatemodeandlevelof careduringtransport·Iftheproposedreceivingdoc﹣ torandfRcili叮areunabletoacceptthepatient’they shouldassistinfindinganalternativeplacementfbr thepatient· Thequalityofcarerenderedenrouteisofvital nnportancetothepatient,soutcome.Onlybydirect communicationbetweentherefbrringandreceiving doctorscanthedetailsofpatienttransfbrbeclearly

∣

MODESOFTRANSPORTATl0N303

geography,cost’andweatherarethemaindetermining fhctorsastowhichtouseinagivenc1rcumstance· TheinterhospitaltransfbrofacriticaⅡyiIjured patientispotentiallyhazardousunlessthepatient,s conditionisoptimallystabilizedbefbretransport, transfbrpersonnelareproperlytrained,andprovision hasbeenmadefbrmanagingunexpectedcrisesdur﹣ ingtransport（■F｛GuRE13﹣4）.Toensuresafbtransfbrs’ traumasurgeonsmustbeinvolvedintraimng,continuingeducation,andqualityimprovementprograms designedfbrtransfbrpersonnelandprocedures.Surgeonsalsoshouldbeactivelyinvolvedinthedevelop﹣ mentandmaintenanceofSystemsoftraumacare.

▼

■F∣GURE13﹣3Tiansfe『Ag『eements.E5tabIishment oft「an5fe「ag『eementsp『ovidefo「thec0nsistentand e什icientm0vementofpatientsbetweeninstitutions’ andenhancethee什iciencyandquality0fthepatient!s t『eatmentdu『ingt「ansfeIt

FaiIu『etoanticipatedete「io「ationinthepatient’5 neu『oIogicc0nditiono「hemodynamic5tatusdu『ing t『anspo「t.

delineated.Ifadequate】ytrainedemergenCymedical personnelarenotavaⅡable’anurseordoctorshould accompanythepatient.Allmonitoringandmanage﹣ mentrenderedenrouteshouldbedocumented.

■

■

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SceⅢa『io■cont『nuedThepatientis intubated!∣nt『aven0usaccessisestab∣i5hed!and 『esuscitati0nwithc「ysta∣I0idisbegun.Achest x﹣『ayc0n↑i『msg00dp05iti0n0↑theend0t「acheal tube』thepate i nt’5hea『t『ateandb∣00dp『e5su『e imp『0veiandape∣vicx﹣『ayd0esn0tdem0nst『ate any↑『a〔tu『eA『ightthighde↑0『mityIsn0ted0n sec0nda「ysu『vey’Aca∣Iismadet0thenea『e5t 【eve∣It『aumacenteK

P I T F A LL

T『an ∣P 『『ansfe『p『otoco∣s Whereprotocolsfbrpatienttransfbrdonotexist’the fbllowingguidelinesaresuggested:

IⅡ『0RMATI0Ⅱ「R0MRE「ERR∣ⅡGD0CT0R Thedoctorwhohasdetermmedthatpatienttransfbr isnecessaryshouldspeakdirectlytothesurgeonac﹦ ceptmgthepatientatthereceivmghospital.Thefbllowinginfbrmationmustbeprovided: ■Patientidentification ■Briefhistoryoftheincident’includingperti﹣ nentpreh0spita1data ■InitialfindingsintheED ■Patient,sresponsetothetherapyadministered

L

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叨 Hb叨s〃甽α觔 I α劂Spo㎡ ●肋epα㎡e㎡β Donoh1rtherharmisthemostimportantprinciplewhen choosingthemodeofpatienttransportation.Ground, water,andairtransportationcanbesafbandeffbctivein fhlfillingthisprinciple’andnoonefbrmisintrinsically superiortotheothersLocalfhctorssuchasavaⅡabⅢty’

Infbrmationregardingthepatient,sc0nditionand needsduringtransfbrshouldbecommumcatedtothe transportingpersonnel.Thisinfbrmationmcludes,but isnotlimitedtα

∣

■Airwaymaintenance ■Fluidvolumereplacement ■Specialproceduresthatmaybenecessary ■RevisedTraumaScore’resuscitationprocedures》 andanychangesthatmayoccurenroute

∣

304CHAPTER13■T「ansfe『toDefinitiveCa「e ＿

︻

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3.Circulation

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a.Controlexternalbleeding· b.Establishtwolarge﹣caliberintravenouslines andbegincrystalloidsolutioninh1sion. cRestorebloodvolumelosseswithc1ystalloid f【uidsorbl0odandcontinuereplacementdur﹣ ingtransfbr. d.InsertanindweⅢngcathetertomonitoruri﹣ naryoutput. e.Momtorthepatient’scardiacrhythmandrate. 4.CentralnervousSystem a·Assistrespirationinunconsciouspatients· b.Administermannitol,ifneeded. CImmobilizeanyhead’neck’thoracic,andlum﹣ barspineinjuries· 5.Diagnosticstudies（Whenindicated;obtaining thesestudiesshouldnotdelaytransfbr.）

■FlGURE13﹣4Theinte『hospitaIt『ansfe「ofac「iticalIy inju「edpatientispotentiaIIyhaza「d0usunle5sthe patient『sconditionisoptimaIIystabilizedbefo『e t「anspo『t!t『ansfe『pe「sonne∣a『ep『ope『lyt『ained’and p「ovisionha5beenmadefo『managingunexpected c「isesdu『ingt『anspo「t.

D0CUⅢENTATI0Ⅱ Awrittenrecordoftheproblem’treatmentgiven’and patientstatusatthetimeoftransfbr,aswellascertain physicalitems,mustaccompanythepatient（■FIGuRE 13﹦5）.Afacsimiletransmissionmaybeusedtoavoid delayintransfbr.

aoObtainx﹣raysofchest’pelvis’andextremities. b。Sophisticateddiagnosticstudies’suchasCT andaortography’areusuallynotindicated. c·Orderhemoglobinorhematocrit’typeand crossmatch’andarterialbloodgasdetermina﹣ tionsfbrallpatients;alsoorderpregnancy testsfbrfbmalesofchildbearingage. d·Determinecardiacrhythmandhemoglobin saturation（electrocardiograph〔ECG】and pulseoximetry）. 6·Wounds（Perfbrmingtheseproceduresshouldnot delaytransfbr.） a·Cleananddresswoundsaftercontrollingex﹣ ternalhemorrhage. b.Administertetanusprophylaxis.

TREA『MEⅡTPRI0RT0TRAⅡs「ER Patientsshouldberesuscitatedandattemptsmade tostabilizetheirconditi0nsascompletelyaspossible basedonthefbllowingsuggestedouthne; 1·Airway a·Insertana1rwayorendotrachealtube’if needed· b.Providesuction. C·Insertagastrictubetoreducetheriskof aspirati0n. Z·Breathing a.Determmerateandadmmistersupplementary o呵gen. b·Providemechanicalventilationwhenneeded. c.Ihsertachesttubeifneeded.

c‘Administerantibiotics,whenindicated· 7·Fractures a’Applyappropriatesplintingandtraction·

Theflurryofactivi叮surroundingtheimtialeval﹣ uation,resuscitation,andpreparationsfbrtransfbr oftraumapatientso仕entakesprecedenceoverother logisticdetails.Thismayresultinthefbiluretomclude certainitemsintheinfbrmationthatissentwiththe patient’suchasx﹣rayfilms,laboratoryreports,or narrativedescriptionsoftheevaluationprocessand treatmentrenderedatthelocalhospital.Acheckhstis helpfUlmthisregardtomakesurethatallimportant componentsofcarehavebeenaddressed（seeFigure 13﹣5）.Checklistscanbeprintedorstampedonanx﹣ray jacketorthepatient,smedicalrecordtoremindthe refbrringdoctortoincludeallpertinentinfbrmation.

MODESOFTRANSpORTATION305

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／

306CHAPTER13■T「ansfe「toDefinitiveCa「e

TREA『MEⅡTDURING丁RAⅡSPORT Theapp『op『iatepe『sonnelshouIdt『ans佗『thepatient, basedoⅡthepatieht,scohditio惻andpotentialp『oblems. Treatmentduringtransp0rt∣Vpicallyincludes: ■Monitoringvitalsignsandpulseoximet1y

∣P T『ansfe『Data Theinfbrmationaccompanymgthepatientshould includebothdemographicandhistoricalinfbrmation pertinenttothepatient’sinjury.Umfbrmtransmissionofinfbrmationisenhancedbytheuseofanes﹣ tablishedtransfbrfbrm’suchastheexampleshown mFigure13﹣5Inadditiontotheinfbrmationalready outlined’spaceshouldbeprovidedfbrrecordingdata 1nanorganized’sequentialfhshion－vitalsigns,cen﹣ tralnervoussystem（CNS）fhnction,andurinaryout﹣

■Continuedsupportofcardiorespirato】ySystem ■Continuedblood-vo】umereplacement ■Useofappropriatemedicationsasorderedbya doctororasallowedbywrittenprotocol ■MaintenanceofcnmmImicationwithadoctor

put－duringtheimtialresuscitationandtransp0rt period SeeSample TraumaFlowSheet

orinstitutiondurmgtransfbr ■Maintenanceofaccuraterecordsduringtransfbr

＝ ﹃

Whilepreparingfbrtransportandwhileitis underway’rememberthat’ifairtransportisused, changesinaltitudeleadt0changesinairpressure’ whichmayresultinincreasesinthesizeofpneumot﹣ horacesandgastricdistention.Hence’placementofa chesttubeorgastrictubeshouldbecarefbllyconsidered·Similarcautionspertaintoanyair﹣fIlleddevice. Forexample,duringprolongedⅡights,itmaybeneces﹣ sarytodecreasethepressureinairsplintsorendotra﹣ cheRItubebHIIo0ns.

P I T F A LL

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Endot「acheaItubesmaybecomedisIodgedo『maIpo﹣ sitioneddu「ingt「anspo「t.Thenecessa『yequipment fo「「eintubationmustaccompanythepatient!and thet『an5fe『pe『sonneImustbecapabIeofpe『fo『m﹣ ingthep「ocedu「e.

「eevaIuated0na『『v i a∣atthe【evetIl『aumacente『｝ hisai『wayissecu「ed!andhehasbiIate『a∣b『eath s0unds.ⅡI5hea「t『ateisl0andbI00dp『e5su「e I00／60ihisGCSis3「ACTscansh0w5a5ubdu『aI hemat0maandam0de『atesp∣enicinlu『y.PIain 「ad0ig『aphsc0n↑『 I ma『g i htfemu『↑『adu『e·

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ChapterSunnnar y ⅢPatientsWhoseinjuriesexceedaninstitution’scapabⅢtiesfbrdefinitivecare shouldbeidentifiedearlyduringassessmentandresuscitation‘Individualcapa﹣ bilitiesofthetreatmgdoctor’institutionalcapabilities,andindicationsfbrtrans﹣ fbrshouldbeknown.Transfbragreementsandprotocolsshouldbeinplaceto supportdefimtivecare.

圃OptimalpreparationfbrtransfbrincludesattentiontoATLS﹫principlesandclear documentation.Therefbrringd0ctorandrece1vmgdoctorshouldc0mmunicate directly.TransfbrpersonnelshouldbeadeqUate】yskiⅡedtoadministerthere﹣ qUiredpatientcareenroute. ﹂

1.AmericanCollegeofSurgeonsCommitteeonTrauma. Reso〃｝℃2s允｝·Op瓦加α／Cα｝它O／靦2In／『〃它dPα瓦e㎡.Chicago,IL:ACS;2006. 2.BledsoeBE,Wesl叮AK,EckstemM,etal.Helicopterscene transportoftraumapatientswithnonli｛b﹣threatening injuries;ameta﹣analysis.J乃α叨／〃α2006;60:1257﹣1266. 3ChampionHR’SaccoWJ’CopesWS,etal.Arevisionof thetraumascore.JTmαmα1989;29:623﹦629 4·MullinsPJ,Veum﹣StoneJ,HelfhndM,etal.Outcomeof hospitalizedinjuredpatientsafterinstitutionofatrauma systeminanurbanarea·JAMA1994﹩271:1919-1924.

5.ScarpioRJ,WessonDE.Splemctrauma.In:Eichel﹣ bergerMR,ed.PediatricTrauma:Prevention’Acute Care,Rehabilitation.St.Louis’MO:MosbyYearbo0k; 1993:456﹣463. 6.SchoettkerP,D’AmoursS’NoceraN,etal.Reductionof timetodefinitivecareintraumapatients;effbctiveness ofanewchecklistsystemI》Vα／y2003;34187.190. 7.ShararSR,LunaGK,RiceCL’etal.Airtransport｛bllo﹣ wingsurgicalstabilization:anextensionofregionalized traumacare.JTJ、αM〃』α1988;28:794.798‘

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309

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APPENDIx

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OcⅡlarTraⅡⅢa（○p加川α』Le咖i刨 ■

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Objectives

∣

Ⅲ0btainpatientandeventhisto『ieS’ 圍Pe『fo『masystematc i examn i ato i noftheo『btiand itscontents.

圃Identfiyeyed il n i 】u『e i 5thatcanbet『eatedby

thep『ima『yca『edocto『andthosethatmustbe 『efe『『edtoanophthalmologistfo『t「eatment.

囤Exp∣ainhowtoexaminetheeyefo「afo「eign bodyandhowto『emovesupe『ficiaIfo『eignbod﹣ e i stop「eventfu「the『In】u『y. 囿ldentifycomealab『asionanddesc『ibeitsp『ope『 management. 圃∣dentifyhyphemaanddesc『ibeitSinitlalman﹣ agementandthenecessiMo『『efe『「aItoan ophthalmoIogi5t. 回Identifyeyein】u『iesthat「equl『e『efe『『altoan 0phthaImologist· 圃ldentify『uptu『ed﹣globein】u『yanddesc「ibe itsinitiaImanagementp『io『to『efe「『altoan ophthalmo∣ogi5t. 圓Evaluateandt「eateyein】u『iesthat『esuItf「om chemC i aIS. ⅢEvaIuateapatientwithano『bitaIf「actu「eand deSc『ibeitsinitialmanagementandtheneCeSSity o f『「ee f『『a.l 田Identi↑y「et「obuIba『hematomaandexpIainthe necessityfo「immediate『efe『「al. L

Theinitialassessmentofapatientwithanoculari叼u﹣ ryrequiresasystematicapproach.Thephysicalexam﹣ inationshouldproceedinanorganized,step﹣by﹣step manner.Itdoesnotrequireextensive,complicatedin﹣ strumentationinthemultiple-traumasetting·Rather, simpletherapeuticmeasuresoftencansavethepa﹣ tient,svisionandpreventserioussequelaebefbrean ophthalmologistisavailable.Thisappendixprovides pertinentinfbrmationregardingtheearlyidentifica﹣ tionandtreatmentofoculariIUuriesthatwillenhance theclinicians,basicknowledgeandmaysavetheirpa﹣ tients’vision.

Assessment Keyfhctorsintheassessmentofpatientswithoculartraumaincludepatienthistory’histo】yofthein﹣ juryincident,initialsymptoms’andresultsofphysical exHm｛hation.

PatientHisto『y Obtainahisto1yofanypreexistingoculardisease.Key questionsinclude: 1.Doesthepatientwearcorrectivelenses? Z.Isthereahistoryofglaucomaorpreviouseye surgery? 3·Whatmedicationsdoesthepatientuse（e.g.’ pilocarpine）?

Histo『yof∣n】u『y∣hcident Obtainadetaileddescriptionofthecircumstancessur﹣ roundingthemjury.Thisinfbrmationoltenraisesthe indexofsuspicionfbrcertainpotentialinjuriesand theirsequelae,suchasthehigherriskofinfbctionfTom certainfbreignbodies（e.g.’woodvs.metallic）.Key qUestionsinclude: 1.Wasthereblunttra】】ma? Z·Wastherepenetratinginju】y?（Inm0torvehicularcrashesthereispotentialfbrglassandmetal﹣ licfbreignbodies.） 3.WasthereamissⅡeiIUury? 4Wasthereap0ssiblethermal,chemical’orflash burn? 311

31ZAPPEhlDIXA■Ocula「T「auma

MtialSymptoms Keyquestionsregardingthepatient’sinitialSymp﹣ tomsinclude: 1.WhatweretheinitialSymptoms? Z·Didthepatientreportpainorphotophobia? 3’Wasthereanimmediatedecreaseinvisionthat hasremainedstable,orisitprogressive?

Physica∣Examination Thephysicalexaminationmustbesystematicsothat fhnctionandanatomicstructuresareevaluated.As withiIUuriestootherorganSystems,thepathology alsomayevolvewithtime,andthepatientmustbe reevaluatedperiodicaⅡy·Adirectedapproachtothe 0cularexamination,beginningwiththemostexternal structuresinan‘‘outside﹣to﹣inside”manner,ensures thatinjuriesarenotmissed.

VisuaIAcuityⅥsualacui∣yisevaluatedfirstbyany meanspossibleandrecorded（e.g.,patientcountmgfin﹣ gersat3fbet〔0.9m】）. EyeIidThemostexternalstructurestobeexam﹣ inedaretheeyelids·Theeyelidsshouldbeassessed fbr:（1）edema;（2）ecclWmosis;（3）evidenceofburns orchemicalmju1y;（4）laceration（s）＿medial,lateral, lidmarg1n,cana1iculi;（5）ptosis,（6）fbreignbodies thatcontacttheglobejand（7）avulsionofthecanthal tendon. O『bitalRimGentlypalpatetheorbitalrimfbrany step﹣o任defbrmityorcrepitus.Subcutaneousemphy﹣ semacanresultfTomafTactureofthemedialorbitinto theethmoidsora仕actureoftheorbitalfloorintothe maxilla1yantrum.

G∣obeTheeyelidsshouldberetractedtoexaminethe globewithoutapplyingpressuretotheglobe.Special】y designedretractorsareavailablefbrthispurpose.Cot﹣ ton﹣tippedapplicatorscanalsobeusedjtheyshouldbe

-

ComeaAssessthecorneafbropacity,ulceration,and fbreignbodies.Fluoresceinandabluelightcanfacili﹣ tatethisassessment.

Con】unctivaAssessthecon】unctivaefbrchemosis’ subconjunctivalemphysema（indicatingprobablefiPac﹣ tureoftheorbitintotheethmoidormaxillarysinus）’ subcoIUunctivalhemorrhage’andfbreignbodies· Ante『io『Chambe『Examinetheanteriorchamberhr hyphema（bloodintheanteri0rchamber）.Thedepth oftheanteriorchambercanbeassessedbyshininga lightintotheeyehomthelateralaspectoftheeye.If thelightdoesnotilluminatetheentiresurihceofthe iris,ashallowanteriorchambershouldbesuspected. Thisconditioncanresultfromananteri0rpenetrat﹣ ingwound.Adeepanteriorchambercanresultfroma posteriorpenetratingwoundoftheglobe·

l『isTheirisshouldbereactiveandregularinshape. Assesstheirisfbriridodialysis（atearoftheiris）and iridod0nesis（afloppyortremulousiris）. LensThelensshouldbetransparent.Assessthe lensfbrpossibleanteriordisplacementintotheante﹣ riorchamber,partialdislocationwithdisplacement intotheposteriorchamber,anddislocationintothe vitreous·

Vit『eousThevitreousshouldbetransparent’allow﹣ ingfbreaSyvisualizationofthehmdus.Visualization maybedifficultifvitreoushemorrhagehasoccurred·In thissituation’ablackratherthanredreflexisseenon ophthalmoscopy.Ⅵtre0usbleedingusuaⅡymdicatesa significantunderlyingocular呵my·Thevitreousalso shouldbeassessedfbranintraocularfbreignbody· RetinaTheretinaisexaminedfbrhemorrhage）pos﹣ sibletears,anddetachment·Adetachedretinaisopal﹣ escent,andthebloodcolumnsaredarker·

Spec『 i C in I 】u『e is

placedgentlyagainstthesuperiorandinfbriororbital rims,enablingtheeyelidstoberolledopen.Thenas﹣ sesstheglobeanteriorlyibranydisplacementfroma retrobulbarhematomaandfbranyposteriororinfb﹣ riordisplacementduetoanorbitfracture.Alsoassess theglobesfbrnormalocularmovement,diplopia’and evidenceofentrapment·

Commontraumaticocularmjuriesincludeeyelidin﹣ jmy,cornealinjury’anteriorchamberinjury,injuryto theiris’injurytothelens,vitreousinjuries,injuryto theretina’globeinjury,chemicalinjury’fractures,ret﹣ robulbarhematoma’andfhtemboli.

PupilAssessthepupilsibrroundness,regularshape’ equality,andreactiontolightstimulus.Itisimportant totestfbranaffbrentpupildefbct.Opticnervetrauma usuallyresultsinthef直ilureofbothpupilstoconstrict whenlightisdirectedattheaffbctedeye‘

Eyelidinjuriesoftenresultinmarkedecchymosis, makingexaminationofinjuriestotheglobeandliddif ficult·However’amoreseriousinjurytotheunderly﹣ ingstructuresmustbeexcluded.Lookbeneaththelid aswelltoexcludedamagetoljheglobeLidretractors

Eye∣idInju『y

APPENDIXA■OcuIa『T『auma313

orcotton﹣tippedapphcatorscanbeusedifnecessa】yto fbrciblyopentheeyetoinspecttheglobe.Ptosismay resultfTomedema’damagetothelevatorpalpebrae,or oculomotornerveiIUmy. Lαce｝u㎡o几s0ftheupperandlowerlidsthatare horizontal’superficial’anddonotinvolvethelevator intheupperlidmaybecl0sedbytheexamimngclini﹣ cianusmginterrupted6﹣0skinsutures.Thechmcian alsoshouldexaminethe叮ebeneaththehdtoruleout damagetotheglobe. L㎡dt／血㎡esr／tα力﹃eqm沱㎡eαt加e〃『byα九0P〃t／jα／﹣ mo／ogts『include: ■Woundsmvolvingthemedialcanthusthat mayhavedamagedthemedialcanaliculus ■Injuriestothelacrimalsacandnasa1lacrimal duct,whiChcanleadtoobstructionifnot properlyrepaired ■Deephorizontallacerationsoftheupperlid thatmayinvolvethelevatorandresultin ptosisifnotrepairedcorrectly ■LacerationsoftheⅡdmarginthataredifficult tocloseandcanleadtonotching’entropion,or ectropion Thesewoundsmaybecoveredwithasalinedress﹣ ingpendingemergenCyophthalmologicconsultation. Fb／它﹠g几b0d古esofthehdresultinprofhsetearing, pam,andafbreign-bodysensationthatincreaseswith lidmovement.Theconjunctivashouldbeinspected’ andtheupperandlowerlidsshouldbeevertedto examinetheinnersurface.Topicalanestheticdrops maybeused’butonlyfbrmitialexaminationand removalofthefbreignbody. Penetratingfbreignbodiesshouldnotbedisturbed andareremovedonlyintheoperatingroombyanoph﹣ thahnologistorappropriatespeciaⅡst.Ifthepatient reqUirestransporttoanotherfhcⅢtyfbrtreatment 0fthisinjmyoro洫ers,consultanophthalmologist regardingmanagementoftheeyeduringtransport.

Co『neaIIniu『y αmeα／αbrαszoⅦsresultmpain,fbreign﹣bodysensa﹣ tion’photophobia’decreasedvisualacuity,andchemo﹣ sis’Theinjuredepitheliumstainswithfluorescein. Cb／Ⅶeα／／bFeZg冗bodtessometimescanberemoved withirrigation.H0wever,ifthefbreignbodylsembed﹣ ded,thepatientshouldberefbrredtoanophthalm0lo﹣ gist.Cornealabrasionsaretreatedwithantibiotic dropsorointmenttopreventulcers.Clinicalstudies havedemonstratednoadvantaget0patchinginterms ofpatientcomfbrtortimereqUiredfbrtheabrasion t0heal.ThepatientshouldbeinstructedtoinstiⅡthe dr0psorointmentandshouldbefbllowedupwithin24 to48h0urs.

Ante『io『Chambe『ln】u『y 正加〃e加αisblo0dintheanteriorChamber’whiChmay bedifficulttoseeifthereisonlyasmallamount.Inextremecases,theentireanteriorchamberisfilled.The hyphemacanoftenbeseenwithapenⅡght.Hyphema usuallyindicatessevereintraoculartrauma. G／α叨co加αdevelopsin7﹪ofpatientswith hyphema.Cornealstainingalsomayoccur.Remember’ hyphemacanbetheresultofseriousunderlyingocular injury.Eveninthecaseofasmallbleed’spontaneous rebleedingoftenoccurswithinthefirst5days,which mayleadtototalhyphema.Therefbre,thepatient mustberefbrredtoanophthalm0logist.Theaffbcted eyewⅢbepatched’andthepatientusuaⅡyishospita1﹣ ized,andreevaluatedfrequently.Painafterhyphema usuallyindicatesrebleedingand／oracuteglaucoma.

In】u『ytotheI『is Contusionmjuriesoftheiriscancausetraumaticmy﹣ driasisornnosis.Theremaybedisruptionoftheirishom theciharybody,causinganirregularpupilandhyphema.

ln】u『ytothelens Contusionofthelenscanleadtolateropacificationor cataract仇rmHtion·Blunttraumacancauseabreakof thezonularfibersthatencirclethelensandanchoritto theciharybody.Thisresultsmsubluxationofthelens’ possiblyintotheanteriorchamber,causingshallowing ofthechamber.Incasesofposteriorsubluxation,the anteriorchamberdeepens.Patientswiththeseinjuries shouldberefbrredtoanophthalmologist.

Vit『eousIn】u『y Blunttraumamayalsoleadtovitreoushemorrhage. Thisusuallyissecondarytoretinalvesseldamageand bleedingintothevitreous,resultingmsudden’pro﹣ fbundlossofvisi0n.Funduscopicexaminationmay beimpossible,andtheredreflex,seenwithanophthalmoscopelight》islost.Apatientwiththisinjmy shouldbeplacedonbedrestwiththeeyeshieldedand refbrredtoanophthahnologist.

∣n】u『ytotheRetina Blunttraumaalsocancauseretinalhemorrhage.The patientmayormaynothavedecreasedvisualacui↑y, dependingoninvolvementofthemacula.Superficial retinalhemorrhagesappearcherryredincolor’where﹣ asdeeperlesionsappeargray. Retinaledemaanddetachmentcanoccurwith headtrauma.Insuchcases,awhite,cloudydiscolora﹣ tionisobserved.Retmaldetachmentsappear“cur﹣ tain﹣like.”Ifthemaculaisinvolved,visualacuityis affbcted.AnacuteretinaltearusuaⅡyoccursincon﹣

31qAPPENDIXA■OcuIa「T「auma

junctionwithblunttraumatoaneyewithpreexist﹣ ingvitreoretinalpathology.Retinaldetachmentmost oftenoccursasalatesequelaofblunttrauma’with thepatientdescribmglightflashesandacurtain﹣like defbctinperipheralvision. Aruptureofthechoroidimtiallyappearsasa beigeareaattheposteriorpole.Lateritbecomesa yellow﹣whitescar.Ifittransectsthemacula’visionis seriouslyandpermanentlyimpaired.

Thetreatmentfbrchemicalinjuriestotheeyes involvescopiousandcontinu0usirrigation.Attempts shouldnotbemadetoneutralizetheagent.Intrave﹣ noussolutions（e.g·,c1ystalloidsolution）andtubing canbeusedtoimprovisecontinuousirrigation.Blepharospasmisextensive’andthehdsmustbemanually openedduringirrigation.Analgesicsandsedation shouldbeused’ifnotcontraindicatedbycoexisting injuries·Thermalinjuriesusuallyoccurtothelidsonly andrarelyinvolvethecornea·However,burnsofthe

GIobeIn】u『y

globeoccasionallyoccur.Asteriledressingshouldbe appliedandthepatientrefbrredtoanophthalmolo﹣

Apatientwitharupturedglobehasmarkedvisual impairment·The叮eissoftbecauseofdecreasedin﹣ traocularpressure’andtheanteriorchambermaybe flattenedorshallow.Iftheruptureisanterior’ocular contentsmaybeseenextrudingfTomtheeye. Thegoalofimtialmanagementoftheruptured globeistoprotectthe叮efTomanyadditionaldamage Assoonasarupturedglobeissuspected,theeyeshould notbemanipulatedanyfhrther.AsterⅡedressingand eyeshieldshouldbeapphedcaremllyt0preventany pressuretotheeyethatmaycause血rtherextrusionof theocularcontents.Thepatientshouldbeinstructed nottosqueezetheimuredeyeshut.Ifnotcontraindicatedbyotherinjuries’thepatientmaybesedatedwhile awaitmgtransportortreatment.Donotremove釦reign ohjects,tissue,orclotsbefbreplacmgthedressing.Do notusetopicalanalgesics＿onlyoralorparenteral,if notcontraindicated叮anyotheriIUuries· An加tmocα／αγ／b祀唔几bodyshouldbesuspectedif thepatientreportssudden,sharppajnwithadecrease invisualacuity,particularlyifthe叮emighthavebeen struckbyasma1l丘agmentofmetal’glass’orwood Inspectthesurihceofthegl0becareh1llyfbranysmall lacerationsandpossiblesitesofentry.Thesemaybe difficulttofind.Intheanteriorchamber’tinyfbreign bodiesmaybehiddenbybloodorinthecryptofthe iris.Atinyirisperfbrationmaybeimpossibletosee directly,butwithapenlighttheredreflexmaybe detectedthroughthedefbct（ifthelensandvitreous arenotopaque）.

Chemica∣In】u『y Chemicalinjuriesrequireimmediateintervention inordertopreservesight.Acidprecipitatesproteins inthetissueandsetsupsomewhatofanaturalbar﹣ rieragainstextensivetissuepenetration.However, alkalicombineswithlipidsinthecellmembrane, leadingtodisruptionoftheceⅡmembranes’rapid penetrationofthecausticagent’andextensivetissue destruction.Chemicalinjurytothecorneacausesdis﹣ ruptionofstromalmucopolysaccharides,leadingto opacification.

gist’Exposureofthecorneamustbepreventedorit mayperfbrate,andthe叮emaybelost. F『actu『es Blunttraumatotheorbitmaycauserapidcompres﹃ sionofthetissuesandincreasedpressurewithinthe orbit.Oneoftheweakestpointsisthe0rbitalfloor’ whichmayfTacture,allowingorbitalcontentstoher﹣ niateintotheantrum＿leadingtotheuseoftheterm ‘‘bo l wout·” Clinically,thepatientpresentswithpain,swell﹣ ing’andecchymosisofthelidsandperiorbitaltissues. Theremaybesubconjunctivalhemorrhage.Facial aSymmetryandpossibleenophthahnoscanbeevident ormaskedbysurroundingedema.Limitationofocu﹣ larmotionanddiplopiaseconda】ytoedemaorentrapmentoftheorbitalcontentsmaybenoted·Palpation oftherimsmayrevealafracturestep﹣offdefbrmity. Subcutaneousand／brsubconJunctivalemphysema may0ccurwhenthefractureisintotheethmoidor maxilla1ysinuses·Hypesthesiaofthecheekoccurs secondarytoinjury0ftheinfraorbitalnerve·Examine theorbitalfloorandlookfbrsoft﹣tissuedensityinthe maxiⅡarysinusoranairfluidlevel（blood）.Computed tomographicscansarealmostessentialfbradequate evaluation. Treatmentoffracturesmaybedelayedupto2 weeks.Watchfhlwaitingmayhelptoav0idunneces﹣ sarysurgerybyallowingtheedematodecrease.Indi﹣ cationsfbrorbitalblowoutrepairincludepersistent diplopiainafhnctionalfieldofgaze,enophthalmos greaterthan2mm,andfractureinvolvingmorethan 50℅0ftheo1bitalHoor.

Ret『obulba『Hematoma AretrobulbarhematomareqUiresimmediatetreat﹣ mentbyanophthalmologist.Theresultingincreased pressurewithintheorbitcompronnsesthebloodsup﹣ plytotheretinaandopticnerve,resultingmbhndness ifnottreated.Ifpossible’theheadshouldbeelevated, withnodirectpressureplacedonthe叮e.

APPENDIXA■OcuIa「T『auma315

〕 ∣

■

Summa 『 y

Thorough,systematicevaluationoftheinjured叮e resultsinfbwsignificantinjuriesbeingmissed.Once injurieshavebeenidentified,treattheeyeinju】yusing simple,systematicmeasures,preventfbrtherdamage; andhelppreservesightuntilthepatientisinanoph﹣ thalmologist,scare.

3.FlynnCA,D,AmicoF,SmithG.Shouldwepatch cornealabrasions?Ameta﹣an刨ysis·JFhmPrαcZ 1998;47:264﹣270 4.HartA,WhiteS,ConboyP,etal.Themana2ementof cornealabrasionsinaccidentandemergency.I〉V吻y 1997,28:527﹣529. 5·PattersonJ’FetzerD,KrallJ,etal.Eyepatchtre﹣ atmentfbrthepainofcornealabrasion·SoM『／jMbdJ 1996;89:227﹣229. 6.PoonA’McCluskeyPJ,HillDAEyeinjuries1npatients withmajortrauma.JTJuM加α1999;46:494﹣499.

■Sb i ∣o i g卹hy 1.ArbourJD’BrunetteI’BoiSjolyHM,etal.Shouldwepatch cornealerosions?A／.c／jOPMiα』〃』o／1997;115:313-317. 2.CampanileTM’StClairDA’BenaimMTheevaluation ofeyepatchinginthetreatmentoftIaumaticcornealepi﹣ thelialdefbcts.JE〃』e／gM它d1997;15:769﹣774.

7·Sast】ySM’PaulBK,BainL’ChampionHR:Oculartraumaamongm勻ortraumavictimsinaregional traumacenter.JZ扣M／Ⅶα1993;34:223﹣226. 8.TasmanWS·Posteriorvitreousdetachmentandperiphe. ralretinalbreaks.Tm几sA〃』AcααOp〃t／iα／／〃o／Oto／αJy几﹣ gO／1968;72:217.

Ⅸ

∣

APPENDⅨ∣ ﹂B

匕蝓 ＼毗.﹃＞

V

＝

≡

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＝

﹃

∣ I∣ I

Hypotl1erⅡ1iaandHeatInjuries Objectives

圓Desc「ibethedi什e「encesbetweenaCcidental hypothe『miaandthe『apeutichypothe『mia

tainadditionalmjuriesorcomplicationsduetothis exposure’withoutsustainingburnsorfTostbite.The environmentalexposuremaybetheonlymjmy’but theexposurecancomplicatetraumaticinjuries·This appendixdescribesthetwoextremesofenvironmental exp0sureandthepotentialresultinginjuries.

圍Exp∣ainthedange「ofhypothe「miainthein】u「ed patient.

Co∣d∣n】u『y;Systemc i Ⅱypothe『ma i

ⅢIdent∣fythep「ob∣emsencounte「edwithin】u「ies duetoexposu『e.

四Definethetwo∣eveIsofheatin】u「y:heatexhaus﹣ tionandheatst『oke. ﹂

∣∣nt『oduction Patientsmaybeexposedtotheenvironmentandsus﹣

Hypothermiaisdefinedasacorebodytemperaturebe﹣ low35。C（95。F）.Intheabsenceofconcomitanttrau﹣ matici叮ury’hypothermiamaybeclassifiedas”／d （35。Cto32。C》or95。Fto896。F）,modb／u／e（32。Cto 30。0,or89.6。Fto86。F）’orseue死（below30。O,or 86。F）.Thisdropincoretemperaturecanberapid’as inimmersioninnear﹣freezingwater’orslow’asinex﹣ posuretomoretemperateenⅥronments. Olderadultsareparticularlysusceptibletohypo﹣ thermiabecauseoftheirimpairedabilitytoincrease heatproductionanddecreaseheatlossbyvasocon﹣ striction.Childrenalsoaremoresusceptiblebecause oftheirrelativeincreasedbody﹣surfhcearea（BSA）and limitedenergysources. Theriskofhypothermiaisofspecialconcernin traumapatients’astheyareexposedfbrexaminations, g1venroomtemperaturefluidboluses）andmaybe g1venmedicationthataffbctstheirabⅡitytomaintain corebodytemperature（e.g.,paralytics）. Hypothermiaiscommonintheseverelyinjured’ butfhrtherlossofcoretemperaturecanbehmited withtheadministrationofonlywarmedintravenous fluidsandblood’judiciousexposureofthepatient, andmaintenanceofawarmenv1ronment.Because determinationofthecoretemperature,prefbrably esophageal》lsessentialfbrthediagnosisofSystemic hypothermia’specialthermometerscapableofreg isteringlowtemperaturesarerequiredinthosesus﹦ pectedofhypothermia. Signs Inadditiontoadecreaseincoretemperature’ade﹣ pressedlevelofconsciousnessisthemostcommon fbatureofhypothermia.Patientswithhypotherm1a arecoldtothetouchandcanappeargrayandcyan﹣ otic.Ⅵtalsigns,includingheartrate’respiratoryrate’ ●

317

318APPENDIXB■Hypothe「miaandHeatIn】u「ie5 andbloodpressure,areallvariable,andtheabsence ofrespirato1yorcardiacactivityisnotuncommonin patientswhoeventuallyrecover.Becauseofseve『ede﹣ p『essiono「the『espi『ato『y『ateandlTea『t『ate,signsof 『espi『ato『yandca『diacactivitya『eeasilymisseduhIess ca『efi』Iassessmentisconducted.

warmedhumidificationtoventilation’andproceeding toinvas1vesurgicalrewarmmgtechniquessuchasperi﹣ toneallavage,th0racic／pleurallavage’arteriovenous rewarⅡnng,andcardiopulmonarybypass,allofWhich arebestaccomphshedinacriticalcaresetting.Car﹣ diopulmona1ybypassisthemosteffbctivemethodof rewarnungpatientswithseverehypothermia.

Management ImmediateattentionisdevotedtotheABCDEs’in﹣ cludingtheinitiationofcardiopuhnonaryresuscita﹣ tion（CPR）andestabhshmentofintravenousaccessif thepatientisincardiopulmonaryarrest·Caremustbe takentoidenti句thepresenceofanorganizedcardiac rhythm;ifoneexists,sufficientcirculationinpatients withmarkedlyreducedmetabolismislikelypresent, andvigorouschestcompressionscanconvertthis rhythmtofibriⅡation.Intheabsenceofanorganized rhythm,CPRsh0uldbeinstitutedandc0ntinueduntil thepatientisrewarmedorthereareotherindications todiscontinueCPR。However,theexactroleofCPRas anadjuncttorewarmingremamscontroversial· Preventheatlossbyremovingthepatientfromthe coldenv1ronmentandreplacingwet’coldclothingwith warmblankets.Administero唧genviaabag﹣reservoir device.Thepatientshouldbetreatedinacriticalcare settingwheneverpossible）andcardiacmonitoring isrequired.Acarefhlsearchfbrassociateddisorders （e。g·’diabetes’sepsis’anddrugoralcoholingestion）0r occultinjuriesshouldbeconducted,andthedisorders shouldbetreatedprompt】y.Bloodshouldbedrawnfbr completebloodcount（CBC）,electrolytes,bloodglu﹣ cose）alcohol,toxins》creatinine,amylase,andblo0d cultures·Abnormalitiesshouldbetreatedaccordingly; fbrexample,hypoglycemiarequiresintravenousglu﹣ coseadministration· DeterminationofdeathcanbeverydifficUltm patientswithhypothermia·Patientswhoappearto havesuiIbredacardiacarrestordeathasaresultof hypothermiashouldnotbepronounceddeaduntⅡfhⅡ e飾rtshavebeenmadetorewarmthem.Remembe『the axiom:‘‘γoua『enotdeaduntiIyoua『ewa『manddead·｝） Anexceptiontothisruleisapatientwithhypotherm1a whohassustainedananoxiceventwhilestiⅡno】。mothermicandwhohasnopulseorrespiration,oroneWho hasaserumpotassiumlevelgreaterthan10mmol／L. TheappropriaterewarmingtechmqUedependson thepatient,stemperatureandhisorherresponseto simplermeasures,aswellasthepresenceorabsence ofconcomitantinjuries.Forexample,treatmⅡdand moderatee卹osurehypothermiawithpassiveexternalrewarmingmawarmroomusmgwarmblankets, ambientoverheadheaters’warmedfbrced﹣airblankets, andwarmedintravenousfluids.Severehypothermia mayrequireactivecorerewarmingmeth0ds’starting withbladderirrigationwithathree﹣wayfbl叮’adding

PhysioIogiCEffectsofⅡypothe『mia CardiacoutputfaⅡsinproportiontothedegreeofhy﹣ pothermia,andcardiacirritabilitybeginsatapprox1﹣ mately33。C（91.4。F）.Ventricularfibrillationbecomes increasinglycommonasthetemperaturefallsbelow 28。C（82.4。F）’andattemperaturesbelow25oC（77。F） asystolecanoccur.Cardiacdrugsanddefibrillation aren0tusuallyeffbctiveinthepresenceofacidosis, hypoxia’andhypothermia.Ingeneral’thesetreat﹣ mentmethodsshouldbepostponeduntilthepatient iswarmedtoatleast28。C（82.4·F）·Giventhehighpo﹣ tentialfbrcardiacirritablity,itisinadvisabletoinsert asubclavianorinternaljugularlineinhypothermic patientsduetotheriskoftriggeringanuncontrolla﹣ blecardiacarrythmia.Bretyliumtosylateistheonly dysrhythmiaagentknowntobeeffbctive,however,it isnolongermanufhcturedLidocaineisinefIbctivein patientswithhypothermiawhohaveventricularfi﹣ brillation.Dopamineisthesingleinotropicagentthat hassomedegree0factioninpatientswithhypother﹣ mia·Administer100℅oxygenwhilethepatientisbe﹣ ingrewarmed·Arterialbloodgasesareprobablybest interpreted“uncorrected,”thatis’thebloodwarmed to37。C（98.6。F）,withthevaluesusedasguidesto 洌刷ministeringsodiumbicarbonateandadjustingven﹣ tilationparametersduringrewarmingandresuscita﹦ tion.Attemptstoactivelyrewarmthepatientshould notdelaytransfbrtoacriticalcaresetting·

Ⅱeatn I 】u『e is Heatexhaustion（HE）andheatstroke（HS）,themost seriousfbrmsofheatinjury,arecommonandprevent﹣ ablec0nditions·Excessivecoretemperatureinitiatesa cascadeofinflammato】ypathologiceventsthatleadsto mildheateyd1austionand,ifuntreated,eventuaⅡyto multi﹣organfhilureanddeath.Theseveri叮ofHScor﹣ relateswiththedurationofhyperthermia·Rapidreductionofbodytemperatureisassociatedwithimproved survival.Othercausesofhyperthermianeedtoberuled out’especiaⅡympatientsonp可chotropicdrugsorwith ahisto1yofrecentexposuretoanesthetics.

TypeSofHeatIniu『ies Hm㎡αhαIzs觔o／】isacommondisordercausedbyexces﹣ sivel0ssofbodywater’electrolytedepletion,orboth.

APPENDIXB■Hypothe「miaandHeatIn】u「ies ItrepresentsanⅢ﹣definedspectrum0fsymptoms’in﹣ cludingheadache,nausea】vomiting》light﹣headedness, malaise’andmyalgia.ItisdistinguishedfromHSby havingmentalfhnctionthatisessentiallyintactand acoretemperatureusuallylessthan39。C（102.2。F）. Hm﹠s力.o〃e（HS）isalifb﹣threateningdisease, generallydefinedashyperthermia≧40。C（104。F） withassociateddehydration’hotflusheddryskin, andcentralnervoussystemdysfUnction’resultingin delirium’convulsions’andcoma.HSisassociatedwith asystemicinflammatoryresponse,whichmayleadto multipleorgandysfhnctionanddisseminatedintravas﹣ cularcoagulation（DIC）. TherearetwofbrmsofHS·Classic,ornon﹣exertionalHS’frequentlyoccursduringenvironmental heatwavesandprimarilyaffbctselderlyand／orill patients.ExertionalHSusuallyoccursinhealthy’ young,andphysicallyactivepeoplewhoareengaged mstrenuousexercisemhotandhumidenvironments· HSoccurswhenthecorebodytemperaturerisesand thethermoregulatorysystemfhilstorespondade﹣ quatelyChildrenleftinp0orlyventilatedautomobiles parkedinthesuncanalsodevelopHS. ThemortalityofHSvariesandrangesfrom33℅ toashi酗as80℅inpatientswithclassicHS.Those individualswhodosurvivemaysustainpermanent neurologicaldamage.PatientswithHSpresentwith tachycardiaandtachypnea.Theymaybehypotensive ornormotensivewithwidepulsepressure.Corebody temperatureis≧40。C（104·F）.Skinisusuallywarm anddryorclammyanddiaphoretic·Liverandmuscle enzymeslevelwillbeelevatedinvirtuallyallcases·

Pathophysiology Thehumanbodyisabletomaintainacorebodytem﹣ peratureatab0ut37oC（98.6。F）,despitebeingexposed toawiderangeofenvironmentalconditions,through multiplephysiologicalresponsesthatservetobalance heatproductionanddissipation.Heatisbothgeneratedbymetabolicprocessesandgainedfromthe environment. Thefirstresponsetoanelevatedcoretempera﹣ tureisperipheralvasodilation’increasinglossthrough radiation.However,iftheambienta1rtemperature isgreaterthanthatofbodytemperature,hyperthermiawillbeexacerbatedTodissipateheatwhenthe ambienttemperatureexceeds37。C（98·6。F）,sweating isrequired·Ambienttemperatureandrelativehumid﹣ itycanafIbcttheeificienCyofheatdissipation’The averagepersoncanproduce1.5Lofsweatperhour, increasingto2.5Linwell﹣trainedathletes.Cutane﹣ ousvasodilatationmayincreaseperipheralbloodflow from5℅toupto20℅oftotalcardiacoutput. Theeffbrentinfbrmationsenttothetemperature﹣ sensitiveneur0nsinthepre﹦opticanteriorhypotha﹣

319

lamusresultsinathermoregulato1yresponse.This responseincludesnoton】yautonomicchanges,such asanmcreaseinskinbloodflowandsweating,but als0behavioralchanges,suchasrem0v1ngclothmg ormovingtoacoolerarea’Properthermoregulation dependsonadequatehydration·Thenormalcardio﹣ vascularadaptationtosevereheatstressisanincrease incardiacoutputupto20L／min.Thisresponsecan beimpairedbysaltandwaterdepletion,cardiovascu﹣ lardisease,ormedicationthatinterfbreswithcardiac fhnction’resultinginincreasedsusceptibilitytoHS. Whenthenormalphysiologicalresponsefhilstodissi﹣ pateheat’thecorebodytemperatureincreasessteadilyuntilitreaches41to42。C（105·8·Fto107.6。F）,or criticalmax1mumtemperature. Atthecellularlevel’exposuretoexcessiveheat canleadtodenaturationofproteins’phospholipids, andlipoprotein’andliquefhctionofmembranelipids. Thisresultsmcardiovascularcollapse,multi﹣organ fhilure,andultimatelydeath.Acoordmatedinflamma﹣ toryreactiontoheatstressinvolvesendothelialceⅡs, leukocytes’andepithelialcellsinanattempttoprotect againsttissuem】uryandpromotehealing.Avarietyof Cytokinesareproducedinresponsetoendogenousor environmentalheat·Cytokinesmediatefbverandleu﹣ kocytosis,andincreasesynthesisofacutephasepro﹣ teins.Endothelialcellinjuryanddiffnsemicrovascular thr0mbosisareprominentfbaturesofHS’leadingto DIOFibrinolysisisalsohighlyactivated·Normaliza﹣ tionofthecorebodytemperatureinhibitsfibrinoly﹣ sis,butnottheactivationofcoagulation’Thispattern resemblesthatseeninsepsis. HSanditsprogressiontomulti-organdysfUnc﹣ tionareduetoacomplexinterplayamongtheacute physiologicalalterationsass0ciatedwithhyperthermia （eg.’circulatoryfhilure,hypoxia,andincreasedmeta﹣ bolicdemand）,thedirectCytotoxicityofheat,andthe inflammatoryandcoagulationresponsesofthehost.

Management SpecialattentiontoaiIwayp『otectioⅡ,adequatevehtiIa﹣ tion）andfiuid『esuscitationa『eessentialtot『eatingheat iⅡiu『ies’aspuImona『yaspi『ationandhypoxiaa『eimpo『﹣ tantcausesofdeath.Initially,100℅o瞰genshouldbe administeredja仳ercooling》fhrtheroXygendelivery shouldbeguidedbyarterialbloodgasresults. Patientswithanalteredlevelofconsciousness,sig﹣ nificanthypercapnia》orpersistenthypoxiashouldbe intubatedandmechanicallyventilated.Arterialblood gas,electrolytes,creatinine’andbloodureanitrogen levelsshouldbeobtainedasearlyaspossible.Renal fhilureandrhabdomyo】ysisarefreqUentlyseeninHS patients.Achestx﹣rayshouldbeperfbrmed.Hypog】ycemia’hyperkalemia’andacidosisshouldbetreatedby standardmethods.Hypokalemiamaybecomeapparent

3Z0APPENDIXB■Hyp0the「miaandHeatln】u「ie5 andnecessitatepotassiumreplacement,particular】y asacidemiaiscorrected.Seizuresmaybetreatedwith benz0diazep1nes. p『omptco『『ectionofhype『the『miabyimmediate ∞olingandsuppo㎡o「o『gan﹣system｛imctiona『ethetwo mainthe『apeuticobiectivesinpatientswithHS. Coohngmeasuresarestartedassoonaspractical andcontinueenroute.Watersprayandairflowover thepatientisidealintheprehospitalsetting’with applicationoficepackstoareasofhighbloodflow （groin’neck’axiⅡa）asanalternative·Rapidreduc﹣ tionofbodytemperatureisassociatedwithimproved survival.Althoughthereisgeneralagreementonthe needfbrrapidandeffbctivecoolingofhypertherm1c patientswithHS,thereiscontroversyoverthebest methodofachievingit.Thecoolingmethodbasedon conduction,namelyimmersioninicedwaterstarted withinminutesoftheonsetofexertionalHS,isfhst, safbandeffbctiveinyoung’healthyandwell﹣trained militarypersonnelorathletes. InmasscasualtyeventswithclassicHS,thebody﹣ coolingunit（BCU）canachieveexceⅡentcoolingrates withimprovedsurvival.TheBCUinvolvesspraying patientswithwaterat15。C（59。F）’andcirculating warmairthatreachestheskinat30to35。C（86。Fto 95。F）.Thistechniqueiswelltoleratedandallowsfbr optimalmonitoringandresuscitationofunconscious andhemodynamicallyunstablepatients.Non﹣inva﹣ siveandwell﹣toleratedcoolingmodalities’suchasice packs,wetgauzesheets’andfhnaloneorincombi﹣ nati0n’couldrepresentreasonablealternatives’since theyareeasⅡyapphedandreadilyaccessible.Surviva1 andoutcomesinHSaredirect】yrelatedtothetime requiredtoinitiatetherapyandcoolpatientsto二39oC （1022。F）.

Summa『y Theinjuriesduetoheatandcoldexposurearenotonly burnsorfTostbite,butcanresultinSystemicaltera﹣ tionsintemperatureregulationandhome0stasis.Itis importanttounderstandtheetiologyandtreatmentof exposure1叼ur1es.

■Ⅲo i 9『aphy Cold!n】u『ies 1.CasteⅡaniJW’Y0ungAJ,DucharmeMB’etal·American CollegeofSportsMedicinepositionstandpreventionof coldinjuriesduringexercise.【Review1MedSα印or妁 E】:er2006;38（11）:2012﹣2029. 2.HildebrandF,GiannoudisPV’vanGriensvenM,etal. Pathophysiologicchangesandeffbctsofhypothermiaon outcomeinelectivesurgeryandtraumapatients.A加J SαJg2004;187（3）:363﹣371. 3.KonstantinidisA,InabaK,DuboseJ,etal.Theimpact ofnontherapeutichypothermiaonoutcomesaltersevere traumaticbraininju1y·JTrα【↓mα2011;71（6）:1627﹦1631. 4.LarachMGAccidentalhypothermia.Lα〃cα1995, 345（8948）:493﹣498. 5.MallettML.Accidentalhypothermia.Qe／M2002;95（12）: 775﹦785. Heat∣n】u『ies 1GlazerJL。Managementofheatstrokeandheatexhau﹣ stion.AmFhmP〃JsJαα〃2005;71（11）:2133﹣2140 2.YeoTP.Heatstroke:acomprehensivereviewAAαV α加ISsαes2004;15（2）:280﹣293·

∣

【

︻

▼

步

V

∣ ∣ ll IAPPENDⅨ∣∣∣》一 ▼ ﹣ C ∣ ∣

酗、

＼

﹁

AustereandArⅢedConflictEnviroⅢnents（0p加肋α／Lec卹.e）

∣Int『oduction Objectives ⅢExp∣an l them i pactofauSte「e＆host∣ i eenv「 i on﹣ mentsoncasualtyca『e

圃Desc「ibetooIsfo『e什ectivemas5casuaItyca『e. 圃DiscusschaIIengesfo「casuaItyca『einauste「e﹠ a『med〔on｛c iI tenv『 i onments. ﹂ 口 ＿ － ＿

DisastersoccurglobaⅡyfromnatural,technological, andhumanconflictcauses.Nocommunityisimmune: Eventhemostsophisticatedhospitalscanbecomeaus﹣ terefRcilitiesafteradisaster’withⅡmitedresources availabletoprovidecaretooverWhelmingcasualties. Thedisasterscenecanbedangerous’withrisksthat includestructuralcoⅡapse,exposedutilities,andfIo0d﹣ ing·Effbctivedisastermanagementisnotbusinessas usual,itrequiresadiffbrentmindsetthatrecognizes theneedfbrcasualtypopulationmanagementandex﹣ plicithealthcareworkersafb叮.“Adaptandovercome” isthemodelsloganfbrreadiness. ATLShaditsoriginsinaNebraskafieldfbllowing aplanecrashinwhichtheinjuredreceivedinadequate careinanaustereenv1ronment.Althoughcommonly seenthroughthelensofplentifUlresources’ATLS providesaframeworkfbrmasscasual叮careinaus﹣ tereandconflict﹣riddenenvironmentswith】imited resources.FurtherdepthcanbefbundintheACS DisasterManagementandEmergenCyPreparedness （DMEP）course·

MassCasualtyCa『e AmasscasualtyeventexistsWhencasualtiesexceed theres0urcestoprovidecompleteindividualcare’typi﹣ caⅡyinasituationofincompleteinfbrmationandun﹣ certain叮regardingeventevolution.Indisaster’the careparadigmshiftsfiPomthegreatestgoodfbrthein﹣ dividualtothegreatestgoodfbrthegreatestnumber ofcasualties.ThisisdiffbrentfTomeverydaytrauma care,inwhichallresourcesaremobⅢzedfbrthego0d ofanindividualiUjuredpatient.Inthecontextofdisas﹣ ter,decisionsmadefbronecasual叮canhaveanef【bct ondecisionsfbrothercasualties’becauseofresource limitationsandthesituati0n. Casual叮dispositionintheaftermathofdisaster relatestotheintersectionofcasual叮’resource’and situationconsiderations.Ctzs叨α／rycharacteristics includeimmediatelylifb﹣threatemnginjuries,simplic﹣ ity0finterventionstomanagethreatstolifb,iIUmy severity’andsurvivability.Inabili｛ytosurv1veisboth absolute（e.g.’100﹪third﹣degreebodysurfhcearea burns）andrelative（e.g.’extensiveinjuriesconsume resourcesfbronecasualtythatcouldbeusedtosave morethanonecasualty）.

3z1

3ZZAPPENDIXC■Auste『eandA『medC0nflictEnvi「onment5 Reso叨／℃econsiderationsincludewhatisavailRble （e.g·,space,staff;supplies,systems）fbrcareandevac﹣ uation（transportation’roads）’asweⅡasthetimeline fbrresupplyandcasualtyevacuation· Thes㎡αα加o〃involveseventprogression》second﹣ aryevents（i’e’’additionaleventsinsequencewiththe incitingevent,toincludesecondarybombs’structural collapseafteranexplosion,andfloodingafterlevees break）》andenv1ronmentalconditions（i.e·,timeofday’ weather,andgeography）.

Toolsfo『EffectivelVIassCasuaItyCa『e Incidentcommandandtriageareessentialtoolsfbr effbctivemasscasualtycare.肋αde㎡commα兀disa systemmanagementtoolthattransfbrmsexisting organizationsacrossplanning,operations,logistics’ andfinance／admih↑strationfimctionsfbrintegrated andcoordinatedresponse.Thereisanincidentcom﹣ manderwhohasresponsibilityfbrtheoverallresponse toensurethesafbtyofresponders,savehves’stabilize theincident,andpreservepropertyandtheenv1ron﹣ ment.CasualtychnicalcarefhllsundertheOperations elementofincidentcommand.Casualtiesinadisas﹣ terrequiremorebasicthanspecialtycare,thus,healt carespecialtyskillsarenotneededinitially’yetthese healthprofbssionalsremainimportantinmorededi﹩ fbrentiated（i.e·’general）rolesindisasterresponse· Specialtyphysicians,fbrexample,maybepartofthe workfbrcepoolfbrlogisticsandcasualtytransport· 乃﹠αgeisasystemdecisiontoolusedtosortcas﹣ ualtiesfbrtreatmentpriori叮’givencasualtyneeds, resources,andthesituation.Thetriagegoalistodo “thebestfbrmost.’’ratherthan“eve】ythingfbreve﹣ 1yone.”Effbctivetriageisaniterativeprocessdone acrossallsettingsofcasualtycare.Ateachsetting’ anexperiencedacutecarepro允ssionalshouldserve asthetriageof（icer·Triageisnota0ne﹣timedecision;itisadynamicsequenceofdecisions.Casualties’ resources’andsituationschange’leadmgtorefined triagedecisions. Thetriagedecisionatthescenefirstdefineswho islivingandmovesthesecasua1tiestosafbtyaway fTomthescenetoacasualtycollectionp0int.Thenext triagedecisiondetermineswhoiscriticallyinjured’ i.e.,whohasimmediatelylifb﹣threateningiIUuries. Ascenetriagesystemthatusesmotorresponseto commandasaquick‘‘sift》’ishelpfhlinfindingthese criticallyinjuredThosecasualtieswhocanwalkt0 anothercollecti0npointorwhocanwaveanarmor aleginresponsetocommandmosthkelydonothave lifb﹣threateningi叮uries·Thosewhodonotmoveare criticallyinjuredordead’Amongthecriticallyinjured, somemaysurviveandsomemaynotsurvive.Triage decisionsdiffbrentiatecasualtiestoagreaterdegreeas

casualtiesmoveawayfromthescenetoothersettings andhealtcarefhcilities. Thefivetriagecategoriesare; 1.Immediate（RED）:immediatelylifb﹣threatening ■

●

●

1IUur1es

Z.Delayed（YELLOW）:injuriesrequirmgtreatment within6hours 3·Minimal（GREEN）:walkingwoundedand pSychiatric 4.Expectant（BLUE）:injuriesgreaterthanlifbor resources

5.Dead（GREY） Eachcasual叮catego1yshouldhaveadefinedarea fbrcollectionandmanagement。Immediatecasualties shouldgainentrancetotheemergencyroom. TheATLSprimarysurveyprovidestheframe﹣ workfbrimtialcasualtyassessmentandintervention. Simplechmcalassessmentsandinterventionsareparamountinaustereandwar﹣relatedenvironments.Cre﹦ atives0lutionsinvolveimprovisationofmaterialsto addresslifb﹣threatemngphysiology.Animtialairway interventionmightstopatside﹣positiomngandanoral a1rwayinanunconsciouspatient’whenendotracheal tubesandtheres0urcestomanagethecasualtypost﹣ intubationarenotavailable.Surgicalairwaymight beconsidered’usingtubesthatarereadilyavailable’ suchasahollowpencasing·CervicalspineimmobⅡiza﹣ tioncanbeperfbrmedwithrolledblanketsorcasualty shoes.Thebest0叮genationmightberoomair’i.e., 21﹪.AbsentstethoscopesandbloodpressurecuffS, assessmentfbrtensionpneumothoraxmightbeper﹣ fbrmedwitheartochestandapulsecheck（carotid60 torr;fbmoral70torr;radial80torr）.Needledecompressionrequireslongerneedlesmmuscularorobese mdividuals.Fieldchesttubescanbemanagedwitha ‘‘Heimlichvalue,,,constructedasthecutfingerofa rubbergloveoveratube. Circulationisaddressedfirstandfbremostby stoppmgthebleeding.Tourmquets’fashionedfiyom belts’clothing,orcables’canmanagebleedingfiDm mangledandamputatedextremitieswellandireethe handsofresponderstomanageadditionalcasualties. Vascularaccessandvolumearesecondaryconsidera﹣ tionst0rapidcessationofbleeding.Inconsciouscasu﹣ alties’oralfluidsmightbeappropriatefbrhypovolemic management.Scalplacerationscanbemanagedwith rapidwhipstitch·Long曰boneextremi叮hacturescan bereducedandsplintedwithimprovisedmaterials fipomthescenetoreducehemorrhage,andpelvisfrac﹣ turescanbereducedwithasheet· Casualtycareisphasedinovertimeasresources becomeavailableandcasualtiesmovetosettingswith greaterresourcesAsopposedtotraumapatientcare》

APPENDIXC■Auste「eandA『medConfIictEnvi「0nments3Z3 whichmovesquicklyfromprimarysurveyandresus﹣ citationtosecondarysurv叮anddefinitivecare’casu﹣ altycaredefbrssecondarysurveyanddefinitivecarein fhvorofidenti鹹ngandmanagmgasmanycasualties aspossiblewithlifb﹣threatemngmjuries.Putanother way,secondarysurveyanddefinitivecarearediscon﹣ tmuousfromtheprima1丁surveyandresuscitation· Beyondthefbcusedassessmentsonographyintrauma （FAST）exam,thereislittlerolefbrradiologicalimag﹣ ingandlaborato】ystudiesinthefirstphasesofmass casual叮response· Damagecontrolsurge】yisanextensionofthe phasedapproachtocareandhasbeenusedextensively incivilianandwarsettings.Theapplicationofdam﹣ agecontrolprinciplestomcludetheuseoftemporary shuntstorestorebloodflowacrossmajorvascularinju﹣ riesisusedtolimitoperativetimesinpatientswhose physiologyprecludesdefimtiverepair.Incomparisonto theintact’resource﹣riChenvironment,severelyinjured traumapatientstreatedinaustereenvironmentsmay havedamagecontrolprinciplesapphed’notbecauseof physiology,butbecauseofresourceconsiderationsFor example’apatientwithbowelinjmywhowouldhave ananastamosisinanintactsetting,mighthavethe enterotomiescontrolledtemporarilywithastapleror sutureandtheabdomenleftopenduetomultipleother casualtieswaitingfbranoperatingroom.

TacticaICombatCasuaItyCa『e Tacticalcombatcasualtycare（TCCC）appliesATLS principlesinanactivelyhostilecombatenvironment. Carebeginsatthepointofinjurywithcasualtysel低 care·Whenunderfire’theprioritiesarereturnoffire andcasual叮safbty.Fewmedicalinterventionscanbe appliedwhenunderfire.St0ppingthebleedingisone oftheseinterventions’withdirectpressure,hemostat﹣ icgauze）andtourniquetsprovidingeffbctivetemporiz﹣ inghemostasis.Exsanguinationisthemostcommon causeofpreventabledeathincombat,andATLSprin﹣ ciplesareappliedinthisc0ntextasCABinterventions （circulation’aIrway’breathing）.Notethatassessment movesquicklythroughABCtogettoCinterventions, withreevaluationofAandBmasa企renvironment amenabletosuchasse臼宮ment.

Wa『Wounds WarinjuriesresultiTomhighvelocitygunsandhigh energye泖losives.HighvelocitygunshotwoundSre﹣ sultfromthelinearandcavitating（radial）energy oftheround,andcausetissuedevitalizationandde﹣ structionbeyondthepathoftheround.Highenergy e期losions’丘ommilitaryordnanceandimprovised explosivedevices（IEDs）’causemult﹣dimensionalblast

injuriesacrossfburmech曰h↑sms:primaryblastfiDm thesupersomcpressurewave;secondaryblastfrom fragments,tertiaryblast仕ombluntorpenetratmg impactintheenvironment;andquaternaryblastas burnsorcrush.Head’body’andeyearmoroffbrsig﹂ nificantprotection,yetleavetheextremities,face’and neckexposed.Aprominentinjmypatternincludes multipletraumaticamputationsandtraumaticbrain inju1y·Astheenergyfromexplosivedevicesincreases inresponsetobodyarmor,thedevastationtotissues increasesdramaticaⅡy. Woundmanagementincludeshemorrhagecontrol anddebridementofdevitalizedtissue.Energytracks alongtissueplanesandstripssofttissuefrombone. Theremaybeskipareas0fviabletissuewithmore proximaldevitalizedtissue.Tissueisassessedfbrcolor’ consistenCy’contractility,andcirculation（bleeding）. Tissuethatdoesnotbleedwithcuttingandisdark, mushy,andn0n﹣contractⅡeisno﹣viableandsh0uld bewidelydebrided.AⅡcombatwoundsaredirtyand shouldbeleftopen;anegative﹣pressuredeviceisause﹣ fhladjunctfbrwoundcoverage.Effbctivedebridement isaprocessthatinvolvesserialwoundassessment fbrinjuryprogressionandfUrtherexcisionofdevital· izedtissue.Woundsmayhealultimate】ybysecondaIy intentionorwithdelayedclosureonceallaspectsof infbctionareruledout.

ChaIIeⅡgesinAuste『eandA『med ConfIictEnvi『onments Cb／mmL㎡cα㎡o几remamsadominantchallengeindis﹣ asterresponseacrossallenvironments.Normalcom﹣ municationsystemsareoftend0wn’andmultiple agenciesandorganizations’eachwiththeirownpro﹣ ceduresandtaxonomies,arebroughttogetherunder stresswithlimitedinter﹣operability.Applicationofm﹣ cidentcommandimprovescommunication.Duplicate andrehearsedcommumcationplansshouldberou﹣ tinelypracticedfbrdisasterpreparation. Normal㎡m／】Spo㎡α㎡o几optionsarelimited,and anyvehiclecanbeusedtomovecasualties,includine buses,cars》andboats· Sα／bⅣα冗dsecαr蚵areChallengedduetoenvi﹣ ronmentalandconⅡictconditions.Theseshouldbe emphasized》planned’andpracticedindrills. Austereconditionsandenvironmentscanlead todisorderedbodytemperatureregulationand／teαt 叫my’eincludingheatcramps,exhaustion’andstroke· PreventionofheatcasualtiesincludesaccIimHtion允r 3﹣5days’alternatingworkandrestCycles’andempha﹣ sisonregularfluidandelectrolytereplacement.Early recognitionofheatcasualtySymptomsmayprevent progress1on.

3Z4APPENDlXC■Auste「eandA『medConfIictEnvi『onments

PSyc／josoαα／／ss邸esdominateinlong﹄termrecov﹣ eryfromdisastersandcanbemorepressinginaus﹣ tereandwar-tornenv1ronments.ResilienCycanbe enabledpriortodisasterwithhealthybehaviorsand orgamzationalpractice.Healthcarepersonnelareat riskfbrpsyChosocialstressdisorders仕omadisaster;

∣ 】

suchstresscanbeattenuatedthroughawarenessand debriefings.

principlesmenvir0nmentsinwhichthetraditional levelofcareisdisrupted’orinwhichresourcesare limitedoroverwhelmed,requirestheabilitytoapply acommonsenseadaptationoftheprinciplestaught inthiscourse.Optimaloutcomesinthesesettingsre﹣

5umma『y

G

∣

TheprinciplesofATLSprovideaframeworkbywhich toevaluateandtreatlifb﹣threatemngmjuriesinvic﹣ timsoftraumaticinjmy.Theabilitytoapplythese

quiresthathealtcareprofbssionalsgivefbrethoughtto thewaysinwhichtheirskiⅡsetssh0uldbeemployed andtoanticipatetheChallengesassociatedwithsuch settings.

山

Ⅵ

APPENDIX

∣

D

∣ ∣

一

l

▼ ︿ 芍 ＼毗、＞

▼『∣∣∣∣

﹄

﹦

︼

＞

﹃

DisasterManageⅢentandEⅡ1ergencyPreparedness （○p／『0〃α／L6咖 6r） ︻

Int『oduction

O吋ectives Ⅲ

De↑inethete「msmuItiplecasua∣tyincident（MCl） andmasscasua∣tyevent（MCE）

圓

ExpIainthediffe『ence5betweenMCIsandMCEs

圃 q ∣

De5c『ibethe刎a∣∣haza『ds〃app「oachtodisaste『 managementandeme『gency.p『epa「edness’ Inc∣udingitsappIicationtoacuteIn】u『yca『e. Identi↑ythefou『phaseso↑disa5te「management andde5c『ibethekeye∣ement5ofeachphasewith 『e5pecttoacutein】u『yca『e

回 Desc『ibetheinCidentc0mmandSyStemthathas beenadoptedinyou『speci↑icp『acticea「ea.

0

Disastersmaybedefined,homamedicalperspective, asincidentsoreventsinwhichtheneedsofpatients overextendoroverwhelmtheresourcesneededtocare fbrthem.Alth0ughdisastersusuallystrikewithout warning,emergencypreparedness一thereadiness fbrandanticipationofthecontingenciesthatfbllow intheaftermathofdisasters＿enhancestheabⅢtyof thehealthcareSystemtorespondtothechallenges imposed.Suchpreparednessistheinstitutionaland personalresponsibililyofeveryhealthcarefhcilityand profbssional.Adherencetothehigheststandardsof qualitymedicalpracticethatareconsistentwiththe availablemedicalresourcesservesasthebestguideⅡnefbrdevelopingdisasterplans.Commonly,theabil﹣ itytorespondtodisastersituationsiscompromisedby theexcessivedemandsplacedonresources,capabili﹣ ties,andorganizationalstructures. MUItiplecasuaItyincidents（MCIs）,ordisas﹣ tersinwhichpatientcareresourcesareoverextended butarenotoverwhelmed,canstresslocalresources suchthattriagefbcusesonidenti助ngthepatients withthemostlifb﹣threateningmjuries. MasscasuaItyevents（MCEs）areeventsin whichpatientcareresourcesareoverwhelmedandcan﹣ notbeimmediatelysupplemented.Triagebynecessity fbcusesonidentifyingthosepatientswiththegreatest probabilityofsurvival NotethatMClsandMCEsa『ebothcaIIedMCIsby manyexpe『ts.TheATLScoursedistinguishesbetween thetermsbecausetheirdilfbrentcircumstancesman﹣ datealternativestrategiesfbrtriageandtreatment》 ThebalHncetobedeterminedisbetweenwhatis neededversuswhatisavailableintermsofhumanand materialresource.AhygivenhospitaImustdete『mine itsownth『eshoIds,『ecognizingthatthehospitaIdisaste『 pIanmustadd『essbothMClsandMCEs· Likemostdisciplines）disastermanagementand emergencypreparednessexpertshavedevelopeda nomenclatureuniquetotheirfield.BoxD﹣1lsaglos﹣ saryofallkeytermsinthisappendix.

325

、

326APPENDIXD■Disaste「ManagementandEme『gencyP『epa『edness ■

BoxD曰1l《eyDisaste『Managementand Eme『gencyP『epa『ednessTe『minoIogy AcuteCa『eTheea『Iy〔a『e0↑victim50↑di5a5te「Sthat isp『0videdInthefieIdandIntheh05pitaI（i’e』eme『gen（y depa『tmentI0pe『ating『00m’intensiveca『eunitlacute ca『euntin i pate i ntuntis）p『0 i 『t0『ec0ve『yand「ehab∣ i tia﹣ t∣0n.

Eme『gencyMedicalSe『vices（EMS）Eme『gen〔y medc i a∣『e5p0nde『s（EMRs）!n i 〔u I dn i geme『gen〔ymedc i al technicians（EMTs）andpa『amedic5lwhop『ovidep『eh0s. p∣taIca「eunde『medIcaId『 i ed0 i naspa『t0↑an0『ganzied 『esp0n5et0medc i aIeme『gendes·

AcuteCa『eSpecia!istsphysidanswh0p『0videacute 〔a『et0vi〔tim5ofdi5aste『s’indudingibutn0tIimitedt0l eme『gen〔ymed〔 i n i ephy5d i an5’t『auma5u『ge0Ⅱ5c I 『ticaI ca『emedidnephy5idan5’anesthe5i0I0gi5ts’andh0spitaI. i5t5＿bothaduItandpediat『ic

Eme『genCy0pe『ationsCente『（E0C）Thehead﹣ qua『te『S0↑Un↑ i e i dn I ddentC0mmand（U〔 I ）↑0『a『eg0 in 0『sy5temle5tabli5hedina5a↑eI0（ati0n0utsidethea『ea 0「0pe『at0 i n5（〃wa『mz0ne〃）’u5uay Il ata↑xi edstiea i nd sta↑↑edbyeme『genCymanage『5.

A『eaof0pe『atioⅡs（〃Wa『mZone〃）Thege0g『aphi〔 5ubdivi5i0ne5tabIi5heda『0undadi5a5te『5iteint0whi（h 0nIyquaI｛ i e i dpe『s0nneI＿↑b『exampIe!haza『d0usmate「a iI （ⅡAZMA「）technd i an5andeme『gencymed∣〔a5 I e『vc i e5 （EMS）p『0vd i e『5＿a『epe「mtied

Eme『gencyp『epa『ednessThe「eadn i e55↑0『andan﹣ tidpati0n0fthec0ntingende5that〔an↑0ll0wintheafte『﹣ math0↑natu『a0 I 「human﹣maded5 i a5te『5.P『epa「edne5s5 i theIn5tituti0na∣andpe『s0na∣『e5p0n5ibiIW0feve『yhea∣th ca『e↑adtiy Iandp『0柏sso i na∣·

CasualtyC0llectioⅡP0int（CCp）A5ed0『withInthe exte『nap l e『m i ete『0fana『ea0f0pe「at0 i ns（刎wa『mz0ne〃） whe『e〔asuaItie5whoexittheSea「chandRescue（SAR） a『ea（〃h0tz0ne’’）va i adec0ntamn i at0 i nc0『『d i 0『a「egath﹣ e『edp『0 i 『t0t『an5p0『t0惦tie

Eme『goT『aiⅡSystem（ET5）An0『ganizati0naIst『uc﹣ tu『eusedchie↑lyinEu『0peandAu5t『aIasiat0heIpc00『﹣ dinateanin﹣↑ieId0『in﹣h0SpitaIdisaste『『esp0n5e.（Ⅱ0te; Ⅱati0nsandh0spitaIstypicaIIyad0ptthei『0wnve『5i0n50f thi5System）

ChemicaI『BiologicaI!RadiologicaI『ⅡucIea『’andEx﹦ pIosive（CBRⅡE）’includinginceⅡdia『y’agentsⅡu. man﹣madehaza『d0u5mate『a i I5（HAZⅢAT5）thatmaybe thecau5e0fhuman﹣madedi5a5te『5’whethe『unintenti0naI 0『intenti0naI.

Exte『naIPe『imete『The0ute『b0unda『y0fanA『ea0f 0pe「at0 i n5（〃wa『mz0ne〃）that5 i e5tab5 il heda『0unda di5aste『sitet05epa『atege0g『aphic5ubdivi5i0nSthata『e Sa↑e↑0『thegene『ap I ubc iI （〃〔0d I z0ne5〃）｛『0mth05ethat a『esa↑e0nlyf0『quaIifiedpe『50nneI.

De仁ontaminati0nCo『『ido『A↑ixedo『depI0yable「a﹣ d∣tiywhe『ehaza『d0u5mate『a i5 l （ⅡAZMATs）a『e『em0ved ｛『0mapatientiandth『0ughwhichthepatientmustpa55 be↑0『et『ansp0『t’etihe『0ut0faSea「chandRescue（SAR） a『ea（〃h0tz0ne〃）’o『n i t0ah05ptia∣.

Ⅱaza『dousMate『ials（ⅡAZMA『s）Chemi〔aI’bi0I0gi﹣ caI’『ad0 i I0g〔 i aI〃nucIea『!andexpIo5v i e（CBRⅡE）!Ⅱ l dudn ig incendia『y﹟agent5thatp05ep0tential『i5k5t0humanIi伯 hea∣th〃we↑ I a『ea i ndSa｛ety·

Di5aste『Anatu『aIo『human﹣madeincident0『event! whethe『Ⅱ i te『naI（0『g in i atn i gn i 5d i etheh0sptia） l 0「exte「na∣ （0『iginating0ut5idetheh05pitaI）inwhichtheneeds0↑ pate i nt50ve『extend0『ove『wheImthe『es0u「cesneededt0 〔a「e↑0『h tem. ■

Ⅱ0spitallncidentCommandSystem（ⅡICS）An0『﹣ gaⅡziat0 i na∣st『u〔tu『euSed〔he i ｛Iyn i theAme『〔 i aSt0heIp c00『dinateanin﹣h0spitaIdi5a5te『『esp0ns巳（Ⅱ0te:Ⅱati0n5 andh0spitaIstypica∣Iyad0ptthei『0wnve『si0ns0「this SysteⅢ.）

■

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3Z8APPENDIXD■Di5aste「ManagementandEme『gencyP「epa「ednes5

TheⅡeed DisastermanagementandemergenCypreparedness constitutekeyknowledgeareasthatprepareATLS providerstoapplyATLSprinciplesduringnaturaland human﹣madedisasters.Successfhlapplicationofthese principlesduringthechaosthat叮picallycomesinthe aftermathofsuchcatastrophesrequiresbothiamiliar﹣ itywiththedisasterresponseandknowledgeofthe medicalconditionslikelytobeencountered.Terror eventsconstituteannnori叮ofalldisasters’butnearly allterroreventscausephysicalinjury,three﹣fburthsof whichareduet0blasttraumaandmostoftherestto gunshotwounds.Assuch’theunderstandingandap﹣ plicationofATLSprinciplesareessentialintheevalu﹣ ationandtreatment0falldisastervictims·

TheApp『oach Disastersareunpredictablebecauseoftheirnature’locati0n,andtiming.An‘‘allhazards,’approachisused incontempora1ydisastermanagement.Thisapproach isbasedonasingle,common,imtialemergenCyre﹣ sponseprotocolthatisflexibleandhasbranchpoints thatleadtospecificactionsdependingonthetypeof disasterencountered.Thefi』ndamentaIp『ihcipIeo「di. saste『managementistodotheg『eatestgood｛b『the g『eatestnumbe『.

PhasesofDisaste『Management

Simp!eDisaste『PIansAbasicandreadⅡyunderstood approachtoMCIsandMCEsisthekeytoeHbctivedis﹣ asterandemergencymanagement·Plansthataretoo complexorcumbersometorememberorimplement aredestinedtofail.Allplansmustincludetraining indisastermanagementandemergenCypreparedness appropriatetotheeducationalpreparationoftheindi﹣ vidualsbeingtrainedandtothespecificfhnctionthey willbeaskedtoperfbrm.

CommunityPIanningDisasterplanning’whetherat thelocal’regional,ornationallevel,involvesawide rangeofindividualsandresources.AⅡplans: ■Shouldinvolveacutecarespecialists （e.g”emergenCymedicmephysicians’trauma surgeons,criticalcaremedicmephysicians’ anesthesiologists,andhospitalists’bothadult andpediatric）andlocalhospitals’asweⅡas officialsofthelocalpohce’hre’emergency medica1services（EMS）,homelandsecu﹣ rity’emergencymanagement’publichealth, andgovernmentalagencieschargedwith hazardousmaterial（HAZMAT）manage﹣ mentanddisasterpreparation. ■Sh0uldbefTequentlytestedandreevaluated. ■Mustprovidefbrameansofcommunication consideringallcontingencies’suchaslossof telephonelandhnesandcellularcircuits’

】.Preparation

■Mustprovidefbrstorageofequipment, supphes,andanyspecialres0urcesthatmay benecessarybasedonlocalhazardvulner· abilityanaIysis（HVA）.

Z·Mitigation

■Mustprovidefbralllevelsofassistance＿from

Thepubhchealthapproachtodisasterandmasscasu﹣ altymanagementconsistsoffburdistinctphases:

3.Response 4.Recovery Inmostnations’localandregionaldisasterresponse plansaredevelopedmaccordancewithnationalresponse plansEmergencymedicine’traumacare,pUblichealth’ anddisastermedicineexpertsmustbeinvolvedinall fburphasesofmanagementwithrespecttothemedical componentsofthe0perationalplan·

P『epa『ation Preparationinvolvestheactivitiesahospitalunder﹣ takestoidentibrrisks’buildcapacity’andidentifyre﹣ sourcesthatmaybeusedifadisasteroccurs.These activitiesincludeariskassessmentofthearea,thede﹦ velopmentofasimple’yetflexible’disasterplanthatis regularlyreⅥewedandrevisedasnecessary’andpro﹣ visionoftrainingthatisnecessarytoallowtheseplans tobeimplementedwhenindicated·

firstaidthroughdefinitivecaretorehabilitation. ■Mustpreparefbrthetransportationofcasual﹣ tiestootherfacⅢtiesbyprioragreementshould thelocalfacili叮becomesaturatedorunusable· ■Mustconsidertheurgentneedsofpatients alreadyhospitalizedfbrconditionsunrelated tothedisaster. Hospita∣PlanningAlthougharegionalapproachto planningisidealfbrthemanagementofmasscasual﹣ ties,circumstancesmayrequireeachhospitaltohmctionwithlittleornooutsidesupport·Earthquakes, floods’riots’ornuclearcontaminationmayrequirethe individualhospitaltooperateinisolation.Thecrisis maybeinstantaneousoritmaydevelopslowly.Situa﹣ tionsmaye】dstthatdisrupttheinfrastructureofsoci﹣ etyandpreventaccesstothemedicalfacihty.Forthis reason’itisvitalthateachhospitaldevelopadisaster planthataccuratelyrefIectsitsHVA.Onceastateof

APPENDIXD■Disaste「ManagementandEme『gencyP『epa『edness3Z9

disasterhasbeendeclared,thehospitaldisasterplan shouldbeputintoeffbct.Specificproceduresshouldbe automaticandinclude: ■Establishmentofanincidentcommand post（ICP）. ■Notificationofon﹣dutyando岱dutypersonnel. ■Preparationofdecontamination’triage,and treatmentareas· ■Classificationofin﹣hospitalpatientsto determinewhetheradditionalresourcescan beacquiredtocarefbrthemorwhetherthey mustbedischargedortransfbrred. ■Checkingofsupplies（e·g.,blood’fluids,medi﹣ cation）andothermaterials（e.g.,fbod’water, power,communications）essentialtosustain hospitaloperations. ■ActivationofdecontaminationfacⅢtiesand staffandappⅡcationofdecontamination procedures,ifnecessary. ■Institutionofsecurityprecautions’includ﹣ inghospitallockd0wnifnecessary’toavoid potentialcontaminationandsubsequent hospitalclosure· ■Establishmentofapublicinfbrmation centerandprovisionofregularbriefingsto infbrmfamily,friends’themedia,andthe government.

Depa㎡mentalP!anningEfIbctivedisasterplann1ng buildsonexistingstrengthstoaddressidentifiedweak＝ nesses.Smcepatientcarecanbestbedeliveredtom﹣ dividualpatientsbyprovidersworkingmsmallteams, eve】yhospitaldepartmentwithreSponsibⅢ叮fbrthe careofinjuredpatientsmustidemi月／itsmedica1re. sponseteamsmadvance.Theseteamsmustbeprovid﹣ edwithspecificinstructionsastoWheretogoandwhat todointheeventofanmternalorexternaldisaster.Such mstructionsshouldnotbeovedycomplex.Th叮sh0uld alsobereadilyaccessibleintheeventofadisaster＿fbr example’printedonthebackofhospitalidentification cardsorpostedonwallcharts.TheyshouldalsobeveⅣ specificintermsofthejobactiontobeperfbrmed;Jobac﹣ tionsheetspredicatedontheincidentc0mmand叮stem （ICS）areaneffbctivemodeltoemplOy. Pe『sonaIPIanningFamilydisasterplanmngconsti﹣ tutesavitalpartofpre﹣eventhospitaldisasterprepara﹣ tionfbrboththehospitalanditsempl叮ees.Mosthealth careprovidershavefhmⅡyresponsibilities’andwillbeat bestuncomfbrtable,andatworstunable’tomeettheir employmentresponsibilitiesmtheeventofadisasterif thehealthandsafbtyoftheirfhmiliesisuncertain.Hos﹣

pitalscanassisthealthcareprovidersinmeetingtheir responsibⅢtiestothehospitalandtotheirfRmiliesina numberofways’anditisobviouslytotheadvantageof bothfbrhospitalstoensurethatemployees’fhmⅡyneeds aremet.Amongtheseneedsareassistanceinidenti觔ng alternativeresourcesfbrthecareofdependentchildren andadultsandensuringthatallemplOyeesdevelopfhm﹣ ilydisasterplans,sinceallhospital﹣specificresponse plansdependonmobilizationofadditionalstaff;whose firstdulyinanydisasterwillbetoensuretheirownand their跑milies》healthandsalbty. HoSpitalDisaste『T『ainingAllhealthcareproviders mustbetrainedintheprinciplesofdisastermanage﹣ mentandemergenCypreparedness.Trainingindisas﹣ termanagementincludesbothoperationalandmedical comp0nents.TheATLSprovidershouldbewellversed inthehmdamentalelementsofthelocal’regional,and nati0naldisasterplans’andunderstandtheroleof medicalcareintheoverallmanagementplan.Itises﹣ sentialtorealizethat,althoughthepurposeofalldis﹣ astermanagementistoensurethesafbtyandsecuri叮 ofthemax1mumnumberofhumanhves,themedical componentisbutoneelementoftheoperationalplan atb0ththehospitalandthecommunitylevels. Beyondthisbasicunderstanding’itisalsovital thattheATLSproviderhaveaworkingunderstanding oftheapplicationofATLSprinciplesindisastersitua﹣ tions.Itisimportanttorecognizethattheapproachto thepatientmjuredmadisasterisnodiffbrentfromthe approachtothepatienti叼uredinthecourseofeve1y﹣ dayactivitiesAirway’Breathing’Circulation’DisabⅡ﹣ ity,andExposure.Rather,itistheapphcationofthis basicapproachthatmaybealtered’whichisbestsum﹣ marizedbythephrase,‘‘Careordinary’circumstances extraordina】V.”Forexample’thefhctthattheATLS providermayneedtocarefbrmultiplevictimsmore orlesssimultaneously’andmaynothavesufficient equipmentorassistancetocanVoutallneededtasks inatimelymanner,reqUiresthatroutinestandardsof caremayneedtobealteredsuchthatdisastermedi﹣ cinemustfbcusontheminimumacceptablestandard ofcarerequiredfbrsalvageoflifbandlimb）notthe highestpossiblestandardofcarenormallyoiIbredto severelyinjuredpatients. ItisvitalthattheATLSproviderobtainsufficient basiceducationtoinitiatethemedicalcareofmulti﹣ plevictimsnotonlyofnaturaldisasters,butofsitua﹣ tionsinvolvingHAZMAT.Theseincludeweaponsof massdestruction（WMDs）,chemical,biologicaI, radioIogicaI,nucIear,ande”losive（CBRNE） agents,andmcendiaryagents.Traininginaustere environmentoperations’suchaswhenresources areconstrained,isessential.Althoughbriefoutlines ofsuchtreatmentareprovidedinthisappendix’

330APPENDIXD■Disa5te『ManagementandEme「gencyP「epa「edne5s

additionaltrainingindisastermedicalcareiscurrently bey0ndthescopeoftheATLSprovidercourse,butcan beobtainedthroughparticipationintheappropriatenationaldisastermanagementcourses,including theACSCOTDisasterManagementandEmergency Preparedness（DMEP）course.http:〃www.fhcs.org／ trauma／disaste】yindex.html

Mitigation Mitigationinvolvestheactivitiesahospitalunder﹣ takesinattemptingtolessentheseverityandimpact ofapotentialdisaster.Theseincludeadoptionofan incidentcommandsystemfbrmanaginginternal（orig inatinginsidethehospital）andexternal（originating outsidethehospital）disasters’andtheexercisesand drillsnecessa1ytosuccessfhllyimplement’test,and refinethehospitaldisasterplan.Z】／je／.ezs／』osαbs蛐α妃 ／brαdCq邸α花㎡α加i唔α〃ddr〃』／／】g.

!ncidentCommandSystemAnincidentconnnand system（ICS）isvitaltooperationalsuccessduring disastersandmustbeknowntoallpersonnelwithin everyhealthcarefacilityandagency.TheICSestab﹣ lishesclearlinesofresponsibility》authority,report﹣ ing,andcommunicationfbrallpersonnel’thereby maximizingc0llaborationandminimizingconflicts duringthedisasterresponse. Thee肚ctiveICSincludesbothverticalandhori﹣ zontalreportingrelationships,toensurethaturgent decisionscanbemadewithouttheneedfbrpriorcon﹣ firmationbyincidentcommanders’whichconsumes valuabletime.InMCEsthataffbctanentirereg1on orsystem’theefIbctiveICSmustbefhl】yintegrated withtheunifiedincidentcommand（UIC）serving theentirereg1onorsystem’whichiscomprisedofall involvedpublichealthandsafbtyagencies,keyofficials fTomwhichshouldbeco﹣locatedintheregion,sorSys﹣ tem,sEmergencyOperationsCenter（EOC）. Ahierarchicalapproachtoincidentcommand’ suchastheHospitalIncidentCommandSystem （HICS）,developedundertheauspices0ftheCahfbrniaEMSAuthority,（http:〃Www·emsa.ca’gov／hics／hics. asp）,isfhvoredintheAmericas.Amorecollaborative andmedicallycenteredapproachtoincidentcommand, suchastheEmergoTrainSystem（ETS）,promulgatedbytheLink0pingUniversityTraumaCenterin Sweden（http:／／Www’emergotrain.com）’isfhvoredin Eur0peandAustralasia.Mostnationsadoptoneof thetwoapproachesfbrincidentcommand（IC）in developingtheirresponseplans,adaptingthemtofit localneedsandresources.Themodelsusedbythese twoSystemsareshownmTableD.1. RegardlessoftheICSsystemused,ICisrespon﹣ siblefbrallaspectsofthedisasterresponseunder itsjurisdiction.Assoonaspossibleafteradisasteris

declaredbyIC’anincidentcommandpost（ICP）’ previouslyknownastheincidentcommandcenter’ mustbeestablished’withreliableconnnumcation hnkstoallfhnctionalunits＿operational／logisticand medical.TheICPmustbeestabli息bedinasecureloca﹣ tion’distantfTom’butwithreadyaccessto’thesiteof primarypatientcareactivi叮,Whetherfieldorhospi﹣ tal·Inthefield’itshouldbelocatedwithintheareaof operations（‘‘warmzone”）boundedbyanexter. naIperimeter’andmustbesiteduphill’upwind, andupstreamofthesearchandrescue（SAR）area （‘‘hotzone,,）boundedbyaninternalperimeter, fTomwhichdecontHni﹩h蝨tioncorridorsleadto casualtycolIectionpoints（CCPs）·Inthehospital, itshouldbelocatedatasa允distance仕omdecontami﹣ nationareas’patientcareareas’fhmilysupportareas） andpotentialhazards,suchascontaminatedventila﹣ tionanddrainage,butcloseenoughtopatientcareand familysupportareassothatmessagescanbetransmit. tedinpersonifelectroniccommumcationsfail· F『equentDisaste『D『iIIsAsintraumaresuscitation’ medicalmanagementofmasscasualtiescanbepro﹣ videdtoindividualpatientsonlybyindividualprovid﹣ ers,workinginsmallmedicalresponseteams’ledbya senioracutecarespecialist.ItiscrucialtoanefIbctive disastermedicalresponsethatsuchteamshavebeen drilled,notsimplytrained,indisastermedicalcare’ undercircumstancesthatareasrealisticaspossible· Disasterdrillssh0uldalwaysemphasizethedisasters expectedonthebasisofthehospital,sHVA·Thepur﹣ poseofdisasterdrillsandexercisesisnotonlytotrain emergencymedicalresponderstoprovidecaretodis﹣ astervictims》butalsotoidentifygapsinthehospita】 disasterplansotheycanbeclosedpriortotheoccur﹣ renceofanactualinternalorexternaldisaster.Inad﹣ dition’theyshouldinvolvescenariosthatemphasize

■TABLED.1CommoⅡIyU』s;edModeI5 fo『!ⅡcideⅡtCommaⅢdS yStemsa ⅡICS『0ⅡC『I0ⅡAL』0B ACTI0ⅡSb

ETS『UNC『l0NAU0B ACTl0Nsc

∣ncidentcommand（hospitaI） ·Commandsta什 ·Pub∣icinf0『mation o【iaiSOn ·Safety ·MedC i a∣／teChnc i a∣ 。FinanCeandadminiSt『ati0n ·logiStiCS oOPe「atiOnS ·P∣anningandinte∣Iigen﹤e

Field ·AmbuIanceinddentcommand ●MedicaIinddentcommand

ⅡospitaI ·Logi5tic5c0mmand ·MedicaIcommand

aRega「d∣e5softhesy5tembeingu5ed〃∣iI《est『uctu『esa『eusedm﹣『ie∣dandin﹦ ho5pitaI. bhttpWWww.emsa·ca·g0Ⅵhics／hics·asp 傳httpWWww嚀eme『g0t「ain令com

APPENDIXD■Disaste『ManagementandEme「gencyP『epa「edness331

theneedsofspecialpopulations,suchasburnpatients, pediatricpatients’geriatricpatients’anddisabledpa﹣ tients’whiChmayrequirethemobilizationanddeploy﹣ mentofpopUlation﹣specificresources.Thetypesof disasterdrillsandexerciseshospitalsshouldholdare describedinB0xD﹣2.Itiswisetoproceedfromsimple drillstocomplexexercisesasstaffmembersgainfamil﹣ iari叮withtheICSandexperiencewiththeproblems likelytoariseduringadisaster.

Response Responseinvolvesactivitiesahospitalundertakesin treatingvictimsofanactualdisaster.Theseinclude activationofthehospitaldisasterplan’includingthe ICS’andmanagementofthedisasterasitunfblds’ implementingsChemesfbrpatientdecontamination, triage,surgecapaciiyandsurgecapability·Given theincreasedlevelofactivityindisasterevents,tra慍 ficcontrolisneededtoensureanuninterruptedfbr﹣ wardflowofcommumcations’patients,supplies,and personnel.Themedicaldisasterresponsemustalso addresstheneedsofspecialpopulations,including children,elders,thedisabled,andthedispossessed.

P『ehospitaICa『eTheprehospital（EMS）responseto disasterstypica1lyoccursinfburstages: 1.Chaosphase,↑ypicaⅡylasting15t020minutes Z.Organizationalphase,usuallylasting1to2hours 3.Site﹣clearingandevacuationstageofvariable length,dependingondisastertype’complexityof SAReffbrts,andnumberofevacuees 4·Gradualrecovery AllSAReifbrtsatthesceneshouldbetherespon﹣ sibilityofHAZMATtechniciansspecificallytrainedfbr thispurpose,andmustproceedasrapidlyandsafbly aspossible·Thep0tentialfbra‘‘secondhit’,designed toinjurefirstrespondingpersonnel,includingvol﹣ unteers’mustbec0nsidered.Sincethefirstrespon﹣

＿

sibilityoffieldprovidersistoprotectthemselves, first﹣responsepersonnel,includingEMSprofbssionals, shouldnotenterthedisastersceneuntilithasbeen declaredsafbandsecurebytheappropriateauthori﹣ ties·Appropriatepersona1protectiveequipment （PPE）ismandatoryfbrallhealthcarepersonnelin directcontactwithpatients.

In﹣HospitaICa『eOncethehospitaldisasterplanis activated,thefirstpriorityofICistoensuresufficient resourcestomountaneffbctivedisasterresponse.This includesmobilizationanddeploymentofadequate sta毗fRcilities,andeqUipmenttomeetanticipated needs·EarlydischargeofeligiblepatientsfTomhos﹣ pitalinpatientand趙sttrackunits;cancellationof electiveoperationsandoutpatientclinics;accuratede﹣ terminationofeachunit,ssurgecapability’notmerely itscapacity;andidentificationandmobilizationofal﹣ ternativecaresitesareaⅡhnportanthmctions.Pre﹣ printedjobactionsheetsshouldbemadeavaⅡablet0 stafffbreachfhnctionaljobdescriptionwithintheICS, toserveasatangiblereminderofthetaskseachstaff memberisexpectedtoundertake. PatientDecontaminationHospitaldisastercarebe﹣ g1nswithdecontamination’theprinciplesandmethods fbrwhicharesh0wninBoxD-3.Nme叮percentofhaz﹣ ardousmaterialstowhichdisastervictimsmayhave beenexposedcanbeeliminatedsimp】ybyremovalof outergarmentscontaminatedwithhazardousmaterials.However,itmaynotbepossiblefbrHAZMAT teamsorfirstresponderstoperfbrmdecontamination underallcircumstances.Moreover’manypatientsare likelytotransportthemselvestothecl0sesthospital’ andwillarriveattheemergencydepartmentbefbre beingdecontaminated’demandingurgentcare. Fo『this『eason’hospitaIsmust『apidlyandcohsci· entiouslydete『minethelⅡ《eIihoodofco㎡aminatioⅡand p『oceedacco『dihgIy.Althoughthesafbstcoursemight betoconsideralldisasterpatientscontaminated

■

BoxD︼2TypesofDisaste『D『iIlsand匾xe『cises

﹂

■Disaste『D『iIISupe「visedactivitywithalimited↑0cⅡs t0testap『0（edu『ethati5alimitedc0mp0nent0↑a ↑actIiy’s0ve『aIdsiaste『p∣an·

■「unctionalExe『ciseSimuIati0n0fadisa5te『inthe m0st「eaIIsti〔manne『p0s5iblewith0Ⅱtm0ving『eaI

■TabletopExe『dseW「ittenandve『ba∣scena『i0sthat evaIuatetheef｛ediveness0fa↑ad∣ity!s0ve『aI∣disa5te『 pIanandc00『dinati0n.

■FieIdExe『cise〔u∣minati0n0｛p『evi0usd『iIlsand exe『dsesthattest5them0bilizati0n0fa5many0↑the 『e5p0nse〔0mp0nentsa5p0ssiblein『ea∣time!using 『ea∣pe0pe l and『ea∣equp i ment·

pe0ple0『『eaIequipmentt0a『ealsite.

33ZApPENDIXD■Disaste「ManagementandEme『gencyP『epa『edne5s

■

BoxD﹦3p『inciplesandMethodsofDecontaⅢination M G『oss（p『ima『y）Decontamination

0R

■pe『↑0『medinthe↑ie∣d0「0utsidetheho5pitaIafte『 『em0vaI0↑d0thing

AssistedDecontamiⅡationwith5oapaⅡdWate『 viaaWa『mSpongeBath

■Patienti5h0sedwitha↑inemi5t5p「ayunde『m0de『ate

■E『adicate5alm05taIl『esidua∣（0ntamlnants〃su什ices ↑0『『adi0adiveagents

P『eS5u『e ■Washesawaym05t『emainingc0ntaminants Techni〔aI（5e〔oⅡda『y）DecontaminatioⅡ Sel卜dec0ntaminati0nwith50apandwate『unde『awa『m Sh0we『bath

■AdditionaIcIeaⅡ5ingwithdilutech∣0『inebIea〔hmay be『ec0mmendedifsu5ceptibIebi0Iogicagents0『 〔hemi〔aIagent5a『esu5pected Remembe『’〃Di∣utionisthe5olutiontopoIlution／』

﹂

untilpUbhcsafbtyofficialsdetermmeotherwise’this approachslowspatientthroughputandcanresultm fhrtherdeteriorationofhigh﹣riskpatients·Another approachistosegregatepatientswhotransportthem﹣ selvestothehospitalinaholdingareaoutsidethehos﹣ pita1untilHAZMATteamsdeterminethenatureofthe event’recognizingthatsuchpatientsarefarlesslikely todeterioratethanpatientstransportedbyambulance. Eitherway’hospitalsmustplanfbrdecontamination ofp0tentiaⅡycontaminatedpatientsbefbreth叮can entertheemergen叮department.Failuretodosocan resultincontaminationandsubseqUentqUarantineof theentirefacility·Involvementofhospitalsecuri叮’and localpohce,maybenecessa】yiflockdownisrequired topreventpresumptivelycontaminatedpatients仕om enteringtheemergenCydepartmentorhospitalbefbre theycanbeefIbctivelydecontaminated.

Disaste『T『iageSChemeAmethodfbrrapididenti﹣ ficationofvictimsrequiringprioritytreatmentisessential.ThegoaloftreatmentmMCIsistotreatthe sickestpatientsfirst’WhereasthegoalinMCEsis tosavethegreatestnumberofⅡves.Assuch,triage schemesinMCEsshouldadoptanapproachthatsepa﹣ ratespatientswithminorinjuriesfromthosewith moreseriousinjuries’befbreproceedingwithevalua﹣ tionandsustentativetreatmentofpatientswithm匈or injuries。Patientswhomaynotsurvivereceivecomfbrt careonlyafterotherpatientshavebeentreated. Overtriageandundertriagecansubstantially afIbctthemedicaldisasterresponse.Overtriageslows systemthroughput,andundertriagedelaysmedically necessa】?ycare.Bothincreasethefatalityrateamong patientswhomaypotentiallysurv1ve.Therefbre, triageshouldbeperfbrmedbyanexpenencedchmcian withspecificknowledgeoftheconditionsaffbcting

mostpatients.Inaddition’alli叼uredpatientsshould becontmuaⅡyreevaluatedandreassessed· E什ectiveSu『geCapabilityTheinitialdisasterre﹣ sp0nseisinvariablyalocalresponse’asregiona1orna﹣ tionalassetscann0ttypicallybemobilizedfbr72hours. Thus》local’regional,andnationaldisasterplansmust presumethathospitalswillbeabletodeploysuf｛icient staff;equipment’andresourcestocarefbranincrease, or“surge,”inpatientvolumethatisapproximately20 percenthigherthanitsbaseline,anestimatethatre﹣ llectsrecentworldwideexperiencewithhmitedMCEs. Thetermsm吾ecαpαc叼ismoreoftenusedindisasterplansthansα｝gecqpαM叼’buttheATLScourse usesthelatterterm,asitismoremclusivethanthe fbrmerterm·Thisisbecausesurgecapaci叮toooften isusedtorefbronlytothenumberofadditionalbeds orassets（eg.,ventⅡatorsandmomtors）thatmight bepressedmtoserv1ceontheoccasionofanMCE. Bycontrast,surgecapabⅢtyrefbrstothenumberof additionalbedsthatcanactuaⅡybestaffbdorventilatorsandmonitorsthatcanactuaⅡybeoperated.In largeurbanareas,manystaffmayworkmultiplejobs’ andmayunknowinglybepartofmorethanonehos﹣ pital’sdisasterplan.Inaddition’mosthospitalstaff areworkingparents,whomustconsidertheneeds oftheirfhmiliesandrelatives,inadditiontothoseof theirworkplaces. AIte『nativeCa『eStahda『dSInMCEs,itcanbeex﹣ pectedthatduringthefirst24to72hoursofthedis﹣ astertherewillbeinsufficientlocalassetstoprovide alevelofcarecomparabletothatroutinelyprovided inlocalhospitalemergenCydepartments0rintensive careumts.Ifscarceresources’particularlymtensive resources,aredevotedt0thefirstseveralcritical】yill

APPENDIXD■Disaste「ManagementandEme『gencyP「epa『edne5s333 orinjuredpatientswhorequirethem’itwillbediffi﹣ cult’ifnotimpossible’tolaterredirectthemtoothers ingreaterneed. Tomaximizetheseresources’hospitaldisas﹣ terplansmuststrivetoprovidethelargestpossible numberofpatientswiththe1ninimu1nacceptabIe care,definedasthelowestappropriatelevelofmedi﹣ calandsurgicaltreatmentrequiredtosustainlifband 】imbuntiladditionalassetscanbemobihzed.Smce eachdisasterresponsepresentshealthcareprovid﹣ erswitha伍ffbrentmixofpatientneedsandavailable resources’nosingledescriptionofamimmumaccept﹣ ablestandardofcareisapplicabletoeveryfacilityor everydisastercircumstance·Theselectionofpatients torece1vescarceormtensiveresourceswillpresentthe traumaspecialistwithanethicaldilemmaandpoten﹣ tiallyalaterlegalproblem.Generalcriteriashouldbe developedbefbrethedisasterevent’basedondemographicandgeographiccircumstancesasweⅡasthe communi叮HVA.Itiswisetodevelopsuchcriteriam collaborationwiththehospital,slegalc0unsel’bioeth﹣ icscommittee,andpastoralcaredepartmenttoensure consisten叮withthecommunitystandardoflegal’ethi﹣ cal,andmoralvalues·Theyshouldthenbemcludedas partofthefhcⅢ叮,sdisasterplan.

T『afficCont『oISystemControllingtheflowofinfbr﹣ mation（commumcations）’equipment（supplies）,pa﹣ tients（transport）’andpersonnel（providers’relatives, thepubhc’andthepress）isofparamountimportance inamedicaldisasterresponse·Thesearetheissues m0stoftencitedinafter﹣actionrep0rtsascausesof disastermismanagement·Theunidirectionalflowof patientsfTomtheemergen叮departmenttoinpatient unitsmustbeensured’sinceemergenCydepartment bedswillbemadeavailablefbrlater﹣arrivingpatients astheyareemptied. Redundantcommumcations叮stems,reliablesupply Chains,andredoubtablesecur呵measuresarealsovital componentsofaneffbctivedisastermedicalandopera﹣ tionalresponse.Theseassetsmustbetestedonaregular basisthroughdrillsandexercisesthatrealisticaⅡyreⅡect thedisasterscenariosthataremostlikelytobeencounteredbyaparticularfhcili叮’Whateveritslocation. SpecialNeedsPopuIation5Specialneedspopulations includechildren,especiallythosewhoareteChnology﹣ dependent;elders,especiaⅡythosewhoarebedridden, includingthenursinghomepopulation;thedisabled’ bothphysicallyandemotionaⅡy,ibrwhomassistance wⅡlbeillness﹣orinjmy﹣specific;andthedispossessed’ includingthepoorandthehomeless’whowillbedif ficulttoreachbytraditionalmeansfbrpurposesofdis﹣ astereducationandtreatment.Specificresponseplans areneededtoensurethattheirspecialneedsaremet.

PathophysiologyandPatte『nsofInju『yAswithall trauma’disastersresultinrecognizablepatterns0f injmythatarebasedonthepropertiesoftheparticu﹣ larwoundingagentandtheuniqUepathophysiology thatresultsfromeachsuchagent·Althoughdetailed descriptionsofthepathophysiologyandpatternsof i叼uryencounteredintheacutedisasterresponseare b叮ondthescopeofthisappendix’100℅ofallnatural disastersRⅥd98﹪ofallterroreventsworldwidein﹣ volvephysicaltrauma.Thus’theprinciplesofATLS areideaⅡysuitedtotheearlycareofpatientswith bluntandpenetratinginjuriesobservedindisasters. CertainadditionalfactorsmustalsobecoDsideredin theearlyandlatercareofseriouslyi叼ureddisaster patients’includingthepossibⅢtythatchemical’ra﹣ diologic,andbiologicinjuriesmaycoexistwithblast injuries.Membersofthemedicalteamshouldbefh﹣ mi】iHrwiththebasicsofdecontaminationandinitial treatmentofallpatientsinjuredbyWMDs,notonly thoseinjuredbybombblastsandgunshotwounds. WMDsmaybethesoleagentused’ormaybeaddedas adulterantstoexplosivedevicestoconstructa“dirty bomb.”Ifpresent’WMDscancomphcatethecareof individualswhohavesuffbredblasttrauma,although theireffbctivenessinsuchscenariosmaybehmitedby theeffbctsoftheblast.DescriptionsofWMDagents andcareofWMDmjuriesotherthancontagiousill﹣ nessesaresummarizedinBoxesD﹣4throughD﹣10. Remembe『,theeme『gencyca『eo「thesepatientsbe﹣ ∞mesevenmo『ecompIexinthe佗ceo「MCEs’with thei『associatedneedsfb『disaste『t『iage,additionaI sta侃andadequatesupplies·Thetreatmentofconta﹣ g1ousⅡlnesses’whichtypicallypresentwithfbverand rashorinfIuenza﹣likesymptomsdaysaftereXposure’ ismicrobe-dependent.

RecoveⅣ Recoveryinvolvesactivitiesdesignedtohelpfacili﹣ tiesresume0perationsafteranemergenCy.Thelocal pubhchealthsystemplaysam可orroleinthisphase ofdisastermanagement,althoughhealthprofbssionals willprovideroutinehealthcaretotheaffbctedcommumtyconsistentwithavailableresources’mtermsof operablefhcⅢties’usableequipment’andcredentialed personnel.Acutecarephysicianswhoprovidecare fbrneglectediIjuriesandchromcillnessesmayfind boththemedicalandorganizationalskiⅡsrequired fbrtheearlycareofthetraumapatientusefUlinthe daysaftertheresponsephasesubsides.Theprinciples ofATLS一thatis’treatmentofthegreatestthreatto hfbfirst,withoutwaitingfbradefinitivediagnosis, andcausmgthepatientnoharm’arenolessusefUlin theaustereenvironmentsthatmayfbllownaturalor human﹣madedisHSters.

＝

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APPENDIXD■Disaste『ManagementandEme「gencyP「epa『edness335

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pitfaⅡS Theiburcommonpitfhllsinthedisastermedicalre﹣ sp0nsearealwaysthesame－communications’sup﹣ plies,security’andvolunteers＿leadingmanydisaster expertstoaskwhyhumansseemmcapableoflearn﹣ ingfiPomthemistakesmadeinpastdisasterevents. Althoughtheexactdates’times’andplacesoffhture disastersareunknown’thelessonslearnedfromprevi﹣ ousdisastersareinvaluableinteachingushowtobetterpreparefbrthem. Itcanbeexpectedthatlandandmobiletelecom﹣ municationsSystemswillbeoverwhelmed.Commu﹣ nicationssystemsmustbemllyinteroperableand

overlyredundant,bothintermsofduplicateequip﹣ mentanddisparatemodes·Capabilityfbrbothverti﹦ calandhorizontalcommumcationsmustbeensured. Suppliesneededfbrdisastersmustbesequestered andstoredinhigh’dry,safb,andsecureareas.Secu﹣ ritymustbeensuredfbrproviders’patients’supplies’ andsystemsneededfbrdisastercare’suchascom﹣ municationsandtransport.Volunteers’wellmean﹣ ingastheymaybe,mustbeproperlytrainedand credentialedtoparticipateinadisasterresponse,and mustparticipateonlyaspartofaproperlyplanned andorganizeddisasterresponse,sincetheyotherwise placeboththemselves’andtheintendedrecipientsof theiraid’mdanger.

■■■■■■■■■■■■■■■■

336APPENDIXD■Disaste「ManagementandEme『gencyP『epa『edne5s

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APPEND∣XD■Disa5te『ManagementandEme「gencyP『epa『edne55337 ＝

BoxD﹦9SpeciaIConside『atioⅡsintheCa『e ofRa〔liationaⅡd!＼Iuclea『ln】Ⅲies IonizingRadiation ■path0phy5i0I0gy: ＝St『p i 5ee l ct『0n5f『0mat0mc i nuc∣e!idamagn i gceI﹣ u l Ia「DⅡA;『apd i Iydv id in l gt5 i 5ue5（ga5t「0n i testⅡ i a∣’ hemat0p0ieti〔lepide『mal）a『em0stsusceptibIet0 i0nizing『adiati0n －／V0帕;Ra加ad／ li Pat0m5e川ripa「td i es（b／／ayB）du仟 加db（aW庇k0／eXp0su伯depe〃dsup0ne〃eUy0／ emBsb i 〃s（〃（〃『tyb0mb〃:／0Ⅷ〃udba「aCddbnrh甽 ■5X: －Sped↑ictod0seandtype!distan〔et0s0u『ceidensity 0↑5hielding;asympt0matic＜50『ad（0.5Sv）l6bu『ns ＞I00『ad（Sl v）’a〔ute『ada i t0 i nsynd『0me＞Z00『ad （Zv s）

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＝αandβ:exte『na∣【士n i te『na｝ I decon＋5upp0『tv ie ca「e;Xandγ:5upp0『tv i eca『e（t『eatexte『na〔 I 0n﹣ taminati0nasdi『t;n0『i5kt0p『0vide『f「0mpatient X0『γexp0su『e） ＝川0帕﹟D0／V0γdb仞尼susd田b i 〃／b「dbm〃ramh i a﹣ 觔0n〃as店kt0p／DVd i b『店n川pe肋〃h0pe眉t0 i 〃5hy 〔by3加aI／0idw0u〃dmmp倔加〃5Z。REy尼〃u尼. ﹩RES﹦『ec tiu0 Iend0the∣a i5 Iy5tem

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338APPENDIXD■Di5aste「ManagementandEme『gencyP「epa『ednes5

■ ﹥

comprisesbothprehospitalandm﹣patientcare’and mustembracetheminimalacceptablestandardofcare neededtoprovidethegreatestgoodfbrthegreatest number·Itrequ1resasoundunderstandingofpatho-

∣

Themedicaldisasterresponseoccurswithinthecon﹣ textofthepublichealthdisasterresponse＿prepara﹣ tion,mitigation’response,andrecovery.Preparation requiresboththeconvictionthatadisasterwilloccur, andthecommitmenttobereadywhenithappens,and mustensureboththatasimpleplanisdevelopedand thatallareeducatedinitsimplementation.Mitigation isthekeytothesuccessofthedisasterresponse’since itprovidesthefiPameworkwithinwhichmedicalcare mustberendered-fbrexample’incidentcommand systemsandeffbctivedisasterdriⅡsandexercises· Responseistheessenceofdisastermanagement·It

■BihIiog卹hy 1.AmericanAcademyofPediatrics（FoltinGL,Schon﹣ fbldDJ,ShannonMW’eds·）·Ad!α／／.!cIb／γoJ、【Smα〃d DZsαs颱rB迢pα祀d几ess了AResoα加e／brAd:α㎡ctα〃s. AHRQPublicationNo.06﹣0056﹣EF.Rockville’MD: Agen叮fbrHealthcareResearchandQuality;2006. http:／／wwwahrq.org／research／pedprep／resource.htIn AccessedFebrua】y26,2008. 2.aufderHeideE.DZsαs蛇rReSpo几sαP｝·加cip／esO／Prepα﹣ ／·α㎡o几α几dαo㎡加αtio几.Chicago,IL;OVMosby;1989. 3.CommitteeonITauma’AmericanCoⅡegeofSurgeons. D『sαsteγMtm吧2加e〃㎡α几dEme】g2几qyPr叩α『它d〃ess αm丐e.Chicago:AmericanCollegeofSurgeons,2009. 4.DiPalmaRG,BurrisDG,ChampionHR’HodgsonMJ. Blastinjuries.ⅣE唔／JMbd2005;352:1335﹣1342 5.F】ykbergER,TepasJJ.Te1Toristbombings:lessonslea﹣ rnedfromBel炮sttoBeirut.A几几S皿／g1988;208:569﹣576· 6‘GutierrezdeCeballosJP,Turegano﹣FuentesF,PerezDiazD,Sanz﹣SanchezM’Martin﹃LlorenteC》Guerrero. SanzJE.Casualtiestreatedattheclosesthospitalinthe Madrid’March11,terroristbombings.Cr肋Oα／、eMbd 2005;33（1Suppl）;S107﹣S112· 7.GutierrezdeCeballosJP’Turegano霪FuentesF,Perez﹣ DiazD’Sanz﹣SanchezM,Martin﹣LlorenteC’Guerrero﹣ SanzJE‘11March2004:theterroristbombexplosions inMadrid’Spain﹣ananalysisofthelogistics’injuries sustainedandclimcalmanagementofcasualtiestreated attheclosesthospital.C『.肋Cα／e2005》9:104﹣111· 8.HirshbergA’ScottBG’GranchiT’WallMJ’MattoxKL’ SteinMHowdoescasualtyloadaffbcttraumacarein urbanbombingincidents?AquantitativeanalysisJ T／·αM〃﹟α2005;58（4）:686﹣693;discussion694·695 9HoldenPJ.TheL0ndonattacks－achronicle;Improvising inanemergency.NEJ】g!JMbd2005;353（6）:541﹣543.

physiologyandpatternsofimuryfbrcaretobedehveredexpeditiouslyanddeteriorationanticipatedand avoided·Recoveryismainlytheprovinceofpubhc healthpersonnel’butitdependsonsupporthomacute carephysiciansfbrtreatmentofuntreatedinjuriesand chronicillnessesthatmaydeveloporbecomeexacer﹣ batedintheaftermathoftheacuteresponse.Thepsy﹣ chosocialissuesthatwillarisemustberec0gnizedand dealtwithtoensureadequaterecoveⅣoftheindividu﹣ alsandcommumtyinvolvedinthemcident·

10JacobsLM,BurnsIg,GrossRI.Terrorism:apUblic hea1ththreatwithatraumaSystemresponse.J乃uαmα 2003;55（6）:1014﹣1021. 11KalesSN,ChristianiDC·AcuteChemica1emergencies.Ⅳ E）lg!JMbd2004;350（8）:800﹣808. 12.KleinJS’WeigeltJA.Disastermanagement:lessonslea﹣ rned.S〃唔α加lVO㎡hAm1991,71:257-266. 13.MettlerFA’VOelzGL.M句orradiationexposure－ Whattoe軔ectandhowtoresp0nd·ⅣE刃g』JM它d 2002;346（20）:1554﹣1561. 14.Multipleauthors.Perspective:TheLondonattacks﹣a chromcle.ⅣEJ】g／JM它d2005;353:541﹣550 15·MusolinoSV,HarperFTEmergencyresponseguidance 允rthehrst48hoursa此ertheoutdoordetonationof anexplosiveradiologicaldispersaldevice·H它α／炕P〃0侶 2006;90（4）:377﹣385. 16·NationalDisasterLifbSupportExecutiveCommittee’ NationalDisasterLifbSupportFoundationandAmericanMedicalAssociation.Aduα兀ceαBαs〔C’αγ.e’α几d Deco几mm加α瓦o几Lj／bS【《PpoJ℉P『Dufde／、MtmMα／s.Chi﹣ cago’IL:AmericanMedicalAssociation’2012. 17.PediatricTaskForce,CentersibrBioterr0rismPrepa﹣ rednessPlanning,NewYorkCi叮DepartmentofHealth andMentalHygiene（ArquillaB,FoltinG,UraneckK’ eds。）C加／d『·e几加D【sαste｝B:HbSp肋α／G咖de／加es／bJ、 Ped﹩α／rtcP／,Cpα『.ed〃ess.3rded.NewYork:NewYork CityDepartmentofHealthandMentalHygiene’2008‘ http:〃www.nycgov／html／doh／downloads加d毗hpp／hepp﹣ peds·childrenindisasters﹣010709·pdf;AccessedMay1’ 2012. 18.Bocca｛brteJD）CushmanJG.Disasterpreparationand m剽hagementfbrtheintensivecareunit.CM〃Op加C）、肋 Cm它2002;8（6）:607﹣615. 19SeverMS,VanholderR’LameireN.Managementof crush-relatedinjuriesalterdisasters.ⅣE〃g!JMed 2006;354（10）:1052﹣1063.

P

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APPENDIX ﹁ ﹁

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TriageScenarios Int『oduction

O叻ectiv e s ⅢDefinet「iage. 圓Exp∣ainthep「indp∣esInvoIvedandthe↑acto「sthat mustbeconsd i e『eddu『n i gthet『a i gep『ocess. 圓AppIythep「incipIeso↑t『iagetoactualscena「ios. ﹂

Thisisaselfkassessmentexercise’t0becompleted be／b了eyouarrivefbrthecoursePleasereadthrough themtroductoryinfbrmationonthefbllowingpages befbrereadingtheindividualscenariosandanswering therelatedquestions.ThisskiⅡstationisconductedin agroupdiscussionfbrmatduringthecourse,inwhich yourparticipationisexpected.Uponcompletionofthis session’yourinstructorwillreviewtheanswers’ Thegoalofthisstationistoapplytraumatriageprm﹣ ciplesinmultiplepatientscenarios.

Definitiono仃『iage Triageistheprocessofprioritizingpatienttreatment duringmass﹣casualtyevents.

P『incipIesofT『iage DotheMostGoodfo『theMostPatients UsingAvaⅡabIeResou『ces Thisisthecentralguidingprinciplethatunderliesall othertriageprinciples》rules》andstrategies.Multiple﹣ casualtyevents’bydefinition’donotexceedthere﹣ sourcesavailable.Mass﹣casualtyevents,however,do exceedavailablemedicalresourcesandrequiretriagej thecareprovider’site’System,and／orfHcilityisunable tomanagethenumberofcasualtiesusingstandard methods。Standardofcareinterventions,evacua﹣ tions,andprocedurescannotbecompleted（fbreach injury）fbreverypatientwithintheusualtimeframe. Theprinciplesoftriageareappliedwhenthenumber ofcasualtiesexceedsthemedicalcapabilitiesthatare immediatelyavailabletoprovideusualandcustoma1y care·

MakeaDecision Timeisoftheessenceduringtriage.Themostdifficult aspectofthisprocessismakingmedicaldecisionswith﹣ outcompletedata·Thetriagedecisi0nmaker（ortriage oificer）mustbeabletorapidlyassessthesceneand thenumbersofcasualties,fbcusonindividualpatients fbrshortperiods,andmakeimmediatetriagedetermi﹣ nationsfbreachpatient.Triagedecisionsaretypically madebydecidingwhichpatients’iIUuriesconstitute thegreatestimmediatethreattolifb.Assuch,theair﹣ way’breathing,circulation’anddisabili↑Vpriorities

339

340APPENDlXE■T「iageScena「io5

ofATLSarethesameprioritiesusedtomaketriage decisions.Thatis’ingeneral》airwayproblemsare morerapidlylethalthanbreathingproblems’which aremorerapidlylethalthancirculationproblems’ whicharemorerapidlylethalthanneurologicinjuries· Allavailableinfbrmation,includingvitalsigns》when available,shouldbeusedtomakeeachtriagedecision.

T『iageOcCu『satMuItiple儿eveIs Triageisnotaone﹣time’one﹣placeeventordecision. Triagefirstoccursatthesceneorsiteoftheeventas decisionsaremaderegardingwhichpatientstotreat firstandthesequenceinwhichpatientswillbeevacu﹣ ated·Next’triage↑ypicallyoccursjustoutsidethehos﹣ pitaltodeterminewherepatientswillbetransp0rted withinthefacility（emergencydepartment’operating room,intensivecareunit》ward’orclinic）.Triagethen occursmthepreoperativeareaasdecisionsaremade regardingtheseqUencemwhichpatientsaretakenfbr operation. KnowandUhde『standthe Resou『cesAvailabIe Optimaltriagedecisionsaremadewithknowledgeand understandingoftheavailableresourcesateachlevel orstageofpatientcare·Thetriageofficermustalsobe immediatelyawareofchangesinresources,whether additiohalor允wer· Asurgeonistheidealtriageofficerfbrhospital triagepositionsbecauseheorsheunderstandsallcom﹣ ponentsofhospitalh1nction,includingtheoperating rooms.Thisarrangementwillnotworkinsituations withhmitednumbersofsurgeonsanddoesnotapply totheihcidentsite.Themedicalincidentcommander （whomayormaynotelecttoserveasthetriageofficer） shouldbethehighest﹣rankingmedicalprofbssionalon thescenewhoistrainedindisastermanagement·

P∣anningandRehea『SaI Triagemustbeplannedandrehearsed,aspossible. Eventsthatarelikelytooccurinthelocalareaarea goodstartingpointfbrmass﹣casual叮planningandre﹣ hearsal.Forexample,simulateamass﹣casual叮event fromanairplanecrashifthefacilityisnearama〕or a1rport’achemicalspiⅡifnearabusyrailroad’oran earthquakeifinanearthquakezone·Specificrehears﹣ alfbreachtypeofpossibledisasterisnotpossible,but broadplanningandfine﹣tuningoffacilityresponses basedonpracticedrⅢsispossibleandnecessary.

Dete『mineT『iageCatego『yTypes Thetitleandcolormarkingsfbreachtriagecategory shouldbedeterminedatasystem﹣widelevelaspartof planningandrehearsal·Manyoptionsareusedaround theworld.Onecommon’simplemethodistousetags thecolorsofastoplight:red’yellow’andgreen·Redim﹣ pheslifb﹣threatemnginju】ythatrequiresimmediateinterventionand／oroperation.Yellowimpliesinjuriesthat maybecomehfb﹣orlimb﹣threaⅡjeningifcareisdelayed beyondseveralhours.Greenpatientsarethewalking woundedwhohavesufIbredon】yminormjuries.These patientscansometimesbeusedtoassistwiththeirown careandthecareofothers.BlackisfreqUentlyusedto markdeadpatients·Manysystemsaddanothercolor’ suchasblue’fbr“expectant,’patients一th0seWhoare soseverelyinjuredthat’giventhecurrentnumberof casualtiesreqUiringcare,thedecisionismadetoslm﹣ p】ygivepalliativetreatmentwhilefIrstcarmgfbrred （andperhapssomeyellow）patients·Patientswhoare classifiedase軔ectantbecauseoftheseverityoftheir iIUurieswould叮picaⅡybethefirstpriori叮insituations mwhichthereareonlytwoorthreecasualtiesrequ1rmgimmediatecare.However,therules,protocols,and standardsofcarechangelnthefaceofamass-casual叮 event·Remember:“Dothemostgoodfbrthemostpatientsusmgavailableresources.,,

T『iage∣sContinuouS（Ret『iage） Triageshouldbecontinuousandrepetitiveateach levelorsitewhereitisrequired.Constantvigilance andreassessmentwillidenti句patientswhosecircum﹣ Stanceshavechanged＿eitherbecauseofachangein physiologicstatusorbecauseofachangeinresource availabili叮.Asthemass-casualtyeventcontinuesto unfbld,theneedfbrretriagebecomesapparent.The physiol0gyofinjuredpatientsisnotconstantorpre﹣ dictable,especiallyconsideringthelimitedrapidas﹣ sessmentrequiredduringtriage.Somepatientswill unexpectedlydeteriorateandrequirean‘‘upgrade,,in theirtriagecategory’perhapsfTomyellowtored.In others’anopenfTacturemaybediscoveredafterinitial triagehasbeencompleted’mandatingan‘‘upgrade” intriagecategoryhPomgreent0yellow.Animportant grouprequiringretriageistheexpectantcategory.Al﹣ thoughaninitialtriagecateg0rizationdecisionmay labelapatientashavingnonsurvivableiILjuries’this maychangeafterallred（orperhapsredandsomeyellow）patientshavebeencaredfbrorevacuated（e.g.’ ayoungpatientwith90℅burnsmaysurv1veifburn centercarebecomesavailable）.

APPENDIXE■T「iageScena「ios341

T『ia geScena『ioI Gas E叩IosiohintheGyⅢⅡasiuⅢ

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34ZAPPENDlXE■T「iageScena『ios

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344APPENDIXE■T『iageScena『ios

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354APPENDIXE■T「iageScena『ios

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∣ Index ABCDEs.SeePrima】ysurvey Abdomenexamination’fbrsecondary survey,17,26 Abdominalandpelvictrauma·Seeα』so Pelvic仕actures anatomyof;124’124／ assessmentoβ127－34 bloodlossin,124 blunttraumacausing,125,125／ evaluationoβ132’132t contraststudiesfbr,131＝32 CTfbr,131,132t inpediatricpatients,261 serialphysicalexaminationue／Bαs double﹣／triple﹣contrast,133 diaphragminjuries,134 DPLibr,131’13M132﹠ inpediatricpatients’262 duodenalrupture’135 evaluationof;132一34 localwoundexploration,133 serialphysicalabdominal examination’133 serialphysicalexamination0e｝Qsαs double﹣／triple﹣contrastCT’133 thoracoabdominalwounds,133 FAST｛br,130,13叱132f inpediatricpatients,261 gastriccathetersfbr’129 genitourinaryinjuries’135 initialassessmentof;123﹣24 laparotomyfbr,133 indicationsfbr,134,13蚱 pancreaticinjuries,135 patienthisto】yfbr,127 inpediatricpatients’260 assessmento!261 CTscanningfbr’261 DPLfbr’262 FhSTfbr,261 nonoperativemanagementof;262 specificvisceralinjurieS,262 pelvicfractures causesof;135＿36 managementof;136＝37,137／ mechanismofinjmy／ classification,136,136／ shockand’83’84r’90一91 penetratmgtraumacausmg,125’ 126／ evaluationof;133 ●

physicalexaminationfbr adjunctsto’129＝32 auscultation’127 glutealexamination,129

inspection,127 pelvicstabilityevaluation,128, 128／ percussionandpalpation, 127＿28 urethral,perineal’rectal 偽xRmination’128＝29 vaginalexamination,129 homrestraintdevices,125’126t smallbowelinjuries’135 solidorganinjuries’135 urinarycathetersibr,129 x﹣rayexaminationsfbr,129＿30 ABG.SeeArterialbloodgases Acidosis’95-96 Acutecare’326b,333 Acutecarespecialists,326b,328 AcuteradiationSyndrome’337b Adenosinetriphosphate（ATP）’65 After﹣Actionreview’21’28 A仳erload’64,64／ Airbags,126¢ Airwaydecisionscheme,37,38／ Airwaymaintenance a1rwaydecisionschemefbr’37’38／ ｛brburninjuries asimmediatelilbsavingmeasure, 232,232／ inprimarysurvey’235 withcervicalspineprotection pitlhllsol｝8 fbrprimarysurvey,6﹣8’8／ CO2detectionfbr’42 skillsetfbr’56－57 deathcausesfiyomlackoM1 definitivea1rways endotrachealmtubationibr, 41－42,42／;54＿55 GEBibrdifficult’42’43／;44 indicationsfbr,41,41㎡ surgical,44－45’44／ typesoM0-41 fbrgeriatricpatients’274 helmetremovalin’34,35／ hemorrhagicshockexamimng,70 ILMAfbr》40 skillsetfbrinsertmg,52－53,53／ LEMONassessmentfbr’35）36b＿ 37b LMAfbr’40’40／ skiⅡsetfbrinserting,52＿53 LTAfbr’40,41／ skillsetfbrinserting,54 Mallampaticlassificationsfbr, 36b－37b

needlecricothyroidotomyfbr’44＿45’ 4蚌 complicationsof;60 skiⅡsetfbr’59－60,59／ ohjectivesignsofobstructionfbr’33 o唧genationmanagementfbr’4546, 45t,55－56,56f fbrpediatricpatients’250－51 anatomyandpositioningfbr,251’ 252／ cricothyroidotomy允r’254 LMAfbr,254 managementof;251－52 oralairwaymsertionfbr,252 orotrachealintUbationfbr, 252－54,253／;254／ pitfhllsof;255 predictingdifficultairwaysm’35 problemrecognition允r’32-33 laryngealtrauma’33 maxillo炮cialtrauma’32,32／ necktrauma,32＿33 〔brresuscitation,10 ibrseverebraininjm?y,162 skillsetfbr’24,50＝57 surgicalcricothyroidotomyfbr,45 complicationsoi;60 skiⅡsetfbr’60,61／ techmqUesfbr,34－35 chin﹣liftmaneuver,37,39／ extraglotticandsupraglottic devices,39＿40,40／;41／ jaw﹣thrustmaneuver,37﹄38,3呀 nasopha】yngealairway1nsertion, 39,51 oropha】yngealairwayinsertion, 38－39,39／;51 fbrthoracicinjury,96 ventilationm effbctivemanagementoi;46 ohjectivesignsofinadequate,34 problemrecognitionfbr’34 Airwayobstructionsigns’33 AmericanBurnAssociation’236 AMPLEhistory,14,25 Amputation’traumatic,214＝15 Analgesics’220,239 Anklefractures,220 Anteriorabdomen’124,12蚓 Anteriorchamberinjury’312－13 AnteriorcordSyndrome’181 Anteriorwedgecompressioninju】3『,184 Antibiotics,239 Anticonvulsants,165 Aorticrupture,traumatic,105－6’106／

355

356IⅡDEX Arachnoidmater,15M152 Areaofoperation（“warmzone,,）, 326b,330 Armedconllictenvironments,321＿24 Arterialbloodgases（ABG）’12 ArterialinjuIy’229 Arteriography,214 Arthritis,275 Asphyxia,traumatic,108 Aspiration,32 Atheroscleroticvascularocclusive dise醞e,76 Athletes’shockand,7佳77 Atlanto﹣occipitaljointdislocation,182, 197’197／ AtlasC1fracture,182’182／ ATP.SeeAdenosinetriphosphate Atropinesulfate’253 Austereandarmedconf】ict env1ronments,321＿24 Autotransfhsion,75 AxisC2fractures,182,184,18似 Back,124’12嘶 serialphysicalexaminationu2rsαs double﹣／triple﹣contrastCTfbr imuriesto,133 Backward,upward,andrightward pressure（BURP）,42’52 Bag﹣maskventilation,51 B月I月ncedresuscitation hemorrhagicshock,69 mitialfluidtherapy’72 massivetransfi1sion’75 Barbiturates’165 BCU·SeeBodycoolingunit BCVI.SeeBluntcarotidandvertebral vascularinjuIy Beck’striad’101 BlastinjuIy,WMDscausmg’334b Bleeding,managementof｝9,83『 Bloodloss mabdominalandpelvictrauma, 12步24 mgeriatricpatients’277 musculoskeletaliI叮uriesand’208 pathophysiolo田of;65 inpediatricpatients,257r ofpediatricpatientswith musculoskeletalinjuries,265 pelvicfiPacturesandshock’ techmquesfbrreducing,9Ⅸ91 Bloodpressure,12 hemorrhagicshockconsiderations fbr,76 inpregnantpatients’290 Bloodreplacement,fbrpediatric patients,259 Bloodtrans允sion auto,75

｛brhemoIThagicshock’74－76’7可 massive,75 Bloodvolume’9 inpregnantpatients,289,290／ Bloodwarmers,75 Blownpupil’152 BluntcardiacinjuIy,104－5 BluntcarotidRndvertebralvascular imuIy（BCⅥ）》186’186／ Bluntesophagealtrauma’107 Blunttrauma,14 abdominalandpelvictraumahPom, 125,12邱 BCⅥ,186,186／ evaluationof;132,132／ inpregnantpatients,291,291』 B0dycoolingunit（BCU）,320 Body﹣surfhcearea（BSA） agechangesin,233 ofpediatricpatientS’249 BonylevelofinjuIy,181 B0nythorax,inx﹣rayexaminationsfbr thoracicinjmy’116 Brain,150／;152 Braindeath,167 BraininjuⅣ.SeeHeadinjuries; Traumaticbraininjmy Brainstem,152 Breathing.Seeα／soVentilation fbrburni叼uries’236 ｛brgeriatricpatients,27屝76’ 276／ hemorrhagicshockexamining’70 ｛brpediatricpatients,255 pitfallsfbr,9 ｛brpr1marysurvey,8 fbrresuscitation’11 severebraininjmyand’162 skillsetfbr’24 fbrthoracicmjuIy’96-99 Bronchi,inx﹣rayexaminations｛br thoracicinjuIy,114－15 BroselowPediatricEmergencyTape, 250’250／ Brown﹣S色quardsyndrome,181 BSA.SeeBody﹣surmcearea Burninjunes,230 assessmentof depthofbumin’233’23可 ◆

patienthistoIyfbr,233 RuleofNinesfbr’233,234／ chemical,23940,239／ circulationresuscitationfbrshock fi.om,236-37’237／ electrical,240 geriatricpatientswith,275 immediatelifbsaⅥngmeasuresfbr a1rwaymaintenance,232’232／ intravenousaccess,233 stopburningprocess’232,232／

patienttransfbrstodefimtivecare 【br,240 primaIysurveyfbr a1rwaymaintenancein,235 breathingin’236 secondarysurveyfbr,14－15’237 antibioticsin,239 baselinedeterminationsfbrma〕or burns,238 documentationin’238 gastriccatheterinsertionin,239 narcotics,analgesics’sedatives fbr,239 peripheralcirculationin circumfbrentialextremity burns,238’23呀 physicalexaminationin,238 tetanusimmunizationin’239 woundcarein’239 temperaturecontrolfbr,231 BURP.SeeBackward,upward,and rightwardpressure Burrholecraniostomy／craniotomy, 167 Burstinjmy’185

C1rotaIysubluxation’182’183／ Calciumadministration,76 Carcrash,triagescenariosfbr,350－51 Carbondioxide（CO2）’42,5佳57 Cardiacdysrhythmias,237 Cardiacoutput,9 inpregnantpatients,290 Cardiacphysiolo田’64,6嘶 Cardiactamponade’67 causesof;101,101／ diagnosis0f;101－2 FAST｛br’102 pericardiocentesisfbr,102 complicationswith,121 skillsetfbr,120-21 skiⅡsetfbr,83¢ Cardiogemcshock’66＿67 Cardiopulmonaryresuscitation（CPR）’ 102 fbrpediatricpatients’260 Casualtycollectionpoint（CCP）,326b, 330 Catheters gastric,12,202 fbrabdominalandpelvictrauma, 129 ibrburninjuries,239 pit｛hllsof;12－13 urinary,11﹣12,202 fbrabdominalandpelvictrauma, 129 fbrhemorThagicshock,71 CBC.Se2Completebloodcount CBF.SeeCerebralbloodHow

IⅡDEX357 CBRNE.S2eChemical’Biological’ Radiological,Nuclear’and Explosiveagents CCP.SeeC“ualtycollectionpoint CentralcordSyndrome,181 Centra』venouspressure（CVP）,102, 202 hemoIThagicshockmonitoring,66, 73,77＿78 inpregnantpatients’290 Cerebellum’152’172 CerebralbloodHow（CBF）,153－55 Cerebralperfhsionpressure（CPP）, 154 CerebrospinalHuid（CSF）,152 Cerebrum,152 Cervicalcap,178 Cervicalspine.Seeα【soAirway mRintenance geriatricpatientswithinjuriesto’ 278 screeningguidelinesfbr,188b tral】ma consequencesof;34 mechanismsof;182 secondarysurveyexamination fbr’16,25 vulnerabilityof;177 x﹣rayexaminationsfbr’186＿87,195, 196／ Chancefractures,185,185／ Chemical,Biological,Radiological, Nuclear,andExplosiveagents （CBRNE）,326b’329 Chemicalagents,WMDs,334b,335b Chemicalburns’239＿40’239／ Chestexamination,fbrsecondary survey,16－17,2屝26 Chestinjuries.SeeThoracicinjuⅡy Chesttubeinsertion,fbropen pneumothorax）98＿99,98／; 119﹣20 Chestwalli叮uIy’276 Chin.liftmaneuver’fbrairway maintenance,37,39／ CircⅢlRtion ｛brburninjuriesandshock’236-37’ 23了 fbrgeriatricpatients changeswithageof;276 evaluationandmanagementof; 277 withhemorrhagecontrol fbrhemoIThagicshock,70 pitfallsof﹩9－10 ibrprimarysurvey,9 fbrresuscitation,11 skillsetfbr,24 mmusculoskeletalinjuriesphysical examination’212

pediatricpatientsevaluationand managementof bloodreplacementfbr,259 circulatoIyc0mpromiserecog mtionin’255＝56,256／;257t huidresuscitationfbr,25＆59, 259／ thermoregulation【br,260 urineoutputfbr,259 venousaccessfbr,257＿58,258／ weightandbloodvolumein, 256－57 severebraininjuIyand’162 ｛brthoracicinjuIy,100＿102 ClassI﹣Ⅳhemorrhage,6佳69 CO2.SeeCarbondioxide Coagulopathy’75－76 Coldi叮uries hypothermiaand,242 managementof;318 pSychologiceHbctsof;318 signsof;317－18 managementof;242 triagescenariosfbr’348＿49 typesof;241－42 Colles,lractures’279＿80 CompartmentSyndrome assessmentof;21岳16,216b devel0pmentof;215’215／ escharotomyfbr,238,23呀 managementof;21佳17’21叮 pitfhllof;217 skillsetfbr,229 Completebloodcount（CBC）,238 CompletespinalcordinjuIy,177 Computedtomography（CT〕,106 fbrabdommalandpelvictrauma’ 131,132t pediatricpatientswith,261 serialphysicalexamination ue炤αsdouble﹣／triple-contrast, 133 ｛brheadinjuries,150 skillsetwith,171－72 fbrMTBI’158,158t Conjunctiva’312 Consent,initialassessmentand,20 Contraststudies,fbrabdommaland pelvictrauma’131－32 Contusions,156,15V musculoskeletalinjuriesand’218 pulmonary’99 causesandtreatmentof｝104 CornealmjuIy,312－13 CPP.SeeCerebralperfhsion pressure CPR.SeeCardiopulmonary resuscitation Cranialanatomy,15叮 brain’15叱152

intracranialcompartments’152＝53’ 152／;153／ meninges’151－52,151／ scalp’150 skull,151 ventricularsystem,152 Cricothyroidotomy,58 needle’44＿45,44／ complicationsof;60 skillsetfbr,59-60’5呀 ｛brpediatricpatients,254 surgical’45 complicationsof;60 skillsetfbr,60’61／ Crossmatchedblood,75 Crushsyndrome（traumatic rhabdomyolysis）,213’240 CrushinginjuIytochest（traumatic asphyxia）,108 C叮stall0id’75 CSF.SeeCerebrospinalfluid CT.SeeComputedtomography CVP.SbeCentralvenouspressure Cyanosis,96 Cystography’132 Cytokines,319 DAI.Se2Drug﹣AssistedIntubation Decelerationinjuries,125,125／ Decontaminationchute’326b,330 Decontaminationprinciples,331－32’ 332b De圃nitivea1rways endotrachealintubationfbr’4142’ 42／ infRnt,54＿55 GEBfbrdilIicult’42’43／;44 indicationsfbr,41,41㎡ surgical’44＝45,4緲 typesof;40－41 Dehnitivecare·S2ePatienttmnsfbrs todehnitivecare ‘‘Delta﹣P,’method,tissuepressure measurement,216 Depressedskullfractures,166 Dermatomes’178’17呀 Diagnosticperitoneallavage（DPL）,7’ 13’124,133,145 fbrabdominalandpelvictrauma, 131’131／;132t pediatricpatientswith’262 complicationsof;145﹣46 Sk面IlseMbr closedtechnique,146 opentechmque,146 scenariosin,142 Diaphragmin】uIy inabdominalandpelvictrauma, 134 traumatic’106’10V

358INDEX inx﹣rayexaminationsfbrthoracic injuIy,116 Diffi1sebraininjuries,156 Directblow,125 Disability.SeeNeurologicevaluation Disaster’326b Disasterdrillsandexercises,330＿31, 331b Disastermanagement.Seeα／so Mass﹣casualtyevents;Multiple﹣ casualtyincidents approachfbr,328 challengesin,323－24 emergenCypreparednessfbr,325, 326b ininitialassessment,20 needfbr,328 phasesof mitigation,327b’330＿31,330t, 331b preparation,327b’328－30 recoveIy,327b’333 response’327b,331-33,332b pitfallsof;333,335 termmolo田fbr,326﹄327b Disastertriagescheme’332 “Don,tbeaDOPE’”254 DPL.SeeDiagnosticperitoneallavage Drug﹣AssistedIntubation（DAI）’253, 253／ Duodenalrupture,135 Duramater’151＿52’151／

ECG.SeeElectrocardiographic momtoring EDDSeeEsophagealdetectordevice Elderly.Se2Geriatricpatients Electricalburns,240 Electrocardiographicmonitoring （ECG）’11’105 EmergenCymedicalservices（EMS）, 326b’328 Emergen叮operationscenter（EOC）, 326b Emergen叮preparedness’｛brdisaster management,325’326b EmergoTrainSystem〔ETS）,326b EMS.SeeEmergen叮medicalserv1ces End﹣ofLlifbdecisions,281＿82 Endotrachealintubation’41＿42, 4琊54－55’25LSeeα【so OrotrachealintubRtion Environmentalcontrol.SeeExposure Rhdenvironmentalcontrol EOCSeeEmergen叮operationscenter Epiduralhematomas’156,157／;172 Escharotomy,238,238／ Egchm且nnTrachealTubeIntroducer （ETTI）,42,42／ Esophagealdetectordevice（EDD）,254

Esophagealtrauma’blunt’107 ETS.SeeEmergoTrainSystem ETTI.SeeEschmRYmTrachealTube Ihtroducer ExposureandenⅥronmentalcontrol fbrgeriatricpatients·27＆79 fbrhemorrhagicshock,70 fbrprimaIysurvey,10 skillSetfbr,2午25 Externalperimeter,326b Extraglotticdevices,39－40’4叱41／ EyelidinjuIy,312－13

Falls,geriatricpatientsand,274＿75 FAST.SeeFocusedassessment sonographyintrauma Fatembohsm’207’315 Femoralfipactures,219’220／ Femoralvenipuncture,Seldinger technique,85’86／;87,257 Femur’227 Fetomaternalhemorrhage,293＝94 Fetus,287.Seeα／soPregnantpatients 血ll-term,28呀 prima1ysurveyfbr,292＿93 FieldTriageDecisionScheme,4,5／ First﹣degreeburns’233 Flailchest,99,9呀 Flank’124’12匈 serialphysicalexaminationue咫αs double-／triple-contrastCTfbr injuriesto,133 Fluidresuscitation.Seeα／so Resuscitation fbrhemorrhagicshock evaluationof;73 initialguidelinesfbr’71－73,72／ therapeuticdecisionsbasedon responseto’73＿74,74! fbrpediatricpatients,25＆59’25呀 FlumazenⅡ,44 Focalheadmjuries’156’157／ Focusedassessmentsonographyin trauma（FAST）’9,13,133, 141 fbrabdominalandpelvictrauma’ 130,13叱132t pediatricpatientswith,261 fbrcardiactamponade’102 equipmentfbr,142／ skillsetfbr,142－43 pit炮llsin,144 scenariosin,142 Forearm,227 Forensicevidence,initialassessment and,20 Fracture﹣dislocations,185 Frostbite,241－42’241／ Frostnip,241 Full-thicknessburns,233’235／

Gasexplosionin田mnasium’triage scenario,341－45 Gastriccatheters’12,202 fbrabdominalandpelvictrauma, 129 fbrburninjuries’239 Gastricdilation／decompression’70－71 Gastricdistention,46 Gastrointestmalcontraststudies, 132 Gastrointestmal鋤stemchanges,in pregnantpatients,290 GCS.SeeGlasgowComaScore GEB.SeeGumelasticboug1e Gemtourinaryinjuries,135 Geriatricpatients’272 airwaymaintenancefbr,275 bloodlossin,277 breathingandventilationfbr, 275＿76,27印 cervicalspineinjuriesin,278 circl】Iationin changeswithageoβ276 evaluationandmanagementoβ 277 end﹣o且ifbdecisionsfbr,281＿82 exposureandenvironmentalcontrol fbr,27＆79 immunesysteminfbctionsin,280 injuriesto ageandmortalityrelationships to,274b burni叨uries’275 fallscausing,274－75 typesandpatternsof;273－75’ 274／ maltreatmentof﹩281 medicationsfbr,280＿81 withmusculoskeletalinjuries, 279－80 nutritionandmetabolismin,280 populationgrowthof｝273 pnmaIysurveyfbr,7’275－79 ribfracturesin’108 shockconsiderationsfbr’76 spineimuIyin’277＿78’278／ GlasgowComaScore（GCS）,7,18 lbrheadinjuries,155,155t,156t fbrmoderatebraininjuIy’160 MTBI,158 fbrseverebrainimury,161 Glaucoma’313 Globeimmy’312’314 Gume】asticbougie（GEB）》42’43／;44 Gunshotwounds,125,133

Handinjuries,immobilization｛br,220 Hazardvulnerabilityanalysis（HVA）, 327b,328 HazardousenvIronmentinjuries,15

INDEX359 Hazardousmaterials（HAZMATs）, 326b’328 HE.SeeHeatexhHl】stion Headexamination,fbrsecondaⅡy survey,15,25 Headi叼uries.Seeα／soTraumatic braininju】y assessmentandmanagementof; 17｝73 braindeath,167 classificationoβ155’155t cranialanatomy’150／ brain,150／;152 intmcranialcompartments, 152＝53’152／;153／ meninges,151＿52,151／ scalp,150 skull,151 ventricularSystem,152,172 CTscanlbr’150 skillseMbr,171一72 difIhse’156 fbcal’156,15〃 GCSfbrseverityof;155’155『’156t helmetremovalin’173 moderatebraininjuIy GCSfbr,160 managementof;160）161／ pitfallsof;161 morpholo盯of intracraniallesions,155r,156 skullh.actures’155＿56,155﹟ MTBI algorithmfbrmanagementof｝159／ dischargeinstructionsfbr,158, 160,16叮 GCSfbr,158 pediatricpatientswith assessmentof;263－64’264﹠ managementol;264 penetratmg,166＿67 physiologicconceptsof CBF’153-55 ICP,18,153,154／ Monro﹣KellieDoctrine,153,153／; 15蚌 primarysurveyskiⅡsetfbr’171 prognosisfbr’167 secondarysurveyskiⅡsetfbr’171 severebraininjury a1rwayandbreathing ●

maintenancefbr,162 algorithm｛brmanagementof;161／ circulationand,162 diagnosticproceduresfbr’163 GCSfbr’161 neurologicexaminationfbr, 162－63 ●

pnma1ysurveyfbr,162＿63,162b secondarysurveyfbr,163

surgicalmanagementof〕165 depressedskulMTactures,166 intracranialmasslesions,166 scalpwounds,166’16印 treatmentgoalsfbr’149－50 Head﹣to﹣toeevaluation’3.Seeα／so Secondarysurvey Heartrate,inpregnantpatients,290 Heatexhaustion（HE）,31佺20 Heatstroke（HS）,318＿20 Helmetremoval inairwaymaintenance’34,3可 inheadandneckinjuries’173 Hematuria,129,135 Hemodynamics’inpregnantpatients, 289－90 Hemorrhagecontrol’circulationwith fbrhemoIThagicshock’70 pitfhllsof;9－10 fbrprimarysurvey,9 fbrresuscitation,11 skillsetfbr’24 HemoIThagicshock,64 a1rwaymaintenanceandbreathing examinedfbr,70 bloodlossbasedon,69／ bloodpressureconsiderationsfbr, 76 bloodtransfUsionfbr’74＝76’7邱 circulationwithhemorrhagecontrol fbr,70 classificationof;6＆69 CVPmonitoringfbr,66）73,77-78 definitionof;68 diagnosisof》66,6印 directeHbctsof;68＝69’68Z exposureandenv1ronmentalcontrol fbr,70 fIuidresuscitation｛br evaluationof;73 imtialguidelinesfbr,71－73’72／ therapeuticdecisionsbasedon responseto,73-74,74／ gastricdilation／decompressionfbr, 7α71 hypothermiaand,77 imtialmanagementof;70-73 intraabdominal,83Z neurologicevaluationfbr’70 physicalexaminationfbr,70＿71 respiratoIyalkalosisand,73 softtissueinjuriesand,69＿70 skillsetfbr’85 urinmycathetersfbr,71 urinaryoutputin,73 vascularaccesslinesfbr,71 他moralvenipuncture’Seldinger technique,85,86／;87 internaljugularvenipuncture: middleorcentralroute’88

intraosseouspuncture／in血sion: proximaltibialmute,88－89,89／ peripheralaccessskillset,85 subclavianvenipuncture: inh.aclavicularapproach,87 venousreturnin,65 Hemothorax,104.Seeα!soMassive hemothorax Hospitalincidentcommand可stem （HICS）,326b’330 Hospitalphase,4’6 HS.SeeHeatstroke Humerus,227 HVA.SeeHazardvulnerability analySis Hypercarbia,95-96 Hypertonicsaline,165’264 Hyperventilation,TBI,164－65 Hyphema,313 Hypothermia,11’15 coldmjuriesand’242 managementof;318 pSychologiceHbctsof;318 signsoβ317＝18 hemorrhagicshockand,77 Hypoventilation’46 Hypovolemia,164 Hypoxemia’31 Hypoxia inhalationinjuIyand,236 inpediatricpatients,255 tissue,95 ICSeeIncidentcommHhd ICP.S“Incidentcommandpost; Intracranialpressure ICSSeeIncidentcommandsystem ILMA.SeeIntubatinglaryngealm“k a1rway ImmobiIization

inline’8,8／ fbrmusculoskeletalinjuries anklefi.actures,220 fbmoralfTactures,219’220／ h.actures,20＆9’20印 kneeinjuries’219 skiⅡsetfbr’227 tibia仕actures,220 upper﹣extremi叮andhand injuries,220 fbrpediatricpatientswith musculoskeletalinjuries,266 spinalcordskillsetfbr,20詐5 fbrspineinjuIy dangersof｝176 managementof;18以90’190／; 189／ Immunesystem,ofgeriatricpatients, 280 Impacted仕actures,279

360INDEX Incidentcommand（IC）,322’327b,330 Incidentcommandpost（ICP）’327b, 329,330 Incidentcommand可stem（ICS）’327b mitigationmodelsfbr’330,330／ Incompletespinalcordinjury,177 Induciblemtricoxide鋤nthase （iNOS）,65 Infhntendotrachealmtubation’54－55 InhPaclavicularapproach,subclavian venipuncture,87 InhalationmjuIy,232 diagnosisandmanagementof;236 hypoxiaand,236 InitialaS巳＠SSment ofabdominalandpelvictrauma, 123＝24 consentfbr’20 disastermanagementin’20 elementsof｝3 fbrensicevidenceand,20 interhospitaltriageand’19－20 fbroculartrRⅡ】mR histoIyofinjuryincidentfbr,311 initialsymptomscheckedm’312

Intracranialpressure（ICP）,18,153, 15叮 Intraocularfbreignbody’314 Intraosseouspuncture／inh1sion:

patienthisto1yin,311 physicalexaminationin,312 patientreevaluationfbr,19,28 preparationfbr’4,4／;6 pr】marysurveyfbr’3’6－13,7／;呀 recordkeepmgduring,20 secondarysurveyfbr,3,13＝19,15﹠’ 19／ ofshock clini哩ldif距rentiationofc且Ⅲse in’6d67 firststepin’63 recognitionoβ65-66 secondstepm’63－64 skillsetfbr’83’83¢ teamworkin’2仆21 fbrthoracicinjuly,96 triagefbr,4,5／;6 Inlineimmobilizationtechniques’8,8／ iNOS.SeeInduciblenitTico㎡de synthase Interhospitaltriage,19－20.鈍eα』so Patienttrah貝佗rstode僩nitive

Lacerations’218 Lapseatbelts’126f Laparotomy,133＿34,134／ La1yngeali叮u叮’96 La1yngealmaskairway（LMA）’40,40／ fbrpediatricpatients’254 skillsetfbrinserting,52-53 La1yngealtrauma’airway maintenancefbr’33 Lmyngealtubeairway（LTA）,40’41／; 54 LED.SeeLight﹣emittingdiode LEMONassessment,35,36b＿37b Lensinjmy’312－13 Light﹣emittingdiode（LED）’55 IMA﹦SeeLaryngealmaskairway LogroⅡing,203 LTA.鈍eLaryngealtubeairway Lumbarspine fi.acturesof;185 x-rayexaminationsfbr’187,189 skⅡlsetfbr,198 Lungparenchyma,inx-ray exRminationslbrthoracic mjuIy’115

care

Internaljugularvempuncture:middle orcentralroute,88 Internalperimeter,327b Intimatepartnerviolence,294,295b Intracerebralhematomas’156,157／ Intracranialcavity,152 Intracranialcompartments,152－53, 152／;153／ Intracraniallesions’155t,156’166 Intracranialmasslesions’166

proximaltibialroute’88－89’ 89／ Intravenouspyelogram（IVP）,132 Intubatinglaryngealmaskairway （IIMA）,40’52＿53,53／ Ionizingradiation,249－50 IrisinjuIy,312＿13 Isotonicelectrolytesolutions’277 IVP·SeeIntravenouspyelogram Jaw﹣thrustmaneuver,ibrairway

maintenance’37＿38,3呀 Jeffbrsonfracture,182,182／ Jointdislocationdefbrmities’common, 211,211t Jointinjuries’218 Kidney,aging,276 Kneeimuries,219 Kussmaul,ssign,101＝2

MABP.SeeMeanarterialblood pressure MajorarterialhemoIThage’212－13’ 213／ Mallampaticlassifications,36b-37b Ma】treatment ofgeriatricpatients,281 ofpediatricpatients’266-67,267! Mannitol,165’264 p

Mass﹣casualtyevents（MCEs）’325’ 327b carefbr,321－22 toolsfbreHbctive,322－23 challengesin’323－24 incidentcommandfbr’322 pSychosocialissueswith,324 TCCC｛br,323 triagefbr,6’322’332 warwounds’323 Massivehemothorax,83¢,99 causesanddevelopmentof;100, 100／ managementof;100－101 pitfhllswith,100 MassivetransfUsion’75 MaxillofRcialtrauma,172 airwaymaintenancefbr,32,32／ secondarysurveyexaminationof; 15－16 skillsetfbr’25 MCEs·SeeMass.casualtyevents MCIs·SeeMultiple﹣casualtyincidents Meanarterialbloodpressure（MABP）, 154 Mediastinum,inx﹣rayexaminations ibrthoracicinjmy,115 Medicalresponseteam,327b’329 Medications’S“α／soSpec碗c med!cα㎡O川s ibrgeriatricpatients,280﹄81 shockand,77 fbrspineinjmymanagement,190 Meninges’151＿52,151／ Metabohcacidosis’73 Midbrain,152 Midlineshifts,172 Minimumacceptablecare’327b, 332＝33 MinortraumaticbraininjuIy（MTBI） algorithmfbrmanagementof,159／ CTscanningfbr,158,158r dischargeinstructions｛br,158’160’ 160／ GCSfbr,158 MIST,20 Mitigation,｛brdisastermanagement, 327b h.equentdisasterdrillsin,33α31, 331b ICSin’330,330t ModeratebraininjuIy GCS｛br,160 managementoβ160,161／ pitfhllsof;161 Monro﹣KellieDoctrine,153,153／;15緲 MotorlevelofinjuIy’180 MTBI·SeeMinortraumaticbrain 1IUuⅣ ●

■

Multilumenesophagealairway,40,4叮

INDEX361 Multiple﹣casualtyincidents（MCIs）, 325,327b triagefbr’6’332 Musclerelaxants’220 Musculoskeletalinjuries’206 arterialinjuIyidentificationfbr,229 associatedinjuriesto’220﹣21,221t bloodlosshom,208 contusionsand,218 fractureimmobilizationfbr’20＆9’ 20印 h.actures’21＆19,21毗279-80 geriatricpatientswith,279＿80 immobiI肱ationfbr anklefractures,220 fbmoralfi.actures,219,22叮 kneeinjuries’219 skillsetfbr,227 tibiafractures,220 upper﹦extremi叮andhand injuries,220 indicationsoβ207 jointinjuries’218 lacerationsand,218 lifb﹣threatemng crushSyndrome’213 m酊orarterialhemorrhage, 212－13,213／ limb﹣threatening compartmentSyndrome,215－17, 216b,21魷229,238,238／ neurologicinjmysecondaryto fi.acture﹣dislocation,217＿18, 217t openfracturesandjointinjuries, 213＿14’213／ traumaticamputation,214-15 vascularinjuries,214－15’228 occultskeletalinjuriesand,221 pamcontrolfbr,220 patienthistoIyfbr env1ronmentinfbrmationin,210 mechanismofinjmyin,209＿10’ 20呀 ●

prehospitalobservationsandcare in,210 preinjmystatusandpredisposing 胞ctorsin,210 pediatricpatientswith bloodlossof;265 immobilizationprinciplesfbr,266 patienthistoⅣfbr’265 specialconsiderationsof immatureskeletonin,265-66 physicalexamination｛br circulationevaluation,212 ｛bel,211＝12,226 goalsfbr’210-11 】ookandask,211,211t》225 skillsetfbr’225＿26

primmysurveyandresuscitation fbr,208,208／ realigningdefbrmedextremitiesin, 227＿28 restraintdevicescausing’209’20呀 seconda1ysurveylbr,209＿12 skillsetfbr,224＝29 tractionsplintapplicationfbr,228 x﹣rayexamination｛br’209 x﹣rayexaminations’212 Musculoskeletalsystemchanges’in

OculartraumH anteriorchamberinju叮,312－13 chemicaliIUuIy’314 cornealinjmy,312－13 印elidinjuIy’312＿13 fatemboli,207’315 fipacturesin’314 globemjuⅣ,312,314 initiHl8釁巴＠sSmentfbr histoIyofinjmyincidentfbr,311 initialsymptomscheckedin,312

pregnantpatients,290 Musculoskeletalsystemevaluation,fbr secondarysurvey,17＿18,26 Myocardialcontractility’64,6邶 Myocardialdysfimction,66－67 Myotomes,178,180／;180／

patienthistoIym’311 physicalexaminationin,312 irismjmy’312＝13 lensinjuIy,312＿13 retinainjuIy,312－14 retrobulbarhematoma’314＝15 vitreousinjuIy,312－13 OdontoidfiPactures,184,18嘶 Ohm,slaw’76 OpenfTactures,21段14,213／ Openpneumothorax（suckingchest wound） causesanddevelopmentof;98,9印 chesttubemsertion允rmanaging, 9＆99,98／ comphcationsof﹩120 skillsetfbr,119＝20 Oralairwayinsertion,fbrpediatric patients,252 Orbitalrim,312 OrophaⅡyngealairwayinsertion alternativetechmquefbr,38﹣39’39／ skiⅡseMbr’51 techmquefbr’38 Orotrachealmtubation,41’42／ fbrpediatricpatients’252－54’25跚 25蚜 skiⅡsetfbr,52 Osteoporosis’279 OXygenation airwaydecisionschemefbr,37,3呀 a1rwaymaintenanceand managementof;45-46,46f, 55－56,56f fbrresuscitation,11 skillsetfbr’24 O刈hem0globmsaturation（SaO2）,45’ 46¢,55－56’56f

Narcotics’239 Nasopharyngealairwayinsertion,39’ 51 Nasotrachealintubation’41 pediatricpatientsand,254 NationalCenteronElderAbuse,281 Necktrauma a1rwaymaintenancefbr,33 assessmentandmanagementof; 170＿73 helmetremovalin,173 mobilityassessmentfbr,36b secondarysurveyexaminationol;16 skillsetfbr’25 Needlecricothyroidotomy,44－45’4蚣 59＿60’59／ Needlethoracentesis,tension pneumothoraxmanagedwith, 97﹣98’97／;119’255 Neurogenicshock’63 diagnosisof;67 spinalshockue炤αs,179名0 Neurologicevaluation fbrhemoIThagicshock,70 pitfallsoβ10 fbrprimarysurvey,10 ｛brseverebrainmjuIy,162－63 skillseMbr】24,26 fbrspinalcord’201 NeurologiclevelofinjuIy’180－81 NeurologicSystem’secondarysurvey fbr’18 Neurologicsystemchanges,in pregnantpatients,290 NonfTeezinginjmy’241＿42 Nonimpacted仕actures,279 Nonresponderskillsetfbrshock,84／’85 Nuclearinjuries,337b Nutrition,｛brgeriatricpatients,280

Obesepatients,prima】ysurveyfbr,7 Occultskeletalinjuries,221

Pacemakers’shockand’77 Pancreaticinjuries,135 PAO2.SeePartialpressureofoXygen inarterialblood Paraplegia,181,188b PartialpressureofoXygeninarterial blood（PAO2）’45,45¢’55＿56, 56f Partial﹣thicknessburns,233,235／ Partnerviolence’intimate’294’295b

36ZINDEX Patientdecontaminationprinciples, 331－32,332b PatienthistoIy,3.Seeα／soSecondary surv叮 fbrabdominalandpelvictrauma,127 fbrburninjuries’233 fbrmusculoskeletalinjuries environmentinfbrmationm,210 mechanismofmjuIym,20以10’ 20呀 prehospitalobservationsandcare in,210 preinjurystatusandpredisposing fhctorsin’210 fbroculartrauma,311 fbrpediatricpatientswith musculoskeletalinjuries’265 Patientreevaluation,19’28 Patienttransfbrstodefinitivecare, 19-20,299＝300 fbrburninjuries’240 criteriafbr’301t datafbr,306 documentationin,304,305／ fhctorsof;300－302 infbrmationtotransfbrring personnelfbr,304 pit｛hllsof;300 inprimarysurv叮andresuscitation’ 13’14／ receivingdoctorm,303 refbrringdoctorin’302＿3,303／ infbrmationfrom,304 shockand,301,302／ skillsetfbr’28 inspineinjurymanagement,190-91 timelinessof;300,300／ transportationmodesin,303’30蚱 treatmentduring,306 treatmentpriorto,304,306 PEA.SeePulselesselectricalactivity Pecoralismuscle（cervicalcap）,178 Pediatricpatients’246 abdominalandpelvictraumam,260 assessmentof;261 CTscanmngfbr’261 DPLfbr,262 FASTfbr,261 nonoperativemanagementof;262 specificvisceralinjuries,262 airwaymaintenancefbr,25α51 anatomyandpositiomngfbr,251’ 252／ cricothyroidotomyfbr,254 IMAfbr,254 managementof;251＿52 oralairwayinsertionfbr,252 orotrachealmtubationfbr’252＝ 54,253／;25蚌 pitfhllsof;255

anatomyof;248－49 bloodlossin’257t breathingandventilationfbr,255 BSAoβ249 circulationevRIl】RtionHhd managementin bloodreplacement’259 circulatorycompromise recognitionin,255一56’256／; 257f Huidresuscitationfbr’258＿59’25呀 thermoregulationfbr,260 urmeoutpuMbr,259 venousaccessfbr,257＿58,258／ weightandbloodvolumein, 25住57 CPRfbr,260 DAIalgorithm｛br,253,253／ equipmenMbr,250,250／;251f withheadinjuries assessmentof;263-64,264／ managementof;264 hypoxiain,255 mjuryto long﹣termelIbctsol;249－50 preventionof;267b typesandpatternsof;247﹣48’248／ logrollingfbr’203 maltreatmentoβ266－67,267／ mortalityratesandcausesof｝247 musculoskeletalinjuriesin bloodlossof;265 immobilizationprinciplesfbr,266 patienthistoIyfbr,265 specialconsiderationsof immatureskeletonin,265－66 nasotrachealintubationand,254 primarysurveyfbr’7 psychologicalstatusof;249 sizeandshapeof;249 skeletonof;249 spineinjuIyin,17屝76 anatomicdiffbrencesfbr’264 radiologicconsiderationsfbr’265 thoracicinjuIyin,260 traumascorefbr,248﹠ PediatricTraumaScore,248f Pelvicbinderapplication,90,136,13V Pelviccavity’124’12嘶 Pelvic儼actures causesof;135-36 managementof;136＿37,137／ mechanismofinjmy／Classification, 136’13印 shockand’83’84t bloodlossreductiontechniques fbr,90＿91 pelvicbinderapplicationfbr,90, 136,13v Pelvicringinjury,136

Pelvicstabilization,13住37,137／ Pelvictrauma.SeeAbdomihHlRnd pelvictrauma Pelvic﹄rocktest,128 Penetratingtrauma abdominalandpelvictraumafTom’ 125’126／ evaluationoβ133 headinjuriesand’166＿67 inpregnantpatients,291 secondarysurveyfbr,14 inspinalcolumn,185－86 Pericardiocentesis,67 ｛brcardiactamponade,102 complicationswith,121 skillsetfbr,120－21 Pericardiotomy’102 Perimortemcesareansection’294 Perineumexamination,fbrsecondaIy survey,17,26 Peripheralnerveassessment’217,217Z Peripheralvenousaccess’85 Personalprotectiveequipment（PPE）, 327b,331 Physicalexamination abdomen’17,26 fbrabdominalandpelvictrauma adjunctsto,129－32 auscultation,127 glutealexamination’129 inspection,127 pelvicstabilityevaluation’128’ 128／ percussionandpalpation’127-28 urethral,perineal,rectal examination,12＆29 vaginalexamination’129 fbrburninjuries,238 cervicalspineandneck,16,25 chest,1佳17,25＿26 head’15’25 maxillofhcialstructures,15－16’25 fbrmusculoskeletalinjuries circulationevaluation,212 ｛bel,211＿12,226 goalsfbr,210＿11 lookandask,211,211f’225 skillsetfbr,22岳26 musculoskeletalsystem,17＿18,26 neurologicalsystem,18,26 fbroculartrauma,312 perineum,rectum,vagina’17,26 Piamater’151／;152 Pleuralspaces’inx﹣rayexaminations ｛brthoracicinjuIy’115 Pneumothorax.SeeOpen pneumothorax;Simple pneumothorax;Tension pneumothorax Poiseuille,slaw,71

INDEX363 Posteriore】ementfTactures’184,184／ Power,sratio,197 PPE.SeePersonalprotective equipment Pregnantpatients,286.Seeα／soFetus anatomicalchangesin’287－89’ 28郎289／ bloodpressurein,290 bloodvolumeandcompositionin’ 289,290』 blunttraumain,291’291t cardiacoutputin,290 CVPin,290 electrocardiographicchangesin,290 gastrointestinalSystemchangesin, 290 heartratein,290 hemodynamicfhctorsin’289＿90 musculoskeletalSystemchangesin, 290 neurologicSystemchangesin,290 patienttrans佗rtodefinitivecare fbr,293＿94 penetratingtraumain’291 perimortemcesareansectionin’294 primarysurvey｛br’7,292－93 respiratoIysystemchangesin,290 secondarysurveyfbr,293 severityofinjuIyin,291＿92 shockand,77 urina】ySystemchangesin,290 x﹣rayexaminationfbr,287 Prehospitalphase,4,4／ Preload,64’64／ Preparation,fbrdisastermanagement, 327b communibyplanningin,328 departmentalplanningin’329 hospitaldisastertrainingin’329－30 hospitalplanningin,32＆29 personalplanningin,329 simpledisasterplansin’328 Primarysurvey（ABCDEs）,7／:Sbe α／soResuscitation adjunctsto,11＝13,25 airwaymaintenancewithcervical spineprotectionfbr,7－8,8／ breathingandventilationfbr,8 fbrburninjuries,235－36 circulationwithhemoⅡThagecontrol ｛br,9 exposureandenv1ronmentalcontrol ｛br,10 fbrfbtus,29Z93 fbrheadinjuries’171 fbrmusculoskeletalinjuries,208, 20印 neurologicevaluationfbr,10 patienttransfbrstodefinitivecare consideredduring’13,1蚌

fbrpregnantpatients,292－93 prioritizedsequencefbr,佳7 repeating,3 fbrseverebrainin】u叮’162－63, 162b skillsetfbr,24－25 fbrspecialpopulations,7 fbrspinalcord’201 fbrthoracicin】uIy’9隹102 Pulmona1ycontusion’99,104 PulseoximetⅣ’12’34’45,55＿56,56／ Pulselesselectricalactivity（PEA）’11’ 100 Pupil,312

Quadriplegia’181,188b Radiation’ionizing’249＿50 Radiationandnuclearinjuries,337b Receivingdoctor,inpatienttrans佗rs todefinitivecare’303 Recordkeeping,initialassessment and’20 RecoveIy,fbrdisastermanagement, 327b,333 Rectalexamination,【brsecondary survey,17,26 Reevaluation’SeePatient reevaluation Refbrringdoctor,inpatienttransfbrs todeHnitivecare,302＝4’303／ Replantation’215 RespiratoⅣalkalosis’73 RespiratoIysystemchanges,in pregnantpatients’290 Response’fbrdis“termanagement’ 327b alternativecarestandardsin’ 332－33 disastertriageschemein’332 effbctivesurgecapability,332 in﹣hospitalcarein,331 pathophysiolo田andpatternsof injuIyin,333 patientdecontaminationin,331－32’ 332b prehospitalcarein’331 specialneedspopulationsin’333 trafficcontrolsystemin】333 Restraintdevices abdominalandpelvictraumahDm’ 125,126t musculoskeletalinjurieShum,209, 209／ Resuscitation·S2eα／soPnmary survey adjunctsto,11＿13,25 a1rwaymaintenancefbr’10 breathing,ventilationand oxygenationfbr’11

circulationwithhemorrhagecontrol fbr,11 Huid fbrhemoIThagicshock’71＿74’ 72／;74』 fbrpediatricpatients’258＿59, 25呀 ｛brmusculoskeletaliIUuries,208, 20印 patienttransfbrstodefinitivecare consideredduring’13’1緲 fbrshock仕omburninjuries,23住 37’237／ skillsetfbr’24－25 fbrspinalcord,201 Resuscitationtape,250,250／ Resuscitativethoracotomy,102 Retinainjmy’312＿14 Retrobulbarhematoma,314一15 Retroperitoneum’277 Rhabdomyo】ysis,traumatic’213,240 RibfiPactures,108 Ringer,slactate’215 RuleofNines,233’234／

Safbtybelts,126¢,209,20呀 SaO2·SeeOxyhemoglobinsaturation SAR.SeeSearchandrescuearea Scalp’150’166,166／ ScapularfiPactures,108 SCIWORA.S“Spina』cordinjmy withoutradiographic RbnormRlities Searchandrescuearea（SAR）’327b’ 330 Seatbelts’126¢,209,20呀 Secondarysurvey adjunctsto’1＆19,1郎27 AMPLEhistoⅣfbr,14’25 fbrburninjuries,14＿15’237 antibioticsin,239 baselinedeterminationsfbrm則or burns,238 documentationin,238 gastriccatheterinsertionin,239 narcotics,analgesics,sedatives br,239 peripheralcirculationin circumfbrentialextremity burns,238,238／ physicalexaminationin,238 tetanusimmunizationin,239 woundcarein’239 dehnitionandprocessof;13＿14’15f fbrheadinjuries,171 mechanismofinjmyin blunttrauma,14 burninjuries,14＝15 bazardousenⅥronmentinjunes’15 penetratingtrauma,14

364INDEX ｛brmusculoskeletalinjuries’209＿12 physicalexaminationfbr abdomen,17’26 abdominalandpelvictrauma, 127－29’128／ cervicalspineandneck’16,25 chest,1住17,2岳26 head,15,25 maxiⅡofacialstructures’1岳16’25 musculoskeletalsystem,17－18,26 neurologicalsystem,18,26 perineum,rectum,vagma’17,26 fbrpregnantpatients’293 repeating’3 ｛brseverebrainimury,163 skiⅡsetfbr,25－28’2W＿28t ｛brspinalcord,202 fbrthoracicmjury,103＝7 Sedatives,239 Seldingertechmque,fbmoral vempuncture,85,86／;87,257 SensoIylevelofinjuIy’180 Septicsh0ck,64,68 Severebraini叮my airwayandbreathingmaintenance fbr,162 algorithmfbrmanagementoβ161／ circulationand’162 diagnosticproceduresfbr,163 GCSfbr,162 neurologicexaminationfbr, 162＿63 primarysurv叮fbr,162＿63,162b secondarysurveyfbr）163 Shearinginjuries,125,125／ Shock athletesand,76 cardiactamponade’67,83¢ cardiogenic,66＿67 circulationresⅢgcitationfbrburn injuriesand’23佳37’237／ dehnitionof;63 diagnosisof;62 geriatricpatientsconsiderations fbr,76 hemorrhagic,65 airwaymaintenanceand breathingexaminedfbr,70 bloodlossbasedon’69／ bloodpressureconsiderations fbr,76 bloodtrans血sionfbr,74＿76’7㎡ circulationwithhemorrhage controlfbr,71 classificationof｝69一70 CVPmomtoringibr,66,73－74’ 77－78 definitionof;68 diagnosisof）66,66／ directe錐ctsof﹩68＿69’69!

exposureandenvironmental controlfbr’71 f】uidresuscitationfbr’72－74’72／; 74¢ gastricdilation／decompression ibr,71 hypothermiaand,77 initialmanagementoβ70－73 intraabdominal,83¢ neurologicevaluationfbr,71 .physicalexaminationfbr,70－71 respiratoIyalkalosisand’73 softtissuei呵uriesand,70,85 urmarycathetersfbr,71 ●

urmaryoutputin,73 ■

vascularaccesslinesfbr’71,85, 8節87＿89 venousreturnin,65 ihitiRl8g已essmentof clini∞ldiHbrentiationofcause in,66＿67 firststepin’63 recognitionoβ65-66 secondstepin,63一64 skillsetfbr’83,83Z medicationsand’76 neurogenic,63 diagnosisoβ66 Spinalue蹈αs,179－80 nonhemorrhagic,66 nonresponderskilIseMbr,84¢,85 pacemakersand’77 pathophysiolo田oβ64－65 bloodloss,65 cardiacphysiolo盯,64,6叮 patienttrans【brstodefinitivecare and,301,302／ pelvicfincturesand’83,84f bloodlossreductiontechmques fbr,90－91 pelvicbinderapplicationfbr,90, 136’13〃 pregnantpatientsand,76 septic,64,67 spinalue稻αsneurogenic,179＿80 tachycardia,65＿66 tensionpneumothorax,68,83t transientresponderskillsetfbr’ 83,84Z Shoulderharness,125Z Simplepneumothorax’103,276 Skeleton,ofpediatricpatients’249 Skull,151 fi.actures,155＝56,155t,166’172 Smallbowelinjuries,135 SofttissueiIUuries,69－70’85 Softtissues’inx﹣rayexaminationsfbr thoracicinjuIy,116 Solidorganinjuries,135 Spinalcolumn,176-77’176／

atlanto﹣occipitaldislocationin,182 assessmentoβ196’19印 atlasC1hncturein’182’182／ axisC2fracturesin,182,184’18緲 BCⅥin,185,186／ C1rotaIysubluxationin,182,183／ C3throughC7ffacturesin,184－85 lumbarh。acturesm,185 penetratingtraumain,185＿86 thoracicspinefiPacturesin,185, 18郎186 thoracolumbarjunctionfi’actures in’185 Spinalcord’199 anatomyof;177,177／ anteriorcordSyndromeof;181 Brown﹣S白quardSyndromeoβ181 centralcordsyndromeoβ181 clinicalexammationof》178,178t complete／incompleteinjuriesto’177 injuIyclassificationsfbr level’180＿81 morpholo田,181 neurologicalde面citseverity’181 Syndromes’181 managementof immobilizationfbr,189＿90,190／; 191／ intravenousfIuidsfbr,190 medicationsfbr’191 patienttransfbrstodefinitive carein,190＿91 昌kⅡlsetfbr examinationfbrlevelofinjuIy in,202 immobilizationandlogrollingin’ 203-5 logrollingin,203 neurologicevaluationm’201 primarysurveyandresuscitation in,201 scenariosin’200 secondarvsurveym’201 treatmentprinciplesin,202 Spinalcordinjmywithout radiographicabnormalities （SCIWORA）’265 Spinalshock,neurogenicshockue咫αs, 179B0 SpineinjuIy,174.Seeα!soCervical spine;Lumbarspme;Thoracic spme anatomyandphysiolo盯in dermatomes,178’17呀 musclestrengthgradingfbr,180E myotomes,178’180／;180f sensoIyexaminationof;178,178¢ spinalcolumn’17佳77,17印 spinalcord’177’177／ spinalnervesegments,178,178t ︾

●

INDEX365 ingeriatricpatients’277一78’27呀 immobⅢzationfbr,176 managementof immobilizationfbr,189＝90,189／; 191／ intravenousHuidsfbr,190 medicationsfbr’191 patienttransfbrstodefimtive carem,191 mechanismsoβ182 neurogemcshockue”αsspinal shock’179-80 inpediatricpatients,175－76 anatomicdiflbrencesfbr,264 radiologicconsiderationsfbr,265 screemngguidelinesfbr’188b－189b spinalcolumn atlanto-occipitaldislocationin, 182,196,19印 atlasC1fracturein’182,182／ axisC2fracturesin’182,184, 18吁 BCⅥin’185,18印 C1rota1ysubluxationin,182’18盯 C3throughC7fracturesm’184－85 lumbarfracturesin’185 penetratingtraumain,185 thoracicspinefincturesin,184, 184／ thoracolumbarjunctionfiPactures m,185 spinalcord’199 injuryclassificationsfbr,180－81 managemento﹠189一91’19畎191／ skillsetfbr’200-205 TBIwith,175 x﹣rayexaminationsfbr’194 cervicalspine,187-190,195,19可 rev1ewof;198 scenar1osandclues｛br,195 thoracicandlumbarspine,187’ 189’197 Stabwounds,125’12節133 SternumhPactures,108 Subclavianvenipuncture: inh?aclavicularapproach’87 Subcutaneousemphysema,108 Subduralhematomas’156’157／;172 Suckingchestwound.SbeOpen ●

pneumothorax Suicidalbombblastatpoliticalrally’ triagescenariosfbr’353＿54 Supraglotticdevices’39﹣40,40／;41／ Surgecapability,327b,331＿32 Surgicalairways,44＿45’4緲 Surgicalcricothyroidotomy,45,60’61／ Tachycardia,65＝66 Tacticalcombatcasualtycare（TCCC）, 323

TBI·SeeTraumaticbraininjmy TCCCSeeTacticalcombatcasual叮 care

Teamwork,ininitialassessment, 20－21 TEE.SeeTransesophageal echocardiography Tensionpneumothorax,68 causesanddevelopmentof;96＝97’ 9〃 needlethoracentesismanaging’ 97－98’97／;119’255 pitfhllSwith,100 signsand可mptomsof;97 skillsetfbr,83f Tetanusimmunization,239 Tetanusprophylaxis,214 Thermalinjuries.S2eBurnmjuries; Coldinjuries Thermoregulation,fbrpediatric patients,260 ThoracicinjuⅡy airwaymaintenancefbr’96 bluntcardiacinjuIy,104－5 bluntesophagealtrauma’107 breathingfbr,9佳99 cardiactamponade’67－68 causesoβ101》101／ diagnosisof;101－2 FAST｛br’102 pericmUiocentesisfbr’102’12仆21 skiⅡsetfbr,83f c】rculationfbr’10｝102 crushingmjurytochest,108 flailchest’99,99／ hemothorax’104 initialassessmenMbr,96 massivehemothorax,83¢’99 causesanddevelopmentof;100, 10叮 managementof;100一101 pitfhllswith’100 mortalityratesfTom’95 openpneumothorax causesanddevelopmentof;98,98／ chesttubeinsertionmanagmg, 9咎99’9毗119－20 inpediatricpatients’260 primarysurveyfbr’96－102 pulmonarycontusion,99,104 resuscitativethoracotomyfbr,102 ribfiPactures’108 scapularhnctures’108 secondarysurveyfbr,103－7 simplepneumothorax,103 sternumfTactures,108 subcutaneousemphysema’107＿8 tensionpneumothorax,68 causesanddevelopmentof; 9住97,97／

needlethoracentesismanaging, 97＿98’97／;119 pitfhllswith,100 signsand叮mptomsof;97 skillsetfbr’83t tracheobronchialtreeinju1y’105 traumaticaorticrupture’10岳6’ 10吋 traumaticdiaphragmaticmjuIy’ 107,107／ x﹣rayexaminationsfbr’113－17 bonythorax’116 diaphragm》116 imtialreviewprocessfbr,11午17 lungparenchyma,115 mediastinum,115 pleuralspaces’115 reassessmentof;11伕17 scenariosfbr’114 softtissues,116 suggestionsfbr’115¢ tracheaandbronchi,114＿15 tubesandlines,116 Thoracicspine fiPacturesof;185,18邱 mobihtyof;177 x﹣rayexaminationsfbr,187,189, 197 Thoraco﹣abdomen,124’12吁 Thoracoabdominalwounds,133 Thoracolumbarjunction,177 fi.acturesof;185 screenmgguidelines｛brinjuIyto, 188－189b Thoracotomy,101－2 3﹣3﹣2rule’36b Tibia,220,227 Tissuehypoxia’95 Tissuepressuremeasurement, ‘‘Delta﹣P’’method,216 TNF.比eTumornecrosis色ctor Tourniquets’212 Toxidromes’336b,337b Trachea,inx-rayexaminationsfbr thoracicinjuIy’114＿15 TracheobronchialtreeinjuIy,105 Tractionsplintapplication’228 TrafficcontrolSystem’333 Trailerhomeexplosionandfire,triage scenario,346-47 Traincrash’triagescenariosfbr’352 Transesophagealechocardiography （TEE）’106 Trans佗r.SeePatienttmns他rsto dehnitivecare Transientresponderskillsetfbr shock,83,84／ Traumaticamputation,214－15 Traumaticaorticrupture,105－6,105／ Traumaticasphyxia,108

366INDEX Traumaticbraininjmy（TBI）,72 braindeath’167 ingeriatricpatients,277－78 managementoverv】ewof;164f medicaltherapiesfbr anticonvulsants,165 barbiturates,165 hypertonicsaline’165 hyperventilationand,164-65 mtravenousHuids’163－64 Mannitol’165 Inlnor

algorithmfbrmanagementoβ 15呀 diSchargeinstructionsfbr,158, 160’16〃 GCSfbr,158 neurosuIgicalconsultationfbr’151b penetrating’166－67 spineinju1ywith,175 surv1vorimpa1rmentsfi.om,149 Traumaticdiaphragmaticinjury,106, 10v Traumaticrhabdomyolysis,213’240 Triage definitionof＼339 disastertriagescheme,332 FieldTriageDecisionScheme,4,可 fbrMCEs’6,322’332 fbrMCIs,6,332 prmciplesoβ339－40 scena而os允r carcrash’350＿51 coldinjuⅣ,348＿49 gasexplosionin田mnasium, 341＿45 suicidalbombblastatpolitical rally,353－54 trailerhomeexplosionandfire, 346－47 traincrash,352 Tubesandlines,inx﹣rayexaminations fbrthoracicinju】y,116 Tum0rnecrosisfhctor（TNF）’65 Tunneling,255 TypeOblood’74 Type﹣specificblood,74

UIC·錠eUnifiedincidentcommfmd Uncus,153,153／ Unifiedincidentcommand（UIC）’ 327b’330 Upper﹣extremityinjuries, immobilizationfbr,220

Urethraldisruptions,135 Urethrography,131－32 UrinaIycatheters’11＿12,202 fbrabdominalandpelvictrauma, 129 ibrhemorrhagicshock’71 UrinaIyoutput’inhemorrhagicshock’ 73 UrinaIySystemchanges,inpregnant patients,290 Urineoutput,fbrpediatricpatients, 259 Uterus,288－89’288／;292＿93

Vaginalexamination’fbrsecondary survey,17,26 Vascularaccesslines’fbrhemorrhagic shock’71 fbmoralvenipuncture’Seldinger technique’85,86／;87 internaljugularvenipuncture: middleorcentralroute,88 mtraosseouspuncture／infhsion: proximaltibialroute’88一89’ 89／ peripheralaccessskillset,85 subclavianvenipuncture: inhaclavicularapproach,87 Vascularinjuries,214－15,228 Venipuncture fbmoral,Seldingertechnique’85’ 8飢87 internaljugular:middleorcentral route,88 subclavian:infraclavicⅡ】IHr approach’87 Venouscutdown’71 anatomicconsiderationsfbr,92,93／ c0mplicationsofperipheral’93 skillseMbr’93’93／ VentilHtion a1rwaydecisionscheme【br,37,38／ inairwaymaintenance effbctivemanagementol;46 ohjectivesignsofinadequate,34 problemrecognitionfbr’34 bag-mask,51 CO2detectionfbr’42’56－57 fbrgeriatricpatients,275-76,27吋 ILMAfbr’40’52－53,53／ LMAfbr’40’40／;52-53 LTAfbr,40,4M54 needlecricothyroidotomy【br’45’ 45／;59-60’59／

fbrpediatricpatients’255 pitfhllsfbr,9 fbrprimarysurvey,6 fbrresuscitation,11 skillsetfbr,24,50－57 surgicalcricothyroidotomyfbr,45’ 60,61／ VentilatoIyrate,12 VentricularSystem,152’172 Violence’intimatepartner’294,295b Visualacuity’312 VitreousmjuIy,312－13

Warwounds,323 “Warmzone.,’S“Areaofoperation Weaponsofmassdestruction（WMDS）’ 327b,329,333 blastinjuryfTom’334b chemicalagentsin,334b careconsiderations允rinjuries h.om,335b radiationandnuclearinjuries’337b radioactiveagents,33肋 toxidromes associatedwithacuteradiRtion syndrome,337b associatedwithcholinerg】ccrisis duetonerveagents,336b

X﹣rayexaminations,13 fbrabdominalandpelvictrauma’ 129－30 fbrmusculoskeletalinjuries’209, 212 fbrpregnantpatients,287 fbrspineinjuIy,194 cervicalspine,186＿87,195’195／ reⅥewof;198 thoracicandlumbarspine’187, 189,197 ofthoraciciIUuⅡy’113-17 bonythorax,116 diaphragm,116 initialreviewprocessfbr,114－17 lungparenchyma,115 mediastinum’115 pleuralspaces,115 reassessmentof;116-17 scenari0sfbr,114 softtissues,116 suggestionsfbr’115／ tracheaandbronchi,114－15 tubesandlines’116