Primary survey - 台灣災難醫學會 · PDF file0‐10 60
Transcript of Primary survey - 台灣災難醫學會 · PDF file0‐10 60
小兒創傷急症
新光醫院急診科
陳欣伶
102.02.06
學習目標
• 小兒創傷(Pediatric trauma)的特殊性
• 小兒創傷的初步評估(primary survey)與再評估(secondary survey)
• 個別創傷的特色與治療方向
• 兒虐(child abuse)以及shaken baby syndrome
1歲以上兒童造成死亡或傷殘最主要的原因為創傷
【大紀元記者施芝吟台北報道】靖娟兒童安全文教基金會昨日公佈2010年「兒童安全十大新聞票選」結果,交通事故仍佔大宗,排名第1的是兒童安全座椅錯放前座,車禍發生時無法發揮保護作用,最後仍導致男嬰不治。……林月琴說:「140公分以下兒童若沒使用輔助椅,繫上安全帶會勒到脖子,而有些家長把抱枕當輔助椅,發生事故時,會往前滑,並沒有保護作用。」(節錄)
小兒創傷的特殊性“Child is not small adult!”
• Size and shape: 大頭下雨不用愁– 最容易 head injury
• Skeleton: 還在轉大人的骨頭– Internal organ damage without bony lesion– Radiography: growth plate
• Surface area: 容易失溫
• Psychological status: 野獸派
• Long‐term effect– PTSD, 長短肢, splenectomy
常見的受傷機轉
受傷機轉 受傷形式
行人被撞 低速:下肢骨折高速: 多重創傷,頭頸部創傷,下肢骨折
汽車乘客 未繫安全帶: 多重創傷,頭頸部,頭臉部撕裂傷繫安全帶:胸腹部與下段脊椎骨骨折
墜落 低處:上肢骨折中處:頭頸部,上下肢骨折高處:多重創傷,頭頸部與上下肢
腳踏車摔車 沒戴安全帽: 頭頸面部撕裂傷,上肢骨折有戴安全帽: 上肢骨折撞到把手: 腹腔內創傷
Reference: ATLS 8E, chapter 10
初級評估 Primary survey
• 如果從小兒評估三角(pediatric assessment triangle: PAT)來看
單純頭部外傷
外觀嗜睡或躁動
循環正常
呼吸加速
多重系統創傷
外觀嗜睡
循環組織灌流不足
大理石斑紋, 四肢冰冷
呼吸加速或過緩
初級評估之ABCDE• Airway + C‐spine: protect airway and c‐spine• Breathing: ventilation, deal with critical problems (tension pneumothorax, open pneumothorax)
• Circulation: evaluate, resuscitation ,抓漏(FAST)• Disability: neurological deficit and GCS• Exposure: total exposure + 保暖
此時要兼評估是否有六大的緊急狀況: Airway obstruction(A), tension PTX/open PTX/Flail chest/Massive hemothorax(B), Cardiac temponade(C)
Airway/ Breathing
• 枕部較突出:不用枕頭用
肩墊
• 大舌頭, 喉咽軟組織多:哭鬧易加重hypoxia• 鼻式呼吸: 若要減低胃壓
需放OG• 最窄處cricoid cartilage:uncuffed endo: 4+age/4• 會厭Ω狀較軟: 直式blade• 氣管軟骨較軟:少執行
surgical cricothyroidotomy• 小兒呼吸速率快: 給氧時
每3‐5秒一次
In‐line position C‐spine protection
• 除非已排除頸椎傷害, 否則要保護頸椎
• Neck collar/ towel rolls• 有下列機轉的,應先保護頸椎
– 任何鎖骨以上明顯的傷
– 任何在路邊被汽機車撞到的小孩
– 任何高速對撞的汽機車車內的小孩
– 沒綁安全帶的乘客
– 任何有明顯外傷而意識昏迷的病人
– 有他處嚴重疼痛的病灶而無法判斷
(distracting pain)
何時需要插管
• Hypoxia•Cyanosis•Desaturation
• Hypoventilation•Abnormal breathing
• Conscious disturbance • Severe head injury• Protect airway
Preoxygenation: BVM
Atropine 0.02mg/kg (min 0.1mg)
HypovolemiaEtomidate0.1mg/kgMidazolam0.1mg/kg
NormovolemiaEtomidate0.3mg/kgMidazolam0.3mg/kg
Succinylcholine <10kg: 2,g/kg;>10kg: 1mg/kg
Vercuronium or Rocuronium 0.6mg/kgCicacurium 015mg/kg
Intubation
Circulation—要先熟悉正常的vital sign
Age Weight (kg) HR (bpm) BP (mmHg) RR (per min)
U/O (cc/kg/hr)
Infant0‐12 mo
0‐10 <160 >60 <60 2.0
Toddler1‐2 yr
10‐14 <150 >70 <40 1.5
Preschool3‐5 yr
14‐18 <140 >75 <35 1.0
School6‐12 yr
18‐36 <120 >80 <30 1.0
Adolescent13 yr
36‐70 <100 >90 <30 0.5
速記: 1‐3‐5‐7‐910‐15‐20‐25‐30
速記: 1‐2‐6‐12160‐140‐120‐100
速記: <1yr 60>1yr: 70 + age x 2
Shock in pediatric System Mild blood loss
(<30%)Moderate blood loss (30%~45%)
Severe blood loss (>45%)
Cardiovascular HR↑, peripheral pulse↓, SBP & PP normal
HR↑↑, central pulse↓, peripheral pulse x, SBP low normal, PP↓
HR先↑後↓, central pulse weak, BP↓, PP↑ (DBP量不到)
CNS Anxious, irritable, confused
Lethargic, 打針時不太掙扎
Coma
Skin Cool and mottled, CRT↑
Cyano c, CRT↑↑ Pale and cold
Urine output low minimal None
20ml/kg warm NS or LR (最多三次)
輸血10ml/kg PRBC 外科手術
Disability• 小朋友如何評GCS (<4 yr者)
– Pediatric coma score
Verbal response V‐score
Appropriate words or social smile, fixed and follows
5
Cries, but consolable
4
Persistently irritable 3
Restless, agitated 2
None 1
Motor response M‐score
Obey commands Normal spontaneous 6
Localize supraorbital pain (>9 months old)
Withdraws to touch 5
Withdraws from nailbed pain 4
Flexion to supraorbital pain 3
Extension to supraorbital pain 2No response to supraorbitalpain 1
Reference: ATLS table 10‐5, Medscape
Secondary survey~詳細檢查,必要時及早轉院~
• AMPLE, head to toe• Revised trauma score: total <12 轉 center
(另; pediatric trauma score, if total score <8)
Score GCS SBP (mmHg) RR (per min)4 13‐15 >89 10‐293 9‐12 76‐89 >292 6‐8 50‐75 6‐91 4‐5 1‐49 1‐50 3 0 0
有下列情況亦即早轉院
Indications for transfer to a pediatric trauma centerMechanism of injury Ejection from motor vehicle
Fall from a heightMotor vehicle collision with prolonged extricationMotor vehicle collision with death of another vehicle occupant
Anatomic injury Multiple severe traumaMore than three long‐bone fracturesAmputationsSevere head and facial traumaPenetrating head, chest and abdominal trauma
Head injury• Structural specialty
– head size, open sutures, cartilage in skull bone
• Hypotension due to head injury?– Subgaleal or epidural hemorrhage
• Impact seizure vs. post‐traumatic seizure– Self‐limited vs. prophylactic AED in risk group
• Image study– CT vs. skull x‐ray
醫生,要不要做個檢查?
• 何時需要進一步檢查?
<2yr: low‐energy mechanism 2hrs free of s/s: OBS
0~2 yr >2 yr•No good predictors!•Neurological abnormality•Any altered MS•Any skull abnormalities•vomiting
•LOC/Amnesia/Vomiting/Lethargy•Facial injury, multiple trauma•Suspect C‐spine injury•Bleeding diathesis•Language barrier
Reference: Image Consult; Inside surgery; Radiology Cases in Pediatric Emergency Medicine Volume 5, Case 7
一定有人問你這個問題:~電腦斷層會不會有危險啊?~
2001 AJR; Brenner et al
(cont.)
罹癌的風險 vs. 嚴重頭部外傷的風險
Management • Protect airway, 需要時及早插管; 頭高20~30度• 避免secondary brain injury: avoid hypoxia and hypotension
• Mannitol 0.5~1 g/kg• Anti‐epileptic drugs
Impact seizure Post‐traumatic seizureCharacter • shortly after injury
• common in children• self‐limited
• Risk: LOC, GCS<8, prolonged coma, abnormal CT findings• long‐term sequelae
management • 第一時間容易被插管 • midazolam, lorazepam; phenytoin(15‐20mg/kg)• seizure ≥ 2 times, seizure for few minutes; prophylaxis if GCS<8
Reference: Tintinalli p1680, ATLS p240
還有一個特別的: Growing fracture
• 又稱craniocerebralerosion
• skull fracture in infancy or early childhood
• 尤其linear fracture extending from a depressed one or diastasis > 4mm
• 產生leptomeningealcyst
3 months later
Reference: Indian Pediatrics, Vol 40, Dec 17, 2003; Radiology Cases in Pediatric Emergency Medicine, Volume 7, Case 2
C‐spine injury
• 常合併head injury• 結構上的特性
• 常見於occiput~C2, vs. 大人為lower C
• Pseudosubluxation(C2/3), basilar odontoidsynchrondrosis, apical odontoidepiphyses
Unstable atlanto‐occiputjoint
Open synchrondrosis
C2
C2
Nonfusion may be mistaken as fracture!
1.
3.2.
1. Atlantodens interval (ADI) : adult 3mm, child 5mm.2. pseudo‐Jefferson fracture: 6mm up to 4 yr3. pseudosubluxation: C2 on C3; (C3 prevertebral space 6mm)
SCIWORASpinal Cord Injury WithOut Radiographic Abnormality
• >50% children with SCIWORA, onset of paralysis is delayed, sometimes up to 4 days.
• Transient paralysis, numbness, or weakness at the time or shortly after the injury.
• Flexion‐extension view is contraindicated!
• C‐spine MRI is indicated.• High dose steroid (30mg/kg within 3hrs of injury)
Reference: Tintinalli; ATLS; RadioGraphics, Vol 23 No.3
Lap‐belt injury
• Ileal and pubic bone fx• Lumbar spine fx• Small bowel mesentery injury
• Bladder rupture
Child abuse• 證詞反覆,支支吾吾,延遲送醫,新舊雜陳, “magic wound”
• 哪些傷要高度懷疑– Multicolored bruise– Frequent fracture – Injuries in perioral/perianal/genital area– Multiple SDH(hematoma)– Retinal hemorrhage– Bizarre injuries– Special fracture pattern (*)
• 24小時內通報!!! (兒童少年保護法)
Suspicious fractures(*)• Spiral fractures (long bones, preambulatory)
– Especially <3yr with long bone fx• Metaphyseal fx
– Bucket‐handle/corner• Rib fractures• Scapula fx• Spinous process fx• Skull
– Multiple, complex, Depressed, Wide(>3cm), Growing, Involving >1 cranial bone, Nonperietal
Subperiosteal hematoma
Corner fracture
Spiral fractures
Forced Immersion Burns Unusual bruiseBite marks
犬齒痕間距>3cm成人
Marks Due to Child Abuse Shaken baby syndrome
Triads: SDH, retinal hemorrhage, consΔ
Chest trauma• Pulmonary contusion: most common• Combine multiple injuries• Rib fractures and mediastinal injuries are uncommon.– Multiple ribs fx or post. Rib fxchild abuse
• Massive hemothorax: initial drainage>15ml/kg or continue >4ml/kg/h operative thoracotomy– Chest tube size: endo size x 4
• Resuscitative thoracotomy: penetrating chest injury at PEA
Trauma造成的 rib fracture多單側
Reference: RiT, Posted by Rathachai Kaewlai, M.D
Rib fracture suspecting child abuse:‐Multiple fractures‐ post. Rib fracture‐新舊雜陳, callus formation
Reference: Radiologic Evaluation of blunt thoracic artery injury in pediatric patients, Pabon‐Ramon et al, AJR 2010
Abdominal trauma
• FAST vs. CT scan• 何時該做CT:
– 但CT無法完全排除bowel injury
• Splenic trauma vs. hepatic trauma• Handlebar injury: involve pancreas, duodenum• Lap‐belt injury: jujenum injury+ lumbar fracture• Operation indication:
– hemodynamic unstable, s/p massive transfusion (>40ml/kg in first 24hrs), hollow organ perforation
Lap‐belt injury
• Ileal and pubic bone fx• Lumbar spine fx• Small bowel mesentery injury
• Bladder rupture
Reference: Imaging children with abdominal trauma, Carlos J.Sivet, AJR 2009
5 wks laterPancreatic injury Pseudocyst formation
Reference: Imaging children with abdominal trauma, Carlos J.Sivet, AJR 2009
Ascites of unknown origin Duodenal wall hematoma
Reference: Imaging children with abdominal trauma, Carlos J.Sivet, AJR 2009;Post‐traumatic intramural duodenal hematoma in children, M.luchtman et al, IMAJ 200b, Vol6
How about these?
Systemic hypoperfusion:Poor enhancement, diminished great vessel diameter
Reference: Imaging children with abdominal trauma, Carlos J.Sivet, AJR 2009
Pelvic and GU trauma
• Pelvic fracture in children: less likely to die of hemorrhage
• Hematuria 的程度與kidney injury不成正比
• Bladder rupture小孩比大人常見
• Straddle injury: 20% associated with urethral injury; mind sexual abuse in girl if Hx & PE incompatible
urinalysis
Penetrating>5 RBCs/HPF
Blunt>50 RBCs/HPF
CT operation
stable unstable
Reference: ATLS 8E
renal contusion Renal collecting system injury
Reference: Imaging children with abdominal trauma, Carlos J.Sivet, AJR 2009
Bladder rupture
MusculoskeletalSalter‐Harris classificationGreenstick vs. Torus fracture
Elbow ossification center
• Capetellum (1‐2yr)• Radial Head (2‐4yr)• Interanal epicondyle
(4‐6yr)• Trochlea (8‐11yr)• Olecranon (9‐11 yr)• External epicondyle(10‐11yr) 案例分享
4 yr女童,被車輪壓到,喘,蒼白
• Vital sign: AVPU, TPR 37.8/145/40, BP 84/52 mmHg, BW 14kg
• 家人述:病患被小貨車輾過左胸 (自前方撞擊,病患背部著地,小貨車車輪自病患右骨盆往左胸處壓過)
• Conscious: E4V5M6• HEENT: pupil 3+/3+• Chest: BS rhonchi, bil; tachycardia, diaphoresis; left chest wall crepitusr/o rib fracture
• Abd: soft• Pelvic: low back area ecchymosis
• Ext: ROM OK
FASTLUQ: PLE(+)Liver and spleen showed no obvious lacerationDx: left hemothoraxConsider Chest CT for further evaluation
13:55 • Respiratory distress,
irritable. Sat 98%• CXR showed lung
contussion with multiple ribs fx, left hemothorax
• Discuss with family for intubation and chest tube first, then do CTfamily agreed
• RSI: Dormicum 2.5mg, succinylcholine 15mg
• On 5# uncuffed endo, fix 15cm; with MV
• On chest tube 20# fix 6cm• On NG 10# with
decompression• On Foley 10#, with U/A• Chest CT with/without
contrast• f/u CXR
CT day1
CT report: 1. Multiple left ant ribs fx, bil lung contussion;
left pneumothorax s/p chest tube insertion2. Large liver laceration (preserved HV and IVC)3. Rt pubic bone fx4. Swelling of Rt iliacus muscle r/o co-existed insidious bleeding
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180
140130 130
10898
76
128
90 95 97111 111
126111
0
50
100
150
200
5月2日 5月3日 5月4日 5月5日 5月6日 5月7日 5月8日 5月9日
HR
SBP
day1 day2 day3 day4 day5 day6 day7
IVF 890 1586 1234 1153 825 670 265
TPN 382 703 624
Lab Hb 11.49.4
Hb 10.28.9
Hb 7.48.6, Plt 9068, aPTT 48.1
Hb 7.5, Plt 69
Hb 12.014.4Plt 138, aPTT 63.1
Hb 14.4Plt 132
BT PRBC 200cc PRBC 1u
WB 250cc, FFP 250cc, PRBC 250cc
PRBC 2u,FFP 4u,
Plt 1u
PO 563 1190
U/O 440 896 1015 2385 1080 1570 1920
Cefotaxime
extubateRemove chest tube
CT CT
day1AC 46cm- on left femoral CVP - Medications:
- Dormicum- Cefazolin 300mg iv q8h- Ranitidine 25mg iv q12h- Dopamine 2.6cc/hr
- coffee ground vomitus 2-3 times
-day2 AC 46.5cm- extubation- Medications:
- lasix 7mg v st- coffee ground vomitus 3 times- amylase 26/ lipase 13
day3 AC 4752cm- 無腹痛主訴- on left femoral CVP - Medications:
- Vit k1 10mg v st- GOT 223, GPT 336, CK 1832 - Abd echo: liver hematoma at caudate lobe, LLL contussion with minimal PLE
day4 AC 5355 cm- f/u abd CT - CK 947 ()- internal bleeding, UGIB supportive, blood transfusion
Day5 AC 5554.5 cm- start NG feeding- CK 544, GPT 231, T-bil 1.4- remove chest tube
Day6~7 AC 54~ cm- GOT 42, GPT 106, CK 139- transferred to ward
ICU course
Day12 MBD CT report: 1. Slightly increase fluid collection in the bil paracolic gutter and pelvic cavity2. Active bleeding at pre-existing liver laceration3. Progressed swelling of Rt psoas and iliacus m.4. Slight regression of Lt pneumothorax and subcutanesou emphysema
CT day4
Take home message
• 面對小兒創傷
– 大膽假設,小心求證
– 寧可錯殺一百,不能放過一人
– 制敵機先,與時間賽跑
– Always team work!