ENP สปร 61

Intraosseous accessIntraosseous access with speciallydesigned equipment is possible inall age groups, and is being usedwith increasing frequency. 9th If peripheral access cannot be obtained, consider placement of an intraosseous needle for temporary access.10th Choice of site for alternate access based clinician experience and skill

C : Circulation and Hemorrhagic control 9th

Initial fluid resuscitation Warmed fluid bolus is given. The usual dose is 1 to 2 L for adults. 9thWarmed fluid bolus of isotonic fluid. Theusual dose is 1 L for adult. 10thAggressive resuscitation before control ofbleeding has been demonstrated to increasemortality

Circulation and Hemorrhagic control 10th

Massive blood transfusion- RBC : Fresh frozen plasma : Platelet = 1:1:1- Massive transfusion protocol- 10 units of pack red cells within 6 hours

NARAINCHOTIROSNIRAMIT MD.

NARAINCHOTIROSNIRAMIT MD.

Thromboelastrography andRotational thromboelastometrycan be helpful in determining the clottingdeficiency and appropriate bloodcomponents to correct the deficiency.



Tranexamic acid in prehospital settingto severely injured patients Demonstratedimproved survival when this drug isadministered within 3 hrs of injury. 1st doseis usually given over 10 mins and isadministered in the field Follow up dose of1 gm is given over 8 hrs.

4. THORACIC TRAUMAUse of e FAST to diagnosis pneumothorax10th Abdomen 9th NARAIN CHOTIROSNIRAMIT MD.

THORACIC TRAUMA Smaller chest tube size 28-32 10thHowever, even with the appropriate sizeneedle, the maneuver will not always besuccessful due to Variable thickness ofthe chest wall Kinking of the catheterOther technical or anatomiccomplications. Needle decompressionmay not be successful. Fingerthoracostomy is an alternative approach.

NARAINCHOTIROSNIRAMIT MD.

5.ABDOMEN AND PELVIC TRAUMA Palpation of the prostate gland is not a reliable sign of urethral injury. 10th Unrecognized abdominal and pelvic injuries continue to cause preventable death.

Pelvic fractureHemorrhage control fixation device Pelvic wrap

6.HEAD TRAUMAAdded use of coagulants to list of items to becommunicated to neurosurgeon when consultingregarding traumatic brain injury. Head traumaseverity changed from minor to mild.

The new GCS score is introduced.

The primary goal of treatment for traumatic braininjury patient “Prevent secondary brain injury” TBI guideline Level III : Maintaining SBP at : >100 mmHg : patients 50-69 years > 110 mmHg : patients 15-49 or >70 yr Decrease mortality and improve outcomes

8.SPINE AND SPINAL“Spinal immobilization”9th“Restriction of spinal motion”10th The spine must be protected until this possibility has been eliminated Use long spine board for transport

8.MUSCULOSKELETAL TRAUMABilateral femur fractures :Risk factor for complications and death.Should alert the clinician to the possibilityof associated injuriessignificant force require to result in the injury).







9.THERMAL INJURY Fluid resuscitation Deep partial & full thickness burns > 20% BSA Begin 2 ml LRS/kg/% burnAvoid boluses unless the patient is hypotensive.Resuscitate pediatric pts using 3ml/kg/%TBSA

10.PEDIATRIC TRAUMAUse of Don’t be a DOPE mnemonic Commoncauses of deterioration in intubated ptD : DislodgementO : ObstructionP : PneumothoraxE : Equipment failureNOTE : no change in site for needledecompression (2nd interspace midclavicularline).1

An initial 20 mL/ kg bolus of isotonic crystalloidfollowed byWeight- based blood product resuscitation :10-20 mL/kg of PRC10-20 mL/kg of FFP & plateletTypically as part of a pediatric mass transfusionprotocol.

NARAIN CHOTIROSNIRAMIT MD.

11.GERIATRIC TRAUMAMortality from pelvic fracture 4 timeshigher in older patients Need more bloodtransfusion even with stable fracture.Longer hospital stays Less return toindependent lifestyles.

12. TRAUMA IN PREGNANCYAND INTIMATE PARTNER VIOLENCE

13.TRANSFER TO DEFINITIVE CARE Transfer should not be delayed for diagnosticprocedures CT scanning at the primary hospital leading toan increased length of stay before transfer. Frequently, CT scans are repeated upon arrivalto the trauma center. Multiple scans : increases radiation exposure ,additional hospital costs and a delay in transferto definitive care.SBAR template to facilitate communicationbetween transferring and accepting physicians.

Optional Chapter : ATLS and TraumaTeam Resource Management A trauma team should at minimum consist of:  Team leader (senior doctor experienced in trauma management)  Airway manager (provider skilled in airway management) :Doctor A  Airway assistant Second provider : Doctor B  2 nurses

Additional staff should include,where possible: A scribe/coordinatorTransporters/technicians/nursingassistants Radiology support Specialist (e.g., neurosurgeon,orthopedic surgeon, vascularsurgeon)

Roles and Responsibilities ofthe team leader  Preparing the team  Receiving the handover  Directing the team and responding to information  Debriefing the team  Talking with the patient’s family/friends

Teamwork in trauma careTeamwork is a learned behavior that onlycomes about with effective communicationand practice.What then are essential components of team?1. Well train (knowledgeable, practice)2. Clearly defined roles for each member3. Must be open to other members input and direction4. Must have high level of respect and trust among team members5. Strong communication skill

Expectations1. Everyone must speak the common language of trauma2. Staff should be trained in ATLS, ACTN,PHTLS3. Organization should have well established policies4. Each team member should have well defined roles5. All members of team should be willing to accept one person as being the leader6. All team members are open to input from other team members including the leader7. Must have an established performance improvement program to assess outcome



Emergency management for wound & pain

Primary survey Secondary surveyEmergency management for wound & pain Head to toe

Facial Trauma Initial Survey –AirwaySpecial Circumstances of AirwayCompromise Massive Ethmoid/Nasal Bleeding Bilateral parasymphyseal Mandible Fracture No nasotracheal intubation in severe midfacefracture Gastric tubes should be placed orally If airway is problem, remove loose teeth toprevent aspiration

Blocking airwayFx maxilla ร่วมกบั มีการยบุ ตขวองเพดาน (palate)

Disimpact fracture segment• โดยใช้นิว้ ชี ้และกลางล้วงไปที่เพดาน ใช้หวั แมม่ อื จบั เหงือก ออกแรงดงึ มาด้านหน้าโดยชือ้ อีกข้างดนั หน้าผาก ให้ศรี ษะอยนู่ ิ่ง จนกวา่ fragment จะ หลดุ

Fx mandible อาจทาให้ ล้นิ ตกไปดา้ นหลัง หรือมเี ลือดออกใต้ ล้ินดงึ ลน้ิ ออกมาด้านหน้าโดยใชน้ ิ้ว Forceps,towel clip, suture

Bleeding and ShockBleeding per nose : - Nasal Packing - Anterior nasal packing - Posterior nasal packing - Double balloons packing

Soft Tissue Injuryสาเหตุของการเกดิ บาดแผล บาดแผลเกิดเมือ่ ใด ตาแหนง่ ของบาดแผล สภาพของบาดแผล

 Contusion Abrasion Lacerated wound Avulsion wound Flap Gunshot wound, punctate wound Animal or Human bite

 ContusionHematoma Cold packing during first 24 hrs à stopbleeding

 Abrasion Traumatic Tattoo เศษหนิ ทราย ยางมะตอยVery superficial skin wounds, e.g. Saddle sores/ grazes fromfalling When they occur on the Knees they are referred to asBroken knees Treatment Must be cleaned to remove grit fromthe wound Skin should be kept moist Allow a good period of timeFor healing

 Lacerated wound Torn edges & irregular shape, with some bruising Frequently, there are torn flaps of skin that die before healing. Treatment Often can’t be stitched Must be kept …………..Best to keep wound open to enableIrrigation –NSS healingDebridement เลก็ นอ้ ยเทา่ ท่จี าเป็นRepair muscle, CN 7, parotid duct