严重创伤病人的麻醉-PPT文档.ppt
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1、1,几个概念,创伤 多发伤 多部位伤 复合伤,轻伤 中等伤 重伤,严重创伤,2,Why should we learn trauma anesthesia?,Anesthesiologists are being faced with anesthetizing an increasing number of trauma patient All anesthesiologists will likely have significant and unpredictable exposure to trauma patients,3,In 1993, approximately 90,000
2、individuals in the U.S died of accidental injuries , for a rate of 34.9 deaths per 100, 000 population, the second lowest accidental death rate on record,4,In the same year there were an estimated 18,200,000 disabling accidental injuries, or about 2,080 injuries every hour, and the 90,000 accidental
3、 deaths amounted to 1 every 6 minutes-and these numbers excluded the rising level of intentional injuries caused by attempted or successful suicides and homicides,5,Injury ranks as the fourth leading cause of death in the U.S. Currently, for American younger than 40 years, trauma is the most common
4、cause of death, following heart disease, cancer, and cerebrovascular disease,6,Potential roles of the anesthesiologist in this area,Trauma team member Trauma team leader Anesthesiologist Critical care physician,7,Pain relief physician Prohospital care physician Critical care transport physician or d
5、irector Disaster planning consultant,8,病情评估,9,病情评估,评分系统(scoring system) 创伤机制 (mechanisms of injury),10,Scoring system,ASAPS GCS: a useful prognostic tool for patient with acute head injuries TS, RTS(revised trauma score) and PTS(pediatric trauma score): used to predict outcome and direct patients to
6、 appropriate facilities. CRAMS Score,ASA分级,12,GCS(Glasgow coma score),Eye opening (41) Verbal responses (51) Motor responses (61),轻型:1315分,意识障碍20min以内 中型:912分,意识障碍20min 6h 重型:38分,伤后昏迷至少6h以上或伤后24h内情况再次恶化者,13,Eye opening,Spontaneous- 4 To voice- 3 To pain- 2 To none- 1,14,Verbal reponses,Oriented- - 5
7、 Confused- 4 Inappropriate- 3 Incomprehensive words- 2 None- 1,15,Motor response,Obeys command- 6 Localizes pain- 5 Withdraws(pain)- 4 Flexion(pain)- 3 Extension(pain)- 2 None- 1,16,创伤机制,虽然创伤的原因多种多样,但各种创伤导致的损伤机制是相同的,因此可以用创伤性疾病(traumatic disease)来概括各种创伤导致的机体损害 了解创伤的损伤机制是创伤治疗的前提 钝性损伤与穿透性损伤 颈部与气道创伤 胸部创
8、伤 闭合性头部损伤与开放性股骨骨折,18,严重创伤病人的病情特点,病情紧急,伤情复杂 生理紊乱重,并发症多,死亡率高 疼痛剧烈 饱胃,19,严重创伤病人的麻醉处理特点,不能耐受深麻醉 难以配合局部麻醉 麻醉药物作用时间明显延长 容易误吸 常需支持循环功能,20,术前准备,Preoperative Preparation,21,原则,按步骤获取病史、体检、诊断和治疗的程序不适用于创伤病人 在经过3045s的病情判断后应立即开始创伤救治 经过初期复苏治疗后,应除外一切可能的隐匿损伤,22,程序(sequence of management of trauma patients),Overview
9、Perform visual scan of patient for obvious injuries Obtain history from prehospital personnel and patient(if able) Primary survey(ascertain “ABCDEs”) Airway maintenance (with cervical spine control) Look for chest wall movements, retraction ,and nasal flaring Listen for breath sounds, stridor, and o
10、bstucted ventilation Feel for air movement,23,Primary survey(ascertain “ABCDEs”) Breathing (give supplemental oxygen) Determine whether ventilation is adequate Inspect chest to exclude open pneumothorax Auscultate for bilateral breath sounds Provide assisted ventilation for ventilatory failure Circu
11、lation (establish venous access) Check peripheral pulses, capillary refill, and blood pressure Obtain electrocardiogram Grade shock according to vital signs Correct hypovolemia and obtain blood samples,24,Primary survey(ascertain “ABCDEs”) Disability (determine neurologic status) Evaluate central fu
12、nction A: alert V: responds to vocal stimulus P: responds to painful stimulus U: unresponsive Evaluate pupil response to light Expose patient for complete examination Resuscitation phase Secondary survey Definitive care phase,25,气管插管术,需要立即行气管插管的适应症 GCS 9的头部创伤病人 休克 气道阻塞 需要镇静的躁动病人 全麻病人 胸部创伤伴低血容量时 复苏后低
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