胸部外伤的初步救治1.pptVIP

胸部外伤的初步救治 北京大学第一医院 胸外科 黄伟明 流行病学 Epidemiology 交通事故死亡人数 位列第七 50%的外伤患者带有 胸部外伤 TRAUMA DEATHS IMMEDIATE EARLY LATE 50% 30%-35% 15%-20% Seconds or Minutes Within Hours (Golden Hour) 2-3 Weeks Spinal Cord Injuries Chest Injuries Sepsis Severe Brain Injuries Liver/Spleen Injuries Lesions to Great Vessels Multiple Pelvic Fractures Others Multiple Organ Failure 损伤机制Mechanism of Injury 钝伤 Blunt thoracic injuries 穿刺伤 Penetrating thoracic injuries 胸部外伤 Thoracic Trauma 胸部外伤的患者可以迅速导致死亡 需要急诊开胸手术治疗只有大约15% 多数患者只需简单处理，即可挽救生命 What structures may be involved with each injury? Components Aims of ATLS ATLS (Advanced Trauma Life Support) Primary survey – To identify what is KILLING the patient. Resuscitation – To treat what is killing the patient. Secondary survey – To identify all other injuries. Definitive care – Develop a definitive management plan. 初步评估Primary survey A – Airway with cervical spine control B – Breathing C – Circulation D – Disability E – Exposure 胸部六大致命伤 1. 呼吸道阻塞 2. 连枷胸 3. 开放性气胸 4. 张力性气胸 5. 大量血胸 6. 心包填塞 Airway Obstruction Flail Chest Open Pneumothorax Tension Pneumothorax Massive hemothorax Cardiac tamponade 诊断方法 单纯的临床检查 指尖氧饱和仪及心电监护 尽快作出判断，“无罪推定” If you are not sure, it isn’t 急救处理 维持呼吸道 供给氧气 开放静脉 针刺减压 胸管引流 连枷胸 Flail Chest 连枷胸 Flail Chest 连枷胸 Flail Chest 连枷胸 Flail Chest 给氧 固定胸壁 不要过度输液 必要时机械正压通气 镇痛 张力性气胸Tension Pneumothorax 严重呼吸困难 颈静脉怒张 胸部叩诊鼓音 单侧呼吸音消失 脉搏细弱血压下降 张力性气胸Tension Pneumothorax 粗针减压 胸管引流 心包填塞 Cardiac tamponade Beck’s triad 低血压 中心静脉压升高 心音遥远 Kussmaul’s sign 吸气时颈静脉怒张 心包填塞 Cardiac tamponade 心包腔穿刺 准备紧急开胸探查 病例讨论 某男性驾驶员，34岁，因躲避来车，撞在路旁的电线杆上，左侧胸壁受伤。于急诊室中。 主诉有呼吸困难，左胸痛；查体发现左侧呼吸音微弱，胸部叩诊鼓音，不久后血压下降到80/40mmHg。 诊断？ 紧急处理？ Summary It’s common and could be serious To identify and treat what is KILLING the patient immediately Remember Airway Breathing Circulation Be alert to change in clinical condition /trauma/atls/index.html