胸外伤（52页）.pptVIP

Oxygenation Oxygenation is the prime concern and the mode of delivery will range from nasal cannula through face masks and non-invasive ventilation to full assisted ventilation. Independent lung ventilation may be needed for major air leaks and special ventilatory techniques are used in acuter respiratory distress syndrome (ARDS), a common complication of multiple injuries. Extracorporeal membranous oxygenation (ECMO) has been used extensively in paediatric intensive care. With the concentration of the more severely injured patients in major trauma centres, there is an opportunity to develop expertise in ECMO, particularly for the management of ARDS. Pain relief Pain relief is the dominant issue for patients with chest wall in- juries, incisions or chest drains. The pain may be minimal if one remains stationary and does not breathe deeply or cough. This, however, results in sputum retention, atelectasis, pneumonia and the need to escalate care. The degree of pain should be anticipated and treated prophylactically; all patients with chest injury or a chest drain will require regular opioid analgesia, rather than ‘as required’. Although requiring expert insertion, indwelling extrapleural paravertebral catheters inserted at the bedside have been shown to improve pulmonary function, and shorten the overall length of stay in patients with rib fractures compared with thoracic epidural. Clearance of secretions Retention of bronchial secretions is what causes pneumonia, respiratory failure and contributes to ARDS. Adequate pain relief, physiotherapy and nebulized bronchodilators (particularly in Smokers and COPD patients) is usually enough for most patients. A good cough clears secretions, expands the lungs, expelsa pneumothorax through the chest drain and obviates the need for chest drain suction. Prophylactic use in high-risk patients will prevent respiratory complications. In the ventilated patient, failure of re-expansion of lung segments by routine suction should pro