Dealing With Trauma Patients

Patients who seriously injured but not fatally injured, will benefit most from treatment in specialized trauma centers, d. H. Hospitals with special facilities and programs for immediate care of critically ill patients. The criteria for this designation (and transport there) are different from state to state, but usually follow the guidelines of the American College of Surgeons’ Committee on Trauma (n. D. Red .: and in Germany the German Society of Trauma Surgery , DGU).

Trauma is the leading cause of death among people 1-44 years. (Ed. Note. D .: More than 3,000 people [1.1 million annually] die every day worldwide in accidents on the roads. Figures from the WHO and the World Bank additionally go from year 50 million casualties.) 2011, there were in the US 187,464 trauma victims, two thirds were due to accidents. The intentional deaths 70% were self-inflicted. In addition to the deaths traumas lead annually to about 41 million emergency contacts. Patients who seriously injured but not fatally injured, will benefit most from treatment in specialized trauma centers, d. H. Hospitals with special facilities and programs for immediate care of critically ill patients. The criteria for this designation (and transport there) are different from state to state, but usually follow the guidelines of the American College of Surgeons’ Committee on Trauma (n. D. Red .: and in Germany the German Society of Trauma Surgery , DGU). Many traumatic injuries are discussed elsewhere in the MSD Manual: bone and joint injuries spinal cord injury head injury facial injury eye injury injury genitourinary wounds etiology People can get hurt in countless ways, most injuries can be divided into two categories: “blunt” or classify “penetrating”. Blunt trauma mean a sharp blow (z. B. a shock or impact occurs through an object, a lintel, an explosion or a car crash). Penetrating injuries represent a breakage of the skin with a boundary object (z. B. knife, broken glass) or a projectile (z. B. ball, explosion splitter). Other forms of injury are thermal and chemical burns, toxic inhalations or ingestions and radiation accidents. Pathophysiology All injuries cause by definition a direct tissue damage depends on the type and degree of localization, the mechanism and the intensity of the trauma. A heavy direct tissue damage important organs (eg. As the heart, brain or spinal cord) is responsible for most immediate trauma death. In addition, patients who survive the initial trauma, develop indirect injuries. A vessel rupture generates a blood flow which can be directed to the outside (and thus visible) or inside, either limited to one organ, as in the contusion or in a hematoma, or as the free blood flow in a body compartment (z. B. peritoneal cavity, thoracic ). Minor bleeding (d.. H <10% of blood volume) are well tolerated by most patients. Larger amounts lead to a progressive hypotension and reduced organ perfusion (to shock), the cellular dysfunction, organ failure and possibly death. Hemorrhagic shock causes most sudden deaths (d. E., Within hours), the multi-organ failure of prolonged crisis, most deaths are caused within the first 14 days. More deaths in this period are due to infections due to destruction of normal anatomical barriers and an immune system disorder. Evaluation and treatment Primary Investigation: Clarification and stabilization of airway, breathing, bleeding, central nervous system (neurological status) and control of the environment Secondary Investigation: from head to toe after initial stabilization Selective use of CT and other imaging tests Here is more care treated in the emergency room than emergency care at the scene. Diagnosis and treatment are carried out simultaneously, starting with the organ systems that represent the greatest immediate danger to life in case of injury. The treatment of the dramatic but non-fatal injuries (z. B. open fracture of the lower limbs, finger amputations) in front of a clarification immediately life threatening findings can be a fatal mistake. The following points need to be clarified in case of emergency: airway, breathing, bleeding, central nervous system, control of the environment. The organ systems are rapidly to severe abnormalities (primary examination) examined, a more particular examination (secondary examination) after the patient is stable. Tips and risks Treatment of dramatic but non-fatal injuries (z. B. open fracture of the lower limbs, finger amputations) in front of a clarification of the immediate life-threatening findings can be a fatal mistake. Respiratory airway can be obstructed by blood clots, teeth or foreign bodies in the oropharynx threatening, but also by the laxity of the soft tissue and the retraction of the tongue backwards with impairment of consciousness (for. Example, due to head injury, shock or poisoning) and by edema or haematomas by direct neck trauma. These obstructions can be easily seen by direct inspection of the oral cavity or pharynx. Can speak the patient, he confirmed that the airways are likely obstruhiert not life threatening. Blood and debris are sucked or manually removed. Unconscious patients whose airway patency, protective mechanisms of the respiratory tract, oxygen or breathing can not definitively be fine, and patients with significant oropharyngeal injuries requiring intubation. As a rule, drugs to paralysis and sedation are administered prior to intubation. Several tools are available to assist breathing, including Extraglottic appliances, rubber-elastic bougie and video laryngoscopy. A CO2 colorimeter or, preferably, capnography can help to control the proper placement of the endotracheal tube. If patients require artificial ventilation and intubation is not possible (eg. B. due to edema of the respiratory tract by a thermal combustion) or contraindicated (z. B. due to severe jaw injury), a surgical or percutaneous Koniotomie is displayed. Note: For the evaluation or treatment of the airways of a patient immobilization of the cervical spine should be maintained (for example, by a neck seal and immobilization.) Until a cervical spine injury by examination, imaging, or both be excluded kann.Atmung Adequate ventilation is threatened by a reduced central respiratory drive (usually after head injury, almost fatal shock or poisoning) or by chest trauma (z. B. hemothorax or pneumothorax, multiple rib fractures, pulmonary contusion). The chest wall is fully exposed to check a sufficient expansion of the chest wall, external signs of trauma, and paradoxical chest wall motion (e.g., as a collection of the chest wall for the inspiration), which can optionally include a traumatic Flatter chest. The chest wall is sampled on rib fractures and subcutaneous accumulations of air (sometimes the only findings in pneumothorax). Adequate ventilation of the lungs can be observed usually auscultation. A tension pneumothorax may decreased breath sounds on the affected side and distended neck veins cause; a deviation of the trachea to the opposite side of the injury can be determined later. Pneumothorax (is carried out as a pleural drainage) by chest tube decompressed. In patients with results that are consistent with a pneumothorax, a chest radiograph prior to the initiation of positive pressure ventilation should be performed. A positive pressure ventilation can zoom in on a simple pneumothorax or convert it into a tension pneumothorax. A suspected tension pneumothorax may by a needle-Thoraskomie (z. B. A 14-gauge needle in the midclavicular line in the 2nd intercostal introduced) can be decompressed in order to stabilize the patient, when a drainage tube can be used immediately. Inadequate ventilation is treated by endotracheal intubation and mechanical ventilation. Flatter a breast is stabilized by a gentle pressure on the fluttering segment. An open pneumothorax is covered with an occlusive dressing of 3 pages; the 4th page is left open to relieve pressure build up and cause a tension pneumothorax könnte.Blutungen A significant external bleeding may be caused by any large vessel and can not be overlooked. Life-threatening internal bleeding are usually less obvious. in the chest, in the stomach and in the soft tissue of the pelvis or the femur (eg by a pelvic fracture or thigh.) However, the blood flow volume can accumulate only in certain compartments. Pulse and blood pressure are measured and registered shock symptoms (eg. B. pale grayish color, diaphoresis, altered state of consciousness, poor capillary back filling). If the internal bleeding have life threatening, there are often a distended and sensitive abdomen, pelvic instability, deformity or instability of the thigh. External bleeding be controlled by direct pressure. About two large-caliber additions (z. B. 14 or 16 g) is added 0.9% isotonic saline or lactated Ringer's solution. In hypovolemia shock and in 1-2 l (20 ml / kg in children) are administered. Subsequently, liquids are in addition to and, if necessary, administered a blood component therapy as indicated. For patients who require large amounts of blood products, special treatment plans were developed (massive transfusion protocols). Patients with strong clinical suspicion of a large intra-abdominal haemorrhage must be fed an immediate laparotomy. Patients with massive intrathoracic hemorrhage may need immediate thoracotomy and possibly an autotransfusion of blood through a chest tube. Tips and risks signs of hypovolemic shock in patients with apparently isolated head injury should be immediately re-examined to internal bleeding because an isolated Kopfverletztung not cause a state of shock. Central Nervous System The neurologic functions are tested facing serious disruption in the brain and spinal cord function. The Glasgow Coma Scale (GCS see table: Glasgow Coma Scale * and see Table: Modified Glasgow Coma Scale for infants and children) and the pupillary response are used to find evidence of severe brain injury. The gross motor skills and sensitivity in every limb provide information on severe spinal cord injury. The cervical spine is palpated with a view of sensitivity and deformation and fixed in a rigid neck brace until a spinal injury can be excluded. After careful manual stabilization of the head and neck of the patient is rolled to the side to allow palpation of the thoracic and lumbar spine, a study of the back and rectal examination with a view to sphincter tone and bleeding (a reduced sphincter tone suggests a possible spinal cord injury to discover) and possible bloodstains. In the US, most patients who reach the ambulance be immobilized to facilitate transportation and stabilization of possible vertebral fractures on a long, rigid board. However, patients should be taken down as soon as possible from the board because it is very uncomfortable and may experience pressure sores after a few hours. Glasgow Coma Scale * Evaluated region reaction points eye opening Spontaneous opening 4. Capable of verbal articulation 3 opening in response to pain, which is caused on the limbs or sternum 2 No one Verbal communication-oriented 5 Lost, but able to respond to questions 4 Inappropriate responses to questions; 3 not to be understood words unintelligible sounds 2 None 1 Motor reaction obey commands 6 responds to pain with targeted movements 5 runs on Sc hmerzreize back towards 4 Responds to pain with abnormal flexion (Dekortikationshaltung) 3 Responds to pain with abnormal (rigid) Extension (Dezerebrationsstarre) 2 None 1 * Combined scores <8 are considered coma normally. Adapted from Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2: 81-84; 1974. Modified Glasgow Coma Scale for infants and children Evaluated area Infants Children Score * eye opening Spontaneous opening Spontaneous opening 4 opening in response to verbal stimuli open in response to verbal stimuli 3 Open only in response to pain No response Open only in response to pain 2 None 1 Verbal response reaction cooing and babbling Clear, logical 5 overwrought shouting Confused 4 Weint in response to pain episode right words moans 3 in response to pain unintelligible words or sounds nonspecific 2 No response No response 1 Motorized reaction † moves spontaneously and specifically Obeys commands 6 drawn to contact back Isolated painful stimulus 5 rotates in response to pain away rotates in response to pain was gone 4 Responds to pain with Dekortikationshaltung (abnormal flexion) Responds to pain with Dekortikationshaltung (abnormal flexion) 3 Responds to pain with Dezerebrationsstarre (abnormal Extension) responds to pain with Dezerebrationsstarre (abnormal Extension) 2 No response No response 1 * A value ? 12 indicates a severe head injury. A value <8 indicates the need for intubation and mechanical ventilation. A value ? 6 refers to the need for a Überachung intracranial pressure. † If the patient is intubated, unconscious or too young to speak, provides the motor response the most important part of this evaluation. This area should be carefully checked. Adapted from Davis RJ, et al: Head and spinal cord injury. In: Textbook of Pediatric Intensive Care, ed. v. MC Rogers. Baltimore, Williams & Wilkins, 1987; James H, N Anas, Perkin RM: Brain Insults in Infants and Children. New York, Grune & Stratton, 1985; and Morray JP et al: Coma Scale for use in brain-injured children. Critical Care Medicine 12: 1018, 1984. Patients with severe traumatic brain injury (GCS <9) requiring endotracheal intubation for airway management, imaging of the brain, a neurosurgical evaluation and treatment to prevent secondary brain damage (eg. B. optimization of blood pressure and oxygenation, prevention of cramps, osmotic diuresis for increased intracranial pressure and sometimes hyperventilation in patients with signs of impending cerebral Einklemmungen- herniation of brain tissue.). control of the environment to ensure that no injuries were missed, patients are fully stripped examined (by cutting the clothes) and the entire body surface for evidence of occult trauma. The patient is kept warm (for. Example, with electric blankets and using heated infusions) conducted a thorough examination and medical history to a supercooling judgment verhindern.Sekundäre After primary evaluation of life-threatening symptoms and stabilizing the patient. If only a limited conversation is possible querying of 5 points can promote important information to light: allergy medications Medical History Last meal injury course of events if the patient is completely stripped, below the investigation generally from head to toe continued. These usually include checking all orifices, and a more thorough investigation of the controlled at the initial assessment areas. All soft tissues are examined for injuries and swelling out, checked all the bones on tenderness and the movement areas of the joints assessed (if no obvious fracture or deformity is present). In severely injured and subdued patients a urinary catheter is placed normally, provided no evidence of Urethraverletzung present (eg., Blood at the meatus, ecchymosis the perineum, high-prostate). In severely injured a nasogastric tube is placed and often when no heavy midface trauma is present (because of isolated reports of intracranial placement of the probe at fracture of the ethmoid). Open wounds are supplied with sterile dressings, but the wound cleansing and wound closure will be postponed until after the examination and treatment of serious injuries. Clinically apparent dislocations with significant deformation or neurovascular impairment are immediately displayed visually and repositioned once the life-threatening factors are treated. Apparent or suspected fractures up to the complete assessment of serious injuries splinted by suitable imaging processes. A clinically manifest unstable pelvic fracture is stabilized with a sheet or a special stabilizing aid, to allow closure of the pelvic cavity and to stop the bleeding; severe bleeding may require immediate angiographic embolization surgical fixation or direct surgical control. In pregnant trauma patients, the first priority is to stabilize the woman. This is the best way to ensure the stability of the fetus. A short-term immobilization in a supine position can cause the uretero-fetoplacental unit to compress the inferior vena cava, which prevents the blood from flowing back, thus causing hypotension. If so, the uterus may be manually pushed to the left side of the patient, or the entire rear wall may be inclined to the left to relieve the compression. Fetal monitoring is necessary if the fetus is> 20 weeks gestation age. It should be continued for at least 4-6 hours. An obstetrician should be consulted early if the patient signs of severe trauma or a complication of pregnancy offebart (z. B. abnormal fetal heart rate patterns, vaginal bleeding, contractions). Rh0 (D) immune globulin is given to all Rh-negative women even after minor injuries. If the woman has a cardiac arrest and can not be revived, a cesarean section may be performed post mortem when the fetus> 24 weeks gestation old ist.Tests The imaging modalities are at the forefront. Laboratory tests are usually complementary measures, except for possible serial “point-of-care” -Hämoglobinuntersuchngen when continuously blood loss. Patients with penetrating trauma typically have focal injuries that limit the necessary imaging to the obviously affected area or areas. Blunt trauma can, especially if high speeds were involved (eg fall from a height, car accident.), Concerning each body; the imaging methods are used generous. Until now routinely x-rays or CT scans of the neck, chest and pelvis were made in most patients with blunt trauma. However, most trauma centers have started to use only imaging techniques that are displayed in the investigation by the mechanism of injury and the findings. X-rays of the spine can be postponed in patients who are not intoxicated, no spine sensitivity along the center line or distracting injuries (z. B. femur fracture) who are awake and alert. For all other patients an imaging technique should be a friend to check the spine, best by CT. A chest X-ray may display a Atemwegsruptur, a lung injury, an hemothorax and pneumothorax, it can also suspected aortic provide (for. Example, by a widening of the mediastinum). However, a CT scan of the chest may be the most intrathoracic injury better and is therefore often preferred. A CT scan of the chest, abdomen, pelvis, spine or head, or combined pictures are taken frequently in patients who require imaging after multiple severe blunt trauma. The identification of intra-abdominal injury is essential. Earlier a diagnostic peritoneal lavage (DPL) was used to assess intraperitoneal bleeding. In the DPL a peritoneal dialysis catheter is inserted through the abdominal wall into the abdominal cavity. If> 10 ml of blood is drawn off, an immediate laparotomy is indicated. If no blood is sucked l 0.9% saline solution is infused through the catheter 1 and rinsed; an analysis of the returned liquid obtained gives information about the further treatment. However, the DPL largely by ultrasound at the bedside (FAST examination: focused assessment with sonography in trauma) has been replaced, especially in unstable patients. It is well suited to detect significant amounts of intraperitoneal bleeding that requires immediate laparotomy. If patients are stable, computed tomography is the best method of investigation; it is accurate, allows the display of retroperitoneal structures and bone, leaving the crowd and sometimes also recognize the origin of the bleeding. Advanced Focused assessment with sonography for trauma created (E-FAST) Video of Hospital Procedures Consultants, var model = {videoId: ‘3903698775001’, playerId ‘SyAEZ6ptl_default’, imageUrl ‘’ title: ‘Advanced Focused assessment with sonography for trauma (e-FAST)’ description: ” credits ‘video created by Hospital Procedures Consultants,’ hideCredits. true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true}; var panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘video element panel..’); ko.applyBindings (model, panel.get (0)); If a pelvic fracture is suspected, a CT of the pelvis is made, which is more accurate than conventional X-ray. A CT scan of the head is made usually in patients with impaired consciousness or focal neurological disorders and in patients with a prolonged loss of consciousness. Some evidence suggests that computed tomography with a brief loss of consciousness (ie <5 seconds) or a transient amnesia or disorientation is necessary in patients when on the Glasgow Coma Scale (GCS) has a value of 15 points during the have investigation. Imaging techniques are applied more frequently in patients with persistent headache, vomiting, amnesia, convulsions and age> 60 years, as well as in patients with a drug or alcohol intoxication and in patients taking anticoagulants or antiplatelet agents. Bei Kindern mit Kopfverletzungen hat das Pediatric Emergency Care Applied Research Network (PECARN) einen Algorithmus erarbeitet, der dabei helfen kann, die Strahlenbelastung bei Kopf-CTs zu limitieren ( Abklärung von Kindern < 2 Jahre mit Kopfverletzungen); eine klinische Beobachtung wird bei Kindern dur

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