acem 2011_medical transport in trauma ekkit
DESCRIPTION
For ACEM 2011 participation : Critical Care transferTRANSCRIPT
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Medical Transport in Trauma
Ekkit Surakarn,M.D General Surgery
Aviation Medicine Emergency Department
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Stabilized patient – Fit to fly
A - Airway secured
B - Breathing with O2 +/- support
Pneumothorax drained
C - Bleeding controlled, Shock treated
D - Deformity immobilized
E - Coverage
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Flight factor
Change in altitude
Vibration
Motion
Limited resource
Limited space
BE PREPARED.
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Flight factor
Change in altitude
Lower oxygen = Hypoxia
Gas expansion
Pneumothorax
Lung cyst / bleb
Bowel gas
Middle ear
Diving / Decompression sickness
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Flight factor
Vibration & Motion
Team : Vertigo, Motion sickness
Patient : Pain / Injury
Equipment : Displaced / Damage
Limited resource
Oxygen / Drugs
Equipment
Space
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Flight Doctor or Specialist
Flight Nurse
Airline Staff
Patient and Family
Payor
Teamwork
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Equipment
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What are possible injury ???
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Burn – Burn – Burn
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Monitor and Observation
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Airway Injury
Risk Prevention Noise - Unable to check breath sound
ET Tube malposition , Pneumothorax Secure airway
Straps + Tape + Marking
Confirm ET Tube Position
End Tidal CO2 Monitoring
Pulse Oximeter
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End tidal CO2
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Airway Injury
Risk Prevention Movement and Vibration
Close observation
Secure airway
Recheck – After each movement
End Tidal CO2 Monitoring
Pulse Oximeter
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Cricothyroidotomy
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C spine immobilization ?
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C-Spine and ET Tube Fixation
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Air Leak – Tension Pneumothorax
Bleeding – Massive Hemothorax
Deformity
Flail Chest / Open Chest Wound
Lung Contusion – ARDS / Pneumonia
Pain – Limited breathing and Cough
Breathing - Chest Injury
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Pneumothorax
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Pneumothorax
Needle thoracostomy
TENSION to SIMPLE
Large bore needle
2nd intercostal space
Midclavicular line
One-way valve
Under water tube
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Needle + One-way Valve + Container
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Preflight Plan - Risk Prevention
Drainage
Any pneumothorax … Before
Monitoring
Chest symptoms
Chest movement
V/S SpO2
Breathing - Chest Injury
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ICD
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Chest Pain
Limited chest movement
Breathing – Inadequate >>> Atelectasis
Cough – Ineffective >>> Secretion
Preflight Plan - Adequate pain control
Epidural block
Analgesic
Breathing - Chest Injury
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One-way valve
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Hemothorax
Bleeding in pleural cavity
Chest wall / Lung
Great vessels / Heart
Preflight Plan – Stable with Patent ICD
Blood < 100 ml/hr
IVF / Blood products
Breathing - Chest Injury
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Chest Surgery
CVT, ICD, Thoracentesis
Preflight Plan
Fly with ICD - Safe
Fly without ICD
No residual air leak – CXR ???
Low risk of leak in flight : 1-2 Week
Prepare for E-Decompression
Breathing - Chest Injury
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Bilateral Pneumothoraces
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Bilateral Pneumothoraces
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Hemopneumothorax
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Bilateral Pneumothoraces
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Respirator circuit
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O2 – Ventilator - Suction
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O2 needed, How much?
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C - Circulation
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Circulation
Preflight Plan - Blood
Secure hemostasis … Before flightBleeding control
Coag. – FFP/ Cryo / Novo 7
Keep Hb > 7 – 8.5 gm%
In trauma > 10 gm%
Occult ongoing blood loss
Cardio / Respiratory Reserve
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Preflight Plan - Volume
Euvolemia
Stable = Controlled hypotension is OK.
No dehydration
Urine output 0.5ml/kg/hr
IVF – Crystalloid, Colloid, Blood
Secure venous access
2 good lines – Large / Patenty checked
Circulation
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Fit to fly ?
Liver injury
Hemopericardium
Burn at chest wall
Post cardiac arrest
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Transfusion Rx
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Preflight preparation
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POCT
Point of Care Test
Blood sugar
PT & INR
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PASG
Application
Standby
Before move
Shock > Inflate
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Urine output
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Preflight Plan - Perfusion
Inotropes
All types – Mixed component
Vasoconstriction – NO FLOW
Keep warm
IVF/ Blood Products
Blankets
Circulation
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On board
Check : venous access sites
Monitor
P, BP, SpO2
Conscious
Cap. Refill – Central / 2 sec
Urine Output
Circulation
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Tubes and Lines
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Deficit – Brain injury
Check list
A-B-C
Initial assessment – AVPU or GCS
Localizing signs
Associated injury – Face/Neck
C-Spine protection
T-L Spine protection
Monitoring : BP and Neuro signs
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Bleeding – Contusion - Swelling
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Secondary Injury
CPP = MAP – ICP
Intracranial SOL / Swelling MAP is normal.
ICP is high.
CPP is LOW !!!
Systemic Perfusion – OK.
Brain – Shock ???
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Save Body & Brain
A – B – C – D
Airway Control
Breathing & Oxygenation
CPP : keep MAP
Decrease demand
Fever – Fighting – Fit
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Pneumocephalus – Tension ???
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Pneumocephalus
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Requirement : Brain injury
Medical staff - Competency in
Neuro. assessment + Consultation
Basic airway technique
Definite airway procedure
Ventilation support
Monitoring
Spine immobilization
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Recheck
• Neck Pain
• Motor Power
• Sensory
• Pulse Rate
• Blood Pressure
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Spinal protection
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Immobilization
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Fx : Femur – T Spine – C Spine
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Deformity – Limb injury
Immobilization
Distal perfusion
Compartment syndrome
Cast
Vascular injury
Reperfusion injury
DVT
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Immobilization – Traction Splint
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Non-constricted immobilizer
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Compound fracture Vascular injury and limb ischemia
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Pelvic fracture with C-Clamp
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Pelvic fracture with Binder
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Burn
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Burn Problems
A – Airway Swelling
Difficult / Obstruction
B – Breathing
Inhalation Injury & ARDS
Increase Systemic Injury
Carbon monoxide + Gaseous toxicity
Body Eschar – Chest Movement
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Burn Problems
C – Burn Shock
20% BSA in Adult
Less in Child/Elderly
Systemic Response
Leak
Depressed Myocardial Fn.
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Burn Problems
C – Distal Circulation
Tissue swelling
Circumferential Burn
Compartment Syndrome
Circum. Dressing
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Burn or more ???
Associated Injury Burn and fall, car accident, ….
Electrical Injury to …
Muscle, Heart, Neuro - Cord, Lens …..
Bleeding Debridement
Escharotomy
Fasciotomy
Myoglobinuria
Heat loss – Cold IVF
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Burn Care – On board
Airway – Swelling
ET Tube ? – Do it on the ground
Breathing – Hypoxia
Ventilator / O2 in flight
Circulation
V/S – Limb swelling : NIBP ?
Urine output
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Distal Limb – SwellingCircumferential Wound
Circum. Dressing
Monitor
Distal pulse/Cap. Refill – SpO2
Sensory / Motor
Bleeding
Burn Care – On board
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Abdominal Distension
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Abdominal
Compartment Syndrome
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Rectal Tube
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Decompression Tube