孕妇创伤急救

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Chapter19TraumainPregnancy

1TraumainPregnancy孕妇创伤

2Overview概要Dualgoalsinmanagingpregnanttrauma需要处理两个或以上的病人Physiologicalchangesofpregnancy孕妇生理改变Responsetohypovolemia对血溶积减少的反应Typesofinjuriesmostcommonlyassociated常见伤势Initialassessmentandmanagement初步检查及处理Traumapreventioninpregnancy预防孕妇创伤2TraumainPregnancy-

3TraumainPregnancy孕妇创伤Uniquechallenges挑战Vulnerabilityofpregnanttraumapatient孕妇于创伤时之弱点Potentialinjuriestounbornchild对胎儿的伤害Dualroles双重角色Providecaretomother照顾母体Providecaretofetus照顾胎儿3TraumainPregnancy-

4TraumainPregnancyLeadingcauseofmorbidityandmortality为孕妇发病率及死亡率的主要原因6–7%ofpregnanciesexperiencesometrauma6-7%孕妇曾遇上创创1in12injuredexperiencesignificanttrauma1-2%遭遇严重创伤Majorcauses主要原因Motor-vehiclecollisions交通意外Falls高处堕下Abuseanddomesticviolence虐待及家庭暴力Penetratinginjuries穿刺性创伤Burns烧伤4TraumainPregnancy-

5PregnantPatientIncreasedriskfortrauma创伤的风险增加Faintingspells,hyperventilation,excessfatiguecommonlyassociatedwithearlypregnancy孕妇初期较易头晕,呼吸过速,易疲倦Balanceandcoordinationaffectedbychangesthroughoutpregnancy怀孕过程可影响其平衡力及身体协调5TraumainPregnancy-

6FetalDevelopment6TraumainPregnancy-

7ViabilityAssessment7TraumainPregnancy-阴道出血肚脐耻骨联合流产可被见宫高

8PhysiologicChanges8TraumainPregnancy-肠蠕动血色素心输出量血量血压心率血含二氧化碳量

9PhysiologicChanges孕妇生理的改变Respiratorysystem呼吸系统Diaphragmelevatedduetouterinesize日渐长大的子宫令横隔膜上升Decreasedthoracicvolume肺容量下降Relativealkalosis血液相对为碱性Predisposedtohyperventilation较易出现呼吸过速9TraumainPregnancy-

10VitalSignsinPregnancy孕妇生命表征的改变Donotmistakenormalvitalsignsforsignsofshock.切勿把正常的生命表征当作休克Normalpulse:10–15beatsfaster正常脉搏:快10-15次Bloodpressure:10–15mmHglower血压:低10=15mmHg30–35%bloodlossbeforesignificantbloodpressurechange失血量达30-35%才出现休克Bealerttoallsignsofshock.注意出现休克征状FrequentITLSOngoingExams反复ITLS”复检”捡查10TraumainPregnancy-

11ResponsetoHypovolemia血溶积减少的反应Vasoconstrictionandtachycardia血管收缩及心跳过速Reductionofuterinebloodflowby20–30%子宫血流量减少20-30%Fetalheartrateandbloodflowdecreases胎儿心跳速率及血流量下降Fetusbecomeshypoxemic胎儿出现血氧过低High-flowoxygenisessential.给予高浓度的氧气Maternalshockhas80%fetalmortalityrate孕妇出现休克,胎儿死亡率可达80%11TraumainPregnancy-

12TraumainPregnancyITLSPrimaryandSecondarySurveys初步检查及进一步检查OptimizematernalandfetaloutcomeHigh-flowoxygenrapidlyadministered尽快给予高浓度氧Fetalhypoxiaoccursbeforematernalhypoxia胎儿会比母体早缺氧Fluidadministrationmustbeprompt必需正确输液Fluidvolumeneededisgreater输液量较多FrequentOngoingExams反复ITLS”复检”捡查Mortalityoffetusrelatedtomaternaltreatment胎儿死亡率与母体处理有关12TraumainPregnancy-

13SupineHypotension仰卧血压低Venousreturndecreases30%insupinepositionwith20-weekorlargeruterus.下腔静脉于仰卧时受压引致心脏血液回流受阻,通常20周以后出现Acutehypotension急性血压低Syncope昏厥Fetalbradycardia胎儿心跳过慢13TraumainPregnancy-

14SupineHypotensionTransportposition运送时之卧式Tiltorrotatebackboard20–30otopatient’sleft将脊板左倾20–30度Elevaterighthip4–6incheswithtowel于盆腔下垫上4-6吋毛巾Manuallydisplaceuterustoleft将子宫移向左侧14TraumainPregnancy-

15SupineHypotensionTransportpositionBetterstabilizedwithvacuumbackboardMorecomfortablethanstandardbackboard固定于真空脊板较比一般脊板舒适15TraumainPregnancy-

16EvaluationofUterineSize16TraumainPregnancy-

1717Relativelyminorabdominaltraumacancausefetaldeath.Maternaldeathismostcommoncauseoffetaldeath.胎儿死亡的原因最主要是母体死亡TraumainPregnancy-

18PregnantTraumaArrest孕妇创伤性心跳停上Treatedsameasforothervictims急救法与普通伤者相同Defibrillationsettingsaresame相同去颤法电量Drugdosagesaresame相同药物剂量Fluidvolumeneededincreases需要较大量静脉输液4litersnormalsalinerapidinfusionduringtransport送院时输液4公升Ifmotherunsalvageable:如孕妇不能挽救ContinueCPR继续CPRNotifyhospitalofpossiblecesareansection通知院方:准备接生/剖腹接生18TraumainPregnancy-

19TypesofTrauma创伤种类Motor-vehiclecollisions交通意外Penetratinginjuries穿刺性创伤Domesticviolence家庭暴力Falls高处堕下Burns烧伤19TraumainPregnancy-

20Motor-VehicleCollisions撞车65–75%ofpregnancy-relatedtrauma交通意外占孕妇创伤65-75%<1%injuredwhenminorvehicledamage如车辆轻微破烂,少于1%孕妇受伤Seatbeltssignificantlydecreasemortality安全带可减低死亡率Hasnotshownanyincreaseinuterineinjury未证实会增加子宫受伤机会20TraumainPregnancy-

21Motor-VehicleCollisionsMaternaldeath母体死亡HeadinjuryMostcommon头部受伤为最常见Uncontrolledhemorrhage不能制止的内出血Secondmostcommon第二常见Assesspelvis检查盆骨Fetalinjury胎儿受伤21TraumainPregnancy-Fetaldistress胎儿衰竭Fetaldeath胎儿死亡Placentalabruption胎盆剥落Uterinerupture子宫破裂Pretermlabor早产

22AbdominalTrauma腹部创伤Physiologicchanges生理改变Decreasedsensitivity敏感度降低Gradualstretching续渐绷紧Hormonalchanges荷尔蒙改变Uterusveryvascular子宫大量有血液供应Clinicalpresentation临床表现Guarding,rigidity,reboundresponseabsent可没有防卫性收缩,硬实,回缩痛等反应AbdominaltraumarequiresEDevaluation所有腹部创伤都需要送院22TraumainPregnancy-

23PenetratingInjuries穿透性创伤Gunshotwoundsandstabbings枪伤及刺伤Entrybelowfundus从子宫下穿入Uterusabsorbsforce,protectsmaternalorgans子宫承受力量,保护母体内脏Highfetalmortalityrate胎儿死亡率:40–70%Lowermaternalmortalityrate减低母体死亡率:4–10%Entryabovefundus从子宫上穿入Bowelinjuryduetodisplacement肠脏受伤23TraumainPregnancy-

24DomesticViolence家庭暴力10%experienceabuseduringpregnancy10%孕妇曾于懐孕期受虐待Proximalandmidlineinjuries近端及中线部位受伤Faceandneckmostcommon面部及颈为最常见Lowbirthweight出生体重较轻Abusedbyspouseorboyfriend:70–85%(U.S被配偶或男友虐待:70-85%24TraumainPregnancy-

25Falls高处堕下Injuryfromfalls高处堕下受伤Increasewithprogressionofpregnancy受伤机会随着怀孕期增加Centerofgravityaltered中心改变Proportionatetoforceandbodypartimpacted与受力及身体撞击点有直接关系Pelvicinjuries盆骨受伤Placentalseparation胎盆分离Fetalfractures胎儿骨折25TraumainPregnancy-

26Burns烧伤FluidvolumeneededincreasesMortalityandmorbidity死亡率及发生率Maternalmortalitysameasnon-pregnant死亡率与非孕妇相同Fetalmortalityincreaseswith>20%BSA烧伤面积>20%会増加胎儿死亡机会26TraumainPregnancy-

27TraumaPrevention预防Properseat-beltuse正确使用安全带Reportdomesticviolence举报家庭暴力Counselingfordomesticviolence辅导Patienteducation病人教育Multiplechangesassociatedwithpregnancy孕妇身体多方面改变Physiological,anatomical,emotional生理,解剖,情绪27TraumainPregnancy-

28Summary总结TraumainPregnancy孕妇创伤Knowledgeofphysiologicalchanges生理上的改变Hypotensionandhemorrhageeasilyoverlooked血压低及出血容易被忽视Rapidevaluationandinterventionstostabilize快速评估及处理Aggressiveoxygenadministration尽怏施氧Aggressivefluidresuscitation尽怏输液Preventsupinehypotension预防仰卧引致的血压低Fetalcaredependsonmaternalcare胎儿依赖母体28TraumainPregnancy-

29Discussion29TraumainPregnancy-