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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
ADVANCED TRAUMA LIFE SUPPORT(ATLS)
2Box 6.6 ATLScourse
In the UK, ATLS courses are coordinated by the Royal College of
Surgeons. The course is currently 2days long, and details of where and
when courses are run can be obtained from the College (E p.629 for
contact details). There is usually a long waiting list for places as this is a
popular course; the cost for the 2- day course is around£900.
The ATLS principles provide a structured approach to managing
complex trauma patients by identifying the life- threatening priorities
and treating quickly. Bear in mind that many departments will have
their own trauma protocols that may not align entirely with ATLS.
Check with your local protocol about how trauma is best managed.
For those who are especially interested in trauma management after sitting
the ATLS, then consider the European Trauma or ATACC (Anaesthesia
Trauma and Critical Care) courses when you are more senior.
2Box 6.7 One on theoor and fourmore?
Hypovolaemia is the main cause of shock in trauma and the way to
think about haemorrhage is that it can accumulate on the oor and in
four other places (Table 6.2): ‘one on the oor and four more’
Table6.2 Potential body cavity capacity in catastrophic haemorrhage
Body cavity Potential capacity (L/blood)
Thorax 2.5L per hemithorax
Abdomen 5L
Pelvis 3L
Thigh –2L each
233
234 CHAPTER6 Resuscitation
2Paediatric Basic Life Support
2 Airway
2 Breathing
2 Circulation
2 Disability
3Call the PAEDIATRIC arrest team if severely unwell; call for senior
early (Fig.6.4). (See Box 6.8 for life- threatening causes.)
help
Airway
• Airway manoeuvres:(head tilt), chin lift, jaw thrust (Table6.3)
• Oropharyngeal or nasopharyngeal airway if responding only topain
• If still impaired,
2If suspected epiglottitis (stridor, drooling, septic), do not look in
mouth; give O
Breathing
• Bag and mask with 5L/ min O2 if poor or absent breathingeort
•
Non- rebreather mask and 5L/ min O
•
Monitor pulse oximeter
•
Eort stridor, wheeze, RR, intercostal recession, grunting, accessory
muscle use (head bobbing in infants), nasal aring
•
Ecacy chest expansion, air entry (does R=L?), O
•
Eects HR, pallor, cyanosis (late sign), agitation, drowsiness.
Circulation
• Start CPR if HR absent or <60bpm and unresponsive
•
Monitor debrillator ECGleads
•
Status
• Eects RR, mottled/ pale/ cold skin, urine output, agitation, drowsiness
•
Venous access (consider intraosseous), check glucose and sendblds
•
Consider uid bolus (20mL/ kg IV 0.9% saline STAT) if shocked
•
Exclude heart failure iJVP, gallop rhythm, crepitations, largeliver.
Disability
• Assess AVPU (Alert, responds to Voice, responds to Pain,
Unresponsive); check
•
Look for pupil size and reexes; assess posture andtone
• E pp. 361–3 for
Exposure
• Look all over body for rashes, check temp, cover with a blanket.
2Box 6.8 Life- threateningcauses
Paediatric cardiorespiratory arrests are usually secondary to other
causes, usually hypoxia, hence why rescue breaths are prioritized.
•
Croup (exclude epiglottitis)
• Inhaled foreignbody
• Bronchiolitis
• Asthma
Check airway is patent; consider manoeuvres/ adjuncts
If poor respiratory eort—CALL PAEDIATRIC ARREST TEAM
If HR <60bpm— CALL PAEDIATRIC ARREST TEAM
If unresponsive to voice—CALL PAEDIATRIC ARREST TEAM
CALL ARRESTTEAM
, call senior help, an anaesthetist, and ENT urgently.
2
in all other patients
2
sats
2
HR + rhythm, pulse volume, cap rell (≤2s normal), BP (Table6.4)
glucose if not alreadydone
seizures.
• Dehydration(DKA)
• Sepsis, meningitis, pneumonia
• Anaphylaxis
• Heart failure (especially infants).
PAEDIATRIC BASIC LIFE SUPPORT
235
Fig.6.4 Paediatric Basic Life Support algorithm; 202 guidelines.
Reproduced with the kind permission of the Resuscitation Council(UK).
236 CHAPTER6 Resuscitation
2Table6.3 Main age- related dierences inpaediatric life support
Feature Infant <yr Child >yr Post- puberty
Airway
position
Breaths Mouth and nose Mouth ±nose Mouth only
Pulse Brachial Carotid Carotid
CPR
technique
Compressions:
breaths
2Table6.4 Normal range forobservationsbyage
Age RR (/min) HR (/min) Systolic BP (mmHg)
<yr 30–40 0–60 70–90
2–5yr 20–30 95–40 80–00
6–2yr 2–20 80–20 90–0
>2yr 2–6 60–00 00–20
Neutral Slightly extended
Encircle chest with hands
placing two thumbs on
lower half of sternum
with tips pointing
towards infant’s head.
Press to depress /3 of
chest depth (~4cm)
5:2 5:2 5:2
position
Heel of one
hand over lower
half of sternum.
Depress /3
of chest depth
(~5cm)
Slightly
extended
position
Two hands
over lower half
of sternum.
Depress /3
of chest depth
(~5cm)
2Choking
3Call the cardiac arrest team and initiate BLS.
2Assess the severity of the choking episode. Is the cough eective? If
the person is responsive, able to take a breath before coughing, has a
loud cough, gives a verbal response to questions, or cries, this indicates
mild obstruction and coughing should be encouraged.
Foreign body airway obstruction in adults
3If the person becomes unresponsive, commence CPR.
• Encourage coughing if the airway obstruction is mild
• If the cough becomes ineective, give up to
If choking continues after 5 back blows, proceed to give 5 abdominal
thrusts
• If choking persists, continue alternating 5 back blows with 5
abdominal thrusts until it is relieved or the person becomes
unresponsive.
Foreign body airway obstruction in children
3If the child becomes unconscious, commence CPR.
• Encourage coughing if there is an eective cough
• If cough is ineective, give
5 back blows
• If choking persists, give 5 chest thrusts in infants or 5 abdominal
thrusts for a child
• Alternate back blows or chest/abdominal thrusts until obstruction is
relieved or the child becomes unresponsive.
2Box 6.9 Relieving airway obstruction
Back blows Use heel of hand between shoulder blades to give 5 sharp
Abdominal
thrusts
Chest thrusts Turn infant into a head-downwards supine position by
back blows. The person should be leaning forwards in
a head-down position. Infants and small children can be
supported by lying them supine on your lap.
Stand behind the adult or child and place your arms around
them with your clenched st in their upper abdomen
(between umbilicus and ribcage). Grasp your st with your
other hand and pull sharply inwards and upwards.
placing arm along infant’s back and holding occiput with
your hand. Support infant down your other arm which is
placed down your thigh. Identify the lower sternum and
deliver chest thrusts (similar to chest compression but
sharper and slower).
5 back blows(Box 6.9).
237CHOKING
238 CHAPTER6 Resuscitation
2Newborn Life Support(NLS)
2Get urgent senior help and CALL THE NEONATAL
ARREST TEAM (Fig.6.5).
Preparation
• Put non- sterile gloveson
• Turn on the heater and place warm towels on the resuscitaire
• Turn on O
for termbabies
• Turn on suction and check itworks
• Get the laryngoscope and size 3.5 and 4.0 (term babies) ETTready
• Check gestation, estimated birth weight, and history (Box 6.0).
Drying and assessment
• Post- delivery start the clock and place the baby on the resuscitaire
•
Dry vigorously with a warm towel andcover
• Babies ≤32/ 40 gestation should be placed directly in a plasticbag
• Perform rapid initial assessment: observe
of
Airway and breathing
• Assess RR and check HR >00/min, if either is impaired during
assessment start respiratory support:
•
•
•
•
• If no chest movement, reposition head and
• Reassess RR and HR—if HR still <00/min, give ventilation breaths
(30 breaths/min) for 30s. Consider laryngeal mask/tracheal tube.
Titrate O
Circulation— if HR <60bpm after30s ventilation, start
chest compressions
• Assess the HR by gripping the umbilicus or listening to theheart
• Start
•
•
•
•
•
Re-assess the response every 30s
• Attempt to get
Drugs
• Adrenaline 0.2mL/ kg of :0,000 IV if HR not improving
•
Na
•
Glucose 0% 2.5mL/ kg IV if hypoglycaemic
•
0.9% saline 0mL/ kg IV if large blood loss suspected.
2
Preterm babies (<32wk) require lower PIP values of 25cmH2O. Ination breaths should be de-
livered with air for term neonates, 2–30% inspired O2 for neonates 28–3wk gestation, and 30%
inspired O
/ air and check pressure, set PIP/ PEEP to 30/ 5–6cmH2O
2
2
tone and colour, adequacy
breathing, and count HR.
place the baby’s head in the neutral position (+ jaw thrust if oppy)
place face mask over nose and mouth, give 5 ination breaths:
look for chest movement, improved HR,colour
look for oropharynx obstruction (eg meconium, mucus, vernix,
blood clots) and consider suctioning
repeat 5 ination breaths
to SpO2.
2
CPR if HR <60bpm/ absent despite ination breaths:
grip round the chest and use both thumbs over lower sternum
aim for a rate of 20 (twice a second)
increase O2 to 00%
use ratio of 3: compressions to breaths until airway secured
(intubation/laryngeal mask airway) then ventilate at 30breaths/min
IV access, eg umbilical venous catheter, check glucose.
+
bicarbonate 4.2% 2– 4mL/ kg IV if acidotic and not improving
if <28wk.
2
NEWBORN LIFE SUPPORT(NLS)
239
Fig.6.5 Newborn Life Support algorithm; 202 guidelines.
Reproduced with the kind permission of the Resuscitation Council(UK).
2Box 6.0 Life- threatening causes ofunresponsive neonate
• Prematurity
• Hypoxia
• Meconium aspiration
• Congenital abnormality.
240 CHAPTER6 Resuscitation
2Obstetricarrest
2 Airway
2 Breathing
2 Circulation
2 Disability
Sta
• Standard arrest team along with obstetrician and neonatologist if
>20wk gestation
Position
2Left lateral position (>5°) using a Cardi Wedge, pillows, or your
knees to take the pressure of the uterus o the vena cava andaorta
•
Push the uterus to the left and up to further relieve pressure.
Airway
• Look inside the mouth, remove obvious objects/ dentures
• Wide- bore
•
Jaw thrust/ head tilt/ chinlift
•
Early intubation to prevent gastric aspiration.
Breathing
• Look/ listen/ feel for respiratoryeort
•
Bag and mask if poor or absent respiratoryeort
•
Monitor O
Circulation
• Feel for a central pulse (carotid/ femoral)— HR andrhythm
• Mid- sternal
•
Arrhythmias— use a debrillator/ drugs as usual (Ep. 560)
•
Venous access, send bloods and give IV uidsSTAT
•
Monitor debrillator ECG leads andBP.
Disability
• Assess GCS and check glucose
• Look/ feel for pupil reexes, limb tone, and plantar reexes.
Surgery
• Peri-mortem emergency Caesarean if >20wk gestation and
resuscitation is not successful by4min (aiming for delivery within 5min
of collapse):
•
improves maternal chest compliance and venousreturn
• The
See Box 6. and Ep. 226 for causes of obstetric arrest.
Check airway is patent; consider manoeuvres/ adjuncts
If no respiratory eort— CALL OBSTETRIC ARREST TEAM
If no palpable pulse— CALL OBSTETRIC ARREST TEAM
If GCS ≤8— CALL OBSTETRIC ARREST TEAM
.
suction under direct vision if secretions present
sats andRR.
2
chest compression (30:2) if pulseabsent
mother’s needs take priority in all decisions.
2Box 6. Causes ofobstetricarrest
Haemorrhage/ hypovolaemia E p. 482 Pre- eclampsia/ eclampsia E p. 501
Excess magnesium sulfate
E OHCM1 p. 671
Acute coronary syndrome E p. 257
Aortic dissection E p. 261 Stroke E pp. 366–7
Pulmonary embolism E p. 292
Amniotic uid embolism E OHCS11 p. 100
Chapter7
Care at the end of life
Thinking aboutdeath 242
Symptom control in palliative care 244
Care in the last days of life 246
Verication of death 247
After death 248
241
242 CHAPTER7 Care at the end of life
Thinking aboutdeath
$ Death is inevitable, even the best medicine can only delay it. As a
junior doctor, you will have a vital role in supporting patients and their relatives at the end of life. Getting it right can be challenging, but rewarding.
Prognostication in advanced disease This is fraught with di-
culty. There are no specic biochemical markers of death and disease trajectories vary greatly between individuals. It is important to establish your
patient’s baseline understanding of their condition (and that of their loved
ones) and how much they wish to know. Prognostication is not about
destroying hope, but rather respecting your patient’s autonomy and allowing them to plan. You should avoid being specic, it can be helpful to
describe prognosis as ‘days to weeks’, ‘weeks to months’, or ‘months to
years’. For further guidance on breaking bad news see Ep. 24.
Talking about death Talking about death allows patients’ wishes to
be known and arrangements to be made. There is no ‘right time’ to talk
about death, this is individual for the patient. It is usually best done in
advance of the nal days, with someone who has built rapport with the
patient and their relatives (Box 7.). However, patients who suddenly
deteriorate or are admitted unexpectedly to hospital may not have had
that opportunity. When deciding where to take a conversation with a
patient, it can be helpful to establish your patient’s current thoughts and
understanding about their condition. If there is a large gap between this
and your own understanding, you may have to bridge this with multiple
conversations over a longer period of time.
Your own emotions and experiences Though helping pa-
tients navigate challenges towards the end of life can be rewarding, it
is normal to nd these conversations emotionally demanding. In a study
from Cambridge, 23.% of medical students had experienced close bereavement prior to the start of the course and between 3% and 22.5%
experienced loss between years –5.
reecting on your own experiences and emotions.
What matters to your patient? Patients approaching the end of
life should have the opportunity to develop a personalized care plan
outlining their wishes regarding important issues such as:
• Current and future symptoms and their control
• Potential treatments (including resuscitation)
• Fears about dying
• Religious or cultural values
3
• Place of death
• Arrangements after death—would the patient like to be cremated?
Death aects us all, it is worth
2
Whyte R, et al. Medical students’ experience of personal loss: incidence and implications. BMC Med
203;3:36. Mhttps://doi.org/0.86/472-6920-3-36
Educ
In 209, the National Audit of Care at the End of Life found that only 9.7% of patients had an
advance care plan before their nal hospital admission.
The gov.uk website provides more information regarding faith at the end of life: Mwww.gov.uk/
government/publications/faith-at-end-of-life-public-health-approach-resource-for-professionals