دانلود رایگان ترجمه مقاله ارزیابی و احیا در مدیریت تروما – الزویر ۲۰۱۷

ارزیابی و احیا در مدیریت تروما

Assessment and Resuscitation in Trauma Management

INTRODUCTION

The Golden Hour was first coined by R. Adams Cowley to emphasize the importance of prompt and efficient management of the acutely injured patient. Advances in both resuscitation and diagnosis have given providers a host of new procedural and imaging options and have resulted in improved trauma care at centers of all levels.

BEYOND ADVANCED TRAUMA LIFE SUPPORT: INITIAL RESUSCITATION IN THE EMERGENCY DEPARTMENT

The Airway, Breathing, Circulation, Disability, Exposure management taught by Advanced Trauma Life Support (ATLS)1 is an effective framework for initial evaluation and management of the injured patient and has been demonstrated to increase efficiency and quality of care.2 As any experienced provider knows, in a well-staffed trauma center, these processes can be run in parallel and their order modified for certain exceptional cases. When performed in full, they represent a complete initial evaluation of the injured patient in an orderly and efficient manner (Box 1).

Airway/Access

Intravenous access

Although typically straightforward, intravenous (IV) access can be a frustrating problem in the care of the trauma patient. Standard resuscitation calls for the placement of 2 large-bore IVs, typically in the antecubital position, with ultrasound (US) assistance if necessary. Alternatives to peripheral cannulation should be performed if peripheral access is not completed quickly. There are several options for access that can be used in the trauma bay, with variability in the rate of fluid administration3 (Box 2). Multiple other solutions to access have been described, including venous cutdown,3 corpus cavernosum,4 catheterization, direct right atrial catheterization, and umbilical vein catheterization in infants, but these are not of common utility in the trauma bay.

Central venous catheterization

Central venous catheterization (CVC) is an efficient mode of vascular access. Subclavian or femoral access is often preferred because of the ease of placement without US guidance. Caution should be maintained when using femoral access in the setting of severe trauma to the chest or abdomen, particularly penetrating injuries, because disruption or injury of the vena cava or iliac veins will prevent adequate delivery. In addition, in the case of accidental arterial access, these lines can be used in an emergency, but should be converted to venous access promptly.

Interosseous catheter

Interosseous (IO) catheter use has become widely accepted in trauma resuscitation and provides a fast alternative to CVCs. In the adult trauma patient, humeral and tibial access is preferred with success rates as high as 97%, although multiple other sites including the sternum, iliac crest, and femur have been described. Humeral IO catheters are preferred to tibial catheters because they provide greater flow rates but are inferior to both large-bore CVCs and IV catheters in this regard (see Box 2). In addition, resuscitation through a humeral IO drains into the subclavian vein, resulting in venous distention that facilities placement of a subclavian CVC when appropriate.