Airway and C-spine protection

• Can talk ?
• Stridor ?
• Remove foreign body
• chin lift or Jaw thrust, mouth gag
• On ET tube if massive bleeding , Inhalation injury ,facial fracture , laryngeal injury , retropharyngeal hematoma

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• NEXUS criteria to R/O C-spine injury
  มีข้อใด ข้อหนึ่งก็ “เอา"
  • Altered level of consciousness
  • Focal neurological deficit
  • Inactive neck movement (intoxication)
  • Tenderness along midline spine
  • Distracting pain/injury interfere
• On Philadelphia collar + Spinal board + stapping 5 points (Manual inline immobilization)

• Film C-Spine AP , Lateral , Open mouth
• CT brain include C-spine

• Maxillofacial injury ?
• Neck trauma ?

Breathing and ventilation

• RR ?
• Rib retraction ?
• Paradoxical chest movement
• Percussion : hyperresonance(air) or dullness(blood)
• Neck vein engorge ?
• Trachea in midline ?
• Clear ? Equal breath sound?
• SpO2 >= 95%
• On Oxygen cannula 11 LPM
• On ET tube if RR >60 , SPO2 < 80% , Air hunger
• Ventilator setting
  • PC mode
  • FiO2 = 100%
  • Tidal Volume = 6 - 8 ml/Kg
  • RR = 16-20 /min
  • PEEP = 5 cmH2O
  • if Head injury --> adjusted RR to keep PaCO2 30 - 35 mmHg

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• ICD
  • เข็ม No.18 เจาะที่ 2nd ICS mid-clavicular line

• Chest X-ray PA upright , Portable
• ABG

• Subcutaneous emphysema
• Neck trauma ?

Circulation

• Pulse rate ?
• Blood pressure ?
  • > 90/60 mmHg in non-trauma
  • > 60/40 mmHg in trauma
• Pulse full
• Extremity : warm or cold
• External bleeding
  • Opened fracture
• Internal bleeding
  • Brain
  • Chest
  • Abdomen
  • Retroperitoneum
  • Pelvic cavity
  • Long bones : Femur

Knwoledge

Blood volume = 70 mL/Kg (adult)

Blood volume = 80-90 mL/Kg (ped)

Neurogenic shock ; injury site ต้อง level เหนือต่อ T6

• Permissive hypotension : SBP 80 mmHg or MAP = 60 mmHg
• On Lactate Ringer solution 1000 ml IV loading
• On Inotrope DRUG

Inotropee	Conce	Rate	Effect
Adrenaline
Dopamine
Dobuthamine

• Urinary catheter
  

  Contraindication (ถ้ามีให้ทำ retrograde urethrogram ก่อน)

  • Bleeding per meatus
  • Perineal ecchymosis
  • High-riding or non-palpable prostate
• ABG

Disability

• GCS score
  if < 8 --> ET tube
• สำลัก , ชัก --> ET tube
Glasgow coma scale : GCS score

Eye opening response	Verbal response	Motor response
		6 : Obeys command
	5 : Oriented to T-P-P	5 : Localized to pain (ปัดมาโดน)
4 : Spontaneously	4 : Disoriented	4 : Withdraw from pain (ปัดไม่โดน)
3 : To speech	3 : Inappropiate words	3 : Abnormal flexion (deCortiCate) งอแขนเข้าหาลำตัว
2 : To deep pain	2 : Incomprehensive sound "อือ...อา"	2 : Abnormal Extension (decErEbratE) งอแขนออกนอกลำตัว
1 : no respnses	1 : no respnses	1 : no respnses

• Severe brain injury : 3 - 8 (coma)
• Moderate brain injury : 9 - 12
• Mild brain injury : 13 - 15

Environment and exposure