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【論文摘要】重大創傷到院前外傷救治經驗分享
【論文摘要】Experience sharing of pre-hospital trauma treatment for major trauma
摘要
研究背景：依據到院前創傷救命術PHTLS，意識狀態的改變通常為休克第一個可見的徵兆，血壓是休克徵兆最不敏感的一項，當橈動脈摸不到時應視為已發生休克，而休克需要再發生失償前的早期確認及治療。但並非所有地方皆是救護車可到達的地方，台灣史上有阿里山小火車充當救護車接駁，前幾年亦有花蓮太魯閣號翻覆，利用火車接駁之前例，本案例為一件藉由火車接駁再由救護車載送送醫之院前救治經驗。案例描述：72歲男性於台鐵內灣線區間車行經上員-榮華間，被發現意識不清趴臥於火車鐵軌旁，故由該火車列車長發現並通報消防人員到場處置；因發生地點需經由火車鐵軌的步行接近，故攜帶裝備並步行約27分鐘，才接觸到傷者。接觸個案時，個案GCS345，呼吸平順，左大腿變形、臀部一處撕裂傷並持續緩慢出血、骨盆穩固，左腰一處血腫，額頭一處2X2擦傷。現場量測生命徵象及評估意識狀態，傷者意識不清、量測血糖134，評估橈動脈摸不到、摸頸動脈摸得到、量測血氧80%，給予頸圈限移、長背板保護及骨折固定，濕紗覆蓋各處傷口及給予輸液、非再吸入型面罩。送醫途中持續監測生命徵象，GCS345、血氧93%、血壓橈動脈摸得到。到院後，做全身的檢查及相關處置。後續傷者轉院到林口長庚醫院救治。案例討論：經由上述個案可知，一、接獲派遣時只知道傷者倒臥鐵軌旁，分隊第一時間立刻聯絡竹東火車站，請負責人協助調度火車車輛及相關事宜。並且根據第一梯次人員的回饋，尋找更接近的地點切入到達現場。以及派1名開救護車依患者動向而機動前往接近患者，以縮減搬運及送醫時間；二、傷者倒臥鐵軌旁，若要步行回程將會超過30分鐘甚至50分鐘，而傷者生命徵象不穩定且火車就停在旁邊，所以決定與火車列車長溝通，徵得同意後，將傷者搬運上火車，由火車接駁一同回到榮華火車站；三、第一梯次人員接觸患者發現橈動脈摸不到，打上IV路徑後，第一梯次與鄰近分隊的支援人員都未攜帶到生理食鹽水或乳酸林格氏液，故現場是決定先給予D10（等張溶液且含90%水），給到橈動脈摸的到後限流，以盡量減少發生給水過多而對傷者造成的傷害，在擔架上救護車後立刻更換為生理食鹽水及送醫。經此個案想提醒院前救護個案時，如果發生地點偏遠或搬運困難，建議尋求幫助，不論是鄰近分隊支援或現場民力及器材的運用，以加快不穩定傷病患的運送及就醫時間。
並列摘要
Background : According to the pre-hospital trauma life-saving surgery PHTLS, the change of consciousness is usually the first visible sign of shock, and blood pressure is the least sensitive one of the signs of shock. When the radial artery cannot be felt, it should be considered that shock has occurred, and shock Early identification and treatment before recurrent loss is required. Case presentation: A 72-year-old man was found unconscious lying on the side of the train track while passing through the Shangyuan-Ronghua section of the Neiwan Line of Taiwan Railway. The conductor of the train found it and notified the firefighters to deal with it at the scene. The railroad tracks were approaching on foot, so carrying equipment and walking for about 27 minutes, it took about 27 minutes to reach the injured. When contacting the case, the case GCS345 had smooth breathing, deformed left thigh, a laceration in the buttocks and continuous slow bleeding, stable pelvis, a hematoma on the left waist, and a 2X2 abrasion on the forehead. On-the-spot measurement of vital signs and assessment of state of consciousness. If the injured person is unconscious, measure blood sugar 134, assess that the radial artery cannot be touched, but the carotid artery can be felt, measure blood oxygen to 80%, and give a cervical collar to limit movement and a long back plate. Protection and fracture fixation, wet gauze covering the wound and infusion, non-rebreather mask. On the way to the hospital, the vital signs were continuously monitored, GCS E3V4M5, blood oxygen 93%, and blood pressure radial artery were palpable. After arriving at the hospital, do a general examination and related treatment. The injured were subsequently transferred to Chang Gung Hospital. It is currently housed in Xionglin Township Nursing Center. Case Discussion: From the above cases, we can see that, 1. When we received the dispatch, we only knew that the injured person was lying on the side of the railway track. The team immediately contacted Zhudong Railway Station and asked the person in charge to assist in dispatching train vehicles and related matters. And according to the feedback from the first echelon personnel, find a closer place to cut in and reach the scene. And send an ambulance to move close to the patient according to the movement of the patient, so as to reduce the time of transportation and medical treatment; 2. The injured person is lying beside the railway track, and it will take more than 30 minutes or even 50 minutes to walk back. The sign was unstable and the train stopped nearby, so I decided to communicate with the conductor of the train. After obtaining consent, the injured were carried onto the train, and they were connected by the train and returned to Ronghua Railway Station; The radial artery could not be felt, and after the IV route was installed, neither the support staff of the first echelon nor the neighboring teams brought normal saline or lactated Ringer's solution, so it was decided to give D10 (isotonic solution with 90% water content) first. ), give the radial artery a palpable flow limit, in order to minimize the damage caused by excessive water supply to the injured, and immediately replace it with normal saline and send it to the hospital after being put on the stretcher in the ambulance. After this case, if you want to remind the pre-hospital ambulance case, if the location is remote or the transportation is difficult, it is recommended to seek help, whether it is the support of the nearby team or the use of on-site personnel and equipment, so as to speed up the transportation and medical treatment time of unstable patients.