THÔNG TIN TÀI LIỆU
Initial management Remove from source of current Cardiopulmonary resuscitation as needed Provide mechanical ventilation until spontaneous ventilation is adequate Immobilize neck and spine Clinical assessment Neurologic examination (thorough evaluation for possible spinal cord injury) Peripheral pulses and perfusion and evaluation of the limbs for compartment syndrome Oral burns/edema Chest wall injury Abdominal distention Eye or ear trauma Cutaneous burns or bruises Laboratory/Imaging determinations Complete blood cell count Blood urea nitrogen, creatinine, urinalysis including myoglobin Electrolytes Troponin Electrocardiogram (ECG) Consider skull, spine, chest, long bone radiographs Consider computed tomography scan of brain (especially in lightning injuries) Consider electroencephalogram Monitoring Heart rate, ECG, respiratory rate, blood pressure Management Maintenance fluids: 5% dextrose in normal saline Volume expansion in presence of thermal burns or extensive deep tissue injury: 0.9% sodium chloride or lactated Ringer’s solution Fluid restriction for central nervous system injury Maintain urine output >1 mL/kg/hr Treat arrhythmias Treat seizures Tetanus toxoid; consider penicillin/other antibiotics Consider general, oral, or plastic surgical consultation Cerebral edema may develop over hours to days after injury, especially after a lightning strike If the child’s neurologic status fails to improve or deteriorates, intracranial pressure monitoring and treatment may be necessary Serum and urine electrolytes and osmolality should be followed closely to recognize promptly the syndrome of inappropriate antidiuretic hormone secretion Myoglobin in the urine is consistent with muscle breakdown and predisposes to renal failure Hydration and brisk diuresis with furosemide and/or mannitol may prevent renal damage but must be undertaken with caution if there is coexistent CNS injury Extensive muscle damage after lightning injury is uncommon, however, major CNS injury is common Treatment should proceed with these relative risks in mind until definitive information is available Most burns associated with low-voltage electrical injury are superficial Although they may become more apparent after several hours, most remain firstor second-degree burns Minor burns on the extremities can be treated with antibiotic ointment and should be allowed to slough and heal Oral and plastic surgeons should evaluate children who sustain oral burns In most cases, similar conservative management is recommended, but a removable stent may be necessary to minimize scarring High-voltage injuries commonly require aggressive treatment Fasciotomy may be necessary to restore adequate circulation to an injured extremity when compartment syndrome has developed The approach to debridement of wounds is controversial, but repeated examinations are considered most useful for detecting nonviable tissue Approximately 30% of survivors of high-tension injuries ultimately require amputation of some part of an extremity The risk of infection in patients with deep tissue injury is high Any patient not clearly immunized against tetanus should be given tetanus toxoid Some have recommended prophylactic antibiotics for oral injuries, but in general, antimicrobial therapy should be reserved for proven or strongly suspected infection Indications for Discharge and Admission Any patient who has sustained cardiopulmonary arrest, loss of consciousness, or deep tissue injury should be admitted to the hospital for evaluation and treatment Heart rate, respiratory rate, and BP should be monitored regularly Doppler evaluation may be helpful in cases of vasospasm, which may complicate assessment of BP and subsequent fluid management True hypotension may require pressor support and ICU care for treatment of multisystem organ failure Electrical or lightning injury in a pregnant woman can pose a risk to the pregnancy and evaluation by an obstetrician is warranted RADIATION INJURIES Goals of Treatment The goals of treatment are to decontaminate the patient without contaminating healthcare providers and to recognize early signs of radiation injury The emergency physician should be aware of the basic principles and management of radiation incidents in order to recognize when it happens, know procedures for triage and decontamination of victims, alleviate public fears and psychological trauma about potential incidents, and prevent mismanagement of potential victims Frequent training and drills can ensure that the ED staff has the knowledge, procedural skills, and supplies to deal with possible victims exposed to radiation accidents CLINICAL PEARLS AND PITFALLS No survivable radiation injury requires direct immediate lifesaving treatment, hence medical staff should focus their attention on injuryrelated, life-threatening conditions The greatest risk of whole-body radiation exposure after to weeks when bone marrow depression reaches its nadir Risk of contamination of ED staff is usually minimal Emergency preparedness for radiation injuries is crucial to managing these incidents and preventing widespread panic among staff and the public Understanding and anticipating the number of casualties and the severity/type of injuries that are most likely to occur is critical for the emergency provider Current Evidence Types of Radiation Radiation is a very general term used to describe energy emitted from a source ( Fig 90.10 ) Ionizing radiation, for example x-ray radiation, deposits a large amount of energy in a small volume of tissue, and energy is sufficient to strip electrons from atoms Nonionizing radiation, for example visible light and microwave radiation, is less energetic, of longer wavelength, and primarily deposits heat in tissue Ionizing radiation can be further subdivided into types of radiation that have no associated mass (nonparticulate ) and those that have mass (particulate ) X-rays and gamma rays are nonparticulate types of radiation and can penetrate deeply into the body and affect radiation-sensitive tissues, for example, bone marrow and the lining of the GI tract X-rays are emitted by excited electrons, whereas gamma rays are emitted by excited or unstable nuclei (radioisotopes or radionuclides) Once x-rays or gamma rays have been emitted, they are indistinguishable Particulate radiation can be further divided into charged and uncharged particles Neutrons, a type of uncharged particulate radiation, can penetrate the body to depths similar to x-rays and gamma rays Because neutrons deposit their energy in a more concentrated area, they cause more biologic damage than x-rays or gamma rays ... without contaminating healthcare providers and to recognize early signs of radiation injury The emergency physician should be aware of the basic principles and management of radiation incidents... when bone marrow depression reaches its nadir Risk of contamination of ED staff is usually minimal Emergency preparedness for radiation injuries is crucial to managing these incidents and preventing... casualties and the severity/type of injuries that are most likely to occur is critical for the emergency provider Current Evidence Types of Radiation Radiation is a very general term used to
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