นวั�ตกรรมการแพทย์ ฉุ�กเฉุ�น

Dr.Sutasinee Jiamprasert

Emergency Team

โรงพยาบาล ภูมิ�พลอดุ�ลยเดุช

รถพยาบาลฉุ�กเฉุ�นขั้��นสูง

Activate code

• Stroke Fast Tract• birth before

admit(BBA)• CPR• MI Fast Tract

• Code A• Code B• Code C• Code M

• Trauma 4 code • Non-trauma 4 code

Trauma 4 code

Code ACode BCode CCode M

Code A

• ใช�สู�าหร�บ ผู้��บาดเจ็�บท��ทางเด�นหาย์ใจ็ส่�วันบนอุ�ดต�น

• ผู้�บาดุเจ็ บหมิดุสูติ� เมิ"#อนอนหงายมิ$น��าลายหร"อเล"อดุออกอ�ดุก��นทางเดุ�นหายใจ็

• มิ$การบาดุเจ็ บร�นแรงท$#ใบหน�า• มิ$สู�#งแปลกปลอมิในช(องปาก คอหร"อลงไปในหลอดุลมิ

• การบาดุเจ็ บขั้องคอ Larynx , trachea มิ$การบวมิ

Code A

• ก�จ็กรรมิเมิ"#อพบผู้�บาดุเจ็ บ• Open air way , Suction ,Clear air way น�าสู�#งแปลก

ปลอมิท$#มิองเห นออก ให�ไดุ�มิากท$#สู�ดุ ช(วยการหายใจ็เท(า ท$#ท�าไดุ� น�าสู(ง รพ. ท$#เหมิาะสูมิโดุยเร วแจ็�ง

• Assess ABCDE , ว�ดุสู�ญญาณช$พ , Provide O2 sat , Stabilize ผู้�บาดุเจ็ บให�เหมิาะสูมิ

• Establish IV Access and obtain Blood samples• ต�ดต�อุ ER Trauma 02 – 5347143 – 45 แจ็�ง

CODE A และแจ็�งเวัลาประมาณท��จ็ะถึ&ง รพ.

Code B

• CODE B ใช�สู�าหร�บ ผู้��บาดเจ็�บท��ม�ควัามผู้�ดปกต� นอุกเหน(อุจ็ากทางเด�นหาย์ใจ็ส่�วันบนอุ�ดต�น ม�

ผู้ลให�เก�ดเก�ดป)ญหาขอุงการหาย์ใจ็ไม�เพ�ย์งพอุ • Tension pneumothorax , Massive hemothorax • Open sucking chest wound• Fail chest

Code B

• ก�จ็กรรมิเมิ"#อพบผู้�บาดุเจ็ บ• ป/ดุบาดุแผู้ลท$#ท�าให�เก�ดุ Open sucking wound

( One valve dressing ) ,จ็�ดุท(าผู้�บาดุเจ็ บให�เหมิาะ สูมิ , ให� O2

• Assess ABCDE , ว�ดุสู�ญญาณช$พ , Provide O2 sat ,

• Establish IV Access ( RLS ) and obtain Blood samples

• ต�ดต�อุ ER Trauma 02 – 5347143 – 45 แจ็�ง CODE B และแจ็�งเวัลาประมาณท��จ็ะถึ&ง รพ.

Code C

• CODE C ใช้�ส่.าหร�บ ผู้��บาดเจ็�บท��ระบบไหลเวั�ย์นผู้�ดปกต� ท$#สู�าค�ญไดุ�แก( Shock เป0นภูาวะท$#ท�าให�Blood supply ไปอว�ยวะติ(างๆไมิ(เพ$ยงพอ(inadequate tissue perfusion ) อาการแสูดุงท$#

สู�าค�ญค"อ Hypotension , impairment of consciousness , Cyanosis , Oliguria

Code C

• Stop External Bleeding , ให� O2

• Assess ABCDE, ว�ดุสู�ญญาณช$พ , Provide O2 sat , Stabilize

• Establish IV Access ( RLS x 2 line ) and obtain Blood samples and G/M

• ต�ดต�อุ ER Trauma 02 – 5347143 – 45 แจ็�ง CODE C และแจ็�งเวัลาประมาณท��จ็ะถึ&ง รพ.

Code M

• CODE M ใช้�ส่.าหร�บผู้��บาดเจ็�บ 2 ระบบข&/นไปและส่�ญญาณช้�พไม�คงท��

• Stop External Bleeding , ให� O2

• Assess ABCDs , ว�ดุสู�ญญาณช$พ , Provide O2 sat , Stabilize

• Establish IV Access ( RLS x 2 line ) and obtain Blood samples and G/M

• ต�ดต�อุ ER Trauma 02 – 5347143 – 45 แจ็�งCODE M และแจ็�งเวัลาประมาณท��จ็ะถึ&ง รพ.

The Efficacy of A Trauma Code Activation System by

The Pre-hospital Care Team at

Bhumibol Adulyadej Hospital

Nickjaree Songsungvorn, MD.,

Sutasinee Jiampresert,MD

Emergency department, Bhumibol Adulyadej Hospital

Background

-199 patients who were transferred to the Emergency Room of Bhumibol Adulyadej Hospital by the Khumklao pre-hospital team

- October 1, 2010 –September 30, 2011

14

Objective • To evaluate the efficacy of triage and

code activation on trauma patients by the pre-hospital care team. • To identify trauma patient

characteristics.• To examine the impact of activation

and non activation of the trauma code.

15

Methods • Design : Retrospective, descriptive

study• Setting : Trauma center, Bhumibol

Adulyadej Hospital

Actually activated code

Accuracy in percentage

Identified correct code

Pre-hospital data

Table 1 : Personnel responsibility for code activation

CODE M (Activate trauma team)

CODE A B and C

Staff trauma surgeonTrauma surgical fellowshipTrauma surgical chief resident and residentEmergency medicine staffEmergency medicine residentNeuro-surgical chief residentOrthopaedic chief residentEmergency department nursing staffEmergency department nursesOperating room nurseBlood bank technicianDiagnostic imaging technician

Emergency medicine staffEmergency medicine residentTrauma surgical residentEmergency department nursing staffEmergency department nurses

17

Results

• During the study period, there were 199 included patients.• The mean of age was 38.6

years.• Male 144 (72%) Female 55

(28%)

18

Results

Study population 199

48 required the code activation

Activated 27 Non activated 21

19Figure 2 : Study population

Results

20

MCA53%

MVA11%

Pedestrian4%

Pedal cyclist1%

fall on same level13%

fall from heigh8%

GSW1%

Stabbing1%

Body assault4%

Hanging1%

Other3%

Figure 1 : Mechanism of injury

Results

CODE Activated Correct triage

Under triage

A 2 1 1B 2 1 1C 1 1 0M 22 22 0

TOTAL 27 25 221

Table 2 : Activated group

Results

CODE NON ACTIVATION

A 1B 0C 3M 17

TOTAL 21

22

Table 3 : Non-activated group

Results Table 4 : A comparison of activated group with non-activated group in code M patients

23

Activated (n = 22)

Non-activated (n = 17)

Statistic (95%CI)

Age mean ± SD 34.6 ± 13.4 35.8 ± 16.4 T-Test P = 0.807

Sex, Male 18(82%) 13(76%) Chi- square P = 0.682

Pre-hospital GCS ≤ 8

17(77%) 15(88) Chi- square P = 0.376

Pre-hospital SBP < 90

12(55%) 5(29%) Chi- square P = 0.117

ResultsTable 4 : A comparison of activated group with non-activated group in code M patients

24

Activate d(n = 22)

Non-activated (n = 17)

Statistic (95%CI)

Hospital LOS for dead patients

3.4 ± 4.9 2.3 ± 1.6 T-Test P = 0.584

Hospital LOS for survive patients

25.6 ± 21.7 29 ± 21 T-Test P = 0.805

Results Table 4 : A comparison of activated group with

non-activated group in code M patients

25

Activated (n = 22)

Non-activated (n = 17)

Statistic (95%CI)

Transferred OR from ER

10(45%) 3(18%) Chi- square P = 0.068

LOS in ER for transferred OR from ER (minutes) mean ± SD

139.5 ± 83.2 208 ± 27.5 T-Test P = 0.048

Results Table 4 : A comparison of activated group with non-activated group in code M patients

26

Activated(n = 22)

Non-activated (n = 17)

Statistic (95%CI)

Died in hospital 8 (36%) 12 (71%) Chi- square P = 0.034

ODD Ratio = 4.2

Totally died 15 (68%) 13 (76%) Chi- square P = 0.568

Code M activated patients (n=22)

•6 Pre-hospital CPR7 Died in ER

•1 died in OR•6 died in hospital•3 survived

10 Emergency OR

•4 OR later 4 survived•1 no operating died in hospital5 admit

27

Code M non-activated patients (n=17)

•1 Pre-hospital CPR1 Died in ER

•3 died in hospital3 Emergency OR

•2 OR later 1 survived, 1died in hospital•11 no operating 3survived, 8 died in hospital

13 admit28

Non-trauma 4 code

• Stroke Fast Tract• birth before admit(BBA)• CPR• MI Fast Tract

Stroke Fast Tract

• Stroke Warning Signs• Sudden weakness or numbness of the

face, arm, or leg, especially on one side of the body

• Sudden confusion• Trouble speaking or understanding• Sudden trouble seeing in one or both eyes• Sudden trouble walking, dizziness, loss of

balance or coordination • Sudden severe headache with no known

cause.

Goal

• Rapid recognition and reaction to stroke warning signs

• Rapid emergency medical services (EMS) dispatch

• Rapid EMS system transport and hospital pre-notification

• Rapid diagnosis and treatment in the hospital

Edward C. Jauch, et al ; Part 11: Adult Stroke; 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The “D’s of Stroke Care”Key points at which delays can

occur

• Detection• Dispatch• Delivery• Door

• Data• Decision• Drug• Disposition

Edward C. Jauch, et al ; Part 11: Adult Stroke; 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

1.Detection

• Rapid recognition of stroke symptoms• ก�จ็กรรมท��ท.าเม(�อุพบผู้��ป0วัย์ขอุงพย์าบาลก��ช้�พ• ถามิประว�ติ�ผู้�ป2วยท$#สู�าค�ญ อาการ ระยะเวลา ประว�ติ�โรคลมิช�ก

เบาหวาน การแพ�ยา อาหารทะเล• Stroke Fast Tract ใช�ในผู้�ป2วยท$#มิ$อาการเขั้�าไดุ�ติามิThe Cincinnati Phehospital Stroke Scale ในระยะเวลา ไม�เก�น 4.5 ช้ม.ประกอบไปดุ�วย– Facial Drop ปากเบ�/ย์วัข�างใดข�างหน&�ง– Arm Drift เม(�อุให�ผู้��ป0วัย์หล�บตาเหย์�ย์ดแขนตรงไปด�านหน�าแล�วัม�แขนข�างใดข�างหน&�งตก

– Abnormal Speech “ผู้��ป0วัย์ไม�ส่ามารถึพ�ด ย์าย์พาหลาน” ไปซื้(/อุขอุงท��ตลาด ได�จ็บประโย์ค

2.Dispatch

Early activation and dispatch

3.Delivery

• Rapid EMS identification, management, and transport

• Assess ABCDs ว�ดุสู�ญญาณช$พ( Evaluate baseline vital signs )Provide oxygen ว�ดุ O2 sat

• Establish IV access ( เป/ดุ IV 2 เสู�น เป0นHeparin lock ขั้�างท$#อ(อนแรง และให� 0.9%nss ขั้�างท$# strong )แ

ละ obtain Blood exam (DTX,CBC,PT,PTT,BS,BUN,Cr,Electrolyte,G/M)

• แจ็�ง CODE Stroke Fast Tract ท�� ER non trauma 02 – 5347147

4.DoorAppropriate triage to stroke center

5.DataRapid triage, evaluation, and management in ED

6.DecisionStroke expertise and therapy selection

7.DrugFibrinolytic therapy, intra-arterial strategies

8.DispositionRapid admission to stroke unit, critical-care unit