특집_이중의

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1 Focused Issue of This Month Joong Eui Rhee, MD Department of Emergency Medicine, Seoul National University College of Medicine rheeje@snubh.org J Korean Med Assoc 2007; 50(8): Abstract The educational courses for trauma care are stratified into two classes. The first is the Advanced Trauma Life Support (ATLS) course, which is sponsored by the Committee on Trauma (COT) of the American College of Surgeons (ACS) and whose target learners are the surgeons who treat the victims of major trauma. The second is the (BTLS) course, which is sponsored by the American College of Emergency Physicians (ACEP) and whose target learners are the prehospital healthcare providers, the nurses in emergency rooms, and the emergency physicians who provide emergency care to the victims of major trauma in the accident scene or in the emergency room before the trauma surgeons. The Emergency Medical Service System (EMSS) of Korea is managing to do its work somewhat well when it functions in the medical emergency situations. However, when it encounters with major trauma patients, it can rarely keep the principles of trauma care, such as the Golden Hour and the rapid transportation to an appropriate trauma center directly due to its systemic failure. Therefore the Preventable Death Rate (PDR) of major trauma patients is presumed to be very high in Korea. To rebuild the EMSS of Korea into a new system suitable for major trauma, the Korean Healthcare Administrations should start to lead the legislation and the support for trauma centers and trauma experts. The spread of the educational courses for trauma care into the emergency medical societies can be a starting point to solve the problem. The BTLS course is one of them. Keywords : ATLS; BTLS; Major trauma; Trauma care provider; Prehospital care 663

2 Rhee JE ATLS Target audience=surgeons in hospitals and trauma centers BTLS Target audience=prehospital care providers and nurses & physicians in ER Scene Sizeup 1. Body substances isolation precautions 2. Scene safety evaluation 3. Initial triage (total numbers of victims & types and severity of the injuries) 4. Requirements of essential equipment/additional resources 5. Mechanism of injury Primary Survey A: Establish airway with Cspine immobilization B: Establish breathing with high concentration O 2 supplementation C: Establish circulation with control of external bleeding D: Disability & deformity E: Exposure & environmental control Initial Assessment 1. General impression of the patient 2. Level of consciousness 3. A: Establish airway with Cspine immobilization 4. B: Establish breathing with high concentration O 2 supplementation 5. C: Establish circulation with control of external bleeding Rapid Trauma Survey or Focused Examination D: Headneckchestabdomenpelvisthigh E: Exposure & environmental control Secondary Survey Headtotoes examination in detail Detailed history Special tests: Xrays, blood labs Detailed Examination Headtotoes exam. in detail SAMPLE history & detailed history Dressing & splinting Reassessment & Monitoring Repeat exam of injuries found & monitor the patient Monitor the treatments done & their effects Ongoing Examination Repeat exam of injuries found & monitor the patient Monitor the treatments done & their effects Figure 1. Comparison between advanced trauma life support and basic trauma life support. 664

3 Figure 2. Golden hour and Platinum 10 minutes. 665

4 Rhee JE Scene Sizeup 1. Body substance isolation precautions 2. Scene safety 3. Initial triage 4. Essential equipment/needed resources 5. Mechanism of injury Have you put on required PPE? Is the scene safe and accessible? How many patients? & How severely injured? What kind of equipment/additional resources are needed? What is the mechanism of injury? How dangerous is it? Before approaching the patient Initial Assessment 1. General appearance of the patient 2. Level of consciousness (AVPU) 3. Airway with Cspine immobilization 4. Breathing with high concentration O 2 5. Circulation with bleeding control Within 15 sec Should he/she be transported immediately? Is resuscitation required? Is there any consciousness change or ABC abnormalities? If the mechanism of injury is blunt trauma, If the mechanism of injury is penetrating trauma, Rapid Trauma Survey Head/neck/chest/abdomen/pelvis/thigh Search only lifethreatening injuries Focused Examination Directly impacted area & related area Anatomical location & depth/angle of enetration Within 2 min Should he/she be transported immediately? Is resuscitation required? Is there major bleeding? Ongoing Examination Monitor LOC/ABC change. Exam head/neck/chest/abdomen/pelvis/thigh. Monitor the injury found. Monitor the effects of the treatment given. Detailed Examination Headtotoes in detail Splint injured limb. Apply dressing on wounds. Do it only after the patient is stabilized. During transportation Figure 3. Basic trauma life support steps of assessment and care for trauma patients. 666

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7 Table 1. The mechanisms of injury Blunt injury a. Abrupt horizontal deceleration: Automobile collisions b. Abrupt vertical deceleration: Falls c. Impacted by blunt objects: Baseball bat, club 2. Penetrating injury a. Missiles: bullet, shell splinter b. Stabbing: knife, awl c. Impaling: iron rod, stake 669

8 Rhee JE Table 2. Level of consciousness (AVPU) A Alert (fully conscious and oriented) V Responds to Verbal stimuli (conscious but confused, or unconscious but responsive to verbal stimuli in some way) P Responds to Pain (unconscious but responsive to painful stimuli in some way) U Unresponsive (without gag reflex or cough reflex) 670

9 Table 3. Normal and abnormal respiration rate 671

10 Rhee JE Table 4. SAMPLE history S Symptoms (the patient's complaints, such as local pain, dyspnea, etc.) A Allergies (any known hypersensitivity to drugs or food) M Medications (drugs such as antihypertensive/hypoglycemic/ corticosteroid agents) P Past medical history/pregnancy (known disability or sequelae, menstruation) L Last oral intake (types of recent food, when? & how much amount?) E Events preceding the incident (mechanism of injury, situation just before the accident) 672

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17 11. Pruitt BA, Pruitt JH, Davis JH. History In: Moore EE, Feliciano DV, Mattox KL, eds. Trauma 5th ed. New York: McGrawHill, 2004: American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors: Student Course Manual 7th ed. Chicago: The American College of Surgeons, 2004: Campbell JE. for Advanved Providers 5th ed. Bloomington: Pearson Education, Hoyt DB, Coimbra R, Potenza BM. Trauma systems, Triage, and Transport In: Moore EE, Feliciano DV, Mattox KL, eds. Trauma 5th ed. New York: McGrawHill, 2004: Korea Institute for Health and Social Affairs. Estimation of loss of income from external causes of mortality: Health and Welfare Forum, 2002, Vol 65. Peer Reviewer Commentary 679

975_983 특집-한규철, 정원호

975_983 특집-한규철, 정원호 Focused Issue of This Month Gyu Cheol an, MD Department of Otolaryngology ead & Neck Surgery, Gachon University of College Medicine E - mail : han@gilhospital.com Won-o Jung, MD Department of Otolaryngology