陈宇
兰州大学第二医院重症医学科，主治医师
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Major trauma: assessment and initial Management
NICE guideline
nice.org.uk/guidance/ng39
严重创伤是指会引起全身反应和导致严重功能障碍的创伤。极大的威胁着人类的生命安全。严重创伤后有3个死亡高峰，即：
1.即刻死亡，指在严重创伤瞬间死亡，约占50%；
2.早期死亡，是指创伤后数分钟或数小时死亡，约在30%；
3.晚期死亡，是指严重创伤后数天或数周死亡，约在20%。
严重创伤的原因主要为交通事故，约占60%-70%，致伤因子能量巨大，暴力形式多为机械性损害，发生瞬间常同时或相继造成数次损伤。各部位创伤发生率以头部、四肢多见，其次为胸部、腹部，以冲撞伤、挤压伤、坠落伤、压砸伤为主，而爆炸伤、切割伤、刺扎伤、绞榨伤少见；平均留医时间长，经济费用高。基于此，NICE于2016年发布严重创伤的评估和初始管理指南，指南从10个方面详细论述了关于严重创伤的早期评估以及初始管理。
1.1 Immediate destination after injury
创伤后的首个救治场所
1.1.1
Be aware that the optimal destination for patients with major trauma is usually a major trauma centre.
首先需要意识到，发生严重创伤的患者，最佳的救治场所是创伤中心。
1.2 Airway management in pre-hospital and hospital settings
院前以及院内的气道管理
1.2.1
Use drug-assisted rapid sequence induction (RSI) of anaesthesia and intubation as the definitive method of securing the airway in patients with major trauma who cannot maintain their airway and/or ventilation.
对于不能自我保护气道或通气的严重创伤患者，药物快速诱导麻醉与插管是保护气道的确定方法。
1.2.2
If RSI fails, use basic airway manoeuvres and adjuncts and/or a supraglottic device until a surgical airway or assisted tracheal placement is performed.
如果RSI失败，应首先采用基础气道策略和/或声门上装置，直到通过外科建立气道或气道内辅助装置成功放置。
Airway management in pre-hospital settings
院前的气道管理
1.2.3
Aim to perform RSI as soon as possible and within 45 minutes of the initial call to the emergency services, preferably at the scene of the incident.
在最初联系急诊的45分钟内即开始实施RSI，而且最好是在事故现场。
If RSI cannot be performed at the scene:
如果现场无法实施RSI
consider using a supraglottic device if the patient's airway reflexes are absent
如果患者气道反射消失，则考虑使用声门上装置。
use basic airway manoeuvres and adjuncts if the patient's airway reflexes are present or supraglottic device placement is not possible
若患者气道反射存在或无法获取声门上装置，则使用基础气道策略。
transport the patient to a major trauma centre for RSI provided the journey time is 60 minutes or less
转运患者至严重创伤中心的路程小于60min，则转运达到后实施RSI。
only divert to a trauma unit for RSI before onward transfer if a patent airway cannot be maintained or the journey time to a major trauma centre is more than 60 minutes.
如果转运途中患者气道无法维持或到达严重创伤中心的时间大于60min，则转运至创伤中心即可，处理后再决定进一步转运。
1.3 Management of chest trauma in pre-hospital settings
胸部创伤的院前管理
1.3.1
Use clinical assessment to diagnose pneumothorax for the purpose of triage or intervention.
应用相关临床评估方法诊断气胸，以便于引流或其他干预措施的实施。
1.3.2
Consider using eFAST (extended focused assessment with sonography for trauma) to augment clinical assessment only if a specialist team equipped with ultrasound is immediately available and onward transfer will not be delayed.
如果有专业的超声专业小组，则使用eFAST来增加临床评估的准确性，但不能因此而耽误转运。
1.3.3
Be aware that a negative eFAST of the chest does not exclude a pneumothorax.
需要注意的是，即使胸部eFAST阴性也不能完全排除气胸。
1.3.4
Only perform chest decompression in a patient with suspected tension pneumothorax if there is haemodynamic instability or severe respiratory compromise.
对于血流动力学不稳定或已经出现严重的呼吸功能损害的疑似张力性气胸患者，需行胸腔减压术。
1.3.5
Use open thoracostomy instead of needle decompression if the expertise is available, followed by a chest drain via the thoracostomy in patients who are breathing spontaneously.
若有专业人员在场，则行胸膜腔穿刺术，而非针头减压，同时对于有自主呼吸的患者，需放置胸腔引流管。
1.3.6
Observe patients after chest decompression for signs of recurrence of the tension pneumothorax.
胸腔穿刺术后，应严密观察是否存在复发性张力性气胸体征。
1.3.7
In patients with an open pneumothorax: cover the open pneumothorax with a simple occlusive dressing and observe for the development of a tension pneumothorax.
对于开放性气胸患者，使用单纯包扎闭合开放性伤口，密切观察是否发生张力性气胸。
1.4 Management of chest trauma in hospital settings
胸部创伤的院内管理
Chest decompression of tension pneumothorax
张力性气胸的引流
1.4.1
In patients with tension pneumothorax, perform chest decompression before imaging only if they have either haemodynamic instability or severe respiratory compromise.
对于张力性气胸的患者，若患者出现血流动力学不稳定或已经出现严重的呼吸功能损害，不应等待相关影像学结果，而应立即行胸腔减压术。
1.4.2
Perform chest decompression using open thoracostomy followed by a chest drain in patients with tension pneumothorax.
对于张力性气胸的患者，实施胸膜腔穿刺引流术。
Imaging to assess chest trauma
影像学评估胸部创伤
1.4.3
Imaging for chest trauma in patients with suspected chest trauma should be performed urgently, and the images should be interpreted immediately by a healthcare professional with training and skills in this area.
使用影像学评估可疑胸部创伤患者应尽快进行，且应立即由相关专家阅片。
1.4.4
Consider immediate chest X-ray and/or eFAST (extended focused assessment with sonography for trauma) as part of the primary survey to assess chest trauma in adults (16 or over) with severe respiratory compromise.
对于严重呼吸功能损害的患者，应将胸部X线片和/或eFAST作为成年人（大于等于16岁）胸部创伤的初步评估手段。
1.4.5
Consider immediate CT for adults (16 or over) with suspected chest trauma without severe respiratory compromise who are responding to resuscitation or whose haemodynamic status is normal.
对于没有严重呼吸功能损害或血流动力学稳定的可疑胸部创伤成人患者（大于等于16岁）则考虑行胸部CT检查。
1.4.6
Consider chest X-ray and/or ultrasound for first-line imaging to assess chest trauma in children (under 16s).
儿童则选用胸部X线片和/或超声检查作为首选影像学检查来评估胸部创伤。
1.4.7
Do not routinely use CT for first-line imaging to assess chest trauma in children (under 16s).
不常规使用CT检查作为首选来评估儿童胸部创伤患者。
1.5 Management of haemorrhage in pre-hospital and hospital settings
院前及院内出血的管理
Dressings and tourniquets in pre-hospital and hospital settings
敷料及止血带的应用
1.5.1
Use simple dressings with direct pressure to control external haemorrhage.
使用敷料直接压迫出血部位，控制外出血。
1.5.2
In patients with major limb trauma use a tourniquet if direct pressure has failed to control life-threatening haemorrhage.
四肢创伤患者，如敷料直接压迫未能控制威胁生命的出血，则需要使用止血带。
Pelvic binders in pre-hospital settings
关于院前使用骨盆粘合剂
1.5.3
If bleeding is suspected from a pelvic fracture after blunt high-energy trauma: apply a purpose-made pelvic binder or consider an improvised pelvic binder, but only if a purpose-made binder does not fit.
如果怀疑活动性出血是由于钝性暴力创伤导致骨盆骨折引起，则使用特制的骨盆粘合剂，但是若特制的粘合剂不合适，则可选用简易的粘合剂。
Haemostatic agents in pre-hospital and hospital settings
止血药的应用
1.5.4
Use intravenous tranexamic acid as soon as possible in patients with major trauma and or suspected active bleeding.
对于活动性出血或疑似活动性出血的严重创伤患者，尽早使用静脉氨甲环酸。
1.5.5
Do not use intravenous tranexamic acid more than 3 hours after injury in patients with major trauma unless there is evidence of hyperfibrinolysis.
除非有证据表明患者存在纤溶亢进，否则对于严重创伤患者，受伤时间超过3hr以上者，禁用氨甲环酸。
Anticoagulant reversal in hospital settings
抗凝作用的逆转
1.5.6
Rapidly reverse anticoagulation in patients who have major trauma with haemorrhage.
对于存在出血的严重创伤患者应快速逆转抗凝作用。
1.5.7
Hospital trusts that admit patients with major trauma should have a protocol for the rapid identification of patients who are taking anticoagulants and the reversal of anticoagulation agents.
收治严重创伤患者的医疗机构，应该有一套快速识别患者是否正在服用抗凝药物的流程，而且一旦识别，应立即逆转抗凝作用。
1.5.8
Use prothrombin complex concentrate immediately in adults (16 or over) with major trauma who have active bleeding and need emergency reversal of a vitamin K antagonist.
对于合并活动性出血和需要紧急逆转维生素K拮抗剂的严重创伤成年患者（大于等于16岁），应立即使用凝血酶原复合物（PCC）
1.5.9
Do not use plasma to reverse a vitamin K antagonist in patients with major trauma.
对于严重创伤患者，不要用血浆去逆转维生素K拮抗剂
1.5.10
Consult a haematologist immediately for advice on adults (16 or over) who have active bleeding and need reversal of any anticoagulant agent other than a vitamin K antagonist.
除了逆转维生素K拮抗剂以外，逆转其他抗凝物质或合并活动性出血的严重创伤成人患者（大于等于16岁），均应请血液病学专家会诊。
1.5.11
Consult a haematologist immediately for advice on children (under 16s) with major trauma who have active bleeding and may need reversal of any anticoagulant agent.
逆转任何抗凝物质或合并活动性出血的严重创伤儿童患者（小于16岁），均应请血液病学专家会诊。
1.5.12
Do not reverse anticoagulation in patients who do not have active or suspected bleeding.
对于无活动性或可疑出血出血的患者，无需逆转抗凝作用。
Activating major haemorrhage protocols in hospital settings
启动严重出血处理流程
1.5.13
Use physiological criteria that include the patient's haemodynamic status and their response to immediate volume resuscitation to activate the major haemorrhage protocol.
使用生理学指标，包括患者的血流动力学状态以及对于最初液体复苏的反应来决定是否启动严重出血处理流程。
1.5.14
Do not rely on a haemorrhagic risk tool applied at a single time point to determine the need for major haemorrhage protocol activation.
不要根据某个单一时间点的出血风险评估工具来决定是否启动严重出血处理流程。
Circulatory access in pre-hospital settings
院前循环状态评估
1.5.15
For circulatory access in patients with major trauma in pre-hospital settings:
院前对于严重创伤患者的循环状态评估：
use peripheral intravenous access or
通过外周静脉评估
if peripheral intravenous access fails, consider intra-osseous access.
若外周静脉无法评估，则考虑通过骨髓腔内评估
1.5.16
For circulatory access in children (under 16s) with major trauma, consider intra-osseous access as first-line access if peripheral access is anticipated to be difficult.
针对严重创伤儿童患者（小于16岁）的循环状态评估，如预计通过外周静脉评估存在困难，则将骨髓腔内评估作为首选。
1.5.17
For circulatory access in patients with major trauma in hospital settings:
院内对于严重创伤患者的循环状态评估：
use peripheral intravenous access or
通过外周静脉评估
if peripheral intravenous access fails, consider intra-osseous access while central access is being achieved.
若外周静脉无法评估，若已完成中心静脉评估后，则考虑通过骨髓腔内评估。
Volume resuscitation in pre-hospital and hospital settings
院前及院内容量复苏
1.5.18
For patients with active bleeding use a restrictive approach to volume resuscitation until definitive early control of bleeding has been achieved.
对于活动性出血的患者，采取限制性补液策略，直到出血已明确被控制。
1.5.19
In pre-hospital settings, titrate volume resuscitation to maintain a palpable central pulse (carotid or femoral).
院前，采取滴定式的容量复苏来维持可触及的脉搏（颈动脉或股动脉）。
1.5.20
In hospital settings, move rapidly to haemorrhage control, titrating volume resuscitation to maintain central circulation until control is achieved.
院内，首先快速的控制出血，滴定式的容量复苏维持循环，直到出血被控制。
1.5.21
For patients who have haemorrhagic shock and a traumatic brain injury:
对于合并失血性休克和颅脑损伤的患者
if haemorrhagic shock is the dominant condition, continue restrictive volume resuscitation or
如果失血性休克是首要情况，则继续限制性容量复苏
if traumatic brain injury is the dominant condition, use a less restrictive volume resuscitation approach to maintain cerebral perfusion.
如果颅脑损伤是首要情况，为了维持脑灌注压，则需适当放开限制性容量复苏。
Fluid replacement in pre-hospital and hospital settings
院前及院内的补液
1.5.22
In pre-hospital settings only use crystalloids to replace fluid volume in patients with active bleeding if blood components are not available.
院前急救时，如无获得成分血的条件，则仅使用晶体液进行补液。
1.5.23
In hospital settings do not use crystalloids for patients with active bleeding.
院内急救时，对于合并活动性出血的患者，不使用晶体液补液。
1.5.24
For adults (16 or over) use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.
对于成人患者（大于等于16岁），按照血浆：红细胞=1：1的比例进行补液。
1.5.25
For children (under 16s) use a ratio of 1 part plasma to 1 part red blood cells, and base the volume on the child's weight.
对于儿童患者（小于16岁），按照血浆：红细胞=1：1的比例进行补液。同时依据儿童体重调整容量。
Haemorrhage protocols in hospital settings
院内出血处理流程
1.5.26
Hospital trusts should have specific major haemorrhage protocols for adults (16 or over) and children (under 16s).
医院应该有具体的针对于成年以及儿童严重出血的处理流程。
1.5.27
For patients with active bleeding, start with a fixed-ratio protocol for blood components and change to a protocol guided by laboratory coagulation results at the earliest opportunity.
对于活动性出血的患者，首先予以固定比率的成分输血，然后尽快根据出凝血实验结果调整方案。
Haemorrhage imaging in hospital settings
出血患者应如何安排影像学检查
1.5.28
Imaging for haemhorrhage in patients with suspected haemorrhage should be performed urgently, and the images should be interpreted immediately by a healthcare professional with training and skills in this area.
怀疑出血的患者，应紧急行相关影像学检查，且尽快请相关影像学专家阅片。
1.5.29
Limit diagnostic imaging (such as chest and pelvis X-rays or FAST [focused assessment with sonography for trauma]) to the minimum needed to direct intervention in patients with suspected haemorrhage and haemodynamic instability who are not responding to volume resuscitation.
对于怀疑出血和对容量复苏无效的血流动力学不稳定患者，应限制相关诊断影像学检查（如：胸部、骨盆X线片或FAST筛查），而需采取直接干预。
1.5.30
Be aware that a negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage.
要意识到，FAST筛查阴性，不能排除腹腔内出血或腹膜后出血。
1.5.31
Consider immediate CT for patients with suspected haemorrhage if they are responding to resuscitation or if their haemodynamic status is normal.
对于容量复苏有效或血流动力学稳定的疑似出血患者，考虑直接予以CT检查。
1.5.32
Do not use FAST or other diagnostic imaging before immediate CT in patients with major trauma.
严重创伤患者在行CT检查前，无需行FAST或其他诊断性影像学检查。
1.5.33
Do not use FAST as a screening modality to determine the need for CT in patients with major trauma.
无需使用FAST筛查来决定严重创伤患者是否需要CT检查。
Whole-body CT of multiple injuries
多发伤的全身CT检查
1.5.34
Use whole-body CT (consisting of a vertex-to-toes scanogram followed by a CT from vertex to mid-thigh) in adults (16 or over) with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole-body CT.
对于钝性严重创伤和疑似多发伤成年患者采用全是CT检查。在检查中，无需复位。
1.5.35
Use clinical findings and the scanogram to direct CT of the limbs in adults (16 or over) with limb trauma.
根据相关临床表现以及CT检查来确诊成人四肢创伤。
1.5.36
Do not routinely use whole-body CT to image children (under 16s). Use clinical judgement to limit CT to the body areas where assessment is needed.
儿童患者不常规使用全身CT检查。通过临床判断来限定需要评估的位置。
Damage control surgery
损伤控制手术
1.5.37
Use damage control surgery in patients with haemodynamic instability who are not responding to volume resuscitation.
对于容量复苏无效的血流动力学不稳定患者实施损伤控制手术。
1.5.38
Consider definitive surgery in patients with haemodynamic instability who are responding to volume resuscitation.
对于容量复苏有效的血流动力学不稳定患者考虑实施确诊手术。
1.5.39
Use definitive surgery in patients whose haemodynamic status is normal.
对于血流动力学正常的患者实施确诊手术。
Interventional radiology
介入放射学
1.5.40
Use interventional radiology techniques in patients with active arterial pelvic haemorrhage unless immediate open surgery is needed to control bleeding from other injuries.
对于活动性骨盆相关动脉出血，实施介入治疗，除非需要直接的开放手术来控制其他损伤导致的出血。
1.5.41
Consider interventional radiology techniques in patients with solid-organ (spleen, liver or kidney) arterial haemorrhage.
对于实质器官（脾脏、肝脏或肾脏）动脉出血，考虑实施介入治疗。
1.5.42
Consider a joint interventional radiology and surgery strategy for arterial haemorrhage that extends to surgically inaccessible regions.
对于外科手术难以操作部位的动脉出血，考虑联合介入与手术治疗策略。
1.5.43
Use an endovascular stent graft in patients with blunt thoracic aortic injury.
对于胸主动脉损伤，使用人工支架型血管。
（未完，接下条）
（本文已经过作者授权，如需转载请注明“来源：重症医学平台”。谢谢合作！）
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