伤情评估和战场伤员分类(江)VIP

伤情评估和战场伤员分类 江雷卫生勤务学教研室 Masscasualties Anylargenumberofcasualtiesproducedinarelativelyshortperiodoftime usuallyastheresultofasingleincidentsuchasamilitaryaircraftaccident hurricane flood earthquake orarmedattack thatexceedslocallogisticalsupportcapabilities Thetermmasscasualtiesmeansthatalargenumberofcasualtieshasbeenproducedsimultaneouslyorwithinarelativelyshortperiodoftime Italsomeansthatthenumberofpatientsrequiringmedicalcareexceedsthemedicalcapabilitytoprovidetreatmentinatimelymanner Anabsolutedisparityexistsbetweenthenumberofpatients theavailablemedicalresourcesandtimelytreatment Masscasualtysituation Amasscasualtysituationispresentwhenonecombatmedicisconfrontedwithtwocriticallyinjuredpatientsatthesametime Withalargenumberofcasualties thedisparitymaybemultipliedmanytimes thisgreatlydisruptsthedoctrinalapproachtotreatmentandevacuation Inadditiontothetreatmentandevacuationofalargenumberofmilitaryandciviliancasualties problemsmayoccurfromdisruptionsinthesupply communication andtransportationsystems 在包扎所内最重要的是伤员优先分类 然后对所有伤员合理配置医疗救护工作 比起仓促慌忙上手术好得多 后者仅只能救活不多的伤员 俄 皮洛果夫 N A 叶菲缅科主编 涂通今主译 野战外科学 P5 人民军医出版社 2005年10月 什么是伤情评估 伤情评估是指在战场上运用简明的应急诊断技术 迅速地对伤员情况进行初步判断 进而以量化标准来判定伤员损伤的严重程度 从而指导战场伤员分类救治 预测战伤结局以及评估救治质量 一 伤情评估方法 院前评分院内救治和创伤研究评分 伤情损伤程度治愈时间预后比例轻伤软组织伤30天内良好40 中等伤广泛软组织伤 60天内部分伤员机能35 上肢骨折 一般脏器伤障碍 影响归队重伤伤情严重 60天以上严重残废25 有生命危险或后遗症 伤势分度与百分比 院前指数 Pre hospitalindex PHI 轻伤 0 3分重伤 4 20分 CRAMS评分法 轻度 9 10分 重度 7 8分 极重度 0 6分 创伤计分 Traumascore 1 16分 12分为重伤 GlasgowComaScale GCS 校正的创伤积分 RevisedTraumaScore RTS 简易战伤评分方法 伤员伤势评估及处置顺序 二 战场伤员分类 Triageofmasscasualties Theevaluationandclassificationofcasualtiesforpurposesoftreatmentandevacuation Itconsistsoftheimmediatesortingofpatientsaccordingtotypeandseriousnessofinjury andlikelihoodofsurvival andtheestablishmentofpriorityfortreatmentandevacuationtoassuremedicalcareofthegreatestbenefittothelargestnumber HistoryThewordtriageisaFrenchwordmeaning sorting whichitselfhasbeeninfluencedfromtheLatintria three Thetermhashistoricallymeantsortingintothreecategories althoughthisisnolongernecessarilythecase MuchofthecreditformoderndaytriagehasbeenattributedtoDominiqueJeanLarrey afamousFrenchsurgeoninNapoleon sarmywhodevisedamethodtoquicklyevaluateandcategorizethewoundedinbattleandthenevacuatethoserequiringthemosturgentmedicalattention Heinstitutedthesepracticeswhilebattlewasinprogressandtriagedpatientswithnoregardtorank OthershavecitedtheRussiansurgeon NikolaiPirogov asdevelopingthetriagesystemduringtheCrimeanWar Triageisaccomplishedbyhighlyexperiencedmedicalpersonnelwhocanmakesoundandquickclinicaljudgments Medicalpersonnelidentifyeachpatientbyacategorytitlewhichindicatestheurgencyofhisreceivingtreatmentandlikelihoodofhissurvivalbasedupontheclinicalproblemsandavailabilityofmedicalcare Rapidtriageassuresthattheavailabletreatmentisdirectedtothepatientswhohavethebestchancetosurvive 分类的意义 战场伤病员分类是实施战场伤病员救护管理的一个重要环节 战时伤员数量大 伤病种类复杂 救治时间紧迫 救治力量有限 由此产生了救治需要与可能之间的矛盾 重伤病员与轻伤病员之间 部分伤病员与全体伤病员之间救治的矛盾 为解决这些矛盾 就必须对伤病员进行分类 通过分类将有限卫勤力量首先用到需挽救生命的危急伤员上 分类的目的 分类的目的在于保证每个伤病员得到及时合理的救治和后送 保证在伤病员众多的条件下 做好救治工作 使救治工作有条不紊地进行 充分发挥卫勤人力物力作用 促进医疗后送工作的多快好省 区分伤病的轻重缓急 确定救治和后送的先后次序 根据伤类 伤情 确定伤员救治措施 确定伤员后送体位和工具 以保证各种伤员得到最合理的处置 分类的方法 伤部伤类伤型伤情 急救优先等级 紧急处置 重伤优先处置 中度伤常规处置 轻伤期待处置 危重伤 Treatmentcategories Psystems P1 ImmediateTreatmentP2 DelayedTreatmentP3 MinimalTreatmentP1Hold ExpectantTreatment priority Immediate Thiscategoryisforthepatientwhoseconditiondemandsimmediate resuscitativetreatment Anexampleofthistreatmentisthecontrolofhemorrhagefromanextremity Generally theproceduresusedareshortindurationandeconomicalintermsofmedicalresources Approximately20percentofthecasualtiesarenormallyinthiscategory Delayed Thiscategoryisforthepatientwhoseconditionissuchthat withtheapplicationofmodestemergencyprocedures thepossibilityofdiseaseordeathincreasesverylittlebydelayingmajordefinitiveproceduresuntiltheycanbeperformed Anexampleofthisemergencyprocedurewouldbeanadequatelysplintedclosedfracture Approximately20percentofthecasualtiesarenormallyinthiscategory Minimal Thiscategoryisforthepatientwhocanbereturnedtosomeformofdutybyperformingproceduresrequiringminimalresources Followuptreatmentmaybeneededafterthedisparityphaseisterminated Approximately40percentofthecasualtiesareinthiscategoryandmostareambulatory Expectant Thiscategoryisforthepatientwhoseinjuriesaremassiveandtheprobabilityofhissurvivalisquestionable Examplesofpatientsinthiscategoryarethosewithsevereheadinjuriesormassivesevereburns Providingthegreatestgoodforthegreatestnumberduringtheperiodofmedicaldisparitydictatesthataminimalnumberofmedicalpersonnelmanagethiscategoryofpatients Patientsshouldbemanagedwithalertness expectancy tochangesintheircondition Theyshouldbegivensymptomaticandsupportivecareuntiltheavailablemedicalresourcespermitanintensiveeffortintheirbehalf Approximately20percentofthecasualtiesarenormallyinthiscategory TheT Treatment systemoftriage isanalternativetothePsystemandisroutinelyusedbytheRN theRAF NATOallies theInternationalCommitteeoftheRedCross civilianambulanceservicesandinciviliandisasterprograms Therelationshipbetweenthetwosystemsisasfollows P1isequivalenttoT1P2isequivalenttoT2P3isequivalenttoT3P1HoldisequivalenttoT4DeadisstillDead Triagefortreatment Asimple safe rapidandreproduciblesystemisrequiredthatcanbeappliedbyanyServicemanwithappropriatemedicaltraining Physiologicalsystemsthatlookattheconsequencesofinjury achangeintheVitalSigns RespiratoryRate PulseRateandCapillaryRefillTime CRT aremorereliablethananatomicalsystems whichrequireextensiveclinicalknowledgeandaneedtoundressthecasualty TriageSieve Simpletriageandrapidtreatment START triagealgorithm Triageisonlya snapshot ofhowthecasualtyisatthetimeofassessment Inordertoidentifychangesinthecasualty scondition thetriagesievemustberepeatedateachlinkoftheevacuationchain Itisimportantinitiallynottotrytopredicthowacasualtymaydeteriorate thiswillleadtoover triage ahigherthannecessarytriagecategory andcanoverwhelmthesystemwithP1andP2casualties Triagefortreatment Limitedtimeandpersonnelresourcesmayprohibitamoredetailedtriageassessmentotherthanthatgivenbythetriagesieve Whenpossible theTriageSortcanbeusedtorefinethetriagesievedecisions Triagesortusestherespiratoryrate systolicbloodpressureandGlasgowComaScale tonumericallyscorethecasualtyfrom0to12andgiveanindicationofpriorityforevacuationand ortheneedforfurtherintervention Thisscorehasaprovendirectrelationshiptooutcomefromsevereinjury Prioritiesareassignedas Theoverlapinscoresallowsfortheseriouslyinjuredtobeplacedineithercategory dependingonnumberofcasualtiesandresourcesavailableofevacuation Evacuationwillbedelayedwhenthenumberofcasualtiesoutstripsavailabletransport Inthissituation thegreatertimespentwiththecasualtywillallowadditionalanatomicalassessmentofinjuries Wheretheprimarydeterminedbyphysiologydoesnotmatchtheanatomicalseverityofinjuries theprioritycanbeupgraded Example Asoldierloseshisleftleginalandmineincident Immediatefirstaidiseffectiveinstoppinghemorrhage Heistransportedtothedivisionaidstation Hecannotwalk hisrespiratoryrateis22andhispulseis110 minute Heistriaged fortreatment TriageSieve Hethenreceivesintravenousfluidsandanalgesia HissystolicBPis115mmHg hisrespiratoryrateis20 heisfullyalert withaGCSof15 Hescores12onhisTriageSort whichisP3forevacuation Clearly herequiresearlysurgicaltreatmentandthesurgeonupgradeshisprioritytoP2forevacuationtothefieldhospital Chinesetriage woundmarker Signofsorting advancedtriagesystems Inadvancedtriagesystems secondarytriageistypicallyimplementedbyparamedics battlefieldmedicalpersonnel orbyskillednursesintheemergencydepartmentsofhospitalsduringdisasters injuredpeoplearesortedintofivecategories Blue ExpectantTheyaresoseverelyinjuredthattheywilldieoftheirinjuries possiblyinhoursordays large bodyburns severetrauma lethalradiationdose orinlife threateningmedicalcrisisthattheyareunlikelytosurvivegiventhecareavailable cardiacarrest septicshock theyshouldbetakentoaholdingare