建设重症急诊医学学科群促进学科建设大发展——深圳市第二人民医院重症急救医学部运行经验与体会

深圳市第二人民医院2011年6月建立重症急救医学部,组成包括重症医学科、急诊科和院前科的急危重症诊治学科群.医学部为半开放式的内循环模式,以建立健全的危重病预警系统为导向,以危重病患者救治体系与监护体系为主导,以危重病患者医疗护理救治环节质量控制为重点,促进急诊医学、重症医学I临床医疗质量与安全水平提高.半年多实践表明,重症急救医学部通过灵活应用"危重病病情评价与预测系统"、组建快速抢救反应团队参与院内其他科室危重病患者抢救、强化将重症医学学科理念和技术方法应用于急诊等措施,大大提高了急危重症患者抢救的成功率,缩短抢救和住院时间.因为资源整合,危重病患者的抢救成功率明显提高;重症急救医学部内的医生和护士临床、科研等综合能力明显增强.我们的经验表明,重症急救医学部模式值得进一步推广实施.     

预见性护理在创伤患者急诊院前院内一体化救治中的应用效果

目的 探究预见性护理在创伤患者急诊院前院内一体化救治中的应用效果。方法 我院 2021 年 5 月到 2022 年 4 月收治的 60 例急诊创伤患者，依循单双数法分为对照组和观察组，每组各 30 例。对照组急诊院前院内一体化救治期间实施常规性护理， 观察组急诊院前院内一体化救治期间实施预见性护理。比较两组的急救时间、急救效果与护理满意度。结果 观察组休克缓解、 病情评估、辅助检查、急诊会诊、术前准备、有效救治时间均短于对照组（P<0.05）。观察组急救有效率（100.00％）高于对照 组（86.67％）（P<0.05）。观察组护理满意度大于对照组（P<0.05）。结论 创伤患者的急诊院前院内一体化救治中应用预见性护 理，可缩短急救时间，提高急救效果和满意度。     

“5环”急救生命链在急诊无名氏患者救治中的应用效果评价

[目的]针对“5环”急救生命链在急诊无名氏患者救治的应用展开研究与分析。[方法]选取2016年1-12月在我院急诊救治的无名氏患者94例设为观察组,对其实施“5环”急救生命链方式进行救治;2015年1-12月采用急诊常规救治方式的无名氏患者88例设为对照组。比较两组无名氏患者在急诊救治的时间、患者及家属的满意度、医疗费用追缴率方面的差异。[结果]观察组在急诊救治的时间低于对照组(P<0.05)观察组患者的患者及家属满意度明显高于对照组(P<0.05);观察组的费用追缴率明显高于对照组的(P<0.05)。[结论]“5环”急救生命链在急诊无名氏患者救治中的应用,缩短了患者救治时间,规范了部门之间的交接,提升了护理工作效率,提升了医院对欠费患者的费用管理,提高了患者及家属满意度。     

流程再造在急诊救治ST段抬高心肌梗死患者中的应用效果

目的探究标准化急救流程在救治ST段抬高心肌梗死(STEMI)中的应用效果。方法选择2016年7~12月使用一般急救流程救治ST段抬高心肌梗死患者为对照组,将2017年1~6月实施标准化急救流程救治ST段抬高心肌梗死患者为观察组,对实施标准化急救流程前后患者首次医疗接触到首次心电图时间医生对急诊护士抢救工作满意率进行比较。结果首次医疗接触到首次心电图时间由改善前(8.40±2.10)min,缩短为(3.62±1.41)min;医生对急诊护士抢救工作满意率由53.33%提高至82.98%,以上差异均有统计学意义(P0.05)。结论制定实施标准化急救流程,能提高STEMI患者的抢救效果,缩短患者在抢救室救治时间和首次医疗接触到首次心电图时间,优化抢救流程,提高医护间的配合。     

分层成组排班急救模式对急危重症患者救治效果的影响

目的：探讨分层成组排班急救模式与传统急救模式对急危重症患者的救治效果差异,寻求更有效的急救模式。方法选择我院急诊科2013年2月至2015年2月96例急危重症患者作为实验组,对患者实施分层成组排班急救模式救治;另选择我院急诊科2010年2月至2012年2月96例急危重症患者作为对照组,对患者实施传统急救救治。对两组研究对象的有效救治时间、救治效果、护理满意度、心理状态进行对比和分析。结果实验组患者有效救治总有效率为92.7%,护理满意率93.8%;对照组患者有效救治总有效率为83.3%,护理满意率79.2%,两组比较差异均具有统计学意义( P<0.05)。抢救后,实验组患者焦虑和抑郁评分均低于对照组,差异有统计学意义( P<0.05)。结论急危重症患者实施分层成组排班急救模式可以有利于提高救治效果,降低不良反应发生率,改善患者心理状态,提高护理满意度。     

危机管理联合无缝隙一体化急救护理在急诊车祸致颅脑损伤患者中的应用

目的 探讨危机管理联合无缝隙一体化急救护理在急诊车祸致颅脑损伤患者中的应用效果。方法 选取2021年3月-2023年3月我院门急诊收治的90例车祸致颅脑损伤患者,将2021年3月-2022年3月收治的患者45例作为对照组,实施无缝隙一体化急救护理;将2022年4月-2023年3月收治的患者45例作为研究组,在对照组的基础上实施危机管理。比较两组急救操作时间、抢救成功率、并发症发生率以及急救过程中不良事件发生率。结果 研究组病情明确时间、急诊室停留时间以及急诊至手术时间短于对照组(P<0.05)。研究组并发症发生率明显低于对照组(P<0.05)。研究组急救护理过程中不良事件发生率低于对照组(P<0.05)。结论 车祸致颅脑损伤患者实施危机管理联合无缝隙一体化急救护理,可提高救治效率,缩短急救时间,降低并发症发生率以及急救过程中不良事件发生率,可应用于临床。     

危机管理配合无缝隙一体化创伤急救护理模式在外伤急诊急救中的应用

目的:探讨危机管理配合无缝隙一体化创伤急救护理模式在外伤急诊急救中的应用效果。方法:选取2015年10月~2017年3月我院收治的外伤急诊急救患者625例,随机分为观察组313例和对照组312例,对照组患者实施无缝隙一体化创伤急救护理模式,观察组患者在对照组基础上联合危机管理,对比两组患者确诊时间、急诊至手术时间、急诊至病房时间、住院时间、并发症发生情况、抢救成功率及护理满意度。结果:观察组患者确诊时间、急诊至手术时间、急诊至病房时间及住院时间与对照组相比均明显较短(P<0.05)。观察组患者抢救成功率高于对照组(P<0.05),并发症发生率明显低于对照组(P<0.05)。观察组患者护理满意度明显高于对照组(P<0.05)。结论:危机管理配合无缝隙一体化创伤急救护理模式可有效缩短外伤急诊急救患者救治时间,提高抢救成功率,降低并发症发生率,且利于患者术后恢复与护患关系和谐。     

基于急诊检伤与急迫度分级量表标准下急诊分诊系统在急腹症患者中的应用

目的探讨基于急诊检伤与急迫度分级量表(TTAS)标准下急诊分诊系统在急腹症患者中的应用效果。方法以TTAS为基础制定急诊分诊标准及分诊信息系统,并应用于急腹症患者中,比较TTAS实施前(2017年6月～2018年5月)和实施后(2018年6月～2019年6月)患者病情评估时间、候诊时间、救治时间、确诊准确率、救治成功率及患者满意率。结果实施后患者病情评估时间、候诊时间、救治时间短于实施前(P0.05),确诊准确率、救治成功率及患者满意率高于实施前(P0.05)。结论 TTAS标准下急诊分诊系统的应用能有效缩短急腹症患者急诊分诊时间,提高患者分诊准确率及满意率。     

“数智一体化”急救模式在重症多发伤患者中的应用

目的 探讨“数智一体化”急救模式在重症多发伤(SMI)患者中的应用价值。方法 选择2020年1-12月收治的148例SMI患者作为对照组。选择我院急诊科2021年1-12月收治的144例SMI患者作为观察组,对照组采用常规急救模式,观察组采用“数智一体化”急救模式,比较2组患者的救治效果(急诊救治效率、急诊时间效能、急救成功率)。结果 观察组创伤救治团队到达时间、完成CT检查时间、完成B超检查时间、接受输血时间、抢救室滞留时间、急诊至手术时间、确诊时间、ICU住院时长较对照组患者明显缩短,差异有统计学意义(P<0.05)。观察组、对照组患者急救成功率分别为84.7%、74.3%,差异有统计学意义(P<0.05)。结论 “数智一体化”急救模式可以提高SMI患者的救治效率及急救成功率,创新急诊急救服务,实现院前院内无缝衔接,构建高效、快速、全覆盖的协同救治体系。     

急救物品箱在损伤控制性手术救治多发伤患者中的应用

目的：探究急救物品箱在手术救治多发伤患者中应用的效果。方法：对2013年6月-9月我院烧创伤手术室为31例多发伤患者实施手术控制性手术的效果进行评价 结果：平均物品准备时间缩短至6±2min,巡回护士平均外出手术间次数降至1±1次,多发伤患者致残率降至12.9%。结论：急救物品箱在损伤控制性手术救治多发伤患者的应用效果满意,提高了医患双方的满意度,值得推广应用。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.