大规模伤亡事件救治中超声的应用策略

目的探讨大规模伤亡事件救治中超声的应用策略。方法回顾性分析我院在汶川大地震发生后地震伤员救治中的超声应用策略。结果医院共接诊地震伤员3307人,震后15分钟即开始超声检查,共计1386人次,超声介入诊治占8．30％（115／1386）,应用便携式超声仪检查占75．4％（1045／1386）,震后初期检查全部采用便携式超声,检查地点以室外为主,方法主要采用“创伤重点超声评估法”。超声筛查出浆膜腔积血（液）、外伤性动静脉瘘、深静脉血栓、肢体软组织深部血肿等创伤性病变,床旁超声监测了多名重症患者（如挤压综合症患者浆膜腔积液变化及肾脏体积和血流灌注改变）。创伤相关病变的超声阳性检出率为6．96％,没有发现假阳性,假阴性率为0．45％。结论科学的超声应用策略可在伤员的救治中发挥重要作用。本次大规模伤亡事件救治中超声应用策略可归纳为快速反应,广泛应用,检查地点灵活,以便携式超声为主要设备以及恰当的超声检查方法。     

腹部创伤院前急救

腹部创伤发生概率高,及时正确的院前救治对于提高救治成功率、减少并发症有重要意义。腹部创伤院前救治涉及快速准确评估、恰当的院前治疗、及时后送、特殊人群的院前救治等。伤情评估需注意评估顺序、评估方法,关注影响评估准确性的因素。治疗注意损害控制性复苏、主动脉球囊阻断等技术的灵活运用。院前救治应特别关注饮酒、吸食毒品、心脏骤停等特殊情况的正确识别和及时处置。     

超声造影在血管损伤中的应用

随着医学成像技术的发展,超声造影(CEUS)已被广泛应用于超声心动图、颈动脉狭窄和颈动脉斑块的评估、腹主动脉瘤腔内隔绝术(EVAR)术后内漏的评估、主动脉夹层的诊断、活动性出血的检测、外周动脉疾病的血流灌注评估等领域。其中,CEUS在血管创伤的早期诊断和治疗中发挥了重要作用。本文将对CEUS在血管创伤中的应用及研究进展进行综述,主要包括CEUS技术的原理、在血管创伤中的应用、相关研究进展以及未来研究方向。     

TRISS在创伤救治质量评估中的应用及其研究进展

ＴＲＩＳＳ在创伤救治质量评估中的应用及其研究进展朱佩芳近二十余年来创伤救治研究的一个重要方面即病人结局的评估或预测［１］．以往曾应用创伤计分（ＴＳ）和创伤严重度计分（ＩＳＳ）预测病人结局［２］，但敏感性和特异性均不理想．由此，提出了ＴＲＩＳＳ法以评估...     

关注超声在胸腹部创伤救治中的价值

超声成像是医学发展史上具有重要里程碑意义的技术,在临床医学中的价值日益突出.超声检查具有快捷、准确、无创、无辐射、适用范围广等优点,可以在床旁反复进行,对危重症的救治具有重要意义.超声应用于创伤的最早报告见于1971年,Kristensen等成功地诊断1例腹腔积血.1976年Asher 等应用超声诊断脾脏外伤,并对损伤的程度进行分级.从20世纪80年代开始出现越来越多的应用研究,最初主要是针对腹部钝性伤,也就是针对腹部伤的超声检查(focused abdominal sonography for trauma,FAST)检查[1].近年来国内外大量的研究提示,超声在创伤中的应用有了很多的更新,需引起国内创伤医师的重视.     

腹腔镜在腹部创伤中的应用

腹部创伤的诊治手段正在不断地更新发展,微创技术的运用为腹部创伤的诊治带来了革命性的变化.随着微创外科技术的不断进步,诊断性和治疗性腹腔镜在腹部创伤救治中的作用日益重要.本文从腹腔镜在腹部创伤救治中应用现状、应用价值、适应证、禁忌证、相关并发症及诊治腹部创伤面临的挑战等方面进行探讨,指出严格筛选腹部创伤患者使用腹腔镜技术...     

严重腹部交通伤患者院前集束化急救策略研究

重度交通伤患者中多达20%的患者被诊断有严重腹部创伤，并且有高达20%的病死率。严重出血是导致死亡的主要原因，但随着医疗技术及设备的发展，目前腹部创伤引起的出血被认为是潜在的可预防性死亡。本研究以“战伤救治理念体系”为依据，集合了包括创伤重点超声评估、腹腔内止血复苏、院前输血等一系列有循证基础的诊疗干预措施，制定院前集束化救治策略，更好地指导严重腹部交通创伤患者的院前急诊救治，以期望延长其有效救治时间窗，为后续的院内治疗创造条件，并且提高患者在院内手术时的耐受力，从而降低创伤患者的病死率。     

胸部创伤评分研究进展

胸部创伤占创伤总数的10%~15%,在创伤导致的死亡中,约25%是由胸部创伤所引起。规范、准确的创伤严重程度评估是患者得到有效救治的基础,应用胸部创伤专科评分评估创伤严重程度对预测患者的并发症和预后、制订临床决策和优化治疗方案均有重要意义。胸部创伤评分类型多样,功能特点各有不同,进行伤情评估时应依据致伤机制、损伤部位及...     

创伤重点超声评估法（FAST）在“5．12”汶川大地震早期伤员筛查中的运用

目的总结“5．12”汶川大地震救治早期我院超声急诊筛查伤员腹部损伤情况,探讨创伤重点超声评估法（FAST）在地震救治早期的运用价值。方法震后初期（72小时内）共有587人接受了腹部超声检查,均采用创伤重点超声评估法。结果有16例伤员超声提示创伤性腹腔积液,后均经急诊手术证实;其中6例伤员超声提示了内脏损伤部位,4例超声定位正确,2例与术中探查损伤部位不符。FAST检查经证实的假阴性5例,术前及治疗中均无大量腹腔积液。结论运用便携式超声FAST具有便捷性、无环境限制、不需移动伤员、可与急救或专科检查同步进行等优点,且对于需紧急手术的腹部闭合损伤患者敏感性为100％,是震后早期最为重要的腹部闭合性损伤的筛查方法;但其不能作为腹部损伤的最终检查。     

创伤超声重点评估在胸腹部创伤急救中的应用

从20世纪70年代超声应用于腹部创伤诊断开始,超声检查在创伤急救领域得到不断应用和发展,并在此基础上提出了创伤超声重点评估(focused assessment with sonography for trauma,FAST)的概念。本文主要综述近年来关于FAST在胸腹部创伤评估方面的应用现状,以促进FAST在我国的应用普及与发展。     

超声在猪心肺复苏后肺损伤评估中的应用价值

目的探讨超声在猪心肺复苏后肺损伤动态评估中的应用价值。方法国产健康雄性猪10头,体质量(35.9±2.4)kg,随机数字法表分为假手术组、心肺复苏组各5头。假手术组仅常规麻醉和气管插管,心肺复苏组在常规麻醉和气管插管后经历心脏骤停与复苏,于复苏前和复苏后1、3、6、12h应用肺超声评分(LUS)评估肺损伤情况,同时进行血气分析监测氧合指数(PaO2/FiO2),脉搏指示连续派血量法测定血管外肺水指数(EVLWI)和肺毛细血管通透性指数(PVPI)。采用重复方差分析各指标的动态变化,分析LUS与PaO2/FiO2、EVLWI、PVPI的相关性。结果两组动物的基本参数具有可比性。假手术组各指标的动态变化差异无统计学意义。心肺复苏组的PaO2/FiO2变化差异无统计学意义,但在复苏后1、3和6h均低于相应时点的假手术组。EVLWI和PVPI在复苏后持续升高(F=17.96、27.70,P<0.001),EVLWI从基线的(9.7±1.3)mL/kg升高到12h的(21.0±5.5)mL/kg,PVPI从(2.3±0.7)mL/kg升到(6.1±0.5)mL/kg,且均高于假手术组同时点的相应值。复苏组的LUS也持续升高(F=34.2,P<0.001),基线和复苏后1、3、6、12h分别为(2.6±0.5)、(13.4±0.9)、(15.0±1.9)、(15.8±0.8)和(17.6±4.0)分,均高于假手术组同时点的值。相关性分析显示,LUS与PaO2/FiO2呈负相关(r=-0.625,P<0.001),与EVLWI、PVPI正相关(r=0.790、0.882,P<0.001)。结论在猪心肺复苏模型中,肺超声评分与传统肺损伤指标的相关性较好,可以实时、连续无创地评估复苏后肺损伤的程度,值得进一步的临床应用研究。     

创伤影像学评估的手段与策略

创伤是当今世界面临的重大卫生问题。优化创伤患者早期评估的流程,缩短受伤至确定性治疗的时间至关重要。影像学检查作为重要的诊断手段,在创伤患者早期评估中发挥了关键作用,为确定性治疗提供依据。本文介绍了创伤影像学检查常用手段的优缺点和价值,包括X线片、CT、介入放射学、MRI、超声,并探讨了放射安全问题,为临床进一步优化创伤影像学评估的策略提供参考。     

内皮祖细胞治疗脑创伤的研究进展

内皮祖细胞(endothelial progenitor cells,EPCs)可促进创伤性脑损伤患者损伤区血管新生,并保护神经元的再生。近年来,外源性EPCs移植、动员内源性EPCs以及运用EPCs等治疗方法在创伤性脑损伤大鼠的实验研究中证实有很好的疗效,并表明EPCs的水平与脑创伤的恢复程度和预后密切相关。为了详细阐明最新相关研究,笔者就EPCs治疗创伤性脑损伤的作用机制、治疗策略、临床应用、预后作一综述。     

Status and problems of postgraduate training of medical staff of Disaster Medicine Service

An analysis of the postgraduate training of doctors of Disaster Medicine Service in the central and local training bases in the federal districts of Russian Federation in 2010 is performed. It was concluded that the existing Department of Emergency Medicine and mobilization training and health education can not reach those who need further training. It was proposed to create on the basis of a FSI VTSMK "Protection" Institute of Emergency Medicine to improve the training of doctors, training and methodological support of teaching and training of the teaching staff.     

Development of a clinical forensic medicine curriculum for emergency physicians in the USA

To address the forensic needs of living patients, the Department of Emergency Medicine at the University of Louisville School of Medicine in Louisville, Kentucky, USA initiated the first clinical forensic medicine training programme in the USA. In July 1991, formal training in clinical forensic medicine was incorporated into the core curriculum of the USA's second oldest academic emergency medicine training programme. The University of Louisville, in cooperation with the Kentucky Medical Examiner's Office, developed the curriculum to provide the emergency physician with the knowledge base and technical skills to perform forensic evaluations of living patients. Forensic lectures are given monthly by local and regional forensic experts including: forensic pathologists, prosecuting attorneys, firearm and ballistics examiners, law enforcement officers, forensic chemists and forensic odontologists. Topics which are presented include: forensic pathology, forensic photography, ballistics and firearms analysis, paediatric physical and sexual assault, crime scene investigation, forensic odontology, courtroom and expert testimony and the forensic evaluation of penetrating trauma. As a result of the introduction of clinical forensic medicine into the core curriculum of an emergency medicine training programme the residents are now actively addressing the forensic issues encountered in the Emergency department. Key, often short-lived forensic evidence, which was frequently overlooked or discarded while delivering patient care is now recognized, documented and preserved. The development and introduction of a clinical forensic medicine curriculum into emergency medicine training has greatly enhanced the emergency physician's ability to recognize, document and address the forensic needs of their patients who are victims of violent and non-fatal trauma.     

不稳定骨盆骨折急救的新进展

骨盆骨折是常见的损伤,仅次于四肢和脊柱骨折,并发症较多,有较高的病死率。高能损伤所致骨盆骨折逐年增多,且复杂而严重,临床处理困难。既往多采取非手术治疗,如骨牵引、骨盆悬吊、石膏固定等方法,但病死率高达5%～20%,致残率为1. 9%～36. 6%。随着对骨盆骨折认识的深入,近年来主张对不稳定性骨盆骨折,采取更加积极的治疗,早期评估、损害控制复苏、血管造影栓塞等新理念降低了病死率和致残率。     

Radiation disaster response: preparation and simulation experience at an academic medical center

OBJECTIVES: A mass casualty disaster drill involving the simulated explosion of a radiation dispersal device (dirty bomb) was performed with the participation of multiple hospitals, emergency responders, and governmental agencies. The exercise was designed to stress trauma service capacities, communications, safety, and logistic functions. We report our experience and critique of the planning, training, and execution of the exercise, with special attention to the integrated response of the Departments of Nuclear Medicine, Health Physics, and Emergency Medicine. METHODS: The Health Physics Department presented multiple training sessions to the Emergency Medicine Department, Operating Room, and ancillary staff; reviewing basics of radiation biology and risk, protection standards, and detection of radiocontamination. Competency-based simulations using Geiger-Müller detectors and sealed sources were performed. Two nuclear medicine technologists played an important role in radiation discrimination-that is, assessment of radioactive contamination with survey meters and radionuclide identification based on gamma-spectroscopy of wipe smears from patients' clothing, skin, and orifices. Three Health Physics personnel and one senior Nuclear Medicine staff member were designated the radiation control officers for assigned teams triaging or treating patients. Patients were triaged and, when indicated, decontaminated. RESULTS: Within a 2-h period, 21 simulated victims arrived at our institution's Emergency Room. Of these, 11 were randomized as noncontaminated, with 10 as contaminated. Decontamination procedures were implemented in a hazardous materials (HAZMAT) decontamination trailer and, for the 5 patients with simulated serious injuries, in a designated trauma room. A full debriefing took place at the conclusion of the exercise. Staff largely complied with appropriate radiation protection protocols, although decontamination areas were not effectively controlled. The encountered limitations included significant lapses in communications and logistics, lack of coordination in the flow of patients through the HAZMAT trailer, insufficient staff to treat acute patients in a radiation control area, additional personnel needed for transport, and insufficient radiation safety personnel to control each decontamination room. CONCLUSION: Nuclear Medicine personnel are particularly well qualified to assist Health Physics and Emergency Medicine personnel in the preparation for, and management of, mass casualty radiation emergencies. Simulation exercises, though resource intensive, are essential to an institution's determination of response capability, performance, and coordination with outside agencies.     

Embolization of transected vertebral arteries in unstable trauma patients

The aim of this paper is to report our experience with coil embolization for the treatment of vertebral artery transection in unstable trauma patients. The course of four patients admitted to our units between 1998 and 2003 with traumatic injuries of the upper thorax or neck is described. All had unstable hemodynamic parameters at presentation. Emergent arteriogram revealed vertebral artery transection, which was managed by immediate coil embolization proximal to the injury site. Initial technical success was achieved in all four patients, with hemodynamic improvement. No further treatment or surgery to control the vessel injury was needed. There were no immediate or late complications of the procedure and no neurological sequelae. Emergency coil embolization is an effective endovascular technique for use in unstable patients with angiography findings of a transected vertebral artery.All the authors are affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.     

慢性伤口细菌生物膜临床和实验诊断的研究进展

细菌生物膜被证实与慢性伤口的持续性感染有关,本文就慢性伤口细菌生物膜的概念及分布、临床特点及识别要点、临床诊断标准、实验室识别方法作一综述。旨在帮助伤口专业人员早期识别及诊断生物膜感染伤口,为尽早实施针对性干预措施提供依据。     

“Concordance” Revisited: A Multispecialty Appraisal of “Concordant” Preliminary Abdominopelvic CT Reports

PurposeTo determine whether resident abdominopelvic CT reports considered prospectively concordant with the final interpretation are also considered concordant by other blinded specialists and abdominal radiologists.MethodsIn this institutional review board–approved retrospective cohort study, 119 randomly selected urgent abdominopelvic CT examinations with a resident preliminary report deemed prospectively “concordant” by the signing faculty were identified. Nine blinded specialists from Emergency Medicine, Internal Medicine, and Abdominal Radiology reviewed the preliminary and final reports and scored the preliminary report with respect to urgent findings as follows: 1.) concordant; 2.) discordant with minor differences; 3.) discordant with major differences that do not alter patient management; or 4.) discordant with major differences that do alter patient management. Predicted management resulting from scores of 4 was recorded. Consensus was defined as majority agreement within a specialty. Consensus major discrepancy rates (ie, scores 3 or 4) were compared to the original major discrepancy rate of 0% (0/119) using the McNemar test.ResultsConsensus scores of 4 were assigned in 18% (21/119, P < .001, Emergency Medicine), 5% (6/119, P = .03, Internal Medicine), and 13% (16/119, P < .001, Abdominal Radiology) of examinations. Consensus scores of 3 or 4 were assigned in 31% (37/119, P < .001, Emergency Medicine), 14% (17/119, P < .001, Internal Medicine), and 18% (22/119, P < .001, Abdominal Radiology). Predicted management alterations included hospital status (0-4%), medical therapy (1%-4%), imaging (1%-10%), subspecialty consultation (3%-13%), nonsurgical procedure (3%), operation (1%-3%), and other (0-3%).ConclusionsThe historical low major discrepancy rate for urgent findings between resident and faculty radiologists is likely underreported.