现代院前急救体系的构建

充分分析目前中国的院前急救体系，剖析中国院前急救的现状及需求，构建出具有中山特色的院前急救体系。通过中国经济发达地区中、小城市院前急救体系的构建，完善EMSS体系，着重加强院前急救的救治能力和水平．从而促进了整体急救水平的提高。     

CBRN considerations in a major incident

Chemical, biological, radiological and nuclear (CBRN) hazards may be encountered during any major incident. General considerations include modifications to triage, managing contaminated or contagious casualties, and the identification and appropriate management of intoxicated/infected/irradiated/injured casualties. In dealing with chemical incidents, characteristics such as toxicity, latency and persistency need to be understood in order to manage casualties appropriately in terms of triage category, life-saving interventions and assessment of contamination risk to responders. Biological agents can be differentiated into live agents (bacteria, viruses and fungi) and toxins. Live agent characteristics and management depend on pathogenicity, virulence, lethality, infectivity and transmissibility, whereas toxins are treated similarly to chemical agents. Radiological and nuclear hazards are managed similarly and may cause irradiation, contamination (external and internal) or a combination with or without trauma. A generic and structured approach is advised to deal with all major incidents including those with a suspected of confirmed CBRN hazard. All healthcare professionals that may be involved in the response to such an incident need to be familiar with the principles of CBRN incident management and of CBRN casualty management as described in this article.     

严重创伤院前急救中值得探讨的几个问题

院前急救是严重创伤救治链中非常重要的一环,也是创伤救治体系"三环理论"中的一个基本环节,是我国急救医疗服务体系中的重要组成部分,是提高严重创伤救治成功率、降低死亡率的根本保证。目前国内院前急救的模式还不统一,存在较多争议,但创伤院前急救的"快、准、稳"是院前急救工作者永远追求的目标。通过回顾文献、结合临床工作经历,就创伤院前急救中涉及的几个问题做一初步探讨,供同仁参考。     

做好严重创伤早期救治的几个关键环节

做好严重创伤早期救治的各个环节对提高创伤救治的整体水平具有非常重要的意义。应尽量缩短院前时间,做好院前急救的各项措施;充分发挥绿色通道的作用;处理好检诊和早期手术的关系;掌握多发伤的伤情特点和救治程序,做好多专业的合作;救治过程中优先处理危及生命的损伤;合理应用损害控制技术。     

Pre-hospital and hospital time delays in thrombolytic treatment in patients with suspected acute myocardial infarction: Analysis of data from the EMIP study

OBJECTIVES: To compare the components of the time delay involved in pre-hospitaland hospital thrombolytic therapy in patients presenting withsuspected acute myocardial infarction. MATERIAL AND METHODS: From October 1988 to January 1992 a total of 198 mobile emergencyunits in 15 European countries and Canada randomized 5469 patientsto receive either pre-hospital thrombolytic treatment, followedby placebo in hospital (pre-hospital group), or pre-hospitalplacebo, followed by thrombolytic treatment in hospital (hospitalgroup) in the European Myocardial Infarction Project trial.We performed a post hoc analysis of these data to correlatecomponents of the interval between symptom onset and treatmentwith baseline patient characteristics. RESULTS: The delay between onset of symptoms and calling for an ambulancewas significantly longer for female patients (P0·0001),older patients (>65 years old; P=0·0001), those whohad experienced pain within the previous 24 h (P=0·0001),and those with pulmonary oedema (P=0·04). This delaywas significantly shorter in patients with previous myocardialinfarction (P=0·02), those with ventricular fibrillation(P=0·0001), and those in shock (P0·0001). Thedelay between the two injections was significantly longer forolder patients (>65 years old; P=0·02), those withprevious myocardial infarction (P=0·03), and those inshock (P=0·003). CONCLUSIONS: Action undertaken to reduce delays between symptom onset andtreatment should focus on modifiable factors such as patientswho are likely to be late callers, i.e. women and those over65 years of age.     

Data quality of a wearable vital signs monitor in the pre-hospital and emergency departments for enhancing prediction of needs for life-saving interventions in trauma patients

Abstract

This study was designed to investigate the quality of data in the pre-hospital and emergency departments when using a wearable vital signs monitor and examine the efficacy of a combined model of standard vital signs and respective data quality indices (DQIs) for predicting the need for life-saving interventions (LSIs) in trauma patients. It was hypothesised that prediction of needs for LSIs in trauma patients is associated with data quality. Also, a model utilizing vital signs and DQIs to predict the needs for LSIs would be able to outperform models using vital signs alone. Data from 104 pre-hospital trauma patients transported by helicopter were analysed, including means and standard deviations of continuous vital signs, related DQIs and Glasgow coma scale (GCS) scores for LSI and non-LSI patient groups. DQIs involved percentages of valid measurements and mean deviation ratios. Various multivariate logistic regression models for predicting LSI needs were also obtained and compared through receiver-operating characteristic (ROC) curves. Demographics of patients were not statistically different between LSI and non-LSI patient groups. In addition, ROC curves demonstrated better prediction of LSI needs in patients using heart rate and DQIs (area under the curve [AUC] of 0.86) than using heart rate alone (AUC of 0.73). Likewise, ROC curves demonstrated better prediction using heart rate, total GCS score and DQIs (AUC of 0.99) than using heart rate and total GCS score (AUC of 0.92). AUCs were statistically different (p?<?0.05). This study showed that data quality could be used in addition to continuous vital signs for predicting the need for LSIs in trauma patients. Importantly, trauma systems should incorporate processes to regulate data quality of physiologic data in the pre-hospital and emergency departments. By doing so, data quality could be improved and lead to better prediction of needs for LSIs in trauma patients.     

张力性气胸野战救护装置的研制及其实验效果

目的设计制作张力性气胸（tension pneumothorax，TPT）野战救护装置并验证其对张力性气胸的救治效果。方法自行设计并制备张力性气胸野战救护装置，以犬为实验动物，将32只犬随机分为4组，每组8只，采用改进的Rutherford的张力性气胸动物模型制作方法制作张力性气胸动物模型，第1组不给予任何干预措施，第2组采取穿刺减压法，第3组采用胸腔闭式引流装置，第4组采用新装置治疗张力性气胸，在干预前及干预后0．5、1、3、6hN定指标：4-dp／dtmax、-dp／dtmax、LVSP、LVEDP、MAP、HR、RR、pH、PaO2、PaCO2、SaO2。结果模型制备成功后6h，第1组动物存活率为75％，其余3组存活率为100％。第2组的操作时间少于与第3、4组，第4组的操作时间少于第3组，差异均有统计学意义（P＜0．01）。干预后6h，第3组与第2组相比，除MAP、pH、PaCO2外，其余指标均与第2组比较，差异均有统计学意义（P＜0．05）；第4组与第2组相比，除HR、MAP、pH、PaCO2外，其余指标均与第2组比较，差异均有统计学意义（P＜0．05）。结论张力性气胸野战救护装置治疗张力性气胸的效果和临床常用的胸腔闭式引流装置无差别，且携带方便、操作简单、可用于自救互救、适合在野战复杂的环境及平时的院前急救中使用。     

The 60 Minutes Myocardial Infarction Project: Treatment and clinical outcome of patients with acute myocardial infarction in Germany

AIMS: To describe patient characteristics, pre-hospital delay, treatment,complications and outcome in patients with acute myocardialinfarction admitted to hospitals in Germany. METHODS AND RESULTS: The study was of prospective observational multicentre design.Those involved were consecutive patients with acute Q-wave myocardialinfarction admitted within 96 h of onset of symptoms to 136German hospitals between July 1992 and September 1994 (n=14980,median age 66 (quartiles 57, 74) years, 68% male, 48% anteriorwall infarction). Median pre-hospital delay was 170 (90, 475)min, with 17% arriving within the first hour and 61% within4 h of onset of symptoms. The following patient groups had ashort pre-hospital delay: males, those aged less than 65 years,those admitted at night or the weekend, those with a previousmyocardial infarction, those in need of cardiopulmonary resuscitation,and those with a diagnostic first ECG. The first ECG was diagnosticin 67·6% of cases. Reperfusion therapy was used in 53%,with thrombolytic therapy in 51·6%. Median time fromadmission to initiation of treatment was 30 (20, 55) min. Respectiverates of treatment with aspirin, nitrates, and beta-blockerswere 81%, 83% and 16%. Major complications were cerebral bleeding(0·4%), bleeding requiring transfusions (0·9%),left ventricular rupture (0·6%) and anaphylactic shock(0·1%). Median hospital stay was 20 (13, 26) days. In-hospitaldeath rate was 17·2%. Increased hospital mortality wasobserved with female gender, an unknown or long pre-hospitaldelay, a diagnostic first ECG, anterior wall infarction, traumaor major operation within the last 14 days, renal insufficiencyand malignoma. CONCLUSIONS: ‘Real-life’ hospital mortality is much higher thanpreviously reported in clinical trials. To reduce hospital mortality,the efficacy of thrombolysis should be increased by shorteningthe pre-hospital delay, and the use of concomitant therapy,especially beta-blockers, should be increased.     

加强军队中小医院院前应急救治能力建设探讨

针对新形势下军事任务多样化、复杂化,保障体系战线“长、小、散、远”等特点,以及需要进行快速应急救治的实际情况,探讨了军队中小医院结合自身特点,采取平战结合,军地急救体系合作,“训保合一”,研制、引进、应用先进的可组装、轻便的多功能战勤装备等措施,建立形成快速、高效、便捷的院前应急救治保障网络系统,大力推进应急战备、应急救援能力建设,提高了军队中小医院院前应急救治卫勤保障能力.