Med J Chin PLA, Vol. 42, No. 12, December 1, 2017 ǂ1029
䃲eڝeᠳࢃ̺ ӵϔߙᡇϊҍᣴ໓͌ܠᣴ̹ࢴҝᣱ
͙ࡧጴࡻцᕑ䃶ܲц ᕑࡧ႒̿͆ༀцۇ͙Ϧℽ㼏ᩪ 䛹⫳ࡧ႒̿͆ༀцۇ͙Ϧℽ㼏ᩪ ͙ࡧጴࡻцᕑ䃶ܲцᕑ䃶โ̿͆ༀц
喞ᕑٷ䩚䃹]Ȟ݇ѐ喞㵬ᕓнڟ] [͙పܲㆧण]ȞR605.97ȞȞȞȞ[᪳⡚ᴳᔃⴭ]ȞAȞȞȞȞ[᪳「㑂ण]Ȟ0577-7402(2017)12-1029-10 [DOI]Ȟ10.11855/j.issn.0577-7402.2017.12.02
Chinese emergency medicine expert consensus on diagnosis and treatment of traumatic hemorrhagic shock Emergency Medicine Branch of Chinese Medical Doctor Association People’s Liberation Army Professional Committee of Emergency Medicine People’s Liberation Army Professional Committee of Critical Care Medicine Professional Committee of Emergency Surgery, Emergency Medicine Branch of Chinese Medical Doctor Association
1ȞẮȞȞ䔜
㏒10%⤯ڔѐ᭛ᠳᱦᷜ߇҈⩔κϦѿऺᝬ䕌⮰ᱦѿ㏿ᲰႸ᪠ᕓ⮰ⵠ౻সߋ㘩䯈ⶹȠᢚWHO㐋䃍喏݇ 40ᆭБ̷Ϧ㓐⮰仂㺭₧ఌ[1]Ƞ⤯ڔ⮰₧ύস16%⮰㜠₷⫱ҷఌ݇ѐᝬ㜠喏सᬢ݇ѐ᭛ ᄽȟ㏰㏳╸∔̹䋟ȟ㏲㘊Џ䅎㈶Νসۻ᭛ᠳ݇ѐ䕌ᱦѿ๓䛻㵬ᝬ㜠ᰵᩴᓖ⣛㵬䛻ٷѐ㵬ᕓн݇ ፤፤ऴᎢѺ㵬ࢷ(͵ͦᩢ㑕ࢷ┯90mmHg喏㘵ࢷ┯20mmHg喏ᝂ࣋ᰵ倄㵬ٷஔჄߋ㘩ःᢋ⮰⫱⤲⩋⤲䓳⼷Ƞн ࢷ㔱ᩢ㑕ࢷ㜖ദ㏫̷䭹Ĺ40mmHg)Ƞ30%~40%⮰݇ѐᗏ㔱₧ύ᭛ఌ㵬䓳ๆᝬ㜠喏ₐㆧᗏ㔱͙喏ᰵ̬䘔ܲ ఌͦ䩅䄛⮰⇧ᵴࣶ̹ᖜᑿ⮰⇧⫃ᣖ㔸₧ύ喏ࢌ10%~20%Ƞᕑᕓ㵬᭛݇ѐ仂㺭⮰छ䶰䭞ᕓ₧ఌ[2-3]Ƞ ᄽๆஔჄߋ㘩䯈ⶹ㐨ऴᒭۻ䛹㺭喏छᰵᩴڟᄥκ͑䛹݇ѐᗏ㔱㜟ٷ㵬喏㏌㵬ᕓнܦࣶᬢȟᔗ䕋ᣓݢ (multiple organ dysfunction syndrome喏MODS)⮰ࣽ⩋喏䭹Ѻ₧ύ⢳Ƞ ⮰ᕑ䃶ٷ䃲ᬔ㻰㠯স倄݇ѐ㵬ᕓнڝᠳࢃȠ᱘ڟᕑ⇧⮰Ⱔ㉓ٷⰚݹᅆᬌ݇ѐ㵬ᕓн ⇧喏ͦᕑ䃶ࡧጴӇ䃶⫃ӉᢚȠ
⤲⩋⤲⫱⮰ٷ2Ȟ݇ѐ㵬ᕓн
᭛㵬ქ䛻̺㵬ネქ⼛⮰̹ࡥ䙹喏䕌โঔ㏰㏳╸∔̹䋟喏Ϻ㔸ᑁٴ⮰⫱⤲⩋⤲ऄࡂ仂ٷѐ㵬ᕓн݇ 㘻ஔჄ⮰㐓ࣽᕓᢋჟȠڱ㵬䯈ⶹБࣶ܉䊣ᓚᓖ⣛ऄࡂȟ⅓Џ䅎ߔ߇႒ᐮ፤ȟ►⫳ࣹᏀȟ ᭛䛹㺭㘻ڢᰬᵥ᱘⮰⫱⤲⩋⤲ᩥऄ᭛㵬ᝬ㜠⮰ᓚᓖ⣛ߋ㘩䯈ⶹ喏ᅐٷ2.1Ȟᓚᓖ⣛ऄࡂȞ݇ѐ㵬ᕓн ၼὍᐻ(damage associatedܲڟϓ⩋ᢋѐⰤٷஔᓚᓖ⣛ᩥऄȠᄨ㜠ᓚᓖ⣛ߋ㘩䯈ⶹ⮰ͧ㺭ᱦݢ࠱᠘喝Ŗн Ꮐむࣶᣓᕓ►⫳ࣹᏀ喏ᑁ䊣㵬⫗ٹ㯷⮩স倄䓭⼧⢳㯷⮩1㼒ࣽٷmolecular patterns喏DAMP)[4-5]喏ຮ☙н 㵬㈧܉⯚ᢋѐᑁ䊣ڱᄽ喏ᰬ㏴ᄨ㜠㏰㏳╸∔̹䋟ȟ㏲㘊㑦⅓喞ŗۻ⯚ᢋѐȟℇ㏲㵬ネ⍃ȟᓖ⣛ქ䛻ڱネ 㐋⓬≧ȟᓚ㵬ᴿᒎ喏䭧ඊℇ㏲㵬ネࣶ㵬ネ㜾㑕ߋ㘩䯈ⶹ喏ߌ䛹㏰㏳㑦㵬㑦⅓喞Ř݇ѐᝬ㜠⮰ᠭ㐙ȟᑦ◴ ᓚᓖ⣛䯈ⶹȠޓߋ㘩喏ᄨ㜠ࣹᄰᕓ㵬ネ㜾㑕ߋ㘩㈶Ν喏ߌ⇸ܲڱ⮰ݦ⓬ᒝ৹⺊㏻
⅓̺(ᗏ㔱ႄ⅓Џ䅎ߔ߇႒ᐮ፤喏࢟⅓ӇᏀ(DO2ٷ2.2Ȟ⅓Џߔ߇႒ᐮ፤ࣶ㏲㘊Џ䅎ᩥऄȞ݇ѐ㵬ᕓн
ᗏ㔱⌣ऴ䲅㘵㵬⅓亝সᏒ(SvO2)⮰䭹Ѻࣹᭌβ⅓䒿䔭̺⅓⊴㕃⮰̹ٷ㕃(VO2)⮰̹㶍Ƞ݇ѐ㵬ᕓн⊵
[䕆䃛҈㔱]Ȟ݄ᬺࡺ喏E-mail喝[email protected]喞䊡͈喏E-mail喝[email protected]喞κ႒ᔌ喏E-mail喝[email protected] ࡧ႒ᱮᔃȞ2017Ꭰ12ᰴ1ᬑȞじ42ࢣȞじ12ۇ1030Ȟ 㼏ᩪ
㶍喏㔸㵬Ο䚤ࡳ倄݅䬠ᣑࣹᭌβᱦѿᓚᓖ⣛Ѻ⅓ࣶ㏰㏳㏲㘊㑦⅓⟢ᔭȠₐᗱ̷ۡ喏㏲㘊㘩䛻Џ䅎(ຮ ㈂ȟ㘮ȟ㯷⮩)ϒцܦ⣜ᬺ᭪ᐮ፤Ƞ ࣹ⫳►⣜ܦᬕ喏㜠ѐఌၼ⮰ݦ⓬̷喏ᱦѿᅬ䘔छٷ㵬䯈ⶹȞ݇ѐ㵬ᕓн܉2.3Ȟ݇ѐᕓ►⫳ࣹᏀ̺ ᏀȠᢋჟ⮰㏰㏳ȟஔჄȟ㏲㘊̹स喏►⫳Ϸ䉔⮰䉔স䛻ᰵ̹स喏㶔⣜ͦᅬ䘔㵬ネ䕆䔻ᕓ්ߌ喏㵬≲ܲ โ⍃喏⮩㏲㘊ࣶ䊷ࡂఌၼ㖆䯲κѐะБॊস⌱䮐㜠⫱㣸ᝂᐮ➕Ƞ䔮ᑿ⮰►⫳ࣹᏀ̬⼷Ꮢ̶ݕκ݇ѐ Ԛู喏Ѳ䓳Ꮢ►⫳ࣹᏀцᄨ㜠►ᕓϷ䉔⮰๓䛻䛶ᩪ喏र㏲㘊ఌၼ̺㏲㘊㶔䲎ԍणܲၼ㏿ऴऺ喏䄝ᄨ㏲㘊 㵬ߋ㘩䯈ⶹ[6](ప1)Ƞ܉ࣽ⩋̬㈧݃⩋➕ࡂ႒ऄࡂ喏ᑁࣽᣓᕓ►⫳ࣹᏀ̺㏰㏳ᢋჟ喏⩆㜟䕌ڱ
Pre-existing factors Age Genetics Co-morbidities Pre-medication
Trauma
Tissue damage
Cytokine and hormone release Blood loss
Inflammation Fibrinolytic protein Clotting factors depletion activation Shock
Hemostasis, Hypoxia Resuscitation Endothelial cell activation
Acidosis Crystalloid solution Erythrocyte transfusion
Hypothermia Dilutional coagulopathy
Traumatic coagulopathy
㵬ߋ㘩䯈ⶹ⮰ࣽ⩋ᱦݢ܉ప1Ȟ݇ѐᄨ㜠 Fig.1ȞMechanism of coagulopathy caused by trauma
䏗►⫳ࣹᏀ㐨ऴᒭ(systemic inflammatory responseڔ፤ᄨ㜠ٷ㘻ஔჄ⮰㐓ࣽᕓᢋჟȞ݇ѐ㵬ᕓнڱ2.4Ȟ κMODS⮰ࣽ⩋ᱦݢᰵБ̷ڟsyndrome喏SIRS)⮰ࣽ⩋喏䔅᭛䔇̬ₑ䕌MODS⮰䛹㺭⫱⤲⩋⤲ദȠⰚݹ ูࣶ㟻ᑁ䊣⮰㏰㏳ஔჄᓚᓖٷᢋѐ喝݇ѐ㵬ᕓн∔╸ڹ-ճ䄠[7]喝Ŗ݇ѐऺᣓᕓ►⫳ࣹᏀ喞ŗ㑦㵬܌ 喏ᄨ㜠ᓚᓖ⣛䯈ⶹ喏ຮ̹ࣶᬢᖎูᰵٷ䓳⼷喏᭛MODSࣽ⩋⮰ദ᱘⣛㞮喏͑䛹݇ѐᑁࣽн∔╸ڹ㑦㵬স⣛ छᑁ䊣㗯㗌ٷMODSᝂ₧ύ[8]喞Ř㗯㗌䕿ᅻ䯈ߋ㘩ᢋჟࣶ㏲㣸⼧ѹ喝݇ѐ㵬ᕓн⣜ܦᩴ㵬ქ䛻喏ᄲछ㘩 ㉌স㏲㣸⼧ѹ喏ᑁࣽ㘿⫳[9]喞řദఌๆᔭᕓ喝ڱ叻㛈㑦㵬喏ᄨ㜠㗌䕿叻㛈ᅻ䯈⮰ⵠ౻喏㐓㔸ࣽ⩋㗌䕿 喏ຮ̺Ϧㆧ⮩㏲㘊ៃ࣋(HLA)-DRȟ⮩㏲㘊Ϸ㉌(IL)-18ȟ㗫ڟѐऺMODS⮰ᬿᙋᕓ̺ദఌ㶔䓪ๆᔭᕓⰤ݇ Ƞ[10]ڟ⭐౻₧ఌၼ(TNF)- ȟ¢-វ㉌(IFN)ふദఌ㶔䓪Ⱔ
⮰ᔗ䕋䃲ݗٷ3Ȟ݇ѐ㵬ᕓн
⮰ᔗ䕋䃲ݗͧ㺭᭛ᵥᢚ㜠ѐᱦݢȟ㏰㏳Ѻ╸∔͠Ꮆ㶔⣜Бࣶ㵬Ο䚤Ⅰふ͠ᎶᠳᴳᲑٷѐ㵬ᕓн݇ ݐȠ 3.1Ȟ͠Ꮆ㶔⣜ȞЏ֫㶔⣜喝ͧ㺭Б⋞ѿ͎ȟქ䛻㵬ネᩢ㑕Џ֫ͦͧ㺭㶔⣜喏࠱᠘ᬕ⮰⯚㗐ᝂ䲎㞞㟹 ᄽふȠۻ⮩喏䋟ࣽ۵喏ए⍠喏ᓯߔ䓳䕋喏⺊㉓ᑌȟ♒㭽喏∔ᘻ߇̹䯲͙喏☒䎭喏ন।ߌᔗ喏ᅫ䛻፤ᝂ ᔃ⌍ȟࣹᏀ䔋䧉⩆㜟ᬻ⺊⣜ܦₐᬢ㵬ࢷछ㘩፤⩆㜟ջ倄ȠЏ֫㶔⣜喝㏰㏳㑦㵬䔇̬ₑߌ䛹喏छ㘩 䔣喞एਲ਼ȟ叻㛈ࣽ㏬喏ఇ㗎⎫ۣ喏㘵᤻㏲喏㵬ࢷ̷䭹喏㘵ࢷᬺ᭪㑕ᄻ喏ᄽᅫȟᬌᅫ喏⯚㗐㟝᪽Ƞₐᬢछ 㘻ஔߋ㘩䯈ⶹ喏➥ݗ᭛ᕑᕓন।⿄䔗㐨ऴᒭ(ARDS)喏⩆㜟MODSȠ⣜ܦБ Med J Chin PLA, Vol. 42, No. 12, December 1, 2017 ǂ1031
[㈧[11ڟᏒ⮰⼷ٷᠳ̺㵬䛻সнٷ3.2Ȟ䛻ࡂݐ∁ 㶔1Ȟн ᠳ(shock index喏SI)᭛㘵 Tab.1ȞRelationship between shock index and blood loss andٷᠳȞнٷ3.2.1Ȟн [11] ᤻(/min)̺ᩢ㑕ࢷ(mmHg)⮰℀ը喏᭛ࣹᭌ㵬≭ߔ the degree of shock ߇႒⮰͠Ꮆᠳᴳͷ̬喏छ⩔κ㵬䛻㇃⪑䃰ќࣶн Shock index Blood loss (%) Degree of shock ≥1.0 20-30 Hypovolemia ը̺㵬ڢᏒܲ㏓ȠSI⮰፤ըͦ0.5~0.8喏⼷ٷ ≥1.5 30-50 Moderate shock [11] 㶔1)Ƞ ≥2.0 50-70 Severe shock) ڟ䛻ॴⰤ 3.2.2Ȟ㐨ऴ䃰ќ∁Ȟछ㐨ऴᓯ⢳ȟ㵬ࢷȟন।䶽 Ꮢ䔇㵸ܲ㏓(㶔2)[12-13]Ƞ⼷ٷȟᅫ䛻ȟ⺊㏻㈧㐋⫳⟢ふᄥ݇ѐ㵬ᕓн⢳
㶔2Ȟ㵬⼷Ꮢ⮰ܲ㏓[12-13] Tab.2ȞGrade of blood loss[12-13] Grade BLV (ml) BLV/BV (%) HR (/min) BP RR (/min) UV (ml/h) Consciousness Ē <750 <15 <100 Normal 14-20 >30 Mild anxiety ē 750-1500 15-30 >100 Decreased 20-30 20-30 Moderate anxiety Ĕ 1500-2000 30-40 >120 Decreased 30-40 5-15 Anxiety, stupor ĕ >2000 40 >140 Decreased >40 anuria Stupor, lethargy ȞȞBLV. Blood loss volume; BP. Blood pressure; BV. Blood volume; HR. Heart rate; RR. Respiratory rate; UV. Urine volume
⮰⯽≷̺䔇䭢䃰ќٷ4Ȟ݇ѐ㵬ᕓн
⼷ڢ⮰ࣽ⩋̺॒ࣶٷ4.1Ȟ̬㝘⯽≷ȞŖ⩋ѿᒭ喝ͧ㺭ᄥ㵬ࢷȟ㘵᤻ȟন।ȟѿ⍕䔇㵸⯽≷Ƞ㵬ᕓн ᰬᬕ⮰͠Ꮆ㶔⣜喏Ѳ᭛䕆䓳ᓯ⢳䃰ќ݇ٷᏒं۟κᱦѿ㵬ქ䛻͎⮰䛻স䕋ᏒȠᓯ⢳්ᔗ᭛݇ѐ㵬ᕓн ᄽ喏ۻЂᄨ㜠ᗏ㔱ᓯ⢳්ᔗ⮰፤㻭ఌ㉌ຮ⫨⬇ȟࣽ☙ふȠŗᅫ䛻喝ᅫ䛻ڢ∔ڟ⮰सᬢᏀ∔ᘻٷѐ㵬ᕓн 㶑⋞ऺᅫ䛻Ϲ┯0.5ml/(kg•h)喏㗪㘻ߋ㘩ःᢋȠŘ⯚㗐喝⯚㗐⎫ۣȟࣽ㏬ȟ㟹⮩ȟ㟝᪽ふ喏ℇ㏲㵬ܲٱ ⯴ᬢ䬠┱2s喏โঔ㏰㏳Ѻ╸∔Ƞř⺊ᔃ⟢ᔭ喝ᘻ䃲ᩥऄ喏ຮ☒䎭ȟ⌍ȟ䅡ະȟᬻ䔣ふ喏᭛ࣹᭌٱネ 㘽Ѻ╸∔⮰䛹㺭ᠳᴳȠ ᗏ㔱Ꮐ⿷࢟䔇㵸㵬≭ߔ߇႒⯽≷(㶔3)ȠᎶ䊱ผᷬᴑछߔᔭ䃰ќᓯ㘻ߋٷ4.2Ȟ㵬≭ߔ߇႒⯽≷Ȟᄥн 㘩ȟ㵬ネโ㗦Ⅰ㗫ȟ̷㚀䲅㘵ऄᐮᏒふᠳᴳȠ㘵᤻ᠳ䔊㐙ᓯᢾ㵬䛻⯽≷ȟ㗦ߔ㘵ᄨネ҈ͦᰵ݇㵬≭ߔ߇ ᝂटაߋ㘩䯈ⶹᗏ㔱[14]ȠٷᏀ⩔喏ᝂ⩔κูᱮȟ䯪⇧ᕓнٯ႒⯽≷∁喏छᰵТ⮰䛹⫳⯽័ࢁ
㶔3Ȟ፤⩔⮰㵬≭ߔ߇႒⯽≷∁ Tab.3ȞMethods of hemodynamic monitoring Hemodynamic monitoring methods Assessment index Noninvasive Vital signs monitoring Blood pressure, heart rate, pulse, blood oxygen saturation Stroke volume, cardiac output, cardiac index, left ventricular end diastolic volume, left Echocardiogram and other non-invasive methods ventricular end systolic volume, ejection fraction, etc. Minimally invasive Cardiac output, cardiac preload, global cardiac end diastolic volume, stroke volume variation, cardiac contractility, global cardiac ejection fraction; Pulse index continuous cardiac output Total systemic vascular resistance/total systemic vascular resistance index; Volume index, global cardiac end diastolic volume, intrathoracic blood volume, extravascular lung water Invasive Right atrial pressure, central venous pressure, right atrial pressure, pulmonary arterial systolic Pulmonary artery floating catheter pressure, pulmonary wedge pressure and cardiac output, etc.
4.3Ȟ侸ა⯽≷ 㵬܉᭛㏎㏲㘊䃍ȟ㏎㏲㘊ࢷ⼛ȟ㵬ᄻᲫ䃍ふ喏ᄥݐ㵬⼷Ꮢȟڢ4.3.1Ȟ㵬፤㻰Ȟߔᔭ㻮ᄋ㵬፤㻰ᅐ ᗱۡ䲊፤䛹㺭Ƞ 4.3.2Ȟߔ㘵㵬⅀ܲȞߔ㘵㵬⅀ܲछࣹᭌᱦѿ䕆⅀ȟ⅓ऴࣶ䚤ⷝ㶍⟢ᔭ喏ᰵߕκ䃰Уন।সᓖ⣛ߋ Ⅰ᭛䃰ќ㏰㏳╸∔̹䋟ᑁ䊣䚤͙҅ޕ㔱ⷝٷᗏ㔱፤㻭Џ䅎ᕓ䚤͙ࣶѺ⅓㵬⫳Ƞ݇ѐ㵬ᕓнٷ㘩Ƞн ࡧ႒ᱮᔃȞ2017Ꭰ12ᰴ1ᬑȞじ42ࢣȞじ12ۇ1032Ȟ 㼏ᩪ
ऄࡂ䔇㵸⯽≷छБᠳᄨ͠Ꮆ⇧⫃Ƞڢ⮰͑䛹⼷Ꮢࣶᠭ㐙ᬢ䬠⮰䬠ᣑ᩻ᙋᠳᴳ[15-16]喏⇧⫃䓳⼷͙ᄥ 4.3.3Ȟߔ㘵㵬Ο䚤Ȟ㵬Ο䚤᭛㏰㏳Ѻ⅓⮰ܳᠳᴳ喏͠Ꮆ̶㷗҈ࣹͦᭌ㏰㏳╸∔̹䋟⮰᩻ᙋᠳᴳȠ ᗏ㔱⫱₧⢳ᬺ᭪ࡳ倄喏ѻ䮎ᬢ䬠ᬺ᭪ᐢ䪫[17]Ƞ㵬Ο䚤2~4mmol/Lࣶٷ㵬Ο䚤┱2mmol/L⮰݇ѐ㵬ᕓн ٷ4mmol/L⮰ᗏ㔱28d₧ύ䷺䮕ܲݗ᭛┯2mmol/Lᗏ㔱⮰3.27Թস4.87Թ[18]Ƞᠭ㐙ߔᔭ⯽≷㵬Ο䚤Ⅰᄥн┱ ⮰ᬕ䃶ȟ⇧⫃ᠳᄨࣶ䶰ऺ䃰ќᰵ䛹㺭ᘻ͵[19]Ƞ䯀2~4hߔᔭ⯽≷㵬Ο䚤Ⅰ̹ϱछᢾ䮐̬䓳ᕓ㵬Ο䚤 倄喏䔄छݐ⋞ѿู㟻⮰⫃ᩴࣶ㏰㏳㑦⅓⮰ᩥરᗱۡȠ් 㵬ߋ㘩䔇㵸ᬕস䔊㐙ᕓ⯽≷喏ᰵТ㔱छᏀ⩔㵬ᴿᑥ܉ᗏ㔱ٷ㵬ߋ㘩ᠳᴳȞᏀᄥ݇ѐ㵬ᕓн܉4.3.4Ȟ ߇ప䔇㵸ᰠᰵᩴ⮰⯽≷Ƞ 4.3.5Ȟ⩋ࡂᠳᴳȞ⯽≷⩡㼏䉔স㗉㗪ߋ㘩ᄥβ㼏⫱ᗱऄࡂসᠳᄨ⇧⫃ϒܲ䛹㺭Ƞ 4.3.6Ȟ►⫳ఌၼȞ►⫳ࣹᏀ݇ѐ⫱⤲䓳⼷͙ࣽᡑⱬ䛹㺭҈⩔喏छ㘩᭛䘔ܲ݇ѐᎢࣽ⫳ຮ㘿⫳ȟMODSȟ 倄Џ䅎ȟ⌝䲅㘵㵬ᴿᒎふ⮰䄝ఌȠTNF- ȟIL-1ȟIL-6ȟCࣹᏀ㯷⮩(CRP)ふ᭛ࣹᭌ݇ѐऺ►⫳ࣹᏀ⼷ 喏ᰵТᬢछ䔇㵸⯽≷ȠڟᏒ⮰᩻ᙋᠳᴳ喏̺ᗏ㔱ѐᗱჲܳⰤ 4.4Ȟᒝ႒ᷬᴑȞႄ㵬≭ߔ߇႒̹⽟(ᄥქ䛻ู㟻ᬌࣹᏀ)㔱喏Ꮐᅩ䛻䭼ݢ䃶ᕓ⮰ᒝ႒ᷬ ᴑȠ݇ѐ䛹◥䊱ผ䃰ќ(focused assessment with sonography for trauma喏FAST)᭛̬䛹㺭⮰ᷬᴑ∁喏Ѳ 㵬⮰ᗏ㔱喏ຮ㵬≭ߔ߇႒⽟ᝂᄥქ䛻ูܦ㵬Ƞᄥᔬ⪽ႄܦস㚥㛈ऺڱᢾ䮐㚥㚀ڔ䭠ᕓᎢ̹㘩Ⴘڢ 㟻ᰵࣹᏀ喏Ꮐ㔯㭽䔇㵸CTភȠᄥκ͑䛹݇ѐ⮰ᗏ㔱喏̹㘩ᵥᢚFAST䃰ќ㏿Ბ۟᭛॒䰬㺭䔇㵸CT ភ[20]Ƞ 䏗CTភ(䘔ܲᗏ㔱䔄䰬㺭ߔᔭูᴑ)喝ϐ䕆ѐȟ倄⾦ಌ㥩ѐȟः߇䘔ѹ̹⌱ẆڔᄥБ̷ᗱۡᏀ䔇㵸 䏗CTភ喏Ꮐᵥᢚ͠Ꮆݐڔѐᗏ㔱፤㻰䔇㵸݇【ѐȟ͑䛹䧉ᕓ݇ѐᝂๆࣽѐ⮰Ꭰᗏ㔱Ƞ̹ᐦ䃚ᄥ٫݇ 䭼ݢCTភࡦഋ喏ԉϱᄥᓱ㺭䘔ѹ䔇㵸CTភȠ 4.5Ȟ݇ѐ䃰̺ܲ䃰ќ 4.5.1ȞPHI(prehospital index)䃰ܲȞ࢟Ą䮎ݹᠳ∁ą喏Ꮐ⩔ᩢ㑕ࢷȟ㘵᤻ȟন।সᘻ䃲4͖⩋⤲ᠳᴳ҈ͦ 䃰࣮ܲ喏㠑ᰵ㘤ᝂ㚥䘔⾫䔻ѐ喏ऒߌ4ܲȠ<3ܲͦ䒧ѐ喏3~7͙ܲͦѐ喏>7ܲͦ䛹ѐȠPHI䃰ܲ᭛Ⱊݹ䮎 ݹᷬѐ䃰ܲѿ㈧͙ᰬຩ⮰̬䛻ܲㆧ∁喏䭱̶ጞ㏻Ꭻ∇Ꮐ⩔Ƞ 4.5.2ȞGCS(Glasgow coma scale)䃰ܲȞGCS䃰ܲ᭛ᵥᢚᗏ㔱Ɑⱨȟ㼬䄙ȟ䓼ߔȟᄥݦ⓬⮰̹सࣹᏀ㐅δ䃰 喏Ϻ㔸ᄥᘻ䃲⟢ᔭ(͙⺊㏻㈧㐋ᢋѐ⼷Ꮢ)䔇㵸ݐ喏ᕧܲ15ܲ喏ᰬѺ3ܲ喏<8ܲछݐͦᬻ䔣喏ܲܲ 䊶Ѻ݅ᬻ䔣⼷Ꮢ䊶⌝Ƞ 4.5.3ȞISS(injury severity scale)䃰ܲȞISS䃰ܲͦ䏗ѿ3͖ᰬ͑䛹ᢋѐࡦഋ⮰ᰬ倄AISܲը⮰সȠAIS᭛ᄥ ஔჄȟ㏰㏳ᢋѐ䔇㵸䛻ࡂ⮰⃡喏ᠵ⚓ᢋѐ⼷Ꮢȟᄥ⩋⮰༭㗭ᕓ๓ᄻᄲะᢋѐ䃰ͦ1~6ܲȠISS䃰ܲ㠯 ఠͦ1~75ܲ喏ຮࢁࡦഋ䃰ܲ䓪6ܲ喏ᕧѿ䃰ܲ݅Ⱐᣑͦ75ܲȠ䕆፤ISSĹ16ܲͦ͑䛹݇ѐ喏ₐᬢ₧ύ䷺䮕 ͦ10%喏䮻ⱬ䃰ܲࡳ倄₧ύ䷺䮕්ߌȠ 4.5.4ȞTRISS(trauma and injury severity score)䃰ܲȞTRISS䃰ܲ᭛̬Бѐऺ⩋⤲࣮ऄࡂ(RTS)ȟᢋѐ㼏ނ ࡦഋ(ISS)সᎠ咰(A)3ఌ㉌ͦӉᢚ⮰㏿ᅬ䃰ќ∁ȠБႄ≧Ắ⢳(Ps)ࣹᭌѐ㏿ᅬ喏䕆፤䃐ͦPs┱0.5⮰ᗏ 㔱छ㘩ႄ≧喏Ps┯0.5㔱ႄ≧छ㘩ᕓᄻȠ 4.5.5ȞAPACHEē(acute physiology and chronic health evaluation ē)䃰ܲȞ䕆䓳APACHEē䃰ܲᄥᕧѿ⫱ᗱ䔇 ᕓ[21]ȠڟᰵⰤڣ⢳₧⫱㵸݉ₑ䃰ќȠⵀ⾢᭪喏APACHEē䃰̺ܲᗏ㔱 ȟࣶᬢ⮰䃰ќসݐܦᗏ㔱⮰⫱ᗱস⇧⫃ࣹᏀֆٷ4.6Ȟߔᔭ䃰ќȞᰵᩴ⮰⯽≷छБᄥ݇ѐ㵬ᕓн ᰵ䮼ᕓ喏ऄࡂᔗ喏䔇ᆁڣᗏ㔱ѐᗱ፤ٷ喏Бݕκᠳᄨস䄯᪠⇧⫃䃍ܾ喏ᩥરᗏ㔱䶰ऺȠ݇ѐ㵬ᕓн ᑦ䄯ᄥݹ䔜䛹㺭ᠳᴳ䔇㵸ߔᔭ⯽≷স䃰ќȠڢᔗ喏ఌₐ喏͑ჲߔᔭ㻮ᄋ͠Ꮆ㶔⣜⮰सᬢ喏䰬ᅐ
⇧⮰㉓ᕑٷ5Ȟ݇ѐ㵬ᕓн
5.1Ȟ⇧̺࣋݅Ⱊᴳ 㼏䮐ࣶ࢝⩋⮰ᗱۡ喏ҫѐᗱᓃݜ݉ₑᣓݢ喏♢ऺ䔇㵸ऺ㐙ะٴ5.1.1Ȟ⇧࣋݅Ȟᄥ݇ѐᗏ㔱喏Ꮐф ᗏ㔱喏ٷᕑऺ㐿ą⮰࣋݅Ƞᄥκ݇ѐ㵬ᕓнٴ䛹ऺ䒧喏ٴ喏䖡ᓖĄ៎⩋じ̬喏ԉ័ߋ㘩じθ喏⤲ Ђᄥ⫳⇧⫃喏सᬢᏀ䛹㻲⇧䓳ڢ㵬ȟԉᠭন।䕿䕆⩱ȟ⋞ѿู㟻ȟ₎⬇Бࣶܦദ᱘⇧⫃ᣖ࠱᠘ᣓݢ ܉䃤ᕓѺ㵬ࢷ喏䒿㵬も⪑喏䶰䭞݇ѐ٭͙⮰ᢋѐᣓݢู㟻も⪑喏ຮᢋѐᣓݢโȟ䭼ݢᕓ⋞ѿู㟻छ⼷ 㵬⫱ふȠ Med J Chin PLA, Vol. 42, No. 12, December 1, 2017 ǂ1033
㵬喏䛳ं͖ѿࡂᣖᩥરᓚᓖ⣛ࣶ⅓ݕ⩔䯈ܦᕧⰚᴳ᭛⼛Ჭᣓݢ⫄⇧ٷ5.1.2Ȟ⇧⫃ⰚᴳȞ݇ѐ㵬ᕓн ද⽟Ƞ̹स䭢⃡⇧⫃Ⱊᴳᰵᝬ̹स喏Ꮐ⯽≷ⰤᏀᠳᴳȠ⣛ڱⶹ喏ᖎู ⩋㵬喏ᰬ๓䭼Ꮢ㐠ᠭܦ⮰⇧⫃छܲͦ4[22]Ƞじ̬ᕑ䭢⃡喝⇧⫃Ⱊᴳͦ⼛Ჭᣓݢٷѐ㵬ᕓн݇ ⫄⇧㠯ఠ喏៎⩋⮰も⪑Ƞじθфࡂ䄯᪠䭢⃡喝ڔ䛻፤ᝂႵܦѿᒭ⽟喏ԉ䃭㵬ࢷȟᓯ䒿
Ⱊᴳ්ͦߌ㏰㏳⅓Ӈ喏фࡂᓯ䒿ܦ䛻ȟSvO2ࣶ㵬Ο䚤ⅠȠじ̵⽟䭢⃡喝⇧⫃Ⱊᴳͦ䭞₎ஔჄߋ㘩䯈 ⶹ喏࢟ҫ㵬≭ߔ߇႒⽟ऺϹᏀ倄Ꮢ䂒ᘁȠじఇ䭹䭢ᷛ⇧⫃䭢⃡喝⇧⫃Ⱊᴳͦ᧐䮐㵬ネ≧ᕓ㢛➕喏Ꮐ ද⽟Ƞ⣛ڱݕᅫݮᝂ㗪㘻ᰫЏ⫃∁䄯᪠ქ䛻喏䓪ݜ⋞ѿ㶍喏ᖎู⩔ ᗏ㔱䮎ݹন।ᩛᠭ⇧⫃⮰ݹসദ[23]Ƞٷ5.2Ȟ⅀䕿̺ন।ネ⤲Ȟᰵᩴ⮰⅀䕿ネ⤲᭛݇ѐ㵬ᕓн (䕿䕆⩱ࣶᰵᩴ䕆⅀喏ᔗ䕋䄝ᄨ叧䚵ネ(RSI⅀ڢᗏ㔱Ბ䄠喏ຮ㜖䏗̹㘩㐠ᠭٷᄥκ݇ѐ㵬ᕓн ⮰ܳ∁Ƞ㠑RSI᧹҈䉑喏Ꮐ⿷࢟䕆䓳ദ᱘⮰⅀䕿䒱ߕ䕆⅀∁স(ᝂ)䕆䓳ผ䬔̶㷱ڔ᭛ԉ䃭⅀䕿Ⴕ 㒚Ბ㐠ᠭ⅀䕿䕆⅀喏Ⱐݜҫ⩔โ∁ᐦ⿷䊣⽟⮰⅀䕿[20]Ƞ 䔵᠕ηࣽ⣜౦⿷࢟ᆁᐬ⇧Ƞຮ⣜౦̹㘩䔇㵸RSÌ⅀䕿ࣹᄰ⊴喏ᐦ䃚ҫٴ䮎ݹ⣛ද̷喏ф 喏݅Ꮐҫ⩔ദ᱘⮰ᒾ⅀䕿ᩛڑผ䬔̶⅀䕿䃪ำ(ຮવ㒕)Ƞຮ⅀䕿ࣹᄰႄᝂผ䬔̶⅀䕿㷱㒚̹㘩㒚⩔ ᠭ∁(፤㻰ͦМ䶻∁)স㷱㒚(ຮए৩ネȟ呧৩ネࣶવネ)Ƞᒾᐬᩪ⅀䕿ᬢ喏Ꮐ∔ᘻᗏ㔱ᰵᬌ䶴Ḻᢋ ѐ喏Ѡࣽ䷈䲎ᢋѐᝂᵨ៵䃰ܲ┯8ܲᬢ㘶ᴝᢋѐ⮰࢝䮕ᕓ๓๓්ߌ[24]喏⣜౦ᕑᬢᏀ仂䔵ᒾద㘶 ᴝ喏⩔ᣔ̷ͪ䶸∁(Jaw thrust)ᐬᩪ⅀䕿Ƞຮᣔ̷ͪ䶸∁᧹҈జ䯪喏̹㘩ᰵᩴ䕆⅀喏ϹᏀᩥ⩔М䶻∁䔇 㵸䕆⅀Ƞຮ䒘䓼ᗏ㔱㜟݇ѐ͙ᓯ䔇㵸RSI喏Ꮐԉ䒘䓼ᬢ䬠̹䊱䓳60minȠຮ̹㘩㐠ᠭ⅀䕿䕆⩱ᕓᝂ䒘 䓼㜟݇ѐ͙ᓯ⮰ᬢ䬠䶰䃍䊱䓳60min喏छБ㔯㭽ᅝ䓽䒘䓼㜟ᰵ៎݇ѐ㘩߇⮰័ࢁѹ[20]Ƞ 5.3Ȟᓖ⣛䕆䌛ᐦ⿷̺⋞ѿู㟻 5.3.1Ȟᓖ⣛䕆䌛䔵᠕ 㵬ネڱ䮎ݹᓖ⣛䕆䌛⮰䔵᠕喝仂䔵โঔ๓䲅㘵䕆䌛喏ຮᐦ⿷โঔ䲅㘵䕆䌛䉑喏ᰵТᏀ㔯㭽俔俿㚀 㵬ネ䕆䌛Ƞڱᗏ㔱喏ຮ䶰ᐦ⿷โঔ䲅㘵䕆䌛జ䯪喏Ꮐ仂䔵俔俿㚀【䕆䌛Ƞᄥ┯16ᆭ⮰٫ ܦᓖ⣛䕆䌛⮰䔵᠕喝仂䔵ᐦ⿷ᰵᩴ⮰โঔ䲅㘵䕆䌛喏Ꭲᅩᬕᐦ⿷͙ᓯ䲅㘵䕆䕿Ƞ㠑̷㚀䲅㘵ᆊᩛڱ䮎 㵬ネ䕆䌛᭛छБसᬢ㔯㭽ڱ䲅㘵䕆䕿Ƞ俔俿㚀ڱ㵬ຮ͑䛹⮰俔⯲俔ោ喏Ꮐ䔵᠕̶㗎䕆䕿ᝂ㔱䨭俔̷ȟ䶴 ⮰䛹㺭䔵᠕Ƞ 㵬䛻䒯๓喏Ꮐࣶᬕ䔇㵸ᔗ䕋䒿㵬㐠ᠭ㵬ქ䛻喏ᩥરᓚܦᗏ㔱䕆፤ٷ5.3.2Ȟ䒿㵬̺⋞ѿ⇧⫃Ȟ݇ѐ㵬ᕓн ᓖ⣛╸∔喏ԉ䃭ͧ㺭㘻ஔ⮰⅓ӇȠᐦ䃚䕆䓳⩋⤲႒ᠳᴳ(࠱᠘㵬≭ߔ߇႒⟢ᔭȟᄥ࢟ᬢქ䛻ู㟻⮰ࣹᏀᗱ ᗏ㔱(┯16ᆭ)⮰㉓ᕑ䒿㵬䶰ᵴȠ【㵬៎䶰ᵴȠࡧ⫃ᱦᲰᏀᐦ⿷䦴ᄥϦᗏ㔱(Ĺ16ᆭ)স٫ܦᲑज़ߔ๓(ۡ 㵬⮰ᗏ㔱喏Ꮐ仂䔵ద℀ҷ⮰ܲ䒿㵬喏ᎢᏀᅩᔗ䓳⍍ݜБ侸აᷬᴑ㏿ͦᠳᄨ⮰䒿ܦ䦴ᄥႄ≧ߔᕓ 㵬䶰ᵴ̶Ƞ ᗏ㔱喏㵬≲̺㏎㏲㘊⮰℀ҷϹͦ【ᄥϦᗏ㔱䔇㵸䒿㵬⇧⫃ᬢ喏㵬≲̺㏎㏲㘊⮰℀ҷͦ1:1Ƞᄥκ٫ 䏗㵬ქ䛻䔇㵸䃍ッ[25-27]Ƞڔ⮰【1:1喏Ѳ᭛㺭ദκ٫ ≦喏ᄥڱ㵬⮰ᗏ㔱छᏀ⩔ふ⍃ᮢѿ⋞䔇㵸ផქ⇧⫃[28]Ƞ䮎ܦ䮎ݹ⣛ද̷ᬌ∁㣣ᓃܲ㵬喏ᄥ≧ߔᕓ ⫱㵬܉ᮢѿ⋞цᄨ㜠⼬䛶ᕓڑ㵬ᗏ㔱̹ᐦ䃚ҫ⩔ᮢѿ⋞㶑⋞喏ᐦ䃚ᠵ⚓1:1ҫ⩔㵬≲স㏎㏲㘊Ƞ䒿ܦߔᕓ ࣽ⩋喏цࡳ㵬ࢷҫጞᒎ⮰㵬܉ಃ㙝㥩䔇̬ₑߌ䛹ܦ㵬喏ᄨ㜠㵬⋞叻⽌Ꮢ䭹Ѻ喏̹ᬿᒎ⮰㵬܉ಃ喏 सᬢ䔄ц්ߌARDSসๆஔჄߋ㘩㶜〙(MOF)ふ⮰ࣽ⩋䷺䮕[29]Ƞ㔯㭽ᄥᱦѿ₎㵬⮰̹㞛ᒝ৹喏㘢ѿᐦ䃚 䭼ݢҫ⩔[6]Ƞ 㵬⮰ᗏ㔱ҫ⩔䭼ݢᕓ⮰ქ䛻ู㟻も⪑[7]喏Ⱐ㜟ጞႸᬕܦ5.3.3Ȟქ䛻ู㟻も⪑Ȟᐦ䃚ᄥႄ≧ߔᕓ 㵬ᣓݢȠ䮎ݹ⣛ද̷喏䕆䓳␠ᐻ䔇㵸ქ䛻ู㟻Бҫ๓ߔ㘵᤻ߔ㐠ᠭछᬺ᭪ᙋⴑ⮰⟢ᔭ[30]喏̬㝘ܦ Б㐠ᠭᩢ㑕ࢷ80mmHgᝂ㔱छ㼒ࣶᶍߔ㘵᤻ߔͦⰚᴳȠຮ䓪̹ݜ喏छ䭹㜟㼒ࣶ䶴ߔ㘵᤻ߔᝂ㔱㐠ᠭѐ㔱 ദᘻ䃲Ƞ䕆፤ᗱ̷ۡSBP䓪ݜ60mmHgछ㼒ࣶ䶴ߔ㘵喏70mmHgछ㼒ࣶ㗍ߔ㘵喏80mmHgछ㼒ࣶᶍߔ㘵Ƞ 㵬ᓃݜᣓݢȠܦ㵬喏ₐݹ̷䔇㵸␠ᐻქ䛻ู㟻Б㐠ᠭ͙ᓯᓖ⣛喏Ⱐ㜟ܦද̷喏Ꮐᔗ䕋ᣓݢ⣛ڱ䮎 㺭䬚䷄喏Ꮐᠭ㐙䔇㵸䭼ݢᕓქ䛻ู㟻喞ຮ݇ͧͦٷস݇ѐᕓ㘽ᢋѐᎢႄᗏ㔱喏ຮ㵬ᕓнٷ䦴ᄥ㵬ᕓн ѿᣓݢⰚᴳ喝ᄥκᬌڣѐᕓ㘽ᢋѐͦͧ㺭䬚䷄喏݅䔇㵸ⰤᄥჩᲪ⮰䭼ݢᕓქ䛻ู㟻Б㐠ᠭ㘽㵬≭╸∔[6]Ƞ 䃤ᕓѺ㵬ࢷ喏ᏀᄲSBP㐠ᠭ80~90mmHg喞ᄥκऴᎢ͑䛹䶱㘽٭㵬ᣓݢͷݹछܦ㘽ᢋѐ⮰ᗏ㔱喏๓ ᢋѐ(GCSĸ8ܲ)⮰ᗏ㔱喏Ꮐ㐠ᠭߔ㘵ࢷ80mmHgБ̶[31]Ƞ ࡧ႒ᱮᔃȞ2017Ꭰ12ᰴ1ᬑȞじ42ࢣȞじ12ۇ1034Ȟ 㼏ᩪ
㵬ܦ5.4Ȟᣓݢ 㵬Ƞᐬᩪᕓఇܦ㵬ᗏ㔱喏छガࢁᏀ⩔᪣᫅ࢷ䔗∁ᣓݢโ䘔ܦ≰5.4.1Ȟ᪣᫅স₎㵬ፒ⮰Ꮐ⩔Ȟᄥκѿ㶔ᝂ㶔 㵬喏โᱛݹᣔ㡼ҫ⩔₎㵬ፒ喏̀䶧ᴳᬺҫ⩔ᬢ䬠Ƞܦ㗎ᢋѐႄࣶ࢝⩋⮰๓ 㵬ᬢ喏Ꮐҫ⩔➥ݢ⮰俔⯲โܦ5.4.2Ȟ俔⯲โదፒ⮰Ꮐ⩔Ȟᑿ俔⯲ःݜ倄㘩䛻䧉ᕓᢋѐऺᔬ⪽ႄ≧ߔᕓ ⩔喏㔯㭽ҫ【దፒȠखᰵᑿ➥ݢ⮰俔⯲โదፒ̹ऴ䔮ᬢ喏ຮᄥκѿಷ䒯๓⮰ᎠϦᝂѿಷ䒯ᄻ⮰٫ ͠ᬢ俔⯲โదፒȠ 㵬ᬢ喏Ꮐᅩᔗ䲅㘵ҫ⩔⅔⩞⣛䚤喏ܦᗏ㔱ႄᝂᔬ⪽ႄ≧ߔᕓٷ5.4.3Ȟ₎㵬ݮ⮰Ꮐ⩔Ȟᑿ݇ѐ㵬ᕓн ᗏ㔱ःѐ䊱䓳ٷ㵬⫱[12]Ƞ仂ݮ1g(Ĺ10min)喏ऺ㐙1g䒿∔㜟ᄽᠭ㐙8h[32]Ƞຮ݇ѐ㵬ᕓн܉䭞₎ѐᕓ 㵬ะ⤲≭⼷ᬢ喏ᐦ䃚ᗏܦ䲅㘵Ꮐ⩔⅔⩞⣛䚤喏䮐䲊ᰵ䃭ᢚ䃭ᬺᗏ㔱ႄ㏐⏢ώ䔇[33]Ƞݢ䃎݇ѐٹ3h喏䖫 䚢ふ܉㵬ᬢछ㔯㭽䔵᠕ⴇ㲚㯳㵬ܦ㔱䒘䔭ࡧ䮎⮰䕀͙Ꮐ⩔仂ݮ⮰⅔⩞⣛䚤Ƞ䶱㘽ȟ㗉㙪ふ䛹㺭㘻ஔᢋѐ 㵬Ꮑ➕ᰫЏ䒿∔⇧⫃ऺ܉⮰ܲٱ㵬㔱ϒछܦ㵬⫱Ꭲࣽ๓܉⩋㵬㢛➕䲅㘵ᝂᅬ䘔Ꮐ⩔₎㵬[34-35]Ƞᄥκࣽ₍ ҫ⩔䛹㏰܉㵬ఌၼ-ĘȠ 㵬ߋ㘩⮰㢛➕喏܉㵬⮰ᗏ㔱喏㠑ͷݹҫ⩔βᒝ৹ܦႄ≧ߔᕓٷݮ⮰҈⩔Ȟ݇ѐ㵬ᕓн܉5.4.4Ȟ䔲䒘ៃ ݮ⮰҈⩔Ƞຮఌᓯ㘽㵬ネ⫪⫱㏻፤ҫ⩔ࡺ∁᳃喏ៃ㵬ᄻᲫݢݮ(⅛्ᵨ䰣ȟ䭫तࡥ᳃)喏܉Ꮐᔗ䕋䔲䒘ៃ 㵬ηТ[6]Ƞᰵ≧ߔᕓܦ⩋㵬䚢ݢݮ(䓪℀ߌ㓐)喏ៃěఌၼݢݮ(ݕм⇅⤙)喏࢟ҫ᭛䒧ѐ喏ᒴქᬿࣽ܉ៃ ܦ㵬䚢ู࣋ऴ➕(PCC)ふ㢛➕Ბ䔲䒘ៃݮ⮰҈⩔Ƞᑿᗏ㔱ᬌ≧ߔᕓ܉⩔㵬⮰͑䛹݇ѐᗏ㔱喏Ꮐ⿷࢟ҫܦ 㢛ᗏ㔱喏ᣔ㡼ᬕҫ⩔≿㑕܉ݮ⮰ᓱ㺭[21]Ƞᄥκ㐠⩋㉌KӉ䊂⮰एៃ܉㵬ᬢ喏ᬌҫ⩔䔲䒘ៃܦ⪾㵬ᝂछ 㵬喏ᐦ䃚㐅δPCC喞ຮ㏐ܦݮ⮰ᗏ㔱ࣽ⩋݇ѐऺ㜠ᕓ܉䒧ҫ⩔ಷएៃۻ⮰PCC䔇㵸㉓ᕑៃ喞ͦ 㐠㯷⮩࣋Ⅰ፤喏㵬ᴿᑥ߇ప⯽≷܉㵬ज़ߔᐢ䔋ᬢᐦ䃚ҫ⩔PCCᝂ㵬≲[36-39]Ƞ ⫄⇧ڑ5.5Ȟᱛ⇧⫃সϷ Ą㜠⣜ܦ᭛ᗏ㔱ڢ5.5.1ȞᢋѐᣓݢᕓᱛসᕓᱛȞᢋѐᣓݢᕓᱛ᭛ᠳ⇧͑䛹݇ѐᗏ㔱喏ᅐ 㵬ߋ㘩䯈ⶹ)ȟ̹㘩㔼ः䪫ᬢ䬠ᱛᬢ喏䛳⩔ᔗᢣȟガࢁ⮰᧹҈ࣶᬢᣓݢ܉㖀ᒭą(Ѻѿ⍕ȟ䚤͙স̵₧ ᝂܲᱛȠᄥκऴᎢ䛹Ꮢ㵬⁍ڹ䔇㵸Ⴘ᪠ȟऴ⤲⮰ڹѐᗱ䔇̬ₑᖢࡂ喏ҫᗏ㔱㣣ᓃู㟻ᬢ䬠喏ᰵᱦц Ђ䰬㺭ᢋѐᣓݢᕓڢ㵬⫱ᒭ䆍⮰͑䛹݇ѐᗏ㔱喏ᣔ㡼ᢋѐᣓݢᕓᱛȠ܉㵬সܦȟᰵᠭ㐙ٷᕓн ᢋѐȟ᧹҈㕃ᬢȟसᬢऴᎢ㚥䘔Бโ⮰͑ނ㵬⫱ȟѺѿ⍕ȟ䚤͙ȟ䯪Бะ⤲⮰㼏܉ᱛ⮰ᗱۡ࠱᠘͑䛹 㵬᱖ܦ䔄ᰵ๓⮰ڱ䛹݇ѐȠᄥκ㵬≭ߔ߇႒⽟̹̀ႄ̶䔜ᗱۡ⮰ᗏ㔱喏ᣔ㡼ᕓᱛȠຮѿ ⮰सᬢᐦ䃚ᬕ⼛Ჭᱛ₎㵬Ƞٷ㘩ᣓݢ喏⼛Ჭៃн Ђ䘔ڢ喏䮐䲊䰬㺭⿷࢟䔇㵸ᐬᩪᕓᱛᣓݢ⫄⇧ڑ㵬喏ᐦ䃚㔯㭽ϷܦȞᄥ⯲㚀ߔ㘵≧ߔᕓ⫄⇧ڑ5.5.2ȞϷ 㵬⮰⇧⫃喏ܦ⮰छ㵸ᕓȠᄥκߔ㘵⫄⇧ڑ㵬喏छ㔯㭽Ϸܦ㵬Ƞᄥ䉔㘻ஔ(㙪㘻ȟ㗉㘻ᝂ㗪㘻)ߔ㘵ܦѹ Ⱔ㏿ऴ⮰も⪑喏छᄲ⇧⫃ᆁ㜟โᱛ䯪Б䓪ݜ⮰ࡦഋȠ⫄⇧ڑโᱛ̺Ϸ 5.6Ȟ㵬ネ≧ᕓ㢛̺ᕓ㖸߇㢛⮰ҫ⩔Ȟ㵬ネ≧ᕓ㢛➕⮰Ꮐ⩔̬㝘Ꮐᐦ⿷⋞ѿู㟻ദ̶喏Ѳᄥκࣶ࢝ ⩋⮰ᲭᏒѺ㵬ࢷ(SBP┯50mmHg)喏ᝂ㏻⋞ѿู㟻ऺ̹㘩㏌⮰Ѻ㵬ࢷ喏छ⋞ѿู㟻⮰सᬢҫ⩔㵬ネ≧ 䏗㵬⋞╸∔[9-10]Ƞ仂䔵ࣧ⩞㗪̶㚦㉌喏ᅩछ㘩䕆䓳͙ᓯڔᕓ㢛➕喏Бᅩᔗࡳߔ㘵ࢷ㜟60mmHgᎢᖎู 䲅㘵䕆䌛䒿∔喏፤⩔ݮ䛻ͦ0.1~2.0«g/(kg·min)Ƞ /䛻Ϲ̹䋟ᬢᏀ⩔喏仂䔵ๆጠ䚆̭㘦喏䊣ݮ䛻2.0~3.0«gܦᕓ㖸߇㢛➕छ㔯㭽ݹ䉋㢣㞛ຩ㔸ᓯ䒿 ᰵᑦᓯস㜾ᑌ㵬ネ⮰㐨ऴᩴᏀ喏छڣkg·min)喏䲅㘵␠∔䕋Ꮢᵥᢚ⫳⟢ȟᅫ䛻ふ䄯᪠Ƞ⸣䚤θ䚛䚢ួݢݮ) ᑦๆጠ䚆̭㘦⮰҈⩔Ƞᑿ¡㗪̶㚦㉌㘩ःѿ҈⩔̷䄯ᝂᗏ㔱䓽Ꮐ⩔¡ःѿ䭧␊ݮᬢ喏⸣䚤θ䚛䚢ួݢ් ݮ⇧⫃छ㘩ᰵᩴ[22]Ƞ 5.7Ȟ݇ѐᕓ܉㵬⫱⮰䶰䭞̺ะ⤲Ȟᬕ࢟ᰵ25%⮰͑䛹݇ѐᗏ㔱छࣽ⩋܉㵬⫱[40-41]Ƞ݇ѐᬢ๓䛻㵬ȟ 㵬ఌၼ⊴㕃ȟѺѿ⍕ᕓ㵬ᄻᲫߋ㘩䯈ⶹস䚢≧ᕓ䭹Ѻ喏䚤͙܉⯚㏲㘊̷ദ䉔㯷⮩ᯠ䱞ᑁ䊣⮰㵬ᄻᲫসڱ ᑁ䊣⮰㵬ڑȠ㮩♢ู㟻ᬢ๓䛻⋞ѿ䒿ڟ㵬⫱ᰵ܉㵬䚢ู࣋ऴ➕≧ᕓ䭹ѺБࣶ㏐⏢ώ䔇ふఌ㉌̺܉䄝ᄨ⮰ 㵬܉㈧喏Ѳๆ䛹⫳݇ѐᗏ㔱ᮢѿ⋞স㘢ѿ⋞ู㟻ݹᅝጞႄڟ㵬⫱⮰ࣽ⩋স䔇ᆁᰵ̬܉䛶̺⼬⋟ ߋ㘩䯈ⶹȠ 㵬܉㵬ߋ㘩Ꮆᔗ䕋ᷬ侸᭛䃶܉㵬⫱䲊፤䛹㺭喏ᐬᆁ܉᭛॒Ѡڢ䮎ᬢڑᗏ㔱ٷѐ㵬ᕓн݇ 㵬ᠳᴳস(ᝂ)㵬ᴿᑥ߇పݢⰚᴳࡂも⪑ᠳᄨู㟻Ƞ܉⮰ᰵᩴ⃡Ƞᣔ㡼ҫ⩔ᴳ۲⮰侸ა⫱ 㵬ᗏ㔱喏ᬕะ⤲ᣔ㡼㵬≲䒿∔喏Ꭲᵥܦ㵬ߋ㘩Ƞᄥ๓܉㵬โ喏Ꮐᅩᬕᷬ≷Ꭲ䛳ंᣖ㐠ᠭܦ䮐ᣓݢ ᢚ㏐㐠㯷⮩࣋ȟ㵬㏎㯷⮩ᷬ侸㏿ݐ᭛॒䰬㺭ҫ⩔㏐㐠㯷⮩ࣶ࣋㏎㏲㘊[33]Ƞ Med J Chin PLA, Vol. 42, No. 12, December 1, 2017 ǂ1035
ᗏ㔱Ѻѿ⍕ࣽ⩋⢳倄䓪10%嗡65%[42-43]ȠѺѿٷᗏ㔱Ѻѿ⍕⮰䶰䭞̺ะ⤲Ȟ݇ѐ㵬ᕓнٷ5.8Ȟ݇ѐᕓн ᄽۻᗏ㔱喏Ꮐᅩ䛻ԉ⍕Бٷ⍕㷗䃐ͦ᭛͑䛹݇ѐᗏ㔱䶰ऺ̹㞛⮰⠘⿷࢝䮕ఌ㉌Ƞఌₐ喏ᄥ݇ѐ㵬ᕓн ᠭ㐙⮰☙䛻͎Ƞᄥκѿ⍕32~35ą⮰ᗏ㔱喏ᐦ䃚䕆䓳倄⣛ද⍕Ꮢȟߌ⍕ℛᝂ㔱්ߌͧߔ≧ߔ(ຮ 䃤)Ბ倄ᵤᓯ⍕Ꮢ喞ᄥκѿ⍕Ѻκ32ą⮰ᗏ㔱छБ㔯㭽ߌ⍕䒿⋞喏ຮϹᬌᩴछ㔯㭽䕆䓳ѿโ㛈㗦٭ᗱ⫱ (ECMO)⇧⫃[44]Ƞ ⫨Ꭰ咰ȟࣽ㗞স䃐ⴑߋ㘩⮰⫨⬇䃰ќ䛻㶔喏ᬢ䔇㵸ڢ5.9Ȟ⫨⬇ネ⤲Ȟᄥκ͑䛹݇ѐᗏ㔱喏Ꮐ䔵᠕䔮ऴ 䃰ќȠݜ䓪ࡧ䮎ऺ㐓㐙ҫ⩔̺䮎ݹⰤस⮰⫨⬇䃰ќ䛻㶔䔇㵸⫨⬇䃰ќȠ⬇ ᄥκ͑䛹݇ѐᗏ㔱喏䔵᠕ृઍ(0.10mg/kg)҈̬ͦ㏫₎⬇ݮ䲅㘵Ꮐ⩔[45]喏Ꭲᵥᢚ⫨⬇ネ⤲Ⱊᴳ䄯᪠ݮ䛻Ƞ 㘦䚚ᝂθ΅䚜ृઍȠ⅛㘦䚚ͦ₎⬇⮰θ㏫ำ䔵ᵴ[46-50]Ƞ⅛ڑຮ䲅㘵䕀ᒰ⇍ᰵᐦ⿷喏छБ㔯㭽䕆䓳䰪ࡂ। ҫ⩔ृઍ₎⬇ᬢ喏Ꮐ͑ჲ⯽≷䭞₎ࣽ⩋ন।ួݢ喏䮐䲊ጞᰵন।ᩛᠭᣖȠ 5.10Ȟ►⫳ᣓݢȞ⋞ѿู㟻⇧⫃ᬔᖎูᓖ⣛ქ䛻স㏰㏳╸∔喏Ѳ̹㘩ᰵᩴ䭧₎►⫳ࣹᏀࣽ⩋ȠᏀᅩᬕᐬ ⯚㏲㘊喏䭹Ѻ㵬ネ䕆䔻ᕓ喏ᩥરᓚᓖ⣛Ƞఌₐ喏ៃ►⇧⫃छ҈ͦڱៃ►⇧⫃喏䭧►⫳㏓㖀ࣹᏀ喏ԉ័ 䔵᠕ͷ̬喏छ䔵⩔तЂ̭ȟ㈂⯚䉔⓬㉌ふȠतЂ̭छᰵᩴᣓݢ䓳Ꮢ►⫳ࣹᏀ喏䭹⫄⇧ٷѐ㵬ᕓн݇ Ѻ㵬⋞ㆾ㏲㘊ᑥᕓ㯷⮩䚢(PMNE)ⅠসCࣹᏀ㯷⮩Ⅰ喏᭪㦃ᩥર㘽⅓Џ䅎ࣶᓚᓖ⣛喏䭹Ѻๆࣽѐᗏ㔱ѻ 䮎๕ȟMODSࣽ⩋⢳স⫱₧⢳[51-52]Ƞ
6Ȟ݇ѐ⇧ఎ䭋̺≭⼷ネ⤲
݇⣜ำφ̿͆ܲ⮰ᕑ䃶โఎ䭋喏सᬢڣ6.1Ȟ⇧ఎ䭋⮰ᐦ⿷ࣶ㏲ࡂネ⤲Ȟᐦ䃚ᐦ⿷̬̿ๆ㘩ȟ ⇧≭⼷㏲㻰㠯ࡂ喏ᰵߕκ⇧҈䓱䕋ࣶᬢ㔸ࣴᰵ̹㈶䶦ݕᐬᆁȠٷѐ㵬ᕓн 6.1.1Ȟ⇧ࡧ័Ϧ⮰Ą㻾㞞Ⱐ㻮ࡂąȞᝬᰵ࣮̺⇧⮰ࡧ័ϦБࣶࠐϦݜ䓪⣜౦ऺ喏䘩ᰵᬺ⮰ 㻾㞞ܲ喏र㜖ҕᝠⰤᏀ㕸䉏⮰㑂ⴭᴳᔃ喏ҫᓃ៎⣜౦Ϧ㻾㞞ܲᬺᮜȠ ҕᝠ㔱⮰ܲڢ6.1.2Ȟ⇧ࡧ័Ϧ⮰Ą㕸䉏㏲ܲࡂąȞࡧ័៎㻾㞞Ⱐ㻮ࡂ⮰ദ̶喏㕸䉏㑂ⴭ㻰β ქ喏Бࣶѐ⮰々ѹ喏㏲㜠㔸⌱ᮜȠڱ҈᧹喏Ϻ䉋䉏⮰ѐ㑂ण喏ݜᏀ䄑ន㵸⮰ 6.1.3Ȟ⇧ᵴ⮰Ąࡧଢ଼丼ࡂąȞݕ⩔៎⣜౦⮰⮩Ძᝂ᭪ᅻ喏᭪ѐ㑂णБࣶⰤᏀ⮰丼ࡧଢ଼㑂 βࡧ⩋ᄥๆ͖ѐ̷䓪ࡧଢ଼ᬢ⮰ᱮ̺⌣ΝȠٹण喏ࡧଢ଼ន㵸ᔗ㔸ᰵᎻ喏䖫 6.1.4Ȟ݇ѐᕑࡧ័Ϧ⮰㑂ᢾࣶ㕸䉏Ȟ݇ѐᕑࡧ័Ϧ⮰㑂ᢾࣶ㕸䉏䄒㻭㶔4Ƞ
㶔4Ȟ݇ѐ⇧ࡧ័Ϧ⮰㑂ᢾࣶ㕸䉏 Tab.4ȞAssignation and duty of medical staff participate in trauma care No. Assignation No. Duty 1-D1 Commander and coordinator of No.1 patient TN0 Nurse in charge of coordination of No.1 patient 1-D2 Major evaluation physician of No.1 patient 1-TN1 Primary nurse of No.1 patient 1-D3 Major operation physician of No.1 patient 1-TN2 Nurse in charge of managing the airway of No.1 patient 1-D4 Chief physician of No.1 patient in trauma center 1-TN3 Circuit nurse of No.1 patient 1-S1 Outworker of No.1 patient 1-D5 Specialized chief physician of No.1 patient 1-S2 Assistant of outworker of No.1 patient ȞȞThe first number represents the number of patient; D represents doctor; TN represents nursing staff; S represents work staff
⇧㐫㞞䕆䕿Ȟᕑࡧ⫃ߍѿ㈧᭛⣜Џᕑ䃶ࡧ႒⮰⤲ᔡ喏᭛ᄲ䮎ݹᕑѿ㈧ȟٷ6.2Ȟ݇ѐ㵬ᕓн सᲰᐦ䕆⩱⮰ᕑ㐫㞞䕆䕿喏Бڝᕑ䃶ᕑѿ㈧সᕑ࢝䛹⫳⯽័ѿ㈧̵ѹ̬ѿᰵᱦ㏿ऴ䊣Ბ喏ڱ䮎 ᕑͷ䬠ᓱ䶧ႄᰵᩴڱᄽ₧ύ⢳Ƞ㻰㠯⮰͑䛹݇ѐ⇧㺭Ⅾ䮎ݹȟ䮎ۻ倄⇧ߋ⢳喏䭹Ѻѐ₷⢳স 䶰䂒㖀ٷԍᖛ⇋䕆䲎喏Ꮐ⩔݇ѐ㵬ᕓнڱ⮰ԍᖛ⇋䕆喏䔅ᵣ㘩ᰵᩴ㑕ⴙ⇧ᬢ䬠Ƞߌᑦ䮎ݹȟ䮎 ߔ㈧㐋Ƞ䮎ݹ120ᕑ͙ᓯᣑݜᗏ㔱ऺ喏Ꮐ⿷࢟䔇㵸䮎ݹᔗ䕋䃰ќܲᷬ喏̺ᣑᩢࡧ䮎ंᓃ㖀㈧喏ज़ߔ㐫㞞 ⇧εं䉡ڱᕑ䃶ࡧߍϦ៑ॶѐᗱۡ喏䄣Ⅾֆຩᣑ䃶۲ำ喏ͦѐ⮰䮎ڱ⇧䕆䕿喏Ꭲガ㺭ऽ䮎 ⇧⇧͙䶧ាᤍᕑ⮰Ąᬢᩴᕓą喏ᒝ৹ఌ㉌࠱᠘ᕑ䃶ᬕ䃰ќࣶᔗ䕋ٷѐ㵬ᕓн݇ڱᬢ䬠Ƞ䮎 㘩߇ȟⰤᏀᱛϦ䛻ࣶឬᱛ߇䛻ȟ叧䚵ࡧጴឬᱛⅠБࣶᱛა⮰ᕑ䃶ᱛ䙹ᆊ߇䛻喏䲊፤䛹㺭⮰̬ ◥᭛㺭ࡧߍะȟᕑ䃶ࡻ䄯̷ᐦ⿷Бᗏ㔱͙ͦᓯ⮰㐫㞞䕆䕿喏фࡂࡧ⫃័⤲≭⼷喏Бԉ䃭㐫㞞䕆䕿⮰⩱ 䕆Ƞ ࡧ႒ᱮᔃȞ2017Ꭰ12ᰴ1ᬑȞじ42ࢣȞじ12ۇ1036Ȟ 㼏ᩪ
7ȞᕧȞȞ㏿
ᄽ݇ۻტᏙ䕌β↵䛹䉋៱Ƞ͑䛹݇ѐ⮰ࣽ⩋⢳䊶Ბ䊶倄喏ڟ䛹݇ѐᄨ㜠⮰₧ύস₷⫪㐅цসⰤ͑ ᰵ䛹㺭ᘻ͵Ƞڣѐ⮰ࣽ⩋স݇ѐऺ⮰ᰵᩴะ⤲ᄥцȟტᏙࣶ͖ѿふ ⫳Ђᄥڢ㵬ȟԉᠭন।䕿䕆⩱ȟ⋞ѿู㟻ȟ₎⬇Бࣶܦᗏ㔱喏ദ᱘⇧⫃ᣖ࠱᠘ᣓݢٷѐ㵬ᕓн݇ ද⣛ڱᕧⰚᴳ᭛䛳ं͖ѿࡂᣖᩥરᓚᓖ⣛ࣶ⅓ݕ⩔䯈ⶹ喏ᖎู⫄⇧ٷ喏सᬢ∔ᘻ㻮ᄋर䶥ᠳᴳȠн⫄⇧ ⽟Ƞ㔸̹स䭢⃡⇧⫃ⰚᴳᏀᰵᝬ̹स喏Ꭲ⯽≷ⰤᏀᠳᴳȠ ⣜স̹ᣎ㉎喏͑䛹݇ѐᗏ㔱⮰⇧ጞ㏻Ϻࡧ⫃ᱦᲰݹݜηࣽڑ⌝䃐䃲⮰ٷ䮻ⱬᄥ݇ѐ㵬ᕓн 䩚Ƞڟ䶰ऺ⮰ٷ౦喏䰬㺭ܲᓱε៎ѐȠദκᓖ䃭ᠳࢃ⮰ๆ႒も⪑᭛ᩥર݇ѐ㵬ᕓн
̿ტ㏰(Б℻⩧ͦᎻ)喝 ȟ䗒↋ȟᅥ᪳ȟ䖿ڜ⦉⢷ȟ⢷ᬙ͈ȟ⢷ћ㞛ȟ⢷ᡛᲜȟڡκ႒ᔌȟκᴽ␔ȟ侘᰷᳃ȟ⢷ȟ⢷Оȟ⢷䰖ȟ⢷๕ ȟतेݕȟुьᴝȟᱝ䪫ͪȟᱝࡺᴷȟᱝ㐓㏎ȟ݄ᬺࡺȟ䬗݆ȟ䃤ۇ⺑ȟጒⅤ∎ȟࢎ͙ȟ⩜㠝ȟ⩜᭙⋇ȟ⮩䷂ ȟ↴ᐬ䛽ȟᑌ⢵ȟᑌछȟۇȟҁᄻڜ䧭ȟ䃤ⶁ䉡ȟ䭟᪳ȟ㟻ⷶȟᱺᄻ㏞ȟᱺഥₒȟᱺ㐠ࠐȟᱺ䊱ΪȟᲔ⿷ᆝȟॠϘ ᑌыȟᑌ㠮ȟᑌ⇿ȟᑌ᪳ₒȟᑌ䔊䭟ȟᑌߞᲪȟᑌᑦȟᑌᐦሜȟᑌ⊣✁ȟᑌ䩍݆ȟᑌ䊱ȟ䭲̬协ȟ䭴ᔃȟ䭴༭ȟ ȟ᳃◟䩡ȟ䛽㏎ᬙȟঔϦᲜȟঔ上㭺ȟঔ㢏᪸ȟ䗽ٲ㠝ȟ䭴⢵ȟ䭴䒵ȟ䭴⊣协ȟ㠯ᮔ㟟ȟ᳃ܐ䭴䨷ȟ䭴丅ȟ䭴 ȟ䊡݆ȟ䊡᩻ȟ䊡᪸ȟ䊡ᄻ݆ȟ䊡͈ȟ༆ᬺȟ⼒ࢲᲜȟ㕮ᬢࢃȟᴠ㞟㟘ȟᴠ㞟㟘ȟۇ❝φႵȟࢁȟࢁᔃ݆ȟࢁ ȟ台Ϛȟᰥ䧜ȟᏣ֑ȟੲᓣφȟᶭ᭪⇵ȟᒙٵȟᒼሜȟ䘙ыȟ䘙ᴽᒘȟ਼ᔌᔃȟ਼ᴆ䱾ȟᵽ䩍ۇᭋ∎ȟ䧝ьνȟᒼچ ȟ偻㩆ڡڬȟ叺ᾬȟ⒄䮕䨷ȟ⒄ᰅᬺȟۇ℗ȟ】᱉䭟ȟᰪ㏎ȟ㩍᪳ыȟ㸠ӻȟἶٯ卻ȟ㦏ทℽȟ㦷哅
ȭ࣮㔯᪳⡚Ȯ
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(ᩢ⽫ᬑ喝2017-11-10喞Ԛఊᬑ喝2017-11-20) (䉏Ч㑂䒽喝⚶♢)