Med J Chin PLA, Vol. 42, No. 12, December 1, 2017 ǂ1029 䃲eڝeᠳࢃ̺ ӵϔߙᡇ੢ϊҍᣴ໓͌ܠ੠ᣴ̹ࢴҝᣱ ͙఩ࡧጴࡻцᕑ䃶ܲц ᕑ᩽ࡧ႒̿͆ༀ঄цۇ͙఩Ϧℽ㼏ᩪ 䛹⫳ࡧ႒̿͆ༀ঄цۇ͙఩Ϧℽ㼏ᩪ ͙఩ࡧጴࡻцᕑ䃶ܲцᕑ䃶โ⻽̿͆ༀ঄ц 喞ᕑ᩽ٷ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⮰⇧⫃ᣖ᫩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᩽⇧⮰Ⱔ㉓ٷⰚݹ᜽఩ᅆᬌ݇ѐ๝㵬ᕓн ⇧喏ͦᕑ䃶ࡧጴ᣼Ӈ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12᱋ۇ1030Ȟ 㼏ᩪ ᎟㶍喏㔸㵬Ο䚤ࡳ倄݅䬠ᣑࣹᭌβᱦѿᓚᓖ⣛Ѻ⅓ࣶ㏰㏳㏲㘊㑦⅓⟢ᔭȠ౔ₐᗱ̷ۡ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κѐะБॊ஘স⌱䮐㜠⫱㣸ᝂᐮ➕Ƞ䔮ᑿ⮰►⫳ࣹᏀ౔̬჆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ᑁࣽ๝ᣓᕓ►⫳ࣹ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⫱⤲⩋⤲ദ⵬ȠⰚݹ ูࣶ㟻ᑁ䊣⮰㏰㏳ஔჄᓚᓖٷᢋѐ喝݇ѐ๝㵬ᕓн∔╸ڹ-⻹ճ䄠[7]喝Ŗ݇ѐऺ๝ᣓᕓ►⫳ࣹ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 ݐ᫙Ƞ 3.1Ȟ͠Ꮆ㶔⣜ȞЏ֫᱋㶔⣜喝ͧ㺭Б⋞ѿ͎๝ȟქ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Ƞ๝Џ֫᱋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⯚㗐㟝᪽Ƞₐᬢ᱋छ 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ٷᠳ᪜̺๝㵬䛻সнٷ3.2Ȟ䛻ࡂݐ᫙᫥∁ 㶔1Ȟн ᠳ᪜(shock index喏SI)᭛㘵 Tab.1ȞRelationship between shock index and blood loss andٷᠳ᪜Ȟнٷ3.2.1Ȟн [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ॴ₏Ⱔ 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छ౔ᰵ᲍Т⮰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ᄥݐ᫙๝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12᱋ۇ1032Ȟ 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Ⅰ᎟ᄥн┱ ⮰ᬕ᱋䃶᫙ȟ⇧⫃ᠳᄨࣶ䶰ऺ䃰ќᰵ䛹㺭ᘻ͵[19]Ƞ⃻䯀2~4hߔᔭ⯽≷㵬Ο䚤Ⅰ᎟̹ϱछᢾ䮐̬䓳ᕓ㵬Ο䚤 倄喏䔄छݐ჆⋞ѿู㟻⮰⫃ᩴࣶ㏰㏳㑦⅓⮰ᩥરᗱۡȠ් 㵬ߋ㘩䔇㵸ᬕ᱋স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⇧⫃ϒ࡭ܲ䛹㺭Ƞ 4.3.6Ȟ►⫳ఌၼȞ►⫳ࣹᏀ౔݇ѐ⫱⤲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 4.4Ȟᒝ׻႒ᷬᴑȞႄ౔㵬≭ߔ߇႒̹⽟჆(ᄥქ䛻ู㟻ᬌࣹᏀ)㔱喏Ꮐᅩ䛻䭼ݢ჊᫩䃶᫙ᕓ⮰ᒝ׻႒ᷬ ᴑȠ݇ѐ䛹◥䊱ผ䃰ќ(focused assessment with sonography for trauma喏FAST)᭛̬⻹䛹㺭⮰ᷬᴑ᫥∁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CTភ᣻Ƞᄥκ͑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ݢCTភ᣻ࡦഋ喏⶚ԉϱᄥᓱ㺭䘔ѹ䔇㵸CTភ᣻Ƞ 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<8ܲछݐ჆ͦᬻ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ᕓ๓ᄻᄲ⃻ะᢋѐ䃰ͦ1~6ܲȠISS䃰ܲ㠯 ఠͦ1~75ܲ喏ຮ᳈ࢁࡦഋ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)3⻹ఌ㉌ͦӉᢚ⮰㏿ᅬ䃰ќ᫥∁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፤ٷ᫙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 ⇧⮰㉓ᕑ᩽ٷ5Ȟ݇ѐ๝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⇧⫃ᣖ᫩࠱᠘ᣓݢ ܉䃤ᕓѺ㵬ࢷ喏䒿㵬も⪑喏䶰䭞݇ѐ٭͙⮰ᢋѐᣓݢู㟻も⪑喏ຮᢋѐᣓݢโ⻽ȟ䭼ݢᕓ⋞ѿู㟻छ⼷ 㵬⫱ふȠ Med J Chin PLA, Vol. 42, No. 12, December 1, 2017 ǂ1033 㵬喏䛳ं͖ѿࡂᣖ᫩ᩥરᓚᓖ⣛ࣶ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θ᱋фࡂ䄯᪠䭢⃡喝ڔ䛻౔₏፤ᝂႵܦ঩ѿᒭ᎟⽟喏ԉ䃭㵬ࢷȟᓯ䒿 Ⱊᴳ්ͦߌ㏰㏳⅓Ӈ喏фࡂᓯ䒿ܦ䛻ȟSvO2ࣶ㵬Ο䚤Ⅰ᎟Ƞ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⇧⫃⮰ݹ᣼সദ⵬[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᠕౔ηࣽ⣜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᳈⅀䕿ࣹᄰႄ౔ᝂผ䬔̶⅀䕿㷱㒚̹㘩㒚⩔ ᠭ᝷∁(፤㻰ͦМ๠᣼䶻∁)স㷱㒚(ຮए৩ネȟ呧৩ネࣶવネ)Ƞᒾ᝷ᐬᩪ⅀䕿ᬢ喏Ꮐ∔ᘻᗏ㔱ᰵᬌ䶴Ḻᢋ ѐ喏Ѡࣽ䷈䲎ᢋѐᝂᵨ៵᫛਑䃰ܲ┯8ܲᬢ㘶ᴝᢋѐ⮰࢝䮕ᕓ๓๓්ߌ[24]喏⣜౦ᕑ᩽ᬢᏀ仂䔵ᒾ᝷ద჆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Ꮐ⶚ԉ䒘䓼ᬢ䬠̹䊱䓳60minȠຮ᳈̹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ᄥ᜼Ϧᗏ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【ᄥ᜼Ϧᗏ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ᓃ᜼ܲ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ц᣼ࡳ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ѿ΋ᐦ䃚 䭼ݢҫ⩔[6]Ƞ 㵬⮰ᗏ㔱ҫ⩔䭼ݢᕓ⮰ქ䛻ู㟻も⪑[7]喏Ⱐ㜟ጞ⶚჆Ⴘ᜼ᬕ᱋ܦ5.3.3Ȟქ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ᠭ౔छᬺ᭪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 ദ⵬ᘻ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౔ₐݹ᣼̷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