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1、伤情评估和战场伤员分类,江 雷卫生勤务学教研室,Mass casualties,Any large number of casualties produced in a relatively short period of time,usually as the result of a single incident such as a military aircraft accident,hurricane,flood,earthquake,or armed attack,that exceeds local logistical support capabilities.,The term
2、 mass casualties means that a large number of casualties has been produced simultaneously or within a relatively short period of time.It also means that the number of patients requiring medical care exceeds the medical capability to provide treatment in a timely manner.An absolute disparity exists b
3、etween the number of patients,the available medical resources and timely treatment.,Mass casualty situation,A mass casualty situation is present when one combat medic is confronted with two critically injured patients at the same time.With a large number of casualties,the disparity may be multiplied
4、 many times;this greatly disrupts the doctrinal approach to treatment and evacuation.In addition to the treatment and evacuation of a large number of military and civilian casualties,problems may occur from disruptions in the supply,communication,and transportation systems.,“在包扎所内最重要的是伤员优先分类，然后对所有伤员
5、合理配置医疗救护工作，比起仓促慌忙上手术好得多，后者仅只能救活不多的伤员。”俄皮洛果夫,N.A.叶菲缅科主编（涂通今主译）：野战外科学，P5.人民军医出版社，2005年10月,什么是伤情评估？,伤情评估是指在战场上运用简明的应急诊断技术，迅速地对伤员情况进行初步判断，进而以量化标准来判定伤员损伤的严重程度，从而指导战场伤员分类救治，预测战伤结局以及评估救治质量。,一、伤情评估方法,院前评分院内救治和创伤研究评分,伤 情 损伤程度 治愈时间 预后 比例轻 伤 软组织伤 30天内 良好 40%中等伤 广泛软组织伤、60天内 部分伤员机能 35%上肢骨折、一般脏器伤 障碍，影响归队重 伤 伤情严重、
6、60天以上 严重残废 25%有生命危险 或后遗症,伤势分度与百分比,院前指数（Pre-hospital index，PHI）,轻伤：0-3分 重伤：4-20分,CRAMS评分法,轻度：9-10分，重度：7-8分，极重度：0-6分,创伤计分（Trauma score）,1-16分，12分为重伤,Glasgow Coma Scale，GCS,校正的创伤积分(Revised Trauma Score，RTS),简易战伤评分方法,伤员伤势评估及处置顺序,二、战场伤员分类,Triage of mass casualties,The evaluation and classification of cas
7、ualties for purposes of treatment and evacuation.It consists of the immediate sorting of patients according to type and seriousness of injury,and likelihood of survival,and the establishment of priority for treatment and evacuation to assure medical care of the greatest benefit to the largest number
8、.,HistoryThe word triage is a French word meaning sorting,which itself has been influenced from the Latin tria three.The term has historically meant sorting into three categories,although this is no longer necessarily the case.Much of the credit for modern day triage has been attributed to Dominique
9、 Jean Larrey,a famous French surgeon in Napoleons army who devised a method to quickly evaluate and categorize the wounded in battle and then evacuate those requiring the most urgent medical attention.He instituted these practices while battle was in progress and triaged patients with no regard to r
10、ank.Others have cited the Russian surgeon,Nikolai Pirogov,as developing the triage system during the Crimean War.,Triage is accomplished by highly experienced medical personnel who can make sound and quick clinical judgments.Medical personnel identify each patient by a category title which indicates
11、 the urgency of his receiving treatment and likelihood of his survival based upon the clinical problems and availability of medical care.Rapid triage assures that the available treatment is directed to the patients who have the best chance to survive.,分类的意义,战场伤病员分类是实施战场伤病员救护管理的一个重要环节。战时伤员数量大，伤病种类复杂，
12、救治时间紧迫，救治力量有限。由此产生了救治需要与可能之间的矛盾,重伤病员与轻伤病员之间、部分伤病员与全体伤病员之间救治的矛盾。为解决这些矛盾，就必须对伤病员进行分类。通过分类将有限卫勤力量首先用到需挽救生命的危急伤员上。,分类的目的,分类的目的在于保证每个伤病员得到及时合理的救治和后送。保证在伤病员众多的条件下,做好救治工作，使救治工作有条不紊地进行；充分发挥卫勤人力物力作用，促进医疗后送工作的多快好省。区分伤病的轻重缓急,确定救治和后送的先后次序;根据伤类、伤情,确定伤员救治措施;确定伤员后送体位和工具。以保证各种伤员得到最合理的处置。,分类的方法,伤部伤类伤型伤情,急救优先等级,紧急处置重
13、伤优先处置中度伤常规处置轻伤期待处置危重伤,Treatment categories:P systems,P1-Immediate TreatmentP2-Delayed TreatmentP3-Minimal TreatmentP1 Hold-Expectant Treatment,priority,Immediate.This category is for the patient whose condition demands immediate,resuscitative treatment.An example of this treatment is the control of
14、hemorrhage from an extremity.Generally,the procedures used are short in duration and economical in terms of medical resources.(Approximately 20 percent of the casualties are normally in this category.),Delayed.This category is for the patient whose condition is such that,with the application of mode
15、st emergency procedures,the possibility of disease or death increases very little by delaying major definitive procedures until they can be performed.An example of this emergency procedure would be an adequately splinted closed fracture.(Approximately 20 percent of the casualties are normally in thi
16、s category.),Minimal.This category is for the patient who can be returned to some form of duty by performing procedures requiring minimal resources.Follow up treatment may be needed after the disparity phase is terminated.(Approximately 40 percent of the casualties are in this category and most are
17、ambulatory.),Expectant.This category is for the patient whose injuries are massive and the probability of his survival is questionable.Examples of patients in this category are those with severe head injuries or massive severe burns.Providing the greatest good for the greatest number during the peri
18、od of medical disparity dictates that a minimal number of medical personnel manage this category of patients.Patients should be managed with alertness(expectancy)to changes in their condition.They should be given symptomatic and supportive care until the available medical resources permit an intensi
19、ve effort in their behalf.(Approximately 20 percent of the casualties are normally in this category.),The T(Treatment)system of triage,is an alternative to the P system and is routinely used by the RN,the RAF,NATO allies,the International Committee of the Red Cross,civilian ambulance services and in
20、 civilian disaster programs.,The relationship between the two systems is as follows:P1 is equivalent to T1P2 is equivalent to T2P3 is equivalent to T3P1 Hold is equivalent to T4Dead is still Dead.,Triage for treatment,A simple,safe,rapid and reproducible system is required that can be applied by any
21、 Serviceman with appropriate medical trainingPhysiological systems that look at the consequences of injury(a change in the Vital Signs：Respiratory Rate,Pulse Rate and Capillary Refill Time CRT are more reliable than anatomical systems（which require extensive clinical knowledge and a need to undress
22、the casualty）,Triage Sieve,Simple triage and rapid treatment(START)triage algorithm,Triage is only a“snapshot”of how the casualty is at the time of assessmentIn order to identify changes in the casualtys condition，the triage sieve must be repeated at each link of the evacuation chain.It is important
23、 initially not to try to predict how a casualty may deteriorate,this will lead to over-triage（a higher than necessary triage category）and can overwhelm the system with P1 and P2 casualties.,Triage for treatment,Limited time and personnel resources may prohibit a more detailed triage assessment other
24、 than that given by the triage sieve.When possible,the Triage Sort can be used to refine the triage sieve decisionsTriage sort uses the respiratory rate,systolic blood pressure and Glasgow Coma Scale，to numerically score the casualty from 0 to 12 and give an indication of priority for evacuation and
25、/or the need for further interventionThis score has a proven direct relationship to outcome from severe injury.,Priorities are assigned as:,The overlap in scores allows for the seriously injured to be placed in either category,depending on number of casualties and resources available of evacuation.,
26、Evacuation will be delayed when the number of casualties outstrips available transport.In this situation，the greater time spent with the casualty will allow additional anatomical assessment of injuries.Where the primary determined by physiology does not match the anatomical severity of injuries,the
27、priority can be upgraded,Example:A soldier loses his left leg in a landmine incident.Immediate first aid is effective in stopping hemorrhage.He is transported to the division aid station.He cannot walk,his respiratory rate is 22 and his pulse is 110/minute.He is triaged?for treatment(Triage Sieve).,
28、He then receives intravenous fluids and analgesia.His systolic BP is 115 mmHg,his respiratory rate is 20,he is fully alert,with a GCS of 15.He scores 12 on his Triage Sort,which is P3 for evacuation.Clearly,he requires early surgical treatment and the surgeon upgrades his priority to P2 for evacuati
29、on to the field hospital.,Chinese triage:wound marker,Sign of sorting,advanced triage systems,In advanced triage systems,secondary triage is typically implemented by paramedics,battlefield medical personnel,or by skilled nurses in the emergency departments of hospitals during disasters,injured peopl
30、e are sorted into five categories.,Blue/Expectant They are so severely injured that they will die of their injuries,possibly in hours or days(large-body burns,severe trauma,lethal radiation dose),or in life-threatening medical crisis that they are unlikely to survive given the care available(cardiac
31、 arrest,septic shock);they should be taken to a holding area and given painkillers to ease their passing.Red/Immediate They require immediate surgery or other life-saving intervention,first priority for surgical teams or transport to advanced facilities,cannot wait but are likely to survive with imm
32、ediate treatment.,Yellow/Observation Their condition is stable for the moment but requires watching by trained persons and frequent re-triage,will need hospital care(and would receive immediate priority care under normal circumstances).Green/Wait They will require a doctors care in several hours or
33、days but not immediately,may wait for a number of hours or be told to go home and come back the next day(broken bones without compound fractures,many soft tissue injuries).White/Dismiss They have minor injuries;first aid and home care are sufficient,a doctors care is not required.,根据以下描述给出伤员创伤计分，并判断相应的急救优先等级。某部队战士赵晓明5小时前，被炮弹弹片炸伤右颞部。当即昏迷，战友包扎救下，到营救护所时清醒15分钟，曾呕吐二次，团救护所注射单位，庆大霉素8万单位。目前伤员仍呈昏迷状态，伤侧瞳孔散大，对光反射消失，左下肢瘫痪，呼吸困难，脉搏55次分，血压14796mmHg。,
