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    創傷的液體復蘇
    原作者: J.V. Nable, Michael 文章來源: 《中華急診醫學雜志》編輯部 發布日期:2013-03-20

    Title: Trauma Fluid Resuscitation
    題目:創傷的液體復蘇
    Authors 作者: J.V. Nable, Michael Bond, & John Greenwood

    I. Pre-hospital 院前
    a. One study found urban trauma patients only receive 17 min and 380mL of IVF before arriving at the hospital
    一個研究報告指出城市外傷病人平均需要17分鐘送到醫院并在到達醫院前僅僅接受380毫升的靜脈液體。
    b. One study of patients with penetrating trauma found no statistical difference in
    mortality between those who received <100mL IVF vs >100mL IVF
    一個研究穿透傷病人的報告顯示在接受100毫升以下和以上液體的病人間的死亡率沒有統計學差異。
    c. Large recent study of 776,000 patients showed a death OR of 1.1 in patients who
    received IVF pre-hospital
    最新的一個包括了77萬6千病人的報告指出院前接受靜脈輸液的病人的死亡比值比是1.1。
    d. More important is to get patients to the hospital quickly than to take the time to place IV in field
    比在現場花時間放置靜脈更重要的是盡快將病人轉運到醫院。

    II. ED management 急診科治療
    a. Permissive hypotension leads to better outcomes!
    允許性低血壓措施預后較好!
    b. Giving lots of IVF leads to increased BP and increased blood loss, which includes loss of clotting factors. This contributes to the trauma “triad of death:” coagulopathy, hypothermia, and acidosis.
    靜脈輸液過多可在升高血壓的同時增加失血量,包括凝血因子的丟失, 進而導致外傷“死亡三要素“的產生:凝血功能紊亂,低溫,和酸中毒。
    c. In patients with significant blood loss and persistent hypotension/AMS despite 1L
    IVF, move quickly to massive transfusion protocol (1:1:1 PRBC, FFP, platelets), leads to better outcomes
    對于大失血和輸1升液體后血壓仍低/神志不清的病人,積極采用快速大量輸血方案(全血,血漿和血小板,按1:1:1的比例)預后較好。
    d. ABC score (1 point for each, higher the points the higher the likelihood of benefit from massive transfusion protocol): Penetrating injury, Tachycardia (HR >120), Hypotension (SBP <90), Positive FAST
    預測輸血評分標準(每一項一分,分越高,大量輸血方案改善預后的可能性越大):穿透傷,心動過速(心率超過120),低血壓(收縮壓低于90),FAST腹部超聲陽性。
    f. CAVEAT: No permissive hypotension in patients with TBI!!!!!
    注意:允許性低血壓在腦外傷中不適用!!!!

    III. CCM in ED 危重病醫學在急診科的應用
    a. Lactate – if going the wrong direction, give more blood, not pressors or crystalloid
    監測乳酸-如升高,多輸血,不要用升壓藥或晶體液
    b. Check ionized calcium when giving bloods
    輸血時要監測游離鈣
    c. Keep patient warm, Continuous rectal temp monitor, In-line IV warmers, Humidified air for vent
    保持病人溫度:持續直腸溫監測,靜脈輸液溫化器,呼吸機氣體霧化
    d. Sedate and control pain (think fentanyl)
    鎮靜和疼痛控制(可考慮用芬太尼)
    e. Complications: Early ARDS or transfusion related acute lung injury and ACS
    注意合并癥:早期呼吸困難窘迫綜合征或與輸血有關的肺損傷和腹部筋膜室綜合征

    References 參考文獻:
    Dalton AM. Prehospital intravenous fluid replacement in trauma: an outmoded concept? Journal of the Royal Society of Medicine 1995;88(4):213-16.
    Yaghoubian A, Lewis RJ, Putnam B, De Virgilio C. Reanalysis of prehospital intravenous fluid administration in patients with penetrating truncal injury and field hypotension. American Surgeon 2007;73(10)-1027-30.
    Haut ER, Kalish BT, Cotton BA et al. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Annals of Surgery 2011;253(2):371-7.
    Bickell WH, Wall MJ Jr., Pepe PE et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New England Journal of Medicine 1994;331(17):1105-9.

    文章來源:《中華急診醫學雜志》編輯部

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