1、傷情評估和戰(zhàn)場傷員分類,江 雷 衛(wèi)生勤務學教研室,1,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.

2、,2,The term 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 dispa

3、rity exists between the number of patients, the available medical resources and timely treatment.,3,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

4、 may be multiplied 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.,4,

5、“在包扎所內最重要的是傷員優(yōu)先分類，然后對所有傷員合理配置醫(yī)療救護工作，比起倉促慌忙上手術好得多，后者僅只能救活不多的傷員?！?俄皮洛果夫,N.A.葉菲緬科主編（涂通今主譯）：野戰(zhàn)外科學，P5.人民軍醫(yī)出版社，2005年10月,5,什么是傷情評估？,傷情評估是指在戰(zhàn)場上運用簡明的應急診斷技術，迅速地對傷員情況進行初步判斷，進而以量化標準來判定傷員損傷的嚴重程度，從而指導戰(zhàn)場傷員分類救治，預測戰(zhàn)傷結局以及評估救治質量。,6,一、傷情評估方法,院前評分 院內救治和創(chuàng)傷研究評分,7,傷 情 損傷程度 治愈時間 預后 比例 輕 傷 軟組織傷 30天內 良好 40% 中等傷 廣泛軟組織傷、 60天內 部

6、分傷員機能 35% 上肢骨折、一般臟器傷 障礙，影響歸隊 重 傷 傷情嚴重、 60天以上 嚴重殘廢 25% 有生命危險 或后遺癥,傷勢分度與百分比,8,院前指數(shù)（Pre-hospital index，PHI）,輕傷：0-3分 重傷：4-20分,9,CRAMS評分法,輕度：9-10分，重度：7-8分，極重度：0-6分,10,創(chuàng)傷計分（Trauma score）,1-16分， 12分為重傷,11,Glasgow Coma Scale，GCS,12,校正的創(chuàng)傷積分 ( Revised Trauma Score，RTS ),13,簡易戰(zhàn)傷評分方法,14,傷員傷勢評估及處置順序,15,二、戰(zhàn)場傷員分類,

7、16,Triage of mass casualties,The evaluation and classification of casualties 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 evacuat

8、ion to assure medical care of the greatest benefit to the largest number.,17,History The 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

9、 case. Much of the credit for modern day triage has been attributed to Dominique 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 the

10、se practices while battle was in progress and triaged patients with no regard to rank. Others have cited the Russian surgeon, Nikolai Pirogov, as developing the triage system during the Crimean War.,18,Triage is accomplished by highly experienced medical personnel who can make sound and quick clinic

11、al judgments. Medical personnel identify each patient by a category title which indicates 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 pati

12、ents who have the best chance to survive.,19,分類的意義,戰(zhàn)場傷病員分類是實施戰(zhàn)場傷病員救護管理的一個重要環(huán)節(jié)。戰(zhàn)時傷員數(shù)量大，傷病種類復雜，救治時間緊迫，救治力量有限。由此產生了救治需要與可能之間的矛盾, 重傷病員與輕傷病員之間、部分傷病員與全體傷病員之間救治的矛盾。為解決這些矛盾，就必須對傷病員進行分類。通過分類將有限衛(wèi)勤力量首先用到需挽救生命的危急傷員上。,20,分類的目的,分類的目的在于保證每個傷病員得到及時合理的救治和后送。保證在傷病員眾多的條件下, 做好救治工作，使救治工作有條不紊地進行；充分發(fā)揮衛(wèi)勤人力物力作用，促進醫(yī)療后送工作的多快好

13、省。區(qū)分傷病的輕重緩急, 確定救治和后送的先后次序; 根據(jù)傷類、傷情, 確定傷員救治措施; 確定傷員后送體位和工具。以保證各種傷員得到最合理的處置。,21,分類的方法,傷部 傷類 傷型 傷情,22,急救優(yōu)先等級,緊急處置重傷 優(yōu)先處置中度傷 常規(guī)處置輕傷 期待處置危重傷,23,Treatment categories:P systems,P1-Immediate Treatment P2-Delayed Treatment P3-Minimal Treatment P1 Hold-Expectant Treatment,priority,24,Immediate. This category

14、is for the patient whose condition demands immediate, resuscitative treatment. An example of this treatment is the control of 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 a

15、re normally in this category.),25,Delayed. This category is for the patient whose condition is such that, with the application of modest emergency procedures, the possibility of disease or death increases very little by delaying major definitive procedures until they can be performed. An example of

16、this emergency procedure would be an adequately splinted closed fracture. (Approximately 20 percent of the casualties are normally in this category.),26,Minimal. This category is for the patient who can be returned to some form of duty by performing procedures requiring minimal resources. Follow up

17、treatment may be needed after the disparity phase is terminated. (Approximately 40 percent of the casualties are in this category and most are ambulatory.),27,Expectant. This category is for the patient whose injuries are massive and the probability of his survival is questionable. Examples of patie

18、nts in this category are those with severe head injuries or massive severe burns. Providing the greatest good for the greatest number during the period of medical disparity dictates that a minimal number of medical personnel manage this category of patients. Patients should be managed with alertness

19、 (expectancy) to changes in their condition. They should be given symptomatic and supportive care until the available medical resources permit an intensive effort in their behalf. (Approximately 20 percent of the casualties are normally in this category.),28,The T(Treatment) system of triage, is an

20、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 civilian disaster programs.,29,The relationship between the two systems is as follows: P1 is equivalent to T1 P2 is equivalent to T2 P3 is e

21、quivalent to T3 P1 Hold is equivalent to T4 Dead is still Dead.,30,Triage for treatment,A simple, safe, rapid and reproducible system is required that can be applied by any Serviceman with appropriate medical trainingPhysiological systems that look at the consequences of injury (a change in the Vita

22、l 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 the casualty）,31,Triage Sieve,Simple triage and rapid treatment (START) triage algorithm,32,33,Triage is only a “snapshot” of

23、how the casualty is at the time of assessment In order to identify changes in the casualtys condition，the triage sieve must be repeated at each link of the evacuation chain. It is important initially not to try to predict how a casualty may deteriorate, this will lead to over-triage（a higher than ne

24、cessary triage category）and can overwhelm the system with P1 and P2 casualties.,Triage for treatment,34,Limited time and personnel resources may prohibit a more detailed triage assessment other than that given by the triage sieve. When possible, the Triage Sort can be used to refine the triage sieve

25、 decisions Triage 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/or the need for further intervention This score has a proven direct relationship to outcome from sever

26、e injury.,35,36,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.,37,Evacuation will be delayed when the number of casualties outstrips available transport. In th

27、is 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 priority can be upgraded,38,Example: A soldier loses his left leg in a landmine incident.I

28、mmediate 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).,39,He then receives intravenous fluids and analgesia. His systolic BP is 115 mmHg

29、, 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 evacuation to the field hospital.,40,Chinese triage :wound marker,41,Sign of sor

30、ting,42,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 people are sorted into five categories.,43,Blue / Expectant The

31、y 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 arrest, septic shock); they should be taken to