创伤的液体复苏
原作者： J.V. Nable, Michael 文章来源： 《中华急诊医学杂志》编辑部 发布日期：2013-03-20

Title: Trauma Fluid Resuscitation
题目：创伤的液体复苏
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
一个研究报告指出城市外伤病人平均需要17分钟送到医院并在到达医院前仅仅接受380毫升的静脉液体。
b. One study of patients with penetrating trauma found no statistical difference in
mortality between those who received <100mL IVF vs >100mL IVF
一个研究穿透伤病人的报告显示在接受100毫升以下和以上液体的病人间的死亡率没有统计学差异。
c. Large recent study of 776,000 patients showed a death OR of 1.1 in patients who
received IVF pre-hospital
最新的一个包括了77万6千病人的报告指出院前接受静脉输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
比在现场花时间放置静脉更重要的是尽快将病人转运到医院。

II. ED management 急诊科治疗
a. Permissive hypotension leads to better outcomes!
允许性低血压措施预后较好！
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.
静脉输液过多可在升高血压的同时增加失血量，包括凝血因子的丢失， 进而导致外伤“死亡三要素“的产生：凝血功能紊乱，低温，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
对于大失血和输1升液体后血压仍低／神志不清的病人，积极采用快速大量输血方案（全血，血浆和血小板，按1：1：1的比例）预后较好。
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
预测输血评分标准（每一项一分，分越高，大量输血方案改善预后的可能性越大）：穿透伤，心动过速（心率超过120），低血压（收缩压低于90），FAST腹部超声阳性。
f. CAVEAT: No permissive hypotension in patients with TBI!!!!!
注意：允许性低血压在脑外伤中不适用！！！！

III. CCM in ED 危重病医学在急诊科的应用
a. Lactate – if going the wrong direction, give more blood, not pressors or crystalloid
监测乳酸－如升高，多输血，不要用升压药或晶体液
b. Check ionized calcium when giving bloods
输血时要监测游离钙
c. Keep patient warm, Continuous rectal temp monitor, In-line IV warmers, Humidified air for vent
保持病人温度：持续直肠温监测，静脉输液温化器，呼吸机气体雾化
d. Sedate and control pain (think fentanyl)
镇静和疼痛控制（可考虑用芬太尼）
e. Complications: Early ARDS or transfusion related acute lung injury and ACS
注意合并症：早期呼吸困难窘迫综合征或与输血有关的肺损伤和腹部筋膜室综合征

References 参考文献:
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.