【创伤外科】第1期（含ppt）。第2期ing：创伤首诊与处理（此处仅有翻译，精彩

我认领第七部分－－－（3）根据bo兄意见修正。________________________________________items needed for trauma bay setup.创伤室的组成1. a bed: it should be mobile, you can move it very easily and change patient position easily床：要求该床具有很强的移动性能，根据需要随时调整位置。2. Operating lights over the bed无影灯：床上方得有手术用的无影灯3. cardiac monitor (including EKG, BP, SaO2)心电监护仪：包括心电图，血压，动脉血氧饱和度。4. A-line set up动脉压监测仪5. O2, and wall suction墙上有供氧及负压吸引通路6. defibrillator电除颤仪7. central line kits中心通路套装8. pressure transfusion set up输液加压器9. warmer for warm fluids液体加温保温箱10. warmer to keep warm blanket毛毯加温保温箱11. FAST machine( Focal Assessment with Sonography for Trauma): it is an ultrasound machine, has replaced DPL)创伤用超声诊断机12. X-ray machineX线机13. X-ray reading monitorX线读片机14. gloves (both sterile and nonsterile), masks, gowns, shoe-covers手套（包括无菌和普通手套），防毒面具，长防护服，鞋套，15. procedure trays: including intubation, cricothyroidotomy, tracheostomy, chest tube, thoracotomy.....操作架：为急救操作提供便利。16. bare hugger (to warm the patient)暖体机（提高患者体温）17. NGT鼻胃管18. foley.Foley导管________________________________________________________________________________________________________________________附段落全文。创伤室的组成1. 创伤床：要求该床具有很强的移动性能，根据需要随时调整位置。2. 无影灯：床上方得有手术用的无影灯3. 心电监护仪：包括心电图，血压，动脉血氧饱和度。4. 动脉压监测仪5. 墙上有供氧及负压吸引通路6. 电除颤仪7. 中心通路套装8. 输液加压器9. 液体加温保温箱10. 毛毯加温保温箱11. 创伤用超声诊断机12. X线机13. X线读片机14.手套（包括无菌和普通手套），防毒面具，长防护服，鞋套，15.操作架：为急救操作提供便利。16.暖体机（提高患者体温）17.鼻胃管18. Foley导管图片上的文字说明The whole view of trauma bay 11号创伤室全景the red line: everybody stands behind the red line except the trauma team doing assessment and the resuscitation.红色警戒线：创伤组对患者做评估和复苏时，其他人员一律站在红色警戒线以外。central line kits and pressure transfusion set up. 中心通路套装和输液加压器FAST machine: with this machine, you can detect cardiac tamponade, any blood/fluid at right upper quadrant (liver laceration), left upper quadrant (spleen laceration), pelvis in 1 minute. 创伤专用超声机：有了这个机器，可以迅速判断是否有急性心包填塞，腹腔积液以及肾盂的损伤。bare hugger: to warm cold patient, treat hypothermia.裸抱机：温暖体温过低患者IV fluids warmer: always resuscitate trauma patients with warm lactated Ringer's (LR)静脉输液加温保温箱：常规用加温后的乳酸林格氏液进行复苏。Portable X-ray machine: 便携式x线机intubation kit:气管插管套装sterile gloves无菌手套triage nurse: she pages us when there is a trauma coming in.分诊护士：创伤患者来了后由她来发出呼叫信号。warmer to keep the warm blanket 毛毯加温保温箱Computers for X-ray reading.X线读片机OR next door. all the operating rooms should be on the first floor, next to emergency room and trauma bay.隔壁就是手术室：所有的手术室要求在一楼，紧邻急诊室和创伤室。认领问答部分(九)(3)至(十)(2)(3)BO:looks like he is not septic. major problems are1. head injury which neurosureon should have some input. he probably can't protect his airway.2. resp. failure. does he have ARDS? How long has he been on Vent. he failed extubation once already, and can't be wean off vent. you probably want to think about tracheostomy. interesting enough, it is easier to wean off after tracheostomy.3. wound: looks like needs aggressive dressing change and debridement PRN.4. Rehab is a big issue for him too. 看起来不像是脓毒症，主要的问题是：1、脑部外伤，应该请神经外科医师会诊。可能没法很好地保护气道。2、呼衰。病人是不是存在ARDS？他上呼吸机已经多久了？他曾经撤过呼吸机，但现在又无法撤机。你们应该考虑下做气管切开。很有意思，做了气管切开后反而更容易撤机。3、外伤：看起来需要更好的包扎和随时清创。4、机能恢复对他也是个大问题。(4)BO:i have too limited information to figure out why he is vent dependent. do you have CXR, CT of the chest, blood gas, ventilator setting in details, like what mode, rate, how much peep and pressure support? how's his phosphorous level? 我现在也说不上他为什么无法撤呼吸机。你们做了胸片、胸部CT、血气分析吗？呼吸机的设置参数具体如何？比如模式、频率、PEEP用了多大？血磷水平？－－－－－－－－－－－－－－－－－（十）－－－－－－－－－－－－－－－－－－－－－(1)BO：even before patient's arrival, we have emergent blood release, type O packed RBC, at least 4 units ready at trauma bay. if the patient needs blood, he will get it in 0 seconds since it is already there. we treat patients first, no money issue is involved at that time. all the blood was donated by volunteers and collected by Red Cross. our blood bank gets blood from Red Cross. 在病人到达以前，我们在创伤急救室就已经准备好了急救血液，是O型血的浓缩RBC，至少4个单位。如果病人需要用血，会立刻得到输血。我们处理病人是放在第一位的，这不涉及到钱的问题。我们这所有的血都是志愿者捐献的，并由红十字会负责采集。我们的血库从红十字会取血。(2)BO：damage control surgery was orignally advocated by trauma surgeons since trauma patients sometimes are very unstable and more time in the OR will just make the patient worse, like the lethal triads i discussed before in a post about damage control surgery. this idea has been adopted by my general surgeons for other situation. for severe trauma injury, as you mentioned, damage control works quite well. we do it almost every day. we always have some trauma patients with an open abdomen in the ICU, waiting for wash-out, second look, completion of the surgery.... i have some disussion about damage control in "trauma case #1" too which was a gun shot wound to the abd, IVC injury. Damage control surgery is an idea. because pt is not stable enough for you to complete the surgery in one stage, we need minimize OR time as short as possible to avoid lethal triads (hypothermia, acidosis, coagulopathy) and we can come back to finish the operation.i recommended some books before in the past discussions. 损伤控制性手术最初由创伤外科医师所倡导，因为有时候创伤病人生命体征非常不稳定，在手术室待的时间越长病人的状况反而越差，正像我在以前关于损伤控制手术的贴子里提到的致命三联征。这种意见也被我们普外科医师所接受并用于其他情况。对于严重创伤，正如你提到的，损伤控制性手术效果非常好。我们几乎每天都这样处理。我们在ICU总有一些开放性腹部外伤的病人等着冲洗创口、二期手术继续处理。 我在“创伤病例1”的讲座中将会有一位腹部枪击伤伴下腔静脉损伤的病人会讨论到损伤控制性手术。 损伤控制性手术是一种观念。因为病人病情非常不稳，你没法一期完成手术，我们需要尽量缩短在手术室处理的时间以避免致命三联征(低体温、酸中毒、凝血障碍)，而且我们可以再次进行二期手术。 我在以前的贴子中曾经推荐过几本书。呵呵，我回来了，前段时间出去了，没有来，继续关注……亲密飞翔 wrote:呵呵，我回来了，前段时间出去了，没有来，继续关注……呵呵 long time no see！～welcome back！～16. bare hugger (to warm the patient)暖体机？ （提高患者体温）---------------- that's right17. NGT正常葡萄糖耐量？-------------NGT: nasogastric tubeBoYang1998 wrote:16. bare hugger (to warm the patient)暖体机？ （提高患者体温）---------------- that's right17. NGT正常葡萄糖耐量？-------------NGT: nasogastric tube17. NGT正常葡萄糖耐量？-------------NGT: nasogastric tubenasogastric tube---鼻胃管认领问答部分(十一)(1)(2),有问题请大家及时指正，谢谢－－－－－－－－－－－－－－－－－（十一）－－－－－－－－－－－－－－－－－－－－－(1)BO:the concept of "Intern" is different between china and USA. HERE, intern means the first year resident, just graduated from medical shcool. it is a transitional year from amedical student to a resident. intern year is the hardest year. you work 80-120 hours a week. starts at 4-5am, goes home at 6-7 pm. always in house call. interns (first year residents) and junior residents are supposed to come to the hospital between 4-5 am, finish rounds and daily notes by 6 - 6:15 pm. then the chief residents start rounding and make plans for patients, finish by 7 am. we start operations (cut the skin) at 7:30 am. in the academic setting, the attendings see the patients whenever they like. each attending sees his own patients only unless he is covering for his/her partners. all the general surgery services are run by the chief residents.the rules for interns are: eat whenever you can, sleep whenever you can. the working hours are getting better due the new rule from ACGME who set up a upper limit of working hours of 80 hours/week. 中国和美国的“intern”定义是不同的。在美国，是指从医学院毕业后第一年的住院医师。它是从医学生向住院医师过渡的一年，这一年是非常辛苦的。你一周工作80—120小时，从早上4、5点钟开始，晚上6、7点钟才回家，而且经常在家里被叫回去。 “实习医师”(intern)和低年资住院医师一般要求早上4、5点就到病房，在6—6：15之前完成查房和一些记录工作。然后是7点前住院总查房并为病人制定治疗计划。我们一般是7：30开始手术(切皮)在教学医院,主治可以在任何时候看望病人，每个主治只看自己的病人，除非他是给其他大夫替班。所有的普通外科处理都是由住院总负责。 对于“实习医师”的原则是：找任何有空的时间吃饭，找任何可能的时间睡一觉。在“研究生医学教育鉴定委员会(ACGME)”出台新的规定即一周工作时间不得高于80小时后，“实习医师”的工作量正逐步改善。(2)BO:rehabilitation is a very important part of managing trauma patients. in the hospital, we have specific physical therapist (PT) and occupational therapist (OT). when patients are stable, they go to some rehab facility if they need rehab. those PTs and OT s are very professional and love their job, love to help patient get better. 康复治疗对于处理创伤病人是非常重要的部分。在医院，我们这有专门的理疗师和职业治疗师。病人病情稳定后，如果需要康复治疗，他们就转到某个康复机构。那些理疗师和职业治疗师是非常专业的而且爱他们的工作，乐于帮助病人恢复。in the academic setting－－－理论上规定?在教学医院？亲密飞翔 wrote:in the academic setting－－－理论上规定?从理论上来说？ （意思是主治想什么时候来就什么时候来，非常自由，没有明文规定主治的查房时间。）道可道非常道 wrote:从理论上来说？ （意思是主治想什么时候来就什么时候来，非常自由，没有明文规定主治的查房时间。）呵呵，我得英语比较差，道兄翻译的不错亲密飞翔 wrote:呵呵，我得英语比较差，道兄翻译的不错飞兄可别过谦！事实证明飞兄的翻译是正确的，呵呵，楼下是bo兄的回复贴。 亲密飞翔 wrote:in the academic setting－－－理论上规定?在教学医院？亲密飞翔 was right. academic setting means university hospitals, different from private practice hospitals. however, in private practice hospitals, it is the same. since there are no residents, the surgeons do rounds themselve. they can do it whenever they want.我认领第七部分－－－（4）。we are getting to the end of the first discussion. i plan to start the second discussion of trauma which is "initial assessment and management for trauma patients" some time next week.第一期的内容已近尾声，我计划下周开始第二期的内容－－－创伤患者的早期评估和处理。one more i'd like to discuss before the ending is the concept of trauma.在结束第一期之前，我想再谈谈创伤外科几个理念。three underlying concepts of trauma management which may be difficult to accept initially:以下是创伤外科三个基本理念，可能刚开始是你比较难以接受的。1. the most important concept is to treat the greatest threat to life first.对创伤患者救治最重要的一点“先救命后治病”2. the lack of a definitive diagnosis should never impede the applicaiton of an indicated treatment不能为了明确诊断而延误治疗。3. A detailed history was not essential to begin the evaluation of an acutely injuryed patient. 在创伤早期评估中，可以暂不必详细追问病史。The result was the development of the "ABCDE" approach to the evaluaiton and treatment of the injuryed, which will be the core of the second discussion of trauma surgery. （理论指导实践）上诉三个理念带来了创伤外科早期评估和处理的发展，也是我们下阶段专题交流的核心内容。－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－附段落全文。第一期的内容已近尾声，我计划下周开始第二期的内容－－－创伤患者的早期评估和处理。在结束第一期之前，我想再谈谈创伤外科几个理念。以下是创伤外科三个基本理念，可能刚开始是你比较难以接受。1. 对创伤患者救治最重要的一点“先救命后治病”2. 不能为了追求明确诊断而延误治疗。3. 在创伤早期评估中，可以暂不必详细追问病史。 （理论指导实践）上述三个理念带来了创伤外科早期评估和处理的发展，也是我们下阶段专题交流的核心内容。认领(十一)(3)(3)BO:i didn't understand Cheng GuoLiang's note before. now i understand because i was blocked from reading two notes which has a minimum requirement of 10 points. i looked at mine which was 6.most people visiting this website are medical professionals and interested in general surgery. we are having a professional scientific discussion about general surgery. everybody is equal here and should have equal opportunate to learn and to express their ideas. i don't know the reasons for the limitation set up in other posts. however, in this trauma discussion i think it is better not to set up any minimum requirement of score. thanks. 我以前不明白Cheng GuoLiang兄的贴子是什么意思，今天我才明白，因为我在浏览两个贴子时受阻，他们要求最低10分的限制，我看了看我的才6分. 大部分来园子里的都是医学专业和对普外感兴趣的。我们进行的是对普外专业科学的讨论。每个人在这都是平等的，并且应该在平等的机会来学习和表达他们的观点。我不理解为什么在其他贴子设定分数限制。不管怎样，在这个创伤讨论里我想最好不要设置任何分数限制。谢谢创伤外科第一期相关内容第1期正文原文 第1期教学问答原文 第1期正文内容同期翻译 第1期专题互动交流翻译（感谢tongdour战友的汇总） 第二期英文原文。红色为已认领部分。（1）trauma surgery: #2: Initial Assessment and ManagementThe treatment of the seriously injured patient requires rapid assessment of the injuries and institution of life-preserving therapy. Because time is of the essence, a systematic approach that can be easily reviewed and practiced is desirable. This process is termed "initial assessment" and includes:1. Preparation2. Triage 3. Primary survey (ABCDEs)4. Resuscitation5. Adjuncts to primary survey and resuscitation6. Secondary survey (head-to-toe evaluation and history)7. Adjuncts to the secondary survey8. Continued post resuscitation monitoring and reevaluation9. Definitive careThe primary and secondary surveys should be repeated frequently to ascertain any deterioration in the patient's status and any necessary treatment to be instituted at the time an adverse change is identified.This sequence is presented as a longitudinal progression of events. In the actual clinical situation, many of these activities occur in parallel or simultaneously. The linear or longitudinal progression allows the doctor an opportunity to mentally review the progress of an actual trauma resuscitation. （2）PREPARATIONPreparation for the trauma patient occurs in 2 different clinical settings. First, during the prehospital phase, all events must be coordinated with the doctors at the receiving hospital. Second, during the hospital phase, preparations must be made to rapidly facilitate the resuscitation of the trauma patient. A Prehospital phase:we discussed the prehospital care before. I'd like to point out Emphasis in the prehospital phase should be placed on airway maintenance, control of external bleeding and shock, immobilization of the patient, and immediate transport to the closest appropriate facility, preferably a verified trauma center. Every effort should be made to minimize scene time. inhospital phaseAdvanced planning for the trauma patient's arrival is essential. Ideally, a resuscitation area should be available for trauma patients. Proper airway equipment (eg, laryngoscopes, tubes) should be organized, tested, and placed where it is immediately accessible. Warmed intravenous crystalloid solutions (eg. Ringer's lactate) should be available and ready to infuse when the patient arrives. Appropriate monitoring capabilities should be immediately available. A method to summon extra medical assistance should be in place. A means to assure prompt response by laboratory and radiology personnel is necessary.（3）Continue the in-hospital preparation:When we get paged, we run down to the trauma bay, put gown, gloves, shoes covers and eye protections on. Have central lines kit and other trays ready based on the patient’s injuries. Nurses have the monitor ready …. The resident doing primary survey keeps the stethoscope and trauma shear with him. Patients are assessed and their treatment priorities established based on their injuries, their vital signs, and the injury mechanism. In the severely injured patient, logical sequential treatment priorities must be established based on overall patient assessment. The patient's vital functions must be assessed quickly and efficiently. Patient management must consist of a rapid primary evaluation, resuscitation of vital functions, a more detailed secondary assessment, and, finally, the initiation of definitive care. （4）Primary Survey-------It is designed to identify all immediate life threatening injuries. it is the most important part for the emergent resuscitation.This process constitutes the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence since this is the sequence how patients get killed:A Airway maintenance with cervical spine protection B Breathing and ventilation C Circulation with hemorrhage control D Disability: Neurologic status E Exposure/Environmental control: Completely undress the patient, but prevent hypothermiaDuring the primary survey, life-threatening conditions are identified and management is instituted simultaneously. Priorities for the care of the pediatric patient are the same as those for adults. Priorities for the care of the pregnant patient are the same as those for nonpregnant patients.please remember ABCDEs for every trauma patients or any patients who are crashing. （5）A Airway maintenance with cervical spine protection ask patient's name, let patient talk, see if patient has stridor, inspect for foreign bodies and facial. mandibular, or tracheal/laryngeal fractures that may result in airway obstruction. initially, the chin lift or jaw thrust maneuvers are recommended to achieve this task. patient with GCS < or = 8 need be intubated. make sure you protect the C-spine when you intubate the patient. it makes the intubation harder. remember: assume a cervical spine injury in any patient with multi-system trauma, especially with an altered level of consciousness or a blunt injury above clavicle. you don't want patient become quadriplegia after your intubation due to the cervical spinal cord injury for cervical fracture. （6）B Breathing and ventilation (listen to the lungs see if air is moving)Airway patency alone does not assure adequate ventilation. Ventilation requires adequate function of the lungs, chest wall, and diaphragm. Each component must be examined and evaluated rapidly.The patient's chest should be exposed to adequately assess chest wall excursion. Auscultation should be performed to assure gas flow in the lungs. Percussion may demonstrate the presence of air or blood in the chest. Visual inspection and palpation may detect injuries to the chest wall that may compromise ventilation.Injuries that may acutely impair ventilation are tension pneumothorax, flail chest with pulmonary contusion, massive hemothorax, and open pneumothorax. These injuries should be identified in the primary survey. Simple pneumo- or hemothorax, fractured ribs, and pulmonary contusion may compromise ventilation to a lesser degree and are usually identified in the secondary survey. （7）C. Circulation with Hemorrhage Control this is the most common problem for trauma patient: hemorrhage. so, it is very important for a trauma surgeon to know how to quickly evaluate circulation of the patient and resuscitate the patient. 1. Blood volume and cardiac outputHemorrhage is the predominant cause of preventable post-injury deaths. Hypotension following injury must be considered to be hypovolemic in origin until proved otherwise. Rapid and accurate assessment of the injured patient's hemody-namic status is therefore essential. The elements of clinical observation that yield important information within seconds are level of consciousness, skin color, and pulse. （8）a. Level of consciousnessWhen circulating blood volume is reduced, cerebral perfusion may be critically impaired, resulting in altered levels of consciousness. However, a conscious patient also may have lost a significant amount of blood.b. Skin colorA patient with pink skin, especially in the face and extremities, is rarely critically hypovolemic after injury. Conversely, the ashen, gray skin of the face and the white skin of the exsanguinate extremities are ominous signs of hypovolemia.c. PulsePulses, usually an easily accessible central pulse (femoral or carotid artery), should be assessed bilaterally for quality, rate, and regularity. A rapid, thready pulse is usually a sign of hypovolemia, but may have other causes as well. An irregular pulse usually is a warning of potential cardiac dysfunction. Absent central pulses, not attributable to local factors, signify the need for immediate resuscitative action to restore depleted blood volume and effective cardiac output if death is to be avoided. （9）2. BleedingExternal hemorrhage is identified and controlled in the primary survey.Rapid, external blood loss is managed by direct manual pressure on the wound. Pneumatic splinting devices also may help control hemorrhage. Tourniquets should not be used (except in unusual circumstances such as a traumatic amputation of an extremity) because they crush tissues and cause distal ischemia. The use of hemostats is time consuming, and surrounding structures, such as nerves and veins, can be injured. There are seven major places occult blood loss to cause severe hypovolemia: bilateral chest, abd, pelvis (retroperitoneal space), bilateral thigh due to femur fracture, and on the street where the patient is injured. For an infant: the 8th one is intracranial hemorrhage. Please remember the 7 places when you see a hypotensive trauma patients. Children, at the other extreme, usually have abundant physiologic reserve and often demonstrate few signs of hypovolemia even after severe volume depletion. When deterioration does occur, it is precipitous and catastrophic.Anticipation and an attitude of skepticism regarding the patient's "normal" hemodynamic status are appropriate. （10）D. Disability (Neurologic Evaluation)A rapid neurologic evaluation is performed at the end of the primary survey. This neurologic evaluation establishes the patient's level of consciousness, pupillary size and reaction, lateralizing signs, and spinal cord injury level.A decrease in the level of consciousness may indicate decreased cerebral oxygenation and/or perfusion or may be due to direct cerebral injury. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status. Hypoglycemia, alcohol, narcotics, and/or other drugs also may alter the patient's level of consciousness. However, if these are excluded, changes in the level of consciousness should be considered to be of traumatic central nervous system origin until proven otherwise. （11）E. Exposure/Environmental ControlThe patient should be completely undressed, usually by cutting off the garments to facilitate thorough examination and assessment. After the patient's clothing is removed and assessment is completed, it is imperative to cover the patient with warm blankets or an external warming device to prevent hypothermia in the emergency department. Intravenous fluids should be warmed before infusion, and a warm environment (room temperature) should be maintained. It is the patient's body temperature that is most important, not the comfort of the health care providers. (12)RESUSCITATIONas i mentioned before, resuscitation should be started at the same time then initial assessment is carried out. Aggressive resuscitation and the management of life-threatening injuries, as they are identified, are essential to maximize patient survival.A. AirwayThe airway should be protected in all patients and secured when the potential for airway compromise exists. The jaw thrust or chin lift maneuver may suffice. A nasopharyngeal airway may initially establish and maintain airway patency in the conscious patient. If the patient is unconscious and has no gag reflex, an oropharyngeal airway may be helpful temporarily. However, a definitive airway should be established if there is any doubt about the patient's ability to maintain airway integrity.Definitive control of the airway in patients who have compromised airways due to mechanical factors, have ventilatory problems, or are unconscious is achieved by endotracheal intubation, either nasally or orally. This procedure should be accomplished with continuous protection of the cervical spine. A surgical airway should be performed if oral or nasal intubation is contraindicated or cannot be accomplished.(13)B. Breathing/Ventilation/OxygenationA tension pneumothorax compromises ventilation and circulation dramatically and acutely, and, if suspected, chest decompression should be accomplished immediately. Every injured patient should receive supplemental oxygen. If not intubated, the patient should have oxygen delivered by a mask/reservoir device to achieve optimal oxy-genation. The use of the pulse oximeter is valuable in ensuring adequate hemoglobin saturation(14)C. CirculationControl bleeding by direct pressure or operative intervention.A minimum of 2 large-caliber intravenous (IV) catheters should be established. Establishment of upper extremity peripheral IV access is preferred. Other peripheral lines, cut-downs, and central venous lines should be utilized as necessary in accordance with the skill level of the doctor caring for the patient. At the time of IV insertion, draw blood for type and crossmatch and for baseline hematologic studies, including a pregnancy test for all females of child-bearing age.Aggressive and continued volume resuscitation is not a substitute for manual or operative control of hemorrhage. Intravenous fluid therapy with a balanced salt solution should be initiated. Ringer's lactate solution is preferred as the initial crystalloid solution and should be administered rapidly. Such bolus IV therapy may require the administration of 2-3 liters of solution to achieve an appropriate patient response in the adult patient. All IV solutions should be warmed either by storage in a warm environment (37°C to 40°C ) or by fluid-warming devices.Shock associated with injury is most often hypovolemic in origin. If the patient remains unresponsive to bolus IV therapy, type-specific blood may be administered as necessary. If type-specific blood is not available, O-negative blood is considered as a substitute. For life-threatening blood loss, the use of unmatched, type-specific blood is preferred over type O blood unless multiple, unidentified casualties are being treated simultaneously. Hypovolemic shock should not be treated by vasopressors, steroids, sodium bicarbonate, or by continued crystalloid/ blood infusion. If blood loss continues, it should be controlled by operative intervention. The process of operative resuscitation provides the surgeon the opportunity to stop the bleeding in addition to the maintenance and restoration of intravascular volume.(15)Hypothermia may be present when the patient arrives, or it may develop quickly in the emergency department in the uncovered patient and by rapid administration of room-temperature fluids or refrigerated blood. Hypothermia is a potentially lethal complication in the injured patient, and aggressive measures should be taken to prevent the loss of body heat and to restore body temperature to normal. The temperature of the resuscitation area should be increased to minimize the loss of body heat. The use of a high-flow fluid warmer or microwave oven to heat crystalloid fluids to 39°C is recommended. Blood products should not be warmed in a microwave oven. （16）ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATIONThere are some tests or studies which can be very fast at the trauma bay to help manage trauma patients. we call those adjuncts, including EKG monitoring, folry, NGT, FAST (see the pitcure posted in discussion #1) and CXR.A. Electrocardiographic MonitoringELectrocardiographic (ECG) monitoring of all trauma patients is important. Dysrhythmias, including unexplained tachycardia, atrial fibrillation, premature ventricular contractions, and ST segment changes, may indicate blunt cardiac injury. Pulseless electrical activity (PEA, formerly termed electromechanical dissociation) may indicate cardiac tamponade, tension pneumothorax, and/or profound hypovolemia. When bradycardia, aberrant conduction, and premature beats are present, hypoxia and hypoperfusion should be suspected immediately. Extreme hypothermia also produces these dysrhythmias.（17）B. Urinary and Gastric CathetersThe placement of urinary and gastric catheters should be considered as part of the resuscitation phase. A urine specimen should be submitted for routine laboratory analysis.1. Urinary cathetersUrinary output is a sensitive indicator of the volume status of the patient and reflects renal perfusion. Monitoring of urinary output is best accomplished by the insertion of an indwelling bladder catheter. Transurethral bladder catheterization is contraindicated in patients in whom urethral transection is suspected. Urethral injury should be suspected if there is (1) blood at the penile meatus, (2) perineal ecchymosis, (3) blood in the scrotum, (4) a high-riding or nonpalpable prostate, or (5) a pelvic fracture. Accordingly, the urinary catheter should not be inserted before an examination of the rectum and genitalia. If urethral injury is suspected, urethral integrity should be confirmed by a retrograde urethrogram before the catheter is inserted.（18）2. Gastric cathetersA gastric tube is indicated to reduce stomach distention and decrease the risk of aspiration. Decompression of the stomach reduces the risk of aspiration, but does not prevent it entirely. Thick or semisolid gastric contents will not return through the tube, and actual passage of the tube may induce vomiting. For the tube to be effective, it must be positioned properly, attached to appropriate suction, and be functioning. Blood in the gastric aspirate may represent oropharyngeal (swallowed) blood, traumatic insertion, or actual injury to the upper digestive tract. If the cribriform plate is fractured or a fracture is suspected, the gastric tube should be inserted orally to prevent intracranial passage. In this situation, any nasopharyngeal instrumentation is potentially dangerous. （19）D. CHEST (CXR) and Pelvis X-RAYX-rays should be used judiciously and should not delay patient resuscitation. The anteroposterior (AP) chest film and an AP pelvis may provide information that can guide resuscitation efforts of the patient with blunt trauma. Chest x-rays may detect potentially life-threatening injuries that require treatment, and pelvic films may demonstrate fractures of the pelvis that indicate the need for early blood transfusion. These films can be taken in the trauma bay usually with a portable x-ray unit, but should not interrupt the resuscitation process. They may be deferred to the secondary survey when appropriate（20）FAST (Focal Assessment of Sonography for Trauma)Diagnostic peritoneal lavage (DPL) and abdominal ultrasonography (FAST) are useful tools for the quick detection of occult intraabdominal bleeding. Their use depends on the skill and experience level of the doctor. Early identification of the source of occult intraabdominal blood loss may indicate the need for operative control of hemorrhage. Now DPL is replaced by FAST. Please see the picture of FAST in discussion #1.（21）SECONDARY SURVEYThe secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are well established, and the patient is demonstrating normalization of vital functions.The secondary survey is a head-to-toe evaluation of the trauma patient, ie, a complete history and physical examination, including a reassessment of all vital signs. Each region of the body is completely examined. The potential for missing an injury or failure to appreciate the significance of an injury is great, especially in the unresponsive or unstable patient. In this survey a complete neurologic examination is performed, including a GCS Score determination, if not done during the primary survey. During this evaluation, examination-indicated x-rays are obtained (CT, X-RAY of bones). Such examinations can be interspersed into the secondary survey at appropriate times.Special procedures, eg, specific radiographic evaluations and laboratory studies, also are obtained at this time. Complete evaluation of the patient requires repeated physical examinations。（22）A. HistoryEvery complete medical assessment should include a history of the mechanism of injury. The AMPLE history is a useful mnemonic for this purpose.A AllergiesM Medications currently usedP Past illnesses/PregnancyL Last mealE Events/Environment related to the injuryThe patient's condition is greatly influenced by the mechanism of injury. Prehospital personnel can provide valuable information on such mechanisms and should report pertinent data to the examining doctor. Some injuries can be predicted based on the direction and amount of energy force. Injury usually is classified into 2 broad categories, blunt and penetrating. （23）1. Blunt traumaBlunt trauma results from automobile collisions, falls, and other transportation-, recreation-, and occupation-related injuries. Important information to obtain about automobile collisions includes seat belt usage, steering wheel deformation, direction of impact, damage to the automobile in terms of major deformation or intrusion into the passenger compartment, and ejection of the passenger from the vehicle. Ejection from the vehicle greatly increases the chance of major injury.Injury patterns may often be predicted by the mechanism of injury. Such injury patterns also are influenced by age groups and activities. The GCS is a quick, simple method for determining the level of consciousness, and is predictive of patient outcome (particularly the best motor response). If not done in the primary survey, the GCS should be performed as part of the more detailed, quantitative neurologic examination in the secondary survey.（24）Glasgow Coma ScaleEye Opening4=spontaneous 3=to speech 2=to pain 1=noneMotor Response6=obeys commands 5=localizes 4=withdraws3=decorticate/flexion 2=decerebrate/extension1=noneVerbal Response5=oriented 4=confused 3=inappropriate words2=incomprehensible sounds 1=noneNormal GCS: 15, lowest: 3（25）BLunt trauma: MECHANISM OF INJURY---------------SUSPECTED INJURY PATTERNSFrontal Impact, • Bent steering wheel • Knee imprint, dashboard • Bull's-eye fracture, windscreen-------------- Cervical spine fracture • Anterior flail chest • Myocardial contusion • Pneumothorax • Traumatic aortic disruption • Fractured spleen or liver • Posterior fracture/ dislocation of hip, kneeSide Impact, automobile-------------• Contralateral neck sprain • Cervical spine fracture • Lateral flail chest • Pneumothorax • Traumatic aortic disruption • Diaphragmatic rupture • Fractured spleen/ liver, kidney depending on side of impact • Fractured pelvis or acetabulumRear Impact, automobile collision------------- • Cervical spine injury • Soft-tissue injury to neckEjection, vehicle (no seat belt)--------------• Ejection from the vehicle precludes meaningful prediction of injury patterns, but places patient at greater risk from virtually all injury mechanismsMotor Vehicle Impact with Pedestrian-------------• Head injury • Traumatic aortic disruption • Abdominal visceral injuries • Fractured lower extremities/ pelvis（26）2. Penetrating traumaFactors determining the type and extent of injury and subsequent management include the region of the body injured, the organs in the proximity to the path of the penetrating object, and the velocity of the missile. Therefore, the velocity, caliber, presumed path of the bullet, and the distance from the weapon to the wound may provide important clues to the extent of injury. regarding to the case we are discussing, what injury do you suspect he has based on all the information we have right now? what do you want to do next.（27）3. Injuries due to burns and coldBurns are another significant type of trauma that may occur alone or may be coupled with blunt and penetrating trauma resulting from a burning automobile, explosion, falling debris, the patient's attempt to escape a fire, or an assault with a firearm or knife. Inhalation injury and carbon monoxide poisoning often complicate burn injury. Therefore, it is important to know the circumstances of the burn injury. Specifically, knowledge of the environment in which the burn injury occurred (open or closed space), as well as of substances consumed by the flames (eg, plastics, chemicals) and possible associated injuries sustained, is critical in the treatment of the patient.Acute or chronic hypothermia without adequate protection against heat loss produces either local or generalized cold injuries. Significant heat loss may occur at moderate temperatures (15°C to 20°C or 59°F to 68°F) if wet clothes, decreased activity, and/or vasodilatation caused by alcohol or drugs compromise the patient's ability to conserve heat. Such historical information can be obtained from prehospital personnel. （28）Physical Examination 1. Head (See Chapter 6, Head Trauma)Hie secondary survey begins with evaluating the head and identifying all related neurologic and significant injuries. the eyes should be reevaluated fora. Visual acuityb Pupillary sizec. Hemorrhages of the conjunctiva and fundid. Penetrating injurye. Contact lenses (remove before edema oc-cnrs)f Dislocation of the lens §. Ocular entrapmentMaxillofacial Maxillofacial trauma, not associated with airway obstruction or major bleeding, should be treated only after the patient is stabilized completely and life-threatening injuries have been managed.（29）Cervical spine and neck --------very importantPatients with maxillofacial or head trauma should be presumed to have an unstable cervical spine injury (fracture and/or ligamentous injury), and the neck should be immobilized until all aspects of the cervical spine have been adequately studied and an injury has been excluded. The absence of neurologic deficit does not exclude injury to the cervical spine, and such injury should be presumed until a complete cervical spine radiographic series is reviewed by a doctor experienced in detecting cervical spine fractures radiographically.Examination of the neck includes inspection, palpatian, and auscultation. Cervical spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal fracture may be discovered on a detailed examination. The carotid arteries should be palpated and auscultated for bruits. Evidence of blunt injury over these vessels should be noted and, if present, should arouse a high index of suspicion for carotid artery injury. Occlusion or dissection of the carotid artery may occur late in the injury process without antecedent signs or symptoms. Angiography or duplex ultrasonography may be required to exclude the possibility of major cervical vascular injury when the mechanism of injury suggests this possibility. Most major cervical vascular injuries are the result of penetrating injury. However, blunt force to the neck or a traction injury from a shoulder-harness restraint can result in intimal disruption, dissection, and thrombosis.Protection of a potentially unstable cervical spine injury is imperative for patients wearing any type of protective helmet. Extreme care must be taken when removing the helmet. Penetrating injuries to the neck have the potential of injuring several organ systems. Wounds that extend through the platysma should not be explored manually or probed with instruments in the emergency department, or by individuals in the emergency department who are not trained to deal with such injuries. The emergency department usually is not equipped to deal with problems that may be encountered unexpectedly. These injuries require evaluation by a surgeon either operatively or with specialized diagnostic procedures under direct supervision by the surgeon. The finding of active arterial bleeding, an expanding hematoma, arterial bruit, or airway compromise usually requires surgical operative evaluation. Unexplained or isolated paralysis of an upper extremity should raise the suspicion signs of a cervical nerve root injury and be accurately documented.（30）Chest Visual evaluation of the chest, both anterior and posterior, identifies such conditions as open pneu-mothorax and large flail segments. A complete evaluation of the chest wall requires palpation of the entire chest cage, including the clavicle, ribs, and sternum. Sternal pressure may be painful if the sternum is fractured or costochondral separations exist. Contusions and hematomas of the chest wall should alert the doctor to the possibility of occult injury.Significant chest injury may be manifested by pain, dyspnea, or hypoxia. Evaluation includes auscultation of the chest and a chest x-ray. Breath sounds are auscultated high on the anterior chest wall for pneumothorax and at the posterior bases for hemothorax. Auscultatory findings may be difficult to evaluate in a noisy environment, but may be extremely helpful. Distant heart sounds and narrow pulse pressure may indicate cardiac tamponade. Cardiac tamponade or tension pneumothorax may be suggested by the presence of distended neck veins, although associated hypo-volemia may minimize this finding or eliminate it altogether. Decreased breath sounds, hyperreso-nance to percussion, and shock may be the only indications of tension pneumothorax and the need for immediate chest decompression.The chest x-ray confirms the presence of a hemothorax or simple pneumothorax. Rib fractures may be present, but they may not be visible on the x-ray. A widened mediastinum or other ra-diographic signs may suggest an aortic rupture ---第二期正文翻译。(1) 对创伤患者来说，时间就是生命。因此一套简洁、快速而又行之有效的创伤首诊处理措施是非常重要的。这个过程包括以下几个方面：1准备2伤员鉴别分类3初评(ABCDEs)4复苏5初评和初次复苏的补充6二次评估7二次评估的补充8继续复苏后监护和重新评估9明确治疗急救过程中应当反复评估患者整体状况，明确病情变化。及时发现患者是否出现加重迹象，以便采取必要相应措施迅速加以处理。以上步骤是救治过程中按照时间先后顺序排列的。但在实际的临床工作中，这些步骤之间并没有明显时间界限，很多操作往往同时进行。这种排序只是为了让医生在救治过程中思路更清晰不至于忙乱。（2）准备为创伤患者做准备包括两种不同临床情况。第一种，来医院前一段时间，所有事情必须与接受患者医院的医生协调好。第二种，院内治疗期间， 必须做好利于创伤患者快速复苏的准备。院前急救我们以前已经讨论过院前急救的内容。我这次指出的是应该把入院前期的重点放在维持气道通畅、控制外部出血和休克以及制动患者，快速把患者运送到距离最近的治疗场所--送到核定的创伤中心更好。应该尽一切努力缩短现场时间。院内急救在患者送达之前就应该做好抢救的各项准备。最好是想要什么就能有什么。开放气道的器具必须确保装好备用并触手可及。加温复苏液、各种监测仪必须备好待用，确保一旦患者到达就能马上投入使用。必须拥有一套和其他科室之间保持联络的即时通讯设备，以便必要时能使相关人员快速就位。（3）继续谈谈入院前的准备：当我们得到急救信号时，我们迅速跑到床上急救室，穿好手术外衣、手套、鞋套还有防护眼罩等，并根据患者的伤情带上中央置管装备以及其它一些必需的托盘，护士带好监测仪准备，等等。准备对患者进行初步检测的住院医师准备好听诊器及创伤用的剪刀（用来剪开伤者衣裤等）。患者经过评估后，根据其伤情、生命体征及损伤的机理确定救治的重点和先后程序。对于一名伤情严重的患者，确立合理的救治程序必须依据对其整体病情的评估。必须对患者重要的生命机能作出迅速而有效的评估。对患者的管理包括对主要伤情的及时评估、回复重要的生命机能、更为详尽的二期评估以及最终对患者实施有效的治疗和护理。（4）初期监测——用来辨别和判定所有最为紧迫的危及生命的伤情，这是急救复苏中最重要的一环。这些急救措施是创伤首诊过程中的5大基础步骤。因为患者往往由于这五个方面的原因死亡，所以通过这五个步骤也可以判断患者病情危重的程度。A：通过对颈椎的保护维持气道的通畅（询问患者的姓名、鼓励患者讲话、观察患者是否有呼吸喘促。这也许会使插管变得困难一些）。B：维持呼吸和通气（听诊肺部呼吸音、观察胸廓运动情况）。C：通过对血流动力学的控制维持循环功能（监测桡动脉、股动脉的脉搏，血压或监测中心静脉压）。D：防止功能障碍：监测神经系统情况（让患者活动四肢及检查其感觉功能）。E：（患者）所暴露的环境因素的控制：脱去患者的外衣同时要注意保护其防止低体温的发生。在对患者初期监测的过程中，对于威胁生命的病情的辨别和对患者的治疗管理是同时进行的。对小儿患者的救治程序与成人相同，对怀孕患者的救治程序与未怀孕者也是一样的。以上五点要牢记在心。（5）在保护好颈椎的前提下畅通气道询问患者的名字，鼓励他说话，观察患者是否有呼吸喘促，检查是否存在（气道内）异物或是颌面部、气管喉部骨折等可能导致气道梗阻的因素。最初可以通过向上牵引下颌的方法实现呼吸道的开放，如果患者的Glasgow昏迷评分小于或等于8则需要气管插管。当你对患者实行插管时要确认颈椎保护良好，这也许会使插管变得困难一些。谨记：假定有一个伴有颈椎损伤的多系统创伤的患者，尤其是伴有意识水平改变或锁骨上遭受钝器伤的患者，你一定不希望你的患者在插管术后由于（没有保护好造成的）颈椎骨折导致的颈部脊髓损伤而变得四肢瘫痪。（6）B 呼吸与通气（听诊肺部看看是否通气）气道开放不一定可以保证足够的通气。通气需要肺、胸壁和膈充分的功能.患者胸部应该暴露以便于充分评估胸壁有无偏移，利用听诊确定肺部的气流，叩诊可以证实胸部气体或血液的存在。视诊和触诊可以检查出胸壁损伤可能影响到了通气。损伤可以对通气造成严重损伤，导致张力性气胸以及由肺挫伤、大量血胸和开放性气胸造成的连枷胸。这些损伤在首诊创伤中就应该鉴别出来。单一的气胸或血胸、肋骨骨折和肺挫伤对肺通气的影响程度较小，通常在二次评估进行鉴别。(7)循环系统出血的控制出血对创伤患者来说是最常见的问题。因此，对一个创伤外科医生来说，知道如何快速评估患者循环系统的情况并且使对其进行副复苏是非常重要的。1血容量和心输出量出血是可以防止损伤后死亡的主要原因。在证实其他情况之前，必须考虑损伤后血压过低是血容减少引起。因此，快速、准确地评估损伤患者的血液动力学状况至关重要。在几秒钟之内通过临床观察获得重要信息的方式有：意识水平，皮肤颜色和脉搏。（8）意识水平循环血容量减少时，脑灌注可能严重受损，导致神志改变。但是，一个神志清醒的患者也可能失血很多。皮肤颜色一个患者的皮肤呈粉红色，尤其是面部和四肢末端呈粉红色，其损伤后几乎很少会失血过多。反之，如果面部呈灰色或苍白，四肢末端呈现贫血样的苍白，则是失血过多的征兆。 脉搏脉搏通常容易受到中心脉搏的影响（股动脉或者颈动脉），应该对其双侧搏动的性质，次数和规律性进行评估。快速、微弱的脉搏通常是失血过多的征兆，但是也可能是其他原因引起。不规则脉通常预示可能存在心衰。中心脉搏没有搏动不应该是由局部原因引起，如果可以避免死亡的话，就意味着快速复苏对于恢复血容量和有效的心输出量的必要性.(9)出血外出血在创伤首诊中可以鉴别出来并加以控制。快速的外部出血可以用手直接压迫伤口进行处理。充气夹板装置也可以控制出血。不应该使用止血带（除非在四肢末端因创伤需行截肢术的特殊情况下），因为其可压伤组织，引起远侧缺血。使用止血钳比较费时，并可以引起周围组织神经和血管的损伤。潜在失血的7个主要部位可以引起严重的血容量减少：双侧胸部，腹部，骨盆（腹膜后间隙），双侧大腿，以及受伤现场的失血。对于儿童而言，第8个部位是颅内出血。在你看到血压过低的创伤患者时，请记住这7个部位。儿童通常有生理储备，即使在严重血容量不足的情况下，常常很少有血容量过低的表现。当病情进一步恶化时，其后果是险恶和灾难性的。预测并且对患者“正常”的血流动力学状态持怀疑态度是应该的。(10)功能障碍（神经系统的评估）在首诊创伤结束时要对神经系统进行一次快速评估。神经系统的评估要确认患者的意识水平、瞳孔大小、侧向运动的体征和脊髓损伤的程度。意识水平的下降可能表明大脑氧和作用和/或灌注减弱，也可能是由于大脑直接损伤引起。意识水平的改变意味着要对患者的氧和作用，通气和灌注状况进行重新评估。低血糖、酒精和/或药物也可以改变患者的意识水平。但是，如果排除上述因素，在证实其他原因之前，意识水平的改变应该被认为是由中枢神经系统受损引起。(11)暴露/环境控制患者应该完全裸露，通常可以剪掉患者的衣服，从而可以进行彻底检查和评估。在去掉患者衣服、评估完成之后，在急诊科要赶快给患者盖上一个热毛毯或者外部加温装置以防止体温过低。静脉液体输注前应该加热，并且应该保持环境温暖（室温）。患者的体温十分重要，而不是为了使得护理人员感到舒适。（12）复苏正如我之前所说的，复苏应该与初始评估同时开始。强有力的复苏措施及对已证实威胁患者生命的损伤的及时处理，对于最大限度的提高伤者的生存率是十分重要的。A、（开放）气道对于所有的患者，只要呼吸道存在着潜在的（受阻）危险，我们都应该注意对气道的保护。下颌牵引或是向上抬下颚的动作应该是足够了。对于清醒的患者，可以早期采用鼻咽导管置管从而保证呼吸道的通畅。如果患者无意识而且咽反射消失，则需要置入口咽呼吸管暂时维持呼吸。无论怎样，对于那些可疑无法自主实现呼吸道完全开放的患者一定要（采用有效的人工方法）保证气道的完全通畅。某些患者因机械损伤或意识丧失导致的气道通风受阻，对于此类情况可以通过经鼻或经口气管插管的方法实现呼吸道的完全通畅。在这个插管过程中要始终注意对颈椎的保护。如果患者有插管禁忌或是插管术不成功，则需要外科的手段实现气道的开放。（13）B、呼吸、通气、给氧张力性气胸会导致呼吸和循环系统的急性严重的功能障碍，如果一旦怀疑此症的存在，必须及时采取胸腔减压的措施。每一名伤者都应该给予辅助性供氧。如果患者没有插管，可以通过呼吸面罩或是氧气袋等装置实现对伤者的供氧。动脉氧含量监测的应用对于保证患者充足的血氧含量是很有价值的。（14）C、循环 通过直接压迫或是手术介入的方法控制出血。至少需要开通两个大孔径静脉通路，插管的部位首选上肢的外周静脉。必要的情况下，有经验的医生也可以利用其它的外周静脉、静脉切开或者中心静脉置管的方法对患者予以诊治。在静脉插管的时候，需抽血进行交叉配血试验并做基本的血液学检查，包括对生育期妇女的妊娠试验检查。有力而持续的复苏并不能代替人工或手术的方法控制出血。开始即应采取静脉内输入平衡盐溶液的液体疗法，首先应快速输入晶体液——首选林格氏乳酸盐溶液。对于一名成人患者，可能需要2-3升的大量输液才能出现（血流动力学）反应。所有的液体（在输入前）均应通过储藏在37°C 到40°C的环境中或通过液体加温装置保持（适当的）温度。损伤伴有休克可早期出现循环血容量减少。如果经过大量液体治疗后患者仍无反应，则必须采取相应血型的输血治疗了。如果患者所需的血型缺乏，也可以用O型血代替。对于威胁生命的失血，除非是在同一时间处理大量伤员且一时未及血型鉴定的情况下可用O型血代替，否则都应首选配型血液治疗。低血容量休克不应该仅仅通过使用血管升压药、甾体类药物、碳酸氢钠或持续输晶体液或输血治疗。如果有持续性的失血，应该及时采取手术的方法控制出血。除了维持和恢复血容量，外科医生可以通过手术的方法达到止血的目的。（15）当患者被送到时，很可能存在低体温，或者因在急诊室内没有盖被子或大量输入常温液体或冷藏的血液而导致体温迅速降低。对于损伤患者，低体温是一种潜在的危及生命的并发症，此时就需采取有力的措施使患者的体温恢复正常。体温的逐步恢复应最大限度的减少体热的丢失。推荐使用高流量液体加温器或微波炉将晶体加温至39°C，但血液制品不能放入微波炉中加热。（16）初评的补充和复苏在创伤急救室，有许多检查方法可以快速评估处理病人，我们称其为辅助检查，包括心电监护、foley导管、鼻胃管、FAST（见讲座一的插图）和胸部平片检查。A、心电监护心电监护对所有外伤病人都十分重要。节律异常，包括难以解释的心动过速、房颤、室早和ST段改变，都提示心脏钝性伤的可能。无脉搏心电活动（PEA，先前称为电机械分离）可提示急性心包填塞、张力性气胸和/或重度血容量不足。当存在心动过缓、差异传导和期前收缩时，应该马上考虑到缺氧和灌注不足的可能。极度的体温过低也可能引起上述心电节律的异常。（17）B、导尿管和胃管导尿管和胃管的放置应该被看作复苏的一部分。应该常规做尿液检查。1、导尿管尿量是判断病人血容量状况及肾灌注的一个敏感指标。监测尿量最好的方法是留置导尿管。对于怀疑有尿道横断伤的病人，禁忌进行经尿管置导尿管。有下列情况应怀疑有尿道损伤：（1）尿道口有血迹（2）会阴部淤斑（3）阴囊内血肿（4）前列腺位置过高或触摸不清？（5）骨盆骨折。因此，在置导尿管前应先进行直肠及外生殖器的检查。如果怀疑有尿道损伤，在置管前应先行逆行性尿道造影以确定尿道的完整性。（18）2、胃管插胃管可以减轻胃扩张并降低发生误吸的危险。胃的减压可以降低发生误吸的危险，但并不能完全阻止其发生。固态及半固态的胃内容物并不会通过胃管反流，而实际上插管的过程还可能引发呕吐。要让胃管真正发挥作用，需要其放置的位置正确、正确的接上吸引管并进行吸引。胃管吸引出血液，可能代表口咽部出血（吞入胃内）、插管损伤或上消化道的损伤。如果存在或怀疑筛状板损伤，应经口留置胃管，以防胃管误插入颅腔。此种情况，任何经鼻咽的操作都存在潜在危险。（19）D. 胸、盆部X线检查X线检查应该谨慎选择不可延误复苏的进行。前后位胸片及盆部平片可以对钝性伤的病人提供有用信息以指导复苏的进行。胸部X线检查可以探查到危胁生命的创伤并及时处理，盆部平片可以发现盆腔骨折并提示需尽早输血。这些平片可以在创伤急救室用便携式X线检查仪方便的摄取，但其前提是不得干扰复苏的进行。适当的时候他们应该在二次评估的时候进行。（20）创伤部位的超声评估（FAST）诊断性腹腔灌洗（DPL）及腹部超声（FAST）检查对于快速确定有无腹腔内出血是非常有用的。他们的使用有赖于大夫的水平和经验。早期鉴别腹腔内出血部位可以决定是否需要手术止血。现在DPL已经被FAST取代，请见讲座一的插图。（21）二次评估在初次评估已经完成，复苏方案得到很好的执行并且病人表现出平稳的生命体征时，才开始进行二次评估的内容。二次评估是对创伤病人从头到脚的彻底的检查评估，例如，完整全面的询问病史及体格检查，包括对所有生命体征的重新评估。身体所有的部位都得到彻底的检查。漏诊某处损伤或对某处损伤的重要性认识不足，这种可能性是很大的，对于无反应或状态不稳的病人更是如此。在二次评估阶段，需要对神经系统进行完整的检查，包括GCS评分（如果在初评未进行）。评估过程中，还需进行确诊性的X线检查（CT、骨骼X线片）。这些检查需要在二次评估中找适当的时机进行。特殊检查，如特异性放射学检查和实验室化验也是在这个阶段进行的。对病人全面的评估需要反复进行体格检查。（22）病史一个完整的医学评估应当包括患者的创伤机制和创伤过程。为此“AMPLE”有助于如何询问完整创伤病史。A　过敏史M　现行的治疗措施P　过去史/孕育史L　伤前进食情况E　受伤原因\环境创伤机制很大的影响到伤员的病情状况。院前救助人员可以提供对了解创伤机制有用的信息，而且他们也应该向查体的医师报告相关情况。根据外力的走行及力度就可以预计到某些损伤的存在。外伤通常可以分成两大类：闭合性损失和开放性损伤。（23）闭合性损伤可以由车祸、跌落引起，也可以由其他交通方式、娱乐或职业相关的创伤引起。对于车祸需了解的重要信息包括是否使用安全带、车受力方向。GCS评分是估计病人意识水平的一种快速、简单的方法，并且可以估计病人预后情况（尤其是在有关患者运动功能方面）。如果在初评时未进行评分，那么在二次评估时就应该进行以完成更详尽的神经系统检查。车轮变形、受压方向、车辆的受损程度与患者受伤严重程度相关。如果患者被车辆甩出则大大增加了严重创伤的几率。受伤的程度往往可以根据受伤机制估计到，也受年龄和伤时活动的影响。（24）格拉斯哥昏迷指数睁眼反应：能自行睁眼——4分；呼之能睁眼——3分；刺痛能睁眼——2分；不能睁眼——1分运动反应：能按吩咐完成动作——6分；刺痛时能定位，手举向疼痛部位——5分；刺痛时肢体能回缩——4分；刺痛时双上肢呈过度屈曲——3分；刺痛时四肢呈过度伸展——2分；刺痛时肢体松弛，无反应——1分言语反应：能对答，定向正确——5分；能对答，定向有误——4分；胡言乱语，不能对答——3分；仅能发音，无语言——2分；不能发音25）闭合性创伤（钝行创伤）：创伤模式―――可能造成的损伤。正面碰撞可能导致机体的创伤（撞向方向盘仪表板，挡风玻璃）：颈椎骨折。正面连枷胸。心肌挫伤。气胸。创伤性主动脉裂伤。肝、脾破裂。骨盆骨折、错位。侧面碰撞可能导致的机体创伤。（车祸中）：双侧颈部扭伤。颈椎骨折。侧面连枷胸。气胸。外伤性主动脉裂伤。膈肌裂伤。肝、脾、肾裂伤。骨盆骨折。后方碰撞可能导致的创伤。（车祸伤）：颈椎脊突损伤。颈部软组织损伤。未系安全带下被甩出车外可能导致的创伤：此种情况下，损伤模式往往难以预测，几乎所有创伤机理都可能存在，所以伤者危险性较高。（谢谢sy老朋友指正 ）摩托车撞上行人可能导致的创伤：颅脑损伤。外伤性主动脉裂伤。腹腔内脏器损伤。骨盆或下肢骨折。（26）开放性损伤创伤类型和预后往往由以下几个方面相关：机体损伤的部位，弹道轨迹临近的脏器，子弹的速率。因此子弹的速度、口径、预计的弹道轨迹以及射击距离为创伤的严重程度提供了重要线索。针对我们正在讨论的病例，结合现有的资料，你认为存在哪些可能的损伤？下一步该如何处理？（27）3. 热烧伤和冷冻伤热烧伤是创伤外科一个非常重要的内容。热烧伤可以单独发生，在一些情况下也可以和闭合性损伤或开放性损伤同时存在。比如火灾，车祸后车辆着火，爆炸，火器伤等情况下。吸入性损伤和二氧化碳中毒使得热烧伤愈发复杂。因此了解烧伤当时的环境显得尤为重要。环境是否密闭，燃烧物体的性质，是否存在伴发伤等内容对于热烧伤病人的急救是非常重要的。骤然或持续的低体温状态没有及时得到改善的话，往往会造成患者冷冻伤。显著的热量消耗会导致患者处于中度体温地下。如果穿着湿衣服，安静状态，服用了酒精或者其他能使血管扩张的药物，则会使得机体热量损失的情况变得更加严重。这些相关病史信息可以从院前急救人员那详细询问得知。第二期交流互动及病例讨论原文：大家的提问用蓝字，BO兄的回答用红字－－－－－－－－－－－－－－－－－（一）－－－－－－－－－－－－－－－－－－－－－(1)道可道非常道：hi，bo xiong.could please take some classic cases for example to show how to do these activities of Initial Assessment and Management such as trauma cases of automobile accidents which are very comon in China .i think it may be interesting and gives us a much wider understanding.well ,you may describe in a brief way as i know you will show some typical cases in detail when we get to that part .thanks! (1)BO：have been quite busy lately. finally find some time to continue.a couple of you guys asked to discuss some cases as we discuss the initial assessment and management. i think it is a good idea. we will discuss cases after we finish the primary survey and secondary survey. (2)BO:Now, you guys know how to do in-hospital preparation and primary survey, and here is the case.you are the trauma surgeon or trauma chief resident on call. you get paged (1-1-1-10). one patient, a trauma red, stab wound to the left lower chest, vital signs stable (pulse 110, bp 136/68 mmHg). patient will arrive in to minutes. what would you do now based on we discussed before? (3)道兄：个人处理意见。1 红色级别意味着来了重病号，可以大展身手了，先要打起十二万分的精神。2 接到信号后，飞速赶到创伤室。3 准备好置管，插管，检测，保温ringer液备用。4 联系辅助科室待命。5 做好胸腔引流和开胸准备。6 若病人生命体征平稳，常规处理完善检查后上手术室做手术。7 若送到后突然加重，立马准备开胸。（3）BO：this is pretty good, and it was what we set up for the coming patient. now the patient arrived, see the following picture. what would you do when you see this patient. (this picture i posted before and asked for you choice. now we will discuss how to manage this patient step by step based on what we did) (4)道可道非常道 wrote:试着接着来回答bo兄的问题。现在病人送到创伤室了。1、迅速剪开患者衣物。2、见左胸部锁骨中线约第5、6肋间刀刺伤。对于胸部刀刺伤，首要考虑心脏和大血管的损伤，其次为肺的损伤。一侧肺损伤应该不足以立刻致命。危险的应该室心包填塞导致急性休克。3、患者为自杀情况，根据体外刀的走形还要一般用力方向，应该是刀的轨迹应该是斜向下，因此有可能存在膈肌损伤或脾外伤。4、观察整体情况，是否有意识障碍等。测量体温、脉搏、呼吸、血压。5、观察循环系统。血压、心率、颈静脉是否怒张、心音是否遥远、大动脉搏动情况。血压正常不代表就一定稳定，也有可能是应激。因此，有条件迅速做心超、X线等检查。存在心包填塞，应立即穿刺或开胸。6、观察呼吸系统情况。听诊双肺呼吸音。少量的气血胸不足以致命，警惕张力性气胸。立即行气管插管，最好插双腔管，手术中麻醉医师好操作。气血胸应行引流。7、先挂上晶体液迅速补液。急查血常规、血气分析、生化全项（关键是离子情况）。8、急性失血，根据HB情况，可能需要输血，需立即配血，和血库联系好。9、注意离子水平和酸碱平衡问题。急性失血可能存在低钾、代酸，补钾和纠酸，大量补液同时注意观察尿量。10、反复判断患者情况，一直很稳定则完善各项检查，CT什么的也可以做。刀可以在术中拔，刀直接指向的受伤方向和深度，跟着刀走，应该会比较好判断受伤程度。11、若是在做这些检查是血压骤降，极有可能是心包填塞，存在心脏或大血管损伤，应以最快速度解除心包压力，准备开胸修补破损的地方。（期待bo兄的系统讲解。）（4）BO：those are excellent thoughts. however, you can't do so much in trauma bay in such a short time. so an more organized approach should be emphasized here. that is the key point of this discussion.when you get paged and have your team in position in trauma bay, you need know who's doing what. as the graph showed in discussion #1 of the organization of trauma team, if you are the assessment MD, you don't start with cutting patient's clothes which should be done by the support MD. your job is to do the primary survey (A,B,C). Whenever you see a trauma patient or a crashing patient, you always remember ABC. (BY now you guys must know what ABC stands for). be stone calm and be cool. don't jump around doing everything. do no harm to patient. （5）BO：back to this patient. first thing is "A" -- "Airway". so first thing you do is to ask him: "what's your name?" he answered his name, then you know his airway is intact. "no intubation"second thing is "B" ----"Breathing". you listen to his lungs. clear bilaterally. so he has air moving in and out. No chest tube. put him on facial mask O2.third thing is "C" ---- "Circulation". you felt his pulse 110, strong, ask the nurse put on EKG Monitoring, pulse oximeter, check blood pressure 136/76 mmHg. start two large bore IV, bolus him warm LR.fourth thing is "D"---"Disability". ask patient to wiggle his toes and squeeze your hands to see if he follows your commands and any motor sensary dysfunction. he is normal.fifth thing "E" ----"Exposure" support MD (your intern) cut all the clothes, check any other wound. no other wound for him. then cover his body wth warm blanket as much as you can.now you need some adjucts to primary survey. what would you do next? what studies you want to do now to help figure out what's going on with this patient at the trauma bay. everybody is looking for you, waiting for your orders. （6）道兄：呵呵，谢谢bo兄细致讲解。经过ABCDE之后，大家应该歇口气了，生命体征平稳，暂时没有急诊开胸的指征。但是那把刀还依然在患者体内，手术不可避免。不过既然，生命体征平稳，就有时间多做一些检查来判断，完善术前准备。比如胸、腹部X线，胸腹部CT，相关的一些实验室检查。可以根据影像结果判断损伤程度，选择手术方式。期待bo兄进一步指点，我们医院似乎在07年发展创伤外科的意思，正好赶上了这么好一个学习机会，致谢。（6）BO：remember, trauma patient' condition can change very fast. so you want to get the results of studies as fast as you can. in the trauma bay, you have all the adjuncts (FAST, CXR) of primary survey, takes seconds to minutes to know the results. Do you think CT of chest abd and pelvis will change your management of this patient? another moto in trauma surgery: "Death starts in radiology."So what do you want to do next? （7）tongdour:试着回答下BO兄的问题：对于此病人，根据刀的位置，最紧急的情况就是心脏及大血管的损伤，伤及肺还不至于立时毕命，前面道兄都已经说了。不过，凡事都有个规章秩序，BO兄已经进行了初评A、B、C、D、E，根据其结果，心里首先对病人的病情程度有了个大概的了解，个人觉得：该病人生命体征平稳，各项检查还好，最少不至于立马毙命，所以悬着的心可以稍稍放松了下，应该没有直接伤到心脏或大的血管。接下来，就需要进行初评的补充了，但并不能忽略了A、B、C的情况，在初评的补充过程中，还应该随时注意A、B、C的情况，这时除了进一步明确初评得到的印象外，还应该努力想办法了解刀伤的具体情况了，如其走向、插入深度、伤到了什么结构，所以我想采用下列检查：1、心电监护：观察心电节律，有无心动过缓、过速、房颤、室早和ST段改变？如果有高度怀疑心脏损伤或心包填塞，这都需要紧急开胸处理；2、胸片：可发现气胸、血胸的情况，刀的位置、走行，膈肌有无受损；3、FAST：在超声下直视心脏搏动情况，有无心包填塞，心功能情况，也可以观察膈肌、脾脏的情况；若有危及生命的情况需立马上手术台了。4、关于胃管和尿管，个人觉得还是放上为好，现在可以从容的置管，而一旦发生紧急情况弄个措手不及就不好玩了……做好以上检查及准备后，经胸片或FAST若能明确刀的走向、刺入深度、伤及的结构，则可以从容将病人推上手术台了，进行相应处理……（7）BO:This is excellent and pretty much we did. remember the adjuncts of primary survey, which were all used by Tongdour for this patient.EKG Monitor: sinus tachy 120 bpmFAST: NO cardiac tamponade. blood in the LUQ around spleen. NO blood in the RUQ around liver, no blood in the pelvis.CXR: Normal. no pneumothorax (PTx) or hemothorax (HTx)Foley was placed. No NGT.Now, what do you want to do next? ( 8) BO:our patient with stab wound in the left upper abd / lower chest is still lying on the bed at the trauma bay. now you know his CXR was fine. FAST was positive. what would you do now? he has been lying at the trauma bay with a knife in his LUQ for a week, don't you guys want to do something? tongdour:with a knife in his LUQ for a week??难以想象，为什么带这么长时间啊？难道检查还有其他阳性发现？让我的话，觉得在trauma bay中没事赶快转手术室取刀得啦!!请问BO兄，这里还有其他处理原则吗？？根据BO兄上面提的，CRX无气胸、血胸，FAST无心包堵塞，说明 未伤及胸腔结构，所以觉得刀是在胸壁膈肌附着处以下刺入了腹腔，脾周积血，根据以上情况及刀的走行，我想可能伤及如下结构：脾、肝左叶部分(以上两者得急诊手术处理)、食管腹段(不知道为什么没插胃管？是因为无法插管吗？如果是这里的损伤的话就比较麻烦了，胃内容物的污染范围可能波及胸腔，处理比较棘手，具体如何还得请BO兄明示)，胃底、体(这也得做急诊手术，根据污染情况选择修补或切除吻合)，暂时只想到这么多啦，请BO兄多指教……再次祝大家新年快乐!!!!!!!!!!!!!!!!!!!!!!!!!!! (9)BO:with a knife in his LUQ for a week??难以想象，为什么带这么长时间啊？"觉得在trauma bay中没事赶快转手术室取刀得啦!!"--------------because you guys hadn't decided to do anything for him for a week until Tongdour decided to take him to the OR. That's why i said he stayed at trauma bay with a knife in his LUQ for a wk.Finally Tongdour took him to the OR. do you think he needs CT scan before the operation? will the CT scan result change your decision to operate on this patient. if it won't, he probably won't need a CT scan. you will cut him any way, and you will see all the injuries in the OR after you open him up.Next question? how do you prep the patient and what type of incision you are going to make? please don't keep him in the OR for another week. 道兄：呵呵，bo兄说得幽默，大家是让患者再创伤处置室等得太久了，一晃都过年了。先简单回顾病例特点，理清头绪。1、老年男性2、左侧胸腹部刀扎伤3、监测血压稳定，心率120次/分，律齐。4、胸片未见气胸、血胸。5、超声提示：左上腹脾区局限性积液。个人下一步处理措施：考虑剖腹探查手术治疗。该患者考虑胸腹联合伤，以腹部损伤为主，考虑有脾及肠道的损伤。1、了解血淀粉酶情况（是否存在胰腺或腹膜后十二指肠的损伤）。2、腹腔穿刺，了解腹腔积液情况。3、备血。4、CT似乎对下一步措施没有太大指导意义，因此非必需的检查。另外，过多的检查看来弊大于利。5、手术可以考虑全麻，开胸探查，扩大膈肌裂口修补或切除腹腔内受损脏器。另外，本例以腹伤为主，胸腔置管引流，行剖腹探查似乎也可行。等待bo 兄进一步的讲解。 （10）BO:1、了解血淀粉酶情况（是否存在胰腺或腹膜后十二指肠的损伤）。Does serum amylase help you make the decision to operate the patient? as i said before, if you decide to take the patient to the OR and if the study doesn't change your decision, why you want to do it. when you open the patient abd, you can yourself what injuries are there, spleen, pancrease, duodenum, small bowel2、腹腔穿刺，了解腹腔积液情况。as i mentioned before, DPL (diagnostic peritoneal lavage) is replace by FAST (the ultrasound). mainly used for blunt trauma. you already have the result of FAST and he has a knife in the belly, why do you want to do DPL3、备血。GOOD idea.4、CT似乎对下一步措施没有太大指导意义，因此非必需的检查。good point.另外，过多的检查看来弊大于利。Do you know why?5、手术可以考虑全麻，开胸探查，扩大膈肌裂口修补或切除腹腔内受损脏器。另外，本例以腹伤为主，胸腔置管引流，行剖腹探查似乎也可行。What is the indication for thoracotomy for possible chest trauma. he doesn't have anything on the CXR, why do you want cut his chest open now. even if he has diaphragm injury, you can repair it easily throught he abdomen. you open another body cavity (chest), you put patient on higher risk of hypothermia and death. what is the indication for a chest tube for this patient.ANY OTHER IDEAS about how to prep and drape the patient and what incision you want to make. thanks, i like this kind discussion. 道兄：bo兄回答细致,我继续不断学习。1、如果决定手术治疗，则淀粉酶检查没有必要了，毕竟术中能探查到。2、FAST无创、快速、便捷。但毕竟是间接的检查，不如穿刺来得准确吧，另外，超声也有出现假阳/阴性的情况的可能。但要是决定手术了，穿刺没有必要了，时间就是生命。3、得注射破伤风免疫球蛋白。4、应用抗菌药物。5、以腹部伤情为主，胸部稳定，选择经腹完成手术。6、手术切口考虑左上腹旁正中切口，便于延口探查。7、CT没有必要。原因个人考虑：此项检查费时，对创伤患者时间就是生命和预后。另外，做检查免不了要搬运，这个过程可能是伤情加重。8、术中根据探查情况，决定术式。胸腔完好的话，修补膈肌创口后，没有必要胸腔引流了。认真努力学习，不断要求自己进步。good good study，day day up！～ （11）BO:2、FAST无创、快速、便捷。但毕竟是间接的检查，不如穿刺来得准确吧，另外，超声也有出现假阳/阴性的情况的可能。但要是决定手术了，穿刺没有必要了，时间就是生命。do you have any data to support you opion that FAST is not accurate as DPL? it has replaced DPL as i mentioned before. it's simple, fast. the patient has a knife in the LUQ, what do you think DPL will show? 3、得注射破伤风免疫球蛋白。Most patient in the US has tetanus immunization. but it is a good point4、应用抗菌药物。good point5、以腹部伤情为主，胸部稳定，选择经腹完成手术。ok6、手术切口考虑左上腹旁正中切口，便于延口探查。the skin prep and drape and incision are very important for trauma patients. for typical trauma patients, esp exploratory laparotomy for blunt trauma patients, you have to prep the skin wide: from the neck to the upper thigh, on both sides of the torso, you prep to the bed (posterior axillary line bilaterally). this preparation can give you opportunaty for mid line abd incision, mediasternotomy (cardiac message, repair great vessel injury), left thoracotomy (for cardiac message, aorta clamping when the patient loses vital signs due to abd injury), and femoral artery and vein access.7、CT没有必要。原因个人考虑：此项检查费时，对创伤患者时间就是生命和预后。另外，做检查免不了要搬运，这个过程可能是伤情加重。i said several times, if the study won't change your management, you don't need to do it. Does CT result change your mind to take the patient to the OR.8、术中根据探查情况，决定术式。胸腔完好的话，修补膈肌创口后，没有必要胸腔引流了。Good. most time, you have to decide what to do in the OR when you open the patient belly. that's the nature of trauma surgery. you don't know what's exactly going on until you are in.thanks for all the answers. they are great. (12)BO:here is what we did for this patient.after patient arrived, ABC was done, two large bore IVs was placed. CXR negaive, FAST positive around spleen. patient was taken to the OR. total less than 10 minutes. in the OR:The patient's skin was prepared from the neck to the upper thigh, bed to bed on both sides of the torso, this preparation can give you opportunaty for mid line abd incision, mediasternotomy (cardiac message, repair great vessel injury), left thoracotomy (for cardiac message, aorta clamping when the patient loses vital signs due to abd injury), and femoral artery and vein access.midline incision from xyphoid process to below umbilicus. about 1 liter blood in the abd, only splenic injury (through and through) was found. no diaphragm injury or any other injuries.what would you do now? *********************************************************************认领线以上翻译完毕*********************************************************************第二期教学互动及病例讨论翻译稿－－－－－－－－－－－－－－－－－（一）－－－－－－－－－－－－－－－－－－－－－(1)道可道非常道：hi，bo xiong.could please take some classic cases for example to show how to do these activities of Initial Assessment and Management such as trauma cases of automobile accidents which are very comon in China .i think it may be interesting and gives us a much wider understanding.well ,you may describe in a brief way as i know you will show some typical cases in detail when we get to that part .thanks! BO兄，你在讲创伤首诊与处理的时候可以结合些创伤的病例讲讲如何做吗，比如国内十分常见的车祸？我觉得这样会使讨论更有趣生动而且理解深刻。（虽然）我知道，在讲到病例部分的时候你也会详细介绍许多典型病例的，谢谢啦(1)BO：have been quite busy lately. finally find some time to continue.a couple of you guys asked to discuss some cases as we discuss the initial assessment and management. i think it is a good idea. we will discuss cases after we finish the primary survey and secondary survey. 最近比较忙，终于找点时间来继续啦。大家想让我在讲创伤首诊与处理的时候讨论些病例，我觉得不错。在讲完初评和二次评估的时候我会讲些病例。(2)BO:Now, you guys know how to do in-hospital preparation and primary survey, and here is the case.you are the trauma surgeon or trauma chief resident on call. you get paged (1-1-1-10). one patient, a trauma red, stab wound to the left lower chest, vital signs stable (pulse 110, bp 136/68 mmHg). patient will arrive in to minutes. what would you do now based on we discussed before? 现在，你们知道了如何进行院内准备及初步评估，现在有个病例：假如你是值班的创伤外科大夫或住院总，你收到如下呼叫：1－1－1－10。一个伤患，红色创伤级别，左下胸部刀刺伤，生命体征平稳（P110，BP136/68 mmHg），病人会在两分钟后到达。根据前面讲的，你会如何去做？（3）BO：this is pretty good, and it was what we set up for the coming patient. now the patient arrived, see the following picture. what would you do when you see this patient. (this picture i posted before and asked for you choice. now we will discuss how to manage this patient step by step based on what we did) 讲的很好，这就是我们怎么为快到达的病人准备的。现在病人来了，见下图。当你见到这例病人的时候你该怎么做？（前面我发过这张图并问大家如何选择，现在根据我们当时如何做的和大家一步步的讨论该如何处理。）（4）BO：those are excellent thoughts. however, you can't do so much in trauma bay in such a short time. so an more organized approach should be emphasized here. that is the key point of this discussion.when you get paged and have your team in position in trauma bay, you need know who's doing what. as the graph showed in discussion #1 of the organization of trauma team, if you are the assessment MD, you don't start with cutting patient's clothes which should be done by the support MD. your job is to do the primary survey (A,B,C). Whenever you see a trauma patient or a crashing patient, you always remember ABC. (BY now you guys must know what ABC stands for). be stone calm and be cool. don't jump around doing everything. do no harm to patient. 上面的想法很好，可是在创伤急救室这么短的时间内你不可能做这么多。所以这里要强调下更加有序合理的处理方法的重要性，这也是此病例的讨论重点。当你收到呼叫达创伤急救室并且创伤组成员都就位时，你需要知道谁应该干什么。正如在上一讲中创伤组成员的组织站位中所示，如果你是伤情评估医师，你不要去管着剪开病人的衣服，这应该由助理医师去做。你的任务是进行初步评估（A、B、C）。无论什么时候你见到创伤或车祸病人，你要时刻想法A、B、C（现在你们应该知道了A、B、C的意思）。一定要异常冷静，不要慌慌张张的动手，别再伤着病人。（5）BO：back to this patient. first thing is "A" -- "Airway". so first thing you do is to ask him: "what's your name?" he answered his name, then you know his airway is intact. "no intubation"second thing is "B" ----"Breathing". you listen to his lungs. clear bilaterally. so he has air moving in and out. No chest tube. put him on facial mask O2.third thing is "C" ---- "Circulation". you felt his pulse 110, strong, ask the nurse put on EKG Monitoring, pulse oximeter, check blood pressure 136/76 mmHg. start two large bore IV, bolus him warm LR.fourth thing is "D"---"Disability". ask patient to wiggle his toes and squeeze your hands to see if he follows your commands and any motor sensary dysfunction. he is normal.fifth thing "E" ----"Exposure" support MD (your intern) cut all the clothes, check any other wound. no other wound for him. then cover his body wth warm blanket as much as you can.now you need some adjucts to primary survey. what would you do next? what studies you want to do now to help figure out what's going on with this patient at the trauma bay. everybody is looking for you, waiting for your orders. 回来这个病例：首先是A——airway：所以你首先要做的是问病人：“你叫啥名字？”他如实回答，那么你就知道了他的气道没问题，不需要插管。其次是B——breathing：肺部听诊，双侧呼吸音清，所以他呼吸正常，不需要留置胸腔引流管。给予面罩吸氧。再次是C——circulation：触摸脉搏，110次/分，有力，让护士测心电监护、动脉血氧分析，测血压136/68 mmHg。开通两条大口径静脉通路，快速滴注加温林格氏液。第四是D——disability：让病人上抬脚趾，你用手感觉下阻力，看病人是否照做或是否有运动障碍。这个病人正常。第五就是E——exposure：助理医师（你的实习大夫）剪开所有衣物，并检查是否是其他外伤。此病人无其他外伤，然后用热毛毯尽量盖好。接下来，你需要进行初步评估的补充了。那你会怎么做呢？在创伤急救室你还需要做哪些检查来确定病人的伤情呢？所有人都在等着你的下一步处理及指挥。　(　8　) our patient with stab wound in the left upper abd / lower chest is still lying on the bed at the trauma bay. now you know his CXR was fine. FAST was positive. what would you do now? he has been lying at the trauma bay with a knife in his LUQ for a week, don't you guys want to do something?各位，我们的那个自杀患者还依然躺在创伤处置室的创伤床上。现在大家知道了，该换胸片未见明显异常，超声有了阳性发现。那么接下去该如何处理呢？兄弟们，自杀的的病人已然在创伤处置室躺了一周了（指的是一周没有回帖，而不是真的让患者躺了一周。此处是反讽。道注，呵呵。），难道你们不想做些什么吗？(9) with a knife in his LUQ for a week??难以想象，为什么带这么长时间啊？"觉得在trauma bay中没事赶快转手术室取刀得啦!!"--------------because you guys hadn't decided to do anything for him for a week until Tongdour decided to take him to the OR. That's why i said he stayed at trauma bay with a knife in his LUQ for a wk.因为大家没有对患者的下一步治疗提供任何措施，可怜的老头只好躺在创伤室等待一周。铜豆现在终于决定带他进手术室了。呵呵。Finally Tongdour took him to the OR. do you think he needs CT scan before the operation? will the CT scan result change your decision to operate on this patient. if it won't, he probably won't need a CT scan. you will cut him any way, and you will see all the injuries in the OR after you open him up.终于，铜豆兄弟决定对患者进行手术治疗。大家是否认为术前应该做个CT 呢？ct结果是否会改变你的决定呢？如果ct结果改变不了手术的决定，那么该患者想必没有必要做手术。毕竟你要手术探查的，到时候哪儿有损伤就一目了然了。Next question? how do you prep the patient and what type of incision you are going to make? please don't keep him in the OR for another week.下一个问题。术前还需准备什么？切口如何选择？希望这次不要再把可怜的老头晾在手术台上一周了，呵呵。(10)1、了解血淀粉酶情况（是否存在胰腺或腹膜后十二指肠的损伤）。Does serum amylase help you make the decision to operate the patient? as i said before, if you decide to take the patient to the OR and if the study doesn't change your decision, why you want to do it. when you open the patient abd, you can yourself what injuries are there, spleen, pancrease, duodenum, small bowel。血淀粉酶的检查结果会改变你手术的决定吗？正如我之前所说的，如果你已经决定进行手术治疗，就不要再在那些改变不了手术决定的检查上瞎耽误功夫。不需要靠间接检查来判断哪里存在损失，手术打开直接探查就都明了了。2、腹腔穿刺，了解腹腔积液情况。as i mentioned before, DPL (diagnostic peritoneal lavage) is replace by FAST (the ultrasound). mainly used for blunt trauma. you already have the result of FAST and he has a knife in the belly, why do you want to do DPL。正如我之前所说。腹腔灌洗已经被超声取代。主要用于闭合性损伤。超声已然有了阳性发现，为何还要做穿刺呢？3、备血。GOOD idea.备血是个不错的想法。4、CT似乎对下一步措施没有太大指导意义，因此非必需的检查。good point.说得好！另外，过多的检查看来弊大于利。Do you know why?知道原因吗？5、手术可以考虑全麻，开胸探查，扩大膈肌裂口修补或切除腹腔内受损脏器。另外，本例以腹伤为主，胸腔置管引流，行剖腹探查似乎也可行。What is the indication for thoracotomy for possible chest trauma. he doesn't have anything on the CXR, why do you want cut his chest open now. even if he has diaphragm injury, you can repair it easily throught he abdomen. you open another body cavity (chest), you put patient on higher risk of hypothermia and death. what is the indication for a chest tube for this patient.胸外伤病人的开胸适应症是什么？既然患者胸片无明显异常，为何还要选择开胸？即使存在膈肌裂伤，也完全可以经腹修补。你另开切口，增加了患者的死亡风险。留置胸腔引流管的适应症又是哪些？ANY OTHER IDEAS about how to prep and drape the patient and what incision you want to make.在术前准备上，还有其他看法吗？你会选择什么切口呢？ thanks, i like this kind discussion.我喜欢这样的讨论，多多益善，望大家多参与！～中午看到了新的，试着翻译了一下，请大家指正。粗体部分是拿不准的地方，请高手修正。chenguoliang wrote:i still remember once you said "we have a lot of gun shot wound here". i'm very interested in the gun shot,can you give us some case and the management?我还记得您曾经说过“我们那里有许多枪击伤”。我对枪击伤非常感兴趣，您能给我们举一些例子以及其处理吗？Gun shot wound (GSW) belongs to penetrating trauma. i will discuss those cases when we get to the individual chapter. i know you want to see the exciting cases, just be patient. after you know the ABC of trauma, then you can understand more about the management for GSW.枪击伤(GSW)属于穿透伤。我将在独立的章节对那些病例进行讨论。我知道你想看到这些令人兴奋的病例，但是你要耐心点。在你知道创伤的ABC后，你就能够对GSW的处理有更多的理解。Surgical/Trauma ICU外科/创伤ICUAnother important component of trauma center is ICU. in our hospital, we have CCU (Coronary Care Unit), CT ICU (for cardiothoracic patients) Medical ICU, Surgical / trauma ICU which has 20 beds. if we have more patients we use Medical ICU beds. ICU is a very important part to treat trauma patients. everyday, we have one trauma attending or an anesthesiologist doing rounds with three residents. all the attending had their training of critical care and certified. besides doing rounds on the ICU patients, trauma surgeons also operate on those ICU patients if they need operations, such as the finishing damage control operation, second look, wash out, tracheostomy, gastrastomy, decompression laparotomy........ that's the difference between ICU trauma attendings and ICU anesthesia attendings. 创伤中心的另外一个重要组成部分是ICU。在我们医院，我们有心脏监护病房（CCU），心胸外科重症监护室 ，内科ICU，外科/创伤ICU（有20张床）。如果我们有较多的患者，我们就用内科ICU的病床。ICU是治疗创伤患者的一个非常重要的部分，我们每天都有一个创伤科的主治医生或者一个麻醉师带领3个住院医师进行查房。所有的主治医生经过重症病治疗的训练，并且都达到了要求。除了对ICU的患者进行查房外，创伤外科医生也对那些ICU需要手术的患者进行手术.包括对之前仅行损伤控制手术的患者彻底完成手术，二期手术，洗胃，气管切开，肠切除，减压，剖腹探查……那是ICU里创伤科主治医生和麻醉师之间的区别。nursing staff are very important. we have 1:1 or 1:2 nurse to patient ratio. they do a lot of work: such as wound dressing change, foley, NGT, dobhoff (naso-duodenal tube) ........护理人员非常重要。我们的护患比例是1:1 或1:2。他们做许多工作：比如伤口换药，Foley导管、鼻胃管和经鼻十二指肠管的护理。since the discussion of ICU is another huge topic, i don't want to get into it too much.由于ICU的讨论是另一个很大的话题，我不想对其进行过多的讨论。编译：chenguoliang问：我还记得您曾经说过“我们那里有许多枪击伤”。我对枪击伤非常感兴趣，您能给我们举一些例子以及其处理吗？bo 兄的回答：枪击伤(GSW)属于穿透伤。我将在独立的章节对那些病例进行讨论。我知道你想看到这些令人兴奋的病例，但是要耐心点。在你知道创伤的ABC后，你就能够对GSW的处理有更多的理解。外科/创伤ICU创伤中心的另外一个重要组成部分是ICU。在我们医院，我们有心脏病监护病房（CCU），CT ICU（为中热患者设立），内科ICU，外科/创伤ICU（有20张床）。如果我们有较多的患者，我们就用内科ICU的病床。ICU是治疗创伤患者的一个非常重要的部分，我们每天都有一个创伤科的主治或者一个麻醉师带领3个住院医师进行查房。所有的主治医生经过重症病治疗的训练，并且都达到了要求。除了对ICU的患者进行查房外，创伤外科医生也对那些ICU需要手术的患者进行手术，包括对之前仅行损伤控制手术的患者彻底完成手术，二期手术，洗胃，气管切开，肠切除，减压，剖腹探查……那是ICU里创伤科主治医生和麻醉师之间的区别。护理人员非常重要。我们的护患比例是1:1 或1:2。他们做许多工作：比如伤口换药，Foley导管、鼻胃管和经鼻十二指肠管的护理。由于ICU的讨论是另一个很大的话题，我不想对其进行过多的讨论。亲密飞翔 wrote:呵呵，两位好积极呀呵呵，方便校对。亲密飞翔 wrote:呵呵，两位好积极呀呵呵，让飞兄笑话了，偶是响应道兄的号召，支持到底啦!!!thanks to everybody, esp. those who have worked hard on translations. without you guys, it wouldn't go so well. lets carry on.道兄: thanks for all the coordination and translation and explanation you did for me using English. i appreciate.和飞兄探讨一段翻译，飞兄以直译为主，我有些地方选择了意译。加粗部分和bo兄商议之后修正。Another important component of trauma center is ICU. in our hospital, we have CCU (Coronary Care Unit), CT ICU (for cardiothoracic patients) Medical ICU, Surgical / trauma ICU which has 20 beds. if we have more patients we use Medical ICU beds. ICU is a very important part to treat trauma patients. everyday, we have one trauma attending or an anesthesiologist doing rounds with three residents. all the attending had their training of critical care and certified. besides doing rounds on the ICU patients, trauma surgeons also operate on those ICU patients if they need operations, such as the finishing damage control operation, second look, wash out, tracheostomy, gastrastomy, decompression laparotomy........ that's the difference between ICU trauma attendings and ICU anesthesia attendings.重症监护室是创伤中心另一个重要组成部分。在我工作的医院，我们同时拥有CCU（冠心病监护室），CT ICU（心胸外科监护室），内科重症监护室，（创伤）外科监护室。我们的创伤外科重症监护病房有20张床，要是病人多，我们就借用内科监护室的病床。监护室在救治创伤外科病人的过程中有着举足轻重的作用。每天，我们都有一个创伤外科主治医师或一个麻醉科医师带领三个住院医师进行查房。所有的创伤外科主治医师均需参加重症病治疗的培训并达到相应的要求。创伤外科主治医师除了每天常规查房处理病人之外，同时也对监护室中需要手术的患者进行手术治疗。包括对之前仅行损伤控制手术的患者彻底完成手术，二期手术，腹腔灌洗，气管切开造口术，肠造瘘术，剖腹探查减压术……这就是重症监护室创伤外科主治医师和麻醉科主治医师的工作性质的区别。wash out: 腹腔灌洗所有的主治医生经过重症病治疗的训练，并且都达到了要求: ------i like this比如伤口换药，Foley导管、鼻胃管和经鼻十二指肠管的护理----------- not just the care of all these tubes. they place all these tubes. nurses do a lot more here.just be patient (adj) not the patient (noun)我认领第二期－－－（1）、（2），请大家多提宝贵意见trauma surgery: #2: Initial Assessment and Management创伤外科：第二期---创伤首诊与处理The treatment of the seriously injured patient requires rapid assessment of the injuries and institution of life-preserving therapy. Because time is of the essence, a systematic approach that can be easily reviewed and practiced is desirable. This process is termed "initial assessment" and includes:对严重损伤患者的治疗需要对伤情作出快速判定和进行挽救生命治疗的设施。由于时间很重要，希望能有一种易于观察和操作的系统方法。这个过程称为“首诊”，包括：1. Preparation2. Triage 3. Primary survey (ABCDEs)4. Resuscitation5. Adjuncts to primary survey and resuscitation6. Secondary survey (head-to-toe evaluation and history)7. Adjuncts to the secondary survey8. Continued post resuscitation monitoring and reevaluation9. Definitive care1准备2伤员鉴别分类3初评(ABCDEs)4复苏5初评和初次复苏的补充6二次评估7二次评估的补充8继续复苏后监护和重新评估9明确治疗The primary and secondary surveys should be repeated frequently to ascertain any deterioration in the patient's status and any necessary treatment to be instituted at the time an adverse change is identified.初次和二次评估应该不断重复进行，以便明确患者的状况的发生的任何恶化以及在确定一个不利改变时进行任何必要的治疗。This sequence is presented as a longitudinal progression of events. In the actual clinical situation, many of these activities occur in parallel or simultaneously. The linear or longitudinal progression allows the doctor an opportunity to mentally review the progress of an actual trauma resuscitation.这个顺序是按照事件纵向进展进行划分。在临床实际情况中，许多这些情况是并行或同时发生的。线性或纵向进展使医生有机会在脑子里回顾一个真正的创伤复苏的过程。PREPARATIONPreparation for the trauma patient occurs in 2 different clinical settings. First, during the prehospital phase, all events must be coordinated with the doctors at the receiving hospital. Second, during the hospital phase, preparations must be made to rapidly facilitate the resuscitation of the trauma patient准备为创伤患者做准备存在两种不同临床情况。第一种，入院前一段时间，所有事情必须与接受患者医院的医生协调好。第二种，住院期间， 必须做好利于创伤患者快速复苏的准备。A Prehospital phase:we discussed the prehospital care before. i'd like to point out Emphasis in the prehospital phase should be placed on airway maintenance, control of external bleeding and shock, immobilization of the patient, and immediate transport to the closest appropriate facility, preferably a verified trauma center. Every effort should be made to minimize scene time.入院前期：我们以前已经讨论过入院前的治疗。我这次指出的是应该把入院前期的重点放在维持气道通畅、控制外部出血、休克和制动患者，快速把患者运送到距离最近的合适场所--送到核定的创伤中心更好。应该尽一切努力缩短现场时间。inhospital phaseAdvanced planning for the trauma patient's arrival is essential. Ideally, a resuscitation area should be available for trauma patients. Proper airway equipment (eg, laryngoscopes, tubes) should be organized, tested, and placed where it is immediately accessible. Warmed intravenous crystalloid solutions (eg, Ringer's lactate) should be available and ready to infuse when the patient arrives. Appropriate monitoring capabilities should be immediately available. A method to summon extra medical assistance should be in place. A means to assure prompt response by laboratory and radiology personnel is necessary.入院阶段对于送达的创伤患者制定进一步计划是很重要的。最理想的是使创伤患者得到一个复苏场所。应该组织和检查合适的通气设施（比如喉镜，），并把他们放在立即可以拿到的地方；应该有可用的加热的静脉注射的晶体液，并且准备好为送达的患者注射；应该准备好适当的监护设施。也应该为召集其他的医疗协助做好准备。一种确保实验室和放射科人员能够快速回应的工具是必需的。编译:创伤外科：第二期---创伤首诊与处理对严重损伤患者的治疗需要对伤情作出快速判定和进行挽救生命治疗的设施。由于时间很重要，希望能有一种易于观察和操作的系统方法。这个过程称为“首诊”，包括：1准备2伤员鉴别分类3初评(ABCDEs)4复苏5初评和初次复苏的补充6二次评估7二次评估的补充8继续复苏后监护和重新评估9明确治疗初次和二次评估应该不断重复进行，以便明确患者的状况的发生的任何恶化以及在确定一个不利改变时进行任何必要的治疗。这个顺序是按照事件纵向进展进行划分。在临床实际情况中，许多这些情况是并行或同时发生的。线性或纵向进展使医生有机会在脑子里回顾一个真正的创伤复苏的过程。准备为创伤患者做准备存在于两种不同临床情况。第一种，入院前一段时间，所有事情必须与接受患者医院的医生协调好。第二种，住院期间， 必须做好利于创伤患者快速复苏的准备。入院前期：我们以前已经讨论过入院前的治疗。我这次指出的是应该把入院前期的重点放在维持气道通畅、控制外部出血和休克和制动患者，快速把患者运送到距离最近的合适场所--送到核定的创伤中心更好。应该尽一切努力缩短现场时间。住院阶段对于送达的创伤患者制定进一步计划是很重要的。最理想的是使创伤患者得到一个复苏场所。应该组织和检查适当的通气设施（比如喉镜，），并把他们放在立即可以拿到的地方。应该有可用的加热的静脉注射的晶体液，并且准备好为送达的患者注射。应该准备好适当的监护设施。也应该为召集其他的医疗协助做好准备。一种确保实验室和放射科人员能够快速回应的工具是必需的。飞翔兄辛苦了!!!想和兄探讨下几处翻译，请多指教：1、Initial Assessment 创伤首诊 初步评估2、The primary and secondary surveys should be repeated frequently to ascertain any deterioration in the patient's status and any necessary treatment to be instituted at the time an adverse change is identified.初次和二次评估应该不断重复进行，以便明确患者的状况的发生的任何恶化以及在确定一个不利改变时进行任何必要的治疗。初次和二次评估应该快速反复进行，以便及时明确病情的恶化并对不利改变进行必要处理。3、This sequence is presented as a longitudinal progression of events. In the actual clinical situation, many of these activities occur in parallel or simultaneously. The linear or longitudinal progression allows the doctor an opportunity to mentally review the progress of an actual trauma resuscitation. 上述评估过程是按照时间先后进行表述的。但在临床实际中，许多过程是同时进行的。这就需要医生能够在脑海中形成一个对实际复苏过程如何进行的印象？？4、the closest appropriate facility, preferably a verified trauma center. 距离最近的合适场所--送到核定的创伤中心更好 距离最近的相应医院，送到获得资质的创伤中心更好(或直接意译为：送到创伤中心更好。)5、Advanced planning for the trauma patient's arrival is essential. 对于送达的创伤患者制定进一步计划是很重要的。 为伤员的到达提前做好准备计划是必要的。6、A method to summon extra medical assistance should be in place. 也应该为召集其他的医疗协助做好准备。 必要时其他各科室人员也应该及时到位。呵呵，让飞兄见笑了，不是觉得兄翻译的不对，飞兄是直译为主了，这次内容小弟觉得意译还是好点，要直译了读着还是不大符合咱中国的说话习惯，偶也绞尽脑汁在想出个合适点的措辞，还有其他地方请飞兄斟琢，也请大家多多发言一块指正，谢谢道兄的意译最拿手，敬等指教我也来凑凑热闹1、The treatment of the seriously injured patient requires rapid assessment of the injuries and institution of life-preserving therapy. Because time is of the essence, a systematic approach that can be easily reviewed and practiced is desirable.对创伤患者来说，时间就是生命。因此一套简洁、快速而又行之有效的创伤首诊处理措施是非常重要的。2、The primary and secondary surveys should be repeated frequently to ascertain any deterioration in the patient's status and any necessary treatment to be instituted at the time an adverse change is identified. 急救过程中应当反复评估患者整体状况，明确病情变化。及时发现患者是否出现加重迹象，以便采取必要相应措施迅速加以处理。3、This sequence is presented as a longitudinal progression of events. In the actual clinical situation, many of these activities occur in parallel or simultaneously. The linear or longitudinal progression allows the doctor an opportunity to mentally review the progress of an actual trauma resuscitation.以上步骤是救治过程中按照时间先后顺序排列的。但在实际的临床工作中，这些步骤之间并没有明显时间界限，很多操作往往同时进行。这种排序只是为了让医生在救治过程中思路更清晰不至于忙乱。4、Advanced planning for the trauma patient's arrival is essential. Ideally, a resuscitation area should be available for trauma patients. Proper airway equipment (eg, laryngoscopes, tubes) should be organized, tested, and placed where it is immediately accessible. Warmed intravenous crystalloid solutions (eg, Ringer's lactate) should be available and ready to infuse when the patient arrives. Appropriate monitoring capabilities should be immediately available. A method to summon extra medical assistance should be in place. A means to assure prompt response by laboratory and radiology personnel is necessary.在患者送达之前就应该做好抢救的各项准备。最好是想要什么就能有什么。开放气道的器具必须确保装好备用并触手可及。加温复苏液、各种监测仪必须备好待用，确保一旦患者到达就能马上投入使用。必须拥有一套和其他科室之间保持联络的即时通讯设备，以便必要时能使相关人员快速就位。Post is deleted亲密飞翔 wrote:刚看到bo兄的新贴，试翻译如下：Continue the in-hospital preparation:When we get paged, we run down to the trauma bay, put gown, gloves, shoes covers and eye protections on. Have central lines kit and other trays ready based on the patient’s injuries. Nurses have the monitor ready …. The resident doing primary survey keeps the stethoscope and trauma shear with him.继续谈谈入院前的准备：当我们得到急救信号时，我们迅速跑到床上急救室，穿好手术外衣、手套、鞋套还有防护眼罩等，并根据患者的伤情带上中央置管装备以及其它一些必需的托盘，护士带好监测仪准备，等等。准备对患者进行初步检测的住院医师准备好听诊器及创伤用的剪刀（用来剪开伤者衣裤等）。Patients are assessed and their treatment priorities established based on their injuries, their vital signs, and the injury mechanism. In the severely injured patient, logical sequential treatment priorities must be established based on overall patient assessment. The patient's vital functions must be assessed quickly and efficiently. Patient management must consist of a rapid primary evaluation, resuscitation of vital functions, a more detailed secondary assessment, and, finally, the initiation of definitive care.患者经过评估后，根据其伤情、生命体征及损伤的机理确定救治的重点和先后程序。对于一名伤情严重的患者，确立合理的救治程序必须依据对其整体病情的评估。必须对患者重要的生命机能作出迅速而有效的评估。对患者的管理包括对主要伤情的及时评估、回复重要的生命机能、更为详尽的二期评估以及最终对患者实施有效的治疗和护理。Primary Survey-------It is designed to identify all immediate life threatening injuries. it is the most important part for the emergent resuscitation.初期监测——用来辨别和判定所有最为紧迫的危及生命的伤情，这是急救复苏中最重要的一环。This process constitutes the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence since this is the sequence how patients get killed:根据对患者生命威胁的先后因素，（我们把）急救治疗的程序概括为ABCDE五个方面，并可通过这五点判断威胁生命的情况。A Airway maintenance with cervical spine protection (ask patient's name, let patient talk, see if patient has stidor... make sure you protect the C-spine when you intubate the patient. it makes the intubation harder)B Breathing and ventilation (listen to the lungs see if air is moving)C Circulation with hemorrhage control (check the pusle at radial A, femoral A, check BP, start IV lines)D Disability: Neurologic status (ask patient to move fingers and toes, check sensation)E Exposure/Environmental control: Completely undress the patient, but prevent hypothermiaA：通过对颈椎的保护维持气道的通畅（询问患者的姓名、鼓励患者讲话、观察患者stidor？等等，在给患者进行插管治疗前要确认对颈椎保护良好，这也许会使插管变得困难一些？）。B：维持呼吸和通气（听诊肺部呼吸音、观察胸廓运动情况）。C：通过对血流动力学的控制维持循环功能（监测桡动脉、股动脉的脉搏，血压或采用静脉置管监测？）。D：防止功能障碍：监测神经系统情况（让患者活动四肢及检查其感觉功能）。E：（患者）所暴露的环境因素的控制：脱去患者的外衣同时要注意保护其防止低体温的发生。During the primary survey, life-threatening conditions are identified and management is instituted simultaneously. Priorities for the care of the pediatric patient are the same as those for adults. Priorities for the care of the pregnant patient are the same as those for nonpregnant patients. 在对患者初期监测的过程中，对于威胁生命的病情的辨别和对患者的治疗管理是同时进行的。对小儿患者的救治程序与成人相同，对怀孕患者的救治程序与未怀孕者也是一样的。积极参与讨论1、This process constitutes the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence since this is the sequence how patients get killed.这些急救措施是创伤首诊过程中的5大基础步骤。因为患者往往由于这五个方面的原因死亡，所以通过这五个步骤也可以判断患者病情危重的程度。2、Airway maintenance with cervical spine protection （see if patient has stridor... ） 在保护好颈椎的前提下畅通气道（观察病人是否有呼吸喘促。）3、start IV lines监测中心静脉压？感谢道兄的指教。再翻译一段：A Airway maintenance with cervical spine protection 在保护好颈椎的前提下畅通气道ask patient's name, let patient talk, see if patient has stidor, inspect for foreign bodies and facial. mandibular, or tracheal/laryngeal fractures that may result in airway obstruction. initially, the chin lift or jaw thrust maneuvers are recommended to achieve this task. patient with GCS < or = 8 need be intubated. make sure you protect the C-spine when you intubate the patient. it makes the intubation harder. 询问患者的名字，鼓励他说话，观察患者是否有意识障碍，检查是否存在（气道内）异物或是颌面部、气管喉部骨折等可能导致气道梗阻的因素。最初可以通过向上牵引下颌的方法实现呼吸道的开放，如果患者的Glasgow昏迷评分小于或等于8则需要气管插管。当你对患者实行插管时要确认颈椎保护良好，这也许会使插管变得困难一些？ remeber: assume a cervical spine injury in any patient with multi-system trauma, especially with an altered level of consciousness or a blunt injury above clavicle. you don't want patient become quadraplegia after your intubation due to the cervical spinal cord injury for cervical fracture.请记住：假定有一个伴有颈椎损伤的多系统创伤的患者，尤其是伴有意识水平改变或锁骨上遭受钝器伤的患者，你一定不希望你的患者在插管术后由于（没有保护好造成的）颈椎骨折导致的颈部脊髓损伤而变得quadraplegia（四肢瘫痪）？