Spahn Donat R, Cerny Vladimir, Coats Timothy J, Duranteau Jacques, Fernández-Mondéjar Enrique, Gordini Giovanni, Stahel Philip F, Hunt Beverley J, Komadina Radko, Neugebauer Edmund, Ozier Yves, Riddez Louis, Schultz Arthur, Vincent Jean-Louis, Rossaint Rolf
Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
Crit Care. 2007;11(1):R17. doi: 10.1186/cc5686.
Evidence-based recommendations can be made with respect to many aspects of the acute management of the bleeding trauma patient, which when implemented may lead to improved patient outcomes.
The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing guidelines for the management of bleeding following severe injury. Recommendations were formulated using a nominal group process and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) hierarchy of evidence and were based on a systematic review of published literature.
Key recommendations include the following: The time elapsed between injury and operation should be minimised for patients in need of urgent surgical bleeding control, and patients presenting with haemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation measures are successful. A damage control surgical approach is essential in the severely injured patient. Pelvic ring disruptions should be closed and stabilised, followed by appropriate angiographic embolisation or surgical bleeding control, including packing. Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further assessment as appropriate using focused sonography, computed tomography, serum lactate, and/or base deficit measurements. This guideline also reviews appropriate physiological targets and suggested use and dosing of blood products, pharmacological agents, and coagulation factor replacement in the bleeding trauma patient.
A multidisciplinary approach to the management of the bleeding trauma patient will help create circumstances in which optimal care can be provided. By their very nature, these guidelines reflect the current state-of-the-art and will need to be updated and revised as important new evidence becomes available.
对于出血性创伤患者的急性处理的许多方面，可以提出基于证据的建议，实施这些建议可能会改善患者的预后。
2005年成立了创伤严重出血高级护理多学科特别工作组，旨在制定严重创伤后出血管理指南。建议采用名义小组法和证据分级（推荐分级评估、制定和评价）证据等级体系制定，并基于对已发表文献的系统评价。
关键建议如下：对于需要紧急手术控制出血的患者，应尽量缩短受伤与手术之间的时间间隔；对于出现失血性休克且已确定出血源的患者，除非初始复苏措施成功，否则应立即进行手术控制出血。损伤控制手术方法对重伤患者至关重要。骨盆环骨折应予以闭合和固定，随后进行适当的血管造影栓塞或手术控制出血，包括填塞。对于出现失血性休克且出血源不明的患者，应立即使用聚焦超声、计算机断层扫描、血清乳酸和/或碱缺失测量等方法进行进一步适当评估。本指南还回顾了出血性创伤患者适当的生理指标以及血液制品、药物和凝血因子替代物的建议使用和剂量。
对出血性创伤患者采用多学科管理方法将有助于创造提供最佳护理的条件。就其性质而言，这些指南反映了当前的技术水平，随着重要新证据的出现，需要进行更新和修订。
