Stanford Penelope, Booth Nicola, Suckley Janet, Twelvetree Timothy, Thomas Debbie
School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, England.
St Mary's Hospital, Manchester, England.
Nurs Stand. 2016 Aug 3;30(49):54-63. doi: 10.7748/ns.2016.e10342.
Major trauma centres provide specialised care for patients who have experienced serious traumatic injury. This article provides information about major trauma centres and outlines the assessment tools used in this setting. Since patients in major trauma centres will be transferred to other settings, including inpatient wards and primary care, this article is relevant for both nurses working in major trauma centres and in these areas. Traumatic injuries require rapid assessment to ensure the patient receives prompt, adequate and appropriate treatment. A range of assessment tools are available to assist nurses in major trauma centres and emergency care to assess the severity of a patient's injury. The most commonly used tools are triage, Catastrophic Haemorrhage Airway to Exposure assessment, pain assessment and the Glasgow Coma Scale. This article summarises the use of these assessment tools in these settings, and discusses the use of the Injury Severity Score (ISS) to determine the severity of patient injuries.
大型创伤中心为经历严重创伤性损伤的患者提供专业护理。本文提供了有关大型创伤中心的信息，并概述了在此环境中使用的评估工具。由于大型创伤中心的患者将被转至其他环境，包括住院病房和初级护理机构，因此本文对在大型创伤中心以及这些领域工作的护士均具有参考价值。创伤性损伤需要快速评估，以确保患者获得及时、充分且恰当的治疗。有一系列评估工具可协助大型创伤中心和急诊护理中的护士评估患者损伤的严重程度。最常用的工具是分诊、灾难性出血气道至暴露评估、疼痛评估和格拉斯哥昏迷量表。本文总结了这些评估工具在这些环境中的使用情况，并讨论了使用损伤严重程度评分（ISS）来确定患者损伤的严重程度。
