紧急医疗服务战术损伤控制复苏方案

EMS Tactical Damage Control Resuscitation Protocol

作者信息

Fulton II Matthew R., Schwartfeger Stephen

机构信息

Texas Tech University Health Sciences Center El Paso

出版信息

DOI:
Abstract

Damage control resuscitation focuses on temporizing measures that prioritize critical interventions to control hemorrhage, life-threatening injuries, and physiological derangements, followed by staged care. The term "damage control" originated from naval tactics during the First World War, which described interventions to keep a damaged ship combat-capable until definitive repairs could be made. In the prehospital setting, damage control resuscitation (DCR) was initially adopted from long-established principles of damage control surgery. The main goal of DCR is to limit blood loss from hemorrhage and prevent the development of coagulopathy. The original 3-phase approach consisted of initial laparotomy with hemorrhage control, contamination control, intraabdominal packing, and temporary closure in the operating room (OR), followed by correction of metabolic derangements and hemodynamic management in the intensive care unit (ICU), and finally, definitive repairs in the OR after stabilization.  Phase 0 of damage control surgery, termed "Damage Control Ground Zero," was later added, implementing early prehospital measures. This early damage control phase begins upon first contact and consists of interventions that may significantly impact patient outcomes. Data from civilian trauma centers suggests that nearly 50% of deaths happen before hospital arrival, and most of these deaths are associated with massive hemorrhage, a preventable cause of death in the field. Modern prehospital management of trauma consists of emphasizing early time-sensitive resuscitation interventions aimed at treating reversible causes of death, and these interventions include hemorrhage control, establishing intravascular (IV) access, intravenous fluids (blood product transfusion when available), and advanced airway management.  In combat environments, uncontrolled hemorrhage accounts for over 90% of fatalities. Implementing interventions to control bleeding at the point of injury, coupled with prehospital Tactical Combat Casualty Care, has yielded successful outcomes. These interventions are particularly effective when combined with rapid evacuation and prehospital blood resuscitation. Administering blood in the prehospital setting immediately post-injury enhances 24-hour and 30-day survival rates. Therefore, a triad approach encompassing point-of-injury hemorrhage control, rapid evacuation, and prehospital blood resuscitation is instrumental in preserving lives in the face of active hemorrhage. Hemorrhage control is a high priority in trauma patients, and active life-threatening bleeding should be addressed immediately. This stems from prehospital research that indicated risks from advanced airway interventions in the early phase of the management of trauma patients, leading to increased mortality from delayed transport to definitive care and adverse physiologic effects of intubation of patients in hemorrhagic hypovolemic shock. This triggered a culture change in the prehospital management of trauma and led to the prioritization of hemorrhage/circulation over airway in initial management, shifting resuscitation from Airway, Breathing, Circulation (ABCs) to Circulation, Airway, Breathing (CAB) or Massive Hemorrhage, Airway, Respiration, Circulation, Hypothermia Prevention (MARCH) in military settings. When addressing hypotension in the prehospital setting, early blood product transfusion has consistently been demonstrated to be superior to crystalloid and colloid resuscitation in the field, with possible harm detected in patients who did not receive blood early. The concept of simultaneously managing life-threatening injuries along with expedited transport to a hospital appears to have a favorable impact on patient outcomes in both civilian urban trauma systems and military combat settings.

摘要

损伤控制复苏侧重于采取临时措施,优先进行关键干预以控制出血、危及生命的损伤和生理紊乱,随后进行分阶段治疗。“损伤控制”一词源于第一次世界大战期间的海战战术,描述了在进行最终修复之前使受损舰艇保持作战能力的干预措施。在院前环境中,损伤控制复苏(DCR)最初是从成熟的损伤控制手术原则中借鉴而来的。DCR的主要目标是限制出血导致的失血,并预防凝血病的发生。最初的三阶段方法包括在手术室(OR)进行初步剖腹手术以控制出血、控制污染、腹腔内填塞和临时关闭,随后在重症监护病房(ICU)纠正代谢紊乱并进行血流动力学管理,最后在病情稳定后在OR进行确定性修复。损伤控制手术的0期,即“损伤控制归零地”,后来被添加进来,实施早期院前措施。这个早期损伤控制阶段从首次接触时开始,包括可能对患者预后产生重大影响的干预措施。来自民用创伤中心的数据表明,近50%的死亡发生在到达医院之前,其中大多数死亡与大量出血有关,这是现场可预防的死亡原因。现代创伤院前管理包括强调早期对时间敏感的复苏干预措施,旨在治疗可逆的死亡原因,这些干预措施包括控制出血、建立血管内(IV)通路、静脉输液(如有可用的血液制品则进行输血)以及高级气道管理。在战斗环境中,失控出血占死亡人数的90%以上。在受伤点实施控制出血的干预措施,再加上院前战术战斗伤员护理,已经取得了成功的结果。当与快速后送和院前血液复苏相结合时,这些干预措施特别有效。受伤后立即在院前环境中输血可提高24小时和30天的生存率。因此,一种包括受伤点出血控制、快速后送和院前血液复苏的三联方法对于在活动性出血情况下挽救生命至关重要。控制出血是创伤患者的首要任务,应立即处理危及生命的活动性出血。这源于院前研究,该研究表明在创伤患者管理的早期阶段进行高级气道干预存在风险,导致因延迟转运至确定性治疗而增加死亡率以及对出血性低血容量休克患者进行插管产生不良生理影响。这引发了创伤院前管理的文化变革,并导致在初始管理中优先处理出血/循环而非气道,在军事环境中将复苏顺序从气道、呼吸、循环(ABC)转变为循环、气道、呼吸(CAB)或大出血、气道、呼吸、循环、预防体温过低(MARCH)。在院前环境中处理低血压时,早期输血在现场一直被证明优于晶体液和胶体液复苏,未早期输血的患者可能会出现不良影响。同时处理危及生命的损伤并加快转运至医院的理念似乎对民用城市创伤系统和军事战斗环境中的患者预后都有积极影响。

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