2015-07-29多发伤柏林新定义
多发伤_什么是多发伤_临床特点
多发伤_什么是多发伤_临床特点多发伤是指同一致伤因素同时或相继造成一个以上部位的严重创伤。
那么你对多发伤了解多少呢?以下是由本文库整理关于什么是多发伤的内容，希望大家喜欢!多发伤的简介头颅伤颅骨骨折合并颅脑损伤(如颅内血肿、脑干挫裂伤等)。
颈部伤颈椎部如颈椎损伤、大血管损伤等。
胸部伤可危及生命的损伤如多发性多段肋骨骨折、心包损伤、血气胸、肺挫裂伤、大血管损伤、气管损伤、膈肌破裂等。
腹部伤腹腔大出血或内脏器官破裂(如肝破裂、脾破裂、肾破裂等)。
骨盆等多处骨折由于骨折可能导致大出血而危及生命，如骨盆骨折伴休克、四肢骨折伴休克、椎体骨折伴神经系统损伤等。
软组织伤四肢或全身广泛撕裂伤。
一般来说，对生命不构成严重威胁的伤情如单纯的四肢骨折不伴休克或单纯的椎体压缩性骨折等不属多发伤范畴。
据统计，战时多发伤的发生率为4.8%-18%，有时甚至高达70%。
平时多发伤由车祸、爆炸、高处坠落、塌方等所致。
据美国1000次汽车撞车事故的1678例伤员统计，多发伤占65%;意大利一次炸药爆炸事故中，多发伤占72%;一组高空坠落伤统计，凡从5楼坠下的伤员全部为多发伤，各部位创伤的发生率以头部、四肢最多，其次为胸部、腹部损伤。
多发伤的临床特点1.伤情变化快、死亡率高由于多发伤严重影响机体的生理功能，此时机体处于全面应激状态，其数个部位创伤的相互影响很容易导致伤情迅速恶化，出现严重的病理生理紊乱而危及1生命。
多发伤的主要死亡原因大多是严重的颅脑外伤和胸部损伤。
2.伤情严重、休克率高多发伤伤情严重、伤及多处、损伤范围大、出血多，甚至可直接干扰呼吸和循环系统功能而威胁生命。
特别是休克发生率甚高。
3.伤情复杂、容易漏诊多发伤的共同特点是受伤部位多、伤情复杂、明显外伤和隐蔽性外伤同时存在、开放伤和闭合伤同时存在、而且大多数伤员不能述说伤情，加上各专科医生比较注重本专科的损伤情况、忽略他科诊断而造成漏诊。
4.伤情复杂、处理矛盾多发伤由于伤及多处，往往都需要手术治疗，但手术顺序上还存在矛盾。
[资料]ards柏林定义
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诊断标准-柏林定义1994年欧美联席会议提出的急性呼吸窘迫综合征（ARDS）诊断标准（表1）存在许多问题。
首先，氧合指数并非随着吸入氧浓度增加而呈线性增加，且受到呼吸机设置、尤其是呼气末正压（PEEP）的影响；其次，双肺浸润影程度受到医师主观判断影响；再次，由于气道压力传导和液体复苏的影响，ARDS患者的肺动脉嵌顿压也可能升高。
近年来临床研究显示，与弥漫性肺泡损伤的病理诊断相比，欧美联席会议诊断标准的敏感性为84%，而特异性仅为51%。
2011年欧洲重症医学学会柏林会议在ARDS流行病学、病理生理学和临床研究基础上，提出了ARDS新定义（表2）。
该定义将ARDS患者分为轻、中、重3个层次，并根据病情危重程度提出目前有循证医学证据支持的治疗方案，但其临床有效性和准确性有待进一步证实。
激素在ARDS中的应用2011年《美国呼吸与重症医学杂志》同期发表了两项非前瞻性随机对照观察性临床研究，评估激素对甲型流感（H1N1）致ARDS患者的作用，结果均提示，早期激素治疗升高了H1N1致ARDS患者的继发院内感染发生率和病死率。
两项研究均未能提供机械通气的相关指标，而保护性通气策略是目前明确降低ARDS患者病死率的方法。
如两组之间机械通气治疗存在偏倚，可能对研究结果产生影响。
因既往研究均未发现激素升高患者的病死率，此类患者是否可接受激素治疗或需要更多大样本量随机对照临床研究证据支持。
在此之前，临床医生应避免对H1N1致ARDS患者早期予以激素治疗。
药物治疗神经肌肉阻滞剂既往研究显示，神经肌肉阻滞剂（NMBA）治疗可减小重症ARDS患者的死亡风险，但2011年有关ARDS药物治疗的前瞻性随机对照研究均未得到明确阳性结果。
免疫营养制剂两项随机对照临床研究均未显示出免疫营养制剂有益于改善ARDS患者预后。
OMEGA研究（多中心、前瞻、随机对照设计）预计纳入符合急性肺损伤（ALI）/ARDS 诊断标准的有创机械通气患者1000例，分入ω3脂肪酸、亚麻酸及抗氧化剂治疗组。
多发伤
多发性创伤【概述】多发性创伤（multiple trauma），简称多发伤，是指在同一机械致伤因素作用下，人体同时或相继有两个或两个以上的解剖部位或器官受到创伤。
多发伤常见于自然灾害、交通事故、战争、工程事故以及坠落等，是导致患者脏器功能衰竭、致死和致残的重要原因。
t病因与临床特点}发生多发伤的原因很多，包括钝性损害和锐器伤，较常见于自然灾害、交通事故、战争工程事故以及坠落等，一般以交通事故最为多见，其次为高处坠落．挤压伤．刀伤和塌方等多发伤具有作用机制复杂，伤情严重、变化快、容易漏诊、并发症多，在临床上，伤情彼此掩盖、相互左右等特征。
多发伤伤情特点如下：l.伤情重且变化快，死亡率高由于多发伤損伤范围广，伤情涉及多个位和多个赃器，引起的创伤反应严重，且多发伤失血多，体液丢失快，休克发生率较高，极易造成机体的生理功能紊乱，容易发生凝血功能紊乱、急性呼吸窘迫综合征（““r ～““，标' -，syndrome, ARDS）和多器官功能衰竭（m司ti““dy“m ． -，M(）俨）等严重并发症，导致患者早期死亡率较高。
据统计，涉及2个部位的多发伤，死亡率约为的．涉及3、4、5个部位的多发伤，死亡率分别为匐． 4 ％、3 ％和7L4 ％。
如果合并有严重的颅燃伤，死亡率高达62，5 ％。
2，低血容量性休克发生率高对于伤情复杂严重的多发伤，由于损伤范围广、失血量大，容易发生低容量性休克（失众性和创伤性），尤其是胸腹部联合伤。
体克的发生率不低于黧躇，大多为中度休克和重度休克。
严重的心、胸外伤可并发心源性休克，高位脊髓燃伤还会导致神经源性休克的发生。
3 ．低氧血症发生率高几乎所有的多发伤患者都存在缺氧的症状，多发伤患者早期发生低氧血症的发生率高达％，特别是合并颅脑损伤、胸部損伤或伴休克和昏迷者：若損伤严重可导致急性肺损伤的发生，或直接并发急性呼吸窘迫综合征（AR早期发生低氧咖症可进一步加重器官损害和多器官功能障碍。
多发伤护理本科
预防和预后
多发伤病人由于休克和感染易发生多器官功能 衰竭，且一旦发生，其死亡率极高，关键在于 预防：早期抗休克及防止感染；如发生：支持 已衰竭的脏器，阻断炎症介质，尽量减少衰竭 脏器的数目。
思考题
⒈多发伤、复合伤、多处伤的定义？ ⒉多发伤的临床特点？ ⒊如何对多发伤患者威胁生命的征象进行 评估？ ⒋如何对多发伤患者进行现场救护？
明显的出血：压迫、缝合
下肢开放性骨折伴活动性出血及严重的骨 盆骨折伴盆腔大出血休克：抗 休克裤，既 可压迫止血，固定骨折，又可提高血压。
当伤员的生命体征稳定或基本稳定后，下一步 处理各系统的损伤 ⑸ 颅脑损伤的处理
★保证呼吸道通畅
★ 迅速诊断并清除颅内 占位病变（包括血肿和挫伤坏死组织）
★ ★
监测和控制颅内压,改善脑灌注压 进行脑保护治疗，防止或减少继发性神经元损伤
★
防治脑水肿：甘露醇+地塞米松，白蛋白、血浆 提高胶体渗透压
⑹
胸部损伤的处理
★反常呼吸→呼吸机正压通气 ★血气胸 →胸腔闭式引流
（如一次引流量达1000 ~ 1500ml或引流3小时内，
引流速度仍在每小时 200ml 以上者 → 剖胸探查 术） 。
⑻ 腹部损伤的处理
怀疑有腹腔内出血→B超、诊断性腹穿
1、大量快速输液，收缩压恢复到 70mmHg。 2、骨折予夹板固定。 3、同时行开胸、剖腹探查术，行左肺破裂缝合 术、左侧膈肌修补术、左胸闭式引流术、脾切 除术、左肾切除术、肠系膜修补术。 4、术中输血和补液。 5、术后继续补充血容量及心、肺、肾功能监测 及保护，对骨折进行处理。
病例4
16 岁男孩，右手雷管爆炸伤，伤后 24h 来诊。神 清， Bp90/70mmHg ，右手第三、四指炸伤， 来诊后作局部检查，更换敷料，准备转院。 后再查发现腹部膨满、压痛、腹肌紧张，腹腔穿 刺有混浊性液体。 剖腹探查，见小肠有110cm的长度上有130处小的 穿孔，腹腔积液1000ml，行小肠切除吻合术。 手术清创，术后痊愈出院。
创伤
6 多发伤在收治及处理顺序上的矛盾
多个组织、器官、跨专科 专科收治的矛质（综合型大医院） 各专科病情危重、均需手术 手术原则：先控制出血及呼吸困难 再处理脑疝及其它损伤 只有成立创伤急救专业队伍，开展 TICU， 才提高成活率
7 合并症多，感染的发生率高 早期 SIRS、MODS 常见. ARDS 最早，也最易发生 感染、败血症、脓毒血症、 急性胃黏膜损害等。
早期高达 90% 尤其脑外伤昏迷、 血气胸休克者. 呼吸困难型：缺氧明显 隐 蔽 型：缺氧体征不明显，病人烦燥不安
5 容易漏诊（12%左右）
未常规全面重点体检 未正确运用 X 线等特殊检查 入院后未重新全面体检 专科医师只注意到本专科情况 另：脑迟发性血肿、脾包膜下血肿、 早期胃肠破裂等也是漏诊的常见疾病。
多发伤死亡率 42.0% 77.1% 2个 49.3% 3个 60.4% 4个 58.3% 5个 71.4% 不同部位 头 胸 腹 84.4% 头胸腹四肢 87.0% 颅脑外伤合并休克 90.0% 各种因素 无脑外伤 伴脑外伤 受伤部位
我院 210 例多发伤 ISS 评分与死亡率的关系
ISS 评分 <10 分 10~19 分 20~29 分 30~39 分 40~49 >50 分 病例数 39 45 52 35 23 16 死亡数 0 0 2 2 2 4 死亡率 0 0 3.84% 5.71% 17.39% 56.25% 总死亡率 8.1% 生存率 91.9% 与专业队伍，抢救及时，效率高，现代医疗技术
2、严重颅脑损伤掩盖了其它合并伤 严重颅脑损伤 Cushing’s 反应掩盖了在内 出血表现，病人昏迷掩盖了腹膜炎体征或脊柱 骨折截瘫和一些骨折。 3、对多发伤伴有胸外伤、血气胸处理不及时 主要原因是在低氧血症基础上，同时合并 胸外伤，死亡率高达 71.1%，应抓主要矛盾， 注意抢救程序：心胸、腹、脑、泌尿、四肢损 伤。
多发伤
病因及特点
致命 因素 死亡 率高
休克 发生 率高
常由交通 事故（道 路、铁路、 航空、航 海）、坠 落伤、塌 方、爆炸 等
胸、头和 腹84.4% 胸、头、 腹、四肢 87% 颅脑外伤 合伴休克 90%
发生率为 50%，多 为创伤性、 失血性休 克 休克后8h 救治死亡 率＞75%
休克是创伤致死的主要原因
急救步骤
第三步：
1、详细询问病史：分析受伤情况，询问患 者或护送人员、事故目击者（病史询问 很重要），了解受伤机制，可以帮助发 现一些隐蔽部位的创伤，如腹部、脊 柱、骨盆损伤。 2、仔细体格检查。
急救步骤
第四步： 1、施行各种诊断性穿刺，如腹腔穿 刺、胸腔穿刺等。
2、各项辅助检查，如X线、B超、 CT、各项化验（一定要有专人护 送，注意患者安全）。
现场救护
1.脱离危险环境 2.解除呼吸道梗阻 3.处理活动性出血 4.处理创伤性气胸 5.保存离断肢体 6.伤口处理
伤口处理
• 伤口内异物不要随意去除；
• 创面中有外露的骨折断端，肌肉，内脏， 严禁将其回纳入伤口； • 有骨折的伤员要进行临时固定； • 脑组织脱出时，应在伤口周围加垫圈保护 脑组织，不可加压包扎。
⑶循环情况：了解出血量多少，观察血压和脉搏，以判 断是否休克。①有无活动性出血，血容量 是否减少②评估血压，手触动脉法，可触 及桡动脉，股动脉或颈内动脉搏动，则 收 缩压分别80mmhg70mmhg 60mmhg (4)中枢神经系统情况：意识状态，瞳孔大小，对光反射， 有无偏瘫或截瘫
评估与诊断
2.全身伤情评估
• 检查诊断时可以参考CRASHPLAN方案，即心 脏(cardiac),呼吸(respiration)，腹部 (abdomen)，脊髓(spine)，头颅(head)，骨盆 (pelvis)，四肢(limbs)，动脉(arteries)，神经 (nervs),了解受伤原因和经过，并进行实验 室及影像检查，根据以上评估，确立损伤 救治的先后顺序。
多发伤特点
多发伤是指在同一致伤因素作用下，机体同时或相继有两个以上解剖部位或脏器的严重损伤，而这些创伤即使单独存在，也属于严重伤，因此它包括三个内容：两个以上解剖部位同时或相继发生刨伤；各个创伤使单独存在，也不能视为轻微创伤，也是有可能对生命构成成胁或导致残废的较严重创伤：各个创伤均为同一因素造成。
多发伤常由交通事故、高处坠落、埋压、爆炸、灾害性事故等因素引起。
多发伤的临床特点有哪些？1.伤情严重，病情变化快严重多发性创伤都伴有一系列的复杂全身应激反应．其反应程度除与创伤严重度有关外，还受创伤的性质、部位和受伤时情况的影响。
由于相互影响，发生严重的生理紊乱及病理变化。
这些严重的奈乱，有时导致伤情变化极快，部分患者可在几分钟内死亡。
2.病死率高由于严重多发性刨伤伤情危重，因此病死率很高，严重多发伤可分为三个死亡高峰：(1)第1死亡高峰：在伤后数分钟内即刻死亡。
死亡原因多为脑、脑干、高位须髓的严重创伤或心脏、大动脉撕裂伤，往往来不及救治而死亡。
(2)第2死亡高峰：出现在伤后6—8h之内。
死因多为脑内脑膜下及硬脑膜外血肿、血气胸、肝或脾破裂，骨盆及骨干骨折所致的血管大出血，如抢救正确，转运及时，上述大部分创伤可免于死亡，此期是创伤急救的黄金时段。
(3)第3死亡高峰：出现在伤后数天或数周内。
死亡的主要原因为严重创伤后引发的重症感染和器官功能衰竭。
因此，严重多发伤急救要加强院前急救、院内急救和重症监护，以降低病死率。
3.伤势重，休克发生率高严重多发伤损伤范围广，失血量大，故休克发生率高，休克总发生率约为50％，胸腔联合伤为67％。
休克发生的主要原因为失血性休克，也不排除胸部创伤、心脏压塞、心肌挫伤、创伤性心肌梗死所致的心源性休克。
4.严重的低氧血症严重多发性创伤早期低氧血症发生率可高达90％，尤其是颅脑创伤、胸部创伤伴有休克及昏迷者，氧分压可低至30—40mmHg的严重水平。
所以对早期严重多发性创伤患者，应注意连续监测血气分析变化情况，以动态观察血液氧合状况。
多发伤
骨盆骨折并腹膜后血 肿及失血性休克。
6 骨盆部创伤
肾脏损伤、膀胱破裂、子宫 破裂、尿道断裂、阴道撕裂 伤。易出现失血性休克，肾 功能衰竭，感染。
7 泌尿系创伤
脊柱骨折并神经系统损 伤。易出现截瘫。
8 脊柱创伤
四肢开放性骨折、四肢 长骨干骨折、四肢大血
9 肢体创伤
管伤。易出现失血性休 克，脂肪栓塞等。
遵循“救命第一 保存器官、肢体第二 维护功能第三”的原则
• 手术处理中遇到对脏器取舍留弃的选择 时，遵循“救命第一，保存器官、肢体 第二,维护功能第三”的原则。
急 救
• 首先建立和保证三个通道的畅通，实 施有效的复苏。
病例 content
才培 男 30岁
4月18日入院 来时神志清楚，T:38.9，RR:38次/分， P:127次/分,BP:92/54mmHg，SpO2：90% 右下肢伤口敷料污染，有恶臭，伤口严 重感染
MODS的病因
SIRS、MODS发病机理示意图
感染性因素
水封瓶应臵于病人胸部水平下60~100cm，保持低位引流，并
应放在特殊的架子上，防止被踢倒或抬高
如何预防呼吸机相关性肺炎？
预防VAP捆绑式方法
从2004年12月，美国促进健康协会督促医院使用循征指南来预防VAP，到2006年 6月共挽救了十万患者的生命
• 尽可能降低、避免气管内插管和呼吸机使用时间 • 使用经口气管内插管和经口胃管降低医院获得性鼻窦 炎的发生 • 避免深度镇静、神经肌肉阻滞剂使用，抑制咳嗽反射 • 保持气管插管囊压力在20cmH2O之上 • 防止气管插管内冷凝液进入下气道 • 保持床头抬头30°～45° • 慎用制酸剂 • 保持口腔卫生 • 保持手卫生
多发性创伤一个人同时受到多个损伤的情况
PART 04
并发症与风险
REPORTING
常见并发症类型
感染
多发性创伤后，皮肤和组织受损，容易引 发感染，包括伤口感染、肺炎、尿路感染
等。
器官功能衰竭
多发性创伤可能导致多个器官功能受损， 严重时可引发器官功能衰竭，如急性呼吸
窘迫综合征、急性肾衰竭等。
休克
严重多发性创伤可导致大量失血，引发休 克，表现为血压下降、心率加快、呼吸急 促等症状。
血等。
药物治疗方案
液体复苏
根据患者情况选择合适的液体 进行复苏，如晶体液、胶体液 等，以维持有效循环血容量。
抗生素应用
对于开放性损伤或存在感染风 险的患者，应及时给予抗生素 以预防感染。
镇痛与Байду номын сангаас静
根据患者疼痛程度和意识状况 ，给予适当的镇痛与镇静药物 ，以减轻患者痛苦和焦虑情绪 。
其他药物治疗
根据患者具体伤情和并发症情 况，给予相应的药物治疗，如
多发性创伤一个人同 时受到多个损伤的情 况
REPORTING
• 引言 • 临床表现与诊断 • 治疗与急救措施 • 并发症与风险 • 康复与预后管理 • 总结与展望
目录
PART 01
引言
REPORTING
定义和背景
定义
多发性创伤（Multiple Trauma）是指一个人在同一事故或事件中同时或相继 受到两个或两个以上解剖部位或脏器的严重损伤，且至少有一个损伤可危及生 命。
PART 06
总结与展望
REPORTING
研究成果回顾
多发性创伤流行病学特征研究
通过对大量多发性创伤病例的分析，揭示了其流行病学特征，包括年龄、性别、致伤原因 、受伤部位等方面的分布规律。
多发性创伤
涉及部位 两处 三处 四处 五处
衰竭器官数 一个 两个 三个 ≥四个
死亡率 49.3% 58.3% 60.4% 71.4%
死亡率 25% 50% 75% 100%
二、病因与临床特点
• 三大死亡高峰：
1
出现在伤后数分 钟内，为即时死 亡。死亡原因主 要为脑、脑干、 高位脊髓的严重 创伤或心脏主动 脉等大血管撕裂 ，往往来不及抢 救。
ห้องสมุดไป่ตู้
无呼吸、声嘶、无反应——有紧急气道问题。
三、病情评估与判断
A: 颈椎保护
❖ 锁骨以上损伤及意识不清者先按照颈椎损伤处理，直至有 证据排除。
❖ 开放气道时需保护颈椎，而不是等待明确诊断后再开放气 道。
三、病情评估与判断 B: 呼吸
❖ 观察有无自主呼吸、胸廓起伏、呼吸频率和形态，听诊双侧 呼吸音情况，同时查看是否存在气管移位、颈静脉怒张、胸 廓塌陷、反常呼吸等。
三、病情评估与判断
3.胸 部
❖ 胸廓呼吸运动是否对称 ❖ 是否有外伤、出血、压痛，胸部挤压实验是否阳性 ❖ 是否存在捻发音及皮下气肿，是否有外来物或穿刺
异物 ❖ 听诊两侧呼吸音是否对称存在、消失、降低或异常
（啰音、干啰音、哮鸣音、噼啪音）
三、病情评估与判断
4.腹 部
❖ 观察腹部整体形状、轮廓，是否有外伤、出血、异 物等
T
A
P
LA
B
S
S P
T L
创伤死亡三峰分布
创伤后数分钟 之内，极少人 救护存活
创伤后数分钟 至数小时内
伤后数日至数周内，多因 继发感染、重要脏器功能 衰竭或MODS死亡
一、创伤分类
❖按致伤因素分类 刺伤、坠跌伤、火器伤、挤压伤、烧伤等
多发伤的名词解释
多发伤的名词解释多发伤是一个常见的医学术语，通常用于描述一个人同时遭受多个部位的损伤或创伤。
这种情况下，一个人往往会面临多个系统的受损，包括骨骼、肌肉、内脏等。
由于多发伤的复杂性和严重性，它常常需要高度专业的医疗团队来进行处理和治疗。
多发伤的发生可以由各种原因引起，例如车祸、跌倒、暴力犯罪、工作场所事故等。
在这些情况下，多个身体部位受到冲击、挤压或刺伤，从而导致不同程度的损伤。
多发伤的程度可以是轻微的，例如扭伤、擦伤等，也可以是严重的，例如骨折、器官损伤等。
在处理多发伤时，医疗团队通常会首先进行全面的体格检查，以评估患者受伤的范围和严重性。
这可能包括观察和询问患者的症状、进行X光、CT扫描等影像学检查，以及进行必要的实验室测试。
通过这些评估，医疗人员可以确定每个部位的损伤程度，并决定适当的治疗方案。
治疗多发伤的方法必须考虑到整体的急救需求和长期复原过程。
在一些情况下，紧急手术可能是必需的，以解决更严重的伤势，例如器官破裂或出血。
此外，各个损伤部位的处理也需要综合考虑，以确保恢复过程的协调和最佳结果。
康复是多发伤患者长期疗养的重要阶段。
这可能包括物理疗法、康复训练和心理支持等。
物理疗法有助于恢复肌肉和关节的功能，康复训练则帮助患者重新学习基本生活技能和活动能力。
同时，心理支持也非常重要，因为多发伤可能对患者的心理健康产生长期影响，例如创伤后应激障碍、焦虑和抑郁等。
尽管多发伤是一种严重的情况，但通过及时和适当的处理，大多数患者都能够实现良好的康复。
然而，恢复的过程可能是漫长而复杂的，需要耐心和专业的护理。
因此，多发伤的治疗需要一个综合的医疗团队，包括外科医生、骨科专家、神经外科医生、康复师等。
总结而言，多发伤是一个医学术语，用于描述一个人同时遭受多个部位的损伤或创伤。
它通常由各种原因引起，需要高度专业的医疗团队来进行处理和治疗。
治疗包括全面的评估、紧急手术、康复等，并需要综合考虑每个部位的损伤。
康复过程可能是漫长而复杂的，需要耐心和专业的护理。
多发性创伤
三、伤情评估
院前评估：创伤指数（TI）评分、 CRAMS评分等。 院内评估：简明创伤分度（ASI）、 损伤严重度评分（ISS）等。
AIS分区： 6个区：头颈部、面部、胸部、腹部及盆腔、 四肢及骨盆、皮肤及软组织。 AIS分级标准：
1、轻度
2、中度
3、重度 4、严重 5、危重 6、极重 (一般不危及生命) (可危及生命，但可能生存) (生存不能肯定) (最危重，存活可能性极小)
ISS方法
ISS是依据损伤最严重的三个解剖分区的检测指 标，应用AIS评定分级方法来判断损伤严重程度，ISS
评 分 则 为 三 个 最 高 AIS(MAIS) 的 平 方 之 和 ， 即
M1+M2+M3 级数平方的相加值，分值范围为1～75分，
对单一部位伤的伤员可用AIS说明其损伤严重程度，
而多部位、多发伤者必须用ISS评分。
Lacerations: 裂伤： • Brain •脑 • Brainstem •脑干 • Aorta •主动脉 • Spinal Cord •脊髓 • Heart •心脏
Trimodal Distribution of Trauma Deaths
创伤死亡的三个高峰
Epidural Subdural Hemo/pneumothorax Pelvic fractures Long bone fractures Abdominal injuries
创伤患者的低温分级：
轻度 中度 重度 34℃＜Tc＜36℃； 32℃＜Tc≤34℃； Tc≤32℃；
创伤后的低温对伤员的危害性较一般患者严重，可直
接危及伤员的生存： 若低温持续4小时以上，死亡可达40％。 Tc＜32℃，机体完全丧失体温调节能力，只能被动 地接受或丧失热量，死亡率为100％。
最新多发伤柏林标准[1]
![最新多发伤柏林标准[1]](https://img.taocdn.com/s3/m/7e8cdedf84254b35eefd3495.png)
The definition of polytrauma revisited:An international consensus process and proposal of the new‘Berlin definition’Hans-Christoph Pape,MD,Rolf Lefering,PhD,Nerida Butcher,MD,Andrew Peitzman,MD,Luke Leenen,MD,Ingo Marzi,MD,Philip Lichte,MD,Christoph Josten,MD,Bertil Bouillon,Uli Schmucker,PhD,Philip Stahel,MD,Peter Giannoudis,MD,and Zsolt Balogh,MD,Aachen,Germany BACKGROUND:The nomenclature for patients with multiple injuries with high mortality rates is highly variable,and there is a lack of a uniform definition of the term polytrauma.A consensus process was therefore initiated by a panel of international experts with the goal ofassessing an improved,database-supported definition for the polytraumatized patient.METHODS:The consensus process involved the following:1.Expert panel.Multiple meetings and consensus discussions(members:European Society for Trauma and Emergency Surgery[ESTES],American Association for the Surgery of Trauma[AAST],German Trauma Society[DGU],and British Trauma Society[BTS]).2.Literature review(original articles before June8,2014).3.A priori assumptions by the expert panel.The basis for a new definition should include the Injury Severity Score(ISS)based on theAbbreviated Injury Scale(AIS);‘‘A patient classified as polytraumatized should have a mortality rate of approximately30%,twiceabove the established mortality of ISS915.’’4.Database-derived resources.Deductive calculation of parameters based on a nationwide trauma registry(TraumaRegister DGU)withthe following inclusion criteria:multiple injuries and need for intensive care therapy.RESULTS:A total of28,211patients in the trauma registry met the inclusion criteria.The mean(SD)age of the study cohort was42.9(20.2)years (72%males,28%females).The mean(SD)ISS was30.5(12.2),with an overall mortality rate of18.7%(n=5,277)and an incidence of3%of penetrating injuries(n=886).Five independent physiologic variables were identified,and their individual cutoff values werecalculated based on a set mortality rate of30%:hypotension(systolic blood pressure e90mm Hg),level of consciousness(GlasgowComa Scale[GCS]score e8),acidosis(base excess e j6.0),coagulopathy(international normalized ratio Q1.4/partial thromboplastintime Q40seconds),and age(Q70years).CONCLUSION:Based on several consensus meetings and a database analysis,the expert panel proposes the following parameters for a definition of ‘‘polytrauma’’:significant injuries of three or more points in two or more different anatomic AIS regions in conjunction with one ormore additional variables from thefive physiologic parameters.Further validation of this proposal should occur,favorably bymutivariate analyses of these parameters in a separate data set.(J Trauma Acute Care Surg.2014;77:780Y786.Copyright*2014byLippincott Williams&Wilkins)KEY WORDS:Definition of polytrauma;assessment of patients with multiple injuries;conventional parameters for assessment;biomarkers for polytrauma;grading of patients.T he terminology applied to quantifying injury severity has been vague and inconsistent.1Y6Descriptions such as‘‘critically injured,’’‘‘severely injured,’’or‘‘critically ill with multiple injuries’’have been used interchangeably.2,3To our knowledge,the term polytrauma wasfirst used ap-proximately half a century ago,when survival rates began to improve for these patients.Descriptive definitions were used,such as‘‘at least two severe injuries of the head,chest or abdomen,one of them in association with an extre-mity injury,’’4‘‘any patient with two or more significant injuries,’’5or‘‘a patient with two or more injuries,one of them being potentially life threatening.’’Isolated life-threatening conditions were also separated and the term barytrauma was coined.6C ONSENSUS P APERFrom the Department of Orthopedics/Trauma(P.L.),Aachen University Medical Center;and Harald Tscherne Lab for Orthopaedic Trauma(H.-C.P.,P.L.),Aachen;Institute for Research in Operative Medicine(IFOM)(R.L.,B.B.),University of Witten/Herdecke,Witten;Department of Orthopaedics(R.L.,B.B.)at Merheim,Cologne;and Department of Trauma,Hand,and Reconstructive Surgery(I.M.),J.W.von Goethe University,Frankfurt;Department of Orthopaedic Trauma(C.J.),University of Leipzig,Leipzig;and AUC Y Academy for Trauma Surgery(U.S.),Munich,Germany;Department of Traumatology(N.B.,Z.B.),John Hunter Hospital and University of Newcastle,Newcastle, Australia;Department of Surgery(A.P.),University of Pittsburgh Medical Center,Pittsburgh,Pennsylvania;and Department of Orthopaedic Surgery(P.S.),Denver Health Medical Center,Denver,Colorado,Department of Trauma(L.L.),Utrecht University,Utrecht,the Netherlands;and Department of Trauma(P.G.),Academic Unit of the University of Leeds,West Y orkshire,United Kingdom.Address for reprints:Hans-Christoph Pape,MD,Department of Orthopedics/Trauma,Aachen University Medical Center,Germany,F.Pauwels Professor and Chairman, Department of Orthopaedic Trauma,30Pauwels St,52074Aachen,Germany;email:papehc@.DOI:10.1097/TA.0000000000000453The Injury Severity Score(ISS)7is the basis for most as-sessments of trauma patients and continues to be recommended by the American College of Surgeons’Committee of Trauma (ACS COT),The Trauma Outcome Research Network(TARN, GB),the German Trauma Registry(GTR),and the Australasian Trauma Society(ATS).The Major Trauma Outcome Study (MTOS)provided thefirst large-scale data that helped develop specific objective parameters to assess the polytrauma patient.1 Physiology-based scoring systems included the description of the ‘‘lethal triad’’to differentiate stable from unstable and‘‘in extremis’’patients.8This terminology has been later expanded to describe patient subsets,such as the‘‘borderline’’polytrauma patient.9,10 Today,the most widely disseminated definitions continue to rely on the basic concept of a combination of injuries that cause a life-threatening condition.4Y6However,this approach is characterized by a lack of objective quantitative measures and represents Level IV evidence only.For these reasons,an international panel of physicians met multiple times to refine the existing descriptions.The objective was to discuss current descriptions and possibly describe pa-rameters to define the critically injured patient(polytrauma)with the potential for unrestricted application.11This article summarizes the results obtained during the pro-cess of four subsequent years of progressive meetings,scientific sessions,consensus discussions,and trauma registry analyses.PATIENTS AND METHODS Consensus ProcessA series of scientific sessions and meetings were held under the auspices of several societies as follows:American Association for the Surgery of Trauma(AAST),European Society for Trauma and Emergency Surgery(ESTES),German Trauma Society(DGU),British Trauma Society(BTS),New Zealand Association for the Surgery of Trauma(ANZAST).Following scientific sessions in conjunction with the Annual ESTES meeting in Brussels,(May15,2010)and Milan (April27,2011),the panel of authors decided upon a formalsubsequent consensus conference to be held in Berlin,Germany.In preparation for the Berlin meeting,numerous dis-cussions and telephone conferences were held.A group of experts was then invited to participate in the process.The in-vitations were based on expertise in thefield(assessed by number and quality of original publications),willingness to contribute to a longstanding process,response to the invitations by e-mail,and availability to join the meeting in Berlin.The meeting was held on May11and12,2012,in Berlin, Germany,and resulted in a draft consensus definition.This was reconfirmed during several interactions and additional calcu-lations of the database.Further recalculations of the database were performed to reach thefinal consensus as documented in Table1.PrerequisitesThe panel decided on the following prerequisites for the data selection;availability and completeness of data in large data sets,worldwide applicability,sensitivity,and specificity to describe the severely injured.These were then used to differ-entiate a core analysis of data.Preparative Literature ReviewA review of the literature was performed on the available definitions of polytrauma.The following MeSH headings were applied to the literature search:Abbreviated Injury Scale,Injury Severity Score,algorithms,clinical coding/methods,consensus, Germany/epidemiology,incidence,multiple trauma/diagnosis, Multiple Trauma/epidemiology,observer variation,prospective studies,registries,trauma centers/statistics&numerical data, United States/epidemiology,Injury Severity Score.All original articles were included if published within January1,1940,and May8,2012.No language restrictions were applied.This review served to determine pertinent parameters and cutoff values for the definition of the trauma patient‘‘at risk.’’Data AcquisitionA National Trauma Registry(TR-DGU,version2012)was used.In this registry,severely injured patients are documented prospectively by hospitals included in the German Trauma Network(www.traumaregister.de).Data from the registry was assessed at four different time points(Table1):(1)before the TABLE1.Time Course‘‘Definition of Polytrauma’’Premeeting Scientific SessionsKickoff session at ESTES2010,Brussels11th International Course on Polytrauma Management,Aachen,Germany Scientific Session at the ESTES,2011,MilanIn-Person Discussions,March1to October15,2012Meeting to discuss composition of expert panel group(Berlin,German Congress of Orthopaedics/Trauma,DKOU2012)Precirculation of preliminary timeline before DKOU2012Empirical Evaluation of Draft DefinitionReview of published dataInvitations and Information for Panelists,October1to December12,2011 Precirculation of definitive timelinePrecirculation of topicsPrecirculation of background materialsTR-DGU Data Analysis I,Deductive Draft DefinitionAssembling of clinical cohort,Cologne,March8,2012Berlin Consensus Conference,May10/11,2012Day I:influence of trauma systems,issues to include or exclude systemic inflammatory response syndrome,current conceptsDay II:presentation of calculations from a nationwide database,discussion of draft definition,consensus on the issue of further calculations in the databaseTeleconference,June15,2012Consensus on database use for later validation(NTDB,TARN,Australian Registry)TR-DGU Data Analysis II,Deductive Draft DefinitionCalculation of thefinal definition,Cologne,November1to December7,2012 In-Person Consensus Discussion at the13th International Polytrauma Course,Aachen,December8,2012Discussion on presentation of dataDiscussion on involvement of other databasesTelephone Conference,March8,2013Consensus on modality of manuscript publicationPermission to use all requested databases for validity assessment Multiple Communications by E-mail,Telephone to Improve and Consent the Berlin Definition(following September16,2013)J Trauma Acute Care SurgVolume77,Number5Pape et al.Berlin meeting to analyze the raw data set and feasibility of the selected parameters;(2)during the Berlin meeting(May2012)to address the individual cutoff values;and(3)before and after the 13th International Polytrauma Course(Aachen,December2012) to calculate thefinal score values.During the inclusion period,a change in documentation occurred for parameters indicative of hemostasis.Therefore,in patients with missing international normalized ratio(INR) data,a relative measure of thromboplastin time(‘‘Quick value’’[Q]was used,expressed as percentage of normal activity)was used as follows:the value was approximated by the formula 0.4+(58/Q).Inclusion CriteriaPatients from the TR-DGU were extracted if they ful-filled the following criteria:admission to an intensive care facility and multiple injuriesDefinitionsMortality was defined as in-hospital mortality. ComplicationsClinical complications included those documented in the registry,such as organ failure and sepsis.The information obtained through this process served as a basis for the discus-sions during the consensus meeting held in Berlin,Germany,on May11/12,2012.Cohort AssemblyBased on the literature review,multiple studies from the Australian group,11preparative in-person meetings(C.J.,I.M., H.-C.P.),and the expert session in Berlin,the following eli-gibility criteria were selected for suitability of the database to be used:(1)large multicenter cohort,(2)availability of data known to be relevant for outcome(namely indicators of hem-orrhagic shock,resuscitation data,laboratory results)and mor-tality,and(3)inclusion of basic trauma scoring values.The panel identified several data sets to be generally ac-ceptable:the National Trauma Data Bank(NTDB,United States), the German Trauma Registry(TR-DGU),the Dutch Trauma Registry,the New South Wales Trauma Registry(Australia).Empirical considerations lead to preliminary draft defi-nitions:pilot data based on single institutions showed the po-tential feasibility of Abbreviated Injury Scale(AIS)score greater than2in two body regions,the potential hurdles with inclusion of systemic inflammatory response syndrome data, and the low interrater and intrarater agreement of the expert opinion-based subjective definition.12The resulting informa-tion was used to perform further calculations on the variables deemed to be available worldwide.General Considerations and Prerequisites Addressed During the Berlin MeetingDuring the meeting,the initial questions addressed by the expert group were as follows:When is the best time to define a patient as a multiply injured/ polytraumatized?Who is the best trained expert to do this?How can feasibility be maintained while accuracy is improved?Timing of the Diagnosis of PolytraumaOn-scene assessment might be useful to initiate trauma team call and triage;however,the panel agreed that it is not useful for defining polytrauma.In-hospital diagnosis should be made before ICU admission because it is affected by treatment and includes the systemic patient response.13Therefore,the diagnosis of polytrauma should be made on thefirst day of the hospital stay after completion of initial diagnostic procedures. Description of the Best Expert to Diagnose PolytraumaThe panel considered the assessment by police or other nonmedical personnel of little use for medical definition be-cause of a lack of specificity.14It was agreed upon that ideally, the diagnosis is made by an expert that has completed his or her trauma fellowship and has fulfilled specific courses,such as Advanced Trauma Life Support(A TLS),),or the Polytrauma Course,).Clinical ScoresThe panel agreed that any practicable definition of polytrauma should be applicable prospectively,that is,early after patient admission.Anatomic scoring was selected as the basis for assessment and for optimal standardization.Because the precise ISS is difficult to calculate during the patient management in the emergency department,it was favored unequivocally that AIS score greater than2in two body regions can be reliably recog-nized by a clinical expert shortly after admission.It has previ-ously been discussed that the parameters providing the most stable sensitivity and specificity in terms of mortality are docu-mented soon after admission.15Parameters:Pathologic Conditions and Ancillary VariablesThe selection of variables was assessed in preparation for the Berlin consensus meeting during a database evaluation for the TR-DGU in Cologne,on September12,2012.The lead author and the second author of this article met to assess the feasibility of variables selected in a previous literature search. The search included criteria used by the ACS COT,data from the Major Trauma Outcome Study,certain parameters suggested previously to define polytrauma,1,16and additional parameters previously used to assess these patients.Among these are the GCS score and certain physiologic criteria.16,17It lists certain valuable combinations of parameters,such as an ISS of16points or greater,two body regions with an ISS of 3or greater,the use of an ISS of16,and one or more addi-tional altered physiologic parameters.18On the basis of this information,the panel present at the Berlin meeting decided on the threshold levels,as described in the following section. Threshold Levels of MortalityCurrently,the ISS is used as a standard anatomic clas-sification of injury severity in major trauma centers across the United States,many European countries,and Australia.The threshold level to determine a severely injured patient is usually an ISS of greater than15points.The mortality rate for the patient population used to be20%or greater.1,6Today,it isJ Trauma Acute Care SurgVolume77,Number5Pape et al.considered to be considerably lower and ranges between9% and15%.19Based on this information,the panel unanimously agreed that an expected mortality rate of approximately15% should be used as threshold level.Criteria Used to Define a‘‘Relevant Change’’in the Clinical ConditionThe assessment of the set mortality rates had been confirmed in the preliminary calculations of the registry.It was decided that the mortality rate to determine polytrauma should be double the value from the mortality rate of patients with an ISS of16points.Therefore,after accounting for different variations of sensitivity,the panel decided that a mortality rate is most relevant when it accounts for approximately30%for any of the parameters.Relevant Physiologic Parameters:Pathologic Conditions and Ancillary Variables-Coma was defined as a GCS score of8points or lower.20 -Hypotension was defined as a systolic blood pressure of 90mm Hg or lower.7-Metabolic acidosis was defined as a base excess of6or lower. -Coagulopathy was defined as a partial thromboplastin time (PTT)of50or greater or an INR value of1.4or greater.The panel agreed that ancillary parameters should be minimized mostly because of the intention of global use of the definition and the availability in databases.Before the Berlin meeting,an assessment of old age was performed as ancillary parameter for the three variants,namely,60years,65years,and 70years of age.This demonstrated that mortality rates justified the inclusion of older than70years as an ancillary parameter. The panel reconfirmed the cutoff value of old age to be70years or older during the Berlin meeting.Draft Consensus DefinitionAs part of the Berlin meeting,the prerequisites for the definition were selected as follows:Based on several presentations during the meeting and a discussion on the requirements of the definition,all panel members agree on the following prerequisites:1.A combination of injury severity,physiologic changes,and/or a relevant physiologic change(as defined earlier)in the clinical condition seem to be useful and should be applied.2.The initial workup should be performed in the GermanRegistry,followed by a reassessment in any large registry.3.At least two body regions should be injured,thus requiringan AIS score of2points or greater in two or more body regions.4.The panel unanimously decided that additional parametersare required to allow for a definition of polytrauma.5.The weight of any selected parameter should be clinicallyrelevant in terms of contributing to increased mortality. Final Consensus on the DataThe results were presented to the panel during the13th International Polytrauma Course in Aachen,Germany,on November30and December1,2012.It was agreed upon that the registry data should be used for the Berlin definition of polytrauma and that the results should be assessed by other databases,such as NTDB,the Dutch Trauma Registry,and the Registry from New South Wales.The consensus process included further telephone conferences and e-mail communication. Statistical AnalysisPanel DecisionsData from the TR-DGU were used to allow subjective decision making regarding the severity of injuries.Continuous variables are presented as means and SDs.Frequencies are presented as percentages with numbers of records available in the database.Database CalculationsData were tested for normal distribution.Nominally scaled variables were tested using W2analysis.Proportions were evaluated using the Y ates-corrected statistics.The relative risks of death of the conventional parameters tested were calculated individually and expressed in odds ratios.The association between conventional parameters and death was evaluated using univariate analysis.Statistical significance was assumed at p G0.05.All calculations were performed using a statistical software package(SPSS,version20,IBM Inc.,Armonk,NY). The number of candidate criteria fulfilled per patient record was also used to build subgroups of patients and to calculate mortality rates.RESULTSTable1describes the time course of the consensus process.Thefirst scientific session was held during the ESTES meeting in Brussels(May15,2010),followed by multiple meetings,telephone conferences,and group discussions. TABLE2.Demographic Data of Patients Included in the Study With an ISS of16or Greater in Two or More Body RegionsV ariable Unit DataNo.cases Patients28,211 Age,mean(SD)Y ears42.9(20.2)Sex Male72%(n=20,433) Mechanism of injury Penetrating3%(n=886) Incidence of intensivecare treatmentV93%(n=26,130) ISS,mean(SD)Points30.5(12.2) Maximum AIS score(MAIS)3points29%(n=8,212)4points40%(n=11,362)5points29%(n=8,207)6points2%(n=430) AIS PointsHead injuries AIS score Q354%(n=15,279) Thoracic injuries AIS score Q367%(n=18,824) Abdominal injuries AIS score Q325%(n=7,005) Extremity injuries AIS score Q344%(n=12,290) Mortality rate18.7%(n=5,277) Mean(SD)for metric variables and n(%)for counts.J Trauma Acute Care SurgVolume77,Number5Pape et al.From January 1,1993,to December 31,2010,67,782patients were documented in the registry.Among these,43,175had experienced multiple injuries.The exclusion of all trans-ferred patients left 34,547patients for further evaluation.Following exclusion of patients with injuries with an AIS score of 2points or less (n =6,336),28,211patients were included in the present study.Table 2lists the study population and basic demographic data from the patients.Within the study population,the following distribution of mortality rates associated with incidences of in-jured body regions was found:11.8%when at least 2AIS injuries with 3points or more 16in two body regions were affected,28.3%for three body regions,37.4%for four body regions,and 58.0%for five body regions.Table 3documents the prevalence of the five physio-logic parameters identified to be associated with increased mortality rates and the odds ratios for death.Univariate mor-tality analysis revealed threshold levels for the five parametersas follows:age of 70years or greater,38.0%;acidosis,38.8%;coagulopathy,48.3%;GCS score of 8points or less,38.3%;and hypotension,35.3%.Figure 1describes mortality rates for different thresholds of the GCS values.The optimal cutoff point that leads to a mortality rate twice as high as in the whole group was a value of 8points or less.A similar approach was performed for each of the criteria listed in Table 3.Figure 2lists the prevalence of pathologic values and ancillary parameters.The highest prevalence was found when one parameter was involved (38.5%),and the lowest prevalence occurred when all five parameters were involved (0.3%).The parameters deemed to be relevant for an improved definition of polytrauma are as follows:ISS of greater than 15points,AIS score of 3or greater in at least two body regions and at least one of five standardized pathologic conditions,(hypotension [systolic blood pressure e 90mm Hg],uncon-sciousness [GCS score e 8],acidosis [BE e j 6.0],coagulopathy [PTT Q 40seconds or INR Q 1.4],and age [Q 70years]).DISCUSSIONTrauma continues to be the leading cause of death worldwide in young individuals younger than 40years,asso-ciated with the highest socioeconomic impact on society.In blunt injuries,those leading to the biggest long-term impact on quality of life are traumatic extremity amputations and spinal cord injuries.21,22The value of a reliable assessment of patients with polytrauma can be manifold.It may serve as a basis for sci-entific,socioeconomic,quality-control,and educational pur-poses.For clinicians,it may help facilitate adequate distribution of in-hospital resource allocations,such as availability of oper-ating rooms and intensive care unit beds.23The current article has both strengths and limitations.1.The panel decision to use the ISS for practicability may be judged as a limitation.Some authors downplayed the im-portance of ISS and argue that mortality is better predicted by describing the patient’s worst injuries.9Others used variations of the ISS to account for shortcomings in the representation of multiple injuries to the same body region.However,none ofTABLE 3.Prevalence of Five Selected Pathologic Conditions/Ancillary Parameters Associated With Increased Postinjury MortalityAncillary Variable/Parameter Criteria Incidence No.Patients Mortality OddsRatio AgeQ 70y 13.0%3,661of 28,07138.0 2.99Unconsciousness GCS score e 834.6%9,232of 26,65738.3 4.17HypotensionSystolic blood pressure e 90mm Hg,preclinical or on admission 29.5%7,955of 26,92335.34.90Acidosis Base excess e j 6.024.9%3,764of 15,11738.3 3.32CoagulopathyPTT Q 40s or INR Q 1.426.2%6,316of 24,14338.45.81Figure 1.Cutoff points for in-hospital mortality rates based on various values for the GCS.Figure 2.Documentation of mortality rates depending on the number of pathologic conditions/ancillary variables.J Trauma Acute Care Surg Volume 77,Number 5Pape et al.these initiatives represented a breakthrough.Likewise,most international databases and many registries use the ISS rather than other coding systems(e.g.,International Classification of Diseases[ICD]).It has therefore been suggested to use risk-adjusted levels of scores and/or parameters,as performed in the current consensus process of the Berlin definition.Among these,it is unclear whether anatomically derived general scoring systems such as ISSs outweigh those that purely describe local changes.24With the addition of other physiologic variables on top of the injury scoring,a sustained increase in coverage of mortality occurred.Thisfinding concurs with previous studies.12,16 Moreover,when using the ISS threshold of greater than15 points,an18.7%mortality rate was found,independent of any of thefive additional parameters used.As soon as one other physiologic parameter was added,a reliable set of data revealed mortality rates of35%to38%,as deemed clinically rele-vant to the panel.Therefore,patient data seem to support the expert opinion.2.One may also argue whether the selection of the additionalparameters and ancillary variables was adequate.The‘‘In-flammation and the Host Response to Injury Collaborative Research Program’’gathered the most recent data on patients with severe injuries and stressed the importance of inflam-mation for the hospital course in severely injured patients.25 However,none of the inflammatory parameters,such as in-terleukin6or other laboratory parameters indicative of in-flammation values,are currently available in any large database.It was considered highly unlikely that any of these markers will be available for global application in the near future.Thus,it seemed to be justified not to consider them in the current analysis.This approach is supported by the fact that similar parameters as used in the current setup have been successful in predicting outcome12,16and by other groups that studied the risk of adverse effects during the hospital course.9,193.A priori selection of mortality rates to identify patients in a life-threatening condition should not have been performed.Yet, the panel that convened in Berlin was under the impression that clinically relevant thresholds for mortality levels are the missing link for database-confirmed values.The a priori use of certain values seems to be supported by previous empirical approaches.25Therefore,it was felt that the current approach was appropriate for the current status of documentation. Nevertheless,we anticipate that future clinical research using a model of definition development may rely on parameters of inflammation in the future.4.During the consensus meeting in Berlin,the sensitivity is-sues of the selected parameters were considered as well.While using the ISS as the only parameter would have been easier,the panel felt that the addition of other physiologic parameters greatly increased the sensitivity and specificity.Similar effects had been described elsewhere.26Further-more,the usability of physiologic parameters has been proven in previous databases.Kondo et al.examined the data sets from35,732patients of115hospitals from the Japanese national trauma database.They documented a good predictive power for GCS,age,and systolic blood pressure in terms of mortality.5.The data set was not divided into a development and avalidation group.Therefore,validation will have to be un-dertaken in a separate analysis using another database.Among the strengths is the use of a database that sum-marizes data from institutions committed to perform optimal trauma care:1.All information available in the database are documentedprospectively.2.The database uses homogenous inclusion criteria by includingonly patients admitted through the emergency department and requiring intensive care therapy.The coding expertise is assessed both by computerized plausibility assessments and by regular feedback to every center.It is part of the quality as-surance program involved in the certification process of the National Trauma Network,and the quality of documentation is accepted to be high.15,17In this line,Kilgo et al.27reconfirm that a high quality of data may be an issue in studies gathered from databases.Likewise,Moore et al.28state that the most important issue to address in registries is high-quality coding practices along with homogenous inclusion criteria.It is im-plied that some variables from the current database V those that could not be used because of a lack of availability and feasibility V may become more useful with future assessments.3.Another issue is the quality of the data collected.Kondoet al.16report a76%complete data set27,154in patients from a nationwide database.The authors conclude that this number seems to be within the normal range.Across several registries V including the one used for the current study V missing values for physiologic data seem to be a similar concern.Some authors therefore advised to use a multiple imputation model.26Kondo et al.16decided to eliminate all patients with missing data to improve the quality of documentation.The same approach was applied in the current study.Given these prerequisites,the panel laid special emphasis on availability and completeness of data in large data sets,sen-sitivity,and specificity.Both the literature review and the database assessment confirmed that this approach leads to a sound asso-ciation with mortality rates.The current definition thus seems to fulfill all criteria listed earlier,thus allowing for global application. One may argue that a pure expert consensus may offer certain advantages over empirical estimation of injury severity.29 Instead,it seems that the combination of a priori expert consensus,review of the literature,and a database analysis provides a more solid basis for a refined assessment.Similar concepts have been successfully applied by previous groups. Despite being more time consuming,a consensus process seems to provide an exceedingly durable statement.30 In summary,a consensus and database-supported defini-tion of the polytraumatized patient is presented.The definition was tested using empirical data on outcome,namely,a mortality rate of30%or greater.The database served to predict the value of multiple parameters,to refine the draft definition,and to include multiple parameters including accepted scoring systems and ancillary variables.The definition implies the following pa-rameters:two injuries that are greater or equal to3on the AIS and one or more additional diagnoses(pathologic condition),that is,J Trauma Acute Care SurgVolume77,Number5Pape et al.。
多发伤诊断标准(一)
多发伤诊断标准(一)#多发伤诊断标准一、什么是多发伤？多发伤（Multiple trauma），指一个人在失事事故或其他暴力行为、自杀等所引起的损伤中，同时发生两个或两个以上的部位或系统损伤的一种病理生理状态。
二、常见伤害类型•骨折•烧伤•中枢神经系统损伤•内脏器官受伤三、诊断标准诊断多发伤有一系列的标准，主要包括以下几个方面：1.冲击过程在冲击过程中，主要需要判断以下几个指标：•被冲击的力量•冲击的区域•冲击的时间2.临床检查临床检查主要是通过以下几个指标：•皮肤表面受损情况•骨折情况•神经功能是否受到损伤•恶性肿瘤是否存在等3.影像学检查影像学检查主要是通过以下几个指标：•X线检查•CT检查•MRI检查4.伤势评分系统伤势评分系统（Injury Severity Score, ISS）通过对伤者伤势的特点进行评估，得到一个相应的评分。
评分越高，表明伤势越严重。
四、急救处置对于急性多发伤的患者，需要尽快进行科学、有效的急救处置措施。
常见的急救措施包括：•停止出血•对呼吸和循环功能进行支持•救护车运送患者前准备•注意感染预防等五、预防预防是最为重要的。
针对多发伤，应该从以下几个方面进行预防：•保持安全意识，预防意外•身体锻炼，增强体质，预防疾病•驾驶安全，不酒驾、超速驾驶等六、结语多发伤是一种常见的严重损伤类型，对于急救、治疗和预防都需要付出更多的努力。
在日常生活中，也需要时刻保持安全意识，预防多发伤的发生。
七、相关注意事项在诊断、急救和治疗过程中，还需要注意以下一些事项：1.必须认真观察患者的病情和病史等信息，制定对应的治疗措施。
2.完善医疗设施，提高急救和诊疗的效率和质量。
3.医疗机构必须对多发伤病例进行定点处理，提高救治效率。
4.针对多发伤病情，需要进行团队合作，包括急救人员、外科医生、骨科医生等进行协作，提高治疗质量和效果。
八、参考文献1.中国抢救、紧急与灾难医学会.多发伤诊断标准.中国急救医学,2006,26(11):880-884.2.后野宣美,西红,张篷.全身性多发伤处理的诊疗策略初探.中国流创外科杂志,2013,17(6):441-443.3.王世曙,周帅中,王晓东,等.全身多发伤的治疗策略.中华创伤杂志,2010,26(2):160-163.以上是多发伤诊断标准的相关内容，希望对您有所帮助。
《ARDS柏林定义》
肿
中华医学会呼吸病整理分课会件, 中华结核和呼吸杂志，2000, 23:203
急性呼吸窘迫综合征的柏林定
时程 胸部影像 学a 水肿起源
氧合b 轻度
中度 重度
义
已知临床发病或呼吸症状新发或加重后1周内 双肺斑片影—不能完全用渗出、小叶/肺塌陷或结 节解释 无法用心力衰竭或体液超负荷完全解释的呼吸衰竭。 如果不存在危险因素，则需要进行客观评估(例如 超声心动图)以排除流体静力型水肿。
示左心房高 之间缺乏一致性
声心动图)a以排除流体
压
静力型水肿；
危险因素 无
没有列入正式定义 有危险因素，但无法识
别时，需要客观评估以
排除流体静力性水肿
整理课件
柏林定义—共识与经验验证结合
• 专家组在制定定义时，首次采用共识讨论 与经验评价相结合的方法
• 重点关注定义的可行性、可靠性、实际有 效性，如：
弥漫性浸润 间，胸片的结果 并进行相应的举
缺乏可靠性
例
整理课件
AECC 定义的局限性 及柏林修正方法
AECC定义 AECC局限性
柏林定义修正
PAWP 测量
高PAWP与ARDS可 去除PAWP；
PAWP≤18m 能同时存在
定义为非流体静力型肺
mHg，或无 PAWP和左心房高压 水肿引起的呼吸衰竭；
临床证据提 的评价在不同观察者 进行客观评估(例如超
呼吸顺应性极大程度反映了肺容积丢失的程度增加的死腔通气在ards患者中十分常见并且与死亡率的增加密切相关其它方法用于改善特异性以识别增加的肺血管通透性和降低的肺含气组织包括ct和炎症或基因标志物等然而由于上述方法缺乏常规应用的可行性在重症患者中缺乏安全性诊断的敏感性或特异性尚无法作为ards定义标准终版柏林定义国际专家小组根据共识意见拟定柏林定义草案后通过来自7个中心2个大规模数据集4项多中心临床研究和3项单中心生理学研究共计4457例患者的meta分析进行了经验验证急性呼吸窘迫综合征的柏林定义时程已知临床发病或呼吸症状新发或加重后1周内胸部影像学a双肺斑片影不能完全用渗出小叶肺塌陷或结节解释水肿起源无法用心力衰竭或体液超负荷完全解释的呼吸衰竭
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of Ningxia Medical University
多发伤（polytrauma） 新柏林定义解读
陈中伟 宁夏医科大学总医院急诊科
2015-7-29
流行病学
Injury
创伤是当今世界面临的一个普遍性问题 2009年全球 600万 死亡 美国150万人/每年 住院 我国多发伤的流行病学特点：
定义简史
Injury
多发伤定义原则 多发伤定义简史 多发伤定义3要素
多发伤柏林定义
宁医大总院急救中心
General Hospital of Ningxia Medical University
定义发展历程
Injury
Baker（1974年）提出以ISS描述多发伤患者的严重度 北大西洋公约组织（1975年）出版的《野战外科学》( Emergency War Surgery) 将多发伤定义为多个脏器或多个部位损伤，并有多个脏
1985年3大宗师提出国内首个定义
Injury
多发伤是指在统一机械因素作用下，人体同时或相继遭受三处以上解剖部 位或脏器的严重创伤，其中至少有一处损伤可危及生命，伤员均有休克。 宁医大总院急救中心
General Hospital of Ningxia Medical University
1994 年国内首个多发伤共识
宁医大总院急救中心
General Hospital of Ningxia Medical University
Schweiberer多发伤分度
Injury
I级
• • • • 中度损伤 需要住院 无休克 PaO2正常
II级
• • • • 重度损伤 休克 丢失约25%血容量 PaO2低于正常
III级
• 紧急的威胁生命损 伤 • 严重休克 • 丢失约50%血容量 • PaO2低于60mmHg
General Hospital of Ningxia Medica
1 简要询问病史,了解伤情
2
监测生命体征,判断有无致命伤 按照”CRASH PLAN”顺序检查,以免漏诊
Respiration 呼吸 Pelvic 骨盆 Abdomen 腹部 Spine 脊柱 Nerves 神经
Injury
3
Cardiac 心脏 Head 头部
Limb 四肢
Arteries 动脉
4
必要的辅助检查
宁医大总院急救中心
General Hospital of Ningxia Medical University
尚无公认定义
Injury
多中心研究、学术交流、救治体系和技术水平评价等困难 2014年Pape等发表了新的柏林定义
解剖部位的损伤，其中一处损伤即使单独存在也可危及生命或肢体
-张连阳，白祥军.多发伤救治学.人民军医出版社，2010:1-2.
宁医大总院急救中心
General Hospital of Ningxia Medical University
多发伤专家共识
Injury
-中华医学会产生学分会创伤急救与多发伤学组.创伤外科杂志，2010，12（1）：96-97.
器功能系统的病理生理紊乱，休克发生率高，程度严重，常有致死性后
果
Border（1975年）将多发伤定义为2个以上部位的创伤
-Baker SP,et al.J Trauma 1974，14：187-196. -NATO. Emergency War Surgery. 1975. 82 - 87. -Border JR, et al.Progress in Surgery. 1975,14:84−120.
宁医大总院急救中心
General Hospital of Ningxia Medical University
多发伤（polytrauma）
Injury
累及身体多个部位或体腔损伤，导致生理状态不稳定及远隔脏器功能障碍 20世纪80年代以来，出现了由多学科外科团队负责其急诊复苏、紧急手术、 ICU救治、稳定后的确定性手术等的整体化救治模式
宁医大总院急救中心
General Hospital of Ningxia Medical University
多发伤定义：国际共识的需要
Injury
尚缺乏共识，缺乏高级别证据 倡导建立国际专家组达成可重复的、普遍适用的多发伤定义
多部位伤（multitrauma） 多发伤（polytrauma）
宁医大总院急救中心
General Hospital of Ningxia Medical University
举例
1.多发伤 （ISS 29） 1.1 钝性胸部伤 1.1.1 左肺挫伤 （AIS 3） 1.1.2 左侧大量血胸 （AIS 4） 1.1.3 左5、6肋骨骨折 （AIS 2） 1.2钝性腹部伤 1.2.1胰腺体部挫裂伤 （AIS 3） 1.2.2 肝裂伤 （AIS 2） 1.3 闭合性肢体损伤 1.3.1左肱骨干下段骨折 （AIS 2） 1.3.2右第2～5掌骨骨折 （AIS 2） 2.失血性休克（重度） 3.低蛋白血症 4.Ⅱ型糖尿病
ISS>15，或ISS<15时伴
明显急性生理功能恶化 （心血管、呼吸或神经
AIS ≥4
系统） 国内多发伤 宁医大总院急救中心
General Hospital of Ningxia Medical University
国际多发伤
-Butcher N,et al.Injury, Int. J. Care Injured 2009,40S4:s12-s22.
General Hospital of Ningxia Medical University
关注全身影响
Injury
Ertel（1994年） ISS≥16的多处损伤及其继发 的全身反应的临床综合征，可
Osterwalder（2002年） ≥2分的ISS 6分法区域中≥2个 部位受伤
Keel（2005年） ISS＞17，合并SIRS至少1天， 可导致无原发损伤的远处脏器
Injury
单一因素造成AIS-90版所指的9个部位中2个或2个以上解剖部位损伤
宁医大总院急救中心
General Hospital of Ningxia Medical University
中华医学会创伤学分会 创伤急救与多发伤学组成立
Injury
机体在单一机械致伤因素作用下，同时或相继遭受两个或两个以上
Injury
ISS≥16……致死率36.1% 96年我国残疾约6000万 交通事故致残—50%截瘫、 四瘫 早期无瑕或疏于矫正——功能障碍 早期处理常需反复权衡，否则难免顾此失彼
最大限度减少功能丧失，提高生存质量
生命支撑，连续监护，加强治疗，手术干预，并发症 处理功能重建
宁医大总院急救中心
临床特征
3、易漏诊
Injury
损伤部位多 明显、隐蔽同在 原因 开放、闭合并存 伤员不能如实诉述伤情 检查者思维定势，检查不细 部位：胸、腹、腹膜后大出血及腹腔肠道损伤
4、处理顺序矛盾 多发伤动态过程、多科损伤、约50%需手术 局部整体、轻重缓急、主次先后的矛盾 抓住危及生命的要害 先急后缓，先重后轻 胸→腹→颅→四肢
-Schweiberer L, et al. Schweregrad und therapeutische Richtlinien. 1978,49:608.
宁医大总院急救中心
General Hospital of Ningxia Medical University
强调致命性
Injury
可以发生在创伤 后即刻或短期内
Injury
宁医大总院急救中心
General Hospital of Ningxia Medical University
1975年来50篇文献定义多发伤
Injury
创伤部位 或脏器的 数量 致伤机制
继发功能 障碍
致命性 创伤
创伤综合 分级
ISS
致命性创
伤+ISS
ISS+SIRS
-Butcher N,et al.Injury, Int. J. Care Injured 2009,40S4:s12-s22.
导致远隔脏器功能障碍
和重要系统的功能障碍或衰竭
-Ertel W,et al. Zentralbl Chir 119:159–167. -Osterwalder JJ.J Trauma. 2002，52:1030−1036. -Keel M, et al.European Journal of Trauma. 2006 32:387−395.
某处 为致命伤
多处创伤叠
加致命
-Faist E,et al.J Trauma. 1983 23:775−787. -Kroupa J. Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca 1990 57:347−360.
宁医大总院急救中心
-Pape HC,et al. J Trauma Acute Care Surg.2014,77(5):780-786.
刀刺伤
交通伤
坠落伤
宁医大总院急救中心
General Hospital of Ningxia Medical University
国内定义
Injury
同一机械性致伤因素作用下，机体有两 个或两个以上解剖部位或脏器同时或相 继发生创伤，且至少有一处损伤是致命 的。
多发伤的特点
范围广、休克多，变化快