创伤外科发展的机遇和挑战-白祥军

创伤外科发展的机遇与挑战同济医学院附属同济医院同济咸宁医院白祥军华中科技大学白祥军教授主任医师博士生导师华中科技大学同济医学院附属同济医院创伤外科主任、急救中心主任同济咸宁医院院长/党委副书记中华医学会创伤学分会常委创伤急救与多发伤专业委员会副组长中华医学会急诊医学分会创伤组副组长《临床急诊》《创伤外科》副主编《中华急诊医学杂志》编委《中华创伤杂志》+英文版编委《Notfall+Rettungsmedizin》海外编委德国急救医学TraumaEpidemiology–InChina中国创伤之现状“Trauma:AnUnder-recognizedPublicHealthProbleminModernSociety.”---founderofMarylandShockTraumaCenterR.AdamsCowley“创伤是一个被现代社会忽视的公共卫生问题”TraumaEpidemiology–AroundtheWorldRatioofTraumainWorldwideDeathCases2012WHOStatisticalData伤害是青壮年死亡主要原因InjurypatternforChineseresidentsLethalinjuryisjustthetipoftheiceberg！Nonfatalinjuryleadtolong-termandheavyburden!Datafrom:Injury-relatedfatalitiesinChina:anunder-recognisedpublic-healthproblem.Lancet.2008Nov15;372(9651):1765-73TraumaEpidemiology–InChina每年因各类伤害死亡约70万人，但仅仅是冰山一角致伤致残则以千万计，生存质量不高Datafrom:ChinaHealthStatisticalYearbook2012TraumaEpidemiology–InChinaBothadmissionrateandmortalityinbasichospitalsaremuchhigherthanthatinlarge-scalehospitals!Datafrom：李继光.辽宁省不同规模医院住院疾病谱对比分析.中国医院管理TraumaEpidemiology–InChinaadmissionratemortality创伤是县级医院主要病种和主要死亡原因TraumaRescueSysteminChinaPre-hospital—EmergencyRoom—In-hospital院前急救—急诊科救治—院内专科的救治Pre-hospitalRescue--metropolisCommandermode(Beijing,Guangzhou):Emergencycenter,asthecommanderandwithoutrescuefunctionbyitself,appointsemergencyunitsfromdifferenthospitalsforrescuetask.Affiliationmode(Chongqing):Emergencycenterisaffiliatedtoalarge-scalehospitalandownspre-andinhospitalrescueunitsbyitself.CommandandCooperationmode(Shanghai):Emergencycenteranditssubstationstakechargeofpre-hospitalrescuethentransferpatientstocooperativehospitalforfurtherrescue.Rescuenetworkisbasicallysetupinmetropolis.Chongqingemergencycenter大城市急救网络相对完善BeijingemergencynetworkPre-hospitalRescue--metropolisLimitationsLackofinformationexchangeandalarminrescuechainLackofemergencyphysiciansandATLStrainingvacancy急救从业人员数量不足且水平参差不齐院前120-急诊科（医院）信息交换及预警系统缺失Pre-hospitalRescue--metropolisTrafficjamingroundaidAirrescuesystemhasalongwaytogoLimitations地面交通拥堵空中急救落后Pre-hospitalRescue--countrylevelPre-hospitalrescueintownandcountryreliedonlocalhealthstationWithoutindependentpre-hospitalrescuesystem！Lackofrescuenetwork:Itisdifficultforlimitedhealthstationstocoversuchalargeareaandpopulationofcountry.Lackofrescueprofessional:Ateamwithchaoticmanagementandpoorrescueskills.乡镇,农村院前急救主要依赖于当地卫生院无独立的院前急救体系Pre-hospitalRescue--countrylevelTheonlywayfortransportation–Ambulance!OldcarswithoutdatedequipmentJustbeavehiclewithouttreatmentfunction!Lackofcontactandalarmwithemergencycenterincity乡镇,农村院前急救转运方式仅有救护车车辆陈旧，车载设备缺乏，仅能作为搬运工，救治功能差EmergencyRoomCareEmergencyRoomCare120Pre-hospitallifesupport?YALSNFASTexamoperation?YNspecialistconsultadmissionOperationroomAnesthetist&surgeonconsultOperationEmergencyRoomadmission我国创伤院内救治模式：专科会诊-分科救治（绝大多数）创伤中心-一体化团队救治（极少数）EmergencyRoomCareATLSqualitycannotbeguaranteedATLS质量无法保证AbsenceofATLStrainingmakesspecialistslackrescueskillsanddamagecontrolconceptInefficiency救治时效性差WastetimeinwaitingforspecialistsfromdifferentdepartmentsandtheirdiscussionandargumentsNoteamwork团队合作不够LackofcooperationandleadermakesshufflingorscramblingforthepatientsnotuncommonWeeksenseofintegrity重局部轻整体救治FocusonthepartbutneglectingthewholeresultinchaosinevaluationandtreatmentofpatientsLimitationsofspecialistsconsultationmodeIn-hospitalTreatmentComplicationsaftertraumaShockInfectionOrganThrombosisLethaltriadofhypothermia,metabolicacidosisandcoagulopathysepsisCrushSyndrome,MODSDVT,pulmonaryembolismrefinementofspecializationstop-gaptherapyignoranceofsystemicstateTraumarescuemode：consultationofspecialists（most）Integrationtreatmentmodel（few）创伤后并发症处理与ICU能力薄弱In-hospitalTreatmentLackofsystemicrehabilitationtrainingplanpressureulcer……Long-termandchroniccomplications缺乏创伤后早期康复或介入时间晚后遗症症多，生存质量差traumaticarthritisamyotrophyTraumaandLaw--indevelopedcountriesWitnessaidEMSBLSATLStransportIn-hospitalGermany：GuidelinesofEMSTimesTheGoldenHourResponseTime15MinutesOnSceneTime15MinutesTransportationTime15MinutesRescueTime45MinutesThereareconcretelawsfordevelopedcountriestoguidetherunoftraumarescuesystemandorganizationofrescueteam.在欧美国家，建立了完善的EMS法律准则TraumarescueandLaw--inChinaNowthereareonlytwolawstoguideemergencymedicalservicesysteminChina—OpinionsofMinistryofHealthonstrengtheningurbanemergencyrescue(1980)andSupplementaryregulationsofMinistryofHealthonstrengtheningemergencyrescue(1986)Inordertomakeuptheweaknessinlawsofnationallevel,morethan10citiesdrafttheirownguidelines.20yearsago!!Thereisstillgreatgap!在中国仅仅只有EMS急救的规范性文件(1980)和加强急诊抢救工作的补充规定（1986）完善的创伤救治体系需要建立一个完善的创伤救治体系需要法律来支持此体系的建设需要行业学会来推动同时需要建立质量控制中心建立综合性创伤救治中心是提高创伤救治效果的迫切需要道路交通伤高速公路车祸温州动车事故矿难各种工伤事故火灾央视大火上海静安高层建筑大火自然灾害地震海啸武力冲突民族冲突局部战争低能量伤单发伤伤情相对较轻专科治疗为主过去当前创伤致伤机理与救治正在发生变化高能量伤多发伤救治主要要求是时效性和整体性需要多学科协作治疗当前伤情复杂严重，死亡率高感染和脓毒症发生率高各系统损伤的治疗措施常有矛盾，需要综合权衡创伤患者死亡的三个高峰数分钟内立即致死—难以救治1-3小时内死亡：休克—快速有效救治可能挽救生命2-4周死亡：脓毒症—早期快速有效救治可降低其发生率早期快速有效救治是减少创伤患者死亡的关键!!!创伤救治的时效性要求若患者能在创伤发生后1小时内得到有效救治，将极大地降低死亡率和致残率----黄金1小时!!!在德国，完善的创伤急救体系使交通事故死亡率从20000/年下降至4000/年当前的救治模式远不能适应创伤救治需要创伤的传统救治模式120急诊科神经外科骨科心胸外科腹部外科外科院前急救、急诊科、外科、重症医学属不同学科部门，缺乏统一协调。多数医院仍采取多