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德国乌尔姆的德国武装部队医院的资源、标准和培训 （英文）
·军事医学 · Management of polytraumatized patients in the resuscitation room Resources,standards and training at the German Armed Forces Hospital in Ulm,Germany M．Kulla A．Bitzl S．Klinger L．Lampl 【Summary】 Continuous quality control of patient management in the resuscitation room has enabled the Federal Armed Forces Medical Centre Ulm to achieve quality standards that are recognized at both the national and the international levels．This is shown in the fact that the hospital is currently being certified as a supraregional trauma center．A major focus has invariably been placed on interdisciplinarity and compliance with nationally and internationally agreed standards．ATLS and PHTLS algorithms,which are recognized both nationally and internationally,have been successfully adapted to meet the latest requirements such as a multi-slice CT examination of the whole body and thromboelastography．With this background,medical service officers and non-commissioned officers are able to use the knowledge and skills they have acquired in Ulm also on foreign deployments,which require a particularly high level of flexibility and adaptability.  M．Kulla 【Key words】 multiple trauma；trauma centers；therapeutics 【CNC number】 R641；R82 【Document Code】 A 【Article ID】 0577-7402（2009）08-1016-05 多发性创伤患者的医疗处理 **—**德国乌尔姆市联邦国防军医院的资源、标准和培训 M．库拉 A．比茨 S．克林格 L．兰波 【摘要】 德国乌尔姆市联邦国防军医疗中心复苏病房对患者实行连续质量控制的医疗处理,此项措施使得该中心的医疗处理 工作质量达到了国内和国际先进水平,该院最近被认证为跨地区的创伤医疗中心。医院始终不渝地坚持多学科性建设并保持医疗技 术处于国内和国际先进水平。按照国内和国际标准制定的 ATLS 和PHTLS 规则系统,例如全身多层 CT 检查、血栓弹性描记法 已被用来满足最新的技术需求。在这样的技术背景下,当部队被派往需要高度的灵活性和适应能力的国外部署时,医务人员和非现 役军官就能够充分地运用他们在乌尔姆中心医院获得的知识和技能来完成他们所承担的任务。本文介绍了在复苏病房中对多发性 创伤患者进行预处理、为复苏医疗组成员提供培训所需要的现有资源,以及对患者的预处理可获得最佳效果的规则方法,此外还介绍 了近十年来为达到现有质量标准所做的改进措施。 【关键词】 多处创伤；创伤诊治中心；治疗学 【中国图书资料分类号】 R641；R82 【文献标识码】 In-hospital care of polytrauma patients at the German Armed Forces Hospital in Ulm As a part of the emergency department ,the resuscitation room is a connecting link between prehospital care provided by an emergency physician and in-hospital treatment provided by a multidisciplinary trauma team consisting anesthesiologists,trauma surgeons,radiologists and non-physician personnel．Fundamental decisions about patient management must be made within a few minutes and are of crucial importance for the definitive treatment and the outcome of severely injured patients. In-hospital management of severely injured patients first and foremost requires appropriate material and personnel resources （Figure 1and Tables 1—2）,which are,for example,specified in the White Book on the Management of Severely Injured Patients published by the German Society of Trauma Surgery．Together with the Ulm University School of Medicine,the German Armed Forces Medical Centre Ulm（FAFMCU ）forms a supraregional trauma center within what is known as the“ Regional Trauma Network of Ulm”（Ruchholtz et al．,2007； Thielemann et al； 2007）．The purpose of this paper is to describe the resources that are currently available for the management of multiple-injured patients in the resuscitation room,the training that is provided to resuscitation team members（“Traumateam ”）,and the algorithms thatare used in ordert to maximize the outcome for patients. Furthermore the changes and improvements that have lead up to A 【文章编号】 0577-7402（2009）08-1016-05 the present quality of treatment over the past ten years shall be discussed. Tab．1 Composition of a（core）trauma team and other specialties at the German Armed Forces Hospital of Ulm Trauma team Other specialties ∗ Members Number Anesthesiologists （ incl． team leader） 2 Neurosurgery Surgeons 2 Oral and maxillofacial surgery Anesthetic nurse 1 Vascular surgery Emergency nurse 1 Visceral surgery Radiology assistant 1 Thoracic surgery Radiologist 1 Ophthalmology Documentation Assistant 1 Otolaryngology Urology Total 9 Laboratory medicine and blood service ∗May be consulted in the management of polytrauma patients in the resuscitation room 【Biography】 Martin Kulla,MD,Major（MC）．E-mail：mail＠kulla．de 【Service】 Department of Anesthesiology and Intensive Care Medicine,German Armed Forces Hospital Ulm,Oberer Eselsberg 40,89070Ulm,Germany（M. Kulla,L．Lampl）；German Armed Forces Hospital of Ulm（E．Franke）  Fig．1 Resuscitation room at the German Armed Forces Hospital in Ulm,Germany Tab．2 A non-exhaustive list of material resources available in the resuscitation room of the German Armed Forces Hospital in Ulm Primary survey Gurney（mobile and adjustable in height） Airway Complete anesthesia workstation including ·Anesthesia cart（identical to that used in the OR） ·Anesthesia machine ·Suction unit ·Tubes and associated equipment for difficult airway management （ laryngeal mask, airway exchange catheter,fiberoptic intubation equipment ）and an emergency cricothyrotomy kit Breathing · Siemens Servo i ventilator mounted on a resuscitation cart ,including oxygen and compressed air bottles,a patient monitor and a Draeger Oxylog 3000emergency ventilator．The resuscitation cart can be connected to the gurney．Ventilated patients can thus be easily moved. ·Chest tubes with pre packed mini-thorakotomy kits ·Pericardiocentesis kit Circulation ·Duplex ultrasonography ·Vascular doppler ·Level 1 pressure infusion system with integrated warming device ·Warming cabinet with infusions ·Blood gas analysis system ·Defibrillator Disability ·Pen torch（for checking pupil response） Exposure ·Bair Hugger warming system Secondary survey ·Multi-Slice CT ·Digital X-ray system ·Dressing material,vacuum splints ·All types of vascular access lines,Foley catheters, gastric tubes,etc. ·Different types of medication such as antibiotics and vaccines Thromboelastography（ROTEM ） The past and present quality management The interdisciplinary emergency department with its resuscitation room is part of the Department of Anesthesiology. Over the last ten years,the FAFMCU has placed a major focus on quality management in order to optimize patient care．For this purpose,one member of the trauma team（usually a doctoral candidate）has the role of a documentation assistant ,prospectively recording patient management data with a digital tablet-PC-based documentation system called“TraumaWatch”（Helm et al．,2005； Kulla et al．,2001； Kulla et al．,2004）．The Federal Armed Forces Medical Centre Ulm not only uses these records for its own evaluation of specific issues but has also provided data to the German Trauma Registry for over ten years now（Ruchholtz et al．,2004；Steffen et al．,2008）．The data obtained from internal and external quality management are discussed in multidisciplinary trauma rounds against the background of the existing literature and the experiences of the specialists participating in the rounds. Necessary changes are made and reevaluated in clinical practice. Using audit filters and tracers,some of which are shown in Table 3,the trauma rounds have introduced major improvements in patient management in the resuscitation room．These have taken place in four different stages. Stage I（beginning in late 1997） ·Introduction of a mobile X-ray unit in the resuscitation room Stage II（beginning in1999） ·Installation of a fixed X-ray system · Diagnostic point-of-care testing（blood gases,hemoglobin, electrolytes,blood glucose）in resuscitation room Stage III（beginning in2001） ·Installation of a digital X-ray system Stage IV（beginning in March2006） ·Expansion of the resuscitation room and integration of a multi- slice CT scanner ·Revision of the existing management algorithm ·Team training in Advanced Trauma Life Support （ATLS ） ·Thromboelastography（ROTEM ）as a diagnostic point-of- care test（haemostasis）in the resuscitation room The resuscitation team Every year,an average of approximately 480 patients is admitted to the resuscitation room of FAFMCU．The majority of these patients present with an acute life-threatening condition. Two thirds of the patients are suffering from trauma and approximately 35％ of all patients have an injury severity score （ISS） ＞ 16,which defines them as polytraumatized patients （Baker et al．,1974；Kulla et al．,2005；Lefering et al．,2002）. · 1018 · 解放军医学杂志 2009年8月 1 日 第 34卷 第8期 Med J Chin PLA,Vol∙ 34,No∙ 8,August 1,2009 Tab．3 Changes in quality（audit）filters for the tracer diagnosis of polytrauma（ISS＞16）in the resuscitation room of the FAF MC in Ulm over four periods of time．The table also provides data from the Trauma Register of the German Society of Trauma Surgery（Kulla,2001） Period 1 Period 2 Period 3 Period 4 Trauma register 1Jan 98to 31Dec 98 1Jan 99to 31Dec 00 1Jan 01to 28Feb 06 1Mar 06to 31Mar 07 05／06 Proportion of patients who received primary care 65．7% 69．4% 82．8% 85．4% 83．3% Age（years） 34．4±17．6 44．5±22．6 42．5±20．7 47．4±23．2 43．1±21．3 Severity of injury（ISS score） Time to（min） 31．6±9．4 28．4±12．2 29．9±13．5 27．2±11．5 24．5 FAST 10．1±16．7 6．2±5．8 4．6±3．5 2．3±1．7 7．0±10．0 chest radiography 60．9±35．1 28．0±22．7 11．0±13．0 — 12．0 pelvic radiography 52．7±30．0 42．5±32．3 28．9±27．8 — 15．0 end of primary survey 26．5±10．6 25．0±12．8 27．8±49．7 8．1±4．7 CT of the head 57．9±47．9 43．3±27．8 37．8±15．3 13．4±5．9 28．0±10．0 CT of the whole body — — 33．6±19．1 18．5±7．4 27．0±20．0 the decision regarding definitive management （end of secondary survey） 90．9±48．6 83．2±45．9 66．4±33．7 37．4±18．1 73．0±41．0 The remaining patients have sustained isolated traumatic brain injuries,intracranial hemorrhage,strokes,or they are less severely injured than previously assumed. Severely injured patients are managed by a trauma team, which consists of nine members（Table 1）and is led by an anaesthesiological consultant ．While this team provides rapid assessment ,treatment and stabilization to the patient on the basis of a defined management algorithm,the main role of the team leader and a surgical consultant is to coordinate measures and procedures for a smooth fast and appropriate management of the patient ．Whereas defined algorithms are used for the initial stabilization of a patient ,the experience of consultants is required to decide whether a patient has to undergo immediate surgery or requires treatment on an intensive care unit．The following sections describe the management algorithm and each team membe s tasks in it . Resuscitation room algorithm Figure 2 provide an overview of trauma management algorithm．The algorithm presented here summarizes a standard operating procedure（SOP）which gives detailed instructions for all trauma team members．Large copies of the algorithm are displayed on the walls of the resuscitation room where they are clearly visible to everyone．The decision to deviate from the algorithm should be made by the two most experienced members of the team（surgical and anaesthesiological consultant ）as unjustified non-compliance with the algorithm is usually associated with poorer outcome （Bernhard et al．,2007；Bishop et al；1991）.  Fig．2 Roles and responsibilities of the trauma team members during the primary and secondary surveys until a decision on definitive patient management is made Preparation and Primary Survey Once the emergency department has been notified of an impending trauma patient arrival by the rescue coordination center, the trauma team is mobilized by pager so that all members are present in the resuscitationiroom and cani .make all necessary preparations prior to the patient＇ s arrival．All trauma team members are required to wear protective clothing（head covers, surgical masks,gowns,disposable gloves）and radiation-protective lead aprons. When the patient arrives and is handed over by the emergency physician,the entire trauma team listens quietly to receive all information concerning history,findings,and treatments initiated. The patient is then transferred to a resuscitation room gurney．The 解放军医学杂志 2009年8月 1 日 第 34卷 第8期 Med J Chin PLA,Vol∙ 34,No∙ 8,August 1,2009 · 1019 · following sections describe how patient management is instituted simultaneously by a team of specialists in anesthesiology,surgery, radiology and emergency medicine using the resuscitation room algorithm. Airway Responsibilities of the anesthesiologist ·Assess and maintain the airway patency ·Administer oxygen to nonintubated patients via an Ohio mask ·Protect the cervical spine at all times（using a cervical collar or manual inline stabilization） ·Carry out a brief examination and assess the skin color（blush discoloration, paleness, cold sweat ）, chest wall excursion （symmetry,paradoxical breathing,frequency,recession）,and head injuries （ unilateral／bilateral periorbital hematoma, cerebrospinal fluid leakage） ·Check position of orotracheal tube Breathing Responsibilities of the anesthesiologist ·Examine the chest by auscultation and percussion（for the presence of equal,reduced,absent or abnormal breath sounds） · Ventilate intubated patients using a mobile intensive care ventilator and monitor end-tidal CO2 ·Immediately decompress a tension pneumothorax by inserting a chest tube in the Monaldi position if a tension pneumothorax is suspected from clinical signs Responsibilities of emergency department staff ·Establish pulse oximetry Circulation Responsibilities of the anesthesiologist ·Establish a minimum of two large-bore intravenous lines ·Give i．v．fluid bolus（e．g．500ml Hydroxyethyl Starch 6% 130／0．4 in an balanced,acetated solution or 1 000ml Ringe s acetated solution） Responsibilities of the surgeon ·Control life-threatening bleeding ·Realign and splint fractures,where indicated Responsibilities of the radiologist · Conduct a focused assessment of sonography for trauma （FAST）examination,which is a special ultrasound examination to screen for intraabdominal free fluid（Kolle s pouch,Moriso s pouch and Dougla pouch）and pericardial effusion Responsibilities of emergency department staff ·Measure blood pressure non-invasively ·Replace infusions with warmed solutions ·Assist with the establishment of intravenous lines ·Assist with the collection of blood samples for venous blood gas analysis,laboratory tests including a pregnancy test for females of childbearing age,crossmatch and thromboelastography Disability（neurological evaluation） Responsibilities of the anesthesiologist ·Establish pupil size and reaction Responsibilities of the surgeon ·Perform a brief neurological examination（Glasgow Coma Scale - GCS,perfusion,motor and sensory function,clinical signs of paraplegia or quadriplegia）s:iiwww.cnki . net Exposure Responsibilities of the surgeon ·Perform a brief physical evaluation（where appropriate,log-roll the patient） Responsibilities of emergency unit staff ·Complete monitoring procedures（e．g．three-lead electrocardio- graphy） ·Completely undress the patient ·Keep the patient warm using a WarmTouch or Bair Hugger system The objective of these first few minutes of stabilization （primary survey）is to identify and manage acute life-threatening conditions．A decision must then be made whether to complete diagnostic procedures in the resuscitation room,as is usually the case,or to discontinue them and perform emergency surgery instead. Adjuncts and Secondary Survey When diagnostic tests are continued,the patient is moved onto the CT table using a spine board． A multi-slice CT examination of the whole body is performed according to a standardized protocol（diagnostic images of the head,spinal cord, chest ,abdomen,pelvis,and upper legs with and without contrast agent）．In patients with signs of complex midfacial or vertebral body fractures,special investigations are performed in addition to a whole-body trauma scan．It is thus possible to prevent any unnecessary movement of the patient and at the same time obtain data that may be required for special reconstructions or surgical procedures including three-dimensional（3D）navigation．While the radiologist evaluates a total of approximately 1 200 images,the patient is transferred back to the resuscitation room gurney．After a brief reevaluation,the secondary survey begins．At the end of the secondary survey,monitoring procedures should be completed and the patien s airway,breathing and circulation should be as stable as possible．In the majority of cases,this requires arterial cannulation for invasive blood pressure monitoring,arterial blood gas analysis,the establishment of a central venous line（ where appropriate）,the induction or maintenance of general anesthesia（if immediate surgery is indicated ）, and an evaluation of thromboelastography results．At the same time,a systematic head- to-toe examination of the patient is repeated,dressings or splints are applied, and （ if indicated ） conventional X-rays of the extremities are obtained．Since the introduction of multi-slice CT , conventional X-rays of the cervical spine,chest and pelvis,which are time-consuming and often of little value,are usually no longer required. A record of all events and procedures in the resuscitation room（including findings,treatments,batch number of blood products,items of patient property）must be maintained．These records are not only important for medicolegal reasons and for medical personnel who become involved in patient management at a later stage but are also necessary for the purpose of quality management . Training and qualifications of resuscitation team members As described above,the management of polytrauma patients consists of many activities that are performed simultaneously by the members of a multidisciplinary trauma team within as short a period of time as possible．The time from patien s arrival to the · 1020 · 解放军医学杂志 2009年8月 1 日 第 34卷 第8期 Med J Chin PLA,Vol∙ 34,No∙ 8,August 1,2009 end of the primary survey is on average eight minutes．The time, from the end of the primary survey to the decision regarding definitive management ,which is made at the end of the secondary survey and completes patient management in the resuscitation room,is on average thirty minutes．These tasks require highly qualified and motivated personnel．All physicians who are members of the trauma team or are consulted must have completed residency in their specialty．The team leader and one of the surgeons must be consultants．Likewise,non-physician personnel must have the skills,knowledge and competence required for their specific roles. This means that someone who is receiving training or familiarization cannot serve as a member of a trauma team but may only assist with patient management under the supervision of an experienced colleague．Medical personnel undergoing training are identified by the color of their protective clothing to prevent misunderstandings and confusion. For a trauma team to be successful,its members must have not only the necessary competence and qualifications but also the willingness and ability to work together in a collaborative effort . For this reason,Advanced Trauma Life Support （ATLS ） courses certified by the German Society of Trauma Surgery and the American College of Surgeons have been held regularly since 2006 at the Federal Armed Forces Medical Centre in Ulm．Non- physician team members of the departments involved（ e．g. radiology and anesthesiology ）as well as nursing and emergency unit staff are encouraged to take part in ATLS courses as guests or mock patients in order to use this opportunity to become familiar with the language of trauma patient management．In addition,they can attend Prehospital Trauma Life Support （PHTLS ） courses（Wölfl et al．,2008）．The Federal Armed Forces Medical Centre also plans to conduct regular familiarization training for new trauma team members,which includes practical exercises in the resuscitation room. Outlook The entire Federal Armed Forces Medical Centre Ulm, including the central interdisciplinary emergency unit and its resuscitation room,is currently being rebuilt．It is expected that the rebuilding of the new interdisciplinary emergency unit and its resuscitation room will be completed by 2009．The experience of the past ten years suggests that the new home of the emergency unit will require a further adaptation of the management algorithm. The future will tell us what measures must be taken in order to maintain or even improve the quality of patient management at what will be“Stage V”. References ［1］ Baker SP,O＇Neil B,Haddon W,et al．The Injury Severity Score：A Method for Describing Patients with Multiple Injuries and Evaluating Emergency Care．J Trauma ,1974,14（3）：187 ［2］ Bernhard M,Becker TK,Nowe T ,et al．Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room．Resuscitation,2007,73（3）：362 ［3］ Bishop M,Shoemaker WC,Avakian S,et al．Evaluation of a comprehensive algorithm for blunt and penetrating thoracic and abdominal trauma．Am Surg,1991,57（12）：737 ［4］ Helm M,Kulla M,Hauke J,et al．Improved Data Quality by Pen - Computer assisted Emergency Room Data Collection following Major Trauma -a Pilot Study．Eur J Trauma ,2005,31（3）：252 ［5］ Kulla M．Pen-Computer gestützte Schockraumdokumentation basierend auf dem Schwerverletzten-Erhebungsbogen des Traumaregisters der Deutschen Gesellschaft für Unfallchirurgie（DGU）,in Medizinische Fakultät．2001,Universität Ulm：Ulm．290 ［6］ Kulla M,Fischer S, Helm M,et al．Traumascores für den Schockraum - eine kritische Übersicht ． Anästhesiol Intensivmed Notfallmed Schmerzther,2005,40（12）：726 ［7］ Kulla M,Helm M,Fischer S,et al．Schockraumdokumentation am Bundeswehrkrankenhaus Ulm -Erfahrungen aus über 1200Patienten. Wehrmed MSchr,2004,48（4）：65 ［8］ Lefering R．Trauma Score Systems for Quality Assessment．Eur J Trauma ,2002,28：52 ［9］ Ruchholtz S． Arbeit sgemeinschaft “ Polytrauma ” der Deutschen Gesellschaft für Unfallchirurgie,Das externe Qualitätsmanagement in der klinischen Schwerverletztenversorgung．Unfallchirurg,2004,107 （10）：835 ［10］Ruchholtz S,Kühne CA,Siebert H．Das Traumanetzwerk der Deutschen Gesellschaft für Unfallchirurgie． Zur Einrichtung, Organisation and Qualitätssicherung eines regionalen Traumane- tzwerkes der DGU．Unfallchirurg,2007,110（4）：373 ［11］Steffen R, Lefering R, Paffrath T , et al． Rückgang der Traumaletalität - Ergebnisse des Traumaregisters der Deutschen Gesellschaft für Unfallchirurgie．Deutsches ? rzteblatt ,2008,105 （3）：225 ［12］Thielemann FW,Siebert H．“Traumanetz Baden-Württemberg”im Traumanetzwerk der Deutschen Gesellschaft für Unfallchirurgie. Beispiel für die Einrichtung eines Traumanetzwerkes auf Landesebene. Unfallchirurg,2007,110（4）：381 ［13］Wölfl CG,Bouillon B,Lackner CK,et al．Prehospital Trauma Life Support（R）（PHTLS（R））：Ein interdisziplinäres Ausbildungskonzept für die präklinische Traumaversorgung．Unfallchirurg,2008 （2009-02-16收稿 2009-05-15修回） （责任编辑 张金桐） ·书 讯 · 实用推拿手册（第 2版） 本书由著名推拿学专家主编,在第 1版的基础上修订而成,共分三篇。第一篇为推拿基础,包括推拿简史、特点与分类、各种推拿 手法及学术流派、推拿常用腧穴、作用原理、治则治法、穴位于部位选择、临床诊断检查和推拿练功等；第二篇为推拿临床,详述了伤 科、内科、妇科、男科、儿科、五官科等 140余种常见病症的临床诊断和推拿治疗方法；第三篇为推拿保健,包括人体各部位推拿保健 法、常见病症家庭推拿保健法和足底反射区推拿法。本书内容丰富,阐述简明,图文并茂,实用性强,可供临床医师、推拿科医务人员 和基层全科医师阅读参考,也可作为中医爱好者学习推拿知识和自我推拿保健的指导用书。本书已由人民军医出版社出版。定价： 52．00元,联系人：宁柯。 中国知网 https:iiwww.cnki . net
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