2024-01-30 17:30 編輯
2024-01-30 15:55 剛在FB看到有人張貼Stop the Bleed 課程內容中文翻譯
所以我又稍微查詢一下資料.
另一篇相關筆記在這
2023-02-16 23:02這篇報告是針對所有外出血的建議處置. 這篇筆記僅節錄止血帶這段. 止血帶的實證醫學建議. 因研究不夠多, 此處建議的證據等級比較薄弱
我把結論放最前面, 實證醫學總結放最下面(原文當然是先講證據等級再給出建議)
專家小組的建議
專家小組對外出血管理的建議總結在圖 2 中。
Recommendation 1:
We recommend the use of tourniquets in the prehospital setting for the control of significant extremity hemorrhage if direct pressure is ineffective or impractical.
Strength of Recommendation: Strong Quality of Evidence: Moderate.
The overall quality of the evidence for survival benefits of tourniquet use was upgraded from Low to Moderate, based on the large effect size. The evidence for preventing amputation was very low, due to a smaller effect size and issues relating to confounding (see Table 2).
Remarks: The panel believes that tourniquets used to treat severe extremity hemorrhage have a clear survival benefit, demonstrated by a large and consistent effect size across several studies. The panel discussed that direct pressure may be ineffective in the setting of major arterial injury or impractical in circumstances with limited manpower, unsecure scene, or when complex extrication or extraction is required.
Recommendation 2:
另一篇相關筆記在這
原先標題是: 野外與登山醫學--到院前救護--外傷---202302162252止血帶的使用-節錄自-外出血控制指引-2014年美國外科醫學會創傷委員會
重點摘要
1. 如果直接加壓止血無法良好控制嚴重的四肢出血, 建議到院前使用止血帶控制嚴重的四肢出血
2. 建議使用有絞盤, 氣壓裝置或棘輪裝置的止血帶商品，不建議使用自製的止血帶。
2. 建議使用有絞盤, 氣壓裝置或棘輪裝置的止血帶商品，不建議使用自製的止血帶。
3. 不要使用狹窄的、有彈性的或蹦極式的裝置。
4. 只有在無法取得止血帶商品時, 才使用臨時自製止血帶 (因無法保證達到良好止血效果)
5. 多數傷患在受傷後送到醫院時間不長, 正確打上止血帶之後, 送醫過程不需要間歇性鬆開，直到患者得到最終治療
(對於長時間才能送到醫院的患者, 建議諮詢當地醫療指導醫師)
(醫療指導醫師有正式法條規範)
(醫療指導醫師施行辦法 99年7月1日施行)
(醫療指導醫師施行辦法 99年7月1日施行)
到院前外出血控制指南：美國外科醫生學會創傷委員會
我把結論放最前面, 實證醫學總結放最下面(原文當然是先講證據等級再給出建議)
專家小組的建議
專家小組對外出血管理的建議總結在圖 2 中。
止血帶
建議 1：如果直接壓力無效或不切實際，我們建議在院前使用止血帶來控制嚴重的肢體出血。推薦強度：強證據質量：中等。基於較大的效應量，使用止血帶的生存益處證據的整體質量從低升級為中等。由於較小的效應量和與混雜相關的問題，預防截肢的證據非常低（見表 2）。
備註：專家組認為，用於治療嚴重肢體出血的止血帶具有明顯的生存益處，這在多項研究中得到了大而一致的效應量的證明。小組討論了直接壓力在大動脈損傷的情況下可能無效，或者在人力有限、現場不安全或需要復雜解脫或撤離的情況下不切實際。
建議 2：我們建議使用商業生產有絞盤, 氣壓裝置或棘輪裝置的止血帶，這些裝置已被證明可以阻斷動脈血流。
推薦強度：弱
證據質量：低
備註：專家組討論了使用不同類型止血帶的軍事經驗，認為止血帶的選擇應基於經證實的動脈閉塞有效性。在沒有充分閉塞動脈的情況下阻礙靜脈回流的止血帶可能只會加重出血並增加並發症。
建議 3：我們建議不要使用狹窄的、有彈性的或蹦極式的裝置。
推薦強度：弱 證據質量：低 備註：專家組討論了使用不同類型止血帶的軍事經驗，認為止血帶的選擇應基於經證實的動脈閉塞有效性。在沒有充分閉塞動脈的情況下阻礙靜脈回流的止血帶可能只會加重出血並增加並發症。
建議 4：我們建議只有在沒有商業設備可用時才使用臨時止血帶。
推薦強度：弱 證據質量：低 備註：專家組討論了使用不同類型止血帶的軍事經驗，認為止血帶的選擇應基於經證實的動脈閉塞有效性。在沒有充分閉塞動脈的情況下阻礙靜脈回流的止血帶可能只會加重出血並增加並發症。除非別無選擇，否則市售的止血帶優於簡易止血帶。
建議 5：我們建議不要鬆開在院前環境中正確應用的止血帶，直到患者得到最終治療。
推薦強度：弱 證據質量：低 備註：鑑於大多數民用 EMS 機構的運輸時間相對較短，委員會認為最安全的選擇是將放置在現場的止血帶留在原地，直到可以對患者進行評估在醫院。對於延長的運輸時間或嚴峻的環境，這種方法可能會有例外。在這些情況下，院前提供者應諮詢直接（在線）醫生的醫療指導。
RECOMMENDATIONS BY EXPERT PANEL The recommendations of the panel for management of external hemorrhage are summarized in Figure 2.
Tourniquets 關於止血帶的相關建議
備註：專家組認為，用於治療嚴重肢體出血的止血帶具有明顯的生存益處，這在多項研究中得到了大而一致的效應量的證明。小組討論了直接壓力在大動脈損傷的情況下可能無效，或者在人力有限、現場不安全或需要復雜解脫或撤離的情況下不切實際。
建議 2：我們建議使用商業生產有絞盤, 氣壓裝置或棘輪裝置的止血帶，這些裝置已被證明可以阻斷動脈血流。
推薦強度：弱
證據質量：低
備註：專家組討論了使用不同類型止血帶的軍事經驗，認為止血帶的選擇應基於經證實的動脈閉塞有效性。在沒有充分閉塞動脈的情況下阻礙靜脈回流的止血帶可能只會加重出血並增加並發症。
建議 3：我們建議不要使用狹窄的、有彈性的或蹦極式的裝置。
推薦強度：弱 證據質量：低 備註：專家組討論了使用不同類型止血帶的軍事經驗，認為止血帶的選擇應基於經證實的動脈閉塞有效性。在沒有充分閉塞動脈的情況下阻礙靜脈回流的止血帶可能只會加重出血並增加並發症。
建議 4：我們建議只有在沒有商業設備可用時才使用臨時止血帶。
推薦強度：弱 證據質量：低 備註：專家組討論了使用不同類型止血帶的軍事經驗，認為止血帶的選擇應基於經證實的動脈閉塞有效性。在沒有充分閉塞動脈的情況下阻礙靜脈回流的止血帶可能只會加重出血並增加並發症。除非別無選擇，否則市售的止血帶優於簡易止血帶。
建議 5：我們建議不要鬆開在院前環境中正確應用的止血帶，直到患者得到最終治療。
推薦強度：弱 證據質量：低 備註：鑑於大多數民用 EMS 機構的運輸時間相對較短，委員會認為最安全的選擇是將放置在現場的止血帶留在原地，直到可以對患者進行評估在醫院。對於延長的運輸時間或嚴峻的環境，這種方法可能會有例外。在這些情況下，院前提供者應諮詢直接（在線）醫生的醫療指導。
RECOMMENDATIONS BY EXPERT PANEL The recommendations of the panel for management of external hemorrhage are summarized in Figure 2.
Tourniquets 關於止血帶的相關建議
Recommendation 1:
We recommend the use of tourniquets in the prehospital setting for the control of significant extremity hemorrhage if direct pressure is ineffective or impractical.
Strength of Recommendation: Strong Quality of Evidence: Moderate.
The overall quality of the evidence for survival benefits of tourniquet use was upgraded from Low to Moderate, based on the large effect size. The evidence for preventing amputation was very low, due to a smaller effect size and issues relating to confounding (see Table 2).
Remarks: The panel believes that tourniquets used to treat severe extremity hemorrhage have a clear survival benefit, demonstrated by a large and consistent effect size across several studies. The panel discussed that direct pressure may be ineffective in the setting of major arterial injury or impractical in circumstances with limited manpower, unsecure scene, or when complex extrication or extraction is required.
Recommendation 2:
We suggest using commercially produced windlass, pneumatic, or ratcheting devices that have been demonstrated to occlude arterial flow. Strength of Recommendation: Weak Quality of Evidence: Low Remarks: The panel discussed the military experience with varying types of tourniquets and felt that tourniquet selection should be based on proven effectiveness at arterial occlusion. Tourniquets that impede venous return without adequate arterial occlusion may only worsen hemorrhage and increase complications.
Recommendation 3:
We suggest against the use of narrow, elastic, or bungee-type devices.
Strength of Recommendation: Weak Quality of Evidence: Low Remarks: The panel discussed the military experience with varying types of tourniquets and felt that tourniquet selection should be based on proven effectiveness at arterial occlusion. Tourniquets that impede venous return without adequate arterial occlusion may only worsen hemorrhage and increase complications.
Strength of Recommendation: Weak Quality of Evidence: Low Remarks: The panel discussed the military experience with varying types of tourniquets and felt that tourniquet selection should be based on proven effectiveness at arterial occlusion. Tourniquets that impede venous return without adequate arterial occlusion may only worsen hemorrhage and increase complications.
Recommendation 4:
We suggest that improvised tourniquets be applied only if no commercial device is available. Strength of Recommendation: Weak Quality of Evidence: Low Remarks: The panel discussed the military experience with varying types of tourniquets and felt that tourniquet selection should be based on proven effectiveness at arterial occlusion. Tourniquets that impeded venous return without adequate arterial occlusion may only worsen hemorrhage and increase complications. Commercially available tourniquets are favored over improvised tourniquets unless there is no other option.
Recommendation 5: We suggest against releasing a tourniquet that has been properly applied in the prehospital setting until the patient has reached definitive care. Strength of Recommendation: Weak Quality of Evidence: Low Remarks: Given the relatively short transport times for most civilian EMS agencies, the committee felt the safest option was to leave a tourniquet that had been placed in the field in place until the patient can be assessed in the hospital. There may be exceptions to this approach for prolonged transport times or austere environments. In these circumstances, prehospital providers should consult direct (online) physician medical direction.
止血帶的使用.實證醫學,證據等級分析
我們確定了 20 篇院前止血帶用於治療外傷性肢體出血的出版物。然而，有四份出版物沒有提供包含在本報告中所需的結果信息：Lairet 等人，20 Gerhardt 等人，21 Kragh 等人，22 Kragh 等人23 在兩個例子中，對同一研究人群進行了評估在兩個單獨的出版物中。Kragh 等人 24 和 Kragh 等人 25 使用同一組 499 名患者，Kragh 等人 26 和 Kragh 等人 27 使用同一組 232 名患者。表 1 列出了 16 篇納入的出版物，以及收集止血帶使用數據的環境和每項研究報告的結果。大部分研究是由美國軍方在伊拉克和阿富汗進行的（8 項研究），其中 3 項研究來自英國軍方，2 項來自以色列軍方，和 1 個來自加拿大軍方。只有一項研究是在平民環境中進行的。一項研究使用了聯合戰區創傷登記處描述的兒科傷亡數據以及在伊拉克和阿富汗戰爭期間收集的數據。28 16 項納入研究中有 13 項報告了死亡數據，11 項報告了不良事件數據，8 項報告了截肢數據，以及沒有報告關於休克的數據。
其中八項研究使用了前瞻性數據收集。大多數研究提供了一些關於如何使用止血帶的信息，但只有少數研究具體說明了使用說明。然而，美國軍方的研究在 2005 年之後收集數據時使用的是 TCCC 做法，止血帶可能被積極用作外傷性肢體出血的首選方法。
只有少數研究試圖對使用止血帶治療的傷員和未使用止血帶治療的類似傷員進行比較。Kotwal 等人 29 報告了接受加壓敷料治療的傷員人數，但未報告該組的結果。Beekley 等人 30 報告了使用止血帶和未使用止血帶的傷員的結局數據，但未報告未使用止血帶的患者接受了哪些院前治療。Clasper 等人 31 將接受止血帶治療的倖存傷員與未接受止血帶治療的倖存傷員進行匹配，以檢查不良事件的發生率。然而，這些作者指出，對報告接受止血帶治療的成年軍人傷員生存率的 9 項研究的薈萃分析表明，生存率的匯總效應量估計為 92%，95% 置信區間為 88-95%。對兒童的研究結果相似（92%，CI 84-96%）。對平民人群的研究規模較小（11 例），因此置信區間較寬，但存活率相似（91%，CI 56–99%）。對報告截肢率的 6 項研究進行的類似分析表明，總效應量估計值為 19%，95% 置信區間為 16-23%。這些截肢可能主要與肢體損傷的嚴重程度有關，因為它們沒有被描述為止血帶使用的並發症。
沒有直接解決 PICOTS 問題 2、3 和 4 的可用研究。這些研究包括交界處出血控制裝置的功效或不同品牌或型號止血帶的比較。關於 PICOTS 問題 5，有 4 項研究將止血帶使用的持續時間與不良事件相關聯，但沒有提供關於止血帶移除的時間和設置的具體信息。 27,30,32,33 因此，PICOTS 問題 5 的證據等級是評級為低
Tourniquet Use
We identified 20 publications of prehospital tourniquet use for trauma-induced extremity hemorrhage. However, four publications did not provide information on outcomes needed for inclusion in this report: Lairet et al.,20 Gerhardt et al.,21 Kragh et al.,22 Kragh et al.23 In two instances, the same study population was assessed in two separate publications. Kragh et al.24 and Kragh et al.25 used the same set of 499 patients and Kragh et al.26 and Kragh et al.27 used the same set of 232 patients. The 16 included publications are listed in Table 1 along with the setting in which the data on tourniquet use were collected and the outcomes reported by each study. The large majority of studies were conducted by the U.S. military in Iraq and Afghanistan (8 studies) with 3 studies from the U.K. military, 2 from the Israeli military, and 1 from Canadian military. Only 1 study was conducted in a civilian setting. One study used data on pediatric casualties described in the Joint Theater Trauma Registry and collected during the wars in Iraq and Afghanistan.28 Thirteen of the 16 included studies reported data on deaths, 11 reported data on adverse events, 8 reported data on amputations, and none reported data on shock.
Eight of the studies used prospective data collection. Most of the studies provided some information on how the tourniquets were to be used, but only a few were specific about the instructions. However, the studies from the U.S. military were using TCCC practices when data were collected after 2005 and tourniquets were likely used aggressively as a first option for traumatic extremity hemorrhage.
Comparisons between casualties treated with a tourniquet and similar casualties not treated with a tourniquet were attempted by only a few studies. Kotwal et al.29 reported the number of casualties treated with compression dressings but did not report outcomes for this group. Beekley et al.30 reported outcome data for tourniquet- and nontourniquet-treated casualties but did not report what prehospital treatments the nontourniquet group received. Clasper et al.31 matched surviving tourniquet-treated casualties with surviving nontourniquet-treated casualties to examine the rate of adverse events. These authors note, however, that “in a standard retrospective study it is likely that there would be considerable bias if simple comparison was made between the two groups as it is likely that those casualties with more severe injuries would have required a tourniquet, but those with a more severe injury are also likely to have worse outcomes and experience more complications.”31
Meta-analysis of the 9 studies reporting survival for adult military casualties treated with tourniquets demonstrated a summary effect size estimate for survival rate of 92% with 95% confidence intervals of 88–95%. Findings in the study of children were similar (92%, with CI 84–96%). The study of a civilian population was small (11 cases), so the confidence interval was wide, but the survival rate similar (91%, CI 56–99%). A similar analysis for 6 studies reporting amputation rates demonstrated a summary effect size estimate of 19% with a 95% confidence interval from 16–23%. These amputations are presumably primarily associated with the severity of the extremity injury, as they are not described as complications of tourniquet use. The overall quality of the evidence for PICOTS Question 1 was rated using the GRADE system as Moderate for survival based on upgrading due to the large effect size and Very Low for amputation rate (Table 2).
There were no studies available that directly addressed PICOTS questions 2, 3, and 4. These included the efficacy of junctional hemorrhage control devices or the comparison of different brand or models of tourniquets. Regarding PICOTS question 5, there were 4 studies that correlated duration of tourniquet use with adverse events but specifics were not provided on the timing and setting of tourniquet removal.27,30,32,33 Thus, the grade of evidence for PICOTS question 5 was rated as Low
止血帶的使用.實證醫學,證據等級分析
我們確定了 20 篇院前止血帶用於治療外傷性肢體出血的出版物。然而，有四份出版物沒有提供包含在本報告中所需的結果信息：Lairet 等人，20 Gerhardt 等人，21 Kragh 等人，22 Kragh 等人23 在兩個例子中，對同一研究人群進行了評估在兩個單獨的出版物中。Kragh 等人 24 和 Kragh 等人 25 使用同一組 499 名患者，Kragh 等人 26 和 Kragh 等人 27 使用同一組 232 名患者。表 1 列出了 16 篇納入的出版物，以及收集止血帶使用數據的環境和每項研究報告的結果。大部分研究是由美國軍方在伊拉克和阿富汗進行的（8 項研究），其中 3 項研究來自英國軍方，2 項來自以色列軍方，和 1 個來自加拿大軍方。只有一項研究是在平民環境中進行的。一項研究使用了聯合戰區創傷登記處描述的兒科傷亡數據以及在伊拉克和阿富汗戰爭期間收集的數據。28 16 項納入研究中有 13 項報告了死亡數據，11 項報告了不良事件數據，8 項報告了截肢數據，以及沒有報告關於休克的數據。
其中八項研究使用了前瞻性數據收集。大多數研究提供了一些關於如何使用止血帶的信息，但只有少數研究具體說明了使用說明。然而，美國軍方的研究在 2005 年之後收集數據時使用的是 TCCC 做法，止血帶可能被積極用作外傷性肢體出血的首選方法。
只有少數研究試圖對使用止血帶治療的傷員和未使用止血帶治療的類似傷員進行比較。Kotwal 等人 29 報告了接受加壓敷料治療的傷員人數，但未報告該組的結果。Beekley 等人 30 報告了使用止血帶和未使用止血帶的傷員的結局數據，但未報告未使用止血帶的患者接受了哪些院前治療。Clasper 等人 31 將接受止血帶治療的倖存傷員與未接受止血帶治療的倖存傷員進行匹配，以檢查不良事件的發生率。然而，這些作者指出，對報告接受止血帶治療的成年軍人傷員生存率的 9 項研究的薈萃分析表明，生存率的匯總效應量估計為 92%，95% 置信區間為 88-95%。對兒童的研究結果相似（92%，CI 84-96%）。對平民人群的研究規模較小（11 例），因此置信區間較寬，但存活率相似（91%，CI 56–99%）。對報告截肢率的 6 項研究進行的類似分析表明，總效應量估計值為 19%，95% 置信區間為 16-23%。這些截肢可能主要與肢體損傷的嚴重程度有關，因為它們沒有被描述為止血帶使用的並發症。
沒有直接解決 PICOTS 問題 2、3 和 4 的可用研究。這些研究包括交界處出血控制裝置的功效或不同品牌或型號止血帶的比較。關於 PICOTS 問題 5，有 4 項研究將止血帶使用的持續時間與不良事件相關聯，但沒有提供關於止血帶移除的時間和設置的具體信息。 27,30,32,33 因此，PICOTS 問題 5 的證據等級是評級為低
Tourniquet Use
We identified 20 publications of prehospital tourniquet use for trauma-induced extremity hemorrhage. However, four publications did not provide information on outcomes needed for inclusion in this report: Lairet et al.,20 Gerhardt et al.,21 Kragh et al.,22 Kragh et al.23 In two instances, the same study population was assessed in two separate publications. Kragh et al.24 and Kragh et al.25 used the same set of 499 patients and Kragh et al.26 and Kragh et al.27 used the same set of 232 patients. The 16 included publications are listed in Table 1 along with the setting in which the data on tourniquet use were collected and the outcomes reported by each study. The large majority of studies were conducted by the U.S. military in Iraq and Afghanistan (8 studies) with 3 studies from the U.K. military, 2 from the Israeli military, and 1 from Canadian military. Only 1 study was conducted in a civilian setting. One study used data on pediatric casualties described in the Joint Theater Trauma Registry and collected during the wars in Iraq and Afghanistan.28 Thirteen of the 16 included studies reported data on deaths, 11 reported data on adverse events, 8 reported data on amputations, and none reported data on shock.
Eight of the studies used prospective data collection. Most of the studies provided some information on how the tourniquets were to be used, but only a few were specific about the instructions. However, the studies from the U.S. military were using TCCC practices when data were collected after 2005 and tourniquets were likely used aggressively as a first option for traumatic extremity hemorrhage.
Comparisons between casualties treated with a tourniquet and similar casualties not treated with a tourniquet were attempted by only a few studies. Kotwal et al.29 reported the number of casualties treated with compression dressings but did not report outcomes for this group. Beekley et al.30 reported outcome data for tourniquet- and nontourniquet-treated casualties but did not report what prehospital treatments the nontourniquet group received. Clasper et al.31 matched surviving tourniquet-treated casualties with surviving nontourniquet-treated casualties to examine the rate of adverse events. These authors note, however, that “in a standard retrospective study it is likely that there would be considerable bias if simple comparison was made between the two groups as it is likely that those casualties with more severe injuries would have required a tourniquet, but those with a more severe injury are also likely to have worse outcomes and experience more complications.”31
Meta-analysis of the 9 studies reporting survival for adult military casualties treated with tourniquets demonstrated a summary effect size estimate for survival rate of 92% with 95% confidence intervals of 88–95%. Findings in the study of children were similar (92%, with CI 84–96%). The study of a civilian population was small (11 cases), so the confidence interval was wide, but the survival rate similar (91%, CI 56–99%). A similar analysis for 6 studies reporting amputation rates demonstrated a summary effect size estimate of 19% with a 95% confidence interval from 16–23%. These amputations are presumably primarily associated with the severity of the extremity injury, as they are not described as complications of tourniquet use. The overall quality of the evidence for PICOTS Question 1 was rated using the GRADE system as Moderate for survival based on upgrading due to the large effect size and Very Low for amputation rate (Table 2).
There were no studies available that directly addressed PICOTS questions 2, 3, and 4. These included the efficacy of junctional hemorrhage control devices or the comparison of different brand or models of tourniquets. Regarding PICOTS question 5, there were 4 studies that correlated duration of tourniquet use with adverse events but specifics were not provided on the timing and setting of tourniquet removal.27,30,32,33 Thus, the grade of evidence for PICOTS question 5 was rated as Low
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