剛在FB看到有網友貼Stop the Bleed 中文翻譯
稍微查詢一下資料. 並更新筆記
另一篇相關筆記在這
底下內容來自 UPTODATE 網站的不同章節
Severe lower extremity injury in the adult patient
Techniques for lower extremity amputation
Complications of total knee arthroplasty
下面是GOOGLE翻譯
Severe lower extremity injury in the adult patient
出血的控制 — 肢體的外部出血，尤其是肢體血管系統交界段（即股總動脈）的出血，會危及生命，應盡快控制[33 ] 。
下肢血管損傷引起的出血通常可以使用直接壓力來控制。然而，由於在院前或戰術環境中轉運過程中長時間施加直接壓力通常不切實際，因此使用了其他方法，包括局部藥物、外部壓力夾和血管內閉塞裝置 [33 ]。這些方法在主流民用臨床實踐中並未被廣泛接受，但已在院前環境中得到美國外科醫師學會的認可 [ 33 ]。
也可以使用止血帶 [ 34,35 ] 或直接夾住可見血管來控制出血。不能夾持不能清楚識別的血管不應 進行 。氣動止血帶通常用於減少肢體手術期間的出血。民間社區對使用止血帶控制肢體出血重新產生了興趣 [ 36 ]。ATLS 贊同明智地使用止血帶治療主要的肢體動脈出血，現在一些民用指南包括止血帶應用作為在直接壓力不成功時控制肢體出血的臨時輔助手段 [ 32,37,38] 或在戰術平民事件期間，這些事件可能會造成彈道或爆炸性傷害（例如，主動射手對峙）[ 39 ]。
已經開發出多種止血帶來治療與戰鬥相關的肢體出血，並且發生缺血和神經系統並發症的風險較低 [ 40,41 ]。戰鬥應用止血帶 (CAT)、緊急和醫療止血帶 (EMT) 和特種作戰部隊戰術止血帶 (SOFTT) 符合美國軍方的有效性標準，並在 >80% 的受試者中阻斷遠端血流 [40,41 ]。這些止血帶的相對有效性已經在人類誌願者中進行了評估，每一種止血帶都顯示出可以減弱四肢的遠端動脈脈搏 [ 42 ]。以下對戰鬥傷亡人群的研究說明了使用止血帶的好處：
●在一項評估了 165 名患者（其中 67 名在院前使用了止血帶）的研究中，與未使用止血帶相比，使用止血帶顯著改善了出血控制（83.3% 對 60.7%），並且二次截肢率沒有差異[40 ]。
●一項針對 232 名戰鬥傷員的前瞻性研究發現，與不使用止血帶相比，使用止血帶（院前或急診）可顯著提高存活率 (77% vs 0%) [41 ]。在這項研究中，沒有因使用止血帶而需要截肢，但報告了四例短暫性神經麻痺。
在院前和院內應用止血帶的平民患者中也證實了類似的結果 [ 43-45 ]。在一項對院前止血帶用於四肢平民創傷的 AAST 多中心前瞻性分析中，院前止血帶的應用被廣泛且安全地採用，並且與休克到達發生率降低相關，而不會增加肢體並發症 [46,47 ]。
Control of hemorrhage — External bleeding from the extremity, and particularly bleeding from the junctional segment of the extremity vasculature (ie, common femoral artery), is life-threatening and should be controlled as soon as possible [33].
Bleeding from lower extremity vascular injury can usually be controlled using direct pressure. However, because prolonged application of direct pressure is often not practical during transport in the prehospital or tactical environment, other approaches have been used including topical agents, external compression clamps, and endovascular occlusion devices [33]. These methods are not widely accepted in mainstream civilian clinical practice but have been endorsed by the American College of Surgeons in the prehospital setting [33].
Bleeding can also be controlled using a tourniquet [34,35] or direct clamping of visible vessels. Clamping vessels that cannot be clearly identified should not be performed. Pneumatic tourniquets are commonly used to lessen bleeding during extremity surgery. There is renewed interest in the civilian community in the use of tourniquets for control of extremity hemorrhage [36]. ATLS endorses the judicious use of a tourniquet for major extremity arterial hemorrhage, and several civilian guidelines now include tourniquet application as a temporary adjunct to control extremity hemorrhage when direct pressure is unsuccessful [32,37,38] or during tactical civilian events, which are situations where ballistic or explosive wounds are possible (eg, an active shooter standoff) [39].
A variety of tourniquets have been developed to manage combat-related extremity hemorrhage with a low risk of ischemia and neurologic complications [40,41]. The Combat Application Tourniquet (CAT), Emergency and Medical Tourniquet (EMT), and Special Operations Forces Tactical Tourniquet (SOFTT) meet the effectiveness standard of the United States military and occlude distal flow in >80 percent of subjects [40,41]. The relative effectiveness of these tourniquets has been evaluated in human volunteers with each shown to attenuate the distal arterial pulse in the extremities [42]. The benefits of tourniquet application are illustrated in the following studies in combat casualty populations:
●In a study that evaluated 165 patients, 67 of whom had a prehospital tourniquet applied, control of bleeding was significantly improved with tourniquet application versus no tourniquet (83.3 versus 60.7 percent), and there were no differences in secondary amputation rates [40].
●A prospective study of 232 combat casualties found a significantly improved survival rate (77 versus 0 percent) when using a tourniquet (prehospital or emergency department) versus no tourniquet [41]. In this study, no amputations were required due to tourniquet use, but four transient nerve palsies were reported.
Similar results have been demonstrated in civilian patients with both pre-hospital and in-hospital tourniquet application [43-45]. In an AAST multicenter prospective analysis of prehospital tourniquet use for extremity civilian trauma, prehospital tourniquet application was being widely and safely adopted and was associated with decreased incidence of arrival in shock without increasing limb complications [46,47].
另一個章節 Techniques for lower extremity amputation
下面是GOOGLE翻譯.
下肢截肢技術
止血帶 — 止血帶已被證明可以減少術中失血，並減少膝上和膝下截肢術後輸血的需要 [ 14 ]。然而，止血帶對因肢體缺血而接受截肢術的患者可能作用不大。
要使用止血帶，首先使用彈性壓縮（例如，Esmarch）對肢體放血，然後通常在大腿近端（膝上和膝下截肢）或小腿（足部截肢）放置無菌止血帶並吹氣至收縮壓的1.5～2.0倍。如果有相關的軟組織感染，則省略放血。
標準技術 —— 在對下肢缺血患者進行下肢截肢時，特定的手術技術可最大限度地減少組織缺血，這些做法同樣適用於下肢灌注正常的患者的下肢截肢，例如肢體損傷的年輕患者或患者患有 Charcot 足畸形。
●輕輕地處理軟組織。
●通過保持手術刀垂直於皮膚表面避免皮膚和組織的斜面。
●不要將皮膚與下面的筋膜分開，以防止皮瓣缺血。
●使用皮膚鉤或細齒鉗縮回皮膚，不要壓碎器械（例如 Debakey 鑷子）。一些外科醫生僅依靠輕柔的手指回縮。
●解剖命名的動脈和靜脈，彼此分開，分別結紮和分開，以防止動靜脈瘺的形成。監督主要動脈並在更近端結紮它們。簡單結紮足以用於閉塞或部分閉塞的血管（最小流量）。對於大多數靜脈，簡單的結紮就足夠了。
●將神經結紮在其橫斷點的近端，以盡量減少神經束膜的出血，並在負重表面近端急劇橫斷神經，以避免神經瘤的發展，神經瘤可導致慢性殘肢痛。目標肌肉神經再支配和再生性周圍神經界面是減少術後神經瘤形成的備選方案 [ 15-17 ]。
●通過使用縫合結紮止血來盡量減少電烙術的使用。
●避免在承重表面上產生手術疤痕（新的或舊的）。
●通過在皮膚和骨骼切面之間插入肌肉和筋膜來防止疤痕收縮。
●近似無張力的皮瓣。用單絲縫合線或釘書釘閉合皮膚是可以接受的。
●避免過度修剪小狗耳朵或其他輕微的外觀違規行為。雖然大量多餘的軟組織會干擾假體的正確貼合，但輕微的不規則會重塑。
●解剖完成後徹底沖洗傷口，以清除任何碎屑或骨碎片。
●使用肌成形術（將拮抗肌群縫合固定到骨上）或肌固結術（將肌肉縫合到骨膜上）穩定拮抗肌群，以防止肌肉萎縮和骨骼錯位 [18 ]。
●斜角骨突和銼刀鋒利的邊緣光滑。
●避免過多的骨膜剝離，以防止環死骨或骨質過度生長。
●用間斷的可吸收縫合線逐層關閉截肢殘端。使用皮膚釘與感染風險增加有關 [ 19 ]。
Tourniquets — Tourniquets have been shown to reduce intraoperative blood loss and decrease the need for postoperative blood transfusion in above-knee and below-knee amputations [14]. However, tourniquets are probably of little benefit in patients undergoing amputation for extremity ischemia.
To use a tourniquet, the extremity is first exsanguinated using elastic compression (eg, Esmarch), followed by placement of a sterile tourniquet usually in the proximal thigh (above-knee and below-knee amputation) or calf (foot amputations) and insufflated to 1.5 to 2.0 times the systolic pressure. Exsanguination is omitted if there is associated soft tissue infection.
Standard techniques — Specific surgical techniques minimize tissue ischemia when performing lower extremity amputation in patients with lower extremity ischemia, and these practices are equally applicable to lower extremity amputation in patients with normal lower extremity perfusion, such as the younger patient with extremity injury or a patient with a Charcot foot deformity.
●Handle the soft tissues gently.
●Avoid beveling of the skin and tissues by maintaining the scalpel perpendicular to the skin surface.
●Do not separate the skin from the underlying fascia to prevent ischemia of the skin flaps.
●Use skin hooks or fine-toothed forceps to retract the skin, and not crushing instruments (eg, Debakey forceps). Some surgeons rely only on gentle finger retraction.
●Dissect named arteries and veins free from one another and ligate and divide each separately to prevent arteriovenous fistula formation. Oversew major arteries and ligate them more proximally. Simple ligation is adequate for occluded or partially occluded vessels (minimal flow). Simple ligation suffices for most veins.
●Ligate nerves just proximal to their point of transection to minimize bleeding from the perineurium and transect the nerve sharply proximal to the weight-bearing surface to avoid the development of neuroma, which can lead to chronic stump pain. Target muscle reinnervation and a regenerative peripheral nerve interface are alternative options to consider to decrease postoperative neuroma formation [15-17].
●Minimize the use of electrocautery by using suture ligatures for hemostasis.
●Avoid creating surgical scars (new or old) on the weight-bearing surface.
●Prevent scar retraction by interposing muscle and fascia between the skin and cut surface of bone.
●Approximate skin flaps without tension. Skin closure with either monofilament sutures or staples is acceptable.
●Avoid excessive trimming of small dog-ears or other minor cosmetic irregularities. Although a large amount of redundant soft tissue will interfere with proper prosthetic fit, minor irregularities will remodel.
●Irrigate the wound thoroughly once the dissection is complete to remove any debris or bony fragments.
●Stabilize antagonistic muscle groups using myoplasty (suture fixation of antagonistic muscle groups to bone) or myodesis (suturing the muscle to the periosteum) to prevent muscle atrophy and skeletal misalignment [18].
●Bevel bony prominences and file sharp edges smooth.
●Avoid excessive periosteal stripping to prevent ring sequestra or bony overgrowth.
●Close the amputation stump in layers with interrupted absorbable sutures. The use of skin staples has been associated with an increased risk for infection [19].
下面是第三個章節
下面是第三個章節
Complications of total knee arthroplasty
Peroneal nerve palsy — The most common severe neurologic complication after TKA is peroneal nerve palsy [14].
Clinical manifestations of peroneal nerve injury include paresthesia, numbness, and extensor weakness (ie, foot drop) (table 1). Patients at highest risk are those with severe valgus deformity or flexion contracture. Intraoperatively, the nerve can be damaged by stretching due to correction of a valgus deformity or flexion contracture, inappropriate placement of a lateral retractor, or prolonged tourniquet time >120 minutes. However, studies indicate that nerve injury from tourniquet use is quite rare, especially when used at lower tourniquet pressures and for shorter time periods [15,16]. Postoperatively, the patient can develop a peroneal nerve palsy from swelling, hematoma, or direct compression of the nerve (eg, leg externally rotated lying in bed). Additionally, patients with previous spinal pathology may be more likely to develop peroneal nerve palsy due to the "double-crush phenomenon." Initial management includes loosening tight dressings and flexing the knee to 30 degrees to relieve pressure on the nerve. Radiographs should also be ordered to ensure no prosthetic-related issues. Fortunately, the majority of patients have complete improvement in 12 to 18 months [14,17]. (See "Foot drop: Etiology, diagnosis, and treatment".)
Tourniquet-related ischemic injury — Tourniquet use, commonly used in TKA to reduce intraoperative blood loss, has been associated with ischemic injury [18]. Nevertheless, tourniquets are widely used and generally considered safe for TKA [19]. Higher cuff pressures and longer duration of cuff use are associated with increasing complications. Thus, the tourniquet should be used at the lowest pressure and for the least ischemic time possible. Some surgeons use 100 mmHg above systolic blood pressure (BP), while others may use twice the systolic BP as their cuff pressure setting. (See "Total knee arthroplasty", section on 'Tourniquet use' and "Clinical features and diagnosis of acute lower extremity ischemia".)
下面是第四個章節-成年患者的嚴重上肢損傷
肢體出血的控制 — 對於無法通過直接壓力充分控制的上肢出血，回顧性研究表明，肢體止血帶可減少出血且並發症發生率較低[ 6-8 ]。
氣動止血帶 (PT) 通常用於減少擇期上肢手術期間的出血。它們也可用於急診室以控制肢體出血，從而提高患者的生存率 [ 9,10 ]。標準 PT 可用於控制上肢腋窩遠端的出血。PT 的充氣壓力應小於 250 mmHg，如果可能，PT 袖帶應放置在距開放性傷口至少 5 cm 的位置。PT 不應連續充氣超過兩個小時，以避免缺血並發症 [ 6-8 ]。患者應前往手術室快速控制出血。
在院前或軍事環境中，最常用的止血帶是無風式戰鬥應用止血帶 (CAT) 或特種部隊戰術止血帶（SOFT-T wide）。如有必要，可以用一隻手快速塗抹這些。在一項回顧性研究中，對上肢應用 CAT 的軍人中有 94% 實現了出血的絕對控制，並且沒有死亡報告 [11 ]。美國軍方的戰術戰鬥傷員護理委員會定期審查商用止血帶的性能 [ 12 ]。對於腋窩處的交界性傷口，建議使用傷口包紮，最好使用止血敷料，並持續加壓 [ 13]]. 市場上有一些交界性止血帶，但目前沒有足夠的證據推薦使用它們。此外，據報導，在戰場上，對腋窩應用專門的止血帶可以控制腋窩（交界處）出血 [ 14 ]。
Control of extremity hemorrhage — For upper extremity hemorrhage that is not adequately controlled with direct pressure, retrospective studies have shown that extremity tourniquets reduce bleeding with a low rate of complications [6-8].
Pneumatic tourniquets (PTs) are commonly used to reduce bleeding during elective upper extremity surgery. They can also be used in the emergency department setting to control extremity hemorrhage to improve patient survival [9,10]. Standard PTs can be used to control hemorrhage in the upper extremity distal to the axilla. The inflation pressure of the PT should be less than 250 mmHg, and the PT cuff should be placed at least 5 cm proximal to the open wound, if possible. The PT should not be inflated continuously for more than two hours to avoid ischemic complications [6-8]. The patient should proceed to the operating room for rapid hemorrhage control.
In the prehospital or military setting, the most commonly used tourniquets are the windless style Combat Application Tourniquet (CAT) or Special Forces Tactical Tourniquet (SOFT-T wide). These can be applied rapidly with one hand, if necessary. In a retrospective study, 94 percent of the service personnel who had applied a CAT to the upper extremity achieved absolute control of hemorrhage, and no deaths were reported [11]. The Tactical Combat Casualty Care Committee of the United States military routinely reviews the performance of commercial tourniquets [12]. For junctional wounds at the axilla, wound packing, ideally with a hemostatic dressing, along with continuous pressure is recommended [13]. There are some junctional tourniquets on the market, but there is insufficient evidence to recommend their use at this time. Also, in the battlefield, application of a specialized tourniquet to the axilla has been reported to control axillary (junctional) hemorrhage [14].
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