Hartford-consensus-compendium:
Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium
這篇共識指引幾乎算一本電子書了. 有92頁. 扣去沒內容的(目錄.專家名單.封面.大標題內頁)還有80頁, 看到頁數就不想念了...
這是美國外科醫學會共識會議的建議. 僅節錄部分內容. 下面中文使用google翻譯. 刪除線的中文字是google翻譯但我覺得不適當而修改的.
這是美國外科醫學會共識會議的建議. 僅節錄部分內容. 下面中文使用google翻譯. 刪除線的中文字是google翻譯但我覺得不適當而修改的.
過去14年的戰爭中我們得到的最重要的教訓之一就是，受傷後儘快使用止血帶和止血敷料絕對是可以挽救生命的。
民間止血帶
戰場和民間創傷的致傷劑(wounding agents)通常不同，但在出血控制和最佳復甦方面的經驗教訓相同。最近，美國外科醫師學會創傷委員會和美國運輸部工作小組評估了外部出血控制措施的證據。 此工作小組關於止血帶的結論是：
(1) 在院前環境中，當直接按壓無效或不切實際時，應使用商用絞盤式止血帶來控制大量肢體出血；
(2) 僅在沒有商用設備可用時才應使用簡易止血帶；
(3) 在院前環境中正確使用的血帶應在患者獲得確定性護理 確切照護(definitive care)之前不要鬆開。
(以前教學說30分鐘鬆開止血帶一下, 目前不建議間隔性鬆開止血帶)
關於止血劑的建議是：
（1）當持續直接加壓無效或不切實際時，應將局部止血劑與直接加壓結合使用，以控制院前環境中的大量出血；
（2）可使用紗布中的局部止血劑來加強傷口填塞。
用止血帶控制出血
自1975年越戰結束至2001年這26年間，院前出血控制幾乎沒有變化。因此，可預防的肢體出血死亡人數在近三十年中也未見變化。在戰術戰鬥傷亡救治委員會（CoTCCC）的止血帶建議廣泛實施後，對4,596名美國戰鬥死亡病例進行的10年回顧顯示，肢體出血導致的戰鬥死亡人數顯著下降。 3 肢體出血死亡人數的急劇下降，得益於現代止血帶和止血敷料在戰場上的廣泛使用，以及對各級急救人員進行有效使用這些敷料的積極訓練。 如前所述，早期使用止血帶可以很大程度上預防肢體出血導致的死亡。由於止血帶可有效控制出血且使用速度快，因此是在戰火紛飛的戰術環境中暫時控制危及生命的肢體出血的最佳選擇。這個概念也適用於平民領域，因為平民傷亡或槍擊事件日益增加。這些概念尤其適用於我國本土發生的恐怖分子爆炸事件。直接加壓和紗布加壓敷料可能有效；然而，缺乏專人進行持續的直接加壓、環境不安全以及可能導致失血的肢體損傷都是快速使用止血帶的指徵適應症(indications)。在常規緊急醫療服務 (EMS,或翻譯為緊急醫療系統) 護理中，對於大量外部出血，所謂的加壓敷料通常是不夠的，只有進行持續的直接手動加壓才有效。由於大多數民間急救醫療服務（EMS）人員受限，止血帶和止血敷料在醫療和後勤方面均有益。 5 儘管大量證據表明其在軍事經驗中獲益良多，但最近的數據表明，只有少數急救醫療系統正在使用推薦的商用止血帶和止血敷料來止血。儘管大量軍事出版物記錄了院前止血帶和止血敷料在戰鬥傷者救治中具有救命的功效且併發症發生率低，但這種情況仍然持續存在。雖然止血帶在患者因失血而休克之前儘早使用效果最佳，但這一點顯而易見。儘管過去急救醫療系統曾因擔心肢體缺血性損傷而不鼓勵使用止血帶，但這種併發症實際上非常罕見。長時間使用止血帶可能會導致截肢，但如果無法移除止血帶，則必須始終優先考慮患者的生命安全。由於其已被證實的救生價值，止血帶如今在現代戰場上隨處可見，然而，許多民用 EMS 系統的採用進展緩慢。儘管數量有限，但有報導稱，軍事上止血帶和止血敷料的使用正在逐漸被民用 EMS 和急救醫學實踐所採用。其中一個關鍵理念是，不僅要讓所有醫護人員，還要讓數量眾多的非醫務第一線反應人員都配備止血設備。在民間領域，許多警察和消防員現在都攜帶這些設備，使其能夠廣泛且快速地普及。對非醫護人員進行有效的止血設備訓練和使用，是減少可預防死亡的關鍵因素。對於肢體嚴重出血的患者，止血是當務之急。大多數肢體損傷不需要止血帶，但危及生命的出血患者則需要止血帶。與大多數創傷情況一樣，過度分診是可以接受的，因為在抵達醫院後，不需要的止血帶可以安全地移除。以下描述是適合使用止血帶的創傷受害者的範例：
•傷口有搏動性或持續性出血。
•血液在地上積聚。
•覆蓋的衣服被血浸透。
•用於包紮傷口的繃帶或暫時繃帶無效，並逐漸被血浸透。
•傷口有搏動性或持續性出血。
•血液在地上積聚。
•覆蓋的衣服被血浸透。
•用於包紮傷口的繃帶或暫時繃帶無效，並逐漸被血浸透。
•手臂或腿部有外傷性截肢
•之前曾有出血，患者現在處於休克狀態（昏迷、神誌恍惚、臉色蒼白）。
在治療因傷口出血而明顯休克的患者時，應先止血，然後進行液體復甦。有效的止血並不會隨著首次止血帶的應用而停止。軍隊使用止血帶的經驗提供了一些關於其使用的關鍵教學要點：
•等待太久才放置止血帶是錯誤的。
•止血帶應放置在嚴重出血部位的近端，切勿直接放置在關節上。
•應視需要收緊止血帶以止住遠端損傷的出血。
•如果一條止血帶無法止血，則應在第一條止血帶的近端使用第二條止血帶。
•當對較大的下肢使用止血帶時，尤其需要使用第二條止血帶。
•止血帶的作用是止住動脈出血。如果遠端脈搏仍然存在，則應收緊止血帶或在第一條止血帶的近端使用第二條止血帶，並再次檢查脈搏。
•如果使用止血帶，則應使用有效的動脈止血帶，而不是無效的靜脈止血帶，因為使用後者會增加出血。
•應定期重新檢查使用止血帶的傷員，以確保止血帶仍然有效且出血得到控制。
•應檢查每個止血帶遠端的脈搏。
•正確使用止血帶可能會引起劇烈疼痛，但這種疼痛並不表示止血帶使用不當或應移除止血帶。
•應酌情使用止痛藥控制疼痛，但休克患者不應使用止血帶。止血帶使用上的錯誤包括：•沒有有效的商用止血帶
•應該使用止血帶時不使用
•在輕微出血或少量出血時使用不應該使用的止血帶
•將止血帶綁得太近
•止血帶綁得不夠緊，無法有效止血•必要時不使用第二條止血帶
•等待太長時間綁上止血帶止血
應始終在患者身上記錄止血帶的使用時間，通常在患者額頭上寫上字母“T”，並註明收緊時間。應使用不褪色的墨水筆進行記錄，以確保這一重要資訊不會被洗掉或擦掉。這些資訊也應記錄在病患的使用記錄表上，並在醫院病歷中記錄止血帶的總缺血時間。最後，所有製造的止血帶均為一次性使用。應使用單獨的一組止血帶進行訓練，訓練用止血帶不應隨後發放用於實際傷員。
•之前曾有出血，患者現在處於休克狀態（昏迷、神誌恍惚、臉色蒼白）。
在治療因傷口出血而明顯休克的患者時，應先止血，然後進行液體復甦。有效的止血並不會隨著首次止血帶的應用而停止。軍隊使用止血帶的經驗提供了一些關於其使用的關鍵教學要點：
•等待太久才放置止血帶是錯誤的。
•止血帶應放置在嚴重出血部位的近端，切勿直接放置在關節上。
•應視需要收緊止血帶以止住遠端損傷的出血。
•如果一條止血帶無法止血，則應在第一條止血帶的近端使用第二條止血帶。
•當對較大的下肢使用止血帶時，尤其需要使用第二條止血帶。
•止血帶的作用是止住動脈出血。如果遠端脈搏仍然存在，則應收緊止血帶或在第一條止血帶的近端使用第二條止血帶，並再次檢查脈搏。
•如果使用止血帶，則應使用有效的動脈止血帶，而不是無效的靜脈止血帶，因為使用後者會增加出血。
•應定期重新檢查使用止血帶的傷員，以確保止血帶仍然有效且出血得到控制。
•應檢查每個止血帶遠端的脈搏。
•正確使用止血帶可能會引起劇烈疼痛，但這種疼痛並不表示止血帶使用不當或應移除止血帶。
•應酌情使用止痛藥控制疼痛，但休克患者不應使用止血帶。止血帶使用上的錯誤包括：•沒有有效的商用止血帶
•應該使用止血帶時不使用
•在輕微出血或少量出血時使用不應該使用的止血帶
•將止血帶綁得太近
•止血帶綁得不夠緊，無法有效止血•必要時不使用第二條止血帶
•等待太長時間綁上止血帶止血
應始終在患者身上記錄止血帶的使用時間，通常在患者額頭上寫上字母“T”，並註明收緊時間。應使用不褪色的墨水筆進行記錄，以確保這一重要資訊不會被洗掉或擦掉。這些資訊也應記錄在病患的使用記錄表上，並在醫院病歷中記錄止血帶的總缺血時間。最後，所有製造的止血帶均為一次性使用。應使用單獨的一組止血帶進行訓練，訓練用止血帶不應隨後發放用於實際傷員。
簡易旋轉柵門
非商用止血帶，或所謂的簡易止血帶，遠不如經過測試和建議的止血帶有效。 2001年阿富汗戰爭爆發時，美軍計畫使用簡易止血帶。然而，簡易止血帶被發現難以組裝和固定。軍事經驗表明，簡易止血帶有時會導致可預防的死亡。在戰爭初期出現不必要的死亡事件後，軍方改變了策略。到2005年，數千條商用止血帶已被送往戰場，由醫護人員和非醫務人員攜帶。 6 將這種經驗和教訓應用到民用領域至關重要。使用止血敷料控制出血
數千年來，人們一直使用各種形式的敷料來止血。 2001年阿富汗戰爭爆發時，美軍使用的紗布敷料自第一次世界大戰以來幾乎沒有改變。在阿富汗戰爭初期，人們開發出了止血敷料，這種敷料重量輕、耐用，止血效果遠勝於標準紗布。在聽取了經驗豐富的軍醫的大量回饋後，美國軍醫協會（CoTCCC）於2003年推薦了一種可以填塞到傷口內，但止血效果優於標準紗布的止血敷料。這些敷料通常與止血帶搭配使用，但對於不適合使用止血帶的傷口尤其有效。 8 研究表明，當出血部位不適合放置止血帶時，止血敷料是控制外部出血的有效輔助。與所有設備一樣，為了確保最大程度的有效性，止血敷料的使用需要經過訓練。關鍵在於確保正確的填塞方法和持續至少三分鐘的手動壓迫。單純施加止血劑而不維持壓力不足以達到最佳止血效果。之後，可以用標準加壓敷料覆蓋傷口和止血敷料。
止血帶和止血劑的選擇
民用急救系統在選擇止血劑時，需要注意的是，研究表明，儘管製造商宣傳和宣傳止血帶和止血劑的效果各不相同，但並非所有止血帶和止血劑都同樣有效。在伊拉克和阿富汗戰爭期間，美國國防部開發了標準化模型和技術，用於評估止血帶、止血敷料、交界性止血帶、胸腔封堵器以及其他用於院前創傷救治的物品。任何機構在購買院前創傷設備時，都應在選擇過程中參考此類文獻。任何選定的採購物品都應符合以下要求：(1) 價格合理；(2) 經過實驗室安全性和有效性測試；(3) 安全性和有效性經驗豐富。 止血帶和止血劑的選擇
個人和預先放置的創傷急救包
軍事經驗表明，至少應有兩類創傷設備：可供多人預先放置的大型急救包和供警官或急救員使用的小型移動急救包。所有專業急救員都應配備止血包。消防員和執法人員在救援時應隨身攜帶止血帶和止血敷料。救護車或直升機上的 EMS 設備應包括止血包。所有創傷中心的急診室都應配備這些設備。培訓至關重要。較大的預先放置的創傷包應放置在最佳位置，以便為當地事件或地點提供醫療服務。這些較大的急救包可在槍擊事件或大規模傷亡情況下滿足緊急需求。預先放置創傷包很有用的場所包括商場、電影院、學校和體育賽事。人們越來越認識到，止血包應放置在自動體外心臟去顫器旁邊。 One of the most important lessons learned in the last 14 years of
war is that using tourniquets and hemostatic dressings as soon as
possible after injury is absolutely lifesaving.
Tourniquets in the civilian setting
The wounding agents are usually different in battlefield and civilian trauma, but the lessons learned regarding hemorrhage control and optimal resuscitation are not. Recently, the American College of Surgeons Committee on Trauma and the U.S. Department of Transportation working group evaluated the evidence for external hemorrhage control measures.2 The group’s conclusions on tourniquets were that: (1) commercial windlass-type tourniquets should be used in the prehospital setting for the control of significant extremity hemorrhage when direct pressure is ineffective or impractical, (2) improvised tourniquets should be used only if no commercial device is available, and (3) a tourniquet that has been properly applied in the prehospital setting should not be released until the patient has reached definitive care. The recommendations on hemostatic agents were that: (1) topical hemostatic agents should be used in combination with direct pressure for the control of significant hemorrhage in the prehospital setting when sustained direct pressure is ineffective or impractical, and (2) topical hemostatic agents in a gauze can be used to enhance wound packing.
Hemorrhage control with tourniquets
In the 26 years between the end of the Vietnam War in 1975 and 2001, little changed in prehospital hemorrhage control. As a result, preventable deaths from extremity hemorrhage also did not change in almost three decades. After the widespread implementation of the tourniquet recommendations from the Committee on Tactical Combat Casualty Care (CoTCCC), a 10-year review of 4,596 U.S. combat fatalities noted a significant decrease in combat fatalities from extremity hemorrhage.3 The dramatic decrease in deaths from extremity hemorrhage resulted from the now ubiquitous fieldingof modern tourniquets and hemostatic dressings on the battlefield and aggressive training of all levels of responders in their effective use.4 As noted earlier, deaths from extremity hemorrhage can largely be prevented by early use of tourniquets. Because of their effectiveness at hemorrhage control and the speed with which they can be applied, tourniquets are the best option for temporary control of life-threatening extremity hemorrhage in the tactical environment when under fire. This concept can apply as well in the civilian arena, with its increasing number of mass casualty or active shooter events. These concepts become especially applicable in terrorist-style bombing events on our home soil. Direct pressure and gauze compression dressings can be effective; however, the lack of dedicated personnel to apply continuous direct pressure, a lessthan-secure environment, and extremity injuries that could lead to exsanguination are all indications for rapid tourniquet application. In routine emergency medical services (EMS) care, the so-called pressure dressing for massive external hemorrhage is frequently inadequate and only effective when continuous direct manual compression is applied. Because of the personnel constraints on most civilian EMS runs, tourniquets and hemostatic dressings are both medically and logistically beneficial.5 Despite the overwhelming evidence of benefit from the military experience, recent data indicate that only a few EMS systems are using recommended commercially manufactured tourniquets and hemostatic dressings for exsanguinating hemorrhage. This situation continues despite numerous military publications documenting the lifesaving benefit and low incidence of complications from prehospital tourniquets and hemostatic dressings used in combat casualties.Although it is somewhat obvious, tourniquets are most effective in saving lives when applied early, before the individual has gone into shock from blood loss.Although tourniquet use has been discouraged by EMS systems in the past because of concerns about ischemic damage to the extremity, this complication is actually very rarely seen. Prolonged use of a tourniquet can potentially result in amputation, but saving the life of the individual must always take precedence if the tourniquet cannot be removed. Because of their proven lifesaving value, tourniquets are now ubiquitous on the modern battlefield, yet adoption has been slow in many civilian EMS systems. Although limited, there are reports that the adoption of the military practice of tourniquets and hemostatic dressings into civilian EMS and emergency medicine practice is increasing. One of the key concepts that emerged was placing the hemorrhage control devices in the hands of not only all medical providers, but also the much more numerous nonmedical first-responding personnel. In the civilian sector, many police officers and firefighters now carry these devices, making them widely and rapidly available. Effective training in, and use of, hemorrhage control devices by nonmedical personnel has been a critical element in reducing preventable deaths. In patients with severe extremity bleeding, hemorrhage control is a priority. Most extremity injuries do not require tourniquets, but patients with life-threatening bleeding do require a tourniquet. As in most trauma situations, over-triage is acceptable, as tourniquets found not to be needed can be safely removed on arrival at a hospital. The following descriptions are provided as examples of trauma victims for whom tourniquet use is appropriate:
•There is pulsatile or steady bleeding from the wound.
•Blood is pooling on the ground.
•The overlying clothes are soaked with blood.
•Bandages or makeshift bandages used to cover the wound are ineffective and steadily becoming soaked with blood.
•There is a traumatic amputation of the arm or leg
•There was prior bleeding, and the patient is now in shock (unconscious, confused, pale).
When treating an individual who is in obvious shock from bleeding wounds, hemorrhage control should be the first priority, before fluid resuscitation. Effective hemorrhage control does not stop with the initial tourniquet application. The military experience with tourniquets has provided some key teaching points about their use:
•Waiting too long to place a tourniquet is a mistake.
•Tourniquets should be applied just proximal to the site of the severe bleeding and never placed directly over a joint.
•Tourniquets should be tightened as necessary to stop bleeding from the distal injury.
•If bleeding is not controlled with one tourniquet, a second tourniquet should be applied just proximal to the first.
•The need for a second tourniquet is especially applicable when applying tourniquets to generously sized lower extremities.
•The purpose of tourniquets is to stop arterial bleeding. If a distal pulse is still present, the tourniquet should be tightened or a second tourniquet applied just proximal to the first, and the pulse should be checked again.
•If a tourniquet is used, it should be an effective arterial tourniquet and not an ineffective venous tourniquet, as use of the latter can increase bleeding.
•Casualties with tourniquets in place should be rechecked periodically to ensure that the tourniquet is still working and that hemorrhage is controlled.
•Pulses distal to every tourniquet should be checked.
•Correctly applied tourniquets can cause significant pain, but this pain does not signify that the tourniquet has been applied incorrectly or that it should be removed.
•Pain should be managed with analgesics as appropriate, but not for patients in shock. Mistakes regarding tourniquets include the following: •Not having an effective commercial tourniquet available
•Not using a tourniquet when one should be used
•Using a tourniquet for minimal or minor bleeding when one should not be used
•Putting the tourniquet on too proximally
•Not making the tourniquet tight enough to effectively stop the bleeding •Not using a second tourniquet if needed •Waiting too long to put the tourniquet on
•Not reevaluating the tourniquet’s effectiveness
•Periodically loosening the tourniquet to allow blood flow into the injured extremity
The time when a tourniquet is applied should always be noted on the individual’s body, customarily by writing the letter T on the person’s forehead, along with the time that it was tightened. This notation should be done with an indelible ink marker to ensure that this important information does not wash or wipe off. The information should also be recorded on the individual’s run sheet and total tourniquet ischemia time recorded in the hospital chart. Finally, all manufactured tourniquets are designed for a single use. A separate group of tourniquets should be used for training, and training tourniquets should not subsequently be issued for actual casualty use.
Improvised tourniquets
Noncommercial, or so-called improvised, tourniquets are not nearly as effective as tested and recommended tourniquets. In 2001, at the start of war in Afghanistan, the U.S. military’s plan was to use improvised tourniquets. Improvised tourniquets have been found to be difficult to assemble and secure. Military experience has shown that improvised tourniquets sometimes result in preventable deaths. After unnecessary deaths early in the war, the military’s strategy changed. By 2005, thousands of commercial tourniquets had been sent to the battlefield and were carried by medical and nonmedical personnel.6 Transitioning this experience and lessons learned to the civilian arena is extremely important.7
Hemorrhage control with hemostatic dressings
Dressings in various forms have been used for thousands of years to help stop bleeding. At the start of the war in Afghanistan in 2001, the U.S. military used a gauze dressing that had not changed appreciably since World War I. Early in the war in Afghanistan, hemostatic dressings were developed that were lightweight, durable, and much more effective than standard gauze at stopping bleeding. After significant feedback from experienced military medics, in 2003 the CoTCCC recommended a hemostatic dressing that could be packed into a wound but that had hemostatic performance that was superior to standard gauze. These dressings were often used in conjunction with tourniquets but were especially useful in wounds not amenable to tourniquet use.8 Hemostatic dressings have been clearly shown to be a valuable adjunct in external hemorrhage control when the source of the bleeding is from a site not amenable to tourniquet placement. As with all devices, to ensure maximum effectiveness, the application of hemostatic dressings requires training. Critical elements are to ensure a correct packing technique and sustained manual compression for a minimum of three minutes. Simply applying the agents without maintaining pressure is not adequate to achieve the best possible hemostatic effect. Afterward, a standard pressure dressing can be applied to cover both the wound and the hemostatic dressing.
Selection of tourniquets and hemostatic agents
Selection of tourniquets and hemostatic agents
As civilian EMS systems make decisions about hemostatic agents, they need to be aware that research has shown that not all tourniquets and hemostatic agents are equally effective despite the manufacturers’ claims and advertising. During the wars in Iraq and Afghanistan, the Department of Defense developed standardized models and techniques for evaluating tourniquets, hemostatic dressings, junctional tourniquets, chest seals, and other items designed to be used in prehospital trauma care. A review of this literature should be part of the selection process for any agency making procurement decisions about prehospital trauma equipment. Any item selected for procurement should ideally be (1) reasonable in price; (2) laboratory tested for safety and effectiveness; and (3) experience proven for safety and effectiveness.
Individual and pre-positioned trauma kits
Military experience suggests that there should be at least two lists of trauma equipment: large kits that are pre-positioned for multiple people and smaller mobile kits for officers or first responders. All professional first responders should be equipped with bleeding control kits. Firefighters and law enforcement officers should carry tourniquets and hemostatic dressings in a kit on their person when responding. EMS equipment in the ambulance or helicopter should include hemorrhage control kits. All trauma centers should have these devices in their emergency departments. Training is paramount. Larger pre-positioned trauma kits should be placed at optimal locations for medical coverage of local events or locations. These larger kits would supply immediate needs in an active shooter event or mass casualty situation. Examples of locations where pre-positioned trauma kits would be of value are malls, movie theaters, schools, and sporting events. There is a growing recognition that the hemorrhage control kits should be positioned next to automated external defibrillators.
Recommendation
External hemorrhage control can be accomplished easily by welltrained and well-equipped people, whether they are professional first responders or civilians. Tourniquets and hemostatic dressings should reduce preventable deaths from external hemorrhage in the civilian sector, just as they have done in the military. The recommendations for early effective hemorrhage control with commercial devices are important and similar to those of the CoTCCC, the U.S. military, the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Technicians, and the Hartford Consensus III. The lessons learned in early hemorrhage control have been gained and applied in the crucible of battle. Widespread application of tourniquets and hemostatic dressings for hemorrhage control after civilian injury will save lives.
