You are called to the Emergency Room to aid in the care of a multiply injured trauma patient. The patient is a 24-year old black male who was involved in a high-speed motorcycle accident with a car. The second passenger on the motorcycle died at the scene. Upon primary survey, you find that your patient's c-spine is immobilized and strapped to a backboard. He has a bleeding de-gloving scalp laceration, multiple facial lacerations, a grossly distended abdomen, and an agonal breathing pattern. Attempts are being made to obtain intravenous access. At this time, he vomits and appears to aspirate. You proceed to attempt to secure the airway. Upon inspecting his face, however, it becomes clear that he has multiple facial fractures involving his mid-face.
How would you manage this injured patient?
从今天开始我们讨论多发伤。
急诊室打电话请您会诊一多发性创伤的患者。患者，男性，24岁，黑人，驾驶摩托车在高速行驶中与一汽车发生碰撞导致车祸。摩托车上的另一个乘客在车祸现场即死亡了，初步检查病人发现，患者被用皮带固定在木版上，颈椎固定。下颌部头皮裂伤并出血，面部多处损伤，腹部明显膨隆，濒死呼吸。医务人员正在试图建立静脉通道，此时，患者出现呕吐并发生误吸。您上前试图保持患者呼吸道通畅，然而在检查了患者的面部后，明确发现包括面中部的多处骨折。
您该如何处理该患者？
多发性创伤的患者的处理具有一定的挑战性。就像这个患者一样，似乎存在处理上的多处矛盾。然而，如果能保持镇静并对该多发伤患者采取全面评估和复苏治疗，事实上危重病患者的初期处理可以相对容易的做到。
在患者到达之前，应该安排一个明确的包括医生、护士、辅助人员在内的治疗小组。集中在这些提供的因素基础上，还有许多对该患者复苏成功起重要作用的因素。患者到来之前应该确定治疗组组长，同时每个成员必须清楚组长的任务。最后，救治系统或过程应该程序化和详细化。
在患者到来之后，治疗组长应该仔细听取急救医疗技术人员的报告，尤其是突出院前症状和治疗的细节，这些在判断患者受伤机制和其他信息具有决定性作用。例如，在该事件中，现场死亡的乘客的报告提示了受伤的严重机制。
为了处理更有效，加强创伤生命支持推荐了对创伤患者的系统性信息获得方法。最初观察包括了观察患者的呼吸道、呼吸、循环情况，此外患者的残疾或神经系统情况的快速观察很重要。为了恰当的观察到患者的全部情况，完全暴露是必要的。呼吸道必须确定保持通畅。对于清醒并保持自主呼吸的患者，可以不进行进一步的呼吸道处理；否则就必须进行气管插管。对于困难气道患者必须预先进行合理的人员和设备准备。对这个面部中央损伤的患者来说，必须进行环甲膜切开术。
一旦建立安全的呼吸道，注意力应该转向循环功能。应该对下颌部头皮伤的出血部位进行加压。在液体复苏建立情况下，应该寻找出血来源。仔细的体格检查是必要的，一些情况比如没有胸部X线检查情况下张力性气胸应该被诊断和治疗。
本系列的其他问题包括特殊的创伤管理事项。
How would you manage this injured patient?
The care of the multiply injured trauma patient can be challenging. As this patient exemplifies, multiple seemingly conflicting priorities are often present simultaneously. In fact, the initial care of the critically ill patient can be made relatively straightforward if one maintains poise and takes a structured approach to the evaluation and resuscitation of the multiply injured patient.
Before the arrival of the patient, a clearly defined team of physicians, nurses, and ancillary staff has to be assembled. Focusing on the provider factors, there are a number of factors that are important for the successful resuscitation of the trauma patient. A team leader has to be identified before the arrival of the patient. Each team member needs to know his/her role. Finally, the system or process of care has to be structured and detailed.
Upon arrival of the patient, the team leader should carefully listen to the report from the emergency medical technicians.
Salient details of the pre-hospital presentation and care aid in determining mechanism of injury and other information about the patient which would otherwise not be available. For example, as in this case, reported death of passengers at the scene suggests a severe mechanism of injury.
For the care to be effective, Advanced Trauma Life Support recommends a structured approach to the trauma patient. The primary survey consists of attention to the airway, breathing, and circulation of the patient. In addition, a quick survey of the patient's disability, or neurologic status, is important. To properly access the patient wholly, complete exposure of the patient is mandatory. The airway needs to be patent or a definitive airway needs to be obtained. For the patient who is awake and breathing spontaneously, no further airway management may be necessary. On the other hand, for patients who are compromised, intubation may be warranted. For the difficult airway, appropriate personnel and tools need to be assembled. For this particular patient with a mid-face injury, cricothyroidotomy may be necessary.
Once the airway is secured, attention can then be turned to circulation. Pressure should be applied to bleeding sites such as a de-gloving scalp wound. As fluid resuscitation is ongoing, an expeditious search for sources of bleeding should be made. A thorough physical examination is mandatory. Conditions such as tension pneumothorax should be diagnosed and treated without a Chest X-ray.
References:
1. Advanced Trauma Life Support
编辑：ache
