Emergency medical treatment is the process of implementing emergency ambulance treatment for sudden injuries to people caused by various factors. These factors include natural or man-made disasters, accidents, military conflicts, etc. The Wenchuan earthquake of May 12, the snowstorm in the southern region, the spread of SARS in 2003, as well as mining accidents, serious traffic accidents, floods, etc. are all fresh in our minds. For surgeons and anesthesiologists, the key task in emergency medical treatment is the emergency treatment of traumatized people. It is necessary for anesthesiologists to deeply understand and think about how to reduce the degree of injury to the lowest possible level, how to complete the rescue and treatment tasks more effectively, and what countermeasures need to be prepared, and to guide and implement them into the specific preparation work.
I. The main characteristics of trauma patients in emergency medical treatment
(i) Injury characteristics
1.Suddenness Usual accidental disasters, accidents and war or military conflicts are often sudden situations, the rescue and treatment forces are not sufficiently prepared, the on-site emergency conditions are very poor, and the injured usually have difficulty in obtaining timely and good early rescue.
2, complex and serious injuries serious natural disasters, including human damage is usually destructive, the rapid development of modern industry and transportation, as well as modern warfare in the increasing lethality of weapons and the application of new weapons, therefore, in many emergency medical treatment will face more complex injury type injury category, the proportion of seriously injured increased and other phenomena.
3.Diverse injury-causing factors Ordinary trauma is mostly seen in traffic accidents, falls from height, crush injuries, etc.. In addition to firearms injuries, burns, shock waves, nuclear radiation, chemical agents and biological weapons, as well as laser, microwave, infrasound and other “new concept weapons” may become wartime injury-causing materials.
4, casualties in batches Severe disasters, large-scale accidents, military conflicts and other emergencies can cause a large number of casualties, in a short period of time and the need for concentrated casualty treatment, coupled with the complexity or severity of the injury and many other factors, often exceed the capacity of ambulance personnel and material requirements.
(ii) Graded treatment
Most of the treatment of trauma patients may be completed in one medical institution. However, in serious or large-scale accidents or emergencies, or under war conditions, due to objective factors such as insufficient manpower and limited conditions, the treatment process for the wounded (especially the seriously wounded) must be separated from time and place, and be divided and implemented by multiple treatment institutions to complete together.
The graded treatment is a basic principle of both war wound treatment and emergency medical treatment in remote areas or under conditions of lack of medical resources. The essence is: the combination of medical and evacuation. That is, the hierarchical division of labor on treatment, before and after the continuous; technically from low to high, gradually perfect.
Second, the task of anesthesiologists in emergency medical treatment
In the early stage of emergency medical treatment tasks, due to factors such as transportation and time urgency, ambulance personnel are usually assembled and dispatched in batches, the early rescue personnel in place are bound to face the task of rescue and treatment forces are extremely incompatible with the situation, must require all ambulance personnel need to have a variety of knowledge and capabilities, anesthesiologists should have the basic injury analysis and assessment capabilities.
(i) Analysis and assessment of injuries
Anesthesiologists should master the principles of casualty classification and at least one kind of trauma scoring method, so as to correctly judge the injury condition and choose anesthesia methods and drugs. Casualty classification is the key to improve and ensure the efficiency of treating batches of casualties. Correct classification can make full use of the limited medical personnel and treatment force, so that those who can obtain the greatest medical effect from the initial care at the scene can receive priority treatment.
(ii) The assessment and replenishment of blood volume
1. Methods of estimating blood loss.
(1) Estimated according to clinical performance: usually divided into four levels.
Grade I Blood loss is about 15% of the total blood volume in the body (>750ml). The main clinical manifestations are increased pulse rate, normal blood pressure and respiration. Grade II
Grade II Blood loss of 15% – 30% of total body blood volume (750-1,500 ml). The patient is agitated, pulse rate > 120 beats/min, respiration is accelerated, systolic blood pressure is decreased, pulse pressure difference is reduced, capillary refill test is > 2 seconds, urine output is normal.
Grade III Blood loss of 30% – 40% of total blood volume (1,500 – 2,000 ml). Clinical symptoms are more severe than grade II, with altered mental status, oliguria, etc.
Grade IV: Blood loss of more than 40% of the total blood volume (> 2,000 ml). Patients often show drowsiness, confusion or even coma, blood pressure below 7 kPa or undetectable, and no urination.
(2) Estimation according to the site of fracture: the amount of blood loss generally caused in unilateral closed fractures at different sites is approximately.
①Pelvis: 1,500-2,000 ml;
② Ilium: 500-1,000 ml;
③Femur: 800-1,200 ml;
④Tibia: 350-500ml;
⑤Humerus: 200-500ml;
⑥Ulnar and radius: 300ml;
⑦Single rib: 100-150ml.
It should be increased appropriately for patients with open trauma or multiple injuries.
(3) According to the chest X-ray: the bleeding volume of hemothorax can be estimated, the patient takes the film in standing or sitting position, if the angle of rib diaphragm disappears on one side, it indicates that the bleeding volume is about 500ml; if the upper boundary of one side reaches the level of lung door, the bleeding volume reaches 500-1,000ml; if it reaches the top of one side of the chest, the bleeding volume reaches about 1,500-2,000ml.
(4) According to the size and depth of the trauma: it is generally believed that the blood loss from a surface trauma of one hand area or a deep trauma of one fist is equivalent to 10% of the blood volume.
2.Replenishment of blood volume
(1) Time, amount and type More and more clinicians have now recognized that the time of starting volume therapy is equally important as the amount of supplementation, as well as the type of infusion. Misconceptions such as not choosing the type of infusion but emphasizing the earlier the better and using too much crystalloid solution should be avoided as much as possible.
This concept of “delayed resuscitation” is of obvious benefit to those who can be effectively intervened during the “golden” time in the early stage of trauma treatment, and it can well avoid the effects of volume therapy on the body’s internal environment (especially the coagulation mechanism). The concept of “resuscitation” has obvious benefits for casualties who can be effectively intervened during the “golden” time of trauma treatment. In terms of the choice of the type of infusion, the previous situation of having no liquid to choose from has been completely changed, and the application of colloidal solutions (such as hydroxyethyl starch, gelatin, albumin, dextrose, and crystalloid mixture with hypertonic effect) and blood components should be considered in time and ensure that they occupy a certain proportion.
(2) Hypertonic solution Hypertonic sodium chloride has the advantages of rapid volume expansion, obvious hemodynamic improvement, small infusion volume and easy to carry, which is especially suitable in pre-hospital rescue treatment. The dosage advocated in the past was about 200ml of 7.5% NaCl (3-4mg/Kg). In recent years, domestic scholars have successfully developed 4.2% hypertonic sodium chloride and hydroxyethyl starch synthetic solution (trade name: Hom, 250ml/bottle), which has obvious clinical effect and is suitable for early treatment of hypovolemic patients.
(3) Application of alkaline drugs The use of sodium bicarbonate in early volume resuscitation of trauma is not routine. The application of alkaline drugs is necessary only when blood gas analysis confirms the presence of severe acidosis.
(iii) Determination of the timing of surgery
The anesthesiologist should actively participate in the preoperative preparation of the trauma patient to maintain the patient’s blood volume at a level that is stable in circulation and can tolerate anesthesia and surgery as much as possible. However, in case of serious bleeding or bleeding that is difficult to be controlled non-operatively, resuscitation measures should be actively carried out under the premise of maintaining basic vital signs, and surgery should be performed as early as possible, and resuscitation treatment should be actively carried out after the blood loss is controlled. It is inappropriate to overemphasize the vital signs to meet the ideal conditions and ineffective rescue or interference with the internal environment, delaying the best time or putting the rescue in a passive and undesirable situation.
(iv) Vital sign support and maintenance
Anesthesiologists are the clinicians with the most practical medical characteristics. In addition to the theoretical knowledge of multidisciplinary patient treatment and management, what is more important is the respiratory and circulatory management ability and practical operation ability created in their usual work.
In the early stage of emergency medical treatment, the anesthesiologist’s arterial and venous puncture and placement techniques, blood and fluid transfusion management, oxygen therapy knowledge, critical care monitoring ability, and airway management ability play an important role in many occasions.
(v) Early analgesia
Pain is a subjective sensation associated with tissue damage or potential tissue damage. Pain caused by trauma not only increases the pain of the injured person, but also can cause a strong stress response in the pole body, which affects the normal physiological and psychological functions of the patient, causing emotional tension, excitement, insomnia, severe blood pressure fluctuations and pulse changes, accelerated breathing, shallow breathing amplitude, and weak cough, which are not conducive to the patient’s postoperative recovery.
Commonly used analgesics are morphine, pethidine, fentanyl, dihydroetorphine and local anesthetics such as lidocaine, dicaine and bupivacaine; they can be administered orally, contained, intramuscularly or intravenously, locally and regionally by blocking methods. In recent years, the Patient Control Analgesia (PCA) device has been applied in China for patient transfer or postoperative analgesia.
Anesthesia strategy for emergency medical treatment
(i) Basic ideas
1.The principle of independence Unlike the usual in-hospital treatment or out-of-hospital consultation and rounds, emergency medical treatment has obvious independence. Due to the limitations of the surrounding environmental conditions, or the lack of local medical resources or severe trauma and other factors, emergency medical treatment personnel to a large extent it is difficult or even impossible to rely on the medical resources of the rescue site. Emergency medical treatment team of each constituent profession should be well prepared to ensure that the main work of the profession can be carried out smoothly, in addition to the rescue team should have sufficient personnel and material preparation in the overall comprehensive survivability, including logistical support.
As far as the anesthesia profession is concerned, how to anesthesia, analgesia and resuscitation of the wounded under field conditions, and how to pre-prepare and rehearse based on the basic requirements of wartime field anesthesia is indeed a problem worth studying.
2.Flexible and mobile principle In fact, the treatment of batches of casualties caused by various emergencies has many commonalities with the treatment of combat trauma casualties under war conditions. When the early treatment of trauma casualties does not arrive at the regular hospital with good conditions in time, it must be carried out at the scene or nearby, and requires strong mobility. The basic requirements of field anesthesia are
①Effective;
②Easy to operate;
③A wide range of safety;
④Lightweight equipment and adequate security;
⑤ rapid onset of action, fast awakening, anesthesia after-effects are small.
3.Standard treatment principle According to the basic treatment principle of disaster medicine, the level and standard of treatment under field conditions should be no less than usual, and all treatment measures should be the usual medical practice.
(ii) the characteristics of anesthesia work
1, anesthesiologists are responsible for the same as usual, namely
1, to ensure the safety of the injured person’s life;
2.Reducing or eliminating the pain and suffering of the casualty;
3, to create suitable conditions for surgery (muscle relaxation, stable and clear surgical field, stable vital signs of the casualty, improvement of the internal environment, etc.).
2, the choice of anesthesia methods and drugs mainly depends on.
1.The local conditions at that time;
2, the availability of anesthesia facilities, monitoring conditions;
3, the skills and experience of the anesthesiologist;
4.Injury site and injury condition;
5.The type and scope of surgery, duration, etc.
3.The influence of the development of medical understanding and technology level of trauma treatment With the development of society and the changes of medical conditions and concepts, the selection and application of anesthesia methods under field conditions also undergo obvious changes.
For example, in the 1950s during our army’s resistance to the United States and aid the DPRK, the early surgery in the division and regiment ambulance station was mainly for clearing trauma, and most of them used procaine local anesthesia; in the 1960s in the counterattack on the Sino-Indian border, there was little change; in the late 1970s in the counterattack on Vietnam, due to the strengthening of the guard and security, the forward movement of the specialist surgery team and the improvement of the evacuation conditions, the types of surgery in the first-line hospital increased, and mainly used ketamine-scopolamine intravenous compound anesthesia, while local anesthesia was significantly reduced, and inhalation anesthesia was basically not used.
In the local wars under modern high-tech conditions since the Gulf War, the gap between war trauma treatment and normal trauma treatment is narrowing. In the emergency medical treatment of this big earthquake, the modern capability of military field treatment was fully demonstrated.
(iii) Wenchuan rescue and treatment model
Less than 2 hours after the Wenchuan earthquake, the emergency medical treatment teams of military medical universities and general hospitals at all levels were assembled and ready to set off in full gear. This efficient and rapid response is obviously closely related to the training and adequate preparation for military emergency preparedness for a long time. The military emergency medical treatment teams distributed throughout the disaster area are basically standardized and established, with personnel and material preparation, logistical support, field survival and mobility significantly better than most local hospitals.
Many medical teams have successfully applied wound ticket triage techniques to large batches of early casualties in accordance with combat wound treatment procedures. The Third Military Medical University Institute of Field Surgery, Daping Hospital in Deyang Hospital, which was the first to arrive in the disaster area outside the province, also creatively integrated a number of local private small medical teams and volunteers from outside to form a joint rescue and treatment force.
Whether from the mobility, response speed, or from the staffing, material preparation, logistical support, etc., the successful experience of the army’s various emergency medical treatment teams is worthy of recognition.
Our experience is that
1, the number of anesthesiologists equipped with not less than 20% of the total number of surgeons is appropriate; dispatched personnel must have excellent physical quality, have sufficient mental preparation for the hardships of life.
2.Preparation of material and equipment The material, equipment and medicine are prepared in accordance with the base of 20 operations per operating table day and night and 10 days as a cycle in wartime.
1, operating table: most of the troops equipped with surgical car is domestic Changfeng 607 series anesthesia machine (volatile tank for isoflurane), after the deployment of 2 surgeries can be carried out at the same time. Those who do not have a standard operating vehicle should use a large tent as the operating room, at least 2 operating tables are required.
2, anesthesia drugs: according to the base of rescue, according to the usual anesthesia program and clinical use of drugs to prepare, the required number must be brought enough. Soft-packaged infusion preparations, plasma substitute, ropivacaine (Nelapin), new drugs such as remifentanil, sufentanil, propofol, Gosunda or Loxac, cis-atracurium benzoate, imipramine, long tonic, endoxifen, etc. are chosen, the advantage is that the preparation is convenient and timely, and the usual clinical reserve base is directly enabled, followed by the usual drugs used by physicians, which can ensure safe and skilled application.
3, equipment and devices: hand-controlled breathing bag is a necessary item, should be spare 2-3; small portable ventilator (no surgical car must carry a small portable anesthesia machine, Beijing Yi’an company products). It is more appropriate to prepare substances, equipment, related equipment and drugs required for general anesthesia according to 1/3 or 1/4 of the treatment base.
Combined lumbar-hard anesthesia is commonly used in orthopedic surgery, and deep venipuncture kits are prepared according to 1/10 to 1/5 of the rescue base. In addition, small bedside devices such as positioning stimulators for nerve block (Beltone products), palm blood gas analyzers (Abbott products), Heman palm hemoglobin meters (made in Switzerland), and cardiac defibrillators are extremely useful. The operating room nurse should carry an electric knife or electrocoagulator, electric tools commonly used in orthopedic surgery, and portable rapid autoclave (preferably electric heating type, Israeli products) whenever possible.
4.Surgical instruments: prepared by the operating room nurse according to the base.
5.Consumable materials: mainly disposable items, surgical sutures (including non-invasive sutures with needles), titanium clips, etc.
3, anesthesia methods Except for the emergency medical treatment during military conflicts may face the threat of war on the lives of ambulance personnel, most emergency medical treatment tasks do not pose a significant threat to the lives of the ambulance personnel themselves, so the choice of anesthesia methods, in addition to focusing on the above basic requirements, is basically similar to the usual clinical practice. The focus is on improving anesthesia management for postoperative observation or weak monitoring power due to staff tension, and choosing anesthesia methods that are beneficial to both patients and medical personnel.
IV. Summary
In a strict sense, emergency medical treatment and anesthesia management, including combat trauma, should be required by high standards, namely.
(1) Not lower than the level of treatment that can be achieved in daily work;
(2) The techniques and drugs used must be the usual clinical practice; the battlefield or emergency treatment site is definitely not a laboratory for techniques and drugs, which is a principle of treatment that must be followed in practice. It is not difficult to imagine that everything is simple, do not pay attention to the treatment program will be difficult to cope with high quality and competent to deal with the sudden emergency and heavy rescue tasks.
In the face of the new situation, we should use a new vision, new thinking, new action, to explore the new situation to adapt to the treatment program. The Wenchuan earthquake emergency medical treatment is an important clinical practice, from which we need to actively learn experience and lessons, in order to better adapt to the needs of various types of emergency medical treatment: truly to
1. The basic theories and operation techniques for the treatment of trauma patients under normal and emergency conditions have commonality. It is necessary and important to strengthen training in normal times, including “professional training” for non-professionals;
2, the current knowledge is rapidly updated, new emergency equipment, anesthetic drugs, consumables, technology and methods are constantly emerging. The personnel involved in emergency medical treatment should take the initiative to learn new knowledge, master the performance of new medical equipment and use it skillfully.
3.Participate actively in the pre-hospital treatment of serious and dangerous casualties and rescue of catastrophic accidents, accumulate and reserve a high degree of rapid response ability, mobility and adaptability.