课堂学习 · 2026-10 更新Classroom learning · October 2026 update

损伤控制复苏Damage control resuscitation

止血与生理保护同时推进：把每项措施的理由、责任人和效果核查说清楚。Hemorrhage control and physiological protection proceed together; state rationale, ownership and response checks.

来源与审核记录Sources and review record

Conceptual teaching illustration, not case evidence — 教学示意，非病例影像。Teaching illustration, not case imaging.

预计学习Estimated learning time · 40 分钟min

学完这门课，你能……After this course, you can…

将止血、抗纤溶、输血和生理保护组织成并行任务。Organize hemorrhage control, antifibrinolysis, transfusion and physiology protection in parallel.
解释 TXA、血压目标、SI 和 MTP 数字及适用边界。Explain TXA, BP targets, SI and MTP anchors with scope limits.
依据趋势和凝血信息提出下一轮复苏与止血讨论。Plan the next resuscitation and hemorrhage-control discussion using trends and coagulation findings.

实习：识别与报告；规培：决策时机与监督下关键步骤；青年主治：团队指挥与资源调度。Intern: recognize/report; resident: decision timing and supervised key steps; early attending: team leadership and resources.

先做 5 题前测Start five-question pretest 学完做 5 题后测Complete five-question posttest 本课口袋卡Course pocket card

课前测 · 5 题Pretest · five questions

每题 1 分；用于形成性反馈。One point per item; formative feedback.

合成情境题Synthetic vignette 1. 32岁男性车祸伤后80 min持续出血，HR132次/min、BP86/54 mmHg、SpO₂92%。骨盆压痛、皮肤湿冷，已准备血液和直接止血；上级询问抗纤溶用药的时间依据。下一步最合适的是？A 32-year-old man has ongoing hemorrhage 80 min after a collision; HR 132/min, BP 86/54 mmHg, SpO₂ 92%. He has pelvic tenderness and clammy skin; blood/control are being arranged and a senior asks about antifibrinolytic timing. What is the most appropriate next step?从受伤起算尽早在3 h内用TXA，按方案核对剂量Use TXA as early as possible within 3 h from injury and verify the regimen从到院时间重新起算3 hRestart the 3-hour clock at hospital arrival先等凝血全套回报再考虑首剂Wait for the full coagulation panel before considering the first dose先完成CT后再决定是否记录受伤时间Complete CT before clarifying injury timing

合成情境题Synthetic vignette 2. 32岁女性高能量车祸伴活动出血，HR132次/min、BP86/54 mmHg、SpO₂92%。已启动血液复苏，Clauss纤维蛋白原1.2 g/L，体温35.1 ℃，化验与临床均提示凝血风险。下一步最合适的是？A 32-year-old woman has active bleeding after a high-energy collision; HR 132/min, BP 86/54 mmHg, SpO₂ 92%. Blood resuscitation has started; Clauss fibrinogen is 1.2 g/L and core temperature is 35.1 C with clinical/laboratory coagulopathy risk. What is the most appropriate next step?补充纤维蛋白原或按本院含量折算冷沉淀并复测Replace fibrinogen or locally quantified cryoprecipitate and recheck仅补红细胞，等出血停止再看凝血Give RBC alone and defer coagulation treatment until bleeding stops直接照抄国外冷沉淀单位数Copy an overseas cryoprecipitate unit count without conversion仅用升压药纠正血压而不处理凝血Correct BP with vasopressor alone without addressing coagulation

3. HR126、SBP88的SI约多少？What is SI for HR 126/SBP 88?1.43，结合灌注与反应判断About1.43; integrate perfusion/response把SBP除HR得出的数当SICalculate SI as SBP divided by HR按一个SI数直接开出精确失血毫升Derive exact lost milliliters from a single SI

4. 是否等24 h输够10 U（国内200 mL全血来源单位）才启动MTP？Wait for 24 hours and 10 domestic200-mL-donation-derived units before MTP?按生理、出血与复苏反应尽早启动评估Assess/activate early by physiology, bleeding and response等足24 h和10 U后才允许启动Require 24 h and 10 U before activation入院Hb正常便不准备血制品Withhold blood preparation if admission Hb is normal

5. 核心温度34.8 ℃伴出血，复苏还需什么？Core34.8 C with bleeding: what else does resuscitation need?去湿衣、保暖和输液/血液加温Remove wet clothing and warm patient/infusions/blood持续全裸查体并输入室温液体Keep full exposure and infuse room-temperature fluid用一次正常室内温度代替测患者核心温度Use room temperature instead of measuring the patient’s core

Conceptual teaching illustration — 教学示意：用于理解任务与关系。Conceptual illustration of tasks and relationships.

并行任务，共同目标Parallel tasks, shared goal

控制外出血，寻找隐匿出血；同步协调手术/介入止血资源。Control visible bleeding, assess occult sources and coordinate surgical/interventional resources.
按受伤时间评估 TXA；按本地大出血流程组织血液资源。Assess TXA using injury time and mobilize blood resources under the local hemorrhage protocol.
限制无效大量补液，同时关注体温、离子钙、凝血和灌注反应。Avoid ineffective excessive fluids while tracking temperature, ionized calcium, coagulation and perfusion response.

输血策略需要随反馈调整Transfusion strategy responds to feedback

大量出血初期按本地固定比例包组织；尽早转向实验室/黏弹性检测指导。Use the local initial fixed-ratio pack, then move to laboratory/viscoelastic-guided therapy as soon as feasible.
区分血浆:红细胞与血浆:血小板:红细胞的写法，核对产品单位。Distinguish plasma:RBC from plasma:platelet:RBC notation and verify product units.
复评活动性出血、灌注、体温和凝血；明确升级与结束 MTP 的责任人。Reassess bleeding, perfusion, temperature and coagulation; assign escalation and MTP termination ownership.

展开教学说明Teaching detail

NICE NG39成人与儿童均为血浆:红细胞1:1，儿童按体重量化；国内R27初始血浆:血小板:红细胞1:1:1–1:1:2，再尽早目标导向。具体；以本院血库方案为准。NICE NG39 uses plasma:RBC 1:1 in adults and children, with weight-based pediatric volumes; Chinese R27 starts plasma:platelets:RBC 1:1:1–1:1:2 before early goal-directed therapy. Follow the institutional blood-bank protocol.

用真实病例改编讨论 MDT 止血Discuss MDT hemorrhage control through an adapted real case

2 分钟时间压力练习Two-minute time-pressure exercise

可暂停或由教师手动释放信息。运行时每 30 秒进入下一预设阶段；不会评估真实患者，也不计算治疗反应。Pause or let the instructor reveal updates manually. Every 30 seconds advances to a scripted stage; this does not assess real patients or calculate treatment response.

2:00

数字与条件：国内依据并列核对Numbers and scope: Chinese guidance alongside

具体方案；以本院为准；每项数字同时核对人群、阶段和来源。Follow institutional protocols; check population, stage and source with every number.

TXA：时间与方案TXA: timing and regimen

≤3 h；1 g 静滴 ≥10 min → 1 g 静脉维持 8 h以本院规范为准。≤3 h; 1 g IV over ≥10 min → 1 g IV over 8 h Follow institutional policy.

成人创伤活动/疑似严重出血；从受伤起算。Adults with active/suspected major traumatic bleeding; time from injury.

尽早使用；国内 R33 维持表述为“8 h以上”，欧洲 R23 为8 h。以本院规范为准。Give early; Chinese R33 states at least eight hours for maintenance, European R23 eight hours. Follow institutional policy.

超过3 h不常规使用；仅有黏弹性检测纤溶亢进证据时由上级结合本院方案决定，已知纤溶抑制者不用。以本院规范为准。Beyond three hours, not routine; only with viscoelastic hyperfibrinolysis evidence and senior/local-policy review; avoid known fibrinolytic shutdown. Follow institutional policy.

创伤失血性休克中国急诊专家共识（2023）Chinese emergency consensus on traumatic hemorrhagic shock (2023) · 欧洲创伤大出血指南第六版（2023）European major bleeding guideline, sixth edition (2023) · NICE NG39 重大创伤NICE NG39 major trauma

国内外依据与适用差异Domestic/international scope differences

按本院药品说明书、配制及输注流程执行；不得快速静推。Follow local product, preparation and infusion policy; avoid rapid IV push.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

成人出血：血压目标Adult bleeding: BP target

SBP 80–90 mmHg以本院规范为准。SBP 80–90 mmHg Follow institutional policy.

止血前、无颅脑/脊髓损伤的成人初期出血。Early adult bleeding before control, without brain/spinal injury.

老年、慢性高血压慎重；儿童与孕妇另按专门方案。Caution with older age/chronic hypertension; separate pediatric/pregnancy protocols.

目标达不到可按欧洲R14加去甲肾上腺素；国内R28在MAP<50或SBP<70危及生命时考虑，不能替代血液和止血。以本院规范为准。If targets fail, consider norepinephrine (European R14); Chinese R28 considers it in life-threatening MAP below 50 or SBP below 70, alongside blood/control rather than replacing them. Follow institutional policy.

创伤失血性休克中国急诊专家共识（2023）Chinese emergency consensus on traumatic hemorrhagic shock (2023) · 欧洲创伤大出血指南第六版（2023）European major bleeding guideline, sixth edition (2023)

国内外依据与适用差异Domestic/international scope differences

国内R22与欧洲R13支持有条件的目标；不是所有伤者通用。Chinese R22 / European R13 support conditional use, not a universal target.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

休克指数Shock index

SI≥1 或脉压<30 mmHg（国内R2）以本院规范为准。SI at least one or pulse pressure below 30 mmHg (Chinese R2) Follow institutional policy.

成人风险识别，结合查体与趋势。Adult risk recognition, with examination and trends.

国内表2：SI≥1.0/≥1.5/≥2.0粗估失血20–30%/30–50%/50–70%；β阻滞剂、老幼及运动员可失真，不能当精确失血量。以本院规范为准。Chinese Table 2: SI at least 1.0/1.5/2.0 roughly associates with20–30%/30–50%/50–70% loss; beta blockers, age and athletic physiology confound it, so not precise volume. Follow institutional policy.

药物抑制心率或老人“正常”生命体征仍保留休克担心。Blunted HR or apparently normal older-adult vitals do not exclude shock.

国内外依据与适用差异Domestic/international scope differences

欧洲R5用SI和/或脉压评估休克与输血需求；同时看机制、意识、灌注、乳酸和反应。European R5 uses SI and/or pulse pressure for shock/transfusion assessment; integrate mechanism, consciousness, perfusion, lactate and response.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

大量输血启动评估MTP activation assessment

ABC ≥2 + 临床状态；以本院规范为准。ABC ≥2 + clinical state Follow institutional policy.

成人；ACS TQIP 评分示例。Adults; ACS TQIP example.

穿透躯干伤、FAST阳性、HR≥120、SBP≤90各1分；ABC≥2启动评估；原版等号边界与本院版本核对。以本院规范为准。Penetrating torso injury, positive FAST, HR at least 120 and SBP at most90 each score one; ABC at least two triggers assessment; verify local boundaries. Follow institutional policy.

抢救室已输血、需手术/介入止血也是TQIP触发因素；结合持续出血和复苏反应，不等24 h累计10 U。以本院规范为准。Blood already required in the bay and operative/interventional control are TQIP triggers; consider ongoing bleeding/response without waiting for 24-hour10-unit totals. Follow institutional policy.

ACS TQIP 大量输血指南ACS TQIP massive transfusion guidance · 创伤失血性休克中国急诊专家共识（2023）Chinese emergency consensus on traumatic hemorrhagic shock (2023) · 国家卫健委：临床用血技术规范（2025年版）NHC clinical blood use technical standard (2025)

国内外依据与适用差异Domestic/international scope differences

初始血浆:血小板:红细胞1:1:1–1:1:2（国内R27）后尽早目标导向。国内1 U红细胞通常来自200 mL全血，不可按国外1 unit原样计数；血小板按血库治疗量换算。以本院规范为准。Initial plasma:platelets:RBC 1:1:1–1:1:2 (Chinese R27), then early goal-directed therapy. Domestic RBC units generally derive from 200 mL whole blood and differ from overseas units; convert platelet therapeutic amounts with the blood bank. Follow institutional policy.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

纤维蛋白原Fibrinogen

Clauss Fib ≤1.5 g/L + 大出血；以本院规范为准。Clauss Fib ≤1.5 g/L + major bleeding Follow institutional policy.

严重活动出血，或黏弹性检测提示功能性缺乏。Major active bleeding or viscoelastic evidence of functional deficit.

欧洲R29首剂约3–4 g纤维蛋白原浓缩物，或按本院冷沉淀每U实际含量折算；国内U来源与国外不同，不能直接套15–20 U；输后复测。以本院血库规范为准。European R29 initial fibrinogen concentrate about 3–4 g, or cryoprecipitate by measured local content per unit; domestic and overseas units differ, so do not copy15–20 units directly; recheck. Follow institutional blood-bank policy. Follow institutional policy.

出血持续、检测恶化：血库/凝血团队按本院方案升级。Ongoing bleeding/worsening tests: blood-bank/coagulation escalation.

欧洲创伤大出血指南第六版（2023）European major bleeding guideline, sixth edition (2023) · 围术期出凝血管理麻醉专家共识Chinese anesthesia consensus on perioperative bleeding

国内外依据与适用差异Domestic/international scope differences

国内围术期共识：严重渗血冷沉淀条款为<1.5，纤维蛋白原条款为<1.5–2.0；场景及边界不同。Chinese perioperative consensus uses <1.5 for cryo in severe oozing and <1.5–2.0 for fibrinogen; scope/operators differ.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

输血时 Hb 目标Hb target during transfusion

Hb 70–90 g/L以本院规范为准。Hb 70–90 g/L Follow institutional policy.

成人创伤，需要红细胞输注时的欧洲R16目标。European R16 target for adult trauma requiring RBC transfusion.

结合活动出血、灌注与病程；早期Hb正常不能排除大出血。Use bleeding/perfusion/trajectory; normal early Hb does not exclude hemorrhage.

TBI、心肌缺血及特殊人群按专科目标；不等Hb下降才启动抢救。TBI, myocardial ischemia and special populations need specific goals; do not await Hb fall.

欧洲创伤大出血指南第六版（2023）European major bleeding guideline, sixth edition (2023) · 国家卫健委：临床用血技术规范（2025年版）NHC clinical blood use technical standard (2025)

国内外依据与适用差异Domestic/international scope differences

国内2025用血规范要求个体评估与输后评价，不能据其声称全国统一70–90目标。Chinese 2025 blood-use standard requires individual assessment/response review, not a national 70–90 target.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

离子钙Ionized calcium

iCa≥1.00 mmol/L（国内）；欧洲正常范围1.1–1.3 mmol/L以本院规范为准。iCa at least 1.00 mmol/L (Chinese); European normal1.1–1.3 mmol/L Follow institutional policy.

成人大出血，尤其大量输血。Adult major bleeding, especially massive transfusion.

开始输血即测iCa；10%氯化钙10 mL约元素钙270 mg，10%葡萄糖酸钙10 mL约90 mg；补低钙时核对浓度、通路及复测。以本院规范为准。Measure iCa at transfusion start; 10 mL of10% calcium chloride contains about 270 mg elemental calcium, versus about 90 mg in10% calcium gluconate. Verify concentration/access and recheck. Follow institutional policy.

输血仍在进行、iCa下降或心律变化：及时团队复评。Ongoing transfusion, falling iCa or rhythm changes: prompt reassessment.

国内外依据与适用差异Domestic/international scope differences

欧洲R31推荐氯化钙纠正低钙；上述为元素钙含量对照，不是两药逐毫升互换处方。国内R27下限与欧洲正常范围分开理解。European R31 prefers calcium chloride for hypocalcemia; this compares elemental content rather than interchangeable volume prescriptions. Distinguish the Chinese lower target from European normal range.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

重型颅脑伤：灌注目标Severe TBI: perfusion target

MAP ≥80 mmHg以本院规范为准。MAP ≥80 mmHg Follow institutional policy.

重型TBI（GCS ≤8）；不能套用允许性低血压。Severe TBI (GCS ≤8); avoid permissive hypotension.

GCS9–15且伤后≤3 h可按CRASH-3讨论TXA；TBI出血血小板目标>100×10⁹/L（欧洲R30）；创伤性ICH用TEG/ROTEM指导凝血纠正（NCS/SCCM2026）。以本院规范为准。For GCS 9–15 within three hours, discuss TXA by CRASH-3 scope; TBI bleeding platelet goal above100×10⁹/L (European R30); VHA-guided traumatic-ICH correction (NCS/SCCM2026). Follow institutional policy.

意识/瞳孔变化、目标未达：同步纠正氧合/灌注并升级神经救治。Changing consciousness/pupils or unmet goals: address oxygenation/perfusion and escalate neurological care.

创伤失血性休克中国急诊专家共识（2023）Chinese emergency consensus on traumatic hemorrhagic shock (2023) · 中华医学会相关学组：重伤院前救治共识（2026）Chinese expert consensus on prehospital major trauma (2026) · 欧洲创伤大出血指南第六版（2023）European major bleeding guideline, sixth edition (2023) · CRASH-3：颅脑损伤TXA随机试验（2019）CRASH-3 TBI TXA randomized trial (2019) · NCS/SCCM：抗栓相关颅内出血更新（2026）NCS/SCCM antithrombotic ICH update (2026)

国内外依据与适用差异Domestic/international scope differences

CRASH-3招募GCS≤12或CT证实颅内出血、无严重颅外出血；轻中度亚组结果不能推广为所有TBI获益。CRASH-3 enrolled GCS at most12 or CT-confirmed intracranial bleeding without major extracranial hemorrhage; subgroup benefit is not universal TBI benefit.

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

低体温与损伤控制Hypothermia and damage control

核心体温<35 ℃；复温目标36–37 ℃以本院规范为准。Core below 35 C; rewarm toward36–37 C Follow institutional policy.

成人创伤大出血；测食管、膀胱或鼻咽等核心温度Adult major traumatic bleeding; use a core-temperature method

到院即去湿衣、保暖、加温毯及输液/血液加温；37 ℃实验室检测可能低估低温凝血障碍；以本院规范为准。Remove wet clothing, insulate and warm patient/infusions/blood;37 C laboratory testing may understate hypothermic coagulopathy Follow institutional policy.

T≤35 ℃合并pH≤7.2、凝血病、持续出血和长重建手术风险：考虑分期损伤控制手术。以本院规范为准。T at most35 C with pH at most7.2, coagulopathy, ongoing bleeding and lengthy-reconstruction risk: consider staged damage-control surgery. Follow institutional policy.

国内外依据与适用差异Domestic/international scope differences

国内R12/R29；不是用一个体温数字单独决定手术Chinese R12/R29; one temperature does not decide surgery alone

来源核对日期：2026-10-14；临床审核：进行中Source check: 2026-10-14; clinical review: ongoing

依据与适用范围Sources and scope

课后测 · 5 题Posttest · five questions

每题 1 分；用于形成性反馈。One point per item; formative feedback.

合成情境题Synthetic vignette 1. 43岁男性车祸伤后110 min持续出血，HR144次/min、BP78/48 mmHg、SpO₂90%。骨盆压痛、皮肤湿冷，已准备血液和直接止血；上级询问抗纤溶用药的时间依据。下一步最合适的是？A 43-year-old man has ongoing hemorrhage 110 min after a collision; HR 144/min, BP 78/48 mmHg, SpO₂ 90%. He has pelvic tenderness and clammy skin; blood/control are being arranged and a senior asks about antifibrinolytic timing. What is the most appropriate next step?从到院时间重新起算3 hRestart the 3-hour clock at hospital arrival先等凝血全套回报再考虑首剂Wait for the full coagulation panel before considering the first dose先完成CT后再决定是否记录受伤时间Complete CT before clarifying injury timing核实受伤时刻，在3 h内尽早按本院方案给TXAConfirm injury time and give early TXA within 3 h under local protocol

合成情境题Synthetic vignette 2. 43岁女性高能量车祸伴活动出血，HR144次/min、BP78/48 mmHg、SpO₂90%。已启动血液复苏，Clauss纤维蛋白原1.4 g/L，体温35.1 ℃，化验与临床均提示凝血风险。下一步最合适的是？A 43-year-old woman has active bleeding after a high-energy collision; HR 144/min, BP 78/48 mmHg, SpO₂ 90%. Blood resuscitation has started; Clauss fibrinogen is 1.4 g/L and core temperature is 35.1 C with clinical/laboratory coagulopathy risk. What is the most appropriate next step?仅补红细胞，等出血停止再看凝血Give RBC alone and defer coagulation treatment until bleeding stops直接照抄国外冷沉淀单位数Copy an overseas cryoprecipitate unit count without conversion仅用升压药纠正血压而不处理凝血Correct BP with vasopressor alone without addressing coagulation按纤维蛋白原缺乏处理并核实本院冷沉淀含量Treat fibrinogen deficiency and verify local cryoprecipitate content

3. HR132、SBP92的SI约多少，应该怎样解读？With HR 132 and SBP 92, what is SI and how is it interpreted?把SBP除HR得出的数当SICalculate SI as SBP divided by HR按一个SI数直接开出精确失血毫升Derive exact lost milliliters from a single SI1.43，结合灌注与反应判断About1.43; integrate perfusion/response

4. 大量输血的累计定义能否作为唯一启动等待条件？Can the cumulative massive-transfusion definition be the sole activation trigger?等足24 h和10 U后才允许启动Require 24 h and 10 U before activation入院Hb正常便不准备血制品Withhold blood preparation if admission Hb is normal按生理、出血与复苏反应尽早启动评估Assess/activate early by physiology, bleeding and response

5. 核心低温伴凝血风险，复苏时怎样避免继续失温？How should resuscitation prevent further heat loss during core hypothermia?持续全裸查体并输入室温液体Keep full exposure and infuse room-temperature fluid用一次正常室内温度代替测患者核心温度Use room temperature instead of measuring the patient’s core去湿衣、保暖和输液/血液加温Remove wet clothing and warm patient/infusions/blood