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

开放性骨盆伤：MDT 病例复盘Open pelvic injury: MDT case debrief

真实病例材料经脱敏、泛化后改编。逐步辨认出血、脏器损伤和后续创面风险。Adapted from a de-identified, generalized real-case source. Identify bleeding, organ injury and later wound concerns in stages.

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 · 30 分钟min

学完这门课，你能……After this course, you can…

描述开放性骨盆伤的出血、污染和脏器损伤风险。Describe bleeding, contamination and organ-injury risks in open pelvic injury.
为止血、结构稳定和脏器处理分配并行任务。Assign parallel hemorrhage-control, stabilization and organ-management tasks.
区分实际记录、教学提问和未提供的结局信息。Distinguish recorded care, teaching questions and unreported outcomes.

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岁男性机械挤压后会阴开放伤，HR132次/min、BP86/54 mmHg、SpO₂92%。骨盆痛、敷料快速浸湿、皮肤湿冷；尚未完成直肠/泌尿道损伤评估，手术团队正在接收。下一步最合适的是？A 32-year-old man has an open perineal wound after machinery crush; HR 132/min, BP 86/54 mmHg, SpO₂ 92%. Pelvic pain, rapidly soaked dressings and clamminess coexist; rectal/urinary injury assessment is incomplete and surgery is receiving the patient. What is the most appropriate next step?并行出血复苏、局部控制及骨盆/污染专科协作Coordinate resuscitation, local bleeding control and pelvic/contamination teams先完整缝合会阴皮肤后再复苏Close perineal skin completely before resuscitation只按皮肤伤处理，不考虑骨盆来源Treat as a skin wound without considering pelvic bleeding先常规全身CT再组织止血团队Complete routine whole-body CT before arranging control

合成情境题Synthetic vignette 2. 32岁女性高能量撞击伴开放骨折，HR96次/min、BP118/72 mmHg、SpO₂97%。伤后25 min，伤口污染、骨外露；已并行控制外出血，未发现药物过敏，血培养尚未送检。下一步最合适的是？A 32-year-old woman has an open fracture after high-energy impact; HR 96/min, BP 118/72 mmHg, SpO₂ 97%. At 25 min after injury the contaminated wound exposes bone; external loss is controlled, allergy history is negative and cultures have not been obtained. What is the most appropriate next step?尽快静脉抗生素，尽量伤后1 h内并核对伤型/本院方案Give early IV antibiotics, ideally within 1 h, using injury/local protocol checks等培养结果出来后再给首剂Wait for culture results before the first dose只在进入手术室后开始抗生素Start antibiotics only after operating-room entry用局部冲洗替代全身抗生素Substitute local irrigation for systemic antibiotics

3. 疑直肠伤评估？Assessment for suspected rectal injury?会阴/直肠检查，阳性直肠镜Perineal/rectal examination; proctoscopy if positive伤口小就不做会阴/直肠专科评估Skip perineal/rectal assessment if the wound is small腹部FAST阴性就排除直肠损伤Exclude rectal injury on negative abdominal FAST

4. 粪便转流适用于？When is fecal diversion used?依据直肠伤/污染专科判断Specialist decision by rectal injury/contamination按开放骨盆诊断自动给所有人转流Perform diversion automatically for all open pelvic injuries单凭疼痛分数决定有无转流Decide diversion using pain score alone

5. 未确认执行的治疗记录怎样写？How to write unconfirmed performed treatments?写拟议教学路径Proposed teaching pathway按常规路径推定已经执行Assume it was performed because it is a common pathway把讨论会建议当成实施记录Treat a conference recommendation as a procedure record

教学改编：身份、精确年龄、日期、地点及资源数量已移除。只使用病例文字要点，原始 PPT 和影像未公开；未提供的信息保留未知。Teaching adaptation: identity, exact age, dates, location and resource quantities are omitted. Only clinical text is used; original slides and imaging are not public. Unreported information remains unknown.

四阶段逐步释放Four-stage information release

1/4 · 到院：先看生理Arrival: physiology first

成人遭受高能量骨盆挤压伤，存在开放创口、盆部损伤和明显循环障碍；伴意识反应减弱、湿冷及心动过速。An adult sustains high-energy pelvic crush injury with an open wound, pelvic injury and marked circulatory compromise, accompanied by reduced responsiveness, cold skin and tachycardia.

本轮问题Discussion prompt
哪些是已知事实？除骨盆外，哪些失血来源和 xABCDE 风险仍未排除？What is known? Which other bleeding sources and xABCDE threats remain unresolved?
2/4 · 新信息：损伤范围扩大New information: broader injury pattern

材料中的检查及术中信息显示骨盆环损伤，同时涉及血管、泌尿生殖和肠道损伤。单一骨折标签不能表达全部任务。Source examination and operative findings show pelvic-ring injury with vascular, genitourinary and bowel involvement. A fracture label alone does not describe all tasks.

本轮问题Discussion prompt
分别列出出血、污染、尿液引流和结构稳定的担心；谁来整合这些信息？List bleeding, contamination, urinary-drainage and structural-stability concerns. Who integrates them?
3/4 · MDT：止血与脏器处理并行MDT: hemorrhage control and organ management

材料记录血管介入止血、骨盆外固定、泌尿系统处理和肠道/会阴损伤处理，由多专科接续完成。此处描述实际记录，不把该组合规定为唯一方案。The source records endovascular hemorrhage control, external pelvic stabilization, urinary-system procedures and bowel/perineal injury management across specialties. This describes the record and does not prescribe a single required combination.

本轮问题Discussion prompt
如何给每条任务分配负责人、核查结果并确认进入下一阶段的条件？How are task owners, effect checks and readiness for the next phase defined?
4/4 · 持续复评：创面与引流Ongoing review: wounds and drainage

后续材料记录多次分期清创与修复，并提出持续尿液引流及后续重建问题。完整长期功能结局未在所提供材料中给出。Later source material records staged debridement and repair and raises persistent urinary-drainage and future reconstruction questions. Complete long-term functional outcome is not supplied.

本轮问题Discussion prompt
哪些发现应触发泌尿/创面团队复评？转科前还需要交接哪些未解问题？Which findings prompt urinary/wound-team review? Which unresolved concerns must be handed over before transfer?

1/4

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

防遗漏：围绕证据提问Prevent omissions by asking about evidence

开放性骨盆伤同时考虑出血、污染、软组织和脏器损伤，避免只盯骨折。Consider bleeding, contamination, soft tissue and organ injury in an open pelvic injury, avoiding a fracture-only focus.
检查报告、术中发现和术后引流信息持续合并；明确“不可靠”和“未检查”。Reconcile investigation, operative and later drainage findings; mark unreliable and unexamined assessments.
这是一组预防遗漏的教学问题；材料不足以证明原病例实际发生漏诊。These are missed-injury prevention questions; the source does not establish that an actual missed injury occurred.

展开教学说明Teaching detail

材料记载早期 CT 检查，但未提供足够的检查前稳定程度、复苏反应与转运条件。本课不据此推断当时决策正确或错误，也不推广“休克患者先做 CT”。课堂应向原救治团队核对当时依据。The source records early CT but does not sufficiently establish pre-scan stability, resuscitation response or transfer conditions. The lesson neither judges that decision nor generalizes CT-first care in shock. The original team should clarify the context.

临床判断与关键步骤Clinical decisions and key steps

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.

开放骨盆：止血、污染与器官损伤Open pelvis: bleeding, contamination and organ injury

尽早抗生素与会阴评估Early antibiotics and perineal assessment

早期静脉抗生素，NICE开放骨折尽量伤后1 h内；会阴伤口保护、污染记录，疑直肠伤由受训者直肠指检，阳性行直肠镜。以本院规范为准。Early IV antibiotics; NICE open-fracture goal within one hour. Protect perineal wounds/document contamination; trained digital rectal assessment when rectal injury suspected, proctoscopy if positive. Follow institutional policy.

清创/填塞与血液复苏并行；直肠/泌尿伤评估后选择粪便转流或耻骨上膀胱造瘘，不是所有患者常规。以下是教学路径，未在原记录确认的措施不标作已实施。以本院规范为准。Debridement/packing and blood resuscitation proceed together. Fecal diversion or suprapubic drainage depends on rectal/urinary injury, not routine for everyone. Proposed teaching pathways are not documented performed care. Follow institutional policy.

原始生命体征、Hb/乳酸/BE不足，不生成看似真实的轨迹。另作模拟时须明确合成并与真实病例分离。以本院规范为准。Do not create a plausible real trajectory when original vitals/Hb/lactate/BE are missing. Any simulation must be distinctly synthetic. Follow institutional policy.

WSES骨盆2017WSES pelvic 2017 · NICE NG37NICE NG37 · 创伤失血性休克中国急诊专家共识（2023）Chinese emergency consensus on traumatic hemorrhagic shock (2023)

本土证据：从队列回到 MDT 问题Local evidence: from cohort to MDT questions

Ding 等，IJEM 2025：32 例多发伤合并骨盆骨折的单中心回顾性研究；报告死亡 3/32（9.4%），胸部合并伤 28/32（87.5%）。Ding et al., IJEM 2025: a single-center retrospective cohort of 32 polytrauma patients with pelvic fractures, reporting 3/32 deaths (9.4%) and 28/32 associated thoracic injuries (87.5%).

教学启示：同时看全身损伤、生理趋势和跨专科接续。方法报告单因素及相关性分析；不能据此证明 MDT 降低死亡，或把 GCS/ISS 解释为已验证的独立因果因素。Teaching implication: integrate whole-body injury, physiological trends and specialty transitions. Reported methods use univariate/correlation analysis; this does not prove that MDT reduces mortality or establish GCS/ISS as independent causal factors.

Clinical characteristics and mortality risk factors in polytrauma patients with pelvic fractures (2025)

单例教学材料与论文队列分别引用；未确认本病例是否属于该队列。The teaching case and publication cohort are cited separately; membership of this case in the cohort is unconfirmed.

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岁男性机械挤压后会阴开放伤，HR144次/min、BP78/48 mmHg、SpO₂90%。骨盆痛、敷料快速浸湿、皮肤湿冷；尚未完成直肠/泌尿道损伤评估，手术团队正在接收。下一步最合适的是？A 43-year-old man has an open perineal wound after machinery crush; HR 144/min, BP 78/48 mmHg, SpO₂ 90%. Pelvic pain, rapidly soaked dressings and clamminess coexist; rectal/urinary injury assessment is incomplete and surgery is receiving the patient. What is the most appropriate next step?先完整缝合会阴皮肤后再复苏Close perineal skin completely before resuscitation只按皮肤伤处理，不考虑骨盆来源Treat as a skin wound without considering pelvic bleeding先常规全身CT再组织止血团队Complete routine whole-body CT before arranging control立即统筹止血复苏与开放骨盆多学科接续Coordinate hemorrhage resuscitation and open-pelvis multidisciplinary care immediately

合成情境题Synthetic vignette 2. 47岁女性高能量撞击伴开放骨折，HR102次/min、BP112/70 mmHg、SpO₂96%。伤后40 min，伤口污染、骨外露；已并行控制外出血，未发现药物过敏，血培养尚未送检。下一步最合适的是？A 47-year-old woman has an open fracture after high-energy impact; HR 102/min, BP 112/70 mmHg, SpO₂ 96%. At 40 min after injury the contaminated wound exposes bone; external loss is controlled, allergy history is negative and cultures have not been obtained. What is the most appropriate next step?等培养结果出来后再给首剂Wait for culture results before the first dose只在进入手术室后开始抗生素Start antibiotics only after operating-room entry用局部冲洗替代全身抗生素Substitute local irrigation for systemic antibiotics在首小时内尽快给合适静脉抗生素Give appropriate IV antibiotics promptly within the first hour

3. 开放骨盆疑直肠损伤，为什么不能只看皮肤口？Why is skin-wound size insufficient when rectal injury is suspected in an open pelvis?伤口小就不做会阴/直肠专科评估Skip perineal/rectal assessment if the wound is small腹部FAST阴性就排除直肠损伤Exclude rectal injury on negative abdominal FAST会阴/直肠检查，阳性直肠镜Perineal/rectal examination; proctoscopy if positive

4. 开放骨盆是否都要常规粪便转流？Does every open pelvic injury require routine fecal diversion?按开放骨盆诊断自动给所有人转流Perform diversion automatically for all open pelvic injuries单凭疼痛分数决定有无转流Decide diversion using pain score alone依据直肠伤/污染专科判断Specialist decision by rectal injury/contamination

5. 原材料未证实AE或转流已做，网页应如何表述？How should AE/diversion be described when original material does not confirm performance?按常规路径推定已经执行Assume it was performed because it is a common pathway把讨论会建议当成实施记录Treat a conference recommendation as a procedure record写拟议教学路径Proposed teaching pathway