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

二次/三次评估与漏诊Secondary/tertiary survey and missed injury

把“还没看”和“还不能排除”留在清单里；每个待办都要有下一位责任人。Keep unexamined regions and unresolved possibilities visible, with an owner for every pending task.

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 · 35 分钟min

学完这门课，你能……After this course, you can…

在状态允许时完成 AMPLE 和头到脚评估。Complete AMPLE and head-to-toe assessment when condition permits.
把未检查、检查不可靠和待回报结果列成清单。List unexamined regions, unreliable assessments and pending results.
安排三次评估并闭环处理新症状和遗漏风险。Arrange tertiary review and close the loop on new symptoms and missed-injury risk.

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岁男性摩托车伤员初评已稳定，HR96次/min、BP118/72 mmHg、SpO₂97%。拟准备抗生素，家属提到既往输液后呼吸困难，但病史表的过敏栏仍空白。下一步最合适的是？A 32-year-old man is stable after primary assessment following a motorcycle collision; HR 96/min, BP 118/72 mmHg, SpO₂ 97%. Antibiotics are planned; a relative recalls breathing difficulty after a previous infusion, but the allergy field is blank. What is the most appropriate next step?补问药名、反应与时间，记录不确定性并调整用药核对Clarify drug/reaction/timing, record uncertainty and check medication choices按无过敏史填写后给常规药Record no allergy and administer the routine drug只问既往手术史，不追问输液反应Ask only about operations, leaving the infusion reaction unexplored以本次血压正常排除药物过敏史Exclude prior drug allergy because BP is currently normal

合成情境题Synthetic vignette 2. 32岁女性侧向碰撞后等待二次评估，HR132次/min、BP86/54 mmHg、SpO₂92%。腹部膨隆、皮肤湿冷，压迫止血后血压仍低；团队正准备完整从头到脚查体。下一步最合适的是？A 32-year-old woman awaits secondary survey after a side-impact collision; HR 132/min, BP 86/54 mmHg, SpO₂ 92%. She is clammy with abdominal distension and persistent hypotension after pressure control; a full head-to-toe examination is being prepared. What is the most appropriate next step?先回到xABCDE和止血复苏，二次查体随状态安排Return to xABCDE and hemorrhage resuscitation; time secondary survey to stability先按顺序完成完整二次查体Finish the full secondary survey in sequence first先送常规全身CT完成伤型Complete routine whole-body CT before reassessing threats只补问AMPLE而暂停生理复评Pause physiological reassessment to finish AMPLE alone

3. 镇静后背部与神经查体不可靠，记录怎样写？Back/neurological assessment is unreliable after sedation. Record?标明未评或受限，安排再查责任人Mark unassessed/limited and assign repeat examination把未完成项目统一记为阴性Record unperformed items as negative只在病历标受限，不安排复查Mark limited without arranging reassessment

4. 三次评估主要解决什么？What is the principal purpose of tertiary survey?复查病史查体与影像以防漏诊Revisit history, examination and imaging for missed injury只确认初次诊断名称没有改变Confirm only that the original diagnostic label is unchanged只重打一份原检查单Reissue the original investigation list alone

5. 肢体固定前后，怎样保留可比较的基线？What comparison is preserved around limb immobilization?感觉运动、灌注、疼痛与皮肤Sensation, motor function, perfusion, pain and skin只比较固定材料是否松动Compare splint tightness alone仅对比骨折成角，不查感觉运动Compare angulation without sensory/motor checks

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

先确认状态允许，再补全 AMPLEConfirm readiness, then complete AMPLE

二次评估在初评与复苏推进、患者状态允许时开展；恶化立即回到 xABCDE。Undertake the secondary survey when primary assessment/resuscitation and condition permit; deterioration returns attention to xABCDE.
A 过敏；M 用药（尤其抗凝）；P 既往史/妊娠；L 最后进食；E 事件与环境。A allergies; M medicines, especially anticoagulants; P past history/pregnancy; L last meal; E events/environment.
患者无法提供时，从院前团队或家属补充，并注明来源与可靠性。Use EMS or family information if the patient cannot provide history, noting source and reliability.

头到脚查体，明确检查限制Head-to-toe examination with explicit limits

头面颈、胸腹骨盆、四肢、神经血管、皮肤与背部系统核对。Systematically review head/face/neck, chest/abdomen/pelvis, limbs, neurovascular status, skin and back.
在保护、保暖、镇痛与隐私条件下完成；不能完成的区域先记录。Work with protection, warmth, analgesia and privacy; record regions that cannot yet be examined.
避免反复挤压疑不稳定骨盆；对阳性发现或不可靠查体安排补查。Avoid repeated springing of a potentially unstable pelvis; arrange follow-up for abnormal or unreliable findings.

三次评估：重新看，核对全部证据Tertiary survey: re-examine and reconcile evidence

患者稳定及可配合后重新问诊查体，结合清醒、镇静变化和活动后的新主诉。Repeat history/examination when stable and able to participate, incorporating new symptoms as alertness, sedation or mobility change.
核对影像最终报告、化验、会诊和操作前后记录，追踪待回报结果。Reconcile final imaging, laboratory results, consultations and records around interventions; track pending results.
由本地流程规定时点（常在入院后首日组织），出院/转科前再次核对未解问题。Local policy defines timing, often within the first inpatient day; reconcile unresolved concerns again before transfer/discharge.

展开教学说明Teaching detail

三次评估不是“24 小时后再处理新症状”。任何新主诉或恶化都即时触发针对性复查；该任务需要明确负责团队与补查安排。儿童参考来源只支持儿童适用内容，成人组织时点由本地创伤流程确认。Tertiary review does not mean waiting 24 hours to address new symptoms. New complaints or deterioration prompt assessment, with a named team and plan. Pediatric references support pediatric content only; local adult trauma policy defines scheduling.

防漏诊交接核对单Missed-injury handover checklist

核对项目Item	发现 / 限制 / 待办Finding / limit / task	责任人 / 时点Owner / timing
AMPLE 补全Complete AMPLE
未检查/不可靠部位Unexamined/unreliable regions
神经血管与新主诉Neurovascular findings/new symptoms
影像最终报告Final imaging reports
三次评估与出院核对Tertiary survey/discharge reconciliation

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. 47岁男性摩托车伤员初评已稳定，HR102次/min、BP112/70 mmHg、SpO₂96%。拟准备抗生素，家属提到既往输液后呼吸困难，但病史表的过敏栏仍空白。下一步最合适的是？A 47-year-old man is stable after primary assessment following a motorcycle collision; HR 102/min, BP 112/70 mmHg, SpO₂ 96%. Antibiotics are planned; a relative recalls breathing difficulty after a previous infusion, but the allergy field is blank. What is the most appropriate next step?按无过敏史填写后给常规药Record no allergy and administer the routine drug只问既往手术史，不追问输液反应Ask only about operations, leaving the infusion reaction unexplored以本次血压正常排除药物过敏史Exclude prior drug allergy because BP is currently normal先核实既往输液反应并标明用药风险Clarify the prior infusion reaction and flag medication risk

合成情境题Synthetic vignette 2. 43岁女性侧向碰撞后等待二次评估，HR144次/min、BP78/48 mmHg、SpO₂90%。腹部膨隆、皮肤湿冷，压迫止血后血压仍低；团队正准备完整从头到脚查体。下一步最合适的是？A 43-year-old woman awaits secondary survey after a side-impact collision; HR 144/min, BP 78/48 mmHg, SpO₂ 90%. She is clammy with abdominal distension and persistent hypotension after pressure control; a full head-to-toe examination is being prepared. What is the most appropriate next step?先按顺序完成完整二次查体Finish the full secondary survey in sequence first先送常规全身CT完成伤型Complete routine whole-body CT before reassessing threats只补问AMPLE而暂停生理复评Pause physiological reassessment to finish AMPLE alone优先初评复苏并随反应分段完成二次评估Prioritize primary resuscitation and stage secondary assessment by response

3. 镇静导致神经检查受限，待办与记录怎样保持一致？How should documentation and follow-up reflect sedation-limited neurology?把未完成项目统一记为阴性Record unperformed items as negative只在病历标受限，不安排复查Mark limited without arranging reassessment标明未评或受限，安排再查责任人Mark unassessed/limited and assign repeat examination

4. 恢复清醒后重新查体并复核影像，主要为了什么？What is the purpose of re-examination and image review after alertness returns?只确认初次诊断名称没有改变Confirm only that the original diagnostic label is unchanged只重打一份原检查单Reissue the original investigation list alone复查病史查体与影像以防漏诊Revisit history, examination and imaging for missed injury

5. 复位固定后检查怎样才能与固定前比较？How can post-reduction/splint findings be compared with baseline?只比较固定材料是否松动Compare splint tightness alone仅对比骨折成角，不查感觉运动Compare angulation without sensory/motor checks感觉运动、灌注、疼痛与皮肤Sensation, motor function, perfusion, pain and skin