戴南人民医院重点病种的急诊服务流程与规范

戴南人民医院重点病种的急诊服务流程与 姜堰市中医院 重点病种的急诊服务流程与规范 为加强急诊质量管理，密切科间协作，促进急诊服务及时、安全、便捷、有效，保障患者获得连贯医疗服务，根据国家中医药管理局《中医医院管理指南(2008版)》的通知等，结合我院实际情况，我院初步建立与医院功能任务相适应的重点病种急诊服务流程与规范，具体规定如下: 一、创伤的急诊服务流程与规范 (1)初步判断病情:确定给予何种程度的抢救支持。 (2)呼吸通路的阶梯化管理:建立可靠的呼吸通路和支持，确保动脉血SaO2，90%。 (3)以中心静脉插管为主的循环通路建立:建立至少一条中心静脉通路(单腔或双腔导管)，必要时建立两条中心静脉导管通路，并备用另外一条或二条静脉(套管针)通路。休克患者先快速补液，继以输血，同时监测中心静脉压。 (4)系统查体和检查:按CRASHPLAN进行系统查体，评估患者的危重程度。对相应的部位进行X线、CT、B超等检查，以得到影像学证据并完善诊断。 (5)以改良氧利用率监测指导全身管理。液体的复苏目标从整体看主要以尽可能提供足够的血液携氧，以满足全身氧代谢的要求。改良氧利用率(MO2UC)当机体的氧载不能满足机体的氧耗时，机体将通过提高氧利用率来代偿对氧的利用，可以从正常的0.22~0.32上升到0.7~0.8。一旦氧载情况改善，氧利用率可以在2~4小时内恢复正常。可以这样认为，只要机体的代偿功能存在，当出现氧利用率提高，即可认为此时氧载不足或相对不足时，在一定限度内，氧利用率的上升就意味着组织缺氧在恶化。当其超过0.4时，说明缺氧超过危险限，要加强干预。如果其持续在0.40~0.50达3~4天，在0.50~0.60持续24小时以上，，0.60的时间超出8~12小时，提示患者缺氧严重且时间过长，出现并发症的机会增多。 因此，复苏的氧代谢目标在氧利用率指标即不应超过0.40。 (6)确定性救治手术:对于内脏损伤患者进行修复和止血以确保救命的目标手术。 ?创伤严重度分类方法: ?轻度:患者为单部位受伤，仅需简单处置，一般不需住院治疗。 ?中度:主要受伤部位损害严重，有功能损害，生命体征基本平稳，一般没有 生命危险;ISS(创伤严重度评分)<13，治愈后可能留有功能障碍。 ?重度:单个或多个部位损害，生命体征不稳定，不救治患者会死亡;ISS 13,25。通过病史采集和初步徒手查体了解伤情后，按如下四个步骤完成救治流程:(l,3 min内完成)一般伤势严重，危及生命 ，多发生严重并发症，治愈后可能遗留残疾。 ?极重度:单个或多个部位损害，生命体征极不稳定，不迅速处置 4 h内即死亡，或濒死状 advantages, facing the Yangtze River Delta, Pearl River Delta, Shandong peninsula, Beijing-Tianjin-Tangshan area, targeted investment promotion several times. Industry-led unit and various town streets are developing detailed promotion plans, the basis of what is specific to each industry, has formed a kind of scale, need to bring in the kind of projects each town street has the kind of resources, what location, focus on the development of the kind of industries. Four stroke technology and science. Determinants of technology is the County's economic development through scientific and technological innovation, improve product value-added and improve economic competitiveness, is the inevitable way to achieve leapfrog development. Talent is the city center city's first resource, is the primary industry development, and revitalization of the social protection. So, in terms of skills: to catch ... Competitive. Encouraging enterprises to actively undertake science and technology projects, strengthening research cooperation, using advanced technology to increase the added value of their products to ensure that introduction of transforming scientific and technological achievements during the year ... ... New research enterprises ... ... Home, creating innovative platforms ... ... Generic classifier. In: first, we must strengthen the cultivation of talent, efforts to increase vocational education and training and meet the basic demand of enterprise development. Then introduced a number of the county needed scarce education, health professionals, meet social development needs to invest more in machinery, pharmaceutical manufacturing research and development in higher education, such as the introduction of talent to meet the need. Third, we must rely on ... ... Post-doctoral workstation, ... ... Food research station platform, to the XX University to find experts 创伤急救流程图 ?在接诊创伤患者的第 1分钟内，完成意识状态的判断， 1(?依据足背动脉、桡动脉 、股动脉、颈内动脉的搏动和张力初步判断血压的大致范围; 护士完成 解剖创 ?A保持气道通畅，有损伤开放气道，伤; 静脉通道的建? 有呼吸减弱或呼吸消失给与呼吸支持 立 ?通过病史采集和初步徒手查体了解伤情后，按如下四个步骤完成救治2 流程:(l,3 min内完成) ?A检B评价?C评价有证据的D基础情况(年?? 查生命体解剖创损伤机制和高能因素龄、心脏疾病、呼吸疾 征和意识伤;特别(汽车一同摔出或同一病、糖尿病、肝硬化、 水平; 是颈椎 环境内有死亡者); 病态肥胖、妊娠等)。 3( ?系统查体三步骤进行快速伤情判断按照(CRASH PLAN方法进行)。3,7 min内完成。简单的骨折固定、包扎和止血 附:CRASH PLAN中每一个字母代表一个脏器 或解剖部位，c为心脏(cardic)，R为呼吸 生命体征平稳 (respiration)，A为腹部(abdomen)，S为脊 生命体征不稳定 柱(spine)，H为头颅(head)，P为骨盆 (pelvis)，L为四肢(1imb)，A为血管 (artery)，N为神经(nerve)。 ?相关检查 ?呼吸和循环支持 ? 术前准备，血常规和血型，凝血功 能 ? 请相关科室会诊,通知手术室 ? 送手术室 大创伤送住院部手术室，小创伤留急诊手术室 advantages, facing the Yangtze River Delta, Pearl River Delta, Shandong peninsula, Beijing-Tianjin-Tangshan area, targeted investment promotion several times. Industry-led unit and various town streets are developing detailed promotion plans, the basis of what is specific to each industry, has formed a kind of scale, need to bring in the kind of projects each town street has the kind of resources, what location, focus on the development of the kind of industries. Four stroke technology and science. Determinants of technology is the County's economic development through scientific and technological innovation, improve product value-added and improve economic competitiveness, is the inevitable way to achieve leapfrog development. Talent is the city center city's first resource, is the primary industry development, and revitalization of the social protection. So, in terms of skills: to catch ... Competitive. Encouraging enterprises to actively undertake science and technology projects, strengthening research cooperation, using advanced technology to increase the added value of their products to ensure that introduction of transforming scientific and technological achievements during the year ... ... New research enterprises ... ... Home, creating innovative platforms ... ... Generic classifier. In: first, we must strengthen the cultivation of talent, efforts to increase vocational education and training and meet the basic demand of enterprise development. Then introduced a number of the county needed scarce education, health professionals, meet social development needs to invest more in machinery, pharmaceutical manufacturing research and development in higher education, such as the introduction of talent to meet the need. Third, we must rely on ... ... Post-doctoral workstation, ... ... Food research station platform, to the XX University to find experts 严重创伤抢救流程图 符合严重伤的诊断 现场评估 院前急救立即排除威胁生命因素 一般处理 ?平卧位，休克者抬高双下肢20。 ?保持呼吸道通畅，必要时建立人工气道， 给氧 ?严密监护生命体征 ?建立静脉通道并适当输入晶体液 ?止血、止痛、镇静 ?休克者注意保温 颅脑伤 腹部伤 泌尿系损伤 胸部伤 脊柱骨盆四肢伤 ?CSF漏时勿填?反复审定腹部?留置尿管观?闭式引流处理张?上颈托、头部固 察尿的颜色和塞冲洗滴药 力性气胸、液气胸 情况，确诊腹腔定器并卧硬质担架 量 ?高颅压者20%?固定浮动的胸壁 出血，可反复穿?固定骨折 ?全血尿提示甘露醇 125 ml快?肺挫伤必要时行刺 ?严重骨盆骨折者 尿路损伤严重，速静滴或速尿20 ?腹腔穿刺阳性机械通气 应常规肛门指诊以 mg静注 率>90% 防止尿管堵塞 ?心包填塞者行紧排除膀胱、直肠损 ?脑疝者就近处?对腹腔出血者?卧床休息，碱急穿刺减压 伤并严密观察 化尿液 理或快速送院 尽早开腹探查 转运途中监护救治、院内处理 颅脑伤 胸部伤 腹部伤 泌屎系损伤 脊柱骨盆四肢 ?头颅 CT检查 ?胸部X线或?Β超、X线、?Β超、CT检 伤 ?颅内血肿、脑 CT检查 CT检查 ?肾挫伤者绝?X线、CT检 挫伤严重水肿、?内固定浮动?腹腔灌洗 对卧床休息、止?脊髓受压者 手术清除血肿胸壁 ?确诊腹腔脏血、碱化尿液 急诊手术减压 或减压 ?胸部开放伤、器损伤者应开?肾，膀胱挫裂?骨盆骨折大 ?非手术治疗: 话动性出血、心腹探查，胃肠减 伤应行手术修出血即血管内 脱水、利屎、降包填塞应开胸压 复 止血 颅压 探查 ?维持水电解?维持水电解?直肠膀胱损 ?维持水、电解?支持呼吸功质酸碱平衡 质酸碱平衡 伤尽早手术 质、酸碱平衡 能 ?预防感染 ?保护肾功能 ?骨折整复手 ?预防感染 ?预防感染 ?营养支持 ?预防感染 术 ?营养支持 ?营养支持 advantages, facing the Yangtze River Delta, Pearl River Delta, Shandong peninsula, Beijing-Tianjin-Tangshan area, targeted investment promotion several times. Industry-led unit and various town streets are developing detailed promotion plans, the basis of what is specific to each industry, has formed a kind of scale, need to bring in the kind of projects each town street has the kind of resources, what location, focus on the development of the kind of industries. Four stroke technology and science. Determinants of technology is the County's economic development through scientific and technological innovation, improve product value-added and improve economic competitiveness, is the inevitable way to achieve leapfrog development. Talent is the city center city's first resource, is the primary industry development, and revitalization of the social protection. So, in terms of skills: to catch ... Competitive. Encouraging enterprises to actively undertake science and technology projects, strengthening research cooperation, using advanced technology to increase the added value of their products to ensure that introduction of transforming scientific and technological achievements during the year ... ... New research enterprises ... ... Home, creating innovative platforms ... ... Generic classifier. In: first, we must strengthen the cultivation of talent, efforts to increase vocational education and training and meet the basic demand of enterprise development. Then introduced a number of the county needed scarce education, health professionals, meet social development needs to invest more in machinery, pharmaceutical manufacturing research and development in higher education, such as the introduction of talent to meet the need. Third, we must rely on ... ... Post-doctoral workstation, ... ... Food research station platform, to the XX University to find experts 二、急性缺血性脑卒中急诊服务及诊治流程 到达急诊前、后:遵守院内急救与院前急救衔接接诊及流程; 参照预检分诊流程及急诊分诊指南; 按神经系统患者预检分诊标准进行分诊。 急诊初筛卒中病人 记录发病和就诊时间、生命体征、体格检查(包括神经系 统检查)、诊断和处理原则 45分钟内完成头颅CT、血常规、急诊生化 和凝血功能检查;进行NIHSS评估 溶栓排除标准: 符合溶栓标准: , 发病时间>3小时 , 发病时间<3小时 , 年龄>80岁或<18岁 , 18岁<年龄<80岁 , 症状迅速改善 , 无出血倾向者 , 其他 筛选有病程记录 取得知情同意 患者和家属不同意者 1. 签字; 联系急诊科主班进行溶栓治疗 2. 就地治疗，联系住院 房颤引起的脑梗死抗凝治疗 (无禁忌者肝素、低分子肝素或华法林) advantages, facing the Yangtze River Delta, Pearl River Delta, Shandong peninsula, Beijing-Tianjin-Tangshan area, targeted investment promotion several times. Industry-led unit and various town streets are developing detailed promotion plans, the basis of what is specific to each industry, has formed a kind of scale, need to bring in the kind of projects each town street has the kind of resources, what location, focus on the development of the kind of industries. Four stroke technology and science. Determinants of technology is the County's economic development through scientific and technological innovation, improve product value-added and improve economic competitiveness, is the inevitable way to achieve leapfrog development. Talent is the city center city's first resource, is the primary industry development, and revitalization of the social protection. So, in terms of skills: to catch ... Competitive. Encouraging enterprises to actively undertake science and technology projects, strengthening research cooperation, using advanced technology to increase the added value of their products to ensure that introduction of transforming scientific and technological achievements during the year ... ... New research enterprises ... ... Home, creating innovative platforms ... ... Generic classifier. In: first, we must strengthen the cultivation of talent, efforts to increase vocational education and training and meet the basic demand of enterprise development. Then introduced a number of the county needed scarce education, health professionals, meet social development needs to invest more in machinery, pharmaceutical manufacturing research and development in higher education, such as the introduction of talent to meet the need. Third, we must rely on ... ... Post-doctoral workstation, ... ... Food research station platform, to the XX University to find experts 住院期间: 1. 中医辨证施护，健康教育，有记录。 2. 24h内，有血管功能评估医嘱(颈动脉超声、TCD等)。 3. 48h内，阿司匹林或氯吡格雷治疗;有禁忌者除外，但病程录中 须有记录。 4. 评价血脂水平并分型对症处理、评价吞咽功能并记录。 5. 严重瘫痪或长期卧床者，应有足底泵等预防深静脉血栓措施。 6. 出院时继续规范使用阿司匹林或氯吡格雷，因禁忌未使用者，病 程录中须有记录。 7. 平均住院日?21天，平均住院费用?15000(自费项目除外)，遇 特殊情况，平均住院日和平均住院费用超标，需加以说明并记录。 8. 以上各项相关内容记录在病程录或出院小结中。 健康教育: 1. 积极控制血压、血糖、血脂于正常水平。 2. 调理养生，戒烟戒酒。 3. 培养合理的饮食习惯:控制钠盐摄人，每人每天应该?6,;减少 饱和脂肪酸和胆固醇的摄入;增加新鲜水果、蔬菜的摄入。 4. 培养健康的生活方式，适当锻炼。 5. 控制体重:理想身体质量指数(BMI)I:18.5,24.9kg/m2 BMI,体重(kg)/ 身高的平方(m2)。 advantages, facing the Yangtze River Delta, Pearl River Delta, Shandong peninsula, Beijing-Tianjin-Tangshan area, targeted investment promotion several times. Industry-led unit and various town streets are developing detailed promotion plans, the basis of what is specific to each industry, has formed a kind of scale, need to bring in the kind of projects each town street has the kind of resources, what location, focus on the development of the kind of industries. Four stroke technology and science. Determinants of technology is the County's economic development through scientific and technological innovation, improve product value-added and improve economic competitiveness, is the inevitable way to achieve leapfrog development. Talent is the city center city's first resource, is the primary industry development, and revitalization of the social protection. So, in terms of skills: to catch ... Competitive. Encouraging enterprises to actively undertake science and technology projects, strengthening research cooperation, using advanced technology to increase the added value of their products to ensure that introduction of transforming scientific and technological achievements during the year ... ... New research enterprises ... ... Home, creating innovative platforms ... ... Generic classifier. In: first, we must strengthen the cultivation of talent, efforts to increase vocational education and training and meet the basic demand of enterprise development. Then introduced a number of the county needed scarce education, health professionals, meet social development needs to invest more in machinery, pharmaceutical manufacturing research and development in higher education, such as the introduction of talent to meet the need. Third, we must rely on ... ... Post-doctoral workstation, ... ... Food research station platform, to the XX University to find experts 三、急性心肌梗死急诊服务流程与规范 1 怀疑缺血性胸痛 2 气道阻塞 ,清除气道异物，保持气紧急评估 道通畅;大管径管吸痰 ,有无气道阻塞 ,气管切开或者插管 ,有无呼吸，呼吸的频率和程度 呼吸异常 ,有无脉搏，循环是否充分 ,神志是否清楚 呼之无反应，无脉搏 心肺复苏 无上述情况或经处理解除危 及生命的情况后 稳定后3 4 ,停止活动，绝对卧床休息，拒探视 快速评估(<10分钟) ,大流量吸氧，保持血氧饱和度95%以上 ,迅速完成12导联的心电图 ,阿司匹林160,325mg嚼服 ,简捷而有目的询问病史和体格检查 ,硝酸甘油0.5mg(舌下含化)，无效5,20µg/min静脉滴注 ,审核完整的溶栓清单(参见《急救流程》一书)、核查禁忌证 ,胸痛不能缓解则给予吗啡2,4mg静脉注射，必要时重复 ,检查心肌标志物水平、电解质和凝血功能 ,建立大静脉通道、监护心电、血压、脉搏和呼吸 ,必要时床边X线检查 10分钟内 5 回顾初次的12导联心电图 6 7 8 ST段抬高或新出现(或可能新)的LBBB* ST段压低或T波倒置 ST段和T波正常或变化无意义 10 9 11 ST段抬高性心肌梗死 非ST段抬高心肌梗死(NSTEMI)中低危性不稳定型心绞痛(UA) (STEMI) 或高危性不稳定型心绞痛(UA) 20分钟内 16 12 19 ****** 辅助治疗(根据禁忌症调节) 辅助治疗(根据禁忌症调整) 辅助治疗(根据禁忌症调整) ,β-受体阻滞剂(禁忌时改用钙离子拮抗剂如,硝酸甘油 ,硝酸甘油 ,β-受体阻滞剂 地尔硫卓15,20mg缓慢静脉推注) ,β-受体阻滞剂 ,氯吡格雷 ,氯吡格雷 ,氯吡格雷 ,普通肝素/低分子肝素 ,普通肝素/低分子肝素 ,普通肝素/低分子肝素 ,低危者GP?b/?a拮抗剂 ,血管紧张素酶抑制剂(ACEI) ,GP?b/?a拮抗剂 ,他汀类 ,血管紧张素转换酶抑制剂(ACEI) ,不能延迟心肌再灌注治疗 ,他汀类 20 是否进展为高中危心绞痛或肌钙是 蛋白转为阳性 17 13 ,收住监护室进行危险分层，高危: 胸痛发作时间?12小时 否 ,顽固性缺血性胸痛 否 21 ,反复或继续ST段抬高 ,收住急诊或者监护病房: 是 ,室性心动过速 ,连续心肌标志物检测 14 ,血流动力学不稳定 ,溶栓治疗 ,反复查心电图，持续ST段监护 ,左心衰竭征象(如气紧、咯血、肺啰音) ,精神应急评估 ,入院溶栓针剂至血管的时间?30分钟 ,诊断性冠脉造影 30分钟内 18 22 ,早期介入治疗的适应症和时机15 ,介入治疗(有无溶栓禁忌症) ,如无心肌梗死或缺血证据，允许出院 存在争议。给予最理想药物治疗,早期PCI:入院-球囊介入?90分后仍有明显进行性的或反复发生 钟 缺血才介入治疗 ,CABG:(冠状动脉搭桥手术) 90分钟内 LBBB:左房室束支传导阻滞 辅助治疗药物: ,β-受体阻滞剂:普奈洛尔10,30mg/次，3,4次/日或1,3mg缓慢静脉注射;美托洛尔6.25,25mg Tid ,氯吡格雷:首剂300mg，此后75mg/d，连续8天 ,普通肝素60U/kg静脉注射，后继12U/(kg?h)静脉滴注;低分子肝素3000,5000U皮下注射，Bid , GP?b/?a拮抗剂:阿昔单抗0.25mg/kg静脉推注，继以10µg/(kg?h)静脉滴注12小时;替罗非班10µg/kg静脉推注，继以0.15µg/(kg?min)维持48小时 ,ACEI/ARB:卡托普利6.25,50mg Tid ，氯沙坦50,100mg Qd，厄贝沙坦 150,300mg Qd ,他汀类:洛伐他汀20,40mg Qn，普伐他汀 10,20mg Qn，辛伐他汀 20,40mg Qn;也可以选择氟伐他汀、西立伐他汀 advantages, facing the Yangtze River Delta, Pearl River Delta, Shandong peninsula, Beijing-Tianjin-Tangshan area, targeted investment promotion several times. Industry-led unit and various town streets are developing detailed promotion plans, the basis of what is specific to each industry, has formed a kind of scale, need to bring in the kind of projects each town street has the kind of resources, what location, focus on the development of the kind of industries. Four stroke technology and science. Determinants of technology is the County's economic development through scientific and technological innovation, improve product value-added and improve economic competitiveness, is the inevitable way to achieve leapfrog development. Talent is the city center city's first resource, is the primary industry development, and revitalization of the social protection. So, in terms of skills: to catch ... Competitive. Encouraging enterprises to actively undertake science and technology projects, strengthening research cooperation, using advanced technology to increase the added value of their products to ensure that introduction of transforming scientific and technological achievements during the year ... ... New research enterprises ... ... Home, creating innovative platforms ... ... Generic classifier. In: first, we must strengthen the cultivation of talent, efforts to increase vocational education and training and meet the basic demand of enterprise development. Then introduced a number of the county needed scarce education, health professionals, meet social development needs to invest more in machinery, pharmaceutical manufacturing research and development in higher education, such as the introduction of talent to meet the need. Third, we must rely on ... ... Post-doctoral workstation, ... ... Food research station platform, to the XX University to find experts