Backgroundì严重创伤是全球重大公共卫生问题。创伤导致全球每年死亡人数580万以上，预测2020＞800万。WHO统计道路交通事故、自杀和他杀为三大主要死亡原因。通过创伤出血患者的管理，教育和先进临床指南协助，早期的恰当处理包括及时查明出血原因，及时减少失血措施，恢复组织灌注和血流动力学稳定，可以减少创伤患者死亡。ì入院时大约1/3创伤出血患者已出现凝血功能障碍，显著增加了病死率和多器官功能衰竭发生率。ì过去十年，创伤后出血病理生理学已被越来越多的认识并伴随管理策略的演变，早期创伤相关的凝血功能障碍主要由失血性休克导致组织损伤相关的凝血酶血栓调节蛋白复合物生成和纤维蛋白原裂解途径的激活。严重凝血障碍导致酸中毒，低体温，稀释、低灌注和凝血因子消耗。此外，与创伤凝血相关因素如脑损伤，与患者相关因素包括年龄、遗传背景、并发症，炎症和术前用药，尤其是口服抗凝药物和院前的流程管理。ì欧洲严重创伤出血和凝血病指南自2007年由创伤出血高级特别小组发布后，分别在
2010,2013年进行了更新并在2013年作为欧洲止血运动（STOPtheBleedingCam-paign）的内容，2016再次更新。
Fig.1Schematicdrawingofthefactors,bothpre-existingandtrauma-related,thatcontributetotraumaticcoagulopathy现在的状态年龄遗传因素合并症受伤前用药损伤组织损伤
细胞因子和激素释放失血炎性反应纤维蛋白原激活凝血因子消耗休克止血机制激活血管内皮损伤组织缺氧复苏酸中毒晶体胶体红细胞输注
低体温创伤性凝血病稀释性凝血病
指南目录I.初始复苏和预防进一步出血II.出血的诊断和鉴别III.组织氧合、液体类型和体温管理IV.出血的紧急控制V.出血和凝血障碍的早期处理VI.进一步复苏VII.指南执行和质量控制
I.初始复苏和预防进一步出血InitialresuscitationandpreventionoffurtherbleedingMinimalelapsedtimeì建议1：建议严重损伤患者直接运送到一个合适的创伤中心救治（1B级）尽量缩短损伤与控制出血之间的时间。（1A级）ìRecommendation1Werecommendthatseverelyin-juredpatientsbetransporteddirectlytoanappropriatetraumafacility.(Grade1B)，Werecommendthatthetimeelapsedbetweeninjuryandbleedingcontrolbeminimised.(Grade1A)
止血带的使用Tourniquetuseì推荐2：建议开放性四肢骨折导致威胁生命大出血在外科手术前使用止血带（1B）ìRecommendation2Werecommendadjuncttourni-quetusetostoplife-threateningbleedingfromopenex-tremityinjuriesinthepre-surgicalsetting.(Grade1B)
通气Ventilationì推荐3：建议避免低氧血症（1A）ì建议创伤患者正常通气（1B）ì如果存在即将发生脑疝迹象，建议过度通气（2C）ìRecommendation3Werecommendtheavoidanceofhypoxaemia.(Grade1A)ìWerecommendnormoventilationoftraumapatients.(Grade1B)ìWesuggesthyperventilationinthepresenceofsignsofimminentcerebralherniation.(Grade2C)
II.出血的诊断和鉴别Diagnosisandmonitoringofbleeding初步评估Initialassessmentì推荐4：我们建议医生结合病人的生理指标、损伤的解剖模式、损伤机制以及患者对初始复苏的反应来综合评估创伤性出血的程度。（1C）ìRecommendation4Werecommendthatthephysicianclinicallyassesstheextentoftraumatichaemorrhageusingacombinationofpatientphysiology,anatomicalinjurypattern,mechanismofinjuryandthepatient’sresponsetoinitialresuscitation.(Grade1C)
紧急干预Immediateinterventionì推荐5：我们建议对于明确出血部位的出血性休克患者，应立即采取控制出血措施，除非初始复苏措施是成功的。（1B）ìRecommendation5Werecommendthatpatientspre-sentingwithhaemorrhagicshockandanidentifiedsourceofbleedingundergoanimmediatebleedingcontrolprocedureunlessinitialresuscitationmeasuresaresuccessful.(Grade1B)
进一步检查Furtherinvestigationì推荐6：建议未明确出血部位的失血性休克患者需要进一步的检查（1B）ìRecommendation6Werecommendthatpatientspresentingwithhaemorrhagicshockandanuniden-tifiedsourceofbleedingundergoimmediatefurtherinvestigation.(Grade1B)
影像学Imagingì推荐7：建议怀疑躯干伤的患者早期行影像学检查（超声或增强CT）明确胸腹腔游离液体（1B）?Recommendation7Werecommendearlyimaging(ultrasonographyorcontrast-enhancedCT)forthedetectionoffreefluidinpatientswithsuspectedtorsotrauma.(Grade1B)
干预Interventionì推荐8：对于严重胸腔、腹腔、腹膜后创伤出血且血液动力学不稳定的患者需立即进行干预（1A）?Recommendation8Werecommendthatpatientswithsignificantintra-thoracic,intra-abdominalorretroperitonealbleedingandhaemodynamicinstabilityundergourgentintervention.(Grade1A)
再次评估Furtherassessmentì对于血液动力学稳定的患者，我们建议进行CT检查评估（1B）?Recommendation9WerecommendCTassessmentforhaemodynamicallystablepatients.(Grade1B)
血红蛋白Haemoglobinì推荐10：将初始低水平血红蛋白作为判断严重出血性凝血病的一个指标（1B）建议反复测量HB作为监测出血的一个指标，因为初始值在正常范围可能掩盖出血（1B）?Recommendation10Werecommendthatalowini-tialHbbeconsideredanindicatorforseverebleedingassociatedwithcoagulopathy.(Grade1B)?WerecommendtheuseofrepeatedHbmeasure-mentsasalaboratorymarkerforbleeding,asaninitialHbvalueinthenormalrangemaymask
bleeding.(Grade1B)
血乳酸和碱缺失Serumlactateandbasedeficitì推荐：检测血乳酸和/或碱缺失作为评估、监测出血和休克的敏感指标（1B）?Recommendation11Werecommendserumlactateand/orbasedeficitmeasurementsassensitiveteststoestimateandmonitortheextentofbleedingandshock.(Grade1B)
凝血功能监测Coagulationmonitoringì推荐12：早期、反复的凝血功能监测，实验室指标[PT、APTT、血小板、纤维蛋白原]（1A）和/或血栓弹力图（1C）?Recommendation12Werecommendthatroutinepracticeincludetheearlyandrepeatedmonitoringofcoagulation,usingeitheratraditionallaboratorydetermination[prothrombintime(PT),activatedpartialthromboplastintime(APTT)plateletcountsandfibrinogen](Grade1A)and/oraviscoelasticmethod.(Grade1C)
III.组织氧合、液体类型和体温管理Tissueoxygenation,typeoffluidandtemperaturemanagement组织氧合Tissueoxygenationì推荐13：对于无颅脑损伤的患者，收缩压应维持在80-90mmHg（1C）对于合并有严重颅脑损伤的患者（GCS≤8）维持平均圧≥80mmHg（1C）?Recommendation13Werecommendatargetsystolicbloodpressureof80–90mmHguntilmajorbleedinghasbeenstoppedintheinitialphasefollowingtraumawithoutbraininjury.(Grade1C)
?InpatientswithsevereTBI(GCS≤8),werecommendthatameanarterialpressure≥80mmHgbemain-tained.(Grade1C)
限制性容量置换Restrictedvolumereplacementì推荐14：使用限制容量置换策略实现目标血压直到出血被控制。(1B)?Recommendation14Werecommenduseofarestrictedvolumereplacementstrategytoachievetargetbloodpressureuntilbleedingcanbecontrolled.(Grade1B)
血管活性药物和强心药物Vasopressorsandinotropicagentsì推荐15：如果存在威胁患者生命的低血压，我们推荐液体治疗同时使用血管活性药物来维持目标动脉压（1C）如果存在心功能不全，推荐使用强心药（1C）?Recommendation15Inthepresenceoflife-threateninghypotension,werecommendadministra-tionofvasopressorsinadditiontofluidstomaintaintargetarterialpressure.(Grade1C)
?Werecommendinfusionofaninotropicagentinthepresenceofmyocardialdysfunction.(Grade1C)
液体类型Typeoffluidì推荐16：初始复苏使用等渗晶体液对低血压的创伤患者（1A）ì建议应避免大量使用0.9%NaCl（2C）ì对于严重颅脑损伤的患者应避免使用低渗液，如乳酸林格氏液（1C）ì因对止血效果的不良影响，我们建议限制性使用胶体液（2C）ìRecommendation16Werecommendthatfluidtherapyusingisotoniccrystalloidsolutionsbeinitiatedinthehypotensivebleedingtraumapatient.(Grade1A)ìWesuggestthatexcessiveuseof0.9%NaClsolutionbeavoided.(Grade2C)ìWerecommendthathypotonicsolutionssuchasRinger’slactatebeavoidedinpatientswithsevereheadtrauma.(Grade1C)ìWesuggestthattheuseofcolloidsberestrictedduetotheadverseeffectson
haemostasis.(Grade2C)
红细胞Erythrocytesì推荐17：维持目标HB7-9g/dl（1C）?Recommendation17WerecommendatargetHbof7to9g/dl.(Grade1C)
体温管理Temperaturemanagementì推荐18：早期采取措施减少热量散失，对于低体温的患者进行复温达到并维持正常体温（1C）ìRecommendation18Werecommendearlyapplica-tionofmeasurestoreduceheatlossandwarmthehypothermicpatientinordertoachieveandmaintainnormothermia.(Grade1C)
V.出血的紧急控制Rapidcontrolofbleeding损伤控制性外科Damagecontrolsurgeryì推荐19：对于合并重度失血性休克、持续性出血和凝血病的患者，建议实施损伤控制性外科治疗（1B）ì其他需要实施损伤控制性外科的情况：严重凝血病、低血压、酸中毒、难以控制的解剖损伤、操作耗时或同时合并腹部以上的严重创伤（1C）ì对于血液动力学稳定的且不存在上述情况的患者，建议实施确定性外科手术（1C）ìRecommendation19Werecommendthatdamagecontrolsurgerybeemployedintheseverelyinjuredpa-tientpresentingwithdeephaemorrhagicshock,signsofongoingbleedingandcoagulopathy.(Grade1B)ìOtherfactorsthatshouldtriggeradamagecontrolapproachareseverecoagulopathy,hypothermia,acidosis,inaccessiblemajoranatomicinjury,aneedfortime-consumingproceduresorconcomitantmajorinjuryoutsidetheabdomen.(Grade1C)
ìWerecommendprimarydefinitivesurgicalman-agementinthehaemodynamicallystablepatientandintheabsenceofanyofthefactorsabove.(Grade1C)
骨盆环关闭和固定Pelvicringclosureandstabilisation推荐20：失血性休克的骨盆环破坏患者，立即采取骨盆环关闭和稳定的措施（1B）?Recommendation20Werecommendthatpatientswithpelvicringdisruptioninhaemorrhagicshockundergoimmediatepelvicringclosureandstabilisa-tion.(Grade1B)
填塞、栓塞和手术Packing、embolisationandsurgeryì推荐21：对于骨盆环稳定后持续血液动力学不稳定的患者，早期实施腹膜外填塞、动脉造影栓塞和/或外科手术控制出血（1B）ìRecommendation21Werecommendthatpatientswithongoinghaemodynamicinstabilitydespitead-equatepelvicringstabilisationreceiveearlypre-peritonealpacking,angiographicembolisationand/orsurgicalbleedingcontrol.(Grade1B)
局部止血措施Localhaemostaticmeasuresì推荐22：对于实质性器官损伤伴有静脉出血或中等程度的动脉出血，联合使用局部止血药物、其他外科方法或填塞止血（1B）ìRecommendation22Werecommendtheuseoftopicalhaemostaticagentsincombinationwithothersurgicalmeasuresorwithpackingforvenousormoderatearterialbleedingassociatedwithparenchy-malinjuries.(Grade1B)
V.出血和凝血障碍的早期处理Initialmanagementofbleedingandcoagulopathy凝血功能支持Coagulationsupportì推荐23：入院后尽早检测并采取措施维持凝血功能（1B）ìRecommendation23Werecommendthatmonitoringandmeasurestosupportcoagulationbeinitiatedim-mediatelyuponhospitaladmission.(Grade1B)
早期止血复苏Initialcoagulationresuscitationì推荐24：预计中大出血患者的早期处理，推荐下列两项中的一项：?血浆（FFP或病原体灭活的血浆），如果需要，血浆：RBC比至少为1:2（1B）?纤维蛋白原和RBC是否使用根据HB水平判断（1C）ìRecommendation24Intheinitialmanagementofpa-tientswithexpectedmassivehaemorrhage,werec-ommendoneofthetwofollowingstrategies:?Plasma(FFPorpathogen-inactivatedplasma)inaplasma–RBCratioofatleast1:2asneeded.(Grade1B)
?FibrinogenconcentrateandRBCaccordingtoHblevel.(Grade1C)
抗纤溶药Antifibrinolyticagentsì推荐25：对于出血或存在大出血风险的创伤患者尽早使用氨甲环酸1g注入10分钟以上，之后静脉注入1g至少持续8h（1A）ì创伤出血患者应在伤后3h内使用氨甲环酸（1B）ì建议制定创伤出血处理流程时，患者在转运医院途中考虑使用首剂氨甲环酸（2C）ìRecommendation25Werecommendthattranexamicacidbeadministeredasearlyaspossibletothetraumapatientwhoisbleedingoratriskofsignifi-canthaemorrhageataloadingdoseof1ginfusedover10min,followedbyani.v.infusionof1gover8h.(Grade1A)ìWerecommendthattranexamicacidbeadminis-teredtothebleedingtraumapatientwithin3hafterinjury.(Grade1B)ìWesuggestthatprotocolsforthemanagementofbleedingpatientsconsideradministrationofthefirstdoseoftranexamicacidenroutetothehospital.(Grade2C
)
VI.进一步复苏Furtherresuscitation目标化治疗Goal-directedtherapyì推荐26：使用标准的实验室凝血指标和/或血栓弹力图制定目标化管理策略指导复苏（1C）ìRecommendation26Werecommendthatresuscita-tionmeasuresbecontinuedusingagoal-directedstrategyguidedbystandardlaboratorycoagulationvaluesand/orviscoelastictests.(Grade1C)
新鲜冰冻血浆Freshfrozenplasmaì推荐27：如果需要以血浆为基础的止血复苏，推荐使用血浆（FFP或病原体灭活的血浆）维持PT和APTT在正常范围＜1.5倍时间（1C）ì对于不是大出血的患者不推荐血浆输注（1B）ìRecommendation27Ifaplasma-basedcoagulationresuscitationstrategyisused,werecommendthatplasma(FFPorpathogen-inactivatedplasma)bead-ministeredtomaintainPTandAPTT<1.5timesthenormalcontrol.(Grade1C)ìWerecommendthatplasmatransfusionbeavoidedinpatientswithoutsubstantialbleeding.(Grade1B)
纤维蛋白原和冷沉淀Fibrinogenandcryoprecipitateì推荐28：如果患者有大出血，血栓弹力图提示功能性纤维蛋白原缺乏或血浆纤维蛋白原水平低于1.5–2.0g/L则输注纤维蛋白原或冷沉淀（1C）ì建议纤维蛋白原起始剂量为3-4g。这相当于15-20单位单采冷沉淀或3-4g纤维蛋白原。重复使用必须在血栓弹力图及对纤维蛋白原水平进行实验室评估的基础上进行（2C）ìRecommendation28Ifaconcentrate-basedstrategyisused,werecommendtreatmentwithfibrinogenconcentrateorcryoprecipitateifsignificantbleedingisaccompaniedbyviscoelasticsignsofafunctionalfibrinogendeficitoraplasmafibrinogenleveloflessthan1.5–2.0g/l.(Grade1C)ìWesuggestaninitialfibrinogensupplementationof3–4g.Thisisequivalentto15–20singledonorunitsofcryoprecipitateor3–4gfibrinogenconcen-trate.Repeatdosesmustbeguidedbyviscoelasticmonitoringandlaboratory
assessmentoffibrinogenlevels.(Grade2C)
血小板Plateletì推荐29：输注血小板维持血小板计数在50109/L之上（1C）ì对于持续出血和/或创伤性颅脑损伤（TBI）患者维持血小板计数在100109/L之上（2C）ì如果使用,推荐输注的起始剂量为4-8u血小板或1个全血单位的血小板（2C）ìRecommendation29Werecommendthatplateletsbeadministeredtomaintainaplateletcountabove50109/L.(Grade1C)ìWesuggestmaintenanceofaplateletcountabove100×10
9/linpatientswithongoingbleedingand/orTBI.(Grade2C)ìIfadministered,wesuggestaninitialdoseoffourtoeightsingleplateletunitsoroneaphaeresispack.(Grade2C)
钙剂Calciumì推荐30：在大量输血期间监测钙水平并维持在正常范围（1C）ìRecommendation30Werecommendthationisedcalciumlevelsbemonitoredandmaintainedwithinthenormalrangeduringmassivetransfusion.(Grade1C)
抗血小板药物Antiplateletagentsì推荐31：建议对接受抗血小板治疗导致的大出血或颅内出血建议输注血小板（2C）ì建议对于接受或怀疑抗血小板的患者，检测血小板功能（2C）ì建议如果明确血小板功能不良且存在持续的微血管出血，使用浓缩血小板治疗（2C）ìRecommendation31Wesuggestadministrationofplateletsinpatientswithsubstantialbleedingorintracranialhaemorrhagewhohavebeentreatedwithantiplateletagents.(Grade2C)ìWesuggestthemeasurementofplateletfunctioninpatientstreatedorsuspectedofbeingtreatedwithantiplateletagents.(Grade2C)ìWesuggesttreatmentwithplateletconcentratesifplateletdysfunctionisdocumentedin
apatientwithcontinuedmicrovascularbleeding.(Grade2C)
去氨加压素Desmopressinì推荐32：建议对于使用抑制血小板药物和血管性血友病（vWD）患者，建议使用去氨加压素(0.3μg/kg)（2C）ì不建议创伤出血患者常规使用去氨加压素（2C）ìRecommendation32Wesuggestthatdesmopressin(0.3μg/kg)beadministeredinpatientstreatedwithplatelet-inhibitingdrugsorwithvonWillebranddisease.(Grade2C)ìWedonotsuggestthatdesmopressinbeusedroutinelyinthebleedingtraumapatient.(Grade2C)
凝血酶原复合物（PCC）Prothrombincomplexconcentrateì推荐33：对于口服依赖维生素K抗凝药患者，早期使用浓缩PCC紧急拮抗（1A）ì建议为减轻使用新型口服抗凝药物的患者发生创伤后致命性出血，给予PCC（2C）ì假如纤维蛋白原水平正常，建议使用血栓弹力图监测出血患者凝血启动延迟时使用PCC或血浆（2C）ìRecommendation33Werecommendtheearlyuseofprothrombincomplexconcentrate(PCC)fortheemergencyreversalofvitaminK-dependentoralanti-coagulants.(Grade1A)ìWesuggesttheadministrationofPCCtomitigatelife-threateningpost-traumaticbleedinginpatientstreatedwithnoveloralanticoagulants.(Grade2C)ìProvidedthatfibrinogenlevelsarenormal,wesug-gestthatPCCorplasmabeadministeredinthebleed-ingpatientbasedonevidenceofdelayedcoagulation
initiationusingviscoelasticmonitoring.(Grade2C)
直接口服抗凝剂-Xa因子抑制剂Directoralanticoagulants–factorXainhibitorsì推荐34：对于正在口服或可疑服用抗Xa-因子药物之一（如利伐沙班、阿哌沙班或依度沙班）的患者需监测血药浓度（2C）ì如果不能进行上述监测，建议征求血液科专家的意见（2C）ì如果出现致命性出血，建议使用氨甲环酸15mg/kg(or1g)同时联合使用大剂量凝血酶原复合物直至可使用特异性拮抗剂（2C）ìRecommendation34Wesuggestthemeasurementofplasmalevelsoforalanti-factorXaagentssuchasrivaroxaban,apixabanoredoxabaninpatientstreatedorsuspectedofbeingtreatedwithoneofthese
agents.(Grade2C)ìIfmeasurementisnotpossibleoravailable,wesug-gestthatadvicefromanexperthaematologistbesought.(Grade2C)ìIfbleedingislife-threatening,wesuggesttreatmentwithTXA15mg/kg(or1g)intravenouslyandhigh-dose(25-50U/kg)PCC/aPCCuntilspecificantidotesareavailable.(Grade2C)
直接口服抗凝药物-凝血酶抑制剂Directoralanticoagulants–thrombininhibitorsì推荐35：建议对于正在口服或可疑口服达比加群药的患者监测达比加群的浓度（2C）ì如果不能进行监测，建议根据凝血酶时间与APTT对比，对达比加群作定性估计（2C）ì如果出现致命性出血，建议使用idarucizumab（5giv）（1B）或无该药，建议使用大剂量PCC/aPCC(25–50U/kg)同时加用氨甲环酸15mg/kg(or1g)（2C）?Recommendation35Wesuggestthemeasurementofdabigatranplasmalevelsinpatientstreatedorsuspectedofbeingtreatedwithdabigatran.(Grade2C)?Ifmeasurementisnotpossibleoravailable,wesug-gestthrombintimeandAPTTtoallowaqualitativeestimationofthepresenceofdabigatran.(Grade2C)?Ifbleedingislife-threatening,werecommendtreatmentwithidarucizumab(5gintravenously)(Grade1B),or,ifunavailable,wesuggesttreatmentwithhigh-dose
(25–50U/kg)PCC/aPCC,inbothcasescombinedwithTXA15mg/kg(or1g)intraven-ously.(Grade2C)
重组活化因子VII（rFVIIa）RecombinantactivatedcoagulationfactorVIIì推荐36：对于已经采取标准的控制出血和最佳的传统止血措施患者，如果持续存在大出血和创伤性凝血病，建议使用rFVIIa（2C）?Recommendation36Wesuggestthattheoff-labeluseofrFVIIabeconsideredonlyifmajorbleedingandtraumaticcoagulopathypersistdespiteallotherattemptstocontrolbleedingandbest-practiceuseofconventionalhaemostaticmeasures.(Grade2C)
血栓预防Thrombo-prophylaxisì推荐37：出血控制24h后使用药物预防血栓（1B）ì尽早使用物理措施预防深静脉血栓，包括间歇气囊加压装置（IPC）（1C）和抗血栓弹力袜（2C）ì不建议常规使用下腔静脉滤器进行血栓预防?Recommendation37Werecommendpharmacologicalthromboprophylaxiswithin24hafterbleedinghasbeencontrolled.(Grade1B)?Werecommendearlymechanicalthromboprophy-laxiswithintermittentpneumaticcompression(IPC)(Grade1C)andsuggestearlymechanicalthrombopro-phylaxiswithanti-embolicstockings.(Grade2C)?Wedonotrecommendtheroutineuseofinferiorvenacavafiltersas
thromboprophylaxis.(Grade1C)
VII.指南执行和质量控制Guidelineimplementationandqualitycontrol指南执行Guidelineimplementationì推荐38：每家医疗机构对创伤出血的患者实施具有循证医学依据的临床指南（1B）?Recommendation38Werecommendthelocalimple-mentationofevidence-basedguidelinesformanage-mentofthebleedingtraumapatient.(Grade1B)
出血控制和预后的评估Assessmentofbleedingcontrolandoutcomeì推荐39：当地的临床质量和安全管理系统应该包括评估出血与结局为关键指标参数（1C）?Recommendation39Werecommendthatlocalclinicalqualityandsafetymanagementsystemsincludeparameterstoassesskeymeasuresofbleedingcontrolandoutcome.(Grade1C)
治疗阶段是否N/A变化原因初始评估与管理创伤出血评估失血性休克患者立即确定出血原因失血性休克患者不明原因的出血进一步检查凝血、HCT、血乳酸、碱缺失评估患者抗凝评估（witk拮抗剂、抗血小板、口服抗凝血药）□□□□□□□□□□□□□□□复苏无颅脑损伤SBP维持在80-90mmHg常规措施的实施目标血红蛋白7-9g/L□□□□□□□□□外科干预腹腔出血控制骨盆环闭合并固定
血液动力学不稳定行腹腔填塞、血管栓塞或外科完成止血血液动力学不稳定行损伤控制性外科手术局部止血措施thromboprophylactic疗法□□□□□□□□□□□□□□□□□□凝血管理凝血、HCT、血乳酸、碱缺失、钙重新评估目标纤维蛋白原水平1.5-2.0g/L达到目标血小板水平如果维生素K拮抗剂使用凝血酶原复合物复合物口服抗凝剂或血栓弹力图确定□□□□□□□□□□□□□□□
图4治疗路径核查单
院前集束化院内集束化凝血集束化?院前时间最小化?遇威胁性生命肢体出血时使用止血带?损伤控制复苏概念的应用?创伤病人直接转入合适的创伤专科中心?在初始15分钟内对全血计数、凝血酶原时间、纤维蛋白原、钙、血栓弹力图，乳酸、BE、PH进行评估?失血性休克患者立即干预和除非初始复苏是成功的否则确定出血的来源?立即进行进一步检查，快速超声评估、CT或腹腔大出血和不明原因的大出血造成失血性休克需立即手术?如果休克或当前凝血功能障碍则应用损伤控制性外科理念
?限制性红细胞输入策略（7-9g/L）?氨甲环酸尽早使用?酸中毒、低温和低钙血症治疗?纤维蛋白原维持在1.5-2.1g/L?血小板维持在＞100×109/L?使用PCC预处理口服华法林或抗凝药的患者（直到解毒剂可以使用）
图5建议集束化管理
谢谢！
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