谢谢道兄提供这样一个学习专业英语的机会.
luohui961 wrote:
这两天老板给活了，有点忙，刚才总结了一下大家对第一部分的修改意见如下，请道兄参考并在总的翻译中修改。如有疏漏的地方，请大家继续指正。
感谢Bo兄的耐心和syyu60、tongdourl、vygwyt等战友的热心，让我们大家的英语和专业知识共同进步！
第一部分：
第一段：
一个整形外科医生…. 一个骨外科医师
第二段：
他发现在那个领域里，利用现有的有限资源… 他发现在当时的现场, …
第三段：
它是人类40岁之前的主要死亡原因 它是人生前40年（1-44岁）的主要死亡原因
在美国，每年大约有150,000人死于三个创伤高峰中不同的时间点。 在美国，每年大约有150,000人死于创伤。创伤造成死亡的三个不同的高峰时段：
损伤后几分钟到几小时 损伤后几十分钟到几小时
第四段：
一个普通外科医生非常适合在创伤科治疗任何创伤病人。一个普通外科医生应该能够非常自如地在创伤室治疗任创伤病人
大部分创伤外科医生都富有进取心 大部分创伤外科医生都很果敢
如果你想做病危特别护理，你需要在大的创伤中心进行1年的病危特别护理的训练
如果你想救治危重病人，你需要在大的创伤中心进行1年的危重病治疗培训
Nice job. Can somebody please make those changes in the final version of the translation. thanks a lot.
Can somebody please help out to translate the answer to all those questions. i appreciate.
Bo
tongdour wrote:
这两天从BO兄的讲座中真的学到了不少，不论专业知识还是英语水平，相信大家能坚持下来对参与进来的站友都会有所收获的。应道兄要求，也看了fish0220站友的贴子，觉得既然是讲座，和“老师”的互动还是相当重要的，大家的翻译工作做得很出色了，可也别光忙着翻译而忘了我们的初衷是为了学习TRAUMA的，觉得界面有点乱，偶搜集了下原贴中有关大家和BO兄互动的内容，集中整理到下面，也算是个习题集吧，偶会不定期的更新，但最主要的是希望大家对BO兄的问题能及时回应，也可以提出自己的疑问，请将回答或疑问发在英文原贴，也好让BO兄及时调整我们的学习内容……
偶也来当回短途搬运工吧，呵呵
以下BO兄的回贴用红字，大家的提问或回答用蓝字吧，方便阅读－－－－－－－－－－－－－－－－－（一）－－－－－－－－－－－－－－－－－－－－－
（1）BO:
interesting case this time:
62 year old male attempted suicide:stab wound to the left chest. stable
what you want to do:
Pull the knife?
Call a psychiatrist?
Give him antibiotics?
Sent him to the CT scan?
Upper GI with SBFU?
Open cardiac massage
fish0220:
1、从图片上看，该患者伤后已存在生命体征不稳，考虑是否存在心脏及大血管的损伤？是否有心包填塞的症状？另外从刀刺入的方向看，考虑是否存在胸腹的联合伤？此时急需做的应该是急诊开胸手术探查，明确损伤情况，积极争取最好的手术时机，诸如CT检查及心理治疗都应该是后期的工作。
2、对于异物刺入体内，在情况不明的时候是禁忌随意拔出的。
3、对于这样一个大的开胸手术，预防性使用抗生素应该是需要的。此外备血输液也都是必须的吧。
4、至于说到开胸心脏按压，还是应该视术中情况而定吧。
说的不对的，请老师多指教，谢谢！
（2）BO:
about the case. Tongdour and fish0220 had very good view.
patient had stab wound to Left lower chest or upper abd. i'd like to discuss it after we talk about how to treat trauma patient first time when you see the patient. you too be patient. i hope at the end , you can tell me what you can do to help this patient fast and right.－－－－－－－－－－－－－－－－－（二）－－－－－－－－－－－－－－－－－－－－－
（3）BO:
a bonus question: please do answer.
how chest have you cracked (which means median sternotomy and thoracotomy)?
fish0220:
对于手术入路的选择，应以简易的手术方式尽快接近心脏为目的，一般来说，左前外切口容易接近左室、右室前壁，胸骨正中或右前外切口用于处理右房和腔静脉伤。该患者个人认为应选择左侧胸廓切开术，这样也有利于必要时增加腹部切口的准备。由于个人对胸外没有临床手术经验，请老师指点。谢谢！
（4）BO:
i want to explain more about the bolus question:
the bolus question about cracking chest is not regarding this patient in the picture. it is a general question for every general surgery. please don't think chest is belong to the thoracic surgeon. as i mentioned before, trauma surgeon should be able to operate on any body cavity, chest is a common one. so i'd like to know how many chests have you cracked, are you comfortable to open a chest if you have to .
fish0220:
我并没有实际做过开胸的手术，当然腹部的某些手术可能涉及到胸腔的问题，如果必须由我来做，也许可以开，但绝对无法达到胸外专科医生的水平。我想大多数医生只可能在某个领域有所专长，可以达到comfortable的水平。个人认为，对于创伤患者的诊治，关键在于及时判断病情、做出初期的处理意见，而在实际的治疗过程中，只要条件允许，可以按照病情需要请相关科室医生会诊，这样也是对患者的负责吧。难道国外的创伤医生真的都是“全能战士”了？
（5）BO:
for trauma surgeon, we always face life threatening injury. you are the first doctor to see the trauma patient. the patient may be dying in front of you, there is no time for you to call consult. for example: stab wound to the left chest, forth intercostal space, patient just arrived, gasping breath, BP 40/0, pulse 30. right after you see him, he lost his pulse. what wound you do? are you going to call cardiothoracic surgeon, or you just cut the patient? i cut one, and brought him back. he walked out the hospital.
you are not going to do complicated vavle repair or CABG, You open the chest to try to save the patient's life, most stop the bleeding, cardiac massage, clamp the aorta.
trauma surgeon (or general surgeon ) treat a patient as a whole, not just a belly surgeon.
fish0220:
回复BoYang1998兄关于创伤医生开胸急救的问题：
对于您举的例子，也就是说在那种只有你一个人在现场的情况下，当然您的处理手段是必需的。但对于一个相对成熟的急救体系而言，我个人认为，对于您举的那样生命危急的患者，应该在急救信息发出时即应预先召集好相关的急救人员做好急救准备，即您在讲座中所提到的“创伤团队”。
据我了解，在美国，院前急救人员会将创伤患者按损伤严重程度分为三类：Ⅰ类(伴或不伴生命体征不稳定，有生命威胁的创伤)由创伤服务主任带领全体创伤小组成员等候在急诊室，以便在患者到达后及时开展诊断和抢救；Ⅱ类(生命体征稳定，有潜在生命威胁的创伤)为选择性要求创伤小组成员在患者到达急诊室时及时展开诊断与救治；Ⅲ类(生命体征稳定，无生命威胁的创伤)为损伤较轻，仅由创伤小组中的急诊医师和急诊护士提供服务，必要时邀请创伤外科医师会诊。
而在主要创伤中心，患者急诊入院处理期间，各专科医师，尤其是骨科、神经外科、胸心外科和整形外科医师都需要密切介入。大多数创伤中心，各专科医师更多地起着会诊作用，但这些专科都是创伤项目必不可少的组成部分，他们的责任是在急诊室检查患者，鉴别专科损伤，设计和实施适合于每个患者的治疗计划。所以我个人认为，除非是情非得以，对于创伤人员的救护还应请相关的专科医师给予最恰当的诊疗。当然，对于您所说的整体诊疗的观点，是完全同意的。
（6）BO:
what you are saying is partially right. those subspecialty will be available but they won't stand at trauma bay as you do, waiting for the patient coming. traumatic injury is so unpredictable, nobody knows what's going on with the coming patient until he comes. so it is not practical to have all the subspecialty be at trauma bay. at the same time, trauma patient's condition changes so fast, you have no time to call for help when the patient arrives.
the fact in the USA now is: as a trauma surgeon, you are supposed to take care of any trauma patient. if you are a certified trauma surgeon, you don't need to be the director of trauma surgery to take critical patient. as far as other specialties, if you don't call for consult, they won't show up. like the case i mentioned above, it happened at midnight, you won't have a cardiothoracic surgeon standing side by side with you, waiting for the patient coming. since critcal trauma injury happens every night, there is no way to have other specialty be in house as a trauma surgeon does. after you stablize the patient, if the patient has complicated heart or aorta injury or other injuries, then you call them and they will come to help you. when you choose to be a trauma surgeon, you choose to be in the disasters, you choose to fight death all the time. i will talk about more about trauma team soon.－－－－－－－－－－－－－－－－－（三）－－－－－－－－－－－－－－－－－－－－－
johnsonyyy：
既然Bo兄有如此好的资源，建议您详细的讲一讲！
关于trauma bay的设置、人员配备、运作流程、工作常规，我觉得都是很好的内容，都值得学习。比如说一个病人送过来，谁站在那个位置，谁负责插管，谁负责开静脉通道，谁负责监控生命体征，都得要有明确的分工协作才能忙而不乱，洁身时间，效率达到最大化，希望Bo兄介绍你们的经验：一个病人送过来，多少个医生护士该立即行动起来？如何行动？
创伤外科医生的培养和条件我觉得也是值得详细讨论的。Bo雄可以结合自己实际的经验，比如说讲一讲您自己当初是怎么走上这条道路的，给我们一点启发！
关于抢救的原则问题，Bo兄应该详细列出来讲。一个病人来了，首先要干什么，怎么作；然后要干什么，怎么做；怎么判断这个病人该进行这个，进行那个？都是有趣的话题！
到具体病例，比如那个自杀的病人，Bo熊可以把你的问题提出来，大家讨论。然后Bo雄给出当时你们的做法，我们在一起回顾那些做对了，哪些做得不够好，对大家对Bo熊都是提高！
这些是我的一点小小的建议，我希望这个讲座会办得很成功，成为的又一经典！我会继续关注这个讲座并积极参与其中，向各位学习！
（7）BO:
Johnsonyyyyyyyyyyyyy, i like your questions, right to the point, ahead of time. your question needs a whole chapter to answer. here comes our second part of this talk. trauma system, trauma center and trauma team.－－－－－－－－－－－－－－－－－（四）－－－－－－－－－－－－－－－－－－－－－
（8）BO:
questions for today: please do answer. i want to know if i need talk about those procedures.
1. how many chest tubes have you put in? how do you do it?
2. how many central lines have you done, including internal jugular vein, subclavian vein, femoral vein? how many arterial lines have you done? how many pulmonary artery catheter(SWAN catheter) have you done?
3. how many emergent cricothyoidectomy or tracheostomy have you done?
as a trauma chief resident or trauma surgeon, cental lines or chest tubes should be done in 1-2 minutes, tracheostomy should be within 5 minutes.
i really appreciate your answers to the questions i asked. they will help me plan the discussion. thanks
tongdour：
偶是在读的研究生，对临床工作真是没大动过手，只是见过气管插管，胸腔引流、环甲膜切开，以上的这些如果对于急救，没有其他学医的在的话，偶相信自己可以大胆进行，而且不会犯什么致命的错误，反正是救命要紧嘛……
对于中心导管置管、SWAN导管只在课本上知道，可从来没见过，其实真的很需要这方面的知识，实习两年都没见过也没听过哪个科用，自己感觉是不是操作真的不简单？不知道BoYang兄能不能传点现场的照片上来看看？有个感性认识也好啊……
还有，BoYang兄讲的创伤级别RED WHITE GREEN，你自己都能记下来吗？能分的那么确切吗？唉，尤其是这样评估划分级别的东西实在太难记了，偶学医最烦的就是这些，不知道BoYang兄有什么妙招没有？其实在临床中，见到的许多东西和课本的理论都是不一样的，很多教授都没有按一些理论来进行操作，比如胃CA的根治，有谁真的按照分组来清扫淋巴结？还D1、D2、D3的分呢？不过真见过一例，是老主任的老同学，教授做了7个小时，平时的一般胃癌2、3个小时就下来了，不知道国外的医疗环境怎么样？
还有那个trauma personnel protocal，BoYang兄那是严格按照理论来站位吗？偶感觉理论归理论，可能说出来大家都明白，但要在国内，估计没人会那么站位……
所以也希望BoYang兄能捎带着介绍下国外的医疗环境，大夫日常工作都是那么的井然有序吗?
(9)BO:
thank you Tongdour for responding all questions. i still hope to see more responses. based on his response, i'd like to discuss a little bit about those basic procedures before we go on.
还有，BoYang兄讲的创伤级别RED WHITE GREEN，你自己都能记下来吗？能分的那么确切吗？唉，尤其是这样评估划分级别的东西实在太难记了，
i can't remember all of them either, ~_^. it took me a while to find those documents. what's important to me is: it is red or white. then i will go down and ask the nurse what is coming in.
比如胃CA的根治，有谁真的按照分组来清扫淋巴结？还D1、D2、D3的分呢？不过真见过一例，是老主任的老同学，教授做了7个小时，平时的一般胃癌2、3个小时就下来
right now, we emphysize evidence based practice. many traditional rules have been proved not right. we have shaped our practice based on large clinical trials. there are standard practice, if you are not following the standards, once you have complication, you will lose your case easily and pay a lot money to compensate the patient.
还有那个trauma personnel protocal，BoYang兄那是严格按照理论来站位吗？偶感觉理论归理论，可能说出来大家都明白，但要在国内，估计没人会那么站位……
Sometimes it is very hard to keep things in order, so trauma surgeon and trauma chief have to be strong and aggressive. you can ask people to shut up or move out of your way. in trauma bay, we work like sodiers.
i was going to discuss how to set up trauma bay, but i found it may be necessary to discuss those skill procedures i mentioned above. please let me know if you like to discuss those procedures. i really like to see more responses.
Another favor i want to ask. my dear friends, could you please translate all my responses to the questions from you guys. thanks a lot.
TO Ivygwyt and 道可道非常道:
Hi, brothers,
you guys had some overlaping of the translation. both work were excellent. please check out each other's to make some changes. thanks a lot.
1. annominate A should be innominate A (A TYPO)
2. Chest tube: should be translate as chest draining tube
3. 急诊内科医师仅仅告诉护士患者受的是什么伤。EMT: emergent medicine technician, reponsible for prehospital care. they call the ER triage nurse to tell her what injury the patient has. they are not ER doctors.
4. lvygwyt：femoral line work work？是不是won’t work---------that's right. sorry about all the typos. i type too fast.
5. 有很多匪徒、毒贩子，他们遭枪击后，任何的手术操作都不需要手术同意书，这是法律，因为患者就要死了，他没法签字。针对创伤外科医师的法律规定不是通用的，（lvygwyt：如果不是创伤急诊，还是要签字），每个人都知道患者来之前就受伤了，外科医生努力去救他的命。好的法律体系能够帮助（医生）应对这些困境。----------- please revise the paragraph. thanks a lot.
thanks again, guys. way to go.
li_88_xin wrote:
以下是前文中出现的部分专业词汇，希望能方便大家以后的阅读
Trauma surgery 创伤外科
General surgery 普外科
orthopedic surgeon 整形外科-----------bone doctor, not plastic surgeon
EMS(emergency medicine services) 急救员 (EMT)
residents 住院医生
trauma chief resident 创伤住院总医师
trauma senior/ junior resident 创伤高/低年资住院医师
ER doctors 急诊室医生
Technician 技术员
respiratory therapist 呼吸治疗师
OR nurse 手术室护士
Anesthesia 麻醉
Anesthesiologists 麻醉师
Neurosurgeons 神经外科医师
trauma orthopedic surgeons 创伤矫形医师
plastic surgeons 整形外科医师
cardiothoracic surgeons 胸心外科医师
trauma system 创伤急救体系
Trauma center 创伤中心
trauma bay 创伤室-------------BEAUTIFUL Translation
trauma codes 创伤代码
critical care 病危特别护理--------- more treating than nursing
access to care 急救反应通道
prehospital care 院前急救
initial care 初步救治
definitive care 最终救治
Transfer agreements 转院同意书
Protocols 协议
hemopneumothorax 血气胸
pneumothorax 气胸 (breviation: PTx)
sepsis 败血症
resuscitate 复苏
rehabilitation 康复
Intubation 插管
chest tube 胸管 ----more like chest draining tube
cricothyroidotomy 气管切开------------ not treachostomy
central line
中心静脉通路
internal jugular vein 颈内静脉
carotid artery 颈动脉
subclavian vein 锁骨下静脉
subclavian A 锁骨下动脉
innominate A 无名动脉
sternotomy 胸骨切开术
what a nice summary. beautiful job.
我认领第六部分－－（1）。请大家翻译前一定先回帖认领，避免重复翻译。
根据bo兄意见修正。
（1）trauma/general surgery basic skill procedure:
创伤外科/普外科基本操作
i'd like to talk about one important airway management first before i talked about lines.
在讨论中心静脉通路前，我想先谈谈气道管理的重要内容。
1 SURGICAL CRICOTHYROIDOTOMY
1、外科环甲膜切开术
A. Place the patient in a supine position with the neck in a neutral position. Palpate the thyroid notch, cricothyroid interval, and the sternal notch for orientation. Assemble the necessary equipment.
A、体位和定位。准备好必要的器具后。患者处平卧位，头颈部保持中线位。（在环状软骨与甲状软骨之间正中处可触到一凹陷，即环甲膜。）分别触摸甲状软骨、环状软骨以及胸骨颈静脉切迹，以帮助定位。
B. Surgically prepare and anesthetize the area locally, if the patient is conscious. no anesthesia is need if patient's unconsious.
B、术区常规消毒。如果病人意识清醒则在术区做局麻。如果病人已然没有意识，则不需要局麻。
C. Stabilize the thyroid cartilage with the left hand and maintain stabilization until the trachea is intubated.
C、在成功置入气管导管前，用左手牢牢固定住甲状软骨。
D. Make a transverse skin incision (2 cm, not too long) over the cricothyroid membrane, and carefully incise through the membrane transversely.
D、于环甲膜上做一横行皮切口（2cm左右，切口不要过长），然后小心切开环甲膜。
E. Insert the scalpel handle into the incision and rotate it 90° to open the airway as i showed before (A hemostat or tracheal spreader also may be used instead of the scalpel handle.)
E、用刀柄在切口内旋转90度撑开切口以开放气道。（也可以用血管钳或气管扩张器来撑开切口）
F. Insert an appropriately sized, cuffed endotracheal tube or tracheostomy tube (usually a #5 or #6) into the cricothyroid membrane incision, directing the tube distally into the trachea.
F、将导管置入切口，并明确导管远端位于气管内。要选用合适型号的导管（一般是5、6号），气管插管用的带气囊的导管或气管切开使用的导管均可选用。
G. Inflate the cuff and ventilate the patient.
G、打上气囊并开始通气。
H. Observe lung inflations and auscultate the chest for adequate ventilation.
H、观察胸廓起伏并行肺部听诊明确是否充分换气。
I. Secure the endotracheal or tracheostomy tube to the patient to prevent dislodging.
I、固定导管，避免脱落。
J. Caution: Do not cut or remove the cricothyroid cartilage.
J、注意事项：手术时应避免切伤环状软骨，以免术后出现喉狭窄。
COMPLICATIONS OF SURGICAL CRICOTHYROIDOTOMY
环甲膜切开术并发症
1. Aspiration (eg, blood)
误吸
2. Creation of a false passage into the tissues
假性通道形成
3、Subglottic stenosis/edema
声门水肿或狭窄
4. Laryngeal stenosis
喉狭窄
5. Hemorrhage or hematoma formation
出血或形成血肿
6. Laceration of the esophagus
食道裂伤
7. Laceration of the trachea
气管裂伤
8. Mediastinal emphysema
纵隔气肿
9. Vocal cord paralysis, hoarseness
声带麻痹，声音嘶哑
10 DON'T DO IT FOR CHILDREA LESS THAN 11 YEARS OLD. IT WILL CAUSE DEFORMITY OF THE LARYNX.
11岁以下患者禁行此术，因为可能导致喉头畸形。
附段落全文：
创伤外科/普外科基本操作
在讨论中心静脉通路前，我想先谈谈气道管理的重要内容。
1、外科环甲膜切开术
A、体位和定位。准备好必要的器具后。患者处平卧位，头颈部保持中线位。（在环状软骨与甲状软骨之间正中处可触到一凹陷，即环甲膜。）分别触摸甲状软骨、环状软骨以及胸骨颈静脉切迹，以帮助定位。
B、术区常规消毒。如果病人意识清醒则在术区做局麻。如果病人已然没有意识，则不需要局麻。
C、在成功置入气管导管前，用左手牢牢固定住甲状软骨。
D、于环甲膜上做一横行皮切口（2cm左右，切口不要过长），然后小心切开环甲膜。
E、用刀柄在切口内旋转90度撑开切口以开放气道。（也可以用血管钳或气管扩张器来撑开切口）
F、将导管置入切口，并明确导管远端位于气管内。要选用合适型号的导管（一般是5、6号），气管插管用的带气囊的导管或气管切开使用的导管均可选用。
G、打上气囊并开始通气。
H、观察胸廓起伏并行肺部听诊明确是否充分换气。
I、固定导管，避免脱落。
J、注意事项：手术时应避免切伤环状软骨，以免术后出现喉狭窄。
环甲膜切开术并发症
1、误吸
2.假性通道形成
3. 声门水肿或狭窄
4. 喉狭窄
5. 出血或形成血肿
6. 食道裂伤
7. 气管裂伤
8. 纵隔气肿
9. 声带麻痹，声音嘶哑
10、11岁以下患者禁行此术，因为可能导致喉头畸形。
认领第六部分－－（2）。请大家注意及时回帖说明，避免重复认领。
（2）Central lines
中心静脉通路（前面有兄弟提出用中心管路，但是个人觉得具体内容并不涉及动脉，故仍用中心静脉通路。欢迎讨论指正。）
For the IV access, you always want to try peripheral IV first, use large bore IV catheters (16, 18 gague catheter). in emergent case, needs large volume resuscitation, you can put central line quickly. femoral line is always a good start except you suspect patient has IVC injury.
你可能会先选择周围静脉选用大孔径导管（16、18号导管）来进行输液急救。在处理急救病人时，需要输注大量的液体来进行抢救，需快速开通中心静脉通路。在明确没有下腔静脉损伤后，经股静脉开通中心静脉通路是首选路径。
there are three types of catheters for centrl line: cordess (single lumen, largest), double lumen and triple lumen catheter. if you have the kit (ARROW central line kit), you should have everything you need to do the line). for resuscitation of trauma patients, cordess is preferred due the largest lumen, delivering resuscitation fluids fastest.
常用的中心静脉导管分三种：单腔大孔径中心静脉导管，双腔、三腔中心静脉导管。如果你有导管套装（比如arrow的导管套装），那么就相对方便不少，因为操作用的器具导管套装里基本都有。对于创伤病人的早期复苏，单腔大孔径中心静脉导管是首选，因为它能在短时间内输注大量治疗药物。
the following are explanation if central line through femoral vein, IJ (internal jugular vein), subclavian vein.
以下，我将结合图示分别讲解经股静脉、经锁骨下静脉、经颈内静脉穿刺中心静脉置管术的操作流程及注意事项。
－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－
附段落全文。
（2）中心静脉通路（前面有兄弟提出用中心管路，但是个人觉得具体内容并不涉及动脉，故仍用中心静脉通路。欢迎讨论指正。）
你可能会先选择周围静脉选用大孔径导管（16、18号导管）来进行输液急救。在处理急救病人时，需要输注大量的液体来进行抢救，需快速开通中心静脉通路。在明确没有下腔静脉损伤后，经股静脉开通中心静脉通路是首选路径。
常用的中心静脉导管分三种：单腔大孔径中心静脉导管，双腔、三腔中心静脉导管。如果你有导管套装（比如arrow的导管套装），那么就相对方便不少，因为操作用的器具导管套装里基本都有。对于创伤病人的早期复苏，单腔大孔径中心静脉导管是首选，因为它能在短时间内输注大量治疗药物。
以下，我将结合图示分别讲解经股静脉、经锁骨下静脉、经颈内静脉穿刺中心静脉置管术的操作流程及注意事项。
我认领第六部分－－－（3）。请大家注意及时回帖说明，避免重复认领。
（3）FEMORAL VENIPUNCTURE: SELDINGER TECHNIQUE
股静脉穿刺中心静脉置管术：SELDINGER法
A. Place the patient in a supine position.
病人取仰卧位。
B. Cleanse the skin well around the venipuncture site and drape the area. Sterile gloves and gown should be worn when performing this procedure.
术野备皮、铺巾。无菌操作非常重要，穿无菌操作衣、戴无菌手套。
C. Locate the femoral vein by palpating the femoral artery. The vein lies directly medial (about 1 cm area) to the femoral artery (nerve, artery, vein, empty space). A finger should remain on the artery to facilitate anatomical location and to avoid insertion of the catheter into the artery.
通过触摸股动脉来进行股静脉定位。股静脉就在股动脉的内侧（大概1cm左右。）（有外至内：神经、动脉、静脉）。用一个手指固定住动脉，既可以找准解剖位置以便穿刺，也可以避免误伤到股动脉。
D. If the patient is awake, use a local anesthetic at the venipuncture site.
如果患者清醒，穿刺区域做局麻。
E. Introduce a large-caliber needle attached to a 10-mL syringe. The needle, directed toward the patient's head, should enter the skin directly over the femoral vein.
使用大口径的针头接一个10ml的注射器。穿刺时，针尖直接朝向病人的头部方向，在股静脉上方直接穿刺入皮。
F. The needle and syringe are held 30 degree to the frontal plane.
进针方向于患者额面成30度角。
G. Directing the needle cephalad and posteriorly, slowly advance the needle while gently withdrawing the plunger of the syringe.
朝患者头部方向，维持注射器负压状态缓慢进针。
H. When a free flow of blood appears in the syringe, remove the syringe and occlude the needle with a finger to prevent air embolism.
当注射器回血通畅，稳住，保留针头、拔下注射器，并用手指遮蔽针头尾部以避免气体进入血管导致气栓。
I. Insert the guidewire and remove the needle. Then insert the catheter over the guidewire.
沿针头置入导丝，沿导丝拔出针头，沿导丝置入导管。
J. Remove the guidewire and connect the catheter to the intravenous tubing.
拔出导丝，接上输液器具。
K. Affix the catheter in place (ie, with suture), apply antibiotic ointment, and dress the area.
固定导丝（比如皮肤缝线固定），局部涂抹抗菌药膏，无菌敷料覆盖。
L. Tape the intravenous tubing in place.
把静脉导管盘在合适的位置。
M. The catheter should be changed as soon as practical.
导管根据情况定时更换。
MAJOR COMPLICATIONS OF FEMORAL VENOUS ACCESS
股静脉穿刺中心静脉置管的主要并发症
1. Deep vein thrombosis
深静脉血栓形成
2. Arterial or neurologic injury
误伤动脉或神经
3. Infection
感染
4. Arteriovenous fistula
动静脉瘘
－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－
附段落全文。
（3）股静脉穿刺中心静脉置管术：SELDINGER法
A.病人取仰卧位。
B.术野备皮、铺巾。无菌操作非常重要，穿无菌操作衣、戴无菌手套。
C.通过触摸股动脉来进行股静脉定位。股静脉就在股动脉的内侧（大概1cm左右。）（有外至内：神经、动脉、静脉）。用一个手指固定住动脉，既可以找准解剖位置以便穿刺，也可以避免误伤到股动脉。
D.如果患者清醒，穿刺区域做局麻。
E.使用大口径的针头接一个10ml的注射器。穿刺时，针尖直接朝向病人的头部方向，在股静脉上方直接穿刺入皮。
F.进针方向于患者额面成30度角。
G.朝患者头部方向，维持注射器负压状态缓慢进针。
H.当注射器回血通畅，稳住，保留针头、拔下注射器，并用手指遮蔽针头尾部以避免气体进入血管导致气栓。
I. 沿针头置入导丝，沿导丝拔出针头，沿导丝置入导管。
J. 拔出导丝，接上输液器具。
K. 固定导丝（比如皮肤缝线固定），局部涂抹抗菌药膏，无菌敷料覆盖。
L. 把静脉导管盘在合适的位置。
M.导管根据情况定时更换。
股静脉穿刺中心静脉置管的主要并发症
1.深静脉血栓形成
2. 误伤动脉或神经
3. 感染
4. 动静脉瘘
我认领第六部分－－（5）。请大家及时回帖，避免重复认领。
（5）SUBCLAVIAN VENIPUNCTURE: INFRACLAVICULAR APPROACH
经锁骨下静脉中心静脉置管术：锁骨下入路（锁骨上、下入路均可行经锁骨下静脉中心静脉置管术。译者注。）
A. Place the patient in a supine position, at least 15° head-down (trendelenberg position) to distend the neck veins and prevent an air embolism. Only if a c-spine injury has been excluded can the patient's head be turned away from the venipuncture site.
病人取仰卧位。头部压低至少15度（特伦德伦伯(氏)卧位:垂头仰卧位）以扩张颈静脉预防空气栓塞。只有在除外颈椎损伤后，才可以将患者头部转向对侧以便操作。
B. Cleanse the skin well around the venipuncture site and drape the area. Sterile gloves should be worn when performing this procedure.
穿刺术野备皮、铺巾（老外的胸毛是否是备皮的重点，呵呵，译者注。）严格无菌操作，穿无菌衣戴无菌手套。
C. If the patient is awake, use a local anesthetic at the venipuncture site.
如果病人清醒，则于术区行局麻。
D. Introduce a large-caliber needle, attached to a 12-mL syringe with 0.5 to 1 mL saline or air, 2 cm below the junction of the middle and lateral thirds of the clavicle, right below the turning for the clavicle.
取大口径针头，接12ml注射器，注射器内留有0.5到1ml左右的生理盐水或空气。于锁骨中外三分之一点下2cm为穿刺点。
E. After the skin has been punctured, with the bevel of the needle upward, expel the skin plug that may occlude the needle.
皮肤穿刺点做好标记后，使穿刺针针尖斜面朝上，注意别让皮肤组织堵塞针头。
F. The needle and syringe are held parallel to the frontal plane.
持穿刺针于患者额面平行
G. Direct the needle medially, slightly cephalad, and posteriorly behind the clavicle toward the posterior, superior angle to the sternal end of the clavicle (toward finger placed in the suprasternal notch).
小心缓慢进针，针尖过锁骨后，往胸锁关节后上角进针（此时可用手指触摸胸骨上凹提示进针方向。）
H. Slowly advance the needle while gently withdrawing the plunger of the syringe.
保持注射器负压，缓慢进针。
I. When a free flow of blood appears in the syringe, rotate the bevel of the needle caudally, remove the syringe, and occlude the needle with a finger to prevent an air embolism.
当注射器内回血通畅，取下注射器，并堵住针口以防空气栓塞。
J. Insert the guidewire while monitoring the electrocardiogram for rhythm abnormalities. Then remove the needle while holding the guidewire in place.
沿针头送入导丝，并同时监测患者心律变化。沿导丝撤出针头并保持导丝在合适位置。
K. Insert the catheter over the guidewire to a predetermined depth (tip_of catheter should be above the fight atrium for fluid administration).
沿导丝置入导管至预定深度（导管头端应在房腔交界处之上）
L. Connect the catheter to the intravenous tubing.
连接导管至静脉输液通路
M. Affix the catheter securely to the skin (eg, with suture), apply antibiotic ointment, and dress the area.
皮肤固定导管（比如缝线缝合固定），涂抹抗菌药膏，无菌敷料覆盖。
N. Tape the intravenous tubing in place.
将导管盘在合适的位置。
O. Obtain a chest film to identify the position of the intravenous line and a possible pneumothorax.
常规做胸片明确导管位置并除外气胸等穿刺并发症。
complications are same as IJ.
并发症同经颈内静脉穿刺置管术
COMPLICATIONS OF CENTRAL VENOUS PUNCTURE
中心静脉穿刺并发症
1.. Pneumo- or hemothorax
气胸、血胸或血气胸
2. Venous thrombosis
静脉血栓形成
3. Arterial or neurologic injury
动脉或神经损伤
4. Arteriovenous fistula
动静脉瘘
5. Chylothorax
乳糜胸
6. Infection
感染
7. Air embolism
空气栓塞
MORE ABOUT central lines: if you know how to do lines at one site, you can apply the same priciples for other sites. very important to review the anatomy on the book or even in the anatomy lab.
补充说明关于中心静脉置管：操作虽然可选不同的静脉，但原则是相通的。有必要回顾一下解剖学教材甚或重新在标本上学习加深理解。
please let me know if you have any questions.
如有疑问请务必告知。
－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－
附段落全文。
（5）经锁骨下静脉中心静脉置管术：锁骨下入路（锁骨上、下入路均可行经锁骨下静脉中心静脉置管术。译者注。）
A. 病人取仰卧位。头部压低至少15度（特伦德伦伯(氏)卧位:垂头仰卧位）以扩张颈静脉预防空气栓塞。只有在除外颈椎损伤后，才可以将患者头部转向对侧以便操作。
B. 穿刺术野备皮、铺巾（老外的胸毛是否是备皮的重点，呵呵，译者注。）严格无菌操作，穿无菌衣戴无菌手套。
C. 如果病人清醒，则于术区行局麻。
D. 取大口径针头，接12ml注射器，注射器内留有0.5到1ml左右的生理盐水或空气。于锁骨中外三分之一点下2cm为穿刺点。
E. 皮肤穿刺点做好标记后，使穿刺针针尖斜面朝上，注意别让皮肤组织堵塞针头。
F. 持穿刺针于患者额面平行
G. 小心缓慢进针，针尖过锁骨后，往锁骨内上方进针（此时可用手指触摸胸骨上凹提示进针方向。）
H. 保持注射器负压，缓慢进针。
I. 当注射器内回血通畅，取下注射器，并堵住针口以防空气栓塞。
J. 沿针头送入导丝，并同时监测患者心律变化。沿导丝撤出针头并保持导丝在合适位置。
K. 沿导丝置入导管至预定深度（导管头端应在房腔交界处之上）
L. 连接导管至静脉输液通路
M.皮肤固定导管（比如缝线缝合固定），涂抹抗菌药膏，无菌敷料覆盖。
N. 将导管盘在合适的位置。
O. 常规做胸片明确导管位置并除外气胸等穿刺并发症。
并发症同经颈内静脉穿刺置管术
中心静脉穿刺并发症
1.气胸、血胸或血气胸
2.静脉血栓形成
3.动脉或神经损伤
4.动静脉瘘
5.乳糜胸
6.感染
7.空气栓塞
补充几点说明关于中心静脉置管：操作虽然可选不同的静脉，但原则是相通的。有必要回顾一下解剖学教材甚或重新在标本上学习加深理解。
如有疑问请务必告知。
呼————终于弄完了刚考完试，比较累，许多地方都是意译，没有太仔细地考虑措词，应该不影响大家理解意思，毕竟不是专业资料，呵呵……
请大家看看有哪些需要改正的，偶尽快改正，谢谢站友的参与
郁闷啊，刚看见上面lvygwyt兄已经翻译部分的内容，又做了遍无用功
所以希望大家以后认领时一定要发贴认领，如果方便的话用红色字弄醒目点哦……
（1）BO:
interesting case this time:
62 year old male attempted suicide:stab wound to the left chest. stable
what you want to do:
Pull the knife?
Call a psychiatrist?
Give him antibiotics?
Sent him to the CT scan?
Upper GI with SBFU?
Open cardiac massage ？
本次有趣的病例：
62岁老年男性，试图自杀：左胸部刀刺伤，(生命体征)平稳
你应该如下做吗：
拔出刀子？
请心理医师会诊？
给予抗生素？
CT扫描？
上消化道钡餐？
开胸心脏按摩？
（2）BO:
about the case. Tongdour and fish0220 had very good view.
patient had stab wound to Left lower chest or upper abd. i'd like to discuss it after we talk about how to treat trauma patient first time when you see the patient. you too be patient. i hope at the end , you can tell me what you can do to help this patient fast and righ
关于此病例，Tongdour和fish0220有很好的看法。
(对于)左下胸部或上腹部刀刺伤的病人，我打算在我们讨论了你刚接诊后如何处理创伤病人后再讨论这个病人。你们要耐心点，我希望到最后你能够告诉我你应该如何快速正确的帮助这名病人。
3）BO:
a bonus question: please do answer.
how chest have you cracked (which means median sternotomy and thoracotomy)?
附加问题，请回答：
你们都是如何开胸的？(意思是正中胸骨切开术还是胸廓切开术？)
（4）BO:
i want to explain more about the bolus question:
the bolus question about cracking chest is not regarding this patient in the picture. it is a general question for every general surgery. please don't think chest is belong to the thoracic surgeon. as i mentioned before, trauma surgeon should be able to operate on any body cavity, chest is a common one. so i'd like to know how many chests have you cracked, are you comfortable to open a chest if you have to .
我想对附加问题做进一步解释：
附加问题中关于开胸不是针对图片所示的病人，这是个对普通外科很常见的问题。请不要认为开胸只属于胸外医生。正如我前面所提到的，创伤外科医师应该能够做任何体腔的手术，胸腔只是很普通的一个。所以我想知道你们做过多少开胸手术？如果万不得已的话你们愿意做开胸手术吗？
（5）BO:
for trauma surgeon, we always face life threatening injury. you are the first doctor to see the trauma patient. the patient may be dying in front of you, there is no time for you to call consult. for example: stab wound to the left chest, forth intercostal space, patient just arrived, gasping breath, BP 40/0, pulse 30. right after you see him, he lost his pulse. what wound you do? are you going to call cardiothoracic surgeon, or you just cut the patient? i cut one, and brought him back. he walked out the hospital.
you are not going to do complicated vavle repair or CABG, You open the chest to try to save the patient's life, most stop the bleeding, cardiac massage, clamp the aorta.
trauma surgeon (or general surgeon ) treat a patient as a whole, not just a belly surgeon.
对于创伤医生，我们经常要面对危胁生命的外伤，你就是接触伤员的第一位医生，伤员可能会在你面前死掉，是没有时间让你请会诊的。比如：左胸第四肋间隙刀刺伤，病人刚到，气急，BP40/0，脉搏30。你刚检查，他就摸不到脉搏了。你会怎么办？你是马上叫胸心外科医师还是自己马上开刀呢？我做过一例，把病人救了回来。他走着出了医院。
你不需要做复杂的瓣膜修补或冠脉旁路移植术(CABG)，你只需要开胸去救病人一命，主要是止血，心脏按摩，钳夹主动脉。
创伤医师(或普外医师)对病人是做为整体处理的，而不是仅仅腹腔手术。
（6）BO:
what you are saying is partially right. those subspecialty will be available but they won't stand at trauma bay as you do, waiting for the patient coming. traumatic injury is so unpredictable, nobody knows what's going on with the coming patient until he comes. so it is not practical to have all the subspecialty be at trauma bay. at the same time, trauma patient's condition changes so fast, you have no time to call for help when the patient arrives.
the fact in the USA now is: as a trauma surgeon, you are supposed to take care of any trauma patient. if you are a certified trauma surgeon, you don't need to be the director of trauma surgery to take critical patient. as far as other specialties, if you don't call for consult, they won't show up. like the case i mentioned above, it happened at midnight, you won't have a cardiothoracic surgeon standing side by side with you, waiting for the patient coming. since critcal trauma injury happens every night, there is no way to have other specialty be in house as a trauma surgeon does. after you stablize the patient, if the patient has complicated heart or aorta injury or other injuries, then you call them and they will come to help you. when you choose to be a trauma surgeon, you choose to be in the disasters, you choose to fight death all the time. i will talk about more about trauma team soon.
你所说的只对了一部分。其他分级学科的医师是可以请到的，但他们并不是和你一样就待在创伤急救室等病人来的。外伤是很难预料的，在病人到来之前没人知道发生了什么。所以让所有分级学科的医师在急救室侯诊是不现实的。同时，创伤病人的病情变化之快，你根本就没有时间去请会诊。
美国 现在的情况是：做为一名创伤外科医师，你应该有能力去处理任何外伤病人。如果你是一名注册的创伤外科医师，你不必以创伤外科主管的身份才能接管危重病人，像其他科室一样，如果你不请会诊，他们不会露面。像我上面提到的病例，发生在深夜，你身边没有胸心外科医师陪着你等病人来。因为创伤每天晚上都有发生，让其他科室的人也像创伤外科医师一样侯诊是不可能的。在你把病人稳定下来后，如果该病人还并发复杂的心脏、大血管的创伤或其他损伤，这样你才可以呼他们过来帮你。当你选择做一名创伤医师的时候，你就选择了面对灾难，你就选择了随时与死亡抗争。一会我会再更详细的讨论创伤组。
Johnsonyyyyyyyyyyyyy，我喜欢你问的问题，切中要点，但超前了点。你的问题需要一整章来回答。下面进行我们第二部分的内容：创伤体系、创伤中心和创伤组
（8）BO:
questions for today: please do answer. i want to know if i need talk about those procedures.
1. how many chest tubes have you put in? how do you do it?
2. how many central lines have you done, including internal jugular vein, subclavian vein, femoral vein? how many arterial lines have you done? how many pulmonary artery catheter(SWAN catheter) have you done?
3. how many emergent cricothyoidectomy or tracheostomy have you done?
as a trauma chief resident or trauma surgeon, cental lines or chest tubes should be done in 1-2 minutes, tracheostomy should be within 5 minutes.
i really appreciate your answers to the questions i asked. they will help me plan the discussion. thanks
(译者注：直接转自lvygwyt兄的翻译，偷个懒)
本次问题：请一定回答。我好知道是否需要展开这些话题。
1、你置过几根胸管？咋放？
2、建过几条静脉通路，包括颈内静脉，锁骨下静脉，股静脉？动脉通道建过几条呢？肺动脉插管做过几次？
3、急诊气管切开做过几次？
作为创伤科住院总或创伤外科医生，建立中心静脉通道或胸管应在1－2分钟内完成，气管造口应在5分钟内完成。
(9)BO:
thank you Tongdour for responding all questions. i still hope to see more responses. based on his response, i'd like to discuss a little bit about those basic procedures before we go on.
谢谢tongdour对所有这些问题的回答。我仍希望看到更多的回应，根据对此的回答，我想在继续之前先对这些基本操作进行下小小的概括。
i can't remember all of them either, ~_^. it took me a while to find those documents. what's important to me is: it is red or white. then i will go down and ask the nurse what is coming in
我也记不全他们我花了点时间来找这些内容。对我重要的是：红色还是白色创伤信号？我会下楼问问护士出了什么事。
right now, we emphysize evidence based practice. many traditional rules have been proved not right. we have shaped our practice based on large clinical trials. there are standard practice, if you are not following the standards, once you have complication, you will lose your case easily and pay a lot money to compensate the patient.
现在，我们强调的是循证医学。许多传统的处理原则被证实是不正确的。我们根据大量的临床试验形成了我们的规程，我们有标准操作，如果你不遵守这些标准，一旦你受到投诉，你很容易败诉并赔偿给病人N多的钱。
Sometimes it is very hard to keep things in order, so trauma surgeon and trauma chief have to be strong and aggressive. you can ask people to shut up or move out of your way. in trauma bay, we work like sodiers.
i was going to discuss how to set up trauma bay, but i found it may be necessary to discuss those skill procedures i mentioned above. please let me know if you like to discuss those procedures. i really like to see more responses.
Another favor i want to ask. my dear friends, could you please translate all my responses to the questions from you guys. thanks a lot.
有时候让事情那么井然有序是非常困难的，所以创伤外科医师和创伤组长必须很牛还有魄力，你可以让别人闭嘴或到一边去。在创伤急救室，我们就像大兵一样工作。(呵呵，刚考完试，有点累，意译为主了哈，不耽误大家理解)
我本打算继续讲怎么布置创伤急救室，但我发现还是有必要对上面所提的基本操作进一步的讲一下。请大家告诉我你们想要讨论这些操作，我真的想看到更多的回应。
我想再麻烦大家一件事，你们能把我对上面问题的回答也翻译过来吗？谢谢(呵呵，BO兄客气，偶们当仁不让译者注)
（1）BO:
there is a little bit confusion. as i said trauma surgery is part of general surgery. general surgeons should be able to take care of trauma patients without further training. means treat patients at trauma bay and in the OR.
the further training part is for critical care. it is one year fellowship. DURING the fellowship, you will certainly treat more trauma patients at trauma bay and in the OR and in the ICU. after one year fellowship of critical care, the surgeon can run ICU, take care of all the ICU patient. trauma and critical care are combined together.
这有点让人费解，像我前面说过创伤外科是普外的一部分，(这样的话)普外医师不需要进一步的培训就应该能够处理创伤病人，也就是说在创伤急救室或手术室处理病人。
(我说的)继续培训部分是对危重病人的处理，这需要为期一年。在学习对危重病人处理后一年，普外医师就能够撑得起ICU，处理所有ICU的病号，包括创伤和危重病人。
（2）BO:
still i want emphasize that trauma is part of general surgery. when we are on call, we take care all the trauma patients and emergent surgical patients. that why general surgeons should be good at trauma and comfortable to take care of trauma patients.
when the trauma attending is operating in the OR and can't go to the trauma bay as the trauma patient is coming, the trauma chief resident is promoted to be the team leader, and so is every body pormoted to upper level in the trauma team. sometimes when we are busy, maybe just a 3rd year resident and an intern take care of trauma patients at trauma bay if the patient is not that sick.
同样我也要强调创伤外科是普外的一部分，当我们值班时，我们会接诊所有创伤病人和急诊外科病人。这就是为什么普外医师应该擅长于并自然的应对创伤病人。
当创伤主治医师正在手术室做手术而病人来时他不能到急救手术室，创伤住院总就被提升到创伤组长的位置，其他创伤组成员都相应上提一级。有时候我们都很忙，而病人病情又不是那么重，可能只有一位3年经验的住院医师和一位实习医师在创伤手术室处理病人。
（3）BO:
Ambulance doesn't belong to the trauma center, here they belong to an organization, lifenet which may be part of the fire department or an independent company. when find the patient, they will contact the closest trauma center first.
急救车不归创伤中心管，这里他们归某个部门管，可能是急救网络中的消防部门或其他某个附属部门。当找到伤员时，他们会和最近的创伤中心联系。
（4）BO:
this happens sometimes. two weeks ago, i had a patient with multiple gun shot wound to abdomen and chest, walked into the ER, asking for help. for those patient, the triage nurse at ER will send out page with code like "1-1-2-0" for last patient which means: trauma read, one patient, at trauma bay 2, 0 minutes--meaning patient's already here. the trauma team are always in house, we just run down from anywhere in the hospital to the ER, trying to get there as soon as possible.
all the pages with codes are sent out to our pager by the ER triage nurse based on the criterior of RED, WHITE. the EMT (emergency medicine technician) just tell the ER nurse what injury the patient has. they don't decide it is trauma red or trauma white.
这种情况有时候也发生。两个周前，我接诊到一个胸腹部多处枪伤的病人，自己走进急诊室求助。对这类病人，急诊室的创伤分级护士就会为最后来的病人发出代码，如“1-1-2-0”，意思是：红色创伤级别、一名病人，在2号急救室，0分钟(后到达)—也就是病人也经到了。创伤组成员均在院内侯诊，我们从不同的地方跑向楼下，以尽可能快的速度到达急救室。
所有的代码都由急诊室创伤分级护士根据红色、白色分类标准发到我们的呼机上。急诊室技师(EMT)只是告诉急诊室护士病人伤在哪了，他们 并不决定其为红色还是白色创伤。
（5）BO:
for stable patient, you may want to do more studies before you cut him. trauma does have a lot socail economic issue. we have many gangsters, drug dealers who get shot, coming to us. any operations to trauma patients don't need operative consent. that is a law, because if the patient is dying, he can't sign the consent. the law suits for trauma surgeon on trauma cases are not common, because everybody knows the patient was injuried before he arrives, the surgeon is trying to save his lift. a good legal system can help this kind problem.
对于体征稳定的病人，你可能会想在开刀前做更详细的检查。创伤确实牵扯到许多社会经济问题。我们接到许多受枪伤的歹徒或毒贩过来。任何对创伤病人的手术都不需要(病人或家属，译者注)同意。这是法律规定，因为如果病人病危，他没签字同意的能力。对创伤医师对创伤病人做手术的投诉并不常见，因为人人都知道病人在到达之前已经受伤，手术是为了救命而进行的。一个完善的法律体系可以有利于此类问题的解决。
（6）BO:
Your result is awesome. one pneumothoax in 200 subclavian, 0.5%. that is excellent. average it is about 1% over the USA. You are an expert for central line. we do have same complication (every surgeon has complications). patients and their family are fine, they understand it. no biggy. but do tell them the risk first and never lie about complication, that is the way how we deal with complications.
We use Arrow central line kit too.
明确气胸后，就立即在患者床边以seldinger‘s法于第二肋间置入单腔arrow中心静脉导管-------- this is very smart way for central line induced PTx. we just put a big chest tube for the patient. he he.
你的纪录让人敬畏，200例锁骨下静脉置管仅发生了一例气胸，仅0.5%，这太牛了在美国的平均发生率在1%左右。你现在是静脉置管的牛人啦(再调节下气氛)。我们也有同样的并发症(每位外科医师都会经历并发症)如果病人和家属好的话，他们 能够理解，没什么大不了。但是一定要事先告诉他们风险，别隐瞒并发症，这就是我们如果对待并发症的。
我们也是使用ARROW 中心静脉包。
明确气胸后，就立即在患者床边以seldinger‘s法于第二肋间置入单腔arrow中心静脉导管————这是处理中心置管引起的气胸很好的方法，我们仅仅是放置大号胸腔引流管，呵呵
（7）BO:
all of us have malpractice insurance. as i said, the law suits have not been that bad from trauma patient. most time it is involved a missed injury. trauma team has to be thorough on trauma patients. anothing is: don't hurt yourself when you are doing procedures or operations, because some patients may have blood-borne diseases, such as hepatitis. you don't want those problems.
Thanks a lot for DAO XIONG's questions. it is very helpful. from your questions, i can find out what you are interested in, how much sense my talkings make. hope to see more questions.
i will start to discuss about procedures next time.
thanks
Bo
我们都有医疗故事保险金，像我前面说的，创伤病人的投诉没有那么差。大多的时候牵涉到漏诊的情况，创伤组必须对病人全面检查。另一方面：在你做手术或操作时不要伤到自己，因为一些病人可能有血液传染性疾病，比如肝炎，你肯定不想发生这种事情。
非常感谢道兄的问题，非常有用。通过你的问题，我可以发现你们对什么感兴趣，我讲的内容有多大意义。希望能看到更多的问题。
下次我将开始讲操作的问题。
谢谢
BO
that's a very sophisticated view of trauma surgery. i don't know that there is any trauma bay at ED in china. Trauma bay is the place for us to do initial assessment and resuscitate patients, especially those dying ones. for the initial resuscitation, we have a trauma surgeon, trauma chief resident and a junior resident. we call neurosurgery for head trauma, ortho for fracture, vascular surgery for large vessel injury, plastic surgery for facial trauma, CT surgery surgery for ruptured aorta. we rarely call urology for consult. we also take care of all the simple chest problems, such as vessel bleeding (not ruptured great vessels), lobectomy for lung injury. trauma surgeon and trauma team is the core taking care of all the trauma patients, other specialties are just consulting teams. i know there is no such subspecialty, trauma surgery, in China. porbably it is time to set up such subspecialty as part of general surgery.
这是对创伤外科精彩的见解。我不知道在国内急救部门是否也有创伤急救室。创伤急救室在我们这里是对病人进行最初的评估及复苏的地方，尤其是对那些濒死的病人。进行最初的复苏，我们这有创伤外科医师、创伤住院总和低年资住院医师。我们会请神经外科医师处理头外伤，骨外医师处理骨折，血管外医师处理大血管操作，整形外科医师处理面部损伤，胸心外科医师对大动脉破裂进行处理。但我们很少请泌尿外医师会诊。我们也能够处理所有简单的胸部外伤，比如出血(不是大血管破裂)、肺损伤的肺叶切除。创伤外科医师及其创伤组是处理所有外伤病人的核心，其他科室仅仅是进行会诊。我知道在中国是没有创伤外科这个亚学科的，在中国，也许应该是从普外分支建立这样一个学科的时候了。
i take the syringe off and put the guide wire through the needle. at the same time make sure it is the vein by looking at the color of the blood and the way it bleeds, pulstile or just dripping.
我是将注射器取下来再沿针置入导丝的。同时通过观察血液的颜色和回流方式(喷射还是滴流)来确定我扎进的是静脉。
pretty much poke below the turning of the clavicle, walk down to the subclavian space and just the hand then shoot to the sternal notch.
those procedures need some practice. shouldn't be too difficult, but you should always be careful.
恰好在锁骨形成转折的下方进针，沿锁骨下间隙向固定在胸骨上凹的手指方向进针。
这些操作需要练习才行，不应该很难，但是你必须小心。
that's pretty much every third year general surgery resident should be able to do. if you don't think you can do that, then you may want to more pracitice.
这是每一个有三年经验的住院医师应该能做到的，如果你认为你还达不到这个水平，那么你应该需要多加练习。
i will have a lot more cases after we start discussions about specific injuries. thanks for your suggestion.
在我们讲到具体的创伤后我会有许多病例来讨论，谢谢你的建议。
when patient has upper airway problem, you can't secure the airway with intubation on time to save the patient. you cut him, either emergent cricothyroidotomy or tracheostomy.
当病人有上气道损伤时，你没法及时的通过气道插管来急救病人。你要么及时做手术，要么做紧急环甲膜切开或气管切开。
(1)i have been putting a lot of time into this discussion. i think it is worthwhile. hope all of us can learn something. it is your supports, interests, responses and questions that keeps me going. i thank you all.
i am very glad to see 小李废刀's question. you all are welcome to discuss your own cases. if i am not sure about the solution, i will discuss with other trauma surgeons in our trauma center.
我在这个讲座中已经投入了大量的精力，但我觉得是值得的。希望我们都能从中学到些东西。是你们的支持、兴趣、回应和问题使我能够继续进行下去。谢谢你们。
我很高兴看到“小李废刀”的问题，欢迎大家来讨论自己的病例。如果我对其也不确定，我会和我们创伤中心的其他医师讨论。
(2)before i give my suggestion, i'd like to know more about the patient as a whole:
from head to toe:
1. CNS: How's his mental status, how bad is the head injury
2. cardiovascular: is he hemodynamically stable, or he's in shock, on pressors?
3. respiratory: what's the reason for his resp. failure? what's the ventilator setting
4. GI: any intra-abdominal injury, abscess, when was the last time he had a CT of abd and pelvis
5. GU: Renal failure, what's the creatinin and urine output.
6. EXT.: how bad is The deglove injury, any necrotic tissue needs to be further debrided
7. hem/ID (hemotology and infections disease): what infection does he have? is he septic, what's blood Cx? is he anemic?
8. FEN (fluids, electrolytes and nutrition): is he fully resuscitated, is he wet or dry? any electrolytes disturbance. it is good he is on enteral nutrition. how do you feed him.
9. prophylaxis: is he on any prophylactic medication for DVT (sq heparin, SCDs) and ulcer stress ulcer
10. dispo: did physical therapist see him? when can the patient be transfer out ICU (not specificly for this patient).
if you see an ICU patient, it is a good idea to have all these item go through your mind, then you probably won't miss something. 小李废刀, i think your debridement helped. if you can take some pictures of that patient, that be helpful.
在我给出建议前，我想全面了解病人的情况。
从头到脚（要了解病人各个方面的详细情况）
1.中枢神经系统：患者的精神状态如何，当时颅脑损伤的有多重？
2.循环系统：患者血液流变学方面稳定吗？是否有休克，需要药物来维持血压？
3.呼吸系统：呼衰的原因考虑什么？目前呼吸机参数是什么模式？
4.消化系统（胃肠道）：腹腔内是否有脏器损伤，是否有脓肿？最近一次的腹部和骨盆CT是什么时候做的？
5.泌尿系统：肾衰竭，肾功如何，尿量怎么样？
6.伤口清创：伤口情况如何，是否有坏死组织需要进一步清除。
7.血液和感染方面：考虑什么感染？考虑败血症吗，血培养结果是什么？患者贫血吗？
8.营养和水电解质平衡问题：患者完全恢复意识了吗？是否存在脱水？是否有电解质紊乱？同意选择肠内营养，你们是如何进行肠内营养的？
9. 预防措施：有没有采取措施预防下肢静脉血栓形成和应激性溃疡？
10. 康复理疗方面：理疗医师看过病人了吗？目前已不太适合住在ICU，准备什么时候转出？
如果你要管一个icu的病人，最好全面了解以上的提到的几点，然后才不至于漏掉什么。废刀兄，我想你做的清创术对患者恢复是很有帮助的。如果你能提供一些患者的照片会更有利于彼此之间的交流。
(3)BO:
looks like he is not septic. major problems are
1. head injury which neurosureon should have some input. he probably can't protect his airway.
2. resp. failure. does he have ARDS? How long has he been on Vent. he failed extubation once already, and can't be wean off vent. you probably want to think about tracheostomy. interesting enough, it is easier to wean off after tracheostomy.
3. wound: looks like needs aggressive dressing change and debridement PRN.
4. Rehab is a big issue for him too.
看起来不像是脓毒症，主要的问题是：
1、脑部外伤，应该请神经外科医师会诊。可能没法很好地保护气道。
2、呼衰。病人是不是存在ARDS？他上呼吸机已经多久了？他曾经撤过呼吸机，但现在又无法撤机。你们应该考虑下做气管切开。很有意思，做了气管切开后反而更容易撤机。
3、外伤：看起来需要更好的包扎和随时清创。
4、机能恢复对他也是个大问题。
(4)BO:
i have too limited information to figure out why he is vent dependent. do you have CXR, CT of the chest, blood gas, ventilator setting in details, like what mode, rate, how much peep and pressure support? how's his phosphorous level?
我现在也说不上他为什么无法撤呼吸机。你们做了胸片、胸部CT、血气分析吗？呼吸机的设置参数具体如何？比如模式、频率、PEEP用了多大？血磷水平？
(1)BO：
even before patient's arrival, we have emergent blood release, type O packed RBC, at least 4 units ready at trauma bay. if the patient needs blood, he will get it in 0 seconds since it is already there. we treat patients first, no money issue is involved at that time. all the blood was donated by volunteers and collected by Red Cross. our blood bank gets blood from Red Cross.
在病人到达以前，我们在创伤急救室就已经准备好了急救血液，是O型血的浓缩RBC，至少4个单位。如果病人需要用血，会立刻得到输血。我们处理病人是放在第一位的，这不涉及到钱的问题。我们这所有的血都是志愿者捐献的，并由红十字会负责采集。我们的血库从红十字会取血。
(2)BO：
damage control surgery was orignally advocated by trauma surgeons since trauma patients sometimes are very unstable and more time in the OR will just make the patient worse, like the lethal triads i discussed before in a post about damage control surgery. this idea has been adopted by my general surgeons for other situation. for severe trauma injury, as you mentioned, damage control works quite well. we do it almost every day. we always have some trauma patients with an open abdomen in the ICU, waiting for wash-out, second look, completion of the surgery....
i have some disussion about damage control in "trauma case #1" too which was a gun shot wound to the abd, IVC injury.
Damage control surgery is an idea. because pt is not stable enough for you to complete the surgery in one stage, we need minimize OR time as short as possible to avoid lethal triads (hypothermia, acidosis, coagulopathy) and we can come back to finish the operation.
i recommended some books before in the past discussions.
损伤控制性手术最初由创伤外科医师所倡导，因为有时候创伤病人生命体征非常不稳定，在手术室待的时间越长病人的状况反而越差，正像我在以前关于损伤控制手术的贴子里提到的致命三联征。这种意见也被我们普外科医师所接受并用于其他情况。对于严重创伤，正如你提到的，损伤控制性手术效果非常好。我们几乎每天都这样处理。我们在ICU总有一些开放性腹部外伤的病人等着冲洗创口、二期手术继续处理。
我在“创伤病例1”的讲座中将会有一位腹部枪击伤伴下腔静脉损伤的病人会讨论到损伤控制性手术。
损伤控制性手术是一种观念。因为病人病情非常不稳，你没法一期完成手术，我们需要尽量缩短在手术室处理的时间以避免致命三联征(低体温、酸中毒、凝血障碍)，而且我们可以再次进行二期手术。
我在以前的贴子中曾经推荐过几本书。
(1)BO:
the concept of "Intern" is different between china and USA. HERE, intern means the first year resident, just graduated from medical shcool. it is a transitional year from amedical student to a resident. intern year is the hardest year. you work 80-120 hours a week. starts at 4-5am, goes home at 6-7 pm. always in house call.
interns (first year residents) and junior residents are supposed to come to the hospital between 4-5 am, finish rounds and daily notes by 6 - 6:15 pm. then the chief residents start rounding and make plans for patients, finish by 7 am. we start operations (cut the skin) at 7:30 am. in the academic setting, the attendings see the patients whenever they like. each attending sees his own patients only unless he is covering for his/her partners. all the general surgery services are run by the chief residents.
the rules for interns are: eat whenever you can, sleep whenever you can. the working hours are getting better due the new rule from ACGME who set up a upper limit of working hours of 80 hours/week.
中国和美国的“intern”定义是不同的。在美国，是指从医学院毕业后第一年的住院医师。它是从医学生向住院医师过渡的一年，这一年是非常辛苦的。你一周工作80—120小时，从早上4、5点钟开始，晚上6、7点钟才回家，而且经常在家里被叫回去。
“实习医师”(intern)和低年资住院医师一般要求早上4、5点就到病房，在6—6：15之前完成查房和一些记录工作。然后是7点前住院总查房并为病人制定治疗计划。我们一般是7：30开始手术(切皮)在教学医院,主治可以在任何时候看望病人，每个主治只看自己的病人，除非他是给其他大夫替班。所有的普通外科处理都是由住院总负责。
对于“实习医师”的原则是：找任何有空的时间吃饭，找任何可能的时间睡一觉。在“研究生医学教育鉴定委员会(ACGME)”出台新的规定即一周工作时间不得高于80小时后，“实习医师”的工作量正逐步改善。
(2)BO:
rehabilitation is a very important part of managing trauma patients. in the hospital, we have specific physical therapist (PT) and occupational therapist (OT). when patients are stable, they go to some rehab facility if they need rehab. those PTs and OT s are very professional and love their job, love to help patient get better.
康复治疗对于处理创伤病人是非常重要的部分。在医院，我们这有专门的理疗师和职业治疗师。病人病情稳定后，如果需要康复治疗，他们就转到某个康复机构。那些理疗师和职业治疗师是非常专业的而且爱他们的工作，乐于帮助病人恢复。
(3)BO:
i didn't understand Cheng GuoLiang's note before. now i understand because i was blocked from reading two notes which has a minimum requirement of 10 points. i looked at mine which was 6.
most people visiting this website are medical professionals and interested in general surgery. we are having a professional scientific discussion about general surgery. everybody is equal here and should have equal opportunate to learn and to express their ideas. i don't know the reasons for the limitation set up in other posts. however, in this trauma discussion i think it is better not to set up any minimum requirement of score. thanks.
我以前不明白Cheng GuoLiang兄的贴子是什么意思，今天我才明白，因为我在浏览两个贴子时受阻，他们要求最低10分的限制，我看了看我的才6分.
大部分来园子里的都是医学专业和对普外感兴趣的。我们进行的是对普外专业科学的讨论。每个人在这都是平等的，并且应该在平等的机会来学习和表达他们的观点。我不理解为什么在其他贴子设定分数限制。不管怎样，在这个创伤讨论里我想最好不要设置任何分数限制。谢谢
1. Aspiration (eg, blood) 误吸. --------that's right. means breath in blood.
2. Creation of a false passage into the tissues 气管食管瘘？----------- not exactly, a false passage into the tissue around, doesn't mean treacheoesophageal fistula
3. 你首先可能会想到经周围静脉使用大孔径导管（16、18号导管）开通中心静脉通路。---------- not right. original meaning is that you want to try have technician start peripheral IV first not central line for every patient.
4. IT WILL CAUSE DIFORMITY（deformity，typo？） for children younger than 11 years old, the larynx is not mature, so crico can cause irreversible stenosis and other deformities.
已根据bo兄提示做修正，更改部分统一使用黑体加粗，以便商榷。
翻译修改了一下Bo兄提供的一幅图Trauma Personnel Protocol，拿不太准，希望大家修改一下。
（缩略图，点击图片链接看原图）
翻译修改了一下Bo兄提供的一幅图Trauma Personnel Protocol，拿不太准，希望大家修改一下。
（缩略图，点击图片链接看原图）
nice job, LUO HUI
第一次翻译这么专业的东西，尤其是从来没看过也没接触过这个操作，许多拿不准的地方，请大家多多指点！！！
相信以后会进步……
（4）INTERNAL JUGULAR VENIPUNCTURE: MIDDLE OR CENTRAL ROUTE
颈内静脉穿刺置管：中央或中心径路
Note: Internal jugular catheterization is frequently difficult in the injured patient due to the precaution necessary to protect the patient's cervical spinal cord.
注意：由于保护病人颈部脊髓所必需的预防措施，颈内静脉插管在外伤病人中大多是困难的
A. Place the patient in a supine position, at least 15° head down (trendelenberg position) to extend the neck veins and to prevent an air embolism. Only if the cervical spine has been cleared radiographically can the patient's head be turned away from the venipuncture site.
A、置病人于仰卧位，头至少下垂15°角（川德伦堡体位）以使颈静脉充盈并防止气栓形成。仅当影像证实颈椎完好时才可以将病人的头转至穿刺点对侧。
B. Cleanse the skin well around the venipuncture site and drape the area. Sterile gloves should be worn when performing this procedure
B、将穿刺点周围彻底消毒并铺单，操作时应戴无菌手套。
C. If the patient is awake, use a local anesthetic at the venipuncture site.
C、如果病人清醒，在穿刺点进行局麻。
D. start with a 5 ml syringe and 22 gague need as a seeker needle. Introduce the needle into the center of the triangle formed by the two lower heads of the sternomastoid and the clavicle, aiming toward s the ipsilateral nipple. After you find the IJ, switch to a large-caliber needle with a 12 ml syringe repeat this step.
D、首先使用5毫升注射器和22号针头做引导穿刺针。在胸锁乳突肌下两头（胸锁乳突肌下端有两个起点，分别起自胸骨柄前面和锁骨的胸骨端，译者注）和锁骨形成的三角中心处进针，穿向同侧乳头方向。在找到颈内静脉后，换大口径穿刺针和12毫升注射器重复以上步骤。
(another way to localize IJ is to use an ultrasound called SITERITE. you can mark the path of IJ with Siteite or even do the ultrasound guided venopuncture if you have this kind ultrasound machine)
（另一个定位颈内静脉的方法是使用称作SITERITE的超声。如果有这种机器的话，你可以用SITEITE找到颈内静脉甚至作超声引导下静脉穿刺）
E. After the skin has been punctured, with the bevel of the needle upward, expel the skin plug that may occlude the needle.
E、在刺穿皮肤之后，将针的斜面向上，排出可能堵塞针头的皮肤。
F. Direct the needle caudally, parallel to the sagittal plane, at a 30° posterior angle with the frontal plane.
F、控制针的方向，与矢状面平行，与冠状面成30°角
G. Slowly advance the needle while gently withdrawing the plunger of the syringe.
G在轻轻回抽注射器的同时缓慢进针。
H. When a free flow of blood appears in the syringe, remove the syringe and occlude the needle with a finger to prevent air embolism. If the vein is not entered, withdraw the needle and redirect it 5° to 10° laterally.
H、当注射器内出现回血时，拨下注射器，用一根手指堵住穿刺针防止气栓。如果未进入静脉，拨出穿刺针，重新向侧方 5° to 10°进针。
I. Insert the guidewire while monitoring the electrocardiogram for rhythm abnormalities.
I、在监测心电图异常节律的同时置入导丝。
J. Remove the needle while securing the guidewire and advance the catheter over the wire. Connect the catheter to the intravenous tubing.
J、保护导丝的同时拨出穿刺针，然后沿导丝置入导管。将导管与静脉输液管连接。
K. Affix the catheter in place to the skin (eg, with suture), apply antibiotic ointment, and dress the area.
K、将静脉导管放好后与皮肤固定（比如缝结），局部应用抗生素软膏，覆盖穿刺区。
L. Tape the intravenous tubing in place.
L、将静脉输液管盘好位置。
M. Obtain a chest film to identify the position of the intravenous line and a possible pneumothorax.
M、拍胸片以确定静脉内导管的位置和可能发生的气胸。
N. If you hit the carotid artery, pull the needle out and hold pressure for 5 minutes.
N、如果误刺到颈动脉，拨出穿刺针并按压5分钟。
COMPLICATIONS OF CENTRAL VENOUS PUNCTURE
1.. Pneumo- or hemothorax
2. Venous thrombosis
3. Arterial or neurologic injury
4. Arteriovenous fistula
5. Chylothorax
6. Infection
7. Air embolism
中心静脉穿刺的并发症：
1、气胸或血胸
2、静脉栓塞
3、动脉或神经损伤
4、动静脉瘘
5、乳糜胸
6、感染
7、气栓
颈内静脉穿刺置管：中央或中心径路
注意：由于保护病人颈部脊髓所必需的预防措施，颈内静脉插管在外伤病人中大多是困难的
A、置病人于仰卧位，头至少下垂15°角（川德伦堡体位）以使颈静脉充盈并防止气栓形成。仅当影像证实颈椎完好时才可以将病人的头转至穿刺点对侧。
B、将穿刺点周围彻底消毒并铺单，操作时应戴无菌手套。
C、如果病人清醒，在穿刺点进行局麻。
D、首先使用5毫升注射器和22号针头做引导穿刺针。在胸锁乳突肌下两头（胸锁乳突肌下端有两个起点，分别起自胸骨柄前面和锁骨的胸骨端，译者注）和锁骨形成的三角中心处进针，穿向同侧乳头方向。在找到颈内静脉后，换大口径穿刺针和12毫升注射器重复以上步骤。
E、在刺穿皮肤之后，将针的斜面向上，排出可能堵塞针头的皮肤。
F、控制针的方向，与矢状面平行，与冠状面成30°角。
G、在轻轻回抽注射器的同时缓慢进针。
H、当注射器内出现回血时，拨下注射器，用一根手指堵住穿刺针防止气栓。如果未进入静脉，拨出穿刺针，重新向侧方 5° to 10°进针。
I、在监测心电图异常节律的同时置入导丝。
J、保护导丝的同时拨出穿刺针，然后沿导丝置入导管。将导管与静脉输液管连接。
K、将静脉导管放好后与皮肤固定（比如缝结），局部应用抗生素软膏，覆盖穿刺区。
L、将静脉输液管盘好位置。
M、拍胸片以确定静脉内导管的位置和可能发生的气胸。
N、如果误刺到颈动脉，拨出穿刺针并按压5分钟。
中心静脉穿刺的并发症：
1、气胸或血胸
2、静脉栓塞
3、动脉或神经损伤
4、动静脉瘘
5、乳糜胸
6、感染
7、气栓
tongdour wrote：
A. Place the patient in a supine position, at least 15° head down (trendelenberg position) to extend the neck veins and to prevent an air embolism. Only if the cervical spine has been cleared radiographically can the patient's head be turned away from the venipuncture site.
A、置病人于仰卧位，头至少下垂15°角（川德伦堡体位）以使颈静脉舒展并阻止气栓形成。仅当影像证实颈椎棘突完好时才可以将病人的头转动至穿刺点。（不大明白，是不是BO兄打错了？from or to?）
i think "from" is right. to turn away from the venipuncture site is one step of this procedure. so the translation of this paragraph maybe:
患者取仰卧位，头部压低至少15°，可以使颈静脉更充盈且能预防气体栓塞。经过影像学的检查明确患者颈椎无损伤后，才可以让患者头部转向对侧。（头部压低时，则颈静脉回流阻力增加，血管越充盈穿刺越容易，另外操作时，往往让患者头部转向对侧以便更好暴露术野以利于操作。）
ps:well done tongdour! and a pic.for you.
screen.width-333)this.width=screen.width-333" width=633 height=524 title="Click to view full 颈内静脉.jpg (633 X 524)" border=0 align=absmiddle>
After the skin has been punctured, with the bevel of the needle upward, expel the skin plug that may occlude the needle.
E、E、在刺穿皮肤之后，将针的斜面向上，排出可能堵塞针头的皮肤。----------good
F. Direct the needle caudally, parallel to the sagittal plane, at a 30° posterior angle with the frontal plane.
F、控制针的方向，与矢状面平行，与冠状面成30°角。（请BO兄看看，posterior or anterior?）------------- posterior
See Dao's graph which is very good. the anatomy is very nice.
some pictures of the central line kits:
Cordis: single lumen, large caliber, good for resuscitation.
（缩略图，点击图片链接看原图）
still cordis
（缩略图，点击图片链接看原图）
triple lumen: three lumens, good for extra line for medication.
（缩略图，点击图片链接看原图）
Femoral arterial line kit:
（缩略图，点击图片链接看原图）
femoral A-LINE kit, front side
（缩略图，点击图片链接看原图）
Trauma Bay
Trauma bay is a part of ER specificly for trauma patients. trauma patients don't go through the regular procedure to see a doctor, instead, they transported directly from ambulance or helicopter to trauma bay.
The setup of ER is different. Only ER attendings and resident working in the ER. they do all the work up for patients, figure out what's going with the patients, if patients have surgical problems, they will call surgery for consult. so no surgical residents or attending sitting in the ER, instead, surgeons are doing their own work until they are paged, then they will go to the ER see patients
顶一下子，不错，谢谢
我认领第七部分－－－－（1）。请大家及时回帖认领，避免重复翻译。
（1）Trauma Bay
创伤（处置）室
Trauma bay is a part of ER specificly for trauma patients. trauma patients don't go through the regular procedure to see a doctor, instead, they transported directly from ambulance or helicopter to trauma bay.
创伤室是急诊室的一部分，是专门为创伤患者设立的。创伤患者会从急救车或急救直升飞机直接送到创伤室，而不是按部就班，走正常急诊诊疗程序。
The setup of ER is different too between china and US. Only ER attendings and resident working in the ER. they do all the work up for patients, figure out what's going with the patients, if patients have surgical problems, they will call surgery for consult. so no surgical residents or attending sitting in the ER, instead, surgeons are doing their own work until they are paged, then they will go to the ER see patients。
中美在急诊科的人员组成上有不同之处。在美国，只有急诊科医护人员候诊，外科医护人员并不在急诊科候诊，他们只有在得到创伤呼叫后才会赶往创伤室救治病人。其他时间则各自忙自己的事情。
－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－
附段落全文。
创伤（处置）室
创伤室是急诊室的一部分，是专门为创伤患者设立的。创伤患者会从急救车或急救直升飞机直接送到创伤室，而不是按部就班，走正常急诊诊疗程序。
中美在急诊科的人员组成上有不同之处。在美国，只有急诊科医护人员候诊，外科医护人员并不在急诊科候诊，他们只有在得到创伤呼叫后才会赶往创伤室救治病人。其他时间则各自忙自己的事情
专题中边边角角的一些话，查漏补缺也翻译一下。
some pictures of the central line kits:
中心通路导管套装的一些图片
Cordis: single lumen, large caliber, good for resuscitation.。
考迪斯[一种6F动脉导管]：单腔，大孔径，用于复苏很管用。
triple lumen: three lumens, good for extra line for medication
三腔管：三腔，可以同时开通三条通路用药。
Femoral arterial line kit
股动脉导管套装
femoral A-LINE kit, front side
股动脉导管套装正面
here is a patient coming from ambulance
救护车正送一个病人过来
here are two patients from two different helicopter 30 minutes apart
两架急救直升飞机先后30分钟送了两个病人过来。
transport to the trauma bay
转运病人到创伤室
30 minutes later, another trauma patient arrived by helicopter.
30分钟过后，另一架急救飞机送来另一个病人。
through this door, they are moved to trauma bay. the door open to outside directly
过了这门儿，直接就是创伤室。
we see >5000 trauma patients per year. when i was taking pictures we had 3 trauma patients came within an hour.
我们平均每年救治至少5000人次的创伤患者。在我拍这些照片的时候，一小时的时间就送来了三个创伤患者。
we will discuss trauma bay setup next time.
下次我想和大家讨论创伤室的组成。
forgot to introduce our EMT (emergency medicine technician) guy. he helped to transport last patient.
差点忘了介绍我们的急救医疗技师，是他帮着把第三个患者转运过来的。
thank you 道兄and BO 兄 for your pics,i like them very much, they are really a great help for me to study those procedures. Although i may make mistakes now ,i have confidence to make progress in this lecture, of course ,with your passionate help.
Thank you again!!!
问答部分第六和第七一块领了，请大家看看有什么 问题及时改正，谢谢……
that's a very sophisticated view of trauma surgery. i don't know that there is any trauma bay at ED in china. Trauma bay is the place for us to do initial assessment and resuscitate patients, especially those dying ones. for the initial resuscitation, we have a trauma surgeon, trauma chief resident and a junior resident. we call neurosurgery for head trauma, ortho for fracture, vascular surgery for large vessel injury, plastic surgery for facial trauma, CT surgery surgery for ruptured aorta. we rarely call urology for consult. we also take care of all the simple chest problems, such as vessel bleeding (not ruptured great vessels), lobectomy for lung injury. trauma surgeon and trauma team is the core taking care of all the trauma patients, other specialties are just consulting teams. i know there is no such subspecialty, trauma surgery, in China. porbably it is time to set up such subspecialty as part of general surgery.
这是对创伤外科精彩的见解。我不知道在国内急救部门是否也有创伤急救室。创伤急救室在我们这里是对病人进行最初的评估及复苏的地方，尤其是对那些濒死的病人。进行最初的复苏，我们这有创伤外科医师、创伤住院总和低年资住院医师。我们会请神经外科医师处理头外伤，骨外医师处理骨折，血管外医师处理大血管操作，整形外科医师处理面部损伤，胸心外科医师对大血管破裂进行处理。但我们很少请泌尿外医师会诊。我们也能够处理所有简单的胸部外伤，比如出血(不是大血管破裂)、肺损伤的肺叶切除。创伤外科医师及其创伤组是处理所有外伤病人的核心，其他科室仅仅是进行会诊。我知道在中国是没有创伤外科这个亚学科的，在中国，也许应该是从普外分支建立这样一个学科的时候了。
i take the syringe off and put the guide wire through the needle. at the same time make sure it is the vein by looking at the color of the blood and the way it bleeds, pulstile or just dripping.
我是将注射器取下来再沿针置入导丝的。同时通过观察血液的颜色和回流方式(喷射还是滴流)来确定我扎进的是静脉。
pretty much poke below the turning of the clavicle, walk down to the subclavian space and just the hand then shoot to the sternal notch.
those procedures need some practice. shouldn't be too difficult, but you should always be careful.
恰好在锁骨形成转折的下方进针，沿锁骨下间隙向固定在胸骨上凹的手指方向进针。
这些操作需要练习才行，不应该很难，但是你必须小心。
高年资住院医师----------------should be junior residents not senior resident
CT室医师对主动脉破裂拍片----------------should be cardiothoracic surgery not CT lab.
肺损伤的肺段切除------------------should be lobectomy, not segmental resection
上传的颈穿的图很漂亮
我认领问答废刀兄和bo兄的第一次问答部分。
根据bo兄指点，加粗文字为更正部分。
小李废刀问:
数日前，应邀到ICU会诊，一男大四学生，车祸伤（脑外伤，骨盆骨折，髋部、下腹部、腰部脱套伤）40天。
主要问题：脓毒症不能控制，呼衰不能脱机。
高热，嗜睡，心动多速，肺清（CT轻微炎症），脱套伤部位多处小切口引流（有脓液，不多），阴囊下肢水肿明显。曾CRRT，水肿可消，停用再肿。肠功能好，EN。
他们考虑脱套伤部位部位感染未能控制，我给予多切口扩大引流，皮下间隙有渗液，脓不多，无明显坏死组织，背部皮下相通。左右放置黎氏管冲洗引流。术毕，阴囊水肿立刻减轻，心率下降。
按时换药，仍发热，阴囊再肿。
目前加强局部换药，有好转。"
boyang1998答：
before i give my suggestion, i'd like to know more about the patient as a whole:
在我给出建议前，我想全面了解病人的情况。
from head to toe:
从头到脚（要了解病人各个方面的详细情况）
1. CNS: How's his mental status, how bad is the head injury
中枢神经系统：患者的精神状态如何，当时颅脑损伤的有多重？
2. cardiovascular: is he hemodynamically stable, or he's in shock, on pressors?
循环系统：患者血液流变学方面稳定吗？是否有休克，需要药物来维持血压？
3. respiratory: what's the reason for his resp. failure? what's the ventilator setting
呼吸系统：呼衰的原因考虑什么？目前呼吸机参数是什么模式？
4. GI: any intra-abdominal injury, abscess, when was the last time he had a CT of abd and pelvis
消化系统（胃肠道）：腹腔内是否有脏器损伤，是否有脓肿？最近一次的腹部和骨盆CT是什么时候做的？
5. GU: Renal failure, what's the creatinin and urine output.
泌尿系统：肾衰竭，肾功如何，尿量怎么样？
6. EXT.: how bad is The deglove injury, any necrotic tissue needs to be further debrided
伤口清创：伤口情况如何，是否有坏死组织需要进一步清除。
7. hem/ID (hemotology and infections disease): what infection does he have? is he septic, what's blood Cx? is he anemic?
血液和感染方面：考虑什么感染？考虑败血症吗，血培养结果是什么？患者贫血吗？
8. FEN (fluids, electrolytes and nutrition): is he fully resuscitated, is he wet or dry? any electrolytes disturbance. it is good he is on enteral nutrition. how do you feed him.
营养和水电解质平衡问题：患者完全恢复意识了吗？是否存在脱水？是否有电解质紊乱？同意选择肠内营养，你们是如何进行肠内营养的？
9. prophylaxis: is he on any prophylactic medication for DVT (sq heparin, SCDs) and ulcer stress ulcer
预防措施：有没有采取措施预防下肢静脉血栓形成和应激性溃疡？
10. dispo: did physical therapist see him? when can the patient be transfer out ICU (not specificly for this patient).
康复理疗方面：理疗医师看过病人了吗？目前已不太适合住在ICU，准备什么时候转出？
if you see an ICU patient, it is a good idea to have all these item go through your mind, then you probably won't miss something. 小李废刀, i think your debridement helped. if you can take some pictures of that patient, that be helpful
如果你要管一个icu的病人，最好全面了解以上的提到的几点，然后才不至于漏掉什么。废刀兄，我想你做的清创术对患者恢复是很有帮助的。如果你能提供一些患者的照片会更有利于彼此之间的交流。
－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－
附问答段落全文：
boyang1998答：
在我给出建议前，我想全面了解病人的情况。
从头到脚（要了解病人各个方面的详细情况）
1.中枢神经系统：患者的精神状态如何，当时颅脑损伤的有多重？
2.循环系统：患者血液流变学方面稳定吗？是否有休克，需要药物来维持血压？
3.呼吸系统：呼衰的原因考虑什么？目前呼吸机参数是什么模式？
4.消化系统（胃肠道）：腹腔内是否有脏器损伤，是否有脓肿？最近一次的腹部和骨盆CT是什么时候做的？
5.泌尿系统：肾衰竭，肾功如何，尿量怎么样？
6.伤口清创：伤口情况如何，是否有坏死组织需要进一步清除。
7.血液和感染方面：考虑什么感染？考虑败血症吗，血培养结果是什么？患者贫血吗？
8.营养和水电解质平衡问题：患者完全恢复意识了吗？是否存在脱水？是否有电解质紊乱？同意选择肠内营养，你们是如何进行肠内营养的？
9. 预防措施：有没有采取措施预防下肢静脉血栓形成和应激性溃疡？
10. 康复理疗方面：理疗医师看过病人了吗？目前已不太适合住在ICU，准备什么时候转出？
如果你要管一个icu的病人，最好全面了解以上的提到的几点，然后才不至于漏掉什么。废刀兄，我想你做的清创术对患者恢复是很有帮助的。如果你能提供一些患者的照片会更有利于彼此之间的交流。
2. cardiovascular: is he hemodynamically stable, or he's in shock, on pressors?
循环系统：患者血液流变学方面稳定吗？是否有休克或高血压状态？
On pressors: means patient needs vasocontrictor to maintain blood pressure, such as: phenylepherine, norepinepherine, vasopressin....
我认领第七部分－－－（2）。
________________________________________
蓝色字体为bo兄笔误之处
HOW TO SET UP TRAUMA BAY:
如何组建创伤室
trauma bay is a very important place for trauma surgery. it is the place we see trauma patients first time. also it is the place to do emergent procedures to save dying patients, such as: intubation, chest tube, resuscitation, emergent thoracotomy, cricothyroidectomy...... so the set up is very important. the worst thing is when you need to cut the patient you can't find a knife.
对创伤患者而言，创伤室无疑是非常重要的地方。创伤室是创伤外科医师首诊患者的地方，同时也是医师抢救危重病人做一些急救操作的地方，比如：气管插管、胸腔置管引流、复苏、急诊胸廓切开术、环甲膜切开术……所以创伤室的组成是非常重要的。可以想像，当你想给患者做手术却找不到手术刀，这样的状况是多么得糟糕。
also, trauma bay should be very close to the operating room (OR). When need move the patient to the OR, you can do it within a minute. we have four trauma bays right next to OR.
另外，创伤室应该紧邻手术室。当患者需要手术时，可以非常迅速送到手术室。我们的四个创伤室就紧挨着手术室。
________________________________________________________________________________
附段落全文。
如何组建创伤室
对创伤患者而言，创伤室无疑是非常重要的地方。创伤室是创伤外科医师首诊患者的地方，同时也是医师抢救危重病人做一些急救操作的地方，比如：气管插管、胸腔置管引流、复苏、急诊胸廓切开术、环甲膜切开术……所以创伤室的组成是非常重要的。可以想像，当你想给患者做手术却找不到手术刀，这样的状况是多么得糟糕。
另外，创伤室应该紧邻手术室。当患者需要手术时，可以非常迅速送到手术室。我们的四个创伤室就紧挨着手术室。
