【作者】 刘国栋；

【导师】 周继红；

【作者基本信息】 第三军医大学 ， 外科学， 2011， 博士

【摘要】 地震是地壳板块间挤压碰撞的结果,是世界上最严重的自然灾害之一。中国是一个震灾严重的国家。2008年5月12日14：28分在中国四川省汶川县发生8.0级地震,是自唐山大地震以来破坏性最强的一次地震,共造成69,227人遇难,374,643人受伤,17,923人失踪。此次地震对震区医疗卫生系统造成毁灭性破坏,导致其救治能力极度降低,难以满足短时期内积聚的大量伤员的救治需求。为了能让伤员接受更系统、合理的治疗,在国家卫生部的统一部署下,将灾区医疗卫生系统收治的10,015例伤员紧急转运至四川省外的医疗卫生机构进行救治,这是我国迄今为止最大规模的地震伤员转运救援行动。为了了解这些转运地震伤员的伤情、救治特点和救治效果,总结此次地震伤员医学救援的经验与教训,积累灾害救援的数据资料,并为以后可能的重大灾害医学救援提供借鉴和准备,本研究依托于国家“863”项目—“5.12地震伤情数据采集及信息整理分析研究”,研制了地震伤情数据库系统软件,全面采集了转运到重庆市和全国部队医院救治的汶川地震伤员的伤情和救治资料,建立了地震伤情数据库,并对数据库中地震伤员的伤情特点和救治情况进行了初步分析。一.材料与方法1.以“创伤数据库系统V3.0”为基础,结合地震损伤特点、转运救治的实际情况,以及地震损伤研究者和临床科研工作者的需求,遵循循证医学原则,采用德尔菲法设计地震伤情调查表。2.在调查表基础上研制“地震伤情数据库系统V1.0”数据管理软件。数据库系统采用B/S模式,分为数据库服务器、逻辑层、客户端(浏览器)三层。开发工具以微软公司的.Net 2.0版本为核心,采用C#作为开发语言,客户端采用微软的IE浏览器,数据库采用MSSQL2000。3.本研究根据国家卫生部和解放军总后勤部卫生部提供的转运地震伤员信息,采集转运至重庆市医院和全国部队医院的地震伤员的病历资料。采集方法以现场阅读病历、填写调查表为主,辅以数据库系统现场数据录入。数据采集前制定了细致的采集计划并对采集人员进行培训。采集过程中质控员要对调查表进行形式和内容检查,对存在的问题及时修改。质控完成后签名确认。最后,将采集的数据集中录入到地震伤情数据库管理软件中,建立地震伤情数据库,录入过程同样也要对数据录入项目的完整性和准确性进行质量控制。4.从地震伤员伤情和救治概况和地震多发伤伤员的损伤和救治特点进行分析：一方面,对总体转运地震伤员的损伤和救治特点进行初步分析,了解本次转运地震伤员的伤情和救治情况概况；其次,对三甲医院多发伤伤员的损伤和救治情况进行深入分析,探讨转运距离等因素对多发伤伤员救治结局的影响。二、主要研究结果1.设计完成了5.12地震伤情调查表,调查表内容包括伤员基本信息、受伤情况、现场救治、转运及后送、急诊救治、院内救治、诊断、并发症、专科治疗及出院等10个部分。2.根据5.12地震伤情调查表研发了网络版“地震伤情数据库系统V1.0”数据管理软件,并获得了国家版权局著作权保护(No.2010SR035530).本软件共有728个字段(含内部字段),其中外部业务字段(界面显示)348个,内部系统字段380个。地震伤情数据库系统共有48个业务模块,含44张业务数据表和软件系统数据表。地震伤情数据库软件主要包括伤员基本信息、受伤情况、现场救治、转运及后送、急诊救治、院内救治、诊断、并发症、专科治疗及出院等板块。能完整记录地震伤员从受伤、院前与院内救治到出院的基本信息,整合了地震伤数据与创伤评分、AIS伤情评定信息,在此基础上,软件还实现了简单和自定义查询、定制报表和自定义报表分析功能,能较好地满足地震伤情数据支撑平台要求和地震伤情临床研究需求。3.经过近一年的时间,完整采集到转运至四川省外11个省、自治区和直辖市共92所医院收治的3,145例转运地震伤员的病历资料,与计划相比总体回收率为95.83%,可以满足转运地震伤员伤情及救治分析的需求。将所有采集到的转运地震伤员数据完整录入到“地震伤情数据库系统V1.0”,建立了地震伤情数据库。4.转运伤员总体伤情和救治特点以及三甲医院多发伤伤员伤情和救治特点。(1)所有转运伤员的一般情况：转运伤员主要来自重灾区(67.37%)。伤员年龄0-103岁,其中7-17岁占17.50%,≥61岁占24.80%。从伤员职业分布来看,农民和学生占55.71%。致伤原因中压砸伤最多,占73.85%。对不同年龄段伤员受伤时活动和受伤场所的分析结果显示,0-6年龄段人群受伤时活动主要为休息／睡眠／进餐等或在学校学习；而≥61岁年龄段人群受伤时主要在家里休息／睡眠／进餐等。受伤至入院时间为0～136 d(中位数为8),时间跨度大。(2)转运伤员总体伤情特点和救治概况：①AIS评分主要集中在1-3分,占96.83%。受伤部位主要为四肢(上肢和下肢)和体表,占64.27%。AIS>4分主要集中在四肢、胸部和头部,分别占11.62%、10.38%和7.52%,与总体致伤部位分布一致。ISS>15分597例,占18.98%。涉及的损伤部位主要为下肢(172处,24.75%)、胸部(137处,19.71%)、头部(117处,16.83%)和上肢(91处,13.09%),与总体损伤部位的分布特点一致。②首次实验室检查结果显示,1,839例(58.47%)血常规检查异常,1,047例(52.91%)凝血功能检查结果异常,810例(37.36%)肝肾功+血清电解质检查结果异常,但这些伤员经过治疗后均好转,提示地震伤员经过前期救治,在转运时身体状况尚可,只需确定性治疗。511例(65.60%)伤员首次心肌酶谱检查结果异常,提示可能存在心肌损伤；1,810例伤员(57.55%)心电图异常,主要表现为快速性心律失常,可能与地震创伤导致强烈的应激反应有关。③转运伤员的治疗以手术为主,包括肌肉骨骼系统手术、体被系统手术及其他诊断性和治疗性操作。肌肉骨骼系统手术中主要包括复位固定术990例次(93.57%),其次为骨折清创术13例次(1.23%)。体被系统手术共实施744例次,其中清创术有413例次(55.51%)。I型伤口中有12例为丙级愈合(0.98%),这些手术主要为下肢骨折切开复位内固定和清除坏死组织。④转运伤员住院时间为1-422 d,伤员住院时间主要集中在100 d以内(97.93%)。住院时间≥100 d共65例,其中残疾21例(32.31%)。伤员总体治愈率为90.56%,残疾率为7.06%,死亡率为0.16%。(3)重庆三甲医院与其他地区三甲医院多发伤伤员特点比较：A组为转运到重庆三甲医院的多发伤伤员,B组为转运其他地区三甲医院的多发伤伤员。两组伤员损伤严重程度评分ISS)比较,差异无统计学意义(P>o.05)。两组受伤至转运时间A组为(11.54+11.04)d,B组为(12.51±3.94)d(P>0.05)。从伤员总体年龄分布来看,年龄≥61岁和≤17岁的占了总数的65.63%。从两组年龄分层来看,A组和B组中年龄≥61岁和≤17岁的伤员比例高于其他年龄段伤员。主要职业为农民(A组占30.53%,B组占39.34%)和学生(A组占27.48%,B组占22.95%),与职业分布的总体特点一致。A、B两组伤员入院时感染率分布为22.90%和9.84%(P<0.05),出院时均治愈。两组伤员都没有发生死亡。两组治愈率和残疾率之间比较,差异无统计学意义(P均>0.05)。但是两组FIM比较,差异有统计学意义(P<0.05)。三、主要结论(1)本研究研发了结构科学合理、具有分类和汇总功能的网络版地震伤情数据库管理软件,并获得了著作权保护(No.2010SR035530)。该软件是目前国内第一个专门记录汶川地震转运伤员伤情的数据管理软件,为研究地震伤员的伤情信息管理提供了良好的工具。(2)本数据库收集了所有重庆市和全国部队医院收治的3,145例转运地震伤员病历资料,是目前国内数据记录完整性和可靠性高的大宗数据。采集数据过程工作量大,数据回收率高(95.83%)。建立了结构科学、合理的地震伤情数据库,为开展地震伤情研究提供了可靠的数据支撑。(3)地震后转运伤员主要为重灾区农村人口和学生,地震发生时间刚好是学生上课和人们午休时间,致伤原因主要为建筑物倒塌所致的四肢压砸伤,提示伤亡人群分布和受伤部位分布与地震发生的时间、人群职业及建筑物性质密切相关。转运时间跨度大,但高峰期集中在发现唐家山堰塞湖后(73.93%),与国家统一调度有关。(4)伤员损伤部位主要为四肢(50.89%),胸部(11.62%)、头部(10.38%)和脊柱(7.52%)所占比例高,提示转运伤员时科室安排以骨科和外科为主。(5)伤员入院时部分检查结果异常,出院时均得到好转,提示入院时伤员生理情况稳定,只需要后续确定性治疗,可能与转运前当时的医疗条件和恶劣环境有关,尽早转运则治疗结果更好。但特别要关注心肌损伤伤员。手术治疗中骨折固定和清创手术多,这可能与前期对骨折的固定不满意有关,也与伤员转运时间延迟有关。提示应建立综合灾害应急预案、伤员转运机制和统筹管理机制,确保灾害发生时能快速反应,这对伤员救治结局有直接影响。(6)部分转运伤员住院时间长,与伤员是否残疾并需要继续康复治疗密切相关。(7)部分转运伤员出现再转院的情况,提示转运前对伤员目标救治科别选择不当,应在转运早期做好合理安排,应有针对性地及早转运特殊伤员。(8)多发伤伤员中老年人(≥61岁)和儿童(≤17岁)所占比例高,提示这部分人群地震灾害中受伤更严重。对多发伤伤员比较研究结果显示,转运距离并没有影响多发伤伤员的救治结局,提示我国急救医疗转运是成功的。(9)本研究中发现部分医院的病历资料记录欠规范和完整,缺乏现场救治的相关信息,不利于对地震伤情的深入研究,提示应在我国卫生管理部门的统一领导下,加强医院伤员信息的规范化录入和管理,为灾害医学的研究和发展创造更好的条件。更多还原

【Abstract】 Earthquake is caused by the squeeze and collision between the tectonic plates and is one of the worst natural disasters in the world. China is an earthquake prone country. An earthquake measuring 8.0 on the Richter scale occurred at 14:28 pm on May 12,2008 in Wenchuan County, Sichuan province of China (called Wenchuan earthquake or Sichuan earthquake). Wenchuan earthquake is the strongest devastating earthquake since Tangshan earthquake (in 1976) in China and has resulted in 69,227 deaths,374,643 injured and 17,923 missing. The earthquake devastated the medical facilities in the quake zones (including the epicenter and the surrounding areas) and seriously affected the emergency response and treatment capacity of the medical care system, which added difficulties in providing sufficient and timely treatment of a large number of the earthquake trauma patients (only the word "patients" will be used with consideration of abstract length) gathered at very short period of time after earthquake. With aim to provide the patients a better and reasonable treatment, some of the patients admitted to the hospitals or the ambulatorium in the quake zones were managed to be transported to the medical facilities outside Sichuan province according to the deployment the Ministry of Health of China, as is also the ever largest disaster relief operation of the patient transfer after an earthquake.In order to understand the injury and treatment characteristics as well as the treatment outcome of the transferred earthquake patients, accumulate the data of the transferred earthquake trauma patients, summary the experiences and lessons in the medical aid after a major earthquake and provide reference for transfer and treatment of the large casualties in the major disasters in the future, under support by the item "5·12 earthquake trauma data collection and information analysis of consolidation" of the national "863" project, an earthquake trauma database system was developed in this study and the clinical data of the earthquake patients transferred to the hospitals in Chongqing and the military hospitals collected for a preliminary study on the injury profile and treatment of these patients.1 Materials and methods (1) Based on the "Trauma Database System V3.0", the studies of earthquake trauma profile and the demand of the specialist treatments of the earthquake trauma, the survey for collecting earthquake trauma data was developed by using the Delphi method.(2) The earthquake trauma database system V1.0 was aimed to be developed based on the survey form. The database system uses the B/S mode and including the database server, the logic layer and the client (browser) layer. The core development tool was Microsoft’s. Net 2.0 version, with C# as development language. The client uses Microsoft’s IE browser and the database uses MSSQL2000.(3) As the major research content of the item, we planned to collect the medical records of 3282 earthquake patients transferred to 91 hospitals outside Sichuan province, which was provided by the Ministry of Health and the General Logistics Department of PLA. The method of data collection was to read medical records on site and fill out the survey form. Before data collection, we made a detailed plan and organized training of the data collection personnel.During data collection, the quality control staff was responsible for a strict quality control that was performed simultaneously to inspect the filled survey form and revise then. The quality control staff signed for confirmation after inspection. Finally, we input the collected clinical data into the earthquake trauma database, when a strict quality control process was done likewise. The time spent in inputting the data was similar with that in collection of the medical records.(4) The injury profile and treatment of earthquake trauma patients were analyzed from two aspects:firstly, a preliminary study was carried out on the injury profile and treatment of the transferred earthquake patients so as to provide a general understanding of these patients; Secondly, the injury profile and treatment of the multiple trauma patients were analyzed to discuss the effect of transfer on the treatment outcome of the multiple trauma patients.2 Main results(1) The survey for collecting earthquake trauma data has been developed. The survey involved the information on the patients, the transfer and evacuation, the clinical treatment, the rehabilitation, the outcome and the discharge, etc.(2) The online earthquake trauma database system V1.0 was developed based on the survey form and had been conferred as the national copyright invention patent (No.2010SR035530). There were a total of 728 fields (including the internal fields), of which there were 348 external fields (screen display). The database system had 48 modules and 44 business data tables and other data tables. The main inside information included basic information, injuries, on-site treatment, transfer & evacuation, emergency treatment, hospital treatment, diagnosis, complications, specialist treatment and discharge. The survey could record the information from injury, prehospital and hospital treatment to hospital discharge and integrated with earthquake trauma score and AIS injury assessment information. The database system had the functions including simple custom queries, custom report and custom reports analysis and could meet the requirements of the earthquake trauma support platform and the clinical research on the earthquake injuries.(3) After nearly a year, we have accomplished the complete collection of the clinical data of 3,145 earthquake trauma patients transferred to 92 hospitals in 11 provinces, autonomous regions and municipalities outside Sichuan province, with overall recovery rate of 95.83%, which could satisfy the requirements of analysis on injury and treatment of the transferred earthquake patients. All the collected data of the transferred earthquake patients were input into the "earthquake trauma database system V1.0" to establish an earthquake trauma database.(4) The injury profile and treatment of overall transferred earthquake patients and the multiple trauma patients.1) The general situation of all the transferred patients:The transferred patients were mainly from the hardest-hit zones (70%). The patients were at age of 0-103 years, including the patients at 7-17 years accounting for 17.504% and those at≥61 years for 24.80%. The main occupation of the patients was farmer and student, accounting for 55.71%. The injury cause of crushing accounted for 73.85% of total. The analysis of the patients at different ages showed that the patients at 0-6 years were mainly in rest/sleep/meal or in school; while the patients at age of≥61 years were mainly in rest/sleep/meal at home. The time from injury to admission was at a range of 0-136 days (median value 8).2) Injury profile and treatment of overall transferred patients:①The abbreviated injury score (AIS) was mainly 1-3 points, accounting for 96.83%. The injury sites were mainly the extremities (including lower limbs and upper limbs) and body surface, accounting for 64.27%. The injury sites with≥4 points were mainly the lower limbs, thorax and head, accounting for 11.62%,10.38% and 7.52% respectively. Of all,597 patients (18.98%) had the ISS> 15 points, involving mainly the lower limbs (172 sites,24.75%), thorax (137 sites,19.71%),head (117 sites,16.83%) and the upper limbs (91 sites,13.09%), in consistent with the distribution of the injury sites.②First laboratory examinations showed abnormal results in blood routine examination (1,839 patients,58.47%), in coagulation test results (1,047 patients,52.91%) and in liver and kidney function plus serum electrolytes (810 patients,37.36%), which were improved after treatment, indicating that the patients were under a not bad physical condition after pre-treatment and only needed definitive treatment. The first abnormal myocardial enzymes results in 511 patients (65.60%) suggested possible myocardial injury. Abnormal ECG was found in 1,810 patients (57.55%), mainly manifesting as abnormal tachyarrhythmia, as may be related with stress response caused by earthquake. The operation included mainly the musculoskeletal system surgery, integumentary system surgery and a variety of diagnostic and therapeutic operations. The musculoskeletal system surgery mainly included reduction and fixation for 990 times (93.57%) and next the fracture debridement for 13 times (1.23%). The integumentary system surgery was implemented for 744 times, including debridement for 413 times (55.51%). Type I operative incision resulted in grade C healing in 12 patients (0.98%), with mainly the open fracture reduction and internal fixation of the lower limbs and the removal of the necrotic tissues.④The in-hospital stay of the transferred patients was at a range of 1-422 days, mainly within 100 days (97.93%). The in-hospital stay for≥100 days was found in 65 patients including 21 disabled patients (32.31%). The overall cure rate, disability rate and mortality rate were 90.56%,7.06%and 0.16%respectively.3) Comparative study on the patients transferred to the Grade 3A military hospitals in Chongqing and other places:The patients transferred to Chongqing were set as Group A and those to the places outside Sichuan province and Chonqqing set as Group B. There was no statistical difference in terms of injury severity score in both group (both P> 0.05). The time from injury to transfer was (11.54±11.04) days in Group A and (12.51+3.94) days in Group B, with no statistical difference (P=0.5079). The overall age was distributed mainly at age≥61 years and≤17 years, which accounted for 65.63% of the total. The analysis on the age sections showed that the patients at≥61 years and≤17 years were more than those at the other age sections. The occupation was mainly the farmers and students, which accounted for 30.53% and 27.48% respectively in Group A and for 39.34% and 22.95% in Group B, with no statistical difference between two groups (P=0.2340 for both groups). The infection rate was 22.90% and 9.84% respectively in Groups A and B (P=0.0308), with no death in both groups. The cure rate (P=0.1535) and the disability rate (P=0.1535) showed no statistical difference between two groups, with no infection in both groups. But the function independence measure (FIM) of two groups showed statistical difference (P=0.017).3 Main conclusions(1) The management software of online version earthquake trauma database is developed, with scientific and reasonable structure and function of classification and aggregation, and has obtained copyright protection. The software is currently the first data management software for recording the clinical data of the transferred earthquake patients and provides a good tools for study of information management of the earthquake patients.(2) The database has collected the medical records of 3,145 earthquake patients transferred to the military hospitals and the hospitals in Chongqing, which is the bulk of the data with high integrity and reliability. Data collection is a heavy workload process, with high recovery rate (95.83%). The database with scientific and reasonable structure is developed and provides a reliable data support for research on injury profile of the earthquake patients.(3) The transferred patients are mainly the rural population and the students from the hardest earthquake hit areas. The earthquake occurred at 14:28, when is the class time for the students and the lunch break for the others. The injuries are mainly the crushing injury caused by building collapse, suggesting that the distribution of casualties and the injury sites is closely related with the quality of the buildings. The transfer lasts for a very long time and the peak time appears after the discovery of the dammed lake (73.93%), which is in accordance with the national integrated scheduling.(4) The main injury sites are the extremity (50.89%), chest (11.62%), head (10.38%) and spine (7.52%), suggesting that the wounded should be arranged to orthopedic and surgical departments.(5) Some of the patients have abnormal results on admission and get improved at discharge, suggesting that the transferred patients are in a stable physiological condition on admission and only need further definitive treatment, which may be related with poor medical conditions and austere environment. Better treatment result may be obtained if as early transfer as possible. Myocardial injury should be paid particular attention. High proportion of fracture fixation and surgical debridement in surgical treatment may be correlated with previous unsatisfactory fracture fixation and with the delayed transfer time, as indicates that the comprehensive disaster contingency plan, the transfer mechanism of the wounded and the integrated management system should be established to ensure rapid response when disaster strikes, which have a direct impact on the treatment outcome of the wounded.(6) Part of the transferred patients stayed long in the hospitals, which is correlated with the disability and rehabilitation requirement of the patients.(7) Some of the transferred patients were transferred repeatedly, suggesting that the target department in the hospitals were chosen inappropriately and that the targeted transfer of the special patients should be reasonably arranged in advance.(8) The elderly (≥61 years) and children (≤17 years) have high proportion of multiple trauma, suggesting that this group of persons may suffer severer injuries in the earthquake disaster. The comparative results of the multiple trauma patients showed that the transport distance does not affect the treatment outcome of the multiple trauma patients, suggesting that the emergency medical evacuation is successful in China.(9) The study found that the medical records of some hospitals lacks standardization and completeness and even on-site treatment information, which is not conducive to in-depth study of the earthquake trauma, indicating a necessity in strengthening the standardization in information input and management under leadership by the health authorities so as to create better conditions for research and development of disaster medicine.更多还原