追加：第 13 节第 47 条（断指保存）、第 48 条（恒牙撞掉）

2026-10-14。主任务给的两个候选，都追加在第 13 节末尾，没有插在中间。节首导览挂进「外伤和烫伤」一块，短名「手指被切断」「恒牙整颗撞掉」。

查重：全书 grep「断指、断肢、离断、再植、撞掉、牙外伤、牙槽」，正文没有同主题条目。第 1 节第 42 条（角磨机）的核实记录提到日本断指病例，只用来说明伤得多重，没有保存断指的动作。第 13 节第 12 条（大出血）管止血，第 47 条只指过去，不重复。

四问：① 切菜、门缝夹手、电动工具切断手指，孩子摔跤撞掉门牙，都常见；② 常见的错误做法是把断指直接埋进冰里、泡进水里，牙用纸巾包着干放或者扔掉，读者多半不知道；③ 动作是新的；④ 有 NLM、NHS、IADT 原文。

第 47 条 断指

1. MedlinePlus, Traumatic amputation（Review Date 8/27/2024）

  • URL：https://medlineplus.gov/ency/article/000006.htm（2026-10-14 带代理 curl 取到）
  • 「Control bleeding by applying direct pressure to the wound. Raise the injured area.」
  • 「If the person has life-threatening bleeding, a tight bandage or tourniquet will be easier to use than direct pressure on the wound.」
  • 「Save any severed body parts and make sure they stay with the person. If possible, remove any dirty material that can contaminate the wound, then gently rinse the body part if the cut end is dirty.」
  • 「Wrap the severed part in a clean, damp cloth, place it in a sealed plastic bag and place the bag in an ice water bath.」
  • 「Do not put the body part directly in water or ice without using a plastic bag.」
  • 「Do not put the severed part directly on ice. Do not use dry ice as this will cause frostbite and injury to the part.」
  • 「If cold water is not available, keep the part away from heat as much as possible. ... Cooling the severed part allows a longer window of time for later reattachment. Without cooling, the severed part is only good for reattachment for about 4 to 6 hours.」
  • 「Do not forget that saving the person's life is more important than saving a body part.」「Do not attempt to push any part or bone back into place.」「Do not decide that a body part is too small to save.」
  • 「4 到 6 小时」只按这一句写，原文说的是「不冷着」的情形。冷着能撑多久原文没给数字，条目没写。

2. AAOS OrthoInfo, Fingertip Injuries and Amputations

  • URL：https://orthoinfo.aaos.org/en/diseases--conditions/fingertip-injuries-and-amputations
  • 「Gently clean the amputated part with water or, if possible, with sterile saline solution. Cover it in a moistened gauze wrap. Place it in a sealed watertight bag ... Place the bag on ice in a sealed container or another watertight bag. Do not allow the amputated part to be in direct contact with ice. You could damage it further. Go immediately to the emergency room, preferably at a hospital that has hand specialists immediately available.」
  • 美国手外科学会（ASSH）页面用 curl 只拿到 3 KB 壳页，没用。

3. 再植存活率与缺血时间（Europe PMC 摘要）

  • Treger D 等 (2026) HAND，DOI 10.1177/15589447241279445：「Of the 31 included studies, 26 studies reported that 1976 digits were successfully replanted, while 27 studies reported that 300 replants failed (86.8% success rate). Among 1087 patients in these studies, 82.9% who underwent replantation returned to work.」
  • Stone N 等 (2021) Microsurgery，DOI 10.1002/micr.30738：「12 retrospective cohort studies met inclusion criteria ... The overall replantation survival rate was 85.3%.」
  • Yu F 等 (2026) Front Surg，DOI 10.3389/fsurg.2026.1795247：「A total of 12 studies involving 3,645 patients were included. ... preoperative ischemic time ≥8 h [OR = 2.25, 95% CI (1.43, 3.54)] ... may be associated with necrosis after digital replantation.」条目按「几率约 2.25 倍」写，保留 OR 原值。
  • 反方或不一致：Ma Z 等 (2016) J Hand Surg Eur，DOI 10.1177/1753193415594572 摘要说「Gender and ischemia time had no significant influence on the survival rate」，同时说保存方法有显著影响，但摘要没写哪种方法好，所以没进条目。缺血时间的影响各研究说法不一，条目只写了 8 小时这一个门槛。
  • Huang RS 等 (2023) 儿童断指再植综述：存活率 76%，撕脱、压伤比切割伤存活几率低。条目备注「压烂的、撕扯下来的比切得整齐的难接」据此，没写数字。

证据等级与收益

  • B：保存方法是指南和教科书共识，没有比较保存方法的对照试验；存活率来自回顾性研究的合并。
  • 收益「中」凭判断：口径归死亡率（含健康终点），但终点是保住手指，不是活命，相对降幅没法按阈值套。

第 48 条 恒牙撞掉

1. NHS, Knocked-out tooth（Page last reviewed: 06 February 2025）

  • URL：https://www.nhs.uk/conditions/knocked-out-tooth/
  • 「Hold the tooth by the white bit that sticks out of the gum (the crown) – do not touch the root.」
  • 「If the tooth is dirty, rinse it gently in milk, saline or saliva.」
  • 「Try to put it back into the hole in the gum.」「Bite down gently on a clean cloth to hold the tooth in place if it goes back in easily.」「Go to a dentist as soon as possible.」
  • 「Do not put a baby tooth back in as it could damage the tooth growing underneath.」
  • 「If you cannot put the tooth back in, you can put it in either milk or saliva.」
  • 「Ask for an emergency dentist appointment if: you have knocked out a tooth, even if you cannot find it」
  • 「If you cannot find the tooth or the dentist is not able to save it, the tooth may be replaced with a denture (false tooth) while the socket heals. Once it's healed, there may be other options like a bridge or dental implant.」

2. IADT「Save your tooth」海报（英文版图片）

  • 页面：https://iadt-dentaltrauma.org/guidelines-and-resources/save-a-tooth-poster/，英文图 https://iadt-dentaltrauma.org/wp-content/uploads/2024/03/Save-Tooth-ENGLISH528w.jpg（用 Read 看图核对）
  • 步骤原文：「Find the tooth」「Hold it by the crown」「(plug the sink) Rinse in cold tap water」「FOLLOW ONE OF THESE ALTERNATIVES: a Put the tooth back in its place / b Place the tooth in a cup of milk or saline / c When milk is not available, place the tooth in the mouth between the cheeks and gums」「Seek immediate specialized dental treatment, within a two hour time period」
  • 海报写的「two hour」和研究里「干放 1 小时」不是同一个口径（前者是就诊时限，后者是牙在体外干着的时间），条目两个都没写成就诊时限，只写「马上去看牙」。
  • 中文版海报 PDF 下载到了（2.5 MB），pdftotext 抽不出字，没用。

3. IADT 2020 指南（未取得正文）

  • Fouad AF 等 (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology（卷期页码没核）. DOI 10.1111/edt.12573，PMID 32460393。
  • Semantic Scholar 标为开放获取（CC BY-NC-ND），但 Wiley 全文页和 pdfdirect 都被 Cloudflare 挡住，curl 和无头 Chrome（带代理、90 秒）都只拿到验证页。摘要只有总述，没有具体动作。所以条目来源栏没列它，动作按 NHS 和 IADT 海报核对。
  • 中华口腔医学会的牙外伤指南没有去找（本机查国内学会指南没有现成通道），条目没引。

4. 骨性粘连风险（Europe PMC 摘要）

  • Gul A 等 (2024) Dent Traumatol，DOI 10.1111/edt.12898：「Data from 116 patients with 145 replanted avulsed permanent teeth were selected from a comprehensive dental trauma database in Copenhagen University Hospital.」「follow-up ranged from 7 months to 23 years」「The overall risk of ankylosis was 17.2% [95% CI: 4.61; 29.79] for immediately replanted teeth, 55.3% [95% CI: 42.54; 68.00] for teeth stored in physiologic media before replantation, and 85.7% [95% CI: 75.70; 95.73] for teeth stored dry more than 1 h.」生理介质指口水和生理盐水（「physiologic storage media (saliva and saline)」）。
  • Lauridsen E 等 (2020) Dent Traumatol，DOI 10.1111/edt.12520，单位 University Hospital, Copenhagen：「The material originates from a previously reported clinical study of 400 replanted teeth.」「The estimated risks of ankylosis after 900 days for teeth with immature root development were: dry time < 20 minutes: 33.9% ... dry time > 60 minutes: 60.0% ... The risks for teeth with mature root development were: dry time < 20 minutes: 59.4% ... dry time > 60 minutes: 86.4%」「However, some teeth may heal without ankylosis even after 60 minutes of dry time. ... Replantation should therefore always be considered for avulsed teeth.」摘要里的 HR 1.22 没写单位（每多少分钟），条目没用。
  • Andreasen JO 等 (1995) 第 1 篇，DOI 10.1111/j.1600-9657.1995.tb00461.x，单位 Rigshospitalet：「During the observation period, 119 teeth (30%) were extracted.」
  • Andreasen JO 等 (1995) 第 4 篇，DOI 10.1111/j.1600-9657.1995.tb00464.x：「Storage in tap water for more than 20 minutes usually led to root resorption.」「Based on these findings, immediate replantation is recommended irrespective of stage of root development.」

证据等级与收益

  • B：一家医院的随访队列，没有分组对照。
  • 收益「中」凭判断：终点是牙根粘连，不是直接掉牙，更不是死亡；粘连风险从 85.7% 降到 17.2% 的相对降幅很大，但这是替代性的健康终点，不按死亡率阈值机械套「大」。
  • 人群标签没加：撞掉牙多见于孩子，但大人摔跤、运动撞到嘴一样适用，按规则不加。