胸腹联合伤48例诊治体会

回顾性分析1992年1月—2006年8月收治的48例胸腹联合伤患者的临床资料，其中车祸伤16例，刀刺伤10例，击打伤8例，坠落伤6例，挤压伤5例，枪击伤3例。形成创伤性膈疝16例。合并有血、气胸者38例，休克20例，创伤性湿肺11例。术前确诊41例，误诊7例，误诊率14.6％。45例行手术治疗，其中经左胸切口24例，经右胸切口7例，经腹、胸分别切口５例，经胸腹联合切口2例，经腹部切口４例，经双侧胸切口3例。治愈43例，死亡5例，病死率为10.4％。失血性休克是死亡的主要原因。胸腹联合伤病情复杂严重，易误诊，病死率高，临床应根据病史、体检、Ｘ线检查及穿刺引流等做出综合判断，对确诊及高度可疑病例应积极行手术治疗。     

创伤性膈肌损伤的诊断及治疗

目的 探讨创伤性膈肌损伤的早期诊断及手术入路选择。方法 回顾性分析近10年来收治的23例创伤性膈肌损伤患者的临床资料。结果 术前诊断12例(52．2％)；术中确诊8例(34．8％)；漏诊3例，漏诊率为13．1％。全组患者均经手术治疗，经胸手术12例，经腹手术8例，胸腹联合切口手术3例。术中见腹腔内脏器疝人胸腔18例，单纯膈性肌损伤5例。术后并发脓胸2例。死亡3例，死亡率13．1％，死亡原因为失血性休克和多器官功能衰竭。结论 创伤性膈肌损伤早期诊断困难，关键是要考虑到膈肌损伤。创伤性膈肌损伤一经诊断或怀疑其可能时，应及早手术治疗。要根据受伤机制、受伤部位，选择手术入路，并根据术中发现选择手术方式。     

创伤性膈肌破裂24例诊治分析

目的总结创伤性膈肌破裂的诊治经验。方法回顾性分析我院10年来收治的24例膈肌破裂的诊治经过，以实例分析的方法，总结膈疝的特点及误诊原因；手术方法采用剖腹术20例，剖胸术2例，胸腹联合切口1例，剖腹术后剖胸术1例。结果本组治愈21例，死亡3例，病死率12．5％。结论对于利器伤所致的膈肌破裂应警惕膈肌多处裂伤的可能；而钝性伤所致的膈肌破裂多伴有合并伤，早期诊断、及时手术是提高治愈率，降低病死率的关键；绝大多数膈肌破裂可经腹手术而治愈。     

外伤性膈肌破裂的临床诊治分析

目的总结外伤性膈肌破裂的诊断与治疗经验。方法该组患者45例,其中开放性损伤18例,闭合性损伤27例。合并其他脏器损伤42例(93.3%)。经腹手术26例,经胸手术9例,经胸腹联合切口6例,经腹手术后改胸腹联合切口3例,未手术死亡1例。结果全组死亡3例,病死率6.7%。结论早期诊断,早期手术治疗可提高本病治愈率,胸部CT检查对本病的诊断具有特异性。外科手术是治疗膈肌损伤的最可靠方法。术中仔细探查膈肌是减少漏诊的关键。     

胸腹联合伤并失血性休克82例分析

目的 探讨胸腹联合伤并失血性休克患者临床处理。方法 回顾性分析82例胸腹联合伤并失血性休克患者临床资料。结果 82例患者均手术治疗，剖胸和（或）剖腹79例，3例单纯胸腔闭式引流，治愈67例，治愈率81．7％，死亡15例。死亡率18．3％，心衰、急性呼吸窘迫综合征（ARDS）、肾衰总发生率34．7％，心衰、ARDS、肾衰分别为11．6％、17．1％、6．00％，ARDS发生率最高，死亡的主要原因是多器官功能障碍综合征（MODS），占53．3％（8／15）。结论 胸腹联合伤并失血性休克诊断的关键是明确受伤机制，下胸部、上腹部外伤，挤压、冲击伤应想到胸腹联合伤可能。体格检查和诊断性胸腹穿刺应放在首位。处理上应首先紧急抗休克治疗、改善通气障碍等。选择手术时机及手术是必要的，早期防治MODS可以降低病死率。     

创伤性膈疝的临床特点及诊治分析

目的总结创伤性膈疝的病因、临床特点及外科治疗经验,以提高早期确诊率和提高预后。方法回顾性分析2005年7月至2016年6月,川北医学院附属医院收治的23例创伤性膈疝患者的临床资料。本组患者均施行手术治疗,术前确诊19例,漏诊4例,漏诊率17.4%。结果全组均在全麻下行手术治疗,其中左侧开胸11例,右侧开胸4例,经腹切口3例,胸腹联合切口5例。手术时间1.5~6.0 h,平均(3.1±1.7)h。手术处理顺序为先处理胸腹腔损伤脏器及致命损伤,再行膈肌缺损修补,全组治愈21例,死亡2例(死亡率8.7%),1例死于失血性休克,1例死于多器官功能衰竭。结论早期诊断对创伤性膈疝预后至关重要,胸腹部平片、CT及B超是诊断创伤性膈疝的重要方法,一旦确诊,应急诊手术治疗。积极抗休克、早期手术及良好的术后管理是降低死亡率的关键。     

胸腹联合伤36例临床分析

目的总结胸腹联合伤的诊断与手术治疗经验。方法对1993-2003年收治的36例胸腹联合伤病例进行回顾性分析。结果开胸手术15例，胸腔闭式引流加开腹手术21例。治愈34例，死亡2例(6％)，死亡病例均因心血管损伤严重失血性休克。结论胸腹联合伤病情重，临床表现复杂，早期正确诊断、及时和合理的手术治疗是减少死亡率、提高救治水平的关键。积极抗休克，重症监护和防治并发症等非常重要。     

胸腹联合伤的诊治体会

目的　总结胸腹联合伤的早期诊断与治疗体会。方法　对我院 1 992年～ 2 0 0 2年收治的 78例胸腹联合伤病例进行回顾性分析。结果　开胸手术 2 7例 ,胸腔闭式引流 +开腹手术 4 0例 ,非手术 1 1例。治愈 72例 ,死亡 6例 (8% )。死亡原因均为心血管损伤伴严重失血性休克。结论　胸腹联合伤病情重 ,表现复杂 ,早期诊断、及时合理治疗是减少死亡率 ,提高救治效果的关键。     

创伤性膈疝25例临床诊治体会

目的总结创伤性膈疝的临床诊断和早期治疗的经验,为减少误诊、漏诊及提高治愈率提供参考。方法对25例创伤性膈疝患者的临床资料与治疗经验进行总结分析,21例于伤后24 h内就诊,3例于伤后48h就诊;1例CT检查发现空腔脏器疝入胸腔,追问病史,2年前有外伤史。术前均完善胸片、胸腹部CT和胸腹部B超检查,术前均获确诊,确诊率100%。采用经胸手术14例,经腹手术8例,胸腹联合切口3例。疝内容物为肝3例,脾6例,胃7例,大网膜4例,结肠2例,其他3例。同时行肝修补术3例,行脾切除术6例,行胃肠破裂修补术13例。结果术中发现左侧膈疝23例,右侧膈疝2例。膈肌呈线性破裂20例,呈不规则破裂5例。膈肌破裂长度平均为7.6(4～16)cm。治愈23例,死亡2例,病死率8%。23例均获随访,平均随访时间28.5(6～40)个月,未见膈疝复发。结论创伤性膈疝多发生于严重胸腹部损伤,缺乏特异性临床表现,一经确诊应尽早手术治疗。修补膈肌裂口,及时正确地处理合并脏器伤是提高治愈率,降低死亡率的关键。     

下胸部损伤合并膈下脏器破裂

本文报告３４例下胸部损伤合并膈下脏器破裂病例，经腹手术２６例，经左侧胸膈手术８例，死亡３例。诊断主要靠物理检查和胸腹腔穿刺，早期抗休克和处理胸部伤是抢救成功的基础。文中对麻醉方法选择，手术入路和术中处理作了讨论。认为胸腹伤均重时，剖胸指征应放宽，重危休克病人于膈上阻断胸主动脉控制腹腔内大出血。     

膈肌损伤的诊断与治疗(附33例报告)

总结３３例膈肌损伤的诊断与治疗经验，其中穿透性损伤１６例，闭合性损伤１７例。３２例（９７％）合并其它脏器伤。经胸手术６例，经腹手术２８例，其中１例为腹剖手术后又开胸。术前确诊２４例（７２％）。全组死亡４例，死亡率１２１％。病人主诉和体检所见常是合并伤的表现，而胸部Ｘ线检查是最可靠的诊断方法。术前对膈肌损伤的高度警惕和术中仔细检查膈肌是减少漏诊的关键。早期剖腹手术无论对左侧或右侧膈肌损伤均是一种较好的手术径路。     

Management of blunt rupture of the heart

Ten patients with blunt heart rupture arrived in our emergency center alive during an 11-year period ending in 1984. Ages ranged from 19 to 65 years (mean, 35), and seven patients were male. Six patients presented with tamponade, three with hemorrhagic shock, and one with combined symptoms. Associated injuries averaged 2.25 organ systems per patient. All but one patient had surgery within 90 minutes of arrival. All patients had primary closure of the defect without cardiopulmonary bypass, five patients had subxiphoid window followed by sternotomy, two had right thoracotomy, two underwent left thoracotomy, and one patient was subjected to immediate sternotomy. Seven patients survived. Three deaths were due to irreversible hemorrhagic shock, two secondary to heart injury, and one from an associated liver injury. Prompt pericardial window with subsequent median sternotomy was successful for patients presenting with tamponade and immediate thoracotomy for those bleeding into a pleural cavity.     

Thoracic Vascular Injuries: A Major Problem in Trauma

Objective - We present a review of our experience in the management of thoracic vascular injuries during the past 10 years in one of Sweden's busiest emergency departments, with morbidity and mortality as the main outcome measures. Design - Of eight patients who sustained chest trauma with thoracic vascular injuries, six presented with shock. Angiography was the gold standard in diagnosing aortic and subclavian injuries. Results - Lesions of the inferior vena cava, left internal mammary artery, and intercostal vessels were detected only at surgery. Two patients died of exsanguination. Managing thoracic vascular injuries is still difficult and challenging for thoracic and trauma surgeons. Conclusion - Early thoracotomy is important for salvage of patients with chest-wall vascular injury. Despite our limited experience, which is characteristic for Scandinavian and European countries, our results were satisfactory.     

Diaphragmatic blunt injuries: analysis of cases

Blunt injuries of diaphragm are frequently encountered in polytrauma and thoraco-abdominal injuries. Between 1992/2001, 12 cases were analyzed, representing 19.64% of of a total of 52 cases with diaphragmatic injuries (12 blunt and 40 penetrating). 11 were victims of traffic accidents (91.66%) and one of precipitation (8.3%). There were six men and five women. When they were admitted all patients presented with signs of trauma and hemorrhagic shock. 11 cases were operated. On the first 3 hours and in 3 cases, the patients were directly transported in operator theatre. Death rate was quite high--27.27%. Hospital stay was 15.54 days in average (13-38 days). Complication rate was 27.3%. Diaphragmatic injury are life threatening injuries, always challenging, associated with a high rate of mortality.     

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

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结直肠损伤的手术治疗：附125例报告

目的:探讨结直肠损伤的手术治疗和围手术期处理。 方法:回顾性分析19年间收治的125例结直肠损伤患者的临床资料。结果:结肠和腹膜内直肠破裂69例中，初期缝合或切除吻合56例（81.16 %），行造口术11例，“损伤控制外科”术式2例。腹膜外直肠破裂18例中，14例行乙状结肠近端造口并骶前引流，4例一期修补未造口;其余38例非全层损伤患者，均做简单修补。全组死亡8例（6.40 %），6例术中、1例术后死于失血性休克，1例术后5 d死于胸腔感染。术后并发症包括局部感染6例、粘连性肠梗阻1例，均治愈。 结论:多数结肠和腹膜内直肠损伤可一期手术，应配合围手术期正确使用抗生素尤其甲硝唑。腹膜外直肠伤应分期手术，为阻断远端污染，应行乙状结肠近端造口而不选择襻式造口。     

Affairs of the wounded heart: penetrating cardiac wounds.

During the 10-year period ending 1 March 1978, 100 consecutive patients with penetrating cardiac wounds entered the Bexar County Hospital with some sign of life. The early and late mortality rate, 11%, declined to 8% during the last 4 years. Noncardiac injuries were responsible for six of the eleven deaths. Complications occurred in 17. The most frequently injured chambers were the right ventricle (46) and left ventricle (30). Sixty-nine patients had stab wounds and 26 had gunshot wounds. Pericardiocentesis was falsely positive or negative in 12 of 47 patients. Two distinct syndromes were apparent, hemorrhagic shock and cardiac tamponade. Patients with shock had immediate thoracotomy. Patients with suspected tamponade had a subxiphoid pericardial window, under local or light general anesthesia, for diagnosis and decompression before endotracheal intubation and sternotomy. Most wounds were repaired by direct suture. Cardiopulmonary bypass and thoracotomy before arrival in the operating room were rarely indicated.     

闭合性十二指肠损伤15例诊疗体会

目的　提高对闭合性十二指肠损伤的诊疗水平。方法　对本组闭合性十二指肠损伤1 5例的病因、伤情、探查时间、手术方法、术后并发症及死亡率作了统计和分析。结果　单纯十二指肠损伤 1例 ,多发伤 1 4例 ,并发症 7例 ,治愈 1 0例 ,死亡 5例 ,死亡原因均为创伤性休克或感染性休克。结论　早期诊断、及时探查和选择合适的手术方式 ,是提高疗效减少并发症、降低死亡率的关键     

Diagnosis and treatment of spinal fractures combined with paraplegia and diaphragm injury

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Kreislaufstillstand nach stumpfem Thoraxtrauma

In German-speaking countries, most serious thoracic injuries are attributable to the impact of blunt force; they are the second most frequent result of injury after head injury in polytrauma patients with multiple injuries. Almost one in every three polytraumatized patients with significant chest injury develops acute lung failure, and one in every four, acute circulatory failure. The acute circulatory arrest following serious chest injury involves a high mortality rate, and in most cases it reflects a tension pneumothorax, cardiac tamponade, or hemorrhagic shock resulting from injury to the heart or one of the large vessels close to it. Brisk drainage of tension pneumothorax and adequate volume restoration are therefore particularly important in resuscitation of multiply traumatized patients, as are rapid resuscitative thoracotomy to allow direct heart massage, drainage of pericardial tamponade, and control of hemorrhage. However the probability of survival described in the literature is very low for patients sustaining severe chest trauma with acute cardiac arrest. The case report presented here describes a female polytrauma patient who suffered an acute cardiac arrest following cardiac tamponade after admission in the emergency department and who survived without neurological deficits after an emergency thoracotomy. Selections from the topical literature can help the treating physician in the emergency department in making decisions on whether an emergency thoracotomy is indicated after a blunt chest injury and on the procedure itself.