胸部创伤损伤严重度评估及死亡原因分析

目的探讨胸部创伤的死亡原因及损伤严重度评估，以提高胸部创伤的诊断及治疗水平。方法回顾性分析我院687例胸部创伤的临床资料，并根据治疗结果（分为生存组、死亡组）、有无合并伤（分为单纯胸伤组、多发伤组）以及是否有胸膜腔与外界沟通（分为闭合伤组、开放伤组）分组进行修正创伤评分（RTS）、简明损伤定级（AIS）、损伤严重度评分（ISS）和计算生存概率（PS），比较不同组间的损伤严重程度，分析死亡的高危险因素。结果闭合伤组488例，其中死亡21例，死亡原因为原发性颅脑损伤10例，急性呼吸衰竭6例，多器官功能不全综合征（M（）DS）4例，低血容量性休克1例；开放伤组199例，其中死亡9例，死亡原因为低血容量性休克9例。创伤评分各指标在生存组、死亡组间差异有统计学意义（GCS：t=4．648，P=0．000，RTS：t=4．382，P=0．000，胸AIS：t=2．296，P=0．027，ISS：t=4．871，P=0．000；Ps：t=4．254，P=0．000）；单纯胸伤组与多发伤组胸AIS差异无统计学意义（t=0．723，P=34．567），但RTS（t=2．553，P=0．032），ISS（t=10．776，P=0．000），Ps（t=3．868，P=0．007）差异有统计学意义；在闭合伤生存组、开放伤生存组间，虽然RTS（t=3．161，P=0．007），ISS（t=4．118，P=0．005）差异有统计学意义，但Ps差异无统计学意义（t=0．857，P=97．453），而在闭合伤死亡组、开放伤死亡组间差异均有统计学意义（GCS：t=4．016，P=0．001；RTS：t=3．168，P=0．006；胸AIS：t=2．303，P=0．043；ISS：t=4．218，P=0．002；Ps：t=4．624，P=0．001）。创伤死亡率随创伤评分增高而增高，全组ISS值在20～25时，死亡率为10．7％，在ISS值相同时，开放伤组死亡率较闭合伤组高。结论胸部创伤应用创伤评分有助于判断损伤严重度，指导临床救治；闭合伤死亡原因较开放伤复杂；严重创伤     

创伤致原发性MODS28例临床分析

目的研究原发性多脏器功能障碍综合征（multiple organ dysfunction syndrome，MODS）的整治与创伤评分的关系及器官功能障碍的发生频度和预后，为治疗提供依据。方法回顾调查28例严重创伤后原发性MODS患者，入院时ISS评分值、脏器受累情况及治疗、预防情况，并做相关分析。结果创伤ISS评分：20～30分8例，死亡2例；31～50分12例，死亡5例；〉50分8例，死亡7例。在原发性MODS中，循环、呼吸功能障碍最常见，其次为中枢神经系统及血液系统。直接死亡原因依次为循环、中枢和呼吸功能衰竭等。结论创伤评分直接反映原发性MODS的预后情况。治疗关键是治疗原发性创伤，包括“手术修复和脏器功能支持”。     

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。     

急诊创伤患者临床特点及早期死亡的危险因素分析

目的 探讨分析急诊创伤患者临床特点及其早期死亡的相关危险因素分析，为急诊创伤性疾病的防治提供参考。方法 选取2020年10月至2022年10月于本院急诊治疗的156例急诊创伤患者进行回顾性研究。按照在院期间是否存活分为存活组（124例）和死亡组（32例），分析156例患者的临床相关资料，并基于单因素及多因素Logistic回归分析早期死亡的相关危险因素，绘制并计算ROC曲线，评估对早期死亡的预测效能。结果 急诊创伤患者多集中于19～60岁（66.67%）之间的中青年男性（52.56%）患者；损伤以交通伤（53.21%）、高处坠落伤（21.79%）、重物砸伤（9.62%）为前三种原因；受伤时间以秋季（36.54%）和夏季（28.21%）为主；损伤部位主要为四肢（47.43%）、头颈部（20.51%）及胸部（13.46%）；损伤部位的数量以<3(75.00%)处为主。笔者将两组存在显著差异的指标带入logistic回归分析，结果显示Lac值、ISS评分、GCS评分3项指标为急诊创伤患者早期死亡的独立危险因素（P<0.05）。其中Lac、ISS评分、GCS评分的ROC曲线下面积分...     

胸腹联合损伤34例临床分析

目的胸腹联合伤是一种多合并多创伤,为了降低死亡率,必须在最短时间内根据受伤情况、症状、体征以及辅助检查作出正确的诊断,迅速做出全面、准确判断。方法回顾性分析本院2009年8月至2011年8月收治的34例胸腹联合伤患者的临床特点、诊断、抢救治疗与转归。结果开胸6例,开腹＋胸腔闭式引流术8例,胸腹联合手术2例,单纯行胸腔闭式引流17例;治愈31例,死亡3例。结论胸腹联合伤患者治疗上,首先应保持呼吸道通畅,维持有效呼吸及循环;在防治休克过程中,紧急进行手术,可提高抢救成功率。     

急救模式下创伤控制性手术治疗严重多发伤的效果分析

目的探讨急救模式下创伤控制性手术治疗严重多发伤的效果。方法对60例严重多发伤患者行一体化急救模式及创伤控制性手术,回顾性分析患者的临床资料。结果存活患者51例,病死患者9例。就诊时间≤1h的患者病死率(8.1%)低于就诊时间1h的患者(30.4%),差异有统计学意义(P0.05)。存活患者ISS评分相比病死患者低,差异有统计学意义(P0.05)。结论急救模式并行早期创伤控制性手术,对严重多发伤患者具有较好的救治效果,可显著降低并发症发生率及病死率,有助于提高患者生存率,改善患者预后,值得在临床上推广应用。     

胸腹联合伤（附56例报告）

目的 分析和总结胸腹联合伤的原因及治疗经验。方法 分析56例胸腹联合伤，意外伤害的原因和分类，为早期治疗提供依据。结果 交通事故致伤15例，占26．8％，建筑施工致伤18例，占32．1％；其它（打架、斗殴、刀伤、爆炸等）致伤23例，占41．1％。轻度伤23例（41．1％），中度伤26例（46．4％），重度伤7例（12．5％）。手术治疗38例，占67．9％。总治愈率82．1％，死亡率17．9％。轻度伤全部（100％）治愈；中度伤治愈21例（80．8％），死亡5例（19．2％）；重度伤治愈2例（28．6％），死亡5例（71．4％）。结论 胸腹联合伤是意外伤害中较严重的一种，胸腹联合伤入院后，应迅速纠正呼吸，循环功能紊乱；有手术指征者应尽快手术，胸腹二组手术重要。及时正确的掌握以胸外伤为主的联合伤的早期开胸指征，是提高治愈率，降低死亡率的关键。     

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。     

胸腹联合损伤的早期诊断与治疗

目的总结胸腹联合伤的早期诊断与治疗体会。方法对我院1996年8月-2004年8月收治的59例胸腹联合伤病例进行回顾性分析。结果入院后早期死亡2例，其余57例中行开胸手术22例，胸腔闭式引流 开腹手术30例，同时胸部和腹部切VI4例，经胸腹联合切口1例。术后发生成人呼吸窘迫综合征6例，死亡1例。本组治愈55例(93．2％)，死亡4例(6．8％)。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，提高救治效果的关键。     

损伤控制手术在以腹部损伤为主的严重胸腹联合伤中的应用

目的：探讨损伤控制手术（DCO）在治疗以腹部损伤为主的严重胸腹联合伤中的应用。方法：回顾性分析2008年3月—2011年6月收治的71例严重胸腹联合伤患者的临床资料,其中,行损伤控制手术41例,另外30例患者行一期确定性手术。结果：损伤控制手术组患者复苏后乳酸水平,pH值,体温,凝血酶原时间（PT）与一期确定性手术组的患者无统计学差异（均P>0.05）。71例患者均治愈后安全出院,但损伤控制手术组患者粘连性肠梗阻、感染的发生率明显低于一期确定性手术组（均P<0.05）。结论：在正确掌握适应证的前提下,损伤控制性手术对于严重胸腹部损伤患者是理想的治疗策略。     

四川汶川地震伤情统计与分析

目的研究四川汶川地震所致伤员的伤情特点和规律。方法对我院收治患者进行登记，采用国际疾病分类方法（ICD-10）统计、分析其损伤的外部因素、疾病分类及构成情况。结果本组患者主要损伤外部原因为被物体击中和被物体挤压。疾病构成前5位为：胫腓骨骨折158例（13．37％），骨盆骨折122例（10．32％），脊柱骨折120例（10．15％），股骨骨折109例（9．22％），前臂骨折／脱位106例（8．97％）。结论深入研究地震所致伤员的伤情特点，对合理使用、调配医疗资源，更好地为灾民提供医疗服务有重要的指导意义。     

Identifying patients at risk for intracranial and extracranial blunt carotid injuries

BACKGROUND: Blunt carotid injuries are rare, often occult, and potentially devastating. Angiographic screening programs have detected this injury in up to 1% of blunt trauma patients. Implementing a liberal angiographic screening program at our hospital is impractical and we want to identify a high-risk group to target for screening. We hypothesize that intracranial and extracranial carotid injuries have different risks, presentations, and outcomes. METHODS: Patients with intracranial and extracranial carotid injuries were identified from the British Columbia trauma registry. Presentation and outcome were reviewed. To facilitate statistical modeling the analysis was done by matching cases to 5 randomly selected controls. Risk factors for injury were evaluated by univariate and multiple logistic regression. RESULTS: A total of 35 carotid injuries were identified. Thirteen intracranial injuries were identified in 10 patients. Twenty-two extracranial injuries were identified in 18 patients. Sixty-seven percent of patients with intracranial injuries and 31% of those with extracranial injuries died (P = 0.11). Eleven percent of intracranial injuries and 56% of extracranial injuries were occult (P = 0.04). Glasgow outcome scores were 2.04 intracranial and 3.12 extracranial (P = 0.18). For intracranial injuries the multiple variable predictive model had two predictors: Glasgow Coma Score or =3). CONCLUSIONS: Intracranial injuries were frequently detected on initial investigations and have very poor outcomes. Extracranial injuries were more frequently occult and stand to benefit from early detection by screening programs. As independent risk factors for these two injuries differ, limited screening resources should focus on risk factors for occult extracranial injury: namely, low GCS and significant thoracic injury.     

Diagnosis and management of bladder injury by trauma surgeons

BACKGROUND: Bladder injuries constitute one of the most common urological injuries involving the lower urinary tract. The methods of diagnosis and management of bladder trauma have been well established and accepted. However, bladder injuries are usually associated with other major injuries, and it is our concern here how bladder injuries have been managed as part of multiple trauma. METHODS: From 1991 to 2000, a total of 51 cases of bladder injury were retrospectively reviewed. The mechanisms of trauma, types of bladder injury, time needed to diagnosis, methods of treatment, and patient outcome, were analyzed. Diagnosis time was defined as the time interval from patient arrival to the establishment of a diagnosis either by image studies or laparotomy. Management followed the general rule that bladder contusions or extraperitoneal ruptures were treated non-operatively, and that those with intraperitoneal rupture or combined rupture underwent operative repair. If bladder injury was noted after the patient left the emergency room (ER), it was defined as a delay diagnosis. The Injury Severity Score (ISS), length of hospital stay, and morbidity were used to evaluate patient outcome. RESULTS: The mean age of all the patients was 31.4 years old, and most of them had sustained an injury from a motor vehicle accident (40 of 51). All but 3 patients had gross hematuria. Ten of the patients underwent emergency laparotomy, and 2 of them underwent emergency neurosurgical procedures, therefore no image studies were performed for these 12 patients. A total of 33 patients underwent abdominal computed tomography (CT), but only 20 were correctly diagnosed, yielding an accuracy rate of 60.6%. There were 3 delay diagnoses, due to either a lack of gross hematuria on presentation or the patient leaving the ER before any bladder injury study could be performed. A retrograde cystogram was performed in 24 patients, with an accuracy rate of 95.9% (23 of 24). The mean diagnosis time of the 48 bladder injuries presented in the ER was 3.2 hours and the time needed to reach a diagnosis was not related to the severity of bladder injury. Those patients who underwent operation immediately did not seem to have a quicker diagnosis. Those patients with a higher injury score (ISS >16), and those patients who suffered from pelvic fracture, stayed in the hospital longer. However, the severity of the bladder injury was not related to the length of hospital stay. There was no bladder-related mortality in our series. CONCLUSIONS: We report our results of dealing with bladder injuries from the point of view of trauma surgeons who treat bladder injury as part of multiple injuries. Although known as a procedure of choice for diagnosis of bladder injury, the retrograde cystogram was performed in fewer than half of the patients (24 of 51), which means it is not feasible in many situations. The patient outcome was determined by the severity of injury of the patient but not by the severity of bladder injury.     

Damage control surgery for severe thoracic and abdominal injuries

OBJECTIVE: To investigate the application of damage control surgery in treatment of patients with severe thoracic and abdominal injuries. METHODS: A retrospective study was done on 37 patients with severe thoracic and abdominal injuries who underwent damage control surgery from January 2000 to October 2006 in our department. There were 8 cases of polytrauma (with thoracic injury most commonly seen), 21 of polytrauma (with abdominal injury most commonly seen) and 8 of single abdominal trauma. Main organ damage included smashed hepatic injuries in 17 cases, posterior hepatic veins injuries in 8,pancreaticoduodenal injuries in 7, epidural or subdural hemorrhage in 4, contusion and laceration of brain in 5, severe lung and bronchus injuries in 4, pelvis and one smashed lower limb wound in 3 and pelvic fractures and retroperitoneal hemorrhage in 6. Injury severity score (ISS) was 28-45 scores (38.4 scores on average), abbreviated injury scale (AIS) > or = 4.13. The patients underwent arteriography and arterial embolization including arteria hepatica embolization in 4 patients, arteria renalis embolization in 2 and pelvic arteria retroperitoneal embolization in 7. Once abbreviated operation finished, the patients were sent to ICU for resuscitation. Twenty-four cases underwent definitive operation within 48 hours after initial operation, 5 underwent definitive operation within 72 hours after initial operation, 2 cases underwent definitive operation postponed to 96 hours after initial operation for secondary operation to control bleeding because of abdominal cavity hemorrhea. Two cases underwent urgent laparotomy and decompression because of abdominal compartment syndrome and 2 cases underwent secondary operation because of intestinal fistulae (1 case of small intestinal fistula and 1 colon fistula) and gangrene of gallbladder. RESULTS: A total of 28 patients survived, with a survival rate of 75.68%, and 9 died (4 died within 24 hours and 5 died 3-9 days after injury). The trauma deaths at the early stage were caused by severe primary injuries resulting in failure of respiration and circulation, while mortality at the later stage was caused by multiple organ failure. CONCLUSIONS: Damage control surgery is important for the treatment against severe thoracic and abdominal injuries. It is suggested that the surgeon should select the reasonable auxiliary examination before operation, and take the proper time to perform damage control and definitive surgery.     

Laparoscopy and major retroperitoneal vascular injuries (MRVI)

Injury to major retroperitoneal vessels is a potential serious complication of laparoscopy occurring when the Veress needle or trocar is inserted. This report is a review of major retropertioneal vascular injuries (MRVI) occurring during laparoscopy, as these injuries have not been well documented in the literature. A retrospective, observational review of general surgical laparoscopy cases was conducted over a 3.5-year period in three community, university-affiliated hospitals. We identified 4 MRVI in 3591 laparoscopic procedures. These cases were critically analyzed and compared. The incidence of MRVI was 0.1%. All cases occurred with the closed (blind) insertion technique of Veress needle and primary trocar insertion technique with disposable safety shield trocars. All patients sustaining MRVI had acute hypotension introperatively and significant blood loss necessitating postoperative transfusions. Recognition and rapid conversion to laparotomy are keys to enhancing outcome. There is significant potential for morbidity and mortality with laparoscopic MRVI, although each patient in this series was discharged without obvious short-term problems. The advantages of an open approach for primary trocar insertion are numerous and should alleviate the risk of MRVI associated with general laparoscopic surgery.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, FL, USA, 11–14 March 1995; and the Third European Congress of the European Association for Endoscopic Surgery, Luxembourg, 13–17 June 1995     

医源性输尿管损伤的原因与处理

目的：探讨医源性输尿管损伤的原因、处理和预防。方法：本组16例,保守治疗行输尿管逆行插管（以J管）2例,输尿管修补术1例,输尿管端端吻合术3例,输尿管膀胱吻合术7例,肾造口术3例,其中2例后期再次行管状膀胱瓣输尿管吻合术。结果：所有患者肾功能均恢复正常。结论：了解与输尿管有关的解剖位置,细致规范的手术操作是预防医源性输尿管损伤的关键。     

影响腹腔镜胆囊切除术胆道损伤修复效果的因素

目的 探讨影响腹腔镜胆囊切除术胆道损伤修复效果的因素。方法 回顾性分析28例腹腔镜胆囊切除术胆道损伤的发现时间、损伤修复前胆道造影情况、修复方法及其对修复效果的影响。结果 术中发现胆道损伤20例，修复成功19例(成功率为95％)；术后发现胆道损伤8例，修复成功7例(成功率为89％)。28例胆道损伤修复前均行胆道造影评估胆道结构，修复成功26例(成功率为93％)。局部缝合、或伴胆总管切开T管引流修复胆道穿孔、胆道撕裂、胆道部分夹闭或部分切开成功率达100%(21／21)，端端吻合修复术中发现的胆道横断2例均成功，胆肠Roux—en—Y吻合修复胆道横断、缺损、瘢痕狭窄4例，3例吻合成功。结论 早期(术中)发现胆道损伤、修复前对胆道结构进行评估、及对修复术式与方法的正确运用有助于提高胆道损伤的修复效果。     

胰腺十二指肠损伤的诊治体会

目的探讨胰腺、十二指肠损伤的诊断及治疗经验。方法回顾性分析45例胰腺、十二指肠损伤患者，包括26例胰腺损伤、13例十二指肠损伤及6例胰十二指肠复合伤的临床资料。结果45例患者中33例（73．3％）合并伴发伤；CT诊断符合率为72．7％（8／11）；4例保守治疗，41例行手术治疗；共21例（46．7％）出现并发症，其中胰瘘9例；治愈38例（84．4％），7例死亡（15．6％）。结论本病早期诊断困难，伴发伤多，并发症发生率及死亡率高。剖腹探查是诊断胰十二指肠损伤的主要方法，根据损伤部位、程度及全身情况选择合理术式，术后积极防治并发症是提高治愈的关键。     

外伤性十二指肠损伤漏诊的临床分析

目的：探讨如何避免十二指肠损伤的漏诊。方法：回顾性分析我院450例腹部外伤中漏诊的8例十二指肠损伤病人处理和临床特点。结果：致伤原因以车祸伤为主(6例)，复合伤6例，术前无一例正确诊断为十二指肠伤，所有病例均行手术治疗，6例治愈，死亡2例，死亡原因为严重感染及多器官功能衰竭。漏诊的主要原因为认识不足并缺乏相应的特殊检查。结论：对有严重上腹外伤史者，应高度警惕十二指肠损伤，反复的物理检查，动态的辅助检查尤其是CT检查，及时剖腹探查等可减少十二指肠损伤的漏、误诊率。     

无伴行动脉损伤的肢体静脉干损伤的修复

目的探讨无伴行动脉损伤的肢体静脉干损伤的机制,以及诊断、救治和修复方法. 方法 1993年1月～2002年6月共收治12例患者,均为男性,年龄18～35岁.受伤至手术时间30 min～2 h.均为锐器刺伤.在积极抗休克的同时进行血管修补7例,端端吻合5例.合并头颅胸腹部损伤患者同时给予相应手术处理. 结果除1例患者因严重的脑外伤死亡外,余11例患者伤口均Ⅰ期愈合.随访1～5年,平均2年4个月,彩色多普勒检查见血流通畅,无血栓形成.其中8例肢体功能和血循环恢复良好;3例合并伴行神经损伤者血循环恢复良好,但肢体功能恢复欠佳,遗留感觉及运动障碍. 结论无伴行动脉损伤的肢体静脉干损伤是一种严重的损伤,采取应急止血、积极抗休克、及早修复损伤血管和合理处理合并伤等是挽救患者生命的重要措施.