城市医院急诊中严重创伤的救治探讨

目的　对我院急诊外科 2 0 0 3- 0 2～ 2 0 0 4 - 0 1收治的严重创伤病例进行回顾性分析 ,以期对城市中常见创伤的急救提出建设性意见。方法　从急诊危重病例中筛选出急需抢救的严重创伤 14 3例进行分析。结果　男性 10 8例 ,女性 35例 ,男 :女为 3.0 9:1;年龄平均 34.2岁 (9～ 73岁 ) ;创伤评分 (TS)平均 13.5± 3.8分 ;格拉斯哥昏迷评分 (GCS)平均 12 .3± 3.7分 ;创伤严重程度评分 (ISS)平均 19.6± 12 .5分 ,多发伤 6 2例 (4 3.4 % )。病因 :交通伤 83例 (5 8% ) ,械斗、工伤 4 3例 (30 % ) ,坠落伤 17例(12 % )。休克 112例 ,脱险率 92 % ,抢救成功率 83.9%。实施确定性抢救手术 116例。急诊滞留时间 :抢救脱险组 5 6± 2 3min ,死亡组 10 9± 4 3min ,两组差异非常显著 (P <0 .0 1)。结论　交通伤、械斗、工伤、坠落伤是城市中严重创伤的主要原因 ;观念上要重视“黄金 1h”、“白金 10min” ,缩短急诊滞留时间 ;早期实施确定性抢救手术 ,可以有效地提高严重创伤的抢救效果。     

重症胸部创伤后ARDS及创伤性失血性休克的治疗

重症胸部创伤并发急性呼吸窘迫综合征(acute respiratory distress syn-drom e,ARDS)和创伤性失血性休克(hemorrhagic traumatic shock,HTS)时因病情危重、复杂、变化大,救治难度高。我院急诊科在胸外科的配合下,自1998年1月—2 0 0 2年12月共救治重症胸部创伤患者5 2例,报告如下。1　临床资料1.1　一般资料:5 2例患者中男4 3例,女9例;年龄18～76岁,平均(4 3.0±14 .3)岁;致伤原因:交通伤2 6例,锐器伤5例,坠落伤11例,挤压伤4例,其他伤6例。1.2　伤情:肋骨骨折4 4例,其中双侧肋骨骨折17例;形成连枷胸2 1例;胸骨骨折3例;肺挫裂伤37例;创伤…     

不同特点胸部创伤救治分析

胸部创伤在整个创伤救治中占重要地位 ,本院与北京市红十字会急诊抢救中心于 1 980年 1月～ 1 987年 9月和1 992年 4月～ 2 0 0 0年 9月共收治胸部创伤患者 4 5 2例 ,并将闭合性纯胸伤与穿透性胸伤进行分类比较与分析 ,以期进一步掌握现代胸伤救治规律与提高诊治水平。一、资料与方法1 .一般资料 :本院与北京市红十字会急诊抢救中心与 1 980年 1月～ 1 987年 9月和 1 992年 4月～ 2 0 0 0年 9月共收治胸部创伤患者 4 5 2例 ,男 389例 ,女6 3例 ,年龄 7～ 82岁 ,平均 37 5岁。其中 ,车祸伤 2 5 5例 (5 6 4 % ) ,刀刺伤 1 0 6例 (2 3 4 % ) ,…     

严重创伤后并发ARDS患者血清TNF-α和IL-8的动态变化及意义

动态观察严重创伤后并发急性呼吸窘迫综合征(ARDS)患者伤后1周血清肿瘤坏死因子α(TNFα)、白细胞介素8(IL 8)的变化,以探讨其在ARDS发生发展中的意义。1　资料与方法1.1　病例组:2 8例严重创伤患者为2 0 0 1年3月—2 0 0 2年10月我院急救部创伤病房收治的住院患者。创伤诊断均经CT、X线及手术证实;ARDS诊断均符合1992年美欧联席会议制订的有关标准〔1〕。所有患者均于伤后2 4～4 8h内发生ARDS。其中男性2 1例,女性7例;年龄18～5 1岁,平均(36 .3±12 .6 )岁;创伤严重度评分(ISS) 18～4 5分,平均(31.2±8.5 )分;伤后有失血性休克…     

多发伤早期血小板计数变化及其对预后的影响

目的 :探讨多发伤后早期外周血小板计数的变化规律及其临床意义。方法 :选择伤后 4 8h内的 90例多发伤者 ,连续观察入院后即刻、2 4、72、12 0和 16 8h的生命体征各指标及血小板、白细胞等变化 ,记录伤后器官功能变化、并发症及创伤严重等级评分 (ISS)和急性生理学与慢性健康状况 (APACHE )等评分。结果 :伤后患者血小板计数总体呈下降趋势 ,72 h为低谷 ,12 0 h基本恢复正常。血小板降低组较血小板正常组伤情重〔 ISS评分为 (2 9.6 0± 9.80 )分比 (2 2 .30± 12 .0 0 )分 ,P<0 .0 5 ;APACHE 评分为 (4 4 .5 0± 15 .30 )分比(30 .6 0± 10 .6 0 )分 ,P<0 .0 5〕、器官功能不全发生率高 (83.9%比 6 2 .7% ,P<0 .0 5 ) ;血小板降低并死亡组血小板下降时间早〔(30 .1± 10 .3) h比 (5 1.3± 14 .8) h,P <0 .0 5〕,持续低值时间长〔(6 3.7± 11.0 ) h比 (5 4 .2±13.4 ) h,P<0 .0 5〕。结论 :多发伤后血小板呈消耗性降低 ,血小板快速下降和持续低值者提示预后不佳。     

快速输液加压器在抢救创伤性休克时的应用

我院自1996年以来,使用自己研制的快速输液加压器快速输液抢救创伤性休克196例,效果良好,现报告如下。1　临床资料1.1　一般资料:196例患者中男12 4例,女72例;年龄12～72岁,平均37.8岁;休克分度〔1〕:轻度36例,中度94例,重度6 6例;车祸伤12 0例,矿山事故伤5 0例,坠落伤10例,其他创伤16例;伴骨折92例,脏器损伤12 8例(单个脏器损伤30例,2个脏器损伤4 2例,3个以上器官损伤5 6例)。1.2　抢救方法:迅速建立1～2条静脉通道,用快速输液加压器输液。轻度休克者1h内输入平衡盐液10 0 0 ml;中度休克者1h内输入平衡盐液2 0 0 0 ml,全血4 0 0 m l,以及质…     

呼气末正压通气在创伤性急性呼吸窘迫综合征中的应用价值

对创伤后合并急性呼吸窘迫综合征(ARDS)研究,使人们认识到机械性通气(MV )在ARDS救治中所起的重要作用,由于呼吸机使用不当引起的呼吸机相关性肺损伤(VIL I)和循环动力学改变也时有发生。拟分析呼气末正压通气(PEEP)在创伤性ARDS中对气道压及血流动力学的影响,报告如下。1　病例与方法1.1　病例:1998年1月—2 0 0 1年1月我院外科ICU (SICU )收治2 4例创伤合并ARDS患者。其中男18例,女6例;年龄2 6～76岁,平均(5 0 .2±6 .0 )岁;车祸伤13例,挤压伤8例,手术创伤3例;平均急性生理学与慢性健康状况评分系统 (APACHE )为(2 3±5 …     

急诊手术室、ICU病房一体化救治重危创伤61例

自 1997年 1月急诊手术室与ＩＣＵ病房合为一体以来 ,已对 6 1例重危创伤患者完成了从术前急救 ,紧急手术到术后处理的整体救治过程。存活 5 2例 ,救治成功率为 85 2 % ,现报道如下。1　临床资料本组男 35例 ,女 2 6例 ;年龄 11～70岁 ;创伤严重程度评分 (ＩＳＳ)均≥16分。致伤原因 :车祸伤 2 5例 ,钝击伤 13例 ,刀刺伤 11例 ,坠落伤 7例 ,挤压伤 3例 ,其他伤 2例。单纯头、胸、腹、四肢伤 5 1例 ,胸腹联合伤 5例 ,胸颅联合伤 4例 ,颅胸腹联合伤 1例。其中一个脏器受损 2 9例 ,2个受损者 2 2例 ,3个或 3个以上者 10例 ,入急诊室时 ,收缩压…     

闭合性腹部创伤256例报告

本院 1990年至 2 0 0 0年收治 2 5 6例闭合性腹部创伤病员 ,由于诊断和治疗及时 ,大部分痊愈出院。其中死亡 6例 ,死亡率 <2 %。死亡病例中有 5例合并脑、胸 (心 )骨盆等多发伤。对于闭合性腹部创伤的抢救要诊断及时 ,手术探查准确 ,注意处理合并并腹部以外的脏器损伤 ,提高抢救成功率。1　临床资料1)　一般资料 :本组男 190例 ,女 66例 ;年龄 6～ 63岁 ,平均 3 8岁。坠伤 13 0例 ,撞击伤 73例 ,挤压伤 5 3例。2 )　伤情 :肝破裂 2 0 % ,脾破裂 2 0 % ,胃肠穿孔 16% ,腹壁伤 16% ,肾脏损伤 4 % ,肠系膜及血管伤 4 % ,胰腺及后腹膜 3 % ,膀胱…     

预防严重创伤监护患者感染的护理

我科ＥＩＣＵ自 1996年 8月至 1999年 7月收治严重创伤病员 66例 ,在救治过程中 ,我们加强了预防和监测感染的措施 ,无 1例因感染发生并发症。1　临床资料我科ＥＩＣＵ在 1996～ 1999年收治严重创伤患者 66例 (ＡＩＳ ＩＳＳ院内评分法[1] ,ＩＳＳ值均大于 16分 ,其中ＩＳＳ值大于 2 5分者 12例 )。男 4 0例 ( 60 .6% ) ,女 2 6例 ( 3 9.4 % )。年龄在 18～ 71岁 ,平均年龄 3 3 .6岁。严重多发伤 14例( 2 1.2 % ) ,重度颅脑伤 10例 ( 15 .1% ) ,腹腔脏器伤 4例( 6.6% ) ,骨盆骨折 12例 ( 18.1% ) ,四肢及其他伤 2 6例( 3 9.1% )。以上伤员…     

Prehospital Triage of Trauma Patients: A Trauma Surgeon's Perspective

A number of triage tools have been developed andused to make triage decisions. Studies have demonstrated better outcomes in patients who receive care in trauma centers. The field triage decision scheme from the American College of Surgeons Committee on Trauma involves patient triage based on the presence of physiologic derangement, specific anatomic injuries, mechanism of injury, andcomorbid factors. Issues such as distance to a trauma center (rural areas) andmethods of transport (e.g., air, ground) complicate the prehospital triage of trauma patients. The best system for a given community or region is one that begins with a triage scheme that is evidence based to the greatest extent possible but is then modified based on community or regional resources andgeography. Delivering the severely injured trauma patient to a facility that can provide optimal care, in the shortest amount of the time, remains the overarching principle.     

Rural Hospital Transfer Patterns before and after Implementation of a Statewide Trauma System

Objective: To evaluate trauma transfer practices in rural Oregon before and after implementation of a statewide trauma system. Methods: A pre- vs post-system implementation (historical control) analysis of trauma transfer practices was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. Medical records of patients with specific index injury diagnoses in 4 anatomic regions (head, chest, liver/ spleen, and femur/open-tibia) were reviewed for a 3-year period before statewide trauma system implementation and 3 years after hospital trauma designation. Results: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had head injuries, 34% had chest injuries, 23% had femur/open-tibia injuries, and 12% had spleen/liver injuries. There were 142 (13%) patients with an injury in >1 index area. After trauma system implementation, there was a significant increase in the proportion of ED trauma patients transferred from Level-4 trauma hospitals (32% vs 68%, p < 0.001), with a corresponding decrease in the number of hospital admissions to these facilities (63% to 29%, p < 0.001). Significant increases in the proportion transferred from Level-4 trauma hospital EDs were noted for all index injury categories (p < 0.001). Trauma patients presenting to Level-4 EDs were significantly more likely to be transferred to Level-2 facilities (66% vs 82%, p = 0.030), while patients at Level-3 facilities were significantly more likely to be transferred to Level-1 centers (2% vs 14%, p = 0.002) following trauma system implementation. Multiple logistic regression modeling indicated that implementation of the statewide trauma system was an independent predictor of rural trauma patient transfer from Level-4 hospitals, while transfers from Level-3 facilities were dependent on type of injury. Conclusion: Implementation of the Oregon statewide trauma system was associated with a redistribution of rural trauma patients to trauma hospitals with greater therapeutic resources.     

888例急诊创伤患者早期辅助检查和抗生素治疗评价

目的：评价888例急诊创伤患者的早期辅助检查和抗生素治疗的合理性及科学性。方法：对创伤病例进行同况调查。所得资料用SPSS软件建立数据库并进行描述性分析。结果：在888例急诊创伤患者中,51.8%的患者做了X线检查,阳性率32.5%;11.5%的患者做了CT检查,阳性率为35 .3%,13.2%的患者检查了血常规阳性率33.1%。40.54%患者使用抗生素,其中,93.9%的患者使用了一种抗生素。5.80%伤势较重的患者采用了联合用药。结论：该室还须进一步严格掌握辅助检查及抗生素使用的指征。     

History of Trauma Field Triage Development andthe American College of Surgeons Criteria

The use of trauma field triage criteria is designed to match a patient's injury type andseverity to prioritized transport andan institution with the resources to provide timely, definitive care. Triage schemes used in austere environments created by war or mass casualty events are less applicable to day-to-day civilian trauma. Civilian triage criteria, developed andrefined over the past 25 years, rely on physiologic, anatomic, andmechanistic indicators of severe injury in an attempt to optimize overtriage andundertriage. As organized trauma systems continue to mature, the need for more accurate direction of high- versus low-acuity patients to regional centers, stratified by their capabilities, becomes more apparent andis essential in avoiding a completely ‘exclusive’ trauma system. New technology utilizing vehicular telemetry andWeb-based information systems may simplify the seemingly simple but often formidable task of creating destination decision rules for victims of major injury.     

喉外伤的急救与处置

喉外伤伤势危急，及时、恰当的诊治处理对降低喉外伤死亡率及并发症发生率甚为重要，其诊断及治疗都应系统化。明确喉外伤的严重程度，了解喉部结构的损伤范围以及喉水肿、声带活动度和关节脱位等情况，是决定治疗原则的依据。其救治原则是保持呼吸道通畅，及时止血，纠正休克，尽快恢复喉和气管的通气功能，预防后遗症的发生。本文综述喉外伤的急救与处置。     

Trauma Triage: New York Experience

New York State developed a statewide trauma program in the early 1990s. Designation of trauma centers andprehospital triage of patients by emergency medical services are pillars of the system. Outcomes are evaluated as part of the quality improvement system. New York has a statewide trauma registry with population-based data for all of the state but New York City. Studies made possible because of the trauma registry provided evidence to guide revision of the emergency medical services trauma triage protocol for adult patients. For example, pulse < 50 or > 120 beats/min was retained as a physiologic criteria, while crumple zone andcrash speed were eliminated as mechanism criteria. Patients with certain physiologic criteria treated in regional centers showed a considerably reduced mortality rate when compared with patients treated in area trauma centers andnoncenters. Other “high-risk” populations were identified for special consideration by emergency medical technicians for trauma center transport because of their associated higher mortality. One “high-risk” group, patients older than 55 years or younger than 5 years, has associated 11% mortality (compare with a statewide average of 7.43%) andrepresents 41% of all registry patients. Population-based trauma registries andstructured prehospital trauma records that accurately record the presence or absence of trauma criteria are essential to evaluate trauma triage criteria; improve quality, efficiency, andaccess; andguide care.     

ATLS P RACTICES AND S URVIVAL AT R URAL L EVEL III T RAUMA H OSPITALS , 1995-1999

Objective: To determine whether Advanced Trauma Life Support (ATLS) practices characterizing initial resuscitation and interfacility transfer at rural trauma hospitals are associated with risk-adjusted survival. Methods: Retrospective, observational analysis of rural injured patient survival. Process-of-care variables were associated with TRISS (trauma and injury severity score)-derived Z-statistics (95% confidence intervals) for high-risk population subsets (defined below). Inclusion criteria: all patients ≥12 years of age entered into a statewide trauma system, January 1, 1995, to December 31, 1999, and initially presenting to Level III trauma centers (N = 4,961). Exclusion criteria: pronounced dead on arrival (n = 26), directly admitted to hospital (n = 3), and unknown disposition at first hospital (n = 2). Process variables include: intubation in emergency department (ED) given Glasgow Coma Scale (GCS) score < 9 [ INTUB ], administration of blood products in ED given systolic blood pressure (SBP) < 90?mm Hg [ BLOOD ], trauma surgeon presence within 5 minutes of patient arrival given GCS < 9?mm Hg or SBP < 90?mm Hg [ UNSTABLE-TS ], trauma surgeon presence within 5 minutes of patient arrival given injury severity score (ISS) > 15 [ ISS-TS ], transfer to higher level of care given ISS > 20 and no hypotension [ TRAN ], transfer to higher level of care given GCS < 9 [ TRAN-GCS ]. Results: For the high-risk subpopulations, the following Z-scores (with and without an intervention) were found: Conclusions: Some ATLS interventions ( BLOOD , TRAN , and TRAN-GCS ) are associated with improved survival for selected high-risk subgroups in these 21 rural Level III trauma hospitals.     

The Significance of Out-of-hospital Hypotension in Blunt Trauma Patients

Objective: To determine the significance of a low out-of-hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival.
Methods: A retrospective case-control study compared admitted blunt trauma patients who were hypotensive (SBP ≤90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra-abdominal injury, and incidence of pelvic or femur fracture.
Results: Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra-abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09).
Conclusion: The injured patients who were hypotensive in the out-of-hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out-of-hospital setting and in the ED. Out-of-hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.     

胸部创伤187例临床分析

本文报告胸部创伤187例,全组死亡6例,死亡率3.2％。根据本组治疗经验,作者认为:1.浮动胸壁的治疗,不过分强调固定胸壁,而着眼于肺挫伤的处理;2.胸部严重钝挫伤后,无论胸廓有无骨折都有可能出现延迟性血气胸;3.伴有膈肌贯穿伤的胸腹外伤才能称为胸腹联合伤;4.腹腔穿刺是诊断腹内脏器伤的有效手段。     

脑外伤植物性存活者康复治疗的探讨

本文报道我院神经外科3年来收治重型颅脑损伤所致植物性存活者3例,入院后按Glasgow昏迷计分法:得6分的1例,5分的1例,4分的1例。脑内血肿2次手术者1例,硬膜外血肿清除术1例,头前部子弹贯通伤行清创引流术1例。通过医生、护士、家属精心护理,用光、声、针刺、物理等综合性康复治疗,1例伤后昏迷10月余清醒,现已基本康复痊愈,1例康复显效,1例康复有效。本文还讨论了植物性存活者,应坚持治疗,获得最大可能的康复。