多发伤一期手术处理(附168例病例分析)

目的：从168例多发伤的处理方法、流行病学、创伤指数、并发症及病死率的总结分析，说明多发伤一期手术处理在急诊科的地位。方法；急诊科直接收治多发伤首诊病人，遇有多发伤合并休克，立即抗休克治疗，做好术前准备，反复体检、观察和评估。手术时，如脑胸腹四肢联合伤，一般分两组进行手术。结果：168例共406处伤，手术处理共246例次。总死亡率7．7％，发生两个脏器功能衰竭16例，死亡4例，占25％，三个脏器功能衰竭8例，死亡6例，占75％。平均住院无数：一期手术处理为1．5±6．4，分期为24±4．4（两者有显著差异）。结论：多发伤一期手术处理，在相同创伤指数下，可减少术后并发症，降低死亡率和病残率；缩短住院时间；简化手续，为多发伤病人的抢救赢得MSOF时间，证明多发伤一期手术处理在急诊科中的重要性和必要性。     

Abdominal Stab Wounds in Children: an 18-Year Experience

Objective: Evaluation of the diagnosis, management, and the role of selective treatment in children with abdominal stab wounds. Patients and Methods: 59 children (56 male and three female) were included in the study. The patients' median age was 11.8 years (range, 5–14 years). Time between injury and admission was about 3 h. Laparotomy was performed in 44 patients (74%). Solid organ injury was detected in 32 of these patients (73%) and could not be observed in twelve (27%). 15 patients (26%) were treated conservatively, and only one (6.6%) underwent laparotomy during the follow-up. The stomach was the most frequently injured organ (ten patients), followed by the intestines (nine patients). Types of surgical treatment were as follows: primary suture in 28 patients, resection-anastomosis in three, and osteotomy in two. Results: Some prognostic factors such as presence of abdominal organ evisceration and pneumoperitoneum were not significantly correlated with intraabdominal organ injury, whereas some other risk factors such as acute abdomen on admission (p < 0.002) or abdominal clinical and hemodynamic findings (p < 0.001) showed significant correlation with intraabdominal organ injury. The relative risk (odds ratio) of developing an intraabdominal organ injury was > 2 for patients with signs of an acute abdomen on admission. Postoperative complications were observed in five patients with organ injuries. None of our patients died. Conclusions: Conservative treatment can be safely performed in most children with abdominal stab injuries. Signs of major internal hemorrhage or generalized peritonitis are an absolute indication for emergency operation for abdominal stab wounds. Peritoneal penetrations, free air on the abdominal X-ray, and omental or intestinal evisceration are poor indicators of significant organ injuries, and patients presenting these signs shold be closely followed up for developing acute abdominal symptoms. Received: November 2, 2001; revision accepted: February 15, 2002     

Small bowel rupture after blunt trauma: Computed tomographic signs and their sensitivity

The purpose of this study is to describe the characteristic computed tomographic (CT) signs of small bowel perforation after blunt abdominal trauma and to evaluate their sensitivity. Nineteen preoperative CT scans were obtained from 16 patients with surgically proven small bowel rupture secondary to blunt abdominal trauma. Only the CT findings described in the original CT reports were used. Eleven of 19 CT scans (58 %) had findings that were unequivocal for bowel rupture (i.e., extraluminal air and/or extravasation of oral contrast medium). Seven CT scans (37 %) had findings that were suggestive of severe small bowel injury (i.e., focal small bowel wall thickening and/or free peritoneal fluid without other accompanying organ injuries). In all, 95 % of cases of small bowel rupture had either pathognomonic or suggestive CT findings. One CT scan did not demonstrate small bowel wall thickening, although a hemoperitoneum was present. CT is a sensitive method for suggesting severe small bowel injury and rupture secondary to blunt abdominal trauma.     

Early and late onset bacteremia have different risk factors in trauma patients

Objective The aim of this study was to identify risk factors and to describe epidemiological patterns for early—(EOB) and late—onset bacteremias (LOB) after trauma.Design A prospective study conducted on 141 consecutive trauma patients.Setting A general intensive care unit (ICU) of a university hospital.Patients All multiple trauma patients admitted to our general intensive care unit (ICU) from December 1990 to May 1992 were prospectively enrolled in the study. The following information was collected for each patient and recorded in a computer database: demography, severity of trauma according to the Abbreviated Injury Scale (AIS), severtity of trauma according to the Glasgow Coma Scale (GCS), presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and abdominal trauma, use of mechanical ventilation, and placement of central venous catheters. Bacteremias were defined as EOB when onset occurred within 96 h after trauma, and as LOB when appearing after 96 h from trauma.Results Thirty-seven patients developed bacteremia during their ICU stay (26%): 11 (29.7%) EOB and 26 (70.3%) LOB. Gram-positive cocci were isolated more frequently in EOB than in LOB (x ²=4.1,P=0.04). The risk of EOB was significantly increased by the presence of pulmonary contusion [relative risk (RR) 15.0; confidence interval (CI) 1.99-113.25], pneumonia before the onset of bacteremia (RR 3.56; CI 1.17-10.69), AIS score greater than 32 and an abdominal injury score greater than 9 (RR 3.11; CI 1.02-9.49), while intravascular catheters and mechanical ventilation did not represent risk factors for EOB. LOB had a very different pattern and their risk was significantly increased by exposure to intravascular catheters (RR 4.96; CI 1.23-19.94) and to mechanical ventilation lasting more than 7 days (RR 3.6; CI 1.6-8.1).Conclusions Scoring with the AIS of the abdominal and thoracic trauma at admission to the ICU appears a useful tool for identifying trauma patients at increased risk of EOB. A rigorous policy of catheter placement and maintenance as a means of reducing late bacteremias in trauma patients is essential.     

336例创伤数据对中国人创伤评分权重系数的评价

目的为了评价国内对ＴＲＩＳＳ评分权重系数的修订，对３３６例创伤患者分别用国外权重和国内权重评定伤情后进行比较。方法３３６例采用ＴＲＩＳＳ法计算生存概率Ｐｓ，所需权重分别采用新近报道的国内权重和国外ＭＴＯＳ权重。Ｐｓ≥０．５预测生存，Ｐｓ＜０．５预测死亡，将预测生死与实际生死结果进行比较。结果中国人权重在敏感性和区别度方面高于国外权重，误判率低于国外权重。结论中国人权重对中国人的创伤程度评估有价值，为进一步精确修订权重，建议建立大型中国人创伤数据库     

Intestinal plethora: An early sign of acute posttraumatic hepatic artery-portal vein arteriovenous fistula

Traumatic communications between the hepatic artery or its branches and the portal vein or its tributaries usually are clinically occult until the late sequelae of portal hypertension, such as esophageal and mesenteric varices, ascites, or congestive heart failure, become manifest. The authors describe the early diagnosis of such a lesion by computed tomography. The CT findings included a hepatic hematoma and, more significantly, diffuse thickening of the small and large bowel wall. This thickening represents vascular congestion of the bowel caused by acute portal hypertension prior to the development of decompressing portal collateral circuits. When this CT finding is not associated with other signs of intestinal ischemia or infarction, it should suggest portal hypertension and lead to arteriography for diagnosis and therapy of arterioportal fistula.     

Intra-abdominal desmoplastic small cell tumor presenting as an acute abdomen after trauma

The intraperitoneal mass most commonly encountered after blunt abdominal truama is a hematoma. However, one must also consider unusual bulky tumors that can have imaging characteristics similar to those of hematoma. The most typical of these neoplasms is lymphoma, but a desmoplastic small cell tumor also may be observed. The presentation and imaging findings of a desmoplastic small tumor are described.     

Functional compartmentalization of energy production in neural tissue

Previous work in our laboratory has shown that neural trauma results in a disparity between oxidative and glycolytic rates. In non-neural tissue, glycolysis and oxidative phosphorylation have been shown to work independently of one another, a phenomenon known as "energy compartmentalization". We believe that functional compartmentalization of energy production may also occur in the brain with glycolysis providing energy for membrane bound ionic pumps. Spreading depression, induced in rodent brain by topical KCl application, results in K+ shifts. The restoration of K+ gradients is accomplished by energy dependent Na(+)-K+ pumps. If these pumps depend upon glycolysis, blocking glycolysis should prevent reconstitution of normal [K+]e levels. The present series of experiments were designed to suggest that energy compartmentalization may also exist in brain, and that glycolytic energy production is preferentially used by Na(+)-K+ pumps to maintain normal ionic homeostasis by observing the dynamics of spreading depression induced K+ shifts before and after glycolytic blockade. Spreading depression was associated with increased K+ (48.6 +/- 16.6 mM over control) that normalized within 2.9 +/- 0.3 minutes. Following superfusion with a glycolytic blocking agent, spreading depression produced similar increases in [K+]e (40.6 +/- 12.0 mM over control) but time for reconstitution of the normal [K+]e was 400% longer than controls (2.9 +/- 0.3 to 14.9 +/- 2.1 minutes, P less than 0.001). Time required for recovery of EEG was identical pre- and post-blockade. We believe these data suggest that energy compartmentalization may exist in neural tissue and that glycolytic pathways of energy production are functionally tied to membrane Na(+)-K+ pumps.(ABSTRACT TRUNCATED AT 250 WORDS)     

Model for Intravital Microscopic Evaluation of the Effects of Arterial Occlusion-caused Ischemia in Bone

An in vivo model has been developed for chronic observation of the effects of ischemia on cortical bone remodeling and perfused vascularity. Diaphragm occluders were implanted around the right common iliac artery of four rabbits and inflated to produce 10 h of ischemia to the limb. Microcirculation was monitored with intravital microscopy of injected fluorescent microspheres and FITC-Dextran 70 through a bone window, the tibial bone chamber implant (BCI). Bone resorption and apposition in the BCI were indicated with mineralization dyes. Between 2 and 12 h following release of the occluder, secondary ischemia/no-reflow and other evidence of reperfusion injury were observed. Vessel damage was suggested by abnormally high leakage of FITC-D70 from the few vessels perfused during secondary ischemia. In the weeks following occluder release perfused vasculature increased beyond pre-occlusion levels. Net bone resorption reached a maximum when vascularity passed normal levels. In order to further validate the arterial occlusion model for osteonecrosis, techniques for (1) confirming bone death and (2) detecting increased leukocyte adherence to endothelial cells were added. The dead cell stain Ethidium homodimer-1 was used to tag dead osteocytes immediately after occlusion and produced a measure designated osteonecrosis index. To detect leukocytes adhering to vessel walls, carboxyfluorescein diacetate, succinimidyl ester was injected at occluder release. An increase in the number of adherent leukocytes was detected. © 1999 Biomedical Engineering Society. PAC99: 8764Rr, 8717-d, 8719Tt     

Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia

Background: Posttraumatic stress disorder (PTSD) is common in refugees but its association with longer-term psychosocial dysfunction remains unclear. We examined whether a subgroup of refugees with comorbid PTSD and depression were at particularly high risk of disability. We also investigated whether specific trauma experiences were linked to this comorbid pattern. Methods: Consecutive Bosnians (and one or two compatriots nominated by them) were recruited from a community centre, yielding a total sample of 126 participants (response rate 86%). Measures included a trauma inventory, the Clinician Administered PTSD Scale (CAPS) (Blake et al., 1995) and the depression module of the Structured Clinical Interview (SCID) (First et al., 1997). Results: Three diagnostic groupings emerged: normals (n=39), pure PTSD (n=29), and comorbid PTSD and depression (n=58). Of four trauma dimensions derived from principle components analysis (human rights violations, dispossession and eviction, life threat and traumatic loss), life threat alone was associated with pure PTSD, with life threat and traumatic loss both being associated with comorbidity. Compared to normals and those with pure PTSD, the comorbid group manifested more severe PTSD symptoms as well as higher levels of disability on all indices (global dysfunction: odds RATIO=5.0, P<0.001, distress: odds RATIO=6.0, P<0.001, social impairment: odds ratio 5.9, P<0.001, and occupational disability: odds ratio 5.0, P<0.001). Limitations: Recruitment was not random, the sample size was modest, and trauma event endorsement was based on retrospective accounts. Conclusions: The combination of life threat and traumatic loss may be particularly undermining to the psychological well-being of refugees and consequent comorbidity of PTSD and depression may be associated with longer-term psychosocial dysfunction. The findings raise the question whether the comorbid pattern identified should be given more recognition as a core posttraumatic affective disorder.