49例严重肢体挤压伤院前院内一体化救治

目的探讨严重肢体挤压伤的院前院内一体化救治方法和效果。方法回顾性分析2008年5月~2015年7月收治的严重肢体挤压伤患者49例的院前院内一体化救治的临床资料,男性44例,女性5例;年龄19~82岁,平均43.7岁。地震伤5例、道路交通伤20例、工矿事故伤17例、其他7例。受伤肢体:肩背上肢8例、骨盆及下肢41例。合并骨盆及肢体骨折脱位32例(闭合伤20例,开放伤12例),多发伤44例。结果院前救援时间35min~49h,现场救援建立静脉通道并输液19例,止血带使用31例。全部病例在解压后行心电监测,救援现场行小腿筋膜室切开1例,膝关节离断1例。院内救治包括清创后负压封闭引流14例,筋膜室切开减压后负压封闭引流17例,负压引流有效率96.8%(30/31),使用负压引流组无截肢者;发生挤压综合征28例(57.1%),其中合并高钾血症11例,肾功能衰竭8例;使用呼吸机辅助治疗8例,连续性肾替代治疗8例。治愈31例;好转13例;未愈5例,包括截肢3例(6.1%),死亡1例(2.0%),死因为高钾血症致心肺复苏失败。结论重视止血带和心电监测在严重肢体挤压伤院前救援中的应用,实施负压封闭引流技术可减少严重肢体挤压伤的截肢率。

Pre-hospital and in-hospital integrated treatment for severe crush injuries of extremities:experience in 49 cases

Objective To evaluate the therapeutic methods and effect of pre-hospital and in-hospital inte-grated treatment for severe crush injuries of extremities . Methods The clinical data of 49 patients with severe crush injuries of extremities from May 2008 to Jul.2015 in Chongqing Emergency Medical Center was retrospectively studied.There were 44 males and 5 females,with age ranging from 19 to 82 years (average,43.7 years).There were 5 cases of earthquake injury ,20 cases of traffic accident injury ,17 cases of mining accident injury ,and 7 cases injured by other causes .Injured sites of crushes were as follows: shoulder and upper limbs in 8 cases ( 16.3%) , pelvic and lower limbs in 41 cases(83.7%).Thirty-two cases(65.3%) were associated with fractures and disloca-tion of pelvis and joints,and 44 cases were associated with multiple injuries (89.8%).Results Pre-hospital time was 35min-49h.Venous pathway was established and infusion was applied in 19 cases during on-the-scene rescue and tourniquet was applied in 31 cases (63.3%).Decompressive fasciotomy was performed in 1 case and amputa-tion was performed in 1 case during on-the-scene rescue .Electrocardiogram monitoring was performed in all cases after decompression.In-hospital therapeutic measures included vacuum sealing drainage (VSD) in 14 cases after debridement and 17 cases with decompressive fasciotomy . The effective rate of VSD was 96.8%( 30/31 ) and no case was amputated in this group .The incidence rate of crush syndrome (CS) was 57.1%(28/49),of which 11 cases (22.4%) were combined with hyperkalemia ,and 8 cases with renal failure.Eight cases were treated with ventilator assisted therapy and 8 cases were treated with continuous renal replacement therapy ( CRRT ) . At the end,31 cases(63.3%) were cured,13 cases(26.5%) were improved,and 5 cases(10.2%) were uncured,which included 3 cases ( 6.1%) of amputation and 1 death case ( 2.0%) died from failed cardiopulmonary resuscitation due to hyperkalemia .Conclusion Tourniquet and electrocardiogram monitoring should be emphasized in pre-hos-pital treatment of severe crush injuries of extremities .Application of VSD in in-hospital treatment can reduce the in-cidence rate of amputation of severe crush injuries of extremities .