就诊时间与急诊创伤患者滞留及预后的关系

目的 研究就诊时间与急诊创伤患者急诊室滞留及预后的关系.方法 从苏州大学附属第一医院创伤中心信息系统提取2016年11月1日至2019年11月30日在急诊抢救室诊治的1 738例急诊创伤患者的临床数据,将从挂号到急诊出科≥4h定义为急诊室滞留,以8:00,15:00及22:00为界将一天分为早、中、夜三个班次,以早班为...     

ICU收治严重创伤57例临床分析

目的对入住ICU的严重创伤患者的创伤原因、部位、预后等进行研究。方法对2002年3月～2004年10月ICU收治的57例严重创伤患者进行回顾性分析研究。结果57例患者中车祸32例,占56.14%,为首位创伤原因,其次为坠落伤。创伤类型以骨折多见,其次为颅脑外伤。死亡组血钾、白细胞、血肌酐、APACHEⅡ评分高于存活组,平均动脉压、血小板计数、哥拉斯哥评分低于存活组。结论车祸是创伤的主要原因,常见的损伤部位为骨骼和颅脑损伤,APACHEⅡ评分对评估患者的预后有一定指导意义,患者的常见死亡原因为休克、颅脑损伤、弥散性血管内凝血和急性肾功能衰竭。     

严重创伤患者在急诊救治中的护理体会

严重创伤患者伤情重、变化快、死亡率高,多合并出血性休克,积极有效的急救,直接影响患者生命。我院急救中心自成立以来,不断总结经验,完善创伤急救的组织系统,为严重创伤患者的救治赢得了抢救时间。现将护理体会报告如下。     

综合创伤急救模式对严重胸腹外伤患者救治效果的影响

目的探讨综合创伤急救模式对严重胸腹外伤患者救治效果的影响。方法选取2013年1月~2014年12月我科收治的68例严重胸腹外伤患者为研究对象,根据综合创伤急救模式开展时间分为传统救治组(2013年1月~12月)32例和综合创伤急救模式组(2014年1月~12月)36例。比较两组救治成功率、并发症发生率、急诊抢救时间、病情初步确诊时间、手术时间、平均住院时间、患者满意度评分、序贯器官衰竭估计(SOFA)、急性生理学与慢性健康状况评分(APACHE II)、创伤严重度评分(ISS)、格拉斯哥昏迷评分(GCS)。结果综合创伤急救模式组救治成功率高于传统救治组(P0.05),致残率、休克发生率、多器官功能衰竭综合征(MODS)、急性呼吸窘迫综合征(ARDS)发生率显著低于传统救治组(P0.05)。综合创伤急救模式组急诊抢救时间、病情初步确诊时间、手术时间、平均住院时间短于传统救治组,患者满意度评分高于传统救治组(P0.05)。综合创伤急救模式组治疗后SOFA评分、APACHE II评分、ISS评分显著低于传统救治组,GCS评分高于对照组(P0.05)。结论综合创伤急救模式能有效提高严重胸腹外伤患者救治成功率,降低并发症发生率,促进患者预后,提高患者及医生满意率。     

损伤控制骨科技术治疗严重多发性骨关节创伤患者的临床效果

目的研究损伤控制骨科(DCO)技术治疗严重多发性骨关节创伤患者的临床效果。方法选择2015年1月至2019年1月采用DCO技术治疗的60例患者作为研究组,另选择同期采用传统早期手术进行治疗的60例患者为参照组。比较两组患者的治疗效果。结果研究组出血量明显少于参照组,手术时间、体温恢复时间、乳酸清除时间、住院时间、骨折愈合时间均明显短于参照组,差异具有统计学意义(P<0.05)。治疗前,两组患者的PLT、APTT、FIB无显著差异(P>0.05);治疗1周后,两组患者的PLT、FIB水平均降低,且研究组低于参照组,差异具有统计学意义(P<0.05);治疗1周后,两组患者的APTT明显延长,且研究组长于参照组,差异具有统计学意义(P<0.05)。治疗1周后,研究组治疗总有效率高于参照组,并发症总发生率低于参照组,差异具有统计学意义(P<0.05)。结论DCO技术治疗严重多发性骨关节创伤患者的临床效果显著,值得在临床上推广应用。     

Pathogenesis and prevention of pneumonia in patients with severe craniocerebral trauma

The results of endoscopic studies of the bronchial tree have been assessed in 150 patients during the acute period of craniocerebral trauma. A correlation has been established between the side and degree of the brain stem damage and the onset of asymmetrical bronchomalacia. The development and signs of the obstructive syndrome within a 2-week post-traumatic period have been demonstrated. The incidence of destructive pneumonia has reduced four-fold. It is concluded that endoscopy of the bronchial tree is highly effective for the prevention of pneumonia in the acute period of severe craniocerebral trauma.     

Probiotics for severe trauma patients

Probiotics are live micro-organisms with a health promoting effect. Because of their immunomodulating capacity as well as improvement of gut barrier function, probiotics have the capacity to prevent infectious complications in a variety of clinical settings. Now selected probiotics show potential for improving the clinical outcome of severe trauma patients.     

Treatment of DIC syndrome in patients with severe craniocerebral trauma

Transfusion of fresh-frozen plasma with fraxiparin is the most rational basic therapy for the first and third clinical pathogenetic variants of subacute disseminated intravascular coagulation in multiple-modality treatment of severe craniocerebral injury. In the second variant of this condition, high doses of proteinase inhibitors in combination with minimum heparin doses are the most rational.     

严重颌面部外伤窒息病人的抢救及护理

对65例严重颌面部外伤窒息抢救病例进行分析,认为严重颌面部外伤病人,因其受伤的解剖位置的特殊性,极易发生窒息危象。针对两大类窒息,即:阻塞性窒息与吸入性窒息,提出了相应的抢救护理对策。文章强调护士必须十分清楚其外伤特点与救护原则,才能确保此类病人呼吸道的畅通。严重颌面外伤气道管理的好坏是抢救成败的关键。     

Spectrum of plasma lipoproteids in patients with severe mechanical trauma

Changes in the plasma lipoprotein spectrum were studied in patients with severe mechanical trauma. These changes were shown to be associated with the severity of injury and with the age of patients. The steady-state reduction in the plasma concentrations of cholesterol in patients aged under 55 years who have a serious mechanical trauma may be considered to be a poor predictor. In patients above 55 years, the severity of their condition may be judged from the changes in the concentration of high density lipoproteins: the positive changes in this parameter are indicative of a good clinical outcome.     

还原型谷胱甘肽对严重多发伤患者肝功能的保护作用

目的 探讨还原型谷胱甘肽（GSH）对严重多发伤患者肝功能保护作用的机制。方法 将46例严重多发伤患者随机分为GSH组（n=23）和对照组（n=23）。GSH组使用GSH1．8g/d静脉点滴，对照组给予门冬氨酸钾镁40mL／d静脉点滴，其他治疗两组相同，疗程均为7d。于治疗前和治疗第8天测定血浆肿瘤坏死因子（TNF—α）和白细胞介素-6（IL-6）及血浆生化指标（AST、ALT、γ-GT）。结果 GSH组与对照组在治疗前AST、ALT、γ-GT、TNF—α、IL-6比较差异无统计学意义。两组血浆AST、ALT、γ-GT治疗后均较治疗前降低（P〈0．05），且GSH组较对照组下降明显（P〈0．05）。治疗后GSH组TNF—α、IL-6下降较对照组明显（P〈0．01）。结论 GSH对严重多发伤时肝功能损伤有良好的保护功能，其作用机制与下调TNF—α和IL-6水平有关。     

创伤后细胞损伤的监测与评价

目的 观测创伤后血清细胞因子、氧自由基及酸性产物的含量变化,探讨其细胞代谢的监控效应及评价细胞损伤的方法.方法 选取本院2005年5月至2007年2月间经规范程序救治,临床资料完整的创伤患者117例,采用损伤严重度评分(ISS)和急性生理学及慢性健康状况评分(APACHEⅡ)对其组织损伤程度和伤后病情危害状况进行层次分组,依据病情变化实时检测各组的动脉血乳酸(ABL)、动脉血碱缺失(BD)、超氧化物歧化酶(SOD)、脂质过氧化物(LPO)、肿瘤坏死因子(TNF-α)和白细胞介素-6(IL-6)的血清水平,数据以((x)±s)表示,多组资料采用方差分析后两两比较,以P<0.05为差异具有统计学意义.结果 本组监测指标伤后就可山现明显变化,随损伤严重程度或病情危害状况的加重而显示组间差异具有统计学:意义(P<0.05).若并发缺血缺氧或休克、全身炎症反应综合征(SIRS)或感染以及多器官功能障碍综合征(MODS)时其异常增向则更为显著差异具有统计学意义(P<0.01).患者发生病情恶化或器官衰竭危机时,各指标水平常呈现持续异常或紊乱状态,与未发生者比较差异具有统计学意义(P<0.01).结论 细胞损伤反应与损伤严重程度、病情演变、MODS危机及患者预后有关,其血清指标的片常变化多预示着病情危危,实时检测有助于提高临床监控水平.     

Short-term effect of inhaled nitric oxide and prone positioning on gas exchange in patients with severe acute respiratory distress syndrome

OBJECTIVE: To compare the short-term effects of inhaled nitric oxide (NO) and prone positioning in improving oxygenation in acute respiratory distress syndrome (ARDS). METHODS: Charts of consecutive ARDS patients (lung injury score >2) during a 2-yr period, tested for both inhaled NO and prone positioning efficacy were retrospectively reviewed. Variations in the Pao2/Fio2 ratio induced by inhaled NO and prone positioning were evaluated. MEASUREMENTS AND MAIN RESULTS: Twenty-seven patients (age, 42+/-17 yrs) were included. Simplified Acute Physiology Score II was 45+/-14. Mortality rate in the intensive care unit was 63%. The causes of ARDS were pneumonia (n = 14), extra-lung infection (n = 5), and noninfectious systemic inflammatory response syndrome (n = 8). Lung injury score was 2.7+/-0.3. At baseline, before the initiation of inhaled NO, the Pao2/Fio2 ratio was 97+/-46 torr and before prone positioning, 92+/-26 torr. Variations in the Pao2/Fio2 ratio were lower at start of NO therapy (11+/-4 ppm) than that observed at prone positioning initiation (23+/-31 vs. 62+/-78 torr, p<.05). An increase in variations in the Pao2/Fio2 ratio of >15 torr was associated with prone positioning in 16 patients (59%) and with NO inhalation in 13 patients (48%) (not significant). An increase in variations in the Pao2/Fio2 ratio of >15 torr was associated with both techniques in only six patients (22%). There was no correlation between the response to prone positioning and the response to inhaled NO (r2 = .005; p = .73). CONCLUSIONS: Prone positioning improves hypoxemia significantly better than does inhaled NO. The response to one technique is not predictive of the response to the other technique.     

重型颅脑损伤合并多发伤的临床治疗

目的总结重型颅脑损伤合并多发伤的临床特点及诊治方法。方法对我科收治的316例重型颅脑损伤合并多发伤的进行回顾性分析。结果治愈184例,轻残19例,中残21例,重残9例,植物生存5例死亡79例。结论重型颅脑损伤合并多发伤应早期诊断、及时抢救,避免漏诊和误诊。对危及生命的损伤的抢救、重要脏器功能的维持、正确的手术时机、骨折早期手术内固定和ICU监护对成功救治有着重要作用。     

Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock

Aim of the study

Death to trauma is caused by disastrous injuries on scene, bleeding shock or acute respiratory failure (ARDS) induced by trauma and massive blood transfusion. Extracorporeal membrane oxygenation (ECMO) can be effective in severe cardiopulmonary failure, but preexisting bleeding is still a contraindication for its use. We report our first experiences in application of initially heparin-free ECMO in severe trauma patients with resistant cardiopulmonary failure and coexisting bleeding shock retrospectively and describe blood coagulation management on ECMO.

Methods

From June 2006 to June 2009 we treated adult trauma patients (n = 10, mean age: 32 ± 14 years, mean ISS score 73 ± 4) with percutaneous veno-venous (v-v) ECMO for pulmonary failure (n = 7) and with veno-arterial (v-a) ECMO in cardiopulmonary failure (n = 3). Diagnosis included polytrauma (n = 9) and open chest trauma (n = 1). We used a new miniaturised ECMO device (PLS-Set, MAQUET Cardiopulmonary AG, Hechingen, Germany) and performed initially heparin-free ECMO.

Results

Prior to ECMO median oxygenation ratio (OR) was 47 (36-90) mmHg, median paCO₂ was 67 (36-89) mm Hg and median norepinephrine demand was 3.0 (1.0-13.5) mg/h. Cardiopulmonary failure was treated effectively with ECMO and systemic gas exchange and blood flow improved rapidly within 2 h on ECMO in all patients (median OR 69 (52-263) mm Hg, median paCO₂ 41 (22-85) mm Hg. 60% of our patients had recovered completely.

Conclusions

Initially heparin-free ECMO support can improve therapy and outcome even in disastrous trauma patients with coexisting bleeding shock.     

Early SjvO2 monitoring in patients with severe brain trauma

Objective: To investigate early cerebral variables after minimal resuscitation and to compare the adequacy of a cerebral perfusion pressure (CPP) guideline above 70 mmHg, with jugular bulb venous oxygen saturation (SjvO₂) monitoring in a patient with traumatic brain injury (TBI). Design: Prospective, observational study. Setting: Anesthesiological intensive care unit. Patients: 27 TBI patients with a postresuscitation Glasgow Coma Scale score less than 8. Intervention: After initial resuscitation, cerebral monitoring was performed and CPP increased to 70 mmHg by an increase in mean arterial pressure (MAP) with volume expansion and vasopressors as needed. Measurements and results: MAP, intracranial pressure (ICP), CPP, and simultaneous arterial and venous blood gases were measured at baseline and after treatment. Before treatment, 37 % of patients had an SjvO₂ below 55 %, and SjvO₂ was significantly correlated with CPP (r = 0.73, p < 0.0001). After treatment, we observed a significant increase (p < 0,0001) in CPP (78 ± 10 vs 53 ± 15 mmHg), MAP (103 ± 10 vs 79 ± 9 mmHg) and SvjO₂ (72 ± 7 vs 56 ± 12), without a significant change in ICP (25 ± 14 vs 25 ± 11 mmHg). Conclusion: The present study shows that early cerebral monitoring with SjvO₂ is critical to assess cerebral ischemic risk and that MAP monitoring alone is not sensitive enough to determine the state of oxygenation of the brain. SjvO₂ monitoring permits the early identification of patients with low CPP and high risk of cerebral ischemia. In emergency situations it can be used alone when ICP monitoring is contraindicated or not readily available. However, ICP monitoring gives complementary information necessary to adapt treatment. Received: 10 July 1998 Final revision received: 5 January 1999 Accepted: 20 January 1999     

重型颅脑损伤术中脑膨出32例

目的探讨重型颅脑损伤开颅术中急性脑膨出的形成原因及防治措施。方法对32例重型颅脑损伤开颅术中急性脑膨出的原因、对策及预后进行回顾性分析,比较各种防治措施的疗效。结果按GOS标准,治疗后6个月评定治疗效果,恢复良好12例,中度残疾8例,重度残疾7例,死亡5例。结论术中迟发性颅内血肿形成、急性弥漫性脑肿胀、脑组织缺氧和低血压、长时间脑疝、严重脑挫裂伤等是颅脑损伤术中急性脑膨出的主要原因,正确判断脑膨出的性质,针对不同病因采取相应措施,可防治颅脑损伤术中脑膨出,降低重残率及病死率,取得良好疗效。