外伤性心脏破裂10例分析

目的：总结外伤性心脏破裂伤的诊断与治疗。方法：10例心脏裂伤患者,开放性损伤7例,闭合性损伤3例,均急诊开胸手术,修补心脏裂口。结果：10例均治愈出院。结论：心脏破裂伤的患者需急诊手术,修补破口是治疗的关键。     

开放性心脏损伤的救治体会

目的:探讨开放性心脏损伤的紧急救治方法和手术治疗的原则.方法:回顾性分析我院自2000年1月至2009年1月收治的3例开放性心脏损伤的病例,均在抗休克的同时行急诊开胸探查,行心脏破裂口直接修补术,用胸壁肌带肌膜的肌块作附垫缝合裂口.结果:3例患者经边抗休克边急诊开胸手术治疗,均痊愈出院.结论:最大限度地缩短术前准备时间,减少不必要的术前检查,对于休克、胸腔大量积血疑有心脏穿透伤的患者非常重要,迅速开胸手术,解除心包填塞,修复心脏裂口是救治成功的关键.     

心脏破裂7例的麻醉处理

<正>心脏破裂常为锐器伤或手术操作误伤心肌所致。患者常以病情危重和死亡率高为特点,易早期出现心包填塞和休克而死亡,需尽快作出正确诊断,急诊开胸修补心脏裂口,解除心脏压塞。麻醉要迅速、术中尽可能维持血流动力学平稳是抢救成功的关键。本文回顾性分析了我院自2004年1月至2009年8月期间收治的7例心脏破裂患者的麻醉处理经过,报告如下。     

心脏外伤的急救护理

总结心脏外伤的急救护理经验。回顾性分析16例心脏外伤患者的临床资料。15例病人在气管插管全麻下剖胸探查,分别给予心肌裂伤修补,心包开窗及其他合并脏器的修补术。死亡5例,其中1例送院后证实死亡,3例术后死于多脏器功能衰竭,1例死于难以控制的肺部感染。早期诊断、早期手术、加强护理是心脏外伤急救的关键所在,急救时生命体征观察、术后加强呼吸道管理、防止并发症则是加强护理的重点。     

心脏外伤的急救护理

总结心脏外伤的急救护理经验.回顾性分析16例心脏外伤患者的临床资料.15例病人在气管插管全麻下剖胸探查,分别给予心肌裂伤修补,心包开窗及其他合并脏器的修补术.死亡5例,其中1例送院后证实死亡,3例术后死于多脏器功能衰竭,1例死于难以控制的肺部感染.早期诊断、早期手术、加强护理是心脏外伤急救的关键所在,急救时生命体征观察、术后加强呼吸道管理、防止并发症则是加强护理的重点.     

胸部创伤急救手术112例临床分析

目的：探讨对胸部创伤实施急救手术的可行性和救治效果。方法：胸外科在1998～2001年间收治胸部创伤854例，其中实施手术救治者112例，其中心脏修补缝合术3例；持续心包引流术2例；肺叶切除或裂伤修补术10例；剖胸探查膈肌修补2例；持续胸腔闭式引流术43例；凝固性血胸清除术14例；刀刺伤探查止血术17例；清创术21例。术中心电监护，术后重症监护综合治疗。结果：本组术后痊愈109例，死亡3例，其中心脏刀刺伤术中死亡1例，严重复合伤术后并发急性呼吸窘迫综合征(ARDS)死亡1例；并发多器官功能不全综合征(MODS)死亡1例。术后并发症18例，主要并发感染性休克3例，低血容量性休克2例，ARDS8例，MODS5例。结论：对胸部创伤患者实施急救手术，可以降低患者并发症的发生率和死亡率。     

一例右颈总动脉穿通伤患者的急救护理

临床上颈部外伤较为多见,但颈总动脉穿通伤则极为罕见。我科曾收治一例右侧颈总动脉穿通伤病例,通过医护人员的全力抢救,成功地进行了剖胸探查,右颈总动脉裂口修补术,术后精心护理,住院25天痊愈出院,现报告如下。     

心脏贯通伤5例治疗分析

目的 探讨各种心脏外伤的治疗方法。方法 心脏贯通伤是一种病情急、死亡率高的严重损伤，多由锐器伤所改，一旦确诊均应行积极手术治疗，本组5例患者3例为刀刺伤，1例为枪击伤．1例为车祸伤，手术切口应视外伤部位而决定，以充分暴露心脏伤口为佳，并发复合伤者应先治疗心脏贯通伤，对出血量大、损伤复杂者必要时可在急诊体外循环下行心脏修补术。结果 本组病人全部存话。结论 各种不同的心脏外伤应该根据伤口的部位采取不同的手术切口，以充分暴露心脏裂口为佳；手术时应先压迫裂口止血然后修补；必要时可在体外循环下行心脏修补术；手术时要注意避免其他脏器损伤的漏诊，但处理顺序是应该先作心脏修补再处理其它脏器的损伤。     

穿透性胸伤120例救治体会

目的 :探讨穿透性胸伤的救治方法。方法 :回顾性分析我院收治的穿透性胸伤 12 0例 ,其中单纯性气胸 2 0例 ,血气胸 48例 ,胸腹联合伤 40例 ,心脏损伤 12例。行胸腔闭式引流 10 8例 ,剖胸手术 32例 ,剖腹手术 38例 ,先剖腹后剖胸术 2例。结果 :治愈 115例 ,死亡 5例。结论 :穿透性胸伤易致血气胸、心脏损伤及胸腹联合伤。胸腔闭式引流可治愈大部分血气胸患者 ,进行性血气胸者应及时剖胸止血 ;怀疑心脏损伤者应扩创探查 ,及时手术 ;胸腹联合伤确诊后应及时手术。     

急诊电视胸腔镜在外伤性血气胸诊治中的应用

该文总结了９例急诊电视胸腔镜诊治外伤性血气胸患者，除１例中转剖胸手术外，余均在胸腔镜下对有关创伤作相应处理，无１例作延缓手术。作者提出急诊电视腹腔镜对外伤性血气胸的适应证、禁忌证。并认为此方法具有诊断准确率高，降低手术剖胸探查率，手术创伤轻，切口小，疼痛轻，并发症少，恢复快，术后病人生活质量高等优点     

Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture

Extracorporeal cardiopulmonary resuscitation (ECPR) followed by operating room sternotomy, rather than resuscitative thoracotomy, might be life-saving for patients with blunt cardiac rupture and cardiac arrest who do not have multiple severe traumatic injuries.A 49-year-old man was injured in a vehicle crash and transferred to the emergency department. On admission, he was hemodynamically stable, but a plain chest radiograph revealed a widened mediastinum, and echocardiography revealed hemopericardium. A computed tomography scan revealed hemopericardium and mediastinal hematoma, without other severe traumatic injuries. However, the patient's pulse was lost soon after he was transferred to the intensive care unit, and cardiopulmonary resuscitation was initiated. We initiated ECPR using femorofemoral veno-arterial extracorporeal membrane oxygenation (ECMO) with heparin administration, which achieved hemodynamic stability. He was transferred to the operating room for sternotomy and cardiac repair. Right ventricular rupture and pericardial sac laceration were identified intraoperatively, and cardiac repair was performed. After repairing the cardiac rupture, the cardiac output recovered spontaneously, and ECMO was discontinued intraoperatively. The patient recovered fully and was discharged from the hospital on postoperative day 7.In this patient, ECPR rapidly restored brain perfusion and provided enough time to perform operating room sternotomy, allowing for good surgical exposure of the heart. Moreover, open cardiac massage was unnecessary. ECPR with sternotomy and cardiac repair is advisable for patients with blunt cardiac rupture and cardiac arrest who do not have severe multiple traumatic injuries.     

The management of stab wounds to the heart with laceration of the left anterior descending coronary artery.

Penetrating cardiac injuries are an increasing cause of traumatic deaths in urban areas. The management of these injuries has undergone a transition from simple pericardiocentesis to cardiac ultrasound evaluation in the stable patient, and emergency thoracotomy and repair of myocardial wounds in the unstable patient in extremes. The incidence of traumatic coronary artery injury is not accurately known because not all victims are examined. With the improvement in emergency medical services, including speed of transportation of these patients, better resuscitation, and knowledgeable use of cardiac ultrasound or emergency room thoracotomy, more patients with coronary artery injuries will survive and reach the operating room. The operative management of the injured coronary artery is dependant on the location of the injury and whether there is myocardial dysfunction. Distal injuries with small myocardial infarction should be treated by ligation alone. Proximal injury and those injuries associate with larger area of ischaemia or infarction are best treated with coronary artery bypass. The role of cardiopulmonary bypass pump in these patients should be evaluated depending on the homodynamic stability of the patient. We present two cases of cardiac stab wounds with transection of the left anterior descending (LAD), which were successfully managed. A literature review regarding the management of combined cardiac and coronary artery injuries is also provided.     

Blunt traumatic pericardial rupture.

A 28-year-old man presented with left chest, head and limb injuries following a road traffic accident (RTA). Increasing haemodynamic instability necessitated an emergency left thoracotomy at which a complete rupture of the pericardium and herniation of the heart was found. After repair, the patient made an uneventful post-operative recovery. The aetiology, investigation and management of this rare injury is discussed.     

急诊室剖胸术救治21例心脏穿透伤分析

目的总结急诊室剖胸术救治心脏穿透伤的临床经验。方法对21例被施行急诊室剖胸术进行救治的心脏穿透伤病例进行回顾性分析。结果治愈20例,一例因合并室间隔及三尖瓣损伤死亡。死亡比为4．8%。结论急诊室剖胸术在救治心脏穿透伤,尤其是濒死型心脏穿透伤患者时有非常重要的价值。     

闭合性胸部外伤致心脏破裂16例

目的 探讨闭合性胸部外伤致心脏破裂的手术抢救入路与方法.方法 2004年1月至2010年12月我院抢救闭合性胸部外伤致心脏破裂患者16例,均采用胸骨正中切口行心脏破裂修补术,分析其效果.结果 除1例在体外循环建立前出现心跳停止、手术修补后心肺复苏失败外,余15例全部救治成功.结论 闭合性胸部外伤致心脏破裂应及时果断进行抢救和急诊手术,心脏破裂修补术可以提高患者的存活率.     

Abdominal vascular injuries

Treatment of major abdominal vascular injuries is a challenge. Since 1973, 93 patients have been treated at our institution for 147 abdominal vascular injuries. The majority of these injuries (67%) resulted from penetrating trauma in young men between 21 and 30 years of age. Upon admission 72% of the patients were in shock. Injured most frequently were the iliac vessels (36%) and the inferior vena cava (20%). Suture repair with preservation of function was possible in 61%; ligation of the damaged vessel was necessary in 24 cases (26%). Overall mortality was 29%. Military anti-shock (MAS) trousers were used in the management of ten patients who had an average admission systolic blood pressure of 52 mm Hg; 50% survived. In six cases of refractory hypotension or cardiac arrest, thoracotomy was done in the emergency room; mortality in this group was 100%. For some abdominal vascular injuries, ER thoracotomy has a very limited application. The key factors for increasing the survival rate in patients with major abdominal vascular injuries include rapid stabilization, reversal of hypotension (especially by the use of MAS trousers), and prevention of coagulopathy, combined with prompt surgical exploration and thoracotomy when indicated.     

二尖瓣置换术后迟发型左心室破裂诊治分析

目的探讨二尖瓣置换术后左心室延迟破裂的原因及防治措施。方法对我院收治二尖瓣置换术后左心室迟发破裂的1例临床资料进行回顾性分析。结果本例因风湿性心脏病联合瓣膜病行主动脉瓣、二尖瓣置换及三尖瓣成形术,手术经过顺利,术后6h出现心包及纵隔引流管有大量血性引流液。患者被立即转运至手术,开胸探查证实为左心室Ⅲ型破裂,行修补术抢救成功,术后顺利出院。结论高龄、左心室偏小和体重较轻是二尖瓣置换术后左心室延迟破裂的危险因素,术中操作粗暴则增加了左心室破裂危险性。左心室延迟破裂一旦明确诊断应急诊手术修补,有可能挽救患者生命。     

Chest injuries - what is new?

PURPOSE OF REVIEW: This article reviews new aspects about the significance, diagnosis and treatment of different chest injuries. RECENT FINDINGS: Age and Injury Severity Score were risk factors for pneumonia and mortality in patients with rib fractures or flail chest. Occult pneumothoraces were detected in 14.5% and occult hemothoraces in 21.4% using computed tomography, whereas lung contusions were detected two times more frequently with computed tomography compared with chest X-ray. The current treatment of acute respiratory distress syndrome has been ameliorated by extracorporeal membrane oxygenation and pumpless extracorporeal lung assist system. Endovascular repair of thoracic aortic injuries has reduced mortality and morbidity compared with open repairs. Increased serum levels of troponin are related to the degree of overall injury severity and physiologic parameters but not to mechanical chest impact. The mortality of penetrating cardiac injuries is still very high (15.6% for stab wounds, 81% for gunshot wounds). SUMMARY: Faster and more detailed diagnosis of thoracic injuries has been achieved by multislice computed tomography. The modern management of thoracic injuries is complex. Minimally invasive techniques (thoracoscopic surgery, endovascular repair) and recent developments in lung supportive therapies reduce mortality and morbidity. However, emergency thoracotomy is still an important and valuable approach for life-saving or damage-control procedures.     

Endovascular stent-graft repair of descending thoracic aortic aneurysms: the nursing implications for care.

Endovascular repair of descending thoracic aortic aneurysms is a minimally invasive procedure performed with the patient under epidural or spinal anesthesia as an alternative to the conventional left thoracotomy repair. A Dacron graft, similar to the one used in the conventional repair, is placed in the thoracic aorta with fluoroscopic guidance via the femoral or iliac artery. Once the graft is in place, the aneurysm is excluded from the general circulation, thereby preventing rupture. Endovascular repair is currently being offered at selected sites to patients who otherwise would not be candidates for surgical repair due to severe comorbidities such as cardiac, pulmonary, or renal disease. As both the technique and the devices become perfected, endovascular stent-graft repair of descending thoracic aortic aneurysms will most likely be offered as a method of treatment in both high- and low-risk patients who are anatomic candidates for the procedure. This article describes the conventional repair and the endovascular repair of descending thoracic aneurysms. It discusses the implications for nursing care in the preoperative and postoperative settings and defines guidelines for the long-term follow-up of patients who undergo endovascular repair.     

Emergency department thoracotomy for penetrating injuries: predictive value of patient classification

In 18 months, 44 patients underwent thoracotomy in an emergency department (ED) for penetrating thoracic injuries. Of 14 patients resuscitated, seven (50%) survived, and all were neurologically intact. Patients were classified according to the quality of signs of life in transit or upon arrival at the ED. Identical survival rates of 29% were noted for patients in Group I (profound shock) and in Group II (agonal), with survival at 14% for individuals in Group III ("dead" on arrival). There were no survivors among patients in Group IV ("dead" on the scene), and ED thoracotomy, in the authors' opinion, is fruitless in this group. In Groups I, II, and III, total salvage from cardiac injuries was six of 24 patients (25%), and for those with non-cardiac injuries, it was one of 11 (9%). The rate of survival from cardiac stab wounds in Groups I, II, and III, was five of 16 (31%) and one of eight (13%) for gunshot wounds. Five of the seven survivors (71%) arrived at the ED by rapid transport without the benefit of any pre-hospital life support. Patient classification appears to be a valuable tool in evaluating the benefit of ED thoracotomy. The neurological status of all survivors and pertinent transportation data should be included in all future studies of ED thoracotomy. "Scoop and run" in the urban setting with rapid transport capability may be superior to pre-hospital stabilization of victims of penetrating thoracic trauma.