不同时期胸部创伤的特点及救治经验

目的比较不同时期收治胸部创伤（胸伤）的特点，围绕其院内死亡原因总结救治经验。方法将１６３９例胸伤分为１９９０年前、后两组，比较不同时期病例数、致伤原因、严重胸伤构成比及住院死亡率，并对伤后早期与晚期常见致死原因失血性休克、成人呼吸窘迫综合征（ＡＲＤＳ）和多系统器官衰竭（ＭＳＯＦ）等进行分析。结果９０年代后收治胸伤病例增多，穿透性刃器伤、重症钝性胸伤、连枷胸、肺挫伤和ＡＲＤＳ病例明显增加，住院死亡率从４．３０％降至２．９６％；住院早期死亡原因以失血性休克为主，晚期死亡原因多为ＡＲＤＳ和ＭＳＯＦ。结论应针对９０年代胸伤特点，围绕严重胸伤常见的致死原因，进一步改进急救和后续处理，降低死亡率。     

多发伤中长骨干骨折的早期髓内固定

目的 探讨多发伤中长骨干骨折的处理时机和方法。方法 共１６６例多发伤中长骨干骨折,伤员损伤严重度评分（ＩＳＳ）平均为２１．６分,伴休克者３９例（２３．５％０,８３％的伤员在到院后２４小时内（９５％在４８小时内）施行手术治疗,２０４处长骨干骨折（包括６６处开放骨折）均采用髓内固定。结果 伤口一期愈合率９５％,骨折愈合率继９３％,未发生脂肪栓塞、急性呼吸窘迫综合征（ＡＲＤＳ）深静脉炎和多器官功能衰竭（ＭＯＦ）等并发症。结论 对多发伤中长骨干骨折早期复位和髓内固定有利于稳定伤员病情、减少并发症、提高治愈率和降低死亡率。     

严重创伤患者白细胞介素-2及其受体变化与多器官功能障碍综合征的关系

目的　探讨血清白介素２（ Ｉ Ｌ２） 与可溶性白介素２ 受体（ｓ Ｉ Ｌ２ Ｒ） 在创伤后多器官功能障碍综合征（ Ｍ Ｏ Ｄ Ｓ） 发生、发展中的作用与机制。　方法　应用 Ｅ Ｌ Ｉ Ｓ Ａ 法动态监测５９ 例严重创伤患者血清 Ｉ Ｌ２ 与ｓ Ｉ Ｌ２ Ｒ 水平变化,比较 Ｍ Ｏ Ｄ Ｓ与非 Ｍ Ｏ Ｄ Ｓ组间 Ｉ Ｌ２ 、ｓ Ｉ Ｌ２ Ｒ 变化之差异。　结果　５９ 例患者血清ｓ Ｉ Ｌ２ Ｒ 水平显著升高而 Ｉ Ｌ２ 明显下降,且升高之峰值与降低之谷值在 Ｍ Ｏ Ｄ Ｓ组更为明显,与非 Ｍ Ｏ Ｄ Ｓ组间差异显著（ Ｐ＜ ００５） 。　结论　 Ｉ Ｌ２ 与ｓ Ｉ Ｌ２ Ｒ 血清浓度的变化可能参与了创伤后 Ｍ Ｏ Ｄ Ｓ的发病过程;严重创伤诱发血清ｓ Ｉ Ｌ２ Ｒ 过度表达进而抑制 Ｉ Ｌ２ 依赖性免疫反应,这可能是创伤后 Ｍ Ｏ Ｄ Ｓ重要发病机制之一。     

肾移植中丙二醛及超氧化物歧化酶的监测及临床意义

连续动态监测４５例肾移植患者手术前后血浆丙二醛（ＭＤＡ）及超氧化物歧化酶（ＳＯＤ）水平变化，发现急性肾小管坏死（ＡＴＮ）组患者术后第１天血浆ＭＤＡ及ＳＯＤ水平较术前明显升高，分别在术后１０天及７天内维持较高水平；急性排斥（ＡＲ）及急性感染（ＡＩ）发生时，ＭＤＡ及ＳＯＤ水平亦升高，但不如ＡＴＮ组显著；术前ＭＤＡ及ＳＯＤ水平明显高于正常对照组；正常恢复组术后ＭＤＡ及ＳＯＤ水平则逐步下降，结果反映了ＡＴ     

低血灌流、细胞因子与内皮细胞的损伤

机械伤、温度伤、创伤、还是胰腺炎或休克都可能引起多系统器官功能衰竭（ＭＳＯＦ），尤以继发于感染的ＭＳＯＦ最为严重。组织损伤和急性胰腺炎可不伴有感染，但仍可诱发复杂贯序性瀑布样介质释放，而出现全身炎性反应综合征（ＳＩＲＳ）。ＳＩＲＳ的临床表现有：（１）...     

MODS研究的现状与展望

１９７７年提出“多器官衰竭”（ＭＯＦ）至１９９２年提出“全身炎症反应综合征”（ＳＩＲＳ）的概念是一次意义深远的突破。这期间曾兴起—个又一个研究“热点”,其研究领域涉及各种相关基础医学,但这一期间ＭＯＦ／ＭＯＤＳ的病死率仍在７０％左右,这不能不引起我们的反思。 ＳＩＲＳ与ＭＯＤＳ １９９２年ＡＣＣＰ／ＳＣＣＭ提出ＳＩＲＳ这一概念,视ＭＯＤＳ为ＳＩＲＳ的一种最严重临床表现,是创伤、休克、感染等危重病人的严重并发症。这一概念的提出,其最大意义即在于将对ＭＯＤＳ的研究侧重点转移到机体防御反应自身。其后,Ｂ…     

脊髓损伤早期三七总皂甙抗氧自由基作用的实验研究

Ｗｉｓｔａｒ大鼠４８只随机分三组，Ａｌｌｅｎ＇ｓ脊髓损伤（ＳＣＩ）模型２５０ｇ·ｃｍ致伤Ｔ_（１３）～Ｌ_１脊髓节段，腹腔注射三七总皂甙（ＰＮＳ），伤后３０ｍｉｎ时１００ｍｇ／ｋｇ，２ｈ及４ｈ各５０ｍｇ／ｋｇ；以二甲亚砜（ＤＭＳＯ）为抗氧自由基阳性对照药物，并设立空白对照。伤后１ｈ及４ｈ取伤区脊髓组织测定丙二醛（ＭＤＡ）及超氧化物歧化酶（ＳＯＤ），发现ＰＮＳ显著减少ＭＤＡ的生成，保护ＳＯＤ活力降低。组织形态学观察到灰质区出血坏死，髓鞘分离及线粒体水肿较轻。提示ＳＣＩ早期ＰＮＳ具有明显的抗氧自由基反应和减轻继发性损害的作用。     

不同海拔梯度严重创伤后诱发急性肺损伤的对比观察

目的：探讨不同海拔梯度创伤性ＡＬＩ／ＡＲＤＳ发病机制、几率、特征和早期防治。方法：按ＡＬＩ／ＡＲＤＳ记分标准将发生在海拔１５００（兰州）以胸伤为主与（或）多发伤病例,ＡＩＳ－ＩＳＳ院内记分在２０分以上的２６例列为Ａ组,将２２６０ｍ（西宁）伤情配比近似Ａ组的２２例列为Ｂ组,观察两组自受伤－－院内救护至发生ＡＬＩ／ＡＲＤＳ的时间、发病特点、几率、临床病征、血气变化。结果：在伤情相近,原发伤处理相近的条     

烧伤后侵袭性感染和多器官功能不全综合征

总结了１５８例烧伤侵袭性感染与多器官功能不全综合征（ＭＯＤＳ）的关系。侵袭性感染导致ＭＯＤＳ有几个特点：①ＭＯＤＳ发病率高，达到８１．６％，每例有平均２．７３个器官发生功能不全。②ＭＯＤＳ发展成ＭＯＦ的发生率也高，约为５０％。③ＭＯＤＳ死亡率低，而发展到ＭＯＦ死亡率明显上升，达到９０％以上。不同菌种感染中，Ｇ＋菌致器官功能不全（ＯＤ）发生率较低，Ｇ－菌致ＯＤ发生率较高，而绿脓杆菌致ＯＤ发生率最高，后果最严重。对发病机制及防治问题进行了讨论，认为由于发病机理尚未充分了解，针对机制的有效治疗缺乏，因此防治的主要手段仍是去除诱因，即控制侵袭性感染。一旦感染发生，则要保护好各个脏器，使ＯＤ不致发展成器官衰竭。     

多发伤合并休克早期大鼠肝脏细胞凋亡的研究

目的　探讨多发伤合并休克早期大鼠肝脏中细胞凋亡的发生情况。方法　采用 Ｄ Ｎ Ａ 琼脂糖凝胶电泳、原位末端标记（ Ｉ Ｓ Ｅ Ｌ） 、光镜和电镜检测细胞凋亡,并测定 Ｄ Ｎ Ａ 片段百分率（ａｐ ％ ） 作定量分析。结果　检测到凋亡所特有的 Ｄ Ｎ Ａ 梯形条带, Ｉ Ｓ Ｅ Ｌ 法亦显示阳性结果,证实创伤后肝脏中细胞凋亡的存在且ａｐ ％ 与 Ａ Ｌ Ｔ、 Ａ Ｓ Ｔ 和 Ｔ Ｂ 间存在正相关（ Ｐ＜ ０ ．００１） 。在复苏后６ 小时,ａｐ ％ 均随创伤程度加重而升高。在６ 处创伤合并休克组,复苏后１ 小时ａｐ ％ 已显著升高,３ 小时达顶峰,以后逐渐下降。形态学结果显示,细胞凋亡主要发生于早期,肝细胞、枯否氏细胞和中性粒细胞均可发生凋亡,而后期以坏死为主。结论　多发伤合并休克早期大鼠肝脏中发生细胞凋亡,且可能参与早期的肝功能损害。     

Epidemiological characteristics and relative factor of hospital death cases with road traffic trauma

Objective:To investigate the epidemiological characteristics and relative factor about hospital death in patients with road traffic trauma. Methods: The age, sex, road-use category, sites of injury, injury severity scale of 159 hospital death cases in 2436 cases with road traffic trauma were observed, and the relation between the causes of death and time elapsed after injury was also studied with likelihood ratio Chi-square test. Results: More hospital deaths happen more likely in the elderly patients and peasants with road traffic trauma. Motor vehicle was the most common culprit, and the majority of victims were pedestrians. The causes of death were related with the time elapsed after injury, and according to which the clinical course of the wounded patients could be divided into cerebral injury / shock phase, transitional phase, infection phase and multiple organ dysfunction syndrome (MODS) phase.Conclusion: There is a significant relation between the hospital deaths and types of the injury and medical care in road traffic accidents. It should be emphasized that strategy of prevention of hospital deaths during hospital care should vary in different phases of the clinical course.     

胸部闭合伤的损伤严重度评估及临床意义

目的：探讨胸部闭合伤的临床特点及其损伤严重度评估的临床意义。方法：分析456例胸部闭合伤的致伤因素和死亡率,并按有无合并伤（分为单纯胸伤组,合并伤组）和结局（分为生存组,死亡组）分组进行创伤评分,分别比较不同组间的损伤严重程度。结果：致伤原因为交通伤发生率最高（60．97％）,其次为高处坠落伤（13．82％）。456例中288例合并其它部位损伤,占63．16％,死亡18例,死亡率3．95％,单纯胸伤组的格拉斯哥昏迷指(GCS),睡正创伤评分（RTS）和生存概率（Ps)较高,损伤严重评分（ISS）低于合并伤组,胸部简明损伤定级（AIS）评分两组间差别无显著性意义,死亡组和生存组比较,前者生理评分低,解剖评分高,生存概率亦低。结论：胸部闭合伤常合并全身多发伤,伤情判断困难,合理使用创伤评分有助于判断损伤严重度,指导临床救治。     

Influence of Injury Pattern on Incidence and Severity of Posttraumatic Inflammatory Complications in Severely Injured Patients

Abstract Background: Severe trauma causes systemic inflammatory response syndrome (SIRS) which may lead to multiple organ dysfunction syndrome (MODS) or multiple organ failure (MOF). The aim of this study was to evaluate the influence of the injury pattern on the incidence and severity of SIRS, sepsis, MODS, and mortality. Methods: A total of 1,273 patients with an injury severity score (ISS) of ≥ 9 points and survival of more than 3 days were included in this retrospective study. Outcome parameters were various grades of SIRS, sepsis, MODS, and mortality. Results: Severe non-infectious SIRS occurred in 23%, sepsis in 14%, and severe MODS in 14% of the patients. Serious (abbreviated injury scale (AIS) ≥ 3 points) head injury and the ISS represented the most potent risk factors for severe SIRS. As estimated by multivariate logistic regression analysis, the presence of severe extremity and pelvic injuries, the ISS, and the male gender were found to be independent risk factors for sepsis. Severe injuries of the abdomen were associated with an increased risk for sepsis in the univariate analysis. Severe injuries to the head or abdomen, the ISS, and the male gender represented independent risk factors for the development of severe MODS. Regarding the late (> 3 days after trauma) hospital mortality, severe head injury, the ISS, and the patient’s age were independent risk factors. Conclusions: Head injury predominantly determines the incidence of non-infectious systemic inflammation, MOF, and late hospital mortality of patients with severe trauma. Skeletal or abdominal injuries represent relevant risk factors for septic complications. Thus, the incidence of posttraumatic, life-threatening inflammatory complications is related with certain injury patterns in addition to the gender and the severity of trauma.     

The significance of the systemic inflammatory response syndrome (SIRS) in 1278 trauma patients

Summary The association between the increasing severity of systemic inflammatory response syndrome (SIRS) and the incidence of posttraumatic complications and mortality was retrospectively investigated in 1278 injured patients. Patients were divided into three groups according to their Injury Severity Score (ISS) (group A: ISS L 9 K16 points (n = 626); group B: ISS > 16 < 40 points (n = 589); group C: ISS L 40 points (n = 63)). SIRS was defined according to the criteria of the American Consensus Conference. The number of fulfilled criteria determined its severity: moderate SIRS: 2 criteria fulfilled, intermediate SIRS: 3 criteria fulfilled, severe SIRS: 4 criteria fulfilled. Additionally, acute respiratory distress syndrome (ARDS) was defined according to the Murray-Score and the multiple organ dysfunction syndrome (MODS) according to the Goris-Score. The incidence of SIRS was 42 % in group A, 70 % in group B and 100 % in group C (p < 0.05). The severity of SIRS increased with severity of trauma. Moreover, 178 of all injured patients (14 %) developed septic complications. In parallel to SIRS, the incidence of these septic complications correlated with the severity of trauma. The occurrence and severity of ARDS and MODS correlated with increased severity of SIRS and septic complications. Among patients without SIRS 15 % developed ARDS and 21 % MODS. In contrast, patients with severe SIRS and septic complications demonstrated ARDS in 99 % and MODS in 97 %. In these patients, no correlation was found between the ISS and the incidence of ARDS or MODS. There were also stepwise increases in mortality rates in the hierarchy from SIRS to septic shock. While 13 of patients with modest SIRS (5 %) and 32 of patients with intermediate SIRS (13 %) died, the mortality rate of patients with severe SIRS was 19 % (p < 0.05). In addition, a significant correlation between the incidence of septic complications and mortality was found. Injured patients with sepsis died in 13 %, those with severe sepsis in 23 %, and patients with septic shock in 33 % (p < 0.05). Thus, the increasing severity of SIRS was associated with the occurrence of posttraumatic ARDS, MODS, and mortality. Using the number of fulfilled SIRS criteria for classifying systemic inflammation, its severity may be predictive for posttraumatic complications and outcome of injured patients.      

肩胛骨骨折与其合并伤关系的探讨

目的 分析115例肩胛骨骨折病例的临床资料,探讨肩胛骨骨折粉碎程度和涉及部位与合并伤之间的关系.方法 回顾性分析2006年8月至2008年3月115例肩胛骨骨折患者的病史及其影像学资料,分为单部分骨折组(83例)和多部分骨折组(32例),比较两组合并伤的发生率及特点.将单部分肩胛骨骨折组按Nordqvist与Petersson方法分成3组:肌肉覆盖部分(64例)、骨突起部分(11例)及肩胛盂部分(8例),并比较3组合并伤的发生率及特点.结果 绝大部分肩胛骨骨折是严重多发伤的一部分,致伤原因与高能量损伤有关.最常见的致伤原因是车祸伤(70.4%).损伤严重程度评分值(injury severity Scale,ISS)平均14.0,42例(36.5%)患者ISS>16.98例(85.2%)患者伴有不同程度和类型的合并伤,其中又以胸部合并伤的发生率最高(85/115,73.9%).多部分肩胛骨骨折组胸部简明损伤定级法评分值(abbreviated injury score,AIS)和总体ISS值均高于单部分肩胛骨骨折组.在单部分肩胛骨骨折组中,肌肉覆盖部骨折组较骨突起部和肩胛盂部骨折组的胸部AIS值和总体ISS值更高.结论 肩胛骨骨折尤其是骨折涉及多部分或肌肉覆盖部时更容易并发严重的胸部损伤.多部分肩胛骨骨折致伤原因多为高能量损伤,常伴发严重的胸部合并伤,可作为胸部严重损伤存在的一项骨性指标.     

创伤患者血清新喋呤的变化及临床意义

目的探讨创伤后血清新喋呤的变化规律及其临床意义.方法创伤患者41例,根据损伤严重度评分将患者分为3组轻伤组10例,重伤组16例,严重伤组15例.于入院后第1、3、7、14、21天取血测定血清新喋呤含量,并分析新喋呤水平与患者伤情、严重并发症及预后的关系.结果严重伤组新喋呤水平高于轻伤组(P＜0.05或P＜0.01),其均值与损伤严重度评分呈显著正相关(r=0.518,P＜0.05).自伤后第3天起创伤后并发多器官功能障碍综合征(MODS)者新喋呤水平持续升高,其中第3、7、14天与未出现MODS者相比差异有显著性意义(P＜0.05或P＜0.01).同时,严重创伤后死亡组患者新喋呤升高幅度亦明显大于存活组,患者死亡前其血清含量多超过50.0nmol/L(8/12,66.7%).结论创伤应激后体内新喋呤合成、释放增多,动态观察循环新喋呤改变可能有助于评价患者损伤程度、监测MODS病理过程和辅助判断预后等.     

北京市道路交通事故伤特点分析

目的：分析具有北方地区特点的北京市道路交通伤的特点，为相应地区道路交通伤的防治提供参考。方法：资料源于地处北京市中等交通繁华地区的首都军队急救中心，调查其道路交通伤的发生率、伤员性别特点、年龄分布、职业、事故发生时间、交通方式、创伤严重度计分和死亡情况.结果：本组交通伤多发生于7、8月份，发生于2月者较少。男性机动车(包括摩托车)伤员的构成比明显大于女性，女性非机动车伤员的构成比明显大于男性。伤员年龄愈趋于两极(年龄愈大或愈小)，其行人交通事故致伤方式所占比例愈高.伤后早期(7d以内)主要死亡原因是脑疝、原发性脑干损伤和休克，伤后晚期(7d以后)主要死亡原因是感染和多脏器功能障碍综合征。结论：在不同地区或不同人群中，道路交通伤的发生具有不同的特点，应该采取不同的防治措施.     

Correlation between crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study

BACKGROUND: The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis. METHODS: A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed. RESULTS: Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred. CONCLUSION: The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.     

Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury

BACKGROUND: Assessment of injury severity is important in the management of patients with brain trauma. We aimed to analyze the usefulness of the head abbreviated injury score (AIS), the injury severity score (ISS), and the Glasgow Coma Scale (GCS) as measures of injury severity and predictors of outcome after traumatic brain injury (TBI). METHODS: Data were prospectively collected from 410 patients with TBI. AIS, ISS, and GCS were recorded at admission. Subjects' outcomes after TBI were measured using the Glasgow Outcome Scale (GOS-E) at 12 months postinjury. Uni- and multivariate analyses were performed. RESULTS: Outcome information was obtained from 270 patients (66%). ISS was the best predictor of GOS-E (rs = -0.341, p < 0.001), followed by GCS score (rs = 0.227, p < 0.001), and head AIS (rs = -0.222, p < 0.001). When considered in combination, GCS score and ISS modestly improved the correlation with GOS-E (R = 0.335, p < 0.001). The combination of GCS score and head AIS had a similar effect (R = 0.275, p < 0.001). Correlations were stronger from patients 8). CONCLUSIONS: GCS score, AIS, and ISS are weakly correlated with 12-month outcome. However, anatomic measures modestly outperform GCS as predictors of GOS-E. The combination of GCS and AIS/ISS correlate with outcome better than do any of the three measures alone. Results support the addition of anatomic measures such as AIS and ISS in clinical studies of TBI. Additionally, most of the variance in outcome is not accounted for by currently available measures of injury severity.