Polytrauma with thoracic and/or abdominal injuries： experience in 1 540 cases

Objective:To investigate the early diagnosis and treatment of polytrauma patients with thoracic and/or abdominal injuries. Methods: The data of all polytrauma patients with thoracic and/or abdominal injuries during the past 10 years were studied retrospectively. Results: In the present study, there were 1 540 polytrauma patients, accounting for 65.0% of all 2368 trauma patients. Of these patients, 62.4% were in shock state on admission. The operative rates were 15.0% (181/1206) and 79.9% (612/766) in patients with thoracic and abdominal injury (P<0.01), 5.2% (39/758) and 31.7% ( 142/448 ) in patients with blunt and penetrating chest trauma (P<0.01). and 72.4% (359/496) and 93.7 % (253/270) in patients with blunt and penetrating abdominal injuries (P<0.01), respectively. To deal with abdominal injury, angioembolization was performed in 43 cases, with 42 cured. The overall mortality rate was 6.2%. And in the blunt and penetrating subgroups, the mortalities were 7.9% (75/950) and 3.6% (21/590), respectively (P<0.01). Most patients died from exsanguination. Conclusions: The first "golden hour" after trauma should be grasped, since the treatment in this hour can determine greatly whether the critically-injured victim could survive. Prompt diagnosis and proper treatment contribute more greatly to the survival of the victim than the severity of injury.     

Diagnosis and treatment of retroperitoneal hematoma in multiple trauma patients

Summary From 1984 to 1991 20 multiple trauma patients with pelvic fractures and retroperitoneal bleeding from pelvic vessels underwent angiographic localization and embolization of massively bleeding arterial vessels. Nine patients survived (multiple trauma index grade III, Hanover polytrauma index), three patients with very severe injuries died immediately (multiple trauma index grade IV). After successful control of bleeding by embolization, three other patients died from severe brain injuries and five patients from septic multiorgan failure. The interval to definite localization and treatment of the bleeding source was three times shorter in the group of survivors, and the amount of transfusions needed was less by a factor of three. This underlines the importance of early angiography in multiple trauma patients with pelvic fractures and persisting hemorrhage. Embolization has proven to be effective in the treatment of such injuries.     

Clinical study of multiple traumas with severe facial injury undergoing emergency endovascular treatment: significance of emergency embolization of the external carotid artery

The outcome of multiple injures freqently depends on the priority of treatments, and the decision as to the procedures and timing of primary care is extremely important. We studied the patients with multiple trauma whounderwent emergency endovascular treatment for facial hemorrhage related to external carotid arterial injury. The subjects are 5 patients who underwent embolization of the external carotid artery by an endovascular approach among patients with multiple traumas who were brought to our hospital by ambulance. In these patients, the vital signs on arrival, interval between injury and intravascular surgery, type of brain injury, type and grade of concurrent injury and outcome were studied. Three patients showed hemorrhagic shock on arrival, and 1 patient showed hemorrhagic shock immediately after arrival. The mean interval between injury and endovascular surgery was 3.9 hours. All patients had skull base fracture, and abnormal intracranial lesions on initial CT including 4 focal injuries and 1 diffuse injury. Moderate to severe thoracic/abdominal injuries were noted in 3 patients. In the remaining 2 patients, there was no trauma in the thoracic or abdominal regions. Intraperitoneal hemorrhage with splenic injury was observed in 3 patients. In 3 of 4 patients died by hemorrhagic shock because of the delay of endvascular treatments. In trauma patients with persistent hemorrhage, emergency endovascular treatment should be considered as a primary survey for initial treatment without delay under intensive conservative treatment.     

Clinical analysis of craniocerebral trauma complicated wiht thoracoabdominal injuries in 2 165 cases

OBJECTIVE: To explore the optimal treatment for craniocerebral trauma complicated with thoraco-abdominal injuries. METHODS: A total of 2165 cases of craniocerebral trauma complicated with thoraco-abdominal injuries admitted to our hospital between July 1993 and June 2003 were retrospectively studied. Among them, 382 cases sustained severe craniocerebral trauma (in which 167 were complicated with shock), 733 thoracic injuries, 645 abdominal injuries and 787 thoraco-abdominal injuries. On admittance, 294 cases had developed shock. With the prime goal of saving life, respiratory and circulatory systems and encephalothilipsis were especially treated and monitored. Priority in management was directed to severe or open injures rather than to moderate or closed injures. For cases with cerebral hernia due to intracranial hematoma and severe shock due to blood loss, cerebral hernia and shock were treated concurrently. RESULTS: After treatment, 2024 (93.49%) cases survived and the other 141 (6.51%) died. Among patients who had severe craniocerebral injury with shock and those without, 78 (46.71%) and 53 (24.56%) died, respectively. For patients who had underwent craniocerebral and thoraco-abdominal operations concurrently and those who had not, the death rates were 58.49%-65.96% and 28.57% respectively, indicating a significant difference (P<0.05). CONCLUSIONS: Treatment for hematoma hernia, shock and disturbed respiration is the key in the management of multiple trauma of craniocerebral, thoracic or abdominal injuries, especially when two or three conditions occurred simultaneously. Unless it is necessary, operations at two different parts at the same time is not recommended. It is preferred to start two concurrent operations at different time.     

Blunt thoracic aortic injury

Blunt thoracic aortic injury (BAI) is a rare but often fatal injury that occurs with severe polytrauma. Immediate diagnosis and treatment of BAI are essential for a successful outcome. We reviewed our experience with 20 patients with BAI treated at a Level I trauma center between 1995 and 2006. The mean Injury Severity Score was 38 +/- 14 and 14 patients had an abnormal Glasgow Coma Score; associated injuries included abdomen in 13 patients, extremity in 12, and head in six. Chest x-ray (CXR) findings were suggestive of aortic injury in 15 patients, equivocal in three, and showed no evidence of aortic injury in two. Diagnosis was made by CT angiography (CTA) in 17 patients, transesophageal echocardiography (TEE) in two, and formal angiography in one. Sixteen patients underwent operative repair of BAI. Of these, eight also underwent laparotomy, six had operative repair of extremity fractures, and three had pelvic embolization. Five patients died, three of whom were treated nonoperatively, and length of hospitalization in survivors was 32 +/- 20 days. BAI is rare and often associated with multiple life-threatening injuries complicating diagnosis and treatment. Our data support the aggressive use of CTA even when classic CXR findings are not present. When CT must be delayed for abdominal exploration, intraoperative TEE is useful.     

Clinical analysis of craniocerebral trauma complicated with thoracoabdominal injuries in 2165 cases

Ourhospitalhadadmittedandtreated2 16 5casesofcraniocerebraltraumacomplicatedwiththoraco abdomialinjuriesbetweenJuly 1993andJune 2 0 0 3.Aretrospectivestudywascarriedouttoexploretheoptimaltreatmentforcraniocerebraltraumacomplicatedwiththoraco abdominalinjuries.METHODSClinicaldataAtotalof 2 16 5cases (112 5malesand 10 4 0females)ofcraniocerebraltrauma (CCT)complicatedwiththoraco abdomialinjurieswereincludedinthestudy (averageage ,35 .5 years) .Causesofinjuriesweretrafficaccidentin 1384 (6 3…     

Damage control orthopaedics in 53 cases of severe polytrauma who have mainly sustained orthopaedic trauma

Objective： To discuss damage control orthopaedics in 53 cases of severe polytrauma who have mainly sustained orthopaedic trauma. Methods： The data of 53 cases of severe polytrauma who had mainly sustained orthopaedic trauma were retrospectively analyzed. And the methods and timing of damage control orthopaedics were discussed in this study.
Results： We succeeded in rescuing the lives of all the 53 patients, and 38 patients returned to their former work. Conclusions： Injury Severity Score （ISS90） should be 17 in severe polytrauma patients, but in severe polytrauma patients who have mainly sustained orthopaedic trauma, the ISS90 of bone and joint injuries should be 16. We recommend that primary minimallyinvasive external fracture stabilization should be made for extremities and pelvis in these patients to avoid additional surgical trauma and that definitive secondary fracture care should be performed after medical stabilization for these patients in intensive care unit （ICU）.     

Management of pancreatic injuries

This is a retrospective analysis of the treatment of 18 patients with pancreatic injuries at our institution. 13 were victims of blunt abdominal trauma. 17 sustained a polytrauma and had an ISS > 15. They had 2.4 associated intraabdominal and 2.7 associated extraabdominal injuries. The mean pancreatic organ injury scale was II. A partial duodenopancreatectomy was performed in one case. In 5 cases a distal pancreatic resection was necessary. In the remaining patients drainage procedures were applied. 3 additional injured organs had to be treated during the first operation. 2 of them were situated intraabdominally. The primary operative procedure was performed in 13 cases during the first 6 hours after the trauma. 7 patients (39%) died during the hospitalisation. None deceased during an operation. 5 patients (28%) died because of abdominal complications. 4 of 5 patients with injuries to the great vessels died. 12 had abdominal complications. The mean hospitalisation time was 49 days. The mean drainage time was 26 days. The patients sustained parenteral nutrition for 21 days. The priority in the primary operative approach is damage control. This consists of bleeding control, control of enteral spillage, assessment of pancreatic damage, especially recognition of any ductal injury and generous drainage of the injured pancreas. Definitive treatment in the severely injured patient has to be performed after hemodynamic stabilisation without delay by an experienced surgeon.     

Management of pancreatic injuries

This is a retrospective analysis of the treatment of 18 patients with pancreatic injuries at our institution. 13 were victims of blunt abdominal trauma. 17 sustained a polytrauma and had an ISS > 15. They had 2.4 associated intraabdominal and 2.7 associated extraabdominal injuries. The mean pancreatic organ injury scale was II. A partial duodenopancreatectomy was performed in one case. In 5 cases a distal pancreatic resection was necessary. In the remaining patients drainage procedures were applied. 3 additional injured organs had to be treated during the first operation. 2 of them were situated intraabdominally. The primary operative procedure was performed in 13 cases during the first 6 hours after the trauma. 7 patients (39 %) died during the hospitalisation. None deceased during an operation. 5 patients (28 %) died because of abdominal complications. 4 of 5 patients with injuries to the great vessels died. 12 had abdominal complications. The mean hospitalisation time was 49 days. The mean drainage time was 26 days. The patients sustained parenteral nutrition for 21 days. The priority in the primary operative approach is damage control. This consists of bleeding control, control of enteral spillage, assessment of pancreatic damage, especially recognition of any ductal injury and generous drainage of the injured pancreas. Definitive treatment in the severly injured patient has to be performed after hemodynamic stabilisation without delay by an experienced surgeon.     

医源性胆总管远段损伤的临床分析

目的探讨医源性胆总管远段损伤早期诊断及腹膜后严重感染的预防。方法 回顾分析1990年至2004年间处理的17例医源性胆总管远段损伤患者的临床资料。结果 17例患者中,15例为术中损伤,2例为ERCP切开取石所致。术中发现胆管损伤14例,术中未及时发现者1例。胆管损伤前行B超检查16例,MRCP检查2例,6例在胆道探查后行胆道镜检查。10例行胆总管穿孔修补加T管引流,2例行Oddi括约肌切开成形术,2例行胆肠吻合术,1例行十二指肠及胆管修补腹膜后引流术。胆管损伤后术中表现为胆道探子异位于胆管壁外,胆道镜见到胆管远段有2个或多个孔隙,经T管注水见腹膜后水肿和积液,注入美蓝出现腹膜后蓝染。损伤后临床表现为腹胀、发热、腰背胀痛、休克等。治愈13例,术后并发症包括十二指肠瘘1例,切口感染1例,死亡4例,其中3例死于感染性休克,1例死于胃切除术后再出血。结论 胆道远段损伤术后表现缺乏特异性,对可疑患者应作CT检查,早期诊断胆总管下段损伤并进行及时治疗可以取得较好效果。术前完善的影像学检查及在胆道探查前进行胆道镜检查有可能减少胆总管远段损伤。     

胸外伤986例治疗体会

目的总结各类胸外伤的治疗经验. 方法回顾性分析986例胸外伤的受伤类型和治疗情况.闭合性损伤942例 (95.5%), 开放性损伤44例 (4.5%).肋骨骨折最常见, 占784例(79.5%),合并血、气胸330例(33.5%),肺挫裂伤168例(17%);创伤性膈疝24例(2.4%),支气管断裂12例(1.2%);其他166例.伴有多发伤者234例.所有患者均接受相应的手术和非手术固定治疗.结果死亡10例(1.0%),7例为重症胸外伤合并呼吸衰竭,3例为粗木穿透胸部致广泛肺及肺血管撕裂伤;其余患者均痊愈出院. 结论对于不同类型的胸部外伤,迅速解除导致呼吸困难的原因,妥善固定胸壁,减少反常呼吸,必要时行剖胸探查、气管切开高频喷射通气等是治疗成功的关键.     

355例以腹部损伤为主的严重创伤救治分析

【摘要】〓目的〓探讨腹部损伤为主的严重创伤的诊断及救治措施。方法〓对1999年9月~2012年9月救治的355例以腹部损伤为主的严重创伤进行分析总结。结果〓本组急诊腹部手术319例/次,其中103例/次在一次麻醉下分组同台完成了两个以上部位的手术。重症监护病房(ICU)平均住院日28.6±10.8天。临床治愈237例(66.8%),致残78例(22.0%),死亡40例(11.2%)。结论〓病史和体格检查应同抢救治疗同步(如维持呼吸道通畅、止血措施,抗休克等);应积极采用诊断性腹腔穿刺、B超、CT等比较简洁和敏感的快速诊断方法;手术顺序应按受损器官的重要性和损伤的严重程度决定,尽可能在一次麻醉下分组同台处理不同部位的损伤;主动采用损伤控制性外科(DCS)策略,可有效降低死亡率。严重多发伤病人术后均应进入ICU监护和治疗。     

损伤控制手术在以腹部损伤为主的严重胸腹联合伤中的应用

目的：探讨损伤控制手术（DCO）在治疗以腹部损伤为主的严重胸腹联合伤中的应用。方法：回顾性分析2008年3月—2011年6月收治的71例严重胸腹联合伤患者的临床资料,其中,行损伤控制手术41例,另外30例患者行一期确定性手术。结果：损伤控制手术组患者复苏后乳酸水平,pH值,体温,凝血酶原时间（PT）与一期确定性手术组的患者无统计学差异（均P>0.05）。71例患者均治愈后安全出院,但损伤控制手术组患者粘连性肠梗阻、感染的发生率明显低于一期确定性手术组（均P<0.05）。结论：在正确掌握适应证的前提下,损伤控制性手术对于严重胸腹部损伤患者是理想的治疗策略。     

Treatment of abdominal injuries: a report of 522 cases

OBJECTIVE: To make a summary of the experiences in the treatment of abdominal injuries. METHODS: A retrospective study was done on 522 cases of abdominal injuries in our department from January 1986 to December 2004. RESULTS: Of all,382 cases were treated by surgery and 140 by conservative method. Among the surgically treated cases, 347 patients (90.8%) recovered, 35(9.2%) died and 21 had postoperative complications (5.6%). For patients undergoing conservative treatment, 139(99.3%) recovered but one (0.7%) died. CONCLUSIONS: The severity of abdominal injury and delayed treatment are two key factors leading to death. Surgical procedure is still the main method against alternative abdominal injuries. It is necessary to strictly control the indications in conservative treatment.     

Blunt hepatic trauma in children: experience with operative and nonoperative management

Between 1974 and 1982, 32 children were treated for blunt hepatic trauma. Twenty-three injuries were secondary to motor vehicle accidents. Twenty-three patients had associated injuries. The hepatic injury was treated surgically in 18 patients. Urgent surgery for massive bleeding was required in 7 patients; 8 underwent laparotomy for continued bleeding after initial stabilization; 2 underwent laparotomy for marked abdominal tenderness, and 1 for an expanding hepatic hematoma. Various excisional, debridement, suture, and drainage procedures were employed. Seven patients died, 5 from uncontrollable bleeding and 2 from associated severe head injury. The eleven survivors did well. The only postoperative complications were two wound infections. Fourteen patients were managed nonoperatively. Liver scan provided the diagnosis in all. Five of these patients required blood transfusion, and the mean volume of transfusion was 33cc/kg. The hospital courses in all cases were uneventful, and there were no late complications. A follow-up liver scan was obtained in 11 patients, showing resolution of the injury in all. We conclude that laparotomy is necessary for hepatic injury when it is associated with continuous massive bleeding. Hemodynamically stable patients can be managed nonoperatively, even when the blood-transfusion requirements are significant.     

Initial care of the patient with blunt polytrauma

The initial care of the patient with blunt polytrauma involves a systematic search for causes of hemodynamic instability. Bleeding most often occurs in the pleural space, peritoneal cavity, and retroperitoneum. Orthopaedic injuries also can contribute to instability after blunt trauma. Blood loss from open fractures may be substantial, and exposure with direct vessel control should be performed early. Pelvic fractures can be associated with severe retroperitoneal bleeding. The treatment of patients with complex pelvic fractures includes closing the pelvic space with a binding device, and early pelvic angiography with embolization. Care of patients with multiple organ and bone injuries requires coordination by one trauma team leader. This physician oversees the resuscitation and sets treatment priorities, including the type and amount of time allowed for fracture stabilization. In many cases, nonorthopaedic injuries will need to be addressed before definitive fracture care. However, optimal care typically involves a coordinated multispeciality approach that sometimes includes concurrent operative procedures. Patients with severe physiologic derangements may require damage control techniques to decrease blood loss and operative time. Understanding the overall care of patients who are injured critically will facilitate the integration of the orthopaedic surgeon into the trauma team.     

142例闭合性肾损伤的诊治

目的：总结闭合性肾损伤的诊断与治疗，提高肾损伤的诊治效果。方法：回顾性分析142例闭合性肾损伤的诊治资料。结果：142例闭合性肾损伤中，伴有并发伤58例(41％)。其中保守治疗115例，发生并发症5例；超选择性肾动脉栓塞术5例；手术治疗22例。死亡5例，死亡率3．5％。结论：B超和CT检查是诊断肾损伤的有效方法。其治疗主要取决于肾脏伤情，保守治疗是重要的治疗方法。     

电视胸腔镜治疗胸部闭合伤的应用体会

目的:探讨电视胸腔镜诊治胸部闭合伤的疗效。方法:回顾分析胸部闭合伤317例患者的临床资料,根据患者病情选择有应用胸腔镜手术指征的患者行胸腔镜手术。结果:317例患者中313例治愈,死亡4例(1.26%),129例复合伤中应用胸腔镜明确诊断117例(90.7%)。结论:创伤性胸部闭合伤多较严重,重视肺挫伤及处理血气胸至关重要,有选择的应用电视胸腔镜可提高治愈率。     

脊柱骨折合并胸部损伤73例

目的探讨合并胸部损伤的脊柱骨折患者的临床特点。方法73例合并胸部损伤的脊柱骨折患者经对症处理、多发伤及脊柱脊髓损伤患者待生命体征平稳后行手术治疗,对其临床特点进行回顾性分析。结果随访3～24（12±4.2）个月。存活71例,死亡2例。延误胸部损伤诊断4例。相对于颈、腰段脊柱骨折,胸段脊柱骨折更易合并胸部损伤,ISS评分最高。24例患者神经功能有不同程度的改善。结论脊柱骨折合并胸部损伤患者创伤多较重,治疗时应优先以抢救生命措施为主。系统、全面的检查可以减少漏诊的发生。在决定是否早期行脊柱手术时,应充分评估患者的全身情况,权衡手术利弊。     

外伤后非治疗性剖腹探查67例分析

目的　探讨腹部外伤后发生非治疗性剖腹探查 (NTEL)的原因 ,对腹部外伤的早期诊断进行优化。方法　调查 6 7例曾有过NTEL的腹部外伤病人 ,了解其术中损伤病理诊断并分析发生的原因。结果　导致NTEL的主要病因有 :开放性腹部损伤 ;腹壁、网膜或系膜损伤 ,腹膜后血肿 ,肝脾外伤后导致的腹腔积血。结论　术前正确评估腹部外伤病人的脏器损伤能降低NTEL的风险