心脏大血管创伤诊断技术的研究进展

心脏大血管创伤无论在战时或和平时期均不少见，近年来，各项诊断技术的不断发展，极大的提高了急诊诊断率，为抢救治疗赢得时间。本文就此类创伤目前主要诊断技术的研究进展作一综述。     

四肢血管创伤的诊断和治疗进展

四肢血管创伤的诊断和治疗尚存在几个难题。四肢血管伤治疗的发展趋势是深入研究临床表现对治疗的提示意义，使用迅速、低廉、侵入性低的诊断方法，尽快修复严重的血管损伤，积极使用相关技术（如筋膜切开术等）。许多问题亟待进一步研究。     

周围血管损伤的诊断与治疗

周围主干动脉损伤在肢体创伤的救治中最为紧要.诊断主要依靠病史和临床检查.其Ⅰ期和Ⅱ期处理都要遵循一定原则.临床骨科医生应该加强警惕,提高对周围血管损伤的认识和处理水平.     

心脏大血管创伤后晚期后遗症的诊断与处理

目的 报告心脏大血管创伤后晚期后遗症的诊断和处理。方法 收集我科１９５４年６月～１９９９年７月收治的２５例心脏大血管损伤后遗症病例资料,其中穿透伤１０列、闭合伤９例、医源性损伤６例。通过回顾其临床资料及随访结果,研究其诊断、处理方法的特点及预后。结果 ２３例经手术治疗痊愈,１例假性动脉瘤手术时出血死亡,１例因动脉导管结扎后,控制假性动脉瘤感染时,瘤体突然破裂出血死亡。结论 早期诊断、早期或择期手术     

闭合性颈椎创伤伴椎动脉损伤的临床研究

目的　研究椎动脉损伤在闭合性颈椎创伤中的发病率及其与颈椎损伤机制、类型、损伤程度的相关性 ,观察椎动脉损伤后的临床症状、体征 ,探讨早期正确诊断的方法。　方法　于2 0 0 0年 8月～ 2 0 0 2年 2月间 ,利用颈部动脉磁共振血管造影 (MRA)技术 ,连续观察 4 6例闭合性颈椎创伤患者 ,结合颈椎X线、MRI、CT检查及患者的临床症状、体征综合分析。　结果 4 6例闭合性颈椎创伤中 ,12例 (2 6 % )伴椎动脉损伤。其中 7例为双侧损伤 (4例一侧未显影、一侧狭窄 ,3例双侧狭窄 ) ,5例为单侧损伤 (均为一侧狭窄 ) ;10例椎动脉损伤患者无任何症状 ,2例出现眩晕、恶心呕吐、面部麻木、偏盲等症状。椎动脉损伤与屈曲型损伤及颈椎严重不稳定相关 (P <0 .0 5 ) ,与小关节绞锁、横突孔骨折及脊髓完全性损伤明显相关 (P <0 .0 1)。　结论　椎动脉损伤是闭合性颈椎创伤的较常见并发症 ,其临床症状体征缺乏特异性。颈椎创伤中的颈椎严重不稳定、屈曲型损伤、伴有脊髓完全性损伤、小关节绞锁和 (或 )横突孔骨折应高度怀疑椎动脉损伤。临床医师应对此类损伤有较高的警惕性 ,常规进行颈部动脉MRA检查是最有效的早期正确辅助诊断方法。     

三版国际脓毒症诊断标准诊断效能分析

目的 探讨中国单个创伤重症医学科(1CU)中创伤后脓毒症患病率和相关危险因素,并评估1992、2001和2012国际脓毒症定义诊断创伤后脓毒症的效力.方法 对大坪医院创伤ICU中符合入选标准的所有患者进行为期1d的横断面调查.调查数据包括人口学资料,临床特征,相关评分(APACHEⅡ、SOFA、GCS、ISS)和致伤机制.按照1992、2001和2012国际脓毒症指南脓毒症诊断标准中所有指标诊断脓毒症,分为A组、B组和C组,同时记录感染部位,感染病原菌,关键医学处置措施,明确感染证据,并追踪28d死亡发生率.选择痰、血液、伤口引流液(腹部、头颅和四肢)病原菌培养阳性作为诊断感染的确定性指标,计算3个版本的诊断灵敏度和特异度,并评估其诊断效能.结果 共入选30例创伤患者,符合脓毒症诊断的A组23例,B组22例,C组20例,患病率分别为76.7％、73.3％、66.7％,3个诊断标准之间差异无统计学意义.28d死亡4例,均符合3个版本诊断标准,各组28d死亡发生率分别为17.4％、18.2％、25.0％,差异无统计学意义.A组诊断灵敏度为77.8％,特异度为25.0％;B组诊断灵敏度为82.2％,特异度为41.7％;C组诊断灵敏度为72.2％,特异度为41.7％.3个版本诊断效能之间差异无统计学意义.结论 3个版本的诊断标准对于创伤后脓毒症的诊断效能没有差异,1992年标准相对简单,可能更有利于创伤后脓毒症的诊断.     

创伤脓毒症研究领域存在的几个关键问题

脓毒症仍然是导致创伤患者晚期死亡的主要"杀手".创伤后脓毒症研究领域存在的诸多瓶颈问题尚未解决,主要体现在预警研究滞后、预防性干预措施有限及诊断标准不清.笔者着重围绕脓毒症的预警、预防性干预措施及早期诊断标准等三个方面进行分析,指导临床积极应对,以降低创伤后脓毒症所致的晚期病死率,进而提升创伤救治的整体水平.     

闭合性胸部创伤致心脏大血管损伤的诊断与治疗

目的探讨胸部闭合性创伤致心脏大血管损伤的诊断和治疗。方法总结我科1983年9月～2003年9月治疗的12例胸部闭合性创伤致心脏大血管损伤的临床诊治经验。本组心脏损伤7例,大血管损伤5例。结果11例经手术治疗痊愈出院,1例假性动脉瘤术中出血死亡。11例随访均显示良好疗效。结论心脏超声对创伤性心脏损伤的诊断是安全而有效的;MRI、CT可对大血管损伤的诊断及手术方法的选择提供重要资料。对心脏及大血管损伤早期或择期手术可取得良好效果。     

胸部创伤的诊断治疗进展

胸部创伤的诊断治疗进展华西医科大学临床学院心胸外科教授石应康由于全世界各行各业的快速发展及人类涉猎领域与活动的多样性与高节奏性，使得创伤的发生数明显增加。仅以儿童为例，近年来创伤已成为美国１岁以上儿童的首位死亡原因，每年的医疗费高达１５０亿美元［１］...     

腔镜技术在肠道损伤诊治中的应用

合并肠道损伤的腹部创伤患者在早期往往因没有可供明确诊断的临床或影像学征象而延误手术时机,导致死亡率升高。随着腹腔镜技术的发展,其在创伤患者中的应用越来越广泛,但由于担心遗漏肠道损伤,腹腔镜技术在腹部创伤患者中应用相对滞后。本文就腹腔镜技术在腹部创伤并肠道损伤诊治中的应用现状及所存在的问题进行探讨,提出腹部创伤中标准化的腹腔镜探查流程,以提高肠道损伤诊断的准确率。     

正确认识和提高脊柱损伤治疗水平

脊柱损伤在脊柱外科领域中既古老又充满活力。随着各种先进诊断技术的应用和现代脊柱外科技术的快速发展及相关基础研究的深入,目前脊柱损伤的诊治水平已进入了一个全新的时代。在不断提高脊柱脊髓损伤理论认识的基础上,应规范脊柱损伤的院前救治以提高救治效果;利用CT、MRI等先进诊断技术,重新认识对脊柱损伤伤情的判断,并作为治疗方案制定及手术选择的客观依据和标准;脊柱损伤手术治疗方式的选择始终是争论的焦点,但尽可能地减少手术创伤、保留运动功能和降低并发症是手术者们始终不渝的努力方向。近年来快速发展的胸腰椎后路手术技术有成为主流术式的趋势;要充分重视预防与治疗各种并发症及伤员的早期功能康复,特别是深静脉血栓等的防治;规范减压、内固定和植骨三大手术操作技术是降低手术直接并发症的关键。     

诊疗规范能否规避腹部钝性伤救治中的风险

临床实践中,医师如果不遵循规范选择某项诊疗技术,则可能存在局限性,容易造成诊治方案的偏差和不一致性,甚至危及医疗安全。本文阐述诊疗规范的概念,分别介绍了国家政府、行业组织、教材专著和医疗机构等层面各类规范的特点和存在问题。以钝性脾损伤为例,指出遵循规范规避腹部钝性伤诊疗风险的初次评估方法,区分血流动力学稳定和不稳定患者的不同救治流程。提出了对现有规范分门别类,减少重复性,增加权威性;积极宣讲、示范规范,评价其实施效果;并注意区分诊疗规范与精益求精的医疗行为等。     

Extremity CT angiography: application to trauma using 64-MDCT

Evolving multi-row detector computed tomography (MDCT) technology has resulted in increasing utility of CT angiography (CTA) in extremity vascular trauma diagnosis and characterization. Given the widespread availability as well as the ease of acquiring CTA in the trauma setting, CTA is increasingly being used as the initial diagnostic evaluation in extremity vascular trauma, replacing digital subtraction angiography in many institutions. One of the significant advantages of the application of 64-MDCT to extremity vascular trauma is the ability to integrate CTA into routine trauma torso protocols. This ultimately yields an efficient, tailored examination to evaluate the multi-trauma patient in a timely manner, a critical concern in this patient population. Although 64-MDCT offers increasing improvement in image quality, technical quality hinges on strict attention to protocol considerations in its implementation. This review article aims to detail the myriad injuries, which may be detected and characterized with CTA. Protocol considerations in the application of 64-MDCT technology to extremity vascular trauma are discussed, drawing from our experience in an urban, Level I trauma center. Finally, the advantages and techniques of integrating extremity CTA into torso trauma protocols will be described.     

腹部钝性创伤中肠道及肠系膜损伤的CT表现

肠道及肠系膜损伤在腹部钝性伤中的发生率较高且易出现诊断延迟或漏诊。多层X线计算机断层成像具有较高的空间、时间和对比度分辨率,提高了肠道及肠系膜损伤诊断率。可显示腹腔内脏器损伤的直接和间接影像,指导非手术治疗或手术治疗的选择和效果评估。本文就肠道及肠系膜损伤在CT中特异性和非特异性征象作一论述。     

简明损伤定级/损伤严重度评分的研究进展与误用解析

创伤评分、创伤登记和创伤数据库建设是创伤中心质量改进的基石.简明损伤定级(AIS)/损伤严重度评分(ISS)自2008年起被各国用作创伤中心评审的依据,现已发展为全球公认的创伤评分系统.笔者介绍自1971年以来发布的9个版本AIS中代码数量和分值设定的变化,以及近年来AIS/ISS评分体系的应用效果,并结合临床多发伤患...     

Imaging colorectal trauma using 64-MDCT technology

Computed tomography has evolved to become the principal imaging modality in the evaluation of colorectal trauma. Direct signs of colorectal trauma are usually highly specific but relatively insensitive and, therefore, indirect signs are important in the diagnostic of colorectal injuries. In addition, prompt recognition of colorectal injury is crucial as even short delays in its diagnosis have been shown to significantly increase both morbidity and mortality. All these things make colorectal injury a challenge for radiologists. The purpose of this review is to describe and analyze the various computed tomography (CT) findings of colorectal injuries in both penetrating and blunt trauma using 64-multirow detector computed tomography technology, based on our experience in a level I trauma center. Additionally, the CT protocol methods specific to colorectal injuries are detailed.     

Multi-detector row computed tomography and blunt chest trauma

Blunt chest trauma is a significant source of morbidity and mortality in industrialized countries. The clinical presentation of trauma patients varies widely from one individual to another and ranges from minor reports of pain to shock. Knowledge of the mechanism of injury, the time of injury, estimates of motor vehicle accident velocity and deceleration, and evidence of associated injury to other systems are all salient features to provide for an adequate assessment of chest trauma. Multi-detector row computed tomography (MDCT) scanning and MDCT-angiography are being used more frequently in the diagnosis of patients with chest trauma. The high sensitivity of MDCT has increased the recognized spectrum of injuries. This new technology can be regarded as an extremely valuable adjunct to physical examination to recognize suspected and unsuspected blunt chest trauma.     

Unexpected findings and misdiagnoses in coroner’s autopsies performed for trauma at the University of the West Indies,Kingston, Jamaica

There has been significant improvement in medical diagnostic technology, but discrepancy rates between clinical and postmortem diagnoses remain relatively high. This study aimed to identify misdiagnoses and missed (unexpected) findings documented during complete coroner’s autopsies performed for trauma at the University of the West Indies (UWI) and evaluate their influence on patient outcome. We retrospectively reviewed the reports of all coroner’s autopsies performed for trauma, between 2003 and 2012, at the UWI. For each case, we extracted age, gender, trauma type, mechanism and topography, clinical and postmortem diagnoses and hospitalization duration. The data were used to calculate frequencies, proportions and discrepancy rates. 955 coroner’s autopsies were performed during the 10-year period; reports were available for 933. 396 of these were performed for trauma; 365 met the inclusion criteria. 260 (71.2%) of the 365 autopsies had at least one discrepancy. There were 746 clinical and 1118 autopsy diagnoses; 382 were discrepant (372 missed [unexpected] diagnoses, 6 mis-diagnoses and 4 over-diagnoses). The discrepancy rate (misdiagnoses and missed diagnoses) was 33.8%, and the majority (55%) occurred in patients hospitalized for <1 day. Cardiopulmonary diseases were the most commonly missed diagnoses. The discrepancy rate was intermediate to those previously reported in the literature. The short hospitalization duration in most patients suggests that limited time for clinical investigation may be a contributor to discrepancy. However, increased awareness among clinicians of the common major missed diagnoses should enhance their early diagnosis, even when clinical signs are subtle, hopefully producing improved patient outcome.     

MDCT diagnosis of penetrating diaphragm injury

The purpose of the study was to determine the diagnostic sensitivity and specificity of multidetector CT (MDCT) in detection of diaphragmatic injury following penetrating trauma. Chest and abdominal CT examinations performed preoperatively in 136 patients after penetrating trauma to the torso with injury trajectory in close proximity to the diaphragm were reviewed by radiologists unaware of surgical findings. Signs associated with diaphragmatic injuries in penetrating trauma were noted. These signs were correlated with surgical diagnoses, and their sensitivity and specificity in assisting the diagnosis were calculated. CT confirmed diaphragmatic injury in 41 of 47 injuries (sensitivity, 87.2%), and an intact diaphragm in 71 of 98 patients (specificity, 72.4%). The overall accuracy of MDCT was 77%. The most accurate sign helping the diagnosis was contiguous injury on either side of the diaphragm in single-entry penetrating trauma (sensitivity, 88%; specificity, 82%). Thus MDCT has high sensitivity and good specificity in detecting penetrating diaphragmatic injuries.