移动监护与急救手术前移在严重胸部创伤急救中的应用

目的 探讨将确定性急救与手术处理前移至基层医院的可行性,以进一步提高危重胸部创伤的救治成功率. 方法 对1998年4月-2008年8月应"120"急救邀请,赴我市基层医院进行院前院内紧急救治的72例严重胸部创伤(AIS≥3)患者的资料进行回顾性分析.分为院前组(院前紧急确定性急救或手术后转回我院)36例和院内组(经院前确定性急救后转回我院手术)36例. 结果 (1)伤后到基层医院时间两组间差异无统计学意义(P>0.05),获确切手术时间院前组显著短于院内组[(3.9±4.1)h比(9.6±8.2)h](P<0.05).(2)院前组失血量、输血量均大于院内组,但差异无统计学意义(P>0.05).(3)ISS值两组差异无统计学意义(P>0.05),RTS值院前组显著低于院内组(P<0.05);院前组总休克发生率显著多于院内组(86.1%比41.7%)(P<0.05).(4)术式:单纯胸腔闭式引流院前组多于院内组(16.7%比5.6%),"胸腔闭式引流+剖胸术"、"胸腔闭式引流+剖腹术"、"胸腔闭式引流+其他"两组间差异无统计学意义,院前组穿透伤"胸腔闭式引流+剖胸术"率是钝性伤的4.8倍,院内组为1.9倍;院前组钝性伤"胸腔闭式引流+剖腹术"率是穿透伤的5倍,院内组为4.5倍.(5)总治愈率95.8%(69/72),院前组中濒死患者8例,生存5例,13.9%(5/36)的院前创伤死亡得以避免. 结论 在伤后"黄金时刻"迅速携带移动监护手术设备,将救命性外科处理前伸至基层医院实施急救或确定性手术后,再安全转送到高级急救中心(医院)进一步救治是安全、有效、可行的,可显著降低严重胸部创伤的院前死亡率.     

创伤性膈肌破裂的诊断与治疗

目的 探讨创伤性膈肌破裂的早期诊断和治疗.方法 回顾性分析我科17年间收治的161例创伤性膈肌破裂患者的临床资料,包括诊断方法、术前确诊率、膈疝发生率、手术治疗方式和患者结局等.结果 161例中男139例,女22例;年龄9～84岁,平均32.4岁.ISS 13～66分,平均27.8;65.2%入院时有休克.钝性伤36例、穿透伤125例.术前膈肌损伤确诊率在钝性和穿透伤分别为88.9%和78.4%.膈疝发生率在钝性和穿透伤分别为94.4%和14.4%(P＜0.01).手术经胸30例,经腹106例,分别剖胸和剖腹18例、胸腹联合切口7例.病死率10.6%,ISS平均41.6;主要死因为失血性休克和严重感染并发症.钝性和穿透伤病死率分别为22.2%和7.2%(P＜0.01).结论 膈伤诊断依据,钝性伤主要为膈疝的影像学表现,穿透伤伤口远处腹或胸部也有阳性体征或影像学征象.膈疝手术的关键是准确判断疝入胃肠的活力.穿透伤预后相对较好.     

高海拔地区胸部锐器伤89例诊治分析

目的：探讨高海拔地区胸部锐器伤的诊断和治疗方法。方法：对89例胸部锐器伤的临床特点和诊治方法进行分析和总结。结果：本组剖胸探查手术56例，清创缝合、胸腔闭式引流、胸腔穿刺保守治疗33例。治愈85例，自动出院3例，转科治疗1例。结论：高海拔地区由于慢性缺氧，肺功能有不同程度的损害，胸部损伤产生血气胸后缺氧症状明显加重。对有明显血气胸和疑有心脏、大血管损伤、腹腔脏器损伤应迅速行剖胸探查手术。     

钝性胸部伤早期救治中64排螺旋CT的应用

目的 探讨64排螺旋CT在钝性胸部伤早期救治中的作用.方法 回顾性分析2006年1月以来收治的170例钝性胸部伤,单纯胸部伤74例,多发伤96例,胸部伤AIS 2～4分,平均3.2分;多发伤 ISS 11～34分,平均24.6分.其中到院后3小时内64排螺旋CT检查160例,平均8分钟.结果 诊断肺挫伤117例,肺挫裂伤及肺内血肿19例,肺不张24例,血胸67例,气胸45例,血气胸52例,纵隔血肿7例,纵隔积气8例,皮下气肿25例,膈疝17例,肋骨骨折103 例,连枷胸34例.143例(84.1%)经非手术处理,其中43例行胸腔闭式引流术,22例行机械呼吸支持.紧急剖胸手术27例(15.9%).治愈161例,死亡9例(5.3%).结论 胸部钝性伤初次评价在有条件时应首选采用64排螺旋CT扫描.     

胸部刀刃穿透伤112例临床分析

目的 总结胸部刀刃穿透伤临床特点、诊断及处理的临床经验。方法 对1995～1999年我科收治的112例胸部刀刃穿透伤临床诊治情况进行分析。结果 早期明确诊断109例,漏诊3例。闭式引流98例、胸穿19例,手术治疗52例,其中开胸27例、开腹25例。治愈105例,死亡5例。结论（1）胸部刀刃穿透伤合并伤多、伤情重、变化快、休克发生率高;（2）迟发性血气我、膈肌破裂、腰背部伤早期易漏诊;（3）刀刃所致的胸腹联合伤,漏诊或手术处理不当易发生胸腔感染;（4）手术率高,早期救治得当预后好。     

胸部穿透伤伴异物存留诊治分析

目的总结胸部穿透伤伴异物存留的救治经验,进一步提高诊治水平。方法笔者回顾性分析1997年1月~2015年5月收治的胸部穿透伤伴异物存留28例患者的临床资料,其中男性24例,女性4例;年龄15~64岁,平均43.5岁。受伤至入院时间20min~37h,平均52.4min。结果本组28例患者均急诊行剖胸探查及异物取出术,剖胸手术入路选择前外侧切口14例(50.00%),后外侧切口7例(25.00%),锁骨及第1、2肋切断3例(10.72%),胸骨正中切口2例(7.14%),胸腹联合切口2例(7.14%);脏器损伤51例次,其中肺裂伤22例次(43.14%),心脏大血管伤5例次(9.80%),肋间动脉伤5例次(9.80%),脊柱及纵隔伤4例次(7.84%),膈肌伤8例次(15.69%),胸导管1例次(1.96%),腹腔脏器伤6例次(11.77%)。对损伤脏器均行一期确定性手术,包括肺裂伤切开深部止血后缝合、心脏大血管修补缝合、肋间动脉缝扎止血、纵隔血肿清除、膈肌修补、胸导管结扎以及肝脏、胃修补和脾切除。27例(96.43%)异物完全取出,1例(3.57%)部分异物残留,死亡2例(7.14%)。结论术前恰当的生命支持、术中针对性选择切口、明确人员分工、合理的手术操作是治疗胸部穿透伤伴异物存留成功的关键。     

损害控制在严重胸部创伤救治中的应用

目的探讨损害控制在严重胸部创伤救治中的应用。方法对我科2007年7月-2008年6月救治的62例严重胸部创伤（AIS≥3）病例资料进行回顾性分析。结果（1）全组死亡率为1．6％（1／62）,手术组无死亡病例。（2）穿透伤单纯胸腔闭式引流术比例（55．6％,10／18）高于钝性伤（36．4％,16／44）（P=0．165）。穿透伤剖胸探查手术率为27．8％（5／18）高于钝性伤15．9％（7／44）（P=0．283）。连枷胸肋骨骨折内固定术占闭合性胸伤的11．4％（5／44）。（3）钝性伤并发症的发生率（63．6％,28／44）显著高于穿透伤（27．8％,5／18）（P=0．010）。老年患者更容易并发肺部并发症。结论初期尽快的确定性急救处理和简化手术修复是损害控制外科技术在严重胸部创伤救治中的基本策略。后期积极的生理复苏与并发症处理是提高严重胸伤救治成功率的关键。     

胸部开放性损伤102例治疗体会

本文报告了 10 2例胸部开放性损伤的治疗 ,认为对胸部开放性损伤造成的胸腔内出血及脏器损伤应有充分的认识 ,积极进行抗休克处理 ,尽早放置胸腔闭式引流 ,必要时行剖胸手术 ,并对其伤情判断、剖胸手术指征、手术时机及合并伤的处理等进行了分析讨论     

手术治疗胸部贯通伤临床回顾(附50例分析)

目的:探讨胸部贯通伤的临床诊断及救治措施.方法:对本院2003 -01～2011 - 10收治的50例胸部贯通伤患者,根据受伤原因、症状、体征、辅助检查诊断,分别给予胸带固定胸壁,胸腔闭式引流或开胸探查,复合伤给予相应处理.结果:50例病人治愈46例,死亡4例,死亡率为8％.结论:胸部外伤多呈重症、急症、危症.能否迅速正确给予检查、诊断及处理是治疗的关键.     

50例外伤性迟发性血胸的诊治

回顾分析我院收治的50例胸外伤迟发性血胸的发生原因及诊治经过。认为胸部创伤易并发迟发性血胸，胸腔闭式引流是安全可靠的治疗方法，电视胸腔镜手术可以替代大多数剖胸探查术。     

胸部穿透伤救治中常见失误及预防

目的 探讨和指出胸部穿透伤救治中的失误、难点,危险因素,并发症及防范措施。方法 回顾总结的胸部穿透伤３１８例,重点分析诊治错误和并发症。结果 胸腔伤的物理和Ｘ线漏误诊率为１１．１％（３５／３１６）,但致使误治率仅为４．１％（１３／３１６）,２４例心脏大血管损伤初期漏误诊５例。２８例膈肌损伤早期漏诊９例。２６７例次有腔闭式引流操作失误１１例次（４．１％）。发生需剖胸处理的并发症１７例。全组治愈３０８     

Penetrating injuries of the thoracic aorta and brachiocephalic arteries: angiographic findings in 18 cases

Eighteen patients with surgically proved penetrating injuries to the thoracic aorta or brachiocephalic arteries were evaluated preoperatively with angiography. Fifteen injuries resulted from direct penetration of a vessel and three were concussion or blast injuries. Arteriography correctly showed vessel damage in 16 (89%), although one was identified only in retrospect. There were two false-negative examinations. False aneurysms were present in nine. Other findings included occlusion, wall irregularity, and an arterial-arterial fistula. Our results show that angiography is an accurate means of detecting penetrating injuries to the thoracic aorta or brachiocephalic arteries.     

心脏创伤22例的诊断和处理

报告２２例心脏损伤，其中穿入性１１例，医源性６例，闭合性５例。１６例行急诊手术，包括缝合心脏裂口，清除心肌异物，闭式二尖瓣分离，清除心包腔心块。择期和Ⅱ期手术７例，其中二尖瓣替换术３例，三尖瓣替换术２例，主动脉瓣成形术１例，心室间隔缺损缝补术１例，诊断主要依据为：大量失血、心脏压塞，心脏杂音及心包穿刺结果。条件允许时可行超声心动图和床旁摄片检查。２２例均经手术治疗，２１例痊愈出院，死亡１例，死亡率     

92例胸腹联合伤临床分析

目的 探讨胸腹联合伤的诊断及治疗特点。方法 总结经手术证实的胸腹联合伤92例，其中开放性损伤41例(44．57％)，以锐器刺伤为主；闭合性损伤51例(55．43％)，以交通伤多见。分析不同原因的损伤类别及不同临床症状与手术方式。结果 92例中，术前明确有膈肌破裂42例(45．65％)；88例在第一次手术中发现膈肌破裂，并予以修补(95．65％)，4例未探查膈肌而漏诊(4．35％)；死亡13例(14．13％)。结论 胸腹联合伤是一种特殊类型的损伤，伤情复杂、严重，死亡率高。诊断应根据受伤机制和出血量判断，特别注意避免漏诊膈肌损伤。治疗原则为先处理胸部损伤，后处理腹内脏器损伤。     

Endophthalmitis in war and peace penetrating eye injuries

BACKGROUND/AIM: Nowadays, eye injuries are a leading cause of one-eye disease or blindness worldwide. The aim of this study was to comparatively analyze the frequency of endophthalmitis following war and peace eye injuries. METHODS: All the patients went throught the detailed ophthalmologic examinations, prophylactic antibiotic treatment, and pars plana vitrectomies (VPP), or other required surgical interventions. RESULTS: Inside the period from 1991 to 1998, 647 patients with eye injuries were hospitalized, out of which 500 with penetrating eye injuries. In the period 1999-2004, 611 patients with eye injuries, were treated, out of which 297 had penetrating eye injuries. Out of 500 patients with war penetrating eye injuries, in 286 of the cases intrabulbar foreign bodies (IFB) were detected. The signs of endophthalmitis were observed in 26 eyes (5.2%) at admission. Out of totally 297 peace penetrating eye injuries, 196 (66%) were IBF. In 25 eyes (8.4%) endophthalmitis was observed. CONCLUSION: In our study, the frequency of posttraumatic endophthalmitis following penetrating war eye injuries was relatively low, even lower than the frequency of endophthalmitis following peace eye injuries.     

96例严重胸腹部血管损伤的早期救治分析

目的探讨严重胸腹部血管损伤的早期诊治方法。方法2000年1月～2008年10月收治严重胸腹部血管损伤96例,其中26例到达急救部时表现明显失血性休克,经胸或腹腔穿刺抽出较多不凝血,立即送手术室紧急手术确诊;45例经64排螺旋CT及血管造影（CTA）检查确诊;25例经数字减影血管造影检查确诊。58例行手术治疗,其中45例行血管损伤缝合修补,手术前12例行血管造影后球囊血管阻断;13例行人造血管吻合,其中3例因伤情太重而行损害控制,即严重破损血管临时插管分流,患者术后在ICU复苏待全身情况改善后于术后48小时内再行血管吻合手术。38例（盆腔腹膜后血管损伤34例,其他4例）行动脉栓塞治疗。结果85例救治成功,救治成功率85．5％。发生严重并发症38例,其中脓毒症6例,急性呼吸窘迫综合征（ARDS）9例,多器官功能障碍综合征（MODS）23例。11例死亡,其中9例于伤后12小时内死亡,主要原因为多脏器严重损伤及失血性休克;2例于创伤后8天及16天死亡,主要原因为脓毒症及MODS。结论胸腹部血管损伤后应快速完成检查及诊断,紧急手术行血管修复或吻合,部分腹部血管损伤及盆骨折引起的腹膜后血管损伤可用动脉栓塞治疗。     

46例钝性与穿透性膈肌损伤的临床比较研究

目的　分析比较钝性与穿透性膈肌损伤的临床特点和伤情,以指导创伤的救治。　方法　46例胸外伤合并膈肌破裂病人分为穿透伤组和钝性伤组,比较两组的损伤情况,并应用创伤评分系统进行创伤严重度评估。　结果　钝性胸外伤造成膈肌破裂的发生率低,复杂,常合并全身多发伤,但伤情进展相对较慢;穿透性胸外伤造成膈肌破裂的发生率高,伤情进展迅速,早期易出现失血性休克。比较损伤严重度评分(ISS)、修正创伤评分(RTS)和胸部简明损伤定级(AIS),两组间差异无统计学意义（P>0.05）,但钝性伤组入院时格拉斯哥昏迷指数(GCS)和腹部AIS较低,分别为12.69±2.69,1.62±1.66（P<0.05）。　结论　针对钝性与穿透性膈肌损伤的不同临床特点,应采取相应的治疗措施,减少并发症,改善预后。     

道路交通事故致胸部损伤813例救治体会

目的 总结道路交通事故致胸部损伤的救治经验.方法 回顾分析2002年1月～2009年12月收治的道路交通事故致胸部损伤(AIS≥3分)病例813例的临床资料.结果 本组伤员中汽车驾驶员239例,行人308例,乘员132例,摩托车驾驶员129例,骑自行车人5 例.其中心脏损伤182例(22.4%),连枷胸171例(21%...     

Surgery of eye injuries in an eight-year period

BACKGROUND: Eye injuries constitute a leading problem in eye surgery worldwide, as well as at our department. Their treatment is very complex, and requires a wide surgical knowledge and surgical skills supported by the material and the equipment. AIM: To analyze the results of vitreoretinal surgery on 647 patients with severe penetrating eye injuries in the period from 1991 to 1998. METHODS: The study included a retrospective analysis of the treatment of 647 injuries, out of which 500 were penetrating, and 147 were severe contusion injuries. Attention was payed to the penetrating injuries with intraocular foreign body (IOFB), to the number of the performed pars plana vitrectomies (VPP), to the number of the extirpated foreign bodies, as well as to the number of the conventional retinal ablation surgeries. Also significant proved the consequences of contusion injuries, and the method of their complete surgical management--the surgery combined with the implantation of intraocular lens, as well as their functional results. RESULTS: Inside the said period, 558 VPPs were performed, 60 conventional retinal ablation surgeries, and 29 combined anterior/posterior segment surgeries. VPP was applied in 286 (51.3%) of the cases with penetrating injuries with IOFB, and in 58 (10.4%) of the cases with contusion injuries. VPP in one eye was applied in 464 (83%) of the cases, in both eyes in 65 (11.8%) of the cases, and in a single eye in 29 (5.2%) of the cases. Following VPP, silicone oil tamponade was done in 352 (63%) of the cases, air tamponade in 123 (22%) of the cases, and Ringer-BSS tamponade in 83 (15%) of the cases. Laser photocoagulation (LFC) was performed in 484 (87%) of the cases, cryocoagulation in 45 (8%), while neither of them was done in 29 (5%) of the cases. In all of the cases of the conventional retinal ablation (n = 60), a placement of a serclage was applied and exocryocoagulation was performed, while in the 52 cases a placement of a scleral flap was applied. Combined surgery--lensectomy, VPP, and an anterior chamber intraocular lens (AC IOL), was applied in 16 of the cases, and phacoemulsification, VPP and a posterior chamber intraocular lens (PC IOL) in 13 of the cases. CONCLUSION: Vitrectomy was the most frequently applied surgery in solving the complex eye injuries. The eye injuries treated in our department were with the IOFB, and the retinal ablation. The IOFBs in our patients were almost completely extirpated. The applied combined anterior/posterior segment surgeries had the potential to safely and successfully condense those separate procedures in one surgery. A relatively high incidence of endophthalmitis was recorded in the injuries treated in our department.