城市医院急诊中严重创伤的救治探讨

目的　对我院急诊外科 2 0 0 3- 0 2～ 2 0 0 4 - 0 1收治的严重创伤病例进行回顾性分析 ,以期对城市中常见创伤的急救提出建设性意见。方法　从急诊危重病例中筛选出急需抢救的严重创伤 14 3例进行分析。结果　男性 10 8例 ,女性 35例 ,男 :女为 3.0 9:1;年龄平均 34.2岁 (9～ 73岁 ) ;创伤评分 (TS)平均 13.5± 3.8分 ;格拉斯哥昏迷评分 (GCS)平均 12 .3± 3.7分 ;创伤严重程度评分 (ISS)平均 19.6± 12 .5分 ,多发伤 6 2例 (4 3.4 % )。病因 :交通伤 83例 (5 8% ) ,械斗、工伤 4 3例 (30 % ) ,坠落伤 17例(12 % )。休克 112例 ,脱险率 92 % ,抢救成功率 83.9%。实施确定性抢救手术 116例。急诊滞留时间 :抢救脱险组 5 6± 2 3min ,死亡组 10 9± 4 3min ,两组差异非常显著 (P <0 .0 1)。结论　交通伤、械斗、工伤、坠落伤是城市中严重创伤的主要原因 ;观念上要重视“黄金 1h”、“白金 10min” ,缩短急诊滞留时间 ;早期实施确定性抢救手术 ,可以有效地提高严重创伤的抢救效果。     

多发性骨关节损伤患者346例损伤特点分析

目的：分析多发性骨、关节损伤的特点。方法：收集广州地区南方医院、珠江医院、解放军广州军区总医院、解放军第157医院、解放军海军421医院等5所部队医院创伤骨科2003年收治的多发性骨关节损伤患者的临床资料，通过计算机系统初步检索后，调阅所有病历进行分析、总结，归纳出多发性骨关节损伤特点。结果：①上述医院2003年全年创伤骨科共收治创伤住院患者3046例，其中符合多发性骨关节损伤诊断标准的患者346例，占所有患者的11．4％，男女比例为4：1，平均年龄（32．8&;#177;14．8）岁。②致伤原因依次为交通伤65-3％、重物压砸伤18．8％、坠落伤15．0％，其他0．8％。③平均住院时间（35．0&;#177;7．0）d，费用（27596．8&;#177;2524．8）元。④全身多处均可致伤，但以下肢最多见，胫腓骨及股骨为最主要的损伤部位，2处骨折69．9％．2处以上骨折31．1％。⑤并发症以休克为主（22．6％），合并损伤以颅脑和胸部损伤最常见（14．7％，6．6％）。结论：多发性骨关节损伤危害严重，青壮年男性为主要受害人群，交通伤为最常见的受伤原因，工业事故所致多发骨关节损伤所占比例也较大，并发症及合并伤多。     

城市创伤失血性休克的急诊救治——附263例分析

目的 对急救部1992年2月－2001年9月收治的中等严重度以上的创伤病人进行回顾性研究，对伤情、急诊科处理与预后的相关性进行分析，为城市创伤失血性休克急诊救治提出建设性意见。方法 从中等严重度以上急诊抢救病例中随机抽取出创伤性与失血性休克263例（抽取率30％）的急诊抢救病例进行统计分析。结果 伤员构成：男210例，女53例，男：女比例为3．96：1；平均年龄35．92岁（4－79岁）；ISS评分平均23分（见表2）。其中创伤性休克206例（78．33％）、失血性休克57例（21．67％）；以20－29岁和30－39岁两个年龄段最突出，占病例总数52．85％；伤因以机械伤所占的比例为67．3％；其中以交通伤、坠落伤、刀伤为主，分别占物理损伤的25．2％和21．1％。烧烫伤及火器伤因素占创伤的比例分别为15．97％和16．73％。交通致急诊死亡数最多。创伤部位以四肢、头、胸、腹为前四位排序。结论 通过对数据的统计分析，可知伤情与预后呈负相关，急诊科处理与预后呈正机关。建立健全的急诊抢救机制以及有效的抢救预案，可以有效地提高城市创伤失血性休克的抢救效果。     

右心房起搏术与双心腔起搏术在病态窦房结综合征患者中的疗效比较

目的：观察右心房起搏术（AAI）与双心腔起搏术（DDD）在病态窦房结综合征（SSS）患者中的疗效。方法：74例患者分为AAI组（共36例，其中男性14例，女性22例；平均66．8&#177;7．9岁）和DDD组（3共8例，其中男性16例，女性22例；平均65．8&#177;9．7岁），回顾分析比较两组心功能变化、房颤、房室传导阻滞和缺血性脑卒中的发生率。结果：心动超声心功能测定，术前和随访结果比较：左室射血分数（LVEF）AAI组从（55．8&#177;3．1％）上升至（56．5&#177;2．4％）（P〉0．05）。DDD组LVEF从（55．5&#177;2．8％下）降至（54．7&#177;2．8％）（P〉0．05）。比较两组患者在心功能、房颤、房室传导阻滞和脑卒中的发生率均无统计学差异。结论：对房室传导功能正常的SSS患者，与DDD比较，安装AAI起搏器不仅手术方法简单、疗效确切、并发症少，而且价廉。     

血清肿瘤坏死因子α及白细胞介素6水平对下肢严重创伤病情变化的预测价值

目的：分析下肢严重创伤患者血清肿瘤坏死因子α、白细胞介素6水平变化对病情发展的预测价值。 方法：选择2000-01／2003-12广州市第一人民医院骨科收治下肢严重创伤患者36例，按下肢创伤严重度评分为（6．24&;#177;1．45）分，下肢创伤严重度评分〈7分29例，≥7分7例。根据感染发生与否把患者分为感染组15例和非感染组21例。正常对照组20例，为同期健康体检者。在伤后6h及入院后1，3，5，7，10，14，21d分别采集静脉血标本，应用酶联免疫吸附法测定血清肿瘤坏死因子α和白细胞介素6水平变化。 结果：纳入患者36例和正常对照20例，均进入结果分析。感染组和非感染组患者肿瘤坏死因子α、白细胞介素6血清浓度与正常对照组比较均显著增高；伤后早期并发感染前，感染组患者血清肿瘤坏死因子α与非感染组相比无明显差异；并发感染后，感染组患者血清白细胞介素6在伤后6h，1，3，5，7，10，14，21d，肿瘤坏死因子α在伤后3，5，7，10，14d明显升高[感染组白细胞介素6在伤后6h，1，3，5，7，10，14，21d分别为（194．93&;#177;23．55），（372．24&;#177;130．04），（520.65&;#177;136．21），（437．85&;#177;115．11）．（380．21&;#177;81．22）。（338．62&;#177;8．37），（230．41&;#177;51．39），（126．71&;#177;20．59）μg／L，非感染组白细胞介素6分别为（56．57&;#177;7．64），（227．15&;#177;7．21），（349．78&;#177;85．13），（201．85&;#177;73．60），（188．20&;#177;96．13），（132．07&;#177;7．42），（74．24&;#177;11．13），（22．12&;#177;6．21）μg／L，P〈0．05；感染组肿瘤坏死因子α在伤后3，5，7，10，14d分别为（1.58&;#177;0.11），（1．47&;#177;0．07），（1.39&;#177;0.23），（1．38&;#177;0．06），（1．15&;#177;0.22）μg／L，非感染组肿瘤坏死因子α分别为（0．93&;#177;0．07），（0.91&;#177;0．05），（0．82&;#177;0.21），（0．81&;#177;0．28），（0．76&;#177;0.13）μg／，L，P〈0．05]。 结论：动态检测下肢严重创伤患者外周血血清肿瘤坏死因子α和白细胞介素6的水平变化可有助于病情的评估，而动态检测下肢严重创伤患者外周血白细胞介素6的水平变化更有助于预测伤后感染并发症的发生。     

急性心肌梗死患者经桡动脉途径行急诊PCI疗效观察

目的探讨急性心肌梗死（AMI）患者经桡动脉途径行急诊经皮冠状动脉介入（PCI）的近期疗效。方法回顾性分析53例AMI患者发病12h内经桡动脉途径行急诊PCI治疗的临床资料。结果本组AMI患者血管穿刺时间（3．8&#177;0．9）min,手术穿刺成功率98,1％,麻醉到球囊扩张时间（28．7&#177;6．0）min,术中置入药物支架（1．3&#177;0．5）枚,病变血管前向血流100％达TIMIⅢ级。术中6例发生低血压,4例发生室颤／室速。成功率94．3％,平均住院（8．4&#177;2．6）d。随访3个月无不良心脏事件,心脏彩超显示射血分数、左室收缩末径和左室舒张末径与出院前比较无明显差异。结论AMI患者经桡动脉行急诊PCI安全可行,效果肯定。     

台州市急诊创伤患者临床特点与流行病学分析

目的：探讨浙江省台州地区急诊创伤患者的临床特点与流行病学，为提高该地区创伤的防范与急救提供科学的依据。方法对2010－03～2014－10台州市博爱医院、台州市立医院及中心医院急诊收治的278例急诊创伤患者的性别、年龄、职业、受伤时间、创伤原因、创伤部位、ISS分值、创伤严重程度、死亡原因等资料进行回顾性分析。结果在278例急诊创伤患者中，男性占68．35％；21～50岁的中青年占75．90％；农民工是创伤的主要群体，占45.32％；7～10月伤员占67．27％，其中7：00～8：59、11：30～13：59、18：00～19：59为创伤发生的高峰时段；交通伤占创伤原因的35．97％，高处坠落占25．18％，台风伤占19．06％；创伤部位以四肢／骨盆为主，占38．13％；ISS评分为（10．78±2．79）分，重症伤员占35．72％，死亡组ISS评分（22．81±7．52）分；死亡原因以头颈部创伤为主，占35．29％。结论台州地区急诊创伤患者以中青年男性农民工为主，主要致伤、致死因素为交通伤、高处坠落伤及台风伤，集中在7～10月，创伤部位以四肢／骨盆为主，但头颈部外伤为主要死因，且死亡病例ISS评分相对较高，故需要多方面加强宣传预防及提高临床救治能力。     

重型颅脑损伤102例院前急救及护理

目的：探讨重型颅脑损伤患者的院前急救措施及护理方法。方法：将190例重型颅脑损伤患者随机分为两组，院前急救组102例经院前急救入院，对照组88例未经任何处理由家属直接送入医院。观察两组患者伤后至入院时间、预后。结果：院前急救组伤后至入院平均时间为20．2&#177;10．3min，预后为良好28例（27.5％），中残34例（33．3％）．重残22例（21．6％），植物状态4例（3．9％），死亡14例（13.7％）；对照组伤后至入院平均时间为60．4&#177;14．5min，预后为良好12例（13．6％），中残19例（21．6％），重残28例（31．8％），植物状态7例（8．0％），死亡22例（25．0％），两组比较均有显著性差异（P〈0．05）。结论：院前急救为重型颅脑损伤患者抢救赢得了时间，对提高生存率与生存质量．改善预后具有重要意义。     

3种途径注入大黄治疗重症急性胰腺炎疗效观察

目的观察3种途径注入大黄治疗重症急性胰腺炎（SAP）的临床疗效。方法将61例SAP患者随机分为鼻空肠组（21例）、灌肠组（20例）、灌胃组（20例）。3组除进行综合治疗外,分别采用鼻空肠管、保留灌肠及胃管给药途径注入大黄液100ml,每日2次。观察治疗15d后急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、BahhazarCT评分及C-反应蛋白（CRP）、淀粉酶、肠道功能恢复时间和腹痛消除时间的变化。结果3组患者治疗后15dAPACHEⅡ评分、BalthazarCT评分无明显差异（均P〉0．05）;鼻空肠组CRP恢复正常时间[（8．8&#177;1．5）d]、淀粉酶恢复正常时间[（8．0&#177;1．2）d3、肠道功能恢复时间[（5．3&#177;1．4）d3及腹痛消除时间[（7．0&#177;1．4）d]均较灌肠组[（9．9&#177;1．6）、（8．9&#177;1．5）、（6．2&#177;1．2）、（8．0&#177;1．2）d]和灌胃组[（9．8&#177;1．4）、（9．7&#177;1．7）、（6．4&#177;1．1）、（8．1&#177;1．3）d3明显缩短（均P〈0．05）,而灌肠组和灌胃组间差异无统计学意义（均P〉0．05）。结论鼻空肠管途径应用大黄能更有效地控制SAP的全身炎症反应。     

稀有血型患者自身输血的临床意义

目的探讨稀有血型患者术前自身输血的临床意义。方法对10例患者（RhO阴性8例,IgG型抗-M1例,IgM型抗-M1例）进行自身贮血术。结果患者RBC、Hb、HCT、WBC、plt采血前和手术前分别为（4．80±0．89）×10^12／L、（143．00±14．07）×g／L、（41±4．97）％、（6．55±2．18）×10^9／L、（231．23±69．70）×10^9／L及（3．80±0．48）×10^22／L、（125．00±13．79）g／L、（32±3．98）％、（7．07±4．06）×10^9／L、（189．33±49．9）×10^9／L。各项指标在采血前和手术前差异无统计学意义（P〉0．05）。自身采血过程中除1例出现轻微迷走神经反应外,其余无不良反应。术后Hb、RBC、HCT、WBC、plt在8d内全部恢复。结论术前自身贮血对稀有血型患者临床用血有一定意义。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.