创伤性连枷胸的救治体会

目的探讨创伤性连枷胸的治疗方法和效果。方法回顾性分析我科2000年3月至2007年12月收治的43例创伤性连枷性胸患者的临床资料。结果43例创伤性连枷性胸患者,经过治疗后,治愈40例（93．0％）,随访肺功能无明显受损;死亡3例（7．0％）。肋骨悬吊牵引13例（双侧1例）,肋骨内固定2例,呼吸机治疗5例。合并肺不张10例,气管切开7例,纤维支气管镜检查治疗6例。结论创伤性连枷胸应采取综合治疗措施。除积极治疗肺挫伤外,对严重的浮动胸壁仍应作牵引固定或内固定。呼吸机的使用指征主要为胸壁固定不能纠正的严重低氧血症和急性呼吸窘迫综合征（ARDS）先兆。早期气管切开能提高生存率。     

创伤性连枷胸与肺挫伤

创伤性连枷胸与肺挫伤万春友金鸿宾王若明（综述）作者单位：３００２１１天津医院创伤急救中心多年来对严重胸部创伤所致连枷胸和肺挫伤的病理生理及其治疗方法一直存在较大争议。阅读近年国内外有关专著，对其病理生理的认识有走向一致的趋势，治疗方法也趋接近。现综述...     

创伤性连枷胸的救治与护理

对我院1994年6月～2006年12月收治的42例创伤性连枷胸患者的治疗进行回顾性分析,治愈36例(85.7%),死亡6例(14.3%).提示创伤性连枷胸常伴有多发伤、肺挫伤和胸壁反常运动,是引起呼吸功能障碍的主要原因,恢复胸壁的稳定性、治疗肺挫伤、合理处理多发伤、加强护理是治疗的关键.     

创伤性连枷胸伴肺挫伤18例救治分析

目的：总结成功救治严重胸外伤的经验。方法：给予常规的预防感染、排痰、止痛治疗,及时的呼吸机应用和合理的手术时机选择及微创伤的肋骨骨折内固定治疗。结果：全部治愈,无死亡病例。结论：连枷胸伴肺挫伤是一种常见的创伤,容易引起急性呼吸窘迫综合征（ARDS）及呼吸衰竭,有较高死亡率。极早的诊断和合理的治疗方法是提高生存率的关键。     

18例创伤性连枷胸的救治体会

创伤性连枷胸是胸部的一种严重外伤，病情凶险，发展迅速．很快造成呼吸循环衰竭，如不及时有效治疗，将很快死亡。2000年2月-2006年2月共收治创伤性连枷胸患者18例，现将其诊疗情况报道如下。     

创伤性连枷胸的救治与护理

通过对65例创伤性连枷胸患者的护理总结,认为胸壁加压包扎、迅速建立有效通气、严密观察生命体征变化、加强呼吸道管理、加强胸壁外固定的护理和基础护理是促进患者早日康复的重要环节。     

创伤性连枷胸28例救治体会

创伤性连枷胸是常见的严重闭合性胸部创伤之一 ,其死亡率可高达 2 0 %～ 5 0 % [1 ] ,对其治疗目前尚无统一意见。我院自 1995年 2月～ 1999年 6月采用以治疗肺挫伤与保持胸壁稳定性并重的方法 ,共救治创伤性连枷胸病人 2 8例 ,均取得良好效果。报告如下。1　临床资料1.1　一般情况　本组男 2 0例 ,女 8例 ,年龄 17～ 5 6岁。致伤原因 :车祸伤 2 5例 ,高处坠落伤 3例。伤情 :前方连枷胸 5例 ,侧方连枷胸 2 2例 ,后方连枷胸 1例 ,其中单侧 16例 ,双侧 12例 ,肋骨骨折分别为 5～ 17根 2～ 5处。临床表现 :全组病人入院时均有胸痛及呼吸困难等 …     

连枷胸91例临床救治分析

目的 比较连枷胸的治疗方式和疗效的不同,探讨连枷胸救治经验。方法回顾性分析我院于1995年1月至2008年6月所收治的91例连枷胸患者的临床资料。结果按时期不同分为两组：2组中采取有创治疗措施增多;两不同时期组伤情严重度比较无差别,但1组死亡率（25％）明显高于2组（6.3％）（P〈0.05）;按治疗方式不同分为两组：有创治疗组伤情量化较保守治疗组重（P〈0.05）,而两组死亡率比较,差异无统计学意义（P〉0.05）,且有创治疗组中残留胸廓畸形例数、肺不张发生率明显低于保守治疗组（P〈0.05）。结论 连枷胸积极的有创治疗效果优于保守治疗;提高连枷胸患者生存率的主要措施是早期稳定胸壁与治疗肺挫伤并重,保持呼吸道通畅,有效止痛,适时给予机械通气,预防和治疗呼吸功能不全和肺部感染。     

创伤性连枷胸48例临床治疗分析

目的探讨创伤性连枷胸的治疗方法。方法分析48例创伤性连枷胸患者机械通气后血气分析等各种参数的变化及手术治疗的疗效。结果 22例患者行机械通气24小时后动脉血氧分压(PaO2)、氧合指数(PaO2/FiO2)和脉搏血氧饱和度(SpO2)均较治疗前明显改善(P0.001);手术治疗23例,ICU住院时间(3.39±2.29)天,肺部感染2例(8.70%),血管活性药物使用率17.39%(4/23);全组死亡2例,明显低于预测死亡风险。结论有创机械通气不仅能固定连枷胸,而且可有效改善氧合,与手术治疗有效结合,可显著改善连枷胸患者预后。     

连枷胸合并急性肺挫伤20例临床护理

对20例连枷胸合并急性肺挫伤患者给予积极治疗与精心护理,19例痊愈出院,1例胸部创伤好转后转院治疗脊柱骨折.认为对连枷胸合并急性肺挫伤患者首先要保持呼吸道通畅,合理氧疗,早期进行胸壁固定,消除反常呼吸,纠正缺氧:协助患者进行有效咳嗽、咳痰,防止肺部感染的发生;要严格控制输液速度和输液量,早期应用糖皮质激素,促进渗液吸收,防止肺水肿加重.其次要通过心理护理尽快帮助患者适应角色变化,配合治疗和护理.     

有创通气治疗连枷胸合并肺挫伤的疗效

目的探讨有创通气治疗连枷胸合并肺挫伤的时间和效果。方法回顾性分析南京医科大学附属南京第一医院2004年1月至2006年7月收治的16例严重连枷胸合并肺挫伤患者,在脉搏氧饱和度（spO2）〈90％、动脉氧分压（PaO2）〈60mmHg时行有创通气,并观察各种参数的变化、气管内固定时间、机械通气的并发症及治疗效果。结果有创通气后PaO2、氧合指数（PaO2／FiO2）分别由机械通气前（55．1±5．0）、（266．3±32．5）mmHg升高为（80．5±14．6）、（323．5±26．5）mmHg（P〈0．01）。SpO2从（83．9±6．0）％上升至（94．6±1．2）％（P〈0．05）,动脉血二氧化碳分压（PaCO2）由（33．0±6．9）mmHg恢复为（37．2±2．4）mmHg（P〈0．01）,心率（HR）从（108．7±10．8）降至（86．5±7．1）（P〈0．01）,血压在机械通气前为（130．9±20．5）,治疗后为（123±6．9）,差异无统计学意义（P〉0．05）。本组治愈14例,肺部感染9例,2例死于重型颅脑损伤。结论有创通气不仅能固定连枷胸,而且可有效地治疗肺挫伤。采用呼吸机相关性肺炎集束化治疗（VAP bundle）是防治肺部感染的关键。     

肋骨内固定术治疗创伤性连枷胸

目的 比较肋骨内固定术和外固定胸廓治疗创伤性连枷胸的临床疗效.方法 回顾性分析2006年1月至2009年6月收治的86例以创伤性连枷胸为主的多发伤病例的临床资料,分为内固定组和外固定组.内固定组45例,采用镍钛记忆合金环抱式接骨器内固定肋骨骨折;外固定组41例,采用外固定胸廓非手术保守治疗.比较2组的临床疗效.结果 内固定组患者胸壁畸形均消失,而外固定组中有19例患者遗留胸壁畸形.内固定组患者平均住院时间、平均住ICU时间和平均机械通气时间均短于外固定组[(15.1±1.8)d与(22.9±2.8)d,t=-15.724;(5.7±1.5)d与(14.4±2.9)d,t=-17.711;(3.9±1.5)d与(11.6 ±2.3)d,t=-17.256;P均＜0.01],内固定组患者呼吸系统并发症[包括肺部炎症或(和)肺不张或(和)呼吸功能衰竭]的发生率低于外固定组(35.6%与70.7%,x2=10.641,P＜0.01).出院3个月后,内固定组患者肺功能指标包括肺总量、用力肺活量、1秒钟用力呼气容积、呼气峰流量、75%肺活量最大呼气流量均高于外固定组[(89.5±3.1)%与(79.1±5.1)%,t=11.705;(80.2±2.8)%与(69.8±3.8)%,t=14.241;(74.8±4.4)%与(71.9±3.6)%,t=3.201;(82.8±4.4)%与(79.8±4.9)%,t=2.885;(68.2±2.2)%与(61.9±2.9)%,t=11.286;P均＜0.01].结论 肋骨内固定手术治疗创伤性连枷胸,可以迅速纠正畸形,稳定胸廓,消除反常呼吸,治疗过程顺利,缩短重症监护及住院时间,减少并发症,还可以减轻连枷胸对患者远期肺功能的影响.采用镍钛记忆合金环抱式接骨器内固定肋骨,手术简单、方便,疗效确切.

Abstract：

Objective To compare the effects of rib internal fixation and thoracic external fixation in treatment of traumatic flail chest. Methods Eighty six cases of traumatic flail chest with multiple injuries,admitted to hospital from January 2006 to June 2009 ,were recruited into the study and divided into rib internal fixation and thoracic external fixation groups randomly. The clinical data were analyzed retrospectively. Rib internal fixations with Ti-Ni shape memory alloy embracing connector were performed in internal-fixation group(n = 45) and thoracic external fixations were performed in external-fixation group(n = 41). The outcomes were compared between the two groups. Results No patient in internal-fixation group developed chest wall deformity,while 19 patients in external-fixation group had chest wall deformity left. The mean times of hospital stay([ 15. 1 ± 1.8]d vs [22. 9 ±2. 8]d,t = - 15. 724,P ＜0. 01) ,ICU stay([5.7 ± 1.5]d vs [ 14. 4 ±2. 9]d,t =- 17.711, P ＜ 0. 01), and mechanical ventilation([ 3.9 ± 1.5 ] d vs [ 1 1.6 ± 2. 3 ] d, t = - 17. 256, P ＜ 0. 01),in internal-fixation group were significantly shorter than those in external-fixation group. The occurrence rate of respiratory complications (including pulmonary inflammation and (or) atelectasis and (or) respiratory failure)in internal-fixation group was significantly lower than those in external-fixation group(35.6% vs. 70. 7% ,x2 =10.641,P ＜ 0.01). Followed-up data of three months after discharge showed that the pulmonary function parameters, such as total lung capacity([ 89. 5 ± 3. 1 ] % vs. [ 79. 1 ± 5. 1 ] %, t = 11. 705, P ＜ 0. 01), forced vital capacity([ 80. 2 ± 2. 8 ] % vs. [ 69. 8 ± 3. 8 ] % ,t = 14. 241 ,P ＜0. 01) ,forced expiratory volume in the 1st second ([74.8 ±4.4]% vs. [71.9 ±3.6]% ,t =3.201,P ＜0.01),peak expiratory flow ([82.8 ±4.4]%vs. [79. 8 ±4. 9]% ,t =2. 885,P ＜0. 01) and forced expiratory flows at 75% of the vital capacity( [68.2 ±2. 2] % vs. [61.9 ± 2. 9 ]%, t = 11. 286; P ＜ 0. 01) were significantly higher in internal-fixation group than those in external-fixation group. Conclusion Rib internal fixation for traumatic flail chest can quickly correct chest wall deformity, stabilize thoracis and eliminate paradoxical chest wall movement. Patients accepted this treatment have a shorter therapy process during the intensive care unit and hospital stay, less pulmonary complications. They also show less long-term restrictive pulmonary functions impairment, when compared to the patients in the thoracic external fixation group. Rib internal fixation with Ti-Ni shape memory alloy embracing connector is a simple and effective therapy.     

Methods of management of flail chest

We have treated 30 patients with flail chest, with priority given to associated factors (pain, secretions retention, hemo-/pneumothorax and underlying pulmonary contusion). When this treatment was insufficient IMV+PEEP was instituted; in this group there was a 58.8% incidence of pneumonia, 47.5% of sepsis and 11.7 days average stay in the ICU. These were significantly different when compared to the patients controlled without mechanical ventilatory support (7.7% pneumonia, 0% sepsis, 3.2 days).Surgical fixation was limited to 4 patients who presented with multiple and greatly displaced rib fractures, which made fixation by mechanical ventilation unpredictable.     

机械通气治疗连枷胸合并呼吸衰竭16例

目的探讨连枷胸致呼吸衰竭的病理生理、机械通气治疗的指征、模式参数调节及撤离.方法总结16例采用机械通气治疗的连枷胸合并呼吸衰竭病例的临床治疗过程及转归.结果其中13例经机械通气4～14d后一次性成功脱机,转普通病房继续治疗5～1 3d后出院;3例死亡病例分别死于重度颅脑损伤及失血性休克.结论连枷胸如有机械通气指征,应尽早使用.机械通气模式可选用SIMV(同步间歇指令通气)+PSV(压力支持),宜选择偏高潮气量(10～12ml/kg),PEEP(呼气末正压)有利于病情恢复.浅快呼吸指数(f/VT)是目前撤机最有预测价值的指标.     

Pressure control ventilation and minitracheotomy in treating severe flail chest trauma

Objective To evaluate pressure control ventilation (PCV) delivered through a minit-racheotomy in treating severe flail chest trauma.Design Case report.Setting Intensive care unit of a trauma center.Patient A 34-year-old woman affected by flail chest trauma and acute respiratory failure, who was initially treated with tracheal intubation to obtain internal pneumatic stabilization. The patient failed extubation and noninvasive mask treatment (pressure support ventilation plus PEEP) due to poor chestwall mechanics.Interventions Minitracheotomy was performed and ventilation was achieved with high levels of inspiratory pressure (PCV or assisted PCV) to overcome the resistance of the cannula (Mini-Trach II, Portex, ID 4 mm). Esophageal and carinal pressures were monitored. Ventilatory treatment was always performed with the full cooperation of the patient; the patient's glottic function was always intact.Measurements and results The patient was successfully treated with pressure control ventilation delivered through the Mini-Trach. After 7 days of PCV, the patient was switched to assisted PCV. On the 20th day after admission, she was weaned from mechanical ventilation.Conclusions We conclude that a suitable gas exchange and pneumatic stabilization in a flail chest condition can be achieved using minitracheostomic ventilation. At the same time, this treatment could reduce some side effects of traditional tracheal intubation.     

BIPAP模式治疗连枷胸合并肺挫伤

目的探讨双相气道正压通气（BIPAP）模式治疗连枷胸合并肺挫伤的临床效果。方法回顾性分析11例连枷胸合并肺挫伤的患者，出现呼吸功能不全需要机械通气时，均采用BIPAP模式，设计高呼气末正压通气（PEEP）、低PEEP、高PEEP持续时间、压力支持（PSV）、呼吸频率（f）、吸氧浓度（FiO2），当低PEEP≤6cmH2O、高PEEP≤10cmH2O、PSV≤5cmH2O、f≤4次／min、FiO2≤0，4时即可脱机。结果采用BIPAP模式治疗后患者症状、氧合指数、Pa02明显改善，经机械通气3—14d后一次性成功脱机，无一例发生急性呼吸窘迫综合征（ARDS）和死亡。结论对连枷胸合并肺挫伤采用BIPAP模式治疗能起到胸廓内固定，同时治疗急性肺损伤的共同作用，阻止ARDS的发生，是一种很好的机械通气方法。     

肋骨内固定术治疗创伤性连枷胸

Objective To compare the effects of rib internal fixation and thoracic external fixation in treatment of traumatic flail chest. Methods Eighty six cases of traumatic flail chest with multiple injuries,admitted to hospital from January 2006 to June 2009 ,were recruited into the study and divided into rib internal fixation and thoracic external fixation groups randomly. The clinical data were analyzed retrospectively. Rib internal fixations with Ti-Ni shape memory alloy embracing connector were performed in internal-fixation group(n = 45) and thoracic external fixations were performed in external-fixation group(n = 41). The outcomes were compared between the two groups. Results No patient in internal-fixation group developed chest wall deformity,while 19 patients in external-fixation group had chest wall deformity left. The mean times of hospital stay([ 15. 1 ± 1.8]d vs [22. 9 ±2. 8]d,t = - 15. 724,P ＜0. 01) ,ICU stay([5.7 ± 1.5]d vs [ 14. 4 ±2. 9]d,t =- 17.711, P ＜ 0. 01), and mechanical ventilation([ 3.9 ± 1.5 ] d vs [ 1 1.6 ± 2. 3 ] d, t = - 17. 256, P ＜ 0. 01),in internal-fixation group were significantly shorter than those in external-fixation group. The occurrence rate of respiratory complications (including pulmonary inflammation and (or) atelectasis and (or) respiratory failure)in internal-fixation group was significantly lower than those in external-fixation group(35.6% vs. 70. 7% ,x2 =10.641,P ＜ 0.01). Followed-up data of three months after discharge showed that the pulmonary function parameters, such as total lung capacity([ 89. 5 ± 3. 1 ] % vs. [ 79. 1 ± 5. 1 ] %, t = 11. 705, P ＜ 0. 01), forced vital capacity([ 80. 2 ± 2. 8 ] % vs. [ 69. 8 ± 3. 8 ] % ,t = 14. 241 ,P ＜0. 01) ,forced expiratory volume in the 1st second ([74.8 ±4.4]% vs. [71.9 ±3.6]% ,t =3.201,P ＜0.01),peak expiratory flow ([82.8 ±4.4]%vs. [79. 8 ±4. 9]% ,t =2. 885,P ＜0. 01) and forced expiratory flows at 75% of the vital capacity( [68.2 ±2. 2] % vs. [61.9 ± 2. 9 ]%, t = 11. 286; P ＜ 0. 01) were significantly higher in internal-fixation group than those in external-fixation group. Conclusion Rib internal fixation for traumatic flail chest can quickly correct chest wall deformity, stabilize thoracis and eliminate paradoxical chest wall movement. Patients accepted this treatment have a shorter therapy process during the intensive care unit and hospital stay, less pulmonary complications. They also show less long-term restrictive pulmonary functions impairment, when compared to the patients in the thoracic external fixation group. Rib internal fixation with Ti-Ni shape memory alloy embracing connector is a simple and effective therapy.     

胸腔镜辅助爪形钢板固定治疗伴有肺挫伤的连枷胸

目的探讨伴有肺挫伤的创伤性连枷胸外科内固定的治疗方法和疗效。方法回顾性分析本院2005年2月至2009年2月26例伴有肺挫伤的连枷胸患者资料,其中15例保守治疗,11例胸腔镜辅助爪形钢板手术内固定,比较两组需呼吸机通气支持率、机械通气时间、ICU时间、肺炎发生率、伤后第3天疼痛指数、病死率等指标。结果需呼吸机支持率手术组（27．3％）与保守组（26．7％）差异无统计学意义（P〉0．05）;机械通气时间手术组（4．45±0．37）d,保守组（14．33±0．50）d,手术组明显短于保守组（P〈0．01）;ICU住院时间手术组（6．09±0．37）d,保守组（20．20±0．98）d,手术组明显短于保守组（P〈0．01）;肺部感染发生率手术组18．2％,保守组73．3％,手术组明显低于保守组（P〈0．05）;病死率手术组9．1％,保守组13．3％,差异无统计学意义（P〉0．05）;疼痛指数手术组（4±1．9）,保守组（7±1．5）,手术组低于保守组（P〈0．05）。结论连枷胸肋骨骨折内固定可以迅速稳定胸壁、改善连枷胸对呼吸功能的影响,减少机械通气时间、ICU住院时间和肺部感染率,减轻疼痛程度,从而缩短病程。但是对病死率影响不大,对需要机械通气率亦影响不大。