胸部闭合伤的损伤严重度评估及临床意义

目的：探讨胸部闭合伤的临床特点及其损伤严重度评估的临床意义。方法：分析456例胸部闭合伤的致伤因素和死亡率,并按有无合并伤（分为单纯胸伤组,合并伤组）和结局（分为生存组,死亡组）分组进行创伤评分,分别比较不同组间的损伤严重程度。结果：致伤原因为交通伤发生率最高（60．97％）,其次为高处坠落伤（13．82％）。456例中288例合并其它部位损伤,占63．16％,死亡18例,死亡率3．95％,单纯胸伤组的格拉斯哥昏迷指(GCS),睡正创伤评分（RTS）和生存概率（Ps)较高,损伤严重评分（ISS）低于合并伤组,胸部简明损伤定级（AIS）评分两组间差别无显著性意义,死亡组和生存组比较,前者生理评分低,解剖评分高,生存概率亦低。结论：胸部闭合伤常合并全身多发伤,伤情判断困难,合理使用创伤评分有助于判断损伤严重度,指导临床救治。     

胸外科：胸部创伤严重度评价与救治结局探讨

采用AIS-98最新修订本对1995年1月至2005年6月救治的3057例胸部创伤病例资料进行回顾性分析。结果：总治愈率93．8％（2866／3057），病死率6．2％（191／3057）。死亡组ISS、GCS、修正创伤评分（RTS）、国人创伤严重度特征评分[ASCOT_CHINA）_生存概率（Ps）、创伤与损伤严重度评分（TRISS）_Ps、ASCOT_Ps与生存组比较，差异具有统计学意义（P〈0．01）。     

修正胸部穿透伤生理评分的初步探讨

目的 探讨胸部穿透伤（PTT）创伤评分预测生死结局的效果,修正生理评分方法。方法 将295例PTT中127例急诊手术患者分为生存组和死亡组进行多种创伤评分,比较两组在各种创伤评分间的差别,分析各种评分指标预测生死和实际生死结果。比较两组入院时、麻醉时伤后时间和各种生理参数的差别,结合实际生死用Logistic回归分析计算各相关因素的权重,命名新指标为穿透伤进程评分（PICS）,比较并评价PICS和修正创伤评分（RTS）。结果 解剖评分的胸AIS和损伤严重度评估（ISS）在生存组和死亡组间差别具有显著性意义（P＜0．05）,而生理评分RTS在预测生死结局的敏感性时并不令人满意。按入院和手术麻醉时生理参数的变化,选择格拉斯哥指数（GCS）、伤后时间（T）、脉压（PP）、动脉收缩压（SPB）作为PICS的参数,经Logistic回归分析得到PICS权重和计算公式;PICS和RTS比较,其预测生死结局的准确性、敏感性提高,特异性不变,死亡误判率降低。结论 建议在急诊评价穿透伤时可试用PICS取代RTS作为生理评分,并进一步观察其临床应用的合理性。     

胸腹联合伤的AIS-ISS评分及外科治疗

目的总结胸腹联合伤创伤评分与临床诊断和治疗方法的关系，旨在提高该病的诊断及治疗水平。方法回顾分析83例胸腹联合伤患者临床资料，并对其进行简明创伤分级（AIS）及损伤严重程度评分（ISS）。其中交通事故伤38例，刀刺伤24例，坠落伤8例，挤压伤8例，重物砸伤5例。患者手术治疗43例，胸腔闭式引流28例，保守治疗12例。结果治愈73例，死亡10例，死亡率12．1％。结论详细询问病史及查体，胸、腹部X平片，CT、胸腹部B超、消化道钡剂造影及钡灌肠造影检查有助胸腹联合伤的诊断。对诊断明确的胸腹合并伤，首先改善呼吸功能，恢复有效循环量，对ISS评分大于26的患者，应积极做好手术准备。     

多发伤患者D-二聚体的变化及临床意义

目的：研究血浆D二聚体及纤维蛋白原在多发伤时的变化及临床意义。方法：以创伤严重程度等级（ISS）评分16分为界，将49例多发伤患者分为轻伤组（ISS≤16分）和重伤组（ISS〉16分），并以30例正常人为对照组，采用免疫胶体金法及仪器法检测了正常人和多发伤患者受伤第1、2及3天的血浆D-二聚体和纤维蛋白原浓度。结果：多发伤后血浆D-二聚体明显增高，且重伤组高于轻伤组（均P〈0．01），第2、3天明显低于第1天（P〈0．01），但仍高于对照组（P〈0．01）。纤维蛋白原重伤组第1天与对照组比较无统计学差异（P〉0．05），轻伤组明显高于对照组和重伤组（P〈0．01）。伤后第2、3天均嘎显高于第1天（P〈0．01），并且高于对照组（P〈0．01）。伤后第1、2、3天纤维蛋白原的含量与D-二聚体呈负相关（r=-0．591，r=0．548，r=-0．470，P〈0．01）。结论：多发伤患者存在高凝状态和继发性纤溶亢进，血浆D-二聚体的浓度与病情、病程密切相关。重型多发伤初期纤维蛋白原不增高与纤溶增强有关。     

严重腹部创伤在SICU和综合ICU的加强治疗

目的 探讨严重腹部创伤在SICU和综合ICU用AIS—ISS评分的意义，对全身多种生理功能及生化指标等进行重症监测和加强治疗的体会。方法 回顾分析1996—2003年在SICU和综合ICU治疗严重腹部创伤72例。其中合并多发伤占66．66％。仅有腹部创伤AIS均≥3分，多发伤ISS的分值≥16分的占87．25％，对以上病例做相应手术处理后住SICU，需呼吸机支持呼吸或血流动力学不稳定的住综合ICU，给予循环、呼吸等多种监测仪的监测和加强治疗及高质量的护理。结果 治愈64例，死亡8例，死亡率11．11％。其中早期死亡4例，是合并严重颅脑损伤、急性呼吸窘迫综合征（ARDS）；中期死亡4例是因腹腔感染、肺部感染、全身炎症反应综合征（SIRS）及多器官功能障碍综合征（MODS）。结论 （1）迅速查明受伤部位及器官，用AIS—ISS评估其损伤的严重程度，优先处理危及生命的部位伤。（2）充分发挥ICU各监测仪的优势，给予高质量的护理，在重要脏器功能出现异常的早期及早发现并予以纠正，可减少并发症及病死率。     

腹腔镜手术治疗老年良性妇科疾病的价值

目的探讨腹腔镜手术在老年妇科良性疾病中的应用价值及安全性。方法比较2001年1月～2006年12月27例腹腔镜手术（腹腔镜组）与25例开腹手术（开腹组）的临床资料。结果腹腔镜组手术时间（20．0±7．9）min明显短于开腹组（44．0±7．2）min（t=-11．419，P：0．000）；腹腔镜组术中出血量（21．9±20．0）m1明显少于开腹组（62．6ml±29．4）（t=-5．875，P：0．000）；腹腔镜组术后病率3例明显少于开腹组12例（，：8．606，P：0．001）；腹腔镜组术后排气时间（13．9±2．9）h明显短于开腹组（23．4±4．3）h（t=-9．404，P=0．000）；腹腔镜组住院时间（7．6±0．9）d明显少于开腹组（10．2±1．2）d（t=-8．882，P=0．000）。结论重视老年患者术前合并症的治疗，术中术后加强监护，腹腔镜是老年妇科疾病手术治疗理想的术式。     

D-二聚体对严重创伤的诊断价值

目的通过检查骨创伤患者术后血浆D-二聚体变化值,观察严重创伤后D-二聚体数据对诊断的价值。方法收集本院骨创伤患者120例,根据创伤和损伤严重程度（ISS）评分将120例骨创伤患者分为：轻度损伤组（ISS≤16）、中度损伤组（16〈ISS〈25）、重度损伤组（ISS〉125）,并将120例骨科创伤患者设为观察组;另取60例健康体检患者设为对照组,对比分析D-二聚体检测数值。结果观察组血浆D-二聚体和对照组相比显著升高,差异有统计学意义（P〈0．05）;创伤程度越重,术后1、3、5天血浆D-二聚体逐渐增高,差异也有统计学意义（P〈0．05）;骨折术后DVT与血浆D－二聚体呈正相关,P〈0．01。结论骨创伤患者血浆中D－二聚体检验值升高后逐渐降低,通过D-二聚体水平检测及动态监测可用于患者伤情的判断和骨折术后DVT的诊断和评估。     

大鼠严重创伤后早期肝组织糖皮质激素受体和热休克蛋白变化与继发性肝损伤

目的：探讨大鼠严重创伤后肝组织糖皮质激素受体（GR）、热休克蛋白（HSP70）的变化及其在肝脏继发性损伤中的作用。方法：采用严重胸部撞击伤伴单侧股骨骨折模型，以500kPa(1kPa=7.5mmHg）驱动压致伤，动态观察创伤后24h大鼠肝组织GR、HSP70、肝脏病理、血清肝功能生化指标等变化，并对GR进行阻断后再致伤。结果：创伤后肝组织GR的最大结合容量即开始下降，12h降至最低，仅为正常对照的12．9％（P＜0．01），24h有所回升，但仍明显低于正常对照（P＜0．05），HSP70在伤后增加，8h达到高峰，24h仍持续在较高水平。但肝脏病理、血清ALT、LDH及白蛋白的改变差异无显著性。使用GR阻断剂后，肝淤血明显，肝窦内有较多炎性细胞浸润；血清ALT、LDH在伤后4h即有明显升高（P＜0．05），白蛋白明显下降（P＜0．05），伤后12h变化更加显著（P＜0．01）；肝组织HSP70较单纯创伤组明显增多。结论：GR不足可导致创伤后继发性肝功能不全的发生；HSP70参与了肝组织细胞抗损伤机制的启动；它们在严重创伤后肝组织细胞的抗损伤机制方面起着重要作用。     

修正创伤评分在急诊躯干损伤救治中的应用与改良

目的 验证修正创伤评分(RTS)用于躯干伤救治时的效能,针对效能不足之处进行改良,以提高RTS用于躯干伤救治时的针对性和准确性. 方法 回顾性分析2006年1月至2012年6月在四川大学华西医院接受急诊外科手术治疗躯干伤278例患者的临床资料,其中男231例、女47例,年龄1～75 (33.7±14.1)岁.计算伤员的RTS,新增伤员入急诊时的血红蛋白(Hb)浓度以衡量失血程度,分析RTS与救治过程和结局的相关性,比较RTS评分正常组与评分异常组两组伤员在救治过程和救治结局方面的差异；对单因素分析提示的对救治结局有影响的变量进一步做多因素分析,通过回归分析建立改良的RTS. 结果 RTS与救治过程和救治结局各指标之间呈显著相关性:RTS与受伤到手术时间(r=0.249,P＜0.001)、胸腹腔出血(r=-0.255,P＜0.001)、扩容总量(r=-0.244,P＜0.001)和住ICU时间(r=-0.202,P=0.001)有关,不同RTS伤员的死亡率差异有统计学意义(P=0.004).RTS评分效能不足主要表现在RTS评分正常组中仍发生伤员死亡(5.1％).单因素分析显示:RTS和急诊时Hb均与救治结局有关,将上述两变量带人回归拟合模型后得到了计算改良RTS评分的新公式:Logit(P死亡)=6.450-0.769×RTS-0.029×急诊Hb. 结论 改良RTS用于评估躯干伤时针对性更强,同时保持了简易、快速的特点.     

Emergency thoracic surgery for penetrating, non-mediastinal trauma

BACKGROUND: Penetrating thoracic injury is commonly found in South Africa. A review of our recent experience was undertaken to assess the effectiveness of our protocols for this type of injury. METHODS: A retrospective study of 61 consecutive patients with penetrating, non-mediastinal trauma to the chest was conducted over 32 months at a single trauma unit. Patient details, mechanism of injury, operative procedure and in-hospital mortality and morbidity rates were recorded. RESULTS: Two thousand and nineteen patients presented with penetrating chest injury of which 61 patients (3%) underwent thoracic surgery for non-mediastinal injury. Twenty-six patients had stab wounds and 35 had gunshot wounds. Overall mortality was 17/61 (28%). Gunshot wounds were more likely to result in death than stab wounds (relative risk = 11.9; 95% confidence interval 1.7-84.0) and thoracoabdominal injury resulted in death more commonly than chest injury (relative risk = 4.8; 95% confidence interval 2.2-10.3) resulted in death. CONCLUSION: Penetrating chest injury is common and most patients can be managed without formal thoracic surgical intervention. However, the patients who do merit surgical intervention have a relatively high mortality and a rapid and practised operative approach is required to achieve acceptable results.     

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

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Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?

Introduction: Previous work suggests that patients with isolated penetrating trauma rarely require spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in Scotland.

Design: Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group (STAG).

Methods: Study patients were identified from the period 1992–1999. Patients coded for both penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre notes and post mortem information were also examined.

Results: 34,903 patients were available for study. Twenty-seven patients were coded as having had penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12 patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10 resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic cardiac arrest. All had spinal immobilisation.

Conclusion: Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do not require spinal immobilisation.     

Factors affecting postoperative mortality in abdominal trauma.

Records of 345 patients in whom laparatomies were performed because of blunt and penetrating abdominal trauma were reviewed retrospectively with respect to factors affecting mortality. One hundred and twenty-eight patients had blunt abdominal trauma (Group I), 114 patients had gunshot wounds of the abdomen (Group II), and 103 patients had stab wounds of the abdomen (Group III). Mortality rates were 14.8%, 12.3% and 1.9% in groups I, II and III respectively. The presence of head trauma especially if accompanied by hypotension in group I, and the presence of chest trauma (hemothorax and/or pneumothorax) and hypotension (less than 90 mmHg) in group II were associated with a high mortality rate (p less than 0.05). Of the two patients who died in group III, one had septic shock due to massive intestinal necrosis and the other had hemorrhagic shock due to multiple organ injury and bleeding from an injured internal thoracic artery as the cause of death.     

Video-assisted thoracoscopic surgery for penetrating thoracic trauma

Purpose: For penetrating thoracic trauma, there is no consensus on whether operative exploration or conservative treatment is better. In this study, we compared the clinical effect of video-assisted thoracoscopic surgery (VATS) and thoracotomy on the patients with penetrating thoracic trauma. Methods: From January 2000 to December 2010, 123 patients with penetrating thoracic trauma were treated in Affiliated Hospital of Chengdu University. Based on the inclusion criteria, 80 patients were enrolled and randomly assigned into VATS and thoracotomy group. Results: The operation time, amount of bleeding and drainage in VATS group were all lower than traditional operation (p < 0.05). Conclusion: The results indicate that VATS has the merits of shorter operation time, non-blind area, exact surgical path and less bleeding comparing with traditional operation.     

Management of penetrating and blunt diaphragmatic injury

The past 5 years' experience with diaphragmatic injuries at the University of Texas Health Science Center in San Antonio was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Ninety-three patients incurred penetrating trauma to the diaphragm and nine patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in four, and free air in one. Peritoneal lavage was positive in six of seven patients with blunt diaphragmatic injury, but was falsely negative in two of five patients (20%) with penetrating diaphragmatic injury. Eighty-nine patients (87%) experienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for three with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was one death in the series from a consumption coagulopathy. It was concluded that injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, we believe that missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries. Care must be taken not to overlook associated injuries.     

The incidence,clinical characteristics,and outcome of polytrauma patients with the combination of pulmonary contusion,flail chest and upper thoracic spinal injury

BackgroundChest trauma was the third most common cause of death in polytrauma patients, accounting for 25% of all deaths from traumatic injury. Chest trauma involves in injury to the bony thorax, intrathoracic organs and thoracic medulla. This study aimed to investigate the incidence, clinical characteristics, and outcome of polytrauma patients with pulmonary contusion, flail chest and upper thoracic spinal injury.MethodsPatients who met inclusion criteria were divided into groups: Pulmonary contusion group (PC); Pulmonary contusion and flail chest group (PC + FC); Pulmonary contusion and upper thoracic spinal cord injury group (PC + UTSCI); Thoracic trauma triad group (TTT): included patients with flail chest, pulmonary contusion and the upper thoracic spinal cord injury coexisted. Outcomes were determined, including 30-day mortality and 6-month mortality.ResultsA total 84 patients (2.0%) with TTT out of 4176 polytrauma patients presented to Tongji trauma center. There was no difference in mean ISS among PC + FC group, PC + UTSCI group and TTT group. Patients with TTT had a longer ICU stay (21.4 days vs. 7.5 and 6.2; p<0.01), relatively higher 30-day mortality (40.5% vs. 6.0% and 4.3%; p<0.01), and especially higher 6-month mortality (71.4% vs. 6.5%, 13.0%; p<0.01), compared to patients with PC + FC or with PC + UTSCI. The leading causes of death for patients with TTT were ARDS (44.1%) and pulmonary infection (26.5%) during first 30 days after admission. For those patients who died later than 30 days during the 6 months, the predominant underlying cause of death was MOF (53.8%).ConclusionsLethal triad of thoracic trauma (LTTT) were described in this study, which consisting of pulmonary contusion,flail chest and the upper thoracic spine cord injury. Like the classic “lethal triad”, there was a synergy between the factors when they coexist, resulting in especially high mortality rates. Polytrauma patients with LTTT were presented relatively high 30-day mortality and 6 months mortality. We should pay much more attention to the patients with LTTT for further minimizing complications and mortality.     

Penetrating Cardiac Injuries: Recent Experience in South Africa

Background Penetrating cardiac injury is a dramatic and lethal form of trauma. The majority of patients will die before reaching medical care, but for those who arrive at hospital alive, the diagnostic acumen and rapid surgical intervention of physicians and surgeons can lead to successful outcomes. Materials and Methods A structured diagnostic and management approach is used in our trauma unit to deal with penetrating cardiac injury. A retrospective study of 117 patients with penetrating trauma to the heart was conducted over 32 months; the purpose of this study was to describe our protocol and review overall outcome with this type of injury. Demographic details, mechanism of injury, and mode of presentation were recorded. Mortality and morbidity data were collated and echocardiographic follow-up was performed. Results There were 109 male patients, mean age 29 years (range: 15–54 years) and 8 female patients, mean age 35 years (range: 23–56 years). Most patients (96/117) had sustained stab wounds, and the associated mortality was 15.6%. Twenty-one patients had sustained gunshot wounds (GSW), with a mortality of 81%. Gunshot wounds were significantly more likely to result in death (P ≤ 0.0001). Five patients sustained multiple cardiac wounds, and three of them died. The risk of death was not different between patients sustaining single or multiple cardiac wounds (P = 0.11). Eleven patients had thoracoabdominal injury, and 3/11 (27%) died; all of those that died had sustained GSW. The risk of death was not different between patients sustaining thoracoabdominal wounds and those with isolated thoracic injury (P = 1.0). Among the 51 patients with stab wounds who presented with cardiac tamponade, the mortality was only 8%. Compared to the other patients with stab wounds, cardiac tamponade conferred a significant survival advantage (P = 0.02). Conclusions A high index of suspicion for penetrating cardiac injury and an understanding of the modes of presentation can lead to rapid diagnosis even by inexperienced junior staff. Such a structured approach to patients with penetrating trauma to the chest leads to early definitive management and acceptable results.     

Penetrating thoracic injury

PURPOSE To clarify the clinical aspects of penetrating thoracic injury. PATIENTS AND METHODS: Eighteen patients with penetrating thoracic injury treated from 1987 to 2005 were evaluated. There were 13 men and 5 women. The age distribution was 8 to 69 years, with an average of 36.7 years. RESULTS: There were 14 patients with stab wound and 4 with impalement injury. Five patients with stab wound were those who attempted suicide. In 4 patients with impalement injuries, the cause was fall in 2, traffic accident in 1 and sports injury in 1. The calculated injury severity score (ISS) was over 15 in 4 patients, 6 to 14 in 12, and under 5 in 2. Thoracotomy was performed in 2 patients with cardiac tamponade, 3 with massive hemothorax and 1 with an impalement injury caused by an iron bar. All of them were rescued and got well. In the other cases, after cleansing and debridement, the wound was closed and thoracic drainage was performed. Only 1 patient with cardiac arrest on arrival died within 24 hours after reviving. CONCLUSIONS: Emergent thoracotomy is indicated for patients with massive bleeding including shock, continuous air leakage and cardiac tamponade. Since cardiac arrest is difficult to cure, appropriate cooperation with the rescue team is necessary to avoid preventable trauma death.