合并颅脑损伤的儿童四肢骨折15例治疗体会

儿童四肢骨折合并颅脑损伤时其诊治有一定的特殊性。1992年1月至1996年6月作者等收治15例，分析报道如下：     

厦门地区1367例创伤性骨折患者流行病学分析

[目的]调查厦门地区创伤性骨折流行病学特征及影响因素,为制定预防和干预措施提供科学依据。[方法]采用描述性流行病学方法回顾性分析2013年1月~2014年12月期间入住本院骨科1 367例创伤性骨折患者的流行病学资料。[结果](1)男性受伤风险大于女性(男938,女429;2.19:1;(2)平均年龄(38.69±19.32)岁,18~60岁构成创伤性骨折主体(占66.60%);(3)职业分布中工人居首位,共613例,占44.84%;(4)致伤原因中以车祸和摔伤为主,共1 177例,占81.13%;(5)受伤地点中城郊结合地带最多见,有963例,占70.45%;(6)受伤时间主要集中在第三季度,共442例,占32.33%;(7)就诊时间主要集中在白天,即上午9点~下午5点,共772例,占56.40%;(8)死亡36例,占2.63%。[结论]创伤性骨折的发生在发病年龄、职业、地点、致伤原因、受伤时间等方面存在一定的规律性;针对高危人群因地制宜采取预防和干预措施,提高公众现场急救意识和能力,可有效降低发病率和病死率。     

重型颅脑创伤患者血糖及胰高血糖素监测及其临床意义

重型颅脑创伤可诱发机体严重的应激反应，使糖代谢紊乱。据统计，78．6％的患者可出现创伤性高血糖，与患者的预后存在着显着的相关性。本文对40例颅脑创伤患者伤后15天的血糖和胰高血糖素水平进行动态观察，联系患者预后结果进行相关性分析，对创伤后糖代谢紊乱与应激性高血糖监测的临床意义，进行初步探讨。     

216例外伤性脊髓损伤住院患者流行病学分析

目的探讨外伤性脊髓损伤的流行病学特点。方法对1998年1月～2008年12月216例外伤性脊髓损伤住院患者进行回顾性分析。结果脊髓损伤以30～60岁常见,男性多见,交通事故、高空坠落、跌倒和创伤性为主要致伤原因,颈髓损伤为主,完全性损伤占33.3%,肺部并发症常见。结论完善脊髓损伤初级预防工作,提高院前急救水平,住院患者特别是完全性脊髓损伤患者防治并发症,从而减少脊髓损伤发病率、致残率。     

江门市中心城区1021例腹部创伤患者流行病学分析

目的调查江门市中心城区腹部创伤流行病学特征及影响因素,为制定预防和干预措施提供科学依据。方法采用描述性流行病学方法回顾分析2005年1月至2009年12月本院就诊的1021例腹部创伤患者的流行病学资料。结果门、急诊治疗356例,以腹壁软组织挫裂伤为主;需要住院治疗665例,以肾、脾、肝损伤为主;AIS≥3分的500例,占75.19%。腹部创伤发生的原因依次为道路交通伤、锐器伤、坠落伤、跌伤。以青壮年人群为最多,男性发病率明显高于女性,男女比例为4.55:1。患者以生产工人为主(57.89%),复合伤390例,占38.20%,死亡49例占4.80%。结论腹部创伤的发生在发病年龄、职业、地点、受伤脏器等方面存在一定的规律性,针对高危人群因地制宜采取预防和干预措施,可有效降低发病率和病死率。     

格拉斯哥昏迷评分与颅脑创伤患者手术预后及麻醉承受力的关系

１０９例单疱角膜间质炎作了治疗性板层角膜移植术。其中９２例术后视力恢复到０．０５－１．０。其长期疗效按移植床剖切是否干净彻底分两组统计复发率，植床剖切彻底组和剖切未净组术后６－９６个月的复发率５．２％和８４．６％。大多数切除标本显示，深浅基质层有肉芽肿性炎症反应，而以邻近后弹力膜水平最为集中。     

骨关节多发性创伤的流行病学分析

目的探讨多发性骨关节损伤的流行病学特点,以提高创伤的防治认识和救治质量,减少死亡率。方法总结2002年1月1日～2004年12月31日间救治的346例多发性骨关节损伤患者资料,按蔡氏法分类,统计分析患者性别、年龄、伤因、部位、数量、并发伤及死亡率。结果346例患者中,男278例,女68例；年龄9个月～89岁,平均32．8岁。致伤原因：交通伤226例,重物压砸伤65例,坠落伤及跌伤52例。胫、腓骨干骨折159处,股骨干骨折96处,尺、桡骨干骨折87处,踝足骨折58处,胸部伤57处,髋和膝部伤分别为50处,骨盆区损伤49例,腕手部伤46处,肩部伤36处,颅骨骨折36处,肱骨干骨折33处,脊柱骨折23处,肘部伤17处。2处伤者242例,3处伤83例,4处伤20例,6处伤1例,平均受伤部位2．3处。闭合伤205例,开放伤141例；合并颅脑伤51例,胸部伤23例,腹部伤5例,泌尿系损伤3例,休克78例,神经血管伤21例,脂肪栓塞6例。死亡5例。结论近年来,多发性骨关节损伤患者有增多趋势,且伤情较重,男性青壮年居多；交通伤是主要致伤原因；四肢多发伤以下肢伤为多,容易发现及确诊,而脑、胸、腹、盆部的闭合伤多易漏误诊治；近年来死亡率明显减少；加强急救创伤救治培训和安全教育,进一步提高医疗质量,可减少残废和死亡率。     

创伤后成人呼吸窘迫综合征的流行病学研究

背景：尽管成人呼吸窘迫综合征是钝性创伤早期重要的并发症，但是对其流行病学和发生危险因素的研究仍很欠缺。本研究的目的是通过对一组受伤后住院的病例进行前瞻性队列研究，来分析这种并发症的患病率和人口统计学特点，同时也研究了损伤的严重程度和类型对这种并发症发生的影响。我们的目标是通过确定成人呼吸窘迫综合征发病的高危因素．研究出便于早期发现该征的途径：方法：我们对8年多来收住在同一所大学医院的7192例创伤性损伤的病例进行了前瞻性研究。除髋部骨折和72小时内出院的病例外，所有创伤后需要住院，年龄在13岁以上，并且是医院属区的居民的病例都包括在本研究之内。对肌肉骨骼系统、胸部、腹部和头部创伤，包括单一或复合性创伤的病例，进行创伤后成人呼吸窘迫综合征的患病率和人口统计学的研究。根据创伤类型分析这种并发症的发病相关危险因素。应用多元logistic回归分析确定成人呼吸窘迫综合征发病的最重要的预测因素。结果：36例（0．5％）患者并发成人呼吸窘迫综合征。年轻人患病率明显较高（p=0．002），其中83％继发于高能量创伤。单一的胸部、头部、腹部或四肢创伤的成人呼吸窘迫综合征的患病率〈1％。两个解剖区域损伤者患病率较高（高达2．9％），三个解剖区域损伤者患病率更高（达10．2％）：多元logistic回归分析显示：入院时损伤严重程度评分、股骨骨折、腹部和四肢联合损伤、以及入院时观察到的生理功能受损均是后期并发成人呼吸窘迫综合征的各自独立的预测因素。结论：成人呼吸窘迫综合征的患病率随损伤的严重程度和所涉及解剖区域损伤的增加而上升。我们已经能够对这些损伤的重要性和相关危险因素进行量化：我们还对此研究结果对便于早期发现这种并发症的意义进行了讨论。     

849例重型颅脑损伤的诊治分析

重型颅脑损伤是常见病、多发病．具有高死亡率、高致残率。本院自2004年1月1日至2008年2月29日,共收治重型颅脑损伤患者849例．笔者对此进行总结分析。     

The incidence of acute kidney injury in patients with traumatic brain injury

There is limited information on the incidence of acute kidney injury (AKI) in patients with traumatic brain injury (TBI) although AKI may contribute to morbidity and mortality. We investigated the incidence of AKI in patients with moderate and severe TBI and the association of AKI with risk factors and outcomes in these patients.

We studied all TBI patients over 16 years of age admitted to the two designated trauma hospitals in the state of Victoria, Australia from 1 January to 31 December 2008. Patients were included if they had head trauma and presented with a Glasgow coma scale (GCS) <13. Prospectively collected data from the hospital trauma registries, ICUs, and pathology databases were analyzed retrospectively. Risk injury failure loss end (RIFLE) criteria were used to categorize renal function.

The incidence of AKI was 9.2% (19/207). Patients who developed AKI were older, had higher severity of illness scores, and a lower GCS. Overall 42.1% of these patients died in hospital compared with 18.1% in patients without AKI. In univariable linear regression analysis, age, severity of illness, and admitting hospital were associated with AKI. After multivariable logistic regression, the occurrence of AKI was associated with age (p < 0.001) and higher APACHE III scores (p = 0.016).

AKI is relatively common even in patients with TBI. Its association with age and APACHE III scores helps identify patients at higher risk of AKI.     

颅脑外伤患者凝血功能异常与预后的相关性研究

目的了解颅脑外伤患者急性期凝血功能改变情况,并分析凝血功能异常与颅脑损伤程度（GCS评分）及预后（GOS评分）的关系。方法监测124例单纯颅脑外伤患者急性期凝血指标,进行DIC评分,对患者入院时颅脑损伤程度及外伤后6个月的临床预后进行评分。结果超过50%的单纯颅脑外伤患者发生凝血功能异常,其中重型颅脑外伤患者及预后不良的颅脑外伤患者PT明显延长,D-DT水平明显升高,其差异具有显著性。结论凝血功能改变,尤其是DIC多发生于脑外伤后6小时内,在重型颅脑外伤患者及预后不良的颅脑外伤患者中表现的更加明显。PT、D-DT水平在颅脑外伤患者预后的评估中起重要作用,可作为患者预后的预测指标。     

Antithrombin treatment in patients with traumatic brain injury: a pilot study

This study will determine if early administration of antithrombin concentrate to patients with traumatic brain injury (TBI) can inhibit or significantly shorten the time of coagulopathy. The progress of brain injury monitored by computed tomographic scan (CT) was also assessed, as was the time needed for intensive care and outcome related to Glasgow outcome scale (GOS). Twenty-eight patients with isolated brain trauma verified with CT were included in either of two parallel groups. The Glasgow coma score (GCS) was mean 7.5, and median 7.0; signifying a moderate to severe traumatic brain injury but with a mortality of only 3.5%. The patients randomized to antithrombin treatment received a total of 100 U/kg BW during 24 hours. To measure hypercoagulability, soluble fibrin (SF), D-dimer (D-d), and thrombin-antithrombin complex (TAT) were assessed together with antithrombin (AT) and routine coagulation tests. Before treatment, SF, D-d, and TAT were markedly increased in both groups. Soluble fibrin and D-dimer (measured after treatment began) appeared to decrease faster in the AT group, and there was a statistically significant difference between the groups at 36 hours for SF and at 36 hours, 48 hours, and at Day 3 for D-d. Thrombin-antithrombin complex levels were very high in both groups but, surprisingly, showed no significant difference between the groups. The authors conclude that antithrombin concentrate administered to patients with severe TBI resulted in a marginal reduction of hypercoagulation. We could not detect any obvious influence by antithrombin on brain injury progress, on CT, or on outcome or time needed for intensive care.     

Secondary injury in traumatic brain injury patients--a prospective study.

OBJECTIVE: Secondary insults of hypotension and hypoxia significantly impact on outcome in patients with traumatic brain injury (TBI). More than 4 hours' delay in evacuation of intracranial haematomas has been demonstrated to have an additional impact on outcome. The objective of this study was to document the incidence of these preventable secondary insults in patients admitted with moderate or severe brain injury. METHODOLOGY: All moderate and severe head injury patients admitted to Groote Schuur Hospital over a 3-month period were studied prospectively. Data were obtained from ambulance dockets, referral letters, patient charts and attending medical staff. Preventable secondary insults (hypotension, hypoxia) and time delay to assessment and surgery were documented. Outcome was assessed using the Glasgow outcome scale (GOS) at discharge or outpatient follow-up. RESULTS: Ninety-six patients were studied. Forty-nine patients experienced at least one recorded preventable event of hypoxia or hypotension. Seventeen had an intracranial haematoma requiring evacuation. The mean time interval between injury and surgery was 455 minutes. No haematoma was evacuated within 4 hours of injury. Patients referred via a primary or secondary care facility experienced a mean additional delay of 70 minutes. These results demonstrated a significant incidence of secondary injury and delay to assessment and surgery. We believe that education and a raised awareness of the impact of secondary insults may have a positive impact on TBI outcome in our referral area.     

The management of traumatic brain injury

Traumatic brain injury (TBI) is a huge global problem with an increasing socioeconomic impact. Current understanding of the pathophysiology of TBI has led to a systematic approach towards management in the pre-hospital, operating theatre and critical care settings, with early management directed towards protecting the brain from secondary injury. TBI is a spectrum of diseases, and rapid radiological identification of the underlying pathology is paramount to determine appropriate surgical intervention. Most modern neurocritical care centres augment intracranial pathophysiology with intracranial pressure (ICP) and cerebral perfusion pressure (CPP) targeted therapies at a minimum. Decompressive craniectomy (DC) can be a useful mechanism to control medically refractory intracranial hypertension and reduce mortality; however, it also results in a spectrum of outcome categories and remains a controversial topic. There is emerging evidence that TBI is a chronic illness, with increased incidence of cognitive and behavioural deficits, neurodegenerative disease, and an increased mortality that extends well beyond the initial TBI stage. Ongoing research into novel biomarkers may yield future therapeutic targets to improve clinical outcomes.     

The management of traumatic brain injury

Traumatic brain injury (TBI) is a global problem with a huge socioeconomic impact. Current understanding of the pathophysiology of TBI has led to a systematic approach towards management in the pre-hospital, operating theatre and critical care settings. Early management is directed towards protecting the brain from secondary injury. TBI is a spectrum of diseases, and rapid radiological identification of the underlying pathology is paramount to determine appropriate surgical intervention. Perioperative management frequently requires neurocritical care, with most modern centres using intracranial pressure and cerebral perfusion pressure targeted therapies. Decompressive craniectomy can be a useful mechanism to control medically refractory intracranial hypertension and reduce mortality; however, it also results in a spectrum of outcome categories and remains a controversial topic. Finally, there is emerging evidence that TBI is a chronic illness, with increased incidence of cognitive and behavioural deficits, neurodegenerative disease and an increased mortality that extends well beyond the initial TBI stage.     

氨甲环酸在创伤性脑损伤患者中的应用

创伤性脑损伤（TBI）后颅内出血很常见,可导致患者发生脑疝甚至死亡。氨甲环酸（TXA）是一种赖氨酸类似物,它竞争性抑制纤溶酶原,抑制纤维蛋白凝块溶解所必需的纤溶酶激活。TXA可以减少颅外大出血的创伤患者因失血而死亡,通过减少颅内出血的扩大来改善TBI患者的预后。全文从TBI对机体的影响、TXA在TBI患者中的应用、TXA相关并发症三个方面,对TXA在TBI患者中的应用做一综述,为指导TBI后不同时间窗内的TXA用药方案、降低TBI并发症发生率提供参考。