汶川地震创伤救治的启示

本文对汶川地震创伤救治的经验进行了总结:(1) 伤员分类是救治的重要步骤;(2) 实施分级救治伤员后送是必需的;(3) 救治要坚持生命第一,肢体第二的原则;(4) 四肢开放骨折处理的最佳方式是外固定架;(5) 早期预防感染,警惕特殊感染的发生;(6) 建立一支常备不懈的医疗应急分队.     

176例汶川地震骨科伤员临床特点分析

目的:回顾性分析地震骨科伤员的临床特点及其救治情况,总结此类伤员的救治经验.方法:系统收集从汶川地震发生后至2008年6月30日我科收治的176例地震骨科伤员的临床资料,包括一般情况、伤情及治疗措施,并对临床救治经验与不足进行分析和探讨.结果:(1)176例地震病人中,男性96例,女性80例,平均年龄42岁,70岁以上伤员23人;(2)受伤原因以重物砸伤和挤压/掩埋为主(62.5%),36.9%的伤员为无骨折脱位的软组织损伤,其中挤压伤占软组织损伤的23.3%,63.1%的伤员有骨折脱位,约34.1%的伤员为多发骨折,开放性损伤多(35.2%),且污染重,多合并感染;下肢骨折多见(65%),26.1%的伤员有上肢骨折,20.7%的伤员有脊柱骨折,6.3%的伤员合并有胸、脑,腹部脏器损伤;(3)截肢伤员多,截瘫伤员少.结论:早期明确诊断,及时合理处置,以注重基础疾病和心理治疗及加强护理为特点的综合治疗有助于提高治疗质量,降低死亡率.     

11例地震伤的救治

对11例由前线医院转入的地震伤的救治进行总结.除1例遗留截瘫外,其余全部治愈.1例严重下肢挤压伤避免了截肢;3例伤口采样培养有梭状芽胞杆菌生长但未发生气性坏疽.诊治重点为对严重下肢挤压伤彻底清创、充分引流,以防止挤压综合征和气性坏疽;及时发现和治疗胸腹脏器伤的延迟性破裂.     

全军医院感染管理高级培训班暨SARS防治研讨会在南昌举办

全军医院感染管理高级培训班暨SARS防治研讨会于2003年9月22日-9月25日在江西省南昌市举办。来自全军78个医疗单位的128名代表以及全军医院感染管理专业委员会的全体委员到会,总后卫生部医疗局田晓丽助理代表医疗局领导到会并讲话。这次培训班暨研讨会的主题是:(1)新形势下的医院感染管理;(2)各单位抗击SARS的经验体会;(3)医院感染监控技术的进展;(4)医院感染监控技术的信息化管理。     

加强汶川地震灾害医学救援的经验总结

汶川地震灾区内受灾严重的医院医学资料严重缺失,灾区内建制相对完整的医院也存在未住院病人资料不全、缺少最后治疗效果等情况,灾区外医院伤员资料较为齐全,但不能反映本次地震灾害医学救援的整体情况.加强经验总结现阶段的弥补措施和重点包括:(1)按照分级救治的策略收集整理资料;(2)努力挖掘现场救治的经验;(3)按行政区域收集灾区内医院资料;(4)收集颅脑损伤、胸腹损伤和休克伤员等的完整数据;(5)加强总结现场转运和院间转运的资料;(6)建立全国或区域性的卫生主管部门或行业协会牵头的资料收集体系.今后应加强创伤医学和灾害医学学科建设,制定全国统一的伤票或伤标、转运病历,以及发展电子伤票和数据库.     

后方医院救治61例地震伤员分析

目的探讨后方医院诊治地震伤员时应掌握的要点。方法对2008年5月由灾区前线医院转送重庆急救中心救治的61例汶川地震伤员的病例资料进行回顾性分析。结果 26例(42.6%)早期漏诊颅脑、胸和腹部损伤,在转入1小时～4天内补充诊断;2例延迟性血气胸和2例腹内脏器延迟性破裂及时发现和处理。11例下肢严重挤压伤和挤压综合征避免了截肢;6例伤口采样培养有梭状芽胞杆菌生长但未发生气性坏疽。除2例遗留截瘫外,其余全部治愈。结论地震伤员的后方医院处理,重点为对初期抢救中的漏诊和治疗不足及时发现和补救;警惕胸腹脏器损伤的延迟性破裂;肢体挤压伤注意防治挤压综合征和气性坏疽,彻底切除坏死肌肉组织可最大限度地避免截肢。     

烧冲复合伤诊疗规范

1 概述 烧冲复合伤是指人员同时或相继受到热能所致的烧伤和中击波所致的冲击伤的复合损伤.如以烧伤为主则称为烧冲复合伤,以冲击伤为主则称为冲烧复合伤,但通常都统称为烧冲复合伤[-2].人体在遭受烧冲复合伤时,既有显而易见的烧伤创面,也有难以看见的脏器冲击伤存在;不仅有显著的烧伤后休克、创面感染和修复等,更有难以看见的严重内脏损伤和功能障碍,给医疗诊治带来很多矛盾和困难.烧冲复合伤通常具有以下一些特点[1-4]:(1)烧冲复合伤具有明显复合加重效应,烧伤和冲击伤发生顺序和程度的不同对其伤势的影响有一定差别;(2)休克更为多见,通常出现较早,经过较复杂,持续时间较长;(3)感染发生早而重,通常严重的创口/创面局部感染与全身感染同时存在;(4)肺功能受损严重,严重者可出现呼吸功能不全;(5)常有多种脏器功能损害存在:如心脏、循环、肝脏、肾脏、神经和免疫系统的损伤和功能障碍等.     

多发伤具有哪些临床特征?

正解答:多发伤具有以下临床特征:(1)病理生理变化急剧,死亡率高;(2)伤情严重,休克发生率高;(3)多伴有严重的低氧血症;(4)伤情复杂,容易漏诊、误诊;(5)伤情复杂,处理矛盾;(6)伤情危重,处理困难;(7)抵抗力低下,易发生感染及其他并发症。     

海地地震医疗救援中挤压伤及挤压综合征救治体会

2010-01—13北京时间凌晨5：56分海地发生7．3级地震,造成20多万人死亡。中国国际救援队于震后约33h到达海地首都太子港,旋即展开搜救与医疗救援,在海地共进行了15d的地震灾害救援,救援外伤伤员2500名,其中挤压伤重伤员约20例,包括挤压综合征6例,笔者主要总结在这次海地地震医疗救援中的挤压伤和挤压综合征的救治体会。     

地震挤压综合征致急性肾功能衰竭临床分析

目的：探讨地震挤压综合征致急性肾功能衰竭患者的早期救治和院内治疗,为以后此类患者的救治提供经验。方法：回顾性分析我院收治的11例在玉树地震中因挤压综合征致急性肾功能衰竭患者的病情特点、早期救援和转入院后的诊治情况。结果：随访1～3月,11例患者肾功能指标均恢复至正常水平。结论：地震挤压综合征所致急性肾功能衰竭易合并多器官功能障碍,在救治过程中要给予积极的对症支持和肾脏替代治疗,彻底清创和有效的感染控制有利于肾功能的快速恢复。     

手热压伤的治疗体会

目的：回顾性总结手部热压伤的临床治疗经验,探讨较为理想的治疗方法。方法：对我院2003年～2006年收治的12例手部热压伤病例资料进行回顾性总结,主要总结指标内容为伤情、治疗方法及结果。结果：12例病人手部功能恢复比较满意,外观基本正常。结论：严重手部热压伤早期实施手术疗法效果比较理想。     

挤压伤和挤压综合征的发病及救治

挤压综合征是挤压伤后严重的并发症,主要原因是肌肉丰富的部位受到挤压及缺血性损害后,解除挤压及恢复血供后,大量有害因子入血,出现以急性肾功能衰竭为主的症候群,死亡率较高,救治困难。挤压伤及挤压综合征提倡早期诊断及救治,救治措施主要包括现场急救、抗休克、预防感染、保护肾脏功能、维持水电解质平衡、人工肾脏替代,及营养支持等几方面措施。     

高频超声对兔坐骨神经急性挤压伤的观察

目的：运用高频超声观察兔坐骨神经急性挤压伤，探讨其临床诊断价值。方法：按观察时间的不同将16只健康家兔随机分为4组。建立兔坐骨神经急性挤压伤模型，损伤后第1、2、4、8周，分别应用高频超声在同一水平上观察双侧坐骨神经的变化。结果：坐骨神经挤压伤后，其声像图和内径均有变化，且与神经损伤后退变、再生及肢体功能的动态变化相一致。结论：高频超声可直观地反映神经退变和再生的过程，提供了诊断外周神经损伤的新方法，对临床判断和预后提供客观依据。     

急诊负压封闭引流术治疗挤压综合征

目的 探讨急诊应用负压封闭引流术(vacuum sealing drainage,VSD)对挤压综合征(crush syndrome,CS)的治疗作用. 方法 随机筛选出我院创伤外科收治的102例挤压伤患者,并分为急诊VSD组(50例),延迟VSD组(22例)和非VSD组(30例),分析各组间VSD术后CS相关指标的变化. 结果 患者术后的生命征、尿量、实验室检查结果、CS发生率、并发症、病死率等评价指标在急诊VSD组均较延迟VSD组和非VSD组显著好转(P<0.05);急诊VSD组和延迟VSD组患者术后并发症、住院时间、病死率等指标较非VSD组显著好转(P<0.05). 结论 早期、急诊应用VSD具有吸附坏死组织和创面渗出物、持续创面主动引流和预防感染等作用,对预防和治疗挤压综合征具有显著效果.     

汶川地震937名伤员流行病学特征

目的 探讨汶川地震伤员的流行病学特征. 方法 对937名汶川地震伤员的性别和年龄构成、致伤原因、损伤部位、并发症及漏诊率等进行分析. 结果 地震伤员男女性别比为1:1.12.致伤原因以砸伤和摔伤为主,损伤部位以颅脑、胸部、足踝、胫腓骨、脊柱和髋部多见.地震直接导致的损伤漏诊率达15.5%,以头、胸部损伤漏诊为主. 结论 地震伤员以砸伤和摔伤为卡要致伤因素,以下肢骨折为多,容易确诊头、胸部闭合伤.     

挤压伤和挤压综合征

创伤总是与自然或人为灾害紧密相关,挤压伤是其中较为常见的一类。挤压伤不仅直接导致伤员死于灾害现场,还可能导致幸存者出现挤压综合征,最终继发死于休克、高钾血症、急性肾功能衰竭等一系列全身并发症。一方面挤压综合征病程进展迅速,另一方面救援者对其认识不足或处理措施不当,从而导致了本可以预防的残疾和死亡。早期诊断和治疗是提高挤压伤患者生存率的关键,院前急救主要包括补液、药物治疗和患肢局部处理,而院内救治的关键是血液净化。挤压综合征的救治目前仍存在诸多争议,国内外尚无标准化方案,需根据患者具体情况进行个性化处理。     

Abdominal crush injury in the Sichuan earthquake evaluated by multidetector computed tomography

AIM:To investigate the features of abdominal crush injuries resulting from an earthquake using multidetector computed tomography(MDCT). METHODS:Fifty-one survivors with abdominal crush injuries due to the 2008 Sichuan earthquake underwent emergency non-enhanced scans with 16-row MDCT. Data were reviewed focusing on anatomic regions including lumbar vertebrae,abdominal wall soft tissue, retroperitoneum and intraperitoneal space;and types of traumatic lesions. RESULTS:Fractures of lumbar vertebrae and abdominal wall soft tissue injuries were more common than retro-and intraperitoneal injuries(P<0.05).With regard to the 49 lumbar vertebral fractures in 24 patients,these occurred predominantly in the transverse process(P<0.05),and 66.67%of patients(16/24) had fractures of multiple vertebrae,predominantly two vertebrae in 62.5%of patients(10/16),mainly in L1-3 vertebrae in 81.63%of the vertebrae(40/49). Retroperitoneal injuries occurred more frequently than intraperitoneal injuries(P<0.05),and renal and liver injuries were most often seen in the retroperitoneum and in the intraperitoneal space,respectively(all P< 0.05). CONCLUSION:Transverse process fractures in two vertebrae among L1-3 vertebrae,injury of abdominal wall soft tissue,and renal injury might be features of earthquake-related crush abdominal injury.     

家兔挤压伤后心脏节段旋转功能评价的实验研究

目的应用超声斑点追踪技术评价家兔挤压伤后的心脏收缩期节段旋转功能,评估挤压伤后心肌继发受损的情况。方法 42只新西兰家兔按标准制作挤压伤模型,随机分为对照组,解压即刻,解压后6、12、24、48、72 h共7组,每组6只,分别检测挤压前及解压后不同时间段左室收缩期节段旋转功能等情况。结果左室感兴趣区域的收缩期节段旋转功能在解压后12～24 h降至最低（P〈0.01）,72 h后逐渐恢复并相对稳定在一定水平。结论挤压伤后由于缺血再灌注等多种因素可导致心肌正性变力及变时效应减低,以致心肌纤维收缩性能及节段旋转功能明显降低,伤后12～24 h为心肌受损达峰时间段。     

家兔挤压伤后心肌组织与心功能变化的对比研究

目的通过对家兔挤压伤后心肌病理组织学改变的观察,对比心脏超声技术评价其心脏整体功能的变化情况,讨论挤压伤后对心肌组织继发损伤及心脏整体功能变化的机制。方法采用42只家兔制作挤压伤家兔动物模型,将其随机分为对照组、解压即刻组、解压后6、12、24、48、72 h共7组,每组6只;光镜观察心肌细胞结构。全自动生化分析仪检测血清尿素氮、肌酐、钾离子、钙离子、肌酸激酶、肌红蛋白浓度变化,多功能复合心脏超声测量心脏整体功能。结果挤压伤后12～24 h血清肌酸激酶、肌酸激酶同工酶、肌钙蛋白I显著升高,光镜下可见心肌细胞肿胀、间质水肿等改变。超声检测心脏整体收缩及舒张功能指标均显著下降。结论严重挤压伤后可致心肌组织继发损伤及心功能障碍,在解压后逐渐加重,至解压后12～24 h达到峰值,持续至伤后72 h后逐渐缓解;多功能复合心脏超声技术能够较精准、客观、快捷评估挤压伤后心脏继发受损的情况。     

Application of contrast-enhanced ultrasonography in the diagnosis of skeletal muscle crush injury in rabbits

Objective:

To explore the diagnostic value of quantitative contrast-enhanced (CE) ultrasonography for crush injury in the hind limb muscles of rabbits.

Methods:

A total of 120 New Zealand white rabbits were randomized to receive compression on the left hind limb for either 2 h (n = 56) or 4 h (n = 56) to induce muscle crush injury. Another eight animals were not injured and served as normal controls. CE ultrasonography parameters such as peak intensity (PI), ascending slop, descending slop and area under curve (AUC) were measured at 0.5, 2, 6 and 24 h and 3, 7 and 14 days after decompression.

Results:

Compared with the uninjured muscles, reperfusion of the injured muscles showed early and high enhancement in CE ultrasonography images. The time-intensity curve showed a trend of rapid lift and gradual drop. The PI and AUC values differed significantly among the three groups and were positively correlated with serum and tissue biomarkers. Rabbits of the 4-h compression group showed significantly higher PI and AUC values, and serum and tissue parameters than the 2-h compression group at each time points.

Conclusion:

CE ultrasonography can effectively detect muscle crush injury and monitor dynamic changes of the injured muscles in rabbits. PI and AUC are promising diagnostic parameters for this disease.

Advances in knowledge:

CE ultrasonography might play an important role in the pre-hospital and bedside settings for the diagnosis of muscle crush injury.Muscle crush injury usually occurs during earthquakes, collapse of buildings and heavy whip beatings, and often induces crush syndrome if not treated promptly. Crush injury is estimated to account for 3–20% of all injuries during natural disasters, and the lower limbs are the most frequently affected.¹ Limb crush injury and its complications are life threatening and the most frequent cause of disability and death after earthquakes.²The mortality rate in patients with crush syndrome can be as high as 21%, which is the most dangerous complication of all injuries during disasters.³ Crush syndrome can cause acute kidney injury and acute osteofascial compartment syndrome (AOCS), which are the most life-threatening complications. AOCS has a 47% mortality, and unrecognized AOCS can leave a patient with non-viable limbs requiring amputation.⁴ Severe muscle crush injury can also result in multiple organ dysfunction syndrome, acute respiratory distress syndrome, disseminated intravascular coagulation and severe arrhythmia.⁵ Early diagnosis of muscle crush injury and correct assessment of its severity are critical for good prognosis of patients. However, bedside and pre-hospital diagnosis of crush injury still lacks effective methods.Typical muscle crush injury and related AOCS are usually diagnosed with clinical symptoms, but the sensitivity of this method is very low.^6,7 Impaired microcirculation is the initial pathological change of crushed muscles.⁴ A variety of imaging methods have been used to examine reperfusion of the extremities and therefore detect the presence of muscle crush injury, such as CT, MRI and ultrasonography.^8–11 However, the equipment of CT and MRI is large and inconvenient for bedside or pre-hospital settings or in situ care at the trauma scene. On the contrary, ultrasonography devices can be light, portable and convenient for bedside or traumatic scenes. Ultrasonography also has no radiation. Conventional ultrasonography has been used to determine limb muscle crush injury, rhabdomyolysis and AOCS during the 2008 Sichuan earthquake in China.¹² However, the sensitivity of conventional ultrasonography is low for the diagnosis of extremity crush injury, and its detecting ability of microvascular perfusion is also very poor.¹³Gas-filled microbubbles can significantly augment the back scattered signals and do not leak out of the blood vessel and therefore are used as a contrast agent for Doppler ultrasonography to trace the bloodstream. Contrast-enhanced (CE) ultrasonography has been successfully used to measure microcirculation of the skeletal muscles, such as measurement of muscle perfusion after exercise, and evaluation of muscle perfusion in inflammatory myopathy or peripheral arterial disease.^14–16 However, application of CE ultrasonography in the assessment of microcirculation perfusion in muscle crush injury has rarely been reported.¹⁷In this study, microcirculation of extremities that underwent crush injury were evaluated using CE ultrasonography to investigate the values of CE ultrasonography in diagnosing limb crush injury.