不同时期胸部创伤的特点及救治经验

目的比较不同时期收治胸部创伤（胸伤）的特点，围绕其院内死亡原因总结救治经验。方法将１６３９例胸伤分为１９９０年前、后两组，比较不同时期病例数、致伤原因、严重胸伤构成比及住院死亡率，并对伤后早期与晚期常见致死原因失血性休克、成人呼吸窘迫综合征（ＡＲＤＳ）和多系统器官衰竭（ＭＳＯＦ）等进行分析。结果９０年代后收治胸伤病例增多，穿透性刃器伤、重症钝性胸伤、连枷胸、肺挫伤和ＡＲＤＳ病例明显增加，住院死亡率从４．３０％降至２．９６％；住院早期死亡原因以失血性休克为主，晚期死亡原因多为ＡＲＤＳ和ＭＳＯＦ。结论应针对９０年代胸伤特点，围绕严重胸伤常见的致死原因，进一步改进急救和后续处理，降低死亡率。     

家兔闭合性胸部创伤早期影像学检查的诊断价值

目的探讨放射性核素显象、胸部CT和X线检查对家兔闭合性胸部创伤的早期诊断价值. 方法建立单侧胸部撞击伤动物模型,采用单光子发射计算机断层显象(SPECT)、胸部CT和X线片对闭合性胸部创伤进行早期诊断,并与病理解剖结果进行对照观察. 结果伤后30分钟伤侧肺感兴趣区致伤部位/心脏部位(ROI2/ROI1)比值立即升高,至伤后6小时达到高峰;对侧肺相对应部位/心脏部位(ROI3/ROI1)比值缓慢升高,至伤后6小时达到高峰,但仍小于伤侧肺,双侧肺之间比较差别具有显著性意义(P＜0.01). 结论胸部X线片检查仍是诊断胸部创伤最基本的方法,但对严重的胸部创伤和多发伤患者应尽早做胸部CT检查,SPECT对肺挫伤有较高的诊断价值.CT对肺挫伤的诊断敏感性优于X线片,但对渗出和水肿则不如SPECT灵敏、准确. 因此,对严重胸部创伤、多发伤患者,急诊检查应采用CT,以尽快明确诊断.     

Comparison of multiple trauma in children and adults

Summary Multiple injuries in children are responsible for a great part of childhood mortality. Remaining handicaps after injuries have a social and economic significance. In this study, the characteristics of polytrauma in childhood are evaluated by comparison with severely injured adults. The two groups of multiple trauma patients (117 children between 3 and 15 years of age and 1159 adults between 16 and 59) were equal in the overall severity of all injuries. Children were mainly hurt as pedestrians, whereas adults had an accident more often as car passengers. The most frequently injured region were in both groups fractures of the extremities. The greatest injury severity represented head injuries in each group. Complications were seen more often in adult patients. Multiple organ failure and isolated liver failure were exclusively seen in the adult group, pneumonia and lung failure occurred significantly more often. The duration of artificial ventilation and the duration of hospital stay were prolonged in the adult group. In summary, children with multiple injuries have a lower mortality rate than adults. The main cause of death are cerebral injuries. Remaining handicaps in surviving children are most often caused by fractures of the lower extremities.      

Influence of primary plate-osteosynthesis of femur fractures on complications in multiple trauma patients with or without thoracic injuries

Summary Primary intramedullary nailing of femoral fractures is well known to increase the risk of pulmonary complications, especially in multiple-trauma patients with severe thoracic injuries. Aim of this study was to investigate the influence of primary plate ostesynthesis of femur fractures on maior complications after trauma. This retrospective study based on the records of 325 multiple trauma patients (Injury severity score ISS > 18, no letal brain injury, age 16–65). According to the abbreviated injury scale of the Thorax (AIS T) patients were divided in groups without (AIS T < 3, “N”) or with relevant thoracic injury (AIS T > = 3, “T”). Both groups were additionally divided in subgroups without severe trauma to the extremities (AIS E< 3, “0”) or primary plate-osteosynthesis of femur fractures (< 24 h, “I”). 4 groups were performed: N0 (n = 39, ISS 25 ± 1, pneumonia 10 %, ARDS 5 %, lethality 10 %); NI (n = 55, ISS 27 ± 1, pneumonia 4 %, ARDS 5 %, lethality 4 %); T0 (n = 137, ISS 28 ± 1, pneumonia 21 %, ARDS 15 %, lethality 16 %); TI (n = 94, ISS 31 ± 1, pneumonia 21 %, ARDS 17 %, lethality 15 %). Primary plate-osteosynthesis of femur fractures did not increase lethality or incidence of pulmonary complications in patients with or without severe thoracic injuries. Also complication rate after primary plate-osteosynthesis was less compared to published results after intramedullary nailing. For this, primary plate-osteosynthesis is recommendable in case of multiple trauma with thoracic injuries.      

Early intramedullary nailing of lower extremity fracture and respiratory function in polytraumatized patients with a chest injuryA retrospective study of 61 patients

Background?The optimal treatment of diaphyseal fractures of the lower extremities in patients who also have serious chest injuries is not known. Patients and methods?We retrospectively evaluated the effect of an early intramedullary nailing (IMN) of femur or tibia fractures on respiratory function in 61 consecutive polytraumatized patients with unilateral or bilateral pulmonary contusion (thoracic AIS=3) admitted to our trauma intensive care unit between January 2000 and June 2001. 27 patients had a diaphyseal fracture of at least one long bone of the lower extremity, which was treated with IMN within 24 hours of admission. Results?We found no difference between patients with or without a lower extremity fracture regarding the length of ventilator treatment, oxygenation ratio (PaO2/FiO2) or in the incidence of acute respiratory distress syndrome (ARDS), pneumonia, multi-organ failure or mortality. Interpretation?In this retrospective study, IMN of a long bone fracture in a patient with multiple injuries and with a coexisting pulmonary contusion did not impair pulmonary function or outcome.     

Early intramedullary nailing of lower extremity fracture and respiratory function in polytraumatized patients with a chest injury: a retrospective study of 61 patients

BACKGROUND: The optimal treatment of diaphyseal fractures of the lower extremities in patients who also have serious chest injuries is not known. PATIENTS AND METHODS: We retrospectively evaluated the effect of an early intramedullary nailing (IMN) of femur or tibia fractures on respiratory function in 61 consecutive polytraumatized patients with unilateral or bilateral pulmonary contusion (thoracic AIS=3) admitted to our trauma intensive care unit between January 2000 and June 2001. 27 patients had a diaphyseal fracture of at least one long bone of the lower extremity, which was treated with IMN within 24 hours of admission. RESULTS: We found no difference between patients with or without a lower extremity fracture regarding the length of ventilator treatment, oxygenation ratio (PaO2/FiO2) or in the incidence of acute respiratory distress syndrome (ARDS), pneumonia, multi-organ failure or mortality. INTERPRETATION: In this retrospective study, IMN of a long bone fracture in a patient with multiple injuries and with a coexisting pulmonary contusion did not impair pulmonary function or outcome.     

Appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making

BACKGROUND: Current techniques for assessment of chest trauma rely on clinical diagnoses or scoring systems. However, there is no generally accepted standard for early judgement of the severity of these injuries, especially in regards to related complications. This drawback may have a significant impact on the management of skeletal injuries, which are frequently associated with chest trauma. However, no convincing conclusions can be determined until standardization of the degrees of chest trauma is achieved. We investigated the role of early clinical and radiologic assessment techniques on outcome in patients with blunt multiple trauma and thoracic injuries and developed a new scoring system for early evaluation of chest trauma. METHODS: A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS] > or = 18) patients admitted to our unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISS > or = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated. RESULTS: A total of 1,495 patients fulfilled the inclusion criteria. Patients' medical records and chest radiographs were reevaluated between May 1, 1998, and June 1, 1999. The association between rib fractures and chest-related death was low (> three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (> three ribs bilateral, mortality 40.9%, odds ratio 3.43). Injuries to the lung parenchyma, as determined by plain radiography, were associated with chest-related death, especially if the injuries were bilateral or associated with hemopneumothorax (lung contusion unilateral, mortality 25.2%, odds ratio 1.82; lung contusion bilateral + hemopneumothorax, mortality 53.3%, odds ratio 5.1). When plain anteroposterior chest radiographs were used, the diagnostic rate of rib fractures (< or = three ribs) increased slightly, from 77.1% to 97.3% during the first 24 hours of admission. In contrast, pulmonary contusions were often not diagnosed until 24 hours after admission (47.3% at admission, 92.4% at 24 h, p = 0.002). A new composite scoring system (thoracic trauma severity score) was developed that combines several variables: injuries to the chest wall, intrathoracic lesions, injuries involving the pleura, admission PaO2/FIO2 ratio, and patient age. The receiver operating characteristic curve demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693). CONCLUSION: Radiographically determined injuries to the lung parenchyma have a closer association with adverse outcome than chest-wall injuries but are often not diagnosed until 24 hours after injury. Therefore, clinical decision making, such as about the choice of surgery for long bone fractures, may be flawed if this information is used alone. A new thoracic trauma severity score may serve as an additional tool to improve the accuracy of the prediction of thoracic trauma-related complications.     

The management of flail chest

Flail chest is an uncommon consequence of blunt trauma. It usually occurs in the setting of a high-speed motor vehicle crash and can carry a high morbidity and mortality. The outcome of flail chest injury is a function of associated injuries. Isolated flail chest may be successfully managed with aggressive pulmonary toilet including facemask oxygen, CPAP, and chest physiotherapy. Adequate analgesia is of paramount importance in patient recovery and may contribute to the return of normal respiratory mechanics. Early intubation and mechanical ventilation is paramount in patients with refractory respiratory failure or other serious traumatic injuries. Prolonged mechanical ventilation is associated with the development of pneumonia and a poor outcome. Tracheotomy and frequent flexible bronchoscopy should be considered to provide effective pulmonary toilet. Surgical stabilization is associated with a faster ventilator wean, shorter ICU time, less hospital cost, and recovery of pulmonary function in a select group of patients with flail chest. Open fixation is appropriate in patients who are unable to be weaned from the ventilator secondary to the mechanics of flail chest. Persistent pain, severe chest wall instability, and a progressive decline in pulmonary function testing in a patient with flail chest are also indications for surgical stabilization. Open fixation is also indicated for flail chest when thoracotomy is performed for other concomitant injuries. There is no role for surgical stabilization for patients with severe pulmonary contusion. The underlying lung injury and respiratory failure preclude early ventilator weaning. Supportive therapy and pneumatic stabilization is the recommended approach for this patient subset.     

Abdominal trauma

Summary While a great part of the Anglo-American medical literature addresses the topic of penetrating trauma the German spreaking countries rather publish on blunt abdominal injury. The presented paper discusses the strategic principles of acute clinical management of abdominal trauma on the combined basis of own research results and a comprehensive review of the literature. Blunt abdominal injuries in most cases from a part in the pattern of multiple trauma. The early, first-hours mortality is most often caused by severe traumatic brain injury or abdominal trauma with massive hemorrhage. The prehospital management of penetrating injuries is characterized rather by the concept of ’load and go', whereas the on-scene stabilization of the patient with blunt abdominal injury should precede transport to the adequate hospital. On arrival in the accident and emergency room an immediate blood transfusion is recommended for hemodynamically unstable patients. If then a stabilization is not achieved, an emergency laparotomy should follow. Abdominal stab injuries should be explored by laparoscopy if an intraperitoneal lesion is suspected. If then the possibility of an intestinal lesion is present a laparotomy should be performed directly thereafter. Firearm injuries require open revision in almost all cases. The standard diagnostic technique in blunt abdominal trauma is sonography, assisted by computed tomography and, if indicated, angiography in hemodynamically stable patients. Isolated abdominal injuries without hemodynamic or coagulation disorders allow conservative treatment in the intensive care setting. In severe multiple trauma as well as in manifest shock even the smallest fluid detection should lead to laparotomy. The surgical treatment of splenic rupture is still a matter of discussion. Splenectomy is indicated in patients with severe concomitating injuries or shock whereas in the remainder of cases the total or partial preservation of the spleen should be pursued. Hepatic injuries offer a broad spectrum of operative interventions, ranging from superficial hemostatic measures over compression techniques like ’packing' and ’mesh-wrapping' to atypical and anatomical resections and to liver transplantation in exceptional cases. Lesions of tubular organs and the pancreas pose especially difficult diagnostical problems but regularly allow a rather easy operative treatment.      

肺挫伤的诊断与治疗进展

肺挫伤在全身多发伤患者尤其是合并胸部钝性损伤患者中很常见,由于常合并肋骨骨折、血气胸、腹部脏器伤、四肢骨折及部分病例早期临床表现不典型,肺挫伤常被漏诊,以至于发展为肺部感染、肺不张,甚至是急性呼吸窘迫综合征(ARDS),临床病死率较高。国内外学者均主张早期准确诊断、综合治疗以提高疗效,降低病死率,但具体治疗策略尚未统一。笔者搜集整理了近年来国内外有关肺挫伤治疗的文献后,对肺挫伤诊断治疗的新进展进行综述。     

Treatment of 336 cases of chest trauma

Objective: To summarize the clinical features,diagnosis and treatment of chest trauma.Methods: A retrospective analysis was conducted among 336 cases of chest trauma admitted to our hospital from Janua...     

Significance of lung contusion in mortality following polytrauma. Possibilities for therapeutic influence

Multiple trauma is often associated with blunt thoracic injuries. Especially lung contusion can result in respiratory insufficiency and therefore a higher mortality rate. In our prospective study comparing 8 multiple trauma patients with and without associated lung contusion, we found that respiratory function was already significantly disturbed (decrease of paO2/FiO2 and increase of AaDO2, a rise in extravascular lung water (EVLW) both early after trauma and also with a second peak following the 4th day. This group (LK) developed significantly more cases of respiratory distress (ARDS). The disturbance of respiratory function seen initially was interpreted as a consequence of the direct mechanical impact, leading to the formation of interstitial fluid and hematoma. The frequent development of ARDS in the LK-group probably results from a pronounced activation of cellular and humoral mechanisms and therefore an enforced injury of the pulmonary capillary bed. A significant increase of pulmonary infections or the development of sepsis was not seen in the LK-group and is probably not responsible for the higher ARDS-rate in this group.     

Outcome of lung trauma.

OBJECTIVE: To find out whether we could manage critical pulmonary haemorrhages in penetrating injuries, and to report our experience with blunt trauma of the lung. DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 81 patients who presented with pulmonary injuries during the period January 1988-December 1997; 6 were penetrating and 75 blunt. RESULTS: There was only one patient with an isolated lung contusion. The remaining was divided into 2 groups: those with pulmonary contusion and thoracic lesions (n = 32), and those with pulmonary contusion and extrathoracic lesions (n = 42). Four patients in the penetrating group were shocked and required urgent operations; emergency room thoracotomy (n = 1), urgent thoracotomy (n = 2), and urgent thoracoabdominal exploration (n = 1) were done successfully. We correlated grade of lung injury [American Association for the Surgery of Trauma-Abbreviated Injury Scale (AIS)] with mortality. All patients with penetrating injuries survived without serious consequences. There were a mean (SD), of 6 (2) injuries/patient in those with extrathoracic injuries compared with 3 (1) injuries/patient in the group with thoracic lesions (p < 0.001). The corresponding hospital mortality was 6/42 (19%) mainly as a result of the central nervous system lesions (4/6) compared with 0/32. The mean (SD) Injury Severity Score (ISS) was 9.3 (4.8) in patients with thoracic lesions compared with 24.1 (14.7) in patients with extrathoracic lesions (p < 0.0001), and 14.9 (9.5) in all survivors compared with 49.9 (13.6) among those who died (p < 0.0001). CONCLUSIONS: An excellent outcome can be achieved managing penetrating injuries of the lung by an aggressive approach and urgent surgical intervention even when emergency room thoracotomy is essential. Pulmonary contusion is considered to be a relatively benign lesion that does not add to the morbidity or mortality in patients with blunt chest trauma. These data may help to decrease the obsession with pulmonary contusion in patients with chest trauma, with or without extrathoracic lesions, and avoid many unnecessary computed tomograms of the chest.     

Diagnosis of lung injury in combined chest trauma

All the lung injuries in combined chest trauma were divided into direct (contused) and indirect (pulmonary complications). Contused injured of lungs were diagnosed in 178 (60.9%) patients with combined chest trauma. Among all contused pulmonary injuries, contusion of the lungs revealed in 141 (48.2%) patients had the most influence on traumatic disease. Criteria of diagnosis of pulmonary complications were defined. Based on the obtained results, classification of lung injuries in combined chest trauma was developed.     

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.     

The frequency and significance of thoracic injuries detected on abdominal CT scans of multiple trauma patients

Of 174 multiple trauma patients undergoing abdominal CT examination for suspected abdominal trauma, 65 patients had 109 chest injuries detected by abdominal CT, chest film, or both examinations. Forty-one patients had 55 chest injuries at the base of the thorax which were not detected on the initial chest film. The most frequent chest injuries detected only by CT were pneumothroax, fracture (rib, thoracic spine, and sternum), lung contusion, aspiration pneumonia, hemothorax, and post-traumatic atelectasis. Seven patients whose chest injury initially was seen only at abdominal CT required treatment of the injury, suggesting that a variety of chest injuries which may vitally affect patients can be detected early in multiple trauma patients by abdominal CT, and that all abdominal trauma CT scans should be scrutinized for signs of a chest injury.     

胸外伤986例治疗体会

目的总结各类胸外伤的治疗经验. 方法回顾性分析986例胸外伤的受伤类型和治疗情况.闭合性损伤942例 (95.5%), 开放性损伤44例 (4.5%).肋骨骨折最常见, 占784例(79.5%),合并血、气胸330例(33.5%),肺挫裂伤168例(17%);创伤性膈疝24例(2.4%),支气管断裂12例(1.2%);其他166例.伴有多发伤者234例.所有患者均接受相应的手术和非手术固定治疗.结果死亡10例(1.0%),7例为重症胸外伤合并呼吸衰竭,3例为粗木穿透胸部致广泛肺及肺血管撕裂伤;其余患者均痊愈出院. 结论对于不同类型的胸部外伤,迅速解除导致呼吸困难的原因,妥善固定胸壁,减少反常呼吸,必要时行剖胸探查、气管切开高频喷射通气等是治疗成功的关键.     

Blunt traumatic lung injuries

Approximately one third of patients admitted to major trauma centers in the United States sustain serious injuries to the chest. The lungs, which occupy a large portion of the chest cavity and lie in close proximity to the bony thorax, are injured in the majority of these patients directly or indirectly. A significant number of lung injuries are also associated with trauma to other critical thoracic structures. This article discusses blunt trauma injuries of the lung, which include pulmonary contusions, hematomas, lacerations, and pulmonary vascular injuries.     

The significance of the systemic inflammatory response syndrome (SIRS) in 1278 trauma patients

Summary The association between the increasing severity of systemic inflammatory response syndrome (SIRS) and the incidence of posttraumatic complications and mortality was retrospectively investigated in 1278 injured patients. Patients were divided into three groups according to their Injury Severity Score (ISS) (group A: ISS L 9 K16 points (n = 626); group B: ISS > 16 < 40 points (n = 589); group C: ISS L 40 points (n = 63)). SIRS was defined according to the criteria of the American Consensus Conference. The number of fulfilled criteria determined its severity: moderate SIRS: 2 criteria fulfilled, intermediate SIRS: 3 criteria fulfilled, severe SIRS: 4 criteria fulfilled. Additionally, acute respiratory distress syndrome (ARDS) was defined according to the Murray-Score and the multiple organ dysfunction syndrome (MODS) according to the Goris-Score. The incidence of SIRS was 42 % in group A, 70 % in group B and 100 % in group C (p < 0.05). The severity of SIRS increased with severity of trauma. Moreover, 178 of all injured patients (14 %) developed septic complications. In parallel to SIRS, the incidence of these septic complications correlated with the severity of trauma. The occurrence and severity of ARDS and MODS correlated with increased severity of SIRS and septic complications. Among patients without SIRS 15 % developed ARDS and 21 % MODS. In contrast, patients with severe SIRS and septic complications demonstrated ARDS in 99 % and MODS in 97 %. In these patients, no correlation was found between the ISS and the incidence of ARDS or MODS. There were also stepwise increases in mortality rates in the hierarchy from SIRS to septic shock. While 13 of patients with modest SIRS (5 %) and 32 of patients with intermediate SIRS (13 %) died, the mortality rate of patients with severe SIRS was 19 % (p < 0.05). In addition, a significant correlation between the incidence of septic complications and mortality was found. Injured patients with sepsis died in 13 %, those with severe sepsis in 23 %, and patients with septic shock in 33 % (p < 0.05). Thus, the increasing severity of SIRS was associated with the occurrence of posttraumatic ARDS, MODS, and mortality. Using the number of fulfilled SIRS criteria for classifying systemic inflammation, its severity may be predictive for posttraumatic complications and outcome of injured patients.      

Die Akutbehandlung der traumatischen Brustmarklähmung

AIM: The aim of this study was to analyse the number of thoracic injuries associated with acute traumatic paraplegia of the upper and middle thoracic spine and review the early management in respect to treatment standards.METHODS: Using a prospective study protocol, data were sampled and analyzed from 12 December 2000 to 31 March 2002 at a level 1 trauma center.RESULTS: Twenty-two consecutive patients were included in the study. Sixteen suffered severe chest traumata. Lung contusion was diagnosed in 81%, followed by haemopneumothorax (75%) and fracture of the bony chest (75%). Intubation was performed 12 times in all. Chest drainage was performed in 14 patients. The mean duration of artificial ventilation was 20 days (range 2-93) and of intensive care treatment 25 days (range 2-93). Five patients died.CONCLUSIONS: Acute traumatic paraplegia of the upper and middle thoracic spine caused by high energy trauma is highly associated with severe chest trauma. Therefore, respiratory impairment must be kept in mind during the early treatment. If respiratory failure becomes more evident, emergency procedures such as intubation and chest drainage have to be performed. Secondary transfer should be avoided.