亚热带山岳丛林眼战伤诊治的回顾与思考

目的 探索亚热带山岳丛林地区眼战伤的特点及规律,提高未来战争中眼战伤的救治成功率,减少伤残率. 方法 回顾分析1979年及1984年两次云南方向对越自卫还击作战期间解放军第五十九中心医院眼战伤的资料,总结其特点. 结果 (1)单眼伤占81.7%,双眼伤占18.2%,左右眼无明显差异;(2)致伤因素以弹片伤为主,占82.2%;(3)眼战伤合并全身各部位伤高达75.6%;(4)眼球伤最多,其中开放性眼外伤占45.1%. 结论及时正确的专科处置可以有效地降低眼战伤的致旨率.     

Atypical wound of entry and unusual presentation in a fatal stab injury

Stab wounds encountered in medico-legal autopsies are usually caused by sharp pointed weapons. Peculiarities of the wound of entry in stab wounds, for example due to the hilt of the weapon, movement of the weapon and sometimes by the hand of the assailant holding the weapon are often described in literature. We report an unusual presentation in a fatal stab injury wherein a single atypical external wound was associated with multiple internal injuries to the organs. The exact cause of such peculiarities can never be accurately determined, rather that can be speculated upon at the time of the autopsy and recorded for the purpose of academic interest.     

Gunshot wounds of the abdomen studied by computed tomography. The authors' personal experience in 30 cases

INTRODUCTION: CT plays an important role in depicting gunshot wounds in parenchymal and hollow organs in the abdomen. Relative to other techniques and to emergency laparotomy, CT permits good assessment of abdominal content, major injuries and changes in other districts, such as chest, pelvis and skull. We investigated the yield and role of CT in diagnosing abdominal gunshot wounds, with their rich and varied radiological signs and associated injuries. MATERIAL AND METHODS: We retrospectively reviewed the findings of 30 patients with abdominal gunshot wounds examined in 4 years at Loreto-Mare Hospital, Naples. All patients were men, age ranging 19-54 years (mean: 35); 6 of them were not from the European Union. Examinations were carried out from diaphragm to pubis with i.v. contrast injection and the CT angiography technique. CT was integrated with chest studies in 6 cases and with skull studies in 5. Subsequent CT follow-ups were necessary in 12 cases submitted to conservative treatment. RESULTS: Liver was the most damaged parenchyma, with hemorrhage and lacerocontusion in 7 cases and mashed in 1 case; spleen was involved in 4 cases; hemoperitoneum was found in 18 cases. Diaphragm was involved in 5 cases and pancreas in 2; gallbladder, stomach and duodenum were involved in 1 case each and jejunum-ileum and colon in 3 and 6 cases, respectively. CT showed renal injury in 3 cases and bladder injury in 2. Eight patients had vertebral gunshot damage. Pneumothorax, hemothorax and lacerocontusion were found in 7 cases; brain was injured in 4 cases and limbs in 16. DISCUSSION AND CONCLUSIONS: Tissue damage extent depends on the speed and kinetic energy the bullet carries into the abdomen. Abdominal radiography shows the bullet and its site, pneumoperitoneum from gastrointestinal perforation, crash bone injuries, vertebral trauma and subcutaneous emphysema. Instead, CT depicts early parenchymal damage and vascular injury and thus becomes a complete and necessary tool for imaging gunshot wounds. CT provides early diagnostic information which help plan emergency treatment and thus decrease mortality. As for angiography and US, we suggest they be used subsequently because in emergency they may delay the diagnosis. Moreover, vessel rupture and active intraabdominal bleeding are easily detected with spiral CT, which appears the best tool for prompt assessment of the injuries associated with gunshot wounds in other districts such as, the skull. To conclude, CT permits adequate planning of emergency surgery and helps select the cases for follow-up, intensive care and conservative treatment.     

现代战争中眼创伤的伤情特点与防治

现代战争中 ,高速、高能、高精确度武器的应用使眼创伤的比率增大 ,伤情严重 ,救治困难。其中 ,眼爆炸伤、穿通伤和异物伤多见 ,复合伤和多发伤增多。头盔及护目镜等防护器具的研制和装备 ,正确的急救原则 ,完善的后送程序是防治眼创伤的主要措施     

106例颌面部火器伤伤情分析

分析１０６例颌面颈部火器伤的伤因、伤道、骨折的特点，由于投射物速度高能量大，致伤时可产生较大的瞬时空腔，不仅有原发伤道的损伤，而且有周围组织的间接损伤，甚至远隔脏器的损伤，损伤广泛而严重，在同一伤员，不同部位伤情，伤型也不相同，多发伤多，伤道曲折，盲管伤多，污染严重，感染率高的特点，临床救治时应注意。     

Bacteriology of war wounds at the time of injury

Bacterial contamination of war wounds occurs either at the time of injury or during the course of therapy. Characterization of the bacteria recovered at the time of initial trauma could influence the selection of empiric antimicrobial agents used to prevent infection. In the spring of 2004, U.S. military casualties who presented to the 31st Combat Support Hospital in Baghdad, Iraq, with acute traumatic injuries resulting in open wounds underwent aerobic culture of their wounds to identify the bacteria colonizing the wounds. Forty-nine casualties with 61 separate wounds were evaluated. Wounds were located predominantly in the upper and lower extremities and were primarily from improvised explosive devices or mortars. Thirty wounds (49%) had bacteria recovered on culture, with 40 bacteria identified. Eighteen casualties (20 wounds) had undergone field medical therapy (irrigation and/or antimicrobial treatment); six of these had nine bacterial isolates on culture. Of the 41 wounds from 31 patients who had received no previous therapy, 24 grew 31 bacteria. Gram-positive bacteria (93%), mostly skin-commensal bacteria, were the predominant organisms identified. Only three Gram-negative bacteria were detected, none of which were characterized as broadly resistant to antimicrobial agents. The only resistant bacteria recovered were two isolates of methicillin-resistant Staphylococcus aureus (MRSA). Our assessment of war wound bacterioly soon after injury reveals a predominance of Gram-positive organisms of low virulence and pathogenicity. The presence of MRSA in wounds likely reflects the increasing incidence of community-acquired MRSA bacteria. These data suggest that the use of broad-spectrum antibiotics with efficacy against more resistant, Gram-negative bacteria, such as Pseudomonas aeruginosa and Acinetobacter spp., is unnecessary in early wound management.     

The emergency care network of a ski marathon

In this paper we report the system of emergency care that was used in a large-scale cross-country ski marathon. We describe the typical terrain encountered, personnel required, physical facilities, communication system, injury protocol, and types and numbers of injuries seen. We have found that many injuries can occur in a cross-country ski race, given specific race conditions. A complete and efficient emergency care network is essential to the success of any athletic event similar to the one we report. These races are rapidly growing in number and size, yet we could not find any previous reports in the literature pertaining to the medical care necessary. We hope to provide a model for emergency care that can be applied to many different athletic events involving large numbers of participants and covering great distances.     

Virtual autopsy: preliminary experience in high-velocity gunshot wound victims

PURPOSE: To retrospectively assess virtual autopsy performed with multidetector computed tomography (CT) for the forensic evaluation of gunshot wound victims. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study and did not require informed consent of the next of kin. Thirteen consecutive male gunshot wound victims (mean age, 27 years) were scanned with 16-section multidetector CT prior to routine autopsy. Retrospectively, the total-body nonenhanced scans were interpreted at a three-dimensional workstation by radiologists blinded to autopsy findings. Images were evaluated for lethal wound, number and location of wound tracks, injured structures, and metal fragment location. After image review, autopsy reports and photographs were compared with the images and interpretations to validate the multidetector CT determinations. RESULTS: Multidetector CT aided in correct identification of all lethal wounds, and metallic fragment location was always precise. In four cases, multidetector CT aided in accurate assessment of organ injuries and lethal wounds but led to underestimation of the number of wounds if comingling paths occurred. In two cases of a chest wound, multidetector CT aided in accurate assessment of the chest as having the lethal wound but failed to help identify specific sites of hemorrhage. In two cases of craniofacial injury, the path of the wound was not clear. Autopsy revealed a total of 78 wound tracks (mean, 6; range, 1-24). Ten (13%) wound tracks were not identified at multidetector CT (six upper extremity wounds and four thigh wounds). In two cases, findings missed at autopsy (fracture of the cervical spine, bullet fragments in the posterior area of the neck) were identified at multidetector CT. CONCLUSION: Multidetector CT can aid prediction of lethal wounds and location of metallic fragments.     

Using the inflammatory cell infiltrate to estimate the age of human burn wounds: A review and immunohistochemical study

The burn wound healing process, which is reviewed in this paper, has features that differ from the healing of incised cutaneous wounds. This study used immunohistochemical staining and cell counting to examine the inflammatory cell response in biopsy samples of burn wounds from live human subjects obtained at six hours until 23 days after injury in order to determine how the age of a burn could be estimated. Acute inflammatory cells predominated in samples taken six hours to two days after injury. However, neutrophils were often minimal in early samples or could be present late. Elevated numbers of macrophages tended to be encountered from days 2 to 20, but it was not uncommon to observe a minimal or absent macrophage response. Unexpectedly, there was no trend in the number of lymphocytes. A small study was also made of burn wound samples that had been obtained at post-mortem examination of subjects that died in a fire or up to 77 days after injury from fire. This revealed a similar trend of neutrophil and macrophage accumulation. Additionally, it appeared that an increase in the number of lymphocytes occurred late, from 35 days. In conclusion: If neutrophils predominate, the wound is probably less than a couple of days old. When macrophages are abundant the wound is probably a few days to weeks old. However, as expected from the review of the literature, the inflammatory cell infiltrate may be low or absent in burn wounds, which can render determination of the age of burn wounds difficult.     

The role of computed tomography in gunshot lesions of the chest. The authors' personal experience

PURPOSE: CT is a valuable tool in assessing thoracic gunshot wounds. CT is also the method of choice in emergency, because it permits rapid depiction of bullet damage to the chest and to other body districts. This in turn permits correct assessment of the main thoracic injuries, plus adequate and prompt planning of surgical treatment or support intensive care. We report on the role of CT in diagnosing the complex pleuropulmonary, cardiovascular and thoracic wall injuries caused by gunshot wounds, with their specific and acute signs which differ greatly from those of other types of chest trauma. MATERIAL AND METHODS: In the last 4 years, we observed 76 cases of gunshot injury, twenty-six of them involved the chest. The patients, 25 men and 1 woman (mean age: 32 years, range: 17-48), were all submitted to emergency CT with i.v. contrast agent injection and the CT-angiography technique. The reanimator was always present to monitor the patients' vital functions and shock state. CT of the chest was integrated with CT of the abdomen and pelvis in 4 cases and with CT of the skull in 3 cases, to detect associated bullet wounds if any. RESULTS: The most frequent CT finding was lung parenchyma tear and bruise (25 cases), followed by hemothorax (18 cases) and subcutaneous chest wall emphysema (9 cases). Pneumothorax was seen in 5 cases, associated with hemothorax in 6; rib injuries were found in 7 cases; pneumomediastinum was found in 4 cases and areas of pulmonary atelectasis in 3; the diaphragm was ruptured in 4 cases. CT showed spinal involvement in 11 patients, with injury of D3 and D5 in 4 and 3 cases, respectively; signs of interrupted spinal marrow were found in 7 cases. Damage from gunshot wounds was detected in the liver, spleen, skull and limbs in 3, 2, 3 and 10 cases, respectively. DISCUSSION AND CONCLUSIONS: Chest radiography shows major gunshot wound damage to the chest and lungs, except for heart injuries and minimal pneumothorax. When abdominal and skull injuries are associated, CT should be the method of choice because it permits prompt and panoramic assessment of the severity of pulmonary and extrathoracic damage. This results in prompt and targeted treatment, avoiding unnecessary delays which may damage the patient further.     

颅脑火器伤的临床特征与救治

目的 总结和分析颅服火器伤的临床特征与救治经验，提高其诊治水平。方法 回顾性分析了259例颅脑火器伤患者的损伤特点和救治情况。结果 本组火器伤类型为：盲管伤162例（62．5％）；贯通伤（32．8％）；切线伤12（4．6％）；合并其他部位伤63例（24．3％），损伤特点是：伤情急、创伤重、病情变化快。经急救和手术处理后，生存225例（86．9％），死亡34例（13．1％）。对187例平均随访5．6年；恢复良好105例（56．1％）；轻残54例（28．9％）；重残23例（12．3％）；植物生存状态5例（2．7％）。结论 迅速对患者开展现场急救、正确地进行伤情评估和急诊手术处理，是提高救治水平的关键。     

汽车内火药爆炸烧伤的特点及其救治

目的:探讨公交车内火药爆炸致伤特点、救治方法及施治中的组织工作。方法:以2001年元月-2004年12月所救治的3大批46例汽车内火药爆炸烧伤为样本,分析受伤人员其成分构成、烧伤部位、烧伤深度、复合伤、并发症等特点及其急救治疗、创面处理和施治中的组织方法。结果:伤员以中小学生为主(69.57%):烧伤面积较大且较深(平均面积/Ⅲ度面积48.31±12.42%TBSA/25.30 6.83%TBSA):伤员几乎均含颜面部和双手烧伤;合并伤及复合伤多(65.22%):治愈45例(治愈率98%);创面愈合时间:浅Ⅱ度6-12天,深Ⅱ度16-26天,Ⅲ度24-36天,未发生明显功能障碍和过度瘢痕形成;其中5例较深部位经异体皮复合自体表皮干细胞移植,经免疫组化法对角蛋白19型细胞的检测和临床愈合过程观察,其结果令人满意。结论:①MEBT/MEBO作为成批伤员救治中创面处理的首选方法具有无可替代的作用:②以异体皮复合自体表皮干细胞移植于较深创面能加速创面的原位再生,进一步提高愈合质量:③公交车内火药爆炸烧伤其伤员多为社会特殊群体组成,且人员集中,伤势严重,社会影响大,医务人员工作量大。因此,做到严密组织和科学分工才能保障对突发事件中的大批伤员实施快捷高效的救治。     

U.S. Army noncombat munitions injuries

OBJECTIVE: The object of this study was to determine the types of noncombat injuries secondary to munitions sustained by U.S. Army soldiers. METHODS: A retrospective review of all noncombat munitions injuries reported to the U.S. Army Safety Center from August 1989 to September 1996 was conducted. RESULTS: There were 742 incidents reported, resulting in 894 injured soldiers. The most common types of injuries were thermal burns, puncture wounds, and lacerations. The extremities were the most common anatomical location injured. The most common activities associated with injuries were combat training exercises, munitions firing, and rendering munitions safe. CONCLUSION: This study demonstrates a distinctive injury pattern for each category of munitions. Military readiness will be improved if we train all personnel to be familiar with the injury patterns and the most common situations associated with injury. By informing unit commanders which activities are associated with increased risk of injury, they may better prepare preventive measures to decrease the number of noncombat injuries.     

Concussion reporting and perceived knowledge of professional fighters

Objective: For concussions to be effectively managed in sports, they need to be correctly identified and reported. The extent to which professional athletes correctly recognize concussions, and their willingness to report symptoms, is not yet well understood. Given the risk of head injuries leading to concussions across combat sports, insight into professional fighters’ knowledge and reporting of concussive symptoms is essential to improve concussion management.

Methods: To investigate understanding and reporting patterns of concussions sustained while training or competing, 257 fighters completed a self-report questionnaire assessing self-perception of concussion knowledge, trust of ringside medical providers, and reported number of previous head injuries. Fighting history, including number of knockouts, was obtained from self-report (amateur) and published (professional) records.

Results: Significant gaps in fighters’ perceived knowledge of concussion symptoms and long-term effects of multiple concussions emerged. Approximately 40% of fighters reported returning to training or competition the same day a head injury was sustained, while 21% of fighters endorsed concealing symptoms of head injury from medical providers and coaches.

Conclusions: Confusion surrounding terms used to describe head injuries amongst fighters (e.g., concussions, knockouts), coupled with limited understanding of concussive symptoms and a desire to return to competition, likely contributes to significant underreporting of symptoms.     

Skatepark-related injuries in a southern California skatepark and their associated short-term disability and healthcare utilization.

OBJECTIVE: To assess the types of injuries, the extent of short-term disability, and the degree of healthcare utilization in skatepark-injured patients. DESIGN: The study design was a prospective case series with 1-year follow-up. SETTING: Level I trauma center and emergency department located in Orange, California. PARTICIPANTS: Subjects age 7 years or older who sustained an injury at a local skatepark and were treated in our emergency department were included in the study. Ninety-five subjects were enrolled with a total of 97 injury encounters. MAIN OUTCOME MEASUREMENTS: Types of injuries, extent of short-term disability, degree of healthcare utilization. RESULTS: Emergency department diagnoses included 57 fractures, 6 dislocations, 15 strains/sprains/contusions, 7 lacerations, 2 dental fractures, 9 head injuries, and 1 intra-abdominal injury. Nine of the emergency department encounters terminated in admission to the hospital. The peak sum of time lost from school, work, parental time lost from work, and specialist visits were found to occur at 1 month postinjury. Similarly, the number of postinjury follow-up medical visits peaked at the 1-month interval. Subject disability was largely categorized as moderate initially, with a subsequent reduction to no disability by the 9th postinjury month. CONCLUSION: Skatepark-related injuries can yield substantial time lost from school and work, considerable short-term disability, and an increase in healthcare resource utilization.     

Wound age estimation based on chronological changes in chitinase 3-like protein 1 expression

In forensic practice, wound age estimation is essential for making assessments of injuries; however, it remains challenging, and markers which correctly indicate wound age are required. Since our previous study showed that chitinase 3-like protein 3 (CHI3L3) expression changed chronologically in murine skin wounds, we hypothesized that other proteins of chitinase and chitinase-like protein (C/CLP) family, which CHI3L3 belongs to, might also have varied expression in wound healing. Therefore, we considered that some proteins of the C/CLP family could be used as markers of wound age estimation, and we aimed to test this hypothesis. Examinations of murine skin wounds revealed that the expression of chitinase 3-like protein 1 (CHI3L1) changed chronologically. CHI3L1 expression in human cadaver skin wounds, which was immunohistochemically analyzed by the average ratio of CHI3L1-expressed cells/total cells in 10 microscopic fields, was weak in wounds from days 0 to 1 after injury (0.11 ± 0.024; mean ± standard error of the mean); however, CHI3L1-positive cells appeared in wounds from days 2 to 3 (1.65 ± 0.19). The number of CHI3L1-expressed cells increased in wounds from days 4 to 6 (5.35 ± 0.35) but dropped from days 7 to 13 (1.53 ± 0.24). Receiver operating characteristic curve analysis indicated that wounds from days 4 to 6 after injury could be clearly distinguished from other wounds based on a cutoff value of 2.75, sensitivity of 92.31%, and specificity of 85.14%. Our findings suggest that CHI3L1 could be a reliable marker for wound age estimation in forensic practice.     

Counting organised sport injury cases: Evidence of incomplete capture from routine hospital collections

Organised sports are a popular form of physical activity, but unfortunately, participation can result in injury. Despite this, there have been surprisingly few studies that have reported the population rate of sports injury. Data from the 2005 New South Wales (NSW, Australia) Population Health Survey were analysed to describe self-reported injury experiences during participation in organised sports activities and the source of treatment for such injuries during a 12-month period in a population representative sample of adults aged 16+ years. At interview, 2414 respondents stated that they had participated in organised sport in the previous 12 months and just under one-third (30.9%) reported that they had been injured during this participation. Half of all injuries required formal treatment from a health or medical practitioner. Physiotherapists most commonly provided treatment for sports injury (26.6% of cases) followed by general practitioners (15.6%). Only 2.8% of all injured sports participants were admitted to hospital for their injury and a further 6.1% received treatment in an emergency department. This corresponds to at most only 8.9% of all treated sports injuries receiving treatment in a hospital setting. Population-based estimates of the rate and burden of sports injuries that rely solely on routine hospital data collections are likely to grossly underestimate the size of the problem, as very few cases are treated in a hospital setting.     

Ventricular injury following cranial gunshot wounds: clinical study

Gunshot wounds to the head are usually fatal injuries, despite all medical and surgical interventions. Ventricular injury is a poor prognostic factor-for penetrating cranial gunshot wounds. Intraventricular hemorrhage and ventricular lacerations are the main components of such injuries. The incidence, management, and outcomes of cases of ventricular injury secondary to cranial gunshot wounds that were treated during a 9-year period at Gülhane Military Medical Academy were examined. The study group consisted of 67 consecutive patients who were admitted to the Department of Neurosurgery with the diagnosis of ventricular injury, with different penetration sites. The patients had been injured by either bullets or shrapnel. Surgical treatment was performed for all patients with ventricular injuries and 22 (32.8%) died. Ventricular injury in cranial gunshot wounds is a complex severe type of trauma that requires serious treatment. Early radiological diagnosis and accurate treatment frequently had lifesaving roles for these patients.     

负压封闭技术治疗难愈性创面的护理体会

目的探讨负压封闭引流技术在治疗难愈性创面过程中的护理工作及体会。方法采用负压封闭引流技术对84例难愈性创面患者进行治疗,在治疗期间护理工作主要包括:(1)观察负压封闭的粘贴是否完好,在改变体位后有无脱落漏气;(2)管道连接准确,各接头处有无密封不严的情况,管道是否堵塞,色泽是否变灰或黑色等;(3)吸引瓶内分泌物每日计量并做细菌培养等。结果本组因体位改变导致创面边缘贴膜脱落,皱褶漏气25例38处,补贴1次19例24处,补贴2次以上6例14处;负压吸引管堵塞5例,管道接头处堵塞3例;管道因变黑更换7例。上述问题护士均在第一时间发现并进行处理,必要时报告医师协助处理,使负压封闭治疗过程连续且按计划进行。结论负压封闭引流技术治疗难愈性创面,比传统创面换药治疗省时省力,缩短治疗时间,并且提高了创面愈合的成功率。