损伤严重度评分在脊柱脊髓型严重多发伤救治中的应用

目的 探讨损伤严重度评分（ISS）在脊柱脊髓型严重多发伤治疗中应用的意义。方法 以简明损伤定级标准2005（AIS 2005）为基础,采用ISS评分对55例脊柱脊髓型严重多发伤进行评估分析。结果 ISS值随损伤部位数增加而增高,并发症也增多;好转率与ISS评分相反。ISS〉25分者在免疫观察期,可较安全地按计划进行最终手术。结论 脊柱脊髓型严重多发伤的救治应根据病人伤情程度及局部情况等决定,ISS评分在治疗选择中有重要的指导意义。     

严重多发伤患者早期血浆内毒素水平变化及与胃肠功能障碍的关系

目的 探讨严重多发伤患者血浆内毒素水平的变化及其与创伤后胃肠功能障碍的关系。方法 将27例多发伤患者分为轻伤组（ISS评分〈16分）12例,重伤组（ISS评分〉16分）15例;将27例多发伤患者分为非胃肠功能障碍组6例和胃肠功能障碍组21例;设正常对照组10例,正常对照组采静脉血1次,27例多发伤患者于伤后第1、3天采静脉血2次,应用动态浊度法检测血浆内毒素变化。结果 与正常对照组相比,轻伤与重伤组血浆内毒素水平在伤后1、3天均明显升高（P〈0．01）;重伤组伤后第3天血浆内毒素水平较轻伤组明显升高（P〈0．01）;创伤后第3天胃肠功能障碍组与非胃肠功能障碍组血浆内毒素水平差异显著,其内毒素水平与胃肠功能障碍程度相关性显著。结论 严重创伤后血浆内毒素水平明显升高,其变化不仅与伤创的严重程度有关还与肠功能障碍密程度密切相关,这种动态变化可能对早期预测创伤后胃肠功能障碍具有一定的临床价值。     

严重多发伤患者血浆凝血酶原片段1+2水平的变化及与弥散性血管内凝血的关系

目的 探讨严重多发伤患者血浆凝血酶原片段1＋2（F1＋2）水平变化及与创伤后弥散性血管内凝血（DIC）之间的关系。方法 将66例多发伤患者分为轻伤组（ISS评分〈16分,21例）和重伤组（ISS评分≥16分,45例）,再把重伤组分为并发DIC组（12例）与未并发DIC组（33例）,另10例健康人为正常对照组。射66例多发伤患者分别于伤后1、3、7天空腹采集外周静脉血,应用ELISA方法测定血浆F1＋2浓度。结果 轻伤组与重伤组血浆F1＋2水平伤后均明显高于正常对照组,且重伤组又明显高于轻伤组。非DIC组伤后F1＋2水平逐渐降低,DIC组伤后F1＋2水平持续升高,DIC组F1＋2水平显著高于非DIC组。结论 创伤后急性期F1＋2水平的升高程度不仅与创伤严重程度有关,而且与创伤后DIC的发生密切相关。因此,测定严重多发伤患者急性期外周血浆F1＋2水平变化对预测创伤后DIC的发生具有一定临床价值。     

严重多发伤的ICU治疗及预后相关因素分析

目的 探讨严重多发伤病情评估与预后相关性及ICU救治的策略特点.方法 回顾性分析我院中心ICU 2009年1月～2010年5月收治的严重多发伤病人50例临床资料,计算入院24小时内ISS评分和急性生理慢性健康评分(APACHEⅡ),对死亡组、存活组的ISS值及APACHEⅡ分值进行比较.结果 死亡6例,死亡率12%; ...     

严重闭合性胸部创伤患者早期凝血功能变化比较

目的探讨各类严重闭合性胸部创伤患者的早期凝血功能变化,以提高该类患者的早期识别及干预。方法回顾性研究2013年1月—2016年6月伤后24h内成都大学附属医院急诊收入ICU及胸外科的胸部创伤患者的临床资料,根据简明损伤分级90版(AIS-90),纳入AIS≥3分的严重闭合性胸部创伤患者,以是否输血、是否为单纯性严重闭合性胸部创伤、是否ISS25分以及是否GCS9分分组,比较入院24h内凝血功能变化差异。结果共纳入228例患者,死亡15例,死亡组ISS评分均高于存活组(t=14.49,P0.01),GCS评分均低于存活组(t=14.44,P0.01)。在严重闭合性胸部创伤患者中,D-二聚体(D-D)和纤维蛋白原降解产物(FDP)在多发伤组、ISS评分25分组及GCS9分组均高于相应的单纯胸部创伤组、ISS﹤25分组及GCS9分组(P﹤0.01);凝血酶原时间(PT)ISS25分组中,高于ISS≤25分组(P0.01)。结论合并多发伤的严重闭合性胸部创伤患者在受伤早期,D-D和FDP明显升高,且该类患者多具有GCS和ISS高评分特点,是临床筛选高危创伤患者并指导进行早期干预的重要指标。     

AIS 2005与AIS 1998在评价创伤救治结局中的应用比较

目的 比较简明损伤定级（AIS）2005与AIS 1998在评价创伤严重度及创伤救治结局的差异,探讨最新版AIS 2005应用的可行性及实用价值。方法 采用AIS 2005和AI S1998,对我院2003年1月-2005年5月救治的3110例创伤病例资料进行回顾性分析。结果 （1）随ISS值递增,两组病死率、并发症发生率均呈上升趋势;ISS〉20,AIS 2005组病死率上升趋势更为明显,在ISS〉15～≤20,AIS 2005组病死率较AIS 1998组有显著降低（P=0．001）。除AIS 2005组ISS≤15并发症发生率较AIS 1998组下降外（P=0．035）,其余各ISS分值段AIS 2005组并发症发生率较AIS 1998组上升趋势更为明显。（2）随ISS值升高,修正创伤评分（RTS）、创伤与损伤严重度评分（TRISS）、创伤严重度特征评分（ASCOT）、ASCOT-CHINA值逐渐降低,且AIS 2005生存概率预测值分布较AIS 1998大。AIS 2005预测性评分指标的区别度和敏感性均高于AIS 1998,除ASCOT-CHINA准确性、ASCOT特异性低于AIS 1998,ASCOT存活误判率高于AIS 1998外,ASCOT、TRISS准确性,ASCOT-CHINA、TRISS特异性均高于AIS 1998,ASCOT-CHINA、TRISS存活误判率较AIS 1998低,AIS 2005对生存组、死亡组生存概率预测优于AIS 1998。结论 以AIS 2005为基础的ISS、TRISS、ASCOT等方法评价创伤及其结局预测总体上优于AIS 1998;建议使用AIS 2005评价多发伤时,以ISS〉20界定为严重多发伤可能更为合理。     

损害控制性手术理念在严重创伤救治中的应用

目的探讨运用损害控制性手术(damage control operation,DCO)救治严重创伤患者,并选择适宜手术时机的临床应用。方法对于2008年8月～2011年1月收治的以DCO原则处理21例严重创伤、复合伤的临床资料进行分析。结果患者损伤包括四肢骨折、四肢严重软组织撕脱伤。平均损伤严重度评分(ISS)30.3±2.1,格拉斯哥昏迷评分(GCS)9.3±2.2。死亡1例,上臂截肢1例,2例感染治疗后痊愈;随访20例,结果满意。结论对严重创伤患者进行损害控制性治疗,选择适宜的手术时机,降低手术风险,疗效满意。     

穿透性胸伤致膈肌破裂的伤情评估与疗效分析

目的 探讨穿透性胸伤致膈肌破裂的创伤评分特点，并评价救治质量。方法 1970～1999年，我科收治穿透性胸伤致膈肌破裂患者28例，运用各种院内创伤评分指标对其进行评价。结果 创伤严重度评分（ISS）与穿透伤指数（PTI）、综合评分方法（TRISS、ASCOT）评分呈显著性相关，PTI仅与TRISS评分有相关性。全组生存率概率计算均≥0.5，即28例患者预测都应生存，实际死亡2例。休克组与无休克组比较，修正创伤评分（RTS）、ASCOT评分有显著性差别。结论（1）ISS较PTI评价穿透性胸伤合并膈肌破裂更合理，且宜以ISS≥20定为重伤标准。（2）解剖损害（ISS、PTI）在休克组与无休克组无明显差别，此为该类伤的重要特征。（3）仍须加强对此类伤的认识，以进一步提高救治水平。     

GCS与AIS、ISS接轨的探讨

创伤评分中目前较通用的简明损伤定级标准(AIS)和损伤严重度评分 (ISS)与格拉斯哥昏迷评分 (GCS)评分不统一 ,影响了对伴有颅脑损伤的多发伤患者总体伤情的评定。作者提出一种方案 ,试图将GCS评分与AIS及ISS接轨 ,并分析其临床依据 ,以便于对伴有颅脑损伤的多发伤患者临床进行快速、简捷的ISS评定     

严重多发伤患者外周血自然杀伤性T细胞的变化及意义

目的观察严重多发伤患者外周血自然杀伤性T细胞（NKT）的变化及意义。方法30例严重多发伤患者按损伤严重度评分（ISS）排序分为严重组（15例）和危重组（15例）,于伤后1、4、7天流式细胞仪检测患者外周血NKT细胞的比率,酶联免疫吸附剂测定（ELASA法）检测血清中干扰素-γ（IFN-γ）、白细胞介素-4（IL-4）浓度,并与健康组进行对比。结果严重多发伤患者伤后1-7天外周血NKT细胞比率均极显著高于健康组（P〈0.01）;伤后第4天,危重组外周血NKT细胞比率极显著高于严重组（〈0.01）,Spearm an相关分析显示NKT细胞比率与ISS呈正相关（r=0.76,P〈0.01）。严重多发伤患者外周血IFN-γ浓度持续下降,而IL-4浓度持续上升。结论NKT细胞比率在严重多发伤患者早期明显升高,其在减少辅助性T淋巴细胞（Th1）类细胞因子分泌增加Th2类细胞因子分泌及抑制创伤免疫等方面发挥了重要作用。     

创伤性颅脑损伤患者的长期预后研究

目的 探讨中重度创伤性颅脑损伤 （ traumatic brain injury, TBI）患者康复治疗出院后的长期预后，以及癫痫对长期预后的影响。方法 对102例康复治疗出院的中重度TBI患者进行随访研究。结果 死亡率为2．0％，不良预后发生率为16．7％，继发癫痫者占33．3％。功能独立性程度和就业状况比例失衡。继发癫痫组在GOS、残疾等级量表功能部分（DRS—F）、就业部分（DRS—E）等级和生存质量指数（QLI）评分上与无癫痫组比较，差异均有统计学意义（P〈0．05），继发癫痫者的长期预后相对更差。经Pearson相关性分析，GOS与DRS—F、DRS—E、QLI评分之间的相关性均达到显著性水平。结论　康复治疗后的中重度TBI患者远期死亡率为2．0％，再就业率低，癫痫对远期生活质量有显著影响。应规范TBI急性期和亚急性期的康复体系，为大样本长期预后研究打下基础。     

特重型颅脑损伤的院前急救和院内处理

目的从创伤现场、院前急救、到院后的神经专科处理及康复等一系列连锁关系，探讨提高特重型颅脑损伤救冶的整体水平的方法。方法对我科自1993年1月至2004年6月救治的124例患者进行回顾性总结。按照颅脑损伤的临床与病理过程，将特重型颅脑损伤分为三期，实行分期的、有重点的连续性治疗。结果在本组124例患者中生存56例(生存率45．2％)。其中恢复良好19例(15．3％)，中残13例(10．5％)，重残24例(19．4％)；死亡68例(54．8％)。结论特重型颅脑损伤成功的救治必须各个环节并重，尤其是事发现场与院前急救十分关键，良好的专科治疗是救冶的根本；如能及时实行现场抢救及专科治疗，不但可挽救部分患者生命，且可改善预后、提高生存质量。     

外伤后急性弥漫性脑肿胀合并二次脑损伤的超微结构观察

目的 探讨外伤后急性弥漫性脑肿胀合并二次脑损伤患者的脑组织超微结构变化与预后的关系。方法 对8例外伤后急性弥漫性腑肿胀合并小同程度二次脑损伤患者行内减压手术，留取32份脑组织标本，透射电镜下观察神经元、星形胶质细胞和毛细血管的超微结构变化，分析其与预后的关系。结果 按格拉斯哥预后评分(G0S)：良好1例，中残2例，重残1例，植物生存1例，死亡3例。良好和中残的患者，神经元和星形胶质细胞超微结构基本正常，血管源性脑水肿为主，细胞内水肿较轻，毛细血管扩张允血。其余患者中，神经元和星形胶质细胞核膜迂曲，核仁偏移，染色质凝集，线粒体和粗面内质网的超微结构明显损伤，细胞内水肿和血管源性脑水肿均较重，毛细血管狭窄缺血。结论 外伤后急性弥漫性脑肿胀合并二次脑损伤患者的脑组织超微结构损伤越重，预后就越差。     

Comparative estimation of rehabilitative abilities after organ preserving operations for severe eye damages

Postoperative analysis of rehabilitative potentialities in 59 patients operated on occasion of severe eye trauma with the use of various methods of ophthalmosurgery has been presented. It has been demonstrated that the method of organ preserving complex vitreoretinal surgery provided evading enucleation and retaining the damaged eyeball in 96.4% of cases. In 82.1% of cases it has been succeeded in retaining some vision functions and raising considerably the indices of life quality. It has been determined that properly made silicone tamponade provides the support of the necessary ophthalmotone and prevention of progressive growing of posttraumatic eyeball subatrothy--the most frequent outcome of a severe eye trauma.     

创伤应激障碍综合征的发展历史与诊断标准的进展

创伤后应对各种实际与潜在损失的能力以及对机体功能障碍的适应性,不仅是决定躯体功能康复与再适应的关键,也将是决定创伤患者创伤后生存质量的关键。是否能够适应"创伤"这一应激性事件对人体整体包括躯体与精神的影响,决定创伤后的社会功能。创伤后引起生存质量降低的最常见疾病即为创伤后应激障碍综合征,本文从这一疾病的认识历史、诊断标准进展的角度进行综述,为创伤医护工作者认识并积极筛查该疾病、早期正确有效干预奠定基础。     

Posttraumatic cardiac dysfunction: assessment with radionuclide ventriculography

The authors studied 54 patients with multisystem trauma, including blunt chest injury, using combined dynamic first-pass and electrocardiographically (ECG) gated radionuclide ventriculography (RNV) to evaluate for posttraumatic myocardial dysfunction. Twenty-six of 54 (48%) patients had abnormalities of ventricular wall motion. The ventricular dysfunction was confined to the right ventricle in 92% of cases. In general, abnormalities consisted of right ventricular dilatation and diffuse hypokinesia, although in seven cases there were localized wall-motion abnormalities. The right ventricular ejection fraction of those patients with wall-motion abnormalities was significantly lower than those with normal studies. Left ventricular ejection fraction did not differ significantly between these groups. ECG changes were not associated with the cardiac dysfunction demonstrated scintigraphically, nor was there a relationship between the number or type of extrathoracic or thoracic injuries demonstrated by RNV. Follow-up studies obtained in 15 cases showed a significant overall improvement in cardiac function by 3 weeks after injury. Combined first-pass and ECG-gated RNV is useful for the identification and follow-up of patients with posttraumatic cardiac dysfunction.     

CT and MR imaging of primary cerebrovascular complications in pediatric head trauma

The incidence of severe traumatic head injury in children has constantly increased over the last years. Diagnostic imaging has become an unrenounceable tool for the documentation and follow-up of intracranial lesions. The use of magnetic resonance imaging (MRI) in the early posttraumatic phase has led to a more thorough understanding of intracranial injuries. We retrospectively analyzed the cranial computed tomography (CCT) and magnetic resonance (MR)-studies of patients with traumatic head injuries for primary cerebrovascular complications. In 64 children (45 male, 19 female) with traumatic head injuries, CCT and MR examinations were available for analysis. The children's age ranged from 3 months to 15 years with a median age of 7 years. All patients had initial CCT on admission to the hospital with follow-up examinations depending on clinical state and initial imaging findings. All patients had at least one MR examination between 0 to 120 days after the trauma with a median time interval of 17 days. In five of 64 (7.8%) patients, cerebrovascular complications were found on imaging studies. Initial imaging within the first 24 h after the trauma detected a complete middle cerebral artery infarction in one patient and extensive sinus thrombosis after a complex skull fracture in another. In two patients, thrombosis of the transverse sinus appeared on MRI 4 to 6 days after the trauma. In another patient with open-skull injury, a posttraumatic aneurysm of the pericallosal artery was diagnosed on MRI 30 days after the trauma. Our study shows that, although primary cerebrovascular lesions after traumatic head injuries in children are rare, the radiologist should be aware of the characteristic injury patterns and the time appearance of imaging findings on CT and MRI.     

Posttraumatic cerebral infarction diagnosed by CT: prevalence, origin, and outcome

Posttraumatic cerebral infarction is a recognized complication of craniocerebral trauma, but its frequency, cause, and influence on mortality are not well defined. To ascertain this information, all cranial CT studies demonstrating posttraumatic cerebral infarction and performed during a 40-month period at our trauma center were reviewed. Posttraumatic cerebral infarction was diagnosed by CT within 24 hr of admission (10 patients) and up to 14 days after admission (mean, 3 days) in 25 (1.9%) of 1332 patients who required cranial CT for trauma during the period. Infarcts, in well-defined arterial distributions, were diagnosed either uni- or bilaterally in the posterior cerebral (17), proximal and/or distal anterior cerebral (11), middle cerebral (11), lenticulostriate/thalamoperforating (nine), anterior choroidal (three), and/or vertebrobasilar (two) territories in 23 patients. Two other patients displayed atypical infarction patterns with sharply marginated cortical and subcortical low densities crossing typical vascular territories. CT findings suggested direct vascular compression due to mass effects from edema, contusion, and intra- or extraaxial hematoma as the cause of infarction in 24 patients; there was postmortem verification in five. In one patient, a skull-base fracture crossing the precavernous carotid canal led to occlusion of the internal carotid artery and ipsilateral cerebral infarction. Mortality in craniocerebral trauma with complicating posttraumatic cerebral infarction, 68% in this series, did not differ significantly from that in craniocerebral trauma patients without posttraumatic cerebral infarction when matched for admission Glasgow Coma Score results. Thus, aggressive management should be considered even in the presence of posttraumatic cerebral infarction.     

Posttraumatic cerebral infarction diagnosed by CT: prevalence, origin, and outcome

Posttraumatic cerebral infarction is a recognized complication of craniocerebral trauma, but its frequency, cause, and influence on mortality are not well defined. To ascertain this information, all cranial CT studies demonstrating posttraumatic cerebral infarction and performed during a 40-month period at our trauma center were reviewed. Posttraumatic cerebral infarction was diagnosed by CT within 24 hr of admission (10 patients) and up to 14 days after admission (mean, 3 days) in 25 (1.9%) of 1332 patients who required cranial CT for trauma during the period. Infarcts, in well-defined arterial distributions, were diagnosed either uni- or bilaterally in the posterior cerebral (17), proximal and/or distal anterior cerebral (11), middle cerebral (11), lenticulostriate/thalamoperforating (nine), anterior choroidal (three), and/or vertebrobasilar (two) territories in 23 patients. Two other patients displayed atypical infarction patterns with sharply marginated cortical and subcortical low densities crossing typical vascular territories. CT findings suggested direct vascular compression due to mass effects from edema, contusion, and intra- or extraaxial hematoma as the cause of infarction in 24 patients; there was postmortem verification in five. In one patient, a skull-base fracture crossing the precavernous carotid canal led to occlusion of the internal carotid artery and ipsilateral cerebral infarction. Mortality in craniocerebral trauma with complicating posttraumatic cerebral infarction, 68% in this series, did not differ significantly from that in craniocerebral trauma patients without posttraumatic cerebral infarction when matched for admission Glasgow Coma Score results. Thus, aggressive management should be considered even in the presence of posttraumatic cerebral infarction.     

颅脑伤后持续性植物状态100例脑组织的核磁共振变化

目的：为了明确创伤性持续性植物状态（PVS）脑损伤的部位、性质和脑组织结构的变化特征。方法：采用MRI对创伤性PVS患者100例进行病灶的定位、定性断定，且进行统计。结果：100例PVS患者中，发现病灶1154处（出血性462处，非出血性692处），每例5－19处，平均约12处病灶。弥漫性脑白质轴索损伤和胼胝体损伤94例，脑干背侧损伤87例，基底节和丘脑损伤分别为52例和32例，大脑皮层伤50例（以额、颞叶居多），海马旁伤47例。结论：创伤性PVS主要是由于弥漫性轴索损伤。统计结果表明，临床与MRI密切结合对确诊脑外伤后PVS有重要意义。