提高心脏大血管创伤救治水平的几点建议

心血管创伤历来是一个具有极端挑战性的医学难题。随着社会的进步和医学的发展 ,自 1896年Ｒｅｈｎ首次成功修补一例右室刺伤的伤员以来 ,心脏大血管创伤的救治水平也在不断提高 ,使许多濒临死亡的伤员获得了生存机会。当代国际社会中 ,随着交通、建筑、医疗业的发展 ,以及近年国际恐怖分子的频繁破坏 ,由此导致的创伤已成为影响人群死亡的“第一杀手”。在交通伤、医源性损伤、空难事故等造成的损伤中 ,心血管创伤具有更高的比例 ,如闭合性胸部损伤中心脏损伤达 10 %～16% ,空难罹难者达 80 % ,车祸死亡者中有 15 %～ 75 %伴有心脏损伤。现…     

心脏和大血管损伤的急救处理

心脏大血管损伤是严重急症 ,由于病程进展迅速 ,可很快致死 ,若及时有效的抢救 ,有可能挽回生命。本院 1976年～ 2 0 0 1年救治了 3 2例心脏大血管损伤患者 ,现报告如下。一、临床资料与方法1.一般资料 :本组患者 3 2例 ,男2 0例 ,女 12例 ,年龄 16～ 68岁。主要症状 :大出血 ,心包填塞 ,开放性血气胸及合并伤的相关症状 ,休克 2 0例。伤因 :枪弹伤、刀及其他金属利器刺伤、车祸伤、金属异物打入伤 ,跃落伤及被牛角刺伤等。伤情 :心脏和心包穿透伤 2 5例 ,心包伤合并股动脉伤 1例 ,心脏和主动脉同时穿透伤 1例 ,心包伤、胸廊内动脉伤胸腺伤 …     

体外循环心内手术致心脏大血管损伤6例报告

198 1年 10月～ 1996年 4月 ,体外循环心内直视手术过程中发生心脏、大血管损伤 6例 ,现报告如下。1　病例报告例 1,女 ,3 2岁。闭式二尖瓣交界扩张术后 4年二尖瓣狭窄并关闭不全 ,体外循环下置换二尖瓣 ,采用牛心包瓣 ,分离下腔静脉粘连时损伤下腔静脉前壁 ,术者食指进入下腔静脉 ,用两把无损伤血管钳顺食指钳夹破口 ,丝线褥式缝合止血 ,康复。例 2 ,男 ,17岁。房间隔缺损 ,体外循环下房间隔缺损修补。电锯锯开胸骨 ,大量暗红色血液涌出 ,血压骤然下降 ,撑开胸骨 ,血液淹没视野 ,加强吸引 ,快速输液 ,检查发现心包上 2 /3撕裂和右心房自心…     

医源性心脏大血管损伤的外科处理

目的 总结各类心胸外科手术中医源性心脏大血管损伤(ICVI)28例的救治体会，探讨其产生的原因及对症采取的措施。方法 大多数病例采用手指按压后用无损伤垫片针褥式缝合，如无法直接缝合止血，即用手指按压出血处，然后迅速做供血插管及肝素化措施，建立体外循环，再予止血。结果 28例在术中采用各种止血方法均获得成功，后因l例肾缺血时间过长并发急性肾衰而死亡(死亡率3．57％)，其他病人均康复出院。结论 ICVI造成的原因很大一部分是术者操作不良及手术经验不足而引起，另一部分是组织粘连紧密或晚期癌肿浸润而引起，采用不同的止血方法，特别是褥式垫片缝合及Prolene线连续缝合或附加止血辅助物可以使手术获得成功，必要时尽早建立心肺体外转流技术，但关键是在术中预防此类合并症的发生。     

8例心脏及大血管损伤的急救处理

８例心脏及大血管损伤的急救处理朱学诚心脏及大血管损伤患者病情危重，需要迅速有效地急救处理，否则迅速导致死亡。１９６４～１９９３年共抢救成功８例心脏大血管损伤患者，报告如下。１临床资料１．１病例：８例中男７例，女１例；年龄５～３６岁。其中穿透性损伤６例...     

心脏创伤的胸部X线诊断

笔者报道心脏外伤２３例，其中心脏刀伤、挫伤共１５例、医源性损伤８例。本文重点讨论了外伤后胸部Ｘ线表现。①心脏及大血管损伤占胸部外伤２．４％；     

26例心脏创伤的外科处理

本文报道26例心脏创伤处理经过,其中穿人性12例,医源性8例,闭合性6例。16例行急诊手术,包括缝合心肌裂口,去除心肌异物,闭式二尖瓣分离,清除心包腔血块和胸腔引流术。Ⅱ期和 /或择期手术10例,其中二尖瓣替换术 2例,三尖瓣替换术2例,主动脉瓣成形术1例。心内膜起搏电极感染去除2例,心室间隔缺损和右心室室壁瘤缝补术1例,左冠状动脉至肺动脉瘘1例。心包积血缩窄和右下肺弹头去除1例。 诊断主要依据为大量失血休克,心脏压塞,心脏出现杂音,心电图显示心肌损害,心包穿刺阳性等。条件允许时可行超声心动图和床旁摄片检查,心脏创伤合并瓣膜损害,VSD,室壁瘤和动脉心腔瘘等需施行超声心动图和多普勒检查确诊,必要时需施行心腔或大血管造影明确诊断。26例均经手术治疗,25例痊愈出院。死亡 1例,死亡率为 3.7％。     

心脏创伤临床救治

目的：探讨心脏创伤救治的方法。方法：回顾性分析95例心脏创伤患者，除14例行保守治疗外，其余均分别行急诊或延迟性开胸手术、修复心脏损伤。结果：全组95例除3例死亡外，其余患者均顺利康复，病死率为3．15％。结论：及时作出正确的诊断和及时行急诊开胸手术修复心脏破口，是救治成功的关键；在处理心脏伤的同时要注意其它合并伤的诊断和处理。     

小儿外伤性硬膜外血肿的诊治及护理

目的 :探讨小儿外伤性硬膜外血肿的诊断、治疗和护理。方法 :回顾分析 12 0例小儿外伤性硬膜外血肿的临床资料。结果 :94例实施手术治疗 ,其中 14例由保守治疗中转为手术治疗 ,2 6例实施保守治疗 ,治愈 99例 ,中重残 17例 ,死亡 4例。结论 :小儿硬膜外血肿的确诊主要依靠头颅CT检查。对保守治疗的患儿需严密观察意识的变化 ,CT动态观察病情变化 ,及时中转手术治疗 ,手术前后合理的护理措施是降低病死率 ,提高治愈率的关键     

体外循环术后心包切开综合征的诊断和治疗：附50例报告及文献复习

本文回顾性分析264例体外循环术病例,其中50例发生心包切开术后综合征。结合文献对其病因、临床特点、诊断标准和治疗进行介绍和讨论。     

外伤多发性颅内血肿的治疗

目的探讨外伤性多发性颅内血肿的治疗方法，提高抢救成功率。方法回顾复习2003年8月至2008年8月收治的100例外伤多发性颅内血肿患者资料，分析外伤多发性颅内血肿的治疗方法。结果本组手术60例，死亡10例，病死率16．7％，40例保守治疗，死亡4例，病死率10％。结论外伤多发性颅内血肿病情重，变化快，预后较差。对于血肿大、中线移位明显、昏迷和意识障碍进行性加重，颅内压过高或已有脑疝表现者应及时手术，保守治疗过程中需要严密监测生命体征变化，实施颅内压监测，动态CT检查，同时必须注重合并症和并发症的治疗。     

肝外伤44例诊断与治疗方法探讨

目的探讨肝外伤的诊断与治疗方法。方法回顾分析本院1993年1月至2003年10月治疗44例肝外伤患者的临床资料。结果全组肝外伤诊断阳性,非手术治疗2例(4.5%),手术治疗42例(95.5%)、全组治愈41例(93.2%)、死亡3例(6.8%)。结论腹穿、B超、CT以及血液动力学是肝外伤诊断的常用有效方法,肝外伤治疗的策略是非手术治疗与手术方法合理选择。     

创伤性膈肌破裂27例分析

目的 探讨创伤性膈肌破裂的致伤因素、诊断及手术方式.方法 对27例创伤性膈肌破裂患者的临床资料进行回顾性分析与总结.结果 本组术前确诊21例;术前未能确诊6例,误诊、漏诊率22.2%.均实施手术治疗,其中经胸手术22例,经腹手术2例,胸腹联合手术3例.26例痊愈出院,1例死亡;治愈率96.3%,病死率3.7%.结论 膈肌的独特解剖结构及舒、缩状态时其在胸腔内位置的巨大变化,导致损伤时临床表现的多样性.胸部X线及CT检查是可靠的诊断方法.术前对创伤性膈肌破裂的高度警惕和术中仔细检查膈肌是减少漏诊的关键.及时手术是治愈创伤性膈肌破裂的有效途径.     

A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries

Objective

The incidence of thoracic injuries resulting from cardiopulmonary resuscitation (CPR) is not well characterized. We describe a case in which a CPR-associated atrial rupture was identified with ultrasound and successfully managed in the intensive care unit with a bedside thoracotomy and atrial repair. We then describe a systematic review with pooled data analysis of CPR-associated cardiovascular, pulmonary, pleural, and thoracic wall injuries.

Data sources

PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Unpublished studies were identified by searching the Australian and New Zealand Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform, Cochrane Library, ClinicalTrials.gov, Current Controlled Trials, and Google.

Study selection

Inclusion criteria for the pooled analysis were any clinical or autopsy study in which (a) patients underwent cardiopulmonary resuscitation, (b) chest compressions were administered either manually or with the assistance of active compression–decompression devices, and (c) autopsy or dedicated imaging assessments were conducted to identify complications. Exclusion criteria for the pooled analysis were pre-clinical studies, case reports and abstracts.

Data extraction

Nine-hundred twenty-eight potentially relevant references were identified. Twenty-seven references met inclusion criteria.

Data synthesis

A systematic review of the literature is provided with pooled data analysis.

Conclusions

The incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely. CPR with active compression–decompression devices has a higher reported incidence of cardiopulmonary injuries. Bedside ultrasound may be a useful adjunct to assess and risk-stratify patients to identify serious or life-threatening CPR-associated injuries.     

Diagnosis and treatment of inhalation injuries

Inhalation injury continues to be a major co-morbid factor in the thermally injured patient. Appreciation of the pathophysiology of inhalation injury has been gradually acquired through active basic science and clinical research. This understanding has led to improvements in diagnosis, ventilatory support, and infection control, all of which have contributed to the improved prognosis of burn patients. As our understanding of inhalation injury continues to develop, further avenues of therapeutic investigation will arise and continue to lead to further improvement in the prognosis of thermally injured patients.     

探索院内成功心肺复苏患者早期发生心血管衰竭的独立危险因素

目的 探索院内成功心肺复苏患者早期发生心血管衰竭的独立危险因素,为临床工作者对预后评估提供依据.方法 收集2010-12～2013-02入住我院急诊重症监护室院内心肺复苏成功(ROSC 20 min以上)的113例患者,并排除发病时未满18周岁、资料不完全、早期家属放弃抢救以及处于疾病终末期引起心脏骤停等病例.将入选的病例按复苏后是否出现早期心血管衰竭(ROSC后12 h之内收缩压小于80 mm Hg,需用升压药物维持血压或原有高血压患者收缩压较基础水平下降20％)分为早期心血管衰竭组和非心血管衰竭组.采用相应的统计方法进行相关临床资料分析.结果 入选病例113例,其中78例发生早期心血管衰竭(69.02％),死亡率87.18％,其余35例未发生心血管衰竭,死亡率为31.43％.本研究发现,未发生心血管衰竭组中有60％患者发病病因为心脏疾病.初始心律为非除颤心律(心脏停搏+无脉电活动)、抢救时间过长、复苏前存在全身炎症反应综合症(SIRS)及血糖紊乱是早期发生心血管衰竭的危险因素,且早期发生心血管衰竭患者入室APACHEⅡ评分及SOFA评分明显高于未发生心血管衰竭组(P＜0.01或P＜0.05).多因素Logistic分析得出,心肺复苏持续时间过长及复苏前存在SIRS、血糖紊乱是早期发生心血管衰竭的独立危险因素.结论 本组研究院内成功心肺复苏患者中有69.02％早期发生心血管衰竭,死亡率较未发生心血管衰竭者明显增高,且入室APACHEⅡ评分及SOFA评分明显高于未发生心血管衰竭组;心肺复苏持续时间过长、复苏前存在SIRS及血糖紊乱是成功复苏后早期出现心血管衰竭的独立危险因素.     

Use of automated external defibrillators in patients with traumatic out-of-hospital cardiac arrest

Background

Because out-of-hospital cardiac arrests (OHCAs) due to a major trauma rarely present with shockable rhythms, the potential benefits of using automated external defibrillators (AEDs) at the scene of traumatic OHCAs have not been examined.

Methods

We conducted an observational, retrospective cohort study using an Utstein-style analysis in Tainan city, Taiwan. The enrollees were adult patients with traumatic OHCAs accessed by emergency medical technicians (EMTs) from January 1, 2004 to December 31, 2010. The exposure was the use or non-use of AEDs at the scene, as determined by the clinical judgment of the EMTs. The primary outcome evaluated was a sustained (≥2 h) return of spontaneous circulation (ROSC), and the secondary outcomes were prehospital ROSC, overall ROSC, survival to hospital admission, survival at one month and favorable neurologic status at one month.

Results

A total of 424 patients (313 males) were enrolled, of whom 280 had AEDs applied, and 144 did not. Only 25 (5.9%) patients had received bystander cardiopulmonary resuscitation (CPR), and merely 21 (7.5%) patients in the AED group presented with shockable rhythms. Compared to the non-AED group, the primary and secondary outcomes of the AED group were not significantly different, except for a significantly lower prehospital ROSC rate (1.1% vs 4.9%, p < 0.05). Multivariate analysis showed no significant interactions between the use of AEDs and other key variables. Use of the AED was not associated with sustained ROSC (OR 1.33; 95% CI 0.75–2.38, p = 0.33).

Conclusions

In a community with a low prevalence of shockable rhythms and administration of bystander CPR in patients with traumatic OHCA, we found no significant differences in the sustained ROSC between the AED and the non-AED groups. Considering scene safety and the possible interruption of CPR, we do not encourage the routine use of AEDs at the scene of traumatic OHCAs.     

外伤性脑梗死61例诊断与治疗

由于影像学的发展,检查技术的不断进步,为外伤性脑梗死提供了更好的诊断手段,外伤性脑梗死的发病率已有明显的增加[1],最新文献报告已达1.6%左右[2]。临床上发现了越来越多的脑外伤后合并脑梗死的病人,梗塞的出现加重了原来脑损伤的病情,对其治疗及转归产生了一定程度的影响,引