重型颅脑损伤合并多发伤的救治体会

目的探讨重症颅脑损伤合并多发伤的救治及预后。方法回顾性分析33例重症颅脑损伤合并多发伤患者的临床资料。结果33例患者经抢救存活22例,存活率为66．7％,死亡11例,病死率为33．3％;存活者术后半年按格拉斯哥昏迷量表（cos）评分分级为恢复良好8例（占36．4％）;中度残疾5例（22．7％）;重度残疾6例（27．3％）,植物生存2例（9．1％）,死亡1例（4．5％）。结论重症颅脑损伤合并多发伤病死率、致残率高,应早期诊断、及时抢救,正确处理危及生命的合并伤、维持重要脏器功能及术后严密监护、预防合并症对成功救治及改善预后起重要作用。     

标准大骨瓣开颅术救治重型颅脑损伤80例疗效分析

目的:探讨标准大骨瓣开颅术救治重型颅脑损伤的临床效果。方法:采用标准大骨瓣开颅术对80例重型颅脑损伤患者进行手术治疗,并观察其治疗效果。结果:本组患者80例,按照GOS标准,术后随访半年,预后较好37例(46.25%),其中恢复良好24例(30.00%),中残13例(3.75%)。预后较差31例(38.75%),其中重残21例(26.25%),植物状态10例(12.50%);死亡12例(15.00%)。结论:标准大骨瓣减压术可明显改善重型颅脑损伤患者的预后,降低病死率,提高生存率。     

腹部创伤39例临床分析

目的:探讨创伤性腹损伤的诊断与治疗。方法:对2006年10月～2009年12月收治的腹部创伤39例,采用手术治疗35例,非手术治疗4例。结果:治愈34例,治愈率为87.2%。死亡5例,1例肠破裂入院2d后中毒性休克死亡;1例肝破裂术后3h死亡;2例脾破裂合并气胸死亡;1例肾破裂者死于心力衰竭。结论:对创伤性腹部损伤的诊断要及时、明确,治疗要首选对生命威胁最大的损伤进行处理。     

Management of severe trauma in intensive care units and surgical wards.

OBJECTIVE: To evaluate the management of severe trauma in intensive care, high dependency and general surgical wards of Victorian hospitals. DESIGN: Retrospective case review by multidisciplinary committees. SUBJECTS: The first 256 people who died from road traffic accidents who were alive on the arrival of emergency services between 1 July 1992 and 30 June 1994. MAIN OUTCOME MEASURES: (1) Severity of injury according to clinical diagnosis, autopsy findings and recognised trauma-scoring methods; (2) errors in management, identified as contributing or not contributing to the cause of death, and categorised as "management", "system", "diagnostic" or "technique" errors. RESULTS: Most patients (61%) were admitted to an intensive care unit (ICU), and 19.5% were admitted to high dependency or general surgical wards. Of 2187 errors of care identified, 11.8% occurred in ICU and 6.7% in wards, with the remainder occurring during the earlier phases of care. Most errors were classified as management errors (82% of ICU errors and 88% of ward errors). Fifty-two per cent of ICU errors and 71% of ward errors were judged to contribute to the patient's death. CONCLUSIONS: A significant number of errors of trauma management occur in the intensive care and general surgical ward. Improvement in late trauma care may reduce the number of preventable trauma deaths.     

Potential role for advanced trauma life support programme in improving trauma care in Jamaica

Data from the Road Safety Unit in the Ministry of Transport and Works, Jamaica, show an increase in road traffic accidents from 7861 in 1991 to 11,010 in 1999. The average number of deaths annually was 380 +/- 48 (SD) while injuries averaged 3320 +/- 262 per year. This represents an injury to death ratio of 8.7 compared with 24.9 for Trinidad and Tobago and 40 for Canada. During the period 1991 to 2000, an average of 796 +/- 159 (SD) murders were committed annually. The number of murders increased by over 280 per cent between the decade of the seventies and the nineties. Data from the trauma registry of the University Hospital of the West Indies showed that 29.6 per cent of all admissions to the surgical ward between January 1998 and December 31, 2000, were due to injuries. There were 97 deaths (3%) during this period and 33 occurred in the Accident and Emergency Department with 70 per cent occurring within 120 minutes of their arrival. The Advanced Trauma Life Support (ATLS) Programme emphasizes the resuscitation and stabilization of injured patients in the first few hours after injury. Most Emergency Departments in Jamaica are staffed by relatively junior medical officers and the low injury to death ratio among victims of motor vehicle accidents may be due to suboptimal care. Introduction of an ATLS programme in Jamaica may reduce the number of preventable deaths and also stimulate interest in trauma care thus increasing preventative measures to decrease the high incidence of trauma in Jamaica.     

严重肝外伤45例的治疗

目的总结严重肝外伤的治疗经验。方法回顾性分析1995年1月～2005年12月45例严重肝外伤病例行外科治疗的临床资料，包括损伤程度、手术方式、治疗效果及手术并发症。结果肝外伤Ⅲ级24例，Ⅳ级16例，Ⅴ级5例。行肝缝合修补术21例，大网膜填塞缝合4例，肝血肿清除3例，清创性肝切除14例，规则性肝切除3例。治愈38例，死亡7例，其中术中出血死亡1例，术后再出血死亡2例，术后多器官功能衰竭死亡4例。术后发生并发症17例（37．8％），并发多器官功能衰竭4例，术后再出血3例，胆漏3例，膈下脓肿3例。结论手术是治疗严重肝外伤的主要方法。术中彻底止血，充分引流，预防多发性器官功能衰竭（MOF），可降低严重肝外伤术后并发症和死亡率。     

Outcome of severely injured trauma patients at a designated trauma centre in the Hong Kong Special Administrative Region

Background The Hong Kong Special Administrative Region （HKSAR） of the People＇s Republic of China （PRC） has seen significant changes in its trauma service over the last ten years including the implementation of a regional trauma system. The author＇s institution is one of the five trauma centres designated in 2003. This article reports our initial clinical experience. Methods A prospective single-centre trauma registry from January 2004 to December 2008 was reviewed. The primary clinical outcome measure was hospital mortality. The Trauma and Injury Severity Score （TRISS） methodology was used for bench-marking with the North America Major Trauma Outcome Study （MTOS） database. Results There were 1451 patients. The majority （83.9%） suffered from blunt injury. The overall mortality rate was 7.8%. Severe injury, defined as the Injury Severity Score 〉15, occurred in 22.5% of patients, and was associated with a mortality rate of 31.6%. A trend of progressive improvement was noted. The M-statistic was 0.99, indicating comparable case-mix with the MTOS. The Z- and W-statistics of each individual year revealed fewer, but not significantly so, number of survivors than expected. Conclusions Trauma centre designation was feasible in the HKSAR and was associated with a gradual improvement in patient care. Trauma system implementation may be considered in regions equipped with the necessary socio-economic and organizational set-up.     

不同转运方式对创伤患者预后影响的研究

目的 观察不同转运方式对创伤患者30 d内预后的影响,为建立新的标准的社会化多层次急诊医疗服务体系整体模式提供临床依据.方法 收集湘雅医院急诊科2009年1月～2010年1月就诊的创伤病人相关资料,根据修正创伤指数(RTI)评分将患者分为轻度、中度和重度,根据是否直接转运将患者分为直接转运组和间接转运组.追踪所有观察对象30 d内的并发症情况、生存情况及ICU入住时间.结果 两组一般情况比较差异无显著性;两组患者30 d内并发症发生率和病死率差异有显著性,而ICU入住时间差异无显著性.结论 重度的创伤患者应该在抢救同时第一时间转运至三级医院救治,以便获得更大的生存机会.     

Relationship between trauma center volume and outcomes

CONTEXT: The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown. OBJECTIVE: To evaluate the association between trauma center volume and outcomes of trauma patients. DESIGN: Retrospective cohort study. SETTING: Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystem Consortium Trauma Benchmarking Study. PATIENTS: Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998. MAIN OUTCOME MEASURES: Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (相似文献   

重型颅脑外伤患者护理体会

目的:总结重型颅脑外伤患者的护理措施。方法:通过对65例颅脑外伤患者定时观察其意识状态、呼吸、脉搏、血压、瞳孔及肢体活动的变化,早期发现脑水肿、急性颅内压增高等并发症,并早期治疗。结果:65例患者中,54例恢复良好,占83.08%;5例表现为轻度残疾,占7.69%;3例重残,占4.62%;3例因为严重的脑挫裂伤合并多脏器损伤而死亡,死亡率为4.62%。结论:护理人员通过严密观察患者生命体征、神志及瞳孔的变化,做好患者围手术期及术后的护理,降低了患者的死亡率及致残率,减少了并发症的发生。     

Transfer of head-injured patients in Jamaica: is there a problem?

Head-injured patients are often transferred to the University Hospital of the West Indies (UHWI) for tertiary care. There is no standardized, agreed protocol governing their transfer. During the three-year period January 1998 to December 2000, 144 head injured patients were transferred to the UHWI from other institutions. They were 70% male, had a mean age of 34 years and spent a mean of 13 days in hospital. Eighteen per cent were admitted to the Intensive Care Unit, where they spent a mean of nine days. On arrival, mean pulse rate was 92 +/- 22 beats/minute, mean systolic blood pressure was 130 +/- 27 mmHg and mean diastolic was 76 +/- 19mmHg. Twenty-eight per cent of patients had a pulse rate above 100/min on arrival and 13.8% had systolic blood pressure below 60 mmHg. The Glasgow Coma Scale score was unrecorded at the referring institution in 70% of cases and by the receiving officers at the UHWI in 23% of cases. Intubation was done on only half of those who were eligible. Junior staff members initiated and carried out transfers whenever this was documented. The types of vehicles and monitoring equipment used could not be determined in most instances. Fifty-eight per cent of patients had minor head injuries, 12%, severe injury and 33%, associated injuries requiring a variety of surgical procedures by multiple specialties. Most patients (80.6%) were discharged home but 11.8% died in hospital. Transfer of head-injured patients, many with multiple injuries is not being performed in a manner consistent with modern medical practice. There is urgent need for implementation of a standardized protocol for the transfer of such patients in Jamaica.     

老年人复合性颅脑损伤临床救治探讨

目的总结重度颅脑损伤伴有胸腹部外伤或四肢骨折的老年患者的治疗方法,使其病死率降低,提高治疗效果。方法收集近年来高平市人民医院收治的老年复合性颅脑损伤患者的一般资料,包括姓名、性别、年龄、过敏史、疾病史以及造成颅脑损伤的原因等。共有老年患者78例,其中脑胸复合伤患者有24例,脑腹外伤患者有6例,脑外伤伴有骨折患者30例。颅脑损伤中开放颅脑损伤的患者有32例,闭合颅脑损伤65例,脑腹外伤伴有骨折患者23例等。进行GCS评分,3—5分8例,6—8分28例,9—11分24例,11—15分18例。受伤原因大多为车祸、坠落、砸伤等。结果78例患者中,69例治愈,9例死亡。其中恢复良好37例,中残23例,重残及植物生存9例。结论高龄颅脑损伤患者的痛死率相对较高,通过之前的研究可以得出患者的年龄越大,恢复能力越弱,病死率也会相对增加。在临床治疗中应当制定适合老年人的治疗、护理方案,选择相应的措施降低病死率。     

23例颅脑外伤后合并脑梗塞的诊治分析

目的 分析总结颅脑外伤后合并脑梗塞的发病机制及有效的预防措施和个体化综合性治疗方案,以提高疗效,降低致死率和致残率。 方法 选取蚌埠医学院第二附属医院2011年12月—2016年11月收治的23例颅脑外伤后合并脑梗塞患者作为研究对象。本组患者中,13例脑挫裂伤严重,出现颅内血肿伴有颅内压增高或脑疝者,给予钻孔血肿引流术或开颅血肿清除术治疗,其中去骨瓣减压者6例;2例外伤后单纯出现脑梗塞者,及时行脑血管造影证实为外伤后栓子形成所致,行积极的溶栓介入治疗;对于8例病情稳定,脑挫裂伤较轻或颅内血肿较小,无显著颅内压增高的脑梗塞者,实施内科保守治疗。本组所有患者均积极给予钙离子拮抗剂、自由基清除剂等药物治疗;合并创伤失血性休克时早期限制性液体复苏、后期积极补液;并早期行高压氧和康复治疗。实行个体化综合性治疗,观察治疗效果。 结果 在23例颅脑损伤后合并脑梗塞患者中,经过积极抢救按格拉斯哥预后评分(GOS)标准评价,恢复良好14例,轻残6例,重残1例,死亡2例。其中死于创伤失血性休克1例,多器官功能障碍综合征(MODS)1例。 结论 早期预防和诊断,及时发现颅脑外伤后并发脑梗塞,并给予积极有效的早期个体化综合性治疗能有效降低致死率和致残率。      

创伤因素和非创伤因素致死率的回顾性分析

目的观察院前急救中创伤因素和非创伤因素致人死亡数量和死亡率的差异性。方法将德阳市第二人民医院2009年1月1日-2010年12月31日实施院前急救的3934例伤(病)员中死亡的202例伤(病)员,根据致死原因分组,因外力损伤经院前急救无效死亡的分入创伤因素致死组,因疾病经院前急救无效死亡分入非创伤因素致死组。将创伤因素致死组和非创伤因素致死组死亡的人数和死亡率进行统计学对比分析,观察院前急救中创伤因素和非创伤因素致人死亡数量和死亡率的差异性。结果创伤因素致死组,急救2657例,死亡89例,死亡率3.35%;非创伤因素致死组,急救1277例,死亡113例,死亡率8.85%;两组在院前急救中的死亡人数,经χ2检验,死亡率经U检验,均P<0.01,差异有统计学意义。即在急救半径内,非创伤性因素致人死亡数量、死亡率明显高于创伤因素致人死亡数量、死亡率。结论应重点加强非创伤性急症院前急救技能和心肺复苏的培训工作,提升院前急救质量。     

额颞部对冲性脑损伤的救治分析

目的:探讨额颞部对冲性脑损伤的手术治疗策略,进一步提高额颞部对冲性脑损伤患者的治愈率。方法:对我科2003年6月～2008年6月手术的58例额颞部对冲性脑损伤患者的临床资料进行回顾性分析。结果:58例手术治疗的患者中,采用格拉斯哥治疗结果分级(GOS)标准对预后进行评估,良好33例,中残8例,重残9例,死亡8例;术前GCS>8分的19例中良好17例,中残2例,无重残及死亡。结论:对于额颞部对冲性脑损伤患者,临床上要密切观察病情变化,动态复查头颅CT,早期及时采用标准外伤大骨瓣开颅手术治疗,充分减压,有利于提高患者生存率与生存质量。     

以颅脑伤为主的全身多发伤快速急救探讨

目的：探讨以颅脑伤为主的全身多发伤快速急救的意义及重要措施。方法：回顾性分析总结１９９１年５月～１９９７年６月７２８例多发伤快速急诊救治的资料。结果：以颅脑伤为主的全身多发伤，最多见于２０～４５岁青壮年，占８０％。死亡５５例中，重型颅脑伤伴顽固性休克死亡者最多，共３６例；脑死亡１２例；伤后感染或多脏器功能障碍死亡１７例。有２３３例为急诊观察治疗。急诊抢救成活率９２％。结论：强调此类伤病员必须由急诊科医师负责组织指挥，连续不断地采取以脑部伤为主的快速、准确、有效的综合措施和处理其他多发伤，其次要对急诊留观的伤员严密观察，并加强脑组织保护和营养支持，以及预防创伤性感染。     

CHEST INJURIES IN BATTLE CASUALTIES

Battle casualties treated as indoor patients at a military hospital between December 89 and December 94 were prospectively evaluated. Out of 3640 patients, 388 (10.7%) had chest injuries. Among the 388 patients 190 (48.9%) had haemothorax. Pleurocentesis was the fastest and the most reliable means of establishing the diagnosis of haemothorax. Thoracostomy with supportive care was adequate to manage 75 per cent of these cases which included more than 50 per cent of those with massive haemothorax. Twelve patients out of the 190 cases (6.3%) who presented with haemothorax needed thoracotomy. The overall mortality in this series was 7 per cent.KEY WORDS: Chest injury, Haemothorax, Pleurocentesis, Thoracostomy, Thoracotomy     

多发伤患者预后因素分析

目的:总结影响多发伤患者病死率的因素。方法:分析住ICU113例多发伤患者的临床资料,并予统计学分析。结果:113例中存活80例,病死33例,病死率29.2%,多器官功能障碍综合征(MODS)43例,发生率38.1%,其中病死25例,病死率58.1%;存活组与死亡组相比较,住ICU时间、SIRS评分、大量输血(复苏时)、急性生理学与慢性健康状况Ⅱ(APACHEⅡ)评分、MODS、休克差异均有统计学意义。结论:多发伤病死率高,住ICU时间、APACHEⅡ评分、全身炎症反应综合征评分、MODS、休克、大量输血是其影响因素。积极干预可以减少病死率。     

重型颅脑损伤合并严重胸损伤的临床救治

目的探讨重型颅脑损伤合并严重胸损伤的诊断和治疗。方法对32例重型颅脑损伤合并严重胸损伤的临床资料进行分析。结果GOS预后评分：恢复良好14例,中残9例,重残3例,植物生存2例,死亡4例。结论重型颅脑损伤合并严重胸损伤其伤情复杂而严重,伤残率和病死率较高。全面详细的检查、正确的诊断和及时有效的治疗和处理,弄清颅脑损伤和胸部损伤的关系,积极防治成人呼吸窘迫综合征（ARDS）及肺部感染等并发症,是提高抢救成功率的关键。     

多学科协作诊疗模式在严重创伤患者救治中的应用

目的 探讨综合医院多学科协作诊疗(multidisciplinary team, MDT)模式对重症创伤患者的救治效果.方法: 选择2017年3月至2019年4月,北京大学人民医院创伤救治中心启动MDT流程收治的严重创伤患者的病例资料进行回顾性分析,讨论MDT组成和严重创伤者启动MDT的指标,并分析MDT救治模式与患者预后的相关性.结果: 共收集启动MDT团队进行创伤救治的病例112例,患者入院GCS(Glasgow coma scale)评分13.0±2.9,TI(trauma index)评分13.0±2.8,ISS(injury severity score)评分21.5±11.9.启动MDT团队呼叫用时(3.7±0.8) min,MDT人员抵达急诊抢救区时间(6.1±0.9) min,完成快速CT时间(23.8±3.0) min,开始损伤控制手术时间(92.6±15.4) min.所有入院患者均得以有效救治,ICU住院时间(12.6±6.7) d,治愈出院患者55例,死亡病例5例,转康复医院患者52例.结论: 综合医院创伤救治中心以MDT模式进行严重创伤患者的救治,能够明显提高严重创伤患者救治能力和水平,弥补了大型综合医院分科过细对严重创伤及多发伤患者治疗的欠缺,提高了严重创伤患者的救治效果,为大型综合医院救治严重创伤及多发伤患者以及创伤救治中心建设提供了一种可参考模式.