心脏钝性损伤的早期诊断及临床意义：附28例报告

总结２８例心脏钝性损伤的早期诊断经验。讨论了心脏钝性损伤的临床特点及早期诊断中的一些问题。强调闭合性胸部损伤病人有合并心脏损伤的可能，心电图检查可以提供比较可靠的诊断依据。早期正确的诊断和及时处理直接影响病人的预后。     

颅脑损伤合并胸部伤78例早期救治体会

目的总结颅脑损伤合并胸部伤的诊断与早期救治策略。方法回顾性分析78例颅脑损伤合并胸部伤患者的临床资料。结果恢复良好52例,中残14例,重残2例,死亡10例,死亡原因为脑损伤过重、脑干功能衰竭6例,多器官功能障碍综合征4例。结论全面的临床评估和必要的影像学检查可以减少胸部合并伤的漏诊,对致命损伤作出早期诊断是成功救治的前提;早期救治的重点是抢救生命,优先处理致命性胸部伤可以为颅脑损伤的救治创造有利条件。     

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.     

中、重度颅脑损伤合并胸部损伤48例救治体会

目的探讨中、重度颅脑损伤合并胸部损伤患者的临床特点及救治体会。方法回顾性分析48例中、重度颅脑损伤合并胸部损伤患者的临床资料。结果本组48例中、重度颅脑损伤合并胸部损伤的患者经救治成功40例,成功率83-3％,死亡8例,病死率16．7％。死亡原因：严重损伤后早期合并失血性创伤性休克3例,脑疝3例,损伤后期并发呼吸窘迫综合症（ARDS）1例,多器官系统功能衰竭（MSOF）1例。结论及时准确的诊断是救治成功的关键,在保持呼吸、循环稳定的前提下及时进行颅胸手术,有效降低颅内压,积极防治肺部并发症,提高综合救治水平。     

46例钝性胸部损伤临床分析

目的总结钝性闭合性胸部损伤的临床特点、诊断及治疗方法。方法肋骨骨折者胸带包扎固定、胸壁牵引固定或肋骨内固定;气胸、血胸或血气胸者,采用胸腔穿刺、胸腔闭式引流术或开胸肺修补术;有活动性出血者行开胸探查止血术。结果 46例治愈42例,治愈率91.30%;4例患者分别死于心脏损伤,肝、脾破裂伴膈疝,重度颅脑损伤及腹腔大血管破裂。结论钝性闭合性胸部损伤患者病情凶险、变化快、并发症多,必须多专业科室合作,尽快明确诊断、及时治疗,是提高钝性闭合性胸部损伤抢救成功率、减少并发症、降低病死率的关键。     

胸部CT与X线检查诊断胸部闭合性损伤的价值分析

目的探讨胸部CT与X线检查诊断胸部闭合性损伤的临床价值。方法选择76例胸部闭合性损伤患者为研究对象,所有患者均接受胸部CT和X线检查,比较二者对于胸部闭合性损伤的诊断价值。结果患者均经临床确诊,其中肋骨骨折66例,血气胸21例,肺不张8例,肺挫裂伤32例,创伤性湿肺9例,膈肌破裂2例。其中胸部CT对于肺不张、血气胸、肺挫裂伤和创伤性湿肺方面的准确率明显高于胸部X线,比较差异均有统计学意义(均P0.05)。2组对于肋骨骨折和膈肌破裂的诊断准确率差异无统计学意义(均P0.05)。结论胸部CT在诊断血气胸、肺不张、肺挫裂伤和创伤性湿肺方面较X线更为准确,可结合患者临床症状及病情合理选择,部分疾病在条件允许的情况下应选择更为准确而有效的CT检查,以提高诊断率和治疗效果。     

腹部闭合性胰腺损伤的诊治

目的 探讨腹部闭合性胰腺损伤的诊断及治疗,以改善病人的预后.方法 回顾性分析自1999年9月至2006年6月收治闭合性胰腺损伤病人10例,进行分析总结.结果 10例患者中9例治愈,1例死亡.结论 腹部闭合性胰腺损伤发生率低,早期诊断困难,并发症多,如处理不当,将影响病人的预后.而CT的诊断准确率高,是重要的辅助检查手段.选择适当的治疗方式可以提高病人的救治率.     

家兔胸部火器伤实验模型建立及早期死亡原因探讨

目的建立家兔胸部火器伤实验模型，探讨致伤机理及早期死亡原因。方法４８只家兔随机均分为８组，分别用气步枪和小口径步枪致胸壁伤和胸腔伤，并分实验模型组与救治组对比研究。实验中对血压、心率、气道压、血气、胸部Ｘ线等指标进行监测和常规病理检查。结果胸壁伤：模型组中气步枪无死亡，小口径步枪死亡１只，救治组无死亡。胸腔穿透伤：模型组与救治组中气步枪死亡率分别为５０％和１６．７％，小口径步枪分别为８３．３％和５０％。结论（１）按实验参数致伤结果符合量效关系，重复性好，且与人类战时火器伤死亡率近似；（２）发现除心脏、大血管损伤外，肋间动脉出血也是动物早期死亡的重要原因；肺损伤出现早而严重；（３）现场初步救治可提高存活率     

78例腹部闭合性损伤诊治分析

目的 总结腹部闭合性损伤的诊治体会。方法 回顾性分析我院78例腹部闭合性损伤患者的临床资料。结果 78例中67例手术治疗，4例行肾动脉栓塞术，7例保守治疗；除1例死亡外，余均治愈。结论 及时诊断和治疗是救治腹部闭合性损伤患者的关键，腹腔穿刺、B超、CT及X线检查的合理应用对诊断有重要价值。     

腹部闭合性多器官损伤48例诊疗分析

目的 探时腹部闭合性多器官损伤的早期诊断与治疗方法。方法 回顺性分析经手术治疗的48例腹部闭合性严重多器官损伤部位、损伤程度、早期诊断方法及手术措施。结果 48例均进行手术治疗，分别施行脏器修补，全部或部分切除。治愈40例(83．33％)，死亡8例(16.67％)。结论 腹部闭合性严重多器官损伤是引起大出血与休克的主要原因，全面仔细检查、及早腹腔穿刺、B超检查、X线检查等对早期确诊、早期施行手术是抢救腹部多器官损伤的治疗原则。     

Concomitant aortic valve and internal mammary artery injuries in blunt chest trauma: Report of a case

We report a case of concomitant injury to the aortic valve and internal mammary artery (IMA) from nonpenetrating chest trauma. To our knowledge, this is the first such case to be reported. Transcatheter arterial embolization (TAE) following diagnostic angiography offers an effective and minimally invasive treatment for traumatic IMA injuries. Because there might be an asymptomatic interval after traumatic aortic valve injuries, serial physical examinations and repeated echocardiography should be mandatory for patients with de novo heart failure after blunt chest trauma. Transesophageal echocardiography can provide a clearer image of cardiac injuries than transthoracic echocardiography, particularly if there is extensive anterior mediastinal hematoma resulting from IMA trauma.     

Traumatic rupture of the pericardium with dislocation of the heart

Isolated rupture of the parietal pericardium with herniation of the heart may occur following closed injury of the chest. Such a case is presented here. Clinical suspicion should be aroused by the presence of low cardiac output with localizing signs of cardiac displacement. X-ray films of the chest may reveal important clues and provide an indication for cardiac angiography, which may be diagnostic.     

四肢主要血管闭合或隐匿损伤的诊断与显微外科修复

目的探讨四肢主要血管闭合或隐匿损伤诊断与修复方法及其临床效果。方法对11例闭合创伤合并动脉损伤或微小伤口合并动脉损伤的患者行血管成像技术（CTA）检查,诊断明确后行手术探查及显微外科修复。结果11例患者经CTA检查均清晰显示血管损伤,行显微外科血管重建后肢体恢复血循环。结论对怀疑肢体有闭合或隐匿主要动脉损伤行CTA检查,有助于早期诊断,明确损伤部位;及时手术探查、采用显微外科修复损伤血管是保全肢体成活起关键。     

Significance of the electrocardiogram in heart contusion due to blunt trauma.

In a series of 24 patients with major blunt chest trauma, 11 presented evidence of heart injury upon re-examination of serial ECGs and four were confirmed at autopsy. The clinical diagnosis had been recorded in only one patient. In every case of closed chest trauma, regardless of the degree of visible injury, cardiac injury must be suspected. A presumptive diagnosis is then made, usually on the basis of ECG changes, which cannot be ruled out by any other cause. Even in some cases with normal ECGs the clinician's suspicion is the only guide. With a presumptive diagnosis made, the patient is treated as is any patient with an irritable myocardium; bedrest, avoidance of conditions which may precipitate arrhythmias, and of fluid overload, and treatment of these complications as they arise. Anticoagulants are usually avoided. Followup for long periods is indicated, because of the occasional emergence of chronic constrictive pericarditis or ventricular aneurysm.     

Neurovascular injury complicating displaced proximal fractures of the humerus

Three cases with injury of the axillary artery and brachial plexus complicating a displaced proximal fracture of the humerus are presented. In two patients the arterial injury was not recognized on admission. Vascular repair had to be carried out in all three cases. Two patients showed a persistent neurological deficit. In two of the cases, the arterial injury may have been caused by an attempt at closed reduction of the fracture. The possibility of axillary arterial injury should be considered in proximal fractures of the humerus with severe medial displacement of the shaft of the humerus.     

The initial management of severe trauma patients at hospital admission

The initial management of trauma patient is a critical period aiming at: stabilizing the vital functions; following a rigorous injury assessment; defining a therapeutic strategy. This management has to be organized to minimize loss of time that would be deleterious for the patients outcome. Thus, before patient arrival, the trauma team alert should lead to the initiation of care procedures adapted to the announced severity of the patient. Moreover, each individual should know its role in advance and the team should be managed by only one individual (the trauma leader) to avoid conflicts of decision. A rapid trauma injury assessment aims not only at guiding resuscitation (chest drainage, pelvic contention, to define the mean arterial pressure goal) but also to decide a critical intervention in case of hemodynamic instability (laparotomy, thoracotomy, arterial embolisation). This initial assessment includes a chest and a pelvic X-ray, abdominal ultrasound (extended to the lung) and transcranial Doppler (TCD). The whole body scanner with administration of intravenous contrast material is the cornerstone of the injury assessment but can be done for patients stabilized after the initial resuscitation.     

The management of large soft-tissue defects following close-range shotgun injury

Large soft-tissue defects following close-range shotgun blasts remain a major technical challenge to trauma surgeons. During the period 1980 through 1988, 43 patients who survived greater than 48 hours following this injury were managed in our center. The locations of their soft-tissue defects were: extremity, 22; abdomen/chest, 18; and head/neck, three. All patients underwent immediate surgical exploration and wide debridement of all devitalized tissue along with repair of associated injuries. Management included mandatory frequent dressing changes, debridement, irrigation in the operating room, and the perioperative administration of broad-spectrum antibiotics. Four patients whose abdominal wall defects could not be initially closed had temporary placement of rayon cloth to prevent evisceration. Overall, four patients underwent delayed primary closure, eight were covered with split-thickness skin grafts, nine had closure with myocutaneous flaps, and 19 closed by secondary intent. Two patients, who were transferred to us following initial management, developed wound sepsis due to inadequate debridement and both eventually required amputation as did one patient who developed early myonecrosis following lengthy arterial repair. Frequent operative dressing changes, adequate debridement, and irrigation minimize sepsis following close-range shotgun blasts and should be the treatment of choice for this devastating injury. Techniques of wound closure need to be individualized to the particular situation.     

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.     

Diagnosis and treatment of post-traumatic coagulated hemothorax

Analysis of 102 cases of coagulated hemothorax (CH) are presented: 32--after penetrating wounds and 70--after closed chest injury. In 57% patients with chest wounds and 72% patients with closed injury the cause of CH was to applying late for medical care. Diagnostic value of X-ray, ultrasonic methods, CT and pleural puncture was studied. Depending on the patients state severity, CH volume and stage of it formation conservative treatment, streptase administration, thoracoscopy and thoracotomy with pleurectomy and lung decortication were performed. Lethality was 2.9%.