严多发伤并发症的早期控制

Objective To analyze the efficacy of early management of eomplications in patients with multi-ple traumas by applying the damage control theory. Method All total of 116 patients admitted to Wuhan Tongji Hospital between Jan 2006 and Jan 2008 were included in this retrospective study and were classified according to treatment method. Overall, 55 cases underwent damage control operations and 61 cases underwent conventional management. The groups of patients were compared in terms of parameters such as length of operation time, time to resuscitate from shock, lethal triad of death (LTD), complications and treatment outcomes after operation. Results The length of operation time was (67.43±19.52) min, resuscitation time from shock was (6.77±3.16) h and LTD was (11.54±4.10) h in the damage control group, and (163.95±55.41) min, (22.51±11.65) h and (34.55±5.63) h, respectively, in the conventional group, with significant differences between the two groups (P< 0.01). The per capita complication and mortality rates were 227.27 % and 3.64 %, respectively, in the dam-age control group and 363.93 % and 9.84%, respectively, in the conventional group (P <0.05). Couclusions Here, we demonstrated that early management of patients with multiple traumas undergoing operations by apply-ing the damage control theory significantly decreased the operation time, and decreased time to resuscitation from shock and LTD. Furthermore, this approach significantly reduced the incidence of comphcations and the mortality rate of patients with severe multiple traumas.     

肢体部位淋巴管瘘的诊断和治疗

淋巴管瘘是一种十分罕见而且相当棘手的医疗难题，临床上对因胸腹段较大淋巴管瘘所致的乳糜胸和乳糜腹研究较多，而对于肢体淋巴管瘘则研究较少。由于肢体部位淋巴管瘘在发病机制、临床表现上均有其自身的特点，因此本文依据国内外文献报道以及我科的诊疗经验综述如下，以期明确淋巴管瘘的诊断和治疗。     

雷公藤内酯醇对内毒素激活小鼠腹腔巨噬细胞分泌促炎症介质NO和IL-6的影响(英文)

Objective Tripterygium wilfordii Hook.f.has been used for centuries in traditional Chinese medicine to treat autoimmune disease associated with increased production of the pro-inflammatory cytokine.Triptolide(TP) is a compound originally purified from T.wilfordii Hook f.and it has potent anti-inflammatory and immunosuppressant activities.In this study,we investigated the effect of TP on secretion of NO and IL-6 in celiac macrophages (MΦ) activated by lipopolysaccharide (LPS) in Kunming mice.Methods Celiac MΦ of mice were separated,purified,and activated by LPS,then cultured in vitro with TP of different concentrations.The level of NO in cellular supernatants was determined by Griess reagent,and that of IL-6 was determined by ELISA.Results We found that pro-inflammatory cytokine NO activity in MΦ induced by LPS was significantly inhibited by TP (10-3-10 μg/ml) from 4-24 h in a time and dose-dependent manner (P<0.01).The level of IL-6 in MΦ was significantly inhibited by TP (10-3-10 μg/ml) at 12 h in a dose-dependent manner(P<0.01).Conclusions We demonstrated that TP can inhibit levels of NO and IL-6 in celiac MΦ of Kunming mice activated by LPS.     

多发伤合并脊柱脊髓损伤的特点分析

目的 探讨多发伤患者合并脊柱脊髓损伤的临床特点.方法 回顾性分析2004年3月-2009年3月收治的143例合并脊柱脊髓损伤的多发伤患者,统计致伤原因、脊柱损伤节段、合并伤、并发症、治疗方式和转归.结果 高处坠落伤和交通伤是主要致伤原因,分别为77例(53.8%)和55例(38.5%),损伤节段依次为腰椎101处(50.8%)、胸椎61处(30.7%)、颈椎29处(14.6%)及骶尾椎8处(4.0%);合并伤依次为胸部163处(38.6%)、腹部84处(19.9%)、头颈部77处(18.3%)、四肢65处(15.4%)、面部17处(4.0%)和体表16处(3.8%).早期并发症依次为电解质紊乱33例(16.8%)、呼吸系统感染30例(15.3%)和腹胀19例(9.7%);晚期并发症依次为营养不良26例(13.3%)、肌萎缩23例(11.7%)和深静脉血栓11例(5.6%).治疗方式依次为手术治疗106例(74.1%),保守治疗37例(25.9%).治疗前美国脊柱损伤协会(ASIA)评级E级20例(14.0%),治疗后E级53例(37.1%).死亡12例,病死率为8.4%,主要死亡原因为MOF、脑疝、营养衰竭等.随着ASIA残损分级的提高,各组并发症和病死率也显著增加(P＜0.05).结论 高能量损伤是多发伤合并脊柱脊髓损伤的主要致伤因素,患者病情重,合并伤复杂,并发症多,治疗棘手,病死率高.

Abstract：

Objective To analyze the clinical features of the multiple trauma patients combined with spine and spinal cord injuries.Methods A retrospective study was performed in 143 multiple trauma patients combined with spine and spinal cord injuries admitted to our department between March 2004 and March 2009.The parameters including injury cause,segment of injuries,associated injuries,complications,treatment methods and outcomes were analyzed.Results Falling and traffic accidents were the main causes for the injuries of spine and spinal cord,accounting for 53.8%(77 cases)and 38.5%(55 cases),respectively.The injured segments involved 101 lumbar vertebrae(50.8%),61 thoracic vertebrae(30.7%),29 cervical spines(14.6%)and 8 sacrococcygeal vertebrae(4.0%).The associated injuries were located at chest(163 regions,38.6%),abdomen(84 regions,19.9%),head and neck(77 regions,18.3%),extremity(65 regions,15.4%),face(17 regions,4.0%)and body surface(16 regions,3.8%).The early complications included electrolyte disturbances in 33 patients (16.8%),respiratory infection in 30(15.3%)and abdominal distention in 19(9.7%).The late complications were malnutrition in 26 patients(13.3%),amyotrophy in 23(11.7%)and deep vein thrombus in 11(5.6%).Treatment methods were operations and expectant treatments in 106 patients (74.1%)and 37(25.9%)respectively.According to American Spinal Injury Association(ASIA)scale,there were 20 patients(14.0%)at grade E before treatment and 53(37.1%)at grade E after treatment.Of all,12 patients were died of mainly multiple organ failure(MOF),cerebral hernia and malnutrition,with mortality rate of 8.39%.There showed an increase of complication and mortality rate with increase of ASIA grade(P ＜ 0.05).Conclusions The spine and spinal cord injuries in patients with multiple trauma are mainly caused by high energy injuries and characterized by high injury severity,complex associated injuries,multiple complications,difficult management and high mortality rate.     

肱三头肌-肘肌瓣人路治疗肱骨髁间骨折

目的 设计一种肘关节后肱三头肌止点剥离、肘肌瓣入路,探讨其治疗肱骨髁间骨折的临床疗效.方法 将肱三头肌止点连同尺骨骨膜从尺骨鹰嘴上自内侧向外侧剥离,保留附着在尺骨外侧肘后肌的止点,将整个肱三头肌-肘肌形成的组织瓣由尺侧向桡侧翻转,术后将肱三头肌在尺骨上的止七点原位缝合.2005年11月至2006年6月,采用此入路治疗C型肱骨髁间骨折11例,骨折类型按AO分类C1型骨折3例,C2型3例,C3型5例,先将骨折复位后,分别采用钢板、拉力螺钉、克氏针内固定,采用Jupiter肘关节功能评分.结果 该入路可取得良好的肘关节暴露,所有病例经过6至12月的随访,无一例出现切口皮肤坏死、深部感染、肱三头肌萎缩及尺神经损伤,1例出现克氏针松动.肘关节功能评价,优7例,良3例,中1例.结论 肱三头肌-肘肌瓣入路是治疗肱骨髁间骨折的理想入路,可取得良好的肘关节和肱骨远端暴露,内固定安放方便,术后可早期功能锻炼.     

重视急性软组织损伤的急救与并发症的处理

急性软组织损伤是指皮肤、皮下组织、筋膜、肌肉、肌腱、韧带、血管、神经、关节囊、关节软骨等软组织的各种急性开放或闭合性损伤.临床上,只要是创伤伤员,均会伴有不同程度的软组织损伤,例如擦挫伤、撕裂伤、切割伤、砍伤和刺伤等.通常轻微的损伤可以自行愈合,但当损伤广泛时,则需要治疗或手术的干预才能修复创面,严重时可引起相应的并发症,例如挤压综合征、骨筋膜室综合征等,并继发感染、坏疽,轻则截肢,重则危及生命. 1 软组织损伤的分类 不同的软组织损伤类别具有了不同损伤的特点,因此掌握软组织损伤的分类,有助于制定不同的急救和治疗措施,加快创伤的愈合. 1.1 按伤口的致伤机制分类     

负压封闭引流对兔皮肤创面炎症细胞趋化和炎症因子分泌的影响

目的观察负压封闭引流(VSD)对兔创面炎症细胞趋化和炎症因子分泌的影响。方法建立兔皮肤创面模型,将建模后的12只实验兔随机分为常规组(n=6,创面消毒后不作特殊处理,仅每日常规换药、包扎)及VSD组[n=6,创面常规消毒,贴膜后给予持续-125mmHg(-16.6kPa)负压吸引]。分别于不同时间点在创缘处取材,经苏木素-伊红染色后光学显微镜观察并行巨噬细胞、中性多形核白细胞(PMN)和淋巴细胞计数,以酶联免疫吸附测定(ELISA)法检测创面组织肿瘤坏死因子-α(TNF-α)和白细胞介素-6(IL-6)含量。结果建模前VSD组与常规组比较,创面组织巨噬细胞、PMN及淋巴细胞计数无显著性差异(P>0.05)。建模后两组创面巨噬细胞和PMN计数均升高,与常规组比较,VSD组创面巨噬细胞计数显著增加(P<0.05),而其PMN及淋巴细胞计数则明显降低(P<0.01)。建模后两组创面TNF-α、IL-6含量均升高,二者均于24h时间点达到峰值后下降,VSD组创面TNF-α及IL-6含量显著低于常规组(P<0.05)。结论 VSD可通过调节巨噬细胞、PMN、淋巴细胞趋化以及细胞TNF-α、IL-6分泌而降低炎症反应并使其局限化。     

rh-aFGF对创伤性关节炎早期大鼠软骨与滑膜中MMP1表达的影响

［摘要］目的观察实验性创伤性关节炎早期大鼠软骨和滑膜组织中基质金属蛋白酶1（MMP1）的表达,以及关节腔注射重组人酸性成纤维细胞生长因子（rh-aFGF）对其表达的影响。方法雄性SD 大鼠24只,随机分为空白组、对照组和实验组,每组8只 。对照组和实验组大鼠采用切断右侧膝关节内侧副韧带和切除部分内侧半月板的方式建立大鼠创伤性关节炎模型。实验组大鼠在造模术中及术后1周分别在手术侧关节腔注入rh aFGF 1 μg。2周后处死大鼠,采用苏木精 伊红（HE）染色观察各组大鼠关节软骨和滑膜组织结构变化,采用免疫组织化学染色法检测各组大鼠的关节软骨和滑膜内MMP1 表达。结果与空白组比较,对照组大鼠关节软骨和滑膜中的MMP1表达明显增高,而实验组大鼠关节软骨和滑膜中的MMP1表达则较对照组减少。结论rh aFGF关节腔注射可以减少创伤性关节炎早期大鼠关节软骨和滑膜组织中MMP1的表达,从而在创伤性关节炎的发生过程中对关节软骨的退变和滑膜组织的炎症发挥一定的抑制作用。     

严重多发伤患者伤后调节性T细胞的变化及其与损伤严重度和脓毒症的关系

目的 观察严重多发伤患者伤后外周血调节性T细胞(Treg细胞)的变化及其与脓毒症和损伤严重度的关系. 方法 60例严重多发伤患者按ISS评分排序后分为严重组(30例),危重组(30例);按是否伴发脓毒症分为脓毒症组(22例)和非脓毒症组(38例).于伤后1,3,5,8 d用流式细胞仪检测各组患者外周血Treg细胞的比率. 结果 严重多发伤患者伤后5 dTreg细胞比率开始升高,与伤后3 d相比差异有统计学意义(P<0.01);伤后8 d仍持续升高(P<0.05).伤后8 d,危重组外周血Treg细胞比率显著高于严重组(P<0.01),脓毒症组外周血Treg细胞比率显著高于非脓毒症组(P<0.05).Spearman相关分析显示Treg细胞比率与ISS评分呈正相关(rs=0.654,P<0.01). 结论 Treg细胞在严重创伤后的免疫抑制中扮演着重要的角色,Treg细胞比率的变化有助于评估患者的预后及判断并发脓毒症的危险度.     

急性硬膜下血肿CT表现与预后

创伤性急性硬膜下血肿(aSDH)患者术后的死亡率相当高(50％～90％),且许多因素可影响其手术效果。本文收集34例aSDH手术病例,依术前CT蛛网膜下腔的表现将其分成两组,回顾性地分析了术前CT蛛网膜下腔的改变对手术预后的影响。1 临床资料1.1 一般资料 从1993年5月至1998年9月共收治34例aSDH,男23例,女11例,年龄17～76岁,平均47.4岁。入院时排除伴有多发伤、颅内多发血肿、原发性脑干损伤、弥漫性轴索损伤以及开放性颅