重度创伤急救原则的临床研究

目的探讨重度创伤(ISS评分≥16分)的急救原则。方法应用"ATP三原则"救治重度创伤:①外科主治以上医师(Attending)首诊并全权、全程指挥抢救原则;②患者入院后立即成立急救小组(Teamwork)救治原则;③抢救、检查、诊断同时进行,使抢救时间最短的并联(Parallel)原则。分析比较应用"ATP三原则"前、后各2年救治重度创伤的临床效果。结果应用"ATP三原则"前2年(2002-01-01~2003-12-31)共抢救、收治重度创伤388例,ISS评分(25.9±6.4)分,死亡152例,死亡率39.2%,抢救室抢救时间、入院至急诊手术时间分别为(102.8±16.7)min、(140.3±20.6)min。应用"ATP三原则"后2年(2004-01-01~2005-12-31)共抢救、收治重度创伤438例,ISS评分(28.6±7.8)分,死亡87例,死亡率19.9%,抢救室抢救时间、入院至急诊手术时间分别为(69.5±11.5)min、(89.6±9.3)min。两组治疗前ISS评分比较差异无统计学意义(P>0.05);两组治疗后死亡率、抢救时间、入院至手术时间比较差异均有统计学意义(P<0.05),应用"ATP三原则"后均明显降低。结论应用"ATP三原则"救治重度创伤能显著缩短抢救时间,降低创伤死亡率。     

皮肤创伤愈合过程的研究

创伤愈合是一个复杂的生物学过程,包括细胞的增殖、分化、上皮化、迁移及基质的合成与沉积[1],现简单介绍创伤愈合的过程及其相关的研究进展。     

多发伤患者外周血单个核细胞NF-κB活性变化及乌司他丁的保护作用

目的 探讨多发伤患者早期外周血单个核细胞NF-κB活性变化及乌司他丁的保护作用.方法 收集2008-01~2010-05急诊收治20～55岁的多发伤患者,将入选的多发伤患者随机分为多发伤对照组、乌司他丁治疗组.乌司他丁治疗组在创伤后12 h内开始给予乌司他丁治疗,20万U溶于100 mL生理盐水中静脉注射,以后每8 h 1次,连续7 d.采集患者在入院时(0)、第1天、第2天、第3天、第4天及第7天外周静脉血.测定外周血单个核细胞NF-κB活性及血清TNF-α、IL-1、IL-6浓度.分析比较不同组患者实验室指标和临床指标的差异.结果 多发伤患者创伤后第1天(24 h)外周血单个核细胞NF-κB活性、血清IL-6、TNF-α浓度均最高,随后逐渐降低,至第3天(72 h)后降至正常.乌司他丁治疗组单个核细胞NF-κB活性、血清IL-6、TNF-α浓度均较对照组降低,但差异无统计学意义.多发伤患者SIRS平均持续(10±3.5)d,乌司他丁治疗组平均持续(7±3.1)d,两组比较差异有统计学意义(t=2.31,P=0.029).多发伤患者MODS平均持续(8.8±2.6)d,乌司他丁治疗组平均持续(5.6±2.7)d,两组差异有统计学意义(t=2.27,P=0.025).结论 多发伤患者早期单个核细胞NF-κB活性及血清前炎症细胞因子呈一过性升高.乌司他丁能缩短多发伤患者SIRS、MODS持续时间,但未发现能显著降低外周血单个核细胞NF-κB活性.     

Comparison of severe trauma care effect before and after advanced trauma life support training

Objective： To study the emergency care effect of in-hospital severe trauma patients with the injury severity score （ISS）≥ 16 after medical staff received advanced trauma life support （ATLS） training.Methods： ATLS training was implemented by lectures,scenarios, field practices, and examinations. The clinical effect of in-hospital severe trauma care was compared 2 years before and after ATLS training.Results： During 2 years （from January 1, 2004, to December 31, 2005） before ATLS training, 438 cases of severe trauma were admitted and treated emergently in our department. Among them, ISS score was 28.6±7.8 on average, and 87 cases died with the mortality of 19.9%. The duration in emergency department and from admission to operation were 69.5 min±l 1.5 min and 89.6 min±9.3 min respectively. Two years （from January 1,2007, to December 31, 2008） after ATLS training, 382 cases of severe trauma were admitted and treated. The ISS was 25.3 ±6.1 on average and 62 cases died with the mortality of 15.1%. The duration in emergency department and from admission to operation were 47.8 min±10.7 min and 61.5 min±9.9 min respectively. The ISS score showed no significant difference between the two groups （P＞0.05）, but the mortality, the duration in emergency department and from admission to operation were markedly decreased after ATLS training and showed significant difference between the two groups （P＜0.05）.Conclusion： ATLS course training can improve the emergency care effect of in-hospital severe trauma patients,and should be put into practice as soon as possible in China.     

The change of angiotensin Ⅱ production and its receptor expression during wound healing: possible role of angiotensin Ⅱ in wound healing

Objective This study was undertaken to observe the change in the local level of angiotensin Ⅱ (Ang Ⅱ) and the expression of its corresponding receptors AT1 and AT2 during wound healing, and explore the possible role of Ang Ⅱ in wound healing . Methods A model of full-thickness cutaneous wound was developed on the back of C57/BL6 mice. Specimens were taken from the wound of each mouse on the day 0, 1, 3, 5, 7, 9, 11, 13 and 15 after wounding. The change in the generation of Ang Ⅱ in wounded tissue during the healing process was detected with ELISA. The proliferation and the apoptosis of cells were detected by bromodeoxyuridine (Brdu) and terminal deoxyuncleotidyl transferase mediated deoxyuridine triphosphate nick end labeling (TUNEL) method in wounded skin during the healing process, respectively. The cellular localization and the mRNA level change of Ang Ⅱ receptors in wounded tissue during healing were detected with immunostaining and RT-PCR. Results Ang Ⅱ produced in wounded skin was increased in the first 7 days to reach the peak, and then gradually decreased during wound healing. BrdU labeling index was increased gradually in the first 7 days to reach the peak, and then gradually decreased during wound healing. The number of TUNEL-positive cells was increased slowly in the first 7 days after wounding. The increase in the number of TUNEL-positive cells was more markedly after epithelization of the wound. In normal mice, AT1 and AT2 receptor were found positively expressed in the whole epidermal layer, while positive expression was only found in the endothelial cells of the capillary vessels within the dermal layer, and positive expression was also found in appendages of the skin, i.e. hair follicle, sweat gland and sebaceous gland respectively. Positive staining signal of both AT1 and AT2 receptors were increased in the first 7 days to reach the peak, then gradually decreased. Expression of AT2R was increased again following the epithelization of wound. The result of RT-PCR showed that the expression of both AT1 and AT2 receptors was detectable, and AT1 receptor was increased in the first 7 days to the peak, and then gradually decreased during wound healing, while AT2 receptor expression reached its peak value on day 7, then gradually decreased, and increased again following the epithelization of wound. Conclusions These results indicate that Ang Ⅱ participate in wound repair and related to remolding in the late stage of wound healing through the change in production of angiotensin Ⅱ and expression of AT1 and AT2 receptors. AT1 receptor might be closely associated with cell proliferation,while AT2 receptor might play a role in cell apoptosis and remolding during wound healing.     

ATLS培训前后重度创伤救治效果比较

高级创伤生命支持(advanced trauma life support,ATLS)培训自1978年在美国首次开展以来,已被认为是创伤救治培训的规范教程和创伤救治方法的指南,被世界广大医务人员所接受、推广~([4]).     

First aid strategy for severe traumatic patients in hospital

Objective： To study the emergency management principles of severe trauma in hospital （injury severity score ≥ 16）. Methods： We used ＂ ATP principle＂ to manage severe traumatic patients. The ATP principle is composed of： 1 ） attending surgeons offering initial management （A） ; 2 ） teamwork commencement immediately after patients admitted to hospital （ T ） ; 3 ） parallel principle, ie, emergency resuscitation, evaluation and laboratory test performed simultaneously （P）. Clinical effects before and after applying ATP principle were retrospectively analyzed and compared. Results： During January 1, 2002 to December 31, 2003, 338 patients were treated without applying ATP principle, in which ISS was 25.9 ± 6.4, 152 cases died with the mortality being 39. 2%, and the time stayed in emergency department and the time to operation room after admission were （102.8±16.7） rain, （140.3 ±20.6） rain,respectively. During January 1, 2004 to December 31, 2005, 438 patients were treated based on ATP principle, in which ISS was 28.6 ± 7.8, 87 cases died with the mortality being 19.9%, and the time in emergency department and the time to operation room after admission were （69.5 ± 11.5） rain, （89.6 ±9 .3） min, respectively. ISS showed no significant difference between the two groups （ P 〉 0.05 ）, but the mortality, the time stayed in emergency department and the time to operation room after admission were greatly reduced and showed significant difference between the two groups （ P 〈 0.05 ）. Conclusions： Applying ATP principle to treat severe traumatic patients can shorten emergency treatment time in hospital and decrease mortality.     

急性胰周积液和胰腺坏死对急性胰腺炎预后的影响

目的 探讨急性胰周积液和胰腺坏死对急性胰腺炎(AP)预后的影响.方法 回顾分析2003年1月至2007年12月收治的323例AP患者早期CT影像学表现,探讨急性胰周积液、胰腺坏死程度与全身炎症反应综合征(SIRS)、胰腺感染及病死率的关系.结果 发病5 d内出现SIRS并持续2 d或以上者97例(30%),12例(3.7%)在病程中、后期出现胰腺感染;病死14例(4.3%).有急性胰周积液者142例(44.0%).单个部位发生急性胰周积液者76例,其中31例发生SIRS,病死2例;多个部位急性胰周积液者66例,发生SIRS 62例,病死11例.急性胰周积液部位数量与早期SIRS发生及病死率显著相关(P＜0.01).277例(85.8%)无胰腺坏死,均未继发胰腺感染,病死4例;46例(14.2%)有不同程度胰腺坏死.胰腺坏死面积≤30%32例,胰腺感染发生率12.5%,病死率15.6%;＞30%～≤50%7例,感染发生率42.9%,病死率28.6%;＞50%7例,感染发生率为71.4%,病死率42.9%,胰腺坏死的程度与胰腺感染的发生及病死率显著相关(P＜0.05).结论 急性胰周积液和胰腺坏死对AP预后的影响不同.急性胰周积液与病程早期SIRS的发生及病死率相关;胰腺坏死与胰腺继发感染的发生及病死率有关,坏死面积越大,越容易发生胰腺感染,病死率越高.     

血管紧张素Ⅱ对增生性瘢痕成纤维细胞PI3K/Akt信号通路的影响

目的 观察血管紧张素Ⅱ(angiotensin Ⅱ,Ang Ⅱ)对增生性瘢痕成纤维细胞磷脂酰肌醇-3激酶/蛋白激酶B(phosphoinositide 3-kinase/Akt,PI3K/Akt)信号通路的影响.方法 体外培养人增生性瘢痕成纤维细胞,用免疫荧光组织化学染色检测细胞Ang Ⅱ受体AT,和AT_2的表达.以PI3k活性测定法和Western Blotting法检测细胞PI3K的活性和Akt的磷酸化.结果 免疫荧光组织化学染色结果显示培养的增生性瘢痕成纤维细胞同表达AT_1和AT_2受体.Ang Ⅱ(10~(-9)～10~(-7)mol/L)刺激可增加细胞Akt的磷酸化和P13K的活性.AT_2受体拮抗剂PD1233191可显著增强AngⅡ诱导的细胞Akt磷酸化和PDK活性增加(P<0.05);AT_1受体拮抗剂Valsartan可显著抑制AngⅡ诱导的细胞Akt磷酸化和PDK活性增加(P<0.05).结论 Ang Ⅱ通过其受体AT_1和AT_2可调控增生性瘢痕成纤维细胞Akt磷酸化和PI3K的活性.