多发伤伴严重骨盆骨折的救治

目的总结救治多发伤伴严重骨盆骨折及其并发症的方法。方法笔者对1998~2011年救治的299例多发伤伴严重骨盆骨折的临床资料进行回顾性对比分析,其中男性172例,女性127例;年龄19~83岁,平均(47.3±8.2)岁。将其中1998年1月~2004年1月收治的116例未采用损害控制外科(DCS)治疗的患者作为对照组,2004年2月~2011年1月收治的183例采用DCS治疗的患者作为治疗组。对照组均行一期手术治疗。治疗组一期急诊先行髂内动脉断血术以控制出血(其中89例加骨盆外固定支架固定),伴脏器损伤者同时行胃肠破裂、膀胱破裂修补以阻断污染,行脾切除、肝修补控制出血,然后转往ICU行复苏治疗,生命体征平稳后行确定性手术,包括骨盆、后尿道和直肠修复重建等。结果对照组和治疗组的生存率分别为75.86%(88/116)和87.98%(161/183)。术后并发症包括失血性休克74例、盆腹腔感染27例、腹腔间隙综合征22例、脂肪栓塞综合征12例和深静脉血栓形成30例。主要死因为失血性休克、多脏器功能障碍综合征(MODS)和感染性休克。结论 DCS救治多发伤伴严重骨盆骨折明显提高生存率。主要方法为初期简化手术控制出血、污染(包括粪尿改道和有效引流),结合骨盆外固定支架使用;ICU复苏期遵循损害控制性复苏,观察处理各种并发症;生命体征稳定后再行确定性手术行骨盆、后尿道和直肠修复重建等。     

Changes in spatial QRS-T angle and QTc interval in patients with traumatic brain injury with or without intra-abdominal hypertension

Introduction

Traumatic brain injury (TBI) affects cardiac electrical function, and several extra-cerebral factors, including intra-abdominal pressure (IAP), might further modulate this brain-heart interaction. The purpose of this study was to investigate the impact of TBI, and of increased IAP during TBI, on cardiac electrical function as measured by vectorcardiographic (VCG) variables.

Characterization of circulating monocytes expressing HLA-DR or CD71 and related soluble factors for 2 weeks after severe, non-thermal injury

BACKGROUND: Severe injury is associated with changes in monocytes that may contribute to poor outcomes. Longitudinal characterization of monocyte response patterns after trauma may provide added insight into these immunological alterations. METHODS: Venous blood obtained seven times during post-injury days 1 through 13 from 61 patients with an injury severity score >20 was assessed by flow cytometry for monocytes (CD14+) expressing HLA-DR or CD71 (transferrin receptor) and for circulating levels of interleukin (IL) 1alpha, IL-1beta, IL-6, soluble CD14 (sCD14), tumor necrosis factor-alpha (TNF-alpha), prostaglandin E(2) (PGE(2)), thromboxane B(2) (TXB(2)), and endotoxin. Urine neopterin was measured by high-pressure liquid chromatography, expressed as a neopterin-creatinine ratio. RESULTS: Trauma patients had leucocytosis days 1 through 13, monocytosis days 5 through 13, reduced proportions of CD14+HLA-DR+ cells days 2 through 5, and elevated proportions of CD14+CD71+ cells days 1 through 13. Neopterin was elevated all days, peaking on day 10. sCD14 was elevated days 2 through 13, and there were sporadic elevations of IL-1alpha, IL-1beta, IL-6, TNF-alpha, PGE(2), TXB(2), and endotoxin. Sepsis syndrome patients (n = 6) had larger and more prolonged reductions in CD14+HLA-DR+ cells and higher neopterin values, in comparison with uneventful patient outcomes. CONCLUSIONS: Altered proportions of monocytes expressing HLA-DR and CD71 and elevated sCD14 and urine neopterin levels, for up to 2 weeks after severe injury, underscores an extended period of profound immunological effects. Additional studies to more fully assess temporal monocyte response patterns after severe injury, including activation, may be warranted.     

Communicating information to families of polytrauma patients: a narrative literature review

Family caregivers of U.S. servicemembers with polytraumatic injuries (injuries to multiple body systems) need support and information to care for their family members. Providing information to patients'families may reduce stress and increase coping abilities. Because the field of polytrauma research is new and evidence is lacking, providers rely on traumatic brain injury (TBI) research to guide their practice. This article presents a narrative literature review on the information needs of families of patients with TBI. It summarizes the types of needed information, the most appropriate time to provide information, and the best approaches for providing information. Future research on information needs is critical if polytrauma rehabilitation providers are to effectively support families in their caregiving roles. Such research likely will benefit caregivers of patients with polytrauma who acquire their injuries as civilians, as well. Research gaps are identified with regard to the information needs of families of patients with TBI; these gaps also are applicable to polytrauma caregivers. Additional research areas are highlighted in light of the new polytrauma population.     

多发伤合并休克早期大鼠肺脏中细胞凋亡的实验研究

目的：观察大鼠多发伤合并休克早期肺脏中细胞凋亡的发生情况。方法：采用ＤＮＡ琼脂糖凝胶电泳、原位末端标记法（ＩＳＥＬ），在光镜和透射电镜下检测细胞凋亡，并测定ＤＮＡ片段百分率（ａｐ％）作定量分析。结果：检测到细胞凋亡所特有的ＤＮＡ电泳梯形带，ＩＳＥＬ法亦显示出阳性结果。复苏后６小时，ａｐ％随创伤程度的加重而升高，且与肺通透指数成正相关（ｒ＝０．６２１，Ｐ＜０．００１）。在６处创伤合并休克组，复苏后１小时ａｐ％已显著升高（５．３％±０．６％，Ｐ＜０．０１），３小时即达顶峰（３１．０％±３．０％，Ｐ＜０．０１），以后逐渐下降。形态学显示，细胞凋亡发生于肺脏中的多种细胞（包括肺泡上皮细胞、血管内皮细胞和中性粒细胞）。结论：多发伤合并休克早期大鼠肺脏中发生细胞凋亡，且细胞凋亡可能在早期的肺功能损伤中发挥作用     

Massive blood transfusion and outcome in 1062 polytrauma patients: a prospective study based on the Trauma Registry of the German Trauma Society

BACKGROUND AND OBJECTIVES: About 15% of polytrauma patients receive massive blood transfusion (MBT) defined as > or = 10 units of packed red blood cells (PRBC). In general, the prognosis of trauma patients receiving MBT is considered to be poor. The purpose of this study was to investigate the impact of MBT on the outcome of polytrauma patients. MATERIALS AND METHODS: Records of 10 997 patients in the Trauma Registry of the German Trauma Society were analysed. Transfusion data were available from 8182 severe trauma patients with a mean injury severity score of 24.5 and, of these 8182 patients, 1062 received > or = 10 units of PRBC. First, a logistic regression model for the predictors of mortality was performed. Second, incidences of organ failure and sepsis as well as survival rates were analysed. RESULTS: The highest risk for mortality was age over 55 years (odds ratios [OR] 4.7; confidence intervals [CI 95%], 3.5-6.5) followed by Glasgow Coma Scale < or = 8 (OR 4.6; 3.4-6.1), MBT > or = 20 units of PRBC (OR 3.3; 2.1-5.4), thromboplastin time < 50% (OR 3.2; 2.2-4.4) and injury severity score > or = 24 (OR 2.9; 2.1-4.1). Transfusion of 10-19 PRBC was identified as the variable with the lowest risk for mortality (OR 1.5; 1.0-2.3). Risk of organ failure, sepsis and death correlated with increasing transfusion amount. For the MBT patients, the survival rate was 56.9% (CI 95%, 53.9-59.9%) compared to 85.2% (84.4-86.0%) of non-MBT patients (P < 0.001). In the MBT group with > 30 PRBC (mean 40.6 PRBC) 39.6% survived (31.7-47.5%). CONCLUSION: Massive blood transfusion is one main prognostic factor for mortality in trauma. Although MBT is generally considered to be critical, every second trauma patient with MBT survived. A cut-off value for the number of PRBC could not be determined. Extended transfusion management even with high amounts of PRBC seems to be justified.     

Circulating phospholipase A2 and C-reactive protein after polytrauma—Effect of superoxide dismutase

Eicosanoids, important inflammatory mediators, are generated in cell membranes from arachidonic acid involving phospholipase A2 (PLA₂). The purpose of our study was to evaluate the effect of the oxygen free radical scavenger recombinant human superoxide dismutase (rh-SOD) on plasma PLA₂ levels in polytraumatized patients. To compare PLA₂ levels with the action of inflammatory mediators, C-reactive protein (C-RP) was measured as an unspecific indicator of the inflammatory reaction and as a marker of the acute phase response. 18 patients with an AIS-ISS score higher or equal than 27 were randomly assigned to either a treatment (3 g/day for 5 days rh-SOD; Grünenthal, Aachen, FRG) or a placebo group. PLA₂ was determined daily by¹⁴C-oleate-labelled E. coli bioassay and C-RP was measured by nephelometry. Both groups were comparable in respect to the initial injury. PLA₂ rose continuously during the first 4 days in placebo (day 1: 25.3±2.5, day 4: 33.6±4.8;^*10³ U/ml; mean ± SEM) and SOD group (day 1: 25.5±4.7, day 4: 38.6±11.2). C-RP levels were similarly increased during the first 4 days (placgr. day 1: 89.4±6.4, day 4: 136.7±21.7; SOD—gr. day 1: 70.2±11.4, day 4: 141.0±28.9; mg/l). From day 5 on, PLA₂ and C-RP decreased in the rh-SOD group (e.g., PLA₂ day 6: 23.5±2.2; C-RP day 6: 100.9±20.9) but continued to rise in the placebo group (PLA₂ day 6: 37.1±5.5; C-RP day 6: 162.0±17.4; p<0.05). A stimulation of a systemic inflammatory response was noted by the significant rise of PLA₂ and C-RP. The efficacy of rh-SOD therapy in reducing PLA₂ and CRP levels from day 5 on suggests that attenuation of the inflammatory response after trauma by rh-SOD may involve extracellular PLA₂. Presented at the 26^th Annual Congress of the European Society for Surgical Research (ESSR), Walter Brendel Session, May 9^th, 1991, Salzburg, Austria.     

颈脊髓损伤为主严重多发伤的伤害控制(附32例报告)

[目的]探讨伤害控制原则在颈脊髓损伤为主严重多发伤救治中的临床应用。[方法]回顾性分析32例颈脊髓损伤为主严重多发伤患者临床治疗资料，颈椎骨折并截瘫18例，外伤性颈椎间盘突出并高位截瘫2例，颈椎骨折脱位并截瘫12例。神经功能评定按ASIA分级。[结果]31例获得平均14个月随访。29例颈椎骨折愈合，神经症状10例完全恢复，13例有Ⅰ级以上恢复，8例无变化。死亡1例。[结论]颈脊髓损伤为主严重多发伤急诊遵循伤害控制原则，待病情稳定后7—10d内安全地进行最终手术，可提高救治成功率。     

伤害控制骨科学在合并骨盆骨折多发伤病人救治中的应用体会

目的探讨运用伤害控制骨科学救治合并骨盆骨折的多发伤病人,并选择合适手术时机的临床体会。方法对26例合并骨盆骨折多发伤患者进行伤害控制治疗,根据血流动力学、氧饱和度、体温、有无凝血障碍、尿量、血乳酸盐浓度及G反应蛋白情况选择合适手术时机进行确定性手术,并对患者住院时间、创伤至二次确定手术固定时间和Matta评分等指标进行量化分析。结果除1例骨盆骨折合并严重胸腹外伤患者,抗休克同时急诊剖腹探查术中因多脏器功能衰竭死亡,4例急诊行骨盆外固定架固定,其余21病例选择合适的确定性手术时机,行骨盆内固定,从创伤至二次确定手术固定时间5～26d,平均9．7d,平均住院天数32．5d,经12～24个月,平均16个月的随访,各部位骨折均达到骨性愈合,肢体功能恢复满意,平均Matta骨盆髋臼骨折功能评级优良率93％．结论对合并骨盆骨折的严重多发伤病人进行伤害控制性治疗选择合适手术时机,疗效满意。