高原寒区战时环境猪肢体枪弹伤简化初期外科处理原则

目的研究高原寒区战时环境下枪弹伤后伤道初期外科处理原则。方法 108头小型猪随机分为高原战时致伤传统清创延期缝合固定组（GCT）、高原战时致伤一期清创固定缝合组（GYQ）、高原战时致伤简单清创引流延期缝合外固定架固定组（GJD）3组,分别于每组伤后6、12、24、36、48、72 h进行相应的初期外科处理。结果 （1）高原战时环境伤道组织肉眼可辨的炎性分界时间为伤后12~24 h;（2）伤道组织在伤后24 h明显肿胀,36~48 h肿胀达高峰,清创后7 d组织肿胀显著消退;（3）伤道感染最早发生在伤后24 h,伤后12~24 h清创细菌清除率最高;（4）GYQ组各时相点初期外科处理的伤道局部总感染率都很高,GCT组和GCT组36 h以后各时相点处理的局部总感染率均很高,GJD组在伤后的6~24 h初期外科处理的未见感染发生,36 h以后各时相点的局部总感染率与GCT组相似;（5）伤道闭合后28 d解剖动物发现,局部感染动物大多有全身脓毒血症,在肺、肝、脑、肾等处均有广泛的散在的脓肿形成,早期死亡动物在肺、肝、肾等脏器也可见广泛的出血点。GCT组和GYQ组早期死亡率较高,GJD组在任一时相点均未见死亡动物。结论高原战时环境肢体枪弹伤不行一期缝合、不做骨折一期内固定,伤后早期不宜扩大清创范围,伤后6~24 h实施简单初期外科处理是可行的,伤口延期缝合较佳时机在清创后7 d,应尽早应用外固定架进行骨折有效固定。

Simplified surgical treatment principles for early gunshot wounds in swine's hind limbs in a wartime environment at high altitude

Objective To investigate surgical treatment principles for early wound track following gunshot wounds in a wartime environment at high altitude.Methods 108 female pigs were randomly divided into GCT group（n=36）,GYQ group（n=36）and GJD group（n=36）.All of animals were sent to high altitude（3670 m above sea level）from plain（351 m above sea level）and lived in a simulated wartime environment for 72 h until their hind limbs were wounded and femurs were broken by gunshot.Then every six pigs in each group received the debridement at 6,12,24,36,48 and 72 h,respectively.In GCT group,a secondary suture and internal fixation of femoral fracture were performed on day 7 following a traditional thorough debridement plus primary external fixation.In GJD group,animals received a simple debridement only removing contaminated and devitalized tissues and other treatments were the same as those in GCT group.In GYQ group,a thorough debridement was performed combined with primary suture and internal fixation.Results（1）In a wartime environment at high altitude,the macroscopical inflammatory sideline of wound track tissues appeared in 12-24 h after injury.（2）Wound track tissues swollen obviously in 24 h after injury and reached the peak at 36-48 h and decreased significantly at 7 d after debridement.（3）The earliest infection of wound track occurred in 24 h after injury.The bacterial clearance rate was the highest when debridement was performed in 12-24 h after injury.（4）In GYQ group,the total local infection rate was high at any time point that early surgical treatment was made.In GCT group and GJD group,it was similarly high since 36 h,and no infected case was found in 6-24 h in GJD group.（5）The anatomical findings in 28 d after the closure of wound track indicated that most of pigs with local infection suffered from systemic pyemia.Widely dispersed abscess were found in lungs,livers,brains and kidneys of these animals.Extensive petechias were also found in lungs,livers and kidneys of early died pigs.Early death rate was high in GCT group and GYQ group,and no dead pig was found at any time point in GJD group.Conclusion In a wartime environment at high altitude,primary suture and internal fixation of fracture should not be made for gunshot-wounded limbs,and debridement range should not be enlarged early after injury.It is feasible to make simplified early surgical treatment in 6-24 h after injury.The ideal time of delayed suture of wound is at day 7 after debridement,and effective fixation of fracture with external fixator should be implemented early.