猪后肢枪弹软组织贯通伤致心血管远达效应的实验研究

目的通过制作猪后肢枪弹软组织贯通伤模型,利用计算机容积成像(volume computed tomography,VCT)观察致伤后心脏形态学改变,结合相关血管活性物质(血管紧张素Ⅰ、血管紧张素Ⅱ、内皮素)及病理、电镜观察,分析枪击对猪心血管系统的影响,以期为平战时肢体枪弹伤伤病员的早期全面救治提供参考依据。方法 7只健康雌性平原猪枪击后肢致软组织贯通伤,分别于枪击前及枪击后瞬时、枪后5’、30’及60’行VCT检查,并抽取猪耳缘静脉血,分别进行血管紧张素Ⅰ(AngiotensinⅠ,AngⅠ)、血管紧张素Ⅱ(AngiotensinⅡ,AngⅡ)及内皮素(endothelin,ET)检测。结果①枪击后冠脉血管直径在短时间内即会发生改变,以枪击后30min改变最为显著,表现为心脏冠脉VCT在枪击后显影质量很差,可出现冠脉血管的痉挛或者局部的狭窄、或者血管中断不连续,管壁显示不清等表现,猪冠状动脉图像重建质量评价在枪击后瞬间基本在II级以上,仅1(7)只猪的冠脉血管图像重建质量评价为I级。且在枪击30min后冠脉直径最小,之后冠脉直径逐渐恢复,到枪击后60min可恢复到接近枪击前的水平;②枪击后AngⅠ在枪击前的水平与其他4个时间点比较发生显著变化(P<0.05),枪后60’与枪后5’发生明显变化(P<0.05);AngⅡ:枪击前与枪后30’比较,具有统计学意义(P<0.05);ET:枪击前与枪击瞬时、枪后5’及30’之间变化明显,枪击后60’与枪击瞬时、枪击后5’及30’之间有变化(P<0.05)。结论猪后肢枪弹软组织贯通伤后可致心脏远达效应,在致伤全过程中,AngⅡ及ET起了重要作用;致伤瞬间,由于应激反应及冲击波的血流扰动影响,可导致血管内皮受损;VCT在心脏冠状动脉扫描对心脏远达效应损伤早期诊断有一定的参考价值。

The experiment study of the remote effect of coronary artery after the posterior limb of swine soft tissue perforating wound caused by gunshot

Objective The morphology changes of the swine hearts at the early stage after the gunshot injury in the pos- terior limb were observed by Volume computed tomography （VCT）, and combined with the changes of vasoactive sub- stance, pathological section, the changes of volume of coronary artery were analyzed in the swine model. Methods 7 healthy sows were shot to set up the model of soft tissue perforating wound, the VCT was performed at different times and their venous blood was taken/tom ear vein before the shoot and 5 mins, 30 rains, 60 mins after the shoot to detect the changes of Angiotensin Ⅰ（Ang Ⅰ ）, AngiotensinⅡ（Ang Ⅱ） and endothelin （ET）. Results （D The diameters were changed shortly after the gunshot, especially ai the 30min after the gunshot, the VCT showed coronary artery stenosis discontinues and unclear artery wall, the coronary artery quality grade evalution almost all above grade If, only 1 （7）was grade I, and the diameter was the smallest at the 30 min after the gunshot, the diameter of coronary artery were recovered gradually, until after 60 rain the diameters of coronary arterv were rrecovered to recreased significantly after the shoot （P〈0.05）, and the level of Ang Ⅰbetween the point of 5 mins after the shoot and that of 40 mins after the shoot was different significantly. AngⅡ The level of Ang Ⅱ at the point of 30 rains after the shoot was in-creased significantly compared with that before the shoot （ P 〈0.05）. ET： The level of ET was increased significantly and at the point of 30 rains after the shoot attained the maximum （ P 〈0.05）. After the shoot, the injures of vascular endothelial cell can be observed by electron microscope, and some smooth muscle cell can be observed under sub- endothelial layer. Conclusion The gunshot in the posterior limb were caused the remote effect in the coronary artery. During the whole process, Ang Ⅱ and ET play important roles; and blood vessel endothelium is injuried because of stress reaction and the impact of shock wave. VCT can diagnose the remote effect-caused-injury to heart at the very early stage.