【作者】 王峰；

【导师】 杨志焕；

【作者基本信息】 第三军医大学 ， 外科学， 2008， 博士

【摘要】 爆炸冲击波通过介质（如空气、水、土壤、岩石、钢板等）向周围传播。根据传播介质的不同,冲击伤可分为空气冲击伤、水下冲击伤和固体冲击伤。因传播介质的密度不同,可对冲击波的传播速度和冲击伤的伤情产生明显的影响。通常传播介质的密度愈高,冲击波的传播速度愈快,传播的距离愈远,冲击伤程度也愈重。特殊环境冲击伤主要是指高原冲击伤、水下冲击伤和坦克、装甲、舱室等有限空间内的冲击伤。高原冲击伤是指发生于海拔3000m以上地区的冲击伤。高原地区空气稀薄,大气压和氧分压低,海拔4000m的大气密度约为海平面的65%,大气压和氧分压约相当于海平面的61%,这种高原环境特点对冲击伤伤情有何影响,目前尚不十分清楚。水的密度约为空气的800倍,几乎不可被压缩,水下冲击波的传播速度远较空气冲击波快得多,衰减更慢,传播的距离也更远,传播速度约为空气中的3～4倍,炸药水下爆炸时产生的冲击波强度是其在空气中爆炸强度的3倍。同质量的TNT地面爆炸与水下爆炸相比,同距离的压力值可相差200倍左右。这种水下冲击波的物理特性对水下冲击伤伤情特点有何影响和如何进行针对性治疗也缺乏详细的研究。为此,针对未来局部冲突的热点地区,本研究重点探讨特殊环境冲击伤中的高原和水下冲击伤的伤情特点和治疗研究。本研究在复制不同海拔高度大鼠高原冲击伤和犬、兔水下冲击伤模型的基础上,从大体、细胞和分子水平不同层次上较系统地探讨了高原和水下冲击伤的伤情特点和治疗效果。得到的主要结果和结论如下:1.高原冲击伤的靶器官仍为肺,具有伤情重、发展快和死亡率高等特点,且随海拔高度的升高,伤情更为严重。肺损伤主要表现为出血和水肿,其程度较平原冲击伤加重1～3级。海拔390m、3500m、4000m和5000m冲击波暴露的动物,重度和极重度肺出血的发生率分别为16.7%、43.3%、60.0%和73.3%,重度和极重度肺水肿的发生率分别为6.6%、13.3%、33.3%和40.0%,死亡率分别为0%、0%、20%和40%,且死亡均发生在冲击波暴露后3h内。2.高原（海拔4000m）冲击伤后,肺组织中IL-6、IL-10、TNF-a含量明显升高,HO-1mRNA表达明显增加,支气管肺泡灌洗液总蛋白浓度显著升高,PaO₂明显下降,提示上述细胞因子和HO-1在高原冲击伤的发生、发展过程中可能起着重要的作用。3.高原（海拔4000m）冲击伤后给予HO-1诱导剂氯化高铁血红素hemin和地塞米松治疗可提高肺组织中IL-10含量,降低IL-6、TNF-a含量,HO-1mRNA表达增加,肺泡灌洗液总蛋白含量降低,PaO₂升高。提示上述治疗措施可减轻肺部炎性反应,对机体起到一定的保护作用,但对极重度肺冲击伤的治疗作用有限。4.阐明了水下冲击伤的伤情特点。水下冲击伤的靶器官仍为肺,具有肺和肠道损伤发生率高、含液脏器（膀胱、胆囊等）损伤发生率低,肝脾等实质脏器损伤轻微,外轻内重表现更为典型和伤情重,死亡率高（31.58%）等特点。5.提出了水下冲击伤的预警指标,凡水下冲击伤后出现呼吸窘迫、心动过缓、体温下降后不回升或无明显回升,提示伤情严重,这对群体水下冲击伤伤员的分类和救治具有重要指导意义。6.水下冲击伤后给予复温、地塞米松、山莨菪碱及复温联合应用地塞米松和山莨菪碱治疗,可改善通气功能、生命体征和预后,其中以复温联合应用地塞米松和山莨菪碱治疗效果更好。更多还原

【Abstract】 Explosion wave spreads through the mediator（namely air , water , soil, rock, steel et al）. According to the different mediator, blast injury can be divided into air blast injury, underwater blast injury and solid blast injury. In different density of the mediator ,there is visible effect on spread velocity of blast wave and traumatic condition of blast injury. Usually, the higher density, faster and father the spread velocity of the blast wave propagates and more severity of the blast injury will be.The blast injury at special environment mainly includes the blast injury at high attitude , underwater and in an enclosed space（namely tank , armored vehicle, cabin, et al）. Blast injury at high attitude occurs at the region of 3000 meters height above sea level. There are scarce air, low barometric pressure and low partial pressure of oxygen. Comparing with the area of sea level, there are only 65% atmosphere density and 61% barometric pressure and partial oxygen pressure in the region of height above sea level 4000 meters. What influence on the characteristics of the blast injury in high attitude environment is still unknown by now . The density of water is 800 times as that of air. Because water is less compressible, an underwater blast wave propagates at high speeds and loses energy less quickly over longer distances. It is estimated that an explosion underwater is approximately three times greater in strength than that which is detonated in the air. The propagating velocity of underwater blast wave is 3～4 times as that of air blast wave. The pressure force is 200 times greater underwater at the same distance from the explosion when TNT of the same quantity exploses under water and in the air. So study emphasis on exploring the characteristics and interventions of the blast injury in special environment （the blast injury at high attitude and underwater blast injury ） with regard to region conflict hot spot area.The present study systemically observed the characteristics and interventions of the blast injury at high attitude and underwater from general, cellular and molecular level based on duplicating the rat blast injury at different attitude and the dog and rabbit underwater blast injury. The main results of the present report are as following:1. The lung was still the main injured target orgen in blast injury at high attitude. The blast injury at high attitude had the characteristics of more severity, fast developing and high mortality . Furthermore, the severity of injuries was increased with rising of the attitude . the most common injury to the lung was hemorrhage and edema, which are 1～3 degree more in severity .than that of the blast injury at plain. When the blast injury occurred at 390meters , 3500meters level ,4000 meters level and 5000 meters level, incidence of severe and very severe hemorrhage of the lung was 16.7%, 43.3%, 60.0%, and 73.3% , respectively, incidence of severe and very severe edema of the lung was 6.6%,13.3%,33.3% and 40.0% ,respectively ; the mortality was 0%, 0%, 20% and 40% respectively; And the mortality occured in 3 hours after injury.2. After blast injury at high attitude（4000 meters） , IL-6,IL-10,TNF-a of the lung tissue were all remarkably increased. The expression of HO-1 mRNA was increased, too. The total protein of the bronchoalveolar lavage fluid was remarkably increased . Arterial oxygen tension （PaO₂）was remarkably decreased .These indicate that the cytokines mentioned above and HO-1 may play an important role in the occurance and development of the blast injury at high attitude .3. The hemin, inductor of HO-1and dexamethason were used to treat the high attitude blast injuried rats. The result showed that they could increase the level of IL-10 of the lung , HO-1 expression and arterial oxygen tension （PaO₂）. decrease the level of IL-6 and TNF-a and the total protein of the bronchoalveolar lavage fluid ; All these indicate that the treatment mentioned above could relieve the inflammatory reaction of the lung, which could be protective for the organism to some degree though they had limited effect on very severe blast injury .4. The characteristics of underwater blast injury were explored systemically. The lung was still the main target orgen. Underwater blast injury had the characteristics of high incidence of lung and intestinal tract injuries , low incidence to fluid-filled organs injuries（namely the bladder, the cholecystis, et al）, little effect on solid organs（namely the liver ,the spleen ,et al）, more typical appearance of light injury outside and severe injury inside, more severity and high mortality（31.58%）et al.5. The warning markers were recommended. It should indicate the severity of the injury when distress of respiratory, brady cardia , no rising or no obvious rising after temperature drop after underwater blast injury appeard. This may be importance to classify and treat the underwater blast injuried patients .6. rewarming, dexamethasone and anisodamine were used to treat the underwater blast injury , respectively. The results showed that all of these could improve pulmonment function , vital sign and prognostic。Among these , combining of these factors had better intervention effects.更多还原