【作者】 胡海波；

【导师】 禹宝庆； 张春才； 纪方； 苏佳灿；

【作者基本信息】 第二军医大学 ， 外科学， 2008， 硕士

【摘要】 研究背景:严重多发伤常导致多系统或器官联合受累,这是一种对全身状态影响较大,病理生理扰乱严重且危及生命的损伤。创伤病人生理功能的紊乱常常与酸中毒、低体温和凝血障碍这三联症联结在一起。近期分子医学的发展使人们认识到炎症介质在多发伤患者中的重要影响,而外科处理可以对全身炎症系统产生累积作用,特别是那些多发伤患者。一般情况下,多发伤患者的临床过程主要由三个因素决定:原发创伤的程度(即“一次打击”,创伤负荷)、患者自身的生物反应以及创伤后的医学干预(即“二次打击”,外科负荷)。基于以上研究认识,有学者提出了对难以完成确定性手术的濒死患者,可用“损伤控制外科的方法,即尽量减少多发伤患者由“二次打击”造成的炎症反应强度,以降低术后并发症发生率及死亡率,首先确保外科复苏,抢救生命,其次才是最终治疗。目的:1、探讨多发伤患者的临床特征及其防治对策;2、探讨严重多发伤时损伤控制外科(DCS)应用的可行性和疗效;3、总结我院多发伤患者诊治经验。方法:通过对长海医院2001年6月—2007年6月间收治的322例严重多发伤病人的临床资料。记录多发伤患者的一般特征和受伤原因及时间,并发症发病率,死亡率等资料进行分析。从中选取病例资料完整多发伤患者90例,其中应用DCS方法救治严重多发伤患者45例,以传统方式抢救的病情严重程度一致病人45例作为ETC治疗组。监测比较两组病人下述指标:体温恢复时间,乳酸清除时间,PT、APTT恢复时间,并发症的发病率,死亡率,出血量,输血量,手术时间,ICU以及住院天数。结果:1、本组多发伤患者总的抢救成功303例(94.1%),死亡19例(5.9%),发生并发症54例(16.8%),其中成人呼吸窘迫综合征(ARDS)16例,弥散性血管内凝血(DIC)8例,多器官衰竭(MODS)9例,腹腔室间隙综合征(ACS)3例,感染18例。2、DCS组抢救成功42例(93.3%),死亡3例(6.7%),死亡组损伤严重度评分(ISS)平均值45分。发生并发症9例,其中成人呼吸窘迫综合征(ARDS)3例,弥散性血管内凝血(DIC)2例,多器官衰竭(MODS)1例,感染3例,所有患者均在ICU复苏治疗后,再做确定性内固定手术。ETC组死亡8例(17.8%),其中24h内死亡5例,发生并发症21例,死亡组损伤严重度评分(ISS)平均值40.6分。其中成人呼吸窘迫综合征(ARDS)6例,弥散性血管内凝血(DIC)4例,多器官衰竭(MODS)3例,腹腔室间隙综合征(ACS)2例,感染6例。3、控制组体温恢复时间、乳酸清除时间要短,并发症发病率和死亡率要低,其差异具有显著性意义(P＜0.05)。住院时间(治疗组27.5±8.5d,对照组21.3±7.8d)及在ICU治疗时间(治疗组10.25±5.61d,对照组8.32±4.93d)比较,两组差异有显著性(P＜0.05)。4、两组出血量,手术时间方面相比无显著性差异(P＞0.05)。结论:1、多发伤有其发生发展的流行病学规律及特征性临床经过;2、形成院前急救、院内救治、康复治疗三点一线形成连续的工作程序,通过完善救治体系才能提高救治水平,可以提高多发伤救治水平,减少死亡率和并发症的发生;3、多发伤患者应用DCS的方法处理可以降低患者的死亡率,减少并发症,提高救治成功率;4、损伤控制理论对于严重多发伤患者伴有胸,腹,血管,骨盆,四肢及软织损伤的治疗提供新的方法。成功的处理需要充分了解病理生理、复苏方法、正确的伤员分类和时间选择,以及精心安排的治疗计划。应将多发性损伤当作全身性外科疾病来考虑,其首要目的是挽救病人的生命。先尽可能完善病人的生理状态,损害控制,再进行非挽救生命的手术。更多还原

【Abstract】 Background:The trauma impact itself determines primary organ or soft-tissue injuries and fractures (first hit, trauma load) with local tissue damages as well as a systemic inflammation with release of pro-inflammatory ("systemic inflammatory response syndrome" ) and anti-inflammatory("compensatory anti-inflammatory response syndrome" )cytokines, complement factors, proteins of the contact phase and coagulation systems, acute-phase proteins, neuroendocrine mediators, and an accumulation of immunocompetent cells at the local side of tissue damage (host defense response). The approach of " damage control" surgery takes the influence of systemic posttraumatic inflammatory and metabolic reactions of the organism into account and is aimed at reducing both the primary and the secondary-delayed-mortality in severely injured patients. The present paper shall provide an overview on the current state of management algorithms for polytrauma patients. Objective:1. To investigate the features of multiple traumas and its management.2. To explore the therapeutical effect of damage control surgery for multiple traumas.3. To conclude our experiences of diagnosising and treating multiple traumas patients. Methods:The clinical data of 322 patients with severe multiple traumas admitted from June 2001 to June 2007 were analyzed retrospectively. These severely injured patients with an ISS > 16 points were included in a retrospective analysis. Data collected for analysis consist of the general characteristic of the multiple traumas patients, mechanism and timing of injury, incidence of complications and mortality. Among these patients, 45 patients were classified to the DCS group, 45 patients to the ETC group. Between the two groups, the body temperature, PT and APTT recovery time, clearance time of lactic acid, incidences of complications, mortality, volume of bleeding and blood transfusion, operation time, duration of hospital and ICU stay were compared respectively. Results:1. 303(91%) of 322 patients were successfully treated and 19(5.9%) patients were dead. Complications occurred in 54 (16.8%)cases. The incidences of adult respiratory distress syndrome, diffuse intravascular coagulation, multiple organs dys- function syndrome, abdominal compartment syndrome and infection were 5% (16 / 322), 2.5% (8 / 322), 2.8% (9 / 322), 1%(3 / 322), 5% (16 / 322), respectively. 2. The damage control surgery was successfully performed in 42(93.3%) of 45 patients. All cases received discriminating internal fixation after resuscitation in ICU. Of 3 died patients, 1 patients died in 24 hours,. with average injury severity score(ISS) of 45. The incidences of adult respiratory distress syndrome, diffuse intravascular coagulation, multiple organs dysfunction syndrome and infection were 6.7% (3 / 45), 4.4% (2 / 45), 2.2%(1 / 45), 6.7% (3 / 45),respectively. 37 (82.2%)of 45 patients survived in the early total care (ETC) group. Of 8 died patients, 5 patients died in 24 hours. The overall mortality rate Was 17.8%(8/45), with average injury severity score(ISS) of 40.6 and shock and combined injuries as the main causes of death. The incidences of adult respiratory distress syndrome, diffuse intravascular coagulation, multiple organs dysfunction syndrome, abdominal compartment syndrome and infection were 13.3%(6 / 45), 8.9% (4 / 45), 6.7%(3 / 45), 22.2% (2 / 45), 13.3% (6 / 45), respectively.3. The recovery time of body temperature, PT, APTT and clearance time of lactic acid in damage control group were shorter than these in early total care group. Incidence of complications and mortality in damage control group were less than these in the other group. There were significant differences in two groups(P<0.05). The mean duration of hospital stay were 27.5±8.5 days in DCS group, of which were longer than 21.4±7.8 days in ETC group. The ICU days were 10.25±5.61 days in DCS group, of which were longer than 8.32±4.93 days in ETC group, too. There were significant difference in two groups (P <0.05).4. No significant differences existed in the volume of bleeding and blood transfusion between two groups(P>0.05).Conclusions:1. Multiple traumas was imbued with epidemiological regularity and characteristic clinical course in its occurrence and development.2. A combined continuous work procedures of pre-hospital emergency treatment, hospital treatment, rehabilitation could improve the level of multiple injuries treatment, reduce mortality and the incidence of complications;3. The concept of DCS could reduce multiple traumas patients’ mortality rate and incidence of complications.4. The concept of DCS was well established for the management of thoracic, abdominal, vascular, pelvic, extremity and soft-tissue injuries in severely injured patients. Multiple traumas should be considered as a systemic surgical disease. The cognition of pathology, physiology, anabiosis, accurate injury classification and elaborative therapeutic plan was the key of successful treatment. In order to save the lives of multiple traumas patients and improve the physiological state, the damage control surgery should be considered first.更多还原