胸部外傷精選文檔

胸外傷胸部外傷精選文檔第1頁

Incidenceandmortality發(fā)生率和死亡率:

Chesttraumaaccountsfor8%occurrencesoftotaltraumaticcases,morethan25%ofdeathcausedbytrauma.IncidenceproportionMortalityproportion胸外傷概況胸部外傷精選文檔第2頁胸外傷病因Penetratingtrauma貫通傷Blunttrauma鈍挫傷車禍傷墜落傷擠壓傷刀刺傷火器傷胸部外傷精選文檔第3頁ResultsfromkineticenergyforcesBlast（爆破傷）PressurewavecausestissuedisruptionTearbloodvessels&disruptalveolartissueDisruptionoftracheobronchialtreeTraumaticdiaphragmruptureCrush(Compression)（擠壓傷）BodyiscompressedbetweenanobjectandahardsurfaceDirectinjuryofchestwallandinternalstructuresDeceleration（減速傷）BodyinmotionstrikesafixedobjectBlunttraumatochestwallInternalstructurescontinueinmotionLigamentumArteriosumshearsaortaBluntTrauma壓力波造成組織破壞

撕裂血管，破壞肺泡組織

破壞氣管支氣管樹創(chuàng)傷性膈肌破裂

胸外傷病理生理胸部外傷精選文檔第4頁LowEnergyArrows,knives,handgunsInjurycausedbydirectcontactandcavitationHighEnergyMilitary,huntingrifles&highpoweredhandgunsExtensiveinjuryduetohighpressurecavitationPenetratingTrauma胸部外傷精選文檔第5頁穿透傷合并損傷ClosedpneumothoraxOpenpneumothoraxTensionpneumothoraxPneumomediastinumHemothoraxHemopneumothoraxLacerationofvascularstructures閉合性氣胸

開放性氣胸

張力性氣胸

氣腫

血胸

血氣胸

血管損傷

胸部外傷精選文檔第6頁TracheobronchialtreelacerationsEsophageallacerationsPenetratingcardiacinjuriesPericardialtamponadeSpinalcordinjuriesDiaphragmtraumaIntra-abdominalpenetrationwithassociatedorganinjury氣管支氣管樹裂傷

食管裂傷

穿透性心臟損傷

心包填塞

脊髓損傷

膈肌損傷傷

腹腔內(nèi)臟器損傷穿透傷合并損傷胸部外傷精選文檔第7頁胸外傷詳細分類及病理生理改變胸部外傷精選文檔第8頁Chestwall

contusionsorhematomas

胸壁挫傷或血腫Ribfractures肋骨骨折

Flailchest連枷胸

Sternalfractures胸骨骨折

Fracturesoftheshouldergirdle肩胛帶骨折Injuriestothechestwall胸部外傷精選文檔第9頁

ContusionDyspneaPainonbreathingHypoventilationCrepitusParadoxicalchestwallmotion呼吸困難

呼吸疼痛

通氣不足

捻發(fā)音

胸壁反常運動

胸部外傷精選文檔第10頁RibFractures>50%ofsignificantchesttraumacasesduetoblunttraumaCompressionalforcesflexandfractureribsatweakestpointsRibs1-3requiresgreatforcetofracturePossibleunderlyinglunginjuryRibs4-7aremostcommonlyfracturedRibs11-12lesslikelytobefracturedTransmitenergyoftraumatointernalorgansIffractured,suspectliverandspleeninjuryHypoventilation（肺換氣不足）isCOMMONduetoPAIN胸部外傷精選文檔第11頁SternalFracture&Dislocation（胸骨骨折和錯位）AssociatedwithseverebluntanteriortraumaDirectBlow(比如：方向盤)Incidence:5-8%Mortality:25-45%Myocardialcontusion（心肌鈍挫傷）Pericardialtamponade（心包填塞）Cardiacrupture（心臟破裂）Pulmonarycontusion（肺挫傷）DislocationuncommonbutsameMOIasfractureTracheal（氣管）depressionifposterior胸部外傷精選文檔第12頁FlailChest(連枷胸)SegmentofthechestthatbecomesfreetomovewiththepressurechangesofrespirationThreeormoreadjacent（毗鄰）ribfractureintwoormoreplacesSeriouschestwallinjurywithunderlyingpulmonaryinjury（潛在肺損傷）ReducesvolumeofrespirationAddstoincreasedmortalityParadoxicalflailsegmentmovement（反常呼吸運動）Positivepressureventilation（通氣）canrestoretidalvolume（潮氣量）胸部外傷精選文檔第13頁Pulmonaryinjuryandinjuriesinvolvingthepleuralspace（胸腔）Pulmonarycontusion

Pulmonarylaceration

Pneumothorax

Hemothorax

Hemopneumothorax

pneumothoraxhemothoraxPulmonarycontusion肺挫傷

肺裂傷

氣胸

血胸

血氣胸

胸部外傷精選文檔第14頁ClosedPneumothoraxOccurswhenlungtissueisdisruptedandairleaksintothepleuralspaceProgressivePathologyAiraccumulatesinpleuralspaceLungcollapsesAlveolicollapseReducedoxygenandcarbondioxideexchangeVentilation/PerfusionMismatchIncreasedventilationbutnoalveolarperfusionReducedrespiratoryefficiencyresultsinHYPOXIAOpenPneumothoraxFreepassageofairbetweenatmosphereandpleuralspaceAirreplaceslungtissueMediastinum（縱膈）shiftstouninjuredsideAirwillbedrawnthroughwoundifwoundis2/3diameterofthetracheaorlargerSigns&SymptomsPenetratingchesttraumaSucking（吮吸）chestwoundFrothybloodatwoundsiteSevereDyspnea（嚴重呼吸困難）Hypovolemia（低血容量）TensionPneumothoraxBuildupofairunderpressureinthethorax.ExcessivepressurereduceseffectivenessofrespirationAirisunabletoescapefrominsidethepleuralspaceProgressionofSimpleorOpenPneumothoraxPneumothoraxNeedemergenttreatment胸部外傷精選文檔第15頁TensionPneumothoraxSigns&SymptomsDyspneaTachypnea（呼吸過速）atfirstProgressiveventilation/perfusionmismatchAtelectasisonuninjuredsideHypoxemiaDiminishedthenabsentbreathsoundsoninjuredsideCyanosisDiaphoresisHypotensionHypovolemiaTrachealShifting低氧血癥

呼吸音減低

紫紺

發(fā)汗

低血壓

低血容量

氣管移位健側(cè)肺不張

呼吸困難通氣/灌注不匹配胸部外傷精選文檔第16頁血液聚集在胸膜腔內(nèi)嚴重者失血量大于1500ml死亡率75%每側(cè)胸腔能夠容納3000ml造成潮氣量降低灌注/通氣失調(diào)&休克常合并氣胸血氣胸HemothoraxSigns&SymptomsShockDyspnea（呼吸困難）Tachycardia(心動過速)Tachypnea（呼吸過速）Diaphoresis（出汗）HypotensionDulltopercussion（叩診）overinjuredside胸部外傷精選文檔第17頁CardiovascularInjuriesOccursin76%ofpatientswithseverebluntchesttraumaRightAtrium（心房）andVentricle（心室）iscommonlyinjuredInjurymayreducestrengthofcardiaccontractions---ReducedcardiacoutputElectricalDisturbancesduetoirritabilityofdamagedmyocardialcellsProgressiveProblemsHematomaHemoperitoneumMyocardialnecrosisDysrhythmiasCHF&orCardiogenicshockMyocardialContusion血腫

腹腔積血

心肌壞死

心律失常

充血性心衰及或心源性休克

BruisingofchestwallTachycardiaand/orirregularrhythm

Retrosternal（胸骨后）painsimilartoMI

ChestpainunrelievedbyoxygenMayberelievedwithrestSigns&Symptoms心肌損傷胸部外傷精選文檔第18頁PericardialTamponadeRestrictiontocardiacfillingcausedbybloodorotherfluidwithinthepericardiumOccursin<2%ofallseriouschesttraumaHowever,veryhighmortalityResultsfromtearinthecoronaryarteryorpenetrationofmyocardiumBloodseepsintopericardiumandisunabletoescape200-300mlofbloodcanrestricteffectivenessofcardiaccontractionsRemovingaslittleas20mlcanprovidereliefSigns&SymptomsDyspnea呼吸苦難PossiblecyanosisBeck’s三聯(lián)征心音遙遠奇脈脈壓差增大胸部外傷精選文檔第19頁MyocardialAneurysmorRuptureOccursalmostexclusivelywithextremebluntthoracictraumaSecondaryduetonecrosisresultingfromMISevereriborsternal（胸骨）fracturePossiblesignsandsymptomsofcardiactamponadeIfaffectsvalves（瓣膜）only

Signs&symptomsofrightorleftheartfailureAbsenceofvitalsignsSigns&Symptoms鈍性傷致心臟破裂病人胸部外傷精選文檔第20頁OtherVascularInjuriesTraumaticAneurysm（動脈瘤）orAortic（主動脈）Rupture

RuptureorlacerationSuperiorVenaCava上腔靜脈InferiorVenaCava下腔靜脈GeneralThoracicVasculature胸腔大血管BloodLocalizinginMediastinum胸膜局部出血Compressionof:Greatvessels大血管Myocardium心肌Esophagus食管GeneralSigns&SymptomsPenetratingTrauma貫通傷Hypovolemia&Shock容量不足或休克Hemothoraxorhemomediastinum血胸或血氣胸胸部外傷精選文檔第21頁OtherThoracicInjuriesTraumaticEsophagealRupture食管破裂TracheobronchialInjury氣管損傷TraumaticAsphyxia（創(chuàng)傷性窒息）胸部外傷精選文檔第22頁胸腹多發(fā)傷thoracoabdominalmultipleinjuries胸腹復合傷（是否伴有膈肌損傷）

thoracoabdominalcombinedinjuries石應康，楊建.外科學（第七版）了解一個概念胸部外傷精選文檔第23頁胸外傷病人評定胸部外傷精選文檔第24頁SceneSize-up環(huán)境評定InitialAssessment初步評定RapidTraumaAssessment快速評定ObserveQuestionPalpate（觸診）Auscultate（聽診）Percuss（視診）BluntTraumaAssessmentPenetratingTraumaAssessmentOngoingAssessment連續(xù)評定評定程序胸部外傷精選文檔第25頁怎樣評定胸外傷程度？創(chuàng)傷評分

各種評分系統(tǒng)孰優(yōu)孰劣？Thisisaproblem!!!胸部外傷精選文檔第26頁PulmonaryContusionscore(PCS),Tyburskietal.Wagner-score1989WagnerandJamiesonThoracicTraumaSeverityscore(TTS)

PapeHCetal.Conclusions：Thoracictraumascorescombininganatomicalandphysiologicparameters（參數(shù)）liketheTTSseemtobemostsuitableforseverityassessmentandpredictionofoutcomeinmultipletraumapatientswithconcomitantbluntchesttrauma.MommsenP,ZeckeyC,AndruszkowH,etal.ComparisonofDifferentThoracicTraumaScoringSystemsinRegardstoPredictionofPost-TraumaticComplicationsandOutcomeinBluntChestTrauma.JSurgRes.1–9()Oct5

Twohundredseventy-eightmultipletraumapatients

onlytheTTSwasanindependentpredictorofmortality.WiththeTTSshowingthebestpredictionpower,theTTS,PCS,andWagner-scorewereindependentpredictorsofventilationtime,lengthofICUstay,andthedevelopmentofpost-traumaticARDSandMODS.assess胸部外傷精選文檔第27頁

EsmeH,SolakO,YurumezY，etal.Theprognosticimportanceoftraumascoringsystemsforbluntthoracictrauma.ThoracCardiovascSurg.Apr;55(3):190-5.RevisedTraumaScore[RTS]TraumaandInjurySeverityScore[TRISS]InjurySeverityScore[ISS]LungInjuryScale[LIS]ChestWallInjuryScale[CWIS])152patientswithbluntthoracictraumaassessonlyTRISSwasanindependentpredictorofmortalityonlyLISwasanindependentpredictorofmorbidity,theneedforthoracotomy,andtubethoracostomyduration.

TRISSandLISwereindependentpredictorsofthelengthofICUstay.ISS,CWIS,andLISwereindependentpredictorsoftheneedformechanicalsupport.RTS,TRISS,ISSandLISwereindependentpredi