上交大外科学课件13创伤

创伤

trauma1Trauma：Traumaisdefinedasthedamagecausedbymechanicalinjuriousagents,withthe

disturbance

oftissuecontinuityandfunction.Vessel

SkininjuriousfactorsClassification1Accordingtotheintegrityofskin：

Damaged----openwounds（开放性创伤）

Intact----closedwounds(闭合性创伤)

openwoundsPenetratingwound(穿入伤)Perforatingwound(穿透伤)Non-penetratingwound(非穿入伤)severalfamiliaropenwoundsAbrasion(擦伤)Puncture(刺伤)severalfamiliaropenwoundsIncisionorcutwound(切伤和砍伤)Laceration(撕裂伤)ClosedwoundsContusion(挫伤)Crushinjury(挤压伤)Sprain(扭伤)Concussion(震荡伤)Luxationandsemi-luxation(脱位和半脱位)Closedbonefracture(闭合性骨折)Closedinternalinjury(闭合性内伤)fracture2AccordingtopositionsCraniocerebralinjury(颅脑伤)Maxillofacialandcervicalinjury(颌面颈部伤)Chestinjury(胸部伤)Abdomeninjury(腹部伤)Pelvisinjury(骨盆部伤)Spineandspinalcordinjury(脊柱脊髓伤)Upperextremityinjury(上肢伤)Lowerextremityinjury(下肢伤)Multipleinjury(多发伤)epiduralhematomaCraniocerebraltrauma3AccordingtoinjuriousfactorsColdweaponwounds(冷兵器伤)Firearmwounds(火器伤)Burns(烧伤)Coldinjury(冷伤)Blastinjury(冲击伤)Chemicalinjury(化学伤)Radiationinjury(放射伤)Combinedinjury(复合伤)burnsColdinjuryTraumaPathologytraumadamageofthetissuestructurehemorrhageinactivationofcelllocal:inflammation,cellularproliferationsystemicchanges:bloodfilm,bodytemperature,functionofimportantorgans,1InflammatoryreactionLocal：hyperemia,edema,exudation(redness,swelling,heat,pain)Benefit:

1.Proliferativecellsfillthedeficit,facilitingthewoundhealing.2.Itclearsthe

bacteria,tissuefragmentandforeignbodycanpromotethehealingprocedure.Harm:

Severeinflammatoryreactionresultsindelayedhealinganddisturbanceofcirculation.Excessiveexudationcausestheinsufficienceofbloodvolume.

brady-kinincomple-mentsHistamineinterferonTNFPAFReleaseofvariousinflammatorymediatorsandcytokinesproductofdamagedtissueandbacterialtoxinPathology2Systemicreaction1）bodytemperature：

inflammatorymediators,infections

heatcenter

bodytemperature:riseordescendPathology2Systemicreaction1）Bodytemperature2）Neuroendocrine

pains,stress,losebloodandwaterHypothalamus

----ACTH，ADH，GHPituitaryglandSynpatheticNerves--renin，nonadrenaline，aldosteroneAdrenalglandheartratearises,vasoconstriction,urinevolumesdecreasePathology2Systemicreaction1）Bodytemperaturereaction

2）Neuro-endocrinereaction

3）Changesofcatabolism

decompositionof

proteinandadiposeincreasecatecholamine,corticosteroids,glucagon,TNFs,ILsincrease

energy,proteinweightloss,myatheniacatabolismaccentuation（肌无力）儿茶酚胺皮质激素胰高糖素Pathology2Systemicreaction1）bodytemperature2）neuro-endocrinereactions

3）changesofmetabolism4）changesofimmunesystemendogenouscorticosteroidsdecreasethefunctionsofNeutrophilsandPhagocyteCatecholamine（儿茶酚胺）

PGE2（前列腺素）

immune

suppressionPathology1Inflammatoryreactions2Systemicreactions3Complicationsoftraumatissueinjury,bacteria,immunesuppression:Infectionbloodloss,infection:Shock

infection,shock,organdammage:MODSrepairThefunctionsofcellintheprocessofwoundhealing

Neutrophil(中性粒细胞)Macrophage(巨噬细胞)Platelet（血小板）Lymphocyte(淋巴细胞)

Inflammatoryreactionstage:PDGF,TGF-α,bFGF,MDGFtissueproliferationstage:IGF-1,bFGF,TGF-β,PDGFscarformationstage:TGF-β,PDGFThefunctionsofgrowthfactorintheprocessofwoundhealing

ParticipateincoagulationprocessEnhancethefunctionofmacrophageChemotaxis(趋化作用)Thefunctionsoffibronectin(Fn)

(纤维连接蛋白)repairproliferationmesenchymaltissuefillthedeficit细胞增生细胞间质充填连接Processofrepair1）fibrinfillingsealingthewound（纤维蛋白充填）Hemostasis（止血）Processofrepair2）proliferation（细胞增生）Fibroblast成纤维细胞endothelialcells

内皮细胞neogeneticvessels新生血管granuloma肉芽肿processofrepairCollagen（胶原）Amino-polysaccharide（氨基多糖）基质沉着fibroblasts,endouthelialcells,epithelialcells,osteoblastsfibroustissue（scar）processofrepair3）tissueplastyMacrophages（巨噬细胞），platelet（血小板）lymphocytes，variousmediators(earlyperiod)hyperplasiasynthesis(lateperiod)decompositionmodelingharmfulfactorsforwouldhealing1infection2foreignbodiesorexcessiveinactivetissue.disturbanceofcirculation

(shock,vesseldamage,edema,bandaging)4lackoflocalbraking5systemicfactors：

1)dystrophy营养不良：protein，vitamin,traceelement

2)theuseofcorticosteroids，chemotherapy,radiation,etc.3)immunocompromise：DM，tumor，cirrhosis，AIDS,etc.Typesofwoundhealing

primaryhealing：（一期愈合）basedonoriginalcells,withawellfunctionalrehabilitationSecondaryhealing：（二期愈合）basedonfibroustissue,recoveringwithfunctionaldisturbances:malformation,stenosis,dysfunction,etc.DiagnosisDiagnosisI.History：(1)causes：injuriousobjects，means，direction,etc.(2)symptomsandevolutionafterinjury(3)PastHistory:eg.DM。II.Physicalexamination：(1)generalconditions：consciousnesspulseBP

(2)Focusonrelatedsitesaccordingtohistory(3)Checkthesurfaceoftheopenwoundcarefully

DiagnosisoftraumaA.HistoryB.PhysicalexaminationC.Accessoryexaminations：laboratoryexaminationsPuncturation,catheter

Image（CT、Ultrasonography、X-Ray）woundscoring（伤情评分）CRAMS----pre-hospitalISS(injuryseverityscore)AIS(abbreviatedinjuryscore)TreatmentFirstaid（急救）Aims：Repairthedamagedorgans,resumephysiologicalfunciton

order：life-threateningconditionsImportantorgansotherscardiacarrestapneahemorrhageshockrupturesofurinetractorgastro-intestinaltractfractures,softtissueinjury(窒息)localtherapy---Debridement(清创术)Fundamentalrequirements1.Enlargewounds,incisiondeepfascia,haemostasis,resectdevitalizedtissue,removeforeignbody,reorganizeirregularedge,suturewound.2.Operationtime(<6h,notexceed72h)3.Aboutshock.4.aboutdebridementorder.5.Aboutsecondarydebridement.(obstructeddrainageornecrotictissuebefound).MethodsandSteps1woundcleaninganddisinfecting2woundanesthesia3checkingthewoundremovingnecrotictissue,foreignbody,hemostasis,

4sutureanddelayedsuture,5drainagedelayedsuturecontaminatedwounds:debridement>8~12hAfter24-48h,non-infectedwoundcanbesuturedtreatmentforinfectedwounds1.Drainage：patency，mtethegrowthofgranulation3.Pseudomonasaeruginosa：sulfamiloon4.Granulationedema:hypertonicsaline5.Excessivegrowthofgranulation：10%silvernitrate

6.

Slowgrowthofgranulation：ShengjiPower。7.TATandantibioticsystemictherapyPreventandtreatinfectionMaintainbodyfluidequilibrium,correctelectrolytedisorderNutritionsupport---estimationofcaloryconsumptionMale:66.5+13.7×weight(kg)+5.0×higher(cm)-6.8×ageFemale:65.6+9.6×weight(kg)+5.0×higher(cm)-4.8×age战伤

warinjurycharacteristicThelargeamountofthewounded,complicatedtrauma,seriouscontaminationMultivariateenvironmentTreatmentinechelons-escalationtherapy

(后送中连续监测和治疗)EvacuationandclassificationofthewoundedWarWoundEmergency

TreatmentProcedureVentilation(通气)Resuscitationofcardiacarrestandapnea(心跳呼吸骤停的复苏)Hermostasis(止血)Bandaging(包扎)Fixation(固定)Transportandevacuation(搬运与后送)Firearmwounds(火器伤)CharacteristicsPrimarywoundtract（原发伤道）Contusionzone（挫伤区）Concussionzone(震荡区)Treatment(处理)preventionandtreatmentshock,transfusionpreventionandtreatmentinfection,antibioticsandTATDebridement(清创术)BlastinjuryCharacteristicsWoundfactor:blastwaveBodysurfacewithoutskindamageacousticorgan(听器)，lung,brain,gastrointestinalaredamageableorgansAcousticorganblastinjurypreventionandtreatmentinfectionClearWashingexternalauditorycanalexternalauditorycanal(外耳道)WashingisprohibedBlastinjuryoflunghalfsupineposture,keeprespiratorypassageunblockedoxygentherapypreventionandtreatmentpulmonaryedemapreventionofinfectionexpectanttreatmentBlastinjuryofAbdomenLyinginbed,fastingPreventio