醫(yī)學(xué)課件胸部外傷2

胸外傷進(jìn)展瀘州醫(yī)學(xué)院附屬醫(yī)院于風(fēng)旭

Incidenceandmortality:

Chesttraumaaccountsfor8%occurrencesoftotaltraumaticcases,morethan25%ofdeathcausedbytrauma.IncidenceproportionMortalityproportion胸外傷概況胸外傷病因PenetratingtraumaBlunttrauma車禍傷墜落傷擠壓傷刀刺傷火器傷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LowEnergyArrows,knives,handgunsInjurycausedbydirectcontactandcavitationHighEnergyMilitary,huntingrifles&highpoweredhandgunsExtensiveinjuryduetohighpressurecavitationPenetratingTrauma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?dú)庑?/p>

血管損傷

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外傷詳細(xì)分類及病理生理改變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

ContusionDyspneaPainonbreathingHypoventilationCrepitusParadoxicalchestwallmotion呼吸困難

呼吸疼痛

通氣不足

捻發(fā)音

胸壁矛盾運(yùn)動(dòng)

RibFractures>50%ofsignificantchesttraumacasesduetoblunttraumaCompressionalforcesflexandfractureribsatweakestpointsRibs1-3requiresgreatforcetofracturePossibleunderlyinglunginjuryRibs4-9aremostcommonlyfracturedRibs9-12lesslikelytobefracturedTransmitenergyoftraumatointernalorgansIffractured,suspectliverandspleeninjuryHypoventilationisCOMMONduetoPAINSternalFracture&Dislocation（胸骨骨折和錯(cuò)位）AssociatedwithseverebluntanteriortraumaDirectBlow(比如：方向盤)Incidence:5-8%Mortality:25-45%MyocardialcontusionPericardialtamponadeCardiacrupturePulmonarycontusionDislocationuncommonbutsameMOIasfractureTrachealdepressionifposteriorFlailChest(連枷胸)SegmentofthechestthatbecomesfreetomovewiththepressurechangesofrespirationThreeormoreadjacentribfractureintwoormoreplacesSeriouschestwallinjurywithunderlyingpulmonaryinjuryReducesvolumeofrespirationAddstoincreasedmortalityParadoxicalflailsegmentmovementPositivepressureventilationcanrestoretidalvolumePulmonaryinjuryandinjuriesinvolvingthepleuralspace

Pulmonarycontusion

Pulmonarylaceration

Pneumothorax

Hemothorax

Hemopneumothorax

pneumothoraxhemothoraxPulmonarycontusion肺挫傷

肺裂傷

氣胸

血胸

血?dú)庑?/p>

ClosedPneumothoraxOccurswhenlungtissueisdisruptedandairleaksintothepleuralspaceProgressivePathologyAiraccumulatesinpleuralspaceLungcollapsesAlveolicollapseReducedoxygenandcarbondioxideexchangeVentilation/PerfusionMismatchIncreasedventilationbutnoalveolarperfusionReducedrespiratoryefficiencyresultsinHYPOXIAOpenPneumothoraxFreepassageofairbetweenatmosphereandpleuralspaceAirreplaceslungtissueMediastinumshiftstouninjuredsideAirwillbedrawnthroughwoundifwoundis2/3diameterofthetracheaorlargerSigns&SymptomsPenetratingchesttraumaSuckingchestwoundFrothybloodatwoundsiteSevereDyspnea（嚴(yán)重呼吸困難）Hypovolemia（低血容量）TensionPneumothoraxBuildupofairunderpressureinthethorax.ExcessivepressurereduceseffectivenessofrespirationAirisunabletoescapefrominsidethepleuralspaceProgressionofSimpleorOpenPneumothoraxPneumothoraxNeedemergenttreatmentTensionPneumothoraxSigns&SymptomsDyspneaTachypneaatfirstProgressiveventilation/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/灌注不匹配血液聚集在胸膜腔內(nèi)嚴(yán)重者失血量大于1500ml死亡率75%每側(cè)胸腔可以容納3000ml導(dǎo)致潮氣量降低灌注/通氣失調(diào)&休克常合并氣胸血?dú)庑豀emothoraxSigns&SymptomsShockDyspneaTachycardiaTachypneaDiaphoresis（出汗）HypotensionDulltopercussionoverinjuredsideCardiovascularInjuriesOccursin76%ofpatientswithseverebluntchesttraumaRightAtriumandVentricleiscommonlyinjuredInjurymayreducestrengthofcardiaccontractions---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

RetrosternalpainsimilartoMI

Chestpainunrelievedbyoxygen

MayberelievedwithrestSigns&SymptomsPericardialTamponadeRestrictiontocardiacfillingcausedbybloodorotherfluidwithinthepericardiumOccursin<2%ofallseriouschesttraumaHowever,veryhighmortalityResultsfromtearinthecoronaryarteryorpenetrationofmyocardiumBloodseepsintopericardiumandisunabletoescape200-300mlofbloodcanrestricteffectivenessofcardiaccontractionsRemovingaslittleas20mlcanprovidereliefSigns&SymptomsDyspneaPossiblecyanosisBeck’s三聯(lián)征心音遙遠(yuǎn)HypotensionShockKussmaul’ssignPulsusParadoxus（奇脈）MyocardialAneurysmorRuptureOccursalmostexclusivelywithextremebluntthoracictraumaSecondaryduetonecrosisresultingfromMISevereriborsternalfracturePossiblesignsandsymptomsofcardiactamponadeIfaffectsvalvesonly

Signs&symptomsofrightorleftheartfailureAbsenceofvitalsignsSigns&Symptoms我院近五年一共收治3例鈍性傷致心臟破裂病人OtherVascularInjuriesTraumaticAneurysmorAorticRupture

RuptureorlacerationSuperiorVenaCavaInferiorVenaCavaGeneralThoracicVasculatureBloodLocalizinginMediastinumCompressionof:GreatvesselsMyocardiumEsophagusGeneralSigns&SymptomsPenetratingTraumaHypovolemia&ShockHemothoraxorhemomediastinumOtherThoracicInjuriesTraumaticEsophagealRuptureTracheobronchialInjuryTraumaticAsphyxia（創(chuàng)傷性窒息）胸腹多發(fā)傷thoracoabdominalmultipleinjuries胸腹復(fù)合傷（是否伴有膈肌的損傷）

thoracoabdominalcombinedinjuries石應(yīng)康，楊建.外科學(xué)（第七版）理解一個(gè)概念胸外傷病人的評(píng)估SceneSize-upInitialAssessmentRapidTraumaAssessmentObserveQuestionPalpate（觸診）Auscultate（聽診）Percuss（視診）BluntTraumaAssessmentPenetratingTraumaAssessmentOngoingAssessment評(píng)估程序如何評(píng)定胸外傷的程度？創(chuàng)傷評(píng)分

多種評(píng)分系統(tǒng)孰優(yōu)孰劣？Thisisaproblem!!!PulmonaryContusionscore(PCS)1999,Tyburskietal.Wagner-score1989WagnerandJamiesonThoracicTraumaSeverityscore(TTS)2000

PapeHCetal.Conclusions：ThoracictraumascorescombininganatomicalandphysiologicparametersliketheTTSseemtobemostsuitableforseverityassessmentandpredictionofoutcomeinmultipletraumapatientswithconcomitantbluntchesttrauma.MommsenP,ZeckeyC,AndruszkowH,etal.ComparisonofDifferentThoracicTraumaScoringSystemsinRegardstoPredictionofPost-TraumaticComplicationsandOutcomeinBluntChestTrauma.JSurgRes.1–9(2011)Oct5

Twohundredseventy-eightmultipletraumapatients

onlytheTTSwasanindependentpredictorofmortality.WiththeTTSshowingthebestpredictionpower,theTTS,PCS,andWagner-scorewereindependentpredictorsofventilationtime,lengthofICUstay,andthedevelopmentofpost-traumaticARDSandMODS.assess

EsmeH,SolakO,YurumezY，etal.Theprognosticimportanceoftraumascoringsystemsforbluntthoracictrauma.ThoracCardiovascSurg.2007Apr;55(3):190-5.RevisedTraumaScore[RTS]TraumaandInjurySeverityScore[TRISS]InjurySeverityScore[ISS]LungInjuryScale[LIS]ChestWallInjuryScale[CWIS])152patientswithbluntthoracictraumaassessonlyTRISSwasanindependentpredictorofmortalityonlyLISwasanindependentpredictorofmorbidity,theneedforthoracotomy,andtubethoracostomyduration.

TRISSandLISwereindependentpredictorsofthelengthofICUstay.ISS,CWIS,andLIS