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创伤性血气胸的紧急处理 与转诊 中南大学湘雅二医院胸心外科 胡建国 陈名久 概 述 n创伤性气胸根据胸膜腔是否与外界相通分 为 开放性气胸: 多由锐器刺穿胸壁造成,空气由胸壁伤口 自由出入胸腔,影响呼吸循环功能。 闭合性气胸: 多由于挤压、冲撞、钝器碰击胸部引起, 常伴有肋骨骨折,胸膜腔与外界不通或通 道已闭塞 。 概 述 当肺的裂伤较大或支气管破裂,其裂口与 胸膜腔相通,且形成活瓣时,易产生张力 性气胸,引起呼吸和循环功能的严重障碍 。 由于肺组织的裂伤、胸壁或胸内血管、心 脏的损伤导致胸腔内积血、积气称为血气 胸。 临床表现 n主要症状: 胸痛 ,呼吸困难 ,咯血 n局部体征: 有肋骨骨折者局部压痛 ,甚至 胸廓畸形,反常呼吸运动 ,皮下气肿,甚 至气管偏移。胸部叩诊积气呈鼓音,积血 呈浊音 。听诊呼吸音减弱或消失 ,胸壁伤 口开放者能听到空气出入胸膜腔的吹风声 。 n大量出血时可出现休克 诊 断 n仔细询问胸部外伤史,了解受伤机制 n体查:胸廓有无畸形,胸壁有无压痛,叩诊 情况,听诊呼吸音及心音、心率 n胸部X片(条件允许时应照),尽可能采用 立位 ,了解有无肋骨骨折或血气胸以及肺组 织有无挫伤 诊 断 n有时在伤后的最初几小时内,胸部X检查 可能无阳性发现,必要时复查胸部X片, 以免延误治疗 n在危急情况下,应先作诊断性穿刺,胸膜 腔抽出不凝固血液或气体即能明确诊断。 n锐器伤的病人应注意创口位置,警惕心脏 和大血管的损伤以及胸腹联合伤。必要时 应作胸部CT及心脏彩超检查 闭合性气胸(Closed Pneumothorax) n临床表现 n肺萎陷在30%以下者,对 呼吸和循环功能影响较小 ,多无明显症状 n大量气胸(压缩50%以上 ), ,病人出现胸闷、胸痛 和气促,气管向健侧移位 ,伤侧胸部叩诊呈鼓音, 听诊呼吸音减弱或消失 n胸部X线检查有助于诊断 闭合性气胸(Closed Pneumothorax) 治疗 n小量气胸(压缩200ml,连续小时,提示进行 性血胸 n膈肌破裂易延误诊断,插入胃管照片或吞钡 n有无大动脉或心脏损伤 血气胸有下列情况应转至有条件的医 院行剖胸探查 n胸腔闭式引流后胸膜腔内进行性出血,成人每小时 200ml,小儿5 ml/Kg/小时,持续3小时以上(探查 ) n胸腔闭式引流后持续大量漏气,呼吸很困难(探查) 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