《胸部PBL第三组》PPT课件.ppt

Thorax: Case 1,A young man who was stabbed in the chest was rushed to a hospital. The stab wound was in the 3rd left intercostal space, just lateral to the sternum. The emergency physician noted that the veins of his face and neck were engorged.,The case,problem1:,pericardial sac & right ventricle,what vital structures may have been injured? the 3rd left intercostal space, just lateral to the sternum,What probably caused the engorgement of his cervical and facial veins?,problem 2:,Probable reasons: 1. more blood is pouring in. 2. less blood is pouring out.,Problem 2,Why?,Problem 2,Traumatic hemopericardium,外伤性血心包是指外伤引起的心包腔内积血。常是心脏创伤、心包内大血管损伤或心包损伤引起的并发症，多为心前区部位的锐器或火器伤所致，部分可由胸部严重闭合性损伤引起。心脏外科手术后或介入性心脏检查治疗时，偶尔也会引起心脏穿孔而致血心包。 如心包腔内积血不多，不产生压迫症状者，叫血心包(hemopericardium)。 如心包腔内积血产生压迫症状者，叫急性心包填塞(acute cardiac tamponade)。即在短时间内有较大量血液流入心包腔内，心包囊不能迅速伸张扩大，导致心包内压力增高，妨碍了心室舒张期充盈，引起排血量下降，静脉回流受阻和静脉压升高。,外伤性血心包Traumatic hemopericardium,1.急性心包填塞症状：胸闷、烦躁不安、面色苍白、皮肤湿冷、呼吸困难、甚至意识丧失。 2.体征：呼吸急促，可有紫绀。颈静脉怒张、脉快弱、血压下降、脉压差变小、中心静脉压增高、心前区有伤口（随呼吸或心跳有血液外溢）、心尖搏动减弱或消失，心音远弱。可有奇脉（吸气时脉搏明显减弱或消失，呼气终了时变强）。也可出现Kussmauis（吸气时颈静脉明显怒张）。,此时，若不降低心包内压力（将血液排出），当心包腔内压力超过上、下腔静脉压力时，则发生心脏停跳，将会导致病人死亡。在急性心包积血时，心包短时间内积血毫升便足以引起压迫，形成致命的心包填塞（死亡率7%）。,What emergency clinical procedure would likely be performed before he was taken to the operating room? Remove blood from the pericardial cavity.,Problem 3,pericardiocentesis,心包穿刺pericardiocentesis,胸骨下穿刺于胸骨剑突与左第7肋软骨交界处之下作穿刺点，穿刺方向与腹壁成45，针刺向上、后、稍向左而入心包腔的后下部。穿刺针尖入皮下后，助手将注射器与穿刺针后的橡胶管相连接，并抽吸成负压，当穿刺针入心包腔后，胶管内立即充满液体，此时即停止进针，以免触及心肌或损