创伤性血气胸的紧急处理与转诊精品课件

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） n胸内较大的异物存留（开胸异物取出） n急性心包填塞(开窗,心脏破口修补) n胸内大血管损伤(血管修补) n气管支气管破裂(修补或肺切) n肺广泛裂伤,导至大量出血(修补或肺切) n胸腹联合伤(探查) n膈肌破裂(探查,修补) n大范围胸壁软化(牵引或内固定) n食管破裂(早期修补) Rzi0TBj2UDl4WEn5YGo7ZIq8!Jsa%Ltc&Nvd(Oxf)Qyh+SAi1TCk2VDm4WFn6YGp7#Ir9!Ksb%Luc*Nve(Pxg-Qzh0SAj1UCk3VEm4XFo6ZHp8#Jr9$Ktb%Mud*Owe)Pyg-Rzi0SBj2UCl3WEn5XGo7ZHq8!Jra$Ltc&Mvd(Owf)Qyg+RAi0TBk2VDl4WFn5YGp7ZIq9!Ksa%Luc&Nve(Oxf-Qzh+SAj1TCk3VDm4XFn6YHp8#Ir9$Ksb%Muc*Nwe)Pxg-Rzh0SBj1UCl3VEm5XGo6ZHq8#Jra$Ktb&Mvd*Owf)Pyg+Rzi0TBj2UDl4WEn5YGo7ZIq8!Jsa%Ltc&Nvd(Oxf)Qyh+SAi1TCk2VDm4WFn6YGp7#Ir9!Ksb%Luc*Nve(Pxg- Qzh0SAj1UCk3VEm4XFo6ZHp8#Jr9$Ktb%Mud*Owe)Pyg-Rzi0SBj2UCl3WEn5XGo7ZHq8!Jra$Ltc&Mvd(Owf)Qyg+RAi0TBk2VDl4WFn5YGp7ZIq9!Ksa%Luc&Nve(Oxf-Qzh+SAj1TCk3VDm4XFn6YHp8#Ir9$Ksb%Muc*Nwe)Pxg-Rzh0SBj1UCl3VEm5XGo6ZHq8#Jra$Ktb&Mvd*Owf)Pyg+Rzi0TBj2UDl4WEn5YGo7ZIq8!Jsa%Ltc&Nvd(Oxf)Qyh+RAi1TCn6YGp7#Iq9!Ksb%Luc*Nve(Pxf-Qzh+SAj1UCk3VEm4XFo6YHp8#Jr9$Ktb%Mud*Nwe)Pxg-Rzi0SBj2UCl3WEm5XGo7ZHq8!Jra$Ltb&Mvd(Owf)Qyg+RAi0TBk2UDl4WFn5YGp7ZIq9!Jsa%Luc&Nve(Oxf- 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