创伤控制理论

创伤控制理论,是一种理念、不是一种技术针对多发伤在最适当的时机做作最恰当的手术,回顾,50Stoo sick to operate on三句话but wait a few days不要急诊髓内钉最好等两天,1970s Early Total Care早期完全干预,多发伤、复合伤的理解,创伤级联瀑布学说,nn n n+nm,damage control surgery创伤控制手术,80S来自腹部外科的实践三步法,创伤控制骨科,利用创伤控制理论 指导骨科实践为了降低有多发伤、 合并伤患者的死亡率为了预防SIRS的 发生率,内容,外固定支架暂时稳定,创伤监护病房,确定性手术,优势,双赢便于后续处理控制出血骨折的稳定,什么样的病人要做创伤控制手术,Stable稳定想怎么做都行do whatever you wantBorderline临界点Unstable不稳定、随时有生命危险In extremis已经濒临死亡了,关键是borderline 的转化,什么是borderline,Borderline,多发性损伤ISS20分，附加胸部损伤(简明损伤评分AIs2分)：多发性损伤伴有腹部、骨盆损伤(Moore评分3分)并出血性休克、入院时血压40分而不附加胸部损伤：入院时第一张胸片发现双肺挫伤：早期平均肺动脉压24 mm Hg：多发性长骨骨折与躯干损伤AIS2分：估计手术时间6 h：,一些提示、能让你记着的pH 7.24Temperature 90 minutes高凝状态老年病人 (physiologic age 65),Pelvic Fractures,针对分型临时固定片子做出大致的判断、神经损伤、失血、不等长是创伤控制理论中要重点处理的简单、快速很重要,Femur Fractures,胸部损伤双侧股骨干骨折、26.8%血乳酸盐扩髓与非扩髓,肢体创伤控制骨科,DCO principles applied to a single, severely injured limb原则上都能用高能量胫骨近端骨折股骨Grade III B and C open fracturesMangled extremties,Secondary Procedures,Days 2, 3, and 4 不合适Objective tests客观的检查标准Lactic acid/pHIL-6 500,骨牵引还是外固定架,对于创伤控制来说没有差别？,血清乳酸盐的测定对股骨干骨折髓内手术的重要参考,Orthopaedic Emergencies,脱位Vascular compromise血管损伤Compartment syndrome间室综合症血流动力不稳定的骨盆骨折,Dislocations,Proximal humerus fracture with humeral head dislocation肱骨近端骨折伴脱位Femoral neck fracture with hip dislocation股骨颈骨折伴脱位一切可能引发血运障碍从而延缓骨折愈合的,Dislocations,Vascular Compromise,要重视闭合性血管损伤要重视血管探查手术要重视体检的意义不是造影的指征、特别是腘动脉伤动态观测,Compartment Syndrome,When in doubt, release,该切就切、警惕部分后果,Open Fracture,When to debride?什么时间清创When to fix?什么时间固定When to close/cover?什么时间闭合创面,Timing of Debridement,6 hour rule based on Freidrichs study of bacteria replication rates黄金6小时？Only one study supports the 6 hour rule, while seven studies over the last 30 years show no significant difference1和6,Timing of Debridement,studyTime to debridement did not predict infection其实没啥关系Time to admission did correlate with infectionAntibiotic administrationResuscitation入院时间和复苏时间和抗生素的投放,Timing of Debridement,Ultimately, quality of debridement is most important,Timing of Fixation,May be performed at time of initial debridement for grade I, II, IIIa fracturesConsider delayed fixation for fractures grossly contaminated with dirt, stagnant water or farmyard related injuries.Delayed fixation and utilization of bead pouches and/or VAC dressings for fractures requiring soft tissue coverageReaming of open fractures well supported,Timing of Closure,The early closure of open fractures grade I, II, IIIa is recommended with the exception of wounds grossly contaminated with dirt, stagnant water or farmyard related injuries“Second look” debridement warranted when there is concern for further tissue compromise or high initial contaminationFree flaps may outperform local f