创伤的病理生理1PPT课件

SectionIIIPathophysiologyoftrauma创伤的病理生理,heat热,redness红,swelling肿,pain痛,lossoffunction功能丧失,1.Inflammation炎症,Inflammatorycells炎性细胞Inflammatorycytokines炎性因子,capillary毛细血管,Inflammationaftertrauma创伤后炎症,SystemicInflammatoryResponseSyndrome(SIRS)全身炎症反应综合征CompensatoryAnti-inflammatoryResponseSyndrome(CARS)代偿性抗炎症反应综合征Traumaandbacteriacancauseinflammation创伤和细菌可引起炎症Thisprocessinvolvemanycellsandcytokine这个过程涉及到许多细胞及细胞因子,inflammationstaging炎症分段,杀灭细菌和毒素去除坏死细胞促进组织愈合,促炎和抗炎平衡，炎性稍占上风,Injury损伤,Bodysresponse身体反应,SIRS,CARS,Uncontrolledsystemicinflammatoryresponsesyndrome失控的全身炎症反应综合征,besides此外,sufficient充分,Death死亡,uns.不充分,Undercontrol得到控制,ClinicalpresentationsofSIRS全身炎症反应综合征的临床表现,Bodytemperature（体温）38Heartrate（心率）90/minBreathe（呼吸）Bloodcellcount（血细胞计数）12109/L,20/min,Typesofinflammatorymediators炎性介质的类型,Cytokines细胞因子,Tumornecrosisfactor(TNF)肿瘤坏死因子Interleukin白介素Interferon(ITF)干扰素Growthfactor-(TGF-)生长因子-,Activationofinflammatorycells炎症细胞的激活(Macrophage)（巨噬细胞）,多器官功能障碍综合征周荣斌,促炎介质过度产生,原始病因感染损伤,抗炎介质过度产生,全身反应全身炎症反应综合征（SIRS）代偿性炎症反应综合征（CARS）混合性抗炎反应综合征（MARS）,平衡SIRS、CARS,细胞调亡SIRS过度,免疫功能障碍CARS过度,MODSSIRS过度,休克SIRS过度,局部促炎介质,局部抗炎介质,SIRS临床发病过程,神经内分泌系统变化,2.全身反应systemicresponse,代谢变化,3.Woundhealing创伤的愈合,Woundhealingiscomposedofseveralsteps创伤的愈合分为几个阶段regeneration再生granulation肉芽组织angiogenesis血管生成epithelialization形成上皮Theprocessismediatedbyavarietyofgrowthfactors.各种生长因子参与Primaryhealingandsecondaryhealing一期愈合、二期愈合,WhatisTissueRepair?组织修复,Theprocesstoreplaceinjuredordeadcellsandtorepairtissuesafterinflammation.炎症后，取代受伤或死亡细胞、修复组织的过程TypesofT.R组织修复的类型completeT.R完全愈合incompleteT.R不完全愈合,WhatisRegeneration?再生,Theprocessofthereplacementofinjuredcellsbycellsofthesametype.损伤细胞被周围同种细胞更换的过程,Whatisgranulation?肉芽组织,Duringthecourseofhealing,fibroplasiaisdevelopedinthewoundbyfibroblasts.在伤口愈合的过程中，纤维母细胞转化形成纤维组织增生Itincludes:smallbloodvessels（小血管）fibroblasts（纤维母细胞）inflammatorycells（炎性细胞）,Whatisangiogenesis?血管生成,Angiogenesisisnecessaryfeatureofrepairandstartedfrompreexistingvenules,itbecomesvisibleabout4daysafterinjury.血管再生是修复的重要特征，在损伤后4天左右时，由先前存在的小静脉开始,Preexistingvenules,Whatisepithelialization?上皮形成,Epithelialcellsisstimulatedbyavarietyofgrowthfactors,suchasTGF-1,andanchoronthefirstunepithelializedplace.上皮细胞受到多种生长因子的刺激作用（例如TGF-1）后，集聚于早期非上皮化的部位,Theprocessofrepair修复的过程,coagulationandinflammation凝聚、炎症Matrixdepositionandgranulation基质沉淀、肉芽组织Angiogenesis血管再生Epithelialization上皮形成Collagenmaturation胶原蛋白成熟Woundcontraction伤口收缩,Typesofwoundhealing伤口愈合的类型,Primaryhealing一期愈合small,cleanandlesstissuedamage.伤口小，清洁，较少组织损伤bystitching,mildinflammatoryreaction.通过缝合，轻度炎症反应epidermalregeneration,asmallamountofgranulationtissue,fewscars.表皮再生，少量肉芽组织，几乎无瘢痕,Primaryhealing一期愈合,Typesofwoundhealing伤口愈合的类型,Secondaryhealing二期愈合Largewound伤口范围大Necrotictissueandinflection组织坏死、变形Granulationtissuefilledthewound肉芽组织填充伤口Bigscars瘢痕大,Nutrition营养水平Metabolicstatus代谢状态Circulatorystatus循环状态Hormones激素水平,Systemicfactors全身因素,Localfactors局部因素,Infection感染Wounddefect伤口缺损Foreignbodies异物Size,location,andtypeofwound伤口大小、位置、类型,plicationoftrauma创伤并发症,感染休克脂肪栓塞综合症应激性溃疡凝血功能障碍器官功能障碍,精选,25,SectionIVTraumadiagnosis创伤的诊断,精选,26,Relationshipbetweensystemicandlocal系统与局部的关系,Systemicdiagnosis（系统诊断）：Fivevitalsigns/Glasgowscale/CRAMS五项生命体征/Glasgow昏迷评分法/CRAMS评分brain/viscus/chest/lung脑/内脏/胸/肺Localdiagnosis（局部诊断）：Woundtypes/scope/depth伤口的类型、范围、深度Infection/non-infection是否感染Bleeding/fracture出血、骨折Systemicdiagnosisbethemostimportant系统诊断尤为重要,精选,27,Respiration呼吸respiratoryrate:25/15/min,cyanosis.呼吸频率25/15次/分，发绀Bloodpressureandpulserate血压、脉率pulserate100/min,bloodpressure100/min，血压90mmHgConsciousnessandpupilsmotion意识、瞳孔GlasgowscaleandCRAMSGlasgow昏迷评分法/CRAMS评分,Generalphysicalexamination(Fivevitalsigns)一般体格检查（五项生命体征）,精选,28,Localwoundinspectionprinciples局部伤口检查的原则,woundsize,depthandshape伤口大小、深度、形状woundcontamination伤口污染情况woundtraits伤口特性bloodvesseldamageandbleeding血管损伤及出血情况foreignbodiesinthewound.伤口中异物情况whetherinvolvedeepviscusinjuryornot是否涉及腹部深层脏器损伤,精选,29,Experimentalpuncture诊断性穿刺abdominocentesis腹腔穿刺thoracentesis胸腔穿刺Exploratorysurgery探查术Adjunctivecheck辅助检查imaging:CTMRIX-ray成像：CT、MRI、X线,Blunttraumaexamination(closewoundcheck)闭合性创伤检查,精选,30,Abdominocentesis腹腔穿刺术,精选,31,Thoracentesis胸腔穿刺术,