《外科学》创伤与战伤(留学生)课件

1、Dr. Zhendong LiuThe Third Xiangya HospitalTrauma And War InjuryRisk factorsTraffic accident, industrial injury,Natural disaster, war injury and so on.Industrial injuryNatural disasterExplosionCONTENT1. The concept of trauma.2. The classification of trauma.3. The pathphysiology of trauma.4. The diagn

2、osis of trauma.5. The treatment of trauma.DEFINITION Trauma is the injury caused by mechanical or chemical factors, which leads to tissue integrity damaged and loss of function.Chapter 1Classification of the Trauma1. For the integrity of skin1). The opened injury :Abrasion（摖伤）Laceration（撕裂伤）Incised

3、wounds or cut wounds （切伤/ 砍伤）Puncture wounds （刺伤）2). The blunt injury :Contusion （挫伤）Crush injury（挤压伤）Sprain（扭伤）Concussion （震荡伤）Luxation and semiluxation （关节脱位/半脱位）Closed bone fracture （闭合性骨折）Closed internal injury （闭合性内脏伤）2. For injured place and organCraniocerebral injury （颅脑伤） : Chest injury （胸部伤

4、）: hematopneumothrax Abdomen injury （腹部伤）: burst spleen, perforated bowelLimbs （四肢伤）: fracture, dislocationSpinal injury （脊柱伤）: fracture, paraplegia3. Wound causing factorsCold weapon wounds （冷兵器伤）: KnifeFirearm wounds （火器伤）: gun Burns（烧伤）: High temperature Cold injury（冷伤）: Low temperatureBlast inju

5、ry （冲击伤）: 爆震伤Chemical injury （化学伤）: chemical weaponRadiation injury （放射性损伤）: Electromagnetic radiation，Particulate radiationOpened injuryOpened fractureChapter 2Pathophysiology of trauma Trauma can trigger a cascade of pathological response which includes inflammatory/immune reaction, neuroendocrine

6、 response and functional change of vital organ.1.The inflammatory/immune reaction1. Inflammatory: local tissue inflammatory2. Immunosuppressing: glucocorticoids inhibit inmmunocytes function.3. Immunomodulating : Systemic inflammatory response syndrome(SIRS) Compensatory anti-inflammatory response s

7、yndrome(CARS)Immunomodulating Both glucocorticoids and catecholamines directly inhibit the production of type 1 cytokines, such as IL-12, IL-2, TNF- and INF-, that enhance cellular immunity and T-helper 1 (Th1) formation and conversely favor the production of type 2 cytokines, such as IL-10, IL-4, I

8、L-13, that induce humoral immunity and T-helper 2 (Th2) formation. Thus, during an immune challenge, stress causes an adaptive Th1 to Th2 shift in order to protect the tissues from the potentially destructive actions of the pro-inflammatory type 1 cytokines and other products of activated macrophage

9、s. The homeostatic role of stress-induced Th2 shift against overshooting of cellular immunity often complicates pathologic conditions where, either cellular immunity is beneficial (e.g. carcinogenesis, infections) or humoral immunity is deleterious (e.g. allergy, autoimmune diseases).Schematic repre

10、sentation of the interactions between the stress and the immune system. LC/NE: locus ceruleus/norepinephrine-sympathetic system, SPGN: sympathetic postgaglionic neurons, CRH: corticotropin-releasing hormone, AVP: arginine vasopressin, ACTH: corticotrophin, PAF: platelet activating factor, NE/E: nore

11、pinephrine/epinephrine,: Th1: T-helper lymphocyte 1, Th2: T-helper lymphocyte 2. Stimulation is represented by solid green lines and inhibition by dashed red lines.1. Sympathetic / adrenocortex system2. Hypothalamus / pituitary system3. Renin-angiotension system2. Neuroendocrine response1.SNS - Neur

12、ohormonal response Stimulated by sympathetic/adrenocortex system (catecholamine )Increased heart rateIncreased contractilityVasoconstriction (SVR-Afterload)Increased Preload2.SNS - Hormonal: Adrenal CortexAnterior pituitary releases adrenocorticotropic hormone (ACTH).Stimulates adrenal Cx to release

13、 glucorticoids.Blood sugar increases to meet increased metabolic needs. 3.SNS - Hormonal: Antidiuretic HormoneOsmoreceptors in hypothalamus stimulatedADH released by Posterior pituitary glandVasopressor effect to increase BPActs on renal tubules to retain water4.SNS - Hormonal: Renin-angiotension sy

14、stemDecrease renal perfusionReleases renin angiotension I angiotension II potent vasoconstriction &releases aldosterone adrenal cortexsodium & water retention3. Functional change of vital organHeart: Catecholamine increases heart rate. Anoxia, acidosis the injuries of cardiac muscle. Lungs: The vent

15、ilation-perfusion imbalance ARDS。Kidneys: Renal failure, oliguria (400 ml/d), anuria (100 ml/d) Brain: Edema, The encephalic pressure increases.Gastrointestine: the intestinal mucosa barrier was damaged shift of bacteria and toxin MODS.Liver: The endotoxicemia metabolic disturbance and acidosis aggr

16、avated.Chapter 3Repair of injured tissue Trauma directly stimulates local tissue and triggers a cascade of tissue repair process which includes:A. Inflammation.B. Proliferation and differentiation of many types of cellgranulation formation.C. Wounds healing and car formation.The concept of inflammat

17、ion Inflammation can be defined as a localized protective tissue response elicited by injury or destruction of tissues, which serves to destroy, dilute or wall off both the injurious agent and the injured tissues. The inflammation is often characterized by injured tissue showing redness, swelling, h

18、eat, pain and loss of function. New Tissue Formation (granulation) Following the inflammation - proliferation and migration of cells at the wound site.This dense population of macrophages, fibroblasts and endothelial cells, etc., embedded in a loose matrix.Granulation formation fill the gap of injur

19、ed tissue before their coverage by epidermal cells.Matrix Formation and Remodeling Remodeling of the immature tissue matrix commences simultaneously with granulation tissue formation. For clarity, however, it is normally regarded as forming the third and final phase of wound healing due to its conti

20、nuation for many months or years after granulation tissue has been resolved. During this phase the highly cellular and highly vascular granulation tissue is gradually replaced and remodeled, forming scar tissue.AngiogenesisTissue healingThe wound healing 1.The first intention : mainly composed of th

21、e original cells, with little fibrous tissue, e.g. epithelial cell-skin, mucosa, osteoblast-bones, endothelial cell-wall of vessels without lose of functionThe wound healing 2. The second intention : mainly composed of fibrous tissue, owning a poor function after healing, not only lacking the origin

22、al function, but owning the scar contraction or hyperplasia, which result in malformation and dysfunction . The disadvantageous factors for heal1. Infection.2. Foreign body.3. Inadequate blood supply.4. Improper local fixation.5. The systemic factors e.g. malnutrition, improper use of medicine, poor

23、 immunity.Chapter 4Diagnosis of TraumaThe systemic examination1. The vital signs:1) Temperature2) R, BP, P3) Others: oliguria, thirsty, sleeplessness, anorexia, etc. 2. Trauma evaluation:1) CRAMS2) ISS(injury severity score)3) AIS(abbreviated injury score) Clinical ManifestationsLocal Manifestations

24、:(1) Pain(2) Swelling(3) Dysfunction 1. The history: (1)The cause, the wounded position and the posture. (2)The symptoms and the evolvement after the wound. (3)The local disposal. (4)The past health. 2. PE: (1)R, P, BP, the consciousness, the face, the posture, shocked or not. (2)According to the hi

25、story, examining the local wound carefully. (3)For the opened wound, examining the size, shape, depth, contamination, bleeding of wound and foreign body in wound.The accessory examinations (1) The tests- B-R, U-R, S-R, HCT, electrolytes, CO2CP, BUN, enzymology, etc. (2) Puncture, Pipe Examination 1.

26、The cavums of thorax, abdomen and joints. 2.To drain the urine, intubation. 3.CVP-the central vein pressure. (3) The imaging examination X-ray, CT, MRI, ultrasonic test, etc.Complications(1) The purulent infection-opened fracture, large wound(2) Shock(3) MODS e.g.: The adult respiratory distress syn

27、drome, acute renal failure, the stress ulcer.Chapter 5Treatment of traumaFirst aidEmergency treatment1.The aim for the treatment is to repair the wounded tissues and the organs, and recover physiological functions.2.The critical cases should be treated firstly, such as stop of heart beat, asphyxia,

28、massive haemorrhage, opened pneumothorax, shock, etc.3.The basic steps for save the severe case “A, B, C”- Airway Breathing CirculationThe general disposal1.The posture and the local fixation.2.To prevent and treat the infection.3.To maintain the balance of body fluid and the nutritious metabolism.4.To cease pain,