胸部外伤精选文档培训课件

胸部外伤精选文档

Incidenceandmortality发生率和死亡率:

Chesttraumaaccountsfor8%occurrencesoftotaltraumaticcases,morethan25%ofdeathcausedbytrauma.IncidenceproportionMortalityproportion胸外伤概况2胸部外伤精选文档胸外伤病因Penetratingtrauma贯穿伤Blunttrauma钝挫伤车祸伤坠落伤挤压伤刀刺伤火器伤3胸部外伤精选文档ResultsfromkineticenergyforcesBlast（爆破伤）PressurewavecausestissuedisruptionTearbloodvessels&disruptalveolartissueDisruptionoftracheobronchialtreeTraumaticdiaphragmruptureCrush(Compression)（挤压伤）BodyiscompressedbetweenanobjectandahardsurfaceDirectinjuryofchestwallandinternalstructuresDeceleration（减速伤）BodyinmotionstrikesafixedobjectBlunttraumatochestwallInternalstructurescontinueinmotionLigamentumArteriosumshearsaortaBluntTrauma压力波造成组织破坏

撕裂血管，破坏肺泡组织

破坏气管支气管树创伤性膈肌破裂

胸外伤病理生理4胸部外伤精选文档LowEnergyArrows,knives,handgunsInjurycausedbydirectcontactandcavitationHighEnergyMilitary,huntingrifles&highpoweredhandgunsExtensiveinjuryduetohighpressurecavitationPenetratingTrauma5胸部外伤精选文档穿透伤合并损伤ClosedpneumothoraxOpenpneumothoraxTensionpneumothoraxPneumomediastinumHemothoraxHemopneumothoraxLacerationofvascularstructures闭合性气胸

开放性气胸

张力性气胸

气肿

血胸

血气胸

血管损伤

6胸部外伤精选文档TracheobronchialtreelacerationsEsophageallacerationsPenetratingcardiacinjuriesPericardialtamponadeSpinalcordinjuriesDiaphragmtraumaIntra-abdominalpenetrationwithassociatedorganinjury气管支气管树裂伤

食管裂伤

穿透性心脏损伤

心包填塞

脊髓损伤

膈肌损伤伤

腹腔内脏器损伤穿透伤合并损伤7胸部外伤精选文档胸外伤详细分类及病理生理改变8胸部外伤精选文档Chestwall

contusionsorhematomas

胸壁挫伤或血肿Ribfractures肋骨骨折

Flailchest连枷胸

Sternalfractures胸骨骨折

Fracturesoftheshouldergirdle肩胛带骨折Injuriestothechestwall9胸部外伤精选文档

ContusionDyspneaPainonbreathingHypoventilationCrepitusParadoxicalchestwallmotion呼吸困难

呼吸疼痛

通气不足

捻发音

胸壁反常运动

10胸部外伤精选文档RibFractures>50%ofsignificantchesttraumacasesduetoblunttraumaCompressionalforcesflexandfractureribsatweakestpointsRibs1-3requiresgreatforcetofracturePossibleunderlyinglunginjuryRibs4-7aremostcommonlyfracturedRibs11-12lesslikelytobefracturedTransmitenergyoftraumatointernalorgansIffractured,suspectliverandspleeninjuryHypoventilation（肺换气不足）isCOMMONduetoPAIN11胸部外伤精选文档SternalFracture&Dislocation（胸骨骨折和错位）AssociatedwithseverebluntanteriortraumaDirectBlow(比如：方向盘)Incidence:5-8%Mortality:25-45%Myocardialcontusion（心肌的钝挫伤）Pericardialtamponade（心包填塞）Cardiacrupture（心脏破裂）Pulmonarycontusion（肺挫伤）DislocationuncommonbutsameMOIasfractureTracheal（气管）depressionifposterior12胸部外伤精选文档FlailChest(连枷胸)SegmentofthechestthatbecomesfreetomovewiththepressurechangesofrespirationThreeormoreadjacent（毗邻的）ribfractureintwoormoreplacesSeriouschestwallinjurywithunderlyingpulmonaryinjury（潜在的肺损伤）ReducesvolumeofrespirationAddstoincreasedmortalityParadoxicalflailsegmentmovement（反常呼吸运动）Positivepressureventilation（通气）canrestoretidalvolume（潮气量）13胸部外伤精选文档Pulmonaryinjuryandinjuriesinvolvingthepleuralspace（胸腔）Pulmonarycontusion

Pulmonarylaceration

Pneumothorax

Hemothorax

Hemopneumothorax

pneumothoraxhemothoraxPulmonarycontusion肺挫伤

肺裂伤

气胸

血胸

血气胸

14胸部外伤精选文档ClosedPneumothoraxOccurswhenlungtissueisdisruptedandairleaksintothepleuralspaceProgressivePathologyAiraccumulatesinpleuralspaceLungcollapsesAlveolicollapseReducedoxygenandcarbondioxideexchangeVentilation/PerfusionMismatchIncreasedventilationbutnoalveolarperfusionReducedrespiratoryefficiencyresultsinHYPOXIAOpenPneumothoraxFreepassageofairbetween

atmosphereandpleural

spaceAirreplaceslungtissueMediastinum（纵膈）shiftsto

uninjuredsideAirwillbedrawnthrough

woundifwoundis2/3

diameterofthetracheaor

largerSigns&SymptomsPenetratingchesttraumaSucking（吮吸）chestwoundFrothybloodatwoundsiteSevereDyspnea（严重呼吸困难）Hypovolemia（低血容量）TensionPneumothoraxBuildupofairunderpressureinthethorax.Excessivepressurereduces

effectivenessofrespirationAirisunabletoescapefrom

insidethepleuralspaceProgressionofSimpleorOpen

PneumothoraxPneumothoraxNeedemergenttreatment15胸部外伤精选文档TensionPneumothoraxSigns&SymptomsDyspneaTachypnea（呼吸过速）atfirstProgressiveventilation/perfusionmismatchAtelectasisonuninjuredsideHypoxemiaDiminishedthenabsentbreathsoundsoninjuredsideCyanosisDiaphoresisHypotensionHypovolemiaTrachealShifting低氧血症

呼吸音减低

紫绀

发汗

低血压

低血容量

气管移位健侧肺不张

呼吸困难通气/灌注不匹配16胸部外伤精选文档血液聚集在胸膜腔内严重者失血量大于1500ml死亡率75%每侧胸腔可以容纳3000ml导致潮气量降低灌注/通气失调&休克常合并气胸血气胸HemothoraxSigns&SymptomsShockDyspnea（呼吸困难）Tachycardia(心动过速)Tachypnea（呼吸过速）Diaphoresis（出汗）HypotensionDulltopercussion（叩诊）overinjuredside17胸部外伤精选文档CardiovascularInjuriesOccursin76%ofpatientswithseverebluntchesttraumaRightAtrium（心房）andVentricle（心室）iscommonlyinjuredInjurymayreducestrengthofcardiaccontractions---ReducedcardiacoutputElectricalDisturbancesduetoirritabilityofdamagedmyocardialcellsProgressiveProblemsHematomaHemoperitoneumMyocardialnecrosisDysrhythmiasCHF&orCardiogenicshockMyocardialContusion血肿

腹腔积血

心肌坏死

心律失常

充血性心衰及或心源性休克

Bruisingofchestwall

Tachycardiaand/orirregularrhythm

Retrosternal（胸骨后）painsimilartoMI

Chestpainunrelievedbyoxygen

MayberelievedwithrestSigns&Symptoms心肌损伤18胸部外伤精选文档PericardialTamponadeRestrictiontocardiacfillingcausedbybloodorotherfluidwithinthepericardiumOccursin<2%ofallseriouschesttraumaHowever,veryhighmortalityResultsfromtearinthecoronaryarteryorpenetrationofmyocardiumBloodseepsintopericardiumandisunabletoescape200-300mlofbloodcanrestricteffectivenessofcardiaccontractionsRemovingaslittleas20mlcanprovidereliefSigns&SymptomsDyspnea呼吸苦难PossiblecyanosisBeck’s三联征心音遥远奇脉脉压差增大19胸部外伤精选文档MyocardialAneurysmorRuptureOccursalmostexclusivelywithextremebluntthoracictraumaSecondaryduetonecrosisresultingfromMISevereriborsternal

（胸骨）fracturePossiblesignsandsymptomsof

cardiactamponadeIfaffectsvalves（瓣膜）only

Signs&symptomsofrightorleftheartfailureAbsenceofvitalsignsSigns&Symptoms钝性伤致心脏破裂病人20胸部外伤精选文档OtherVascularInjuriesTraumaticAneurysm（动脉瘤）orAortic（主动脉）Rupture

RuptureorlacerationSuperiorVenaCava上腔静脉InferiorVenaCava下腔静脉GeneralThoracicVasculature胸腔大血管BloodLocalizinginMediastinum胸膜局部出血Compressionof:Greatvessels大血管Myocardium心肌Esophagus食管GeneralSigns&SymptomsPenetratingTrauma贯穿伤Hypovolemia&Shock容量不足或休克Hemothoraxorhemomediastinum血胸或血气胸21胸部外伤精选文档胸腹多发伤thoracoabdominalmultipleinjuries胸腹复合伤（是否伴有膈肌的损伤）

thoracoabdominalcombinedinjuries石应康，杨建.外科学（第七版）理解一个概念23胸部外伤精选文档胸外伤病人的评估24胸部外伤精选文档SceneSize-up环境评估InitialAssessment初步评估RapidTraumaAssessment快速评估ObserveQuestionPalpate（触诊）Auscultate（听诊）Percuss（视诊）BluntTraumaAssessmentPenetratingTraumaAssessmentOngoingAssessment持续评估评估程序25胸部外伤精选文档如何评定胸外伤的程度？创伤评分

多种评分系统孰优孰劣？Thisisaproblem!!!26胸部外伤精选文档PulmonaryContusionscore(PCS)2019,Tyburskietal.Wagner-score1989WagnerandJamiesonThoracicTraumaSeverityscore(TTS)2000

PapeHCetal.Conclusions：Thoracictraumascorescombininganatomicalandphysiologicparameters（参数）liketheTTSseemtobemostsuitableforseverityassessmentandpredictionofoutcomeinmultipletraumapatientswithconcomitantbluntchesttrauma.MommsenP,ZeckeyC,AndruszkowH,etal.ComparisonofDifferentThoracicTraumaScoringSystemsinRegardstoPredictionofPost-TraumaticComplicationsandOutcomeinBluntChestTrauma.JSurgRes.1–9(2019)Oct5

Twohundredseventy-eightmultipletraumapatients

onlytheTTSwasanindependentpredictorofmortality.WiththeTTSshowingthebestpredictionpower,theTTS,PCS,andWagner-scorewereindependentpredictorsofventilationtime,lengthofICUstay,andthedevelopmentofpost-traumaticARDSandMODS.assess27胸部外伤精选文档

EsmeH,SolakO,YurumezY，etal.Theprognosticimportanceoftraumascoringsystemsforbluntthoracictrauma.ThoracCardiovascSurg.2019Apr;55(3):190-5.RevisedTraumaScore[RTS]TraumaandInjurySeverityScore[TRISS]InjurySeverityScore[ISS]LungInjuryScale[LIS]ChestWallInjuryScale[CWIS])152patientswithbluntthoracictraumaassessonlyTRISSwasanindependentpredictorofmortalityonlyLISwasanindependentpredictorofmorbidity,theneedforthoracotomy,andtubethoracostomyduration.

TRISSandLISwereindependentpredictorsofthelengthofICUstay.ISS,CWIS,andLISwereindependentpredictorsoftheneedformechanicalsupport.RTS,TRISS,ISSandLISwereindependentpredictorsofthe