医学课件胸部外伤2

胸外伤进展泸州医学院附属医院于风旭

Incidenceandmortality:

Chesttraumaaccountsfor8%occurrencesoftotaltraumaticcases,morethan25%ofdeathcausedbytrauma.IncidenceproportionMortalityproportion胸外伤概况胸外伤病因PenetratingtraumaBlunttrauma车祸伤坠落伤挤压伤刀刺伤火器伤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LowEnergyArrows,knives,handgunsInjurycausedbydirectcontactandcavitationHighEnergyMilitary,huntingrifles&highpoweredhandgunsExtensiveinjuryduetohighpressurecavitationPenetratingTrauma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

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胸外伤详细分类及病理生理改变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Injuriestothechestwall

ContusionDyspneaPainonbreathingHypoventilationCrepitusParadoxicalchestwallmotion呼吸困难

呼吸疼痛

通气不足

捻发音

胸壁矛盾运动

RibFractures>50%ofsignificantchesttraumacasesduetoblunttraumaCompressionalforcesflexandfractureribsatweakestpointsRibs1-3requiresgreatforcetofracturePossibleunderlyinglunginjuryRibs4-9aremostcommonlyfracturedRibs9-12lesslikelytobefracturedTransmitenergyoftraumatointernalorgansIffractured,suspectliverandspleeninjuryHypoventilationisCOMMONduetoPAINSternalFracture&Dislocation（胸骨骨折和错位）AssociatedwithseverebluntanteriortraumaDirectBlow(比如：方向盘)Incidence:5-8%Mortality:25-45%MyocardialcontusionPericardialtamponadeCardiacrupturePulmonarycontusionDislocationuncommonbutsameMOIasfractureTrachealdepressionifposteriorFlailChest(连枷胸)SegmentofthechestthatbecomesfreetomovewiththepressurechangesofrespirationThreeormoreadjacentribfractureintwoormoreplacesSeriouschestwallinjurywithunderlyingpulmonaryinjuryReducesvolumeofrespirationAddstoincreasedmortalityParadoxicalflailsegmentmovementPositivepressureventilationcanrestoretidalvolumePulmonaryinjuryandinjuriesinvolvingthepleuralspace

Pulmonarycontusion

Pulmonarylaceration

Pneumothorax

Hemothorax

Hemopneumothorax

pneumothoraxhemothoraxPulmonarycontusion肺挫伤

肺裂伤

气胸

血胸

血气胸

ClosedPneumothoraxOccurswhenlungtissueisdisruptedandairleaksintothepleuralspaceProgressivePathologyAiraccumulatesinpleuralspaceLungcollapsesAlveolicollapseReducedoxygenandcarbondioxideexchangeVentilation/PerfusionMismatchIncreasedventilationbutnoalveolarperfusionReducedrespiratoryefficiencyresultsinHYPOXIAOpenPneumothoraxFreepassageofairbetweenatmosphereandpleuralspaceAirreplaceslungtissueMediastinumshiftstouninjuredsideAirwillbedrawnthroughwoundifwoundis2/3diameterofthetracheaorlargerSigns&SymptomsPenetratingchesttraumaSuckingchestwoundFrothybloodatwoundsiteSevereDyspnea（严重呼吸困难）Hypovolemia（低血容量）TensionPneumothoraxBuildupofairunderpressureinthethorax.ExcessivepressurereduceseffectivenessofrespirationAirisunabletoescapefrominsidethepleuralspaceProgressionofSimpleorOpenPneumothoraxPneumothoraxNeedemergenttreatmentTensionPneumothoraxSigns&SymptomsDyspneaTachypneaatfirstProgressiveventilation/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&SymptomsShockDyspneaTachycardiaTachypneaDiaphoresis（出汗）HypotensionDulltopercussionoverinjuredsideCardiovascularInjuriesOccursin76%ofpatientswithseverebluntchesttraumaRightAtriumandVentricleiscommonlyinjuredInjurymayreducestrengthofcardiaccontractions---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

BruisingofchestwallTachycardiaand/orirregularrhythm

RetrosternalpainsimilartoMI

Chestpainunrelievedbyoxygen

MayberelievedwithrestSigns&SymptomsPericardialTamponadeRestrictiontocardiacfillingcausedbybloodorotherfluidwithinthepericardiumOccursin<2%ofallseriouschesttraumaHowever,veryhighmortalityResultsfromtearinthecoronaryarteryorpenetrationofmyocardiumBloodseepsintopericardiumandisunabletoescape200-300mlofbloodcanrestricteffectivenessofcardiaccontractionsRemovingaslittleas20mlcanprovidereliefSigns&SymptomsDyspneaPossiblecyanosisBeck’s三联征心音遥远HypotensionShockKussmaul’ssignPulsusParadoxus（奇脉）MyocardialAneurysmorRuptureOccursalmostexclusivelywithextremebluntthoracictraumaSecondaryduetonecrosisresultingfromMISevereriborsternalfracturePossiblesignsandsymptomsofcardiactamponadeIfaffectsvalvesonly

Signs&symptomsofrightorleftheartfailureAbsenceofvitalsignsSigns&Symptoms我院近五年一共收治3例钝性伤致心脏破裂病人OtherVascularInjuriesTraumaticAneurysmorAorticRupture

RuptureorlacerationSuperiorVenaCavaInferiorVenaCavaGeneralThoracicVasculatureBloodLocalizinginMediastinumCompressionof:GreatvesselsMyocardiumEsophagusGeneralSigns&SymptomsPenetratingTraumaHypovolemia&ShockHemothoraxorhemomediastinumOtherThoracicInjuriesTraumaticEsophagealRuptureTracheobronchialInjuryTraumaticAsphyxia（创伤性窒息）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）理解一个概念胸外伤病人的评估SceneSize-upInitialAssessmentRapidTraumaAssessmentObserveQuestionPalpate（触诊）Auscultate（听诊）Percuss（视诊）BluntTraumaAssessmentPenetratingTraumaAssessmentOngoingAssessment评估程序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!!!PulmonaryContusionscore(PCS)1999,Tyburskietal.Wagner-score1989WagnerandJamiesonThoracicTraumaSeverityscore(TTS)2000

PapeHCetal.Conclusions：ThoracictraumascorescombininganatomicalandphysiologicparametersliketheTTSseemtobemostsuitableforseverityassessmentandpredictionofoutcomeinmultipletraumapatientswithconcomitantbluntchesttrauma.MommsenP,ZeckeyC,AndruszkowH,etal.ComparisonofDifferentThoracicTraumaScoringSystemsinRegardstoPredictionofPost-TraumaticComplicationsandOutcomeinBluntChestTrauma.JSurgRes.1–9(2011)Oct5

Twohundredseventy-eightmultipletraumapatients

onlytheTTSwasanindependentpredictorofmortality.WiththeTTSshowingthebestpredictionpower,theTTS,PCS,andWagner-scorewereindependentpredictorsofventilationtime,lengthofICUstay,andthedevelopmentofpost-traumaticARDSandMODS.assess

EsmeH,SolakO,YurumezY，etal.Theprognosticimportanceoftraumascoringsystemsforbluntthoracictrauma.ThoracCardiovascSurg.2007Apr;55(3):190-5.RevisedTraumaScore[RTS]TraumaandInjurySeverityScore[TRISS]InjurySeverityScore[ISS]LungInjuryScale[LIS]ChestWallInjuryScale[CWIS])152patientswithbluntthoracictraumaassessonlyTRISSwasanindependentpredictorofmortalityonlyLISwasanindependentpredictorofmorbidity,theneedforthoracotomy,andtubethoracostomyduration.

TRISSandLISwereindependentpredictorsofthelengthofICUstay.ISS,CWIS,andLIS