创伤的病理生理1.ppt

SectionIIIPathophysiologyoftrauma创伤的病理生理创伤的病理生理heat热redness红swelling肿pain痛lossoffunction功能丧失1.Inflammation炎症Inflammatorycells炎性细胞炎性细胞 Inflammatorycytokines炎性因子炎性因子sitmulateInjury外伤刺激plasma血浆cytokine细胞因子protein蛋白IGF-1类胰岛素生长因子-1FGF成纤维细胞生长因子TNF肿瘤坏死因子fibronectin纤维连接蛋白fibrin纤维蛋白cells细胞neutrophils嗜中性粒细胞macrophage巨噬细胞lymphocyte淋巴细胞platelet血小板capillary毛细血管毛细血管Inflammationaftertrauma创伤后炎症nSystemicInflammatoryResponseSyndrome(SIRS)全身炎症反应综合征nCompensatoryAnti-inflammatoryResponseSyndrome(CARS)代偿性抗炎症反应综合征nTraumaandbacteriacancauseinflammation创伤和细菌可引起炎症nThisprocessinvolvemanycellsandcytokine这个过程涉及到许多细胞及细胞因子inflammationstaging炎症分段(2)Limited stage of systemic inflammatory response 局限的全身炎症反应(3)SIRS/CARS the stage is imbalance SIRS/CARS阶段不平衡KillingbacteriaandtoxinsRemovalofnecroticcells,PromotetissuerecoveryProinflammatory and anti-inflammatory is banlanced,pro-inflammatory slightly the upper hand(1)Partial reaction 局部反应局部反应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SIRSCARSUncontrolledsystemicinflammatoryresponsesyndrome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nBodytemperature（体温）38nHeartrate（心率）90/minnBreathe（呼吸）nBloodcellcount（血细胞计数）12109/L20/minTypes of inflammatory mediators炎性介质的类型炎性介质的类型Cytokines细胞因子nTumor necrosis factor(TNF)肿瘤坏死因子nInterleukin 白介素nInterferon(ITF)干扰素nGrowth factor-(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多器官功能障碍综合征周荣斌周荣斌促促炎炎介介质质过过度度产产生生原始病因原始病因感感染染损损伤伤抗抗炎炎介介质质过过度度产产生生全 身 反 应 全身炎症反应综合征全身炎症反应综合征 （SIRS）代偿性炎症反应综合征（代偿性炎症反应综合征（CARS）混合性抗炎反应综合征（混合性抗炎反应综合征（MARS）平 衡 SIRS、CARS细胞调亡 SIRS过度过度免疫功能障碍 CARS过度过度 MODSSIRS过度过度休 克 SIRS过度过度局部促炎介质局部抗炎介质 SIRS临床发病过程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.Wound healing 创伤的愈合创伤的愈合nWoundhealingiscomposedofseveralsteps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nTheprocessismediatedbyavarietyofgrowthfactors.各种生长因子参与nPrimaryhealingandsecondaryhealing一期愈合、二期愈合What is Tissue Repair?组织修复nTheprocesstoreplaceinjuredordeadcellsandtorepairtissuesafterinflammation.炎症后，取代受伤或死亡细胞、修复组织的过程nTypesofT.R组织修复的类型completeT.R完全愈合incompleteT.R不完全愈合What is Regeneration?再生nThe process of the replacement of injured cells by cells of the same type.损伤细胞被周围同种细胞更换的过程 What is granulation?肉芽组织肉芽组织nDuringthecourseofhealing,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nItincludes:small blood vessels（小血管）fibroblasts （纤维母细胞）inflammatory cells（炎性细胞）What is angiogenesis?血管生成血管生成nAngiogenesisisnecessaryfeatureofrepairandstartedfrompreexistingvenules,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PreexistingvenulesWhat is epithelialization?上皮形成上皮形成nEpithelialcellsisstimulatedbyavarietyofgrowthfactors,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The process of repair 修复的过程修复的过程ncoagulationandinflammation凝聚、炎症nMatrixdepositionandgranulation基质沉淀、肉芽组织nAngiogenesis血管再生nEpithelialization上皮形成nCollagenmaturation胶原蛋白成熟nWoundcontraction伤口收缩Types of wound healing 伤口愈合的类型伤口愈合的类型Primary healing一期愈合nsmall,cleanandlesstissuedamage.伤口小，清洁，较少组织损伤nbystitching,mildinflammatoryreaction.通过缝合，轻度炎症反应nepidermalregeneration,asmallamountofgranulationtissue,fewscars.表皮再生，少量肉芽组织，几乎无瘢痕Primaryhealing一期愈合一期愈合Types of wound healing 伤口愈合的类型伤口愈合的类型Secondaryhealing二期愈合二期愈合nLargewound伤口范围大伤口范围大nNecrotictissueandinflection组织坏死、变形组织坏死、变形nGranulationtissuefilledthewound肉芽组织填充伤口肉芽组织填充伤口nBigscars瘢痕大瘢痕大 nNutrition 营养水平 nMetabolic status 代谢状态nCirculatory status 循环状态nHormones 激素水平Systemicfactors全身因素全身因素Localfactors局部因素局部因素Infection感染感染Wounddefect伤口缺损伤口缺损Foreignbodies异物异物Size,location,andtypeofwound 伤口大小、位置、类型伤口大小、位置、类型plicationoftrauma创伤创伤并发症并发症 n 感染感染n 休克休克n脂肪栓塞综合症脂肪栓塞综合症n应激性溃疡应激性溃疡n凝血功能障碍凝血功能障碍n器官功能障碍器官功能障碍TraumahistoryexaminationSysmeticphysicalcheckAdjunctiveobservationCloseandcontinuous创伤史创伤史体格检查体格检查辅助检查辅助检查密切监测、持续观察密切监测、持续观察SectionIVTraumadiagnosis创伤的诊断创伤的诊断25.Relationshipbetweensystemicandlocal系统与局部的关系系统与局部的关系nSystemicdiagnosis（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nLocaldiagnosis（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nSystemicdiagnosisbethemostimportant系统诊断尤为重要26.nRespiration呼吸呼吸respiratoryrate:25/15/min,cyanosis.呼吸频率呼吸频率 25/1525/15次次/分，发绀分，发绀nBloodpressureandpulserate血压、脉率血压、脉率pulserate100/min,bloodpressure100/min100/min，血压，血压90mmHg90mmHgnConsciousnessandpupilsmotion意识、瞳孔意识、瞳孔nGlasgowscaleandCRAMS GlasgowGlasgow昏迷评分法昏迷评分法/CRAMS/CRAMS评分评分Generalphysicalexamination(Fivevitalsigns)一般体格检查（五项生命体征）27.Localwoundinspectionprinciples局部伤口检查的原则局部伤口检查的原则 nwoundsize,depthandshape伤口大小、深度、形状nwoundcontamination伤口污染情况nwoundtraits伤口特性nbloodvesseldamageandbleeding血管损伤及出血情况nforeignbodiesinthewound.伤口中异物情况nwhetherinvolvedeepviscusinjuryornot是否涉及腹部深层脏器损伤28.nExperimentalpuncture诊断性穿刺abdominocentesis腹腔穿刺thoracentesis胸腔穿刺nExploratorysurgery探查术nAdjunctivecheck辅助检查imaging:CTMRIX-ray成像：CT、MRI、X线Blunttraumaexamination(closewoundcheck)闭合性创伤检查29.Abdominocentesis腹腔穿刺术30.Thoracentesis胸腔穿刺术胸腔穿刺术injectorDiagnosticpuncturetodeterminewhetherthechestcavityfluid(orgas),andsenttothelaboratorypuncturefluidandpathologicalexaminationtodeterminethenatureandcauseofeffusion.诊断性穿刺后将穿刺诊断性穿刺后将穿刺液送检，可以确定液送检，可以确定胸腔积液（气）的胸腔积液（气）的性质和病因性质和病因31.休息一会儿休息一会儿.32.