胸部外伤文档培训课件.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,胸部外伤精选文档,*,胸部外伤精选文档,Incidence and mortality发生率和死亡率:,Chest trauma accounts for 8%occurrences of total traumatic cases,more than 25%of death caused by trauma.,Incidence proportion,Mortality proportion,胸外伤概况,2,胸部外伤精选文档,胸外伤病因,Penetrating trauma贯穿伤,Blunt trauma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,Results from kinetic energy forces,Blast,（爆破伤）,Pressure wave causes tissue disruption,Tear blood vessels&disrupt alveolar tissue,Disruption of tracheobronchial tree,Traumatic diaphragm rupture,Crush(Compression,)（挤压伤）,Body is compressed between an object and a hard surface,Direct injury of chest wall and internal structures,Deceleration,（减速伤）,Body in motion strikes a fixed object,Blunt trauma to chest wall,Internal structures continue in motion,Ligamentum Arteriosum,shears aorta,Blunt Trauma,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,Low Energy,Arrows,knives,handguns,Injury caused by direct contact and cavitation,High Energy,Military,hunting rifles&high powered hand guns,Extensive injury due to high pressure cavitation,Penetrating Trauma,5,胸部外伤精选文档,穿透伤合并损伤,Closed pneumothorax,Open pneumothorax,Tension pneumothorax,Pneumomediastinum,Hemothorax,Hemopneumothorax,Laceration of vascular structures,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,Tracheobronchial tree lacerations,Esophageal lacerations,Penetrating cardiac injuries,Pericardial tamponade,Spinal cord injuries,Diaphragm trauma,Intra-abdominal penetration with associated organ injury,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,Chest wall,contusions,or,hematomas,胸壁挫伤或血肿,Rib fractures,肋骨骨折,Flail chest,连枷胸,Sternal fractures,胸骨骨折,Fractures,of the,shoulder girdle,肩胛带骨折,Injuries to the,chest wall,9,胸部外伤精选文档,Contusion,D,yspnea,P,ain,on breathing,H,ypoventilation,Crepitus,Paradoxical chest wall motion,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,Rib Fractures,50%of significant chest trauma cases due to blunt trauma,Compressional forces flex and fracture ribs at weakest points,Ribs 1-3 requires great force to fracture,Possible underlying lung injury,Ribs 47 are most commonly fractured,Ribs 11-12 less likely to be fractured,Transmit energy of trauma to internal organs,If fractured,suspect liver and spleen injury,Hypoventilation,（肺换气不足）,is COMMON due to PAIN,11,胸部外伤精选文档,Sternal Fracture&Dislocation,（胸骨骨折和错位）,Associated with severe blunt anterior trauma,Direct Blow(比如：方向盘),Incidence:5-8%,Mortality:25-45%,Myocardial contusion（心肌的钝挫伤）,Pericardial tamponade（心包填塞）,Cardiac rupture（心脏破裂）,Pulmonary contusion（肺挫伤）,Dislocation uncommon but same MOI as fracture,Tracheal（气管）depression if posterior,12,胸部外伤精选文档,Flail Chest(连枷胸),Segment of the chest that becomes free to move with the pressure changes of respiration,Three or more adjacent,（毗邻的）,rib fracture in two or more places,Serious chest wall injury with underlying pulmonary injury（潜在的肺损伤）,Reduces volume of respiration,Adds to increased mortality,Paradoxical flail segment movement（反常呼吸运动）,Positive pressure ventilation（通气）can restore tidal volume（潮气量）,13,胸部外伤精选文档,Pulmonary injury and injuries involving the,pleural space,（胸腔）,Pulmonary contusion,Pulmonary laceration,Pneumothorax,Hemothorax,Hemopneumothorax,pneumothorax,hemothorax,Pulmonary contusion,肺挫伤肺裂伤气胸血胸血气胸,14,胸部外伤精选文档,Closed Pneumothorax,Occurs when lung tissue is disrupted and air leaks into the pleural space,Progressive Pathology,Air accumulates in pleural space,Lung collapses,Alveoli collapse,Reduced oxygen and carbon dioxide exchange,Ventilation/Perfusion Mismatch,Increased ventilation but no alveolar perfusion,Reduced respiratory efficiency results in,HYPOXIA,Open Pneumothorax,Free passage of air between,atmosphere and pleural,space,Air replaces lung tissue,Mediastinum,（纵膈）,shifts to,uninjured side,Air will be drawn through,wound if wound is 2/3,diameter of the trachea or,larger,Signs&Symptoms,Penetrating chest trauma,Sucking,（吮吸）,chest wound,Frothy blood at wound site,Severe Dyspnea,（严重呼吸困难）,Hypovolemia,（低血容量）,Tension Pneumothorax,Buildup of air under pressure in the thorax.,Excessive pressure reduces,effectiveness of respiration,Air is unable to escape from,inside the pleural space,Progression of Simple or Open,Pneumothorax,Pneumothorax,Need emergent treatment,15,胸部外伤精选文档,Tension Pneumothorax Signs&Symptoms,Dyspnea,Tachypnea,（,呼吸过速,）,at first,Progressive ventilation/perfusionmismatch,Atelectasis on uninjured side,Hypoxemia,Diminished then absent breath sounds on injured side,Cyanosis,Diaphoresis,Hypotension,Hypovolemia,Tracheal Shifting,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 3000 ml,导致潮气量降低,灌注/通气失调,&,休克,常合并气胸,血气胸,Hemothorax,Signs&Symptoms,Shock,Dyspnea,（,呼吸困难）,Tachycardia,(心动过速),Tachypnea,（呼吸过速）,Diaphoresis,（出汗）,Hypotension,Dull to percussion叩诊）,over injured side,17,胸部外伤精选文档,Cardiovascular Injuries,Occurs in 76%of patients with severe blunt chest trauma,Right Atrium,（心房）,and Ventricle,（心室）,is commonly injured,Injury may reduce strength of cardiac contractions-,Reduced cardiac output,Electrical Disturbances due to irritability of damaged myocardial cells,Progressive Problems,Hematoma,Hemoperitoneum,Myocardial necrosis,Dysrhythmias,CHF&or Cardiogenic shock,Myocardial Contusion,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,Bruising of chest wall,Tachycardia and/or irregular rhythm,Retrosternal,（胸骨后）,pain similar to MI,Chest pain unrelieved by oxygen,May be relieved with rest,Signs&Symptoms,心肌损伤,18,胸部外伤精选文档,Pericardial Tamponade,Restriction to cardiac filling caused by blood or other fluid within the pericardium,Occurs in 2%of all serious chest trauma,However,very high mortality,Results from tear in the coronary artery or penetration of myocardium,Blood seeps into pericardium and is unable to escape,200-300 ml,of blood can,restrict,effectiveness of,cardiac contractions,Removing as little as 20 ml can provide relief,Signs&Symptoms,Dyspnea呼吸苦难,Possible cyanosis,Becks 三联征,心音遥远,奇脉,脉压差增大,19,胸部外伤精选文档,Myocardial Aneurysm or Rupture,Occurs almost exclusively with,extreme blunt thoracic trauma,Secondary due to necrosis resulting from MI,Severe rib or,sternal,（,胸骨,）,fracture,Possible signs and symptoms of,cardiac,tamponade,If affects valves,（,瓣膜）,only,Signs&symptoms of right or left heart failure,Absence of vital signs,Signs&Symptoms,钝性伤致心脏破裂病人,20,胸部外伤精选文档,Other Vascular Injuries,Traumatic Aneurysm,（动脉瘤）,or Aortic,（主动脉）,Rupture,Rupture or laceration,Superior Vena Cava上腔静脉,Inferior Vena Cava下腔静脉,General Thoracic Vasculature胸腔大血管,Blood Localizing in Mediastinum胸膜局部出血,Compression of:,Great vessels大血管,Myocardium心肌,Esophagus食管,General Signs&Symptoms,Penetrating Trauma贯穿伤,Hypovolemia&Shock容量不足或休克,Hemothorax or hemomediastinum血胸或血气胸,21,胸部外伤精选文档,胸腹多发伤,thoracoabdominal multiple injuries,胸腹复合伤,（,是否伴有膈肌的损伤,）,thoracoabdominal combined injuries,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,Scene Size-up环境评估,Initial Assessment初步评估,Rapid Trauma Assessment快速评估,Observe,Question,Palpate（触诊）,Auscultate（听诊）,Percuss（视诊）,Blunt Trauma Assessment,Penetrating Trauma Assessment,Ongoing Assessment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？,This is a problem!,26,胸部外伤精选文档,Pulmonary Contusion score,(PCS),2019,Tyburski,et al.,Wagner-score,1989 Wagner and Jamieson,Thoracic Trauma Severity score,(TTS),2000,Pape,HC et al.,Conclusions：,Thoracic trauma scores combining anatomical and physiologic parameters（参数）like the TTS seem to be most suitable for severity assessment and prediction of outcome in multiple trauma patients with concomitant blunt chest trauma.,Mommsen P,Zeckey C,Andruszkow H,et al.,Comparison of Different Thoracic Trauma Scoring Systems in Regards to Prediction of Post-Traumatic Complications and Outcome in Blunt Chest Trauma.,J Surg Res.,19(2019)Oct 5,Two hundred seventy-eight multiple trauma patients,only the TTS was an independent predictor of mortality.With the TTS showing the best prediction power,the TTS,PCS,and Wagner-score were independent predictors of ventilation time,length of ICU stay,and the development of post-traumatic ARDS and MODS.,assess,27,胸部外伤精选文档,Esme H,Solak O,Yurumez Y,，et al.The prognostic importance of trauma scoring systems for blunt thoracic trauma.,Thorac Cardiovasc Surg.,2019 Apr;55(3):190-5.,Revised Trauma Score RTS,Trauma and Injury Severity Score TRISS,Injury Severity Score ISS,Lung Injury Scale LIS,Chest Wall Injury Scale CWIS),152 patients with blunt thoracic trauma,assess,only TRISS was an independent predictor of mortality,only LIS was an independent predictor of morbidity,the need for thoracotomy,and tube thoracostomy duration.,TRISS and LIS were independent predictors of the length of ICU stay.,ISS,CWIS,and LIS were independent predictors of the need for mechanical support.,RTS,TRISS,ISS and LIS were independent predictors of the length of hospital stay.,CONCLUSIONS:,The LIS grade appeared to correlate with the severity of blunt thoracic injury and was found to be the most useful scoring system in predicting the outcomes of these patients,28,胸部外伤精选文档,结论：,PTTCS方法对PTT结局的预测效果优于RTS。,胸部穿透伤进程评分(PTT,CS,),修订创伤评分（,RT,S）,梁贵友;石应康;杨建;张尔永;胸部穿透伤损伤严重度新评分方法初探.中华创伤杂志，2019,1 018例,胸部穿透伤,患者,assess,新评分方法的数学模型为：,与 RTS比较，PTTCS预测PTT结局的敏感性、特异性和准确性显著提高，死亡误判率明显降低。PTTCS分值与患者的死亡率呈现明显的负相关关系。,29,胸部外伤精选文档,胸外伤的诊断,30,胸部外伤精选文档,诊断方法：,诊断性胸腔穿刺,X-ray,CT,超声,diagnostic,thoracocentesis,诊断性心包穿刺,diagnostic,pericardiocentesis,31,胸部外伤精选文档,胸外伤种类的诊断,依据辅助检查和查体可以完成。,严重程度诊断,？,指导治疗措施的选择,急诊剖胸探查,单纯胸腔闭式引流,无需特殊处理,32,胸部外伤精选文档,胸外伤的治疗,33,胸部外伤精选文档,呼吸支持,气管插管或气管切开，呼吸机辅助呼吸,气胸处置,出血处置,合并伤处置,先重后轻，先急后缓的原则,胸外伤处理的基本原则,AUSCULTATE!AUSCULATE!AUSCULATE!,34,胸部外伤精选文档,Chest wall injury,稳定断端,包扎固定,牵引固定,内固定,止痛,35,胸部外伤精选文档,VATS在胸外伤诊治中的应用,气胸、血胸、血管损伤的诊断和治疗,。,36,胸部外伤精选文档,Thanks,37,胸部外伤精选文档,