上交大外科學(xué)課件13創(chuàng)傷

創(chuàng)傷

trauma1Trauma：Traumaisdefinedasthedamagecausedbymechanicalinjuriousagents,withthe

disturbance

oftissuecontinuityandfunction.Vessel

SkininjuriousfactorsClassification1Accordingtotheintegrityofskin：

Damaged----openwounds（開放性創(chuàng)傷）

Intact----closedwounds(閉合性創(chuàng)傷)

openwoundsPenetratingwound(穿入傷)Perforatingwound(穿透?jìng)?Non-penetratingwound(非穿入傷)severalfamiliaropenwoundsAbrasion(擦傷)Puncture(刺傷)severalfamiliaropenwoundsIncisionorcutwound(切傷和砍傷)Laceration(撕裂傷)ClosedwoundsContusion(挫傷)Crushinjury(擠壓傷)Sprain(扭傷)Concussion(震蕩傷)Luxationandsemi-luxation(脫位和半脫位)Closedbonefracture(閉合性骨折)Closedinternalinjury(閉合性內(nèi)傷)fracture2AccordingtopositionsCraniocerebralinjury(顱腦傷)Maxillofacialandcervicalinjury(頜面頸部傷)Chestinjury(胸部傷)Abdomeninjury(腹部傷)Pelvisinjury(骨盆部傷)Spineandspinalcordinjury(脊柱脊髓傷)Upperextremityinjury(上肢傷)Lowerextremityinjury(下肢傷)Multipleinjury(多發(fā)傷)epiduralhematomaCraniocerebraltrauma3AccordingtoinjuriousfactorsColdweaponwounds(冷兵器傷)Firearmwounds(火器傷)Burns(燒傷)Coldinjury(冷傷)Blastinjury(沖擊傷)Chemicalinjury(化學(xué)傷)Radiationinjury(放射傷)Combinedinjury(復(fù)合傷)burnsColdinjuryTraumaPathologytraumadamageofthetissuestructurehemorrhageinactivationofcelllocal:inflammation,cellularproliferationsystemicchanges:bloodfilm,bodytemperature,functionofimportantorgans,1InflammatoryreactionLocal：hyperemia,edema,exudation(redness,swelling,heat,pain)Benefit:

1.Proliferativecellsfillthedeficit,facilitingthewoundhealing.2.Itclearsthe

bacteria,tissuefragmentandforeignbodycanpromotethehealingprocedure.Harm:

Severeinflammatoryreactionresultsindelayedhealinganddisturbanceofcirculation.Excessiveexudationcausestheinsufficienceofbloodvolume.

brady-kinincomple-mentsHistamineinterferonTNFPAFReleaseofvariousinflammatorymediatorsandcytokinesproductofdamagedtissueandbacterialtoxinPathology2Systemicreaction1）bodytemperature：

inflammatorymediators,infections

heatcenter

bodytemperature:riseordescendPathology2Systemicreaction1）Bodytemperature2）Neuroendocrine

pains,stress,losebloodandwaterHypothalamus

----ACTH，ADH，GHPituitaryglandSynpatheticNerves--renin，nonadrenaline，aldosteroneAdrenalglandheartratearises,vasoconstriction,urinevolumesdecreasePathology2Systemicreaction1）Bodytemperaturereaction

2）Neuro-endocrinereaction

3）Changesofcatabolism

decompositionof

proteinandadiposeincreasecatecholamine,corticosteroids,glucagon,TNFs,ILsincrease

energy,proteinweightloss,myatheniacatabolismaccentuation（肌無力）兒茶酚胺皮質(zhì)激素胰高糖素Pathology2Systemicreaction1）bodytemperature2）neuro-endocrinereactions

3）changesofmetabolism4）changesofimmunesystemendogenouscorticosteroidsdecreasethefunctionsofNeutrophilsandPhagocyteCatecholamine（兒茶酚胺）

PGE2（前列腺素）

immune

suppressionPathology1Inflammatoryreactions2Systemicreactions3Complicationsoftraumatissueinjury,bacteria,immunesuppression:Infectionbloodloss,infection:Shock

infection,shock,organdammage:MODSrepairThefunctionsofcellintheprocessofwoundhealing

Neutrophil(中性粒細(xì)胞)Macrophage(巨噬細(xì)胞)Platelet（血小板）Lymphocyte(淋巴細(xì)胞)

Inflammatoryreactionstage:PDGF,TGF-α,bFGF,MDGFtissueproliferationstage:IGF-1,bFGF,TGF-β,PDGFscarformationstage:TGF-β,PDGFThefunctionsofgrowthfactorintheprocessofwoundhealing

ParticipateincoagulationprocessEnhancethefunctionofmacrophageChemotaxis(趨化作用)Thefunctionsoffibronectin(Fn)

(纖維連接蛋白)repairproliferationmesenchymaltissuefillthedeficit細(xì)胞增生細(xì)胞間質(zhì)充填連接Processofrepair1）fibrinfillingsealingthewound（纖維蛋白充填）Hemostasis（止血）Processofrepair2）proliferation（細(xì)胞增生）Fibroblast成纖維細(xì)胞endothelialcells

內(nèi)皮細(xì)胞neogeneticvessels新生血管granuloma肉芽腫processofrepairCollagen（膠原）Amino-polysaccharide（氨基多糖）基質(zhì)沉著fibroblasts,endouthelialcells,epithelialcells,osteoblastsfibroustissue（scar）processofrepair3）tissueplastyMacrophages（巨噬細(xì)胞），platelet（血小板）lymphocytes，variousmediators(earlyperiod)hyperplasiasynthesis(lateperiod)decompositionmodelingharmfulfactorsforwouldhealing1infection2foreignbodiesorexcessiveinactivetissue.disturbanceofcirculation

(shock,vesseldamage,edema,bandaging)4lackoflocalbraking5systemicfactors：

1)dystrophy營養(yǎng)不良：protein，vitamin,traceelement

2)theuseofcorticosteroids，chemotherapy,radiation,etc.3)immunocompromise：DM，tumor，cirrhosis，AIDS,etc.Typesofwoundhealing

primaryhealing：（一期愈合）basedonoriginalcells,withawellfunctionalrehabilitationSecondaryhealing：（二期愈合）basedonfibroustissue,recoveringwithfunctionaldisturbances:malformation,stenosis,dysfunction,etc.DiagnosisDiagnosisI.History：(1)causes：injuriousobjects，means，direction,etc.(2)symptomsandevolutionafterinjury(3)PastHistory:eg.DM。II.Physicalexamination：(1)generalconditions：consciousnesspulseBP

(2)Focusonrelatedsitesaccordingtohistory(3)Checkthesurfaceoftheopenwoundcarefully

DiagnosisoftraumaA.HistoryB.PhysicalexaminationC.Accessoryexaminations：laboratoryexaminationsPuncturation,catheter

Image（CT、Ultrasonography、X-Ray）woundscoring（傷情評(píng)分）CRAMS----pre-hospitalISS(injuryseverityscore)AIS(abbreviatedinjuryscore)TreatmentFirstaid（急救）Aims：Repairthedamagedorgans,resumephysiologicalfunciton

order：life-threateningconditionsImportantorgansotherscardiacarrestapneahemorrhageshockrupturesofurinetractorgastro-intestinaltractfractures,softtissueinjury(窒息)localtherapy---Debridement(清創(chuàng)術(shù))Fundamentalrequirements1.Enlargewounds,incisiondeepfascia,haemostasis,resectdevitalizedtissue,removeforeignbody,reorganizeirregularedge,suturewound.2.Operationtime(<6h,notexceed72h)3.Aboutshock.4.aboutdebridementorder.5.Aboutsecondarydebridement.(obstructeddrainageornecrotictissuebefound).MethodsandSteps1woundcleaninganddisinfecting2woundanesthesia3checkingthewoundremovingnecrotictissue,foreignbody,hemostasis,

4sutureanddelayedsuture,5drainagedelayedsuturecontaminatedwounds:debridement>8~12hAfter24-48h,non-infectedwoundcanbesuturedtreatmentforinfectedwounds1.Drainage：patency，mtethegrowthofgranulation3.Pseudomonasaeruginosa：sulfamiloon4.Granulationedema:hypertonicsaline5.Excessivegrowthofgranulation：10%silvernitrate

6.

Slowgrowthofgranulation：ShengjiPower。7.TATandantibioticsystemictherapyPreventandtreatinfectionMaintainbodyfluidequilibrium,correctelectrolytedisorderNutritionsupport---estimationofcaloryconsumptionMale:66.5+13.7×weight(kg)+5.0×higher(cm)-6.8×ageFemale:65.6+9.6×weight(kg)+5.0×higher(cm)-4.8×age戰(zhàn)傷

warinjurycharacteristicThelargeamountofthewounded,complicatedtrauma,seriouscontaminationMultivariateenvironmentTreatmentinechelons-escalationtherapy

(后送中連續(xù)監(jiān)測(cè)和治療)EvacuationandclassificationofthewoundedWarWoundEmergency

TreatmentProcedureVentilation(通氣)Resuscitationofcardiacarrestandapnea(心跳呼吸驟停的復(fù)蘇)Hermostasis(止血)Bandaging(包扎)Fixation(固定)Transportandevacuation(搬運(yùn)與后送)Firearmwounds(火器傷)CharacteristicsPrimarywoundtract（原發(fā)傷道）Contusionzone（挫傷區(qū)）Concussionzone(震蕩區(qū))Treatment(處理)preventionandtreatmentshock,transfusionpreventionandtreatmentinfection,antibioticsandTATDebridement(清創(chuàng)術(shù))BlastinjuryCharacteristicsWoundfactor:blastwaveBodysurfacewithoutskindamageacousticorgan(聽器)，lung,brain,gastrointestinalaredamageableorgansAcousticorganblastinjurypreventionandtreatmentinfectionClearWashingexternalauditorycanalexternalauditorycanal(外耳道)WashingisprohibedBlastinjuryoflunghalfsupineposture,keeprespiratorypassageunblockedoxygentherapypreventionandtreatmentpulmonaryedemapreventionofinfectionexpectanttreatmentBlastinjuryofAbdomenLyinginbed,fastingPreventio