1、胸外伤,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,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,Results from kinetic energy forces Blast（爆破
2、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
3、） 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,Low Energy Arrows, knives, handguns Injury caused by direct contact and cavitation High Energy Mili
4、tary, hunting rifles & high powered hand guns Extensive injury due to high pressure cavitation,Penetrating Trauma,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,Trache
5、obronchial 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,胸外伤详细分类及病理生理改变,Chest wall contusions or hematomas
6、 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,ContusionDyspnea Pain on breathing Hypoventilation 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,Rib Fractures50% of significant chest trauma cases
7、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 4-7 are most commonly fractured Ribs 11-12 less likely to be fractured Transmit energy of trauma to internal organs If fractured, suspect l
8、iver and spleen injury Hypoventilation（肺换气不足） is COMMON due to PAIN,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 con
9、tusion（肺挫伤） Dislocation uncommon but same MOI as fracture Tracheal（气管） depression if posterior,Flail Chest(连枷胸) Segment of the chest that becomes free to move with the pressure changes of respirationThree or more adjacent（毗邻的） rib fracture in two or more places Serious chest wall injury with underly
10、ing 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）,Pulmonary injury and injuries involving the pleural space （胸腔）Pulmonary contusion Pulmonary laceration Pne
11、umothorax Hemothorax Hemopneumothorax,pneumothorax,hemothorax,Pulmonary contusion,肺挫伤 肺裂伤 气胸 血胸 血气胸,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
12、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 wi
13、ll 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 PneumothoraxBuildup of air under pressure in the thorax. Excessive pressure reduce
14、s effectiveness of respiration Air is unable to escape from inside the pleural space Progression of Simple or Open Pneumothorax,Pneumothorax,Need emergent treatment,Tension Pneumothorax Signs & Symptoms,Dyspnea Tachypnea（呼吸过速） at first Progressive ventilation/perfusionmismatch Atelectasis on uninjur
15、ed 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,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 & SymptomsShock D
16、yspnea（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,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 contract
17、ions-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 wallTachycardia and/or ir
18、regular rhythmRetrosternal（胸骨后） pain similar to MIChest pain unrelieved by oxygenMay be relieved with rest,Signs & Symptoms,心肌损伤,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 mort
19、ality 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
20、三联征 心音遥远奇脉脉压差增大,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）onlySigns & symptoms of right or left hear
21、t failure Absence of vital signs,Signs & Symptoms,钝性伤致心脏破裂病人,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 vessel
22、s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,Other Thoracic Injuries,Traumatic Esophageal Rupture食管破裂 Tracheobronchial Injury气管损伤 Traumatic Asphyxia（创伤性窒息）,胸腹多发伤thoracoabdominal multiple injuries 胸腹复合伤（是否伴
23、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,胸外伤病人的评估,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,如何评定胸外伤的程度？创伤评分 多
24、种评分系统孰优孰劣？,This is a problem!,Pulmonary Contusion score (PCS) 1999, Tyburski et al. Wagner-score1989 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 suita
25、ble 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
26、 Trauma. J Surg Res. 19 (2011) 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
27、development of post-traumatic ARDS and MODS.,assess,Esme H ,Solak O, Yurumez Y，et al. The prognostic importance of trauma scoring systems for blunt thoracic trauma. Thorac Cardiovasc Surg. 2007 Apr;55(3):190-5.,Revised Trauma Score RTS Trauma and Injury Severity Score TRISS Injury Severity Score ISS
28、 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 predic
29、tors 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 f
30、ound to be the most useful scoring system in predicting the outcomes of these patients,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 (PTTCS) 修订创伤评分（RTS）,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，2005,1 018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。,
31、胸外伤的诊断,诊断方法：,诊断性胸腔穿刺,X-rayCT超声,diagnostic thoracocentesis,诊断性心包穿刺,diagnostic pericardiocentesis,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,胸外伤的治疗,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!,Chest wall injury,稳定断端 包扎固定 牵引固定 内固定止痛,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。,Thanks,
