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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 forcesBlast（爆破伤）Pres
2、sure wave causes tissue disruptionTear blood vessels&disrupt alveolar tissueDisruption of tracheobronchial treeTraumatic diaphragm ruptureCrush(Compression)（挤压伤）Body is compressed between an object and a hard surfaceDirect injury of chest wall and internal structuresDeceleration（减速伤）Body in motion s
3、trikes a fixed objectBlunt trauma to chest wallInternal structures continue in motionLigamentum 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 EnergyArrows,knives,handgunsInjury caused by direct contact and cavitationHigh EnergyMilitary,hunting rifles&high power
4、ed hand gunsExtensive injury due to high pressure cavitation,Penetrating Trauma,穿透伤合并损伤,Closed pneumothoraxOpen pneumothorax Tension pneumothoraxPneumomediastinumHemothoraxHemopneumothoraxLaceration 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,Tracheobronchial tree lacerationsEsophageal lacerat
5、ionsPenetrating cardiac injuriesPericardial tamponadeSpinal cord injuriesDiaphragm traumaIntra-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 胸壁挫伤或血肿 Rib fractures 肋骨骨折Flail chest 连枷胸Sternal fractur
6、es 胸骨骨折Fractures of the shoulder girdle 肩胛带骨折,Injuries to the chest wall,ContusionDyspneaPain on breathingHypoventilationCrepitusParadoxical 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 due to blunt traumaCompressional forces flex and fracture ribs at wea
7、kest pointsRibs 1-3 requires great force to fracturePossible underlying lung injuryRibs 4-7 are most commonly fracturedRibs 11-12 less likely to be fracturedTransmit energy of trauma to internal organsIf fractured,suspect liver and spleen injuryHypoventilation（肺换气不足）is COMMON due to PAIN,Sternal Fra
8、cture&Dislocation（胸骨骨折和错位）Associated with severe blunt anterior traumaDirect 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 fractureTracheal（气管）depression if posterior,
9、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 placesSerious chest wall injury with underlying pulmonary injury（潜在的肺损伤）Reduces volume of respirationAdds to increased mortalityParadoxical fl
10、ail 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 Pneumothorax Hemothorax Hemopneumothorax,pneumothorax,hemothorax,Pulmonary contusion,肺挫伤肺裂伤气胸血胸血气胸,Closed P
11、neumothoraxOccurs when lung tissue is disrupted and air leaks into the pleural spaceProgressive PathologyAir accumulates in pleural spaceLung collapsesAlveoli collapse Reduced oxygen and carbon dioxide exchangeVentilation/Perfusion MismatchIncreased ventilation but no alveolar perfusionReduced respi
12、ratory efficiency results in HYPOXIA,Open PneumothoraxFree passage of air between atmosphere and pleural spaceAir replaces lung tissueMediastinum（纵膈）shifts to uninjured sideAir will be drawn through wound if wound is 2/3 diameter of the trachea or largerSigns&SymptomsPenetrating chest traumaSucking（
13、吮吸）chest woundFrothy blood at wound siteSevere Dyspnea（严重呼吸困难）Hypovolemia（低血容量）,Tension PneumothoraxBuildup of air under pressure in the thorax.Excessive pressure reduces effectiveness of respirationAir is unable to escape from inside the pleural spaceProgression of Simple or Open Pneumothorax,Pneum
14、othorax,Need emergent treatment,Tension Pneumothorax Signs&Symptoms,DyspneaTachypnea（呼吸过速）at firstProgressive ventilation/perfusionmismatchAtelectasis on uninjured sideHypoxemiaDiminished then absent breath sounds on injured sideCyanosisDiaphoresisHypotensionHypovolemiaTracheal Shifting,低氧血症呼吸音减低紫绀发
15、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&SymptomsShockDyspnea（呼吸困难）Tachycardia(心动过速)Tachypnea（呼吸过速）Diaphoresis（出汗）HypotensionDull to percussion（叩诊）over injured side,Cardiovascular Injuries,Occurs in 76%of patients with
16、severe blunt chest traumaRight Atrium（心房）and Ventricle（心室）is commonly injuredInjury may reduce strength of cardiac contractions-Reduced cardiac outputElectrical Disturbances due to irritability of damaged myocardial cellsProgressive ProblemsHematomaHemoperitoneumMyocardial necrosisDysrhythmiasCHF&or
17、 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,Pericardial Tamponade,Restriction to cardiac filling caused
18、by blood or other fluid within the pericardiumOccurs in 2%of all serious chest traumaHowever,very high mortalityResults from tear in the coronary artery or penetration of myocardiumBlood seeps into pericardium and is unable to escape200-300 ml of blood can restrict effectiveness of cardiac contracti
19、onsRemoving as little as 20 ml can provide relief,Signs&Symptoms,Dyspnea呼吸苦难Possible cyanosisBecks 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 traumaSecondary due to necrosis resulting from MI,Severe rib or sternal（胸骨）fracturePossible signs and
20、 symptoms of cardiac tamponadeIf affects valves（瓣膜）only Signs&symptoms of right or left heart failureAbsence 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 lacerationSuperior Vena Cava上腔静脉Inferior Vena Cava下腔静脉General Thoracic
21、 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&SymptomsPenetrating 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Trauma
22、tic Asphyxia（创伤性窒息）,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,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ObserveQuestionPalpate（触诊）Auscultate（听诊）Percuss（视诊）Blunt Trauma AssessmentPenetrating Trau
23、ma AssessmentOngoing Assessment持续评估,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？,This is a problem!,Pulmonary Contusion score(PCS)1999,Tyburski et al.Wagner-score 1989 Wagner and JamiesonThoracic Trauma Severity score(TTS)2000 Pape HC et al.,Conclusions：Thoracic trauma scores combining anatomical and physiologi
24、c 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-Trau
25、matic Complications and Outcome in Blunt Chest 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 ventilat
26、ion time,length of ICU stay,and the 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
27、TRISSInjury Severity Score ISSLung Injury Scale LISChest 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 LI
28、S 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 thoraci
29、c injury and was found 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
30、呈现明显的负相关关系。,胸外伤的诊断,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,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,
