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TRAUMA

TRAUMA. Definition Classification Affecting Factors Pathology Clinic manifestation Diagnosis & Treatment Basic Principles. Definition of Trauma. Physical agents → ← Human body ↓ energy release & absorbed ↓

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TRAUMA

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  1. TRAUMA • Definition • Classification • Affecting Factors • Pathology • Clinic manifestation • Diagnosis & Treatment Basic Principles

  2. Definition of Trauma Physical agents → ← Human body ↓ energy release & absorbed ↓ Structural alteration & Physiologic imbalance ↓ Injury OR Wound

  3. Classification I - Injury type traffic injury Industrial injury sports injury war or nuclear war injury

  4. Classification II – Injury causing agent penetrating injury - sharp instrument inj. Least force knife cut , missiles blunt force injury - contusion, bruise more force crush injury - car running over inj. most force other sources - thermal inj. freeze inj. electrical inj. radiation inj.

  5. Classification III – Location of Injury cranial or skull injury thoracic or chest injury abdominal injury extremity injury maxillofacial injury visceral injury

  6. Classification VI – Integrity of the skin close injury skin intact open injury skin damage possible to be contaminated or infected septic infection

  7. Classification V- Severity of injury slight injury severe or mortal injury affect vital signs consciousness breathing circulation

  8. Affecting factors • Age of victim • Anatomy • Mechanism of Injury

  9. Affecting factors • Age of victim the elder - worse result & high mortality rate reasons – difficulty in diagnosis limited on organ reserve less flexible of skeleton concurrent medical disease

  10. Affecting factors • Anatomy impact resistance fixation of body parts anatomic protection

  11. Affecting factors • Anatomy 5 high impact resistance parts significant energy & associate injury 1th rib 2ed rib sternum scapula femur

  12. Affecting factors • Anatomy high impact resistance – associate inj. 1th rib F.- mortality chest cranium abdomen 36.3% 64% 53% 33% mortality & morbidity 1th rib F. 89% 2ed rib F. 80%

  13. Affecting factors • Anatomy high impact resistance – associate inj. Sternum F.- cardiac contusion or injury Scapula F. - thoracic injury Femur F. - Knee ligament injury

  14. Affecting factors • Anatomy fixation of body parts Part small intestine duodenum vertebra Nature intraperitoneal retroperitoneal solid Fixation poor good solid Rate of decel. slow ↓ fast ↓ immediate Injury rapture perforation crush ↑ close of pylorus contracture of Treits lig.

  15. Affecting factors • Anatomy anatomic protection of body parts vehicle ← skull ← brain 1th impact 2ed impact ↓ protection ↓ production brain trauma

  16. Affecting factors • Mechanism of Injury Blunt impact Force →Organ → Deform ↓ beyond its limits of Elasticity & Viscosity ↓ Rapture

  17. Affecting factors • Mechanism of Injury Penetrating trauma E = mass ×velocity2÷2g E: kinetic energy

  18. TRAUMA • 病理 • 创伤性炎症（局部反应） • 出血 • 失活组织 → 微血管改变 → 血管通透性增高 • 血块 收缩 扩张 充血 水、电解质、血浆渗出 • 炎性细胞游出 • *炎性介质：组织胺、缓激肽、前列腺素、慢反应物质

  19. TRAUMA 病理 1.创伤性炎症（局部反应） 作 用 正常创伤性炎症有利修复 血浆纤维蛋白渗出 → 纤维网架→充填裂隙→细胞增生 细胞游出 → 中性细胞：抗感染；单核细胞：清除异物、免疫监视 过多炎症反应不利于修复 微循环持久充血→血循环障碍 大量水、电解质渗出(组织水肿) *细菌、异物存在→加重创伤性炎症

  20. TRAUMA 病理 2. 全身性反应 （1） 体温升高 出血、组织分解产物、炎性介质 (T <38) 脑部损伤致中枢性高热，并发感染(T > 38.5)

  21. TRAUMA 病理 2. 全身性反应 （2）内分泌变化疼痛、精神紧张、失血、失液 → 下丘脑～垂体系统 应激反应 促肾上腺皮质激素 ACTH ↑ → 肾上腺皮质激素 ↑ 抗利尿激素 ADH ↑ 生长激素 GH↑ → 交感神经～肾上腺髓质轴 应激反应 儿茶酚胺 ↑ → 有效循环血量下降 醛固酮↑ → 贫血 促红细胞生长素 ↑

  22. TRAUMA 病理 2. 全身性反应 作 用 保证重要器官血液灌注 儿茶酚胺：周围血管收缩、心肌收缩增强 → 维持血压 抗利尿激素、醛固酮：促进水分、钠回收 → 保持血容量

  23. TRAUMA 病理 2. 全身性反应 （3） 代谢变化 糖、脂肪、蛋白质： 早期为分解活动为主，后期合成活动为主 由于进食少、机体细胞对外源糖利用率低 胰高糖素↑→ 内源糖元分解→血糖↑ 脂肪分解 → 血脂肪酸↑ 肌蛋白分解 → 氨基酸↑ 作用动员机体静息能量，满足创伤后能量需要的增加

  24. TRAUMA 病理 2. 全身性反应 （3） 代谢变化蛋白质 早期为分解活动为主，后期合成活动为主 尿含氮物排出↑→ 氮负平衡 白蛋白分解 → 血白蛋白 ↓→ 氨基酸↑ 肌蛋白分解 → 氨基酸↑ 作 用 满足创伤组织修复所需 血球蛋白、纤维蛋白并不降低、相反有所↑ 作用有利于抗感染与凝血作用有关

  25. TRAUMA 病理 3. 创伤修复 二种形式 原始修复：指组织缺损完全由原来性质的细胞修复， 恢复原来结构与功能 疤痕修复：指组织缺损通过肉芽组织充填、 纤维组织替代原始细胞的修复， 不能完全恢复原来组织的结构与功能

  26. TRAUMA 病理 3. 创伤修复三个阶段 （1）纤维蛋白充填（炎症期） 48-72小时 血凝块充填 → 炎症反应 → 纤维蛋白渗出 → 止血、封闭创面 （2）细胞增生（增生期） 4 - 8 周 6小时 ： 成纤维细胞增生 → 纤维组织 肉芽组织 24小时 ：血管内皮细胞增生→ 新生血管 胶原纤维增多 → 强度增高 → 疤痕组织 （胶原量过多，疤痕过硬） 成骨细胞增生 → 骨痂 皮肤（粘膜）细胞增生 → 新生上皮、粘膜 巨噬细胞、白细胞 → 清除血凝块、坏死组织 （3）组织塑形（塑形期） 1年-几年 运动应力、酶 →疤痕组织、骨痂 → 在数量、分布、强度上调整 → 逐渐适应生理需要 →保持修复强度、疤痕软化 多余骨痂吸收

  27. TRAUMA 修复 不利因素 1. 感染：机械性因素 + 生物性致伤因素（毒素、酶） 2. 异物：阻隔新生细胞基质覆盖创面 + 继发感染 3. 血循环不良：缺氧、能量不足，如休克、伤口包扎 过紧、缝合过紧，修复延迟 4. 治疗不当：应用大量抑制创伤性炎症的药物，如皮质 激素，抗癌细胞毒药物，放射治疗； 制动不良，增加新的机械性损伤 5.全身营养不良：低蛋白 （白蛋白主要内源）、 缺乏维生素C、微量元素（参与胶原形成）； 内科消费性疾病：糖尿病、尿毒症、肝硬化

  28. TRAUMA 愈合分类 一期愈合：伤口裂隙小、对合良好、上皮迅速再生、 愈合疤痕很少、功能良好 二期愈合：伤口裂隙大或并发感染、上皮缺损、 依靠肉芽组织增生和伤口收缩达到愈合、 愈合疤痕多、外观及功能均差 延期愈合：伤口持续开放24-72小时、引流分泌物， 确认无感染后予缝合，愈合疤痕少于一期

  29. TRAUMA 临床表现 一、局部表现 疼痛 炎症反应、神经丰富与否 *伴休克常不述疼痛 *一般2-3天，持续或加重有感染可能 *慎用麻醉止痛药 肿胀 炎性渗出、出血（青紫、红肿） 血肿形成（波动感） 静脉回流障碍（水肿） 动脉血流障碍（苍白、皮温下降） 伤口或创面 出血、异物 功能障碍 组织破坏直接造成（骨折影响运动） 组织水肿压迫间接造成（咽喉水肿影响呼吸）

  30. TRAUMA 临床表现 二、全身表现 体温 38 过高，感染可能 脉搏、心率 ↑， 舒张压 ↑ 、收缩压 ↑、脉压 ? ， 休克时收缩压 ↓ 口渴、少尿 其它，疲惫、食欲不振、嗜睡

  31. TRAUMA 临床表现 三、并发症 化脓性感染 开放伤 、异物 创伤性休克 低血容量性、疼痛性（神经性）、心源性 器官功能衰竭挤压综合症（肾）、脂肪栓塞（肺、脑）

  32. TRAUMA 诊断 1.病史 致伤原因、作用部位、受伤姿势 症状及其演变过程 处理方式和处理时间 以往健康状况

  33. TRAUMA 诊断 2.体检 a 生命体征 T 、 P 、 R、BP 主要有无窒息、休克 b 根据病史及突出体征详细检查受伤局部 如四肢：肿胀、畸形、异常活动、骨擦音、 肢体感觉运动、肢端脉搏 c 开放性损伤 注意有无出血、污染、渗出、创道位置

  34. TRAUMA 诊断 3.辅助检查 化验 血常规、血电解质 穿刺 胸腔穿刺 腹腔穿刺 关节穿刺 影像学检查X-线CT MR

  35. TRAUMA 诊断 注意事项： 1.危重病人（窒息、大出血）立刻抢救 2.检查简捷、谨慎、轻巧 3.多个病人组织人力、不忽视不出声病人 4.未确诊病人密切观察、尽早确诊

  36. TRAUMA 治疗 • First aid at the scene of an accident 1 check the airway clear it if obstructed 2 feel the pulse 3 recovery position for unconscious P take special care of the cervical spine 4 stop oncoming traffic 5 treat the patientcover exposed bone reduce fracture arrest bleeding 5 call for emergency rescue & wait for ambulance

  37. TRAUMA 治疗 • Immediate management A B C routine airway breathing & circulation

  38. TRAUMA 治疗 • Immediate management airway & breathing 1 . obstructed airway causes blood , vomit , broken teech, tongue fractured mandible soft tissue swelling dure to injuries to neck, larynx or facial fracture 2. respiratory failure causes chest injuries , pain above C3 cervical spine injuries (damage the phrenic nerve)

  39. TRAUMA 治疗 • Immediate management airway & breathing way to establish clear the mouth and pharynx endotracheal intubation nasotracheal intubation tracheostomy

  40. TRAUMA 治疗 • Immediate management circulation 1.stop bleeding tourniquet used time of application release once per hour 2.restore blood volume intravenous infusion

  41. TRAUMA 治疗 • Monitoring and complete examination After Immediate management 1.begin charts set up record of P rate, BP ,R rate,T level of consciousness ,pupil sizes 2.complete the examination cut the cloth , do not pull it out measure the wounds & examine every bone 3. record ECG 4. CVP line set up central venous pressure line for monitoring the blood volume, CVP is 4-8cmH2O at normal 5. ISS grading (based on AIS abbreviate injury score)(1-75) ISS Injury severity score > 16 severe , >20 high mortality, >50 few alive >75 almost impossible to cure 6.advanced trauma life support specialist for systematic review

  42. TRAUMA Patient assessed and classified into 3 categories 1. Those requiring immediate & energetic treatment immediate resuscitation 2. Those with minor or none injuries general trauma treatment 3. Those with serious but non-urgent injuries specialist for systematic review and treatment

  43. TRAUMA 治疗 • Immediate management immediate resuscitation or medical rescue should be given to the patient in following situation: cardiac arrest (心脏骤停 ) asphyxia ( 窒息) extensive bleeding ( 大出血) open pneumothorax (开放气胸 ) shock (休克) viscera breakaway (内脏脱出)

  44. TRAUMA 治疗 • Local treatment ( general treatment) 1. immobilization of injuried limb or trunk for pain relieve & prevention of furtherdamages 2. emergent surgery for hemostasis , debridement or tissue repair 3. reduction & fixation of the deplaced bone and joint traction, reduction, fixation with cast or brace 4.soft tissue treatment physical treatment , cold compress with ice within 48 h of injury at site of bruising ,hot compress after for the inhibition of over-inflammatory reaction

  45. TRAUMA • Systematic treatment( general treatment) 1. maintain efficient circulation saline infusion or blood transfusion 2. maintain airway & breathing oxygen inhaling 3. Prevention of secondary infection usage of prophylactic antibioticsin cases of open injury with contaminated wound, close injury at chest or abdomen, any injury that need surgery, any injury with severe tissue necrosis 4. maintain the balance of metabolism ,nutrition and hydro-dielectric 5. pain control and psychological treatment

  46. TRAUMA 开放伤口处理 • Classification 1.Clean wound sterilized cutting during operation , can suture it for one-stage healing 2.Contaminated wound the wound with amount of bacteria not yet enough to developing infection as open wound within 8 hours or facial wound within 12 hours or severe Contaminated woundwithin 4 hours, can be cleaned by debridement aiming for one-stage healing 3.Infected woundthe wound with amount of bacteria having developed infection as open wound over 8 hours cutting wound for abscess drainage wound with red and swollen or fluid leakage, can only be treated by wound dressing and resulting in two-stage healing

  47. TRAUMA 清创术 （1）清洗去污 无菌砂布覆盖创面 a 周围皮肤 肥皂水洗刷 剪去毛发、去除污垢油腻 生理盐水冲洗 b 创面 冲洗 无菌生理盐水 洁而灭或洗必太溶液 双氧水溶液（疑有厌氧感染） 去除表面血块、异物

  48. TRAUMA 清创术 2）清理创面 麻醉、消毒、铺巾 探查，清除血块、异物、失活组织 保留并复位与软组织相连的或较大的游离骨块 清除明显挫伤皮肤(0.2-0.3cm)及皮下组织 深部伤口 适当扩大伤口、切开筋膜 随时生理盐水冲洗 至显露清洁、血循环好的组织

  49. TRAUMA 清创术 （3） 缝合伤口 重新消毒，更换手术单、器件、手套 彻底止血、放置引流、 伤口干净 头面部 手部 外阴部 一期缝合 污染明显延期缝合 （腹膜，硬脑膜，关节囊必须缝合 四肢只缝深筋膜、1-4天后缝皮下与皮肤） 皮肤缺损可考虑植皮

  50. TRAUMA 清创术 注意事项： 无菌操作，认真清洗和消毒 清除异物、血块、坏死组织， 大骨块清洗后复位 彻底止血，消灭死腔 腹膜，硬脑膜，关节囊必须缝合 皮肤缺损、尤在神经、血管、骨关节处应植皮

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