外科学创伤教学(英文)..pptx

外科学创伤教学(英文)..pptx

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创伤,trauma,医院外科,1,Trauma：

Traumaisdefinedasthedamagecausedbymechanicalinjuriousagents,withthedisturbanceoftissuecontinuityandfunction.,SkinVessel,injuriousfactors,Classification,1Accordingtotheintegrityofskin：

Damaged-openwounds（开放性创伤）,Intact-closedwounds（闭合性创伤）,openwounds,Penetratingwound（穿入伤）Perforatingwound（穿透伤）Non-penetratingwound（非穿入伤）,severalfamiliaropenwounds,Abrasion（擦伤）,Puncture（刺伤）,severalfamiliaropenwounds,Incisionorcutwound（切伤和砍伤）,Laceration（撕裂伤）,Closedwounds,Contusion（挫伤）Crushinjury（挤压伤）Sprain（扭伤）Concussion（震荡伤）Luxationandsemi-luxation（脱位和半脱位）Closedbonefracture（闭合性骨折）Closedinternalinjury（闭合性内伤）,fracture,2Accordingtopositions,Craniocerebralinjury（颅脑伤）Maxillofacialandcervicalinjury（颌面颈部伤）Chestinjury（胸部伤）Abdomeninjury（腹部伤）Pelvisinjury（骨盆部伤）Spineandspinalcordinjury（脊柱脊髓伤）Upperextremityinjury（上肢伤）Lowerextremityinjury（下肢伤）Multipleinjury（多发伤）,epiduralhematoma,Craniocerebraltrauma,3Accordingtoinjuriousfactors,Coldweaponwounds（冷兵器伤）Firearmwounds（火器伤）Burns（烧伤）Coldinjury（冷伤）Blastinjury（冲击伤）Chemicalinjury（化学伤）Radiationinjury（放射伤）Combinedinjury（复合伤）,burns,Coldinjury,TraumaPathology,trauma,damageofthetissuestructurehemorrhageinactivationofcelllocal:

inflammation,cellularproliferationsystemicchanges:

bloodfilm,bodytemperature,functionofimportantorgans,1Inflammatoryreaction,Local：

hyperemia,edema,exudation（redness,swelling,heat,pain）Benefit:

Proliferativecellsfillthedeficit,facilitingthewoundhealing.Itclearsthebacteria,tissuefragmentandforeignbodycanpromotethehealingprocedure.Harm:

Severeinflammatoryreactionresultsindelayedhealinganddisturbanceofcirculation.Excessiveexudationcausestheinsufficienceofbloodvolume.,brady-kinin,comple-ments,Histamine,interferon,TNF,PAF,Releaseofvariousinflammatorymediatorsandcytokines,productofdamagedtissueandbacterialtoxin,Pathology,2Systemicreaction1）bodytemperature：

inflammatorymediators,infectionsheatcenterbodytemperature:

riseordescend,Pathology,2Systemicreaction1）Bodytemperature2）Neuroendocrinepains,stress,losebloodandwater,-ACTH，ADH，GH,HypothalamusPituitarygland,SynpatheticNerves-renin，nonadrenaline，aldosterone,Adrenalgland,heartratearises,vasoconstriction,urinevolumesdecrease,Pathology,energy,protein,weightloss,myathenia（肌无力）,2SystemicreactionBodytemperaturereactionNeuro-endocrinereactionChangesofcatabolismdecompositionofproteinandadiposeincreasecatecholamine,corticosteroids,glucagon,TNFs,ILsincrease儿茶酚胺皮质激素胰高糖素catabolismaccentuation,Pathology,2Systemicreaction1）bodytemperatureneuro-endocrinereactionschangesofmetabolismchangesofimmunesystemendogenouscorticosteroidsdecreasethefunctionsofNeutrophilsandPhagocyteCatecholamine（儿茶酚胺）,PGE2（前列腺素）,immunesuppression,Pathology,InflammatoryreactionsSystemicreactionsComplicationsoftraumatissueinjury,bacteria,immunesuppression:

Infection,bloodloss,infection:

Shock,infection,shock,organdammage:

MODS,repair,Thefunctionsofcellintheprocessofwoundhealing,Neutrophil（中性粒细胞）Macrophage（巨噬细胞）Platelet（血小板）Lymphocyte（淋巴细胞）,Inflammatoryreactionstage:

PDGF,TGF-,bFGF,MDGFtissueproliferationstage:

IGF-1,bFGF,TGF-,PDGFscarformationstage:

TGF-,PDGF,Thefunctionsofgrowthfactorintheprocessofwoundhealing,Thefunctionsoffibronectin（Fn）,（纤维连接蛋白）ParticipateincoagulationprocessEnhancethefunctionofmacrophageChemotaxis（趋化作用）,repair,proliferation,细胞增生,mesenchymaltissuefillthedeficit细胞间质充填连接,Processofrepair,1）fibrinfilling,sealingthewound,（纤维蛋白充填）,Hemostasis（止血）,Processofrepair,Fibroblast成纤维细胞,endothelialcells内皮细胞,2）proliferation（细胞增生）neogeneticvessels,新生血管,granuloma肉芽肿,processofrepair,Collagen（胶原）Amino-polysaccharide（氨基多糖）,基质沉着,fibroblasts,endouthelialcells,epithelialcells,osteoblasts,fibroustissue（scar）,processofrepair,3）tissueplasty,Macrophages（巨噬细胞），platelet（血小板）lymphocytes，variousmediators,（earlyperiod）hyperplasiasynthesis,（lateperiod）decompositionmodeling,harmfulfactorsforwouldhealing1infection,foreignbodiesorexcessiveinactivetissue.disturbanceofcirculation（shock,vesseldamage,edema,bandaging）lackoflocalbrakingsystemicfactors：

dystrophy营养不良：

protein，vitamin,traceelementtheuseofcorticosteroids，chemotherapy,radiation,etc.immunocompromise：

DM，tumor，cirrhosis，AIDS,etc.,Typesofwoundhealing,primaryhealing：

（一期愈合）basedonoriginalcells,withawellfunctionalrehabilitation,Secondaryhealing：

（二期愈合）basedonfibroustissue,recoveringwithfunctionaldisturbances:

malformation,stenosis,dysfunction,etc.,Diagnosis,Diagnosis,I.History：

（1）causes：

injuriousobjects，means，direction,etc.

（2）symptomsandevolutionafterinjury（3）PastHistory:

eg.DM。

II.Physicalexamination：

（1）generalconditions：

consciousnesspulseBP

（2）Focusonrelatedsitesaccordingtohistory（3）Checkthesurfaceoftheopenwoundcarefully,Diagnosisoftrauma,HistoryPhysicalexaminationAccessoryexaminations：

laboratoryexaminationsPuncturation,catheterImage（CT、Ultrasonography、X-Ray）,woundscoring（伤情评分）,CRAMS-pre-hospitalISS（injuryseverityscore）AIS（abbreviatedinjuryscore）,Treatment,order：

life-threateningconditions,Importantorgans,others,Firstaid（急救）Aims：

Repairthedamagedorgans,resumephysiologicalfuncitoncardiacarrest,apnea（窒息）hemorrhageshockrupturesofurinetractorgastro-intestinaltractfractures,softtissueinjury,localtherapy-Debridement（清创术）,FundamentalrequirementsEnlargewounds,incisiondeepfascia,haemostasis,resectdevitalizedtissue,removeforeignbody,reorganizeirregularedge,suturewound.Operationtime（6h,notexceed72h）Aboutshock.4.aboutdebridementorder.5.Aboutsecondarydebridement.（obstructeddrainageornecrotictissuebefound）.,MethodsandSteps,1woundcleaninganddisinfecting2woundanesthesiacheckingthewoundremovingnecrotictissue,foreignbody,hemostasis,sutureanddelayedsuture,5drainage,delayedsuture,contaminatedwounds:

debridement812h,After24-48h,non-infectedwoundcanbesutured,treatmentforinfectedwounds,1.Drainage：

patency，thoroughly2.promtethegrowthofgranulation3.Pseudomonasaeruginosa：

sulfamiloon4.Granulationedema:

hypertonicsalineExcessivegrowthofgranulation：

10%silvernitrateSlowgrowthofgranulation：

ShengjiPower。

7.TATandantibiotic,systemictherapy,PreventandtreatinfectionMaintainbodyfluidequilibrium,correctelectrolytedisorderNutritionsupport-estimationofcaloryconsumptionMale:

66.5+13.7weight（kg）+5.0higher（cm）-6.8ageFemale:

65.6+9.6weight（kg）+5.0higher（cm）-4.8age,战伤,warinjury,characteristic,Thelargeamountofthewounded,complicatedtrauma,seriouscontaminationMultivariateenvironmentTreatmentinechelons-escalationtherapy（后送中连续监测和治疗）Evacuationandclassificationofthewounded,WarWoundEmergencyTreatmentProcedure,Ventilation（通气）Resuscitationofcardiacarrestandapnea（心跳呼吸骤停的复苏）Hermostasis（止血）Bandaging（包扎）Fixation（固定）Transportandevacuation（搬运与后送）,Firearmwounds（火器伤）,Characteristics,Primarywoundtract（原发伤道）Contusionzone（挫伤区）Concussionzone（震荡区）,Treatment（处理）,preventionandtreatmentshock,transfusionpreventionandtreatmentinfection,antibioticsandTATDebridement（清创术）,Blastinjury,Characteristics,Woundfactor:

blastwaveBodysurfacewithoutskindamageacousticorgan（听器），lung,brain,gastrointestinalaredamageableorgans,Acousticorganblastinjury,preventionandtreatmentinfectionClearWashingexternalauditorycanalexternalauditorycanal（外耳道）Washingisprohibed,Blastinjuryoflung,halfsupineposture,keeprespiratorypassageunblockedoxygentherapypreventionandtreatmentpulmonaryedemapreventionofinfectionexpectanttreatment,BlastinjuryofAbdomen,Lyinginbed,fastingPreventionandtreatmentinfectionandshockexploratorylaparotomy,Nuclearweaponinjury,woundfactors:

lightradiation（光辐射）blastwave（冲击波）nuclearradiation（核辐射）nuclearcontamination（放射性核沾染）,Protection,迅速进入临时工事就近用土丘、沟渠、弹坑等掩护如在开阔地，足向爆心俯卧，衣物遮盖头面部，闭紧眼睛，暂时屏气，手指堵耳穿防护衣和面具，或用雨衣、白布、毛巾、口罩、棉球等保护体表、呼吸道、听器等迅速撤离杀伤区,Chemicalweaponinjuries（化学武器伤）,protectivedevicesdecomtamination（消洗）,Warcombinedinjury,处理原则,对单一伤的有效措施，也适用于复合伤重点解决主要损伤，兼顾次要损伤,Nucleo-combinedinjury（核爆复合伤）,处理原则,按险重后轻的原则命名，如放烧冲复合伤,原则上应尽早手术损伤创面的处理与一般烧伤相同放射性损伤复合骨折愈合缓慢，固定时间需延长1/4-1/2放射性沾染时避免使用髓内钉开放性骨折有放射性沾染时伤口做延期缝合,Chemico-combinedinjury（毒剂复合伤）,特点,容易发生休克易引起伤口出血、感染及组织坏死软组织愈合慢，骨折愈合延迟或畸形毒剂迅速经伤口吸收，可引起全身中毒死亡,临床表现,神经性毒气：

持续性肌颤，出汗、呼吸困难、惊厥、昏迷等。

糜烂性毒气：

皮肤粘膜化学性烧伤窒息性毒气：

肺水肿,诊断,中毒史症状体征化验检查：

神经性毒气血胆碱酯酶路易氏剂尿砷含量毒剂检查：

伤口分泌物取样毒剂鉴定,急救,使用防护面具或防护器材尽快消毒四肢伤口疑有染毒，近端扎止血带抗毒剂及其他急救措施,治疗,保持呼吸道通畅，防止肺水肿氨茶碱、甘露醇、高渗葡萄糖液对复合创伤进行手术，需加强防护，用橡皮或塑料围裙、手套等皮肤防护用具，并使用消毒剂,