創(chuàng)傷控制理論

1、創(chuàng)傷控制理論,是一種理念、不是一種技術(shù) 針對多發(fā)傷 在最適當(dāng)?shù)臅r機做作最恰當(dāng)?shù)氖中g(shù),回顧,50S too sick to operate on 三句話but wait a few days不要急診髓內(nèi)釘最好等兩天,1970s Early Total Care早期完全干預(yù),多發(fā)傷、復(fù)合 傷的理解,創(chuàng)傷級聯(lián)瀑布學(xué)說,nn n n+nm,damage control surgery創(chuàng)傷控制手術(shù),80S 來自腹部外科的實踐 三步法,創(chuàng)傷控制骨科,利用創(chuàng)傷控制理論 指導(dǎo)骨科實踐 為了降低有多發(fā)傷、 合并傷患者的死亡率 為了預(yù)防SIRS的 發(fā)生率,內(nèi)容,外固定支架暫時穩(wěn)定,創(chuàng)傷監(jiān)護(hù)病房,確定性手術(shù),優(yōu)勢,

2、雙贏 便于后續(xù)處理 控制出血 骨折的穩(wěn)定,什么樣的病人要做創(chuàng)傷控制手術(shù),Stable穩(wěn)定想怎么做都行do whatever you want Borderline臨界點 Unstable不穩(wěn)定、隨時有生命危險 In extremis已經(jīng)瀕臨死亡了,關(guān)鍵是borderline 的轉(zhuǎn)化,什么是borderline,Borderline,多發(fā)性損傷ISS20分，附加胸部損傷(簡明損傷評分AIs2分)：多發(fā)性損傷伴有腹部、骨盆損傷(Moore評分3分)并出血性休克、入院時血壓40分而不附加胸部損傷：入院時第一張胸片發(fā)現(xiàn)雙肺挫傷：早期平均肺動脈壓24 mm Hg：多發(fā)性長骨骨折與軀干損傷AIS2分：估計

3、手術(shù)時間6 h：,一些提示、能讓你記著的 pH 90 minutes 高凝狀態(tài) 老年病人 (physiologic age 65),Pelvic Fractures,針對分型臨時固定 片子做出大致的判斷、神經(jīng)損傷、失血、不等長 是創(chuàng)傷控制理論中要重點處理的 簡單、快速 很重要,Femur Fractures,胸部損傷 雙側(cè)股骨干骨折、26.8% 血乳酸鹽 擴髓與非擴髓,肢體創(chuàng)傷控制骨科,DCO principles applied to a single, severely injured limb 原則上都能用 高能量脛骨近端骨折 股骨 Grade III B and C open frac

4、tures Mangled extremties,Secondary Procedures,Days 2, 3, and 4 不合適 Objective tests客觀的檢查標(biāo)準(zhǔn) Lactic acid/pH IL-6 500,骨牽引還是外固定架,對于創(chuàng)傷控制來說沒有差別？,血清乳酸鹽的測定對股骨干骨折髓內(nèi)手術(shù)的重要參考,Orthopaedic Emergencies,脫位 Vascular compromise血管損傷 Compartment syndrome間室綜合癥 血流動力不穩(wěn)定的骨盆骨折,Dislocations,Proximal humerus fracture with hume

5、ral head dislocation肱骨近端骨折伴脫位 Femoral neck fracture with hip dislocation股骨頸骨折伴脫位 一切可能引發(fā)血運障礙從而延緩骨折愈合的,Dislocations,Vascular Compromise,要重視閉合性血管損傷 要重視血管探查手術(shù) 要重視體檢的意義 不是造影的指征、特別是腘動脈傷 動態(tài)觀測,Compartment Syndrome,When in doubt, release,該切就切、警惕部分后果,Open Fracture,When to debride?什么時間清創(chuàng) When to fix?什么時間固定 Whe

6、n to close/cover?什么時間閉合創(chuàng)面,Timing of Debridement,6 hour rule based on Freidrichs study of bacteria replication rates黃金6小時？ Only one study supports the 6 hour rule, while seven studies over the last 30 years show no significant difference1和6,Timing of Debridement,study Time to debridement did not pred

7、ict infection其實沒啥關(guān)系 Time to admission did correlate with infection Antibiotic administration Resuscitation 入院時間和復(fù)蘇時間和抗生素的投放,Timing of Debridement,Ultimately, quality of debridement is most important,Timing of Fixation,May be performed at time of initial debridement for grade I, II, IIIa fractures Co

8、nsider delayed fixation for fractures grossly contaminated with dirt, stagnant water or farmyard related injuries. Delayed fixation and utilization of bead pouches and/or VAC dressings for fractures requiring soft tissue coverage Reaming of open fractures well supported,Timing of Closure,The early c

9、losure of open fractures grade I, II, IIIa is recommended with the exception of wounds grossly contaminated with dirt, stagnant water or farmyard related injuries “Second look” debridement warranted when there is concern for further tissue compromise or high initial contamination Free flaps may outperform local fla