胸部外伤.ppt
胸外伤胸外伤 Incidence and mortality发生率和死亡率发生率和死亡率:8%8%92%92%Incidence proportionMortality proportion胸外伤概况胸外伤概况 胸外伤病因胸外伤病因 Penetrating trauma贯穿伤贯穿伤Blunt trauma钝挫伤钝挫伤 车祸伤车祸伤坠落伤坠落伤挤压伤挤压伤刀刺伤刀刺伤火器伤火器伤lResults from kinetic energy forceslBlast（爆破伤）（爆破伤）Pressure wave causes tissue disruptionTear blood vessels&disrupt alveolar tissueDisruption of tracheobronchial treeTraumatic diaphragm rupturelCrush(Compression)（挤压伤）（挤压伤）Body is compressed between an object and a hard surfaceDirect injury of chest wall and internal structureslDeceleration（减速伤）（减速伤）Body in motion strikes a fixed objectBlunt trauma to chest wallInternal structures continue in motionLigamentum Arteriosum shears aortaBlunt 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 胸外伤病理生理胸外伤病理生理lLow EnergylArrows,knives,handgunslInjury caused by direct contact and cavitationlHigh EnergylMilitary,hunting rifles&high powered hand gunslExtensive injury due to high pressure cavitationPenetrating Trauma穿透伤合并损伤穿透伤合并损伤lClosed pneumothoraxlOpen pneumothorax lTension pneumothoraxlPneumomediastinumlHemothoraxlHemopneumothoraxlLaceration 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 lTracheobronchial tree lacerationslEsophageal lacerationslPenetrating cardiac injurieslPericardial tamponadelSpinal cord injurieslDiaphragm traumalIntra-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 穿透伤合并损伤穿透伤合并损伤胸外伤详细分类及病理生理改变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 fractures 胸骨骨折Fractures of the shoulder girdle 肩胛带骨折 Injuries to the chest wall 呼吸困难呼吸疼痛通气不足捻发音胸壁反常运动 lRib Fracturesl50%of significant chest trauma cases due to blunt traumalCompressional forces flex and fracture ribs at weakest pointslRibs 1-3 requires great force to fracturelPossible underlying lung injurylRibs 4-7 are most commonly fracturedlRibs 11-12 less likely to be fracturedlTransmit energy of trauma to internal organslIf fractured,suspect liver and spleen injurylHypoventilation（肺换气不足）is COMMON due to PAINlSternal Fracture&Dislocation （胸骨骨折和错位）lAssociated with severe blunt anterior traumalDirect Blow(比如：方向盘)lIncidence:5-8%lMortality:25-45%lMyocardial contusion（心肌的钝挫伤）lPericardial tamponade（心包填塞）lCardiac rupture（心脏破裂）lPulmonary contusion（肺挫伤）lDislocation uncommon but same MOI as fracturelTracheal（气管）depression if posteriorlFlail Chest(连枷胸)lSegment of the chest that becomes free to move with the pressure changes of respirationlThree or more adjacent（毗邻的）rib fracture in two or more placeslSerious chest wall injury with underlying pulmonary injury（潜在的肺损伤）lReduces volume of respirationlAdds to increased mortalitylParadoxical flail segment movement（反常呼吸运动）lPositive 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 pneumothoraxhemothoraxPulmonary contusion肺挫伤肺裂伤气胸血胸血气胸 Closed PneumothoraxlOccurs when lung tissue is disrupted and air leaks into the pleural spacelProgressive PathologylAir accumulates in pleural spacelLung collapseslAlveoli collapse lReduced oxygen and carbon dioxide exchangelVentilation/Perfusion MismatchIncreased ventilation but no alveolar perfusionReduced respiratory efficiency results in HYPOXIA（低血容（低血容量）量）Need emergent treatmentTension Pneumothorax Signs&SymptomslDyspnealTachypnea（呼吸过速）at firstlProgressive ventilation/perfusionmismatchlAtelectasis on uninjured sidelHypoxemialDiminished then absent breath sounds on injured sidelCyanosislDiaphoresislHypotensionlHypovolemialTracheal 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l血液聚集在胸膜腔内血液聚集在胸膜腔内l严重者失血量大于严重者失血量大于1500ml1500mll死亡率死亡率 75%75%l每侧胸腔可以容纳每侧胸腔可以容纳 3000 m 3000 ml ll导致潮气量降低导致潮气量降低l灌注灌注/通气失调通气失调&休克休克l常合并气胸常合并气胸l血气胸血气胸HemothoraxCardiovascular InjurieslOccurs in 76%of patients with severe blunt chest traumalRight Atrium（心房）（心房）and Ventricle（心（心室）室）is commonly injuredlInjury may reduce strength of cardiac contractions-Reduced cardiac outputlElectrical Disturbances due to irritability of damaged myocardial cellslProgressive ProblemslHematomalHemoperitoneumlMyocardial necrosislDysrhythmiaslCHF&or Cardiogenic shockMyocardial 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 心肌损伤Pericardial TamponadelRestriction to cardiac filling caused by blood or other fluid within the pericardiumlOccurs in 2%of all serious chest traumalHowever,very high mortalitylResults from tear in the coronary artery or penetration of myocardiumlBlood seeps into pericardium and is unable to escapel200-300 ml of blood can restrict effectiveness of cardiac contractionsRemoving as little as 20 ml can provide reliefMyocardial Aneurysm or RupturelOccurs almost exclusively with extreme blunt thoracic traumalSecondary due to necrosis resulting from MIlSevere rib or sternal（胸骨）fracturelPossible signs and symptoms of cardiac tamponadelIf affects valves（瓣膜）only Signs&symptoms of right or left heart failurelAbsence of vital signsSigns&Symptoms钝性伤致心脏破裂病人钝性伤致心脏破裂病人Other Vascular I
