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(jī)做作最恰當(dāng)?shù)氖中g(shù),回顧,50Stoo 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,n＋n ＋n ＋n+…＞nm,≠,,damage control surgery創(chuàng)傷控制手術(shù),80S

2、來自腹部外科的實(shí)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(shí)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,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 wantBorderline臨界點(diǎn)Unstable不穩(wěn)定、隨時有生命危險(xiǎn)I

3、n extremis已經(jīng)瀕臨死亡了,關(guān)鍵是borderline 的轉(zhuǎn)化,什么是borderline,Borderline,①多發(fā)性損傷ISS>20分，附加胸部損傷(簡明損傷評分——AIs>2分)：②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：④入院時第一張胸片發(fā)現(xiàn)雙肺挫傷：⑤早期平均肺動脈壓>24 mm Hg：⑥多發(fā)性長骨骨折與軀干損傷AIS≥2分：⑦估計(jì)手

4、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(diǎn)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(kuò)髓與非擴(kuò)髓,肢體創(chuàng)傷控制骨科,DCO principles ap

5、plied 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 fracturesMangled extremties,Secondary Procedures,Days 2, 3, and 4 不合適Objective tests客觀的檢查標(biāo)準(zhǔn)Lactic acid/pHIL-6 500,骨牽引還是外固定架,對于創(chuàng)傷

6、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 humeral head dislocation肱骨近端骨折伴脫位Femoral neck fract

7、ure with hip dislocation股骨頸骨折伴脫位一切可能引發(fā)血運(yùn)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 debri

8、de?什么時間清創(chuàng)When to fix?什么時間固定When to close/cover?什么時間閉合創(chuàng)面,Timing of Debridement,6 hour rule based on Freidrich’s study of bacteria replication rates黃金6小時？Only one study supports the 6 hour rule, while seven studies ov

9、er the last 30 years show no significant difference1和6,Timing of Debridement,studyTime to debridement did not predict infection其實(shí)沒啥關(guān)系Time to admission did correlate with infectionAntibiotic administrationResuscitatio

10、n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 fracturesConsider delayed fixation f

11、or 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 coverageReaming of open

12、 fractures well supported,Timing of Closure,The early closure of open fractures grade I, II, IIIa is recommended with the exception of wounds grossly contaminated with dirt, stagnant water or farmyard related injuries“S

13、econd look” debridement warranted when there is concern for further tissue compromise or high initial contaminationFree flaps may outperform local flaps,結(jié)論,(DCO) 和 (ETC)DCO 的適應(yīng)證Unresolved issuesborderline patient股骨干