开放性胸部创伤胸腔封闭器材的研制和胸部外固定新型器材的研制及应用

发布时间：2018-07-23 16:30

【摘要】：背景胸部创伤（thoracic traumaTT）在历次战争中发生率（IR)约占8％，直接导致的死亡占创伤死亡的25％，是导致死亡的创伤类型中仅次于颅脑伤的第2位原因。开放性胸外伤是胸部创伤中导致死亡的主要伤情，在战时因爆炸伤导致的开放性胸外伤较为多见，陆战中，开放性胸外伤占伤员总数的7％～12％，在海战中，发生率更是高达20%。如果能够进行前线现场救治，将为后续治疗创造机会，极大地降低开放性胸部创伤的死亡率（MR)。开放性胸外伤最主要的急救方法是早期边抢救边判明伤情，尽早恢复胸壁完整性及胸内负压，防止出现严重呼吸循环功能障碍，如何及时有效的封闭胸腔成为关键所在。开放性胸外伤多合并肋骨骨折甚至是连枷胸（flail chest FC），在胸腔封闭后送途中，患者常常引起胸部剧烈疼痛和呼吸困难，严重抑制患者的呼吸运动，，选择合适的材料固定胸壁，能够有效镇痛，防止胸壁内陷也成为救治胸部创伤患者不可或缺的一环。而在我军以往的救治方案和装备中，尚未检索到制式的开放性胸外伤现场临时胸腔封闭装置及胸壁固定装置等急救器材，通常急救所用的简单的纱布敷料等物品存在种种缺点，无法满足战场急救（ETOB）及院前急救（pre-HC）的需要。研制并装备简易的急救器材以简化手术操作，实施及时、正确的前线现场救治及院前急救，对降低死亡率（MR）具有重要现实意义。第一部分：单向阀瓣临时胸腔封闭装置的设计制备及动物实验研究目的：设计制备单向阀瓣临时胸腔封闭装置，并通过开放性胸部创伤现场急救动物实验，评价其在开放性胸部创伤的急救中的封闭效果。方法：以犬为实验动物，采用数字表法随机分为对照组（4只）和实验组（4只），建立开放性胸外伤动物模型。对照组以临床常用敷贴加压封闭，实验组以单向阀瓣临时胸腔封闭装置封闭。观察2组犬的胸腔封闭固定操作时间、胸腔闭式引流术操作时间、实验犬心率、呼吸频率、血氧饱和度变化、胸腔封闭装置所承受的最大拉力及引流效果。结果：实验组胸腔封闭实验组为（0.58±0.14）min，对照组为（1.17±0.21）min，两组差异有统计学意义（P0.01），前者优于后者；实验组后续胸腔闭式引流术操作时间为（0.48±0.07）min，对照组时间为（2.20±0.11）min，两组差异有统计学意义（P0.01），前者优于后者。实验组在胸腔封闭前后心率(HR)、呼吸频率（RR）、血氧饱和度（SpO2）变化与对照组相比差异均有统计学意义（P 0.05）,两组引流术后各时间点胸腔积液积血引流量差异无统计学意义（P0.05）。结论：单向阀瓣临时胸腔封闭装置能及时有效封闭胸腔，变开放性胸外伤为闭合性胸外伤，固定效果确切，继而为实施有效的胸腔闭式引流术以及后续治疗创造条件，适合应用于开放性胸外伤患者的前线救治及院前急救。第二部分：气柱调压式外固定胸带的设计制备与临床试验研究目的：设计制备气柱调压式外固定胸带，并通过临床对照试验评价其对胸部创伤的固定、减轻疼痛及改善呼吸的效果。方法：将我科50例开胸术后患者采用数字表法随机分成实验组和对照组，每组各25例，实验组术后使用气柱调压式外固定胸带固定胸部，对照组使用普通弹性胸带，观察两组患者术后各时间点平静及咳嗽时疼痛评分（VAS）、呼吸频率(RR)，用便携式肺功能仪测试两组患者术前及术后24h、48h、72h的肺功能，术前及术后24h、48h、72h行血气分析检查，记录两组患者术后第1次主动咳嗽时间、胸引液总量、胸引管拔除时间、术后住院天数、肺部并发症的发生率(IR)及止痛药的使用总剂量。结果：实验组与对照组术后3h、6h、24h、48h、72h平静时疼痛评分及呼吸频率差异均具有统计学意义(P 0.05)；实验组与对照组术后3h、6h、24h、48h、72h咳嗽时疼痛评分及呼吸频率差异均具有统计学意义(P 0.05)；实验组患者术后FVC、FEV1、MVV、FVC%预计值、FEV1%预计值、MVV%预计值与对照组的差异有统计学意义（P 0.05），实验组FEV1/FVC与对照组的差异无统计学意义（P0.05）；实验组PaO2、PaCO2、SpO2与对照组的差异无统计学意义（P0.05）。实验组术后第1次主动咳嗽时间、术后镇痛药物的使用剂量与对照组的差异具有统计学意义（P 0.05），实验组胸引液总量、引流管拔除时间、术后住院天数、肺部并发症发生率与对照组比较的差异均无统计学意义（P0.05）。结论：气柱调压式外固定胸带外形美观、选用材料安全柔和，患者佩戴后舒适感强，其固定效果确切，能提高患者的疼痛阈值，减轻患者痛苦，促进患者主动咳嗽咳痰，有利于肺功能的恢复，适合应用于胸部创伤患者的紧急救治及胸部术后患者的胸部固定。综合上述实验结果，本研究显示：单向阀瓣临时胸腔封闭装置能及时有效封闭胸腔，变开放性胸外伤为闭合性胸外伤，适合开放性胸外伤的前线救治及院前急救。气柱调压式外固定胸带能及时有效的固定胸壁，减轻疼痛，改善呼吸，促进肺功能的恢复，适合胸部创伤的前线救治、院前急救及临床胸部术后患者的胸部固定。
[Abstract]:background
The incidence of thoracic traumaTT (IR) in all previous wars (IR) is about 8%, and the direct cause of death accounts for 25% of the death of the trauma. It is the second cause of death in the type of trauma only next to the craniocerebral injury. Open chest trauma is the main injury caused by the death in the chest trauma, and the open chest trauma caused by the explosion injury during the war. More common, open chest trauma accounts for 7% to 12% of the total number of wounded. In the naval battle, the incidence is up to 20%., if it can be treated at the front, it will create an opportunity for follow-up treatment and greatly reduce the death rate of open chest trauma (MR). The most important first aid method of open chest trauma is the early side rescue. It is important to restore the integrity of the chest wall and the negative pressure in the chest as soon as possible to prevent severe respiratory dysfunction. How to close the thoracic cavity in time and effectively is the key. Open chest trauma combined with rib fracture and even flail chest (flail chest FC), the patient often causes severe chest pain and breathing difficulties during the closed chest delivery. It is difficult to restrain the respiratory movement of the patients and to choose the proper material to fix the chest wall, which can effectively relieve the pain of the chest wall and prevent the collapse of the chest wall as an integral part of the treatment of chest trauma. Equipment and other first-aid equipment, the simple gauze dressings used in first aid have various shortcomings, which can not meet the needs of ETOB and pre-HC, and have developed and equipped simple emergency equipment to simplify operation, implement timely, correct front line treatment and pre hospital first aid, and reduce the mortality rate (MR). Important practical significance.
Part I: Design and fabrication of a temporary thoracic sealing device with one-way valve disc and animal experimental study
Objective: to design and prepare one way valve petal temporary pleural sealing device, and to evaluate the closed effect in the first aid of open chest trauma through the open chest trauma field first aid animal experiment.
Methods: dogs were used as experimental animals. The animals were randomly divided into control group (4 rats) and experimental group (4 rats) to establish an open thoracic injury animal model. The control group was closed by the common clinical application, and the experimental group was closed by the one way valve temporary pleural sealing device. The closed thoracic operation time of the 2 groups of dogs was observed and the thoracic closed drainage was performed. Operating time, heart rate, respiratory rate, oxygen saturation, maximal pulling force and drainage effect of thoracic cavity sealing device were studied.
Results: the experimental group was (0.58 + 0.14) min, and the control group was (1.17 + 0.21) min. The two groups had statistical significance (P0.01), the former was superior to the latter; the operation time of the closed thoracic drainage in the experimental group was (0.48 + 0.07) min, the control group was (2.20 + 0.11) min, and the two groups were statistically significant (P0.01), the former was superior to the latter. In the experimental group, the changes of heart rate (HR), respiratory frequency (RR) and oxygen saturation (SpO2) before and after thoracic closure were statistically significant (P 0.05). There was no significant difference between the two groups after drainage at each time point in the pleural effusion (P0.05).
Conclusion: the one way valve petal temporary pleural sealing device can effectively close the thoracic cavity in time, and the open chest trauma is closed thoracic trauma. The fixation effect is accurate, then it can be used for the effective thoracic closed drainage and the following treatment. It is suitable for the frontline treatment and pre hospital emergency treatment for open chest trauma patients.
Part 2: Design, fabrication and clinical trial of pneumatic pressure-adjustable external fixation chest band
Objective: To design and prepare a pneumatic pressure-regulated external fixation chest band, and to evaluate its effect on chest trauma fixation, pain relief and breathing improvement through clinical controlled trials.
Methods: 50 patients in our department were randomly divided into experimental group and control group by digital table method, with 25 cases in each group. The experimental group used air column pressure regulating external fixed chest band to fix the chest, and the control group used the common elastic chest band. The pain score (VAS) and the respiratory frequency (RR) were observed in the two groups of patients at all time points at all time points. A portable pulmonary function tester was used to test the pulmonary function of two groups of patients before and after operation 24h, 48h, 72h. Blood gas analysis was performed before and after operation, 24h, 48h, 72h. The first active cough time of two groups of patients after operation, the total amount of thoracic injection, the extraction time of thoracic duct, the number of hospitalization days after operation, the incidence of pulmonary complications (IR) and the total dosage of analgesics were recorded.
Results: the pain scores and respiratory frequency differences of 3H, 6h, 24h, 48h and 72h were statistically significant (P 0.05) in the experimental group and the control group (P 0.05). The pain scores and respiratory frequency differences were statistically significant (P 0.05) in the experimental group and the control group after the operation of 3H, 6h, 24h, 48h, and 72h (P 0.05). FEV1% estimated value, the difference between the MVV% predicted value and the control group was statistically significant (P 0.05), the difference between the experimental group FEV1/FVC and the control group was not statistically significant (P0.05). The difference between the experimental group PaO2, PaCO2, SpO2 and the control group was not statistically significant (P0.05). In the experimental group, the first active cough time after the operation, the dosage of postoperative analgesic drugs and the control group were in the experimental group. The difference was statistically significant (P 0.05). There was no significant difference between the total amount of thoracic fluid intake in the experimental group, the time of drainage tube extraction, the number of days after the operation and the incidence of pulmonary complications compared with the control group (P0.05).
Conclusion: the external fixation of air column pressure external fixation has a beautiful appearance, the material is safe and soft, the patient has strong comfort after wearing, and its fixation effect is accurate. It can improve the pain threshold of the patient, reduce the pain of the patient, promote the patient's active cough and expectoration, and be beneficial to the recovery of lung function. It should be used for emergency treatment of chest trauma patients and postoperative chest surgery. The patient's chest is fixed.
Combined with the results of the above experimental results, this study shows that the one way valve petal temporary pleural sealing device can effectively close the thoracic cavity in time, change the open chest trauma to closed thoracic trauma, and be suitable for the frontline and pre hospital emergency treatment of open thoracic trauma. The recovery of lung function is suitable for front-line treatment of chest trauma, pre-hospital first aid and chest fixation of patients after clinical thoracic surgery.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R655

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