创伤性截肢的流行病学特征及其一种常见原因（创面血管破裂）的临床分析

发布时间：2018-06-18 20:27

本文选题：流行病学 + 创伤　；参考：《河北医科大学》2016年硕士论文

【摘要】：目的:截肢作为创伤后的严重并发症,无论是对临床工作者还是患者及其家属,都是一项巨大的挑战,临床工作者应对其有全面而客观的了解。而创伤后创面出现的大出血则是导致截肢的重要原因之一,应引起临床工作者的重视,在出现此类并发症时积极有效地进行处理。为此,我们对此类患者的病历进行了详尽的回顾性研究,旨在对临床工作作出指导。方法:对2009年1月至2013年12月期间河北医科大学第三医院收治的由于创伤导致的截肢患者以及2006年1月至2013年7月我院收治的严重软组织损伤后出现创面血管破裂并发生急性大出血的患者的病历资料进行回顾性调查。利用我院病案查询系统调取创伤性截肢患者的病历资料,由6名经过统一培训的医护人员按设计要求进行资料查询和收集。首先设计调查表,随机选取30份病例进行预调查,并根据调查结果对调查表的内容进行修改,最终确定的调查项目包括:年龄、性别、受伤机制、损伤类型、损伤程度、伤后就诊时间、手术次数、住院天数、以及截肢的时机、部位、原因等。损伤程度的评估:对开放性损伤患者使用Gustilo分型和MESS评分;对于闭合性损伤,由于缺乏客观的评价方法,且损伤程度难以界定,因此主要采取描述性语言对其血运及组织坏死程度进行叙述。采用Excel表进行资料的录入与整理,运用SPSS 19.0统计软件对数据进行统计描述和分析。计量资料用(?)±S表示,并使用两个独立样本的t检验,对不同截肢时机患者的住院时间及手术次数进行比较,P0.05为有统计学意义。结果:2009年至2013年我院共收治创伤患者71569例,其中截肢患者651例(668肢),截肢率约为0.91%。男性525例(80.65%),女性126例(19.35%),男女比例为4.17:1。年龄从10个月至77岁不等,平均39.02±15.12岁,其中41-50岁截肢人病人例数最多。在668个肢体中,上肢238肢(35.63%),其中前臂截肢率最高,约占半数;下肢430肢X(64.37%),其中以小腿截肢率最高,超过半数。651例截肢患者受伤原因,交通事故居于首位,其他常见原因有机器伤、重物砸伤、爆炸伤、高空坠落伤,其他原因较为少见,均不足1%。上肢截肢和下肢截肢的受伤原因有所不同,上肢截肢以机器伤为主(72.77%),下肢截肢以交通事故为主(70.67%)。本组截肢病人绝大多数为开放伤,共计614例(94.32%)。Gustilo分型中,2A型1例,3A型5例,3B型28例,其余494例(93.56%)均为3C型。MESS评分结果如表5所示,其中7分者24例(4.55%),≥7分者504例(95.45%)。I期截肢391个肢体(58.53%),II期截肢258个肢体(38.62%),III期截肢20个肢体(2.85%),II期截肢患者的住院天数和手术次数均多于I期截肢患者。开放性截肢140肢(20.96%),闭合截肢528肢(79.04%),无论是在住院时间还是手术次数方面,开放性截肢均大于闭合性截肢。2006年1月至2013年7月,我院收治的严重软组织损伤患者中有45例创面血管破裂发生急性大出血。32例为动脉出血,其中下肢动脉出血18例(髂外动脉出血3例,股动脉出血3例,乆动脉6例,胫前、后动脉5例,足背动脉1例),上肢动脉出血14例(腋动脉1例,肱动脉9例,桡动脉2例,指间动脉1例,肩部无名小动脉1例);13例为静脉出血,其中下肢静脉出血9例(股静脉2例,其余为小静脉),上肢静脉出血4例(腋静脉、贵要静脉各1例,小静脉2例)。MESS评分≥7分37例(下肢24例,上肢13例),7例行Ⅰ期截肢,17例出血后行Ⅱ期截肢,13例未予截肢;MESS评分7分者8例,1例行手指近端Ⅰ期截指外,7例保肢成功。共计25例截肢(指)患者中上肢6例,下肢19例。紧急止血方法:1例使用VSD者停用负压后出血自行停止,21例止血带止血,11例加压包扎止血,8例指压法止血,4例钳夹法止血;其中30例患者在选用上述紧急方法前首先对创面进行直接压迫止血;39例紧急止血后行手术止血:12例行血管结扎术(11例动脉,1例静脉),17例行截肢术(其中2例患者截肢同时行高位动脉结扎),7例行动脉(1例胫前动脉,1例胫后动脉,5例肱动脉)修补术,5例单纯清创术。结论:通过对2009年至2013年5年间因外伤导致的截肢患者的调查研究,可以粗略了解截肢的流行病学特点及其好发因素,为临床预防和治疗提供参考。但由于截肢患者伤情严重且复杂,难以全面地对其进行分析,且本文为为回顾性调查,其中难免出现误差,还需要进一步调查研究。对于创面继发性出血的止血分3步:(1)发现出血后立即进行创面压迫止血;(2)根据出血性质、出血部位以及MESS评分采用有效的止血方法,首选加压包扎,其次指压止血或钳夹止血,无效时或肢体保肢无望时选择止血带;(3)进行手术彻底止血。通过上述步骤,尽可能达到即不损伤肢体软组织,又能有效止血的目的。
[Abstract]:Objective: amputation is a serious complication after trauma. It is a great challenge for clinical workers, patients and their family members. The clinical workers should have a comprehensive and objective understanding of it. The massive bleeding of the wound surface after trauma is one of the important causes of amputation. This kind of complication is active and effective. To this end, we have carried out a detailed review of the medical records of these patients to guide the clinical work. Methods: Patients with trauma guided amputations admitted to the Third Hospital of Hebei Medical University from January 2009 to December 2013 and from January 2006 to July 2013. The medical records of patients with traumatic amputation were collected by the medical record system of our hospital, and 6 medical and nursing staff who had been trained in the unified training were collected and collected according to the design requirements. The questionnaire, randomly selected 30 cases for pre investigation, and revised the contents of the questionnaire according to the results of the survey. The final investigation items included age, sex, injury mechanism, injury type, injury degree, time of treatment after injury, number of operations, days of hospitalization, time, location, cause, etc. of amputation, and the assessment of damage degree: Gustilo typing and MESS score were used for patients with open injury. For closed injury, due to lack of objective evaluation methods, and the degree of injury was difficult to define, descriptive language was used to describe the blood transport and tissue necrosis. The Excel table was used to record and arrange the data, and the logarithm of SPSS 19 statistical software was used. According to the statistical description and analysis, the measurement data were expressed with (?) + S, and the t test of two independent samples was used to compare the hospitalization time and the number of operation times of the patients with different amputations. The results showed that there were 71569 cases of trauma patients in our hospital from 2009 to 2013, of which 651 cases (668 limbs) were amputated, and the amputation rate was about For 0.91%. male 525 (80.65%), female 126 cases (19.35%), the ratio of men and women was from 10 months to 77 years from 10 months to 77 years. The average number of amputations at 41-50 years was the most. In 668 limbs, the upper extremity of 238 limbs (35.63%), of which the forearm amputation rate was the highest, about half of the limbs, and lower limb 430 limbs X (64.37%), among which the amputation rate of the calf was the most. High, more than half of the.651 cases of amputation patients were injured in the first place. Other common causes were machine injury, heavy weight injury, explosion injury, high altitude falling injury, and other reasons were rare. All the causes were different from 1%. upper limb amputation and lower limb amputation. The main limb amputation was machine injury (72.77%), lower limb amputation with traffic accident. The majority of the amputation patients were open injuries, including 614 cases (94.32%).Gustilo type, 1 cases of type 2A, 5 cases of type 3A, 28 cases of type 3B, and the other 494 cases (93.56%), such as 3C, as shown in Table 5, 7 of 24 cases (4.55%),.I stage amputations and II stage amputations. 8.62%) stage III amputation of 20 limbs (2.85%), II amputation patients in hospital days and the number of operations are more than the I amputation patients. Open amputation 140 limbs (20.96%), closed amputation 528 limbs (79.04%), whether in hospital time or the number of operations, open amputation is greater than closed amputation for.2006 years from January to July 2013, our hospital treated. Of the patients with severe soft tissue injury, there were 45 cases of acute massive hemorrhage of the wound of the wound, including 18 cases of lower extremity arterial hemorrhage (3 cases of external iliac artery hemorrhage, 3 cases of femoral artery hemorrhage, 6 cases of arterial artery, 5 cases of anterior tibial artery, 1 cases of dorsal artery, 14 cases of artery 1 cases, 9 cases of brachial artery, 2 of radial artery, of the radial artery, and between the fingers. " There were 1 cases of artery and 1 cases of innominate arterioles in the shoulder; 13 cases were venous hemorrhage, of which 9 cases of lower extremity venous hemorrhage (2 cases of femoral vein, other small veins), 4 cases of upper limb venous hemorrhage (axillary vein, 1 case of precious vein and 2 case of small vein).MESS score of 37 cases (24 cases of lower extremity, 13 cases), 7 routine stage I amputation and second stage amputation after hemorrhage after hemorrhage Amputation; 8 cases of MESS score 7, 1 cases outside of the proximal finger of the finger, 7 cases of limb salvage. There were 6 cases of upper extremity in 25 amputation (finger), 19 cases of lower limbs, 19 cases of lower limbs. 1 cases were stopped bleeding after negative pressure, 21 cases of tourniquet with tourniquet, 11 cases of pressure bandage hemostasis, 8 cases of finger pressing hemostasis, 4 cases clamping hemostasis, 30 30. The patients underwent direct compression and hemostasis of the wound before using the above emergency method, and 39 cases underwent hemostasis after emergency hemostasis: 12 cases of vascular ligation (11 cases of artery, 1 cases of veins), 17 cases of amputation (2 cases of amputation and high artery ligation), 7 cases of action pulse (1 cases of tibial artery, 1 case of posterior tibial artery, 5 case of brachial artery) Supplement, 5 cases of Dan Chunqing creation. Conclusion: through the investigation and study of the amputation patients caused by trauma from 2009 to 2013, the epidemiological characteristics and good factors of amputation can be roughly understood to provide reference for clinical prevention and treatment. However, it is difficult to analyze the amputation in an all-round way because of the severity and complexity of the amputated patients. For retrospective investigation, it is unavoidable to have errors and need further investigation. 3 steps are needed to stop bleeding from secondary bleeding: (1) to stop bleeding immediately after bleeding; (2) to use effective hemostasis according to the nature of bleeding, bleeding site and MESS score, the first choice is compression bandage, followed by finger pressure hemostasis or clamp. Stop bleeding, ineffective or limb salvage when the limb is hopeless to choose tourniquet; (3) complete hemostasis by operation. Through the above steps, as far as possible to achieve the purpose of not damaging the soft tissue of the limbs and effective hemostasis.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R641

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