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目的:探讨严重多发伤的院内分期救治策略。方法:回顾性分析我科2008-01-2012-12收治的204例严重多发伤患者的临床资料。本研究将病例分为3组:组1,以胸伤腹伤为主的病例107例(52.5%);组2,以四肢骨盆脊柱骨折为主的病例79例(38.7%);组3,以胸伤腹伤四肢骨盆脊柱骨折均严重的18例(8.8%)。采用分期救治的策略,即按照严重多发伤在不同治疗阶段(手术复苏期、脏器功能支持期、创伤修复期和功能康复期)的特点,对伤者进行救治的方法。主要分析了手术复苏期各种急诊手术的复苏方式,心肺肝肾等各个主要脏器的功能支持手段以及创伤修复的方式。结果:全组204例,存活190例,存活率93.1%;死亡14例,死亡率6.9%。其中以胸伤腹伤为主的107例病例中,存活100例(93.5%),死亡7例(6.5%);以四肢骨盆脊柱骨折为主的79例病例中,存活77例(97.5%),死亡2例(2.5%);以胸伤腹伤四肢骨盆脊柱骨折均严重的18例病例中,存活13例(72.2%),死亡5例(27.8%)。全组病例在手术复苏期死亡8例,占死亡总数的57.1%,死亡原因:创伤失血性休克3例,急性肺挫裂伤呼吸功能衰竭2例,弥散性血管内凝血(DIC)2例,急性脂肪栓塞并肺栓塞1例;在脏器功能支持期死亡4例,占死亡总数的28.6%,死亡原因:急性呼吸窘迫综合征(ARDS)2例,严重脓毒血症并发多器官功能障碍综合征(MODS)2例;在创伤修复期死亡2例,占死亡总数的14.3%,死亡原因:迟发型肠坏死和创伤后脓胸全身感染各1例。结论:从接诊严重多发伤的第一刻起,特别是胸伤腹伤或合并骨盆脊柱损伤,即应主动、有计划地实施分期救治。掌握手术复苏期合理的手术复苏方式、加强重要脏器的功能支持以及选择最佳的创伤修复方式,是提高救治成功率、实施多发伤分期救治一体化模式的重要途径。
Objective: To investigate the staging strategy of severe multiple trauma in hospital. Methods: The clinical data of 204 patients with severe multiple trauma admitted in our department from January 2008 to January 2012 were retrospectively analyzed. In this study, the patients were divided into three groups: group 1, 107 cases (52.5%) were mainly abdominal incisional wounds; group 2, 79 cases (38.7%) were mainly pelvic spinal fractures; Group 3, Abdominal pelvic fractures were all severe in 18 cases (8.8%). The strategy of staging treatment is to treat the injured patients according to the characteristics of severe multiple trauma in different stages of treatment (surgical recovery period, organ function support period, trauma repair period and functional rehabilitation period). Mainly analyzed the resuscitation of various emergency surgery recovery methods, heart and lungs and liver and other major organs of the functional support methods and methods of wound repair. Results: The whole group of 204 cases, 190 cases of survival, the survival rate of 93.1%; 14 cases of death, the mortality rate of 6.9%. Of the 107 cases, which mainly consisted of chest wounds and abdomen wounds, 100 (93.5%) survived and 7 (6.5%) died. Of the 79 cases with pelvic spine fractures, 77 survived (97.5%), , And 2 deaths (2.5%). Among the 18 cases with severe abdominal and pelvic fractures of the limbs, 13 (72.2%) survived and 5 (27.8%) died. All the patients died during the surgical resuscitation in 8 cases, accounting for 57.1% of the total deaths. The causes of death were: 3 cases of traumatic hemorrhagic shock, 2 cases of respiratory failure of acute pulmonary contusion and laceration, 2 cases of disseminated intravascular coagulation (DIC) 1 case of acute fat embolism and pulmonary embolism; 4 cases died of organ function support, accounting for 28.6% of the total deaths, causes of death: 2 cases of acute respiratory distress syndrome (ARDS), severe sepsis with multiple organ dysfunction 2 cases of syndrome (MODS); 2 cases died of wound repair, accounting for 14.3% of the total deaths, causes of death: delayed intestinal necrosis and systemic infection of post-traumatic empyema in 1 case. CONCLUSIONS: From the very first moment of admissions for severe multiple traumatic injuries, especially the traumatic abdominal injury or combined pelvic spine injury, staging should be implemented actively and systematically. It is an important way to improve the success rate of treatment and to implement the multi-injury staging model to grasp the reasonable surgical recovery mode, strengthen the functional support of important organs and choose the best wound repair method.