创伤控制理论.

创伤控制理论•是一种理念、不是一种技术•针对多发伤•在最适当的时机做作最恰当的手术回顾•50S•toosicktooperateon……•三句话——butwaitafewdays不要急诊髓内钉最好等两天1970s——EarlyTotalCare早期完全干预多发伤、复合伤的理解创伤级联瀑布学说n＋n＋n＋n+…＞nm≠damagecontrolsurgery创伤控制手术•80S•来自腹部外科的实践•三步法创伤控制骨科•利用创伤控制理论指导骨科实践•为了降低有多发伤、合并伤患者的死亡率•为了预防SIRS的发生率内容外固定支架暂时稳定创伤监护病房确定性手术优势•双赢•便于后续处理•控制出血•骨折的稳定什么样的病人要做创伤控制手术•Stable稳定——想怎么做都行dowhateveryouwant•Borderline临界点•Unstable不稳定、随时有生命危险•Inextremis已经濒临死亡了关键是borderline的转化什么是borderlineBorderline•①多发性损伤ISS20分，附加胸部损伤(简明损伤评分——AIs2分)：②多发性损伤伴有腹部、骨盆损伤(Moore评分3分)并出血性休克、入院时血压90mmHg③ISS40分而不附加胸部损伤：④入院时第一张胸片发现双肺挫伤：⑤早期平均肺动脉压24mmHg：⑥多发性长骨骨折与躯干损伤AIS≥2分：⑦估计手术时间6h：•一些提示、能让你记着的–pH7.24–Temperature35oC–Operativetime90minutes–高凝状态–老年病人(physiologicage65)PelvicFractures•针对分型临时固定•片子做出大致的判断、神经损伤、失血、不等长•是创伤控制理论中要重点处理的•简单、快速•很重要FemurFractures•胸部损伤•双侧股骨干骨折、26.8%•血乳酸盐•扩髓与非扩髓肢体创伤控制骨科•DCOprinciplesappliedtoasingle,severelyinjuredlimb–原则上都能用–高能量胫骨近端骨折–股骨–GradeIIIBandCopenfractures–MangledextremtiesSecondaryProcedures•Days2,3,and4不合适•Objectivetests客观的检查标准–Lacticacid/pH–IL-6500骨牵引还是外固定架对于创伤控制来说没有差别？血清乳酸盐的测定对股骨干骨折髓内手术的重要参考OrthopaedicEmergencies•脱位•Vascularcompromise血管损伤•Compartmentsyndrome间室综合症•血流动力不稳定的骨盆骨折Dislocations–Proximalhumerusfracturewithhumeralheaddislocation肱骨近端骨折伴脱位–Femoralneckfracturewithhipdislocation股骨颈骨折伴脱位–一切可能引发血运障碍从而延缓骨折愈合的DislocationsVascularCompromise•要重视闭合性血管损伤•要重视血管探查手术•要重视体检的意义•不是造影的指征、特别是腘动脉伤•动态观测CompartmentSyndrome•Whenindoubt,release该切就切、警惕部分后果OpenFracture•Whentodebride?什么时间清创•Whentofix?什么时间固定•Whentoclose/cover?什么时间闭合创面TimingofDebridement•6hourrulebasedonFreidrich’sstudyofbacteriareplicationrates黄金6小时？•Onlyonestudysupportsthe6hourrule,whilesevenstudiesoverthelast30yearsshownosignificantdifference1和6TimingofDebridement•study–Timetodebridementdidnotpredictinfection其实没啥关系–Timetoadmissiondidcorrelatewithinfection•Antibioticadministration•Resuscitation•入院时间和复苏时间和抗生素的投放TimingofDebridement•Ultimately,qualityofdebridementismostimportantTimingofFixation•MaybeperformedattimeofinitialdebridementforgradeI,II,IIIafractures•Considerdelayedfixationforfracturesgrosslycontaminatedwithdirt,stagnantwaterorfarmyardrelatedinjuries.•Delayedfixationandutilizationofbeadpouchesand/orVACdressingsforfracturesrequiringsofttissuecoverage•ReamingofopenfractureswellsupportedTimingofClosure•TheearlyclosureofopenfracturesgradeI,II,IIIaisrecommendedwiththeexceptionofwoundsgrosslycontaminatedwithdirt,stagnantwaterorfarmyardrelatedinjuries•“Secondlook”debridementwarrantedwhenthereisconcernforfurthertissuecompromiseorhighinitialcontamination•Freeflapsmayoutperformlocalflaps结论•(DCO)和(ETC)•DCO的适应证•Unresolvedissues–borderlinepatient–股骨干骨折的处理headand/orchesttraumaThankYou!最重要的是，说服你的麻醉师吧！P.V.Giannoudis