【摘要】：背景 胸部創(chuàng)傷（thoracic traumaTT）在歷次戰(zhàn)爭(zhēng)中發(fā)生率（IR)約占8％，直接導(dǎo)致的死亡占創(chuàng)傷死亡的25％，是導(dǎo)致死亡的創(chuàng)傷類型中僅次于顱腦傷的第2位原因。開(kāi)放性胸外傷是胸部創(chuàng)傷中導(dǎo)致死亡的主要傷情，在戰(zhàn)時(shí)因爆炸傷導(dǎo)致的開(kāi)放性胸外傷較為多見(jiàn)，陸戰(zhàn)中，開(kāi)放性胸外傷占傷員總數(shù)的7％～12％，在海戰(zhàn)中，發(fā)生率更是高達(dá)20%。如果能夠進(jìn)行前線現(xiàn)場(chǎng)救治，將為后續(xù)治療創(chuàng)造機(jī)會(huì)，極大地降低開(kāi)放性胸部創(chuàng)傷的死亡率（MR)。開(kāi)放性胸外傷最主要的急救方法是早期邊搶救邊判明傷情，盡早恢復(fù)胸壁完整性及胸內(nèi)負(fù)壓，防止出現(xiàn)嚴(yán)重呼吸循環(huán)功能障礙，如何及時(shí)有效的封閉胸腔成為關(guān)鍵所在。開(kāi)放性胸外傷多合并肋骨骨折甚至是連枷胸（flail chest FC），在胸腔封閉后送途中，患者常常引起胸部劇烈疼痛和呼吸困難，嚴(yán)重抑制患者的呼吸運(yùn)動(dòng)，，選擇合適的材料固定胸壁，能夠有效鎮(zhèn)痛，防止胸壁內(nèi)陷也成為救治胸部創(chuàng)傷患者不可或缺的一環(huán)。而在我軍以往的救治方案和裝備中，尚未檢索到制式的開(kāi)放性胸外傷現(xiàn)場(chǎng)臨時(shí)胸腔封閉裝置及胸壁固定裝置等急救器材，通常急救所用的簡(jiǎn)單的紗布敷料等物品存在種種缺點(diǎn)，無(wú)法滿足戰(zhàn)場(chǎng)急救（ETOB）及院前急救（pre-HC）的需要。研制并裝備簡(jiǎn)易的急救器材以簡(jiǎn)化手術(shù)操作，實(shí)施及時(shí)、正確的前線現(xiàn)場(chǎng)救治及院前急救，對(duì)降低死亡率（MR）具有重要現(xiàn)實(shí)意義。 第一部分：?jiǎn)蜗蜷y瓣臨時(shí)胸腔封閉裝置的設(shè)計(jì)制備及動(dòng)物實(shí)驗(yàn)研究 目的：設(shè)計(jì)制備單向閥瓣臨時(shí)胸腔封閉裝置，并通過(guò)開(kāi)放性胸部創(chuàng)傷現(xiàn)場(chǎng)急救動(dòng)物實(shí)驗(yàn)，評(píng)價(jià)其在開(kāi)放性胸部創(chuàng)傷的急救中的封閉效果。 方法：以犬為實(shí)驗(yàn)動(dòng)物，采用數(shù)字表法隨機(jī)分為對(duì)照組（4只）和實(shí)驗(yàn)組（4只），建立開(kāi)放性胸外傷動(dòng)物模型。對(duì)照組以臨床常用敷貼加壓封閉，實(shí)驗(yàn)組以單向閥瓣臨時(shí)胸腔封閉裝置封閉。觀察2組犬的胸腔封閉固定操作時(shí)間、胸腔閉式引流術(shù)操作時(shí)間、實(shí)驗(yàn)犬心率、呼吸頻率、血氧飽和度變化、胸腔封閉裝置所承受的最大拉力及引流效果。 結(jié)果：實(shí)驗(yàn)組胸腔封閉實(shí)驗(yàn)組為（0.58±0.14）min，對(duì)照組為（1.17±0.21）min，兩組差異有統(tǒng)計(jì)學(xué)意義（P0.01），前者優(yōu)于后者；實(shí)驗(yàn)組后續(xù)胸腔閉式引流術(shù)操作時(shí)間為（0.48±0.07）min，對(duì)照組時(shí)間為（2.20±0.11）min，兩組差異有統(tǒng)計(jì)學(xué)意義（P0.01），前者優(yōu)于后者。實(shí)驗(yàn)組在胸腔封閉前后心率(HR)、呼吸頻率（RR）、血氧飽和度（SpO2）變化與對(duì)照組相比差異均有統(tǒng)計(jì)學(xué)意義（P 0.05）,兩組引流術(shù)后各時(shí)間點(diǎn)胸腔積液積血引流量差異無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。 結(jié)論：?jiǎn)蜗蜷y瓣臨時(shí)胸腔封閉裝置能及時(shí)有效封閉胸腔，變開(kāi)放性胸外傷為閉合性胸外傷，固定效果確切，繼而為實(shí)施有效的胸腔閉式引流術(shù)以及后續(xù)治療創(chuàng)造條件，適合應(yīng)用于開(kāi)放性胸外傷患者的前線救治及院前急救。 第二部分：氣柱調(diào)壓式外固定胸帶的設(shè)計(jì)制備與臨床試驗(yàn)研究 目的：設(shè)計(jì)制備氣柱調(diào)壓式外固定胸帶，并通過(guò)臨床對(duì)照試驗(yàn)評(píng)價(jià)其對(duì)胸部創(chuàng)傷的固定、減輕疼痛及改善呼吸的效果。 方法：將我科50例開(kāi)胸術(shù)后患者采用數(shù)字表法隨機(jī)分成實(shí)驗(yàn)組和對(duì)照組，每組各25例，實(shí)驗(yàn)組術(shù)后使用氣柱調(diào)壓式外固定胸帶固定胸部，對(duì)照組使用普通彈性胸帶，觀察兩組患者術(shù)后各時(shí)間點(diǎn)平靜及咳嗽時(shí)疼痛評(píng)分（VAS）、呼吸頻率(RR)，用便攜式肺功能儀測(cè)試兩組患者術(shù)前及術(shù)后24h、48h、72h的肺功能，術(shù)前及術(shù)后24h、48h、72h行血?dú)夥治鰴z查，記錄兩組患者術(shù)后第1次主動(dòng)咳嗽時(shí)間、胸引液總量、胸引管拔除時(shí)間、術(shù)后住院天數(shù)、肺部并發(fā)癥的發(fā)生率(IR)及止痛藥的使用總劑量。 結(jié)果：實(shí)驗(yàn)組與對(duì)照組術(shù)后3h、6h、24h、48h、72h平靜時(shí)疼痛評(píng)分及呼吸頻率差異均具有統(tǒng)計(jì)學(xué)意義(P 0.05)；實(shí)驗(yàn)組與對(duì)照組術(shù)后3h、6h、24h、48h、72h咳嗽時(shí)疼痛評(píng)分及呼吸頻率差異均具有統(tǒng)計(jì)學(xué)意義(P 0.05)；實(shí)驗(yàn)組患者術(shù)后FVC、FEV1、MVV、FVC%預(yù)計(jì)值、FEV1%預(yù)計(jì)值、MVV%預(yù)計(jì)值與對(duì)照組的差異有統(tǒng)計(jì)學(xué)意義（P 0.05），實(shí)驗(yàn)組FEV1/FVC與對(duì)照組的差異無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）；實(shí)驗(yàn)組PaO2、PaCO2、SpO2與對(duì)照組的差異無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。實(shí)驗(yàn)組術(shù)后第1次主動(dòng)咳嗽時(shí)間、術(shù)后鎮(zhèn)痛藥物的使用劑量與對(duì)照組的差異具有統(tǒng)計(jì)學(xué)意義（P 0.05），實(shí)驗(yàn)組胸引液總量、引流管拔除時(shí)間、術(shù)后住院天數(shù)、肺部并發(fā)癥發(fā)生率與對(duì)照組比較的差異均無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。 結(jié)論：氣柱調(diào)壓式外固定胸帶外形美觀、選用材料安全柔和，患者佩戴后舒適感強(qiáng)，其固定效果確切，能提高患者的疼痛閾值，減輕患者痛苦，促進(jìn)患者主動(dòng)咳嗽咳痰，有利于肺功能的恢復(fù)，適合應(yīng)用于胸部創(chuàng)傷患者的緊急救治及胸部術(shù)后患者的胸部固定。 綜合上述實(shí)驗(yàn)結(jié)果，本研究顯示：?jiǎn)蜗蜷y瓣臨時(shí)胸腔封閉裝置能及時(shí)有效封閉胸腔，變開(kāi)放性胸外傷為閉合性胸外傷，適合開(kāi)放性胸外傷的前線救治及院前急救。氣柱調(diào)壓式外固定胸帶能及時(shí)有效的固定胸壁，減輕疼痛，改善呼吸，促進(jìn)肺功能的恢復(fù)，適合胸部創(chuàng)傷的前線救治、院前急救及臨床胸部術(shù)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.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R655

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