本文選題：流行病學(xué) + 創(chuàng)傷�。� 參考：《河北醫(yī)科大學(xué)》2016年碩士論文

【摘要】：目的:截肢作為創(chuàng)傷后的嚴(yán)重并發(fā)癥,無論是對臨床工作者還是患者及其家屬,都是一項巨大的挑戰(zhàn),臨床工作者應(yīng)對其有全面而客觀的了解。而創(chuàng)傷后創(chuàng)面出現(xiàn)的大出血則是導(dǎo)致截肢的重要原因之一,應(yīng)引起臨床工作者的重視,在出現(xiàn)此類并發(fā)癥時積極有效地進行處理。為此,我們對此類患者的病歷進行了詳盡的回顧性研究,旨在對臨床工作作出指導(dǎo)。方法:對2009年1月至2013年12月期間河北醫(yī)科大學(xué)第三醫(yī)院收治的由于創(chuàng)傷導(dǎo)致的截肢患者以及2006年1月至2013年7月我院收治的嚴(yán)重軟組織損傷后出現(xiàn)創(chuàng)面血管破裂并發(fā)生急性大出血的患者的病歷資料進行回顧性調(diào)查。利用我院病案查詢系統(tǒng)調(diào)取創(chuàng)傷性截肢患者的病歷資料,由6名經(jīng)過統(tǒng)一培訓(xùn)的醫(yī)護人員按設(shè)計要求進行資料查詢和收集。首先設(shè)計調(diào)查表,隨機選取30份病例進行預(yù)調(diào)查,并根據(jù)調(diào)查結(jié)果對調(diào)查表的內(nèi)容進行修改,最終確定的調(diào)查項目包括:年齡、性別、受傷機制、損傷類型、損傷程度、傷后就診時間、手術(shù)次數(shù)、住院天數(shù)、以及截肢的時機、部位、原因等。損傷程度的評估:對開放性損傷患者使用Gustilo分型和MESS評分;對于閉合性損傷,由于缺乏客觀的評價方法,且損傷程度難以界定,因此主要采取描述性語言對其血運及組織壞死程度進行敘述。采用Excel表進行資料的錄入與整理,運用SPSS 19.0統(tǒng)計軟件對數(shù)據(jù)進行統(tǒng)計描述和分析。計量資料用(?)±S表示,并使用兩個獨立樣本的t檢驗,對不同截肢時機患者的住院時間及手術(shù)次數(shù)進行比較,P0.05為有統(tǒng)計學(xué)意義。結(jié)果:2009年至2013年我院共收治創(chuàng)傷患者71569例,其中截肢患者651例(668肢),截肢率約為0.91%。男性525例(80.65%),女性126例(19.35%),男女比例為4.17:1。年齡從10個月至77歲不等,平均39.02±15.12歲,其中41-50歲截肢人病人例數(shù)最多。在668個肢體中,上肢238肢(35.63%),其中前臂截肢率最高,約占半數(shù);下肢430肢X(64.37%),其中以小腿截肢率最高,超過半數(shù)。651例截肢患者受傷原因,交通事故居于首位,其他常見原因有機器傷、重物砸傷、爆炸傷、高空墜落傷,其他原因較為少見,均不足1%。上肢截肢和下肢截肢的受傷原因有所不同,上肢截肢以機器傷為主(72.77%),下肢截肢以交通事故為主(70.67%)。本組截肢病人絕大多數(shù)為開放傷,共計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%)均為3C型。MESS評分結(jié)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個肢體(58.53%),II期截肢258個肢體(38.62%),III期截肢20個肢體(2.85%),II期截肢患者的住院天數(shù)和手術(shù)次數(shù)均多于I期截肢患者。開放性截肢140肢(20.96%),閉合截肢528肢(79.04%),無論是在住院時間還是手術(shù)次數(shù)方面,開放性截肢均大于閉合性截肢。2006年1月至2013年7月,我院收治的嚴(yán)重軟組織損傷患者中有45例創(chuàng)面血管破裂發(fā)生急性大出血。32例為動脈出血,其中下肢動脈出血18例(髂外動脈出血3例,股動脈出血3例,乆動脈6例,脛前、后動脈5例,足背動脈1例),上肢動脈出血14例(腋動脈1例,肱動脈9例,橈動脈2例,指間動脈1例,肩部無名小動脈1例);13例為靜脈出血,其中下肢靜脈出血9例(股靜脈2例,其余為小靜脈),上肢靜脈出血4例(腋靜脈、貴要靜脈各1例,小靜脈2例)。MESS評分≥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評分7分者8例,1例行手指近端Ⅰ期截指外,7例保肢成功。共計25例截肢(指)患者中上肢6例,下肢19例。緊急止血方法:1例使用VSD者停用負(fù)壓后出血自行停止,21例止血帶止血,11例加壓包扎止血,8例指壓法止血,4例鉗夾法止血;其中30例患者在選用上述緊急方法前首先對創(chuàng)面進行直接壓迫止血;39例緊急止血后行手術(shù)止血:12例行血管結(jié)扎術(shù)(11例動脈,1例靜脈),17例行截肢術(shù)(其中2例患者截肢同時行高位動脈結(jié)扎),7例行動脈(1例脛前動脈,1例脛后動脈,5例肱動脈)修補術(shù),5例單純清創(chuàng)術(shù)。結(jié)論:通過對2009年至2013年5年間因外傷導(dǎo)致的截肢患者的調(diào)查研究,可以粗略了解截肢的流行病學(xué)特點及其好發(fā)因素,為臨床預(yù)防和治療提供參考。但由于截肢患者傷情嚴(yán)重且復(fù)雜,難以全面地對其進行分析,且本文為為回顧性調(diào)查,其中難免出現(xiàn)誤差,還需要進一步調(diào)查研究。對于創(chuàng)面繼發(fā)性出血的止血分3步:(1)發(fā)現(xiàn)出血后立即進行創(chuàng)面壓迫止血;(2)根據(jù)出血性質(zhì)、出血部位以及MESS評分采用有效的止血方法,首選加壓包扎,其次指壓止血或鉗夾止血,無效時或肢體保肢無望時選擇止血帶;(3)進行手術(shù)徹底止血。通過上述步驟,盡可能達到即不損傷肢體軟組織,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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R641

【參考文獻】

相關(guān)期刊論文 前8條

1 付文倩;康豐娟;劉喜文;;加壓止血帶戰(zhàn)地應(yīng)用的不良反應(yīng)及預(yù)防[J];人民軍醫(yī);2014年07期

2 陳鵬;田曉濱;;四肢毀損傷患者開放性截肢與閉合性截肢的適應(yīng)證選擇[J];中華創(chuàng)傷骨科雜志;2014年04期

3 姜鈺;吳新寶;;我國創(chuàng)傷流行病學(xué)的現(xiàn)狀與未來[J];中華創(chuàng)傷骨科雜志;2014年02期

4 孫魯源;汪春陽;文根;韓培;柴益民;;下肢GustiloⅢB型和ⅢC型骨折的保肢治療及療效評價[J];中華創(chuàng)傷骨科雜志;2012年10期

5 白宇;莊小強;吳穎潔;陸生林;方旭;;持續(xù)封閉式負(fù)壓引流治療嚴(yán)重軟組織損傷致出血的臨床觀察[J];中國修復(fù)重建外科雜志;2012年06期

6 馮芳;劉志紅;王鋼;;肢體擠壓傷嚴(yán)重程度評分系統(tǒng)比較及對預(yù)后的評估意義[J];遼寧醫(yī)學(xué)雜志;2011年06期

7 周飛亞;郭曉山;高偉陽;陳星隆;李志杰;蔣良福;;MESS評分在治療下肢骨折伴血管損傷中的臨床意義[J];中國骨傷;2010年06期

8 陳建常,傅源,盧開柏,王樂農(nóng),陸裕樸,石凱軍;不同止血帶時間止血帶下及其以遠(yuǎn)肌損傷形態(tài)學(xué)觀察[J];骨與關(guān)節(jié)損傷雜志;1994年04期

，

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