【摘要】：目的:近年來隨著玉米聯(lián)合收割機的普遍應用,此類機器所致手外傷也逐年增加,此類機器常有擠壓,牽拉等多種致傷機制并存,且創(chuàng)面多被油污及植物碎屑嚴重污染,臨床上此類外傷是較難治療的一種外傷,且預后普遍較差,本研究對本地區(qū)玉米收割機所致手外傷的外傷特點、治療規(guī)律及預后進行總結(jié),對感染病原菌分布及感染因素進行調(diào)查分析,意在為臨床醫(yī)生接診此類外傷患者時提供經(jīng)驗及科學依據(jù)。方法:選用2014年9月至2014年11月間我科兩個病區(qū)收治的玉米聯(lián)合收割機致傷患者共48例,男33例,女15例,年齡18-78歲,平均44歲。對本組患者進行回顧性調(diào)查與分析。對此類外傷的轉(zhuǎn)歸進行分類,總結(jié)外傷及治療特點。對本研究中26例術后感染的患者感染的危險因素進行統(tǒng)計學分析。對細菌培養(yǎng)及藥敏實驗結(jié)果進行整理,分析感染原因并提出對策。結(jié)果:本組所有患者未出現(xiàn)死亡病例。均經(jīng)過1-6次手術,平均3次手術的治療,平均住院天數(shù)為55.3天。初次手術均為清創(chuàng)術,骨折和神經(jīng)、肌腱、血管損傷均一期修復;皮膚缺損處理方式視創(chuàng)口污染情況而定,污染較輕者一期皮瓣覆蓋,污染較重者早期應用可灌洗封閉式負壓引流(VSD),二期皮膚移植覆蓋。31例發(fā)生術后感染或壞死,17例未發(fā)生術后感染或壞死,感染壞死率64.6%,一次手術治愈率20.8%,需要多次手術治愈者38例,占79.2%。本地區(qū)此類外傷的常見病原菌為:銅綠假單胞菌。經(jīng)卡方檢驗χ2=29.561,P=0.000。對玉米聯(lián)合收割機致手外傷術后感染的危險因素的Logistic回歸方程有統(tǒng)計學意義。結(jié)論:(1)玉米收割機傷多造成手部的嚴重損傷,是一種極難治療和治愈的疾病,傷后預防和控制創(chuàng)面感染及組織遲發(fā)性壞死是治療的難點。(2)玉米收割機傷后常有多種感染的危險因素共同存在,在諸多感染的危險因素中就診時間、損傷程度、術后壞死、清創(chuàng)程度、手術時間等5項是具顯著性意義的因素。這些是發(fā)生術后感染的主要因素,臨床醫(yī)師應該豐富經(jīng)驗提高手術水平,盡可能的降低易感因素的數(shù)量及水平。努力預防術后感染的發(fā)生(3)面對此類外傷主治醫(yī)師應密切觀察病情做好多次手術的心理準備,同時反復向患者及家屬交代病情,使其做好長期治療和患肢預后不良的心理準備,避免醫(yī)療糾紛發(fā)生。
[Abstract]:Objective: in recent years, with the widespread application of maize combine harvester, the hand injury caused by this kind of machine also increased year by year. There are many kinds of injury mechanisms such as squeezing, pulling and so on, and the wound surface is mostly polluted by oil and plant debris. Clinically, this kind of trauma is difficult to treat, and the prognosis is generally poor. This study summarized the characteristics, treatment rules and prognosis of hand trauma caused by corn harvester in this area. In order to provide experience and scientific basis for clinicians to receive such traumatic patients, the distribution of pathogenic bacteria and the factors of infection were investigated and analyzed. Methods: from September 2014 to November 2014, 48 patients (33 males and 15 females, aged 18-78 years, with an average age of 44 years) were treated by maize combine harvester in our department. The patients were retrospectively investigated and analyzed. The outcome of this kind of trauma is classified, and the characteristics of trauma and treatment are summarized. The risk factors of infection in 26 patients with postoperative infection were analyzed statistically. The results of bacterial culture and drug sensitivity test were analyzed and countermeasures were put forward. Results: there were no death cases in all patients. All patients were treated with 1-6 operations with an average of 3. The average hospital stay was 55.3 days. The first operation was debridement, and the fracture and nerve, tendon and vascular injury were repaired in one stage. The treatment of skin defect depends on the condition of wound contamination. The first stage skin flap covering with less contamination and the skin graft covering with (VSD), secondary skin graft with lavage and closed negative pressure drainage can be used in the early stage of serious contamination. Infection or necrosis occurred in 31 cases after operation. There were no postoperative infection or necrosis in 17 cases, the rate of infection and necrosis was 64.6%, the cure rate of one operation was 20.8%, 38 cases (79.2%) needed to be cured by multiple operations. The common pathogens of this kind of trauma in this area are Pseudomonas aeruginosa. Chi-square test showed that 蠂 2 was 29.561 and 0.000. The Logistic regression equation of infection after hand injury caused by maize combine harvester was statistically significant. Conclusion: (1) Corn harvester injury is a very difficult disease to treat and cure. Prevention and control of wound infection and delayed necrosis of tissue after injury are difficult points in the treatment. (2) there are many kinds of risk factors of infection after maize harvester injury. Postoperative necrosis, debridement and operative time were significant factors. These are the main factors of postoperative infection. Clinicians should improve the operation level and reduce the number and level of susceptible factors as much as possible. Try hard to prevent postoperative infection (3) in the face of this kind of trauma, the attending physician should closely observe the condition of the patient and make psychological preparations for many operations, and at the same time repeatedly explain the condition to the patient and his family. Make them prepare for long-term treatment and poor prognosis of the affected limb, to avoid medical disputes.
【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R658.2

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