本文選題：爆炸傷 + 密閉環(huán)境��； 參考：《第三軍醫(yī)大學(xué)》2010年碩士論文

【摘要】： 現(xiàn)代戰(zhàn)爭(zhēng)中坦克、裝甲車等作戰(zhàn)密閉艙室是戰(zhàn)時(shí)主要的作戰(zhàn)裝備,也是被打擊的重點(diǎn),而世界范圍內(nèi)以公交車、地鐵、公共建筑等人群聚集的密閉場(chǎng)所為主要目標(biāo)的恐怖襲擊發(fā)生率也不斷增加。因此,無(wú)論平時(shí)和戰(zhàn)時(shí),密閉艙室環(huán)境爆炸傷發(fā)生率均較高。已經(jīng)有大量研究報(bào)告艙室內(nèi)爆炸傷重要臟器的損傷特點(diǎn)和機(jī)制,研究發(fā)現(xiàn)密閉環(huán)境內(nèi)爆炸沖擊波傳播與開(kāi)闊地爆炸不同,呈現(xiàn)復(fù)雜波特征,表現(xiàn)為沖擊波在艙室內(nèi)反射、疊加,多重壓力峰值重疊,超壓持續(xù)時(shí)間長(zhǎng),作用機(jī)體后造成的組織臟器挫傷重,肺、腦損傷發(fā)生率高。同時(shí),爆炸可造成機(jī)體毀損,爆炸產(chǎn)生的彈片和艙體碎片可擊中大血管,導(dǎo)致大量失血。因此,密閉環(huán)境內(nèi)爆炸多造成復(fù)雜沖擊波損傷合并不同程度的失血,重傷員比例高。 休克是戰(zhàn)創(chuàng)傷最終發(fā)展到多臟器功能衰竭必定要經(jīng)歷的階段,其本質(zhì)是有效循環(huán)血量減少、灌注障礙,炎癥介質(zhì)生成、高水平氧化應(yīng)激。了解戰(zhàn)創(chuàng)傷休克發(fā)生、發(fā)展的特點(diǎn)和影響因素,開(kāi)展容量復(fù)蘇是戰(zhàn)創(chuàng)傷救治研究的重要內(nèi)容。以往雖然有文獻(xiàn)報(bào)告沖擊傷、燒傷和創(chuàng)傷失血性休克的的特點(diǎn),但對(duì)密閉艙室爆炸合并休克少有研究。本項(xiàng)研究采用艙室爆炸實(shí)驗(yàn)裝置,建立復(fù)雜沖擊波致傷復(fù)合30%失血的大鼠實(shí)驗(yàn)?zāi)Ｐ?了解密閉環(huán)境爆炸合并休克的特點(diǎn),探討與炎癥因子腫瘤壞死因子(TNF)、白介素-6(IL-6)以及氧化應(yīng)激的關(guān)系,檢測(cè)肺臟中的胱硫醚-γ-裂解酶/硫化氫(CSE/H2S)體系變化,觀察肺、腦、肝等臟器損傷改變,在此基礎(chǔ)上分別應(yīng)用晶體、膠體、高滲鹽液進(jìn)行抗休克容量復(fù)蘇,探討密閉艙室爆炸傷合并休克的復(fù)蘇方案以及傷前給予外源性H2S供體對(duì)密閉艙室爆炸傷合并失血性休克的調(diào)節(jié)作用。 本研究主要包括以下三個(gè)部分,所取得的主要實(shí)驗(yàn)結(jié)果及結(jié)論如下: 第一部分密閉艙室大鼠爆炸傷合并失血性休克特點(diǎn)研究 大鼠分為密閉艙室爆炸傷合并失血性休克組,艙外爆炸傷合并失血性休克組和單純失血性休克組。在與實(shí)際裝甲車等比例縮小的模擬陸軍裝甲艙室,將400mg二硝基重氮酚(DDNP)柱狀紙質(zhì)點(diǎn)爆源距離大鼠胸腹部中心11cm瞬時(shí)引爆,迅速抽離艙內(nèi)煙霧,數(shù)據(jù)采集系統(tǒng)記錄艙內(nèi)壓力變化并通過(guò)Origin7.0進(jìn)行濾波和分析處理。然后由股動(dòng)脈導(dǎo)管勻速放血, 30min放總血量的30%,模擬密閉艙室爆炸傷合并失血性休克。艙外組將大鼠于開(kāi)闊地致爆炸傷,余實(shí)驗(yàn)方法及操作步驟與艙內(nèi)組相同,單純失血性休克組作為對(duì)照組不做爆炸致傷處理,僅由股動(dòng)脈放血致休克,統(tǒng)計(jì)死亡率,觀察各組大鼠血壓變化。應(yīng)用SEDIMENTATION彩色微球沉淀法檢測(cè)艙內(nèi)組、艙外組不同時(shí)間點(diǎn)肺、肝、腦的血流灌注變化,檢測(cè)血?dú)�、血漿炎癥因子變化,觀察大鼠肺腦含水率及肺、肝、腦組織的病理變化,檢測(cè)肺組織過(guò)氧化反應(yīng)水平及肺胱硫醚-γ-裂解酶/硫化氫體系(cystathionine-γ-lysase/hydrogen sulfide, CSE/H2S)體系的變化情況。實(shí)驗(yàn)可見(jiàn)艙內(nèi)組爆炸沖擊波為復(fù)雜沖擊波。與對(duì)照組相比,艙內(nèi)組、艙外組大鼠休克中血壓下降快,血壓低,而艙內(nèi)組變化更為明顯。與艙外組相比,艙內(nèi)組大鼠肺、肝、腦組織血流灌注水平低;動(dòng)脈血氧分壓和血氧飽和度低,乳酸濃度高,且氧分壓、血氧飽和度開(kāi)始下降的時(shí)間和乳酸濃度增高的時(shí)間早;血漿中TNF-α、IL-6濃度升高明顯。解剖見(jiàn)艙內(nèi)組大鼠60%存在顱底出血,肺、肝組織大面積淤血,存在明顯的挫傷,而艙外組大鼠幾乎不見(jiàn)顱底出血,肺、肝組織僅有少量出血點(diǎn),無(wú)明顯挫傷,所有大鼠均無(wú)腹腔重要臟器破裂及穿孔,肺腦含水率高于艙外組及對(duì)照組。艙內(nèi)組肺MDA、MPO活性增加幅度大,H2O2濃度高,而SOD活性低(p0.05或p0.01),與此同時(shí)肺組織CSE活性和H2S濃度顯著降低(p0.05或p0.01)。說(shuō)明本實(shí)驗(yàn)艙內(nèi)大鼠爆炸傷合并失血性休克,模型穩(wěn)定,可控性高,可以滿足后續(xù)實(shí)驗(yàn)要求。密閉艙室爆炸傷合并失血性休克死亡率高,血壓下降快,幅度大,肺、肝、腦血流灌注水平低,炎癥反應(yīng)明顯,且合并多器官?gòu)?fù)合傷,組織損傷程度重,肺臟氧化應(yīng)激水平高,肺組織H2S濃度與氧化反應(yīng)水平密切相關(guān),提示CSE/H2S體系可能參與了肺臟損傷及爆炸傷合并失血性休克過(guò)程的調(diào)節(jié)。 第二部分不同類型液體的容量復(fù)蘇及效果評(píng)價(jià) 對(duì)密閉艙室爆炸傷合并失血性休克大鼠進(jìn)行早期容量復(fù)蘇。隨機(jī)將大鼠分為生理鹽水組(NS)、羥乙基淀粉膠體組(HS)、7. 5%高滲氯化鈉/6%右旋醣酐組(HSD)。觀察各組大鼠一般情況,記錄平均動(dòng)脈壓變化;在爆炸傷后150min、210min、270min分別活殺8只大鼠,觀察大體解剖,血壓變化,檢測(cè)各時(shí)相點(diǎn)大鼠肺、肝、腦血流灌注水平,動(dòng)脈血?dú)庵笜?biāo),血漿炎癥因子濃度,計(jì)算肺、腦含水率,檢測(cè)密閉艙室爆炸傷合并失血性休克容量復(fù)蘇過(guò)程中肺組織過(guò)氧化反應(yīng)水平及CSE/H2S濃度變化,以評(píng)價(jià)不同液體容量復(fù)蘇對(duì)休克血流動(dòng)力學(xué)、炎癥反應(yīng)及組織損傷的改善程度。實(shí)驗(yàn)可見(jiàn):HSD可明顯升高血壓,增加重要臟器血流灌注,改善血?dú)庵笜?biāo),抑制炎癥反應(yīng),同時(shí)也減輕了肺組織氧化應(yīng)激損傷(p0.05或p0.01),在一定程度上減弱了密閉艙室爆炸傷合并失血性休克對(duì)CSE/H2S體系的影響,容量復(fù)蘇效果好。 第三部分H2S外源性供體NaHS對(duì)密閉艙室爆炸傷合并失血性休克的作用大鼠致傷前,由腹腔注射H2S外源性供體,隨后靜脈輸注HSD進(jìn)行容量復(fù)蘇,其余檢測(cè)方法與指標(biāo)同第二部分。實(shí)驗(yàn)結(jié)果見(jiàn)早期給予NaHS (10mg/kg, ip)后,大鼠血壓變化與對(duì)照組差異不明顯,但肺、肝、腦組織血流灌注增加,血漿炎癥因子水平降低,肺組織過(guò)氧化水平較單純高滲氯化鈉/6%右旋醣酐復(fù)蘇組顯著降低(p0.05或P0.01),肺腦含水率下降明顯(p0.05或P0.01),治療效果較單純應(yīng)用高滲氯化鈉/6%右旋醣酐好。 上述研究結(jié)果提示 1.密閉艙室爆炸傷合并失血性休克,其發(fā)生時(shí)間早,血流灌注水平低,炎癥反應(yīng)明顯,存在嚴(yán)重的肺、腦水腫和組織損傷,有嚴(yán)重缺氧、酸中毒,進(jìn)展迅速,代償能力弱,與艙外組及單純失血性休克相比,休克休克程度重,預(yù)后差,死亡率高。 2.7.5%高滲氯化鈉/6%右旋醣酐(HSD)更適合密閉艙室爆炸傷合并失血性休克大鼠容量復(fù)蘇,可有效升高血壓改善肺、肝、腦組織血流灌注,抑制炎癥反應(yīng),改善氧化應(yīng)激損傷,保護(hù)肺、腦組織。 3.早期給予低劑量H2S(10mg/kg NaHS)可改善肺、肝、腦組織血流灌注,減輕炎癥反應(yīng)及肺組織損傷程度。
[Abstract]:In the modern war, tanks, armored cars and other airtight cabin are the main combat equipment in wartime, and also the focus of the war. The incidence of terrorist attacks in the closed cabin in the world is increasing as the main target of the crowded places, such as buses, subways, public buildings, and so on. The occurrence rate is high. There have been a large number of research reports on the damage characteristics and mechanism of the important organs of the chamber explosion injury. It is found that the explosion shock wave propagation in the closed environment is different from the open explosion, showing the characteristics of complex waves, which shows the reflection, superposition, overlapping of the peak pressure peak, the longer overpressure and the function of the body. At the same time, the incidence of tissue viscera is heavy and the incidence of lung and brain damage is high. At the same time, the explosion can cause damage to the body, the bomb produced by the bomb and the fragments of the hatch can hit the large blood vessels and cause a large amount of blood loss. Therefore, the explosion in the closed environment causes complicated shock wave damage with different range of blood loss, and the proportion of the heavy casualties is high.
Shock is a stage that war trauma eventually develops to multiple organ failure. Its essence is effective circulation reduction, perfusion disorder, inflammatory mediator formation, high level oxidative stress. Understanding the characteristics and influencing factors of the development of war shock, and carrying out capacity recovery is an important content of the research on the treatment of war trauma. There are literature reports on the characteristics of shock, burn, and traumatic hemorrhagic shock, but there are few studies on explosion and shock in closed cabin. In this study, a chamber explosion experimental device was used to establish an experimental model of complex shock induced complex 30% blood loss in rats. The relationship between necrosis factor (TNF), interleukin -6 (IL-6) and oxidative stress was used to detect changes in the cystthioether gamma lyase / hydrogen sulfide (CSE/H2S) system in the lung, and to observe the changes in the lung, brain, liver and other organ damage. On this basis, the shock capacity recovery was carried out with crystal, colloid and hypertonic salt solution, and the explosion injury of the closed cabin combined with shock was discussed. The resuscitation plan and exogenous H2S donor before injury were used to regulate the blast injury and hemorrhagic shock in closed cabin.
This study mainly includes the following three parts. The main results and conclusions are as follows:
Part one characteristics of explosive injury and hemorrhagic shock in closed cabin rats
Rats were divided into closed cabin explosion injury combined with hemorrhagic shock group, extravehicular explosion injury combined with hemorrhagic shock group and simple hemorrhagic shock group. The 400mg two nitro diazonium (DDNP) columnar paper point explosion source was instantaneously detonated from the center of chest and abdomen of rat and quickly extracted from the simulated Army armoured cabin with the actual armoured vehicle. In the cabin smoke, the data collection system records the pressure change in the cabin and filtered and analyzed through Origin7.0. Then the femoral artery catheter is bleeding at a constant speed, and the total blood volume is 30% of the 30min. The explosion injury and hemorrhagic shock are simulated in the closed cabin. The extravehicular group will open the explosion and blast in the open ground, the residual experiment method and the operation steps and the cabin group As the same, the group of simple hemorrhagic shock was not treated as the control group. The blood pressure changes were observed only by the hemorrhagic shock of the femoral artery. The blood pressure changes were observed in each group. The SEDIMENTATION color microsphere precipitation method was used to detect the pulmonary, liver, cerebral blood flow, blood gas and plasma inflammatory factors at different time points of the capsule. The changes in the level of peroxidation and cystathionine- gamma -lysase/hydrogen sulfide (CSE/H2S) system of pulmonary cystathion lysis lyase / hydrogen sulfide (CSE/H2S) system were detected in the lung, liver and brain tissues of the rats. The experimental results showed that the blast shock wave in the capsule was a complex shock wave. Compared with the control group, the cabin was compared with the control group. In the group, the blood pressure of the rats in the extravehicular group was decreased quickly and the blood pressure was low, but the changes in the cabin group were more obvious. Compared with the extravehicular group, the blood flow of the lungs, the liver, the brain tissue was low, the blood oxygen pressure and oxygen saturation were low, the concentration of lactic acid was low, the oxygen pressure, the oxygen saturation began to decline and the time of the lactate concentration increased early. The concentration of TNF- alpha and IL-6 in plasma increased obviously. In the anatomic group, 60% of the rats in the capsule group had skull base bleeding, lung and liver tissue in large area of blood, and there were obvious contusions, but the rats in the outer group had almost no skull base bleeding. There were only a few bleeding points in the lungs and liver tissues, without obvious contusion. All rats had no abdominal major organ rupture and perforation and pulmonary brain water content. The lung MDA, MPO activity increased greatly, the H2O2 concentration was high, and the SOD activity was low (P0.05 or P0.01), while the CSE activity and H2S concentration in the lung tissue decreased significantly (P0.05 or P0.01) in the pulmonary tissue, indicating that the rat explosion injury combined with the hemorrhagic Hugh, the model was stable and high controllability, which could meet the requirements of the follow-up experiment. The mortality of explosion injury combined with hemorrhagic shock is high, blood pressure drops fast, the amplitude is large, lung, liver, cerebral blood flow is low, inflammatory reaction is obvious, and multiple organ complex injury is combined, the degree of tissue injury is heavy, lung oxidative stress level is high, H2S concentration of lung tissue is closely related to the level of oxygenation reaction, suggesting that CSE/H2S system may be involved Regulation of lung injury and explosive injury combined with hemorrhagic shock.
The second part is the capacity recovery and evaluation of different types of fluids.
Early volume recovery was carried out in rats with closed cabin explosion and hemorrhagic shock. Rats were randomly divided into physiological saline group (NS), hydroxyethyl starch colloid group (HS), 7.5% hypertonic sodium chloride /6% dextran group (HSD). The average dynamic pulse pressure changes were recorded in each group, and 150min, 210min, and 270min killed 8 respectively after the explosion injury. Only rats, observe the general anatomy, change of blood pressure, detect the level of lung, liver, cerebral blood flow, arterial blood gas index, plasma inflammatory factor concentration, calculate the lung and brain water content, and detect the changes of lung tissue peroxidation and CSE/H2S concentration in closed cabin explosion injury combined with hemorrhagic shock. The effect of fluid volume resuscitation on shock hemodynamics, inflammatory response and tissue damage can be seen: HSD can obviously increase hypertension, increase blood flow of important organs, improve blood gas index, inhibit inflammatory reaction, and reduce oxidative stress (P0.05 or P0.01) in lung tissue, and to a certain extent weaken the closed cabin explosion. The effect of blast injury combined with hemorrhagic shock on CSE/H2S system is good.
The third part of H2S exogenous donor NaHS was injected with H2S exogenous donor by intraperitoneal injection, followed by intravenous infusion of HSD for volume recovery before injury of rats in closed chamber explosion injury combined with hemorrhagic shock, and the other detection methods and indexes were the same as second parts. The experimental results showed that after early NaHS (10mg/kg, IP), the change of blood pressure and control in rats The difference of the group was not obvious, but the blood flow perfusion in the lung, liver and brain tissue increased, the level of plasma inflammatory factors decreased, the level of lung tissue peroxidation was significantly lower than that of the simple hypertonic sodium chloride /6% dextran resuscitation group (P0.05 or P0.01), and the water content of the lung and brain decreased significantly (P0.05 or P0.01), and the therapeutic effect was better than that of hypertonic sodium chloride /6% dextran.
The results mentioned above suggest
1. the explosive injury of the airtight cabin combined with hemorrhagic shock, its occurrence time is early, the blood flow perfusion level is low, the inflammatory reaction is obvious, there are serious lung, brain edema and tissue damage, there are severe hypoxia, acid poisoning, rapid progress, and weak compensatory ability, and the shock shock degree is heavy, the prognosis is bad, the prognosis is bad, and the mortality is high.
2.7.5% hypertonic sodium chloride /6% dextran (HSD) is more suitable for the volume recovery of rats with airtight compartment explosion and hemorrhagic shock, which can effectively improve hypertension and improve the blood perfusion of the lungs, liver and brain tissue, inhibit the inflammatory reaction, improve the oxidative stress damage, and protect the lung and brain tissue.
3. early administration of low dose H2S (10mg/kg NaHS) can improve the perfusion of lung, liver and brain, reduce inflammation and lung tissue damage.

【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2010
【分類號(hào)】：R82

【引證文獻(xiàn)】

相關(guān)期刊論文 前1條

1 李長(zhǎng)棟;孫建軍;荔志云;;顱腦傷合并復(fù)合傷動(dòng)物模型的研究進(jìn)展[J];中華神經(jīng)外科疾病研究雜志;2012年03期

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本文編號(hào)：1841989