严重肺创伤治疗中的损害控制技术
Damage-control techniques in the management of severe lung trauma.
作者信息
Garcia Alberto, Martinez Juan, Rodriguez Julio, Millan Mauricio, Valderrama Gustavo, Ordoñez Carlos, Puyana Juan Carlos
机构信息
From the Department of Surgery (AG, JR, MM, GV, CO) and CISALVA Institute (AG, CO), Universidad del Valle, Cali, Colombia. Departments of Surgery (AG, CO) and Intensive Care Unit (AG, JM, CO), Fundaciœn Valle del Lili, Cali, Colombia. Department of Surgery (JM), Universidad CES, Cali, Colombia. Department of Surgery (JR, MM, GV), Hospital Universitario del Valle, Cali, Colombia. Department of Surgery (JCP), University of Pittsburgh, Pittsburgh, PA.
出版信息
J Trauma Acute Care Surg. 2015 Jan;78(1):45-50; discussion 50-1. doi: 10.1097/TA.0000000000000482.
BACKGROUND
Damage control (DC) has improved survival from severe abdominal and extremity injuries. The data on the surgical strategies and outcomes in patients managed with DC for severe thoracic injuries are scarce.
METHODS
This is a retrospective review of patients treated with DC for thoracic/pulmonary complex trauma at two Level I trauma centers from 2006 to 2010. Subjects 14 years and older were included. Demographics, trauma characteristics, surgical techniques, and resuscitation strategies were reviewed.
RESULTS
A total of 840 trauma thoracotomies were performed. DC thoracotomy (DCT) was performed in 31 patients (3.7%). Pulmonary trauma was found in 25 of them. The median age was 28 years (interquartile range [IQR], 20-34 years), Revised Trauma Score (RTS) was 7.11 (IQR, 5.44-7.55), and Injury Severity Score (ISS) was 26 (IQR, 25-41). Nineteen patients had gunshot wounds, four had stab wounds, and two had blunt trauma.Pulmonary trauma was managed by pneumorrhaphy in 3, tractotomy in 12, wedge resection in 1, and packing as primary treatment in 8 patients. Clamping of the pulmonary hilum was used as a last resource in seven patients. Five patients returned to the intensive care unit with the pulmonary hilum occluded by a vascular clamp or an en masse ligature. These patients underwent a deferred resection within 16 hours to 90 hours after the initial DCT. Four of them survived.Bleeding from other intrathoracic sources was found in 20 patients: major vessels in nine, heart in three, and thoracic wall in nine.DCT mortality in pulmonary trauma was 6 (24%) of 25 because of coagulopathy, or persistent bleeding in 5 patients and multiorgan failure in 1 patient.
CONCLUSION
This series describes our experience with DCT in severe lung trauma. We describe pulmonary hilum clamping and deferred lung resection as a viable surgical alternative for major pulmonary injuries and the use of packing as a definitive method for hemorrhage control.
LEVEL OF EVIDENCE
Epidemiologic study, level V.
背景
损伤控制（DC）已提高了严重腹部和肢体损伤患者的生存率。关于采用损伤控制治疗严重胸部损伤患者的手术策略和结局的数据较少。
方法
这是一项对2006年至2010年在两个一级创伤中心接受损伤控制治疗胸部/肺部复合创伤患者的回顾性研究。纳入14岁及以上的受试者。对人口统计学、创伤特征、手术技术和复苏策略进行了回顾。
结果
共进行了840例创伤性开胸手术。31例患者（3.7%）进行了损伤控制开胸手术（DCT）。其中25例发现有肺损伤。中位年龄为28岁（四分位间距[IQR]，20 - 34岁），改良创伤评分（RTS）为7.11（IQR，5.44 - 7.55），损伤严重度评分（ISS）为26（IQR，25 - 41）。19例患者为枪伤，4例为刺伤，2例为钝性创伤。3例肺损伤采用肺缝合术处理，12例采用肺叶切断术，1例采用楔形切除术，8例患者以填塞作为主要治疗方法。7例患者在最后采用了肺门阻断。5例患者返回重症监护病房时肺门被血管夹或整体结扎阻断。这些患者在初次DCT后16小时至90小时内接受了延期切除术。其中4例存活。20例患者发现有其他胸内出血来源：9例为大血管出血，3例为心脏出血，9例为胸壁出血。25例肺损伤患者中，因凝血功能障碍、5例持续性出血和1例多器官功能衰竭，DCT死亡率为6例（24%）。
结论
本系列描述了我们在严重肺损伤中应用DCT的经验。我们将肺门阻断和延期肺切除术描述为严重肺损伤可行的手术选择，以及将填塞作为控制出血的确定性方法。
证据级别
流行病学研究，V级。
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