【作者】 曹伟；

【导师】 赵刚；

【作者基本信息】 山东大学 ， 临床医学（外科学）（专业学位）， 2016， 硕士

【摘要】 [背景及目的]创伤性大血管损伤很容易导致肢体濒临缺血,对肢体的存活及病人的生命安全造成威胁。肢体缺血时间是保肢成功与否的一个重要影响因素。生理学及解剖学研究表明,肢体缺血3小时后肌细胞开始发生不可逆性损伤,缺血6小时后肌肉几乎完全坏死。因此,人们普遍认为应该在动脉损伤发生后6-8小时内恢复血管再通。然而,由于诊断延误或到处咨询专家,部分动脉外伤的病人在接受治疗时往往超过了这个时间限制。特别是这些病人往往伴随皮肤软组织损伤、骨折及神经损伤等其他周围组织损伤,对于这种外伤的管理跟救治面临巨大的挑战。[方法]本项研究中,我们回顾性分析了34例收治于我院急救中心的四肢创伤性大血管损伤超过8小时患者(我们称之为超时限性血管损伤病人)的临床资料,确定了该病种的人口学特征,并利用多元逻辑回归模型分析比较了导致截肢与致残的独立影响因素以提供完善合理的保肢治疗指导指南。[结果]1.发生超时限性四肢血管损伤高危人群的年龄分布为18岁至40岁；2.下肢损伤(82.4%)所占比例是上肢损伤(17.6%)的四倍以上；3.多为开放性钝器伤(76.5%)；4.保肢成功率为82.4%(28/34),其中肢体功能良好者50%(14/28);5.跟截肢密切相关的因素是神经损伤(P=0.011)、复杂软组织损伤(P=0.034)以及骨筋膜室综合症的发生(P=0.001),P<0.05有统计学意义。6.与致残密切相关的因素包括损伤部位的解剖位置(P=0.044)、动静脉复合伤(P=0.043)、神经损伤(P=0.022)、复杂软组织损伤(P=0.002)及骨筋膜综合征的发生(P=0.002),P<0.05有统计学意义。[结论]我们建议对于超时限性四肢血管损伤病人应行保肢治疗,特别是对于那些年龄在18岁和40岁的病人。治疗动脉损伤的同时,还应妥善处理好神经及复杂软组织的损伤,特别注意预防骨筋膜综合征的发生。此外,我们应鼓励发展、提高救治超时限性血管损伤的保肢技术。更多还原

【Abstract】 Background and objectiveA traumatic major arterial trunk injury can easily lead to limb-threatening ischemia, which can endanger the viability of the extremity and/or the patient’s life.Ischemic time is an important factor that affects limb survival, and physiological and anatomical studies have shown that irreversible muscle cell damage begins after 3 h of ischemia and is nearly complete after 6 h of ischemia. Therefore, it is generally accepted that vascular recanalization should be performed 6-8 h after the arterial injury has occurred. However, a proportion of patient’s with traumatic arterial injuries present after this time, because of delays in their diagnoses and referrals to specialists. The management of these injuries presents a daunting challenge, especially in patients who have associated injuries that are severe, namely, skin and soft tissue injuries, osseous damage, and damage to the neural elementsMethodsIn this study, we conducted a retrospective analysis of 34consecutive patients who presented to the emergency department with traumatic arterial trunk injuries of their extremities more than 8 h after the injuries had occurred. We called these injuries "ultra-time vascular injuries". We determined the demographic characteristics of these patients.A multivariate logistic regression model was used to identify the determinants that were independently associated with limb amputation and disability to provide sound and defensible guidelines for limb salvage.Results1. The age distribution of the high-risk population was from 18 years to 40 years;2. Injuries to the lower limbs (82.4%) were over four times more common than injuries to the upper limbs (17.6%), and open;3. Blunt injuries occurred most commonly (76.5%).4. The overall rate of limb salvage was 82.4%(28/34) and limb function is excellent in 50%(14/28) of the patients.5. The factors that were significantly associated with amputation were nerve injury (P=0.011), complex soft tissue injury (P=0.034), and the occurrence of compartmentsyndrome (P=0.001).6. The factors that were significantly associated with disability included the anatomical location of the injury (P=0.044), a combined arterial and venous (AV) injury (P=0.043), nerve injury (P=0.022), complex soft tissue injury (P=0.002), and the occurrence of compartment syndrome (P=0.002).ConclusionsWe recommend limb-salvage treatment for patients with traumatic ultra-time vascular injuries, particularly for those aged between 18 years and 40 years. While treating the arterial injury, we should pay more attention to nervousl injury and complex soft tissue injury especially the occurrence of compartment syndrome. Furthermore, we encourage the development of limb salvage techniques for ultra-time vascular injuries.更多还原