外伤后皮肤软组织缺损患者肺栓塞的早期诊断  

Early diagnosis of pulmonary embolism in patients with skin and soft tissue defects after trauma

作　　者：周剑 王淑琴[2] 林樾[1] 郑东风[2] 谭谦[1] Zhou Jian;Wang Shuqin;Lin Yue;Zheng Dongfeng;Tan Qian(Drum Tower Clinical Medical College of Nanjing Medical University,Nanjing 210008,China;Department of Plastic Surgery and Burns,Affiliated Drum Tower Hospital of Nanjing University Medical School,Nanjing 210008,China)

机构地区：[1]南京医科大学鼓楼临床医学院,210008 [2]南京大学医学院附属鼓楼医院整形烧伤科,210008

出　　处：《中华烧伤杂志》2019年第5期351-355,共5页Chinese Journal of Burns

基　　金：国家自然科学基金(81671922、81272108).

摘　　要：目的探讨外伤后皮肤软组织缺损患者肺栓塞的早期诊断方法。方法2011年1月—2014年7月,南京大学医学院附属鼓楼医院整形烧伤科收治5例外伤后皮肤软组织缺损合并肺栓塞患者,其中男4例、女1例,年龄26~68岁,对其病历资料进行回顾性分析。入院后4~45d,对怀疑肺栓塞的患者进行分层筛选。2例患者存在血流动力学障碍,但能耐受CT肺动脉造影(CTPA),立即行CTPA检查,确诊为肺栓塞。另外3例患者无明显血流动力学障碍,仅出现胸痛、呼吸困难等肺栓塞的临床表现,进行临床危险评估,其中2例患者临床危险评估为高危可能,立即行CTPA确诊为肺栓塞;另1例患者临床危险评估为中危可能,但D-二聚体阳性,立即行CTPA确诊为肺栓塞。所有患者入院后1周内,取创面分泌物行微生物培养,并视创面情况行创面清创术及植皮术。出现肺栓塞症状后,行下肢血管彩色多普勒超声检查明确下肢深静脉血栓情况。确诊肺栓塞后,立即予静脉滴注尿激酶或重组组织型纤溶酶原激活剂进行溶栓治疗,治疗结束后,监测活化部分凝血活酶时间,≤70s时开始规范的抗凝治疗。记录患者治疗结局、D-二聚体检测值、肺栓塞确诊前卧床时间,住院期间进行创面清创术的患者数及术后肺栓塞确诊时间、下肢深静脉血栓和创面感染患者数。结果患者皮肤软组织缺损创面均完全愈合,移植皮片存活良好,肺栓塞经过及时治疗后均恢复良好,患者病变肺动脉主干及分支恢复血供,病程为1~3个月。本组患者D-二聚体检测值为2.4~31.7mg/L,其中4例患者D-二聚体检测值≥5.0mg/L。本组患者肺栓塞确诊前卧床时间4~46d,平均23.2d。4例患者在院期间经历创面清创术,术后确诊肺栓塞的时间是14~40d,平均20.5d。4例患者确诊下肢深静脉血栓。所有患者均存在创面感染,引起创面感染的细菌包括铜绿假单胞菌2例、金黄色葡萄球菌2例以及粪�Objective To investigate the early diagnosis method of pulmonary embolism in patients with skin and soft tissue defects after trauma.Methods From January 2011 to July 2014,5 patients with skin and soft tissue defects and pulmonary embolism after trauma were admitted to Department of Plastic Surgery and Burns of the Affiliated Drum Tower Hospital of Nanjing University Medical School,including 4 males and 1 female,aged 26-68 years.The medical records of the 5 patients were retrospectively analyzed.Hierarchical screening of patients with suspected pulmonary embolism was performed after admission for 4-45 days.Computed tomography pulmonary angiography(CTPA)was performed immediately in 2 patients who had hemodynamic disorder and were able to tolerate CTPA,and pulmonary embolism was confirmed.Clinical risk assessment was conducted for the other 3 patients who had no obvious hemodynamic disorder and only had clinical manifestations of pulmonary embolism such as chest tightness and dyspnea.Among the 3 patients,two of them were assessed as high risk possibility by clinical risk assessment and diagnosed with pulmonary embolism by CTPA immediately.The other one patient's clinical risk assessment was moderate risk possibility,but D-dimer was positive,and the patient was diagnosed with pulmonary embolism by CTPA immediately.Wound exudation of all patients was collected within 1 week after admission for microbial culture,and wound debridement and skin grafting were performed according to the wound condition.The color Doppler ultrasonography of blood vessel on lower extremity was performed to determine deep venous thrombosis of lower extremity after appearance of symptoms of pulmonary embolism.The patient was immediately given urokinase or recombinant tissue plasminogen activator by intravenous infusion for thrombolysis after definite diagnosis of pulmonary embolism.The activated partial thromboplastin time(APTT)was monitored after treatment,and standardized anticoagulation began when APTT was equal to or lower than 70 seconds.

关 键 词：创伤和损伤 肺栓塞 诊断 皮肤软组织缺损 

分 类 号：R641[医药卫生—外科学] R563.5[医药卫生—临床医学]