单肺机械通气联合损伤控制策略救治重度多发性外伤患者的体会  

Experience on single-lung mechanical ventilation combined with damage control in treatment of patients with severe multiple trauma

作　　者：冯静 张允忠 高兴斌 Feng Jing;Zhang Yunzhong;Gao Xingbin(Department of Intensive Care Unit,Qingzhou Hospital Affiliated to the First Medical University of Shandong(Qingzhou People's Hospital),Qingzhou 262500,Shandong,China)

机构地区：[1]山东第一医科大学附属青州医院(青州市人民医院)重症医学科,山东青州262500

出　　处：《中华危重病急救医学》2020年第9期1128-1130,共3页Chinese Critical Care Medicine

摘　　要：山东第一医科大学附属青州医院于2020年4月6日收治1例头、颈、胸部及右上肢重度碾压伤合并休克、挤压综合征、创伤性凝血病(TIC)、急性呼吸窘迫综合征(ARDS)的重症患者.患者女性,44岁,因交通事故伤及头、颈、胸部、右上肢等多处伴意识障碍1 h于2020年4月6日07:00入院.入院查体:体温35.6℃,呈嗜睡状态,右侧眼眶周围及右侧颊部肿胀、青紫,皮肤严重擦伤伴渗血,结合膜苍白,口唇轻度发绀,右侧胸廓塌陷畸形,伴有反常呼吸,胸壁皮肤大片青紫伴广泛皮下握雪感;右肺呼吸音低,可闻及干湿啰音.实验室检查:血常规示白细胞计数(WBC)正常,红细胞计数(RBC)、血红蛋白(Hb)、血小板计数(PLT)降低,血糖升高;尿常规示葡萄糖+++,尿隐血+++,尿蛋白+++,可见透明及颗粒管型;凝血指标和血生化均异常;吸纯氧条件下动脉血气分析示pH值和动脉血氧分压(PaO2)降低.X线显示右侧肱骨远端及右尺桡骨近端粉碎性骨折并右肘关节脱位;CT显示右侧眼眶周围软组织肿胀,内壁凹陷性骨折.入院后应用单肺通气、气管切开和俯卧位通气等策略纠正氧合和ARDS;给予合理的损伤控制性液体复苏纠正休克,积极应用血制品控制大出血及TIC;根据患者伤情和损伤控制性手术理论,实施右侧胸腔闭式引流、右上肢截肢术;之后行右侧中下肺切除、肺修补、肋骨内固定术;最后择期行右胸切痂创伤敷料覆盖中心负压吸引术及胸部"邮票"植皮术.经治疗后,患者脱离危险,达到了满意的临床疗效.On April 6,2020,a case of severe crush injuries in head,neck,chest and right upper extremity was admitted to Qingzhou Hospital Affiliated to the First Medical University of Shandong Province.In addition to the crush injuries,the case also suffered from shock,crush syndrome,trauma-induced coagulopathy(TIC),and acute respiratory distress syndrome(ARDS).The female patient was 44 years old,and was admitted to the hospital at 07:00 on April 6,2020 due to traffic accident with head,neck,chest,right upper limb injuries with disturbance of consciousness for 1 hour.Admission physical examination:body temperature was 35.6℃.The patient was drowsy,with swelling and cyanosis around the right orbit and right cheek.The skin was severely abraded with blood seepage.The conjunctiva was pale.The lips were slightly cyanotic.The right chest collapsed and deformed with abnormal breathing.The skin of chest wall was blue and purple with extensive feeling of holding snow under the skin.The breath sound of right lung was low and dry and wet rales could be heard.Laboratory examination:routine blood test showed that white blood cell count(WBC)was normal,red blood cell count(RBC),hemoglobin(Hb)and platelet count(PLT)decreased,blood glucose increased;urine routine examination showed glucose+++,urine occult blood+++,urinary protein+++,visible transparent and granular tube type;coagulation indicators and blood biochemical examination were abnormal.Arterial blood gas analysis showed that pH and arterial partial pressure of oxygen(PaO2)decreased.X-ray showed comminuted fracture of distal humerus and proximal end of right ulna and radius with dislocation of right elbow joint.CT showed swelling of soft tissue around the right orbit and depressed fracture of inner wall.After admission,single-lung ventilation,tracheotomy and prone ventilation were applied to increase oxygenation level and relieving ARDS.Fluid of damage control for resuscitation was applied to reverse shock and blood transfusion was used to control hemorrhage and TIC.According to th

关 键 词：单肺机械通气 损伤控制策略 休克 创伤性凝血病 急性呼吸窘迫综合征 

分 类 号：R641[医药卫生—外科学]