上臂及胸壁挤压综合征的诊断及治疗
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摘要
目的探讨上臂及胸壁挤压综合征的发病机制、诊断及治疗方法。方法 2010年1月—2015年1月,收治5例由于CO中毒及饮酒昏迷后自身压迫导致的上臂及胸壁挤压综合征患者。其中男4例,女1例;年龄28～46岁,平均36.7岁。左上臂及左胸壁2例,右上臂及右胸壁3例。受压时间4～12 h,平均7 h。5例入院后急诊给予筋膜切开减压术联合封闭式负压引流,术后转入ICU给予连续性肾替代治疗(continuous renal replacement therapy,CRRT),待患者病情稳定后,肢体创面行游离植皮修复。结果患者住院时间26～48 d,平均33 d。1例植皮术后皮片部分坏死,经扩创后再次植皮成活;其余4例植皮顺利成活,创面Ⅰ期愈合。治疗期间无1例发生感染。5例患者均获随访,随访时间12～18个月,平均15个月。末次随访时,根据顾玉东提出的全臂丛功能评定标准,5例均为优,肌力Ⅴ级,完全恢复正常生活与工作。结论 CO中毒、醉酒与自身挤压3种因素共同作用,导致上臂及胸壁挤压综合征病情严重、进展快速。确诊后应尽早进行切开减张,同时行CRRT以及纠正贫血、电解质紊乱等综合性治疗,可获得良好预后。
Objective To investigate pathogenesis, diagnosis, and treatment of crush syndrome of chest and arm.Methods Between January 2010 and January 2015, 5 cases of crush syndrome of chest and arm caused by pressing oneself in a coma after CO poisoning or alcoholic intoxication were treated. There were 4 males and 1 female with an average age of 36.7 years(range, 28-46 years). Two patients involved left upper limb and chest, while the other three patients involved right upper limb and chest. The crushed time ranged from 4 to 12 hours(mean, 7 hours). All 5 cases received emergency decompression and vacuum sealing drainage(VSD). After surgery, the patients were transferred to Intensive Care Unit to receive continuous renal replacement therapy(CRRT). The wounds were repaired with skin grafts after the patients' condition were stable. Results The hospitalization time was 26-48 days(mean, 33 days).Necrosis of the skin graft occurred in 1 case, which cured after debridement and skin graft again. The skin graft survived in the other cases and the wounds healed by first intension. Five patients were followed up 12-18 months(mean,15 months). At last follow-up, the results were excellent in all 5 cases according to the assessment criteria proposed by GU Yudong. The patients got full recovery of their upper limb activities and sensation. All the patients returned to the normal life and work. Conclusion CO poisoning, drunkenness, and pressing oneself together will lead the crush syndrome to severe and rapid progress. The key of the treatment is a comprehensive therapy including a thorough and rapid tension reduction to save the limb function, CRRT, and correction of anemia and electrolyte imbalance.
Objective To investigate pathogenesis, diagnosis, and treatment of crush syndrome of chest and arm.Methods Between January 2010 and January 2015, 5 cases of crush syndrome of chest and arm caused by pressing oneself in a coma after CO poisoning or alcoholic intoxication were treated. There were 4 males and 1 female with an average age of 36.7 years(range, 28-46 years). Two patients involved left upper limb and chest, while the other three patients involved right upper limb and chest. The crushed time ranged from 4 to 12 hours(mean, 7 hours). All 5 cases received emergency decompression and vacuum sealing drainage(VSD). After surgery, the patients were transferred to Intensive Care Unit to receive continuous renal replacement therapy(CRRT). The wounds were repaired with skin grafts after the patients' condition were stable. Results The hospitalization time was 26-48 days(mean, 33 days).Necrosis of the skin graft occurred in 1 case, which cured after debridement and skin graft again. The skin graft survived in the other cases and the wounds healed by first intension. Five patients were followed up 12-18 months(mean,15 months). At last follow-up, the results were excellent in all 5 cases according to the assessment criteria proposed by GU Yudong. The patients got full recovery of their upper limb activities and sensation. All the patients returned to the normal life and work. Conclusion CO poisoning, drunkenness, and pressing oneself together will lead the crush syndrome to severe and rapid progress. The key of the treatment is a comprehensive therapy including a thorough and rapid tension reduction to save the limb function, CRRT, and correction of anemia and electrolyte imbalance.
引文
1严政,於四军,刘惠亮.挤压综合征治疗的最新进展.中华临床医师杂志:电子版,2015,9(15):2901-2906.
2 Smith J,Greaves I.Crush injury and crush syndrome:a review.J Trauma,2003,54(5 Suppl):S226-S230.
3Guner SI,Oncu MR.Evaluation of crush syndrome patients with extremity injuries in the 2011 Van Earthquake in Turkey.J Clin Nurs,2014,23(1-2):243-249.
4 陈怀祥,田海平,刘学军.51例挤压伤院前急救分析.华西医学,2016,31(1):53-56.
5顾玉东.臂丛神经损伤的功能评定标准与治疗方案.中华手外科杂志,2011,27(3):130.
6 陈曦,刘跃洪,徐巍,等.简易大鼠挤压伤-挤压综合征模型建立的实验研究.中国修复重建外科杂志,2013,27(1):77-82.
7Bagley WH,Yang H,Shah KH.Rhabdomyolysis.Internal and Emergency Medicine,2007,2(3):210-218.
8 卢丹萍,白燕,张虹丽.急性一氧化碳中毒致急性肾衰竭4例报告.内科急危重症杂志,2007,13(6):317-318.
9王婷,俞昌赫.一氧化碳中毒并发横纹肌溶解症1例.广东医学,2017,38(z2):216.
10 卿胜强,张静波.横纹肌溶解致急性肾损伤1例并文献复习.重庆医学,2018,47(6):863-864.
11陈碧琳.大量饮酒致横纹肌溶解.中国临床实用医学,2009,3(4):85-86.
12 孙晓辉,张彧,李春树.酒精致横纹肌溶解合并急性肾功能衰竭1 例报告.山东医药,2009,49(9):76.
13曹玉萍.急性酒精中毒所致横纹肌溶解综合征的临床护理方法及效果.中国当代医药,2016,23(15):194-196.
14 权毅,潘显明,邓少林,等.汶川大地震挤压伤特点与手术方式选择.中国修复重建外科杂志,2009,23(5):549-551.
15姜正明,张承铭,钱伟,等.严重挤压伤5例救治体会.中华临床新医学,2002,2(7):645-646.
16 钟洲,刘熹,张晖,等.地震挤压综合征迟发性肌肉坏死的临床研究.中国修复重建外科杂志,2014,28(10):1317-1319.
17Fleischmann W,Strecker W,Bombelli M,et al.Vaccum sealing as treatment of soft tissue damage in open fracture.Ufallchirurg,1993,96(9):488-492.
18 裘华德,王彦峰.负压封闭引流技术介绍.中国实用外科杂志,1998,18(4):233-234.
2 Smith J,Greaves I.Crush injury and crush syndrome:a review.J Trauma,2003,54(5 Suppl):S226-S230.
3Guner SI,Oncu MR.Evaluation of crush syndrome patients with extremity injuries in the 2011 Van Earthquake in Turkey.J Clin Nurs,2014,23(1-2):243-249.
4 陈怀祥,田海平,刘学军.51例挤压伤院前急救分析.华西医学,2016,31(1):53-56.
5顾玉东.臂丛神经损伤的功能评定标准与治疗方案.中华手外科杂志,2011,27(3):130.
6 陈曦,刘跃洪,徐巍,等.简易大鼠挤压伤-挤压综合征模型建立的实验研究.中国修复重建外科杂志,2013,27(1):77-82.
7Bagley WH,Yang H,Shah KH.Rhabdomyolysis.Internal and Emergency Medicine,2007,2(3):210-218.
8 卢丹萍,白燕,张虹丽.急性一氧化碳中毒致急性肾衰竭4例报告.内科急危重症杂志,2007,13(6):317-318.
9王婷,俞昌赫.一氧化碳中毒并发横纹肌溶解症1例.广东医学,2017,38(z2):216.
10 卿胜强,张静波.横纹肌溶解致急性肾损伤1例并文献复习.重庆医学,2018,47(6):863-864.
11陈碧琳.大量饮酒致横纹肌溶解.中国临床实用医学,2009,3(4):85-86.
12 孙晓辉,张彧,李春树.酒精致横纹肌溶解合并急性肾功能衰竭1 例报告.山东医药,2009,49(9):76.
13曹玉萍.急性酒精中毒所致横纹肌溶解综合征的临床护理方法及效果.中国当代医药,2016,23(15):194-196.
14 权毅,潘显明,邓少林,等.汶川大地震挤压伤特点与手术方式选择.中国修复重建外科杂志,2009,23(5):549-551.
15姜正明,张承铭,钱伟,等.严重挤压伤5例救治体会.中华临床新医学,2002,2(7):645-646.
16 钟洲,刘熹,张晖,等.地震挤压综合征迟发性肌肉坏死的临床研究.中国修复重建外科杂志,2014,28(10):1317-1319.
17Fleischmann W,Strecker W,Bombelli M,et al.Vaccum sealing as treatment of soft tissue damage in open fracture.Ufallchirurg,1993,96(9):488-492.
18 裘华德,王彦峰.负压封闭引流技术介绍.中国实用外科杂志,1998,18(4):233-234.