肺冲击伤转化研究——历史、现状与挑战
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摘要
冲击伤是火药、炸药等易燃、易爆品发明的副产物。肺脏作为爆炸冲击致伤中最易受累的空腔脏器,是临床冲击伤诊治的重点。与普通急性肺损伤相比,肺冲击伤在致伤原因、病理生理反应、诊治和防护、转归和预后等方面,有其特定表现形式与制约瓶颈。既往依据伤员症状、体征、影像学、血气分析,在肺冲击伤诊治中积累了许多经验。然而,鉴于当前安全形势和生产、生活潜在爆炸风险,爆炸物种类、理化性质、爆炸当量以及爆炸现场的复杂空间分布为肺冲击伤的诊治与防护提出了新的要求,特别是在我国创伤救治水平显著提升背景下,肺冲击伤伤员在诊治上对基于疗效和后期康复的个体化诊治需求尤为迫切,对肺冲击伤高效防护新措施渐趋关注。因此,笔者在系统回顾肺冲击伤流行病学规律基础上,从精准诊断、精准治疗和高效防护三方面概述肺冲击伤转化研究现状,并基于瓶颈问题提出愿景和展望,以期从转化医学视角分析肺冲击伤的历史、现状,探究肺冲击伤理论成果向精准治疗和高效防护转化的可行性,尝试从既往定性诊治转化为以量化评估为基础的个体化诊治,旨在为肺爆炸冲击伤精准救治和防护范式提供借鉴和启示。
Blast injuries are negative products of inflammable and explosive materials such as gunpowder and explosives. As the most vulnerable hollow organ in the explosion,the lung is the focus of clinical diagnosis and treatment for blast injuries. Compared with common acute lung injury,pulmonary blast injury(PBI) has its specific manifestation and constraint bottleneck in the causes of injury,pathophysiological responses,diagnosis and treatment,prevention,outcome and prognosis,etc. In the past,based on the symptoms,signs,imaging,blood gas analysis of the wounded,many experiences have been accumulated in the diagnosis and treatment of PBI. However,in view of the current security situation and the potential risks of production and life,the types of explosives,physical and chemical properties,explosive equivalents and the complex spatial distribution of the explosion site have continuously put forward new requirements for the diagnosis and treatment of PBI. With the significant improvement of trauma treatment in China,it is particularly urgent in the individualized diagnosis and treatment based on curative effect and post-rehabilitation,and effective protective measures for PBI patients. Therefore,based on the systematic review of the epidemiological data of PBI,this paper summarizes its research status from the precision diagnosis,precision treatment and high efficiency protection,and proposes the vision and prospect based on the bottleneck problem,in order to analyze from the perspective of translational medicine. The history and current situation of PBI,and the feasibility of transforming the theoretical results of PBI to precision treatment and efficient protection were given. It may propel the transformation of patterns of its diagnosis and therapy from routine experienced qualitative to personalized quantitive treatment. The aim of this paper tries to supply a new paradigm for the precision diagnosis,therapy and protection of PBI.
Blast injuries are negative products of inflammable and explosive materials such as gunpowder and explosives. As the most vulnerable hollow organ in the explosion,the lung is the focus of clinical diagnosis and treatment for blast injuries. Compared with common acute lung injury,pulmonary blast injury(PBI) has its specific manifestation and constraint bottleneck in the causes of injury,pathophysiological responses,diagnosis and treatment,prevention,outcome and prognosis,etc. In the past,based on the symptoms,signs,imaging,blood gas analysis of the wounded,many experiences have been accumulated in the diagnosis and treatment of PBI. However,in view of the current security situation and the potential risks of production and life,the types of explosives,physical and chemical properties,explosive equivalents and the complex spatial distribution of the explosion site have continuously put forward new requirements for the diagnosis and treatment of PBI. With the significant improvement of trauma treatment in China,it is particularly urgent in the individualized diagnosis and treatment based on curative effect and post-rehabilitation,and effective protective measures for PBI patients. Therefore,based on the systematic review of the epidemiological data of PBI,this paper summarizes its research status from the precision diagnosis,precision treatment and high efficiency protection,and proposes the vision and prospect based on the bottleneck problem,in order to analyze from the perspective of translational medicine. The history and current situation of PBI,and the feasibility of transforming the theoretical results of PBI to precision treatment and efficient protection were given. It may propel the transformation of patterns of its diagnosis and therapy from routine experienced qualitative to personalized quantitive treatment. The aim of this paper tries to supply a new paradigm for the precision diagnosis,therapy and protection of PBI.
引文
[1]王正国.冲击伤[M].北京:人民军医出版社,1983:1-10.
[2]王正国.冲击伤的历史沿革与精准诊断[J].中华诊断学电子杂志,2016,4(1):1-3.
[3]郭光.冲击波损伤动物实验[M].北京:人民军医出版社,1988:1-2.
[4] YANG C,GAO J,WANG HY,et al. Effects of hypothalamus destruction on the level of plasma corticosterone after blast injury and its relation to interleukin-6 in rats[J]. Cytokine,2011,54(1):29-35.
[5] HAQUE M,DAS A,SCOTT TE,et al. Primary blast lung injury simulator:a new computerised model[J]. J R Army Med Corps,2018,pii:jramc-2018-000989.
[6] LI XF,KUANG JM,NIE SB,et al. A numerical model for blast injury of human thorax based on digitized visible human[J].Technology and Health Care:Official Journal of the European Society for Engineering and Medicine,2017,25(10):1029-1039.
[7]中华医学会创伤学分会.天津港“8.12”大爆炸伤员伤情特点与救治反思[J].中华创伤杂志,2015,31(9):810-813.
[8]张国安.燃爆伤[M].北京:科学技术文献出版社,2016:1-9.
[9] ABOUDARA M,MAHONEY PF,HICKS B,et al. Primary blast lung injury at a NATO Role 3 hospital[J]. J R Army Med Corps,2014,160(2):161-166.
[10]范乃军,宋薇,张淼丹,等.现代恐怖袭击致冲击伤的病征及防治[J].实用医药杂志,2014,31(12):1057-1060.
[11] COOPER GJ,TOWNEND DJ,CATER SR,et al. The role of stress waves in thoracic visceral injury from blast loading:modification of stress transmission by foams and high-density materials[J]. J Biomech,1991,24(3):273-285.
[12] SCOTT TE,KIRKMAN E,HAQUE M,et al. Primary blast lung injury-a review[J]. Br J Anaesth,2017,118(3):311-316.
[13] SMITH JE,GARNER J. Pathophysiology of primary blast injury[J]. J R Army Med Corps,2018,pii:jramc-2018-001058.
[14]杨志焕,朱佩芳,蒋建新,等.水下冲击伤损伤特点的初步探讨[J].中华创伤杂志,2003,19(2):111-114.
[15]翁格文,杨志焕,李晓炎,等.大鼠模拟高原冲击伤早期伤情和血液流变学的变化[J].创伤外科杂志,1999,1:157-158.
[16]张连阳.爆炸冲击伤的诊断[J].创伤外科杂志,2017,19(2):157-160.
[17] CHEN X,WANG M,HU B,et al. Imaging analysis of burst injury of the lungs in coal miners workers[J]. Zhonghua Laodong Weisheng Zhiyebing Zazhi,2014,32(3):225-228.
[18] WOLF SJ,BEBARTA VS,BONNETT CJ,et al. Blast injuries[J]. Lancet,2009,374(4):405-415.
[19] BOURN S,T ES,E JH. A comparison of CT lung voxel density analysis in a blast and non blast injured casualty[J]. J R Army Med Corps,2018,doi:10.1136/jramc-2018-000979.
[20] CHANG Y,ZHANG DH,HU Q,et al. Usage of density analysis based on micro-CT for studying lung injury associated with burn-blast combined injury[J]. Burns,2018,44(9):905-916.
[21] BARNARD J,SHARMAN A,BRAZIER A. Bomb blast shrapnel trauma to the main pulmonary artery:learning points to achieve a safe outcome[J]. Eur J Cardiothorac Surg,2018,doi:10.1093/ejcts/ezy326.
[22] BALLIVET DE REGLOIX S,CRAMBERT A,MAURIN O,et al. Blast injury of the ear by massive explosion:a review of41 cases[J]. J R Army Med Corps,2017,163(3):333-338.
[23]周继红,袁丹凤,邱俊.原发冲击伤[J].伤害医学(电子版),2017,6(4):5-8.
[24] SMITH JE,WATTS S,SPEAR AM,et al. Nebulised recombinant activated factor VII(rFVIIa)does not attenuate the haemorrhagic effects of blast lung injury[J]. J R Army Med Corps,2018,doi:10.1136/jramc-2018-001029.
[25] SINGH A,DESHKAR AM,KASHYAP BK,et al. Blast lung:experience at CIMS[J]. J Indian Med Assoc,2012,110(2):126-127.
[26] LUMLEY A,OSBORN E,MELLOR A,et al. The role of neutrophil gelatinase-associated lipocalin(NGAL)in the detection of blast lung injury in a military population[J]. J Crit Care,2018,43(3):312-315.
[27] YU M,LV Q,DING H,et al. Evaluation of blast injury patients from the 2015 Tianjin explosions in China[J]. Burns,2016,42(5):1133-1140.
[28]胡泉,柴家科,杨红明.烧冲复合伤肺损伤的研究进展[J].人民军医,2013,38(5):428-432.
[29] RATTO J,JOHNSON BK,CONDRA CS,et al. Pediatric blast lung injury from a fireworks-related explosion[J]. Pediatr Emerg Care,2012,28(5):573-576.
[30]朱佩芳.水下冲击伤的防治[J].人民军医,2006,49(10):560-562.
[31]杨志焕,黄建钊,王正国,等.冲击伤复合高速破片致伤的损伤特点和冲击伤防护研究[J].爆炸与冲击,1998,18(2):162-166.
[32] WOOD GW,PANZER MB,SHRIDHARANI JK,et al. Attenuation of blast pressure behind ballistic protective vests[J]. In J Prev,2013,19(1):19-25.
[33] SEDMAN A,HEPPER A. Protection of the lung from blast overpressure by stress wave decouplers,buffer plates or sandwich panels[J]. J R Army Med Corps,2018,doi:10.1136/jramc-2017-000882.
[34] CERNAK I. The importance of systemic response in the pathobiology of blast-induced neurotrauma[J]. Front Neurol,2011,1(2):151.
[35] BOUTILLIER J,DECK C,MAGNAN P,et al. A critical literature review on primary blast thorax injury and their outcomes[J]. J Trauma Acute Care Surg,2016,81(4):371-379.
[2]王正国.冲击伤的历史沿革与精准诊断[J].中华诊断学电子杂志,2016,4(1):1-3.
[3]郭光.冲击波损伤动物实验[M].北京:人民军医出版社,1988:1-2.
[4] YANG C,GAO J,WANG HY,et al. Effects of hypothalamus destruction on the level of plasma corticosterone after blast injury and its relation to interleukin-6 in rats[J]. Cytokine,2011,54(1):29-35.
[5] HAQUE M,DAS A,SCOTT TE,et al. Primary blast lung injury simulator:a new computerised model[J]. J R Army Med Corps,2018,pii:jramc-2018-000989.
[6] LI XF,KUANG JM,NIE SB,et al. A numerical model for blast injury of human thorax based on digitized visible human[J].Technology and Health Care:Official Journal of the European Society for Engineering and Medicine,2017,25(10):1029-1039.
[7]中华医学会创伤学分会.天津港“8.12”大爆炸伤员伤情特点与救治反思[J].中华创伤杂志,2015,31(9):810-813.
[8]张国安.燃爆伤[M].北京:科学技术文献出版社,2016:1-9.
[9] ABOUDARA M,MAHONEY PF,HICKS B,et al. Primary blast lung injury at a NATO Role 3 hospital[J]. J R Army Med Corps,2014,160(2):161-166.
[10]范乃军,宋薇,张淼丹,等.现代恐怖袭击致冲击伤的病征及防治[J].实用医药杂志,2014,31(12):1057-1060.
[11] COOPER GJ,TOWNEND DJ,CATER SR,et al. The role of stress waves in thoracic visceral injury from blast loading:modification of stress transmission by foams and high-density materials[J]. J Biomech,1991,24(3):273-285.
[12] SCOTT TE,KIRKMAN E,HAQUE M,et al. Primary blast lung injury-a review[J]. Br J Anaesth,2017,118(3):311-316.
[13] SMITH JE,GARNER J. Pathophysiology of primary blast injury[J]. J R Army Med Corps,2018,pii:jramc-2018-001058.
[14]杨志焕,朱佩芳,蒋建新,等.水下冲击伤损伤特点的初步探讨[J].中华创伤杂志,2003,19(2):111-114.
[15]翁格文,杨志焕,李晓炎,等.大鼠模拟高原冲击伤早期伤情和血液流变学的变化[J].创伤外科杂志,1999,1:157-158.
[16]张连阳.爆炸冲击伤的诊断[J].创伤外科杂志,2017,19(2):157-160.
[17] CHEN X,WANG M,HU B,et al. Imaging analysis of burst injury of the lungs in coal miners workers[J]. Zhonghua Laodong Weisheng Zhiyebing Zazhi,2014,32(3):225-228.
[18] WOLF SJ,BEBARTA VS,BONNETT CJ,et al. Blast injuries[J]. Lancet,2009,374(4):405-415.
[19] BOURN S,T ES,E JH. A comparison of CT lung voxel density analysis in a blast and non blast injured casualty[J]. J R Army Med Corps,2018,doi:10.1136/jramc-2018-000979.
[20] CHANG Y,ZHANG DH,HU Q,et al. Usage of density analysis based on micro-CT for studying lung injury associated with burn-blast combined injury[J]. Burns,2018,44(9):905-916.
[21] BARNARD J,SHARMAN A,BRAZIER A. Bomb blast shrapnel trauma to the main pulmonary artery:learning points to achieve a safe outcome[J]. Eur J Cardiothorac Surg,2018,doi:10.1093/ejcts/ezy326.
[22] BALLIVET DE REGLOIX S,CRAMBERT A,MAURIN O,et al. Blast injury of the ear by massive explosion:a review of41 cases[J]. J R Army Med Corps,2017,163(3):333-338.
[23]周继红,袁丹凤,邱俊.原发冲击伤[J].伤害医学(电子版),2017,6(4):5-8.
[24] SMITH JE,WATTS S,SPEAR AM,et al. Nebulised recombinant activated factor VII(rFVIIa)does not attenuate the haemorrhagic effects of blast lung injury[J]. J R Army Med Corps,2018,doi:10.1136/jramc-2018-001029.
[25] SINGH A,DESHKAR AM,KASHYAP BK,et al. Blast lung:experience at CIMS[J]. J Indian Med Assoc,2012,110(2):126-127.
[26] LUMLEY A,OSBORN E,MELLOR A,et al. The role of neutrophil gelatinase-associated lipocalin(NGAL)in the detection of blast lung injury in a military population[J]. J Crit Care,2018,43(3):312-315.
[27] YU M,LV Q,DING H,et al. Evaluation of blast injury patients from the 2015 Tianjin explosions in China[J]. Burns,2016,42(5):1133-1140.
[28]胡泉,柴家科,杨红明.烧冲复合伤肺损伤的研究进展[J].人民军医,2013,38(5):428-432.
[29] RATTO J,JOHNSON BK,CONDRA CS,et al. Pediatric blast lung injury from a fireworks-related explosion[J]. Pediatr Emerg Care,2012,28(5):573-576.
[30]朱佩芳.水下冲击伤的防治[J].人民军医,2006,49(10):560-562.
[31]杨志焕,黄建钊,王正国,等.冲击伤复合高速破片致伤的损伤特点和冲击伤防护研究[J].爆炸与冲击,1998,18(2):162-166.
[32] WOOD GW,PANZER MB,SHRIDHARANI JK,et al. Attenuation of blast pressure behind ballistic protective vests[J]. In J Prev,2013,19(1):19-25.
[33] SEDMAN A,HEPPER A. Protection of the lung from blast overpressure by stress wave decouplers,buffer plates or sandwich panels[J]. J R Army Med Corps,2018,doi:10.1136/jramc-2017-000882.
[34] CERNAK I. The importance of systemic response in the pathobiology of blast-induced neurotrauma[J]. Front Neurol,2011,1(2):151.
[35] BOUTILLIER J,DECK C,MAGNAN P,et al. A critical literature review on primary blast thorax injury and their outcomes[J]. J Trauma Acute Care Surg,2016,81(4):371-379.