双下肢近端绑扎止血带在创伤骨折伴失血性休克中的临床应用
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摘要
目的探讨双下肢近端绑扎止血带在四肢骨折伴失血性休克急救中实际临床应用的有效性和安全性。方法采用回顾性病例对照研究分析西南医科大学附属中医医院骨科2010年1月—2017年7月收治的四肢骨折伴失血性休克53例,其中仅在创伤肢体常规使用止血带(伤肢组) 26例,双下肢近端绑扎止血带+创伤肢体常规使用止血带组(双下肢组) 27例,观察两组入院24h内病死率,血压恢复到正常值低限范围所需时间,止血带休克发生率,术后神经、肌肉、皮肤损害及血栓发生率。结果入院24h内病死率:双下肢组无一例死亡,伤肢组3例(病死率11. 5%),差异有统计学意义(P <0. 05)。双下肢组血压恢复到正常值低限范围所需时间为(18. 59±3. 05) min,伤肢组血压恢复到正常值低限范围所需时间为(49. 22±7. 66) min(P <0. 05)。伤肢组无止血带休克反应,双下肢组止血带休克反应发生1例(P> 0. 05)。术后发生神经、肌肉、皮肤损害双下肢组2例,伤肢组1例(P> 0. 05);伤肢组术后肢体未发生静脉血栓,双下肢组术后发生静脉血栓1例(P> 0. 05)。结论在创伤四肢骨折伴严重休克的急救中使用双下肢近端绑扎止血带的方法可以降低入院24h内病死率,血压可以更快恢复到正常值的低限,且不会提高止血带休克发生率、血栓形成率和术后神经、肌肉、皮肤损伤发生率。
Objective To investigate the effectiveness and safety of the clinical application of tourniquets in the proximal extremity of both lower extremities in emergency treatment of limb fracture with hemorrhagic shock.Methods A retrospective case-control study was used to analyze 53 cases from Jan. 2010 to Jul. 2017. The control group used only tourniquets on traumatic limbs for 26 patients; the experimental group used tourniquets on both traumatic limbs and lower extremities for 27 patients. The death rate within 24 h after admission,the time required for blood pressure to recover to the lowest normal value,the incidence of tourniquet shock,and the incidence of postoperative neurological,muscular,and skin damage,and the thrombosis rate were observed. Results The number of died patients within 24 h after admission was 0 in the experimental group( mortality rate 0%) and 3 in the control group( mortality rate 11. 5%,P < 0. 05). The time required for the blood pressure of the experimental group to recover to the lowest normal value was( 18. 59 ± 3. 05) min,and the time for the blood pressure of the control group to recover to the lowest normal value was( 49. 22 ± 7. 66) min( P < 0. 05). There was no tourniquet shock in the control group and 1 case of tourniquet shock in the experimental group( P > 0. 05). Nerve,muscle,and skin damage occurred in 2 patients in the experimental group and 1 in the control group( P > 0. 05). No venous thrombosis occurred in the control group,and 1 patient with venous thrombosis occurred in the experimental group( P > 0. 05).Conclusion When traumatic fracture with severe shock occurs,the usage of tourniquet to both proximal lower extremities can reduce death rate within 24 h of admission. It can restore blood pressure to the lowest normal range more quickly,and will not increase the incidence of tourniquet shock and thrombosis and the damage of nerve,muscle,and skin after surgery.
Objective To investigate the effectiveness and safety of the clinical application of tourniquets in the proximal extremity of both lower extremities in emergency treatment of limb fracture with hemorrhagic shock.Methods A retrospective case-control study was used to analyze 53 cases from Jan. 2010 to Jul. 2017. The control group used only tourniquets on traumatic limbs for 26 patients; the experimental group used tourniquets on both traumatic limbs and lower extremities for 27 patients. The death rate within 24 h after admission,the time required for blood pressure to recover to the lowest normal value,the incidence of tourniquet shock,and the incidence of postoperative neurological,muscular,and skin damage,and the thrombosis rate were observed. Results The number of died patients within 24 h after admission was 0 in the experimental group( mortality rate 0%) and 3 in the control group( mortality rate 11. 5%,P < 0. 05). The time required for the blood pressure of the experimental group to recover to the lowest normal value was( 18. 59 ± 3. 05) min,and the time for the blood pressure of the control group to recover to the lowest normal value was( 49. 22 ± 7. 66) min( P < 0. 05). There was no tourniquet shock in the control group and 1 case of tourniquet shock in the experimental group( P > 0. 05). Nerve,muscle,and skin damage occurred in 2 patients in the experimental group and 1 in the control group( P > 0. 05). No venous thrombosis occurred in the control group,and 1 patient with venous thrombosis occurred in the experimental group( P > 0. 05).Conclusion When traumatic fracture with severe shock occurs,the usage of tourniquet to both proximal lower extremities can reduce death rate within 24 h of admission. It can restore blood pressure to the lowest normal range more quickly,and will not increase the incidence of tourniquet shock and thrombosis and the damage of nerve,muscle,and skin after surgery.
引文
[1] Hess JR,Holcomb JB,Hoyt DB. Damage control resuscitation:the need for specific blood products to treat the coagulopathy of trauma[J]. Transfusion,2006,46(5):685-686.
[2]房笑丽,周纪平,赛小珍,等.下肢气压止血带分次放气减缓血压下降的研究[J].中国中医骨伤科杂志,2008,(9):18-19.
[3]盛卓人,王俊科.实用临床麻醉学[M]. 4版.北京:科学出版社,2009:652.
[4] kauvar DS,Lefering R,Wade CE. Impact of hemorrhage on trauma outcome:an overview of epidemiology,clinical presentations,and therapeutic considerations[J]. J Trauma,2006,60(6):S3-11.
[5]刘良明,白祥军,李涛,等.创伤失血性休克早期救治规范[J].创伤外科杂志,2017,19(12):881-883,891.
[6]张英杰,王绚,李培杰.心搏骤停后脑损伤机制及脑复苏的研究进展[J].医学综述,2014,20(2):301-303.
[7] Rall J,Cox JM,Maddry J. The use of the abdominal aortic and jnctional tourniquet during cardiopulmonary resuscitation following traumatic cardiac arrest in swine[J]. Mil Med,2017,182(9):e2001-2005.
[8] Kheirabadi BS,Terrazas IB. Physiological consequences of abdominal aortic and junctional tourniquet(AAJT)application to control hemorrhage in swine model[J]. Shock,2016,46(3S1):160-166.
[9]陈黎敏,沈碧玉,何燕.应用气压止血带不良反应的原因分析与对策[J].现代中西医结合杂志,2012,21(27):3073-3076.
[10] Finsen V,Kasseth AM. Tourniquets in forefoot surgery:less pain when placed at the ankle[J]. J Bone Joint Surg(Br),1997,79(1):99-101.
[11]冯尚华,付亚辉,王鹏飞,等.止血带应用时间和手术时间对胫腓骨骨折术后深静脉血栓发生率的影响[J].中国骨与关节损伤杂志,2016,31(8):868-869.
[12] Noordin S,Mcewen JA,Kragh CJ,et al. Surgical tourniquets in orthopaedics[J]. J Bone Joint Surg(Am),2009,91(12):2958-2967.
[1]盛玄霜,张桂琴,王海云,等.健康成人使用抗休克裤的血流动力学效应[J].中华创伤杂志,1986,(3):157-160.
[2]张晓峰,宋韦吴.战伤与创伤抗休克裤的研制[J].医疗设备信息,2006,21(8):3-5.
[3] Kragh JF,Littrel ML,Jones JA,et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding[J]. J Emergency Med,2011,41(6):590-597.
[4]李阳,张连阳.直面挑战躯干战伤出血的紧急控制[J].解放军医学杂志,2017,42(1):1-5.
[5] Rappold JF,Bochicchio GV. Surgical adjuncts to noncompressible torso hemorrhage as tools for patient blood management[J]. Transfusion,2016,56(S2):S203-207.
[6]李阳,张连阳.战伤战术阶段救治技术的创新策略[J].实用医药杂志,2017,34(1):1-3.
[2]房笑丽,周纪平,赛小珍,等.下肢气压止血带分次放气减缓血压下降的研究[J].中国中医骨伤科杂志,2008,(9):18-19.
[3]盛卓人,王俊科.实用临床麻醉学[M]. 4版.北京:科学出版社,2009:652.
[4] kauvar DS,Lefering R,Wade CE. Impact of hemorrhage on trauma outcome:an overview of epidemiology,clinical presentations,and therapeutic considerations[J]. J Trauma,2006,60(6):S3-11.
[5]刘良明,白祥军,李涛,等.创伤失血性休克早期救治规范[J].创伤外科杂志,2017,19(12):881-883,891.
[6]张英杰,王绚,李培杰.心搏骤停后脑损伤机制及脑复苏的研究进展[J].医学综述,2014,20(2):301-303.
[7] Rall J,Cox JM,Maddry J. The use of the abdominal aortic and jnctional tourniquet during cardiopulmonary resuscitation following traumatic cardiac arrest in swine[J]. Mil Med,2017,182(9):e2001-2005.
[8] Kheirabadi BS,Terrazas IB. Physiological consequences of abdominal aortic and junctional tourniquet(AAJT)application to control hemorrhage in swine model[J]. Shock,2016,46(3S1):160-166.
[9]陈黎敏,沈碧玉,何燕.应用气压止血带不良反应的原因分析与对策[J].现代中西医结合杂志,2012,21(27):3073-3076.
[10] Finsen V,Kasseth AM. Tourniquets in forefoot surgery:less pain when placed at the ankle[J]. J Bone Joint Surg(Br),1997,79(1):99-101.
[11]冯尚华,付亚辉,王鹏飞,等.止血带应用时间和手术时间对胫腓骨骨折术后深静脉血栓发生率的影响[J].中国骨与关节损伤杂志,2016,31(8):868-869.
[12] Noordin S,Mcewen JA,Kragh CJ,et al. Surgical tourniquets in orthopaedics[J]. J Bone Joint Surg(Am),2009,91(12):2958-2967.
[1]盛玄霜,张桂琴,王海云,等.健康成人使用抗休克裤的血流动力学效应[J].中华创伤杂志,1986,(3):157-160.
[2]张晓峰,宋韦吴.战伤与创伤抗休克裤的研制[J].医疗设备信息,2006,21(8):3-5.
[3] Kragh JF,Littrel ML,Jones JA,et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding[J]. J Emergency Med,2011,41(6):590-597.
[4]李阳,张连阳.直面挑战躯干战伤出血的紧急控制[J].解放军医学杂志,2017,42(1):1-5.
[5] Rappold JF,Bochicchio GV. Surgical adjuncts to noncompressible torso hemorrhage as tools for patient blood management[J]. Transfusion,2016,56(S2):S203-207.
[6]李阳,张连阳.战伤战术阶段救治技术的创新策略[J].实用医药杂志,2017,34(1):1-3.