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1、CHAPTER 4 Thoracic Trauma 第四章 胸部创伤 PITFALLS 陷阱 Both tension pneumothorax and massive hemothorax are associated with decreased breath sounds on auscultation. Differentiation on physical examination can be made by percussion; hyperresonance supports a pneumothorax, whereas dullness suggests a massive
2、hemothorax. The trachea is often deviated in a tension pneumothorax, and the affected hemithorax can appear elevated without respiratory movement. 无论是张 力性气胸还是血胸在听诊时都会出现呼吸音减弱。可以通过叩诊将其区分。过 清音提示气胸，而浊音提示血胸。张力性气胸还会伴有气管移位，受影响的胸 腔将会抬高、呼吸运动也将消失。CIRCULATION 循环 The patients pulse should be assessed for qualit
3、y, rate, and regularity. In patients with hypovolemia, the radial and dorsalis pedis pulses may be absent because of volume depletion. Blood pressure and pulse pressure are measured and the peripheral circulation is assessed by observing and palpating the skin for color and temperature. Neck veins s
4、hould be assessed for distention, however, keep in mind that neck veins may not be distended in patients with concomitant hypovolemia and either cardiac tamponade, tension pneumothorax, or a traumatic diaphragmatic injury.病人的脉搏 也需要从特性、速率和节律上予以评估。有血容量减少的病人，由于血容量不 足足背动脉将会消失。监测血压、脉压，末梢血运通过观察皮肤颜色和触摸皮 肤温
5、度来评估。颈静脉是否扩张也要被评估，记住当病人伴有血容量减少、其 他心脏填塞疾病、张力性气胸或者创伤性膈肌损伤时，颈静脉也可以不充盈。 A cardiac monitor and pulse oximeter should be attached to the patient. Patients who sustain thoracic trauma especially in the area of the sternum or from a rapid deceleration injury, are also susceptible to myocardial injury, which
6、 can lead to dysrhythmias. Hypoxia and acidosis enhance this possibility. Dysrhythmias should be managed according to standard protocols. Pulseless electric activity (PEA) is manifested by an electrocardiogram (ECG) that shows a rhythm while the patient has no identifiable pulse. PEA can be present
7、in cardiac tamponade, tension pneumothorax, profound hypovolemia, and cardiac rupture.应当对胸部创伤患者使用心电监测和血氧饱和度监测。胸部 创伤的患者尤其是胸骨受伤，。经常容易并发心肌损伤，从而导致心律失 常。低氧血症和酸中毒增加了发病几率。心律失常应根据标准的方法进行管理。 当病人脉搏不可触及时，可通过心电图观察心脏节律，从而诊断PEA（无脉性电 活动（心律失常？）。心脏填塞、张力性气胸、严重血容量不足、心脏破裂 同样可以出现PEA。 The major thoracic injuries that aff
8、ect circulation and should be recognized and addressed during the primary survey are tension pneumothorax, massive hemothorax, and cardiac tamponade.大的胸部损伤 会影响循环，张力性气胸、血胸、心脏填塞应该被意识到并且早期处理。Massive Hemothorax 大量血胸 Massive hemothorax results from the rapid accumulation of more than 1500 mL of blood or
9、one-third or more of the patients blood volume in the chest cavity (FIGURE 4-6). It is most commonly caused by a penetrating wound that disrupts the systemic or hilar vessels. However, massive hemothorax can also result from blunt trauma.大量血 胸是由于胸腔中迅速积累了超过1500ml血液或者总血容量1/3以上。（图4-6）. 这大部分是由于贯通伤，损伤了肺门
10、或全身血管造成的。然而血胸也可由于钝 挫伤引起。 In patients with massive hemothorax, the neck veins may be flat as a result of severe hypovolemia, or they may be distended if there is an associated tension pneumothorax. Rarely will the mechanical effects of massive intrathoracic blood shift the mediastinum enough to cause
11、 distended neck veins. A massive hemothorax is suggested when shock is associated with the absence of breath sounds or dullness to percussion on one side of the chest. This blood loss is complicated by hypoxia.有大量血胸的患者，如果有严重的血容量不足，颈静脉可能很平坦。 如果伴有张力性气胸，颈静脉也可充盈。少量的血液由于机械作用由胸腔内进 入纵膈，足以引起颈静脉膨胀。休克患者一侧胸腔呼吸
12、音消失或叩诊浊音可能 提示严重血胸。由于血液的丢失常常伴有低氧血症。 Massive hemothorax is initially managed by the simultaneous restoration of blood volume and decompression of the chest cavity. Large-caliber intravenous lines and a rapid crystalloid infusion are begun, and type-specific blood is administered as soon as possible. B
13、lood from the chest tube should be collected in a device suitable for autotransfusion. A single chest tube (36 or 40 French) is inserted, usually at the nipple level, just anterior to the midaxillary line, and rapid restoration of volume continues as decompression of the chest cavity is completed. W
14、hen massive hemothorax is suspected, prepare for autotransfusion. If 1500 mL of fluid is immediately evacuated, early thoracotomy is almost always required.严重的血胸最初处理办法是补充血容量、胸腔减压。选用直径大的静 脉输液管并在开始时快速输注晶体液体和特定类型的血液。通常在乳头水平， 腋中线之前插入引流管，并在胸腔减压完成时快速补充血容量。当怀疑有严重 血胸时，要准备自体输血。如果胸腔引流超过1500ml液体，一般来说需要早期 开胸手术。
15、 Patients who have an initial output of less than 1500 mL of fluid, but continue to bleed, may also require thoracotomy. This decision is not based solelyon the rate of continuing blood loss (200 mL/hr for 2 to 4 hours), but also on the patients physiologic status.The persistent need for blood trans
16、fusions is an indication for thoracotomy. During patient resuscitation,the volume of blood initially drained from the chest tube and the rate of continuing blood loss must be factored into the amount of intravenous fluid required for replacement. The color of the blood (indicating an arterial or venous source) is a poor indicator of the necessity for thoracotomy.如果患者胸腔初期引流小于 1500ml，但有持续性出血，也需要开胸。这不仅仅取决于持续出血的速度 （200ml/h，持续2-4小
