1、Dr. Zhendong Liu The Third Xiangya Hospital,Trauma And War Injury,Risk factors,Traffic accident, industrial injury, Natural disaster, war injury and so on.,Traffic Accident,Industrial injury,Natural disaster,Explosion,CONTENT,1. The concept of trauma. 2. The classification of trauma. 3. The pathphys

2、iology of trauma. 4. The diagnosis of trauma. 5. The treatment of trauma.,DEFINITION,Trauma is the injury caused by mechanical or chemical factors, which leads to tissue integrity damaged and loss of function.,Chapter 1 Classification of the Trauma,1. For the integrity of skin,1). The opened injury

3、: Abrasion（摖傷） Laceration（撕裂傷） Incised wounds or cut wounds （切傷/ 砍傷） Puncture wounds （刺傷）,2). The blunt injury : Contusion （挫傷） Crush injury（擠壓傷） Sprain（扭傷） Concussion （震蕩傷） Luxation and semiluxation （關(guān)節(jié)脫位/半脫位） Closed bone fracture （閉合性骨折） Closed internal injury （閉合性內(nèi)臟傷）,2. For injured place and org

4、an,Craniocerebral injury （顱腦傷） : Chest injury （胸部傷）: hematopneumothrax Abdomen injury （腹部傷）: burst spleen, perforated bowel Limbs （四肢傷）: fracture, dislocation Spinal injury （脊柱傷）: fracture, paraplegia,3. Wound causing factors,Cold weapon wounds （冷兵器傷）: Knife Firearm wounds （火器傷）: gun Burns（燒傷）: High

5、 temperature Cold injury（冷傷）: Low temperature Blast injury （沖擊傷）: 爆震傷 Chemical injury （化學(xué)傷）: chemical weapon Radiation injury （放射性損傷）: Electromagnetic radiation，Particulate radiation,Opened injury,Opened fracture,Chapter 2 Pathophysiology of trauma,Trauma can trigger a cascade of pathological respon

6、se which includes inflammatory/immune reaction, neuroendocrine response and functional change of vital organ.,1.The inflammatory/immune reaction,1. Inflammatory: local tissue inflammatory 2. Immunosuppressing: glucocorticoids inhibit inmmunocytes function. 3. Immunomodulating : Systemic inflammatory

7、 response syndrome(SIRS) Compensatory anti-inflammatory response syndrome(CARS),Immunomodulating Both glucocorticoids and catecholamines directly inhibit the production of type 1 cytokines, such as IL-12, IL-2, TNF- and INF-, that enhance cellular immunity and T-helper 1 (Th1) formation and converse

8、ly favor the production of type 2 cytokines, such as IL-10, IL-4, IL-13, that induce humoral immunity and T-helper 2 (Th2) formation. Thus, during an immune challenge, stress causes an adaptive Th1 to Th2 shift in order to protect the tissues from the potentially destructive actions of the pro-infla

9、mmatory type 1 cytokines and other products of activated macrophages. The homeostatic role of stress-induced Th2 shift against overshooting of cellular immunity often complicates pathologic conditions where, either cellular immunity is beneficial (e.g. carcinogenesis, infections) or humoral immunity

10、 is deleterious (e.g. allergy, autoimmune diseases).,Schematic representation of the interactions between the stress and the immune system. LC/NE: locus ceruleus/norepinephrine-sympathetic system, SPGN: sympathetic postgaglionic neurons, CRH: corticotropin-releasing hormone, AVP: arginine vasopressi

11、n, ACTH: corticotrophin, PAF: platelet activating factor, NE/E: norepinephrine/epinephrine,: Th1: T-helper lymphocyte 1, Th2: T-helper lymphocyte 2. Stimulation is represented by solid green lines and inhibition by dashed red lines.,1. Sympathetic / adrenocortex system 2. Hypothalamus / pituitary sy

12、stem 3. Renin-angiotension system,2. Neuroendocrine response,The purpose of the physical reaction is to maintain the circulation of the blood and tissue perfusion,1.SNS - Neurohormonal response Stimulated by sympathetic/adrenocortex system (catecholamine ) Increased heart rate Increased contractilit

13、y Vasoconstriction (SVR-Afterload) Increased Preload,2.SNS - Hormonal: Adrenal Cortex Anterior pituitary releases adrenocorticotropic hormone (ACTH). Stimulates adrenal Cx to release glucorticoids. Blood sugar increases to meet increased metabolic needs.,3.SNS - Hormonal: Antidiuretic Hormone Osmore

14、ceptors in hypothalamus stimulated ADH released by Posterior pituitary gland Vasopressor effect to increase BP Acts on renal tubules to retain water,4.SNS - Hormonal: Renin-angiotension system Decrease renal perfusion Releases renin angiotension I angiotension II potent vasoconstriction & releases a

15、ldosterone adrenal cortex sodium & water retention,3. Functional change of vital organ,Heart: Catecholamine increases heart rate. Anoxia, acidosis the injuries of cardiac muscle. Lungs: The ventilation-perfusion imbalance ARDS. Kidneys: Renal failure, oliguria (400 ml/d), anuria (100 ml/d) . Brain:

16、Edema, The encephalic pressure increases. Gastrointestine: the intestinal mucosa barrier was damaged shift of bacteria and toxin MODS. Liver: The endotoxicemia metabolic disturbance and acidosis aggravated.,Chapter 3 Repair of injured tissue,Trauma directly stimulates local tissue and triggers a cas

17、cade of tissue repair process which includes: A. Inflammation. B. Proliferation and differentiation of many types of cellgranulation formation. C. Wounds healing and car formation.,The concept of inflammation,Inflammation can be defined as a localized protective tissue response elicited by injury or

18、 destruction of tissues, which serves to destroy, dilute or wall off both the injurious agent and the injured tissues. The inflammation is often characterized by injured tissue showing redness, swelling, heat, pain and loss of function.,New Tissue Formation (granulation),Following the inflammation -

19、 proliferation and migration of cells at the wound site. This dense population of macrophages, fibroblasts and endothelial cells, etc., embedded in a loose matrix. Granulation formation fill the gap of injured tissue before their coverage by epidermal cells.,Matrix Formation and Remodeling,Remodelin

20、g of the immature tissue matrix commences simultaneously with granulation tissue formation. For clarity, however, it is normally regarded as forming the third and final phase of wound healing due to its continuation for many months or years after granulation tissue has been resolved. During this pha

21、se the highly cellular and highly vascular granulation tissue is gradually replaced and remodeled, forming scar tissue.,Angiogenesis,Tissue healing,The wound healing 1.The first intention : mainly composed of the original cells, with little fibrous tissue, e.g. epithelial cell-skin, mucosa, osteobla

22、st-bones, endothelial cell-wall of vessels without lose of function,The wound healing 2. The second intention : mainly composed of fibrous tissue, owning a poor function after healing, not only lacking the original function, but owning the scar contraction or hyperplasia, which result in malformatio

23、n and dysfunction .,The disadvantageous factors for heal 1. Infection. 2. Foreign body. 3. Inadequate blood supply. 4. Improper local fixation. 5. The systemic factors e.g. malnutrition, improper use of medicine, poor immunity.,Chapter 4 Diagnosis of Trauma,The systemic examination 1. The vital sign

24、s: 1) Temperature 2) R, BP, P 3) Others: oliguria, thirsty, sleeplessness, anorexia, etc. 2. Trauma evaluation: 1) CRAMS 2) ISS(injury severity score) 3) AIS(abbreviated injury score),Clinical Manifestations Local Manifestations: (1) Pain (2) Swelling (3) Dysfunction,1. The history: (1)The cause, th

25、e wounded position and the posture. (2)The symptoms and the evolvement after the wound. (3)The local disposal. (4)The past health.,2. PE: (1)R, P, BP, the consciousness, the face, the posture, shocked or not. (2)According to the history, examining the local wound carefully. (3)For the opened wound,

26、examining the size, shape, depth, contamination, bleeding of wound and foreign body in wound.,The accessory examinations (1) The tests- B-R, U-R, S-R, HCT, electrolytes, CO2CP, BUN, enzymology, etc. (2) Puncture, Pipe Examination 1.The cavums of thorax, abdomen and joints. 2.To drain the urine, intu

27、bation. 3.CVP-the central vein pressure. (3) The imaging examination X-ray, CT, MRI, ultrasonic test, etc.,Complications (1) The purulent infection-opened fracture, large wound (2) Shock (3) MODS e.g.: The adult respiratory distress syndrome, acute renal failure, the stress ulcer.,Chapter 5 Treatmen

28、t of trauma,First aid,Emergency treatment 1.The aim for the treatment is to repair the wounded tissues and the organs, and recover physiological functions. 2.The critical cases should be treated firstly, such as stop of heart beat, asphyxia, massive haemorrhage, opened pneumothorax, shock, etc. 3.The basic steps for save the severe case “A, B, C”- Airway Breathing Circulation,The general disposal 1.The posture and the local fixation. 2.To prevent and treat the infection. 3.To maintain the balance of body fluid and the nutritious metabolism. 4.To cease