汶川地震灾区伤员伤口和创面处理

目的研究地震灾区软组织损伤伤口和烧伤创面特点和处理方法。方法对汶川地震中受伤的124例软组织损伤和烧伤进行回顾性分析和总结。根据受伤情况,采用清创、缝合、换药、皮片移植和皮瓣移植等方法处理伤口和创面。结果地震伤员软组织损伤特点有：伤口污染严重,损伤严重,常伴有感染,严重损伤或感染可导致软组织缺损并需要行皮片或皮瓣修复。120例伤员伤口和创面正常愈合,4例皮肤缺损大者根据统一安排转运至外省医院治疗。结论经过专科医生治疗,地震灾区伤员的软组织损伤伤口和烧伤创面可得到满意的结果。     

汶川地震转移伤员32例临床分析

汶川大地震后17d，徐州医学院第二附属医院骨科接收了从汶川地震灾区转来的32例伤员，最大97岁，最小12岁，平均48．6岁。直接砸、压、埋所致多发伤30例（93．8％）。骨折27例（84.4％）。发病部位多在四肢（26例，57．8％），脊柱（5例，11．1％），骨盆（3例，6．7％），和肋、锁骨（8例，17．8％）。术后合并症包括皮肤软组织坏死及骨外露，创面不同程度感染，肺部感染，胸腔积液，霉菌感染，褥疮，贫血，低氧血症，神经损伤等。通过正确处理伤口尽早闭合创面，运用综合措施合理处理骨折，进行肢体术后的早期康复锻炼，积极防治并发症，加强护理，注重心理疏导和亲情关爱，32例伤员全部康复出院。     

大地震初期紧急医疗救援要点：绵竹现场抢救工作经验

5．12汶川地震后，唐山红十字医疗救护队急赴四川绵竹地震灾区进行救援工作。从灾区现场工作中总结出以下经验：地震灾区医疗救援队的组成人员应以外科、骨科医师和护士为主，应选择年龄相对较轻、体质较好的人员；伤情分类、分级制度必须坚持；就地取材，应用硬塑料板、硬纸板等进行伤肢固定时要注意消毒；注意彻底清创；使用最多的抗菌药物包括头孢菌素类和喹诺酮类，避免应用可能损害肾功能的药物，镇痛药物主要选用非甾体类药物，如布洛芬；必要的心理干预在地震初期救援中发挥了重要的作用。     

犬咬伤创口清创研究

目的探讨适合犬咬伤创口的外科清创方法。方法选取400例犬咬伤致撕裂伤患者,随机分为对照组和试验组,对照组用清水或肥皂水进行创口清洗,继之用3％碘酒或75％酒精进行消毒,试验组用0．05％等渗碘伏溶液进行清洗和内部消毒,比较2组疼痛指数、愈合时间和感染率。结果对照组（A）平均疼痛指数为7．37±1．18,感染率为21％,显著高于试验组（B）[（5．24±0．92、8％,均P〈0．05]。愈合时间在感染病例A组为（20．86±3．04）d,B组为（18．98±2．17）d;在未感染病例A组为（16．24±2．56）d,显著高于B组[（13．41±1．83）d,P〈0．05]。结论用0．05％等渗碘伏溶液代替清水或肥皂水对犬咬伤创口进行清洗和用碘酒、酒精消毒和清创明显降低创口的感染率、减少愈合时间,并且减轻清创过程中患者的疼痛感。     

4·20芦山地震261例不同灾情地区伤员伤情分析

目的：通过比较分析4·20芦山地震重灾区与轻灾区伤员的伤情特点,为优化震后医疗资源调配提供依据。方法收集震后1周内、就诊于四川大学华西医院急诊科的地震伤员病历资料,回顾性分析重灾区与轻灾区伤员的伤情严重程度、受伤部位、受伤类型。结果重灾区与轻灾区伤员伤情严重程度及受伤部位无统计学差异。重灾区伤员中,骨折伤员比例少于轻灾区（50%和69%,P=0.020）,软组织伤比例大于轻灾区（22%和10%,P=0.005）。结论在震后灾区医疗资源配置上,绝大部分医疗资源的需求比例在重灾区与轻灾区无差异,仅需在有关骨折伤与软组织伤的个别医疗资源调配比例方面稍作调整,但仍以骨科医疗资源为主。     

从汶川地震灾区疾病谱构成规律分析医疗救援队的组配变化

“5·12”四川汶川地震发生后，海军总医院即派出医疗队前往灾区，人员以外科，尤其是骨科医生为主，物资配备以清创包，夹板，和抗生素、麻醉药、止痛药等药品为主。灾区疾病谱随时间变化，灾后1周内疾病构成以骨折等外伤为主，之后内科类疾病在疾病谱中所占比例明显上升。罹病率居前的疾病为：呼吸道感染（35．3％），外伤（19．5％），急性胃肠炎（10．9％）和皮炎（9．3％）。1周后需要增加呼吸科、消化科、皮肤科、儿科等专科医生和心理、防疫方面的医务人员，需要增加常见内科疾病药物的配备。     

地震灾区犬咬伤的情况分析

目的了解地震后灾区犬咬伤流行病学特征，为制定干预措施提供科学依据。方法通过对四川省绵竹市九龙镇白玉村的1217户约3340人进行入户走访调查，了解犬咬伤的情况及处理。结果共监测到36例犬咬伤伤员，约占被调查者总数的1％。受伤部位以下肢居多，为30例。咬伤事件大多发生在震后1周内出现的2次雷雨过程中，为19例。伤口未得到及时并且正确的处理者12例，4例至今未能接种狂犬病疫苗。结论地震后山区犬咬伤者数量明显超过平时，部分犬咬伤患者不能得到及时正确的处理，犬未能得到及时的管理或捕杀。震后要加大对犬的管理，被犬咬伤后要及时正确地处理伤口，接种狂犬病疫苗，防止狂犬病的发生。     

2005年巴基斯坦地震伤员创面回顾性分析

目的分析2005年10月8日巴基斯坦西北部7．8级地震伤病员的病情及创面情况。方法对中国第二批国际医疗队在巴拉考特镇治疗的2194例伤病员的临床资料进行回顾性分析。结果2194例患者中,创伤患者为29％,腹泻患者4％,上呼吸道感染患者为14％,其他类型患者52％。在630例创伤患者中,426例为地震中受伤。426例地震伤患者中,291例（68％）存在皮肤创面,85例（20％）患者主要为软组织挫伤;76例（18％）为骨折患者。最常见的创面部位为下肢,成年男性发生率为41％,妇女为45％,儿童为33％。儿童头部创面发生率明显高于成人,为30％。在地震伤员中,创面感染非常普遍,成年男性、女性和儿童发生率分别为72％、64％和78％。结论地震后,灾区主要病种随不同阶段而改变。在震后晚期,常见病,遗留创面,创面感染和骨折是主要问题。伤员中的下肢创面高发生率和儿童中头部创面的较高发生率应该引起注意。     

左乳腺癌伴腋窝淋巴结转移患者癌性伤口的护理

报告1例左乳腺癌伴腋窝淋巴结转移患者癌性伤口的护理经验。患者女，55岁。左乳出现一大量粘稠脓性渗出伴有恶臭的伤口2个月，皮肤科检查：左侧乳腺乳头下内、外象限可见一10 cm×11.5 cm×3 cm肿物，破溃，近圆形，伤口表面覆盖黄白色腐肉和脓苔，大量黄褐色粘稠渗出液（患者所穿衣物被浸透）伴有恶臭，腋窝可触及多发肿大的淋巴结，融合成团，边界不清，质地韧，无压痛，活动度差。免疫组化：雌激素受体（ER）（阳性率<1%），人表皮生长因子受体2(HER-2)(+++),P53（阳性率约20%），细胞增殖标记Ki-67（阳性率约40%）。诊断：左乳浸润性癌HER-2扩增型cT4N2aM0Ⅲ期腋窝淋巴结转。     

汶川地震致头皮伤口感染细菌谱及耐药性分析

目的探讨地震灾害引起的开放性头皮损伤伤121感染的病原菌分布,耐药性特点及抗生素治疗措施。方法回顾分析5·12汶川地震后,四川大学华西医院神经外科收治的38例开放性颅伤患者头皮伤口感染的病原学资料。结果全组38例开放性头皮伤口感染的病原菌菌株51株,革兰阳性菌35株（68．63％）,分别是金黄色葡萄球菌21株（41．18％）,表皮葡萄球菌14株（27．45％）;革兰阴性菌16株（31．37％）,分别是阴沟肠杆菌8株（15．69％）,肺炎克雷伯杆菌4株（7．84％）,绿脓杆菌2株（3．92％）,深红沙雷氏菌2株（3．92％）。这些菌株对临床常用抗生素都有不同程度的耐药。经彻底清创及应用敏感抗生素,能有效控制感染。结论地震引起的开放性头皮伤口感染的病原菌,多以革兰阳性的金黄色葡萄球菌感染为主。早期彻底清创,营养支持,应用敏感抗生素能提高治疗效果。     

海地地震救援中骨折患者的现场救治分析

探讨地震所致骨折患者现场救治的有效方法。方法分析2010年1月海地地震发生后2周内,中国国际救援队现场治疗的153例骨折患者的临床资料。结果153例中上肢骨折61例,下肢骨折87例,关节脱位5例,其中开放性骨折25例,合并挤压伤17例。18例重伤员现场治疗后送医院治疗,其余135例中118例至少随诊1次;13例开放性骨折中,4例伤口感染,2例可疑感染,7例伤口处于愈合中,11例肢体挤压伤患者肿胀减轻或未进一步加重,其余患者骨折固定稳定,疼痛明显减轻,未见明显并发症发生。结论地震所致骨折中四肢骨折为主。治疗主要立足于现场抢救和早期救治。     

汶川大地震首日医院急诊流程的应急调整

5.12四川汶川大地震发生后，成都市第二人民医院立即启动了紧急医疗救援预案，对急诊流程进行应急调整优化。在15min内将病员56名，包括6名重症患者和4名正准备入院的患者转移至安全空旷地带继续治疗；10min内开始救治成都市内地震伤员。地震后1h内医疗救援队即驱车赶赴地震重灾区都江堰市参与救治伤员。建立临时分诊台和眼科、产科急诊室。简单外科处理如包扎、固定和化验、X线检查、B超检查等辅助检查在急诊室进行。对一些病例进行心理干预。地震发生后6h内，救护车出车56次，转运伤员182名；急诊科收治创伤患者268名，清创缝合179名，石膏固定52名。院内无伤员死亡。笔者认为，原来的急诊预案缺少有关地震的内容，应予补充。     

Tissue-engineered skin in the healing of wound stumps from limb amputations secondary to purpura fulminans

Currently wound treatment options of amputation stumps due to purpura fulminans include healing by secondary intention from wound debridement, split-thickness skin grafting, tissue and muscle flaps, plantar skin free transfer, skin expansion, artificial skin, and hyperbaric oxygen therapy. We saw a 6-month-old girl with purpura fulminans as a complication of meningococcemia. She developed necrosis of the distal extremities resulting in bilateral amputation of the lower limbs. Shortly thereafter the leg stumps also became necrosed and she underwent unsuccessful split-thickness grafts of lower limb ulcers. The patient's difficult-to-heal wounds made her an excellent candidate for treatment with tissue-engineered skin. At 10 months of age, this was applied to her previously nonhealing wounds. The tissue-engineered skin induced rapid healing of the patient's chronic amputation stump ulcers and provided her with substantial pain relief. In conclusion, tissue-engineered skin appears to be a potential beneficial treatment for chronic wounds in children with nonhealing amputation stumps.     

Mikrobielle Belastung von Haut und Wunden in Klinik und Praxis

The antibiotic treatment of microbial pathogens of the skin and wounds could so far not fulfil the expectations of an effective and permanent elimination of pathogens so that local treatment with antiseptic agents as a flanking measure to wound cleansing and debridement has become increasingly more established. Because an antiseptic treatment does not actually represent a treatment of infections, the current antimicrobial treatment strategy for infections in skin and wound areas consists of combined antibiotic and flanking antiseptic administration following debridement. However, the combined therapy is not always successful. There is an urgent need for new forms of therapy particularly to combat multiresistant pathogens in biofilms in infections of chronic and other complicated wounds.     

Maggot therapy for the treatment of intractable wounds

BACKGROUND: Fly maggots have been known for centuries to help debride and heal wounds. Maggot therapy was first introduced in the USA in 1931 and was routinely used there until the mid-1940s in over 300 hospitals. With the advent of antimicrobiols, maggot therapy became rare until the early 1990s, when it was re-introduced in the USA, UK, and Israel. The objective of this study was to assess the efficacy of maggot therapy for the treatment of intractable, chronic wounds and ulcers in long-term hospitalized patients in Israel. METHODS: Twenty-five patients, suffering mostly from chronic leg ulcers and pressure sores in the lower sacral area, were treated in an open study using maggots of the green bottle fly, Phaenicia sericata. The wounds had been present for 1-90 months before maggot therapy was applied. Thirty-five wounds were located on the foot or calf of the patients, one on the thumb, while the pressure sores were on the lower back. Sterile maggots (50-1000) were administered to the wound two to five times weekly and replaced every 1-2 days. Hospitalized patients were treated in five departments of the Hadassah Hospital, two geriatric hospitals, and one outpatient clinic in Jerusalem. The underlying diseases or the causes of the development of wounds were venous stasis (12), paraplegia (5), hemiplegia (2), Birger's disease (1), lymphostasis (1), thalassemia (1), polycythemia (1), dementia (1), and basal cell carcinoma (1). Subjects were examined daily or every second day until complete debridement of the wound was noted. RESULTS: Complete debridement was achieved in 38 wounds (88.4%); in three wounds (7%), the debridement was significant, in one (2.3%) partial, and one wound (2.3%) remained unchanged. In five patients who were referred for amputation of the leg, the extremities was salvaged after maggot therapy. CONCLUSIONS: Maggot therapy is a relatively rapid and effective treatment, particularly in large necrotic wounds requiring debridement and resistant to conventional treatment and conservative surgical intervention.     

Rapid healing of intractable diabetic foot ulcers with exposed bones following a novel therapy of exposing bone marrow cells and then grafting epidermal sheets

BACKGROUND: Diabetic foot ulcers with exposed bones commonly result in amputation. OBJECTIVES: To determine whether exposure of bone marrow cells and subsequent grafting of epidermal sheets accelerates healing and reduces the need for amputation. METHODS: Thirty-eight patients with chronic wounds caused by diabetes mellitus were enrolled in this study. Epidermal sheets obtained from suction blisters of each patient were grafted on to diabetic foot ulcers without exposed bones (n = 10) and were compared with the standard treatment of local wound care, debridement with a scalpel when indicated, bed rest and parenteral antibiotics (n = 8). In another group of patients, diabetic wounds with exposed bones were treated either with the standard procedure (n = 9) or with a newly developed experimental procedure (n = 11). In that new procedure, the affected bone was initially exposed by debridement with a scalpel, followed by partial excision with a bone scraper until fresh bleeding was observed from the exposed bone. The lesions were then immediately covered with an occlusive dressing, and finally the wound was covered with an epidermal graft of skin harvested from suction blisters. Patients in each group were matched with their counterparts by age, sex, wound size, wound infection and wound duration, to compare the time needed for total skin repair and rates of amputation. RESULTS: Epidermal grafting significantly accelerated the healing of diabetic foot ulcers (P = 0.042) without exposed bones, with site-specific differentiation. The newly developed combination therapy resulted in the healing of all diabetic ulcers with exposed bones without the occurrence of osteomyelitis or the necessity for amputation (P < 0.0001). CONCLUSIONS: Our study indicates that early aggressive debridement of diabetic foot ulcers with exposed bones down to a bleeding vascularized base and then grafting epidermal sheets significantly improves healing and reduces the rate of amputation.     

Maggot debridement therapy in the tropics – Preliminary outcomes from a tertiary hospital

This paper aimed to describe the clinical outcomes and patients’ acceptance of Maggot debridement therapy (MDT) at a tertiary hospital in Singapore. Patients with non-viable tissue (NVT) covering at least 25% of wound bed on lower limbs and/or unable to tolerate sharp debridement at the bedside were recruited between January and August 2021. Sterile medical-grade maggots of Lucilla Cuprina were used. Wound specialist nurses assessed the size and wound to determine the type of MDT, either Baggots or free-range larvae (FRL), and the number of maggots required prior to commencement of therapy. Wound sites were measured and photographed at multiple time points: before the start of MDT therapy, during the wound review at 48 or 72 h after each cycle of MDT and completion of therapy. Three patients received Baggot therapy, while the remaining 11 received FRL therapy. The mean age for patients receiving Baggot and FRL were 78.3 (SD = 10.6) and 63.6 (11.4), respectively. Each patient received three cycles of MDT treatment on average. The most common type of wound was ray amputated toe wounds (n = 8), while the most common wound aetiology was arterial ulcerations (n = 12). A reduction of NVT was observed in 11 out of 14 patients, and ten of these 11 patients achieved successful debridement (at least 25% reduction in NVT). Five out of 14 patients had to undergo amputation within the same admission due to poor wound healing, and 60% of these five patients failed to achieve successful debridement. MDT was quite well-accepted by the patients, and they felt some improvement in their wounds. MDT can facilitate wound healing through successful debridement and potentially reduce the need for amputation. Further research needs to be done regarding the type of MDT that is optimal to use in tropical countries with high humidity.     

Experiences with the use of povidone-iodine-containing local therapeutics in dermatological surgery and in the treatment of burns: testing for allergic sensitization in postsurgery patients

In dermatological surgery where the lesions to be removed are very often contaminated with bacteria, local use of antiseptics that are effective against a wide range of germs is often indicated. Polyvinylpyrrolidone (povidone = PVP)-bound iodine (in Hungary marketed as Betadine is used successfully in our department. After excision and suture in per primam healing wounds as well as after tissue destruction in per secundam healing wounds, a thin layer of Betadine ointment on the dressing right after surgery and at dressing changes may reduce the risk of wound infection. When the defect requires split-thickness skin grafting, a combination of tulle gras and a layer of gauze soaked with 1:10 dilution of Betadine solution is suggested. In the treatment of leg ulcers, Betadine is used for cleansing and for impregnating the gauze on top of the tulle gras layer both in the debridement and in the epithelization phases. PVP-I is beneficial on burn wounds due to its effect reducing bacterial colony counts. Its use is advised for superficial (grades 1 and 2a) burns as well as surgical debridement of deep burns or temporary xenograft or definitive autograft coverage of these wounds. After treating a large number of patients with Betadine, a statement can be made: despite its theoretical risk, no cytostatic effect is seen in the clinical setting. No allergy towards Betadine was observed among the author's patients over several years of its use. Fifty patients previously treated with PVP-I were challenged with epicutaneous patch testing, and no sensitization was found. An account is made on the adverse effects attributed to Betadine found in the scientific literature, and its use with regard to the proper indications is suggested.     

Pain control in the surgical debridement of leg ulcers by the use of a topical lidocaine--prilocaine cream, EMLA

The analgesic effect of EMLA 5% cream for surgical cleansing of leg ulcers was investigated in an open study and in a double-blind comparison with placebo. Eighty patients with ulcers of venous or arterial origin participated. The cream was applied under occlusion and removed before cleansing. Plasma concentrations of lidocaine and prilocaine were assessed. The maximum individual concentrations were 0.8 microgram/ml for lidocaine and 0.08 microgram/ml for prilocaine. Pain was assessed according to a verbal rating scale and on a 100 mm visual analogue scale. The median VAS pain scores for EMLA and placebo were 18.5 and 84 mm (p less than 0.01). There were no severe adverse reactions. The results show that there is a need for pain control in surgical debridement of leg ulcers and that EMLA cream gives satisfactory analgesia for this procedure.