亚低温治疗创伤性凝血病合并肺损伤的实验研究

目的观察亚低温对创伤性凝血病并肺损伤的临床治疗效果,寻找创伤性凝血病治疗方法。方法 30只日本大耳白兔行剖胸探查术,制作创伤性凝血病动物模型,选择合并呼吸道出血的创伤性凝血病动物,随机分为对照组、亚低温组,观察动物呼吸机应用时间、呼吸机参数,评估呼吸机支持力度,测定血气分析,评估氧代谢,监测凝血功能、ELISA法测定肺组织局部TNF-α水平,评估亚低温对创伤性凝血病治疗效果。结果与对照组相比,亚低温治疗组呼吸机平均机械通气时间短,脱机早,呼吸机辅助呼吸力度低(P0.05),血气分析结果显示氧分压(PaO2),动脉血氧饱和度(SPO2)明显升高(P0.05),肺泡-动脉氧分压差(P(A-a)O2)明显下降(P0.05),肺组织局部TNF-α水平明显下降(P0.05)。结论亚低温可有效治疗创伤性凝血病,机制与改善氧合、抑制肺组织局部炎症等因索有关。     

创伤性凝血病的诊断和干预原则

创伤性凝血病(TIC)是威胁患者生命的主要并发症之一,早期识别和规范化救治可对后续治疗以及患者预后产生积极的影响.国内外针对TIC发布了诊断管理流程,但侧重点不同,为了提高国内学者创伤相关凝血障碍的关注和临床医生诊治的水平,促进科研和临床的思考,文章就TIC的诊断和干预进行讨论.     

缺血性卒中与凝血病的实验诊断

高凝状态是缺血性卒中的少见病因之一。文章总结了缺血性卒中患者出现凝血病的概率,分析了凝血试验结果的影响因素及相关因素,对现有的凝血病诊断性试验作出了评价,指出应结合缺血性卒中患者的病史和临床特征,有针对性地选择试验时机与特异性凝血试验方法。     

缺血性卒中与凝血病的实验诊断

高凝状态是缺血性卒中的少见病因之一。文章总结了缺血性卒中患者出现凝血病的概率,分析了凝血试验结果的影响因素及相关因素,对现有的凝血病诊断性试验作出了评价,指出应结合缺血性卒中患者的病史和临床特征,有针对性地选择试验时机与特异性凝血试验方法。     

休克指数和纤维蛋白原对老年严重创伤患者并发创伤性凝血病的发生及预后价值

目的 探讨休克指数(SI)和纤维蛋白原对老年严重创伤患者并发创伤性凝血病(TIC)发生的预测及预后意义。方法 回顾性收集198例老年创伤患者,根据是否发生TIC分为TIC组(n=47)和非TIC组(n=151)。收集并比较两组患者的临床和实验室检查资料,通过单因素和多因素分析明确影响TIC发生的危险因素。采用受试者工作特征曲线明确所构建风险模型的预测效能。结果 同非TIC组相比,TIC组入院时平均动脉压、血红蛋白、血小板、血气分析pH、碱剩余及纤维蛋白原含量均显著下降,而入院时SI和损伤严重度(ISS)评分、使用升压药物和输血比例及血乳酸、凝血酶原时间和活化部分凝血活酶时间均显著升高(P<0.05,P<0.001)。TIC组不良预后比例显著高于非TIC组(P=0.002)。多因素分析提示,入院平均动脉压<60 mmHg、入院时SI高、血小板<100×10⁹ g/L和纤维蛋白原含量低与TIC发生显著相关,据此构建的回归方程为：F=4.87+0.67×入院平均动脉压(<60 mmHg=1;≥60 mmHg=0)+2.07×入院时SI+0....     

老年重症颅脑损伤患者发生急性创伤性凝血病的影响因素分析及列线图模型的建立

目的 探究老年重型颅脑损伤(severe traumatic brain injury, STBI)患者发生急性创伤性凝血病的影响因素及列线图模型的建立。方法 回顾性选取2020年1月—2023年6月在联勤保障部队第九〇九医院接受治疗的93例老年STBI患者作为研究对象,依照7∶3的比例使用R软件将其随机分为建模队列(n=65)和模型验证队列(n=28);同时根据患者是否发生急性创伤性凝血病(ATC),将建模列队分为ATC组(n=39)和非ATC组(n=26)。比较建模队列中2组的年龄、性别构成、 BMI、 ISS评分、收缩压、输液量、体温、动脉血PH、 PT、 APTT、 FIB、 D-DT、 PLT值;采用二元多因素Logistic回归分析方法分析老年STBI患者发生ATC的影响因素,建立路线图预测模型并验证,ROC评价模型预测效能,校准曲线评估预测事件与实际事件的一致性,DCA曲线评价模型的有效性。结果 建模队列ATC组ISS评分、输液量、 PT、 APTT及D-DT值显著高于非ATC组,而动脉血pH、 GCS评分、 PLT值显著低于非ATC组,差异均有统计学意义(P<0....     

FDP、D-D联合PLT预测创伤性凝血病患者生存预后的效能分析

［摘要］　目的　分析纤维蛋白原降解产物（FDP）、D-二聚体（D-D）联合血小板（PLT）预测创伤性凝血病（TIC）患者生存预后的效能。方法　回顾性收集2020年2月至2023年2月昆明市第一人民医院收治的182例创伤患者的临床资料,根据TIC发生情况将其分为TIC组（85例）和非TIC组（97例）。比较两组临床资料,采用多因素logistic回归分析探讨TIC患者入院时FDP、D-D、PLT水平对入院后30 d内死亡发生的影响,并采用受试者工作特征（ROC）曲线分析探讨上述指标的预测效能。结果　TIC组创伤严重程度评分（ISS)、凝血酶原时间（PT）、活化部分凝血酶原时间（APTT）、凝血酶原时间比值（PTR）、国际标准化比值（INR）水平以及死亡发生率高于非TIC组,纤维蛋白原（Fib）、PLT、血红蛋白（Hb）水平低于非TIC组,差异有统计学意义（P<0.05）。TIC患者入院后30 d内存活59例,死亡26例。存活组FDP、D-D水平显著低于死亡组（P<0.05）,PLT水平显著高于死亡组（P<0.05）,两组Fib水平比较差异无统计学意义（P>0.05）。经调整年龄、性别、住院时间、ISS因素后,多因素logistic回归分析结果显示,FDP［OR(95%CI)=1.021（1.007～1.036)］、D-D［OR(95%CI)=1.087（1.027～1.250)］水平升高是促进TIC患者发生死亡的危险因素（P<0.05）,PLT［OR(95%CI)=0.990（0.983～0.997）］水平升高是抑制TIC患者发生死亡的保护因素（P<0.05）。ROC曲线分析结果显示,FDP、D-D、PLT可有效预测TIC患者入院30 d内死亡（P<0.05）,且三项指标联合的预测效能更高［AUC(95%CI)=0.823(0.720～0.925),P<0.001］。结论　入院时检测FDP、D-D、PLT指标有助于评估TIC患者的生存预后情况,值得临床医师关注。     

感染中毒症所致急性肺损伤时凝血-纤溶变化的研究进展

在过去的20年中,人们通过细胞学、动物实验和临床实验探讨了急性肺损伤／急性呼吸窘迫综合征（ALI／ARDS）病理生理学过程中凝血和纤溶的作用。正常情况下,人肺泡内处于抗凝和促纤溶状态,当发生ALI／ARDS时,则转变为促凝和抗纤溶状态。及时地干预ALI／ARDS的凝血-纤溶异常,有可能中断凝血和炎症的自身放大效应,起到保护性作用。     

老年创伤凝血功能异常与静脉系血栓风险相关性研究进展

老年创伤患者数量逐年增多, 其发生创伤性凝血病(TIC)等各种凝血功能异常的风险较高, 而创伤患者在治疗期间并发静脉系血栓(VTE)也同样常见, 这都影响老年创伤患者的救治策略及预后。由于创伤性凝血功能紊乱的机制尚未完全阐明, TIC等创伤相关凝血功能紊乱和VTE形成之间的病理生理过程及相关性的研究较少。本文针对老年创伤凝血状态、TIC发病机制与治疗以及VTE的相关研究进行综述, 为老年创伤血栓预防和治疗提供一定的依据。     

急性肺损伤/急性呼吸窘迫综合征中凝血与纤溶研究进展

纤维蛋白沉积有其利与弊。凝血级联活化、纤溶抑制和生理性抗凝物质下调均参与急性肺损伤／急性呼吸窘迫综合征（ALI／ARDS）中纤维蛋白的沉积。三系统功能异常与其基因多态性有关联,微肺不张、死腔增加和炎性因子的表达上调是纤维蛋白沉积的主要致病机制。活化的蛋白C具有抗凝和抗炎的作用，可能有效抑制ALI／ARDS中肺损伤和加速肺纤维化。     

Gender-related differences in the coagulofibrinolytic responses and long-term outcomes in patients with isolated traumatic brain injury: A 2-center retrospective study

Coagulation function differs by gender, with women being characterized as more hypercoagulable. Even in the early stages of trauma, women have been shown to be hypercoagulable. Several studies have also examined the relationship between gender and the prognosis of trauma patients, but no certain conclusions have been reached. Patients with isolated traumatic brain injury (iTBI) are known to have coagulopathy, but no previous studies have examined the gender differences in detail. This is a retrospective analysis of a prospective registry conducted at 2 centers. The study included adult patients with iTBI enrolled from April 2018 to March 2021. Coagulofibrinolytic markers were measured in each patient at 1 hour, 24 hours, 3 days, and 7 days after injury, and neurological outcomes were assessed with the Glasgow Outcome Scale Extended at 6 months. Subgroup analysis was also performed by categorizing patients into groups according to neurological prognosis or age at 50 years. Males (n = 31) and females (n = 21) were included in the analysis. In males, there was a significant difference in the levels of activated partial thromboplastin time (P = .007), fibrin/fibrinogen degradation products (P = .025), D-dimer (P = .034), α2-plasmin inhibitor (P = .030), plasmin-α2-plasmin inhibitor complex (P = .004) at 1 hour after injury between favorable and unfavorable long-term neurological outcome groups, while in females there was no significant difference in these markers between 2 groups. In the age group under 50 years, there were significant gender differences in fibrinogen (day 3: P = .018), fibrin/fibrinogen degradation products (1 hour: P = .037, day 3: P = .009, day 7: P = .037), D-dimer (day 3: P = .005, day 7: P = .010), plasminogen (day 3: P = .032, day 7: P = .032), and plasmin-α2-plasmin inhibitor complex (day 3: P = .001, day 7: P = .001), and these differences were not evident in the age group over 50 years. There were differences in coagulofibrinolytic markers depending on gender in patients with iTBI. In male patients, aggravation of coagulofibrinolytic markers immediately after traumatic brain injury may be associated with poor neurologic outcome 6 months after injury.     

胸腔镜探查在外伤性血气胸并多发伤诊治中的应用体会

目的探讨胸腔镜在多发伤并外伤性血气胸诊断及治疗中的应用体会。方法分析多发伤并胸部外伤中21例具有胸部探查指征的临床资料,并根据伤情情况决定行胸腔镜下探查、治疗或中转开胸手术。结果21例患者均在胸腔镜下作出正确诊断,3例中转开胸手术,术后无并发症发生,均治愈出院。结论严重的多发伤可危及生命,行胸腔镜探查可用于胸部外伤性血气胸的诊断及治疗,具有创伤小,胸内手术处理简单化可减轻二次创伤。     

4911例颅脑创伤患者的流行病学特征分析

目的 探讨颅脑创伤的发生规律和临床特点.方法 对4 911例颅脑创伤住院患者的性别、年龄、受伤时间、职业、受伤原因、损伤类型、治疗结果等进行分析.结果 本组患者男:女为3.18: 1.00;31～40岁者占25.3%;农民占57.2%;4、5月份发病者占21.52%;车祸致伤占58.8%;创伤发生于普通公路者占59.8%;轻型颅脑损伤占57.5%;病死率为4.6%. 结论 颅脑创伤的发生在年龄、职业、时间、地点、受伤原因、损伤类型等方面均有一定的规律性.     

Early posttraumatic changes in coagulation and fibrinolysis systems in isolated severe traumatic brain injury patients and its influence on immediate outcome

Objective/background

Early coagulopathy in isolated severe traumatic brain injury occurs despite the lack of severe bleeding, shock, and fluid administration. We aimed to correlate coagulation activation/inhibition, thrombin generation and fibrinolysis with the development of acute trauma induced coagulopathy (TIC) and its effects on early mortality in isolated severe traumatic brain injury (iSTBI) patients.

Transfusion strategies for traumatic coagulopathy

Uncontrolled bleeding is the most common preventable cause of death for patients with severe injury. Coagulopathy inevitably accompanies severe bleeding, exacerbated by the ongoing blood loss and the treatments administered. There is debate about the underlying pathophysiological mechanisms of early traumatic coagulopathy and uncertainty about whether injury induces a unique coagulopathy when compared to other forms of major haemorrhage. This review describes current understanding of the coagulopathy of major blood loss and focuses on the early coagulation changes that occur following severe injury. It then reports on the contemporary management of coagulopathic bleeding using new transfusion strategies. Finally this review presents some practical points to the delivery of transfusion for major blood loss in the modern hospital setting.     

异丙托溴铵雾化吸入治疗重型颅脑损伤合并创伤性湿肺疗效观察

目的分析并探讨异丙托溴铵雾化吸入治疗重型颅脑损伤合并创伤性湿肺的临床效果。方法选取来我院接受治疗的重型颅脑损伤合并创伤性湿肺患者50例,随机分为观察组与对照组,每组25例。两组患者均给予常规的支持治疗,在此基础上,观察组给予异丙托溴铵联合雾化治疗,对照组仅给予雾化吸入治疗。观察两组患者治疗前后血气分析指标和机械通气时间,计算氧和指数。结果观察组治疗后氧和指数为(354.76±31.71)mmHg,机械通气时间为(219.54±35.63)h。对照组治疗后氧和指数为(314.76±30.68)mmHg,机械通气时间为(254.29±36.74)h。观察组治疗后氧和指数明显高于对照组,且机械通气时间短于对照组。经统计学检验,差异具有统计学意义(P0.05)。两组患者治疗后各项血气指标均有明显改善,观察组PaO_2指标与对照组相比,改善更加明显。经统计学检验,差异具有统计学意义(P0.05)。结论异丙托溴铵联合雾化治疗重型颅脑损伤合并创伤性湿肺的临床效果显著。     

Cross-sectional study of major procedure codes among hospitalized patients with traumatic brain injury by level of injury severity in the 2004 to 2014 Nationwide Inpatient Sample

Despite its public health significance, TBI management across US healthcare institutions and patient characteristics with an emphasis on utilization and outcomes of TBI-specific procedures have not been evaluated at the national level.We aimed to characterize top 10 procedure codes among hospitalized adults with TBI as primary diagnosis by injury severity.A Cross-sectional study was conducted using 546, 548 hospitalization records from the 2004 to 2014 Nationwide Inpatient Sample were analyzed.Data elements of interest included injury, patient, hospital characteristics, procedures, in-hospital death and length of stay.Ten top procedure codes were “Closure of skin and subcutaneous tissue of other sites”, “Insertion of endotracheal tube”, “Continuous invasive mechanical ventilation for less than 96 consecutive hours”, “Venous catheterization (not elsewhere classified)”, “Continuous invasive mechanical ventilation for 96 consecutive hours or more”, “Transfusion of packed cells”, “Incision of cerebral meninges”, “Serum transfusion (not elsewhere classified)”, “Temporary tracheostomy”, and “Arterial catherization”. Prevalence rates ranged between 3.1% and 15.5%, with variations according to injury severity and over time. Whereas “Closure of skin and subcutaneous tissue of other sites” was associated with fewer in-hospital deaths and shorter hospitalizations, “Temporary tracheostomy” was associated with fewer in-hospital deaths among moderate-to-severe TBI patients, and “Continuous invasive mechanical ventilation for less than 96 consecutive hours” was associated with shorter hospitalizations among severe TBI patients. Other procedures were associated with worse outcomes.Nationwide, the most frequently reported hospitalization procedure codes among TBI patients aimed at homeostatic stabilization and differed in prevalence, trends, and outcomes according to injury severity.     

血浆蛋白水平变化与颅脑损伤程度的相关性分析

【】目的：探讨颅脑外伤患者的血浆蛋白变化与损伤程度的相关性,为辅助诊断急性颅脑损伤提供参考,减少迟发性脑损伤的发生率。方法：选取我院159例急性颅脑外伤当天直接送入我院就诊的患者。依据Glasgow 评分,分为轻型组53例,中型组53例,重型组53例。同时,选取在我院治疗的癫痫病人53例作为对照组。入院后根据患者的病情给予适当的营养治疗,四组在入院的第2d,7d,14d早上空腹静脉采血,立即送至检验科测定血浆白蛋白、丙氨酸氨基转移酶(ALT),比较各组之间不同时间段血浆蛋白含量。结果：急性颅脑损伤程度越重,血浆白蛋白下降越明显,ALT上升越明显。急性颅脑损伤程度与血浆白蛋白含量呈负相关,与ALT呈正相关。重型组、中型组血浆白蛋白含量显著低于对照组,差异有统计学意义(P<0.05)。轻型组与对照组相比,未见明显差异;重型组、中型组血浆ALT含量比对照组显著升高,差异有统计学意义(P<0.05)。轻型组与对照组相比,未见明显差异。结论：血浆蛋白水平变化与颅脑损伤程度有密切关系。急性颅脑损伤发生后,机体各个器官正常表达的各种蛋白将会异常分泌,使血浆蛋白水平发生变化,血浆白蛋白降低,ALT分泌增加,血浆蛋白水平变化越大,表明患者颅脑损伤程度越重。     

Diagnostic sensitivity of traumatic axonal injury of the spinothalamic tract in patients with mild traumatic brain injury

Diffusion tensor tractography (DTT) can detect traumatic axonal injury (TAI) in patients whose conventional brain magnetic resonance imaging results are negative. This study investigated the diagnostic sensitivity of TAI of the spinothalamic tract (STT) in patients with a mild traumatic brain injury (TBI) suffering from central pain symptoms, using DTT.Thirty-five patients with central pain following mild TBI and 30 healthy control subjects were recruited for this study. After DTT-based reconstruction of the STT, we analyzed the STT in terms of configuration (narrowing and/or tearing) and the DTT parameters (fractional anisotropy and tract volume).Thirty-three (94.3%) patients had at least 1 DTT parameter value at 1 standard deviation below the control group value, and 20 (57.1%) patients had values at 2 standard deviations, below the control group value. All 35 patients showed STT abnormalities (tearing, narrowing, or both) on DTT.A high diagnostic sensitivity of TAI of the STT in patients with mild TBI was achieved. However, the small number of subjects who visited the university hospital and the limitations of DTT should be considered when generalizing the results of this study.