Emergency treatment of craniocerebral firearm wounds

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Supplemental oxygen after outpatient oral and maxillofacial surgery.

Arterial oxygen saturation (SpO2) was monitored postoperatively with pulse oximetry in 72 dental patients. Intravenous general anesthesia was employed in 57 patients. All of these patients received supplemental oxygen intraoperatively, and of these, 29 received supplemental oxygen postoperatively. Fifteen patients received only local anesthesia without supplemental oxygen and served as the control group. Continuous pulse oximetry revealed 43 episodes of arterial oxygen desaturation (SpO2 decreases greater than 3% from baseline) in patients who did not receive postanesthesia supplemental oxygen and eight episodes of desaturation in patients who did receive postanesthesia oxygen. Patients with a smoking history had more episodes of desaturation than did nonsmokers in the group that received general anesthesia and breathed room air postoperatively. The total amount of methohexital administered had no significant effect on the number of patients with desaturation episodes. These observations emphasize the need for postoperative oxygen for patients who undergo general anesthesia for outpatient oral and maxillofacial surgery.     

火器多发伤时血液动力学变化特点的研究

目的　通过建立小型猪火器多发伤模型 ,探讨多发伤时血液动力学变化的特点。方法　采用 5 8mm子弹射击颅顶骨和双侧股骨 ,制作火器多发伤模型。 12只小型猪随机分为对照组(不致伤 )和多发伤组各 6只。观察创伤后平均动脉压 (MAP)、平均肺动脉压 (MPAP)、肺动脉嵌压(PCWP)、心输出量 (CO)、外周血管阻力指数 (SVRI)以及门静脉血流量和胃粘膜内 pH值的变化特点。结果　对照组血液动力学指标无明显变化 ;多发伤组伤后MAP一过性升高 ,4 8～ 72h出现“高排低阻”现象 :心输出量明显增加 ,平均动脉压和体循环外周阻力指数下降 (伤后 72h为 978± 6 5 ) ,MPAP和PCWP升高 ;门静脉血流量下降伤后 72h为 [(344± 84 )ml·kg-1·min-1];胃粘膜缺血缺氧。结论　火器多发伤后在无严重失血情况下也会发生全身血流重新分布 ,内脏灌流不足。     

Low-velocity gunshot wounds to the maxillofacial complex.

A review of the past literature of gunshot wounds indicates that the clinical material deals mainly with high-velocity missile injuries from military experience. A series of 66 cases of low-velocity gunshot wounds to the maxillofacial complex at San Francisco General Hospital between 1971 and 1978 indicates a clinical difference between injuries caused by low-velocity as compared to previously reported high-velocity missiles. Damage to vital structures resulting from missile injury to the maxillofacial complex are classified in three anatomic areas: 1) supra-orbital (28 cases of which 20 involved neurological damage); 2) mid-face (24 cases of which 8 involved the orbits and/or globe); 3) lower face (14 cases, of which 3 involved laceration of the carotid and 2 involved airway obstruction necessitating tracheostomy). The management of gunshot wounds to the maxillofacial area is outlined, emphasizing: 1) Debridement and prompt closure of intraoral wounds with antibiotic coverage: 2) Early stabilization of mandible fractures: 3) Indications for tracheostomy; 4) Arteriographic studies. In our series there were only four infections, which were treated easily with incision and drainage and appropriate antibiotic selection.     

Ultrastructural analysis of fetal rabbit wounds

Fetal wound healing proceeds rapidly with minimal inflammation and fibroplasia and little or no scar formation. These observations have led to the hypothesis that fetal wound healing more closely resembles regeneration rather than adult wound repair. To test this hypothesis, this study used ultrastructural analysis of fetal and adult fibroblasts and collagen to gain greater insight into differences in the healing processes. Full-thickness, primarily closed linear incisions were created dorsally on 24-day gestational age fetal rabbits (n = 9). The fetuses were killed 5 days later, and the wounds were excised and evaluated with transmission electron microscopy. Similarly, uninjured fetal skin of the same gestational age was obtained and analyzed. Adult rabbit dermal wounds were analyzed after 8 days of healing. Resting adult dermal fibroblasts had features of quiescent, inactive cells, whereas adult wound fibroblasts were highly active and filled with secretory vesicles. In contrast, both fetal normal dermal and wound fibroblasts appeared highly active and contained numerous secretory vesicles. In the adult wound, collagen fibril diameter was only 45% of the diameter of normal dermal collagen. However, fetal wound collagen fibrils were basically the same as normal dermal collagen, having a diameter that was 82% of the size of dermal collagen. These observations suggest that fetal wound fibroblasts do not require activation from an inactivated state and that fetal wound collagen deposition undergoes more rapid organization and maturation. These findings have significance in extending our understanding of the rapidity and functional superiority of fetal wound healing compared with adult wound healing.     

Management of maxillofacial problems in self-inflicted rifle wounds

Severe gunshot wounds to the face, produced by high-velocity rifles or shotgun blasts, present a formidable challenge to reconstructive surgeons. In this study, the results of 14 cases with gunshot wounded faces caused by fire from rifles are presented, and the principles of the management of those victims were determined. These patients had attempted to commit suicide and placed the muzzles of the rifles beneath their chins. The ages of the patients ranged from 20 to 24 years, with a mean age of 22 years. These wounds were caused by close-range gunshots (<10 cm), and the missiles had high velocity (more than 800 m/second). All patients had wounds in their submental triangle areas. The exit sites of the missiles differed among patients. All exit wounds were in the angle limited by the deviation from the gun-barrel axis. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the fractures were reduced and stabilized appropriately. Large bony defects were treated by bone grafting, and all soft tissue lesions were closed in layers. The entrance and exit sites were covered primarily after thorough debridement except one case whose defect was reconstructed with bilateral sternocleidomastoid (SCM) flaps, one for submental skin and the other for the mouth floor. Intraoral soft tissues were then repaired by primary closure, tongue flaps, or SCM flaps in case they were necessary. Free tissue transfers were not required for treatment of secondary soft-tissue problems. Resolution of tissue edema, softening of scars in time, and insertion of bone graft may improve the deformity significantly. The initial anatomic reconstruction of the existing bone skeleton and the maximal use of regional tissue for cutaneous reconstruction provide an esthetic appearance that can never be duplicated by secondary reconstruction.     

组织胶水在急诊颌面部小伤口的应用研究

目的:探讨Hi st oacryl组织胶水应用于急诊颌面部小伤口愈合的疗效。方法:将100名颌面部皮肤裂伤患者随机分为对照组和治疗组,对照组采用清创后经皮间断缝合术,治疗组清创后给予Hi st oacryl组织胶水闭合伤口,观察伤口处理时间、术后疼痛感以及伤口愈合情况。结果:治疗组术后伤口愈合优于对照组(P<0.05),在操作时间与疼痛度上有显著优势(P<0.01)。结论:Hi st oacryl组织胶水对于浅表、张力小的颌面部皮肤小伤口闭合作用好,且操作简便、安全,减少疼痛。     

蛛网膜下腔出血后皮层微血管及神经元的超微结构改变

目的 观察蛛网膜下腔出血(SAH)后皮层微血管及神经元超微结构的动态变化.方法 将SD大鼠随机分为正常、假手术和手术组,采用改良血管内穿刺法制作大鼠蛛网膜下腔出血的动物模型,通过透射电子显微镜观察不同时间点各组脑组织皮层微血管及神经元的超微结构改变.结果 蛛网膜下腔出血后1 h即可观察到皮层神经元和血管内皮细胞出现轻度水肿,其后水肿逐渐加重,并出现线粒体的嵴膜融合、消失,粗面内质网脱颗粒,毛细血管内皮细胞核固缩,甚至部分微血管闭塞;出血后48 h损伤达到高峰,神经元坏死增多,部分呈裸核改变;随后水肿逐渐减退,于7 d时基本恢复正常.结论 蛛网膜下腔出血后皮层微血管及神经元存在明显的病理性损伤与修复过程,及早保护血管内皮结构与功能的完整,改善微循环功能,对蛛网膜下腔出血的治疗和预后具有重要意义.

Abstract：

Objective To investigate the dynamic ultrastructural changes of micrangiums and neurons in cortex after subarachnoid hemorrhage (SAH). Methods The SD rats were divided into three groups: normal control group, sham-operated control group and SAH group. A modified endovascular perforation model was used to induce SAH in rats. In each group, the brains were collected at different time points for observation on the ultrastructural changes of micrangiums and neurons in cortex under the transmission electron microscopy (TEM). Results The mild edema could be obviously seen in cortex micrangiums and neurons at 1 h after SAH. Thereafter, the edema became serious gradually, membrane and cristae fusion appeared or disappeared, rough endoplasmic reticulum degranulated, and there was pyrosis of capillary endothelial cell nuclei, even blockage of partial capillaries. At the 48th h week aftyer onset of SAH, pathologic changes reached the peak: neurons necrosis increased, and partial showed naked nucleus. Then, the edem was gradually alleviated and returned basically to the normal state at the 7th day.Conclusion There were obviously pathologic changes and repair procedures in cortex micrangiums and neurons after SAH. It was very important for the therapy and prognosis of SAH to protect structural and functional integrity as soon as possible and improve microcirculation.     

西帕依固龈液用于口腔颌面外科患者口腔护理

目的探讨西帕依固龈液在口腔颌面外科患者口腔护理中的应用效果。方法将90例口腔颌面外科患者随机分为三组,对照1组(n=30)、对照2组(n=28)、实验组(n=32)分别采用常规生理盐水、口泰含漱液、西帕依固龈液进行口腔擦洗和口腔冲洗。结果三组口腔护理效果比较,差异有统计学意义(P0.01),实验组效果最好,对照2组次之,对照1组最差。结论西帕依固龈液作为口腔护理液可有效降低牙菌斑指数和牙龈出血指数,口腔护理效果确切。     

Ultrastructural aspects of the microvasculature of the cochlea: the internal spiral network.

We performed a study of the microvasculature of the cochlea with scanning electron microscopy on corrosion casts in the guinea pig. This study was performed in 140 cochleas from healthy adult guinea pigs. Different microvascular techniques were used, including injection-microdissection in 53 cases, injection-diaphanization in 27 cases, a histologic technique in 34 cases, injection-microdissection-diaphanization in 32 cases, and scanning electron microscopy on corrosion casts in 14 cases. The internal radiating arterioles branch off as collateral branches of the spiral modiolar artery, as first-order collateral branches. We detail the morphology, caliber, trajectory, and collateral branches. Among their collateral branches, are third-order arterioles, the arterioles to the spiral ganglia, and the arterioles of the tympanic lip. The arterioles of the tympanic lip form, through their anastomosis, a rich capillary network at the edge of the spiral lamina, called the internal spiral network. We emphasize the glomeruli of Schwalbe, which arise near the scala tympani as third-order arterioles with a medium caliber of 14 microm. The upper glomeruli, situated in the bony wall, and the lower glomeruli, situated in the width of the osseous spiral lamina, form vascular loops made of anastomosed capillaries with a caliber of less than 10 microm. These loops play an important role as efficient devices, or "relay stations," for regulation of cochlear blood flow. The comparison of results obtained with each technique gave the perspective of the cochlear microvasculature with great accuracy.     

介入栓塞术联合术后注射无水乙醇治疗颌面部动静脉畸形

目的：探讨以数字减影成像显影下血管介入栓塞技术联合术后注射无水乙醇治疗颌面部动静脉畸形的疗效。方法：对6例颌面部动静脉畸形患者行血管介入造影检查,并超选择性插管栓塞供血动脉及病灶,注入聚乙烯醇颗粒、无水乙醇等栓塞剂栓塞畸形血管团,术后根据恢复情况定期在病灶血管腔内注射无水乙醇。结果：6例颌面部动静脉畸形患者均栓塞成功,达到临床治疗目的,无严重并发症发生。结论：血管介入造影下超选择性插管栓塞联合术后无水乙醇是治疗颌面部动静脉畸形的一种有效、安全的方法。