1、创伤的病理生理创伤的病理生理1.Inflammation炎症Inflammatory cells炎性细胞炎性细胞 Inflammatory cytokines炎性因子炎性因子2创伤的病理生理sitmulateInjury外伤刺激plasma血浆cytokine细胞因子protein蛋白IGF-1 类胰岛素生长因子-1FGF 成纤维细胞生长因子TNF 肿瘤坏死因子fibronectin 纤维连接蛋白fibrin 纤维蛋白cells细胞neutrophils 嗜中性粒细胞macrophage 巨噬细胞lymphocyte 淋巴细胞platelet 血小板capillary毛细血管毛细血管3创伤的病
2、理生理Inflammation after trauma创伤后炎症n Systemic Inflammatory Response Syndrome(SIRS)全身炎症反应综合征n Compensatory Anti-inflammatory Response Syndrome(CARS)代偿性抗炎症反应综合征n Trauma and bacteria can cause inflammation 创伤和细菌可引起炎症n This process involve many cells and cytokine 这个过程涉及到许多细胞及细胞因子4创伤的病理生理inflammation stagi
3、ng 炎症分段(2)Limited stage of systemic inflammatory response 局限的全身炎症反应(3)SIRS/CARS the stage is imbalance SIRS/CARS阶段不平衡Killing bacteria and toxinsRemoval of necrotic cells,Promote tissue recoveryProinflammatory and anti-inflammatory is banlanced,pro-inflammatory slightly the upper hand杀灭细菌和毒素去除坏死细胞促进组
4、织愈合促炎和抗炎平衡，炎性稍占上风5创伤的病理生理Injury损伤Bodys response身体反应SIRSCARSUncontrolled systemic inflammatory response syndrome失控的全身炎症反应综合征besides此外sufficient 充分Death 死亡uns.不充分Under control得到控制6创伤的病理生理Clinical presentations of SIRS全身炎症反应综合征的临床表现nBody temperature（体温）38 nHeart rate（心率）90/minnBreathe（呼吸）nBlood cell co
5、unt （血细胞计数）12109/L 20/min7创伤的病理生理Types of inflammatory mediators炎性介质的类型炎性介质的类型DerivedDerivedPlasma-derivedPlasma-derivedCytokinesCytokinesComplementComplementLipid inflammatory Lipid inflammatory mediatorsmediatorsBradykininBradykininAdherence factorAdherence factorFibrinogen degradation Fibrinogen
6、degradation products(FgDP/FBP)products(FgDP/FBP)Oxygen free radicals and Oxygen free radicals and NONO衍生物衍生物血浆衍生物血浆衍生物细胞因子细胞因子补体补体脂类炎性介质脂类炎性介质缓激肽缓激肽粘附因子粘附因子纤维蛋白原降解产物纤维蛋白原降解产物(FgDP/FBP)(FgDP/FBP)氧自由基和一氧化氮氧自由基和一氧化氮8创伤的病理生理Cytokines细胞因子n Tumor necrosis factor(TNF)肿瘤坏死因子n Interleukin 白介素n Interferon(ITF
7、)干扰素n Growth factor-(TGF-)生长因子-9创伤的病理生理Activation of inflammatory cells炎症细胞的激活(Macrophage)（巨噬细胞）10创伤的病理生理多器官功能障碍综合征多器官功能障碍综合征周荣斌周荣斌促促 炎炎 介介 质质 过过 度度 产产 生生 原始病因原始病因 感感 染染 损损 伤伤抗抗 炎炎 介介 质质 过过 度度 产产 生生 全 身 反 应 全身炎症反应综合征全身炎症反应综合征 （SIRS）代偿性炎症反应综合征（代偿性炎症反应综合征（CARS）混合性抗炎反应综合征（混合性抗炎反应综合征（MARS）平 衡 SIRS、CARS
8、细胞调亡 SIRS过度过度 免疫功能障碍 CARS过度过度 MODS SIRS过度过度 休 克 SIRS过度过度 局部促炎介质 局部抗炎介质 11创伤的病理生理神经内分泌系统变化 下丘脑下丘脑-垂体垂体-肾上腺皮质轴肾上腺皮质轴交感神经交感神经-肾上腺髓质轴肾上腺髓质轴肾素肾素-血管紧张素血管紧张素-醛固酮系统醛固酮系统调节各器官功能和代谢动员机体代偿能力 2.全身反应 systemic response 12创伤的病理生理水、电解质代谢紊乱水、电解质代谢紊乱基础代谢率增高，能量消耗增加基础代谢率增高，能量消耗增加机体的分解代谢状态机体的分解代谢状态 高乳酸血症高乳酸血症负氮平衡负氮平衡水、钠
9、潴留水、钠潴留钾排出钾排出 增多增多高血糖高血糖钙、磷钙、磷 代谢异常代谢异常 代谢变化13创伤的病理生理3.Wound healing 创伤的愈合创伤的愈合 Wound healing is composed of several steps 创伤的愈合分为几个阶段 regeneration 再生 granulation 肉芽组织 angiogenesis 血管生成 epithelialization 形成上皮 The process is mediated by a variety of growth factors.各种生长因子参与 Primary healing and seconda
10、ry healing 一期愈合、二期愈合14创伤的病理生理What is Regeneration?再生The process of the replacement of injured cells by cells of the same type.损伤细胞被周围同种细胞更换的过程 16创伤的病理生理What is granulation?肉芽组织肉芽组织 During the course of healing,fibroplasia is developed in the wound by fibroblasts.在伤口愈合的过程中，纤维母细胞转化形成纤维组织增生 It includes
11、:small blood vessels（小血管）fibroblasts （纤维母细胞）inflammatory cells（炎性细胞）17创伤的病理生理What is angiogenesis?血管生成血管生成Angiogenesis is necessary feature of repair and started from preexisting venules,it becomes visible about 4 days after injury.血管再生是修复的重要特征，在损伤后4天左右时，由先前存在的小静脉开始Preexisting venules18创伤的病理生理What i
12、s epithelialization?上皮形成上皮形成 Epithelial cells is stimulated by a variety of growth factors,such as TGF-1,and anchor on the first unepithelialized place.上皮细胞受到多种生长因子的刺激作用（例如TGF-1）后，集聚于早期非上皮化的部位19创伤的病理生理The process of repair 修复的过程修复的过程coagulation and inflammation 凝聚、炎症Matrix deposition and granulation
13、 基质沉淀、肉芽组织Angiogenesis 血管再生Epithelialization 上皮形成Collagen maturation 胶原蛋白成熟Wound contraction 伤口收缩20创伤的病理生理Types of wound healing 伤口愈合的类型伤口愈合的类型Primary healing一期愈合small,clean and less tissue damage.伤口小，清洁，较少组织损伤 by stitching,mild inflammatory reaction.通过缝合，轻度炎症反应epidermal regeneration,a small amount
14、of granulation tissue,few scars.表皮再生，少量肉芽组织，几乎无瘢痕Primary healing一期愈合一期愈合21创伤的病理生理Types of wound healing 伤口愈合的类型伤口愈合的类型Secondary healing二期愈合二期愈合 nLarge wound 伤口范围大伤口范围大nNecrotic tissue and inflection 组织坏死、变形组织坏死、变形nGranulation tissue filled the wound 肉芽组织填充伤口肉芽组织填充伤口nBig scars 瘢痕大瘢痕大22创伤的病理生理 Nutriti
15、on 营养水平 Metabolic status 代谢状态Circulatory status 循环状态Hormones 激素水平Infection 感染感染Wound defect 伤口缺损伤口缺损Foreign bodies 异物异物 Size,location,and type of wound伤口大小、位置、类型伤口大小、位置、类型23创伤的病理生理 感染感染 休克休克脂肪栓塞综合症脂肪栓塞综合症应激性溃疡应激性溃疡凝血功能障碍凝血功能障碍器官功能障碍器官功能障碍24创伤的病理生理Trauma history examinationSysmetic physicalcheck Adju
16、nctiveobservationClose and continuous创伤史创伤史体格检查体格检查辅助检查辅助检查密切监测、持续观察密切监测、持续观察Section IV Trauma diagnosis创伤的诊断创伤的诊断25创伤的病理生理Relationship between systemic and local 系统与局部的关系系统与局部的关系vSystemic diagnosis（系统诊断）：Five vital signs/Glasgow scale/CRAMS 五项生命体征/Glasgow昏迷评分法/CRAMS评分 brain/viscus/chest/lung 脑/内脏/胸
17、/肺vLocal diagnosis（局部诊断）：Wound types/scope/depth 伤口的类型、范围、深度 Infection/non-infection 是否感染 Bleeding/fracture 出血、骨折vSystemic diagnosis be the most important 系统诊断尤为重要26创伤的病理生理nRespiration 呼吸呼吸 respiratory rate:25/15/min,cyanosis.呼吸频率呼吸频率 25/1525/15次次/分，发绀分，发绀nBlood pressure and pulse rate 血压、脉率血压、脉率 pu
18、lse rate 100/min,blood pressure 100/min100/min，血压，血压90mmHg90mmHgnConsciousness and pupils motion 意识、瞳孔意识、瞳孔nGlasgow scale and CRAMS GlasgowGlasgow昏迷评分法昏迷评分法/CRAMS/CRAMS评分评分General physical examination (Five vital signs)一般体格检查（五项生命体征）27创伤的病理生理Local wound inspection principles 局部伤口检查的原则局部伤口检查的原则 vwoun
19、d size,depth and shape 伤口大小、深度、形状vwound contamination 伤口污染情况vwound traits 伤口特性vblood vessel damage and bleeding 血管损伤及出血情况vforeign bodies in the wound.伤口中异物情况vwhether involve deep viscus injury or not 是否涉及腹部深层脏器损伤28创伤的病理生理vExperimental puncture 诊断性穿刺 abdominocentesis 腹腔穿刺 thoracentesis 胸腔穿刺 vExplorat
20、ory surgery 探查术vAdjunctive check 辅助检查 imaging:CT MRI X-ray 成像：CT、MRI、X线 Blunt trauma examination(close wound check)闭合性创伤检查29创伤的病理生理Abdominocentesis腹腔穿刺术30创伤的病理生理Thoracentesis胸腔穿刺术胸腔穿刺术injectorDiagnostic puncture to determine whether the chest cavity fluid(or gas),and sent to the laboratory puncture fluid and pathological examination to determine the nature and cause of effusion.诊断性穿刺后将穿刺诊断性穿刺后将穿刺液送检，可以确定液送检，可以确定胸腔积液（气）的胸腔积液（气）的性质和病因性质和病因31创伤的病理生理休息一会儿休息一会儿.32创伤的病理生理
