1、Section III Pathophysiology of trauma 创伤的病理生理创伤的病理生理heat热redness红swelling肿pain痛loss of function功能丧失1.Inflammation炎症Inflammatory cells炎性细胞炎性细胞 Inflammatory cytokines炎性因子炎性因子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neutr
2、ophils 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 invol
3、ve many cells and cytokine 这个过程涉及到许多细胞及细胞因子inflammation staging 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 banla
4、nced,pro-inflammatory slightly the upper hand杀灭细菌和毒素去除坏死细胞促进组织愈合促炎和抗炎平衡，炎性稍占上风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Clinical presentations of SIRS全身炎症反应综合征的临床表现nBody temperature（体温）38 nH
5、eart rate（心率）90/minnBreathe（呼吸）nBlood cell count （血细胞计数）12109/L 20/minTypes of inflammatory mediators炎性介质的类型炎性介质的类型Cytokines细胞因子n Tumor necrosis factor(TNF)肿瘤坏死因子n Interleukin 白介素n Interferon(ITF)干扰素n Growth factor-(TGF-)生长因子-Activation of inflammatory cells炎症细胞的激活(Macrophage)（巨噬细胞）多器官功能障碍综合征多器官功能障碍
6、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 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 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
7、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 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
8、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 secondary healing 一期愈合、二期愈合What is Tissue Repair?组织修复The process to replace injured or dead cells and to repair tissues after inflammation.炎症后，取代受伤或死亡细胞、修复组
9、织的过程Types of T.R 组织修复的类型 complete T.R 完全愈合 incomplete T.R 不完全愈合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 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
10、母细胞转化形成纤维组织增生 It includes:small blood vessels（小血管）fibroblasts （纤维母细胞）inflammatory cells（炎性细胞）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 venule
11、sWhat is 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 基
12、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 of granulat
13、ion 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 Nutrition 营养水平 Metabolic status 代谢状态
14、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 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Trauma history examinationSysmetic physicalcheck AdjunctiveobservationClose and continuous创伤史创伤史体格检查
15、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.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/肺vLocal diagnosis（局部诊断）：Wound types/scope/depth 伤口的类
16、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.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 pulse rate 100/min,blood pressure 100/min100/min，血压，血压90mmHg9
17、0mmHgnConsciousness 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.Local wound inspection principles 局部伤口检查的原则局部伤口检查的原则 vwound size,depth and shape 伤口大小、深度、形状vwound contamination 伤口污染情况vwoun
18、d 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.vExperimental puncture 诊断性穿刺 abdominocentesis 腹腔穿刺 thoracentesis 胸腔穿刺 vExploratory surgery 探查术vAdjunctive check 辅助检查 imaging:CT MRI X-ray 成像：CT、MRI、X线
19、 Blunt trauma examination(close wound check)闭合性创伤检查29.Abdominocentesis腹腔穿刺术30.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.休息一会儿休息一会儿.32.
