外科学-各论英文课件：Chest Trauma
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外科学（第二版）（五年高职）教学配套课件王品琪第10章胸部疾病（..
2．乳癌最早的临床表现是 ，好发的部位是 。
三、单选题
1．急性乳腺炎病人，最初的症状是
A．寒战高热
B．局部硬节
C．排乳不畅
D．同侧腋窝淋巴结肿大
E．乳房肿胀疼痛
2．女性，25岁，无意中发现左侧乳房有一花生米 大小圆形肿块，无压痛，表面光滑，活动度大，
质坚韧，应考虑
A．乳癌
B．乳腺纤维腺瘤
C．乳房结核
一、闭合性气胸
空气经胸部伤口或肺、支气管破裂口进入胸 膜腔后，伤口自行闭合。
临床表现 ①小量气胸多无明显症状；②大量气 胸有以下表现：
症状 胸闷、胸痛、呼吸困难。
体检 伤侧胸廓饱满，呼吸运动减弱，气管向健 侧移位，叩诊呈鼓音，呼吸音减弱或消失。
胸部X线检查 不同程度积气与肺萎陷。 治疗 小量气胸不需特殊治疗。大量气胸需进行
损伤性气胸
病例
男性，24岁，右前胸刀刺伤30min，急诊 入院。伤后病人气促、呼吸困难，口唇紫绀。体 检：T 36.5℃，P 102/min，R 34/min，BP 70/44mmHg。右胸腋前线第4肋间处有一长约 3cm伤口，随呼吸有气体出入响声。气管左移， 右胸叩诊呈鼓音，听诊呼吸音消失。胸部X线检 查显示：右肺萎缩50%，右侧肋膈角消失，右 侧胸膜腔大量积气，气管、心脏等纵隔器官向左 侧移位。请问：病人可能的诊断是什么？怎样进 行急救处理？入院后如何进一步处理？
增生可发生于腺管周围并伴有大小不 等的囊肿形成；或腺管内表现为不同 程度的乳头状增生，伴乳管囊性扩张。 发生于小叶实质者，主要为乳管及腺 泡上皮增生。
临床表现
主要表现：一侧或两侧乳房胀痛和肿块。 部分病人疼痛具有周期性，在月经前疼痛 加重，月经来潮后减轻或消失。
检查：乳腺肿块呈颗粒状、结节状或片 状，质地韧而不硬，与周边组织界限不 清，与皮肤和基底组织不粘连，腋窝淋巴 结不肿大。
外科学-腹部创伤-Abdominal trauma(英文版)
This plain PA radiograph of the chest taken with the patient upright reveals a small amount of free air under the right hemidiaphragm confirming the diagnosis of a perforated abdominal viscus.
Limitations of ultrasound: 1. Injury to solid parenchyma, the
retroperitoneum, or the diaphragm is not well seen. 2. Uncooperative patients, obesity, bowel gas, and subcutaneous air interfere with image quality. 3. Blood cannot be distinguished from ascites or urine. 4. Insensitive for detecting bowel injury.
Plain radiographs
Trauma series radiographs, typically including portable radiographs of the chest and pelvis, are often obtained in an unstable patient with BAT.
3. Shearing forces created by sudden deceleration can cause lacerations of both solid and hollow organs at their points of attachment to the peritoneum.
(外科学课件)10.Chest trauma
• A detailed exam is only done if time and the patient's condition allow it.
9
Specific Thoracic Injuries
• Injuries to the chest wall • Pulmonary injury (injury to the lung) Injury to the
mechanical ventilation, pulmonary contusion or collapsed lung tissue
Hypotension: compressed myocardium or hemothorax
7
Assessment
Initial assessment :
• Identify any obvious life-threatening injuries or conditions that may require immediate management
• Concept :
1.extreme stress
2. multiple adjacent ribs are broken in multiple places
3.separating a segment result paradoxical motion- a part of the chest wall moves independently , the flail segment moves in the opposite direction to the rest of the chest wall, it goes in while the rest of the chest is moving out, and vice versa
9
Specific Thoracic Injuries
• Injuries to the chest wall • Pulmonary injury (injury to the lung) Injury to the
mechanical ventilation, pulmonary contusion or collapsed lung tissue
Hypotension: compressed myocardium or hemothorax
7
Assessment
Initial assessment :
• Identify any obvious life-threatening injuries or conditions that may require immediate management
• Concept :
1.extreme stress
2. multiple adjacent ribs are broken in multiple places
3.separating a segment result paradoxical motion- a part of the chest wall moves independently , the flail segment moves in the opposite direction to the rest of the chest wall, it goes in while the rest of the chest is moving out, and vice versa
《外科学》创伤与战伤(英文)
DEFINITION
Trauma is the injury caused by mechanical or chemical factors, which leads to tissue integrity damaged and loss of function.
Chapter 1 Classification of the Trauma
3. Wound causing factors
Cold weapon wounds （冷兵器伤）: Knife Firearm wounds （火器伤）: gun Burns（烧伤）: High temperature Cold injury（冷伤）: Low temperature Blast injury （冲击伤）: 爆震伤 Chemical injury （化学伤）: chemical weapon Radiation injury （放射性损伤）: Electromagnetic radiation，Particulate radiation
Trauma And War Injury
Risk factors
Traffic accident, industrial injury, Natural disaster, war injury and so on.
CONTENT
1. The concept of trauma. 2. The classification of trauma. 3. The pathphysiology of trauma. 4. The diagnosis of trauma. 5. The treatment of trauma.
Immunomodulating
Both glucocorticoids and catecholamines directly inhibit the production of type 1 cytokines, such as IL-12, IL-2, TNF-α and INF-γ, that enhance cellular immunity and T-helper 1 (Th1) formation and conversely favor the production of type 2 cytokines, such as IL-10, IL-4, IL-13, that induce humoral immunity and T-helper 2 (Th2) formation. Thus, during an immune challenge, stress causes an adaptive Th1 to Th2 shift in order to protect the tissues from the potentially destructive actions of the pro-inflammatory type 1 cytokines and other products of activated macrophages. The homeostatic role of stress-induced Th2 shift against overshooting of cellular immunity often complicates pathologic conditions where, either cellular immunity is beneficial (e.g. carcinogenesis, infections) or humoral immunity is deleterious (e.g. allergy, autoimmune diseases).
胸部外伤 推荐
Internal intercostal muscles
肋间外肌
External intercostal muscles
肋下肌 subcostales 胸导管
thoracic duct
概 论
胸膜腔负压
吸气 -0.78～0.98KPa 呼气 -0.29～0.49KPa (-8～-10cmH2O) (-3～-5cmH2O)
二、院内急诊处理
胸部损伤急诊室处理
胸部损伤开胸探查指征 Exploratory Thoracotomy
1).胸腔内进行性出血; 2).心脏大血管损伤; 3).严重肺裂伤或气管,支气管断裂; 4).食管破裂; 5).胸腹联合伤; 6).胸壁大块缺损; 7).胸内存留较大异物.
急诊室开胸手术
1.穿透性胸伤重度休克者(进行性出血).
快速致命性损伤： 心脏压塞、气道梗阻、进行性或大量血胸、 张力性气胸、开放性气胸、连枷胸
潜在致命性损伤： 食管破裂、膈肌破裂、肺挫伤、心脏钝挫伤
Boerhaave syndrome
概 论
与胸部损伤有关的病理生理改变
• • • • • • • • 疼痛和胸壁稳定性破坏 失血 肺与纵隔受压 胸腔负压受损 肺损伤 气道阻塞 膈肌破裂 纵隔和心脏压塞
前胸壁垂直线
概 论
-- 胸 部 解 剖
后正中线 脊柱旁线 肩胛线 肩胛下角
inferior angle of scapula
posterior median line paravertebral line scapulary line
后胸壁垂直线
概 论
-- 胸 部 解 剖
腋前线 anterior axillary line 腋中线 midaxillary line 腋后线 posterior axillary line
肋间外肌
External intercostal muscles
肋下肌 subcostales 胸导管
thoracic duct
概 论
胸膜腔负压
吸气 -0.78～0.98KPa 呼气 -0.29～0.49KPa (-8～-10cmH2O) (-3～-5cmH2O)
二、院内急诊处理
胸部损伤急诊室处理
胸部损伤开胸探查指征 Exploratory Thoracotomy
1).胸腔内进行性出血; 2).心脏大血管损伤; 3).严重肺裂伤或气管,支气管断裂; 4).食管破裂; 5).胸腹联合伤; 6).胸壁大块缺损; 7).胸内存留较大异物.
急诊室开胸手术
1.穿透性胸伤重度休克者(进行性出血).
快速致命性损伤： 心脏压塞、气道梗阻、进行性或大量血胸、 张力性气胸、开放性气胸、连枷胸
潜在致命性损伤： 食管破裂、膈肌破裂、肺挫伤、心脏钝挫伤
Boerhaave syndrome
概 论
与胸部损伤有关的病理生理改变
• • • • • • • • 疼痛和胸壁稳定性破坏 失血 肺与纵隔受压 胸腔负压受损 肺损伤 气道阻塞 膈肌破裂 纵隔和心脏压塞
前胸壁垂直线
概 论
-- 胸 部 解 剖
后正中线 脊柱旁线 肩胛线 肩胛下角
inferior angle of scapula
posterior median line paravertebral line scapulary line
后胸壁垂直线
概 论
-- 胸 部 解 剖
腋前线 anterior axillary line 腋中线 midaxillary line 腋后线 posterior axillary line
(胸心外科课件)(参考翻译)10.3 empyema-2017
Physical examination findings can vary as well.
Auscultation 听诊 reveals rales 啰 音,
decreased breath sounds possibly a pleural rub 胸膜摩擦音.
Physical examination findings :
• Empyema is caused by an infection of the structures surrounding the pleural space.
• Risk factors include: bacterial pneumonia the most common cause lung abscess 肺脓肿 thoracic surgery 胸科手术 trauma to the chest thoracentesis 胸腔穿刺 subdiaphragmatic infections 膈下感染
Phase 3
• Fibro-blasts 成纤维细胞 grow into exudates on both the visceral and parietal pleural surfaces 脏壁 胸膜表面, producing an inelastic membrane 非弹 性膜 “the peel 皮". Thickened pleural peel may prevent the entry of anti-microbial drugs in the pleural space and in some cases can lead to drug resistance.
Parapneumonic Empyema Physiopathology
胸部外科学
病理生理：
1、空气进入胸腔，伤侧肺萎陷； 呼吸功能丧失。 2、伤侧胸内压高于健侧，纵隔 移向健侧，健侧肺扩张受限； 呼吸功能受损。 3、呼吸时，双侧胸腔压力不均 衡，使纵隔吸气时移向健侧 呼气时移向伤侧，称为纵隔 扑动（mediastinal flutter)； 减少静脉回流。
结果：导致呼吸、循环功能衰竭。
原因：
较大肺大泡破裂
较大较深的肺裂伤
支气管破裂
急救措施 排气减压
正规处理：1、胸引 2、剖胸探查
3、抗感染
血胸（hemothorax)
肺挫伤（pulmonary contution)
气管支气管损伤
草图
胸主动脉撕裂（tears of the thoracic aorta)
气管移位 左肺尖盖帽 主动脉球 结构模糊
胸外伤病理生理特点
严重者可致：
呼吸功能紊乱 循环功能紊乱 失血性休克
感染
临床表现
症状：
胸痛
呼吸困难、烦躁不安 痰中带血、咳血
体征： 望：胸壁挫裂伤、胸廓畸形、反常呼吸 触：皮下气肿、压痛、骨擦感、气管心脏移位 叩：积气呈鼓音、积血呈浊音 听：呼吸音减弱或消失、痰鸣音、罗音
胸部外科学
（Surgery
of the chest)
胸部上经胸廓入口连 与颈部，下凭膈肌与 腹腔相隔；包括外围 胸廓和内部重要组织 器官（心脏、肺脏、 气管、支气管、食管、 胸部大血管等）。胸 外科所授内容包括： 创伤（trauma)、 感染（infaction)、 肿瘤（neoplasm)、 畸形（deformation)等。
临床表现和治疗
临床表现：患者表现为严重或极度呼吸困难、烦躁、大汗淋漓、意识障碍、甚 至休克。体检：气管移位、颈静脉怒张、口唇紫绀，多有皮下气肿；伤侧 胸廓饱满、肋间增宽、叩诊鼓音、听诊呼吸音消失；部分患者出现脉搏细 速、血压下降等休克体征； 胸部x-线检查：患侧胸腔大量积气、 肺完全萎陷、纵隔移位， 可能有纵隔及皮下气肿。 治疗：张力性气胸是危及生命的急症 须紧急处理，用粗针头胸腔穿刺排气 减压并连接单向活瓣装臵。院内需紧急行胸 腔闭式引流术，负压吸引往往是必需的； 同时抗生素预防感染。张力性气胸病情危急， 无需等待影像学结果应先行处理。并且胸管拔除应谨慎，有时 迟发气胸增加会危及生命。
外科学总论 课件 13 创伤教学
burns
Cold injury
Trauma Pathology
trauma
damage of the tissue structure
hemorrhage
inactivation of cell
local: inflammation, cellular proliferation
systemic changes: blood film, body temperature, function of important organs,
fibroblasts, endouthelial cells, epithelial cells, osteoblasts
fibrous tissue（scar）
Collagen （胶原）
Amino-polysaccharide
（氨基多糖）
基 质 沉 着
process of repair
Macrophages（巨噬细胞），platelet（血小板）
1 Inflammatory reaction
Local：hyperemia, edema, exudation (redness, swelling, heat, pain)
Benefit:
1.Proliferative cells fill the deficit, faciliting the wound healing. 2. It clears the bacteria, tissue fragment and foreign body can promote the healing procedure.
urine volumes decrease
Pathology
2 Systemic reaction
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• 脉搏逐渐增快 pulse + • 快速输液后，血压仍逐渐下降 Bp • Hb、RBC、HCT持续下降 • 胸穿无法抽出血液，胸片胸腔阴影渐大
pleural shadow + • 胸引量连续3小时大于200ml/hr
创伤性窒息Traumatic Asphyxia
胸部挤压综合征 Chest Squeeze Syndrome Cyanosis of the upper extremities, neck, and head
• Petechiae in the conjunctiva • Jugular venous distention, facial edema • Associated injuries include:
Pulmonary contusion mocardial contusion, rib fractures, hemo/pneumothorax
decrease venous return • Hypotension • Respiratory distress
Decompression!
血胸 Hemothorax
1. Concepts
• 小量血胸： <500ml • 中等量血胸：500--1000ml • 大量血胸： >1000ml
2 Pathophysiology
• Massive hemothorax • Cardiac and vascular injuries, with temponade • Large open wounds • Tracheobronchial、esophageal injury • Thoracoabdominal injury • Foreign body
心脏损伤 Cardiac injury
1 钝性伤 Blunt cardiac injury 诊断方法：临床、实验室、辅助检查 治疗原则：保守治疗
2 穿透伤 Penetrating card原则：手术治疗
return • Hypoxia, hypercapnia
hypotention, respiratory and circulatory failure
Tension Pneumothorax
Life-threatenting
• Complete lung collapsing • Tracheal deviation • Mediastinal shifting,
pnemo-thorax, flail chest, cardiac tamponade • shock treatment • drainage
手术探查指征
Indications for Exploration（thoracotomy）
• Cardiac arrest(resuscitative kthoracotomy)
• 呼吸困难 dyspnea • 反常呼吸运动 paradoxical respiratory motion • 咯血 hemoptysis • 脏器出血 visceral hemorrhage • 休克 shock
Principles of Treatment
轻伤 minor injury
• 固定 immobilization • 镇痛 pain control • 引流 drainage • 清创缝合 debridement and suture • 抗感染治疗 antibiotic therapy
Rib Fracture
Predominant locations (4th-7th)
Single Multiple Multiple fractures of single rib Multiple breaks of multiple ribs
Fail Chest
Paradoxcial motion the chest wall Flail chest--mediastinal flutter Respiratory failure: Ineffective air movement Pulmonary contusion Pain
• 临床表现 Clinical manifestation • 诊断方法 Diagnostic methods • 处理原则 Treatment principles
Open Pneumothorax
Sucking chest wound • Mediastinal flutter • Decreased venous
气胸 Pneumothorax
定义及分类
Definition & Classification
• 闭合性气胸 closed • 开放性气胸 open (纵隔扑动) • 张力性气胸 tension
Closed Pneumothorax
• 病理生理 Pathophysiology
➢ 少量气胸（肺压缩15%） ➢ 中等量气胸（15-60%） ➢ 大量气胸（>60%）
• 伤侧肺受压，影响呼吸功能 • 失血性休克 • 形成凝固性血胸或纤维胸
血胸 Hemothorax
处理原则 Principles of treatment
• 保守治疗 Non-surgical treatment
• 手术治疗 operation 进行性血胸
Progressive Hemothorax
重伤 Critical Trauma
ATLS (advanced trauma life support)
• Initial evaluation（triage, polytrauma） • airway patency • pneumo-thorax, massive hemothorax, open
Chest Trauma
Thoracic Trauma
分类 Classification：
• 钝性伤和穿透伤 Blunt & Penetrating injury
• 开放性和闭合性损伤 Open & Closed injury
临床表现 Clinical Manifestations
• 胸痛 chest pain
pleural shadow + • 胸引量连续3小时大于200ml/hr
创伤性窒息Traumatic Asphyxia
胸部挤压综合征 Chest Squeeze Syndrome Cyanosis of the upper extremities, neck, and head
• Petechiae in the conjunctiva • Jugular venous distention, facial edema • Associated injuries include:
Pulmonary contusion mocardial contusion, rib fractures, hemo/pneumothorax
decrease venous return • Hypotension • Respiratory distress
Decompression!
血胸 Hemothorax
1. Concepts
• 小量血胸： <500ml • 中等量血胸：500--1000ml • 大量血胸： >1000ml
2 Pathophysiology
• Massive hemothorax • Cardiac and vascular injuries, with temponade • Large open wounds • Tracheobronchial、esophageal injury • Thoracoabdominal injury • Foreign body
心脏损伤 Cardiac injury
1 钝性伤 Blunt cardiac injury 诊断方法：临床、实验室、辅助检查 治疗原则：保守治疗
2 穿透伤 Penetrating card原则：手术治疗
return • Hypoxia, hypercapnia
hypotention, respiratory and circulatory failure
Tension Pneumothorax
Life-threatenting
• Complete lung collapsing • Tracheal deviation • Mediastinal shifting,
pnemo-thorax, flail chest, cardiac tamponade • shock treatment • drainage
手术探查指征
Indications for Exploration（thoracotomy）
• Cardiac arrest(resuscitative kthoracotomy)
• 呼吸困难 dyspnea • 反常呼吸运动 paradoxical respiratory motion • 咯血 hemoptysis • 脏器出血 visceral hemorrhage • 休克 shock
Principles of Treatment
轻伤 minor injury
• 固定 immobilization • 镇痛 pain control • 引流 drainage • 清创缝合 debridement and suture • 抗感染治疗 antibiotic therapy
Rib Fracture
Predominant locations (4th-7th)
Single Multiple Multiple fractures of single rib Multiple breaks of multiple ribs
Fail Chest
Paradoxcial motion the chest wall Flail chest--mediastinal flutter Respiratory failure: Ineffective air movement Pulmonary contusion Pain
• 临床表现 Clinical manifestation • 诊断方法 Diagnostic methods • 处理原则 Treatment principles
Open Pneumothorax
Sucking chest wound • Mediastinal flutter • Decreased venous
气胸 Pneumothorax
定义及分类
Definition & Classification
• 闭合性气胸 closed • 开放性气胸 open (纵隔扑动) • 张力性气胸 tension
Closed Pneumothorax
• 病理生理 Pathophysiology
➢ 少量气胸（肺压缩15%） ➢ 中等量气胸（15-60%） ➢ 大量气胸（>60%）
• 伤侧肺受压，影响呼吸功能 • 失血性休克 • 形成凝固性血胸或纤维胸
血胸 Hemothorax
处理原则 Principles of treatment
• 保守治疗 Non-surgical treatment
• 手术治疗 operation 进行性血胸
Progressive Hemothorax
重伤 Critical Trauma
ATLS (advanced trauma life support)
• Initial evaluation（triage, polytrauma） • airway patency • pneumo-thorax, massive hemothorax, open
Chest Trauma
Thoracic Trauma
分类 Classification：
• 钝性伤和穿透伤 Blunt & Penetrating injury
• 开放性和闭合性损伤 Open & Closed injury
临床表现 Clinical Manifestations
• 胸痛 chest pain