Diagnosis and treating medicine for treatment of _ that the skin of penetrating diaphragm damages

Diagnosis and treating medicine for treatment of _ that the skin of penetrating diaphragm damages
China's general other foundation and clinical magazine Vol. 0 of number 3 of 1999 Exchange the experience clinically
Author: Cui XinMin has celebrated Zhang XingHong
Unit: Central hospital of Sanxia of Chongqing (Chongqing the Wan 's 404000)
Penetrating the intersection of diaphragm and skin damage until peacetime comparatively rare, the damage except that because internal organs enter thorax by the intersection of diaphragm and the intersection of skin and crack in the abdominal cavity, cause and breathe and circulate the function disorderlily outside, thorax and abdominal cavity are often damaged at the same time, cause massive haemorrhage and stomach intestinal perforation, make the condition of the injury very complicated, the incidence of shock is high, apt to misdiagnose, mortality higher ( 1) . The our academy summarized now and analyzed as follows through 22 the surgery treatment and the intact one of materials from January of 1984 to December of 1997.
A clinical materials
1.1 General materials
20 men in 22 of the whole group, 2 women, 16-52 years old, 29 years old, being injured to admitted to hospital for time is 10 minutes shortest in the location of China, it is the 14 hours longest. The knife stabs 19, 1 gunshot wound, wound of metal work piece is one, drill rod stabs one.
1.2 Injury and physical sign
10 underparts of left chest, 6 underparts of right chest, 4 back chests, 2 for chest of dual sides. The skin of left diaphragm damages 14 (63.6%) ,Diaphragm skin damages 7 (31.8%) on the right side ,Dual side diaphragm skin damages one (4.5%) . When 11 are admitted to hospital blood pressure ' 12/8 kPa (1 kPa =7.5 mmHg) ,Among them 3 cases of blood pressure are zero. Many knives of whole body stab 14, among them the belly stabs 9. The whole group's case amalgamates other internal organs to damage, details as per attached list.
Attached list The skin of diaphragm damages and amalgamates other internal organs to damage the situation (example time)

Group this lose consciousness 2 in the case, suffer from abdominal pain 9, 20 have the intersection of chest and ache, situation uncomfortable in chest, out of breath. Check the body gets rid of trachea and shifts, suffer from the side respiration is weakened and the belly tenderness, skin are danced and ached outside tensely and instead, 5 chest lay one's hand on and hold the intersection of snow and sense, small intestine and big omentum deviate from 6, belly expand grand 4. Chest scene have blood pneumothorax, lung to dampen etc. and unusually change in 16 X-rays; 3 rib fractures, 1 metal foreign matter of left chest. Left radius 1 fracture, 20 thoraxes puncture and take the blood out. 7 abdominal cavities puncture and take blood, 19 persons who made a definite diagnosis of (86.4%) before the skill out .
1.3 Treatment and result
The whole the intersection of group and in 14 hour expert's emergency call operation case. Positive dilatation before the skill, resisting shock. Go ahead of the rest thorax to patient, pneumothorax of blood, person who close and then cut open the belly and ascertain 10 skills guide. 11 customary chest belly jointly cut-out and ascertain. Thorax closing type of going ahead of the rest of person who injures companion's blood pneumothorax of dorsal work piece of chest is guided after one, because the bleeding amount is great to change one's profession the belly of chest jointly cut-outs the operation. See the skin of diaphragm break the length 1- 8cm in the skill, 5 cases of diaphragm hernia among them, it is big omentum, stomach, small intestine respectively. Walk and mend each of skill 36 (8 cases of 11 cases of liver, spleen, 7 lungs, 5 stomaches, 2 hearts, 2 pericardiums, 1 small intestine) ,Walk and excise 5 skills (4 cases of spleen, 1 gallbladder) . The whole the intersection of group and case competent diaphragm skin mend and the intersection of chest and abdominal cavity guide, competent pericardium guide 2. Cure 21, 1 case of death (postoperative gunshot wound died in losing blood shock of wound) ,2 cases of postoperative infection of erupting the lung simultaneously.
2 is discussed
The skin of diaphragm is damaged and damaged with other internal organs at the same time more, according to the dissection characteristic of the skin of diaphragm, upper abdomen and the 5th rib of brisket, the penetrating damage under the 8th rib of back chest has possibility of hurting the skin of diaphragm. Ascertain, can make a definite diagnosis of ( 2) according to traumatic history, position, wounded direction and subsequent operation of dish of wound while being clinical . It is the main reason that the skin of penetrating diaphragm is damaged that the knife is stabed, generally see more the skin of left diaphragm, this group of left diaphragm skin damages 15 (account for 68.2%) ,Perhaps its reason gets used to the right hand and holds the lethal weapon with the ruffian, it is apt to stab the patient's left chest underpart. So, should understand the length of the edge device before the skill, all wounds lay under the 4th rib, it may all cause the skin of diaphragm to damage that the knives of the umbilicus above level are stabed.
Penetrating diaphragm inconsistent in clinical manifestation that skin damage, have shock, dyspnea, the intersection of chest and skin down angry and swollen, behave generally. These display majority, amalgamate wounded to cause, literature it is wounded to account for penetrating the intersection of diaphragm and 87% ( 3) that skin damages for report to amalgamate ,This group of materials are shown 100%. It is successively spleen, lung, stomach, liver, rib, heart, small intestine that the amalgamation that the skin of penetrating diaphragm of left chest of this group of cases damages is wounded; It is liver, lung, gallbladder that the amalgamation that the skin of penetrating diaphragm of right chest damages is wounded; The chest back stings the direction entered and hurts lung, spleen, liver,etc. according to the cutting edge.
Stimulate and solicit the obvious peritoneum on the chest as to the wound, the abdominal cavity takes out not to solidify the blood, or wound appear to have difficulty in breathing person who go on in belly, injure side breathe sport to be limited, when the chest smells and has gurgling sounds, should consider the existence that the skin of diaphragm damages. The X-ray examination of chest is the only most valuable inspection making correct diagnosis, 75% of the persons who breaks skin of diaphragm have X-ray examination unusual ( 4, 5) of chest . Except that rib fracture, blood pneumothorax, lung are dampened etc. and behaved, it was possible that for instance, X-ray examination found highly watch out for the skin of diaphragm and damage in following situation: Diaphragm skin is raised on one side, fuzzy, suffer from the border not clear printing opacity district in the chest of side or see the not of uniform size round printing opacity district in a scene of fuzzy shade or there are levels of liquid, the vertical diaphragm shifts etc. to the offside. But the critical patient relies on the X-ray of belly of chest to take a photograph of one to diagnose it is inadvisable that diaphragm skin due to cutting edge is damaged correctly, moving may aggravate the condition, has and delayed valuable rescue time. This 2 groups have checked and aggravated shock through this, has delayed the time of operation.
I realize, it is a simple and fast method to diagnose a disease that the diagnosing chest abdominal cavity punctures, especially suitable for the critical patient. By bed on it appear in recent years it have simple and convenient Ultrasonography B inspection, create, and can going on advantage repeatedly, diaphragm skin break and diaphragm can see the intersection of diaphragm and continuity of skin cut off ( 6) at the the intersection of audiovideo and picture at the hernia ,And can distinguish hernia and enter liver and spleen in the chest, but its accuracy remains to further verify clinically. CT can confirm position and hernia of diaphragm hernia enter the properties organized, but the price is comparatively expensive while checking.
The prompt surgery treatment is to cure the important links that the skin of penetrating diaphragm is damaged, suspect chest belly unite wounded, should surgery ascertain resolutely. I realize, prepare and anaesthetize and must pay attention to the following questions before the skill: The skin of penetrating diaphragm damages the majority with shock, should be strengthened and resisted the shock treatment before the skill, including many passway fast infusing, blood transfusion, oxygen intake,etc.; Obvious blood pneumothorax or needing to guide in the leading thorax closing type of skill by the belly operation person; No matter should adopt the general anesthesia of the intubate in the trachea by the belly operation through the chest. About the operation route issue, should determine according to the concrete condition of the injury. Belly it is wounded to cut open belly, ascertain chest situation that belly injure jointly relatively complicated at first undoubtedly for chest to unite, the following situations should cut open the chest operation: Going on hemothorax is the main clinical manifestation; The right chest underpart edge device is doubting the liver, person who damages diaphragm wounded. Can also make and cut open the belly to cut-out if necessary; Chest wound is a large amount of external hemorrhage; Suspect the trunk damages ( 7) in the heart and chest . I think all thorax person who close thorax bleed> 300ml/h guide, should cut open the chest to ascertain too more than 3 hours person continuously. Diaphragm skin it damages to be no matter big or small, can't heal by oneself, should perform the operation, mend as soon as possible, diaphragm skin mend, adopt, absorb line, make disconnected horizontal cotton-padded mattress type sew up and 8 words are sewn up. The postoperative maintenance respiratory tract is unobstructed. Chest patient that belly injure jointly organize dampening at various degrees with lung more and tearing is wounded, in addition diaphragm skin damage, expectoration difficult, incident pneumonia and the intersection of lung and piece. To have difficulty in breathing, expectoration should walk tracheostomy in early days while being getting unable, adopt the breathing machine, support if necessary, shock discharges too much moisture in the body with diuretic promptly after correcting, lighten the heart and lungs burden, it prevents the renal function from to be the whole, keep urine quantity in above 1 000ml every day. Choose antibiotic of wide table, generally first choose not to have the second generation of or the third generation of very beginning spore antibiotic of the side effect, strengthen support, treat while being postoperative, make patient spend critical days.

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