成批烧冲复合伤患者的临床救治

Clinical characteristics and treatment of combined burn-blast injury

目的 总结烧冲复合伤的临床特点及救治经验。方法 2005年6月7日收治一批5例烧冲复合伤患者，烧伤面积达总体表面积（TBSA）的80％-97％[（89．6±7．2）％]，其中Ⅲ度面积达TBSA的75％-92％[（83．4±7．3）％]，所有患者已行气管切开。对这些患者病情变化特点进行总结，动态测定部分凝血功能指标的变化。对1例死亡患者的病理组织进行了检查。结果 除1例入院时已并发脓毒性休克于入院后23h死亡外，其余4例均救治成功。入院时5例患者均有心、肝、肺、胰腺等多器官功能障碍，尤以肺脏损伤为重。死亡患者心、肝、肺等器官出现了严重的冲击伤病理变化。本组血小板均明显降低，凝血功能明显异常，使用低分子量肝素钙抗凝治疗，5000U／次，2-4次／d静脉给予后凝血功能得到改善，未发生弥漫性血管内凝血。2例呼吸功能不全、低氧血症的患者，给予呼吸机支持，采用保护性通气策略，加用低水平呼气末正压通气，短时间内给予纯氧纠正低氧血症。尽早封闭烧伤创面，所有患者于入院后12-16h分别行四肢和胸腹部切削痂和异体皮微粒皮移植手术，一次封闭创面（55±8）％。患者异常升高的血、尿淀粉酶、血脂肪酶在使用大剂量乌司他丁（60万U／次，4次／d）治疗后恢复至生理水平。结论 烧冲复合伤伤情重，多器官功能严重受损，临床过程复杂，凝血功能明显异常。正确判断伤情，尽早封闭创面，审慎使用抗生素，积极抗凝治疗，注重营养支持与代谢调理，强化胰岛素治疗，及时有效地行脏器功能支持与保护是救治成功的关键。

Objective To further improve the treatment of combined bum-blast injury, elucidate its clinical characteristics and sum up treatment experiences. Methods Five cases with combined bum-blast injury transferred for three times were admitted from a remote area to our bums institute 77 hours after injury on June 7, 2005. The bum extent was （89.6 ±7.2）% （80% -97% ） TBSA, with （83.4 ±7.3 ）% （75% - 92% ） TBSA full-thickness injury. All cases were found to have moderate or severe inhalation injury, for which trachesotomy had been done. Blast injury was confirmed by clinical manifestations and chest X-ray films. The changes of parameters related to coagulation function were measured. The pathological tissues were examined in one case who died in spite of energetic treatment. Preliminary experiences in treatment of these cases were summarized. Results Among these five patients, one died of septic shock 23 hours after admission （ at day 4 post burn） and the other four survived. Examination on admission showed that heart function, liver function, pulmonary function and pancreatic function were markedly abnormal, especially pulmonary function. Autopsy of the non-survivor showed serious blast injury to the heart, liver and lungs . Low platelet count and abnormal coagulation function were found in all cases, in which dyspnea and manifestation of hypoxia at various degrees was seen. Two cases immediately received assisted respiration with a ventilator. Because of lung injury, pure oxygen was given for a short period of time to improve oxygenation as soon as possible. Eventually, the cases recovered from respiratory injury. Early closure of burn wounds as soon as possible is of utmost importance by escharectomy. All these cases underwent escharectomies on the upper, lower extremities or with the trunk 12-16 hours after admission, with suture extent of 55% ± 8% at one time. Low molecular weight heparin （5 000 u, 2 - 4 times per day） was administered intravenously after admission for cases with hypercoagulability. As a result, D-dimer was decreased. The prolonged clotting time was shortened to prevent the occurrence of disseminated intravascular coagulation. High dose ulinastin （600,000 unit, four times per day） was given intravenously after admission for cases with high level of blood serum, urinary amylase and blood serum lipase. The amylase and lipase were restored to normal. All four cases survived. Conclusions The cases with combined burn-blast injury are all in critical condition of multiple organ injuries. Coagulation function is markedly abnormal, which is deemed that proper judgment of case＇s condition, closure of the burn wounds as early as possible, rational use of antibiotics, energetic anticoagulant treatment, emphasis on nutritional support, intensive insulin treatment, timely, and effective support and protection of the organ function are important contributory factors to success in the treatment of combined burn-blast injury.