一线三甲医院23例汶川地震伤四肢开放性骨折合并严重感染伤员的分区分类救治

Treatment of 23 Cases of Axial Open Fractures and Resulting Severe Infection in the Sichuan Wenchuan Earthquake in Front-line Hospital of Grade Ⅲ Level A

目的回顾性分析汶川地震后7天内收治的23例四肢开放性骨折合并严重感染伤员的分区分类救治情况,为今后类似重大灾难事件的伤员救治提供参考。方法根据23例伤员较为完整的临床诊断、治疗和实验室检测资料,分析伤员伤口内分泌物细菌直接涂片结果、细菌培养分离及药敏试验结果、经验选用抗菌药物和抗菌药物的联合使用与控制严重感染及愈后之间的关系。结果全部伤员均为Ⅵ型开放性骨折,其中男8例,女15例,平均年龄46.61岁。均伴发热、畏寒等感染中毒症状,且合并四肢骨折部位的较大或大范围的肌肉缺血坏死和严重感染。直接涂片检出单一菌感染者6例(26.09%),双重菌感染者12例(52.18%),多重菌感染者5例(21.74%);伤口内分泌物细菌有氧培养结果显示,伤口感染11种细菌共计18株:肠杆菌科细菌11株(61.11%),非发酵菌5株(27.78%),表皮葡萄球菌和人葡萄球菌各1株(各占5.56%);2例伤员为2种细菌合并感染,另2例伤员未培养分离出细菌,有5例未能进行细菌培养。早期经验采用单一抗菌药物治疗者12例中有10例(83.33%)伤员感染病原菌对经验选用的单一抗菌药物耐药,仅有2例(16.67%)伤员敏感。早期抗菌药物联合应用药,结合早期清创、充分引流及分区分类治疗后,有效控制了伤员原有感染并避免院内感染发生。结论地震伤四肢开放性骨折合并严重感染伤员抗菌药物早期联合使用以及早期受伤部位的彻底清创和充分引流有利于降低致残率和病死率,为地震伤开放性骨折合并严重感染的伤员进一步转入二线三甲医院接受外科专科治疗创造了有利条件。

Objective To retrospectively analyze and classify 23 open fractures that resulted in severe infection, in order to provide evidence that can be used in future disaster scenarios. Methods Based on medical records of 23 cases of open fracture and subsequent bacterial infection, we analyzed the clinical diagnosis, treatment, laboratory tests, bacterial smear of wound secretion, and the bacterial culture of the wound secretion. We then analyzed which antimicrobial agents were used and how they were applied, and the subsequent effect on controlling the serious infection. Results All cases were related to seismic injury and belonged to class Ⅵ open fracture. Eight cases were male and 15 were female. All cases had similar symptoms such as chills, fever, large scale muscle necrosis, and severe infection. A direct smear of the wound showed that the number of cases with one bacterial infection was 6 （26.09%）, the number that had double bacterial infections was 12 （52.18%）, and the number with multiple bacterial infections was 5 （21.74%）. There were 18 strains of 11 types of bacteria recovered from wound samples. Conclusion Early treatment with the joint application of multiple antibacterial agents, early debridement, and adequate drainage all helped to control the infection and avoid nosocomial infection. Employing these strategies in the future will control infection in disaster situations.