心脏穿透伤后生存过程：类型演变和分类救治的研究

Injury evolution and classified treatment in survival process of penetrating cardiac trauma

目的分析心脏穿透伤（penetratingcardiactrauma，PCT）患者病理生理发展过程演变情况，探讨其分类救治对策。方法回顾性调查133例PCT患者的伤后病情及医疗干预措施等临床资料，分别按患者送达急诊室时的症状分型或病程分期，按症状类型分为亚临床型、心脏压塞型、失血性休克型、濒死型四组；按病程分期分为：亚临床期、临床期、濒死期三组。使用生存分析法考察各组患者伤后各个时相点的病情演变特点，并分析医疗干预措施如心包腔探查术、急诊室剖胸术（emergencyroomthoracotomy，ERT）、手术室剖胸术（operatingroomthoracotomy，ORT）等对患者预后的影响。结果在院内救治过程中部分亚临床期患者进展至临床期及濒死期，而部分临床期患者进展至濒死期。亚临床型、心脏压塞型、失血性休克型、濒死型四组患者伤后生存过程差异有统计学意义（P〈0．01）；亚临床期、临床期、濒死期三组伤后生存过程差异也有统计学意义（P〈0．01）。结论PCT伤后演变过程中，患者的临床症状分型（或病程分期）不是一成不变的，应根据患者就诊时的症状分型或病程分期将患者分类救治。

Objective To analyze the pathophysiological variation in patients with penetrating cardiac trauma （PCT） and discuss the classified treatment strategies. Methods A retrospective analysis was conducted on pathogenetic condition, medical interventions and other clinical information of 133 PCT patients. The patients were divided into four groups in accordance with their symptom classification on arri- val at emergency department, including sub-clinic type, cardiac tamponade type, hemorrhagic shock type and agonal type. Meanwhile, the patients were classified into three groups according to their pathogenesis phase, including sub-clinical phase, clinical phase and agonal phase. Development characteristic of patients＇ condition in each group was investigated in each time point by survival analysis. Impacts of medical interventions on prognosis of those patients were analyzed, such as pericardial space exploration, emergency room thoracotomy （ERT）, operating room thoracotomy （ORT）. Results Some patients at sub-clinical phase were aggravated into clinical phase or agonal phase, as well as some patients at clinical phase were aggravated into agonal phase during in-hospital treatment. There were significance differences of posttrau- matic survival course among the four groups, namely sub-clinical type, cardiac tamponade type, hemorrhagic shock type and agonal type （P 〈 0.01 ）. The differences of posttraumatic survival course were also significant among the three groups, namely sub-clinical phase, clinical phase and agonal phase （ P 〈 0.01 ）. Conclusion Clinical symptom classification （or pathogenesis phase） of PCT may not be always un- changeable, thus it is recommended that PCT patients should be treated based on their clinical symptom classification or pathogenesis phase at consultation.