肢体创伤后人体凝血状态变化的研究

Changes in coagulation status after injuries to the extremities

目的 了解肢体创伤后人体凝血状态的变化和急诊显微外科手术的安全性。 方法 将 47例肢体创伤病人分成 3组 :Ⅰa组 (例数 =2 0 )为单个肢体外伤 ,无失血性休克及头、胸部损伤 ,也未做显微外科手术 ;Ⅰb组 (例数 =13)创伤同Ⅰa组 ,但做了急诊显微外科修复 ;Ⅱ组 (例数=14)为肢体多发性创伤 ,合并失血性休克或头、胸部损伤。各组均测定血小板计数 (PLC)、血小板黏附性 (PadT)、凝血酶原时间 (PT)、纤溶酶原 (Pg)、抗凝血酶Ⅲ (AT -Ⅲ )和D -二聚体 (D -Di)。 结果 Ⅰa、Ⅰb组仅在创伤后手术前有PadT升高和AT -Ⅲ下降 ,且术后 2 4h均恢复至正常 ;Ⅱ组创伤后各期PadT、D -Di显著升高 ,Pg、AT -Ⅲ明显下降 ,术后 2 4h分别为 49.3%、2 .7mg/L、1.1g/L和 6 9.1% ,与正常值及Ⅰa ,Ⅰb组比较 ,差异均有显著性意义 (P <0 .0 5 ) ,术后 72h仍未完全恢复。 结论 肢体开放性创伤后 ,只要不发生失血性休克 ,施行急诊显微外科手术是安全的 ;肢体严重损伤后数小时即可发生高凝状态 ,施行显微外科手术应慎重 ;D -Di测定可作为创伤后早期高凝状态预测和评估的筛选试验。

Objective To investigate the changes of blood coagulation status and the safety of emergency microsurgery in patients with acute trauma to their extremities. Methods Forty- seven patients with open injuries to the extremities were divided into 3 groups: In GroupⅠa (n=20)the patients presented with open injury to a single limb without traumatic shock and chest or head injuries, and they did not undergo microsurgery; while in Group Ⅰb (n=13) an emergency microsurgery was done. In Group Ⅱ ( n =14) the patients suffered from multiple compound fractures of the extremities with traumatic shock and chest or head injuries. The blood coagulation status of the patients was evaluated by testing platelet count(PLC), platelet adhesiveness(PadT),serum antithrombin Ⅲ(AT-Ⅲ) and D-dimer level. Results In Groups Ⅰa and Ⅰb only PadT was increased and AT-Ⅲ declined preoperatively, then they returned to normal 24 h after operation. In Group Ⅱ, at different periods after trauma ,there was significant evidence of Pg and AT-Ⅲ decline accompanied by high increase of PadT and D-Di level. At 24 h after operation, the mean values were 49.3%(PadT), 2.7 mg/L(D-Di), 1.1 g/L(Pg)and 69.1% (AT-Ⅲ), respectively. All these changes showed significant difference( P <0.05) when compared with the normal value and those of Groups Ⅰa and Ⅰb, and did not completely return to normal even 72 h after operation. Conclusions An emergency microsurgery could be safely performed in patients with ordinary open injuries to their limbs as long as no traumatic shock has occurred; however it could only be done with caution in cases of severe injuries with traumatic shock, as hypercoagulation status would follow in several hours after injuries. D-Di measurement may be used as a screening test to predict and assess hypercoagulation status early after trauma.