创伤性心脏破裂的手术治疗.pptxVIP

创伤性心脏破裂的手术治疗湖州市中心医院心胸外科李鸿伟内 容 1.心脏破裂的临床分型及手术适应证 2.术前准备及麻醉 3.切口选择及手术技巧心脏破裂的临床分型及手术适应证急性失血性休克型 胸部锐器伤 ，尤其是心脏体表投影区的贯通性损伤，伴有进行性失血性休克症状者。急性心包填塞型 重度胸部闭合性损伤 ，伴有循坏障碍，颈静脉怒 张或有Beck三联征者。亚急性心包填塞型 心脏处于一个相对“正常”状态，入院时循环平稳， 但心超或胸部CT提示心包腔内积血。此型更应提 高警惕，以免延误手术时机导致患者死亡。术 前 准 备抢救室病情评估，建立静脉通路，备血，通知手术室循环稳定意识清楚者，行床边心超或胸部CT检查，明确诊断，制定手术方案，行手术室开胸循环不稳定或昏迷者，急诊气管插管，抢救休克，有条件者行手术室开胸，无条件行急诊室开胸抢救的过程中突发心脏骤停者，行急诊室开胸，胸外按压不仅浪费抢救时间，而且会加重心包填塞麻 醉全身麻醉及呼气末正压通气将进一步减少回心血量，诱发心脏骤停，故心包切开前以少量浅麻醉为主。麻醉与手术要密切配合，麻醉诱导时即紧急开胸，切开心包后应给予充足氧供，维持血压，以保护重要脏器的功能。以气管插管全身麻醉为宜，但病情危重，昏迷者，可不用麻醉直接开胸，以提高抢救成功率。根据心脏可能受伤的部位，选择合理的手术切口正中切口左侧第四肋间前外侧切口右侧第四肋间前外侧切口手 术 技 巧迅速进胸，打开心包减压，清除积血按压破口止血。迅速补充血容量，维持血压、心率，保证充分供氧。高度集中密切配合沉着应战循环稳定后探查破口类型，制定修补方案，实施修补。严重裂伤者，应抗休克的同时快速连续缝合缩小破口。破口小者可直接上无损伤止血血钳后缝合修补；破口大者可手指压迫，逐步移开手指，逐步间断缝合，再连续缝合加固。心 房 损 伤 予手指压迫后于破口两侧置牵引线，交叉牵拉闭合破口，再以带涤纶片褥式缝合，缝针不应穿透心内膜。靠近冠脉时，可于血管下潜行褥式缝合。心 室 损 伤 冠脉远端小分支损伤可直接缝扎止血；若冠脉主干损伤应尽量缝合修补或待心脏修补后同期行心脏不停跳冠脉旁路搭桥术。冠 脉 损 伤 除非影响患者存活，一般不做急诊修补术待术后情况稳定，辅助检查明确损伤性质后再行体外循环下修补术。对于没有血流动力学意义的心内结构损伤可不予修复。心内结构损伤 Thank You !Speaker NotesUse this space for overall notes and general comments. Simply select this text and replace it with your own comments.SummaryHeading. Text. Heading. Text.Heading. Text.Heading. Text.Many people do not understand that ethics are situation-specific and time-based -- and business ethics are no exception. Teaching Tip: But this does not mean that ethics are capricious or unimportant. In fact, all societies have a code of ethics and more businesses than ever recognize that a strong code of ethics is good business: it can protect the company from internal wrong-doing and possible legal liability, and, for marketers, serve as a strong foundation upon which to build long-term customer relationships. Ethical development can be thought of as having three levels:Preconventional Morality. This childlike level is calculating and self-centered. As a selfish morality, it is typically based upon what is likely to be immediately rewarded or punished.Conventional Morality. At this lev