急进高原后重度胸部爆炸伤的伤情特点分析

doi:10.3877/cma.j.issn.1674-6902.2024.01.001

中华肺部疾病杂志(电子版) ›› 2024, Vol. 17 ›› Issue (01) : 1 -8. doi: 10.3877/cma.j.issn.1674-6902.2024.01.001

论著

急进高原后重度胸部爆炸伤的伤情特点分析

伍正彬¹, 邵世锋², 张良潮², 段朝霞², 王震², 王耀丽², 王建民², 梁宗安³^,^†(

)

^1. 610041　成都，四川大学华西医院呼吸与危重症医学科；400042　陆军军医大学大坪医院战创伤医学中心，创伤与化学中毒全国重点实验室
^2. 400042　陆军军医大学大坪医院战创伤医学中心，创伤与化学中毒全国重点实验室
^3. 610041　成都，四川大学华西医院呼吸与危重症医学科

收稿日期:2023-11-13 出版日期:2024-02-25
通信作者: 梁宗安
基金资助:
国家自然科学基金资助项目(81970259); 重庆市技术创新与应用发展专项重点项目(318-084063)

Analysis of the characteristics of severe chest blast injuries after rapid ascent to high altitude

Zhengbin Wu¹, Shifeng Shao², Liangchao Zhang², Zhaoxia Duan², Zhen Wang², Yaoli Wang², Jianmin Wang², Zongan Liang³^,^†()

^1. Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, 610041, China; Medical Center of Trauma and War Injury, Daping Hospital, Army Medical University, Trauma and Chemical Poisoning National Key Laboratory, Chongqing, 400042, China
^2. Medical Center of Trauma and War Injury, Daping Hospital, Army Medical University, Trauma and Chemical Poisoning National Key Laboratory, Chongqing, 400042, China
^3. Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, 610041, China

Received:2023-11-13 Published:2024-02-25
Corresponding author: Zongan Liang

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伍正彬, 邵世锋, 张良潮, 段朝霞, 王震, 王耀丽, 王建民, 梁宗安. 急进高原后重度胸部爆炸伤的伤情特点分析[J]. 中华肺部疾病杂志(电子版), 2024, 17(01): 1-8.

Zhengbin Wu, Shifeng Shao, Liangchao Zhang, Zhaoxia Duan, Zhen Wang, Yaoli Wang, Jianmin Wang, Zongan Liang. Analysis of the characteristics of severe chest blast injuries after rapid ascent to high altitude[J]. Chinese Journal of Lung Diseases(Electronic Edition), 2024, 17(01): 1-8.

目的

建立急进高原条件下山羊重度胸部爆炸伤模型，分析不同类型爆炸伤的损伤特点。

方法

选取健康山羊70只，从2 800 m常驻地转运至海拔4 600 m地区，路程约130 km，采用8 kg TNT当量，根据爆炸源距离随机分为3 m组30只、3.5 m组12只、8 m组1只、12 m组4只及16 m组23只；每组山羊同向右侧固定在特制铁架内，分次静爆致伤。致伤前后采集山羊生命体征、动脉血气、影像学资料、肺大体解剖等，采用描述性研究方法比较高原爆炸伤后的特点。

结果

常驻2 800 m山羊急进高原4 600 m体温下降[(39.58±0.35)vs. (38.1±0.65)]℃；PaO₂下降[(47.00±5.51 )vs. (36.97±4.69)]mmHg；SaO₂降低[(86.83±4.02)vs. (71.1±12.54)]%。重度胸部爆炸伤后存活时间>15 min山羊43只(61.42%)，其中一型29只(41.42%)，二型14只(20.00%)；存活时间>30 min 37只(52.86%)，其中一型24只(34.28%)，二型13只(18.57%)。一型与二型重度胸部爆炸伤存活例数差异无统计学意义(P>0.05)；一型重度胸部爆炸伤主要表现为气胸、肺冲击伤，部分伴有烧伤、耳、肠道和心脏冲击伤等；二型重度胸部爆炸伤表现为胸部穿透伤、肺撕裂伤，部分伴有胸腹或心肺联合穿透伤、肝撕裂伤等。一型和二型胸部爆炸伤后平均动脉压增高(P<0.05)。

结论

2 800 m山羊急进海拔4 600 m出现缺氧、低体温等高原反应；两种重度胸部爆炸伤30 min内致死率相同，一型爆炸伤伤情表现隐匿，伤后呼吸增快、低氧血症、酸中毒。二型伤情易发现，早期救治困难。

关键词: 高原重度胸部爆炸伤, 一型爆炸伤, 二型爆炸伤, 早期检伤, 山羊

Objective

Under the conditions of rapid highland, by establishing models of severe thoracic blast injuries in sheep, the characteristics of injuries from two different types of blast injuries were analyzed.

Methods

It was selected that 70 healthy goats from their permanent residence at 2 800 meters and transport them approximately 130 km to an altitude of 4 600 meters, using 8 kg TNT equivalent. Divide the goats into groups based on distance from the explosion source using a random number method: 30 goats at 3 meters, 12 goats at 3.5 meters, 1 goat at 8 meters, 4 goats at 12 meters, and 23 goats at 16 meters. Secure the goats in custom iron frames facing to the right, and then detonate in separate controlled explosions. Collect vital signs, arterial blood gases, imaging data, and gross lung anatomy of the goats before (2 800 m, 4 600 m) and after the explosions, and analyze the characteristics of high-altitude blast injuries using descriptive research methods.

Results

After reaching an altitude of 4 600 meters, the goats which resided at an altitude of 2 800 meters experienced a decrease in body temperature [(39.58±0.35) vs. (38.1±0.65)]℃, a decline in arterial oxygen pressure[(47.00±5.51 )vs. (36.97±4.69)]mmHg, and a reduction in SaO₂ [(86.83±4.02)vs. (71.1±12.54)]%. Severe thoracic blast injuries resulted in a survival rate of over 15 minutes of 43 individuals(61.42%) in primary, there were 29 individuals (41.42%), and in secondary, there were 14 individuals (20.00%). And over 30 minutes of 37 individuals(52.18%), in primary, there were 24 individuals (34.28%), and in secondary, there were 13 individuals (18.57%). Primary and secondary severe thoracic blast injuries showed no statistically significant difference in survival rate (P>0.05). severe primary thoracic blast injuries mainly presented as pneumothorax and lung contusion, sometimes accompanied by burns, ear, intestinal, and cardiac contusions. Secondary severe thoracic blast injuries were characterized by chest penetration injuries and lung lacerations, sometimes accompanied by thoracoabdominal or cardiorespiratory penetrating injuries, liver lacerations, and others. Following both types of thoracic blast injuries, the average arterial pressure significantly increased (P<0.05).

Conclusion

At an altitude of 2 800 meters, local goats exhibit symptoms of high-altitude sickness such as hypoxia and hypothermia after reaching an altitude of 4 600 meters. There are two types of severe chest blast injuries with the same fatality rate within 30 minutes. primary blast injury manifest discreetly and are followed by increased breathing, hypoxemia, and acidosis. Secondary injuries are easily detected but pose relative difficulties in early treatment.

Key words: High-altitude severe chest blast injury, Primary blast injury, Secondary blast injury, Early injury triage, Goat

图1 山羊布放图。注：A、B：一型胸部爆炸伤山羊统一右侧胸部朝向爆心布放；C、D、E：二型胸部爆炸伤山羊固定于特制钢架内，采用钢板防护只暴露右侧胸部；E：8 m组坐姿山羊布放图

图2 山羊布放图。注：A、B：一型胸部爆炸伤见口鼻出血、全身烧灼等；C、D二型胸部爆炸伤见胸部盲管伤、出血、腹腔脏器外露等

表1 高原胸部爆炸伤前后山羊生命体征变化

致伤前/后	例数	体温(℃)	心率(次/min)	呼吸(次/min)	平均动脉压(mmHg)
伤前
2 800 m	8	39.58±0.35	117.8±16.00	28.63±9.43	111.13±11.04
4 600 m	35	38.1±0.65^a	117.15±26.11	21.5±3.47^a	121.48±33.85
伤后
一型胸部爆炸伤	17	37.8±1.14^a	141.24±20.74	43.59±17.37^ab	141.24±20.74^ab
二型肺部爆炸伤	19	37.64±0.95^ab	149.63±44.33	20.25±5.08^ac	149.63±44.33^ab

表1 高原胸部爆炸伤前后山羊生命体征变化

致伤前/后	例数	体温(℃)	心率(次/min)	呼吸(次/min)	平均动脉压(mmHg)
伤前
2 800 m	8	39.58±0.35	117.8±16.00	28.63±9.43	111.13±11.04
4 600 m	35	38.1±0.65^a	117.15±26.11	21.5±3.47^a	121.48±33.85
伤后
一型胸部爆炸伤	17	37.8±1.14^a	141.24±20.74	43.59±17.37^ab	141.24±20.74^ab
二型肺部爆炸伤	19	37.64±0.95^ab	149.63±44.33	20.25±5.08^ac	149.63±44.33^ab

表2 急进高原胸部爆炸伤动脉血气分析

海拔及伤型	例数	pH	PaCO₂(mmHg)	PaO₂(mmHg)	HCO₃^－(mmol/L)	SaO₂(%)	LAC(mmol/L)
伤前
2 800 m	8	7.52±0.04	30.53±2.64	47.00±5.51	25.08±3.12	86.83±4.02	6.32±2.22
4 600 m	35	7.49±0.07	29.77±4.08	36.97±4.69^a	22.74±3.34	71.1±12.54^a	6.19±2.14
一型胸部爆炸伤	17	7.41±0.13^ab	26.95±2.18	30.71±6.77^a	16.72±5.24^ab	64.29±12.61^a	11.33±4.61^ab
二型肺部爆炸伤	19	7.50±0.12	27.02±7.65	30.17±6.37^ab	20.87±5.57	44.5±18.14^abc	7.67±6.67

表2 急进高原胸部爆炸伤动脉血气分析

海拔及伤型	例数	pH	PaCO₂(mmHg)	PaO₂(mmHg)	HCO₃^－(mmol/L)	SaO₂(%)	LAC(mmol/L)
伤前
2 800 m	8	7.52±0.04	30.53±2.64	47.00±5.51	25.08±3.12	86.83±4.02	6.32±2.22
4 600 m	35	7.49±0.07	29.77±4.08	36.97±4.69^a	22.74±3.34	71.1±12.54^a	6.19±2.14
一型胸部爆炸伤	17	7.41±0.13^ab	26.95±2.18	30.71±6.77^a	16.72±5.24^ab	64.29±12.61^a	11.33±4.61^ab
二型肺部爆炸伤	19	7.50±0.12	27.02±7.65	30.17±6.37^ab	20.87±5.57	44.5±18.14^abc	7.67±6.67

图3 胸部爆炸伤后1 h内X线检查结果。注：A、B、C：一型胸部爆炸伤，X线见膈肌太高、气胸及肺挫伤；D、E、F：二型胸部爆炸伤，见膈肌抬高、气胸、破片残留；F：安置胸腔闭式引流

图4 胸部爆炸伤后6 h时CT检查结果。注：A、B：CT肺窗见肺挫伤及气胸表现；C、D：CT纵隔窗见肺组织水肿、出血表现

图5 一型胸部爆炸伤。注：A、B：见肺出血、水肿及肺大疱形成；C：见肠道多发出血、水肿；E：见鼓膜破裂；F：左心内膜下多发出血点

图6 二型胸部爆炸伤。注：A、B：肺撕裂、毁损伤；C：胸壁穿透伤及胸腹联合伤；D：肝撕裂伤；E：左心内膜下散在出血点

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