高壓氧治療之應用－急性創傷輾壓傷之治療

虞希堯

書田診所外科萬芳醫院高壓氧中心․

名詞說明• Crush Injury

壓挫傷• Compartment Syndrome

腔室症候群• Acute Traumatic Ischemias (ATIs)

創傷型急性缺血• Acute Traumatic Peripheral Ischemias (ATPIs)

創傷型急性四肢缺血

資料來源：彰基醫院高壓氧中心， 1999 年

Crush InjuryCompartment Syndrome

阻斷血管主幹／阻斷側枝微循環

ATPIs

感染壞疽，傷口不癒，骨折不癒

引發 ATPIs 的常見原因：• 嚴重壓挫傷• 腔室症候群• 燒燙傷• 嚴重感染或過敏反應• 手術

組織水腫氧氣瀰散距離變長

微循環被壓迫關閉

組織缺氧

ATPIs

停止血管新生

自癒能力下降

2ATA 的 HB02使得：•PaO2 上升為 125%•Plasma 與 Tissue 的 [O2] 上升為10 倍•擴散於組織液的氧量增加 3 倍

HB02於 ATPIs 部位的作用 :•提供水腫組織的氧需求•提升單位血流的供氧量•緩解水腫•減輕缺血再灌流損傷

資料來源：彰基醫院高壓氧中心， 1999 年

ATPIs 的治療原則：• 外科與骨科的手術治療 （清創、血管與軟組織修補、骨骼固定） • 足量體液補充• 適量抗生素• 維持組織氧濃度

四肢 Crush Injuries 何時輔以 HBO2 ? ~ 用 Gustilo Open Fracture Classification System 來評估

Type Mechanism Expected Outcome HBO2 Indications

I Small (< 1 cm) laceration from inside to outside

Usually not different from a closed fracture

None

II Large laceration, but minimal soft tissue damage

Usually no different from a closed fracture

Compromised hosts such as diabetics, advanced peripheral vascular disease, collagen vascular diseases, etc., where concern is raised about primary healing of flaps

III Crush tissue:

A. Sufficient soft tissue to close wound (primary and delayed)B. Flaps or grafts required to obtain soft tissue coverageC. Major (macrovascular) vessel injury

A. Infections and/or nonunion rates < 10 %B. About 50% incidence of complications (infection, nonunion)C. About 50% incidence of complications (infections, nonunion)

A. Same as for type II fractures

B. All injuries

C. All injuries

四肢 Crush Injuries 何時輔以 HBO2 ? ~ 用 Mangled Extremity Severity Score (MESS) 來評估

A. Skeletal/soft tissue injuryLow energy (stab, simple fracture; low velocity gun shot wound)Medium energy (open or multiple fractures, dislocations)High energy (close-range shot gun or high velocity GSW, crush injury)Very high energy (above plus gross contamination, soft tissue avulsion)

B. Limb ischemiaPulse reduced or absent, but perfusion presentPulselessness, paresthesias, diminished capillary refill 2*Cool, paralyzed, insensate, numb 3**Double score if ischemia time > 6 hours

C. ShockSystolic BP always > 90 mmHgHypotension transientlyPersistent hypotension

D. Age< 3030-50> 50

Points1234

1*2*3*

012

012

• MESS=A+B+C+D • Johansen et al 建議當 MESS 7 分以上時應行截肢。• MESS 在 3~8 分時，依以下原則決定 HBO2 輔助治療。

MESS（甲） 7 (possibly 8)

（乙） 5, 6

（丙） 3, 4

HB02 Indications （甲） 分數主要來自 B,C,D 三項的健常患者。 （乙） 糖尿病、周邊動脈硬化、凝血或膠原蛋白功能異常、、、等不良癒傷因子，輕或中度者。 （丙）糖尿病、周邊動脈硬化、凝血或膠原蛋白功能異常、、、等不良癒傷因子，重度者。

I. 臨床症狀：1. Severe pain in muscle compartment2. Marked increase in pain with passive stretch of muscles in the compartment3. Marked swelling of the compartment4. Marked tenseness of the muscle compartment5. Neuropathy, myelopathy, and/or encephalopathy II. 骨骼肌腔室壓力測量： 1. Greater than 40 mmHg in the uncomprotnised host2. Rising serial compartment pressure measurements as values approach 35 mmHg3. 30-40 mmHg in mildly compromised host (diabetic, peripheral vascular disease, collagen vascular disease, etc.)4. 20-30 mmHg in hypotensive patients where systolic blood pressure is 33 to 50% lower than is expected.

下二項任一時建議輔以 HBO2 ：• 在 I. 臨床症狀 內有 3 項以上。•在 II. 骨骼肌腔室壓力測量 內有任何一項。

評估骨骼肌群 Compartment Syndrome

資料來源：彰基醫院高壓氧中心， 1999 年

ATPIs 時，併用 HBO2的建議：• HBO 不能完全取代手術與藥物！• 創傷後 4-6 小時內開始 HBO 預後較佳。• 第一個 48 小時 90 min, 2.0~2.5 ata HBO2, q8h 。 第二個 48 小時 90 min , 2.0~2.5 ata HBO2, q12h 。 第三個 48 小時 90 min , 2.0~2.5 ata HBO2, qD 。* 特別注意，類似的 protocol 尚有許多，都需更多臨床數據來驗證。• 六天後，症狀應減輕至不需 HBO2 ，否 則需全面重新評估。

ADJUNCTIVE HYPERBARIC OXYGEN TREATMENT FOR 8 PATIENTS WITH CRUSH SYNDROME IN DEVASTATING EARTHQUAKE. SY Yu. Wound Care and Hyperbaric Medicine Center, Department of Surgery, Changhua Christian Hospital, Changhua City, Taiwan 500 BACKGROUND: Hyperbaric oxygen therapy (HBOT) has been reported as an useful adjunct for the management of crush injuries. A devastating earthquake scaled 7.3 hit central Taiwan in the early morning on Sep. 21, 1999, and aftershocks scaled between 5 to 6 persisted for months. Changhua Christian Hospital, the nearest medical center to the quake region, has received more than 2000 emergent trasferral during the disaster.CASE REPORT: There were 8 severely injured patients managed with both traditional treatments and adjunctive hyperbaric oxygen treatment. Two of them received amputation finally. An 8-year-old girl with severe crush over both lower limbs lost her left leg by a below-knee amputation because of irreversible gangrenous change and uncontrolled sepis. Hypoxia of her right leg was reversed by fasciotomy and intensive HBOT. A 6-year-old girl with duodenal perforation and totally crushed left lower limb underwent emergent laparotomy, fasciotomy and early HBOT. An inevitable transmetatarsal amputation was done for her to remove the gangrenous part of foot. A back hoes tilted over a 25-year-old young man resulting in an open tibial fracture and severe crush, which was corrected by repeated operations and HBOT. Compartment syndrome also developed in another 4 patients, and relieved with no or mild neurologic deficit after 5 to 20 dives of HBOT. A 6-year-old girl with cardiac tamponade underwent emergent cardiac ventricle repair and depended on ventilator for pulmonary contussion postoperatively. The sternotomy wound was dehescenced and deeply infected, but healed well after repeated operations and 12 dives of HBOT.CONCLUSION: With the benefit of promoting wound healing, decreasing infection and shortening hospital day, these cases are to be presented to conclude that early adjunctive hyperbaric oxygen therapy plays an important role in the treatment of crush syndrome.