Clinical characteristics and analysis of risk factors for heart injuries in 55 patients with lightning injury on plateau in Tibet Autonomous Region
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摘要:
目的 探讨西藏自治区高原雷击伤患者的临床特征、治疗情况及发生心脏损伤的危险因素。 方法 采用回顾性病例系列研究方法。2008年1月―2023年7月，解放军西藏军区总医院收治55例符合入选标准的雷击伤患者。统计患者的性别、年龄、民族、受伤时间、受伤地（平均海拔）、受伤时活动、发生体表热力烧伤的情况、发生并发症情况、发生复合伤情况、伤前合并基础疾病/生理过程、住院天数、治疗结局、治疗有效率。按年龄段将患者分为少年组（11例）、青年组（28例）、中年组（14例）、老年组（2例），比较4组患者性别、民族分布。根据入院时是否发生心脏损伤，将患者分为心脏损伤组（44例）和非心脏损伤组（11例），比较2组患者性别、年龄、民族、受伤地平均海拔、住院天数、发生并发症情况、发生复合伤情况、体表热力烧伤部位、体表热力烧伤面积。对数据行Mann-Whitney U检验、 χ 2检验、Fisher确切概率法检验。行多因素logistic回归分析，筛选影响雷击伤患者发生心脏损伤的独立危险因素。 结果 55例患者中，男39例、女16例，年龄为10~68岁，藏族47例、汉族8例。4个年龄段组患者性别和民族分布比较，差异均无统计学意义（ P>0.05）。受伤时间为5~9月，以6、7月多发，拉萨市城关区（平均海拔3 650 m）、那曲市巴青县（平均海拔4 500 m）雷击伤发病率较高，分别为20.0%（11/55）、16.4%（9/55）。96.4%（53/55）的患者受伤时正在进行室外活动，如放牧、挖虫草、收青稞等。55例患者中发生体表热力烧伤者46例，占83.6%，烧伤面积以不超过10%体表总面积为主，烧伤深度以深Ⅱ度为主。52例（94.5%）患者发生并发症，以心脏损害（44例，80.0%）最为常见；22例（40.0%）患者共发生11种复合伤，最常见的是创伤性颅脑损伤；17例（30.9%）患者伤前共合并11种基础疾病/生理过程；患者住院天数为9（5，17）d。55例患者中治愈出院14例、好转40例、死亡1例，治疗有效率为98.2%。与非心脏损伤组比较，心脏损伤组患者并发症发生比例（ χ 2=12.28）、躯干烧伤比例（ χ 2=5.15）、受伤地平均海拔（ Z=-2.38）均明显增加（ P<0.05），其余指标均无明显变化（ P>0.05）。多因素logistic回归分析显示受伤地平均海拔为雷击伤患者发生心脏损伤的独立危险因素（比值比为3.28，95%置信区间为1.35~7.99， P<0.05）。 结论 西藏自治区高原雷击伤主要发生在5~9月、受伤地平均海拔为4 500 m、受伤时活动主要为室外活动，受累患者以男性、青年、藏族为主，受伤程度以轻度烧伤居多；伤情复杂且并发症多，以心脏损伤最为常见。受伤地平均海拔为雷击伤患者发生心脏损伤的独立危险因素。 Abstract:Objective To explore the clinical characteristics and treatment outcomes of patients with lightning injury on plateau in Tibet Autonomous Region, and to analyze the risk factors for heart injuries in these patients. Methods A retrospective case series study was conducted. From January 2008 to July 2023, 55 patients with lightning injury who met the inclusion criteria were admitted to the General Hospital of PLA Tibet Military Area Command. The gender, age, ethnicity, time of injury, location of injury (average altitude), activity at the time of injury, the occurrence of thermal burns on the body surface, the occurrence of complication, the occurrence of combined injury, underlying disease or physiological process before injury, length of hospital stay, treatment outcome, and effective rate of treatment were recorded. The patients were divided into juvenile group (11 cases), young group (28 cases), middle-aged group (14 cases), and elderly group (2 cases) according to age bracket, then the gender and ethnicity distribution of patients in the 4 groups were compared. According to the occurrence of heart injuries at admission, the patients were divided into heart injury group (44 cases) and non-heart injury group (11 cases), then the gender, age, ethnicity, average altitude of location of injury, length of hospital stay, the occurrence of complication, the occurrence of combined injury, site of thermal burns on the body surface, and area of thermal burns on the body surface in patients were compared between the two groups. Data were statistically analyzed with Mann-Whitney U test, chi-square test, or Fisher's exact probability test. The multivariate logistic regression analysis was conducted to screen the independent risk factors for heart injury in patients with lightning injury. Results Among the 55 patients aged 10-68 years, 39 were male and 16 were female, including 47 Tibetans and 8 Hans. There were no statistically significant differences in gender or ethnicity distribution of patients among the 4 groups with different age brackets ( P>0.05). Lightning injuries occurred from May to September, which mostly occurred in June and July. The incidence of lightning injury was higher in Chengguan District of Lhasa City (average altitude of 3 650 m) and Baqing County of Naqu City (average altitude of 4 500 m), being 20.0% (11/55) and 16.4% (9/55), respectively. A total of 96.4% (53/55) of the patients were engaged in outdoor activities when injured, such as grazing, digging Cordyceps, and harvesting highland barley. Among the 55 patients, 46 (83.6%) cases had thermal burns on the body surface, with burn area mainly being not more than 10% total body surface area and burn depth mainly being deep partial-thickness. Fifty-two (94.5%) patients had complications, with heart injury being the most common complication (44 cases, 80.0%). Twenty-two (40.0%) patients had 11 combined injuries, and traumatic brain injury was the most common combined injury. Seventeen (30.9%) patients had 11 underlying diseases or physiological processes before injury. The length of hospital stay of patients was 9 (5, 17) d. Among the 55 patients, 14 cases were cured and discharged, 40 cases were improved, and 1 case died, with effective rate of treatment of 98.2%. Compared with those in non-heart injury group, the proportion of complication occurrence ( χ 2=12.28), the proportion of trunk burns ( χ 2=5.15), and the average altitude of location of injury ( Z=-2.38) of patients in heart injury group were increased significantly ( P<0.05), while there were no significant changes in the other indicators ( P>0.05). Multivariate logistic regression analysis showed that the average altitude at the location of injury was the independent risk factor for heart injury in patients with lightning injury (with odds ratio of 3.28, 95% confidence interval of 1.35-7.99, P<0.05). Conclusions Lightning injuries on plateau in Tibet Autonomous Region mainly occur from May to September, with an average altitude of 4 500 m at the location of injury. Patients with lightning injury are injured when participating outdoor activities, and the affected patients are mainly mainly young male Tibetans. Most of the injuries are mild burns. Lightning injuries are complex and have many complications, with heart injury being the most common one. The average altitude at the location of injury is the independent risk factor for heart injury in patients with lightning injury. -
Key words:
- Lightning injuries /
- Risk factors /
- Epidemiologic studies /
- Heart injuries /
- Clinical characters
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参考文献
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1 例1患者因雷击伤致睾丸缺血坏死行睾丸切除术。1A.入院时左上臂屈侧可见“条索样”雷击纹；1B.入院时右侧睾丸及大腿创面；1C.入院时睾丸彩色多普勒超声检查显示右侧睾丸回声不均匀，未见明显血流信号；1D.伤后57 d创面愈合，遗留右侧睾丸缺损
2 例2患者因雷击伤致内脏器官损害及皮肤损伤伤后21 h入院时的情况。2A.腹部CT示肝周多发游离气体；2B.胸部CT示双肺挫伤、水肿、炎症，右肺淤血；2C.腹部CT示升结肠周围、右侧后腹膜水肿，肠腔气液平；2D.臀部及下肢可见雷击纹
表1 4组雷击伤患者性别和民族分布比较（例）
表1. Comparison of gender and ethnicity distribution of patients with lightning injury among 4 groups
组别 例数 性别 民族 男 女 藏族 汉族 少年组 11 6 5 11 0 青年组 28 22 6 23 5 中年组 14 9 5 11 3 老年组 2 2 0 2 0 P值 0.360 0.461 
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表2 55例雷击伤患者受伤地点及平均海拔分布
表2. Location of injury and average altitude distribution of 55 patients with lightning injury
市与区/县 平均海拔（m） 例数 山南市 3 600 2 贡嘎县 3 680 1 扎囊县 3 680 1 林芝市 3 100 1 工布江达县 3 600 1 拉萨市 3 650 24 城关区 3 650 11 墨竹工卡县 4 000 3 林周县 4 200 3 当雄县 4 200 3 堆龙德庆县 4 500 4 日喀则市 4 000 3 桑珠孜区 4 000 3 那曲市 4 500 25 巴青县 4 500 9 比如县 4 500 5 嘉黎县 4 500 4 色尼区 4 500 4 聂荣县 4 700 2 安多县 5 200 1
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表3 2组雷击伤患者临床资料比较
表3. Comparison of clinical data of patients with lightning injury between 2 groups
组别 例数 性别（例） 年龄［岁， M（ Q 1， Q 3）］ 民族（例） 受伤地平均海拔（例） 男 女 藏族 汉族 3 600~3 680 m 4 000~4 200 m ≥4 500 m 心脏损伤组 44 31 13 29.0（18.3，41.8） 39 5 7 11 26 非心脏损伤组 11 8 3 27.0（24.0，32.0） 8 3 6 2 3 统计量值 χ 2=0.02 Z=-0.67 χ 2=1.79 Z=-2.38 P值 0.882 0.500 0.181 0.017 注：TBSA为体表总面积
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