Treatment of 568 patients with frostbite in northeastern China with an analysis of rate of amputation
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摘要: 目的 了解冻伤患者的治疗要点及截肢情况,以提高救治成功率。 方法 2005年1月—2014年12月,笔者单位收治568例冻伤住院患者。(1)对于伤后1周内入院者,伤后7 d内采用42 ℃中药液浸泡(每日2次,每次30 min)结合红外线或红光照射冻伤部位(每日3次,每次40 min),其间同时行改善微循环、扩张血管、抗感染治疗;之后仅应用红外线或红光照射冻伤部位。超过伤后1周入院者,仅用红外线或红光照射冻伤部位,若创周出现炎症表现则行抗感染治疗。本组5例冻僵患者入院后除行上述处理外,还行补液复苏。(2)所有患者入院后立即行创面处理。264例患者的浅Ⅱ、深Ⅱ度创面行常规换药处理;79例患者的Ⅲ度创面常规换药处理后行暴露治疗,其中肉芽创面移植自体大腿刃厚皮修复;225例患者的Ⅳ度创面行清创、暴露治疗后,于伤后3~4周行截肢术,其中4例跟骨外露创面移植逆行腓肠神经营养血管岛状皮瓣覆盖。统计浅Ⅱ度及深Ⅱ度创面平均愈合时间、Ⅲ度创面植皮成活率及Ⅳ度足跟创面移植皮瓣成活率;统计冻伤发生于12月、1月、2月及其他月份的患者截肢率,入院时间小于伤后1 d、伤后1~3 d、大于伤后3 d且小于或等于伤后5 d及超过伤后5 d的患者截肢率,因醉酒、精神障碍、防护不周、迷路、车祸等外伤所致冻伤患者的截肢率,院前行室温自然复温、雪搓、棉被包裹、温水浸泡处理后的患者截肢率。对部分数据行
χ 2检验。 结果 568例冻伤患者均治愈。浅Ⅱ、深Ⅱ度创面平均愈合时间分别为10、23 d。Ⅲ度创面植皮成活率约95%,Ⅳ度足跟创面移植皮瓣的成活率为100%。患者中,冻伤发生于12月、1月的截肢率分别为47.46%(84/177)、42.56%(103/242),均明显高于冻伤发生于2月及其他月份的截肢率[分别为29.55%(26/88)、13.11%(8/61),χ 2值为42.595~220.900,P 值均小于0.01]。小于伤后1 d入院患者的截肢率为32.06%(84/262),明显低于伤后1~3 d、大于伤后3 d且小于或等于伤后5 d及超过伤后5 d入院患者的截肢率[分别为40.48%(68/168)、49.02%(50/102)、52.78%(19/36),χ 2值为107.284~165.350,P 值均小于0.01]。患者中因醉酒、精神障碍及车祸等外伤导致的截肢率分别为42.06%(106/252)、43.48%(60/138)和53.12%(17/32),明显高于防护不周及迷路所致截肢率[分别为27.45%(28/102)、22.73%(10/44),χ 2值为187.260~209.738,P 值均小于0.01]。患者中院前采用室温自然复温、雪搓和棉被包裹处理冻伤创面的截肢率分别为44.29%(62/140)、48.28%(84/174)和35.38%(46/130),明显高于用温水浸泡处理冻伤创面的截肢率[23.39%(29/124),χ 2值为97.364~136.189,P 值均小于0.01]。 结论 冻伤后及早就诊治疗、早期正确复温、恰当的创面处理是降低患者截肢率的关键,对于冻伤高发时间段(12月及1月)和高危人群(精神障碍患者、酗酒者)的防护应予以高度重视。Abstract: Objective To study the key points of treatment and amputation in patients with frostbite, so as to increase the successful rate of the treatment. Methods Five hundred and sixty-eight patients with frostbite admitted to our department from January 2005 to December 2014. (1) For the patients admitted to our department within one week after injury, the frostbite wounds were soaked in 42 ℃ herbal fluid (twice per day, 30 min for each time) and irradiated with infrared or red light (three times per day, 40 min for each time) from the day of admission to the 7th day after injury. Meanwhile, treatment for improvement of microcirculation, vasodilation, and anti-infection were also given. Then they received infrared or red light irradiation to the wound sites. For the patients admitted to our department longer than one week after frostbite, the frostbite wounds were irradiated with infrared or red light, and treated with antibiotics if inflammation was found around the wound. Among all the patients, 5 cases suffered from frozen stiff, and they were given fluid resuscitation as well as above-mentioned treatments after admission. (2) All patients were given wound treatment immediately after admission. The superficial partial-thickness wounds and deep partial-thickness wounds of 264 patients were given routine dressing change. The full-thickness wounds in 79 patients were treated with exposure therapy after routine dressing change first, and then granulation tissue of these wounds were grafted with autologous thigh split-thickness skin grafts. After debridement and exposure therapy, amputation was done in 225 patients 3 to 4 weeks after injury when the underlying bone was exposed. In 4 patients with exposure of calcaneus, the wounds were covered with reverse sural nerve nutrient vessels island flap. Mean healing time of superficial partial-thickness wound and deep partial-thickness wound, survival rate of skin graft in full-thickness wound, and survival rate of flap covering wound deep to bone at the heel were all recorded. The amputation rate of patients injured in December, January, February, and other months, that of patients admitted shorter than 1 day after frostbite, 1 to 3 days after frostbite, longer than 3 days and shorter than or equal to 5 days after frostbite, and longer than 5 days after frostbite, that of patients caused by drunkenness, mental disorders, improper protection, going astray, and trauma including traffic accident etc., and that of patients treated with rewarming under room temperature, rubbing with snow, wrapping with quilt, and soaking in warm water before admission were all recorded and analyzed. Parts of the data were processed withχ 2 test. Results All patients were survived after treatment. Average wound healing time of superficial partial -thickness wound and deep partial-thickness wound was respectively 10 and 23 days. The survival rate of skin graft on full-thickness wound was about 95%. Survival rate of flap on wound deep to bone at the heel was 100%. Amputation rates of patients injured in December and January were respectively 47.46% (84/177), 42.56% (103/242), and both were significantly higher than those of patients injured in February and the other months [respectively 29.55% (26/88), 13.11% (8/61), withχ 2 values from 42.595 to 220.900,P values below 0.01]. Amputation rate of patients with admission time shorter than 1 day after frostbite was 32.06% (84/262), which was obviously lower than that of patients with admission time from 1 to 3 days after frostbite, longer than 3 days and less than or equal to 5 days after frostbite, or longer than 5 days after frostbite [respectively 40.48% (68/168), 49.02% (50/102), 52.78% (19/36), withχ 2 values from 107.284 to 165.350,P values below 0.01]. Amputation rates of patients with frostbite occurring after getting drunkenness, mental disorders, and trauma including traffic accident etc. were respectively 42.06% (106/252), 43.48% (60/138), and 53.12% (17/32), and they were all significantly higher than those of patients with frostbite caused by improper protection and going astray [respectively 27.45% (28/102), 22.73% (10/44), withχ 2 values from 187.260 to 209.738,P values below 0.01]. Amputation rates of patients undergoing treatment of rewarming under room temperature, rubbing with snow, wrapping with quilt before admission were respectively 44.29% (62/140), 48.28% (84/174), and 35.38% (46/130), and they were significantly higher than the amputation rate of patients who received the treatment of soaking in warm water [23.39% (29/124), withχ 2 values from 97.364 to 136.189,P values below 0.01]. Conclusions Early diagnosis and treatment, properly rewarming at early stage, and correct wound treatment are the key points for reducing amputation rate of patients after frostbite. Attention should be paid to the occurrence of frostbite in December and January, and also to protection of high-risk groups (patients with mental disorders and drunker).-
Key words:
- Frostbite /
- Rewarming /
- Amputation /
- Wound repair
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