腿伤了,人却出现神志不清,最后原因却在肺上......

2018-06-11 江河 医学界急诊与重症频道

抽丝剥茧找原因……

病例简介

患者男性,农民工,48岁,既往健康,因高处坠落伤3小时余,送诊于外院,在工地干活时,不慎从高处坠落,伤及右侧下肢。

来诊时见神志清楚,痛苦面容,右侧下肢明显肿胀,表皮有擦皮伤及渗血,当地医院查头部CT未见明显异常,下肢x光检查,诊断为右侧股骨骨折,胫骨腓骨双骨折。

给以抗炎补液,并行右侧股骨牵引,胫骨腓骨钢板固定,术后患者恢复尚可,神志清楚,还安慰其他人自己没事,大家也松了口气。

不料,手术后大概9小时,距离受伤大概40小时左右,患者无明显诱因,突然出现神志不清,伴有呼吸困难,呼吸急促,频率40次/分,并有周身出汗,体温上升到37.7℃,当地复查头部ct,仍无明显异常,查血常规及电解质未见异常,查床头胸片为双肺纹理增强,于是转诊我院。

肺栓塞?都这么想!

说到这里,估计有的医生脑中已经有了一个大概的诊断,肺栓塞,可以引起呼吸困难,神志不清,而患者长骨骨折,术后卧床制动,提供了栓子的来源,而肺栓塞引起呼吸困难也是顺理成章,似乎一切都是那么正常,的确,接诊的医生也是这么想的。

给予吸氧,心电监护,抗炎,解痉平喘,对症治疗,并及时完善血常规,生化,凝血功能,血气分析检查,最关键的,进行肺部动脉CTA检查,明确肺栓塞,并交代溶栓治疗可能,

化验回报二聚体升高,血气分析提示氧分压在吸氧情况下只有55毫米汞柱,二氧化碳分压28毫米汞柱,低氧血症,过度换气,一型呼吸衰竭,也符合肺栓塞的表现,似乎一切都顺理成章,就等着CTA的结果,决定下一步治疗了。

出人意料的 CTA 报告结果

结果出乎医生的预料,患者的CTA报告,没有肺栓塞存在,这让人大吃一惊,似乎开了个玩笑,所有的证据都指向了一个诊断,而最关键的金指标却一票否决,让人一头雾水,难道是栓塞的动脉比较小,CTA看不到?

这样虽然可以解释CTA结果,也能解释患者呼吸困难,可是,这么小的肺栓塞,又无法解释患者的神志不清,这到底是怎么回事呢?引起患者昏迷的真正原因又是什么呢?

会诊!抽丝剥茧找病因

这种情况下,医院组织了会诊,一名医生指出,患者手术后制动,是引起肺栓塞的常见高危因素,但患者的检查结果并不符合,考虑到患者为长骨骨折,还应该注意到脂肪栓塞综合征的存在。

该病多在伤后48小时内发病,因为栓子大小和部位的不同,临床表现差别很大,有的病情轻微,仅仅表现为皮肤出血点,有的发病很急,出现呼吸困难,咳嗽,昏迷,伴有头痛,头晕,恶心呕吐,抽搐发热,皮肤黏膜出血点等,患者的目前表现,高度怀疑该病。

肺栓塞可以诱发ARDS,危及生命,而脂肪栓塞,一般表现为局部栓塞区,出现出血,渗出,并形成间质水肿,气体交换困难,而ARDS的表现则肺部改变更为明显。

按照这个思路,再次仔细查体,发现患者的大腿内侧有少量针尖状的出血点,虽然进行化验血和尿中没有发现脂肪滴,但是仍然考虑脂肪栓塞。按照治疗方法,使用激素甲强龙冲击治疗,并且进行高压氧治疗,经过上述治疗两天后,患者神志逐步转清,对答正确,但反应仍略迟钝,经过继续使用高压氧治疗,结合药物治疗一周后,病情好转,反应正常,转回当地医院继续治疗。

Tips:脂肪栓塞综合征:

脂肪栓塞综合征,是指直径10-40微米的血管内,脂肪颗粒堵塞血管官腔而引起的一系列病理改变的综合征,多法伤装严重外伤,骨折,特别是长骨骨折。

24-48小时后,以意识障碍,进行性低氧血症,呼吸困难,皮肤瘀斑为特征。临床表现差异大,经常与休克,颅脑外伤,肺挫伤等并发。

在骨折时,脂肪细胞核静脉窦破裂,脂肪作为血肿内容物进入静脉循环,海绵状骨颗粒和较大的脂肪滴阻塞最小的肺血管分支,而小的脂肪滴可以通过肺前毛细血管旁路,进入肺静脉。

其毒性作用会导致肺内皮细胞核肺细胞的直接损伤。在此基础上,毛细血管漏出,血管周围出现,血小板粘附和血凝块形成。表现为肺水肿,出血,不张和纤维蛋白沉积为特点的化学性肺炎表现,由于栓子被水解,肺的机械性梗塞已经不是主要矛盾,而是出现肺通气/血流比例失调出现气体弥散障碍,最终导致低氧血症,呼吸窘迫综合征。

临床上,肺栓塞在骨折后制动的患者比较常见,此类病人突然出现呼吸困难时,容易想到肺栓塞,但是如果同时存在用颅脑损伤或急性脑血管病不能解释的意识障碍时,一定要注意到脂肪栓塞的可能。

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    2018-06-13 1dd8c52fm63(暂无匿称)

    了解了解.学习学习

    0

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    2018-06-13 张新亮1853311252142e2fm

    好文献学习了

    0

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    2018-06-13 易水河

    知之为知之.学习学习

    0

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    2018-06-12 慢节奏

    前不久上了中医骨伤科学.讲到了脂肪栓塞综合征.这里就又见到了.这下印象深刻了

    0

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    2018-06-12 飛歌

    学习了很有用不错

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1597851, encodeId=b55d159e851a3, content=<a href='/topic/show?id=2105e4128d7' target=_blank style='color:#2F92EE;'>#神志不清#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74128, encryptionId=2105e4128d7, topicName=神志不清)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=506e18545200, createdName=dongjia2016, createdTime=Wed Jun 13 13:52:00 CST 2018, time=2018-06-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323750, encodeId=6544323e50cf, content=了解了解.学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Jun 13 06:37:29 CST 2018, time=2018-06-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323735, encodeId=5ed3323e35c3, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jun 13 06:16:27 CST 2018, time=2018-06-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323730, encodeId=3145323e30b2, content=知之为知之.学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKibA62IFMeUJEmSyIe8DvYFeERuOsfrRd8iano7nENqQU1dRR3tqeQOUL3eqgYgEZRT2t2iaEsib0JEw/132, createdBy=66771693911, createdName=易水河, createdTime=Wed Jun 13 06:11:05 CST 2018, time=2018-06-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323579, encodeId=410c3235e9dc, content=前不久上了中医骨伤科学.讲到了脂肪栓塞综合征.这里就又见到了.这下印象深刻了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJRFtjbCMwNPy2g88RyetT0pKBHZYCUiaZBSIU9yBXXibBVK5xptCa2KEoS6rA1mvZbcQtribeePnFAQ/132, createdBy=6f6b2361429, createdName=慢节奏, createdTime=Tue Jun 12 16:12:08 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323463, encodeId=815f323463d3, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Jun 12 06:40:54 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323450, encodeId=cba03234503b, content=学习学习.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Tue Jun 12 06:18:26 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323418, encodeId=8abe32341842, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/03/18/9fba4e8a3782366829a5645367fdb658.jpg, createdBy=b5732293938, createdName=青山颖钰, createdTime=Tue Jun 12 05:10:16 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323396, encodeId=fbd7323396fd, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Mon Jun 11 23:43:54 CST 2018, time=2018-06-11, status=1, ipAttribution=)]
    2018-06-12 1dd8c52fm63(暂无匿称)

    学习学习.继续关注

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1597851, encodeId=b55d159e851a3, content=<a href='/topic/show?id=2105e4128d7' target=_blank style='color:#2F92EE;'>#神志不清#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74128, encryptionId=2105e4128d7, topicName=神志不清)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=506e18545200, createdName=dongjia2016, createdTime=Wed Jun 13 13:52:00 CST 2018, time=2018-06-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323750, encodeId=6544323e50cf, content=了解了解.学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Jun 13 06:37:29 CST 2018, time=2018-06-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323735, encodeId=5ed3323e35c3, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jun 13 06:16:27 CST 2018, time=2018-06-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323730, encodeId=3145323e30b2, content=知之为知之.学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKibA62IFMeUJEmSyIe8DvYFeERuOsfrRd8iano7nENqQU1dRR3tqeQOUL3eqgYgEZRT2t2iaEsib0JEw/132, createdBy=66771693911, createdName=易水河, createdTime=Wed Jun 13 06:11:05 CST 2018, time=2018-06-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323579, encodeId=410c3235e9dc, content=前不久上了中医骨伤科学.讲到了脂肪栓塞综合征.这里就又见到了.这下印象深刻了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJRFtjbCMwNPy2g88RyetT0pKBHZYCUiaZBSIU9yBXXibBVK5xptCa2KEoS6rA1mvZbcQtribeePnFAQ/132, createdBy=6f6b2361429, createdName=慢节奏, createdTime=Tue Jun 12 16:12:08 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323463, encodeId=815f323463d3, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Jun 12 06:40:54 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323450, encodeId=cba03234503b, content=学习学习.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Tue Jun 12 06:18:26 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323418, encodeId=8abe32341842, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/03/18/9fba4e8a3782366829a5645367fdb658.jpg, createdBy=b5732293938, createdName=青山颖钰, createdTime=Tue Jun 12 05:10:16 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=323396, encodeId=fbd7323396fd, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Mon Jun 11 23:43:54 CST 2018, time=2018-06-11, status=1, ipAttribution=)]
    2018-06-12 青山颖钰

    学习了

    0

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    2018-06-11 惠映实验室

    学习了.谢谢分享.

    0

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