compartment syndrome
description
Transcript of compartment syndrome
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腔室症候群腔室症候群
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什麼是腔室症候群 ?
(Compartment syndromes)
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腔室症候群1912: Wilson first described the exertional c
ompartment syndrome.1956: Mavor reported a case of chronic com
partment syndrome. 14% of leg pain with anterior compartment
syndrome (Qvarfordt et al).1-9% of leg fractures with compartment syn
drome.
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腔室症候群
極嚴重的臨床問題惡性循環組織受創釋出發炎物質微血管擴張且血管內膜之通透性上升血漿向外滲至筋膜腔合併紅血球滯流腔室內壓力上升血液循環受阻組織缺氧釋放更多發炎物質
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腔室症候群
當壓力上升至 50 mm Hg ,血流量下降至 70% ;而壓力到達 80 mm Hg 時,血流只剩下 5% 。
有兩種分類:1. 外傷引起,如:骨折,肌肉挫傷。2. 日常生活引起 (microtrauma) ,稱之為
exertional compartment syndrome 。
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腔室症候群
悄悄地發生 (insidious onset)在傷害後的數小時到數天均有可能若不及時處理,則會造成肌肉壞死、以及二度感染、變縮變形、 . 神經缺損、壞疽、傷口不癒合以及骨折不癒合等等的合併症。
甚至於急性腎衰竭,休克,死亡。
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成因
Decreased compartment size Constrictive dressing and casts. Closure of fascial defects. Thermal injuries and frostbite.
Increased compartment contents Increased capillary permeability Trauma, fracture, contusion Postischemic swelling: lying on a limb
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成因
Burns Orthopaedic procedures: osteotomy, fra
cture fixation Intensive use of muscles: seizures, tetan
y, eclampsia Intraarterial drugs Snakebite
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成因
Increased capillary pressure Venous obstruction Exercise Vascular injury Bleeding disorder, anticoagulant therapy Muscle hypertrophy Nephrotic syndrome Popliteal cyst
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腔室的位置
Upper arm Anterior compartment Posterior compartment
Forearm Volar compartment Dorsal compartment
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腔室的位置
Hand Thenar and hypothenar compartment Interosseous compartment Lower extremity Gluteal compartment Thigh compartment
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腔室的位置
Leg Anterior compartment
Lateral compartment
Superficial posterior compartment
Deep posterior compartment
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組織可承受多久的壓力組織可承受多久的壓力 ??
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How long can tissues tolerate the increased compartmental
pressure? Whitesides et al noted:
50 mm Hg 的壓力可承受 4-8 小時40 mm Hg 的壓力可承受 6 小時即出現早期神經肌肉的傷害
Gelberman et al noted:在正中神經施於 50 mm Hg 的壓力, 4 小時即出現感覺及運動的異常
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臨床症狀
典型的症狀為 5P :PainPallorParesthesiaPulselessParalysis
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疼痛 (pain)
疼痛是最早且最重要的症狀,但並不是最可靠的症狀。
腔室症候群疼痛不同於骨折的疼痛,它是“深的、無法定位、持續地、且常無法用一般止痛劑止痛的”痛。 (out of proportion to the injury )
當我們拉扯患肢之末梢時,常會加重此一疼痛。
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感覺異常 (paresthesia)
神經已受到影響還處於可逆的時期感覺異常的情況,通常比運動神經出現異常為早,但若已出現知覺喪失的現象,則表示是屬於較晚期的症狀。
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蒼白 (pallor)
不一定會出現受傷的肢體可能會出現發紫或小塊紫青,此二種症狀的出現會較早,而一般蒼白的現象若出現則已屬晚期症狀,因為它表示動脈已有阻塞現象。
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肢體癱瘓 (paralysis)
當出現此症狀時多半表示,缺血及缺氧之狀況可能已有一段時間,且永久之損傷常常已經發生了。
不可逆之肌肉壞死最早可在缺血後六個小時即發生。
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脈搏消失 (pulseless)
疾病已到了晚期所造成的組織傷害已是不可逆的。因為當腔室內的壓力增加超過靜脈壓力時,其動脈血尚可進入,但靜脈回流卻已終止了,故會出現脈搏消失的症狀。
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症狀的總結 : “7P”
Pain disproportionate to the primary diagnosis.
Pain worsened by passive stretch of the affected muscles.
Pressure palpable over the compartment.
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症狀的總結 : “7P”
Paresis of affected muscles. Paresthesias in the distribution of affect
ed nerves. Pallor. Pulselessness in the most severe cases.
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診斷方式
早期高度懷疑是診斷之鑰單純要經由臨床之症狀來確定診斷腔室症候群非常不容易,且常會有延遲診斷之現象。
測量腔室內之壓力是診斷的黃金標準。 Dr.Whitesides 及其同僚提出了一種簡易的方式,來測量腔室內的壓力。
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Measurement of compartment pressures
Infusion Technique (Whitesides) Needle in the most pain or tense location Too much saline: false high readings
Wick Catheter Technique (Mubarak)Continuous Monitoring Technique (Matse
n)每個人有不同的臨界值會因血壓的變動有所變動
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Pressure Threshold for Fasciotomy
正常的密閉腔室壓力約為 0-8 mmHg 。15-20 mmHg 組織的血流將會不足,且發生缺氧之狀況。
Matsen: 45 mmHgWhitesides: diastolic BP – 20 mmHgMubarak and Hargens: 30 mmHg30-40 mmHg for emergent fasciotomy
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實驗室及放射線檢查
急性期做腎功能的監測由都卜勒超音波檢查脛骨之靜脈血流,可用來決定是否須行筋膜切開術。
MRI 或超音波:肌肉裂傷神經傳導檢查: nerve entrapment synd
romes.
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治療
1. 休息及藥物止痛2.抬高患肢 ( 只適用於早期 )3.去除任何緊繃之紗布或石膏4. 而外科醫師應隨時注意觀察是否須行筋膜切開術
5.搭配高壓氧治療。
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Method of Skin Incision
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Method of Skin Incision
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什麼是高壓氧治療?什麼是高壓氧治療?
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組織在高於一大氣壓之環境下吸入 100 % 的氧氣。
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高壓氧治療對腔室症候群的治療原理
A. 利用高濃度之氧氣,使組織中的含氧量提高,因為實驗顯示,若組織中氧氣壓力小於 30mmHg ,則白血球之殺菌力會減弱,且纖維母細胞也不會再製造膠原蛋白,故而無法使血管新生及傷口癒合,所以提高組織中氧氣之濃度可以提高本身之免疫力及修護能力。
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高壓氧治療對腔室症候群的治療原理
B. 利用高氧濃度可使血管收縮而使水腫減退。因高氧濃度可以使血流減少 20% ,而血流減少 20% ,可以使水腫減少 20% 。
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高壓氧治療對腔室症候群的治療原理
C. 因水腫減少使微血管循環改善,而使氧氣之輸送更有效率。
使用高壓氧治療應該愈早愈好,最好在受傷後 4 至 6 小時內施行,如果手術已經延誤了,則應先給予高壓氧治療,然後再予以手術。
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高壓氧治療對腔室症候群的治療方法
前 48 小時 ---1.5 小時 /次 x 3 次 / 天第二個 48 小時 ---1.5 小時 /次 x 2 次 / 天第三個 48 小時 ---1.5 小時 /次 x 1 次 / 天一般來說到第六天時血液循環應該已恢復,水腫減退且復原之範圍也明顯了,此時即可停止高壓氧治療。
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結論
腔室症候群是個急性且嚴重的臨床問題 , 若處理的不好,可能會使肢體壞死,甚至導致截肢的命運。
早期的診斷及治療是很重要的,若適當的予以治療,則可拯救肢體受不必要的傷害,也可使傷害程度降到最低。
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