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提　要:目的　观察兔股动脉火器伤合并海水浸泡的病理形态学特点。方法　将大白兔30只随机均分为单一致伤 组、海水浸泡30 min组和海水浸泡60 min组,用钢珠弹致伤兔单侧股动脉后,将海水浸泡组动物置于海水中浸泡30 min或 60 min,单一致伤组动物不浸泡,于伤后2、4、6、8、12 h取弹着点中心两端股动脉,做光镜、电镜观察。结果　动脉损伤类型 主要为完全断裂伤和挫伤。完全断裂伤的动脉分为原发伤道区、挫伤区和震荡区。与单一致伤组相比,海水浸泡组的原 发伤道区和挫伤区的血管壁显著肿胀,以中膜外2/3为甚,肌浆内空泡样结构常见,内皮细胞之间纵行皱褶紊乱、变平。浸 泡30 min组与60 min组之间病变程度无明显差异。3组中动脉挫伤和完全断裂伤的震荡区的病理表现类似。结论　兔股 动脉完全断裂伤合并海水浸泡时,其原发伤道区和挫伤区的细胞、细胞间隙显著肿胀。 　　

关键词:火器伤;海水;浸泡;血管;病理学

Abstract:Objective　To investigate the pathological characteristics of a compound trauma, which refers to seawater immersion followinggunshotwound of femoral artery.Methods　Atotal of 30 rabbitswere divided randomly into 3 groups: single-wounded group (SWG,n=10), seawater immersion for 30 mins group(SIG-Ⅰ,n=10) and seawater immersion for 60 mins group(SIG-Ⅱ,n=10). Femoral arteries were impacted by 0.38 g steel balls fired from 7.62 mm rifle. After beingwounded, rabbits in SIG-Ⅰ,Ⅱwere immersed in seawater(saline 25.4, pH8.2 ~8.4, temperature 21℃) for 30 or 60 mins. At 2 h, 4 h, 6 h, 8 h and 12 h following injury, segments of arteries measuring 40 mm on each side of the hit spotwere extracted(every 10 mmas a unit) forthe examination by light(H. E. and Verhoff’s stain) and electron (TEM, SEM) microscopy.Results　Types of arterial injury were contusion, complete and incomplete transection. Completely transected arterywas divided as primary-wound-tract area, contused area and shocked area. Compared tothose ofSWG, primary-wound-track and contused area of arteryofSIGmanifest- ed obvious swelling of arterial wall, especially at 2/3 outside of media. Balloon structures were often detected in smooth muscle cells ofmedia, and intercellular space among smoothmuscle cellswere fulfilled by homogeneous, aci- diphilic substance. Deep rugae among endothelial cells became flattened orrugal folds losttheirstrict longitudinal ori- entation, and marked fibrin and platelet depositionwere noticed. No significant differencewas detected between SIG- Ⅰand SIG-Ⅱ. Pathological changes of contused artery were similar in 3 groups.Conclusion　The pathological characteristics of seawater immersion followinggunshotwounds of rabbit femoral arteries are obviously cellular and in- tercellular edema of arterial wall in primary-wound-track and contused area of completely transected artery. 　　

Key words: wound; gunshot; seawater; immersion; blood vessel; pathology

四肢大动脉火器伤在历次战争中的发生率为 0·07%~2·4%[1]。海上及登陆作战中四肢大动脉火 器伤的发生率与陆战类似[2]。由于特殊的作战环境, 伤口常合并不同程度的海水浸泡[3]。大动脉火器伤合 并海水浸泡的病理学变化,目前尚未见报道。本实验以兔股动脉火器伤合并海水浸泡为实验模型,研究四 肢大动脉火器伤合并海水浸泡的病理形态学特点,为 该伤情的外科修复可行性研究提供实验依据。

1　材料与方法

1·1　实验动物与分组 　　

健康成年新西兰大白兔30只,雌雄不拘,体重(3·29± 0·94) kg,随机分为单一致伤组(Single-wounded group, SWG,n= 10)、海水浸泡30 min组(Seawater-immersion group-Ⅰ, SIG-Ⅰ,n =10)和海水浸泡60 min组(Seawater-immersion group-Ⅱ, SIG- Ⅱ,n=10)。

1·2　动物模型 　　

将麻醉状态下的兔固定在实验架上。用7·62 mm滑膛枪 发射质量380 mg的钢珠,射击兔单侧股动脉中点,射距3·5 m。 伤后立即局部加压包扎。将海水浸泡组兔双后肢及胸腹部浸 入人工海水(盐度25·3, pH 8·4,水温21℃)中,SIG-Ⅰ组浸泡 30 min,SIG-II组浸泡60 min,SWG不浸泡。浸泡组出水后擦干 水迹,更换敷料,复温。

1·3　取材 　　

于火器伤后2、4、6、8、12 h在手术显微镜下(×10倍)探查 股动脉伤情,以断端或损伤最重点为中心,取远、近端各40 mm 股动脉,每10 mm为单位,置于4%多聚甲醛或3%戊二醛中, 4℃下固定24 h。

1·4　光镜标本的制作 　　

酒精逐级脱水、浸蜡、石蜡包埋、连续切片,HE及Verhoff染 色。

1·5　电镜标本的制作

1·5·1　透射电镜　　标本经丙酮系列脱水后经环氧树脂包 埋,切片,超薄切片经醋酸铅染色后在JEOL JEM-100SX透射电 子显微镜下观察。

1·5·2　扫描电镜　　标本经酒精系列脱水及液态CO2培养点 干燥,喷铂后在JEOL JSE-T300扫描电子显微镜下观察。

2　结果

2·1　大体观察 　　动脉损伤类型在各实验组中分布见表1。3组的损伤表现 及范围类似。

完全断裂伤:断端参差不齐,质软,损伤重者触之如泥,范 围达2~5 mm,外膜出血达6~15 mm,取材时断端多已有血栓 形成。不完全断裂伤:仅1例,断裂超过周径1/3,破口边缘收 缩,出血不止,无血栓形成,纵行剖开见距断端约1·5 mm范围 内内膜粗糙。挫伤:距弹着点最近处动脉外膜出血,范围达5~ 12 mm,损伤处未见明显内膜粗糙,偶见内皮与内皮下层分离, 损伤严重者动脉呈梭形或动脉瘤样改变,多于伤后2 h内形成 血栓阻塞全部或部分管腔。值得注意的是海水浸泡组弹道周 围软组织显著水肿。