目的 观察天津港“8·12”特别重大火灾爆炸事故危重伤员距爆炸中心的距离与病情严重程度及预后的关系,分析本次事故的伤情特点以及伤员近期并发症和隐匿伤的发生特点,为创伤救治提供依据.方法 采用多中心回顾性研究方法,收集2015年8月12日23:35至12月12日23:35由天津市10家医院、12个重症医学科或专科监护室收治的天津港“8·12”特别重大火灾爆炸事故全部危重伤员共58例,根据伤员受伤时所处位置分为室外组(29例)和室内组(29例),每组再按照伤员受伤时距爆炸中心的距离分为近距离(≤200 m)、中远距离(200～1 000 m)和远距离(＞1000 m)3个亚组;比较各组伤员距爆炸中心不同距离与致伤因素、致伤部位、病情严重程度和预后的关系.同时根据受伤时间分为伤后1d内、2～3d、4～6d、7d后4个时间段进行观察,分析近期并发症和隐匿伤在不同时间段的分布特点.结果 (1)室外组近距离、中远距离和远距离伤员分别为14、13、2例,室内组分别为3、22、4例.①室内外两组伤员均以冲击波直接或间接致伤为主.室外组近距离和中远距离伤员受各致伤因素影响均较大,以冲击波直接致伤(14/14和12/13)、冲击物砸伤(12/14和4/13)和破片伤(12/14和12/13)最多;远距离伤员较少,仅出现冲击波直接致伤和冲击物砸伤各1例.室内组伤员以近距离和中远距离致伤因素影响较大,仍以冲击波直接致伤为主(2/3和14/22),火焰伤、破片伤及受冲击后摔伤的情况少于室外组,但被冲击物砸伤的情况较多;远距离伤员较少,但仍存在破片伤.②室内外两组伤员致伤部位主要分布于体表和头面部,其次为胸部、下肢、骨盆、臀部等,以近距离和中远距离伤员表现最为明显;而颈部、腹部及盆腔、脊柱、上肢等部位损伤较少.③室内外两组损伤严重度评分(ISS)、多器官功能障碍综合征(MODS)评分、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分均随伤员远离爆炸中心而逐渐降低,说明伤员距爆炸中心距离越近伤情越重;当处于相同距离时,室内组伤员的伤情较室外组伤员更重,室内中远距离和远距离组ISS评分明显高于室外相应距离组(分:中远距离为25.56±3.34比11.83±1.62,远距离为13.53±3.96比5.50±0.71,均P＜ 0.05),室内远距离组MODS评分明显高于室外远距离组(分:6.53±1.62比2.50±0.71,P＜0.01).除室内远距离组重症加强治疗病房(ICU)住院时间明显短于中远距离组外(d:5.23±2.03比8.23±4.96,P＜ 0.05),两组伤员距爆炸中心不同距离时机械通气和ICU住院时间均无明显差异.ICU伤员28 d死亡情况为室外近距离组2例,室内中远距离组2例.(2)近期并发症:①全身反应及MODS:以高应激反应、高代谢反应、毛细血管渗漏综合征(CLS)及呼吸、心血管、血液、胃肠等器官功能障碍较多见,伤后1d内发生率均达50％以上;随时间延长,所有并发症发生率均逐渐下降,直至7d后均降至10％以下.②感染:以皮肤软组织感染为主(25.9％),其次为肺部感染和呼吸道感染(分别为19.0％和15.5％),其他部位感染发生率从高到低依次为腹腔感染(6.9％)、颅内感染(3.4％)、眼部感染(1.7％);伤后1d内无感染发生,感染高峰发生在伤后2～3d,之后逐渐减少.在医院获得性感染中,仅伤后4～6d和7d后发生呼吸机相关性肺炎(VAP)各1例,发生率为1.4％,且无其他医院获得性感染发生.③其他并发症:以下肢及颅脑并发症最多(分别为22.4％和19.0％),胸部和面部并发症较少(分别为10.3％和1.7％),且集中出现在伤后1d内,随后逐渐减少.(3)隐匿伤:隐匿伤主要集中在面部(23例,39.7％),其次为下肢、骨盆、臀部15例(25.9％),上肢7例(12.1％),头部、胸部、腹部及盆腔较少,颈部、脊柱、体表等部位未发现隐匿伤;隐匿伤发生在伤后1d内较少,2～3d达高峰,随后逐渐减少.结论 在天津港“8·12”特别重大火灾爆炸事故危重伤员中,无论在室外还是室内,均表现出距爆炸中心越近损伤越重的趋势,以室外伤员表现更加典型;当处于同样的中远距离或远距离时,室外伤员伤情轻于室内伤员;ICU内伤员死亡原因主要集中在颅脑损伤.危重伤员中,并发症和隐匿伤在早期较少,伤后2～3d达峰值后逐渐减少,但至7d后仍有隐匿伤出现;主要以全身反应和MODS发生率较高,感染主要发生在皮肤软组织、肺部和呼吸道,其他并发症主要发生在颅脑和四肢;隐匿伤主要发生在面部和肢体,但致命性创伤较少.“,”Objective To observe the correlation between the distance from the center of explosion and severity as well as prognosis in critical patients in Tianjin port “8 · 12” special major explosion accident,and to investigate the characteristics of the injury,short-term complications and hidden trauma in the accident,so as to provided the basis for trauma care.Methods A multicenter retrospective study was conducted.Fifty-eight patients with critical wound admitted to 12 related intensive care units (ICUs) or specialist ICUs in 10 hospitals in Tianjin since 23∶35 on August 12th,2015 to 23∶35 on December 12th,2015 were enrolled.The patients were divided into two groups according to the location when they were injured:outdoor group (n =29) and indoor group (n =29),the patients in each group were subdivided into three subgroups according to the distance from the center of explosion:close distance (≤200 m),middle long distance (200-1 000 m) and long distance (＞1 000 m).The relationships between the different distance from the center of the explosion and injury factors,injury site,severity and prognosis were analyzed in the two groups.Meanwhile,the patients were divided into four groups according to the time:within 1 day,2-3 days,4-6 days,and 7 days after injury.The distribution characteristics of the short-term trauma complications and hidden trauma in different times were observed.Results (1) In outdoor group,14 patients were in close distance,13 in middle long distance,and 2 in long distance,and in indoor group,3,22 and 4 in each distance respectively.① The patients in outdoor group and indoor group were given priority to blast injury directly or indirectly.In outdoor close distance and middle long distance groups,all injury factors had great influence on the patients,especially blast injury directly (14/14 and 12/13),impact eject hurt (12/14 and 4/13),and blast-fragment injury (12/14 and 12/13).The patients in outdoor long distance group were less,only blast injury directly and impact eject hurt was found in 1 case,respectively.In indoor close distance and middle long distance groups,injury factors had more effect on the patients,mainly was blast injury directly (2/3 and 14/22),and the flame injury,fragment injury and blast bruise were less than outdoor group but with more impact eject hurt.There were less patients,and mainly blast-fragment injury in the indoor long distance group.② The injury parts in both outdoor group and indoor group mainly distributed in the body,head and face followed by chest,leg,pelvis,hip,etc.,especially in close distance and middle long distance group.There were less injury in neck,abdomen and pelvic cavity,spine,and upper limb.③ In both outdoor and indoor group,injury severity score (ISS),multiple organ dysfunction syndrome (MODS) score,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score were gradually decreased with the injured away from the explosion center,suggesting that the nearer distance from the center of the explosion,the heavier the injury was.In the same distance,the injury in indoor group was heavier than outdoor group.ISS in indoor middle long distance group and long distance group was significantly higher than outdoor corresponding distance groups (25.56-3.34 vs.11.83 ± 1.62 in middle long distance,P ＜ 0.05;13.53 ± 3.96 vs.5.50± 0.71 in long distance,P ＜ 0.01).MODS score in indoor long distance group was significantly higher than outdoor long distance group (6.53 ± 1.62 vs.2.50±0.71,P ＜ 0.01).The length of ICU stay in indoor long distance group was significantly shorter than middle long distance group (days:5.23 ± 2.03 vs.8.23 ± 4.96,P ＜ 0.05).No statistical differences in the duration of mechanical ventilation and length of ICU stay among different distances from the center of the explosion were found in the both groups,as well as between indoor group and outdoor group.The 28-day mortality of 58 cases patients were that 2 patients in outdoor close long distance group and 2 in indoor middle long distance group dead.(2) Short-term complications:① systemic reactions and MODS:high stress,high metabolic reactions and capillary leak syndrome (CLS),and organ failure of respiratory,cardiovascular,hematological,and gastro intestinal systems were frequent within 1 day after injury with the incidence of above 50％.With the prolongation of time,all complications were gradually decreased,until 7 days after injury,the incidence was decreased to less than 10％.② Infection:sorted by the sites,by skin and soft tissue infection primarily (25.9％),followed by pulmonary infection (19.0％) and respiratory tract infection (15.5％),the incidence of other part from high to low were abdominal cavity infection (6.9％),intracranial infection (3.4％),eye infection (1.7％).Sorted by the time,no infection was found within 1 day after injury,and infection peak occurred in 2-3 days after injury,then the infection was gradually reduced.In the respect of hospital-acquired infection,only ventilation-associated pneumonia (VAP) was found in 2 patients,respectively occurred in 4-6 days and 7 days after injury,and with the incidence of 1.4％,and no other hospital acquired infection appeared.③ Other complications:other complications ranks as lower limbs (22.4％) and cerebral (19.0％),chest (10.3％) and facial (1.7％) were relatively few,and all appeared mainly within 1 day after injury,then gradually reduced.(3) Hidden traumas:in 58 patients,hidden traumas were given priority to facial (23 cases,39.7％) followed by lower limbs,pelvic and hip (15 cases,25.9％) and upper limb trauma (7 cases,12.1％);head,chest,and abdominal were fewer.No hidden trauma was found in neck,spine,and body surface.Within 1 day after injury,hidden trauma were less,peaked in 2-3 days after injury,and reduced later gradually.Conclusions No matter outdoor or indoor groups of critically wounded patients in Tianjin port “8 · 12” special major explosion accident,the closer from the center of explosion injury,the heavier the injury was,particularly in outdoor group.In middle long distance or long distance,the injury severity in the indoor wounded patients group was more serious than outdoor group.In ICU wounded patients,the causes of death were mainly concentrated in craniocerebral injury.In the wounded patients in the accident,the early incidence of short-term complications and hidden trauma was less,peak in 2-3 days after injury,reduced later gradually,but hidden trauma can happen 7 days after injury.The incidence rate of systemic reactions and MODS were high,infection-related complication mainly occurs in skin and soft tissue,pulmonary and respiratory tract,and other complications mainly occurred in cerebral and lower limbs.The hidden trauma mainly occurred in face and limbs,but lethal trauma was less.