外科感染专业知识培训ppt课件

外科感染外科感染专业知知识外科感染专业知识110 x20 x20 xGeneral surgery department of SEUsurgical infection第一节第一节 概论概论外科感染是指需要外科治疗的感染，包括创伤、手术、烧伤等并发症的感染。这类感染临床多见，需注意防治。2外科感染专业知识10 x20 x20 xGeneral surgery depar210 x20 x20 xGeneral surgery department of SEUsurgical infection分类（一）按病菌种类分：（二）按病情进展分：（三）按发生条件分：3外科感染专业知识10 x20 x20 xGeneral surgery depar310 x20 x20 xGeneral surgery department of SEUsurgical infection按病菌种类分、非特异性感染（化脓性或一般性感染）常见致病菌：金葡菌、溶血性链球菌、大肠杆菌、拟杆菌、变形杆菌、绿脓杆菌等。可单一或共同致病。、特异性感染 指分类一般性感染以外的细菌或真菌等：结核杆菌、破伤风、产气荚膜梭菌、白念珠菌、新型隐球菌等4外科感染专业知识10 x20 x20 xGeneral surgery depar410 x20 x20 xGeneral surgery department of SEUsurgical infection按病情进展1、急性感染：病变进展快，一般3周内。非特异性感染分类多属此类2、慢性感染：病变持续2个月以上。如结核3、亚急性感染：介于急性与慢性之间，由急性感染迁延而来，亦可由于病毒毒力弱但耐药或抵抗力差所致5外科感染专业知识10 x20 x20 xGeneral surgery depar510 x20 x20 xGeneral surgery department of SEUsurgical infection病因（一）病菌的致病因素1、粘附因子、荚膜2、病菌的数量与增殖速率3、胞外酶、外毒素、内毒素（二）宿主的抗感染免疫1、天然免疫：宿主屏障 吞噬细胞与NK 补体 细胞因子2、获得性免疫：T细胞 B细胞 免疫记忆6外科感染专业知识10 x20 x20 xGeneral surgery depar610 x20 x20 xGeneral surgery department of SEUsurgical infection（三）人体受感染的原因1、局部情况：皮肤粘膜缺损管腔阻塞血循障碍先有其它病变2、全身抗感染力降低：消耗性疾病、激素、放化疗、营养不良、低蛋白血症、AIDS3、条件性感染：机会性感染、二重感染等7外科感染专业知识10 x20 x20 xGeneral surgery depar710 x20 x20 xGeneral surgery department of SEUsurgical infection病理（一）非特异性感染 酶及毒素作用，炎性细胞及补体等的参与病变的演变：1、炎症好转2、局部化脓3、炎症扩展4、转为慢性炎症8外科感染专业知识10 x20 x20 xGeneral surgery depar810 x20 x20 xGeneral surgery department of SEUsurgical infection病理（二）特异性感染1、结核：形成独特的浸润、结节、肉芽肿、干酪样坏死、冷脓肿2、破伤风、气性坏疽：起病急，前者致肌痉挛，局部炎症少；后者组织水肿产气，病变重 3、真菌感染：形成肉芽肿、出现溃疡、脓肿、空洞9外科感染专业知识10 x20 x20 xGeneral surgery depar910 x20 x20 xGeneral surgery department of SEUsurgical infection临床表现1、局部症状 红、肿、热、痛和功能障碍2、器官-系统功能障碍 泌尿系；肝脓肿等3、全身状态 发热、心跳加快、头痛、食欲减退等4、特殊表现 破伤风、气性坏疽等10外科感染专业知识10 x20 x20 xGeneral surgery depar1010 x20 x20 xGeneral surgery department of SEUsurgical infection(一)临床检查 1、全身状态：生命体征、营养、休克 2、局部表现：红、肿、热、痛 3、相应系统障碍：4、特异表现：破伤风肌痉挛；气性坏疽捻发音 5、相关病史(二)辅助检查：实验室检查、影像检查诊断11外科感染专业知识10 x20 x20 xGeneral surgery depar1110 x20 x20 xGeneral surgery department of SEUsurgical infection预防(一)防止病原微生物侵入(二)增强机体的抗感染能力(三)切断病原菌传播环节12外科感染专业知识10 x20 x20 xGeneral surgery depar1210 x20 x20 xGeneral surgery department of SEUsurgical infection治疗(一)局部处理 1、保护局部，避免扩散。2、浅部：湿敷、理疗、引流。3、深部：手术切除(二)抗炎：根据菌种选择(三)改善全身状况13外科感染专业知识10 x20 x20 xGeneral surgery depar1310 x20 x20 xGeneral surgery department of SEUsurgical infection第二节第二节浅部组织的化脓性感染浅部组织的化脓性感染14外科感染专业知识10 x20 x20 xGeneral surgery depar1410 x20 x20 xGeneral surgery department of SEUsurgical infection疖单个毛囊及周围组织的急性化脓性感染，金萄菌多见临床表现：发于皮肤，红肿热痛表现，其中心可有脓头，破后可愈。亦有无头疖，破溃较迟，需设法促使脓液排出15外科感染专业知识10 x20 x20 xGeneral surgery depar1510 x20 x20 xGeneral surgery department of SEUsurgical infection疖胸前壁疖16外科感染专业知识10 x20 x20 xGeneral surgery depar1610 x20 x20 xGeneral surgery department of SEUsurgical infection下腰及臀部多个散在疖肿，中央有白色脓头17外科感染专业知识10 x20 x20 xGeneral surgery depar1710 x20 x20 xGeneral surgery department of SEUsurgical infection诊断：表现明显，诊断较易鉴别诊断：1.痤疮合并感染：顶端有凝脂。2.粉瘤合并感染：病变较久，表皮正常。3.痈：病变范围大防治：1.初期：理疗外敷。2.成脓后：剔出脓栓，出脓后敷利凡诺等。3.应用抗生素。18外科感染专业知识10 x20 x20 xGeneral surgery depar1810 x20 x20 xGeneral surgery department of SEUsurgical infection痈指邻近多个毛囊及周围组织的急性化脓性感染，以金萄菌多见临床表现：中老年多见。初起为红肿，可见数个脓点，继之红肿扩大，脓点增大增多，中心处坏死。项背部多见诊断：诊断较容易19外科感染专业知识10 x20 x20 xGeneral surgery depar1910 x20 x20 xGeneral surgery department of SEUsurgical infection20外科感染专业知识10 x20 x20 xGeneral surgery depar2010 x20 x20 xGeneral surgery department of SEUsurgical infection预防：与疖同治疗：1.及时应用抗生素，防止脓毒症 2.局部处理：A.初期可外敷(鱼石脂、金黄散)；B.成脓后“十”字切开21外科感染专业知识10 x20 x20 xGeneral surgery depar2110 x20 x20 xGeneral surgery department of SEUsurgical infection指疏松结缔组织的急性感染，发于人体各部，乙型溶血性链球菌、金萄菌多见临床表现：1.一般性皮下蜂窝织炎 2.产气性皮下蜂窝织炎 3.新生儿皮下坏疽 4.颌下急性蜂窝织炎皮下急性蜂窝织炎22外科感染专业知识10 x20 x20 xGeneral surgery depar2210 x20 x20 xGeneral surgery department of SEUsurgical infection23外科感染专业知识10 x20 x20 xGeneral surgery depar2310 x20 x20 xGeneral surgery department of SEUsurgical infection一般性皮下蜂窝织炎 先有病损或感染，发病时伴恶寒发热，局部肿痛，边缘不清，淋巴结肿大新生儿皮下坏疽 背臀部多见，患儿发热、不进乳或昏睡，皮肤发红、质地变硬并扩大，中央变软起水泡，严重时皮肤坏死破溃24外科感染专业知识10 x20 x20 xGeneral surgery depar2410 x20 x20 xGeneral surgery department of SEUsurgical infection老年人皮下坏疽 背部或侧卧着床处红肿痛，伴发热，全身不适，继之变暗波动感，穿刺有脓颌下急性蜂窝织炎 源于口腔或面部，口腔者易阻塞通气，颌下、口底肿胀；面部者红肿热痛，全身反应重25外科感染专业知识10 x20 x20 xGeneral surgery depar2510 x20 x20 xGeneral surgery department of SEUsurgical infection26外科感染专业知识10 x20 x20 xGeneral surgery depar2610 x20 x20 xGeneral surgery department of SEUsurgical infection产气性皮下蜂窝织炎 病菌为厌氧菌，炎症仅在皮下层，初期同一般性皮下蜂窝织炎，但进展快，且有捻发音27外科感染专业知识10 x20 x20 xGeneral surgery depar2710 x20 x20 xGeneral surgery department of SEUsurgical infection诊断 根据病史及化验易于诊断鉴别诊断1.硬皮病：皮肤不红，体温不热2.小儿急性咽炎：颌下肿胀较轻，咽部发红明显3.气性坏疽：伤及肌肉，运动障碍，细菌培养确诊防治：注意卫生，选择有效药物，局部切开引流。对证支持治疗。28外科感染专业知识10 x20 x20 xGeneral surgery depar2810 x20 x20 xGeneral surgery department of SEUsurgical infection丹毒皮内淋巴管网受乙型溶血性链球菌侵袭所致。常先有皮损如癣、溃疡临床表现：恶寒发热、全身不适；多见下肢、面部；皮肤发红、灼热、痛、微隆、界清；邻近淋巴可大，反复发作可致“象皮肿”治疗：应用抗菌药物29外科感染专业知识10 x20 x20 xGeneral surgery depar2910 x20 x20 xGeneral surgery department of SEUsurgical infection30外科感染专业知识10 x20 x20 xGeneral surgery depar3010 x20 x20 xGeneral surgery department of SEUsurgical infection丹毒 丝虫病 淋巴管阻塞淋巴淤滞象皮肿31外科感染专业知识10 x20 x20 xGeneral surgery depar3110 x20 x20 xGeneral surgery department of SEUsurgical infection链球菌、金萄菌侵入淋巴流，发于各部位临床表现：急性淋巴结炎：淋巴结肿大、疼痛、触痛形成肿块、疼痛加重、皮肤红热脓肿形成 急性淋巴管炎：淺层红丝疔；深层条形触痛区诊治：诊断不难，但需同时诊治原发病淺部急性淋巴结炎和淋巴管炎32外科感染专业知识10 x20 x20 xGeneral surgery depar3210 x20 x20 xGeneral surgery department of SEUsurgical infection第三节第三节 手部急性化脓性感染手部急性化脓性感染33外科感染专业知识10 x20 x20 xGeneral surgery depar3310 x20 x20 xGeneral surgery department of SEUsurgical infection甲沟炎和指头炎临床表现 甲沟炎：一侧甲沟皮下，红肿痛波动感扩至另侧，疼痛加剧指头炎 指头炎：手指末节，轻度肿红剌痛跳痛，伴全身症状疼痛减轻，皮色变白破溃，可伴骨髓炎 34外科感染专业知识10 x20 x20 xGeneral surgery depar3410 x20 x20 xGeneral surgery department of SEUsurgical infection治疗 35外科感染专业知识10 x20 x20 xGeneral surgery depar3510 x20 x20 xGeneral surgery department of SEUsurgical infection急性化脓性腱鞘炎、化脓性滑囊炎、掌深间隙感染（自学内容）36外科感染专业知识10 x20 x20 xGeneral surgery depar3610 x20 x20 xGeneral surgery department of SEUsurgical infection临床表现一、化脓性腱鞘炎：疼痛，肿胀以中、近节为主，关节轻屈二、化脓性滑囊炎：桡侧拇肿胀不能伸，中节及大鱼际触痛；尺侧小指肿、环指半屈，小鱼际触痛三、掌深间隙感染：虎口肿、痛，示拇微屈，伸则痛，掌心变平37外科感染专业知识10 x20 x20 xGeneral surgery depar3710 x20 x20 xGeneral surgery department of SEUsurgical infection治疗一、化脓性腱鞘炎：二、化脓性滑囊炎：38外科感染专业知识10 x20 x20 xGeneral surgery depar3810 x20 x20 xGeneral surgery department of SEUsurgical infection治疗三、化脓性深间隙感染：39外科感染专业知识10 x20 x20 xGeneral surgery depar3910 x20 x20 xGeneral surgery department of SEUsurgical infection第四节第四节全身性外科感染全身性外科感染40外科感染专业知识10 x20 x20 xGeneral surgery depar4010 x20 x20 xGeneral surgery department of SEUsurgical infection脓毒症 有全身性炎症反应表现，体温呼吸等明显改变菌血症 是脓毒症的一种，血中检出病原菌，但不指一过性的如拨牙病因 致病菌多、毒力强、抵抗力低41外科感染专业知识10 x20 x20 xGeneral surgery depar4110 x20 x20 xGeneral surgery department of SEUsurgical infection常见致病菌1、革兰氏阴性菌 大肠杆菌、绿脓杆菌、变形杆菌、克雷伯菌、肠杆菌等。多见于腹腔、肠道、泌尿系2、革兰氏阳性菌 金萄菌、表萄菌、肠球菌3、无芽胞厌氧菌 多见于腹腔脓肿、阑尾脓肿、肛旁脓肿、吸入性肺炎等，多同时有需氧菌感染4、真菌 白念珠菌、曲霉菌，条件感染42外科感染专业知识10 x20 x20 xGeneral surgery depar4210 x20 x20 xGeneral surgery department of SEUsurgical infection1.革兰氏阳性菌：多见于痈、蜂窝织炎。可有或无寒战，稽留热/弛张热，面红肢暖，谵妄/昏迷，可出现转移性脓肿2.革兰氏阴性菌：多见于胆道、尿路、肠道、烧伤。突起寒战，间歇热，严重可体温不升，四肢冷、发绀、少尿，白细胞可减少，休克出现早，时间长。3.真菌：多为二重感染。突起寒热(39.540)，迅速恶化、休克，血中出现晚幼粒、中幼粒43外科感染专业知识10 x20 x20 xGeneral surgery depar4310 x20 x20 xGeneral surgery department of SEUsurgical infection临床表现主要表现：寒战高热或低温；头昏头痛呕吐甚至谵妄；心率快、脉细、呼吸急；肝脾大实验室检查：白细胞高、左移、幼稚型；酸中毒、溶血；培养有细菌44外科感染专业知识10 x20 x20 xGeneral surgery depar4410 x20 x20 xGeneral surgery department of SEUsurgical infection诊断与治疗诊断：原发感染灶临床表现，结合实验室检查（细菌培养）治疗：1.原发感染灶处理 清除坏死物，消灭死腔，脓肿引流2.抗菌药 早期联用足量，根据结果调整3.支持治疗 补充血容量，纠正低蛋白4.对症处理45外科感染专业知识10 x20 x20 xGeneral surgery depar45外科感染专业知识培训ppt课件4610 x20 x20 xGeneral surgery department of SEUsurgical infection破伤风病因病理 破伤风梭菌 缺氧环境 芽孢增殖体外毒素-痉挛毒素临床表现 潜伏6-12日 肌紧张性收缩，阵发性痉挛：张口困难“苦笑”面容“角弓反张”面唇青紫、通气困难。可因声光触、饮水诱发，间隙不等，神志清楚47外科感染专业知识10 x20 x20 xGeneral surgery depar4710 x20 x20 xGeneral surgery department of SEUsurgical infection48外科感染专业知识10 x20 x20 xGeneral surgery depar4810 x20 x20 xGeneral surgery department of SEUsurgical infection诊断 根据临床表现诊断鉴别诊断1.化脓性脑膜炎：有“角弓反张”无阵挛，有剧烈头痛、高热、喷射性呕吐、神志可不清，脑脊液、血像异常2.狂犬病：动物咬伤史，吞咽肌抽搐为主49外科感染专业知识10 x20 x20 xGeneral surgery depar4910 x20 x20 xGeneral surgery department of SEUsurgical infection预防：早期清创人工免疫自动免疫：类毒素 第一次：0.5ml 第二次：0.5ml 4-8周 第三次：0.5ml 0.5-1年 加强：0.5ml 每5年 伤后：0.5ml被动免疫：抗毒素1500-300050外科感染专业知识10 x20 x20 xGeneral surgery depar5010 x20 x20 xGeneral surgery department of SEUsurgical infection治疗1.处理伤口2.抗毒素：早期中和游离毒素3.避免声、光剌激：镇静解痉药物4.防治并发症：窒息、肺部感染，骨折、舌咬伤，必要时气管切开、辅助呼吸5.支持治疗：高热、高蛋白、高维生素药物，水电平衡51外科感染专业知识10 x20 x20 xGeneral surgery depar5110 x20 x20 xGeneral surgery department of SEUsurgical infection气性坏疽（自学内容）病因：梭状芽孢杆菌（产气荚膜梭菌、水肿杆菌、腐败杆菌、溶组织杆菌）致肌坏死、肌炎，进展快，预后重，常混合感染病理生理：产生外毒素、酶产气、水肿筋膜下压力增加压迫微血管组织缺血缺氧坏死52外科感染专业知识10 x20 x20 xGeneral surgery depar5210 x20 x20 xGeneral surgery department of SEUsurgical infection临床表现：伤后1-4天，病情突然恶化、烦燥、皮肤口唇变白、脉速、体温上升 自诉伤肢沉重，持续加重，裂痛，并向上下扩展，大量渗出，伤口有气泡、恶臭、捻发音，皮肤呈大理石花纹。X线示软组织间积气53外科感染专业知识10 x20 x20 xGeneral surgery depar5310 x20 x20 xGeneral surgery department of SEUsurgical infection诊断与鉴别诊断要求早期诊断，依靠局部体征、涂片检查、X线鉴别诊断：1.其它手术误伤致组织间积气：无全身中毒症状2.部份产气菌感染：不易在组织间积聚，无臭3.链球菌蜂窝织炎：病情发展慢，全身症状轻54外科感染专业知识10 x20 x20 xGeneral surgery depar5410 x20 x20 xGeneral surgery department of SEUsurgical infection预防 尽早彻底清创、深部伤口敞开引流、筋膜下压力大者切开治疗1.急症清创：广泛多处切开、必要时截肢2.应用抗生素：大剂量青霉素，大环内酯类、硝咪唑类3.高压氧4.支持疗法：输血，水电平衡55外科感染专业知识10 x20 x20 xGeneral surgery depar5510 x20 x20 xGeneral surgery department of SEUsurgical infection第六节外科应用抗菌药原则56外科感染专业知识10 x20 x20 xGeneral surgery depar5610 x20 x20 xGeneral surgery department of SEUsurgical infection适应证较重感染如蜂窝织炎、丹毒、手部感染、骨髓炎等就使用，一般性感染不用特异性感染选用有效抗菌药严重污染损伤、开放性损伤、高危手术可预防性用药(术前1小时滴入，手术时间长可术中加用一次)57外科感染专业知识10 x20 x20 xGeneral surgery depar5710 x20 x20 xGeneral surgery department of SEUsurgical infection药物选择与使用分泌物的细菌培养+药敏结合感染部位、局部体征、病情选择根据药物的组织分布能力选择婴幼儿、老年人酌情加减剂量58外科感染专业知识10 x20 x20 xGeneral surgery depar5810 x20 x20 xGeneral surgery department of SEUsurgical infection思考题1.疖和痈的临床表现有什么不同？痈就如何局部处理？2.化脓性腱鞘炎、化脓性滑囊炎、化脓性深间隙感染的切口设计是什么？3.破伤风应与哪些病鉴别？4.气性坏疽的治疗原则是什么？59外科感染专业知识10 x20 x20 xGeneral surgery depar5910 x20 x20 xGeneral surgery department of SEUsurgical infection 目的和要求：目的和要求：1熟悉外科感染的发生、发展和防治原则。2学会诊断疖、痈、蜂窝组织炎、丹毒、急性淋巴结炎、脓肿、甲沟炎和化脓性指头炎、以及治疗方法。3熟悉全身性外科感染的诊断和治疗原则。4了解破伤风的临床表现、预防和治疗。5熟悉外科抗菌药物的应用。60外科感染专业知识10 x20 x20 xGeneral surgery depar60