腹部创伤 黄 粱课件

,黄梁 瑞金医院急诊创伤外科 2013年8月,院前评分和分拣,（一） 创伤指数（TI）,59分为轻伤；1016分为中度伤；17分为重伤。现场急救人员可将TI10分的伤员送往创伤中心或大医院,创伤评分,1昏迷评分,2呼吸频率,3呼吸困难,5.毛细血管充盈,4收缩血压,上述5项相加为创伤评分，低于12分者生存率很低,GSC评分 1415为5分 1113为4分 810为3分 57为2分 34为1分,2024为4分 2535为3分 35为2分 10为1分 无为0分,无为1分 有为0分,90mmHg为4分 7089mmHg为3分 5069mmHg为2分 049mmHg为1分 无脉搏为0分,正常为2分 延迟2秒以上为1分 无为0分,确认现场环境安全，IV、O2、Monitor 创伤诊治的“ABCDE” A：气道 Airway（注意颈椎保护） B：呼吸 Breathing C：循环 Circulation D：功能障碍 Disability（注意判定神经系统状况及意识状况） E：暴露及环境 Expose & Environment （使患者完全暴露做彻底检查，但要设法防止低体温的发生）,初次评估与处置初级评估：ABCDE,5,Objectives目的,Identify key anatomic features of the abdomen. 明确腹部主要解剖特征 Describe blunt and penetrating injury patterns. 描述腹部钝性和穿透性损伤 Describe the evaluation of the patient with suspected abdominal injury. 关注疑似腹部损伤患者的病情发展, ACS,6,Objectives,Identify and apply the most appropriate diagnostic and therapeutic procedures. 辨明并提出最可能的诊断和诊疗手段 Discuss acute management of pelvic fracture 探讨急性骨盆骨折的治疗措施, ACS,7,External Anatomy腹部外部解剖区域, ACS,8,腹腔内部的区域划分, ACS,9,Internal Abdominal Regions 腹腔内部的区域,上腹腔,下腹腔,Pelvic cavity盆腔 Intraperitoneal 腹膜间 Retroperitoneal 腹膜后的, ACS,10,Abdominal Trauma 腹部外伤,What is one of the leading causes of preventable mortality? 导致（实际上）可避免的死亡的主要因素？, ACS,11,Mechanism of Injury 损伤的途径, ACS,Why is it important to know? 了解它是非常重要的：,12, ACS,Compression 挤压 Crushing 撞击 Shearing 剪切 Deceleration (fixed organs) 突然减速（对于固定器官）,Blunt Force Mechanism 钝性伤害的发生,How does it injure? 如何造成钝性损害,13,Blunt Force Mechanism 钝性伤害的发生, ACS,Spleen 脾脏 Liver 肝脏 Small bowel 小肠,What organs are commonly injured? 最常见的钝性伤的脏器,14, ACS,Stab 刺入,Low energy 低能量 Lacerations 割裂,Gunshot 枪击伤,Transfer of kinetic energy运动能的传递 Cavitation 缺损形成 Tumble 塌陷 Fragments 碎裂,Penetrating Mechanism 穿透伤的发生,How does it injure? 如何造成穿透伤,High energy 高能量,15,Penetrating Mechanism 穿透伤的发生, ACS,Liver 肝脏 Small bowel 小肠 Diaphragm 横膈 Colon 结肠,Low Energy低能量,High Energy 高能量,Small bowel 小肠 Colon 结肠 Liver 肝脏 Vascular structures 血管,Common injuries? 常见的穿透损伤,16,Abdominal Trauma Diagnostic & Treatment Priorities 腹部损伤的诊断和治疗,1. recognize presence of shock or intraabdominal bleeding 明确存在的休克或腹腔内出血 2. start resuscitative measures for shock / bleeding 实施早期休克复苏的措施 3. determine if abdomen is source for shock or bleeding 确定腹部损伤是否为休克或出血的主要原因 4. determine if emergency laparotomy is needed 确定是否需要急诊剖腹探查 5. complete secondary survey, lab and radiographic studies to determine if “occult” abdominal injury is present 继续完善各项相关检查，如实验室，影像学等，以排除隐匿性腹部损伤的存在。 6. conduct frequent reassessments 进行反复评估,17,Abdominal Trauma Decision Scheme for Emergent Laparotomy 腹部损伤急诊剖腹探查的决定策略,Emergent laparotomy indicated for 指征: Hypotension / shock with 低血压合并: Penetrating injury & external bleeding 穿透伤和外出血 Positive peritoneal lavage 腹腔冲洗阳性 Secondary deterioration 病情再次恶化 Rapid abdominal distention 腹部急性扩张,18,Penetrating Abdominal Trauma Decision Scheme for Urgent Laparotomy 腹部损伤急诊剖腹探查的决定策略,Urgent laparotomy indicated for 指征: Gunshot wound 枪击伤 Deeply impaled foreign object 异物深度刺入 Evisceration 腹腔脏器脱出 Signs of peritoneal irritation (peritonitis) 腹膜刺 激征（腹膜炎）,19,Abdominal Trauma Physical Exam 腹部损伤腹部体检,Mainly is part of secondary survey 主要用于第2次检视患者 Inspection (logroll) 视诊 Auscultation 听诊 Percussion 叩诊 Palpation 触诊,20,Abdominal Trauma Physical Exam (cont.) 腹部损伤腹部体检,Exam of genitalia 生殖系统检查 Inspection 视诊 Blood at urethral meatus 尿道口出血 Perineal or scrotal hematomas 会阴或阴囊血肿 Palpation 触诊,21,Abdominal Trauma Physical Exam (cont.) 腹部损伤腹部体检,Rectal exam 直肠检查 - Sphincter muscle tone 括约肌紧张度 - Tenderness / mass 质地柔软/肿块 - Prostate position ( if “high-riding“ implies urethral disruption) 前列腺位置 （“高悬”意味着尿道撕裂） Should be done before placing foley catheter 直肠检查应先于置导尿管前完成,22, ACS,Adjuncts: X-ray Studies 附录 X线检查,Routine 常规,Blunt: AP chest and pelvis 钝性伤：胸部盆腔前后位 Penetrating: AP chest and abdomen with markers (if hemodynamically normal) 穿透伤：胸腹盆腔并予造影剂检查（血液动力学稳定的前提下）前后位 Lumbal spine AP and lateral 腰椎脊柱：前后位和侧位,23,No mandatory blood tests 血液检查不是强制性检查 Injury severity and likely injuries 严重的损伤和可疑的损伤 Hemodynamically abnormal: Type & crossmatch 血液动力学异常 ：血型和交叉配血 Pregnancy testing 妊娠检查 Alcohol or other drug testing 酒精和药物检查 Gross hematuria vs microscopic 肉眼和镜下血尿,Adjuncts: Blood / Urine Tests 附录：血液和尿液检查,24, ACS,Adjuncts: Contrast Studies 附录：造影剂检查,Urethrogram 尿路造影 Cystogram 膀胱造影 IVP 静脉肾盂造影 GI 食道-胃肠道造影检查,Abdominal CT 腹部CT,25,Abdominal Trauma Indications for Diagnostic Peritoneal Lavage (DPL) 腹部外伤行腹腔诊断性穿刺的指征,Should generally be done as part of secondary survey (NG and foley should be placed first) 作为2次检视的常规操作（胃管和导尿管首先应该放置） - Blunt trauma 钝伤 Unstable patient ; possible intrabdominal bleeding 不稳定的患者 ：腹腔内出血可能 Suspected diaphragm rupture 可疑的横膈破裂 Stable patient with unreliable physical exam 稳定的患者但其体检不可靠,- Penetrating trauma 穿透伤 Stable patient 稳定的患者 Stab wound of abd. & no peritoneal signs 无腹膜征的刺入伤 Stab or gunshot wound of chest below nipple 乳头平面下的刺入上或枪击伤 Flank or back stab wound 协肋部或背部的刺入伤,Abdominal Trauma Indications for Diagnostic Peritoneal Lavage (DPL) 腹部外伤行腹腔诊断性穿刺的指征,27,Abdominal Trauma腹部创伤 Contraindications to DPL诊断性腹腔灌洗的禁忌症,- Need for laparotomy already known需剖腹手术的 Gunshot wound枪伤 Evisceration脏器外露 Peritoneal signs腹膜炎体征 Free air腹腔游离气体 - Prior laparotomy scar先前有剖腹手术疤痕 Open technique may still be possible开放的安全法仍可行 - Advanced pregnancy 妊娠晚期 Supraumbilical approach may still be possible脐带入路仍可行,28,Abdominal Trauma Prerequisites to Perform DPL实施诊断性腹腔灌洗的前提,- NG tube placed and is on suction鼻胃管胃肠减压 - Foley placed留置导尿 - Abdominal exam completed 腹部检查已毕 - Abdominal films to rule out free air done腹部已摄片排除游离气体,29,Abdominal Trauma Positive Peritoneal Lavage Criteria 阳性腹腔灌洗标准,Any of these indicate need for laparotomy :下列任何一项均需剖腹手术 RBC count红细胞计数 100,000 / mm3 (blunt钝器伤) RBC count 10,000 / mm3 (chest penetrating wounds胸部穿透伤) WBC count 白细胞计数 500 / mm3 Stool or food fibers or bile 粪便、食物纤维或胆汁 Lavage fluid exits via chest tube, NG tube, or foley灌洗液通过胸腔引流管、胃管、或导尿管排出 Elevated amylase in lavage fluid灌洗液中淀粉酶升高,30,Abdominal Trauma Computed Tomography (CT) Versus DPL CT与DPL的比较,DPL has high sensitivity but low specificity for source of intraabdominal bleeding DPL对腹内出血敏感性高而特异性差 - DPL sometimes will detect small bowel perforations missed by other studies DPL有时能检测出其他检查未发现的小肠穿孔 - CT highly accurate to delineate solid organ lacerations (spleen, liver) CT能高度精确的描绘固体脏器的破裂伤（脾，肝） - CT can determine retroperitoneal injuries missed by DPL CT能发现DPL未检测出的腹膜后损伤 If oral (via NG) & IV contrast used, CT can readily identify GI tract perforations & GU injuries 如果使用经口（胃管）和静脉的造影，CT能轻易区分胃肠道穿孔和泌尿系统的损伤,31,Intrasplenic hematoma with subcapsular hematoma,32,Diagnostic Ultrasound for Abdominal Trauma 腹部创伤的超声诊断,- Very useful and quick to determine intraabdominal bleeding非常有效迅速的诊断腹腔内出血 - “FAST” (Focused Abdominal Sonography for Trauma) exam uses probe at 4 positions (posterolateral lower chest wall bilaterally, subxiphoid, and suprapubic) to determine intraperitoneal fluid (blood)创伤中腹部超声检查关注4处探查（肝肾隐窝、脾脏、心包、Douglas窝）以诊断腹腔内液体（出血） - May obviate need for DPL 可以排除使用DPL - No radiation exposure so can be repeated as often as needed无放射暴露因而可随需要不断重复,33,Normal Morisons Pouch,Free fluid in Morisons Pouch,34,Disadvantages of Diagnostic Ultrasound超声诊断的劣势,- Visualization may be limited by bowel gas or obesity 可视程度可因肠道气体和肥胖受限 - Not good at showing retroperitoneal injuries 腹膜后损伤显示不佳 - May not directly visualize solid organ lacerations 无法直接显示固体脏器的破裂,35,Special Studies in Abdominal Trauma腹部创伤的特殊检查, ACS,时间,病患移动,敏感性,特异性,适用性,DPL,FAST*,CT,* Operator dependent,36,Lumbar or Thoracic Spine Fractures 胸腰椎脊柱骨折,- Anterior wedge compression fractures are usually mechanically stable前方楔形变的压缩骨折通常是稳定型的 - May require admission for pain control or concurrent ileus 可因疼痛及并发的肠梗阻需入院 - Lumbar fractures may be associated with bowel perforations from lap belt injury 腰椎骨折可伴有因汽车安全带损伤造成的肠穿孔 - If any neuro deficit, should obtain emergent consult with spine surgeon 如有任何神经功能缺损，应急诊马上进行脊柱手术 - Maintain back immobilization 保持背部固定,37,Lumbar or Thoracic Spine Fractures (cont.)胸腰椎脊柱骨折,- Indications to obtain spine CT after plain films平片后做脊柱CT的适应证: Neurologic symptoms or deficit 有神经症状或功能缺损 Fracture of posterior elements 脊柱后柱的骨折 Vertebral body fractures other than simple anterior wedge fracture锥体的骨折而不单是前柱楔形骨折,38,Abdominal Trauma Summary 腹部创伤概述,- Assess abdomen as potential source of shock or bleeding 把腹部作为一个潜在休克或出血灶评价 - Start resuscitation 开始复苏 - Complete the abd. exam with the secondary survey完成腹部检查的次级评估 Decide if emergent or urgent laparotomy needed 判断是否需紧急的腹部手术 - Decide if additional diagnostic studies needed判断是否需更多的诊断检查 - Reassess frequently 不断的重新评估 - Decide if transfer to a trauma center needed 判断是否要转去创伤中心,Pelvic Trauma 骨盆创伤,40,Pelvic Fractures Epidemiology骨盆骨折的流行病学,- Overall mortality 6 to 19 % 总体死亡率619 - If hypotensive, mortality 40 to 50 %如有低血压，则总死亡率在4050 60 % due to motor vehicle crashes (MVCs) 60因车祸 30 % due to falls 30 %因坠落伤 - 10 % due to direct crush of pelvis 10因骨盆直接碰撞,41, ACS,Pelvic Fractures 骨盆骨折,Mechanism机制,AP compression前后的压力 Lateral compression 侧向的压力 Vertical shear垂直的剪切力,Classification,Open Closed,42, ACS,Pelvic Fractures,显著的冲击力致合并伤,Pelvic bleeding骨盆出血,Bone ends骨端 Pelvic muscles骨盆肌肉, Veins / arteries动静脉,43, ACS,Pelvic Fractures 骨盆骨折,Assessment评估,Inspection检测 Palpate prostate触诊前列腺,Leg-length discrepancy, external rotation 大腿长短的差异和外旋 Pain on palpation of bony pelvic ring 触诊骨盆环时疼痛,Pelvic ring骨盆环,44,Pelvic Fractures : Radiology 骨盆骨折：放射学,- Anteroposterior (AP) view shows most fxs前后位：显示大多数骨折 - Inlet view