上海交大外科学腹损PBL

腹 部 损 伤Abdominal Trauma,上海交通大学医学院外科学教研室上海交通大学医学院附属瑞金医院普外科,About myself,Name: 费 健Email: Mobile:137-0176-9798,开始了大家要专心啊,一个例子四大问题,A 22 year old man was driving drunk and without his seatbelt fastened when he was involved in a single-vehicle automobile accident. When attended by EMT（abbr. emergency medical technician 急诊医士） personnel, no information was available about the time of the accident. He was found agitated and complaining of abdominal pain.,Study Questions 1:Whats your first impression of this case?,Open or Closed Injuries ?Hollow or Solid Organs ?Single or Multiple ?,病史询问 病患受伤之可能机转，如车祸之车体损伤严重度，是否用安全带，救援病患之时间从病患或家属快速取得AMPLE资料，但不可因为问病史而耽误急救处置。,病史询问A : Allergy 过敏史M : Medication 用药史P : Past history 过去病史L : Last meal 最后一次进食喝水时间及 LMP ( 女性 )E : Event 外伤发生之经过史,Study Questions 2:Whats the key points of physical exam?,His airway was patent. At the scene, he was breathing at 20 per minute with a blood pressure of 90/60 and a pulse of 130. He was placed in a hard cervical collar and on a back board and transported to your emergency room. Upon arrival his vital signs are the same, with a temperature of 36oC.,His abdomen is markedly distended. His hands and feet are cold, his legs mottled.,理学检查 病患是否有休克症状 ( tachycardiatachypneacold swealing ) 胸腹部是否有开放性伤口 胸腹部是否有挫伤瘀血肿等 女性病患应注意是否怀孕,Study Questions 3:What will you do next?,-A nasogastric tube reveals green liquid.-A urinary catheter reveals dark yellow urine. -His hemoglobin is 7. -His abdominal lavage（灌洗）reveals gross blood.,诊断工具 Laboratory Data Hb,Hct ( serial measurement ) Base line WBC Coagulation studies Baseline electrolyte Liver and renal function tests Serum amylase Urinalysis,Study Questions 4:Whats the final diagnosis?,影像学检查： X线平片、CT、 B超、DSA,目的要求：,了解：腹部损伤的分类、病因和病理；掌握：腹部损伤的临床表现；熟练掌握：腹部闭合性损伤引起的脏器破裂、出血、穿孔的诊断及治疗原则。,思考题,腹部闭合性损伤的诊断腹腔诊断性穿刺的方法及意义脾破裂的治疗方法,New Eng J MedVolume 356:1353-1360March 29, 2007Number 13NextCase 10-2007 A 55-Year-Old Man Impaled in a Rowing Accident,男30岁，由5m高处跌下2小时。腹痛，腹肌紧张，有压痛和反跳痛，肠鸣音弱。血压104/70mmHg，脉率120次/分，血红蛋白80g/L。X线检查：右侧第9、10肋骨骨折，右侧膈肌升高。最可能的诊断是（ ）。A肝破裂B胃破裂C脾破裂D横结肠破裂E胰腺断裂,腹部闭合伤，确诊有无内脏伤最简便，最可靠的诊断方法为（ ）。AX线照片BCTC白细胞计数DB超E腹腔穿刺。,腹部闭合性损伤，以下都是不能早期确诊的原因除了（ ）。A实质脏器损伤但其被膜未破B同时合并其他部位的严重损伤C空腔脏器穿孔不大D腹腔穿刺抽出不凝固血液E后腹膜脏器的损