外科学第二十八章腹部损伤

腹部损伤AbdominalInjury何为腹部损伤?外来暴力(锐性或钝性)作用于腹部腹壁和/或腹腔内脏器、组织受损合并局部和全身的生理病理改变常有其他部位合并伤或复合伤影响腹部损伤严重程度的因素致伤物暴力强度及着力部位脏器的位置和自身结构弱点特定的病理生理状态腹部损伤分类按腹壁是否破损分为

开放性腹部损伤闭合性腹部损伤按损伤的不同脏器分为

实质脏器损伤空腔脏器损伤★上述分类在诊治早期具有重要的临床意义

提示病因及损伤部位提示受损脏器警示后果指导治疗闭合性腹部损伤:开放性腹部损伤

联合脏器损伤伤情评估1.全身情况评估2.联合脏器损伤评估3.腹腔内脏器损伤评估临床表现大面积严重的腹壁损伤持续而剧烈的腹痛空腔脏器破裂肝胆、胰腺破裂致胆汁或胰漏腹痛伴腹肌紧张,空腔脏器破裂腹肌压痛反跳痛

肝胆、胰腺破裂致胆汁或胰漏肩背放射痛

肝脾破裂腹痛伴腹胀早期腹腔内积血后期继发弥漫性腹膜炎腹痛临床表现失血性休克表现心慌、虚汗、面色苍白、无力、晕厥、脉搏快而细弱、脉压变小、血压下降实质脏器或血管破裂临床表现腹痛范围逐渐扩大,最终波及全腹;腹肌紧张,压痛反跳痛、伴有恶心、呕吐或呕血、便血弥漫性腹膜炎表现合并感染空腔脏器破裂临床表现常见的合并伤:泌尿生殖系统损伤(常表现为血尿)肋骨骨折(常与肝脾破裂共存)骨盆骨折临床表现威胁生命需紧急救治的合并伤:

任何部位的大血管破裂严重的颅脑外伤颈椎骨折或脱位开放性气胸或张力性气胸心包填塞及心脏破裂诊断思路1.目前有没有生命危险?(生命体征:P,HR,BP,神志.)2.有没有危及生命的合并伤?(头、颈、胸、腹)3.有无腹腔内脏损伤?(有伤假设)4.哪类脏器损伤?(实质?空腔?混合?)5.是否存在腹腔内多个脏器损伤?6.伤情评估漏、误诊原因小创伤就诊时表现不明显严重腹壁损伤掩盖了腹腔内脏器损伤只注意了一处伤，忽略了多个脏器伤多处合并伤或意识障碍影响判断严重腹壁损伤误为弥漫性腹膜炎而剖腹探查

检查1.病史询问2.当前表现3.体格检查4.辅助检查辅助检查1.三大常规2.腹腔穿刺(灌洗)3.B型超声4.X线检查5.CT或MR检查6.腹腔镜探查或剖腹探查腹腔穿刺1.工具2.穿刺点3.操作方法4.结果分析超声应用床边B超

＊器官破裂和创伤评估

＊胸腹腔和心包积液

1.肝周间隙和肝肾隐窝2.脾周间隙3.盆腔4.心包5.胸腔B超1.Perihepatic2.Perisplenic3.Pericardium4.Pelvis

FAST:B超--FAST

●

钝性腹部损伤●血液动力学不稳定FAST:FocusedAssessmentwithSonographyforTraumaFASTstrategyFAST:FocusedAssessmentwithSonographyforTraumaFASTstrategyDPL:

diagnosticperitoneallavageFAST:FocusedAssessmentwithSonographyforTrauma治疗早期复苏治疗手术治疗

DamagecontrolsurgeryICU监护治疗再手术治疗非手术治疗早期复苏院前急救和急诊接诊心肺脑复苏（初期复苏、后期复苏和复苏后治疗）迅速控制出血和循环复苏手术治疗

Damagecontrolsurgery：whatis

thesignificance标准、彻底的手术是决定性的这一传统观念受到挑战大而彻底的手术加重脏器功能障碍和代谢紊乱，增加死亡率（coagulopathy,hypothermiaandmetabolicacidosis）

Damagecontrolsurgery：whathavetodo?

控制出血防治污染防止或减少进一步的损伤非手术治疗不能确定有无内脏损伤轻度单纯的实质脏器损伤生命体征稳定严密观察一般治疗肝破裂(liverrupture)--临床特点:多为右季肋区暴力损伤常合并肋骨骨折以失血为主,常表现为失血性休克腹痛常合并右肩放射痛合并胆汁泄漏时腹痛剧烈腹腔穿刺、B超、CT可予定性和定位肝破裂:(LiverRupture)

AASTOrganInjuryScale

Grade

InjuryDescription

I

Haematoma

Subcapsular,<10%surfacearea

Laceration

Capsulartear,<1cmparenchymaldepth

ⅡHaematoma

Subcapsular,10-50%surfacearea

Intraparenchymal,<10cmdiameter

Laceration

1-3cmparenchymaldepth,<10cmlength

III

Haematoma

Subcapsular,>50%surfaceareaorexpanding.Ruptured

subcapsularor

parenchymalhaematoma

Intraparencymalhaematoma>10cmorexpanding

Laceration

>3cmparenchymaldepth

IV

Laceration

Parenchymaldisruptioninvolving25-75%ofhepaticlobeor1-3

Coinaud'ssegmentsinasinglelobe

VLacerationParenchymaldisruptioninvolving>75%ofhepaticlobeor>3

Coinaud'ssegmentswithinasinglelobe

VascularJuxtahepaticvenousinjuriesie.retrohepaticvenacava/central

majorhepaticveins

VIVascularHepaticAvulsion

AdvanceonegradeformultipleinjuriestosameorganuptoGradeIII.CT扫描：

LiverTraumaImagesCT扫描:

LiverTraumaImagesCT扫描:LiverTraumaImages肝破裂分类肝破裂肝破裂Liverlaceration

LiverTraumaImages

LiverTraumaImages肝破裂:处理要点目的:控制出血;处理创面;建立引流1.缝合2.清创3.创面血管、胆管结扎4.肝叶切除5.加压填塞肝破裂:处理要点

Pringer手法控制肝门肝破裂:处理要点

创面处理及肝门控制肝破裂:处理要点

创面血管、胆管断端结扎肝破裂处理要点:纱布填压肝破裂处理要点肝破裂处理要点:纱布填压后缝闭切口肝后腔静脉破裂填压止血网膜补片补片修补

脾破裂(splenicinjury)--临床特征:多为左季肋部暴力伤可有左肩部放射痛以失血为主病理性脾更易于破裂包膜下血肿可迟发性破裂腹腔穿刺、B超和CT可提供诊断帮助SpleenTraumaImages脾破裂(splenicinjury)—处理要点脾切除脾部分切除脾修补脾切除后再植placementofabsorbablesutures

completedrepairwithomentalpedicle

postsplenectomy

胰腺损伤(PancreasInjury)胰腺损伤(PancreasInjury)—临床特点胰腺位置深,常为中上腹严重暴力损伤所致常合并胰周或胰后大血管损伤及胰漏,故死亡率高腹痛剧烈,可放射至腰背部,伴腹肌紧张和压痛、反跳痛血、尿淀粉酶增高B超、CT可见胰腺形态损害改变胰腺损伤--AASTOrganInjuryScale

Grade

InjuryDescription

I

Haematoma

Minorcontusionwithoutductinjury

Laceration

Superficiallacerationwithoutductinjury

II

Haematoma

Majorcontusionwithoutductinjuryortissueloss

Laceration

Majorlacerationwithoutductinjuryortissueloss

III

Laceration

Distaltransectionorparenchymalinjurywithductinjury

IV

LacerationProximaltransectionorparenchymalinjuryinvolvingampulla

V

Laceration

Massivedisruptionofpancreatichead

AdvanceonegradeformultipleinjuriestosameorganuptoGradeIII.

Proximalpancreasistotherightofthesuperiormesentericvein.胰腺横断伤胰腺横断伤胰腺横断伤GunshotwoundtopancreaticHead胰腺枪弹伤

胰腺横断伤肾脏损伤(RenalInjury)腰部暴力多与腹部损伤共存血尿腹膜后血肿

Grade

InjuryDescription

I

Contusion

Microscopicorgrosshaematuria,urologicalstudiesnormalHaematoma

Subcapsular,nonexapndingwithoutparenchymallacerationII

Haematoma

Nonexpandingperirenalhaematomaconfinedtorenalretroperitoneum

Laceration

<1cmparenchymaldepthofrenalcortexwithouturinaryextravasationl

III

Laceration

>1cmdepthofrenalcortex,withoutcollectingsystemruptureorurinaryextravasationl

IV

Laceration

Parenchymallacerationextendingthroughtherenalcortex,medullaandcollectingsystem

Vascular

Mainrenalarteryorveininjurywithcontainedhaemorrhagel

V

Laceration

Completelyshatteredkidneyl

Vascular

Avulsionofrenalhilumwhichdevascularizeskidney

Advanceonegradeformultipleinjuriestosameorgan.

肾脏损伤--AASTOrganInjuryScaleX线检查1.Extravasationofcontrast

fromrightkidneyX线检查3.Nofillingofupperpole

ofrightkidney肾脏损伤(RenalInjury)肾脏损伤(RenalInjury)胃肠道损伤(InjuryofGastrontestinalTract)

—特点弥漫性腹膜炎为主

重或剧烈腹痛可有气腹(立位腹部平片可见膈下游离气体)

腹痛伴腹肌紧张,腹部压痛反跳痛腹腔穿刺为混浊腹水或消化道漏出物小肠损伤--AASTOrganInjuryScale

I

Haematoma

Contusionorhematomawitho