外科學第二十八章腹部損傷

腹部損傷AbdominalInjury何為腹部損傷?外來暴力(銳性或鈍性)作用于腹部腹壁和/或腹腔內臟器、組織受損合并局部和全身的生理病理改變常有其他部位合并傷或復合傷影響腹部損傷嚴重程度的因素致傷物暴力強度及著力部位臟器的位置和自身結構弱點特定的病理生理狀態(tài)腹部損傷分類按腹壁是否破損分為

開放性腹部損傷閉合性腹部損傷按損傷的不同臟器分為

實質臟器損傷空腔臟器損傷★上述分類在診治早期具有重要的臨床意義

提示病因及損傷部位提示受損臟器警示后果指導治療閉合性腹部損傷:開放性腹部損傷

聯(lián)合臟器損傷傷情評估1.全身情況評估2.聯(lián)合臟器損傷評估3.腹腔內臟器損傷評估臨床表現(xiàn)大面積嚴重的腹壁損傷持續(xù)而劇烈的腹痛空腔臟器破裂肝膽、胰腺破裂致膽汁或胰漏腹痛伴腹肌緊張,空腔臟器破裂腹肌壓痛反跳痛

肝膽、胰腺破裂致膽汁或胰漏肩背放射痛

肝脾破裂腹痛伴腹脹早期腹腔內積血后期繼發(fā)彌漫性腹膜炎腹痛臨床表現(xiàn)失血性休克表現(xiàn)心慌、虛汗、面色蒼白、無力、暈厥、脈搏快而細弱、脈壓變小、血壓下降實質臟器或血管破裂臨床表現(xiàn)腹痛范圍逐漸擴大,最終波及全腹;腹肌緊張,壓痛反跳痛、伴有惡心、嘔吐或嘔血、便血彌漫性腹膜炎表現(xiàn)合并感染空腔臟器破裂臨床表現(xiàn)常見的合并傷:泌尿生殖系統(tǒng)損傷(常表現(xiàn)為血尿)肋骨骨折(常與肝脾破裂共存)骨盆骨折臨床表現(xiàn)威脅生命需緊急救治的合并傷:

任何部位的大血管破裂嚴重的顱腦外傷頸椎骨折或脫位開放性氣胸或張力性氣胸心包填塞及心臟破裂診斷思路1.目前有沒有生命危險?(生命體征:P,HR,BP,神志.)2.有沒有危及生命的合并傷?(頭、頸、胸、腹)3.有無腹腔內臟損傷?(有傷假設)4.哪類臟器損傷?(實質?空腔?混合?)5.是否存在腹腔內多個臟器損傷?6.傷情評估漏、誤診原因小創(chuàng)傷就診時表現(xiàn)不明顯嚴重腹壁損傷掩蓋了腹腔內臟器損傷只注意了一處傷，忽略了多個臟器傷多處合并傷或意識障礙影響判斷嚴重腹壁損傷誤為彌漫性腹膜炎而剖腹探查

檢查1.病史詢問2.當前表現(xiàn)3.體格檢查4.輔助檢查輔助檢查1.三大常規(guī)2.腹腔穿刺(灌洗)3.B型超聲4.X線檢查5.CT或MR檢查6.腹腔鏡探查或剖腹探查腹腔穿刺1.工具2.穿刺點3.操作方法4.結果分析超聲應用床邊B超

＊器官破裂和創(chuàng)傷評估

＊胸腹腔和心包積液

1.肝周間隙和肝腎隱窩2.脾周間隙3.盆腔4.心包5.胸腔B超1.Perihepatic2.Perisplenic3.Pericardium4.Pelvis

FAST:B超--FAST

●

鈍性腹部損傷●血液動力學不穩(wěn)定FAST:FocusedAssessmentwithSonographyforTraumaFASTstrategyFAST:FocusedAssessmentwithSonographyforTraumaFASTstrategyDPL:

diagnosticperitoneallavageFAST:FocusedAssessmentwithSonographyforTrauma治療早期復蘇治療手術治療

DamagecontrolsurgeryICU監(jiān)護治療再手術治療非手術治療早期復蘇院前急救和急診接診心肺腦復蘇（初期復蘇、后期復蘇和復蘇后治療）迅速控制出血和循環(huán)復蘇手術治療

Damagecontrolsurgery：whatis

thesignificance標準、徹底的手術是決定性的這一傳統(tǒng)觀念受到挑戰(zhàn)大而徹底的手術加重臟器功能障礙和代謝紊亂，增加死亡率（coagulopathy,hypothermiaandmetabolicacidosis）

Damagecontrolsurgery：whathavetodo?

控制出血防治污染防止或減少進一步的損傷非手術治療不能確定有無內臟損傷輕度單純的實質臟器損傷生命體征穩(wěn)定嚴密觀察一般治療肝破裂(liverrupture)--臨床特點:多為右季肋區(qū)暴力損傷常合并肋骨骨折以失血為主,常表現(xiàn)為失血性休克腹痛常合并右肩放射痛合并膽汁泄漏時腹痛劇烈腹腔穿刺、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掃描：

LiverTraumaImagesCT掃描:

LiverTraumaImagesCT掃描:LiverTraumaImages肝破裂分類肝破裂肝破裂Liverlaceration

LiverTraumaImages

LiverTraumaImages肝破裂:處理要點目的:控制出血;處理創(chuàng)面;建立引流1.縫合2.清創(chuàng)3.創(chuàng)面血管、膽管結扎4.肝葉切除5.加壓填塞肝破裂:處理要點

Pringer手法控制肝門肝破裂:處理要點

創(chuàng)面處理及肝門控制肝破裂:處理要點

創(chuàng)面血管、膽管斷端結扎肝破裂處理要點:紗布填壓肝破裂處理要點肝破裂處理要點:紗布填壓后縫閉切口肝后腔靜脈破裂填壓止血網(wǎng)膜補片補片修補

脾破裂(splenicinjury)--臨床特征:多為左季肋部暴力傷可有左肩部放射痛以失血為主病理性脾更易于破裂包膜下血腫可遲發(fā)性破裂腹腔穿刺、B超和CT可提供診斷幫助SpleenTraumaImages脾破裂(splenicinjury)—處理要點脾切除脾部分切除脾修補脾切除后再植placementofabsorbablesutures

completedrepairwithomentalpedicle

postsplenectomy

胰腺損傷(PancreasInjury)胰腺損傷(PancreasInjury)—臨床特點胰腺位置深,常為中上腹嚴重暴力損傷所致常合并胰周或胰后大血管損傷及胰漏,故死亡率高腹痛劇烈,可放射至腰背部,伴腹肌緊張和壓痛、反跳痛血、尿淀粉酶增高B超、CT可見胰腺形態(tài)損害改變胰腺損傷--AASTOrganInjuryScale

Grade

InjuryDescription

I

Haematoma

Minorcontusionwithoutductinjury

Laceration

Superficiallacerationwithoutductinjury

II

Haematoma

Majorcontusionwithoutductinjuryortissueloss

Laceration

Majorlacerationwithoutductinjuryortissueloss

III

Laceration

Distaltransectionorparenchymalinjurywithductinjury

IV

LacerationProximaltransectionorparenchymalinjuryinvolvingampulla

V

Laceration

Massivedisruptionofpancreatichead

AdvanceonegradeformultipleinjuriestosameorganuptoGradeIII.

Proximalpancreasistotherightofthesuperiormesentericvein.胰腺橫斷傷胰腺橫斷傷胰腺橫斷傷GunshotwoundtopancreaticHead胰腺槍彈傷

胰腺橫斷傷腎臟損傷(RenalInjury)腰部暴力多與腹部損傷共存血尿腹膜后血腫

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.

腎臟損傷--AASTOrganInjuryScaleX線檢查1.Extravasationofcontrast

fromrightkidneyX線檢查3.Nofillingofupperpole

ofrightkidney腎臟損傷(RenalInjury)腎臟損傷(RenalInjury)胃腸道損傷(InjuryofGastrontestinalTract)

—特點彌漫性腹膜炎為主

重或劇烈腹痛可有氣腹(立位腹部平片可見膈下游離氣體)

腹痛伴腹肌緊張,腹部壓痛反跳痛腹腔穿刺為混濁腹水或消化道漏出物小腸損傷--AASTOrganInjuryScale

I

Haematoma

Contusionorhematomawitho