腹部闭合性损伤(英文)

AbdominalInjury

1Section1

Introduction

AbdominalinjuryreferstothehistologicaldamageanddysfunctioncausedbydifferentkindsofinjuriestotheabdomenAbdomenoccupylargesurfaceofthetotalbody，noskeletontoprotectit,soabdominalinjuryismorecommon.Inparticular,withtheincreasingdevelopmentofmoderntransportation，thedamageismoreandmorepopular.

morbidity0.4---1.8%Mortality10---20%2ThefocusandthedifficultiesofthischapterEmphasis：（1）Masterthefirstaid,theprinciplesoftheearlydiagnosisandtreatment

（2）Familiarwiththedifferentdiagnosisandtreatmentoftheruptureofintestinal,liver,orspleen3Difficulties1istherevisceralinjury?2Whichkindofvisceralorganshasgotteninjured?3Aretheremultipleinjuries?4Whatdowedowithdiagnosticdifficulties?4Anatomyofthehumanabdomen,byTiesvanBrussel/tiesworks.nl5TheclassificationoftheAbdominalinjury

1Openabdominalinjuries(Open)

Usuallycausedbysharpobject,obviouswoundtract,clearinjuries,diagnosisiseasyandclear.timelyandeasyhandling,thetreatmentandprognosisisgood.（1）Penetratinginjury:perforationoftheperitoneumare;non-penetratinginjuries:evenvisceralinjury（2）Penetratingwound;non-penetratingwound（3）Iatrogenicinjury62Bluntabdominalinjury(Closed)

Usuallycausedbyabluntobject,nosurfacescars,oftenvisceralinjury,easilymissed,sotheyhaveimportantclinicalsignificance.Identificationofseriousintra-abdominalpathologyisoftenchallenging7一、Etiology1、Violence(direct,indirect),fall,collision,impact,squeezing,kicking,punchingandsoon.2、Commonvisceralinjuryintheorderis:

Closedinjury:spleen,kidney,smallintestine,liver,mesentery

Openinjury:liver,smallintestine,stomach,colon,largevessels

3、Theseverityoftheinjurydependonmechanismofinjuryandorgananatomy,pathology,functionalstatus.8MechanismofinjuryTheintensityofviolence:size,speed,directionSiteoftheactionviolence,hardness

9CharacteristicsoftheorgansPhysiologicalfactors:

：1、liver,spleenisfragile,pipe-rich,fixed,easybleeding.2、Intestinefixedplace3、OrganinfrontofthespinePathologicalfactors：TheoriginalpathologicalconditionsofliverandspleenFunctionalstatus：Stomach,bladderfilling

10Themainpathologicalchangesinsevereabdominalinjuries：

Intra-,retroperitonealbleedingandperitonitisAbdominalretroperitonealduodenalinjuryperformance：Testicularpain,scrotalhematoma,priapism11二、ClinicalmanifestationSimpleabdominalinjury:Signsandsymptomsofmildpainintheinjuredarea,thelimitationsofabdominalswellingandtenderness,subcutaneousecchymosis,etc.,toreduceovertime.Oftenwithoutgastrointestinalsymptoms12Abdominalhollowviscusinjury：(1)Diffuseperitonitis(peritonitis)based(2)

Gastrointestinalsymptoms(3)

Systemicsymptomscanoccurinsepticshock.Intra-abdominalorganinjurymixed:hemorrhageandperitonitis13Parenchymalorganinjury:Hemorrhage,shock,abdominalsigns(Thepartwiththemostobvioussignsisoftentheplaceofthedamagewhichbit)Intra-abdominalorganinjurymixed:

Hemorrhageandperitonitis14三、Diagnosis

Themostcriticalissueistodeterminewhethervisceralinjury,followedbythenatureofthemultipleorganinjuryandwhetherthedamageisnotone1、Withorwithoutvisceralinjury(1）EmphasisonthegeneralconditionofT,P,R,BP,andconsciousness（2）Learnmoreaboutthehistoryofinjury,especiallyinjuryconditions（3）Comprehensiveandfocusedphysicalexamination（4）Thenecessarylaboratorytests:bloodcount,urinetest,serumorurineamylase15Youshouldconsiderorgandamageifoneofthefollowingthingshappen1、Earlyshock(hemorrhagic).2、Continuousoraggravatingabdominalpainwithprogressivegastrointestinalsymptoms.3、Significantperitonealirritation.4、pneumoperitoneumperformers.5、Withshiftingdullness6、Hematemesis吐血orhematochezia便血,orhematuria尿血7、Rectalexaminationpositivefindings:Rectalwalltenderness,asenseofvolatility,blood-stainedfingerEasytolosesightoftheforestforthetrees162、Whatkindoforgandamage

Substantiveorgan--------mainshock

Holloworgan

--------PeritonitisbaseVomiting,nausea,haematemesis,hematocheziapneumoperitoneum---gastrointestinaltract

Dysuria,hematuriaandreferredpainofgenitals---UrinarysystemLowerribbonefractures,backpain--RuptureofliverorSpleenDiaphragmirritation---liverorspleenPelvisfractures---rectumandbladder17AmylaseincreasedPancreaticinjuryGastrointestinalperforationRetroperitonealduodenalrupture,ButThenormalamylasecannotexcludetheorgandamageaboveImportantindicatorofurinarytractinjury:Hematuria183、Isitthemultipleinjury?（attention

specially）

Include:（1）multipleinjuries

inoneorgan

（2）morethanoneorgandamagedinsidetheperitonealcavity

（3）injuriesinsidetheperitonealcavitycombinedwithinjuriesoutsidetheperitonealcavity

（4）organsinsidetheperitonealcavityinvolvedbyinjuriesoutsidetheperitonealcavity194、Measuresaimeddirectlyatthedifficultiesof

diagnosis（1）dootherauxiliaryexaminationifallowedA、Diagnosticparacentesisorperitoneallavage:90%positiverate,simple，donotneedtomove，havenocomplication

20ParacentesisIndications

1.

Newonsetascitesorascitesofunknownorigin2.

Patientswithascitesofknownetiologywhomayhaveadecompensationclinicalstateasindicatedbyfever,painfulabdominaldistention,peritonealirritation,hypotension,encephalopathyorsepsis3.

Suspectedmalignantascites4.

Peritonealdialysispatientswithfever,abdominalpainorothersignsofsepsis(usuallytheparacentesisfluidmayberemoveddirectlyfromthepatient’sdialysiscatheter)

21ParacentesisContraindications1.

Uncorrectedbleedingdiathesis2.

Previousabdominalsurgerieswithsuspectedadhesions3.

Severeboweldistention4.

Abdominalwallcellulitisattheproposedsiteofpuncture5.Latepregnancy22B、X-rayexamination：KUB、Underthediaphragmthereisfreegas(chestradiograph)---Fractureofrib—selectiveangiography、CTC、B-modeultrasonicexaminationconvenientandreliablePneumoperitoneum,seenasanairbubbleonthelowerleftsideoftheX-rayfilm23Measuresaimeddirectlyat

thedifficultiesof

diagnosis（2）observe

rigorouslycontent：A、Vitalsignper15to30minB、Abdominalphysicalexaminationper30min（ST）C、determinationHB、RBCper30—60minD、repeatparacentesisifnecessary24Whatcloseobservationinclude

(Don'tdo)

（1）Don'tmoveatwillinordertoavoidaggravatingpatient'scondition

（2）

Don'tinjectanalgesicinordertoavoidcoveruptheinjury

（3）

Don'tgivedietinordertoavoidincreasingpollution

(Needtodo):

（1）Positivefluidadministrationsarerequiredtopreventandcontroltheshock

（2）Antibioticsaredemandtopreventandcontroltheinfection

（3）GastrointestinalreducedpressureNomovement,nofood,noanalgesic.Transfusion,Reducedpressure,Antibiotics25（3）ExploratoryLaparotomy：AnexploratoryLaparotomyshouldbeproceededimmediatelyifapatientfailtodiagnoseandcan'truleoutvisceralinjurythroughthemethodsabove.Moreover,thesymptomsthatthepatient’sconditiondeterioratedwiththeaggravationofabdominalpainanddistension,accompaniedwiththevariationofthegeneralappearanceevenbyactivetherapiesaretheindicationofaexploratoryLaparotomy.Itisstillbeyondreproacheventhoughtheresultoftheexplorationisnegative.26Laparotomy

Indications：1Abdominalpainandperitonealirritationprogressiveincreaseorexpandthescope2Bowelsoundsdiminished,disappearedorAbdominaldistention3Deteriorationofgeneralcondition4Withfreegas5RBCcountsweredecreased6Bloodpressurefromstabletounstableorshock,refractoryshock7Abdominalpunctureextractedgas,incoagulableblood,bileandgastrointestinalcontents8Gastrointestinalbleedingisnoteasytocontrol27TheprinciplesofcombinedinjuryTheabdomenshouldneitherbeignorednorthesolefocusofthephysiciansSequenceoftreatment:▲CRP:cardiopulmonaryresuscitation▲Controlexternalbleeding▲Controlopenandtensionpneumothorax▲Managementofshock▲Craniocerebraltrauma▲Abdominalinjury28TreatmentPrinciplesOverridingPrinciple:

Lifecomesfirst!Firsthandleinjurieswhichthreatlifemost.Intra-abdominalorganinjury:Solidorgan:Anti-shock,whilesurgery;holloworgan:firstanti-shockthensurgery.Insurgery:Firststopbleedingthenprobe;firstheavilypollutedregionthenlightregion;comprehensiveexploration,watchoutforcombinedinjury.29AbdominalinjuryinclinicalthinkingroadmapAbdominalinjury?

↓Viscerainvolved?

↓Whatkindoforgan?

↓Whichorgan?

↓Multipleinjuries?30Thesecondfestival1、Ruptureofthespleen2、Ruptureoftheliver3、Ruptureofthesmallbowel4、Ruptureofthelargebowel31一、SplenicRuptureTheincidenceofthesplenicruptureinabdominalinjuryis40-50%，themosteasilydamaged,thepathologyofthespleenaremorepronetorupture.Threetypes（1）Subcapsularrupture(Filmwithoutrupture)（2）Centralrupture:formahematoma

（3）

truesplenicrupture85%Clinicalmanifestationsanddiagnosis：Typicallyhemorrhagicshockperformance32TraumaticruptureofthespleenoncontrastenhancedaxialCT(portalvenousphase)33Spleen,trauma.Contrast-enhancedCTscanoftheabdomenshowssomeperisplenicfluidintheanterioraspect.Asmallwell-definedirregularityisnotedinthesplenicwallposteriorly.Thiswasacongenitalspleniccleftinapatientwithperisplenicfluidsecondarytononsplenicinjury.Spleen,trauma.Chestradiographshowsaperipherallycalcifiedmassintheleftupperquadrantunderthediaphragm.Themassrepresentsacalcifiedsplenichematoma.34Spleen,trauma.Contrast-enhancedCTscanshowsalocalizedareaofdensecontrastcollectioninthesplenichilum,withamassiveamountofsurroundingfluid/blood.Findingshereareindicativeofactiveextravasationofcontrastinapatientwithtraumaticautosplenectomy.ThisisagradeVinjury.Spleen,trauma.Contrast-enhancedCTscanoftheabdomenintheequilibriumphaseshowsperisplenicfluidwithmasseffectonthespleen.Thespleenappearscompressedbythefluid,reminiscentofsubcapsularfluidcollections.Inthispatient,thefluidwassecondarytopancreaticpseudocystsmimickingsubcapsularhematomas.

35TheClassificationofsplenicruptureⅠ级:Length≤5.0cm,depth≤1.0cmⅡ级：Length＞5.0cm,depth＞1.0cmⅢ级：Injurysplenicportalorsplenicpartialamputation,orspleniclobevasculardamageⅣ级：Widerupture,orspleenpedicle,splenicarteriovenousdamage36Specialattentionshouldbepaidtotheconditionandtreatment：Subcapsularhematoma:insomeweakforces,suddenlytransformintotruesplenicrupture,leadingtobetakenbysurpriseinthetreatmentsituation,oftenoccurintraumaafter36-48hr,shouldbegivenhighvigilance.Calleddelayedsplenicrupture.3738SplenicRuptureOPSI(overwhelmingpostsplenectomyinfection)Non-surgicaltreatment；I、IIclassForgradeⅢ,Ⅳ，upondiagnosis,immediatesurgical。SplenectomyIsthefirstchoice,Childrenalsotakethespleenrepairandspleentransplantation.Subtotalsplenectomy,39Subtotalsplenectomysplenorrhaphysplenicarteryligation脾动脉结扎术splenicarteryembolization脾动脉栓塞40

二liverRupture4142二、

liverRuptureIncidenceofabdominalinjuryaccountsfor15-20%，RighthepaticdamagemorethanthelefthepaticdamagePathologyandclinicalmanifestationsareverysimilarwiththesplenicruptureButtheremaybearuptureoftheliverbilespilledintotheabdominalcavity,theabdominalpainandperitonealirritationismoreobviousthanthespleenruptureHemobiliamaybecyclical,asbrokenbloodvesselsandbileductcommunicationCentralruptureofliverformabscess43LiverRuptureverysimilarwithSpleenRupture

Difference：

peritonitisismoresevere（Bile）

traumatichemobilia;(uppergastrointestinalbleeding)4445BasicrequirementsforthetreatmentofliverruptureDebridement,precisehemostasis,eliminationofbileleakage,unobstructeddrainageThefirstportaltriadclampingtime：＜30minutesLessthan15minuteswhenCirrhosisoftheliver46liverruptureSurgery①Temporarycontrolofbleeding②Simplesuture③Hepaticarteryligation④Liverresection⑤Gauzepadpackingmethod⑥Vascularrepair47DuodenalinjuryWhippleprocedure48ruptureofsmallintestineMorechancesofinjury.ObviousperitonitisGenerallyappearedearlier.AsmallnumberofpatientspneumoperitoneumWithgastrointestinalsymptomsSymptoms,latesepticshockOncediagnosed,immediatesurgery.Repairand/orbowelresectionMatchplusdrainage4950PancreaticdamageinjuryFeature：①Deepandhiddenlocation②Earlydetectionisnoteasy,easilymissed、③Highmortality(20%)④Oftencomplicatedbypancreaticfistula51PancreaticdamageinjuryThevalueofamylaseCTTheboundariesofpancreaticneck52pancreatictraumaCTscanfindings:directsigns(eg,pancreaticlaceration):specificbutlacksensitivityindirectsigns(eg,peripancreaticfluid):sensitivebutlackspecificity.

Retroperitonealhematoma,retroperitonealfluid,freeabdominalfluid,andpancreaticedemafrequentlyaccompanyinjuriestothepancreas.IncasesinwhichtheCTscanfindingsareindefiniteorclinicalsuspicionofapancreaticinjuryremains,furtherinvestigationwithmagneticresonancecholangiopancreatography(MRCP)maybeused.53PancreaticinjuryPreventionandtreatmentofpancreaticfistula：Radicalsurgery,adequatedrainage,somatostatin,TPNTotal

Parenteral

Nutrition

enteralnutrition,EN(bynasojejunaltube,jejunostomy,PEJ

)

PEG:PercutaneousEndoscopicGastrostomyPEJ:PercutaneousEndoscopicJejunostomy54SurgicalpurposesHemostasis,debridement,controlandtre