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1、,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
2、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
3、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
4、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
5、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
6、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,
7、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. de
8、termine 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 rea
9、ssessments 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
10、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
11、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
12、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,Rou
13、tine 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 abno
14、rmal: 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
15、,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,
