UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

成人腹部钝挫伤的初始评估和处理

Author
Michael A Puskarich, MD
Section Editors
Robert S Hockberger, MD, FACEP
Maria E Moreira, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM
Translators
范家乔, 副主任医师，副教授

引言

在急诊科，经常能见到腹部钝挫伤(blunt abdominal trauma, BAT)患者。当缺乏病史资料，并且存在分散注意力的损伤或者存在头部损伤或中毒(药物或酒精)导致的神志改变时，难以诊断和处理BAT。钝挫伤患者经常同时存在腹部和腹部外损伤，这使治疗变得更为复杂。

BAT患者的初始评估和处理将总结在此。腹部穿透伤的讨论、成人急性损伤的一般处理和腹部或胸部创伤患者的超声评估参见其他专题。(参见“成人腹部刺伤的初步评估及处理”和“成人腹部枪伤的初步评估和处理”和“成人创伤的早期处理”和“成人腹部和胸部创伤的急诊超声”)

流行病学

BAT最常发生于机动车辆碰撞(motor vehicle collision, MVC)，这类事故加上机动车和行人的碰撞事故，共占病例总数的75%以上。腹部撞击和跌倒分别占15%和6%-9%[1]。隐匿性BAT可见于儿童虐待和家庭暴力。(参见“儿童身体虐待：诊断性评估和处理”)

在因BAT就诊急诊科的患者中，腹腔内损伤的患病率约为13%[2]。当损伤确由BAT造成时，脾是最常见的损伤器官。在超过60%的病例中，脾是唯一受损的腹膜内结构[1]。肝脏和肾脏也可受损伤[1,3]。少数情况下，可能发生空腔脏器损伤(hollow viscus injury, HVI)。

损伤机制

BAT患者可存在数种病理生理学机制[1,3]。外力所致腹腔内压力突然显著升高可使空腔脏器破裂。对于系腰部安全带而未系肩部安全带的乘客，当安全带剧烈压迫腹部时，会因这一机制受伤。

                        

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2016-07-06.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Davis JJ, Cohn I Jr, Nance FC. Diagnosis and management of blunt abdominal trauma. Ann Surg 1976; 183:672.
  2. Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA 2012; 307:1517.
  3. Marx, JA, Isenhour, JL. Abdominal Trauma. In: Emergency Medicine Concepts and Clinical Practice, 6th ed, Marx, JA (Eds), Elsevier, 2006.
  4. Rivara FP, Koepsell TD, Grossman DC, Mock C. Effectiveness of automatic shoulder belt systems in motor vehicle crashes. JAMA 2000; 283:2826.
  5. Brasel KJ, Nirula R. What mechanism justifies abdominal evaluation in motor vehicle crashes? J Trauma 2005; 59:1057.
  6. Newgard CD, Lewis RJ, Kraus JF. Steering wheel deformity and serious thoracic or abdominal injury among drivers and passengers involved in motor vehicle crashes. Ann Emerg Med 2005; 45:43.
  7. Demetriades D, Murray J, Martin M, et al. Pedestrians injured by automobiles: relationship of age to injury type and severity. J Am Coll Surg 2004; 199:382.
  8. Roudsari BS, Mock CN, Kaufman R. An evaluation of the association between vehicle type and the source and severity of pedestrian injuries. Traffic Inj Prev 2005; 6:185.
  9. Brown CK, Dunn KA, Wilson K. Diagnostic evaluation of patients with blunt abdominal trauma: a decision analysis. Acad Emerg Med 2000; 7:385.
  10. Poletti PA, Mirvis SE, Shanmuganathan K, et al. Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography? J Trauma 2004; 57:1072.
  11. Beck D, Marley R, Salvator A, Muakkassa F. Prospective study of the clinical predictors of a positive abdominal computed tomography in blunt trauma patients. J Trauma 2004; 57:296.
  12. Schurink GW, Bode PJ, van Luijt PA, van Vugt AB. The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study. Injury 1997; 28:261.
  13. Ferrera PC, Verdile VP, Bartfield JM, et al. Injuries distracting from intraabdominal injuries after blunt trauma. Am J Emerg Med 1998; 16:145.
  14. Salim A, Sangthong B, Martin M, et al. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg 2006; 141:468.
  15. Rodriguez A, DuPriest RW Jr, Shatney CH. Recognition of intra-abdominal injury in blunt trauma victims. A prospective study comparing physical examination with peritoneal lavage. Am Surg 1982; 48:457.
  16. Livingston DH, Lavery RF, Passannante MR, et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial. J Trauma 1998; 44:273.
  17. Mahoney EJ, Biffl WL, Harrington DT, Cioffi WG. Isolated brain injury as a cause of hypotension in the blunt trauma patient. J Trauma 2003; 55:1065.
  18. Velmahos GC, Tatevossian R, Demetriades D. The "seat belt mark" sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents. Am Surg 1999; 65:181.
  19. Sullivan, DM. Myths in Trauma Management. In: Trauma Management: An emergency medicine approach, Ferrera, PC, Marx, J, Colucciello, SA, et al (Eds), Mosby, St. Louis 2001. p.706.
  20. Asimos AW, Gibbs MA, Marx JA, et al. Value of point-of-care blood testing in emergent trauma management. J Trauma 2000; 48:1101.
  21. Schnüriger B, Inaba K, Barmparas G, et al. Serial white blood cell counts in trauma: do they predict a hollow viscus injury? J Trauma 2010; 69:302.
  22. Takishima T, Sugimoto K, Hirata M, et al. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg 1997; 226:70.
  23. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 2002; 39:500.
  24. Knudson MM, McAninch JW, Gomez R, et al. Hematuria as a predictor of abdominal injury after blunt trauma. Am J Surg 1992; 164:482.
  25. Richards JR, Derlet RW. Computed tomography for blunt abdominal trauma in the ED: a prospective study. Am J Emerg Med 1998; 16:338.
  26. Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Radiology 2012; 265:678.
  27. Holmes JF, Wisner DH, McGahan JP, et al. Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma. Ann Emerg Med 2009; 54:575.
  28. Deunk J, Brink M, Dekker HM, et al. Predictors for the selection of patients for abdominal CT after blunt trauma: a proposal for a diagnostic algorithm. Ann Surg 2010; 251:512.
  29. Haan JM, Biffl W, Knudson MM, et al. Splenic embolization revisited: a multicenter review. J Trauma 2004; 56:542.
  30. Mele TS, Stewart K, Marokus B, O'Keefe GE. Evaluation of a diagnostic protocol using screening diagnostic peritoneal lavage with selective use of abdominal computed tomography in blunt abdominal trauma. J Trauma 1999; 46:847.
  31. Williams MD, Watts D, Fakhry S. Colon injury after blunt abdominal trauma: results of the EAST Multi-Institutional Hollow Viscus Injury Study. J Trauma 2003; 55:906.
  32. Mitsuhide K, Junichi S, Atsushi N, et al. Computed tomographic scanning and selective laparoscopy in the diagnosis of blunt bowel injury: a prospective study. J Trauma 2005; 58:696.
  33. Ekeh AP, Saxe J, Walusimbi M, et al. Diagnosis of blunt intestinal and mesenteric injury in the era of multidetector CT technology--are results better? J Trauma 2008; 65:354.
  34. Phelan HA, Velmahos GC, Jurkovich GJ, et al. An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study. J Trauma 2009; 66:641.
  35. Allen TL, Mueller MT, Bonk RT, et al. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004; 56:314.
  36. Stafford RE, McGonigal MD, Weigelt JA, Johnson TJ. Oral contrast solution and computed tomography for blunt abdominal trauma: a randomized study. Arch Surg 1999; 134:622.
  37. Neal MD, Peitzman AB, Forsythe RM, et al. Over reliance on computed tomography imaging in patients with severe abdominal injury: is the delay worth the risk? J Trauma 2011; 70:278.
  38. ROOT HD, HAUSER CW, MCKINLEY CR, et al. DIAGNOSTIC PERITONEAL LAVAGE. Surgery 1965; 57:633.
  39. Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma 2009; 67:330.
  40. Marx, JA. Peritoneal procedures. In: Clinical procedures in emergency medicine, 3rd ed, Hedges, JR, Roberts, JR (Eds), WB Saunders, Philadelphia 1997.
  41. Henneman PL, Marx JA, Moore EE, et al. Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma 1990; 30:1345.
  42. Radlauer, M, Marx, JA, Moore, EE. Peritoneal aspiration in patients with pelvic fractures. J Emerg Med 1993; 11:372.
  43. Mendez C, Gubler KD, Maier RV. Diagnostic accuracy of peritoneal lavage in patients with pelvic fractures. Arch Surg 1994; 129:477.
  44. Otomo Y, Henmi H, Mashiko K, et al. New diagnostic peritoneal lavage criteria for diagnosis of intestinal injury. J Trauma 1998; 44:991.
  45. Marx JA, Bar-Or D, Moore EE, Tercier JA. Utility of lavage alkaline phosphatase in detection of isolated small intestinal injury. Ann Emerg Med 1985; 14:10.
  46. Branney SW, Moore EE, Cantrill SV, et al. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma 1997; 42:1086.
  47. Blackbourne LH, Soffer D, McKenney M, et al. Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma. J Trauma 2004; 57:934.
  48. Thomason M, Messick J, Rutledge R, et al. Head CT scanning versus urgent exploration in the hypotensive blunt trauma patient. J Trauma 1993; 34:40.
  49. Winchell RJ, Hoyt DB, Simons RK. Use of computed tomography of the head in the hypotensive blunt-trauma patient. Ann Emerg Med 1995; 25:737.
  50. Weinberg JA, McKinley K, Petersen SR, et al. Trauma laparotomy in a rural setting before transfer to a regional center: does it save lives? J Trauma 2003; 54:823.