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颈部穿透伤的初始评估和处理

Author
Kim Newton, MD
Section Editors
Maria E Moreira, MD
Richard G Bachur, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM
Translators
王林, 主治医师

引言

颈部穿透伤(penetrating neck injury, PNI)指的是颈部受到枪伤(gunshot wound, GSW)、刺伤(stab wound, SW)或穿透性碎片(如，玻璃或弹片)造成的穿透颈阔肌的损伤。PNI可引起呼吸消化系统和神经血管系统的损伤。

在第二次世界大战之前，所有PNI都采取期待治疗(“观察和等待”)，使得死亡率高达35%[1]。为了降低PNI相关的、不可接受的高死亡率，人们开始采用强制性外科治疗。不管患者的体征和症状如何、病情稳定情况或损伤部位如何，所有PNI患者均进行探查手术。这一方法显著降低了死亡率[2]。对PNI的强制性手术探查得到广泛认可一直到20世纪90年代，此时很明确的是，尽管强制性手术改善了结局，但它有不可接受的高阴性探查率(一项大型病例系列研究显示，58%的患者没有遭受严重损伤)[3]。

由于较高的阴性手术率，人们发展出了在PNI稳定患者中基于区域的选择性手术方法。这一新方法为急诊科医生和外科医生提供了基于颈受伤部位(图 1)和患者状态的一系列诊断和治疗方法。分区选择性手术方法的基本原理，在一定程度上是基于：相比于更具技术挑战的Ⅰ区和Ⅲ区损伤，外科医生手术到达Ⅱ区(颈中部)损伤部位相对容易。对有症状的稳定患者的最好方法存在很多的争议[1,4,5]。一个持久的争论是，是否所有Ⅱ区PNI都需要手术探查，或者是某些特定患者可采取非手术治疗。

在20世纪90年代和21世纪早期，大部分研究和许多创伤外科医生支持某种选择性处理方案。一项早期回顾性研究得出结论，不管是采取强制性手术还是选择性处理，Ⅱ区损伤的结局相似，而随后的研究则支持选择性方法[4,6-9]。美国东部创伤外科学会(Eastern Association for the Surgery of Trauma, EAST)的实践指南指出，这两种方案均是合理、安全的[10]。

在某种程度上由于诊断性影像学的发展，人们开发出了“不分区”的处理策略[11]。这一策略将患者分类为不稳定和稳定两类，而不是根据颈部损伤的区域，将不稳定患者迅速转移至手术室。病情稳定但有症状的患者进行多排螺旋计算机断层扫描血管造影(multidetector computed tomography angiography, MDCT-A)，这一检查结果结合其他检查发现有助于确定是进行进一步的诊断性检查还是需要手术干预。

                             

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Literature review current through: 2017-07 . | This topic last updated: 2017-06-07.
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