处理肝外伤应当注意的几个问题

临床上急诊处理肝外伤,首先必须关注的问题是腹腔内出血以及可能导致的出血性休克,循环复苏是抢救的要点.肝外伤常伴有大血管、胆管或其他脏器的损伤,病情危急,急诊处理的方式意义重大.由于肝外伤多为非上班时间或夜间急诊入院,经验丰富的高年资医师多不在现场,值班医师对肝外伤的严重程度和患者的状况的评估以及选择治疗方式至关重要.     

Nonoperative management of athletic ankle injuries

Few injuries in sports are more ubiquitous than those involving the ankle. Athletes in some endeavors, notably football and basketball, routinely have their ankles prophylactically taped at a cost of hundreds of thousands of dollars and, probably, millions of man hours. Other sports, such as skiing, involve encasement of the foot, ankle and lower leg in plastic and foam to the extent of almost complete exclusion of motion. In spite of these rather heroic measures, ankle injuries continue to constitute a significant threat to athletes in these and most other activities.     

Nonoperative and operative management of snapping scapula

Snapping scapula is a painful crepitus of the scapulothoracic articulation. This crepitus is a grinding or snapping noise with scapulothoracic motion that may or may not accompany pain. This condition is commonly seen in overhead-throwing athletes. Treatment of patients with this syndrome begins with nonoperative methods; when nonoperative treatment fails, several surgical options exist. This article will discuss both nonoperative and operative management of this common shoulder condition.     

Nonoperative management of benign postoperative biliary strictures

Selected benign biliary strictures can be treated safely and successfully by percutaneous balloon dilatation. Primary biliary strictures appear to be less responsive to balloon dilatation alone and require stenting with large catheters (16-20 F) for several months to permit scarring around the catheter. A long period of healing around such a large-bore stent is crucial to the success of such treatment. The most important physiologic indicators for successful dilatation are a long period of stricture challenge with a catheter placed proximal to the dilated segment to allow bile to drain internally across the previously strictured segment, and a near anatomic result as demonstrated by cholangiogram.     

Expanding role of emergency embolization in the management of severe blunt hepatic trauma

Emergency embolization using Gelfoam particles alone, or in combination with stainless steel coils or epinephrine, was attempted in 4 patients with severe blunt hepatic trauma complicated by hypovolemic shock to control exsanguinating hemorrhage. Angiography prior to embolization revealed extravasation in all cases. None of the patients rebled or required further intervention. Postembolization course was uneventful in each case. Embolization could become the treatment of choice for more unstable and complicated patients than previously considered.     

Imaging of blunt hepatic trauma

This article focuses on the clinical role of high resolution computed tomography (CT) in the initial diagnosis and management of hemodynamically stable patients with blunt hepatic trauma. The increased utilization and diagnostic confidence afforded by CT has dramatically changed the surgical approach and need for laparatomy. The most important development has been the growing realization by many trauma surgeons that nonoperative management is often successful in stable patients who have CT evidence of isolated blunt hepatic trauma.     

交通事故所致肝脏损伤76例急救分析

目的探讨交通事故所致肝脏损伤的特点、手术时机与救治成功率的关系。方法对76例交通事故所致肝脏损伤病例的病例资料进行回顾性分析,探讨其多发伤的临床特点,比较不同手术时机与救治成功率的关系。结果本组67例(88．2％)合并多脏器损伤,伤后6小时内行了肝止血术的伤者有较高的救治成功率。结论早期诊断,及时实施合理的手术以及行有效止血是提高救治成功率的关键。     

Computed tomography in hepatic trauma

Twenty-five patients with hepatic injury from blunt upper abdominal trauma were examined by computed tomography (CT). The spectrum of CT findings was recorded, and the size of the hepatic laceration and the associated hemoperitoneum were correlated with the mode of therapy used in each case (operative vs. nonoperative). While the need for surgery correlated roughly with the size of the hepatic laceration, the size of the associated hemoperitoneum was an important modifying factor. Fifteen patients with hepatic lacerations but little or no hemoperitoneum were managed nonoperatively. CT seems to have significant advantages over hepatic scintigraphy, angiography, and diagnostic peritoneal lavage. By combining information on the clinical state of the patient and CT findings, therapy of hepatic injury can be individualized and the incidence of nontherapeutic laparotomies decreased.     

Nonoperative management for in-season athletes with anterior shoulder instability

BACKGROUND: Acute or recurrent anterior shoulder instability is a frequent injury for in-season athletes. Treatment options for this injury include shoulder immobilization, rehabilitation, and shoulder stabilization surgery. PURPOSE: To determine if in-season athletes can be returned to their sports quickly and effectively after nonoperative treatment for an anterior instability episode. METHODS: Over a 2-year period, 30 athletes matched the inclusion criteria for this study. Nineteen athletes had experienced anterior dislocations, and 11 had experienced subluxations. All were treated with physical therapy and fitted, if appropriate, with a brace. These athletes were followed for the number of recurrent instability episodes, additional injuries, subjective ability to compete, and ability to complete their season or seasons of choice. RESULTS: Twenty-six of 30 athletes were able to return to their sports for the complete season at an average time missed of 10.2 days (range, 0-30 years). Ten athletes suffered sport-related recurrent instability episodes (range, 0-8 years). An average of 1.4 recurrent instability episodes per season per athlete occurred. There were no further injuries attributable to the shoulder instability. Sixteen athletes underwent surgical stabilization for their shoulders during the subsequent off-season. CONCLUSIONS: Most of the athletes were able to return to their sport and complete their seasons after an episode of anterior shoulder instability, although 37% experienced at least 1 additional episode of instability during the season.     

Nonoperative management of malignant biliary obstruction: a radiologic alternative

Twelve patients with advanced malignant biliary obstruction were managed with a combination of sonography, percutaneous fine-needle aspiration biopsy, transhepatic cholangiography, and percutaneous biliary drainage. Excellent palliation of biliary obstruction was obtained in nine patients, four of whom are still living. Surgery was avoided in all cases, and a single episode of sepsis was the only complication. The literature indicates that surgical bypass procedures for malignant bile duct obstruction incur an average 20% operative mortality and provide only a 6 month mean survival. A combined radiologic approach offers an alternative to standard operative management of malignant biliary obstruction. When the cost-benefit ratios of operative vs. nonoperative management are considered, perhaps more patients should undergo radiologic management.     

闭合性肝外伤的治疗决策

目的探讨闭合性肝外伤治疗方案的进展。方法回顾性分析15年来解放军总医院急诊收治的闭合性肝外伤患者的临床资料，结合近年国内外相关文献，从流行病学角度阐述国内外在闭合性肝外伤治疗方案选择上的异同及变化。结果国内闭合性肝外伤非手术治疗比例（10％～30％）与国外（50％～80％）相比仍偏低，相关CT检查应用还不充分，治疗方案选择观念较陈旧。结论非手术治疗是闭合性肝外伤治疗的重要手段，血流动力学稳定的患者均可列为候选对象；应适当扩大CT检查指征；临床上观念更新很有必要。     

急性肝创伤的CT诊断

目的：总结急性肝创伤CT扫描的各种影像表现并对其分型，评价其诊断价值。方法：总结回顾我院50例肝创伤住院患者的CT扫描结果。将其影像表现，临床症状，手术结果相对照，并按美国创伤外科学会（AAST）的分型标准对损伤程度进行分型。结果：本组50例患者中，48例CT检查阳性，阳性征象包肝挫伤21例次，肝撕裂伤32例次，肝内血肿12例次，肝包膜下血肿20例次及门静脉周围轨迹征5例次，此48例CT诊断肝创伤与临床情况，手术结果相符，其中Ⅰ度损伤8例，Ⅱ度损伤15例，Ⅲ度损伤19例，Ⅳ度损伤4例，Ⅴ度损伤2例，2例CT检查阴性，但手术中见有小撕裂伤。结论：急诊CT检查诊断肝创伤安全、迅速、准确，同时可以发现腹部其他脏器损伤，为临床处置提供可靠信息，是肝脏急性创伤诊断的首选方法。     

Priorities in trauma management

The overriding concern in trauma care is not only to minimize mortality, but to maintain a functional human being. Treatment should first be directed to preserve the brain and the cardiopulmonary viscera.     

以循证医学为依据的创伤处理指南

本文以循证医学为基础,总结了10类常见严重创伤的急救处理指南,以及运用特殊的分析方法和决策手段来评估临床资料,制定医疗卫生决策、规范医疗服务行为,从而提供经济、高效的医疗服务。通过筛选高质量的临床证据,对创伤进行系统的评估,使医护工作实践基于合理的证据,而非主观经验之上,并利用证据建立标准化的医疗护理体系,以达到改善病人预后、减少医疗费用之目的。     

Non-operative management of liver trauma

The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.     

心脏创伤诊治体会

目的 探讨心脏创伤的诊断、手术方式及围手术期处理方法。方法 回顾分析1982年10月～1999年7月我科收治的心脏创伤11例病历资料,其中锐器伤10例,钝性心脏创伤例。11例全部经手术抢救治疗。结果 10例抢救成功痊愈出院,1例死亡。结论 尽早诊断、积极剖胸探查、迅速解除心包压塞、控制出血是心脏创伤抢救成功的关键。     

The management of pancreatic trauma

Pancreatic trauma is an uncommon occurrence and so a consensus about optimal management is not readily available. Isolated pancreatic injury occurs only occasionally, as in the majority of cases there is concurrent visceral or vascular injury. Morbidity and mortality are related to delay in diagnosis, concurrent organ injury or the presence and extent of pancreatic duct injury.