肝外伤的诊治体会(附55例报告)

目的 总结肝外伤的诊断和治疗经验.方法 回顾55例肝外伤患者的临床资料.结果 55例肝外伤中Ⅰ～Ⅱ级18例,Ⅲ级15例,Ⅳ级17例,Ⅴ级5例;采用非手术治疗31例,均痊愈;于术治疗24例,痊愈22例,自动出院2例.结论 肝外伤诊断以伞腹B超和腹腔穿刺为首选检杏,血液动力学稳定时可行腹部CT平扫或加增强扫描对判断是否行于术治疗彳丁帮助.目前,肝外伤的治疗主要考虑两个方面:血液动力学的稳定性和外伤的性质:钝挫伤或贳通伤;在判断是否行保守治疗时,血液动力学稳定性比肝外伤分级相对更重要.对血液动力学稳定的Ⅰ级、Ⅱ级和部分Ⅲ级钝性肝外伤可存严密连续临测下行非于术治疗;根据m液动力学变化和伤情判断及时中转于术;对血液动力学不稳定的部分Ⅲ级、Ⅳ级和Ⅴ级严重肝外伤以下术治疗为宜.早期复苏、有效止血、充分引流和防治术后并发症足降低严重肝外伤病死率的关键.     

儿童闭合性肝外伤治疗体会

目的　探讨儿童闭合性肝外伤的治疗经验和体会。方法　作者回顾性分析了 1995～ 2 0 0 3年所有闭合性肝外伤的临床病例共有 30例。。均有明确的腹部外伤史。创伤原因以车祸伤居首位 ,其次为撞击伤和坠落伤。运用 PTS和 AAST对肝外伤程度作评估。结果　根据 AAST分级 , 级肝外伤 2例 , 级肝外伤 4例。其中 3例手术 ,1例死亡。PTS评分≤ 8有 3例 ,PTS>8有 2 7例。其中有 2例手术。30例患者中 ,共有 5例作手术治疗 ,包括部分肝切除和肝、大血管修补术 ,占总数的 16 .7% ,其余 2 5例均作保守治疗。在所有患者中 ,并发肝脓肿 2例 ,腹腔感染 2例 ,腹腔包裹性积液 3例 ,胸水 4例。其中 1例肝脓肿和 2例包裹性积液作外引流。除 1例死亡外 ,其余 2 9例患者均恢复良好。结论　儿童闭合性肝外伤的治疗以保守治疗为主。运用 PTS外伤评分和 AAST分级对肝外伤的严重程度作出初步评估 ,对治疗和预后有积极作用 ,在治疗过程中 ,综合分析和评价显得尤为重要     

57例闭合性肾外伤的诊断和治疗

目的 提高闭合性肾外伤的诊治效果。方法 回顾分析我院近10年来57例肾外伤的诊治资料：结果 本组非手术治疗45例，手术治疗12例，治愈55例，死亡2例。结论 肾外伤的分级需通过临床表现结合影像学检查综合判定。CT和大剂量的IVU对明确肾脏损伤的程度及是否存在着合并伤提供确实可靠的依据。肾外伤的治疗尽量采取保守治疗，即使手术治疗也需最大程度的保留更多的肾组织。     

外伤性脾破裂91例诊治分析

目的总结外伤性脾破裂的诊治经验。方法回顾性分析91例外伤性脾破裂的临床资料。结果结合外伤史及腹部体征、腹穿结果及CT、B超等辅助检查确定诊断,区别不同情况保守治疗和选择不同术式的手术治疗。结论手术方法众多,但首要的是抢救生命。     

胰腺外伤的诊治体会

目的 :探讨胰腺外伤的诊断、治疗和预后。方法 :回顾性分析 2 3例闭合性腹外伤致胰腺外伤的诊断、治疗的临床资料。结果 :入院时经CT检查 18例患者 ,明确胰腺损伤诊断者 13例。 2 3例患者均行诊断性腹腔穿刺 ,17例患者抽出不凝血。首诊漏诊 10例 ,漏诊率 43 %。手术治疗 17例 ,保守治疗 6例。手术组并发胰漏 4例 ,胰腺囊肿形成 1例 ,腹腔感染 3例 ,死亡 3例。保守治疗组胰腺假性囊肿形成 4例 ,合并感染 2例 ,创伤性胰腺炎 1例 ,囊肿择期手术致胰漏 1例。结论 :闭合性腹外伤致胰腺外伤早期明确诊断较为困难 ,易漏诊 ,延误治疗。在治疗上因损伤的个体差异大 ,故手术方式的选择应视具体胰腺损伤的性质、部位及合并损伤的脏器而个体化。通畅有效的引流可降低感染、脓腔形成等并发症的发生率 ,并关系到胰漏的早期愈合。双套管持续冲洗及负压引流是一种有效可靠引流方式。对于术中发现胰腺部位腹膜后血肿者应积极的探查 ,以便能及时发现胰腺损伤 ,正确处理。保守观察的患者应及时的复查CT、B超、血 尿淀粉酶 ,以便能及时准确的处理     

肾外伤52例诊断与治疗分析

目的探讨肾外伤分级与肾切除手术指征的关系，提高肾外伤的诊治水平。方法对52例肾外伤的临床资料进行回顾性分析。结果52例肾外伤中30例保守治疗成功，22例行肾切除术。结论对肾外伤患者需及时地诊断、分型，明确提供治疗的依据；患者创伤严重程度、有尢并发伤、全身情况、肾脏有无病理基础和肾切除的手术指征密切相关。     

57倒闭合性肾外伤的诊断和治疗

目的 提高闭合性肾外伤的诊治效果。方法 回顾分析我院近10年来57例肾外伤的诊治资料。结果 本组非手术治疗45例,手术治疗12例,治愈55例,死亡2例。结论 肾外伤的分级需通过临床表现结合影像学检查综合判定。CT和大剂量的IVU对明确肾脏损伤的程度及是否存在着合并伤提供确实可靠的依据。肾外伤的治疗尽量采取保守治疗,即使手术治疗也需最大程度的保留更多的肾组织。     

肝外伤诊断和治疗的改进

为探讨钝性肝外伤时改进诊断和治疗对降低并发症和死亡率的影响，分析了１９５１～１９９６年间长海医院１８０例肝外伤的资料。全组有钝性伤１５２例和开放伤２８例。结果显示：腹腔穿刺诊断钝性肝外伤的阳性率为９２．９％（１０５／１１３），急症室超声检查的阳性率为９６．２％（２５／２６）。治疗方法包括３例非手术治疗和１７７例手术治疗。总并发症发生率、治愈率和总死亡率分别为３２．８％（５９／１８０），８５．６％（１５４／１８０）和１４．４％（２６／１８０）。比较前期（１９５１～１９８８年）与近期（１９８９～１９９６年）的资料，通过近年在诊断和治疗上的改进，并发症发生率有显著差异（Ｐ＜０．０５），死亡率有非常显著差异（Ｐ＜０．０１）。讨论了急症室超声检查对钝性肝外伤早期诊断的价值、非手术治疗的利弊、手术方式的选择和并发症的预防     

多层螺旋CT对钝性肾挫伤的诊断与临床评估

近年来，由于建筑业的迅速发展，以及交通事故、社会治安等问题的增多，临床上肾损伤较为常见。CT评估钝性肾挫伤及其邻近组织病变的敏感性及特异性已为临床重视．并为外科治疗提供重要依据。CT是至关重要的保守或手术治疗病人的依据。为了进一步探讨CT检查在钝性肾挫伤中的诊断及分级对临床治疗的价值．将本院2000年10月至2009年7月收集资料完整的48例钝性肾挫伤分析如下。     

钝性胸部外伤致气管支气管裂伤十例报告

目的探讨钝性胸部外伤所致的气管、支气管断裂的诊治要点,提高早期诊断率、治疗效果及患者生存率。方法回顾性分析我院1990年至2010年间收治的10例钝性胸部外伤所致的气管支气管断裂的病例资料。7例行支气管、气管端端吻合术,1例行气管修补术,2例行狭窄气道切除、支气管端端吻合术。结果术后4例出现了严重感染,住院时间最短20d,最长81d。所有病例术后复查纤支镜,均无异常。结论部分钝性胸部外伤所致的气管支气管断裂极易被误诊,纤支镜与胸部64排CT气管重建能有助于早期诊断。尽早手术治疗与感染的控制是治疗的关键,术后应复查纤支镜了解气道的通畅情况。     

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization

Background

The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation.

Methods

The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications.

Results

One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications.

Conclusions

Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.     

Primary hepatic artery embolization in pediatric blunt hepatic trauma

Non-operative management of isolated blunt hepatic trauma is recommended except when hemodynamic instability requires immediate laparotomy. Hepatic artery angioembolization is increasingly used for hepatic injuries with ongoing bleeding as demonstrated by contrast extravasation on the CT scan. It is used primarily or after laparotomy to control ongoing hemorrhage. Hepatic angioembolization as part of multimodality management of hepatic trauma is reported mainly in adults, with few pediatric case reports. We describe our institution experience with primary pediatric hepatic angioembolization and review the literature with regard to indications and complications. Two cases (3 and 8 years old), with high-grade blunt hepatic injuries with contrast extravasation on the CT scan were successfully managed by emergency primary hepatic angioembolization with minimal morbidity and avoided laparotomy. To date, the only reports of pediatric hepatic angioembolization for trauma are 5 cases for acute bleeding and 15 delayed cases for pseudoaneurysm. The role of hepatic angioembolization in the presence of an arterial blush on CT in adults is accepted, but contested in a pediatric series, despite higher transfusion rate and mortality rate. We propose that hepatic angioembolization should be considered adjunct treatment, in lieu of, or in addition to emergency laparotomy for hemostasis in pediatric blunt hepatic injury.     

Comparison of the ability of adult and pediatric trauma scores to predict pediatric outcome following major trauma

The Pediatric Trauma Score (PTS) has been identified as the only accurate and adequate means of predicting outcome in pediatric trauma. In answer to the increasing number of trauma patients arriving at local hospitals, the ability of the adult Trauma Score (TS) to predict pediatric trauma outcome was tested. Of the total 2,604 pediatric trauma cases in the North Carolina State Trauma Registry, 441 had both a PTS and TS available for analysis. The primary measures of outcome were emergency department and hospital dispositions. Logistic regression demonstrated that TS (R2 = 0.50) was a stronger predictor of pediatric outcome and PTS (R2 = 0.35) for emergency department disposition and TS (R2 = 0.63) with PTS (R2 = 0.51) for hospital disposition. The correlation between TS and PTS was high (R = 0.8). Stepwise discriminant analysis demonstrated that TS was the stronger predictor of outcome and the PTS added only 9% (partial R2 = 0.09) more accuracy to TS for emergency department disposition and only 6% (partial R2 = 0.06) for hospital disposition. The results of this research demonstrate that TS is a useful method of predicting outcome in pediatric trauma. The use of both scores for each patient does not increase the predictive value of the scores.     

Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure

Purpose

We hypothesized that pediatric blunt trauma patients, initially evaluated at nontrauma centers with abdominal computed tomography (CT) scans, often undergo repeat scans after transfer. This study was designed to quantify this phenomenon, assess consequences, and elucidate possible causes.

Methods

This article is an institutional review board-approved, retrospective chart review of pediatric blunt abdominal trauma patients transferred to a level I trauma center from 2002 to 2007 and evaluated with abdominal CT at the trauma center or at a referring facility.

Results

A total of 388 patients met the study criteria, with 6 patients being excluded because of inability to verify outside records resulting in study group of 382 patients. Of those 382 patients, 199 (52%) underwent abdominal CT before transfer. Thirty-six (18%) of those 199 patients underwent repeat CT scanning at our level I trauma center. Of these 36 patients, 19 (53%) were transferred without their outside CT scans, with 10 (53%) of these 19 having significant abdominal injuries. Of the remaining 17, 6 (17%) had repeat scans to assess changes in vital signs, or patient condition, or because of inadequate outside imaging. The remaining 11 (30%) were repeated despite an acceptable outside CT and no change in patient condition. Only 2 of 11 resulted in changed management. Additional radiation delivered from these repeat scans totaled 180 mSv, and additional patient charges totaled more than $110,000. There was an apparent trend toward increased repeat scanning (from 6.7% in 2002 to 16.7% in 2007).

Conclusions

Abdominal CT scans, for evaluation of pediatric blunt trauma, are frequently repeated after transfer from outside hospitals. In many cases, repeat scans provide useful diagnostic information. However, more than 80% of repeat scanning is potentially preventable with better education of transport personnel (paramedics, emergency medical technicians, and nurses) and emergency department physicians.     

多层螺旋CT增强扫描对肾损伤的诊断价值

目的探讨多层螺旋CT（MSCT）增强扫描在肾损伤中的诊断价值。 方法回顾性分析2012年1月至2017年12月间我院收治116例肾损伤患者的MSCT扫描和超声检查资料,其中增强扫描92例,延迟期扫描41例,比较二者在肾损伤临床分级诊断的符合率。 结果根据美国创伤外科协会肾损伤分级标准,对所有患者进行明确诊断和分级,本组116例患者中Ⅰ级26例,Ⅱ级27例,Ⅲ级39例,Ⅳ级14例,Ⅴ级10例;MSCT对Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级、Ⅴ级闭合性肾损伤的分级诊断符合率分别为88.5%、88.9%、89.7%、92.8%、100.0%,显著高于超声的诊断符合率80.7%、81.5%、84.6%、85.7%、90%,二者比较差异具有统计意义（P<0.05）。MSCT平扫有1例考虑右肾损伤行探查发现肾脏完整,而增强扫描与手术结果符合率100%。 结论MSCT增强扫描能快速明确患者肾损伤的程度及合并伤情况,对肾损伤诊断和分级具有重要临床指导价值。     

腹部闭合性外伤与开放性外伤的围手术期临床特征分析

目的分析腹部闭合性外伤与开放性外伤患者围手术期的临床特征,比较两者在外科手术救治过程中的差别。方法回顾性分析2011年1月至2017年12月87例腹部外伤手术患者的临床资料,根据受伤后有无腹部开放性伤口将患者分为闭合组(n=41)和开放组(n=46).使用统计学软件SPSS 26.0进行统计学分析,正态分布的计量资料以平均值±标准差(x±s)表示,组间比较采用t检验。非正态分布的定量资料以中位数M(四分位间距IQR)表示,组间比较采用秩和检验。以P<0.05为差异具有统计学意义。结果致伤因素中,闭合组主要致伤原因为车祸伤,占46.3%,开放组主要致伤原因为刀刺伤,占56.5%。多发伤在闭合组和开放组中分别占58.5%、23.9%0闭合组与开放组相比,术前中性粒细胞与淋巴细胞之比(3.31 vs.2.35)、住院时间(12d vs.9 d)、术中出血量(650 ml vs.400 ml)、伤口乙级愈合(34例vs.28例)、术中输血(38例vs.33例)、肠道-腹壁造痿(25例vs.37例)、术后并发症≤Ⅱ级(23例vs.36例),差异均具有统计学意义(P<0.05)。结论腹部闭合性外伤与开放性外伤具有不同的临床特征,总体而言,闭合性损伤患者病情较重,手术难度大,术后并发症较严重,围手术期管理更复杂,闭合性外伤应当采取专门的诊疗方案。     

A novel streamlined trauma response team training improves imaging efficiency for pediatric blunt abdominal trauma patients

Background/purposeThe morbidity and mortality of children with traumatic injuries are directly related to the time to definitive management of their injuries. Imaging studies are used in the trauma evaluation to determine the injury type and severity. The goal of this project is to determine if a formal streamlined trauma response improves efficiency in pediatric blunt trauma by evaluating time to acquisition of imaging studies and definitive management.MethodsThis study is a chart review of patients < 18 years who presented to a pediatric trauma center following blunt trauma requiring trauma team activation. 413 records were reviewed to determine if training changed the efficiency of CT acquisition and 652 were evaluated for FAST efficiency. The metrics used for comparison were time from ED arrival to CT image, FAST, and disposition.ResultsTime from arrival to CT acquisition decreased from 37 (SD 23) to 28 (SD27) min (p < 0.05) after implementation. The proportion of FAST scans increased from 315 (63.5%) to 337 (80.8%) and the time to FAST decreased from 18 (SD15) to 8 (SD10) min (p < 0.05). The time to operating room (OR) decreased after implementation.ConclusionThe implementation of a streamlined trauma team approach is associated with both decreased time to CT, FAST, OR, and an increased proportion of FAST scans in the pediatric trauma evaluation. This could result in the rapid identification of injuries, faster disposition from the ED, and potentially improve outcomes in bluntly injured children.Type of studyTherapeuticLevel of evidenceLevel III     

Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center?

Purpose

To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging.

Methods

A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry.

Results

A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score < 14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%).

Conclusion

The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging.     

Genitourinary trauma

Genitourinary trauma occurs in up to 10% of all trauma cases and can be associated with significant morbidity and long-term complications if not managed appropriately. The majority of patients presenting with trauma will have had a CT trauma protocol scan which will guide management, but injuries are still missed and good clinical evaluation of the patient is crucial. Iatrogenic injuries, especially to the ureters, bladder and urethra are common, and prompt recognition and management are vital to ensure a good outcome. The management of genitourinary trauma has shifted in recent years towards a more conservative approach. Interventional radiology offers excellent alternative management options in many cases. Where surgical exploration is indicated, the aims are to achieve haemostasis, debride necrotic tissue but also to preserve as much functioning tissue as possible. This article outlines the incidence, investigation and management of trauma to the genitourinary system.     

肝脏外伤的20年诊治体会

目的 总结肝脏外伤的诊治经验.方法 回顾性总结1988年1月～2007年12月260例肝脏外伤病例的临床资料,包括损伤程度、治疗方式、治疗效果和并发症等.结果 经开放于术治疗153例,非手术治疗107例.236例治愈,24例死亡,病死率为10.2%,其中,肝脏损伤Ⅰ～Ⅱ级139例,死亡0例;Ⅲ-Ⅴ级119例,死亡22例;Ⅵ级2例均死亡,死亡与肝脏损伤级别相关.并发症发生82例次,主要包括继发性出血、腹腔感染等.结论 血流动力学稳定的肝脏外伤患者可在有效监护下选择非手术治疗,血流动力学不稳定的患者应及时于术止血,多学科的协作处理可扩大非手术治疗的应用,减少并发症.