腹部创伤最好的分类依据是按照损伤机制划分为钝性腹部损伤或穿透性腹部损伤。损伤机制决定了诊断性检查。腹部损伤的范围广泛,因此腹部创伤患者常难以评估。如果再涉及更为复杂的因素,例如伴随的腹外损伤及意识状态改变(由于头部损伤或中毒),就会使评估更加困难。[1]Enderson BL, Reath DB, Meadors J, et al. The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990 Jun;30(6):666-9.
http://www.ncbi.nlm.nih.gov/pubmed/2352294?tool=bestpractice.com
本专题仅包括对成人腹部创伤的评估。有关儿童腹部创伤的信息,请参阅“儿童腹痛评估”专题。
解剖学
腹部的表面解剖标志为,前侧上至乳头线,下至两侧腹股沟皱褶,后侧上至两侧肩胛骨下缘,下至臀部皮肤皱褶。腹部的特殊解剖界限是:膈肌、腹壁肌肉组织、盆腔骨骼结构和脊柱。腹部有 3 个基本区域:腹膜腔及其腔内组织、腹膜后腔、盆腔。膈肌上升至第 4 肋间隙时,低位胸部创伤可能会累及腹部器官。
腹部钝性外伤
钝性腹部创伤的原因包含:机动车事故 (motor vehicle accident, MVA)、摩托车交通事故 (motorcycle crash, MCC)、行人-机动车碰撞、坠落和遭受攻击。机动车事故是最常见的钝性腹部创伤原因,导致 75% 的该类损伤。2016 年在美国,34,439 例致死性机动车事故导致 37,461 例死亡,摩托车交通事故相关死亡有 5286 例,行人死亡有 5987 例。[2]National Highway Traffic Safety Administration. Fatality analysis reporting system (FARS): 2016. September 2017 [internet publication].
http://www-fars.nhtsa.dot.gov/Main/index.aspx
近1/3的死者涉及到酒精因素。[3]National Highway Traffic Safety Administration. Traffic safety facts: 2016 data. October 2017 [internet publication].
https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812450
一些预防策略,譬如禁止酒驾、鼓励使用安全带,已经被证实可减少腹部钝性外伤相关的致死和致残。[4]American College of Emergency Physicians. Motor vehicle safety. Ann Emerg Med. 2009 May;53(5):698.
http://www.ncbi.nlm.nih.gov/pubmed/19380055?tool=bestpractice.com
[5]Centers for Disease Control and Prevention (CDC). Impact of primary laws on adult use of safety belts - United States, 2002. MMWR Morb Mortal Wkly Rep. 2004 Apr 2;53(12):257-60.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5312a2.htm
http://www.ncbi.nlm.nih.gov/pubmed/15057190?tool=bestpractice.com
[6]Allen S, Zhu S, Sauter C, et al. A comprehensive statewide analysis of seatbelt non-use with injury and hospital admissions: new data, old problem. Acad Emerg Med. 2006 Apr;13(4):427-34.
https://onlinelibrary.wiley.com/doi/epdf/10.1197/j.aem.2005.11.003
http://www.ncbi.nlm.nih.gov/pubmed/16531597?tool=bestpractice.com
[7]Goss CW, Van Bramer LD, Gliner JA, et al. Increased police patrols for preventing alcohol-impaired driving. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005242.
http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005242.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/18843684?tool=bestpractice.com
腹部钝性外伤可导致多器官损伤。并发症包括:腹膜炎、出血性休克和死亡。常见外伤可分为两类:实质脏器(如肝、脾、胰腺、肾)损伤以及空腔脏器(胃、大肠、小肠、胆囊、膀胱)损伤。实质脏器损伤包括从轻度的无血液动力学意义的肝、脾或肾脏裂伤等轻微损伤到需要立即干预的致命损伤。肠道损伤需要手术修复以防止腹膜炎及感染性休克。
膈肌损伤在腹部钝性外伤中不到10%,脾脏损伤在钝性外伤中更为常见。
胰腺损伤很罕见。一般来说,它更可能是由钝性腹部创伤引起,但在一些国家/地区(如南非)和军人中,穿透性损伤可能更常见。[8]Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:56.
https://www.doi.org/10.1186/s13017-019-0278-6
http://www.ncbi.nlm.nih.gov/pubmed/31867050?tool=bestpractice.com
腹部穿透伤
腹部穿透伤是异物穿透皮肤所致。最常见的穿透伤为枪弹伤和刺伤。在美国,穿透伤仍然是导致疾病和死亡的主要原因,2019 年,与火器伤相关的死亡人数达 39,707。[9]Centers for Disease Control and Prevention. Fatal injury reports, national, regional and state, 1981 - 2020. Feb 2020 [internet publication].
https://wisqars.cdc.gov/fatal-reports
在这些死者中,38,850 例是故意伤害所致死亡(即自杀或谋杀),486 例是意外死亡。[9]Centers for Disease Control and Prevention. Fatal injury reports, national, regional and state, 1981 - 2020. Feb 2020 [internet publication].
https://wisqars.cdc.gov/fatal-reports
但在欧洲国家,火器伤要少见得多。[10]Krüsselmann K, Aarten P, Liem M. Firearms and violence in Europe-a systematic review. PLoS One. 2021;16(4):e0248955.
https://www.doi.org/10.1371/journal.pone.0248955
http://www.ncbi.nlm.nih.gov/pubmed/33852590?tool=bestpractice.com
穿透伤的表面伤口和其腹腔内伤口之间并无联系。 界定穿透伤口的腔道,考虑所有可能的内部损伤非常重要。 腹部穿透伤的死亡和其所造成的腹腔内器官损伤有必然联系,其中难治性的失血性休克是主要死因。[11]Nicholas JM, Rix EP, Easley KA, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma. 2003 Dec;55(6):1095-108.
http://www.ncbi.nlm.nih.gov/pubmed/14676657?tool=bestpractice.com
与钝性创伤后果相比,穿透性腹部创伤之后,胃、小肠和结直肠损伤的发生率更高。小肠是穿透性腹部创伤中最常受损的器官。
在胸-腹腔穿透伤中,膈肌损伤的发生率较高。[12]Powell BS, Magnotti LJ, Schroeppel TJ, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008 May;39(5):530-4.
http://www.ncbi.nlm.nih.gov/pubmed/18336818?tool=bestpractice.com