胸腹部刺伤的持续诊断挑战。

The persistent diagnostic challenge of thoracoabdominal stab wounds.

机构信息

From the Division of Trauma Surgery and Surgical Critical Care, Los Angeles County Medical Center-University of Southern California, Los Angeles, California.

出版信息

J Trauma Acute Care Surg. 2014 Feb;76(2):418-23. doi: 10.1097/TA.0000000000000120.

DOI:10.1097/TA.0000000000000120

PMID:24458047

Abstract

BACKGROUND

Penetrating thoracoabdominal trauma, with potential injury to two anatomic cavities, significantly challenges surgical management, yet this injury pattern has not been reviewed across a large patient series.

METHODS

The trauma registry of a major level 1 center was queried for all adult patients admitted with thoracoabdominal stab wounds between January 1996 and December 2011.

RESULTS

The study identified 617 patients; 11% arrived hypotensive (systolic blood pressure < 90 mm Hg), 6.5% had Glasgow Coma Scale (GCS) score less than 8, and 3.6% were in cardiac arrest. Of those arriving alive, 350 (59%) of 595 underwent surgery (88% laparotomy, 3% thoracotomy, and 9% both procedures). Nontherapeutic laparotomy was performed on 12.3% of these patients. Cardiac injury occurred in 71% (29 of 41) of the patients arriving alive undergoing thoracotomy. Among this group, only 1 (2.4%) of 41 had a major thoracic vessel or aortic injury without cardiac trauma. Diaphragmatic injury (DI) occurred in 224 (38%) of 595, with 72 (32.1%) of these 224 demonstrating no computed tomographic evidence of DI. Either hollow viscus injury or DI occurred in 50%. Only 36.8% of liver, 58% of spleen, and 29.8% of kidney injuries required surgical repair. The need for dual-cavitary intervention was associated with a precipitous increase in patient mortality.

CONCLUSION

Patients with thoracoabdominal stab wounds present considerable clinical challenges due to high surgical need, high occult DI incidence, persistently high rates of negative laparotomy, and significant mortality with dual-cavitary intervention. Many patients with solid-organ injuries do not require intervention. High incidence of hollow viscus injury and DI ultimately limits nonoperative management. Laparoscopy is necessary to exclude occult DI. In unstable patients, determination of which anatomic cavity to explore primarily requires exclusion of cardiac injury. In those with equivocal clinical or ultrasonographic evidence of cardiac trauma, laparotomy, with transdiaphragmatic pericardial window, if a causative abdominal injury is not immediately apparent, seems the most effective strategy.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

摘要

背景

穿透性胸腹联合创伤，可能导致两个解剖腔受伤，这对手术治疗构成了重大挑战，但这种创伤模式尚未在大量患者系列中进行回顾。

方法

对一家主要的 1 级中心的创伤登记处进行了检索，以获取 1996 年 1 月至 2011 年 12 月期间所有因胸腹刺伤而入院的成年患者的数据。

结果

研究共纳入 617 例患者；11%的患者到达时血压低（收缩压<90mmHg），6.5%的患者格拉斯哥昏迷评分（GCS）<8，3.6%的患者发生心搏骤停。在存活到达的患者中，595 例中有 350 例（59%）接受了手术（88%剖腹术，3%开胸术，9%两者均行）。对这些患者中的 12.3%进行了非治疗性剖腹术。在接受开胸术的存活患者中，有 71%（29/41）发生了心脏损伤。在这一组中，只有 1 例（2.4%）发生了无主要胸血管或主动脉损伤的心脏创伤。膈损伤（DI）发生于 595 例中的 224 例（38%），其中 72 例（32.1%）无膈肌损伤的 CT 证据。有或无中空脏器损伤的发生率为 50%。仅 36.8%的肝损伤、58%的脾损伤和 29.8%的肾损伤需要手术修复。需要双腔干预与患者死亡率的急剧增加有关。

结论

胸腹刺伤患者由于手术需求高、隐匿性膈肌损伤发生率高、持续存在剖腹术阴性率高以及双腔干预死亡率高，带来了相当大的临床挑战。许多实质性器官损伤的患者不需要干预。中空脏器损伤和 DI 的高发率最终限制了非手术治疗。腹腔镜检查对于排除隐匿性膈肌损伤是必要的。对于不稳定的患者，确定首先探查哪个解剖腔需要排除心脏损伤。对于那些临床或超声心动图证据不确定的心脏创伤患者，如果立即没有明显的腹部损伤，开胸术联合膈切开术似乎是最有效的策略。