2007-04-02 00:00 来源:丁香园 作者:西门吹血
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We continue our discussion of polytrauma today.

You are called to the Emergency Room to aid in the care of a multiply injured trauma patient. The patient is a 24-year old black male who was involved in a high-speed motorcycle accident with a car. The second passenger on the motorcycle died at the scene. Upon primary survey, you find that your patient's c-spine is immobilized and strapped to a backboard. He has a bleeding de-gloving scalp laceration, multiple facial lacerations, a grossly distended abdomen, and an agonal breathing pattern. Attempts are made to obtain intravenous access. The patient is successfully intubated.

1.  How would you initially manage this multiply injured patient?
2.  What is the most commonly injured intra-abdominal organ with blunt trauma?
3.  How are splenic injuries characterized?
4.  Why has non-operative management of splenic injuries become more popular?


1、  首先您会如何处理该患者?
2、  钝性损伤患者最常见的腹内脏器损伤是什么?
3、  脾脏损伤的特点?
4、  为什么脾脏损伤的非手术治疗越来越广泛?


1、  首先您会如何处理该患者?


2、  钝性损伤患者最常见的腹内脏器损伤是什么?


3、  脾脏损伤的特点?


表1 脾脏损伤评分



4、  为什么脾脏损伤的非手术治疗越来越广泛?


How would you initially manage this multiply injured patient?

Clearly, management of this patient requires a coordinated team approach. Priorities in management include cervical stabilization and primary survey including attention to airway, breathing, and circulation (A,B,C's of trauma resuscitation). Attention should be paid to bleeding wounds and the diagnosis and management of life-threatening emergencies such a tension pneumothorax or cardiac tamponade. In this particular case, the scenario is worrisome for an intra-abdominal injury. In unstable patients, a diagnostic peritoneal lavage (DPL) is warranted to rapidly diagnose intra-abdominal bleeding. For stable patients, abdominal CT will readily diagnose solid organ injury.

What is the most commonly injured intra-abdominal organ with blunt trauma?

The most commonly injured intra-abdominal organ with blunt trauma is the spleen. Embryologically, the spleen appears as a thickening in the dorsal mesogastrium near the tail of the pancreas in the 8-10 mm embryo during the fifth week of fetal life. The spleen is primarily a lymphoid organ with a rich blood supply from end segmental arteries via splenic and short gastric arteries. Within the spleen, macrophages phagocytose aged blood cells and bacteria. The spleen also produces IgM. IgG, properdin, and tuftsin, all of which serve immunologic roles against encapsulated bacteria.

How are splenic injuries characterized?

Following trauma, patients with splenic injury may have abdominal pain or distension. If there are distracting injuries (e.g., long bone fractures) or drug or alcohol intoxication, the abdominal exam may be silent. In the unstable patient, a DPL with >100,000 RBC's/cc is diagnostic of intraperitoneal bleeding. Left lower rib fractures (9-11) are associated with splenic injuries. For stable patients, an abdominal CT scan can be enormously helpful to characterize the splenic injury and potential associated injuries.

Table I. Splenic Injury Scale

The abdominal CT scan has allowed us to grade splenic injuries as depicted in Table I.

For therapeutic interventions, unstable patients require operative management. Operative management consists of various strategies to salvage the spleen including splenorraphy, topical hemostasis, partial splenectomy, and splenic wrapping. For unsalvageable spleens or patient instability, emergent splenectomy is indicated.

Why has non-operative management of splenic injuries become more popular?

Concerns for the development of overwhelming post splenectomy sepsis (OPSI), particularly in the pediatric population, popularized the concept of non-operative management of splenic injuries. OPSI results from the development of sepsis caused by encapsulated bacteria that the asplenic host can not eradicate. Streptococcus pneumoniae, Meningococcus, E. coli, Haemophilus influenza, Staphylococcus species, and other Streptococcus species are the primary culprits. 50% of cases occur within two years of splenectomy. Preoperative, if possible, or postoperative vaccines provide some protection. The majority of isolated splenic injuries in children heal without surgery. Non-operative management in the adult population is limited to hemodynamically stable patients who have minimal transfusion requirements.


1.  Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, kidney. J Trauma 1989;29:1664.
2.  Management of Trauma: Pitfalls and Practice, 2nd edition. Edited by Wilson RF & Walt AJ. Williams & Wilkins, 1996.


编辑: ache