1、A 35 year old executive was the unrestrained driver when her BMW crashed into a retaining wall. She was obtunded （迟钝）at the scene of the crash and had a Glasgow Coma Score of 13. Her blood pressure at the scene was 100/80. Her pulse was 90/min. Her respiratory rate was 16/min. Her past medical histo
2、ry is unremarkable. She is a recreational scuba diver （休闲潜水员）and long distance runner. She does not smoke, and she takes no medications. She was given 1 liter of IV fluid on the way to the hospital. In the Emergency Department you note the following: Glasgow Coma Score=9 BP: 110/90 Pulse:105/min Res
3、piratory rate: 12/min Physical Exam: Head: Frontal abrasion. Pupils react equally to light. Neck: trachea is in the midline; no evident tenderness.（压痛） Chest: Normal breath sounds are heard in all lung fields. There are palpable（可以触诊的）rib fractures on on the left (7,8,9 laterally). Heart: Tachycardi
4、a (105/min), but otherwise normal.（其它正常） Abdomen: There may be mild distention（隆起）. Bowel sounds are scarce. On palpation, the abdomen is soft, with no evidence of tenderness or guarding. Pelvis: Appears stable. Extremities: No evidence of bony deformity. All peripheral pulses are palpable and are e
5、qual bilaterally. What are your initial managements? Initial Management: Blood type and screen（视频监测） Coagulation panel Complete blood count (CBC) Arterial blood gas Arterial blood gases are drawn, and the patient is intubated. The following imaging studies are requested: 1) X-Rays: chest, cervical s
6、pine, pelvis 2) Head CT 3) Abdomen CT Arterial blood gases: Prior to intubation: pH: 7.15; pCO2: 45; pO2: 105 After intubation: pH: 7.11;pCO2: 35; pO2: 254 on 100% oxygen X-rays: Normal except for rib fractures as noted above Head CT: Bi-frontal contusions, no mass effect, open cisterns. Abdomen CT:
7、 Fractured spleen with extravasation（溢出液） and a fractured liver. Blood typing is essential because the patient may need transfusions and possibly surgery. The coagulation panel and CBC will be helpful as baseline and to see if other factors such as plasma may be required. Note that the hematocrit （血
8、细胞容量计）is not going to reflect the amount of bleeding this patient may have because the hematocrit is a percentage of red blood cells in the blood. When a trauma victim bleeds, the shed blood is whole blood (both red cells and plasma) which has the same hematocrit as the intravascular blood. It is on
9、ly after the movement of interstitial fluid into the vascular space in an attempt to increase the total volume does the hematocrit drop from dilution. The arterial blood gas is an important indicator of blood loss, therefore hypoperfusion, resulting in metabolic acidosis (decreased bicarbonate). Dia
10、gnostic techniques used include CT scanning, ultrasound,1 and X-ray.4 X-ray : penetrating object and locate any foreign matter left in the wound.4 Diagnostic peritoneal lavage（腹腔灌洗） :detect injury to abdominal organs 1 Butrisk of injuring the abdominal organs,difficult to perform, may lead to unnece
11、ssary surgery; largely been replaced by ultrasound in Europe and North America.1 Ultrasound :detect fluid .blood or gastrointestinal contents,1 and it is a noninvasive procedure and relatively safe.5 CT :preferred （首选） technique _not at immediate risk of shock, but since ultrasound can be performed
12、right in an emergency room, the latter is recommended for people who are not stable enough to move to CT scanning.1 However, people with abdominal trauma frequently need CT scans for other trauma (for example, head or chest CT); in these cases abdominal CT can be performed at the same time without w
13、asting time in patient care.5 Diagnostic laparoscopy（腹腔镜） or exploratory laparotomy may also be performed if other diagnostic methods do not yield conclusive results.3 CT is only able to detect 76% of hollow viscous injuries and patients who have negative scans must often be observed and rechecked i
14、f they deteriorate.13 However, CT has been demonstrated to be useful in screening patients with certain forms of abdominal trauma in order to avoid unnecessary laparotomies, which can significantly increase the cost and length of hospitalizations.14 A meta-analysis（整合分析） of CT use in penetrating（探测）
15、 abdominal traumas demonstrated sensitivity, specificity and accuracy = 95%, with a PPV of 85% and an NPV of 98%.15 This suggests that CT is excellent for avoiding unnecessary laparotomies but must be augmented by other clinical criteria to determine the need for surgical exploration (23.37 positive
16、 likelihood ratio（概率比）, 0.05 negative likelihood ratio). 分类：分类： （一）（一） 根据颅腔是否与外界相通而分为闭合性和开放性两大类。前者硬膜未破裂前者硬膜未破裂，脑与外，脑与外 界不交通。后者硬膜破裂，脑与外界相交通，伤口常流出界不交通。后者硬膜破裂，脑与外界相交通，伤口常流出 csf 或脑组织。或脑组织。 （二）（二） 标准的诊断书写格式：标准的诊断书写格式： 重度闭合性颅脑损伤重度闭合性颅脑损伤 1.左枕头皮挫裂伤左枕头皮挫裂伤 2.左顶开放性颅骨线性骨折左顶开放性颅骨线性骨折 3.右额颞挫裂伤右额颞挫裂伤 4.右额颞急性硬膜下血肿右额颞急性硬膜下血肿 (1) 挥鞭样损伤 (2)传递性损伤 (3) 胸部挤压伤： 又称创伤性窒息， 外 力 直 接 暴 力 间 接 暴 力 (1) 加速性损伤 (2) 减速性损伤 接触力接触力 惯性力惯性力 着力点伤 挤压伤
