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?
急诊室因为一多发性创伤患者请您会诊。患者，男性，黑人，24岁，其驾驶一高速行驶的摩托车与汽车相撞，坐在摩托后坐的搭乘者当场死亡。初步检查后发现，患者颈椎固定，绑在硬板床上。下颏部头皮裂伤，多处面部撕裂，腹部明显膨隆，并呈濒死呼吸。已建立静脉通路并气管插管。
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？
参考答案：
1、 首先您会如何处理该患者？
显然，在这种情况下需要一个成立一个协调小组。前期处理包括确保颈椎稳定及初步判断，包括检察呼吸道、呼吸、循环情况（创伤复苏A、B、C）。应注意伤口出血情况，及时诊断并处理危及生命的紧急情况如张力性气胸或急性心包填塞。本例患者，腹内损伤成为处理的难点。在病情并未稳定的情况下，诊断性腹腔灌洗（DPL）可用于快速准确的用于腹腔内出血的诊断。对病情稳定的患者，可行腹腔CT检察用于诊断实质脏器的损伤。
2、 钝性损伤患者最常见的腹内脏器损伤是什么？
钝性损伤患者最常见的腹内脏器损伤是脾脏。从胚胎学上看，在五周胎龄时脾脏为靠近胰腺尾部的胃背系膜的延伸增厚部分，表现为8-10mm的胚胎。脾脏主要是一个富含血液供应的淋巴器官，其血供主要来自脾动脉和胃短动脉。在脾脏内，巨噬细胞可吞噬衰老的血细胞和细菌。脾脏也可针对有荚膜细菌产生IgM、IgG、裂解素及吞噬刺激肽，从而发挥免疫作用。
3、 脾脏损伤的特点？
创伤后，脾脏损伤患者可有腹痛或腹胀。如同时伴有其他部位损伤（如长骨骨折）或药物、酒精中毒等，腹部体征可为阴性。不稳定患者，DPL>100，000RBC/cc可诊断腹膜内出血。左侧位置较低的肋骨骨折（9-11）常合并脾损伤。病情稳定患者，可行腹部CT检察，不仅可很大程度的诊断脾脏损伤，也可发现其他腹部隐匿性损伤。
表1 脾脏损伤评分
可通过腹部CT检查进行脾脏损伤的分级。
病情不稳定患者常需要手术治疗。挽救脾脏功能的手术方法有很多，包括脾缝合术、脾脏局部止血、脾脏部分切除术、脾脏包扎。脾脏损伤严重无法保留或患者情况较差时，可行脾脏切除术。
4、 为什么脾脏损伤的非手术治疗越来越广泛？
考虑到脾切除术后爆发性脓毒症（OPSI）的出现，特别是在小儿患者发生更多，因此非手术治疗的观点日益流行。OPSI常为荚膜细菌导致的脓毒症所致，而无脾患者不能消灭荚膜细菌。肺炎链球菌、脑膜炎双球菌、结肠E、流感嗜血杆菌、葡萄球菌及其他链球菌属是主要致病因素。50%的病例出现在脾切除术后2年内。术前或术后的接种疫苗处理可有一定的预防作用。大多数只有单纯脾脏损伤的患儿常不需要手术治疗，而成人患者的非手术治疗主要局限于不需要输血治疗的血流动力学稳定患者。
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.
References:
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.
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