Abdominal trauma

　　Abdominal trauma is mainly caused by external trauma. Abdominal trauma can be divided into open and closed types, and open trauma is easier to diagnose. Closed injuries often occur with abdominal organ injury. The onset of symptoms varies, which is prone to missed or misdiagnosis, resulting in timely treatment and poor prognosis, high mortality. Since abdominal trauma is common in both peacetime and wartime, how to perform early diagnosis and reasonable treatment for abdominal trauma patients is the key to reducing mortality. The following discusses the early correct diagnosis in clinical practice.

　　The mortality rate of abdominal trauma is closely related to the time from injury to definitive surgery. Those who receive correct treatment within two hours after injury have a 90% chance of recovery. With the delay of time, the mortality rate increases significantly, so in order to reduce the mortality rate, it is necessary to strive to shorten the time from injury to definitive surgery, and at the same time, to improve the rescue and diagnosis and treatment technology, to prevent missed diagnosis.

　　After abdominal trauma, common symptoms include nausea, vomiting, hematochezia, and hematuria. Physical examination should pay attention to blood pressure, pulse, and respiration, as well as signs of shock, whether there is bleeding or ecchymosis on the abdominal wall skin, whether it is a closed or open injury, and whether there is any visceral prolapse or organ content leakage inside the wound, as well as the presence of abdominal breathing movement restriction, abdominal distension, abdominal muscle tension, tenderness, mobile dullness, and weakened or absent bowel sounds, which are all manifestations of visceral injury and signs of intra-abdominal hemorrhage. Digital rectal examination should check for tenderness or mass, and whether there is blood on the glove. All abdominal penetrating injuries (open injuries that penetrate the peritoneum) should be considered as having the possibility of visceral injury. Any injury to the chest, lumbar sacral region, buttocks, and perineum (especially firearm injuries) must be carefully examined for abdominal injuries.

　　Abdominal trauma is a relatively common severe external trauma at any time. There is currently no special preventive method for abdominal trauma caused by accidents. Try to keep away from dangerous situations, independently avoid fights and fights, and avoid the occurrence of外伤.

　　

　　The patient should describe in detail to the doctor the time of injury, the location of injury, the nature of violence, the direction of violence, the position at the time of injury, the location, degree, and nature of abdominal pain after injury, whether there is nausea, vomiting, hematochezia, hematuria, and how the treatment and effect are.

　　Physical examination
　　Pay attention to blood pressure, pulse, and respiration, and whether there are signs of shock, abdominal wall skin bleeding or ecchymosis, whether it is a closed or open injury, and carefully check for any visceral prolapse or organ content leakage within the wound, whether there is restricted abdominal breathing movement, abdominal distension, abdominal muscle tension, tenderness, shifting dullness, decreased or absent bowel sounds, and other signs of visceral injury and intraperitoneal hemorrhage. Digital rectal examination for tenderness or mass, and the presence of blood on the glove. All abdominal penetrating injuries (open wounds穿透abdominal membranes) should be considered as having the possibility of visceral injury. Any injury to the chest, lumbar sacral, buttocks, and perineum (especially firearm injuries) must be carefully examined for abdominal injuries.

　　Examination
　　Blood and urine routine tests; if there is hematuria, it suggests urinary tract injury. For severely injured patients, a catheter should be placed to observe the hourly urine volume and its characteristics, which is more important for patients with traumatic shock. If pancreatic injury is suspected, blood and urine amylase levels should be checked, and rechecked according to the condition, observing their changes. For suspected internal hemorrhage, red blood cell volume should be measured and blood typing performed, and blood should be prepared.

　　Auxiliary examination
　　If the condition permits, X-ray examination can be performed, such as abdominal fluoroscopy or film, which can observe the presence of pneumoperitoneum, diaphragmatic position and range of motion, the presence and position of metal foreign bodies, and can also show the presence of spinal and pelvic fractures. For low rib fractures, attention should be paid to the possibility of liver and spleen rupture. For suspected solid organ injury and intraperitoneal hemorrhage, ultrasound, CT, or selective celiac arteriography can be performed when the condition permits to assist in diagnosis. Diagnostic abdominal puncture and lavage can be used to directly diagnose.

　　1. Diagnostic abdominal puncture: Before puncture, the bladder should be emptied. The puncture site is located in the four quadrants of the abdomen, namely the upper left, upper right, lower left, and lower right, and it is generally selected to puncture in the lower left or lower right quadrant. The puncture point is at the middle and outer 1/3 junction of the umbilicus and anterior superior iliac spine. When puncturing the upper abdomen, the puncture point is selected along the outer edge of the rectus abdominis muscle. The patient lies on the injured side or on the side, and an 18-gauge needle with a short bevel tip is used for puncture (the bevel tip faces outward). When the resistance of the needle tip decreases, it indicates that it has entered the peritoneal cavity, and aspiration can be performed while withdrawing the needle. If clotted blood or turbid fluid is aspirated, it is positive. If the puncture technique is correct, it can be diagnosed as intraperitoneal hemorrhage or perforation of hollow organs. Pay attention to prevent puncturing the retroperitoneal hematoma on the injured side to obtain a false positive result, leading to incorrect surgery. If one puncture is negative, punctures can be performed in the other three quadrants. For patients with unconsciousness, craniocerebral injury, and chest injury who still suspect abdominal organ injury despite multiple negative punctures, diagnostic peritoneal lavage can be performed.

　　2. Diagnostic peritoneal lavage: The patient lies in the supine position, the bladder is emptied, and local anesthesia is administered at 3 cm below the umbilicus along the midline. A 14-gauge needle attached to a syringe is inserted into the peritoneum at a 30° angle. After piercing the peritoneum, remove the syringe and insert a silicone tube with lateral holes into the pelvis (generally 20-25 cm). Then, remove the needle. The outer end of the tube is connected to a physiological saline bottle, and 20 ml/kg of physiological saline is slowly infused into the peritoneum. After the fluid is exhausted, lower the infusion bottle so that the peritoneal lavage fluid flows back into the bottle by suction. After the operation is completed, remove the silicone tube, and cover the puncture site with sterile gauze. The effluent is examined under a microscope (cell count exceeding 0.01×10^12/L, white blood cell count exceeding 0.5×10^9/L has diagnostic significance) and amylase determination. Even if the peritoneal effusion or exudate is less, this procedure often yields positive results.

　　Postoperative dietary注意事项 for abdominal trauma patients:
　　1. After the patient's gastrointestinal function is restored, the gastric tube can be removed, and then food can be given. The principle is to start with less and increase gradually, from thin to thick, and eat in small and frequent meals. Start with a small amount of congee, meat soup, vegetable soup, or egg soup, and gradually increase or change to semi-liquid food. The food should contain abundant protein, high calories, and various vitamins.
　　2. Eat more foods that have a blood-boosting effect, such as jujube and longan.
　　3. Eat more fresh cooked vegetables and fruits, more mushrooms, sunflower seeds, asparagus, tomatoes, carrots, and other foods.
　　4. When the gastrointestinal function is not fully restored in the early postoperative period, try to consume less milk, sugar, and other gas-producing foods to prevent intestinal bloating.
　　5. Avoid smoking, alcohol, and spicy刺激性 foods.
　　6. Avoid moldy, fried, smoked, and salted foods.
　　7. Avoid hard, sticky, and difficult-to-digest foods.

　　The principle of treatment for this disease is that for patients with mild symptoms and signs, close observation should be carried out. For patients with severe conditions, immediate surgical exploration should be performed.

　　1. Preoperative preparation
　　1. Rapidly relieve respiratory obstruction, ensure airway patency, perform cardiopulmonary resuscitation, actively counter shock, rapidly control external hemorrhage, and treat immediate life-threatening craniocerebral injuries, open chest, tension pneumothorax, and other conditions.
　　2. Supplement blood volume, maintain multi-channel infusion and blood transfusion with a large-gauge needle.
　　3. Place the catheter and record the urine output, observing its characteristics.
　　4. Place a gastric tube, aspirate the gastric contents, observe for bleeding, and maintain gastrointestinal decompression.
　　5. Apply antibiotics as soon as possible to prevent infection.
　　6. If there is visceral prolapse, the sterile saline gauze should be used to cover it first, and then wrap it with a sterile towel. It should be flushed with saline again before surgery.
　　7. Enema is prohibited.

　　Second, Points to Note During Surgery
　　1. If the diagnosis has not been determined, a median incision can be made. If the diagnosis has been confirmed, the incision should be close to the injury site. For open wounds, it is generally not necessary to enter the abdominal cavity through the original incision.
　　2. After the peritoneum is incised, the abdominal fluid should be aspirated clean with a suction apparatus; the nature and approximate location of the injury can be preliminarily judged according to the contents of the abdomen. The systematic examination should be carried out in a certain order: first find the ruptured blood vessels and explore organs and tissues prone to bleeding, such as liver, spleen, mesentery, etc. If bleeding foci are found, stop the bleeding, and then check the gastrointestinal system, pelvis, and finally the retroperitoneal space. The exploration must be systematic and comprehensive to avoid missing the site of injury.
　　3. Treatment of visceral prolapse: Flush the prolapsed viscera with sterile normal saline, make an incision along the midline of the abdomen, then enlarge the original incision, and return the prolapsed viscera to the abdominal cavity. If the prolapsed material is the omentum, it can be appropriately resected.
　　4. After the abdominal organ injury is treated, the abdomen should be flushed with normal saline, and then the abdominal fluid should be aspirated clean.
　　5. Abdominal drainage: Abdominal drainage tubes should be placed in the following situations: ① Injury to hollow organs; ② Bleeding at the wound surface; ③ When the injury time is long, there is a possibility of infection or poor healing at the site of repair or suture; ④ Severe liver, spleen, pancreas injury, retroperitoneal large hematoma, etc. The drain can be selected according to the situation, such as smoke drain or double lumen drain, and it must be properly fixed.
　　6. Incision suture: Generally, it can be sutured in one stage. In the case of war wounds, only the peritoneum is sutured, and after 4-8 days, if there is no infection, secondary suture can be performed. For severe injury cases, or cases with conditions such as hypoalbuminemia and anemia, extraperitoneal tension-reducing suture should be performed.

　　Third, Nursing
　　1. The same as general nursing routine in surgery.
　　2. Ensure that the patient has a quiet rest, avoid excessive movement, and closely observe the changes in the patient's condition.
　　3. After the anesthetic has taken effect and the blood pressure is stable, the patient can assume a slope lying position.
　　4. Continue to reduce gastrointestinal pressure and keep the stomach tube unobstructed.

　　Fourth, Follow-up Severely injured patients should have follow-up examinations 3 months, 6 months, and 1 year after discharge.