Traumatic retroperitoneal hemorrhage or hematoma
Introduction
Introduction to traumatic retroperitoneal hemorrhage or hematoma Retroperitoneal hemorrhage and hematoma are organs located in the retroperitoneal space, blood vessels, muscles, nearby bone tissue traumatic hemorrhage and hematoma formed. Because of the different organs of the primary injury, the severity of the injury is different, so the clinical Different performance, small amount of bleeding and hematoma can be covered by the symptoms of tissue and organ damage, massive hemorrhage and large hematoma can mainly cause hypovolemic shock, abdominal symptoms are often confused with gastrointestinal damage, diagnosis errors can lead to Negative laparotomy, delaying the surgical rescue opportunity and causing the patient to die. basic knowledge Sickness ratio: 0.0001% Susceptible people: no special people Mode of infection: non-infectious Complications: hypovolemic shock
Cause
Traumatic retroperitoneal hemorrhage or hematoma etiology
(1) Causes of the disease
There are 3 zones in the retroperitoneal space, which contain different tissues and organs, which leads to different direct causes of bleeding.
1. In the middle of the area there are abdominal aorta, inferior vena cava, superior mesenteric artery, pancreas and duodenum and other organs, the back of the back, the anterior abdominal violence is easy to cause these organs to suffer from major bleeding, back fracture of the spine, fracture The bleeding at the end also makes it a hematoma.
2. On both sides (kidney circumference), there are kidney and adrenal glands on both sides, ascending colon and descending colon, lateral crushing, and collision is easy to cause kidney and colon injury.
3. There are pelvic fractures and iliac arteriovenous veins in the pelvic region, internal and external arteries and veins and their branches, vascular injuries in the branch, bleeding at the fracture end, rupture of blood vessels, and hemorrhage may cause massive hematoma or even persistent bleeding. The hematoma is enlarged.
(two) pathogenesis
The vast majority of retroperitoneal hemorrhage and hematoma are caused by retroperitoneal structural damage. Pelvic fractures and lumbar fractures are the most common causes, accounting for about 2/3, followed by retroperitoneal vascular or organ damage, more common in accelerated travel. Motor vehicle traumatic abdomen, causing retroperitoneal organ damage or vascular injury, such as kidney, pancreas and duodenal injury, due to the loose tissue behind the retroperitoneum, bleeding easily spread in the retroperitoneal space, forming a large hematoma, and can seep Between the mesentery, the amount of bleeding can be as much as 2000 to 4000 ml.
Prevention
Traumatic retroperitoneal hemorrhage or hematoma prevention
In case the body part has an infected part.
Complication
Traumatic retroperitoneal hemorrhage or hematoma complications Complications hypovolemic shock
Hypovolemic shock: When the hemorrhage is large, the patient's hemoglobin is progressively decreased, blood pressure is lowered, the pulse is weak, the central venous pressure is decreased, and the urine volume is decreased.
Symptom
Traumatic retroperitoneal hemorrhage or hematoma symptoms Common symptoms Abdominal pain Abdominal muscle tension Intestine paralysis Abdominal pain Abdominal mass Abdominal tenderness Back pain Back spot shock
The retroperitoneal hematoma is different in the primary injury organs, the severity of the injury is different, the clinical manifestations are different, lack of fixed typical symptoms, a small amount of hemorrhage forms a small hematoma, often without obvious symptoms and signs and self-absorption, and the clinical hematoma The main performances are:
1. Hematoma compression symptoms Hematoma compression nerves and internal organs can cause neuropathic pain and gastrointestinal or urinary system dysfunction, about 60% of patients have abdominal pain, 40% of patients have shock symptoms and signs, 25% of patients have back pain .
2. abdominal pain and intestinal paralysis abdominal pain is relatively vague, can be full abdominal pain or limited to the pain of the hematoma, often have varying degrees of intestinal paralysis, retroperitoneal hematoma did not infiltrate the abdominal cavity, but only abdominal tenderness without obvious muscle tension and anti Jumping pain, if the blood penetrates into the abdominal cavity, abdominal muscle tension, tenderness and rebound pain may occur, and intestinal paralysis may be aggravated.
3. Side abdominal mass and large cerebral hematoma, the lateral abdomen can be full, swollen, sometimes subcutaneous ecchymosis, and occasionally touch the tender mass.
4. Rectal irritation When the pelvic retroperitoneal hematoma is large, the patient may have rectal irritation.
5. Physical examination of the palpation side of the abdomen can be full, swelling, percussion can sometimes be found in the lumbar or back with a position that does not change position with the voiced area, pelvic retroperitoneal hematoma, rectal examination can touch the mass.
Examine
Traumatic retroperitoneal hemorrhage or hematoma examination
1. The decrease in blood routine hematocrit and hemoglobin amount.
2. Urine routines sometimes see red blood cells in the urine.
3. B-ultrasound examination of acute abdominal B-ultrasound, to a certain extent can show the abdominal organ damage, such as abdominal hemorrhage, effusion.
4. X-ray film found pelvic fractures, lumbar vertebrae fractures, lumbar muscles shadows blurred or block shadows, etc., suggesting that there is retroperitoneal hemorrhage, due to flatulence, intestinal paralysis is characterized by inflatable intestinal tube displacement.
5. Intravenous pyelography may have renal pelvic pressure or displacement, see contrast agent leakage from the kidney, indicating renal trauma and retroperitoneal hemorrhage.
6. CT examination of general hematoma showed abnormal soft tissue density, with occlusion and displacement of retroperitoneal space, hematoma density due to the length of bleeding, acute hematoma density increased, subacute hematoma in the center of high density, surrounded by In the low-density area (Fig. 1), the chronic phase is characterized by a non-specific low-density block with a thickened annular wall, enhanced enhancement of the scanning ring wall, and calcification in the late stage. The location of the hematoma helps to diagnose the source of bleeding.
7. MRI examination of its performance depends on hematoma time, pulse sequence and magnetic field strength, in the high field strength (0.5 ~ 2.0 T) hyperacute hematoma performance: T1 weighted image signal can be slightly lower than the muscle, slightly higher Or equal signal, T2 weighted image, mostly high signal; acute hematoma: T1 weighted image showed peripheral high signal, central low signal, T2 weighted image showed very low signal; subacute stage hematoma: T1, T2 weighted image There is a high signal on the top, surrounded by a black low signal loop.
8. Abdominal puncture If there is no retroperitoneal rupture, the blood does not flow into the abdominal cavity, abdominal puncture is often negative, but some retroperitoneal hematoma can extend to the abdominal wall, puncture in the right or left lower abdomen can also extract non-coagulated blood, no intra-abdominal Organ injuries, therefore, the analysis of abdominal abdominal puncture should be further analyzed to avoid negative laparotomy.
Peritoneal lavage for abdominal lavage can help identify intra-abdominal hemorrhage and retroperitoneal hematoma, dynamic observation of intra-abdominal hemorrhage.
The method is as follows: under the local anesthesia, the lavage tube is inserted into the abdominal cavity as a puncture point, for example, the gastrointestinal contents or the non-coagulation of more than 10 ml is taken out, that is, the lavage is stopped and the laparotomy is performed, and the lavage is performed by infusion, in 10~ Within 15 minutes, rapid instillation of normal saline, Ringer's solution or sodium lactate Ringer's solution 1000ml, the lavage reflux solution has one of the following ones for intra-abdominal hemorrhage or intra-abdominal organ injury rather than retroperitoneal hematoma.
(1) It is bloody.
(2) Containing bile fluid or gastrointestinal contents.
(3) The red blood cell count exceeds 0.1×10 12 /L.
(4) Amylase assay > 175 U/L (Karowan).
(5) Smear microscopy revealed a large number of bacteria.
Engran reported that if the red blood cell count exceeds 0.1×1012/L in the peritoneal lavage fluid, the probability of intra-abdominal organ damage is 85%, and (0.05-0.1)×1012/L is 59%, <0.05×1012/L. Only 4%.
Diagnosis
Diagnosis and diagnosis of traumatic retroperitoneal hemorrhage or hematoma
Diagnostic criteria
Retroperitoneal hemorrhage and hematoma due to the lack of fixed typical symptoms, especially in other parts of the trauma and intra-abdominal hemorrhage, the symptoms of retroperitoneal hemorrhage are often masked, so the diagnosis is often difficult, the diagnosis of errors can lead to unnecessary negative laparotomy, Delaying the surgical rescue opportunity leads to the death of the patient.
1. The diagnosis of traumatic retroperitoneal hemorrhage and hematoma is mainly the diagnosis of primary site injury and/or the diagnosis of intra-abdominal organ injury. Therefore, it is very important to ask about the history of trauma, including the time of injury and the cause of injury. , location, post-injury symptoms and their evolution.
2. Clinical manifestations and signs of neuropathic pain and gastrointestinal or urinary system dysfunction, total abdominal tenderness or local tenderness, with varying degrees of intestinal paralysis, may have peritoneal irritation or rectal irritation, may also have shock symptoms Wait.
3. Auxiliary examination suggests retroperitoneal hemorrhage.
Differential diagnosis
Need to distinguish from abdominal closed injury, how to accurately and timely determine the presence and extent of intra-abdominal organ injury, is important for distinguishing whether abdominal symptoms are retroperitoneal hematoma, the following conditions should be noted when abdominal closed injury .
1. Cavity organ damage The contents of the gastrointestinal tract are often infected into the abdominal cavity. The clinical manifestations are acute peritonitis. After the injury, there is severe persistent abdominal pain accompanied by nausea, vomiting, abdominal muscle tension, and obvious tenderness in the abdomen. And rebound tenderness, bowel sounds weakened or disappeared, the extent and extent of abdominal pain, depending on the severity of the injury and the amount of gastrointestinal content into the abdominal cavity, and the length of the injury to the time of the visit, several organs or the same The number of organs is ruptured, and a large amount of gastrointestinal contents or bile fluid enters the abdominal cavity. Those who have been more than 4 hours after the injury often show full abdominal pain, that is, diffuse peritonitis is formed, such as only one organ is ruptured, and the gap is not Large or fasting injuries, short intervals between injury and treatment, and less serious abdominal infection, manifested as signs of localized peritonitis, abdominal pain, abdominal muscle tension and rebound pain are limited to the surrounding organs, and the degree of abdominal pain is also higher than the former Light, some patients may be due to free gas in the abdominal cavity, the liver dullness circle shrinks or disappears, X-ray examination can be clearly diagnosed, abdominal abdomen has a mobile dullness in the abdomen, abdominal puncture can be obtained Results of laboratory examination showed increased WBC, increased neutrophil count, hemoglobin is associated with internal bleeding, decreased red blood cell count.
2. The clinical manifestations of parenchymal organ damage are mainly internal hemorrhage. If the organ rupture injury and large blood vessels or cracks are large and deep, the bleeding is rapid and the amount is large. The patient is already in a serious hemorrhagic shock state due to blood. Biliary fluid, gastrointestinal fluid, etc. are less irritating to the peritoneum, so the degree of abdominal muscle tension and rebound tenderness are lighter than those of the hollow organ rupture. The patient is characterized by anemia, cold limbs, thirst, and fast pulse. Weak, blood pressure drops, when the amount of bleeding exceeds 500ml, there may be mobile dullness in the abdomen, puncture can be extracted without coagulation, X-ray examination without free gas, part of liver, spleen injury, visible shadow under X-ray fluoroscopy, the same The lateral diaphragm muscles are elevated, the activity is weakened, the hemoglobin and red blood cell counts are significantly decreased, and the total number and classification of white blood cells can also be increased. Repeated examination of hemoglobin and red blood cell counts, and observation of changes, often provide a diagnostic basis.
3. The combination of abdominal cavity and parenchymal organ is more serious and complicated. The main signs of hemorrhage are not obvious. The main cause of rupture of the hollow organ is to cover up the bleeding sign, so it is more suitable for such patients. Careful analysis of the injury and physical examination, in the case of the condition, can be observed for a short time, repeated examination of blood, X-ray and abdominal puncture, in order to make appropriate treatment measures as soon as possible, such as the condition is not allowed to observe, and has been basically determined If there is visceral injury, it should be decisively exploratory laparotomy. After laparotomy, it should be treated according to the specific circumstances. Otherwise, blind observation will delay the rescue opportunity.
