外傷(Trauma)シリーズ16 EXPERT COURSE 解答 【症例 TE 78】

胸部刺創・横隔膜損傷・肝刺創(出血).Stab wound of chest,diaphragm and liver with active bleeding



乳頭を結ぶ線から尾側の刺創と銃創は腹腔内臓器損傷の可能性があることを忘れてはならない.左側に胸水(※)があるが,densityを計測すれば30HUを示し,血液であると判断できたと思われる.図4〜図8の△は,周囲に血腫(図6で白矢印の横隔膜の外側だから縦隔内)を伴うのでextravasationである.心臓刺創の可能性が高いと手術になった.図1の2の刺創が横隔膜を貫通し,肝左葉外側区域の刺創から縦隔内へ活動性の出血を認めた.図6の↑が横隔膜の断裂部で,▲が肝臓の刺創であろう.






文献考察:手術適応のない胸腹部刺創(thoracoabdomimal stab wound:上は乳頭部,下は臍,側方は後腋窩線の範囲)で,胸腔鏡下に検索すると7%に横隔膜損傷を認める
J Trauma. 2003 Oct;55(4):646-50.
Occult diaphragmatic injuries caused by stab wounds.
Leppäniemi A, Haapiainen R.

BACKGROUND: Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult diaphragmatic injuries in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries caused by stab wounds of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries. METHODS: On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation). RESULTS: In the exploration group (n = 47), four diaphragmatic injuries (9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries in left-sided thoracoabdominal stab wounds was 4 of 24 (17%), and was much lower after stab wounds of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%). CONCLUSION: In asymptomatic patients with anterior or flank stab wounds of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent hollow viscus herniation. Exclusion of an occult diaphragmatic injury with invasive diagnostic methods, such as laparoscopy or thoracoscopy, should be considered at least in left-sided stab wounds of the lower chest.PMID: 14566117
  【参照症例】   1. 外傷(Trauma)シリーズ7 【症例 TE 32】

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