每日一题_2022.07.16

An unstable, 27-year-old woman who was involved in a high-speed motor vehicle collision has just been brought to the trauma resuscitation bay and is being resuscitated. She has altered mental status, agonal respirations with gurgling noises from her airway, but equal breath sounds. She is cold and diaphoretic, with a blood pressure of 87/40 mm Hg and heart rate of 140 beats/min. Her airway has been secured, and peripheral IV access (14 g and 16 g) has been obtained to begin crystalloid and blood product resuscitation. Chest and pelvic radiographs are normal. A bedside ultrasound reveals the image shown below. After initial fluid resuscitation, there is no change in vital signs.

Which of the following should be the next course of action? 

A. Placement of a central line

B. Diagnostic peritoneal lavage

C. Placement of an intracranial pressure monitor 

D. Abdominal and pelvic CTs

E. Immediate exploratory laparotomy

答案解析：

该多系统创伤患者处于急性循环性休克。创伤患者应接受有组织的快速团队复苏，遵循高级创伤生命支持 (ATLS) 或麻醉创伤和重症监护 (ATACC) 指南。这两者都侧重于快速评估和立即稳定气道、呼吸和循环。患者已成功插管，开始晶体液和理想血液制品复苏。临床评估、X线摄片和超声可用于快速诊断急性循环性休克的病因。急性失血引起的低血容量性休克是最常见的原因，但也可发生阻塞性（张力性气胸、心包填塞）、心源性（钝性心脏损伤）和分布性休克（神经源性）。创伤超声 (eFAST) 检查的扩展重点评估可帮助临床医生快速诊断张力性气胸、心包填塞和腹腔内游离液体，这可能意味着在这种临床情况下腹腔内出血。患者在初始复苏后出现低血压。她的 FAST 检查结果为阳性，低血压；因此，她需要接受剖腹探查术。

标准三腔导管可用于同时给予多种不同药物以及血管加压药。它们的长度和相对较窄的内径不利于快速流动。在血流动力学不稳定的钝性创伤患者 FAST 检查阳性的情况下，无需进行诊断性腹腔灌洗。一个主要问题是延迟治疗其他危及生命的损伤。虽然 CT 的诊断效用很重要，但不应延误明确的治疗。延迟控制危及生命的出血可能是致命的。神经创伤的处理重点是保留脑灌注压，等于平均动脉压减去颅内压。在诊断潜在颅内损伤之前，应处理出血和低血压。在复苏不足的患者中，颅内监护仪的经验性放置充其量是有争议的。无论哪种方式，都不应延迟剖腹手术。

正确答案：E