重症创伤性膈疝合并心包破裂漏诊分析  

Analysis of Misdiagnosis of Severe Traumatic Diaphragmatic Hernia Complicated with Pericardial Rupture

作　　者：陈宇晟 崔俊 CHEN Yusheng;CUI Jun(Department of Critical Care Medicine,Xiangyang Central Hospital,Affiliated Hospital of Hubei University of Arts and Science,Xiangyang,Hubei 441000,China;Department of Cardiothoracic Surgery,Xiangyang Central Hospital,Affiliated Hospital of Hubei University of Arts and Science,Xiangyang,Hubei 441000,China)

机构地区：[1]湖北文理学院附属医院襄阳市中心医院急诊重症医学科,湖北襄阳441000 [2]湖北文理学院附属医院襄阳市中心医院心胸外科,湖北襄阳441000

出　　处：《临床误诊误治》2024年第2期39-43,共5页Clinical Misdiagnosis & Mistherapy

基　　金：湖北省自然科学基金(2023AFD040)。

摘　　要：目的探讨重症创伤性膈疝合并心包破裂漏诊的原因及防范措施。方法回顾性分析重症创伤性膈疝合并心包破裂漏诊1例的临床资料。结果本例因车祸后进行性呼吸困难、血压下降由外院转入,予有创机械通气、药物升压难以维持呼吸、循环。螺旋CT示:双侧肋骨骨折;左侧气胸,予左侧胸腔闭式引流后病情仍加重。动脉血气分析:氧分压53 mmHg、二氧化碳分压33 mmHg、血乳酸6.8 mmol/L。行增强CT后发现左肺受压上移,左胸气腔与食管相通,考虑创伤性膈疝。立即全麻下开左胸探查,发现膈肌破裂、心包裂伤、部分腹腔脏器疝入胸腔,还纳脏器、修补裂口。术后患者呼吸、循环迅速平稳;血乳酸降至1.6 mmol/L。1月余后痊愈出院。结论创伤性膈疝合并心包破裂很罕见,尽早诊断、治疗是关键。接诊时应保持鉴别膈疝的意识,CT提示胸腔积气需仔细寻找来源,增强CT可有助于诊断,血乳酸可评判病情严重程度。一旦确诊应尽早行胃管减压、手术以解除呼吸、循环梗阻,手术入路应根据伤情而定。Objective To investigate the causes and preventive measures of missed diagnosis of severe traumatic diaphragmatic hernia(TDH)complicated with pericardial rupture.Methods The clinical data of 1 case of severe TDH complicated with pericardial rupture were retrospectively analyzed.Results The patient was transferred from another hospital due to progressive dyspnea and decreased blood pressure after a car accident,and it was difficult to maintain breathing and circulation after receiving invasive mechanical ventilation and drug use to increase blood pressure.Spiral CT showed bilateral rib fracture and left pneumothorax,and the condition worsened after closed drainage of left thoracic cavity.Arterial blood gas analysis revealed oxygen partial pressure of 53 mmHg,carbon dioxide partial pressure of 33 mmHg,and blood lactic acid of 6.8 mmol/L.After enhanced CT scan,it was found that the left lung was compressed and shifted upward,and the left thoracic cavity was connected to the esophagus.TDH was considered.Immediate exploration of the left chest under general anesthesia revealed rupture of diaphragm,laceration of pericardium,herniation of part of abdominal organs into the chest,restoration of organs,and repair of the tear.After surgery,the patient's breathing and circulation became stable rapidly.Blood lactic acid decreased to 1.6 mmol/L.One month later,he recovered and was discharged.Conclusion TDH complicated with pericardial rupture is rare;therefore,early diagnosis and treatment is the key.The awareness of diaphragmatic hernia should be maintained at the time of admission.The source of chest gas indicated by CT should be carefully explored,and enhanced CT may be helpful for diagnosis.Blood lactic acid can be used to evaluate the severity of the disease,and gastric tube decompression and operation should be performed as soon as possible to relieve respiratory and circulatory obstruction.The surgical approach should be determined according to the injury condition.

关 键 词：疝 横膈 创伤性 心包破裂 漏诊 呼吸困难 诊断 鉴别 血乳酸 减压术 外科 体层摄影术 螺旋计算机 

分 类 号：R826.65[医药卫生—临床医学]