腹部内脏取出和腹部开放伤口护理¶

当皮肤、皮下脂肪、腹直肌、筋膜和壁层腹膜全层撕裂，导致内脏器官（最常见的是小肠或脂肪大网膜）伸出腹腔外时，就会发生腹部内脏掏空。掏空内脏可能是由于穿透性创伤（刀划伤、高能弹片或动物角刺伤）、严重的钝器冲击力或剖腹手术后手术缝线破裂（手术伤口裂开）造成的。

虽然看到体外的粉红色、闪闪发光的肠环对伤员和旁观者来说都是可怕的，但掏出内脏本身并不会立即致人死亡，除非伴有严重的血管出血。相反，对生存和器官活力的三个直接院前威胁是肠系膜绞窄和肠道干燥（干燥），如果受污染的器官被推回内部则发生暴发性细菌性腹膜炎，以及快速蒸发性低温引发致命创伤三联征。了解如何弯曲受害者的膝盖以减轻腹壁的张力，为什么绝对不能将突出的器官推回腹部，以及如何构建两层湿润加闭塞的热屏障可以挽救肠道和患者的生命。

现在就这样做¶

1. 立即拨打您当地的紧急电话号码，请求高级生命支持 (ALS) 护理人员进行紧急手术转运。 在美国和加拿大拨打 911，在欧盟拨打 112，在英国拨打 999，在澳大利亚拨打 000，或查看电话号码簿 紧急号码。
2. 将受害者平躺，膝盖弯曲（弯曲）30 到 45 度角，并支撑在枕头或卷毯上。 弯曲臀部和膝盖可以放松腹直肌和腰肌，降低腹内压力，并阻止额外的肠袢从伤口中挤出。
3. NEVER attempt to push protruding intestines or organs back inside the abdominal cavity. Shoving exposed bowel back through a tight fascial defect kinks the delicate blood vessels in the mesentery (causing rapid bowel necrosis) and drives dirt, skin bacteria, and debris deep into the sterile peritoneal cavity. Only if a loop of bowel has spilled onto the ground beside the patient should you gently lift it onto the skin of the patient's own abdomen without twisting it.
4. **立即用用无菌生理盐水（0.9%氯化钠）或干净饮用水充分润湿的大无菌敷料覆盖暴露的器官。**切勿将干纱布、纸巾、薄纸或蓬松的脱脂棉直接放在暴露的肠道上；干燥的纤维像胶水一样粘在湿润的浆膜表面上，去除后会撕裂肠壁。
5. Apply a second outer occlusive moisture-and-heat barrier (clean plastic cling wrap, a sterile burn sheet, foil, or a dry multi-trauma dressing) loosely over the wet dressing. Tape the edges of the outer plastic or dry dressing to the surrounding skin without pressing down on the organs, locking in moisture and stopping massive evaporative heat loss.
6. 严格控制患者NPO（严禁经口），并用温暖的毯子包裹其整个身体，以防止体温过低和休克。 切勿给腹部有伤口的患者提供水、冰片、食物或口服止痛药，即使他们因失血而口渴而乞讨水。如果患者有咳嗽或呕吐的冲动，请告诉患者用手轻轻支撑敷料。

Emergency decision tree for open abdominal wounds and evisceration¶

flowchart TD
    Start["Penetrating or Open Abdominal Trauma / Post-Surgical Dehiscence"]
    CallEMS["Call Emergency Medical Services (ALS Paramedics) Immediately<br/>Put on nitrile gloves and expose abdomen by cutting shirt"]
    Position["Position Patient Supine with Knees Flexed (Bent)<br/>Slide pillow or rolled blanket beneath knees to relax abdominal wall<br/>Keep patient strictly NPO (nothing by mouth)"]
    ImpaleCheck{"Is a Knife, Rod, or Object Still Impaled in the Abdomen?"}
    ImpaleProtocol["IMPALED ABDOMINAL OBJECT PROTOCOL<br/>1. DO NOT pull out the impaled object<br/>2. Press sterile gauze around base to control bleeding<br/>3. If bowel protrudes beside blade, cover bowel with moist saline gauze<br/>4. Stabilize blade with bulky twin-roll or ring dressing"]
    EviscCheck{"Are Internal Organs or Fatty Omentum Protruding<br/>Outside the Abdominal Wall (Evisceration)?"}
    OpenNoEvisc["OPEN ABDOMINAL WOUND WITHOUT EVISCERATION<br/>1. Control active external bleeding with firm direct pressure<br/>2. Cover wound with sterile dressing and tape securely<br/>3. Never probe the wound with fingers to see how deep it goes"]
    EviscCare["ABDOMINAL EVISCERATION TWO-LAYER DRESSING PROTOCOL<br/>1. DO NOT push organs back inside cavity<br/>2. Layer 1 (Inner): Cover organs with sterile saline-soaked non-adherent pad<br/>   (OR direct sterile plastic cling wrap if no saline is available)<br/>3. Layer 2 (Outer): Cover wet pad with clean plastic wrap or dry trauma pad<br/>4. Tape outer edges loosely without compressing organs"]
    ShockCare["Prevent the Lethal Trauma Triad (Hypothermia, Acidosis, Coagulopathy)<br/>1. Wrap patient head-to-toe in warm blankets / foil thermal blanket<br/>2. Re-wet inner dressing with warm sterile saline if it begins drying<br/>3. Monitor pulse, skin color, and breathing every 5 minutes"]

    Start --> CallEMS
    CallEMS --> Position
    Position --> ImpaleCheck
    ImpaleCheck -->|Yes: Object Impaled| ImpaleProtocol
    ImpaleCheck -->|No: No Object Present| EviscCheck
    EviscCheck -->|No: Organs Inside| OpenNoEvisc
    EviscCheck -->|Yes: Organs Protruding| EviscCare
    ImpaleProtocol --> ShockCare
    OpenNoEvisc --> ShockCare
    EviscCare --> ShockCare

Comparing abdominal trauma presentations and surgical emergencies¶

Abdominal injuries range from blunt hidden solid-organ ruptures to open penetrating slashes and post-surgical wound separations. Understanding what lies in each abdominal quadrant and how hollow versus solid organs behave helps rescuers anticipate shock and peritonitis.

Anatomy and physiology of an abdominal evisceration¶

为什么小肠和大网膜先突出¶

The peritoneal cavity houses both fixed retroperitoneal organs (kidneys, pancreas, duodenum, abdominal aorta, and inferior vena cava) and mobile intraperitoneal organs suspended on flexible folds of tissue. When the muscular abdominal wall is sliced open and intra-abdominal pressure rises (as the victim cries out, tenses their core muscles, or coughs), the two most mobile structures inside the belly are immediately pushed out through the gap:

1. The Greater Omentum: A yellow-gold, lacy apron of vascular adipose (fat) tissue that hangs down from the stomach over the intestines like a protective curtain. In small stab wounds, a plug of yellow-pink omentum often herniates out first, partially plugging the hole.
2. The Small Intestine (Jejunum and Ileum): Roughly 6 meters (20 feet) of muscular, pinkish-tan peristaltic tubing attached to the back wall of the abdomen by a fan-shaped sheet of tissue called the mesentery, which carries the superior mesenteric artery branches, veins, and lymphatics.

The three physiological traps that threaten an eviscerated patient¶

1. Mesenteric Venous and Arterial Strangulation: As loops of bowel squeeze out through a narrow, 3-to-6-centimeter (1-to-2.5-inch) tear in the tough abdominal fascia, the edges of the fascia pinch the base of the protruding bowel and its mesentery like a tight ring. Because veins have thin walls and low pressure, venous outflow from the protruding bowel is pinched off first while high-pressure arterial blood keeps pumping in. Within minutes, the trapped loop of intestine swells up with edema, which makes the fascial ring even tighter, eventually cutting off arterial inflow and turning the pink glistening bowel dark purple or black (ischemic bowel necrosis / infarction). Trying to forcefully shove this swollen bowel back through the tight hole kinks and tears the mesenteric vessels completely.
2. Serosal Desiccation and Bacterial Translocation: Exposed to dry outdoor air, wind, or dry cotton bandages, the delicate serosal cells lining the outside of the intestine dehydrate and die within 15 to 30 minutes. Once the serosa dries out and cracks, bacteria inside the gut lumen translocate across the weakened wall, and post-surgical adhesions or intestinal fistulas become almost inevitable.
3. Massive Evaporative Heat Loss and the "Lethal Trauma Triad": The human peritoneal cavity and intestines receive nearly 25 percent of resting cardiac output and have a massive warm wet surface area. Exposing wet, vascular loops of bowel to ambient air acts like a giant evaporative radiator, dropping the patient's core body temperature rapidly. In trauma medicine, Hypothermia (core temperature below 35 degrees Celsius / 95 degrees Fahrenheit) inactivates blood-clotting enzymes, triggering Coagulopathy (uncontrollable microvascular bleeding) and Metabolic Acidosis from tissue hypoxia, a self-reinforcing downward spiral known as the Lethal Trauma Triad.

Step-by-step technique: Managing an abdominal evisceration¶

Step 1: Scene safety, gloves, and knee-flexed positioning¶

1. Put on clean medical nitrile gloves (or wash your hands and use the cleanest barrier available if no gloves are present).
2. Lay the patient flat on their back (supine) on the ground, bed, or stretcher. Never let a patient with an abdominal evisceration stand up, walk to the ambulance, or sit upright at 90 degrees, as gravity and upright abdominal pressure will push massive amounts of additional bowel out of the wound.
3. Flex the knees and hips: Gently bend the patient's knees upward to a 30-to-45-degree angle and slide a thick rolled blanket, pillow, backpack, or folded coat underneath their knees so their legs rest effortlessly without muscle effort. This single maneuver takes mechanical tension off the rectus abdominis fascia and immediately reduces the squeezing pressure on the protruding bowel.

Step 2: Expose the wound and handle displaced loops safely¶

1. Use scissors or trauma shears to cut the shirt, belt, and waistband open around the wound. Never pull clothing upward over exposed organs; if a piece of cloth is stuck directly to the bowel, cut around it and leave the stuck patch in place to be soaked off with warm saline in the hospital.
2. Never push organs back inside the abdomen.
3. What if a loop of intestine is hanging off the side of the torso into dirt, gravel, or glass on the ground? While you must never push bowel back inside the abdominal cavity, you also cannot leave a loop of intestine dangling over the edge of the flank into dirty gravel or kinked sharply over the skin edge. Using two gloved hands (or a sterile saline-soaked dressing), gently rinse gross gravel off with sterile saline if available and lift the dangling loop without twisting it so it rests gently on top of the patient's own abdominal skin right next to the wound.

Step 3: Build the Two-Layer Moist-and-Occlusive Dressing¶

To keep the bowel viable, wet, and warm, build a two-layer sandwich dressing (or use the direct sterile cling-wrap method):

• Option A: The Classic Two-Layer Saline + Occlusive Sandwich (ATLS & Red Cross Standard)
• Inner Moist Layer: Take the largest sterile trauma dressing, sterile abdominal pad (ABD pad), sterile surgical towel, or clean lint-free cloth available. Pour sterile 0.9% normal saline (or clean potable drinking water if sterile saline is unavailable; warmed to body temperature 37 degrees Celsius / 98.6 degrees Fahrenheit if possible, never ice-cold) over the dressing until it is thoroughly dampened, then lay it gently over the entire mound of protruding organs.
• Outer Occlusive Vapor-and-Heat Barrier: Immediately cover the wet inner dressing with a sheet of clean plastic food cling wrap, a sterile plastic burn sheet, clean aluminum foil, a plastic bag cut open, or a thick dry multi-trauma dressing. This outer layer stops the wet inner dressing from drying out in the wind and stops evaporative cooling from chilling the patient into hypothermia.
• Tape the perimeter loosely: Tape the four outer edges of the plastic cover gently to the intact skin of the flanks and chest without pressing down on top of the bowel mound.
• Option B: Direct Clean Plastic Cling-Wrap Application (UK NHS, ANZCOR, and Paramedic Field Standard)
• If you do not have sterile saline and thick lint-free trauma pads immediately on hand, clean household polyvinyl chloride (PVC) kitchen cling wrap (pulled fresh after discarding the outer turn of the roll) or a sterile plastic burn sheet can be laid directly and loosely in longitudinal strips over the moist protruding bowel. Cling wrap is smooth, completely non-adherent (it will never stick to or tear the serosa), transparent (allowing trauma surgeons to inspect bowel color and perfusion immediately without unwrapping the patient), waterproof, and traps natural peritoneal moisture and heat. Never wrap cling wrap circumferentially tight around the torso.

Special scenario: Postoperative surgical wound dehiscence at home¶

Roughly half of all abdominal eviscerations seen by emergency medical services are not caused by stabbings or car crashes at all; they occur at home 5 to 10 days after a major abdominal surgery (laparotomy, C-section, bowel resection, or hernia repair) when the deep fascial stitches give way, an emergency called acute abdominal wound dehiscence or "burst abdomen".

The warning sign that precedes surgical evisceration by hours¶

Before a surgical incision pops completely open, the deep fascial layer typically separates first while the outer skin staples or stitches are still holding on: * The "Salmon-Colored Fluid" Sign: The patient feels a sudden painless "pop" or tearing sensation inside their incision after coughing, sneezing, vomiting, or getting out of bed, followed by a sudden soaking gush of pinkish-orange, watery fluid (serosanguinous peritoneal fluid, classically described by surgeons as "salmon-colored fluid") soaking through their shirt or surgical bandage. * 每当手术后腹部切口突然漏出大量粉橙色水状液体时，就会发生筋膜裂开，即将全部肠子切除。

Immediate home first aid for surgical dehiscence or evisceration¶

1. 立即让患者平躺在床上或地板上，并在弯曲的膝盖下放一个枕头。 不要让他们走到浴室或汽车里。
2. 教导“枕头夹板”治疗咳嗽或呕吐： 如果患者感觉再次咳嗽、打喷嚏或干呕，请让他们用双手轻轻地在手术敷料上夹住柔软的枕头或折叠的浴巾以支撑腹壁，以免更多的肠道被挤出。
3. 用浸有无菌盐水或冷却的煮沸/瓶装饮用水的干净毛巾覆盖任何暴露的肠道或开放切口，并用厨房保鲜膜松散地覆盖。
4. 拨打 911 / 112 / 999 安排救护车送回外科医院并严格保证患者 NPO（不吃不喝）。

Recognizing internal abdominal bleeding and protecting against shock¶

Because 70 to 80 percent of traumatic abdominal eviscerations are accompanied by internal lacerations to the liver, spleen, mesentery, or major retroperitoneal blood vessels, you must continuously monitor the patient for hypovolemic hemorrhagic shock:

Early vs. Late signs of abdominal hemorrhagic shock¶

• Early Compensated Shock: Anxiety, restlessness, pale cool clammy skin, rapid heart rate (tachycardia > 100 bpm), slightly rapid breathing, and intense thirst (remember: never give water to drink, even when the patient begs; you may only lightly moisten their dry lips with a damp cloth).
• Signs of Peritoneal Irritation (Hemoperitoneum / Peritonitis): Diffuse tenderness, involuntary guarding (the abdominal muscles clamp down rigid like a wooden board even when touched lightly), progressive abdominal distension (though note that the belly can hold 2 to 3 liters of blood before visibly expanding), and Kehr's sign (sharp pain felt at the tip of the left shoulder caused by blood from a ruptured spleen irritating the phrenic nerve).
• Late Decompensated Shock: Falling blood pressure (weak or absent radial pulse at the wrist), confusion or lethargy, mottled bluish skin, and rapid shallow gasping breaths.

Active thermal management¶

1. Insulate beneath AND above the patient: Cold pavement or metal floors drain body heat three times faster by conduction than cold air does by convection. Slide a folded blanket, cardboard, or jacket underneath the patient's back and legs if possible without jarring their torso.
2. Wrap head-to-toe in warm blankets: Cover the chest, arms, legs, and head with wool or fleece blankets and a metallic foil space blanket to stop shivering and preserve blood clotting function until the patient reaches the operating room.

Four-quadrant abdominal organ map and referred pain patterns¶

Even when an abdominal wound is small or when blunt trauma leaves the skin completely intact, clinicians divide the abdomen into four anatomical quadrants centered at the umbilicus (navel) to predict which solid or hollow organs are injured and why pain often radiates to distant body sites:

First aid care for an open abdominal wound requires calm composure when everyone else at the scene may panic at the sight of the injury. Consider taking a certified first aid, Stop the Bleed, or emergency medical responder course through your national Red Cross or Red Crescent society, the American College of Surgeons, or St John Ambulance.

常见问题¶

来源已检查¶

• American College of Surgeons (ACS, United States): Advanced Trauma Life Support (ATLS) Student Course Manual: Abdominal and Pelvic Trauma, Evisceration, and Hemorrhagic Shock.
• National Association of Emergency Medical Technicians (NAEMT, United States): Prehospital Trauma Life Support (PHTLS): Management of Abdominal Evisceration and the Lethal Trauma Triad.
• 战术战斗伤亡护理委员会（CoTCCC/关节创伤系统，美国）： TCCC 医务人员指南：腹部穿透性创伤和内脏切除管理。
• 国家医疗服务体系（英国 NHS）和联合皇家学院救护车联络委员会 (JRCALC)： 临床实践指南：腹部创伤、内脏切除和闭塞保鲜膜敷料。
• 澳大利亚和新西兰复苏委员会（ANZCOR，澳大利亚和新西兰）： 开放性腹部损伤和内脏切除的急救管理。
• International Federation of Red Cross and Red Crescent Societies (IFRC, International): International First Aid, Resuscitation, and Education Guidelines: Severe Bleeding and Penetrating Torso Injuries.

相关指南¶

• 穿刺和嵌入异物稳定
• 吸吮胸部伤口及肺部塌陷的急救
• Severe bleeding control and tourniquets
• 休克识别和紧急护理
• 低温和寒冷暴露的预防
• 紧急号码和国际调度