外傷(Trauma)シリーズ10 EXPERT COURSE 解答 【症例 TE 48】

骨盤損傷 Ia.fracture of left iliac bone with active bleeding.



図3〜図7で左腸骨骨折を認め(↑),対側と比較するとわかるが周囲に相当量の血腫を伴う.輸血4単位を要する程Hb値が低下し続けたため血管造影を行った.図Aで多発性のextravasationを認め(▲),塞栓術を行い(図B),以後Hb値が安定した.図3と図4の△はextravasationと読影するには無理な所見であり,double phase造影CTがほしいところである.






文献考察:骨盤損傷に伴う出血
J Trauma. 2003 Oct;55(4):696-703.
Predictors of death in patients with life-threatening pelvic hemorrhage after successful transcatheter arterial embolization.
Hagiwara A, Minakawa K, Fukushima H, Murata A, Masuda H, Shimazaki S.

OBJECTIVE: The purpose of this study was to determine predictors of death in patients with pelvic fracture whose pelvic arterial hemorrhage is controlled successfully by transcatheter arterial embolization (TAE). METHODS: From January 1996 to December 2000, 61 patients with a pelvic fracture who had pelvic arterial hemorrhage were treated at our Level I trauma center according to a protocol that assigns a high priority to diagnostic and therapeutic angiography within the algorithm. Angiography is performed before laparotomy in patients with hemoperitoneum, who can be stabilized by fluid resuscitation, and otherwise afterward. External fixation was performed immediately after TAE in the angiography suite. Predictors of outcome were determined retrospectively by univariate and multivariate analysis using anatomic and physiologic parameters. RESULTS: Forty-eight patients survived and 13 died. TAE successfully controlled pelvic arterial hemorrhage in all patients. Predictors of death included posterior pelvic arterial injury and an elevated Acute Physiology and Chronic Health Evaluation II score (odds ratio, 15.6 and 23.9, respectively). Need for fluid requirements to achieve hemodynamic stability were higher in nonsurvivors than in survivors. Outcome did not correlate with the type of fracture or the Injury Severity Score. CONCLUSION: Application of angiography as a therapeutic intervention in patients with pelvic arterial bleeding may reduce the need for surgery, thereby avoiding or minimizing this additional trauma.PMID: 14566125
追記:造影CTでextravasationと,膀胱を圧排する大きさの血腫は血管撮影の適応である.

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