Hagiwara Akiyoshi, Murata Atsuo, Matsuda Takeaki, Matsuda Hiroharu, Shimazaki Shuji
Department of Traumatology and Critical Care Medicine, School of Medicine, Kyorin University, Tokyo, Japan.
J Trauma. 2004 Aug;57(2):271-6; discussion 276-7. doi: 10.1097/01.ta.0000131198.79153.3c.
This study aimed to determine whether nonsurgical management using transcatheter arterial embolization (TAE) is safe for patients with blunt multiple trauma who transiently respond to the initial fluid resuscitation.
Contrast computed tomography was performed for patients with blunt abdominal injuries, excluding those who did not respond to initial fluid resuscitation. Angiography was performed for patients with injuries showing contrast extravasation or solid organ injury classified, according to the American Association for the Surgery of Trauma, as grade 3 or higher on computed tomography. Transcatheter arterial embolization was performed when angiography showed arterial extravasation. The protocol was abandoned for any patients who became profoundly hypotensive (with systolic blood pressure 60 mm Hg or lower) during computed tomography or angiography.
Between January 2000 and December 2002, 269 patients with blunt abdominal injuries underwent TAE immediately after admission. Of these patients, 41 had injuries in at least two regions and underwent TAE for these regions. Among them, 22 patients were hemodynamically stable or showed rapid response to fluid resuscitation. The nonsurgical treatment was successful in all these cases. The remaining 19 patients (Injury Severity Score, 37.3 +/- 8.2), who showed a transient response, were the subjects of this study. Of these patients, 15 underwent TAE for injuries in two regions (13 pelvic fractures, 7 splenic injuries, 6 hepatic injuries, 3 facial bleeding, and 1 renal injury), and 4 patients underwent TAE for injuries in three regions (4 had splenic injuries, 3 hepatic injuries, 2 renal injuries, 2 pelvic fractures, and 1 facial bleeding). For all these patients, TAE was successfully performed. Before TAE, the systolic blood pressure was 79.9 +/- 8.4 mm Hg, and the shock index was 1.45 +/- 0.25 mm Hg. After TAE, the corresponding values were 120.6 +/- 19.3 mm Hg and 0.87 +/- 0.16 mm Hg, respectively (p < 0.001). The rate of fluid administration required after TAE (214.2 +/- 139.3 mL/hour) was significantly less than that required before TAE (1244.2 +/- 347.1 mL/hour; range, 632-1,728 mL/hour) (p < 0.001). The deaths of two patients were classified as nonpreventable on the basis of the Trauma and Injury Severity Score (TRISS), and their respective probabilities of survival were determined to be 0.13 and 0.03.
Nonsurgical management using TAE can be performed safely even for patients with blunt multiple trauma who are in hemorrhagic hypotension if their hemodynamics are improved by resuscitation with 2 L of fluid.
本研究旨在确定经导管动脉栓塞术（TAE）这种非手术治疗方法对于钝性多发伤且对初始液体复苏有短暂反应的患者是否安全。
对钝性腹部损伤患者进行对比增强计算机断层扫描，排除那些对初始液体复苏无反应的患者。对损伤表现为对比剂外渗或根据美国创伤外科协会分类在计算机断层扫描上为3级或更高的实质性器官损伤患者进行血管造影。当血管造影显示动脉外渗时进行经导管动脉栓塞术。对于在计算机断层扫描或血管造影期间出现严重低血压（收缩压60 mmHg或更低）的任何患者，放弃该方案。
在2000年1月至2002年12月期间，269例钝性腹部损伤患者入院后立即接受TAE治疗。在这些患者中，41例至少在两个区域有损伤并对这些区域进行了TAE治疗。其中，22例患者血流动力学稳定或对液体复苏反应迅速。所有这些病例的非手术治疗均成功。其余19例（损伤严重度评分，37.3±8.2）表现出短暂反应的患者是本研究的对象。在这些患者中，15例因两个区域的损伤接受TAE治疗（13例骨盆骨折、7例脾损伤、6例肝损伤、3例面部出血和1例肾损伤），4例因三个区域的损伤接受TAE治疗（4例有脾损伤、3例肝损伤、2例肾损伤、2例骨盆骨折和1例面部出血）。对所有这些患者，TAE均成功实施。TAE前，收缩压为79.9±8.4 mmHg，休克指数为1.45±0.25 mmHg。TAE后，相应值分别为120.6±19.3 mmHg和0.87±0.16 mmHg（p<0.001）。TAE后所需的液体输注速率（214.2±139.3 mL/小时）明显低于TAE前所需的速率（1244.2±347.1 mL/小时；范围，632 - 1728 mL/小时）（p<0.001）。根据创伤和损伤严重度评分（TRISS），两名患者的死亡被归类为不可预防，其各自的生存概率分别确定为0.13和0.03。
即使对于出血性低血压的钝性多发伤患者，如果通过2 L液体复苏改善了他们的血流动力学，使用TAE进行非手术治疗也可以安全实施。
