Seamon Mark J, Pathak Abhijit S, Bradley Kevin M, Fisher Carol A, Gaughan John A, Kulp Heather, Pieri Paola G, Santora Thomas A, Goldberg Amy J
Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania 19104, USA.
J Trauma. 2008 Jan;64(1):1-7; discussion 7-8. doi: 10.1097/TA.0b013e3181606125.
Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage.
A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival.
The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days).
Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.
尽管关于腹部大出血后急诊开胸手术（EDT）结果的文献有限，但众多报告已记录，除心脏创伤外，存在解剖学损伤的患者进行急诊开胸手术的生存率较低。因此，许多创伤外科医生认为，对于因腹腔内出血而濒死的患者，剖腹术前进行急诊开胸手术是徒劳的。我们的主要研究目标是证明剖腹术前进行急诊开胸手术对腹腔大出血患者有益。
对2000年至2006年期间因穿透伤连续进行的237例急诊开胸手术进行回顾性分析，发现50例患者因腹腔大出血接受了急诊开胸手术。分析了年龄、性别、损伤机制和部位、现场及急诊科（ED）生命体征、院前时间、初始急诊科心律、生命体征、格拉斯哥昏迷评分、输血需求、预测死亡率、主要腹部损伤以及临时腹部关闭的必要性。主要研究终点是神经功能完好的住院生存率。
50例因腹腔大出血接受剖腹术前急诊开胸手术的患者大多为年轻男性（平均年龄27.3±8.2岁），占94%，因火器伤导致的占98%。患者在平均院前时间21.2±9.8分钟后出现现场生命体征（84%）和急诊科生命体征（78%）。初始急诊科心律各异，格拉斯哥昏迷评分较低（平均4.2±3.2）。8例（16%）患者神经功能完好地存活至出院。在这8例患者中，均因严重腹部血管损伤（75%）或严重肝损伤（25%）而处于失血性休克状态，均需要大量输血（平均28.6±17.3单位），并在重症监护病房延长住院时间（平均36.3±25.7天）。
尽管伤势严重，但在因腹腔大出血接受急诊开胸手术后，16%的患者神经功能完好地存活至出院。我们的结果表明，剖腹术前进行急诊开胸手术能为因腹腔内出血而濒死的穿透性创伤患者带来生存益处。
