Tomescu Dana, Vişan Anca, Popescu I, Tulbure D
Centrul ATI, Institutul Clinic Fundeni, Bucureşti, România.
Chirurgia (Bucur). 2008 Sep-Oct;103(5):577-82.
We report the case of a 56 years old male patient, smoker, obese, with untreated arterial hypertension, hospitalized on 16.02.07 with the diagnosis of inferior acute myocardial infarction, for which he received thrombolysis with streptokinase, followed by anticoagulation with non fractioned heparin. Two days later he started to complain of acute abdominal pain, and laboratory findings showed a low hemoglobin level. Imaging findings (ultrasonography and CT scan) showed evidence of subcapsular liver haematoma, caused by bleeding at hepatic and splenic level. He received red blood packed cells, fresh frozen plasma, cryoprecipitate, activated factor VII and was transferred by helicopter to Fundeni Clinical Institute--Intensive care unit (ICU). On admission, the patient was conscious, anxious, dyspneic, with mild hypoxia, with no signs of low cardiac output and with a painful abdomen. ECG, echocardiography and elevated myocardial necrosis enzymes confirmed myocardial infarction. Shortly after admission there was a worsening of his clinical condition, with a decrease in hemoglobin level despite red blood packed cells administration (Hb=7.8 g/dl) and thrombocytopenia (82000/mmc), with normal coagulation tests, thus suggesting active intraabdominal bleeding. Echography and CT scan confirmed bleeding. Emergency surgery was performed, showing massive haemoperitoneum (approx 4.5 L of blood), due to spontaneous rupture of a subcapsular hematoma in the liver. The surgical hemostasis was performed on the liver parenchyma laceration. Duration of surgery was 4 hours. There were no significant cardiac events during surgery (no signs of ischemia on ECG, no ST elevation), despite the need for inotropic agent. After surgery, the patient was referred to the ICU, intubated and ventilated, with inotropic support - dobutamine. Sequential ECG's, enzymatic trend and echocardiographies were performed to monitor myocardial ischemia. The outcome was favourable, no further bleeding and no postoperative myocardial infarction occurred. Secondary prevention was started early (thromboprophylaxis, selective beta-blocker, angiotensin inhibitors and statins). The patient had a favorable outcome and was discharged from the ICU the fourth day after surgery. He had a total length of stay in hospital of seven days, with a follow-up in the cardiology department.
我们报告一例56岁男性患者，有吸烟史、肥胖，患有未经治疗的动脉高血压。该患者于2007年2月16日因下壁急性心肌梗死入院，接受了链激酶溶栓治疗，随后使用普通肝素进行抗凝。两天后，他开始诉说急性腹痛，实验室检查发现血红蛋白水平较低。影像学检查结果（超声和CT扫描）显示存在肝包膜下血肿，是由肝脏和脾脏部位出血所致。他接受了红细胞悬液、新鲜冰冻血浆、冷沉淀、活化凝血因子VII治疗，并通过直升机转至Fundeni临床研究所重症监护病房（ICU）。入院时，患者意识清醒、焦虑、呼吸困难，有轻度缺氧，无低心排血量迹象，腹部疼痛。心电图、超声心动图及心肌坏死酶升高证实了心肌梗死。入院后不久，其临床状况恶化，尽管输注了红细胞悬液，但血红蛋白水平仍下降（Hb = 7.8 g/dl），且出现血小板减少（82000/mmc），凝血试验正常，提示腹腔内有活动性出血。超声和CT扫描证实了出血。进行了急诊手术，发现大量腹腔积血（约4.5升），系肝脏包膜下血肿自发破裂所致。对肝实质裂伤进行了手术止血。手术持续时间为4小时。尽管需要使用血管活性药物，但手术期间未发生重大心脏事件（心电图无缺血迹象，无ST段抬高）。术后，患者被转入ICU，进行气管插管和机械通气，并给予血管活性药物支持——多巴酚丁胺。连续进行心电图、酶学动态监测及超声心动图检查以监测心肌缺血情况。结果良好，未再出血，也未发生术后心肌梗死。早期开始了二级预防（血栓预防、选择性β受体阻滞剂、血管紧张素抑制剂及他汀类药物）。患者预后良好，术后第四天从ICU出院。他总共住院七天，之后在心脏病科进行随访。
