DuBose Joseph, Inaba Kenji, Barmparas Galinos, Teixeira Pedro G, Schnüriger Beat, Talving Peep, Salim Ali, Demetriades Demetrios
R Adams Cowley Shock Trauma Center, University of Maryland Medical System Baltimore C-STARS, Baltimore, Maryland, USA.
J Trauma. 2010 Dec;69(6):1507-14. doi: 10.1097/TA.0b013e3181d74c2f.
The management of massive retroperitoneal hemorrhage in unstable patients with pelvic fractures remains a considerable therapeutic challenge after blunt mechanisms of injury. We present our study using emergent bilateral ligation of the internal iliac arteries (BLIA) and pelvic packing as a damage control adjunct.
We reviewed our experience during 22 months (May 2006 to March 2008) with damage control management of massive retroperitoneal hemorrhage caused by blunt pelvic injury encountered at the time of emergent laparotomy. Clinical courses were reviewed.
During the study period, 201 patients with pelvic fractures underwent operative intervention. Treatment of an expanding retroperitoneal hematoma was required in 33. Five of these patients were adequately stable for angioembolization, with a resultant 40% survival. Twenty-eight patients required BLIA and pelvic packing intraoperatively. The mean injury severity score of patients who underwent BLIA was 33.1, with 89.3% having an injury severity score of ≥ 16. Overall survival after BLIA was 35.7%. Causes of mortality included brain death, intraoperative arrest, refractory coagulopathy, and sepsis. Techniques used for BLIA included Rummel tourniquet (in 1), clip occlusion (in 5) and suture ligation (in 4). Four patients had subsequent removal of Rummel tourniquet or clips at 24 hours to 72 hours after initial procedure, with the remainder undergoing permanent ligation. No survivors after BLIA were noted to have apparent adverse ischemic sequelae.
BLIA is a damage control tool potentially useful for a select group of patients with massive retroperitoneal hemorrhage after pelvic fracture. Further study is required to determine the appropriate selection criteria for this potentially life-saving maneuver.
在钝性损伤机制后，骨盆骨折不稳定患者的大量腹膜后出血的处理仍然是一个相当大的治疗挑战。我们介绍了我们使用双侧髂内动脉紧急结扎（BLIA）和骨盆填塞作为损伤控制辅助手段的研究。
我们回顾了22个月（2006年5月至2008年3月）期间在急诊剖腹手术时遇到的钝性骨盆损伤导致的大量腹膜后出血的损伤控制管理经验。回顾了临床病程。
在研究期间，201例骨盆骨折患者接受了手术干预。33例需要处理不断扩大的腹膜后血肿。其中5例患者病情足够稳定可进行血管栓塞，生存率为40%。28例患者术中需要进行双侧髂内动脉结扎和骨盆填塞。接受双侧髂内动脉结扎的患者平均损伤严重程度评分为33.1，89.3%的患者损伤严重程度评分≥16。双侧髂内动脉结扎后的总体生存率为35.7%。死亡原因包括脑死亡、术中心跳骤停、难治性凝血障碍和败血症。双侧髂内动脉结扎使用的技术包括鲁梅尔止血带（1例）、夹子夹闭（5例）和缝合结扎（4例）。4例患者在初次手术后24小时至72小时取出了鲁梅尔止血带或夹子，其余患者进行了永久性结扎。双侧髂内动脉结扎后没有幸存者出现明显的缺血性不良后遗症。
双侧髂内动脉结扎是一种损伤控制工具，可能对骨盆骨折后大量腹膜后出血的特定患者群体有用。需要进一步研究以确定这种潜在的救命操作的适当选择标准。
