Hussmann B, Taeger G, Lefering R, Waydhas C, Nast-Kolb D, Ruchholtz S, Lendemans S
Klinik für Unfallchirurgie, Universitätsklinikum Essen, Essen, Deutschland.
Unfallchirurg. 2011 Aug;114(8):705-12. doi: 10.1007/s00113-010-1842-4.
Uncontrollable hemorrhaging after blunt trauma and the resulting hemorrhagic shock is still one of the main causes of death in trauma patients. Starting volume replacement before admission to hospital is one of the main pillars of immediate treatment. The statements concerning the quantity of the preclinically administered fluid are still controversial and have a low level of evidence in the literature. Massive abdominal trauma and unstable pelvic fractures belong to the most relevant causes of hemorrhagic shock. The aim of this study was to analyze the influence of the quantity of the preclinically administered fluid on the posttraumatic course of patients with massive abdominal and pelvic injuries.
All patients of the trauma registry of the DGU (German Society for Trauma Surgery) who met the following criteria were included: injury severity score ≥16 points, primary admission to hospital, age ≥16 years, initial blood pressure <100 mmHg and transfusion of erythrocyte concentrate (EC). Out of this collective patients with an AIS abdomen ≥4 or an AIS pelvis ≥4 were analyzed. Both groups were divided into 4 subgroups subject to the preclinically infused volume (<1000 ml, 1000-2000 ml, 2001-3000 ml and >3000 ml).
Of the 375 patients with abdominal trauma and 229 patients with pelvic trauma were consistent with the inclusion criteria. In both groups an increasing volume replacement was associated with an increased need for transfusion and a reduction of the coagulation ability (Quick 61% in the case of <1000 ml versus 49.1% in the case of >3000 ml). The rescue time had a relevant influence on the quantity of preclinically infused volume (62 min for <1000 ml versus 88 min for >3000 ml). On admission to hospital the blood pressure values were on average the same in all patients (~ 95 mmHg). With an increasing volume a slight elevation of lethality was found as well as a significant increase of the transfused erythrocyte concentrates, a significant deterioration of coagulation and an increase of patients with mass transfusions.
In the case of a preclinical relevant bleeding after blunt pelvic or abdominal trauma moderate volume replacement (<1000 ml) results in an enhancement of the initial coagulation situation and in a reduction in the need for transfusion. The results of this study support the concept of a restrained volume therapy after massive trauma with and bleeding requiring transfusion.
钝性创伤后无法控制的出血及由此导致的失血性休克仍是创伤患者死亡的主要原因之一。入院前开始进行容量复苏是紧急治疗的主要支柱之一。关于临床前给予液体量的说法仍存在争议，且文献中的证据水平较低。严重腹部创伤和不稳定骨盆骨折是失血性休克最相关的原因。本研究的目的是分析临床前给予液体量对严重腹部和骨盆损伤患者创伤后病程的影响。
纳入德国创伤外科学会（DGU）创伤登记处所有符合以下标准的患者：损伤严重度评分≥16分、首次入院、年龄≥16岁、初始血压<100 mmHg且输注红细胞浓缩液（EC）。从该总体中分析腹部简明损伤定级（AIS）≥4或骨盆AIS≥4的患者。两组根据临床前输注量分为4个亚组（<1000 ml、1000 - 2000 ml、2001 - 3000 ml和>3000 ml）。
375例腹部创伤患者和229例骨盆创伤患者符合纳入标准。在两组中，补液量增加与输血需求增加及凝血能力降低相关（<1000 ml时Quick值为61%，>3000 ml时为49.1%）。抢救时间对临床前输注量有显著影响（<1000 ml时为62分钟，>3000 ml时为88分钟）。入院时所有患者的血压值平均相同（约95 mmHg）。随着补液量增加，发现致死率略有升高，输注的红细胞浓缩液显著增加，凝血功能显著恶化，大量输血的患者增多。
在钝性骨盆或腹部创伤后临床上存在相关出血的情况下，适度补液（<1000 ml）可改善初始凝血状况并减少输血需求。本研究结果支持在严重创伤伴出血且需要输血时采用限制性容量治疗的理念。
