Charbit J, Millet I, Lakhal K, Brault-Noble G, Guillon F, Taourel P, Capdevila X
Department of Anesthesiology and Critical Care, Lapeyronie University Hospital, Montpellier, F-34295 Cedex 5, France.
Injury. 2014 Jan;45(1):88-94. doi: 10.1016/j.injury.2012.05.018. Epub 2012 Jul 5.
We hypothesised that in blunt trauma patients with haemodynamic instability and haemoperitoneum on hospital admission, the haemorrhagic source may not be confined to the peritoneum. The purpose of this study was to describe the incidence and location of bleeding source in this population.
The charts of trauma patients admitted consecutively between January 2005 and January 2010 to our level I Regional Trauma Centre were reviewed retrospectively. All hypotensive patients presenting a haemoperitoneum on admission were included. Hypotension was defined by a systolic blood pressure ≤ 90 mmHg. The haemoperitoneum was quantified on CT images or from operative reports as moderate (Federle score<3 or between 200 and 500 ml) or large (Federle score ≥ 3 or >500 ml). Active bleeding (AB) was defined as injury requiring a surgical or radiologic haemostatic procedure, regardless of origin (peritoneal (PAB) or extraperitoneal (EPAB)).
Of 1079 patients admitted for severe trauma, 110 patients met the inclusion criteria. Seventy-eight (71%) were male, mean age 35.3 (SD 19) years and mean ISS 36.5 (SD 20.5). Among the 91 patients who had AB, 37 patients (41%) had PAB, 34 (37%) had EPAB and 20 had both (22%). Forty-eight (53%) of them had moderate haemoperitoneum and 43 (47%) had large haemoperitoneum. A large haemoperitoneum had positive predictive value for PAB of 88% (95% CI 75-95%) and negative predictive value of 65% (95% CI 49-79%). The corresponding values in the subgroup of patients with EPAB were 65% (95% CI 38-86%) and 76% (95% CI 59-88%).
Haemoperitoneum was associated with PAB in only 52% of hypotensive blunt trauma patients and 63% of bleeding patients. In contrast, 59% of bleeding patients had at least one EPAB. The screening of a haemoperitoneum as a marker of active haemorrhagic source may be confusing and lead to misdiagnosis and inappropriate strategy. Clinician should exclude carefully the presence of any EPAB explaining haemorrhagic shock, before to decide haemostatic treatment.
我们推测，对于入院时存在血流动力学不稳定和腹腔积血的钝性创伤患者，出血源可能不限于腹膜。本研究的目的是描述该人群中出血源的发生率和位置。
回顾性分析2005年1月至2010年1月间连续入住我院一级区域创伤中心的创伤患者病历。纳入所有入院时出现腹腔积血的低血压患者。低血压定义为收缩压≤90 mmHg。根据CT图像或手术报告将腹腔积血量化为中度（费德勒评分<3或200至500 ml之间）或大量（费德勒评分≥3或>500 ml）。活动性出血（AB）定义为需要手术或放射学止血程序的损伤，无论其来源如何（腹膜内（PAB）或腹膜外（EPAB））。
在1079例因严重创伤入院的患者中，110例符合纳入标准。78例（71%）为男性，平均年龄35.3（标准差19）岁，平均损伤严重度评分（ISS）为36.5（标准差20.5）。在91例有活动性出血的患者中，37例（41%）有腹膜内出血，34例（37%）有腹膜外出血，20例两者皆有（22%）。其中48例（53%）有中度腹腔积血，43例（47%）有大量腹腔积血。大量腹腔积血对腹膜内出血的阳性预测值为88%（95%可信区间75 - 95%），阴性预测值为65%（95%可信区间49 - 79%）。腹膜外出血亚组中的相应值分别为65%（95%可信区间38 - 86%）和76%（95%可信区间59 - 88%）。
在低血压钝性创伤患者中，仅52%的患者腹腔积血与腹膜内出血有关，在出血患者中这一比例为63%。相比之下，59%的出血患者至少有一处腹膜外出血。将腹腔积血作为活动性出血源的标志物进行筛查可能会造成混淆，导致误诊和不恰当的治疗策略。在决定止血治疗之前，临床医生应仔细排除任何可解释失血性休克的腹膜外出血的存在。
