Stagnitti Franco
Ann Ital Chir. 2013 Jul-Aug;84(4):365.
Haemodynamically unstability after severe abdominal injuries requires a new therapeutic strategy. European guidelines recommend: reduced time, non-invasive investigations, avoid massive volemic replacement before surgery. The primary aim of Damage Control Resuscitation protocol is to prevent the lethal triad: hypothermia, acidosis and coagulopathy. The treatment includes contemporary: permissive hypotension, haemostatic resuscitation, and Damage Control Surgery (DCS). Systolic pressure below the physiological limits maximize the benefits of resuscitation and haemostasis, decreasing vessel clots expulsion. Haemostatic resuscitation uses blood components and substitutes, to allow volemic replacement and to avoid trauma-induced coagulopathy (25% - 30% of complex trauma). The use of PRBCs and plasma 1 to 1 is an independent survival predictor in patients undergoing DCS. Military haemostatic resuscitation protocol suggests massive transfusion using 10 or more PRBCs during 24 or 6 hours if 3 or more triggers are present: pressure > 90, hemoglobin > 11 g, temperature < 35.5°C, INR > 1.5, base deficit </=6. Joint Theater Trauma Registry demonstrated if we maintain PAS around 70-80 mmHg, using plateled, plasma PRBCs (1-1-1) and limiting crystalloids (250 cc), haemocomponents utilization decrease, mortality is reduced 65 % vs 19 % and Abdominal Compartment Syndrome incidence is limited. When bleeding persists despite 10 PRBCs are infused, rFVIIa is recommended and Tranexanic Acid is essential in the drug list. Contemporary DCS performs packing for bleeding solve, intestinal diversion to avoid contamination and temporary wall closure to limit abdominal tension.
Major abdominal trauma, Traumatic induced coagulopathy, Uncontrolled bleeding.
严重腹部损伤后血流动力学不稳定需要一种新的治疗策略。欧洲指南建议：缩短时间、进行非侵入性检查、避免术前大量液体复苏。损伤控制复苏方案的主要目标是预防致死三联征：低体温、酸中毒和凝血功能障碍。治疗包括同时进行：允许性低血压、止血复苏和损伤控制手术（DCS）。收缩压低于生理极限可使复苏和止血的益处最大化，减少血管内血栓排出。止血复苏使用血液成分和替代品，以实现液体复苏并避免创伤性凝血病（复杂创伤的25% - 30%）。在接受DCS的患者中，红细胞悬液（PRBCs）与血浆按1:1使用是独立的生存预测指标。军事止血复苏方案建议，如果出现3个或更多触发因素：血压>90、血红蛋白>11 g、体温<35.5°C、国际标准化比值（INR）>1.5、碱缺失≤6，则在24小时或6小时内使用10个或更多PRBCs进行大量输血。联合战区创伤登记处表明，如果我们将收缩压维持在70 - 80 mmHg左右，使用血小板、血浆、PRBCs（1:1:1）并限制晶体液（250 cc），血液成分的使用量会减少，死亡率从65%降至19%，腹部间隔综合征的发生率也会降低。当输注10个PRBCs后出血仍持续时，建议使用重组活化凝血因子VII（rFVIIa），氨甲环酸是药物清单中的必需药物。当代DCS通过填塞来解决出血问题，进行肠造口术以避免污染，并进行临时腹壁关闭以限制腹内压力。
严重腹部创伤、创伤性凝血病、失控性出血
