严重骨盆骨折出血的当前治疗方法：美国创伤外科学会多机构试验的结果
Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial.
作者信息
Costantini Todd W, Coimbra Raul, Holcomb John B, Podbielski Jeanette M, Catalano Richard, Blackburn Allie, Scalea Thomas M, Stein Deborah M, Williams Lashonda, Conflitti Joseph, Keeney Scott, Suleiman Ghada, Zhou Tianhua, Sperry Jason, Skiada Dimitra, Inaba Kenji, Williams Brian H, Minei Joseph P, Privette Alicia, Mackersie Robert C, Robinson Brenton R, Moore Forrest O
机构信息
From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery (T.W.C., R.Co.), Department of Surgery, University of California San Diego Health Sciences, San Diego; Department of Surgery, Loma Linda University Medical Center (R.Ca., A.B.), Loma Linda; Department of Surgery, University of Southern California (D.S., K.I.), Los Angeles; and Department of Surgery, San Francisco General Hospital and Trauma Center (A.P., R.C.M.), San Francisco, California; Department of Surgery, University of Texas Health Sciences Center-Houston (J.B.H., J.M.P.), Houston; Department of Surgery, East Texas Medical Center (L.W., J.C.), Tyler; and Department of Surgery, University of Texas Southwestern Medical Center (B.H.W., J.P.M.), Dallas, Texas; Department of Surgery, R Adams Cowley Shock Trauma Center (T.M.S., D.M.S.), Baltimore, Maryland; Department of Surgery, St. Luke's University Health Network (S.K., G.S.), Bethlehem; and Department of Surgery, University of Pittsburgh Medical Center (T.Z., J.S.), Pittsburgh, Pennsylvania; and Department of Surgery, Chandler Regional Medical Center (B.R.R., F.O.M), Chandler, Arizona.
出版信息
J Trauma Acute Care Surg. 2016 May;80(5):717-23; discussion 723-5. doi: 10.1097/TA.0000000000001034.
BACKGROUND
There is no consensus as to the optimal treatment paradigm for patients presenting with hemorrhage from severe pelvic fracture. This study was established to determine the methods of hemorrhage control currently being used in clinical practice.
METHODS
This prospective, observational multi-center study enrolled patients with pelvic fracture from blunt trauma. Demographic data, admission vital signs, presence of shock on admission (systolic blood pressure < 90 mm Hg or heart rate > 120 beats per minute or base deficit < -5), method of hemorrhage control, transfusion requirements, and outcome were collected.
RESULTS
A total of 1,339 patients with pelvic fracture were enrolled from 11 Level I trauma centers. Fifty-seven percent of the patients were male, with a mean ± SD age of 47.1 ± 21.6 years, and Injury Severity Score (ISS) of 19.2 ± 12.7. In-hospital mortality was 9.0 %. Angioembolization and external fixator placement were the most common method of hemorrhage control used. A total of 128 patients (9.6%) underwent diagnostic angiography with contrast extravasation noted in 63 patients. Therapeutic angioembolization was performed on 79 patients (5.9%). There were 178 patients (13.3%) with pelvic fracture admitted in shock with a mean ± SD ISS of 28.2 ± 14.1. In the shock group, 44 patients (24.7%) underwent angiography to diagnose a pelvic source of bleeding with contrast extravasation found in 27 patients. Thirty patients (16.9%) were treated with therapeutic angioembolization. Resuscitative endovascular balloon occlusion of the aorta was performed on five patients in shock and used by only one of the participating centers. Mortality was 32.0% for patients with pelvic fracture admitted in shock.
CONCLUSION
Patients with pelvic fracture admitted in shock have high mortality. Several methods were used for hemorrhage control with significant variation across institutions. The use of resuscitative endovascular balloon occlusion of the aorta may prove to be an important adjunct in the treatment of patients with severe pelvic fracture in shock; however, it is in the early stages of evaluation and not currently used widely across trauma centers.
LEVEL OF EVIDENCE
Prognostic study, level II; therapeutic study, level III.
背景
对于严重骨盆骨折出血患者的最佳治疗模式尚无共识。本研究旨在确定目前临床实践中用于控制出血的方法。
方法
这项前瞻性、观察性多中心研究纳入了因钝性创伤导致骨盆骨折的患者。收集了人口统计学数据、入院时的生命体征、入院时是否存在休克（收缩压<90mmHg或心率>120次/分钟或碱缺失<-5）、出血控制方法、输血需求和结局。
结果
从11个一级创伤中心共纳入了1339例骨盆骨折患者。57%的患者为男性，平均年龄±标准差为47.1±21.6岁，损伤严重程度评分（ISS）为19.2±12.7。住院死亡率为9.0%。血管栓塞和外固定架置入是最常用的出血控制方法。共有128例患者（9.6%）接受了诊断性血管造影，其中63例患者发现造影剂外渗。79例患者（5.9%）接受了治疗性血管栓塞。178例骨盆骨折患者（13.3%）入院时处于休克状态，平均ISS±标准差为28.2±14.1。在休克组中，44例患者（24.7%）接受了血管造影以诊断骨盆出血来源，其中27例患者发现造影剂外渗。30例患者（16.9%）接受了治疗性血管栓塞。5例休克患者接受了复苏性血管内主动脉球囊阻断术，且仅由一个参与中心使用。休克入院的骨盆骨折患者死亡率为32.0%。
结论
休克入院的骨盆骨折患者死亡率很高。使用了多种出血控制方法，各机构之间存在显著差异。复苏性血管内主动脉球囊阻断术可能被证明是治疗休克严重骨盆骨折患者的重要辅助手段；然而，它尚处于评估早期，目前在各创伤中心并未广泛使用。
证据水平
预后研究，二级；治疗研究，三级。
Zotero 插件