非压迫性躯干出血的多中心回顾性研究：出血的解剖位置及血管内治疗与开放手术方法的比较
Multicenter retrospective study of noncompressible torso hemorrhage: Anatomic locations of bleeding and comparison of endovascular versus open approach.
作者信息
Chang Ronald, Fox Erin E, Greene Thomas J, Eastridge Brian J, Gilani Ramyar, Chung Kevin K, DeSantis Stacia M, DuBose Joseph J, Tomasek Jeffrey S, Fortuna Gerald R, Sams Valerie G, Todd S Rob, Podbielski Jeanette M, Wade Charles E, Holcomb John B
机构信息
From the Center for Translational Injury Research (R.C., E.E.F., J.S.T., J.M.P., C.E.W., J.B.H.), Department of Surgery (R.C., E.E.F., C.E.W., J.B.H.), McGovern Medical School; Department of Biostatistics (T.J.G., S.M.D.), School of Public Health, Department of Surgery (B.J.E.), University of Texas Health Science Center at San Antonio, San Antonio; Michael E. DeBakey Department of Surgery (R.G., S.R.T.), Baylor College of Medicine, Houston; United States Army Institute of Surgical Research (K.K.C.); San Antonio Military Medical Center (V.G.S.), Fort Sam Houston; and Department of Cardiothoracic and Vascular Surgery (J.J.D., G.R.F., McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas).
出版信息
J Trauma Acute Care Surg. 2017 Jul;83(1):11-18. doi: 10.1097/TA.0000000000001530.
BACKGROUND
Rational development of technology for rapid control of noncompressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) management versus open (OPEN) management.
METHODS
This is a retrospective study of adult trauma patients with NCTH admitted to four urban Level I trauma centers in the Houston and San Antonio metropolitan areas in 2008 to 2012. Inclusion criteria include named axial torso vessel disruption, Abbreviated Injury Scale chest or abdomen score of 3 or higher with shock (base excess, <-4) or truncal operation in 90 minutes or less, or pelvic fracture with ring disruption. Exclusion criteria include isolated hip fractures, falls from standing, or prehospital cardiopulmonary resuscitation. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, Injury Severity Score, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients.
RESULTS
Five hundred forty-three patients with NCTH underwent ENDO (n = 166, 31%), OPEN (n = 309, 57%), or RT (n = 68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, whereas OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs. 34% vs. 32%); severe injuries (median Injury Severity Score, 34 vs. 27 vs. 21), and increased time to intervention (median, 298 vs. 92 vs. 51 minutes) compared with OPEN and RT. Mortality was 15% versus 20% versus 79%. ENDO was associated with decreased mortality compared to OPEN (relative risk, 0.58; 95% confidence interval, 0.46-0.73).
CONCLUSION
Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding.
LEVEL OF EVIDENCE
Therapeutic, level V.
背景
合理开发快速控制非压缩性躯干出血（NCTH）的技术需要详细了解出血部位。我们的目标是描述NCTH患者躯干出血的解剖位置，并比较血管内（ENDO）治疗与开放手术（OPEN）治疗。
方法
这是一项对2008年至2012年入住休斯顿和圣安东尼奥大都市地区四个城市一级创伤中心的成年NCTH创伤患者的回顾性研究。纳入标准包括明确的轴向躯干血管破裂、简略损伤量表胸部或腹部评分为3分或更高且伴有休克（碱剩余，<-4）或在90分钟或更短时间内进行躯干手术，或伴有骨盆环破裂的骨盆骨折。排除标准包括孤立的髋部骨折、站立时跌倒或院前心肺复苏。根据控制NCTH的初始方法将患者分为开放手术组、血管内治疗组和复苏性开胸手术（RT）组后，采用具有稳健误差方差的混合效应泊松回归（将年龄、机制、损伤严重程度评分、休克、低血压和严重颅脑损伤作为固定效应，将部位作为随机效应进行控制）来检验ENDO与降低NCTH患者院内死亡率相关的假设。
结果
543例NCTH患者接受了ENDO治疗（n = 166，31%）、开放手术治疗（n = 309，57%）或RT治疗（n = 68，12%）。解剖学出血部位为胸部25%、腹部41%、骨盆31%。ENDO用于治疗的血管损伤类型相对较少，而开放手术和RT治疗的损伤类型更多样化。与开放手术和RT治疗相比，接受ENDO治疗的患者钝性创伤更多（95%对34%对32%）；损伤更严重（损伤严重程度评分中位数，34对27对21），干预时间更长（中位数，298对92对51分钟）。死亡率分别为15%、20%和79%。与开放手术相比，ENDO与死亡率降低相关（相对风险，0.58；95%置信区间，0.46-0.73）。
结论
虽然ENDO可能降低NCTH患者的死亡率，但显著的组间差异限制了这一发现的普遍性。
证据水平
治疗性，V级。
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