硬体征变软：对外伤性肢体血管损伤表现体征的批判性评估。
Hard signs gone soft: A critical evaluation of presenting signs of extremity vascular injury.
机构信息
From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital (A.N.R., A.D.), Boston, MA; Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center (J.D., R.B., J.M., D.F.), Baltimore MD; Division of Trauma/Surgical Critical Care, University of Tennessee Health Science Center (T.B., T.F.), Memphis, TN; Division of Acute Care Surgery, University of Florida Health Jacksonville (D.S.), Jacksonville, FL; Center for Translational Injury Research, University of Texas Health Science Center at Houston (J.P.), Houston TX; Division of Trauma and Critical Care, University of Southern California (K.I.), Los Angeles; and Vascular Surgery Service, Brook Army Medical Center (D.K.), San Antonio, TX.
出版信息
J Trauma Acute Care Surg. 2021 Jan 1;90(1):1-10. doi: 10.1097/TA.0000000000002958.
BACKGROUND
Despite advances in management of extremity vascular injuries, "hard signs" remain the primary criterion to determine need for imaging and urgency of exploration. We propose that hard signs are outdated and that hemorrhagic and ischemic signs of vascular injury may be of greater clinical utility.
METHODS
Extremity arterial injuries from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry were analyzed to examine the relationships between hard signs, ischemic signs, and hemorrhagic signs of extremity vascular injury with workup, diagnosis, and management.
RESULTS
Of 1,910 cases, 1,108 (58%) had hard signs of vascular injury. Computed tomography angiography (CTA) was more commonly used as the diagnostic modality in patients without hard signs, while operative exploration was primarily used for diagnosis in hard signs. Patients undergoing CTA were more likely to undergo endovascular or hybrid repair (EHR) (10.7%) compared with patients who underwent exploration for diagnosis (1.5%). Of 915 patients presenting with hemorrhagic signs, CTA was performed 14.5% of the time and was associated with a higher rate of EHR and observation. Of the 490 patients presenting with ischemic signs, CTA was performed 31.6% of the time and was associated with higher rates of EHR and observation. Hemorrhagic signs were associated with arterial transection, while ischemic signs were associated with arterial occlusion. Patients with ischemic signs undergoing exploration for diagnosis received more units of packed red blood cells during the first 24 hours. There was no difference in amputation rate, reintervention rate, hospital length of stay, or mortality in comparing groups who underwent CTA versus exploration.
CONCLUSION
Hard signs have limitations in identification and characterization of extremity arterial injuries. A strategy of using hemorrhagic and ischemic signs of vascular injury is of greater clinical utility. Further prospective study is needed to validate this proposed redefinition of categorization of presentations of extremity arterial injury.
LEVEL OF EVIDENCE
Diagnostic, level III.
背景
尽管在四肢血管损伤的治疗方面取得了进展，但“硬体征”仍然是确定是否需要影像学检查和紧急探查的主要标准。我们认为“硬体征”已经过时，血管损伤的出血和缺血体征可能具有更大的临床实用价值。
方法
分析美国创伤外科学会前瞻性观察性血管损伤治疗登记处的四肢动脉损伤病例，以研究硬体征、缺血体征和出血性血管损伤体征与检查、诊断和治疗之间的关系。
结果
在 1910 例患者中，有 1108 例（58%）存在血管损伤的硬体征。在没有硬体征的患者中，更常使用计算机断层血管造影（CTA）作为诊断方式，而在有硬体征的患者中，主要采用手术探查进行诊断。接受 CTA 的患者更有可能接受血管内或杂交修复（EHR）（10.7%），而接受探查诊断的患者则为 1.5%。在 915 例出现出血体征的患者中，有 14.5%的患者进行了 CTA 检查，且 EHR 和观察的比例更高。在 490 例出现缺血体征的患者中，有 31.6%的患者进行了 CTA 检查，且 EHR 和观察的比例更高。出血体征与动脉横断有关，而缺血体征与动脉闭塞有关。接受探查诊断的缺血体征患者在 24 小时内接受的红细胞单位更多。与接受 CTA 检查的患者相比，接受探查检查的患者在截肢率、再干预率、住院时间和死亡率方面没有差异。
结论
硬体征在识别和描述四肢动脉损伤方面存在局限性。使用血管损伤的出血和缺血体征的策略具有更大的临床实用价值。需要进一步的前瞻性研究来验证这种对四肢动脉损伤表现分类的重新定义。
证据等级
诊断，III 级。
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