Ťoupal O, Kurfirst V, Pták P
Rozhl Chir. 2025;104(5):211-216. doi: 10.48095/ccrvch2025211.
The patient suddenly experienced shortness of breath, collapse, and loss of consciousness at home. Layperson-performed, telephone-guided cardiopulmonary resuscitation was initiated, and upon the arrival of the emergency medical team, suc-cessful extended CPR was performed, after which the patient was transported to the emergency department at Hospital of České Budějovice. Basic stabilization of the clinical condition was carried out, the patient was secured, intubated, and transported to the CT scanner. A massive bilateral pulmonary embolism was verified byCT. Thrombolysis was immediately performed in the emergency room, circulation was stabilized, and the patient was transferred to the ICU. An hour later, the patient experienced severe circulatory instability in the ICU, requiring high-dose norepinephrine support. Ultrasound was performed, followed by a CT scan of the abdomen, which revealed massive hemoperitoneum. An urgent surgical consultation was performed, and surgery was recommended on a vital indication. An urgent laparotomy was performed on a hemodynamically unstable patient with the blood pressure 60/30 and the pulse 180/min. Despite massive circulatory support and erythrocyte transfusion, 4 liters of noncoagulable blood were drained from the hepatic region. The liver was torn in several places due to fractured ribs, most severely in the left lobe at the hepatic veins. Due to severe circulatory instability, the injury was -deemed inoperable, and it was decided to stabilize the condition with perihepatic packing, after which the patient was transferred to the ICU. The ICU continued conservative therapy, and there was a gradual reduction in the drainage output. A second-look operation was performed after 48 hours - revision of the original wound and removal of the drapes. Multiple fissures were found in the -right lobe, caused by broken ribs, with heavy bleeding from the dorsal hepatic veins. A combination of selective suturing and electrocoagulation of the fissures was performed. Due to ongoing circulatory instability, the decision was made to use perihepatic packing once again. The patient was left in the ICU for further circulatory stabilization, with a plan to do another surgical revision after stabilization in 48 hours. Another surgical revision was performed, revisiting the perihepatic space and performing an anatomical resection of liver segments II and III, followed by selective ligation of the hepatic vein. Hemodynamic stabilization was achieved. Postoperatively, a fluidothorax developed, which was managed by thoracic drainage, and acute acalculous cholecystitis, which was treated with puncture cholecystostomy. The patient is now primarily healed and has been started on long-term anticoagulation therapy by the angiologist. The cause of the pulmonary embolism was not determined.
患者在家中突然出现呼吸急促、晕倒及意识丧失。在非专业人员进行电话指导下的心肺复苏后，急救医疗队到达，成功进行了延长心肺复苏，随后患者被转运至捷克布杰约维采医院急诊科。对临床状况进行了基本稳定处理，患者被固定、插管并送往CT扫描仪处。CT证实为大面积双侧肺栓塞。立即在急诊室进行溶栓治疗，循环得以稳定，患者被转至重症监护病房（ICU）。一小时后，患者在ICU出现严重循环不稳定，需要高剂量去甲肾上腺素支持。进行了超声检查，随后进行腹部CT扫描，结果显示大量腹腔积血。进行了紧急外科会诊，基于关键指征建议进行手术。对一名血流动力学不稳定、血压为60/30、脉搏为180次/分钟的患者进行了紧急剖腹手术。尽管给予了大量循环支持和红细胞输注，但仍从肝区引出4升无法凝固的血液。由于肋骨骨折，肝脏多处撕裂，最严重的是肝静脉处的左叶。由于严重的循环不稳定，该损伤被认为无法手术，决定采用肝周填塞来稳定病情，之后患者被转至ICU。ICU继续进行保守治疗，引流液量逐渐减少。48小时后进行了二次手术——检查原伤口并拆除敷料。发现右叶有多处因肋骨骨折导致的裂缝，肝后静脉大量出血。对裂缝进行了选择性缝合和电凝联合处理。由于持续的循环不稳定，决定再次使用肝周填塞。患者留在ICU进一步稳定循环，计划在48小时循环稳定后再次进行手术检查。再次进行了手术检查，探查肝周间隙并对肝段II和III进行解剖切除，随后选择性结扎肝静脉。实现了血流动力学稳定。术后出现胸腔积液，通过胸腔引流进行处理，还出现了急性非结石性胆囊炎，通过胆囊穿刺造瘘术进行治疗。患者目前基本康复，血管病专家已开始对其进行长期抗凝治疗。肺栓塞的病因未明确。
