Hoyt D B, Bulger E M, Knudson M M, Morris J, Ierardi R, Sugerman H J, Shackford S R, Landercasper J, Winchell R J, Jurkovich G
University of California, San Diego.
J Trauma. 1994 Sep;37(3):426-32.
To characterize causes of death in the operating room (OR) following major trauma, a retrospective review of admissions to eight academic trauma centers was conducted to define the etiology of death and challenges for improvement in outcome. Five hundred thirty seven OR deaths of 72,151 admissions were reviewed for mechanism of injury, physiologic findings, resuscitation, patterns of injury, surgical procedures, cause of death, and preventability. Blunt injuries accounted for 61% of all injuries, gunshot wounds (GSW) accounted for 74% of penetrating injuries. Sixty two percent of all patients arrived in shock. Average blood pressure (BP) was 52 mm Hg at the scene and 60 mm Hg on admission, with the period of shock > 10 minutes in 74%. Only 56% were resuscitated to a BP > 90 mm Hg before surgery. Average time to the OR was 30.1 minutes and mean best postresuscitation pH was 7.18. Mean best OR temperature was 32.2 degrees C. Recurrent injury patterns judged as the primary cause of patient death included head/neck injury (16.4%), chest injury (27.4%), and abdominal injury (53.4%). Actual cause of death was bleeding (82%), cerebral herniation (14.5%), and air emboli (2.2%). A different strategy for improved outcome was identified in 54 patients with the following conclusions: (1) delayed transfer to the OR remains a problem with significant BP deterioration during delay, particularly following interfacility transfer; (2) staged injury isolation and repair to allow better resuscitation and warming may lead to improved results; (3) combined thoraco-abdominal injuries, particularly with thoracic aortic disruption, often require a different sequence of management; (4) aggressive evaluation of retroperitoneal hematomas is essential; (5) OR management of severe liver injuries remains a technical challenge with better endpoints for packing needed; and (6) resuscitative thoracotomy applied to OR patients in extremis from exsanguination offers little.
为了明确严重创伤后手术室（OR）内的死亡原因，对八家学术性创伤中心的入院病例进行了回顾性研究，以确定死亡病因及改善预后面临的挑战。对72151例入院病例中的537例手术室死亡病例进行了审查，内容包括损伤机制、生理检查结果、复苏情况、损伤类型、外科手术、死亡原因及可预防性。钝性损伤占所有损伤的61%，枪伤（GSW）占穿透性损伤的74%。所有患者中有62%在入院时处于休克状态。现场平均血压（BP）为52mmHg，入院时为60mmHg，74%的患者休克时间超过10分钟。只有56%的患者在手术前复苏至血压>90mmHg。平均到达手术室的时间为30.1分钟，复苏后最佳pH值平均为7.18。手术室最佳平均温度为32.2摄氏度。被判定为患者死亡主要原因的反复出现的损伤类型包括头/颈部损伤（16.4%）、胸部损伤（27.4%）和腹部损伤（53.4%）。实际死亡原因是出血（82%）、脑疝（14.5%）和气栓（2.2%）。在54例患者中确定了一种改善预后的不同策略，得出以下结论：（1）延迟转运至手术室仍然是一个问题，延迟期间血压会显著恶化，尤其是在机构间转运后；（2）分阶段进行损伤隔离和修复以实现更好的复苏和升温可能会改善结果；（3）胸腹联合伤，特别是伴有胸主动脉破裂时，通常需要不同的处理顺序；（4）积极评估腹膜后血肿至关重要；（5）严重肝损伤的手术室处理仍然是一项技术挑战，需要更好的填塞终点指标；（6）对因失血处于濒死状态的手术室患者实施复苏性开胸手术效果甚微。
