经导管动脉栓塞治疗地震伤挤压综合征巨大创面大出血
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摘要
目的评价经导管动脉栓塞治疗地震伤挤压综合征伴巨大创面大出血的安全性和有效性。方法2008年5月12日-5月26日,收治"5·12"汶川大地震挤压综合征伴巨大创面大出血伤员11例。男6例,女5例;年龄16～36岁,平均21岁。创面共19处,均发生感染。出血部位:髋部创面7例,大腿残端创面3例,肩部创面1例。伴失血性休克6例。11例伤员均行动脉造影明确出血血管,根据造影结果行导管动脉栓塞治疗。动脉栓塞后48h行增强螺旋CT扫描、CT三维血管成像检查有无造影剂外漏及栓塞部位远端血管有无塌陷。结果11例伤员动脉栓塞后行造影检查无造影剂外漏,栓塞平面以远动脉分支不显影,出血动脉栓塞血压明显回升,栓塞成功。栓塞后48h创面无活动性出血。6例发生失血性休克的伤员行动脉栓塞后,创面出血明显减少;予支持治疗后血压逐渐回升,生命体征逐渐恢复正常,病情稳定;栓塞后24h输液总量6750～19600mL,平均8740mL,输血和血浆总量1800～6400mL,平均3500mL。增强螺旋CT扫描示6例远端血管不显影,无造影剂外漏,CT三维血管成像示远端血管塌陷;5例远端血管显影,无造影剂外漏,CT三维血管成像示远端血管仍充盈,血管腔明显变细。无臀部和髋部肌肉坏死、膀胱坏死、排尿困难、大便失禁、阳痿等严重并发症发生。结论动脉栓塞是治疗挤压综合征巨大创面大出血的安全、快速、有效且微创的方法。
Objective To evaluate the safety and efficacy of transcatheter angiographic embolization(AE) in the control of massive haemorrhage from large wound due to crush syndrome after Wenchuan earthquake.Methods From May 12 to May 26, 2008, 11 injured persons in Wenchuan earthquake with massive haemorrhage from large wound due to crush syndrome were treated, including 6 males and 5 females aged 16-36 years old(average 21 years old).All 19 wounds were infected.The hemorrhage was from the hip in 7 cases, the thigh stump in 3 cases, and the shoulder in 1 case.Six patients had hemorrhagic shock.All patients underwent arteriography to locate the bleeding artery, and transcatheter AE was performed according to the result of arteriography.Contrast-enhanced spiral CT scan and three-dimensional angiography were performed 48 hours after AE to evaluate leakage of contrast media and collapse of distal artery of embolism site.Results Angiography for 11 injured persons after AE showed no occurrence of contrast media leakage, faint shadow to the distal branch artery of embolic level, and signifi cant increase of blood pressure of the bleeding artery, indicating the embolization was successful.No active hemorrhage was evident in the wounds 48 hours after AE.For the 6 patients with hemorrhagic shock, obvious decrease of hemorrhage was observed after AE, gradual recovery of blood pressure and vital signs, and stability of their condition were evident after supportive therapy.During the fi rst 24 hours after AE, total volume of infusion was 6 750-19 600 mL(average 8 740 mL), and total volume of blood and plasma transfusion was 1 800-6 400 mL(average 3 500 mL).In 6 cases, contrast-enhanced spiral CT scan demonstrated faint shadow of the distal artery without contrast media leakage, and three-dimensional CT angiography showed collapse of the distal artery;in the rest 5 cases, contrast-enhanced spiral CT scan demonstrated shadow of the distal artery without contrast media leakage, and three-dimensional CT angiography displayed the full-fi lling of distal artery with obviously decreased vascular cavity.No severe complications such as muscle necrosis in the buttock and hip, bladder necrosis, dysuria, fecal incontinence, and impotence occurred.Conclusion The transcatheter AE is a safe, fast, effective and mini-invasive method of controlling massive haemorrhage from large wound caused by crush syndrome after Wenchuan earthquake.
Objective To evaluate the safety and efficacy of transcatheter angiographic embolization(AE) in the control of massive haemorrhage from large wound due to crush syndrome after Wenchuan earthquake.Methods From May 12 to May 26, 2008, 11 injured persons in Wenchuan earthquake with massive haemorrhage from large wound due to crush syndrome were treated, including 6 males and 5 females aged 16-36 years old(average 21 years old).All 19 wounds were infected.The hemorrhage was from the hip in 7 cases, the thigh stump in 3 cases, and the shoulder in 1 case.Six patients had hemorrhagic shock.All patients underwent arteriography to locate the bleeding artery, and transcatheter AE was performed according to the result of arteriography.Contrast-enhanced spiral CT scan and three-dimensional angiography were performed 48 hours after AE to evaluate leakage of contrast media and collapse of distal artery of embolism site.Results Angiography for 11 injured persons after AE showed no occurrence of contrast media leakage, faint shadow to the distal branch artery of embolic level, and signifi cant increase of blood pressure of the bleeding artery, indicating the embolization was successful.No active hemorrhage was evident in the wounds 48 hours after AE.For the 6 patients with hemorrhagic shock, obvious decrease of hemorrhage was observed after AE, gradual recovery of blood pressure and vital signs, and stability of their condition were evident after supportive therapy.During the fi rst 24 hours after AE, total volume of infusion was 6 750-19 600 mL(average 8 740 mL), and total volume of blood and plasma transfusion was 1 800-6 400 mL(average 3 500 mL).In 6 cases, contrast-enhanced spiral CT scan demonstrated faint shadow of the distal artery without contrast media leakage, and three-dimensional CT angiography showed collapse of the distal artery;in the rest 5 cases, contrast-enhanced spiral CT scan demonstrated shadow of the distal artery without contrast media leakage, and three-dimensional CT angiography displayed the full-fi lling of distal artery with obviously decreased vascular cavity.No severe complications such as muscle necrosis in the buttock and hip, bladder necrosis, dysuria, fecal incontinence, and impotence occurred.Conclusion The transcatheter AE is a safe, fast, effective and mini-invasive method of controlling massive haemorrhage from large wound caused by crush syndrome after Wenchuan earthquake.
引文
1Sever MS,Vanholder R,Lameire N.Management of crush-related in-juries after disasters.N Engl J Med,2006,354(10):1052-1063.
2Gonzalez D.Crush syndrome.Crit Care Med,2005,33(1Suppl):S34-41.
3Duman H,Kulahci Y,Sengezer M.Fasciotomy in crush injury result-ing from prolonged pressure in an earthquake in Turkey.Emerg Med J,2003,20(3):251-252.
4Better OS,Rubinstein I,Reis D.Musle crush compartment syndrome:fulminant local edema with threatening systemic effects.Kidney Int,2003,63(10):1155-1157.
5Wu MJ,Lian JD,Lee MC.et al.Rhabdomyolysis following crush injury in the Taiwan Chi-Chi earthquake.Acta Nephrologica,2005,19:62-67.
6王锦权,赵劲松,潘爱军,等.连续性血液净化对多器官功能障碍综合征患者评分和凝血功能的影响.中华急诊医学杂志,2003,12(2):79-81.
7Fangio P,Asehnoune K,Edouard A,et al.Early embolization and va-sopressor administration for management of life-threatening hemor-rhage from pelvic fracture.J Trauma,2005,58(5):978-984.
8Cook ER,Keating FJ,Gillespie I.The role of angiography in the man-agement of haemorrhage from major fractures of the pelvis.J Bone Joint Surg(Br),2002,84(2):178-182.
9Velmahos GC,Toutouzas KG,Vassiliu P,et al.A prospective study on the safety and effi cacy of angiographic emobilization for pelvic and visceral injuries.J Trauma,2002,53(2):303-308.
10Weigert AL,Schafer AL.Uremic bleeding:pathogenesis and therapy.Am J Med Sci,1998,316(2):94-104.
11Matsuoka T,Yoshioka T,Tanaka H,et al.Long-term physical outcome of patients who suffered crush syndrome after the1995Hanshin-Awaji earthquake:prognostic indicators in retrospect.J Trauma,2002,52(1):33-39.
12Kauvar DS,Lefering R,Wade CE.Impact of hemorrhage on trauma outcome:an overview of epidemiology,clinical presentations,and therapeutic considerations.J Trauma,2006,60(6Suppl):S3-11.
13Ketchum L,Hess JR,Hiippala S.Indications for early fresh frozen plasma,cryoprecipitate,and platelet transfusion in trauma.J Trauma,2006,60(6Suppl):S51-58.
14Takahira N,Shindo M,Tanaka K,et al.Gluteal muscle necrosis follow-ing transcatheter angiographic embolization for retroperitoneal haem-orrhage associated with pelvic fracture.Injury,2001,32(1):27-32.
15Yasumura K,Ikegami K,Kamohara T,et al.High incidence of isch-emic necrosis of the gluteal muscle after transcatheter angiographic mmbolization for severe pelvic fracture.J Trauma,2005,58(5):985-990.
16Holcomb JB,Jenkins D,Rhee P,et al.Damage control resuscitation:directly addressing the early coagulopathy of trauma.J Trauma,2007,62(2):307-310.
17Velmahos GC,Chahwan S,Hanks SE,et al.Angiographic embolization of bilateral internal iliac arteries to control life threatening hemor-rhage after blunt trauma to the pelvis.Am Surg,2000,66(9):858-862.
18Osborn TM,Bell B,Qaisi W,et al.Computed tomographic angiogra-phy as an aid to clinical decision making in the selective management of penetrating injuries to the neck:a reduction in the need for opera-tive exploration.J Trauma,2008,64(6):1466-1471.
19Inaba K,Munera F,Rivas L,et al.Computed tomographic angiography in the initial assessment of penetrating extremity injuries.J Trauma,2007,62(2):520-522.
2Gonzalez D.Crush syndrome.Crit Care Med,2005,33(1Suppl):S34-41.
3Duman H,Kulahci Y,Sengezer M.Fasciotomy in crush injury result-ing from prolonged pressure in an earthquake in Turkey.Emerg Med J,2003,20(3):251-252.
4Better OS,Rubinstein I,Reis D.Musle crush compartment syndrome:fulminant local edema with threatening systemic effects.Kidney Int,2003,63(10):1155-1157.
5Wu MJ,Lian JD,Lee MC.et al.Rhabdomyolysis following crush injury in the Taiwan Chi-Chi earthquake.Acta Nephrologica,2005,19:62-67.
6王锦权,赵劲松,潘爱军,等.连续性血液净化对多器官功能障碍综合征患者评分和凝血功能的影响.中华急诊医学杂志,2003,12(2):79-81.
7Fangio P,Asehnoune K,Edouard A,et al.Early embolization and va-sopressor administration for management of life-threatening hemor-rhage from pelvic fracture.J Trauma,2005,58(5):978-984.
8Cook ER,Keating FJ,Gillespie I.The role of angiography in the man-agement of haemorrhage from major fractures of the pelvis.J Bone Joint Surg(Br),2002,84(2):178-182.
9Velmahos GC,Toutouzas KG,Vassiliu P,et al.A prospective study on the safety and effi cacy of angiographic emobilization for pelvic and visceral injuries.J Trauma,2002,53(2):303-308.
10Weigert AL,Schafer AL.Uremic bleeding:pathogenesis and therapy.Am J Med Sci,1998,316(2):94-104.
11Matsuoka T,Yoshioka T,Tanaka H,et al.Long-term physical outcome of patients who suffered crush syndrome after the1995Hanshin-Awaji earthquake:prognostic indicators in retrospect.J Trauma,2002,52(1):33-39.
12Kauvar DS,Lefering R,Wade CE.Impact of hemorrhage on trauma outcome:an overview of epidemiology,clinical presentations,and therapeutic considerations.J Trauma,2006,60(6Suppl):S3-11.
13Ketchum L,Hess JR,Hiippala S.Indications for early fresh frozen plasma,cryoprecipitate,and platelet transfusion in trauma.J Trauma,2006,60(6Suppl):S51-58.
14Takahira N,Shindo M,Tanaka K,et al.Gluteal muscle necrosis follow-ing transcatheter angiographic embolization for retroperitoneal haem-orrhage associated with pelvic fracture.Injury,2001,32(1):27-32.
15Yasumura K,Ikegami K,Kamohara T,et al.High incidence of isch-emic necrosis of the gluteal muscle after transcatheter angiographic mmbolization for severe pelvic fracture.J Trauma,2005,58(5):985-990.
16Holcomb JB,Jenkins D,Rhee P,et al.Damage control resuscitation:directly addressing the early coagulopathy of trauma.J Trauma,2007,62(2):307-310.
17Velmahos GC,Chahwan S,Hanks SE,et al.Angiographic embolization of bilateral internal iliac arteries to control life threatening hemor-rhage after blunt trauma to the pelvis.Am Surg,2000,66(9):858-862.
18Osborn TM,Bell B,Qaisi W,et al.Computed tomographic angiogra-phy as an aid to clinical decision making in the selective management of penetrating injuries to the neck:a reduction in the need for opera-tive exploration.J Trauma,2008,64(6):1466-1471.
19Inaba K,Munera F,Rivas L,et al.Computed tomographic angiography in the initial assessment of penetrating extremity injuries.J Trauma,2007,62(2):520-522.
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