严重胸腹部血管损伤的早期诊治(附81例报告)

Early diagnosis and treatment for severe thoracic and abdominal vascular injuries:report of 81 cases

目的探讨严重胸腹部血管损伤的早期诊治方法。方法2000年1月-2007年10月收治的严重胸腹部血管损伤患者81例,其中22例到达急救部时表现为明显失血性休克,经胸或腹腔穿刺抽出较多不凝血,立即送手术室紧急手术确诊,38例经64排螺旋CT及血管造影(CTA)检查确诊,21例经数字减影血管造影检查确诊。45例行手术治疗,其中36例行血管损伤缝合修补,手术前12例行血管造影后球囊血管阻断;9例行人造血管吻合,其中3例患者因伤情太重而行损害控制,即严重破损血管临时插管分流,术后于ICU复苏,待全身情况改善后于术后48h内再手术行血管吻合。36例行动脉栓塞治疗(盆腔腹膜后血管损伤31例,其他5例)。结果73例救治成功,救治成功率90.1%。发生严重并发症35例,其中脓毒症6例、ARDS 8例、MODS 23例(其中MODS伴发脓毒症2例)。8例死亡,其中6例于伤后12h内死亡,主要原因为多脏器严重损伤及失血性休克;2例于创伤后8d及16d死亡,主要原因为脓毒症及MODS。结论胸腹部血管严重损伤后应快速完成检查及诊断,紧急手术行血管修复或吻合,部分腹部血管损伤及盆骨骨折引起的腹膜后血管损伤可用动脉栓塞治疗。

Objective To explore the methods for early diagnosis and treatment on severe thoracic and abdominal vascular injuries. Methods Eighty one patients were diagnosed as severe thoracic and abdominal vascular injuries and treated from January 2000 to October 2007. Twenty two cases suffered from hemorrhagic shock when admitted to the Emergency Department, from whom amount of inaggluti- nable blood were drawn out by thoracentesis or peritoneocentesis, and underwent operation immediately; 38 cases were diagnosed by spiral and angiography （CTA） ; 21 cases were diagnosed by digital substraction angiography. Forty-five patients accepted operation, and 36 cases underwent blood vessel suture and repair. Angiography was performed and blood vessels were blocked by sacculus in 12 cases before operation. Nine cases underwent artificial blood vessel anastomosis, among them 3 eases had to receive damage control for heavy injury, i. e. temporary shunting was made by intubating in the severe damaged blood vessel, the patients were then resuscitated in ICU to improve system condition, and operations were performed in 48 hours. Thirty six patients, including 31 cases of retroperitoneal blood vessel injuries in pelvic cavity, were treated by arterial embolization. Results Of the 81 patients, 73 cases were cured （90.1%）. Thirty-five cases devel- oped severe complications, including 6 cases of sepsis, 8 ARDS and 23 MODS. Eight cases died, of them 6 cases died of multiple organs damaged and hemorrhagic shock within 12 hours after injury, and 2 eases died of sepsis and MODS respectively at 8 and 16 days after injury. Conclusions Examination and diagnosis must be done immediately when the thoracic and abdominal vascular injured, and then the urgent operation of blood vessel repair or anastomosis should be performed. Some abdominal and retroperitoneal vascular injuries may be treated with artery embolization.