骨盆型严重多发伤的损伤控制复苏

Damage control resuscitation of severe multiple trauma in the pelvic fractures

目的 :探讨骨科损伤控制复苏(damage contral resuscitation,DCR)在救治骨盆型严重多发伤中的临床疗效。方法:回顾性分析2009年3月至2013年9月收治的28例骨盆型严重多发伤患者的临床资料。其中男19例,女9例;年龄21~51岁,平均32.5岁。骨盆骨折Tile分型:B型16例,C型12例;ISS评分32.0±3.4。采用骨科损伤控制手术的同时应用DCR策略救治。即入院时迅速采用小容量平衡盐液维持收缩压80~90 mm Hg,同时急诊Ⅰ期简易清创、外固定支架或捆绑带固定骨盆,优先处理胸腹部合并伤。四肢骨折临时骨牵引或石膏外固定等。手术控制出血后快速容量复苏,按照悬浮红细胞(RBC)∶血浆(FFP)=2 U∶1 U^3 U∶2 U的比例给予血浆综合救治。记录休克纠正前的平衡盐液用量及输血量,观察血清乳酸和凝血功能恢复时间。结果:5例入院后4~15 h抢救无效死亡(严重创伤失血性休克3例,急性呼吸窘迫综合征2例)。23例休克均在伤后1.6~4.3 h纠正,平均2.4 h。Ⅰ期手术持续时间(78.2±10.3)min。平衡盐液平均用量(3 798±340)ml,输入悬浮红细胞14~18 U,新鲜冰冻血浆(FFP)(1 267±58)ml(1U FFP=100 ml);9例输注血小板(PLT)8~12 U。乳酸清除时间(11.4±2.1)h,PT、APTT恢复时间(4.3±0.8)h。监测电解质及酸碱无失衡。复苏成功率约82.2%(23/28)。结论:DCR整合了损伤控制性手术、允许性低血压(或限制性液体复苏)和止血性复苏等主要环节,是骨盆型严重多发伤早期救治的有效措施。

Objective：To discuss the clinical effects of damage control resuscitation（DCR）in treating severe multiple trauma in the pelvic fractures. Methods：From March 2009 to September 2013,a restrospective analysis was conducted on the clinical data of 28 patients with multiple trauma in the pelvic fractures,including 19 males and 9 females,ranging in age from 21 to 51 years old with an average of 32.5 years old. According to Tile classification of pelvic fractures,16 cases were type B and 12 cases were type C. Injury severity score（ISS）averaged 32.0±3.4. All cases were treated with damage contral orthopae-dics and DCR strategy,namely that used immediately with small capacity of balanced salt solution on admission so as to main-tain the blood pressure between 80 to 90 mmHg. At the same time,emergency phaseⅠsimple debridement plus external fix-ator or bundled with fixed pelvic was done,and the chest or abdomen combined injury was treated at first. And limbs fracture was temporary dealing with bone traction or plaster external fixation,etc. After bleeding was controlled by operation,fluid re-suscitation was done as fast as possible and the plasma was transfused early according to the proportion of plasma and red cell suspension（2 U∶1 U-3 U∶2 U）. Dosage of balanced salt solution and blood before remedy shock was recorded,and the re-moval of time of lactic acid and coagulation were observed. Results：Five cases were died after 4 to 15 hours into hospital（3 cases died for severe trauma hemorrhagic shock and 2 cases for acute respiratory distress syndrome）. Twenty three cases were remedy shock at 1.6 to 4.3 hours after injury with an average of 2.4 hours. Period I operation duration was（78.2±10.3）min-utes. Dosage of balanced salt solution was（3 798 ± 340）ml and red cell suspension was 14 to 18 U,fresh frozen plasma （FFP）was（1 267±58）ml（1U FFP=100 ml）,blood platelet was 8 to 12 U for 9 patients. The removel time of lactic acid and PT-APTT was（11.4 ± 2.1）hours and（4.3 ± 0.8）hours. Measures were taken to correct electrolyte and acid base imbalance was normal. The success rat of recovery was 82.2%（23/28）. Conclusion：Damage control resuscitation（DCR）integrates the main links such as damage control operation and allowable low blood pressure（or limited liquid resuscitation）and hemostatic control resuscitation,was early effective treatment measures for the patients with severe multiple trauma in the pelvic fractures.