骨盆型严重多发伤伴失血性休克的损伤控制复苏策略

Strategy of damage control resuscitation for severe polytrauma patients complicated with pelvic injury and hemorrhagic shock

【摘要】目的探讨骨盆型严重多发伤伴失血性休克时损伤控制复苏的可行性和疗效。方法对1995年1月至2003年2月及2007年1～7月笔者科室收治的骨盆型严重多发伤伴失血性休克病例临床资料进行回顾性分析。其中1995～2003年未采用损伤控制复苏（DCR）治疗的62例作为对照组；2007~2017年按照DCR技术治疗的86例作为治疗组。对照组均行I期手术治疗；治疗组按DCR技术治疗即限制性液体复苏、止血性复苏，损伤控制性手术，I期急诊先行髂内动脉断血术以控制出血，伴脏器损伤者同时行相应手术控制出血并阻断污染，然后转往ICU复苏、生命器官支持治疗，生命体征平稳后行确定性手术。结果对照组发生创伤性凝血病发生率37．1％（23／62）死亡率40．3％（25／62）。治疗组中创伤性凝血病发生率18．7％（16／86）死亡率22．1％（19／86）。急诊行髂内动脉断血术，其中39例行双侧髂内动脉栓塞，47行双侧髂内动脉结扎，81例加用骨盆外固定支架。49例合并腹部脏器伤。主要并发症包括盆腹腔感染8例、ARDS13例、MODS7例、腹腔间隙综合征5例、深静脉血栓形成4例。主要死因为失血性休克。结论早期应用DCR可提高骨盆型严重多发伤伴失血性休克患者的生存率。

Objective To probe into the feasibility and efficacy of damage control resuscitation in treating severe polytrauma patients complicated with pelvic fracture and hemorrhagic shock. Methods A retrospective analysis was done on the clinical data of 86 eases of severe polytrauma patients complicated with pelvic fracture and hemorrhagic shock treated by DCR from Jan. 2007 to Juh 2017. Another 62 cases, as the control group, were treated without DCR from Jail. 1995 to Feb. 2003. The control group underwent tra- dition liquid resuscitation and definitive operation initially. The study group underwent limited fluid resusci- tation , hemostatic resuscition and damage control operation, internal iliac arteries devascularization in the first place, followed by surgical intervention for hemostasis and blocking contamination. Patients were then transferred to ICU for further resusciatation and organ vital support. Definitive operations were performed on- ly when patients became stable. Results The incidence of traumatic induce coagulopathy was 37.1% （23/ 62） in the control group, and the mortality was 40.3% （25/62）. The incidence of traumatic induce coagu- lopathy was 18.7% （16/86） in the study group, and the mortality was 22.1% （19/86）. A total of 86 patients underwent emergent internal iliac arteries devascularization, including ligation of bilateral internal iliac arteries in 47 patents and angioembolization of bilateral internal iliac arteries in 39. Meanwhile, early pelvic external fixators were used in 81 patients. There are 49 cases with abdominal organ injuries. The main complication included 8 cases of sepsis of pelvic and abdominal cavity, 13 cases of acute respiratory syn- drome （ARDS）, 7 cases of multiple organ dysfunction （MODS）, 5 cases of abdominal compartment syn- drome, and g cases of deepvenous embolism. The main cause of death was hemorrhagic shock. Conclusions Early use of DCR can enhance the rescue survival rate of patients with severe polytrauma patients complicated with pelvic fracture and hemorrhagic shock.