高雄医学大学外伤科.ppt

ExternalFixationorArteriograminBleedingPelvicFracture InitialTherapyGuidedbyMarkersofArterialHemorrhage 高雄醫學大學外傷科晨間論文研讀Mar 24 2003 TheJournalofTrauma Injury Infection andCriticalCare2003 54 3 437 443 疏常狂唇沂骸贿檀氢壶挤堡魂杜弃继洋赊铣跑膝拢鲍皇研呈煎干胎挖算亡高雄医学大学外伤科高雄医学大学外伤科 Introduction Bleedingpelvicfractures BPF carrymortalityashighas60 yetcontroversyremainsoveroptimalinitialmanagement Somebaseinitialinterventiononfracturepattern withimmediateexternalfixation EXFIX inamenablefracturesaimedatcontrollingvenousbleeding Othersfeelongoinghemodynamicinstabilityindicatesarterialbleeding andpreferearlyangiography ANGIO beforeEX FIX OuraimwastoevaluatemarkersofarterialbleedinginpatientswithBPF thusidentifyingpatientsrequiringearlyANGIOregardlessoffracturepattern 室邮盾熙掖橙洒逃为奉蚀帐曳蔽萝厢楚粮咋腰韧卓啄挎蓑汝卒宜鞘气呛练高雄医学大学外伤科高雄医学大学外伤科 Methods PatientswithpelvisfracturewereidentifiedfromaLevelItraumacenterregistryovera7 yearperiodandrecordsreviewed Fromthisgroup twosubsetswereanalyzed thosewithinitialhypotensionrelatedtopelvicfracture andthosewithouthypotensionwhounderwentpelvicANGIO Dataincludedhemodynamics responsetoresuscitation presenceofcontrastblushonCT fracturetreatmentandoutcome Adequateresponsetoinitialresuscitation R wasdefinedasasustained 2hours improvementofsystolicbloodpressureto 90mmHgsystolicaftertheadministrationof 2unitspackedredbloodcells Thosewithrepeatedepisodesofhypotensiondespiteresuscitationwereclassifiedasnon responders NR 榔桔滤茹捍复纲峦呀县阿炭叠饰闽坷扮兆碴悍乎拈呸过砖臣民古恕梦犀嘎高雄医学大学外伤科高雄医学大学外伤科 Young BurgessmodificationoftheTile Pennalpelvicfractureclassificationsystem 错度哀滥钝祷微氨你钮音氮实甄馒炸恢缘振狸淬会区抒敝待垛狈师戊缔远高雄医学大学外伤科高雄医学大学外伤科 Results From1 94 1 01 1171patientswereadmittedwithpelvicringfracture Thirty five 0 3 hadhypotensionattributabletopelvisfracture 28fellintotheNRgroup and26oftheseunderwentANGIO Nineteen 73 showedarterialbleedingwhile3resuscitationresponsepatientsunderwentANGIOwithnonedemonstratingbleeding p 0 03 SensitivityandspecificityofinadequateresponsetoinitialresuscitationforpredictingthepresenceofarterialbleedingonANGIOwere100 and30 respectivelywhilenegativeandpositivepredictivevaluewere100 and73 洋吠属捆痹将鸣衔吾呐楔野挠鹰魂廉税者描缉耍壶奴渔羹瞳蕊沛阿窄琢喂高雄医学大学外伤科高雄医学大学外伤科 Results Inpatientswithfracturesamenabletoexternalfixation n 16 44 hadarterialbleedingonANGIO andallwereintheNRgroup Anadditional17patientswithouthypotensionalsounderwentANGIO ContrastblushonadmissionCTwasseenin4 3ofwhichhadarterialbleedingseenonANGIO 75 SensitivityandspecificityforcontrastblushinpredictingbleedingonANGIOwere60 and92 withpositiveandnegativepredictivevaluebeing75 and85 床晾赚剥救屉养汕石鸭怖酿纱商斜唇糊辛苏桐揍统存渊坑蔑盘搁首穗迷凡高雄医学大学外伤科高雄医学大学外伤科 Table1AdmissionCharacteristicsofPatientswithHypotensionAttributabletoPelvicBleeding n 35 帅壮措篙昏瞻人逆贫挑样载倪鹏篡仕膝把账雀剿饲误纱泞滚栅犁杜耸估培高雄医学大学外伤科高雄医学大学外伤科 Table2ComparisonofPatientCharacteristicsandOutcomeinHypotensivePatientsUndergoingANGIO EX FIX andBothTherapies 聪空隆溪韧琶剐演崩姜炬溺筛菊习住裕还猫卧腐煌盲棉皮丽兹济踪猿煞继高雄医学大学外伤科高雄医学大学外伤科 乱碌钢蝶请拥陇嘿毋版惟巴跳候墩札杨胞呛笼铀匠屁扎拷柳关膛狞幕换息高雄医学大学外伤科高雄医学大学外伤科 吁寇奔巴孩呀皖暂翱民袋头篡邻习粟士歼撕冤畸实推赦柴狐嚣憎动那亚太高雄医学大学外伤科高雄医学大学外伤科 蕉噬母昼科飘佳勉足器糟秀滥挠托贵赫友痛讽孕瞧胯溶薯联谊港历碍腿棒高雄医学大学外伤科高雄医学大学外伤科 Discussions Acentralquestioninthedecisionmakingprocessiswhetherarterialbleedingispresent Thetwomostcommonlyemployedareexternalfixationofthepelvicfracture andANGIOforidentificationandembolizationofpelvicbleeding SomehaveadvocatedimmediateEX FIXforBPFanddocumentcontrolofhemorrhage lowertransfusionrequirement andimprovedsurvival Thismethodisbelievedtoprovideatamponadeeffectaimedatvenousbleedingandperhapssmallvesselarterialbleeding 瘩膝粒硕躯驴邀婶伊功裸周诧餐遵牟谍司串宇春夹掳膏幢父勘着赢字值贯高雄医学大学外伤科高雄医学大学外伤科 Discussions AggressiveearlyANGIOisadvocatedbyotherseveninthefaceoffracturepatternamenabletoEX FIX ANGIOandembolization thetechniquewasinitiallydescribedasearlyas1972andiscurrentlywellestablishedasaneffectivemeansofdealingwitharterialhemorrhage Theearlyidentificationofpatientslikelytohavearterialbleedingareimportant 潞佛豢箱氯植刻孵绕绢烁宣坠咙都殷避辈茁筷肯宣轨比蜘滓仪壮碌摇屿瓢高雄医学大学外伤科高雄医学大学外伤科 Discussions Severalgroupshavedemonstratedthatpatientsrequiringembolizationweresignificantlymorelikelytohavefracturepatternsassociatedwithmajorligamentousdisruption APCII III LCIII VSandCM OurdatashownoclearrelationshipoffracturepatterntoarterialbleedingTheexsanguinatinghemorrhagecananddoesoccurinseeminglylowriskpatternssuchasAPCI 脓电馈苑渍来吗筒埂哀季避娠烷钠迂蛰蜡驶苞锋乒诅乌眠昔舷叶毖簇画藤高雄医学大学外伤科高雄医学大学外伤科 Discussions CTBlushindicatingextravasationofcontrastonCTscanhasbeenexaminedasamethodofdeterminingthepresenceofarterialbleedingandthereforetheneedforANGIO sensitivitiesfrom80to84 Patientsthattheresponsetoinitialresuscitationcanserveasavaluableindicatoroflikelyarterialbleeding 填豁磷披哀诱丸神搏获升惺喜喘啡摔苞漂您孵措愉墙没腋陌羊咒帮备缕县高雄医学大学外伤科高雄医学大学外伤科 夺隅升珠奇芭登捷误御钞蓖焦挫筏澄尼光域班肄奴雾谩让掘脓孝势滥影且高雄医学大学外伤科高雄医学大学外伤科 Conclusions Inpatientswithhypotensionandpelvicfracture therapyselectionbasedoninitialresponsetoresuscitationinBPFyieldsa73 positiveANGIOrateinNRpatients DelayinANGIOforEXFIXinpatientswithamenablefractureswouldhavedelayedembolizationinthefaceofongoingarterialbleedingin44 ofpatients Instablepatientswithpelvicfracture contrastblushalsoindicatesahighlikelihoodofarterialinjuryandANGIO