External Fixation or Arteriogram in Bleeding Pelvic Fracture: Initial Therapy Guided by Markers of Arterial Hemorrhage,高雄醫學大學外傷科 晨間論文研讀 Mar. 24, 2003,The Journal of Trauma: Injury, Infection, and Critical Care 2003; 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,Bleeding pelvic fractures (BPF) carry mortality as high as 60%, yet controversy remains over optimal initial management. Some base initial intervention on fracture pattern, with immediate external fixation (EX FIX) in amenable fractures aimed at controlling venous bleeding. Others feel ongoing hemodynamic instability indicates arterial bleeding, and prefer early angiography (ANGIO) before EX-FIX. Our aim was to evaluate markers of arterial bleeding in patients with BPF, thus identifying patients requiring early ANGIO regardless of fracture pattern.,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,Patients with pelvis fracture were identified from a Level I trauma center registry over a 7-year period and records reviewed. From this group, two subsets were analyzed: those with initial hypotension related to pelvic fracture, and those without hypotension who underwent pelvic ANGIO. Data included hemodynamics, response to resuscitation, presence of contrast blush on CT, fracture treatment and outcome. Adequate response to initial resuscitation (R) was defined as a sustained (2 hours) improvement of systolic blood pressure to 90 mm Hg systolic after the administration of 2 units packed red blood cells. Those with repeated episodes of hypotension despite resuscitation were classified as non-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-Burgess modification of the Tile-Pennal pelvic fracture classification system.,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,From 1/94-1/01, 1171 patients were admitted with pelvic ring fracture. Thirty-five (0.3%) had hypotension attributable to pelvis fracture. 28 fell into the NR group, and 26 of these underwent ANGIO. Nineteen (73%) showed arterial bleeding while 3 resuscitation response patients underwent ANGIO with none demonstrating bleeding (p = 0.03). Sensitivity and specificity of inadequate response to initial resuscitation for predicting the presence of arterial bleeding on ANGIO were 100% and 30% respectively while negative and positive predictive value were 100% and 73%.,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,In patients with fractures amenable to external fixation (n = 16), 44% had arterial bleeding on ANGIO, and all were in the NR group. An additional 17 patients without hypotension also underwent ANGIO. Contrast blush on admission CT was seen in 4, 3 of which had arterial bleeding seen on ANGIO (75%). Sensitivity and specificity for contrast blush in predicting bleeding on ANGIO were 60% and 92% with positive and negative predictive value being 75% and 85%.,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,Table 1 Admission Characteristics of Patients with Hypotension Attributable to Pelvic Bleeding (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,Table 2 Comparison of Patient Characteristics and Outcome in Hypotensive Patients Undergoing ANGIO, EX-FIX, and Both Therapies,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,A central question in the decision making process is whether arterial bleeding is present. The two most commonly employed are external fixation of the pelvic fracture, and ANGIO for identification and embolization of pelvic bleeding. Some have advocated immediate EX-FIX for BPF and document control of hemorrhage, lower transfusion requirement, and improved survival. This method is believed to provide a tamponade effect aimed at venous bleeding and perhaps small vessel arterial bleeding.,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,Aggressive early ANGIO is advocated by others even in the face of fracture pattern amenable to EX-FIX. ANGIO and embolization, the technique was initially described as early as 1972 and is currently well established as an effective means of dealing with arterial hemorrhage. The early identification of patients likely to have arterial bleeding are important.,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,Several groups have demonstrated that patients requiring embolization were significantly more likely to have fracture patterns associated with major ligamentous disruption (APC II, III, LC III, VS and CM) Our data show no clear relationship of fracture pattern to arterial bleeding The exsanguinating hemorrhage can and does occur in seemingly low risk patterns such as APC I.,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,CT Blush indicating extravasation of contrast on CT scan has been examined as a method of determining the presence of arter