Huber-Wagner et al. showed an association between increased survival and early full body CT in polytrauma when compared to targeted body CT [6]. No adverse effects were attributable to CT, though obviously radiation dose and intravenous contrast are potential concerns. There were several limitations to the study however, and the authors admit their ?ndings show associations rather than causalities. Average time to CT from admission was between 35 and 46min with the emphasis placed on an easily accessible CT scanner near the trauma room. This is vital if CT is to be used in management algorithms for unstable patients.
Huber-Wagner等的研究显示，与特定部位CT检查相比，对多发伤患者早期行全身CT检查与增加的生存率之间存在相关性[6]。尽管存在明显的辐射剂量和静脉造影剂的潜在问题，CT检查并无不良反应。然而由于研究本身的局限性，作者承认其发现显示为相关性而非因果关系。重点放置容易接近的CT扫描装置于创伤病房附近，自入院到CT检查的平均时间在35 ~ 46分钟之间。至关重要的是CT是否用于不稳定患者的诊疗。
It is proposed that CT is elevated to the ‘third tier’ alongside circulation in the ATLS algorithm for management of haemodynamically unstable patients. This holds numerous advantages:
- Locating the primary source of bleeding quickly;
- Allowing earlier angiography and embolisation for arterial haemorrhage;
- Guiding the vascular radiologist to the likely bleeding vessel, thereby allowing selected angiography and improving sensitivity for detection of haemorrhage when compared to angiography from a larger proximal vessel. This also reduces unnecessary ‘runs’, minimising the use of contrast and radiation exposure;
- Reducing the number of transfused units thereby lowering the risk of DIC and other transfusion related complications;
- Identifying other organ injuries early;
- Reducing the number of unnecessary laparotomies.
建议在血流动力学不稳患者的ATLS诊疗规则中将CT检查提升至第三级与循环并列。其优点如下：
- 快速定位出血来源；
- 能够早期行血管造影术并对出血的动脉进行栓塞止血；
- 引导血管造影医师定位可能出血的血管，从而选择性血管造影，与起自更近端的血管造影相比可改善检测出血的敏感度。这也可减少不必要的“行程”，将造影剂和射线照射剂量最小化。
- 减少输血量，降低DIC和其它输血相关并发症的风险；
- 早期发现其他器官损伤；
- 减少不必要的剖腹探查。
5. Vascular injuries
5. 血管损伤
In pelvic fractures, the most common life-threatening complication is bleeding.Where there is haemodynamic instability, pelvic fractures are reported to have a high mortality rate of up to 60% [4] (Fig. 2a–c). CT can quickly and accurately reveal the presence or absence of haemorrhage with an accuracy quoted in the region of 90% [7].
对于骨盆骨折，失血为最常见的危及生命的并发症。由于存在血流动力学不稳，报道称骨盆骨折的死亡率高达60%以上[4] (图2)。CT能够快速准确的显示出血或未出血情况，其准确率接近90%[7]。
图(2)：(a–c) 不稳定性骨盆骨折(a, 箭头所示)。CT显示造影剂外溢(b, 箭头所示)。血管造影术显示广泛性出血(c, 箭头所示)。随后患者行血管栓塞止血。
