骨盆骨折分类及治疗指南(二)

2011-08-15 00:00 来源:互联网 作者:
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Three sources of bleeding are recognised in pelvic fractures,arterial, venous and bleeding from cancellous bone. Management of these different sources varies greatly. It is generally accepted that venous and cancellous bleeding is managed by initial stabilization of the fracture to facilitate tamponade. In such cases, close monitoring is advised as young patients in particular can appear stable or metastable despite ongoing arterial haemorrhage.

可识别的骨盆骨折出血源有3种,动脉、静脉和骨折端松质骨出血。不同的出血源其处理方式迥异。对于静脉和松质骨出血的处置,通用做法是稳定骨折促使填塞压迫止血。在这种情况下,建议对年轻患者行密切监测,特别是即使存在进行性动脉出血却状态表现稳定或相对稳定患者。

Arterial bleeds are commonly from the superior gluteal and the internal pudendal arteries. The greater sciatic foramen is a common exit pathway form any pelvic vessels and any fracture involving this area incurs a higher risk of bleeding. The superior gluteal artery is at risk of laceration from the sharp fascia of the piriformis muscle as it enters the greater sciatic foramen. The internal pudendal artery also exits the pelvis here but re-enters through the lesser sciatic foramen. It is injured in anterior–posterior compression fractures where there are inferior pubic rami fractures or fractures involving the lesser sciatic foramen. Therefore the fracture location can be used to predict which artery has been injured.

动脉出血通常来自臀上动脉和阴部内动脉。坐骨大孔是骨盆血管共同的走行通道,此部位发生骨折出血风险极高。梨状肌进入坐骨大孔处筋膜锐利,增加了臀上动脉撕裂的风险。阴部内动脉亦在此处出骨盆并通过坐骨小孔再次进入,前后挤压型骨折包括耻骨下支骨折或涉及坐骨小孔的骨折可致其损伤。因此,骨折部位可用于预测那种动脉受到损伤。

Debate has raged over the management of arterial haemorrhage for many years. Some advocate external ?xation and pelvic packing for arterial and venous haemorrhage and reserve angiography only for more stable patients where ongoing bleeding is suspected [8].Others propose external ?xation followed by angiography if the patient remains unstable [9]. Some argue that external ?xation provides no additional advantage over pelvic wrapping [10]. Equally,angiography has been said to be time-consuming and inhibits concurrent treatment of associated injuries [11], unlike pelvic packing in theatre [8]. One group expressed concerns over complications associated with angiography, in particular sepsis when subsequently proceeding to operative ?xation of the fracture [12].

关于动脉出血治疗的激烈争论已持续多年。一些人主张行外固定和骨盆包裹以控制动、静脉出血,血管造影术仅用于怀疑进行性出血但状态更稳定的患者[8]。另一些人建议如果患者状态不稳,于外固定后行血管造影术[9]。一些人认为外固定并不比骨盆包裹术提供更多的益处[10]。同样,也有人认为不同于在手术室行骨盆包裹术[8],血管造影术耗时且限制了对相关损伤的及时治疗[11]。一个研究组表达了对血管造影术相关并发症的关注,特别是随后进行骨折内固定时并发的败血症[12]。

However, angiography has been utilised to good effect, with a reported success rate of 85–100% in bleeding cessation [13–16].Despite this, several of these studies have shown a high mortality rate associated with angiography. This is partly due to the group of patients treated. Those recruited for embolisation have arterial bleeding and are also likely to have signi?cant concurrent injuries.The success of angiographic embolisation is also highly dependant on early intervention and patients who undergo prompt embolisation have improved mortality rates [4,15]. Where there are no other life-threatening injuries there is a strong case to argue that angiography should be the intervention of choice [10,16,17].

然而,应用血管造影术已获得良好效果,报道的止血成功率达85–100%[13–16]。尽管如此,诸多研究显示与血管造影术相关的死亡率较高。这部分归因于所治疗患者的状况。因动脉出血而行动脉栓塞术的患者可能也存在严重的合并伤。血管栓塞术的成功主要依赖于对患者的早期干预,行快速栓塞术的患者死亡率有所改善[4,15]。有充分的理由认为,无其他危及生命的损伤存在时,血管造影术应是首选诊疗措施[10,16,17]。
 

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