今日の臨床サポート

骨盤外傷

著者: 伊澤祥光 自治医科大学 救急医学

監修: 箕輪良行 みさと健和病院 救急総合診療研修顧問

著者校正/監修レビュー済:2021/08/04
参考ガイドライン:
  1. 日本外傷学会:外傷専門診療ガイドライン JETEC 改訂第2版
  1. 日本外傷学会:外傷初期診療ガイドライン JATEC 改訂第6版
患者向け説明資料

概要・推奨   

  1. 骨盤外傷では、骨盤輪骨折と寛骨臼骨折とを区別する。骨盤輪骨折では出血性ショックをきたすことがあり、ショックの場合には速やかな止血処置が重要となる。
  1. 消化器系や泌尿器生殖器系の臓器損傷を合併することが多く、合併損傷に対する多角的な診療が必要となる。
  1. 不安定型骨盤骨折が判明したら速やかにpelvic binderを装着する。ただし、骨盤形態が側方圧迫型と判明した場合は無理に装着しない(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
閲覧にはご契
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
伊澤祥光 : 特に申告事項無し[2021年]
監修:箕輪良行 : 特に申告事項無し[2021年]

改訂のポイント:
  1. JATECガイドラインが改訂されたため、本編の確認・改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 骨盤外傷は多発外傷全体の25%に合併する。来院時ショックの場合、死亡率は40%以上となる。
  1. 骨盤外傷は骨盤輪骨折と寛骨骨折の2つに大別される。骨盤輪骨折は出血性ショックの原因となることがある。一方、寛骨骨折は循環動態よりも機能予後に問題を生じることが多い。
  1. 骨盤輪骨折では、後腹膜腔への出血によりショックになる。出血源としては、骨折部からの出血、静脈からの出血、動脈からの出血が挙げられる。骨折部からの出血は骨折部の整復固定を行い、静脈からの出血はパッキングなどの圧迫により止血する。動脈性の出血は経皮的血管塞栓術の適応となる。
  1. 骨盤外傷により、運動機能障害、泌尿生殖器障害、直腸肛門障害、神経障害、深部静脈血栓症、感染症を合併する可能性がある。
  1. 不安定型骨盤輪骨折の90%以上に他部位の損傷が合併するため、腹部骨盤臓器だけでなく他部位の合併損傷も念頭に置く。
問診・診察のポイント  
  1. 初期診療は基本的に外傷初期診療ガイドラインJATECの診療方針に従って診療を進める( メジャートラウマ )。
  1. 受傷機転においては、高エネルギー事故の場合や骨盤部への大きな外力が加わった場合に骨盤外傷を念頭に置く。腰部の痛みや体表上の創傷を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Richard P Gonzalez, Peter Q Fried, Mikhail Bukhalo
雑誌名: J Am Coll Surg. 2002 Feb;194(2):121-5.
Abstract/Text BACKGROUND: Current recommendations of the American College of Surgeons Advanced Trauma Life Support course is routine radiographic screening of the pelvis for all patients who suffer blunt torso trauma. The purpose of this study is to evaluate in a prospective manner the sensitivity of clinical examination as a screening modality for pelvic fractures in awake and alert blunt trauma patients.
STUDY DESIGN: During a 32-month period, 2,176 consecutive blunt trauma patients who presented with Glasgow Coma Scores of 14 or 15 were evaluated at an urban Level I trauma center. Clinical examination of all patients was prospectively performed by trauma resident housestaff. The clinical examination of each patient was documented in a study form before performance of a standard anterior-posterior (A-P) pelvic x-ray.
RESULTS: We evaluated 2,176 blunt trauma patients, 97 (4.5%) of whom were diagnosed with pelvic fracture. There were seven missed injuries on clinical examination (sensitivity 93%). None of the missed injuries on clinical examination required surgical intervention. The sensitivity of A-P pelvic x-ray was 87%, with 13 missed injuries. There were 463 patients who entered with ethanol levels equal or greater than 100 mg/dL (range 100 to 480 mg/dL). There were 20 pelvic fractures diagnosed in this group, with only 1 missed injury on clinical examination (sensitivity 95%).
CONCLUSIONS: 1) Clinical examination of the pelvis can reliably rule out significant pelvic fracture in the awake and alert blunt trauma patient. 2) The addition of routine A-P pelvic x-ray does not improve the sensitivity in diagnosis of surgically significant pelvic fractures nor does it have significant impact on outcomes of pelvic fracture patients. 3) Elevated ethanol level is not a contraindication to use of clinical examination as a screening modality for pelvic fractures in the awake and alert blunt trauma patient.

PMID 11848627  J Am Coll Surg. 2002 Feb;194(2):121-5.
著者: Eric Alan Gross, Brandie Ann Niedens
雑誌名: J Emerg Med. 2005 Apr;28(3):263-6. doi: 10.1016/j.jemermed.2004.10.013.
Abstract/Text We sought to validate a set of criteria that predict, with a high degree of sensitivity, which patients may safely forgo pelvic radiography in their initial trauma evaluation. This is a prospective observational study. Adult blunt trauma patients presenting from July 1, 2002 to June 30, 2003 who underwent pelvic radiography were eligible for the study. Physicians completed data sheets that outlined five criteria (altered level of consciousness, complaint of pelvic pain, pelvic tenderness on examination, distracting injury, clinical intoxication) before viewing pelvic radiographs. Final radiographic results were later added. Fractures were classified as clinically significant or insignificant based on the Tile classification. There were 973 patients enrolled in the study; 62 patients had pelvic fractures (prevalence 6.4%). The decision instrument predicted fracture in 60 patients, (sensitivity 96.8%, 95% CI 92.4-100%). Two fractures were clinically insignificant. If only clinically significant fractures were considered, the instrument had a sensitivity of 100%. The decision instrument predicted, with a high degree of sensitivity, those patients who could safely forgo pelvic radiography after blunt trauma. Approximately 44% of our patient population could have done without a pelvic X-ray, resulting in significant saving of health care dollars. These criteria need to be prospectively validated.

PMID 15769565  J Emerg Med. 2005 Apr;28(3):263-6. doi: 10.1016/j.jemer・・・
著者: Gerard P Slobogean, Kelly A Lefaivre, Savvas Nicolaou, Peter J O'Brien
雑誌名: J Orthop Trauma. 2009 May-Jun;23(5):379-84. doi: 10.1097/BOT.0b013e3181a5369c.
Abstract/Text OBJECTIVES: Pelvic and acetabular fractures have been identified as risk factors for deep venous thrombosis (DVT) and thromboembolic complications. A systematic review was performed to evaluate the effectiveness of thromboprophylactic strategies to prevent DVT or pulmonary embolism (PE) after pelvic or acetabular fractures.
DATA SOURCES: Relevant articles were identified by searching MEDLINE, MEDLINE In Process & Other Non-indexed Citations, EMBASE, CENTRAL, and the Cochrane Database of Systematic Reviews. All languages and years indexed were searched.
STUDY SELECTION: Manuscripts were included if (1) the study included an intervention or strategy aimed at preventing thromboembolic disease, (2) the subjects in the study had suffered a pelvic or acetabular fracture, and (3) the primary outcome of the study was DVT or PE.
DATA EXTRACTION: The intervention, sample size, DVT, and/or PE incidence, and method of diagnosis were recorded for each study.
DATA SYNTHESIS: Eleven studies with 1760 subjects were included. Included studies were grouped into 5 types of interventions: mechanical compression devices, inferior vena cava filters, low-molecular weight heparins, ultrasound screening, and magnetic resonance venography screening. Most studies were observational designs with minimal control data for comparison. Quantitative pooling was not possible based on significant study heterogeneity.
CONCLUSIONS: Although several strategies have been used to prevent thromboembolism in pelvic and acetabular fracture patients, our results suggest that clinicians have limited data to guide their prophylactic decisions. Well-designed clinical trials to prevent and detect venous thromboembolism in pelvic and acetabular trauma are still needed.

PMID 19390367  J Orthop Trauma. 2009 May-Jun;23(5):379-84. doi: 10.109・・・
著者: Chad G Ball, S Mohammed Jafri, Andrew W Kirkpatrick, Ravi R Rajani, Grace S Rozycki, David V Feliciano, Amy D Wyrzykowski
雑誌名: Injury. 2009 Sep;40(9):984-6. doi: 10.1016/j.injury.2009.03.003. Epub 2009 Jun 16.
Abstract/Text INTRODUCTION: The digital rectal examination (DRE) has been commonly employed as a trauma screening tool since the inception of the ATLS program. Because of weak evidence, its utility as a screening test has recently been questioned. The primary goal of this study was to identify the sensitivity of the DRE for detecting blunt urethral injuries in a level 1 trauma center. The secondary goal was to evaluate the interaction of DRE with additional clinical indices of urethral trauma.
METHODS: A retrospective review of all blunt injured patients diagnosed with a urethral disruption at an urban level 1 trauma center from 1995 to 2008 was performed. Urethral injuries were diagnosed by retrograde urethrogram, urethroscopy and operative exploration. Demographics and injury data were collected. The value of the DRE in diagnosing urethral trauma was assessed (p=0.05).
RESULTS: Urethral injuries were diagnosed in 41 male patients (mean age=39 years), 34 (83%) of whom were injured via a motor vehicle (median ISS=21). Associated injuries were present in 40 (95%) patients, including 39 (95%) pelvic fractures. No clinical signs of urethral injury were evident on initial examination in 25 (61%) patients. All patients had hematuria after catheter insertion. An abnormal prostate on DRE, blood at the urethral meatus, and hematuria prior to catheter insertion was present in 1 (2%), 8 (20%) and 7 (17%) patients, respectively. Both meatal blood and hematuria were better screening tests than the DRE (p<0.05).
DISCUSSION: The sensitivity of the DRE for identifying urethral disruption is 2%. The majority of patients with urethral trauma undergo urinary catheterization prior to diagnosis of the injury. Additional signs of disruption including meatal blood and hematuria detected prior to catheter insertion are also infrequent. While the DRE remains clinically indicated in patients with penetrating trauma in the vicinity of the rectum, pelvic fractures, and spinal cord injuries, it appears to be insensitive for detecting blunt urethral injuries.

PMID 19535063  Injury. 2009 Sep;40(9):984-6. doi: 10.1016/j.injury.200・・・
著者: Daniel C Cullinane, Henry J Schiller, Martin D Zielinski, Jaroslaw W Bilaniuk, Bryan R Collier, John Como, Michelle Holevar, Enrique A Sabater, S Andrew Sems, W Matthew Vassy, Julie L Wynne
雑誌名: J Trauma. 2011 Dec;71(6):1850-68. doi: 10.1097/TA.0b013e31823dca9a.
Abstract/Text BACKGROUND: Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice.
METHODS: Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence.
RESULTS: Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing?
CONCLUSIONS: Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

PMID 22182895  J Trauma. 2011 Dec;71(6):1850-68. doi: 10.1097/TA.0b013・・・
著者: Willem R Spanjersberg, Simon P Knops, Niels W L Schep, Esther M M van Lieshout, Peter Patka, Inger B Schipper
雑誌名: Injury. 2009 Oct;40(10):1031-5. doi: 10.1016/j.injury.2009.06.164. Epub 2009 Jul 17.
Abstract/Text BACKGROUND: Pelvic fractures can cause massive haemorrhage. Early stabilisation and compression of unstable fractures is thought to limit blood loss. Reposition of fracture parts and reduction of pelvic volume may provide haemorrhage control. Several non-invasive techniques for early stabilisation have been proposed, like the specifically designed pelvic circumferential compression devices (PCCD). The purpose of this systematic review was to investigate current evidence for the effectiveness and safety of non-invasive PCCDs.
METHODS: To investigate current literature the search string: "pelvi* AND fract* AND (bind* OR t-pod OR tpod OR wrap OR circumferential compression OR sling OR sheet)" was entered into EMBASE, PubMed (Medline), PiCarta, WebofScience, Cochrane Online, UptoDate, CINAHL, and Scopus. All scientific publications published in indexed journals were included.
RESULTS: The search resulted in 17 included articles, none of which were level I or II studies. One clinical cohort study (level III) and 1 case-control study (level IV) were found. These showed a significant reduction of pelvic volume after applying a PCCD, without an effect on outcome. Other included literature consisted of 4 case series (level V). Two biomechanical analysis studies of fractures in human cadavers showed pelvic stabilisation and effective volume reduction by PCCD, especially when applied around the greater trochanters. Finally, 7 case reports (level VI) and 3 expert opinions (level VII) were identified. These case reports suggested complications such as pressure sores and nerve palsy.
CONCLUSION: PCCDs seem to be effective in early stabilisation of unstable pelvic fractures. However, prospective data concerning mortality and complications is lacking. Some complications, like pressure sores have been described.

PMID 19616209  Injury. 2009 Oct;40(10):1031-5. doi: 10.1016/j.injury.2・・・
著者: Mark L Prasarn, MaryBeth Horodyski, Bryan Conrad, Paul T Rubery, Dewayne Dubose, John Small, Glenn R Rechtine
雑誌名: J Trauma Acute Care Surg. 2012 Jun;72(6):1671-5. doi: 10.1097/TA.0b013e31824526a7.
Abstract/Text BACKGROUND: Most institutions treating pelvic fractures use some method of acute mechanical stabilization. This typically involves use of pelvic binders or circumferential sheeting, and/or external fixation. The comparative value of these different modalities is controversial. We hypothesized that an external fixator would provide more stability to an unstable pelvic injury than a commercially available binder device (trauma pelvic orthotic device [T-POD]).
METHODS: Unstable pelvic injuries (Tile C) were surgically created in five fresh whole human cadavers. Electromagnetic sensors were placed on the same position of each hemipelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device. Maximum displacements were recorded during application of the stabilizing devices, bed transfer, logrolling, and head-of-bed elevation. External fixation frames were constructed by placing two 5.0-mm half pins into the iliac crest and then connected them with a 10-mm curved bar. The T-POD device was placed at the level of the greater trochanters as per manufacturer's recommendations.
RESULTS: While logrolling the patient and performing bed transfers, the T-POD conferred more stability in all planes of motion, although this did not reach statistical significance. During elevation of the head of the bed, the T-POD allowed less motion in the sagittal and coronal planes but permitted equivalent motion in axial rotation. These differences were not statistically significant.
CONCLUSION: There were no significant differences in stability conferred by an external fixator or a T-POD for unstable pelvic injuries. We advocate acute, temporary stabilization of pelvic injuries with a binder device and early conversion to internal fixation when the patient's medical condition allows.

Copyright © 2012 by Lippincott Williams & Wilkins.
PMID 22695439  J Trauma Acute Care Surg. 2012 Jun;72(6):1671-5. doi: 1・・・
著者: Laszlo Toth, Kate L King, Benjamin McGrath, Zsolt J Balogh
雑誌名: Injury. 2012 Aug;43(8):1330-4. doi: 10.1016/j.injury.2012.05.014. Epub 2012 Jun 6.
Abstract/Text BACKGROUND: Urgent non-invasive pelvic ring stabilisation (pelvic binding, PB) in shocked patients is recommended by state and institutional guidelines regardless of the fracture pattern. The purpose of this study was to determine the adherence to the guidelines, efficacy of the technique and identification of potential adverse effects associated with PB.
PATIENTS AND METHODS: A 41-month retrospective analysis of the prospective pelvic fracture database was undertaken at a level 1 trauma centre. High-energy pelvic fractures were included in the analysis with exclusion of the A type injuries (AO/OTA classification) and patients who were dead on arrival. Collected data included patient demographics, injury severity score, fracture classification, application and timing of PB, associated injuries, physiological parameters, resuscitation fluids and outcomes. Pre and post-PB radiographs were reviewed. The potential effects of the PB on soft tissue (femoral vessel, bladder and rectal injury) complications were assessed by independent experts.
RESULTS: 115 patients with high-energy B and C type pelvic ring injuries were included. Thirty-six (31%) patients presented in haemorrhagic shock on arrival. A total of 43 pelvic bindings were performed, 18 of them on shocked patients. The adherence to the guidelines was 50% (18/36) overall. Analysing fracture types of shocked patients the adherence was: B1 80%, B2 20%, B3 20%, C1 66%, C2 86%, C3 33%. The alignment of the pelvis was improved or perfect on post-PB radiographs in 68% and had not changed in 21%. In some cases of B2 and B3 type injuries the PB increased the deformity after application (11%). There were 10 deaths (8.7%) in the study group, with 4 deaths attributed to acute pelvic bleeding. Two of these had PB applied and two were identified as potential for improvement. One femoral artery injury, four bladder injuries and three rectum injuries were identified in patients who had PB applied. Association between the PB and these injuries is unlikely.
CONCLUSION: The adherence to the guidelines should be improved with further education and system development. The good effect of the technique was evident on radiographs. Although in some lateral compression fracture patterns the deformity increased, no hazards were associated with the use of PB.

Copyright © 2012 Elsevier Ltd. All rights reserved.
PMID 22677220  Injury. 2012 Aug;43(8):1330-4. doi: 10.1016/j.injury.20・・・
著者: Patrick M Osborn, Wade R Smith, Ernest E Moore, C Clay Cothren, Steven J Morgan, Allison E Williams, Philip F Stahel
雑誌名: Injury. 2009 Jan;40(1):54-60. doi: 10.1016/j.injury.2008.08.038. Epub 2008 Nov 30.
Abstract/Text OBJECTIVE: To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation.
METHODS: A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n=20) or early pelvic angiography (ANGIO group, n=20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded.
RESULTS: The PACK group underwent operative packing at a median of 45min from admission; the median time to angiography in the ANGIO group was 130min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage.
CONCLUSIONS: Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.

PMID 19041967  Injury. 2009 Jan;40(1):54-60. doi: 10.1016/j.injury.200・・・
著者: Costas Papakostidis, Peter V Giannoudis
雑誌名: Injury. 2009 Nov;40 Suppl 4:S53-61. doi: 10.1016/j.injury.2009.10.037.
Abstract/Text OBJECTIVE: To assess the role of pelvic packing as an emergency therapeutic intervention in pelvic fractures with concomitant haemodynamic instability.
METHODS: A systematic review of the literature in English from the past two decades yielded only three eligible studies. Clinical and methodological heterogeneity across the component studies was assessed by careful recording of certain descriptive characteristics. Statistical heterogeneity was detected using Cochran chi-square and I2 tests. The principal outcomes of interest were early mortality (within 24 hours of injury), late mortality (within the first month) and certain complications (infection and multiple organ failure (MOF)).
RESULTS: Methodological and clinical heterogeneity was evident across component studies, although it was not strongly associated with the observed results. All component studies were assigned a low to moderate quality score. The pooled estimates of effect size for mortality were as follows: early mortality rate 10% (95% confidence intervals [95 CI]: 3-18%), late mortality rate 13% (95 CI: 5-22%), overall mortality 28% (95 CI: 16.8-39.4%). As for the recorded complications, a pooled estimate of 35%, (95 CI: 21-48%) was calculated for infection rate and 9%, (95 CI: 2-16%) for MOF rate. Apart from one study, in which pelvic packing was used exclusively as an emergency resuscitative procedure, pelvic angiography played a significant complementary role to pelvic packing for final haemorrhage control in the other two studies.
CONCLUSION: Haemodynamically unstable pelvic ring injuries are characterised by significant mortality and complications. Pelvic packing, as a part of a damage control protocol, could potentially aid in early intrapelvic bleeding control and provide crucial time for a more selective management of haemorrhage.

PMID 19895954  Injury. 2009 Nov;40 Suppl 4:S53-61. doi: 10.1016/j.inju・・・
著者: Qinghu Li, Jinlei Dong, Yongliang Yang, Guodong Wang, Yonghui Wang, Ping Liu, Yohan Robinson, Dongsheng Zhou
雑誌名: Injury. 2016 Feb;47(2):395-401. doi: 10.1016/j.injury.2015.10.008. Epub 2015 Oct 22.
Abstract/Text AIMS: Both retroperitoneal pelvic packing and primary angioembolization are widely used to control haemorrhage related to pelvic fractures. It is still unknown which protocol is the safest. The primary aim of this study is to compare survival and complications of pelvic packing and angioembolization in massive haemorrhage related to pelvic fractures.
METHODS: Patients with haemodynamically unstable pelvic fractures were quasi-randomized to either pelvic packing (PACK) or angiography (ANGIO) using the time of admission as separator. Physiological markers of haemorrhage, time to intervention, procedure/surgical time, transfusion requirements, complications and early mortality were recorded and analyzed.
RESULTS: 29 patients were randomized to PACK and 27 patients to ANGIO. The Injury Severity Score (ISS) in the ANGIO group was lower than in the PACK group (43±7 vs 48±6) (p<0.01). The median time from admission to angiography for the ANGIO group was 102min (range 76-214), and longer than 77min (range 43-125) from admission to surgery for the PACK group (p<0.01). The procedure time for the ANGIO group was 84min (range 62-105); while the surgical time was 60min (range 41-92) for the PACK group (p<0.001). The ANGIO group received 6.4 units packed red blood cells (range 4-10) in the first 24h after angiography. The PACK group required 5.2 units (range 3-10) in the first 24h after leaving the operating theatre (p=0.124). 9 patients in the ANGIO group underwent pelvic packing for persistent bleeding. 6 patients in the PACK group required pelvic angiography after pelvic packing for ongoing hypotension following packing (p=0.353). 5 patients in the ANGIO group died (2 from exsanguination), while 4 in the PACK group died (none from exsanguination) (p=0.449). Complications occurred without differences in both groups.
CONCLUSIONS: Compared with angioembolization, pelvic packing has shorter time to intervention and surgical time. Thus pelvic packing is the more rapid treatment of severe pelvic trauma than pelvic angioembolization. It is suitable for patients with haemodynamic instability at centers where the interventional radiology staff is not in-house at all times.
REGISTRATION: ClinicalTrials.gov (NCT02535624) and ISRCTN registry (ISRCTN91713422).

Copyright © 2015 Elsevier Ltd. All rights reserved.
PMID 26508436  Injury. 2016 Feb;47(2):395-401. doi: 10.1016/j.injury.2・・・
著者: Thomas Lustenberger, Sebastian Wutzler, Philip Störmann, Helmut Laurer, Ingo Marzi
雑誌名: Injury. 2015 Oct;46 Suppl 4:S33-8. doi: 10.1016/S0020-1383(15)30016-4.
Abstract/Text BACKGROUND: In recent years a wide variety of strategies to treat the haemodynamically unstable patient with pelvic ring fractures have been proposed. This study evaluates our institutional management of patients with severe pelvic fractures and analyses their outcomes.
METHODS: Retrospective review of all severely injured trauma patients with pelvic ring injuries admitted to a level I trauma centre from 2007 to 2012. Patient records were documented prospectively in a trauma database and evaluation was performed by SPSS.
RESULTS: During the study period, a total of 173 patients with pelvic ring fractures were admitted and formed the basis of this study. Overall, 46% of the patients had suffered a type A fracture, 25% a type B fracture and the remaining 29% a type C pelvic ring fracture. Surgical treatment was required in 21% of the patients (pelvic C-clamp, n = 6; supra-acetabular external fixator, n = 32; pelvic packing, n = 12; definitive plate osteosynthesis of the pubis symphysis, n = 6). Angio-embolization was performed in 16 patients (9%); in 8 patients it was the only specific treatment for the pelvic injury on day 0 and in 8 patients it was performed immediately post-operatively. The overall mortality rate was 12.7% (n = 22), with the type C pelvic fractures having the highest mortality (30.0%). Four patients died immediately after admission in the shock room.
CONCLUSIONS: Angiographic embolization as a first-line treatment was only performed in haemodynamically stable patients or in patients responding to fluid resuscitation with the finding of an arterial blush in the CT scan. In haemodynamically unstable patients, pre-peritoneal pelvic packing in combination with mechanical pelvic stabilization was immediately carried out, followed by angio-embolization post-operatively if signs of persistent bleeding remained present.

Copyright © 2015 Elsevier Ltd. All rights reserved.
PMID 26542864  Injury. 2015 Oct;46 Suppl 4:S33-8. doi: 10.1016/S0020-1・・・
著者: I Marzi, T Lustenberger
雑誌名: Scand J Surg. 2014 Apr 15;103(2):104-111. doi: 10.1177/1457496914525604. Epub 2014 Apr 15.
Abstract/Text INTRODUCTION: In patients with severe pelvic fractures, exsanguinating hemorrhage represents the major cause of death within the first 24 h. Despite advances in management, the mortality rate in these patients remains significantly high. Recently, multiple treatment algorithms have been proposed for patients with severe pelvic fractures; however, the optimal modalities in particular in the hemodynamically unstable patient are still a matter of lively debate.This review article focuses on the recent body of knowledge on the different treatment options in patients with severe pelvic fractures and proposes the possible role of each modality in the management of these patients.
METHODS: The MEDLINE database was searched for medical literature addressing the management of severe pelvic fractures with specific attention given to recent, clinically relevant publications.
RESULTS: Angiography and embolization have emerged as excellent methods for addressing arterial bleeding. Mechanical pelvic stabilization and surgical hemostasis by pelvic packing, on the other hand, may effectively control venous bleeding and bleeding from the fractured bony surface. However, since there is no precise way to determine the major source of bleeding that is responsible for the hemodynamic instability, controversy remains over the timing and optimal order of angiography, mechanical pelvic stabilization, and packing.
CONCLUSIONS: The author's own approach to these patients includes angiographic embolization as a first-line treatment only in hemodynamically stable patients with an arterial blush seen in the computed tomography scan, indicating acute arterial bleeding. Hemodynamically unstable patients are immediately transferred to the operating room, where pelvic packing and mechanical stabilization of the pelvic ring are carried out. Optionally, a subsequent postoperative angio-embolization is performed if signs of further bleeding remain present.

© The Finnish Society of Surgery 2014.
PMID 24737854  Scand J Surg. 2014 Apr 15;103(2):104-111. doi: 10.1177/・・・
著者: Bradley D Figler, Brad Figler, C Edward Hoffler, William Reisman, K Jeff Carney, Thomas Moore, David Feliciano, Viraj Master
雑誌名: Injury. 2012 Aug;43(8):1242-9. doi: 10.1016/j.injury.2012.03.031. Epub 2012 May 14.
Abstract/Text Pelvic ring fractures often result in severely injured patients with multiple organ injuries. The most common associated injuries are intraabdominal or urogenital, and urogenital injuries are the most common associated injuries in those with severe pelvic fractures. Prompt and effective diagnosis and management of these injuries is essential to successful outcomes, but this is potentially complicated by poor communication and coordination among the many specialists involved. To address this, we present a multi-disciplinary review of pelvic fracture-associated bladder and urethral injuries that is specifically geared towards orthopaedic, urology, and trauma surgeons caring for these patients.

Copyright © 2012. Published by Elsevier Ltd.
PMID 22592152  Injury. 2012 Aug;43(8):1242-9. doi: 10.1016/j.injury.20・・・
著者: Joseph DuBose, Kenji Inaba, Galinos Barmparas, Pedro G Teixeira, Beat Schnüriger, Peep Talving, Ali Salim, Demetrios Demetriades
雑誌名: J Trauma. 2010 Dec;69(6):1507-14. doi: 10.1097/TA.0b013e3181d74c2f.
Abstract/Text INTRODUCTION: The management of massive retroperitoneal hemorrhage in unstable patients with pelvic fractures remains a considerable therapeutic challenge after blunt mechanisms of injury. We present our study using emergent bilateral ligation of the internal iliac arteries (BLIA) and pelvic packing as a damage control adjunct.
METHODS: We reviewed our experience during 22 months (May 2006 to March 2008) with damage control management of massive retroperitoneal hemorrhage caused by blunt pelvic injury encountered at the time of emergent laparotomy. Clinical courses were reviewed.
RESULTS: During the study period, 201 patients with pelvic fractures underwent operative intervention. Treatment of an expanding retroperitoneal hematoma was required in 33. Five of these patients were adequately stable for angioembolization, with a resultant 40% survival. Twenty-eight patients required BLIA and pelvic packing intraoperatively. The mean injury severity score of patients who underwent BLIA was 33.1, with 89.3% having an injury severity score of ≥ 16. Overall survival after BLIA was 35.7%. Causes of mortality included brain death, intraoperative arrest, refractory coagulopathy, and sepsis. Techniques used for BLIA included Rummel tourniquet (in 1), clip occlusion (in 5) and suture ligation (in 4). Four patients had subsequent removal of Rummel tourniquet or clips at 24 hours to 72 hours after initial procedure, with the remainder undergoing permanent ligation. No survivors after BLIA were noted to have apparent adverse ischemic sequelae.
CONCLUSION: BLIA is a damage control tool potentially useful for a select group of patients with massive retroperitoneal hemorrhage after pelvic fracture. Further study is required to determine the appropriate selection criteria for this potentially life-saving maneuver.

PMID 20495490  J Trauma. 2010 Dec;69(6):1507-14. doi: 10.1097/TA.0b013・・・

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