外傷(Trauma)シリーズ17 RESIDENT COURSE 解答 【症例 TR 83】

左恥骨・坐骨骨折(活動性出血).Fracture of left pubic and ischial bone with active bleeding












図1の単純写真で骨折を認識するのは困難である.下段の骨用画像の↑はすべて骨折を示している.骨盤腔内に大量の血腫を認めるが,出血量は大まかな体積計算をして,図7で7×14=98,スライス幅10mmの10スライス分として980mlとなる.図8〜図13の△はextravasationを示しており,即TAE目的の血管造影の適応である.腹膜刺激症状のため開腹されたが,骨盤腔内血腫以外に腹腔内臓器損傷を認めず,血管造影が施行された.図Aと図Bでextravasation(▲)が確認され,スポンゼル細片で塞栓した.Hbは12.8から8.1g/dlに低下し4単位の輸血を要したが,その後は順調に経過した.尿道損傷を認めず,血尿は膀胱打撲によるものと思われた.骨盤骨折では一見軽症に見えてもこのように大量出血を伴うことがあるので注意を喚起したい.












文献考察:preventable trauma death(防ぎうる外傷死)
5)11.2%
質評価としての同僚評価 外傷の救急医療の質の研究委員会EMSQの方法(総説)
Author:高柳和江(日本医科大学 医療管理学教室)
Source:Journal of Nippon Medical School(1345-4676)71巻6号 Page371-378(2004.11)

6)小児で9%,入院後は16%.
J Trauma. 1999 Aug;47(2):243-51; discussion 251-3. Links
Analysis of preventable pediatric trauma deaths and inappropriate trauma care in Montana.
Esposito TJ, Sanddal ND, Dean JM, Hansen JD, Reynolds SA, Battan K.

OBJECTIVE: To determine the rates of preventable mortality and inappropriate care, as well as the nature of treatment errors associated with pediatric traumatic deaths occurring in a rural state. METHODS: Retrospective multidisciplinary consensus panel review of deaths attributed to mechanical trauma in children aged 18 years or less, occurring in Montana between October 1, 1989, and September 30, 1992. The care rendered in both preventable and nonpreventable cases was evaluated for appropriateness according to nationally accepted guidelines. Rates of pediatric preventable death and inappropriate care, as well as the nature of inappropriate care, were compared with that of the adult population. RESULTS: One hundred thirty-eight cases were reviewed. One death (less than 1%) was judged frankly preventable, 11 deaths (8%) were judged possibly preventable, giving a total preventability rate of 9% for all cases reviewed. Considering only in-hospital deaths (n = 77), the total preventability rate was 16%. The rate of inappropriate care rendered for all deaths, regardless of preventability, was 36%. The rate of inappropriate care in the prehospital phase was 16%; for in-hospital deaths, it was 47%. In the emergency department (ED), the rate was 36%, and in post-ED care, 22%. In comparison to the adult population, the rates of preventable death (9% vs. 14%) and inappropriate care in the hospital phase (64% vs. 66%) were lower. Inappropriate care for the pediatric group was more prevalent in patients less than or equal to 14 years old. The nature of inappropriate care was most frequently associated with the management of respiratory problems, including airway control and management of chest trauma. CONCLUSION: Preventable mortality from traumatic injuries in children in a rural state appears to be low, and lower than that reported for adult trauma victims in the same state. A preponderance of these preventable deaths occur in the subgroup of children less than or equal to 14 years if age. Inappropriate trauma care in children occurs frequently, particularly in the ED phase of care, and is primarily associated with the management of the airway and chest injuries. Education of ED primary care providers in basic principles of stabilization and initial treatment of the injured child 14 years old or younger may be the most effective method of reducing preventable trauma deaths in the rural setting.PMID: 10452457
  【参照症例】   1. 外傷(Trauma)シリーズ10 【症例 TR 48】

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