上段の図１〜図４，下段の図９〜図１２の胃背側の▲は血腫であり，図１〜図４の腹水（※）は血性腹水であろう．図１と図２の白矢印は図５と図６で肺より高濃度を示しているので遊離ガスではなく脂肪組織である．晩期相（Delayed）の図７〜図１５の，腹部大動脈（A）と同濃度を示す△はextravasationであり，動脈相では描出されていないので静脈性出血と解釈する．図１２の虚脱したIVCは重度のhypovolemiaを示唆する．早期相（Early）でIVCが大動脈より強く造影されているのは大腿静脈から造影剤が注入されているからである．

上段の図１８，図２０と下段の図２６の早期相（Early）の△は，図２２〜図３０の晩期相（Delayed）で▲となり広がるのでextravasationであり，活動性動脈性出血を示している．手術で胃大網動静脈（gastroepiploic artery and vein）からの活動性出血を認め，結紮止血した．

文献考察：Preventable death． 外傷入院患者35,311例中死亡例は2,081例（5.9%），その中でpreventable deathは51例（2.5%）であった（図１），原因となった病態は図２，エラーの種類は図３，時間帯は図４，死亡した場所は図５．
J Trauma. 2007 Dec;63(6):1338-46; discussion 1346-7.
Preventable or potentially preventable mortality at a mature trauma center.
Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, Browder T, Noguchi TT, Demetriades D.

OBJECTIVE: The objective of this study was to analyze the preventable and potentially preventable deaths occurring at a mature Level I trauma center. METHODS: All trauma patients that died during their initial hospital admission during an 8-year period (January, 1998 to December, 2005) were analyzed. The deaths were initially reviewed at a weekly Morbidity and Mortality (M&M) conference followed by a multidisciplinary (Trauma Surgery, Critical Care, Emergency Medicine, Neurosurgery, Nursing, and Coroner) Combined Trauma Death Review Committee, and were classified into nonpreventable, potentially preventable, and preventable deaths. All preventable and potentially preventable deaths were identified for the purpose of the study. Quality improvement death forms included data on epidemiology, vital signs, injury severity, type of injury, probability of survival with Trauma and Injury Severity Score methodology, preventability (nonpreventable, potentially preventable, and preventable deaths), errors in the evaluation and management of the patient, and classification of errors (system, judgment, knowledge). Additional injury details, clinical course, circumstances leading to the death and autopsy findings were abstracted from the trauma registry and individual chart review. RESULTS: During the study period, 35,311 patients meeting trauma registry criteria were admitted and a total of 2,081 (5.9%) deaths occurred. Fifty-one deaths were classified as preventable or potentially preventable deaths (0.1% of admissions, 2.5% of deaths). Eleven of them (0.53% of deaths) were classified as preventable and 40 (1.92% of deaths) as potentially preventable deaths. Mean age was 40 years, 66.7% were men, mean Injury Severity Score was 27, 74.5% were blunt. The most common cause of death was bleeding (20, 39.2%) followed by multiple organ dysfunction syndrome (14, 27.5%) and cardiorespiratory arrest (8, 15.6%). This was caused by a delay in treatment (27, 52.9%), clinical judgment error (11, 21.6%), missed diagnosis (6, 11.8%), technical error (4, 7.8%), and other (3, 5.9%). The deaths peaked at two time periods: 26 (51.1%) during the first 24 hours and 16 (31.4%) after 7 days. Only one patient (2.0%) died in the first hour. The most common location of death was the intensive care unit (28, 54.9%), operating room (13, 25.5%), and emergency room (5, 9.8%). CONCLUSION: Preventable or potentially preventable deaths are rare but do occur at an academic Level I trauma center. Delay in treatment and error in judgment are the leading causes of preventable and potentially preventable deaths.PMID: 18212658