2000ml以上の輸液と，さらに輸血まで行って血圧が70mmHg台ならnon-responderと判断し，CT検査と血管造影の適応はなく，即刻手術室へ搬送すべきである．晩期相（Delayed）で右肝静脈（図５：RHV）を中肝静脈（図６：MHV）を認めるが，左肝静脈は認識できない．早期相（Early）の図２〜図１１の△は晩期相で変形し広がるのでextravasationであるが，晩期相の図８〜図１５の▲は早期相と形態と大きさに変化がないので仮性動脈瘤（pseudoaneurysm）を示している可能性が高い．

下段でも図１７，図２０，図２６と図２８の△はextravasationで，図２９〜図３１の▲は早期相と比較して形態と大きさに大きな変化を認めないので仮性動脈瘤と思われる．さらに上段の晩期相の図１５〜図２２の↑は早期相では認めない所見だから，静脈性のextravasation，すなわちIVCまたは肝静脈損傷を示唆する．同部位のIVCは虚脱しており，重度のhypovolemiaを意味する．出血量は，上段の図９で肝周囲に200，図１４で脾臓周囲に200，図３３の右結腸傍溝に200，図３４で左結腸傍溝に200，図３５で骨盤腔に6cm＋4cmとして500，合計900mlとなる．PV：門脈，LPV：左門脈，RPV：右門脈．

血管造影（図Aと図B）が施行され，仮性動脈瘤（▲）とextravasation（△）を認め，スポンゼル細片で塞栓した．しかし，Hbは低下し続けたのでさらに数単位の輸血が必要であった．図Cと図Dは2日後のCTで，肝壊死（↑）と明らかな出血の増量（※）を認めたので手術となった．開腹すると3100mlの血液が吸引され自己輸血として還元した．活動性の出血はなく，S4，S5，S6とS8の一部が壊死に陥っており切除した．中肝静脈と左肝静脈の根部周囲に凝血塊を認め，損傷されていたが凝血塊で止血されているものと思われた．

文献考察：Emergency department thoracotomy：腹腔内大量出血でショック状態の外傷例（銃創49例，刺創1例）に対してERでの開胸・大動脈閉塞は有効であった．50例中8人（16%）が神経学的異常を残さず生存した．
J Trauma. 2008 Jan;64(1):1-7; discussion 7-8.
Emergency department thoracotomy: still useful after abdominal exsanguination?
Seamon MJ, Pathak AS, Bradley KM, Fisher CA, Gaughan JA, Kulp H, Pieri PG, Santora TA, Goldberg AJ.

BACKGROUND: Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage. METHODS: A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival. RESULTS: The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days). CONCLUSIONS: Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.PMID: 18188091