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文献考察１）：【多発外傷 preventable trauma deathの回避をめざして】 各外傷からみた多発外傷の治療 胸部外傷からみた治療戦略
Author：水島靖明(大阪府立泉州救命救急センター), 田中裕
Source：救急医学(0385-8162)30巻5号 Page564-570(2006.05)
要旨：鈍的外傷例で胸部外傷があれば高頻度に頭部，腹部，骨盤や四肢の合併損傷が存在する．筆者らの大阪府立泉州救命救急センターでの検討では，重症胸部外傷（胸部AIS≧3）312例中多部位に何らかの損傷があるものは93％，AISが3以上の多部位合併症例は61％である．また逆に重症外傷（ISS≧16）673例でみると，胸部外傷の合併は47％であり，そのうち85％は胸部AIS≧3の重症胸部外傷を合併していた．胸部外傷では，呼吸と循環の維持に必要な臓器に直接障害が及ぶため，緊急性の高い病態に直結しやすい．JATECTMではprimary surveyにおいて生理的徴候に異常をきたす外傷として9損傷（表１）を位置づけているが，胸部損傷に関連するものは6損傷にも及ぶ．大量気道内出血，air leakによる換気不全や大量の胸腔内出血は手術の適応となる．胸腔ドレナージからみた開胸基準は表２に示す．primary surveyで胸部に異常を認めなくても胸部外傷には重篤化しやすく，見落とすと致命的となる損傷があり，secondary surveyでは表３の損傷を検索する．AISとISSについては参照症例（Expert course症例８）の解説を参照．
文献考察２）：【多発外傷 preventable trauma deathの回避をめざして】 各外傷からみた多発外傷の治療 腹部外傷からみた治療戦略 重症他部位損傷を合併した鈍的腹部外傷の診療
Author：佐々木淳一(東北大学 大学院医学系研究科外科病態学講座救急医学分野), 北野光秀
Source：救急医学(0385-8162)30巻5号 Page571-576(2006.05)
要旨：胸腔内出血が大量または進行性（排液が胸腔ドレーン挿入時1000ml以上，または出血が200ml/hrが2時間以上継続）でかつ腹腔内出血も大量の場合，開腹開胸同時手術を要するが予後は極めて悪い．ガーゼパッキングを含めたdamage control surgeryも考慮する．腹腔内大量出血に骨盤骨折に起因する大量後腹膜出血を合併してショックに陥っている場合は，開腹術を施行して腹腔内の動脈性出血を止血（脾臓損傷→脾摘）した後，骨盤腔にパッキングを施行し，その後に血管造影で骨盤の出血部位をTAEで止血する．
文献考察３）：Extraperitoneal pelvic packing（骨盤腔の腹膜外パッキング法）
J Trauma. 2007 Apr;62(4):843-52.
Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage.
Tötterman A, Madsen JE, Skaga NO, Røise O.
OBJECTIVE: To describe the method of extraperitoneal pelvic packing (EPP), and to assess the impact of EPP on outcome in severely hemodynamically unstable patients after blunt pelvic trauma. METHODS: Of 661 patients treated for pelvic trauma, 18 underwent EPP as part of our protocol with the intent to control massive pelvic bleeding and constituted the study population. Data retrospectively collected from the medical records and from the Ullevål Trauma Registry included demographics, fracture classification, additional injuries, blood transfusions, surgical interventions, angiographic procedure, physiologic parameters, and survival. RESULTS: Survival rate within 30 days was 72% (13/18), and correlated inversely to the age of the patient (p = 0.038). Only one of the nonsurvivors died of exsanguination. A significant increase in systolic blood pressure (BP) (p = 0.002) was observed immediately after EPP. Angiography performed after EPP was positive for arterial injury in 80% of patients. All types of pelvic ring fractures were represented. CONCLUSIONS: EPP as part of a multi-interventional resuscitation protocol might be life saving in patients with life-threatening pelvic injury who are exsanguinating. However, the high rate of arterial injuries seen after EPP indicates that the procedure should be supplemented with angiography once the patient is sufficiently stabilized to tolerate transportation to the angiography suite.PMID: 17426538
要旨：他の適応で開腹し，骨盤腔内に大量の，または腫大する血腫を認めたときの骨盤腔パッキング法を解説している．膀胱傍腔には血腫を認めるので，血腫を除去すれば腹膜外で左右の膀胱傍腔から仙骨前腔へは腹膜を新たに剥離することなく容易に到達できる．腹膜外で両側の膀胱傍腔から仙骨前腔に4〜8個の大ガーゼを詰めることで効果的なﾀﾝﾎﾟﾅｰｾﾞが可能である．手術終了後にTAE目的の血管造影を行い，extravasationを認めたら塞栓術を施行する．
文献考察４）：MDCTでTriple phase 造影CT（造影剤注入開始から23秒，70秒と5分）を撮れば静脈性出血も診断可能である．
Radiology. 2008 Feb;246(2):410-9
Blunt trauma: feasibility and clinical utility of pelvic CT angiography performed with 64-detector row CT.
Anderson SW, Soto JA, Lucey BC, Burke PA, Hirsch EF, Rhea JT.
PURPOSE: To retrospectively evaluate the integration of pelvic computed tomographic (CT) angiography into the thoracoabdominal CT examination of blunt trauma by using 64-detector row CT to differentiate active arterial from active venous hemorrhage. MATERIALS AND METHODS: This study was institutional review board approved and HIPAA compliant; the requirement for informed patient consent was waived. Fifty-three patients (30 male, 23 female; mean age, 42 years) with multiple blunt trauma underwent pelvic CT angiography with 64-detector row CT at admission. Arterial phase and portal venous phase pelvic CT angiograms were evaluated for evidence of vascular injury. In patients with active extravasation, the size of the hemorrhaging area was measured on arterial, portal venous, and delayed phase images. The Fisher exact test was used to correlate presence of vascular injury with subsequent clinical management. The Wilcoxon rank sum test was used to test the association between size of active hemorrhage during the vascular enhancement phases and subsequent clinical outcome. Finally, the Fisher exact test was used to correlate presence of vascular injury with severity of osseous injury. RESULTS: At pelvic CT angiography, 21 of the 53 patients had evidence of vascular injury: 10 isolated active arterial extravasations, three isolated arterial occlusions, three cases of both arterial extravasation and occlusion, two cases of arterial and venous extravasations, and three isolated venous extravasations. Eleven of the 21 patients also underwent conventional angiography, with subsequent embolization performed in seven of these 11 patients. The remaining 10 patients were successfully treated conservatively. When the foci of active arterial extravasation were compared on arterial, portal venous, and delayed phase images, the mean areas of hemorrhage across all three phases were larger in patients who required conventional angiography than in those successfully treated with conservative management. CONCLUSION: With use of 64-detector row scanning, pelvic CT angiography was successfully integrated into the authors' CT protocols and enabled differentiation between active arterial and active venous hemorrhage, which may influence clinical management.PMID: 18227538
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