図３〜図５の↑が脾臓と思われるが，肝臓と比較して全く造影効果を認めず，脾門部血管損傷を強く疑う．図２〜図１４の△はすべてextravasationであり，スライス数を考慮するとかなり高速の大量出血だと思われる．出血量は，図２の肝周囲で250ml，図５あたりが脾臓周囲の血腫と液貯留の平均的な部位とし400ml，図１０のMorison窩で250ml，図１６の右傍結腸窩で400ml，図１７の左傍結腸窩で350ml，図１８の骨盤腔に12cmで600mlとし，合計は2000mlを超える．図７でIVCは扁平化し重度の循環血液量不足状態を示している．緊急手術で脾門部脾動脈が断裂し大量出血を認めたので脾臓摘出を行った．輸液を2000ml以上投与しても低血圧を呈する出血性ショック例では腹部エコーですばやく診断し直ちに手術を行うべし．造影CTは不要であるどころか，手術のタイミングを遅らせ重症化させる原因となる．

文献考察１：初期輸液でも血圧不安定な症例は15分以内に手術室へ搬送すべき．
Surg Clin North Am. 2004 Apr;84(2):437-50.
Hepatic trauma: contemporary management.
Trunkey DD.

In the introduction, I posed several questions that were issues/controversies. The answers will probably be interpreted as equally controversial. I do not believe there is strong evidence that the incidence of liver injuries has increased. Diagnostic modalities have contributed to this seeming increase, as well as population increases and the concentration of severe liver injuries in trauma centers, now present in 35 states. I believe there are more blunt injuries now, relative to penetrating injuries. The peak of penetrating injuries occurred in the 1970s and 1980s and lasted almost 2 decades. I believe some authors are overly enthusiastic for nonoperative management. I am particularly critical of authors who do not include all components of the surgical armamentarium into their treatment of severe liver injuries. I also believe that the complications following nonoperative management are currently unacceptable, as documented in the references. I have shared with you the strategies for operative management, but there are equally good or better strategies in the surgical literature.　PMID: 15062654

文献考察２：血圧が90mmHg以下の腹部外傷患者で，救急室に滞在する時間が3分延長するごとに死亡率は1％ずつ増加する．
J Trauma. 2002 Mar;52(3):420-5.
Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes.
Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ.

OBJECTIVE: We examined the relationship between survival and time in the emergency department (ED) before laparotomy for hypotensive patients bleeding from abdominal injuries. METHODS: Patients in the Pennsylvania Trauma Systems Foundation trauma registry with isolated abdominal vascular, solid organ, or wall injuries grade 3 to 6 and hypotension were identified. Deaths were predicted from the prehospital time, systolic blood pressure (SBP) on ED admission, and time in the ED before either laparotomy or ED death. RESULTS: Two-hundred forty-three patients met the criteria. SBP ranged from 30 to 90 mm Hg. Time to the ED ranged from 7 to 185 minutes. Time in the ED ranged from 7 to 915 minutes. Overall, 98 patients died (40%). The risk ratio for the SBP increased, as expected, as SBP dropped. The risk ratio for time spent in the ED before laparotomy increased until 90 minutes, then significantly decreased below all earlier values. Logistic regression on the 165 patients spending 90 minutes or less in the ED showed that the probability of death increased with time in the ED. The increase was as much as 0.35% per minute. CONCLUSION: Among patients in a trauma registry who were hypotensive on arrival in the ED and had major injuries isolated to the abdomen requiring emergency laparotomy, the probability of death showed a relationship to both the extent of hypotension and the length of time in the ED for patients who were in the ED for 90 minutes or less. The probability of death increased approximately 1% for each 3 minutes in the ED.　PMID: 11901314