図１で脾臓周囲に腹水が（※），図１〜図１８（一部省略）で，大量の後腹膜腔内血腫（※）がある．出血量は，図９を平均的な部位とし体積計算すると6cm×12cm＝72，スライス数は少なく見込んでも20だから72×20＝1440，1440×8/10（10mmスライスに変換）で1000ml以上である．FASTの腹部エコー検査で容易に診断できたと思われ，CT検査は不要である．図６〜図１４の△はextravasationであり，図１２と図１３の↑あたりが大動脈に最接近し出血部位と思われる．図１でIVCは虚脱し重度のhypovolemiaを意味する．白矢印は中心静脈カテーテル．手術で後腹膜腔に巨大な血腫を認め，下腸間膜動脈分岐部より末梢の腹部大動脈前壁に8mm大の刺創があり，活動性に出血しており止血した．

文献考察：腹部穿通性外傷の治療戦略
Surg Clin North Am. 1999 Dec;79(6):1331-56.
New concepts in the management of patients with penetrating abdominal wounds.
Ferrada R, Birolini D.

In the future, trauma research and care will have to become better, faster, and less expensive. Surgeons in the next millennium must be able to diagnose wounds, initiate correct procedures, and anticipate complications more accurately than before. Violent crime will not abate, nor will the proliferation of more powerful arms; these trends translate into graver traumatic wounds, giving the operating team less time to stabilize patients. Time management and team coordination are becoming key elements for patient survival, especially for patients with potentially fatal wounds, such as those to the heart. The authors have reduced the time from arrival to surgery to a few minutes. The keys to this feat are readiness, team coordination, and high morale. Financial resources will continue to be limited and allocated on a need-first basis. In the future, trauma centers will compete for dwindling funds. Technology is and always will be just a tool, whereas qualified trauma surgeons are irreplaceable, much more so than in any other surgical specialty. Observation, diagnosis, and surgery are, of course, greatly facilitated by ever-evolving technology, but since the time of Hippocrates, split-second decisions can ultimately be made only by the caregiver in the white smock. Trauma surgeons in the next millennium will have to exercise judgment based on knowledge, surgical skills, and contact with patients. To err is human, but in surgery, errors often cause death, and no machine will ever relieve surgeons of that burden.　PMID: 10625982
追記．Fig．１：vital signsが安定→Fig．２へ．低血圧なら輸液1500mlを急速投与し安定すれば種々の検査を行う．血圧不安定→手術．agonal（臨終の）とは自発呼吸がない，大腿動脈で脈を触れない，疼痛刺激に反応しない重症者．Fig．２：創検索で穿通性または穿通の疑いがある→Fig．３へ．Fig．３：経過観察中に腹膜刺激症状が発現→手術．Fig．４：胸郭腹部（上は乳頭のレベル，下は肋骨弓下端）穿通性外傷のmanagement．