図７〜図１０で肝損傷（↑）があり，周囲に大量の血腫と腹水を認める．図１５で腹部大動脈は1cmに縮小し，IVCが虚脱しているので大量出血に伴う重度のhypovolemiaを示している．出血量（計算法は下記に再掲）は図９で肝周囲に400ml，脾臓周囲に400ml，図１７で両側傍結腸溝に800ml，図１８で骨盤腔に750mlで，計2350mlもある．本来は，血圧は極めて不安定な状態であることから腹部エコー検査（FAST：Focused Assessment with Sonography for Trauma）で腹水を確認し手術室へ直行すべきで，CT検査は不要である．図２〜図５の△はextravasationの可能性が高いが，断定するにはdouble phase CTが不可欠である．図９〜図１４の▲は副腎であり（下記症例参照），IVCからのextravasationを描出するにはdelayed phase CTが必要である．血管造影が施行され，図Aでextravasationを認めたのでコイルで塞栓したが，血圧不安定の状態では血管造影の適応もない．手術で約2500mlの出血と，肝右葉損傷に加え肝後部下大静脈からの出血を認めた．ガーゼパッキングし閉腹したが出血は続き死亡した．

腹腔内を，１：肝周囲（右横隔膜下），２：脾臓周囲（左横隔膜下），３：Morison窩，４：右傍結腸溝，５：左傍結腸溝，６：小腸間，７：骨盤腔の７つの部位に分ける．腹水の厚さを各部位の平均的な場所でおおまかに計測し，1cm未満を50ml，1cm＝100ml，1．5cm＝150ml，2cm＝200ml，2．5cm＝250ml，3cm＝300ml．．．5cm＝500mlとし合計する．骨盤腔は比較的横径が狭いので半分値で計算する（例：前後に4cmあれば200ml）．

文献考察：1)外傷例で初療24時間以内に50単位以上の血液製剤の大量輸血例の生存率は43％，aggressiveに治療すべき．
J Trauma. 2002 Aug;53(2):291-5; discussion 295-6.
Massive transfusion exceeding 50 units of blood products in trauma patients.
Vaslef SN, Knudsen NW, Neligan PJ, Sebastian MW.

BACKGROUND: Massive transfusion of blood products in trauma patients can acutely deplete the blood bank. It was hypothesized that, despite a large allocation of resources to trauma patients receiving more than 50 units of blood products in the first 24 hours, outcome data would support the continued practice of massive transfusion. METHODS: A retrospective review of charts and registry data of trauma patients who received over 50 units of blood products in the first day was conducted for a 5-year period at a Level I trauma center. Patients were stratified into groups on the basis of the number of transfusions received. Results are expressed as mean +/- SD. Univariate analysis and multivariate logistic regression were used to identify those risk factors determined in the first 24 hours after admission that were predictive of mortality. Physiologic differences between survivors and nonsurvivors were also examined. RESULTS: Of 7,734 trauma patients admitted between July 1, 1995, and June 30, 2000, 44 (0.6%) received > 50 units of blood products in the first day. Overall mortality in these patients was 57%. There was no significant difference (p = 0.565, chi2) in mortality rate between patients who received > 75 units of blood products in the first day versus those who received 51 to 75 units. Multiple logistic regression analysis identified only one independent risk factor, base deficit > 12 mmol/L, associated with mortality. Base deficit > 12 mmol/L increases the risk of death by 5.5 times (p = 0.013; 95% confidence interval, 1.44-20.95). Neither the total blood product transfusion requirement in the first day nor the packed red blood cell transfusion amount in the first day were significant independent risk factors. Causes of the 25 deaths in this series included exsanguination in the operating room (n = 1) or in the surgical intensive care unit (n = 12), multiple organ failure/sepsis (n = 3), head injury (n = 3), respiratory failure (n = 2), cerebrovascular accident (n = 1), and other (n = 3). Of the survivors, 63% were discharged to home, 21% to rehabilitation, 11% to nursing home, and 5% to another acute care facility. Of the nonsurvivors, the mean Injury Severity Score was 43, 88% had a base deficit > 12 mmol/L, 68% had a Glasgow Coma Scale score 10. CONCLUSION: The 43% survival rate in trauma patients receiving > 50 units of blood products warrants continued aggressive transfusion therapy in the first 24 hours after admission.PMID: 12169936

文献考察：２）bilhemia．
Carrillo EH, Wohltmann C, Richardson JD, Polk HC Jr.
Evolution in the treatment of complex blunt liver injuries.
Curr Probl Surg. 2001 Jan;38(1):1-60. Review. PMID: 11202160
要旨：多くの深在性肝損傷が保存的に治療されるようになり，まれだがbilhemia（高ビリルビン血症？）と呼ばれる合併症が見られるようになった．肝中心部に及ぶ損傷で中心部で胆道と門脈が破綻すると，胆道系の方が圧が高いので胆汁が門脈内へ流入する．このbiliovenous fistulaが形成され，短期間の間に血中ビリルビン値が40mg/dl以上に上昇する．他の酵素はそれほど高値にはならない．治療法は内視鏡的乳頭部切開とステント挿入である．