骨盆骨折大出血伴凝血病的救治策略

目的总结骨盆骨折大出血伴凝血病的救治方法和治疗效果。方法对1995年1月~2003年2月及2007年1月~2015年12月笔者科室收治的严重骨盆骨折大出血病例临床资料进行回顾性分析。其中1995~2003年未采用损害控制外科(DCS)及损害控制复苏(DCR)治疗的198例作为对照组;2007~2015年按照DCS及DCR技术治疗的423例作为治疗组。对照组均行Ⅰ期手术治疗;治疗组Ⅰ期急诊先行髂内动脉断血术以控制出血,伴脏器损伤者同时行相应手术控制出血并阻断污染,然后转往ICU按DCR原则行复苏治疗,生命体征平稳后行确定性手术。结果对照组发生创伤性凝血病52例,其中死亡23例,死亡率44.23%(23/52)。治疗组中382例有进行性出血,86例出现凝血障碍。382例进行性出血急诊行髂内动脉断血术,其中206例加用骨盆外固定支架。对合并脏器伤按DCS原则行剖腹手术,同时按DCR原则作止血性复苏,及时输入血液制品及凝血因子。ICU复苏治疗生命体征平稳后行骨盆骨折固定等确定性手术。主要并发症包括盆腹腔感染17例、腹腔间隙综合征22例、脂肪栓塞综合征12例、深静脉血栓形成30例。治疗组中发生凝血病者死亡率为22.09%(19/86),主要死因为失血性休克。结论严重骨盆骨折易并发创伤性凝血病。按照DCR原则行低压复苏和止血性复苏,同时行髂内动脉断血术加骨盆外固定支架控制出血,将明显提高救治生存率。     

正确应用损害控制性剖腹术

损害控制策略是提高腹部创伤救治成功率的关键环节之一,有助于改善面临低体温、酸中毒和凝血功能障碍的危重患者的预后。首先是通过短时间的剖腹手术紧急控制出血和污染,然后在ICU继续积极复苏,在致命性三联征纠正后再进行确定性手术处理。     

多发伤伴严重骨盆骨折的救治

目的总结救治多发伤伴严重骨盆骨折及其并发症的方法。方法笔者对1998~2011年救治的299例多发伤伴严重骨盆骨折的临床资料进行回顾性对比分析,其中男性172例,女性127例;年龄19~83岁,平均(47.3±8.2)岁。将其中1998年1月~2004年1月收治的116例未采用损害控制外科(DCS)治疗的患者作为对照组,2004年2月~2011年1月收治的183例采用DCS治疗的患者作为治疗组。对照组均行一期手术治疗。治疗组一期急诊先行髂内动脉断血术以控制出血(其中89例加骨盆外固定支架固定),伴脏器损伤者同时行胃肠破裂、膀胱破裂修补以阻断污染,行脾切除、肝修补控制出血,然后转往ICU行复苏治疗,生命体征平稳后行确定性手术,包括骨盆、后尿道和直肠修复重建等。结果对照组和治疗组的生存率分别为75.86%(88/116)和87.98%(161/183)。术后并发症包括失血性休克74例、盆腹腔感染27例、腹腔间隙综合征22例、脂肪栓塞综合征12例和深静脉血栓形成30例。主要死因为失血性休克、多脏器功能障碍综合征(MODS)和感染性休克。结论 DCS救治多发伤伴严重骨盆骨折明显提高生存率。主要方法为初期简化手术控制出血、污染(包括粪尿改道和有效引流),结合骨盆外固定支架使用;ICU复苏期遵循损害控制性复苏,观察处理各种并发症;生命体征稳定后再行确定性手术行骨盆、后尿道和直肠修复重建等。     

Angiography-assisted computed tomography for the detection and intervention of a subtle aneurysm of the omentum

Intra-abdominal hemorrhage caused by omental artery rupture is a rare condition traditionally diagnosed via exploratory laparotomy in hemodynamically unstable patients. We experienced a case in which contrast-enhanced multidetector computed tomography (MDCT) and digital subtraction angiography did not identify the rupture site, whereas CT during left omental arteriography depicted a small 4-mm aneurysm. The lesion was then embolized with microcoils and N-butyl cyanoacrylate lipiodol glue. We consider that performing a CT during selective arteriography could be useful in cases in which the rupture site is unclear with other imaging techniques such as contrast-enhanced MDCT and digital subtraction angiography.     

Experience with a continuous, single-pass whole-body multidetector CT protocol for trauma: the three-minute multiple trauma CT scan

Purpose: To test the clinical feasibility and utility of a single-pass, whole-body multidetector CT (MDCT) protocol in the evaluation of the multiple trauma patient. Materials and methods: A whole-body, single-pass MDCT protocol was designed for optimal imaging quality and maximum flexibility for retrospective reconstruction and multiplanar reformation. Five consecutive trauma patients with moderate to severe mechanisms of injury were scanned on an MDCT scanner using the single-pass protocol. Times were recorded for the scan alone and for time spent in the CT bay. Times were compared with those for five random trauma patients scanned on a single-detector helical CT (SDHCT) scanner who were matched for body segments imaged and trauma severity. Results: Compared to SDHCT, MDCT scan times were shortened by a factor of 10 (3 min for MDCT vs 41 for SDHCT) and patient throughput times by a factor of 3 (23 min for MDCT vs 65 for SDHCT). Image quality was mildly compromised in MDCT by beam hardening due to arm position, but overall was comparable to segmental imaging. Conclusion: Whole-body MDCT is feasible and offers a marked time advantage over conventional segmental imaging in multiple trauma patients. Added flexibility through reformation of image data allows imaging evaluation as needed even after the patient has left the scanner bay.     

Coronary artery bypass grafts and MDCT imaging: what to know and what to look for

Multi-detector row CT (MDCT) scanners with high spatial and temporal resolutions are now available and are increasingly used for non-invasive assessment of vascular disease, including coronary arteries and coronary artery bypass grafts (CABG). Follow-up of patients who have previously undergone surgical revascularization for coronary artery disease is nowadays one of the main applications of MDCT. Thanks to the continuous technical evolution of the CT scanners, it is now possible to scan the heart and the full anatomic extent of grafts with sub-millimeter slice-thickness within a single breath-hold. In the evaluation of these patients, it is important for the radiologist to be familiar with the different types of grafts and surgical techniques to know the main characteristics of each graft type and what to look for in the assessment of a patient who has undergone coronary artery surgical revascularization. This review summarizes some surgical aspects, the biological characteristics of conduits, and the main technical MDCT features, and describes the CABG anatomy together with some typical CT findings.     

Musculoskeletal Imaging with Computed Tomography and Magnetic Resonance Imaging: When is Computed Tomography the Study of Choice?

Indications for computed tomography (CT) of the musculoskeletal system, especially with the advent of 16-slice multidetector CT (MDCT), are numerous. In addition to the evaluation of the trauma patient where CT is essential when imaging complex skeletal injuries, MDCT is particularly useful in patients who have had prior surgery. In postoperative cases, metal artifact typically prohibits magnetic resonance imaging evaluation, but volume-rendering of a MDCT axial database virtually eliminates streak artifact associated with hardware. For the evaluation of masses, CT provides the ability to detect and characterize calcification, cortical disruption, and periosteal reaction. In this article, these and other indications for performance of CT of the musculoskeletal system will be discussed.     

Multidetector-row computed tomography and 3-dimensional computed tomography imaging of small bowel neoplasms: current concept in diagnosis

The diagnosis of small bowel neoplasms can present a difficult challenge to the radiologist because the tumors are uncommon, often small, and may be difficult to detect radiographically. The most common small bowel neoplasms include adenocarcinoma, carcinoid, lymphoma, and gastrointestinal stromal tumors. The location and computed tomography (CT) appearance of the small bowel tumors may aid in the diagnosis. For instance, small bowel adenocarcinoma occurs more frequently in the duodenum and may result in obstruction. Carcinoid tumors are more common in the ileum and are typically hypervascular submucosal masses that produce a characteristic mesenteric mass when they spread to the mesenteric nodes. Lymphoma can occur anywhere along the gastrointestinal tract and have a variable CT appearance. It may appear as a single mass, multiple masses, an infiltrating lesion resulting in aneurysmal dilatation of the bowel, or as an exophytic mass. Gastrointestinal stromal tumors are more common in the jejunum and ileum and usually appear exophytic and bulky often with ulceration. Traditionally, small bowel series and enteroclysis have been used for imaging patients with suspected small bowel tumors. More recently, CT is beginning to play a more important role for this clinical indication. The thinner collimation possible with multidetector CT (MDCT) along with water as oral contrast and a good intravenous contrast bolus may improve the sensitivity of CT for detecting small bowel tumors. In addition, MDCT scanners improve the quality of the 3-dimensional CT (3D CT) images that are valuable to the clinicians and surgeons for surgical planning. It is important for the radiologist to be familiar with the CT appearance of these neoplasms and the potential role of MDCT and 3D imaging in their diagnosis and surgical planning.     

CT of the acute (emergency) abdomen

Over the past 20 years, CT has become the premier imaging technique for evaluating patients presenting with symptoms of acute, severe, abdominal pain. The advent of multidector helical CT (MDCT) has improved the accuracy and expanded the indications for CT of the acute abdomen. MDCT is accurate for nearly all of the numerous etiologies of conditions that require emergency medical or surgical treatment. The proper execution and interpretation of CT in this setting reduces morbidity, mortality, and medical expenses.     

Multidetector CT evaluation of abdominal trauma

CT is the imaging modality of choice to evaluate blunt abdominal trauma. With the advent of multidetector CT (MDCT), scanning times have progressively decreased while image resolution has increased owing to thinner collimation and reduced partial volume and motion artifacts. MDCT also allows high quality two-dimensional and three-dimensional multiplanar reformatted images to be obtained, which aid in the diagnosis of the complex multisystem injuries seen in the trauma patient. This article describes the authors' current imaging protocol with 16-detector MDCT, the spectrum of CT findings seen in patients with blunt abdominal injuries, and the role MDCT has in guiding injury management.     

Multidetektor-CT zur Diagnostik traumatologischer Notfälle

Diagnosis of trauma-related injuries is a key task in modern radiology. Early, thorough and accurate detection of potentially life-threatening injuries is crucial for fast and targeted initiation of treatment. Conventional radiography (CR) and ultrasound (US) are well-established and still represent the basic diagnostic tools for trauma imaging. However, a number of studies have shown a lower detection rate of injuries for radiography and ultrasound compared with computed tomography (CT). Multi-detector CT (MDCT) with its shorter scan time and increased accuracy has become the gold standard for many indications in trauma imaging. As MDCT has a higher radiation dose, its use should be restricted and carefully indicated especially when dealing with a younger patient population. Careful optimization of imaging parameters has to be performed to minimize exposure and maximize diagnostic safety. Modern MDCT examinations produce a large number of images, which have to be limited to a reasonable number for interpretation. This review article focuses on optimization of examination protocols and on how to handle the flood of images for viewing and archiving.     

Low-dose MDCT findings of blunt hepatobiliary trauma

This pictorial essay shows low-dose multi-detector computed tomography (MDCT) findings of blunt hepatobiliary trauma, and describes the indications and protocol for MDCT. Given the universal usage of MDCT in assessing the liver in blunt abdominal trauma, reduction of patient dose is essential. The new l0se MDCT protocol presented here can achieve up to 50% dose reduction while maintaining diagnostic image quality and thus facilitate dose sensitive patient management. Our institution’s blunt hepatobiliary MDCT imaging algorithm can help determine which patients require operative therapy. Injury to the liver is graded on various schemes, one being the Organ Injury Scale devised by the American Association for the Surgery of Trauma classification based on the extension of the lesion and bleeding.     

Traumatic injuries: imaging of abdominal and pelvic injuries

The availability of new imaging modalities has altered the diagnostic approach to patients with abdominal and pelvic trauma. Computed tomography and ultrasound have largely replaced diagnostic peritoneal lavage. Ultrasound is used in most trauma centers as the initial imaging technique for the detection of hemoperitoneum and helps to determine the need for emergency laparotomy. Computed tomography allows for an accurate diagnosis of a wide range of traumatic abdominal and pelvic conditions. The speed of single-detector helical and multi-detector row CT (MDCT) permits a rapid CT examination of the seriously ill patient in the emergency room. In particular, the technology of MDCT permits multiple, sequential CT scans to be quickly obtained in the same patient, which is a great advance in the rapid assessment of the multiple-injured patient. The evolving concepts in trauma care promoting non-operative management of liver and splenic injuries creates the need for follow-up cross-sectional imaging studies in these patients. Computed tomography and, less frequently, MR or ultrasound, are used for this purpose.     

Splenic Trauma: What is New?

Evaluation for splenic injury is an important component of patient assessment after blunt abdominal trauma. Key imaging modalities include ultrasound, particularly for rapid identification of hemoperitoneum, and computed tomography (CT), which permits a more detailed and accurate determination of splenic integrity. Specific findings at contrast-enhanced multidetector CT (MDCT) should prompt the consideration of catheter angiography with arterial embolization as an adjunct to nonsurgical management. This article reviews the roles of imaging in the management of splenic trauma, illustrates the MDCT appearance of various splenic injuries, and discusses imaging-based indications for operative and angiographic intervention.     

Pictorial review: computed tomography features of cardiovascular emergencies and associated imminent decompensation

Multi-detector computed tomography (MDCT) scanner is available in most hospitals and is increasingly being used as the first line imaging in trauma and suspected cardiovascular emergencies, such as acute coronary syndrome, pulmonary artery thrombo-embolism, abdominal aortic aneurysm and acute haemorrhage (Ryan et al. Clin Radiol 60:599-607, 2005). A significant number of these patients are haemodynamically unstable and can rapidly progress into shock and death. Recognition of computed tomography (CT) signs of imminent cardiovascular decompensation will alert the clinical radiologist to the presence of shock. In this review, the imaging findings of cardiovascular emergencies in both acute traumatic and non-traumatic settings with associated signs of imminent decompensation will be described and illustrated.     

多层螺旋CT后处理图像对亲属活体供肾术前的综合评价

目的 评价多层螺旋CT(MDCT)后处理图像对亲属活体供肾摘取手术前评估供肾状况的价值.资料与方法 施行开放供肾摘取手术20例,术前全部供者均使用MDCT后处理图像显示供肾血管、上尿路、肾实质及供肾与周围脏器的空间关系,重建层厚和层距采用1.25 mm和1 mm,将术中所见和术后摘取的供肾与术前的CT后处理图像进行对照,评价CT后处理图像的敏感性和准确性.结果 20例供肾者CT数据经后处理后均获得了满意的CT血管成像(CTA)、CT尿路成像(CTU)、多平面重建(MPR)及容积再现(VR)图像,清晰地显示了肾血管的分支、数目、长短、粗细,上尿路的形态,肾实质情况,肾脏与毗邻周围器官的空间立体关系,CT后处理图像显示的肾脏血管情况、上尿路形态、肾实质及供肾与周围脏器的空间关系与手术所见相同.结论 使用MDCT后处理图像可代替DSA、排泄性尿路造影(IVP)及超声检查,准确而全面地评价移植前亲属供体的肾脏血管、上尿路、肾实质及肾脏与周围脏器的空间立体关系.     

Detection and characterization of benign focal liver lesions with multislice CT

MDCT is a rapidly evolving technique that significantly improves CT imaging for several indications including depiction of focal benign lesions. Imaging mainly profits from improved longitudinal spatial resolution allowing high-quality non-axial reformations and 3D reconstructions and CT angiography as well as rapid accurate multiphase imaging with short breath-holding periods. This review provides an overview of the current status of MDCT with respect to liver imaging and the implications for characterizing benign focal liver lesions. MDCT currently allows the acquisition of thin slices in daily routine diagnostics providing an improved detection rate of small liver lesions. Whereas large benign focal liver lesions exhibit typical patterns of morphology, attenuation and perfusion, which also may be assessed with single-slice scanners, small lesions remain challenging even with MDCT, since the specific criteria for confident diagnosis become more ambiguous. Here, MR imaging provides more detailed information about tissue components and the availability of liver-specific contrast agents, adding further impact to this technique. With respect to dose considerations, the number of necessary multiphase scans as well as the application of very thin collimation should be strictly checked for each patient undergoing MDCT based on the individual clinical situation and question.     

Comparative evaluation of multidetector CT and MR imaging in the differentiation of adnexal masses

The purpose was to compare the accuracy of multidetector CT (MDCT) on a 16-row CT scanner and magnetic resonance (MR) imaging in the characterization of ovarian masses. Preoperative CT examination of the abdomen and MR imaging of the pelvis was performed in 67 women, with clinically or sonographically detected adnexal masses. The CT examinations were performed on a 16-row CT scanner, and the protocol included scanning of the abdomen during the portal phase, using a detector collimation of 16 × 0.75 mm and a pitch of 1.2. We used a 1.5-T magnet unit to perform T1, T2 and fat-suppressed T1-weighted sequences, before and after intravenous administration of gadolinium chelate compounds. The accuracy of multidetector CT and MR imaging in the differentiation between benign and malignant ovarian masses was evaluated, using histopathologic results as the standard of reference. The sensitivity, specificity and accuracy of MDCT in the characterization of ovarian masses were 90.5%, 93.7% and 92.9%, respectively, and that of MR imaging 95.2%, 98.4% and 97.6%, respectively. Although MRI performed slightly better, this did not reach statistical significance. In conclusion, both MDCT on a 16-row CT scanner and MR imaging demonstrated satisfactory results in the characterization of ovarian masses.     

MDCT Findings of renal trauma

OBJECTIVE: The purposes of this pictorial essay are to show MDCT findings of renal trauma and describe the indications and protocol for MDCT. CONCLUSION: CT is indicated when patients have gross hematuria, hypotension, lumbar spinal injury, and fractures of lower ribs or the transverse process. The CT examination must be designed specifically for urinary tract evaluation, and MDCT is especially useful for this purpose. Injury to the kidney is graded I to V according to degree of laceration and amount of hematoma.