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。

Treatment for severe pelvic fractures associated with polytrauma

Objective To summarize managing methods for severe pelvic fracture and its complications ac-cording to the principle of damage control surgery.Methods The data of 299 patients with severe pelvic fractures from 1998 to 2011 was retrospectively analyzed.Among them 172 were males and 127 were females;the mean age was(47.3 ±8.2)years(19-83) years.The control group consisted of 116 cases without DCS during Jan.1998 and Jan.2004 and the study group consisted of 183 cases during Feb.2004 and Jan.2011 undergoing treatment with DCS.The control group underwent decisive operation initially.The study group underwent internal iliac arteries de-vascularization initially;89 of them were performed pelvic external fixation.In patients with visceral injuries,repair of stomach or intestineand cystostomy was performed to control contamination, and splenectomy and repair of the liv-er were conducted to control bleeding.All patients in the study group were transferred to ICU for resuscitation.The definitive surgery including repair of the pelvis,posterior urethra and rectum was performed when vital signs got sta-ble.Results The survival rates in the control group and the study group were 75.86%( 88/116 ) and 87.98%(161/183) ,respectively.Postoperative complications included hemorrhagic shock in 74 cases,sepsis of pelvic and abdominal cavity in 27,abdominal compartment syndrome in 22,fat embolism in 12,and deep venous embolism in 30.The main causes of death were hemorrhagic shock,multiple organ dysfunction syndrome(MODS),and septic shock.Conclusion The survival rate of severe pelvic fractures was obviously improved by DCS principles.DCS, including initial control of bleeding and contamination ( including fecal and urinary rechanneling ) for simplifying early surgical intervention,is applied by combining with pelvic external fixation.Damage control resuscitation was performed in ICU as well as dealing with complications.Only if the vital signs get stable,the definitive operations such as pelvic,posterior urethra and rectum reconstruction could be done.