严重肝脏损伤并发凝血病32例救治分析

目的探讨严重肝脏损伤并发凝血病的救治方法。方法回顾性分析重庆市急救医疗中心2010年2月—2016年4月收治的32例严重肝脏损伤并发凝血病患者的临床资料。其中男性23例,女性9例;年龄15~84岁,平均37.4岁。致伤原因:道路交通伤17例(56.3%),坠落/跌倒10例(28.1%),压砸/掩埋伤3例,其他2例。分析其救治方法及治疗结果。结果 32例均为多发伤。入院后按"CRASH PLAN"原则,快速做出伤情评估,同时建立静脉通道及抽血做凝血功能、配血等检测,按照损害控制复苏(DCR)原则进行复苏。术前有凝血功能障碍19例。大量输血按新鲜冰冻血浆、悬浮红细胞各6~10U和10U冷沉淀配送22例。肝脏损伤Ⅳ级20例、Ⅴ级12例。手术包括清创性肝切除22例,改良肝周填塞13例;手术时间30~90min。本组共存活24例,死亡8例(25%),因肝脏损伤及其并发症死亡6例(18.8%,6/32)。结论Ⅳ、Ⅴ级肝脏损伤容易并发创伤性凝血病;DCR是严重肝脏损伤并发凝血病的救治策略;"改良肝周填塞法"和清创性肝切除是抢救严重肝脏损伤并发凝血病时的主要损害控制性手术措施。

Analysis of the diagnosis and treatment of severe liver trauma associated with trauma-induced coagulopathy in 32 cases

Objective To summarize treatment methods for severe liver trauma associated with trauma-in-duced coagulopathy .Methods The clinical data of 32 sustained severe liver trauma patients associated with trau-ma-induced coagulopathy were collected from Feb .2010 to Apr.2016 in Chongqing Emergency Medical Center . There were 23 males and 9 females with an average age of 37.4(15-84) years.Seventeen cases (56.3%) were in-jured from road traffic accidents ,10 were from high falling/falling,3 were from crushing and 2 were from other causes . The methods of damage control resuscitation and treatment results were analyzed retrospectively .Results All the 32 cases had multiple injuries .The rapid assessment of the severity of injury was done in admission according to the principle of"CRASH PLAN",while the establishment of venous access and coagulation function ,cross matching and other tests were performed ,and the cases were resuscitated according to the principle of damage control resuscitation (DCR).Preoperative coagulation dysfunction occurred in 19 cases.Massive blood transfusion was achieved in 22 cases by fresh frozen plasma(FFP),packed red blood cells(PRBC) in the ratio of 6-10u, respectively and 10u of cryoprecitation.Liver trauma was grade Ⅳ in 20 cases,and was grade Ⅴin 12 cases.Damage control surgery in-cluding debridement hepatectomy was performed in 22 cases and improved peri-hepatic packing was performed in 13 cases.The operative time was 30min-1.5h.In this group,24 cases were survived ,and the overall mortality rate was 25%(8/32).Six (18.8%,6/32)cases died of liver injury with or without complications .Besides associated inju-ries inside and outside the abdomen , exsanguination due to liver trauma and coagulopathy was the main cause of death.Conclusion Trauma-induced coagulopathy would easily develop in patients with liver trauma of grade Ⅳand gradeⅤ.DCR is the main protocol in treating such patients .Improved perihepatic packing and debridement hepatectomy are the main damage control measures in treating severe liver trauma associated with trauma -induced coagulopathy .