한국산학기술학회논문지 (Journal of the Korea Academia-Industrial cooperation Society)

  • 제20권3호
  • /
  • Pages.417-422
  • /
  • 2019
  • /
  • 1975-4701(pISSN)
  • /
  • 2288-4688(eISSN)
한국산학기술학회 (The Korea Academia-Industrial cooperation Society)
권호 표지
DOI QR코드

DOI QR Code

장 천공을 동반한 혈역학적으로 불안정한 골반골 골절에서 전산화 단층촬영 전 시행한 혈관색전술의 지혈효과: 증례보고

Emergency preoperative angioembolization without computed tomography to treat unstable pelvic fractures with bowel perforation

  • 박찬용 (원광대학교병원 외상외과) ;
  • 강우성 (원광대학교병원 외상외과)
  • Park, Chan-Yong (Department of Trauma Surgery, Wonkwnag University Hospital) ;
  • Kang, Wu-Seong (Department of Trauma Surgery, Wonkwnag University Hospital)
  • 투고 : 2018.11.28
  • 심사 : 2019.03.08
  • 발행 : 2019.03.31
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

혈역학적으로 불안정한 골반골 골절 환자의 사망율은 40-60%에 이를 정도로 매우 높다. 하지만 이러한 환자들을 어떻게 치료해야 하는지에 대해서는 아직 논란의 여지가 많다. 저자들은 혈역학적으로 불안정한 골반골 골절 환자에서 빠른 응급 혈관조영술을 통해 효과적으로 지혈을 시행한 증례를 보고하고자 한다. 78세 여자가 넘어져서 발생한 골반 통증을 주소로 응급실을 통해 내원하였다. 내원 후 시행한 단순골반촬영에서 골반골 골절이 관찰되었으며, 혈압은 60/40 mmHg였다. 혈역학적으로 불안정하여 전산화단층촬영을 시행하지 않고 곧바로 혈관조영술을 시행하였으며, 빠른 지혈을 위해 세부적인 출혈 혈관을 선택하지 않고 양측 내장골동맥에 대해 색전술을 시행하였다. 색전술 시행 후 혈압이 안정화되고 나서 전산화단층촬영을 시행하였으며, 이 검사에서 장천공을 의심할 수 있는 다수의 복강내 공기 음영이 관찰되었다. 응급 개복술을 시행하였으며, 수술 소견상 소장에 약 1 cm 크기의 천공이 관찰되어 봉합을 시행하였고, 골반 주변 후복막강에 혈종이 있었으나 더 이상 팽창하지 않고 출혈 소견이 보이지 않아 그대로 두고 수술을 종료하였다. 환자는 중환자실로 입원하여 집중치료 시행하였고, 수술 3일째 일반병실로 전실하였다. 저자들은 이 증례에서 출혈을 동반한 골반골 골절과 소장천공 대해 전산화 단층촬영을 생략하고 빠른 혈관 조영술을 시행하여 효과적으로 치료할 수 있었다.

Hemodynamically unstable pelvic fractures show a remarkably high mortality rate of 40% to 60%. However, their standard of care remains controversial. We report here a case of a 78-year-old woman who was admitted to the Emergency Department with pelvic pain following a fall. Based on pelvic radiography, she was diagnosed with an unstable pelvic fracture. Her blood pressure was 60/40 mmHg, and owing to her unstable vital signs, emergency angiography was performed without computed tomography (CT). Both internal iliac arteries were embolized without sub-branch selection for prompt control of pelvic bleeding. Following embolization, her vital signs were stabilized. Subsequent CT revealed free intra-abdominal air, suggesting bowel perforation had occurred and necessitating emergency laparotomy. An approximately 1 cm-sized free perforation of the small intestine was identified intraoperatively, and primary closure was performed. A retroperitoneal hematoma identified intraoperatively was not explored further because it was a non-expanding and non-pulsatile mass. The patient was admitted to the Intensive Care Unit and transferred to the general ward on postoperative day 3. In this case, the hemodynamically stable pelvic fracture with bowel perforation was successfully and safely treated by prompt angioembolization without conducting CT.

키워드

SHGSCZ_2019_v20n3_417_f0001.png 이미지

Fig. 2. CT scan was performed after angiography. (A) Free air was shown (red arrows). (B) No additional bleeding was shown in pelvic area.

SHGSCZ_2019_v20n3_417_f0002.png 이미지

Fig. 3. Jejunal perforation was observed during emergency laparotomy. The black arrow indicates perforation site.

SHGSCZ_2019_v20n3_417_f0003.png 이미지

Fig. 1. (A) Pelvic fracture was shown in simple pelvic radiography (red arrow). (B) Internal iliac artery embolization (red arrow) was done and computed tomography (CT) scan was omitted.

참고문헌

  1. Tran TL, Brasel KJ, Karmy-Jones R, Rowell S, Schreiber MA, Shatz DV, Albrecht RM, Cohen MJ, DeMoya MA, Biffl WL, Moore EE, Namias N, "Western Trauma Association Critical Decisions in Trauma: Management of pelvic fracture with hemodynamic instability-2016 updates", J Trauma Acute Care Surg, Vol. 81, No. 6, pp. 1171-1174, 2016. DOI: https://doi.org/10.1097/ta.0000000000001230
  2. Stahel PF, Burlew CC, Moore EE, "Current trends in the management of hemodynamically unstable pelvic ring injuries", Curr Opin Crit Care, Vol. 23, No. 6, pp. 511-519, 2017. DOI: https://doi.org/10.1097/mcc.0000000000000454
  3. DuBose J, Inaba K, Barmparas G, Teixeira PG, Schnuriger B, Talving P, Salim A, Demetriades D, "Bilateral internal iliac artery ligation as a damage control approach in massive retroperitoneal bleeding after pelvic fracture", J Trauma, Vol. 69, No. 6, pp. 1507-1514, 2010. DOI: https://doi.org/10.1097/TA.0b013e3181d74c2f
  4. Burlew CC, Moore EE, Stahel PF, Geddes AE, Wagenaar AE, Pieracci FM, Fox CJ, Campion EM, Johnson JL, Mauffrey C, "Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures", J Trauma Acute Care Surg, Vol. 82, No. 2, pp. 233-242, 2017. DOI: https://doi.org/10.1097/ta.0000000000001324
  5. Jang JY, Shim H, Jung PY, Kim S, Bae KS, "Preperitoneal pelvic packing in patients with hemodynamic instability due to severe pelvic fracture: early experience in a Korean trauma center", Scand J Trauma Resusc Emerg Med, Vol. 24, No. pp. 3, 2016. DOI: https://doi.org/10.1186/s13049-016-0196-5
  6. Lee MA, Yu B, Lee J, Park JJ, Lee GJ, Choi KK, Park Y, Gwak J, Han A, "Effects of the establishment of a trauma center and a new protocol on patients with hemodynamically unstable pelvic fractures at a single institution in Korea", Eur J Trauma Emerg Surg, Vol. No. pp. 2018. DOI: https://doi.org/10.1007/s00068-017-0899-y
  7. White CE, Hsu JR, Holcomb JB, "Haemodynamically unstable pelvic fractures", Injury, Vol. 40, No. 10, pp. 1023-1030, 2009. DOI: https://doi.org/10.1016/j.injury.2008.11.023
  8. Stannard A, Eliason JL, Rasmussen TE, "Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock", J Trauma, Vol. 71, No. 6, pp. 1869-1872, 2011. DOI: https://doi.org/10.1097/TA.0b013e31823fe90c
  9. Smith WR, Moore EE, Osborn P, Agudelo JF, Morgan SJ, Parekh AA, Cothren C, "Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique", J Trauma, Vol. 59, No. 6, pp. 1510-1514, 2005. https://doi.org/10.1097/01.ta.0000197330.81352.94
  10. Muntasar AE, Toner E, Alkhazaaleh OA, Arumugam D, Shah N, Hajibandeh S, Hajibandeh S, "Effect of angioembolisation versus surgical packing on mortality in traumatic pelvic haemorrhage: A systematic review and meta-analysis", World J Emerg Med, Vol. 9, No. 2, pp. 85-92, 2018. DOI: https://doi.org/10.5847/wjem.j.1920-8642.2018.02.001
  11. Matsumoto J, Lohman BD, Morimoto K, Ichinose Y, Hattori T, Taira Y, "Damage control interventional radiology (DCIR) in prompt and rapid endovascular strategies in trauma occasions (PRESTO): A new paradigm", Diagn Interv Imaging, Vol. 96, No. 7-8, pp. 687-691, 2015. DOI: https://doi.org/10.1016/j.diii.2015.06.001
  12. Matsushima K, Piccinini A, Schellenberg M, Cheng V, Heindel P, Strumwasser A, Benjamin E, Inaba K, Demetriades D, "Effect of door-to-angioembolization time on mortality in pelvic fracture: Every hour of delay counts", J Trauma Acute Care Surg, Vol. 84, No. 5, pp. 685-692, 2018. DOI: https://doi.org/10.1097/ta.0000000000001803
  13. Weber DG, Bendinelli C, Balogh ZJ, "Damage control surgery for abdominal emergencies", Br J Surg, Vol. 101, No. 1, pp. e109-118, 2014. DOI: https://doi.org/10.1002/bjs.9360
  14. Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF, "Damage control: collective review", Journal of Trauma and Acute Care Surgery, Vol. 49, No. 5, pp. 969-978, 2000. https://doi.org/10.1097/00005373-200011000-00033