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J Am Acad Orthop Surg. 2009 Jul;17(7):447-57.
Management of Hemorrhage in Life-threatening Pelvic Fracture
危及生命的骨盆骨折中的出血处理
David J. Hak, MD, MBA, Wade R. Smith, MD , Takashi Suzuki, MD
Dr. Hak is Associate Professor, Department of Orthopaedic Surgery, Denver Health/University of Colorado, Denver, CO.
Dr. Smith is Professor, Department of Orthopaedic Surgery, Denver Health/University of Colorado.
Dr. Suzuki is AO Research Fellow, Denver Health/University of Colorado, and Assistant Professor, Orthopaedic Trauma, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan.
Abstract
摘要
Emergent life-saving treatment is required for high-energy pelvic fracture with associated hemorrhage and hemodynamic instability. Advances in prehospital, interventional, surgical, and critical care have led to increased survival rates. Pelvic binders have largely replaced military antishock trousers. The availability and precision of interventional angiography have expanded considerably. External pelvic ?xation can be rapidly applied, often reduces the pelvic volume, and provides temporary fracture stabilization. Pelvic packing, popularized in Europe, is now used in certain centers in North America. The use of standardized treatment algorithms may improve decision making and patient survival rates. Active involvement of an experienced orthopaedic surgeon in the evaluation and care of these critically injured patients is essential.
伴出血和血流动力学不稳定的高能量骨盆骨折患者需要紧急的挽救生命的治疗。入院前、介入性操作中（影像学检查、治疗等）、术中和急救护理中采取挽救生命的治疗能增加该类患者的存活率。骨盆束带已广泛取代了军用抗休克裤。介入性血管造影术的有效性和准确性已得到恨大的提高。迅速应用骨盆外固定器械能减小骨盆体积，并且能起到临时固定骨盆的作用。现在，在北美的一些医疗中心也采用了欧洲流行的骨盆包裹术。应用标准的治疗程序可能有助于作出医疗决策，并提高患者生存率。在评估和转交这类严重损伤患者时需要一位有经验的骨科医生的积极参与。
High-energy pelvic fractures are life-threatening injuries. Extensive bleeding associated with pelvic fractures is relatively common but is especially prevalent with high-energy fractures. Approximately 15% to 30% of patients with high-energy pelvic injuries are hemodynamically unstable, which may be directly related to blood loss from the pelvic injury. 1,2 Hemorrhage remains the leading cause of death in patients with pelvic fractures, with an overall mortality rate between 6% and 35% in large series of high-energy pelvic fractures. 1,3-6 Bleeding associated with pelvic fractures requires efficient evaluation and rapid intervention. Evaluation and treatment of patients with pelvic fractures necessitates a multidisciplinary approach. Although the general surgery trauma specialist ultimately directs the treatment of the multiply injured person, it is important for the patient with pelvic fracture that the orthopaedic surgeon be involved in every phase of treatment, including primary resuscitation. 7 Early assessment by an orthopaedic surgeon familiar with pelvic fracture patterns allows the treatment team to establish diagnostic and treatment priorities, and it expedites the institution of life-saving maneuvers. A thorough understanding of potential sources of bleeding and an awareness of treatment options are essential for all physicians involved.
高能量骨盆骨折是危及生命的损伤。尽管骨盆骨折伴大出血比较常见，但是，在高能量骨折中，尤其明显。可直接因骨盆骨折的失血量，近15%- 30%高能量骨盆损伤患者存在血流动力学不稳定1,2。大出血仍然是骨盆骨折患者死亡的主要原因，在大规模的高能量骨盆骨折系列研究中，总的死亡率在6%-35%之间1,3-6。与骨盆骨折相关的出血需有效评估和紧急处理。骨盆骨折患者的评估和治疗需要多学科途径。尽管基本上普外科创伤专家负责治疗这类多重损伤的患者，但是，在包括最初复苏的治疗的各个阶段，骨科医生的参与对骨盆骨折患者非常重要7。经熟悉骨盆骨折类型的骨科医生的早期评估，能让治疗团队采取诊断学和治疗学的优先措施，并加快该机构抢救生命的程序。所有参与的内科医生必须完全了解患者可能的出血来源，并清楚该如何治疗。
1. Anatomy
解剖
The pelvis is a ring-like structure made up of three bones: the sacrum and two innominate bones, each comprising the ilium, ischium, and pubis. The innominate bones join the sacrum posteriorly at the two sacroiliac joints; anteriorly, these bones are joined at the pubic symphysis. The symphysis acts as a strut during weight bearing to maintain the structure of the pelvic ring. 8
骨盆是骶骨和两块由髂骨、坐骨和耻骨组成的髋骨构成的环状骨性结构。两块髋骨在后面与骶骨相连于骶髂关节，在前面，则通过耻骨联合相连。在承重过程中，耻骨联合担当一个支柱的作用来维持骨盆环状结构8。
The three bones and three joints constituting the pelvic ring are stabilized by ligamentous structures, the strongest and most important of which are the posterior sacroiliac ligaments. These ligaments are made up of short oblique fibers that run from the posterior ridge of the sacrum to the posterosuperior and posteroinferior iliac spines as well as longer longitudinal fibers that run from the lateral sacrum to the posterosuperior iliac spine and merge with the sacrotuberous ligament. The anterior sacroiliac ligament is far less robust than the posterior sacroiliac ligament. The sacrotuberous ligament is a strong band that runs from the posterolateral sacrum and dorsal aspect of the posterior iliac spine to the ischial tuberosity. This ligament, along with the posterior sacroiliac ligaments, provides vertical stability to the pelvis. The sacrospinous ligament runs from the lateral edge of the sacrum and coccyx to the sacrotuberous ligament and inserts onto the ischial spine. The iliolumbar ligaments run from the fourth and fifth lumbar transverse processes to the posterior iliac crest; the lumbosacral ligaments run from the fifth lumbar transverse process to the sacral ala (Figure 1).
组成骨盆环的三块骨头与三个关节通过韧带结构获得稳定，其中，最强壮最重要的韧带要属骶髂后韧带，它们由从骶骨后脊至髂后上棘和髂后下棘由短斜形纤维构成的韧带连同从骶骨外侧面至髂后上棘由较长纵行纤维组成的韧带与骶结节韧带融合组成。骶髂前韧带远没有骶髂后韧带强壮。骶结节韧带是一条强健的纤维束，起自于骶骨后外侧和髂嵴背侧后部，止于坐骨结节，连同骶髂后韧带为骨盆提供垂直面的稳定。骶棘韧带起自骶骨和尾骨的外侧缘，跨过骶结节韧带止于坐骨棘。髂腰韧带起自第4、5腰椎横突，止于髂嵴后部，腰骶韧带起自第5腰椎横突止于骶骨翼（图1）。
 
Posterior (A) and anterior ( view of the pelvic ligaments. (Reproduced with permission from Tile M, Helfet DL, Kellam JF, eds: Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 13, 15.)
图1.骨盆韧带的后面观 (A) 及前面观 (。（经允许节选自Tile M, Helfet DL, Kellam JF, eds: Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 13, 15.）
Major blood vessels lie on the inner wall of the pelvis. The common iliac artery divides, giving off the external iliac artery, which exits the pelvis anteriorly over the pelvic brim. The internal iliac artery lies over the pelvic brim. It courses anterior and in close proximity to the sacroiliac joint. The posterior branches of the internal iliac artery include the iliolumbar, superior gluteal, and lateral sacral arteries. The superior gluteal artery sweeps around to exit the greater sciatic notch, where it lies directly on bone. Anterior branches of the internal iliac artery include the obturator, umbilical, vesical, pudendal, inferior gluteal, rectal, and hemorrhoidal arteries. The pudendal and obturator arteries are anatomically related to the pubic rami and can be injured with fractures or injuries to these structures. These arteries and their associated veins can all be injured during pelvic disruption (Figure 2). An understanding of pelvic anatomy will help the orthopaedic surgeon recognize which fracture patterns are more likely to cause direct damage to major vessels and result in significant retroperitoneal bleeding.
主要的血管位于骨盆内侧壁上，从髂总动脉的分出的髂外动脉于骨盆上缘的前面出骨盆，髂内动脉跨过骨盆边缘骨盆进入盆腔，紧贴骶髂关节前面走行。髂内动脉的后干包括：髂腰动脉、臀上动脉和骶外侧动脉。臀上动脉于坐骨大切迹紧贴骨面出骨盆。髂内动脉的前干包括：闭孔动脉、脐动脉、膀胱动脉、阴部动脉、臀下动脉、直肠动脉和肛周动脉。由于阴部动脉和闭孔动脉与耻骨支的解剖关系，常因耻骨支的骨折或损伤而损伤。这些动脉及其伴行的静脉在骨盆损伤时可能被累及（图2）。对骨盆解剖知识的掌握，有助于骨科医生认识到哪种骨折类型更有可能直接损伤大血管，进而导致严重的腹膜后大出血。
Internal aspect of the pelvis showing the major blood vessels that lie on the inner wall of the pelvis. (Copyright ? Jesse B. Jupiter, MD, and Bruce D. Browner, MD.)
图2. 骨盆内面观显示位于骨盆内壁的主要血管（版权所有归Jesse B. Jupiter, MD, and Bruce D. Browner, MD.）
2. Patient Evaluation
患者评估
Complete evaluation of the patient with a high-energy pelvic fracture is essential because this is rarely an isolated injury.9,10 The same forces that lead to disruption of the pelvic ring are frequently associated with abdominal, head, and thoracic injury.1,11 In addition to these injuries, 60% to 80% of patients with a highenergy pelvic fracture have other associated musculoskeletal injuries, 12% have urogenital injuries, and 8% have lumbosacral plexus injuries. 3,12
必须对高能量骨盆骨折患者进行全面评估，因为很少有单纯的骨折9,10。能导致骨盆环破裂的暴力同样也能导致腹部、头部和胸部的损伤1,11。除了这些损伤，60%- 80%的高能量骨盆骨折患者有其他肌肉骨骼的并发伤、12%的患者合并泌尿生殖系统损伤及8%的患者合并腰骶丛损伤3,12。
A plan for simultaneous assessment and treatment of a patient with a high-energy pelvic fracture is required. An interdisciplinary team, including a general surgeon, an orthopaedic surgeon, a representative from the blood bank, and an interventional radiologist, is equipped to promptly assess and manage the spectrum of injuries associated with pelvic fractures. Priority should be given to the evaluation and treatment of airway, breathing, and circulatory problems. Evaluation and management of hypovolemic shock is mandatory as the airway and breathing are being stabilized.
在给高能量骨盆骨折患者进行评估的同时还需进行治疗。应组建一个包括普外科医生、骨科医生、输血科专家和介入影像学专家的多学科团队以迅速评估并治疗与骨盆骨折相关的损伤征兆。首先应评估并治疗气道、呼吸和循环问题。当气道和呼吸建立后必须评估并治疗低血容量休克。
Hypotension is associated with an increased risk of mortality, adult respiratory distress syndrome, and multiple organ failure. 1 Hypotension associated with blunt trauma may result from a variety of insults, including hypovolemic, septic, cardiac, or neurologic compromise. A rapid and systematic search for the source of the hypotension must be undertaken. Hemorrhagic shock is the most common cause of hypotension in blunt trauma patients. A patient can be hypotensive from blood loss associated with one bleeding site or a combination of many bleeding sites. Physical examination, chest radiographs, and tube thoracostomy will detect the presence and severity of intrathoracic blood loss. Physical examination of the abdomen may be unremarkable in the unresponsive patient. However, the intraabdominal space must be excluded as a possible bleeding source in the patient who is hemodynamically unstable. Emergent evaluation is most commonly made by a focused abdominal sonography for trauma examination.
低血压与死亡率、成人呼吸窘迫综合征和多器官衰竭增加的风险有关1。与钝性创伤相关的低血压可能来自各种各样的损害，包括血容量减少、败血症、心血管疾病或神经学疾病。必须快速、系统的寻找低血压的原因。钝性创伤患者低血压最常见的原因是出血性休克。患者可因一个或多个部位的的出血导致低血压。体格检查、胸部影像学检查和管状胸廓造口术可探查胸廓内是否存在出血，并明确失血量。腹部体格检查在反应迟钝患者身上可能不明显，但是，血流动力学不稳定患者必须排除腹腔内可能的出血来源。创伤检查紧急评估最常用的是腹部超声。
Bleeding from the pelvic fracture site is seldom the only cause of blood loss in the patient with multiple injuries, and massive bleeding from a pelvic fracture alone is uncommon. In one large series of patients with pelvic fractures, the major bleeding occurred at nonpelvic sites.10 Nevertheless, pelvic fracture must be considered among the most prominent sites of significant bleeding in a hemodynamically unstable patient, particularly when initial attempts to control bleeding from other sources fail to stabilize the patient. 13 In cases of suspected pelvic fracture bleeding, provisional pelvic stabilization should occur immediately during initial evaluation and resuscitation. Provisional stabilization may consist of a pelvic binder or a simple sheet wrapped securely around the pelvis and secured with a sturdy clamp.
骨盆骨折部位的出血很少是多发性损伤患者失血的唯一原因，并且单纯骨盆骨折也很少引起大出血。在一个骨盆骨折大样本系列研究中，主要的出血并不是骨盆部位10。但是，血流动力学不稳定患者的大量失血必须考虑到骨盆骨折这一显著的部位，尤其是在早期控制了其他部位出血后仍然没有控制住失血的患者13。如果怀疑骨盆骨折，在早期评估及复苏时，应立即临时固定骨盆。临时固定可包括骨盆束带或简单用布单包裹住骨盆并用可靠的夹子夹住。
The severity of blood loss can be determined on initial evaluation by assessing pulse, blood pressure, and capillary refill. The Advanced Trauma Life Support classification system of the American College of Surgeons is useful for understanding the manifestations associated with hemorrhagic shock in adults 14 (Table 1). Blood volume is estimated at 7% of ideal body weight, or approximately 4,900 mL in a patient weighing 70 kg (155 lb).
通过评价脉搏、血压和毛细血管充盈度可初步评估失血量的严重度。美国外科医生学会的高级创伤生命支持分类系统对理解成人出血性休克相关的临床表现非常有用（表1）。一个体重为70 kg (155 lb)的患者理想的血容量约占体重的7%，即4,900 mL。
 
Class I hemorrhage, defined as blood loss of <15% of total blood volume, leads to no measurable changes in heart or respiratory rates, blood pressure, or pulse pressure and requires little or no treatment. Class II hemorrhage is defined as blood loss of 15% to 30% of blood volume (750 to 1,500 mL), with clinical signs including tachycardia and tachypnea. Systolic blood pressure may be only slightly decreased, especially when the patient is in the supine position, but the pulse pressure is narrowed. Urine output is only slightly reduced (ie, to 20 to 30 mL/hr). The patient with a class II hemorrhage can usually be resuscitated with a crystalloid solution alone, but some patients may require blood transfusion.
出血等级I的定义：失血量<总血容量的15% 。心率、呼吸频率、血压和脉搏均无可测量的改变，很少需要治疗或无需治疗。出血等级II的定义：失血量占总血容量的15%- 30% (750 -1,500 mL)。临床体征包括心动过速和呼吸急促，收缩压可能仅有轻微的降低，尤其是仰卧位患者，脉压变小，尿排出量轻微减少(20 - 30 mL/hr)。出血等级为II的患者通常仅补充晶体溶液，但是，有些患者也可能需要输血。
Class III hemorrhage is defined as loss of 30% to 40% (1,500-2,000 mL) of blood volume. Inadequate perfusion in patients with class III hemorrhage results in marked tachycardia and tachypnea, cool extremities with significantly delayed capillary refill, hypotension, and significant negative changes in mental status. Class III hemorrhage represents the smallest volume of blood loss that consistently produces a decrease in systemic blood pressure. The resuscitation of these patients frequently requires blood transfusion in addition to administration of crystalloid solutions. Finally, class IV hemorrhage is defined as blood loss >40% of blood volume (>2,000 mL), representing life-threatening hemorrhage. Signs include marked tachycardia, significantly depressed systolic blood pressure, and narrowed pulse pressure or unobtainable diastolic blood pressure. The skin is cold and pale, and the mental status is severely depressed. Urine output is negligible. These patients require immediate transfusion for resuscitation and frequently need immediate surgical intervention.
出血等级III的定义：失血量占总血容量的30%- 40% (1,500-2,000 mL)。出血等级为III灌注不足的患者导致显著的心动过速和呼吸急促，四肢发凉且毛细血管充盈度显著减少，低血压，患者精神状态明显变差。出血等级为III代表着收缩压持续下降时最少的失血量，复苏这类患者除了补充晶体溶液外，通常需要输血。最后，出血等级IV的定义：失血量>总血容量的40% ((>2,000 mL)。代表危及生命的出血。体征包括显著的心动过速，收缩压显著降低、脉压变小或舒张压不可触及。皮肤冰凉且苍白，患者精神状态极差。尿排出量极少或无尿。患者需立即输血以复苏，并且通常需要立即手术治疗。
The practice of grasping the iliac crests in search of palpable instability lacks sensitivity and specificity and rarely provides information that cannot be obtained on a single anteroposterior pelvic radiograph. Gross posterior disruption of the pelvis is usually evident on this view when the pelvis is fractured. Inlet and outlet views of the pelvis, which can provide more information about the presence and location of posterior ring injuries, should be obtained only after the patient has achieved hemodynamic stability. CT is extremely valuable for defining posterior ring instability. A rapid CT protocol for abdominal trauma evaluation can include cut scans through the sacrum and sacroiliac joints. The information from this study often helps direct early management because it may aid in defining the magnitude of the posterior ring injury. However, prolonged CT scanning in the acutely hypotensive patient should be avoided. Additional thin-cut CT scans may be indicated to further evaluate pelvic or acetabular fractures, but only after the patient is stabilized.
通过查看髂嵴以发现能被感知的不稳定性缺乏敏感性和特异性，单一的X线前后位片很难提供能够得到骨盆不稳定的信息。骨盆骨折时明显的骨盆后部破裂在骨盆前后位片非常明显。骨盆入口和出口位片只能在患者血流动力学获得稳定之后才可以进行，它可提供骨盆后环是否存在骨折及骨折的部位等更多的信息。CT在骨盆后环不稳定的诊断方面非常有价值。评价腹部创伤的快速CT方案包括穿过骶骨和骶髂关节的断层扫描。通过这种CT扫描得到的信息因为可能有助于确定骨盆后环损伤的程度可直接应用到早期治疗中。但是，应避免给急性低血压患者做延长的CT扫描。额外的超薄CT扫描可应用于进一步评估骨盆或髋臼患者，但是仅在患者稳定后才可以应用。
Contrast-enhanced CT imaging of the pelvis, which is often done in the hemodynamically stable trauma patient, is a noninvasive technique that has proved to be reasonably accurate in determining the presence or absence of ongoing pelvic hemorrhage. In a study comparing this methodology with findings on pelvic angiography, CT detected bleeding in 16 of 19 patients who had extravasation or vascular injury demonstrated by angiography, for a sensitivity of 84%. 15 Results of pelvic angiography were negative in 11 patients, and no patient had evidence of bleeding on preangiographic CT scans. Two sites of contrast-agent extravasation identified by CT imaging in two patients did not show bleeding at angiography, for a specificity of 85% for the detection of bleeding. The overall accuracy of CT for determining the presence or absence of bleeding in this study was 90%. 15
骨盆对照加强的CT图像一般用于血流动力学稳定的患者，该检查是一项无创技术，在确定是否存在持续的盆腔出血具有相当的准确性，有一项研究，在19位中的16位用血管造影术检查出有出血或血管损伤患者中，比较该方法与骨盆血管造影术及CT在探明他们出血情况的差异，该方法的敏感性为84%15。骨盆血管造影术的结果中有11为患者显示无出血，并且没有患者在血管造影术之前的CT扫描中有出血的证据。该研究CT监测是否存在出血的总的准确性为90%15。
3. Classi?cation Systems and Prognostic Value
分类系统及预后价值
Several classification systems have been devised to describe pelvic injuries based on the nature and stability of the pelvic disruption or on the magnitude and direction of forces delivered to the pelvis. 8,16-18 Each classification has been developed to provide guidance to general and orthopaedic surgeons about the type and likelihood of difficult management problems that might be encountered with each fracture type. Of these pelvic fracture classification systems, the one described by Young and Burgess 16 is most closely correlated with resuscitation needs and patterns of associated injuries. This system is based on a standard series of pelvic views, including an anteroposterior pelvis view and an inlet and outlet view, as described by Pennal et al. 17
根据骨折的特征和骨盆破坏的稳定性或者根据传到在骨盆的暴力的大小及方向，已有数种分类系统来描述骨盆损伤8,16-18。关于每种骨折类型中可能碰到的治疗难题的形式及可能性，形成的每一种分类方法都为普外科医生和骨科医生提供了指导。在这些骨盆骨折分类系统中，Young 和Burgess描述的分类系统与相关损伤复苏需求和类型联系地最紧密，就像Pennal描述的一样17，该系统是根据含骨盆前后位、骨盆入口位和出口位等骨盆视图的标准系列制定而成。
The Young-Burgess classification divides pelvic disruptions into anteriorposterior compression (APC), lateral compression (LC), vertical shear (VS), and combined mechanism (CM) injuries (Figure 3). The APC and LC categories are further subdivided from type I to III based on the increasing severity of the injury produced by increasing force magnitude. APC injuries are caused by an anterior impact to the pelvis, often leading to pubic symphysis diastasis. They are “open book” injuries that disrupt the anterior sacroiliac ligaments as well as the ipsilateral sacrospinous and sacrotuberous ligaments. APC injuries are considered to be good radiographic markers for the branches of the internal iliac vessels, which are in close juxtaposition with the anterior sacroiliac joint.
Young-Burgess分类将骨盆破裂分成前后压缩(APC)、侧面压缩 (LC)、垂直剪切 (VS)和 复合机制(CM)损伤四类 (Figure 3)。根据因暴力的大小逐渐增大导致的不断增加的损伤严重度，前后压缩(APC)和侧面压缩 (LC)又分为type I 至 III的亚型。APC损伤是由于骨盆前方的碰撞，经常导致耻骨联合分离，由于破坏了骶髂前韧带及同侧的骶棘和骶结节韧带，这类损伤是“开卷式”损伤，APC损伤被认为是紧贴于骶髂关节前侧的髂内血管分支的良好影像学标记。
Figure 3. The Young-Burgess classi?cation of pelvic fracture. A, Anteroposterior compression type I. B, Anteroposterior compression type II. C, Anteroposterior compression type III. D, Lateral compression type I. E, Lateral compression type II. F, Lateral compression type III. G, Vertical shear. The arrow in each panel indicates the direction of force producing the fracture pattern. (Copyright ? Jesse B. Jupiter, MD, and Bruce D. Browner, MD.)
图3. 骨盆骨折Young-Burgess分类。A, 前后压缩I型， B, 前后压缩II型， C, 前后压缩III型； D, 侧面压缩 I型、E, 侧面压缩 II型、F, 侧面压缩 III型； G, 垂直剪切。The arrow in each 每个面板的箭头表示导致该骨折类型的暴力方向 (版权归属于 Jesse B. Jupiter, MD, and Bruce D. Browner, MD.)
LC injury results from a lateral impact to the pelvis that rotates the pelvis on the side of the impact toward the midline. The sacrotuberous and sacrospinous ligaments, as well as the internal iliac vessels, are shortened and are not subjected to tensile forces. Disruption of large named vessels (eg, internal iliac artery, superior gluteal artery) is relatively uncommon with LC injuries; when this does occur, it is thought to result from laceration from fracture fragments.
LC损伤是由于骨盆受到了侧面撞击使被撞击侧骨盆转向骨盆的中线。像髂内血管一样，骶结节和骶棘韧带将短缩，不用承受牵拉力。很少有大血管（例如：髂内动脉、臀上动脉）在LC损伤中破裂，如果有，一般认为是骨折块割破了血管所致。
VS injuries are distinguished by vertical translation of the hemipelvis. Displacement of the hemipelvis may be accompanied by severe local vascular injury. The CM injury pattern includes high-energy pelvic fractures produced by a combination of two separate force vectors.
VS损伤以一侧骨盆的垂直移位为特征，一侧骨盆的移位可能伴有严重的血管损伤。CM损伤类型包括由两种不同方向合并的暴力矢量造成的高能量骨盆骨折。
The Young-Burgess classification of pelvic fractures and presumed force vectors has also been shown to correlate well with the pattern of organ injury, resuscitation requirements, and mortality. 1 In particular, a rise in mortality has been shown as the APC grade increases. The pattern of injuries seen in the APC type III fracture has been correlated with the greatest 24-hour fluid requirements. 1 In a series of 210 consecutive patients with pelvic fractures, Burgess et al 2 found that transfusion requirements for patients with LC injuries averaged 3.6 units of packed red blood cells (PRBCs), compared with a mean of 14.8 units for patients with APC injuries. In the same series, patients with VS injuries averaged 9.2 units, and patients with CM injuries had an average transfusion requirement of 8.5 units. The overall mortality rate in this series was 8.6%. A higher mortality rate was seen in the APC (20%) and CM (18%) patterns than in the LC (7%) and VS (0%) patterns. Burgess et al 2 noted that exsanguination from pelvic injuries resulting from lateral compression was rare, and the authors attributed death in patients with LC injuries to other causes. The most common identifiable cause of death in patients in this series with LC fractures was closed head injury. In contrast, the identifiable cause of death in patients with APC injuries was combined pelvic and visceral injury. These findings indicate that the ability to recognize the pelvic fracture pattern and the direction of the corresponding injury force can help the resuscitation team anticipate requirements for fluids and blood transfusion as well as help to direct early assessment and treatment. The patient with complete posterior instability can be anticipated to present with a severe hemorrhage.
骨盆骨折和假定的暴力矢量的Young-Burgess分类凸显了骨盆损伤类型与复苏要求和死亡率之间的关联1。尤其是，随着APC(前后压缩)等级的增高，死亡率也增高。APC III型损伤的患者对应的的是最急需24小时液体补充1。在一项210例连续的骨盆骨折患者的系列病例研究中，Burgess等发现LC损伤患者的输血需求平均为3.6个单位的浓缩红细胞(PRBCs)，相比之下，APC损伤患者的输血需求平均为14.8个单位。在同一个系列病例研究中，VS损伤患者的输血需求平均为9.2个单位，而CM损伤患者的输血需求平均为8.5个单位.该系列病例研究的总死亡率8.6%，APC (20%)和CM (18%)损伤患者的死亡率较LC (7%) 和VS (0%)损伤患者高。Burgess等注意到LC型骨盆损伤很少导致出血，作者们将LC型损伤患者的死亡率归结到其他原因，最常见最明显的原因是闭合性头部损伤。相比之下，APC型损伤患者的死亡原因是骨盆和内脏的联合伤。该研究结果显示：辨清骨盆骨折的类型及相关损伤的暴力方向的能力有助于复苏团队提前判断出输液和输血的需要，同样有助于早期评估及早期治疗。骨盆后部完全不稳定的患者可预测伴有严重的出血。
4. Treatment Methods
治疗方法
4.1 Military Antishock Trousers
军用抗休克裤
Military antishock trousers (MAST) can provide temporary compression and immobilization of the pelvic ring and lower extremity via pneumatic pressure. In the 1970s and 1980s, the use of MAST was advocated to induce pelvic tamponade and increase venous return to aid resuscitation. 19 However, MAST use limits abdominal examination and may cause lower extremity compartment syndrome or aggravate an existing one. Although still useful for stabilization of patients with pelvic fractures, MAST has largely been replaced by the use of commercially available pelvic binders.
军用抗休克裤(MAST)通过气压能临时压迫并固定骨盆环和下肢。在上世界七八十年代，提倡使用MAST能压迫骨盆并促进静脉回流利于复苏19，但是，MAST的使用限制了腹部检查，并可能引起下肢的筋膜室综合症或加重已用的筋膜室综合症。尽管MAST在骨盆患者患者的固定方面非常有用，但是，它已经被市场上就能买到的骨盆束带广泛的取代。
4.2 Pelvic Binders and Sheets
骨盆束带和骨盆带
Circumferential compression can be readily achieved in the prehospital setting and provides early, beneficial stabilization during transport and resuscitation. A folded sheet wrapped circumferentially around the pelvis is cost effective, noninvasive, and easy to apply. 20 Various commercial pelvic binders have been devised. A tension of about 180 N has been shown to provide maximum effectiveness. 21 One study reported that pelvic binders reduced transfusion requirements, length of hospital stay, and mortality in patients with APC injuries 22 (Figure 4).
在患者送至医院前，（应用骨盆束带）很容易就能环形压迫骨盆，并在运送和复苏患者的期间，能尽早地提供良好的固定。将折叠的床单包裹住骨盆，系紧是一种经济、无创简单的操作20。市场上可见许多已设计出的骨盆束带。研究显示180 N的紧缩力能提供最大的固定效果21，一项研究报道骨盆束带能减少输血需求、住院天数和APC型损伤患者的死亡率22。（图4）
Figure 4. Illustration demonstrating proper application of a pelvic circumferential compression device (pelvic binder), with an adjustable buckle (arrow) to control tension. (Adapted with permission from Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M: Emergent stabilization of pelvic ring injuries by controlled cicumferential compression: A clinical trial. J Trauma 2005;59:659-664.)
图4. 正确使用骨盆环形压迫装置（骨盆束带）的示意图，束带上有一个可控制松紧度的可调节扣（箭头）。(经许可节选自 Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M: Emergent stabilization of pelvic ring injuries by controlled cicumferential compression: A clinical trial. J Trauma 2005;59:659-664.)
External rotation of the lower extremities is commonly seen in persons with displaced pelvic fractures, and forces acting through the hip joint may contribute to pelvic deformity. Correction of lower extremity external rotation can be achieved by taping the knees or feet together, and this may improve the pelvic reduction that can be achieved with circumferential compression.
骨盆移位骨折患者经常可以看到下肢呈外旋位。可能是外旋力作用于髋关节所致畸形。通过将患者的膝关节或足绑在一起就能纠正下肢的外旋，这样有助于用骨盆束带使骨盆复位。
4.3 External Fixation
外固定
4.3.1 Standard Anterior External Fixation
标准前外固定
Multiple studies have reported a benefit of emergent pelvic external fixation in the resuscitation of the hemodynamically unstable patient with an unstable pelvic fracture. 2,5,23 The beneficial effects of external fixation in pelvic fractures may arise from several factors. Immobilization may limit pelvic displacement during patient movements and transfers, decreasing the possibility of clot disruption. In certain patterns (eg, APC II), reduction of pelvic volume may be achieved by application of the external fixator. Experimental studies have shown that reduction of open book pelvic injury leads to increases in retroperitoneal pressures, which may aid in tamponade of venous bleeding. 24 Apposition of the displaced fracture can facilitate the hemostatic pathway to control bleeding from any raw bony surfaces.
许多研究报道了给伴血流动力学不稳定的骨盆不稳定骨折患者进行紧急的骨盆外固定有助于患者的复苏2,5,23。骨盆骨折外固定有益的效果可能来自多方面因素。固定可能减少骨盆在患者移动和运送过程中的移位、减少凝血块破裂的可能性。在一些骨折类型（如APC II），通过应用外固定器械可能会减小盆腔的体积。实验研究显示减少开卷式骨盆损伤会增加腹膜后压力，可能会有助于压迫静脉出血24。复位移位的骨折能使折断的骨面止血更容易，进而控制出血。
4.3.2 C-Clamp
C形夹
Standard external pelvic fixation does not provide adequate posterior pelvic stabilization. This limits its effectiveness in fracture patterns that involve significant posterior disruption or in cases in which the iliac wing is fractured. A posteriorly applied C-clamp has been developed to address these inadequacies. The clamp allows prompt application of a compressive force posterior across the sacroiliac joints. Extreme care must be exercised to avoid iatrogenic injury during its application; the procedure generally should be performed under fluoroscopic guidance. 25 Applying the C-clamp to the trochanteric region of the femur offers an alternative to standard anterior external fixation for provisional fixation of APC injuries. 26
标准的骨盆外固定器械没有为骨盆后部提供足够的稳定。这就限制其在固定涉及骨盆后部严重破裂或髂骨翼骨折的患者时的功效。针对这种不足，形成了一种实用的后部C形夹。该C形夹跨过骶髂关节后面能迅速提供压缩力。在使用过程中要格外小心避免医源性损伤，通常在透视的监控下进行25。将C形夹应用在股骨转子区域为临时固定APC损伤提供了一个很好的前侧外固定选择。
4.4 Angiography
血管造影术
Angiographic exploration should be considered in patients with continued unexplained blood loss despite pelvic fracture stabilization and aggressive fluid infusion. The overall prevalence of patients with pelvic fractures who require embolization is reported to be <10%. 2,27-31 In one recent series, angiography was performed in 10% of patients who sustained a pelvic fracture. 32 Patients who were older and who had a higher Revised Trauma Score were most likely to undergo angiography. In another study, 8% of the 162 patients reviewed by the authors required angiography. 2 Embolization was needed in 20% of APC injuries, VS injuries, and complex pelvic fracture patterns, but in only 1.7% of LC injuries. Eastridge et al 31 reported that 27 of 46 patients with persistent hypotension and a severely unstable pelvic fracture, including APC II, APC III, LC II, LC III, and VS injuries, had active arterial bleeding (58.7%). Miller et al 30 found that 19 of 28 patients with persistent hemodynamic instability attributable to pelvic fracture showed arterial bleeding (67.9%). In other studies, when angiography was performed, it was successful in stopping pelvic arterial bleeding in 86% to 100% of the cases. 5,29,31 Ben-Menachem et al 33 advocate “preemptive embolization,” stressing that if an artery is found at angiography to be transected, it should be embolized to avoid the risk of delayed hemorrhage that can occur with clot lysis. Other authors describe nonselective embolization of bilateral internal iliac arteries to control multiple bleeding sites and concealed arterial injuries caused by vasospasm. 13
尽管患者骨盆已经固定，也有充足的补液，但是还是存在不明原因的出血，这时候得考虑应用血管造影术探查出血原因。报道的骨盆骨折患者需栓塞止血的总概率<10%2,27-31。在一个病例系列研究中，10%的骨盆患者患者进行了血管造影术32，年龄较高和修正创伤评分更高的患者进行血管造影术的几率更大。在另一个研究中，回顾的162例病例中有8%的患者需要进行血管造影术2。APC损伤、VS损伤和复杂骨盆骨折类型的患者中，20%需要血管栓塞术，LC损伤类型则仅为1.7%。Eastridge等报道了在46例持续低血压和包括APC II、 APC III、LC II、LC III和VS损伤类型的严重不稳定性骨盆骨折的患者中， 有27例(58.7%)出现了急性动脉性出血。Miller等发现28例患者中有19例(67.9%)因骨盆骨折动脉性出血血流动力学持续不稳定。在另外的研究中，当进行血管造影术后，86% -100%的患者止住了骨盆动脉性出血5,29,31。Ben-Menachem等提倡“优先栓塞”以强调如果某一动脉在血管造影术中显示被割断，应该栓塞该血管，以避免凝血块溶解而导致延迟性出血的风险。其他一些作者们则表示，对于控制多处出血及由于血管痉挛引起的隐匿性血管损伤，栓塞两侧的髂内动脉是别无选择13。
Early angiography and subsequent embolization have been demonstrated to improve patient outcomes. Agolini et al 29 showed that embolization within 3 hours of arrival resulted in a significantly greater survival rate. Another study found that pelvic angiography performed within 90 minutes of admission improved survival rates. 34 However, aggressive use of angiography may cause ischemic complications. 35 Angiography and embolization are not effective in controlling bleeding from venous injuries and bony sites, and venous bleeding represents the preponderance of hemorrhage source in high-energy pelvic fractures. Time spent in the angiography suite for hypotensive patients without arterial injury may not contribute to survival.
早期的血管造影术和随后的血管栓塞术显示可以改善患者的疗效。Agolini等研究显示能在3小时内进行血管栓塞术患者的生存率明显增高。另外一个研究发现在入院90分钟内进行了骨盆血管造影术患者的生存率明显改善34。但是，过度使用血管造影术可能引起缺血性并发症35。血管造影术和栓塞术在控制静脉出血和骨折部位出血方面效果不明显，而且，静脉性出血占高能量骨盆骨折患者出血量的多数，无动脉血管损伤的低血压患者因血管造影术消耗了更多的时间可能对患者的生存率无改善。
4.5 Pelvic Packing
骨盆包裹术
Pelvic packing was developed as a method to achieve direct hemostasis and to control venous bleeding resulting from pelvic fracture. For more than a decade, trauma surgeons in Europ have been advocating exploratory laparotomy followed by pelvic packing. 36 This technique is believed to be especially useful in patients in extremis. Ertel et al 37 showed that multiply injured patients with pelvic fractures can be safely treated using a C-clamp and pelvic packing without arterial embolization. Local packing was also effective in controlling arterial bleeding.
骨盆包裹术是一种控制骨盆骨折静脉性出血的直接止血法。欧洲的创伤外科医生曾倡导骨盆包裹术后进行开腹探查超过一个十年期36。这种方法在四肢骨折患者尤为适用。Ertel等研究显示伴骨盆骨折的多发损伤患者不用动脉栓塞术，只用C形夹和骨盆包裹术固定也是安全的。局部包裹术对控制动脉性出血同样有效。
More recently, a modified method of pelvic packing—retroperitoneal packing—has been introduced in North America. 38 This technique facilitates control of retroperitoneal bleeding through a small incision (Figure 5). The intraperitoneal space is not entered, leaving the peritoneum intact to help develop a tamponade effect. The procedure is quick and easy to perform, with minimal blood loss. Retroperitoneal packing is appropriate for patients with a variety of severity of hemodynamic instability, and it can reduce unnecessary angiography. Cothren et al 39 reported no deaths as a result of acute blood loss in persistent hemodynamically unstable patients when direct packing was used. Only 4 of 24 nonresponders in this study required subsequent embolization (16.7%), and the authors concluded that packing can quickly control hemorrhage and reduce the need for emergent angiography. 39
在北美，介绍了一个最新的改良的骨盆包裹术——腹膜后包裹术38。该技术同过一个小切口可帮助控制腹膜后出血（图5）。没有进入到腹膜内空间，完整的腹膜起到了填塞压迫的作用。这个操作简单迅速，出血很少。腹膜后包裹术可适用与血流动力学不稳定程度不同的患者，并且能减少不必要的血管造影术。Cothren等报道了因急性失血持续血流动力学不稳定患者直接应用腹膜后包裹术无一例死亡，研究中，只有24例无反应者中的4例需要随后的血管栓塞术(16.7%)，作者们总结指出腹膜后包裹术能迅速控制出血并减少紧急血管造影术的需求量。
Figure 5. Illustrations demonstrating the retroperitoneal packing technique. A, An 8-cm midline vertical incision is made. The bladder is retracted to one side, and three unfolded lap sponges are packed into the true pelvis (below the pelvic brim) with a forceps. The ?rst is placed posteriorly, adjacent to the sacroiliac joint. The second is placed anterior to the ?rst sponge at a point corresponding to the middle of the pelvic brim. The third sponge is placed in the retropubic space just deep and lateral to the bladder. The bladder is then retracted to the other side, and the process is repeated. B, Illustration demonstrating the general location of the six lap sponges following pelvic packing. (Adapted with permission from Smith WR, Moore EE, Osborn P, et al: 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 2005;59:1510-1514.)
图5. 腹膜后包裹术示意图。A, 8cm正中纵行切口，将膀胱牵向一侧，用钳子将三块未展开的膝盖海绵置入到真正的骨盆里（骨盆边缘以下）。第一块置入到后侧，临近骶髂关节。第二块放置在第一块的前面与骨盆边缘的中点一致。第三块则放置在耻骨后间隙、膀胱的侧面及深部。然后将膀胱牵向另一侧，重复上述步骤。B,六块海绵在骨盆包裹术后的一般放置位置示意图（经允许节选自Smith WR, Moore EE, Osborn P, et al: 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 2005;59:1510-1514.）
4.6 Fluid Resuscitation
液体复苏
Fluid resuscitation assumes critical importance as efforts are undertaken to determine and control the site of hemorrhage. Two large-bore (≥16-gauge) intravenous cannulas should be established centrally or in the upper extremities during the initial assessment. Crystalloid solution ≥2 L should be given over 20minutes, or more rapidly in patients who are in shock. If an adequate blood pressure response is obtained, crystalloid infusion can be continued until type-specific or fully matched blood is available. Type-specific blood, which is cross matched for ABOand Rh type, can usually be provided within 10 minutes; however, such blood may contain incompatabilities with other minor antibodies. Blood that has been fully typed and cross-matched carries the least risk of transfusion reactions, but it also takes the most time to obtain (approximately 60 minutes). 14 When the response to crystalloid infusion is transient or blood pressure fails to respond, 2 additional liters of crystalloid solution are given, and type-specific or non–cross-matched universal-donor (ie, group O negative) blood is administered immediately. A lack of response indicates that ongoing blood loss is likely, and angiographic and/or surgical control of the bleeding may be needed. 14
液体复苏为确定和控制出血点所作出的努力具有决定性的价值，在开始评估期间应该在中心静脉或上肢建立两个大孔径静脉通道。晶体补充速度应该在20分钟内≥2 L，对于休克患者应该更快。如果患者已有足够的血压反应，晶体输液一直持续到血型匹配或全完全匹配的血液已准备好。血型匹配血液是指经ABO和 Rh 血型交叉配型血型匹配的血液。一般10分钟就能提供，但是，这些血液中可能还含有不兼容的小抗体。完全匹配的血液能较小输血反应的风险，但是耗时更长才能得到（近60分钟）14。当晶体输液的反应只是一过性或血压没有作出反应时2，还需继续给予晶体溶液，并且立刻给予血型匹配的或没有交叉配型的一般献血者（例如，O型Rh阴性献血者）的血液。没有反应提示明年存在持续的出血点，可能需要血管造影术和/或手术控制出血14。
4.7 Blood Products and Recombinant Factor VIIa
血液制品和重组因子VIIa
Hypotensive patients who do not respond to initial fluid resuscitation require massive amounts of fluid subsequently, leading to deficiency of the hemostatic pathway. Therefore, all such patients should be assumed to require platelets and fresh-frozen plasma (FFP). In general, 2 or 3 units of FFP and 7 to 8 units of platelets are required for every5Lof volume replacement. 14
在最初液体复苏后无反应的低血压患者随后需要更多的补液，这可引起凝血功能不足，所以，这类患者应该补充血小板和新鲜冰冻血浆（FFP）。一般来说，每补充5L血液替代品需输入2-3个单位的FFP和7-8个单位的血小板。
Massive blood transfusion has potential risks of immunosuppression, inflammatory effects, and dilutional coagulopathy. Thus, the optimal volume and relative requirements of blood products for resuscitation remain controversial. In addition, the amount of PRBC transfusion is an independent risk factor for postinjury multiple organ failure. 6,40 Some authors have proposed that coagulopathic trauma patients should be primarily resuscitated with more aggressive use of FFP, with a transfusion composed of PRBCs, FFP, and platelets in a 1:1:1 ratio to prevent early coagulopathy promotion. 7,41
大量输血有免疫抑制、炎症效应和稀释性凝血障碍的潜在危险，因此，用来复苏的血液制品的理想输入量和相关需求仍存在争议。此外，PRBC的输入量是创伤后多器官衰竭的独立危险因素6,40。有些作者们提议存在凝血障碍创伤的患者在最初复苏时应该输入更多的FFP。输血时PRBC、FFP和血小板的输入的比例为1：1：1以防止凝血障碍的发生7,41。
Recombinant factor VIIa (rFVIIa) may be considered as a final intervention when coagulopathy and lifethreatening bleeding persist despite other treatment. This is an off-label use of rFVIIa. Boffard et al 42 performed a multicenter study in which severely traumatized patients who received 6 units of PRBCs within 4 hours of admission were randomized to either rFVIIa treatment or placebo. In the rFVIIa group, the number of red cell transfusions was significantly reduced (approximately 2.6 red blood cell units; P = 0.02), and there was a trend toward a reduction in mortality and complications.
重组因子VIIa(rFVIIa)可能被认为是经其他治疗后仍存在凝血障碍和危及生命出血患者的最后干预措施，一般不常规使用rFVIIa。Boffard等进行了一项多中心随机对照实验，将入院后4小时内输入了6个单位的PRBC的严重创伤患者随机分到接受rFVIIa治疗组或安慰剂治疗组。在rFVIIa治疗组，明显减少了红细胞输入量（近2.6个单位RBC，P = 0.02），并且有减少死亡率和并发症的趋势。
5. Evaluation of Resuscitation Status
复苏状况的评估
End points of resuscitation are determined based on the combination of laboratory data and physiologic signs. A hemoglobin level reading is known to be inaccurate during the acute phase of resuscitation. The commonly considered end points of resuscitation include normal blood pressure, decreased heart rate, adequate urine output (≥30 mL/hr), and normal central venous pressure. 14 However, even after normalization of these parameters, inadequate tissue oxygenation may persist. Additional laboratory measures that can be used to evaluate tissue oxygenation include base deficit, bicarbonate, and lactate. All of these assess anaerobic glycolysis. The terms base deficit and base excess are used interchangeably, the only difference being that base deficit is expressed as a positive number and base excess is expressed as a negative number. A normal base deficit is 0 to 3 mmol/L; this is routinely measured with an arterial blood gas analysis. A persistent base deficit suggests insufficient resuscitation.
复苏的终止时间根据实验室数据和生理性指征来决定。已知在复苏急性期查看血红蛋白水平是不准确的。常用的复苏终止指标包括：正常的血压、减缓的心率、足够的尿排出量(≥30 mL/hr)，和正常的中心静脉压14，但是，尽管这些参数均正常后，组织可能还存在缺氧状态，可评估组织的氧合状态的额外实验室检测包括：碱缺失（BD）、碳酸氢盐和乳酸，所有这些评价指标都是用来评估无氧糖酵解。术语“碱缺失”和“碱剩余”可以互换，两者唯一的区别是碱缺失以正数表示，而碱剩余则以负数表示。正常的碱缺失在0-3 mmol/L，常规用动脉血血气分析测量所得。持续的碱缺失提示未完全复苏。
6. Treatment Algorithms and Survival Rates
治疗原则及生存率
Retrospective analysis of outcomes before the institution of treatment algorithms dramatically illustrates the pitfalls that these protocols seek to avoid. In one series, the deaths of 43 patients, representing 60% of the deaths in the series, were attributed entirely or in part to pelvic fractures. 9 Of the 26 patients in whom pelvic fracture was considered to be the primary cause of death, 24 were in shock or had clinical evidence of hypovolemia at the time of admission, and 18 exsanguinated from their pelvic fractures shortly after hospital admission.
在治疗原则醒目的说明方案中应避免的错误建立之前，回顾性的分析了疗效。在一个系列病例研究中，占研究死亡总数60%的43例死亡病例，其死因全部或部分归结于骨盆骨折9，在骨盆骨折是其死亡主要原因的26例患者中，24例在入院时存在休克或血容量过低，18例在入院后很短的时间内因骨盆骨折出血过多死亡。
The establishment of standardized clinical treatment algorithms for patients with pelvic fracture greatly increased the probability of rapid stabilization and survival. 22,29,30 Bosch et al 4 reported that implementation of a standard protocol at a trauma center led to a decrease in mortality associated with high-energy pelvic fractures from 66.7% to 18.7%. Biffl et al 7 reported that their clinical pathway, which included the immediate presence of orthopaedic attending surgeons in the emergency department, pelvic wrapping, and subsequent aggressive use of C-clamps, led to significantly decreased mortality, from 31% to 15% (P < 0.05). Balogh et al 34 established evidence-based institutional guidelines consisting of pelvic binding and abdominal clearance within 15 minutes, pelvic angiography within 90 minutes, and minimally invasive orthopaedic fixation within 24 hours. Use of this guideline reduced 24-hour PRBC transfusion volume from 16±2Uto11±1U(P < 0.05) and reduced mortality from 35% to 7% (P < 0.05).
骨盆骨折标准的治疗原则的建立显著提高了这类患者的快速稳定率和生存率22,29,30。Bosch等报道了一个创伤中心启用标准方案后高能量骨盆骨折患者的死亡率从66.7% 降到了18.7%。Biffl等则报道了临床治疗历程，包括骨科医生立即参与的急诊部、骨盆包裹术和随后更多使用的C形夹，患者的死亡率从31% 降到了15% (P < 0.05)。Balogh等建立了询证的治疗指南，包括在15分钟内完成骨盆束带捆绑及排除腹部间隙、在90分钟内完成血管造影术和在24小时内完成微创骨科固定。应用该指南24小时 PRBC输入量从16±2U降到了11±1U(P < 0.05)，并且死亡率从35% 降到了7% (P < 0.05)。
Some algorithms are so complex that they may seem impossible to follow. One reason for this complexity is the myriad of variations in causes of shock and in sources of bleeding in patients with pelvic fractures. Also, treatment tends to be highly case-dependent. The other reason is that many treatment algorithms are established according to the capabilities of the institution for which they are developed. Although the fundamental principle of the protocols is useful, it may be necessary to modify the algorithms to fit the resources and staff expertise at each institution.
有些原则太过复杂很难实施。其中一个原因是骨盆骨折患者间导致休克的原因和出血的来源的差别太大，而且，治疗还强调个体差异性。另外一个原因是许多治疗原则的提出是根据这些作者们所在的医疗单位的能力提出来的。尽管这些方案的基本原则非常有用，但是，可能还需修改一些原则来适应每个医疗单位人力和物力。
The patient with a high-energy pelvic fracture who presents to our institution with hemodynamic instability is initially given 2Lof crystalloid solution (Figure 6). A portable chest radiograph, along with radiographic views of the pelvic and lateral cervical spine, are examined to rule out a thoracic source of blood loss. A central venous pressure line is placed, and base deficit is measured. A focused abdominal sonography for trauma (FAST) examination is performed. If the result is positive, the patient is taken directly to the operating room for an exploratory laparotomy. A pelvic external fixator is placed, and pelvic packing is performed. The patient who remains hemodynamically unstable undergoes pelvic angiography prior to transfer to the intensive care unit (ICU). If hemodynamic stability is restored, the patient is transferred directly to the ICU. In the ICU, the patient receives further fluid resuscitation and is warmed; attempts are made to normalize the coagulation status. If the patient requires ongoing transfusion while in the ICU, angiographic assessment, if not previously done, should be performed. Recombinant factor VIIa should be considered if the patient is recalcitrant to all other interventions.
在我们医院，伴血流动力学不稳定的高能量骨盆骨折患者最初是给予2L晶体溶液（图6），通过简便的胸片、加骨盆片和颈椎侧位片检查以明确是否存在胸部出血，插入中心静脉管并测量碱缺失值，应用创伤专用腹部超声(FAST)检测腹部，如果患者结果为阳性，患者直接送到手术室进行开腹探查术。放置骨盆外固定物，进行骨盆包裹术。血流动力学不稳定的患者在送至重症监护室（ICU）之前进行血管造影术。如果血流动力学恢复了稳定，患者直接送至ICU。在ICU，患者接受进一步液体复苏和保暖治疗以恢复正常的凝血状态。如果患者在ICU需持续输血，需进行血管造影术，尤其是先前没有做的患者。如果患者经其他一切治疗后都未见好转可考虑rFVIIa。
 
Figure 6. Algorithm for the treatment of patients with pelvic fracture who present with hemodynamic instability. *Patients in whom a laparotomy was not done usually have an abdominal CT scan en route to the intensive care unit (ICU). In the ICU, the patient receives further ?uid resuscitation and is warmed; attempts are made to normalize the coagulation status. Recombinant factor VIIa should be considered if the patient is recalcitrant to all other interventions. FAST = focused abdominal sonography for trauma, PRBCs = packed red blood cells
图6. 伴血流动力学不稳定骨盆骨折患者治疗的原则。没有开腹探查的患者在送至重症监护室（ICU）进行腹部CT扫描。在ICU，在ICU，患者接受进一步液体复苏和保暖治疗以恢复正常的凝血状态。如果患者经其他一切治疗后都未见好转可考虑rFVIIa。FAST =创伤专用腹部超声，PRBCs = 浓缩红细胞。
If the FAST result is negative, transfusion of PRBCs is begun in the emergency department. If the patient remains hemodynamically unstable following the second unit of PRBCs, she or he is taken to the operating room for pelvic external fixation and pelvic packing. The patient who remains hemodynamically unstable undergoes pelvic angiography prior to transfer to the ICU. If hemodynamic stability is restored, the patient is transferred directly to the ICU. An abdominal CT scan can be performed at this time. If the patient requires ongoing transfusion while in the ICU, angiographic assessment, if not previously done, should be performed.
如果FAST结果为阴性，在急诊部就开始输入PRBCs。如果患者在输入两个单位的PRBCs之后仍然存在血流动力学不稳定，那么她/他要送至手术室进行骨盆外固定术和骨盆包裹术，血流动力学不稳定的患者在送至ICU之前要进行血管造影术。如果患者血流动力学恢复稳定，那么，直接送往ICU，这时候可进行腹部CT检查，如果先前没有进行血管造影术的患者送至ICU后仍需持续输血，那么，需进行血管造影术来评估。
7. Summary
概要
High-energy pelvic fracture combined with hemodynamic instability is among the most severe of traumatic injuries. Efficient, coordinated assessment and treatment are necessary to ensure the best chance for survival. Hemodynamic evaluation and recognition of the fracture patterns are the first steps in management. In many centers, the treatment paradigm consists of angiographic embolization along with early mechanical stabilization of the pelvis. Emergent pelvic packing may also be an effective treatment. Aggressive resuscitation, including the use of FFP and platelets, should be considered, as should the use of rFVIIa in patients whose bleeding is refractory to all other methods.
伴血流动力学不稳定的高能量骨盆骨折属于严重创伤。必须要有相应的、有效的评估和治疗来确保最大的生存率。血流动力学评估和分清骨折类型是治疗的第一步。在许多医疗中心，治疗规范包括在早期机械固定骨盆时一并施行血管造影的栓塞术。紧急的骨盆包裹术可能也是一个有效的治疗，应该采用包括FFP和血小板的足量液体复苏，同时，经其他治疗后仍难以控制出血的患者可考虑应用rFVIIa。
Successful management of pelvic fracture hemorrhage is best accomplished by a team approach involving professionals from a variety of specialties. The experienced orthopaedic surgeon can provide precise recognition of fracture patterns, achieve immediate pelvic stabilization, and assist with proper decision making to maximize patient survival.
通过多学科专家参与的团队方式，能最佳地成功治疗骨盆骨折出血。有经验的骨科医生能准确辨明骨折的类型，迅速完成骨盆固定，并且协助其他人员一起制定能最大化提高患者生存率的医疗决策。
References
Evidence-based Medicine: Levels of evidence are described in the table of contents. Most of the references cited in this article are level IV case series. Reference 42 is a level I study. References 7, 11, 13, 15, 16, 25, and 33 are review articles, textbooks, or expert opinion. References 24 and 26 are biomechanical/anatomic studies. Citation numbers printed in bold type indicate references published within the past 5 years.
参考文献：
循证医学：在目录已描述证据的等级。本文大部分参考文献为证据等级IV的系列病例研究。参考文献42是证据等级I的研究，参考文献7、 11、13、 15、16、25和33为综述、教科书或专家意见。参考文献24和26是生物力学/解剖学研究。用黑体显示编号的引用文献是近5年内发表的文章。
具体参考文献目录（见原文）
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发表于 2011-1-5 15:05:32
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