每日一题_2022.09.17

A 22-year-old man crashed into a tree at 60 miles per hour. He was ejected from the car and was found by emergency medical services unresponsive with agonal respirations, was intubated for a Glasgow Coma Scale (GCS) score of 3 and transported to the closest level 1 trauma center, 45 minutes away. On arrival, his GCS score remains 3, he is intubated, with equal breath sounds bilaterally, a firm abdomen, and no evidence of active external hemorrhage. Temperature is 34°C (93.2°F), heart rate 140 beats/min, blood pressure 80/40 mm Hg, oxygen saturation 93% on 100% fraction of inspired oxygen. Chest radiograph shows right lower lobe aspiration, pulmonary contusions and the endotracheal tube in the correct position. Pelvis radiograph shows an open-book pelvic fracture. Focused assessment with sonography in trauma (FAST) examination shows anechoic fluid in Morison pouch.

In addition to placing a pelvic binder, which of the following are the most appropriate next steps in management?

A. Give bolus of 3 liters IV crystalloid, and transfer patient directly to operating room.

B. Transfer patient directly to operating room, without giving any IV fluids, and practice permissive hypotension.

C. Start uncrossed blood product resuscitation, and consult with interventional radiology for patient’s unstable pelvic bleeding.

D. Start uncrossed blood product resuscitation, transfer patient directly to operating room, and consider tranexamic acid.

答案解析：

该患者血压低，可能是腹腔内出血和/或不稳定的骨盆骨折。在紧急转移到手术室时，应放置骨盆粘合剂以试图稳定骨盆骨折并填塞任何出血，并通过创伤超声检查 (FAST) 检查和血流动力学不稳定进行积极的重点评估。高级创伤生命支持 (ATLS) 指南的最新更新更加强调早期血液制品复苏（使用较少的晶体液）和对特定患者的允许性低血压的考虑。必须怀疑这名患者在现场插管，格拉斯哥昏迷评分 (GCS) 评分为 3，除非另有证明，否则他患有创伤性脑损伤，因此不适合接受允许性低血压。考虑到不稳定的骨盆骨折和疑似出血，在他护理的某个阶段可能需要进行介入放射学检查，但考虑到 FAST 检查阳性和低血压，在去手术室之前不需要。

考虑到伤害的严重性和事故发生后尽早到达创伤中心，有必要考虑使用氨甲环酸。这是基于前瞻性的 CRASH-2 试验，该试验表明，如果在受伤后三小时内对严重休克的患者给予氨甲环酸，全因死亡率会降低。这还不是 ATLS 指南的一部分；进一步的研究以确认氨甲环酸的效用正在进行中。

正确答案：D