中华急诊医学杂志  2017, Vol. 26 Issue (5): 603-606
主动脉球囊阻断术预防创伤性心脏骤停的研究进展
黄明伟, 孔来法, 王健, 陈丽倩, 赵小纲     
321000 浙江省金华,浙江大学金华医院急诊医学中心 (黄明伟、孔来法、王健、陈丽倩);310009 杭州,浙江大学医学院附属第二医院急诊科 (赵小纲)

根据《欧洲复苏指南》,创伤性心脏骤停的临床诊断标准是:创伤患者无反应、呼吸暂停和无脉搏。心排血量为零的心脏停搏和规律心脏活动均视为创伤性心脏骤停[1]。普遍认为创伤性心脏骤停的预后较差。但是,已报道病例的生存率存在很大差别,有证据表明创伤性心脏骤停的生存率正在提高[2-4]。在欧洲,每年约五十万人发生心脏骤停[5]。急诊科 (ED) 收治的大多数 (84%~99%) 心脏骤停患者,是由于内科因素 (MCA),而非创伤性原因 (TCA)[6-7]。创伤导致的心脏骤停具有很高的致命性,总生存率仅为5.6%(范围0%~17%)[8-14]。总的来说,穿透伤生存率为10%~16%;但是,如果心脏穿透伤患者到达急诊科时仍有生命体征,则其生存率会升至35%[15]。在各中心,闭合性创伤患者的生存率为0%~5%。与“疑似心脏病”的院外心脏骤停病例相比,创伤性院外心脏骤停病例均非常年轻,其心律不太可能是室颤VF/无脉性室速VT的可除颤心律,并且目击者通常是非专业人员和急救人员。但是,他们很少能得到目击者实施的心肺复苏救治和急救人员实施的复苏救治[16-18]。尽管目击者心肺复苏和急救人员复苏的救治时间有所增加,创伤性院外心脏骤停患者生存率仍很低,在过去18年里创伤性院外心脏骤停患者中仅有9例幸存[19]。在现场已无生命体征的儿童,其预后非常差,生存率为0%~8%[20]。因创伤导致心脏骤停的儿童,预后普遍较差;并且存活者常伴有严重的神经系统损伤[21-22]。在创伤性院外心脏骤停患者得到救治的情况下,儿童的生存几率要高于成人,但是在出院时,儿童的神经系统损伤通常比成人严重[23]

1 创伤性心脏骤停的预后

严重创伤是现代社会所面临的主要医疗问题之一,全球每年死于创伤的人数超过五百万,并且到2020年这一数字将增至八百万[24]。对于这些患者,非控制性创伤出血是导致潜在可预防性死亡的主要原因[25-26]。尽管现代急救技术已经很有效,但创伤性心脏骤停的预后仍然很差,生存率低于10%[27]。血容量过低为主因而导致心脏骤停的患者罕有幸存者[2]。在过去,试图救治创伤性心脏骤停患者曾被认为是徒劳的。但是,过去5年里创伤性心脏骤停病例 (特别是来自部队的病例) 的报告结果表明,这一情况正在改善。

2 创伤性心脏骤停的原因

《2010美国心脏学会心肺复苏及心血管急救指南》说明了需要特殊治疗或处置的心脏骤停情况。15种特殊心脏骤停情况,包括与内部生理或代谢条件相关的情况 (如哮喘、过敏、妊娠、肥胖症、肺栓塞和电解质失衡等),与外部或环境相关的情况 (如摄入有毒物质、创伤、意外低体温、雪崩、溺水、触电/雷击等),以及特定情况下发生的可能影响心脏的情况[如经皮冠状动脉介入治疗 (PCI)、心脏填塞和心脏手术等]。尽管对于无脉搏外伤患者,心肺复苏在整体上可能是徒劳的,但是在外伤导致心脏骤停情况下,有几个可逆性原因是可以纠正的并且立即处置有利于挽救生命。这些原因包括缺氧、血容量过低、心输出量减少、继发性气胸或心包填塞和低体温症等[28]。创伤性心脏骤停的最常见原因 (占比超过90%) 是重型颅脑损伤和低血容量症。失血过多对各器官或器官系统同时发生的钝性伤和 (或) 穿透性严重损伤、不合并重要脏器损伤,因失血性休克而成为主要致死原因[29]。对于因简易爆炸装置 (IED) 爆炸而伤亡的52例成人病例,下肢是最常见的损伤部位并且失血过多是导致心脏骤停的最常见原因[30]。关于造成损伤的机制类型,闭合性创伤 (占比87.2%) 和血容量过低是导致心脏骤停的直接原因[31]。考虑到创伤性心脏骤停时心输出量下降的可能性,初始复苏措施应集中于有效控制大出血,并找出低血容量和缺氧的原因[32]

3 控制危重出血的措施

低血容量是导致心脏骤停和死亡的主要原因,因此,急救人员 (创伤小组) 的主要任务是发现“隐匿性死亡”并尽量避免。采用各种适合的方法尽快地控制出血,从而维持足够的血容量和携氧能力。如果外部压力不能止血或内出血仍在继续,则需要手术探查[33]。创伤大出血患者的恰当管理包括出血源的早期发现和后续的及时措施 (如减少出血量、恢复组织灌注以及保持血流动力学稳定等)[34-35]。“创伤出血高级处理特别工作小组”更新了严重创伤出血处理的欧洲指南。他们推荐使用填塞、直接外科手术止血以及局部止血措施以达到早期控制腹腔出血的目的[36]。用于“控制不能通过压迫止血的躯干出血”的新型基于主动脉导管的复苏干预和复苏灌注正在积极研发中。这些方法包括主动脉的复苏血管内球囊阻断、选择性主动脉弓灌注、和 (用于紧急保存和复苏的) 深低温等[37-38]。选择性主动脉弓灌注 (SAAP) 将一个胸主动脉球囊阻断导管用于心脏骤停情况下的心脑灌注,从而恢复自主循环 (ROSC)[39]。Martinelli等[40]曾报道,应用主动脉内球囊阻断术可以减少出血并可支持血管造影。主动脉球囊阻断术 (ABO) 在患者到达时便可实施并且是切实可行的。主动脉球囊阻断术是一种有效的方法,可暂时地稳定“血流动力学严重不稳定的失血性休克患者”,并且可以作为出血患者确定性治疗的一个桥梁方法[41]。据报道,剖腹探查前降主动脉的阻断是控制近端血管的必要措施,可以暂时减少腹腔内出血并维持大脑和心脏的血流供应[42-43]

4 出血患者采用主动脉球囊阻断术的优劣势

主动脉球囊阻断术于1953年由Edwards等[44]研发,最初用于手术治疗腹主动脉瘤,而后被用于治疗创伤失血性休克。据报道,该技术不仅可有效治疗闭合性腹部损伤,亦可有效治疗骨盆骨折后腹膜后大出血[40]、穿透性腹部创伤[45]和非创伤性病例 (例如产后出血[46-47]) 等。Morrison等[48]描述主动脉球囊阻断术的步骤如下:(1) 动脉通路;(2) 球囊选择和定位;(3) 球囊充气;(4) 球囊放气;(5) 鞘管回收。采用主动脉球囊阻断术 (ABO) 的降主动脉阻断更微创,并且可根据生命体征状况控制充气量和持续时间。与采用胸廓切开术控制近端主动脉相比,主动脉球囊阻断术的优势更为明显。主动脉球囊阻断术属微创手术,是一种相对快速的方法, 可起到“手术桥梁”的作用并获得短暂的血流动力学稳定性。可改变球囊位置 (撤回至主动脉分叉处),并且可使球囊短暂放气 (或部分充气,即部分主动脉球囊阻断),这些做法可能有助于减少内脏器官严重缺血的情况。主动脉球囊阻断术的另一个优势是,即使作为救生演习和作为明确外科和血管内修复的桥梁方法,亦可直接实施主动脉球囊阻断术。实施主动脉球囊阻断术无需昂贵的设备,在医疗资源有限的地区这一点尤为重要。未能为主动脉球囊阻断建立血管通路并不影响实施胸廓切开术,对于严重休克患者应同时采用胸廓切开术。主动脉球囊阻断术还具有其他优势,例如为液体复苏留有时间和为麻醉医师或重症监护专科医生“操作”留有时间,并且可从理论上减少大量输血的需求。几分钟的血流动力学稳定还可以给外科医生留出考虑手术策略的时间,甚至可以做一次CT增强扫描,以确定外伤性病变并制定复杂病例的手术方案。主动脉球囊阻断术的劣势也十分明显。这种方法不能解决出血问题,主动脉球囊阻断术不能阻止血流入胸腔,还存在对股动脉、髂动脉、内脏动脉和主动脉造成损伤 (动脉夹层或穿孔) 的重大风险,特别是不做重复考虑地采用该技术的情况下。另外,主动脉球囊阻断术超时使用可能造成内脏器官和四肢的缺血和再灌注损伤,并存在多器官功能衰竭的潜在危险[49]

5 结语

创伤合并血流动力学不稳定骨盆骨折失血性休克患者,可选择腹主动脉球囊阻断术[50-51],需要多学科协作治疗,充分体现救治的整体性与时效性。急救时,倾向于使用主动脉球囊阻断术。主动脉球囊阻断术是一种有效的治疗创伤失血性休克方法;但是,必须参考相关建议并充分考虑到潜在并发症才能成功运用这种方法。需要进行附加的多中心研究,以判定这种方法的有效性;并且在并入即时创伤护理前,主动脉球囊阻断术用于创伤病例的更多数据应被采集。

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