血管内治療を施行した顔面外傷を伴う多発外傷例の検討―超緊急の外頸動脈塞栓術の意義

Clinical Study of Multiple Traumas with Severe Facial Injury Undergoing Emergency

Ⅰ．はじめに

　多発外傷症例は治療の優先順位により転帰が左右されることが多く，初期診療の手順とタイミングの決定が極めて重要である．特に交通事故の場合には頭部，顔面外傷を伴っていることが多く，初期診療において脳神経外科医の果たす役割は大きい．

　多発外傷症例の中でも血管損傷などにより出血が持続して出血性ショックを呈している重症例は，出血源の同定と止血方法およびその時期について判断に苦慮する場合がある．顔面外傷を伴った症例においても鼻腔および口腔内から多量の出血が持続しショックとなる場合があるが，その止血方法やタイミングについて検討した報告は少ない^4,8)．

　近年の血管内手術の進歩により，顔面外傷による出血例に対して血管内アプローチによる外頸動脈塞栓術が行われるようになった．われわれは，これまでに顔面外傷に対して血管内手術による止血術を施行した5例の多発外傷症例を経験した．これらの症例について治療内容，治療までの時間経過，合併損傷の有無と程度，転帰などを検討することにより，多発外傷症例における初期診療の観点からみた本療法の適応および緊急性について分析したので報告する．

The outcome of multiple injures freqently depends on the priority of treatments,and the decision as to the procedures and timing of primary care is extremely important. We studied the patients with multiple trauma who underwent emergency endovascular treatment for facial hemorrhage related to external carotid arterial injury. The subjects are 5 patients who underwent embolization of the external carotid artery by an endovascular approach among patients with multiple traumas who were brought to our hospital by ambulance. In these patients,the vital signs on arrival,interval between injury and intravascular surgery,type of brain injury,type and grade of concurrent injury and outcome were studied. Three patients showed hemorrhagic shock on arrival,and 1 patient showed hemorrhagic shock immediately after arrival. The mean interval between injury and endovascular surgery was 3.9 hours. All patients had skull base fracture,and abnormal intracranial lesions on initial CT including 4 focal injuries and 1 diffuse injury. Moderate to severe thoracic/abdominal injuries were noted in 3 patients. In the remaining 2 patients,there was no trauma in the thoracic or abdominal regions. Intraperitoneal hemorrhage with splenic injury was observed in 3 patients. In 3 of 4 patients died by hemorrhagic shock because of the delay of endvascular treatments. In trauma patients with persistent hemorrhage,emergency endovascular treatment should be considered as a primary survey for initial treatment without delay under intensive conservative treatment.