手術開始直後に突然の出血性ショックを来し左室損傷が判明した胸部刺創の1例
症例は55歳男性，自殺企図で左前胸部に包丁が刺さって倒れている患者が発見され救急搬送された．エコーで左血胸と診断され，胸腔ドレナージを行った．CT検査を行ったところ，包丁が左肺を貫通し左下肺静脈に包丁先端が位置している所見であった．心嚢液はなく，人工心肺準備下に左開胸での肺切除と左下肺静脈の損傷があれば修復する方針で，仰臥位として，手術を開始した．大腿動静脈を剥離していたところ，急激な血圧低下をきたした．ただちに人工心肺を確立し，胸骨正中切開を行い，出血部位を観察すると左室側壁長軸方向に5 cm程度の損傷があり，拍動性に出血していた．心室細動下に修復術と左肺上葉舌区部分切除を行った．術後経過は...
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| Published in | 日本心臓血管外科学会雑誌 Vol. 49; no. 2; pp. 72 - 76 |
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| Main Authors | , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
特定非営利活動法人 日本心臓血管外科学会
15.03.2020
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| Subjects | |
| Online Access | Get full text |
| ISSN | 0285-1474 1883-4108 |
| DOI | 10.4326/jjcvs.49.72 |
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| Abstract | 症例は55歳男性，自殺企図で左前胸部に包丁が刺さって倒れている患者が発見され救急搬送された．エコーで左血胸と診断され，胸腔ドレナージを行った．CT検査を行ったところ，包丁が左肺を貫通し左下肺静脈に包丁先端が位置している所見であった．心嚢液はなく，人工心肺準備下に左開胸での肺切除と左下肺静脈の損傷があれば修復する方針で，仰臥位として，手術を開始した．大腿動静脈を剥離していたところ，急激な血圧低下をきたした．ただちに人工心肺を確立し，胸骨正中切開を行い，出血部位を観察すると左室側壁長軸方向に5 cm程度の損傷があり，拍動性に出血していた．心室細動下に修復術と左肺上葉舌区部分切除を行った．術後経過は良好で第25病日紹介病院へ転院となった．胸部鋭的損傷の場合，心嚢液貯留がなく，一見安定した血行動態であっても，心血管損傷による血行動態の破綻の可能性も考慮し，人工心肺を準備した上での加療が重要である． |
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| AbstractList | 症例は55歳男性，自殺企図で左前胸部に包丁が刺さって倒れている患者が発見され救急搬送された．エコーで左血胸と診断され，胸腔ドレナージを行った．CT検査を行ったところ，包丁が左肺を貫通し左下肺静脈に包丁先端が位置している所見であった．心嚢液はなく，人工心肺準備下に左開胸での肺切除と左下肺静脈の損傷があれば修復する方針で，仰臥位として，手術を開始した．大腿動静脈を剥離していたところ，急激な血圧低下をきたした．ただちに人工心肺を確立し，胸骨正中切開を行い，出血部位を観察すると左室側壁長軸方向に5 cm程度の損傷があり，拍動性に出血していた．心室細動下に修復術と左肺上葉舌区部分切除を行った．術後経過は良好で第25病日紹介病院へ転院となった．胸部鋭的損傷の場合，心嚢液貯留がなく，一見安定した血行動態であっても，心血管損傷による血行動態の破綻の可能性も考慮し，人工心肺を準備した上での加療が重要である． |
| Author | 長沼, 政亮 畠山, 正治 板垣, 皓大 永谷, 公一 神田, 桂輔 増田, 信也 鈴木, 伸章 |
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| References | 7) Omura T, Mori H, Nimura S. False negative pericardial focused assessment with sonography for trauma examination following cardiac rupture from blunt thoracic trauma : a case report. JJAAM 2017 ; 28 : 205-10. 18) Suda H, Nakayama T, Sunada M et al. Penetrating injury of the left ventricle caused by a nail gun ; report of a case. Kyobu Geka 2014 ; 67 : 411-4. 8) Connelly TM, Kolcow W, Veerasingam D et al. A severe penetrating cardiac injury in the absence of cardiac tamponade. Interact Cardiovasc Thorac Surg 2016 ; 24 : 286-7. doi : 10.1093/icvts/ivw342 21) Kirklin JW, Barratt-Boyes. Cardiac trauma. Cardiac Surgery. 3rd ed. New York : Churchill Livingstone ; 2003, pp 1671-7. 20) Duric Z, Gosev I, Belina D. Penetrating injury to the right side of the heart without hemodynamic compromise. J Thorac Cardiovasc Surg 2012 ; 144 : 263-4. doi : 10.1016/j.jtcvs.2012.03.053 3) Furukawa H, Tsuchiya K, Iida Y et al. Penetrating knife injury to the heart. Jpn J Thorac Cardiovasc Surg 2000 ; 48 : 142-4. 5) Follette DM. Penetrating cardiac injuries—A look to the future. Ann Thorac Surg 1991 ; 51 : 701-2. 10) Miyoshi Y, Ohara K. Traumatic cardiac injury. Kyobu Geka 2004 ; 57 : 742-50. 2) Tamura K, Kuinose M, Yoshitaka H et al. Penetrating cardiac injury by a needle which was buried in the heart. Jpn J Cardiovasc Surg 2008 ; 37 : 244-6. 19) Sauer PE, Murdock CE Jr. Immediate surgery for cardiac and great vessel wounds. Arch Surg 1967 ; 95 : 7-11. 14) Fullum TM, Siram SM, Righini M. Stab wounds to the chest : a retrospective review of 100 consecutive cases. J Natl Med Assoc 1990 ; 82 : 109-12. 4) Knott-Craig CJ, Dalton RP, Rossouw GJ et al. Penetrating cardiac trauma : management strategy based on 129 surgical emergencies over 2 years. Ann Thorac Surg 1992 ; 53 : 1006-9. 9) The Organ Injury Classification Committee of the Japanese Association for the Surgery of Trauma. The classification of cardiac injury. JJAST 2008 : 22 : 272. 17) Mitchell ME, Muakkassa FF, Poole GV et al. Surgical approach of choice for penetrating cardiac wounds. J Trauma 1993 ; 34 : 17-20. 13) Arreola-Risa C, Rhee P, Boyle EM et al. Factors influencing outcome in stab wounds of the heart. Am J Surg 1995 ; 169 : 553-6. 6) Shimizu K, Taguchi S, Kiyota K. A case of penetrating cardiac injury (III b) discharged on foot. JJAAM 2012 ; 23 : 109-15. 12) Honigman B, Rohweder K, Moore EE et al. Prehospital advanced trauma life support for penetrating cardiac wounds. Ann Emerg Med 1990 ; 19 : 145-50. 1) Sano T, Teshima H, Tai R et al. A penetrating cardiac injury by a sawing needle. Jpn J Cardiovasc Surg 2014 ; 43 : 310-2. 15) Asensio JA, Berne JD, Demetriades D et al. One hundred five penetrating cardiac injuries : a 2-year prospective evaluation. J Trauma 1998 ; 44 : 1073-82. 16) Nakano H, Chikazawa G, Tabuchi T. Penetrating right ventricular trauma by stab injury ; report of a case. Kyobu Geka 2005 ; 58 : 915-9. 11) Mochizuki Y, Sugita Y, Okamura Y et al. A case report of recurrent self-inserted needle in heart. Jpn J Thorac Cardiovasc Surg 1998 ; 46 : 473-7. |
| References_xml | – reference: 21) Kirklin JW, Barratt-Boyes. Cardiac trauma. Cardiac Surgery. 3rd ed. New York : Churchill Livingstone ; 2003, pp 1671-7. – reference: 18) Suda H, Nakayama T, Sunada M et al. Penetrating injury of the left ventricle caused by a nail gun ; report of a case. Kyobu Geka 2014 ; 67 : 411-4. – reference: 10) Miyoshi Y, Ohara K. Traumatic cardiac injury. Kyobu Geka 2004 ; 57 : 742-50. – reference: 4) Knott-Craig CJ, Dalton RP, Rossouw GJ et al. Penetrating cardiac trauma : management strategy based on 129 surgical emergencies over 2 years. Ann Thorac Surg 1992 ; 53 : 1006-9. – reference: 2) Tamura K, Kuinose M, Yoshitaka H et al. Penetrating cardiac injury by a needle which was buried in the heart. Jpn J Cardiovasc Surg 2008 ; 37 : 244-6. – reference: 1) Sano T, Teshima H, Tai R et al. A penetrating cardiac injury by a sawing needle. Jpn J Cardiovasc Surg 2014 ; 43 : 310-2. – reference: 17) Mitchell ME, Muakkassa FF, Poole GV et al. Surgical approach of choice for penetrating cardiac wounds. J Trauma 1993 ; 34 : 17-20. – reference: 12) Honigman B, Rohweder K, Moore EE et al. Prehospital advanced trauma life support for penetrating cardiac wounds. Ann Emerg Med 1990 ; 19 : 145-50. – reference: 3) Furukawa H, Tsuchiya K, Iida Y et al. Penetrating knife injury to the heart. Jpn J Thorac Cardiovasc Surg 2000 ; 48 : 142-4. – reference: 14) Fullum TM, Siram SM, Righini M. Stab wounds to the chest : a retrospective review of 100 consecutive cases. J Natl Med Assoc 1990 ; 82 : 109-12. – reference: 19) Sauer PE, Murdock CE Jr. Immediate surgery for cardiac and great vessel wounds. Arch Surg 1967 ; 95 : 7-11. – reference: 6) Shimizu K, Taguchi S, Kiyota K. A case of penetrating cardiac injury (III b) discharged on foot. JJAAM 2012 ; 23 : 109-15. – reference: 9) The Organ Injury Classification Committee of the Japanese Association for the Surgery of Trauma. The classification of cardiac injury. JJAST 2008 : 22 : 272. – reference: 13) Arreola-Risa C, Rhee P, Boyle EM et al. Factors influencing outcome in stab wounds of the heart. Am J Surg 1995 ; 169 : 553-6. – reference: 5) Follette DM. Penetrating cardiac injuries—A look to the future. Ann Thorac Surg 1991 ; 51 : 701-2. – reference: 8) Connelly TM, Kolcow W, Veerasingam D et al. A severe penetrating cardiac injury in the absence of cardiac tamponade. Interact Cardiovasc Thorac Surg 2016 ; 24 : 286-7. doi : 10.1093/icvts/ivw342 – reference: 7) Omura T, Mori H, Nimura S. False negative pericardial focused assessment with sonography for trauma examination following cardiac rupture from blunt thoracic trauma : a case report. JJAAM 2017 ; 28 : 205-10. – reference: 15) Asensio JA, Berne JD, Demetriades D et al. One hundred five penetrating cardiac injuries : a 2-year prospective evaluation. J Trauma 1998 ; 44 : 1073-82. – reference: 20) Duric Z, Gosev I, Belina D. Penetrating injury to the right side of the heart without hemodynamic compromise. J Thorac Cardiovasc Surg 2012 ; 144 : 263-4. doi : 10.1016/j.jtcvs.2012.03.053 – reference: 11) Mochizuki Y, Sugita Y, Okamura Y et al. A case report of recurrent self-inserted needle in heart. Jpn J Thorac Cardiovasc Surg 1998 ; 46 : 473-7. – reference: 16) Nakano H, Chikazawa G, Tabuchi T. Penetrating right ventricular trauma by stab injury ; report of a case. Kyobu Geka 2005 ; 58 : 915-9. |
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| SubjectTerms | 出血性ショック 左室損傷 心嚢液 胸部刺創 |
| Title | 手術開始直後に突然の出血性ショックを来し左室損傷が判明した胸部刺創の1例 |
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