受傷初日に両下肢切断術を施行した高齢者の広範囲火焔熱傷の1救命例(A case of survival of elderly patient with extensive flame burn after amputation of bilateral lower limbs on the first day)

要旨 症例は81歳の男性で，田んぼでの野焼き中に衣服へ着火して受傷し，当院へ搬送された。腹部から両下肢にかけて皮膚の著明な炭化を認め，両膝より遠位では熱傷が筋層に達していた。深達性II度熱傷7%，III度熱傷46%で熱傷予後指数（prognostic burn index: PBI）は130.5であり，予測される死亡率は98%以上であった。検査所見では血清CPK値の上昇，急性腎傷害，高カリウム血症を認めた。受傷から約4時間後，股関節から10cmの部位での両下肢切断術を施行し，ICUへ入室した。4日目に昇圧剤を終了，7日目に抜管，人工呼吸器離脱に至った。分層植皮術を繰り返し，119日目の転院時には車椅子で自走可能な状態であった。高齢者の広範囲火焔熱傷に対する受傷初日の四肢切断術がその後の集中治療管理や手術戦略に寄与し，救命し得た。過去に熱損傷での両下肢切断術を受傷初日にしたとする症例報告はなく，その臨床経過について詳述した。 ABSTRACT An 81–year–old man who suffered a flame burn during burning on the soil presented to our hospital. His skin from the abdomen to bilateral lower limbs seemed to be carbonized. The burn depth extended to the muscles on the distal area from the knees. Because 7% of his body surface area was covered in deep dermal burn (DDB) and 46% was covered in deep burn (DB), his prognostic burn index was 130.5, so mortality was estimated more than 98%. Laboratory test results were consistent with elevation of serum CPK and revealed acute kidney injury and hyperkalemia. Four hours after the accident, an emergency amputation of the bilateral limbs at an area 10cm distal from his hip was performed, and he was admitted to the intensive care unit. Vasopressor was discontinued on day 4, and he was extubated and weaned from the ventilator on day 7. After several split thickness skin graft and debridement, on day 119 he could use a wheelchair at the time of his transfer. In the case of an elderly patient with an extensive flame burn, performing amputation on day 1 may affect subsequent critical care and operative strategy, and in this case, the patient survived. This is a detailed first report of bilateral limb amputation for thermal injury on day 1.