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Martinez B, Breeding T, Katz J, Patel H, Santos RG, Elkbuli A. Outcomes of Preperitoneal Packing and Angioembolization for Hemorrhage Control in Hemodynamically Unstable Pelvic Fractures: A Systematic Review and Meta-Analysis. Am Surg 2024; 90:455-464. [PMID: 37970830 DOI: 10.1177/00031348231216488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Hemodynamically unstable pelvic fractures are often life-threatening injuries; however, the optimal management remains uncertain. This systematic review and meta-analysis aim to evaluate the most appropriate primary management of hemorrhage in adult patients with hemodynamically unstable pelvic fractures by comparing outcomes following the initial use of preperitoneal packing (PPP) vs angioembolization (AE). METHODS A systematic search of PubMed, Embase, Google Scholar, and ProQuest databases was conducted following PRISMA guidelines. Studies assessing hemorrhage management in trauma patients with hemodynamically unstable pelvic fractures were included. The data extracted from selected articles included patient demographics, study design, and outcomes such as 24-hour PRBC transfusions, in-hospital mortality, and DVT rate. RESULTS Eight articles were included in the systematic review. Among the included studies, 2040 patients with hemodynamically unstable pelvic fractures were analyzed. Meta-analyses revealed that treatment with PPP was associated with fewer 24-hour PRBC transfusions (mean difference = -1.0, 95% CI: -1.8 to -.2) than AE. However, no significant differences were noted in in-hospital mortality (RR: .91, 95% CI: .80-1.05) and the rate of deep vein thrombosis (RR: .89, 95% CI: .62-1.28) between groups. CONCLUSION The findings of this study suggest that primary management with PPP was associated with fewer 24-hour PRBC transfusions compared to AE. The choice of primary management with PPP or AE did not significantly impact in-hospital mortality. Future studies should address clinical outcomes and the factors that affect them to better understand the impact of different management strategies and direct the creation of practice management guidelines.
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Affiliation(s)
- Brian Martinez
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Tessa Breeding
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Joshua Katz
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Heli Patel
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Radleigh G Santos
- Department of Mathematics, NSUNOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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2
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Liu Y, Zhang J, Song HX, Tian QS, Liu L. Fatal motorcycle straddle injury consolidated with traumatic testicular dislocation: A case report. J Forensic Leg Med 2023; 100:102608. [PMID: 37913575 DOI: 10.1016/j.jflm.2023.102608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 10/05/2023] [Accepted: 10/21/2023] [Indexed: 11/03/2023]
Abstract
Straddle injuries are those to the perineum region brought on by straddling or riding over something, such as a horse, vehicle, or other object. The motorcycle fuel tank or handlebars are primarily responsible for the typical injury to the perineum area in motorcycle accidents. Motorcycle straddle injury usually manifest as abrasions to the scrotum or penis, and severe cases can cause pelvic fractures or even testicular dislocation. Because these injuries are usually closed with unclear internal damage, diagnosis presents a significant challenge and can easily lead to misdiagnosis. However, pelvic fractures and the bleeding and nerve damage associated with perineal injury are often fatal, and testicular dislocation can also have serious consequences for patients. Therefore, a clear diagnosis and timely treatment are crucial for patients with this type of injury. This article reports the case of a motorcycle rider who died 4 h after a traffic accident with only minor surface injury visible, showing only bruising in the waist and scrotum. A forensic examination revealed multiple fractures throughout the patient's body, with a slightly more severe pelvic fracture and testicular dislocation on the left side in the left inguinal area. This article analyzes the cause of death and related issues in this case, aiming to provide assistance to clinical physicians and forensic practitioners and to emphasize the importance of handling straddle injury in treatment and related investigations to avoid serious consequences.
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Affiliation(s)
- Yong Liu
- Huazhong University of Science and Technology Tongji Medical College Department of Forensic Medicine, Wuhan, Hubei, China
| | - Jie Zhang
- Huazhong University of Science and Technology Tongji Medical College Department of Forensic Medicine, Wuhan, Hubei, China
| | - Hua-Xiong Song
- Huazhong University of Science and Technology Tongji Medical College Department of Forensic Medicine, Wuhan, Hubei, China
| | - Qi-Shuo Tian
- Huazhong University of Science and Technology Tongji Medical College Department of Forensic Medicine, Wuhan, Hubei, China
| | - Liang Liu
- Huazhong University of Science and Technology Tongji Medical College Department of Forensic Medicine, Wuhan, Hubei, China.
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3
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Minici R, Mercurio M, Guzzardi G, Venturini M, Fontana F, Brunese L, Guerriero P, Serra R, Piacentino F, Spinetta M, Zappia L, Costa D, Coppola A, Galasso O, Laganà D. Transcatheter Arterial Embolization for Bleeding Related to Pelvic Trauma: Comparison of Technical and Clinical Results between Hemodynamically Stable and Unstable Patients. Tomography 2023; 9:1660-1682. [PMID: 37736986 PMCID: PMC10514840 DOI: 10.3390/tomography9050133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/23/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites. Despite international guidelines and widespread awareness of the role of angioembolization in clinical practice, robust evidence comparing the outcomes of angioembolization in hemodynamically stable and unstable patients is still lacking. This study aims to directly compare the outcomes of angioembolization for the treatment of pelvic traumatic arterial injury in patients with hemodynamic stability vs. hemodynamic instability. METHODS In our multicenter retrospective investigation, we analyzed data from consecutive patients who underwent, from January 2020 to May 2023, angioembolization for traumatic pelvic arterial injury. RESULTS In total, 116 angioembolizations were performed. Gelatin sponges (56.9%) and coils (25.9%) were the most widely used embolic agents. The technical and clinical success rates were 100% and 91.4%, respectively. No statistically significant differences were observed between the two groups in terms of technical success, clinical success, procedure-related complication rate, or 30-day bleeding-related mortality. CONCLUSIONS Angioembolization is an effective and safe option for the management of traumatic pelvic arterial lesions even in hemodynamically unstable patients, despite technical variations such as greater use of prophylactic angioembolization.
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Affiliation(s)
- Roberto Minici
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
| | - Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, Magna Græcia University, Dulbecco University Hospital, 88100 Catanzaro, Italy; (M.M.); (O.G.)
| | - Giuseppe Guzzardi
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy; (G.G.); (M.S.)
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Federico Fontana
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Luca Brunese
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy; (L.B.); (P.G.)
| | - Pasquale Guerriero
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy; (L.B.); (P.G.)
| | - Raffaele Serra
- Vascular Surgery Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Dulbecco University Hospital, 88100 Catanzaro, Italy;
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Marco Spinetta
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy; (G.G.); (M.S.)
| | - Lorenzo Zappia
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
| | - Davide Costa
- Department of Law, Economics and Sociology, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy;
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - MGJR Research Team
- Magna Graecia Junior Radiologists Research Team, 88100 Catanzaro, Italy;
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, Magna Græcia University, Dulbecco University Hospital, 88100 Catanzaro, Italy; (M.M.); (O.G.)
| | - Domenico Laganà
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
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4
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Dai J, He J, Ying Y, Huang D, Feng L. Clinical and epidemiological characteristics of 369 patients with pelvic fractures in Eastern Zhejiang Province of China: a retrospective study. BMC Musculoskelet Disord 2023; 24:495. [PMID: 37328894 DOI: 10.1186/s12891-023-06632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Data on the epidemiological characteristics and prognostic factors of patients with pelvic fractures are lacking, particularly in China. This study aimed to summarise the clinical and epidemiological characteristics of patients with pelvic fractures in eastern Zhejiang Province, China, and to identify risk factors for poor prognosis. METHODS The clinical data of 369 patients with pelvic fractures admitted to the Ningbo No. 6 Hospital between September 2020 and September 2021 were retrospectively analysed. Data on the demographic characteristics; fracture classification; injury time, cause, and site; treatment plan; and prognosis were collected using the Picture Archiving and Communication System and the Hospital Information System. Differences in constituent proportions were analysed using the chi-square test. Logistic regression analysis was used to identify factors affecting patient prognosis. Statistical significance was set at p ≤ 0.05. RESULTS Among the 369 patients, there were 206 men and 163 women, at a ratio of 1.26:1, and the average age was 53.64 ± 0.78 years. More than 50% of patients were aged 41-65 years. The average length of hospital stay was 18.88 ± 1.78 days. The three most common causes of pelvic fractures were traffic accidents (51.2%), falls from height (31.44%), and flat-ground falls (14.09%). There were significant differences in the distribution of the three causes of injury depending on age (p < 0.001), sex (p < 0.001), and occupation (p < 0.0001). Most patients were manual workers (48.8%). Furthermore, most patients (n = 262, 71.0%) underwent surgical treatment for pelvic fractures. Postoperative complications occurred in 26 patients (7.05%), and infection was the main complication (73.08%). Age (p = 0.013), occupation (p = 0.034), cause of injury (p = 0.022), treatment options (p = 0.001), and complications (p < 0.0001) were independent factors affecting the prognosis of patients with pelvic fractures. One death (0.027%) occurred, which was due to severe blood loss. CONCLUSIONS Age, occupation, cause of injury, treatment options and complications were factors affecting patient prognosis. In addition, changes in blood flow and prevention of infection warrant attention.
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Affiliation(s)
- Jiao Dai
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Junhong He
- Department of Pharmacy, Ningbo No. 6 Hospital, Ningbo, China
| | - Ying Ying
- Department of Nursing, Ningbo No. 6 Hospital, Ningbo, China
| | - Dichao Huang
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Leling Feng
- Department of Nursing, Ningbo No. 6 Hospital, Ningbo, China.
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Hörer TM, Ierardi AM, Carriero S, Lanza C, Carrafiello G, McGreevy DT. Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes. Semin Vasc Surg 2023; 36:283-299. [PMID: 37330241 DOI: 10.1053/j.semvascsurg.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 06/19/2023]
Abstract
Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.
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Affiliation(s)
- Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Sciences, Örebro University Hospital and Örebro University, Södra Grev Rosengatan, 701 85 Örebro, Sweden; Department of Surgery, Faculty of Life Sciences, Örebro University Hospital and Örebro University, Örebro, Sweden; Carmel Lady Davis Hospital, Technion Medical Faculty, Haifa, Israel.
| | - Anna Maria Ierardi
- Radiology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Serena Carriero
- Post Graduate School of Radiology, University of Milan, Milan, Italy
| | - Carolina Lanza
- Post Graduate School of Radiology, University of Milan, Milan, Italy
| | - Gianpaolo Carrafiello
- Radiology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Sciences, Örebro University Hospital and Örebro University, Södra Grev Rosengatan, 701 85 Örebro, Sweden
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Choi K, Keum MA, Choi B, Noh M, Choi S, Kyoung KH, Kim S, Hong ES, Kim JT. Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma. Injury 2023; 54:598-603. [PMID: 36400630 DOI: 10.1016/j.injury.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 10/13/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
This study analyzed the outcomes of bilateral internal iliac artery (IIA) ligation with preperitoneal pelvic packing (PPP) in hemodynamically unstable patients with major pelvic fractures. All-cause mortality was examined, periprocedural safety for critical circumstances was reviewed, and iliac artery ligation-related complications of the postoperative phase were evaluated. A total of 20 patients who suffered substantially from severe pelvic trauma with hemodynamic instability and subsequently underwent bilateral IIA ligation with PPP between January 1, 2017, and December 31, 2021, were enrolled in the study. The median participant age was 60.5 years, and 65.0% were male. The median systolic blood pressure was 68.5 mmHg on arrival. Increased lactate level (median, 11.05 mmol/L) suggested that the patients were in shock distinctly due to hypovolemia. It took approximately 1 h to complete the ligation of bilateral IIA to accomplish hemostasis (median, 65.5 min). The iliac vein was injured during dissection in three cases. During the ICU stay (median, 17.5 days), acute kidney injury was identified in 13 patients, likely due to volume depletion. The median ventilator-free days was 13.5; six patients were confirmed with ventilator-associated pneumonia. Moreover, 12 patients were diagnosed with acute respiratory distress syndrome. There was one case in which the lower extremity artery was acutely occluded. Anatomic hemostasis was achieved in 18 patients. The two patients for which anatomic hemostasis failed became two mortality cases from preperitoneal hemorrhage. Our analysis showed that bilateral IIA ligation with PPP was effective as a lifesaving procedure in hemodynamically unstable patients with a major pelvic fracture in terms of mortality due to fracture-related exsanguination. Moreover, the incidence of periprocedural complications was considered tolerable, making the procedure worth a try, especially in austere and underdeveloped healthcare settings.
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Affiliation(s)
- Kyunghak Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Min Ae Keum
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Byungho Choi
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Minsu Noh
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Seongho Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Sungjeep Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Eun Seog Hong
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Jihoon T Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea.
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Aoki R, Nakajima K, Kobayashi Y, Sakai Y, Kamide H, Yamamoto T, Furugori S, Sawamura S, Terauchi M, Kamiyama K, Ikeda S, Tsuji G, Koyama S, Yoshigi J, Sekikawa Z, Utsunomiya D. Common and uncommon vascular injuries and endovascular treatment associated with pelvic blunt trauma: a real-world experience. Jpn J Radiol 2023; 41:258-265. [PMID: 36350523 PMCID: PMC9974705 DOI: 10.1007/s11604-022-01355-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
Pelvic fractures are common in cases of blunt trauma, which is strongly associated with mortality. Transcatheter arterial embolization is a fundamental treatment strategy for fatal arterial injuries caused by blunt pelvic trauma. However, vascular injuries due to blunt pelvic trauma can show various imaging findings other than arterial hemorrhage. We present a pictorial review of common and uncommon vascular injuries, including active arterial bleeding, pseudoaneurysm, arteriovenous fistula, arterial occlusion, vasospasm, and active venous bleeding. Knowledge of these vascular injuries can help clinicians select the appropriate therapeutic strategy and thus save lives.
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Affiliation(s)
- Ryo Aoki
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan. .,Department of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan.
| | - Kento Nakajima
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yusuke Kobayashi
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Yodo Sakai
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Hiroyuki Kamide
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Toh Yamamoto
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Shintaro Furugori
- grid.413045.70000 0004 0467 212XAdvanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shungo Sawamura
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Miki Terauchi
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kazutoshi Kamiyama
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shin Ikeda
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Gengo Tsuji
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Shingo Koyama
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Jun Yoshigi
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Zenjiro Sekikawa
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Daisuke Utsunomiya
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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8
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Gupta B, Farooque K. Early total care to early appropriate care - What every anesthesiologist must know! J Anaesthesiol Clin Pharmacol 2023; 39:3-10. [PMID: 37250253 PMCID: PMC10220203 DOI: 10.4103/joacp.joacp_157_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/03/2021] [Accepted: 06/06/2021] [Indexed: 03/21/2023] Open
Abstract
Orthopedic trauma is one of the commonest injuries necessitating surgical intervention in a trauma patient. The management protocols in such severely injured orthopedic patients have evolved from conservative treatment to 'early total care' (ETC) to 'damage control orthopedics' (DCO) and recently to 'early appropriate care' (EAC)/'safe definitive surgery' (SDS). 'DCO' involves emergent, basic minimum life- or limb-saving surgery with continued resuscitation and definitive fixation of fractures being done later, once the patient has been resuscitated and stabilized. An insight into the immunological processes at a molecular level evoked in a poly-traumatized patient led to the evolution of the 'two-hit theory;' 'first hit' being the injury itself while the 'second hit' caused by the surgical trauma. As the 'two-hit theory' gained popularity, it led to a delay of definitive surgery for 2-5 days following trauma, since a higher complication rate was observed following definitive surgery within the first 5 days of the injury. This is a review article on the historical perspectives of DCO, immunological mechanisms involved, and various injuries requiring damage control approach or EAC/ETC and their anesthetic management.
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Affiliation(s)
- Babita Gupta
- Department of Anesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kamran Farooque
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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9
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Nakajima K, Yamaguchi K, Abe T, Taniguchi H, Mizukami S, Sekikawa Z, Takeuchi I. Extravasation and outcomes in computed tomography and angiography in patients with pelvic fractures requiring transcatheter arterial embolization: A single-center observational study. J Trauma Acute Care Surg 2022; 92:873-879. [PMID: 34711794 DOI: 10.1097/ta.0000000000003446] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extravasation on contrast-enhanced computed tomography (CECT) is a helpful indicator of the need for transcatheter arterial embolization (TAE) for pelvic fractures. However, previous reports were inconsistent on cases in which angiography is necessary, even though there is no extravasation on computed tomography. This study aimed to describe and analyze the contradictory findings in cases where extravasation is observed on angiography but not on CECT, to contribute to improved management of patients with pelvic fractures. METHODS This was a retrospective single-center study. Patients with pelvic fractures who underwent CECT and TAE between 2014 and 2020 were included. We classified the patients into three groups: CECT and angiography with extravasation (CT+Angio+), CECT with no extravasation and angiography with extravasation (CT-Angio+), and CECT with extravasation and angiography without extravasation (CT+Angio-). RESULTS A total of 113 patients were included in the study: the CT+Angio+ group had 54 patients, CT-Angio+ group, 47; and CT+Angio- group, 12. The CT-Angio+ group had a significantly longer time from arrival to CECT than the CT+Angio+ group (27 minutes vs. 23 minutes, p < 0.05). The CT-Angio+ group had significantly more blood transfusions (fresh frozen plasma, platelets) within 24 hours than the CT+Angio- group did (p < 0.05), and ventilator management days (p < 0.05) and intensive care unit stays (p < 0.05) were significantly longer. CONCLUSION There was no significant difference in outcomes among the three groups. There was no difference in severity, transfusion volume, or mortality in patients with pelvic fractures needing TAE, classified as CT-Angio+, compared with that of CT+Angio+ patients. Even in the absence of extravasation in the pelvic region on CECT, angiography or TAE may still be necessary. LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Kento Nakajima
- From the Department of Radiology (K.N.), Yokosuka Kyosai Hospital; Department of Emergency Medicine (K.N., K.Y., T.A., H.T., S.M., I.T.), Graduate School of Medicine, Yokohama City University; and Advanced Critical Care and Emergency Center (T.A., H.T., I.T.) and Department of Radiology (Z.S.), Yokohama City University Medical Center, Kanagawa, Japan
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10
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Li W, Du S, Guo H, Han X, Huang T. To Summarize and Analyze the Epidemiological Characteristics and Prognostic Risk Factors of Patients with Pelvic Fracture Complicated with Perineal Injury. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:4831330. [PMID: 35399837 PMCID: PMC8986410 DOI: 10.1155/2022/4831330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/28/2022] [Indexed: 11/24/2022]
Abstract
This study is aimed at summarizing and analyzing the epidemiological characteristics and prognostic risk factors of patients with a pelvic fracture with perineal injury. The clinical data of 153 patients with pelvic fracture with perineal injury treated in our hospital from January 2012 to June 2021 were analyzed retrospectively. The data of sex, age, injury mechanism, pelvic fracture type, shock index (SI), perineal wound depth, concomitant injury, total hospital stay, and death were collected by the electronic medical record system. Among the 153 patients, there were 94 males and 59 females, with an average age of (43.2 ± 16.8) years. The cases were mainly concentrated into two age groups: 20-29 years old and 50-59 years old. In a year, pelvic fractures were mainly concentrated in 1-2 months and 11-12 months. In terms of injury time, there were mainly two periods of time in a day: 10 : 00~12 : 00 and 15 : 00~18 : 00. The MOTS-RTS scores of the patients in the undead group and the dead group were (7.12 ± 1.52), (2.69 ± 0.96), ISS scores were (27.36 ± 15.84), (61.32 ± 7.08), GCS scores were (12.84 ± 3.69), (4.13 ± 1.25), APACH II scores were (12.87 ± 8.84), (32.41 ± 6.98), and SOFA scores were (6.68 ± 5.87), (17.12 ± 3.12). The MOTS-RTS and GCS scores of the nondeath group were significantly higher, while the ISS score, APACH II score, SOFA score, and shock index were significantly lower. The overall mortality rate of 153 patients was 13.7%. The average area of perineal trauma in undead and dead patients was (54.5 ± 113.52) cm2 and (262.63 ± 300.84) cm2, respectively. The average depth of perineal trauma was (9.63 ± 7.22) cm and (16.23 ± 10.13) cm, respectively. The larger the area of perineal injury and the deeper the depth of perineal trauma, the worse their prognosis. Cox multivariate analysis showed that complications, MOTS-RTS score, ISS score, GCS score, perineal trauma area, and perineal trauma depth were independent risk factors affecting the prognosis of patients with pelvic fracture with perineal injury. Most of the patients with pelvic fracture complicated with perineal injury are 20-29 years old and 50-59 years old. The more serious the perineal injury is, the higher the mortality is. The main causes of death are refractory hemorrhagic shock and infection.
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Affiliation(s)
- Wen Li
- General Hospital of Central Theater Command, No. 627 Wuluo Road, Wuhan, Hubei Province 430070, China
| | - Shasha Du
- Daye City People's Hospital, No. 25 Dongfeng Road Chengbei Development Zone, Daye, Hubei Province 435100, China
| | - Houcai Guo
- General Hospital of Central Theater Command, No. 627 Wuluo Road, Wuhan, Hubei Province 430070, China
| | - Xuan Han
- General Hospital of Central Theater Command, No. 627 Wuluo Road, Wuhan, Hubei Province 430070, China
| | - Tao Huang
- Daye City People's Hospital, No. 25 Dongfeng Road Chengbei Development Zone, Daye, Hubei Province 435100, China
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11
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Comparative effectiveness of pelvic arterial embolization versus laparotomy in adults with pelvic injuries: A National Trauma Data Bank analysis. Clin Imaging 2022; 86:75-82. [DOI: 10.1016/j.clinimag.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/21/2022]
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12
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Renzulli M, Ierardi AM, Brandi N, Battisti S, Giampalma E, Marasco G, Spinelli D, Principi T, Catena F, Khan M, Di Saverio S, Carrafiello G, Golfieri R. Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma. Eur J Med Res 2021; 26:123. [PMID: 34649598 PMCID: PMC8518287 DOI: 10.1186/s40001-021-00594-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/27/2021] [Indexed: 12/02/2022] Open
Abstract
Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.
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Affiliation(s)
- Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy. .,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy.
| | - Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | | | | | - Giovanni Marasco
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
| | - Daniele Spinelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Tiziana Principi
- Intensive Care Unit and Anesthesia, Emergency Department, ASUR MARCHE AV5, San Benedetto del Tronto, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy
| | - Mansoor Khan
- Digestive Diseases Department, Brighton and Sussex University Hospitals, Brighton, UK.,Royal College of Surgeons of England, DSTS Faculty, London, UK
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Varese, Regione Lombardia, Italy
| | - Giampaolo Carrafiello
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
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13
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Weir A, Kennedy P, Joyce S, Ryan D, Spence L, McEntee M, Maher M, O'Connor O. Endovascular management of pelvic trauma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1196. [PMID: 34430637 PMCID: PMC8350659 DOI: 10.21037/atm-20-4591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/18/2020] [Indexed: 11/06/2022]
Abstract
Traumatic pelvic injuries are an important group of acquired pathologies given their frequent association with significant vascular compromise. Potentially fatal as a consequence of rapid hemorrhage, achievement of early hemostasis is a priority; endovascular management of traumatic pelvic arterial injuries is an important potential option for treatment. Precipitated by any number of mechanisms of trauma, pelvic vascular injury necessitates timely patient assessment. Variable patterns of arterial injury may result from blunt, penetrating or iatrogenic trauma. Selection of the most appropriate imaging modality is a priority, ensuring streamlined access to treatment. In the case of CT, this is complemented by acquisition of the most appropriate phase of imaging; review of both arterial and delayed phase imaging improves the accuracy of detection of low-flow hemorrhage. In cases where surgical intervention is not deemed appropriate, endovascular treatment provides an alternative means for cessation of hemorrhage associated with pelvic injuries. This may be achieved in a selective or nonselective manner depending on the patient's clinical status and time constraints. Consequently, a detailed understanding of vascular anatomy is essential, including an appreciation of the normal variant anatomy between males and females. Additional consideration must be given to variant anatomy which may co-exist in both sexes. This review article aims to provide a synopsis of endovascular management of pelvic vascular injury. Through case examples, available treatment options will be discussed, including thrombin injection and transcatheter arterial embolization. Furthermore, potential adverse complications of pelvic arterial embolization will be highlighted. Finally, in view of the potential severity of these injuries, a brief overview of initial management of the hemodynamically unstable patient is provided.
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Affiliation(s)
- Arlene Weir
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Padraic Kennedy
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Stella Joyce
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - David Ryan
- School of Medicine, University College Cork, Cork, Ireland
| | - Liam Spence
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Mark McEntee
- School of Medicine, University College Cork, Cork, Ireland
| | - Michael Maher
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - Owen O'Connor
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
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14
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Quencer KB. Endovascular interventions in trauma, an introduction. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1191. [PMID: 34430632 PMCID: PMC8350691 DOI: 10.21037/atm-20-4418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/13/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Keith Bertram Quencer
- Division of Interventional Radiology, Department of Radiology, University of Utah, Salt Lake City, UT, USA
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15
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Armbruster M, Seidensticker M. [Interventional radiology as emergency treatment for pelvic injuries]. Unfallchirurg 2021; 124:627-634. [PMID: 34283262 DOI: 10.1007/s00113-021-01045-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
CLINICAL ISSUE Pelvic arterial bleeding constitutes a potentially life-threatening event, which can be difficult to control with surgical procedures alone, especially in the case of ligamentous ruptures and a subsequently increased pelvic volume. STANDARD RADIOLOGICAL PROCEDURES Using angiography and embolization (AE) with resorbable gelatine-based particles or permanent coils, plugs, liquid embolic systems or by vascular stenting, in most cases traumatic pelvic arterial bleeding can be stopped and can also be used to close pseudoaneurysms, arteriovenous fistulas or dissections. METHODOLOGICAL INNOVATION AND EVALUATION The AE has become established as a fast and effective minimally invasive procedure in the treatment of traumatic pelvic vascular injuries with an advantageous risk-benefit ratio. PRACTICAL RECOMMENDATIONS An interdisciplinary approach should be used in the indications for AE; which can be used as definitive treatment as well as in combination with surgical procedures. To improve the clinical outcome any delay between establishing the indications and the start of the intervention must be avoided.
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Affiliation(s)
- Marco Armbruster
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - Max Seidensticker
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
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16
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El Khudari H, Abdel Aal AK. Endovascular Management of Pelvic Trauma. Semin Intervent Radiol 2021; 38:123-130. [PMID: 33883809 DOI: 10.1055/s-0041-1725112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Major pelvic fractures result from high-energy trauma including traffic accidents and falls, which usually leads to multiple injuries complicating the patient's management. Management of these patients requires a coordinated multidisciplinary approach. Transcatheter embolization is a minimally invasive and effective technique to control massive hemorrhage and can be performed using a variety of embolic agents. It has become an accepted first-line management option for retroperitoneal bleeds in many centers. In this article, the indications for endovascular management of hemorrhage from pelvic trauma, the various embolization techniques, and potential complications will be discussed.
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Affiliation(s)
- Husameddin El Khudari
- Division of Interventional Radiology, Department of Radiology, The University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Ahmed Kamel Abdel Aal
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
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17
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Abstract
Trauma is the leading cause of death in patients younger than 45 years. Over the last decade, there has been a progressive paradigm shift toward a nonoperative management of many blunt and penetrating injuries, placing interventional radiology in the forefront in this critical field. Transcatheter embolization is an established technique that plays a significant role in the modern treatment of traumatic injuries of the extremities, pelvis, and solid organs. The purpose of this article is to review the updated principles and techniques used in transcatheter embolization in trauma.
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Affiliation(s)
- Jorge E Lopera
- Department of Radiology, UT Health San Antonio, San Antonio, Texas
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18
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Luckhurst CM, Mendoza AE. The Current Role of Interventional Radiology in the Management of Acute Trauma Patient. Semin Intervent Radiol 2021; 38:34-39. [PMID: 33883799 PMCID: PMC8049765 DOI: 10.1055/s-0041-1725113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Trauma is one of the most common causes of death, particularly in younger individuals. The development of specialized trauma centers, trauma-specific intensive care units, and trauma-focused medical subspecialties has led to the formation of comprehensive multidisciplinary teams and an ever-growing body of research and innovation. The field of interventional radiology provides a unique set of minimally invasive, endovascular techniques that has largely changed the way that many trauma patients are managed. This article discusses the role of interventional radiology in the care of this complex patient population, and in particular how the specialty fits into the overall team management of these patients.
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Affiliation(s)
- Casey M. Luckhurst
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - April E. Mendoza
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
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19
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Perumal R, S DCR, P SS, Jayaramaraju D, Sen RK, Trikha V. Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates. J Clin Orthop Trauma 2021; 12:101-112. [PMID: 33716435 PMCID: PMC7920327 DOI: 10.1016/j.jcot.2020.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/30/2022] Open
Abstract
Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.
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Affiliation(s)
- Ramesh Perumal
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Sivakumar S. P
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Ramesh Kumar Sen
- Institute of Orthopedic Surgery, Max Super Specialty Hospital, Mohali, 160055, India
| | - Vivek Trikha
- Department of Orthopedics, All India Institute of Medical Science, New Delhi, 110029, India
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20
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Haraguchi T, Hamaguchi S. Nonselective Bilateral Embolization of Internal Iliac Arteries with N-Butyl-2-Cyanoacrylate in Hemodynamically Unstable Patients with Pelvic Fracture. INTERVENTIONAL RADIOLOGY 2021; 6:37-43. [PMID: 35909907 PMCID: PMC9327384 DOI: 10.22575/interventionalradiology.2019-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 04/08/2021] [Indexed: 11/17/2022]
Abstract
Purpose: This study was designed to evaluate the efficacy and safety of nonselective bilateral embolization of the internal iliac arteries (IIAs) with n-butyl-2-cyanoacrylate (NBCA) in hemodynamically unstable patients with pelvic fractures. Material and Methods: Twelve patients underwent nonselective bilateral embolization of the IIAs using NBCA diluted with lipiodol at our institution between January 2004 and March 2014. We analyzed the time of bilateral occlusion of the IIAs, the time from admission to entrance into the interventional radiology room, the need for repeat embolization, outcomes, cause of death, follow-up period, and complications. Results: The mean duration of bilateral occlusion of the IIAs was 17 min (range, 4-34 min), and the mean time from admission to entrance into the interventional radiology room was 89 min (range, 28-168 min). All patients underwent technically successful embolization. Repeat embolization was required after treatment in three patients. The mortality rate was 33.3%. Complications after embolization were suspected in one patient. Conclusions: Nonselective bilateral embolization of IIAs with NBCA could be a choice of treatment for hemodynamically unstable patients with severe pelvic fracture hemorrhage.
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Affiliation(s)
| | - Shingo Hamaguchi
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine
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21
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Kim H, Jeon CH, Kim JH, Sun HW, Ryu D, Lee KH, Park CI, Jang JH, Park SJ, Yeom SR. Transarterial embolisation is associated with improved survival in patients with pelvic fracture: propensity score matching analyses. Eur J Trauma Emerg Surg 2020; 47:1661-1669. [PMID: 32949247 PMCID: PMC8629886 DOI: 10.1007/s00068-020-01497-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/08/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Transarterial embolisation (TAE) is an effective intervention for management of arterial haemorrhage associated with pelvic fracture. However, its effects on survival and clinical outcomes are unclear. METHODS Trauma patients with survival data between November 2015 and December 2019 were identified using a trauma database. Patients were divided between TAE and non-TAE groups, and a propensity score was developed using multivariate logistic regression. Survival at 28 days was compared between the groups after propensity score matching. RESULTS Among 881 patients included in this study, 308 (35.0%) were treated with TAE. After propensity score matching, 130 pairs were selected. Survival at 28 days was significantly higher among patients treated with TAE than among those treated without TAE [122 (93.9%) vs. 112 (86.2%); odds ratio = 2.45; 95% CI 1.02-5.86; p = 0.039]. CONCLUSIONS TAE use was associated with improved survival at 28 days in patients with pelvic fracture and should therefore be considered in the management of severely injured patients with pelvic fracture.
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Affiliation(s)
- Hohyun Kim
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Pusan National University School of Medicine, Yangsan, Korea
| | - Chang Ho Jeon
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Pusan National University School of Medicine, Yangsan, Korea.,Department of Diagnostic Radiology, Pusan National University Hospital, Busan, Korea
| | - Jae Hun Kim
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739, Korea. .,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea. .,Pusan National University School of Medicine, Yangsan, Korea.
| | - Hyun-Woo Sun
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dongyeon Ryu
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kang Ho Lee
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Chan Ik Park
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jae Hoon Jang
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Pusan National University School of Medicine, Yangsan, Korea.,Department of Orthopaedic Surgery, Pusan National University Hospital, Busan, Korea
| | - Sung Jin Park
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Seok Ran Yeom
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Pusan National University School of Medicine, Yangsan, Korea.,Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
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22
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Abstract
EPIDEMIOLOGY Traumatic fractures of the pelvic ring are relatively rare, but are associated with increased risk of mortality. Depending on injury mechanism and main vector of energy impact, a distinction is made between anteroposterior compression, lateral compression, and vertical shear (Young and Burgess classification), while the stability-related classification according to Tile distinguishes between type A (stable), type B (rotationally unstable) and type C (completely unstable). A comprehensive modern classification is given by the AO/OTA. RADIOLOGICAL FRACTURE DIAGNOSIS Plain pelvis x‑rays lack sufficient sensitivity but are still used to detect highly unstable pelvic fractures. CT has superior sensitivity and specificity. In addition to fracture classification, CT allows reliable assessment of associated vascular and bladder/urethral injuries and large soft tissue hemorrhage. MRI is unparalleled in showing bone marrow edema, cauda and plexus complications, and peripelvic soft tissue damage. MRI may also prove to be a valuable diagnostic tool for pelvic ring injuries in children, adolescents and young women, provided they are hemodynamically stable. Angiography, ultrasonography and bone scintigraphy are additional important diagnostic and therapeutic options. PRACTICAL RECOMMENDATIONS Knowledge of basic pelvic trauma mechanisms is important to understand the potential severity of traumatic pelvic fractures and to classify them correctly in terms of stability. Being familiar with typical concomitant injuries in pelvic ring fractures allows reliable diagnosis and their communication with the clinician. CT remains the "diagnostic workhorse". In fragile pelvic fractures, the often prolonged course with fracture progression must be taken into account, which is why MRI is of particular importance herein.
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Affiliation(s)
- Thomas Grieser
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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23
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Do we really need the arterial phase on CT in pelvic trauma patients? Emerg Radiol 2020; 28:37-46. [PMID: 32686046 PMCID: PMC7835176 DOI: 10.1007/s10140-020-01820-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/08/2020] [Indexed: 11/03/2022]
Abstract
PURPOSE To evaluate whether an arterial phase scan improves the diagnostic performance of computed tomography to identify pelvic trauma patients who received angiographic intervention on demand of the trauma surgeon. METHODS This retrospective single-center study was performed at an academic Scandinavian trauma center with approximately 2000 trauma admissions annually. Pelvic trauma patients with arterial and portal venous phase CT from 2009 to 2015 were included. The patients were identified from the institutional trauma registry. Images were interpreted by two radiologists with more than 10 years of trauma radiology experience. Positive findings for extravasation on portal venous phase alone or on both arterial and portal venous phase were compared, with angiographic intervention as clinical outcome. RESULTS One hundred fifty-seven patients (54 females, 103 males) with a median age of 45 years were enrolled. Sixteen patients received angiographic intervention. Positive CT findings on portal venous phase only had a sensitivity and specificity of 62% and 86%, vs. 56% and 93% for simultaneous findings on arterial and portal venous phase. Specificity was significantly higher for positive findings in both phases compared with portal venous phase only. Applying a threshold > 0.9 cm of extravasation diameter to portal venous phase only resulted in sensitivity and specificity identical to those of both phases. CONCLUSION Arterial phase scan in addition to portal venous phase scan did not improve patient selection for angiography. Portal venous phase extravasation size alone may be used as an imaging-based biomarker of the need for angiographic intervention.
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24
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Selective angioembolization in a pelvic fracture patient with refractory bleeding and hemodynamic instability. Radiol Case Rep 2020; 15:624-627. [PMID: 32256923 PMCID: PMC7109378 DOI: 10.1016/j.radcr.2020.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 11/21/2022] Open
Abstract
Angioembolization for hemodynamically unstable patients with pelvic fracture has become the standard of care. However, the selection and extent of contrast of the distal artery in such patients remains undetermined. In this case, an octogenarian man was hit by a truck and was hemodynamically unstable with pelvic fracture. Based on enhanced computed tomography, selective angiography visualized arterial extravasation and the arterial bleeding could be arrested. This approach may be required for the treatment of patients in this setting.
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Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol 2020; 31:363-369.e2. [PMID: 31948744 DOI: 10.1016/j.jvir.2019.11.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 11/22/2022] Open
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Bonde A, Velmahos A, Kalva SP, Mendoza AE, Kaafarani HMA, Nederpelt CJ. Bilateral internal iliac artery embolization for pelvic trauma: Effectiveness and safety. Am J Surg 2019; 220:454-458. [PMID: 31902526 DOI: 10.1016/j.amjsurg.2019.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/01/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Bilateral internal iliac artery embolization (BIIAE) with temporary embolic materials epitomizes damage-control principles in the treatment of exsanguinating hemorrhage from pelvic trauma. However, instances of ischemic complications have been reported. The aim of our study was to assess safety and effectiveness of BIIAE. METHODS All patients who received BIIAE for pelvic trauma at a Level I Trauma Center between 1998 and 2018 were reviewed. Effectiveness was assessed by radiographic bleeding control and clinical bleeding control, i.e. stabilization of vital signs and reduction in blood transfusion. Safety was assessed by any evidence for ischemic damage of pelvic organs or tissues. RESULTS Of 61 patients undergoing BIIAE, bleeding control was confirmed radiographically in 60 (98%) and clinically in 55 (90%), including 4 (7%) patients who required repeat embolization. Six (10%) patients died due to insufficient pelvic bleeding control. No BIIAE-related complications were identified. CONCLUSION The overall clinical effectiveness and safety rates of BIIAE for pelvic bleeding control, when combined with other methods of hemostasis, were 90% and 100% respectively.
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Affiliation(s)
- Alexander Bonde
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States; Department of Anesthesia, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Andriana Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical, School, Boston, United States
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States
| | - Charlie J Nederpelt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States.
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Pelvic Fractures and Associated Genitourinary and Vascular Injuries: A Multisystem Review of Pelvic Trauma. AJR Am J Roentgenol 2019; 213:1297-1306. [DOI: 10.2214/ajr.18.21050] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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