The effect of angioembolization for life-threatening retroperitoneal hemorrhage in patients with pelvic fracture

Impact of Pelvic Fracture on Patients with Blunt Bowel Mesenteric Injury: Is Immediate Laparotomy Warranted?

The management of blunt abdominopelvic trauma with combined hemoperitoneum and pelvic fractures is challenging for trauma surgeons. Although angioembolization can achieve hemostasis in most visceral organ injuries and pelvic fractures after blunt abdominal trauma, it cannot effectively control hemorrhage in patients with blunt bowel mesenteric injury (BBMI). This study aimed to determine the risk factors associated with hemodynamically unstable patients with BBMI and to test the hypothesis that pelvic fracture is an independent risk factor for patients with unstable BBMI and concomitant pelvic fracture to guide the therapeutic sequence for difficult-to-manage patients. This retrospective study reviewed the data of hospitalized patients with trauma between 2009 and 2021 and included 158 adult patients with surgically proven BBMI. The patients were divided on the basis of the presence of a shock episode before emergency laparotomy. The shock group included 44.3% of all patients in the study (n = 70). Clinical injury severity and prognosis for patients in the shock group were poorer than those for patients in the non-shock group, and more invasive treatments and transfusions were performed for patients in the shock group than for those in the non-shock group. Pelvic fractures were more frequently associated with the shock group than with the non-shock group (21.4% vs. 5.7%; p = 0.003). In multivariate analysis, the presence of intracerebral hemorrhage (odds ratio [OR] = 10.87, 95% confidence intervals [CIs]: 1.70-69.75) and rib fracture (OR = 5.94, 95% CIs = 1.06-33.45) was identified as an independent predictor of shock, whereas the effect of pelvic fracture did not achieve statistical significance (OR = 2.94, 95% CIs = 0.66-13.13) after adjusting for confounding factors. For patients with BBMI, outcomes need to be improved during early diagnosis, and treatments should be expeditiously performed on the basis of the rapid identification of unstable hemodynamic status. Our results support the recommendation of emergency laparotomy in unstable patients with concomitant pelvic fractures, followed by damage control TAE if needed.

Speeding pelvic fracture fixation: CT scan with simultaneous 3-D pelvic reconstruction in the emergency department

INTRODUCTION

Contrast-enhanced computed tomography (CT) scans are usually needed in the emergency department (ED) to evaluate intra-abdominal injuries associated with pelvic fractures. Three-dimensional (3-D) images for pelvis reconstruction are also needed for planning surgical fixation after admission. This study investigates the advantages integrating a one-stage computed tomography (CT) scan with these two diagnostic modalities simultaneously to reduce the time to surgery and improve the outcomes of pelvic fracture fixation.

METHODS

A retrospective cohort study (2018-2021) of patients with pelvic fractures was performed. Patients were categorized into the one-stage CT group or the two-stage CT group, and propensity score matching was used to address biases. The outcome measures included time to surgical fixation, time to CT scan for 3-D pelvis reconstruction, and overall length of hospital stay.

RESULTS

Four hundred forty-four pelvic fracture patients who underwent definite surgical fixation were identified. Of those, 320 underwent a one-stage CT scan, while the remaining 124 underwent a two-stage CT scan. After well-balanced matching, those in the one-stage CT group had a significantly shorter time to surgical fixation than those in the two-stage CT group (4.6 vs. 6.8 days, p < 0.001). Even among critically ill patients necessitating intensive care unit (ICU) admission, the one-stage CT scan group had a shorter time to definitive surgical fixation (5.5 vs. 7.2 days, p = 0.002) and a shorter hospital stay (19.0 vs. 32.7 days, p = 0.006).

CONCLUSION

A one-stage contrast-enhanced CT scan combined with simultaneous 3-D pelvis reconstruction is promising for expediting surgical fixation in pelvic fracture patients. This innovative strategy may improve patient outcomes by facilitating timely surgical interventions and minimizing delays associated with additional CT scans.

Is It Beneficial to Optimize Vital Signs Before Embolization for Pelvic Fractures? A Dilemma Between Resuscitation and Hemostasis

Purpose

Adequate resuscitation and definitive hemostasis are both important in the management of hemorrhage related to pelvic fracture. The goal of this study was to analyze the relationship between the amount of blood transfused before transcatheter arterial embolization (TAE) and the clinical outcome later in the disease course.

Methods

Patients with pelvic fractures who underwent TAE for hemostasis from January 2018 to December 2019 were studied. The characteristics of patients who received blood transfusions of >2 U (1000 mL) and ≤2 U before TAE were compared. The mortality rate, blood transfusion-related complications, and length of stay were compared between these two groups.

Results

Among the 75 studied patients, 39 (52.0%) received blood transfusions of ≤2 U before TAE, and the other 36 (48.0%) patients received blood transfusions of >2 U before TAE. The incidence rates of systemic inflammatory response syndrome, sepsis, and coagulopathy were significantly higher in the >2 U group (97.2% vs 81.1%, P = .027; 50.0% vs 27.0%, P = .045; and 44.4% vs 5.4%, P < .01, respectively). After nonsurvivors were excluded, the >2 U group had a significantly higher proportion (43.8% vs 14.7%, P < .001) of prolonged intensive care unit (ICU) length of stay (7 days or more) and a longer hospital length of stay (33.8 ± 15.1 vs 21.9 ± 94.0, P < .01) than the ≤2 U group. Pre-TAE blood transfusion >2 U serves as an independent risk factor for prolonged ICU length of stay and increased hospital length of stay.

Conclusion

Early hemostasis for pelvic fracture-related hemorrhage is suggested to prevent pre-TAE blood transfusion-associated adverse effects of blood transfusion.

Accuracy of the WSES classification system for pelvic ring disruptions: an international validation study

Background

In 2017, a novel classification for pelvic injuries was established by the World Society of Emergency Surgery (WSES). We validated its effectiveness using nationwide real-world data. The roles of associated vascular injury and open fracture in this system were also evaluated.

Methods

Patients with pelvic fractures in the National Trauma Data Bank 2015 dataset were retrospectively studied. First, the mortality rates were compared by WSES classification. Second, independent predictors of mortality were evaluated using a multivariate logistic regression model. Patients with and without associated vascular injuries and the same hemodynamic and pelvic ring stability statuses were compared. Patients with associated vascular injuries were compared to the proportion of nonsurvivors and survivors with unstable pelvic ring injuries. Third, the outcomes were compared between patients with open pelvic fracture and closed pelvic fracture in the mild, moderate and severe WSES classes.

Results

During the 12-month study period, 44,163 blunt pelvic fracture patients were included. The mortality rates were 1.8%, 3.8% and 10.6% for the mild, moderate and severe WSES classes, respectively (p < 0.001). MLR analysis showed that unstable pelvic ring injury did not significantly affect mortality (p = 0.549), whereas open pelvic fracture and associated vascular injury were independent predictors of mortality (odds of mortality: open pelvic fracture 1.630, p < 0.001; associated vascular injury 1.602, p < 0.001). Patients with associated vascular injuries showed that there was no significant difference in the proportion of patients with unstable pelvic ring injuries between survivors and nonsurvivors (37.2% vs. 32.7%, p = 0.323). In all three classes, patients with open pelvic fractures had significantly higher mortality rates and infection rates than patients with closed fractures (mortality rates: minor 3.5% vs. 1.8%, p = 0.009, moderate 11.2% vs. 3.3%, p < 0.001, severe 23.8% vs. 9.8%, p < 0.001; infection rates: minor 3.3% vs. 0.7%, p < 0.001, moderate 6.7% vs. 2.1%, p < 0.001, severe 7.9% vs. 2.8%, p < 0.001).

Conclusions

Based on this nationwide study, the WSES guideline provides an accurate and reproducible classification of pelvic fractures. It is recommended that open/closed fractures and associated vascular injuries be evaluated as supplements of the WSES classification.

Acute external iliac artery thrombosis following pelvic fractures: Two case reports

RATIONALE

Pelvic fractures associated with acute external iliac artery thrombosis is less common, it is easily ignored in clinical practice, and it can result in limb amputation and hemipelvectomy due to prolonged limb ischemia. We present 2 patients with acute external iliac artery thrombosis following pelvic fractures.

PATIENT CONCERNS

Case 1 is a 49-year-old male with occlusion of the right external iliac artery and pelvic fractures. Case 2 is a 52-year-old male with left external iliac artery occlusion and bilateral internal iliac artery rupture following pelvic fractures.

DIAGNOSES

Case 1 was diagnosed with computed tomography angiography. Case 2 was diagnosed with ultrasound examination and computed tomography angiography.

INTERVENTIONS

Case 1 was performed an open incision to remove thrombus of the right external iliac artery, the right iliac-femoral artery artificial bypass was adopted to restore the blood flow. Case 2 underwent segmental resection of the damaged artery and artificial vascular implantation of left external iliac artery, and angiographic embolization of bilateral internal iliac artery. However, a left hip disarticulation was performed due to osteofascial compartment syndrome at last.

OUTCOMES

Case 1 was cured and discharged smoothly. Case 2 survived but left with a disability after disarticulation.

LESSONS

Acute external iliac artery thrombosis after pelvic fractures is rare and limb-threatening, life-threatening. It is very important to detect and treat this potential complication timely when a patient with a pelvic fracture.

Transarterial embolisation is associated with improved survival in patients with pelvic fracture: propensity score matching analyses

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.

The Road to Survival for Haemodynamically Unstable Patients With Open Pelvic Fractures

Management of haemodynamically unstable pelvic ring injuries has been simplified into treatment algorithms to streamline care and emergent decision making in order to improve patient outcomes whilst decreasing mortality and morbidity. Pelvic ring injuries are most commonly a result of high-velocity and energy forces that exert trauma to the pelvic bones causing not only damage to the bone but the surrounding soft-tissue, organs, and other structures and are usually accompanied by injuries to other parts of the body resulting in a polytraumatised patient. Open pelvic fractures are a rare subset of pelvic ring fractures that are on the more severe end of the pelvic fracture continuum and usually produce uncontrolled haemorrhage from fractured bone, retroperitoneal haematomas, intraabdominal bleeding from bowel injury, soft tissue injuries to the anus, perineum, and genitals, fractures of the pelvic bones, causing bleeding from cancellous bone, venous, and arterial injuries combined with bleeding from concomitant injuries. This is a very complex and challenging clinical situation and timely and appropriate decisions and action are paramount for a positive outcome. Consequently, open pelvic fractures have an extremely high rate of mortality and morbidity and outcomes remain poor, despite evidence-based improvements in treatment, knowledge, and identification of haemorrhage; in the pre-hospital, critical care, and operative settings. In the future utilisation of haemostatic drugs, dressings, devices, and procedures may aid in the time to haemorrhage control.

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Background

The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity.

Methods

Medical records of patients with pelvic fracture at a single center between January 2016 and December 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥ 3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups.

Results

Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p = 0.000) and total hospital stay (20.7 vs. 10.1 days, p = 0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear, and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I, and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p = 0.034). These findings were similar even if only patients with ISS ≥ 16 were considered.

Conclusions

Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to the outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.

High incidence of surgical site infection may be related to suboptimal case selection for non-selective arterial embolization during resuscitation of patients with pelvic fractures: a retrospective study

Background

In most institutions, arterial embolization (AE) remains a standard procedure to achieve hemostasis during the resuscitation of patients with pelvic fractures. However, the actual benefits of AE are controversial. In this study, we aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of contrast extravasation (CE) during computed tomography (CT) for patients with hemodynamically unstable closed pelvic fractures.

Methods

We retrospectively reviewed data from patients who were treated for closed pelvic fractures at a single center between 2014 and 2017. Data regarding the AE and clinical parameters were analyzed to determine whether poor outcomes could be predicted.

Results

During the study period, 545 patients were treated for closed pelvic fractures, including 131 patients who underwent angiography and 129 patients who underwent AE. Nonselective bilateral internal iliac artery embolization (nBIIAE) was the major AE strategy (74%). Relative to the non-AE group, the AE group had higher values for injury severity score, shock at hospital arrival, and unstable fracture patterns. The AE group was also more likely to require osteosynthesis and develop surgical site infections (SSIs). Fourteen patients (10.9%) experienced late complications following the AE intervention, including 3 men who had impotence at the 12-month follow-up visit and 11 patients who developed SSIs after undergoing AE and osteosynthesis (incidence of SSI: 11/75 patients, 14.7%). Nine of the 11 patients who developed SSI after AE had undergone nBIIAE. The positive predictive value of CE during CT was 29.6%, with a negative predictive value of 91.3%. Relative to patients with identifiable CE, patients without identifiable CE during CT had a higher mortality rate (30.0% vs. 11.0%, p = 0.03).

Conclusion

Performing AE for pelvic fracture-related hemorrhage may not be best practice for patients with no CE detected during CT or for unstable patients who do not respond to resuscitation after exclusion of other sources of hemorrhage. Given the high incidence of SSI following nBIIAE, this procedure should be selected with care. Given their high mortality rate, patients without CE during imaging might be considered for other hemostasis procedures, such as preperitoneal pelvic packing.

Inequality of trauma care under a single-payer universal coverage system in Taiwan: a nationwide cohort study from the National Health Insurance Research Database

​OBJECTIVES: To assess the impact of lower socioeconomic status on the outcome of major torso trauma patients under the single-payer system by the National Health Insurance (NHI) in Taiwan. ​DESIGN: A nationwide, retrospective cohort study. ​SETTING: An observational study from the NHI Research Database (NHIRD), involving all the insurees in the NHI. ​PARTICIPANTS: Patients with major torso trauma (injury severity score ≥16) from 2003 to 2013 in Taiwan were included. International Classification of Disease, Ninth Revision, Clinical Modification codes were used to identify trauma patients. A total of 64 721 patients were initially identified in the NHIRD. After applying the exclusion criteria, 20 009 patients were included in our statistical analysis. ​PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was in-hospital mortality, and we analysed patients with different income levels and geographic regions. Multiple logistic regression was used to control for confounding variables. ​RESULTS: In univariate analysis, geographic disparities and low-income level were both risk factors for in-hospital mortality for patients with major torso trauma (p=0.002 and <0.001, respectively). However, in multivariate analysis, only a low-income level remained an independent risk factor for increased in-hospital mortality (p<0.001). ​CONCLUSION: Even with the NHI, wealth inequity still led to different outcomes for major torso trauma in Taiwan. Health policies must focus on this vulnerable group to eliminate inequality in trauma care.

Hemostasis as soon as possible? The role of the time to angioembolization in the management of pelvic fracture

Introduction

While transcatheter arterial embolization (TAE) is an effective way to control arterial bleeding associated with pelvic fracture, delayed TAE may increase mortality risk. The purpose of the current study was to determine how time to TAE affects outcomes in patients with pelvic fracture in the emergency department.

Methods

From January 2014 to December 2016, the trauma registry and medical records of patients with pelvic fracture who underwent TAE were retrospectively reviewed. The relationship between the time to TAE and patient outcomes was evaluated. The characteristics of surviving and deceased patients were also compared to search for prognostic factors affecting survival.

Results

Eighty-four patients were enrolled in the current study. Among patients with pelvic fracture who underwent TAE, the overall mortality rate was 16.7%. There were positive relationships between the time to TAE and the requirement for blood transfusion and between the time to TAE and intensive care unit (ICU) length of stay (LOS). Nonsurviving patients were significantly older (57.4 ± 23.3 vs. 42.7 ± 19.3 years old, p = 0.014) and had higher injury severity scores (ISSs) (36.4 ± 11.9 vs. 23.9 ± 10.9, p < 0.001) than were observed in surviving patients. There was no significant difference in the time to TAE between nonsurviving and surviving patients (76.9 ± 47.9 vs. 59.0 ± 29.3 min, p = 0.068). The multivariate logistic regression analysis showed that ISS and age served as independent risk factors for mortality. Every one unit increase in ISS or age resulted in a 1.154- or 1.140-fold increase in mortality, respectively (p = 0.033 and 0.005, respectively). However, the time to TAE serves as an independent factor for ICU LOS (p = 0.015).

Conclusion

In pelvic fracture patients who require TAE for hemostasis, longer time to TAE may cause harm. An early hemorrhage control is suggested.

Factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma: a retrospective study

Background

Blunt pelvic injuries are often associated with pelvic fractures and injuries to the rectum and genitourinary tract. Pelvic fractures can lead to life-threatening hemorrhage, which is a common cause of morbidity and mortality in trauma. Thus, early identification of patients with pelvic fractures at risk severe bleeding requiring urgent hemorrhage control is crucial. This study aimed to investigate early factors predicting the need for hemorrhage control in blunt pelvic trauma.

Methods

The medical records of 1760 trauma patients were reviewed retrospectively between January 2013 and June 2018. We enrolled 187 patients with pelvic fracture due to blunt trauma who were older than 15 years. The pelvic fracture pattern was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) classification. A multivariate logistic regression model was used to determine independent predictors of the need for pelvic hemorrhage control intervention.

Results

The most common pelvic fracture pattern was type A (54.5%), followed by types B (36.9%) and C (8.6%). Of 187 patients, 48 (25.7%) required pelvic hemorrhage control intervention. Hemorrhage control interventions were most frequently performed in patients with type B fractures (54.2%). Multivariate logistic regression analysis revealed that type B (odds ratio [OR] = 4.024, 95% confidence interval [CI] = 1.666–9.720, p = 0.002) and C (OR = 7.077, 95% CI = 1.781–28.129, p = 0.005) fracture patterns, decreased body temperature (OR = 2.275, 95% CI = 0.134–0.567, p < 0.001), and elevated serum lactate level (OR = 1.234, 95% CI = 1.061–1.435, p = 0.006) were factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma.

Conclusion

Patients with type B and C fracture patterns on the OTA/AO classification, hypothermia, or an elevated serum lactate level are at risk for bleeding and require pelvic hemorrhage control intervention.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0438-8) contains supplementary material, which is available to authorized users.