The role of angio-embolization in the acute treatment concept of severe pelvic ring injuries

Anterior peri-sacroiliac joint osteotomy in the treatment of malunion and nonunion of complex pelvic ring fracture: techniques and preliminary results

PURPOSE

To introduce anterior peri-sacroiliac joint osteotomy (APSJO) through the lateral-rectus approach (LRA) for treating pelvic fracture malunion and nonunion, and to evaluate the safety, feasibility, and potential effectiveness.

METHODS

Data of 15 patients with pelvic fracture malunion and nonunion who underwent treatment by APSJO were selected and analyzed. The reduction quality was assessed using the Mears and Velyvis criteria, while the pre-operative and post-operative function was revealed by the Majeed scoring system. The British Medical Research Council (BMRC) grading system was recruited for the evaluation of lumbosacral plexus function.

RESULTS

The average operative duration was 264.00 ± 86.75 min, while the intra-operative blood loss was 2000 (600, 3000) mL. Anatomical reduction was complete in three cases, satisfactory in ten cases, and unsatisfactory in two cases. Among the seven patients with lumbosacral plexus injury, the pre-operative Majeed grades were good in two cases, fair in two cases, and poor in three cases, while the post-operative Majeed grades were excellent in three cases, good in three cases, and fair in one case. Muscle strength recovered to M5 in two cases, M4 in three cases, and showed no recovery in two cases. The pre-operative Majeed grades were good in five cases, fair in two cases, and poor in one case of the series without lumbosacral plexus injury, while the post-operative Majeed grades were excellent in seven cases and good in one case.

CONCLUSION

APSJO through LRA may be a feasible strategy for treating pelvic fracture malunion and nonunion with promising application.

Pelvic fractures in blunt trauma patients: A comparative study

BACKGROUND

Pelvic fractures (PF) with concomitant injuries are on the rise due to an increase of high-energy trauma. Increase of the elderly population with age related comorbidities further complicates the management. Abdominal organ injuries are kindred with PF due to the proximity to pelvic bones. Presence of contrast blush (CB) on computed tomography in patients with PF is considered a sign of active bleeding, however, its clinical significance and association with outcomes is debatable.

AIM

To analyze polytrauma patients with PF with a focus on the geriatric population, co-injuries and the value of contrast blush.

METHODS

This retrospective cohort study included 558 patients with PF admitted to level 1 trauma center (01/2017-01/2023). Analyzed variables included: Age, sex, mechanism of injury (MOI), injury severity score (ISS), Glasgow coma scale (GCS), abbreviated injury scale (AIS), co-injuries, transfusion requirements, pelvic angiography, embolization, laparotomy, orthopedic pelvic surgery, intensive care unit and hospital lengths of stay, discharge disposition and mortality. The study compared geriatric and non-geriatric patients, patients with and without CB and abdominal co-injuries. Propensity score matching was implemented in comparison groups.

RESULTS

PF comprised 4% of all trauma admissions. 89 patients had CB. 286 (52%) patients had concomitant injuries including 93 (17%) patients with abdominal co-injuries. Geriatric patients compared to non-geriatric had more falls as MOI, lower ISS and AIS pelvis, higher GCS, less abdominal co-injuries, similar CB and angio-embolization rates, less orthopedic pelvic surgeries, shorter lengths of stay and higher mortality. After propensity matching, orthopedic pelvic surgery rates remained lower (8% vs 19%, P < 0.001), hospital length of stay shorter, and mortality higher (13% vs 4%, P < 0.001) in geriatric patients. Out of 89 patients with CB, 45 (51%) were embolized. After propensity matching, patients with CB compared to without CB had more pelvic angiography (71% vs 12%, P < 0.001), higher embolization rates (64% vs 22%, P = 0.02) and comparable mortality.

CONCLUSION

Half of the patients with PF had concomitant co-injuries, including abdominal co-injuries in 17%. Similarly injured geriatric patients had higher mortality. Half of the patients with CB required an embolization.

Concomitant severe traumatic brain injury is not associated with increased red blood cell transfusion volumes in patients with pelvic fractures: A retrospective observational study

INTRODUCTION

Traumatic brain injury (TBI)-associated coagulopathy significantly influences survival outcomes in patients with multiple injuries. Severe TBI can potentially affect systemic hemostasis due to coagulopathy; however, there is limited evidence regarding whether the risk of hemorrhage increases in patients with pelvic fractures complicated with TBI. Therefore, through multivariable analysis, we aimed to examine the association between severe TBI and increased blood transfusion requirements in patients with pelvic fractures.

MATERIALS AND METHODS

This retrospective observational study was conducted at a tertiary care facility in Japan. Patients aged 16 years or older with pelvic fractures who were admitted to our intensive care unit between April 2014 and December 2021 were included in the analysis. The patients were categorized into no to mild and severe TBI groups according to whether the Head Abbreviated Injury Scale (AIS) score was 3 or higher. The primary outcome was the number of red blood cell (RBC) units transfused within 24 h after arrival at the hospital. The primary outcome was analyzed using univariable and multivariable linear regression analyses. The covariates used for the multivariable linear regression analysis were age, sex, antithrombotic therapy, mechanism of injury, Pelvic AIS score, and extravasation on contrast-enhanced computed tomography on admission.

RESULTS

We identified 315 eligible patients (221 and 94 in the no to mild and severe TBI groups, respectively). In the univariable analysis, the RBC transfusion volume within 24 h after arrival was significantly higher in the severe TBI group than in the no to mild TBI group (2.53-unit increase; 95 % confidence interval [CI]: 0.46-4.61). However, in the multivariable analysis, no statistically significant association was detected between severe TBI and the RBC transfusion volume within 24 h after arrival at the hospital (0.87-unit increase; 95 % CI: -1.11-2.85).

CONCLUSIONS

Concomitant severe TBI was not associated with increased RBC transfusion volumes in patients with pelvic fractures on multivariable analysis.

Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis

INTRODUCTION

Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital.

METHODS

All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint.

RESULTS

Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups.

CONCLUSION

Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

The pelvic vascular injury score (P-VIS): a prehospital instrument to detect significant vascular injury in pelvic fractures

PURPOSE

The purpose of this study was to identify predictive factors for peri-pelvic vascular injury in patients with pelvic fractures and to incorporate these factors into a pelvic vascular injury score (P-VIS) to detect severe bleeding during the prehospital trauma management.

METHODS

To identify potential predictive factors, data were taken (1) of a Level I Trauma Centre with 467 patients (ISS ≥ 16 and AISPelvis ≥ 3). Analysis including patient's charts and digital recordings, radiographical diagnostics, mechanism and pattern of injury as well as the vascular bleeding source was performed. Statistical analysis was performed descriptively and through inference statistical calculation. To further analyse the predictive factors and finally develop the score, a 10-year time period (2012-2021) of (2) the TraumaRegister DGU® (TR-DGU) was used in a second step. Relevant peri-pelvic bleeding in patients with AISPelvis ≥ 3 (N = 9227) was defined as a combination of the following entities (target group PVITR-DGU N = 2090; 22.7%): pelvic fracture with significant bleeding (> 20% of blood volume), Injury of the iliac or femoral artery or blood transfusion of ≥ 6 units (pRBC) prior to ICU admission. The multivariate analysis revealed nine items that constitute the pelvic vascular injury score (P-VIS).

RESULTS

In study (1), 467 blunt pelvic trauma patients were included of which 24 (PVI) were presented with significant vascular injury (PVI, N = 24; control (C, N = 443). Patients with pelvic fractures and vascular injury showed a higher ISS, lower haemoglobin at admission and lower blood pressure. Their mortality rate was higher (PVI: 17.4%, C: 10.3%). In the defining and validating process of the score within the TR-DGU, 9227 patients met the inclusion criteria. 2090 patients showed significant peripelvic vascular injury (PVITR-DGU), the remaining 7137 formed the control group (CTR-DGU). Nine predictive parameters for peripelvic vascular injury constituted the peripelvic vascular injury score (P-VIS): age ≥ 70 years, high-energy-trauma, penetrating trauma/open pelvic injury, shock index ≥ 1, cardio-pulmonary-resuscitation (CPR), substitution of > 1 l fluid, intubation, necessity of catecholamine substitution, remaining shock (≤ 90 mmHg) under therapy. The multi-dimensional scoring system leads to an ordinal scaled rating according to the probability of the presence of a vascular injury. A score of ≥ 3 points described the peripelvic vascular injury as probable, a result of ≥ 6 points identified a most likely vascular injury and a score of 9 points identified an apparent peripelvic vascular injury. Reapplying this score to the study population a median score of 5 points (range 3-8) (PVI) and a median score of 2 points (range 0-3) (C) (p < 0.001). The OR for peripelvic vascular injury was 24.3 for the patients who scored > 3 points vs. ≤ 2 points. The TR-DGU data set verified these findings (median of 2 points in CTR-DGU vs. median of 3 points with in PVITR-DGU).

CONCLUSION

The pelvic vascular injury score (P-VIS) allows an initial risk assessment for the presence of a vascular injury in patients with unstable pelvic injury. Thus, the management of these patients can be positively influenced at a very early stage, prehospital resuscitation performed safely targeted and further resources can be activated in the final treating Trauma Centre.

Superior gluteal artery injury in pelvic ring injury and acetabular fracture: Single center observational study

BACKGROUND

Intrapelvic hemorrhage following pelvic fractures, including pelvic ring and acetabular fractures, originates from the venous system and the fracture. Arterial injury often causes significant bleeding and hemodynamic instability. The superior gluteal artery (SGA) is a frequently injured artery in patients with pelvic fractures. This study investigated the incidence and pattern of SGA injuries associated with pelvic fractures.

METHODS

We retrospectively reviewed the medical records of patients with pelvic fractures who visited our institution between January 2016 and April 2022. Patients who underwent angiography for suspected arterial injury and SGA embolization were identified. Furthermore, the demographics and patterns of pelvic fractures were evaluated.

RESULTS

In total, 2042 patients with pelvic fractures visited our trauma emergency department and 498 patients (24.4%) underwent embolization for arterial injuries. Of these, 30 patients (1.5% of the total and 6.0% of the patients who underwent procedures) received embolization therapy of the main trunk of the SGA. The mean age of patients was 51.2 (23-85 years), and the injury mechanisms were all high-energy injuries. There were 19 pelvic ring injuries, eight acetabular fractures, and three combined injuries. Acetabular fractures involved mostly both columns. The three combined injuries were lateral compression involving both columns, vertical shear involving both columns, and lateral compression with T-type fractures. Twelve (40.0%) occurred through the sciatic notch of different patterns.

CONCLUSIONS

SGA injury occurred in 1.5% of all pelvic fractures and was identified in 6% of patients receiving embolization. SGA injury occurs through various injury mechanisms and fracture patterns, even in the absence of a fracture in the sciatic notch. However, no conclusions could be drawn in this study on the association between SGA injuries, injury mechanisms, and fracture patterns. Since the prediction of SGA injury by fracture pattern is limited, angiography should be performed regardless of fracture pattern when an injury is suspected.

[Interventional Management for Pelvic Trauma]

Traumatic pelvic injuries usually include high-energy crush injuries and are associated with significant morbidity and mortality. Mortality rates range from 6% to 15% and increase to 36%-54% in cases of fractures that result in increased pelvic volume. Therefore, retroperitoneal hemorrhage can spiral and progress to hemorrhagic shock. Pelvic hemorrhage most commonly occurs secondary to disrupted pelvic veins or fractured bones, and 10%-20% of cases involve arterial injuries. Owing to extensive bleeding and limitations of surgery for pelvic hemorrhage, interventional treatment is at the forefront of pelvic hemorrhage management. CT is an accurate indicator of active hemorrhage in patients with pelvic trauma that affects the diagnosis and management, including interventions. Identification of the site of hemorrhage is necessary for focused interventional treatment. The current trend toward a more conservative approach for treatment of pelvic trauma and advances in interventional radiology in the field of pelvic trauma may favor widespread use of interventional treatment for patients with pelvic injuries. In this review, we discuss therapeutic modalities available to the interventional radiologist and common angiographic treatment strategies and techniques.

Bladder deformity accompanied by pelvic fracture indirectly indicates clinical severity

BACKGROUND

That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF.

METHODS

From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups.

RESULTS

During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group.

CONCLUSIONS

The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF.

Prolonged ileus in traumatic pelvic ring injury patients who underwent arterial angio-embolization: A retrospective study

Paralytic ileus occurs in up to 18% of the patients with pelvic bone fractures. The aim of this study is to determine if massive bleeding requiring arterial angio-embolization is related with the duration of ileus in patients with traumatic pelvic ring injuries. This retrospective study included 25 patients who underwent arterial angio-embolization for traumatic pelvic ring injuries. Data were collected from prospectively maintained databases of two independent hospitals. Demographic characteristics (such as age, sex, body mass index, and Charlson Comorbidity Index), cause of trauma, and severity of pelvic injuries were similar in the non-prolonged and prolonged ileus groups. As expected, the prolonged ileus group had a significantly longer duration of ileus than the non-prolonged ileus group (8.0 ± 4.2 days vs 1.2 ± 0.4 days, respectively; P < .001). The mortality rate was higher in the prolonged ileus group (20% vs 0%), but it was not significantly different (P = .13). Interestingly, the prolonged ileus group received significantly higher amounts of packed red blood cell transfusions (6.1 ± 2.1 units vs 3.8 ± 2.5 units; P = .02). The amount of packed red blood cell transfusions was associated with a greater risk of prolonged ileus development (P = .03, odds ratio = 2.04, 95% confidence interval = 1.08-3.88). This study supports the idea that the duration of the ileus is related with the amount of bleeding caused by the traumatic pelvic ring injury. In order to prevent further complications, conservative treatments of the ileus should be considered.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing

INTRODUCTION

in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality.

METHODS

a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing.

RESULTS

data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05).

CONCLUSION

age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

Fatores preditivos de mortalidade em pacientes com fratura de pelve e instabilidade hemodinâmica submetidos ao tamponamento extraperitoneal de pelve

RESUMO Introdução: nas últimas décadas, tem sido difundida a técnica de tamponamento pélvico extraperitoneal, porém ainda existem poucos estudos. Decidiu-se analisar os resultados do tamponamento extraperitoneal de pelve, em pacientes com fratura pélvica e choque, com objetivo de identificar fatores preditivos de mortalidade. Métodos: foi realizada revisão do prontuário dos pacientes submetidos ao tamponamento extraperitoneal de pelve. Foram analisadas as características dos pacientes, dados do atendimento pré-hospitalar e na sala de emergência, classificação da fratura, presença de lesões associadas, exames laboratoriais e de imagem, dados relativos ao tamponamento, e outros procedimentos realizados, complicações, parâmetros hemodinâmicos e quantidade de hemoderivados transfudidos. Resultados: foram analisados os dados de 51 pacientes, com sinais de choque desde o atendimento pré-hospitalar, presença de acidose, elevado déficit de bases e lactato arterial. Houve alta prevalência de lesões graves associadas, requerendo múltiplos procedimentos cirúrgicos. A incidência de coagulopatia foi 70,58% e mortalidade 56,86%. O grupo de pacientes não sobreviventes apresentou idade e intubação orotraqueal pré-hospitalar maiores, e escores na escala de coma de Glasgow menores (p<0,05). O mesmo grupo apresentou, antes e após o tamponamento extraperitoneal de pelve, parâmetros hemodinâmicos menores de pressão arterial média, pH, déficit de bases e hemoglobina, e maior de lactato arterial (p<0,05). O grupo de pacientes não sobreviventes recebeu mais concentrados de hemácias, plasma fresco congelado e concentrado de plaquetas nas 24h seguintes ao tamponamento extraperitoneal de pelve (p<0,05). Conclusão: idade e o excesso de bases são fatores preditivos independentes de mortalidade em pacientes submetidos ao tamponamento extraperitoneal de pelve.

Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma

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.

[Interventional radiology as emergency treatment for pelvic injuries]

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.

Does transarterial pelvic embolization have a negative effect on perioperative outcomes in pelvic ring injury and acetabular fracture?

OBJECTIVE

The purpose of this study was to determine whether TAE negatively impacted perioperative outcomes in patients who underwent open surgery for pelvic trauma.

METHODS

We retrospectively reviewed the medical records and radiographs of patients who had open surgery for an acute pelvic trauma between February 2014 and May 2017. The patients were classified into two groups: those who underwent TAE and those who did not. We evaluated preoperative demographics and perioperative outcomes between the two groups. Injury type-specific comparisons were also performed.

RESULTS

A total of 136 patients (50 TAE and 86 non-TAE) were included in this study. There were significant differences in preoperative demographics including the type of injury, injury severity score, revised trauma score, surgical approach, initial blood pressure, and the amount of transfusion within 24 h between the two groups. However, no differences in perioperative outcomes were identified except for the amount of total transfusion. There were significant differences between the two groups in the injury type-specific comparisons, specifically in the amount of transfusion within 24 h in patients with pelvic ring injury and in the injury severity score in patients with acetabular fracture. However, there was no difference in perioperative outcomes between the groups for either injury type.

CONCLUSION

In the present study, we were unable to identify negative effects of TAE on perioperative outcomes. Therefore, when considering open surgery subsequent to TAE, there is no evidence of increased risk for negative perioperative outcomes, especially with respect to bone healing and deep infection.

Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis

INTRODUCTION

Treatment of pelvic trauma related hemorrhage is challenging and remains controversial. In hemodynamically unstable patients suspected for massive bleeding, pre-peritoneal packing (PPP) with temporary external fixation (EF) and subsequent trans-arterial embolization (TAE) can be performed in order to control bleeding. In hemodynamically stable patients suspected for minor to moderate bleeding, primary TAE with EF may be performed. The goal of this study was to determine effectiveness and safety of both strategies.

METHODS

Retrospectively, patients that received treatment for pelvic trauma-related hemorrhage at two level 1 trauma centers located in the United States between January 2001 and January 2019 were evaluated. Both centers advocate subsequent TAE in addition to PPP and EF in hemodynamically unstable patients, and primary TAE in stable patients. Demographic and clinical data was collected and mortality, ischemic and infectious complications were determined.

RESULTS

In total, 135 patients met the inclusion criteria. Of these, 61 hemodynamically unstable patients suspected for massive pelvic bleeding underwent primary PPP (45%) and 74 stable patients suspected for minor/moderate bleeding underwent primary TAE (55%). In total, 37/61 primary PPP patients underwent EF (61%) and 48 underwent adjunct TAE (79%), performed bilaterally in 77% and unselective by use of gelfoam in 72% of cases. Primary TAE patients received embolization bilaterally in 49% and unselective in 35% of cases. Exsanguination-related deaths were found in 7/61 primary PPP patients (11%). There were none among the primary TAE patients. Potentially ischemic in-hospital complications, of which one could be considered severe (gluteal necrosis), occurred more in patients that received bilateral unselective TAE compared to all other TAE patients (p=0.02).

CONCLUSION

Primary TAE appears to be an effective and safe adjunct for (minor) pelvic hemorrhage in hemodynamically stable patients. Primary PPP followed by EF and adjunct bilateral unselective TAE with gelfoam appears effective for those suspected of massive pelvic bleeding. This unselective embolization approach using gelfoam might be related to (ischemic) complications. When considering the amount and severity of complications and the severity of pelvic trauma, these might not outweigh the benefit of fast hemorrhage control.

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database

BACKGROUND

Knowledge on practice patterns for aortic occlusion (AO) in the setting of severe pelvic fractures is limited. This study aimed to describe clinical outcomes based on number and types of interventions after zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment.

METHODS

A retrospective review of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery multicenter registry was performed for patients who underwent zone 3 AO from 2013 to 2020. Patients with a blunt mechanism who survived beyond the emergency department were included. Interventions evaluated were preperitoneal pelvic packing (PP), angioembolization (AE), and external fixation (EF) of the pelvis. Management approaches were compared against the primary outcome of mortality. Secondary outcomes included transfusion requirements, overall complications and acute kidney injury (AKI).

RESULTS

Of 207 patients who underwent zone 3 AO, 160 (77.3%) fit the inclusion criteria. Sixty (37.5%) underwent AO alone, 50 (31.3%) underwent a second hemostatic intervention, and 49 (30.6%) underwent a third hemostatic intervention. Overall mortality was 37.7% (n = 60). There were no differences in mortality based on any number or combination of interventions. On multivariable regression, only EF was associated with a mortality reduction (odds ratio, 0.22; p = 0.011). Increasing number of interventions were associated with higher transfusion and complication rates. Pelvic packing + AE was associated with increased AKI than PP or AE alone (73.3% vs. 29.5% and 28.6%, p = 0.005), and AE was associated with increased AKI resulting in dialysis than PP alone (17.9% vs. 6.8%, p = 0.036).

CONCLUSION

Zone 3 REBOA can be used as a standalone hemorrhage control technique and as an adjunct in the management of severe pelvic fractures. The only additional intervention associated with a mortality reduction was EF. The benefit of increasing number of interventions must be weighed against more harm. Heterogeneity in practice patterns for REBOA use in pelvic fracture management underscores the need for an evidence base to standardize care.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries

Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated.

Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization.

Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury.

Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.

Is Blush on CT Scan in Patients With Pelvic Fracture Associated With Embolization Rates and Outcomes?

INTRODUCTION

In trauma patients with pelvic fractures, computed tomography (CT) scans are a critical tool to evaluate life-threatening hemorrhage. Contrast extravasation, or "blush", on CT may be a sign of bleeding, prompting a consult for angiography and possible embolization. However, the utility of blush on CT is controversial. We sought to evaluate our experience with patients who sustained pelvic fractures and had blush on CT.

METHOD

A retrospective review was performed for all patients with blunt pelvic fractures between January 1, 2017 and December 31, 2018. Demographic, clinical, radiographic, and injury data were obtained. Comparison of mortality, hospital length of stay (LOS), and intensive care unit (ICU) LOS was performed for 3 subgroups: angio versus no angio; embo versus no embo; prophylactic embo versus therapeutic embo. We also calculated the sensitivity, specify, positive predictive value (PPV), and negative predictive value (NPV) of CT blush to predict the need for embolization.

RESULTS

889 patients were found to have a blunt pelvic fracture. 51 patients had blush on CT scan. 29 (56.9%) underwent angiography. 17 (58.6%) of these 29 patients were found to have extravasation and were embolized. 12 patients had an angio with no extravasation, and 6 of these patients (50%) underwent prophylactic embolization. No significant difference was found for hospital LOS, ICU LOS, or mortality in our 3 groups. Sensitivity, specificity, PPV, and NPV for CT blush were 74%, 96%, 33%, 99%, respectively.

CONCLUSION

Patients with active extravasation undergoing embolization had similar outcomes to patients without active extravasation. Blush on CT scan had low sensitivity and low PPV but high specificity and high NPV. Future studies need to include careful attention to the CT protocol utilized as well as patient selection.

Transcatheter arterial embolisation is efficient and safe for paediatric blunt torso trauma: a case-control study

BACKGROUND

It remains unclear whether transcatheter arterial embolisation (TAE) is as safe and effective for paediatric patients with blunt torso trauma as it is for adults in Japan, owing to few trauma cases and sporadic case reports. The study aimed to compare the efficacy and safety of TAE performed in paediatric (age ≤ 15 years) and adult patients with blunt torso trauma.

METHODS

This was a single-centre, retrospective chart review study that included blunt torso trauma patients who underwent TAE in the trauma centre from 2012 to 2017. The comparative study was carried out between a 'paediatric patient group' and an 'adult patient group'. The outcome measures for TAE were the success of haemorrhage control and complications and standardised mortality ratio (SMR).

RESULTS

A total of 504 patients with blunt torso trauma were transported to the trauma centre, out of which 23% (N = 114) with blunt torso trauma underwent TAE, including 15 paediatric and 99 adult patients. There was no significant difference between the use of TAE in paediatric and adult patients with blunt torso trauma (29% vs 22%, P = .221). The paediatric patients' median age was 11 years (interquartile ranges 7-14). The predicted mortality rate and SMR for paediatric patients were lower than those for adult patients (18.3% vs 25.9%, P = .026, and 0.37 vs 0.54). The rate of effective haemorrhage control without repeated TAE or additional surgical intervention was 93% in paediatric patients, which was similar to that in adult patients (88%). There were no complications in paediatric patients at our centre. There were no significant differences in the proportion of paediatric patients who underwent surgery before TAE or urgent blood transfusion (33% vs 26%, P = .566, or 67% vs 85%, P = .084).

CONCLUSIONS

It is possible to provide an equal level of care related to TAE for paediatric and adult patients as it relates to TAE for blunt torso trauma with haemorrhage in the trauma centre. Alternative haemorrhage control procedures should be established as soon as possible whenever the patients reach a haemodynamically unstable state.

In-Hospital Mortality Risk of Transcatheter Arterial Embolization for Patients with Severe Blunt Trauma: A Nationwide Observational Study

This study investigated the risk factors for in-hospital mortality of severe blunt trauma patients who underwent transcatheter arterial embolization (TAE). We analysed data from the Japan Trauma Data Bank from 2009 to 2018. Patients with severe blunt trauma and an Injury Severity Score (ISS) ≥ 16 who underwent TAE were enrolled. The primary analysis evaluated patient characteristics and outcomes, and variables with significant differences were included in the secondary multivariate logistic regression analysis. In total, 5800 patients (6.4%) with ISS ≥ 16 underwent TAE. There were significant differences in the proportion of male patients, transportation method, injury mechanism, injury region, Revised Trauma Score, survival probability values, and those who underwent urgent blood transfusion and additional urgent surgery. In multivariable regression analyses, higher age, urgent blood transfusion, and initial urgent surgery were significantly associated with higher in-hospital mortality risk [p < 0.001, odds ratio (OR), 95% confidence interval (CI): 1.01 (1.00–1.01); p < 0.001, 3.50 (2.55–4.79); and p = 0.001, 1.36 (1.13–1.63), respectively]. Inter-hospital transfer was significantly associated with lower in-hospital mortality risk (p < 0.001, OR = 0.56, 95% CI = 0.44–0.71). Treatment protocols for urgent intervention before and after TAE and a safe, rapid inter-hospital transport system are needed to improve mortality risks for severe blunt trauma patients.

Prehospital use of pelvic circumferential compression devices in a physician-based emergency medical service: A 6-year retrospective cohort study

Fractures of the pelvic ring are a potential source of significant bleeding. Pelvic circumferential compression devices (PCCDs) can reduce and immobilize unstable fractures, but their hemostatic effect is unproven. Our aim was to assess the current practice of prehospital PCCD application and to identify factors available in the field predictive of significant pelvic ring injuries. All interventions (n = 13,435) in the Lausanne University Hospital Emergency Medical Service (EMS) were screened for PCCD placements from January 2008 to November 2014. Significant pelvic ring injuries (Tile types B or C) were considered as potentially benefitting from a PCCD. Data were extracted from the local prehospital registry. During the study period, 2366 trauma missions were performed. A PCCD was applied to 552/2366 (23%) patients. Significant pelvic ring injuries were present in 105/2366 (4.4%). Factors associated with the presence of significant pelvic ring injury were increased respiratory rate (OR 1.04), prolonged capillary refill time (OR 2.11), increased shock index (OR 3.91), pedestrians hit by a vehicle (OR 2.19), and presenting with falls from more than 2 m (OR 1.91). Among patients with a significant pelvic ring injury, a PCCD was placed in 79 (75%) and omitted in 26 (25%). One sixth of patients with a PCCD had a final diagnosis of significant pelvic ring injury. Further studies are needed to better understand which patient-, or accident-related factors are associated with prehospital PCCD omission among patients with significant pelvic ring injury.

Transcatheter arterial embolization for postoperative arterial complications after pelvic or hip surgery

PURPOSE

We aimed to study the technical and clinical outcome of urgent transcatheter arterial embolization (TAE) for postoperative arterial complications after pelvic or hip surgery, and to accumulate additional experience about the role of embolization for these injuries.

METHODS

Patients who received TAE procedure for arterial complications after pelvic or hip surgery between September 1st, 2002 and December 1st, 2014 were screened on medical records and included in the analysis. Angiographic findings included active contrast agent extravasation, pseudoaneurysm formation, arteriovenous fistula, and other suspicious signs such as sighting of coarse margin or distortion of vessels. Embolic agents consisted of coils, gelatin sponge, and polyvinyl alcohol. Technical success was defined as complete occlusion of targeted artery through angiography, and clinical success as sustained resolution of symptoms.

RESULTS

A total of 22 patients (15 males, 19-76 years old) were enrolled. Prior to TAE, 12 patients developed hemorrhagic shock and the remaining 10 patients had hemorrhage-related pain, hematoma, or anemia. Contrast agent extravasation occurred in 12 cases, pseudoaneurysm formation in 5 cases, and other suspicious signs in 5 cases. Injury occurred in the internal iliac artery stem in 6 cases, inferior gluteal artery in 6 cases and superior gluteal artery in 6 cases. Multiple vascular lesions appeared in 5 cases. After TAE, technical success occurred in 22 patients and clinical success in 21 patients (95.5%). A 36-year-old woman died of irreversible multiple organ failure; no other severe procedure-related complications were recorded.

CONCLUSION

TAE is safe and effective for postoperative arterial complications after pelvic or hip surgery.

Prospective validation of a new protocol with preperitoneal pelvic packing as the mainstay for the treatment of hemodynamically unstable pelvic trauma: a 5-year experience

PURPOSES

Hemodynamically unstable pelvic trauma has been a significant challenge even in most experienced Trauma Centres. In 2011 preperitoneal pelvic packing (PPP) was introduced in our Hospital as the first manoeuvre. This study aims to review overall mortality at 24 h from arrival in the emergency department.

METHODS

A retrospective review of our prospective database was performed considering patients with systolic blood pressure (SBP) < 90 mmHg or with the need for more than 2 Units of packed red blood cells (PRBC) on admission in the emergency department, (ED) and a pelvic fracture. Values were expressed as a median and interquartile range. Continuous variables were compared with the Mann-Whitney test.

RESULTS

Between September 2011 and December 2016, we treated 30 patients. Median age was 51 years (40-65) and Injury Severity Score 36 (34-42). SBP in the ED was 90 (67-99), heart rate was 115 (90-130), Base Excess - 8 (- 11.5/- 4.8), pH 7.23 (7.20-7.28). Median PRBC requirements during the first 24 h (from admission) were 13 Units (8-18.8). Time to emergency treatment was 63 min (51-113). 17 patients (56.6%) underwent angiography after PPP. Overall 24 h mortality was 30%. A comparison between survivors and non-survivors showed no statistically significant differences between groups.

CONCLUSIONS

In our experience, PPP resulted to be quick to perform and effective. No death occurred from direct pelvic bleeding.

Where and what arteries are most likely injured with pelvic fractures?: The Influence of Localization, Shape, and Fracture Dislocation on the Arterial Injury During Pelvic Fractures

Blood vessels passing through pelvic region come into intimate contact with pelvic bone and can be injured by the sharp edges of the dislocated fracture fragments. The aim of the study was to evaluate the influence of localization, shape, and dislocation of individual pelvic ring bones' fractures on arterial injuries. The study group consisted of 474 patients enrolled in a 1-year prospective multicenter study. The pattern of pelvic fracture lines was characterized and recorded on a planar diagram of the subjected side of the pelvis. The diagram was subdivided into 11 designated areas. Frequency of injury at each 11 areas was recorded. The course of individual arteries in the 11 areas was also recorded in relation to each type of pelvic fractures. Out of the 474 investigated patients, the highest proportion of fractures occurred in the areas of the superior (62%) and inferior (59%) ramus of the pubis as well as in the lateral part of the sacrum (19%). These locations can be associated with injuries of the external iliac, obturator, internal iliac, and aberrant obturator arteries. The highest risk of arterial injuries was associated with vertically displaced fractures in the middle part of the superior and inferior pubic rami, along the ischial ramus, in the apex of the greater sciatic notch and in the vicinity of the ventral part of the sacroiliac joint, where the artery runs at a distance of less than 1 cm from the bone. Clin. Anat. 32:682-688, 2019. © 2019 Wiley Periodicals, Inc.

Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre

BACKGROUND

Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm.

MAIN BODY

Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE.

CONCLUSION

Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.

Clinical implications of fracture-associated vascular damage in extremity and pelvic trauma

BACKGROUND

Vascular damage in polytrauma patients is associated with high mortality and morbidity. Therefore, specific clinical implications of vascular damage with fractures in major trauma patients are reassessed.

METHODS

This comprehensive nine-year retrospective single center cohort study analyzed demography, laboratory, treatment and outcome data from 3689 patients, 64 patients with fracture-associated vascular injuries were identified and were compared to a control group.

RESULTS

Vascular damage occurred in 7% of patients with upper and lower limb and pelvic fractures admitted to the trauma room. Overall survival was 80% in pelvic fracture and 97% in extremity fracture patients and comparable to non-vascular trauma patients. Additional arterial damage required substantial fluid administration and was visible as significantly anemia and disturbed coagulation tests upon admission. Open procedures were done in over 80% of peripheral extremity vascular damage. Endovascular procedures were predominant (87%) in pelvic injury.

CONCLUSION

Vascular damage is associated with high mortality rates especially in combination with pelvic fractures. Initial anemia, disturbed coagulation tests and the need for extensive pre-clinical fluid substitution were observed in the cohort with vascular damage. Therefore, fast diagnosis and early interventional and surgical procedures are necessary to optimize patient-specific outcome.

Imaging and endovascular management of traumatic pelvic fractures with vascular injuries

This paper will give an overview of the relevant anatomy, management and imaging, aspects as well as therapeutic aspects of traumatic pelvic fractures with vascular injuries.

Imaging and Endovascular Treatment of Bleeding Pelvic Fractures: Review Article

Pelvic fractures are potentially life-threatening injuries with high mortality rates, mainly due to intractable pelvic arterial bleeding. However, concomitant injuries are frequent and may also be the cause of significant blood loss. As treatment varies depending on location and type of hemorrhage, timely imaging is of critical importance. Contrast-enhanced CT offers fast and detailed information on location and type of bleeding. Angiography with embolization for pelvic fracture hemorrhage, particularly when performed early, has shown high success rates as well as low complication rates and is currently accepted as the first method of bleeding control in pelvic fracture-related arterial hemorrhage. In the current review imaging workup, patient selection, technique, results and complications of pelvic embolization are described.

Bilateral Internal Iliac Artery Embolization Results in an Unacceptably High Rate of Complications in Patients Requiring Pelvic/Acetabular Surgery

OBJECTIVES

To assess complication rates in patients undergoing open reduction internal fixation (ORIF) of pelvic/acetabular fractures with and without pelvic angiography embolization (PAE).

DESIGN

Retrospective case series.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

One hundred eleven patients with pelvic or acetabular fractures that required orthopaedic fixation.

INTERVENTION

Retrospective analysis of outcomes in patients who underwent ORIF of pelvic/acetabular fractures with and without PAE.

MAIN OUTCOME MEASUREMENTS

Comparison of surgical wound infections, necrosis, and/or fracture nonunions between the PAE group and a control group (no PAE).

RESULTS

Final study groups consisted of 50 patients in the PAE group and 61 patients in the control group. Ninety-six percent of patients underwent nonselective PAE. Significantly higher complications were noted in the PAE group than in the control group (20% compared with 4.9%; P = 0.020). In addition, posterior surgical approaches combined with internal iliac artery embolization represented the highest complication rate.

CONCLUSIONS

Patients requiring PAE and pelvic/acetabular ORIF should undergo a multidisciplinary treatment approach with the trauma surgeon, interventional radiologist, and orthopaedic surgeon before PAE being performed to decrease complications and avoid nonselective bilateral internal iliac artery embolization.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of active arterial hemorrhage on angiography in pelvic fracture patients

PURPOSE

To determine predictors of active angiographic hemorrhage in pelvic fracture patients.

MATERIALS AND METHODS

This retrospective study included 66 trauma patients who had major hemorrhages due to pelvic fractures, and who underwent pelvic angiography between January 2012 and December 2014. The study population comprised 31 males and 35 females (mean age 44.2 ± 20.7 years). The main outcome was active hemorrhage on pelvic angiography. Clinical and imaging variables including demographics, hemodynamic parameters, injury severity, types of pelvic fracture, laboratory data, blood transfusions and CT findings were analyzed. Multivariate logistic regression was used to identify predictors of active angiographic hemorrhage.

RESULTS

Of the 66 study patients included, 41 patients had active angiographic hemorrhage. These patients had more blood transfusions, higher activated partial thromboplastin times and higher rates of contrast extravasation on CT (p < 0.05). Three independent predictors of active angiographic hemorrhage were identified, including contrast extravasation on CT (OR: 74.6, p < 0.001), more than 8 units of RBC transfusions (OR: 12.5, p = 0.018) and ISS ≥ 16 (OR: 11.1, p = 0.029).

CONCLUSION

Contrast extravasation on CT, high volume RBC transfusions and ISS ≥ 16 can help us to select pelvic fracture patients for angiography more precisely.

Association of pelvic fracture patterns, pelvic binder use and arterial angio-embolization with transfusion requirements and mortality rates; a 7-year retrospective cohort study

Background

Pelvic fractures are severe injuries with frequently associated multi-system trauma and a high mortality rate. The value of the pelvic fracture pattern for predicting transfusion requirements and mortality is not entirely clear. To address hemorrhage from pelvic injuries, the early application of pelvic binders is now recommended and arterial angio-embolization is widely used for controlling arterial bleeding. Our aim was to assess the association of the pelvic fracture pattern according to the Tile classification system with transfusion requirements and mortality rates, and to evaluate the correlation between the use of pelvic binders and arterial angio-embolization and the mortality of patients with pelvic fractures.

Methods

Single-center retrospective cohort study including all consecutive patients with a pelvic fracture from January 2008 to June 2015. All radiological fracture patterns were independently reviewed and grouped according to the Tile classification system. Data on patient demographics, use of pelvic binders and arterial angio-embolization, transfusion requirements and mortality were extracted from the institutional trauma registry and analyzed.

Results

The present study included 228 patients. Median patient age was 43.5 years and 68.9% were male. The two independent observers identified 105 Tile C (46.1%), 71 Tile B (31.1%) and 52 Tile A (22.8%) fractures, with substantial to almost perfect interobserver agreement (Kappa 0.70-0.83). Tile C fractures were associated with a higher mortality rate (p = 0.001) and higher transfusion requirements (p < 0.0001) than Tile A or B fractures. Arterial angio-embolization for pelvic bleeding (p = 0.05) and prehospital pelvic binder placement (p = 0.5) were not associated with differences in mortality rates.

Conclusions

Tile C pelvic fractures are associated with higher transfusion requirements and a higher mortality rate than Tile A or B fractures. No association between the use of pelvic binders or arterial angio-embolization and survival was observed in this cohort of patients with pelvic fractures.

Contemporary Role of Embolization of Solid Organ and Pelvic Injuries in Polytrauma Patients

Abdominopelvic trauma (APT) remains a leading cause of morbidity and mortality in the 15- to 44-year-old age group in the Western World. It can be life-threatening as abdominopelvic organs, specifically those in the retroperitoneal space, can bleed profusely. APT is divided into blunt and penetrating types. While surgery is notably considered as a definitive solution for bleeding control, it is not always the optimum treatment for the stabilization of a polytrauma patient. Over the past decades, there has been a shift toward more sophisticated strategies, such as non-operative management of abdominopelvic vascular trauma for haemodynamically stable patients. Angiographic embolization for bleeding control following blunt and/or penetrating intra- and retroperitoneal injuries has proven to be safe and effective. Embolization can achieve hemostasis and salvage organs without the morbidity of surgery, and the development and refinement of embolization techniques has widened the indications for non-operative treatment in solid organ injury. Moreover, advances in computed tomography provided more efficient scanning times with improved image quality. While surgery is still usually recommended for patients with penetrating injuries, non-operative management can be effectively used as well as an alternative treatment. We review indications, technical considerations, efficacy, and complication rates of angiographic embolization in APT.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a Propensity Score Analysis

Background

An option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures. The aim of this study was to demonstrate the efficacy of early EPP in reducing mortality due to hemorrhage from pelvic fractures, and to evaluate the impact of packing on transfusion requirements within the first 24 h and ICU length of stay (ICU-LOS).

All data pertaining trauma patients admitted from October 2002 and December 2103 with hemodynamic instability and pelvic fractures were selected from the Hospital Trauma Registry. Patients with severe brain injury and bleeding from extra-pelvic sources were excluded. Patient population was divided into two groups: EPP group, including patients admitted from 2009 to 2013, with EPP as part of the treatment algorithm, and NO-EPP group, from 2002 to 2008, without EPP as atherapeutic option. Descriptive statistical analysis was performed on allpatients. Twenty-five patients of each group with similar features were matched using Propensity Score Analysis (PSA).

Results

Six hundred eighty out of 4659 major trauma (14.6 %) presented a pelvic fracture. In 78 hemodynamically unstable patients (30 in EPP group,48 in NO-EPP group) the major source of bleeding was the pelvis. Among patients selected by PSA early mortality was significantly reduced in EPP group (20 vs 52 %, p = .03) compared to NO-EPP, notwithstanding similar hemodynamic impairment. No difference was observed in transfusion requirements and ICU-LOS.

Conclusions

The EPP is a safe and quick procedure, able to improve hemodynamic stabilization and to reduce acute mortality due to hemorrhage in patients with pelvic fracture, in combination with optimized transfusion protocol. EPP may be useful as a bridge for time-consuming procedures, such as angio-embolization.