Management of Hemorrhage in Severe Pelvic Injuries

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.

Military experience in the management of pelvic fractures from OIF/OEF

INTRODUCTION

Pelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify the incidence, patterns of injury and management of pelvic fractures.

METHODS

We conducted a retrospective review on all combat-injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification and treatment strategies were examined.

RESULTS

Of 562 patients identified within the study time period, 14% (81 of 562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device. The average Injury Severity Score for patients with pelvic fracture was 31±12 and 70% were classified as open. Of the 228 patients with any traumatic lower extremity amputation, 23% had pelvic fractures, while 30% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anteroposterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical shear (VS) (7%). Only 2% (nine of 562) of all patients were recorded as having pelvic binders placed in the prehospital setting. 49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34 of 40; 85%), followed by preperitoneal packing (16 of 40; 40%) and angioembolisation (three of 40; 0.75%). 17 (42.5%) patients required combinations of these three treatment modalities, the majority of which were a combination of external fixator and preperitoneal packing. The likelihood to need procedural therapy was impacted by injury pattern, as 72% of patients with an APC injury, 100% of patients with a VS injury and 25% of patients with an LC injury required procedural therapy.

CONCLUSIONS

Pelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations. APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality. Considering angioembolisation was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation±preperitoneal packing. Finally, prehospital pelvic binder application may be an area for further process improvement.

Material characterization of GPX®: A versatile in situ solidifying embolic platform technology

Endovascular embolization is a minimally invasive procedure during which blood flow to targeted tissues is selectively occluded. The list of clinical indications for embolization continues to expand. Liquid embolic agents are injectable compositions that transition into a solid or semi-solid form when introduced into blood vessels. The mechanism that triggers the liquid-to-solid transition is a key distinguishing feature of liquid embolic agents. GPX is a waterborne liquid embolic agent comprising oppositely charged polyelectrolytes: polyguanidinum and inorganic polyphoshate. In situ solidification is driven by electrostatic condensation of the polyelectrolytes, triggered by ionic strength differentials. We report in vitro characterization of the material properties of GPX, it is in vivo effectiveness in acute animal studies, and its potential for chemoembolization. The viscosity of GPX can be varied over a wide range by adjusting the polyguanidinium MW and/or concentration. Formulation of GPX with either tantalum microparticles (30 wt%) or iodinated radiocontrast agents (300 mgI ml^-1) did not significantly change the flow behavior of GPX; the viscosity was independent of shear rate and remained within a clinically practical range (80-160 cP). Formulation of GPX with doxorubicin substantially increased viscosity at low shear rates and resulted in a power law dependence on shear rate. High contrast and effective vascular occlusion were demonstrated in both swine kidneys and rete mirabile. Contrast from iodinated compounds was temporary, dissipating within hours. The doxorubicin in vitro release profile was linear over 90 days. The results demonstrate that GPX is a versatile liquid embolic platform that can be formulated with a wide range of viscosities injectable at clinically practical flow rates, with either transient or permanent contrast, and that can provide prolonged zero-order delivery of doxorubicin to embolized tissues.

Interventional Radiology in Pelvic Trauma

Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. As fractures and ligamentous disruption result in increased pelvic volume, retroperitoneal hemorrhage can spiral and progress to hemorrhagic shock. Due to the extensive collateral supply and limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management. This article will discuss typical injuries seen in pelvic trauma, treatment modalities available to the interventional radiologist, and common angiographic treatment strategies and techniques.

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.

Institutional Review of Hemorrhagic Pelvic Emergencies Effectively Managed with Percutaneous Arterial Embolization

OBJECTIVE

Our aim was to review the results of pelvic arterial embolization (PAE) performed in the interventional radiology suite.

METHOD

The data of all patients in whom pelvic angioembolization was performed was collected from July 2011 to June 2017. Procedures were performed by an experienced interventional radiologist. The clinical and laboratory data, as well as the outcome data, were obtained from the medical records of our hospital. The following parameters were collected for each patient, including the age, gender, presenting symptoms, site of bleeding, catheters used for embolization, material used for embolization, previous computed tomography (CT) scan and/or focused assessment with sonography for trauma (FAST) ultrasound, average hemoglobin before the procedure, and patient clinical status on discharge.

RESULT

A total of 37 patients underwent pelvic angiography for acute hemorrhage at our institution. They had contrast blush, active extravasation, or abnormal vascularity from the branches of the internal iliac artery and underwent therapeutic transcatheter embolization. A total of 29 patients (78.3%) were male and 8 (21.7%) were female. The average age was 30.0 years (range: 6-90 year). Of these, 16 patients (43.2%) presented with road traffic accidents (RTAs), six with gunshot injuries (16.2%), six with iatrogenic injuries (16.2%), four with a history of a fall (10.8%), two with bomb blast injuries (5.4%), one with a history of a glass injury (2.7%), one had a history of a roof falling on her during an earthquake, and one patient had a pelvic pseudoaneurysm secondary to an abscess. The type of embolic material used for embolization included coils in 16 patients, polyvinyl alcohol (PVA) particles were used in eight patients, both PVA particles and coils were used in 11 patients, and glue was used in one patient. All were successfully embolized. Thirty-four were discharged while three patients expired during the course of hospital stay due to other coexisting morbidities.

CONCLUSION

The management of pelvic injuries has always been a topic of debate, with multiple methods reported to date but growing evidence supports the use of pelvic arterial embolization in hemorrhagic pelvic injuries. The formulation of a standardized protocol is the need of the day.

Prognostic factors in endovascular treated pelvic haemorrhage after blunt trauma

Background

Angioembolization is the method of choice for treating haemorrhage after blunt pelvic trauma. The aim of this study was to determine technical factors related to endovascular procedures which might be related to patient outcome.

Methods

This retrospective study included 112 consecutive patients (40 women and 72 men; mean age 57.2 ± 20.0).

Results

There were age peaks at 43 and at 77 years. Patients over 65 years had mainly “low-energy” trauma; younger patients were more likely to have polytraumas. Younger patients were more severely injured and had more surgical interventions, larger haematoma volumes, lower Hb levels and required more transfusions than older patients. Women were older than men, had fewer surgeries and waited longer for an angiography (p < 0.05 each). Logistic regression analyses identified the injury severity score (ISS) as relevant for survival before age, haematoma volume and Hb. Propensity score analyses showed that in addition to the need for transfusions, haemoglobin, and haematoma volume, the length of the coils and the number of microcoils used were relevant (p < 0.05 each). The location of haemorrhage in peripheral parietal arteries (superior and inferior gluteal artery) was an influencing factor for re-angiographies, which were associated with considerably longer hospital stays of more than 40 days. Fewer particles had generally been used in these patients.

Conclusions

The use of too few coils and not using microparticles in angioembolization for pelvic haemorrhage are major influencing factors for the mortality or re-angiography rate. Special attention should be given to thorough peripheral embolization with microcoils, in particular for haemorrhage from the parietal branches of the internal iliac artery.

Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies

BACKGROUND

Extraperitoneal pelvic packing (EPP) was introduced at Oslo University Hospital Ulleval (OUHU) in 1994. Published studies from other institutions have advocated its application as a first-line therapy in lieu of angiography. Extraperitoneal pelvic packing is invasive with a high risk of complications, and its role remains an issue of discussion. In line with international trends, an updated massive hemorrhage protocol was implemented at OUHU in 2007. We hypothesized a decreased need for EPP owing to the major changes in resuscitation strategies.

METHODS

Retrospective analysis of data from the OUH Trauma Registry and patient charts for the period 2002-2012 was performed. All pelvic fractures with Abbreviated Injury Severity (AIS) score of 3 or higher and/or transfused during the period before intensive care unit admission regardless of the pelvic AIS were included. The population was analyzed for trends and differences between 2002-2006 (P1) and 2007-2012 (P2). Further analysis was performed on the group of patients transfused five or more units of red blood cells (RBCs).

RESULTS

We included 648 patients (P1, 297; P2, 351). There was no difference in median injury severity score, pelvic AIS, or age between the two periods. Median base deficit on admission was higher in P2 (4.2 vs 3.3 mmol/L; p < 0.01). The EPP rate decreased from P1 to P2 (17-10%; p < 0.01). A similar reduction in the angiography rate (15% vs 9%; p < 0.01) was observed, with a concomitant decrease in hemorrhage-related deaths (10% vs 5%; p = 0.01). The subgroup analysis of patients transfused five or more units of RBCs revealed significant increase in the use of plasma and platelets in P2. Multiple logistic regression models for the subgroup transfused five or more units of RBCs confirm the change in resuscitation strategy to be significantly associated with reduced EPP, and identifying admission in P2 to be associated with a 63% decreased odds ratio for EPP.

CONCLUSIONS

The EPP and angiography rates for exsanguinating pelvic injuries have decreased with improved resuscitation strategies, reducing RBC requirements and hemorrhage-related deaths.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Haemorrhage control in pelvic trauma

A pelvic fracture usually indicates high energy transfer from a significant mechanism and a high likelihood of associated injuries. Mortality from pelvic trauma is usually due to massive haemorrhage mandating expedient resuscitation of the patient and immediate control of exsanguinating haemorrhage. Damage control resuscitation incorporates permissive hypotensive resuscitation and early replacement of clotting factors with early aggressive surgical control of bleeding. A commercially available pelvic binder provides circumferential compression and rapidly closes the pelvis, leading to fracture splintage and reduction in pelvic volume, both of which reduce haemorrhage. It is critical to distinguish ongoing bleeding due to a pelvic ring injury from intra-peritoneal haemorrhage. The identification of intra-peritoneal bleeding in a haemodynamically unstable patient mandates laparotomy. On-going haemorrhage from the pelvis requires diagnostic pelvic angiography, followed by selective embolisation if a source of bleeding is identified. If angiography is not available pelvic packing can be life-saving.

The role of interventional radiology in abdominopelvic trauma

The management of trauma patients has evolved in recent decades owing to increasing availability of advanced imaging modalities such as CT. Nowadays, CT has replaced the diagnostic function of angiography. The latter is considered when a therapeutic option is hypothesized. Arterial embolization is a life-saving procedure in abdominopelvic haemorrhagic patients, reducing relevant mortality rates and ensuring haemodynamic stabilization of the patient. Percutaneous transarterial embolization has been shown to be effective for controlling ongoing bleeding for patients with high-grade abdominopelvic injuries, thereby reducing the failure rate of non-operative management, preserving maximal organ function. Surgery is not always the optimal solution for stabilization of a patient with polytrauma. Mini-invasivity and repeatability may be considered as relevant advantages. We review technical considerations, efficacy and complication rates of hepatic, splenic, renal and pelvic embolization to extrapolate current evidence about transarterial embolization in traumatic patients.

Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study

BACKGROUND

The use of abbreviated or damage control (DC) interventions may improve outcomes in severely injured patients when appropriately indicated. We sought to determine which indications for DC interventions have been most commonly reported in the peer-reviewed literature to date and evaluate the opinions of experts regarding the appropriateness (expected benefit-to-harm ratio) of the reported indications for use in practice.

METHODS

Two investigators used an abbreviated grounded theory method to synthesize indications for 16 different DC interventions reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. For each indication code, an international panel of trauma surgery experts (n = 9) then rated the appropriateness of conducting the DC intervention of interest in an adult civilian trauma patient.

RESULTS

The 424 indications identified in the literature were synthesized into 101 unique indications. The panel assessed 12 (70.6%) of the coded indications for the 7 different thoracic, 47 (78.3%) for the 7 different abdominal/pelvic, and 18 (75.0%) for the 2 different vascular interventions to be appropriate for use in practice. These included indications for rapid lung-sparing surgery (pneumonorrhaphy, pulmonary tractotomy, and pulmonary wedge resection) (n = 1); pulmonary tractotomy (n = 3); rapid, simultaneously stapled pneumonectomy (n = 1); therapeutic mediastinal and/or pleural space packing (n = 4); temporary thoracic closure (n = 3); therapeutic perihepatic packing (n = 28); staged pancreaticoduodenectomy (n = 2); temporary abdominal closure (n = 12); extraperitoneal pelvic packing (n = 5); balloon catheter tamponade (n = 6); and temporary intravascular shunting (n = 11).

CONCLUSION

This study identified a list of candidate appropriate indications for use of 12 different DC interventions that were suggested by authors of peer-reviewed articles and assessed by a panel of independent experts to be appropriate. These indications may be used to focus future research and (in the interim) guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.

The utility of FAST for initial abdominal screening of major pelvic fracture patients

BACKGROUND

Focused Assessment with Sonography for Trauma (FAST) is widely used in pelvic fracture patients. We examined the performance of FAST for detecting hemoperitoneum and predicting the need for intra-abdominal hemorrhage control in major pelvic fracture patients.

METHODS

A 5-year retrospective study of major pelvic fracture patients was performed. The presence of hemoperitoneum was confirmed on CT or at laparotomy. The need for hemorrhage control was defined as requiring a surgical or radiological intervention for intra-abdominal bleeding. Hemorrhagic shock (HS) patients had a systolic blood pressure ≤ 90 mmHg or base deficit of ≥ 6 mEq/L on admission.

RESULTS

A total of 120 patients were included, 42 (35 %) of which had any hemoperitoneum and 21 (18 %) had a moderate-large amount. The sensitivity, specificity, and positive and negative predictive values of FAST for any hemoperitoneum were 64, 94, 84, and 83 % and for a moderate-large amount they were 86, 86, 56, and 97 %. In HS patients the indices were 68, 93, 88, and 78 % for any hemoperitoneum and 79, 83, 65, and 91 % for a moderate-large amount. For the need for hemorrhage control, FAST had a positive predictive value of 50 % (16/32) in all and 71 % (12/17) in HS patients. The negative predictive value was 99 % (87/88) in all and 97 % (31/32) in HS patients.

CONCLUSION

FAST had a good to excellent diagnostic accuracy, depending on the size of hemoperitoneum. A positive FAST result (even in HS patients) does not reliably predict the need for immediate intra-abdominal hemorrhage control but a negative FAST result renders the need for an intervention highly unlikely.

The risk factors of concomitant intraperitoneal and retroperitoneal hemorrhage in the patients with blunt abdominal trauma

Introduction

Intraperitoneal and retroperitoneal hemorrhages may occur simultaneously in blunt abdominal trauma (BAT) patients. These patients undergo emergency laparotomies because of concomitant unstable hemodynamics and positive sonographic examination results. However, if the associated retroperitoneal hemorrhage is found intraoperatively and cannot be controlled surgically, then the patients require post-laparotomy transcatheter arterial embolization (TAE). In the current study, we attempted to determine the risk factors for post-laparotomy TAE.

Materials and methods

Patients with concomitant BAT and unstable hemodynamic were retrospectively analyzed. The characteristics of the patients who underwent laparotomy or who required post-laparotomy TAE were investigated and compared. The Tile classification system was used to evaluate the pelvic fracture patterns.

Results

Seventy-four patients were enrolled in the study. Fifty-nine (79.7%) patients underwent laparotomy to treat intra-abdominal hemorrhage, and fifteen (20.3%) patients underwent additional post-laparotomy TAE because of concomitant retroperitoneal hemorrhage. Pelvic fracture was present in 80.0% of the post-laparotomy TAE patients. This percentage was significantly greater than that of the laparotomy only patients (80.0% vs. 30.5%, p < 0.001). Furthermore, 30 patients (40.5%, 30/74) had concomitant pelvic fracture diagnoses. Of these patients, eighteen (60%, 18/30) underwent laparotomy only, while the other twelve patients (40%, 12/30) required post-laparotomy TAE. Compared with the patients who underwent laparotomy only, more patients with Tile B₁-type pelvic fractures (58.3% vs. 11.1%, p = 0.013) required post-laparotomy TAE.

Conclusion

Regarding BAT patient management, the likelihood of post-laparotomy TAE should be considered in patients with concomitant pelvic fractures. Furthermore, more attention should be directed toward patients with Tile B₁-type pelvic fractures because of the specific fracture pattern and impaction force.

Angiographic embolization for major trauma in a low-middle income healthcare setting--A retrospective review

INTRODUCTION

Interventional radiology (IR) provides a range of adjunctive techniques to assist with hemorrhage control after trauma that can be employed pre- or post-operatively. The role of IR in lower-middle income countries (LMICs) remains unexplored. This study describes the use of adjunctive angioembolization (AE) in severely injured patients following its recent implementation at an urban trauma center in a LMIC.

METHODS

Adult patients (≥ 16 years) requiring AE from 2011 to 2013 at a single trauma-care facility were included. Data was collected on demographic parameters, transfer status, injury severity score (ISS), emergency resuscitation characteristics, AE and operative characteristics, complications, and in-hospital mortality. Descriptive analyses were performed.

RESULTS

Thirty six patients underwent AE for trauma-related hemorrhagic complications and were included in the study. Average age was 31.5 (± 11.3) years with a male preponderance (91.7%). Penetrating trauma (61.1%) was the most common type of injury. The primary mechanism of injury was gunshot (58.3%). The median ISS was 24 (IQR: 20-29). Pre-operative AE was performed in 23 (63.9%) patients and these patients had a lower median ISS (22) than those who underwent post-operative AE (p = 0.015). Hepatic (55.6%) and pelvic (33.3%) trauma more commonly required radiological intervention. Bleeding from the right hepatic (n = 14), and the right internal iliac (n = 6) arteries and/or their branches, were more often embolized. Microcoils were the preferred AE agents (61.1%). Median length of hospital stay was 7.5 (IQR: 3-14) days. Eight (22.2%) patients did not survive.

CONCLUSION

With the availability of multi-detector computed tomography and a dedicated interventional radiology suite, implementation of AE for the care of trauma patients in LMIC settings is possible.

Damage-control orthopedics versus early total care in the treatment of borderline high-energy pelvic fractures

The purpose of this study was to compare the effectiveness of damage-control orthopedics (DCO) vs early total care (ETC) in the treatment of borderline high-energy pelvic fractures. Seventy-two patients with borderline high-energy pelvic fractures were retrospectively reviewed; 39 received DCO and 33 received ETC. Demographic data and initial injury severities were comparable between groups, except for Abbreviated Injury Scale (AIS) head scores and Glasgow Coma Scale (GCS) scores. Regarding postoperative complications, the incidence rates of acute lung injury and acute respiratory distress syndrome and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score were significantly lower in the DCO group compared with the ETC group. Similar results were also observed in subgroups stratified by age (younger than 40 years and 40 years and older). Regarding patients with Tile B fractures, there was no significant difference between groups in incidence rates of overall postoperative complications. However, in patients with Tile C fractures, especially in those 40 years and older, the DCO group had a lower incidence rate of ALI and had lower APACHE II scores than did the ETC group. This study's findings indicate that DCO is the most suitable therapeutic option for patients with Tile C fractures, especially for those 40 years and older, whereas ETC is preferred for patients with Tile B fractures, provided that it is possible to avoid a second operation as well as any delays in patient mobilization.

Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery)

Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.

Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.

Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention

BACKGROUND

We hypothesized that patients with pelvic fractures and hemorrhage admitted during daytime hours were undergoing interventional radiology (IR) earlier than those admitted at night and on weekends, thereby establishing two standards of time to hemorrhage control.

METHODS

The trauma registry (January 2008 to December 2011) was reviewed for patients admitted with pelvic fractures, hemorrhagic shock, and transfusion of at least 1 U of blood. The control group (DAY) was admitted from 7:30 AM to 5:30 PM Monday to Friday, while the study group (after hours [AHR]) was admitted from 5:30 PM to 7:30 AM, on weekends or holidays.

RESULTS

A total of 191 patients met the criteria (45 DAY, 146 AHR); 103 died less than 24 hours and without undergoing IR (29% DAY group vs. 62% AHR, p < 0.001). Sixteen patients (all in AHR group) died while awaiting IR (p = 0.032). Eighty-eight patients (32 DAY, 56 AHR) survived to receive IR. Among these, the AHR group were younger (median, 30 years vs. 54 years; p = 0.007), more tachycardic (median pulse, 119 beats/min vs. 90 beats/min; p = 0.001), and had more profound shock (median base, -10 vs. -6; p = 0.006) on arrival. Time from admission to IR (median, 301 minutes vs. 193 minutes; p < 0.001) and computed tomographic scan to IR (176 minutes vs. 87 minutes, p = 0.011) were longer in the AHR group. There was no difference in the 30-day mortality by univariate analysis. However, after controlling for age, arrival physiology, injury severity, and degree of shock, the AHR group had a 94% increased risk of mortality.

CONCLUSION

The current study demonstrated that patients admitted at night and on weekends have a significant increase in time to angioembolization compared with those arriving during the daytime and during the week. Multivariate regression noted that AHR management was associated with an almost 100% increase in mortality. While this is a single-center study and retrospective in nature, it suggests that we are currently delivering two standards of care for pelvic trauma, depending on the day and time of admission.

LEVEL OF EVIDENCE

Therapeutic study, level II.

Critical review of pelvic fractures associated with external iliac artery lesion: a series of six cases

INTRODUCTION

Bleeding associated with pelvic fracture mostly comes from the pre-sacral and lumbar venous plexus, or directly from the fracture site. Bleeding as a consequence of arterial lesion is less common (15-20%), and that resulting from lesion of the external iliac artery (EIA) is extremely rare. The mortality rate associated with iliac artery injury ranges from 38% to 72%. Total body CT-scan with contrast medium, angiography or packing can be performed when there is arterial injury. In some cases, embolisation can stop bleeding; however, when there is involvement of the aorta, common iliac artery or EIA, immediate surgery is mandatory. The aim of this study was to report our experience of pelvic fractures associated with EIA lesion.

MATERIALS AND METHODS

Six patients with pelvic fracture and associated rupture of the EIA have been observed at our unit from 2004 to 2009. According to Tile classification there were three cases of type C and two cases of type B fracture. One case was a two-column acetabular fracture. Angiography was performed in all cases.

RESULTS

Three patients died on the day of trauma: two after angiography, and one after surgery of vascular repair. Three patients survived: two underwent a hemipelvectomy, and one underwent hip disarticulation.

DISCUSSION

Haemodynamic instability in patients with pelvic ring fracture is usually because of venous bleeding from the pre-sacral and lumbar plexus, or from the fracture site. Arterial injury is present in around 20% of cases. EIA lesions require immediate surgical treatment to restore blood flow. Depending on the type of injury, vascular surgery can be associated with pelvic fracture stabilisation.

CONCLUSIONS

Pelvic ring fracture associated with an EIA lesion is extremely rare, with few cases reported in the literature. Angiography is used for diagnosis, and immediate surgical treatment is required to restore blood flow. Associated injuries and open fracture can lead to fatal complications or amputation. Rates of mortality and severe disability are extremely high.

Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients

BACKGROUND

The early diagnosis of pelvic arterial haemorrhage is challenging for initiating treatment by transcatheter arterial embolization (TAE) in multiple trauma patients. We use an institutional algorithm focusing on haemodynamic status on admission and on a whole-body CT scan in stabilized patients to screen patients requiring TAE. This study aimed to assess the effectiveness of this approach.

METHODS

This retrospective cohort study included 106 multiple trauma patients admitted to the emergency room with serious pelvic fracture [pelvic abbreviated injury scale (AIS) score of 3 or more].

RESULTS

Of the 106 patients, 27 (25%) underwent pelvic angiography leading to TAE for active arterial haemorrhage in 24. The TAE procedure was successful within 3h of arrival in 18 patients. In accordance with the algorithm, 10 patients were directly admitted to the angiography unit (n=8) and/or operating room (n=2) for uncontrolled haemorrhagic shock on admission. Of the remaining 96 stabilized patients, 20 had contrast media extravasation on pelvic CT scan that prompted pelvic angiography in 16 patients leading to TAE in 14. One patient underwent a pelvic angiography despite showing no contrast media extravasation on pelvic CT scan. All 17 stabilized patients who underwent pelvic angiography presented a more severely compromised haemodynamic status on admission, and they required more blood products during their initial management than the 79 patients who did not undergo pelvic angiography. The incidence of unstable pelvic fractures was however comparable between the two groups. Overall, haemodynamic instability and contrast media extravasation on the CT-scan identified 26 out of the 27 patients who required subsequent pelvic angiography leading to TAE in 24.

CONCLUSIONS

An algorithm focusing on haemodynamic status on arrival and on the whole-body CT scan in stabilized patients may be effective at triaging multiple trauma patients with serious pelvic fractures.

The imaging and classification of severe pelvic ring fractures: Experiences from two level 1 trauma centres

We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young-Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ. Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young-Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries.

Pelvic fractures presenting with haemodynamic instability: treatment options and outcomes

The management of trauma patients with haemodynamic instability and an unstable pelvic fracture is an issue of vivid debate in "trauma community". A multidisciplinary approach needs to be instituted regarding the required diagnostic and therapeutic measures. Control of haemorrhage is the first priority. Arterial embolization and/or preperitoneal pelvic packing follow the provisional skeletal pelvic stabilization. The sequence of these interventions still remains an issue of controversy. It needs to be determined on an institutional basis based on the available local resources such as angiography suite and whole-body CT scan and the expertise of the treating surgical team. Despite the fact that recent advances in diagnostic modalities and trauma care systems have improved the overall outcome of patients with pelvic fractures, the early mortality associated with high-energy pelvic injuries presenting with haemodynamic instability remains high. Any suspected injured person with pelvic ring injury should automatically be taken to a level one-trauma centre where all the facilities required are in place for these patients to survive.

The use of Celox gauze as an adjunct to pelvic Packing in otherwise uncontrollable pelvic haemorrhage secondary to penetrating trauma

Haemorrhage from severe pelvic fractures can be associated with significant mortality. Modern civilian trauma centres may manage these injuries with a combination of external pelvic fixation, extra-peritoneal packing and/or selective angiography; however, military patterns of wounding are different and deployed medical facilities may be resource constrained. We report two successful instances of pelvic packing using chitosan impregnated gauze (Celox) when conventional surgical attempts at vascular control had failed. We conclude that pelvic packing should be considered early in patients with military pelvic trauma and major haemorrhage, as part of damage control surgery and that Celox gauze may be a useful adjunct. In our cases, the Celox gauze was easily removed after 24-48 hours without significant bowel adhesions and did not leave a residual phelgmon (of exudate or gel) that may predispose to infection.

Angioembolization for pelvic hemorrhage control: results from the German pelvic injury register

BACKGROUND

Hemorrhage from pelvic vessels is a potentially lethal complication of pelvic fractures. There is ongoing controversy on the ideal treatment strategy for patients with pelvic hemorrhage. The aim of the study was to analyze the role of angiography and subsequent embolization in patients with pelvic fractures and computed tomography scan-proven vascular injuries.

METHODS

The data from the prospective multicenter German pelvic injury registry were analyzed. Of 5,040 patients with pelvic fractures, 152 patients with associated vascular injuries were identified. Patients undergoing angioembolization (n = 17) were compared with those undergoing conventional measures for hemorrhage control (n = 135) with regard to demographic and physiologic parameters, fracture type distribution, and treatment measures. Outcome measures were mortality, requirement for blood transfusions, complications, and hospital length of stay.

RESULTS

Embolization and nonembolization groups were comparable with regard to age, sex, Injury Severity Score, Hannover Polytrauma Score, initial hemoglobin levels, blood pressure, fracture distribution, and conventional measures. Blood transfusion requirement was significantly prolonged in the embolization group. This resulted in a higher adult respiratory distress syndrome incidence and a tendency toward increased multiple organ failure rate in this group. There was no significant difference in overall mortality rate when compared with the nonembolization group (17.6% vs. 32.6%, respectively; p = 0.27). None of the patients undergoing embolization died from exsanguination when compared with 20.6% in the nonembolization group (p = 0.038).

CONCLUSION

Angioembolization alongside with conventional measures is an effective complementary means for hemorrhage control in patients sustaining pelvic fracture-related vascular lesions. It might prove even more effective when performed early enough to avoid prolonged blood transfusion requirement. Further studies without the mentioned limitations of the study are desired.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Improvised explosive device related pelvi-perineal trauma: anatomic injuries and surgical management

BACKGROUND

Pelviperineal injuries, primarily due to blast mechanisms, are becoming the signature injury pattern on operations in Afghanistan. This study set out to define these injuries and to refine our team-based surgical resuscitation strategies to provide a resuscitation-debridement-diversion didactic on our Military Operational Surgical Training predeployment course to optimize our field care of these injuries.

METHODS

A retrospective study of the UK Joint Theatre Trauma Registry was performed looking at consecutive data from January 2003 to December 2010, identifying patients with perineal injuries. Data abstracted included patient demographics, mechanism of injury, Injury Severity Score (ISS), management, and outcomes.

RESULTS

Of 2204 UK military trauma patients, 118 (5.4%) had a recorded perineal injury and 56 (47%) died . Pelvic fractures were identified in 63 (53%) of 118 patients of which only 17 (27%) of 63 survived. Mortality rates were significantly different between the combined perineal and pelvic fracture group compared with the pelvic fractures or perineal injuries alone (107 [41%] of 261 and 11 [18%] of 56, respectively, p < 0.001). The median (interquartile range) ISS for all patients was 38 (29-57). The ISS for those with pelvic fractures were significantly higher than those with perineal injuries alone, 50 (38-71) versus 30 (15-35) (p < 0.001).

CONCLUSION

Improvised explosive device-related perineal injuries with pelvic fractures had the highest rate of mortality compared with perineal injuries alone. Early aggressive resuscitation (activation of the massive hemorrhage protocol) is essential to survival in this cohort. Our recommendations are uncompromising initial debridement, immediate fecal diversion, and early enteral feeding.

Use of Computed Tomography Findings and Contrast Extravasation in Predicting the Need for Embolization with Pelvic Fractures

Transarterial embolization (AE) can be a lifesaving procedure for severe hemorrhage associated with pelvic fractures. The purpose of this study was to identify demographic and radiographic findings that predict the need for embolization. We performed a retrospective review of all patients with at least one pelvic fracture and admission to the intensive care unit over a 35-month period. Computed tomography (CT) and pelvic radiographs were reviewed. Patient demographics, outcomes, time to angiography, and whether or not embolization was performed were determined. Statistical analysis was used to determine factors associated with the need for AE. Of the 327 total patients with pelvic fractures, 317 underwent CT scanning. Forty-four patients (13.5%) underwent angiography and 25 (7.6%) required therapeutic embolization. There were 39 total deaths (11.6%) with five deaths related to pelvic hemorrhage (1.5%). Multivariate analysis revealed that age older than 55 years (odds ratio [OR], 1.06; P < 0.001), systolic blood pressure less than 90 mmHg in the emergency department (OR, 11.64; P = 0.0008), and CT extravasation (OR, 147.152; P < 0.0001) were significantly associated with the need for embolization. Contrast extravasation was not present in 25 per cent of patients requiring therapeutic AE. The presence of contrast extravasation is highly associated with the need for pelvic embolization in patients with pelvic fractures, but its absence does not exclude the need for pelvic angiography.

Hemorrhage detection and segmentation in traumatic pelvic injuries

Automated hemorrhage detection and segmentation in traumatic pelvic injuries is vital for fast and accurate treatment decision making. Hemorrhage is the main cause of deaths in patients within first 24 hours after the injury. It is very time consuming for physicians to analyze all Computed Tomography (CT) images manually. As time is crucial in emergence medicine, analyzing medical images manually delays the decision-making process. Automated hemorrhage detection and segmentation can significantly help physicians to analyze these images and make fast and accurate decisions. Hemorrhage segmentation is a crucial step in the accurate diagnosis and treatment decision-making process. This paper presents a novel rule-based hemorrhage segmentation technique that utilizes pelvic anatomical information to segment hemorrhage accurately. An evaluation measure is used to quantify the accuracy of hemorrhage segmentation. The results show that the proposed method is able to segment hemorrhage very well, and the results are promising.

Operating room or angiography suite for hemodynamically unstable pelvic fractures?

BACKGROUND

Few patients require angiography and therapeutic embolization for bleeding pelvic fractures, but they are risk for significant morbidity and mortality. In hemodynamically unstable trauma patients with pelvic fractures, the decision to proceed to the operating room (OR) to address intraabdominal bleeding, or angiography to address pelvic bleeding (ANGIO), is rarely straightforward. This study tested the hypothesis that outcomes are similar regardless if the sequence was OR-ANGIO or ANGIO-OR.

METHODS

All pelvic fractures between 1999 and 2011 were retrospectively reviewed and stratified by initial management with ANGIO or OR.

RESULTS

Of 2,922 patients with pelvic fractures, only 183 (6%) required angiography for suspected bleeding. For OR-ANGIO (n = 49) versus ANGIO (n = 134), injury severity score was similar (40 ± 15 vs. 35 ± 16), but systolic blood pressure (97 ± 28 vs. 108 ± 32 mmHg, p = 0.038) and base excess were both lower (-9 ± 5 vs. -5 ± 5 mEq/L, p < 0.001). During initial resuscitation and in the first 24 hours, crystalloid, blood product usage and total fluid requirements were all increased 50% to 100% (all p < 0.001). Despite these differences, lengths of stay (32 ± 32 vs. 26 ± 28 days) and mortality (33% vs. 31%) were similar. The same trends in fluid requirements remained in the subset of patients with unstable pelvic fractures, with an increased mortality (67% vs. 20%, p = 0.011) in those requiring ANGIO-OR versus OR-ANGIO.

CONCLUSION

These data support current management algorithms. In hemodynamically unstable trauma patients with pelvic fractures, those who proceeded immediately to the OR to address intraabdominal bleeding tended to be sicker but had outcomes that were the same or better compared with those who received angiography to address pelvic bleeding.

LEVEL OF EVIDENCE

III, retrospective review.

Predictors of mortality following severe pelvic ring fracture: results of a population-based study

INTRODUCTION

Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system.

METHODS

Cases aged≥15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated.

RESULTS

There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged≥65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15-34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres).

CONCLUSIONS

The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.

Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability

Background

This case series report discusses patients presenting with hemorrhage and hemodymanic compromise due to severe pelvic fractures and undergoing intraoperative angioembolization (IAE) with other resuscitative procedures.

Methods

We used portable digital subtraction fluoroscopy units for IAE in patients with severe pelvic hemorrhage and hemodynamic instability (5/03-4/09). Data was collected on demographics, injury severity, resource utilization, and outcomes at our Level 1 trauma center.

Results

There were 6,538 adult admissions with 912 having pelvic fractures and 65 of these undergoing pelvic angioembolization. Twelve hemodynamically compromised patients (10 males, 2 females) had intraoperative pelvic angiography (age: 22-79 years; mean 51.3 ± 17.4). Injury severity score (ISS) was 37.5 ± 8.4 (22-50). Mean emergency department (ED) length of stay (LOS) was 57.4 min ± 47.9 with 10 patients transported directly to the OR and 2 to the SICU prior to OR. Ten of 12 patients underwent exploratory laparotomy followed by angioembolization. Mortality was 50%. Among the 6 survivors (ISS 22 - 50), all had a pre-op CT scan, five had an initial base deficit <13, and four were transfused ≤ 6 units pre-incision/pre-procedure. Four of the 6 survivors had unilateral embolization. In contrast, all 6 non-survivors (ISS 29-41) required massive transfusion prior to OR (>6 units PRBCs) with 4 having a based deficit >13. Three of these patients bypassed CT and five underwent bilateral internal iliac embolization (BIIE).

Conclusions

IAE for severe pelvic hemorrhage can be successfully performed concurrently with exploratory laparotomy, pelvic packing or other resuscitative procedures. Patients most likely to benefit have a base deficit <13, and do not require massive transfusion prior to IAE or suffer from a vertically unstable pelvis fracture.

Interventional radiology in pelvic trauma

Blunt pelvic trauma is commonly encountered in major trauma centers. Associated injuries are common but mortality related to pelvic fractures alone when associated with haemodynamic instability is not insignificant. Interventional radiology (IR) can provide rapid cessation of haemorrhage if considered early in patient management and there is a vast amount of evidence in support of IR in this setting. Early identification of patients who are likely to benefit from angiography and embolisation is of paramount importance and demands a multidisciplinary approach to provide the patient with the best chance of survival. This article reviews the evidence for IR in this setting and discusses the techniques available.

Introduction to interventional radiology in trauma

Interventional radiology (IR) has much to offer in the treatment of the trauma patient and should be integral in multidisciplinary trauma management. Many minimally invasive endovascular techniques are available with a vast amount of evidence to support their successful application. These techniques are both safe and effective and can in many circumstances negate further trauma caused by surgery in this high risk group. IR should not necessarily be considered a direct replacement for surgery as the two can often be synergistic in providing optimal care to many trauma patients. Despite the body of evidence and wealth of experience, IR is often overlooked or thought of late in trauma management when therapies are less effective. This article explores the role of IR and reviews the techniques and evidence behind their use.

The role of arterial embolization in controlling pelvic fracture haemorrhage: a systematic review of the literature

OBJECTIVE

To evaluate the efficacy of emergency transcatheter arterial embolization (TAE) in controlling retroperitoneal arterial haemorrhage associated with unstable pelvic fractures.

METHODS

A systematic review of the English literature yielded 21 eligible studies published from 1979 to 2010. Evaluation of clinical and methodological heterogeneity was based on recording certain descriptive characteristics in the component studies. Statistical heterogeneity was detected using Cochran chi-square and I square tests and, when absent, a pooled estimate of effect size for each outcome of interest was calculated. The principal outcomes of interest were efficacy rate of TAE to control intrapelvic bleeding, mortality rates and frequency of associated complications.

RESULTS

All component studies were assigned a low to moderate quality score. Methodological and clinical heterogeneity was evident across component studies, but not strongly associated with the observed results. The efficacy rate of TAE ranged from 81 to 100%, while the frequency of repeat TAE for effective control of haemorrhage was 10% (95% CI: 7-13%, range: 0-19%). TAE was associated with an overall mortality ranging from 7 to 47%, and a 0-25% mortality due to intrapelvic bleeding (pooled estimate of effect size: 6%, 95% CI: 4-8%). A very low rate of associated complications were recorded in the component studies (pooled estimate of effect size: 1.1%, 95% CI: 0.1-2.1%).

CONCLUSION

TAE is an efficient acute intervention for controlling severe arterial bleeding related to pelvic trauma with a low complication rate. Repeat of the procedure is occasionally necessary before the effective haemorrhage control.

Challenges of surgical trauma emergency admission

INTRODUCTION

Trauma still remains as one of the leading causes for mortality in Western civilization. The early clinical management of severely injured patients leads to structural and organizational challenges involving different specialties.

EMERGENCY DEPARTMENT

Trauma team leaders have to coordinate diagnostic and therapeutic steps in cooperation with different involved specialties. Furthermore, they have to make decisions based on contrary department-depending assessments. In addition, several special injuries commonly found in multiple traumatized patients require special attention.

RECENT DEVELOPMENT

Actually, structural changes in generating trauma networks are to be mentioned. Trauma networks suggest to improve patients survival in close cooperation between hospitals with different structural and personal capabilities. Close communication networks are required to guarantee transportation to an adequate trauma center.