Management of Bleeding Pelvic Fractures

Abstract

Introduction: in patients with severe pelvic fractures, exsanguinating hemorrhage represents the major cause of death within the first 24 h. despite advances in management, the mortality rate in these patients remains significantly high. recently, multiple treatment algorithms have been proposed for patients with severe pelvic fractures; however, the optimal modalities in particular in the hemodynamically unstable patient are still a matter of lively debate.this review article focuses on the recent body of knowledge on the different treatment options in patients with severe pelvic fractures and proposes the possible role of each modality in the management of these patients.Methods: the Medline database was searched for medical literature addressing the management of severe pelvic fractures with specific attention given to recent, clinically relevant publications.Results: angiography and embolization have emerged as excellent methods for addressing arterial bleeding. Mechanical pelvic stabilization and surgical hemostasis by pelvic packing, on the other hand, may effectively control venous bleeding and bleeding from the fractured bony surface. However, since there is no precise way to determine the major source of bleeding that is responsible for the hemodynamic instability, controversy remains over the timing and optimal order of angiography, mechanical pelvic stabilization, and packing.Conclusions: the author's own approach to these patients includes angiographic embolization as a first-line treatment only in hemodynamically stable patients with an arterial blush seen in the computed tomography scan, indicating acute arterial bleeding. Hemodynamically unstable patients are immediately transferred to the operating room, where pelvic packing and mechanical stabilization of the pelvic ring are carried out. optionally, a subsequent postoperative angio-embolization is performed if signs of further bleeding remain present.

The importance of pelvic ring stabilization as a life-saving measure in pre-hospital – A case report commented by autopsy

“…Nevertheless, most deaths are related not with organ lesions, but with free space available for the potential internal uncontrolled bleeding. 11 Bleeding usually originates from cancellous bone, presacral venous plexus, and/or iliac vessels. 12 Hemorrhage can also occur in other locations to the high-energy trauma history -most frequently long bones and abdominal viscera.…”

“…With this early measure, it is possible to avoid blood accumulation and achieve a relative bleeding control, during the transportation of the patient to the hospital for definitive care. 11 The available pelvic binders studies show advantages of pelvic binders in bleeding control. 16,17 Manipulation of the fracture was performed during the necropsy to demonstrate and prove how a simple sheet contention can promote stabilization of the pelvic ring by closing the sacroiliac joints in open book fractures -allowing an early control of lifethreatening bleeding on-site (Fig.…”

Embolization of Trauma-Associated Pelvic Hemorrhage: Feasibility of Super-Selective Catheterization in Heavily Injured Patients as a Damage Control for Life-Threatening Pelvic Bleeding

“…This patient did not survive after embolization due to complications from a combined hypoxic brain injury. toneal hemorrhage resulting from pelvic fracture is difficult to control, and mortality remains high (2,3,9).…”

“…Currently, despite ongoing debates, TAE for bleeding pelvic trauma in hemodynamically unstable patients is regarded as a fundamental treatment option with open surgery, like pelvic packing (1)(2)(3)(4). Notably, according to the Eastern Association for Surgery's pelvic trauma guideline, emergent pelvic angiography and embolization in patients with unstable hemodynamic status has the highest level of recommendation (5).…”

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

“…Vascular damage in combination with fractures is associated with higher mortality and inferior outcome, especially due to rapid and voluminous blood loss into pelvic or femoral soft tissue compartments. Correct diagnosis may be difficult due to low body temperature and masking effects of other injuries [8–10]. Doppler ultrasound and CTA increase the detection rate, yet incorrect diagnosis remains frequent thus requiring re-examination after initial stabilization [11, 12].…”