The size of pelvic hematoma can be a predictive factor for angioembolization in hemodynamically unstable pelvic trauma

Abstract

Purpose: Unstable pelvic fracture with bleeding can be fatal, with a mortality rate of up to 40%. Therefore, early de tection and treatment are important in unstable pelvic trauma. We investigated the early predictive factors for possible embolization in patients with hemodynamically unstable pelvic trauma. Methods: From January 2011 to December 2013, 46 patients with shock arrived at a single hospital within 24 hours after injury. Of them, 44 patients underwent CT scan after initial resuscitation, except for 2 who were dead on arrival. Nine patients with other organ injuries were excluded. Seventeen patients underwent embolization. A single radiologist measured the width (longest length in axial view) and length (longest length in coronal view) of pelvic hematoma on CT scans. Demographic, clinical, and radiological data were reviewed retrospectively. Results: Among 35 patients with hemodynamically unstable pelvic fracture, 22 (62.9%) were men. Width (P = 0.002) and length (P = 0.006) of hematoma on CT scans were significantly different between the embolization and nonembolization groups. The predictors of embolization were width of pelvic hematoma (odds ratio [OR], 1.07; P = 0.028) and female sex (OR, 10.83; P = 0.031). The cutoff value was 3.35 cm. More embolization was performed (OR, 12.00; P = 0.003) and higher mortality was observed in patients with hematoma width >3.35 cm (OR, 4.96; P = 0.048). Conclusion: Patients with hemodynamically unstable pelvic trauma have a high mortality rate. CT is useful for the initial identification of the need for embolization among these patients. The width of pelvic hematoma can predict possible embolization in patients with unstable pelvic trauma.

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

“…Other forms of arterial injuries, such as pseudo-aneurysm, AV fistula, amputated/truncated vessel and intimal tear/dissection have also been described as indirect signs of recent or ongoing arterial bleeding (but not necessary bleeding during CT examination). Similarly, another indirect sign of bleeding is represented by retroperitoneal hematoma, which may be present without signs of contrast extravasation [ 10 ]. Finally, additional indications for AE include age older than 55 years [ 30 ], a systolic blood pressure < 90 mmHg [ 38 ], and a pelvic hematoma > 3.35 cm [ 10 ].…”

“…Pelvic hemorrhages are caused by the destruction of bone structures with subsequent vascular bleeding, caused by venous injuries in the vast majority of cases. However, 3–15% of patients who sustained pelvic fractures demonstrate arterial bleeding [ 10 – 13 ]. Pelvic fracture hemorrhages caused by venous injury at the fracture site can be effectively treated with external fixators, C-clamps, and belts by reducing the pelvic volume and stabilizing the fracture [ 14 ].…”

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

“…CT hemorrhage volumes exceeding 500 ml have a 45% rate of pelvic arterial injury compared to 5% in volumes below 200 ml (26). A pelvic hematoma of >3.35 cm in size is correlated to an increased need for angiography and increased mortality (27). The presence of intravenous contrast extravasation on a CT scan, often called a "blush, " indicates vascular disruption and active arterial bleeding (either contained or free) (28)(29)(30).…”

Hemodynamically Unstable Pelvic Fracture: A Damage Control Surgical Algorithm that Fits your Reality

“…Pelvic ring volume increases significantly from fractures and/or ligament disruptions which precludes its inherent ability to self-tamponade resulting in accumulation of hemorrhage in the retroperitoneal space which inevitably leads to hemodynamic instability and the lethal diamond. Pelvic hemorrhage is mainly venous (80%) from the pre-sacral/pre-peritoneal plexus and the remaining 20% is of arterial origin (branches of the internal iliac artery) 5 , 6 . This reality can be altered via a sequential management approach that is tailored to the specific reality of the treating facility which involves a collaborative effort between orthopedic, trauma and intensive care surgeons.…”

“…La hemorragia pélvica, la inestabilidad hemodinámica y el posterior desarrollo del rombo de la muerte son secundarios a la reducción del efecto intrínseco de auto-taponamiento de la pelvis ocasionado por los trazos de fractura y la disrupción ligamentaria. El sangrado pélvico es de origen venoso en un 80% procedente de los plexos presacro y prevesical y el otro 20% de los casos es de las ramas de la arteria ilíaca interna 5 , 6 . Por esta razón, es fundamental realizar un abordaje secuencial y organizado que esté acorde a la realidad de cada centro hospitalario, con integración de un trabajo organizado y sincrónico entre los servicios de cirugía general, trauma y emergencias, con el de ortopedia y la Unidad de Cuidado Intensivo.…”