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

Severe pelvic injury: vascular lesions detected by ante- and post-mortem contrast medium-enhanced CT and associations with pelvic fractures

OBJECTIVES

The objectives of this study were to compare arterial and venous contrast medium extravasation in severe pelvic injury detected by ante- and post-mortem multi-detector CT (MDCT) and determine whether vascular injury is associated with certain types of pelvic fracture.

METHODS

We retrospectively included two different cohorts of blunt pelvic trauma with contrast medium extravasation shown by MDCT. The first group comprised 49 polytrauma patients; the second included 45 dead bodies undergoing multi-phase post-mortem CT-angiography (MPMCTA). Two radiologists jointly reviewed each examination concerning type, site of bleeding and pattern of underlying pelvic ring fracture.

RESULTS

All 49 polytrauma patients demonstrated arterial bleeding, immediately undergoing subsequent angiography; 42 (85%) had pelvic fractures, but no venous bleeding was disclosed. MPMCTA of 45 bodies revealed arterial (n = 33, 73%) and venous (n = 35, 78%) bleeding and pelvic fractures (n = 41, 91%). Pelvic fracture locations were significantly correlated with ten arterial and six venous bleeding sites in dead bodies, with five arterial bleeding sites in polytrauma patients. In dead bodies, arterial haemorrhage was significantly correlated with the severity of pelvic fracture according to Tile classification (p = 0.01), unlike venous bleeding (p = 0.34).

CONCLUSIONS

In severe pelvic injury, certain acute bleeding sites were significantly correlated with underlying pelvic fracture locations. MPMCTA revealed more venous lesions than MDCT in polytrauma patients. Future investigations should evaluate the proportional contribution of venous bleeding to overall pelvic haemorrhage as well as its clinical significance.

Mortality in trauma patients with active arterial bleeding managed by embolization or surgical packing: An observational cohort study of 66 patients

Objective:

Exsanguination due to coagulopathy and vascular injury is a common cause of death among trauma patients. Arterial injury can be treated either by angiography and embolization or by explorative laparotomy and surgical packing. The purpose of this study was to compare 30-day mortality and blood product consumption in trauma patients with active arterial haemorrhage in the abdominal and/or pelvic region treated with either angiography and embolization or explorative laparotomy and surgical packing.

Material and Methods:

From January 1^st 2006 to December 31^st 2011 2,173 patients with an ISS of >9 were admitted to the Trauma Centre of Copenhagen University Hospital, Rigshospitalet, Denmark. Of these, 66 patients met the inclusion criteria: age above 15 years and active arterial haemorrhage from the abdominal and/or pelvic region verified by a CT scan at admission. Gender, age, initial oxygen saturation, pulse rate and respiratory rate, mechanism of injury, ISS, Probability of Survival, treatment modality, 30-day mortality and number and type of blood products applied were retrieved from the TARN database, patient records and the Danish Civil Registration System.

Results:

Thirty-one patients received angiography and embolization, and 35 patients underwent exploratory laparotomy and surgical packing. Gender, age, initial oxygen saturation, pulse rate and respiratory rate, ISS and Probability of Survival were comparable in the two groups.

Conclusion:

A significant increased risk of 30-day mortality (P = 0.04) was found in patients with active bleeding treated with explorative laparotomy and surgical packing compared to angiography and embolization when data was adjusted for age and ISS. No statistical significant difference (P > 0.05) was found in number of transfused blood products applied in the two groups of patients.

The Role of Transcatheter Arterial Embolization in Traumatic Pelvic Hemorrhage: Not Only Pelvic Fracture

Purpose: The most common life-threatening complication of pelvic trauma is bleeding. Arterial bleedings frequently require active management, preferably with transcatheter arterial embolization (TAE). Hemodynamic instability and/or contrast extravasation at computer tomography (CT) examination are reliable indicators of arterial injury. Unstable pelvic fractures are much more hemorrhagic than stable fractures. Nevertheless, an absent or isolated pelvic fracture does not exclude pelvic hemorrhage.

Materials and Methods: A retrospective study was conducted on our institutional database by collecting data of patients who underwent pelvic angiography and/or embolization due to pelvic blunt trauma in the period between August 2010 and August 2015.

Results: In a period of five years, 39 patients with traumatic pelvic bleeding underwent angiography at our institution. Thirty-six of the 39 (92%) patients did show CT signs of active pelvic bleeding. Nineteen of 39 (49%) patients were hemodynamically unstable at presentation. Three of the 39 patients did not require embolization. Technical success was 35/36 (97%), and overall mortality was 3/39 (8%). Notably, 5/39 (13%) patients did not have any pelvic fracture at presentation, and 18/39 (46%) had only isolated or stable pelvic ring fracture.

Conclusions: TAE is an effective technique to treat arterial pelvic bleeding after trauma. The absence of a major pelvic fracture does not exclude the risk of active bleeding requiring prompt treatment.

Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures--Quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥33

AIMS

Both retroperitoneal pelvic packing and primary angioembolization are widely used to control haemorrhage related to pelvic fractures. It is still unknown which protocol is the safest. The primary aim of this study is to compare survival and complications of pelvic packing and angioembolization in massive haemorrhage related to pelvic fractures.

METHODS

Patients with haemodynamically unstable pelvic fractures were quasi-randomized to either pelvic packing (PACK) or angiography (ANGIO) using the time of admission as separator. Physiological markers of haemorrhage, time to intervention, procedure/surgical time, transfusion requirements, complications and early mortality were recorded and analyzed.

RESULTS

29 patients were randomized to PACK and 27 patients to ANGIO. The Injury Severity Score (ISS) in the ANGIO group was lower than in the PACK group (43 ± 7 vs 48 ± 6) (p<0.01). The median time from admission to angiography for the ANGIO group was 102 min (range 76-214), and longer than 77 min (range 43-125) from admission to surgery for the PACK group (p<0.01). The procedure time for the ANGIO group was 84 min (range 62-105); while the surgical time was 60 min (range 41-92) for the PACK group (p<0.001). The ANGIO group received 6.4 units packed red blood cells (range 4-10) in the first 24h after angiography. The PACK group required 5.2 units (range 3-10) in the first 24h after leaving the operating theatre (p=0.124). 9 patients in the ANGIO group underwent pelvic packing for persistent bleeding. 6 patients in the PACK group required pelvic angiography after pelvic packing for ongoing hypotension following packing (p=0.353). 5 patients in the ANGIO group died (2 from exsanguination), while 4 in the PACK group died (none from exsanguination) (p=0.449). Complications occurred without differences in both groups.

CONCLUSIONS

Compared with angioembolization, pelvic packing has shorter time to intervention and surgical time. Thus pelvic packing is the more rapid treatment of severe pelvic trauma than pelvic angioembolization. It is suitable for patients with haemodynamic instability at centers where the interventional radiology staff is not in-house at all times.

REGISTRATION

ClinicalTrials.gov (NCT02535624) and ISRCTN registry (ISRCTN91713422).

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.

Effects of internal iliac artery embolization on systemic inflammatory response syndrome in dogs with simulated-pelvic-fracture combined with massive bleeding

BACKGROUND

Pelvic fracture combined with massive bleeding (PFCMB) is a complex issue in clinical practice. Currently, the use of angiography and embolization for the treatment of PFCMB obtains good results. The aim of this study is to observe the effects of early internal iliac artery embolization on the SIRS in dogs with simulated-pelvic-fracture combined with massive bleeding.

METHODS

Twenty adult dogs were randomly divided into an embolization group (EG) and a control group (CG). For the two groups, heart rate, respiratory rate and body temperature and other physiological variables were measured, and IL-6, TNF-α and arterial blood gas levels were monitored. These variables were assayed every 30 min until death in the CG, while dogs in the EG underwent arterial angiography after 60 min of modeling. The internal iliac artery was embolized on the injured side.

RESULTS

The average time to SIRS in the CG was 3.56 h, occurring at a rate of 90 % (9/10) within 24 h, with a mortality rate of 50 % (5/10); the average time to SIRS for the EG was 5.33 h, occurring at a rate of 30 % (3/10) within 24 h, with a mortality rate of 10 % (1/10). When SIRS occurred in the EG, the mean plasma IL-6 level was 52.66 ± 7.38 pg/ml and the TNF-α level was 11.45 ± 2.72 ng/ml, showing a significant difference with those of the CG (P < 0.05). In the two groups, the respiratory rate and leukocyte levels were higher at each monitored time after modeling than those before modeling; the mean arterial pressure, levels of hemoglobin and oxygen partial pressure were significantly lower at each time point after modeling than those before modeling except for the mean arterial pressure at 0 h in EG; the platelet levels at 4 and 8 h were higher than those before modeling; and the differences were statistically significant (P < 0.05). In the EG, the mean arterial pressure, heart rate, respiratory rate and hemoglobin levels at 2 , 4 and 8 h were lower than those at 0 h; the levels of leukocytes, platelets and carbon dioxide partial pressure at 4 and 8 h after modeling were higher than those at 0 h, and the differences were statistically significant (P < 0.05, P < 0.01); in the CG after modeling, the mean arterial pressure, levels of hemoglobin and carbon dioxide partial pressure at 2, 4 and 8 h were lower than those at 0 h; the levels of heart rate and leukocytes were higher than those before modeling; the respiratory rate and platelet levels at 4 and 8 h were higher than those at 0 h; and the differences were statistically significant (P < 0.05). The levels of the mean arterial pressure and hemoglobin at 4 and 8 h and the pH values at 8 h after modeling in the EG were significantly higher than those in the CG, while the heart rate and respiratory rate at 4 and 8 h were significantly lower than those in the CG. The pH values at 8 h after modeling were significantly lower than those of the other monitored times in the CG (P < 0.05, P < 0.01). The two groups had elevated levels of alkaline phosphatase after injury induction.

CONCLUSION

Through the use of an on-spot interventional treatment cabin, early internal iliac artery embolization can control bleeding associated with pelvic fractures, delay the occurrence of SIRS, and improve the success rate of the treatment of pelvic fracture combined with bleeding.

Relative hypotension increases the probability of the need for angioembolisation in pelvic fracture patients without contrast extravasation on computed tomography scan

INTRODUCTION

In the evaluation of haemorrhage in trauma patients with pelvic fractures, contrast extravasation (CE) on computed tomography (CT) scan often implies active arterial bleeding. However, the absence of CE on CT scan does not always exclude the need for transcatheter arterial embolisation (TAE) to achieve haemostasis. In the current study, we evaluated the factors associated with the need for TAE in patients without CE on CT scan. These factors may be evaluated as adjuncts to CT scanning in the management of patients with pelvic fractures.

METHODS

We retrospectively reviewed our trauma registry and medical records of patients with pelvic fractures. When CE was observed, indicating active haemorrhage, the patients underwent TAE to achieve haemostasis. In contrast, patients without CE were held for observation and treatment of their injuries, and if their condition deteriorated after a delayed interval, they were then also referred for TAE if no other focus of haemorrhage was found. Patients without CE on CT scan but with retroperitoneal haemorrhage requiring TAE were investigated. Their demographic characteristics, associated injuries, fracture patterns, and changes in systolic blood pressure were described and analysed.

RESULTS

In total, 201 patients with pelvic fracture underwent CT scan examination; 47 (23.4%) had CE by CT scan, whereas the other 154 (76.6%) did not. Of the 154 patients who did not show CE by CT scan, 124 (80.5%) patients never underwent TAE; however, 30 (19.5%) of these patients did eventually undergo TAE. In comparing the patients who underwent TAE to those who did not undergo TAE among patients without CE on CT scan, the systolic blood pressure (SBP) on arrival (median: 100.0 mmHg vs 136.0 mmHg, p<0.01) and the lowest SBP recorded in the ED (median: 68.0 mmHg vs 129.0 mmHg, p<0.01) were significantly lower in the patients who underwent TAE. The ROC curve analysis revealed that the most appropriate cutoff value of decrement of SBP (SBP on arrival minus the lowest SBP in the ED) was 30 mmHg (AUC=0.89).

CONCLUSION

In the management of pelvic fracture patients, greater attention should be directed toward patients with relative hypotension. The higher likelihood of haemodynamic deterioration and the need for TAE for haemorrhage control should remain under consideration in such cases, despite the absence of CE by CT scan.

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.

[Endovascular interventions for multiple trauma]

CLINICAL ISSUE

In recent years interventional radiology has significantly changed the management of injured patients with multiple trauma. Currently nearly all vessels can be reached within a reasonably short time with the help of specially preshaped catheters and guide wires to achieve bleeding control of arterial und venous bleeding.

STANDARD TREATMENT/TREATMENT INNOVATIONS

Whereas bleeding control formerly required extensive open surgery, current interventional methods allow temporary vessel occlusion (occlusion balloons), permanent embolization and stenting.

DIAGNOSTIC WORK-UP

In injured patients with multiple trauma preinterventional procedural planning is performed with the help of multidetector computed tomography whenever possible.

PERFORMANCE

Interventional radiology not only allows minimization of therapeutic trauma but also a considerably shorter treatment time.

ACHIEVEMENTS

Interventional bleeding control has developed into a standard method in the management of vascular trauma of the chest and abdomen as well as in vascular injuries of the upper and lower extremities when open surgical access is associated with increased risk. Additionally, pelvic trauma, vascular trauma of the superior thoracic aperture and parenchymal arterial lacerations of organs that can be at least partially preserved are primarily managed by interventional methods.

PRACTICAL RECOMMENDATIONS

In an interdisciplinary setting interventional radiology provides a safe and efficient means of rapid bleeding control in nearly all vascular territories in addition to open surgical access.

Extremity War Injuries IX: Reducing Disability Within the Military

Extremity War Injury Symposium IX focused on reducing disability within the military, centering on cartilage defects, amputations, and spinal cord injury. Many areas of upper and lower extremity trauma and disability were discussed, including segmental nerve injuries, upper extremity allotransplantation, and the importance of patient-reported functional outcomes compared with the traditionally reported measures. Strategic planning addressed progression toward clinical solutions by setting clear objectives and goals and outlining pathways to address the "translation gap" that often prevents bridging of basic science to clinical application.

Major haemorrhage in pubic rami fractures

A 62-year-old man presented to the emergency department, having fallen 6 ft from a ladder, with pain over his left hip and shoulder. He was managed according to the Advanced Trauma Life Support (ATLS) protocol, and his primary survey showed no haemodynamic compromise. Initial radiographs showed a unilateral left superior and inferior pubic rami fracture, which was treated conservatively. Forty-eight hours post-admission, the patient became tachycardic and hypotensive and was found to have dropped his haemoglobin from 125 to 89 g/L. After resuscitation, a repeat contrast CT scan revealed an enlarging haematoma in his pelvis. This was treated with urgent angioembolisation and the patient was further stabilised in the intensive care unit. This report shows the need for a low threshold in suspecting intrapelvic bleeds in patients with pubic rami fractures, and the need for prompt treatment of such patients, either surgically or radiologically.

The role of endovascular treatment of pelvic fracture bleeding in emergency settings

PURPOSE

To evaluate the role of endovascular treatment for controlling haemorrhage in haemodynamically unstable patients with pelvic bone fractures and to relate clinical efficacy to pre-procedural variables.

MATERIALS AND METHODS

From March 2009 through April 2013, 168 patients with major pelvic trauma associated with high-flow haemorrhage were referred to our emergency department and were retrospectively reviewed. Pelvic arteries involved were one or more per patient. Embolisation was performed using various materials (micro-coils, Spongostan, plug, glue, covered stent), and technical success, complications, treatment success, clinical efficacy, rebleeding, and mortality rates were assessed. Factors influencing clinical efficacy were also evaluated.

RESULTS

The technical success rate was 100%; no complications occurred during the procedures. Treatment was successful in 94.6% cases, and clinical efficacy was 85.7%. Three patients had to undergo a second arteriography due to recurrent haemorrhage. Fifteen patients died. Pre-embolisation transfusion demand was significantly associated with clinical efficacy.

CONCLUSIONS

Percutaneous embolisation of pelvic bleeding may be considered a safe, effective, and minimally invasive therapeutic option. As haemodynamic stability is the first objective with traumatic haemorrhagic patient, arterial embolisation can assume a primary role. On the basis of our results, pre-procedural transfusion status may be considered a prognostic factor.

KEY POINTS

• The series presented is one of the largest in a single centre. • Arterial embolisation is a life-saving procedure in patients with pelvic haemorrhage. • In pelvic traumas associated with haemorrhage, prognosis is dependent upon prompt treatment. • Transfusion status is significantly related to clinical efficacy.

Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Haemorrhage in fragility fractures of the pelvis

INTRODUCTION

Fragility fractures of the pelvis (FFP) are one of the most visible and debilitating consequences of osteoporosis. In contrast to pelvic ring fractures of the young, fragility fractures are caused by falls from a standing height or even by repetitive physiological loads. Even though haemorrhage is rarely found in fragility fractures of the pelvis, one must be aware of the potential risk.

MATERIALS AND METHODS

In a computer literature search, we identified eight papers about patients with haemorrhage and/or haemodynamic instability as a complication of a low-velocity pelvic ring fracture, all of which were case reports.

CONCLUSION

In our review, an overview of the case reports is provided, risk factors identified and a recommendation for the treatment and clinical observation given.

[Vascular complications after pelvic rami fracture]

The case is presented of a 78 year-old patient who suffered a right ileo- and ischiopubic rami fracture after a casual fall. A few hours later, she presented with sudden abdominal pain and hypotension. Imaging test showed extraperitoneal hemorrhage with active bleeding and hemodynamic compromise. The progressive worsening, with anemia and hemodynamic instability, required her being sent to the reference hospital for selective embolization of the bleeding point. After embolization, the patient́s situation stabilized, and she was then able to sit down one week later. The fracture consolidated 3 months later. Although low-energy pelvic fractures by lateral compression do not usually present with complications, sometimes they require a strict control due to the potential risk of vascular injuries.

The management of retroperitoneal haematoma discovered at laparotomy for trauma

AIM

To review our local experience with presentation and management of retroperitoneal haematomas (RPH) discovered at laparotomy and factors affecting outcome.

METHODS

Patients with retroperitoneal haematomas (RPHs) were identified from a prospective database. Data collected included demographics, clinical presentation, zones and organs involved, management and outcome.

RESULTS

Of a total of 488 patients with abdominal trauma, 145 (30%) with RPH were identified 136 of whom were male (M:F=15:1). Mean age was 28.8 (SD 10.6) years and median delay before surgery was 7h. The injury mechanisms were firearms (109), stabs (24), and blunt trauma (12). Twenty-four patients (17%) presented with shock. There were 58 Zone I, 69 Zone II, and 38 Zone III haematomas. The median injury severity score (ISS) was 9. Fifty-two patients (36%) developed complications and 26 (18%) patients died. Sixty-four (44%) patients required ICU with median ICU stay of 3 days. All Zone I injuries were explored; Zones II and III were explored selectively. The mortality for Zones I, II, III and IV was 14%, 4%, 29% and 35%, respectively. Mortality was highest for blunt trauma and lowest for stabs (p=0.146). Twelve of 24 patients with shock died (50%) compared to 14 of 121 (12%) without shock (p<0.0001). Eighteen of 64 patients with <6-h delay before surgery died (28%) compared to 8 of 81 (10%) with >6-h delay (p<0.017). Mortality increased with increasing ISS. Median hospital stay was 8 days.

CONCLUSION

RPH accounted for 30% of abdominal trauma. Injury mechanism, presence of shock, delay before surgery and ISS showed a significant association with mortality.

Utility of simultaneous interventional radiology and operative surgery in a dedicated suite for seriously injured patients

PURPOSE OF REVIEW

In recent years, combined interventional radiology and operative suites have been proposed and are now becoming operational in select trauma centres. Given the infancy of this technology, this review aims to review the rationale, benefits and challenges of hybrid suites in the management of seriously injured patients.

RECENT FINDINGS

No specific studies exist that investigate outcomes within hybrid trauma suites. Endovascular and interventional radiology techniques have been successfully employed in thoracic, abdominal, pelvic and extremity trauma. Although the association between delayed haemorrhage control and poorer patient outcomes is intuitive, most supporting scientific data are outdated. The hybrid suite model offers the potential to expedite haemorrhage control through synergistic operative, interventional radiology and resuscitative platforms. Maximizing the utility of these suites requires trained multidisciplinary teams, ergonomic and workplace considerations, as well as a fundamental paradigm shift of trauma care. This often translates into a more damage-control orientated philosophy.

SUMMARY

Hybrid suites offer tremendous potential to expedite haemorrhage control in trauma patients. Outcome evaluations from trauma units that currently have operational hybrid suites are required to establish clearer guidelines and criteria for patient management.

Utilization of angiography and embolization for abdominopelvic trauma: 14 years' experience at a level I trauma center

OBJECTIVE

The objective of our study was to evaluate the long-term trends in the use of angiography and embolization for abdominopelvic injuries.

MATERIALS AND METHODS

Utilization rates for pelvic and abdominal angiography, arterial embolization, and CT were analyzed for trauma patients with pelvic fractures and liver and kidney injuries admitted to a level 1 trauma center from 1996 to 2010. Multivariable linear regression was used to evaluate trends in the use of angioembolization.

RESULTS

A total of 9145 patients were admitted for abdominopelvic injuries during the study period. Pelvic angiography decreased annually by 5.0% (95% CI, -6.4% to -3.7%) from 1996 to 2002 and by 1.8% (-2.4% to -1.2%) from 2003 to 2010. Embolization rates for these patients varied from 49% in 1997 to 100% in 2010. Utilization of pelvic CT on the day of admission increased significantly during this period. Abdominal angiography for liver and kidney injuries decreased annually by 3.3% (95% CI, -4.8% to -1.8%) and 2.0% (-4.3% to 0.3%) between 1996 and 2002 and by 0.8% (95% CI, -1.4% to -0.1%) and 0.9% (-2.0% to 0.1%) from 2003 to 2010, respectively. Embolization rates ranged from 25% in 1999 to 100% in 2010 for liver injuries and from 0% in 1997 to 80% in 2002 for kidney injuries. Abdominal CT for liver and kidney injuries on the day of admission also increased.

CONCLUSION

A significant decrease in angiography use for trauma patients with pelvic fractures, liver injuries, and kidney injuries from 1996 to 2010 and a trend toward increasing embolization rates among patients who underwent angiography were found. These findings reflect a declining role of angiography for diagnostic purposes and emphasize the importance of angiography as a means to embolization for management.

[The initial management in intensive care of pelvic ring injury patients]

Pelvic trauma care is complex since it is frequently associated with multiple injuries and may lead to dramatic and uncontrollable haemorrhage. After pelvic trauma, the mortality, around 8 to 10%, is mainly related to severe pelvic hemorrhage but also to extrapelvic injuries (thoracic, abdominal or brain injuries). It is therefore crucial to manage pelvic trauma in specialized trauma center. The initial trauma assessment aims to determine the role of the pelvic injury in hemorrhage to define the therapeutic strategy of pelvic trauma care (arterial embolisation/pelvic ring stabilisation). This review was performed with a systematic review of the literature; it describes the pelvic fracture pathophysiology, and the efficacy and safety of haemostatic procedures and with their respective indications. A decision making algorithm is proposed for the treatment of trauma patients with pelvic fracture.

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.

Haemorrhagic shock, therapeutic management

The management of a patient in post-traumatic haemorrhagic shock will meet different logics that will apply from the prehospital setting. This implies that the patient has beneficiated from a "Play and Run" prehospital strategy and was sent to a centre adapted to his clinical condition capable of treating all haemorrhagic lesions. The therapeutic goals will be to control the bleeding by early use of tourniquet, pelvic girdle, haemostatic dressing, and after admission to the hospital, the implementation of surgical and/or radiological techniques, but also to address all the factors that will exacerbate bleeding. These factors include hypothermia, acidosis and coagulopathy. The treatment of these contributing factors will be associated to concepts of low-volume resuscitation and permissive hypotension into a strategy called "Damage Control Resuscitation". Thus, the objective in situation of haemorrhagic shock will be to not exceed a systolic blood pressure of 90 mmHg (in the absence of severe head trauma) until haemostasis is achieved.

The early management of patients with multiple injuries: an evidence-based, practical guide for the orthopaedic surgeon

There have been many advances in the resuscitation and early management of patients with severe injuries during the last decade. These have come about as a result of the reorganisation of civilian trauma services in countries such as Germany, Australia and the United States, where the development of trauma systems has allowed a concentration of expertise and research. The continuing conflicts in the Middle East have also generated a significant increase in expertise in the management of severe injuries, and soldiers now survive injuries that would have been fatal in previous wars. This military experience is being translated into civilian practice. The aim of this paper is to give orthopaedic surgeons a practical, evidence-based guide to the current management of patients with severe, multiple injuries. It must be emphasised that this depends upon the expertise, experience and facilities available within the local health-care system, and that the proposed guidelines will inevitably have to be adapted to suit the local resources.