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

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Pelvic angioembolization in trauma - Indications and outcomes

INTRODUCTION

Pelvic stabilization with angioembolization (AE) is steadily supplanting operative management for the treatment of pelvic hemorrhage in trauma. We aimed to provide a brief review of the indications, effectiveness and complications associated with AE for pelvic injuries.

METHODS

We conducted a literature search using the terms "trauma," "angioembolization," and "pelvis" limited to studies published in the English language. Abstracts and full text were manually reviewed to identify suitable articles.

RESULTS

The current brief review is based on content from articles published in the last 10 years related to pelvic AE for retroperitoneal hemorrhage after trauma.

DISCUSSION

Pelvic injuries often require complex management because the high energy transfer causes concomitant injuries. Outcomes for hemodynamically unstable patients may be better with AE than with operative management.

CONCLUSION

Pelvic AE is the most effective intervention for management of hemorrhage associated with pelvic fracture in both hemodynamically stable and unstable patients. It can be used as the primary definitive intervention or in conjunction with operative management in the setting of concomitant intra-abdominal injury.

Trends in the management of pelvic fractures, 2008-2010

BACKGROUND

Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time.

METHODS

The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality.

RESULTS

A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001).

CONCLUSIONS

AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.

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.

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.

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.

[Current treatment of pelvic ring fractures]

Pelvic injuries are often associated with multiple injuries of other body regions, neurovascular and visceral lesions, as well as hemodynamic instability. The use of a standardized classification characterizing the severity and stability of pelvic fractures and the early stabilization of pelvic ring injuries in appreciation of damage control principles has helped to improve the number of survivors. This is particularly necessary due to the higher number of older patients. Complex pelvic trauma still represents a life-threatening situation for the patient, particularly in multiple traumatized patients. Standardized clinical investigations and modern concepts even in the preclinical therapy of complex pelvic fractures make a contribution to enhancement of treatment options. Because of the still problematic long-term results after surgery of instable pelvic fractures, the need for modern treatment concepts has to be adapted to the requirements.

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.

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.

[Current treatment of pelvic ring fractures]

Pelvic injuries are often associated with multiple injuries of other body regions, neurovascular and visceral lesions, as well as hemodynamic instability. The use of a standardized classification characterizing the severity and stability of pelvic fractures and the early stabilization of pelvic ring injuries in appreciation of damage control principles has helped to improve the number of survivors. This is particularly necessary due to the higher number of older patients.Complex pelvic trauma still represents a life-threatening situation for the patient, particularly in multiple traumatized patients. Standardized clinical investigations and modern concepts even in the preclinical therapy of complex pelvic fractures make a contribution to enhancement of treatment options. Because of the still problematic long-term results after surgery of instable pelvic fractures, the need for modern treatment concepts has to be adapted to the requirements.

Intra- and postoperative complications of navigated and conventional techniques in percutaneous iliosacral screw fixation after pelvic fractures: Results from the German Pelvic Trauma Registry

BACKGROUND

Percutaneous iliosacral screw placement following pelvic trauma is a very demanding technique involving a high rate of screw malpositions possibly associated with the risk of neurological damage or inadequate stability. In the conventional technique, the screw's correct entry point and the small target corridor for the iliosacral screw may be difficult to visualise using an image intensifier. 2D and 3D navigation techniques may therefore be helpful tools. The aim of this multicentre study was to evaluate the intra- and postoperative complications after percutaneous screw implantation by classifying the fractures using data from a prospective pelvic trauma registry. The a priori hypothesis was that the navigation techniques have lower rates of intraoperative and postoperative complications.

METHODS

This study is based on data from the prospective pelvic trauma registry introduced by the German Society of Traumatology and the German Section of the AO/ASIF International in 1991. The registry provides data on all patients with pelvic fractures treated between July 2008 and June 2011 at any one of the 23 Level I trauma centres contributing to the registry.

RESULTS

A total of 2615 patients were identified. Out of these a further analysis was performed in 597 patients suffering injuries of the SI joint (187×with surgical interventions) and 597 patients with sacral fractures (334×with surgical interventions). The rate of intraoperative complications was not significantly different, with 10/114 patients undergoing navigated techniques (8.8%) and 14/239 patients in the conventional group (5.9%) for percutaneous screw implantation (p=0.4242). Postoperative complications were analysed in 30/114 patients in the navigated group (26.3%) and in 70/239 patients (29.3%) in the conventional group (p=0.6542). Patients who underwent no surgery had with 66/197 cases (33.5%) a relatively high rate of complications during their hospital stay. The rate of surgically-treated fractures was higher in the group with more unstable Type-C fractures, but the fracture classification had no significant influence on the rate of complications.

DISCUSSION

In this prospective multicentre study, the 2D/3D navigation techniques revealed similar results for the rate of intraoperative and postoperative complications compared to the conventional technique. The rate of neurological complications was significantly higher in the navigated group.

What are predictors for patients' quality of life after pelvic ring fractures?

BACKGROUND

Data from literature on predictors for patients' quality of life after pelvic ring fractures are conflicting and based on small study populations.

QUESTIONS/PURPOSES

We therefore evaluated predictors for health-related quality of life in patients with pelvic ring injuries at a minimum of 1 year postfracture.

METHODS

We surveyed 172 patients of the German Pelvic Trauma Registry admitted to four medical centers between February 3, 2004, and May 11, 2011. The median age of the followup cohort was 47 years (range, 8-88 years); 69 of 172 (40%) patients were female. Patients were characterized by a median Injury Severity Score of 17. There were 31 Tile Type A fractures (18%), 77 Type B fractures (45%), and 64 Type C fractures (37%). The incidence of complex fractures and multiple traumas was 34 of 172 (20%) and 116 of 172 (67%), respectively. One hundred twenty-five (73%) patients were treated operatively. We obtained the EQ-5D™ score to assess patients' health-related quality of life. For the analysis of predictors for quality of life, a multivariate linear regression model was built. The median followup was 3 years (range, 1-6 years).

RESULTS

The median EQ-5D™ score was 0.78 (interquartile limits, 0.63 and 1.00). Age, complex trauma, and surgery independently predicted the EQ-5D™ score.

CONCLUSIONS

We conclude patients with higher age, complex trauma, and surgery had a higher likelihood for a reduced quality of life after pelvic ring 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.