[Pelvic and perineal trauma. Diagnosis and interventional radiotherapy]

The pelvic vascular injury score (P-VIS): a prehospital instrument to detect significant vascular injury in pelvic fractures

PURPOSE

The purpose of this study was to identify predictive factors for peri-pelvic vascular injury in patients with pelvic fractures and to incorporate these factors into a pelvic vascular injury score (P-VIS) to detect severe bleeding during the prehospital trauma management.

METHODS

To identify potential predictive factors, data were taken (1) of a Level I Trauma Centre with 467 patients (ISS ≥ 16 and AISPelvis ≥ 3). Analysis including patient's charts and digital recordings, radiographical diagnostics, mechanism and pattern of injury as well as the vascular bleeding source was performed. Statistical analysis was performed descriptively and through inference statistical calculation. To further analyse the predictive factors and finally develop the score, a 10-year time period (2012-2021) of (2) the TraumaRegister DGU® (TR-DGU) was used in a second step. Relevant peri-pelvic bleeding in patients with AISPelvis ≥ 3 (N = 9227) was defined as a combination of the following entities (target group PVITR-DGU N = 2090; 22.7%): pelvic fracture with significant bleeding (> 20% of blood volume), Injury of the iliac or femoral artery or blood transfusion of ≥ 6 units (pRBC) prior to ICU admission. The multivariate analysis revealed nine items that constitute the pelvic vascular injury score (P-VIS).

RESULTS

In study (1), 467 blunt pelvic trauma patients were included of which 24 (PVI) were presented with significant vascular injury (PVI, N = 24; control (C, N = 443). Patients with pelvic fractures and vascular injury showed a higher ISS, lower haemoglobin at admission and lower blood pressure. Their mortality rate was higher (PVI: 17.4%, C: 10.3%). In the defining and validating process of the score within the TR-DGU, 9227 patients met the inclusion criteria. 2090 patients showed significant peripelvic vascular injury (PVITR-DGU), the remaining 7137 formed the control group (CTR-DGU). Nine predictive parameters for peripelvic vascular injury constituted the peripelvic vascular injury score (P-VIS): age ≥ 70 years, high-energy-trauma, penetrating trauma/open pelvic injury, shock index ≥ 1, cardio-pulmonary-resuscitation (CPR), substitution of > 1 l fluid, intubation, necessity of catecholamine substitution, remaining shock (≤ 90 mmHg) under therapy. The multi-dimensional scoring system leads to an ordinal scaled rating according to the probability of the presence of a vascular injury. A score of ≥ 3 points described the peripelvic vascular injury as probable, a result of ≥ 6 points identified a most likely vascular injury and a score of 9 points identified an apparent peripelvic vascular injury. Reapplying this score to the study population a median score of 5 points (range 3-8) (PVI) and a median score of 2 points (range 0-3) (C) (p < 0.001). The OR for peripelvic vascular injury was 24.3 for the patients who scored > 3 points vs. ≤ 2 points. The TR-DGU data set verified these findings (median of 2 points in CTR-DGU vs. median of 3 points with in PVITR-DGU).

CONCLUSION

The pelvic vascular injury score (P-VIS) allows an initial risk assessment for the presence of a vascular injury in patients with unstable pelvic injury. Thus, the management of these patients can be positively influenced at a very early stage, prehospital resuscitation performed safely targeted and further resources can be activated in the final treating Trauma Centre.

[Complex pelvic trauma : A case report with special consideration of the accompanying urogenital injury]

The following case report shows a young male patient with a complex pelvic trauma due to a traffic accident. In addition to the pelvic ring fracture, he also suffered a severe accompanying injury to the efferent urinary tract in combination with extensive damage of the lumbosacral plexus. Multiple extensive operations were necessary to address the C3 fracture of the pelvic ring and the bladder injury. Due to an infection a wound healing disorder subsequently occurred, which necessitated a myocutaneous flap plasty. This case highlights the complexity of this injury and confirms the necessity for an interdisciplinary individualized treatment.

[Influence of external pelvic stabilization on hemodynamically unstable pelvic fractures]

BACKGROUND

In the treatment of complex pelvic fractures hemorrhage control is of primary importance; however, studies regarding the localization of bleeding are contradictory so that various treatment approaches are recommended. The primary aim of external pelvic compression applied in the trauma room is to reduce the pelvic volume and counteract blood loss through self-induced tamponade. This study examined the influence of external pelvic compression on mortality and outcome in cases of hemodynamically unstable pelvic fractures in a larger number of cases.

MATERIAL AND METHODS

The current study used the TraumaRegister DGU® (TR-DGU) to retrospectively evaluate the records of 104 patients treated between 2002 and 2011. All patients suffered severe injury with an injury severity score (ISS) of at least 16 points. In addition, the patients were hemodynamically unstable with confirmed relevant isolated pelvic injuries. To evaluate the effectiveness of external pelvic compression, patients with and without external pelvic stabilization were compared.

RESULTS

Of the investigated patients 26.9 % died of their injuries and of these the mortality was 78.6 % within the first 6 h of admission to the trauma room. External pelvic stabilization was performed in 45.2 % of patients. The mortality was 19.1 % in patients with external pelvic stabilization and in contrast, the mortality in the group of patients without external pelvic stabilization was 33.3 %. During the course of hospitalization, surviving patients with external pelvic stabilization were significantly more likely to develop sepsis or multiple organ failure and required longer periods of intensive care.

CONCLUSION

External pelvic stabilization seems to be an important instrument for the initial treatment of hemodynamically unstable pelvic fractures and showed a positive effect on patient mortality.

[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.

[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.

[Interventional emergency embolization for severe pelvic ring fractures with arterial bleeding. Integration into the early clinical treatment algorithm]

OBJECTIVE

Presentation of our own experiences and results of an early clinical algorithm for treatment integrating emergency embolization (TAE) in cases of unstable pelvic ring fractures with arterial bleeding.

METHOD

Consecutive patient series from April 2002 to December 2006 at a level 1 trauma center. The data of the online shock room documentation (Traumawatch) of patients with a pelvic fracture and arterial bleeding detected on multislice computed tomography (MSCT) were examined for the following parameters: demographic data, injury mechanism, fracture classification according to Tile/AO and severity of the pelvic injury assessed with the Abbreviated Injury Score (AIS), accompanying injuries with elevation of the cumulative injury severity according to the Injury Severity Score (ISS), physiological admission parameters (circulatory parameters and initial Hb value) as well as transfusion requirement during treatment in the shock room, time until embolization, duration of embolization, and source of bleeding.

RESULTS

Of a total of 162 patients, arterial bleeding was detected in 21 patients by contrast medium extravasation on MSCT, 12 of whom were men and 9 women with an average age of 45 (14-80) years. The mechanism of injury was high energy trauma in all cases. In 33% it involved type B pelvic fractures and in 67% type C fractures with an average AIS pelvis of 4.4 points (3-5) and a total severity of injury with the ISS of 37 points (21-66). Upon admission 47.6% presented hemodynamic instability with an average Hb value of 7.8 g/dl (3.2-12.4) and an average transfusion requirement of 6 red blood cell units (4-13). The time until the TAE was started was on average 62 min (25-115) with a duration period of the TAE of 25 min (15-67). Branches of the internal iliac artery were identified as the sole source of bleeding. The success rate of TAE amounted to over 90%.

CONCLUSION

Interventional TAE represents an effective as well as a fast procedure for hemostasis of arterial bleeding detected on MSCT in patients with pelvic fractures. If an experienced radiologist on 24-h stand-by is assured and the infrastructure is efficient, this can be performed shortly after hospital admission and therefore should be integrated into the early clinical treatment protocol.