The diagnostic accuracy of 64-slice computed tomography in detecting clinically significant arterial bleeding after pelvic fractures

Transcatheter Arterial Embolization for Bleeding Related to Pelvic Trauma: Comparison of Technical and Clinical Results between Hemodynamically Stable and Unstable Patients

BACKGROUND

Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites. Despite international guidelines and widespread awareness of the role of angioembolization in clinical practice, robust evidence comparing the outcomes of angioembolization in hemodynamically stable and unstable patients is still lacking. This study aims to directly compare the outcomes of angioembolization for the treatment of pelvic traumatic arterial injury in patients with hemodynamic stability vs. hemodynamic instability.

METHODS

In our multicenter retrospective investigation, we analyzed data from consecutive patients who underwent, from January 2020 to May 2023, angioembolization for traumatic pelvic arterial injury.

RESULTS

In total, 116 angioembolizations were performed. Gelatin sponges (56.9%) and coils (25.9%) were the most widely used embolic agents. The technical and clinical success rates were 100% and 91.4%, respectively. No statistically significant differences were observed between the two groups in terms of technical success, clinical success, procedure-related complication rate, or 30-day bleeding-related mortality.

CONCLUSIONS

Angioembolization is an effective and safe option for the management of traumatic pelvic arterial lesions even in hemodynamically unstable patients, despite technical variations such as greater use of prophylactic angioembolization.

Extravasation and outcomes in computed tomography and angiography in patients with pelvic fractures requiring transcatheter arterial embolization: A single-center observational study

BACKGROUND

Extravasation on contrast-enhanced computed tomography (CECT) is a helpful indicator of the need for transcatheter arterial embolization (TAE) for pelvic fractures. However, previous reports were inconsistent on cases in which angiography is necessary, even though there is no extravasation on computed tomography. This study aimed to describe and analyze the contradictory findings in cases where extravasation is observed on angiography but not on CECT, to contribute to improved management of patients with pelvic fractures.

METHODS

This was a retrospective single-center study. Patients with pelvic fractures who underwent CECT and TAE between 2014 and 2020 were included. We classified the patients into three groups: CECT and angiography with extravasation (CT+Angio+), CECT with no extravasation and angiography with extravasation (CT-Angio+), and CECT with extravasation and angiography without extravasation (CT+Angio-).

RESULTS

A total of 113 patients were included in the study: the CT+Angio+ group had 54 patients, CT-Angio+ group, 47; and CT+Angio- group, 12. The CT-Angio+ group had a significantly longer time from arrival to CECT than the CT+Angio+ group (27 minutes vs. 23 minutes, p < 0.05). The CT-Angio+ group had significantly more blood transfusions (fresh frozen plasma, platelets) within 24 hours than the CT+Angio- group did (p < 0.05), and ventilator management days (p < 0.05) and intensive care unit stays (p < 0.05) were significantly longer.

CONCLUSION

There was no significant difference in outcomes among the three groups. There was no difference in severity, transfusion volume, or mortality in patients with pelvic fractures needing TAE, classified as CT-Angio+, compared with that of CT+Angio+ patients. Even in the absence of extravasation in the pelvic region on CECT, angiography or TAE may still be necessary.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Imaging Review of Pelvic Ring Fractures and Its Complications in High-Energy Trauma

Pelvic ring fractures are common in high-energy blunt trauma, especially in traffic accidents. These types of injuries have a high rate of morbidity and mortality, due to the common instability of the fractures, and the associated intrapelvic vascular and visceral complications. Computed tomography (CT) is the gold standard technique in the evaluation of pelvic trauma because it can quickly and accurately identify pelvic ring fractures, intrapelvic active bleeding, and lesions of other body systems. To properly guide the multidisciplinary management of the polytrauma patient, a classification criterion is mandatory. In this review, we decided to focus on the Young and Burgess classification, because it combines the mechanism and the stability of the fractures, helping to accurately identify injuries and related complications.

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

Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.

Accuracy of Contrast Extravasation on Computed Tomography for Diagnosing Severe Pelvic Hemorrhage in Pelvic Trauma Patients: A Meta-Analysis

Background and objective: The early detection of underlying hemorrhage of pelvic trauma has been a critical issue. The aim of this study was to systematically determine the diagnostic accuracy of computed tomography (CT) for detecting severe pelvic hemorrhage. Materials and Methods: Relevant articles were obtained by searching PubMed, EMBASE, and Cochrane databases through 28 November 2020. Diagnostic test accuracy results were reviewed to obtain the sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve of CT for the diagnosis in pelvic trauma patients. The positive finding on CT was defined as the contrast extravasation. As the reference standard, severe pelvic hemorrhage was defined as an identification of bleeding at angiography or by direct inspection using laparotomy that required hemostasis by angioembolization or surgery. A subgroup analysis was performed according to the CT modality that is divided by the number of detector rows. Result: Thirteen eligible studies (29 subsets) were included in the present meta-analysis. Pooled sensitivity of CT was 0.786 [95% confidence interval (CI), 0.574-0.909], and pooled specificity was 0.944 (95% CI, 0.900-0.970). Pooled sensitivity of the 1-4 detector row group and 16-64 detector row group was 0.487 (95% CI, 0.215-0.767) and 0.915 (95% CI, 0.848-0.953), respectively. Pooled specificity of the 1-4 and 16-64 detector row groups was 0.956 (95% CI, 0.876-0.985) and 0.906 (95% CI, 0.828-0.951), respectively. Conclusion: Multi-detector CT with 16 or more detector rows has acceptable high sensitivity and specificity. Extravasation on CT indicates severe hemorrhage in patients with pelvic trauma.

Clinical and laboratory parameters in blunt pelvic trauma not associated with subsequent positive conventional angiography in patients with positive CTA

PURPOSE

This study evaluates clinical and laboratory parameters, as well as extravasation and hematoma size on CTA as potential predictors of conventional angiogram (CA) results.

METHODS

This is a retrospective study of 380 adult patients presenting with pelvic trauma over a 9-year period. Of these patients, 91 were found to have active arterial extravasation on initial CTA. Statistical analysis between the two groups +CA versus -CA was performed to determine whether clinical and laboratory parameters, as well as extravasation size and hematoma size could predict CA results.

RESULTS

There were no significant differences in all clinical and laboratory data, including hemodynamic instability (defined as systolic blood pressure < 90 mmHg) on presentation (22.2% vs. 21.4%), except for Glasgow Coma Scale (p = 0.015) when comparing the two groups. Extravasation size and hematoma size as continuous or categorical variables were not predictive of subsequent positive CA. Secondary analysis demonstrated no association between select parameters (i.e., hematocrit, systolic blood pressure, and lactate) and subsequent positive CA while controlling for extravasation size or hematoma size.

CONCLUSION

Clinical and laboratory parameters in blunt pelvic trauma with arterial hemorrhage were not significantly associated with subsequent conventional angiography results, once accounting for degree of hemorrhage. The area of the foci of active extravasation and hematoma size in the axial plane were not significantly associated with the need for embolization. We conclude from these findings that catheter angiography should be considered in patients with blunt pelvic trauma found to have active arterial extravasation, regardless of size of bleed or the patient's clinical or laboratory values.

Is Blush on CT Scan in Patients With Pelvic Fracture Associated With Embolization Rates and Outcomes?

INTRODUCTION

In trauma patients with pelvic fractures, computed tomography (CT) scans are a critical tool to evaluate life-threatening hemorrhage. Contrast extravasation, or "blush", on CT may be a sign of bleeding, prompting a consult for angiography and possible embolization. However, the utility of blush on CT is controversial. We sought to evaluate our experience with patients who sustained pelvic fractures and had blush on CT.

METHOD

A retrospective review was performed for all patients with blunt pelvic fractures between January 1, 2017 and December 31, 2018. Demographic, clinical, radiographic, and injury data were obtained. Comparison of mortality, hospital length of stay (LOS), and intensive care unit (ICU) LOS was performed for 3 subgroups: angio versus no angio; embo versus no embo; prophylactic embo versus therapeutic embo. We also calculated the sensitivity, specify, positive predictive value (PPV), and negative predictive value (NPV) of CT blush to predict the need for embolization.

RESULTS

889 patients were found to have a blunt pelvic fracture. 51 patients had blush on CT scan. 29 (56.9%) underwent angiography. 17 (58.6%) of these 29 patients were found to have extravasation and were embolized. 12 patients had an angio with no extravasation, and 6 of these patients (50%) underwent prophylactic embolization. No significant difference was found for hospital LOS, ICU LOS, or mortality in our 3 groups. Sensitivity, specificity, PPV, and NPV for CT blush were 74%, 96%, 33%, 99%, respectively.

CONCLUSION

Patients with active extravasation undergoing embolization had similar outcomes to patients without active extravasation. Blush on CT scan had low sensitivity and low PPV but high specificity and high NPV. Future studies need to include careful attention to the CT protocol utilized as well as patient selection.

Diagnostic value of CT contrast extravasation for major arterial injury after pelvic fracture: A meta-analysis

PURPOSE

We conducted a meta-analysis to determine diagnostic performance of CT intravenous contrast extravasation (CE) as a sign of angiographic bleeding and need for angioembolization after pelvic fractures.

MATERIALS AND METHODS

A systematic literature search combining the concepts of contrast extravasation, pelvic trauma, and CT yielded 206 potentially eligible studies. 23 studies provided accuracy data or sufficient descriptive data to allow 2x2 contingency table construction and provided 3855 patients for meta-analysis. Methodologic quality was assessed using the QUADAS-2 tool. Sensitivity and specificity were synthesized using bivariate mixed-effects logistic regression. Heterogeneity was assessed using the I2-statistic. Sources of heterogeneity explored included generation of scanner (64 row CT versus lower detector row) and use of multiphasic versus single phase scanning protocols.

RESULTS

Overall sensitivity and specificity were 80% (95% CI: 66-90%, I2 = 92.65%) and 93% (CI: 90-96, I2 = 89.34%), respectively. Subgroup analysis showed pooled sensitivity and specificity of 94% and 89% for 64- row CT compared to 69% and 95% with older generation scanners. CE had pooled sensitivity and specificity of 95% and 92% with the use of multiphasic protocols, compared to 74% and 94% with single-phase protocols.

CONCLUSION

The pooled sensitivity and specificity of 64-row CT was 94 and 89%. 64 row CT improves sensitivity of CE, which was 69% using lower detector row scanners. High specificity (92%) can be maintained by incorporating multiphasic scan protocols.

Clinical Approach to and Work-up of Bleeding Patients

A bleeding patient is a common consult for interventional radiologists. Prompt triage, preprocedural evaluation specific to the site of hemorrhage, and knowledge of resuscitative strategies allow for a potentially life-saving procedure to be appropriately and safely performed. Having a firm understanding of the clinical work-up and management of a bleeding patient has never been more important. In this article, a discussion of the clinical approach and work-up of a bleeding patient for whom interventional radiology is consulted is followed by a discussion of etiology-specific preprocedural work-up.

Distribution of radiation exposure in patients with partially stable and unstable pelvic ring fractures: first-time use of highly accurate assessment by Monte Carlo calculations

PURPOSE

Radiological examinations including X-ray and CT play a critical role in the assessment and treatment of trauma patients. The ionizing radiation used is known to be carcinogenic. However, little is known about the total radiation exposure in trauma patients. The objective of this study was to accurately estimate radiation exposure of patients with severe pelvic ring fractures.

METHODS

In this retrospective dynamic cohort study, adult patients with partially stable and unstable pelvic ring fractures were included. For each patient, data concerning demography and injury characteristics were collected. Subsequently, the total effective radiation dose due to all trauma-related X-rays and CT scans during initial assessment, treatment and follow-up was calculated using Monte Carlo software.

RESULTS

A total of 114 patients were included. The median total effective dose was 49.7 millisievert (mSv). 57 patients (50.0%) received more than 50 mSv and 13 patients (11.4%) received more than 100 mSv. 62.4% of the total effective dose was received within the 24 h after admission. The median total effective dose for survivors (n = 95) was 52.0 mSv. Polytrauma patients received a significantly higher total effective dose than non-polytrauma patients.

CONCLUSIONS

This study showed that a substantial number of patients with partially stable and unstable pelvic ring fractures have an increased cancer risk due to trauma-related medical imaging. Physicians should be aware of the amount of radiation their patients are exposed to, and minimize imaging related increase of cancer risks during initial assessment, treatment and follow-up.

Prediction of arterial extravasation in pelvic fracture patients with stable hemodynamics using coagulation biomarkers

Background

Determining the presence of an active arterial hemorrhage in the acute phase is important as a treatment strategy in patients with pelvic fracture. The purpose of this study was to evaluate whether coagulation biomarkers could predict arterial extravasation, especially in pelvic fracture patients with stable hemodynamics.

Methods

We studied patients with a pelvic fracture who had a systolic blood pressure above 90 mmHg and lactate level less than 5.0 mmol/L on hospital arrival. Patients were divided into two groups: those with arterial extravasation on enhanced computed tomography (CT) or angiography (extravasation [+] group) and those without arterial extravasation (extravasation [−] group). Coagulation biomarkers measured on arrival were statistically compared between the two groups. Predictive ability of arterial extravasation using coagulation biomarkers was evaluated by receiver-operating characteristic analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators with optimal cutoff point including sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio (DOR).

Results

Sixty patients were analyzed. Fibrin degradation products (FDP), D-dimer, prothrombin time–international normalized ratio (PT–INR), and the ratio of FDP to fibrinogen were significantly higher in the extravasation (+) group than in the extravasation (−) group (FDP, 242 μg/mL [145–355] vs. 96 μg/mL [58–153]; D-dimer, 81 μg/mL [41–140] vs. 39 μg/mL [21–75]; PT–INR, 1.09 [1.05–1.24] vs. 1.02 [0.98–1.08]; and ratio of FDP to fibrinogen, 1.06 [0.85–2.01] vs. 0.46 [0.25–0.74]). The highest AUROC was with a ratio of FDP to fibrinogen of 0.777 (95% confidence interval, 0.656–0.898), and the highest predictive ability in terms of DOR was with a ratio of FDP to fibrinogen (sensitivity, 0.76; specificity, 0.76; DOR 9.90).

Conclusion

Coagulation biomarker could predict of arterial extravasation in pelvic fracture patients with stable hemodynamics.

Electronic supplementary material

The online version of this article (10.1186/s13017-019-0234-5) contains supplementary material, which is available to authorized users.

Predictive ability and interobserver reliability of computed tomography findings for angioembolization in patients with pelvic fracture

BACKGROUND

The purpose of this study was to identify computed tomography (CT) findings that predict the need for angioembolization in patients with pelvic fracture.

METHODS

This retrospective cross-sectional study was performed between April 2006 and October 2015 at two urban emergency medical centers in Japan. The study included patients who underwent CT within 3 hours of arrival and were diagnosed with a pelvic fracture. The study outcome was undergoing angioembolization within 24 hours of arrival. Four independent readers blinded to all clinical information interpreted the CT scans for blush, thickness of retroperitoneal hematoma, and diameter and laterality of muscle swelling around the pelvis. Receiver operating characteristics analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators at the estimated thresholds including sensitivity, specificity, positive and negative predictive values and diagnostic odds ratio (DOR). The interobserver reliability of all radiographic findings was also evaluated.

RESULTS

Fifty-two of 244 eligible patients underwent angioembolization. The predictive ability in terms of DOR was relatively better with blush on CT scan (sensitivity, 0.57; specificity, 0.86; DOR, 8.05) than with laterality of muscle swelling of 12.9 mm or greater (sensitivity, 0.79; specificity, 0.55; DOR, 4.60; AUROC, 0.75) and thickness of retroperitoneal hematoma of 22.7 mm or greater (sensitivity, 0.65; specificity, 0.74; DOR, 5.39; AUROC, 0.73). The interobserver reliability of blush, laterality of muscle swelling, and thickness of retroperitoneal hematoma was 0.43, 0.54, and 0.70, respectively.

CONCLUSION

All of the tested CT findings failed to show both sufficient predictive ability and sufficient interobserver agreement. Further diagnostic accuracy studies to validate these findings or establish a prediction model incorporating these findings are expected.

LEVEL OF EVIDENCE

Diagnostic, level V.

Early management of severe pelvic injury (first 24 hours)

OBJECTIVE

Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject.

DESIGN

A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE^® methodology.

RESULTS

The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ).

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.

Clinical significance of computed tomography contrast extravasation in blunt trauma patients with a pelvic fracture

INTRODUCTION

Blunt pelvic fractures can be associated with major pelvic bleeding. The significance of contrast extravasation (CE) on computed tomography (CT) is debated. We sought to update our experience with CE on CT scan for the years 2009-2014 to determine the accuracy of CE in predicting the need for angioembolization.

METHODS

This is a retrospective review of the trauma registry and our electronic medical record from a Level I trauma center. Patients seen from July 1, 2009, to September 7, 2014, with blunt pelvic fractures and contrast-enhanced CT were included. Standard demographic, clinical, and injury data were obtained. Patient records were queried for CE, performance of angiography, and angioembolization. Positive patients were those where CE was associated with active bleeding requiring angioembolization. All other patients were considered negative.

RESULTS

There were 497 patients during the study time period with blunt pelvic fracture meeting inclusion criteria, and 75 patients (15%) had CE. Of those patients with CE, 30 patients (40%) underwent angiography, and 17 patients (23%) required angioembolization. The sensitivity, specificity, positive predictive value, and negative predictive value of CE on CT were 100%, 87.9%, 22.7%, and 100%, respectively. Two patients without CE underwent angiography but did not undergo embolization. Patients with CE had higher mortality (13 vs. 6%, p < 0.05) despite not having higher ISS scores.

CONCLUSIONS

This study reinforces that CE on CT pelvis with blunt trauma is common, but many patients will not require angioembolization. The negative predictive value of 100% should be reassuring to trauma surgeons such that if a modern CT scanner is used, and there is no CE seen on CT, then the pelvis will not be a source of hemorrhagic shock. All of these findings are likely due to both increased comfort with observing CEs and the increased sensitivity of modern CT scanners.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Prediction of extravasation in pelvic fracture using coagulation biomarkers

PURPOSE

To evaluate the usefulness of coagulation biomarkers, which are easy and quick to analyze in emergency settings, for prediction of arterial extravasation due to pelvic fracture.

PATIENTS AND METHODS

The medical records of pelvic fracture patients transferred to the emergency department of Gunma University Hospital between December 2009 and May 2015 were reviewed. Patients were divided into two groups, those with (Extra(+)) and without (Extra(-)) arterial extravasation on enhanced CT or angiography. Levels of fibrin degradation products (FDP), D-dimer, fibrinogen, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, systolic blood pressure, heart rate, the Glasgow Coma Scale, pH, base excess, hemoglobin and lactate levels, the pattern of pelvic injury, and injury severity score were measured at hospital admission, and compared between the two groups. Parameters with a significant difference between the two groups were used to construct receiver operating characteristic (ROC) curves.

RESULTS

The study included 29 patients with pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most useful parameters for predicting arterial extravasation due to pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, and hemoglobin and lactate levels were significantly higher in the Extra(+) group than in the Extra(-) group (FDP, 354.8μg/mL [median] versus 96.6μg/mL; D-dimer, 122.3μg/mL versus 42.1μg/mL; the ratio of FDP to fibrinogen, 3.39 versus 0.42; the ratio of D-dimer to fibrinogen, 1.14 versus 0.18; hemoglobin, 10.5g/dL versus 13.5g/dL; lactate, 3.5mmol/L versus 1.7mmol/L). The area under the ROC curves for FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, hemoglobin and lactate levels were 0.900, 0.882, 0.918, 0.900, 0.815 and 0.765, respectively.

CONCLUSION

Coagulation biomarkers, and hemoglobin and lactate levels could be useful to predict the existence of arterial extravasation due to pelvic fracture. The ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most accurate markers. Coagulation biomarkers may enable more rapid and specific treatment for pelvic fracture.

The emergency radiology of pelvic trauma

The imaging of pelvic trauma is complex and may involve different radiological techniques depending on the severity and type of injury. Following high-energy blunt trauma, computed tomography (CT) is the investigation of choice as it can identify life-threatening findings such as arterial extravasation as well as bony and soft tissue injuries, in particular that of the urological system. In this overview of pelvic imaging in trauma, the role of CT, plain radiography and focussed assessment with sonography in trauma (FAST) are considered, as well as the role of interventional radiology for pelvic haemorrhage.

[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.

Management of pelvic ring fracture patients with a pelvic "blush" on early computed tomography

BACKGROUND

The sliding computed tomographic (CT) scanner in our trauma resuscitation room can be used early in the assessment of pelvic ring fracture patients. We determined the association between the presence of a pelvic blush on CT scan and the need for pelvic hemorrhage control (PHC). We hypothesized that many pelvic blushes found early in the resuscitation phase can be safely managed without intervention.

METHODS

Contrast-enhanced CT scans of pelvic ring fracture (pelvic ring disruption) patients admitted from January 1, 2004, to June 31, 2012, were reviewed for the presence of a pelvic blush. PHC was defined as requiring a surgical or radiologic intervention for pelvic bleeding. A subanalysis was performed in "isolated" pelvic fracture/ blush patients (absence of a major nonpelvic bleeding source).

RESULTS

Overall, 68 (42%) of 162 pelvic ring fracture patients and 53 (40%) of 134 isolated pelvic fracture patients had a pelvic blush. Of those 32 (47%) and 27 (51%) patients, respectively, required PHC. In the absence of a pelvic blush, 87 (93%) of 94 of all and 77 (95%) of 81 of isolated pelvic fracture patients did not require PHC. Of all patients with a pelvic blush and of isolated pelvic blush, those with PHC had a higher Injury Severity Score (ISS) (p = 0.01 and p = 0.05), base deficit (p = 0.03 and p = 0.01), as well as 24-hour and any packed red blood cells requirement (p <0.001 and p = 0.05; p <0.001 and p = 0.02). In isolated pelvic blush patients, there was a trend toward a higher hospital and hemorrhage-related mortality in patients with PHC (p = 0.06 and p = 0.06).

CONCLUSION

In pelvic ring fracture patients, a pelvic blush on early contrast-enhanced CT is a frequent finding. Many patients with (particularly isolated) pelvic blushes have stable vital signs and can be managed without surgical or radiologic PHC. The need for an intervention for a pelvic blush seems to be determined by the presence of clinical signs of ongoing bleeding.

LEVEL OF EVIDENCE

Therapeutic study, level IV. Prognostic/epidemiologic study, level III.

Time to pelvic embolization for hemodynamically unstable pelvic fractures may affect the survival for delays up to 60 min

INTRODUCTION

We evaluated the relationship between survival and time from arrival to angiography for hemodynamically unstable patients with pelvic trauma.

METHODS

A retrospective review of patients admitted to Fukui Prefectural Hospital with pelvic fractures during a 7.5-year period. Charts were reviewed for age, injury characteristics, injury severity score, systolic blood pressure and heart rate on arrival, base deficit, and the lactate concentration on arrival, transfusion requirement, fracture pattern, the time from hospital arrival to angiography, and the time spent in the angiography suite.

RESULTS

Of a total of 140 patients, 68 patients underwent pelvic angiography and embolization. Of the patients, 24 patients were hemodynamically unstable. The average injury severity score was 41.7. Of the patients, 17 had major ligamentous disruption. The average time from hospital arrival to angiography suite was 76 min. Of the hemodynamically unstable 24 patients, there were 12 deaths (50%). Patients who were embolized within 60 min of arrival had a significantly lower mortality rate (16 vs. 64%; p=0.04). There was no embolization-related complication and repeat angiography was not required in all patients.

CONCLUSION

Earlier pelvic embolization within 60 min may affect the survival of hemodynamically unstable patients with pelvic fracture.

Management of a gluteal region impalement injury caused by three reinforced aluminum bars: a case report

Introduction

Impalement injuries with multiple objects are rare and their management is complex. Rapid confirmation of vascular injuries requiring urgent endovascular or surgical management and accurate location of multiple objects are essential for efficient preoperative management. We report the case of a patient with septic shock secondary to a perforated rectum caused by an impalement injury with three reinforced aluminum bars.

Case presentation

A 58-year-old Asian man fell from the roof of a house and received gluteal impalement injuries from three reinforced aluminum bars. A physical examination showed paralysis of his left leg and no active bleeding from the insertion sites of the impaled objects. Multidetector computed tomography angiography confirmed the location of the aluminum bars, which had spared his small bowel, ureter and major vessels. No significant extravasation was observed. Two bars were successfully removed under general anesthesia in the lithotomy position. The third bar, which pierced his rectum, passed through the left side of his vertebrae and extended up to the superior side of his left kidney, was removed following a celiotomy. After removal of this bar, bleeding from the anterior side of the sacral bone was controlled by gauze packing. After surgery, our patient was admitted to our intensive care unit under endotracheal intubation and mechanical ventilation. Dopamine therapy was initiated, followed by direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) for septic shock secondary to a perforated rectum. This treatment was continued for two hours, resulting in stabilization of our patient’s hemodynamic condition. Daily peritoneal lavage was performed for several days, along with a colostomy. Although there were motor and sensory disturbances below the L3 level, there were no complications. On day 191 of admission, our patient was discharged with motor and sensory disturbances below the L3 level. He now uses a wheelchair and depends on assistance from others for daily activities.

Conclusion

Preoperative multidetector computed tomography angiography confirmed the anatomic location of the aluminum bars and the absence of extravasation; these findings aided in treatment planning. Our patient was successfully managed by colostomy and aggressive surgical and critical care including direct hemoperfusion with polymyxin B-immobilized fiber, and developed no intra-abdominal infection or meningitis.

Treatment decision-making for post-partum hemorrhage using dynamic contrast-enhanced computed tomography

AIM

Post-partum hemorrhage (PPH) is the leading cause of maternal mortality. Identification of the precise bleeding site is generally important to control hemorrhage, but such an approach has not been fully established in the context of PPH. We postulated that visualization of bleeding sites could aid treatment decisions in the management of PPH.

METHODS

We conducted a prospective review of 26 patients who underwent dynamic computed tomography (CT) for PPH.

RESULTS

A total of 17 cases presented with uterine bleeding, eight with vaginal hematomas, and one with hemoperitoneum. Overall, dynamic CT identified contrast media extravasation in the arterial phase in 12 of 26 (46.2%) cases: the upper (n = 4) and the lower uterine segment including the cervix (n = 2), subfascial space (n = 1) and vagina (n = 5). Identification of precise arterial bleeding sites using CT provided informative guidance about where to place balloons for intractable uterine bleeding, and how to manage hemoperitoneum and vaginal hematomas. In addition, dynamic CT revealed the existence of a subtype of uterine atony, which is characterized by focal active arterial bleeding in the upper uterine segment. Furthermore, negative contrast extravasation extracted cases of PPH that were well controlled without the need for surgical or radiological intervention. No patient required emergency hysterectomy to control PPH.

CONCLUSION

Dynamic CT has potential clinical utility in treatment decision-making for PPH.

Use of Computed Tomography Findings and Contrast Extravasation in Predicting the Need for Embolization with Pelvic Fractures

Transarterial embolization (AE) can be a lifesaving procedure for severe hemorrhage associated with pelvic fractures. The purpose of this study was to identify demographic and radiographic findings that predict the need for embolization. We performed a retrospective review of all patients with at least one pelvic fracture and admission to the intensive care unit over a 35-month period. Computed tomography (CT) and pelvic radiographs were reviewed. Patient demographics, outcomes, time to angiography, and whether or not embolization was performed were determined. Statistical analysis was used to determine factors associated with the need for AE. Of the 327 total patients with pelvic fractures, 317 underwent CT scanning. Forty-four patients (13.5%) underwent angiography and 25 (7.6%) required therapeutic embolization. There were 39 total deaths (11.6%) with five deaths related to pelvic hemorrhage (1.5%). Multivariate analysis revealed that age older than 55 years (odds ratio [OR], 1.06; P < 0.001), systolic blood pressure less than 90 mmHg in the emergency department (OR, 11.64; P = 0.0008), and CT extravasation (OR, 147.152; P < 0.0001) were significantly associated with the need for embolization. Contrast extravasation was not present in 25 per cent of patients requiring therapeutic AE. The presence of contrast extravasation is highly associated with the need for pelvic embolization in patients with pelvic fractures, but its absence does not exclude the need for pelvic angiography.