Clinical review: initial management of blunt pelvic trauma patients with haemodynamic instability

Transcatheter Arterial Embolization for Hemorrhagic Pelvic Fracture: Review Article

Pelvic fractures are severe trauma that can cause hemorrhagic shock. The mortality rate is high when patients fall into shock. Therefore, prompt diagnosis and treatment are necessary. Hemostasis for hemorrhage associated with pelvic fractures is achieved through the mechanical stabilization of the fracture site, preperitoneal pelvic packing, and transcatheter arterial embolization. These techniques are frequently employed in hemodynamically unstable patients presenting with pelvic fractures. Among them, transcatheter arterial embolization is often considered the first-line choice: it is a particularly effective hemostatic method for arterial hemorrhage caused by pelvic fracture. An embolization technique and embolic agents should be considered comprehensively while considering the patient's hemodynamics, angiographic findings, and the urgency of the situation. This article describes the indications, techniques, results, and complications of transcatheter arterial embolization for pelvic fractures.

The characteristics and clinical outcomes of trauma patients transferred by a physician-staffed helicopter emergency medical service in Korea: a retrospective study

Purpose

Helicopter transport with medical teams has been proven to be effective, with improvements in patient survival rates. This study compared and analyzed the clinical characteristics and treatment outcomes of trauma patients transported by doctor helicopters according to whether patients were transferred after a clinical evaluation or without a clinical evaluation.

Methods

This study retrospectively reviewed data from the Korean Trauma Data Bank of trauma patients who arrived at a regional trauma center through doctor helicopters from January 1, 2014, to December 31, 2022. The patients were divided into two groups: doctor helicopter transport before evaluation (DHTBE) and doctor helicopter transport after evaluation (DHTAE). These groups were compared.

Results

The study population included 351 cases. At the time of arrival at the trauma center, the systolic blood pressure was significantly lower in the DHTAE group than in the DHTBE group (P=0.018). The Injury Severity Score was significantly higher in the DHTAE group (P<0.001), and the accident to trauma center arrival time was significantly shorter in the DHTBE group (P<0.001). Mortality did not show a statistically significant between-group difference (P=0.094). Surgical cases in the DHTAE group had a longer time from the accident scene to trauma center arrival (P=0.002). The time from the accident to the operation room or from the accident to angioembolization showed no statistically significant differences.

Conclusions

DHTAE was associated with significantly longer transport times to the trauma center, as well as nonstatistically significant trends for delays in receiving surgery and procedures, as well as higher mortality. If severe trauma is suspected, air transport to a trauma center should be requested immediately after a simple screening test (e.g., mechanism of injury, Glasgow Coma Scale, or Focused Assessment with Sonography in Trauma), which may help reduce the time to definitive treatment.

[Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review]

BACKGROUND

Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy.

METHOD

Analysis, summary, and discussion of published review articles and expert recommendations.

RESULTS

The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance.

CONCLUSION

Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome.

KEY POINTS

· The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates..

CITATION FORMAT

· Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.

Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit

BACKGROUND

The management of high-grade pancreatic trauma is controversial.

AIM

To review our single-institution experience on the surgical management of blunt and penetrating pancreatic injuries.

METHODS

A retrospective review of records was performed on all patients undergoing surgical intervention for high-grade pancreatic injuries [American Association for the Surgery of Trauma (AAST) Grade III or greater] at the Royal North Shore Hospital in Sydney between January 2001 and December 2022. Morbidity and mortality outcomes were reviewed, and major diagnostic and operative challenges were identified.

RESULTS

Over a twenty-year period, 14 patients underwent pancreatic resection for high-grade injuries. Seven patients sustained AAST Grade III injuries and 7 were classified as Grades IV or V. Nine underwent distal pancreatectomy and 5 underwent pancreaticoduodenectomy (PD). Overall, there was a predominance of blunt aetiologies (11/14). Concomitant intra-abdominal injuries were observed in 11 patients and traumatic haemorrhage in 6 patients. Three patients developed clinically relevant pancreatic fistulas and there was one in-hospital mortality secondary to multi-organ failure. Among stable presentations, pancreatic ductal injuries were missed in two-thirds of cases (7/12) on initial computed tomography imaging and subsequently diagnosed on repeat imaging or endoscopic retrograde cholangiopancreatography. All patients who sustained complex pancreaticoduodenal trauma underwent PD without mortality. The management of pancreatic trauma is evolving. Our experience provides valuable and locally relevant insights into future management strategies.

CONCLUSION

We advocate that high-grade pancreatic trauma should be managed in high-volume hepato-pancreato-biliary specialty surgical units. Pancreatic resections including PD may be indicated and safely performed with appropriate specialist surgical, gastroenterology, and interventional radiology support in tertiary centres.

Management strategy for open pelvic fractures: A 11-year single-centre, retrospective observational study

INTRODUCTION

Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures.

METHODS

We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality.

RESULTS

Forty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27-57 years) and median ISS was 34 (24-43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p<0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907-0.980; p = 0.003).

CONCLUSION

A low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings.

Angioembolization versus preperitoneal packing for severe pelvic fractures: A propensity matched analysis

BACKGROUND

Whether AE or PPP would be associated with survival among hemodynamically unstable pelvic fracture remains controversial.

STUDY DESIGN

This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2018. Patients >16 years with a severe pelvic fracture (abbreviated injury scale 3-5) who underwent AE or PPP were recruited. The primary outcome was in-hospital survival. Data were evaluated using a propensity-score matching (PSM) analysis.

RESULTS

A total of 1123 patients met our inclusion criteria. Of these, AE and PPP were performed in 964 (85.8%) and 159 (14.2%) patients, respectively. Concomitant hemorrhage control laparotomy was performed in 25.6% and 82.4% of AE and PPP patients, respectively. In 220 PSM patients, the mortality rate between AE and PPP groups was not significantly different (30.9% vs. 38.2%, P = 0.321).

CONCLUSIONS

Though patients' characteristics differed between AE and PPP groups, comparable propensity-matched patients with severe pelvic fractures showed no significant difference in in-hospital survival. PPP was more likely to be selected for severe pelvic fractures necessitating laparotomy.

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.

Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries

Unstable pelvic injuries are rare (3–8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD^® succeeded best on average (333 ± 234 cm³), but with higher average peak traction (110 N). The reduction results of the VBM^® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD^® or the VBM^® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM^® pneumatic pelvic sling to 200 mmHg.

Effects of nonselective internal iliac artery angioembolization on pelvic venous flow in the swine model

BACKGROUND

Pelvic angioembolization (AE) is a mainstay in the treatment algorithm for pelvic hemorrhage from pelvic fractures. Nonselective AE refers to embolization of the bilateral internal iliac arteries (IIAs) proximally rather than embolization of their tributaries distally. The aim of this study was to quantify the effect of nonselective pelvic AE on pelvic venous flow in a swine model. We hypothesized that internal iliac vein (IIV) flow following IIA AE is reduced by half.

METHODS

Nine Yorkshire swine underwent nonselective right IIA gelfoam AE, followed by left. Pelvic arterial and venous diameter, velocity, and flow were recorded at baseline, after right IIA AE and after left IIA AE. Linear mixed-effect model and signed rank test were used to evaluate significant changes between the three time points.

RESULTS

Eight swine (77.8 ± 7.1 kg) underwent successful nonselective IIA AE based on achieving arterial resistive index of 1.0. One case was aborted because of technical difficulties. Compared with baseline, right IIV flow rate dropped by 36% ± 29% (p < 0.05) and 54% ± 29% (p < 0.01) following right and left IIA AE, respectively. Right IIA AE had no initial effect on left IIV flow (0.37% ± 99%, p = 0.95). However, after left IIA AE, left IIV flow reduced by 54% ± 27% (p < 0.01). Internal iliac artery AE had no effect on the external iliac arterial or venous flow rates and no effect on inferior vena cava flow rate.

CONCLUSION

The effect of unilateral and bilateral IIA AE on IIV flow appears to be additive. Despite bilateral IIA AE, pelvic venous flow is diminished but not absent. There is abundant collateral circulation between the external and internal iliac vascular systems. Arterial embolization may reduce venous flow and improve on resuscitation efforts in those with unstable pelvic fractures.

LEVEL OF EVIDENCE

Prognostic, level IV.

Angiography in patients with pelvic fractures and contrast extravasation on CT following high-energy trauma

INTRODUCTION

Pelvic fracture may be accompanied by severe bleeding. Computed tomography (CT) is a gold standard diagnostic tool in stable trauma patients. Contrast extravasation detected on CT of pelvis is a sign of hemorrhage, but its significance is not clear. We aimed to evaluate the need for angiography in patients with pelvic fracture and CT revealed contrast extravasation. We tried to identify parameters that might help to choose patients who will benefit from therapeutic angiography.

METHODS

Electronic medical records of patients with pelvic fracture admitted to Level II Trauma Center during 10 years were retrospectively reviewed. Patients who had contrast extravasation on CT were included. Data base consisted of demographics, injury severity, initial physiologic parameters, laboratory data, results of CT and angiography.

RESULTS

Forty out of 396 patients had contrast extravasation detected by CT. Twelve patients underwent angiography and 4 of them benefited from embolization. The sensitivity of contrast extravasation in evaluating the need for embolization was 1.0 (95% CI 0.398, 1.0), positive predictive value was 0.1 (95% CI 0.028, 0.237), and the negative predictive value was 1.0 (95% CI 0.990, 1.0).

CONCLUSION

The role of angiography in stable patients with pelvic fracture and CT identified contrast extravasation remains questionable. Most of these patients are not in need of angioembolization.

Efficacy of transarterial embolisation in patients with life-threatening spontaneous retroperitoneal haematoma

AIM

To evaluate the technical and clinical success of embolisation in patients with life-threatening spontaneous retroperitoneal haematoma (SRH) and to assess predictors of clinical outcome.

MATERIALS AND METHODS

Thirty patients (mean age: 71.9±9.8 years) with SRH underwent digital subtraction angiography (DSA). All patients received anticoagulant or antiplatelet medication or a combination of both at the time the SRH occurred.

RESULTS

Pre-interventional computed tomography angiography (CTA) revealed active retroperitoneal bleeding in 28 of 30 (93.3%) patients. DSA identified active haemorrhage in 22 of 30 patients (73.3%). Twenty-nine of 30 (96.7%) patients underwent embolisation. n-Butyl-2-cyanoacrylate (NBCA) was used in 15 patients (51.7%), coils were used in 10 patients (34.5%), and both embolic agents were used in four patients (13.8%). The technical success rate was 100%. Pre-interventional haemoglobin levels increased significantly after embolotherapy from 70.9±16.1 g/l to 87±11.3 g/l (p<0.001), whereas partial thromboplastin time decreased from 58±38 to 30±9 seconds (p<0.001) after embolotherapy. The need for transfusion of concentrated red cells decreased from 3±2.2 to 1±1.1 units (p<0.001) after the intervention. Clinical success was achieved in 19 of 29 (65.5%) patients. No major procedure-related complications occurred. Seven patients (24.1%) died within 30 days after the procedure.

CONCLUSION

Embolotherapy in patients with life-threatening SRH leads to a high technical success rate and is a safe therapeutic option. The clinical success rate was acceptable and influenced by pre-interventional coagulation status and by the amount of transfused concentrated red cells.

Predictors of False-Negative Focused Assessment With Sonography for Trauma Examination in Pediatric Blunt Abdominal Trauma

OBJECTIVES

This study investigated associations between patient and injury characteristics and false-negative (FN) focused assessment with sonography for trauma (FAST) in pediatric blunt abdominal trauma (BAT). We also evaluated the effects of FN FAST on in-hospital mortality and length of stay (LOS) variables.

METHODS

This retrospective cohort studied children younger than 18 years between January 1, 2002, and December 31, 2013, with BAT, documented FAST, and pathologic fluid on computed tomography, surgery, or autopsy. Multivariable and bivariate analyses were used to assess associations between FN FAST and patient injury characteristics, mortality, and hospital LOS.

RESULTS

A total of 141 pediatric BAT patients with pathologic free fluid were included. There were no patient or injury characteristics, which conferred increased odds of an FN FAST. Splenic and bladder injury were negatively associated with FN FAST odds ratio of 0.4 (95% confidence interval [CI], 0.2-0.8) and 0.1 (95% CI, 0-0.8). Abbreviated Injury Scale score of 4 or greater to the abdomen and extremity was negatively associated with FN FAST odds ratio of 0.1 (95% CI, 0-0.3) and 0.3 (95% CI, 0.1-0.9). There was no association between FN FAST and mortality. Patients with an FN FAST had increased hospital LOS after controlling for sex, age, and Injury Severity Score.

CONCLUSIONS

Clinicians need to be cautious applying a single initial FAST to patients with minor abdominal trauma or with suspected injuries to organs other than the spleen or bladder. Formalized studies to develop risk stratification tools could allow clinicians to integrate FAST into the pediatric patient population in the safest manner possible.

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

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied 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 re-examined and revised based on scientific evidence that has emerged since the previous edition 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.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma: a retrospective study

Background

Blunt pelvic injuries are often associated with pelvic fractures and injuries to the rectum and genitourinary tract. Pelvic fractures can lead to life-threatening hemorrhage, which is a common cause of morbidity and mortality in trauma. Thus, early identification of patients with pelvic fractures at risk severe bleeding requiring urgent hemorrhage control is crucial. This study aimed to investigate early factors predicting the need for hemorrhage control in blunt pelvic trauma.

Methods

The medical records of 1760 trauma patients were reviewed retrospectively between January 2013 and June 2018. We enrolled 187 patients with pelvic fracture due to blunt trauma who were older than 15 years. The pelvic fracture pattern was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) classification. A multivariate logistic regression model was used to determine independent predictors of the need for pelvic hemorrhage control intervention.

Results

The most common pelvic fracture pattern was type A (54.5%), followed by types B (36.9%) and C (8.6%). Of 187 patients, 48 (25.7%) required pelvic hemorrhage control intervention. Hemorrhage control interventions were most frequently performed in patients with type B fractures (54.2%). Multivariate logistic regression analysis revealed that type B (odds ratio [OR] = 4.024, 95% confidence interval [CI] = 1.666–9.720, p = 0.002) and C (OR = 7.077, 95% CI = 1.781–28.129, p = 0.005) fracture patterns, decreased body temperature (OR = 2.275, 95% CI = 0.134–0.567, p < 0.001), and elevated serum lactate level (OR = 1.234, 95% CI = 1.061–1.435, p = 0.006) were factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma.

Conclusion

Patients with type B and C fracture patterns on the OTA/AO classification, hypothermia, or an elevated serum lactate level are at risk for bleeding and require pelvic hemorrhage control intervention.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0438-8) contains supplementary material, which is available to authorized users.

The impact of external fixation on mortality in patients with an unstable pelvic ring fracture: a propensity-matched cohort study

AIM

There is not adequate evidence to establish whether external fixation (EF) of pelvic fractures leads to a reduced mortality. We used the Japan Trauma Data Bank database to identify isolated unstable pelvic ring fractures to exclude the possibility of blood loss from other injuries, and analyzed the effectiveness of EF on mortality in this group of patients.

PATIENTS AND METHODS

This was a registry-based comparison of 1163 patients who had been treated for an isolated unstable pelvic ring fracture with (386 patients) or without (777 patients) EF. An isolated pelvic ring fracture was defined by an Abbreviated Injury Score (AIS) for other injuries of < 3. An unstable pelvic ring fracture was defined as having an AIS ≥ 4. The primary outcome of this study was mortality. A subgroup analysis was carried out for patients who required blood transfusion within 24 hours of arrival in the Emergency Department and those who had massive blood loss (AIS code: 852610.5). Propensity-score matching was used to identify a cohort like the EF and non-EF groups.

RESULTS

With the use of propensity-score matching using the completed data, 346 patients were matched. When the propensity-score matching was adjusted, EF was associated with a significantly lower risk of death (p = 0.047). In the subgroup analysis of patients who needed blood transfusion within 24 hours and those who had massive blood loss, EF was associated with a significantly lower risk of death in patients who needed blood transfusion within 24 hours (p = 0.014) and in those with massive blood loss (p = 0.016).

CONCLUSION

The use of EF to treat unstable pelvic ring fractures was associated with a significantly lower risk of death, especially in patients with severe fractures. Cite this article: Bone Joint J 2018;100-B:233-41.

Haemorrhage control in pelvic trauma

A pelvic fracture usually indicates high energy transfer from a significant mechanism and a high likelihood of associated injuries. Mortality from pelvic trauma is usually due to massive haemorrhage mandating expedient resuscitation of the patient and immediate control of exsanguinating haemorrhage. Damage control resuscitation incorporates permissive hypotensive resuscitation and early replacement of clotting factors with early aggressive surgical control of bleeding. A commercially available pelvic binder provides circumferential compression and rapidly closes the pelvis, leading to fracture splintage and reduction in pelvic volume, both of which reduce haemorrhage. It is critical to distinguish ongoing bleeding due to a pelvic ring injury from intra-peritoneal haemorrhage. The identification of intra-peritoneal bleeding in a haemodynamically unstable patient mandates laparotomy. On-going haemorrhage from the pelvis requires diagnostic pelvic angiography, followed by selective embolisation if a source of bleeding is identified. If angiography is not available pelvic packing can be life-saving.

Scoring system to predict hemorrhage in pelvic ring fracture

BACKGROUND

Risk factors for hemorrhage in patients with pelvic ring fracture have been widely reported. Because there are many risk factors, it is thought that prediction accuracy of hemorrhage in cases of pelvic ring fracture could be improved by using a scoring system.

HYPOTHESIS

We investigated the risk factors for massive hemorrhage (MH) and created a novel predictive score of MH in pelvic ring fractures.

MATERIAL AND METHODS

We retrospectively reviewed patients with pelvic ring fractures (Abbreviated Injury Score≥3 and age≥16 years) from January 2007 to June 2015. We excluded the cases that might have hemorrhage from other sites sufficient to require a blood transfusion. Massive hemorrhage was defined as hemorrhage requiring transfusion of≥6 red cell concentrate units within 24h of admission.

RESULTS

The MH group included 27 patients and the non-MH group included 71 patients. Lactate level, AO/OTA classification and extravasation of computed tomography (CT) contrast fluid had a significantly higher risk as a result of multivariable analysis. The combined score using these risk factors according to their odds-adjusted ratios was created to predict for MH: lactate level>2.5-5.0 (mmol/L)=1 point,>5.0 (mmol/L)=2 points, partially stable (OA/OTA classification B1/B2/B3)=1 point, unstable (C1/C2/C3)=2 points, pelvic extravasation of contrast on CT=4 points. The AUC of the calculated score was 0.93 (95% CI: 0.89-0.98).

CONCLUSION

The combined score using these risk factors according to their odds-adjusted ratios was created to predict MH and was an effective prediction score.

LEVEL OF EVIDENCE

IV, retrospective study.

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.

Integrating eFAST in the initial management of stable trauma patients: the end of plain film radiography

Background

The initial management of a trauma patient is a critical and demanding period. The use of extended focused assessment sonography for trauma (eFAST) has become more prevalent in trauma rooms, raising questions about the real “added value” of chest X-rays (CXRs) and pelvic X-rays (PXR), particularly in haemodynamically stable trauma patients. The aim of this study was to evaluate the effectiveness of a management protocol integrating eFAST and excluding X-rays in stable trauma patients.

Methods

This was a prospective, interventional, single-centre study including all primary blunt trauma patients admitted to the trauma bay with a suspicion of severe trauma. All patients underwent physical examination and eFAST (assessing abdomen, pelvis, pericardium and pleura) before a whole-body CT scan (WBCT). Patients fulfilling all stability criteria at any time in transit from the scene of the accident to the hospital were managed in the trauma bay without chest and PXR.

Results

Amongst 430 patients, 148 fulfilled the stability criteria (stability criteria group) of which 122 (82 %) had no X-rays in the trauma bay. No diagnostic failure with an immediate clinical impact was identified in the stability criteria group (SC group). All cases of pneumothorax requiring chest drainage were identified by eFAST associated with a clinical examination before the WBCT scan in the SC group. The time spent in the trauma bay was significantly shorter for the SC group without X-rays compared to those who received any X-ray (25 [20; 35] vs. 38 [30; 60] min, respectively; p < 0.0001). An analysis of the cost and radiation exposure showed savings of 7000 Є and 100 mSv, respectively.

Conclusions

No unrecognized diagnostic with a clinical impact due to the lack of CXR and PXR during the initial management of stable trauma patients was observed. The eFAST associated with physical examination provided the information necessary to safely complete the WBCT scan. It allowed a sensible cost and radiation saving.

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.

The Outcome of Complex Pelvic Fracture after Internal Fixation Surgery

Introduction: Complex pelvic fracture, which has a very high mortality and even higher morbidity, needs internal fixation surgery as an integral part for its management. It was necessary to conduct a study regarding outcome of complex pelvic fractures after internal fixation surgery. Material & Method: Twenty-six patients with complex pelvic fractures that had been treated with internal fixation surgery during 2011-2014 were enrolled. These patients had an open pelvic fractures or Tile type B or C pelvic fracture who had undergone internal fixation surgery with at least 6 months follow-up. Evaluation of the morbidity and functional scoring was performed using Majeed and Hannover Score. Results and Discussions: Average of age was 31 years old and follow up time was 25 months. There were 7 patients with open pelvic fracture and 19 with closed fracture. Excellent Majeed Score were found on 78.6% cases in Tile B fractures and 50% in Tile C. Good Hannover Score was found in 64.3% Tile B cases and 80% Tile C cases. Fracture type was statistically insignificant with acquired sexual dysfunction (p>0.05), but significant with the chronic pain (p=0,.017). We also found that urogenital injury is associated with sexual dysfunction (p=0.005). Conclusions: The outcome of complex pelvic fracture after internal fixation surgery was excellent. More than 90% patients got an excellent and good result on Majeed Score, and also very good and good result on Hannover Score.

An unusual case of a patient who presented with haemorrhagic shock following massive subcutaneous haematomas of the lower back due to blunt trauma

An 83-year-old woman with no significant medical history was transferred to our tertiary hospital after being hit by a car and presenting with haemorrhagic shock. Immediate fluid resuscitation was performed; physical, chest/pelvic X-ray and echographic examinations did not detect any major sources of bleeding. However, a contrast-enhanced CT scan revealed multiple regions of significant contrast extravasation in an extensive part of the subcutaneous tissue of the patient's lower back, which is an unusual source of bleeding. Transcatheter arterial embolisation of the lumbar and internal iliac arteries and their branches was carried out. In addition, haemostatic resuscitation was performed for damage control resuscitation, which successfully resolved the patient's haemorrhagic shock.

Which pelvic ring fractures are potentially lethal?

PURPOSE

Global mortality of polytraumatised patients presenting pelvic ring fractures remains high (330%), despite improvements in treatment algorithms in Level I Trauma Centers. Many classifications have been developed in order to identify and analyse these pelvic ring lesions. However, it remains difficult to predict intra-pelvic haemorrhage. The aim of this study was to identify pelvic ring anatomical lesions associated with significant blood loss, susceptible to lead to life-threatening haemorrhage.

MATERIAL AND METHOD

This study focused on a retrospective analysis of patients' medical files, all of whom were admitted to one of the shock rooms of Grenoble University Hospital, France, between January 2004 and December 2008. Treatment was given according to the institutional algorithm of the Alps Trauma Center and Emergency North Alpine Network Trauma System (TRENAU). Different hemodynamical parameters at arrival were measured, and the fractures were classified according to Young and Burgess, Tile, Letournel and Denis. One hundred and ninety seven patients were analysed. They were subdivided into two groups, embolised (Group E) and non-embolised (Group NE).

RESULTS

Group NE included 171 patients with a mean age of 40.2 ± 8.7 years (15-90). Group E included 26 patients with a mean age of 41.6 ± 5.3 years (18-67). Twenty-six patients died during the initial treatment phase. Eleven belonged to Group E and 15 to Group NE. Mortality was significantly higher in Group E (42.3% vs 8.8% in Group NE) (p < 0.05). There were significantly many more Tile C unstable fractures in Group E (p = 0.0014), and anterior lesions, according to Letournel, with pubic symphysis disruption were significantly more likely to lead to active bleeding treated by selective embolisation (p = 0.0014). Posterior pelvic ring lesions with iliac wing fracture and transforaminal sacral fractures (Denis 2) were also more frequently associated with bleeding treated by embolisation (p = 0.0088 and p = 0.0369 respectively).

DISCUSSION/CONCLUSION

It appears that in our series the primary identification and classification of osteo-ligamentous lesions (according to Letournel and Denis' classifications) allows to anticipate the importance of bleeding and to adapt the management of patients accordingly, in order to quickly organise angiography with embolisation.

[Out-of-hospital equipment of emergency medical services for hemorrhagic shock management: can do better!]

INTRODUCTION

Hemorrhagic shock is an emergency, which may benefit from a medicalized prehospital care. Our goal was to survey the means available in the 370 French prehospital medicalized emergency services (SMUR) for hemorrhagic situations.

METHODS

Multicenter descriptive observational study by email then phone with all the 370 French SMUR leaders. The questionnaire was created by investigators of the project through a Delphi method, and was about service protocols concerning hemorrhagic patient care, hemorrhagic parameters measure equipment available, intravenous solutes and drugs as well as various medical devices useful or perceived to be useful to support prehospital hemorrhagic shock. The results are expressed in numbers and percentages.

RESULTS

The overall response rate was 48% (n=178). Protocols were established in between 43% (n=76) and 47% (n=83) according to etiology, measuring devices were available in 5% (n=9) of the Smur for hemostasis up to 89% (n=158) for hemoglobin measurement. Available intravenous solutes were mainly isotonic salty serum (95%, n=169), hydroxylethylstarch (83%, n=148) and Ringer lactate (73%, n=130). Tranexamic acid was available in 84 (47%) Smur. The teams had access to erythrocytes concentrates, fresh frozen plasma and platelets in 84% (n=150), 44% (n=79) and 23% (n=41) respectively. Eighty-one (46%) Smur had tourniquets and 127 (71%) anti-shock trousers. Finally, 57 (32%) had a pelvic restraint belt.

CONCLUSION

There is a great disparity in the means available in the French Smur for the support of prehospitalization bleeding. The majority the Smur physicians can transfuse in a prehospital setting. On the other hand, a minority of teams can actively warm patients, employ tranexamic acid or use pelvic restraint belts.

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.

Impact on outcome of a targeted performance improvement programme in haemodynamically unstable patients with a pelvic fracture

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths.

Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients.

Cite this article: Bone Joint J 2014;96-B:1090–7.

[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.

Emergency computed tomography for acute pelvic trauma: where is the bleeder?

Contrast medium extravasation at computed tomography (CT) is an accurate indicator of active haemorrhage in pelvic trauma. When this is present, potentially lifesaving surgical or endovascular treatment should be considered. Identification of the site or territory of haemorrhage is helpful for the interventional radiologist as it allows for focused angiographic evaluation and expedites haemostatic angio-embolisation. Even with thin-section arterial phase CT, tracing the bleeding vessel is not always possible and is often time consuming. We introduce a technique for predicting the bleeding vessel based on knowledge of the cross-sectional anatomical territory of the vessel as an alternative to tracing the vessel's course. Several case examples with digital subtraction angiography (DSA) correlation will be provided.

Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients

BACKGROUND

The early diagnosis of pelvic arterial haemorrhage is challenging for initiating treatment by transcatheter arterial embolization (TAE) in multiple trauma patients. We use an institutional algorithm focusing on haemodynamic status on admission and on a whole-body CT scan in stabilized patients to screen patients requiring TAE. This study aimed to assess the effectiveness of this approach.

METHODS

This retrospective cohort study included 106 multiple trauma patients admitted to the emergency room with serious pelvic fracture [pelvic abbreviated injury scale (AIS) score of 3 or more].

RESULTS

Of the 106 patients, 27 (25%) underwent pelvic angiography leading to TAE for active arterial haemorrhage in 24. The TAE procedure was successful within 3h of arrival in 18 patients. In accordance with the algorithm, 10 patients were directly admitted to the angiography unit (n=8) and/or operating room (n=2) for uncontrolled haemorrhagic shock on admission. Of the remaining 96 stabilized patients, 20 had contrast media extravasation on pelvic CT scan that prompted pelvic angiography in 16 patients leading to TAE in 14. One patient underwent a pelvic angiography despite showing no contrast media extravasation on pelvic CT scan. All 17 stabilized patients who underwent pelvic angiography presented a more severely compromised haemodynamic status on admission, and they required more blood products during their initial management than the 79 patients who did not undergo pelvic angiography. The incidence of unstable pelvic fractures was however comparable between the two groups. Overall, haemodynamic instability and contrast media extravasation on the CT-scan identified 26 out of the 27 patients who required subsequent pelvic angiography leading to TAE in 24.

CONCLUSIONS

An algorithm focusing on haemodynamic status on arrival and on the whole-body CT scan in stabilized patients may be effective at triaging multiple trauma patients with serious pelvic fractures.

Comparison between laparotomy first versus angiographic embolization first in patients with pelvic fracture and hemoperitoneum: a nationwide observational study from the Japan Trauma Data Bank

BACKGROUND

A common dilemma in the management of pelvic fractures is recognizing the presence of associated abdominal injury. The purpose of this study was to determine the association between initial therapeutic intervention (laparotomy or transcatheter arterial embolization (TAE)) and mortality.

METHODS

This was a cohort study using the Japan Trauma Data Bank between 2004 and 2010, including blunt trauma patients with pelvic fractures and positive Focused Assessment with Sonography in Trauma (FAST) results. Eligible patients were restricted to those who underwent laparotomy or TAE/angiography as the initial therapeutic intervention. Crude and adjusted odds ratio (AOR) for in-hospital mortality were compared between the laparotomy first and TAE first groups (reference group). Multiple logistic regression analysis and propensity score adjusted analysis were used to adjust for clinically relevant confounders, including the severity of injury.

RESULTS

Of the 317 participants, 123 patients underwent laparotomy first and 194 patients underwent TAE first. The two groups were similar in terms of age, although the laparotomy first group had higher mean Injury Severity Scores (ISS) and higher mean scores based on the abdominal Abbreviated Injury Scale (AIS), as well as lower mean pelvic AIS and systolic blood pressure (SBP). Half of the patients who were hypotensive (SBP < 90 mmHg) on arrival underwent TAE first. The laparotomy first group had a significantly higher crude in-hospital mortality (41% vs. 27%; P < 0.01). After adjusting for confounders, the choice of initial therapeutic intervention did not affect the in-hospital mortality (AOR, 1.20; 95% Confidence Interval (CI), 0.61-2.39). Even in the limited subgroup of hypotensive patients (SBP 66-89 mmHg and SBP < 65 mmHg subgroup), the effect was similar (AOR, 1.50; 95% CI, 0.56-4.05 and AOR, 1.05; 95% CI, 0.44-3.03).

CONCLUSIONS

In Japan, laparotomy and TAE are equally chosen as the initial therapeutic intervention regardless of hemodynamic status. No significant difference was seen between the laparotomy first and TAE first groups regarding in-hospital mortality.

Flight vibrations and bleeding in helicoptered patients with pelvic fracture

Depending on their amplitude and frequency, vibrations may facilitate bleeding and worsen the prognosis of patients with pelvic fractures transported by helicopter emergency medical services (HEMS). We measured the range of frequencies and amplitudes of forced vibrations produced by the helicopter used by the HEMS of the Italian Friuli Venezia Giulia region on the pelvis of transported persons. We performed 3 flight tests with 3 different volunteers (mass 70, 80, and 90 kg, respectively) loaded on the helicopter's stretcher and recorded the amplitudes and frequencies of vibrations through a triaxis sensor placed on the HEMS stretcher in the pelvis area. The flight profile planned was identical for each of the 3 iterations. Over the whole flight, the frequencies of vibration were between 26.4 and 53.5 Hz, and the greastest amplitude was 0.035 mm. The vibrations recorded in the helicopter may facilitate bleeding in unstable fractures. In the management of patients with pelvic fractures, HEMS crews should provide prehospital care that includes the use of specific splinting devices in addition to the spinal board, which allows an early immobilization of fractures and the limitation of pelvic motion.

Management of pelvic fractures

PURPOSE OF REVIEW

The management of patients with pelvic fractures can be demanding. Severe pelvic fractures pose a great challenge for physicians and can greatly contribute to significant patient morbidity and mortality. The purpose of this review is to highlight recent, positive changes in the management of patients with pelvic fractures.

RECENT FINDINGS

The current status of pelvic fracture management is presented, including a recently proposed algorithm for management, an evaluation of roles of angioembolization and preperitoneal packing. Additionally, the approach of bilateral internal iliac artery ligation as a salvage procedure is reviewed, and the outcome of acute (<24 h) pelvic fracture operative fixation. Regardless of the strategy adopted, a multidisciplinary approach is required for the proper management of hemodynamically unstable patients with pelvic fractures.

SUMMARY

The key elements in managing patients with pelvic fractures are swift and adequate resuscitation, reversal of shock and acidosis, and rapid control of hemorrhage to facilitate survival of these patients. Multimodality therapies including external pelvic stabilization, angioembolization and preperitoneal pelvic packing are useful adjuncts that require appropriately trained and immediately available personnel. A multidisciplinary approach has been shown to be beneficial for patient outcomes.

Management of bleeding and coagulopathy following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.

Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients

The management of the polytraumatized orthopedic patient remains a challenging issue. In recent years many efforts have been made to develop rescue techniques and to promote guidelines for the management of these patients. Currently controversies persist between two orthopedic approaches: the Early Total Care and the Damage Control Orthopedics. An overview of the current literature on the orthopedic management of polytrauma patient is provided. Subsequently, femoral shaft fractures, representing extremely common lesions, and pelvic ring injuries, that are associated with a high mortality rate, are analyzed in detail.

Nonsurgical techniques to control massive bleeding

Significant advancements in nonsurgical and surgical approaches to control bleeding in severely injured patients have also improved the treatment of critical trauma-related coagulopathy. Nonsurgical procedures such as angiographic embolization are progressively considered to terminate arterial bleeding from pelvic fractures. The disturbance of coagulation may aggravate bleeding and hamper surgical procedures. The administration of coagulation factors and factor concentrates may be useful for correcting systemic coagulopathy and reducing the need for fresh frozen plasma, platelet, and red blood cell transfusions, which are associated with various adverse outcomes. In this review, nonsurgical management of critical trauma bleeding is discussed.

Retroperitoneal pelvic packing for haemodynamically unstable pelvic fractures in children and adolescents: a level-one trauma-centre experience

PURPOSE

This study aims to review the outcomes of haemodynamically unstable paediatric patients with pelvic fractures undergoing protocol intervention of retroperitoneal pelvic packing (RPP) with external fixation and angiography.

METHODS

From 2004 to 2011, consecutive patients younger than 19 years treated in our centre for haemodynamically unstable pelvic fractures were retrospectively reviewed. From 2008, protocol intervention triad of external fixation, RPP, and angiography with embolization was implemented.

RESULTS

Before 2008, only 2 boys with fall injuries received intervention. One received initial angiography showing extravasation near iliac bifurcation. Laparotomy proceeded without embolization for multiple visceral injuries, but he succumbed postoperatively. The other had persistent bleeding after external fixation but became stabilized after embolization. After 2008 protocol implementation, 5 youngsters received the triad of interventions for unstable pelvic fractures. Mean age was 15.4 yrs. The mean injury severity score was 42 (18-66) with 62.5% mean probability of survival (6.8-98.8%). The mean operating time for RPP was 23 mins (20-35 mins). One boy died of rapid exanguination intraoperatively. The other 4 youngsters recovered for rehabilitation.

CONCLUSION

Fall from heights is a major cause for severe pelvic injuries in our locality. RPP is a simple effective procedure to include in protocol intervention for pelvic fractures. This case series suggests it helps improve haemostasis and survival in unstable young patients, although larger cohorts will be necessary to validate this.

Emergency angio-embolisation in the operating theatre for trauma patients using the C-Arm digital subtraction angiography

BACKGROUND AND AIMS

Angio-embolisation in trauma is a relatively new technique that is gaining popularity and recognition in identifying and arresting bleeding in trauma patients. We studied the possibility whether angio-embolisation using the Digital Subtraction Angiography (DSA), in the operating theatre (OT) could achieve successful haemostasis in trauma patients. We further studied the feasibility of using this technique as part of trauma resuscitation/damage control.

METHODS

A retrospective study of trauma patients, with Injury Severity Score (ISS ≥ 9), admitted to Tan Tock Seng Hospital (TTSH) from January 2004 to December 2008 was done. Patients who had received angio-embolisation in the OT or angiography suite were evaluated in terms of age, gender, ISS, the site and type of angioembolisation used. The primary end point was to assess the success rate of angioembolisation using the C-Arm DSA in the OT, and whether there were any complications necessitating a repeat procedure or surgical intervention. The secondary end points of the study were aimed at studying the cost effectiveness of this technique, logistical feasibility and evaluating this technique as part of the initial trauma resuscitative efforts.

RESULTS

A total of 43 trauma patients received angioembolisation. 32 patients had the angio-embolisation done using the C-Arm DSA in the OT (n = 32). None of the patients who received angioembolisation in the operating theatre (n = 32) had any re-bleeding. 15 out of 32 survived. There were no complications related to the angio-embolisation procedure. The majority of angio-embolisations done were for pelvic fractures.

CONCLUSION

The success of angio-embolisation in the OT using the C-Arm DSA for a trauma patient and its complication rates are similar to that done in a dedicated angio-graphic suite. We conclude that angio-embolisation in the operating theatre using the C-Arm DSA is feasible, cost effective and can be a modality in the initial trauma resuscitation/damage control in any lead lined operating theatre. We believe that we are the first to describe this method of angio-embolisation using the C-Arm DSA in a conventional lead lined trauma operating theatre and its use as a feasible option in a trauma resuscitation/damage control algorithm.

Current management of severe pelvic and perineal trauma

Mortality associated with pelvic and perineal trauma (PPT) has fallen from 25% to 10% in the last decade thanks to progress accomplished in medical, surgical and interventional radiology domains (Dyer and Vrahas, 2006) [1]. The management strategy depends on the hemodynamic status of the patient (stable, unstable or extremely unstable). Open trauma requires specific treatment in addition to control of bleeding. All surgical centers can be confronted some day with patients with hemorrhagic PPT and for this reason, all surgeons should be familiar with the initial management. In expert centers, management of patients with severe PPT is complex, multidisciplinary and often requires several re-interventions. Obstetrical and sexual trauma, also requiring specific management, will not be dealt with herein.

Delayed hypogastric artery pseudoaneurysm following blunt trauma without evidence of pelvic fracture

Arterial pelvic bleeding caused by bony fragments is a common finding in patients with pelvic fractures after blunt trauma (Durkin et al., Am J Surg 2006;192:211-23). However, arterial injury in the absence of bony fracture is extremely rare, and in the event that it does occur, is immediately discovered on cross-sectional imaging. We present an unusual case of a 15-year-old boy who was involved in a bicycle accident, and who, a week after his injury, developed a delayed hypogastric branch artery pseudoaneurysm causing sciatic nerve compression with a right foot drop. Initial magnetic resonance imaging scan and pelvic X-ray at the time of the injury showed no evidence of pelvic fracture or vascular damage. The pseudoaneurysm was successfully treated with selective coil embolization and hematoma evacuation. This study represents only the second reported case of delayed pelvic pseudoaneurysm in the absence of pelvic fracture.

Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic fractures: a level I trauma center experience

BACKGROUND

Our objective is to evaluate the mortality and outcomes of hemodynamically unstable patients with pelvic fractures treated with a protocol that directs the patient to either early pelvic angiography or early retroperitoneal pelvic packing.

METHOD

This is a retrospective review of prospectively collected database at a local trauma center. Hemodynamically unstable pelvic fracture patients received treatment according to our hospital protocol during two different time periods. Before June 2008, these patients underwent early angiography (ANGIO group, n=13), and from June 2008 onward, these patients underwent early pelvic packing and subsequent angiography if there was continued hemorrhage from the pelvis (PACKING group, n=11). The mechanism of injury, physiologic parameters, blood transfusion requirements, time to intervention, trauma scores, and mortality were recorded.

RESULTS

Mean time to intervention in the ANGIO group was longer than that in the PACKING group, although this was not statistically significant (139.5 minutes vs. 78.8 minutes, respectively, p=0.248). Mortality in the ANGIO group was higher than that in the PACKING group; however, this was also not significant (69.2% vs. 36.3%, p=0.107). After univariate analysis, factors associated with mortality included systolic blood pressure, Glasgow Coma Score, Injury Severity Score, Revised Trauma Score, Trauma and Injury Severity Score, pH, and base excess. In the PACKING group, one patient died of uncontrolled hemorrhage from a liver laceration. In the ANGIO group, three patients died of uncontrolled hemorrhage from the pelvic fracture.

CONCLUSION

Early experience in our institution suggests that early pelvic packing with subsequent angiography if needed is as good as angiography with embolization in treating patients with hemodynamically unstable pelvic fractures.

Predictors of mortality following severe pelvic ring fracture: results of a population-based study

INTRODUCTION

Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system.

METHODS

Cases aged≥15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated.

RESULTS

There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged≥65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15-34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres).

CONCLUSIONS

The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.

[The damage control resuscitation concept]

OBJECTIVE

Damage control is a strategy of care for bleeding trauma patients, involving minimal rescue surgery associated to perioperative resuscitation. The purpose of this review is to draw up a statement on current knowledge available on damage control.

DATA SOURCES

References were obtained from recent review articles, personal files, and Medline database research of English and French publications. All categories of articles on this topic have been selected.

DATA SYNTHESIS

Historical damage control surgery, that consist of abbreviated laparotomy with second-look after resuscitation, is now included in a wider concept called "damage control resuscitation", addressing the lethal triad (coagulopathy, hypothermia and acidosis) at an early phase. Care is focused on coagulopathy prevention. Early resuscitation, or damage control ground zero, has been improved: aggressive management of hypothermia, bleeding control techniques, permissive hypotension concept and early use of vasopressors. Transfusion practices also have evolved: early platelets and coagulation factors administration, use of hemostatic agents like recombinant FVIIa, whole blood transfusion, denote the damage control hematology. Progress in surgical practices and development of arteriographic techniques lead to wider indications of damage control strategy.

Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature

PURPOSE

The purpose of this study was to evaluate the relation between pelvic fracture patterns and the angiographic findings, and to assess the effectiveness of the embolisation.

METHODS

This retrospective study, included patients with pelvic fractures and angiographic evaluation. Demographics, Injury Severity Score (ISS), associated injuries, embolisation time, blood units needed, method of treatment and complications were recorded and analysed. Fractures were classified according to the Burgess system.

RESULTS

Between 1998 and 2008, 34 patients with pelvic fractures underwent angiographic investigation. Twenty six were males. The mean age was 41 years. Twenty-seven were motor vehicle accidents and seven were falls. There were 11 anterior posterior (APC) fractures, 12 lateral compression (LC), eight vertical shear (VS) patterns and three with combined mechanical injuries. The median ISS was 33.1 (range 5-66). From the 34 who underwent angiography, 29 had positive vascular extravasations. From them, 21 had embolisation alone, two had vascular repair and embolisation, five required vascular repair alone and one patient died while being prepared for embolisation. Five cases were re-embolised. The findings suggested that AP fractures have a higher tendency to bleeding compared with LC fractures. Both had a higher chance of blood loss compared to VS and complex fracture patterns. We reported 57 additional injuries and 65 fractures. The complications were: one non lethal pulmonary embolism, one renal failure, one liver failure, one systemic infection, two deep infections and two psychological disorientations. Seven patients died in hospital.

CONCLUSION

Control of pelvic fracture bleeding is based on the multidisciplinary approach mainly related to hospital facilities and medical personnel's awareness. The morphology of the fracture did not have a predictive value of the vascular lesion and the respective bleeding.

Clinical outcome of intra-arterial embolization for treatment of patients with pelvic trauma

Purpose. To analyse the technical success of pelvic embolization in our institution and to assess periprocedural hemodynamic status and morbidity/mortality of all pelvic trauma patients who underwent pelvic embolization. Methods. A retrospective analysis of patients with a pelvic fracture due to trauma who underwent arterial embolization was performed. Clinical data, pelvic radiographs, contrast-enhanced CT-scans, and angiographic findings were reviewed. Subsequently, the technical success and peri-procedural hemodynamic status were evaluated and described. Results. 19 trauma patients with fractures of the pelvis underwent arterial embolization. Initially, 10/19 patients (53%) were hemodynamically unstable prior to embolization. Technical success of embolization was 100%. 14/19 patients (74%) were stable after embolization, and treatment success was high as 74%. Conclusion. Angiography with subsequent embolization should be performed in patients with a pelvic fracture due to trauma and hemodynamic instability, after surgical intervention or with a persistent arterial blush indicative of an active bleeding on CT.

Tratamento endovascular de hemorragia pélvica após trauma fechado: desafio terapêutico

Paciente de 16 anos do sexo masculino sofreu trauma pélvico fechado, seguido de formação de abscesso do músculo psoas e outras complicações infecciosas. Submetido a drenagem do abscesso retroperitonial onde foi encontrado extenso sangramento. A hemorragia foi contida com compressas. Após abordagem endovascular por embolização dos ramos da artéria hipogástrica, houve cessação da hemorragia, as compressas foram retiradas e o paciente recebeu alta do hospital sem complicações.