Hemostasis as soon as possible? The role of the time to angioembolization in the management of pelvic fracture

Assessment of fetal radiation exposure in pregnant women undergoing computed tomography and rotational angiography examinations for pelvic trauma

This study aimed to assess fetal radiation exposure in pregnant women undergoing computed tomography (CT) and rotational angiography (RA) examinations for the diagnosis of pelvic trauma. In addition, this study aimed to compare the dose distributions between the two examinations. Surface and average fetal doses were estimated during CT and RA examinations using a pregnant phantom model and real-time dosemeters. The pregnant model phantom was constructed using an anthropomorphic phantom, and a custom-made abdominal phantom was used to simulate pregnancy. The total average fetal dose received by pregnant women from both CT scans (plain, arterial and equilibrium phases) and a single RA examination was ~60 mGy. Because unnecessary repetition of radiographic examinations, such as CT or conventional 2D angiography can increase the radiation risk, the irradiation range should be limited, if necessary, to reduce overall radiation exposure.

A short decision time for transcatheter embolization can better associate mortality in patients with pelvic fracture: a retrospective study

Background

Early use of hemostasis strategies, transcatheter arterial embolization (TAE) is critical in cases of pelvic injury because of the risk of hemorrhagic shock and other fatal injuries. We investigated the influence of delays in TAE administration on mortality.

Methods

Patients admitted to the Advanced Critical Care Center at Gifu University with pelvic injury between January 2008 and December 2019, and who underwent acute TAE, were retrospectively enrolled. The time from when the doctor decided to administer TAE to the start of TAE (needling time) was defined as "decision-TAE time."

Results

We included 158 patients, of whom 23 patients died. The median decision-TAE time was 59.5 min. Kaplan-Meier curves for overall survival were compared between patients with decision-TAE time above and below the median cutoff value; survival was significantly better for patients with values below the median cutoff value (p = 0.020). Multivariable Cox proportional hazards regression analysis revealed that the longer the decision-TAE time, the higher the risk of mortality (p = 0.031). TAE duration modified the association between decision-TAE time and overall survival (p = 0.109), as shorter TAE duration (procedure time) was associated with the best survival rate (p for interaction = 0.109).

Conclusion

Decision-TAE time may play a key role in establishing resuscitation procedures in patients with pelvic fracture, and efforts to shorten this time should be pursued.

Does time to angiography affect the survival of trauma patients with embolization to the pelvis? A retrospective study across trauma centers in the United States

INTRODUCTION

Traumatic pelvic injuries can result in rapid exsanguination. Bleeding control interventions include stabilization, angiography, and possible embolization. Previous studies yielded conflicting results regarding the benefit of a shorter time to embolization.

OBJECTIVES

The aim of this study is to examine the impact of the time to angioembolization on the survival of patients presenting with pelvic injuries using a national database.

MATERIALS AND METHODS

This was an observational retrospective study that used the National Trauma Data Bank 2017 dataset. Adult patients with pelvic injuries and who received angiography with embolization to the pelvis were included. Univariate and bivariate analyses (survival to hospital discharge yes/no) were done. This was followed by a multivariable logistic regression analysis to assess the impact of time to angiography on survival to hospital discharge after adjusting for potential confounders.

RESULTS

A total of 1,057 patients were included. They were predominantly of male gender (69.3 %) with a median age of 50 years (IQR = [31-64]). The mean time to pelvic angiography was 264.0 ± 204.4 min. The overall survival rate at hospital discharge was 72.0 %. Time to angiography was not significantly associated with survival to hospital discharge before and after adjusting for clinically and statistically significant confounders (aOR = 1.000; 95 %CI=[0.999 - 1.001]; p = 0.866).

CONCLUSION

Time to angiography was not associated with survival to hospital discharge of patients with pelvic injuries who required embolization. Further research examining specific patterns of injuries and assessing the impact of early angioembolization is needed.

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.

The impact of time to hemostatic intervention and delayed care for patients with traumatic hemorrhage: A systematic review

BACKGROUND

Uncontrolled bleeding is a common cause of preventable mortality in trauma. While it is intuitive that delays to hemostasis may lead to worse outcomes, the impacts of these delays remain incompletely explored. This systematic review aimed to characterize the extant definitions of delayed hemostatic intervention and to quantify the impacts of delays on clinical outcomes.

METHODS

We searched EMBASE, MEDLINE, and Web of Science from inception to August 2022. Studies defining "delayed intervention" and those comparing times to intervention among adults presenting to hospital with blunt or penetrating injuries who required major hemostatic intervention were eligible. The coprimary outcomes were mortality and the definition of delay to hemostasis used. Secondary outcomes included units of packed red blood cells received, length of stay in hospital, and length of stay in intensive care.

RESULTS

We identified 2,050 studies, with 24 studies including 10,168 patients meeting the inclusion criteria. The majority of studies were retrospective observational cohort studies, and most were at high risk of bias. A variety of injury patterns and hemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from 10 minutes to 4 hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital.

CONCLUSION

The extant literature is heterogeneous with respect to injuries included, methods of hemostasis employed, and durations of delay examined. While the majority of the included studies demonstrated a statistically significant relationship between time to intervention and mortality, an evidence-informed definition of delayed intervention for bleeding trauma patients at large has not been solidified. In addition, standardized research is needed to establish targets, which could reduce morbidity and mortality.

LEVEL OF EVIDENCE

Systematic Review; Level IV.

Impact of trauma teams on high grade liver injury care: a two-decade propensity score approach study in Taiwan

High-grade liver laceration is a common injury with bleeding as the main cause of death. Timely resuscitation and hemostasis are keys to the successful management. The impact of in-hospital trauma system on the quality of resuscitation and management in patients with traumatic high-grade liver laceration, however, was rarely reported. We retrospectively reviewed the impact of team-based approach on the quality and outcomes of high-grade traumatic liver laceration in our hospital. Patients with traumatic liver laceration between 2002 and 2020 were enrolled in this retrospective study. Inverse probability of treatment weighting (IPTW)-adjusted analysis using the propensity score were performed. Outcomes before the trauma team establishment (PTTE) and after the trauma team establishment (TTE) were compared. A total of 270 patients with liver trauma were included. After IPTW adjustment, interval between emergency department arrival and managements was shortened in the TTE group with a median of 11 min (p < 0.001) and 28 min (p < 0.001) in blood test reports and duration to CT scan, respectively. Duration to hemostatic treatments in the TTE group was also shorter by a median of 94 min in patients receiving embolization (p = 0.012) and 50 min in those undergoing surgery (p = 0.021). The TTE group had longer ICU-free days to day 28 (0.0 vs. 19.0 days, p = 0.010). In our study, trauma team approach had a survival benefit for traumatic high-grade liver injury patients with 65% reduction of risk of death within 72 h (Odds ratio (OR) = 0.35, 95% CI = 0.14-0.86) and 55% reduction of risk of in-hospital mortality (OR = 0.45, 95% CI = 0.23-0.87). A team-based approach might contribute to the survival benefit in patients with traumatic high-grade liver laceration by facilitating patient transfer from outside the hospital, through the diagnostic examination, and to the definitive hemostatic procedures.

Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma

This study analyzed the outcomes of bilateral internal iliac artery (IIA) ligation with preperitoneal pelvic packing (PPP) in hemodynamically unstable patients with major pelvic fractures. All-cause mortality was examined, periprocedural safety for critical circumstances was reviewed, and iliac artery ligation-related complications of the postoperative phase were evaluated. A total of 20 patients who suffered substantially from severe pelvic trauma with hemodynamic instability and subsequently underwent bilateral IIA ligation with PPP between January 1, 2017, and December 31, 2021, were enrolled in the study. The median participant age was 60.5 years, and 65.0% were male. The median systolic blood pressure was 68.5 mmHg on arrival. Increased lactate level (median, 11.05 mmol/L) suggested that the patients were in shock distinctly due to hypovolemia. It took approximately 1 h to complete the ligation of bilateral IIA to accomplish hemostasis (median, 65.5 min). The iliac vein was injured during dissection in three cases. During the ICU stay (median, 17.5 days), acute kidney injury was identified in 13 patients, likely due to volume depletion. The median ventilator-free days was 13.5; six patients were confirmed with ventilator-associated pneumonia. Moreover, 12 patients were diagnosed with acute respiratory distress syndrome. There was one case in which the lower extremity artery was acutely occluded. Anatomic hemostasis was achieved in 18 patients. The two patients for which anatomic hemostasis failed became two mortality cases from preperitoneal hemorrhage. Our analysis showed that bilateral IIA ligation with PPP was effective as a lifesaving procedure in hemodynamically unstable patients with a major pelvic fracture in terms of mortality due to fracture-related exsanguination. Moreover, the incidence of periprocedural complications was considered tolerable, making the procedure worth a try, especially in austere and underdeveloped healthcare settings.

Effect of angioembolization for isolated complex pelvic injury: A post-hoc analysis of a nationwide multicenter trauma database in Japan

BACKGROUND AND IMPORTANCE

Complex pelvic injuries are among the types of trauma with the highest mortality. Treatment strategies should be based on the hemodynamic status, the anatomical type of fracture, and the associated injuries. Combination therapies, including preperitoneal pelvic packing, temporary mechanical stabilization, resuscitative endovascular balloon occlusion of the aorta, and angioembolization, are recommended for pelvic injuries.

OBJECTIVE

To investigate the effect of urgent angioembolization alone on severe pelvic injury-associated mortality.

DESIGN, SETTINGS, AND PARTICIPANTS

We used the Japan Trauma Data Bank database, a multicenter observational study, to retrospectively identify adult patients with isolated blunt pelvic injuries (Abbreviated Injury Scale [AIS] score: 3-5) from 2004 to 2018.

OUTCOME MEASURES AND ANALYSIS

The primary outcome measure was in-hospital mortality. We subdivided patients into two groups, those who underwent urgent angioembolization and non-urgent angioembolization, and compared their mortality rates. We performed multiple imputation and multivariable analyzes to compare the mortality rates between groups after adjusting for known potential confounding factors (age, sex, Glasgow Coma Scale score, systolic blood pressure on hospital arrival, Injury Severity Score, pelvic AIS score, laparotomy, resuscitative endovascular balloon occlusion of the aorta, and external fixation) and for within-hospital clustering using the generalized estimating equation.

MAIN RESULTS

We analyzed 4207 of 345,932 trauma patients, of whom 799 underwent urgent angioembolization. The in-hospital mortality rate was significantly higher in the urgent embolization group than in the non-urgent embolization group (7.4 vs. 4.0%; p < 0.01). However, logistic regression analysis revealed that the mortality rates of patients with urgent angioembolization significantly decreased after adjusting for factors independently associated with mortality (odds ratio: 0.60; 95% confidence interval: 0.37-0.96; p = 0.03).

CONCLUSION

Urgent angioembolization may be an effective treatment for severe pelvic injury regardless of the pelvic AIS score and the systolic blood pressure on hospital arrival.

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.

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.

Novel resuscitation strategies in patients with a pelvic fracture

Patients with a pelvic ring injury and hemodynamic instability can be challenging to manage with high rates of morbidity and mortality rates. Protocol-based resuscitation strategies are critical to successfully manage these potentially severely injured patients in a well-coordinated manner. While some aspects of treatment may vary slightly from institution to institution, it is critical to identify pelvic injuries and their associated injuries expediently. The first step at the scene of injury or in the trauma resuscitation bay should be the immediate application of a circumferential pelvic sheet or binder, initiation of physiologically optimal fluid resuscitation in the form 1:1:1 (pRBC:FFP:platelets) or whole blood, and to consider TXA as a safe adjunct to treat coagulopathy. Providers should have a very low threshold for emergent operative intervention in the form of pelvic external fixation and/or pelvic packing. This occurs in addition to simultaneous interventions addressing the other possible sources of bleeding in patients demonstrating signs of hemorrhagic shock and failure to respond to early resuscitation and external pelvic tamponade. Finally, while arterial injury is only present in a small percentage of patients with a pelvic ring injury, percutaneous vascular intervention with selective angiography and REBOA have been shown to be efficacious for patients with clinical indicators of arterial injury or who remain hemodynamically unstable despite external pelvic tamponade and packing to address venous bleeding. They should be performed when as early as possible for patients in true extremis limit further hemorrhage and allow resuscitation efforts to continue.

Delayed embolization associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival

Background

Embolization is widely used for controlling arterial hemorrhage associated with pelvic fracture. However, the effect of a delay in embolization among hemodynamically stable patients at hospital arrival with a pelvic fracture is unknown. Therefore, our aim was to investigate the association between the time to embolization and mortality in hemodynamically stable patients at hospital arrival with a pelvic fracture.

Methods

A multicenter, retrospective cohort study was undertaken using data from the Japan Trauma Data Bank between 2004 and 2018. Hemodynamically, stable patients with a pelvic fracture who underwent an embolization within 3 h were divided into six groups of 30-min blocks of time until pelvic embolization (0–30, 30–60, 60–90, 90–120, 120–150, and 150–180 min). We compared the adjusted 30-day mortality rate according to time to embolization.

Results

We studied 620 hemodynamically stable patients with a pelvic fracture who underwent pelvic embolization within 3 h of hemorrhage. The median age was 68 (48–79) years and 55% were male. The median injury severity score was 26 (18–38). Thirty-day mortality was 8.9% (55/620) and 24-h mortality was 4.2% (26/619). A Cochran–Armitage test showed that a 30-min delay for embolization was associated with increased 30-day (p = 0.0186) and 24-hour (p = 0.033) mortality. Mortality within 0–30 min to embolization was 0%. The adjusted 30-day mortality rate increased with delayed embolization and was up to 17.0% (10.2–23.9) for the 150–180 min group.

Conclusion

Delayed embolization was associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival. When you decide to embolize pelvic fracture patients, the earlier embolization may be desirable to promote improved survival regardless of hemodynamics.

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database

BACKGROUND

Knowledge on practice patterns for aortic occlusion (AO) in the setting of severe pelvic fractures is limited. This study aimed to describe clinical outcomes based on number and types of interventions after zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment.

METHODS

A retrospective review of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery multicenter registry was performed for patients who underwent zone 3 AO from 2013 to 2020. Patients with a blunt mechanism who survived beyond the emergency department were included. Interventions evaluated were preperitoneal pelvic packing (PP), angioembolization (AE), and external fixation (EF) of the pelvis. Management approaches were compared against the primary outcome of mortality. Secondary outcomes included transfusion requirements, overall complications and acute kidney injury (AKI).

RESULTS

Of 207 patients who underwent zone 3 AO, 160 (77.3%) fit the inclusion criteria. Sixty (37.5%) underwent AO alone, 50 (31.3%) underwent a second hemostatic intervention, and 49 (30.6%) underwent a third hemostatic intervention. Overall mortality was 37.7% (n = 60). There were no differences in mortality based on any number or combination of interventions. On multivariable regression, only EF was associated with a mortality reduction (odds ratio, 0.22; p = 0.011). Increasing number of interventions were associated with higher transfusion and complication rates. Pelvic packing + AE was associated with increased AKI than PP or AE alone (73.3% vs. 29.5% and 28.6%, p = 0.005), and AE was associated with increased AKI resulting in dialysis than PP alone (17.9% vs. 6.8%, p = 0.036).

CONCLUSION

Zone 3 REBOA can be used as a standalone hemorrhage control technique and as an adjunct in the management of severe pelvic fractures. The only additional intervention associated with a mortality reduction was EF. The benefit of increasing number of interventions must be weighed against more harm. Heterogeneity in practice patterns for REBOA use in pelvic fracture management underscores the need for an evidence base to standardize care.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

The role of angioembolization and C-clamp fixation: Damaged control orthopaedic in haemodynamically unstable pelvic fracture

INTRODUCTION

Unstable pelvic fracture may emerge to major bleeding complication. Angioembolization is one of method to stop the bleeding effectively. This case series aims to analyze whether the bleeding of unstable pelvic fracture is managed by angioembolization to achieve the better functional outcome.

PRESENTATION OF CASE

Three cases of haemodynamically unstable pelvic fracture were studied retrospectively and prospectively. A staged approach using damage control orthopaedic surgery was performed. Initial resuscitation began from fluid resuscitation, pelvic wrapping using binder. All patients followed with pelvic external fixation, while 2 patients immediately replaced binder to C-Clamp, and 1 patient with anterior frame. Angioembolization was done to all patients. All patients required definitive internal fixation, while only 2 patients reach the definitive surgery. Finally, we measured the functional outcome of all patients using Hannover Pelvic score, Majeed pelvic score, and Iowa Pelvic score.

DISCUSSION

We review some literatures regarding pelvic angioembolization. The previous study suggested to resuscitate patients when the hemodynamic is unstable, the angioembolization procedure is still preferred. The indication and successful definition of this procedure is still unclear, yet it shows decrease of mortality rate of pelvic injury if this procedure starts ahead a schedule.

CONCLUSION

Angioembolization as a part of damaged control orthopaedic has been shown a favorable result in managing unstable pelvic injury.

A scalable physician-level deep learning algorithm detects universal trauma on pelvic radiographs

Pelvic radiograph (PXR) is essential for detecting proximal femur and pelvis injuries in trauma patients, which is also the key component for trauma survey. None of the currently available algorithms can accurately detect all kinds of trauma-related radiographic findings on PXRs. Here, we show a universal algorithm can detect most types of trauma-related radiographic findings on PXRs. We develop a multiscale deep learning algorithm called PelviXNet trained with 5204 PXRs with weakly supervised point annotation. PelviXNet yields an area under the receiver operating characteristic curve (AUROC) of 0.973 (95% CI, 0.960-0.983) and an area under the precision-recall curve (AUPRC) of 0.963 (95% CI, 0.948-0.974) in the clinical population test set of 1888 PXRs. The accuracy, sensitivity, and specificity at the cutoff value are 0.924 (95% CI, 0.912-0.936), 0.908 (95% CI, 0.885-0.908), and 0.932 (95% CI, 0.919-0.946), respectively. PelviXNet demonstrates comparable performance with radiologists and orthopedics in detecting pelvic and hip fractures.

Relationship between door-to-embolization time and clinical outcomes after transarterial embolization in trauma patients with complex pelvic fracture

Background

While transarterial embolization (TAE) is an effective way to control arterial bleeding associated with pelvic fracture, the clinical outcomes according to door-to-embolization (DTE) time are unclear. This study investigated how DTE time affects outcomes in patients with severe pelvic fracture.

Methods

Using a trauma database between November 1, 2015 and December 31, 2019, trauma patients undergoing TAE were retrospectively reviewed. The final study population included 192 patients treated with TAE. The relationships between DTE time and patients’ outcomes were evaluated. Multiple binomial logistic regression analyses, multiple linear regression analyses, and Cox hazard proportional regression analyses were performed to estimate the impacts of DTE time on clinical outcomes.

Results

The median DTE time was 150 min (interquartile range, 121–184). The mortality rates in the first 24 h and overall were 3.7% and 14.6%, respectively. DTE time served as an independent risk factor for mortality in the first 24 h (adjusted odds ratio = 2.00, 95% confidence interval [CI] = 1.20–3.34, p = 0.008). In Cox proportional hazards regression analyses, the adjusted hazard ratio of DTE time for mortality at 28 days was 1.24 (95% CI = 1.04–1.47, p = 0.014). In addition, there was a positive relationship between DTE time and requirement for packed red blood cell transfusion during the initial 24 h and a negative relationship between DTE time and ICU-free days to day 28.

Conclusion

Shorter DTE time was associated with better survival in the first 24 h, as well as other clinical outcomes, in patients with complex pelvic fracture who underwent TAE. Efforts to minimize DTE time are recommended to improve the clinical outcomes in patients with pelvic fracture treated with TAE.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01601-7.

Angioembolization in intra-abdominal solid organ injury: Does delay in angioembolization affect outcomes?

INTRODUCTION

Angioembolization (AE) is an integral component in multidisciplinary algorithms for achieving hemostasis in patients with trauma. The American College of Surgeons Committee on Trauma recommends that interventional radiologists be available within 30 minutes to perform emergent AE. However, the impact of the timing of AE on patient outcomes is still not well known. We hypothesized that a delay in AE would be associated with increased mortality and higher blood transfusion requirements in patients with blunt intra-abdominal solid organ injury.

METHODS

A 4-year (2013-2016) retrospective review of the ACS Trauma Quality Improvement Program database was performed. We included adult patients (age, ≥18 years) with blunt intra-abdominal solid organ injury who underwent AE within 4 hours of hospital admission. Patients who underwent operative intervention before AE were excluded. The primary outcome was 24-hour mortality. The secondary outcome was blood product transfusions. Patients were grouped into four 1-hour intervals according to their time from admission to AE. Multivariate regression analysis was performed to accommodate patient differences.

RESULTS

We analyzed 1,009,922 trauma patients, of which 924 (1 hour, 76; 1-2 hours, 224; 2-3 hours, 350; 3-4 hours, 274) were deemed eligible. The mean ± SD age was 44 ± 19 years, and 66% were male. The mean ± SD time to AE was 144 ± 54 minutes, and 92% of patients underwent AE more than 1 hour after admission. Overall 24-hour mortality was 5.2%. On univariate analysis, patients receiving earlier AE had decreased 24-hour mortality (p = 0.016), but no decrease in blood products transfused. On regression analysis, every hour delay in AE was significantly associated with increased 24-hour mortality (p < 0.05).

CONCLUSION

Delayed AE for hemorrhagic control in blunt trauma patients with an intra-abdominal solid organ injury is associated with increased 24-hour mortality. Trauma centers should ensure timeliness of interventional radiologist availability to prevent a delay in vital AE, and it should be a focus of quality improvement projects.

LEVEL OF EVIDENCE

Prognostic, level III.

Immobilisation du bassin par contention externe dans la prise en charge des traumatisés sévères : évaluation des pratiques professionnelles

Introduction : En traumatologie, la ceinture pelvienne stabilise le bassin en réduisant le volume pelvien, ce qui permet de tamponner l’hémorragie. L’objectif principal de l’étude était d’évaluer le respect des indications théoriques de pose de ceinture pelvienne dans la prise en charge des traumatisés sévères en préhospitalier.

Méthode : Une étude rétrospective, monocentrique, observationnelle a été réalisée en 2017–2018 afin d’évaluer les pratiques professionnelles en termes de respect des indications d’immobilisation et la fiabilité de l’évaluation clinique. Les critères d’inclusion étaient les interventions prenant en charge des patients pour accident de la route ou chute. L’analyse de la concordance entre pose de ceinture pelvienne et indication théorique a été réalisée avec un test du kappa de Cohen. L’intensité de la liaison entre cette évaluation et la confirmation d’une fracture par tomodensitométrie a été analysée par le coefficient Q de Yule.

Résultats : Cent soixante-seize dossiers ont été analysés, dont 98 ont été inclus dans l’étude. La ceinture a été posée chez 26 % d’entre eux. Le coefficient d’agrément kappa de Cohen était de à 0,08, avec un pourcentage d’agrément de 57 %. L’intensité de la liaison entre l’évaluation clinique et la présence d’une fracture à la tomodensitométrie était très forte avec un coefficient de Q de Yule calculé à 0,92.

Conclusion : Il n’y avait pas d’agrément entre l’indication théorique et la décision de poser la ceinture démontrant un recours insuffisant à la contention pelvienne lors de la prise en charge des patients traumatisés sévères en préhospitalier.

Pelvic angioembolization: how urgently needed?

Purpose

Angioembolization (AE) has been questioned as first-line modality for hemorrhage control of pelvic fracture (PF)-associated bleeding due to its potential inconsistent timely availability. We aimed to describe the patterns of AE use with hemostatic resuscitation and hypothesized that time to AE improved during the study period.

Methods

A Level-1 trauma center’s prospective PF database was analyzed. All consecutive PFs referred to angiography between 01/01/2009 and 12/31/2018 were included. All suspected pelvic hemorrhage was managed with AE; pelvic packing was not performed. Demographics, injury/shock severity, 24-h transfusion data, time to AE and mortality were recorded. Data are presented as median (IQR).

Results

During the 10-year study period, 1270 PF patients were treated. Thirty-six (2.8%) [75% male, 49 (33;65) years, ISS 36 (24;43), base deficit 3.65 (5.9;0.6), transfusions 4(2;7)] had AE. The indication for AE was clinical suspicion (CS) of pelvic bleeding [CS 24(67%)] or arterial blush on CT [CT 12 (33%)]. Median time to AE was 141 min for CS, and 223 min for CT, with no change over the study period. Patients with CS had a higher ISS, worse base deficit, greater transfusion requirements and faster time to AE. Five patients (14%) died. There were no deaths attributed to exsanguination.

Conclusions

Time to AE did not improve. Patients referred from CT are physiologically different from CS and should be analyzed accordingly, with CS resulting in faster time to AE in sicker patients. Contemporary resuscitation challenges the need for hyperacute AE as no patients exsanguinated despite time to AE of more than 2 h.

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Background

The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity.

Methods

Medical records of patients with pelvic fracture at a single center between January 2016 and December 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥ 3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups.

Results

Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p = 0.000) and total hospital stay (20.7 vs. 10.1 days, p = 0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear, and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I, and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p = 0.034). These findings were similar even if only patients with ISS ≥ 16 were considered.

Conclusions

Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to the outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.

An analysis of 979 patients with pelvic fractures stratified by the presence or absence of solid organ injury

BACKGROUND

Pelvic fractures (PF) require high force mechanism and their severity have been linked with an increase in the incidence of associated injuries within the abdomen and chest. Our goal is to assess the impact of solid organ injury (SOI) on the outcome of patients with PF and to identify risk factors predictive of morbidity and mortality among these patients.

STUDY DESIGN

We conducted a single-center retrospective review of medical records of patients 16 years or older admitted to our level 1 trauma center with pelvic fracture with and without OI associated from blunt trauma between 1/1/2010-7/31/2015.

RESULTS

979 patients with PF were identified. 261/979 (26.7%) had at least one associated SOI. The grade of the SOI ranged from I to III in 246 patients, grade IV in five patients and grade V in 10 patients with SOI sustained a higher pelvic AIS grade and required a statistically significant greater amount of blood products (BP). Thoracic and urogenital injuries were also more common. The mortality of patients with PF was not affected by the presence of SOI. Increasing age, Injury Severity Score, Glasgow Coma Scale, hypothermia and the amount of BP transfused were predictive of mortality.

CONCLUSIONS

The presence of SOI did not affect the outcome of patients with pelvic fracture, although our results may be linked to the limited number of patients with high grade SOI. The degree of pelvic AIS is predictive of associated injuries within the abdomen and chest.

Bilateral internal iliac artery embolization for pelvic trauma: Effectiveness and safety

INTRODUCTION

Bilateral internal iliac artery embolization (BIIAE) with temporary embolic materials epitomizes damage-control principles in the treatment of exsanguinating hemorrhage from pelvic trauma. However, instances of ischemic complications have been reported. The aim of our study was to assess safety and effectiveness of BIIAE.

METHODS

All patients who received BIIAE for pelvic trauma at a Level I Trauma Center between 1998 and 2018 were reviewed. Effectiveness was assessed by radiographic bleeding control and clinical bleeding control, i.e. stabilization of vital signs and reduction in blood transfusion. Safety was assessed by any evidence for ischemic damage of pelvic organs or tissues.

RESULTS

Of 61 patients undergoing BIIAE, bleeding control was confirmed radiographically in 60 (98%) and clinically in 55 (90%), including 4 (7%) patients who required repeat embolization. Six (10%) patients died due to insufficient pelvic bleeding control. No BIIAE-related complications were identified.

CONCLUSION

The overall clinical effectiveness and safety rates of BIIAE for pelvic bleeding control, when combined with other methods of hemostasis, were 90% and 100% respectively.

Trends and predictors of mortality in unstable pelvic ring fracture: a 10-year experience with a multidisciplinary institutional protocol

Background

Pelvic ring fracture is often combined with other injuries and such patients are considered at high risk of mortality and complications. There is controversy regarding the gold standard protocol for the initial treatment of pelvic fracture. The aim of this study was to assess which risk factors could affect the outcome and to analyze survival using our multidisciplinary institutional protocol for traumatic pelvic ring fracture.

Material and methods

This retrospective study reviewed patients who sustained an unstable pelvic ring fracture with Injury Severity Score (ISS) ≥ 5. All patients were admitted to the emergency department and registered in the Trauma Registry System of a level I trauma center from January 1, 2008, to December 31, 2017. The annular mortality rate after the application of our institutional protocol was analyzed. Patients with different systems of injury and treatments were compared, and regression analysis was performed to adjust for factors that could affect the rate of mortality and complications.

Results

During the 10-year study period, there were 825 unstable pelvic ring injuries, with a mean ISS higher than that of other non-pelvic trauma cases. The annual mortality rate declined from 7.8 to 2.4% and the mean length of stay was 18.1 days. A multivariable analysis showed that unstable initial vital signs, such as systolic blood pressure < 90 mmHg (odds ratio [OR] 2.53; confidence interval [CI] 1.11–5.73), Glasgow Coma Scale < 9 (OR 3.87; CI 1.57–9.58), 24 > ISS > 15 (OR 4.84; CI 0.85–27.65), pulse rate < 50 (OR 11.54; CI 1.21–109.6), and diabetes mellitus (OR 3.18; CI 1.10–9.21) were associated with higher mortality. No other specific system in the high Abbreviated Injury Scale increased the rates of mortality or complications.

Conclusion

Poor initial vital signs and Glasgow Coma Scale score, higher ISS score, and comorbidity of diabetes mellitus affect the mortality rate of patients with unstable pelvic ring fractures. No single system of injury was found to increase mortality in these patients. The mortality rate was reduced through institutional efforts toward the application of guidelines for the initial management of pelvic fracture.