American Journal of Emergency Medicine (2012) 30, 342-346

Brief Report

Early embolization without external fixation in pelvic trauma

Shinsuke Tanizaki MD ^a,?, Shigenobu Maeda MD ^a, Hiroyuki Hayashi MD ^a,

Hideyuki Matano MD ^a, Hiroshi Ishida MD ^a, Jun Yoshikawa MD ^b, Toru Yamamoto MD ^b

^aDepartment of Emergency Medicine, Fukui Prefectural Hospital, Fukui 910-8526, Japan

^bDepartment of Radiology, Fukui Prefectural Hospital, Fukui 910-8526, Japan

Received 24 September 2010; revised 28 October 2010; accepted 29 November 2010

Abstract

Purposes: In this retrospective study, we reviewed our protocol consisting of early embolization without acute external fixation in patients with pelvic fracture.

Patients and Methods: Eighty-eight patients with pelvic fracture were identified by reviewing the records of the Fukui Prefectural Hospital from April 2005 through September 2009. We managed the patients with a treatment protocol consisting of Hemodynamic resuscitation and early pelvic embolization. Patients with hemodynamic instability without nonpelvic hemorrhage or extravasation of contrast in the pelvis by computed tomography (CT) were indicated to angiography and embolization. External fixation of the pelvic ring was not used in our protocol.

Results: Of the 88 patients with pelvic fractures, 43 underwent angiography. Twenty-eight patients (65%) were hemodynamically unstable. Twenty-five patients (58%) had major ligamentous disruption. Computed tomography detected extravasation in 21 patients (48%). Of the 43 patients who underwent angiography, 29 (67%) were positive. The average time from hospital arrival to angiography was 76.3 +-

34.5 minutes. The packed red blood cell requirement in the initial 24 hours was 8.4 +- 8.2 U, required in the embolization group. There was no complication-related embolization. Repeat angiography was not required in all patients. The mortality rate of patients requiring angiography was 11%.

Conclusions: Early pelvic embolization without external fixation may be useful for the initial treatment for patients with hemodynamic instability without nonpelvic hemorrhage or with extravasation of contrast in the pelvis by CT.

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Introduction

The management of unstable patients with pelvic fracture is a multidisciplinary challenge with high mortality and remains a controversial issue [1-3]. Hemorrhage due to disruption of the surrounding venous and arterial vessels is

* Corresponding author. Tel.: +81 776 54 5151; fax: +81 776 57 2991.

E-mail address: [email protected] (S. Tanizaki).

the leading cause of death in these patients and requires prompt therapy aimed at hemostasis [1,2].

The combination of angiography and embolization of bleeding arterial vessels has emerged as an excellent management method [4]. External fixation has been shown to reduce venous bleeding from pelvic soft tissue, pelvic veins, and fracture ends. Although both modalities are vital to improve outcomes in hemodynamically unstable patients with pelvic fracture, the optimal order of external fixation and angiography continues to be a matter of debate. Some have used angiography without external

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Pelvic angiography“>fixation if hemodynamic instability persisted despite volume resuscitation for 24 hours [4-6]. Angiography within 90 minutes with external fixation was reported [7]. This retrospective study analyzed our protocol consisting of early embolization without acute external fixation in patients with pelvic fracture.

Patients and methods

Methods

We conducted a review of a consecutive series of 88 trauma patients with pelvic ring fractures who were admitted to Fukui Prefectural Hospital from April 1, 2005, through September 30, 2009. The patients were transported to the hospital by ground transportation or by helicopter. The patient data were obtained from the hospital records. Patients with any pelvic fractures were included in this study. Data examined included age, injury character- istics and injury severity score (ISS), systolic Blood pressure and heart rate on arrival, response to Initial resuscitation, transfusion requirement, contrast blush on initial computed tomography (CT), and Fracture pattern. The fractures were classified according to the Young- Burgess classification [8]. Major ligamentous disruption was defined as anteroposterior compression type II and type III, lateral compression type III, combined mechanism, and vertical shear. Abbreviated Injury Scale 1990-Update 98 was used to calculate ISS.

Table 1 Demographic and clinical characteristics of patients with pelvic fractures

General management

The treatment protocol established for all patients included an initial evaluation and volume resuscitation in the emergency department (ED). focused assessment with sonography for trauma examination was performed to detect hemoperitoneum, massive hemothorax, or hemopericardium. An anteroposterior chest radiograph was obtained to exclude intrathoracic injury. clinical examinations of the pelvis and anteroposterior pelvic radiographs were used to determine whether the patient had a pelvic fracture and to assess the fracture pattern. If hemodynamic stability permitted radio- graphic workup, CT scanning of the whole body was performed. Patients with Arterial extravasation on the contrast-enhanced pelvis CT underwent angiography and embolization. If patients were hemodynamically unstable with only pelvic hemorrhage, angiography and embolization were performed immediately. Hemodynamic instability was defined as systolic arterial pressure less than 90 mm Hg after an infusion of 2 L of lactated Ringers. External fixation of the pelvic ring was not used in our protocol. Laparotomy was indicated by concomitant hemodynamic instability and progressive Abdominal effusion or by the existence of a pneumoperitoneum.

Pelvic angiography

Angiography was performed using the femoral puncture approach. A pelvis flush was performed at the aortic bifurcation level after an abdominal flush. Thoracic aortography was performed in the case of severe chest trauma. Embolization agents included gelfoam and steel coils. Gelfoam of about 3 mm in each dimension diluted in contrast medium was injected to avoid permanent Arterial occlusion. The signs of Vascular injury, such as contrast extravasation, vasospasm, pseudoaneurysm, and arteriove- nous fistula, were reasons for embolization. Bleeding sites were directly identified to be controlled with embolization. Selective embolization of discrete bleeding sites was performed with gelfoam. Nonselective embolization of the internal iliac artery was performed in patients with multiple bleeding areas. Embolization with steel coils was performed in patients with pseudoaneurysm, arteriovenous fistula, or bleeding that was difficult to arrest with gelfoam. Comple- tion angiography was necessary to stabilize the hemody- namic status of the patients and was not used exclusively to confirm the cessation of bleeding radiographically.

Characteristic	With angiography (n = 43)	Without angiography (n = 45)	P
Age (y) Male sex (%) Admission SBP (mm Hg) Admission HR (beats per min) Transient/no response to resuscitation (%) ISS Mechanism (%) Fall Pedestrian injury MVC Pelvic fracture pattern (%) Major ligamentous disruption Positive angiography The average time from hospital arrival to angiography (min) The PRBC requirement in the initial 24 h (U) ICU length of stay (d) Mortality (%)	58.4 +- 22.5	55.8 +- 27.2	NS
	20 (46.5)	18 (40.0)	NS
	103.2 +- 25.9	124.2 +- 29.3	b.01
	91.6 +- 20.6	91.2 +- 17.2	NS
	28 (65.1)	2 (4.7)	b.01
	24.3 +- 11.1	13.8 +- 10.6	b.001
	10 (23.2)	16 (35.5)	NS
	16 (37.2)	7 (15.5)	b.05
	10 (23.2)	7 (15.5)	NS
	25 (58.1)	0 (0)	b.001
	29 (67.4)	-	-
	76.3 +- 34.5	-	-
	8.4 +- 8.2	1.8 +- 6.6	b.001
	5.43 +- 4.86	0.92 +- 2.67	b.001
	5 (11.6)	3 (6.6)	NS
NS indicates nonsignificant; SBP, systolic blood pressure; HR, heart rate; MVC, motor vehicle crash; PRBC, packed red blood cell; ICU, intensive care unit.

Statistical analysis

All data in the tables are presented as mean +- SD, unless otherwise specified. Demographic discontinuous variables were compared using the ?2 test. Continuous variables were compared using Student t test. Significance was defined as P b .05.

Results

During the 4.5-year period, 88 patients with pelvic fractures were treated in the Fukui Prefectural Hospital. Forty-three patients underwent angiography. The mean patient age was 58 +- 22 years, and sex distribution was

20 men and 23 women (Table 1; Fig. 1). Twenty-eight patients (65%) were hemodynamically unstable. The ISS was 24.3 +- 11.1. Of the patients, 25 (59%) had major ligamentous disruption, and all of them had lateral compression type III (Table 2). Eighteen patients (41%) with angiography did not have major ligamentous disrup- tion. Open pelvic fracture was observed in 1 patient. All injuries were the result of blunt trauma; the mechanisms included 16 (37%) pedestrians struck by motor vehicles, 10 (23%) falls from a height, and 10 (23%) motor vehicles

crashes. Computed tomography detected extravasation in 21 patients (48%). The sensitivity and specificity in predicting arterial bleeding in patients with extravasation of intrave- nous contrast by CT were 68.9% and 92.3%, respectively. Associated extrapelvic injuries were as follows: 14 (15%) intracranial injuries, 28 (31%) intrathoracic injuries, 10

(11%) Intra-abdominal injuries, and 6 (6%) extremity

injuries (Table 3).

Of the 43 patients who underwent angiography, 29 (67%) were positive. Multiple arteries were injured in 17 patients (40%). Embolization with steel coils was performed in 7 patients (16%). Embolization was required to 25 unstable patients with Unstable fractures (58%). The average time from hospital arrival to angiography was 76.3 +- 34.5 minutes. The packed red blood cell requirement in the initial 24 hours was 8.4 +- 8.2 U, required in the embolization group. There was no complication-related embolization, such as the gluteal muscle and Skin necrosis, necrosis of the vesical wall, or urogenital complication. Repeat angiography was not required in all patients.

Two patients with positive focused assessment with sonography for trauma examination were treated with the same embolization because of intra-abdominal effusion due to splenic injury. Five patients (11%) died. One patient death was the result of an exsanguinated pelvic fracture. The other 4 deaths were related to multiple-

Angiography 43(49%)

Conservative 45(51%)

Pelvic Fractures (n = 88)

Negative Angiography 14(33%)

Embolization 29(100%)

Positive Angiography 29(67%)

Named vessel 12(42%)

Multiple vessels 17(58%)

Fig. 1 Management algorithm of patients with pelvic fractures.

Table 2 The breakdown of pelvic fracture type and number of fractures per pelvis

n (%)

Pelvic fracture type Anteroposterior compression

Type I Type II Type III

Lateral compression Type I

Type II Type III Vertical shear

Combined mechanism No. of fractures per pelvis 1

2

3

4

5

6

7

8

2 (2.2)

0 (0)

0 (0)

42 (47.7)

19 (21.5)

25 (28.4)

0 (0)

0 (0)

28 (31.8)

15 (17.0)

12 (13.6)

5 (5.6)

14 (15.9)

3 (3.4)

8 (9.0)

3 (3.4)

organ failure with acute respiratory distress syndrome (Table 1).

Discussion

Early identification and control of pelvic hemorrhage are pivotal to decreasing pelvic fracture-related mortality [4,6,9]. This hemorrhage can originate from injury to arteries, injury to the venous plexus in the pelvis, and fracture bleeding. The most common methods for arresting pelvic bleeding are external fixation of the pelvic fracture and angiography for the identification and embolization of pelvic bleeding.

External fixation has been shown by many authors to aid in venous Hemorrhage control and to improve survival, although the reason why pelvic stabilization is effective is not completely clear. Some have proposed that closure of the pelvis reduces pelvic volume, thereby limiting the amount of bleeding to the Retroperitoneal hematoma and promoting tamponade of the bleeding [10]. Other proposed mechanisms include the reduction of bleeding by returning the bony pelvis components back into apposition, promotion of hemostasis by preventing clot dislodgement, reinitiation of the thrombotic process, and consumption of clotting factors [11]. All of these mechanisms may play complimentary roles in the efficacy of external fixation in controlling bleeding.

Angiographic embolization is considered by most authors to be the optimal method for controlling Arterial hemorrhage [4-6,12]. Some found early embolization to be associated with improved outcome [5]. For this reason, markers for the

early identification of patients likely to have arterial bleeding are important. Fracture pattern and its relationship to outcome have been examined. Some have demonstrated that patients requiring embolization were significantly more likely to have fracture patterns associated with major ligamentous disruption [13,14]. Others showed no clear relationship between fracture pattern and arterial bleeding [15]. The decision to obtain angiography based on fracture pattern alone would lead to a very low yield. We used angiography in the face of hemodynamic instability, even if there were no fracture patterns associated with major ligamentous disruption.

Extravasation of intravenous contrast on CT scan has been examined as a method of determining the presence of arterial bleeding and the need for angiography [15,16]. This method has been found to be a reliable marker with sensitivities from 80% to 84% and specificities from 85% to 98% [17,18]. Our study showed that contrast blush on CT was a specific sign of arterial bleeding. Transferring hemodynamically unstable patients to the CT scanner increases some risk. Agolini et al [5] reported that patients who were embolized within 3 hours of arrival had a significantly greater survival rate. The Probability of death increased approximately 1% for every 3 minutes of hemodynamic instability that elapsed without hemorrhage control in the ED [19]. Hemodynamically unstable patients without nonpelvic bleeding sources were transported to an angiography suite as soon as possible.

Angiography might inhibit the simultaneous treatment of extrapelvic injuries [16]. Our study showed that extrapelvic hemorrhage could be treated during the same angiography. When angiography is performed as a First-line treatment, hepatic and splenic injury can be treated with embolization. Embolization has been demonstrated as an effective means of controlling bleeding caused by abdominal and pelvic injuries that are difficult to manage with surgery [12].

Complications of embolization have been reported in limited case-series studies. Our data showed no complication- related embolization, even using bilateral internal iliac artery embolization, as shown by other previous reports [12]. Gelfoam of about 3 mm in each dimension (which is larger than the previously reported 2 mm) was the occluding agent of choice [20,21]. This may help to occlude the larger branches of the internal iliac artery temporarily, while leaving the smaller branches open to collateral blood flow, as well as to avoid significant ischemia. The reasons why there was no complication-related embolization may be that larger

Table 3 Number of associated extrapelvic injuries

Associated extrapelvic injuries	n (%)
Intracranial injuries	14	(15.9)
Intrathoracic injuries	28	(31.8)
Intra-abdominal injuries	10	(11.3)
extremity injuries	6	(6.8)

gelfoam was used and that completion angiography was not always necessary to confirm the cessation of bleeding radiographically.

This study has limitations, the greatest being the small sample size. We had difficulty in reaching many patients because our institution was a Rural hospital in Japan.

In summary, the present study suggests that early pelvic embolization without acute external fixation to pelvic fracture may be useful for the initial treatment for patients with hemodynamic instability without nonpelvic hemorrhage or with extravasation of contrast in the pelvis by CT. In the future, prospective randomized trials comparing the protocols of external fixation with angiog- raphy would be required to determine the effectiveness of the method.

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