a b s t r a c t

Introduction: transcatheter arterial embolization is usually necessary in the management of hemodynamically unstable patients with concomitant pelvic fractures. Given the critical conditions of such patients, TAE is at times performed only according to the results of a Primary evaluation without computed tomographic (CT) imaging. Therefore, the evaluation of associated Intra-abdominal injuries (IAIs) might be insufficient. Clinically, some patients have required post-TAE laparotomy due to further deterioration. In this study, we attempted to determine a feasible protocol for post-TAE observation.

Materials and methods: This study focused on patients who received TAE to achieve hemostasis of Retroperitoneal hemorrhage and who did not undergo CT imaging due to their unstable hemodynamics. The characteristics of patients with and without associated IAIs requiring post-TAE laparotomy were compared. We also analyzed the effects of the timing of post-TAE CT imaging on patients with IAIs requiring surgery. Results: A total of 41 patients were enrolled in the study. Of these patients, all of whom underwent primary TAE without preprocedure CT imaging; 15 patients (15/41, 36.6%) required post-TAE laparotomy due to further deterioration. Comparisons between the 2 patient groups revealed no significant differences in the rate of endotracheal intubation (80.0% vs 65.4%, P = .480), loss of consciousness (66.7% vs 73.1%, P = .730), or abdominal symptoms (20.0% vs 23.1%, P = 1.000).

Conclusion: In the management of hemodynamically unstable patients with concomitant Pelvic fractures, greater attention should be paid to associated IAIs. Early CT imaging is encouraged after the patient’s hemodynamic status is stabilized with TAE.

(C) 2014

Introduction

Pelvic fractures are usually caused by high-kinetic-energy blunt trauma. These fractures usually occur with hemorrhage, not only from the Fractured pelvis but also from the presacral venous plexus and/or the iliac vessel branches, which can result in retroperitoneal hemor- rhage and subsequent mortality [1-3]. Transcatheter arterial embo- lization (TAE) serves as an effective alternative to surgery in the management of pelvic fracture-related retroperitoneal hemorrhage [4-6]. Previous reports have indicated that 5% to 20% of patients with pelvic fractures require TAE for retroperitoneal hemostasis [7,8]. However, in many cases, pelvic fracture occurs concurrently with

* Corresponding author. Tel.: +886 3 3281200 3651; fax: 886 3 3285818.

E-mail addresses: [email protected] (C.-Y. Fu), [email protected]

(C.-A. Liao), [email protected] (C.-H. Liao), [email protected] (S.-C. Kang), [email protected] (S.-Y. Wang), [email protected] (Y.-P. Hsu), [email protected] (B.-C. Lin), [email protected] (K.-C. Yuan), [email protected] (I.-M. Kuo), [email protected] (C.-H. Ouyang).

¹ Author contributions: Fu CY and Liao CA contributed equally to this work.

injuries to other organs. Past studies have reported that up to 16.5% of patients with pelvic fractures have associated intra-abdominal in- juries (IAIs) [9]. Although the principles of managing blunt abdo- minal trauma have shifted to Nonoperative management since the advancement of treatment concepts and improvements in diagnostic modalities, laparotomy for IAI is still necessary in some clinical situa- tions [10,11]. Therefore, early diagnosis of associated IAI and detection of the necessity of further laparotomy are both necessary in the management of patients with pelvic fractures.

According to the concept of Advanced Trauma Life Support guideline, the controlling of Life-threatening hemorrhage takes prio- rity over the treatment of other injuries. Furthermore, the definitive hemostasis should be decided and performed primarily for the patients with unstable hemodynamics under such critical condition. Therefore, when the cavitary hemorrhage, which requires operation, is excluded by the primary examination (sonographic examination), the TAE should be considered for the retroperitoneal hemorrhage in the patients with concomitant pelvic fracture and unstable hemody- namics [12,13]. For most of these patients, conservative management, consisting of observation in the intensive care unit (ICU), is

http://dx.doi.org/10.1016/j.ajem.2014.02.013

0735-6757/(C) 2014

appropriate after TAE. However, some patients still require post-TAE laparotomy due to further deterioration.

This study seeks to determine the characteristics of hemodynam- ically unstable trauma patients with pelvic fractures who undergo TAE. Furthermore, we attempt to determine any differences in patients who underwent post-TAE laparotomies to those who did not. Finally, whether time to computed tomography (CT) impacted on patient management is also discussed.

Materials and methods

From May 2008 to September 2012, the trauma registry and medical records of patients with pelvic fractures were reviewed retrospectively. In our institution, the in-house trauma surgeons pro- vide the primary survey and resuscitation, according to the Advanced Trauma Life Support for trauma patients in the emergency depart- ment (ED) [14]. The operating room was available 24 hours per day, and a TAE procedure could be performed within 1 hour. Attend- ing physicians (trauma surgeons and interventional radiologists), appropriate facilities (monitors and rapid-transfusion sets), and a blood bank were available during the procedures.

During the 53-month investigational period, hemodynamically unstable patients with concomitant pelvic fractures were recruited. Hemodynamic instability was defined as systolic blood pressure less than 90 mm Hg without a response to fluid resuscitation of 2000 mL. All such patients were treated using our established protocol (Fig. 1). They received a detailed abdominal physical examination and a sonographic examination during resuscitation. Sonography, per- formed by attending trauma surgeons, was used as an adjunct to the primary survey to evaluate patients for intra-abdominal hemor- rhages [14]. The results of the sonographic examination were used to determine the necessity of laparotomy. Laparotomy was per- formed immediately in patients with positive sonographic exami- nations that indicated intra-Abdominal hemorrhages [15,16]. In

contrast, if hemoperitoneum was excluded by the sonographic examination, the patients received immediate angioembolization for hemostasis [12,13].

This study focused on patients who received TAE for hemostasis of retroperitoneal hemorrhage without undergoing a primary CT scan due to their unstable vital signs. The patients’ demographic characteristics, Abbreviated Injury Scale scores of the pelvis, Injury Severity Score (ISS), numbers of blood transfusions in the ED, hemodynamic status, levels of consciousness, Hemoglobin levels, urine output, and intra-abdominal pressures (IAPs) were recorded routinely in the ICU. The characteristics of patients with and without associated IAIs requiring post-TAE laparotomy were compared. The role of post-TAE CT imaging was discussed and delineated. Further- more, the effects of the timing of CT imaging and further laparotomy after TAE were also analyzed.

All of the data are presented as percentages of patients or means with SDs. The numerical data were compared using Wilcoxon 2-sample exact test with 95% confidence intervals. The nominal data were compared using Fisher exact test with 95% confidence intervals. All of the statistical analyses were performed using the SPSS computer software package (version 13.0; Chicago, IL).

Results

Over the study period, 899 patients were admitted to our insti- tution with diagnoses of pelvic fractures. A total of 69 patients had concomitant pelvic fractures and were hemodynamically unstable without responses to fluid resuscitation of 2000 mL. Twenty-eight of these patients underwent primary laparotomy due to positive sonographic examinations indicating intra-abdominal hemorrhages. The other 41 patients who were unable to receive a CT scan eval- uation due to their unstable hemodynamics were enrolled in our study. These patients received primary TAE without CT imaging after intra-abdominal hemorrhage was excluded by sonographic

Fig. 1. The established protocol in this study for the management of hemodynamically unstable patients with concomitant pelvic fractures.

examination. The mean age of the 41 patients enrolled was 41.0 +-

26.6 years old. Of these patients, 28 were male (68.3%), and 13 were

female (31.7%).

The patient distribution for the study is displayed in Fig. 1. In the patients who received primary TAE, 26 patients (26/41, 63.4%) could be observed in the ICU conservatively, without requiring any other intervention. In contrast, 15 patients (15/41, 36.6%) required post-TAE laparotomy due to further deterioration. Of these patients, 80% (12/15) received endotracheal tube intubation, and 66.7% (10/15) experienced loss of consciousness during the primary eval- uation in the ED. Furthermore, only 20% (3/15) of the patients had abdominal symptoms. Compared with the patients who did not require laparotomy after TAE, there were no significant differences in the rate of endotracheal intubation (80.0% vs 65.4%, P = .480), loss of consciousness (66.7% vs 73.1%, P = .730), or abdominal symptoms (20.0% vs 23.1%, P = 1.000). In addition, the patients who required post-TAE laparotomy had significantly higher AIS scores (4.1 +- 2.5 vs 3.4 +- 2.0, P = .044), ISS (28.7 +- 19.6 vs 15.7 +-

4.8, P = .012), and post-TAE IAP (19.5 +- 13.7 vs 7.5 +- 12.2, P =

.006) than the patients who did not require post-TAE laparotomy (Table 1).

In our study, 30 patients (30/41, 73.2%) received post-TAE CT imaging for further evaluation after they were hemodynamically stable post-TAE. Fig. 2 displays the distribution of the timing of post- TAE CT imaging. Nine (30%) of these patients underwent CT imaging within 6 hours after TAE, and 12 (40%) of these patients underwent CT imaging more than 24 hours after TAE. Moreover, of the patients who received post-TAE laparotomy (n = 15), 7 (46.7%) underwent surgery within 6 hours after TAE, and 6 (40%) underwent surgery more than 24 hours after TAE. Table 2 demonstrates that the patients who underwent surgery more than 24 hours after TAE had significantly larger Blood transfusion requirements (3291.7 +- 1474.2 vs 1625.0 +- 530.3 vs 1035.7 +- 723.4 mL, P = .023), longer ICU

length of stay (LOS) (12.3 +- 8.4 vs 4.5 +- 7.7 vs 6.9 +- 6.0 days, P =

.009), and longer hospital LOS (24.8 +- 11.5 vs 12.0 +- 5.66 vs 18.7 +-

7.4 days, P = .002).

The indications for surgery and the intraoperative findings for the post-TAE laparotomies are shown in Fig. 3. Of the 15 patients displayed in Fig. 3, 8 (53%), 2 (13%), 1 (7%), 1 (7%), and 3 (20%) of them underwent post-TAE laparotomy due to small bowel perfora-

Table 1

Comparisons between the patients with and without IAIs requiring post-TAE laparotomies

12

9

7

7

6

2

2

0

<6 hours 6~12 hours 12~24 hours >24 hours Timing of post-TAE CT scan Timing of post-TAE laparotomy

Fig. 2. The distributions of patients with different timing of post-TAE CT imaging and laparotomy.

tion, colon perforation, bladder rupture, splenic injury and Mesenteric injuries, respectively (Fig. 3).

Discussion

Pelvic fractures are the result of excessive force applied to the human body, and they can cause extensive retroperitoneal hemor- rhage [17,18]. In 90% of patients, pelvic fractures are associated with injuries to other important organs [19,20]. Therefore, the manage- ment of patients with pelvic fractures continues to pose a challenge to physicians.

In the management of patients with pelvic fractures, abdominal/ pelvic CT imaging has been used worldwide in recent decades [21,22]. In contrast to conventional x-rays, CT imaging can improve the detection of small fractures, IAIs, and/or active Arterial hemorrhage. Based on the results of CT imaging (contrast extravasation or Retroperitoneal hematoma), the TAE, which is the standard method for the management of retroperitoneal hemorrhage, might be sub- sequently performed [5,6,23,24]. Practically, CT imaging has been considered to be an adjunct or a secondary survey that can be per- formed in patients in stable condition [13]. However, a pelvic frac- ture can result in hemodynamic instability in 5% to 20% of patients [7,8,17]. For those patients who are hemodynamically unstable, a definitive hemostatic procedure should be determined first, and time- consuming CT imaging might not seem appropriate. These patients can only be evaluated with primary tools, such as sonography. In the management of hemodynamically unstable patients with con-

Variables IAI required

laparotomy (+) (n = 15)

IAI required P

laparotomy (-) (n = 26)

comitant pelvic fractures, TAE has been performed without prepro-

Age 39.1 +- 22.4 42.1 +- 17.9 .978^a

Sex, n (%) .734^b

Female 4 (26.7%) 9 (34.6%)

Male 11 (73.3%) 17 (65.4%)

GCS (score) 9.4 +- 5.2 10.1 +- 8.5 .524^a

Table 2

Comparisons among different timings of post-TAE operations in the patients with IAIs who required laparotomies (n = 15)

Variables b6 h (n = 7) 6-24 h (n = 2) N 24 h (n = 6) P

Intubation in ED, n (%) Yes	12 (80.0%)	17 (65.4%)	.480b	Age Sex, n (%)	39.1 +- 22.4	42.1 +- 17.9	42.1 +- 17.9	.978a .277b
No	3 (20.0%)	9 (34.6%)		Female	1 (14.2%)	0 (0%)	3 (50%)
Loss of consciousness (GCS <=13), n (%)			.730b	Male	6 (85.8%)	2 (100%)	3 (50%)
Yes	10 (66.7%)	19 (73.1%)		AIS (score)	3.9 +- 2.1	4.0 +- 0.0	4.5 +- 2.4	.899a
No	5 (33.3%)	7 (26.9%)		ISS (score)	17.1 +- 13.2	33.0 +- 11.3	40.8 +- 22.4	.022a
Abdominal symptoms, n (%)			1.000b	Blood transfusion	1035.7 +- 723.4	1625.0 +- 530.3	3291.7 +- 1474.2	.023a
Yes	3 (20.0%)	6 (23.1%)		(mL)
No (or could not be checked)	12 (80.0%)	20 (76.9%)		ICU LOS	6.9 +- 6.0	4.5 +- 7.7	12.3 +- 8.4	.009a
AIS (score)	4.1 +- 2.5	3.4 +- 2.0	.044a	Hospital LOS	18.7 +- 7.4	12.0 +- 5.66	24.8 +- 11.5	.002a
ISS (score)	28.7 +- 19.6	15.7 +- 4.8	.012a	Outcome, n (%)				1.000b
Blood transfusion (mL)	2016.7 +- 889.1	1990.4 +- 934.7	.995a	Mortality	2 (28.6%)	0 (0%)	1 (16.7%)
Post-TAE IAP (mm Hg)	19.5 +- 13.7	7.5 +- 12.2	.006a	Survival	5 (71.4%)	2 (100%)	5 (83.3%)

Variables are expressed as means +- SDs. Abbreviation: GCS, Glasgow Coma Scale.

^a Wilcoxon rank sum test.

^b Fisher exact test.

Variables are expressed as means +- SDs.

^a Wilcoxon rank sum test.

^b Fisher exact test.

Bladder rupture (N = 1)

7%

Splenicinjury (N = 1)

7%

Mesentery injuries (N = 3)

20%

sepsis [26,27]. The Timely diagnosis of IAIs depends on early detec- tion by CT imaging because the clinical signs and symptoms of these injuries are not specific and are usually late to develop. The need to operate could be detected earlier based on CT imaging. In this study, comparisons of outcomes among patients with different timing of post-TAE CT imaging could not be performed due to discrepancies in subsequent treatment after post-TAE CT imaging. However, the comparisons of patients with different timings of post-TAE laparot-

Colonperforation (N=2) 13%

Smallbowel perforation (N = 8)

53%

omy showed that the patients who underwent the earlier surgery had significantly better clinical course after the post-TAE laparotomy (Table 2). Although the comparison of mortality rates showed no significant differences among patients with different post-TAE lapa- rotomy timing, this result might have been limited by the small number of cases. Therefore, in the management of hemodynamically unstable patients with concomitant pelvic fractures, early CT imaging should be considered after the patient is hemodynamically stabilized by TAE.

In addition to the hemodynamic status of the patients, the IAP should also be closely monitored during the post-TAE observation period. Retroperitoneal hemorrhage related to pelvic fracture can result in the formation of large hematomas in the intra-abdominal space. Intra-Abdominal injury-related hemoperitoneum or ascites

Fig. 3. The distribution of indications for surgery and the intraoperative findings in the

patients who underwent post-TAE laparotomy.

cedure CT imaging, after excluding the intra-abdominal hemorrhages requiring emergency surgery [12,14]. As a result, the evaluation of associated IAIs was not sufficient in these situations. Such patients should be monitored closely during the post-TAE observation period. Further evaluation should be considered after the patient is hemodynamically stable.

In this study, an associated IAI requiring post-TAE laparotomy occurred in 36.6% (15/41) of all of the patients. The operations and laparotomic procedures for these patients were performed based on the results of post-TAE CT imaging (Fig. 1). However, there were no clear physician guidelines available to guide the decision to order CT imaging during the post-TAE observation period, so post-TAE CT imaging was performed based on the physicians’ clinical judgment or the patients’ complaints of abdominal symptoms. Unfortunately, hemodynamically unstable patients are usually initially intubated in the ED. In addition, up to 16.9% of patients with pelvic fractures are reported to have concomitant head injuries, leading to loss of consciousness [25]. This state makes it difficult for patients describe their symptoms clearly. Furthermore, patients’ reports of abdominal symptoms can be unreliable, as the lower abdominal pain related to pelvic fractures sometimes mimics the symptoms of peritonitis. Table 1 reveals that it is difficult to identify patients with associated IAIs during the primary evaluation because of their nonspecific clinical presentations. The possibility of missing a diagnosis presents physicians with a dilemma in the evaluation of hemodynamically unstable patients with concomitant pelvic fractures. However, CT imaging can provide sufficient and accurate information for the evaluation of associated IAIs. Post-TAE CT imaging is recommended because of the high rates of associated IAIs and the difficulties in diagnosing IAIs during primary evaluation.

Another concern is the timing of post-TAE CT imaging. We agree

that greater priority should be placed on the control of retroperitoneal hemorrhage in the management of hemodynamically unstable patients with concomitant pelvic fractures. However, any associated IAIs should also be treated as soon as possible after hemodynamic stabilization. The decision to operate was based on the results of CT imaging; thus, the timing of CT imaging played a key role in the timing of the operations. In other words, delayed CT imaging could delay diagnosis and further treatment. It has been reported that delayed diagnosis of a bowel or mesenteric injury resulted in significant morbidity and mortality from hemorrhage, peritonitis, or abdominal

secondary to fluid resuscitation can lead to IAP elevation. Further- more, the tissue swelling related to resuscitation or intra-Abdominal infection can also contribute to the elevation of IAP [28,29]. In this study, the patients who underwent post-TAE laparotomy due to associated IAIs had significant higher IAP values than the patients who did not undergo post-TAE laparotomy (19.5 +- 13.7 vs 7.5 +- 12.2 mm Hg, P = .006) (Table 1). Therefore, an elevated IAP value could be an objective sign of an associated IAI. Frequent measurement of IAP is necessary during the post-TAE observation period.

Fig. 3 displays the distributions of patients with IAIs who re- quired laparotomy. Most of these patients had bowel perforation, which usually presented with minimal intra-abdominal fluid accumulation or isolated abdominal pain. Therefore, these conditions were difficult to diagnose during the primary evaluation, which included History taking or a sonographic examination. In contrast, diagnosis of bowel perforation can depend on whether intra- abdominal Free air is seen on CT imaging [30,31]. In contrast, 1 patient required post-TAE laparotomy due to a ruptured splenic pseudoaneurysm. In this patient, the injury was initially confined to the parenchyma of the spleen without hemoperitoneum. Therefore, the IAI could not be detected with sonography during the primary evaluation. However, after the patient was noted to experience a persistent drop in hemoglobin level in the ICU, the ruptured pseudoaneurysm was diagnosed with subsequent CT imaging. The above reasons indicate the difficulties in primary IAI detection and the necessity of early post-TAE CT scans.

The management of hemodynamically unstable patients with concomitant pelvic fractures is difficult. Of these patients, relatively rare cases require post-TAE laparotomy, which made it difficult to recruit a large number of subjects for this study. We recognize the limitations of this study, including its retrospective nature and the small number of cases examined. Possible selection bias might limit our conclusions. However, the results of this study demonstrate the benefit of post-TAE CT imaging for hemodynamically unstable patients with concomitant pelvic fractures. Further studies, with larger sample sizes and prospective designs, are warranted to establish algorithms for Prompt diagnosis and precise treatment plans in the ED.

Conclusion

In the management of hemodynamically unstable patients with concomitant pelvic fractures, greater attention should be paid to the associated IAIs. Early CT imaging is suggested after the patient is

hemodynamically stabilized with TAE. Patients with more severe extra-abdominal or pelvic-Associated injuries and elevated post-TAE IAP values are of greater concern due to their higher probability of requiring post-TAE laparotomy.

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