Brief Report
Angioembolization provides benefits in patients with concomitant unstable pelvic fracture and unstable hemodynamics

https://doi.org/10.1016/j.ajem.2010.11.005Get rights and content

Abstract

Introduction

Pelvic fractures result in hemodynamic instability in 5% to 20% of patients, and the reported mortality rate is 18% to 40%. Previous studies have reported the application of angioembolization in pelvic fracture patients with a systolic blood pressure (SBP) less than 90 mm Hg, a fluid resuscitation requirement of more than 2000 mL, or a blood transfusion of more than 4 to 6 units within 24 hours. In the current study, we attempted to delineate the efficacy and outcome of angioembolization in unstable pelvic fracture patients with concomitant unstable hypotension status.

Methods

We retrospectively reviewed the charts of patients with pelvic fractures between January 2005 and May 2010. We focused on unstable pelvic fracture patients with an SBP less than 90 mm Hg after fluid resuscitation who did not receive computed tomography scans. The demographics, injury severity score, abbreviated injury scale, and hemodynamic status after angioembolization were analyzed.

Results

In total, 26 patients were enrolled. There were 16 patients receiving angioembolization directly without computed tomography scans and 12 patients receiving emergency laparotomy due to a finding of hemoperitoneum on sonography, followed by angioembolization. In both groups, the SBP improved significantly after angioembolization. The overall survival rate was 85.7%.

Conclusions

In patients with concomitant unstable hemodynamics and unstable pelvic fracture, angioembolization serves as an effective adjunct to hemostasis. Aggressive embolization should be performed even in patients without contrast extravasation in angiography.

Introduction

Pelvic fractures account for approximately 3% of all skeletal injuries following blunt trauma, usually trauma with high kinetic energy. Several reports have indicated that most pelvic fractures result from motor vehicle accidents [1], [2], [3], [4], [5]. It has been reported that 10% to 15% of hemorrhages related to pelvic fracture are arterial, and the most-often identified source in angiography is the internal iliac system, with damage to the pudendal (anterior) and superior gluteal (posterior) arteries [6], [7], [8], [9]. Pelvic fracture may result in hemodynamic instability in 5% to 20% of patients, and the subsequent reported mortality rate is 18% to 40% [10], [11], [12], [13], [14], [15].

Pelvic fracture is a marker for excessive force applied to the human body and is often associated with extrapelvic hemorrhage from other injuries (chest, 15%; intra-abdominal, 32%; long bones, 40%) [16]. For pelvic fracture patients presenting hemodynamic instability, an emergency laparotomy should be performed based on the observance of hemoperitoneum on focused assessment of sonography for trauma (FAST) [17]. However, although there have been few reports of the indication of preperitoneal packing for hemodynamically unstable pelvic fracture, surgical intervention seems to be less effective in the management of fracture-related retroperitoneal hemorrhage [18], [19]. Instead, the combination of pelvic angiography and embolization has been reported as an effective method for controlling retroperitoneal hemorrhage caused by pelvic fractures, and this technique is commonly used to treat fracture-associated retroperitoneal arterial hemorrhage [8], [11], [20], [21]. However, there have been other reports suggesting that angioembolization is appropriate only for hemodynamically stable patients [8], [22], [23]. As a result, the management of retroperitoneal hemorrhage related to pelvic fracture resulting in hemodynamic instability remains a challenge for trauma surgeons and emergency department (ED) physicians. Clinicians thus face a dilemma regarding the application of angioembolization for such patients in the ED.

Previous studies have reported the application of angioembolization in pelvic fracture patients with a systolic blood pressure (SBP) less than 90 mm Hg, a fluid resuscitation requirement of more than 2000 mL, or a blood transfusion of more than 4 to 6 units within 24 hours [5], [24], [25]. However, the condition of patients with hypotension in the ED seems more severe and more dangerous than that of others who can receive a blood transfusion and be observed for 24 hours. To our knowledge, reports on the application of angioembolization in unstable pelvic fractures with hypotension in the acute setting have been scarce to date. Therefore, the purpose of the current study was to evaluate efficacies and outcomes in the treatment of such patients.

Section snippets

Materials and methods

From January 2005 to May 2010, the trauma registry and medical records of pelvic fracture patients at the China Medical University Hospital were reviewed retrospectively. During the 65-month investigational period, pelvic fracture patients were identified and treated according to our established algorithm (Fig. 1). Pelvic x-ray (PXR) was used as an adjunct to the primary survey in patients with suspected pelvic fracture [25]. The Young-Burgess classification system was used to evaluate the

Results

During the 65-month period, 358 patients were admitted to China Medical University Hospital with a diagnosis of pelvic fracture. The patients' distribution is listed in Fig. 2. There were 52 patients diagnosed with unstable pelvic fracture and 306 patients diagnosed with stable pelvic fracture in the initial PXR. In these 52 unstable pelvic fracture patients, there were 34 patients with an initial SBP less than 90 mm Hg after a fluid resuscitation of 2000 mL. There were 18 patients with

Discussion

Pelvic fractures are often associated with a high mortality rate and with chest, abdominal, and pelvic organ injuries [12], [16], [27]. Pelvic fractures can result in hemorrhage from the surface of the fracture site or associated venous structures and in hemorrhage of the retroperitoneal arteries [12], [27]. Therefore, immediate recognition of the presence of a pelvic ring disruption and concomitant vessel injuries can be pivotal during an evaluation of blunt abdominal trauma.

The use of PXR as

Conclusions

In patients with concomitant unstable hemodynamics and unstable pelvic fracture, angioembolization served as an effective adjunct for hemostasis. Because of the probability of a vasospasm effect, aggressive embolization should be performed even in patients without contrast extravasation in angiography.

Acknowledgment

The authors thank Ying Chi Lin and Graduate Institute of Health Service Management, Chang Gung University, for their assistance in statistical analysis.

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