Hemodynamicaly Unstable Pelvic Fractures: Retrospective Review of Early Embolization.
OTA Annual Meeting 2000
"...embolization in conjunction with binding the thighs or skeletal traction may facilitate the resuscitation process and preclude emergent frame application."
Daniel N. Segina, M.D., Samuel G. Agnew, M.D., FACS, Tim Daniel, M.D., Pete Swischuck, M.D., H. Martin Northrup, M.D., Robert Booth, M.D., F.W. Clevenger, M.D., FACS, University of Florida-Jacksonville 655 West 8th Street Jacksonville, Florida 32209
Objectives: To determine the incidence of patients requiring embolization and the correlation with their pelvic injury and vascular lesions and associated morality.
Design: Retrospective retrieval
Setting: Level One Trauma Center-University Hospital
Methods: Review of consecutive series of patients presenting to the Trauma Center with angiographically confirmed arterial injury, and subsequent life saving endovascular embolization prior to any other intervention constitute the study cohort. The time from injury until embolization, mode of embolization and incidence of soft tissue problems were data points sought.
Measures: The patient population identified all sustained some type of pelvic fractures, as classified by the OTA modified of the Tile Classification system. Mechanism of injury-Location of artery-Morality rate was correlated.
Results: Three hundred and sixty five consecutive patients sustaining pelvic fractures exclusively from road or industrial trauma between October 1995 and December 1999 constitute the base population. Using the modified resuscitation protocol described one emergency external fixation frame was applied over the study period. Pelvic fractures were temporized with binding of the thigh (11) or skeletal traction (4) applied on arrival, where appropriate for the injury type.
Fifty-six patients (15%) underwent embolization as a method of acute resuscitation for persistent hemodynamic instability with a negative abdominal ultrasound in Trauma Center. Nineteen patients (33%) underwent therapeutic embolization of bilateral Hypogastric system injuries. Mechanism of injury: MVC (22), Auto vs. Pedestrian (18), Crush (7), Ejection (6), MCC (4) The average time from injury until embolization completion was 3.3 hr. (1.5-5.2). Multiple named vessel injury occurred in 30 (52.6%). Gelfoam and coil combination was utilized in 50/57 procedures. Forty patients (76%) survived the initial trauma and resuscitation, 22 male and 18 female. The nonsurvivors reviewed died from non-hemorrhagic sources in all cases: Brain Injury, MSOF, and sepsis. All patients reviewed sustained significant multi-system trauma with average ISS of 42 (19-66). The skeletal profile of pelvic fractures undergoing resuscitative embolization: Rotationally unstable OTA B type (24), Rotationally and vertically unstable OTA C type (28), and four patients with mechanically stable A type injuries. Those requiring bilateral systems or vessel embolization: Title OTA C type (17) 40%, and B type (5) 8%, and A type (1) 2%.
| OTA Fracture Type | N | Age (range) | ISS | Mortality |
A |
4 | 40 (18-81) | 24 | 1 (25%) |
B1 |
2 | 30 (13-46) | 33 | 0 |
B2 |
8 | 33 (15-66) | 33 | 2 (25%) |
B3 |
14 | 34 (2-73) | 32 | 4 (28%) |
C1 |
4 | 38 (22-50) | 36 | 2 (50%) |
C2 |
4 | 27 (5-55) | 24 | 0 |
C3 |
20 | 35 (18-56) | 48 | 11 (55%) |
Discussion: The use of emergent embolization has been employed routinely at our institution prior to any other intervention for four years in the hemodynamically unstable patients with a negative abdominal ultrasound. Fifty-two consecutive patients presented with mechanically unstable pelvic injury and remained hemodynamically unstable in the Trauma center, the use of emergency external fixation was rare (1). 75% of patients presenting with combination C3 pelvic injuries and bilateral arterial injuries sustained an unsurvivable amount of trauma. Wound problems developed following subsequent hemipelvis operative fixation in only one patient with massive degloving; despite 33% of patient cohort sustaining traumatic loss of Hypogastric systems bilaterally, and 52% having multiple arterial injuries and concomitant massive truncal trauma.
Conclusion: The placement of angiography and embolization in the decision algorithm for the hemodynamically unstable pelvic fracture patient is typically in the later stages of the decision scheme. These data suggest that embolization in conjunction with binding the thighs or skeletal traction may facilitate the resuscitation process and preclude emergent frame application, as well. No evidence of perineal dysvascular changes were detected.