Case Report: A 47 year old patient was hit by a truck and presented to the emergency room with hemodynamic instability. There were multiple rib fractures on the left side and an unstable pelvis. Ultrasound revealed a retroperitoneal hematoma.
With return of a reasonable blood pressure following resuscitation and the placement of a left chest tube,
S/P Lt Chest Tube
a rapid spiral CT (5 cuts) of the posterior pelvic ring was obtained.
Rapid Spiral CT
The CT showed transforminal sacral fracture on the right side and an ilium fracture on the left. Because of the CT findings and a requirement for a continuous extensive volume resuscitation , the patient was taken to the OR where the posterior pelvic ring was stabilized with a C-clamp.
The patient became hemodynamically stable for 30 min. Just prior to leaving the OR, the patient suddenly showed again all signs of circulatory collapse as severe hemorrhage exited the Left chest tube.
An X-ray of the chest demonstrated a hemothorax on the left side. An immediate thoracotomy was performed and 4 litres of blood were evacuated from the left chest. The source of bleeding could not be identified and the patient died on the table due to exsanguination.
An autopsy revealed the the C-clamp had effectively controlled bleeding from the cancellous bone of the pelvic fracture surfaces. An arterial injury was not found. Continuous bleeding from the completely disrupted presacral venous plexus had caused extensive retroperitoneal hematoma which eventually communicated with the left chest cavity and was accelerated by the evacuation of the left chest tube.
Comment: This case serves as an important example that angiography, which is routinely recommended by most pelvic bleeding algorithms, is not necessarily an appropriate treatment either before or after "when all else fails". With proper pelvic packing technique, the odds for the survival of this patient would have been much improved.
As a result of this case, we have changed our diagnostic strategy and now use lactate and base excess to estimate the real severity of hemorrhage. Moreover, we now use the very aggressive treatment protocol with the combination of C-clamp and pelvic packing. This has decreased our mortality to 25% in patients in extremis which is far better than the mortality rate published in similar studies.