The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showing transient response to fluid resuscitation

BACKGROUND: This study aimed to determine whether nonsurgical management using transcatheter arterial embolization (TAE) is safe for patients with blunt multiple trauma who transiently respond to the initial fluid resuscitation. METHODS: Contrast computed tomography was performed for patients with blunt abdominal injuries, excluding those who did not respond to initial fluid resuscitation. Angiography was performed for patients with injuries showing contrast extravasation or solid organ injury classified, according to the American Association for the Surgery of Trauma, as grade 3 or higher on computed tomography. Transcatheter arterial embolization was performed when angiography showed arterial extravasation. The protocol was abandoned for any patients who became profoundly hypotensive (with systolic blood pressure 60 mm Hg or lower) during computed tomography or angiography. RESULTS: Between January 2000 and December 2002, 269 patients with blunt abdominal injuries underwent TAE immediately after admission. Of these patients, 41 had injuries in at least two regions and underwent TAE for these regions. Among them, 22 patients were hemodynamically stable or showed rapid response to fluid resuscitation. The nonsurgical treatment was successful in all these cases. The remaining 19 patients (Injury Severity Score, 37.3 +/- 8.2), who showed a transient response, were the subjects of this study. Of these patients, 15 underwent TAE for injuries in two regions (13 pelvic fractures, 7 splenic injuries, 6 hepatic injuries, 3 facial bleeding, and 1 renal injury), and 4 patients underwent TAE for injuries in three regions (4 had splenic injuries, 3 hepatic injuries, 2 renal injuries, 2 pelvic fractures, and 1 facial bleeding). For all these patients, TAE was successfully performed. Before TAE, the systolic blood pressure was 79.9 +/- 8.4 mm Hg, and the shock index was 1.45 +/- 0.25 mm Hg. After TAE, the corresponding values were 120.6 +/- 19.3 mm Hg and 0.87 +/- 0.16 mm Hg, respectively (p < 0.001). The rate of fluid administration required after TAE (214.2 +/- 139.3 mL/hour) was significantly less than that required before TAE (1244.2 +/- 347.1 mL/hour; range, 632-1,728 mL/hour) (p < 0.001). The deaths of two patients were classified as nonpreventable on the basis of the Trauma and Injury Severity Score (TRISS), and their respective probabilities of survival were determined to be 0.13 and 0.03. CONCLUSION: Nonsurgical management using TAE can be performed safely even for patients with blunt multiple trauma who are in hemorrhagic hypotension if their hemodynamics are improved by resuscitation with 2 L of fluid.     

A potentially expanded role for enoxaparin in preventing venous thromboembolism in high risk blunt trauma patients

BACKGROUND: Venous thromboembolism (VTE) is a frequent and potentially life-threatening complication after trauma. The purpose of this study is to investigate the effectiveness of enoxaparin in preventing deep venous thrombosis (DVT) and pulmonary embolism (PE) after injury in patients who are at high risk for developing VTE. STUDY DESIGN: A prospective single-cohort observational study was initiated for seriously injured blunt trauma patients admitted to a Level I trauma center during a 7-month period. Patients were eligible for the study if time hospitalized was > or = 72 hours, Injury Severity Score (ISS) was > or = 9, enoxaparin was started within 24 hours after admission, and one or more of the following high risk criteria were met: age > 50 years, ISS > or = 16, presence of a femoral vein catheter, Abbreviated Injury Score (AIS) > or = 3 for any body region, Glasgow Coma Scale (GCS) Score < or = 8, presence of major pelvic, femur, or tibia fracture, and presence of direct blunt mechanism venous injury. Patients with closed head injuries and nonoperatively treated solid abdominal organ injuries were also potential participants. The primary outcomes measured were thromboembolic events--either a documented lower extremity DVT by duplex color-flow doppler ultrasonography or a PE documented by rapid infusion CT pulmonary angiography or conventional pulmonary angiography. RESULTS: There were 118 patients enrolled in the study. Two patients (2%) developed DVT, one of which was proximal to the calf (95% confidence interval, 0% to 6%). Two of 12 patients (17%) with splenic injuries who received enoxaparin failed initial nonoperative management. There were no other bleeding complications, and no clinical evidence or documented episodes of PE. One patient died from multiple system organ failure. CONCLUSIONS: Enoxaparin is a practical and effective method for reducing the incidence of VTE in high risk, seriously injured patients. This study supports further investigation into the safety of enoxaparin prophylaxis in patients with closed head injuries and nonoperatively treated solid abdominal organ injuries.     

Interventionelle Notfallembolisation bei schweren Beckenfrakturen mit arterieller Blutung

Objective

Presentation of our own experiences and results of an early clinical algorithm for treatment integrating emergency embolization (TAE) in cases of unstable pelvic ring fractures with arterial bleeding.

Method

Consecutive patient series from April 2002 to December 2006 at a level 1 trauma center. The data of the online shock room documentation (Traumawatch®) of patients with a pelvic fracture and arterial bleeding detected on multislice computed tomography (MSCT) were examined for the following parameters: demographic data, injury mechanism, fracture classification according to Tile/AO and severity of the pelvic injury assessed with the Abbreviated Injury Score (AIS), accompanying injuries with elevation of the cumulative injury severity according to the Injury Severity Score (ISS), physiological admission parameters (circulatory parameters and initial Hb value) as well as transfusion requirement during treatment in the shock room, time until embolization, duration of embolization, and source of bleeding.

Results

Of a total of 162 patients, arterial bleeding was detected in 21 patients by contrast medium extravasation on MSCT, 12 of whom were men and 9 women with an average age of 45 (14–80) years. The mechanism of injury was high energy trauma in all cases. In 33% it involved type B pelvic fractures and in 67% type C fractures with an average AIS pelvis of 4.4 points (3–5) and a total severity of injury with the ISS of 37 points (21–66). Upon admission 47.6% presented hemodynamic instability with an average Hb value of 7.8 g/dl (3.2–12.4) and an average transfusion requirement of 6 red blood cell units (4–13). The time until the TAE was started was on average 62 min (25–115) with a duration period of the TAE of 25 min (15–67). Branches of the internal iliac artery were identified as the sole source of bleeding. The success rate of TAE amounted to over 90%.

Conclusion

Interventional TAE represents an effective as well as a fast procedure for hemostasis of arterial bleeding detected on MSCT in patients with pelvic fractures. If an experienced radiologist on 24-h stand-by is assured and the infrastructure is efficient, this can be performed shortly after hospital admission and therefore should be integrated into the early clinical treatment protocol.     

The outcome of open pelvic fractures in the modern era

BACKGROUND: Recent series have reported that the mortality rate of open pelvic fractures has decreased to < 10%. These injuries are often associated with intra-abdominal visceral damage, although few series have documented the prognostic significance of this injury complex. METHODS: A retrospective review in an urban level I trauma center of all patients who sustained open pelvic fracture between 1995 and 2004. RESULTS: Forty-four patients were identified as having sustained open pelvic fracture. Average Injury Severity Score was 30, with 77% of patients having a score > or = 16. Overall mortality was 45% (n = 20): 11 early deaths and 9 late deaths at an average of 17 days. Vertical shear injuries, although rare, were universally fatal. Other risk factors for overall mortality included revised trauma score, Injury Severity Score, transfusion requirement, Faringer zones I or II injury, Gustilo grade III soft tissue injury, need for therapeutic angiography, and presence of intra-abdominal injury, the latter of which conferred 89% mortality. Risk factors for late deaths also included pelvic sepsis, which occurred in 5 patients and was fatal in 3 (60%). CONCLUSIONS: The morbidity of open pelvic fractures remains high. Associated intra-abdominal injury or active arterial bleeding requiring therapeutic angiography is associated with a grim prognosis. There is a continuing need for new therapeutic approaches to this injury complex.     

Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients

BACKGROUND: Whether pelvic fracture instability is correlated to mortality in blunt multiply-injured trauma patients is debatable. This is the first prospective study on patients with pelvic fractures aiming at finding whether pelvic fracture type affects mortality. METHODS: There were 100 consecutive patients (77 males, mean age of 31 [3-73] years) studied between September 2003 and October 2004. Data were collected regarding mechanism of injury, associated injuries, Injury Severity Score (ISS), Revised Trauma Score, blood transfusions, and mortality. The fractures were classified according to instability, where type O is stable, type R is rotationally unstable, and type RV is both rotationally and vertically unstable. Because a pure acetabular fracture is a single break in the pelvic ring, we classified it as type O. Computer tomography was used for fracture classification in 73 patients and plain X-rays in 27 patients. RESULTS: There were 77 fractures caused by road traffic collisions. Type O fractures (n = 63) had lower median ISS (13 [4-48]) than type R (n = 19) (18 [9-75]) and type RV (n = 18) (18 [6-66]) (p = 0.019, Kruskall Wallis). There was no significant difference in ISS between type R and RV fractures. A logistic regression model has shown that ISS was the only significant factor that predicts mortality. CONCLUSIONS: ISS is the most important predictor in defining mortality in patients with pelvic fracture and not the type of pelvic instability.     

Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes.

BACKGROUND: Recent reports suggest that early fracture fixation worsens central nervous system (CNS) outcomes. We compared discharge Glasgow Coma Scale (GCS) scores, CNS complications, and mortality of severely injured adults with head injuries and pelvic/lower extremity fractures treated with early versus delayed fixation. METHODS: Using trauma registry data, records meeting preselected inclusion criteria from the years 1991 to 1995 were examined. We identified 171 patients aged 14 to 65 years (mean age, 32.7 years) with head injuries and fractures who underwent early fixation (< or = 24 hours after admission) (n = 147) versus delayed fixation (> 24 hours after admission) (n = 24). RESULTS: Patients were severely injured, with a mean admission GCS score of 9.1, Revised Trauma Score of 6.2, Injury Severity Score of 38, median intensive care unit length of stay of 16.5 days, and hospital length of stay of 23 days. No differences between groups were found by age, admission GCS score, Injury Severity Score, Revised Trauma Score, intensive care unit length of stay, hospital length of stay, shock, vasopressors, major nonorthopedic operative procedures, total intravenous fluids or blood products, or mortality rates. In survivors, no differences in discharge GCS scores or CNS complications were found. CONCLUSION: We found no evidence to suggest that early fracture fixation negatively influences CNS outcomes or mortality.     

Blunt gastric injuries

Gastric rupture after blunt abdominal trauma is a rare injury with few reports in the literature. The purpose of this study was to review our experience with blunt gastric injuries and compare outcomes with small bowel or colon injuries. All patients with hollow viscus perforations after blunt abdominal trauma from 1992 to 2005 at our level I trauma center were reviewed. Of 35,033 blunt trauma admissions, there were 268 (0.7%) patients with a total of 319 perforating hollow viscus injuries, 25 (0.07%) of which were blunt gastric injuries. When compared with the small bowel or colon injuries, the blunt gastric injury group had a higher Injury Severity Score (22 versus 17, P = 0.04), more patients with a chest Abbreviated Injury Score greater than 2 (36% versus 12%, P < 0.01), and a shorter interval from injury to laparotomy (221 versus 366 minutes, P = 0.017). Multivariate analysis identified five independent risk factors for mortality: age older than 55 years, head Abbreviated Injury Score greater than 2, chest Abbreviated Injury Score greater than 2, the presence of hypotension on admission, and Glasgow Coma Scale 8 or less. The results of this study suggest that mortality in patients with blunt hollow viscus injuries can be attributed to concurrent head and chest injuries, but not the specific hollow viscus organ that is injured.     

Use of extracorporeal membrane oxygenation in combination with high‐frequency oscillatory ventilation in post‐traumatic ARDS

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life‐threatening complications in trauma patients. Despite the implantation of a veno‐venous extracorporeal membrane oxygenation (vv ECMO), sufficient oxygenation (arterial SaO₂ > 90%) is not always achieved. The additive use of high‐frequency oscillation ventilation (HFOV) and ECMO in the critical phase after trauma could prevent the occurrence of life‐threatening hypoxaemia and multi‐organ failure. We report on a 26‐year‐old female (Injury Severity Score 29) who had multiple injuries as follows: an unstable pelvic fracture, a blunt abdominal trauma, a blunt trauma of the left thigh, and a thoracic injury. Three days after admission, the patient developed fulminant ARDS (Murray lung injury score of 11 and Horovitz‐ Index <80 mmHg), and vv ECMO therapy was initiated. The Horovitz‐ Index was <80 mm Hg, and the lung compliance was minimal. With HFOV, almost complete recruitment of the lung was achieved, and the fraction of inspired oxygen (FiO₂) was significantly reduced. The pelvic fracture was treated non‐operatively. The HFOV was terminated after 3 days, and the ECMO was stopped after 19 days.     

The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures

In order to identify the prognostic factors and to evaluate the impact of associated injuries in the outcome of patients with pelvic fractures, a retrospective review of the medical records of patients admitted with a pelvic fracture during a 42-month period was carried out. Demographic data, the mechanism of injury, the physiologic status on admission, associated injuries, pelvic fracture classification, complications and mortality were analysed. One hundred and three patients were included in the study. Fifty-nine were male, and the mean age was 34. The mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.1 and 20, respectively. Pedestrian vs vehicle (59%), was the most frequent mechanism of injury. Twenty patients died (19%) most frequently due to "shock". Complications developed in 37 patients (36%), pneumonia being the most frequent. Age greater than 40 years (p=0.02), "shock" upon admission (p=0.002), a Glasgow Coma Scale (GCS)<9, Head AIS>2 (p<0. 001), Chest AIS>2 (p=0.007), and abdominal AIS>2 (p=0.03) all correlated with increased mortality. No correlation between pelvic fracture classification or fracture stability with mortality was observed. The outcome of patients with pelvic fractures due to blunt trauma correlates with the severity of associated injuries and physiological derangement on admission rather than with characteristics of or the type of fracture.     

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

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Predictors of death in patients with life-threatening pelvic hemorrhage after successful transcatheter arterial embolization

OBJECTIVE: The purpose of this study was to determine predictors of death in patients with pelvic fracture whose pelvic arterial hemorrhage is controlled successfully by transcatheter arterial embolization (TAE). METHODS: From January 1996 to December 2000, 61 patients with a pelvic fracture who had pelvic arterial hemorrhage were treated at our Level I trauma center according to a protocol that assigns a high priority to diagnostic and therapeutic angiography within the algorithm. Angiography is performed before laparotomy in patients with hemoperitoneum, who can be stabilized by fluid resuscitation, and otherwise afterward. External fixation was performed immediately after TAE in the angiography suite. Predictors of outcome were determined retrospectively by univariate and multivariate analysis using anatomic and physiologic parameters. RESULTS: Forty-eight patients survived and 13 died. TAE successfully controlled pelvic arterial hemorrhage in all patients. Predictors of death included posterior pelvic arterial injury and an elevated Acute Physiology and Chronic Health Evaluation II score (odds ratio, 15.6 and 23.9, respectively). Need for fluid requirements to achieve hemodynamic stability were higher in nonsurvivors than in survivors. Outcome did not correlate with the type of fracture or the Injury Severity Score. CONCLUSION: Application of angiography as a therapeutic intervention in patients with pelvic arterial bleeding may reduce the need for surgery, thereby avoiding or minimizing this additional trauma.     

Criteria for level 1 and level 2 trauma codes: Are pelvic ring injuries undertriaged?

AIM: To determine the association of unstable pelvic ring injuries with trauma code status.METHODS: A retrospective review of all pelvic ring injuries at a single academic center from July 2010 to June 2013 was performed. The trauma registry was used to identify level 1 and level 2 trauma codes for each injury. The computed tomography scans in all patients were classified as stable or unstable using the Abbreviated Injury Scale. Pelvic injury classifications in level 1 and level 2 groups were compared. Patient disposition at discharge in level 1 and level 2 groups were also compared.RESULTS: There were 108 level 1 and 130 level 2 blunt trauma admissions. In the level 1 group, 67% of pelvic injuries were classified as stable fracture patterns and 33% were classified as unstable. In the level 2 group, 62% of pelvic injuries were classified as stable fracture patterns and 38% were classified as unstable. level 1 trauma code was not associated with odds of having an unstable fracture pattern(OR = 0.83, 95%CI: 0.48-1.41, P = 0.485). In the level 1 group with unstable pelvic injuries, 33% were discharged to home, 36% to a rehabilitation facility, and 32% died. In the level 2 group with unstable pelvic injuries, 65% were discharged to home, 31% to a rehabilitation facility, and 4% died. For those with unstable pelvic fractures(n = 85), assignment of a level 2 trauma code was associated with reduced odds of death(OR = 0.07, 95%CI: 0.01-0.35, P = 0.001) as compared to being discharged to home.CONCLUSION: Trauma code level assignment is not correlated with severity of pelvic injury. Because an unstable pelvis can lead to hemodynamic instability, these injuries may be undertriaged.     

Blunt vascular trauma in the extremity: diagnosis, management, and outcome

BACKGROUND: Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity. METHODS: A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted. RESULTS: From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors. CONCLUSION: Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.     

Pelvic fractures in pregnant multiple trauma patients

OBJECTIVE: To study the outcome of pelvic fractures and fetuses in pregnant patients involved in blunt multiple trauma. DESIGN: Retrospective follow-up study. SETTING: Level I trauma center. PATIENTS: Pregnant multiple trauma patients with pelvic fractures between 1974 and 1998. INTERVENTIONS: Conservative and operative treatment of pelvic fractures adapted to the clinical status of the mother. MAIN OUTCOME MEASURES: Clinical, functional, and social outcomes were evaluated. RESULTS: Out of 4,196 patients with blunt multiple trauma treated between 1974 and June 1998, seven demonstrated the combination of blunt multiple trauma, pregnancy, and pelvic fractures. These patients had a mean Injury Severity Score of 29.9 points. Five mothers and three fetuses survived their injuries. All dead fetuses died on the scene. One surviving fetus was found to have hydrocephalus unrelated to the injury; the remaining fetuses had an uneventful delivery and were healthy. In two of the three patients whose fetuses survived, the treatment of the pelvic fracture was modified for the sake of fetal well-being. In all of these patients, acceptable outcome was achieved. CONCLUSION: Modification of the treatment of the pelvic fracture in pregnant women with multiple trauma may be necessary to minimize the risk of fetal injury. In our experience with these rare cases, this modified treatment did not severely alter the clinical outcome of the mother's pelvic fracture.     

Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes

BACKGROUND: Pelvic fractures are often associated with major intraabdominal injuries or severe bleeding from the fracture site. OBJECTIVE: To study the epidemiology of pelvic fractures and identify important risk factors for associated abdominal injuries, bleeding, need for angiographic embolization, and death. METHODS: Trauma registry study on pelvic fractures from blunt trauma. Stepwise logistic regression was used to identify risk factors of severe pelvic fractures, associated abdominal injuries, need for major blood transfusion, therapeutic embolization, and death from pelvic fracture. Adjusted relative risks and 95% confidence intervals were derived. RESULTS: There were 16,630 trauma registry patients with blunt trauma, of whom 1,545 (9.3%) had a pelvic fracture. The incidence of abdominal injuries was 16.5%, and the most common injured organs were the liver (6.1%) and the bladder and urethra (5.8%). In severe pelvic fractures (Abbreviated Injury Scale [AIS] > or =4), the incidence of associated intraabdominal injuries was 30.7%, and the most commonly injured organs were the bladder and urethra (14.6%). Among the risk factors studied, motor vehicle crash is the only notable risk factor negatively associated with severe pelvic fracture. Major risk factors for associated liver injury were motor vehicle crash and pelvis AIS > or = 4. Risk factors of major blood loss were age > 16 years, pelvic AIS > or =4, angiographic embolization, and Injury Severity Score (ISS) > 25. Age> 55 years was the only predictor for associated aortic injury. Factors associated with therapeutic angiographic embolization were pelvic AIS > or =4 and ISS > 25. The overall mortality was 13.5%, but only 0.8% died as a direct result of pelvic fracture. The only pronounced risk factor associated with mortality was ISS>25. CONCLUSIONS: Some epidemiological variables are important risk factors of severity of pelvic fractures, presence of associated abdominal injuries, blood loss, and need of angiography. These risk factors can help in selecting the most appropriate diagnostic and therapeutic interventions.     

Pelvic fracture pattern does not always predict the need for urgent embolization

BACKGROUND: The intimate relationship between the pelvis and related vasculature can lead to life-threatening arterial hemorrhage after blunt trauma. Unfortunately, hemorrhage related to pelvic fracture is often associated with other serious injuries, complicating clinical decision making. Previous clinical reviews have associated fracture geometry with arterial hemorrhage, specifically implicating those injuries with evidence of major ligamentous disruption (MLD). METHODS: We analyzed pelvic fractures for evidence of a relationship between MLD and the need for angiographic embolization. Our trauma registry was reviewed from 1996 to 2002; 283 patients with pelvic fractures arrived in the emergency department with a systolic blood pressure < or = 90 mmHg. MLD was defined as anteroposterior compression types II and III, lateral compression type III, combined mechanism, and vertical shear according to the Young-Burgess classification. RESULTS: Thirty-seven (13%) of the patients studied required angiographic embolization for control of pelvic hemorrhage. The pelvic fracture pattern (MLD vs. non-MLD) did not differ significantly between the embolized and nonembolized groups. The predictive value of other variables varied by gender. Age had a significant correlation with the need for embolization in women, whereas Injury Severity Score did not. Conversely, age had no predictive value for men, whereas Injury Severity Score had a significant correlation. CONCLUSION: The findings in this study suggest that pelvic fracture pattern does not consistently correlate with the patient's need for urgent embolization and should not be used as the sole determinant for angiography. Furthermore, variables such as age and gender should be further investigated, as they may potentially have a predictive value in this clinical setting.     

A protocol for angiographic embolization in exsanguinating pelvic trauma: a report on 31 patients

Background The indication for acquiring angiographic embolization in the initial treatment of severe pelvic fractures is controversial. We describe the characteristics and outcome of 31 patients with traumatic pelvic bleeding who underwent percutaneous angiography with embolization according to a standardized protocol.

Patients and methods During an 8.5-year period, 1,260 patients were treated for pelvic trauma. We performed a prospective registration of the 46 patients who underwent angiography, and report the 31 patients who had signs of significant arterial injury on angiography, necessitating embolization.

Results The rate of significant arterial injury after pelvic trauma was 2.5%. All patients had been subjected to high-energy injuries and all were severely injured as measured by the Injury Severity Score: 41 (17-66). Pelvic arterial injury was observed with all types of pelvic trauma, including isolated acetabular (4/31) and sacral fractures (3/31). The internal iliac artery or its branches was injured in 28 of 31 patients. Survival rate after embolization was 84%, and correlated inversely with increasing patient age. None of the patients died of bleeding.

Interpretation Our findings show that significant pelvic arterial injuries occur in a minority of patients after pelvic trauma, and predominantly affect patients with multiple high-energy injuries regardless of fracture type. The effect of angiographic embolization was good.     

A protocol for angiographic embolization in exsanguinating pelvic trauma: A report on 31 patients

Background?The indication for acquiring angiographic embolization in the initial treatment of severe pelvic fractures is controversial. We describe the characteristics and outcome of 31 patients with traumatic pelvic bleeding who underwent percutaneous angiography with embolization according to a standardized protocol.

Patients and methods?During an 8.5-year period, 1,260 patients were treated for pelvic trauma. We performed a prospective registration of the 46 patients who underwent angiography, and report the 31 patients who had signs of significant arterial injury on angiography, necessitating embolization.

Results?The rate of significant arterial injury after pelvic trauma was 2.5%. All patients had been subjected to high-energy injuries and all were severely injured as measured by the Injury Severity Score: 41 (17–66). Pelvic arterial injury was observed with all types of pelvic trauma, including isolated acetabular (4/31) and sacral fractures (3/31). The internal iliac artery or its branches was injured in 28 of 31 patients. Survival rate after embolization was 84%, and correlated inversely with increasing patient age. None of the patients died of bleeding.

Interpretation?Our findings show that significant pelvic arterial injuries occur in a minority of patients after pelvic trauma, and predominantly affect patients with multiple high-energy injuries regardless of fracture type. The effect of angiographic embolization was good.     

Scapular fractures and concomitant injuries

Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized.Few studies have investigated this presumed association...     

Complications of pelvic fractures from blunt trauma.

Significant external forces are required to fracture a normal pelvis. These forces usually result from rapid deceleration or crushing injuries, and energy often is delivered to multiple anatomic sites in addition to the pelvis. Associated injuries are common, and numerous complications can occur in patients with pelvic fractures. During 4 years, the authors treated 144 men and 92 women with pelvic fractures from blunt trauma who were admitted directly to the University of Mississippi Medical Center. They had a mean age of 31.5 years, a mean Injury Severity Score of 21.3, and an average hospital stay of 16.8 days. Seventy-seven of the 236 patients (32.6%) had 137 complications, including 18 deaths. Most of these were infections such as pneumonia (6), urinary tract infections (8), wound infections (8), or sepsis without a defined source (10). There was a high incidence of pulmonary complications including Adult Respiratory Distress Syndrome (12), significant atelectasis (7), and fat emboli (3). Musculoskeletal complications (13) and coagulopathy (12) also occurred frequently. Eight patients had thromboembolic events, but prophylactic, subcutaneous heparin was not beneficial in preventing these complications. Patients with complications had higher Injury Severity Scores, lower Trauma Scores, increased transfusion requirements, longer hospital stays, and greater hospital charges compared to those without complications (P less than 0.01 for all variables). There was no association of complications with patient age, sex, mechanism of injury, anatomic site or amount of displacement of the pelvic fracture, or vector of injury. Patients with unstable pelvic fractures were much more likely to have complications than were those with stable pelvic fractures (P = 0.013).(ABSTRACT TRUNCATED AT 250 WORDS)