Analysis of early treatment of multiple injuries combined with severe pelvic fracture

Abstract

Purpose To summarize and analyze the early treatment of multiple injuries combined with severe pelvic fractures, especially focus on the hemostasis methods for severe pelvic fractures, so as to improve the successful rate of rescue for the fatal hemorrhagic shock caused by pelvic fractures. Methods A retrospective analysis was conducted in 68 cases of multiple trauma combined with severe pelvic fractures in recent 10 years (from Jan. 2006 to Dec. 2015). There were 57 males and 11 females. Their age ranged from 19 to 75 years, averaging 42 years. Causes of injury included traffic accidents in 34 cases (2 cases of truck rolling), high falling injuries in 17 cases, crashing injuries in 15 cases, steel cable wound in 1 case, and seat belt traction injury in 1 case. There were 31 cases of head injury, 11 cases of chest injury, 56 cases of abdominal and pelvic injuries, and 37 cases of spinal and limb injuries. Therapeutic methods included early anti-shock measures, surgical hemostasis based on internal iliac artery devasculization for pelvic hemorrhage, and early treatment for combined organ damage and complications included embolization and repair of the liver, spleen and kidney, splenectomy, nephrectomy, intestinal resection, colostomy, bladder ostomy, and urethral repair, etc. Patients in this series received blood transfusion volume of 1200–10,000 mL, with an average volume of 2850 mL. Postoperative follow-up ranged from 6 months to 1.5 years. Results The average score of ISS in this series was 38.6 points. 49 cases were successfully treated and the total survival rate was 72.1%. Totally 19 patients died (average ISS score 42.4), including 6 cases of hemorrhagic shock, 8 cases of brain injury, 1 case of cardiac injury, 2 cases of pulmonary infection, 1 case of pulmonary embolism, and 1 case of multiple organ failure. Postoperative complications included 1 case of urethral stricture (after secondary repair), 1 case of sexual dysfunction (combined with urethral rupture), 1 case of lower limb amputation (femoral artery thrombosis), and 18 cases of consumptive coagulopathy. Conclusion The early treatment of multiple injuries combined with severe pelvic fractures should focus on pelvic hemostasis. Massive bleeding-induced hemorrhagic shock is one of the main causes of poor prognosis. The technique of internal iliac artery devasculization including ligation and embolization can be used as an effective measure to stop or reduce bleeding. Consumptive coagulopathy is difficult to deal with, which should be detected and treated as soon as possible after surgical measures have been performed. The effect of using recombinant factor VII in treating consumptive coagulopathy is satisfactory.

Letter to the Editor: Non-selective bilateral internal iliac artery embolization is a safe and effective way in hemorrhage control for hemodynamically unstable pelvic fractures

“…The trunk of the left internal iliac artery was embolized with a metal coil, and there was no evident necrosis on this side. This seems to have led to the opposite conclusion from the authors, which is that reliable trunk embolization does not lead to ischemia in the dominant region, whereas selective embolization may lead to ischemia or even necrosis of the organ [ 4 , 5 ]. From the picture, the case is also considered a Moral-Lavallee injury.…”

“…Subsequent delayed bleeding may result in a shock state that is difficult to correct and may require re-intervention to stop the bleeding [ 6 ]. Non-selective internal iliac artery embolization may be the best choice at this time [ 5 , 7 ]. In our experience, if a pelvic fracture is considered base on the injury mechanism and physical examination, a CT scan with three-dimensional reconstruction should be performed routinely.…”

“…In theory, the reduction of arterial blood flow can also help to reduce venous bleeding [ 7 ]. From our experience, bleeding from veins or bones can usually be controlled by pressure or packing, and blood clots can form with a strong chance of remaining in place after embolization [ 5 , 9 , 10 ]. In our previous studies [ 5 , 10 ], a total of 22 patients with unstable pelvic fractures underwent nBIIAE for hemostasis, and only two died of hemorrhagic shock, with a success rate of 90.9%.…”

The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures

“…Nearly 90% of the unstable pelvic fractures are associated with other injuries and the sources of major haemorrhage in almost half of them are not a pelvic fractures, which makes the patient condition more complicated. 8 , 15 , 16 Different strategies have been put forward by many previous studies, to solve the problem of unstable hemodynamics in some pelvic fracture patients. 4 , 17 , 18 , 19 , 20 , 21 , 22 Unfortunately, the ideal resuscitation has high reliance on the presented symptoms, so as to their treatment options can be varied from individuals.…”

“…In the current study, all patients with unstable pelvic fractures were performed by standard anterior external fixation or C-clamp, which was consistent with previous studies. 2 , 9 , 16 , 24 , 25 The reduction and stabilization of the pelvic ring resulted in spontaneous hemostasis of retroperitoneal bleeding by decreasing pelvic volume and exerting self-tamponade effect. In addition, external fixation decreased bony motion to facilitating stable clot formation at the fractured bone surfaces.…”