Hemostasis as soon as possible? The role of the time to angioembolization in the management of pelvic fracture

Chou, Chang-Hua; Wu, Yu-Tung; Fu, Chih-Yuan; Liao, Chien‐Hung; Wang, Shang‐Yu; Bajani, Francesco; Hsieh, Chi-Hsun

doi:10.1186/s13017-019-0248-z

Cited by 35 publications

(58 citation statements)

References 41 publications

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“…An incorrect choice of where to transport these patients for further intervention could delay the time to definite hemorrhage control and increase the risk of mortality. In this regard, the assessment of potential severe vascular injury and timely hemorrhage control should be the highest priorities in the acute management of pelvic fracture [25].…”

Section: Discussionmentioning

confidence: 99%

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Cheng

Tee

et al. 2020

World J Emerg Surg

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Background: The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity. Methods: Medical records of patients with pelvic fracture at a single center between January 2016 and December 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥ 3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups. Results: Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p = 0.000) and total hospital stay (20.7 vs. 10.1 days, p = 0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear, and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I, and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p = 0.034). These findings were similar even if only patients with ISS ≥ 16 were considered. Conclusions: Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to the outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.

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Section: Discussionmentioning

confidence: 99%

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Cheng

Tee

et al. 2020

World J Emerg Surg

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“…Patients who present with pelvic fractures and hemodynamic instability (with other sources of blood loss addressed according to their priority) are reassessed during the first pack of MTP and if they continue to remain hemodynamically unstable despite hemostatic resuscitation are either transferred directly to angioembolization, or if their hemodynamic response to MTP makes it safe to do so, they are taken for trauma Computed Tomography (CT). At our institution, preperitoneal packing is not performed and all suspected pelvic hemorrhage is managed with pelvic angiography, in keeping with current consensus and long-standing functional institutional guidelines [3,[9][10][11].…”

Section: Methodsmentioning

confidence: 87%

Pelvic angioembolization: how urgently needed?

Devaney

King

Balogh

2020

Eur J Trauma Emerg Surg

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Purpose Angioembolization (AE) has been questioned as first-line modality for hemorrhage control of pelvic fracture (PF)-associated bleeding due to its potential inconsistent timely availability. We aimed to describe the patterns of AE use with hemostatic resuscitation and hypothesized that time to AE improved during the study period. Methods A Level-1 trauma center’s prospective PF database was analyzed. All consecutive PFs referred to angiography between 01/01/2009 and 12/31/2018 were included. All suspected pelvic hemorrhage was managed with AE; pelvic packing was not performed. Demographics, injury/shock severity, 24-h transfusion data, time to AE and mortality were recorded. Data are presented as median (IQR). Results During the 10-year study period, 1270 PF patients were treated. Thirty-six (2.8%) [75% male, 49 (33;65) years, ISS 36 (24;43), base deficit 3.65 (5.9;0.6), transfusions 4(2;7)] had AE. The indication for AE was clinical suspicion (CS) of pelvic bleeding [CS 24(67%)] or arterial blush on CT [CT 12 (33%)]. Median time to AE was 141 min for CS, and 223 min for CT, with no change over the study period. Patients with CS had a higher ISS, worse base deficit, greater transfusion requirements and faster time to AE. Five patients (14%) died. There were no deaths attributed to exsanguination. Conclusions Time to AE did not improve. Patients referred from CT are physiologically different from CS and should be analyzed accordingly, with CS resulting in faster time to AE in sicker patients. Contemporary resuscitation challenges the need for hyperacute AE as no patients exsanguinated despite time to AE of more than 2 h.

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“…An incorrect choice of where to transport these patients for further intervention could delay the time to de nite hemorrhage control and increase the risk of mortality. In this regard, the assessment of potential severe vascular injury and timely hemorrhage control should be the highest priorities in the acute management of pelvic fracture [25].…”

Section: Discussionmentioning

confidence: 99%

“…The most critical factor of this result was that interventional radiologists were available at our institution for 24 hours along with trauma surgeons. Most exsanguinating patients could be stabilized by transarterial embolization shortly after initial resuscitation whenever indicated [20,25,27,28]. Another reason for the lack of mortality was that pelvic trauma patients with associated injuries that were con rmed to be the principal cause of death, such as severe brain injury, were not included in the current study [17,[21][22][23].…”

Section: Discussionmentioning

confidence: 99%

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: The WSES classification for pelvic trauma makes sense

Cheng

Tee

et al. 2020

Preprint

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Background: The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity. Methods: Medical records of patients with pelvic fracture at a single center between Jan 2016 and Dec 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups.Results: Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p=0.000) and total hospital stay (20.7 vs. 10.1 days, p=0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p=0.034). These findings were similar even if only patients with ISS >=16 were considered.Conclusions: Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.Trial registration: This is a retrospective review study, not a clinical trial.

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Hemostasis as soon as possible? The role of the time to angioembolization in the management of pelvic fracture

Cited by 35 publications

References 41 publications

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Pelvic angioembolization: how urgently needed?

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: The WSES classification for pelvic trauma makes sense

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