UROGENITAL TRAUMA

Predictors of death in patients with life-threatening pelvic hemorrhage after successful transcatheter arterial embolization
Hagiwara A, Minakawa K, Fukushima H, Murata A, Masuda H, Shimazaki S
Department of Traumatology and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
J Trauma. 2003; 55: 696-703

• 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.
  
  
• Editorial Comment
  This article from Tokyo, nicely illustrates the controversy over the timing and optimal order of external fixation (ex-fix) and transarterial embolization (TAE). One camp utilizes external fixation as first-line treatment and reserves TAE for ongoing instability after pelvic stabilization. Others aggressively advocate TAE early in the treatment and place an ex-fix after TAE. Bleeding sources from pelvic fracture are cancellous bone at fracture sites, pelvic venous plexuses and pelvic arteries. The methods to control venous bleeding are pelvic ring stabilization, re-approximation of bleeding bone edges, and closure of the pelvic ring to reduce the true pelvic volume. To control pelvic arterial bleeding usually needs TAE of injured pelvic arteries. Making the distinction of predominant arterial versus venous bleeding is often difficult in the multi-injured trauma patient. In our experience, patients with hypotension and pelvic fracture that respond poorly or transiently to resuscitation typically have arterial bleeding, while good responses to resuscitation typically excludes arterial pelvic bleeding. The other main point illustrated is the concept of “damage control”. Clearly, patients who have the fatal triad of cold, coagulopathy, and acidosis have a high mortality. Rapid resuscitation, control of bleeding, and deferring definitive repair to a later date, are the keys to the injured patient’s survival (1).

References
1. Brandes S, Borrelli J Jr.: Pelvic fracture and associated urologic injuries. World J Surg. 2001; 25: 1578-87.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA