UROGENITAL TRAUMA

The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showing transient response to fluid resuscitation
Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S
Department of Traumatology and Critical Care Medicine, School of Medicine, Kyorin University, Tokyo, Japan
J Trauma. 2004; 57: 271-6; discussion 276-7

• 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.
  
  
• Editorial Comment
  This article nicely reviews contemporary treatment methods for unstable pelvic fractures, and presents a easy to follow protocol. In general, pelvic bleeding can be from a venous or arterial source. Methods to control venous bleeding are pelvis stabilization and closure of the pelvic ring. By doing so, the volume of the pelvis is markedly reduced; and thus allows venous bleeding to tamponade and promote hemostatic pathways in a confined space. Furthermore, re-approximated open bony surfaces will control cancellous bleeding. The typical methods employed are non invasive methods, external stabilization or internal stabilization. Placement of an anterior pelvic external fixator is typical; and if the patient is too unstable to go to the operating room, then temporary stabilization is achieved with military anti-shock trousers, pelvic “binder”, or a pelvic “C” clamp in the emergency room.
  When pelvic arterial bleeding exists, arteriography and trans-catheter embolization of the bleeding arteries are often required. Pelvic arterial injuries from pelvic fracture are in decreasing frequency, to the internal pudendals, superior gluteal, obturator and lateral sacral arteries. Arteriography is indicated in the presence of ongoing blood loss after intra-abdominal sources have been eliminated and the pelvis, at least temporarily, is stabilized. In stable patients, contrast blush on CT imaging indicates a high likelihood of arterial injury and angiography and embolization should be pursued.

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