UROGENITAL TRAUMA

Predicting Major Hemorrhage in Patients with Pelvic Fracture
Blackmore CC, Cummings P, Jurkovich GJ, Linnau KF, Hoffer EK, Rivara FP
Harborview Injury Prevention and Research Center, University of Washington School of Public Health and Community Medicine, Seattle, Washington, USA
J Trauma. 2006; 61: 346-52

• Background: Pelvic fractures can be an important source of major hemorrhage in victims of blunt trauma. However, no rapid and reliable noninvasive method exists for predicting which subjects will have major hemorrhage. The objective of this study is to use information available upon presentation to the trauma center to develop a clinical prediction rule to identify subjects with pelvic fracture who are at high risk of major hemorrhage.
• Methods: A retrospective cohort study was performed on all subjects with pelvic fracture from blunt force mechanism at a single level one trauma center during a 4.3 year period. Chart review identified findings from initial pelvic radiographs and from emergency department care including mechanism of injury, and hemodynamic status. Major hemorrhage was defined by angiographic findings, transfusion requirement and pelvic hemorrhage volume. Logistic regression was used to formulate a clinical prediction rule to stratify subjects based on probability of major hemorrhage.
• Results: Complete data were available on 627 of 783 eligible subjects. Predictors of major hemorrhage included emergency department hematocrit 30 or less, pulse rate of 130 or greater, displaced obturator ring fracture and pubic symphyseal wide diastasis. Combinations of predictors defined groups with probability of major hemorrhage from 1.6% to 66%.
• Conclusions: Probability of major pelvic fracture related hemorrhage can be estimated from initial pelvic radiograph, pulse, and hematocrit.
  
  
• Editorial Comment
  When dealing with pelvic fractures and a hypotensive patient (in shock) it is essential to first determine where the bleeding is coming from, whether from the chest, abdomen or pelvis. Initial methods to determine this are by physical exam, plain films of the pelvis and chest, and FAST scan. When the bleeding source is the pelvis, bleeding is either from a venous and/or arterial source. Pelvic fractures that increase the volume of the true pelvis can result in massive blood loss. Open book pelvic fractures are examples of potential great blood loss since a small increase in pelvis radius results in a volume increase of radius cubed. Methods to control venous bleeding then are to reduce the pelvic fracture and return the true pelvis to its original size. Such methods to reduce and stabilize pelvic fracture include pelvic binder, C clamp device, pelvic external fixation device, and internally rotating the lower legs and tying them together. For arterial bleeding, embolization of the pelvic vessels via angiography is typically needed.

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