Elsevier

Injury

Volume 40, Issue 4, April 2009, Pages 343-353
Injury

Review
Pelvic packing or angiography: Competitive or complementary?

https://doi.org/10.1016/j.injury.2008.12.006Get rights and content

Abstract

Pelvic angiography is an established technique that has evolved into a highly effective means of controlling arterial pelvic haemorrhage. The current dominant paradigm for haemodynamically unstable patients with pelvic fractures is angiographic management combined with mechanical stabilisation of the pelvis. However, an effective rapid screening tool for arterial bleeding in pelvic fracture patients has yet to be identified. There is also no precise way to determine the major source of bleeding responsible for haemodynamic instability. In many pelvic fracture patients, bleeding is from venous lacerations which are not effectively treated with angiography to fractured bony surfaces. Modern pelvic packing consists of time-saving and minimally invasive techniques which appear to result in effective control of the haemorrhage via tamponade. This review article focuses on the recent body of knowledge on angiography and pelvic packing. We propose the optimal role for each modality in trauma centres.

Introduction

Pelvic fractures continue to represent a challenge in terms of life-threat and functional outcome. Despite advances in management during the past decade, mortality remains significantly high. Overall mortality of patients with any pelvic fracture has been reported to be 5–10%.7, 11, 49, 71, 74, 83, 86, 93, 98, 99 Haemodynamically unstable pelvic fractures, however, have a mortality rate of 40–60%.15, 23, 71, 73, 98 The mortality rate in patients with open pelvic fractures is as high as 70% because of loss of the self-tamponade effect.18, 43, 85, 88

There are a wide variety of strategies to treat haemodynamically unstable patients with pelvic fractures.1, 7, 14, 16, 21, 22, 27, 39, 44, 45, 48, 67, 71, 91, 104, 109 However, the proposed algorithms in recent years have become so complex that they are often not useful in practice, and no gold standard guidelines have been established.2 The major contributor to this lack of concordance is that there is a myriad of variations in causes of shock and sources of bleeding in patients with pelvic fractures, and each treatment tends to become highly case dependent. High-energy impact is needed to disrupt the pelvic ring and these high-energy transfers are absorbed by the rest of the body producing major injury to other critical organs. Up to 90% of patients with unstable pelvic fractures have associated injuries and 50% of patients have sources of major haemorrhage other than pelvic fractures.75, 83, 88 Therefore, it is important to presume that a pelvic fracture is an indicator of multiple trauma. In the initial resuscitation of haemodynamically unstable patients with pelvic fractures, it is crucial to exclude concealed causes of shock, such as tension pneumothorax, pericardial tamponade, and neurogenic shock. The next step is digital control of external bleeding and immobilisation of multiple long bone fractures. Subsequently, focus should be on the intraperitoneal haemorrhage.2

Retroperitoneal haemorrhage should be assumed when a pelvic fracture is seen on the initial anteroposterior pelvis X-ray. However, there has not been a reliable method to estimate the amount of haemorrhage in the retroperitoneal space or to ascertain the relative contribution of arterial versus venous bleeding to the overall pelvic haemorrhage. Thus, to determine if the major cause of ongoing bleeding is due to pelvic fractures may often be a diagnosis of exclusion. Large transfusion requirement is not a reliable predictor for bleeding from the pelvis and that clinical assessment of haemodynamic instability with exclusion of other sources of haemorrhage is the best predictor of the need for haemostasis of the pelvis.3, 7, 45, 83, 93, 111 Therefore, while continuing fluid resuscitation, a rapid, systemic evaluation of the whole body is needed to manage patients with pelvic fractures. Once other sources have been excluded for the persistent haemodynamic instability, it is advisable to proceed immediately to advanced haemostasis of the pelvis, because haemorrhage is the major contributor to overall mortality in multiply injured patients with pelvic fractures.23, 27, 31, 71, 76, 81, 86, 88, 97

Currently, two different fundamental modalities have been advocated to treat persistent haemodynamically unstable patients due to pelvic fractures. Angiography and sequential embolisation can control arterial bleeding, while pelvic packing mainly controls bleeding from veins and fracture sites. However, specific indications for each treatment option remain controversial. Randomised, prospective studies examining which procedure is more effective do not exist because of the wide variations of associated multi-system trauma and reticence to challenge what is considered the standard.

This review article describes the current and future trends in the initial management of persistent haemodynamically unstable patients with pelvic fractures. Early identification of patients who do not respond to fluid resuscitation and prompt implementation of haemostatic techniques are the cornerstones to improve the mortality rate. The respective roles of pelvic angiography and pelvic packing are proposed based on the literature and our experience.

Section snippets

Overview of current management

In general, patients with haemodynamic instability due to haemorrhage should be initially resuscitated with 2 L of crystalloid followed by packed red blood cells (PRBC) and fresh frozen plasma (FFP) in a 1:1 ratio.2, 40 If the patients’ systolic blood pressure remains less than 90 mmHg despite PRBC transfusion, the patient is considered as a “non-responder,” and requires more advanced treatment.1, 2, 7, 15, 45, 67, 90, 91, 97 There is a poor correlation between the severity of the pelvic fracture

Controversies and problems of current strategies

Even with aggressive resuscitation, mechanical stabilisation, and successful embolisation, mortality remains high. Evers et al. reported that 88.9% of patients treated with embolisation eventually died.27 Several authors have reported that the mortality of patients treated with embolisation was around 50% despite successful control of arterial bleeding.1, 14, 18, 45, 61, 67 The disappearance of extravasation by embolisation is impressive and makes angiography appear to be a highly effective

Pelvic packing

The concept of damage control surgery evolved from packing to control hepatic bleeding and matured when applied for coagulopathy resulting from multiple abdominal injuries.100 Packing of liver injuries was initially discouraged due to serious complications in World War II and the Vietnam War. However, the technique was improved and re-established as an acceptable method during the past decades.29 Recently perihepatic packing has been used successfully not only for liver laceration but when

Combination of packing and angiography

In the resuscitation phase, immediate and precise identification of the major source of pelvic haemorrhage responsible for haemodynamic instability appears to be impossible at present. Major arterial injuries can occur with pelvic fractures, but is not always the case. Attempts to identify patients with major arterial bleeding to predict who needs angiography have been relatively unsuccessful. Furthermore, angiographic occlusion of the internal iliac artery does not affect the venous perfusion,

Conclusions and future directions

Haemodynamically unstable patients with pelvic fractures continue to represent the most frequent source of preventable death following blunt trauma. The major causes of death in these patients are early exsanguination and the late sequela of prolonged shock and mass transfusion. It is clear that successful management of pelvic fracture bleeding is best accomplished by a multidisciplinary team approach involving a variety of specialties. The immediate availability and total commitment from the

Conflict of interest

All authors confirm that they have no financial and personal relationships with other people, or organisations, that could inappropriately influence (bias) this work, all within 3 years of the beginning the work submitted.

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