Bleeding pelvic fractures: updates and controversies in acute phase management

Transcription

1 Hong Kong Journal of Emergency Medicine Bleeding pelvic fractures: updates and controversies in acute phase management CH Lai and CW Kam Background: The management of patients with haemodynamic instability related to pelvic fractures is a major challenge with high mortality and morbidity. The treatment priorities have long been a source of debate. Many advocate emergent external fixation (EX-FIX) as the first line of treatment, whereas another school favours the efficacy of transcatheter arterial embolisation (TAE). Decision-making within the 'Golden Hour' in the emergency department (ED) is crucial to patients' ultimate outcome. Our aim was to evaluate the current management pathways in our centre and to review the latest literature. Methods: We present a 2-year case series (from January 2005 to December 2006) of patients with pelvic ring disruption and haemodynamic instability. Data were collected regarding patients' demographics, fracture patterns according to the Young & Burgess classification, concomitant intra-abdominal injuries, treatment pathway and the response to treatment. Results: There were 7 patients identified. Five were males and 2 were females, with a mean age of 42 years. Fracture types included 3 lateral compression, 1 anteroposterior compression, 2 vertical shear, and 1 combined mechanism. Four patients had significant intraperitoneal haemorrhage identified by Focused Assessment by Sonography for Trauma (FAST). They all needed laporotomy and pelvic packing, initially or subsequently. EX-FIXs were offered to 6 patients as the primary intervention, and 4 of them subsequently required diagnosis with angiography followed by therapeutic embolisation to restore haemodynamic stability. Only 1 patient underwent a second angiographic study to control the arterial bleeding. Two patients died of severe intra-abdominal injuries within 24 hours after admission. Conclusion: In patients with pelvic fractures and hypotension, EX-FIX is currently the first line of treatment, with variable efficacy. On the other hand, the high successful embolisation rate and reasonable safety profile of TAE in our patients have been impressive. The latter offers a much better alternative to surgical intervention in selected patients. However, precautions should be taken including proper pelvic stabilisation by noninvasive devices, creation of a safe environment in the angiography suite, and early multidisciplinary decision in the ED. (Hong Kong j.emerg.med. 2008;15:36-42) Correspondence to: Lai Cing Hon, MBBS, MRCSEd, FHKAM(Emergency Medicine) Tuen Mun Hospital, Accident & Emergency Department, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong laichj@yahoo.com Kam Chak Wah, FRCSEd, FHKAM(Emergency Medicine)

2 Lai et al./bleeding pelvic fractures Keywords: Bone fractures, external fixators, fracture fixation, haemorrhage, therapeutic embolisation Introduction Pelvic fractures are indicative of high-energy transfer to the patient and associated injuries including thoracic injury and intra-abdominal injury are common. However, profuse venous or arterial haemorrhage as a result of pelvic fracture alone, is also a significant contributor to the overall mortality in multiply injured patients. 1 Haemodynamically compromised patients with pelvic fractures present a complex challenge to emergency physicians (EPs) as well as the trauma team as a whole. The evolution of clearly agreed clinical pathways coordinating trauma surgeons, orthopaedic traumatologists, interventional radiologists and EPs has been proven to improve patient survival. 2 Reported effective treatments have included the use of external fixation (EX-FIX), transcatheter arterial embolisation (TAE), retroperitoneal or preperitoneal pelvic packing, 3 endovascular stenting of iliac vein, 4 administration of activated Factor VII, 5 and intra-aortic balloon occlusion 4 in extreme cases. Despite such multidisciplinary management, the mortality for these high-risk patients still exceeds 40%. 6 Since each therapeutic intervention addresses different bleeding sources, judicious patient selection and allocation to the most appropriate treatment is vital for improving patient outcome. In this case series, we report 7 patients with pelvic ring fracture and unstable haemodynamics. The treatments given, as well as the patients response to them were analysed. The latest literature concerning the acute management of bleeding pelvic fractures was reviewed and the role of EPs in facilitating the best patient care was also discussed. Methods A review of a consecutive series of trauma patients with pelvic fractures was conducted at Tuen Mun Hospital (TMH), within a 24-month period from January 2005 to December Patients were sorted out from the Clinical Data Analysis & Reporting System (CDARS). We searched for the diagnosis of pelvic fracture (ICD 9 coding 808) under the categories of principal and secondary diagnoses. TMH served a population of 1.5 millions with facilities comparable to a level one trauma centre in the United States of America. Patient data were extracted from emergency department (ED) and hospital records. The inclusion criterion for this study was a major pelvic disruption with haemodynamic instability at presentation in the ED, which was defined as systolic blood pressure less than or equal to 90 mmhg. Data retrospectively collected from the ED and hospital medical records included patients sex and age, fracture classification according to the Young & Burgess system, 7 Revised Trauma Score (RTS) and concomitant injuries to other body regions. The treatments offered in the acute phase including EX-FIX, TAE, laparotomy and pelvic packing,

3 38 Hong Kong j. emerg. med. Vol. 15(1) Jan 2008 and the sequences of management were analysed for each patient. The clinical course and treatment outcome were noted. Results Within the study period, 178 cases of pelvic fracture were identified. Among these patients, 17 involved a major disruption of the pelvic ring, and 7 of them had unstable haemodynamics. There were 5 males and 2 females. The mean age was 42 years (range 35-48). The fracture patterns were as follows: lateral compression - LC-I (1), LC-II (1), LC-III (1); anteroposterior compression - APC- III (1); vertical shear - VS (2) and combined mechanism - CM (1). Focused Assessment by Sonography for Trauma (FAST) was used as a diagnostic tool to look for intraperitoneal haemorrhage in the ED. Four of the 7 patients had positive FAST. The patients physiological parameters, fracture patterns and significant related injuries are shown in Table 1. The treatment sequence and outcome of the cases are summarised in Table 2. For those FAST positive cases, 2 were transferred to the operation theatre for laparotomy and retroperitoneal pelvic packing. One of them (case 3) died of extensive intraperitoneal haemorrhage. The other patient (case 2) underwent TAE and arterial bleeders were identified and embolised in two attempts. Two other cases (cases 4 and 5) with positive FAST were treated with anterior external fixators. One of them eventually required laparotomy and died (case 5), and the other proceeded to TAE followed by laparotomy and survived (case 4). For the 3 FAST negative cases (cases 1, 6 and 7), EX-FIX using either anterior frames (Figure 1) or C-clamp (Figure 2) was the first line of treatment, but 2 of them (cases 1 Table 1. Summary of fracture pattern, trauma score and concomitant injuries of the cases Classification* SBP RTS Major concomitant injuries Young Tile Case 1 CM C Case 2 LC-III B #right forearm, IPH Case 3** APC-III C Chest injury, liver injury with IPH Case 4 VS C Splenic injury, #LS, IPH, shock bowel Case 5** VS C Splenic injury with IPH, #ribs, #bilateral LL Case 6 LC-I B #LS, #ribs, pneumothorax, lung contusion Case 7 LC-II B IPH, #LS *Fracture classifications according to Young & Burgess and Tile's systems; **deceased cases; # = fracture; APC = anteroposterior compression; CM = combined mechanism; IPH = intraperitoneal haemorrhage; LC = lateral compression; LL = lower limb; LS = lumbar spine; RTS = Revised Trauma Score; SBP = systole blood pressure on arrival at the emergency department; VS = vertical shear Table 2. Sequence of treatment given to the cases and clinical outcome Case Classification* FAST scan Sequence of treatment Outcome 1 CM NEG EX-FIX > ANGIO > ORIF Discharged 2 LC-III POS Lap + EX-FIX > PP > ANGIO > ANGIO >ORIF Discharged 3 APC-III POS Lap > PP Dead 4 VS POS EX-FIX > ANGIO > Lap Discharged 5 VS POS EX-FIX > Lap Dead 6 LC-I NEG EX-FIX > CRIF Discharged 7 LC-II NEG C-Clamp > ANGIO > ORIF Discharged *Fracture classification according to Young & Burgess system; ANGIO = pelvic angiography with embolisation; APC = anteroposterior compression; CM = combined mechanism; CRIF = closed reduction and sacroiliac screw fixation; EX-FIX = anterior external fixator; FAST = Focused Assessment by Sonography for Trauma; Lap = laparotomy; LC = lateral compression; ORIF = open reduction and internal fixation; PP = pelvic packing; VS = vertical shear

4 Lai et al./bleeding pelvic fractures 39 and 7) subsequently required TAE (Figure 3a & 3b) because of persistent unstable haemodynamics. Both angiographic studies were successful in identifying the bleeding vessels which were embolised. Internal fixations were done for all 3 cases at a later stage and their clinical course was uneventful. No complications were reported for both EX-FIX and TAE. Mortalities seemed to be related to the severity of intra-abdominal trauma. None of the significant intraperitoneal injuries was missed by FAST and no diagnostic peritoneal lavage (DPL) was performed. All laparotomies were therapeutic. Figure 1. Radiograph of a patient with anterior external fixator applied. Discussion For years, we have been utilising the Advanced Trauma Life Support (ATLS) algorithm as the gold standard to stabilise multiply traumatised patients. However, its authority is being questioned recently especially for its shortcomings in specific areas including haemorrhage in pelvic disruptions. 8 It mainly stresses on the initial resuscitation of patients and pelvic stabilisation employing simple methods. It has been criticised for not reflecting the complexity of the bleeding in major pelvic disruptions, 8 not to mention the controversial topic of choosing EX- FIX or TAE as the primary intervention. 9 Figure 2. Radiograph of a patient after pelvic C-Clamp was applied. (a) (b) Figure 3. (a) Angiogram showing small bleeders and pseudoaneurysms (black arrow) over branches of the left internal iliac artery; (b) angiographic study of the same patient after successful embolisation of the left internal iliac artery.

5 40 Hong Kong j. emerg. med. Vol. 15(1) Jan 2008 Multidisciplinary management protocols have been developed in many trauma centres but there is no consensus about the sequence and timing of different treatment modalities. As a general rule, optimal therapies would be best chosen based on haemodynamic status, evidence of extra-pelvic haemorrhage, likelihood of arterial versus venous bleeding and availability of personnel and facilities. Evidence of intraperitoneal haemorrhage FAST has become the preferred method for the rapid detection of haemoperitoneum during the initial evaluation of patients sustaining blunt abdominal trauma. 10 However, its sensitivity and specificity in patients with pelvic fracture remain poorly defined. Friese et al reported a low sensitivity of only 26% for the detection of haemoperitoneum in pelvic fracture cases and suggested that further abdominal evaluation by DPL or abdominal-pelvic computed tomography (APCT) is warranted. 11 False negatives are certainly disastrous for our patients, but false positives can also lead to unnecessary non-therapeutic operations. Tayal et al also noticed a low specificity because of anatomical distortion, seepage of retroperitoneal haemorrhage, presence of bile or uroperitoneum. 12 The role of FAST in major pelvic fractures still needs further investigation. Nonetheless, interpretation of DPL results was also difficult in the presence of pelvic fractures, and a 29% false positive rate has been reported. 13 In our case series, in the hands of experienced EPs, FAST was deemed to be a reliable imaging to confidently rule out significant haemoperitoneum. Arterial or venous bleeding Given that each therapy addresses different bleeding sources, optimal treatment would be best chosen based on the origin of bleeding, whether it is arterial or venous. The majority of bleeding is of venous origin from injured soft tissue and pre-sacral venous plexuses, or from fractured cancellous bone edges. Arterial bleeding occurs in only 10% of patients, 14 which is more likely in elderly patients with atherosclerotic vessels, 15 and in patients with posterior element injuries. 16 Previous reports have implicated specific fracture patterns indicative of major ligamentous disruption (APC-II/III, LC-III, VS, CM) as having an association with arterial injury. 14 However, other authors were unable to define such a predictive role. 17 Even innocent looking fractures can lead to arterial bleeding. Patients with refractory shock despite fluid resuscitation and pelvic stabilisation were frequently reported to have a higher chance of positive angiography. 18 This correlation can be strengthened if patient age, trauma scores and biochemical markers were also considered. 19 If the patients are stable enough for transfer, APCT is a reliable tool to search for the sources of bleeding. Volume of retroperitoneal haematoma, presence of pseudoaneurysm and contrast blush, and clot location have been reported to be helpful. EX-FIX or TAE The principle of EX-FIX is to stabilise the fracture fragments in order to prevent dislodgement of formed clots. 20 Its tamponade effect in the pelvic cavity was not well demonstrated, and was not adequate for controlling arterial bleeding. 21 Since it is not a common practice to apply EX-FIX in the ED, initial patient resuscitation and management of co-existing injuries can be hindered. TAE will also be delayed in a subgroup of patients. 18 Complications including pin misplacement, pin tract infection, buttock or flank haematoma can also cause significant morbidity. The posterior fixator C-clamp would be a better solution, which can be applied rapidly in the ED, not requiring fluoroscopy, and the anterior bar can be rotated up and down to permit access for laparotomy or lower limb exploration. 2 Despite its high efficacy and successful rate, TAE has not been employed as the first line treatment in our locality. The possible reasons include potential hazards of patient transfer, unavailability of round-the-clock service and the controversial claim of venous bleeding not amenable to angiography. 22 Another school of thought, based on its high efficacy and safety, and the ability to control both intraperitoneal and retroperitoneal bleeding, recommended TAE for high risk patients. 19 If patients are eligible for TAE, it should be done as early as possible to reduce mortality. Angiography suite should provide intensive care unit quality of haemodynamic and ventilation support. Trauma surgeons should be available to perform continuous reassessment. 23

6 Lai et al./bleeding pelvic fractures 41 In our series, EX-FIX failed to control bleeding in 4 of the 6 patients, who subsequently needed TAE to achieve haemodynamic stability. This was compatible to the failure rate reported in another study. 22 For those with TAE performed, only 1 needed a second angiography and active bleeders were successfully embolised. Non-invasive devices for pelvic stabilisation In most management algorithms, temporary pelvic stabilisation using non-invasive devices is advised before sending the patient to the angiography suite. It may simply be a folded bed sheet acting as a pelvic wrap only. This is especially helpful in APC and posterior pelvic ring injuries, dramatically reducing the pelvic volume. Besides, it can be applied quickly and safely in the ED, without significant complications. 24 A lot of commercial products are also available in the market, such as pelvic sling, pelvic binder and Trauma Pelvic Orthotic Device (T-POD). When compared with anterior external fixators, they are of comparable strength, but less labour-intensive, radiolucent, less bulky, and can be cut in the groin area for femoral access for angiographic studies. 25 They are ideal devices for temporary pelvic stabilisation for patient transfer. EX-FIX, especially for posterior injuries. 28 The risk of releasing the tamponade effect of the pelvic peritoneum can be minimised by proper application of EX-FIX. 29 It is being used for bleeding of venous origin, but some advocate this approach as the treatment of choice for arterial bleeding. Extraperitoneal or preperitoneal pelvic packing was a novel approach with less surgical trauma to the patients and has been proved to be equally effective. 3 It may have an important role in managing bleeding pelvic trauma, particularly in exanguinating patients. Summary Haemodynamically unstable pelvic fractures carry a high mortality. The major causes of death in the acute phase are massive haemorrhage and associated injuries. Despite the improvement in initial care, controversy remains over the timing and optimal sequence of different therapeutic interventions. EX-FIX is being used as the primary intervention in our centre, with limited success. An alternative algorithm is therefore suggested (Figure 4). Patients with positive FAST scans Patients with unstable vital signs and positive FAST were generally operated. This is especially logical for those with stable pelvic fracture patterns, since the risk of pelvic arterial haemorrhage is low. However, in patients with abdominal visceral injuries, less than 50% were noticed to have ongoing active bleeding. 26 Even if life-threatening haemorrhage is present, up to % of hepatic, splenic and kidney haemorrhage have been reported to be controlled by TAE. For patients in shock with positive FAST and unstable fracture patterns, Hagiwara observed a reduction in mortality if TAE had been performed before laparotomy. TAE could also improve the surgical conditions of the patients, and reduce non-therapeutic operations. 27 Role of pelvic packing Although pelvic packing has been largely abandoned in North America, it is being practiced in some European trauma centres as the first procedure concurrently with EX-FIX = anterior external fixator; TCI = transvascular catheter intervention (includes transcatheter arterial embolisation [TAE] and transvenous stenting) Figure 4. Management algorithms for patients with haemodynamically unstable pelvic fracture and negative FAST scan. (A) The usual pathway in our centre. (B) Suggested alternative pathway for patients with high risk of arterial bleeding.

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