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The surgical haemostatic options for damage control
of Pelvic Fractures
HU Pan and ZHANG YingZe
Department of Orthopaedics, Third Hospital of Hebei Medical University,
Shijiazhuang, Hebei, China.
Correspondence to: Professor Ying-Ze Zhang, Department of Orthopaedic Surgery,
The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi
District, Shijiazhuang, Hebei 050051, P.R. China. (Tel:86-311-88603682 Fax:86-3118702362 Email:[email protected] )
Abstract: Unstable pelvic fractures usually associated with haemodynamic instability
and early mortality is usually secondary to uncontrolled haemorrhage, so the goal of
unstable pelvic ring disruptions treatment is preventing early death from lifethreatening haemorrhage. Damage control orthopedics is a good choice for the
treatment of severely injured pelvic fracture patients who are in an ‘unstable’ or ‘in
extremis’ clinical condition. In this case, according to the principle of damage control,
timely and decisively implement of appropriate as well as effective surgical
hemostasis is necessary, so pelvic packing, angiography and embolization, internal
iliac artery ligation, and/or artery balloon occlusion must be considered immediately
life-saving. The blood loss and the subsequent transfusion requirement can be
decreased by performing limited surgical interventions, which may be beneficial to
critical ill patients, reduce the developing of systemic complications, affecting the
outcome of patients, and eventually reduce early mortality.
Key words: pelvic fracture, damage control, surgical
1
The diagnosis and treatment of pelvic ring disruption have significantly changed
over the past 30 years. It was not until 1980s that the concept of damage control
surgery was applied to the management of severely traumatic patients. The contents of
damage control surgery mainly including three-phase: the initial stage, the goal of
severely pelvic trauma treatment is using simple surgical techniques to control lifethreatening bleeding; the second stage, the physiological disturbances of the patients
were corrected by ICU resuscitation; and the third stage, the definitive surgery is to
perform for the injuries.[1]10% to 20% of patients with severe unstable pelvic fracture
also present with hemodynamic instability, and the mortality rate of them can be as
high as 40%. [2,3,4]Although hemodynamic resuscitation techniques have made great
progress, some patients do not respond or poorly respond to resuscitation treatment. In
this case, according to the principle of damage control, timely and decisively
implement of appropriate as well as effective surgical hemostasis is necessary. What's
more, any surgical intervention must be considered immediately life-saving. The first
step to control the hemorrhage is to restore pelvic stability and compress pelvis
volume, now often used external fixator or C-clamp, in order to reduce bleeding, use
some surgical options further to control the bleeding.[5]
1. Pelvic packing
Pelvic packing is used to control hemorrhage from unstable pelvic fractures in
the 1960s, ventral midline incision into the retroperitoneal space, pelvic packing is
usually performed by packing three surgical gauze pads on each side of anterior sacral
area and next to the bladder, into the true pelvis below the pelvic brim, stuffing is to
be removed or replaced within 24 ~ 48h.[6] Ertel et al[7] applied pelvic packing to the
treatment of 14 cases of pelvic fracture caused sustained hemorrhagic shock (13 cases,
bleeding from the venous plexus, and 1 case from the ruptured iliac vein). The
unstable pelvic ring was externally fixed with C-clamp before laparotomy. The author
suggested using external fixation (such as the C-clamps) to restore the stability of the
2
pelvis and to reduce the volume of the pelvis before pelvic packing, which improved
hemostatic effect of pelvic packing.
The pelvic packing is mainly used to control venous bleeding, while
angiography and embolization is used to control arterial bleeding，but now the two
methods in hemodynamic used in specific indications of unstable pelvic fracture is
controversial.[2] Osbom et al[8] compared the pelvic hemostasis effect of pelvic
packing surgery and angiography embolization in patients with pelvic fractures (20
patients each group). Since admissions to surgery, preoperative preparation of pelvic
packing cost significantly less time than that required by angiography (45 min vs. 130
min); within the first 24h after surgery, the patients of embolization group required
significantly more transfusion than patients of pelvic packing group; non of the
patient in pelvic packing group died of excessive bleeding, while 2 deaths was
occurred in embolization group. It is indicated that pelvic packing can contribute to
the overall control of bleeding, reducing transfusion and early postoperative mortality.
Nowadays, in order to improve the success rate of hemostasis, more scholars
tend to combine pelvic packing with angiography and embolization to treat
hemodynamically unstable pelvic fractures.[2,9]Tai et al.[10] compared 11 patients
treated with pelvic packing and 13 cases with angiography and embolization. 5
patients in pelvic packing group underwent angiography as well. The preparation time
of pelvic packing was less than that of angiography and embolization (78.8 min vs.
139.5 min). The mortality of pelvic packing group was 36.3%, while the mortality of
embolization group was 69.2%. Cothren et al[2] reported 28 cases of retroperitoneal
pelvic packing treatment for hemodynamically unstable pelvic fracture with fixation
of C-clamp or external fixation for anterior pelvic ring at first, and then
retroperitoneal pelvic packing. The first 4 cases underwent conventional angiography
3
postoperatively, 1 of which was treated with embolization simultaneously; among the
subsequent 24 cases, only the patients occurred with postoperative hemodynamic
unstable (4 cases) were treated with the angiography and embolization, resulting in
satisfactory hemostasis. There were 7 mortality however; they did not die of acute
bleeding. These results suggest that pelvic packing as early as possible combined
with angiography if necessary is more efficient than simple angiography and
embolization in hemostasis for patients with hemodynamically unstable pelvic
fractures.
Compared with minimally invasive angiography and embolization, the
shortcomings of pelvic packing are its open invasiveness and its related secondary
infection.[2,11] In addition, another drawback is that the stuffing needs to be removed
by the second surgery 24 to 48 hours after pelvic packing.[10] Some scholars worry
about that
laparotomy
may
increase
pelvic
volume,
in which
abdominal
decompression thus directly increases pelvic hemorrhage. The surgery may damage
the integrity of peritoneum as well as causes rupture of pelvic hematoma, which will
destroy filling effect of retroperitoneal space.[12]
2. Angiography and Embolization
In 1972, Margolies et al[13] first reported angiography and embolization for
pelvic fracture bleeding. At present, this is one of the preferred surgical hemostasis
techniques to control sustained bleeding of pelvic fractures. Balogh et al[14] showed
that when the patients with severe pelvic fracture were treated with angiography and
embolization within 90 minutes after admission, the mortality rate is reduced. Cherry
et al[15] also reported that the survival rate was significantly improved when the
patients received an embolization treatment within a short time after admission.
Hence, many scholars believe that all of the tertiary trauma centers should perform the
4
angiography and embolization at any time, to ensure the pelvic fracture patients with
unstable hemodynamics are timely treated.[16,18] With the increase of treatment
experience and the improvement of the treatment process, a recent research report
shows that the average time from the patients admitted to hospital till the time taken to
complete operation in past was about 17 hours ,[17] which has been reduced to 2
hours.[18]
In order to determine the exact types of pelvic bleeding patients who will
benefit from angiography and embolization treatment, Salim et al[19] reviewed 85
cases of embolization treatment for closed pelvic fracture in a Level 1 trauma center,
and found that female, hypotension and sacroiliac joint separation were independent
predictors to benefit of artery embolization. Some scholars found that the type of
pelvic fracture and the mechanism of pelvic fracture injury usually help to determine
the demand of pelvic angiography embolization.[20] Costantini et al[21] reviewed 819
pelvic fracture cases in tertiary trauma centers, 31 patients underwent pelvic artery
angiography, 18 patients suffered with active arterial bleeding and required for arterial
embolization. The most common type of pelvic fracture was complex pelvic fracture;
those were the patient who needed angiography. Sacral fracture and sacroiliac joint
dislocation are more likely to show positive angiography results, while negative
results often occur in patients with anterior-posterior compression. Karadimas et al[22]
reviewed 34 cases of pelvic fracture, the pelvic angiography results on comparisons to
the transverse compression fractures and the anterior-posterior compression the latter
tends to bleed more, but the difference is not significant.
It is reported that angiography and embolization can effectively control
the retroperitoneal hematoma and arterial bleeding caused by pelvic fracture,
and improve the patient's hemodynamic stability.[23] Fu[24] reviewed 28 cases of pelvic
5
fractures associated with hemodynamic instability (systolic blood pressure less than
90 mmHg). After angiographic embolization, the systolic blood pressure was
significantly improved and hemodynamic stability was recovered. Out Of 16 cases
treated with embolization alone, 2 dead resulting from persistent bleeding due to
multiple organ failure. On the contrary, of another 12 cases received pelvic packing
and subsequent angiography & embolization, only 1 patient died of uncontrolled
intra-abdominal
hemorrhage.
The
authors
insisted
that
angiography
and
embolization is effective for patients with hemodynamically unstable. Considering the
possible presence of arterial contracture, it is recommended that the patients should
undergo embolization without contrast extravasation.
Although angiography embolization can effectively control bleeding in pelvic
fracture, still the mortality rate is as high as 50%, and its efficacy has been
questioned.[25] To this end Hauschild et al.[26] the clinical data from German pelvic
injury has been registered. There were 152 cases of pelvic fractures, patients with
arterial and venous injuries confirmed by enhanced CT, including 17 cases underwent
angiography and embolization and 135 cases with external fixation and pelvic packing.
The patients treated with embolization required larger volume of blood transfusion,
leading to higher incidence of adult respiratory distress syndrome and multiple organ
failure, but the cause of death was not excessive bleeding. In contrast, 20.6% patients
of non-embolization group died of bleeding. Vascular embolization overall is an
effective hemostasis method for pelvic fractures associated with vascular damage.
Angiography and embolization requires specialized imaging equipment, which
are not available in some operating rooms. To this end Teo[27] studied whether
embolization can be fulfilled with the aid of C-arm digital subtraction angiography in
operating room. Of 43 patients treated with angiographic embolization, 32 patients
6
received C-arm digital subtraction angiography guided embolization, including 26
cases present with pelvic vascular injury. No bleeding was documented in patients
who received C-arm digital subtraction angiography guided embolization. Fifteen
cases survived and 17 cases died. Autopsy proved that the deaths were related with
severe injury and not due to hemorrhage.
Although arterial bleed only accounts for 10% to 20% of the bleeding caused
by pelvic fractures,[28] the proportion of arterial bleed in hemodynamically unstable
pelvic fracture may be even higher. Therefore, angiography and embolization
for these patients is conducive to control bleeding. Zhang et al.[29] reviewed the
treatment of 44 patients with pelvic fracture patients associated with hemorrhagic
shock. The 41 cases confirmed with bleeding from internal iliac artery and its
branches received puncture via femoral artery under local anesthesia, the catheter was
inserted to the proximal ends of left and right common iliac artery branches and
selective angiography was carried out. When the sites of bleeding were identified, the
wool-tufted wire coils were preloaded into the catheter for embolization, which
resulted in 39 successful cases and 2 cases of hemorrhagic shock and died because
of the downward shift of embolization.
Complications of pelvic angiography and embolization include hematoma at
arterial puncture sites, vascular intimal breakdown, pseudoaneurysm and gluteal
muscle necrosis, the incidence of which is very low.[30,31] In some certain patients
associated with a huge hematoma, hypotension or degloving injury, it may be difficult
to insert the catheter into the femoral artery, which affects the angiography. Ramirez
et al[32] studied the symptoms of the urinary and reproductive systems in 3 different
subgroups of trauma patients. The first group differentiated with serious pelvic
injuries but not with embolization; the second group was with serious pelvic fractures
7
and embolization; and the third group was with other serious injuries but no pelvic
trauma. The authors found that genitourinary dysfunction derived from the pelvic
fracture itself, rather than embolization.
To categorize the patients who needed second angiography and embolization,
in patients with initial successful embolization. Shapiro et al[33] described out of 31
pelvic fracture cases of angiography, 16 (51.6%) cases initially diagnosed with arterial
bleeding and underwent embolization, of which 3 cases were treated with
angiography and embolization again due to sustained pelvic bleeding .In previous 15
cases with negative angiography without embolization, 5 cases received angiography
again due to persistent hypotension and acidosis. 4 of these 5 patients required
embolization because of arterial bleeding .Comparing multiple variables in successful
embolization and second embolization, the authors found 3 independent risk factors
for second embolization: continuous or recurrent hypotension (systolic blood pressure
<90 mmHg); intra-abdominal injury; alkaline deletion of more than 10 for at least 6
hours. The presence of all three independent predictors was associated with a 97%
probability of pelvic bleeding, while none of the three factors indicated 9%
probability. Therefore, the authors suggested that pelvic fracture patients with
persistent bleeding should adopt second angiography when other potential sources of
bleeding have been excluded. Therefore, for severe pelvic fracture patients with
negative angiography sustained shock, or unstable blood pressure after angiography
and embolization, it should be considered that whether the laparotomy and pelvic
packing to control bleeding from venous plexus, as well as repeat angiography.
3. Internal iliac artery ligation
Internal iliac artery ligation is a "second-line" hemostasis means to control
pelvic hemorrhage. Combined with pelvic packing, it may be quick and efficient in
8
controlling hemorrhage in some special cases, such as rapid deterioration of
hemodynamics or serious hemodynamic instability during the emergency abdominal
exploration. It controls pelvic hemorrhage by blocking the blood flow and reducing
venous bleeding. DuBose et al[34] reported that in 201 pelvic fracture cases required
emergency laparotomy, out of which 28 cases undertook damage-controlled internal
iliac artery ligation. There were 15 cases of hypotension (systolic blood pressure <90
mmHg) reported after arrival in the emergency. When the bleeding from other organs
was controlled, pelvic expansion hematoma was found and continuous hemodynamic
instability occurred during surgery. Another 13 cases without hypotension occurred
with refractory hypotension or decompensation subsequently. Tissue isolation was
performed from the hematoma ,carefully along the common iliac artery in the
retroperitoneal space from proximal to distal, bilateral ligation of internal iliac artery
and routine pelvic packing were carried out while anterior internal artery was freed at
the bifurcation. Out of 18 deaths (64%), 7 deaths were due to severe brain trauma,
other 7 patients died of respiratory and cardiac arrest in the operating room, 3 patients
died of coagulation disorders within 48 hours after surgery, 1 patient died of sepsis
and multiple organ failure on 8th postoperative day and 1 patient died of sepsis which
was not related with ischemia caused by bilateral internal iliac artery ligation. The 10
patients survived without any ischemic complications related to bilateral internal iliac
artery ligation.
Ran XJ et al[35] stabilized the pelvis by external fixators and double ligation of
bilateral internal iliac artery and its main branches to treat 23 cases of unstable pelvic
fractures patients with varying degrees of hemorrhagic shock, within 2 to12 hours
after injury. First immediate primary management should be done for pelvic fractures;
patients with severe bleeding were planned for transfusion about 3000 to 4000ml for
9
hemodynamic stability as they have poor prognosis or hemodynamically unstable.
After transfusion of more than 2000ml blood the patient were planned for emergency
surgery. A midline incision was made in lower abdomen to expose retro peritoneum
through pelvis; the bilateral internal iliac artery was ligated along with the other
possible damaged main branches. The hemorrhage of 19 cases was under control
within 24 hours after emergency surgery, while 4 patients expired. Out of them, 1
patient expired before surgery due to
severe multiple injuries, 2 patients died
of uncontrolled bleeding and the other patient had pulmonary contusion one of the
complication with severe bleeding leading to death, main cause being multiple organ
failure and coagulopathy 48 hours after surgery. As there are rich branches of
anastomosis within and outside of pelvis, to improve the control of bleeding, double
ligation of bilateral internal iliac artery and possible damaged branches can block the
circulation.
Pelvic fractures, mostly caused by high-energy injury, are often accompanied
by damage to other organ. Zhang K et al[36] reported exploratory laparotomy and
ligation of the internal iliac artery planned treatment for 16 patients with intraabdominal organ injury and pelvic fracture caused bleeding. The patients received on
admission were unstable in shock, 1 patient died after surgery because of renal rupture
with excessive blood loss, coagulation disorders, and severe shock. 8 cases of
hemorrhagic shock disappeared after surgery; in 5 cases the hemorrhage was
controlled and patients were hemodynamically stable.
The amount of bleeding
reduced and hemodynamically improved in 5 cases; 2 patients with seriously open
pelvis crush showed no improvement. Yang J et al[37] reported 39 cases of unstable
pelvic fractures associated with abdominal organ injury, which were first treated with
internal iliac artery ligation, followed by rapid processing of abdominal injuries and
10
adjacent organ injuries (sometimes combined abdominal injuries in liver, spleen, etc.).
The mortality rate was 21% (8/39), including 6 patients occurred with hemorrhagic
shock and died within 24 hours during or after surgery, 1 patient died of chest injuries
combined with acute respiratory distress syndrome, and 1 case of postoperative with
multiple organ failure. In closed pelvic fracture with abdominal organ injury, if
retroperitoneal hematomas ruptured and continuous extra peritoneal bleeding
(especially arterial bleeding) are found in explorative laparotomy, the retroperitoneal
incision should be expanded and internal iliac artery should be ligated as soon as
possible.
4. Artery balloon occlusion
The percutaneous aortic balloon occlusion has been applied for the treatment
of hemorrhagic shock caused by rupture of abdominal aortic aneurysm, abdominal
trauma, gastrointestinal bleeding and postpartum hemorrhage.[4] Rieger et al[38] for the
first time reported the iliac artery balloon occlusion technique for the treatment of
pelvic fracture complicated with uncontrollable bleeding. All 7 patients with complex
pelvic fracture patients had signs of hemorrhagic shock, and artery angiography
showed arterial bleeding of the internal iliac artery. Temporary non-selective balloon
occlusion via femoral artery, with balloon placed in the proximal bleeding site,
effectively controlled postoperative bleeding. The patient's hemodynamic stability
makes transfer, further surgery and / or ICU resuscitation become possible. It is
advised to place the balloon in situ with no pressure for another 24 to 48 hours, in
order to facilitate the control of possible re- bleeding. Before removing the balloon,
angiography should be performed to confirm that the arterial bleeding has been under
control.
11
In order to save preparation time and save life, Linsenmaier al[39] introduced
the CT-guided abdominal aorta balloon occlusion. When active bleeding in the
abdomen or pelvis was found in CT diagnostic scanning in patients with severe
hemodynamic instability, CT scanning was used to confirm the position of the guide
needle and the balloon. The occlusion could be completed within 4 to 6 minutes.
After occlusion the systolic blood pressure rose to 100mmHg or above, and the
blocking time lasted for 60 minutes. In their study, 2 of 3 cases died due to prolonged
shock and combined injuries. CT-guided abdominal aorta balloon occlusion can save
time for hemodynamic recovery.
As artery balloon occlusion is temporary, there is no need to be highly selective.
Therefore, Martinelli et al[4] reported blind insertion (without the aid of the imaging
method) of balloon occlusion of the infra renal aorta to control pelvic hemorrhagic
shock. In 2064 cases of pelvic fractures, 13 pelvic fractures patients with severe
uncontrolled hemorrhagic shock underwent abdominal aortic balloon occlusion. Such
patients may die any time and cannot be transferred .The balloon was put into the
aorta and slowly expanded with gently back and forth pulling the friction between
aorta wall and balloon was felt, the balloon was pulled out until it got stuck at the
bifurcation of the abdominal aorta. The balloon was then sent back by 5cm to the
aorta below renal artery until pulse of the bilateral femoral artery disappeared after the
balloon occlusion, indicating successful aortic occlusion. 10 cases of abdominal aortic
balloon occlusion were performed in rescue room, 1 case was completed in operating
room after splenectomy and 2 cases were transferred from secondary hospitals
because of lacking angiography equipments (after abdominal aorta balloon
occlusion).2 patients died because CT scans after abdominal aortic balloon occlusion
were carried out for an average time of 56 minutes. Considering CT examination will
12
delay the follow-up treatment, patients should receive direct angiography and
embolization after occlusion, regardless of their hemodynamic status. The average
time of abdominal aortic occlusion was 70 ± 39 minutes. After abdominal aortic
balloon occlusion, systolic blood pressure maintained to 111mmHg on average. Apart
of the immediate intervention one case of abdominal aortic balloon block died in the
emergency room. 12 cases of abdominal aortic balloon occlusion were transferred
to angiography room, and angiography showed multiple bleeding sites at the internal
iliac artery branches (12 cases, 8/12 cases of bilateral), iliolumbar arterial bleeding (2
cases), median sacral artery (three cases), superior gluteal artery (2 cases), pudendal
artery (1 case). The balloon was released before embolization in 11 cases, and after
embolization in 1 case. Hemodynamic shock recurred after balloon release in 6
cases, 2 cases died despite of rapid inflation of the balloon, 1 case required temporary
recharge of the balloon to treat hemorrhagic shock, and the other 3cases only need
resuscitation treatment. The overall survival rate was 54%, and all the deaths occurred
within the first 24 hours, with an average death time of 6.6 hours. Except for 1 case
died in the emergency room, 2 cases died due to the shock induced by releasing the
balloon before embolization, 2 cases died of secondary hemoptysis and hemothorax
during embolization process, and 2 cases died after the completion of the
embolization (1 died of coagulopathy and the other died of unknown
cause).They proposed that the patients should be immediately transported to the
intervention room for embolization as soon as possible after abdominal aortic balloon
occlusion, even when the abdominal aorta hemodynamics shows considerable
improvement after balloon occlusion.
The intra-aortic balloon occlusion compared with the other life saving measures
of pelvic fracture bleeding, such as pelvic stuffing, the former is a minimally invasive
13
treatment, doesn’t require any incision and balloon can be easily deflated and
removed without foreign body left into the peritoneal or retroperitoneal with less risk
of infection. In addition, this technique avoids the complications of peritoneal incision,
including scars, ventral hernia, etc, and there are no difficulties in wound closure in
obese patients. Intra-aortic balloon occlusion can also be applied in combination with
other treatment methods, such as C-clamp, pelvic tamponade.
Summary
In patients with concomitant unstable hemodynamics and severe pelvic
fracture, the first phase of damage control is to control the life-threatening
hemorrhage. On a comprehensive assessment of the patient's general condition and
composite on the basis of the degree of injury, and initial recovery of the pelvic
stability. According to the principle of damage control rapidly taken alone or
combined application of pelvic tamponade, arterial embolization, internal iliac artery
ligation surgery and balloon artery occlusion surgery is the key to manage and
improve hemodynamically unstable pelvic fracture for patient’s rescue success rate
and reduce the mortality.
14
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