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A 47 year old man is brought to the trauma centre having had a wall collapse on him. On arrival he is fully conscious and has a pulse rate of 115 and blood pressure of 110/70. There are obvious abrasions over his abdomen and pelvis. Pelvis X-ray shows a complex lateral compression injury with iliac fracture. A pelvic belt was applied, though this did not improve the patient's haemodynamic status.
FAST ultrasound examination revealed a small amount of free fluid in the peritoneal cavity. A CT scan showed a small (Grade 1) liver tear. The lateral compression pelvic injury is complicated by a contralateral sacral fracture. There is evidence of active haemorrhage (contrast blush) in the pudendal and gluteal regions.
Contrast extravasation (Pudendal)
Contrast extravasation (Gluteal)
The small amount of fluid in the peritoneal cavity with minor liver tear was not thought to be responsible for the persistent tachycardia. The patient was transferred to the angiography suite. Angiography showed free haemorrhage from the pudendal artery (not shown) and complete cut off of the anterior division of the internal iliac artery. The pudendal vessel was embolised with gelfoam, and the transeted vessel was coiled. The patient rapidly stabilised haemodynamically and was transferred to a critical care area for further monitoring.
Anterior division cut-off
Coils in place
Patients with unstable pelvic fractures arriving in the emergency department in shock are likely to have an arterial injury. Failure to respond to non-invasive pelvic stabilisation is another marker of on-going pelvic haemorrhage. Once significant intra-peritoneal bleeding has been excluded angiography is the modality of choice to arrest pelvic haemorrhage.
trauma.org (7:8) August 2002