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Management of Exsanguinating Pelvis Injuries

An algorithm for the management of exsanguinating pelvic trauma

Karim Brohi, London, UK, May 20, 2008

Severe pelvic injuries associated with disruption of pelvic vasculature carry an extremely high mortality.  A directed approach to management can significantly improve survival in this critical patient group.

Case Presentations

Anal Necrosis Following Pelvic Crush Injury

John S.Berry MD, Alfred F. Trappey MD, Joseph L. Petfield MD, Julia M. Greene MD, Katherine Markell MD

Julia Greene, November 28, 2012

Arterial haemorrhage within the pelvic circulation can be controlled by nonselective embolization. However, complications are associated with distal ischemia from disruption of the aortoiliac circulation. Reported complications of pelvic crush injury include impotence, lower extremity nerve deficits, left colon ischemia, spinal cord injury, and necrosis of the rectum and gluteal musculature. We report a case of anal canal necrosis after a pelvic crush injury attributed to hypotension, compression by pelvic hematoma, and arterial disruption after selective unilateral transcatheter arterial embolization (TAE).

Research Blog Entries

PubMed ID: 19204518
J Trauma. 2009 Feb;66(2):429-35
Authors: Fang JF, Shih LY, Wong YC, Lin BC, Hsu YP


BACKGROUND: Most arterial hemorrhage associated with pelvic fracture can be adequately controlled by a single transcatheter arterial embolization (TAE). However, there is a small group of patients who remain hemodynamically unstable after TAE, have no other identifiable source of bleeding, and who benefit from repeat TAE of the pelvis. METHODS: We conducted a retrospective study of patients with hemorrhage from pelvic fractures between January 2001 and June 2006. Clinical parameters and results were compared between patients requiring more than one pelvic TAE and those undergoing a single TAE. Risk factors for repeat TAE were identified by univariate and stepwise logistic regression analyses. RESULTS: During the study period, 174 of 964 patients with pelvic fracture received pelvic angiography for suspected arterial hemorrhage. One hundred forty TAEs were performed. Thirty-four (24.3%) patients underwent more than one angiography for suspected recurrent arterial hemorrhage, and 26 (18.6%) underwent repeat TAE. Repeat angiography was performed 3 to 58 hours (mean, 21 hours) after initial TAE. Patients with repeat TAE had significantly more blood transfusions, higher mortality rate, and longer intensive care unit stay. Independent predictors for repeat TAE included initial hemoglobin level lower than 7.5 g/dL (OR, 6.22), superselective arterial embolization in initial TAE (OR, 3.22), and more than 6 units of blood transfusion after initial TAE (OR, 3.22). CONCLUSION: Careful monitoring and prompt recognition of patients requiring repeat TAE is paramount. The arterial access sheath should remain in place for up to 72 hours after angiography. Initial hemoglobin level lower than 7.5 g/dL and more than 6 units of blood transfusion after initial angiography are predictors for repeat TAE. Superselective TAE is associated with a significantly higher risk of recurrent hemorrhage, and its use should be limited.