DOI: 10.1148/rg.246045112
RadioGraphics 2004;24:1605-1606
Invited Commentary
Clare Savage, MD and
Alan M. Cohen, MD
Department of Radiology, University of Texas Health Science Center, Houston
Frederick A. Moore, MD
Department of Surgery, University of Texas Health Science Center, Houston
The advent of multidetector helical CT, with rapid imaging of the chest, abdomen, and pelvis, has made CT an integral part of the secondary trauma survey. During CT for pelvic fractures, detection of a blush representing contrast material extravasation is used to identify arterial bleeding, with noted high correlation between the site of the blush and the injured vessel identified during angiography. In the preceding article, Yoon et al (1) eloquently delineate the course of the internal iliac artery and its branches in relation to the pelvic bony and ligamentous anatomy. The authors emphasize the sensitivity, specificity, and accuracy of contrast-enhanced CT in predicting arterial injury that will require angiographic embolization. Emphasizing the urgency of pelvic arterial bleeding and the increased mortality with delayed diagnosis and treatment, the authors focus on cross-sectional pelvic arterial anatomy to provide a road map to the interventionalist.
Pelvic arterial injuries directly correlate to the mechanism and severity of injury as well as the degree of instability of the pelvic ring, with arterial injuries more common in fractures with ligamentous disruption (2). Pelvic bleeding may be venous from soft tissues, veins, or the ends of fractured bones or may be arterial (3). An external fixator or pelvic binder may stabilize the pelvis and tamponade venous hemorrhage; however, these devices are often ineffective against hemodynamically significant arterial bleeding.
Confounding treatment of the pelvic trauma is concomitant abdominal injuries that often result from blunt trauma severe enough to disrupt the pelvic ring. The frequency of intra-abdominal injuries in patients with pelvic fractures ranges from 16% to 55%, with increasing frequency reported in patients with unstable pelvic fractures (2,4–6). In unstable patients with hemoperitoneum and pelvic fractures with CT evidence of arterial hemorrhage, the dilemma becomes one of triage. Many institutions, including our own, typically perform laparotomy in hemodynamically unstable patients with hemoperitoneum and pelvic ring factures, followed by pelvic angiography with embolization as needed (Figure).
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Figure. Algorithm for management of traumatic pelvic fractures. ABCs = airway, breathing, circulation, Angio = angiography, DPL = diagnostic peritoneal lavage, ICU = intensive care unit, OR = operating room, + = positive, – = negative, ± = with or without.
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Advocating early angiography and embolization in trauma patients with CT evidence of pelvic arterial injury, Yoon et al (1) quote a study from Parkland Memorial Hospital (7), which reports 25% mortality in patients with unstable pelvic fractures and abdominal injuries who underwent angiography and embolization followed by laparotomy versus 60% mortality in patients who underwent laparotomy then angiography. However, the Parkland study is a retrospective review that may include selection bias, with only four patients included in the patient group who underwent angiography and embolization followed by laparotomy. Although the merit of performing angiography prior to surgery in patients in shock is compelling from a radiologist’s perspective, the trauma literature is replete with reports that addressing the intra-abdominal injuries first may be lifesaving.
The authors also state that with decreased CT examination times, even patients with some degree of hemodynamic instability can be scanned. While recognizing that the decision as to whether a patient is stable enough to undergo CT is based on the clinical expertise of the trauma surgeon, we emphasize that a CT blush should not be the sole trigger for performing pelvic angiography in a hypotensive patient. In hypotensive patients with negative results at trauma ultrasound and/or diagnostic peritoneal lavage and a known pelvic fracture who fail to respond to initial resuscitation, pelvic angiography—without initial CT—should be considered, since over 70% of these unstable patients are reported to have arterial bleeding requiring embolization (3).
At our institution, hemodynamically unstable patients with pelvic fractures and significant intra-abdominal injuries undergo emergent laparotomy with placement of a pelvic binder. If a blush was present on the initial CT scans, pelvic angiography is performed. However, all discussion must include resources and response times. The response time of our interventional team during weekday working hours is immediate. At other times, our response time is 60 minutes, which is similar to or better than that of most level I trauma centers. In more remote hospitals, the interventional radiology response time may be longer. With in-house trauma surgery coverage 24 hours a day and 7 days a week, the question of laparotomy versus pelvic angiography often becomes academic in an unstable patient who presents after working hours.
Financial Interest: All authors have no financial relationships to disclose.
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References
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- Yoon W, Kim JK, Jeong YY, Seo JJ, Park JG, Kang HK. Pelvic arterial hemorrhage in patients with pelvic fractures: detection with contrast-enhanced CT. RadioGraphics 2004; 24:1591-1606.[Abstract/Free Full Text]
- Ben-Menachem Y, Coldwell DM, Young JWR, Burgess AR. Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management. AJR Am J Roentgenol 1991; 157:1005-1014.[Abstract/Free Full Text]
- Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003; 54:437-443.[Medline]
- Cryer H, Miller FB, Evers BM, Rouben LR, Seligson DL. Pelvic fracture classification: correlation with hemorrhage. J Trauma 1988; 28:973-980.[Medline]
- Murr PC, Moore EE, Lipscomb R, Johnston RM. Abdominal trauma associated with pelvic fracture. J Trauma 1980; 20:919-923.[Medline]
- Panetta T, Sclafini SJA, Goldstein AS, Phillips TF, Shaftan GW. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 1985; 25:1021-1029.[Medline]
- Eastridge BJ, Starr A, Minei JP, O’Keefe GE. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002; 53:446-451.[Medline]
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