Compare and contrast the roles of angiography and surgical management in the management of the critically ill patient with ongoing haemorrhage due to pelvic fractures.
Practice management guidelines exist for the management of haemorrhage in pelvic fracture. The general principles are included below.
Angiography is not always required but may be life saving. It requires specialist radiology expertise (not necessarily widely available), requires transport to and needs to be performed in an area that may not be adequately set up for the complex monitoring and resuscitation that may be required in an unstable patient. Definitive selective embolisation may be able to be achieved to control arterial bleeding where other strategies (e.g. pelvic stabilisation or laparotomy) have failed.
Some form of surgical management is probably required in all cases, as at least some form of immobilisation (usually external fixation) will be required for unstable pelvic fractures. Laparotomy is indicated for the associated traditional signs of intra-abdominal bleeding or intestinal perforation. Apart from definitive stabilisation, other definitive surgical management is not usually helpful apart from general packing (without exploration) for venous haemorrhage, and rarely ligation of internal iliac arteries for uncontrollable arterial haemorrhage. Some aspects of surgical management may be able to be performed outside the operating room; otherwise transport is required (but to an area set up for ongoing monitoring and stabilisation).
Since 2004, technology has moved on, and so the opinion has shifted in favour of early angioembolisation. Even in 2003 this study supported the use of earlier angio for anybody with evidence of arterial bleeding. Furthermore, there is good evidence for a angiographic "mop-up" of bleeding which has not resolved after external surgical fixation.
This question would benefit from a 2 × 2 table of advantages and disadvantages.
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Miller, Preston R., et al. "External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage." Journal of Trauma-Injury, Infection, and Critical Care 54.3 (2003): 437-443.
Flint Jr, LEWIS M., et al. "Definitive control of bleeding from severe pelvic fractures." Annals of surgery 189.6 (1979): 709.
Cullinane, Daniel C., et al. "Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture—update and systematic review." Journal of Trauma and Acute Care Surgery 71.6 (2011): 1850-1868.
Metsemakers, W-J., et al. "Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience." Injury 44.7 (2013): 964-968.
Rossaint, Rolf, et al. "Management of bleeding following major trauma: an updated European guideline." Crit care 14.2 (2010): R52.