Management options for haemorrhage from pelvic fractures

By Alex Yartsev - 01/01/2016

The ideal management option for unstable pelvic injuries with haemorrhage is still being debated. The 2004 guidelines (Heetveld et al) call for urgent surgical fixation, followed by angioembolisation if the bleeding cannot be controlled. This paper was the contemporary of Question 5 from the first paper of 2004, which asked directly about a comparison of surgery and angiography. Subsequently, technology moved on (the 2004 guidelines also asked for a DPL). The more recent 2010 guidelines (Cullinane et al) makes stronger recommendations for the use of angiography early.

Specific statements from these recent guidelines include the following Level I and II recommendations, regarding who should have urgent angioembolisation after a pelvic fracture:

Patients who are haemodynamicaly unstable and in whom non-pelvic sources of bleeding have been excluded
Patients in whom a "blush" of contrast is seen on a CT angio
Patients who are older than 60 with major pelvic fractures

More recently, authors have been swayed yet further towards angioembolisation as the primary method of control. In 2013, Abrassart et al have recommended that angioembolisation be the first approach, and laparotomy with pelvic packing only resorted to if there is no other option. Even more recently, the Italian Consensus Conference (Magnone et al, 2014) has come up with a sort of agreement among themselves. Again the guidelines were similar to the above, putting angiography in the role of primary therapy, and reserving pelvic packing for salvage procedures when all else has failed.

Question 21 from the first paper of 2012 asks the candidate to discuss the management of haemorrhagic shock due to pelvic fractures, in an unfocused what-would-you-do sort of way. This would not be very different to the emergency management of any severe trauma, until things came to the actual pelvis (and at that stage the choice of angio vs. surgery would again come up). Thus, that question is not dealt with here.

Other interesting options which are not mentioned in the table below are resuscitative endovascular balloon occlusion of the aorta (REBOA); this is dealt with well in the LITFL CCC entry of the same name.

Comparision of Management Strategies for Unstable Pelvic Fractures
	Advantage	Disadvantages
Conservative management	Non-invasive by definition May be most appropriate in patients whose perioerative risk is intolerably high (and is therefore a prelude to palliation) Usually, key measures are already in place on arrival to hospital (i.e. the pelvic binder).	Not a plan of management (in fact, the opposite of a plan) The pelvic binder is uncomfortable, contrary to the goals of palliation.
Surgery	Definitive control of bleeding under direct vision Definitive (external or internal) fixation of fractures Venous bleeding can be controlled, as well as arterial Ligation of large vessels is possible Temporary bypass of major vessel injuries can be performed as a part of damage control surgery	Invasive Availability depends on specialist expertise Damage control surgery may require a return to theatre to retrieve shunts and packs Usually II requires some radiation exposure Recommended by consensus guidelines to remain a salvage option, after primary angioembolisation
Angio-embolisation	Less invasive More immediately available May be performed before or after definitive surgery A sheath can be left in situ, and the procedure can be repeated An effective means of controlling bleeding which was not corrected by stabilisation surgery	Depends on the presence of arterial bleeding May require CT angiography to localise the "blush", to guide catheterisation Arterial bleeding has to be sufficiently vigorous to appear on CT and DSA Ischaemia of pelvic muscles and organs may result Vascular damage may result due to arterial access Requires specialist expertise Exposes the patient to radiation and contrast Exposes the patient to risk of transport

References

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.

Heetveld, Martin J., et al. "Guidelines for the management of haemodynamically unstable pelvic fracture patients." ANZ journal of surgery 74.7 (2004): 520-529.

Abrassart, Sophie, Richard Stern, and Robin Peter. "Unstable pelvic ring injury with hemodynamic instability: What seems the best procedure choice and sequence in the initial management?." Orthopaedics & Traumatology: Surgery & Research 99.2 (2013): 175-182.

Magnone, Stefano, et al. "Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian ...." World Journal of Emergency Surgery 9.1 (2014): 18.

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