Pelvic ring fracture in the older adults after minor pelvic trauma - is it an innocent injury?

OBJECTIVE: This study aimed to evaluate the prevalence of severe hemorrhage as a potentially life-threatening complication in elderly patients with isolated, low-energy pelvic ring fractures, which may be more common than previously described. PATIENTS AND METHODS: A retrospective cohort study was conducted at an academic level 1 trauma center, including 579 patients aged over 65 who suffered from isolated low-energy pelvic fractures between 2006 and 2020. Pelvic computer tomography (CT) scans, with or without contrast, were performed and reviewed for patients with suspected posterior ring injury or bleeding. Patients without CT scans were excluded from the study. RESULTS: Among the 123 patients with isolated pubic rami fractures, 30 (24.4 %) had bleeding with a significant hemoglobin drop (>2 g%). 21(70 %) patients of these had posterior pelvic ring involvement as compared to 45 who did not bleed (51 %, p = 0.07). There was a significantly larger proportion of patient who received anticoagulant therapy (ACT) with posterior ring injury among the bleeding group (20 % vs 3.2 % p < 0.01). Treatment included blood transfusion (19/123, 15.5 %), and arterial angiographic embolization (5/123, 4 %). No complications related to angio-embolization were observed, and all patients survived the initial 90-day period. No other source of bleeding was identified in any of these patients. CONCLUSION: Severe pelvic hemorrhage in the older adults due to a minor pelvic injury after a low-energy trauma is not an uncommon complication, especially with combination of ACT and posterior pelvic ring fracture. This indicates that these injuries more challenging than previously believed. Geriatric pelvic ring injuries should be monitored carefully with serial blood counts, and low threshold for imaging including contrast enhanced CT scans and angiography.

Factors Associated With Pelvic Infection After Pre-Peritoneal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures.

Background: Preperitoneal pelvic packing (PPP) and external fixation has led to improved mortality after devastating pelvic trauma. However, there is limited literature on infection after this intervention. We aim to study the risk factors associated with pelvic infection after PPP. Patients and Methods: A retrospective review of patients who underwent PPP at a single level 1 trauma center was performed. Results: Over the 18-year study period, 222 patients were identified. Twenty-three percent of patients had an open fracture. Pelvic angiography was performed in 24% of patients with 16% requiring angioembolization (AE). The average time to packing removal was two (one to two days) days, although 10% of patients had their pelvis re-packed. Overall infection rate was 14% (n = 31); if pelvic re-packing was performed, the infection rate increased to 45%. Twenty-two of the patients with an infection required additional procedures for their infection, and ultimately hardware removal occurred in eight patients. On univariable analysis, patients with pelvic infections had more open fractures (55% vs. 17%; p < 0.01), underwent AE more frequently (29% vs. 14%; p = 0.04), were more likely to undergo repacking (32% vs. 6%; p < 0.01), and had packing in place for longer (2 [1,2] vs. 2 [2,3]; p = 0.01). On logistic multivariable regression analysis, open fracture (odds ratio [OR], 5.8; 95% confidence interval [CI], 2.4-14.1) and pelvic re-packing (OR, 4.7; 95% CI, 1.2-18.5) were independent risk factors for pelvic infection. Conclusions: Pelvic infection after PPP is a serious complication independently associated with open fracture and re-packing of the pelvis. Re-intervention was required in most patients with infection.

Can Nondisplacement Osteoporotic Pubic Rami Fracture Be Life-Threatening Injuries? A Case Report, Overview, and Algorithm Protocol for Management.

Pubic rami fractures in the geriatric population are usually osteoporotic fractures resulting from low energy trauma and are characterized as stable injuries. Established treatment of these injuries is conservative, including rest, analgesic medication, and progressive active mobilization. These injuries are life-threatened when pubic rami fractures are accompanied by acute bleeding, either from an injury to a vessel (corona mortis) or from medication (anticoagulant or antiplatelet) for comorbidities, then. In this case study, we present the unusual case of an 82-year-old woman admitted to the emergency department 24 hours after a simple fall, causing nondisplacement osteoporotic pubic rami fracture, who, after 48 hours, developed a hematoma on the contralateral side of the pelvis, with progressive anemia and acute abdominal pain. This study has 2 objectives: to increase awareness of this life-threatening injury in the emergency department and to describe diagnosis and treatment modalities.

[Comparison of planimetric CT­based volumetry with simplified models for determining the size of intrapelvic hematomas due to pelvic fractures in emergency room diagnostics]. / Vergleich von planimetrisch CT­gestützter Volumetrie mit vereinfachten Modellen zur Größenbestimmung intrapelviner Hämatome bei Beckenfrakturen im Rahmen der Schockraumdiagnostik.

BACKGROUND: Bleeding in the pelvis can lead to a circulatory problem. The widely used whole-body computed tomography (WBCT) scan in the context of treatment in the trauma resuscitation unit (TRU) can give an idea of the source of bleeding (arterial vs. venous/osseous); however, the volume determination of an intrapelvic hematoma by volumetric planimetry cannot be used for a quick estimation of the blood loss. Simplified measurement techniques using geometric models should be used to estimate the extent of bleeding complications. OBJECTIVE: To determine whether simplified geometric models can be used to quickly and reliably determine intrapelvic hematoma volume in fractures type Tile B/C during emergency room diagnostics or whether the time-consuming planimetric method must always be used. MATERIAL AND METHODS: Retrospectively, 42 intrapelvic hemorrhages after pelvic fractures Tile B + C (n = 8:B, 34:C) at two trauma centers in Germany were selected (66% men, 33% women; mean age 42 ± 20 years) and the CT scans obtained during the initial trauma scan were analyzed in more detail. The CT datasets of the included patients with 1-5 mm slice thickness were available for analysis. By area labelling (ROIs) of the hemorrhage areas in the individual slice images, the volume was calculated by CT volumetrically. Comparatively, volumes were calculated using simplified geometric figures (cuboid, ellipsoid, Kothari). A correction factor was determined by calculating the deviation of the volumes of the geometric models from the planimetrically determined hematoma size. RESULTS AND DISCUSSION: The median planimetric bleeding volume in the total collective was 1710 ml (10-7152 ml). Relevant pelvic bleeding with a total volume > 100 ml existed in 25 patients. In 42.86% the volume was overestimated in the cuboid model and in 13 cases (30.95%) there was a significant underestimation to the planimetrically measured volume. Thus, we excluded this volume model. In the models ellipsoid and measuring method according to Kothari, an approximation to the planimetrically determined volume could be achieved with a correction factor calculated via a multiple linear regression analysis. The time-saving and approximate quantification of the hematoma volume using a modified ellipsoidal calculation according to Kothari makes it possible to assess the extent of bleeding in the pelvis after trauma if there are signs of a C-problem. This measurement method, as a simple reproducible metric, could be embedded in trauma resuscitation units (TRU) in the future.

Management and Morbidity of Major Pelvic Hemorrhage in Complex Abdominopelvic Surgery.

INTRODUCTION: Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management, and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdominopelvic surgery. METHODS: Patients who had major intraoperative pelvic hemorrhage during complex abdominopelvic surgery at 11 tertiary referral centers between 1997 and 2017 were included. Patient characteristics, management strategies to control bleeding, short- and long-term postoperative outcomes were evaluated retrospectively. RESULTS: There were 120 patients with a mean age of 56.6 ± 2.4 years and a mean BMI of 28.3 ± 1 kg/m2. While 104 (95%) of the patients were operated for malignancy, 16 (5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90 (75%). Major pelvic hemorrhage was managed simultaneously in 114 (95%) patients. Electrocauterization 27 (23%), pelvic packing 26 (22%), suturing 7 (6%), thumbtacks application 7 (6%), muscle welding 4 (4%), use of energy devices 2 (2%), and topical hemostatic agents 2 (2%) were the management tools. Combined techniques were used in 43 (36%) patients. Short-term morbidity and mortality rates were 48 (40%) and 2 (2%), respectively. High preoperative CRP levels (p = 0.04), history of preoperative radiotherapy (p = 0.04), longer bleeding time (p = 0.006), and increased blood transfusion (p = 0.005) were the factors associated with postoperative morbidity. CONCLUSION: Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdominopelvic surgery.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) prior to interfacility transfer: Who might benefit in a statewide trauma system?

BACKGROUND: Rural trauma patients are often seen at lower-level trauma centers before transfer and have higher mortality than those seen initially at a Level 1 Trauma Center. This study aims to describe the potential for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to bridge this mortality gap. METHODS: We queried the Arizona Trauma Registry between 2014 and 2017 for hypotensive patients who were later transported to a level 1 center. REBOA candidates were identified as those with injuries consistent with major infra-diaphragmatic torso hemorrhage as the likely cause of death. RESULTS: Of 17,868 interfacility transfers during the study period, 333 met inclusion criteria and had sufficient data for evaluation. 26 of the 333 patients were identified as REBOA candidates. CONCLUSIONS: Our study suggests that REBOA may be an effective means to extend survivability to those severely injured trauma patients needing interfacility transfer to a higher level of care.

Complications Following Temporary Bilateral Internal Iliac Artery Ligation for Pelvic Hemorrhage Control in Trauma.

Background: Temporary bilateral internal iliac artery ligation (TBIIAL) is an option for surgical control of pelvic hemorrhage after trauma. Concerns persist that complications, particularly gluteal necrosis, following TBIIAL should preclude its use, despite a lack of formal research on TBIIAL complications. This study aimed to define complications following TBIIAL for emergent control of traumatic pelvic bleeding.Study Design: Patients undergoing TBIIAL after blunt trauma (2008-2020) at our level 1 trauma center were included without exclusions. Demographics, clinical/injury data, and outcomes were collected. Descriptive statistics summarized study variables. Multivariable analysis of factors independently associated with mortality after TBIIAL was performed.Results: In total, 77 patients undergoing emergent TBIIAL after blunt trauma were identified. Median age was 46 [IQR 29-63] years. Most patients (n = 70, 91%) were severely injured (ISS ≥16), with 43% undergoing resuscitative thoracotomy prior to TBIIAL. No local complications (gluteal necrosis, iatrogenic injury, fascial dehiscence, surgical site infection) after TBIIAL occurred over the 13-year study period. In the first 28 days after injury, median hospital-, ICU-, and ventilator-free days were 0. Mortality was 70% (n = 54). On multivariable analysis, older age was the only variable independently associated with in-hospital mortality (OR 1.081, P = .028).Conclusion: Zero cases of gluteal necrosis, iatrogenic injury to surrounding structures, or surgical site infection/fascial dehiscence of the exploratory laparotomy occurred over the study period. High concern for gluteal necrosis after TBIIAL in severely injured trauma patients is unfounded and should not prevent a surgeon from obtaining prompt pelvic hemorrhage control with this technique among patients in extremis.

Radiographic and Clinical Predictors of Therapeutic Pelvic Angiography.

BACKGROUND: Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures. METHODS: All patients with blunt pelvic fractures who underwent angiography following admission CT scan were identified over a 6-year period. A radiologist reviewed the CT scans to identify potential predictors of pelvic hemorrhage. Patients were stratified by intervention [therapeutic angiography (TA) vs non-therapeutic angiography (NTA)] and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of TA. Youden's index was used to identify the optimal value of selected predictors identified on MLR. RESULTS: 177 patients were identified: 42% underwent TA and 58% underwent NTA. Patients undergoing TA were more likely to have a higher injury burden and greater resuscitative transfusion requirements, display both a brighter blush density on arterial phase CT and a larger % change in arterial to venous phase blush density. The optimal arterial blush density was determined to be 250 HU. MLR identified pre-angiography transfusion requirements (OR 1.175; 95% CI 1.054-1.311, P = .0189) and arterial blush density (OR 1.011; 95% CI 1.005-1.016, P < .0001) as independent predictors of therapeutic angiography. CONCLUSION: CT imaging remains vital in assessing patients with pelvic fractures and associated hemorrhage following blunt trauma. For patients requiring multiple resuscitative transfusions with CT findings of an arterial blush measuring ≥250 HU, early angiography should be the preferred approach.

Survival benefit for pelvic trauma patients undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta: Results of the AAST Aortic Occlusion for Resuscitation in Trauma Acute Care Surgery (AORTA) Registry.

BACKGROUND: Aortic occlusion (AO) to facilitate the acute resuscitation of trauma and acute care surgery patients in shock remains a controversial topic. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an increasingly deployed method of AO. We hypothesized that in patients with non-compressible hemorrhage below the aortic bifurcation, the use of REBOA instead of open AO may be associated with a survival benefit. METHODS: From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry, we identified 1494 patients requiring AO from 45 Level I and 4 Level II trauma centers. Presentation, intervention, and outcome variables were analyzed to compare REBOA vs open AO in patients with non-compressible hemorrhage below the aortic bifurcation. RESULTS: From December 2014 to January 2019, 217 patients with Zone 3 REBOA or Open AO who required pelvic packing, pelvic fixation or pelvic angio-embolization were identified. Of these, 109 AO patients had injuries isolated to below the aortic bifurcation (REBOA, 84; open AO, 25). Patients with intra-abdominal or thoracic sources of bleeding, above deployment Zone 3 were excluded. Overall mortality was lower in the REBOA group (35.% vs 80%, p <.001). Excluding patients who arrived with CPR in progress, the REBOA group had lower mortality (33.33% vs. 68.75%, p = 0.012). Of the survivors, systemic complications were not significantly different between groups. In the REBOA group, 16 patients had complications secondary to vascular access. Intensive care lengths of stay and ventilator days were both significantly shorter in REBOA patients who survived to discharge. CONCLUSIONS: This study compared outcomes for patients with hemorrhage below the aortic bifurcation treated with REBOA to those treated with open AO. Survival was significantly higher in REBOA patients compared to open AO patients, while complications in survivors were not different. Given the higher survival in REBOA patients, we conclude that REBOA should be used for patients with hemorrhagic shock secondary to pelvic trauma instead of open AO. LEVEL III EVIDENCE: Therapeutic.

Development of an Endovascular Model of Pelvic Hemorrhage Using Volumetric Computed Tomography Validation.

PURPOSE: Uncontrolled pelvic hemorrhage from trauma is associated with mortality rates above 30%. The ability of an intervention to reduce blood loss from pelvic trauma is paramount to its success. The objective of this study was to determine if computed tomography volumetric analysis could be used to quantify blood loss in a porcine endovascular pelvic hemorrhage model. MATERIALS AND METHODS: Yorkshire swine under general anesthesia underwent balloon dilation and rupture of the profunda femoris artery, which was confirmed by digital subtraction angiography. Computed tomography angiography and postprocessing segmentation were performed to quantify pelvic hemorrhage volume at 5 and 30 minutes after injury. Continuous hemodynamic and iliofemoral flow data were obtained. Baseline and postinjury hemoglobin, hematocrit and lactate were collected. RESULTS: Of 6 animals enrolled, 5 survived the 30-minute post-injury period. One animal died at 15 minutes. Median volume of pelvic hemorrhage was 141±106 cm3 at 5 minutes and 302±79 cm3 at 30 minutes with a 114% median increase in hematoma volume over 25 minutes (p=0.040). There was a significant decrease in mean arterial pressure (107 to 71 mm Hg, p=0.030) and iliofemoral flow (561 to 122 mL/min, p=0.014) at 30 minutes postinjury, but no significant changes in hemoglobin, hematocrit, or heart rate. CONCLUSION: Computed tomography volumetric analysis can be used to quantify rate and volume of blood loss in a porcine endovascular pelvic hemorrhage model. Future studies can incorporate this approach when evaluating the effect of hemorrhage control interventions associated with pelvic fractures.

Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis.

INTRODUCTION: Treatment of pelvic trauma related hemorrhage is challenging and remains controversial. In hemodynamically unstable patients suspected for massive bleeding, pre-peritoneal packing (PPP) with temporary external fixation (EF) and subsequent trans-arterial embolization (TAE) can be performed in order to control bleeding. In hemodynamically stable patients suspected for minor to moderate bleeding, primary TAE with EF may be performed. The goal of this study was to determine effectiveness and safety of both strategies. METHODS: Retrospectively, patients that received treatment for pelvic trauma-related hemorrhage at two level 1 trauma centers located in the United States between January 2001 and January 2019 were evaluated. Both centers advocate subsequent TAE in addition to PPP and EF in hemodynamically unstable patients, and primary TAE in stable patients. Demographic and clinical data was collected and mortality, ischemic and infectious complications were determined. RESULTS: In total, 135 patients met the inclusion criteria. Of these, 61 hemodynamically unstable patients suspected for massive pelvic bleeding underwent primary PPP (45%) and 74 stable patients suspected for minor/moderate bleeding underwent primary TAE (55%). In total, 37/61 primary PPP patients underwent EF (61%) and 48 underwent adjunct TAE (79%), performed bilaterally in 77% and unselective by use of gelfoam in 72% of cases. Primary TAE patients received embolization bilaterally in 49% and unselective in 35% of cases. Exsanguination-related deaths were found in 7/61 primary PPP patients (11%). There were none among the primary TAE patients. Potentially ischemic in-hospital complications, of which one could be considered severe (gluteal necrosis), occurred more in patients that received bilateral unselective TAE compared to all other TAE patients (p=0.02). CONCLUSION: Primary TAE appears to be an effective and safe adjunct for (minor) pelvic hemorrhage in hemodynamically stable patients. Primary PPP followed by EF and adjunct bilateral unselective TAE with gelfoam appears effective for those suspected of massive pelvic bleeding. This unselective embolization approach using gelfoam might be related to (ischemic) complications. When considering the amount and severity of complications and the severity of pelvic trauma, these might not outweigh the benefit of fast hemorrhage control.

Comparison of zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta and the Abdominal Aortic and Junctional Tourniquet in a model of junctional hemorrhage in swine.

BACKGROUND: Traumatic injuries to the pelvis and high junctional injuries are difficult to treat in the field; however, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the Abdominal Aortic and Junctional Tourniquet (AAJT) constitute two promising treatment modalities. The aim of this study is to use a large animal model of pelvic hemorrhage to compare the survival, hemostatic, hemodynamic, and metabolic profile of both techniques. METHODS: Yorkshire swine (n = 10, 70-90 kg) underwent general anesthesia, instrumentation, and surgical isolation of the femoral artery. Uncontrolled hemorrhage was initiated by an arteriotomy. Animals were randomly allocated to either REBOA or AAJT. Following completion of device application, both groups received a 500 mL Hextend bolus. After 1 hour, the injured femoral artery was ligated to simulate definitive hemostasis followed by a second Hextend bolus and device removal. Animals were observed for two more hours. Physiological data were collected throughout the experiments and compared between groups. RESULTS: Both techniques achieved 100% hemostasis, and all animals survived the entire experiment except one in the REBOA group. During the hour treatment phase, the AAJT group had a higher mean arterial pressure than the REBOA group (59.9 ± 16.1 versus 44.6 ± 9.8 mm Hg, respectively; P < 0.05). The AAJT-treated group had higher lactate levels than the REBOA-treated group (4.5 ± 2.0 versus 3.2 ± 1.3 mg/dL, respectively; P < 0.05). CONCLUSIONS: Despite their mechanistic differences, both techniques achieved a similar hemostatic, hemodynamic, and metabolic profile. Some differences do exist including lactate levels and blood pressure.

Embolization of iatrogenic uterine pseudoaneurysm.

Uterine artery pseudoaneurysms (UAPs) are rare vascular lesions that may be life threatening if not diagnosed and properly treated. The clinical presentation of UAPs includes a spectrum of symptoms that are often associated with other and more frequent gynecologic/obstetric pathologies, both with and without vaginal bleeding, and may span from postpartum hemorrhage to the absence of symptoms. We report cases of two patients with UAP, both of whom were diagnosed with ultrasonography and contrast-enhanced computed tomography and successfully treated with transcatheter embolization. The first patient presented delayed hypovolemic shock following surgery for endometriosis, whereas the second patient suffered from postpartum hemorrhage after cesarean section. Diagnosis of UAPs relies on noninvasive imaging; transcatheter arterial embolization is an effective treatment to control bleeding in both hemodynamically stable and unstable patients.

Ligating Internal Iliac Artery: Success beyond Hesitation.

AIM: To study the outcomes, benefits and complications of internal iliac artery ligation in both obstetric and gynecological cases. OBJECTIVE: To study the outcomes, effectiveness and complications of internal iliac artery ligation (IIAL). METHOD: This is an analytical longitudinal study done among women who have undergone internal iliac artery ligation in Dr. BRAMH a tertiary referral center from July 2013 to June 2015. Follow-up was done through color Doppler analysis of pelvic arteries before discharge, after 6 weeks and after 6 months. RESULT: The efficacy of IIAL was 96.87 %. The mean shock index was 0.94 ± 0.26. Sixty-four women underwent IIAL out of which placenta previa (21.8 %) was the major indication. There were four maternal deaths. There were no intraoperative or ischemic complications. The greater the time interval between onset of hemorrhage and IIAL, the graver the outcome. For all women in whom uterus could be salvaged, resumption of menstrual cycles was seen within 6 months of IIAL. There was a significant decrease in the RI and PI of uterine arteries. In the ovarian arteries, there was a significant increase in RI and no significant change in PI initially. Flow in distal part of ligated internal iliac arteries could be detected in 54 (90 %) women out of 60 after 6 months of ligation of internal iliac arteries. CONCLUSION: IIAL is an effective life-saving method to control obstetric and gynecological hemorrhage, and a hysterectomy can often be avoided. Early resort to IIAL is vital for improving the patient outcome. Uterine perfusion is well maintained, while there may be a decrease in ovarian perfusion. Resumption of menstrual cycles and presence of distal flow in internal iliac artery within 6 months suggest the preservation of future fertility; in order to better understand the impact of IIAL on ovarian functions and future fertility, larger studies with longer follow-up periods need to be conducted.

Balloon occlusion of the hypogastric arteries in the management of placenta accreta: a case report and review of the literature.

Obstetric hemorrhage from placenta accreta is associated with a high rate of maternal morbidity and mortality. Recently, balloon occlusion catheters have been used to control intraoperative bleeding during the surgical management of placenta accreta. In this article, we present a review of the literature reporting the use of balloon occlusion catheters in the management of placenta accrete, and a case presentation outlining the use of a Fogarty balloon occlusion catheter to achieve hemostasis in the preoperative management of placenta percreta.

The role of uterine artery embolization in cervical cancer - single case report.

Massive vaginal bleeding represents one of the emergencies that the gynecologists have to deal with. When unresponsive to the haemostatic treatment (local or iv), the bleeding can be stopped by using the uterine artery embolization. It provides visualization of the bleeding site and enables targeted, minimally invasive therapy to achieve hemostasis. We present a case of a patient with cervical cancer associated with massive vaginal bleeding and the beneficial effects of the uterine artery embolization in the therapy management.

Management of Acute Hemorrhage in Pelvic Trauma: An Overview.

Pelvic disruption is a combination of fractures or dislocations of the pelvic ring with trauma of the soft tissues on the inside and outside of this ring. Hemodynamic instability is the result of blood loss out of the fracture fragments, the posterior venous plexus, ruptured pelvic organs, or arterial lesions. In the resuscitation phase, different measures are possible to reduce the volume of the disrupted pelvis and to restore mechanical stability. They are not competitive but complementary. Pelvic binders should be used in the prehospital phase before and during transport. Application of a pelvic C-clamp is restricted to inhospital patients with C-type pelvic ring lesions and with severe and ongoing hemodynamic instability. External fixation is most useful in B-type but also has limited value in C-type injuries. The prerequisite for pelvic packing is the restoration of mechanical stability by pelvic C-clamping or external fixation. It is effective in severe venous bleeding in the small pelvis. Pelvic angiography and selective embolization is performed in patients with active arterial bleeding. These patients can be identified by a convincing clinical picture, by early multislice computed tomography (CT) with contrast- enhanced angiographic technique, or by the persistent need for volume replacement after C-clamping, external fixation, or pelvic packing.

Obstetric and gynecologic emergencies: a review of indications and interventional techniques.

There are many interventional techniques that can be used to aid the obstetrician or gynecologist in caring for their patients in the acute setting. Embolization can be life saving in the case of postpartum hemorrhage. Bleeding related to cervical cancer or the threat of bleeding from cervical ectopic pregnancy is amenable to embolization as is hemorrhage related to uterine arteriovenous malformations. Postpartum women are also at a uniquely high risk for deep vein thrombosis and pulmonary emboli and may benefit from consultation and treatment by an interventional radiologist. The goal of this article is to discuss the valuable role that the interventional radiologist plays in the treatment of these obstetric and gynecologic conditions.

Hypogastric artery ligation to treat massive hemorrhage in pelvic fractures with abdominal organ injuries / 中华创伤骨科杂志

Objective To evaluate the effects of hypogastric artery ligation to treat massive hemorrhage in pelvic fractures with abdominal organ injuries. Methods The pelvic fractures of 16 patients were classified as Tile B type in 10 cases and C type in 6. Among them there were 6 open fractures and 20 sites of abdominal visceral injuries. The capacity of retroperitoneal hematoma, which was ruptured in 6 cases, ranged from 800 ～2 500ml with 1 400ml on average. The bleeding volume in the survivals was 1 500～5 800ml with 2 600ml on average. Ligation of bilateral hypogastric artery was carried out in all patients with intra abdominal injuries within 6h. Of them, skeletal traction was used in 7 cases while pelvic external fixation in 5 cases. Results One death occured dut to consumptive coagulopathy with hematorrhea. Of the 15 survivals, bleeding was controlled in 8 cases, decreased in 5 and uncontrolled in 2. The effective rate was 81.3%(13/16) and the survival rate 93.8%(15/16). Conclusion When emergency celiotomy is performed for abdominal injuries, a rational application of hypogastric artery ligation can play a positive role in control of pelvic hematorrhea.