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External Fixation or Arteriogram in Bleeding Pelvic Fracture: Initial Therapy Guided by Markers of Arterial Hemorrhage

Miller, Preston R. MD; Moore, Phillip S. MD; Mansell, Eric MD; Meredith, J. Wayne MD; Chang, Michael C. MD

The Journal of Trauma: Injury, Infection, and Critical Care: March 2003 - Volume 54 - Issue 3 - p 437-443
doi: 10.1097/01.TA.0000053397.33827.DD

Background  Bleeding pelvic fractures (BPF) carry mortality as high as 60%, yet controversy remains over optimal initial management. Some base initial intervention on fracture pattern, with immediate external fixation (EX FIX) in amenable fractures aimed at controlling venous bleeding. Others feel ongoing hemodynamic instability indicates arterial bleeding, and prefer early angiography (ANGIO) before EX-FIX. Our aim was to evaluate markers of arterial bleeding in patients with BPF, thus identifying patients requiring early ANGIO regardless of fracture pattern.

Methods  Patients with pelvis fracture were identified from a Level I trauma center registry over a 7-year period and records reviewed. From this group, two subsets were analyzed: those with initial hypotension related to pelvic fracture, and those without hypotension who underwent pelvic ANGIO. Data included hemodynamics, response to resuscitation, presence of contrast blush on CT, fracture treatment and outcome. Adequate response to initial resuscitation (R) was defined as a sustained (>2 hours) improvement of systolic blood pressure to >90 mm Hg systolic after the administration of ≤2 units packed red blood cells. Those with repeated episodes of hypotension despite resuscitation were classified as non-responders (NR)

Results  From 1/94–1/01, 1171 patients were admitted with pelvic ring fracture. Thirty-five (0.3%) had hypotension attributable to pelvis fracture. 28 fell into the NR group, and 26 of these underwent ANGIO. Nineteen (73%) showed arterial bleeding while 3 resuscitation response patients underwent ANGIO with none demonstrating bleeding (p = 0.03). Sensitivity and specificity of inadequate response to initial resuscitation for predicting the presence of arterial bleeding on ANGIO were 100% and 30% respectively while negative and positive predictive value were 100% and 73%. In patients with fractures amenable to external fixation (n = 16), 44% had arterial bleeding on ANGIO, and all were in the NR group. An additional 17 patients without hypotension also underwent ANGIO. Contrast blush on admission CT was seen in 4, 3 of which had arterial bleeding seen on ANGIO (75%). Sensitivity and specificity for contrast blush in predicting bleeding on ANGIO were 60% and 92% with positive and negative predictive value being 75% and 85%.

Conclusions  In patients with hypotension and pelvic fracture, therapy selection based on initial response to resuscitation in BPF yields a 73% positive ANGIO rate in NR patients. Delay in ANGIO for EX FIX in patients with amenable fractures would have delayed embolization in the face of ongoing arterial bleeding in 44% of patients. In stable patients with pelvic fracture, contrast blush also indicates a high likelihood of arterial injury and ANGIO is indicated. Optimal therapy in the face of BPF requires early determination of the presence of arterial bleeding so that ANGIO can be rapidly obtained, and response to initial resuscitation as well as the presence of contrast blush aid in this decision.

From the Departments of General Surgery (P.R.M., P.S.M., J.W.M., M.C.C.) and Radiology (E.M.), Wake Forest University, Winston-Salem, North Carolina, U.S.A.

Submitted for publication October 8, 2002.

Accepted for publication December 7, 2002.

Presented at the 61st Annual Meeting of the American Association for the Surgery of Trauma, September 26-28, 2002, Orlando, Florida.

Address for correspondence: Preston R. Miller, MD, Assistant Professor, Department of General Surgery, Wake Forest University, Medical Center Boulevard, Winston-Salem North Carolina, 27157, U.S.A.; email:

© 2003 Lippincott Williams & Wilkins, Inc.