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Chin Med J (Taipei) 1997;60:98-104.
1Department of Emergency Medicine, China Medical College Hospital, Taichung;
2Department of Emergency Medicine, Veterans General Hospital-Taipei,
Taipei, Taiwan, R.O.C.
Background. The early management of patients with pelvic injury remains a great challenge for emergency physicians and trauma surgeons. A retrospective study was performed in this hospital to identify the clinical significance of different responses in the resuscitation of pelvic injury.
Methods. From March 1989 to May 1995, 75 patients with pelvic ring injury who had initially had unstable hemodynamic status were studied. They were divided into four groups as "good response" (GR), "delayed response" (DR), "poor response" (PR) and "no response" (NR) according to the time when hemodynamics became stable after immediate resuscitation.
Results. Motor vehicle accidents (MVA) had a higher incidence than other causes in the trauma mechanism. The fracture types of pelvis had no correlation with the response to resuscitation. The injury severity score (ISS) was higher in the PR group (41.7 +/- 18.3) than in the GR (17.5 +/- 8.6) or DR (19.5 +/- 17.0). The incidence of extrapelvic hemorrhage (EPH) and of mortality rates was higher in the PR group (38% and 75%, respectively), and the DR group (25% and 13%, respectively), than in the GR group (6% and 2%, respectively).
Conclusions. The responses of resuscitation is a valuable parameter in the management of multiple trauma with pelvic injury. Nonoperative treatment may be tried in patients of good response to resuscitation with EPH. In those patients with poor or delayed response, delayed extrapelvic bleeding (especially from abdominal injury) must be ruled out besides aggressive management for pelvic injury. Poor prognosis can also be expected in those patients with poor response.
[Chin Med J (Taipei) 1997;60:98-104.]
Keywords: hemodynamics, pelvic fracture, resuscitation
Received: May 29, 1996.
Accepted: June 19, 1997.
Address reprint requests to: Dr. Wei-Kung Chen, Department of Emergency Medicine, China Medical College Hospital, No. 2, Yuh Der Road, Taichung, Taiwan, R.O.C.
Multiple trauma with pelvic injury is commonly seen in the Emergency Room (ER), remaining a great challenge to emergency physicians and trauma surgeons today, not only for diagnosis but also for management. Minor or isolated pelvic fractures are relatively simple injuries and tend to be associated with mild or moderate injuries to other systemic organs which require no direct treatment. Life-threatening hemorrhage, associated injuries and late complications frequently result in mortality in patients with pelvic injury. According to Agnew's review [1], the mortality rate ranged from 3% to 78%. Mucha and Farnell [2] reported that the mortality was 42% in patients with initial unstable hemodynamics, and only 3% in patients with stable hemodynamics on arrival. The priorities of management of pelvic injury are frequently directed toward controlling the hemorrhage from associated injuries. Several protocols are designed to treat the pelvic injury, and hemodynamic status is presumed to be the most important guide in these protocols [2-5]. In experience here, response to resuscitation was another important parameter of patient outcome in management of pelvic ring injury. It directly reflects the patient's prognosis and represents the potential risk of nonpelvic hemorrhage. This study was designed to analyze the clinical significance of different responses of resuscitation.
From March, 1989 to May, 1995, there were 263 patients with pelvic injury (ICD-9CM2 codes 808.0 through 808.9) treated at Veterans General HospitalTaipei. Seventy-five patients with unstable initial hemodynamics who were treated at this ER were studied. Among them, six patients with initial stable hemodynamics had turned to unstable after rechecked in 30 minute after admission were included.
The unstable initial hemodynamics was defined as BP< 100mmHg and/ or HR > 100/min in first 30 minute after admission to emergency room. All these injured patients were evaluated and resuscitated according to the advanced trauma life support (ATLS) for physicians. According to the response to resuscitation, patients were divided into four groups: 1) "good response" (GR), when the unstable hemodynamics status turned to normal status in four hours after resuscitation; 2) "delayed response" (DR), when the hemodynamics status turned to normal status in four to eight hours without further change; 3) "poor response" (PR), when the hemodynamics was persistently unstable longer than eight hours after resuscitation; and 4) "no response" (NR), when the unstable hemodynamics did not respond to treatment only deteriorating after resuscitation.
Medical record charts were reviewed for age, sex, trauma mechanism, initial vital signs and blood transfusion. The blood types of transfusion include whole blood and packed RBC (1 unit = 250 ml). All patients received continuous monitoring of vital signs during resuscitation. Injury severity score (ISS) was assessed using the abbreviated injury scale (AIS) - 90 scoring system. Associated injuries means body injury except bony structure of pelvic ring and the major associated injuries defined when AIS >= 3 in each body region.
Anterior-posterior pelvic roentgenogram was performed at the ER to determine if a pelvic fracture was suspicious. Further roentgenogram was done when clinical conditions indicated. The Kane modification of the Key and Conwell classification of pelvic fracture was used in the study. Type I is individual bone not involving the pelvic ring; Type II is a single break of the pelvic ring; Type III is double breaks in the pelvic ring; Type IV is associated with acetabular fractures. Open fractures is defined as those fractures communicating with an external wound. Types I and II are described to be stable fractures, while the Types III, IV and open fractures are described as unstable fractures.
Exploratory laparotomy was carried out when diagnostic peritoneal lavage (DPL) and/or abdominal sonogram led to suspicious of internal bleeding. Extrapelvic hemorrhage (EPH) was proved by exploratory laparotomy, sonogram, computed tomography or chest tubing. Early external fixation was defined as surgically applied treatment given within two days after injury.
To analyze continuous data, one way analysis of variance was used. For nominal data, Chi-square test was used. A p < 0.05 was accepted as significant.
There were 52 males and 23 females in this series. According to the response to resuscitation, 50 (67%) patients had GR, 16 (21%) patients had DR, 8 (11%) patients had PR and 1 (1 %) had NR.
The relationship between trauma mechanisms and age distribution is shown in Figure 1. Trauma mechanism was 34 (45%) in motor vehicle accidents (MVA), while 17 (23%) suffered falls, 22 (29%) were pedestrian versus automobile accidents (PVAA) and 2 (3%) had other causes. Twenty patients (59%) with MVA were in the young adult group (age < 30 years old), while 15 patients (68%) with PVAA were primarily from the old age group (age >= 60). Mortality rates were 9% in MVA, 6% in falls and 27% in PVAA. Ages related to response of resuscitation are shown in Figure 2. In the DR group, 50% were older than 60 years, while the percentage was 24% in GR group. In the PR group, patients younger than 20 years and older than 60 years distributed in 33%, respectively.
Fracture types related to response of resuscitation are shown in Table 1. There was no significant correlation between orthopedics stability and response of resuscitation.
The characteristics of patients with GR, DR, PR are shown in Table 2. The ISS was significantly elevated in PR. Old age patients ( >= 60 years old) were more frequently seen (50%) than others (p < 0.05) in the DR group. The major associated injuries (AIS >= 3) were 52% in GR, 69% in DR, 88% in PR and 100% in NR. The incidence of associated injury progressively increased from GR to NR. Extrapelvic hemorrhage was 6% in GR group, 25% in DR group, 38% in PR group and 100% in NR group. Fluid resuscitation was about 4100c.c crystalloid fluid and 15.3 units of blood in PR group. In GR group, EPH came from spleen in two patients, while it came from both liver and spleen in one patient. In the DR group, the EPH came from liver, spleen and mesocolon, respectively. In the PR group, the EPH came from the liver in two patients while it came from lung in one. The bleeding source came from lung in only one case of NR.
In the GR group, nine patients had received laparotomy. Among them, four patients showed urinary bladder rupture as diagnosed by retrograde cystography. Three patients had definitive viscera organ injury and the other two showed retroperitoneal hematoma. In the DR group, four patients received laparotomy. Among them, three patients had definite viscera organ injury. In the PR group, three patients received laparotomy to stop the possibility of internal bleeding. Two patients had abdominal viscera organs injury while one patient showed retroperitoneal hematoma. The unnecessary exploratory laparotomy was 40% in GR group, while it was 25% in DR group and 33.3% in PR group.
In this series, 18 patients received orthopedic treatment, among them, three patients received early external fixation. In these patients, only one patient received external fixation three hours later after arrival because of open pelvic fracture with unstable hemodynamics. His vital signs did not obviously return to normal after external fixation was applied.
Ten (13.3%) of the 75 patients died . Among them, one patient was in the GR group, while two in DR group, six in PR group and one in NR group. The mortality in GR group was 2%, while it was 13% in DR group, 75% in PR group and 100% in NR group. Two patients in the PR group survived. The causes of PR in these two patients were open type pelvic fracture and paroxismal supraventricular tachycardia (PSVT), respectively. The data for patients with mortality are listed in Table 3.
The management of life-threatening pelvic hemorrhage is very troublesome for emergency physicians and traumatologists, especially in cases of open fracture, recognized as the most lethal fracture in orthopedic practice. Fortunately, the incidence of life-threatening pelvic hemorrhage has rarely been seen in this hospital. However, the EPH is another challenge in the ER, not only difficult in diagnosis but also in management. Though the protocols of treatment in pelvic injury had been well discussed in the literature [2-5], the mortality rate still varies from 3% to 78% [1].
The trauma mechanism of MVA played the most important role in unstable hemodynamic pelvic injury in several series [3,6,7] as well as in this series . The mechanism of PVAA had higher ISS and mortality rate than others. It was also commonly seen in the older age group. In contrast, MVA was more frequent in younger people. This result is similar to that Moreno et al. [3] and Hanson et al. [8] reported. With regard to response to resuscitation, old age patients ( >= 60 years old) were commonly seen in the DR and PR groups than the GR group. It may be because cardiopulmonary function is progressively decadent and more underlying diseases are present in the old age group. The effectiveness of resuscitation and compensation might be delayed because of these underlying diseases instead of associated major injuries. One of the patients presented with poor response to resuscitation because of a PSVT attack after trauma and resuscitation. These findings could confirm that pelvic injury has an age correlation .
Classification of pelvic fracture has been done by several methods, include Tiles classification, Pennel and Sutherland classification and Kane modification of the Key and Conwell classification. Unstable fracture is thought to be more likely to have bony bleeding or a disruption of the surrounding venous and arterial vessels. Dalal et al. [7] reported that pelvic classification by mechanical force type and severity of the pelvic fracture was the key to expected organ injury pattern, resuscitation requirements and outcome. Using the Kane modification of the Key and Conwell classification, Mucha et al. [2] reported that unstable fractures had a high incidence of unstable hemodynamics while stable fractures presented with stable hemodynamics. In a previous report from here [9], 45% of stable fractures presented with unstable initial hemodynamics while these were 55% in stable fracture. There was no correlation between the fracture type and hemodynamics. In this study, fracture types had no correlation with the response of fluid resuscitation, either. Nine (36%) of 25 patients in DR, PR and NR groups had stable fractures and seven (78%) of these nine patients had major associated injuries. This means that fracture classification can not predict the response and prognosis after resuscitation. Briefly speaking, in patients with stable fracture but unstable hemodynamics, the potential of EPH should not be overlooked, especially in those patients who presented with a delayed response or poor response after resuscitation. Which and whether fracture classification to accept, and whether it is useful and effective for the emergency physicians and traumatologists purposes when resuscitating needs prospective, randomized study.
Immediate life-threatening pelvic hemorrhage was rarely found in our series (2%), it was less frequent than in the reports of Moreno et al. (11%) [3], Riemer et al. (24%) [10] and Ever et al. (52%) [5]. The causes of death in patients here were mostly from associated injuries, and most were caused by infection culminating sepsis. Soft tissue infection, intraabdominal abscess or pneumonia were the most common causes of sepsis. These complications might be intensified after massive transfusion and/or an undercontrolled aseptic resuscitation. Baker et al. [11] reported that even in the absence of a direct injury to the gut, hypotension and trauma-induced immunosupression might favor translocation of bacteria from the lumen of the intestine to the portal and systemic circulation. In the early resuscitation stage, blood transfusion has been very frequently performed for patients of hypotension, and such transfusion may directly effect the ability to control any following infection .
Most of the protocols using the status of hemodynamics to determine the priority of management. Life-threatening pelvic hemorrhage is primarily caused by artery injury and most bleeding sites come from branches of the hypogastric arteries. An aggressive surgical approach may be unsuccessful because bleeding sites are difficult to localize. Artery ligation often does not achieve hemostasis, and opening of the retroperitoneum may destroy the tamponading effect of the hematoma as well as increase the danger of infection. Angiography with selective embolization can successfully control the hemorrhage. Early embolization is imperative in reducing transfusion requirements and associated complications [12]. Emergency laparotomy or thoracotomy is indicated when the primary survey reveals internal bleeding. In experience here, not all laparotomy was necessary in patients with internal bleeding. Non-operative treatment had been successfully tried in some patients with internal bleeding and stable hemodynamics. Laparotomies in some of these patients may not benefit but may even be harmful because of destroying the tamponade effect of the abdominal wall. Retroperitoneal hematoma resulting in transient hypotension may stop bleeding spontaneously after tamponade effect. Transient hypotension may turn to stable after aggressive resuscitation. If the etiology of malignant hypotension is caused by EPH, and the hemodynamics revealed no response after fluid resuscitation, emergency operation should be performed. When the resuscitation showed a GR, the incidence of EPH, associated injuries, and mortality rate would be relatively low. In this instance, a secondary survey should follow, and definitive care is an important safety procedure. Bleeding from a retroperitoneal hematoma, the liver or the spleen which is managed by good resuscitation, may indicate choice of nonoperative treatment with adequate monitoring. Conversely, when response to resuscitation evolves into DR, the incidence of EPH or the mortality rate will increase. At this point, abdominal sonogram, which is an accurate diagnostic adjunct for detecting not only free peritoneal, but also thoracic fluid [13-16], should again be performed to seek out the possibility of delayed bleeding. DPL can compare with abdominal sonogram in sensitivity and specificity. However, patients with pelvic hematoma will exhibit a higher false positive result in DPL because of blood leaking into the peritoneal cavity. In this course of resuscitation, computed tomography may be used for assess of the abdominal condition to exclude the possibility of retroperitoneal viscera organ injury or retroperitoneal hematoma. Choosing a nonoperative treatment instead of laparotomy may be of more benefit to these patients. Nonoperative management of the liver or spleen injuries which contribute to most internal bleeding in the abdomen is thought to be a safe and effective technique applicable to hemodynamically stable patients [17-19]. However, it is not wise to delay an emergency laparotomy or thoracotomy when the hemodynamics could not maintain to stable, or the further study revealed hallow organ injuries. When the course of resuscitation went into the stage of PR the mortality rate may increase. In the course of PR, repeat sonogram is usefully to exclude a delay intraabdominal EPH. If there was no evidence of EPH, the priority of management was change to treat the associated injuries and pelvic bone stabilization. Bleeding from bone marrow or sacrum venous plexus may result in persisting blood loss. Early external skeleton fixation would be capable in reducing the hospital stay, long term function result, and may result in fewer complication, decreased blood loss [20,21]. Unfortunately, there is still no any report to define the time of early fixation. The algorithm for management of multiple trauma with pelvic fracture and unstable hemodynamics is shown in Figure 3.
We conclude that the outcome of pelvic injury was determined by the aggressive resuscitation and treatment the associated injuries. Using the change of hemodynamics and response of resuscitation as a guide in early management of pelvic injuries would help to determine the priority of management and predict the outcome.
Copyright: 1997, Chinese Medical Association (Taipei)