Abstract
Pelvic trauma can lead to severe, uncontrollable haemorrhage and death related to prolonged shock and multiple organ failure. Massive retroperitoneal haematoma should be assumed to be present in cases of post-traumatic haemodynamic instability associated with pelvic fracture in the absence of extrapelvic haemorrhagic lesions. This review describes the pathophysiology of retroperitoneal haematoma in trauma patient with blunt pelvic fracture, considering the roles of venous and arterial bleeding. Efficacy and safety of haemostatic procedures are also discussed, and particular attention is given to the efficacy of pelvic angiographic embolization and external pelvic fixation. A decision making algorithm is proposed for the treatment of trauma patients with pelvic fracture that takes haemodynamic status and associated lesions into account.
Highlights
The initial management of patients presenting with pelvic fracture and haemodynamic instability remains difficult
Surgical ligature of the internal iliac arteries has been proposed but has not been demonstrated to be effective [23]. Such surgical exploration in injured patients with haemodynamically unstable pelvic fractures is associated with high mortality rates (66% to 83%) and so it does not appear to be an appropriate treatment [24]
A recent retrospective study performed in our university hospital of patients presenting with pelvic fractures complicated by haemorrhagic shock demonstrated the efficacy of a protocol combining haemodynamic optimization and early, first-line pelvic arterial embolization [31]
Summary
The initial management of patients presenting with pelvic fracture and haemodynamic instability remains difficult. Surgical ligature of the internal iliac arteries has been proposed but has not been demonstrated to be effective [23] Such surgical exploration in injured patients with haemodynamically unstable pelvic fractures is associated with high mortality rates (66% to 83%) and so it does not appear to be an appropriate treatment [24]. A recent retrospective study performed in our university hospital of patients presenting with pelvic fractures complicated by haemorrhagic shock (requiring more than 4 units of blood during the first 24 hours) demonstrated the efficacy of a protocol combining haemodynamic optimization and early, first-line pelvic arterial embolization (not preceded by pelvic ring fixation) [31]. Because application of institutional practice guidelines may reduce mortality rate and transfusion requirements in pelvic trauma patients [55], we propose our institutional algorithm, based on existing literature and personal clinical experience (Figure 2)
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