Pelvic Fracture Hemorrhage Research Articles

Bilateral Adrenal Hemorrhage Secondary to Heparin Induced Thrombocytopenia in a Trauma Patient

We report a case of a trauma patient with Bilateral Adrenal Hemorrhage (BAH) associated with Heparin Induced Thrombocytopenia (HIT). An 80-year-old man was brought to our hospital after falling from a height of 3 m. His vital signs were stable, and whole body Computed Tomography (CT) showed that he had right multiple rib fractures, hemothorax, and pelvic fracture. The patient subsequently underwent Transcatheter Arterial Embolization (TAE) for the pelvic fracture hemorrhage treatment. Then, the patient was admitted to the intensive care unit and was transfused 2 units of red cell concentrate and 2 units of fresh frozen plasma. On Day 3, we started with the subcutaneous injection of unfractionated heparin (15,000 units per day) to prevent Deep Vein Thrombosis (DVT). On Day 6, the patient vomited and had fever (39°C) with a confused mental status. His systolic blood pressure suddenly dropped to 90 mmHg. Abdominal CT scan demonstrated BAH (Figure 1) and laboratory findings exhibited a platelet count of 50 × 103 mm−3 (which was 160 × 103 mm−3 5 days earlier). We suspected HIT leading to BAH and stopped heparin injection; we subsequently started anticoagulation therapy with argatrovan (continuous infusion: 0.5 μg/BW kg/min) and checked heparin antibody. As the patient was in a shock status, we diagnosed adrenal insufficiency and started the administration of steroids. Subsequently, the patient gained consciousness, his other symptoms regressed, and his platelet count gradually increased. Later, heparin antibody was found to be positive, and the diagnosis of HIT was confirmed.

Pelvic Fractures at a New Level 1 Trauma Centre: Who Dies from Pelvic Trauma? The Inkosi Albert Luthuli Central Hospital Experience

To identify the incidence of pelvic trauma, causes of death and factors predicting death with pelvic fractures. All pelvic fractures were retrospectively identified from a registry spanning from March 2007 to August 2009. Data was captured on a proforma. Data for survivors, non-survivors and a subgroup with pelvic injury as the underlying cause of death were compared. Pelvic fracture incidence was 16% of major trauma cases. Patient with pelvic fractures had 31% mortality and 9% pelvic fracture-induced mortality. Motor vehicle collisions were the commonest external cause of pelvic fractures (59%); however, the highest mortality was from falls >6 m. The Injury Severity Score (ISS) was 29 in survivors, 36 in non-survivors, and 54 in the pelvic death subgroup. Type C fracture was a predictor of mortality (P = 0.135). 53% of the cases required transfusion in the first 24 hours. The pelvic death subgroup received a mean of 10.7 units of blood, versus 4 units for survivors and 3.7 units for non-survivors (P = 0.259). The overall incidence of pelvic fracture and associated mortality were higher than previously reported. Fracture severity and falls from heights are associated with additional injuries (higher ISS) and mortality. More severe fractures cause deaths directly attributable to the pelvic injury. The requirement for major blood transfusions for pelvic fracture hemorrhage was related to mortality. Female patients appeared to fare worse than males.

Operating room or angiography suite for hemodynamically unstable pelvic fractures?

Few patients require angiography and therapeutic embolization for bleeding pelvic fractures, but they are risk for significant morbidity and mortality. In hemodynamically unstable trauma patients with pelvic fractures, the decision to proceed to the operating room (OR) to address intraabdominal bleeding, or angiography to address pelvic bleeding (ANGIO), is rarely straightforward. This study tested the hypothesis that outcomes are similar regardless if the sequence was OR-ANGIO or ANGIO-OR. All pelvic fractures between 1999 and 2011 were retrospectively reviewed and stratified by initial management with ANGIO or OR. Of 2,922 patients with pelvic fractures, only 183 (6%) required angiography for suspected bleeding. For OR-ANGIO (n = 49) versus ANGIO (n = 134), injury severity score was similar (40 ± 15 vs. 35 ± 16), but systolic blood pressure (97 ± 28 vs. 108 ± 32 mmHg, p = 0.038) and base excess were both lower (-9 ± 5 vs. -5 ± 5 mEq/L, p < 0.001). During initial resuscitation and in the first 24 hours, crystalloid, blood product usage and total fluid requirements were all increased 50% to 100% (all p < 0.001). Despite these differences, lengths of stay (32 ± 32 vs. 26 ± 28 days) and mortality (33% vs. 31%) were similar. The same trends in fluid requirements remained in the subset of patients with unstable pelvic fractures, with an increased mortality (67% vs. 20%, p = 0.011) in those requiring ANGIO-OR versus OR-ANGIO. These data support current management algorithms. In hemodynamically unstable trauma patients with pelvic fractures, those who proceeded immediately to the OR to address intraabdominal bleeding tended to be sicker but had outcomes that were the same or better compared with those who received angiography to address pelvic bleeding. III, retrospective review.

Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture—Update and Systematic Review

Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice. Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence. Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing? Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

Efficacy and procedural time of angioembolization in ongoing pelvic fracture hemorrhage

ObjectiveTo study the effectiveness and procedural time of different techniques of angioembolization, in patients with hemorrhage associated with pelvic fracture. Patients and methodsCase series study of 17 patients underwent angiography and 16 of them underwent embolization for treatment of hemorrhage associated-pelvic fracture. The total time spent for angioembolization, the actual time of work, and the sum of time of patient transport, preparation and compression of the femoral puncture were calculated. ResultsTranscatheter arterial embolization was successful at stopping the pelvic arterial bleeding in all 16 (100%) patients. The actual time spent in angioembolization; ranged from 18 to 110min (mean=63.3). The time lapsed for patient transport between the trauma unit and angiography suite, patient preparation and compression of the femoral puncture ranged from 20 to 40min (mean=29.5). Bilateral occlusion of the internal iliac main trunk was the fastest effective technique (mean time 22min). The survival rate was 76.5%, and none of deaths resulted from ongoing hemorrhage. ConclusionEmbolization among patients bleeding from pelvic fractures is very effective at arresting pelvic arterial hemorrhage. Angioembolization should not be considered a time consuming procedure, if the technique is well-tailored to the general condition of the patient.

Higher glucose on admission is associated with need for angioembolization in stable pelvic fracture

Background Angioembolization is an effective adjunct to the management of retroperitoneal hemorrhage in pelvic fractures. Most patients with stable-type pelvic fracture are treated conservatively. However, in some stable pelvic fracture cases, patients should receive angioembolization for hemostasis upon incidental finding of contrast extravasation on computed tomography (CT). In this study, we attempted to define the characteristics of patients with stable pelvic fracture requiring angioembolization. Methods We retrospectively reviewed the charts of patients with pelvic fractures between January 2005 and November 2009. We focused on stable pelvic fracture patients with contrast extravasation on CT who then received angioembolization. The demographics, Injury Severity Score (ISS), Abbreviated Injury Scale score, and the blood glucose levels on admission were analyzed. Results In total, 334 patients were enrolled. Patients with higher blood glucose level on admission with stable pelvic fracture had a higher rate of angioembolization. Furthermore, these patients presented with a higher Abbreviated Injury Scale score and ISS. Conclusions In patients with stable pelvic fracture, higher blood glucose level on admission was associated with a higher likelihood of needing angioembolization. Blood glucose level should be checked during the initial survey of a pelvic fracture, and greater attention should be given to patients with higher blood glucose level or with an ISS of 25 or greater, even when the imaging study only reveals a stable pelvic fracture.

Abstract No. 258 EE: Imaging and interventions in bleeding pelvic fractures: The pelvic plumbing

Abstract No. 258 EE: Imaging and interventions in bleeding pelvic fractures: The pelvic plumbing

Impact of Mobile Angiography in the Emergency Department for Controlling Pelvic Fracture Hemorrhage With Hemodynamic Instability

Rapid trauma evaluation and intervention without time delay are considered integral to time-efficient management of trauma patients, particularly for those with hemodynamic instability. This study examined the impact of immediate availability of mobile angiography with digital subtraction angiography technology in the emergency department (ED) for hemodynamically unstable multiple trauma patients with pelvic injury. This retrospective review examined a cohort of all blunt trauma patients with pelvic injury who underwent transcatheter arterial embolization (TAE) using mobile angiography by trauma surgeons in the ED. This system was set up on a 24-hour basis with full-time trauma surgeons available in-hospital. Data collected included clinical characteristics, injury severity, resuscitation intervals from admission through to completion of hemostasis, metabolic factors (pH and core body temperature), mortality, and TAE-related complications. Subjects comprised 29 patients (hemodynamically stable group, n = 17; hemodynamically unstable group, n = 12) with a median age of 36 years (interquartile range [IQR], 29-53 years). Mean shock index, injury severity score, and trauma and injury severity score were 1.1 +/- 0.5, 32 +/- 12, and 0.79 +/- 0.27, respectively. Median intervals from ED arrival to diagnosis and from diagnosis to starting TAE were 66 minutes (IQR, 42-80 minutes) and 30 minutes (IQR, 25-37 minutes), respectively. Median interval from diagnosis to completion of TAE was 107 minutes (IQR, 93-130 minutes). Physical and anatomic injury statuses were more severe in the hemodynamically unstable group than in the hemodynamically stable group. However, intervals from diagnosis to starting TAE and from diagnosis to completion of hemostasis did not differ significantly between groups. No exacerbations of metabolic factors during resuscitation were identified. Pelvic injury related mortality was 17% and no TAE-related complications were encountered. Immediate availability of mobile angiography in the ED seems safe and effective for hemodynamically unstable trauma patients with pelvic injury and results in a rapid improvement in resuscitation intervals without leaving the ED. An adequately randomized controlled trial of mobile angiography in this subset of patients, who would seem to derive the most benefit from mobile angiography, would be ideal.

Management of Hemorrhage in Life-threatening Pelvic Fracture

Emergent life-saving treatment is required for high-energy pelvic fracture with associated hemorrhage and hemodynamic instability. Advances in prehospital, interventional, surgical, and critical care have led to increased survival rates. Pelvic binders have largely replaced military antishock trousers. The availability and precision of interventional angiography have expanded considerably. External pelvic fixation can be rapidly applied, often reduces the pelvic volume, and provides temporary fracture stabilization. Pelvic packing, popularized in Europe, is now used in certain centers in North America. The use of standardized treatment algorithms may improve decision making and patient survival rates. Active involvement of an experienced orthopaedic surgeon in the evaluation and care of these critically injured patients is essential.

Hemorrhage in Pelvic Fractures Does Not Correlate With Fracture Length

To analyze whether hematogenous marrow bleeding is the major source of hemorrhage after fractures of the pelvic ring. Retrospective cohort study. Academic Level I trauma center. Three hundred seven consecutive pelvic ring injuries from January 1, 2000 to December 31, 2003 were evaluated. After exclusion for age, significant nonpelvic hemorrhage sources, and delayed transfer to this institution, 72 patients remained. Pelvic injuries were classified as fractures, fracture dislocations, or pure dislocations. These classifications were correlated to change in hematocrit between assumed preinjury and final hematocrit readings, correcting for blood transfused. The dislocation group had a greater change in hematocrit than the fracture group (2.1%), though not statistically significant. No significant correlations were found between change in hematocrit and length of fracture lines. Pelvic fracture surfaces may be sources of bleeding in pelvic injuries, but the fact that bleeding is similar in fractures and dislocations indicates fracture surfaces do not constitute the primary source. Based on our analysis one cannot reliably predict pelvic hemorrhage based on A/P radiograph assessments, such as fracture type.

Control of severe pelvic fracture hemorrhage with pelvic packing

Control of severe pelvic fracture hemorrhage with pelvic packing

Preperitonal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures: A Paradigm Shift

The current management of pelvic fracture patients who are hemodynamically unstable in the United States consists of aggressive resuscitation, mechanical stabilization, and angioembolization. Despite this multidisciplinary approach, our recent analysis confirms an alarming 40% mortality in these high-risk patients. Therefore, we pursued alternate therapies to improve patient outcomes. European trauma groups have suggested the technique of pelvic packing via laparotomy to directly address the venous bleeding that comprises 85% of pelvic fracture hemorrhage. We hypothesized that a modified technique of direct preperitoneal pelvic packing (PPP) would reduce the need for angiography, decrease blood transfusion requirements, and lower mortality. Since September 2004, all patients at our ACS-verified level I trauma center with hemodynamic instability and pelvic fractures underwent PPP/external fixation, according to our protocol. Statistics are reported as mean +/- SEM and analyzed using Student's t test. During the study period, 28 consecutive patients underwent PPP. There was one protocol deviation of prePPP angiography to evaluate an extremity vascular injury. The majority were men (68%) with a mean age of 40 +/- 3.9 years and a mean injury severity score of 55 +/- 3.0. The mean emergency department (ED) systolic blood pressure was 77 +/- 3.0 mm Hg, heart rate was 120 +/- 4.3 bpm, and base deficit 13 +/- 0.8 mmol/L. Pelvic fracture classifications included lateral compression (LC) II (9), anteroposterior compression (APC) III (8), LC I (3), vertical shear (3), LC III (3), and APC II (2). Patients required 4 +/- 1.2 units of packed red blood cells (PRBCs) during 82 +/- 13 minutes in the ED. Blood transfusion requirements before postoperative surgical intensive care unit (SICU) admission compared with the subsequent 24 postoperative hours were significantly different (12 +/- 2.0 versus 6 +/- 1.1; p = 0.006). The first 4 patients underwent routine angiography postPPP, with 1 undergoing therapeutic embolization; 4 of the subsequent 24 patients underwent angioembolization with clinical concern of ongoing pelvic hemorrhage. Seven (25%) patients died from multiple organ failure (2), postinjury myocardial infarction/pulseless electrical activity (PEA) arrest (2), invasive mucormycosis (1), withdrawal of care (1), and closed head injury (1); there were no deaths as a result of acute blood loss. PPP is a rapid method for controlling pelvic fracture-related hemorrhage that can supplant the need for emergent angiography. There is a significant reduction in blood product transfusion after PPP, and this approach appears to reduce mortality in this select high-risk group of patients.

The Role of Repeat Angiography in the Management of Pelvic Fractures

Angiographic embolization has emerged as the treatment modality of choice for bleeding pelvic fractures. The purpose of this study is to identify potential indicators for ongoing pelvic hemorrhage despite initial therapeutic or non-diagnostic angiography. The trauma registry of a Level I trauma center was used to identify patients with pelvic fractures between January 2000 and June 2002. Records were reviewed for demographics, severity of injury, hemodynamic status, initial and subsequent base deficit, blood and fluid requirements, length of stay, and mortality. Statistical analysis was performed using Student's t test, and univariate and multivariate analysis, significance was assigned to p < or = 0.05. During the study period, 678 patients had pelvic fractures. Angiography was performed in 31 (4.6%) of these patients. Arterial hemorrhage was diagnosed initially on 16 (51.6%) patients requiring embolization. Three (18.8%) of these embolized patients required repeat angiography and embolization due to ongoing pelvic hemorrhage. Of the initial 15 patients with negative angiograms, five (33.3%) had repeat angiograms due to continued hypotension and acidosis. Four (80.0%) of these five patients were found to have arterial hemorrhage requiring embolization. Of the seven (22.6%) patients requiring repeat angiography for control of ongoing pelvic hemorrhage, three independent factors were predictive: continued or recurrent hypotension (SBP < 90), absence of intra-abdominal injury, and persistent base deficit of 10 for greater than 6 hours. The presence of all three independent predictors was associated with a 97% probability of pelvic bleeding (p = 0.001). Angiographic embolization is highly effective in controlling arterial bleeding associated with pelvic fractures. However, repeat angiography should be performed in patients with pelvic fractures with ongoing evidence of hemorrhage demonstrated by persistent base deficit and hypotension once other potential sources of bleeding have been excluded.

Anatomy of the anterior sacral veins and its clinical significance in hemorrhage in pelvic fractures

目的 探讨骶前区静脉的解剖和骨盆骨折大出血的关系.方法结合50例骨盆骨折伴盆腔内血管损伤出血f临床病例救治,选成年尸体标本5具,研究骶前区静脉走行,骶骨的解剖学特点,骨折部位与出血的关系.结果骶前区静脉由骶前静脉丛和骶椎椎体静脉组成,有广泛的侧支循环,骶骨C区骨折及严重的B区骨折易损伤骶前静脉丛.临床骶前静脉出血者经剖腹探查证实、止血.结论骶骨C区骨折及严重的B区骨折易引起骶前静脉丛损伤.一旦确诊应立即恢复骨盆环的完整性,腹外加压止血,非必要时不能行剖腹探查止血。

Hemorrhage in pelvic fracture: who needs angiography?

Pelvic fractures are rare but potentially devastating injuries. An understanding of the bony and peripelvic anatomy along with common patterns and the classification of the injury are of critical importance in their management. These form the basis for a general treatment algorithm for pelvic fracture patients. Angiographic embolization is time-consuming and often delayed. Hemodynamic instability with unstable pelvic fracture is therefore best approached with a combination of pelvic emergency stabilization (C-clamp) and surgical hemostasis by pelvic tamponade. This is especially true for critically injured patients in extremis.

External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage.

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. 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 < or = 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%. 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.

Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage.

To review the success rate of embolization in stopping hemorrhage for unstable patients with severe pelvic fractures, to calculate the time to achieve embolization, and to determine the yield from angiography. Retrospective review of patients admitted to a Level I trauma center with pelvic fractures during a 5-year period. Charts were reviewed for Injury Severity Score, age, blood pressure, prothrombin time/partial thromboplastin time, pelvic fracture type, mortality, time to reach the angiography suite, time to achieve embolization, and mechanism of injury. Of 806 patients admitted with pelvic fractures, 35 underwent pelvic angiography, and 15 (1.9%) required embolization. Embolization was successful for all patients. No deaths resulted from ongoing hemorrhage. Angiography yield in initially unstable patients was 64%. The mean age and initial hemodynamic instability were significantly greater in nonsurvivors. The time from arrival in the trauma bay to arrival in the angiography suite ranged from 50 to 1,140 minutes, and the time spent in the angiography suite performing embolization ranged from 50 to 140 minutes, with an average time of 90 minutes. Patients who were embolized within 3 hours of arrival had a significantly greater survival rate. Only a small percentage of patients with pelvic fractures require embolization, but when it is used, embolization can be 100% effective. Age, time to achieve embolization, and initial hemodynamic instability appear to be important factors in survival.

The Technique of Packing for Control of Hemorrhage in Complex Pelvic Fractures

The Technique of Packing for Control of Hemorrhage in Complex Pelvic Fractures

Hemorrhage in Major Pelvic Fractures

Significant hemorrhage following major pelvic fractures should always be expected. Early recognition of such fractures during the resuscitation of any multiply injured patient is essential before instituting measures that might combat blood loss. In the majority of patients, simple resuscitative measures, including employment of the pneumatic antishock garment, will suffice. With certain types of fracture geography, the early application of external fixation devices may also play an important role. Increasingly popular has been the technique of diagnostic angiography and therapeutic embolization, applicable to approximately 3 per cent of all pelvic fracture patients. With exsanguinating hemorrhage, even the best equipped and most sophisticated major trauma centers can be taxed. The decision whether a patient should be taken directly to the operating room or to the angiography suite remains one of the most difficult for even the most highly skilled trauma surgeon. Patients with rapidly expanding or free rupture of pelvic hematomas noted at the time of celiotomy, or those with large open wounds, usually leave no recourse but to attempt direct operative control, to include even the most morbid option of a life-saving hemipelvectomy or corpectomy. More often, however, once other sources of surgically correctable hemorrhage are controlled or ruled out, diagnostic angiography followed by therapeutic embolization is a mainstay in the modern-day management of pelvic fracture hemorrhage.

Selective management of pediatric pelvic fractures: A conservative approach

An analysis of clinical characteristics and pelvic fracture management in a recent 5-year period is presented. Ninety-eight percent of pelvic fractures were the result of a motor vehicle accident, which included 61% auto-pedestrian accidents. Seventy-nine percent of patients sustained one or more major injuries while 21% sustained an isolated pelvic fracture. Head injury was the most common concomitant injury (23% of patients). Forty-six percent of patients required blood transfusions (mean 15.8 mL/kg). Forty-one (72%) patients were treated with bedrest. The remainder were treated with traction (5), spica cast immobilization (5), open reduction and internal fixation (4), or anterior external fixation (2). Overall mortality was 14%. In comparing nonsurvivors with survivors there were significant differences in Modified Injury Severity Scores and Glasgow Coma Scores. The types of pelvic fractures that occur in children were found to be similar to those of adults. There was no significant difference in mortality among children with different types of pelvic fractures. In contrast to adults, pelvic fracture hemorrhage was not a major contributing cause of death in this series of patients. All eight deaths were secondary to severe closed head injury.