Multi-organ injuries are the commonest cause of death amongst individuals below the age of 45 years [1]. The majority of them are cerebrocranial trauma after single or multiple body injuries, followed by abdominal injuries. The death can result from massive bleeding or its sequelae and infections [1].

Pelvic injuries are associated with high-energy forces; the mortality rates related to them are high – 5-50%, with the highest rate observed amongst haemodynamically unstable patients. Pelvic injuries often coexist with CNS and abdominal injuries. The resultant massive bleeding to the retroperitoneal space leading to haemorrhagic shock is the commonest, life-threatening complication. In many cases, such patients require massive transfusions of blood substitutes (15-30 U of red blood cells) and intense fluid resuscitation [2]. In patients with severe pelvic injuries, bleeding is the commonest cause of death within the first 24 h of treatment [3].

The majority of retroperitoneal bleedings originate from low-pressure vessels within the pelvis (numerous venous plexi) or from the surface of pelvic fractures. External stabilisation of the pelvis or surgery with internal stabilisation can stop this type of bleedings [2].

Arterial bleedings constitute only 5-10% of large bleedings within the pelvic region. They are usually associated with high-energy forces [2] and develop in all kinds of pelvic fractures, including an isolated iliac acetabulum fracture or a sacral fracture [3]. There is no correlation between the place of fracture and probable bleeding site [4]. In anterior pelvic fractures, bleedings most commonly originate from the pudental artery and/or obturator artery whereas in posterior fractures from the internal iliac arteries, superior gluteal artery or sacroiliac artery [2]. Arterial bleedings cannot be staunched by pelvic stabilisation as the blood extravasates under relatively high pressure into the retroperitoneal fascial spaces, which can accommodate the entire volume of circulating blood and several litres of transfused blood substitutes. The life-saving procedure is embolisation of the injured arterial vessels [2]. The first embolisation of pelvic arterial bleeding was performed by Margolies and colleagues in 1972 [4]. Since that time, intravascular embolisation has been recognised a safe and effective method of treatment of small pelvis bleedings [3].

The aim of the present report was to describe the case of multi-organ trauma with co-existing retroperitoneal bleeding treated with arterial embolisation.

CASE REPORTS

A 24-year-old patient, who had sustained severe traffic accident-related multi-organ injury, was admitted to hospital; he was unconscious (GCS 10) and in haemorrhagic shock. The diagnostic procedures (CT of the head, cervical spine, abdomen, chest, X-ray of the chest, pelvis and lower limbs, abdominal US) revealed: the head injury with brain oedema, abdominal injury with ruptured spleen, small intestine mesentery and sigmoid mesentery, damage to the right ureter, ruptured anterior wall of the urinary bladder, extra- and intraperitoneal bleeding, pelvic injury with a bilateral fracture of the superior pubic and sciatic bone rami as well as of the sacral bone on the right, and cervical spine injury with a compression fracture of C5-C7, and an open fracture of both crural bones.

Considering the US-detected large amount of fluid in the peritoneal cavity and unstable haemodynamic condition, the patient was qualified for emergency laparotomy. The pelvic rupture and massive retroperitoneal haematoma were confirmed intraoperatively. The spleen and part of the small intestine were removed, the small intestine mesentery was secured, and the injured sigmoid mesentery and disrupted anterior wall of the urinary bladder were sutured. After laparotomy, the fractured pelvis and left crural bone were temporarily externally stabilised. During surgery, the patient’s condition was extremely severe, with hypotension (SAP/DAP 45/25 mm Hg) and estimated blood loss of about 3000 mL. After surgery, the patient was transferred to the ITU.

After ITU admission, the patient’s condition remained extremely severe, symptoms of hypovolaemic shock maintained: SAP/DAP 80/40 mm Hg, HR 105 min-1, impaired organ perfusion, cyanosis of the nail vascular beds, pale and cool body integuments, core temperature – 32.6O C. The patient was administered mechanical lung ventilation, analgosedation, antibiotic therapy and intensive fluid resuscitation (during the first 24 h he received 16000 mL of crystalloids and 3000 mL of colloids, 16 U of red blood cells, 15 U of FFP, 15 U of PLT); moreover, cryoprecipitate (12 U) was given due to clotting abnormalities. Since it was impossible to maintain sufficient arterial pressure, catecholamines, noradrenaline and dobutamine were included. The anti-oedematous treatment was initiated due to cerebrocranial injury (mannitol in the fractionated doses and infusion of 3% NaCl). On ITU day 2, the head CT was repeated and disclosed the presence of peri-cerebral haematoma on the right; emergency craniotomy with haematoma evacuation was performed.

Despite the transfusions of platelets and cryoprecipitate, warming of the patient, acidosis and blood ionised calcium control, the clotting disturbances (platelet values 66-75 G L-1, abnormal coagulogram: APTT 48.3 secs., INR 1.81) and anaemisation (Hb 4.6 mmol L-1) were still observed. Moreover, haemodynamic stabilisation was not achieved despite fluid therapy and catecholamines. The intra-abdominal pressure gradually increased (from 16 mm Hg/2.13 kPa immediately after laparotomy to 22 mm Hg/2.93 kPa on day 4). On day 4, the CT scan revealed active extravasation of contrast within the pelvis on the left, anteriorly to the sacroiliac joint, from the internal iliac branch (Fig. 1). The extravasated blood covered the area of about 24x40mm, the haematoma in this region was of about 85×65 mm; the urinary bladder was injured (the parts above the prostatic fragment of the urethra). Moreover, inflow of the contrast medium to the perirectal region and rectum, injury to the right renal pelvis and right ureter, injury to the left renal pelvis were found. 

The patient was qualified for embolisation of the injured left internal iliac artery branch. After puncturing the right femoral artery, the catheter was introduced to the left common iliac artery and active contrast escape from the gluteal branch of the left internal iliac artery was visualized. Three embolisation spirals were implanted closing the superior gluteal artery; the internal iliac artery was preserved patent.

After the procedure, the patient was transferred to the ITU. No clinical symptoms of further bleeding were found, which was confirmed on CT (Fig. 2). Vital parameters stabilised soon.

On the following day, re-laparotomy was undertaken and the catheter was inserted to the right ureter. After the procedure, abdominal integuments were left unsutured due to high pre-operative values of intra-abdominal pressure (20-22 mmHg/2.67-2.93 kPa). The crush syndrome was vigorously treated (initial laboratory results: elevated CK 12730 U L-1, creatinine 194.5 mmol L-1 and urea 11.3 mmol L-1) applying systemic alkalisation and forced diuresis. CK started to decrease gradually (to 885 U L-1 on day 10). The renal function was preserved.  The repeated abdominal CT did not show the leakage of urine from the right ureter; the urine leaked through the rectum because of a cysto-rectal fistula. On day 7, the preternatural anus was created on the sigmoid, abdominal integuments were left unsutured.

The patient’s neurological condition gradually improved and he regained consciousness.

On ITU day 17, tracheostomy was performed. Catecholamines were discontinued and the patient was gradually weaned from the ventilator; the abdominal integuments were finally sutured. On day 44, the patient in general good condition, stable, conscious, without complaints, with efficient circulation and respiration, was transferred to the orthopaedic ward. After the two-month treatment, the patient was discharged from hospital. At present, two years after hospitalization, he is staying at home, feels good and does not report any side effects of the therapy administered.

DISCUSSION

Blunt pelvic injuries are associated with high mortality and morbidity; the majority of deaths are related to retroperitoneal bleedings. In haemodynamically unstable patients with large haematomas in the small pelvis (without any other sources of bleeding), arteriography and embolisation are indicated [2, 5]. 

The embolisation effectiveness reaches 80-100% [2, 5]. In some cases, the bleeding vessel cannot be closed, especially when numerous tiny arterial branches are injured. In such cases, embolisation of one or both internal iliac arteries is the only solution. In cases of injuries to numerous vessels, bilateral embolisation is the best and most effective management method as numerous arterial junctions in the pelvis are associated with the risk of repeated bleedings through the collateral circulation [5]. During the procedures, embolisation spirals, spongostan, patient’s blood clots or glues can be used [4]. 

No significant differences were observed in the incidence of muscle and skin necrosis, infection of pelvic tissues, bladder wall necrosis or nerve injuries in patients with small pelvis injuries, embolised or otherwise [2, 6]. There were no differences between uni- and bilateral embolisation of the internal iliac artery. Moreover, the 18-month observation did not show differences in the incidence of skin ulceration and local pain. During the long-term follow-up, the number of parastesias of the buttocks, thighs and perineum was slightly higher [6].

Retroperitoneal bleedings are difficult to secure surgically. The surgery of the bleeding site and haematoma evacuation are associated with higher risk of further blood loss due to abolition of the tamponade effect by the haematoma after opening of the retroperitoneal space. In many cases, the bleeding is stopped by ligating the internal iliac artery. Intra-vascular embolisation is a better option than a classical surgical procedure; in the majority of cases, the place of bleeding is visualized and the appropriate artery embolised [5]. During embolisation, it is possible to selectively close only the injured branch of the internal iliac artery preserving the flow in the remaining branches, which is essential to reduce the incidence of adverse side effects related to ligation (of the internal iliac artery), e.g. ischaemic colitis, urination abnormalities, intermittent claudication, and sexual dysfunction, particularly important for young patients. Embolisation performed as soon as possible after admission is likely to prevent the bleeding sequelae – haemorrhagic shock, massive transfusions and their consequences. Massive transfusions can lead to severe coagulopathy and, after initial haemodynamic stabilisation, to further bleeding and deterioration of the general condition. Moreover, massive transfusions are an independent risk factor of abdominal compartment syndrome requiring the „open abdomen” treatment [8].

In the case described, attempts to stop the small pelvis bleeding failed. The patient was qualified for embolisation of branches of the internal iliac artery on post-traumatic day 4. If embolisation had been performed earlier (e.g. on day 2), the patient would have needed fewer transfusions and the abdominal compartment syndrome or coagulopathy would have been less severe. Since more and more reported data confirm the adverse effects of massive transfusions on the incidence of complications in retroperitoneal bleedings, pre-laparotomy embolisation might even be considered.  In patients with pelvic fractures, haemodynamically unstable (inability to maintain SAP of 90 mm Hg, despite transfusion of 2000 mL of crystalloids or 2 U of red blood cells), it is recommended to perform arteriography and embolisation even before external stabilization of the pelvis [2]. The procedure performed within three post-traumatic hours results in significantly lower mortality rates [9]. 

The available prospective studies have demonstrated that in haemodynamically unstable patients with pelvic fractures, 44-76% of bleedings originate from arteries; therefore, arteriography should be carried out in all such patients, particularly when transfusions of large blood volumes are required or symptoms of anaemisation or persistent bleedings are observed [2, 3, 7].

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REFERENCES

1.     Pakulski C, Wudarska B: Urazy narządów jamy brzusznej – diagnostyka i leczenie ratunkowe. Anestezjologia i Ratownictwo 2007; 3: 189-197.

2.     Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J: Initial management of blunt pelvic trauma patients with haemodynamic instability. Crit Care 2007; 11: 204.

3.     Totterman A, Dormagen J, Madsen JE, Klow N-E, Skaga N, Roise O: A protocol for angiographic embolization in exsanguinating pelvic trauma. Acta Orthopaed 2006; 77: 462-468.

4.     Hamill J, Holden A, Paice R, Civil I: Pelvic fracture pattern predicts pelvic arterial haemorrhage. Aust N Z J Surg 2000; 70: 338-343.

5.     Velmahos GC, Chahwan S, Hanks SE, Murray J, Berne T, Asensio J, Demetriedes D: Angiographic embolization of bilateral internal iliac arteries to control life-threatening hemorrhage after blunt trauma to the pelvis. Am Surg 2000; 8: 858-861.

6.     Travis T, Monsky WL, London J, Danielson M, Brock J, Wegelin J, Link DP: Evaluation of short-term and long-therm complications after emergent internal iliac artery embolization in patients with pelvic trauma. J Vasc Interv Radiol 2008; 19: 40-47.

7.     Spahn RD, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Gordini G, Stahel PF, Hunt BJ, Komadina R, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent J-L, Rossaint R: Management of bleeding following major trauma: guideline. Crit Care 2007; 11: R17.

8.     Onichimowski D, Podlińska I, Sobiech S, Ropiak R: Pomiar ciśnienia śródbrzusznego w praktyce klinicznej. Anaestesiol Intensive Ther 2010; 42: 107-111.

9.     Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF: Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 1997; 43: 395-397.

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address:

*Dariusz Onichimowski
Oddział Anestezjologii i Intensywnej Terapii
Wojewódzki Szpital Specjalistyczny w Olsztynie
ul. Żołnierska 18, 10-561 Olsztyn
tel.: 501 173 866
e-mail:onichimowskid@wp.pl

received: 25.02.2011
accepted: 21.06.2011