Pathophysiology of haemorrhage in pelvic fractures

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. Introduction The initial management of patients presenting with pelvic fracture and haemodynamic instability remains difficult. An early evaluation of severity is essential in these patients, many of whom have suffered multiple trauma. The immediate risk to life is linked to the possible occurrence of refractory haemorrhagic shock, with the associated major coagulation disorders. The main problem is linking bleeding to a retroperitoneal lesion that is accessible for arterial embolization, as early as possible. Retroperitoneal haematoma should be assumed in cases of post-traumatic haemodynamic instability associated with pelvic fracture in the absence of extrapelvic haemorrhagic lesions. When possible, thoracic-abdominalpelvic computed tomography (CT) scanning with contrast should be used to screen for arterial lesions. Rigorous management as part of a decisional algorithm aimed at achieving haemostasis as rapidly as possible is indispensable. The respective roles of angiographic embolization and pelvic ring fixation in this algorithm remain subject to debate and controversy. This clinical review focuses on the initial management of patients with blunt pelvic trauma and haemodynamic instability. The Medline database was searched for English language medical literature published since 1980, with specific attention given to recent, clinically relevant publications. The specific objectives of this review were to describe the pathophysiology of haemorrhage in pelvic fractures as well as efficient therapeutic options to control retroperitoneal bleeding. Where there is insufficient evidence, we describe our opinion based on clinical experience. Pathophysiology of haemorrhage in pelvic fractures Most pelvic fractures result from motor vehicle accidents, but severe complex pelvic fractures may also result from falls from buildings [1]. The pelvic ring is much more solid than many other bone structures, and high-energy trauma is required to disrupt this complex. Consequently, these fractures are rarely found in isolation, and patients with pelvic fractures often have multiple trauma. The seriousness of pelvic fractures lies in the possible occurrence of retroperitoneal haematomas and haemorrhagic shock [2]. The pelvic ring is anatomically connected to a large number of blood vessels (Figure 1). The internal iliac (or hypogastric) artery originates in the sacroiliac joint and gives rise to the superior and inferior gluteal arteries. The external iliac artery follows an oblique path, in front of the arcuate line. The venous system follows a pattern similar to that of the arterial system, but in a more posterior Review Clinical review: Initial management of blunt pelvic trauma patients with haemodynamic instability Thomas Geeraerts1, Vibol Chhor1, Gaëlle Cheisson1, Laurent Martin1, Bertrand Bessoud2, Augustin Ozanne3 and Jacques Duranteau1 1Département d’Anesthésie-Réanimation chirurgicale, Centre Hospitalier Universitaire de Bicêtre, Assistance Publique Hôpitaux de Paris, Univ Paris Sud, Le Kremlin-Bicêtre, France 2Service de radiologie générale et interventionnelle, Centre Hospitalier Universitaire de Bicêtre, Assistance Publique Hôpitaux de Paris, Univ Paris Sud, Le Kremlin-Bicêtre, France 3Service de neuroradiologie diagnostique et thérapeutique, Centre Hospitalier Universitaire de Bicêtre, Assistance Publique Hôpitaux de Paris, Univ Paris Sud, Le Kremlin-Bicêtre, France Corresponding author: Thomas Geeraerts, [email protected] Published: 12 February 2007 Critical Care 2007, 11:204 (doi:10.1186/cc5157) This article is online at http://ccforum.com/content/11/1/204 © 2007 BioMed Central Ltd CT = computed tomography.