Injury, Int. J.

Care Injured 45 (2014) 738741

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Injury
journal homepage: www.elsevier.com/locate/injury

Time to pelvic embolization for hemodynamically unstable pelvic

fractures may affect the survival for delays up to 60 min
Shinsuke Tanizaki *, Shigenobu Maeda, Hideyuki Matano, Makoto Sera,
Hideya Nagai, Hiroshi Ishida
The Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: We evaluated the relationship between survival and time from arrival to angiography for
Received 19 January 2013 hemodynamically unstable patients with pelvic trauma.
Received in revised form 10 September 2013 Methods: A retrospective review of patients admitted to Fukui Prefectural Hospital with pelvic fractures
Accepted 11 November 2013
during a 7.5-year period. Charts were reviewed for age, injury characteristics, injury severity score,
systolic blood pressure and heart rate on arrival, base decit, and the lactate concentration on arrival,
Keywords: transfusion requirement, fracture pattern, the time from hospital arrival to angiography, and the time
Pelvic trauma
spent in the angiography suite.
Angiography
Embolization
Results: Of a total of 140 patients, 68 patients underwent pelvic angiography and embolization. Of the
patients, 24 patients were hemodynamically unstable. The average injury severity score was 41.7. Of the
patients, 17 had major ligamentous disruption. The average time from hospital arrival to angiography
suite was 76 min. Of the hemodynamically unstable 24 patients, there were 12 deaths (50%). Patients
who were embolized within 60 min of arrival had a signicantly lower mortality rate (16 vs. 64%;
p = 0.04). There was no embolization-related complication and repeat angiography was not required in
all patients.
Conclusion: Earlier pelvic embolization within 60 min may affect the survival of hemodynamically
unstable patients with pelvic fracture.
2013 Elsevier Ltd. All rights reserved.

Introduction embolization would reduce the mortality of hemodynamically

The management of hemodynamically unstable patients with
pelvic fracture is a multidisciplinary challenge with high mortality
and remains a controversial issue [14]. Haemorrhage due to
disruption of the surrounding venous and arterial vessels is the
leading cause of death in these patients and require prompt
therapy aimed at hemostasis [1,2].
The combination of angiography and embolization of bleeding
arterial vessels has emerged as an excellent management method
[5]. Some have used angiography without invasive external
xation if haemodynamic instability persisted despite volume
resuscitation for 24 h [57]. Angiography within 90 min with
external xation was reported [8]. It is unclear whether the delay
in controlling bleeding from pelvic trauma is associated with
worsened outcomes. We hypothesized that earlier pelvic
* Corresponding author at: Fukui Prefectural Hospital, The Department of
Emergency Medicine, 2-8-1, Yotsui, Fukui, 910-8526 Japan. Tel.: +81 776 54 5151;
fax: +81 776 57 2991.
E-mail address: sytanizak@yahoo.co.jp (S. Tanizaki).
unstable patients with pelvic fractures. This retrospective study
analyzed our protocol consisting of early embolization in
hemodynamically unstable patients with pelvic fracture, and
evaluated the relationship between survival and time from
arrival to angiography.
Methods
We conducted a review of a consecutive series of 140 trauma
patients with pelvic ring fractures who were admitted to Fukui
Prefectural Hospital (FPH) from April 1, 2005, through September
30, 2012. The patients were transported to the hospital by ground
transportation or by helicopter. The patient data were obtained
from the hospital records. Patients with any pelvic fractures were
included in this study. Patients who died in the emergency
department and patients requiring emergency laparotomy were
excluded. Data examined included age, injury characteristics,
injury severity score (ISS), systolic blood pressure and heart rate on
arrival, base decit and the lactate concentration on arrival,
transfusion requirement, fracture pattern, the time from hospital

00201383/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.injury.2013.11.007
 S. Tanizaki et al. / Injury, Int. J. Care Injured 45 (2014) 738741
arrival to angiography suite, and the time spent in the angiography
suite. The fractures were classied according to the YoungBurgess
classication [9]. Major ligamentous disruption was dened as
anteroposterior compression type II and type III, lateral compres-
sion type III, combined mechanism, and vertical shear. Abbreviated
injury scale (AIS) 1990update 98 was used to calculate ISS.
General management
The treatment protocol established for all patients included an
initial evaluation and volume resuscitation in the emergency
department (Fig. 1). Focused assessment with sonography for
trauma examination (FAST) was performed to detect hemoper-
itoneum, massive haemothorax, or hemopericardium. An ante-
roposterior chest radiograph was obtained to exclude intrathoracic
injury. Clinical examinations of the pelvis and anteroposterior
pelvic radiographs were used to determine whether the patient
had a pelvic fracture and to assess the fracture pattern. If
haemodynamic stability permitted radiographic workup, comput-
ed tomography (CT) scanning of the whole body was performed.
Patients with arterial extravasation on the contrast-enhanced
pelvis CT underwent angiography and embolization. The CT-room
and the angiography suite in our hospital are next to the
emergency room. If patients were hemodynamically unstable
with only pelvic haemorrhage, angiography, and embolization
were performed immediately. Haemodynamic instability was
dened as systolic arterial pressure <90 mm Hg after an infusion
of 2 l of lactated ringers and the initiation of the transfusion of the
packed red blood cells (PRBCs). SAM Pelvic Sling1 (Seaberg,
Wilsonville, OR) was used as pelvic binder in our protocol.
Laparotomy was indicated by concomitant haemodynamic insta-
bility and progressive abdominal effusion or by the existence of a
pneumoperitoneum.
Pelvic angiography
Angiography was performed using the femoral puncture
approach. A pelvis ush was performed at the aortic bifurcation
level after an abdominal ush. Thoracic aortography was
performed in the case of severe chest trauma. Embolization agents
included gelfoam and steel coils. Gelfoam of about 3 mm in each
dimension diluted in contrast medium was injected to avoid
permanent arterial occlusion. The signs of vascular injury, such as
contrast extravasation, vasospasm, pseudoaneurysm, and arterio-
venous stula, were reasons for embolization. Bleeding sites were
directly identied to be controlled with embolization. Selective
embolization of discrete bleeding sites was performed with
Pelvic Fracture
Hemodynamically Hemodynamically
unstable stable
FAST CT scan
Positive Negative Extravasation
positive
Emergent
Angiography
laparotomy
Fig. 1. Treatment protocol for pelvic fractures.
739
gelfoam. Non-selective embolization of the internal iliac artery
was performed in patients with multiple bleeding areas. Emboli-
zation with steel coils was performed in patients with pseudoa-
neurysm, arteriovenous stula, or bleeding that was difcult to
arrest with gelfoam. Completion angiography was necessary to
conrm the cessation of bleeding radiographically.
Statistical analysis
All data in the tables are presented as mean SD unless
otherwise specied. Demographic discontinuous variables were
compared using the Chi Square test. Continuous variables were
compared using Students t-test. Signicance was dened as p < 0.05.
Results
During the 7.5-year period, 140 patients with pelvic fractures
were treated in the FPH. 68 patients (49%) underwent pelvic
angiography and embolization (Fig. 2). Of the patients, 24 patients
(35%) were hemodynamically unstable. All 44 hemodynamically
stable patients had extravasations on CT. The mean patient age was
6  22 years and sex distribution was 13 male and 11 female. The
average injury severity score (ISS) was 41.7  9.1. Out of the patients,
17 (70%) had major ligamentous disruption. All injuries were the
result of blunt trauma; the mechanisms included 10 (41%) falls from a
height, 10 (41%) pedestrians struck by motor vehicles, and 4 (16%)
motor vehicles crashes (Table 1). Associated extrapelvic injuries AIS
>3 were as follows: 13 (54%) intracranial injuries, 12 (50%)
intrathoracic injuries, 4 (16%) intraabdominal injuries, and 2 (8%)
extremity injuries (Table 2).
Nonsurvivors of the hemodynamically unstable patients, who
underwent embolization, were signicantly associated with lower
GCS score and higher ISS than survivors (Table 1). There were no
signicant differences between survivors and nonsurvivors in age,
gender, injury mechanism, the presence of major ligamentous
disruption, base decit on arrival, the lactate concentration on
arrival, PRBCs requirement in the initial 6 and 24 h, or associated
extrapelvic injuries (Tables 1 and 2).
The time from hospital arrival to angiography suite ranged from
30 to 145 min, with an average of 76 min. The time from lesion to
angiography suite ranged from 70 to 250 min, with an average of
110 min. The time spent in the angiography suite ranged from 30
to 125 min, with an average of 58 min. The bleeding was difcult to
arrest even with steel coils in one case. The catheter was not
positioned easily in the main trunk of the internal iliac artery
because of severe tortuosity in two cases. Survivors had a lower
average time from hospital arrival to angiography suite than
Pelvic Fractures
(n=140)
No angiography Angiography
72 (51%) 68 (49%)
Extravasation Hemodynamically stable
Hemodynamically unstable
negative 44 (65%)
24 (35%)
Observe Positive angiography Positive angiography
24 (100%) 36 (88.2%)
Fig. 2. Management algorithm of patients with pelvic fractures.
740 S. Tanizaki et al. / Injury, Int. J. Care Injured 45 (2014) 738741

Table 1
Demographic and clinical characteristics of patients with hemodynamically unstable pelvic fractures.

Characteristic Survivor (n = 12) Non-survivor (n = 12) p Value

Age (yr) 57.2  22.2 65.9  23.2 0.361

Male gender (%) 8 (66.7) 5 (41.6) 0.133
Admission SBP (mm Hg) 95.1  34.0 76.5  16.6 0.101
Admission HR (beats/min) 102.6  15.2 107.5  22.8 0.542
GCS score 13.6  0.98 9.25  4.55 <0.01
ISS 37.9  8.03 45.5  8.84 <0.05
Mechanism (%)
Fall 6 (50.0) 4 (33.3) 0.407
Pedestrians accident 3 (25.0) 7 (58.3) 0.097
MVC 3 (25.0) 1 (8.33) 0.273
Pelvic fracture pattern (%)
Major ligamentous disruption 9 (75.0) 8 (66.7) 0.653
The average time from hospital arrival to angiography (min) 63.1  23.5 89.9  28.6 <0.05
The average time from lesion to angiography (min) 94.7  14.5 125.8  49.3 <0.05
The average time of angiography (min) 55.8  29.0 60.8  25.3 0.658
Base decit on arrival (mmol/l) 3.93  4.44 5.44  4.13 0.454
The lactate concentration on arrival (mmol/l) 4.32  2.49 7.38  4.10 0.057
The PRBCs requirement in the initial 6 h (units) 10.4  6.68 10.5  3.52 0.94
The PRBCs requirement in the initial 24 h (units) 13.7  9.51 18.2  10.1 0.274
ICU length of stay (days) 6.92  3.89 3.75  1.96 <0.05

SBP, systolic blood pressure; HR, heart rate; GCS, Glasgow Coma Scale; ISS, injury severity score; MVC, motor vehicle crash; PRBCs, packed red blood cells.

nonsurvivors (63 vs. 89 min; Table 1). If the patient was in the
angiography suite within 60 min, the mortality rate was 16%;
however, after 60 min this rate signicantly increased to 64%.
Embolization was performed in all 68 patients who underwent
angiography. Of these 68 patients, 60 patients (88.2%) had active
arterial bleeding. Angiography was positive in all 24 hemodynam-
ically unstable patients received angiography. Of the 44 hemody-
namically stable patients who underwent angiography, 36 patients
(81.8%) had active arterial bleeding. In the other 8 patients,
embolization was done because vasospasm occurred in the
internal iliac artery.
There was no embolization-related complication, such as the
gluteal muscle and skin necrosis, necrosis of the vesical wall, or
urogenital complication. Repeatative angiography was not re-
quired in all patients.
Of the 68 patients who underwent angiography, there were 12
deaths (17%). Of the hemodynamically stable 44 patients, there
was no death. Of the hemodynamically unstable 24 patients, there
were 12 deaths (50%). One patient died from acute respiratory
distress syndrome due to haemorrhagic shock. Mortality in three
patients was the result of multiple organ dysfunction syndrome
failure. The other eight deaths were related to severe head injury.
Discussion
Early identication and control of pelvic haemorrhage is pivotal
to decreasing pelvic fracture-related mortality [5,7,10]. This
haemorrhage can originate from injury to arteries, injury to the
venous plexus in the pelvis, and fracture bleeding. The most
common methods for arresting pelvic bleeding are external
xation of the pelvic fracture, and angiography for the identica-
tion and embolization of arterial pelvic bleeding.
Angiographic embolization is considered by most authors to be
the optimal method for controlling arterial haemorrhage, and
Table 2
Number of associated extrapelvic injuries.
Associated extrapelvic injuries Survivor Non-survivor
Intracranial injuries 5 (41.7%) 8 (66.7%)
Intrathoracic injuries 6 (50.0%) 6 (50.0%)
Intraabdominal injuries 2 (16.7%) 2 (16.7%)
Extremity injuries 2 (16.6%) 0 (0%)
allowing the tamponade effect of the haematoma to control venous
bleeding [57,11]. Some found early embolization to be associated
with improved outcome [6]. The probability of death increased
approximately 1% for every 3 min of haemodynamic instability
that elapsed without haemorrhage control in the emergency
department [12]. Although the sample had small size, those
patients who had delayed arrival to the angiography suite because
of prolonged resuscitation or unnecessary radiographic tests had a
higher mortality than those patients who had arrived within
60 min. Six of seven patients who arrived to the angiography suite
within 60 min survived, whereas only six of seventeen patients
who arrived after 60 min survived. This result emphasized the
need for emergency physician or trauma surgeon to make decision
for transportation of the hemodynamically unstable patients
without nonpelvic bleeding sources as soon as possible to the
angiography suite. And also, this result emphasized that angiogra-
phy was meaningful only in cases when it could be done as fast as
an urgent laparotomy for haemorrhage control.
Markers for the early identication of patients likely to have
arterial bleeding are important. Fracture pattern and its relation-
ship to outcome have been examined. Some have demonstrated
that patients requiring embolization were signicantly more likely
to have fracture patterns associated with major ligamentous
disruption [13]. Others showed no clear relationship between
fracture pattern and arterial bleeding [14]. The decision to obtain
angiography based on fracture pattern alone would lead to a very
low yield. We employed angiography in the face of haemodynamic
instability, even if there were no fracture patterns associated with
major ligamentous disruption.
The diagnostic accuracy of the modern 64-slice multidetector
computed tomography (MDCT) in detecting active pelvic arterial
bleeding associated with blunt pelvic fractures has also been
examined. Some showed that the MDCT provides relatively high
diagnostic accuracy in detecting a clinically relevant arterial
haemorrhage [15]. They concluded angiography or operative
intervention, warranted in patients with clinical signs of ongoing
haemorrhage, even in the absence of MDCT contrast extravasation.
Some showed that the negative predictive value of contrast
P value extravasation on CT scans needing embolization was 98% [16].
0.219 They concluded that the presence of contrast extravasation on CT
1.000 scans was an indication for angiography, regardless of haemody-
1.000
namic status. Others retrospectively examined CT scans with
0.139
contrast extravasation in pelvic trauma and found that nearly half
 S. Tanizaki et al. / Injury, Int. J. Care Injured 45 (2014) 738741
of contrast extravasation on CT scans did not require embolization
[17]. They concluded that angiography may not be required in
patients with stable haemodynamics. Need for angiography in
hemodynamically stable patients with contrast extravasation from
pelvic trauma requires further study to determine its usefulness.
The mortality rate was 17% (12/68) in those patients requiring
embolization, and this was lower than that reported in the
literature of 36% [18]. All of death was hemodynamically unstable
and the mortality rate was 50% in those patients with haemody-
namic instability requiring embolization. The higher mortality rate
may be attributed to the fact that these patients had more severe
injuries. Most patients died from acute respiratory distress
syndrome, multiple organ dysfunction syndrome failure, or severe
head trauma, which is similar to the previous report [6].
Various noninvasive external xation devices are available to
provide emergent stabilization of pelvic fracture. The efcacy of
temporary external xation devices in controlling pelvic haemor-
rhage has not been conrmed. However, some reported that the
use of temporary external xation devices placed in the emergency
department reduced blood transfusion needs compared with
invasive external xation placed in the operation room [19].
Noninvasive external xation device was used in the present
report because of the rapidity of the device placement compared
with invasive external xation.
Preperitoneal pelvic packing (PPP) has been used as a new part
of clinical pathway in controlling haemorrhage from pelvic
fracture [5]. Cothren et al. reported that the success rate of PPP
in controlling haemorrhage was 83% in those patients with
hemodynamically instability. Another study in their institution
reported that the mortality rate was 20% in those patients who
underwent PPP at a median of 45 min from admission, and this was
not similar with that of patients who underwent angiography at a
median of 130 min (30%) [20]. Most relevant is that nobody in the
packing group died from haemorrhagic shock, but 2 in the
angiography group. Our study showed that the mortality rate was
16% in those patients with haemodynamic instability who
underwent angiography within 60 min from arrival. If angiography
is available immediately, earlier angiography may be effective in
controlling haemorrhage from pelvic fracture.
Complications of embolization have been reported in limited
case-series studies. Our study showed no embolization-related
complication, even using bilateral internal iliac artery emboliza-
tion, as shown by other previous reports [11]. Gelfoam of about
3 mm in each dimension (which is larger than the previously
reported 2 mm) was the occluding agent of choice [21,22]. This
may help to occlude the larger branches of the internal iliac artery
temporarily while leaving the smaller branches open to collateral
blood ow, as well as to avoid signicant ischaemia. The reasons
why there was no embolization-related complication may be, that
larger gelfoam was used.
This study has limitations, the greatest being the small sample
size. We had difculty in reaching many patients, because our
institution is a rural hospital in Japan.
In summary, the present study suggests that earlier pelvic
embolization within 60 min may affect the survival of hemody-
namically unstable patients with pelvic fracture.
741
Conict of interest statement
There are no potential conicts of interest. The authors report
this study did not receive any outside funding.
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