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Diederik O.F. Verbeek, MD, Ijsbrand A.J. Zijlstra, MD, Christaan van der Leij, MD,
Kornelis J. Ponsen, MD, PhD, Otto M. van Delden, MD, PhD,
and J. Carel Goslings, MD, PhD, Amsterdam, the Netherlands
BACKGROUND: The sliding computed tomographic (CT) scanner in our trauma resuscitation room can be used early in the assessment of
pelvic ring fracture patients. We determined the association between the presence of a pelvic blush on CT scan and the need
for pelvic hemorrhage control (PHC). We hypothesized that many pelvic blushes found early in the resuscitation phase can be
safely managed without intervention.
METHODS: Contrast-enhanced CT scans of pelvic ring fracture (pelvic ring disruption) patients admitted from January 1, 2004, to
June 31, 2012, were reviewed for the presence of a pelvic blush. PHC was dened as requiring a surgical or radiologic
intervention for pelvic bleeding. A subanalysis was performed in isolated pelvic fracture/ blush patients (absence of a
major nonpelvic bleeding source).
RESULTS: Overall, 68 (42%) of 162 pelvic ring fracture patients and 53 (40%) of 134 isolated pelvic fracture patients had a pelvic blush.
Of those 32 (47%) and 27 (51%) patients, respectively, required PHC. In the absence of a pelvic blush, 87 (93%) of 94 of all
and 77 (95%) of 81 of isolated pelvic fracture patients did not require PHC. Of all patients with a pelvic blush and of iso-
lated pelvic blush, those with PHC had a higher Injury Severity Score (ISS) (p = 0.01 and p = 0.05), base decit (p = 0.03 and
p = 0.01), as well as 24-hour and any packed red blood cells requirement (p G0.001 and p = 0.05; p G0.001 and p = 0.02).
In isolated pelvic blush patients, there was a trend toward a higher hospital and hemorrhage-related mortality in patients with
PHC (p = 0.06 and p = 0.06).
CONCLUSION: In pelvic ring fracture patients, a pelvic blush on early contrast-enhanced CT is a frequent nding. Many patients with
(particularly isolated) pelvic blushes have stable vital signs and can be managed without surgical or radiologic PHC. The need
for an intervention for a pelvic blush seems to be determined by the presence of clinical signs of ongoing bleeding. (J Trauma
Acute Care Surg. 2014;76: 374Y379. Copyright * 2014 by Lippincott Williams & Wilkins)
LEVEL OF EVIDENCE: Therapeutic study, level IV. Prognostic/epidemiologic study, level III.
KEY WORDS: Pelvic fracture; hemorrhage; contrast extravasation; angiographic embolization; pelvic packing.
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg
Volume 76, Number 2 Verbeek et al.
pelvic ring fracture patients as well as in a subgroup of iso- bleeding (clinical signs of hypovolemic shock with a continuing
lated pelvic fracture patients (without a major nonpelvic transfusion requirement) were considered for radiologic hem-
bleeding source). We hypothesized that many pelvic blushes orrhage control. Digital subtraction angiography was performed
found early in the resuscitation phase can be safely managed using Philips V3000 (the Netherlands) equipment. Patients with
without intervention. an arterial injury on pelvic angiography received pelvic angio-
graphic embolization. Embolization was performed using a va-
riety of platinum embolization coils, Gelatin sponge particles
PATIENTS AND METHODS (Gelfoam, Upjohn, Kalamazoo, MI) or a combination of both.
All adult patients with a high-energy major pelvic frac- Pelvic blush patients with refractory hemorrhagic shock
ture admitted to the trauma resuscitation room of our aca- (ATLS nonresponders) had immediate surgical hemorrhage
demic Level 1 trauma center between January 1, 2004, and control by pelvic packing or (occasionally) surgical ligation
June 31, 2012, were identied from our prospective trauma of pelvic arteries (followed by pelvic angiography if needed).
registry and the hospitals DRG International Classication of Intraperitoneal pelvic packing was generally performed in pa-
DiseasesV9th Rev. database. Patients who had an intravenous tients who required a laparotomy and preperitoneal packing in
contrast-enhanced CT scan were considered for inclusion. A patients who did not require a laparotomy (rarely at the time of
pelvic ring fracture was dened as a disruption of the pelvic study). Surgical hemorrhage control was also performed in
ring in at least two places. Patients with a single break of the patients with signs of pelvic hemorrhage at immediate lapa-
pelvic ring (i.e., single acetabular, iliac wing, or pubic rami rotomy for abdominal hemorrhage. A pelvic external xator
fractures), transfer patients, and patients declared dead on was placed before laparotomy for unstable fracture patterns. The
arrival were excluded from the analysis. overall patient management was at the trauma surgeons dis-
Medical records were reviewed for age, sex, mechanism cretion in conjunction with the anesthesiologist and interven-
of injury, Injury Severity Score (ISS), systolic blood pres- tional radiologist on call.
sure (SBP) and base decit on arrival, packed red blood cell For the purpose of the study, all CT scans were reviewed
transfusion within 24 hours after arrival, and (hospital and for the presence of a pelvic blush (focal area of high-contrast
hemorrhage-related) mortality. density) by two senior radiology residents and a board-
Pelvic fractures were classied using the Young and certied interventional radiologist in consensus. All pelvic
Burgess classication; major ligamentous disruption (MLD) was angiographies were independently reviewed by a board-certied
dened as anteroposterior Type II and III, lateral compression interventional radiologist for the presence of arterial injury
Type III, vertical shear, and combined mechanism.19Y21 Opera- (contrast extravasation, cutoff, or pseudoaneurysm).
tive and radiology reports were examined for surgical and/or
Denitions
radiologic interventions performed to control pelvic or non-
pelvic bleeding sources. The need for pelvic hemorrhage control was dened as
having received a surgical (pelvic packing or surgical ligation)
Patient Management and Imaging and/or radiologic (angiographic embolization) intervention for
Initial patient assessment followed our institutional pro- pelvic bleeding. A major nonpelvic bleeding source was de-
tocol and advanced trauma life support (ATLS) principles. ned as an abdominal, thoracic, or extremity injury that re-
According to the local imaging protocol, all high-energy trauma quired surgical or radiologic hemorrhage control. A patient
patients receive a chest and pelvic radiography as well as a was considered to have an isolated pelvic fracture or blush in
FAST within 5 minutes of arrival. Pelvic ring fracture patients the absence of a major nonpelvic bleeding source.
also have an abdominopelvic intravenous contrast-enhanced CT
scan. The location of the multislice CT scanner (SOMATOM Statistical Analysis
Sensation 4 and 64 [from 2008], Siemens Medical Systems, Continuous variables are presented as median values
Erlangen, Germany) in the trauma resuscitation room enables us with interquartile ranges (IQRs) and are compared using
to safely perform a rapid CT scan in all patients except for those Mann-Whitney U-test or as mean values with SDs and compared
with refractory hemorrhagic shock despite adequate uid re- with independent t test, depending on data distribution. Cate-
suscitation (ATLS nonresponders). On arrival, patients are gorical values were calculated as percentage of frequency of
placed on the trauma room table, which is radiolucent and also occurrence. Discrete variables were compared using Fishers
acts as the CT table. The CT scanner is able to slide over the exact analyses. Statistical signicance was declared at the
patient without interrupting ongoing resuscitation.5,6 Images are 0.05 level.
viewed in stacked mode using picture archiving and communi- Two-by-two contingency tables were constructed to cal-
cation system. culate the diagnostic indices (sensitivity, specicity, as well as
After the CT scan is obtained, the images are immedi- positive and negative predictive values) for the presence of a
ately reviewed by the attending trauma surgeon and radiologist. pelvic blush on CT scan and the need for pelvic hemorrhage
An interventional radiologist is available on a 24-hour basis. control in all patients as well as in the subgroup of isolated
The decision to proceed for surgical or radiologic hemorrhage pelvic fracture patients. Results are presented with 95% con-
control was typically based on the patients hemodynamic dence intervals.
status and presence of associated injuries. In general, patients All data management and statistical analysis were per-
with a pelvic blush received pelvic angiography on a liberal formed using Statistical Package for the Social Science
basis. Particularly, pelvic blush patients with signs of ongoing (SPSS\, IBM\, Armonk, New York).
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg
Verbeek et al. Volume 76, Number 2
TABLE 1. Characteristics, Management, and Outcome of All Patients by Presence of a Pelvic Blush on CT Scan
All Patients Pelvic Blush Pelvic Blush
(n = 162) Present (n = 68) Absent (n = 94) p
Age, mean (SD), y 41 (19) 44 (20) 38 (18) 0.04
Sex, n (%) 124 (77) 54 (79) 70 (75) 0.20
Mechanism of injury, motor vehicle collision, n (%) 35 (22) 12 (18) 23 (25) 0.25
ISS, mean (SD) 27 (14) 31 (16) 24 (12) G0.01
Type fracture, MLD, n (%) 56 (35) 31 (46) 25 (27) 0.01
SBP, mean (SD), mm Hg 119 (33) 113 (40) 124 (25) 0.04
Base decit, median (IQR), mEq/L 4 (5) 4 (6) 3 (4) G0.01
Nonpelvic hemorrhage control 28 (17) 15 (22) 13 (14) 0.12
Pelvic external xator 86 (53) 47 (69) 39 (42) G0.01
Pelvic hemorrhage control 39 (24) 32 (47) 7 (7) G0.01
Packed red blood cells in 24 h, median (IQR), U 2 (10) 8 (19) 2 (4) G0.01
Any packed red blood cell 111 (69) 55 (81) 56 (60) G0.01
Hospital mortality 19 (12) 12 (18) 7 (7) 0.04
Hemorrhage-related mortality 10 (6) 8 (12) 2 (2) 0.01
Italics indicate statistical signicance ( p G 0.05).
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J Trauma Acute Care Surg
Volume 76, Number 2 Verbeek et al.
TABLE 2. The Association Between the Presence of a Pelvic TABLE 4. The Association Between the Presence of a Pelvic
Blush on CT Scan and the Need for Pelvic Hemorrhage Control Blush on CT Scan and the Need for Pelvic Hemorrhage Control
in all Pelvic ring Fracture Patients (n = 162) in Isolated Pelvic Fracture Patients (With No Other Source of
Major Hemorrhage) (n = 134)
Pelvic Hemorrhage
Control Pelvic Hemorrhage
Yes No Control
Yes No
Blush 32 36 68
Present 7 87 94 Blush 27 26 53
Absent 39 123 162 Present 4 77 81
Absent 31 103 134
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J Trauma Acute Care Surg
Verbeek et al. Volume 76, Number 2
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J Trauma Acute Care Surg
Volume 76, Number 2 Verbeek et al.
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