The role of angio-embolization in the acute treatment concept of severe pelvic ring injuries

Injury, Int. J. Care Injured 46S4 (2015) S33–S38

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Injury j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / i n j u r y

The role of angio-embolization in the acute treatment concept of severe pelvic ring injuries Thomas Lustenberger*, Sebastian Wutzler, Philip Störmann, Helmut Laurer, Ingo Marzi Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany

K E Y W O R D S

A B S T R A C T

pelvic fracture management mechanical pelvic stabilization angiography embolization

Background:  In recent years a wide variety of strategies to treat the haemodynamically unstable patient with pelvic ring fractures have been proposed. This study evaluates our institutional management of patients with severe pelvic fractures and analyses their outcomes. Methods:  Retrospective review of all severely injured trauma patients with pelvic ring injuries admitted to a level I trauma centre from 2007 to 2012. Patient records were documented prospectively in a trauma database and evaluation was performed by SPSS. Results:  During the study period, a total of 173 patients with pelvic ring fractures were admitted and formed the basis of this study. Overall, 46% of the patients had suffered a type A fracture, 25% a type B fracture and the remaining 29% a type C pelvic ring fracture. Surgical treatment was required in 21% of the patients (pelvic C-clamp, n = 6; supra-acetabular external fixator, n = 32; pelvic packing, n = 12; definitive plate osteosynthesis of the pubis symphysis, n = 6). Angio-embolization was performed in 16 patients (9%); in 8 patients it was the only specific treatment for the pelvic injury on day 0 and in 8 patients it was performed immediately post-operatively. The overall mortality rate was 12.7% (n = 22), with the type C pelvic fractures having the highest mortality (30.0%). Four patients died immediately after admission in the shock room. Conclusions:  Angiographic embolization as a first-line treatment was only performed in haemodynamically stable patients or in patients responding to fluid resuscitation with the finding of an arterial blush in the CT scan. In haemodynamically unstable patients, pre-peritoneal pelvic packing in combination with mechanical pelvic stabilization was immediately carried out, followed by angio-embolization post-operatively if signs of persistent bleeding remained present. © 2015 Elsevier Ltd. All rights reserved.

Introduction Pelvic fractures represent a significant challenge for the trauma surgeon in terms of life-threat and functional outcome. An increased recognition of pelvic fractures as a marker of injury severity, as well as improved algorithms for resuscitation, skeletal fixation, and critical care monitoring, have done much to advance the care of these often severely injured patients [1]. However, mortality still remains significantly high; the overall mortality rate of patients with any pelvic fracture ranges between 5-10% [2-6], in haemodynamically unstable pelvic ring fractures it is up to 60% [7-9] and in patients with open pelvic fracture as high as 70% [10,11]. While in recent years a wide variety of strategies to treat the haemodynamically unstable patient with pelvic fractures have been proposed [2,12-20], there is still no clear consensus as to the best management strategy for these patients. Basically, two

* Corresponding author at: Department of Trauma, Hand and Reconstructive ­Surgery, University Hospital, Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt / Main, Germany. Tel.: +069 6301 6123; fax.: +069 6301 6439. E-mail address: [email protected] (Thomas Lustenberger).

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different fundamental treatment modalities have been advocated to address persistent haemodynamic instability due to pelvic fractures: angiography with sequential embolization controlling arterial hemorrhage versus pelvic packing, which mainly controls venous bleeding and bleeding from the fracture sites. However, the establishment of gold standard treatment guidelines is difficult due to the associated multisystem injury pattern in these patients. Recently, our group published our institutional management algorithm for patients with severe pelvic fractures, basically describing the integration of angio-embolization into the early clinical treatment protocol based on the contrast media extravasation in the initial CT-scan [18]. This study evaluates our management decisions in patients with severe pelvic fractures, in particular in the light of the current controversy with regards to the optimal emergent treatment, and analyses their outcomes. Patients and methods After approval by the Institutional Review Board, we retrospectively reviewed all severely injured trauma patients with pelvic ring injuries admitted to the Hospital of the J. W. Goethe University Frankfurt/Main from January 2007 through December

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2012. Further inclusion criteria were: acute blunt trauma, primary admission and age ≥18 years. Data was prospectively documented using a computer-based online documentation tool [21,22]. The exact pelvic fracture pattern according to the Tile classification (type A/B/C) and the acute (day 0) management of the pelvic injury was extracted from the database and the electronic patient file (X-rays/CT scan, operation report, discharge summary). Patient variables abstracted included age, gender, mechanism of injury, blood pressure and Glasgow Coma Scale (GCS) score on admission, Injury Severity Score (ISS), Abbreviated Injury Score (AIS) for each body region (head, chest, abdomen, extremity), and outcome (intensive care unit [ICU] and hospital length of stay, sepsis, multiple organ failure [MOF], mortality). Continuous variables were converted into dichotomous variables using clinically relevant cut-points (Age ≥ 55 years, systolic blood pressure < 90mmHg, GCS ≤ 8, ISS ≥ 25, AIS ≥ 3). Emergency Department Algorithm in Patients with Pelvic Fractures All patients presenting with pelvic ring injuries underwent management according to our institutional protocol for pelvic injuries, outlined in Fig. 1. The general approach is based on the patient’s haemodynamic stability and the patient’s response to volume resuscitation. The evaluation of the trauma pattern and the initial management follows the principles of Advanced Trauma Life Support (ATLS®). Surgeon-performed focused assessment sonography for trauma (FAST) is performed in the emergency room upon arrival. Further assessment includes plain radiographs of the chest and pelvis. In parallel, a definitive airway is obtained (liberal intubation in patients with severe pelvic trauma) and a large-bore intravenous access is established

(preferably large-bore central catheters). In terms of volume resuscitation, 2 litres of crystalloid solution are administered followed by packed red blood cells (PRBC) and fresh frozen plasma (FFP) in the haemodynamically unstable patient. For temporary mechanical fracture stabilization, a pelvic binder is placed on arrival if it has not been done in the pre-hospital phase. If the patient’s systolic blood pressure remains less than 90mmHg despite PRBC transfusion, the patient is considered to be a “non-­ responder”. These patients are not amenable to further diagnostic procedures and undergo urgent exploration, pre-­peritoneal pelvic packing and mechanical stabilization of the pelvic fracture (pelvic C-clamp, supra-acetabular external fixator). During pelvic packing, associated injuries that contribute to mortality, such as intra-abdominal haemorrhage, haemo-pneumothoraces and long bone fractures are simultaneously assessed and treated with damage control techniques. In the case of persistent haemodynamic instability with ongoing need of volume resuscitation following surgery, a subsequent angiography is performed. If extravasation of contrast is seen, selective embolization with coils or foam is performed. Evidence of vessel spasm or abrupt cut-offs of vessels are likewise seen as signs of injury and embolization is carried out. If the patient stabilizes after angio-­ embolization, their trauma evaluation is completed, including CT scans and any necessary plain radiographs. Subsequently, the patient is transferred to the ICU for further resuscitation. Patients initially responding adequately to fluid boluses and holding the systolic blood pressure >90mmHg (“responder”) undergo contrast-enhanced CT scan evaluation following the primary survey. In case of contrast extravasation, a pelvic angiography with embolization is subsequently performed with the pelvic binder in place. Patients with ongoing need of volume replacement to achieve haemodynamic stability, with ongoing

Primary Survey according to ATLS ® Anteroposterior X-Ray of chest and pelvis, FAST, Blood gas analysis Intubation, large-bore i.v. access, decompression of chest/pericard Fluid resuscitation (crystalloids, PRBC), mechanical pelvic stabilization (pelvic binder) Re-Evaluation „non-responder“

Emergency operation

„transient-responder“

„responder“

Multislice CT with contrast media

No contrast blush

Contrast blush

Angio-Embolization

ICU or required surgical procedures (osteosynthesis / pelvic packing) Fig. 1. Emergency department algorithm in patients with pelvic fractures.

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suspicion of pelvic haemorrhage following angio-embolization or with the need for a mechanical stabilization of the pelvic ring are urgently transferred to the operating room for pelvic stabilization and pre-peritoneal pelvic packing. Similar to the “responders”, in patients with at least temporarily achieved haemodynamic stability by volume resuscitation (“transient responder”), an additional multislice CT scan with contrast is performed and – according to the results – followed by angiography, surgical damage control procedures and/or ICU admission similar to the “responder” situation. Statistical analysis The p values for categorical variables were derived from the two-sided Fisher’s exact test, and those for continuous variables from the Mann-Whitney U test or the Kruskal Wallis Test. Values are reported as mean ± standard deviation (SD) for continuous variables and as percentages for categorical variables. A p value <0.05 was considered statistically significant. All analyses were performed using the Statistical Package for Social Sciences (SPSS for Mac©), version 16.0 (SPSS Inc., Chicago, IL). Results During the study period, a total of 173 patients with pelvic ring fractures were admitted. The majority of the patients (n = 80, 46%) suffered a type A fracture, 25% (n = 43) of the patients a type B fracture and the remaining 29% (n = 50) a type C pelvic fracture (Table 1). The mean age was 44.7 ± 20.8 years and the mean ISS 33.2 ± 18.1 (median 32, interquartile range 31) with 65.3% having an ISS ≥25. As expected, with increasing pelvic fracture pattern severity, the transfusion requirement increased significantly. The overall mortality rate was 12.7% (n = 22), with type C fractures having the highest mortality (30.0%). In 21% of the patients (n = 37) the pelvic fracture was addressed surgically and in 79% of the patients (n = 136) it was

addressed non-surgically. In 9% (n = 16) of the patients an angio-­ embolization was performed. With regards to the haemodynamic stability, 82.1% (n = 142) of the patients were classified as “responder”, 10.4% (n = 18) as “transient responder” and 4.0% (n = 7) as “non-responder”. Fig. 2 outlines the acute management of the pelvic ring fractures on admission in the overall patient cohort stratified by the haemodynamic status. Six patients (3.5%) demonstrated severe, non-survivable traumatic brain injury and no further therapy was performed. Four of the non-responders were admitted in extremis and died in the shock room. The remaining 3 non-responders were transferred to the operating room (OR) where external pelvic fixation in combination with pre-peritoneal pelvic packing were carried out. One patient required post-operative angio-embolization (selective embolization of branches of the bilateral internal iliac artery). Of the transient responders, 14 patients underwent surgical management of their pelvic injury. Of those, 6 patients were angio-embolized post-operatively. In the remaining 4 transient-responder, angio-embolization was performed to address the pelvic injury (pre-operative [neurosurgical intervention], n = 1; post-operative, [thoracotomy for lung laceration], n = 1). Of the responders, 20 patients were managed surgically for their pelvic fracture and in 5 patients an angio-embolization was carried out; in 4 patients the angio-embolization was performed as sole therapy for the pelvic injury (in 1 patient pre-operative and in 2 patients post-operative (damage control procedures for extremity injuries)). In the remaining one patient, the angio-embolization was performed following a plate osteosynthesis of the pubis symphysis. The majority of the responders (n = 118, 83.1%) did not require any emergent therapy for their pelvic ring fracture on the day of admission. Table 2 describes the angiographically identified bleeding sources. While in 18 cases a selective embolization of the bleeding vessel was undertaken, a complete occlusion of the internal iliac artery had to be performed in 5 cases. In these later instances, the bleeding sources were the inferior (n = 1) and superior (n = 1)

Table 1 Demographic and admission parameters, transfusion requirement and outcome stratified by pelvic fracture type. All patients (n = 173)

Type A (n = 80)

Type B (n = 43)

Type C (n = 50)

p-value

Age (years), mean ± SD

44.7 ± 20.8

42.8 ± 18.4

45.3 ± 20.3

47.1 ± 24.7

0.517

Male

63.0% (109/173)

58.8% (47/80)

67.4% (29/43)

66.0% (33/50)

0.555

SBP < 90mm Hg

17.9% (31/173)

5.0% (4/80)

16.3% (7/43)

40.0% (20/50)

<0.001

GCS ≤ 8

52.0% (89/171)

39.2% (31/79)

55.8% (24/43)

69.4% (34/49)

0.003

AIS head ≥3

31.8% (55/173)

21.2% (17/80)

34.9% (15/43)

46.0% (23/50)

0.011

AIS chest ≥3

31.8% (55/173)

27.5% (22/80)

27.9% (12/43)

42.0% (21/50)

0.184

AIS abdomen ≥3

21.4% (37/173)

13.8% (11/80)

34.9% (15/43)

22.0% (11/50)

0.024

AIS extremity ≥3

30.6% (53/173)

27.5% (22/80)

37.2% (16/43)

30.0% (15/50)

0.534

ISS, mean ± SD ISS, median (IQR)

33.2 ± 18.1 32 (31)

23.9 ± 15.0 20.5 (23)

35.7 ± 15.3 34 (26)

46.0 ± 16.7 43.5 (25)

<0.001

ISS ≥ 25

65.3% (113/173)

43.8% (35/80)

72.1% (31/43)

94.0% (47/50)

<0.001

PRBC (Units), mean ± SD

5.0 ± 8.8

2.0 ± 5.3

5.3 ± 8.4

9.4 ± 11.5

<0.001

FFP (Units), mean ± SD

3.8 ± 8.1

1.4 ± 4.9

4.1 ± 7.0

7.4 ± 11.4

<0.001

PLT (Units), mean ± SD

0.6 ± 1.5

0.2 ± 0.9

0.9 ± 1.9

0.9 ± 1.7

0.008

Sepsis

11.6% (20/173)

6.2% (5/80)

16.3% (7/43)

16.0% (8/50)

0.128

MOV

3.5% (6/173)

0% (0/80)

7.0% (3/43)

6.0% (3/50)

0.067

In-Hospital Mortality

12.7% (22/173)

2.5% (2/80)

11.6% (5/43)

30.0% (15/50)

<0.001

Transfusion until ICU admission

Outcome

Abbreviations: SBP, Systolic blood pressure; GCS, Glasgow coma scale; ISS, Injury severity score; ICU, Intensive care unit; PRBC, Packed red blood cells; FFP, Fresh frozen plasma; PLT, Platelets; SD, Standard deviation; IQR, Interquartile range.

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„Non-Responder“ n = 7 (4.0%)

Death in ED n=4

Angio-Embolization as sole therapy

Angio-Embolization as sole therapy

n=4

n=4

Operation n=3

Operation n = 14

ext. fix., n = 2 C-clamp, n = 2 Packing, n = 3

-

„Responder“ n = 142 (82.1%)

„Transient-Responder“ n = 18 (10.4%)

ext. fix., n = 14 C-clamp, n = 4 Packing, n = 9 plate osteosynthesis symphysis, n = 5

-

Operation n = 20 -

ext. fix., n = 15 plate osteosynthesis symphysis, n = 5

Angio-Embolization post-operativ

Angio-Embolization post-operativ

Angio-Embolization post-operativ

n=1

n=6

n=1

Fig. 2. Acute management of the pelvic ring fractures on admission stratified by the haemodynamic status.

Table 2 Bleeding sources, embolized vessels and pelvic fracture pattern in patients undergoing angio-embolization. Bleeding source

n

Embolization

Pelvic fracture type*

Obturator artery

2

Selective

Type C (n = 2)

Internal pudendal artery

2

Selective

Type C (n = 2)

Inferior gluteal artery

2

Complete Occlusion, Internal iliac artery (n = 1) Selective (n = 1)

Type B (n = 1), Type C (n = 1)

Superior gluteal artery

4

Complete Occlusion, Internal iliac artery (n = 1) Selective (n = 3)

Type C (n = 4)

Lumbar artery

1

Selective

Type B (n = 1)

Lateral sacral artery

3

Selective

Type B (n = 1), Type C (n = 2)

Medial sacral artery

2

Selective

Type B (n = 2)

Branches of internal iliac artery

4

Complete Occlusion, Internal iliac artery (n = 1) Selective (n = 3)

Type B (n = 2), Type C (n = 2)

Fracture zone

2

Complete Occlusion, Internal iliac artery (n = 2)

Type C (n = 2)

Umbilical artery

1

Selective

Type C (n = 1)

*  Tile classification.

gluteal artery, the fracture site (n = 2) and in 1 case a non-identifiable branch of the internal iliac artery. In all 16 patients, angio-embolization was successfully performed with complete haemostasis. The time to pre-operative angio-embolization, and in those patients with angio-embolization as sole therapeutic intervention for their pelvic injury on day 0, was on average 55 minutes (39 – 72 minutes). No specific complications of embolization including necrosis or ischemia of tissues were observed, however, in the later hospital course, 4 of the 16 embolized patients died due to severe traumatic brain injury (n = 1) and multiple organ failure (n = 3). Discussion Pelvic ring injuries are associated with high-energy trauma and an increased risk of mortality rate. They are often seen within the spectrum of polytrauma and continue to be a subject of great interest to both clinicians and researchers [23-30].

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While vascular lesions in pelvic fractures are thought to be more frequently of venous than arterial origin, in cases of haemodynamic instability arterial lesions are more frequent with a higher incidence of arterial extravasation being found in these instances. Eastridge and colleagues reported that 58.7% of patients with both persistent hypotension and a severely unstable pelvic fracture had arterial bleeding [9]. Likewise, in the study by Miller et al., 67.9% of patients with persistent haemodynamic compromise demonstrated arterial bleeding [16]. Based on these results, early angiography and embolization has been recommended by many authors to improve patient outcome [9,12,31]. Our group has previously published our institutional management algorithm for severe pelvic ring fractures, describing the integration of interventional emergency embolization into the early clinical treatment protocol [18]. In 21 patients with arterial bleeding, defined by acute contrast extravasation in the initial CT-scan, (representing 13% of all patients with pelvic ring fractures) and

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almost 50% of those presenting with haemodynamic instability, angio-embolization was successfully performed in >90%. The time until angio-embolization was started was on average 62 minutes (25-115 minutes). Due to ongoing bleeding, two patients underwent pelvic packing following embolization. In the present follow-up study, an angio-embolization was performed in 9% of the pelvic fracture patients, which is comparable with our previous results. However, contrary to our earlier examination, the majority of angio-embolizations were undertaken postoperatively in the subsequent years as indicted in the result section. In these cases, ongoing signs of bleeding following pelvic packing and mechanical pelvic stabilization indicated the need for a pelvic angiography on the way from the OR to the ICU. Angioembolization of bleeding arteries then stopped blood loss definitively. With regards to embolization as the primary therapeutic intervention, careful patient selection is of utmost importance. Angiography is a time-consuming procedure precluding the simultaneous performance of other diagnostic or therapeutic interventions. Furthermore, multiple authors have pointed out that considerable delays exist in the performance of angiography [5,17,32-34]. In a multicentre review of 11 major trauma centres in Australia and New Zealand describing the management practice for haemodynamically unstable pelvic trauma patients, only 14.7% of pelvic angiographies were performed within 90 minutes of arrival [35]. In the present study, those patients with primary angio-embolization (2 pre-operative, 3 as only therapeutic intervention) were haemodynamically “responders” or “transient responders”, allowing time for organisation and preparation of the angio-embolization. The time until the angiography started was on average 55 minutes, which is comparable with previously published results in the literature. However, although there was an experienced radiologist and associated technical staff on 24-hour stand-by, the time until start of the embolization procedure was on average likely >60 minutes, which may not be tolerated by haemodynamically unstable patients. For the past decade, European trauma surgeons in particular have recommended exploratory laparotomy followed by pelvic packing [14,15,36-39]. Posterior pelvic ring stabilization with a pelvic C-clamp or an external fixator provides mechanical stability for the pelvic tamponade and fracture reduction leads to a reduction in fracture haemorrhage. In the study by Cothren et al., using the technique of pre-peritoneal pelvic packing in haemodynamically unstable patients not responding to 2 units of packed red blood cells (PRBCs), no deaths were reported as a result of acute blood loss. In their study, angio-embolization was only used in 4 of 24 non-responders as a rescue intervention after everything else had failed. They concluded that packing is an effective method that can quickly control pelvic bleeding and can serve as a triage tool for emergent angiography [7]. In a study of 40 haemodynamically unstable patients with pelvic ring fractures, external pelvic fixation in combination with direct retroperitoneal pelvic packing effectively stabilized the haemodynamic situation and significantly reduced post-procedure blood transfusion [8]. Ertel and colleagues from the Zurich group reported success in controlling both arterial and venous bleeding by tightly packing the pelvis [14,15]. In the present study, all the non-responders underwent immediate mechanical stabilization of the pelvis followed by pre-peritoneal pelvic packing. One of these patients required post-surgical angiographic embolization, as previously described. Nevertheless, although having straightforward treatment algorithms, early mortality in these patients remains high (4 of 7 patients in the present study). It is difficult to compare the effectiveness of pelvic angiography and packing, mainly because these patients represent cohorts with varying severity and complexity of injuries. In particular the patients undergoing immediate pelvic packing represent a group of extremely unstable patients with massive pelvic bleeding. However, both treatment modalities – angio-embolization and pelvic packing - are important techniques to improve

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patient outcome in bleeding pelvic fractures and they should not be seen as antagonistic but as complementary. Possibly, the quality of the pelvic packing and the specific anatomy of the bleeding artery might be further parameters that may influence the success of the treatment. Our established algorithm for patients with severe pelvic fractures incorporates angio-embolization into the early management protocol, however, considers and continuously re-evaluates the haemodynamic status of the patient, and therefore allows for individual treatment. In conclusion, the question of which patients should undergo angiography and the most appropriated timing of angiography with respect to other treatment options, including early mechanical stabilization of the pelvis and pelvic packing, remains a matter of controversy and likely one of the most difficult aspects of the management of these patients. The present study evaluated a six year time period with regard to the management of patients with pelvic fractures at a level I trauma centre. Angiographic embolization as a first-line treatment was only performed in responders and in transient responders with an arterial blush seen in the CT scan. In non-responders, pre-peritoneal pelvic packing in combination with mechanical pelvic stabilization was immediately carried out, followed by angio-embolization post-operatively if signs of persistent bleeding were present. Conflict of interest The authors have no conflict of interest. References [1] Scalea TM, Stein DM, O’Toole RV. Pelvic Fractures. In: Trauma, Feliciano DV, Mattox KL, Moore EE (eds). Mc Graw Hill Medical, 2008;759–88. [2] Biffl WL, Smith WR, Moore EE, Gonzalez RJ, Morgan SJ, Hennessey T, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 2001;233:843–50. [3] Starr AJ, Griffin DR, Reinert CM, Frawley WH, Walker J, Whitlock SN, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma 2002;16:553–61. [4] Shapiro M, McDonald AA, Knight D, Johannigman JA, Cuschieri J. The role of repeat angiography in the management of pelvic fractures. J Trauma 2005;58:227–31. [5] Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury 2009;40:343–53. [6] Ten Broek RPG, Bezemer J, Timmer FA, Mollen RMHG, Boekhoudt FD. Massive haemorrhage following minimally displaced pubic ramus fractures. Eur J Trauma Emerg Surg 2014;40:323–30. [7] Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007;62:834–9; discussion 839–842. [8] Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, Stahel PF. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 2009;40:54–60. [9] Eastridge BJ, Starr A, Minei JP, O’Keefe GE, Scalea TM. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002;53:446–50; discussion 450–441. [10] Dente CJ, Feliciano DV, Rozycki GS, Wyrzykowski AD, Nicholas JM, Salomone JP, Ingram WL. The outcome of open pelvic fractures in the modern era. Am J Surg 2005;190:830–5. [11] Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005;36:1–13. [12] Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF, 3rd. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 1997;43:395–9. [13] Croce MA, Magnotti LJ, Savage SA, Wood GW, 2nd, Fabian TC. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg 2007;204:935–9; discussion 940–932. [14] Ertel W, Eid K, Keel M, Trentz O. Therapeutical strategies and outcome of polytraumatized patients with pelvic injuries. Eur J Trauma Emerg Surg 2000;26:278–86. [15] Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001;15:468–74. [16] Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003;54:437–43.

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