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The Role of Interventional Radiology in Trauma
The Role of Interventional Radiology in Trauma j Guy E. Johnson, MD; Matthew J. Kogut, MD; and Christopher R. Ingraham, MD ABSTRACT: Trauma is a leading and preventable cause of death in many age groups. Emergency care of trauma patients is complex and requires a team approach, which includes nurses and physicians. Interventional radiology (IR) plays a significant part in the management of some trauma patients with solid organ or pelvic injuries. This article reviews the role of IR and aspects of radiology nursing in this patient population. (J Radiol Nurs 2014;33:181-187.) KEYWORDS: Interventional radiology; Angiography; Trauma radiology; Radiology nursing.
INTRODUCTION In the United States, unintentional injury is a leading cause of death after the first year of life up to the age of 44 and is the fourth leading cause of death overall (Feliciano, Mattox, & Moore, 2008). Blunt trauma from motor vehicle collisions and falls as well as penetrating trauma from firearms account for many of these deaths. Successful management of adults with blunt or penetrating trauma is quite complex and requires a multidisciplinary team approach. Nursing care is critical particularly with regard to management during interventional radiology (IR) procedures. The goal of this article is to review the role of IR in the management of adult trauma patients, with perspectives on IR nursing. PELVIC TRAUMA Background Pelvic fractures occur in less than 10% of blunt trauma patients, with motorcycle and pedestrian accidents accounting for the greatest percentage of pelvic fractures. Mortality in trauma patients who have pelvic fractures is around 14% but can be up to 40% to Guy E. Johnson, MD, Matthew J. Kogut, MD, and Christopher R. Ingraham, MD, are from the Department of Radiology, Section of Interventional Radiology, University of Washington, Seattle, WA. Corresponding author: Guy E. Johnson, Department of Radiology, Section of Interventional Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2014 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2014.09.003
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60% in those who present with hemodynamic instability (Demetriades et al., 2002; Suzuki, Smith, & Moore, 2009). However, most deaths are not the direct result of the pelvic fractures but rather other associated injuries (Demetriades et al., 2002; Karadimas et al., 2011). Accordingly, angiography is needed in a small percentage of pelvic trauma patients, but in these patients, arterial embolization (AE) to treat bleeding may be essential (Demetriades et al., 2002). In blunt trauma, major pelvic bleeding is often associated with pelvic fractures. Bleeding can arise not only from the fractured bones themselves but also from arteries and veins that are lacerated by the jagged bone edges. Some pelvic fractures cause disruption of the pelvic ring, which encloses the relatively contained space of the pelvis. Thus, pelvic ring injuries can lead to increased pelvic volume and a decreased tamponade effect. Therefore pelvic “sheeting” is used to treat some pelvic fractures. This involves binding of the pelvis with a folded sheet that is wrapped around the pelvis and clamped, which may help to decrease pelvic volume and venous bleeding (Grimm, Vrahas, & Thomas, 1998; Suzuki et al., 2009). Some investigators have sought to create prediction rules to identify which patients may have major pelvic bleeding associated with pelvic fractures. Among the factors suggesting higher probability include initial hematocrit %30, pulse R130 beats/min, and displaced pubic symphysis or obturator ring fracture (Blackmore et al., 2006). When three or four factors are present, the probability of major hemorrhage is 66%. Other criteria such as fracture pattern have been less fruitful at predicting hemorrhage.
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Unstable blunt trauma patients with pelvic fractures and without gross hemoperitoneum identified on computed tomography (CT), ultrasound, or diagnostic peritoneal lavage should undergo pelvic arteriography. Occasionally, hemodynamically stable patients will also undergo angiography if major bleeding or injury is identified on CT. Trauma patients treated in IR are frequently hemodynamically unstable and often need high-level nursing care to provide hemodynamic support, blood products, and sedation. Nursing staff is a critical part of the care team for safe patient transport and continuing the trauma resuscitation. Technique Pelvic arteriography generally starts with contrast injection in the distal aorta to image the pelvic arteries (Figure 1). Both the internal and external iliac arteries are typically selectively catheterized for more detailed imaging. In general, the closer the catheter is positioned to the source of bleeding during contrast injection, the more likely the bleeding will be seen (Figure 1) (Roy-Choudhury et al., 2007). If selective angiography is omitted, injuries could be missed (Johnson et al., 2013). The interventional radiologist scrutinizes the arteriogram for signs of arterial injuries. These may manifest as leakage of contrast material beyond the expected confines of the vessel, either as extravasation (uncontained bleeding, Figure 2) or a confined collection representing a pseudoaneurysm (a contained arterial rupture, Figure 1). Other findings of acute arterial injury include occluded vessels, filling defects within the vessel, vessels that have been abnormally stretched, or arteriovenous fistulae (an abnormal communication between an artery and a vein). Most pelvic arterial injuries can be treated with AE. Although a number of different agents are available, the most common embolic agents used are gelatin sponge (Gelfoam, Upjohn, Kalamazoo, MI) slurry and metal coils.
Interventional Radiology in Trauma
Gelatin sponge is a material that has been used topically in surgery since the 1940s (Jenkins, Janda, & Clarke, 1946). Its endovascular use in pelvic trauma began in the early 1970s (Ring, Waltman, Athanasoulis, Smith, & Baum, 1974). It is supplied as a sheet in various sizes. Gelatin sponge slurry is prepared by either cutting the material into small pieces with scissors (Figure 3) or by shearing apart large pieces suspended in contrast material by using two syringes connected by a three-way stopcock valve. The particles are then injected into the target artery once the catheter has been positioned appropriately. This leads to a mechanical obstruction of the injured vessel. One potential benefit of gelatin slurry use in trauma is the temporary nature of the occlusion. Generally, occlusion lasts weeks to months as the material is absorbed and the artery recanalizes (Cho, Reuter, & Schmidt, 1976). By the time the artery recanalizes, the injury has also healed. Metal coils are another material that may be used to embolize injured arteries (Figure 1). In this case, the occlusion is intended to be permanent. There are no prospective randomized trials investigating the efficacy of pelvic AE in trauma; however, a number of retrospective studies show very good efficacy in the range of 85% to 100% (Agolini et al., 1997). Adverse effects of pelvic AE are remarkably infrequent. Skin sloughing or parasthesias are rare, and gluteal necrosis occurs infrequently. Male sexual dysfunction occurs at similar rates in those embolized compared with matched controls with pelvic trauma, suggesting that the cause is the trauma itself (Travis et al., 2008). At the conclusion of angiography, the catheter is removed. The arterial sheath can be sutured to the skin and left in place. This may be done because of risk of puncture site bleeding in a coagulopathic
Figure 1. A 65-year-old man sustained pelvic fractures after falling and was brought to interventional radiology. (A) A frontal pelvic digital subtraction arteriogram was obtained. (B) Selective left internal iliac arteriogram demonstrates a pseudoaneurysm (long arrow) or contained rupture of the superior gluteal artery. This was not evident on the nonselective arteriogram. The arterial injury was treated with metallic coil embolization. (C) After this, arteriography shows expected occlusion of the vessel (short arrow). 182
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sheath removal can be attained by manual compression or with the use of a closure device. In either case, the interventional radiologist and nurse should monitor the pedal pulses for evidence of thrombosis or distal ischemia complicating the procedure. SOLID ORGAN INJURY
Figure 2. A 47-year-old male pedestrian was struck by a vehicle and sustained pelvic fractures. A selective internal iliac arteriogram shows active extravasation (arrow) from the iliolumbar artery. This was treated with gelatin sponge slurry (not shown).
patient, or it may be left for use in the intensive care unit (e.g., for invasive blood pressure monitoring). Alternatively, the sheath may be removed at the conclusion of angiography if the patient has stabilized, and there are no ongoing concerns. Hemostasis after
Nonoperative management (NOM) is the preferred strategy in blunt abdominal trauma patients who have evidence of solid organ injury and are hemodynamically stable. Historically, surgical management of injured patients was the standard of care. However, improvements in imaging, particularly CT, have allowed for the diagnosis of injuries without operative exploration. The advancements in imaging combined with advances in critical care have permitted a shift toward NOM (Christmas et al., 2005). NOM generally involves supportive measures, such as bed rest, intravenous (IV) fluid administration, limiting oral intake, measurement of serial hematocrits, and serial physical examination. IR plays an important role in NOM of liver, spleen, and renal injuries. Embolization of arterial bleeding has been shown to be safe and effective in the treatment of solid organ injury (Velmahos et al., 2002). Liver Trauma The liver is a commonly injured solid organ in abdominal trauma. Over the last several decades, NOM of
Figure 3. Materials needed to make gelatin sponge (Gelfoam) slurry are readily available. (A) The gelatin sponge (arrow) is supplied as a small sheet of material. (B) The sheet can be made into slurry by cutting it first into strips and (C) then small particles that are mixed with contrast material using two syringes and a stopcock. VOLUME 33 ISSUE 4
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Figure 4. A 32-year-old woman fell 35 feet. She was hemodynamically unstable in the emergency room, and there was blood in her abdomen. She was taken immediately to the operating room for exploratory laparotomy. A high-grade liver laceration was seen, and her abdomen was packed. She remained unstable and was brought to interventional radiology for angiography. (A) Celiac arteriography showed massive bleeding (black arrow) from branches of the hepatic artery (asterisk). The bleeding stopped after metallic coil embolization (black arrow) that was done via a microcatheter (white arrow). (B) Note the radiopaque marker on the surgical packing material (dashed arrow). After embolization, she quickly stablilized.
liver injury in stable patients has become the standard of care in most centers. Mortality from liver injury has decreased over this period, suggesting that nonsurgical management has contributed to this pattern (Richardson et al., 2000). This suggestion was confirmed in a review of trauma centers showing that those with higher rates of NOM had decreased riskadjusted mortality (Shafi, Parks, Ahn, Gentilello, & Nathens, 2010). One important adjunct in NOM is the use of angiography and AE. Many low-grade liver injuries will heal with conservative measures alone, whereas high-grade injuries in hemodynamically stable patients may benefit from AE (Hagiwara et al., 1997). Furthermore, those who undergo early AE require fewer blood transfusions compared with those in whom angiography is delayed. Hepatic AE can be associated with liver-related complications, such as bile leaks, fluid collections, and hepatic necrosis (Mohr et al., 2003). Fortunately, many of these complications can also be managed conservatively or nonoperatively. For example, bilomas and abscesses can often be managed with image-guided percutaneous drain placement. Furthermore, there is evidence that AE is beneficial in patients who remain hemodynamically unstable after initial operative management with surgical packing (Misselbeck et al., 2009). Patients with severe hepatic injuries who had surgery followed by AE showed a lower mortality ratio (0.51, p Z .02) in one study (Asensio et al., 2003). Illustrated in another study, about half of all unstable patients with severe liver injury who underwent surgery had persistent bleeding that required embolization, despite adequate packing (Figure 4) (Misselbeck et al., 2009). The advantage of AE alone or as an adjunct to surgery may be partially because of the surgical inaccessibility of the deeper aspects of the liver parenchyma. 184
Spleen Trauma The spleen is the most commonly injured solid organ in blunt abdominal trauma. Like other solid abdominal organs, the management of blunt splenic trauma has continued to evolve toward conservative nonoperative measures. Splenic conservation leads to decreased morbidity and does not expose the patient to risk of postsplenectomy sepsis. Splenic artery embolization in blunt splenic injury (Figure 5) results in a decreased need for transfusions, intra-abdominal complications, and need for surgical management (Wei, Hemmila, Arbabi, Taheri, & Wahl, 2008). This increases the rate of splenic salvage compared with operative management (Banerjee et al., 2013; Bessoud, 2006). Patient selection for splenic AE, and the technique for embolization itself, remains a matter of debate in splenic trauma; however, the data indicate an important role for IR in NOM in splenic trauma.
Figure 5. A 24-year-old man was injured in a motor vehicle collision. Splenic angiography demonstrates active arterial extravasation (arrow). A nasogastric tube is positioned in the stomach (asterisk). The splenic artery was embolized with metallic coils with resolution of bleeding (not shown).
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Kidney Trauma Unlike other solid abdominal organs, renal injury is relatively unusual, seen in only 1% to 3% of all traumas (Santucci et al., 2004). Unlike the liver and spleen, the kidneys have additional protection that is provided by the posterior ribs and a layer of retroperitoneal fat. Most renal trauma is minor and self-limited, with major injury comprising only 5% of all cases of renal trauma (Knudson et al., 2000). CT can be helpful in identifying patients with injuries that can be managed nonoperatively. However, expanding perinephric hematomas and/or hemodynamic instability may require operative management or angioembolization (Bittle, Gunn, Gross, & Stern, 2012). Operative management of major renal trauma can be quite difficult and may result in nephrectomy in many cases (Wessells et al., 2003). AE is an attractive option for some renal injuries as the arterial source of bleeding can be selectively embolized (Figure 6), often sparing normal portions of the kidney that might have to be removed if treated surgically. One review of 9,002 patients with renal injures included 165 patients who underwent renal angiography. Of these, 78 required angioembolization with an overall renal salvage rate of 92% (Hotaling et al., 2011). NURSING CONSIDERATIONS Occasionally, trauma patients are profoundly unstable and require advanced hemodynamic support and monitoring from anesthesiologists during angiography; however, in many cases monitoring and sedation can
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be administered by radiology nurses. The nurse works hand in hand with the IR physician. The primary focus of the interventional radiologist is the technical aspect of the procedure, whereas the nurse is essential for hemodynamic monitoring, resuscitation, and administration of sedation, when appropriate. Resuscitation begins with administration of crystalloid IV fluids, but transfusion of blood products may also be necessary. Adequate IV access is essential. Generally, two large-bore IVs are required for adequate access. Hypothermia, together with acidosis and coagulopathy, contributes to a lethal triad. These features are often associated with severe trauma and may contribute to increased mortality. Therefore, the patient’s temperature should be monitored by noninvasive methods or by invasive means, such as with probes in the esophagus, rectum, or urinary bladder. Active warming should be considered where appropriate. This can be achieved with heated IV fluids and warmed blankets. Moderate sedation is important for patient comfort and to allow the patient to remain still and fully cooperative during angiography. Generally, moderate sedation is administered as incremental doses of a sedative/ anxiolytic and a narcotic analgesic. Moderate sedation is a state of comfort and consciousness that exists along a continuum from minimal sedation to general anesthesia. Under moderate sedation, a patient should be able to respond to verbal commands (with tactile stimulation, when needed), and no intervention is necessary to maintain the airway (Rex, 2006). Although other
Figure 6. A 48-year-old man fell off a ladder. Coronal image from a computed tomography shows a large retroperitoneal hematoma (asterisk) compressing the inferior pole of the left kidney. (A) There is active extravasation of contrast material (white arrow). (B) Renal arteriogram shows corresponding bleeding (black arrow). (C) After metallic coil embolization (arrowheads), the bleeding has stopped. VOLUME 33 ISSUE 4
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regimens exist, for nonanesthetists, the most commonly used drugs are midazolam (a benzodiazepine) and fentanyl (an opioid). These drugs have a short onset of action and short duration of effect so that the dose may be titrated to achieve the desired effect. When used in combination, the drugs are synergistic. The patient’s blood pressure, oxygen saturation, and electrocardiogram are monitored during sedation. Medications used in moderate sedation are respiratory depressants, so careful monitoring of spontaneous breathing and oxygen saturation is important in patients who are not mechanically ventilated. These medications can also decrease blood pressure; therefore, some trauma patients with hemodynamic instability may not be candidates for moderate sedation. CONCLUSION IR is a valuable resource in the care of blunt trauma patients. IR plays a significant role in the stabilization of patients with pelvic fractures and associated arterial bleeding. Additionally, as the care of blunt trauma patients with solid organ injury has evolved, IR has taken on an important role as an adjunct to NOM. All these changes have occurred as the care of trauma patients has evolved into a multidisciplinary approach involving nurses and physicians from a number of specialties. References Agolini, S.F., Shah, K., Jaffe, J., Newcomb, J., Rhodes, M., & Reed, J.F. (1997). Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. The Journal of Trauma: Injury, Infection, and Critical Care, 43, 395-399. Asensio, J.A., Roldan, G., Petrone, P., Rojo, E., Tillou, A., & Kuncir, E., et al. (2003). Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: Trauma surgeons still need to operate, but angioembolization helps. The Journal of Trauma: Injury, Infection, and Critical Care, 54, 647-653. discussion 653-654. Banerjee, A., Duane, T.M., Wilson, S.P., Haney, S., O’Neill, P.J., & Evans, H.L., et al. (2013). Trauma center variation in splenic artery embolization and spleen salvage. The Journal of Trauma and Acute Care Surgery, 75, 69-75. Bessoud, B. (2006). Nonoperative management of traumatic splenic injuries: Is there a role for proximal splenic artery embolization? American Journal of Roentgenology, 186, 779-785. Bittle, M.M., Gunn, M.L., Gross, J.A., & Stern, E.J. (2012). Trauma radiology companion: Methods, guidelines, and imaging fundamentals. Philadelphia: Wolters Kluwer Health/ Lippincott Williams Wilkins. Blackmore, C.C., Cummings, P., Jurkovich, G.J., Linnau, K.F., Hoffer, E.K., & Rivara, F.P. (2006). Predicting major hemorrhage in patients with pelvic fracture. The Journal of Trauma: Injury, Infection, and Critical Care, 61, 346-352. Cho, K.J., Reuter, S.R., & Schmidt, R. (1976). Effects of experimental hepatic artery embolization on hepatic function. American Journal of Roentgenology, 127, 563-567.
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Christmas, A.B., Wilson, A.K., Manning, B., Franklin, G.A., Miller, F.B., & Richardson, J.D., et al. (2005). Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy. Surgery, 138, 606-611. Demetriades, D., Karaiskakis, M., Toutouzas, K., Alo, K., Velmahos, G., & Chan, L. (2002). Pelvic fractures: Epidemiology and predictors of associated abdominal injuries and outcomes. ACS, 195, 1-10. Feliciano, D., Mattox, K., & Moore, E. (2008). Trauma. New York: McGraw Hill Professional. Grimm, M.R., Vrahas, M.S., & Thomas, K.A. (1998). Pressurevolume characteristics of the intact and disrupted pelvic retroperitoneum. The Journal of Trauma: Injury, Infection, and Critical Care, 44, 454-459. Hagiwara, A., Yukioka, T., Ohta, S., Tokunaga, T., Ohta, S., & Matsuda, H., et al. (1997). Nonsurgical management of patients with blunt hepatic injury: Efficacy of transcatheter arterial embolization. AJR. American Journal of Roentgenology, 169, 1151-1156. Hotaling, J.M., Sorensen, M.D., Smith, T.G., Rivara, F.P., Wessells, H., & Voelzke, B.B. (2011). Analysis of diagnostic angiography and angioembolization in the acute management of renal trauma using a national data set. The Journal of Urology, 185, 1316-1320. Jenkins, H.P., Janda, R., & Clarke, J. (1946). Clinical and experimental observations on the use of gelatin sponge or foam. Surgery, 20, 124-132. Johnson, G.E., Sandstrom, C.K., Kogut, M.J., Ingraham, C.R., Stratil, P.G., & Valji, K., et al. (2013). Frequency of external iliac artery branch injury in blunt trauma: Improved detection with selective external iliac angiography. Journal of Vascular and Interventional Radiology, 24, 363-369. Karadimas, E.J., Nicolson, T., Kakagia, D.D., Matthews, S.J., Richards, P.J., & Giannoudis, P.V. (2011). Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. International Orthopaedics, 35, 1381-1390. Knudson, M.M., Harrison, P.B., Hoyt, D.B., Shatz, D.V., Zietlow, S.P., & Bergstein, J.M., et al. (2000). Outcome after major renovascular injuries: A Western trauma association multicenter report. Journal of Trauma and Acute Care Surgery, 49, 1116-1122. Misselbeck, T.S., Teicher, E.J., Cipolle, M.D., Pasquale, M.D., Shah, K.T., & Dangleben, D.A., et al. (2009). Hepatic angioembolization in trauma patients: Indications and complications. The Journal of Trauma, 67, 769-773. Mohr, A.M., Lavery, R.F., Barone, A., Bahramipour, P., Magnotti, L.J., & Osband, A.J., et al. (2003). Angiographic embolization for liver injuries: Low mortality, high morbidity. The Journal of Trauma: Injury, Infection, and Critical Care, 55, 1077-1081. discussion 1081-1082. Rex, D.K. (2006). Review article: Moderate sedation for endoscopy: Sedation regimens for non-anaesthesiologists. Alimentary Pharmacology and Therapeutics, 24, 163-171. Richardson, J.D., Franklin, G.A., Lukan, J.K., Carrillo, E.H., Spain, D.A., & Miller, F.B., et al. (2000). Evolution in the management of hepatic trauma: A 25-year perspective. Annals of Surgery, 232, 324-330. Ring, E.J., Waltman, A.C., Athanasoulis, C., Smith, J.C., & Baum, S. (1974). Angiography in pelvic trauma. Surgery, Gynecology & Obstetrics, 139, 375-380. Roy-Choudhury, S.H., Gallacher, D.J., Pilmer, J., Rankin, S., Fowler, G., & Steers, J., et al. (2007). Relative threshold of detection of active arterial bleeding: In vitro comparison of
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MDCT and digital subtraction angiography. American Journal of Roentgenology, 189, W238-W246. Santucci, R.A., Wessells, H., Bartsch, G., Descotes, J., Heyns, C.F., & McAninch, J.W., et al. (2004). Evaluation and management of renal injuries: Consensus statement of the renal trauma subcommittee. BJU International, 93, 937-954. Shafi, S., Parks, J., Ahn, C., Gentilello, L.M., & Nathens, A.B. (2010). More operations, more deaths? Relationship between operative intervention rates and risk-adjusted mortality at trauma centers. The Journal of Trauma, 69, 70-77. Suzuki, T., Smith, W.R., & Moore, E.E. (2009). Pelvic packing or angiography: Competitive or complementary? Injury, 40, 343-353. Travis, T., Monsky, W.L., London, J., Danielson, M., Brock, J., & Wegelin, J., et al. (2008). Evaluation of short-term and long-term complications after emergent internal iliac artery
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embolization in patients with pelvic trauma. Journal of Vascular and Interventional Radiology, 19, 840-847. Velmahos, G.C., Toutouzas, K.G., Vassiliu, P., Sarkisyan, G., Chan, L.S., & Hanks, S.H., et al. (2002). A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. The Journal of Trauma: Injury, Infection, and Critical Care, 53, 303-308. discussion 308. Wei, B., Hemmila, M.R., Arbabi, S., Taheri, P.A., & Wahl, W.L. (2008). Angioembolization reduces operative intervention for blunt splenic injury. The Journal of Trauma: Injury, Infection, and Critical Care, 64, 1472-1477. Wessells, H., Suh, D., Porter, J.R., Rivara, F., MacKenzie, E.J., & Jurkovich, G.J., et al. (2003). Renal injury and operative management in the United States: Results of a population-based study. Journal of Trauma and Acute Care Surgery, 54, 423-430.
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INTRODUCTION In the United States, unintentional injury is a leading cause of death after the first year of life up to the age of 44 and is the fourth leading cause of death overall (Feliciano, Mattox, & Moore, 2008). Blunt trauma from motor vehicle collisions and falls as well as penetrating trauma from firearms account for many of these deaths. Successful management of adults with blunt or penetrating trauma is quite complex and requires a multidisciplinary team approach. Nursing care is critical particularly with regard to management during interventional radiology (IR) procedures. The goal of this article is to review the role of IR in the management of adult trauma patients, with perspectives on IR nursing. PELVIC TRAUMA Background Pelvic fractures occur in less than 10% of blunt trauma patients, with motorcycle and pedestrian accidents accounting for the greatest percentage of pelvic fractures. Mortality in trauma patients who have pelvic fractures is around 14% but can be up to 40% to Guy E. Johnson, MD, Matthew J. Kogut, MD, and Christopher R. Ingraham, MD, are from the Department of Radiology, Section of Interventional Radiology, University of Washington, Seattle, WA. Corresponding author: Guy E. Johnson, Department of Radiology, Section of Interventional Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2014 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2014.09.003
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60% in those who present with hemodynamic instability (Demetriades et al., 2002; Suzuki, Smith, & Moore, 2009). However, most deaths are not the direct result of the pelvic fractures but rather other associated injuries (Demetriades et al., 2002; Karadimas et al., 2011). Accordingly, angiography is needed in a small percentage of pelvic trauma patients, but in these patients, arterial embolization (AE) to treat bleeding may be essential (Demetriades et al., 2002). In blunt trauma, major pelvic bleeding is often associated with pelvic fractures. Bleeding can arise not only from the fractured bones themselves but also from arteries and veins that are lacerated by the jagged bone edges. Some pelvic fractures cause disruption of the pelvic ring, which encloses the relatively contained space of the pelvis. Thus, pelvic ring injuries can lead to increased pelvic volume and a decreased tamponade effect. Therefore pelvic “sheeting” is used to treat some pelvic fractures. This involves binding of the pelvis with a folded sheet that is wrapped around the pelvis and clamped, which may help to decrease pelvic volume and venous bleeding (Grimm, Vrahas, & Thomas, 1998; Suzuki et al., 2009). Some investigators have sought to create prediction rules to identify which patients may have major pelvic bleeding associated with pelvic fractures. Among the factors suggesting higher probability include initial hematocrit %30, pulse R130 beats/min, and displaced pubic symphysis or obturator ring fracture (Blackmore et al., 2006). When three or four factors are present, the probability of major hemorrhage is 66%. Other criteria such as fracture pattern have been less fruitful at predicting hemorrhage.
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Unstable blunt trauma patients with pelvic fractures and without gross hemoperitoneum identified on computed tomography (CT), ultrasound, or diagnostic peritoneal lavage should undergo pelvic arteriography. Occasionally, hemodynamically stable patients will also undergo angiography if major bleeding or injury is identified on CT. Trauma patients treated in IR are frequently hemodynamically unstable and often need high-level nursing care to provide hemodynamic support, blood products, and sedation. Nursing staff is a critical part of the care team for safe patient transport and continuing the trauma resuscitation. Technique Pelvic arteriography generally starts with contrast injection in the distal aorta to image the pelvic arteries (Figure 1). Both the internal and external iliac arteries are typically selectively catheterized for more detailed imaging. In general, the closer the catheter is positioned to the source of bleeding during contrast injection, the more likely the bleeding will be seen (Figure 1) (Roy-Choudhury et al., 2007). If selective angiography is omitted, injuries could be missed (Johnson et al., 2013). The interventional radiologist scrutinizes the arteriogram for signs of arterial injuries. These may manifest as leakage of contrast material beyond the expected confines of the vessel, either as extravasation (uncontained bleeding, Figure 2) or a confined collection representing a pseudoaneurysm (a contained arterial rupture, Figure 1). Other findings of acute arterial injury include occluded vessels, filling defects within the vessel, vessels that have been abnormally stretched, or arteriovenous fistulae (an abnormal communication between an artery and a vein). Most pelvic arterial injuries can be treated with AE. Although a number of different agents are available, the most common embolic agents used are gelatin sponge (Gelfoam, Upjohn, Kalamazoo, MI) slurry and metal coils.
Interventional Radiology in Trauma
Gelatin sponge is a material that has been used topically in surgery since the 1940s (Jenkins, Janda, & Clarke, 1946). Its endovascular use in pelvic trauma began in the early 1970s (Ring, Waltman, Athanasoulis, Smith, & Baum, 1974). It is supplied as a sheet in various sizes. Gelatin sponge slurry is prepared by either cutting the material into small pieces with scissors (Figure 3) or by shearing apart large pieces suspended in contrast material by using two syringes connected by a three-way stopcock valve. The particles are then injected into the target artery once the catheter has been positioned appropriately. This leads to a mechanical obstruction of the injured vessel. One potential benefit of gelatin slurry use in trauma is the temporary nature of the occlusion. Generally, occlusion lasts weeks to months as the material is absorbed and the artery recanalizes (Cho, Reuter, & Schmidt, 1976). By the time the artery recanalizes, the injury has also healed. Metal coils are another material that may be used to embolize injured arteries (Figure 1). In this case, the occlusion is intended to be permanent. There are no prospective randomized trials investigating the efficacy of pelvic AE in trauma; however, a number of retrospective studies show very good efficacy in the range of 85% to 100% (Agolini et al., 1997). Adverse effects of pelvic AE are remarkably infrequent. Skin sloughing or parasthesias are rare, and gluteal necrosis occurs infrequently. Male sexual dysfunction occurs at similar rates in those embolized compared with matched controls with pelvic trauma, suggesting that the cause is the trauma itself (Travis et al., 2008). At the conclusion of angiography, the catheter is removed. The arterial sheath can be sutured to the skin and left in place. This may be done because of risk of puncture site bleeding in a coagulopathic
Figure 1. A 65-year-old man sustained pelvic fractures after falling and was brought to interventional radiology. (A) A frontal pelvic digital subtraction arteriogram was obtained. (B) Selective left internal iliac arteriogram demonstrates a pseudoaneurysm (long arrow) or contained rupture of the superior gluteal artery. This was not evident on the nonselective arteriogram. The arterial injury was treated with metallic coil embolization. (C) After this, arteriography shows expected occlusion of the vessel (short arrow). 182
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sheath removal can be attained by manual compression or with the use of a closure device. In either case, the interventional radiologist and nurse should monitor the pedal pulses for evidence of thrombosis or distal ischemia complicating the procedure. SOLID ORGAN INJURY
Figure 2. A 47-year-old male pedestrian was struck by a vehicle and sustained pelvic fractures. A selective internal iliac arteriogram shows active extravasation (arrow) from the iliolumbar artery. This was treated with gelatin sponge slurry (not shown).
patient, or it may be left for use in the intensive care unit (e.g., for invasive blood pressure monitoring). Alternatively, the sheath may be removed at the conclusion of angiography if the patient has stabilized, and there are no ongoing concerns. Hemostasis after
Nonoperative management (NOM) is the preferred strategy in blunt abdominal trauma patients who have evidence of solid organ injury and are hemodynamically stable. Historically, surgical management of injured patients was the standard of care. However, improvements in imaging, particularly CT, have allowed for the diagnosis of injuries without operative exploration. The advancements in imaging combined with advances in critical care have permitted a shift toward NOM (Christmas et al., 2005). NOM generally involves supportive measures, such as bed rest, intravenous (IV) fluid administration, limiting oral intake, measurement of serial hematocrits, and serial physical examination. IR plays an important role in NOM of liver, spleen, and renal injuries. Embolization of arterial bleeding has been shown to be safe and effective in the treatment of solid organ injury (Velmahos et al., 2002). Liver Trauma The liver is a commonly injured solid organ in abdominal trauma. Over the last several decades, NOM of
Figure 3. Materials needed to make gelatin sponge (Gelfoam) slurry are readily available. (A) The gelatin sponge (arrow) is supplied as a small sheet of material. (B) The sheet can be made into slurry by cutting it first into strips and (C) then small particles that are mixed with contrast material using two syringes and a stopcock. VOLUME 33 ISSUE 4
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Figure 4. A 32-year-old woman fell 35 feet. She was hemodynamically unstable in the emergency room, and there was blood in her abdomen. She was taken immediately to the operating room for exploratory laparotomy. A high-grade liver laceration was seen, and her abdomen was packed. She remained unstable and was brought to interventional radiology for angiography. (A) Celiac arteriography showed massive bleeding (black arrow) from branches of the hepatic artery (asterisk). The bleeding stopped after metallic coil embolization (black arrow) that was done via a microcatheter (white arrow). (B) Note the radiopaque marker on the surgical packing material (dashed arrow). After embolization, she quickly stablilized.
liver injury in stable patients has become the standard of care in most centers. Mortality from liver injury has decreased over this period, suggesting that nonsurgical management has contributed to this pattern (Richardson et al., 2000). This suggestion was confirmed in a review of trauma centers showing that those with higher rates of NOM had decreased riskadjusted mortality (Shafi, Parks, Ahn, Gentilello, & Nathens, 2010). One important adjunct in NOM is the use of angiography and AE. Many low-grade liver injuries will heal with conservative measures alone, whereas high-grade injuries in hemodynamically stable patients may benefit from AE (Hagiwara et al., 1997). Furthermore, those who undergo early AE require fewer blood transfusions compared with those in whom angiography is delayed. Hepatic AE can be associated with liver-related complications, such as bile leaks, fluid collections, and hepatic necrosis (Mohr et al., 2003). Fortunately, many of these complications can also be managed conservatively or nonoperatively. For example, bilomas and abscesses can often be managed with image-guided percutaneous drain placement. Furthermore, there is evidence that AE is beneficial in patients who remain hemodynamically unstable after initial operative management with surgical packing (Misselbeck et al., 2009). Patients with severe hepatic injuries who had surgery followed by AE showed a lower mortality ratio (0.51, p Z .02) in one study (Asensio et al., 2003). Illustrated in another study, about half of all unstable patients with severe liver injury who underwent surgery had persistent bleeding that required embolization, despite adequate packing (Figure 4) (Misselbeck et al., 2009). The advantage of AE alone or as an adjunct to surgery may be partially because of the surgical inaccessibility of the deeper aspects of the liver parenchyma. 184
Spleen Trauma The spleen is the most commonly injured solid organ in blunt abdominal trauma. Like other solid abdominal organs, the management of blunt splenic trauma has continued to evolve toward conservative nonoperative measures. Splenic conservation leads to decreased morbidity and does not expose the patient to risk of postsplenectomy sepsis. Splenic artery embolization in blunt splenic injury (Figure 5) results in a decreased need for transfusions, intra-abdominal complications, and need for surgical management (Wei, Hemmila, Arbabi, Taheri, & Wahl, 2008). This increases the rate of splenic salvage compared with operative management (Banerjee et al., 2013; Bessoud, 2006). Patient selection for splenic AE, and the technique for embolization itself, remains a matter of debate in splenic trauma; however, the data indicate an important role for IR in NOM in splenic trauma.
Figure 5. A 24-year-old man was injured in a motor vehicle collision. Splenic angiography demonstrates active arterial extravasation (arrow). A nasogastric tube is positioned in the stomach (asterisk). The splenic artery was embolized with metallic coils with resolution of bleeding (not shown).
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Kidney Trauma Unlike other solid abdominal organs, renal injury is relatively unusual, seen in only 1% to 3% of all traumas (Santucci et al., 2004). Unlike the liver and spleen, the kidneys have additional protection that is provided by the posterior ribs and a layer of retroperitoneal fat. Most renal trauma is minor and self-limited, with major injury comprising only 5% of all cases of renal trauma (Knudson et al., 2000). CT can be helpful in identifying patients with injuries that can be managed nonoperatively. However, expanding perinephric hematomas and/or hemodynamic instability may require operative management or angioembolization (Bittle, Gunn, Gross, & Stern, 2012). Operative management of major renal trauma can be quite difficult and may result in nephrectomy in many cases (Wessells et al., 2003). AE is an attractive option for some renal injuries as the arterial source of bleeding can be selectively embolized (Figure 6), often sparing normal portions of the kidney that might have to be removed if treated surgically. One review of 9,002 patients with renal injures included 165 patients who underwent renal angiography. Of these, 78 required angioembolization with an overall renal salvage rate of 92% (Hotaling et al., 2011). NURSING CONSIDERATIONS Occasionally, trauma patients are profoundly unstable and require advanced hemodynamic support and monitoring from anesthesiologists during angiography; however, in many cases monitoring and sedation can
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be administered by radiology nurses. The nurse works hand in hand with the IR physician. The primary focus of the interventional radiologist is the technical aspect of the procedure, whereas the nurse is essential for hemodynamic monitoring, resuscitation, and administration of sedation, when appropriate. Resuscitation begins with administration of crystalloid IV fluids, but transfusion of blood products may also be necessary. Adequate IV access is essential. Generally, two large-bore IVs are required for adequate access. Hypothermia, together with acidosis and coagulopathy, contributes to a lethal triad. These features are often associated with severe trauma and may contribute to increased mortality. Therefore, the patient’s temperature should be monitored by noninvasive methods or by invasive means, such as with probes in the esophagus, rectum, or urinary bladder. Active warming should be considered where appropriate. This can be achieved with heated IV fluids and warmed blankets. Moderate sedation is important for patient comfort and to allow the patient to remain still and fully cooperative during angiography. Generally, moderate sedation is administered as incremental doses of a sedative/ anxiolytic and a narcotic analgesic. Moderate sedation is a state of comfort and consciousness that exists along a continuum from minimal sedation to general anesthesia. Under moderate sedation, a patient should be able to respond to verbal commands (with tactile stimulation, when needed), and no intervention is necessary to maintain the airway (Rex, 2006). Although other
Figure 6. A 48-year-old man fell off a ladder. Coronal image from a computed tomography shows a large retroperitoneal hematoma (asterisk) compressing the inferior pole of the left kidney. (A) There is active extravasation of contrast material (white arrow). (B) Renal arteriogram shows corresponding bleeding (black arrow). (C) After metallic coil embolization (arrowheads), the bleeding has stopped. VOLUME 33 ISSUE 4
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regimens exist, for nonanesthetists, the most commonly used drugs are midazolam (a benzodiazepine) and fentanyl (an opioid). These drugs have a short onset of action and short duration of effect so that the dose may be titrated to achieve the desired effect. When used in combination, the drugs are synergistic. The patient’s blood pressure, oxygen saturation, and electrocardiogram are monitored during sedation. Medications used in moderate sedation are respiratory depressants, so careful monitoring of spontaneous breathing and oxygen saturation is important in patients who are not mechanically ventilated. These medications can also decrease blood pressure; therefore, some trauma patients with hemodynamic instability may not be candidates for moderate sedation. CONCLUSION IR is a valuable resource in the care of blunt trauma patients. IR plays a significant role in the stabilization of patients with pelvic fractures and associated arterial bleeding. Additionally, as the care of blunt trauma patients with solid organ injury has evolved, IR has taken on an important role as an adjunct to NOM. All these changes have occurred as the care of trauma patients has evolved into a multidisciplinary approach involving nurses and physicians from a number of specialties. References Agolini, S.F., Shah, K., Jaffe, J., Newcomb, J., Rhodes, M., & Reed, J.F. (1997). Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. The Journal of Trauma: Injury, Infection, and Critical Care, 43, 395-399. Asensio, J.A., Roldan, G., Petrone, P., Rojo, E., Tillou, A., & Kuncir, E., et al. (2003). Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: Trauma surgeons still need to operate, but angioembolization helps. The Journal of Trauma: Injury, Infection, and Critical Care, 54, 647-653. discussion 653-654. Banerjee, A., Duane, T.M., Wilson, S.P., Haney, S., O’Neill, P.J., & Evans, H.L., et al. (2013). Trauma center variation in splenic artery embolization and spleen salvage. The Journal of Trauma and Acute Care Surgery, 75, 69-75. Bessoud, B. (2006). Nonoperative management of traumatic splenic injuries: Is there a role for proximal splenic artery embolization? American Journal of Roentgenology, 186, 779-785. Bittle, M.M., Gunn, M.L., Gross, J.A., & Stern, E.J. (2012). Trauma radiology companion: Methods, guidelines, and imaging fundamentals. Philadelphia: Wolters Kluwer Health/ Lippincott Williams Wilkins. Blackmore, C.C., Cummings, P., Jurkovich, G.J., Linnau, K.F., Hoffer, E.K., & Rivara, F.P. (2006). Predicting major hemorrhage in patients with pelvic fracture. The Journal of Trauma: Injury, Infection, and Critical Care, 61, 346-352. Cho, K.J., Reuter, S.R., & Schmidt, R. (1976). Effects of experimental hepatic artery embolization on hepatic function. American Journal of Roentgenology, 127, 563-567.
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Christmas, A.B., Wilson, A.K., Manning, B., Franklin, G.A., Miller, F.B., & Richardson, J.D., et al. (2005). Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy. Surgery, 138, 606-611. Demetriades, D., Karaiskakis, M., Toutouzas, K., Alo, K., Velmahos, G., & Chan, L. (2002). Pelvic fractures: Epidemiology and predictors of associated abdominal injuries and outcomes. ACS, 195, 1-10. Feliciano, D., Mattox, K., & Moore, E. (2008). Trauma. New York: McGraw Hill Professional. Grimm, M.R., Vrahas, M.S., & Thomas, K.A. (1998). Pressurevolume characteristics of the intact and disrupted pelvic retroperitoneum. The Journal of Trauma: Injury, Infection, and Critical Care, 44, 454-459. Hagiwara, A., Yukioka, T., Ohta, S., Tokunaga, T., Ohta, S., & Matsuda, H., et al. (1997). Nonsurgical management of patients with blunt hepatic injury: Efficacy of transcatheter arterial embolization. AJR. American Journal of Roentgenology, 169, 1151-1156. Hotaling, J.M., Sorensen, M.D., Smith, T.G., Rivara, F.P., Wessells, H., & Voelzke, B.B. (2011). Analysis of diagnostic angiography and angioembolization in the acute management of renal trauma using a national data set. The Journal of Urology, 185, 1316-1320. Jenkins, H.P., Janda, R., & Clarke, J. (1946). Clinical and experimental observations on the use of gelatin sponge or foam. Surgery, 20, 124-132. Johnson, G.E., Sandstrom, C.K., Kogut, M.J., Ingraham, C.R., Stratil, P.G., & Valji, K., et al. (2013). Frequency of external iliac artery branch injury in blunt trauma: Improved detection with selective external iliac angiography. Journal of Vascular and Interventional Radiology, 24, 363-369. Karadimas, E.J., Nicolson, T., Kakagia, D.D., Matthews, S.J., Richards, P.J., & Giannoudis, P.V. (2011). Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. International Orthopaedics, 35, 1381-1390. Knudson, M.M., Harrison, P.B., Hoyt, D.B., Shatz, D.V., Zietlow, S.P., & Bergstein, J.M., et al. (2000). Outcome after major renovascular injuries: A Western trauma association multicenter report. Journal of Trauma and Acute Care Surgery, 49, 1116-1122. Misselbeck, T.S., Teicher, E.J., Cipolle, M.D., Pasquale, M.D., Shah, K.T., & Dangleben, D.A., et al. (2009). Hepatic angioembolization in trauma patients: Indications and complications. The Journal of Trauma, 67, 769-773. Mohr, A.M., Lavery, R.F., Barone, A., Bahramipour, P., Magnotti, L.J., & Osband, A.J., et al. (2003). Angiographic embolization for liver injuries: Low mortality, high morbidity. The Journal of Trauma: Injury, Infection, and Critical Care, 55, 1077-1081. discussion 1081-1082. Rex, D.K. (2006). Review article: Moderate sedation for endoscopy: Sedation regimens for non-anaesthesiologists. Alimentary Pharmacology and Therapeutics, 24, 163-171. Richardson, J.D., Franklin, G.A., Lukan, J.K., Carrillo, E.H., Spain, D.A., & Miller, F.B., et al. (2000). Evolution in the management of hepatic trauma: A 25-year perspective. Annals of Surgery, 232, 324-330. Ring, E.J., Waltman, A.C., Athanasoulis, C., Smith, J.C., & Baum, S. (1974). Angiography in pelvic trauma. Surgery, Gynecology & Obstetrics, 139, 375-380. Roy-Choudhury, S.H., Gallacher, D.J., Pilmer, J., Rankin, S., Fowler, G., & Steers, J., et al. (2007). Relative threshold of detection of active arterial bleeding: In vitro comparison of
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MDCT and digital subtraction angiography. American Journal of Roentgenology, 189, W238-W246. Santucci, R.A., Wessells, H., Bartsch, G., Descotes, J., Heyns, C.F., & McAninch, J.W., et al. (2004). Evaluation and management of renal injuries: Consensus statement of the renal trauma subcommittee. BJU International, 93, 937-954. Shafi, S., Parks, J., Ahn, C., Gentilello, L.M., & Nathens, A.B. (2010). More operations, more deaths? Relationship between operative intervention rates and risk-adjusted mortality at trauma centers. The Journal of Trauma, 69, 70-77. Suzuki, T., Smith, W.R., & Moore, E.E. (2009). Pelvic packing or angiography: Competitive or complementary? Injury, 40, 343-353. Travis, T., Monsky, W.L., London, J., Danielson, M., Brock, J., & Wegelin, J., et al. (2008). Evaluation of short-term and long-term complications after emergent internal iliac artery
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embolization in patients with pelvic trauma. Journal of Vascular and Interventional Radiology, 19, 840-847. Velmahos, G.C., Toutouzas, K.G., Vassiliu, P., Sarkisyan, G., Chan, L.S., & Hanks, S.H., et al. (2002). A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. The Journal of Trauma: Injury, Infection, and Critical Care, 53, 303-308. discussion 308. Wei, B., Hemmila, M.R., Arbabi, S., Taheri, P.A., & Wahl, W.L. (2008). Angioembolization reduces operative intervention for blunt splenic injury. The Journal of Trauma: Injury, Infection, and Critical Care, 64, 1472-1477. Wessells, H., Suh, D., Porter, J.R., Rivara, F., MacKenzie, E.J., & Jurkovich, G.J., et al. (2003). Renal injury and operative management in the United States: Results of a population-based study. Journal of Trauma and Acute Care Surgery, 54, 423-430.
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