Pelvic Arterial Injury

Reviewed and revised 6 June 2016

OVERVIEW

• potentially lethal complication of pelvic trauma
• more common that previously reported: >10%

SITES

• gluteal arteries – SIJ and sacral fractures
• pudendal arteries – pubic ramus fractures and widening of the pubic symphysis

WHEN TO SUSPECT

• elderly
• AP compression or vertical shear mechanism
• haemodynamic compromise
• open pelvic fracture
• vascular blush or large hematoma on CT
• Fractures of the sacrum, SI joint or pubic symphysis widening

MANAGEMENT

• Standard approach to major trauma
• Operative intervention is generally unsuccessful, ligation of the iliac arteries or their branches may be required
• If ‘controllable hypotension’ or only BP lability then IR for transcatheter arterial embolisation is preferred
• Aortic tamponade with an inflated intra-aortic balloon pump can be perfromed as a rescue manourvre

References And Links

LITFL

• Weingart on Pelvic Trauma
• Pelvic and Hip injuries in the Emergency Department
• Trauma Tribulation 026 — Trauma! Genitourinary injuries
• CCC — Pelvic arterial injury
• CCC — Pre-peritoneal packing
• CCC — Pelvic Fracture Management

Journal articles and textbooks

• Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, Holevar M, Sabater EA, Sems SA, Vassy WM, Wynne JL. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture–update and systematic review. J Trauma. 2011 Dec;71(6):1850-68. PMID: 22182895.
• Fildes J, et al. Advanced Trauma Life Support Student Course Manual (8th edition), American College of Surgeons 2008.
• Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J Surg. 2004 Jul;74(7):520-9. Review. PubMed PMID: 15230782.
• Legome E, Shockley LW. Trauma: A Comprehensive Emergency Medicine Approach, Cambridge University Press, 2011.
• Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice (7th edition), Mosby 2009. [mdconsult.com]
• Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review. PubMed PMID: 19278678.
• White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871.

FOAM and web resources

• LITFL — Weingart on Pelvic Trauma
• Resus.ME — Exsanguinating pelvis – occlude the aorta
• The Trauma Professional’s Blog — Bleeding And Pelvic Fractures
• The Trauma Professional’s Blog — Predicting Bleeding In Patients With Stable Pelvic Fractures
• The Trauma Professional’s Blog — Pelvic Fractures: OR vs Angio In The Unstable Patient
• Trauma.org — Management of exsanguinating pelvis injuries