Angioembolization and laparotomy for patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma.

BACKGROUND: Treatment of patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma (BAT) is challenging. Controversies remain over the diagnostic approach and the priority of available treatment resources.
METHODS: Between 1999 and 2008, 545 patients were admitted due to concomitant BAT and pelvic fracture. Seventy-six patients receiving both angiography and laparotomy were studied. Focused abdominal sonography for trauma (FAST) was used as the primary triage tool in the early 5 years and multi-detector computed tomography (MDCT) in the later 5 years. The clinical courses and results were retrospectively analyzed to determine if the evolution of the clinical pathways for managing these patients resulted in improved outcomes.
RESULTS: Performing laparotomy solely based on FAST during the early 5 years resulted in a high nontherapeutic laparotomy rate (36%). Contrast enhanced MDCT, as the primary triage tool, accurately disclosed active intra-abdominal and pelvic injuries and was helpful in promptly tailoring the subsequent treatment. Additional surgical trauma was avoided in some patients and nontherapeutic laparotomy rate decreased to 16%. Multiple bleeders were found in 70% of positive angiograms; bilateral internal iliac artery embolization for the purpose of damage control showed a lower repeat angioembolization rate for these severely injured patients.
CONCLUSION: The revised clinical algorithm served well for guiding the treatment pathway. Priority of laparotomy or angiography should be individualized and customized according to the clinical evaluation and CT findings. Angiography can be both diagnostic and therapeutic and simultaneously treat multiple bleeders; thus, it has a higher priority than laparotomy. The primary benefits of our later clinical pathway were in reducing nontherapeutic laparotomy and repeat angioembolization rates.