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Vascular Injuries from Pelvic Fractures

- Discussion: 
    - pelvic fracture menu / arterial anatomy of lower limbs 
    - massive retroperitoneal hemorrhage may result from bony fragments and lacerated blood vessels, leading to coagulopathy and
    - associated injuries:
           - up to 40% of pts who have a pelvic fracture will have an intra-abdominal source of bleeding that contributes to mortality and
                   morbidity after blunt trauma;
           - evaluation of hematuria 
           - reference:
                 - Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients.
    - arterial bleeding:
           - massive blood loss usually occurs from injury to superior gluteal artery or anterior branches of the internal iliac artery;
                     - superior gluteal injury occurs because of its relation to SI joint;
                     - internal pudendal artery injury occurs from sharp fascia of piriformis;
                     - less often occurs injury to lateral sacral artery in disruptions of posterior portion of pelvic ring; 
                     - obturator artery:
                           - ref: Aberrant obturator artery is a common arterial variant that may be a source of unidentified hemorrhage in pelvic fracture patients.
           - arterial injuries are uncommon & usually seen w/ open pelvic frx;
           - arterial injuries occur most often in APC - Type II & Type III
           - arterial bleeding is amenable to a variety of embolization techniques;
    - magnitude of bleeding:
           - damage control orthopaedics
           - magnitude of blood loss often goes unrecognized;
                     - retroperitoneal space may accumulate upto 4 liters of blood before venous tamponade occurs;
                     - w/ 3-cm pubic symphysis diastasis will cause doubling of normal volume of pelvis, which would allow several units of
                               addition blood to accumulate before a tamponade effect occurs;
                     - w/ posterior instability, avg blood loss is > 15 units pRBC compared to avg of 5 pRBC required for pelvic frx w/o
                               posterior instability;
                     - always consider need for FFP inaddition to pRBC in cases of massive blood loss;

- CT Scan:
    - CT scanning has become an alternative to peritoneal lavage for the diagnosis of intra-abdominal hemorrhage;
    - references:
             - Contrast-enhanced CT accurately detects hemorrhage in torso trauma: direct comparison with angiography. 
             - Detection of bleeding in patients with major pelvic fractures: value of contrast-enhanced CT

- Management Options: 
    - fluid management in the trauma patient
    - blood product menu and medical management of bleeding 
    - angiography & embolization
          - in pelvic fractures, selective angiography may aid in the dx of of superior gluteal artery lacteration;
                 - during the angiography, the artery may be embolized thru the diagnostic cannula, avoiding a pelvic exploration;
          - if one is using the anterior or posterior approaches to the acetabulum using trochanteric osteotomy, superior gluteal vessels
                 must be intact in order to avoid necrosis of medius & minimus;
                 - this is becuase origin and insertion of muscles is detached in these approaches;
          - if acetabular fracture involves a displaced frx of sciatic notch preoperative angiography is advised to ensure that
                 neurovascular pedicle is intact;
    - laparotomy to control hemorrhage 
            - Preperitoneal pelvic packing is not associated with an increased risk for surgical site infections after internal anterior pelvic
                      ring fixation.
    - external fixators to control bleeding 
    - reduction of pelvic volume

Delaying urinary catheter insertion in the reception and resuscitation of blunt multitrauma and using a full bladder to tamponade pelvic bleeding.

Pelvic ring disruptions: effective classification system and treatment protocols.

Hemodynamic Instability Following an Avulsion of the Corona Mortis Artery Secondary to a Benign Pubic Ramus Fracture. 

Traction vertical shear pelvic ring fracture: a marker for severe arterial injury? A case report.

Hemorrhage After Low-Energy Pelvic Trauma

Predicting major hemorrhage in patients with pelvic fracture.

Hemodynamically Unstable Pelvic Fracture Management by Advanced Trauma Life Support Guidelines Results in High Mortality

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review.

Physiologic parameters may help predict pelvic fracture-related arterial bleeding