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ED placement of arterial sheath for endovascular management in multiple trauma

      To the Editor:—Hemorrhage control and prevention of secondary neuronal damage are major problems in acute trauma care. We present a case of cranial epidural hemorrhage and continuous bleeding resulting from pelvic fracture. To provide temporary percutaneous aortic balloon occlusion (TABO) for hypovolemic shock in the intra-operative period of craniotomy, we performed insertion of a sheath into the right femoral artery in advance of craniotomy.
      A-40-year-old woman was brought to our institution after being struck by a car. Her vital signs were as follows: temperature 36.0°C (96.8° F), pulse 88 beats/min, and blood pressure 79/38 mm Hg. She was unconscious and sustained an unstable pelvic fracture. Initial fluid resuscitation improved her hemodynamics as follows: pulse 100 beats/min and blood pressure 126/70 mm Hg. Emergency computed tomographic scan revealed acute epidural hematoma in the right hemisphere (Fig 1) and continuous bleeding as a result of pelvic fracture (Fig 2). We judged that acute epidural hematoma was of immediate concern and that, because the patient showed hemodynamic improvement, craniotomy should be performed before endovascular management of the bleeding pelvic vessels. An 8-Fr 10-cm sheath through the right femoral artery was inserted percutaneously in the ED. The purpose of this action was to facilitate immediate intraoperative TABO should the patient become unstable. We performed emergency craniotomy with the aim of evacuation of the epidural hematoma. Her postoperative vital signs were as follows: pulse 120 beats/min and blood pressure 104/46 mm Hg. We performed angiographic embolization of the branches of the left internal iliac artery through the sheath, which had been inserted preoperatively (Fig 3). The patient subsequently made a full recovery. At this time, the patient has remained asymptomatic for 11 months.
      Figure thumbnail GR1
      FIGURE 1Brain computed tomography scan showing epidural hemorrhage (arrows) and extravasation of contrast media (arrow) resulting from pelvic fracture (small arrow).
      Figure thumbnail GR2
      FIGURE 2Computed tomography scan of pelvis showing extravasation of contrast media (arrow) resulting from a pelvic fracture (small arrow).
      Figure thumbnail GR3
      FIGURE 3Arteriogram before embolization showing extravasation of contrast media from the branch of the left internal iliac artery (arrow).
      The management of patients with multiple trauma is a complex task and requires a multidisciplinary approach.
      • Wilson R.F
      • Tyburski J.G
      Management of patient with head injuries and multiple other trauma.
      ,
      • Tscherne H
      • Regel G
      • Pape H.C
      • Pohlemann T
      • Krettek C
      Internal fixation of multiple fractures in patients with polytrauma.
      ,
      • Perez J.V
      • Hughes T.M
      • Bowers K
      Angiographic emblization in pelvic fracture.
      The most important considerations within the first hours after trauma are adequate hemorrhage control and the prevention of secondary neuronal damage.
      • Wilson R.F
      • Tyburski J.G
      Management of patient with head injuries and multiple other trauma.
      ,
      • Tscherne H
      • Regel G
      • Pape H.C
      • Pohlemann T
      • Krettek C
      Internal fixation of multiple fractures in patients with polytrauma.
      Although angiographic embolization for the control of hemorrhage resulting from pelvic fracture are reported to be effective, emergency craniotomy could be needed for prevention of secondary neuronal damage. Thus, the determination of the therapeutic sequence for severe multiple trauma is still difficult and controversial.
      • Wilson R.F
      • Tyburski J.G
      Management of patient with head injuries and multiple other trauma.
      ,
      • Tscherne H
      • Regel G
      • Pape H.C
      • Pohlemann T
      • Krettek C
      Internal fixation of multiple fractures in patients with polytrauma.
      ,
      • Perez J.V
      • Hughes T.M
      • Bowers K
      Angiographic emblization in pelvic fracture.
      For severe hemorrhagic shock, TABO provides an alternative to thoracotomy with aortic crossclamping.
      • Matsuoka S
      • Uchiyama K
      • Shima H
      • Ohishi S
      • Nojiri Y
      • Ogata H
      Temporary percutaneous aortic balloon occlusion to enhance fluid resuscitation prior to definitive embolization of posttraumatic liver hemorrhage.
      ,
      • Gupta B.K
      • Khaneja S.C
      • Flores L
      • Eastliick L
      • Longmore W
      • Shaftan G.W
      The role of intra-aortic balloon occlusion in penetrating abdominal trauma.
      TABO before a curable hemostatic procedure is effective, and a 9-Fr balloon catheter (Block balloon; AISIN SEIKI Co., Ltd, Kariya, Japan) for TABO through a 10-Fr sheath has been developed recently.
      • Matsuoka S
      • Uchiyama K
      • Shima H
      • Ohishi S
      • Nojiri Y
      • Ogata H
      Temporary percutaneous aortic balloon occlusion to enhance fluid resuscitation prior to definitive embolization of posttraumatic liver hemorrhage.
      ,
      • Gupta B.K
      • Khaneja S.C
      • Flores L
      • Eastliick L
      • Longmore W
      • Shaftan G.W
      The role of intra-aortic balloon occlusion in penetrating abdominal trauma.
      Although insertion of the introducer into the femoral artery could fail as a result of a decrease of blood pressure and succeeding arterial spasm in severe hypovolemic shock, the exchange of an 8-Fr introducer for a 10-Fr one using the Seldinger technique is easy.
      • Matsuoka S
      • Uchiyama K
      • Shima H
      • Ohishi S
      • Nojiri Y
      • Ogata H
      Temporary percutaneous aortic balloon occlusion to enhance fluid resuscitation prior to definitive embolization of posttraumatic liver hemorrhage.
      Thus, we performed preoperative placement of the 8-Fr sheath in readiness for immediate intraoperative TABO. Although we have not performed TABO, we believe that we can have perform craniotomy with a low risk of deterioration of the hemodynamic condition.
      In conclusion, EPs should consider the preceding placement of an arterial sheath in cases of multiple trauma with active bleeding, especially in cases that require radiographic embolization.

      References

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        • Pohlemann T
        • Krettek C
        Internal fixation of multiple fractures in patients with polytrauma.
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        Angiographic emblization in pelvic fracture.
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        • Ohishi S
        • Nojiri Y
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        Temporary percutaneous aortic balloon occlusion to enhance fluid resuscitation prior to definitive embolization of posttraumatic liver hemorrhage.
        Cadiovasc Intervent Radiol. 2001; 24: 274-276
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        • Eastliick L
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        The role of intra-aortic balloon occlusion in penetrating abdominal trauma.
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