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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.
The management of patients with multiple trauma is a complex task and requires a multidisciplinary approach.
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.
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.
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.
Management of patient with head injuries and multiple other trauma.