Article, Traumatology

Predictability of successful trans-arterial embolization in pelvic fracture bleeding based on patient initial presentation

a b s t r a c t

Background: Pelvic fracture bleeding generally leads to hemorrhagic shock. Trans-arterial embolization (TAE) is regarded as the most useful treatment; however, the initial presentation of the patient can impact the effective- ness of TAE for pelvic fracture bleeding. The aim of this retrospective study is to explore whether the patient data at the initial presentation can predict the success of TAE for pelvic fracture bleeding.

Methods: Twenty-seven charts were retrospectively reviewed. TAE failure was defined as any patient who even- tually received an exigent laparotomy or who died due to uncontrolled bleeding after TAE. For patients who re- ceived TAE, we analyzed factors recorded at the initial presentation, including age, gender, systolic blood pressure, heart rate, respiratory rate, body temperature, Glasgow Coma Scale score, injury severity score (ISS) and Associated injuries, using Pearson’s correlation and independent t-tests. The odds ratio was used to de- termine the cut-off values for the patient presentation findings related to successful TAE and thus was used to assess congruity.

Results: Successful TAE was not correlated with age or gender. The hierarchical order of statistically significant as- sociations between successful TAE and initial presentation data was as follows: the patient’s body temperature, associated injury, respiratory rate, systolic blood pressure, GCS score, and ISS. The odds ratios for all statistically significant initial presentation factors were within a 95% confidence interval.

Conclusion: The findings upon initial presentation of a patient with pelvic fracture bleeding that were related to

the predictability of successful TAE include the following: hypothermia prevention with maintenance of the body temperature above 36 ?C, associated injuries limited to two organ systems, maintenance of the respiratory rate at approximately twenty-two breaths per minute, a sustained systolic blood pressure of approximately 90 mm Hg, maintenance of a heart rate of approximately one hundred beats per minute, a Minor head injury with a GCS score greater than thirteen and a moderate ISS of less than twenty.

(C) 2017

Background

Pelvic fracture bleeding generally leads to hemorrhagic shock. Hypo- thermia [1], acidosis [2], coagulopathy [3,4] and mortality [5] can result

Abbreviations: TAE, trans-arterial embolization; AIS, Abbreviated Injury Score; ISS, injury severity score; SBP, systolic blood pressure; HR, heart rate; RR, respiratory rate; T, body temperature; GCS, Glasgow coma scale; AI, associated injury; AIS, abbreviated injury score; FAST, focused assessment sonography in trauma; CT, computed tomography; ATLS, Advanced Trauma Lift Support.

? This manuscript has not been published or presented elsewhere in part or in entirety

and is not under consideration by another journal.

* Corresponding author at: Trauma Center, Department of Surgery, Yuan Rung Hospital, Changhua 510, Taiwan.

E-mail addresses: [email protected] (C.-C. Tung), [email protected] (S.-J. Lan).

from uncontrolled bleeding. The first priority for survival is to stop the bleeding as soon as possible. Trans-arterial embolization (TAE) is regarded as the most useful Management strategy for stopping bleed- ing. However, how soon should this procedure be considered after pa- tient presentation? Does TAE have to wait until all examinations, such as laboratory tests and imaging studies, are completed? Delaying the procedure may result in death. The findings upon initial presentation of the patient may be important factors to consider in effective patient management [6].

The trauma scoring system and the injury severity score (ISS) were proposed by Baker to indicate the potential trauma outcome [7]; the ISS score was directly correlated with mortality. Additionally, the trau- ma outcome was directly associated with the patient’s age [7]; that is, older patients have a higher mortality rate. Mostafa demonstrated that female patients had better trauma outcomes [8].

https://doi.org/10.1016/j.ajem.2017.12.044

0735-6757/(C) 2017

1364 C.-C. Tung et al. / American Journal of Emergency Medicine 36 (2018) 13631366

Champion predicted the trauma outcomes using indicators such as the patient’s systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Scale score [9]. Lipsky demonstrated that Prehospital hypotension was a predictor of a successful therapeutic op- eration in trauma patients [10]. Fathizadeh evaluated autonomic activity in trauma patients using the heart rate (HR) and RR [11]. Norris used HR variability to predict trauma mortality [12]. Raux assessed the severity of trauma patients using the RR and peripheral oxygen saturation [13].

Hypothermia is a cogent factor in trauma mortality and is associated with microvascular permeability and reactive oxygen in the peripheral tissues after hemorrhagic shock [14]. Meanwhile, hypothermic injury causes a reduction in adenosine triphosphate (ATP) production by the mitochondria [15]. The peripheral tissue is in an anaerobic and acidotic state [2,16], and hypothermia and acidosis worsen coagulopathy and hyper-fibrinolysis via enzymes that expunge intrinsic and extrinsic co- agulation factors [3-5,16,17]. Eventually, the patient bleeds to death due to uncontrolled coagulopathy [5].

Gonzalez et al. reported that a poor GCS score increased mortality in patients with pelvic fracture [18]. Banerjee et al. found that the GCS score was associated with the survival rate of children with pelvic frac- tures [19]. The ISS is a significant risk factor [20], and a higher ISS leads to mortality in pelvic fracture cases [21]. Among trauma patients who have an associated injury, e.g., head injury, chest trauma, or abdominal trauma, the risk of mortality is higher in pelvic fracture cases [20,22].

Many extraneous risk factors associated with the effectiveness of TAE for pelvic fracture bleeding were reviewed. The initial presentation of the patient should be considered when assessing the effectiveness of TAE for pelvic fracture bleeding. Factors that should be considered in cases of pelvic fracture bleeding include the patient’s age, gender, SBP, HR, RR, body temperature, GCS score, ISS, and associated injury detected by a Focused assessment with sonography in trauma (FAST). Therefore, we propose to determine the predictability of the success of TAE in ef- fectively stopping bleeding in pelvic fracture cases using patient data collected upon initial presentation.

Methods

Participants

A total of twenty-seven charts of patients who underwent TAE for pelvic fracture bleeding from 2014 to 2016 in Changhua Christian Hos- pital were retrospectively reviewed following the Advanced Trauma Life Support (ATLS) guidelines. Patients who had a failed TAE procedure received an exigent laparotomy due to uncontrolled bleeding post-TAE. Additionally, some patients died as a result of a failed TAE procedure.

For patients who underwent TAE due to pelvic fracture bleeding, pa- tient data upon initial presentation were analyzed, including SBP (mm Hg), HR (beats per minute), RR (breaths per minute), body tem- perature (?C), GCS score, ISS and associated injuries (organ systems were evaluated using the Abbreviated Injury Scale score [23]) de- tected by the FAST method. Additionally, we analyzed the patient’s de- mographic factors such as age and gender.

Statistical analysis

All consecutive pelvic fracture bleeding patients presenting to the emergency room were included, and data upon initial presentations of

the patients are reported in this study. We explored the bivariate corre- lations between TAE (success or failure) and extraneous factors (avail- able initial presentation information and demographic factors) through Pearson’s correlation. We then applied an independent t-test to determine cut-off points of extraneous factors associated with suc- cessful TAE in pelvic fracture bleeding management. Finally, the odds ratio was used to assess the predictability of successful TAE in pelvic fracture bleeding management based on initial presentation informa- tion (cut-off point). The statistical software package IBM SPSS version 22 was used for statistical analyses.

Results

The results of the Pearson’s correlation and independent t-tests showed no statistically significant association between successful TAE and age or gender. The cogent associations between successful TAE and the findings upon initial presentation included patient body tem- perature, associated injuries, RR, SBP, HR, GCS score, and ISS (Table 1). The success of TAE for pelvic fracture bleeding was dependent upon the following criteria: the patient’s body temperature was in the range of 36.32 to 36.95 ?C (cut-off point: 36 ?C); the associated injury involved two organ systems; the RR was in the range of twenty-one to twenty-six breaths per minute (cut-off point: twenty-two breaths per minute); the SBP was in the range of 88 to 96 mm Hg (cut-off point: 90 mm Hg); the HR was in the range of ninety-three to one hundred and four beats per minute (cut-off point: one hundred beats per minute); the GCS score

was at least thirteen; and the ISS was less than twenty (Table 2).

The confidence limits of the odds ratios for all patient data upon ini- tial presentation and successful TAE were in the 95% confidence inter- val. The odds ratios for the previously mentioned ranges of patient data upon initial presentation and successful TAE were 12.9 for body temperature, 8.47 for associated injury, 6.99 for RR, 8.50 for SBP, 13.00 for HR, 6.99 for GCS score, and 15.87 for ISS, which met the cut-points for all patient data upon initial presentation for TAE for pelvic fracture bleeding management (Table 3). The predictability of successful TAE was based on the following patient findings upon initial presentation: body temperature N 36 ?C, associated injury involving less than two organ systems, RR of approximately twenty-two breaths per minute, SBP of approximately 90 mm Hg, HR of approximately one hundred beats per minute, GCS score N 13, and ISS b 20.

Discussion

The success of TAE was not associated with age and gender. These results are different from the findings of Baker and Mostafa. Further studies are necessary to validate this finding.

Hypothermia is the cogent risk factor for TAE failure in pelvic frac- ture bleeding management. Hypothermia can result in acidosis, coagu- lopathy and death; therefore, a rewarming procedure and hypothermia prevention should precede the use of TAE to stop bleeding and should invariably be applied in pelvic fracture bleeding manage- ment. The recommendations are as follows: the surrounding environ- ment should be warm; the temperature of the infusion fluid must be maintained at 41 ?C; and a heat lamp or electric blanket can be used to prevent hypothermia in patients [24]. For successful TAE in pelvic fracture bleeding, the body temperature of the patient must be main- tained at least at 36 ?C.

Table 1

Pearson’s correlations.

Pearson’s correlations

Age

Gender

SBP

HR

RR

T

GCS

ISS

AI

TAE

0.39

-0.14

-0.91??

0.89??

-0.91??

-0.94??

-0.82??

0.77??

0.91??

TAE indicates trans-arterial embolization, SBP indicates systolic blood pressure, HR indicates heart rate, RR indicates respiratory rate, T indicates body temperature, GCS indicates Glasgow coma scale, ISS indicates injury severity score, AI indicates associated injury.

?? Indicates p b 0.01.

C.-C. Tung et al. / American Journal of Emergency Medicine 36 (2018) 13631366 1365

Table 2

Independent t-test.

Age

Gender

SBP

HR

RR

T

GCS

ISS

AI

Successful TAE

48.0 +- 23.8

1.5 +- 0.5

92.0 +- 3.6

98.6 +- 5.5

23.6 +- 2.0

36.6 +- 0.3

13.7 +- 1.0

18.6 +- 1.5

1.5 +- 0.5

Failed TAE

65.0 +- 15.9

1.3 +- 0.5

77.6 +- 4.2

118.0 +- 9.8

14.3 +- 2.4

34.1 +- 0.6

6.9 +- 3.5

49.3 +- 19.5

4.1 +- 0.7

t

-2.2

0.7

11.2?

-8.8?

10.7?

12.8?

6.5?

-5.4?

10.9?

TAE indicates trans-arterial embolization, SBP indicates systolic blood pressure, HR indicates heart rate, RR indicates respiratory rate, T indicates body temperature, GCS indicates Glasgow coma scale, ISS indicates injury severity score, AI indicates associated injury.

* Indicates p b 0.05.

Patients with pelvic fracture bleeding should receive Damage control surgery [25-27] if their injuries involve more than two organ systems. The emergency physician or trauma surgeon should first determine the nature of the patient’s associated injuries using the FAST method

[28] or imaging studies, including X-rays of the chest, cervical spine, and pelvis, computed tomography (CT), and others.

The RR is associated with oxygen saturation [13]. The maintenance of a normal RR helps to prevent the peripheral tissues from developing an anaerobic status associated with acidosis. Early intubation should be performed immediately if the patient’s RR is less than fifteen breaths per minute [29,30]. Consequently, a normal RR of approximately twenty- two breaths per minute is associated with successful TAE in patients with pelvic fracture bleeding.

The HR and SBP are associated with cardiac output [31,32]. Poor car- diac output elicits poor perfusion of peripheral tissues, which results in acidosis and coagulopathy [33]. The infusion of warm crystalloid fluids through peripheral infusion lines should be performed to maintain the SBP at approximately 90 mm Hg and the HR at approximately one hun- dred beats per minute in patients with pelvic fracture bleeding who are being considered for TAE.

A minor head injury with a CGS score of thirteen to fifteen and a moderate ISS less than twenty are acceptable for patients with pelvic fracture bleeding who are being considered for TAE. For proper manage- ment of pelvic fracture bleeding, it is very important for the trauma sur- geon or first-aid physician to follow the ATLS guidelines [34] for the initial assessment of the patient’s airway, breathing, circulation, disabil- ity and injury event.

Conclusion

Before a patient receives TAE for treatment of pelvic fracture bleed- ing, an initial assessment of the trauma victim using the ATLS guidelines should be performed. The predictability of successful TAE can be based on the following patient findings upon initial presentation: body tem- perature more than 36 ?C, associated injuries involving less than two organ systems, respiratory rate of approximately twenty-two breaths per minute, systolic blood pressure of approximately 90 mm Hg, heart rate of approximately one hundred beats per minute, a GCS score N 13, and an ISS b 20.

Table 3

Odds ratio for successful TAE for pelvic fracture bleeding.

Initial presentations Cut-off point Odds ratio 95% confidence

interval

lower

upper

Body temperature

36 ?C

12.9

2

83.3

Associated injury

2 organ systems

8.47

2.3

31.3

Respiratory rate

22 breaths per minute

6.99

1.9

25

Systolic blood pressure

90 mm Hg

8.5

2.3

31.3

Heart rate

100 beats per minute

13

2

85.5

GCS score

13

6.99

1.9

25

ISS

20

15.87

2.4

52.6

TAE indicates trans-arterial embolization. GCS indicates Glasgow coma scale. ISS indicates injury severity score.

Ethics approval and consent to participate

The Institutional Review Board approvals were obtained from Asia University Ethics Committee, approval number 10209001. After gaining approval from the committee, the research team explained the purpose, risks, and benefits of the study to participants, including their right to refuse to participate with jeopardizing treatment. Patients and care- givers provided consent before participation.

Consent to publish

Not applicable.

Availability of data and supporting materials section

Please contact author for data requests.

Competing interests

The authors declare that they have no competing interests.

Funding

Funding information is not applicable/no funding was received.

Authors’ contributions

CT carried out the prospective study, participated in its conception, design and coordination, performed the statistical analysis, and drafted the manuscript. JY conceived of the study, and participated in its design. SL conceived of the study, and participated in its design and helped to perform the statistical analysis. All authors read and approved the final manuscript.

Acknowledgements

We acknowledge Montelle Felix, M.S., for editing assistance.

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