Predictive factors of mortality in polytrauma patients with life threatening pelvic hemorrhage after transarterial embolization (TAE)

Objective

To determine the predictive factors of mortality in patients with severe pelvic trauma after transarterial embolization (TAE).

Methods and materials

We developed a protocol for the management of patients with severe pelvic trauma with stressing the roles of TAE, and performed a study according to it between January 1996 and December 2000. When patients with unstable pelvic fracture and without hemoperitoneum were in shock on admission, angiography was immediately performed after admission. In case of hemodynamically stable patients, angiography was performed only when contrast-enhanced CT showed hematoma in the pelvic cavity. For patients with stable pelvic fracture and without hemoperitoneum, angiography was performed when they were in shock and had CT evidence of hematoma in the pelvic cavity. When patients in shock with stable or unstable pelvic fracture had hemoperitoneum, we first chose either of angiography or laparotomy according to our previously reported protocol. All the patients who had angiographic evidence of extravasation of contrast medium underwent TAE. In addition, all the patients with unstable pelvic fracture immediately underwent external fixation after TAE.

Result

TAE was successfully performed to all the 61 patients with the angiographic evidence of extravasation of contrast medium. Forty-eight patients survived and 13 died. To analyze the predictive factors of mortality on admission, the damages that the patients sustained were divided into two types; anatomical and physiological. Tile's classification, the positions of arterial injury, ISS, and head injury (AIS ≥ 4) were used as anatomical damage parameters. For the physiological damage parameter, APACHE II score was used. Multivariate analysis was performed for these five factors inclusive of anatomical and physiological parameters. The arterial injury in the posterior position and APACHE II score had a significantly high odds ratio, 16.3 and 26.2, respectively. The items that were statistically significant among the APACHE II parameters were age, mean arterial blood pressure (MAP), core temperature and pH. Volume of positive water balance (ml/kg/hour) during the period from admission to TAE, total units of blood transfusion, time from onset to TAE, and numbers of surgery for complicated injuries (AIS ≥ 4) were examined using multivariate analysis for the predictive factors of mortality after admission. Among these four factors, only the positive water balance had significantly high odds ratio (8.3).

Conclusion

MAP, core temperature, pH, and volume of positive water balance were hemodynamic factors. Therefore, the predictive factors of mortality could be said to be determined by the location of arterial injury which should be the posterior position, age, and degree of deterioration of hemodynamics.