Review Question - QID 211529

In this clinical scenario, repeat angiography of the pelvis will most likely reveal arterial bleeding from a new source.

High-energy pelvic ring injuries are associated with significant intra-pelvic bleeding and the need for transfusion. Immediate application of a pelvic binder or sheet has been shown to effectively reduce the pelvic volume and thereby mitigate continued blood loss. While venous bleeding is the most common source, and is often self-limited, arterial sources may necessitate angiography and embolization. However, patients requiring continued resuscitation after angiography and embolization should undergo repeat angiography to evaluate for potential new sources (68%), recurrent bleeding from a previously embolized source (18%), or both (14%).

Langford et al. reviewed the evaluation, classification, and resuscitation of pelvic fractures. They recommend initial hemostasis with noninvasive tamponade methods, such as a pelvic binder or folded sheet, and pelvic angiography in patients not responding to resuscitation and without other identifiable sources. The authors recommended that selective embolization should be performed to minimize gluteal necrosis, especially if the affected region involves the planned surgical approach.

Gourlay et al. performed a retrospective case-control study of 556 patients undergoing pelvic angiography for traumatic pelvic arterial hemorrhage. They reported that 7.5% of patients required a second angiography, and that bleeding was identified at a new site in 68% of patients and at the previously embolized site in 23%. The authors recommend repeat angiography in patients with continued hypotension who required more than 2 units of transfusion before the initial angiogram, pubic symphysis widening, and more than 2 arteries requiring embolization.

Fang et al. retrospectively evaluated 174 patients treated with pelvic angiography for pelvic arterial hemorrhage. They found 24.3% of patients underwent repeat angiography and 18.6% underwent repeat embolization within 58 hours of the initial embolization. The authors recommend retaining the initial arterial access sheath for 72 hours and maintaining a high suspicion for recurrent hemorrhage in patients with initial hemoglobin less than 7.5 g/dL and more than 6 units transfused since initial embolization.

Figure A is an AP radiograph of the pelvis with the widening of the symphysis pubis and left SI joint consistent with an APC 3 pelvic ring injury.

Incorrect answers:
Answer 1: The presence of continued hemodynamic instability after a previous angiogram is likely to reveal an arterial bleed.
Answer 2: Venous bleeding is the most common source of blood loss in pelvic ring injuries but rarely leads to hemodynamic instability requiring multiple angiographies.
Answer 3: Bleeding at the previously embolized arterial site is less common than isolated arterial bleeding from a new source.
Answer 5: Combined bleeding at a new site and the previously embolized site is less common than isolated arterial bleeding from a new source.