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Interventionelle Notfallembolisation bei schweren Beckenfrakturen mit arterieller Blutung

Integration in den frühklinischen Behandlungsalgorithmus

Interventional emergency embolization for severe pelvic ring fractures with arterial bleeding

Integration into the early clinical treatment algorithm

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Zusammenfassung

Zielsetzung

Vorstellung eigener Erfahrungen und Ergebnisse eines frühklinischen Behandlungsalgorithmus unter Integration der Notfallembolisation (TAE) bei instabilen Beckenfrakturen mit arterieller Blutung.

Methodik

Retrospektive Untersuchung einer konsekutiven Patientenserie der Jahre 04/2002-12/2006 an einem Level-1-Traumacenter. Die Daten der Online-Schockraumdokumentation (Traumawatch®) bei Patienten mit Beckenfraktur und einer im Multislice-Computertomographie (MSCT) nachgewiesenen arteriellen Blutung wurden auf folgende Parameter hin untersucht: demographische Daten, Unfallmechanismus, Frakturklassifikation nach Tile/AO und Verletzungsschwere Becken nach „Abbreviated Injury Score“ (AIS), Begleitverletzungen mit Erhebung der Gesamtverletzungsschwere nach „Injury Severety Score“ (ISS), physiologische Aufnahmeparameter (Kreislaufparameter und initialer Hb-Wert) sowie Transfusionsbedarf während der Schockraumversorgung, Zeit bis zur Embolisation, Dauer der Embolisation und identifizierte Blutungsquelle.

Ergebnisse

Von insgesamt 162 Schockraumpatienten mit instabiler Beckenfraktur wurde bei 21 Patienten eine arterielle Blutung durch Kontrastmittelextravasation im MSCT nachgewiesen. 12 Patienten waren männlich und 9 weiblich, das Durchschnittsalter lag bei 45 (17–80) Jahre. Als Unfallmechanismus lagen ausschließlich Hochrasanztraumen vor. Es handelte sich zu 33% um Becken-B-Verletzungen und 67% um Typ-C-Verletzungen mit einem durchschnittlichen AISBecken von 4,4 Punkte (3-5) und einer Gesamtverletzungsschwere anhand des ISS von 37 Punkte (21–66). Bei Aufnahme lag bei 47,6% eine Kreislaufinstabilität vor mit einem durchschnittlichen Hb-Wert von 7,8 (3,2–12,4) g/dl und einem durchschnittlichen Transfusionsbedarf von 6 (4–13) Erythrozytenkonzentraten während der Stabilisierungsphase. Die Zeit von Eintreffen im Schockraum bis zur Durchführung der TAE betrug im Mittel 62 (25–115) min mit einer Durchführungsdauer der TAE von 25 (15–67) min. Als Blutungsquelle wurden ausschließlich Äste der A. iliaca interna identifiziert. Die primäre Erfolgsrate der TAE betrug >90%.

Schlussfolgerung

Die interventionelle Notfallembolisation (TAE) stellt sowohl ein effektives als auch schnelles Verfahren zur Blutstillung bei einer im MSCT nachgewiesenen arteriellen Blutung bei Schockraumpatienten mit stabilen oder stabilisierbaren Kreislaufverhältnissen und Beckenfrakturen dar. Bei gesicherter 24-h-Bereitschaft durch die Radiologie und effizienter Infrastruktur kann diese zeitnah nach Klinikaufnahme durchgeführt werden und sollte somit in das frühklinische Behandlungsprotokoll integriert werden.

Abstract

Objective

Presentation of our own experiences and results of an early clinical algorithm for treatment integrating emergency embolization (TAE) in cases of unstable pelvic ring fractures with arterial bleeding.

Method

Consecutive patient series from April 2002 to December 2006 at a level 1 trauma center. The data of the online shock room documentation (Traumawatch®) of patients with a pelvic fracture and arterial bleeding detected on multislice computed tomography (MSCT) were examined for the following parameters: demographic data, injury mechanism, fracture classification according to Tile/AO and severity of the pelvic injury assessed with the Abbreviated Injury Score (AIS), accompanying injuries with elevation of the cumulative injury severity according to the Injury Severity Score (ISS), physiological admission parameters (circulatory parameters and initial Hb value) as well as transfusion requirement during treatment in the shock room, time until embolization, duration of embolization, and source of bleeding.

Results

Of a total of 162 patients, arterial bleeding was detected in 21 patients by contrast medium extravasation on MSCT, 12 of whom were men and 9 women with an average age of 45 (14–80) years. The mechanism of injury was high energy trauma in all cases. In 33% it involved type B pelvic fractures and in 67% type C fractures with an average AIS pelvis of 4.4 points (3–5) and a total severity of injury with the ISS of 37 points (21–66). Upon admission 47.6% presented hemodynamic instability with an average Hb value of 7.8 g/dl (3.2–12.4) and an average transfusion requirement of 6 red blood cell units (4–13). The time until the TAE was started was on average 62 min (25–115) with a duration period of the TAE of 25 min (15–67). Branches of the internal iliac artery were identified as the sole source of bleeding. The success rate of TAE amounted to over 90%.

Conclusion

Interventional TAE represents an effective as well as a fast procedure for hemostasis of arterial bleeding detected on MSCT in patients with pelvic fractures. If an experienced radiologist on 24-h stand-by is assured and the infrastructure is efficient, this can be performed shortly after hospital admission and therefore should be integrated into the early clinical treatment protocol.

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  1. Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Theodor Stern Kai 7, 60590, Frankfurt am Main, Deutschland

    J. Westhoff, H. Laurer, S. Wutzler, H. Wyen, B. Maier & I. Marzi

  2. Klinik für diagnostische Radiologie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Deutschland

    M. Mack

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  1. J. Westhoff
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  2. H. Laurer
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  3. S. Wutzler
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  4. H. Wyen
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  5. M. Mack
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  6. B. Maier
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  7. I. Marzi
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Correspondence to J. Westhoff.

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Westhoff, J., Laurer, H., Wutzler, S. et al. Interventionelle Notfallembolisation bei schweren Beckenfrakturen mit arterieller Blutung. Unfallchirurg 111, 821–828 (2008). https://doi.org/10.1007/s00113-008-1479-8

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  • DOI: https://doi.org/10.1007/s00113-008-1479-8

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