Management of multiple injuries with a severe pelvic fracture is difficult; the early focus is on hemostasis. However, due to the complex source of bleeding; there is no definitive method suitable for all patients with pelvic fractures. The incidence of pelvic fractures in all fractures is about 5%, and the mortality rate is less than 20%. However, pelvic fractures caused by high-energy injuries such as traffic accidents, high falling; heavy objects are often accompanied by adjacent organs or vascular injuries.
And the degree of fracture is severe, which seriously affects hemodynamic stability and greatly increases the difficulty of treatment. The mortality rate of the severe pelvic fracture combined with multiple injuries is as high as 30%e70%,2,3 and the prognosis is poor. The reason may relate to the following factors the complicated source of bleeding in severe pelvic fractures, rapid bleeding, lacking timely and effective hemostasis measures; consumptive coagulopathy caused by severe blood loss and complicated treatment of combined damage.
Fractures and hemodynamic
68 multiple injury patients with severe pelvic fractures and hemodynamic instability surgically treated in our department. The treatment methods are reported in this study; especially hemostasis methods for the severe pelvic fracture, so as to improve the success rate of fatal hemorrhagic shock caused by the pelvic fracture. There 31 cases of head injury, 11 cases of a chest injury, 56 cases of abdominal and pelvic injuries, and 37 cases of spinal and limb injuries.
Therefore the therapeutic methods included early anti-shock measures, surgical hemostasis based on internal iliac artery devascularization for pelvic hemorrhage; so early treatment for combined organ damage and complications included embolization and repair of the liver, spleen, and kidney, splenectomy, nephrectomy, intestinal resection, colostomy, bladder ostomy, and urethral repair, etc. But patients in this series received blood transfusion volume of 1200–10,000 mL; with an average volume of 2850 mL. Postoperative follow-up ranged from 6 months to 1.5 years.
Multiple organ failure
Therefore the average score of ISS in this series was 38.6 points. 49 cases successfully treated and the total survival rate was 72.1%. Totally 19 patients died (average ISS score 42.4); including 6 cases of hemorrhagic shock, 8 cases of brain injury, 1 case of cardiac injury, 2 cases of pulmonary infection, 1 case of pulmonary embolism, and 1 case of multiple organ failure. Postoperative complications included 1 case of the urethral stricture; 1 case of sexual dysfunction (combined with urethral rupture), 1 case of lower limb amputation; 18 cases of consumptive coagulopathy.
The early treatment of multiple injuries combined with severe pelvic fractures should focus on pelvic hemostasis. Massive bleeding-induced hemorrhagic shock is one of the main causes of poor prognosis. Hence the technique of internal iliac artery devascularization including ligation and embolization can be used as an effective measure to stop or reduce bleeding. Consumptive coagulopathy is difficult to deal with, which should detected and treated as soon as possible after surgical measures have performed. The effect of using recombinant factor VII in treating consumptive coagulopathy is satisfactory.