Selective Computed Tomography and Angioembolization Provide Benefits in the Management of Patients with Concomitant
Unstable Hemodynamics and Negative Sonography Results
Chih-Yuan Fu
•Chi-Hsun Hsieh
•Chun-Han Shih
•Yu-Chun Wang
•Ray-Jade Chen
•Hung-Chang Huang
•Jui-Chien Huang
•Shih-Chi Wu
•Hsun-Chung Tsuo
•Hsiu-Jung Tung
Published online: 14 February 2012 Ó Socie´te´ Internationale de Chirurgie 2012
Abstract
Background The FAST (focused assessment of sonogra- phy for trauma) examination can rapidly identify free fluid in the abdominal or thoracic cavity, which is indicative of hemorrhage requiring emergency surgery in multiple- trauma patients. In patients with negative FAST examination results, it is difficult to identify the site of the hemorrhage and to plan treatment accordingly. We attempted to delineate the role of selective computed tomography (CT) and tran- sarterial angioembolization (TAE) in the management of such unstable patients.
Methods From January 2005 to April 2011 patients with concomitant unstable hemodynamics and negative FAST examination results were identified. Their demographic and time to start of embolization were recorded. The initial systolic blood pressure (SBP) in emergency department patients was compared with the SBP after TAE.
Results A total of 33 patients were enrolled, and 85%
required TAE. SBP improved significantly after TAE.
There were 18 patients who received TAE without CT scan because the site of hemorrhage was obvious. Fifteen patients received a CT scan during the time required for angiography preparation. Ten of them received subsequent TAE based on the CT scan findings, and the treatment plan was changed in the other five patients. There was no sig- nificant difference between patients with or without a CT scan with respect to the time interval between arrival and starting embolization.
Conclusions Transarterial angioembolization is suggested in the management of patients with concomitant unstable hemodynamics and negative FAST examination results.
During the time interval required for angiography prepa- ration, a CT scan can be performed. This approach provides
C.-Y. Fu C.-H. Shih R.-J. Chen
Department of Trauma and Emergency Surgery,
Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan e-mail: drfu5564@yahoo.com.tw
C.-H. Shih
e-mail: 99183@wanfang.gov.tw R.-J. Chen
e-mail: rayjchen@tmu.edu.tw
C.-H. Hsieh Y.-C. Wang ( &) H.-C. Huang J.-C. Huang S.-C. Wu
Trauma and Emergency Center, China Medical University Hospital, Yue Der Road No. 2, Taichung, Taiwan e-mail: traumawang@yahoo.com.tw
C.-H. Hsieh
e-mail: hsiehchihsun@yahoo.com.tw H.-C. Huang
e-mail: adam0936287309@yahoo.com.tw
J.-C. Huang
e-mail: gary.kmt@msa.hinet.net S.-C. Wu
e-mail: rw114@www.cmuh.org.tw C.-H. Hsieh Y.-C. Wang S.-C. Wu School of Medicine, China Medical University, Taichung, Taiwan
H.-C. Tsuo H.-J. Tung
School of Medicine, Taipei Medical University, Taipei, Taiwan
e-mail: b101095067@tmu.edu.tw H.-J. Tung
e-mail: thjami@gmail.com
DOI 10.1007/s00268-012-1457-8
valuable information for further decision making without delaying definitive treatment.
Introduction
Trauma remains one of the leading causes of morbidity and mortality worldwide [1–3]. Regardless of the mechanism of injury, most deaths that occur within the first hour fol- lowing a traumatic event are the result of injury-induced hemorrhage. Such instances cause 30–50% of injury- associated deaths within the first 24 h of trauma care [4–9].
Moreover, hemorrhage-induced hypotension in trauma patients is predictive of mortality. Therefore, in addition to aggressive resuscitation, it is important to identify the source of the hemorrhage and achieve adequate hemostasis rapidly in trauma patients suffering from hemorrhagic shock.
In the primary survey of trauma patients with unstable hemodynamics, the focused assessment of sonography for trauma (FAST) examination was applied to identify cavi- tary hemorrhages, which present as free fluid in the
abdominal or thoracic cavity and mandate emergency operation without any further imaging studies [10, 11].
However, for some patients, the source of hemorrhage will remain unclear after history taking, physical examination, and FAST examination. A computed tomography (CT) scan can be used to identify the source of hemorrhage. For hemodynamically unstable patients, however, CT scanning is considered traditionally to be a time-consuming proce- dure that might delay definitive treatment. Therefore, physicians face a dilemma in the management of unstable patients with negative FAST examination results.
In the hemostasis procedure for such patients, the role of exploratory surgery was considered insignificant; further- more, non-therapeutic surgery may delay definitive treat- ment. In contrast, transarterial angioembolization (TAE) can be used to achieve hemostasis in the case of hemor- rhage that cannot be detected by FAST examination [12, 13].
To our knowledge, reports on trauma patients with concomitant unstable hemodynamics and negative FAST examination results have been scarce to date. Thus, the purpose of the present study was to delineate the further
Blunt trauma patients (N=18774)
SBP<90mmHg (N=243) (after resuscitation)
FAST: negative for cavitary hemorrhage (N=33)
(Excluded) 1. Died in ED 2. Severe head or
spinal injury
Initiation of angiography preparation
TAE (N=28)
Indications for angioembolization without CT scan:
1. Unstable pelvic fracture on PXR (N=17) 2. Ongoing craniofacial hemorrhage (N=1) N=10
CT scan (N=15)
1. Emergency surgery due to false negative of FAST results (N=1)
2. Emergency surgery for high-grade renal injury (N=2)
2. Negative CT scan (no hematoma or contrast extravasation) (N=2)
N=5 Fig. 1 The established
algorithm and patient
distribution
management of such patients in the acute setting, and to evaluate the role and efficacy of selective CT scanning and TAE in such situations.
Materials and methods
We retrospectively reviewed the trauma registry and medical records of trauma patients at the China Medical University Hospital (CMUH) and Wan Fang Hospital (WFH) from January 2005 to April 2011. Both of these institutions are major trauma referral centers. There were no discrepancies in surgical techniques or technical skill levels between CMUH and WFH.
During the 76-month investigational period, the blunt trauma patients were identified and treated according to an established algorithm (Fig. 1). In the present study, hemodynamic instability was defined as systolic blood pressure (SBP) less than 90 mmHg after an initial fluid bolus of 2,000 ml of lactated Ringer’s solution or normal saline solution over 15–20 min. The trigger of blood transfusion (packed red blood cells or whole blood) in the resuscitation is considered in patients who are either non- responders or transient responders with an estimated acute blood loss of [30% blood volume [10].
The trauma series plain films (chest X-ray: CXR; pelvic X-ray: PXR) and FAST examination were performed routinely as an adjunct to the primary survey [10]. Patients who died in the emergency department (ED) without other evaluation or who had severe head/spinal injury, which may have contributed to unstable hemodynamics and hemorrhage, were not enrolled in the study. Patients who underwent emergency surgery (thoracotomy, laparotomy, or both) due to cavitary hemorrhage noted on the FAST examination were also excluded.
Patients with concomitant unstable hemodynamics and negative FAST examination results were the focus of this study. Angiography preparation was initiated while these patients’ unstable hemodynamics and negative FAST examination results were analyzed in the ED. Patients with unstable pelvic fractures observed on PXR and those with ongoing craniofacial hemorrhage were sent directly to the angiography room for embolization without undergoing other imaging studies. For the embolization of these patients, the external carotid artery was examined for cra- niofacial hemorrhage, and the internal iliac artery (IIA) was examined for possible retroperitoneal hemorrhage related to pelvic fracture. The other patients without obvious foci of TAE received CT scans during the time required for angi- ography preparation. In patients who underwent CT scan- ning, subsequent TAE was focused on the sites with contrast extravasation or hematoma formation. Other patients did not receive angiogram or TAE after the CT scan.
At both institutions, the resuscitation room, ED operat- ing room, and CT and angiography suite were integrated in the same area. Patients could be transferred between the resuscitation room and the imaging study suite in a notably short time with continuous resuscitation. Besides, the FAST was performed by experienced attending ED phy- sicians or trauma surgeons, who provided reliable exam- inations. Furthermore, there were in-house trauma surgeons available 24 h a day who assisted in femoral arterial puncture, arterial line placement, or cut-down with arteri- otomy in difficult puncture cases. The TAE procedure was performed by experienced radiologists who used absorb- able gelatin-sponge pledgets (Gelfoam), stainless-steel coils, or both. The protocol was abandoned for any patient who became profoundly hypotensive (SBP 60 mmHg or lower) before or during angiography [14]. These patients were managed with additional resuscitation (continued fluid administration and/or vasopressor administration) [15].
In the present study, we investigated the characteristics of patients with concomitant unstable hemodynamics and negative FAST examination results in the ED according to the medical records and trauma registration data bank. The demographic characteristics, injury severity scores (ISS), injury mechanisms, time to start of embolization (with or without CT scan), and outcomes in these patients were recorded and analyzed. The initial SBP in the ED was compared with the SBP after TAE. The efficacy of selec- tive CT scanning and TAE was also examined. The cases of patients who received CT scans but not TAE were analyzed.
All data are presented as percentages of patients or means with standard deviations. The Wilcoxon two-sam- ple exact test was used for the comparison of numerical data, and the chi-square test was used in the comparison of nominal data. All statistical analyses were performed with the SPSS computer software package (version 13.0, Chicago, IL). A value of p \ 0.05 was considered significant.
Results
During the 76-month study period, 18,774 blunt trauma patients admitted to the CMUH or the WFH were studied.
The patient distribution is presented in Fig. 1. After
excluding severe head or spinal injury patients and patients
who died in the ED, there were 243 patients with
SBP \ 90 mmHg after fluid resuscitation with 2,000 ml of
lactated Ringer’s solution or normal saline. Thirty-three
of these 243 patients had negative FAST examination
results and were subsequently enrolled in the study. The
mean age of the 33 patients with concomitant unstable
hemodynamics and negative FAST examination results was 40.2 ± 9.9 years. Of these patients, 24 were male (73%) and nine were female (27%).
There were 18 patients who received TAE after the primary survey without CT scan because the site of injury or source of hemorrhage was obvious (unstable pelvic fracture on PXR; 17 had ongoing craniofacial hemorrhage:
During the preparation for angiography, a CT scan was performed on the 15 patients without obvious injury sites or sources of hemorrhage. Based on the CT scan findings, 10 (67%) of these 15 patients received further TAE, and 5 (33%) of them received other treatment instead of TAE.
Comparisons of the patients who received TAE with and without undergoing CT scanning are presented in Table 1.
There was no significant difference between these two groups of patients in terms of age, sex, ISS, and outcome.
The time between arrival and starting embolization was not significantly longer in patients who underwent CT scanning compared with those patients who did not undergo CT scanning (p = 0.178). Furthermore, the SBP after TAE was higher than SBP in the ED patient and in patients either who did (69.4 ± 22.6 versus 118.0 ± 23.1 mmHg;
p \ 0.001) or did not (63.1 ± .27.5 versus 95.3 ± 12.2 mmHg; p \ 0.001) undergo CT scanning.
Table 2 presents the 15 patients without obvious foci for TAE during the primary survey who then underwent CT scanning during the time required for angiography prepa- ration. The CT scan was followed by TAE in 10 patients because of specific findings on the CT scan. Most of these 10 patients (9/10, 90%) had pelvic fracture-related hem- orrhages (contrast extravasation: 7, retroperitoneal hema- toma: 2), although the PXR revealed normal or stable pelvic fractures. Five patients did not undergo angiogram or TAE after CT scanning. Their demographic character- istics, injury mechanisms, CT scan findings, and sub- sequent treatment are listed in Table 3. Computed tomography scans revealed hemoperitoneum in one patient, and this result indicated that the FAST examination find- ings were false negative. This patient was sent for an Table 1 Demographics of the 28 patients with concomitant unstable
hemodynamics and negative FAST (focused assessment of sonogra- phy for trauma) examination results who received TAE (transarterial angioembolization)
Variables Patients underwent CT scanning followed by TAE (n = 10)
Patients received TAE directly without CT scanning (n = 18)
p Value
Age, years 38.4 ± 13.8 39.2 ± 17.4 0.744
aGender, n (%) 0.809
bMale 6 (60%) 13 (72%)
Female 4 (40%) 5 (28%)
ISS 31.4 ± 21.2 28.1 ± 15.5 0.112
aInjury mechanism, n (%) –
Traffic crash 8 (80.0%) 16 (89%) Fall ([3 m) 2 (20.0%) 2 (11%) SBP in ED,
mmHg
69.4 ± 22.6 63.1 ± .27.5 – SBP after TAE,
mmHg
118.0 ± 23.1 95.3 ± 12.2
p Value \0.001
a\0.001
aTime to start of embolization, min
a39.7 ± 11.3 (CT scan)
31.4 ± 18.1 (no CT scan)
0.178
aMortality, n (%) 2 (20%) 2 (11%) –
Variables are expressed as mean ± SD
There was no significant difference in the time interval from arrival to TAE between patients who did or did not undergo computed tomography (CT) scanning
ISS injury severity score; SBP systolic blood pressure, ED emergency department
a
Wilcoxon two-sample exact test
b
Chi-square test
Table 2 The patients without obvious focus of TAE during the primary survey received CT scans during the time required for angiography preparation
CT scan findings Subsequent treatment Hemostasis results
and outcome TAE (?) (n = 10) Pelvic fracture with
contrast extravasation
7 (47%) Followed with TAE according to CT scan findings
Success (5/7); failure/
death (2/7) Pelvic fracture with
retroperitoneal hematoma
a2 (13%) Success (2/2)
Lumbar artery contrast extravasation 1 (7%) Success (1/1)
TAE (–) (n = 5) High-grade renal injury 2 (13%) Emergency surgery (2/2) Survived (1/2); died (1/2) Mesentery hemorrhage
with hemoperitoneum
b1 (7%) Emergency surgery Survived (1/1)
Negative finding 2 (13%) Maintain resuscitation Died (2/2)
a
Contrast extravasation on CT scan indicates active hemorrhaging and the need for TAE. Although there were two patients without contrast extravasation, they were sent for TAE because of retroperitoneal hematoma and possible hemorrhaging
b