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Bleeding inthePelvis
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EdwardKelly andFrancescaIzzo
62
Penetrating injuries to the pelvis often cause complex multiorgan injuries due the crowded space of the pelvic cavity,
which contains the rectum, the bladder and ureters, the iliac
arteries and veins, and the boney pelvis. The trauma surgeon’s urgent goals are hemostasis and control of contamination; restoration of continuity of hollow organs should only
be undertaken after the urgent goals are met. In this chapter,
we will focus on rapid control of bleeding and briey discuss
reconstruction options.
Modern techniques enable control of bleeding prior to
operative exposure, using resuscitative balloon occlusion of
the aorta (REBOA). In cases of pelvic injury without evidence of aortic disruption, this approach involves insertion
of a seven-French vascular sheath into the common femoral
artery either percutaneously or by open technique. An endovascular balloon catheter is then advanced to the aortic bifurcation (zone 3, see Table62.1) with or without radiographic
guidance. The balloon is inated using saline to produce
inow occlusion to the pelvic vessels, distal to the takeoff of
the renal arteries. Upon occlusion of the aorta, peripheral
blood pressure should rise, and the patient may then be trans-
ported more safely and undergo further evaluation and repair
of injuries. Removal of the balloon and sheath often requires
surgical repair of the entry site in the common femoral artery.
Adoption of this approach in the emergency room and in the
eld has been growing in the USA and in Japan, and early
results have shown a benet in transfusion requirement.
If FAST exam is negative for evidence of intra-abdominal
free uid, extraperitoneal packing can be performed to control venous bleeding. When performed in conjunction with
REBOA, extraperitoneal packing can provide temporary
hemostasis and allow for transport to interventional radiology for angioembolization or endovascular intervention. A
low midline incision is made and carried down through the
midline fascia. The intact peritoneum is displaced cephalad,
allowing for clot removal and packing of the lateral rectal
fossae, the retro pubic space, and the retro-inguinal space.
Extraperitoneal packing can also be used in patients who
continue to have uncontrolled bleeding following embolization, stabilization of pelvic injuries, or surgical hemostasis.
If FAST is positive in a hemodynamically unstable
patient, they should be brought to the operating room for
Table 62.1 Zones for REBOA placement
Zone Landmark (P tip) Depth Indications
1 Left subclavian artery—upper
border celiac trunk
2 Celiac trunk—distal takeoff of
renal arteries
3 Distal takeoff renal artery—aortic
bifurcation
E. Kelly (*) · F. Izzo
Department of Surgery, Baystate Medical Center Hospital,
University of Massachusetts Chan School of Medicine,
Springeld, MA, USA
e-mail: Edward.Kelly@baystatehealth.org;
Francesca.Izzo@baystatehealth.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_62
Sternal notch 46cm Cardiac arrest
Life-threatening intra-abdominal
hemorrhage
NONE
Xiphoid process 28cm Life-threatening pelvic or lower
limb hemorrhage
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E. Kelly and F. Izzo
exploratory laparotomy and hemorrhage control. Bleeding
from the pelvis can be encountered unexpectedly, for example, in a patient with a bullet entry wound in the chest or
lower extremity. Therefore, every operation for penetrating
trauma should have long vascular instruments ready and a
self-retaining retractor system available to facilitate exposure in the pelvis. Likewise, have the appropriate sutures
(4–0 Prolene for the iliac artery, 3–0 for the aorta, and 6–0
for the iliac vein), grafts, and vascular shunts available. Have
endovascular balloon occlusion catheters ready to control
bleeding from vessels that are hard to reach (distal external
iliac, internal iliac). Have at least two suction lines available,
and cell-scavenging equipment may also be useful.
Midline laparotomy is the exposure of choice for penetrating injuries to the pelvis, as it offers the best access to the
crowded space and enables proximal vascular control in the
abdomen, outside of the eld of injury. The pelvis also borders the extremities, and injuries to the pelvis can also
involve the groins or more distal structures. When more distal control is indicated, a vertical incision in the groin can be
used to expose the femoral arteries and the vein. Therefore,
the skin prep should include chest, abdomen, both groins,
and extremities down to the knees.
Begin with a long vertical midline laparotomy. Liquid
blood, bowel contents, and clots should be removed quickly
to enable exposure. Four quadrant packing can be used to
control abdominal sources of bleeding. Evisceration of the
small intestine out of the abdomen will facilitate exposure, as
will wide retraction with a Bookwalter retractor.
First, we will discuss hematomas. Unlike blunt trauma,
pelvic hematomas from penetrating trauma should always be
explored, as they are strongly associated with injury to the
iliac vessels. Obtain proximal control outside of the hematoma at the origin of the iliac artery or at the distal aorta. For
a hematoma on either side of the pelvis, perform a right- sided
medial visceral rotation, taking care not to disrupt the hematoma, in order to expose the inferior vena cava and the distal
aorta. If the origin of the iliac artery is free, clamp it with an
angled vascular clamp; if the origin is not free, cross- clamp
the aorta with a large straight vascular clamp. For rapid distal
control, direct pressure on the external iliac vessels in the
groin will sufce, or compression with a sponge- on- a-stick
applied to the distal vessel within the pelvis, if not involved
with hematoma. Rapid proximal control of the inferior vena
cava (IVC) can also be achieved with simple compression.
Once proximal and distal control is obtained, open the
hematoma and identify the injury. Keep in mind that the
internal iliac vessels are not controlled with this approach
and may bleed copiously. The ureter may be inside the hematoma, or compressed, or distorted, or injured. After the vascular injury is dealt with, it is necessary to expose the ureter
and determine if it requires repair. When the hematoma is
entered, there may be ongoing bleeding from the uncon-
trolled internal iliac artery or vein. These may be rapidly
controlled with a balloon occlusion catheter or, if the exposure is sufcient, with vessel loops or vascular clamps.
The surgeon then is faced with the decision to repair the
injury in some fashion or to ligate the injured vessel and
manage the consequences. This decision is challenging, as
the patient may have other injuries that require urgent attention or may be physiologically depleted (in terms of temperature, coagulation, and acidosis) and may benet from
the damage control approach. In order to make the best decision, identify the injury completely before committing to a
specic approach. That is, do not decide on placing an interposition graft until you have seen both ends of the vessel you
plan to repair, and do not ligate vessels until you know you
have all bleeding ends identied. Damage control surgery
only works if the damage is actually controlled!
Proximal iliac vein injury deserves special attention.
Anatomically, the conuence of the IVC lies behind the aortic bifurcation, immediately posterior to the right common
iliac artery. Rapid control can be achieved with compression
as outlined above, but to ligate or repair the vein requires
more exposure. Division of the right common iliac artery
between vascular clamps will enable exposure of the IVC
and proximal common iliac veins. Once the vein injury has
been addressed, the artery can be repaired with 4–0 Prolene
suture or temporized with a shunt.
Iliac vein injuries have a high rate of thrombosis, even if
the injury is limited and a good technical repair is achieved.
It is therefore not reasonable to expend valuable time to
achieve a perfect venous repair via paneled vein patch or
venous interposition graft when the patient has multiple injuries that require intervention.
Destructive complex injuries with profuse bleeding call
for lifesaving interventions to stop the hemorrhage. These
injuries require a damage control approach, using suture
ligation, compression with packing, and topical hemostatic
agents (such as BioGlue) to achieve control. By comparison,
injuries to the iliac or femoral arteries are more forgiving.
The higher ows in these vessels make them more resistant
to thrombosis, and thus the results of repair are much better.
Single-layer repair with 3–0 or 4–0 Prolene yields a reliable
long-term outcome for simple arterial lacerations.
Transections with no loss of length can be managed with primary anastomosis, again with good results. Destructive injuries to the arteries, characterized by loss of length that is too
great to allow straightforward primary anastomosis, should
be controlled in one of three ways: (1) Reconstruct immediately with conduit. (2) Insert a shunt and return to the operating room when the patient is more stable for denitive
reconstruction. (3) Ligate the ends and reconstruct extraanatomically as soon as possible.
Immediate reconstruction with conduit should only be
undertaken when the patient is hemodynamically stable and
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does not have a high burden of contamination or other injuries. Time spent on a denitive repair should not be time
taken away from controlling bleeding from the mesenteric
vein or liver injury. However, when the patient is stable and
has minimal other injuries, reconstruction with conduit
yields a reliable long-term result.
In the setting of gross spillage of bowel contents, there is
a high rate of infection for both arterial and venous graft
reconstruction. When bioprosthetic conduits such as reversed
saphenous vein become infected, there is often severe necrolysis of the conduit, leading to renewed hemorrhage in the
necrotic infected eld. This observation has prompted the
author to use non-biological conduits such as expanded
PolyTetraFluoroEthylene (ePTFE) or Dacron. Irrespective of
the strategy for managing penetrating injury of the pelvis, the
risks of deep vein thrombosis, venous hypertension, and pulmonary embolism are very high and should be considered as
part of the treatment of all such patients. The author advocates early lower extremity fasciotomy for patients with
combined arterial and venous injury.
Endovascular intervention in the setting of penetrating
pelvic trauma may be considered in select cases, especially if
life-threatening hemorrhage is not present. Potential interventions include transcatheter arterial embolization for
peripheral injuries, stent placement for non-transectional
injuries, and thrombin injection for pseudoaneurysm to name
a few. While endovascular management is gaining in popularity, due to the complex and highly variable nature of these
injuries, there are no consensus guidelines. Initial management should focus on patient stabilization using a multidisciplinary approach.
Important Points
• REBOA can be utilized for proximal aortic control.
• Extraperitoneal packing can be utilized to control venous
hemorrhage.
• Be prepared! Have the deep vascular instruments you use
ready every time you explore a penetrating injury that
may include the pelvis.
• Trap the external iliac artery against the boney pelvis for
rapid control.
• Remember vascular shunts for the bailout option.
• It is OK to divide the common iliac artery to expose the
conuence of the IVC.
• Fasciotomy is indicated for complex injury.
• Consider endovascular intervention when appropriate.
Summary
Penetrating injury to the pelvis requires early rapid intervention via endovascular approach or open surgery to control
bleeding and contain contamination from the bowel. Vascular
control outside of the pelvis should be achieved using an
anatomical exposure of the aorta and inferior vena cava.
Distal control may be most effectively achieved using compression against the bony pelvis. Balloon occlusion catheters
can be used for control of the hypogastric vessels. Once control is established, the total burden of injury and the complexity (i.e., time to repair) of the pelvic injury should guide
the surgeon’s decision to ligate, shunt, or repair the vascular
injury. Prosthetic material is usually the best choice when a
conduit or patch is needed. Early fasciotomy and IVC lter
should be employed liberally due to the high rate of thromboembolic complications.
Suggested Reading
Burch J, Richardson RJ, Martin RR, Mattox KL.Penetrating iliac vas-
cular injuries: recent experience with 233 consecutive patients. J
Trauma. 1990;30:1450–9.
Carillo E, Spain DA, Wilson MA, Miller FB, Richardson
DJ. Alternatives in the management of penetrating injuries to the
iliac vessels. J Trauma. 1998;44:1024–30.
Mattox KL, Rea J, Coyness LE, Beall AC, DeBakey ME.Penetrating
injuries to the iliac arteries. Am J Surg. 1978;136:663–7.
Norii T, Crandall C, Terasaka Y.Survival of severe blunt trauma patients
treated with resuscitative endovascular balloon occlusion of the
aorta compared with propensity score/adjusted untreated patients. J
Trauma ACS. 2015;78:721–8.
Ryan W, Snyder W, Bell T, Hunt J.Penetrating injuries to the iliac ves-
sels. Am J Surg. 1982;144:642–5.
Part V
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Neurological Trauma
Gunshot Injuries totheHead
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EkkehardM.Kasper, HananAlgethami, RadwanTakroni,
andBurkhardS.Kasper
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Traumatic brain injury (TBI) remains a major cause of death
and disability worldwide, and missile-induced TBI remains
the deadliest of all traumas since rst reported and has
always been associated with high mortality and morbidity. It
also results in signicant socioeconomic burden to the health
care system. The prevalence of TBI secondary to gunshots is
geographically strikingly variable and reects the global
scenery of violence as well as access to weaponry. Injuries
from gunshot wounds (GSW) to the head place an extreme
economic burden on the public while disabling most victims
in the zenith of their life and imposing enormous medical,
legal, and emotional costs. Since every gun/projectile combination is associated with a typical pattern of injury, war injuries differ signicantly from others. We will focus here on
predominantly penetrating civilian gunshot wounds with low
muzzle velocity (<1000f/s) as they occur in the setting of
homicide, and suicide attempts or during domestic and hunting accidents as well as during legal interventions. Many surgeons rushed patients to the OR over the last 30years, and
they have achieved a remarkable reduction in morbidity from
well above 50% to less than 25%, even in patients admitted
with severe brain injury. However, in the setting of increasingly limited resources, recent research focus has shifted
toward more precise prediction of survival as well as on better functional outcome.
Among rearm injuries, gunshot wounds to the head and
brain are nightmares for all involved. Pre-hospital mortality
remains >50% and the in-hospital mortality for civilians with
penetrating neurocranial injury is around 50–95% depending
E. M. Kasper (*)
Department of Surgery, Division of Neurosurgery, St. Elizabeth’s
Medical Center, Cambridge, MA, USA
e-mail: ekkehard.kasper@steward.org
H. Algethami · R. Takroni
Department of Surgery, Division of Neurosurgery, McMaster
University, Hamilton, ON, USA
B. S. Kasper
Department of Neurology, University of Erlangen,
Erlangen F.R.G., Germany
on the study and the proportion of suicide victims in the
series. Of note is the observation that female victims seem to
have worse outcome based on a different causative injury
pattern. It is clear from all studies that “time is brain,”—so
we must act swiftly on all patients brought to a trauma center
and ensure protocol-guided resuscitation. You must obtain an
accurate qualied exam upon arrival, since this is the most
relevant determinant and reports of any GSC from the scene
are often established pre-resuscitation and hence grossly
inaccurate due to e.g., intoxication, hypotension or hypoxia/
hypothermia. “Time is brain” is a key concept aiming at
improved outcome. Therefore, it is essential to initiate ATLSguided treatment (pressors, mannitol, and hyperventilation)
even prior to completing the imaging. To prevent secondary
damage perioperatively, one must ensure sufcient cerebral
perfusion (goal >70mmHg) by keeping intracranial pressure
below 25mmHg and arterial blood pressure above 90mmHg
and use ICP monitoring, broad-spectrum antibiotics, and
anticonvulsants.
Most studies support intervention for patients with a postresuscitation GCS of greater than 5, but there are exceptions
to the rule, and despite a rst impression of devastation,
some patients will have good outcome against all odds. So,
our credo is to treat any not clearly hopeless case, and in
particular in young individuals, as fast and aggressively as
possible.
In managing gunshot-injured brain-patients, you should
be well aware that only a part of the neurological harm
arises at the moment of impact. The prognostic relevant
damage most frequently evolves in the time span immediately after the incident and any achievable outcome correlates to the time between injury and the time of intervention
and postoperative management. By managing and preventing secondary problems aggressively, you justify swift surgical treatment and improve your outcome.
If the patient is comatose with a GCS of 3–5, we initiate
intracranial pressure (ICP) treatment already in the
trauma bay and even prior to the acquisition of imaging.
However, as soon as the patient is systemically stabilized, it is
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_63
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E. M. Kasper et al.
mandatory to immediately obtain a standardized CT scan
(5-mm cuts parallel to the skull base in brain/bone windows
with automated reformats in coronal and sagittal planes) in
ALL patients to make a decision on operative intervention; CT
scanning does not differ from other trauma patient workup, but
we scan the patient head rst during the trauma protocol
workup to get a better idea about the prognosis, the urgency of
the situation, and to get the chance to swiftly plan a precise
setup for the OR.Workup and handling of patients with stab
injuries to the brain does not differ signicantly from those
Fig. 63.1 Patient No. 1:
22-year-old female crime
victim, who sustained
multiple GSW with a single
non-penetrating GSW to the
head. Entry wound at R
cheek, exit wound on R
supraorbital forefront. Plates
a and b: Scout images A/P
and lateral without evidence
of bullet. Plates c and d:
preoperative images (bone
windows) demonstrating R
frontal skull fracture with
pneumocephalus and orbital
roof fracture. Plates e and f:
axial and coronal views of
large R epidural hematoma
and intraorbital hematoma.
Plates g and h: axial views of
postoperative results status
post-evacuation of hematoma
and autologous cranioplasty.
Plates i and j: reconstructed
orbital roof status posttransfrontal evacuation of
retro-orbital hematoma
a
c
with gunshot wounds, but injury is usually more localized since
the impact transforms less energy than that of a projectile.
The acquisition of CT scans must NOT be postponed
ever because of a good presenting clinical status (high GCS),
since approximately 10% of patients with non-penetrating
injury (without breach of the neurocranium) may still suffer
a signicant intracranial injury and will require life-saving
neurosurgical intervention; Please see also our own patient
illustrated in Fig.63.1). The reverse is also true: even in the
setting of a GSC as low as 3–5, many young patients deserve
b
d
e
f
gh
ij
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a
Fig. 63.1 (continued)
surgical intervention as soon as a dened space-occupying
lesion (e.g., hematoma) is identied on admission CT.
Initial patient management should be according to ATLS
protocols or equivalent algorithms to insure isotonic volume resuscitation, normotonia, normorhythmia, and normothermia. Traumatic GSW brain injury is classied as
critical in any patients presenting with a GCS score below
eight and an abnormal CT scan, e.g., showing a skull fracture or deformation, hematoma, contusion, swelling, or
other signs of local or global mass effect possibly causing
incipient herniation. Remember that patients with GCS
scores >8 and/or a supratentorial single lobe lesion have the
best chance to show good outcome after aggressive surgical
treatment.
Available literature also offers some outcome prediction
models (see Fig.63.2) for head-injured patients using a number of parameters including age, GCS score, pupil reactivity,
and the presence of extracranial injuries. Further adjustments
are made by including ndings on CT scanning. As expected,
outcome is also dened by the locally available treatment
resources and hence reects the socioeconomic status of the
country. Based on our experience in an urban trauma level 1
center, we strongly suggest aggressive surgical treatment in
all not clearly hopeless cases.
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Fig. 63.2 Head injury prognosis model
63.1 Some Rules forWorkup Leading
toOperative Management
The most important rule to memorize at the very beginning
is: “Time is brain.”
As profane as it may sound: Clear thinking and a high
speed of coordinated action is crucial and it requires a well
pre-instructed and well-drilled team.
What we really mean here is: Swiftly coordinated actions
are vital in the true sense of the word and will dene the
outcome for such challenging endeavors and are an absolute
requirement if you want to succeed. This applies to all parts
of the care-provider chain: from Advanced Life Support
trained EMTs who pick up and transport the patient, their
management en route, communication with and concise presentation upon arrival in the ER.Admission examination and
timely workup is critical and potentially life-saving with premeditated bedside algorithms until a possible intervention in
the OR can be performed. The latter can only be successful
with a well-prepared and very well carried-out surgical plan.
Here are my personal rules (EMK):
No. 1: DO NOT PANIC! In many ways, it is a case like
many others; therefore: RUN YOUR ROUTINE.Do all the
work-up and make related decision similar to a decision tree
and according to protocol.
No. 2: DO NOT WASTE TIME—and save it wherever
you can do it safely. This means: When the hospital is notied
about the arrival of a GSW patient, GET READY BEFORE
THEY ARRIVE. Call the OR upfront to get a trauma room
set up for a craniotomy. Announce the most likely scenario
(20-year-old male; R crani/supine or suboccipital crani/prone,
etc.). Ask to assemble a team for the OR that you already
know/can work with, do not rely on newcomers (Fig.63.3).
No. 3: GO TO THE ER AND WAIT IN THE TRAUMA
BAY FOR THE PATIENT TO ARRIVE. If you are out of
the hospital, start driving in NOW. Meanwhile organize
things by phone on your way. These are most valuable minutes that you can save for later (Fig.63.4).
No. 4: Touch base with the ER attending. In an experi-
enced setting, the ER will get prepared ahead of time and
have identication labels/numbers and a trauma team
assigned prior to the patient’s arrival (Fig.63.5).
ab
cd
ef
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Fig. 63.3 Patient No. 2: 23-year-old female, who sustained a solitary
GSW to the head from close range. Entry wound on the R cheek, exit
wound R parietal. Plates a and b: Scout images A/P and lateral without
evidence of bullet but large R sided skull fracture. Plates c and d: preoperative images (bone windows) demonstrating R fronto-parietotemporal blowout skull fracture and skull base fracture from middle
cranial fossa entry point. Plates e and f: axial views of large R SAH,
epidural and intraparenchymal hematoma and contusions with pneumocephalus. Plates g and h: axial views of postoperative results status
post- hemicraniectomy for evacuation of hematoma. Plates i and j: nal
results of reconstructed R allograft cranioplasty with Porex® and
encephalomalacia along the bullet tract.
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Fig. 63.3 (continued)
No. 5: Make sure they notify the blood bank for possible
need of products with “emergent release.” Make sure they
have pressors and Mannitol/Lasix IV ready, as well as a
respiratory therapist on site to immediately initiate controlled hyperventilation. Remember the rule of 30s: height
of bed 30°, hyperventilation with f=30 for a goal pCO2<30.
No. 6: Get the trauma team ready in the bay and assign
tasks by talking to the senior/attending running the case. A
GSW IS NOT THE PATIENT TO PRACTICE ON.
Newcomers can stand by and watch, but should stay at a distance and out of the way! Try to pass all preliminary information around as it can be gathered from the EMT-call-in
from the scene or en route (ask about patient age, single
wound or systemic injury, patient awake or with loss of consciousness (LOC)/comatose; patient intubated, patient sta-
ble; blood loss at the scene; other issues). No. 7: Call the ER
CT scanner upfront that you will bring a critically ill patient
ASAP so they can keep the scanner FREE for your case!
No. 8: Listen well to what the transport team has to say
upon presenting the case, they sometimes know important
details (downtime, seizures at the scene, difculties with the
airway, etc.). Have a second person conrm this information
after handover has been done and the EMT team has a
relaxed moment to communicate.
No. 9: WATCH if there is any sign of life upon arrival.
Get a good glimpse at the patient (I recommend you stand
behind the chief running the case at the head end of the
patient) and once the primary survey is done.
No. 10: You should get a 10–30s neuroexam yourself.
THEN MAKE THE RUN AGAINST THE CLOCK!
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