Masood, R

Mateen, M A

Qasim, Z A

English

eCommons@AKU

eCommons@AKUSection of Paediatric Surgery Department of SurgeryJanuary 2004Successful use of angiographic embolization tocontrol hemorrhage from blunt pelvic trauma in apediatric patientZ A. QasimAga Khan UniversityR MasoodAga Khan UniversityM A. MateenAga Khan University, arif.mateen@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_paediatrPart of the Pediatrics Commons, and the Surgery CommonsRecommended CitationQasim, Z. A., Masood, R., Mateen, M. A. (2004). Successful use of angiographic embolization to control hemorrhage from bluntpelvic trauma in a pediatric patient. Journal of Pakistan Medical Association, 54(1), 32-33.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_paediatr/3319. Strassburger S, Hyckel P, Schumann D, et al.  Basaloid squamous epithelialcarcinoma (basaloid- squamous carcinoma) of the mouth floor: differentialdiagnosis and response to neoadjuvant chemotherapy. Mund- Kiefer-Gesichtchir 1997;1:239-43. 20. Maritn RC 2nd, Edward MJ, Cawte TG, et al.  Basosquamous carcinma:analysis of prognostic factors influencing recurrence. Cancer 2000;15:1365-9.21. Zamecnik M, Skalova A, Pelikam Ket al. Basaloid squamous carcinoma withcollagen spheroles and crystalloid. Ann Diagn Pathol 2001;5:233-9.22. Nishimura W, Naomoto Y, Hamaya K, et al. Basaloid squamous cellcarcinoma of oesophagus. J Gastroentrol Hepatol 2001;16: 566-90.Successful Use of Angiographic Embolization to control Hemorrhage from BluntPelvic Trauma in a Pediatric PatientZ. A. Qasim, R. Masood, M. A. MateenSection of Pediatric Surgery, Department of Surgery, Aga Khan University Hospital, Karachi.IntroductionIn adults, the role of angioembolization in bluntpelvic trauma is fairly well established.1 However, its role inpediatric practice is not clearly defined.  We present the caseof a child, initially operated for blunt abdominal and pelvictrauma, later treated successfully by angioembolization. Itsrole as a safe and effective treatment modality inappropriately selected cases is discussed.Case ReportA 10-year-old boy, involved in a motor vehicleaccident was transferred to our Emergency Department.  Onarrival, he was in grade III shock. Examination revealed adistended abdomen, with bruising over the suprapubicregion and blood at the urethral meatus. Both lowerextremities showed extensive abrasions. He wasimmediately resuscitated and intubated in accordance withestablished advanced trauma life support (ATLS) protocols.Initial x-rays demonstrated extensive pelvic andlower limb fractures involving the right sacroiliac joint,right acetabular fracture, right pubic rami, right femur, andright tibia and fibula. As he remained hypotensive andtachycardic despite fluid resuscitation, and no other obviousbleeding site was found, he was taken to the operating roomfor abdominal exploration.Laparotomy revealed 500 milliliters of blood in theperitoneal cavity, no solid or hollow viscus injury, presence ofmassive retroperitoneal hematomas, and a distended andcontused urinary bladder.  Suprapubic tube cystostomy wasperformed, and external fixators were applied to the right leg.Postoperatively in the intensive care unit, the childremained hemodynamically unstable and required massiveblood transfusion.  Angiography was performed 17 hoursafter surgery, which showed contrast extravasation frombranches of the right internal pudendal artery (Figure 1).These bleeding points were successfully embolized using2mm x 2.5mm platinum coils (Trufill-Cordis, USA) andPoly vinyl alcohol particles (Cordis, USA )  (Figure 2).The child's condition improved followingJ Pak Med Assoc32angioembolization. The remainder of his hospital stay wasunremarkable, and he was discharged home, with close follow-up and rehabilitation in the outpatient clinic.  He has remainedwell and is awaiting delayed repair of his urethral injury.DiscussionTrauma is the leading cause of childhood morbidityand mortality2, the majority being blunt trauma secondary tomotor vehicle accidents.3 The appropriate management ofthese injured children involves adhering to well-establishedprotocols such as those set out by the American College ofSurgeons in its ATLS Manual.4Blunt pelvic trauma in the pediatric populationcomprises a small but very significant portion of injuries.Exsanguination from associated vascular injury carries amortality of 5-45%.5 It represents a complex clinicaldecision-making situation, especially in the face of ahemodynamically unstable child with concomitant injury toother organ systems. Advances in imaging technology have altered thediagnostic and therapeutic interventions available for use bythe pediatric trauma team. An example is the use ofemergency department ultrasound, which has now replacedthe more conventional diagnostic peritoneal lavage indetermining the presence of free fluid in the abdomen.6Likewise, interventional radiology has made adramatic contribution to the field of trauma surgery,allowing an alternative to open surgical exploration andrepair of significant vascular injuries.7The success of angioembolization in the adulttrauma victim ranges from 85-100%.1,8,9 In children,angioembolization has proven to be useful in managingpatients with hepatic hemangiomas, vascularmalformations, renal artery stenosis, and congenital heartdisease.10 Its use in pediatric trauma, however, has not beenclearly defined.  The main reasons include the lack ofappropriate size coils and catheters, as well as the fact thatfew interventional radiologists have sufficient expertise incarrying out procedures in children.10 However, there areno such limitations now.In addition to the presence of trained personnel,specific considerations include the maintenance of adequateroom temperature, proper dosage of sedative medicationsand contrast material, and proper pre- and postprocedurecare, including attention to fluid status.10 Particular care isneeded to ensure the minimum amount of radiationexposure to the child, and this may involve recalibratingequipment normally used on adults, if a dedicated pediatricfacility is not available.  Techniques used in pediatric angioembolization aremodifications of those used in adults.10 Coils and cathetersare now available in varying sizes as required.  As withadults, pediatric anesthesia and surgery teams should beavailable in-house, should the need arise.General complications are similar to those seen inthe adult population, and include complications withcatheter placement, bleeding, and infarction.  Inexperienced hands, however, these risks are almostnegligible.10 Careful preprocedure screening and correctionof coagulopathy if present minimizes the risk of bleedingduring the procedure.  The use of smaller catheters and morerefined techniques allows selective angioembolization to bedone, allowing the most distal bleeding site to be embolized,thus minimizing the risk of infarction.7Angioembolization has been used successfully in thepediatric patient to treat numerous pathologies. Although itis a single case report, but it shows that if performedappropriately in selective group of trauma patients,angioembolization is a safe and effective modality incontrolling bleeding associated with pelvic fractures in thispopulation.  Adequate patient selection, delineatingconcomitant injuries, proper initial resuscitation, and amultidisciplinary approach allow improved survival.  Aproperly conducted trial will be necessary to provide furthersolid evidence of the benefits of angioembolization in thepediatric trauma patient.References1. Velmahos GC, Toutouzas KG, Vassiliu P, et al.  A prospective study on thesafety and efficacy of angiographic embolization for pelvic and visceralinjuries.  J Trauma 2002;52:303-8.2. Stafford PW, Blinman TA, Nance ML. Practical points in evaluation andresuscitation of the injured child. Surg Clin North Am 2002;82:273-301.3. Nguyen TD, Raju R, Lee S. Considerations in pediatric trauma. E Med2001,2:11 (www.emedicine.com)4. Advanced Trauma Life Support Student Manual. 6th ed.  Chicago: AmericanCollege of Surgeons 1997, pp. 353-376.5. Junkins EP, Nelson DS, Carroll KL, et al.  A prospective evaluation of theclinical presentation of pediatric pelvic fractures.  J Trauma 2001;51:64-8.6. Fabian TC, Croce MA, Minard G, et al. Current Issues in trauma. Curr ProblSurg 2002;39:1160-1244.7. Scalea TM, Sclafani S.  Interventional techniques in vascular trauma.  SurgClin North Am 2001;81:1281-97.8. Wong YC, Wang LJ, Ng CJ, et al. Mortality after successful transcatheterarterial embolization in patients with unstable pelvic fractures: rate of bloodtransfusion as a predictive factor. J Trauma 2000;49:71-4.9. Agolini SF, Shah K, Jaffe J, et al.  Arterial embolization is a rapid andeffective for controlling pelvic fracture hemorrhage.  J Trauma1997;43:395-9.10. Culham JAG. Pediatric Interventional Angiography. In: Baum S, Abrams HLed. Abram's Angiography: vascular and interventional radiology. 4th ed.London: Little, Brown and Co. 1996 pp. 903-21.Vol. 54, No. 1, January 2004 33

Successful use of angiographic embolization to control hemorrhage from blunt pelvic trauma in a pediatric patient

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Successful use of angiographic embolization to control hemorrhage from blunt pelvic trauma in a pediatric patient

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