Is CT-A Always Reliable in Detecting Active Bleeding in Closed Pelvic Fractures? Management of a Case with Multiple Closed Pelvic Fratures and Internal Iliac Artery Bleeding.

One of the most important complications of pelvic injuries is hemorrhage which can be attributed to the venus plexus of the pelvis, the damaged bone on the fracture site, or in 15% of cases to arterial cause. In the last case mortality could reach 70%. Clinical case presentation, a 77-year-old man, presented in the emergency department of our hospital hemodynamically unstable due to fall from height (3 meters) with comminuted bilateral fractures of the pubic rami, right sacral and iliac wing fracture, right acetabular fracture, fractures of transverse processes of the first, second, and fifth lumbar spine vertebrae and a periprothetic fracture of the right femur. Advanced trauma life support (ATLS) protocol was followed throughout. Computed tomography (CT) scans and CT angiography performed, showed the above mentioned pelvic fractures that did not require stabilization, without further injuries, and a well described retroperitoneal hematoma without any evidence of active bleeding. During the resuscitation process the patient developed cardiac arrest and cardiopulmonary resuscitation (CPR) protocol was followed. The patient was intubated and retained his cardiac rhythm. However, he remained unstable and an angiography was then performed that revealed internal iliac artery bleeding and embolism of the internal iliac artery was performed. The patient was stabilized and was transferred to the intensive care unit for further management. Arterial hemorrhage due to pelvic injury is less common, however presents with high rates of mortality. CT angiography may in some cases not reveal existing active bleeding, misleading the clinician. Therefore, in patients with high clinical suspicion of arterial pelvic hemorrhage who remain unstable during the initial resuscitation and do not present with other primary source of bleeding, an angiography and embolism should be performed as soon as possible.