Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Soci

Abstract

Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.

Current management of hemorrhage from severe pelvic fractures

“…While there is no debate regarding the need for urgent hemorrhage control for patients with ongoing bleeding from the pelvis, there is no consensus as to a standard algorithm for the treatment of patients with hemorrhagic shock and pelvic injury. 10,12,13 In this study of 1,339 patients with pelvic fracture, we found an overall in-hospital mortality rate of 9.0%. This mortality rate is similar to a study of more than 24,000 patients with pelvic fracture during a 10-year period using the Nationwide Inpatient Sample that found an in-hospital mortality of 8.3%.…”

Pelvic trauma: WSES classification and guidelines

“…Since venous bleeding sources are inadequately managed by angio-embolization, studies have shown that the traditional ATLS-guided management of hemodynamically unstable pelvic ring injuries with angio-embolization results in poor patient outcomes with high post-injury mortality rates greater than 40% [80, 81]. The notion of a mainly venous retroperitoneal bleeding source in pelvic fractures provides the main rationale for pelvic packing for acute surgical hemorrhage control [4, 82]. …”

“…Pelvic trauma (PT) is one of the most complex management in trauma care and occurs in 3% of skeletal injuries [1–4]. Patients with pelvic fractures are usually young and they have a high overall injury severity score (ISS) (25 to 48 ISS) [3].…”

“…Patients with pelvic fractures are usually young and they have a high overall injury severity score (ISS) (25 to 48 ISS) [3]. Mortality rates remain high, particularly in patients with hemodynamic instability, due to the rapid exsanguination, the difficulty to achieve hemostasis and the associated injuries [1, 2, 4, 5]. For these reasons, a multidisciplinary approach is crucial to manage the resuscitation, to control the bleeding and to manage bones injuries particularly in the first hours from trauma.…”

Impact of ATLS Guidelines and Trauma Team Introduction an 24 Hours Mortality in Severe Trauma in a Busy Italian Metropolitan Hospital: a Case Control Study.

“…In early 2011, surgeons, emergency physicians, and intensive care unit doctors drafted several diagnostic and therapeutic protocols, which in some cases were published. [15] Though this certainly contributed to the present results, we are confident that implementation of ATLS provided the necessary improvement. Surgeons were the first to complete the ATLS provider course, followed by emergency physicians, and intensive care and anesthesiologist teams.…”