Balloons up: shorter time to angioembolization is associated with reduced mortality in patients with shock and complex pelvic fractures (original study)

Abstract

BackgroundAngioembolization has been the gold standard for management of pelvic arterial bleeding, but applicability has been limited by delays in access at many trauma centers. We hypothesized that a quality improvement program to reduce time to start of angiography would be associated with lower in-hospital mortality in patients with pelvic fractures and shock.MethodsRetrospective study of adults with a pelvic fracture and vital signs consistent with shock admitted to a level I trauma center after the initiation of a quality improvement project to reduce the time to angioembolization (2012 to 2016). Time from admission to procedure start for hemorrhage control was examined based on destination and time of day. In-hospital mortality was the primary outcome and was compared with US benchmarks in the literature.ResultsThe study group included 424 patients with a mean Injury Severity Score of 41±14. Of these, 212 (50%) responded to resuscitation and were admitted to the intensive care unit; 143 (34%) patients went directly to interventional radiology (IR) with a median time to start of angiography of 86 minutes (IQR 66 to 116); and 69 (16%) patients went directly to the OR with a median time to start of operation of 52 minutes (IQR 37 to 73). There were no significant differences in time to procedures based on time of day or transfer status. In-hospital mortality for patients in shock on admission was 15%.DiscussionPatients with pelvic fracture and hemorrhagic shock, with a median time to angioembolization of <90 min, had a lower in-hospital mortality compared with published US benchmarks. These times were achieved by protocolization of pelvic fracture management that includes expeditious mobilization of the IR team, bypassing the CT scanner, and institutional quality metrics for compliance.Study typeCase series.Level of evidenceIV.

A Short Decision Time For Transcatheter Embolization Can Better Predict Mortality In Patients With Pelvic Fracture

“…The overall decision-TAE time was 60 min, even after performing other resuscitation procedures. Although PPP may have advantages over TAE, namely that of early start time [7,12], most patients with pelvic fracture, even if they are unstable, can be managed with primary TAE strategies at centers that have 24-h availability of interventional radiologists [35].…”

Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control

“…Unstable fracture patterns were defined as anterior posterior compression (APC) type 2/3, lateral compression 2/3, and vertical shear. 80 In the aforementioned AAST multicenter study, Constantini and colleagues 1 also found that APC 3 and open book pelvic fractures were significantly associated with intervention need.…”

Pelvic packing or endovascular interventions: which should be given priority in managing hemodynamically unstable pelvic fractures? A systematic review and a meta-analysis

“…AE is indicated for the suspicion of an injured pelvic artery that is actively bleeding [37]. REBOA, a temporary hemostatic measure to control combined multiple arterial bleedings or damage of main artery, could be used to transport the hemorrhagic shock patients to the operation suite [10,44].…”

“…Endovascular intervention (EI), such as angiography-embolization (AE) and resuscitative endovascular balloon occlusion of the aorta (REBOA), recent years has been successfully used in hemostatic resuscitation [9]. Early angiography and subsequent embolization or balloon occlusion help to stop the arterial bleeding and displays a signi cant improvement in survival rate [10,11] .…”