Current management of hemorrhage from severe pelvic fractures

Costantini, Todd W.; Coimbra, Raúl; Holcomb, John B.; Podbielski, Jeanette; Catalano, Richard D.; Blackburn, Allie; Scalea, Thomas M.; Stein, Deborah M.; Williams, Lashonda; Conflitti, Joseph; Keeney, Scott; Suleiman, Ghada; Zhou, Tianhua; Sperry, Jason L.; Skiada, Dimitra; Inaba, Kenji; Williams, Brian H.; Minei, Joseph P.; Privette, Alicia; Mackersie, Robert C.; Robinson, Brenton; Moore, Forrest O.

doi:10.1097/ta.0000000000001034

Cited by 204 publications

(130 citation statements)

References 33 publications

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“…Moreover a dedicated pelvic orthopedic surgeons can improve ( p = 0.004) the number of patients that undergoing definitive unstable pelvic fractures repair with a consequently improvement in outcome [5]. Similar data about the importance of the adherence to defined guidelines have been reported by Balogh et al [16] and recently confirmed by the multi-institutional trial by Costantini et al [10]. …”

Section: Methodsmentioning

confidence: 60%

“…Ten to fifteen percent of patients with pelvic fractures arrive to the ED in shock and one third of them will die reaching a mortality rate in the more recent reports of 32% [10]. The causes of dying are represented in the major part by uncontrolled bleeding and by patient’s physiologic exhaustion.…”

Section: Methodsmentioning

confidence: 99%

“…Most published clinical guidelines recommend the use of early angioembolization, in conjunction with external pelvic fixation if indicated, as the main measure of acute bleeding control [10, 46, 93, 110–117]. As a counterpart it is important to consider a number of factors that are critical to decision-making.…”

Section: Methodsmentioning

confidence: 99%

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Pelvic trauma: WSES classification and guidelines

et al. 2017

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Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

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Section: Methodsmentioning

confidence: 60%

Section: Methodsmentioning

confidence: 99%

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Pelvic trauma: WSES classification and guidelines

et al. 2017

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“…Pelvic fractures patterns included APC III (29), LC II (26), LC III (20), APC II (20), LC I (13), vertical shear (14), APC I (4) and CM (2). Of these, 18 patients had open pelvic fractures.…”

Section: Resultsmentioning

confidence: 99%

“…The most recent analysis, a multicenter observational study by the American Association for the Surgery of Trauma (AAST), reported a 32% mortality rate for complex pelvic fracture patients who presented in shock (14). The majority of trauma centers in that study, and in the United States, emphasize angioembolization (AE) for primary hemorrhage control (14–16). While angioembolization is effective in controlling arterial sources of hemorrhage, it does not address the venous or bony hemorrhage within the pelvis (17).…”

Section: Introductionmentioning

confidence: 99%

Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures

Burlew

Moore

Stahel

et al. 2017

Journal of Trauma and Acute Care Surgery

146

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Background A 2015 AAST trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality. Methods In 2004 we initiated a PPP protocol for pelvic fracture hemorrhage. Results During the 11-year study, 2293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age 44 ± 2 years and ISS 48 ± 1.2). The lowest emergency department SBP was 74 mmHg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions prior to SICU admission compared to the 24 postoperative hours were 8 versus 3 units (p<0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush. Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the OR at 89 and 100 minutes after arrival while 1 died 9 hours after arrival. Conclusions PPP results in a shorter time to intervention and lower mortality compared to modern series utilizing AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be employed for pelvic fracture related bleeding in the patient who remains unstable despite initial transfusion.

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Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures

et al. 2023

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ImportanceManagement of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture.ObjectiveTo characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures.Design, Setting, and ParticipantsIn this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021.Main Outcomes and MeasuresPrimary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications.ResultsA total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P &lt; .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P &lt; .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications.Conclusions and RelevanceThis study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.

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Current management of hemorrhage from severe pelvic fractures

Abstract: Prognostic study, level II; therapeutic study, level III.

Cited by 204 publications

References 33 publications

Pelvic trauma: WSES classification and guidelines

Pelvic trauma: WSES classification and guidelines

Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures

Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures

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