Extraperitoneal packing in unstable blunt pelvic trauma: A single-center study

Abstract

BACKGROUND Hemodynamically unstable pelvic fractures often require a multi-modal approach including both operative and endovascular management. While an important adjunct in hemorrhage control, time to angioembolization even at the most advanced trauma centers may take hours. Extraperitoneal packing (EPP) is a fast and effective procedure that can immediately address pelvic hemorrhage from the retroperitoneal space in severe pelvic injuries. The aim of this study was to evaluate the efficacy of early EPP, looking at 24 hours and overall mortality, and the hemodynamic impact of EPP in unstable blunt pelvic trauma. METHODS All trauma patients admitted to an urban Level I trauma center were evaluated from 2002 to 2018 in a retrospective single-center comparative study. Inclusion criteria were patients 14 years or older who sustained blunt trauma with pelvic fractures and hemodynamic instability. Exclusion criteria were a concomitant head injury (Abbreviated Injury Scale >3) and patients who underwent resuscitative thoracotomy. The patient population was divided into two groups: an EPP group and a no-EPP group. Propensity score matching was used to adjust for differences in baseline characteristics in the two groups: a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each patient. RESULTS Two hundred forty-four patients presented hemodynamically unstable, with a pelvic fracture (180 no-EPP, 64 EPP). With propensity score matching, 37 patients in each group were analyzed. Survival within the first 24 hours was significantly improved in the EPP group (81.1% vs. 59.5%, p = 0.042) and we registered similar results in overall survival rate (78.4% EPP group vs. 56.8% no-EPP group, p = 0.047). Those patients who underwent early EPP (n = 64) were associated with a significant improvement in hemodynamic stability, with a pre-EPP mean arterial pressure of 49.9 mm Hg and post-EPP mean arterial pressure of 70.1 mm Hg (p < 0.01). CONCLUSION Extraperitoneal pelvic packing is an effective procedure that can be performed immediately, even within the trauma bay, to improve hemodynamic stability and overall survival in patients who sustain severe blunt pelvic trauma. The early use of EPP can be lifesaving. LEVEL OF EVIDENCE Therapeutic, Level III.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis

“…Moreover, the evidence was limited to observational studies. In all studies, the clinical indication to REBOA was haemorrhage from a pelvic fracture or abdominal injury, conditions that recognize optimal clinical results with standard damage control approaches, such as abdominal or extraperitoneal packing [ 38 ] . Both manoeuvres improve haemodynamics and survival and are easily performed by surgical personnel with specific experience.…”

Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis

“… 15 , 17 , 18 , 21 – 23 , 25 , 27 , 31 Two of these studies reported more than 80% of patients treated with PPP in their cohort required secondary AE. 23 , 29…”

“…[16][17][18] Injury Severity Score Data were pooled from 16 studies of 516 patients. 11,[15][16][17][18][20][21][22][23][24][25][27][28][29][30]32 The mean ISS in the PPP group was 41 (95% CI, 37-46; n = 384), while, in the AE group, the mean ISS was 36 (95% CI, 33-40; n = 132) (Fig. 5).…”

Comparison between external fixation and pelvic binder in patients with pelvic fracture and haemodynamic instability who underwent various haemostatic procedures

“…In addition, a pelvic orthotic device has been developed and marketed that can be conveniently used in various emergency centres for patients with unstable pelvic fractures (T-POD, Morrisville, NC, US) 11 . Although various studies on the application of PPP and PA in such patients have been published recently, limited studies have compared PEF and PB 8 , 12 – 14 . Therefore, this study aimed to compare clinical outcomes between patients who underwent PEF and PB for pelvic volume reduction.…”