Impact of a simplified management algorithm on outcome following exsanguinating pelvic fractures: A 10-year experience

Abstract

BACKGROUND Optimal management of exsanguinating pelvic fractures remains controversial. Our previous experience suggested that management decisions based on a defined algorithm were associated with a significant reduction in transfusion requirements and mortality. Based on these outcomes, a clinical pathway (PW) for the management of exsanguinating pelvic fractures was developed. The purpose of this study was to evaluate the impact of this PW on outcomes. METHODS Consecutive patients over 10 years with blunt pelvic fractures subsequent to the implementation of the clinical PW were identified. Patients with hemodynamically unstable pelvic fractures are managed initially with a pelvic orthotic device. For those with continued hemodynamic instability and no extrapelvic source of hemorrhage, pelvic angiography was performed followed by elective pelvic fixation. Patients managed according to the PW were compared with those patients whose management deviated (DEV) from the PW. RESULTS There were 3,467 patients identified. Three hundred twelve (9%) met entry criteria: 246 (79%) comprised the PW group and 66 (21%) the DEV group. Injury severity, as measured by Injury Severity Score (35 vs. 36; p = 0.55), admission Glasgow Coma Scale (10 vs. 10; p = 0.58), admission BE (−7.4 vs. −6.4, p = 0.38), admission SBP (107 vs. 104, p = 0.53), and PRBC requirements during initial resuscitation (6.1 units vs. 6.6 units, p = 0.22) were similar between the groups. Pelvic orthotic device use was 48% in the DEV group (p < 0.001). Twenty-four percent of the PW group required angiography compared with 74% of the DEV group (p < 0.001). Forty-eight-hour transfusions (11 vs. 16, p = 0.01) and mortality (35% vs. 48%, p = 0.04) were reduced in the PW group compared with the DEV group. Pathway adherence was identified as an independent predictor of both decreased transfusions (β = −5.8, p = 0.002) via multiple linear regression and decreased mortality (hazard ratio, 0.74; 95% confidence interval, 0.42–0.98) via multivariable cox proportional hazards analysis. CONCLUSION Adherence to a defined clinical PW simplified the management of exsanguinating pelvic fractures and contributed to a reduction in both transfusion requirements and mortality. LEVEL OF EVIDENCE Prognostic, level III.

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

“…Most recently, they reported on 128 hypotensive and severely injured PPP patients who sustained a 21% all-cause mortality rate. This compares favorably to the 32% rate reported by the 2015 AAST multicenter study, 2 a 41% mortality rate reported after AE alone, 63 an algorithm-driven management protocol study with a 35% mortality rate, 64 and a study prioritizing hemostatic resuscitation with a 37% mortality rate. 65 A recent analysis of the Trauma Quality Improvement Program database compared hemodynamically unstable pelvic fractures treated with PPP to with treated with zone 3 REBOA and found improved survival with PPP (37.3% vs. 52.0%, p = 0.048).…”

Increasing the Threshold to Perform Preperitoneal Pelvic Packing Decreases Morbidity Without Affecting Mortality

“…In comparison, Tesoriero et al 1 reported a mortality rate of 27.8% in 151 patients treated with angiography, 17.0% of which also underwent PPP. Similarly, Lewis et al 2 reported a 35.0% mortality rate in 246 patients treated under a protocol that prioritized angiography with 24.0% undergoing AE and 6.5% undergoing RT. A large multicenter prospective observational study reported a 32.0% mortality rate in 178 patients; AE was used in 16.9%, PPP in 5.6%, and REBOA in 2.8%.…”

“…Despite modern advancements in clinical pathways, resuscitation strategies, and interventions, such as angioembolization (AE) and resuscitative endovascular balloon occlusion of the aorta (REBOA), patients with pelvic ring injuries presenting with hemodynamic instability have a persistently high mortality, with rates in recent literature ranging from 28% to 35%. [1][2][3] The most common method for treating patients with pelvic ring injuries with hemodynamic instability at trauma centers in the United States is AE, however, at the investigators' institution, a protocol that prioritizes preperitoneal pelvic packing (PPP) has been in place since 2004 due to historical delays in AE and subsequent deaths by exsanguination. [1][2][3][4][5] This PPP protocol has been shown to be effective with a mortality rate of 21% and few patients dying from exsanguination.…”

“…[1][2][3] The most common method for treating patients with pelvic ring injuries with hemodynamic instability at trauma centers in the United States is AE, however, at the investigators' institution, a protocol that prioritizes preperitoneal pelvic packing (PPP) has been in place since 2004 due to historical delays in AE and subsequent deaths by exsanguination. [1][2][3][4][5] This PPP protocol has been shown to be effective with a mortality rate of 21% and few patients dying from exsanguination. 6 PPP is not without morbidity, however, as it has been shown to increase the risk of infection and venous thromboembolism (VTE).…”