Mortality in trauma patients with active arterial bleeding managed by embolization or surgical packing: An observational cohort study of 66 patients

Froberg, Lonnie; Helgstrand, Frederik; Clausen, Caroline; Steinmetz, Jacob; Eckardt, Henrik

doi:10.4103/0974-2700.185274

Cited by 15 publications

(9 citation statements)

References 45 publications

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“…Marzi et al [16] conducted a literature review on pelvic fracture management in 2009 and concluded that pelvic packing should be used for hemodynamically unstable patients who do not respond to resuscitative fluids and those requiring continuous fluids to maintain hemodynamic stability. Many studies [9, 11, 16–18] have compared PP to angioembolization as a treatment modality, leading to some [4, 15, 19–21] concluding that that the two approaches should not be compared and should instead be viewed as complementary. In 2018, Muntasar et al [9] found insufficient evidence to support superiority of one treatment modality over the other.…”

Section: Discussionmentioning

confidence: 99%

Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers

et al. 2019

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BackgroundMortality from hemodynamically unstable pelvic fractures remains high. Guidelines offer varying care approaches including the use of pelvic packing (PP), which was recently adopted for potential control of bleeding for this condition. However, the implementation of PP is uncertain as the debate on the optimal resuscitation strategy, angioembolization or PP continues. The study was designed to assess current practices among level 1 trauma centers in the US in regard to PP treatment for hemodynamically unstable pelvic fractures.MethodsA cross-sectional survey was created to assess when to apply PP, application approach, and the respondent’s anecdotal perception on safety and effectiveness. Trauma Medical Directors at 158 US level 1 trauma centers were sent biweekly email invitations for 3 months. Participants were allowed to skip questions for any reason. The study hypothesis was that PP practices vary by US census bureau region, annual trauma admissions, and length of time in years since each trauma center received their respective level 1 trauma center designation.ResultsTwenty-five percent (40/158) of trauma medical directors participated and 75% (118/158) of the trauma medical directors did not participate. Of those who took the survey, 36/40 (90%) completed the survey and 4/40 (10%) partially completed the survey. Only 36 trauma medical directors responded on their perception of safety and effectiveness; 72% (26/36) of participants perceived PP as safe, whereas only a third (12/36) of participants perceived PP as effective. There were 25 trauma medical directors who provided the sequence of treatment modalities utilized at their level 1 trauma center, 76% (19/25) of participants reported that PP is utilized as the third or fourth priority. None of the participating level 1 trauma centers reported a preference towards utilization of PP as the first priority treatment. Half of the participants reported a preference towards applying PP only as a last resort to control hemorrhage. Northeastern and Western level 1 trauma centers were significantly more likely than Midwestern and Southern level 1 trauma centers to have reported application of PP to all hemodynamically unstable patients (p = 0.05). Midwestern, Southern, and Western level 1 trauma centers were significantly more likely to have perceived PP as safe than Northeastern level 1 trauma centers (p = 0.04). All low-volume and 38% high-volume level 1 trauma centers perceived PP to increase infection risks, (p = 0.03). We observed no association between the length of time each trauma center was designated a level 1 trauma center, and all participant responses.ConclusionControversy and varying anecdotal perception regarding safety and effectiveness of PP prevails among trauma medical directors at level 1 trauma centers in the US.

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Section: Discussionmentioning

confidence: 99%

Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers

et al. 2019

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“…Transfusion is an imperative method to resuscitate patients and is an indispensable step within peri-operation. There were 10 studies comparing preoperative transfusion between PP and AE [3,21,22,[24][25][26][27][28][29][30] and two studies on PP and REBOA [31,32] , which showed much more transfusion in PP group than in EI group (MD=2.53, 95% CI [0.01, 5.06], Fig. 3).…”

Section: Basic Characteristics Of Included Patientsmentioning

confidence: 99%

“…After reviewing the full text, 15 studies met the inclusion criteria in the meta-analysis [3,5,[21][22][23][24][25][26][27][28][29][30][31][32][33]. All studies had a low risk of bias for selective blinding.…”

Section: Systematic Literature Searchmentioning

confidence: 99%

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

Zhang

et al. 2022

Preprint

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Background: Pelvic fractures in trauma patients can be associated with substantial massive hemorrhage. Mainly hemostasis interventions consist of pelvic packing (PP) and endovascular intervention (EI), such as angiography-embolization (AE) and resuscitative endovascular balloon occlusion of the aorta (REBOA). Whether PP or EI should be given priority for the management of hemodynamic unstable patients with pelvic fractures is still under debate. This meta-analysis aims to find out the evidence-based recommendations to fill the gap in literature. Materials and Methods: PubMed, CENTRAL, and EMBASE was searched for articles published from Jan 1st, 2000 to Jan 31st, 2022. Eligible studies, such as retrospective cohort study, propensity score matching studies, prospective cohort study, observational cohort study, quasi-randomized clinical trial evaluating PP and EI (AE or REBOA) managing patients with hemodynamically unstable pelvic fractures, were included. Mean Difference (MD), relative risk (RR), and 95% confidence intervals (CI) were calculated employing fixed- or random-effects models depending on the heterogeneity of included trials. This meta-analysis was performed to compare the effectiveness of the two methods in terms of mortality, unstable fracture pattens, Injury Severity Score (ISS), systolic blood pressure (SBP), lactate (LA), base deficiency (-BE), hemoglobin preoperatively, blood transfusion requirement, the time to and of operation, the complications.Results: 15 trials enrolling 1,136 patients were analyzed with the total mortality of 28.4% (323/1136). In our study, there was no effect of PP preference on the ISS (PP 36.4±10.4 vs. EI 34.5±12.7,), SBP (PP 81.1± 24.3 mmHg vs. EI 94.2±32.4 mmHg), LA (PP 4.66±2.72 mmol/L vs. 4.85±3.45 mmol/L), BE (PP 8.14±5.64 mmol/L vs. 6.66±5.68 mmol/L), unstable fracture pattens (RR=1.10, 95% CI [0.63, 1.92]). The application of PP was associated with lower preoperative hemoglobin level(PP 8.11±2.28 g/dl vs. EI 8.43±2.43 g/dl, p<0.05), more preoperative transfusion(MD=2.53, 95% CI [0.01, 5.06]), less postoperative transfusion within first 24 hours(MD=-1.09, 95% CI [-1.96, -0.22]), shorter waiting time to intervention(MD=-0.93, 95% CI [-1.54, -0.31]), shorter operation time of intervention(MD=-0.41, 95% CI [-0.52, -0.30]). PP has lower mortality rate due to uncontrolled hemorrhage in the acute phase (RR= 0.41, 95% CI [0.22, 0.79]). There is neither difference on mortality due to other complications (RR=1.60, 95% CI [0.79, 3.24]), nor total mortality (RR=0.92, 95%CI [0.49, 1.74]) (p>0.05).Conclusions: We firstly reached a conclusion that PP, a reliable hemostatic method, had advantages of reducing the amount of postoperative transfusion, shortening the time of waiting and operating and decreasing the mortality due to uncontrolled hemorrhage in the acute phase, without raising the odds of mortality due to complications. PP should be given a high priority in resuscitating the most pelvic fractures with hemodynamically unstable, especially in case of bleeding from veins and fracture sites, as well as inadequate EI. Sometimes AE should be regarded as a complementary treatment in case of the relative stable branch artery injury, the recurrent hypotension and ongoing hypotension after PP. REBOA is recommended in temporally transporting the hemorrhagic shock patients and stopping fatal bleeding from the main artery or multiple-sources.

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“…All the above considerations must take into account the possible disadvantages in the transportation of a severely injured patient to the angiographic room [ 57 ]. However, the increasingly widespread use of hybrid OR, where trauma surgeons, orthopedic surgeons, and interventional radiologists can work together, is progressively enabling the simultaneous or alternate performance of the initial assessment, resuscitation, damage control surgery, and endovascular procedures, without the need to transfer the patient to the radiological room or the OR [ 9 ].…”

Section: Treatment For Hemorrhage In Pelvic Fracture: State Of the Artmentioning

confidence: 99%

Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma

et al. 2021

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Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.

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Mortality in trauma patients with active arterial bleeding managed by embolization or surgical packing: An observational cohort study of 66 patients

Cited by 15 publications

References 45 publications

Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers

Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers

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

Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma

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