Preperitoneal pelvic packing in patients with hemodynamic instability due to severe pelvic fracture: early experience in a Korean trauma center

Abstract

Background: The mortality rate of patients with hemodynamic instability due to severe pelvic fracture is reported to be 40-60 % despite a multidisciplinary treatment approach. Angioembolization and external fixation of the pelvis are the main procedures used to control bleeding in these patients. Several studies have shown that preperitoneal pelvic packing (PPP) is effective for hemorrhage control, despite being small and observational in nature. The purpose of this study was to describe a Korean trauma center's early experience with PPP in unstable patients with pelvic fractures and to evaluate its effectiveness. Methods: Between January 2012 and May 2015, 30 patients with hemodynamic instability caused by pelvic fracture were enrolled in this study. PPP has been performed in 14 patients since May 2014. Data of pelvic fracture patients with hemodynamic instability were selected from Wonju Severance Christian Hospital Pelvic Trauma Database and were analyzed retrospectively. Results: Mean age and mean ISS were 60.4 ± 18.8 years and 39.2 ± 8.1 in 30 unstable patients with pelvic fracture. Mean SBP was 89.1 ± 24.7 mmHg, and mean hemoglobin was 10.6 ± 2.3 g/dL. When the non-PPP group (16 patients) and the PPP group (14 patients) were compared, there was no significant difference in the age, gender, ISS, and occurrence of associated injury (p = 0.82, p = 0.23, p = 0.92, and p = 0.60, respectively). Mortality rate due to acute hemorrhage were 37.5 % in the non-PPP group and 14.3 % in the PPP group. In the PPP group, three patients underwent PPP in the hybrid operating room, and a laparotomy was performed in three patients. Mean systolic blood pressure increased significantly after PPP (71.6 ± 9.8 vs. 132.2 ± 36.4 mmHg, p = 0.002). Conclusions: In unstable patients with pelvic fractures, PPP can be used as an effective treatment, complementary to AE, to control pelvic bleeding.

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

“…On multivariate analysis, PPP was a significant independent predictor for 24 hour survival. A similar reduction in mortality was identified with the institution of PPP, from 38% in the non-PPP group to a 14% mortality rate due to acute hemorrhage over a 3 year study (3). Interestingly, those who died due to acute hemorrhage in the PPP group had actually undergone angioembolization first only to require packing for ongoing hemorrhage and instability.…”

“…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.…”

“…Fracture classification of those who died included LC II (7), LC I (7), LC III (5), APC III (4), APC II (2), APC I (1), and CM (1). Death was due to traumatic brain injury (9), multiple organ failure (4), withdrawal of support by family (4), pulmonary failure (3), cardiac failure (3), refractory metabolic collapse (3), and invasive Mucor infection (1). Of those three (2%) patients with physiologic exhaustion, two died in the OR at 89 min and 100 minutes after hospital arrival while one died in the ICU 9 hours after arrival.…”

“…A similar finding was reported in a small study of 24 patients from China; time to packing was 79 minutes while time to angiography was 140 minutes (24). Time to emergency angiography in a Korean evaluation of PPP was 194 minutes compared to 55 minutes with operative intervention (3). Our group previously demonstrated that time to packing was significantly faster than time to angiography, with angiography taking three times longer despite interventional radiology availability at a level I trauma center (33).…”

Internal Iliac Artery Ligation with Pad Packing for Hemodynamic Unstable Open Comminuted Sacral Fracture

“…However, there is a lack of evidence addressing surgical ligation of the bilateral internal iliac arteries and this issue was not mentioned in the algorithm. Nowadays, pelvic stabilization, angioembolization, and PPP are widely used as treatment modalities for unstable pelvic fractures since the establishment of a regional trauma center in South Korea [4]. However, bilateral internal iliac artery ligation is not popular worldwide or in South Korea.…”