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

Abstract

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.

Multicenter retrospective study of noncompressible torso hemorrhage

“…A recent multicenter prospective observational study of 1,339 patients with pelvic fracture found that angioembolization and external pelvic fixation were the most common hemorrhage control techniques for arterial and venous bleeding respectively. 25 Whereas the subgroup with hemorrhagic shock had 32% mortality, a recent single-institution observational study by Burlew et al found that pre-peritoneal packing as first-line therapy for 128 patients with hemorrhagic shock from unstable pelvic fractures was associated with mortality of only 21%, 26 challenging the notion that pre-peritoneal packing should be relegated to salvage therapy. In the present study, mortality in patients with hemorrhagic shock from pelvic hemorrhage was 27%.…”

Prehospital use of pelvic circumferential compression devices in a physician-based emergency medical service: A 6-year retrospective cohort study

“…Disruption of the pelvic ring not only acts as a marker for the high amount of kinetic energy absorbed by the body at the time of impact but may also cause significant blood loss into the retroperitoneal space from fractured bone surfaces, disruption of the pelvic venous plexus, and/or torn branches of the internal iliac arteries 3,4 . Active arterial bleeding can be managed in the hospital either non-surgically with arterial angioembolization 5 or surgically with preperitoneal pelvic packing 6 , alone or in combination with arterial angioembolization 7,8 . While several studies have shown the effectiveness of PCCDs in terms of fracture reduction [9][10][11] , data on their hemodynamic efficiency are lacking or controversial [12][13][14] .…”

Análise dos resultados do tratamento multidisciplinar de pacientes com fratura pélvica e choque, submetidos ao tamponamento extraperitoneal de pelve, no Hospital das Clínicas da FMUSP

“…A presença de lesão abdominal associada, com necessidade de laparotomia exploradora (LE), é relatada entre 50% e 77,77% pelas séries que publicaram os resultados do TXP (13,18,31,37) Vários estudos (13,20,30,37,40) demonstraram melhora significativa dos parâmetros hemodinâmicos e diminuição da necessidade de transfusões sanguíneas (9,13,18,20,36,40,42) (95) . A infusão de soluções intravenosas que contenham lactato pode confundir a interpretação da sua concentração, embora seja necessária uma quantidade muito grande destas soluções para causar tal efeito (96) .…”

“…O atendimento do paciente com fratura de pelve deve seguir a sequência de prioridades preconizada pelo ATLS e a presença de fratura pélvica deve ser considerada indicadora de trauma grave e múltiplo (11,20) . O tratamento possui quatro pilares: a) o diagnóstico rápido das possíveis causas de choque e fontes de sangramento, b) o controle de danos da reanimação volêmica utilizando protocolos de transfusão maciça, c) tratamento multidisciplinar da hemorragia pélvica e d) tratamento das lesões associadas.…”

“…Além disso, em fraturas Compressas preenchendo a pequena pelve expostas de pelve, o tamponamento com compressas da ferida se mostrou o único método eficaz para controlar sangramentos externos (8) . As vantagens deste procedimento e os resultados publicados permitem que o TXP seja recomendado por diversas diretrizes e consensos de sociedades de cirurgia do trauma como prioridade no controle da hemorragia pélvica nos pacientes com choque (8,20,32,33) . Entretanto, recente estudo multicêntrico com 11 centros de trauma norte-americanos evidenciou que o TXP foi realizado somente em 5,61% dos 178 pacientes admitidos com choque (12) .…”