Western Trauma Association Critical Decisions in Trauma

Tran, Thai Lan N.; Brasel, Karen J.; Karmy-Jones, Riyad; Rowell, Susan; Schreiber, Martin A.; Shatz, David V.; Albrecht, Roxie M.; Cohen, Mitchell J.; DeMoya, Marc; Biffl, Walter L.; Moore, Ernest E.; Namias, Nicholas

doi:10.1097/ta.0000000000001230

Cited by 78 publications

(38 citation statements)

References 36 publications

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“…However, until now it has not been analyzed whether the emergency treatment itself is effective and/or an independent risk factor for complications. Considering that current guidelines for treatment of hemodynamically unstable pelvic fractures recommend use of pelvic clamp and external fixation [13,14], the need for a clarification of this issue becomes obvious -also regarding a risk-benefit evaluation. Our data confirm recent studies [7] and show an absolute increase in mortality, infection-and complication rate in this population by 2.5-2.8 (crude odds).…”

Section: Discussionmentioning

confidence: 99%

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

Schmal

Larsen

Stuby

et al. 2019

Injury

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Background and purpose Unstable pelvic fractures frequently require emergency stabilization using a C-clamp or external (CC/EF) fixation. However, the effectiveness of this intervention and associated complications are still a matter of debate. Patients and methods The analysis used data available from the German Pelvic Trauma Registry to study general complications, infections and mortality after primary stabilization using CC/EF in 5,499 patients (n=957 with vs n=4,542 without). Furthermore, the subgroups with secondary surgery (n=713 vs n=1,695), and ilio-sacral screw implantation following C-clamp stabilization were evaluated (n=24 vs n=219). Calculated odds ratios were adjusted for potential confounders. Results Patients treated by CC/EF were younger (45±20 vs 62±24 years), had more C-type fractures (65% vs 28%), higher ISS (≥25 63% vs 20%) and displacement (≥3mm 81% vs 41%), and more complex fractures (32% vs 5%). These features were independent risk factors for complications (p<0.001). While mortality was reduced after CC/EF stabilization by 32% (OR 0.68 95%CI 0.49-0.95), the risk for general complications was slightly increased (OR 1.25 95% CI 1.02-1.53). In patients undergoing secondary surgery, CC/EF fixation had no influence on mortality, general complications or infections. Related to preceding C-clamp stabilization (OR 4.67 95% CI 1.06-20.64), the risk for infection increased from 3.2% to 20.8% in ilio-sacral screw fixation. Interpretation Primary stabilization of unstable pelvic fractures with C-clamp or external fixation is associated with a decreased mortality and was not an independent risk factor for complications after secondary surgery. However, the risk for infection after ilio-sacral screw fixation increased almost 5-fold after C-clamp use.

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Section: Discussionmentioning

confidence: 99%

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

Schmal

Larsen

Stuby

et al. 2019

Injury

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“…21,22 Guidelines from the Eastern Association for the Surgery of Trauma (EAST), published in 2011, recommend pursuing endovascular management for any hemodynamically unstable patient with hemorrhage related to pelvic fractures without significant bleeding from another source (Level I recommendation), while pre-peritoneal packing is recommended as salvage therapy after failure of endovascular therapy (Level III recommendation). 23 On the other hand, a more recent guideline from the Western Trauma Association (WTA), published in 2016, describes several “complimentary, and not mutually exclusive, options” including pelvic stabilization, pre-peritoneal packing, REBOA, and endovascular therapy, 24 without clear superiority of any one strategy. 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.…”

Section: Discussionmentioning

confidence: 99%

Multicenter retrospective study of noncompressible torso hemorrhage

Chang

Fox

Greene

et al. 2017

Journal of Trauma and Acute Care Surgery

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Objective Rational development of technology for rapid control of non-compressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) versus open (OPEN) management. Methods Retrospective study of adult trauma patients with NCTH admitted to 4 urban level 1 trauma centers in the Houston and San Antonio metropolitan areas in 2008–2012. Inclusion criteria: named axial torso vessel disruption, AIS chest or abdomen ≥3 with shock (base excess <−4) or truncal operation in ≤90 minutes, or pelvic fracture with ring disruption. Exclusion criteria: isolated hip fractures, falls from standing, or prehospital CPR. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, ISS, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients. Results 543 patients with NCTH underwent ENDO (n=166, 31%), OPEN (n=309, 57%), or RT (n=68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, while OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs 34% vs 32%); severe injuries (median ISS 34 vs 27 vs 21), and increased time to intervention (median 298 vs 92 vs 51 min), compared to OPEN and RT. Mortality was 15% vs 20% vs 79%. ENDO was associated with decreased mortality compared to OPEN (RR 0.58, 95% CI 0.46–0.73). Conclusion Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding. Level of Evidence Level V (Prognostic and Epidemiologic)

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“…Computerised tomography (CT) is also useful to determine bone, organ, soft tissue injury, and active bleeding shown as “blush” using CT angiogram with contrast, but should be avoided in a patient who is in extremis and should be performed after the patient has been stabilised ( 1 , 4 , 7 , 16 , 21 , 22 , 32 , 38 ).…”

Section: Managementmentioning

confidence: 99%

“…The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) is also a controversial temporising measure to manage haemorrhagic shock prior to gaining definitive haemostasis which requires access to the operating theatre and interventional radiology (which can sometimes take time to activate) ( 32 , 39 ). Temporary fracture stabilisation, angioembolisation, and extraperitoneal packing (EPP) are used to manage the haemorrhagic phase for patients with pelvic ring fractures ( 22 , 32 – 34 , 40 – 42 ), however the technique and the order in which they are applied is determined by the surgeon, resources, and institution. In addition to these management options soft tissue injuries to the perineum, genitals, bladder, and bowel need to be considered and managed in patients with open pelvic fractures, complicating the treatment, and decision making in this group of patients.…”

Section: Managementmentioning

confidence: 99%

“…The Western Trauma Association (WTA) algorithm for the management of pelvic fractures with haemodynamic instability was published in 2008 and has become the mainstay for management of these patients. This modern evidence-based approach encompasses a multidisciplinary team approach involving input from trauma surgeons, orthopaedic surgeons interventional radiologists, plastic surgeons, urological surgeons, wound-care nurses, and rehabilitation physicians to optimise outcome through the co-ordination and prioritisation of care, from evaluation, to stabilisation and treatment of the polytraumatised patient ( 21 , 22 ).…”

Section: Introductionmentioning

confidence: 99%

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The Road to Survival for Haemodynamically Unstable Patients With Open Pelvic Fractures

Watkins

Hsu

2020

Front. Surg.

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Management of haemodynamically unstable pelvic ring injuries has been simplified into treatment algorithms to streamline care and emergent decision making in order to improve patient outcomes whilst decreasing mortality and morbidity. Pelvic ring injuries are most commonly a result of high-velocity and energy forces that exert trauma to the pelvic bones causing not only damage to the bone but the surrounding soft-tissue, organs, and other structures and are usually accompanied by injuries to other parts of the body resulting in a polytraumatised patient. Open pelvic fractures are a rare subset of pelvic ring fractures that are on the more severe end of the pelvic fracture continuum and usually produce uncontrolled haemorrhage from fractured bone, retroperitoneal haematomas, intraabdominal bleeding from bowel injury, soft tissue injuries to the anus, perineum, and genitals, fractures of the pelvic bones, causing bleeding from cancellous bone, venous, and arterial injuries combined with bleeding from concomitant injuries. This is a very complex and challenging clinical situation and timely and appropriate decisions and action are paramount for a positive outcome. Consequently, open pelvic fractures have an extremely high rate of mortality and morbidity and outcomes remain poor, despite evidence-based improvements in treatment, knowledge, and identification of haemorrhage; in the pre-hospital, critical care, and operative settings. In the future utilisation of haemostatic drugs, dressings, devices, and procedures may aid in the time to haemorrhage control.

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Western Trauma Association Critical Decisions in Trauma

Cited by 78 publications

References 36 publications

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

Multicenter retrospective study of noncompressible torso hemorrhage

The Road to Survival for Haemodynamically Unstable Patients With Open Pelvic Fractures

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