Trends and efficacy of external emergency stabilization of pelvic ring fractures: results from the German Pelvic Trauma Registry

Management of Pelvic Trauma

Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.

Team Approach: The Unstable Trauma Patient

» A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.» The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries» Effective and open dialog with consulting specialists is paramount for effective team-based care.» Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Developments in the understanding of staging a "major fracture" in polytrauma: results from an initiative by the polytrauma section of ESTES

PURPOSE

Although the term "major fracture" is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of "major fractures" has changed and is modified by a better understanding of patient physiology.

METHODS

A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades.

RESULTS

4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000.

CONCLUSION

Over time, the way "major fractures" influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.

Effect of C-Clamp Application on Hemodynamic Instability in Polytrauma Victims with Pelvic Fracture

Background and Objectives: C-clamp application may reduce mortality in patients with unstable pelvic fractures and hemodynamic instability. Decreasing C-clamp use over the past decades may have resulted from concerns about its effectiveness and safety. The purpose of this study was to document effective hemodynamic stabilization after C-clamp application by means of vital parameters (primary outcome parameter), and the subsequent effect on metabolic indices and volume management (secondary outcome parameters). Materials and Methods: C-clamp application was performed between 2014 and 2021 for n = 13 patients (50 ± 18 years) with unstable pelvic fractures and hemodynamic instability. Vital parameters, metabolic indices, volume management, and the correlation of factors and potential changes were analyzed. Results: After C-clamp application, increases were measured in systolic blood pressure (+15 mmHg; p = 0.0284) and mean arterial pressure (+12 mmHg; p = 0.0157), and a reduction of volume requirements (p = 0.0266) and bolus vasoactive medication needs (p = 0.0081) were observed. The earlier C-clamp application was performed, the greater the effect (p < 0.05; r > 0.6). Heart rate, shock index, and end-tidal CO2 were not significantly altered. The extent of base deficit, hemoglobin, and lactate did not correlate with changes in vital parameters. Conclusions: In the majority of hemodynamically unstable trauma patients not responding to initial fluid resuscitation and severe pelvic fracture, early C-clamp application had an additive effect on hemodynamic stabilization and reduction in volume substitution. Based on these findings, there is still a rationale for considering early C-clamp stabilization in this group of severely injured patients.

Comparison between external fixation and pelvic binder in patients with pelvic fracture and haemodynamic instability who underwent various haemostatic procedures

Haemostatic procedures such as preperitoneal pelvic packing (PPP), pelvic angiography (PA), and internal iliac artery ligation are used for haemorrhage control in pelvic fracture patients with haemodynamic instability. Pelvic external fixation (PEF) and pelvic binder (PB) are usually applied with haemostatic procedures to reduce the pelvic volume. This study aimed to compare the clinical outcomes between patients who underwent PEF and PB. Among 173 patients with pelvic fracture admitted to the emergency room of three regional trauma centres between January 2015 and December 2018, the electronic charts of haemodynamically unstable patients were retrospectively analysed. Among the 84 patients included in the analysis, 20 underwent PEF with or without PB, and 64 underwent only PB. There were significant differences in tile classification and laparotomy between the PEF and PB groups (p = 0.023 and p = 0.032). PPP tended to be more frequently preformed in the PEF group (p = 0.054), whereas PA tended to be more commonly performed in the PB group than in the PEF group (p = 0.054). After propensity score matching to adjust for differences in patient characteristics and adjunct haemostatic procedure, there was no significant difference in 7-day, 30-day, and overall mortality rates between the PEF and PB groups (10.5% vs 21.1%, p = 0.660, 21.1% vs 26.3%, p = 1.000, and 26.3% vs 26.3%, p = 1.000). Cox proportional hazard regression analysis and multivariate analysis for correction of covariates (age, lactate, and abdominal injury) showed that PEF was not an independent factor for 30-day mortality compared with PB (adjusted hazard ratio, 0.526; 95% confidence interval, 0.092-3.002; p = 0.469). Among the volume reduction procedures performed with other haemostatic procedures in patients with pelvic fracture and haemodynamic instability, PEF did not significantly reduce the 30-day mortality rate compared to PB.

Causes of death and characteristics of non-survivors rescued during recreational mountain activities in Japan between 2011 and 2015: a retrospective analysis

OBJECTIVES

This study aimed to describe the cause of death and characteristics at the prehospital setting associated with care and rescue processes of non-survivors rescued in the mountain of Japan.

DESIGN

Retrospective analysis.

SETTING

Prehospital setting of mountain searches and rescues in Japan. A total of 10 prefectural police headquarters with >10 cases of mountain death from 2011 to 2015.

PARTICIPANTS

Data were generated from the existing records. Of the total 6159 rescued subjects, 548 mountain deaths were caused by recreational activities.

RESULTS

Among the 548 mountain deaths, 83% were men, and major causes of death were trauma (49.1%), hypothermia (14.8%), cardiac death (13.1%) and avalanche-related death (6.6%). The alive rate at rescue team arrival in all non-survivors was 3.5%, with 1, 4 and 14 cases of cardiac, hypothermia and trauma, respectively. Cardiac deaths occurred in 93.1% (67/72) of men and individuals aged >41 years, and 88.7% (63/71) were found on mountain trails. In hypothermia, callouts were made between 17:00 and 6:00 at 49% (40/81) and by persons not on-site in 59.7% (46/77). People with >6 hours in trauma or >1 hour in cardiac death already died on rescue team arrival, but some with hypothermia after 6 hours were alive.

CONCLUSION

This study is one of the first large-scale retrospective analyses of prehospital non-survivors in mountain emergencies. The alive rate at rescue arrival in all mountain deaths was only 3.5%. These data showed that the circumstances related to onset and the process until the rescue team arrives have different characteristics, depending on the cause of death. Survival may be enhanced by targeting better use of the time before rescue team arrival and by providing further education, particularly mountain rescue-related medical problems to rescuers including bystanders.

Comparison of pelvic C-clamp and pelvic binder for emergency stabilization and bleeding control in type-C pelvic ring fractures

Severe bleeding is the major cause of death in unstable pelvic ring fractures. Therefore, a quick and efficient emergency stabilization and bleeding control is inevitable. C-clamp and pelvic binder are efficient tools for temporary bleeding control, especially from the posterior pelvic ring. Yet the C-clamp requires more user knowledge, training and equipment. However, whether this makes up for a more efficient bleeding control, is still under debate. Patients with a type-C pelvic ring fracture were identified from the German Pelvic Registry (GPR) and divided into three groups of 40 patients (1. no emergency stabilization, 2. pelvic binder, 3. C-clamp). The matching occurred according to the parameters age, gender, initial RR and initial HB. Complication-and mortality rates were compared especially regarding bleeding control. Regarding ISS and fracture dislocation there was no difference. The use of the C-clamp resulted in more complications, a higher mortality rate due to severe bleeding and more blood transfusions were admitted. Moreover the pelvic binder was established noticeably faster. However, the C-clamp was more often rated as effective. There is no evidence of advantage comparing the C-clamp to the pelvic binder, regarding bleeding control in type-C pelvic ring fractures. In fact, using the pelvic binder even showed better results, as the time until established bleeding control was significantly shorter. Therefore, the pelvic binder should be the first choice. The C-clamp should remain a measure for selected cases only, if an adequate bleeding control cannot be achieved by the pelvic binder.

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

How effective are different models of pelvic binders: results of a study using a Pelvic Emergency Simulator

BACKGROUND

The application of pelvic binders in the preclinical and early clinical phase is advisable to avoid or treat C-problems in unstable and potential bleeding pelvic ring fractures, even if the clinical effectivity is not completely proved. The use for pathologies in the posterior pelvic ring is still debatable.

QUESTIONS/PURPOSES

We determined if there is a difference in achievable compression in the dorsal pelvic ring depending on position and pelvic binder model. Can this effect be tested with a simplified artificial model?

METHODS

We simulated a Tile type C fracture within the established pelvic emergency trainer and measured in a test series the effectivity of reduction with a non-invasive stabilization technique using 3 different pelvic binders.

RESULTS

Any therapeutic effect of a pelvic binder with compression to the posterior pelvic ring requires at first a reduction maneuver. While the compression effect in the symphysis depends only on positioning of the binder, in the posterior pelvic ring, the result varies with the used model. The achievable pressure in the SI joint with a pelvic binder is only 20-25% (33.5-47 N) compared to the C-Clamp values (156 N).

CONCLUSIONS

The use of pelvic binders for non-invasive pelvic ring stabilization, even with a posterior pathology, could be proven in a simplified fracture model. A proper fracture reduction and an adequate device positioning influence the effectiveness.

CLINICAL RELEVANCE

The use of an emergency pelvic trainer even for a non-invasive maneuver is advisable.