Haemorrhage control in pelvic fractures--a survey of surgical capabilities

Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury

BACKGROUND

Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury.

METHODS

Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay.

RESULTS

In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching.

CONCLUSIONS

PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

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.

Role of pelvic packing in the first attention given to hemodynamically unstable pelvic fracture patients: a meta-analysis

PURPOSE

To evaluate the effectiveness of pelvic packing (PP) in pelvic fracture patients with hemodynamic instability.

MATERIALS AND METHODS

Three databases-PubMed, Embase and the Cochrane Library-were systematically searched to identify studies presenting comparisons between a protocol including PP and a protocol without PP. Mortality, transfusion requirement and length of hospitalization were extracted and pooled for meta-analysis. Relative risk (RR) and standard mean difference (SMD), along with their confidence intervals (CIs), were used as the pooled statistical indices.

RESULTS

Eight studies involving 480 patients were identified as being eligible for meta-analysis. PP usage was associated with significantly reduced overall mortality (RR = 0.61, 95% CI = 0.47-0.79, p < 0.01) as well as reduced mortality within 24 h after admission (RR = 0.42, 95% CI = 0.26-0.69, p < 0.01) and due to hemorrhage (RR = 0.26, 95% CI = 0.14-0.50, p < 0.01). The usage of PP also decreased the need for pre-operative transfusion (SMD = - 0.44, 95% CI = - 0.69 to - 0.18, p < 0.01), but had no influence on total transfusion during the first 24 h after admission (SMD = 0.05, 95% CI = - 0.43-0.54, p = 0.83) and length of hospitalization (ICU stay and total stay).

CONCLUSIONS

This meta-analysis indicates that a treatment protocol including PP could reduce mortality and transfusion requirement before intervention in pelvic fracture patients with hemodynamic instability vs. angiography and embolization. This latter technique could be used as a feasible and complementary technique afterwards.

LEVEL OF EVIDENCE: 3

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

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 (≥3 mm 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.

Damage control orthopaedics: State of the art

Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the “second hit” effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.

[Influence of external pelvic stabilization on hemodynamically unstable pelvic fractures]

BACKGROUND

In the treatment of complex pelvic fractures hemorrhage control is of primary importance; however, studies regarding the localization of bleeding are contradictory so that various treatment approaches are recommended. The primary aim of external pelvic compression applied in the trauma room is to reduce the pelvic volume and counteract blood loss through self-induced tamponade. This study examined the influence of external pelvic compression on mortality and outcome in cases of hemodynamically unstable pelvic fractures in a larger number of cases.

MATERIAL AND METHODS

The current study used the TraumaRegister DGU® (TR-DGU) to retrospectively evaluate the records of 104 patients treated between 2002 and 2011. All patients suffered severe injury with an injury severity score (ISS) of at least 16 points. In addition, the patients were hemodynamically unstable with confirmed relevant isolated pelvic injuries. To evaluate the effectiveness of external pelvic compression, patients with and without external pelvic stabilization were compared.

RESULTS

Of the investigated patients 26.9 % died of their injuries and of these the mortality was 78.6 % within the first 6 h of admission to the trauma room. External pelvic stabilization was performed in 45.2 % of patients. The mortality was 19.1 % in patients with external pelvic stabilization and in contrast, the mortality in the group of patients without external pelvic stabilization was 33.3 %. During the course of hospitalization, surviving patients with external pelvic stabilization were significantly more likely to develop sepsis or multiple organ failure and required longer periods of intensive care.

CONCLUSION

External pelvic stabilization seems to be an important instrument for the initial treatment of hemodynamically unstable pelvic fractures and showed a positive effect on patient mortality.

Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a Propensity Score Analysis

Background

An option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures. The aim of this study was to demonstrate the efficacy of early EPP in reducing mortality due to hemorrhage from pelvic fractures, and to evaluate the impact of packing on transfusion requirements within the first 24 h and ICU length of stay (ICU-LOS).

All data pertaining trauma patients admitted from October 2002 and December 2103 with hemodynamic instability and pelvic fractures were selected from the Hospital Trauma Registry. Patients with severe brain injury and bleeding from extra-pelvic sources were excluded. Patient population was divided into two groups: EPP group, including patients admitted from 2009 to 2013, with EPP as part of the treatment algorithm, and NO-EPP group, from 2002 to 2008, without EPP as atherapeutic option. Descriptive statistical analysis was performed on allpatients. Twenty-five patients of each group with similar features were matched using Propensity Score Analysis (PSA).

Results

Six hundred eighty out of 4659 major trauma (14.6 %) presented a pelvic fracture. In 78 hemodynamically unstable patients (30 in EPP group,48 in NO-EPP group) the major source of bleeding was the pelvis. Among patients selected by PSA early mortality was significantly reduced in EPP group (20 vs 52 %, p = .03) compared to NO-EPP, notwithstanding similar hemodynamic impairment. No difference was observed in transfusion requirements and ICU-LOS.

Conclusions

The EPP is a safe and quick procedure, able to improve hemodynamic stabilization and to reduce acute mortality due to hemorrhage in patients with pelvic fracture, in combination with optimized transfusion protocol. EPP may be useful as a bridge for time-consuming procedures, such as angio-embolization.

Resuscitation of Polytrauma Patients: The Management of Massive Skeletal Bleeding

The term ‘severely injured patient’ is often synonymous of polytrauma patient, multiply-injured patient or, in some settings, polyfractured patient. Together with brain trauma, copious bleeding is the most severe complication of polytrauma. Consequently hypotension develop. Then, the perfusion of organs may be compromised, with the risk of organ failure. Treatment of chest bleeding after trauma is essential and is mainly addressed via surgical manoeuvres. As in the case of lesions to the pelvis, abdomen or extremities, this approach demonstrates the application of damage control (DC). The introduction of sonography has dramatically changed the diagnosis and prognosis of abdominal bleeding. In stable patients, a contrast CT-scan should be performed before any x-ray projection, because, in an emergency situation, spinal or pelvic fractures be missed by conventional radiological studies. Fractures or dislocation of the pelvis causing enlargement of the pelvic cavity, provoked by an anteroposterior trauma, and in particular cases presenting vertical instability, are the most severe types and require fast stabilisation by closing the pelvic ring diameter to normal dimensions and by stabilising the vertical shear. Controversy still exists about whether angiography or packing should be used as the first choice to address active bleeding after pelvic ring closure. Pelvic angiography plays a significant complementary role to pelvic packing for final haemorrhage control. Apart from pelvic trauma, fracture of the femur is the only fracture provoking acute life-threatening bleeding. If possible, femur fractures should be immobilised immediately, either by external fixation or by a sheet wrap around both extremities.

Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques

BACKGROUND

Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge of the outcome of these techniques is currently based on limited information.

METHODS

Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding.

RESULTS

Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p=0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality.

CONCLUSIONS

The data suggest that emergency stabilization of the pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping.

LEVEL OF EVIDENCE

Level III.

Current management of severe pelvic and perineal trauma

Mortality associated with pelvic and perineal trauma (PPT) has fallen from 25% to 10% in the last decade thanks to progress accomplished in medical, surgical and interventional radiology domains (Dyer and Vrahas, 2006) [1]. The management strategy depends on the hemodynamic status of the patient (stable, unstable or extremely unstable). Open trauma requires specific treatment in addition to control of bleeding. All surgical centers can be confronted some day with patients with hemorrhagic PPT and for this reason, all surgeons should be familiar with the initial management. In expert centers, management of patients with severe PPT is complex, multidisciplinary and often requires several re-interventions. Obstetrical and sexual trauma, also requiring specific management, will not be dealt with herein.