Scoring system to predict hemorrhage in pelvic ring fracture

Prolonged ileus in traumatic pelvic ring injury patients who underwent arterial angio-embolization: A retrospective study

Paralytic ileus occurs in up to 18% of the patients with pelvic bone fractures. The aim of this study is to determine if massive bleeding requiring arterial angio-embolization is related with the duration of ileus in patients with traumatic pelvic ring injuries. This retrospective study included 25 patients who underwent arterial angio-embolization for traumatic pelvic ring injuries. Data were collected from prospectively maintained databases of two independent hospitals. Demographic characteristics (such as age, sex, body mass index, and Charlson Comorbidity Index), cause of trauma, and severity of pelvic injuries were similar in the non-prolonged and prolonged ileus groups. As expected, the prolonged ileus group had a significantly longer duration of ileus than the non-prolonged ileus group (8.0 ± 4.2 days vs 1.2 ± 0.4 days, respectively; P < .001). The mortality rate was higher in the prolonged ileus group (20% vs 0%), but it was not significantly different (P = .13). Interestingly, the prolonged ileus group received significantly higher amounts of packed red blood cell transfusions (6.1 ± 2.1 units vs 3.8 ± 2.5 units; P = .02). The amount of packed red blood cell transfusions was associated with a greater risk of prolonged ileus development (P = .03, odds ratio = 2.04, 95% confidence interval = 1.08-3.88). This study supports the idea that the duration of the ileus is related with the amount of bleeding caused by the traumatic pelvic ring injury. In order to prevent further complications, conservative treatments of the ileus should be considered.

Predictors of transfusion in trauma and their utility in the prehospital environment: a scoping review

Background: Hemorrhage is a leading cause of preventable mortality from trauma, necessitating resuscitation through blood product transfusions. Early and accurate identification of patients requiring transfusions in the prehospital setting may reduce delays in time to transfusion upon arrival to hospital, reducing mortality. The purpose of this study is to characterize existing literature on predictors of transfusion and analyze their utility in the prehospital context.Objectives: The objectives of this study are to characterize the existing quantity and quality of literature regarding predictor scores for transfusion in injured patients, and to analyse the utility of predictor scores for massive transfusions in the prehospital setting and identify prehospital predictor scores for future research.Methods: A search strategy was developed in consultation with information specialists. A literature search of OVID MEDLINE from 1946 to present was conducted for primary studies evaluating the predictive ability of scoring systems or single variables in predicting transfusion in all trauma settings.Results: Of the 5824 studies were identified, 5784 studies underwent title and abstract screening, 94 studies underwent full text review, and 72 studies were included in the final review. We identified 16 single variables and 52 scoring systems for predicting transfusion. Amongst single predictor variables, fluids administered and systolic blood pressure had the highest reported sensitivity (100%) and specificity (89%) for massive transfusion protocol (MTP) activation respectively. Amongst scoring systems for transfusion, the Shock Index and Modified Shock Index had the highest reported sensitivity (96%), while the Pre-arrival Model had the highest reported specificity (95%) for MTP activation. Overall, 20 scores were identified as being applicable to the prehospital setting, 25 scores were identified as being potentially applicable, and seven scores were identified as being not applicable.Conclusions: We identified an extensive list of predictive single variables, validated scoring systems, and derived models for massive transfusion, presented their properties, and identified those with potential utility in the prehospital setting. By further validating applicable scoring tools in the prehospital setting, we may begin to administer more timely transfusions in the trauma population.

Multi-center Retrospective Study of Factors Affecting Perioperative Transfusion of Packed Red Blood Cells for Pelvic Fracture Patients

Objective

To analyze the use of packed red blood cells (PRBCs) for patients with pelvic fracture and evaluate factors associated with PRBC transfusion for patients with pelvic fracture.

Methods

This retrospective cohort study collected 551 patients with pelvic fractures from six hospitals between September 1, 2012, and June 31, 2019. The age span of patients varied from 10 to 95 years old, and they were classified into two groups based on high‐energy pelvic fractures (HE‐PFs) or low‐energy pelvic fractures (LE‐PFs). The study's outcome was the use of PRBCs, fresh frozen plasma (FFP), and albumin. Demographic data, characteristics, laboratory tests, clinical treatment details, and clinical outcomes were compared between the two groups. Factors that were statistically associated with perioperative PRBCs in univariate analyses were included to conduct an optimal scale regression to determine the independent factors for perioperative PRBCs.

Results

A total of 551 patients were screened from six hospitals, and after inclusion and exclusion, 319 were finally included and finished the follow‐up from admission to discharge, while four patients died during hospitalization. Three hundred and nineteen patients were classified into two groups by their injury mechanisms. A total of 230/319 (72.1%) patients were classified into the HE‐PF group, and 89/319 (27.8%) patients were classified into the LE‐PF group. Patients in the HE‐PF group were transfused with 4.5 (3–8) units of PRBCs, 300 (0–600) ml of FFP, and 0 (0–30) g of albumin, while patients in the LE‐PF group were transfused with 3.5 (2–4.5) units of PRBCs, 0 (0–295) ml of FFP, and 0 (0–0) g of albumin (all P < 0.001). There were higher proportions of male patients and patients under 65 in the HE‐PF group (all P < 0.001). HE‐PF group patients were more severely injured and likely to take external fixation. The optimal scale regression revealed four significant factors associated with perioperative transfused PRBCs, which were patients on admission with hemorrhagic shock (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.148, P = 0.039), and methods of pelvic fixation (importance = 0.008, P = 0.026), ranked by the importance.

Conclusion

Patients with HE‐PFs had increased transfusions of PRBCs, FFP, and albumin, and hemorrhagic shock on admission, Tile classification, Hb levels, and stabilization methods were found to be associated with perioperative PRBCs.

Risk Factors for Mortality Associated With Pelvic Fractures at a Level I Trauma Center

Pelvic bone fractures are usually caused by high-energy trauma and are often accompanied by organ injuries. For hemodynamically unstable patients with pelvic bone fractures, knowing the anatomic type of fracture-whether it is a pelvic ring injury or an acetabular fracture-might be helpful in prioritizing treatment. A total of 302 patients with pelvic bone fractures who received treatment at the authors' level I trauma center between March 1, 2015, and February 28, 2017, were included in this study. Patients with pelvic bone fractures were enrolled in the Korea Trauma Data Bank and classified by anatomic type of pelvic bone fracture: pelvic ring injury, acetabular fracture, or combined fractures. The authors used t tests to analyze survival and death groups and multivariate regression to analyze mortality factors. Different types of pelvic bone fractures had significantly different mortality rates (P<.001). Forty-four (22.6%) of 195 patients with pelvic ring injuries and 6 (18.8%) of 32 patients with combined fractures died. Meanwhile, only 1 of 75 patients with isolated acetabular fractures died (1.3%). The mortality rate was lowest for type A pelvic ring injuries (8.2%) and highest for type C pelvic ring injuries (68.2%). The difference was statistically significant (P<.001). It is commonly acknowledged that age, combined injuries, higher Injury Severity Score, and lower initial systolic blood pressure are risk factors for mortality, but research has shown that classification and anatomic type of pelvic bone fracture are also highly related. [Orthopedics. 2021;44(6):e724-e728.].

A nomogram to predict arterial bleeding in patients with pelvic fractures after blunt trauma: a retrospective cohort study

Background

Pelvic bone fractures are one of the biggest challenges faced by trauma surgeons. Especially, the presence of bleeding and hemodynamic instability features is associated with high morbidity and mortality in patients with pelvic fractures. However, prediction of the occurrence of arterial bleeding causing massive hemorrhage in patients with pelvic fractures is difficult. Therefore, the aim of this study was to develop a nomogram to predict arterial bleeding in patients with pelvic bone fractures after blunt trauma.

Methods

The medical records of 1404 trauma patients treated between January 2013 and August 2017 were retrospectively reviewed. Patients older than 15 years with a pelvic fracture due to blunt trauma were enrolled (n = 148). The pelvic fracture pattern on anteroposterior radiography was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) system. Multivariable logistic regression modeling was used to determine the independent risk factors for arterial bleeding. A nomogram was constructed based on the identified risk factors.

Results

The most common pelvic fracture pattern was type A (58.8%), followed by types B (34.5%) and C (6.7%). Of the 148 patients, 28 (18.9%) showed pelvic arterial bleeding on contrast-enhanced computed tomography or angiography, or in the operative findings. The independent risk factors for arterial bleeding were a type B or C pelvic fracture pattern, body temperature < 36 °C, and serum lactate level > 3.4 mmol/L. A nomogram was developed using these three parameters, along with a systolic blood pressure < 90 mmHg. The area under the receiver operating characteristic curve of the predictive model for discrimination was 0.8579. The maximal Youden index was 0.1527, corresponding to a cutoff value of 68.65 points, which was considered the optimal cutoff value for predicting the occurrence of arterial bleeding in patients with pelvic bone fractures.

Conclusions

The developed nomogram, which was based on the initial clinical findings identifying risk factors for arterial bleeding, is expected to be helpful in rapidly establishing a treatment plan and improving the prognosis for patients with pelvic bone fractures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02247-2.

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Background

The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity.

Methods

Medical records of patients with pelvic fracture at a single center between January 2016 and December 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥ 3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups.

Results

Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p = 0.000) and total hospital stay (20.7 vs. 10.1 days, p = 0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear, and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I, and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p = 0.034). These findings were similar even if only patients with ISS ≥ 16 were considered.

Conclusions

Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to the outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.

Higher enhanced computed tomography attenuation value of the aorta is a predictor of massive transfusion in blunt trauma patients

Objective

Several scoring systems have been developed to identify patients who require massive transfusion (MT) after major trauma to improve survival. The primary goal of this study was to investigate the usefulness of enhanced computed tomography attenuation values (CTAVs) of major vessels to determine the need for MT in patients with major blunt trauma.

Methods

This single-center retrospective cohort study evaluated patients aged 16 years or older who underwent contrast-enhanced computed tomography scan of the torso after major blunt trauma. The CTAVs of six major vessel points in both the arterial and portal venous phases at initial computed tomography examination were assessed and compared between the MT and the no MT group. The capability of enhanced CTAVs to predict the necessity for MT was estimated based on the area under the receiver operating characteristic curve.

Results

Of the 254 eligible patients, 36 (14%) were in the MT group. Patients in the MT group had significantly higher CTAVs at all sites except the inferior vena cava in both the arterial and portal venous phases than that in the no MT group. The descending aorta in the arterial phase had the highest accuracy for predicting MT, with an AUROC of 0.901 (95% confidence interval, 0.855 to 0.947; P<0.001).

Conclusion

Initial elevation of enhanced CTAV of the aorta is a predictor for the need for MT. A higher CTAV of the aorta should alert the trauma surgeon or emergency physician to activate their MT protocol.

Hemostasis as soon as possible? The role of the time to angioembolization in the management of pelvic fracture

Introduction

While transcatheter arterial embolization (TAE) is an effective way to control arterial bleeding associated with pelvic fracture, delayed TAE may increase mortality risk. The purpose of the current study was to determine how time to TAE affects outcomes in patients with pelvic fracture in the emergency department.

Methods

From January 2014 to December 2016, the trauma registry and medical records of patients with pelvic fracture who underwent TAE were retrospectively reviewed. The relationship between the time to TAE and patient outcomes was evaluated. The characteristics of surviving and deceased patients were also compared to search for prognostic factors affecting survival.

Results

Eighty-four patients were enrolled in the current study. Among patients with pelvic fracture who underwent TAE, the overall mortality rate was 16.7%. There were positive relationships between the time to TAE and the requirement for blood transfusion and between the time to TAE and intensive care unit (ICU) length of stay (LOS). Nonsurviving patients were significantly older (57.4 ± 23.3 vs. 42.7 ± 19.3 years old, p = 0.014) and had higher injury severity scores (ISSs) (36.4 ± 11.9 vs. 23.9 ± 10.9, p < 0.001) than were observed in surviving patients. There was no significant difference in the time to TAE between nonsurviving and surviving patients (76.9 ± 47.9 vs. 59.0 ± 29.3 min, p = 0.068). The multivariate logistic regression analysis showed that ISS and age served as independent risk factors for mortality. Every one unit increase in ISS or age resulted in a 1.154- or 1.140-fold increase in mortality, respectively (p = 0.033 and 0.005, respectively). However, the time to TAE serves as an independent factor for ICU LOS (p = 0.015).

Conclusion

In pelvic fracture patients who require TAE for hemostasis, longer time to TAE may cause harm. An early hemorrhage control is suggested.

Contrast blush on CT is a poor predictor of active bleeding on pelvic angiography

Objective:

Determine if contrast extravasation (CE) on computed tomography (CT), also called CT blush, is a reliable predictor of clinically relevant arterial bleeding from pelvic ring injury.

Design:

Retrospective cohort.

Setting:

Single level I trauma center.

Patients/participants:

A total of 189 patients who underwent pelvic angiography between 1999 and 2015.

Intervention:

Demographic and injury data, including Young–Burgess fracture classification, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and clinical data including hypotension and heart rate upon presentation were recorded. Charts, radiographs, and interventional radiology reports and studies were reviewed.

Main outcome measurements:

CE on CT scan was noted from reports. Angiography studies were reviewed for active arterial bleeding.

Results:

Mean age was 49 years, with 64% male. CE was noted in 111 patients (66%), with increasing frequency over the study period. Patients under age 55 were less likely to have CE (P < .001). GCS was higher and ISS lower in patients with CE (both P < .05). For CE as predictor of active bleeding, sensitivity was 67%, specificity 34%, and positive predictive value (PPV) was 58% (P = .95). For CE as predictor of overall mortality, the sensitivity, specificity, and PPV were 67%, 33%, and 16%, respectively (P = 1.0). However, hypotension had sensitivity of 83% for active bleeding and 97% for mortality, both P < .001.

Conclusions:

While CT blush was neither a sensitive nor specific predictor of active bleeding on pelvic angiography, hypotension was a sensitive indicator of both bleeding and mortality. These findings suggest that CE is not an independently sufficient indication for pelvic angiography.

Level of Evidence: Level III

Factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma: a retrospective study

Background

Blunt pelvic injuries are often associated with pelvic fractures and injuries to the rectum and genitourinary tract. Pelvic fractures can lead to life-threatening hemorrhage, which is a common cause of morbidity and mortality in trauma. Thus, early identification of patients with pelvic fractures at risk severe bleeding requiring urgent hemorrhage control is crucial. This study aimed to investigate early factors predicting the need for hemorrhage control in blunt pelvic trauma.

Methods

The medical records of 1760 trauma patients were reviewed retrospectively between January 2013 and June 2018. We enrolled 187 patients with pelvic fracture due to blunt trauma who were older than 15 years. The pelvic fracture pattern was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) classification. A multivariate logistic regression model was used to determine independent predictors of the need for pelvic hemorrhage control intervention.

Results

The most common pelvic fracture pattern was type A (54.5%), followed by types B (36.9%) and C (8.6%). Of 187 patients, 48 (25.7%) required pelvic hemorrhage control intervention. Hemorrhage control interventions were most frequently performed in patients with type B fractures (54.2%). Multivariate logistic regression analysis revealed that type B (odds ratio [OR] = 4.024, 95% confidence interval [CI] = 1.666–9.720, p = 0.002) and C (OR = 7.077, 95% CI = 1.781–28.129, p = 0.005) fracture patterns, decreased body temperature (OR = 2.275, 95% CI = 0.134–0.567, p < 0.001), and elevated serum lactate level (OR = 1.234, 95% CI = 1.061–1.435, p = 0.006) were factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma.

Conclusion

Patients with type B and C fracture patterns on the OTA/AO classification, hypothermia, or an elevated serum lactate level are at risk for bleeding and require pelvic hemorrhage control intervention.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0438-8) contains supplementary material, which is available to authorized users.

Internal Iliac Artery Embolization versus Silastic Loop Ligation for Control of Traumatic Pelvic Hemorrhage

Angioembolization versus open control of traumatic pelvic hemorrhage is debated. We sought to compare outcomes between angioembolization and open internal iliac artery occlusion. A 14-year retrospective review (2004–2017) was performed at our academic Level I trauma center. All pelvic hemorrhage patients who underwent internal iliac artery angioembolization or silastic loop ligation via laparotomy were compared for outcomes. Patient demographics included vital signs, mechanism, and injury severity score (ISS). Outcomes included mortality (%), operating room visits, reoperation for hemorrhage (%), transfusion burden (units), and infection (%). A total of 163 trauma patients matched for age, ISS, mechanism, and cavitary involvement were included for analysis. Compared with silastic loop ligation (n = 51, mean ISS = 32 ± 14), patients who underwent angioembolization (n = 112, mean ISS = 30 ± 8.9) demonstrated decreased mortality (23% vs 57%, P < 0.01), made fewer operating room trips (mean = 2.2 vs 3.6 trips, P < 0.01), made fewer trips for pelvic (2.8 vs 11%, P = 0.05) and nonpelvic-related bleeding (3.6 vs 22%, P < 0.01), used fewer blood products [packed red blood cells, fresh-frozen plasma, platelets, and cryoprecipitate] ( P < 0.01 for all), and indicated a trend toward fewer infections (5.7% vs 14%, P = 0.07). Internal iliac artery angioembolization demonstrates lower mortality, lower reoperation rates, decreased transfusion burden, and a trend toward fewer infections compared with silastic loop ligation.

Factors that influence the survival of unstable pelvic fracture in the acute phase

Background: The fatality rate of unstable pelvic fracture is still high (20–50%) due to acute phase hemorrhage or late multiple organ failure. The assurance for 100% survival in acute phase had been reported if the emergency room team have the right technique, right timing, and right protocol. The aim of this study was to evaluate and to date factors that influence the non-survival unstable pelvic fracture within 2x24 hours.Methods: This retrospective study was conducted in emergency unit of Dr. Soetomo General Hospital Surabaya during 2012–2016 for unstable pelvic fracture with unstable hemodynamic, without concomitant head or thoracic injury and admitted within 4 hours after the incident. All patients were handled according to the protocol for resuscitation and C-clamp insertion immediately. X-ray was taken after the insertion to check the C-clamp position and to confirm the diagnosis. The 2x24-hour data were taken whether the patient survive or not survive, including mean arterial pressure (MAP) pre-and post, heart rate (HR) pre-and post, and initial hemoglobin and platelet count. Data were analyzed with independent t-test and multiple regression analysis.Results: Twenty two patients were recorded as the inclusive criteria, separated into 17 survivors and 5 non-survivors. They were comprised of 14 males and 8 female patients, with an average of 31.9±15.3 years old. The MAP post, HR pre-and post, and platelet count were significantly different. The factor that influenced the survival within 2x24 hours was the MAP post C-clamp (>70 mmHg) (p<0.05).Conclusion: The acute phase 2x24-hour outcome after C-clamp insertion and resuscitation was significantly influenced by MAP post C-clamp and resuscitation.

Acute Management of the Traumatically Injured Pelvis

Severe pelvic trauma is a challenging condition. The pelvis can create multifocal hemorrhage that is not easily compressible nor managed by traditional surgical methods such as tying off a blood vessel or removing an organ. Its treatment often requires reapproximation of bony structures, damage control resuscitation, assessment for associated injuries, and triage of investigations, as well as multimodality hemorrhage control (external fixation, preperitoneal packing, angioembolization, REBOA [resuscitative endovascular balloon occlusion of the aorta]) by multidisciplinary trauma specialists (general surgeons, orthopedic surgeons, endovascular surgeons/interventional radiologists). This article explores this complex clinical problem and provides a practical approach to its management.