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Ascenti V, Ierardi AM, Alfa-Wali M, Lanza C, Kashef E. Damage Control Interventional Radiology: The bridge between non-operative management and damage control surgery. CVIR Endovasc 2024; 7:71. [PMID: 39358662 PMCID: PMC11447184 DOI: 10.1186/s42155-024-00485-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 09/12/2024] [Indexed: 10/04/2024] Open
Abstract
Traumatic injuries continue to be on the rise globally and with it, the role interventional radiology (IR) has also expanded in managing this patient cohort. The role of damage control surgery (DCS) has been well established in the trauma management pathway, however it is only recently that Damage Control IR (DCIR) has become increasingly utilized in managing the extremis trauma and emergency patient.Visceral artery embolizations (both temporary and permanent), temporary balloon occlusions including Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in iliac arteries and aorta respectively are amongst the treatment options now available for the trauma (and non-traumatic bleeding) patient.We review the literature for the role of DCS and utilization of IR in trauma, outcomes and the paradigm shift towards minimally invasive techniques. The focus of this paper is to highlight the importance of multi-disciplinary working and having established pathways to ensure timely treatment of trauma patients as well as careful patient selection.We show that outcomes are best when both surgical and IR are involved in patient care from the outset and that DCIR should not be defined as Non-Operative Management (NOM) as it currently is categorized as.
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Affiliation(s)
- Velio Ascenti
- Postgraduate School of Radiology, University of Milan, Milan, IT, Italy
| | - Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, IT, Italy
| | - Maryam Alfa-Wali
- Major Trauma Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Carolina Lanza
- Radiology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, IT, Italy
| | - Elika Kashef
- Department of Imaging, Imperial College Healthcare NHS Trust, London, W2 1NY, UK.
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Li H, Ai T, Huang GB, Yang J, Wei GB, Gao JM, He P, Cao XM, Du DY. Internal iliac artery ligation as a damage control method in hemodynamically unstable pelvic fractures: A systematic review of the literature. Chin J Traumatol 2024; 27:288-294. [PMID: 39025704 PMCID: PMC11401483 DOI: 10.1016/j.cjtee.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 06/20/2024] [Accepted: 07/02/2024] [Indexed: 07/20/2024] Open
Abstract
PURPOSE Internal iliac artery ligation (IIAL) has been used as a damage control procedure to treat hemodynamically unstable pelvic fracture for many years. However, there is ongoing debate regarding the effectiveness and safety of this hemostatic method. Therefore, we performed a systematic literature review to assess the efficacy and safety of IIAL for pelvic fracture hemostasis. METHODS Three major databases, PubMed, Embase, and Google Scholar, were searched to screen eligible original studies published in English journals. Two reviewers independently read the titles, abstracts, and full texts of all literature. Articles were included if they reported the use and effects of IIAL. RESULTS A total of 171 articles were initially identified, with 22 fully meeting the inclusion criteria. Among the analyzed cases, up to 66.7% of patients had associated abdominal and pelvic organ injuries, with the urethra being the most frequently injured organ, followed by the bowel. The outcomes of IIAL for achieving hemostasis in pelvic fractures were found to be satisfactory, with an effective rate of 80%. Hemorrhagic shock was the leading cause of death, followed by craniocerebral injury. Notably, no reports of ischemic complications involving the pelvic organs due to IIAL were found. CONCLUSION IIAL has a good effect in treating hemodynamically unstable pelvic fracture without the risk of pelvic organ ischemia. This procedure should be considered a priority for hemodynamically unstable pelvic fracture patients with abdominal organ injuries.
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Affiliation(s)
- Hui Li
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Tao Ai
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Guang-Bin Huang
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Jun Yang
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Gong-Bin Wei
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Jin-Mou Gao
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Ping He
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Xue-Mei Cao
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Ding-Yuan Du
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China.
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Hanif H, Fisher AD, April MD, Rizzo JA, Miskimins R, Dubose JD, Cripps MW, Schauer SG. An assessment of nationwide trends in emergency department (ED) resuscitative endovascular balloon occlusion of the aorta (REBOA) use - A trauma quality improvement program registry analysis. Am J Surg 2024; 238:115898. [PMID: 39173564 DOI: 10.1016/j.amjsurg.2024.115898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/17/2024] [Accepted: 08/12/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemorrhage control in severe non-compressible torso trauma remains controversial, with limited data on patient selection and outcomes. This study aims to analyze the nationwide trends of its use in the emergency department (EDs). METHODS A retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) from 2017 to 2022 was performed, focusing on REBOA placements in EDs. RESULTS The analysis included 3398 REBOA procedures. Majority patients were male (76 %) with a median age of 40 years (27-58) and injury severity score of 20 (20-41). The most common mechanism was collision (64 %), with emergency surgeries most frequently performed for pelvic trauma (14 %). Level 1 trauma centers performed 82 % of these procedures, with consistent low annual utilization (<200 facilities). Survival rates were 85 % at 1-h post-placement, decreasing significantly to 42 % by discharge. CONCLUSIONS REBOA usage in remains limited but steady, primarily occurring at level 1 trauma center EDs. While short-term survival rates are favorable, they drop significantly by the time of discharge.
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Affiliation(s)
- Hamza Hanif
- University of New Mexico Hospital, Albuquerque, NM, USA.
| | - Andrew D Fisher
- University of New Mexico Hospital, Albuquerque, NM, USA; Texas National Guard, Austin, TX, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Trauma, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
| | | | - Joseph D Dubose
- Department of Surgery, University of Texas Dell School of Medicine, Austin, TX, USA
| | - Michael W Cripps
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA; Center for Combat and Battlefield Research (COMBAT), University of Colorado School of Medicine, Aurora, CO, USA
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Kenyon RM, Leighton JL. Control of Haemorrhage in Orthopaedic Trauma. J Clin Med 2024; 13:4260. [PMID: 39064300 PMCID: PMC11277702 DOI: 10.3390/jcm13144260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/26/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
This paper aims to outline current practices and examine promising new advancements in the modern management of haemorrhage in orthopaedic trauma. Many prehospital and perioperative haemorrhage control strategies and techniques have been available to clinicians for multiple decades, yet our understanding and utilisation of these practices continues to be refined and optimised. There is a particular focus in this article on issues related to resuscitation and coagulation in trauma. We examine the complex mechanisms that lead to coagulopathy in trauma patients as well as the transformative effect tranexamic acid has had in limiting blood loss. We also explore some emerging technologies such as endovascular interventions and clot-stabilising dressings and devices that are likely to have a significant impact going forward.
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Singh A, Kotzur T, Koslosky E, Gonuguntla R, Canseco L, Momtaz D, Seifi A, Martin C. Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures. J Orthop Trauma 2024; 38:254-258. [PMID: 38378177 DOI: 10.1097/bot.0000000000002789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVES To compare cost, hospital-related outcomes, and mortality between angioembolization (AE) and preperitoneal pelvic packing (PPP) in the setting of pelvic ring or acetabulum fractures. METHODS . DESIGN Retrospective database review. SETTING National Inpatient Sample, years 2016-2020. PATIENT SELECTION CRITERIA Hospitalized adult patients who underwent AE or PPP in the setting of a pelvic ring or acetabulum fracture. OUTCOME MEASURES AND COMPARISONS Mortality and hospital-associated outcomes, including total charges, following AE versus PPP in the setting of pelvic ring or acetabulum fractures. RESULTS A total of 3780 patients, 3620 undergoing AE and 160 undergoing PPP, were included. No significant differences in mortality, length of stay, time to procedure, or discharge disposition were found ( P > 0.05); however, PPP was associated with significantly greater charges than AE ( P = 0.04). Patients who underwent AE had a mean total charge of $250,062.88 while those undergoing PPP had a mean total charge of $369,137.16. CONCLUSIONS Despite equivalent clinical efficacy in terms of mortality and hospital-related outcomes, PPP was associated with significantly greater charges than AE in the setting of pelvic ring or acetabulum fractures. This data information can inform clinical management of these patients and assist trauma centers in resource allocation. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | | | | | | | | | - Ali Seifi
- Department of Neurosurgery, UT Health San Antonio, San Antonio, TX
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Jin X, Chu Q, Bing H, Li F, Bai J, Lou J, Sun L, Zhang C, Lin L, Li L, Wang H, Zhou Z, Zhang J, Lian H. Preperitoneal pelvic balloon tamponade-an effective intervention to control pelvic injury hemorrhage in a swine model. Front Bioeng Biotechnol 2024; 12:1340765. [PMID: 38737537 PMCID: PMC11082274 DOI: 10.3389/fbioe.2024.1340765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/11/2024] [Indexed: 05/14/2024] Open
Abstract
Objective: This study aimed to estimate the effects of the volume of preperitoneal balloon (PPB) on arterial and venous hemorrhage in a swine pelvic fracture model. Methods: Twenty-four swine were randomized into 0-mL, 500-mL, 800-mL, and 1000-mL intra-hematoma PPB groups. They were subjected to open-book pelvic fracture and reproducible injuries in the external iliac artery and vein. The pelvic binder and IH-PPBs with different volumes of fluid were applied to control the active hemorrhage after arterial and venous injuries. The survival time and rate during 60-min observation and digital subtraction angiography (DSA) images were the primary endpoints in this study. Secondary endpoints included survival rate within 70 min, peritoneal pressure, hemodynamics, blood loss, infusion fluid, blood pH, and lactate concentration. Results: Our results indicated that the 800-mL and 1000-mL groups had a higher survival rate (0%, 50%, 100% and 100% for 0, 500, 800, and 1000-mL groups respectively; p < 0.0001) and longer survival time (13.83 ± 2.64, 24.50 ± 6.29, 55.00 ± 6.33, and 60.00 ± 0.00 min for 0, 500, 800, and 1,000 groups respectively; p < 0.0005) than the 0-mL or 500-mL groups during the 60 min observation. Contrastingly, survival rate and time were comparable between 800-mL and 1000-mL groups during the 60-min observation. The IH-PPB volume was associated with an increase in the pressure of the balloon and the preperitoneal pressure but had no effect on the bladder pressure. Lastly, the 1000-mL group had a higher mean arterial pressure and systemic vascular resistance than the 800-mL group. Conclusion: IH-PPB volume-dependently controls vascular bleeding after pelvic fracture in the swine model. IH-PPB with a volume of 800 mL and 1000 mL efficiently managed pelvic fracture-associated arterial and venous hemorrhage and enhanced survival time and rate in the swine model without evidences of visceral injury.
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Affiliation(s)
- Xiaogao Jin
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Qinjun Chu
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hailong Bing
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Fang Li
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Jingyue Bai
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Junge Lou
- Department of Peripheral Vascular Intervention, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Liwei Sun
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Chenxi Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Lin Lin
- Department of Ultrasound Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Liumei Li
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Haibo Wang
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Zhanfeng Zhou
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Junfeng Zhang
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongkai Lian
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- Department of Ultrasound Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- Research of Trauma Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
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Martinez B, Breeding T, Katz J, Patel H, Santos RG, Elkbuli A. Outcomes of Preperitoneal Packing and Angioembolization for Hemorrhage Control in Hemodynamically Unstable Pelvic Fractures: A Systematic Review and Meta-Analysis. Am Surg 2024; 90:455-464. [PMID: 37970830 DOI: 10.1177/00031348231216488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Hemodynamically unstable pelvic fractures are often life-threatening injuries; however, the optimal management remains uncertain. This systematic review and meta-analysis aim to evaluate the most appropriate primary management of hemorrhage in adult patients with hemodynamically unstable pelvic fractures by comparing outcomes following the initial use of preperitoneal packing (PPP) vs angioembolization (AE). METHODS A systematic search of PubMed, Embase, Google Scholar, and ProQuest databases was conducted following PRISMA guidelines. Studies assessing hemorrhage management in trauma patients with hemodynamically unstable pelvic fractures were included. The data extracted from selected articles included patient demographics, study design, and outcomes such as 24-hour PRBC transfusions, in-hospital mortality, and DVT rate. RESULTS Eight articles were included in the systematic review. Among the included studies, 2040 patients with hemodynamically unstable pelvic fractures were analyzed. Meta-analyses revealed that treatment with PPP was associated with fewer 24-hour PRBC transfusions (mean difference = -1.0, 95% CI: -1.8 to -.2) than AE. However, no significant differences were noted in in-hospital mortality (RR: .91, 95% CI: .80-1.05) and the rate of deep vein thrombosis (RR: .89, 95% CI: .62-1.28) between groups. CONCLUSION The findings of this study suggest that primary management with PPP was associated with fewer 24-hour PRBC transfusions compared to AE. The choice of primary management with PPP or AE did not significantly impact in-hospital mortality. Future studies should address clinical outcomes and the factors that affect them to better understand the impact of different management strategies and direct the creation of practice management guidelines.
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Affiliation(s)
- Brian Martinez
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Tessa Breeding
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Joshua Katz
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Heli Patel
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Radleigh G Santos
- Department of Mathematics, NSUNOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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Park CR, Nam JG, Lee JH, Hwang JC, Lee SH. Safety and efficacy of pelvic arterial embolization for primary postpartum hemorrhage in hemodynamically stable and hemodynamically unstable patients: Is it "time" for a paradigm change? J Gynecol Obstet Hum Reprod 2024; 53:102762. [PMID: 38432627 DOI: 10.1016/j.jogoh.2024.102762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/11/2024] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Pelvic artery embolization (PAE) is an effective and safe technique for treating postpartum hemorrhage (PPH) with hemodynamic stability. However, its use in hemodynamically unstable patients remains controversial. PURPOSE To determine the safety and efficacy of pelvic arterial embolization (PAE) according to the hemodynamic state of primary postpartum hemorrhage (PPH) patients. METHODS This cohort study was conducted retrospectively, using data from January 2004 to December 2021, in a resource-rich setting at a tertiary Level 1 trauma academic center. A total of 437 patients were diagnosed with PPH during the study period. Of these 437 patients, 161 with primary PPH who underwent PAE were enrolled in the study. The outcomes assessed included the clinical success rate, mortality, the overall success rate, predictive factors for failed PAE, and time-dependent changes in hemodynamic parameters, such as systolic blood pressure (SBP), heart rate (HR), and shock index (SI). Propensity score (PS) matching analysis was performed to assess the influence of specific variables or conditions on the outcomes. RESULTS Of the 161 patients who underwent PAE for primary PPH (mean age, 32.9 ± 4.3 [SD]), 85 were retrospectively categorized as having hemodynamic stability (mean age, 32.6 ± 4.1 [SD]), while 76 were categorized as having hemodynamic instability (mean age, 33.3 ± 4.4 [SD]). This study showed PAE for primary PPH had a success rate of 91.9 %, with no significant difference in mortality rates between the groups. The clinical success rate was 98.8 % for patients with hemodynamic stability and 84.2 % for those with hemodynamic instability (p < .001). The overall success rate was 98.8 % for hemodynamic stability and 89.5 % for hemodynamic instability (p = .014). After propensity score matching, the clinical success rate was higher in hemodynamically stable patients than in unstable ones (100 % vs. 86.3 %, p = .013). However, there was no significant difference in the overall success rate (100 % vs. 90.2 %, p = .056). Among the PS-matched population, predictive factors for the failed PAE in primary PPH were hemodynamic instability (adjusted odds ratio [aOR] 21.22, 95 % CI 1.27-355.76; p = .034) and emergency Cesarean delivery with accompanying hemorrhag (aOR 54.00, 95 % CI 11.93-244.56; p = .008). In three groups within a PS-matched population - hemodynamically stable, unstable with successful outcomes, and unstable with unsuccessful outcomes, a generalized linear mixed model (GLMM) analysis for time-dependent changes in hemodynamic parameters revealed a statistically significant difference in SBP, HR, and SI at various time points. CONCLUSION Pelvic arterial embolization of primary postpartum bleeding in hemodynamic instability has been identified as an alternative, safe, and effective life-saving procedure for multidisciplinary treatment in resource-rich environments even after the baseline characteristics are balanced by the PS matching, suggesting it is a primary care option.
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Affiliation(s)
- Chang Ryul Park
- Department of Thoracic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Jeong Gu Nam
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Jong Hwa Lee
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Jae Cheol Hwang
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Sang Hun Lee
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan 44033, South Korea.
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Devaney GL, Balogh ZJ. We asked the experts: Traumatic shock from pelvic trauma: Eliminating pelvic hemorrhage-related mortality. World J Surg 2024; 48:11-13. [PMID: 38686552 DOI: 10.1002/wjs.12009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
- Giles L Devaney
- Department of Traumatology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
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10
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Kim YJ, Scott BL, Pieracci FM, Moore EE, Mauffrey C, Parry JA. Open Fixation After Preperitoneal Pelvic Packing Is Associated With a High Surgical Site Infection Rate. J Orthop Trauma 2023; 37:547-552. [PMID: 37828686 DOI: 10.1097/bot.0000000000002662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To evaluate the incidence of pelvic space surgical site infection (SSI) after preperitoneal pelvic packing (PPP) for persistent hemodynamic instability. DESIGN Retrospective comparative study. SETTING Urban Level 1 trauma center. PATIENTS/PARTICIPANTS 83 patients who received PPP and 55 patients who had open reduction and internal fixation (ORIF) of the anterior pelvic ring without PPP. INTERVENTION Operative fixation. MAIN OUTCOME MEASUREMENTS Pelvic space SSI. RESULTS The SSI rate in the PPP group was 31.3% (26/83) compared with 10.9% (6/55) in the control group (proportional difference 20.4%, confidence interval (CI) 6.4-32.5, P = 0.007). Patients in the PPP group (n = 43) were 1:1 propensity score matched with patients in the control group to account for differences in Injury Severity Score and American Society of Anesthesiologists score. In this matched cohort, the rate of pelvic space SSI remained higher in the PPP group compared with that in the control group (30.2% vs. 9.3%; proportional difference 20.9%, CI, 3.7-36.3; P = 0.02). On multivariate analysis of the PPP group, anterior ORIF (odds ratio 6.56, CI, 2.00-21.47, P = 0.002) was found to be independently associated with SSI. CONCLUSIONS PPP is an independent risk factor of space SSI. The likelihood of SSI after PPP is increased with anterior ORIF. The morbidity of SSI after PPP must be weighed against the risk of exsanguination. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Fredric M Pieracci
- Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
| | - Ernest E Moore
- Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
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Chu J, Xie C, Fu J, Yao W. Extraperitoneal pelvic packing versus angiographic embolization for hemodynamically unstable pelvic fractures: a retrospective single-center analysis. J Int Med Res 2023; 51:3000605231208601. [PMID: 37898110 PMCID: PMC10613400 DOI: 10.1177/03000605231208601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/02/2023] [Indexed: 10/30/2023] Open
Abstract
OBJECTIVE To retrospectively analyze the clinical data and treatment procedures of angiographic embolization (AE) and extraperitoneal pelvic packing (EPP) for traumatic pelvic fractures in our center for the purpose of providing recommendations on the selection of treatment protocols. METHODS We analyzed 110 patients with traumatic pelvic fractures treated with AE and EPP from January 2015 to May 2023. The patients were divided into the AE group (69 men, 41 women) and the EPP group (20 men, 12 women). The primary outcomes were the mortality rate and incidence of complications. RESULTS The mortality rate was slightly lower in the AE than EPP group (7.3% vs. 9.4%). The overall blood transfusion volume was lower and the length of hospital stay was shorter in the AE than EPP group (7.79 ± 12.04 vs. 9.14 ± 14.21 units and 20.48 ± 11.32 vs. 22.14 ± 10.47 days). CONCLUSIONS Both AE and EPP have good treatment effects. AE is preferred for patients in stable condition with severe hemorrhage. This study suggests that EPP should be the primary treatment and that AE should serve as a complementary treatment for critical patients.
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Affiliation(s)
| | | | - Jiaojiao Fu
- Department of Vascular Intervention, Yuyao People’s Hospital, Zhejiang Province, China
| | - Weigen Yao
- Department of Vascular Intervention, Yuyao People’s Hospital, Zhejiang Province, China
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Klingebiel FKL, Hasegawa M, Parry J, Balogh ZJ, Sen RK, Kalbas Y, Teuben M, Halvachizadeh S, Pape HC, Pfeifer R. Standard practice in the treatment of unstable pelvic ring injuries: an international survey. INTERNATIONAL ORTHOPAEDICS 2023; 47:2301-2318. [PMID: 37328569 PMCID: PMC10439026 DOI: 10.1007/s00264-023-05859-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/27/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe. METHODS A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents). RESULTS The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization). CONCLUSION The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.
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Affiliation(s)
- Felix Karl-Ludwig Klingebiel
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Morgan Hasegawa
- Division of Orthopaedic Surgery, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI USA
| | - Joshua Parry
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO USA
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW Australia
| | | | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Michel Teuben
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
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de Ridder VA, Whiting PS, Balogh ZJ, Mir HR, Schultz BJ, Routt M“C. Pelvic ring injuries: recent advances in diagnosis and treatment. OTA Int 2023; 6:e261. [PMID: 37533441 PMCID: PMC10392441 DOI: 10.1097/oi9.0000000000000261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/30/2022] [Indexed: 08/04/2023]
Abstract
Pelvic ring injuries typically occur from high-energy trauma and are often associated with multisystem injuries. Prompt diagnosis of pelvic ring injuries is essential, and timely initial management is critical in the early resuscitation of polytraumatized patients. Definitive management of pelvic ring injuries continues to be a topic of much debate in the trauma community. Recent studies continue to inform our understanding of static and dynamic pelvic ring stability. Furthermore, literature investigating radiographic and clinical outcomes after nonoperative and operative management will help guide trauma surgeons select the most appropriate treatment of patients with these injuries.
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Affiliation(s)
| | - Paul S. Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | - Hassan R. Mir
- Director of Orthopedic Trauma Research, Florida Orthopedic Institute, Tampa FL; and
| | - Blake J. Schultz
- University of Texas Health Science Center at Houston, Houston TX
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14
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Current Management of Hemodynamically Unstable Patients with Pelvic Fracture. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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15
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Benjamin ER, Warriner Z, Demetriades D. Preperitoneal Packing for Pelvic Fracture Bleeding Control: A Human Cadaver Study. World J Surg 2023; 47:621-626. [PMID: 36536259 DOI: 10.1007/s00268-022-06859-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Preperitoneal packing (PPP) has been widely accepted as a damage control technique for severe bleeding from pelvic fractures. It is supposed to work by direct compression and tamponade of the bleeding source in the pelvis and it has been suggested to be effective for both venous and arterial bleeding. However, there is little evidence to support its efficacy or the ability to place the laparotomy pads in proximity of the desired location. METHODS Bilateral PPP was performed on 10 fresh human cadavers, followed by laparotomy and measurements of resultant pad placement in relation to critical anatomic structures. RESULTS A total of 20 assessments of laparotomy pad placement were performed. Following completion of PPP, a midline laparotomy was performed to determine proximity and closest distance of the laparotomy pads to sites of potential bleeding in pelvic fractures. In almost all cases, the pad placement was not contiguous with the key anatomic structure with mean placement 3.9 + 1.1 cm from the sacroiliac joint, 3.5 + 1.6 cm from the common iliac artery, 1.1 + 1.2 cm from the external iliac artery, 2.8 + 0.8 cm from the internal iliac artery, and 2.3 + 1.2 cm from the iliac bifurcation. Surgeon experience resulted in improved placement relative to the sacroiliac joint, however the pads still did not directly contact the target point. CONCLUSION This human cadaver study has shown that PPP, even in experienced hands, may not be placed in significant proximity of anatomical structures of interest. The role of PPP needs to be revisited with better clinical or human cadaver studies.
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Affiliation(s)
| | - Zachary Warriner
- Department of Surgery, University of Kentucky Chandler Medical Center, Lexington, KY, USA
| | - Demetrios Demetriades
- Department of Surgery, University of Southern California, Los Angeles, CA, USA. .,LAC+USC Medical Center, IPT, 2051 Marengo Street, C5L100, Los Angeles, CA, 90033, USA.
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16
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Aoki M, Matsushima K, Matsumoto S. Angioembolization versus preperitoneal packing for severe pelvic fractures: A propensity matched analysis. Am J Surg 2023; 225:408-413. [PMID: 36115706 DOI: 10.1016/j.amjsurg.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/22/2022] [Accepted: 09/03/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether AE or PPP would be associated with survival among hemodynamically unstable pelvic fracture remains controversial. STUDY DESIGN This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2018. Patients >16 years with a severe pelvic fracture (abbreviated injury scale 3-5) who underwent AE or PPP were recruited. The primary outcome was in-hospital survival. Data were evaluated using a propensity-score matching (PSM) analysis. RESULTS A total of 1123 patients met our inclusion criteria. Of these, AE and PPP were performed in 964 (85.8%) and 159 (14.2%) patients, respectively. Concomitant hemorrhage control laparotomy was performed in 25.6% and 82.4% of AE and PPP patients, respectively. In 220 PSM patients, the mortality rate between AE and PPP groups was not significantly different (30.9% vs. 38.2%, P = 0.321). CONCLUSIONS Though patients' characteristics differed between AE and PPP groups, comparable propensity-matched patients with severe pelvic fractures showed no significant difference in in-hospital survival. PPP was more likely to be selected for severe pelvic fractures necessitating laparotomy.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan.
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
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