Preperitoneal pelvic packing in patients with hemodynamic instability due to severe pelvic fracture: early experience in a Korean trauma center

Internal iliac artery ligation as a damage control method in hemodynamically unstable pelvic fractures: A systematic review of the literature

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.

Comparison of Conventional versus Modified Preperitoneal Pelvic Packing in Patients with Bleeding Pelvic Fractures: A Single-Center Retrospective Pilot Study

Background: Bleeding pelvic fractures have high mortality rates, primarily due to severe hemorrhage. Treatment options include mechanical stabilization based on preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta, and angioembolization (AE). The bilateral preperitoneal approach, which uses three pads on each side, is the conventional PPP method. We aimed to compare the bilateral preperitoneal approach with a modified approach, involving selectively packing only heavily bleeding areas, in terms of clinical outcomes and mortality risks. Methods: We included patients who underwent PPP and compared the outcomes between conventional (three sponges placed on each side) and modified PPP (selective packing of critical areas). The primary outcome was 30-day mortality; the secondary outcomes included 24 h mortality, pelvic complications, and transfusion requirements. Univariate and multivariate analyses were performed to determine risk factors for 30-day and 24 h mortality. Results: Among the 47 included patients, 19 and 28 underwent conventional and modified PPP, respectively. There were no significant between-group differences in the 24 h (26.3% vs. 42.9%, p = 0.247) and 30-day mortality rates (47.4% vs. 60.7%, p = 0.366). Using univariate and multivariate analyses, initial lactate levels and the decision to perform AE were found to be significant risk factors for mortality. However, the selected PPP method was not a risk factor for 30-day mortality (odds ratio [OR], 2.22; 95% confidence interval [CI], 0.27-18.26; p = 0.457) or 24 hr mortality (OR, 1.77; 95% CI, 0.24-13.19; p = 0.557). Conclusions: The modified PPP method may be considered in patients with bleeding pelvic fractures for effective bleeding control while minimizing potential complications associated with the conventional PPP.

Self-expanding foam versus preperitoneal packing for exsanguinating pelvic hemorrhage

BACKGROUND

Mortality for pelvic fracture patients presenting with hemorrhagic shock ranges from 21% to 57%. The objective of this study was to develop a lethal and clinically relevant pelvic hemorrhage animal model with and without bony fracture for evaluating therapeutic interventions. ResQFoam is a self-expanding foam that has previously been described to significantly decrease mortality in large-animal models of abdominal exsanguination. We hypothesized that administration of ResQFoam into the preperitoneal space could decrease mortality in exsanguinating pelvic hemorrhage.

METHODS

Two pelvic hemorrhage models were developed using noncoagulopathic swine. Pelvic hemorrhage model 1: bilateral, closed-cavity, major vascular retroperitoneal hemorrhage without bony pelvic fracture. After injury, animals received no treatment (control, n = 10), underwent preperitoneal packing using laparotomy pads (n = 11), or received ResQFoam (n = 10) injected into the preperitoneal space. Pelvic hemorrhage model 2: unilateral, closed-cavity, retroperitoneal hemorrhage injury (with intraperitoneal communication) combined with complex pelvic fracture. After injury, animals received resuscitation (control, n = 12), resuscitation with preperitoneal packing (n = 10) or with ResQFoam injection (n = 10) into the preperitoneal space.

RESULTS

For model 1, only ResQFoam provided a significant survival benefit. The median survival times were 50 minutes and 67 minutes for preperitoneal packing and ResQFoam, compared with 6 minutes with controls ( p = 0.002 and 0.057, respectively). Foam treatment facilitated hemodynamic stabilization and resulted in significantly less hemorrhage (21.5 ± 5.3 g/kg) relative to controls (31.6 ± 5.0 g/kg, p < 0.001) and preperitoneal packing (32.7 ± 5.4 g/kg, p < 0.001). For model 2, both ResQFoam and preperitoneal packing resulted in significant survival benefit compared with controls. The median survival times were 119 minutes and 124 minutes for the preperitoneal packing and ResQFoam groups, compared with 4 minutes with controls ( p = 0.004 and 0.013, respectively).

CONCLUSION

Percutaneous injection of ResQFoam into the preperitoneal space improved survival relative to controls, and similar survival benefit was achieved compared with standard preperitoneal pelvic packing. The technology has potential to augment the armamentarium of tools to treat pelvic hemorrhage.

Assessment and management of pelvic fractures from high-energy trauma in adults

Pelvic fractures caused by high-energy trauma such as falling from a height or road traffic collisions have a high mortality rate and patients are also at high risk of life-changing injuries. High-energy trauma to the pelvis is associated with major haemorrhage and injuries to the internal pelvic organs. Emergency nurses have a fundamental role in the initial assessment and management of patients, as well as in their ongoing care once the fracture has been stabilised and bleeding is controlled. This article describes the anatomy of the pelvis, discusses the initial assessment and management of patients who have sustained high-energy pelvic trauma, details the complications of pelvic fractures and explains patients' ongoing care in the emergency department.

["Stop the bleeding"-Acute bleeding control in injuries to the trunk and extremities]

Trauma-related blood loss is still associated with a high mortality and is a major factor in the development of a deadly triad consisting of acidosis, hypothermia and coagulopathy. Sources of bleeding occur particularly in the thoracic, abdominal and pelvic regions as well as in the extremities. For control of bleeding a timely identification of the source of bleeding and the initiation of a targeted treatment are essential. The principles are to stop the blood loss as soon as possible and to restore the lost volume to avoid the complications associated with traumatic hemorrhage. Surgical treatment in the acute situation is especially important due to its efficiency. The present article focuses on the current literature with respect to the appropriate diagnostic and treatment measures in the thoracic, abdominal and pelvic regions as well as the extremities and describes the latest scientific insights and developments. Available trauma algorithms are presented and the value of various strategies regarding surgical hemostasis for the thorax and abdomen are shown, whereby organ preservation can increasingly be achieved, particularly in the abdomen. With respect to hemostasis in severe pelvic injuries and injuries to the extremities, the regularly used surgical techniques are described and their values are differentially classified.

Preperitoneal Packing for Pelvic Fracture Bleeding Control: A Human Cadaver Study

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.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing

INTRODUCTION

in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality.

METHODS

a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing.

RESULTS

data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05).

CONCLUSION

age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

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

Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis

BACKGROUND

Hemodynamically unstable pelvic fracture patients are challenging to manage. Preperitoneal packing (PPP) and angioembolization (AE) are two interventions commonly used to help gain hemorrhage control. Recently, there has been a tendency to support PPP in hemodynamically unstable pelvic fracture seemingly in direct comparison with AE. However, it seems that key differences between published cohorts exist that limits a comparison between these two modalities.

METHODS

A systematic literature search of the MEDLINE, CINAHL, and EMBASE databases was conducted. Prospective and retrospective studies were eligible. No limitation was placed on publication date, with only manuscripts printed in English eligible (PROSPERO CRD42021236219). Included studies were retrospective and prospective cohort studies and a quasirandomized control trial. Studies reported demographic and outcome data on hemodynamically unstable patients with pelvis fractures that had either PPP or AE as their initial hemorrhage control intervention. The primary outcome was in-hospital mortality rate. Eighteen studies were included totaling 579 patients, of which 402 were treated with PPP and 177 with AE.

RESULTS

Significant differences were found between AE and PPP in regard to age, presence of arterial hemorrhage, Injury Severity Score, and time to intervention. The crude mortality rate for PPP was 23%, and for AE, it was 32% (p = 0.001). Analysis of dual-arm studies showed no significant difference in mortality. Interestingly, 27% of patients treated with PPP did not get adequate hemorrhage control and required subsequent AE.

CONCLUSION

Because of bias, heterogeneity, and inadequate reporting of physiological data, a conclusive comparison between modalities is impossible. In addition, in more than a quarter of the cases treated with PPP, the patients did not achieve hemorrhage control until subsequent AE was performed. This systematic review highlights the need for standardized reporting in this high-risk group of trauma patients.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Positive impact of trauma center to exsanguinating pelvic bone fracture patient survival: A Korean trauma center study

Background:

Trauma center and multidisciplinary management protocols have been proven to improve the outcomes of severely injured patients. Hemorrhage from pelvic injury is associated with high mortality and is a common cause of preventable trauma death. This study aimed to evaluate the effects of the establishment of a trauma center and management protocols on the outcomes of hemodynamically unstable patients with pelvic fractures.

Methods:

Hemodynamically unstable patients with pelvic fractures were reviewed retrospectively over a 10-year period. They were grouped into the pre-phase and post-phase, which were defined as before and after the establishment of a trauma center and protocols, respectively. Basic characteristics and outcomes were compared between periods.

Results:

This study enrolled a total of 106 patients. Basic and physiological characteristics were not significantly different in both phases. Pre-peritoneal packing and resuscitative endovascular balloon occlusion of aorta were only performed in the post-phase (pre-peritoneal packing, N = 27; resuscitative endovascular balloon occlusion of aorta, N = 10). In the post-phase, the time from emergency department arrival to hemostatic intervention was significantly shorter (269 ± 132.4 min vs 147.2 ± 95.5 min, p < 0.0001), and mortality due to acute hemorrhage was significantly lower (p = 0.003; absolute risk reduction: 0.22; relative risk reduction: 0.72). Multivariate logistic regression analysis identified age, injury severity score, and the pre-phase as independent risk factors for mortality.

Conclusion:

The establishment of a trauma center and multidisciplinary management protocols, such as pre-peritoneal packing and resuscitative endovascular balloon occlusion of aorta, improved the outcomes of hemodynamically unstable patients with pelvic fractures.

Current management and clinical outcomes for patients with haemorrhagic shock due to pelvic fracture in Korean regional trauma centres: A multi-institutional trial

INTRODUCTION

The purpose of this study was to evaluate the current management and clinical outcomes in patients with hemodynamic instability due to pelvic fracture in three regional trauma centres in Korea.

PATIENTS AND METHODS

Three regional trauma centres participated in this study, and 157 patients who were admitted between January 2015 and December 2018 were enroled. Clinical data were collected prospectively as part of the Korean trauma data bank and were analysed retrospectively.

RESULTS

The mean age was 59.3 years, and 107 of 157 (68.2%) were male patients. The most common cause of injury was auto-pedestrian accidents, followed by falls and motor vehicle crashes. The mean admission systolic blood pressure and serum lactate level were 86.7 mmHg and 6.68 mmol/L, respectively. Twenty-four patients (15.3%) had a cardiac arrest in the emergency department (ED). The mean injury severity score was 39.1, and the mean probability of survival (Trauma and Injury Severity Score) was 48.7%. Sixty-six patients (42%) underwent pelvic angiography; 89 (56.7%), preperitoneal pelvic packing (PPP); 27 (17.2%), resuscitative endovascular balloon occlusion of the aorta (REBOA); 20 (12.7%), pelvic external fixation (PEF); and 13 patients (8.3%), internal iliac artery ligation (IIAL). Seventy-three patients (46.5%) died, including 40 (25.5%) who died from acute haemorrhage. With each year, the rates of REBOA and pelvic binder use continued to increase (p<0.001 and p = 0.005, respectively), but the number of PEF cases significantly decreased (p = 0.006). Age, initial lactate, low revised trauma score (RTS), combined abdominal injury, REBOA, and 4-hour requirement of packed red blood cells were independent risk factors associated with mortality, whereas during the period of 2017 and 2018, there were protective factors. The risk factors of mortality due to haemorrhage were cardiac arrest in the ED, RTS, combined chest and abdominal injuries, and IIAL.

CONCLUSIONS

Since the establishment of regional trauma centres, the clinical outcomes of patients with hemodynamic instability due to pelvic fracture have significantly improved. As a haemostatic procedure for these patients, PEF has been used less frequently, while pelvic binder and REBOA showed significant increase in their use.

Fatores preditivos de mortalidade em pacientes com fratura de pelve e instabilidade hemodinâmica submetidos ao tamponamento extraperitoneal de pelve

RESUMO Introdução: nas últimas décadas, tem sido difundida a técnica de tamponamento pélvico extraperitoneal, porém ainda existem poucos estudos. Decidiu-se analisar os resultados do tamponamento extraperitoneal de pelve, em pacientes com fratura pélvica e choque, com objetivo de identificar fatores preditivos de mortalidade. Métodos: foi realizada revisão do prontuário dos pacientes submetidos ao tamponamento extraperitoneal de pelve. Foram analisadas as características dos pacientes, dados do atendimento pré-hospitalar e na sala de emergência, classificação da fratura, presença de lesões associadas, exames laboratoriais e de imagem, dados relativos ao tamponamento, e outros procedimentos realizados, complicações, parâmetros hemodinâmicos e quantidade de hemoderivados transfudidos. Resultados: foram analisados os dados de 51 pacientes, com sinais de choque desde o atendimento pré-hospitalar, presença de acidose, elevado déficit de bases e lactato arterial. Houve alta prevalência de lesões graves associadas, requerendo múltiplos procedimentos cirúrgicos. A incidência de coagulopatia foi 70,58% e mortalidade 56,86%. O grupo de pacientes não sobreviventes apresentou idade e intubação orotraqueal pré-hospitalar maiores, e escores na escala de coma de Glasgow menores (p<0,05). O mesmo grupo apresentou, antes e após o tamponamento extraperitoneal de pelve, parâmetros hemodinâmicos menores de pressão arterial média, pH, déficit de bases e hemoglobina, e maior de lactato arterial (p<0,05). O grupo de pacientes não sobreviventes recebeu mais concentrados de hemácias, plasma fresco congelado e concentrado de plaquetas nas 24h seguintes ao tamponamento extraperitoneal de pelve (p<0,05). Conclusão: idade e o excesso de bases são fatores preditivos independentes de mortalidade em pacientes submetidos ao tamponamento extraperitoneal de pelve.

Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries

Unstable pelvic injuries are rare (3–8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD^® succeeded best on average (333 ± 234 cm³), but with higher average peak traction (110 N). The reduction results of the VBM^® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD^® or the VBM^® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM^® pneumatic pelvic sling to 200 mmHg.

Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis

INTRODUCTION

Treatment of pelvic trauma related hemorrhage is challenging and remains controversial. In hemodynamically unstable patients suspected for massive bleeding, pre-peritoneal packing (PPP) with temporary external fixation (EF) and subsequent trans-arterial embolization (TAE) can be performed in order to control bleeding. In hemodynamically stable patients suspected for minor to moderate bleeding, primary TAE with EF may be performed. The goal of this study was to determine effectiveness and safety of both strategies.

METHODS

Retrospectively, patients that received treatment for pelvic trauma-related hemorrhage at two level 1 trauma centers located in the United States between January 2001 and January 2019 were evaluated. Both centers advocate subsequent TAE in addition to PPP and EF in hemodynamically unstable patients, and primary TAE in stable patients. Demographic and clinical data was collected and mortality, ischemic and infectious complications were determined.

RESULTS

In total, 135 patients met the inclusion criteria. Of these, 61 hemodynamically unstable patients suspected for massive pelvic bleeding underwent primary PPP (45%) and 74 stable patients suspected for minor/moderate bleeding underwent primary TAE (55%). In total, 37/61 primary PPP patients underwent EF (61%) and 48 underwent adjunct TAE (79%), performed bilaterally in 77% and unselective by use of gelfoam in 72% of cases. Primary TAE patients received embolization bilaterally in 49% and unselective in 35% of cases. Exsanguination-related deaths were found in 7/61 primary PPP patients (11%). There were none among the primary TAE patients. Potentially ischemic in-hospital complications, of which one could be considered severe (gluteal necrosis), occurred more in patients that received bilateral unselective TAE compared to all other TAE patients (p=0.02).

CONCLUSION

Primary TAE appears to be an effective and safe adjunct for (minor) pelvic hemorrhage in hemodynamically stable patients. Primary PPP followed by EF and adjunct bilateral unselective TAE with gelfoam appears effective for those suspected of massive pelvic bleeding. This unselective embolization approach using gelfoam might be related to (ischemic) complications. When considering the amount and severity of complications and the severity of pelvic trauma, these might not outweigh the benefit of fast hemorrhage control.

Accuracy of Contrast Extravasation on Computed Tomography for Diagnosing Severe Pelvic Hemorrhage in Pelvic Trauma Patients: A Meta-Analysis

Background and objective: The early detection of underlying hemorrhage of pelvic trauma has been a critical issue. The aim of this study was to systematically determine the diagnostic accuracy of computed tomography (CT) for detecting severe pelvic hemorrhage. Materials and Methods: Relevant articles were obtained by searching PubMed, EMBASE, and Cochrane databases through 28 November 2020. Diagnostic test accuracy results were reviewed to obtain the sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve of CT for the diagnosis in pelvic trauma patients. The positive finding on CT was defined as the contrast extravasation. As the reference standard, severe pelvic hemorrhage was defined as an identification of bleeding at angiography or by direct inspection using laparotomy that required hemostasis by angioembolization or surgery. A subgroup analysis was performed according to the CT modality that is divided by the number of detector rows. Result: Thirteen eligible studies (29 subsets) were included in the present meta-analysis. Pooled sensitivity of CT was 0.786 [95% confidence interval (CI), 0.574-0.909], and pooled specificity was 0.944 (95% CI, 0.900-0.970). Pooled sensitivity of the 1-4 detector row group and 16-64 detector row group was 0.487 (95% CI, 0.215-0.767) and 0.915 (95% CI, 0.848-0.953), respectively. Pooled specificity of the 1-4 and 16-64 detector row groups was 0.956 (95% CI, 0.876-0.985) and 0.906 (95% CI, 0.828-0.951), respectively. Conclusion: Multi-detector CT with 16 or more detector rows has acceptable high sensitivity and specificity. Extravasation on CT indicates severe hemorrhage in patients with pelvic trauma.

Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries

Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated.

Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization.

Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury.

Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.

Management of Hemodynamically Unstable Pelvic Ring Fractures

Hemodynamically unstable pelvic fractures are challenging high-energy traumas. In many cases, these severely injured patients have additional traumatic injuries that also require a trauma surgeon's attention. However, these patients are often in extremis and require a multidisciplinary approach that needs to be set up in minutes. This calls for an evidence-based treatment algorithm. We think that the treatment of hemodynamically unstable pelvic fractures should primarily involve thorough resuscitation, mechanical stabilization, and preperitoneal pelvic packing. Angioembolization should be considered in patients that remain hemodynamically unstable. However, it should be used as an adjunct, rather than a primary means to achieve hemodynamic stability as most of the exsanguinating bleeding sources in pelvic trauma are of venous origin. Time is of the essence in these patients and should therefore be used appropriately. Hence, the hemodynamic status and physiology should be the driving force behind each decision-making step within the algorithm.

The need for a rapid transfer to a hybrid operating theatre: Do we lose benefit with poor efficiency?

PURPOSE

Recent studies on hybrid operating rooms (ORs) have mainly reported their applications in orthopaedic surgery and interventional radiology (IR); there are few studies assessing severely injured patients who underwent IR or surgery in hybrid ORs for haemostasis. Therefore, this study aimed to evaluate our early experience with the use of hybrid OR to control haemorrhage in severe trauma patients.

METHODS

Medical charts of patients who underwent an emergency surgery or IR for haemostasis were analysed retrospectively between January and December 2015.

RESULTS

Of the 95 patients directly transported to the general or hybrid OR, 69 (73%) were transported to the non-hybrid OR and underwent emergency surgeries, whereas 26 (27%) were transported to the hybrid OR and underwent emergency IR or surgery on-site. Patients transported to the hybrid OR had a higher median Injury Severity Score (median: 29, interquartile range[IQR]: 21-36.5 vs median: 21, IQR: 16-27) and lower median initial systolic blood pressure (median: 96, IQR: 82.75-128.75 vs median: 114, IQR: 95-151.5) than those transported to the non-hybrid OR. The median time from the emergency room (ER) arrival to the start of the emergency procedure in the hybrid OR group was similar with that in the non-hybrid OR group (median: 80, IQR: 62.75-91.5 vs median: 75, IQR: 56.5-99). Seven patients underwent IR and surgery concurrently in the hybrid OR because of a haemodynamically unstable pelvic fracture, severe liver injury, and severe brain haemorrhage. The median time from the ER arrival to the start of the haemostatic procedure or operation was 64(43-97) minutes.

CONCLUSIONS

Although the hybrid OR may be used for haemostasis in severely injured patients, the long median time from ER arrival to the start of a haemostatic procedure in hybrid OR indicates the need for a new workflow to reduce this time and to facilitate hybrid OR use.

Effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing for patients with pelvic fractures and hemodynamic instability: A propensity score matching analysis

INTRODUCTION

We evaluated the effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing (PPP) for patients with hemodynamic instability due to severe pelvic fractures.

MATERIALS AND METHODS

Between May 2014 and October 2018, 53 of 75 patients who underwent PPP due to hemodynamic instability induced by pelvic fracture were enrolled. Their medical records were prospectively collected and retrospectively analyzed. QuikClot combat gauze (hydrophilic gauze impregnated with kaolin) and general surgical tape were used in 21 patients, while general surgical tape was used in the remaining 32 patients.

RESULTS

As there were differences in the characteristics of patients between the hemostatic gauze (HG) group and control group, propensity score matching (PSM) was performed to adjust for age, sex, and lactate levels. After PSM, the clinical characteristics between the two groups became similar. There were no differences in the rates of mortality and hemorrhage-induced mortality between the two groups. However, the packed red blood cell (RBC) requirement for an additional 12 hours in the HG group was significantly lower than that in the control group (4.1 ± 3.5 vs. 7.6 ± 6.1 units, p = 0.035). The lengths of intensive care unit and hospital stays tended to be shorter in the HG group than in the control group (11.6 vs. 18.5 days, p = 0.1582; 30.8 vs. 47.4 days, p = 0.1861, respectively).

CONCLUSIONS

The use of HG during PPP did not reduce hemorrhage-induced mortality, but did reduce the need for additional packed RBC transfusions in patients with hemodynamic instability due to severe pelvic fractures.

Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center

BACKGROUND

Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center.

METHOD

The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality.

RESULT

Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80 min, p = 0.022), time from admission to operation (125 vs. 112 min, p = 0.010), time from admission to first treatment (119 vs. 99 min, p = 0.004), and time from admission to first transfusion (70 vs. 52 min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24 h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period.

CONCLUSION

After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.

Extraperitoneal packing in unstable blunt pelvic trauma: A single-center study

BACKGROUND

Hemodynamically unstable pelvic fractures often require a multi-modal approach including both operative and endovascular management. While an important adjunct in hemorrhage control, time to angioembolization even at the most advanced trauma centers may take hours. Extraperitoneal packing (EPP) is a fast and effective procedure that can immediately address pelvic hemorrhage from the retroperitoneal space in severe pelvic injuries. The aim of this study was to evaluate the efficacy of early EPP, looking at 24 hours and overall mortality, and the hemodynamic impact of EPP in unstable blunt pelvic trauma.

METHODS

All trauma patients admitted to an urban Level I trauma center were evaluated from 2002 to 2018 in a retrospective single-center comparative study. Inclusion criteria were patients 14 years or older who sustained blunt trauma with pelvic fractures and hemodynamic instability. Exclusion criteria were a concomitant head injury (Abbreviated Injury Scale >3) and patients who underwent resuscitative thoracotomy. The patient population was divided into two groups: an EPP group and a no-EPP group. Propensity score matching was used to adjust for differences in baseline characteristics in the two groups: a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each patient.

RESULTS

Two hundred forty-four patients presented hemodynamically unstable, with a pelvic fracture (180 no-EPP, 64 EPP). With propensity score matching, 37 patients in each group were analyzed. Survival within the first 24 hours was significantly improved in the EPP group (81.1% vs. 59.5%, p = 0.042) and we registered similar results in overall survival rate (78.4% EPP group vs. 56.8% no-EPP group, p = 0.047). Those patients who underwent early EPP (n = 64) were associated with a significant improvement in hemodynamic stability, with a pre-EPP mean arterial pressure of 49.9 mm Hg and post-EPP mean arterial pressure of 70.1 mm Hg (p < 0.01).

CONCLUSION

Extraperitoneal pelvic packing is an effective procedure that can be performed immediately, even within the trauma bay, to improve hemodynamic stability and overall survival in patients who sustain severe blunt pelvic trauma. The early use of EPP can be lifesaving.

LEVEL OF EVIDENCE

Therapeutic, Level III.

The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study

BACKGROUND

Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects.

METHODS

This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05.

RESULTS

A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%).

CONCLUSION

Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Clinical outcomes of blood transfusion to patients with pelvic fracture in the initial 6 h from injury

As part of the treatment of pelvic fracture, major hemorrhage poses a challenge for trauma surgeons. The aim of the present study was to evaluate the clinical outcomes of blood transfusion in the initial 6 h after pelvic fracture, and to define the blood transfusion volume required for each pelvic fracture type. A retrospective cohort study was performed on patients with pelvic fracture at a single Level I Trauma Centre over a 3-year period. A total of 1,297 patients were transported to our trauma centre within 2 h of injury and blood transfusion was administered in the initial 6 h after pelvic fracture. Review of the patients' medical records provided the initial pelvic radiographs and data from emergency department care. Clinical outcomes, including frequency of blood transfusion, blood transfusion volume, injury severity scores and mortality, were evaluated. All pelvic fractures were defined as closed fractures and patients were categorized according to the Arbeit fuer Osteosynthese (AO) classification system. Statistical methods were used to identify trends to provide guidance for clinical prediction. Complete data were available for 497 patients with pelvic fracture, 104 (20.9%) of which received blood transfusion. The blood transfusion volume in the initial 6 h ranged from 0 to 10,000 ml, with a mean of 1,213.94±1354.11 ml. The total mortality rate was 1.8%. Among the patients with C-type pelvic fractures, the frequency of blood transfusion was 59.0% and the mean volume was 2,191.30±1,740.93 ml. The mortality rate for C-type pelvic fractures was 11.43%. The B3 subtype of pelvic fractures had the highest transfusion frequency (53.6%), while the C3 subtype had the largest blood transfusion volume (5,700.00±4,666.90 ml). Patients with type A-C pelvic fractures had a progressively larger mean transfusion volume, transfusion frequency and mortality in the initial 6 h after pelvic fracture. The AO classification system was demonstrated to be a useful tool for the identification of pelvic fracture risk in the present study.

Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation

OBJECTIVE

To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP).

DESIGN

Retrospective observational cohort study.

SETTING

Level I academic trauma center.

PATIENTS

Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring.

INTERVENTION

Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87).

MAIN OUTCOME MEASURE

Incidence of postoperative surgical site infections of the pelvic space.

RESULTS

Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1-3 days) and 3.4 ± 3.7 days (range: 0-15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures.

CONCLUSIONS

These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures.

LEVEL OF EVIDENCE

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

Prospective validation of a new protocol with preperitoneal pelvic packing as the mainstay for the treatment of hemodynamically unstable pelvic trauma: a 5-year experience

PURPOSES

Hemodynamically unstable pelvic trauma has been a significant challenge even in most experienced Trauma Centres. In 2011 preperitoneal pelvic packing (PPP) was introduced in our Hospital as the first manoeuvre. This study aims to review overall mortality at 24 h from arrival in the emergency department.

METHODS

A retrospective review of our prospective database was performed considering patients with systolic blood pressure (SBP) < 90 mmHg or with the need for more than 2 Units of packed red blood cells (PRBC) on admission in the emergency department, (ED) and a pelvic fracture. Values were expressed as a median and interquartile range. Continuous variables were compared with the Mann-Whitney test.

RESULTS

Between September 2011 and December 2016, we treated 30 patients. Median age was 51 years (40-65) and Injury Severity Score 36 (34-42). SBP in the ED was 90 (67-99), heart rate was 115 (90-130), Base Excess - 8 (- 11.5/- 4.8), pH 7.23 (7.20-7.28). Median PRBC requirements during the first 24 h (from admission) were 13 Units (8-18.8). Time to emergency treatment was 63 min (51-113). 17 patients (56.6%) underwent angiography after PPP. Overall 24 h mortality was 30%. A comparison between survivors and non-survivors showed no statistically significant differences between groups.

CONCLUSIONS

In our experience, PPP resulted to be quick to perform and effective. No death occurred from direct pelvic bleeding.

Effectiveness and postoperative wound infection of preperitoneal pelvic packing in patients with hemodynamic instability caused by pelvic fracture

Introduction

Despite the use of a multidisciplinary treatment approach, the mortality rate of hemodynamic instability due to severe pelvic fracture remains 40–60%. Several recent studies have shown that preperitoneal pelvic packing (PPP) was useful for achieving hemostasis in these patients in the acute phase. However, few studies have examined postoperative complications. The purpose of the present study was to evaluate clinical outcomes and wound infections of PPP in these patients.

Materials and methods

We retrospectively reviewed the medical charts of 62 patients with hemorrhagic shock due to pelvic fracture between March 2011 and May 2017. Excluding four patients (two with other major hemorrhage sites and two who experienced cardiac arrest in the emergency room), the patients were divided into PPP (n = 30) and non-PPP (n = 28) groups according to PPP application. Clinical outcomes including early-stage mortality, transfusion amount, and surgical site infection (SSI) were compared between the two groups.

Results

The overall mortality rate was 48.3% and the mean Injury Severity Score (ISS) was 39 ± 9. The 30 patients in the PPP group had a significantly lower hemorrhage-induced mortality rate than the 28 patients in the non-PPP group (16.7% vs 50%, p = 0.019), although both groups had similar patient characteristics (age, ISS, and initial serum lactate level). Independent factors associated with hemorrhage-induced mortality were PPP and the requirement of packed red blood cells for 4 h. In the PPP group, SSI occurred in 5 of 25 (20%) patients.

Conclusions

PPP may be considered as a hemostatic modality for hemodynamic instability due to pelvic fracture because it reduces the hemorrhage-induced mortality rate. However, wound infections after the procedure should be considered.

Current trends in the management of hemodynamically unstable pelvic ring injuries

PURPOSE OF REVIEW

Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries.

RECENT FINDINGS

Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization.

SUMMARY

Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.

Renal pelvicalyceal rupture secondary to extraperitoneal pelvic packing (EPP) in the unstable trauma patient

Presented here is the case of an 86-year-old man who was found to have right-sided pelvicalyceal rupture and anuric renal failure, secondary to obstructive uropathy caused by life-saving extraperitoneal pelvic packing (EPP) in the settling of severe trauma. In efforts to control haemorrhage in this haemodynamically unstable patient, EPP placement deviated from the recognised method of three extraperitoneal packs bilaterally with seven surgical packs placed. Progress postoperative imaging revealed right-sided hydroureteronephrosis with obstruction evident at the level of the extraperitoneal pelvic packs, identified by delayed contrast excretion from the preceding CT angiography imaging. Urology performed bilateral retrograde pyelograms at his relook laparotomy, timed after removal of his extraperitoneal packs and haemostasis, which showed impression of the surgical pack on the distal ureter but no persisting obstruction or short-term complications. Anuric renal failure improved, and renal function returned to near premorbid levels on day 4 postoperatively.

Vertical shear pelvic injury: evaluation, management, and fixation strategies

Vertical shear pelvic ring fractures are rare and account for less than 1% of all fractures. Unlike severely displaced antero-posterior compression and lateral compression pelvic fractures, patients' mortality is lower. Nevertheless, patients must be managed acutely using well-defined ATLS protocols and institution-specific protocols for haemodynamically unstable pelvic ring fractures. The definitive treatment of vertical shear pelvic fractures is however more controversial with a paucity of literature to recommend the ideal reduction and fixation strategy. While the majority of injuries can be reduced and fixed in a closed manner, orthopaedic traumatologists should be familiar with the contraindications to those techniques as well as options such as tension band plating and lumbo pelvic fixation. Our paper reviews the acute management, associated injuries and definitive reduction and fixation strategies of vertical shear pelvic fractures. In addition, we propose a treatment algorithm for the selection of the most appropriate fixation technique.

Severe Bleeding in Pelvic Fractures: Considerations in Planning Damage Control

Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.

Improvement of outcomes in patients with pelvic fractures and hemodynamic instability after the establishment of a Korean regional trauma center

PURPOSE

Despite using a multidisciplinary treatment approach, the mortality rate of patients with hemodynamic instability from severe pelvic fractures is still 40-60%. We evaluated the improvement of outcomes in this patient population after the establishment of a regional trauma center in Korea.

METHODS

We retrospectively reviewed the medical charts of 50 patients with hemodynamic instability due to pelvic fractures between March 2011 and November 2016. Patients were divided into two groups: the pre-trauma center (PTC) group (n = 23) and trauma center (TC) group (n = 27).

RESULTS

Sixteen (32.0%) patients died of exsanguination. Patients in the TC group had shorter trauma resuscitation room stay (101 vs 273 min, p < 0.001) and underwent preperitoneal pelvic packing (PPP) more frequently (88.9 vs 8.7%, p < 0.001) than those in the PTC group. During the TC period, emergent procedures such as PPP and pelvic angiography were performed more frequently (92.6 vs 39.1%, p < 0.001). Although there was no statistical difference in the overall mortality rate between groups, patients in the TC group had less mortality due to hemorrhage (18.5 vs 47.8%, p = 0.027). Logistic regression analysis demonstrated that initial systolic blood pressure and establishment of trauma center were independent protective factors of mortality from hemorrhage [odds ratio (OR) 0.957, 95% confidence interval (CI) 0.926-0.988, p = 0.007; OR 0.134, 95% CI 0.028-0.633, p = 0.011].

CONCLUSIONS

Since the regional trauma center was established, emergent procedures such as pelvic angiography and PPP were performed more frequently, and mortality due to exsanguination was significantly decreased.

Complex pelvic ring injuries associated with floating knee in a poly-trauma patient: A case report

RATIONALE

Complex pelvic ring fracture associated with floating knee is comparatively rare which usually results from high-energy trauma including vehicle-related accidence, falls from height, and earthquake-related injury. To our knowledge, few literatures have documented such injuries in the individual patient. Management of both injuries present challenges for surgical management and postoperative care. The purpose of this study is to prove the feasibility and benefits of damage control orthopedics (DCO).

PATIENT CONCERN

Our case involved a 45-year-old lady who was hit by a dilapidated building. The patient was anxious, pale and hemodynamically stable at the initial examination. The pelvis was unstable and there were obvious deformities in the left lower extremities. Significant degloved injuries in the left leg were noted. Her radiographs and physical examination verified the above signs.

DIAGNOSES

Unstable pelvic fractures, multiple fractures of bilateral lower limbs with floating knee injury, multiple pelvic and rib fractures and multiple degloving injuries and soft tissue contusion formed the characteristics of the multiple-injury.

INTERVENTIONS

The algorithm of DCO was determined as the treatment. Early simplified procedures such as wound debridement, pelvis fixation, closed reduction and EF of the right shoulder joint, and chest wall fixation were conducted as soon as possible. After a period of time, internal fixations were applied to the fracture sites. The subsequent functional exercise was also conducted in accordance with this algorithm.

OUTCOMES

This patient got recovery after the treatments which were guided by the criterion of DCO. The restoration of limb functional and the quality of life greatly improved.

LESSONS

The DCO plays a decisive role in the first aid and follow-up treatment of this patient. The guidelines of management of complex pelvic ring injuries and floating knee should be established by authorities.

Effect of Retroperitoneal Pelvic Packing on Pelvic Cavity Pressure: A Cadaveric Study

Limited clinical evidence demonstrates the effectiveness of direct retroperitoneal pelvic packing for hemorrhage control in pelvic fractures due to the difficulty in measuring pressure on the pelvic walls within the pelvic cavity after retroperitoneal pelvic packing. Using a cadaver model, the authors aimed to assess whether retroperitoneal pelvic packing generates pressure that exceeds the venous return and arterial pressure in the pelvis. The pressure on the pelvic wall was measured in 5 fresh Japanese cadavers. Sensors were placed at 4 points on the pelvic wall, and the pressure at each point was measured after the insertion of each of 3 sponges, per the procedure originally described for direct retroperitoneal pelvic packing. In each specimen, the average pressure across all 4 points on the pelvic wall increased with the addition of each sponge, reaching 12.3±4.5 mm Hg when all 3 sponges were inserted. Furthermore, the pressure at the pelvic floor and posterior pelvic brim increased significantly, whereas the pressure at the anterior and middle pelvic brim increased nonsignificantly. The results of this study suggest that retroperitoneal pelvic packing provides pressure on the pelvic wall that exceeds the venous pressure and is thus effective for the control of venous hemorrhage in pelvic fractures. Currently, the recommended procedure combines external fixation for venous bleeding, transcatheter arterial embolization, and pelvic packing; however, the authors' results suggest that pelvic packing alone may be effective for controlling venous hemorrhage in pelvic fracture. [Orthopedics. 2017; 40(6);e947-e951.].

Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures

BACKGROUND

A 2015 American Association for the Surgery of Trauma trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized that preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality.

METHODS

In 2004, we initiated a PPP protocol for pelvic fracture hemorrhage.

RESULTS

During the 11-year study, 2,293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age, 44 ± 2 years; Injury Severity Score (ISS), 48 ± 1.2). The lowest emergency department systolic blood pressure was 74 mm Hg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions before SICU admission compared with the 24 postoperative hours were 8 versus 3 units (p < 0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush.Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the operating room at 89 and 100 minutes after arrival, whereas 1 died 9 hours after arrival.

CONCLUSIONS

PPP results in a shorter time to intervention and lower mortality compared with modern series using AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be used for pelvic fracture-related bleeding in the patient who remains unstable despite initial transfusion.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Preperitoneal balloon tamponade for lethal closed retroperitoneal pelvic hemorrhage in a swine model: A comparable and minimally invasive alternative to open pre-peritoneal pelvic packing

BACKGROUND

The management of massive pelvic fracture-associated hemorrhage is extremely challenging, particularly in the unstable patient. We sought to characterize and compare the efficacy of a minimally invasive preperitoneal balloon technique (MIB) to standard open packing.

METHODS

Twenty-six swine were randomized to control (C), open preperitoneal packing technique (OP), and MIB groups. A closed extraperitoneal iliac vascular injury followed by intervention + resuscitation over a 120-minute OP and MIB efficacy was assessed by procedure time, hemodynamics, extraperitoneal tamponade pressures (ETPs), blood loss, and survival. Angiography was performed in select animals, and ETPs were also measured in humans undergoing MIB placement for an elective procedure.

RESULTS

Baseline parameters (mean arterial pressure [MAP] 29, 38, and 38 mm Hg; cardiac index [CI] 3.5, 3.8, and 4.2; and EPTs 5, 4, and 5 mm Hg) were similar among C, OP, and MIB groups, respectively (all p's > 0.05). The OP and MIB groups had markedly improved MAP and CI versus C. MIB generated significantly higher ETP (28 vs 17 mm Hg), was faster to deploy (164 vs 497 seconds), and had lower total blood loss versus OP (0.7 vs 1.2 L, all p's < 0.05). OP and MIB had equivalent survival times that were significantly improved versus C (91 and 116 vs 43 minutes, p < 0.05). Survival to 2 hours was 80% with OP versus 100% in the MIB group. Angiography showed no active extravasation in both study groups, but controlled partial deflation of the MIB allowed easy visualization of extravasation. Minimally invasive preperitoneal balloon inflation in five human subjects demonstrated a significant increase in mean ETP from 2.4 to 31 mm Hg (p < 0.01).

CONCLUSION

Minimally invasive preperitoneal balloon tamponade was as effective as OP in improving hemodynamics and prolonging survival times, and performed superiorly to OP in time to placement, blood loss, and generation of tamponade pressures. The MIB allows for controlled deflation and reinflation to facilitate angiographic interventions, and may represent a promising new bedside intervention in this patient population.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

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.