Abstract
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.
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References
Kim Y, Jung KY, Cho KH, Kim H, Ahn HC. Preventable trauma deaths rates and management errors in emergency medical system in Korea. J Korean Soc Emerg Med. 2006;17:385–94.
Kim H, Jung KY, Kim SP, Kim SH, Noh H, Jang HY, et al. Changes in preventable death rates and traumatic care systems in Korea. J Korean Soc Emerg Med. 2012;23(2):189–97.
Jung K, Huh Y, Lee JC, Kim Y, Moon J, Youn SH, et al. Reduced mortality by physician-staffed HEMS dispatch for adult blunt trauma patients in Korea. J Korean Med Sci. 2016;31(10):1656–61. https://doi.org/10.3346/jkms.2016.31.10.1656.
Costantini TW, Coimbra R, Holcomb JB, Podbielski JM, Catalano R, Blackburn A, et al. Current management of hemorrhage from severe pelvic fractures: results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care. 2016;80(5):717–23. https://doi.org/10.1097/Ta.0000000000001034.
Sathy AK, Starr AJ, Smith WR, Elliott A, Agudelo J, Reinert CM, et al. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am. 2009;91a(12):2803–10. https://doi.org/10.2106/Jbjs.H.00598.
Mucha P, Welch TJ. Hemorrhage in major pelvic fractures. Surg Clin N Am. 1988;68(4):757–73.
ONeill PA, Riina J, Sclafani S, Tornetta P. Angiographic findings in pelvic fractures. Clin Orthop Relat R. 1996;329:60–7.
Eastridge BJ, Starr A, Minei JP, O’Keefe GE. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma. 2002;53(3):446–50. https://doi.org/10.1097/01.Ta.0000025659.37314.82.
Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury. 2004;35(7):671–7. https://doi.org/10.1016/j.injury.2004.03.003.
Starr AJ, Griffin DR, Reinert CM, Frawley WH, Walker J, Whitlock SN, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma. 2002;16(8):553–61. https://doi.org/10.1097/00005131-200209000-00003.
Jang JY, Shim H, Jung PY, Kim S, Bae KS. Preperitoneal pelvic packing in patients with hemodynamic instability due to severe pelvic fracture: early experience in a Korean trauma center. Scand J Trauma Resus. 2016. https://doi.org/10.1186/s13049-016-0196-5.
Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007;62(4):834–9. https://doi.org/10.1097/TA.0b013e31803c7632.
Burlew CC, Moore EE, Smith WR, Johnson JL, Biffl WL, Barnett CC, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surgeons. 2011;212(4):628–35. https://doi.org/10.1016/j.jamcollsurg.2010.12.020.
Jang JY, Shim H, Jung PY, Kim S, Bae KS. Preperitoneal pelvic packing prior to pelvic angiography in patients with hemodynamic instability due to severe pelvic fracture: two cases. J Acute Care Surg. 2016;6(1):34–9. https://doi.org/10.17479/jacs.2016.6.1.34.
Biffl WL, Smith WR, Moore EE, Gonzalez RJ, Morgan SJ, Hennessey T, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg. 2001;233(6):843–50.
Conolly WB, Hedberg EA. Observations on fractures of the pelvis. J Trauma. 1969;9(2):104–11.
Huittinen VM, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery. 1973;73(3):454–62.
Burlew CC, Moore EE, Stahel PF, Geddes AE, Pieracci AE, Wagenaar AE, et al. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care. 2017;82(2):233–42.
Cheng M, Cheung MT, Lee KY, Lee KB, Chan SCH, Wu ACY, et al. Improvement in institutional protocols leads to decreased mortality in patients with haemodynamically unstable pelvic fractures. Emerg Med J. 2015;32(3):214–20. https://doi.org/10.1136/emermed-2012-202009.
Li QH, Dong JL, Yang YL, Wang GD, Wang YH, Liu P et al. Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures-Quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥33. Injury. 2016;47(2):395–401. https://doi.org/10.1016/j.injury.2015.10.008.
Chiara O, di Fratta E, Mariani A, Michaela B, Prestini L, Sammartano F, et al. Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a propensity score analysis. World J Emerg Surg. 2016. https://doi.org/10.1186/s13017-016-0077-2
Acknowledgements
We thank the staff of all the regional trauma centers in Korea for their enthusiasm and commitment to patient care. The authors confirm that were not in receipt of any grants.
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There are no potential conflicts of interest for each of the authors.
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The present study protocol was reviewed and approved by the institutional review board of Wonju Severance Christian Hospital (Reg. No. CR316111). Informed consent was exempted, because it was a retrospective study.
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Jang, J.Y., Shim, H., Kwon, H.Y. et al. Improvement of outcomes in patients with pelvic fractures and hemodynamic instability after the establishment of a Korean regional trauma center. Eur J Trauma Emerg Surg 45, 107–113 (2019). https://doi.org/10.1007/s00068-017-0886-3
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DOI: https://doi.org/10.1007/s00068-017-0886-3