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Acute Management of Hemodynamically Unstable Pelvic Trauma Patients: Time for a Change? Multicenter Review of Recent Practice

World Journal of Surgery volume 32, pages 1874–1882 (2008)Cite this article

An Erratum to this article was published on 28 May 2014

Abstract

Background

Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM.

Methods

Blunt trauma patients [Injury Severity Score (ISS) ≥16] with a major pelvic fracture (Abbreviated Injury Score, pelvis ≥3) and hemodynamic instability [admission systolic blood pressure (SBP) ≤90 mmHg or receiving ≥6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean ± SD.

Results

A total of 217 patients (mean age 41 ± 19 years, 71% male, ISS 42 ± 16) were studied. The admission SBP was 96 ± 37 mmHg and the Glascow Coma Scale (GCS) 11 ± 5. Patients received 4 ± 2 liters of fluids including 4 ± 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%).

Conclusion

HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by.

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Acknowledgments

We thank the data managers and nursing staff from the Trauma, Orthopedics, and Accident and Emergency departments of all participating hospitals.

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Affiliations

  1. Trauma Department, Academic Medical Center, PO Box 22660, Amsterdam, 1100 DD, The Netherlands

    Diederik Verbeek

  2. Trauma Department, Liverpool Hospital, Sydney, NSW, Australia

    Michael Sugrue

  3. Trauma Department, John Hunter Hospital, Newcastle, NSW, Australia

    Zsolt Balogh & Vanessa Wills

  4. Institute of Trauma and Injury Management (ITIM), Sydney, NSW, Australia

    Danny Cass

  5. Trauma Department, Auckland Hospital, Grafton, New Zealand

    Ian Civil

  6. Department of Orthopaedics, Liverpool Hospital, Sydney, NSW, Australia

    Ian Harris

  7. Trauma Department, Alfred Hospital, Prahran, VIC, Australia

    Thomas Kossmann

  8. Trauma Department, Royal North Shore Hospital, Sydney, NSW, Australia

    Steve Leibman

  9. Trauma Department, Westmead Hospital, Westmead, NSW, Australia

    Valerie Malka

  10. Orthopaedics and Trauma Departments, Royal Adelaide Hospital, Adelaide, SA, Australia

    Anthony Pohl

  11. Trauma Department, Royal Perth Hospital, Perth, WA, Australia

    Sudhakar Rao

  12. Department of Orthopaedics, Royal Melbourne Hospital, Parkville, VIC, Australia

    Martin Richardson

  13. Trauma Department, Princess Alexandra Hospital, Brisbane, QLD, Australia

    Michael Schuetz

  14. Trauma Department, St. George Hospital, Sydney, NSW, Australia

    Caesar Ursic

Authors
  1. Diederik Verbeek
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  2. Michael Sugrue
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  3. Zsolt Balogh
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  5. Ian Civil
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  6. Ian Harris
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  8. Steve Leibman
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  9. Valerie Malka
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  10. Anthony Pohl
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  11. Sudhakar Rao
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  12. Martin Richardson
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  13. Michael Schuetz
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  14. Caesar Ursic
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  15. Vanessa Wills
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Correspondence to Diederik Verbeek.

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Verbeek, D., Sugrue, M., Balogh, Z. et al. Acute Management of Hemodynamically Unstable Pelvic Trauma Patients: Time for a Change? Multicenter Review of Recent Practice. World J Surg 32, 1874–1882 (2008). https://doi.org/10.1007/s00268-008-9591-z

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Keywords

  • Injury Severity Score
  • Pelvic Fracture
  • Primary Treatment Modality
  • Angiographic Embolization
  • Pelvic Fixation