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

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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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References

  1. McMurtry R, Walton D, Dickinson D et al (1980) Pelvic disruption in the polytraumatized patient: a management protocol. Clin Orthop 151:22–30

    PubMed  Google Scholar 

  2. Panetta T, Scalfani S, Goldstein AS et al (1985) Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 25:1021–1029

    CAS  PubMed  Google Scholar 

  3. Moreno C, Moore EE, Rosenberger A et al (1986) Hemorrhage associated with major pelvic fracture: a multispecialty challenge. J Trauma 26:987–994

    Article  CAS  PubMed  Google Scholar 

  4. Flint L, Babikian G, Anders M et al (1990) Definitive control of mortality from severe pelvic fracture. Ann Surg 211:703–706

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  5. Gruen GS, Leit ME, Gruen RJ et al (1994) The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures. J Trauma 36:706–711

    Article  CAS  PubMed  Google Scholar 

  6. Hamill J, Holden A, Paice R et al (2000) Pelvic fracture pattern predicts pelvic arterial haemorrhage. Aust N Z J Surg 70:338–343

    Article  CAS  PubMed  Google Scholar 

  7. Ertel W, Keel M, Eid K et al (2001) Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 15:468–474

    Article  CAS  PubMed  Google Scholar 

  8. Eastridge BJ, Starr A, Minei JP et al (2002) The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 53:446–451

    Article  PubMed  Google Scholar 

  9. Balogh Z, Caldwell E, Heetveld M et al (2005) Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability: do they make a difference? J Trauma 58:778–782

    Article  PubMed  Google Scholar 

  10. Heetveld MJ, Harris I, Schlaphoff G et al (2004) Guidelines for the management of haemodynamically unstable pelvic fracture patients. Aust N Z J Surg 74:520–529

    Article  Google Scholar 

  11. Biffl WL, Smith WR, Moore EE et al (2001) Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 233:843–850

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  12. Burgess AR, Eastridge BJ, Young JWR et al (1990) Pelvic ring disruption: effective classification system and treatment protocols. J Trauma 30:848–856

    Article  CAS  PubMed  Google Scholar 

  13. EAST Trauma Practice Guidelines. Available at: http://www.east.org/tpg.html/. Accessed October 10, 2006

  14. Pohlemann T, Bosch U, Gänsslen A et al (1994) The Hannover experience in management of pelvic fractures. Clin Orthop 305:69–80

    Article  PubMed  Google Scholar 

  15. Van Vugt AB, van Kampen A (2006) An unstable pelvic ring: the killing fracture. J Bone Joint Surg Br 88:427–433

    Article  PubMed  Google Scholar 

  16. Riemer BL, Butterfield SL, Diamond DL et al (1993) Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and external fixation. J Trauma 35:671–675

    Article  CAS  PubMed  Google Scholar 

  17. Cothren CC, Osborn PM, Moore EE et al (2007) Preperitoneal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 62:834–842

    Article  PubMed  Google Scholar 

  18. Tötterman A, Madsen JE, Skaga NO et al (2007) Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma 62:843–852

    Article  PubMed  Google Scholar 

  19. Baker SP, O’Neill B, Haddon W Jr et al (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187–196

    Article  CAS  PubMed  Google Scholar 

  20. Sarin EL, Moore JB, Moore EE et al (2005) Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma 58:973–977

    Article  PubMed  Google Scholar 

  21. Burgess AR, Tile M (1991) Fractures of the pelvis. In: Rockwood C, Green D (eds) Fractures in Adults. Lippincott, Philadelphia, pp 1399–1442

    Google Scholar 

  22. Patt A, McCroskey BL, Moore EE (1988) Hypothermia induced coagulopathy. Surg Clin North Am 68:775–785

    CAS  PubMed  Google Scholar 

  23. Demetriades D, Karaiskakis M, Toutouzas K et al (2002) Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 195:1–10

    Article  PubMed  Google Scholar 

  24. Agolini SF, Shah K, Jaffe J et al (1997) Arterial embolization is a rapid and effective technique for controlling pelvic fracture haemorrhage. J Trauma 43:395–399

    Article  CAS  PubMed  Google Scholar 

  25. Velmahos GC, Chahwan S, Falabella A et al (2000) Angiographic embolization for intraperitoneal and retroperitoneal injuries. World J Surg 24:539–545

    Article  CAS  PubMed  Google Scholar 

  26. Velmahos GC, Konstantinos GT, Vassiliu P et al (2002) A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 52:303–308

    Article  Google Scholar 

  27. Cook RE, Keating JF, Gillespie I (2002) The role of angiography in the management of haemorrhage from major fractures of the pelvis. J Bone Joint Surg Br 84:178–182

    Article  CAS  PubMed  Google Scholar 

  28. Fangio P, Asehnoune K, Edouard A et al (2005) Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture. J Trauma 58:978–984

    Article  PubMed  Google Scholar 

  29. Hagiwara A, Minakawa K, Fukushima H et al (2003) Predictors of death in patients with life-threatening pelvic hemorrhage after successful transcatheter arterial embolization. J Trauma 55:696–703

    Article  PubMed  Google Scholar 

  30. Kimbrell BJ, Velmahos GC, Chan LS et al (2004) Angiographic embolization for pelvic fractures in older patients. Arch Surg 139:728–733

    Article  PubMed  Google Scholar 

  31. Miller PR, Moore PS, Mansell E et al (2003) External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 54:437–443

    Article  PubMed  Google Scholar 

  32. Gourlay D, Hoffer E, Routt M et al (2005) Pelvic angiography for recurrent traumatic pelvic arterial hemorrhage. J Trauma 59:1168–1174

    Article  PubMed  Google Scholar 

  33. Shapiro M, McDonald A, Knight D et al (2005) The role of repeat angiography in the management of pelvic fractures. J Trauma 58:227–231

    Article  PubMed  Google Scholar 

  34. Gänsslen A, Giannoudis P, Pape HS (2003) Hemorrhage in pelvic fracture: who needs angiography? Curr Opin Crit Care 9:515–523

    Article  PubMed  Google Scholar 

  35. Ruchholtz S, Waydhas C, Lewan U et al (2004) Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary? J Trauma 57:278–286

    Article  PubMed  Google Scholar 

  36. Sugrue M, Caldwell E, D’Amours S, et al (2008) Time for a change in injury and trauma care delivery; a trauma death review analysis. ANZ J Surg (in press)

  37. Rhodes M (1994) Practice management guidelines for trauma care: presidential address, seventh scientific assembly of the eastern association for the surgery of trauma. J Trauma 37:635–644

    Article  CAS  PubMed  Google Scholar 

Download references

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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Authors and 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

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  1. Diederik Verbeek
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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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