Control of hemorrhage from pelvic fractures remains a problem. Is it better to control with external fixation, preperitoneal packing, angio-embolization, or REBOA. This multi-institutional study attempts to sort this out...
CURRENT MANAGEMENT OF HEMORRHAGE FROM SEVERE PELVIC FRACTURES: RESULTS OF AN AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA MULTI-INSTITUTIONAL TRIAL
Todd W. Costantini MD, Raul Coimbra* MD,Ph.D., John Holcomb* MD, Richard Catalano MD, Thomas M. Scalea* MD, Lashonda Williams MD, Scott Keeney DO, Jason Sperry* MD, Dimitra Skiada MD, Brian H. Williams MD, Alicia Privette MD, Forrest Moore* MD, Pelvic Fracture Study Group, AAST Multi-Institutional Trials Committee
Introduction: There is no consensus as to the optimal treatment paradigm for patients presenting with hemorrhage from severe pelvic fracture. This study was established to determine the methods of hemorrhage control currently being employed in clinical practice.
Methods: This prospective, observational multi-center study enrolled patients with pelvic fracture from blunt trauma. Demographic data, admission vital signs, presence of shock on admission (SBP < 90mmHg or HR>120 or base deficit < -5), method of hemorrhage control, time to hemorrhage control, transfusion requirements, and outcome were collected.
Results: A total of 1339 patients with pelvic fracture were enrolled from eleven Level 1 trauma centers. 57% were male with a mean age of 47.1 ± 21.6 and ISS of 19.2 ± 12.7. In-hospital mortality was 9%. Angioembolization and external fixator placement were the most common methods of hemorrhage control utilized (see Table). 128 patients (9.6%) underwent diagnostic angiography with contrast extravasation noted in 63 patients. Therapeutic angioembolization was performed on 79 patients (5.9%). There were 178 patients (13.3%) with pelvic fracture admitted in shock with a mean ISS of 28.2 ± 14.1. In the shock group, 44 patients (24.7%) underwent angiography to diagnose a pelvic source of bleeding with contrast extravasation found in 27 patients. 30 patients (16.9%) were treated with therapeutic angioembolization. Aortic balloon occlusion (REBOA) was performed on 5 patients in shock and utilized by only 1 of the participating centers. Patients admitted in shock received an average of 11.8 ± 12.8 units of PRBCs and 10.3 ± 12.5 units of FFP. Mortality was 32% for patients with pelvic fracture admitted in shock.
Conclusion: Patients with pelvic fracture admitted in shock have high mortality. Several methods were utilized for hemorrhage control with significant variation across institutions. The use of REBOA may prove to be an important adjunct in the treatment of patients with severe pelvic fracture in shock; however, it is in the early stages of evaluation and not currently used widely across trauma centers.
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