Current Management of Hemorrhage from severe pelvic fracture: Results of an AAST multi-institutional trial. Costantini TW, Coimbra R, Holcomb JB, et al. J Trauma Acute Surg. 2016 May: 80(5):717-725.
Eleven Level 1 trauma centers compiled 1,339 patients with pelvic fractures over a two year period ending in January 2015. Just over half were male with a mean age of 47 +/- 20 years. Typical mechanisms were motor vehicle crashes, falls, auto versus pedestrian and motorcycle crashes and the mean injury severity score (ISS) was severe at 19. The average ICU and overall length of stay was long at 8 and 11 days respectively. The diagnosis was made by pelvic x-ray and CT imaging.
There were 178 (13.3%) who presented meeting the criteria for shock with a mean ISS of 28. All of which had the same mechanisms mentioned above. The management used in these patients included pelvic binders (33, 18.5%), therapeutic angioembolization (30, 16.9%), External fixation (17, 9.6%), preperitoneal pelvic packing (6, 5.1%), Resuscitative endovascular balloon aortic occlusion REBOA (5 2.8%), or some combination of those above (10, 17.8%). The in-hospital mortality overall was 9.0% but for those who presented in shock is rose to 32.0%. There was however, no data mentioned as to the mortality rates associated with each intervention for hemorrhage control.
The paper concluded, “the mortality in patients with pelvic fractures is high and the treatment paradigms are variable. This suggests an opportunity for improvement in the care of these seriously injured patients. Findings from this study demonstrate no clear relationship between the choice of hemorrhage control intervention used and the patient’s clinical status. This suggests variability in management strategies across the participating centers and demonstrates the lack of consensus by trauma surgeons as to the optimal algorithm for hemorrhage control interventions.”
Trading scalpels for sheaths: Catheter-based treatment of vascular injury can be effectively performed by acute care surgeons trained in endovascular techniques. Brenner M, Hoehn M, Teeter W, et al. J Trauma Acute Care Surg. 2016 May 80(5):783-786.
REBOA and other endovascular catheter based therapies have been used in the management of bleeding patients for over 40 years around the world. Recent surge in its application in trauma has become a hot topic.
This article explores the experience of REBOA and other catheter based treatments performed by acute care surgeons (ACS) at a high volume single institution. The patients analyzed were mostly male suffering from blunt injury and were severely injured with mean ISS 32. All patients survived at least 24 hours. All patients were treated by two faculty with board certification in general and vascular surgery but whose clinical practice is “considered ACS by virtue of certifications, experience and a majority clinical practice focused on the care of trauma patients.”
The procedures performed for pelvic hemorrhage were pelvic embolization (13) and REBOA (4) placement. Many other catheter based procedures were performed but not discussed in this review due to the nature of the topic. Overall mortality in the patient population as a whole was 14.7% and not related to an endovascular procedure.
The paper concluded that the modern increased use of angioembolization needed in trauma warranted catheter based techniques as part of ACS training.
The potential benefit of a hybrid operating environment among severely injured patients with persistent hemorrhage: How often could we get it right? Fehr A, Beveridge J, D’Amours SD, et al. J Trauma Acute Care Surg. 2016 Mar;80(3):457-60.
The hybrid operating room can eliminate the need to transfer a bleeding patient from the OR to the angiography suite. This article thoughtfully looks at all adult, severely injured, persistently hypotensive trauma patients over 18 years who were admitted to a single level 1 trauma center (N = 911). The authors reviewed each case to determine if there would have been “clear” and “potential” benefit for the theoretical use of a hybrid OR based on the need for both procedural and open therapeutic interventions. “Clear” benefit meant a hybrid OR was a must for a good outcome. “Potential” benefit meant a hybrid OR would have been nice but not needed.
A total of 35 patients (7%) required both angiography and an operative intervention. Pelvic fractures and liver hemorrhage were the most common injury in these patients. The mortality in those who underwent angiography first was 32% compared to 90% mortality if angiography was employed after open operative treatment was used.
The authors conclude, “up to 6% of patients with sustained hypotension will require both operative and angiographic procedures that would clearly benefit” from a hybrid OR and an additional 30% of patients could potentially benefit from the hybrid OR as well.
Thromboelastography in Orthopaedic Trauma Acute Pelvic Fracture Resuscitation: A Descriptive Pilot Study. Mamczak Ca, Maloney M, Fritz B, et al. J Orthop Trauma. 2016 June 30(6):299-305.
Hemostatic resuscitation advocates for permissive hypotension, optimal blood ratios, minimization of crystalloids, while factoring in the patients severity of trauma and physiologic response. Thromboelastography (TEG) assesses real time clot stability and can guide directed transfusion efforts.
This study looked at 40 multi-injured patients with pelvic and acetabular fractures that all had TEG. Transfusions were initiated in 92.5% of cases and hemodynamics, laboratory and TEG parameters were used to determine transfusion need. With the use of TEG, the ratios of blood products transfused resulted in a higher ratio of PRBC:platelets rather than PRBC:FFP with an average ratios of 2.5:1:2.8 (PRBC:FFP:Platelets).
Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures. a Propensity Score Analysis. Chiara O, di Fratta E, Mariani A, et al. World J Emerg Surg. 2016 June 1;11:22.
Extra-peritoneal pelvic packing (EPP) was first described 20 years ago and has been shown to be quick and effective in reducing mortality and transfusion rates.
This study looked at 78 hemodynamically unstable patients and compared 30 who underwent EPP to 48 patients who did not undergo EPP (NO-EPP) to evaluate the transfusion requirement in the first 24 hours and ICU length of stay. Patients were evaluated over an 11 year period (2003-2013) and case control matching was performed. A treatment algorithm change in 2009 included EPP.
“The propensity score analysis was used to adjust the difference in the baseline characteristic and severity of condition at admission between the two groups.” 25 patients in each group were matched. Overall mortality was decreased in the EPP group and showed fewer early deaths. There were no differences in PRBC requirements in the first 24 hours or ICU length of stay.