The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study

Juan Duchesne, Todd W. Costantini, Mansoor Khan, Ethan Taub, Peter Rhee, Bryan Morse, Nicholas Namias, Alon Schwarz, Joanne Graves, Dennis Y. Kim, Erin Howell, Jason Sperry, Vincent Anto, Robert D. Winfield, Martin Schreiber, Brandon Behrens, Benjamin Martinez, Shariq Raza, Mark Seamon, Danielle Tatum

Research output: Contribution to journalArticle

Abstract

BACKGROUND Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE Therapeutic study, level IV.

Original languageEnglish (US)
Pages (from-to)117-124
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Volume87
Issue number1
DOIs
StatePublished - Jul 1 2019

Fingerprint

Balloon Occlusion
Aorta
Hemorrhage
Shock
Interventional Radiology
Operating Rooms
Mortality
Blood Pressure
Glasgow Coma Scale
Injury Severity Score
Trauma Centers
Resuscitation
Heart Rate
Wounds and Injuries

Keywords

  • hemorrhage control
  • pelvic binder
  • Pelvic fracture
  • preperitoneal packing
  • REBOA

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture : A multi-institutional study. / Duchesne, Juan; Costantini, Todd W.; Khan, Mansoor; Taub, Ethan; Rhee, Peter; Morse, Bryan; Namias, Nicholas; Schwarz, Alon; Graves, Joanne; Kim, Dennis Y.; Howell, Erin; Sperry, Jason; Anto, Vincent; Winfield, Robert D.; Schreiber, Martin; Behrens, Brandon; Martinez, Benjamin; Raza, Shariq; Seamon, Mark; Tatum, Danielle.

In: Journal of Trauma and Acute Care Surgery, Vol. 87, No. 1, 01.07.2019, p. 117-124.

Research output: Contribution to journalArticle

Duchesne, J, Costantini, TW, Khan, M, Taub, E, Rhee, P, Morse, B, Namias, N, Schwarz, A, Graves, J, Kim, DY, Howell, E, Sperry, J, Anto, V, Winfield, RD, Schreiber, M, Behrens, B, Martinez, B, Raza, S, Seamon, M & Tatum, D 2019, 'The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study', Journal of Trauma and Acute Care Surgery, vol. 87, no. 1, pp. 117-124. https://doi.org/10.1097/TA.0000000000002316
Duchesne, Juan ; Costantini, Todd W. ; Khan, Mansoor ; Taub, Ethan ; Rhee, Peter ; Morse, Bryan ; Namias, Nicholas ; Schwarz, Alon ; Graves, Joanne ; Kim, Dennis Y. ; Howell, Erin ; Sperry, Jason ; Anto, Vincent ; Winfield, Robert D. ; Schreiber, Martin ; Behrens, Brandon ; Martinez, Benjamin ; Raza, Shariq ; Seamon, Mark ; Tatum, Danielle. / The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture : A multi-institutional study. In: Journal of Trauma and Acute Care Surgery. 2019 ; Vol. 87, No. 1. pp. 117-124.
@article{f5f3c9bd744c418ebbc68f45e3814a34,
title = "The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study",
abstract = "BACKGROUND Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62{\%}) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32{\%}. The most common adjunct used was pelvic binder (50{\%}) followed by no adjunct (30.5{\%}); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5{\%}). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46{\%}). CONCLUSION Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE Therapeutic study, level IV.",
keywords = "hemorrhage control, pelvic binder, Pelvic fracture, preperitoneal packing, REBOA",
author = "Juan Duchesne and Costantini, {Todd W.} and Mansoor Khan and Ethan Taub and Peter Rhee and Bryan Morse and Nicholas Namias and Alon Schwarz and Joanne Graves and Kim, {Dennis Y.} and Erin Howell and Jason Sperry and Vincent Anto and Winfield, {Robert D.} and Martin Schreiber and Brandon Behrens and Benjamin Martinez and Shariq Raza and Mark Seamon and Danielle Tatum",
year = "2019",
month = "7",
day = "1",
doi = "10.1097/TA.0000000000002316",
language = "English (US)",
volume = "87",
pages = "117--124",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",
number = "1",

}

TY - JOUR

T1 - The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture

T2 - A multi-institutional study

AU - Duchesne, Juan

AU - Costantini, Todd W.

AU - Khan, Mansoor

AU - Taub, Ethan

AU - Rhee, Peter

AU - Morse, Bryan

AU - Namias, Nicholas

AU - Schwarz, Alon

AU - Graves, Joanne

AU - Kim, Dennis Y.

AU - Howell, Erin

AU - Sperry, Jason

AU - Anto, Vincent

AU - Winfield, Robert D.

AU - Schreiber, Martin

AU - Behrens, Brandon

AU - Martinez, Benjamin

AU - Raza, Shariq

AU - Seamon, Mark

AU - Tatum, Danielle

PY - 2019/7/1

Y1 - 2019/7/1

N2 - BACKGROUND Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE Therapeutic study, level IV.

AB - BACKGROUND Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE Therapeutic study, level IV.

KW - hemorrhage control

KW - pelvic binder

KW - Pelvic fracture

KW - preperitoneal packing

KW - REBOA

UR - http://www.scopus.com/inward/record.url?scp=85068728985&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85068728985&partnerID=8YFLogxK

U2 - 10.1097/TA.0000000000002316

DO - 10.1097/TA.0000000000002316

M3 - Article

C2 - 31260426

AN - SCOPUS:85068728985

VL - 87

SP - 117

EP - 124

JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

IS - 1

ER -