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

4 Scopus citations

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

Keywords

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

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

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    Duchesne, J., Costantini, T. W., Khan, M., Taub, E., Rhee, P., Morse, B., Namias, N., Schwarz, A., Graves, J., Kim, D. Y., Howell, E., Sperry, J., Anto, V., Winfield, R. D., 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, 87(1), 117-124. https://doi.org/10.1097/TA.0000000000002316