Preperitoneal Pelvic Packing/External Fixation with Secondary Angioembolization: Optimal Care for Life-Threatening Hemorrhage from Unstable Pelvic Fractures - 10/08/11

Doi : 10.1016/j.jamcollsurg.2010.12.020

Clay Cothren Burlew, MD, FACS ^a,^⁎ , Ernest E. Moore, MD, FACS ^a, Wade R. Smith, MD, FACS ^c, Jeffrey L. Johnson, MD, FACS ^a, Walter L. Biffl, MD, FACS ^a, Carlton C. Barnett, MD, FACS ^a, Philip F. Stahel, MD, FACS ^b
^a Department of Surgery, Denver Health Medical Center and the University of Colorado Denver, Denver, CO
^b Department of Orthopedics, Denver Health Medical Center, Denver, CO
^c Department of Orthopedics, Geisinger Health System, Danville, PA

Correspondence address: Clay Cothren Burlew, MD, FACS, Director, Surgical Intensive Care Unit, Program Director, Trauma and Acute Care Surgery Fellowship, Department of Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204

Résumé

Background

Preperitoneal pelvic packing/external fixation (PPP/EF) for controlling life-threatening hemorrhage from pelvic fractures is used widely in Europe but has not been adopted in North America. We hypothesized that PPP/EF arrests hemorrhage rapidly, facilitates emergent operative procedures, and ensures efficient use of angioembolization (AE).

Study Design

In 2004 we initiated a PPP/EF guideline for pelvic fracture patients with refractory shock requiring ongoing blood transfusion at our regional trauma center.

Results

Among 1,245 patients admitted with pelvic fractures, 75 consecutive patients underwent PPP/EF (age 42 ± 2 years and injury severity score 52 ± 1.5). Emergency department systolic blood pressure was 76 ± 2 mmHg and heart rate 119 ± 2 beats/min. Time to operation was 66 ± 7 minutes, and 65 patients (87%) underwent 3 ± 0.3 additional procedures. Blood transfusion before PPP/EF compared with the first postoperative 24 hours was 10 ± 0.8 units versus 4 ± 0.5 units (p < 0.05). The fresh frozen plasma–red blood cell ratio was 1:2. After PPP/EF, 10 patients (13%) underwent angioembolization with a documented blush; time to angioembolization was 10.6 ± 2.4 hours (range 1 to 38 hours). Mortality for all pelvic fractures was 8%, with 21% mortality in this high-risk group. There were no deaths due to acute hemorrhage.

Conclusions

PPP/EF was effective in controlling hemorrhage from unstable pelvic fractures. None of these high-risk patients died due to pelvic bleeding. Secondary angioembolization was needed in a minority, permitting selective use of this resource-demanding intervention. Additionally, PPP/EF temporizes arterial hemorrhage, providing valuable transfer time for facilities without angiography. With other urgent operative interventions required in >85% of patients, combining these procedures with PPP/EF for operative pelvic hemorrhage control appears to optimize patient care.

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Abbreviations and Acronyms : AE, ED, EF, FFP, IR, ISS, OR, PPP, RBC, SBP, SICU