Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a Propensity Score Analysis.

Osvaldo Chiara,Anna Mariani,Stefania Cimbanassi,Lucia Prestini,Bertuzzi Michaela,Emanuele Di Fratta,Fabrizio Sammartano

doi:10.1186/s13017-016-0077-2

Osvaldo Chiara, Anna Mariani + Show 5 more

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https://doi.org/10.1186/s13017-016-0077-2

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Abstract

BackgroundAn option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures. The aim of this study was to demonstrate the efficacy of early EPP in reducing mortality due to hemorrhage from pelvic fractures, and to evaluate the impact of packing on transfusion requirements within the first 24 h and ICU length of stay (ICU-LOS).All data pertaining trauma patients admitted from October 2002 and December 2103 with hemodynamic instability and pelvic fractures were selected from the Hospital Trauma Registry. Patients with severe brain injury and bleeding from extra-pelvic sources were excluded. Patient population was divided into two groups: EPP group, including patients admitted from 2009 to 2013, with EPP as part of the treatment algorithm, and NO-EPP group, from 2002 to 2008, without EPP as atherapeutic option. Descriptive statistical analysis was performed on allpatients. Twenty-five patients of each group with similar features were matched using Propensity Score Analysis (PSA).ResultsSix hundred eighty out of 4659 major trauma (14.6 %) presented a pelvic fracture. In 78 hemodynamically unstable patients (30 in EPP group,48 in NO-EPP group) the major source of bleeding was the pelvis. Among patients selected by PSA early mortality was significantly reduced in EPP group (20 vs 52 %, p = .03) compared to NO-EPP, notwithstanding similar hemodynamic impairment. No difference was observed in transfusion requirements and ICU-LOS.ConclusionsThe EPP is a safe and quick procedure, able to improve hemodynamic stabilization and to reduce acute mortality due to hemorrhage in patients with pelvic fracture, in combination with optimized transfusion protocol. EPP may be useful as a bridge for time-consuming procedures, such as angio-embolization.

Highlights

An option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures
In the United States, EPP was originally adopted by the Denver group and when used in association with pelvic stabilization, it showed a reduction of the mortality rate and need for transfusions and angiography [9]
All patients sustained a blunt trauma (Table 1) and common causes of pelvic fractures were falls from height, pedestrian struck and motorcycle crash

Summary

Introduction

An option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures. Despite the multidisciplinary approach mortality remains as high as 40 %, with one third of Chiara et al World Journal of Emergency Surgery (2016) 11:22 promptly available in all hospitals In this situation, it is not advised to transfer hemodynamically unstable patients to interventional radiology suites or to higher level facilities [5]. Extra-peritoneal Pelvic Packing (EPP) is a quick and effective procedure for the emergency control of pelvic hemorrhage that directly addresses the bleeding coming from the retroperitoneal space in severe pelvic injuries. This technique was first described in Germany in 1994 [6] and subsequently adopted by several European groups [7, 8]. In the United States, EPP was originally adopted by the Denver group and when used in association with pelvic stabilization, it showed a reduction of the mortality rate and need for transfusions and angiography [9]

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