Pelvic Packing Research Articles

Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. MethodsRetrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). ResultsDuring the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. ConclusionPPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.

Pelvic Packing and Resuscitative Endovascular Balloon Occlusion of the Aorta.

Department of Orthopedic Surgery, Denver Health Medical Center, Denver, Colorado and Department of Orthopedics at Colorado University for Mauffrey, Denver, CO Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado and Department of Surgery at Colorado University for Moore, Denver, CO The authors report no conflict of interest.

Place of preperitoneal pelvic packing in severe pelvic traumatisms: 20 cases in a French level 1 trauma center

The overall mortality of hemodynamically unstable patients with pelvic trauma is high. Their management is controversial concerning places of arterioembolization and pelvic packing associated with pelvic stabilization. The aim of this study was to collect the pre-peritoneal pelvic packing (PPP) performed in our institution over 10years in order to propose a management algorithm. From January 2010 to December 2020, all patients with a hemodynamically unstable pelvic fracture who had PPP combined with pelvic stabilization were included. Data were collected prospectively and analyzed retrospectively. The main judgement criteria were early hemorrhage-induced mortality (<24h) and overall mortality (<30d). Twenty patients had PPP out of 287 polytrauma patients with pelvic fracture. The first-line PPP proposed in our algorithm significantly reduced the number of red blood cells (RBCs) (P=0.0231) and improved systolic blood pressure (SBP) (P<0.001) within 24hours of first-line PPP (compared with preoperative). Six patients (30%) were embolized postoperatively for active bleeding not necessarily pelvic. The overall mortality at 30days was 50% (10/20). PPP is a fast, easy, effective and safe procedure for venous, bone and sometimes arterial bleeding. PPP is part of damage control surgery and we propose it as a first-line procedure. AE remains complementary in a second step.

Comparison of mortality among hemorrhage-control methods performed for hemodynamically unstable patients with traumatic pelvic fractures: A multi-center study

/Objective: We aimed to analyze the effects of hemorrhage control methods on the mortality of patients with hemodynamic instability due to pelvic fracture and investigate independent mortality risk factors in these patients. Ninety-seven pelvic bone fracture patients with hemodynamic instability who visited the emergency departments of two university hospitals over 5 years were enrolled. These patients were categorized based on 28-day mortality (survival group) and acute hemorrhage mortality (non-survival group). Forty-seven patients (48.5%) underwent pelvic angiography; 45 (46.4%), pre-peritoneal pelvic packing; and 19 (19.6%), external fixation. Differences in hemorrhage control methods did not significantly affect mortality. However, there was a significant difference in mortality between the groups with and without hemorrhage control methods. Multivariate logistic regression analysis revealed that patient age, trauma and injury severity score (probability of survival), and blood transfusion amount within 24h were independent risk factors for 28-day mortality. Meanwhile, patient age, Glasgow coma scale (GCS) score, systolic blood pressure (SBP), and blood transfusion amount within 24h were independent risk factors for mortality due to acute hemorrhage. Rapid and appropriate application of hemorrhage control methods can reduce acute hemorrhage-related mortality in hemodynamically unstable patients with pelvic fractures. Moreover, none of the hemorrhage control methods were superior for the decreasing mortality rate in these patients.

Determination of risk factors associated with surgical site infection in patients undergoing preperitoneal pelvic packing for unstable pelvic fracture.

BackgroundSeveral recent studies have shown that preperitoneal pelvic packing (PPP) effectively produces hemostasis in patients with unstable pelvic fractures. However, few studies have examined the rate of surgical site infections (SSIs) in patients undergoing PPP following an unstable pelvic fracture. The purpose of the present study was to evaluate factors associated with SSI in such patients.MethodsWe retrospectively reviewed the medical charts of 188 patients who developed hemorrhagic shock due to pelvic fracture between April 2012 and May 2021. Forty-four patients were enrolled in this study.ResultsSSI occurred in 15 of 44 patients (34.1%). The SSIs occurred more frequently in cases of repacking during the second-look surgery (0 vs. 4 [26.7%], P=0.010) and combined bladder-urethra injury (1 [3.4%] vs. 4 [26.7%], P=0.039). The incidence of SSIs was not significantly different between patients undergoing depacking within or after 48 hours (12 [41.4%] vs. 5 [33.3%], P=0.603). The mean time to diagnosis of SSI was 8.1±3.9 days from PPP. The most isolated organism was Staphylococcus epidermidis.ConclusionsRepacking and combined bladder-urethra injury are potential risk factors for SSI in patients with unstable pelvic fracture. Close observation is recommended for up to 8 days in patients with these risk factors. Further, 48 hours after PPP, removing the packed gauze on cessation of bleeding and not performing repacking can help prevent SSI. Additional analyses are necessary with a larger number of patients with the potential risk factors identified in this study.

Management Approach for Traumatic Complex Degloving Perineal Injuries: A Retrospective Review of 6 Cases.

Degloving perineal injury is defined as avulsion of the perineal skin and subcutaneous tissue from its surrounding fascia, bone, and organs. This injury is most commonly caused by road vehicle accidents or alleged falls from heights. This devastating injury is associated with high morbidity and mortality if mismanaged. We retrospectively evaluated our management protocol for degloving perineal injury and the clinical outcomes of our case series. Six cases of open perineal degloving injuries were managed and retrospectively reviewed at our center from 2018 to 2020, comprising 2 cases of isolated degloving wounds of the scrotum and 4 cases of complex perineal injuries associated with pelvic fracture, anorectal injuries, or complete transacted urethral injuries. Two of the 6 patients had open-book pelvic fractures that required pelvic stabilization. Complex degloving perineal injuries can be managed through (1) resuscitation and pelvic packing; (2) urgent life-threatening treatments; (3) pelvic exploration with debridement; and (4) primary repair of anorectal or transacted urethral injuries with external pelvic fixation. All patients promptly underwent surgical repair after immediate diagnosis and resuscitation. Additionally, patients were operated by specialized teams according to the proposed management approach as shown in Figure 1. All patients recovered well and had good functional outcomes. A multidisciplinary team comprising general surgeons, urologists, orthopedic surgeons, and plastic surgeons was involved in this review. Prompt diagnosis and immediate surgical intervention remain the standard requirements for complex degloving perineal injuries. We proposed a management protocol that is safe for managing complex perineal injuries.

Survival benefit for pelvic trauma patients undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta: Results of the AAST Aortic Occlusion for Resuscitation in Trauma Acute Care Surgery (AORTA) Registry

BackgroundAortic occlusion (AO) to facilitate the acute resuscitation of trauma and acute care surgery patients in shock remains a controversial topic. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an increasingly deployed method of AO. We hypothesized that in patients with non-compressible hemorrhage below the aortic bifurcation, the use of REBOA instead of open AO may be associated with a survival benefit. MethodsFrom the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry, we identified 1494 patients requiring AO from 45 Level I and 4 Level II trauma centers. Presentation, intervention, and outcome variables were analyzed to compare REBOA vs open AO in patients with non-compressible hemorrhage below the aortic bifurcation. ResultsFrom December 2014 to January 2019, 217 patients with Zone 3 REBOA or Open AO who required pelvic packing, pelvic fixation or pelvic angio-embolization were identified. Of these, 109 AO patients had injuries isolated to below the aortic bifurcation (REBOA, 84; open AO, 25). Patients with intra-abdominal or thoracic sources of bleeding, above deployment Zone 3 were excluded. Overall mortality was lower in the REBOA group (35.% vs 80%, p <.001). Excluding patients who arrived with CPR in progress, the REBOA group had lower mortality (33.33% vs. 68.75%, p = 0.012). Of the survivors, systemic complications were not significantly different between groups. In the REBOA group, 16 patients had complications secondary to vascular access. Intensive care lengths of stay and ventilator days were both significantly shorter in REBOA patients who survived to discharge. ConclusionsThis study compared outcomes for patients with hemorrhage below the aortic bifurcation treated with REBOA to those treated with open AO. Survival was significantly higher in REBOA patients compared to open AO patients, while complications in survivors were not different. Given the higher survival in REBOA patients, we conclude that REBOA should be used for patients with hemorrhagic shock secondary to pelvic trauma instead of open AO. Level III EvidenceTherapeutic

Comparison between external fixation and pelvic binder in patients with pelvic fracture and haemodynamic instability who underwent various haemostatic procedures

Haemostatic procedures such as preperitoneal pelvic packing (PPP), pelvic angiography (PA), and internal iliac artery ligation are used for haemorrhage control in pelvic fracture patients with haemodynamic instability. Pelvic external fixation (PEF) and pelvic binder (PB) are usually applied with haemostatic procedures to reduce the pelvic volume. This study aimed to compare the clinical outcomes between patients who underwent PEF and PB. Among 173 patients with pelvic fracture admitted to the emergency room of three regional trauma centres between January 2015 and December 2018, the electronic charts of haemodynamically unstable patients were retrospectively analysed. Among the 84 patients included in the analysis, 20 underwent PEF with or without PB, and 64 underwent only PB. There were significant differences in tile classification and laparotomy between the PEF and PB groups (p = 0.023 and p = 0.032). PPP tended to be more frequently preformed in the PEF group (p = 0.054), whereas PA tended to be more commonly performed in the PB group than in the PEF group (p = 0.054). After propensity score matching to adjust for differences in patient characteristics and adjunct haemostatic procedure, there was no significant difference in 7-day, 30-day, and overall mortality rates between the PEF and PB groups (10.5% vs 21.1%, p = 0.660, 21.1% vs 26.3%, p = 1.000, and 26.3% vs 26.3%, p = 1.000). Cox proportional hazard regression analysis and multivariate analysis for correction of covariates (age, lactate, and abdominal injury) showed that PEF was not an independent factor for 30-day mortality compared with PB (adjusted hazard ratio, 0.526; 95% confidence interval, 0.092–3.002; p = 0.469). Among the volume reduction procedures performed with other haemostatic procedures in patients with pelvic fracture and haemodynamic instability, PEF did not significantly reduce the 30-day mortality rate compared to PB.

Effect of angioembolization for isolated complex pelvic injury: A post-hoc analysis of a nationwide multicenter trauma database in Japan

Background and importanceComplex pelvic injuries are among the types of trauma with the highest mortality. Treatment strategies should be based on the hemodynamic status, the anatomical type of fracture, and the associated injuries. Combination therapies, including preperitoneal pelvic packing, temporary mechanical stabilization, resuscitative endovascular balloon occlusion of the aorta, and angioembolization, are recommended for pelvic injuries. ObjectiveTo investigate the effect of urgent angioembolization alone on severe pelvic injury-associated mortality. Design, settings, and participantsWe used the Japan Trauma Data Bank database, a multicenter observational study, to retrospectively identify adult patients with isolated blunt pelvic injuries (Abbreviated Injury Scale [AIS] score: 3–5) from 2004 to 2018. Outcome measures and analysisThe primary outcome measure was in-hospital mortality. We subdivided patients into two groups, those who underwent urgent angioembolization and non-urgent angioembolization, and compared their mortality rates. We performed multiple imputation and multivariable analyzes to compare the mortality rates between groups after adjusting for known potential confounding factors (age, sex, Glasgow Coma Scale score, systolic blood pressure on hospital arrival, Injury Severity Score, pelvic AIS score, laparotomy, resuscitative endovascular balloon occlusion of the aorta, and external fixation) and for within-hospital clustering using the generalized estimating equation. Main resultsWe analyzed 4207 of 345,932 trauma patients, of whom 799 underwent urgent angioembolization. The in-hospital mortality rate was significantly higher in the urgent embolization group than in the non-urgent embolization group (7.4 vs. 4.0%; p < 0.01). However, logistic regression analysis revealed that the mortality rates of patients with urgent angioembolization significantly decreased after adjusting for factors independently associated with mortality (odds ratio: 0.60; 95% confidence interval: 0.37–0.96; p = 0.03). ConclusionUrgent angioembolization may be an effective treatment for severe pelvic injury regardless of the pelvic AIS score and the systolic blood pressure on hospital arrival.

Revisiting Role of Bilateral Ligation of Internal Iliac Arteries and Preperitoneal Pelvic Packing for Hemorrhage Control in Patients with Pelvic Injuries in Resource Constraint Settings

Since the description of bilateral ligation of internal iliac arteries (BLIIA) and preperitoneal pelvic packing (PPP) for hemorrhage control in pelvic injury patients, multiple reports have been published advocating its use with acceptable outcomes. We analyzed our experience with this technique in a setting where the facility of hybrid operating room for simultaneous angioembolization is not available. We analyzed data of sixty-six patients who presented in a state of unresponsive shock with pelvic fracture between January 2014 and September 2019. After initial resuscitation, they all underwent BLIIA with PPP as part of damage control surgery. Out of 66 patients, 55 were male. The mean age was 36.12 years. All patients sustained blunt trauma, with road traffic injuries being the most common mechanism involving 65% of the patients followed by fall from height. The mean systolic blood pressure at the time of surgery was 77 ± 34.46 mm Hg. Median packed red blood cell transfusion in the first 24 h was 8.5 units with IQR of 6–12. The hemorrhage-related mortality was 48%. BLIIA with PPP may be considered as a viable treatment option in hemodynamically unstable patients with pelvic injuries in resource constraint facilities.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing.

in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality. a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing. data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05). age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

Current management and clinical outcomes for patients with haemorrhagic shock due to pelvic fracture in Korean regional trauma centres: A multi-institutional trial

IntroductionThe purpose of this study was to evaluate the current management and clinical outcomes in patients with hemodynamic instability due to pelvic fracture in three regional trauma centres in Korea. Patients and MethodsThree regional trauma centres participated in this study, and 157 patients who were admitted between January 2015 and December 2018 were enroled. Clinical data were collected prospectively as part of the Korean trauma data bank and were analysed retrospectively. ResultsThe mean age was 59.3 years, and 107 of 157 (68.2%) were male patients. The most common cause of injury was auto-pedestrian accidents, followed by falls and motor vehicle crashes. The mean admission systolic blood pressure and serum lactate level were 86.7 mmHg and 6.68 mmol/L, respectively. Twenty-four patients (15.3%) had a cardiac arrest in the emergency department (ED). The mean injury severity score was 39.1, and the mean probability of survival (Trauma and Injury Severity Score) was 48.7%. Sixty-six patients (42%) underwent pelvic angiography; 89 (56.7%), preperitoneal pelvic packing (PPP); 27 (17.2%), resuscitative endovascular balloon occlusion of the aorta (REBOA); 20 (12.7%), pelvic external fixation (PEF); and 13 patients (8.3%), internal iliac artery ligation (IIAL). Seventy-three patients (46.5%) died, including 40 (25.5%) who died from acute haemorrhage. With each year, the rates of REBOA and pelvic binder use continued to increase (p<0.001 and p = 0.005, respectively), but the number of PEF cases significantly decreased (p = 0.006). Age, initial lactate, low revised trauma score (RTS), combined abdominal injury, REBOA, and 4-hour requirement of packed red blood cells were independent risk factors associated with mortality, whereas during the period of 2017 and 2018, there were protective factors. The risk factors of mortality due to haemorrhage were cardiac arrest in the ED, RTS, combined chest and abdominal injuries, and IIAL. ConclusionsSince the establishment of regional trauma centres, the clinical outcomes of patients with hemodynamic instability due to pelvic fracture have significantly improved. As a haemostatic procedure for these patients, PEF has been used less frequently, while pelvic binder and REBOA showed significant increase in their use.

Successful management of perimortem cesarian section with two types of pelvic packing; a case report

Perimortem cesarean is rare and one of the worst possible scenarios in obstetrics. Multidisciplinary approach and speed are extremely important. Pelvic packing in massive postpartum hemorrhages is a method which obstetricians do not commonly use. The patient who had cardiac arrest during travail was successfully managed with a peripartum hysterectomy and two different types of pelvic packing after perimortem cesarean. The mother and baby were healthily discharged. Fetal and maternal survival after perimortem cesarean is quite low. The most important factor determining survival is speed. Pelvic packing is effective in postpartum unstoppable bleeding.

Comparison of iliac crest versus supraacetabular external fixator in hemodynamically unstable patients with a pelvic ring injury.

External fixation has been widely implemented as a resuscitation strategy in combination with pelvic packing for high energy, hemodynamically unstable, pelvic ring injuries. The primary aim of this study is to compare urgent iliac crest (IC) versus supraacetabular (SA) external fixation in the setting of haemodynamic instability. This is a retrospective review of a prospectively gathered registry at an urban level one trauma centre comparing placement of pelvic external fixator by SA or IC technique. Outcomes assessed were accuracy of pin placement, duration of procedure, and the effect on true pelvic circumference depending on type of fracture by Young and Burgess Classification system. Ninety-three haemodynamically unstable patients with a pelvic fracture included. Pin malpositioning was more common with IC than SA groups (proportional difference, - 40%; 95% CI, - 57 to - 20%; p < 0.0001). For APC injuries, there was a larger median reduction in pelvic circumference in the SA group than the IC group (median difference [MD], - 12.85cm; 95% CI, - 27 to 0.1; p = 0.0485). In LC injuries, the SA group had an overall increase in pelvic circumference compared to an overall decrease in IC group (MD, 6.5cm; 95% CI, 1.5 to 16.8; p = 0.0221). There was no difference in the operating room (OR) time (mean difference, - 5.4min; 95% CI, - 32 to 22; p = 0.68). In this clinical setting, we recommend placement of SA external fixator (versus IC) with similar operative times, fewer pin malpositions, and improved stabilization of pelvic circumference in APC and LC injuries.

The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures

PurposeHemodynamically unstable patients with pelvic fractures still represent a challenge to trauma surgeons and have a very high mortality. This study was designed to explore the effect of the interventions of direct preperitoneal pelvic packing for the hemodynamically unstable pelvic fractures. MethodsThis retrospective study enrolled 67 cases of severe pelvic fractures with unstable hemodynamics from October 2011 to December 2019. All patients presented in our emergency center and received preperitoneal pelvic packing were included in this study. The indication was persistent systolic blood pressure ≤90 mmHg during initial resuscitation and after transfusion of two units of red blood cells. Patients with hemodynamic stability who need no preperitoneal pelvic packing to control bleeding were excluded. Their demographic characteristics, clinical features, laboratory results, therapeutic interventions, adverse events, and prognostic outcomes were collected from digital information system of electronic medical records. Statistics were described as mean ± standard deviation or medium and analyzed using pair sample t-test or Mann-Whitney U-test. ResultsThe patients’ average age was 41.6 years, ranging from 10 to 88 years. Among them, 45 cases were male (67.2%) and 22 cases were female (32.8%). Significant difference was found regarding the systolic blood pressure (mmHg) in the emergency department (78.4 ± 13.9) and after preperitoneal pelvic packing in the surgery intensive care unit (100.1 ± 17.6) (p < 0.05). Simultaneously, the arterial base deficit (mmol/L) were significantly lower in the surgery intensive care unit (median -6, interquartile range -8 to -2) than in the emergency department (median -10, interquartile range -14 to -8) (p < 0.05). After preperitoneal pelvic packing, 15 patients (22.4%) underwent pelvic angiography for persistent hypotension or suspected ongoing haemorrhage. The overall mortality rate was 29.5% (20 of 67). ConclusionsPreperitoneal pelvic packing, as a useful surgical technique, is less invasive and can be very efficient in early intra-pelvic bleed control.

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database.

Knowledge on practice patterns for aortic occlusion (AO) in the setting of severe pelvic fractures is limited. This study aimed to describe clinical outcomes based on number and types of interventions after zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment. A retrospective review of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery multicenter registry was performed for patients who underwent zone 3 AO from 2013 to 2020. Patients with a blunt mechanism who survived beyond the emergency department were included. Interventions evaluated were preperitoneal pelvic packing (PP), angioembolization (AE), and external fixation (EF) of the pelvis. Management approaches were compared against the primary outcome of mortality. Secondary outcomes included transfusion requirements, overall complications and acute kidney injury (AKI). Of 207 patients who underwent zone 3 AO, 160 (77.3%) fit the inclusion criteria. Sixty (37.5%) underwent AO alone, 50 (31.3%) underwent a second hemostatic intervention, and 49 (30.6%) underwent a third hemostatic intervention. Overall mortality was 37.7% (n = 60). There were no differences in mortality based on any number or combination of interventions. On multivariable regression, only EF was associated with a mortality reduction (odds ratio, 0.22; p = 0.011). Increasing number of interventions were associated with higher transfusion and complication rates. Pelvic packing + AE was associated with increased AKI than PP or AE alone (73.3% vs. 29.5% and 28.6%, p = 0.005), and AE was associated with increased AKI resulting in dialysis than PP alone (17.9% vs. 6.8%, p = 0.036). Zone 3 REBOA can be used as a standalone hemorrhage control technique and as an adjunct in the management of severe pelvic fractures. The only additional intervention associated with a mortality reduction was EF. The benefit of increasing number of interventions must be weighed against more harm. Heterogeneity in practice patterns for REBOA use in pelvic fracture management underscores the need for an evidence base to standardize care. Therapeutic, Level IV.

A review of blunt pelvic injuries at a major trauma centre in South Africa

Background The collective five-year experience with the acute management of pelvic trauma at a busy South African trauma service is reviewed to compare the usefulness and applicability of current grading systems of pelvic trauma and to review the compliance with current guidelines regarding pelvic binder application during the acute phase of resuscitation. Methods A retrospective review was conducted over a 5-year period from December 2012 to December 2017 on all polytrauma patients who presented with a pelvic fracture. Mechanism of injury and presenting physiology and clinical course including pelvic binder application were documented. Pelvic fractures were graded according to the Young- Burgess and Tile systems. Results There was a cohort of 129 patients for analysis. Eighty-one were male and 48 female with a mean age was 33.6 ± 13.1 years. Motor vehicle-related collisions (MVCs) were the main mechanism of injury (50.33%) and pedestrian vehicle collisions (PVCs) were the second most common (37.98%). The most common associated injuries were abdominal injuries (41%), chest injury (37%), femur fractures (21%), tibia fractures (15%) and humerus fracture (14.7%). Thirty patients in this cohort (23%) underwent a laparotomy. They were mainly in the Tile B (70%) and lateral compression (63%) groups. Nine patients underwent pelvic pre-peritoneal packing. Thirty-five (27%) patients were admitted to ICU. Fifteen (12%) patients died. The Young-Burgess classification had a greater accuracy in predicting death than the Tile classification. Forty per cent of deaths occurred in ICU, 33% died secondary to a traumatic brain injury (TBI). Twenty per cent died in casualty and 6.6% in the operating room from ongoing haemorrhage. A pelvic binder was not applied in 66% of patients. In the 34% of patients who had a pelvic binder applied, it was applied post CT scan in 24.8%, in the pre-hospital setting in 7.2%, and on arrival in 2.4% of patients. In 73% of deaths, a binder was not applied, and of those deaths, 54% showed signs of haemodynamic instability. Conclusion It would appear that our application of pelvic binders in patients with acute pelvic trauma is ad hoc. Appropriate selection of patients, who may benefit from a binder and it's timely application, has the potential to improve outcome in these patients.

Emergency Management of Pelvic Bleeding.

Pelvic trauma continues to have a high mortality rate despite damage control techniques for bleeding control. The aim of our study was to evaluate how Extra-peritoneal Pelvic Packing (EPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) impact the efficacy on mortality and hemodynamic impact. We retrospectively evaluated patients who sustained blunt trauma, pelvic fracture and hemodynamic instability from 2002 to 2018. We excluded a concomitant severe brain injury, resuscitative thoracotomy, penetrating trauma and age below 14 years old. The study population was divided in EPP and REBOA Zone III group. Propensity score matching was used to adjust baseline differences and then a one-to-one matched analysis was performed. We selected 83 patients, 10 for group: survival rate was higher in EPP group, but not significantly in each outcome we analyzed (24 h, 7 day, overall). EPP had a significant increase in main arterial pressure after procedure (+20.13 mmHg, p < 0.001), but this was not as great as the improvement seen in the REBOA group (+45.10 mmHg, p < 0.001). EPP and REBOA are effective and improve hemodynamic status: both are reasonable first steps in a multidisciplinary management. Zone I REBOA may be useful in patients ‘in extremis condition’ with multiple sites of torso hemorrhage, particularly those in extremis.

Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries.

Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated.Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization.Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury.Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.

Unplanned Reoperation Rate at a Government-Designated Regional Trauma Center in Gangwon Province

Purpose Determining appropriate ways to assess health care quality within the National Health Insurance System is of interest to both the Korean government and the medical community. However, in the trauma field, the number of indicators used to evaluate surgical quality is limited. Using data collected over 5 years at Wonju Severance Christian Hospital Trauma Center in Korea, this study aimed to determine whether the unplanned reoperation rate in the field of trauma surgery could be used to assess the quality of an institution’s surgical care. Methods In total, 665 general surgical procedures were performed at the Trauma Center in 453 patients with abdominopelvic injuries from January 2015 to December 2019. Data were collected from the Trauma Center’s data registry and medical records, and included information regarding patients’ demographic characteristics, the type of index operation, and the reason for unplanned reoperations. Results A total of 453 index operations were evaluated. The proportion of patients with an Injury Severity Score (ISS) >15 was 48–70% over the 5-year period, with an unplanned reoperation rate of 2.1–9.3%. Patients had an average ISS score of 17.5, while the average Abbreviated Injury Scale score was 2.87. Unplanned reoperations were required in about 7% of patients. The most common complications requiring reoperation were recurrent bleeding (26.9%), wound problems (26.9%), intestinal infarction (15.4%), and anastomosis site leakage (7.7%). The procedures most frequently requiring unplanned reoperations were bowel surgery (segmental resection, primary repair, enterostomy, etc.) (24.5%) and preperitoneal pelvic packing (10.6%). Conclusions The proportion of reoperations was confirmed to be affected by injury severity. Keywords: Wounds and injuries; Reoperation; Quality of health care