LAS VEGAS – Methods for controlling hemorrhage from severe pelvic fractures vary widely across institutions, according to findings from a prospective observational study.
In particular, the findings from the 2-year multicenter study of 1,339 patients show that resuscitative endovascular balloon occlusion of the aorta (REBOA) is rarely used, despite its inclusion in recent management algorithms, Dr. Todd W. Costantini reported at the annual meeting of the American Association for the Surgery of Trauma (AAST).
The most common methods used for hemorrhage control were angioembolization alone and external fixator placement alone, used in 55 (4.1%) and 78 (5.8%) patients, respectively. These methods were also used in 19 (10.7%) and 17 (9.6%) of the 178 patients of the overall study population who presented in shock, said Dr. Costantini of the University of California San Diego Health System.
Other methods included preperitoneal pelvic packing alone in 20 patients overall and 6 patients in shock, embolization plus external fixator in 11 patients overall and 6 patients in shock, embolization and pelvic packing in 6 patients overall and 2 patients in shock, external fixator plus pelvic packing in 6 patients overall and 1 patient in shock, embolization plus external fixator plus pelvic packing in 5 patients overall and 1 patient in shock.
“As most pelvic fracture algorithms suggest the use of preperitoneal packing prior to embolization in patients who present with hemodynamic instability, we were interested to find that only two patients [in shock] were treated with this method,” Dr. Costantini said.
Further, REBOA with or without any other method was used in only five patients overall (0.4%) and five patients in shock (2.8%), and all of these were from only 1 of the 11 participating centers, he noted.
Study subjects were adults with a mean age of 47 years with pelvic fracture from blunt trauma, and 57% were men. The mean Injury Severity Score was high at 19.2 on a scale of 75. Associated injury was common; 32% had an abbreviated injury scale (AIS) score of 3 or higher (out of 6) for chest injury.
The average intensive care unit length of stay was 8.2 days, and the average hospital length of stay was 10.9 days. In-hospital mortality was 9%.
“Pelvic fractures are associated with significant disability, demonstrated by the fact that only 43% of patients were discharged home from the hospital after admission for pelvic fractures. The remainder required ongoing care in either skilled nursing facilities or acute rehab facilities,” he said.
Of the patients who met criteria for shock, the mean age was 44 years, 59% were men, and the mean ISS was 28.2, with nearly half having a chest AIS of 3 or greater, nearly 39% having a head AIS of 3 or greater, and 32% having an abdominal AIS of 3 or greater. The mean ICU stay was 11.6 days, and the mean hospital stay, 19.3 days. In-hospital mortality among those presenting in shock was 32%.
Most patients underwent computed tomography, and arterial blush was noted in 10% of cases. Angiography was used in 148 patients, and half of those were noted to have contrast extravasation.
Therapeutic angioembolization was used in 79 patients (5.9%) overall, and in 60% of those undergoing angiography. The most common indication for angiography was ongoing hemorrhage, hemodynamic instability, and blush on CT scan.
The findings demonstrate significant variability in the approach to hemorrhage control across participating institutions.
“We found that there is currently limited use of REBOA in the treatment of hemorrhage associated with pelvic fracture. However, this may change as management strategies evolve with advances in training and technology,” Dr. Costantini concluded.
As a discussant for Dr. Costantini’s paper, Dr. Walter Biffl of the University of Colorado, Denver, expressed concern regarding the lack of adherence to management algorithms, saying that the data suggest a lack of standardization and orderly application of principles that have been shown to reduce mortality.
“Only 19% had pelvic binding. In our algorithm, 100% get that. And 85% of those in shock had CT scans. In our algorithm that comes after all these other interventions,” he said. “This study clearly opens the door for further research. If we could start with a pelvic binder and hemostatic resuscitation and maybe add REBOA for the severely hypertensive patients, maybe we can begin to determine the goals and efficacy of more interventions,” he said.
Dr. Costantini’s study was supported by the AAST Multi-Institutional Trials Committee. He reported having no disclosures.