WAIKOLOA, HAWAII – Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage caused by unstable pelvic fractures, results from a long-term single-center study showed.

“Despite advances in care of the critically injured patient, mortality rates for patients with hemodynamic instability due to pelvic fractures remains greater than 30%,” Clay Cothren Burlew, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “The majority of trauma centers in the United States use angioembolization for hemorrhage control. While angioembolization is effective in controlling arterial sources of hemorrhage, which constitutes about 15% of pelvic bleeding, it does not address the venous or bony sources of hemorrhage within the pelvis. Additionally, time to arterial hemorrhage control using angioembolization usually takes several hours to accomplish, even at the most advanced level I trauma centers.”

Preperitoneal pelvic packing in combination with external fixation has been advocated to rapidly arrest hemorrhage, facilitate other emergent operative procedures, and provide efficient use of angioembolization, said Dr. Burlew of the department of surgery at Denver Health Medical Center. However, a 2015 AAST multicenter trial reported a 32% mortality rate for complex pelvic fracture patients who present in shock. The time to intervention for these patients was 3-5 hours (J Trauma Acute Care Surg. 2016;80:717-25).

For the current study, the researchers hypothesized that pelvic packing would result in a shorter time to intervention and lower mortality, compared with other pelvic fracture management strategies.

Since September 2004 all patients at the Denver Health Medical Center with persistent hemodynamic instability and a pelvic fracture underwent pelvic packing. Indication for packing is a persistent systolic blood pressure of less than 90 mm Hg in the initial resuscitation period despite the transfusion of two units of red blood cells. “Initial stabilization of the pelvis is performed in the emergency department with a pelvic sheet or a binder,” Dr. Burlew explained. “Skeletal fixation of the pelvis with an external fixator or a pelvic C clamp is done concurrently with preperitoneal pelvic packing in the operating room. Angiography is performed for ongoing pelvic bleeding, defined as greater than four units of red blood cells after the patients’ coagulopathy is corrected; immediate postpacking angiography is performed for ongoing hemodynamic instability despite packing and external fixation.”

Over a period of 11 years, 2,293 patients were admitted to Denver Health Medical Center with pelvic fractures. Of these, 128 patients in refractory shock underwent pelvic packing. More than half of the patients (70%) were men, their mean age was 44 years, and their mean Injury Severity Score was 48. The most common mechanism of injury was motor vehicle collision, followed by auto/pedestrian accidents and motorcycle collision. Pelvic fracture patterns included every classification, with anterior posterior compression (APC) III and lateral compression (LC) II patterns predominating. Of these, 18 patients had open pelvic fractures. More than half of patients (70%) had an extremity injury, 65% had a thoracic injury, 63% had an abdominal injury, 43% had a traumatic brain injury, and 38% had a spine injury.

The mean systolic blood pressure of patients was 74 mm Hg and their mean heart rate was 120 beats per minute in the emergency department. Their mean base deficit was 12. However, 32% of patients did not have an arterial blood gas reported during this time frame. When the researchers compared 13% of patients who underwent postpacking angioembolization with those who did not require angioembolization after pelvic packing, they observed no significant differences in age, injury severity score, presenting systolic BP, presenting systolic BP/base deficit, or ED transfusions. The only difference that reached statistical significance was a lower heart rate in the ED in the postpacking angioembolization group, compared with the preperitoneal pelvic packing alone group (110 vs. 121 beats per minute). “We also realized that the angioembolization group received more red blood cells and fresh frozen plasma prior to ICU admission, as well as in the subsequent 24 hours,” Dr. Burlew said.

The majority of patients (84%) had a single packing of the preperitoneal space, while 20 patients underwent repacking when returned to the operating room; all occurred prior to July 2011. “At this time point we determined that there was an increased infection rate with repacking of the pelvis,” Dr. Burlew said. “There were 15 pelvic space infections. Four occurred in those with open fractures or perineal degloving, four developed in those with associated bladder injuries, and seven pelvic space infections occurred in patients without an open fracture.” The infection rate was 6% among patients with a single packing of the pelvis, compared with an infection rate of 45% among those who underwent repacking. “This emphasizes the need for local control of small bleeders when the pelvis in unpacked, using electrocautery and topical hemostatic agents,” she said.

Dr. Burlew went on to note that comparison of two prospective observational study groups with differing management schema may provide salient information. “The AAST multicenter study was an evaluation of the modern-day care of pelvic fracture patients from 11 different centers,” she said. “In that study, the mortality rate among patients presenting in shock who did not undergo pelvic packing was 32%. The mortality rate in our series was 21%, with a relative risk reduction that was statistically significant.” She concluded that pelvic packing “has a faster time to intervention for pelvic fracture–related hemorrhage. Arterial bleed was only present in 13% of patients, rendering angiography of limited utility. Pelvic packing should be utilized for pelvic fracture–related bleeding in the patient who remains hemodynamically unstable despite red blood cell transfusion.”

One of the study authors, Ernest E. Moore, MD, disclosed that he has received research funding from Haemonetics, TEM, and Prytime Medical Devices, and Charles J. Fox, MD, is on the clinical advisory board for Prytime Medical Devices. Dr. Burlew reported having no financial disclosures.

dbrunk@frontlinemedcom.com

Preperitoneal pelvic packing benefits subset of pelvic fracture patients