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

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.

Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures

“…Pelvic fractures patterns included APC III (29), LC II (26), LC III (20), APC II (20), LC I (13), vertical shear (14), APC I (4) and CM (2). Of these, 18 patients had open pelvic fractures.…”

“…Interestingly, those who died due to acute hemorrhage in the PPP group had actually undergone angioembolization first only to require packing for ongoing hemorrhage and instability. In a propensity matched, comparative study of hemodynamically unstable pelvic fracture patients, mortality was significantly reduced with PPP compared to no-PPP (20% vs 52%) (29). This cohort of patients was multiply injured, evidenced by an ISS > 40 for both groups and associated injuries in over 70%.…”

“…We implemented PPP because despite protocolized care utilizing hemostatic resuscitation, pelvic stabilization, and emergent angiography (34), patients continued to die acutely of hemorrhage. Several international studies have reported equivalence (24,27) or a reduction (28,29) in mortality in patients undergoing PPP compared to AE. The goal of this study was to evaluate the time to intervention and outcomes of an operative approach to hemorrhage from pelvic fractures.…”

Pelvic trauma: WSES classification and guidelines

“…More recent observational studies confirmed the notion that extraperitoneal pelvic packing is a safe and fast procedure associated with a significantly reduced mortality in hemodynamically unstable patients with pelvic fractures, compared to patients managed by conventional measures without pelvic packing [89–91]. …”

“…As a counterpart it is important to consider a number of factors that are critical to decision-making. The exclusive use of angioembolization has been associated with a high mortality in patients with bleeding pelvic fractures [118], which was significantly reduced by application of a combined protocol with initial preperitoneal pelvic packing and subsequent (secondary) angioembolization, if indicated [28, 56, 79, 86, 89]. It has been estimated that 85% of pelvic bleeding originates from bone, soft tissues, or major venous structures [2].…”