Prospective validation of a new protocol with preperitoneal pelvic packing as the mainstay for the treatment of hemodynamically unstable pelvic trauma: a 5-year experience

Magnone, Stefano; Allievi, Niccolò; Ceresoli, Marco; Catena, Fausto; Pisano, Michele; Ansaloni, Luca

doi:10.1007/s00068-019-01115-3

Cited by 14 publications

(25 citation statements)

References 48 publications

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“…In the whole population and the subgroup of later operatively treated patients, pelvic packing (laparotomy) was an independent risk factor for death, which is in line with recently published data [11,21]. Although the procedure has shown to be effective [22], patients with necessity for this procedure had an overall increased risk to die compared to all pelvic fractures.…”

Section: Discussionsupporting

confidence: 85%

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

Schmal

Larsen

Stuby

et al. 2019

Injury

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Background and purpose Unstable pelvic fractures frequently require emergency stabilization using a C-clamp or external (CC/EF) fixation. However, the effectiveness of this intervention and associated complications are still a matter of debate. Patients and methods The analysis used data available from the German Pelvic Trauma Registry to study general complications, infections and mortality after primary stabilization using CC/EF in 5,499 patients (n=957 with vs n=4,542 without). Furthermore, the subgroups with secondary surgery (n=713 vs n=1,695), and ilio-sacral screw implantation following C-clamp stabilization were evaluated (n=24 vs n=219). Calculated odds ratios were adjusted for potential confounders. Results Patients treated by CC/EF were younger (45±20 vs 62±24 years), had more C-type fractures (65% vs 28%), higher ISS (≥25 63% vs 20%) and displacement (≥3mm 81% vs 41%), and more complex fractures (32% vs 5%). These features were independent risk factors for complications (p<0.001). While mortality was reduced after CC/EF stabilization by 32% (OR 0.68 95%CI 0.49-0.95), the risk for general complications was slightly increased (OR 1.25 95% CI 1.02-1.53). In patients undergoing secondary surgery, CC/EF fixation had no influence on mortality, general complications or infections. Related to preceding C-clamp stabilization (OR 4.67 95% CI 1.06-20.64), the risk for infection increased from 3.2% to 20.8% in ilio-sacral screw fixation. Interpretation Primary stabilization of unstable pelvic fractures with C-clamp or external fixation is associated with a decreased mortality and was not an independent risk factor for complications after secondary surgery. However, the risk for infection after ilio-sacral screw fixation increased almost 5-fold after C-clamp use.

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Section: Discussionsupporting

confidence: 85%

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

Schmal

Larsen

Stuby

et al. 2019

Injury

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“…Additionally, surgery as first line procedure may "buy" time for setting up the emergent pelvic angiography. Our management algorithm is in line with previously reported protocols for patients with pelvic ring injuries (22,28,(33)(34)(35). In the study by Burlew and coauthors, 13% of the patients underwent secondary angio-embolization.…”

Section: Discussionsupporting

confidence: 76%

“…The mortality rate in this high-risk patient group was 21% with only 2% (n = 3) death cases due to acute bleeding (33). Magnone et al (22) recently published a prospective validation of a pre-peritoneal pelvic packing protocol for hemodynamically unstable pelvic trauma patients. Similar to the previously mentioned study, the authors concluded that pelvic packing was a quick and effective method in the treatment of these severely injured patients.…”

Section: Discussionmentioning

confidence: 96%

“…In the past years, many different approaches to effectively manage the hemodynamically unstable patient with pelvic ring injury have been suggested and have been lively and controversially discussed in the contemporary literature (2,(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25). These controversies have their origin-among other reasons-in different trauma system developments comparing European countries and North America and therefore have resulted in different favored pathways in the treatment of these highly challenging injuries.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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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.

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“…Data were pooled from 14 studies of 483 patients. [15][16][17][18][20][21][22][23][24][25]27,28,30,32 The average age in the PPP group was 51 years (95% CI, 46-56 years; n = 370), while, in the AE group, it was 40 years (95% CI, 33-48 years; n = 113) (Supplemental Digital Content, Supplementary Fig. 1, http://links.lww.…”

Section: Agementioning

confidence: 99%

Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis

McDonogh

Lewis

Tarrant

et al. 2022

J Trauma Acute Care Surg

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Prospective validation of a new protocol with preperitoneal pelvic packing as the mainstay for the treatment of hemodynamically unstable pelvic trauma: a 5-year experience

Cited by 14 publications

References 48 publications

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

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

Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis

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