Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers

Abstract

BackgroundMortality from hemodynamically unstable pelvic fractures remains high. Guidelines offer varying care approaches including the use of pelvic packing (PP), which was recently adopted for potential control of bleeding for this condition. However, the implementation of PP is uncertain as the debate on the optimal resuscitation strategy, angioembolization or PP continues. The study was designed to assess current practices among level 1 trauma centers in the US in regard to PP treatment for hemodynamically unstable pelvic fractures.MethodsA cross-sectional survey was created to assess when to apply PP, application approach, and the respondent’s anecdotal perception on safety and effectiveness. Trauma Medical Directors at 158 US level 1 trauma centers were sent biweekly email invitations for 3 months. Participants were allowed to skip questions for any reason. The study hypothesis was that PP practices vary by US census bureau region, annual trauma admissions, and length of time in years since each trauma center received their respective level 1 trauma center designation.ResultsTwenty-five percent (40/158) of trauma medical directors participated and 75% (118/158) of the trauma medical directors did not participate. Of those who took the survey, 36/40 (90%) completed the survey and 4/40 (10%) partially completed the survey. Only 36 trauma medical directors responded on their perception of safety and effectiveness; 72% (26/36) of participants perceived PP as safe, whereas only a third (12/36) of participants perceived PP as effective. There were 25 trauma medical directors who provided the sequence of treatment modalities utilized at their level 1 trauma center, 76% (19/25) of participants reported that PP is utilized as the third or fourth priority. None of the participating level 1 trauma centers reported a preference towards utilization of PP as the first priority treatment. Half of the participants reported a preference towards applying PP only as a last resort to control hemorrhage. Northeastern and Western level 1 trauma centers were significantly more likely than Midwestern and Southern level 1 trauma centers to have reported application of PP to all hemodynamically unstable patients (p = 0.05). Midwestern, Southern, and Western level 1 trauma centers were significantly more likely to have perceived PP as safe than Northeastern level 1 trauma centers (p = 0.04). All low-volume and 38% high-volume level 1 trauma centers perceived PP to increase infection risks, (p = 0.03). We observed no association between the length of time each trauma center was designated a level 1 trauma center, and all participant responses.ConclusionControversy and varying anecdotal perception regarding safety and effectiveness of PP prevails among trauma medical directors at level 1 trauma centers in the US.

Variability in the timeliness of interventional radiology availability for angioembolization of hemodynamically unstable pelvic fractures: a prospective survey among U.S. level I trauma centers

“…Of the survey responses, 90% (36/40) completed and 10% (4/40) partially completed the survey; all responses were included. Participating Level I trauma centers’ characteristics have been reported [10]. The median (IQR) survey completion time was 11 min (8, 21).…”

“…We previously reported the priority treatment sequence for hemodynamically unstable pelvic fractures [10]. The median priority treatment sequence for angioembolization was examined according to the IR arrival time when working off-site and to the time it took IR to prepare for intervention (Table 3).…”

Utilization of pre-hospital pelvic circumferential compression devices for pelvic fractures: survey of U.S. level I trauma centers

“…Although not everyone used pre-hospital PCCD, all participants [100% (27/27)] utilized in-hospital PCCD. The priority treatment sequence for hemodynamically unstable pelvic fractures was previously reported; almost all of the participants, [89% (24/27)], applied PCCD first [10]. There were two participants who applied PCCD following angioembolization and external fixation and one participant who applied PCCD following angioembolization, external fixation, and exploratory laparotomy.…”

“…Participants were also able to skip questions for any reason; therefore, the denominator reported for each question varies based on the number of participants who responded. Level I trauma center characteristics have been previously reported and included the US census bureau region, volume of trauma admissions in 2017, and length in time the center has been an ACS-verified Level I trauma center [10,11]. The volume of trauma admissions was dichotomized as high-volume (≥1501 admissions) and low-volume (≤1500 admissions).…”

The effect of orthopaedic surgeons’ and interventional radiologists’ availability on the priority treatment sequence for hemodynamically unstable pelvic fractures: a survey of US Level I trauma centers

“…A majority of participants (90% [36/40]) had more than 1501 trauma patients in 2017 and 58% (23/40) had been an ACS-verified Level I trauma center for over 10 years. More details on the characteristics of the participating Level I trauma centers have been reported [17].…”