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European Journal of Orthopaedic Surgery & Traumatology

Erschienen in:

16.03.2023 | Original Article

Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock

verfasst von: Samuel Walters, Rory Cuthbert, Jonathan Ward, Homa Arshad, Paul Culpan, Zane Perkins, Nigel Tai, Peter Bates

Erschienen in: European Journal of Orthopaedic Surgery & Traumatology | Ausgabe 7/2023

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Abstract

Background

High energy pelvic ring injuries are associated with significant morbidity and mortality and can be accompanied by haemorrhagic shock following associated vascular injury. This study evaluated the causes and predictors of mortality in haemodynamically unstable pelvic fractures.

Methods

This retrospective observational study at a Major Trauma Centre reviewed 938 consecutive adult patients (≥ 18yrs) with pelvic ring injuries between December 2014 and November 2018. Patients with features of haemorrhagic shock were included, defined as: arrival Systolic BP < 90 mmHg, Base Deficit ≥ 6.0 mmol/l, or transfusion of ≥ 4 units of packed red blood cells within 24 h.

Results

Of the 102 patients included, all sustained injuries from high energy trauma, and 47.1% underwent a haemorrhage control intervention (Resuscitative Endovascular Balloon Occlusion of the Aorta—REBOA, Interventional Radiology—IR, or Laparotomy). These were more often required following vertical shear injuries (OR 10.7, p = 0.036).

Overall, 33 patients (32.4%) died; 16 due to a head injury, and only 2 directly from acute pelvic exsanguination (6.1%). Multivariable logistic regression demonstrated that increasing age, Injury Severity Score, Abbreviated Injury Scale (AIS) Head ≥ 3 and open pelvic fracture were all independent predictors of mortality, and IR was associated with reduced mortality. Lateral Compression III (LC3) injuries were associated with mortality due to multiple organ dysfunction syndrome (MODS).

Conclusion

Haemodynamically unstable patients with pelvic ring injuries have a high mortality rate, but death is usually attributed to other injuries or later complications, and not from acute exsanguination. This reflects improvements in resuscitative care, transfusion protocols, and haemorrhage control techniques.

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White CE, Hsu JR, Holcomb JB (2009) Haemodynamically unstable pelvic fractures. Injury 40:1023–1030. https://doi.org/10.1016/j.injury.2008.11.023CrossRefPubMed

Perkins ZB, Maytham GD, Koers L et al (2014) Impact on outcome of a targeted performance improvement programme in haemodynamically unstable patients with a pelvic fracture. Bone Jt J 96-B:1090–1097. https://doi.org/10.1302/0301-620X.96B8.33383CrossRef

Mauffrey C, Cuellar DO, Pieracci F et al (2014) Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy. Bone Jt J 96-B:1143–1154. https://doi.org/10.1302/0301-620X.96B9.33914CrossRef

Costantini TW, Coimbra R, Holcomb JB et al (2016) Current management of hemorrhage from severe pelvic fractures: results of an American association for the surgery of trauma multi-institutional trial. J Trauma Acute Care Surg 80(5):717–725. https://doi.org/10.1097/TA.0000000000001034CrossRefPubMed

Costantini TW, Coimbra R, Holcomb JB et al (2017) Pelvic fracture pattern predicts the need for hemorrhage control intervention-results of an AAST multi-institutional study. J Trauma Acute Care Surg 82:1030–1038. https://doi.org/10.1097/TA.0000000000001465CrossRefPubMed

Jang JY, Bae KS, Chang SW et al (2022) Current management and clinical outcomes for patients with haemorrhagic shock due to pelvic fracture in Korean regional trauma centres: a multi-institutional trial. Injury 53:488–495. https://doi.org/10.1016/j.injury.2021.12.015CrossRefPubMed

Verbeek DO, Verbeek D, Sugrue M et al (2008) Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice. World J Surg 32:1874–1882. https://doi.org/10.1007/s00268-008-9591-zCrossRefPubMed

Eastridge BJ, Starr A, Minei JP et al (2002) The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma Inj Infect Crit Care 53(3):446–451. https://doi.org/10.1097/00005373-200209000-00009CrossRef

Chiara O, di Fratta E, Mariani A et al (2016) Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a propensity score analysis. World J Emerg Surg WJES 11:22. https://doi.org/10.1186/s13017-016-0077-2CrossRefPubMed

10.

Borg T, Berg P, Fugl-Meyer K, Larsson S (2010) Health-related quality of life and life satisfaction in patients following surgically treated pelvic ring fractures. a prospective observational study with two years follow-up. Injury 41:400–404. https://doi.org/10.1016/j.injury.2009.11.006CrossRefPubMed

11.

Rojas DG, Coleman JR, Moore EE et al (2021) The association of surgical timing and injury severity with systemic complications in severely injured patients with pelvic ring injuries. J Orthop Trauma 35:171–174. https://doi.org/10.1097/BOT.0000000000001946CrossRefPubMed

12.

Burlew CC, Moore EE, Stahel PF et al (2017) Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg 82:233–242. https://doi.org/10.1097/TA.0000000000001324CrossRefPubMedPubMedCentral

13.

Werner N, Moore E, Hoehn N et al (2022) Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. Injury. https://doi.org/10.1016/j.injury.2022.07.025CrossRefPubMed

14.

Mauffrey C, Moore EE (2022) Pelvic Packing and Resuscitative Endovascular Balloon Occlusion of the Aorta. J Orthop Trauma 36:297–299. https://doi.org/10.1097/BOT.0000000000002106CrossRefPubMed

15.

Klein SR, Saroyan RM, Baumgartner F, Bongard FS (1992) Management strategy of vascular injuries associated with pelvic fractures. J Cardiovasc Surg (Torino) 33:349–357PubMed

16.

Marmor M, El Naga AN, Barker J et al (2020) Management of pelvic ring injury patients with hemodynamic instability. Front Surg 7:588845. https://doi.org/10.3389/fsurg.2020.588845CrossRefPubMedPubMedCentral

17.

Smith W, Williams A, Agudelo J et al (2007) Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma 21:31–37. https://doi.org/10.1097/BOT.0b013e31802ea951CrossRefPubMed

18.

Mutschler M, Nienaber U, Brockamp T et al (2013) Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®. Crit Care Lond Engl 17:R42. https://doi.org/10.1186/cc12555CrossRef

19.

Cothren C, Osborn P, Moore E et al (2007) Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. https://doi.org/10.1097/TA.0b013e31803c7632CrossRefPubMed

20.

Young JWR, Burgess AR (1987) Radiologic management of pelvic ring fractures: Systematic radiographic diagnosis. Urban and Schwarzenberg, Baltimore

21.

Guthrie HC, Owens RW, Bircher MD (2010) Fractures of the pelvis. J Bone Joint Surg Br 92:1481–1488. https://doi.org/10.1302/0301-620X.92B11.25911CrossRefPubMed

22.

JASP Team (2022) JASP Version 0.16.2

23.

Dahill M, McArthur J, Roberts GL et al (2017) The use of an anterior pelvic internal fixator to treat disruptions of the anterior pelvic ring: a report of technique, indications and complications. Bone Jt J 99-B:1232–1236. https://doi.org/10.1302/0301-620X.99B9.BJJ-2016-1025.R2CrossRef

24.

Patel S, Aggarwal S, Jindal K et al (2021) Outcomes and complications of the INFIX technique for unstable pelvic ring injuries with high-velocity trauma: a systematic review and meta-analysis. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03742-7CrossRefPubMedPubMedCentral

25.

Papakostidis C, Kanakaris N, Dimitriou R, Giannoudis PV (2012) The role of arterial embolization in controlling pelvic fracture haemorrhage: a systematic review of the literature. Eur J Radiol 81:897–904. https://doi.org/10.1016/j.ejrad.2011.02.049CrossRefPubMed

26.

Black SR, Sathy AK, Jo C et al (2016) Improved survival after pelvic fracture: 13-year experience at a single trauma center using a multidisciplinary institutional protocol. J Orthop Trauma 30:22–28. https://doi.org/10.1097/BOT.0000000000000443CrossRefPubMed

27.

Asim M, Amin F, El-Menyar A (2020) Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum. Qatar Med J 2020:22. https://doi.org/10.5339/qmj.2020.22CrossRefPubMedPubMedCentral

28.

Poole GV, Ward EF, Muakkassa FF et al (1991) Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. Ann Surg 213:532–538. https://doi.org/10.1097/00000658-199106000-00002CrossRefPubMedPubMedCentral

29.

Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ (2007) Predicting blood loss in isolated pelvic and acetabular high-energy trauma. J Orthop Trauma 21:603–607. https://doi.org/10.1097/BOT.0b013e3181599c27CrossRefPubMed

30.

Lendrum R, Perkins Z, Chana M et al (2019) Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation 135:6–13. https://doi.org/10.1016/j.resuscitation.2018.12.018CrossRefPubMed

31.

Perkins ZB, Lendrum RA, Brohi K (2016) Resuscitative endovascular balloon occlusion of the aorta: promise, practice, and progress? Curr Opin Crit Care 22:563–571. https://doi.org/10.1097/MCC.0000000000000367CrossRefPubMed

32.

Asmar S, Bible L, Chehab M et al (2021) Resuscitative endovascular balloon occlusion of the aorta vs pre-peritoneal packing in patients with pelvic fracture. J Am Coll Surg 232:17-26.e2. https://doi.org/10.1016/j.jamcollsurg.2020.08.763CrossRefPubMed

33.

Mikdad S, van Erp IAM, Moheb ME et al (2020) Pre-peritoneal pelvic packing for early hemorrhage control reduces mortality compared to resuscitative endovascular balloon occlusion of the aorta in severe blunt pelvic trauma patients: a nationwide analysis. Injury 51:1834–1839. https://doi.org/10.1016/j.injury.2020.06.003CrossRefPubMed

34.

Joseph B, Zeeshan M, Sakran JV et al (2019) Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma. JAMA Surg 154:500–508. https://doi.org/10.1001/jamasurg.2019.0096CrossRefPubMedPubMedCentral

Titel: Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock
verfasst von: Samuel Walters
Rory Cuthbert
Jonathan Ward
Homa Arshad
Paul Culpan
Zane Perkins
Nigel Tai
Peter Bates
Publikationsdatum: 16.03.2023
Verlag: Springer Paris
Erschienen in: European Journal of Orthopaedic Surgery & Traumatology / Ausgabe 7/2023
Print ISSN: 1633-8065
Elektronische ISSN: 1432-1068
DOI: https://doi.org/10.1007/s00590-023-03516-y

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Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock