title: Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice.
abstract: BACKGROUND
  Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM.
  
  
  METHODS
  Blunt trauma patients [Injury Severity Score (ISS) >or=16] with a major pelvic fracture (Abbreviated Injury Score, pelvis >or=3) and hemodynamic instability [admission systolic blood pressure (SBP) <or=90 mmHg or receiving >or=6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean +/- SD.
  
  
  RESULTS
  A total of 217 patients (mean age 41 +/- 19 years, 71% male, ISS 42 +/- 16) were studied. The admission SBP was 96 +/- 37 mmHg and the Glascow Coma Scale (GCS) 11 +/- 5. Patients received 4 +/- 2 liters of fluids including 4 +/- 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%).
  
  
  CONCLUSIONS
  HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by.
authors.forename: Diederik O
authors.initials: DO
authors.lastname: Verbeek
authors.affiliation: Trauma Department, Academic Medical Center, PO Box 22660, Amsterdam 1100 DD, The Netherlands. diederikverbeek@hotmail.com
authors.forename: Diederik
authors.initials: D
authors.lastname: Verbeek
authors.forename: Michael
authors.initials: M
authors.lastname: Sugrue
authors.forename: Zsolt
authors.initials: Z
authors.lastname: Balogh
authors.forename: Danny
authors.initials: D
authors.lastname: Cass
authors.forename: Ian
authors.initials: I
authors.lastname: Civil
authors.forename: Ian
authors.initials: I
authors.lastname: Harris
authors.forename: Thomas
authors.initials: T
authors.lastname: Kossmann
authors.forename: Steve
authors.initials: S
authors.lastname: Leibman
authors.forename: Valerie
authors.initials: V
authors.lastname: Malka
authors.forename: Anthony
authors.initials: A
authors.lastname: Pohl
authors.forename: Sudhakar
authors.initials: S
authors.lastname: Rao
authors.forename: Martin
authors.initials: M
authors.lastname: Richardson
authors.forename: Michael
authors.initials: M
authors.lastname: Schuetz
authors.forename: Caesar
authors.initials: C
authors.lastname: Ursic
authors.forename: Vanessa
authors.initials: V
authors.lastname: Wills
mesh_terms: D000328:Adult; D000792:Angiography; D001315:Australia / Q000453:epidemiology; D002423:Cause of Death; D005260:Female; D050723:Fractures, Bone / Q000150:complications / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*; D015600:Glasgow Coma Scale; D006439:Hemodynamics; D006470:Hemorrhage / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D009520:New Zealand / Q000453:epidemiology; D010384:Pelvic Bones / Q000293:injuries*; D012189:Retrospective Studies; D014193:Trauma Centers; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*