Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice.
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.
Verbeek
Diederik O
DO
Verbeek
Diederik
D
Trauma Department, Academic Medical Center, PO Box 22660, Amsterdam 1100 DD, The Netherlands. diederikverbeek@hotmail.com
Sugrue
Michael
M
Balogh
Zsolt
Z
Cass
Danny
D
Civil
Ian
I
Harris
Ian
I
Kossmann
Thomas
T
Leibman
Steve
S
Malka
Valerie
V
Pohl
Anthony
A
Rao
Sudhakar
S
Richardson
Martin
M
Schuetz
Michael
M
Ursic
Caesar
C
Wills
Vanessa
V
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*