title: Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures.
abstract: BACKGROUND
  Preperitoneal pelvic packing/external fixation (PPP/EF) for controlling life-threatening hemorrhage from pelvic fractures is used widely in Europe but has not been adopted in North America. We hypothesized that PPP/EF arrests hemorrhage rapidly, facilitates emergent operative procedures, and ensures efficient use of angioembolization (AE).
  
  
  METHODS
  In 2004 we initiated a PPP/EF guideline for pelvic fracture patients with refractory shock requiring ongoing blood transfusion at our regional trauma center.
  
  
  RESULTS
  Among 1,245 patients admitted with pelvic fractures, 75 consecutive patients underwent PPP/EF (age 42 ± 2 years and injury severity score 52 ± 1.5). Emergency department systolic blood pressure was 76 ± 2 mmHg and heart rate 119 ± 2 beats/min. Time to operation was 66 ± 7 minutes, and 65 patients (87%) underwent 3 ± 0.3 additional procedures. Blood transfusion before PPP/EF compared with the first postoperative 24 hours was 10 ± 0.8 units versus 4 ± 0.5 units (p < 0.05). The fresh frozen plasma-red blood cell ratio was 1:2. After PPP/EF, 10 patients (13%) underwent angioembolization with a documented blush; time to angioembolization was 10.6 ± 2.4 hours (range 1 to 38 hours). Mortality for all pelvic fractures was 8%, with 21% mortality in this high-risk group. There were no deaths due to acute hemorrhage.
  
  
  CONCLUSIONS
  PPP/EF was effective in controlling hemorrhage from unstable pelvic fractures. None of these high-risk patients died due to pelvic bleeding. Secondary angioembolization was needed in a minority, permitting selective use of this resource-demanding intervention. Additionally, PPP/EF temporizes arterial hemorrhage, providing valuable transfer time for facilities without angiography. With other urgent operative interventions required in >85% of patients, combining these procedures with PPP/EF for operative pelvic hemorrhage control appears to optimize patient care.
authors.affiliation: Department of Surgery, Denver Health Medical Center and the University of Colorado Denver, Denver, CO 80204, USA. clay.cothren@dhha.org
authors.forename: Clay Cothren
authors.initials: CC
authors.lastname: Burlew
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: Wade R
authors.initials: WR
authors.lastname: Smith
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Johnson
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: Carlton C
authors.initials: CC
authors.lastname: Barnett
authors.forename: Philip F
authors.initials: PF
authors.lastname: Stahel
mesh_terms: D000328:Adult; D002985:Clinical Protocols; D015331:Cohort Studies; D004621:Embolization, Therapeutic; D005260:Female; D005592:Fracture Fixation; D050723:Fractures, Bone / Q000150:complications* / Q000601:surgery*; D006470:Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D006801:Humans; D008297:Male; D010384:Pelvic Bones / Q000293:injuries*; D012189:Retrospective Studies