Operating room or angiography suite for hemodynamically unstable pelvic fractures?
BACKGROUND
Few patients require angiography and therapeutic embolization for bleeding pelvic fractures, but they are risk for significant morbidity and mortality. In hemodynamically unstable trauma patients with pelvic fractures, the decision to proceed to the operating room (OR) to address intraabdominal bleeding, or angiography to address pelvic bleeding (ANGIO), is rarely straightforward. This study tested the hypothesis that outcomes are similar regardless if the sequence was OR-ANGIO or ANGIO-OR.


METHODS
All pelvic fractures between 1999 and 2011 were retrospectively reviewed and stratified by initial management with ANGIO or OR.


RESULTS
Of 2,922 patients with pelvic fractures, only 183 (6%) required angiography for suspected bleeding. For OR-ANGIO (n = 49) versus ANGIO (n = 134), injury severity score was similar (40 ± 15 vs. 35 ± 16), but systolic blood pressure (97 ± 28 vs. 108 ± 32 mmHg, p = 0.038) and base excess were both lower (-9 ± 5 vs. -5 ± 5 mEq/L, p < 0.001). During initial resuscitation and in the first 24 hours, crystalloid, blood product usage and total fluid requirements were all increased 50% to 100% (all p < 0.001). Despite these differences, lengths of stay (32 ± 32 vs. 26 ± 28 days) and mortality (33% vs. 31%) were similar. The same trends in fluid requirements remained in the subset of patients with unstable pelvic fractures, with an increased mortality (67% vs. 20%, p = 0.011) in those requiring ANGIO-OR versus OR-ANGIO.


CONCLUSIONS
These data support current management algorithms. In hemodynamically unstable trauma patients with pelvic fractures, those who proceeded immediately to the OR to address intraabdominal bleeding tended to be sicker but had outcomes that were the same or better compared with those who received angiography to address pelvic bleeding.


METHODS
III, retrospective review.
Dewitt-Daughtry Family Department of Surgery and Ryder Trauma Center, University of Miami Miller School of Medicine,1800 NW 10th Avenue, Miami,FL 33136, USA.
Chad M
CM
Thorson
Mark L
ML
Ryan
Christian A
CA
Otero
Thai
T
Vu
Maria J
MJ
Borja
Jean
J
Jose
Carl I
CI
Schulman
Alan S
AS
Livingstone
Kenneth G
KG
Proctor
D000328:Adult; D000465:Algorithms; D000704:Analysis of Variance; D000792:Angiography; D016009:Chi-Square Distribution; D004621:Embolization, Therapeutic; D005260:Female; D050723:Fractures, Bone / Q000150:complications* / Q000000981:diagnostic imaging*; D006470:Hemorrhage / Q000000981:diagnostic imaging* / Q000209:etiology*; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009873:Operating Rooms; D010384:Pelvic Bones / Q000098:blood supply / Q000000981:diagnostic imaging / Q000293:injuries; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers