title: Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies.
abstract: Extraperitoneal pelvic packing (EPP) was introduced at Oslo University Hospital Ulleval (OUHU) in 1994. Published studies from other institutions have advocated its application as a first-line therapy in lieu of angiography. Extraperitoneal pelvic packing is invasive with a high risk of complications, and its role remains an issue of discussion. In line with international trends, an updated massive hemorrhage protocol was implemented at OUHU in 2007. We hypothesized a decreased need for EPP owing to the major changes in resuscitation strategies.
  
  
  
  Retrospective analysis of data from the OUH Trauma Registry and patient charts for the period 2002-2012 was performed. All pelvic fractures with Abbreviated Injury Severity (AIS) score of 3 or higher and/or transfused during the period before intensive care unit admission regardless of the pelvic AIS were included. The population was analyzed for trends and differences between 2002-2006 (P1) and 2007-2012 (P2). Further analysis was performed on the group of patients transfused five or more units of red blood cells (RBCs).
  
  
  
  We included 648 patients (P1, 297; P2, 351). There was no difference in median injury severity score, pelvic AIS, or age between the two periods. Median base deficit on admission was higher in P2 (4.2 vs 3.3 mmol/L; p < 0.01). The EPP rate decreased from P1 to P2 (17-10%; p < 0.01). A similar reduction in the angiography rate (15% vs 9%; p < 0.01) was observed, with a concomitant decrease in hemorrhage-related deaths (10% vs 5%; p = 0.01). The subgroup analysis of patients transfused five or more units of RBCs revealed significant increase in the use of plasma and platelets in P2. Multiple logistic regression models for the subgroup transfused five or more units of RBCs confirm the change in resuscitation strategy to be significantly associated with reduced EPP, and identifying admission in P2 to be associated with a 63% decreased odds ratio for EPP.
  
  
  
  The EPP and angiography rates for exsanguinating pelvic injuries have decreased with improved resuscitation strategies, reducing RBC requirements and hemorrhage-related deaths.
  
  
  
  Therapeutic study, level IV.
authors.affiliation: From the Department of Traumatology (I.A.G., P.A.N, C.G), Department of Gastrointestinal Surgery (G.I.A.), Department of Orthopedic Surgery (J.B, J.E.M., G.F.), Department of Anesthesiology (N.O.S), and Department of Radiology (N.E.K), Oslo University Hospital, Ulleval, Oslo, Norway.
authors.forename: Iver Anders
authors.initials: IA
authors.lastname: Gaski
authors.forename: Jeppe
authors.initials: J
authors.lastname: Barckman
authors.forename: Paal Aksel
authors.initials: PA
authors.lastname: Naess
authors.forename: Nils Oddvar
authors.initials: NO
authors.lastname: Skaga
authors.forename: Jan Erik
authors.initials: JE
authors.lastname: Madsen
authors.forename: Nils Einar
authors.initials: NE
authors.lastname: Kløw
authors.forename: Gunnar
authors.initials: G
authors.lastname: Flugsrud
authors.forename: Christine
authors.initials: C
authors.lastname: Gaarder
mesh_terms: D000328:Adult; D000792:Angiography; D005260:Female; D050723:Fractures, Bone / Q000628:therapy*; D006470:Hemorrhage / Q000517:prevention & control*; D006489:Hemostatic Techniques; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009664:Norway; D010384:Pelvic Bones / Q000293:injuries*; D012042:Registries; D012151:Resuscitation / Q000592:standards*; D012189:Retrospective Studies; D014193:Trauma Centers