Hemodynamically Unstable Pelvic Fracture Management by Advanced Trauma Life Support Guidelines Results in High Mortality (original) (raw)
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The Road to Survival for Haemodynamically Unstable Patients With Open Pelvic Fractures
Frontiers in Surgery, 2020
Management of haemodynamically unstable pelvic ring injuries has been simplified into treatment algorithms to streamline care and emergent decision making in order to improve patient outcomes whilst decreasing mortality and morbidity. Pelvic ring injuries are most commonly a result of high-velocity and energy forces that exert trauma to the pelvic bones causing not only damage to the bone but the surrounding soft-tissue, organs, and other structures and are usually accompanied by injuries to other parts of the body resulting in a polytraumatised patient. Open pelvic fractures are a rare subset of pelvic ring fractures that are on the more severe end of the pelvic fracture continuum and usually produce uncontrolled haemorrhage from fractured bone, retroperitoneal haematomas, intraabdominal bleeding from bowel injury, soft tissue injuries to the anus, perineum, and genitals, fractures of the pelvic bones, causing bleeding from cancellous bone, venous, and arterial injuries combined with bleeding from concomitant injuries. This is a very complex and challenging clinical situation and timely and appropriate decisions and action are paramount for a positive outcome. Consequently, open pelvic fractures have an extremely high rate of mortality and morbidity and outcomes remain poor, despite evidence-based improvements in treatment, knowledge, and identification of haemorrhage; in the pre-hospital, critical care, and operative settings. In the future utilisation of haemostatic drugs, dressings, devices, and procedures may aid in the time to haemorrhage control.
2008
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) C16] with a major pelvic fracture (Abbreviated Injury Score, pelvis C3) and hemodynamic instability [admission systolic blood pressure (SBP) B90 mmHg or receiving C6 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
Management of Haemodynamically Unstable Pelvic Fracture
Pelvic ring fractures represent from 2% to 8% of all skeletal injuries and they are often associated with high-energy trauma. Frequently these lesions are the result of motor vehicle accidents or falls from height. Haemodynamically unstable pelvic fractures are a diagnostic and therapeutic challenge for trauma team. For example, blood loss from cancellous bone surfaces, presacral venous plexus and/or iliac arterial or venous branches may cause hypotension and lead to haemorragic shock.
South African Journal of Surgery, 2018
Background: We present our experience after the introduction of Advanced Trauma Life Support (ATLS) © , Trauma Team (TT) and Preperitoneal Pelvic Packing (PPP) protocols for the treatment of hemodynamically unstable pelvic blunt trauma. Methods: This is a retrospective study with historical controls: before (Control Group, CG) and after (Study Group SG) the introduction of the protocol. A single physician managed the CG and angiography was the emergency manoeuvre. A team with ATLS guidelines and PPP as an emergency manoeuvre managed the SG. Data were collected retrospectively. Patients were divided into two groups: before and after the introduction of protocols.
World Journal of Surgery, 2014
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) C16] with a major pelvic fracture (Abbreviated Injury Score, pelvis C3) and hemodynamic instability [admission systolic blood pressure (SBP) B90 mmHg or receiving C6 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
Emergency treatment for clinically unstable patients with pelvic fracture and haemorrhage
Collegium antropologicum, 2012
Unstable pelvic fractures very frequently occur with haemorrhage, not only from the broken pelvis but from the presacral venous plexus and/or iliac arterial or venous branches which may cause hypotension and increases the mortality rate. Very often this type of injury is concurrent with injuries in other organ systems. The compounded nature of these injuries makes it necessary for doctors who may encounter this type of patient to be educated in the techniques to effectively stabilise and treat the patient's complex injuries. After completing the international standard ATLS (Advanced Trauma Life Support) primary survey to identify a haemodinamically unstable patient with pelvic fracture, we discuss adequate replenishment of lost blood volume and standards of care for such a patient. The best diagnostics are described from transport immobilisation to the placement of external fixators or C-clamps. Likewise indication for intervention of pelvic angiography and therapeutic embolisat...
Journal of Orthopaedic Trauma, 2013
In a 3-year period ending in December 2008, consecutive high-energy pelvic fracture patients older than 18 years were included. Patients who arrived .4 hours after injury or dead on arrival were excluded. Patient management followed advanced trauma life support and institutional guidelines. Collected data included patient demographics, mechanism of injury, vital signs, acid-base status, fluid resuscitation, trauma scores, fracture patterns, procedures, and outcomes. Potential predictors were identified using standard statistical tests: Univariate analysis, Pearson correlation (r), receiver operator characteristic, and decision tree analysis.
Hemodynamically Unstable Pelvic Fractures: Recent Care and New Guidelines
World Journal of Surgery, 2004
Consistent care of hemodynamically unstable pelvic fracture patients is a major management issue. It was uncertain whether the introduction of newly developed clinical practice guidelines would require much change in current delivery of care at our institution. Assessment of recent care was undertaken and compared with the newly developed evidencebased best practice guidelines. A multidisciplinary project team developed clinical practice guidelines for determination of early optimum management of hemodynamically unstable patients with pelvic fractures. The guidelines recommend a definitive management plan to arrest hemorrhage within 30 minutes. Intra-abdominal hemorrhage should be assessed with diagnostic peritoneal aspiration (DPA) and/or focused assessment with sonography for trauma (FAST). Early noninvasive stabilization of the pelvis followed by angiography within 90 minutes are recommended if intraabdominal hemorrhage is not found. Recent care was assessed in a historical cohort of patients, identified in a prospectively maintained trauma registry, between June 1999 and December 2001. Investigations, interventions, and times were then compared with the new guidelines. The delivery of care to 30 patients (mortality 37%, mean ISS 37.8 ± 20.9) was studied. Compared with the new guidelines, the abdominal assessment rate with DPA and/or FAST was 53% and early (< 90 minutes) angiography rate was 38%. A form of pelvic external stabilization was applied in 27% of cases. Noninvasive pelvic stabilization was not performed at all. The recent care of hemodynamically unstable pelvic fracture patients was not in line with newly developed guidelines. There is an opportunity to markedly improve the rates of initial assessment of the abdomen, pelvic stabilization, and early angiography.