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Int. Int. 林泰祺林泰祺

IntroductionIntroduction Pelvic fracture patients who are hemodyn

amically unstable are a diagnostic and therapeutic challenge for the trauma team

These injuries often occur in conjunction with other life-threatening injuries, and there is not universal agreement among clinicians on management

The mortality for these high-risk patients exceeds 40%

IntroductionIntroduction Time to definitive stabilization followed by

appropriate interventional radiology access and embolization may consume hours while the patient remains hemodynamically compromised

Additionally, in patients with indications for laparotomy such as evidence of intra-abdominal hemorrhage on Focused Assessment with Sonography for Trauma (FAST) examination, this time delay may be even longer

IntroductionIntroduction We have modified this technique to directly add

ress pelvic hemorrhage through direct packing of the pelvis using a preperitoneal approach for all patients with hemodynamic instability and a pelvic fracture

Such an approach would simplify the often difficult decision between immediate operative intervention and interventional radiology

Additionally, this approach more rapidly and directly addresses the primary source of bleeding with pelvic fractures—venous and bone hemorrhage

IntroductionIntroduction

We hypothesized that preperitoneal pelvic packing (PPP) reduces need for angiography, decreases blood transfusion requirements, and lowers mortality

ResultsResults

During the study period, from September 2004 to June 2006, 139 patients qualified for inclusion in the pelvic fracture KCP and received blood transfusions

Of these, 28 consecutive patients met the KCP criteria of an SBP 90 mm Hg despite the transfusion of two units of PRBCs and underwent external fixation and PPP

There was one protocol deviation of prePPP angiography to evaluate an extremity vascular injury

OutcomeOutcome Patients required 4± 1.2 units of PRBCs during 82 ± 13

minutes in the ED Blood transfusion requirements before postoperative S

ICU admission compared with the subsequent 24 postoperative hours were significantly different

Abdominopelvic complications included infection of the pelvic space (3 total; 2 in patients with a bladder rupture), infection of the buttock and back related to a perineal degloving with rectal injury

Superficial wound infections (2 total; 1 anterior PPP incision, 1 posterior incision used for fixation of a comminuted sacral fracture)

Two patients had intra-abdominal abscesses associated with visceral injuries

OutcomeOutcome Patients required a mean of 14± 2.8 days of mechanical

ventilation and remained in the surgical intensive care unit for 18 ± 2.9 days

Overall length of hospital stay was 26 ± 3.4 days Seven (25%) patients died during their hospitalizationa

s a result of multiple organ failure (MOF) (2), postinjury myocardial infarction/pulseless electrical activity (PEA) arrest (2), invasive mucormycosis (1), closed head injury (1), and withdrawal of care (1)

There were no differences in presenting SBP, HR, base deficit, ISS or transfusion requirement between those who lived versus died

The only significance between the two groups was mean patient age (34 ± 3.9 years for patients who lived versus 55±8.1 years for patients who died)

DiscussionDiscussion 85% of bleeding as a result of pelvic fractures i

s venous or bony in origin – Hemorrhage is therefore only arrested by tamponad

e within the retroperitoneal space– Angioembolization does not address such bleeding.

In fact, patients undergoing diagnostic angiography frequently do not have active bleeding sites visualized and/or few patients require angioembolization

Secondly, although angioembolization may be effective in controlling pelvic arterial bleeding, it has not been shown to decrease the necessity for blood product resuscitation

Third, there are a number of institutions that do not have angiographic capabilities

DiscussionDiscussion In our study population, there was a significant

reductionin blood transfusion requirements in the postoperative 24hours compared with the prePPP period. By surgically packing the pelvic space

The overall potential space required to tamponade bleeding from the pelvis is reduced, therefore hypothetically reducing the amount of blood transfusion required to fill this potential space

Since blood transfusion is an independent risk factor for increased ICU length of stay, the development of multiple organ failure, and mortality

DiscussionDiscussion PPP may be ideally suited for austere conditio

ns and in settings where angiography is unavailable or unable

Emergent retroperitoneal packing appears to be a safe procedure that has a role in damage control of critically injured patients. It can be done immediately and with ease in conjunction with external fixation of the pelvis and other surgical

24-hour angiographic, the time delay to angiography can be significant. the time to angiography was four times longer in the nonPPP group compared with the PPP study group

DiscussionDiscussion There were five abdominoperineal space infecti

ons and two superficial wound infections, although the majority occurred in patients with associated bladder or bowel injuries

There was no apparent relationship between the time packs were removed and incidence of infection

The 25% mortality rate in this cohort was lower than historical reports of similar patient populations

There were no deaths as a result of exsanguination, and two patients died of MOF.

ConclusionConclusion Eliminate the often difficult decision between t

he operating room and interventional radiology Additionally, this approach directly addresses t

he primary source of bleeding with pelvic fractures—venous and bone hemorrhage.

Combined external pelvic fixation and preperitoneal pelvic packing may represent a revolutionary management strategy for these critically multiply injured patients, and offer a life-saving procedure in environments where IR is unavailable

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