J Korean Orthop Assoc.  2012 Jun;47(3):191-197. 10.4055/jkoa.2012.47.3.191.

Comparison of the Mortality Rate according to the Presence of Trauma Team in Hemodynamically Unstable Patients with Pelvic Ring Injury

• Kim JW
• Hong SK
• Kyoung KH
• Choi JH
• Kim JJ

• KMID: 2106647
• DOI: http://doi.org/10.4055/jkoa.2012.47.3.191

Abstract

PURPOSE
To compare the clinical results of hemodynamically unstable patients diagnosed with pelvic ring injury according to the presence of a trauma team.
MATERIALS AND METHODS
Patients with hemodynamically unstable pelvic fracture were enrolled in the study and were divided into two groups: Group I, patients who were managed before March 2009, when there was no trauma team; and Group II, patients who were managed after March 2009, when emergent trauma team began to work. Data were collected regarding the time the trauma team began patient management, the treatment modality used to control bleeding, transfusion requirement, and patient mortality.
RESULTS
The time when the trauma team began patient management was five hours and 48 minutes in Group I and 57 minutes in Group II. The time to definitive treatment in order to control bleeding in Group I and Group II was 14.4 hours and 4.2 hours, respectively. The amount of the transfusion was 41.1 unit in Group I and 13.2 unit in Group II patients. In Group I, four patients (57.1%) died, although only one of the seven patients in Group II (14.3%) died.
CONCLUSION
Using a multidisciplinary approach, the trauma team has only a short amount of time to determine their treatment strategy and to achieve prompt management of bleeding, with the final objective to decrease the mortality rate in patients with hemodynamically unstable pelvic fractures.

Keyword

trauma; pelvic fracture injury; mortality; trauma team

MeSH Terms

Hemorrhage
Humans

Figure

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  Figure 1 Comparison of treatment modality to control bleeding between the two groups. EF, external fixation; Emb, embolization.

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  Figure 2 (A) Plain radiograph of a 42-year-old male shows vertical shear type of pelvic ring injury due to falling down from 9 meters high. Initial blood pressure was 79/33 mmHg at 30 minutes after trauma. (B) External fixation for anterior ring and percutaneous iliosacral screw fixation were done 5 hours after arrival and the vital sign was finally stabilized.

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  Figure 3 (A) Plain radiograph of a 43-year-old male shows combined mechanism type of pelvic ring injury due to falling down from 7 meters high. He was transferred to emergency room (ER) 7 hours after trauma. On arrival at ER, blood pressure was 44/30 mmHg and mental state was semi-coma state. (B) Angiography reveals extravasation of contrast at the internal iliac artery and branch of lumbar artery. Embolization in the past 3 hours made mental status alert but blood pressure was 91/76 mmHg with heart rate of 127 per minutes. (C) External fixation for anterior ring and percutaneous iliosacral screw fixation were done 11 hours after arrival and the vital sign was stabilized at last.

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  Figure 4 Comparison of clinical results between the two groups.

Reference

1. Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg. 2001. 233:843–850.

2. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990. 30:848–856.

3. Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J Surg. 2004. 74:520–529.

4. Panetta T, Sclafani SJ, Goldstein AS, Phillips TF, Shaftan GW. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma. 1985. 25:1021–1029.

5. Poole GV, Ward EF. Causes of mortality in patients with pelvic fractures. Orthopedics. 1994. 17:691–696.

6. Riemer BL, Butterfield SL, Diamond DL, et al. Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and external fixation. J Trauma. 1993. 35:671–675.

7. Shapiro M, McDonald AA, Knight D, Johannigman JA, Cuschieri J. The role of repeat angiography in the management of pelvic fractures. J Trauma. 2005. 58:227–231.

8. Starr AJ, Griffin DR, Reinert CM, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma. 2002. 16:553–561.

9. O'Neill PA, Riina J, Sclafani S, Tornetta P 3rd. Angiographic findings in pelvic fractures. Clin Orthop Relat Res. 1996. 329:60–67.

10. Eastridge BJ, Starr A, Minei JP, O'Keefe GE, Scalea TM. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma. 2002. 53:446–450.

11. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007. 62:834–839.

12. Gilliland MD, Ward RE, Barton RM, Miller PW, Duke JH. Factors affecting mortality in pelvic fractures. J Trauma. 1982. 22:691–693.

13. Evers BM, Cryer HM, Miller FB. Pelvic fracture hemorrhage. Priorities in management. Arch Surg. 1989. 124:422–424.

14. Balogh Z, Caldwell E, Heetveld M, et al. Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability: do they make a difference? J Trauma. 2005. 58:778–782.

15. McMurtry R, Walton D, Dickinson D, Kellam J, Tile M. Pelvic disruption in the polytraumatized patient: a management protocol. Clin Orthop Relat Res. 1980. 151:22–30.

16. Gruen GS, Leit ME, Gruen RJ, Peitzman AB. The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures. J Trauma. 1994. 36:706–711.

17. Moore FA, Moore EE, Sauaia A. Blood transfusion. An independent risk factor for postinjury multiple organ failure. Arch Surg. 1997. 132:620–624.

18. Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007. 21:31–37.

19. Huittinen VM, Slätis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery. 1973. 73:454–462.

20. Kellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture. Operative treatment. Orthop Clin North Am. 1987. 18:25–41.

21. Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma. 2001. 15:468–474.

22. Gänsslen A, Giannoudis P, Pape HC. Hemorrhage in pelvic fracture: who needs angiography? Curr Opin Crit Care. 2003. 9:515–523.

23. Pohlemann T, Bosch U, Gänsslen A, Tscherne H. The Hannover experience in management of pelvic fractures. Clin Orthop Relat Res. 1994. (305):69–80.

24. Smith WR, Moore EE, Osborn P, et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma. 2005. 59:1510–1514.

25. Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D. Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture. J Trauma. 2005. 58:978–984.

26. Velmahos GC, Toutouzas KG, Vassiliu P, et al. A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma. 2002. 53:303–308.

27. Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF 3rd. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma. 1997. 43:395–399.

28. Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma. 2003. 54:437–443.

29. Kimbrell BJ, Velmahos GC, Chan LS, Demetriades D. Angiographic embolization for pelvic fractures in older patients. Arch Surg. 2004. 139:728–732.