Pre-peritoneal pelvic packing for the management of life-threatening pelvic fractures

Managing severe (and open) pelvic disruption

Open pelvic fractures are a rare yet catastrophic injury pattern, often resulting from high-energy trauma such as motor vehicle collisions, motorcycle accidents, and pedestrian impacts. They account for only 2%-4% of all pelvic fractures, but their severity lies in the complex anatomy of the pelvis and its associated structures, including the vasculature, bowel, bladder, and genital organs. Mortality rates range from 15% to 50%, with some studies reporting rates as high as 70% in cases involving severe perineal or rectal injuries. These injuries pose two main risks to survival: hemorrhagic shock in the acute phase and pelvic sepsis during the later phases of recovery. Acute hemorrhage can occur from arterial injury (eg, internal iliac arteries), venous plexuses, or bony sources. Delayed deaths are often caused by sepsis due to fecal contamination of wounds or infected hematomas. Additionally, these fractures are often associated with other life-threatening injuries, including intra-abdominal trauma, genitourinary disruptions, and neurovascular compromise, further complicating their management. Management of these injuries has evolved significantly with advancements in hemorrhage control techniques such as preperitoneal pelvic packing and resuscitative endovascular balloon occlusion of the aorta. A multidisciplinary approach is essential to address the multifaceted challenges posed by these injuries.

Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification

INTRODUCTION

Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification.

METHODS

Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016.

RESULTS

A total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock.

CONCLUSIONS

Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Preperitoneal Pelvic Packing versus Angioembolization for Patients with Hemodynamically Unstable Pelvic Fractures with Pelvic Bleeding: A Single-Centered Retrospective Study

The aim of this study was to compare the outcomes of preperitoneal pelvic packing (PPP) and angioembolization (AE) for patients with equivocal vital signs after initial resuscitation. This single-centered retrospective study included information from the database of a regional trauma center from April 2014 to December 2022 for patients with pelvic fractures with a systolic blood pressure of 80-100 mmHg after initial fluid resuscitation. The patients' characteristics, outcomes, and details of AE after resuscitative endovascular balloon occlusion of the aorta (REBOA) placed in zone III were collected. The follow-up duration was from hospital admission to discharge. A total of 65 patients were enrolled in this study. Their mean age was 59.2 ± 18.1 years, and 40 were males. We divided the enrolled patients into PPP (n = 43) and AE (n = 22) groups. The median time from emergency department (ED) to procedure and the median duration of ED stay were significantly longer in the AE group than in the PPP group (p ≤ 0.001 for both). The median mechanical ventilation (MV) duration was significantly shorter (p = 0.046) in the AE group. The number of patients with complications, overall mortality, and mortality due to hemorrhage did not differ between the two groups. Three patients (13.6%) were successfully treated with AE after REBOA. AE may be beneficial for patients with hemodynamically unstable pelvic fractures who show equivocal vital signs after initial fluid resuscitation in terms of reducing the MV duration and incidence of infectious complications.

Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma

This study analyzed the outcomes of bilateral internal iliac artery (IIA) ligation with preperitoneal pelvic packing (PPP) in hemodynamically unstable patients with major pelvic fractures. All-cause mortality was examined, periprocedural safety for critical circumstances was reviewed, and iliac artery ligation-related complications of the postoperative phase were evaluated. A total of 20 patients who suffered substantially from severe pelvic trauma with hemodynamic instability and subsequently underwent bilateral IIA ligation with PPP between January 1, 2017, and December 31, 2021, were enrolled in the study. The median participant age was 60.5 years, and 65.0% were male. The median systolic blood pressure was 68.5 mmHg on arrival. Increased lactate level (median, 11.05 mmol/L) suggested that the patients were in shock distinctly due to hypovolemia. It took approximately 1 h to complete the ligation of bilateral IIA to accomplish hemostasis (median, 65.5 min). The iliac vein was injured during dissection in three cases. During the ICU stay (median, 17.5 days), acute kidney injury was identified in 13 patients, likely due to volume depletion. The median ventilator-free days was 13.5; six patients were confirmed with ventilator-associated pneumonia. Moreover, 12 patients were diagnosed with acute respiratory distress syndrome. There was one case in which the lower extremity artery was acutely occluded. Anatomic hemostasis was achieved in 18 patients. The two patients for which anatomic hemostasis failed became two mortality cases from preperitoneal hemorrhage. Our analysis showed that bilateral IIA ligation with PPP was effective as a lifesaving procedure in hemodynamically unstable patients with a major pelvic fracture in terms of mortality due to fracture-related exsanguination. Moreover, the incidence of periprocedural complications was considered tolerable, making the procedure worth a try, especially in austere and underdeveloped healthcare settings.

Preperitoneal Pelvic Packing is Associated With Increased Risk of Venous Thromboembolism

INTRODUCTION

Preperitoneal pelvic packing (PPP) is an important intervention for control of severe pelvic hemorrhage in blunt trauma patients. We hypothesized that PPP is associated with an increased incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

A retrospective cohort analysis of blunt trauma patients with severe pelvic fractures (AIS ≥4) using the 2015-2017 American College of Surgeons-Trauma Quality Improvement Program database was performed. Patients who underwent PPP within four hours of admission were matched to patients who did not using propensity score matching. Matching was performed based on demographics, comorbidities, injury- and resuscitation-related parameters, vital signs at presentation, and initiation and type of prophylactic anticoagulation. The rates of DVT and PE were compared between the matched groups.

RESULTS

Out of 5129 patients with severe pelvic fractures, 157 (3.1%) underwent PPP within four h of presentation and were matched with 157 who did not. No significant differences were detected between the two matched groups in any of the examined baseline variables. Similarly, mortality and end-organ failure rates were not different. However, PPP patients were significantly more likely to develop DVT (12.7% versus 5.1%, P = 0.028) and PE (5.7% versus 0.0%, P = 0.003).

CONCLUSIONS

PPP in severe pelvic fractures secondary to blunt trauma is associated with an increased risk of DVT and PE. A high index of suspicion and a low threshold for screening for these conditions should be maintained in patients who undergo PPP.

Determination of risk factors associated with surgical site infection in patients undergoing preperitoneal pelvic packing for unstable pelvic fracture

Background

Several recent studies have shown that preperitoneal pelvic packing (PPP) effectively produces hemostasis in patients with unstable pelvic fractures. However, few studies have examined the rate of surgical site infections (SSIs) in patients undergoing PPP following an unstable pelvic fracture. The purpose of the present study was to evaluate factors associated with SSI in such patients.

Methods

We retrospectively reviewed the medical charts of 188 patients who developed hemorrhagic shock due to pelvic fracture between April 2012 and May 2021. Forty-four patients were enrolled in this study.

Results

SSI occurred in 15 of 44 patients (34.1%). The SSIs occurred more frequently in cases of repacking during the second-look surgery (0 vs. 4 [26.7%], P=0.010) and combined bladder-urethra injury (1 [3.4%] vs. 4 [26.7%], P=0.039). The incidence of SSIs was not significantly different between patients undergoing depacking within or after 48 hours (12 [41.4%] vs. 5 [33.3%], P=0.603). The mean time to diagnosis of SSI was 8.1±3.9 days from PPP. The most isolated organism was Staphylococcus epidermidis.

Conclusions

Repacking and combined bladder-urethra injury are potential risk factors for SSI in patients with unstable pelvic fracture. Close observation is recommended for up to 8 days in patients with these risk factors. Further, 48 hours after PPP, removing the packed gauze on cessation of bleeding and not performing repacking can help prevent SSI. Additional analyses are necessary with a larger number of patients with the potential risk factors identified in this study.

Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control

ABSTRACT

Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined.

LEVEL OF EVIDENCE

Review, level IV.

Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis

INTRODUCTION

Treatment of pelvic trauma related hemorrhage is challenging and remains controversial. In hemodynamically unstable patients suspected for massive bleeding, pre-peritoneal packing (PPP) with temporary external fixation (EF) and subsequent trans-arterial embolization (TAE) can be performed in order to control bleeding. In hemodynamically stable patients suspected for minor to moderate bleeding, primary TAE with EF may be performed. The goal of this study was to determine effectiveness and safety of both strategies.

METHODS

Retrospectively, patients that received treatment for pelvic trauma-related hemorrhage at two level 1 trauma centers located in the United States between January 2001 and January 2019 were evaluated. Both centers advocate subsequent TAE in addition to PPP and EF in hemodynamically unstable patients, and primary TAE in stable patients. Demographic and clinical data was collected and mortality, ischemic and infectious complications were determined.

RESULTS

In total, 135 patients met the inclusion criteria. Of these, 61 hemodynamically unstable patients suspected for massive pelvic bleeding underwent primary PPP (45%) and 74 stable patients suspected for minor/moderate bleeding underwent primary TAE (55%). In total, 37/61 primary PPP patients underwent EF (61%) and 48 underwent adjunct TAE (79%), performed bilaterally in 77% and unselective by use of gelfoam in 72% of cases. Primary TAE patients received embolization bilaterally in 49% and unselective in 35% of cases. Exsanguination-related deaths were found in 7/61 primary PPP patients (11%). There were none among the primary TAE patients. Potentially ischemic in-hospital complications, of which one could be considered severe (gluteal necrosis), occurred more in patients that received bilateral unselective TAE compared to all other TAE patients (p=0.02).

CONCLUSION

Primary TAE appears to be an effective and safe adjunct for (minor) pelvic hemorrhage in hemodynamically stable patients. Primary PPP followed by EF and adjunct bilateral unselective TAE with gelfoam appears effective for those suspected of massive pelvic bleeding. This unselective embolization approach using gelfoam might be related to (ischemic) complications. When considering the amount and severity of complications and the severity of pelvic trauma, these might not outweigh the benefit of fast hemorrhage control.

Management of Hemodynamically Unstable Pelvic Ring Fractures

Hemodynamically unstable pelvic fractures are challenging high-energy traumas. In many cases, these severely injured patients have additional traumatic injuries that also require a trauma surgeon's attention. However, these patients are often in extremis and require a multidisciplinary approach that needs to be set up in minutes. This calls for an evidence-based treatment algorithm. We think that the treatment of hemodynamically unstable pelvic fractures should primarily involve thorough resuscitation, mechanical stabilization, and preperitoneal pelvic packing. Angioembolization should be considered in patients that remain hemodynamically unstable. However, it should be used as an adjunct, rather than a primary means to achieve hemodynamic stability as most of the exsanguinating bleeding sources in pelvic trauma are of venous origin. Time is of the essence in these patients and should therefore be used appropriately. Hence, the hemodynamic status and physiology should be the driving force behind each decision-making step within the algorithm.

Pelvic Trauma: factors predicting arterial hemorrhage and the role of Angiography and preperitoneal pelvic packing

OBJECTIVES

(1) To identify the factors predicting arterial extravasation in pelvic trauma and (2) to assess the efficacy of preperitoneal pelvic packing (PPP) in controlling arterial hemorrhage.

METHODS

Institutional review board approved the retrospective study of 139 consecutive pelvic trauma patients who underwent angiographic intervention with or without prior PPP between January 2011 and December 2016. Patient demographics and presenting characteristics were recorded. Both groups of patients were combined for analysis of predictors for arterial extravasation using univariate logistic regression followed by multivariate logistic regression. Significance level was defined as p < 0.05.

RESULTS

Forty-nine out of 139 patients had PPP prior to pelvic angiogram. Embolization was performed in 85 (61.2%) patients and the technical and clinical success rate was 100%. Sixty-nine (49.7%) patients had unstable Young-Burgess (Y&B) type fractures, of which 58% had arterial hemorrhage compared with 38.6% of those with stable Y&B fractures (p = 0.02). Of the patients who had PPP prior to angiogram, 28(57.1%) continued to have arterial extravasation on subsequent angiography. Unstable Y&B type fractures are independent predictors of arterial hemorrhage (OR 2.3, 95%CI 1.1 to 4.7, p = 0.02).

CONCLUSION

Unstable Y&B type pelvic fractures are predictors of arterial extravasation. PPP alone is not effective for arterial hemorrhage control in pelvic trauma. Angiographic intervention remains a minimally invasive and definitive treatment of arterial hemorrhage from pelvic trauma.

KEY POINTS

• Unstable Young-Burgess pelvic fractures are predictors of arterial hemorrhage in pelvic trauma. • Pelvic angiography and embolization should precede PPP wherever feasible.

Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation

OBJECTIVE

To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP).

DESIGN

Retrospective observational cohort study.

SETTING

Level I academic trauma center.

PATIENTS

Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring.

INTERVENTION

Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87).

MAIN OUTCOME MEASURE

Incidence of postoperative surgical site infections of the pelvic space.

RESULTS

Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1-3 days) and 3.4 ± 3.7 days (range: 0-15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures.

CONCLUSIONS

These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.