Initial experience with the T-Clamp for temporary fixation of mechanically and hemodynamically unstable pelvic ring injuries

Pelvic Ring Resuscitation Pathways

A 35 year-old female is injured in a high-speed motor vehicle collision in which her car is struck on the driver's side by a distracted driver. The patient is unable to self-extricate from the vehicle and she is confused at the scene. She comes directly to the trauma bay via EMS and a binder is placed in transit for suspicion of a pelvic ring injury. Upon presentation she has a GCS of 14 due to confusion, and an initial pressure of 87/50. Workup does not disclose an associated head, chest or abdominal injury and the anteroposterior pelvis radiograph demonstrates a windswept pelvis injury pattern. Despite being transfused 4 units of whole blood, her hypotension does not improve. Please describe your institution's advanced resuscitation protocol and management of this scenario, and provide the rational and support for it.

Pelvic Ring Injury Mortality: Are We Getting Better?

OBJECTIVES

To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study.

INTERVENTION

Pelvic ring management, years 1999-2006 versus years 2007-2018.

MAIN OUTCOME MEASUREMENTS

In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score.

RESULTS

The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01).

CONCLUSION

Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients.

LEVEL OF EVIDENCE

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

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.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.