The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture

A multi-institutional study

Juan Duchesne, Todd W. Costantini, Mansoor Khan, Ethan Taub, Peter Rhee, Bryan Morse, Nicholas Namias, Alon Schwarz, Joanne Graves, Dennis Y. Kim, Erin Howell, Jason Sperry, Vincent Anto, Robert D. Winfield, Martin Schreiber, Brandon Behrens, Benjamin Martinez, Shariq Raza, Mark Seamon, Danielle Tatum

    Research output: Contribution to journalArticle

    Abstract

    BACKGROUND Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE Therapeutic study, level IV.

    Original languageEnglish (US)
    Pages (from-to)117-124
    Number of pages8
    JournalJournal of Trauma and Acute Care Surgery
    Volume87
    Issue number1
    DOIs
    StatePublished - Jul 1 2019

    Fingerprint

    Balloon Occlusion
    Aorta
    Hemorrhage
    Shock
    Interventional Radiology
    Operating Rooms
    Mortality
    Blood Pressure
    Glasgow Coma Scale
    Injury Severity Score
    Trauma Centers
    Resuscitation
    Heart Rate
    Wounds and Injuries

    Keywords

    • hemorrhage control
    • pelvic binder
    • Pelvic fracture
    • preperitoneal packing
    • REBOA

    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

    Cite this

    The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture : A multi-institutional study. / Duchesne, Juan; Costantini, Todd W.; Khan, Mansoor; Taub, Ethan; Rhee, Peter; Morse, Bryan; Namias, Nicholas; Schwarz, Alon; Graves, Joanne; Kim, Dennis Y.; Howell, Erin; Sperry, Jason; Anto, Vincent; Winfield, Robert D.; Schreiber, Martin; Behrens, Brandon; Martinez, Benjamin; Raza, Shariq; Seamon, Mark; Tatum, Danielle.

    In: Journal of Trauma and Acute Care Surgery, Vol. 87, No. 1, 01.07.2019, p. 117-124.

    Research output: Contribution to journalArticle

    Duchesne, J, Costantini, TW, Khan, M, Taub, E, Rhee, P, Morse, B, Namias, N, Schwarz, A, Graves, J, Kim, DY, Howell, E, Sperry, J, Anto, V, Winfield, RD, Schreiber, M, Behrens, B, Martinez, B, Raza, S, Seamon, M & Tatum, D 2019, 'The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study', Journal of Trauma and Acute Care Surgery, vol. 87, no. 1, pp. 117-124. https://doi.org/10.1097/TA.0000000000002316
    Duchesne, Juan ; Costantini, Todd W. ; Khan, Mansoor ; Taub, Ethan ; Rhee, Peter ; Morse, Bryan ; Namias, Nicholas ; Schwarz, Alon ; Graves, Joanne ; Kim, Dennis Y. ; Howell, Erin ; Sperry, Jason ; Anto, Vincent ; Winfield, Robert D. ; Schreiber, Martin ; Behrens, Brandon ; Martinez, Benjamin ; Raza, Shariq ; Seamon, Mark ; Tatum, Danielle. / The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture : A multi-institutional study. In: Journal of Trauma and Acute Care Surgery. 2019 ; Vol. 87, No. 1. pp. 117-124.
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    abstract = "BACKGROUND Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62{\%}) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32{\%}. The most common adjunct used was pelvic binder (50{\%}) followed by no adjunct (30.5{\%}); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5{\%}). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46{\%}). CONCLUSION Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE Therapeutic study, level IV.",
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    author = "Juan Duchesne and Costantini, {Todd W.} and Mansoor Khan and Ethan Taub and Peter Rhee and Bryan Morse and Nicholas Namias and Alon Schwarz and Joanne Graves and Kim, {Dennis Y.} and Erin Howell and Jason Sperry and Vincent Anto and Winfield, {Robert D.} and Martin Schreiber and Brandon Behrens and Benjamin Martinez and Shariq Raza and Mark Seamon and Danielle Tatum",
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    T1 - The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture

    T2 - A multi-institutional study

    AU - Duchesne, Juan

    AU - Costantini, Todd W.

    AU - Khan, Mansoor

    AU - Taub, Ethan

    AU - Rhee, Peter

    AU - Morse, Bryan

    AU - Namias, Nicholas

    AU - Schwarz, Alon

    AU - Graves, Joanne

    AU - Kim, Dennis Y.

    AU - Howell, Erin

    AU - Sperry, Jason

    AU - Anto, Vincent

    AU - Winfield, Robert D.

    AU - Schreiber, Martin

    AU - Behrens, Brandon

    AU - Martinez, Benjamin

    AU - Raza, Shariq

    AU - Seamon, Mark

    AU - Tatum, Danielle

    PY - 2019/7/1

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    N2 - BACKGROUND Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE Therapeutic study, level IV.

    AB - BACKGROUND Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE Therapeutic study, level IV.

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    KW - pelvic binder

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    KW - preperitoneal packing

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