Session IV - Pelvis

The Acute Outcome of Hemodynamically Unstable Pelvis Fractures with Massive Hemorrhage

Wade R. Smith, MD; Michael Shannon, MD; Steven J. Morgan, MD; Walter L. Biffl, MD; Reginald Franciose, MD; Jon M. Burch, MD; Earnest Moore, MD; Denver Health Medical Center, Denver, Colorado, USA

Purpose: Hemodynamically unstable pelvic fractures represent a life-threatening injury requiring intensive resuscitation. Numerous authors have reported improved outcomes with use of a focused, multidisciplinary algorithm. In most studies hemodynamic instability is defined in terms of systolic blood pressure readings of less than 90, tachycardia, or transfusion requirements exceeding 4 to 6 units of packed red blood cells (PRBC). However, there is a subset of these patients who are "massively unstable," with enormous transfusion requirements often exceeding 50 units of PRBC, lactate levels more than 5.0, and other severe indicators of hemodynamic instability. Many of these patients have open pelvic fractures, associated chest or abdominal injuries, or limb-threatening injuries to the iliac tree.

Unfortunately, there is little information available in the literature describing the resuscitation and outcome of these injuries. We described previously our experience with successive protocols for the management of hemodynamically unstable pelvis fractures. In the course of our series we noted a highly injured subset whose management ultimately could not be directed by protocol and whose outcome was unpredictable. The purpose of this investigation was to characterize this group so that identification can lead to appropriate triage and management.

Methods: From January 1993 through December 2001, 288 patients with hemodynamically unstable pelvic fractures were treated at a level-1 trauma center. During this period, a protocol was in place categorizing all pelvic injuries with a systolic blood pressure of less than 90 as potentially unstable. Patients were treated according to a standardized algorithm, and their information was entered into a prospective database. This database was reviewed retrospectively, and additional information was added from the patient's medical records and the regional blood bank database. "Massive hemorrhage" was defined as requiring more than 10 units of PRBC within 24 hours, based on previously published projections of blood requirements for pelvic fractures and from data on multisystem organ-failure risk factors.

Results: Seventy-six of the 288 patients entered into the protocol fit the criteria for massive hemorrhage. Group 1 (76 patients) included patients that required 10 or more units of PRBC in the first 24 hours. Group 2 (212 patients) required less than 10 units of PRBC in the first 24 hours. The mean ISS scores, TRISS scores, units of PRBC, and ICU length of stay (LOS) were calculated as well as the percentage of patients receiving pelvic angiography; the morbidity and mortality in each group was recorded. The P values between these two groups were statistically significant. Outcome was assessed independently for the presence of head injury, pelvic fracture type, arterial injury pattern, and cause of death.

Group	ISS Score	Units PRBC	ICU LOS	Pelvic Angio	Morbidity	Mortality
1 (> or = 10units)	36	20	16.5 days	47.4%	52.6%	42.1%
2 (<10units)	23.8	3.2	9 days	13.7%	42%	10%

Thirty-three percent of patients in group 1 were predicted to die by TRISS analysis. 81.3% of group 1 deaths and 77.8% of group 2 deaths occurred within 48 hours.

Discussion: The definition of hemodynamic instability is controversial. Protocols are designed to insure that a potentially life-threatening injury is not overlooked or under-treated. Consequently, reports concerning the outcome of pelvic fracture management include injuries ranging >from transitory hypotension, which may respond to crystalloid, to sustained shock necessitating extreme volume replacement and complex resuscitative maneuvers. We have described a subset of pelvic fracture patients requiring massive resuscitation whose chance of survival is low, as evidenced by TRISS scores and clinical outcome. Many of these patients have open pelvic fractures or major associated arterial injury. Unlike reports of more inclusive groupings, we found that death is related directly to the effects of the pelvic injury and not necessarily to the presence of associated injuries.

Conclusion: Pelvic injury with massive hemorrhage is a distinct entity which is often lost in the analysis of the unstable pelvic fracture. These injuries have a much worse outcome than is commonly reported in the literature. Institutional and state system reviews of pelvic fracture outcome should consider these injuries in a separate category in order to have an accurate estimate of the efficacy of resuscitation protocols.