Thurs., 10/18/07 Polytrauma, Paper #13, 3:05 pm OTA-2007
Direct Retroperitoneal Pelvic Packing versus Pelvic Angiography: A Comparison of Two Protocols Treating Hemodynamically Unstable Patients with Pelvis Fractures
Patrick M. Osborn, CAPT, MC USAF (n); Wade R. Smith, MD (n); C. Clay Cothren, MD (n); Steven J. Morgan, MD (n); Allison R. Williams, PhD (n); Philip F. Stahel, MD (n);
Ernest E. Moore, MD (n);
Denver Health Medical Center, Denver, Colorado, USA
Introduction: Hemodynamically unstable patients with pelvis fractures continue to suffer from high mortality. Current treatment consists of fluid resuscitation, pelvic angiography, and embolization or, in some centers, surgical control of bleeding by transperitoneal packing of the retroperitoneum. We hypothesized that a protocol emphasizing early direct retroperitoneal pelvic packing would result in decreased transfusion requirements and mortality compared to a protocol emphasizing early angiography.
Methods: From 1998 until September 2004, hemodynamically unstable patients with pelvis fractures were treated by a protocol emphasizing early angiography (ANGIO). Since September 2004, these patients were treated in a protocol based on early surgical pelvic packing (PACK). The first 20 consecutive PACK patients were age- and ISS-matched to 20 ANGIO patients. Patient demographics, physiologic markers, transfusion requirements, and acute outcomes were analyzed.
Results: The PACK group underwent operative packing at a median of 45 minutes after arrival in the ED. The median time to angiography in the ANGIO group was 130 minutes (P <0.01). The PACK group demonstrated a significant decrease in blood transfusions following intervention, from a mean of 11.8 units of PRBCs through the packing procedure to 6.9 over the next 24r hours (P <0.01). The ANGIO group displayed no decrease in blood transfusion requirement following intervention (mean, 9.2 PRE to 10.1 POST; P = 0.67). Ten patients in the ANGIO group and three in the PACK group required embolization of bleeding pelvic arteries (P = 0.041). Six ANGIO patients died, two acutely from pelvic hemorrhage. Four PACK patients died, but none due to uncontrolled hemorrhage.
Conclusions and Significance: Pelvic packing reduces the need for postprocedure blood transfusions, the incidence of pelvic embolization, and decreases mortality due to exsanguination from pelvic hemorrhage. Decreases in blood transfusion requirements may have clinical significance in reducing multiorgan failure and mortality in this population.
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