The aim of this study is to evaluate treatment outcomes and mortality risks associated with hemodynamic instability caused by severe pelvic fracture in a regional trauma center.
The medical charts of 44 patients with hemodynamic instability due to pelvic fractures who were admitted to a regional trauma center from January 2014 to May 2017 were analyzed retrospectively.
The mean age was 61.8 years, and the mean injury severity score was 39.1. Twenty-six patients (59.1%) were transferred from other hospitals, and the median time from injury to emergency room arrival was 115.5 minutes. Preperitoneal pelvic packing, pelvic angiography, and external pelvic fixation were performed in 38 patients (86.4%) for hemostasis. The mortality rate was 52.3%, and 15 patients (34.1%) died from hemorrhage. Logistic regression analysis showed that initial low systolic blood pressure and packed red blood cell (PRBC) requirement were independent risk factors associated with mortality. PRBC requirement for four hours and application of emergent hemostatic procedures were independent factors associated with hemorrhage-induced mortality.
Emergency procedures for hemostasis should be performed immediately for patients with hemodynamic instability due to pelvic fracture, and they should be transferred to a regional trauma center as soon as possible.
Although several hemostatic procedures have been developed in the management for patients with hemodynamic instability due to pelvic fracture, the mortality rate of these patients is still reported to be 30∼60% [
Between January 2014 and May 2017, 366 pelvic fracture patients were admitted at the trauma center in Wonju Severance Christian Hospital. Forty-four patients with hemodynamic instability caused by fractures were enrolled in this study. Data were obtained from the hospital’s Pelvic Trauma Database, which was developed as part of the Korean Trauma Data Bank, and were analyzed retrospectively. They were reviewed for patient demographics, injury severity score (ISS), injury mechanism, time from injury to arrival at the emergency room (ER), combined injuries, type of pelvic fracture (Tile classification), hemodynamic status and laboratory findings at the time of ER arrival, packed red blood cell (PRBC) requirement, emergent hemostatic procedures (PPP, PA, and EPF), overall mortality, and hemorrhage-induced mortality. Hemodynamic instability was defined as persistent hypotension (systolic blood pressure [SBP], <90 mmHg) or tachycardia (pulse rate, >110/min) despite loading 2 L of crystalloids and transfusion of two units of PRBCs. Patients who had severe traumatic brain injury (head Abbreviated Injury Scale [AIS] score ≥4) or other sites with major hemorrhage were excluded from present study.
This clinical investigation was approved by the institutional review board (IRB no. CR-316111). We did not obtained written informed consent from each patient. Before data analysis, the records of patients were anonymized and de-identified. The approaches are following ordinances informed consent and enrollment expounded in guidelines.
Since the hospital was selected as a regional trauma center in 2012, a trauma team consisting of general, cardiothoracic, and orthopedic surgeons and emergency medicine physicians were tasked with managing trauma patients who met the criteria for the team’s activation. When patients with pelvic fracture had persistent shock, a massive transfusion protocol was initiated, and extended Focused Assessment with Sonography for Trauma (eFAST) and trauma series X-ray (cervical spine lateral, chest anterior-posterior [AP], and pelvis AP X-ray) were performed. If fluid collection was detected in the thoracic or abdominal cavity by eFAST and severe pelvic fracture was observed on pelvis AP X-ray imaging, PPP or PA was performed before or after emergent thoracotomy or laparotomy. The order of procedures for hemostasis was determined by the trauma surgeon depending on the patient’s hemodynamic status and type of associated injuries. PPP was performed on pelvic fracture patients who were hemodynamically unstable. The orthopedic surgeon will decide on the necessity of EPF.
Continuous variables were expressed as mean±standard deviation or median (range) and compared with Student’s t-test or Mann-Whitney U test. Binary variables were compared with chi-square or Fisher’s exact test. Logistic regression analysis was used to evaluate risk factors associated with mortality or hemorrhage-induced mortality, and results were expressed as odds ratios (ORs) with 95% confidence interval (CI). Statistical significance was considered at p-value <0.05. All statistical calculations were performed using IBM SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, USA).
A total of 44 patients were enrolled in this study, of whom 27 (61.4%) were men. The mean age was 61.8±17.5 years. The mean ISS was 39.1±9.7, and five patients (11.4%) were taking anticoagulants. The most common injury mechanism was auto-pedestrian accident (40.9%), followed by fall (29.5%), motor vehicle collision (18.2%), and motorcycle or bicycle accident (6.8%). Twenty-six patients (59.1%) were transferred from other hospitals, and the median time from injury to ER arrival was 115.5 (5∼715) minutes. Using Tile classification for pelvic fracture, 32 (72.7%) patients were classified as type B and 12 (27.3%) as type C. The mean values of initial SBP, hemoglobin, and lactate were 67.2±9.8 mmHg, 10.1±2.9 g/dL, and 5.59±3.38 mmol/L, respectively. Thirty-eight patients (86.4%) underwent hemostatic procedure emergently. PPP was performed in 34 patients (77.3%), and emergent laparotomy was conducted in 11 (25.0%). Among 15 patients (34.1%) who underwent emergent PA, seven (46.7%) had internal iliac artery branch embolization. Twenty-three mortalities (52.3%) were reported, with 15 (34.1%) caused by hemorrhage. The median duration of intensive care unit admission was seven (0∼76) days (
Comparison between survivors and non-survivors
Variable | Total (n=44) | Survivors (n=21) | Non-survivors (n=23) | p-value |
---|---|---|---|---|
Age (y) | 61.8±17.5 | 59.3±13.2 | 64.1±20.6 | 0.355 |
Sex, male | 27 (61.4) | 13 (61.9) | 14 (60.9) | 0.944 |
Anticoagulant medication | 5 (11.4) | 1 (4.8) | 4 (17.4) | 0.345 |
Injury severity score | 39.1±9.7 | 37.7±8.0 | 40.4±11.0 | 0.374 |
Injury mechanism | 0.825 |
|||
Auto-pedestrian accident | 18 (40.9) | 8 (38.1) | 10 (43.5) | |
Motor vehicle collision | 8 (18.2) | 4 (19.0) | 4 (17.4) | |
Fall | 13 (29.5) | 8 (38.1) | 5 (21.7) | |
Crush | 2 (4.5) | 0 | 2 (8.7) | |
Motorcycle and bicycle | 3 (6.8) | 1 (4.8) | 2 (8.7) | |
Transfer from another hospital | 26 (59.1) | 12 (57.1) | 14 (60.9) | 0.802 |
Time from injury to ER arrival (min) | 115.5 (5∼715) | 105 (21∼370) | 126 (5∼715) | 0.537 |
Trauma resuscitation room stay (min) | 108±62 | 113±74 | 104±50 | 0.639 |
Open fracture | 2 (4.5) | 0 | 2 (8.7) | 0.489 |
Pelvic fracture type | 0.853 | |||
Tile classification B | 32 (72.7) | 15 (71.4) | 17 (73.9) | |
Tile classification C | 12 (27.3) | 6 (28.6) | 6 (26.1) | |
Combined injury | 39 (88.6) | 19 (90.5) | 20 (87.0) | 1.000 |
Initial SBP (mmHg) | 67.2±9.8 | 70.6±9.8 | 64.0±8.8 | 0.025 |
Initial hemoglobin (g/dL) | 10.1±2.9 | 10.2±2.2 | 10.1±3.4 | 0.833 |
Initial lactate (mmol/L) | 5.59±3.38 | 4.12±2.17 | 6.92±3.77 | 0.004 |
PRBC requirement for 4 h (unit) | 11.9±9.7 | 8.7±5.2 | 14.8±11.9 | 0.031 |
PRBC requirement (unit) | 17.4±12.6 | 12.9±6.3 | 21.5±15.3 | 0.019 |
Preperitoneal pelvic packing | 34 (77.3) | 7 (33.3) | 16 (69.6) | 0.287 |
Laparotomy | 11 (25.0) | 3 (14.3) | 8 (34.8) | 0.117 |
Emergent external fixation | 9 (20.5) | 6 (28.6) | 3 (13.0) | 0.272 |
ORIF | 13 (29.5) | 11 (52.4) | 2 (8.7) | 0.002 |
Emergent pelvic angiography | 15 (34.1) | 8 (38.1) | 7 (30.4) | 0.592 |
Emergent hemostatic procedure | 38 (86.4) | 21 (100) | 17 (73.9) | 0.022 |
ICU stay (day) | 7 (0∼76) | 14 (4∼76) | 1 (0∼39) | 0.002 |
Values are presented as mean±standard deviation or number (%).
ER: emergency room, SBP: systolic blood pressure, PRBC: packed red blood cell, ORIF: open reduction and internal fixation, ICU: intensive care unit.
Results of Fisher’s exact test;
The data were statistically significant
When the survivor and non-survivor groups were compared, there was no significant difference in patient characteristics (age, gender, and history of anticoagulant use), injury mechanism, ISS, rate of transfer from another hospital, time from injury to ER arrival, combined injury, and pelvic fracture type. The non-survivor group had significantly lower initial SBP (64.0±8.8 vs. 70.6±9.8 mmHg, p=0.025) and higher initial lactate (6.92±3.77 vs. 4.12±2.17 mmol/L, p=0.004) than the survivor group. The total amount of transfusion (21.5±15.3 vs. 12.9±6.3 units, p=0.019) and amount of blood transfusion for 4 hours (14.8±11.9 vs. 8.7±5.2 units, p=0.031) were significantly higher in the non-survivor than in the survivor group. Although there was no difference in the frequencies of PPP, PA, and EPF between the two groups respectively, the overall frequency of hemostatic procedures was significantly higher in the survivor group (100% vs. 73.9%, p=0.022) (
Factors such as “emergent hemostatic procedure,” “initial SBP,” “initial lactate,” and “PRBC requirement” were subjected to multivariate analysis with logistic regression model. The results showed that initial SBP (OR, 0.902; 95% CI, 0.825∼0.987; p=0.024) and PRBC requirement (OR, 1.112; 95% CI, 1.008∼1.228; p=0.034) were independent factors associated with mortality in pelvic fracture patients with hemodynamic instability (
Multivariate analysis of factors associated with mortality in pelvic fracture patients with hemodynamic instability
Variable | Risk factors for mortality | |
---|---|---|
OR (95% CI) | p-value | |
Emergent hemostatic procedure | Undefined | 0.999 |
Initial systolic blood pressure | 0.902 (0.825∼0.987) | 0.024 |
Initial lactate | 1.142 (0.836∼1.562) | 0.404 |
PRBC requirement | 1.112 (1.008∼1.228) | 0.034 |
OR: odds ratio, CI: confidence interval, PRBC: packed red blood cell.
The data were statistically significant
When 15 patients with hemorrhagic mortality were compared with patients without hemorrhage mortality, there were significant differences in “application of PPP” (53.3% vs. 89.7%, p=0.011), “application of emergent procedures” (66.7% vs. 96.6%, p=0.013), “initial lactate” (7.33 vs. 4.68 mmol/L, p=0.012), and “PRBC requirement for 4 hours” (17.1 vs. 9.2 units, p=0.004). Logistic regression analysis showed that “emergent hemostatic procedure” (OR, 0.045; 95% CI, 0.004∼0.489; p=0.011) and “PRBC requirement for 4 hours” (OR, 1.129; 95% CI, 1.022∼1.247; p=0.017) were independent factors associated with hemorrhage-induced mortality (
Multivariate analysis of factors associated with hemorrhagic mortality in pelvic fracture patients with hemodynamic instability
Variable | Risk factors for mortality due to hemorrhage | |
---|---|---|
OR (95% CI) | p-value | |
Preperitoneal pelvic packing | 0.191 (0.024∼1.523) | 0.118 |
Emergent hemostatic procedure | 0.045 (0.004∼0.489) | 0.011 |
Initial lactate | 1.110 (0.826∼1.492) | 0.489 |
PRBC requirement for 4 h | 1.129 (1.022∼1.247) | 0.017 |
The logistic regression model includes “preperitoneal pelvic packing,” “emergent hemostatic procedure,” “initial lactate,” and “PRBC requirement for 4 hours.”
OR: odds ratio, CI: confidence interval, PRBC: packed red blood cell.
The data were statistically significant
In this study, initial SBP and PRBC requirements were identified as factors associated with overall mortality. Previous studies showed that predictors of mortality for pelvic ring fracture were age, ISS, pelvic ring instability, open fracture, rectal injury, combined head injury, units of PRBC transfused, and admission base deficit [
There are several reasons for the high overall mortality (52.3%), which was compared with previous studies. First, although patients who were admitted after the establishment of a trauma center were enrolled in this study, the median time from injury to ER arrival was 115.5 minutes, which was still a long duration. This seems to be due to the deterioration of the patient’s condition upon arrival at the trauma center, with about 60% of the patients being transferred from other hospitals. Second, despite the formation of a trauma team in our hospital in 2014, definite management protocols for pelvic fracture patients with shock has still not been established. Biffl et al. [
Fifteen patients (34.1%) died of acute hemorrhage, and independent factors associated with mortality were PRBC requirement for 4 hours and emergent hemostatic procedure. Generally, PPP, PA, and EPF were performed as emergent procedures to control hemorrhage due to pelvic fracture. Several studies showed that PPP provided effective hemostasis and improved clinical outcomes in pelvic fracture patients with hemodynamic instability [
Burlew et al. [
Hemorrhage in pelvic fracture patients is mainly caused by bleeding from the fractured bone and injury of internal iliac vessels and their branches [
The major limitations of our study are its small size and retrospective nature, and that patients with pelvic fractures but no hemodynamic instability were not analyzed. In spite of these limitations, this study is still meaningful as it provides information on the outcomes and factors related to death in pelvic fracture patients with hemodynamic instability in a Korean regional trauma center. However, a large-scale and multicenter study with Korean trauma data bank analysis will be needed in the future.
We thank the trauma team and the staff of the trauma intensive care unit of Wonju Severance Christian hospital for their devotion and affection for patients.
No potential conflict of interest relevant to this article was reported.