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Operating room or angiography suite for hemodynamically unstable pelvic fractures?

Thorson, Chad M. MD; Ryan, Mark L. MD; Otero, Christian A. MD; Vu, Thai MD; Borja, Maria J. MD; Jose, Jean MD; Schulman, Carl I. MD, PhD; Livingstone, Alan S. MD; Proctor, Kenneth G. PhD

The Journal of Trauma and Acute Care Surgery: February 2012 - Volume 72 - Issue 2 - p 364–372
doi: 10.1097/TA.0b013e318243da10
AAST 2011 Papers
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Background: Few patients require angiography and therapeutic embolization for bleeding pelvic fractures, but they are risk for significant morbidity and mortality. In hemodynamically unstable trauma patients with pelvic fractures, the decision to proceed to the operating room (OR) to address intraabdominal bleeding, or angiography to address pelvic bleeding (ANGIO), is rarely straightforward. This study tested the hypothesis that outcomes are similar regardless if the sequence was OR-ANGIO or ANGIO-OR.

Methods: All pelvic fractures between 1999 and 2011 were retrospectively reviewed and stratified by initial management with ANGIO or OR.

Results: Of 2,922 patients with pelvic fractures, only 183 (6%) required angiography for suspected bleeding. For OR-ANGIO (n = 49) versus ANGIO (n = 134), injury severity score was similar (40 ± 15 vs. 35 ± 16), but systolic blood pressure (97 ± 28 vs. 108 ± 32 mmHg, p = 0.038) and base excess were both lower (−9 ± 5 vs. −5 ± 5 mEq/L, p < 0.001). During initial resuscitation and in the first 24 hours, crystalloid, blood product usage and total fluid requirements were all increased 50% to 100% (all p < 0.001). Despite these differences, lengths of stay (32 ± 32 vs. 26 ± 28 days) and mortality (33% vs. 31%) were similar. The same trends in fluid requirements remained in the subset of patients with unstable pelvic fractures, with an increased mortality (67% vs. 20%, p = 0.011) in those requiring ANGIO-OR versus OR-ANGIO.

Conclusion: These data support current management algorithms. In hemodynamically unstable trauma patients with pelvic fractures, those who proceeded immediately to the OR to address intraabdominal bleeding tended to be sicker but had outcomes that were the same or better compared with those who received angiography to address pelvic bleeding.

Level of Evidence: III, retrospective review.

Miami, Florida

From the Dewitt-Daughtry Family Department of Surgery and Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, Florida.

Submitted: September 7, 2011, Revised: November 9, 2011, Accepted: November 25, 2011.

Supported, in part, by grant No. N140610670 from the Office of Naval Research and #09078015 from U.S. Army Medical Research & Materiel Command.

Presented at the 70th Annual Meeting of the American Association for the Surgery of Trauma, September 14–17, 2011, Chicago, Illinois.

Address for reprints: Kenneth G. Proctor, PhD, Divisions of Trauma and Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136; email: kproctor@miami.edu.

© 2012 Lippincott Williams & Wilkins, Inc.