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Pelvic fracture pattern predicts the need for hemorrhage control intervention—Results of an AAST multi-institutional study

Costantini, Todd W. MD; Coimbra, Raul MD, PhD; Holcomb, John B. MD; Podbielski, Jeanette M. RN; Catalano, Richard D. MD; Blackburn, Allie MD; Scalea, Thomas M. MD; Stein, Deborah M. MD, MPH; Williams, Lashonda MD; Conflitti, Joseph MD; Keeney, Scott DO; Hoey, Christy RN; Zhou, Tianhua; Sperry, Jason MD, MPH; Skiada, Dimitra MD; Inaba, Kenji MD; Williams, Brian H. MD; Minei, Joseph P. MD; Privette, Alicia MD; Mackersie, Robert C. MD; Robinson, Brenton R.; Moore, Forrest O. MDthe AAST Pelvic Fracture Study Group

Journal of Trauma and Acute Care Surgery: June 2017 - Volume 82 - Issue 6 - p 1030–1038
doi: 10.1097/TA.0000000000001465
AAST 2016 Plenary Papers
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Background Early identification of patients with pelvic fractures at risk of severe bleeding requiring intervention is critical. We performed a multi-institutional study to test our hypothesis that pelvic fracture patterns predict the need for a pelvic hemorrhage control intervention.

Methods This prospective, observational, multicenter study enrolled patients with pelvic fracture due to blunt trauma. Inclusion criteria included shock on admission (systolic blood pressure <90 mm Hg or heart rate >120 beats/min and base deficit >5, and the ability to review pelvic imaging). Demographic data, open pelvic fracture, blood transfusion, pelvic hemorrhage control intervention (angioembolization, external fixator, pelvic packing, and/or REBOA [resuscitative balloon occlusion of the aorta]), and mortality were recorded. Pelvic fracture pattern was classified according to Young-Burgess in a blinded fashion. Predictors of pelvic hemorrhage control intervention and mortality were analyzed by univariate and multivariate regression analyses.

Results A total of 163 patients presenting in shock were enrolled from 11 Level I trauma centers. The most common pelvic fracture pattern was lateral compression I, followed by lateral compression I, and vertical shear. Of the 12 patients with an anterior-posterior compression III fracture, 10 (83%) required a pelvic hemorrhage control intervention. Factors associated with the need for pelvic fracture hemorrhage control intervention on univariate analysis included vertical shear pelvic fracture pattern, increasing age, and transfusion of blood products. Anterior-posterior compression III fracture patterns and open pelvic fracture predicted the need for pelvic hemorrhage control intervention on multivariate analysis. Overall in-hospital mortality for patients admitted in shock with pelvic fracture was 30% and did not differ based on pelvic fracture pattern on multivariate analysis.

Conclusion Blunt trauma patients admitted in shock with anterior-posterior compression III fracture patterns or patients with open pelvic fracture are at greatest risk of bleeding requiring pelvic hemorrhage control intervention.

Level of Evidence Prognostic/epidemiologic study, level III.

Supplemental digital content is available in the text.

From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.W.C., R.C.), University of California San Diego Health Sciences, San Diego, California; University of Texas Health Sciences Center–Houston (J.B.H., J.M.P.), Houston, Texas; Loma Linda University Medical Center (R.D.C., A.B.), Loma Linda, California; R Adams Cowley Shock Trauma Center (T.M.S., D.M.S.), Baltimore, Maryland; East Texas Medical Center (L.W., J.C.), Tyler, Texas; St. Luke’s University Health Network (S.K., C.H.), Bethlehem, Pennsylvania; University of Pittsburgh Medical Center (T.Z., J.S.), Pittsburgh, Pennsylvania; University of Southern California (D.S., K.I.), Los Angeles, California; University of Texas Southwestern Medical Center (B.H.W., J.P.M.), Dallas, Texas; San Francisco General Hospital and Trauma Center (A.P., R.C.M.), San Francisco, California; and Chandler Regional Medical Center (B.R.R., F.O.M), Chandler, Arizona.

Submitted: August 24, 2016, Revised: November 11, 2016, Accepted: December 6, 2016, Published online: March 23, 2017.

This study was presented at the 75th annual meeting of the American Association for the Surgery of Trauma, September 14–17, 2016, in Waikoloa, Hawaii.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Address for reprints: Todd W. Costantini, MD, 200 W Arbor Dr, #8896, San Diego, CA 92103; email: tcostantini@ucsd.edu.

© 2017 Lippincott Williams & Wilkins, Inc.